Le

NotMyNotes:
NCLEX

Delegation
RN
LPN
SpecializedCare(Inc.Levelofskill,Newlyrecovered) RoutineCare
SevereCases
Chroniccases
SterileProcedure
Stableclients
NewlyDiagnosed
Unstableclients
WithComplications(acute,lifethreatening)
Assessment,Teaching,Evaluation

UAP/NC
ActivitiesofDailyLiving

o LatexAllergy=Kiwifruitallergy
o HistoryofMVA(headtrauma)PolyuriaDiabetesInsipidus
o Cushingstriad:1.)widepulsepressure
2.)Dec.RR
3.)Dec.PR
*Noteadec.inLOCbeforeCushingstriad
o SawPalmetto=SameasFinasteridepreventsdysuriagiventoclientswithBPHtodec.thesizeof
prostate.
o MaHuang=SameasephedrasubstituteofSudafedShabuoramphetaminelikeeffect
o DiHuang=Dec.bloodsugarforDM
o BlackCohosh=Inc.Estrogenformenopauserelieveshotflushes
o BlueCohosh=auterinetonicforstartinglaboralsoafterdeliveryforuterinecontraction
o Chamomile=CIinasthmacausesbronchospasm
=CIwithgingkobiloba
o HeartBlock=AtropineSulfate
o Tachycardia=Lidocaine
o Howmanyservingsofmilk,fruitandvegetablesaday=34/meal
ChemotherapeuticAgents
1. Cisplastin=causesstomatitis
2. Azathioprine=
3. Methotrexate=Psychotropicprecautions
ConversionDisturbances
PrimaryGain
MotivationBehindthes/sx

SecondaryGain
Theattentionthattheyget

TertiaryGain
Extenttow/cthes/sxis
manifestedinordertoplease
thehealthcareprovider

o GoalonPreeclampsia=Topreventseizure
o IleostomyNormal23daysafter()discharge
Fatembolism
1.) Dyspnea
2.) Chestpain
3.) Petechiaeonthechest
o PriorityadministerO2Todec.surfacetensionoffatglobules
DIC=DisseminatedIntravascularCoagulation
o Systemicclottingbleeding
o Priority=Preventsystemicclotting
o NormalFibrinogenlevel=180340mg/dl <100bleeding

NarcoticWithdrawalSyndrome

FetalAlcoholSyndrome

Hypertonicity
Hyperactivity
Irritability
PoorSucking
Sleepiness
Shrillcry
Highpitchedcry

Hypotonicity
Irritability
PoorSucking
FacialDeformity
Microcephaly

o Priority=PhysiologicIntegrityVitalssignsGiveValium
MacularDegeneration
o CMV=Cytomegalovirusinfection
o Lossofcentral&peripheralvisionblindness
ErbsPalsy
o Attainedduringdeliveryreversiblecompleterecoveryafter3months
StepsofHeimlichManeuver
=standbehind
=wraparmsaroundtheclient
=fistoverxiphoidprocess
=upwardabdominalthrust
SepticShock
o Systemicinfection
o Centralizedvasodilation
o Dec.BP
o Inc.Temperature
CleftPalate
o Postsurgery=prone
o Postfeeding=sidelying
CleftLip&Palate
o Postsurgery=sidelying
o Cleftlipis1st donefollowedbytherepairofthepalate
o Mustfirstsatisfytheruleof10:
1.) 10weeks
2.) 10lbs.
3.) 10Hgb
Situationinwhichconsentofparentsarenotneeded:
1.) STDs
2.) Delivery
3.) Substanceabuse
DiabeticClients
o 5070%CHO
o Raisinbesttobringduringtravel
o 1riceisequalto2servingsofpopcorn

MI
SequenceofenzymesthatincreasesduringMI:
1.)
2.)
3.)
4.)
5.)

Myoglobin=30min1hrpostMI
Troponin=36hrsupto3weeks
CKMB=Inc48hrspostMI,backtonormalin34days
AST=820u/Lnormal,Inc610hrspostMI,backtonormalaweeklater
LDH=Inc23dayspostMI,backtonormalby1014days

LDH=4590u/mlNormal
LDH1=Heart
LDH2=RES
LDH3=Lungs
LDH4=Kidney&Pancreas
LDH5=Liver
PilocarpinesweatTest(InduceSweating)CysticFibrosis(Autosomalrecessive)
DysthemiaLesssevereformofdepression
IncentiveSpirometerInhale
PeakFlowmeterBlowashardasfastaspossible
GentamycinToxicEffects:
1.) Ototoxic
2.) Nephrotoxic
3.) Neurotoxic
Influenzaevaccine
VarivaxDonotgiveAspirinmayleadtoReyesSyndrome
Kwell CItoptwithseizure
DxProcedures:
1.)
2.)
3.)
4.)
5.)

ABG
Amniocentesis
Thoracocentesis
Bronchoscopy
MRI

Angiogram:
1.) CapillaryRefilltime
2.) DistalPulses
3.) Puncturesiteforbleeding
=IfthesiteisonthefemoralKeeplegextendedfor24hrs.
RespiratoryAlkalosisbreathtoapaperbag
RespiratoryAcidosisDeepBreathing
Commonlyaskeddrugs:
1.) Lanoxin
2.) Heparin

3.)
4.)
5.)
6.)
7.)

Acetaminophen
MgSO4
Cytoxan
Synthroid
Vaccines

DotheCHECKmethod
Theophylloine=1020mg/dladult
=510mg/dlpedia
AcetaminophenSE=Hardstools
Commonlyaskeddiseases:
1.) Alzeihmenrs
2.) SickleCellAnemia
3.) Pancreatitis
4.) BipolarDisorders
5.) LiverCirrhosis
6.) Hemophilia
7.) AIDS
8.) DM
9.) CysticFibrosis
Droplet within3feet
AirborneBeyond3feet
Informedconsent
o Foradultorminorwithcapacity
o Requirefullunderstandingofprocedure
o Protectstheclient,nurse,surgeonandhospital
o Foremancipatedminors:
o Marriedminors
o Militaryservice
o Livingawayfromhome
o Hadachild
Proceduresrequiringconsent:
1. SurgicalProcedure
2. Invasivethatrequiresentrytoabodycavity
3. Visualizationorradiologicprocedurewithcontrastmedium
4. GeneralAnaesthesia,localinfiltrationandregionalblock
Conditionsthatdoesntneedparentsconsent:
15y/o=antibioticsforacne
16y/o=pelvicexam
17y/o=requestforcontraceptives
18y/o=DxexamforrecurrentH/A
19y/o=surgeryforbonetumor
Assesment
o Empoweringchildrentothegreatestextentfeasible
ELEMENTS
o Explaintothechildhisconditionandthereasonwhytheprocedurehastobedoneinlaymansterm
o Clinicalassessmentofpatientsunderstanding
o Solicitchildswillingness
o Expectation
EthicalCareConcept
1.)Autonomy=Livingwill,freedomofchoice,selfdeterminationandprivacy.

a. AdvanceDirective=Listofdonts(clientswithprogressivechronicillnessinwhichdeathisexpected)
b. DurablePowerofAttorneyforhealthCare=appointsaproxythatwilldecideforthepatient.
2.)Beneficence=dutytopromotewellbeingofothers
IdealBeneficence=Nagkusa
3.)NonMaleficence=Restrainedselffromdoingsomethingthatmightharmsomeone.Donotharm.
4.)Justice=Fairness
ClinicalIssues
1.Unsafenurse/ptratio
Intervention:
o Addressverballyanddocument.
o ReporttochargenurseSupervisordirector
2.NoresponsebyPhysician
PromoteSafety:
o Siderailsup
o Moveptnearnursesstation
o Userestraintsappropriately(lastresort)
3.Inappropriateorder
o Documentit
o Notifythechargenurse
o Notifythephysician
LegalIssues
Malpractice=Negligentconductinrenderingprof.service
=didnotexercisecare
RespondeatSuperior=Superiorisresponsibletotheactionsofsubordinates.
ReferralAgenciesforspecialcareduringadmission
Ptadvocate=Empowerpttoknowhis/herrightsandprivileges
1.)
2.)
3.)
4.)

socialworker
Childrensprotectiveservices
Adultprotectiveservices
Organizations

Careofthehospitalizedclients
MantouxTest
15mm=gen.population
10mm=DM,Alcoholism
5mm=HIV
Areaswherebruisesareindicativeofchildabuse:
1. LowerBack
2. UpperBack
3. Sideoftheabdomen
SpecialConsiderations
Infants

o Greatestriskforfluidandelectrolyteimbalance
o Hypothermiaandinfections
o Approachtheminnonthreateningmanner

Toddler
o Increasedseparationanxiety
o Brieflypreparethemforproceduresduetoshortattentionspan
o Describesensationthattheymayfeelduringprocedure
Preschooler
o
o
o
o
o

Fearofphysicalharm
Believethatillnessesisaformofpunishment
Explanationsmustbebrief,honestandinnaturalterms
Usedemonstrationsandplayinprovidinghealthteaching
Canuseadultseatbeltif40lbsor40inchestall,alsoifhecouldlookatthewindowinsittingposition

SchoolAge
o Realisticunderstandingofdeath=910
o Needsmoredetailedteachings
o Allowthemtomakesomechoices
Adolescence
o
o
o
o
o

Developedabstractthinkingandabilitytoproblemsolve
Logicandreasoning
Fullandhonestexplanation
Primaryconcernarewiththepresenttime
Focusonappearance

Elderly
o
o
o
o
o
o

Nutritionisaprimaryconcern
Muscleatrophy
Decbodywater,BMR
Decrenal,CV,GITfunction
Dectaste,smell, visualacuity(cataract,arcucsenilis=fattydepositsaroundpupil_)
WithmultiplemedicationsduetochronicdiseasesOH,Nephrotoxic

Triage=asystemofclientevaluationtoestablishpriorities
PRINCIPLES
EmergencySituation=greatestriskreceivespriority
MajorDisasters=thoserequiringminimalcarearetreatedfirst
=Thoserequiringspecializedcaremaybegivenminimalcareornocare

TreeofStrategyforPrioritizing
Ask
Look

Where DisasterArea=Leastinjured
EmergencyArea=Mostinjured
Case

SameArea
=allOB
=allPsycho
=allMS
=allPedia

VariousAreas
Physiologicvs.Psychological
Acutevs.Chronis
Unstablevs.Stable

Evaluateandlookfor
=Complications
=Immediateneed
=Adverseeffects
PrioritizingSignsandsymptoms
Consider
=SymptomsrelatedtoABC
=symptomswhichareindicativeofcomplications
PrioritizingNursingDiagnosis
Consider
=TyoeofN.Dx
=Actual(Problem)
=Risk(Vulnerable)
=Possible(Inadequatedata)
=Wellness
PrioritizingInterventions
DiagnosticVerifytheDxAssessment
TherapeuticAssesspt
TeachingInformingthepatient
ReferralInvolvesamemberofthehealthteam
IndependentDecisionMaking
Levelsofprioritizing
Level1:Emergent
S=evereshcock
C=ardiacarrest,CervicalSpineInjury
A=irwaycompromise,alteredLOC
M=ultisystem

E=clampsia
Level2:Urgent(stable)
Fe=ver
Mi=norburnless10%
Mi=normusculoSkeletald/o
La=creation
Di=zziness
Level3:Chronic/MinorInjuries
Dentalproblems
RoutineMedications
MissedMenses
ChronicLowBackPain
Prioritize
Cardiovascular=NeurologicalCases
AcuteComplications
Consider=AgeandDxofthept
FortMSCases:ThinkABC
ForPsyche:SafetyFirst
Incaseoffire:ARCE(new)
:RACEIfcausedbyO2,turnoffO2first
DELEGATION:Transferofresponsibilityfortheperformanceofanactivityfromoneindividualtoanother.
Direct:IdentifiedbytheRN
Indirect:Taskbasedonthefamilieslist
Complextask=neverdelegated
=requiresjudgmentonhowtoproceed
Noncomplextask:canbesafelyperformedrecordingtoexactdirections
:canbedelegated
Taskthatcannotbedelegated(HOSPITAL)
1.Administrationof:
=Investigationaldrugs
=CancerDrugs
=IVpushdrugs
=Bloodandbloodproducts
=TPN
=Implanteddevice
2.HemodialysisFunctions
Taskthatcannotbedelegated(HOMEHEALTH)
a.)initialsetupofptcontrolledanalgesicpump
=changingofflowrates
=changingmedicationsreservoir
=fillingthereservoir
b.)NGTfeeding
KNOWTHERULES
1.)Donotdelegate:

o
o
o
o

Assessment
Teaching
Evaluation
Preparationandadministrationofmeds

2.)Delegate
o ADL
o Routine
o StandardProcedures
Knowthe5rightsofdelegation
1.)RightTask
2.)RightCircumstances
3.)RightPerson
4.)RightPerson/Communication
5.)RightSupervision
Social

Therapeutic
Relationship

Goals:Socialization

Goal:MentalHealth
trust

Phases:
1. Preinteractionselfawarenessofnurses
2. Orientationcontractdosanddonts
3. Workingphaseidentification&resolutionofproblems
4. Terminationphaseevaluation
TherapeuticCommunication
1.
2.
3.
4.
5.

Dontaskwhy
Avoidpassingthebuck
Dontgivefalsereassurance
Avoidnursecenteredresponse
Recognizetheptsfeelings

CORECONCEPTS
o
o
o
o
o

Therapeuticphrases
Openendedquestionsare
GenerallyTherapeutic
Closedendedeffectiveformanicandptsincrisis
Directquestionsforsuicidalpts

Bruit=highpitched
Murmur=lowpitched
20/20=Visionattainedat36yearsold
Decorticate

Decerebrate

Flexed
Adducted

Arms

Flexed
Abducted

Plantar
Flexed
Extended

Legs

Plantar
Flexed
Extended

Howtoattackthequestions?
1.
2.
3.
4.

Considertheptsdx
Knowwhatisnormal
Someconditionshaveinherentandexpectedchangesinthenormalvalues
Minimaldeviationfromnormalvaluesarenotreportable

Sodium=135145Meq/L
DilutionalHyponatremia=<120Increiskforseizure
=115SeizurePrecaution
AddisonHyponatremia,Hyperkalemia
CushingsHypernatremia,Hypokalemia
Potassium=3.54.5Meq/LNormal
=<3.5Muscleweakness
Calcium=4.55.5Meq/LNormal
=910mg/dl
HypercalcemiaIncH2Ointake
MultipleMyelomaIncserumcalciumlevel
HypoparathyroidDecCa
Levelsinblood
ThyrocalcitoninDepositsCatobones
ParathyroidHormoneBoneCatoblood
Glucose
=<50Hypoglycemia
=>140Hyperglycemia
CREATININE=.51.5Meq/L
=Bestindicatorforkidneyfunction
=InccreatinineKidneyfailure
BUN=1020mg/dl
=Alsoanindicatorforkidneyfunction
=IncBUNKidneyfailure
RBC=4.55.5
=Decbleeding,shock,anemia
=Incinpolycythemia
=Phlebotomyremovalof500mlofblood
=DecRBCActivityintolerance
=IncRBCCVARiskforinjury
WBC=5,00010,000
=Postpartum>15,000
=Leukemia>150,000HyperleukocytosisRiskforinjury
Platelets=150,000450,000
=<150,000Thrombocytepenicprecaution
=<20,000bleedingprecaution
=>500,000bleedingd/o
=RiskforInjury
PT=1112seconds
INR=24seconds
=>24bleeding

X20

10

PTT=6070seconds
INR=175seconds
APTT=3040seconds
INR=100seconds
MonitoredHeparin
=>INRbleeding

X25
X25

Hbg
Female=1216
Male=1418
Newborn=1424
Pregnant =1012
=<10report
=ResultstoAnemiaActivityIntolerance
Hematocrit=3545
Dangerofhydration
=<35OverhydrationFluidVolumeexcess
=>45UnderhydrationFluidVolumedeficit

AcidBaseImbalance
Respiratory

Metabolic

Alkalosis

Acidosis

Alkalosis

Acidosis

DefinCO2

ExcessCO2

ExcessHCO3

DefHCO3

Hyperventilation
Hypermetabolism
Hypoxia
Hypotension

LungDisease
Airwayobstruction
RespDepression
Neurological&Musculardse

Cushings
Hypokalemia
Excessivelossofacids
GIvomiting

Ketoneoverload
LacticAcidproduction
KidneyDisease
GIdisease

s/sx

s/sx

s/sx

s/sx

Restlessness
Anxiety
Tachycardia
Syncope

Restlessness
Apprehension
Tachycardia
DecLOC
DecDTR

Cyanosis
Hypotension
Apathy
Weakness

Confusion
Hyponatremia
Anorexia
Weakness
DullH/A
Kaussmaulsbreathing

Breaththrupaperbag
Breaththrucuppedhand

Deepbreathing

AdministerAmmoniumCl

Mechanicalventilator

ABGdetermination

PH7.357.45
Hco32226
CO23545

Alkalosis

Acidosis

Inc
Inc
Dec

Dec
Dec
Inc

11

HCO3determinantforMetabolicd/o
CO2determinantforrespiratoryd/o
RAMS=Respiratoryd/o,Alternatearrowdirection
=Metabolicd/o,Samearrowdirection
Compensation
Compensation

PH

Uncompensated
Partially
compensates
Fully
compensated

Abnormal
Abnormal

Compensatory
Mechanism
NoChange
Change

Normal

Change

APGAR
1minteAssesscardio,pulmonaryandneurologicalstatusofthebaby
5minutesadjustmenttoextrauterinelife
10minuteswhen2nd apgarisbelow6
710admission
46O2andwarm
03Resuscitation

Appearance
Pulse
Grimace
Activity
Respiratoryeffort

0
Allblue
Absent
Norxn
Flaccid

1
Acrocyanosis
<100
Weakcry
Someflexionandextension

Abnormal

Irregular

2
Pink
>100
Vigorouscry
Spontaneousflexion&
extension
Lusty

Computation:
1.)

D
S

2.)

Vol.inccXgttfactor
#ofhrs.X60

3.)IVfluidreplacementinpediatricpt
Weight
<10kg X100/kg
1120kg 1000ml/10kg
InexcessX50
2kgs 1,500ml/20kg
inexcessX20
IsolationPrecaution

I.Standard
II.Transmission
Based
a.Doplet
b.Airborne

HW

PR
X

Mask,goggles
(surgical)

Gloves

Gown

(PRM)

X
X

X
X

12

c.Contact

PRM(particulateRespiratorMask)

I.
StandardAiDS,HIV,Hepa,Roseola
II.
TransmissionBased:
A. DropletMumps,MycoplasmalPneumonia,Rubella
B. AirborneMeasles(Rubeola),TB,Varicella
C. ContactClostridiumdeficile,Respiratoryborne,scabies,Sarcoidosis,RSV
HepawithbowelincontinenceContactprecaution
Principles:
1. Ifpatientgoesoutfromtheroomletthepatientwearmask
2. CohertingSameillnessShareroom
3. StandardPrecautionexemptioninpediadiapered,incontinent,<6y/ocontactprecaution
HERBALREMEDIES
SawPalmetto
o StopsprogressionofBPHlikeFinasteride
o Easeurinarydifficulty
o Interfereswithironabsorption
o CI:pregnancyandlactation
o SE:stomachache
BlueCohosh
o Uterinetonic
o Usedinthelast24weeks
o Toeaselaborpains
o Jumpstartstalledlabor
o Deliverretainedplacenta
o Stopbleedingafterdelivery
BlackCohosh
o SppressLHbutnotFSH
o Relievessymptomsofmenopause
o Nothabitforming
o Doesnotcausecancer
o Limituseto6monthsaltersthenormalhormonalbalance
MaHuang
o CNSStimulant
o Causesaddiction
o Withdrawalsymptoms:depression,fatigue,irritability
o Withephedralikeeffect
o Usedtotreatasthma
o Cancauseweightloss
o NotgiveninpatientswithDMaltersthebloodsugarlevel
Chamomile
o Fordiarrhea,antibacterial,antiviral
o CI:Bronchialasthma,anticoagulanttherapy
Cranberry
o ForUTIandasthma
o NotforDM
o Safeinpregnancy
o UsewithcautioninDM
Echinacea
o Immunesystemstimulant

13

o Notusedformorethan14days
o Storeitawayfromdirectlight
o NotgiveninTBandchronicconditions
Ginger
o Antiemetic,txforcolicandflatulence
o ReportbleedingandCNSdepression
Ginseng
o Fatigue,atherosclerosis,depression,Ca
o Reportginsengabusesyndrome,Diarrhea,nervousness,edema,insomnia
GingkoBiloba
o Improvesbloodcirculation
o UsedinAlzheimersDisease
o CIpregnancy,lactationandclottingd/o
GotuKova
o Improvesmemory
o ForUTI,snakebites,rheumatism
o CI:pregnancy,lactationanduseofsedatives
KAVA
o Anxiety,menstrualproblem,leprosy
o AE:CNSdepression,hepatotoxicity
o Notgiventoptswithantipsychoticincsedativeeffectsofdrugs
VALERIAN
o Tranquilizer,sedative
o Notgivenwithvalium
o Uses:insomnia,mm.spasm
DRUGS
IronSupplements FeSO4
C=MineralSupplementAnemia
H=Reliefoffatigue/Incstrength
E=Bestbeforemeals,aftermealsifwithGIirritation
C=takeseffectafter23weeks,Incabsorptionwithorangejuice
K=
Elixiformusestraw
InjectableZtrackmethod(laterallystretchtheskin,10seconds)
SE:Constipationandblackstools
Antidote:DeferoxamineHCL(Desferal)
RHOGAM
C=PreventsRHsensitization
H=()Hemolyticreaction
E=2728weeksAOG,ideally72hrsafterdeliveryofbabywithRh(+)and()Coombs
C=Painininjectionsite
K=CheckCoombstestonlyin()
OXYTOCIN
Pitocin
C=

Methergine

InduceLabor

Contractsuterusafterplacentaldelivery
Increaseforceof
Uterinecontraction

H=firmlycontracteduterus

14

E=Asprescribed
C=Reportprolongeddurationofcontraction
K=Avoid:Bluecohosh
CheckBP
o PitocininitiallycausesHypotensionthenreboundhypertension
o MethergineinitiallycausesHypertensionthenreboundHypotension

TOCOLYTICS
C=Relaxestheuterinemm.duringpretermlabor
H=()contractions/relaxeduterus
RitodrineHCl(Yutopar)
E=Onsetofpretermlabor
C=Reportmaternaltachycardia
HR>130Arrhythmia
K=PrepareantidotePropanolol
MagnesiumSulfate
C=Anticonvulsant,NSdepressant
H=()Seizure
E=AsprescribedPIH
C=ReportMgSO4intoxicationHypotension,hypocalcemiaandH/A
K=CheckBP,urineoutput,RR,Patellarreflex ifDecantidoteCaGluconate
Therapeuticlevel:
o Loadingdose47Meq/L
o Maintenance 1.53Meq/L
o DepressionofDTRif8Meq/L
o DecRRif1012Meq/L
CoagulationProcess
VitKdependentclottingFactors
Thromboplastin

FibrinogenFibrin(clot)

Prothrombin
Coumadin

Thrombin
Heparin

Coumadin/Heparin
Coumadin
(Oral)
C=
H=
E=
C=
K=

Heparin
(Injectable)

Anticoagulant
()Clotformation
Onset:25days
12days
Reportsignsofbleeding
AvoidgreenleafyVegetable(containsVitK)

15

Avoidhardbristletoothbrush
Antidote:
Lab:

VitK
PT

ProtamineSulfate
PTT

CHEMOTHERAPY
CELLCYCLE
G0

Mitosis
Interphase

Resting

G1

RNAproductionDNAsynthesis

G2

Celldivision

RNAsynthesis

AlkalatingAgents

Antimetabolites

Antibiotic

PlantAlkaloid

Hormones

InterferesDNA
replication

InterferesDNA&
RNAReplication

InhibitDNA&
RNAsynthesis

InterferesDNA
synthesis

InterferesRNA
synthesis

*CYTOXAN
*MUSTARGEN

*METHOTREXATE
*ADRIAMYCIN
(antidote:Leucoverin) GLENOXANE

*ONCOVIN

*TAMOXIFEN

C=

ANTIPSYCHOTIC
Typical

Atypical
Antiemetic
Mania
Schizophrenia
Bipolard/o

H=

Haloperidol(Haldol)
Dec(+)symptoms
(walasanormalbeing)

Clozapine(Clozaril)
Dec(+)and()symptoms

Hallucinations
Delusion
LoosenessofAssociation

Apathy
Alogia
Avolition
Anhidonia
Decdopaminelevels

16

E=
C=

pc=aftermeals
Sideeffects:
1.)Agranulocytosis
Fever,sorethroat
2.)NMS
Fever,mmrigidity
3.)EPS
Mmrigidity

Anticholinergic
Tachycardia
Drymouth
BlurredVision
Constipation
DecBP

SideEffects:
Leukopenia(<3,500=signsofinfxn)
(if<2,00=protectiveisolation)

EPS=Cogentin
Akineton
Artane
MalignantHyperthermia=Parlodel
Musclerigidity=Dantrolene,Dantrium
K=

LiverFxnTest
Nodirectexposuretosunlight=Photosensitivity
AntiParkinsonianathand
CI=St.Johnswort

C=

ANTIPARKINSONIANAGENT

H=

Dopaminergic
IncDopamine

Anticholinergic
DecAch

LDopa
Carbidopa
(Sinimet)

Congentin
Benadryl

E=

Decmmrigidity
Decpillrolling
(after23weeks)
aftermeals

C=

H/A,Irritability,Restlessness

K=

NotoVitB6=decabsorptionofdrug
CheckBPandHR
NoCHON
ANTIANXIETY

C=

Valium
Librium=Acutealcoholwithdrawalsyndrome
=dectremors
H=

Deccenterofwakefulness

E=

Beforemeals

C=

Dizziness
Drowsiness
DryMouth

K=

AvoidAlcoholandCaffeine
AdministerValiumseparately=incompatiblewithanyotherdrugs
AvoidKAVA&VALERIAN=IncRespdepression

17

C=

H=

ANTIDEPRESSANT
SSRI

TCA

MAOI

Stimulant

ZOLOFT

VIVACTIL
CETAVIL
TOFRANIL

PARNATE
NARDIL
MARPLAN

RITALIN

Decreuptakeof
Serotonin

Preventsreabsorption
ofNorepinephrine

Preventsthedestruction
ofserotonin&
Norepinephrine

Directlystimulates
theCNS

E=

Aftermeals

C=

Incappetite
Adequatesleep
Initialeffect=23weeks
Fulleffect=34weeks
Sideeffects:
Declibido
Impotence

K=

CardiacArrhythmias

Growthsuppression

ChecktheBP
AvoidCitrusjuicesDecabsorptionofantidepressants
Observedietarymodifications
AvoidSt.JohnWort
AvoidTyraminecontainingfoods:
Cheddar,Swiss,CottageandAgedcheese
Cola,coffee,soysauce

C=

ANTIMANICAGENTS
LITHIUM

H=
E=

TEGRETOL
DEPAKENE
(Carbamazipine)
(ValproicAcid)
AntiConvulsant
Alternativedrugforpregnant
Women
DecHyperactivitywithin23weeks
AcuteMania=GiveAntiPsychoticwithantimanic
Aftermealspc

C=
Mild
1.5Meq/L
Thirst
Ataxia
H/A
Irritability
BeginningFinehandtremors

K=

HypertensiveCrisis

Checksignsoftoxicity:
Moderate
2.5Meq/L
Nausea
Anorexia
Vomiting
Diarrhea
Coarsehandtremors
AbdominalCramps
ComaDeath

Severe
>2.5Meq/L

MonitorLithiumLevelearlymorning(beforebreakfast)
Outpatientatleastonceamonth

18

DrugofchoicefortoxicityDiamox,Mannitol
CI:
1.) Pregnancy
2.) Lactation
3.) RenalFailure
DietaryModificationIncNa(610gm)andIncFluid(3Lormore)
AcuteDose:.51.5Meq/L
Maintenance:.51.2Meq/L
Elderly:notexceed1.0Meq/Lduetopoorrenalexcretion

MUSCULOSKELETALDRUGS

C=

Focus:GoldTherapy
SuppressesArthritis

H=

()Inflammation

E=

IMweekly
Liesupinefor10minstopreventOH

C=

Check:
SignsofStomatitis
Dermatitis
UnusualBleeding
UnusualBruising
Fever
SoreThroat

K=

MonitorRenalFunctionTest

C=

ANTIINFLAMMATORY

H=

Aspirin

AntiInflammatory
Antipyretic
Analgesic
ForRA&OA

AntiInflammatory
Antipyretic
Analgesic
AntiPlateletaggregate
Antirheumatic
()Inflammation,()pain,()RA
()fever,()plateletaggregation

E=
C=

Ibuprofen
(NSAIDs)

pcaftermeals
Report:

19

Visualdisturbances
Allergy
Sorethroat
Fever
BlackStool
K=

Ringingintheears
Nausea&Vomiting
Rapidbreathing
Hyperpneatoxicity

Annualeyeexam
Checkbleedingtime

C=

ANTIGOUTAGENTS
Probenecid

Excretionofu.a.

Colchicine

Allopurinol

Acute
(812hrs)
Preventdepositionofu.a.
Antiinflammatory

Chronic
(13weeks)
Preventformationofu.a.

H=

Decreaseuricacid

E=

Givenwithfood

C=

NAVDA
Allergy

K=

Bruising

H/A,drowsiness
Agranulocytosis

Incfluidintake23L/day
Frequentlycheckserumuricacidlevel
CARDIACDRUGS

NITRATE
A.Nitroglycerine
Sublingual
Transmucosal=betweengums,cheecksandlips
B.Isordil
Sustainedrelease,withwateranddontcrush
Patch
NasalSpray
C=
Caridacdrug(Nitrate)
DilatecoronaryarteriesandarteriolesDecpreload
H=

()AnginalPain

E=

Givebeforeonsetofpain
3Xat5minsinterval
After15mins(+)painreportMayindicateMI
1.Ointment=Coverwithplasticandputadhesivetape
2.Patch=NonHairypart
3.Oralspray=3spraysin15mins

C=

S.E.Facialflushing,H/A,Hypotension
K=

RiseslowlytopreventOH
Tabletondry,darkcontainer
6monthsDiscard

20

BurningSensationIndicationthatthedrugisstillpotent
C=

CARDIACGLYCOSIDE
Digoxin

H=

E=

Digitoxin
StrengthenMyocardialContraction
NaKpumpisconvertedtoNaCapump
Thusincreasingforceofcontraction

Onset520mins

Onste30mins2hrs
ObserveGIirritation

C=

K=

Excretedbykidneys

Excretedbytheliver

Normallevel1426

Antidote:Digibive
Normallevel52ug/dl

CheckHR=Adult60
OlderChildren=70
Infants=90110

DOPAMINEandDOBUTAMINE
DOPAMINE

DOBUTAMINE
Incforceofcontraction
CorrectHemodynamic
ForEmergencySituation

H=AdequateUrineOutput
E=EmergencySituation
C=Alwaysindilutedform
K=Computethedrugsproperly

C=

ANTIARRYTHMICS
Lidocaine
(Xylocaine)
ForPVCs

H=

Quinidine
AtrialFibrillation
()Arrythmia
Slowventricularrate
Slowatrialrate

E=Givenasprescribed
C=

Rash
Convulsion

BlurringofVision
Tinnitus/Ototoxicity

K=CheckHR
EvaluateECG

21

C=

H=

THROMBOLYTICS
Streptokines
TPA
Dissolvestheclotbypreventingtheformationoffibrin(fibrinolysis)
()Clotformation
ClotDissolved

E=

Effectivewithin6hours
AfterMIwithin24hrs

C=

Report Bleeding
MonitorVS

K=

Contraindicatedtoclientsthatarepronetobleeding

C=

ANTILIPEMICAGENTS
LOVASTATIN
(Tablet)

H=

QUESTRAN
(Powder)
DecLDL=3080
(HDLshouldbe>80andLDL<80)

E=

Beforemealsoratnighttime

C=

Caution:Hepatotoxic

K=

Questran1packofpowder+46ozoffluid(water,milkorjuice)
Checkliverfunctiontest
Rashandbleeding

C=

PERIPHERALVASODILATOR
Paracid
SmoothmusclerelaxantFacilitatesbloodcirculation

H=
E=
C=
K=

()Ischemia
AfterMeals
InstructpatientthatdrugmaycauseH/AandSOB
Longtermuseisindividual

C=
H=

BETABLOCKER
(Timolol,Esmolol,Nadolol)
DecBP,forHyperthyroidism,Decsympathetic(Autonomic)nervoussystemstimulation

E=

Beforemeals

C=

Riseslowly:Liedownfor30minsaftermedication.
Instructpatientthatmedsmaycausebronchospasm
Donotgivechamomileandaspirin

K=
C=

ANTICHOLINERGIC

22

AtropineSulfate
VasolyticAgent
H=

Incheartrate(checkcompleteheartrate)

E=

Beforemeals

C=

Avoidhotenvironments

K=

CheckforrashesandSOB
NEURODRUGS
Anticonvulsants
(Dilantin)

C=
H=

DecreaseSeizureThreshold

E=

AfterMeals

C=

EpilepsyMaintenance
ChronisUseGingivitis
Visitdentistatleastonceayear
Softbristletoothbrush,massagethegums
Urineispinktinged

K=

SAS(SalineFlushAdministerdrugSalineFlush
ToPreventprecipitate

C=

CHOLINESTERASE
Neostigmine

Tensilon
MyastheniaGravis

Alzeihmers

LongActing

ShortActing

Maintenance

Treatment

Diagnostic

Treatment

H=
E=

Incmusclestrength
BeforeActivity
BeforemealsUsemusclesofmastication

C=

Chewingbecomesstronger
Medicationislifetime
ReportS/Sxofhepatotoxicity

K=

Checkliverfxntest
KeepatbedsideNeostigmineAntidote:atropinesulfate
Donotgiveechinicea
PrepareTracheostomy

C=

Incmentalfunctioning
Atbedtime
Decdizziness

ANTITB
Rifampicin

H=

Cognex

INH

Streptomycin

Ethambutol

()Infection

23

E=

BeforeMeals

C=

Redorangeurine
Dontusecontactlenses

K=

Takethecompletetreatmentasprescribedbythedoctor(612months)
IncompleteTBtreatmentLeadtoMDRTB

PeripheralNeuritis
(GiveB6)

C=

Oto,nephro,neuro
TOXIC

Hepatotoxic
PsychoticlikeSx

ANTIASTHMA
Theophylline
Adult=1020mg/dl
Pedia=510mg/dl
Dilatesbronchioles

CromolynNa
Preventsantihistaminerelease

H=

Easebreathing

E=

Inthemorningbecauseitcausesinsomnia

C=

Nauseaandvomiting
Theophyllinetoxicity

K=

Checkthepulserate
AvoidChamomilecausebronchospasm
Avoidaspirin?Causebronchospasm
InhalerAcute
SteroidChronic

C=

Rashes

MUCOLYTICS
(Mucomyst)

H=

Antidoteforaspirintoxicity
Decviscosityofmucous
Loosephlegm

E=

Nospecifictime

C=

IncOFI
S.E.bronchospasm

K=

Suction
Medicationhasafoulodorthatresemblerottenegg

C=

EMETIC
SyrupofIpecac

H=

Toinducevomitingnoncorrosive
Pediabelow6months()vomiting

E=

Dosedependsonage
6mos1yr=10ml
112yrs=15ml
>12yrs=30ml

C=

Administerwithglassofwatertoenhanceeffectsofipecac
Cardiotoxic=Ensurethatchildvomitstheentireamount

24

C=
Maalox
12hrs

ANTACIDS
PepticUlcerDisease
Ranitidine
46wks

Sucralfate
8wks

NeutralizesHCl

DecHClsecretion

CoatsGIT

NormalHCL25
Maximum10
H=

()Pain,decHCl

E=

Usuallyonanemptystomach
1hourbeforemeals
2hoursaftermeals
Shakeliquid
SE:diarrhea
Constipation

C=

K=

ShorttermtherapyElectrolyteimbalance

ENDOCRINEDISEASE
C=

INSULIN

OHA

Type1

DiabetesMellitus

RegularHumulin
IntermediateNPH
Longactingultralente
H=

Orinase
Diabinase
Metformin

Inctransferofglucosetocellmembrane

Pancreastosecreteinsulin

E=

Beforebreakfast

C=

ReportHypoglycemia:
Dizziness
DecLOC
Diff.ofproblemsolving

K=

Type2

Hypooccursusuallyoccursatthepeakofactionofmeds:
Beforelunch
Intheafternoonorbeforedinner
Inmidnightornextday
Rank:4812/16

C=

THYROIDDRUGS
Synthroid
(supplement)
ForHypothyroidism

H=

NormalBMR

PTU
Tapazole(10timesgreaterthanPTU)
ForHyperthyroidism
DecT3andT4,Adequateappetiteandsleep

25

E=
C=

Inmorningtopreventinsomnia
Reportsignsofoverdose:
Insomnia,palpitation&Nervousness

Roundtheclock
Report:
Fever,sorethroat,bodymalaise

K=

Lifetime

MonitorHR&BP

C=

STEROID
Cortisone

Floricef
ReplacementTherapy
AddisionsDisease

H=

CorrectFluidandelectrolyteImbalance

E=

Inthemorning

C=

Givenintramuscularly
Avoidabruptwithdrawal
AE:BruisingBonemarrowdepression

K=

Avoidsaltyfoodsedema
Maintainabalancedietobesity
AvoidcrowdedareasInfection

C=

RENALDRUGS
EPOGEN
IncRBCproduction forChronicRenalFailure

H=

NormalHemoglobin

E=

Asprescribed

C=

ReportPolycythemiaIncproductionofRBCCVA
CheckCompleteBloodCount

C=
LoopDiuretic
(Lasix)

DIURETIC
ThiazideDiuretic
(Hydrochlorothiazide)
Duiril

KSparringDiuretic
(Spirinolactone)
Aldactone

LoopofHenle
PreventNaabsorption

DistalTubule
PreventsNaabsorption

Blocksaldosterone
Retainswater

H=

Increaseurineoutputanddecreaseptsweight

E=
C=

K=

Earlymorningpreventnocturia
Hypokalemia
DecK
Decna

Hypokalemia
DecK
DecNa
DecCa
Decmg

IncK
DecNa

IncSodiumindiet
CheckElectrolytelevel
CheckBP

26

IMMUNUREN
(Azathioprine)
C=
H=
E=
C=

Immunosuppressant
()rejectionoforgans
Asprescribed
Report:
Nausea,vomiting
Thrombocytopenia
Bruising
Infection

K=

CheckCBC
FrequentHandwashing

C=

MIOTICS
(Pilocarpine)
ForGlaucoma

MYDRIATICS
(ATSO4)
CIforGlaucoma
Foreyeexam

H=

NormalIOP

Dilatationofpupils

E=

Lifetimeinglaucoma

Asprescribed

C=

Lowerconjunctivalsac
Pressinnercanthus12minsto
preventsystemicSE

Report:eyepain&blurringofvision
Avoidalertnessaftermedication

K=

CheckBPandBloodsugar

C=

ANTIBIOTICS
Vancomycin
MRSA

H=

K=

Tetracycline
Lymes
RockyMountainFever

()Infection

E=
C=

Penicillin
Gonorrhea
Syphillis

Beforemeals
WithGIirritationAftermeals
Ototoxic,Nephrotoxic,
Neurotoxic

Allergy

Hepatotoxic

CheckIandO
PeakLevel=1530minsafteradministration
Troughlevel=1530minsbeforethenextdose
Antidote:Epinephrine
Givenwithprobenecid

DeepIMandcheckCBC

GuidelinesonGrossCulturalOrientationandadjustment

27

Trytogettoknowasmuchasyoucanabout:
o Socialcustoms
o FamilyLife
o Classstructure
o Religion
o Economics
o ValueSystem
SomeAreasofCultureDifferences
1.Communication
o Messageinterpretation
o PersonalSpace
o Eyecontact
o Touch
2.ViewofTime
o Presentoriented(Hispanics,Africans)
o Futureoriented(Europeans,Americans)
o PastOriented(Tribal/Traditional)
3.FamilyType
o Nuclear
o Extended
4.Nutrition=kosherdiet,jalal
5.Religion
o Catholics
o JehovasWitnesses
o 7th dayAdventist
o Mormons
CultureBoundSyndrome
BlackIncblood
ChineseKoro
HispanicsPasmo
WhitesAnorexia,Bullimia
DeathandDying
ASIANS
Familyandfriendsofsamesexwillprepareandwashthebody
MUSLIM
1. Washingofthebody
womencleansewomen
mencleansemen
2. Afterwashing3timethebodyiswrappedin3piecesofcleanwhitecloth
3. Specialprayers
4. Burythebodywiththeheadfacingmecca
5. Burialoffetus=<130daysdiscardliketissue
=>130daysproperburialrites
JEHOVASWITNESS
o Autopsyisacceptedifrequiredbylaw
o Thepartstoberemovedfromthebody
o Cremationispermitted

28

FRAMEWORK
MainProblem: SIADHNeuroendocrine
Mostcommon/initialmanifestations=SIADH Oliguria
LaboratoryData=DecNa,IncBP
NursingDiagnosisDecNaN.Dx.FluidandElectrolyteimbalance
PriorityIntervention=DecNa115meq/LImplementseizureprecaution
Leukemia
MainProblem: ProliferationofImmatureWBC
Periodsofremissionandexacerbation
Remission=Absenceofs/sxLymphycyticLymphocytesPedia
Exacerbation=Actives/sxMyelogenousGranulocytesAdults
S/SxInitial:Anemia
Bleedingsevere/unexplained
Infection
Lab.Data:

WBCHyperleukocytosis WBC150,000

N.Dx: PrioritySafety
Reverse,Isolationprecautionrelativewearmask
Thrombocytopenicprecaution
CytotoxicPrecaution
BleedingPrecaution
StandardPrecaution
HEMOPHILIA
MainProblemInheriteddisorder
TypeA
Xlinked
Recessive
50%maleoffspring
()Factor8

TypeB
Xlinked
recessive
50%maleoofspring
()factor9

VonWillebrandsdisease
Autosomaldominant
Male&Female

S/Sx: HemarthrosisHallmarkelbow,wrist,ankles,knees
Hematoma
Hematuria
Hematemesis
Hemmorhage
LabData:Clottingtime
N.Dx:Riskforinjury,alteredgrowth
Priority:Safety
BloodTransfusion,PlasmaExpanded
1. Rest
2. Immobilize
3. Coldcompress
4. Elevate

29

SICKLECELLANEMIA
IRON
DEFICIENCY
ANEMIA

PERNICIOUS
ANEMIA

FOLICACID
DEFICIENCY

SICKLECELL
ANEMIA

APLASTICOR
FANCONIS
ANEMIA

THALASSEMIAS
1.Minor
2.Intermediate
3.Major

Inc.def.ofiron
Decabsorption
Excessiveloss

LackofVit.B12
Absenceof
intrinsicfactor
Instomach:

Deficiencyin
FolicAcid

Inherited Autosomal
Recessivestatusof
Parents
(SeeTableA.1below)

Pancytopenia
Hemolytic

Duetodefectinpolypeptidechains
ofRBC

Babychubby
butpale
Duetooverintake
ofmilk
Women
menstruation

Agingatrophy
Surgery
removal

RBCC/Sshape
thrombusoccludebv
VasoclusiveCrisisduetoDHN
AplasticCrisis(hemolyticanemia)
decRBC,WBC&platelets
Spleenicsequestrationcrisis
spleendestroysrbcrapidly

DecRBC,wbcand
platelet

RBCdestruction
Commoninblacks,Indians,Greeks,
Chinese&Italians

S/Sx:3Fs:
Fatigue,Fainting,
Forgetfulness

S/Sx:3Fs+
beefyred
Tongue
(glossitis)
Peripheral
neuritis

Pregnant
Breastfeeding
Infant
Adolescent
Alcoholic
Poorfeeding
practice
Overcookingof
veggie
S/Sx:3Fs
Withperipheral
neuritis

S/Sx:Fever,jointpain,
paralysis&weakness
CVA

S/Sx:3Fs,Inc
infection,Inc
bleeding

N.Dx:
ActivityIntolerance
Priority:
Bedrest,
supplementIron2
wks,
Incirondiet
organmeats,
Greenleafy
vegetables,dried
fruits
ReliefofFatigue
*Desferral
Antidote

Lab:schillings
test
N.Dx.Riskfor
injury
Priority:
Rest
B12supplement
*Absenceof
beefyred
tongue

Lab:FolicAcid
<4mg/dl
N.Dx:Fatigue
Injury
Priority:Rest
FAsupplement
GreenLeafy
veg
Spinach,
broccoli
HelpRBC
production

Labdata:
*Sickledextesttrait
*HgbelectrophoresisConfirmsthe
disease
N.Dx:ActivityIntolerance,Riskfor
injury,unilateralneglect
Priority:Painrelief&hydration
Bloodtransfusionreferto
geneticists

LabData:DecHgb,
wbc&platelet
N.Dx:Riskforinjury,
Infection,activity
intolerance
Priority:protectform
infection,CBR,BT

S/Sx:Dependsintypes
Mild:Mildanemia
Intermediate:Anemia,spleeno
megaly,hemosiderosis,
accumulationofironintissues
Major:severeanemiawith
hepatomegaly
LabData:DecHgb
N.Dx:ActivityIntolerance
Priority:Bedrest,steroids,
spleenectomy

30

TableA.1:AutosomalRecessive
Normal
A.1parentwithtrait
50%
B.2parentswithtrait
25%
C.1parentwithtraitthe
0%
Theotherwithdisease
D.Bothparentswithdisease )%

Trait
50&
50%
50%

Disease
0%
25%
50%

0%

100%

NeoplasticThrombocytopenia
PurpuraDecPlateletduetoviralinfectionautoimmunereactiondruguse
S/sx:Petechiae,ecchymosis,hematoma
LabData:Platelet<20,000,DecHgb
N.DX:Riskforinjury
Priority:Safety,preventbleeding
Supplementwithfolicacid
Bloodtransfusion
CHD
ACYANOTIC
(Lefttorightshunting)

CYANOTIC
(Righttoleftshunting)

Incpulmonarybloodflow

Obstructiveconditions

Decpulmonarybloodflow

Ventricularseptaldefect
Atrialseptaldefect
Patentductusarteriousus

Pulmonarystenosis
Aorticstenosis
Coarctationoftheaorta

TetralogyofFallot
Truncusarteriosus
Transpositionofgreatvessels
Tricuspidatresia
Hypoplasticleftheartsyndrome

Riskfactors:
Maternalinfection(14mos)
Age(>40)
MedicalCondition(DM)
Alcoholism
Browseating(feeding)duetoactivationofANS
Babysleepsafter3minutesofsucking
Difficultyinfeeding
Tachycardia
Tachypnea
FrequentURTI
HeartFailure
RetardedGrowth
SemiFowlers
Priority:providewarmth
Initial:Lsidedheartfailuredyspnea
&O2&surgery
Late:Rsidedheartfailure
<2y/o=O2
27y/o=Surgery>7=Surgeryassoonaspossible

Cyanotic(tetspell)
CVA
Ifwalkingsquat
Ifnotwalkingkneechest

31

RHEUMATICFEVER
Systemicinflammationofconnectivetissues(joints,CNS,heart)
RiskFactors:(conditions24weeksbeforediagnosis)
Sorethroat
Impetigo
ScarletFever
S/Sx:
Major:
Carditistachycardiaatrest
Arthritismigratory
SubQnodulespainless
EryythemaMarginatumrashes
ChoreaAbnormalmovement

Minor:
Fever
Murmur
Tachycardia

Lab:IncESR=Male(12mm/hr,Female20mm/hr),IncASItiter
N.Dx:Alteredtissueperfusion,DecCO,Pain
Diet:Incfluidintake,IncCHON
Meds:ASA,Penicillintopreventheartvalvulardamage
Complications:CardiacValvularDiseasestenosisandregurgitation
Stenosisnarrowing,fusionofleaflets
Regurgitataionincompleteclosure
STENOSIS
Mitral
Decpitch
Diastolicmurmur

REGURGITATION
Aortic
Highpitch
Systolicmurmur

Mitral
Highpitch
Systolicmurmur

Aortic
Blowingdiastolic
murmur

Treatment:
Antibiotics
Anticoagulants
PregnantClientsClassifications:
I

II

III

IV

NoLimitationofactivities

Symptomswithactivities
ofdailyliving

Symptomswithless
thanordinaryADLs

Symptomsevenat
rest

Fibrillation

PVC

Fibrillation

ExtraQRS

WidenedQRS

ARRYTHMIAS
=Abnormalcardiacrhythm
ATRIAL
Flutter

VENTRICULAR

SawtoothpatterPwaveP:QRSratio2:14:16:1
Quinidine
Defibrillation

Epinephrine
Defibrillation

Lidocaine
Defibrillation

32

CPR
CPR,Quinidine
QRS=<.10,2squares
PR=.12.20=35smallsquares

CPR

ABNORMALCARDIACRHYTM
HeartBlockPRinterval
PrimaryprolongedPRInterval
=Nointervention
SecondaryProgressivelyprolongedPRInterval
=AtropineSulfate
TertiaryP&Rwaveareindependentofeachother
=Pacemaker
=HR<5beatsbelowthelimit
=HiccupsFailure
=Belchingdecreasingheartrate
=Signsofshockweakpulse
=Stayawayfromelectromagneticfield
CAD
o
o
o
o

Narrowingandobstructionofcoronaryarteries
DecO2HypoxiaAngina
()O2Neurosis
RiskFactors:
CAD
Atherosclerosis
Smoking
ElevatedCholesterol
HPN
Obesity
Physicalinactivity
Stress

Angina

MI

StablePatternispredictable AnteriorWall
UnstablePatternisunpredictable
Variant(Printzmetal)Severeform PosteriorWall
Nocturnal__>@night
Decubituswhenlyingdown LateralWall
IntractableUnresponsivetotreatment
PostMIAfterMI
Pain
<20min
Uppersternum
Pressure
Relievedbyrest
Nitroglycerine

Precipitates:
Eating
Elimination
Extremetemp
Emotion
Effort

Pain
>20min
Lowersternum
Crushing,Excruciating
Notrelievedbyrest
Morphine(CheckRR)AntidoteNaloxone

AssociatedS/sx:
Agitation
Restlessness
Coldclammyskin

33

HPN

LabData:
Inccholesterol<200
ECGchanges

Inccardiacenzymes
IncSTsegment
IncESR

N.Dx:Pain
PositioninSemiFowlers
Administerdrugsasordered
Diet:
Cholesterolrestricteddiet
PercutaneousTransluminalCardioAngioplasty
=Doneif50%ofbloodsupplytoheartisimpended
=Insertionofaballoontippedcatheterballooningcardiacstent
CoronaryArteryBypassGraft
=Doneif50%ofbloodsupplytoheartisimpended
=Placinganewbloodvessel
HealthTeaching:
o Avoidstrenuousactivities
o Canresumesexualactivityifcanclimb23flights ofstairswithnodyspnea
o Providefrequentrestperiods
o DischargeInstructionsAvoidlifethreateningconditions
HEARTFAILURE
=Inabilityofthehearttopumpadequateamountofbloodtomeetthemetabolicdemandofthebody.
RiskFactors:
MI
Heartvalvulardisease
RHD
HPN
Arrhythmia
S/Sx:
Leftsided:
Dyspnea,pinksputum,productivecough,pulmonaryedema
Rightsided:
Distendedneckveins,ascites,ankleedema,hepatomegaly
LabData:
LeftcardiacfunctionSwanGanz
RightCardiacFunctionCVP
N.Dx:
AlteredtissueperfusionanddecCO
Priority:
ToIncCO
Positioninsemifowlers
AdministerdrugsasprescribedDigitalis,Vasodilators,Diuretics
*Morphinedecvenousreturntotheheartperipheralvasodilatingeffects
DietLowNa,LowCholesterol

34

Assessbreathsounds,edema,heartsounds
HYPERTENSION
=SilentKillerdisease
Hypertensivedisordersofpregnancy
=PersistentelevationofBPabove140/90
=120/80Prehypertensive
=110/70normal
RiskFactors:
FamilyHx
Age
Blacks
Obesity
Stress
Smoking
Types:
1.)EssentialUnknown
2.)BenignUnknown/Longduration
3.)MalignantAcute,shortduration
4.)Secondary?Duetomedicalcondition
Complications:
OccipitalHA
RetinalHemorrhage
PedalEdema

4commoncomplications:
CAD
CVA
CRF
CHF

Lab:Incincholesterol,IncLDL,IncTAG
N.Dx:AlteredhealthmaintenanceTxisprolonged
=Vasodilator,Antilipemicagents
*CommoncauseofconcernBronchospasm,Declibido
DietDecNa,Deccholesterol
NONPHARMACOLOGICREGIMEN
StressMx:Exercisedeepbreathing,walking,stressfreehobbies(likewalkingbythebay)
HPNinpregnancyUnknown
=GeneralizedvasospasmduetovirusH.Lualba
=2nd trimester
=B420wksAOGH.Mole/GTD
=after20wksAOGPIH
=Beforeandafterpregnancychronichypertension
HYPERTENSIVED/OOFPREGNANCY
o IncBP

35

PREECLAMPSIA
o IncBP
o Edema
o Proteinuria:
Mild:BP140/90
Protein<5gm/24hrs
Severe:BP160/110&above
Protein>5gm/24hrs
o Mx:Darkenedroom
IncCHONdiet
MgSO4:Antidote>CaGluconate
ECLAMPSIA
o IncBP
o Edema
o Proteinuria
o ConvulsionbleedingHELLPSyndrome(hemolysis,elevatedliverenzyme,lowplatelet manifestedwith
petechiae
PVD

ArterialOcclusion
Pallor
()orminimal
Thick&brittle
*IntermittentClaudication
()
Cold
Dry

Color
Edema
Nails
Pain
Pulse
Temperature
Ulcer

BUERGERS
(ThromboantgitisObliterans)
Acute
A&V
Male
Lowerex
Smoking
Inflammationofarteriesandveins

RAYNAUDS
DISEASE
Intermittent
arteries
Female
Upperex(97%)toes,ears,LE(3%)
Cold
Vasospasmofarteries

VenousOcclusion
Ruddy
Severe
Normal
Homanssign
Normal
Warm
Wet

ARTERIOSCLEROSIS
OBLITERANS
Chronic
arteries
Male
Upper&Lowerex
hardeningarteries

Pain
IntermittentClaudicationIntermittentcolorchanges
(Pallor,Cyanosis,Redness)
Labdata:PainlessDopplerUTZ
N.Dx:Pain&alteredtissueperfusion
Priority:AntiHPN,Vasodilator,Anticoagulants
Instructions:Avoidsmoking,swimmingincoldwater

36

PULMONARYEMBOLISM
Aclotlodgesinoneofthepulmonaryarteries
RiskFactors:
1.)
2.)
3.)
4.)

VATrauma
Hypercoagulation
Arrhythmia
Thombosis

S/Sx: Anxiety/Agitation
Dyspnea
Restlessness
Tachycardia
Tachypnea
ChestPain
*Crackles
LabData:PerfusionLungScan
N.Dx:Pain,Ineffectivebreathingpattern
Priority:PositioningRightsidelying
AdministerAnticoagulant
ABDOMINALAORTICANEURYSM
Weakeningofthewallsoftheaorta
Congenital
Angina
ChronicHPN
Types:
1.) Fusiformbulgingofbothsidesofbv
2.) DisectingDissectedinnerwallofbv
3.) Saccular formsapouchorsac
S/Sx:Assymptomatic
PulsatingAbdominalmass
LowBackPain
IncBPofUe,DecBPinLE
Labdata:Aortography,XRay
N.Dx:RiskPoorinjuryalteredtissueperfusion
SafetyMostAbdominalPalpation
Prepareptforsurgerythatwillinvolvegrafting
Aftersurgeryassessfordistalpulses
KAWASAKISDISEASE
Acutesystemicinflammationofthevascularsystem
Heart&bloodVessels
CommoninJapanese,toddler&preschooler
Unknown
S/Sx:Highspikingfeverfor5daysofmore
Strawberrutongue,palmardesquamation
LabData:2DEcho,ECG
N.Dx:Alteredtissueperfusion,DecCardiacoutput
Priority:Txissupportive,ASA
Diet:ClearLiquid
DischargeInfection:TeachPt.CPR
5:1Pedia
15:2Adult
30:2

37

1.ToAssessriskofdevelopingmitralvalvestenosisinpt.Whatshouldthenurseaskthept?
A:Didyouhavestreptococcalinfection
2.HowtoassessintermittentClaudication:
A:Askthepttowalkandnotepresenceofpain
3.WhatshouldthenurseprepareatbedsidewithPVC
A:Xylocaine
4.Priorityinptwithcompleteheartblock
A:Alteredtissueperfusion
5.GoalofCarewithatrialfibrillation
A:IncCO
6.Coomoncomplicationofsicklecellanemia?
A:CVA
7.Signsofleftsidedheartfailure
A:Dyspneaonexcretion
8.WhenplanninganexerciseprograminptwithHPN,Nurseshouldask?
A:Howdoyouspendyourleisuretime
CYSTICFIBROSIS
Inheritedmultisystemdiseaseaffectingtheexocrinegland
Autosomalrecessiveeachpregnancy(Disease25%,trait50%)
ExcessiveMucousproductionMade=Sterility,Female=Diff.inconcerning
S/Sx:Initial:Abdominaldistention
MalabsorptionSyndromeSteatorrheaFoulsmellingfatty,stool
Saltywhenkissed
Lab:PilocarpineSweattest
RespiratoryTherapy:BlowingExerciseTrumpetBlowingBubbles
GITherapy:PancreaticEnzymePancreasViokasewitheachmeal&snacks
Referptspreventsgeneticist
Pt.GrowsOB
PNEUMONIA
MycoplasmaPneumonia(pedia),Legionnairesdisease(elderly,alcoholic,immunosuppresion)
InflammationAllveoliExudate,Consolidation
Viral,Bacterial,Rickettsia
S/Sx:5Cardinalsigns&symptoms
1. Fever
2. Sputum
3. PleuriticChestPain
4. Chills
5. Cough

38

PNEUMONIA

Viral:

Lowgradefever
Thin&waterysputum
WBCeithernormalorslightlyincreased

Bacterial
Highgradefever
Rustysputum
WBCseverelyincreased
Labdata:ChestXray,sputumexam,ABGanalysis
N.Dx:ImpairedGasExchange
IneffectiveAirwayclearance
IneffectiveBreathingpattern
Priority:BedRest,IncOFI,Administermedsasordered:antibiotics
CROUP
ACUTELARYNGITIS

LTB

BRONCHIOLITIS

Toddler

Infant&toddler
Viral&Bacterial

Infant<6mos
(RSV)

Larynx

InflammationoftheLarynxandtrachea

Bronchioles

S/Sx:
Cough:Barking,metallic
Stridor:Present
Wheezing:Absent
Fever:Absent

Harsh&Brasky
Present
Absent
LowGrade

Paroxysmal&Hacking
Present
Present
Moderatetohighgrade

LabData:
ThroatSwab
PE
Xray

Xray
Throatswab
PE

Xray
ELISA
Throatswab
PE

N.Dx: Infection,Ineffectivebreathingpattern
Priority:Txofinfection
Multidrugtherapy
OPD(ObstructivePulmonaryDisease)
Narrowingandobstructionoftheairway
Emphysema
overdistendedalveoli

Bronchitis
inflammationofbronchioles

Asthma
excessivemucus

Smoking
RE,TACY,TACHYDC
BarrelChest

GelatinousSputum
Inccoughing

Whitishsputum
Orthopnea

39

LabData:Xray,ABGAnalysis
N.Dx:IneffectiveBreathingPattern
IneffectiveAirwayClearance
Orthopneic
SemiFowlers

Bronchodilators

Activity:Softball
Baseball

PrinciplesinNursingCare:
Bronchodilator
Rest
Oxygenlowflow
Nebulize
ChestPhysiotherapy
HighFowlers
IPPBIntermittentPositivePressureBreathing
Aerosol
LiberalFluidIntake

Aminophylline
Steroid
Theophylline
HistamineAntagonist
Mucolytic
Antabuse

Complication:
CorPulmonale
RightVentricularHypertrophy
Pneumothorax
Spontaneous

Open

Tension

Ruptured
Bullae/alveoli

Chestinjury

Trauma

Increasetensionandpressure
Thoraciccavity
Lungcollapse
()breathsounds
Dyspnea
Pain
3waybottlesys
PointersforRespiratory:
1.) MistPriority?
A:Changethelinenandclothingtokeeptheptdry.
2.) Goalofcareforchildwithbronchiolitis?
A:MinimizeO2expenditure
3.) Pancreaseisgivenwithmeal
4.) PatientwithTB WhatisthepurposeofNGT?
A:Toaspirateswallowedsputum
5.) S/Sxthatindicatesemphysema?
A:Barrelshapedchest
6.) DevelopmentofEdema?
A:Moistandnoisybreathing
7.) CommonriskfactorforLegionnairesdisease?
A:Immunosuppression
8.) MycoplasmalPneumoniaismanifestedby?
A:Fever&productivecough

40

PKU
o Inheriteddisordercharacterizedbyabsenceofphenylalaninehydroxylase(PH)whichconvertsphenylalanine
totyrosine(precursor) melaninforhair,eyes,skin
o Normallevel=2mg/dl,4mgmayindicatePKU,8mgconfirmsPKU
o Autosomalrecessive
o PhenylalaninistoxictothebrainandcausesMR
S/Sx:Asymptomaticatbirth:Diarrhea,Anorexia,Lethargy,Anemia,skinrashes
N.Dx:Knowledgedeficit
Alterednutrition
Riskforinjuryseizure
HealthTeachings:
LowPhenylalanineuptoadolescence910y/o
RefertoGeneticistsandnutritionist
Producelistoffoodsthatsisallowedandnotallowed

HASHIMOTODISEASE
o
o
o
o
o

CongenitaldeficiencyinT3andT4
S/sxAsymptomaticmaternalhormonaltransfer
23moss/sxappear
Behavioral:Apathy,wellbehavedbaby
Physical:Largetongue,shortstructure,retardedgrowthMR

Labdata:DecT3andT4
N.Dx: Knowledgedeficit
Riskforactivityintolerance
Alteredgrowth&development
Priority:AdministerSynthroid,singlemorningdoseforever
Report:Tachycardia(palpitations)
Insomnia
Nervousness
*Providewarmenvironment
*Refertospecialeducationcenter
PANCREAS
ALPHACELLS
Glucagon

BETACELLS
Insulin

MODY
(MaturityonsetDiabetesinyoungadults)
CombinationofIDDM&NIDDM
Pregnancy2nd trimester
DevelopedplacentasecretesHPL
(Humanplacentallactogelcounteracts
insulin

Absence
IDDM(TypeI)
Juvenileonset
Ketosisprone
Thin

Deficiency
NIDDM(TypeII)
Maturityonsetafter35
NonKetosisform
Obese

Gestational:(Whitesclassification)
Types:
A:ChemicalDM:
B:onset:>20y/o
C:1019y/o

41

D:<10y/o
D1:<10y/o
D2:>20y/o
D3:Beginningretinopathy
D4:Hardeningarteries
D5:HPN
E:Pelvicarteries
F:Retinopathy
H:Cardiopathy
R:Retinopathy
T:Transplantkidney
Absenceordeficiencyininsulinaffects,CHO,Fats&CHONmetabolism
Insulinfacilitatesentryofglucoseintothecell
Ifthereisnoinsulinglucoseremainsoutsidethecellhyperglycemiafluidsareattractedtocell&blood
Cellsdehydrated(brain)compensatorymechanismPolydipsia
Cellsdehydrated(brain)IncglomerularfiltrationratePolyuria leadstoweightlosscellstonesbrain
polyphagia
LabData:FBS,GlycosylatedHgb,Hemoglucotest
N.Dx: Knowledgedeficit
AlteredNutrition
AlteredElimination
RiskforInfection
Priority:Tomaintainnormalbloodsugar
Diet:5070%CHO,2030%Fats,1020%CHON
Wellbalanceddiet
Insulin:TypeI,pregnant2nd trimesterIncdose
AntiDiabeticAgentssulfonylreasCI>sulfaDrugs
Bloodsugaramandpm
EnsureAdequatefoodintake
Transplantofpancreaticcells
ExerciseModerate
ScrupulousFootcareAvoidbarefoot,avoidsyntheticshoesIndicated:Footpowder,snugglyfittingshoes,cotton
socks,visitpodiatristatleastonceayear
Complications:
Hypoglycemia:BloodSugar<150mg/dl
RF:toomuchinsulin,missedmeal,exercise
S/Sx:
Diaphoresis
DecreasedLOC
Diffinproblemsolving

Tx:Simplesugar

Hyperglycemia:Bloodsugar>140mg/dl
RF:Toolittleinsulin,Incfoodintake,pregnancy,
Infection,stress,surgery
TypeI
typeII
DKA
HHNK
Acetonebreath
IncGIs/sx
DeH2O
DeH2O
Warmskin
IncserumOsmolality
3Ps
3Ps
Kussmaulsbreathing
TX:Airway,FluidandInsulinrapidactinginsulin

OtherComplications:
1.) Microangiographydamagetosmallretinalbloodvessels
2.) AtherosclerosishardeningofarteriesHPN
3.) NeuropathyKidneydamage
4.) RetinopathyOpthalmopathydamagetonerves
5.) Peripheral/AutonomicDecnerveimpulsetransmission

42

PITUITARYGLAND
ADH
FluidRetention

RiskFactor
S/sx:
LabData:

Deficiency
DiabetesInsipidus

Exercise
SIADH

Trauma
Surgery
Polyuria(21L/day)
Polydipsia

Trauma
Tumor

Fluiddeprivationtest
NPOX12hrs
Concentratedurine
SpecificGravity:<1.005

Vasopressin
Depressin
Lepressin

CheckspecificGravity

Monitorandoutputandspecificgravityofurine
Goalofcare:ExcretionoffluidDiureticsandantiHPN

Fluidretention
DilutionalHyponatremia
CheckSodium

GrowthHormone
Ant.PituitaryGland
Promotesgrowth
Deficiency
DwarfismMahal
AchondroplasiaNanusSyndromeDagul

Excess
*BeforeclosureofgrowthplateGigantismTaller,slender
MarfansSyndromeGeneticd/o,a.Dominantspined/o
ScoliosisCardiacproblem
*AfterclosureofgrowthplateAcromegallyenlargementof
Extremities
*Incgrowthhormoneandglucose
ADRENAL

Outer
Cortex
Glucocorticoids
Gluconeogenesis
Def.
Addisons

Middle
Medulla
Mineralocorticoids
Naretention
Excess
Cushings

Excess
Conns Syndrome
Commonssyndrome
Aldosteronism

Epinephrine
Norepinephrine
fight/flightresponse
Tumor
Pheochromocytomaexcessepiand
norepinephrine
HPN,H/A
Inchyperglycemia
Hypermetabolism

LabData:IncVMA27mg/dlin24hrs
Avoidvanillacontainingfoods,14hrsbeforethetest

43

ADDISONS
Deficiency
Glucocorticoids Mineralocoticoids
RF:Autoimmune
Surgery

Glucocorticoids

S/Sx: Hypoglycemia
Hyponatremia
Hyperkalemia
Hypotensionshocklike
Brownskinpigmentation
TruncalObesity
Moodswings
Facialhirsutism
Buffalohump
MoonFacie

CUSHINGS

CONNS

Excess
Mineralocoticoids
Tumor

Excess
Mineralocoticoids
tumor

Hyperglycemia
Hypernatremia
Hypertension

Hypertesnsion
Hypernatremia
Hypertension

TruncalObesity
Moodswings
Facialhirsutism
Buffalohump
MoonFacie

TruncalObesity
Moodswings
Facialhirsutism
Buffalohump
MoonFacie

MaintainFluidandelectrolyteBalance
Steroids
steroidsinhibitor
*FludrocotisoneFlorinef
Mitotaine
Decs/sx:
NormalNaandbloodsugar
Diet: IncNa,DecK
DecNa,IncK
ClientTeachings:
Medsforlife
Pronetoosteoporosis
Avoidcrowdedareas
Excessivepoorwoundhealing

incNa&decK,IncBP
AntiHPN
Diuretics
DecNa,IncK

THYROID
T3,T4
BMR

CALCITONIN
DepositionofCainthebones

Deficiency

Excess

Hypothyroidism
Cretinism
Myxedema

Hyperthyroidism
Gravesdisease
Basedowsdisease
Parrysdisease

RF:Autoimmune,tumor
S/Sx:
Facialedema
Intolerancetocold
Hypometabolism
LabData:
DecT3,T4,IncTSH
Activityintolerance
UthyroidstateNormal
Givethyroidsupplement
Synthroid
SE:
Insomnia
Nervousness
Palpitation

Exopthalmos
Goiter
Hypermetabolism
Intolerancetocold
IncT3,T4,DecTSH
Riskforinjury
Uthyroidstate
Antithyroiddrugs
Propylthiouracil
Agranulocytosis(Fever,Soarthroat)

44

Diet:
DecCalories
Warmenvironment

IncCalories
Coldenvironment

THYROIDSURGERY
Preparation

Postoperative

Lugolssolution(2wksbeforesurgery)
Decsize&vascularityofthyroidgland
Giveinstrawanddilutedinwaterorapplejuice
S/sxofiodismMetallictaste

Monitorcomplication
1.Hemmorrhagebruises
2.Laryngospasmtracheostomy
3.Damagetolaryngealinabilitytospeak,aphonia
4.TetanyDecinCa>Tingling,chvostek,Trouseausign
5.Thyroidcrisis
Complications:Fever,IncHR,checkVS

PARATHYROID
IncCaintheblood
Hypothyroidism

Hyperthyroidism

Surgery

Tumor

S/Sx
Early:Tingling,chvostek,Trouseausign

Pain,bonedestruction,fracture/osteoporosis
VonRecklinghausendisease

N.Dx:
Riskforinjury
GiveCasupplements
IncCaindiet

Renalcalculiformation
LabData:IncCainblood
N.Dx:Riskforinjury
Priority:Surgery
Mx:IncOFI

Pointers:
1.ManifestationsofKetoacidosis:
A:Rapidanddeepbreathing
2.PostthyroidectomyTetanyofhands,feetandmuscletwitching,thenurseknowsthedoctorwouldorder?
A:CaGluconate
3.W/coftheff.indicateshypothyroidism?
A:Intolerancetocold
4.InPKU,whichisnotindicated?
A:MilkShake
5.Whichoftheff.manifestationindicatesacomplicationpostthyroidectomy?
A:Tachycardia
6.Whichoftheff.interventionsisappropriateforaptwithAddisonsdisease?
A:MonitortheBP
7.Insulinwasgivenat8am,whendoyouexpecthypoglycemia?
A:Beforelunch
8.InPTUanexpectedoutcomeisa?
A:DecinPR
9.Hypothyroidism bestquestion?
A:Doyoutire?
10.Whichoftheff.dataneedstobeassuredinheadinjury?
A:DecurinespecificGravity

45

NEPHROTICSYNDROME
Congenital
Autoimmune

ACUTEGLOMERULONEPHRITIS
Acquiredsorethroat
Autoimmune

Inabilityofthekidneystomaintainfluidbalance
*hyponatremia

Kidneydamage

S/Sx:
NormalordecinBP
PeripheralEdemasubsidesattheendoftheday
Frothyurinecolor

IncBP
Progressiveperipheraledemaattheendoftheday
teacoloredurine/cola

LabData:
MostsignificantdataProteinuria=>10mg/24hrs
Proteinuria=<10mg/24hrs
()Colloidosmoticpressureedema
IncASOT
N.Dx:
FluidVolumeexcess
Riskforimpairedskinintegrity
Mx:
Goalofcarepromotefluidbalance
Restrictedfluid
Frequentlyturnclient
Steroids
AGN:AntiHPN
DecNa,IncCHON
DecNa,DecCHON

WILMSTUMOR
Congenitaltumorofkidneys
unilateralleftkidney
palpableonabdomen
commoninchildren<5y/o
(+)HPN,Hematuria
Riskforinjury
PromoteSafety
Prepareptforsurgery&chemotherapy
Avoidabdominalpalpation
CYSTITIS
Ascendinginfection
BladderUretersKidneyspyelonephritisCVAtendency
RF:
bubblebath
Silkunderwear
Prolongeddriving
Catheterization
S/Sx:
Burningsensation
LabData:
Urinalysis
IncWBC
Incglucose
Tx:
Treatinfection
antibiotics
Acidashdiet
IncOFI
Avoidriskfactors

46

RENALFAILURE
ACUTE

CHRONIC

Suddencessationofkidneyfunction
RF:
Pre
Renal
Deccirculationof
Bloodvolume
S/sx
Oliguric
Phase
Decurineoutput
<400ml

Progressive/irreversibledestructionofkidneytissues
Scarformation

Intra
Renal
diseaseofkidney

Post
Renal
obstruction
stone

AGN,NS

Diuretic
Phase

Recovery
Phase

polyuria,decNa&K

12yrs

1.Decrenalreservepolyuria,nocturia,polydipsia
2.RenalinsufficiencyIncBUN&creatinine
3.RenalFailureHPN,RenalDamage
4.ESRDAzotemia,uremia
LabData:
IncBUN&Crea

N.Dx:
Fluid&electrolyteimbalance
Priority:Restorecirculatingfluids
Monitorintakeandoutput
Responseofclientontherapyoutput,BP
Meds:Diuretics,DecNadiet,AntiHPN,digoxin

N.Dx:
Fluid&electrolyteimbalance
Priority:Fluidrestrictions
Meds:Epogentopreventanemia
Amphogelpreventhyperphosphatemia
Diuretics,AntiHPN,Digitalis
Diet:DecChon
Mx:Dialysis:3Xaweekorevery48hours

DIALYSIS
Hemodialysis
DialyzingagentDialyzingMachine
Access
Fistula
shunt
internalaccess
externalaccess
anastomisisofa&v
palpateforthrillsandauscultatebruit

Peritoneal
DialyzingagentPeritoneum
Access
Tenkhoffcatheter
assessrigidabdomenperitonitis

Complications
Disequilibrium

DialysisEncephalopathy

Rapidremovalofwasteproduct
Fluidsandelectrolytes
GI
CNS
NAVDA
H/A
Dizziness
Restlessness
ReporttoMD

Aluminumtoxicity
S/Sx:dementia,dizziness
ReporttoMD

47

BPH
Glandularenlargementoftheprostate
Afterage40,male
S/Sx: Decsize&forceofurinarystream
Nocturia
Dysuria
Frequency,urgency,hesitancy
LabData:
DRE@age40
Priority:PromoteUrinaryeliminationPrepareforsurgery
TURPnoincision
Suprapubic
Retropubic
abovethebladder
belowthebladder

Perineal
causesimpotence

Pointers
1.Anelderlywitholiguriaandflankpainmayindicateaproblemscausedby?
A:Intakeofneomycin
2.Whichlaboratorydataneedstobereported?
A:urinespecificgravityof1.004
3.12hrsafterTURPtheptcomplainsofspasm
A:Checkpatencyofretentioncatheter.
4.A2y/oboywithNephroticSyndromewithperiorbitaledema&frontaledemawhatwillbetheessentialnursing
measure:A:turnptfrequently
5.Whichoftheffisacommoncomplicationofchronicrenalfailure?
A:Anemia
6.AptwithNephroticSyndromeasksWhyamIgainingweight?thebestreponseis?
A:youhavesodiumretentionthatattractswater
7.Duringhemolysis,ptwithHAandvomiting,restlessandconfused,heishaving?
A:Disequilibriumsyndrome
8.Afterperitonealdialysisthereturnflowwithdialyzatesolutionisinadequate,Whatshouldthenursedo?
A:Turnptfromsidetoside.
9.APriorityN.dxtoaptwithrenalstones?
A:Pain

OTITISMEDIA
Infection ofmiddleear
URTI
Faultyfeeding
swimmingindirtywaters
Pain,fever,earache
LabData:PE,otoscope,bulgingtympanicmembrane
N.Dx:Painantibiotic,decongestant,Pseudafed
Chronic:myringotomytubeinsertion
RETINALDETECHMENT
o Separation
o Sensorypigmentretina
o Aging40y/o
o Trauma
o S/sx:visualfloaterspainless
Cobwebs,veillike,floatingspots
o LabData:Opthalmoscopy,PE
o N.Dx:Riskforinjury
o Priority:Safety,bedrest,affectedsidetowardsthebed
o Scleralbucklingusinglasertocreateascar
o Avoidsuddenheadmovement,bendingandblowingofnose
o Surgery:

48

Trabeculoplastytrabecularmeshworklaseroutpt
Ttrabeculectomytrabecularmeshworkremovalinptfor12days
o Avoidbendingandsuddeneyemovement
o Report:eyepainandbleeding
GLAUCOMA
o IncIOP
o OpenAngle:ChronicIncaqueoushumor
o ClosedAngle:Acute forwarddisplacementofiris
o Aging>40y/o
o Familial
o tunnelvision
o Gunbarrelvision
o halosaroundlights
o Lossofperipheralvision
o Blindness
o LabData:Tonometry,(gonioscopydifferentiateopenfromclosedangleglaucoma),perimetry>visualfields
o N.Dx:riskforinjury,safety,decIOP
o Meds:Myoticspilocarpine
o CI:Midriatics
CATARACT
o Opacityoflenses
o Poorcolorperception
o Painless
o Aging>40y/o
o Prolongedsteroids
o LabData:Opthalmoscopy()redlightreflex
o N.Dx:Riskforinjury
o Surgery:
Peripheraliridectomy holeinlenscataractissuctioned
Photoemulsificationneedlelikestructureinsertedintothelens>crushcataract
o Avoidbendingandsuddeneyemovement
o Report:eyepainandbleeding
MENIERESDISEASE
Imbalanceintheendolymphaticfluids
innerear
RF:
Highaltitudes(pilotsanddivers)
s/sx:
Hearingloss
Tinnitus
Vertigorevolvingmotion
LabData:
Caloricstimulationtest
N.Dx:
Riskforinjury
Intervention:
Safety
Positionsupineorflat
Diet:LowNa
CI:Streptomycinototoxic
Meds:DIAMOX

OTOSCLEROSIS
Hardeningofthebonesintheinnerear
affectedstapes
Aging
diffincommunicating
tinnitus
conductivehearingloss
WeberandRhinestest
Impairedcommunication
establishcommunication
stapedectomymobilizestapes
postsurgery:avoidblowingofnose
avoiddeepdiving
avoidflyinginsmallairplanes

Pointers:
1.Posttrabeculoplastyeyepain.

49

A:CallMD
2.Ptwithtunnelvision,N.Dx?
A:Incriskforinjury
3.Whichdrugwillhelpdecaqueoushumor?
A:DIAMOX
4.PostCataractextraction,whatistheposition?
A:Onunaffectedsidetodecedema
5.Whichinterventionwillhelppreventlossofvisioninglaucoma?
A:Takingthemedscorrectlyasordered
6.Whichdescribestrabeculoplasty?
A:Surgicalinterventionthataimstocreateapassagewayfortheblockedfluid.

DUCHENNESMUSCULARDYSTROPHY

ERBDUCHENNEPARALYSIS

geneticallytransmitted
Xlinkedrecessive(mothertoson50%disease,
Mothertodaughter25%trait)
S/sx:
Gowerssignarmsusedtopushbodytostandup
Waddlinggait
Difficultyinrunningandclimbing1to2
Progressiveweaknessrespiratoryparalysis
LabData:EMG,PE
N.Dx:Ineffectivebreathingpattern
Impairedphysicalmobility
Preparetracheostomyset
Referparentstogeneticists
refertoPT
Treatsymptoms

acquired
Birthtrauma(hyperextensionofshoulder)
BrachialPlexusupperplexus
Reversible,recoveryafter3mos
Klumpkesparalysislowerplexus

CEREBRALPALSY
nonprogressive(fixed)d/o
neuromuscularsystem
uncoordinatedmovements
relatedtobrainanoxiaandprolongedlabor
S/sx:
Exaggeratedreflexes
Earlypatternofhanddominance1012months
poorposture
Archingofback
Frequenttonguethrusting
scissorgait
LabData:
CTScan
Musclebiopsy
N.Dx:
Riskforinjury
ImprovedPhysicalintegrity
Alterednutrition
Priority:PromoteSafety&mobility
Assistambulation
Support:crutches,cane,walker,legbraces
Drugsmusclerelaxants,anticonvulsants
SurgeryreleaseoftendonofAchilles
Foodsthatsticksonspoon

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CSFFLOW
rd
th
LateralVentricles ForamenofMonroe3 VentricleAqueductofSylviusForamenofLushka&Magendie4
VentricleSubarachnoidspaces
HYDROCEPHALUS
InterruptionofCSFflow
Notadisease
Manifestationd/o
ArnoldChiariMalformationElongationofbrainstemObstructstheflowofCSF
DandyWalker atresianarrowingofforamenofLushka&MagendieCSFflow
Excessiveproduction(communicating)orobstructionofCSF(noncommunicating)
S/Sx:Projectilevomiting,irritability,enlargedhead(Normal3335cm),Sunseteyes,separationofsutures,seizure)
Bossingsignpronouncedforehead
Macewenssigncrackedpotpercussionofhead
Labdata:CTScan,MRI
N.Dx:Riskforinjury
Priority:Safety,Seizureprecaution
Meds:Anticonvulsants
Position:SemiFowlers
Lowfowlers
Surgery:Insertionofventriculoperitonealshunt
CheckIncinICP
Measureheadfrequently
SPINABIFIDA
Failureofspinalprocessestofuse
neuraltubedefects
Occulta:Dimpling,tuffofhair,lumbosacralarea
Cystica:MeningocelCSF&meniges,MyelomeningoceleCSF,meninges,spinalcord
LabData:PE,MRI
AlphaFetoCHONanalysisIncreased
Normal1530
N.Dx:Riskforinfection,Impairedmobility
Sidelyingorpronebestposition
Coverwithwetsterilegauze
Surgerywithin48hrspreventparalysisofLE
Aftersacisclosedmayleadtohydrocephalus
Tapemeasure@bedsidetomeasurehead

IncreaseICP
ICPmorethan15mmHg
Normal010
1120 mild
2130 moderate
31andabovesevere
Maybeduetotrauma
Spaceoccupyinglesion
Acongenitaldefect
S/Sx:
Early:DecreasingLOC
Late:VSchanges,Cushingstriad,widenedPP,DecPR,DecRR
LabData:Subdural/intravascularmonitoring
N.Dx:Riskforinjury

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Priority:Safety,headofbedelevated,evaluateLOC,promoteapatentairway
Dischargeinstutions:meds,mitoring,seizureprecaution
BACTERIALMENIGITIS
Infectionsinflammationwithmenigitis
N.Menigitides
InfluenzeVirus
HIBVaccine
S/Sx:IncICP,Brudzinskissign,Kernigssign
LabData:CSF,DecSugar,IncWBC,IncProtein
NDx:Riskforinjury,Riskforinjection
Meds:Antibioticsasprescribed
Precaution:RespiratoryDroplet
Complication:HearingImpairment
AudiologistScreeningandtesting
REYESSYNDROME
Toxic
Encephalopathy&Hepatopathy
Fattyinfiltration
CNSandLiver
V.VaxrelatedtoReyes
TriadSymptoms:Fever,DecLOC,Bleedingtendencies
Stages:
1.) Stage1=Confused
2.) Stage2=Lehargic
3.) Stage3=Decorticate
4.) Stage4=Decerebrate
5.) Stage5=Comma
Diagnostic:Biliaryfxntest,bleedingtime,clottingtime,NeuroassessmentGCS
NDx:Riskforinjury
Priority:Safety
Bleedingprecaution,clottingtime,NeuroassessmentGCS
Vivax(+)chickenpoxReyes
SEIZURE
Abnormaldischargeofelectricalimpulseinthebrain
RF:
Metabolicd/oDelirium
Alcoholismwithdrawalsymptoms
Intakeofdrugs&trauma
S/Sx:
Types
1.) Absence/petitmalbriefperiodsofnonactivity
2.) JacksonianStartsonbodypartstowholebody
3.) GrandmalTonic:gen.contractions,Clonic:alternatingcontraction&relaxation
S/Sx:Dura feelingofuneasinessbeforeseizureandLOCandconvulsion.
N.Dx:IneffectiveAirwayClearance
Riskforinjury
Smalpillowatthebackofheadorlap
Meds:Anticonvulsants,Dilantin
RefertoNeorologist
Subs.Abusescreening
EEG,MRI,CTScan
Precaution:Avoidextremes
Avoidemotionalstress
Lifetimeanticonvulsants

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CVA
SuddencessationofbrainfunctionsduetodecO2
RF:Thrombosis,embolism,hemorrhage&infarction
Progression:
1.) TIAbriefneurologicdeficits30secs24hrs
2.) Strokeinevolutionbodyweakness/facialweakness
3.) Completedstroke
FrontalLobepersonality,speechchangesBrocasaphasia
ExpressiveAphasiaInabilitytosaytherightwords
TemporalMemory,WernickesAphasiaInabilitytocomprehend
ParietalLobesensation&orientation
OccipitalVisualdisturbance
S/Sx:IndicativeofComplication
HemiplegiaParalysisofrightorleftsideofbody
HomonymousHemianopsia
EmotionalLabilityMoodswings
AphasiaExpressiveandreceptive
DysphagiaSwallowfoodatleasttwice
C4C5deccusationofspinalcord
RightlesionLefteye,rightface,Leftbodyaffectation
UnilateralNeglect
LabData:InccholesterolNormal200
EEG,MRI,CTscan
N.Dx:Ineffectivebreathingpattern
Headofbedelevated
RefertoPT&OT
Diet:LowNa,LowFat
Meds:Anticonvulsants,vasodilator,diuretics

53

NEUROMUSCULARDISEASE

GBS

MG

MS

ALS(LouGehrig)

PNS

NMJ

CNS

Upper&LowerMotorNeuron

Inflammation&destructionofPNS
Autoimmune viralinfection
Nogenderrelatedfactors

Autoimmune(early male2040
y/o,latefemale>50y/o)
Deficiencyinacetylcholinereceptor
sites
descendingmuscleweakness
fromfacedownward

Whites/females
DemyelinationofneuronsinCNS
BrainandSpinalCord

Autosomaldominant
Male&Female

S/Sx:
Ascendingordescendingmuscle
paralysis
Mixture
RespiratoryDepression
Lab.CSFAnalysisIncCHON
N.Dx:
Ineffectivebreathingpattern
Priority:
Promotepatentairway

Preparetracheotomyset@bedside
steroids
RefertoRespiratoryTherapist

Ptosis
Difficultyinchewing
Decreasevoice

Diplopia
Ptosis
Impairedsensation
Impairedsexualfunction
Generalmuscleparalysis
CI:Talkinglongrespiratory
Lab:MRI,localizesareasofplaque
depression
formation
Diagnostic:
N.Dx:
Tensilonshort30secslastsfor5 Ineffectivebreathingpattern
mins
Sensoryperceptualalteration
Drugs:
Priority:
NeostigminelifetimeAntidote Maintainpatentairway
ATSO4
Meds:
steroids
Musclerelaxants
Bladderstimulant
Complications:
Avoidhotorcoldshower
Crisis
Assistdietinambulation
Myesthenic:DecMeds
*Bladderretrainingprogramself
Neostigmine
catheterization
Cholinergic:IncMedsATSO4
Handwashingtoprevent
ascendinginfection
RefertoPT&OT

Dysphagia

Lab:EMG,CTScan,MRI
N.Dx:
Ineffectivebreathingpattern
Priority:
Airway
Preparetracheostomyset

Supportiveandpreventive
Advancedirective&livingwill

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