ex: 5:00am+ 12= 1700 PM

Pharmacology
Drugs and their antidotes
1. acetaminophen (Tylenol)- acetylcycteine
2. benzodiazepine - flumazenil
3. coumadin - vitamin k
4. Heparin- Protamin Sulfate
5. cyanide poisoning - methylene blue
6. digitalis - digibind
7. ethylene poisoning - antizol
8. Curare - tensilon
9. iron - desferal
10. lead - edetate disodium (edta), dimercaprol (bal), succimer (chemet)
11. lovenox - protamin sulfate
12. magnesium sulfate - calcium gluconate
13. morphine sulfate (opiod) – IV Naloxone hydrochloride
• Opiod toxicity s/sy:
• Respiratory depression
• Small (constricted) pupils
• Slowed breathing
• Absent breathing
• Extreme fatigue
• Changes in heart rate
• ↓ BP, ↓pulse, ↓ RR
14. methotrexate - leucovorine
15. mestinon - atropine sulfate
16. neostigmine - pralidoxime chloride (pam)
17. penicillin - epinephrine

Alcohol Antagonist
Antabuse (Disulfiram)
Use: Used as part of a treatment plan for problem drinking. Creates an unpleasant reaction
when drinking alcohol, which reduces the desire to drink. Take at night.
Contraindication: Potential contact with alcohol by both inhalation of paint or wood stain fumes
as well as by skin contact with these substances; any contact with any amount or any form of
alcohol will cause an alcohol- Disulfiram reaction, which is extremely uncomfortable and may
even lead to shock and cardiac arrhythmias.
S/SY
If you drink alcohol while on this drug, you will experience uncomfortable symptoms such as:
 Severe nausea & vomiting
 Severe Head-aches
 Body-face flushing
 Blurred vision
 Sweating
** Chronic alcohol abuse is the most common cause of hypomagnesia (<1.5); which may result
in cardiac arrest.
o Manifestation includes: increased neuromuscular irritability, tremors, tetany, and
seizures.

 Alcohol withdrawal symptoms: Restlessness, irritable, agitated, Tremors, elevated

temperature, nocturnal leg cramps, complaints of pain symptoms, fever, ↑HR ↑pulse,
delusions and hallucinations.

Early symptoms: tremors, elevated ↑pulse, hyper-alert, startled easily, anxiety,

anorexia; signs begin a few hrs after reduction of alcohol intake and peak 24-48 hrs.
 Chlordiazepoxide (Librium)-
USE: Treats anxiety, symptoms of alcohol withdrawal, and tremor
 Cocaine withdrawal = sever cravings, depression , hypersomnia, fatigue
o S/Sy of use: insomnia, rhinorrhea, facial pain

 Heroin (NARCOTIC) withdrawal = Runny nose, yawning , fever, muscle & joint pain,
diarrhea, tremors (remember flu like symptoms)

o Heroin overdose: No breathing, Shallow breathing, slow or difficulty breathing, small

pupils, dry mouth, tongue discoloration, low BP, weak pulse, bluish- colored lips and
nails.
o Narcan (naloxone)- given as the antidote; client will experience: Nausea, vomiting,
restlessness, abdominal cramping (Opioid w/d symptoms).

 Barbiturate withdrawal- N/V, tachycardia, coarse tremors, seizures

 Opioid withdrawal- Nausea, vomiting, restlessness, abdominal cramping.

 Cannabis derivatives withdrawal: insomnia, hyperactivity, decreased appetite

 Amphetamine withdrawal- – depression, disturbed sleep, restlessness, disorientation

 Narcotics Depressants Stimulants Hallucinogens
Heroine Alcohol Cocaine Marijuana
Morphine Alprazolam Amphetamine LSD
Codeine Diazepam Crystal Meth LSA
Dihydrocodeine Clonazepam Crank Psilocybin
Tramadol Nitrazepam Methamphetamine Mescaline
Buprenonorphine Flunitrazepam Methylphenidate DMT
Hydrocodone Temazepam Ephedrine AMT
Hydromorphone Barbiturates Caffeine Ketamine
Oxycodone (Seconal, Butalbital) Nicotine PCP
Oxymorphone GHB Cathinone 2C-B
Methadone Alcohol 4_methylaminorex 2C-T-7
Methaqualone 2C-(anything)
Carisoprodol MDMA
Cyclobenzaprine DOM
TMA-2
TMT: symtoms of w/d
subside w/ decreased
stimuli

Narcotics
Narcotic withdrawal symptoms: flulike symptoms, night sweats, elevated temperature,
decreased deep tendon reflexes.
Heroin

Anxiolytics
Benzodiazepine anxiolytics:
 Diazepam (Valium)
USE: can be given to stop seizures
 Alprazolam (Xanax)
 Lorazepam (Ativan)
 chlordiazepoxide (Librium)-
USE: Treats anxiety, symptoms of alcohol withdrawal, and tremor.
SE: blurred vision, drowsiness, constipation, slurred speech, anorexia, dermitis,
pancytopenia, thrombocytopenia
Interventions: Give after meals or with milk to decrease GI irritation.

 Buspirone (BuSpar): Used for treatment of general anxiety disorder (GAD)

Action: Binds to serotonin and dopamine receptors

Anti-Depressants
Monoamine Oxidase inhibitors (MAOI’s)
(eg. Phenelzine Sulfate (Nardil) , MARPLAN, & PARNATE & ELEVIL (Amitriptyline)
USE: Best for depression associated with acute anxiety attacks, phobic attacks, or many physical
complaints.
SE: Hypertensive crisis resulting from intake of dietary tyramine. (H/A, nausea, increased HR &
BP)
MAOI Teaching
 Avoid Tyramine containing foods: aged cheese, red wine, chocolate, beer,
processed meat, soy sauce, coffee, Dried fruits (figs, raisins, dates), bananas, avocados,
and yogurt.
 Watch BP if pt cheats on diet for HTN crisis
 Should be discontinued 2 weeks before surgery

MOOD-Stabilizers
Lithium carbonate (Eskalith):
Lithium is an anti-manic used to treat bipolar disorder, mild thirst is an expected side effect,
other side effects include fine hand tremor, polyuria, metallic taste, & weight gain (about 20lbs).

Early signs of toxicity: Nausea/Vomiting, slurred speech, & muscle weakness/twitching

Advanced signs of toxicity: Coarse hand tremors, diarrhea, persistent GI upset, slurred speech,
mental confusion, incoordination, Ataxia (uncoordinated walking) (severe toxicity).
NURSING IMPLICATIONS OF LITHIUM
 Administer with meals
 SERUM LITHIUM LEVELS AT LEAST TWICE WEEKLY – THEN MONTHLY
 THERAPEUTIC LEVELS - 0.5 – 1.5 mEq/L
 Lithium Toxicity: greater than >2.0 mEq/L
 Maintain an adequate intake of sodium –excretion of lithium depends on normal lithium
levels

**With hold medication and obtain blood lithium level.

**MAINTAIN NORMAL SODIUM INTAKE

Anti-Psychotic
- Initial treatment for crisis; Eg. Olanzapine (zyprexa)
Haloperidol (Haldol)
Use: Typical- Treats mental illness (such as schizophrenia), behavior problems, agitation, and
symptoms of Tourette's syndrome.
SE: hematologic problems, primarily blood dyscrasia, and EPs symptoms, Galactorreah
(spontaneous flow of milk), gynecomastia (growth of male mammory glands).
o Monitor VS ever 30 mins. – This med lowers BP and causes postural hypotension

Anti-consultants
(eg. Phenytoin (Dilantin))
USE: Treatment of tonic-clonic seizures, status epilepticus, and treatment of seizures after
neurosurgery
Adverse effects: Nystagmus (involuntary eye movement), dysarthria, slurred speech, ataxia, Gingival
hyperplasia, bone marrow suppression, hirsutism (hairy).
o May make urine pink, red or red-brown

Interventions
 Do not administer with Milk
 If given in suspension; DO NOT SHAKE the bottle
  Monitor phenytoin toxicity level
 THERAPEUTIC level: 10-20 g/ml
 Phenytoin Toxicity: greater than >30 mcg/mL
 Toxicity effects: Nystagmus (involuntary eye movement), ataxia, slurred speech

 can cause folate and Vitamin D deficiencies. Folate deficiencies can cause anemia, symptoms
reflective of these nutritional deficiencies; good sources of folate are green leafy vegetables
(kale), legumes, tomatoes and various fruits such are oranges and cantaloupe; good sources of
vitamin D include milk.
S/SY of Anemia
 Shortness of breath
 Breathlessness
 Fatigue/ weakness

S/SY vit D deficiency

 Muscle weakness
 Bone pain
 Tiredness

Phenobarbital (Luminal)
USE: long term treatment of tonic-clonic seizures, simple partial, febrile seizures; used as a
emergency control status epilepticus (IV form) .
Adverse effects: drowsiness, deep coma, hypotension, respiratory depression, and nightmares.

Carbamazepine (Tegretol)
USE: Treats partial seizures, Tonic-clonic seizure; treatment of trigeminal neuralgia,
bipolar disorder
Contraindications: interferes with the action of hormonal contraceptives; client should
use another form of birth control. Wear sunscreen can cause (photosensitivity)

Valproic acid (Depakote)

Therapeutic levels 50-100 mcg .Toxicity s/s include chills, fevers, abdominal pains, s/s of liver
disease

Biguanide Oral Hypoglycemic

Metformin (glucophage)
Treats type 2 diabetes.
SE: metallic taste, abdominal cramps,
Interventions: take with food

Cardiac Glycoside
LANOXIN (digoxin) Digitalis
Use: Treats certain heart rhythm problems (atrial fibrillation). Also used to treat heart failure,
usually in combination with a diuretic (water pill) and an angiotensin-converting enzyme (ACE)
inhibitor.
-↑ myocardial contraction and left ventricular outputà increased CO
  0.25 mg is the digitalizing dose and should be administered in divided doses over
24hrs.
 Caution: check for apical pulses for 1 min before administration; watch out for
toxicity that can cause dangerous dysrhymias
 Apical pulse: between the 4th and 5th intercostal space at the mid-claviclular line
 When the pts rhythm is AFIB and the heart rate is less than <60 bpm or greater than
>100/min, or the rhythm becomes regular, the nurse may with hold the med and
notify physician bc this may indicate the development of AV conduction block
 Direct IV administration; requires infusing over 5mins; use diluted solution
immediately; observe IV site; extravasation can lead to tissue irritation and
sloughing.
 Normal Heart Rate for an infant is 120-160 bpm (resting); bradycardia is rate below
80-100; withhold medication if rate is below <90-110;
 Infant TOXICITY: excessive slowing of beats may indicate digitalis toxicity.

 Take digoxin at the same time everyday, AM

 Do not take anti-acids at the same time . Separate meds by at least 2 hrs
 Digoxin THERAPEUTIC LEVEL 0.5- 2.0 ng/ml
 Digoxin Toxicity greater than >2.4 ng/ml
SE: anorexia, Nausea, vomiting, fatigue (early effects of digitalis toxicity), bradycarida,
yellow or green halo around objects especially lights
Antidote: Digifab (Digibind)

Drug-drug interactions- verapamil, amiodarone, quinine, erythromycin, tetracycline, or

cyclosporine.
Herbals: don’t admin with St. John’s wort as it decreases effectiveness of digoxin;  digoxin
toxicity when admin with ginseng and licorice
*** A low potassium level (hypokalemia) could increase the serum digoxin sensitivity level. It
can rapidly deteriorate to ventricular tachycardia or sudden death.

Analgesics
NSAID’s (non- steroidal anti-inflammatory)
Side effects: Headache, dizziness, gastrointestinal distress, pruritus, and rash
Naproxen Sodium
Ibuprofen (Motrin)
Aspirin (acetylsalicylic acid)
Use: Treats pain, fever, arthritis, and inflammation. It may also be used to reduce the risk of
heart attack.
SE: ringing in the ears, GI & duodenal ulcers, bleeding, GI symptoms, nausea, dyspepsia
Toxicity: ringing in the ears, headache, hyperventilation, agitation, confusion, sweating, GI
distress and diarrhea
Contraindications: cross-sensitivity between tartrazine & aspirin; an allergic response to one
may indicate an allergic response to another.
- Do not give to children; can cause Reye syndrome: Sudden (acute) brain damage and liver
function problems.
Not an NSAID
Acetaminophen (Paracetamol) - Tylenol
Use: Treats minor aches and pain and reduces fever
Complications- Overdose: hepatic toxicity is a serious complication resulting from acute acetaminophen
overdose that manifests 1-3 days after initial ingestion; there is an increase in the serum transaminase
liver enzymes, (ALT) and (AST); PT should also be monitored as acetaminophen prolongs it.

Pyridium (Phenazopyridine)
USE: Relieves pain, burning, and discomfort caused by urinary tract infections and other urinary
problems.
SE: yellow discoloration of the skin or sclera indicates medication accumulation due to renal
impairment.

Nitrates
Nitrostat (Nitroglycerin)
Use: This medication relaxes blood vessels allowing more blood to flow through. This improves
blood flow to the heart. Oral dose forms are used to prevent angina (chest pain). This
medication is NOT for treating an attack of chest pain that is already happening.

Nitroglycerin (SL, no chewing, check the effectiveness of med, MR q 5 min. for 15 min.)
CLIENT EDUCATION regarding response to chest pain
 Vasodilators can cause orthostatic hypotension
 Stop activity and rest
 Place Nitroglycerin tablet under tongue to dissolve
 If pain is unrelieved in 5 min, the client should call 911
 The client can take up to 2 more doses or Nitroglycerin at 5-min intervals
 Remind client headache is a common side effect
 Encourage the client to sit and lie down slowly
 keep med in a dark container
** When a client first takes a nitrate, the nurse expects which symptom that often occurs?
Headaches

Anti-Hypertensive
Betablockers "olol"- Blocks the beta1-adrenergic receptors in the cardiac tissues. They are as
effective as anti-anginals b/c Decrease heart rate and decrease myocardial contractility.

Propranolol (Inderal)
Use: Treats high blood pressure, angina (chest pain), irregular heartbeat, migraine headaches,
tremors, and lowers the risk of repeated heart attacks.
Warning: May mask symptoms of hypoglycemia, removing your body’s early warning system.
CAUTION diabetic patients about this.
Contraindicated in clients w/ asthma bc it can cause bronchospasms.

ACE-Inhibitors (Angiotensin-Converting Enzyme inhibitors) "pril”

These drugs treat hypertension and congestive heart failure. All generics end in "pril”
BENZAPRIL (Lotensin), LISINOPRIL (Zetril), CATOPRIL (Capoten), ENALAPRIL (Vasotec)
 SE: hypotension, dry cough, N & V, headache, angioedema (swelling of the face, lips, tongue,
throat), salty or metallic taste, Irregular heartbeats (this could be caused by too much potassium in
your blood).
Considerations:
o Monitor ↑ k (potassium) levels, ace inhibitors cause the body to retain potassium.
o Avoid foods high in potassium.
o Do not use salt substitutes (they contain potassium)
o Signs of too much potassium in the body include confusion, irregular heartbeat,
nervousness, numbness or tingling in hands, feet or lips, shortness of breath or difficulty
breathing, and weakness or heaviness in legs.

Calcium channel blockers (End in “Pine”)

 Diltiazem (Cardizem)
TMT: essential (age related) HTN Also treats angina.
Drug-drug interactions with beta-blockers, digoxin, carbamazepine, Prazosin (Minipress-alpha
blocker), quinidine; don’t mix with beta-adrenergic meds within 48 hours of each other
Nursing implications: Avoid grapefruit juice because can lead to toxic level of drug, encourage
fiber and fluid because of constipation side effects

Antibiotics
AninoGlycosides Tertracylines Vancomycin Cephalosporin
Name -Gentamycin Doxycycline Vancomycin Cephalexin (keflex)
(geramycin) (Vibramycin) Hydrochloride, Bleomycin -Ceftriaxone sodium
-kanamycin (Kantrex) (Rocephin)
-Tobramycin (Nebcin)
Action -Aerobic-Gram-Negative -Pneumonia For bacterial infections -Respiratory infections
bacteria -Respiratory tract -Rheumatic fever -Otitis media (ear
-TB infections -C.diff infection)
-Meningitis, -Acne -Bone/joint infections
-Osteomyelitis, -Infections of skin, -UTI
-Endocarditis, -Genital
-Toxic shock syndrome -Stomach ulcers
(TSS), (Helicobacter pylori)
-Ghonorrhea,
-Salmonella,
-E. coli,
-Pneumonia,
-Shigellosis,
-Pseudomonas,
-Septicemia,

(*can be uses in
combination with
Vancomycin)
Side Effects Photosensitivity -Photosensitivity -Red neck or red man -Nephrotoxicity
Superinfection -Discoloration of syndromeOccurs when IV -Pseudomembraneous
Ototoxicity permanent teeth years too rapid:Severe colitis
 Nephrotoxicity -Stomatitis, hypotensionRed flushing -Steven-Johnson
-GI distress of face, neck, chest, Syndrome,
Pseudomembranous extremities -hepatic and renal
colitis -Ototoxicity-hearing loss dysfunction.
-Blood dyscrasia -Pseudomembraneous
-Superinfection colitis
-CNS toxicity, Nephrotoxicity
hepatotoxicity -Blood dyscrasias
-Nephrotoxicity in high -Stevens-Johnson
doses syndrome
Considerati Check C&S.Monitor renal Do not take anti-acids -Check C&S before Eat yogurt & acidophilus
ons function, hearing loss. w/I 1-3 hrs after taking therapy. milk to maintain normal
Warn client to use this -Give over 1 to 2 hours IV. intestinal flora
sunblock.Monitor for -Rotate sites.
superinfection.Monitor Do not give to children -Monitor BP. -patient with a history of
peak and trough level younger than 8 -Monitor IV site. PCN would also be
-Monitor renal function allergic to cephalosporin
-use sunblock tests and hearing.
-Monitor client for
superinfection
- never give IV push
Drug-drug -Penicillins decrease -Do Not take w/ milk
interaction aminoglycoside products.
s effectiveness. -Do not take w/
-Penicillins increase antacids.
warfarin's effec -Decrease effects of
oral contraceptives.

-Digoxin absorption is
increased leading to
toxicity.

***Nephrotoxicity (renal toxicity)- When kidney damage occurs, you are unable to rid your
body of excess urine, and wastes. Your blood electrolytes (such as potassium, and magnesium)
will all become elevated. Nephrotoxicity can be temporary with a temporary elevation of lab
values (BUN and/or creatinine)

**Super infection: infection occurring after or on top of an earlier infection, especially following
treatment with broad-spectrum antibiotics.

Antibiotics
 Quinalone
Cipro (Ciprofloxacin)
Drink w/ plenty of fluids; may cause crystalluria and stone formation
Do not take w/ milk or yogurt – decreases the absorption of cipro
Do not at the same time as vitamins

Immunosuppressant
Cyclosporine
Use: This medication is used to prevent organ rejection in people who have received a liver,
kidney, or heart transplant. It’s also used to treat severe rheumatoid arthritis and a certain skin
condition (severe psoriasis).
SE:
 reduction in urine output
 Hypertension and tremor
 Other common: headache, gingival hyperplasia, elevated hepatic enzymes
 Periodic blood counts are necessary to ensure WBC's don't fall below 4,000 or platelets
below 75,000
 Long-term therapy increases risk of malignancy - especially lymphomas and skin cancers

Interactions: DO NOT take with grapefruit juice b/c the bioavailability of cyclosporine will
increase from 20 to %200.

Hormone replacement therapy

Synthroid (levothyroxine)
Treats hypothyroidism. Also treats an enlarged thyroid gland and thyroid cancer.
SE: nervousness, insomnia, irritable, headache, fever, hot flashes, sweating

Tapazole (methimazole)
Treats hyperthyroidism (too much thyroid hormone produced by the thyroid
gland).
SE: flue like, sore throat, easy bruising

Herbal Alternatives
-Ginkgo is an antiplatelet agent and CNS stimulant given for dementia syndrome; increase
risk of bleeding when given with NSAID’s.

- Herbal Licorice- used for digestive system complaints including stomach ulcers, heartburn,
colic, and ongoing inflammation of the lining of the stomach (chronic gastritis).Some people
use licorice for sore throat, bronchitis, cough, and infections caused by bacteria or viruses.
 Contraindication: Do not take if you have HF or taking digoxin; ; can increase
potassium loss and ma cause digoxin toxicity

Drugs affecting blood coagulation

Heparin Warfarin (Coumadin)

IV or SQ oral
Prevents clots in the blood vessels before or after surgery Prevent new blood clots from forming, and helps to keep
or during certain medical procedures. existing blood clots from getting worse. This medicine is a
blood thinner (anticoagulant).

-Labs - APTT -Labs= PT, INR 2-3

-Protamine sulfate (antidote) for an abnormal lab value if pt is Afib or has had sx its 2-4
- if pt is on heparin they must also be on Coumadin -Pt. can go home w/ this
-Always give at 5pm in a health care setting
SE: Bleeding, decreased LOC = intracranial bleeding - Give Vitamin K (antidote) for an abnormal lab value (eg
Drug-to-Drug Interactions PT/INR 4.5-5)
Heparin and oral anticoagulants, salicylates, penicillins, or
cephalosporins, nitroglycerine SE: bleeding, bruising Nausea, loss of appetite, or
stomach/abdominal pain
Considerations: DO NOT increase foods w/ high vit K;
maintain an adequate amount diet w/ potassium
Heparin: It works by decreasing the clotting ability of the blood.
 Given for DVT/Thrombosis to prevent it from clotting
 Increased aPTT
PT/PTT are laboratory tests that measure the clotting time (how long it takes blood to clot.)

PT/PTT are blood tests and INR is a ratio calculated from the PT

Teach pt’s about bruising (normal),

Bleeding precautions
-No electric razors
- Dr may discontinue before a sx or dental procedure
- Stop taking a couple days before menstruation.

VIt K- never given IV push

Iron is a mineral. Most of the iron in the body is found in the hemoglobin of red blood cells and
in the myoglobin of muscle cells. Iron is needed for transporting oxygen and carbon dioxide
Ferrous sulfate
 
 Fiber
 Fluid
 Take iron and vitamin C (orange juice) together, your body can better absorb the iron.
 Dark stools
 Ask if you see blood when they wipe
 Drink liquid form from straw
 IV iron sucrose
 Can take while menstruating
 Try to avoid taking it with foods containing dairy products, coffee, tea, or cereals .

Foods High in iron

 Red meat
• Egg yolks
• Dark, leafy greens (spinach, collards)
• Dried fruit (prunes, raisins)
• Iron-enriched cereals and grains (check the labels)
• Mollusks (oysters, clams, scallops)
• Turkey or chicken giblets
• Beans, lentils, chick peas and soybeans
• Liver
• Artichokes

Vaccines
Influenza (flu-vaccine)- contraindications: allergies to eggs.
Recommended for
 65 or older
 Chronic respiratory or cardiovascular disease
 Ppl in contact w/ young children

Lipid lowering agents

Anti-lipemic (end in STATIN) Simvastatin (zocor), lovastatin (mevacor), rosuvastatin (crestor),
atrovstatin (liptor)
Lowers high cholesterol and triglyceride levels in the blood.
General Side effects:
 Muscle aches
 Hepatoxicity
 Myopathy
 Rhabdomyolysis (breakdown of muscle fibers)
 Peripheral neuropathy
Interventions
 Take at night
 Take w/ food
 Monitor liver profiles (AST, SGOT)
 Monitor renal function
 Low fat high fiber diet
Drug integrations: digoxin, Coumadin, grapefruit juice, thiazide diuretics, thyroid
hormones, NSAIDS, phenobarbital, tetracycline, gemfibrozil (lopid),
** propranolol decreases the effectiveness of atorvastatin.

Fibric Acid- HDLTG cholesterol synthesis Tricor (fenofibrate), Lopid (Gemfibrozil)

SE: dyspepsia (Indigestion), gallstones, and myopathy
** Should not be given w/ statins- take w/ meals
** Monitor liver function (AST, SGOT)
** May interfere w/ anti-coagulants

Antiemetic
Promethazine
Prevents and controls motion sickness, nausea, vomiting, and dizziness. Also used to relieve or
prevent allergic reactions, helps people go to sleep, and control their pain or anxiety before or
after surgery or other procedures.

Chlorpromazine
Treats mental disorders, severe behavior disorders, severe hiccups, severe nausea and vomiting,
and certain types of porphyria. Also used before and after surgery to relieve anxiety.
SE: anticholinergic, difficulty urinating
Contraindicated for pts w/ alcohol withdrawal symptoms.

Histamine H2 Antagonist
Zantac (ranitidine HCl)– treats active duodenal ulcers or benign gastric ulcers
Avoid taking NSAID’s and alcohol b/c of increased gastric irritation, avoid smoking.

Gastrointestinal Meds
CLASSIFICATION/ MEDICATIONS NURSING CLEINT EDUCATION
ACTION INTERVENTIONS
Histamine 2 Antagonists  Nizatidine (axide)  Allow 1 hr  Take at Bedtim
o Decreases gastric  Famotidine before or after QD)
acid output by (Pepcid) to give antacid  Take with food
blocking gastric  Ranitidine (zantac)  Monitor for  Monitor for GL
histamine 2 receptors  Cimetidine neutropenia & bleeding (tarry s
o Treats GERD (gastric hypotension coffee ground emes
(Tagamet)
reflux)
Antacids  Aluminum  Do NOT give to  Advise the clien
o  gastric PH and hydroxide clients with take on an emp
neutralizes pepsin (Amphojel) renal failure or stomach
o Improves mucosal renal  Advise to wait 1
protection dysfunction hr to take other
 Magnesium  Monitor: medications
hydroxide w/ Aluminum
aluminum antacids for
hydroxide (Maalox, aluminum
Mylanta) toxicity and
constipation
Proton pump Inhibitor  Omeprazole  Take on empty
o gastric acid by (Prilosec) stomach
stopping acid-  Lansoprazole  Allow 30 mins b
producing proton (prevacid) eating. Don not
pump  Rabeprazole or chew pills
sodium (acipex)
  Pantoprazole
(Protonix)
 Esomeprazole
(nexium)
Prostaglandins  Misoprostol  May be given  Take w/ Food
o gastric acid (cytotec) w/ NSAIDs to  Advise to use
secretion prevent contraceptives.
mucosal  Do Not take wh
damage pregnant or a c
that they will b
pregnant or it w
induce abortion
Anti-ulcer/mucosal barrier  Sucralfate  Allow 30mins  Take on empty
o Inhibits acid and (Carafate) before or after stomach
forms a protective to give anti-
coating over mucosa acid
Antibiotics  Tetracycline  Monitor  No Sun; wear
o Eliminates H. pylori (Achromycin V) electrolytes sunscreen
infection and hydration  Can NOT take w
if fluid is pregnant
depleted.  No milk/dairy

 Metronidazole  Monitor for  Can NOT drink

(flagyl)- metallic abdominal alcohol
taste pain and  Advise client to
 Clarithromycin diarrhea complete dosag
(biaxin)
 Check for allerg
 Amoxicillin penicillin
(Amoxil)
 Notify provide
persistent diarr

Cardiovascular assessment: inspection, palpation, and auscultation

Abdominal assessment: auscultation, palpation, percussed

Medical Surgical
Vascular Disorders
 S/SY of Circulatory Insufficiency
Characteristic Arterial Venous
Pulses Diminished or absent Present but may be difficult to palpate through
edema
Skin -Cool to cold - Warm to touch
-Loss of hair over toes and dorsum of foot
-Nails thickened and ridged Skin thickened and tough
-Dry shiny skin May be reddish / blue
-Dependent rubor:
Reddish blue within 2 minutes of lowering extremity
(suggests severe arterial damage, vessels cannot
constrict, remain dilated)
- Pain
- Pulselessness
- Pallor (pale)
- Paresthesia
- Paralysis
** the client cannot distinguish between sharp or
dull pressure.
Ulcer depth Deep Minimal pain is superficial
Shape Circular
Base Pale to black and dry gangrene Granulation tissue (beefy red to yellow)

Leg edema Minimal Moderate to severe

Pain Very painful Minimal pain is superficial
Intermittent claudication - The patient reports Aching and cramping
experiencing pain in the left lower leg and foot when
walking. This pain is relieved with rest

PAD nursing management PVD nursing management

Dangle extremities and put in high fowlers position – Elevate extremities- usually relieved by movement.
cool and pale while elevated, cramps, aching while Increases venous return
walking Warm to touch

Pain relieved by Rest
To improve peripheral Arterial Circulation:
o -Position part below the heart (for legs elevate
HOB or sit in chair with feet on floor)
o -Instruct pt to walk to the point of pain (tissues
not receiving enough O2); rest until pain subsides
and resume walking to increase endurance
o Dependent position relieves pain
o Sit with feet flat on the floor; avoid crossings
legs or constrictive clothing
Not all pt’s with PVD should exercise; conditions worsen by
exercise:
o Leg ulcers
o Cellulitis
o Gangrene
o Acute Thrombotic occlusions
 Position ↑above heart level
 Discourage sitting or walking for prolonged periods
 Maintain warm temperature
 Applications of warmth (cold causes vasoconstriction)
 o Wear socks or insulated shoes at all times; Body  Avoid applying heating pad to extremities b/c
can’t adjust to temperature extremes; keep decreased to sensitivity may result in burns; applying
home warm to the abdomen can cause reflex vasodilation and is
safer; should use gloves or socks.
 Encourage to stop using tobacco (causes vasospasm)
Disorders of the Arteries:  Avoid tight clothing
o Acute (short-term) arterial occlusion (blockage)  Avoid crossing the legs (compresses leg vessels)
o Arteriosclerosis obliterans  Elevate affected leg and apply warm moist most
o Buerger's Disease compress
o Raynauds disease
Disorders of the Veins:
• Chronic venous insufficiency
• Varicose veins
• Foot Ulcers
• Thrombophlebitis

DVT Interventions
 S/SY- leg is warm to touch, edema on ankles
 On bed rest for 5-7 days to prevent pulmonary embolism
 Monitor peripheral pulses
 Administer anticoagulants
 Elevate legs
 Apply warm moist packs

**On bed rest until heparin therapy has begun

o Early ambulation after acute VTE results in rapid resolutions of complications

DVT complications
 Pulmary Embolism: heaviness in chest 1st sign, Chest pain, SOB, cough, cyanosis, leg
pain diaphoresis, rapid HR

Cerebrovascular System
HEART FAILURE
CHF or Heart Failure is defined as the inability of the heart to maintain adequate circulation to
meet the tissues need for oxygen and nutrients.

RISK FACTORS
 People over 75 yrs old
 Pt’s w/ DM are at high risk
 Atherosclerosis of the coronary arteries (primary cause of HF)
 Left sided HF
 HTN
 CAD, angina, MI
 Valvular disease (mitral and aortic)
 Right sided HF
 Left sided HF, Right ventricular MI ,Pulmonary problems (COPD, ARDS)
Left-Sided Heart Failure Right-Sided Heart Failure
Blood backs up to the Lungs Blood is backs up to the Rest of the body

Assessment Findings: Assessment Findings:

 Engorgement of the pulmonary veins eventually
leads to difficulty breathing  Jugular vein distention (JVD)
 Anorexia, nausea, vomiting
 Dyspnea (SOB), orthopnea (difficulty breathing  Abdominal distention, ascites
while lying flat),  Hepatomegaly (enlarged liver), ascites
 Nocturnal dyspnea, tachypnea  Liver and spleen enlargement
 Crackles, wheezes, rhonchi,  Dependent edema, peripheral
Cough Edema (legs, ankles, sacrum)
 Hemoptysis (coughing up blood)-frothy pink  Weight gain
sputum indicating severe pulmonary edema.  Signs of left-sided heart failure
 Gallop rhythm: S3, S4 o Tachycardia, fatigue,
 Palpitations, arrhythmias, o Elevated CVP
Dysrhythmias, tachycardia o Nocturia
 Fatigue  Ascites may increase pressure in the stomach and
 Third hart sound (S3) intestines causing GI distress
 Anxiety
 Diaphoresis
 Anorexia
 Altered mental status
CO , reduced urine output

 ** LEFT-sided symptoms of heart failure take priority over right- sided symptoms.
Pulmonary edema is manifested as Dyspnea.
 Dyspnea may occur or become worse with physical exertion.
PHARMALOGICAL MANAGEMENT
 ACE inhibitors (Angiotensin converting enzyme inhibitors) (Afterload reducing agent)
Prototype : Lisinopril , (Vasotec) Enalapril, Captopril (capoten)

 (Are prescribed 1st for heart failure.) They are used for:
-Management of heart failure due to systolic dysfunction.
-Promotion of vasodilation & diuresis by decreasing afterload & preload.
 Observe for hypotension, increased serum K+, dry cough, rash, swelling of the
tongue/lips (angioedema), and renal dysfunction, decreased sense of taste
 Remind client to monitor BP for 2 hrs after the initial dose to detect hypotension
 Avoid foods that are high in potassium (Ace-I retains potassium)

Alternatives for pt. who can not take ACE inhibitors:

 ARBS (Angiotensin II receptor blockers)
Hydralazin & Isosorbide Dinitrate

 Beta Blockers can be used with ACE inhibitors to reduce

mortality & morbidity. They are contraindicated with pt. with
severe or uncontrolled asthma.
  Observe for  heart rate, symptomatic hypotension, and fatigue
 ** Propranolol (Inderal) is contraindicated w/ pts with a hx of HF and pulmonary
edema.
Medications: Carvedilol, Metoprolol, Bisoprolol

 Diuretics (for treatment of edema)-they remove extracellular fluid by increasing the rate of
urine produced in pts w/ s/sy of fluid overload.
o Loop diuretics for pt. with renal insufficiency- Furosemide (Lasix),
o Potassium-sparing diuretic to inhibit sodium reabsorption - spironolactone
(aldactone)
o Thiazides for mild treatment - HCTZ
 Check serum K+ levels often
 Pt should have a low sodium diet< 2g/day
 Position pt supine after dose is taken for 1-2 hrs after taken
 Give early in the morning to avoid nocturia
 Give K+ supplements w thiazide and/loop
 Check labs for electrolyte depletion, esp: K, Na, Mg, and for electrolyte elevation esp
K w/ K sparing-agents.
 Monitor daily weighs, intake and output to assess response
 Report a weight gain of more than 2-3 pounds a week
 Monitor serum blood urea nitrogen and creatinine for  levels which indicate renal
dysfunction
 Assess lung sounds, jugular vein distention and peripheral, abdominal edema
 Avoid prolonged exposure to the sun
 Do NOT take herbal licorice; can increase potassium loss and ma cause digoxin
toxicity
 TEACH clients on loop or thiazide diuretics to ingest foods high is potassium
Foods high in Potassium
o Avocados o Prunes
o Apricots o Tomatoes
o Beets o Cantaloupe
o kiwi o Winter squash
o Grapefruits o Navy Beans
o Peaches o Rhubarb
o Sunflower o Watermelon
Seeds o Dried Fruits; dates, figs
o Bananas o Nuts
o Lima Beans Low in K
o Oranges -Cabbage
o Fresh pears - alfalfa sprouts
o Potatoes
o Spinach
o Broccoli
o Milk , yogurt

Side effects can cause electrolyte imbalance, hypotension, hyperuricemia (causing gout)
 Digitalis
-↑ myocardial contraction and left ventricular outputà increased CO
-↓conduction through the AV node
 Caution: check for apical pulses for 1 min before administration; watch out for
toxicity that can cause dangerous dysrhymias
 When the pts rhythm is AFIB and the heart rate is < than 60 bpm or greater than
100/min, or the rhythm becomes regular, the nurse may with hold the med and
notify physician bc this may indicate the development of AV conduction block
 Take digoxin at the same time everyday
 Do NOT take antiacids at the same time . Separate meds by at least 2 hrs
 Digoxin therapeutic level
SE: anorexia, nausea, vomiting, fatigue (early effects of digitalis toxicity), bradycarida,
yellow or green halo around objects especially lights
Medications: Digoxin (Lanoxin)
Antidote: Digifab (Digibind)

 Calcium Channel Blockers

Interfere with the ability of muscles to contract, leading to vasodilation & reducing systemic
vascular resistance
Medications: Amlodipine (Norvasc), Nifedipine (Procardia), Diltiazem (Cardizem), verapamil
(isoptin)
SE: dizziness or lightheadedness, headache, swelling of the hands, feet, ankles, or lower legs
(peripheral edema), difficulty breathing or swallowing, slow heartbeat.

 Additional Medical Management:

o Avoid NSAIDs, decongestants, excessive amounts of fluids
o Keep a restricted sodium diet (2-3 g / day) , limit fluids to 2 L/day
 Avoid dried fruits bc they are naturally high in sodium, avoid canned meats/
vegetables, avoid salad dressings, processed foods.
 Can eat whole grains, fruits, and vegetables , fresh poultry
o Oxygen therapy
o Administer analgesics (Morphine IV) & assess RR & keep Narcan antidote available

Stroke
Risk factors: African American, Male gender, substance abuse (especially cocaine), smoking,
heavy alcohol abuse

Hemorrhagic Stroke:
Caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Primary
intra-cerebral hemorrhage is from a spontaneous rupture of small vessels.
S/SY
 Severe headache
 Vomiting
 Early sudden change in LOC
 Motor, sensory, cranial nerve, cognitive impairments
Ischemic Stroke: Is a sudden loss of function resulting from disruption of the blood supply to a
part of the brain. This event is usually a result of a long-standing cerebrovascular diseases.

Clinical manifestation:
 Dysphasia – (difficulty swallowing)
 Numbness or weakness of the face, arm, or leg, especially on one side of the body.
 Confusion or change in mental status.
 Trouble speaking or understanding words
 Visual disturbances
 Difficulty walking, dizziness, or loss of balance or coordination
 Sudden severe headache
 Motor, sensory, cranial nerve, cognitive and other functions may be disrupted.

Right sided stroke

Left sided stroke
 Paralysis in the R
 R visual field defect
 Altered in intellectual ability
 Slow caution behaviors
 Aphasia (disturbance of the
comprehension and expression of
language) expressive or receptive
 Impaired speech
 Left hemi controls; speech, math
skills, & analytical thinking
 Paralysis and weakness in the L
 L visual deficit
 Spatial –perceptual deficit
 Increase distractibility
 Impulsive behavior and poor judgment
 Disorientation to person, place, time
 Lack of awareness of deficit

Interventions
 During acute phase of stroke
o Position supine w/ HOB elevated 15-30 degrees; keeps head in mid-line position

Medical Management
Thrombolytic therapy
Thrombolytics work by dissolving a major clot quickly. This helps restart blood flow to the heart
and helps prevent damage to the heart muscle. Thrombolytics can stop a heart attack.

Plasminogen activator (tPA)

tPA criteria for adm
 18 years or older
 For ischemic stroke only
 Time onset 3 hour or less
 Systolic BP<185 diastolic<110
 No seizure at onset
  No taking Coumadin
 Protobhrombin <15 INR <1.7
 Not heparin during lass 48 hours
 Platelet >100,000
 No prior intracranial hemorrhage or aneurism
 No prior hemorrhagic stroke
 No surgery within 14 days
 No stroke head injury or intracranial surgery for 3 months
 No GI/urinary bleeding or active bleeding within 21 days
If adm TPA
 Continue cardiac monitor and bleeding precautions
 Begin therapy as soon as possible after the onset of symptoms.
 Monitor vital signs, including temperature, continuously for coronary thrombosis and at
least every 4 hr during therapy for other indications.
 Do not use lower extremities to monitor blood pressure.
 Assess patient carefully for bleeding every 15 min during the 1st hr of therapy, every
15–30 min during the next 8 hr, and at least every 4 hr for the duration of therapy.
 Keep epinephrine, an antihistamine, and resuscitation equipment
 Assess neurologic status throughout therapy. Altered sensory or neurologic changes
may be indicative of intracranial bleeding.
 Check for Foley and IV sites for bleeding.
 Instruct patient to report hypersensitivity reactions (rash, dyspnea) and bleeding or
bruising.
 Explain need for bed rest and minimal handling during therapy to avoid injury.
 Avoid all unnecessary procedures such as shaving and vigorous tooth brushing.
 Avoid intramuscular (IM) injections; risk for bleeding

Neurologic complication & Implicataions

 Homonymous –(unaware of persons or objects o n side of visual loss)
 Hemianopsia- (loss of half of the visual field) (neglect of one side of body /difficulty
judging distances)
-Place the object in the intact field of vision
-Approach the pt from side of intact field of vision
-Instruct/ remind pt to turn head in direction of visual loss.
 Loss of peripheral vision- (difficulty seeing at night / unaware of objects or the borders
of objects)
- Encourage the pt to use a cane
 Diplopia- (double vision)
- Explain location of the objects when placing it near pt
- Always place items in the same location
Motor deficits
 Hemiparesis- weakness of the face, arm, and leg on the same side (due to lesion on
opposite hemisphere)
- Instruct to exercise unaffected side
 Flaccid paralysis
 Hemiplegia- Paralysis of the face, arm, and leg on the same side (due to lesion in the
opposite hemisphere)
 -Encourage ROM. of the affected site,
- Maintain body alignment, and exercise affected limb
 Ataxia (unsteady gait. Unable to keep feet together) support pt in initial ambulation.
Provide cane or walker
 Paresthesia- sensation of numbness and tingling to extremity.
- provide ROM to affected areas

Communication
 Dysarthria (difficulty forming words) give time to respond, give alternative methods of
communicating.
 Dysphagia (difficulty swallowing) -test pharyngeal reflexes before offering fluid or food,
Assist pt with meals, place food in unaffected site of the mouth.
 Apraxia (inability to perform a previous learning action)
 Expressive aphasia (unable to form words that are understandable) encourage pt to
repeat sounds of alphabet, explore ability to write.
 Receptive aphasia (unable to comprehend the spoken word; can speak but do not make
sense) speak slowly to the pt, explore pts ability to read.
 Global aphasia (mixed)- (combination of both receptive and expressive aphasia)- speak
clearly to the pt, simple sentences, use picture and gestures.

Myocardial Infarction (MI)

s/sy
 Nausea
 Diaphoresis
 Chest pain (tightness or pressure)
 Chest pain radiating to arm, jaw and neck
 Dyspnea
 Indigestion
DX test
** After myocardial injury,
o ST elevation on ECG
o Elevated Creatine Kinase-(CK-MB)- levels no longer evident after 3 days
(ELEVATES with in 12- 24 hrs)
o Elevated serum Troponin T and I concentrations can be detected
within 3 to 4 hours
o Normal Levels
 Troponin I : less than 10 µg/L
 Troponin T : 0–0.1 µg/L

 Coronary angiography (cardiac catheterization): Rt. vs Lt. (for unstable angina)

o Evaluates the presence and degree of coronary artery blockage
o Angiography involves the insertion of a catheter into femoral (sometimes a
brachial vessel) and threading it to the right of left side of the heart. Coronary
artery narrowing or occlusions are identified by the injection of contrast media
under fluoroscopy
o Used to diagnose CAD
o Cardiac catheterization is usually used to assess coronary artery
patency to determine if revascularization procedures are necessary.
 NURSING ACTIONS
 Ensure client is kept NPO 8 hr prior to the procedure
 Assess that the client and family understand the procedure
 Assess for iodine / shellfish allergy (contrast media)
 Catheter access site is observed for bleeding or hematoma formation
 Monitor VS every 15 mins until stable, then every hour
 Assess temp, color, capillary refill in the affected extremity
 Serial ECG
 Monitor bleeding from catheter access site and for orthostatic hypotension
 Bed rest is maintained for 2 to 6 hrs after procedure.
 If manual or mechanical pressure is used, pt must remain on bed rest for up
to 6 hrs with the affected extremity straight
 Location, severity, quality, and duration of pain
 Hourly urine out put – greater than 30 ml/hr indicates renal perfusion
 Admin oxygen (2-4 L)
 After discharge, for the next 24 hrs , do not bend at the waist (to lift
anything) , strain, or lift heavy objects

-Pacemaker- following an MI, the purpose of the pacemaker is to increase cardiac output. It
acts to regulate cardiac rhythm.
- Ventricular Dysrhythmias are common after MI
- Morphine- decreases preload and afterload pressures and cardiac workload; causes
vasodilation and pooling of fluid in the extremities; provides relief form anxiety.

Interventions
O- Oxygen
N- Nitroglycerin
A- Aspirin
M- Morphine

Angina Management
Nitroglycerin (SL, no chewing, check the effectiveness of med, MR q 5 min. for 15 min.)
CLIENT EDUCATION regarding response to chest pain
 Stop activity and rest
 Place Nitroglycerin tablet under tongue to dissolve
 If pain is unrelieved in 5 min, the client should call 911
 The client can take up to 2 more doses or Nitroglycerin at 5-min intervals
 Vasodilators can cause orthostatic hypotension
 Remind client headache & tingling sensation is a common side effect
 Encourage the client to sit and lie down slowly
 May resume sexual activity when they can walk one city block or climbing 2 flights of
stairs w/o having chest pain.
 No intercourse after heavy meals

Heart Block
Heart block is an abnormal heart rhythm where the heart beats too slowly (bradycardia).
In this condition, the electrical signals that tell the heart to contract are partially or totally
blocked between the upper chambers (atria) and the lower chambers (ventricles).

First-Degree Heart Block

In first-degree heart block, the heart's electrical signals are slowed as they move from the
atria to the ventricles (the heart's upper and lower chambers, respectively). This results in a
longer, flatter line between the P and the R waves on the EKG (electrocardiogram).
First-degree heart block rarely causes any symptoms, and it usually doesn't require
treatment.

Second-Degree Heart Block

In this type of heart block, electrical signals between the atria and ventricles are slowed to a
large degree. Some signals don't reach the ventricles. On an EKG, the pattern of QRS waves
doesn't follow each P wave as it normally would.Second-degree heart block is divided into
two types: Mobitz type I and Mobitz type II.

Mobitz Type I
In this type (also known as Wenckebach's block), the electrical signals are delayed more
and more with each heartbeat, until the heart skips a beat. On the EKG, the delay is shown
as a line (called the PR interval) between the P and QRS waves. The line gets longer and
longer until the QRS waves don't follow the next P wave.
Sometimes people who have Mobitz type I feel dizzy or have other symptoms. This type of
second-degree heart block is less serious than Mobitz type II.

Mobitz Type II
In second-degree Mobitz type II heart block, some of the electrical signals don't reach the
ventricles. However, the pattern is less regular than it is in Mobitz type I. Some signals move
between the atria and ventricles normally, while others are blocked.
On an EKG, the QRS wave follows the P wave at a normal speed. Sometimes, though, the QRS
wave is missing (when a signal is blocked).

Mobitz type II is less common than type I, but it's usually more severe. Some people who
have type II need medical devices called pacemakers to maintain their heart rates.

Third-Degree Heart Block

In this type of heart block, none of the electrical signals reach the ventricles. This type also
is called complete heart block or complete AV block. Complete heart block can result in
sudden cardiac arrest and death. This type of heart block often requires emergency
treatment. A temporary pacemaker may be used to keep the heart beating until you get a
long-term pacemaker.

Respiratory System
Chronic obstructive pulmonary disease (COPD)
S/SY
 Hypoxemia
 Hypercapnia,( ↑CO2)
 Pallor
 Dyspnea on exertion and at rest
 Oxygen desaturation with exercise
 The use of accessory muscles of respiration
 Chest x-rays reveal a hyper-inflated chest and a flattened diaphragm if the disease is
advanced.
 Early Clubbing of fingernails: The nail base is spongy on palpation; straightening or
flattening beyond 180 degrees
o Clubbing is a sign of hypoxemia- low O2 in blood; s/sy: confusion, pallor, SOB,
fast breathing , sweating, and wheezing.

Intervention
 Pursed lip breathing- Promote carbon dioxide elimination

How to do pursed lip breathing:

1. Breath in (inhale) slowly through your nose for 2 counts.

2. Feel your belly get larger as you breathe in.
3. Pucker your lips, as if you were going to whistle or blow out a candle.
4. Breathe out (exhale) slowly through your lips for 4 or more counts.
** NEVER hold breath during pursed lip breathing

PNEUMONIA: An inflammation of the lung Parenchyma caused by various microorganisms

including: bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites, and viruses.
S/SY
 Sudden onset of fever and chills
 Pleuritic chest pain
 Cough
 Profuse perspiration
 Tachypnea
 Sputum purulent (rusty- blood tinged)
 Central cyanosis is a late sign of hypoxemia
 Orthopnea

Risk factors
  Advanced age
 A client w/ cystic fibrosis
 Bed rest decreases lung expansion
 Pan of fractures ribs causes shallow breathing pattern
 Being postop
 Immunosuppressed
 Colon cancer
 Underlying lung disease
 White sputum indicates a decrease in pneumonia

Tuberculosis (TB): Mycobacterium tuberculosis

TB is an infectious disease that primarily affects the lung parenchyma. It is an acid-fast aerobic
rod that grows slowly and is sensitive to heat and ultraviolet light:
• Airborne transmission
S/SY
 Persistent cough
 Cough: non productive or w/ blood-tinged sputum
 Night sweats
 Low grade fever
 Fatigue
 Weight loss
 Anorexia
DX Tests
 Mantoux skin test (PPD):
o Intracutaneous injection (tuberculin syringe w/ 26 or 27 gauge needle)
o Read 48-72 hours to measure size of induration
o The reaction to the Mantoux test usually consists of a wheal, a hive like, firm welt.
o A reaction of 0 - 4 mm is considered non significant.
o A reaction of 5 mm or greater is considered positive for immunocompromisesd
clients. Eg. (HIV) positive or have HIV.
o An induration of 10 mm or greater indicates a positive skin test for a normally
healthy person. The area is palpable, raised and hardened.

 QuantiFERON-TB: new test for TB

o enzyme-linked immunosorbent assay (ELISA) that detects the release of
interferon-gamma by white blood cells when the blood of a patient with TB
is incubated with peptides
o 24 hour results: indicates that a person has been infected with TB
o Positive only indicates infection of TB ; not if client has active progression of
disease
 Chest x-ray: usually detects Lesions in the upper lobe
 Acid-fast bacilli smear and culture:
o A positive acid- fast suggest an active infection
o The diagnosis is confirmed by a positive culture for Myobacterium Tuberculosis

Medical Management:
Treated primarily with anti-tuberculosis agents for 6 to 12 months
4 first LINE medications used :
1. INH (isoniazid) – monitor for hepatitis and neuropathy, Bactericidal, Pyridoxine is
used as prophylaxis for neuritis. Monitor AST and ALT. PROPHALACTIC (preventative):
 INH + vitamin B6 (pyridoxine) – prevent INH-associated peripheral neuropathy
 Prophylqactic (preventive) measures taken daily for 6 to 12 months
 Household family members of patients with active disease
 Pts with HIV infection who have a PPD test reaction with 5 mm of induration or
more
 Patients whose current PPD test results show a change from former test results,
suggesting recent exposure to TB and possible infection (skin test converters)
 Users of IV/injection drugs who have PPD test results with 10 mm of induration
or more
 Patients with high-risk comorbid conditions and a PPD result with 10 mm of
induration or more
 Patients taking INH should avoid foods that contain Tyramine and histamine
(tuna, processed meats, aged cheese, red wine, Dried fruits (figs, raisins, dates), soy
sauce, yeast extracts, bananas, avocados), because eating them while taking INH
may result in headache, flushing, hypotension, lightheadedness, palpitations,
and diaphoresis.
 Monitor AST and ALT
o Fatigue & dark urine- indications for hepatic/liver dysfunction
 SE: peripheral nephropathy; numbness & tingling in the extremities
2. Rifampin (rifadin) – orange-red colorations of body secretions; contact lenses, dentures, and
urine.
 Monitor for neuropathy.
 Discoloration of body fluids- reddish-orange , urine, sweat, tears, feces, and sputum
(harmless side-effect)
 Permanent discoloring of contact lenses. – Therefore should not be worn
 Advise client to report yellowing of the skin , pain or swelling of joints, loss of appetite,
or malaise immediately.
 Monitor AST and ALT
 May interfere w/ the efficiency of birth control

3. Pyrazinamide – monitor for hepatotoxicity Bactericidal, Monitor uric acid, AST, ALT
4.Ethambutol (Myambutol) – monitor visual acuity and color discrimination
Bacteriostatic. Use with caution with renal disease or when eye testing is not feasible.
 Monitor visual acuity, color discrimination
 AE: Neuritis; with reduced visual activity; lessened ability to see green is a
possible initial sign.

5. Rifapentine (Priftin): Orange-red coloration of body secretions, contact lenses,

dentures. Use with caution in elderly or in those with renal disease

Legionnaires' Disease- is a severe form of pneumonia — lung inflammation usually caused by

infection. Legionnaires' disease is caused by a bacterium known as legionella .
Risk factors: advanced age, and sever immunosuppression.
S/SY
 Headache
 Muscle pain
 Chills
 Fever that may be 104 F (40 C) or higher

By the second or third day, you'll develop other signs and symptoms that may include:
 Cough, which may bring up mucus and sometimes blood
 Shortness of breath
 Chest pain
 Gastrointestinal symptoms, such as nausea, vomiting and diarrhea
 Confusion or other mental changes

Asthma
S/SY
 Cough
 Dyspnea
 Expiratory wheezing,
 Hypoxemia
 Tachycardia,
 Widened pulse pressure
 Diaphoresis
 chest tightness

Asthma attack: Difficulty breathing, shortness of breath, or very rapid breathing, rapid pulse,
coughing, chest tightening.
w/ severe spasm or obstruction decreasing breath sounds and crackles inaudible

** Inspiratory wheezing might indicate obstruction (assess throat)

Pharmalogical Intervention
Shorting acting Beta2 adrenergic agonists:
o 1. Albuterol (Proventil) ( Ventolin)
o 2. Levalbuterol (Xopenex)
o 3. Pirbuterol (Maxair)
 These are the meds of choice for relief of acute symptoms and preventions of exercise
induced asthma; they are used to relax smooth muscle.
 Anticholinergics: Ipratropium (Atrovent) : inhibit muscarinic cholinergic receptors and
reduce intrinsic vagal tone of the airway.
 Use albuterol inhaler (bronchodilator ) 1st ; it open passageways , then use
beclomethasone inhaler (steroid); so steroid can get into the bronchioles.

Long-Acting Control Medications:

  Corticosteroids are the most potent and effective anti inflammatory meds currently
available: effective in alleviating symptoms, improving airway function, and decreasing
peak flow variability. (beclomethasone)
 A spacer should be used w/ inhaled corticosteroids and patients should rinse their
mouth after administration to prevent thrush (yeast infection around mouth).
 Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade) are mild to
moderate anti inflammatory agents and are considered alternative meds for treatment;
these meds stabilize mast cells.
 Effective on a prophylactic basis to prevent exercise induced asthma or in unavoidable
exposure to known triggers; CONTRAINDICATED in acute asthma exacerbations.
 Long acting beta2 adrenergic agonists are used w/ anti-inflammatory meds to control
asthma symptoms, particularly those that occur during the night.
 Theophylline (Slobid, Theo-Dur) is a mild to moderate bronchodilator that is usually
used in inhaled corticosteroids, mainly for relief of nighttime symptoms.
 Salmeterol (Serevent) and formoterol (Foradil) have a duration of at least 12 hours and
are used w/ other meds for the long term control of asthma.
 Leukotriene modifiers (inhibitors) or antileukotrienes are a class of meds that include:
montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo).
Peak Flow monitoring:

Metered Dose Inhaler (MDI)

 Always use spacer w/ corticoid steroid
 Shake inhaler before use
 Remove cap from inhaler and from spacer
 Breath out, away from spacer
 Bring spacer to mouth, put mouthpiece between teeth and close lips around it
 Press top of your inhaler
 Breath in very slowly, until you have taken a full breath
 Hold breath for 10 seconds, then breath out
 Exhale just before pressing down on the canister to release the medicine
 If a whistling sound is heard, the pt is likely inhaling too quickly
 Contact Dr. if you develop a persistent cough; asthma pt’s are at increased risk for
Upper respiratory disease and infection

** Propanalol (Inderal) is contraindicated in pts w/ asthma bc it can cause bronchospasms

Tuberculosis (TB) is an infection, primarily in the lungs (a pneumonia ) caused by bacteria

called Mycobacterium tuberculosis. It is spread usually from person to person by breathing
infected air during close contact.
-TB can remain in an inactive (dormant) state for years without causing symptoms or spreading
to other people.

S/SY
 Dry cough (persistent for several weeks)
 Night sweats
 Fatigue
  Fever
 Weight loss
 Hemoptysis (expectoration of blood)

Nursing Interventions
 Place patient in a negative air pressure room to prevent spread of disease.

Acute Respiratory Distress Syndrome (ARDS)

 Increased respiratory rate (earliest sign)
 Which can begin from 1 to 96 hours after the initial insult to the body.
 Absence of wheezing
This is followed by
 Increasing dyspnea,
 Air hunger
 Retraction of accessory muscles, and cyanosis.
 Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse
crackles.

Brain Tumors
 Frontal lobe: personality, behavior, emotions, voluntary activity, concentration, and
intellectual functions
 Occipital lobe: primary visual receptor center
 Temporal lobe (behind ear): Auditory reception area
 Parietal lobe: center for sensation
 Brain stem: controls bowel and bladder

Gastrointestinal System

INFLAMMATORY BOWEL DISEASE

Inflammatory bowel disease (IBD) refers to two chronic inflammatory GI disorders:
 Regional Enteritis: Crohn’s Disease
o Subacute and chronic inflammation
o Extends through all layers of bowel wall
o Fistulas, fissures and abscesses
 Ulcerative Colitis
Recurrent ulcerative and inflammatory disease of mucosal and submucosal layers of colon
 Diverticulitis
Crohn’s disease (regional Enteritis) Ulcerative Colitis Diverticulitis
CLINICAL MANIFESTATION CLINICAL MANIFESTATIONS CLINICAL MANIFESTATION
 Onset of symptoms is usually  Predominate symptoms:  Asymptomatic in
insidious (gradual), with diarrhea, passage of mucus and diverticulosis
prominent right lower right pus, left lower quadrant  Abdominal pain most often
quadrant (RLQ) abdominal pain abdominal pain (LLQ). in the lower quadrant (LLQ)
 Abdominal tenderness and  Exacerbation and remission with diverticulitis
spasm  Diarrheaà dehydration  Low grade Fever
 Crampy pain after meals; the pt  10-20 liquid stools/day  Nausea/ anorexia, vomiting
 tends to limit intake, causing:
 Weight loss,
 Anorexia
 Malnutrition
 Secondary anemia.
 Exacerbation and remission
 Chronic Diarrheaà 5 loose
stools/day àdehydration
o Steatorrhea- fat in
stool
 Fever
 Fistulas, abscesses, and
fissures are common
ACUTE NUSING MANAGEMENT
 Promote rest periods
 Low ↓ residue, low ↓
roughage, low fat, high ↑
protein (eggs, soy), high calorie
diet, supplemental vitamin and
iron replacement, no milk
 Administer TPN for severe case
o Mucus, pus, or
blood may be
present
 Abdominal pain
 Rectal bleeding
(mild/severe)->hypotension
 Anorexia, Vomitingà
dehydration
 àWeight loss
 Fever
 Hypocalcemia may occur
ACUTE NURSING MANAGEMENT
 Maintain NPO during acute
phase
 Need TPN to rest bowel
 Monitor for dehydration
 Diet: Low ↓ residue, high
↑ calorie, ↑ high protein,
increased fluids. (Eg. Baked fish,
cream of potato soup, cooked baby
carots, tea)
 Tachycardia
 Chills
 Mild to sever pain
 Constipation w/ diarrhea
 Peritonitis if diverticula
ruptures
 Rectal bleeding
ACUTE NUSING MANAGEMENT
 Diverticulitis: start w/ Clear
liquid diet until
inflammation subsides;
then, a high-fiber, low fat
diet
DISCHARGE
↑ high-Fiber, low-fat diet
 Diverticulosis: high ↑ fiber
diet; avoid foods w/ nuts,
seeds, or kernels , increased
fluid intake 3L/day
 Antibiotics 7-10 days
 Bulk forming laxative
(Metamucil, psyllium
hydrophilic mucilloid)

↓Low-residue diet= low in fiber. All meats, fish, or poultry must be baked or broiled.
Foods w/ high-Fiber: legumes, bread, fruits, beans , nuts, seeds

Diverticulosis
Diverticulosis is diverticula in the colon without inflammation.

S/SY: Abdominal pain, constipation, and diarrhea,

Diet- ↓ Low fat, ↑high Fiber (eg. Tuna/turkey sandwich on whole-wheat bread- provides bulk in
stools). Eat fruits and vegetables with every meal.

** Avoid fiber if diverticulitis occurs

Foods with seeds or indigestible material may block diverticula; should avoid seeds, nuts, corn,
popcorn cucumbers, figs, strawberries, and caraway seeds.

Acute Appendicitis
S/SY:
 Abdominal pain (RLQ)(around navel)
o McBurney’s point
 Nausea, vomiting,
 Low fever
 Loss of appetite.
**In acute appendicitis the pain usually comes prior to N/V and anorexia. N/V that comes before
abdominal pain frequently indicates gastroenteritis .

Appendectomy
 Elevate the HOB 30-45 degrees
 Diet: ↑ protein, ↑ calories, ↑ vitamin C and multivitamins to aid in wound healing and
formation of RBS’s

Stomach or Duodenal (Peptic) Ulcer Disease

Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of
the small intestine, called the duodenum

Ulcers can be caused by:

• Infection with a type of bacteria called Helicobacter pylori (H. pylori)
• Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin,
naproxen (Aleve, Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, Midol, and
others), and many others available by prescription. Even safety-coated aspirin and aspirin in
powered form can frequently cause ulcers.
• Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach
that increases acid output (seen in Zollinger-Ellison syndrome).

S/SY
An ulcer may or may not have symptoms. When symptoms occur, they may include:
• A gnawing or burning pain in the middle or upper stomach (mid-epigastrium) between
meals or at night
• Bloating
• Heartburn
• Nausea or vomiting
• Pain often occurs 2-4 hrs after meals, eg. mid-morning or mid afternoons
• Pain can be relieved by eating
In severe cases, symptoms can include:
• Dark or black stool (due to bleeding)
• Vomiting blood (that can look like "coffee-grounds")
• Weight loss
• Severe pain in the mid to upper abdomen

Interventions
• Eat 3 meals each day
• Avoid diets rich in milk and cream; stimulates acid secretions
• Avoid aspirin, meat extracts, alcohol, and caffeinated beverages, avoid all coffee

Gastric Ulcer
 Pain occurs 30 mins- 1 hr after a meal
 And rarely at night
 Pain is NOT helped by the indigestion of food

Intestinal Obstruction
 S/Sy: abdominal pain, abdominal distention, and nausea

*** no sounds heard in 3-5 mins; indicates intestinal obstruction

Higher- level obstructions- (pyloric stenosis) have crampy pain that is wavelike and
colicky, intermittent pain, and profuse (projectile) vomiting.

Low intestinal obstruction: N/V, abdominal distention, hyperactive bowel sounds, no

stool as mobility below the obstruction will crease.
SMALL BOWEL AND LARGE
OBSTRUCTIONS
Obstipation- the inability to
pass stool and/or flatus for
more than 8hrs despite feeling
the need to defecate.
Abdominal distention
High-pitched bowel sounds
before site of obstruction.
SMALL BOWEL LARGE INTESTINE OBSTRUCTION
OBSTRUCTIONS
Pain is spasmodic and colicky Pain is diffuse and constant
Visible peristaltic waves Significant abdominal distention
Profuse, (projectile) sudden Infrequent vomiting; the pt can have
vomiting with fecal odor; diarrhea around an impaction
vomiting relieves pain
The pt will pass blood and
mucus but no fecal matter
and no flatus (fart)

Gastric Surgery
COMPLICATIONS
o Common problems include dysphagia (difficulty swallowing) and gastric retention
o bile reflux gastritis
o Dumping syndrome -
o A complication of gastric sx that consists of vasomotor symptoms in response to food
indigestion.
o Symptoms: pallor (pale), palpitations, dizziness, tachycardia, headache, nausea,
vomiting, sensation of fullness.
o Sweating, weakness or tachy after eating
o A desire to lie down after eating is an early sign of dumping syndrome
NURSING INTERVENTIONS
o Administer powdered pepsin or octreotide (sandostatin)
o Prevent complications by:
o Eat in reclining position
o Lay down for 30 min AFTER meals
o No liquid with meals
o Drink liquids only between meals.
o Avoid drinking fluids with meals
o LOW charbohyrate & fiber
o Avoid sugars; honey, syrups, sorbital, xylitol
o Low fowlers position
o Avoid over eating or smoking
 o Small, frequent meals
o Consume a high ↑ protein, ↑ high fat, low ↓ fiber, and low to moderate carb diet
o Avoid milk, sweets or sugars (fruit juice, sweetened fruit, milk shakes, honey, syrup,
jelly)
o Decrease intake of carbohydrates since they are the first food to be digested

Perforation/Hemorrhage

 When peptic ulcers perforate or bleed, it is an emergency situation

 Perforation presents severe gastric pain across the abdomen.
 Abdominal pain radiates into the right shoulder
 The abdomen is rigid board like, hyperactive to diminished bowel sounds.
 GI bleeding in the form of hematemesis (vomiting of blood) or melena
(bloody stools) may cause symptoms of shock (hypotension, tachycardia,
dizziness, confusion) and  hemoglobin.

Gastroenteritis (Stomach Flu)

-An inflammation of the lining of the intestines caused by a virus, bacteria or parasite.
S/SY
 Watery diarrhea
 Nausea & vomiting
 Stomach pain
 Cramping,
 Fever
 Headache
 Dehydration
 Hypoactive bowel sounds
*** Hypoactive bowel sounds (>30 sounds per/min); indicates increased motility due to
gastroenteritis, diarrhea and laxative use
*** no sounds heard in 3-5 mins; indicates intestinal obstruction
*** 1-2 sounds per/min; indicates decreased motility of bowel
*** 5-30 sounds per/min; indicates normal bowel sounds

Colorectal Cancer
Risk factors
 Age over 40
 History of ulcerative colitis
o Diet for ulcerative colitis; high protein high calorie, low residue
 Diet; high ↑ fat, ↑ protein and low↓ fiber (residue)– risk factor

Biliary System
Cholecystitis- inflammation of the gallbladder

S/SY: Right upper abdominal pain (RUQ), N/V

+ Murphy’s sign: pain w/ palpation of the gallbladder

Diet- ↓ Low fat; Avoid fatty and gas forming foods (eg. BBQ chicken, rice, baked potato, salad).
AVOID – eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming veggies, and alcohol.

Pharmacologic – Analgesics (Demoral not Morphine); fat-soluble vitamins; Bile salts; IV

antibiotics in acute stage

CHOLELITHIASIS
Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they
vary greatly in size shape and composition.
 The pt develops a fever and may have a palpable mass
 May have a biliary colic w/ excruciating upper right abdominal pain (RUQ) that radiates
to the back or right shoulder.
 Biliary colic is usually associated with N/V, and is notable after a heavy meal (fried/fatty
foods)
 Frequent belching
 Moves about Restlessly
 When gallbladder is distended, marked Tenderness in the RUQ on deep inspiration and
prevents full inspiratory excursion.
o Pain – is controlled with Demerol rather than Morphine b/c it can cause spasms
of the sphincter of Oddi.
 Bowel sounds decreased/absent
 + Murphy’s sign - test for gallbladder disease in which the patient is asked to inhale
while the examiner's fingers are hooked under the liver border at the bottom of the rib
cage. The inspiration causes the gallbladder to descend onto the fingers, producing pain
if the gallbladder is inflamed. Deep inspiration can be very much limited.
 Leukocytosis & Vitamin deficiency
 Jaundice – occurs w/ few pt. with obstruction of the common bile duct

Pancreatitis
– Inflammation of the pancreas. Commonly described as autodigestion of the pancreas.
Risk Factors:
 This can result from gallstones (biliary tract disease)
 Alcohol abuse (80% the cause)
 Other less common causes are bacterial or viral infection
Risk Factors
S/SY:
 Onset is sudden w/ severe upper abdominal pain accompanied by N/V and ↑of
serum amylase.
 ↓ hypocalcemia - tetany
 rigid or board-like abdomen
 Dehydration due to N/V
 Back pain
 Hypotension
 Tachycardia; cyanosis, cold/ clammy skin, BS diminished or absent;
 Fever, mental confusion, and agitation
 Mild jaundice
 Ecchymosis (bruising) in the flank or around the umbilicus may indicate severe
pancreatitis.
  If hemorrhagic pancreatitis: bluish discoloration (ecchymosis) around umbilicus
(Cullen’s Sign) or in the flank area; grayish-blue (Turner’s Sign)
Management
 ALL oral intake is with held (NPO)
 Parenteral nutrition (TPN)
 NG suctioning should be used to relive N/V and to ↓ painful abdominal distention, and
paralytic ileu
 Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or
hydromorphone (Dilaudid).
 Morphine is contraindicated; use Demerol for pain
 Strict Bed Rest
Endocrine System
Hypothyroidism Hyperthyroidism
↑ TSH ↓ TSH
Clinical Manifestations When hyperthyroidism is due to autoimmune disease it is called
- Weakness; lethargy Grave’s Disease
- Hair loss, brittle nails, and dry skin
- Mask-like facial expression Clinical Manifestations
- Numbness and tingling of the fingers. thyrotoxicosis:
- Voice may become husky, and hoarseness  Nervousness, emotional hyper-excitable, irritable and
- Enlarged tongue; drooling apprehension, pt. isn’t able to sit quietly
- Muscle aches  ↑ peristalsis; diarrhea
- Menstrual disturbances such as menorrhagia (heavy  Fine hand tremors may be observed
bleeding) and amenorrhea (no period), in addition to  Neurologic Changes; Sleep problems; Amenorrhea
loss of libido.  Fatigue
- Apathy; bradycardia; loss of DTR; anorexia [not eating  Weight loss due to diarrhea [↑appetite ↓wt.];
but still gaining wt.]  Do not tolerate Heat; perspire unusually freely; localized
- Weight gain edema
- Do not tolerate COLD temperatures  Skin is flushed [salmon color] and it’s warm, soft, and
- pt is very sensitive to narcotics, barbiturates, and moist
anesthetics.  Exophthalmos (bulging eyes) that produce startled
facial expression
Myxedema  Osteoporosis and fracture
-Untreated severe hypothyroidism. Can be life-threatening.  Cardiac: ↑BP ↑palpitations and rapid ↑pulse at rest as
S/S hypothermic (↓ low body temp) & ↓unconsciousness; well as exertion. & S3 heard. Systolic increase not
initially pt. may show signs of diastolic, atrial fib
- Depression, lethargy, and somnolence (drowsy). Thyrotoxic Crisis (Thyroid Storm)
- ↓ RR, resulting in hypoventilation, progressive CO2 Extreme exacerbation of severe hyperthyroidism.
retention, narcosis, and coma. May be precipitated by several factors, including stress, abrupt
TMT: synthroid (levothyroxine)- increases metabolic rate, ↑ thyroid medication withdrawal, diabetes mellitus, and infection.
U/O, ↑ glomerular filtration, decrease edema Clinical Manifestations:
 High ↑ fever (hyperpyrexia) above 38.5 (101.3F)
 ↑ HTN ↑ pulse
 Severe tachycardia (>130 bpm)
 Disturbances of a major system (GI:
 eg. Weight loss, diarrhea, abdominal pain),
Cardiovascular (edema, chest pain, dyspnea,

Hypoparathyroidism
Absolute or relative deficiency of (PTH); Most commonly
follows thyroidectomy.
Clinical manifestations
↓ Hypocalcemia causes irritability of the neuromuscular
system – Tetany
-Tetany- muscle hypertonia (uncontrollable muscle spasms,
stiffening), with tremor and spasmodic or uncoordinated
contractions occurring w/ or w/o efforts to make voluntary
movements.
-Latent tetany – numbness, tingling, and cramps in
extremities, and pt. complains of stiffness in the hands and
palpitations)
 Delirium, psychosis, somnolence, or coma
 Extreme diaphoresis, vomiting, diarrhea, significant F&E
imbalance
 Treatment according to clinical findings
Management
Diet: 4500-5000 cal/day; increase ↑ protein
& Carbs. Foods high in ↑ calcium, vitamins, minerals. Avoid
stimulants like tea.
- ↑ high- calorie snacks
- Instill artificial tears for exophthalmos
TMT: thyroidectomy:
-Priority: monitor signs of respiratory distress every hour.
-Elevate HOB
-Post sx: semi-fowlers , prevent neck flextion- Trach at bedside
Hyperparathyroidism
Excessive secretion of (PTH), resulting in hypercalcemia
characterized by bone decalcification and the development
of renal calculi (kidney stones) containing calcium.
Clinical Manifestations
↑ Hypercalcemia
-Apathy (lack of interest), fatigue, muscle weakness,
N/V, loss of appetite, constipation, HTN, and cardiac
dysrhythmias.
- ↑ rest & sleep, shortened attention span.
- Irritability and psychoses
- Osteoporosis
 feet.
-Overt tetany – bronchospasms, laryngeal spasms,
carpopedal spasm, dysphagia, photophobia, cardiac
dysrhythmias, facial twitching and seizures.
- Other symptoms include: anxiety, irritability,
depression, and even delirium.
ECG changes and ↓BP
- ↓ calcium (hypocalcemia) levels , ↑ phosphate
(hyerphosphatemia)
- + Trousseau’s sign or + Chvostek’s sign suggests
latent tenany.
o TMT: calcium chloride or gluconate over
10-15 mins (emergency care)
o Monitor for respiratory distress due to
swelling or tetany; assess for laryngeal
stridor
TMT: Diet: high calcium, low phosphate
Posterior Pituitary Disorders
Diabetes Insipidus (DI)
Lack of ADH (vasopressin), failure of the kidneys to
respond to ADH, failure of the kidneys to conserve water.
(Remember Losing WATER retaining Sodium).
Causes:
 Neurogenic DI-
-Cranial surgery
- Head trauma
-Brain tumors,
-Infections on CNS such as encephalitis, meningitis,
TB or irradiation of the pituitary gland
 Nephrogenic [failure for the renal tubules to
respond to ADH]
-Adverse drug effects,
-Hypercalcemia, hypokalemia
-Variety of medications (eg, lithium, demeclocyline)
S/SY
 Fatigue & muscle weakness
- Formation of stones in one or both kidneys, r/t
↑urinary excretion of calcium and phosphorus
- Renal calculi (kidney stones), obstruction,
pyelonephritis (kidney infection), and renal failure.
- Hematuria (sign of renal calculi)
- Demineralization of the bones or bone tumors
composed of benign giant cells resulting from
overgrowth of osteoclasts.
 Pt. may develop skeletal pain, tenderness,
especially of the back and joints; pain of wt.
bearing; pathologic fractures; deformities;
and shortening of body stature.
 Fractures due to bone loss
- Incidence of peptic ulcer and pancreatitis increases;
GI symptoms
Complications: Hypercalcemic crisis
Acute Hypercalcemia: Ca >15mg considered life threatening;
result in neurologic, cardiovascular, and renal symptoms
that can be life-threatening.
TMT: Parathyroidectomy: Diet: low calcium, high in
phosphorus, preoperatively.
SIADH
[Syndrome of inappropriate antidiuretic hormone secretion]
SIADH includes excessive ↑ ADH secretion from the pituitary
gland even in the face of subnormal serum osmolality.
Occurs when ADH secretion continues without regard to serum
osmolality resulting in excessive ADH; pt. cannot excrete dilute
urine, retain fluid. (Retaining WATER losing SODIUM)
Causes: Disorders of CNS, such as:
 Head injury
 Cancer (most common cause) especially lung cancer
 Brain surgery, or tumor
 Infections are thought to produce SIADH by direct
stimulation of the pituitary gland.
S/SY
 Hyponatremia
 Confusion
 Rapid reduction of Na.; reduced LOC; reduced deep
  Polyuria -excessive urination
 Polydipsia-excessive thirst [drink 2-20L of fluid
daily and crave cold water]
 Severe dehydration
 Weight loss; loss of appetite; constipation
 ↑ serum Osmolarity & ↑ Na
 low specific gravity (1.005-1.030)
 Nocturia
TMT: administer Vasopressin or desmopressin (DDAVP)
tendon reflexes (DTR); Hypothermia ( body temp);
seizures; coma; death
 ↑ Weight gain
 Thirst; lethargy; weakness; confusion; anorexia; N/V;
abnormal muscle cramps; dyspnea on exertion;
hypotension
 urine Output and ↑ Specific gravity is elevated
because the kidneys cant excrete dilute urine
 Normal specific gravity is 1.005-1.030
 Water intoxication

TMT: Fluid restriction, Na replacement, diuretics, I&O , position

flat in bed

Adrenal Gland Disorders

 ADDISON’S DISEASE  CUSHING’S DISEASE
Definition ↓Hypo-secretion of Adrenocortical hormones (ACH)   ↑Hyper-secretion of Adrenocortical hormon
leading to:

• Metabolic disturbances (sugar)

• Fluid and electrolyte imbalances (salt)
• Deficiency of neuromuscular function (salt and
sex)
Predisposing • Atrophy of the Adrenal gland 1. Hyperplasia of Adrenal gland
Factors • Fungal infections 2. Tubercular infection (MILIARY – TB to adjace
organs)
Signs and 1.  ↓ Hypoglycemia (TIRED) 1.   ↑ Hyperglycemia à can lead to DM
Symptoms ◦ Tremors and tachycardia o Polyuria
◦ Irritability o Polydipsia
◦ Restlessness o Polyphagia
◦ Extreme fatigue o Wt. Gain
◦ Diaphoresis and depression o Glucosuria
2. Decreased tolerance to stress (d/t decreased 2. Increased susceptibility to infection (Reverse
cortisol) à Addisonian Crisis isolation!)
3. ↓ Hyponatremia (Na) 3. ↑Hypernatremia (Na)
◦ Hypotension/ hypovolemia o HPN
◦ Muscle twitching o Edema
◦ siezures o Wt. gain
◦ Signs of dehydration 4. Moon-face appearance, buffalo hump, obes
◦ Weight loss pendulous abdomen, thin extremities
4. ↑Hyperkalemia (K) 5. ↓ Hypokalemia (K)
◦ Irritability and agitation o Weakness and fatigue
◦ Diarrhea o Constipation
 ◦ Arrhythmias o U wave on ECG tracing
5. Decreased Libido 6. Hirsutism (male-pattern hair growth)
6. Loss of pubic and axillary hair 7. Easy bruising
7. Bronze-like skin pigmentation d/t decreased 8. Acne and Striae
cortisolà stimulation of MSH from pituitary 9. Increased masculinity in females
gland 10. ↑ fluid, BP, Wt
8. ↓ fluid, BP, WT, N/V, diarrhea
Diagnostics 1. FBS decreased (N= 80-120 mg/dl) 1. FBS elevated
2. Serum Na decreased (N= 135-145) 2. Elevated Na
3. Serum K elevated (N=3.5-5.5meq/L) 3. Decreased K
4. Plasma cortisol decreased 4. Elevated Cortisol
Nursing 1.  Monitor strictly VS, IO to determine presence of 1. Monitor IO, VS
Management Addisonian crisis which results from acute  Respirations 1st priority, these pts. are
exacerbation of Addison’s disease characterized by: fluid overload and CHF due to ↑Na &
o Hyponatremia retention
o Hypovolemia 2. Restrict Na and Fluids
o Dehydration 3. Weigh pt. daily and assess for pitting edema
o Severe ↓Hypotension (ANASARCA – generalized edemà  neph
syndrome)
o Weight loss, which may lead to
4. Measure abdominal girth daily, notify MD
progressive stupor à coma. 5. Diet: low ↓ Carbs, Na, ↑High protein and ↑
Assist in mech vent, steroids as ordered, forced
6. Administer medications as ordered
fluids
o K-sparing diuretics - Spironolactone
2. Administer medications as ordered
(Aldactone); excretes sodium but retai
o Steroid Replacement :Corticosteroids
potassium
 Universal rule: administer 2/3 dose in
7. Prevent Complications – DM
AM and 1/3 dose in PM to mimic the N
8. Provides meticulous skin care
diurnal rhythm of the body
9. Assist in Surgical Procedure – Bilateral
 Taper the dose. Withdraw gradually
Adrenalectomy
from the drug
10. Hormonal replacement for life
 Monitor SE: Cushingoid Sx
11. Importance of f/up care
 HTN, Increased susceptibility to
infection, Weight gain, Hirsutism,
Moon face appearance
 Ex: Hydrocortisone, Dexamethasone,
Prednisone
o Mineralocorticoids – Fluorocortisone
3. Forced fluids
4. Maintain patent IV line
5. Diet: high ↑Carb/calories, ↑Na and Protein, low
↓K
o Monitor for dysthymias due to the increased
retention of potassium ↑K
6. Meticulous skin care
7. Provide health teaching and d/c planning
o Avoidance of precipitating factors leading to
addisonian crisis:
 Stress, Infection, Sudden withdrawal to
steroids
 ↑Sodium intake should be increased in
periods of stress (eg. Infection/sick)
o Prevent Complications – hypovolemic shock
o Hormonal replacement therapy for life
o Importance of f/up care
**Do not give potassium (k), w/o adequate urine out put

Addisonian Crisis
Sudden life-threatening exacerbation of Addison’s Disease usually triggered by stress. Patient
experiences extremes of: hypotension, hyponatremia, hypoglycemia, dehydration &
hyperkalemia. Fever that may be unrelated to any other cause is not uncommon. Without
immediate attention, condition will progress to coma and death.

S/S
- Cyanosis and the Classic signs of circulatory shock;
- Pallor; extreme weakness;
- Apprehension; ↑ rapid and weak pulse; ↑rapid respirations, and low ↓BP.
- Headache, nausea, abdominal pain, and diarrhea, vomiting
- confusion and restlessness.
- Even slight overexertion, exposure to cold, acute infection, or a decrease in salt intake
my lead to circulatory collapse, shock, and death if untreated. The stress of surgery or
dehydration resulting from preparation for diagnostic tests or surgery may precipitate
an Addisoniain or hypotensive crisis.
- Restlessness, and rapid, weak pulse – May be signs of SHOCK
 Adm IV D5NS and steroid in high doses
 hydrocortisone therapy &vasopressors
 Rest & monitor VS

Preventing Addisonian Crisis

 Should increase fluids and sodium in hot weather
 Avoid exposure to cold
 Avoid overexertion
 Avoid infections
 When traveling, a needle, syringe, and an injectable form of cortisol should be
carried for emergencies.
TRIck:
Put the symptoms in alphabetical order minus the hyper/hypo:
-Calcemia
-Glycemia
-Kalemia
-Natremia

Start with Addison's: alphabetically, hyper comes before hypo. the order is hyper, hypo, hyper, hypo
(hypercalcemia, hypoglycemia, hyperkalemia, hyponatremia)
Cushing's is the opposite: hypo, hyper, hypo, hyper (hypocalcemia, hyperglycemia, hypokalemia,
hypernatremia).

Alterations in the Genitourinary System (Renal)

Neurologic Bladder: damage to the upper motor neurons and interruption in cortical spinal
nerve pathways; results in urinary retention.
o Residual urine can cause UTI’s.

Nephrotic syndrome
- Nephrotic syndrome (NS) is a condition that is often caused by any of a group of diseases that
damage the kidneys' filtering system, the glomeruli. The structure of the glomeruli prevents
most protein from getting filtered through into the urine.
Nephrotic syndrome can affect all age groups. In children, it is most common between ages 2
and 6. This disorder occurs slightly more often in males than females.
S/SY:
 Proteinuria
 Hypoalbuminemia (low level of albumin in the blood)
 Edema (swelling)
o Face and around the eyes
o Arms and legs, especially in the feet and ankles
o Belly area
  Hypercholesterolemia
Other symptoms include:
 Foamy appearance of the urine
 Poor appetite
 Weight gain (unintentional) from fluid retention
Nursing Care
Diet: adequate protein and low sodium intake
-Monitor for S/Sy of venous thrombosis (DVT)

Glomerulonephritis
Glomerulonephritis is a group of diseases that injure the part of the kidney that filters blood
(called glomeruli). Other terms you may hear used are nephritis and nephrotic syndrome. When
the kidney is injured, it cannot get rid of wastes and extra fluid in the body. If the illness
continues, the kidneys may stop working completely, resulting in kidney failure.

Acute Glomerulonephritis
The acute form develops suddenly. You may get it after an infection in your throat
(strep throat) or on your skin (impetigo). Sometimes, you may get better on your own.
Other times, your kidneys may stop working unless the right treatment is started
quickly.

S/SY
The early symptoms of the acute disease are:
 Puffiness of your face in the morning
 Peri-orbital edema
 Blood in your urine (urine appears dark, tea-colored, or cloudy)
 Urinating less than usual.
 You may be short of breath and cough because of extra fluid in your lungs.
 You may also have high blood pressure.

Causes of Acute GN

Acute GN can start in response to an infection such as strep throat or an abscessed

tooth. It may be caused by problems with your immune system overreacting to the
infection. Illnesses that have been known to trigger GN include:

 Strep throat

 Systemic lupus erythematosus (also called SLE or lupus)

 Goodpasture’s syndrome (a rare autoimmune disease where antibodies attack
the kidneys and lungs)
 amyloidosis (proteins that are deposited in organs and tissue, and can cause
harm)
 Wegener’s granulomatosis (a rare disease that causes inflammation of the blood
vessels)
  polyarteritis nodosa (a disease where cells attack arteries)
 Heavy use of NSAID pain relievers (ibuprofen, naproxen) may also be a risk
factor.

Chronic Glomerulonephritis The chronic form may develop silently (without symptoms)
over several years. It often leads to complete kidney failure.

S/SY
Early signs and symptoms of the chronic form may include:
 Blood or protein in the urine (hematuria, proteinuria)
 High blood pressure
 Swelling of your ankles or face (edema)
 Frequent nighttime urination
 Very bubbly or foamy urine
 Symptoms of kidney failure include:
 Lack of appetite
 Nausea and vomiting
 Tiredness
 Difficulty sleeping
 Dry and itchy skin
 Nighttime muscle cramps

Causes of Chronic GN
 The chronic form of GN can develop over several years with no or very few
symptoms. This can cause irreversible damage to your kidneys and lead to
complete kidney failure.
 Chronic GN may sometimes be caused by a genetic disease. Hereditary
nephritis occurs in young men with poor vision and poor hearing.
 Immune diseases may also cause chronic GN.

Treatment
 Antihypertensive
 Corticosteroids -may be prescribed reduce your immune response if your immune
system is attacking your kidneys.
 Plasmapheresis- to reduce the immune-triggered inflammation.
 For the chronic form of the disease, you will need to reduce the amount of protein, salt,
and potassium in your diet. Additionally, you must watch how much liquid you drink.
Calcium supplements may be recommended, and you may need to take diuretics to
reduce swelling.
 If your condition becomes advanced and you develop kidney failure, you may need to
have dialysis where your blood is filtered by a machine. Eventually you may need a
kidney transplant.
Renal Failure & End-Stage-Renal Disease
Renal Calculi (Kidney stones)
 Severe right-flank pain (side of back)
 Chills
 Fever
 Blood in urine
 N/V
Interventions
 Increase fluids to help pass the stone 3000ml/day
 Measure and strain urine

Acute Renal Failure

Rapid loss of renal function due to damage to the kidneys; this can be reversible. Criterion for
ARF are:
- 50% or ↑ creatinine above baseline (normal is less than 1 mg/dL). Urine volume may
include ↓oliguria (low urine output)(↓500 mL/day), nonoliguria (↑than 800 mL/day),
and anuria (less than 500mL/day). ↓ Specific gravity
Clinical manifestations
Almost every system of the body is affected with failure of normal renal regulatory mechanisms.
- Pt. may appear critically ill and lethargic
- Skin and mucous membranes are dry from dehydration
- CNS – drowsiness, headache, muscle twitching, and seizures.
- Breath odor – urea smell on breath (ammonia odor)
- Due to fluid retention pt. may have crackles, effusion…

Nutritional therapy
ARF causes severe nutritional imbalance b/c N/V contribute to inadequate dietary intake,
impaired glucose use and protein synthesis, and increase tissue catabolism.
- Pt. weighed daily and loses 0.5-1lb daily if the nitrogen balance is negative. If the pt.
gains or doesn’t lose wt. or develops HTN, fluid retention should be suspected.
- High-carb meals, b/c carbs have a protein-sparing effect [↑carb diet, protein is not used
for meeting energy requirements but is “spared” for growth and tissue healing].
 Food & fluids containing potassium (K) or phosphorus (bananas, citrus fruits and
juices, and coffee) are restricted.

Chronic Renal Failure (ESRF)

CRF - no distinct phases; renal function declines, end products of protein metabolism (normally
excreted in urine) accumulate in blood. The greater the buildup of waste products, the more
pronounced the symptoms are. Disease tends to progress rapidly in pt. that excretes significant
amt. of protein or have HTN.

S/SY: ↑hyperkalemia , ↓ urine output

Diet: increased ↑ calories, ↑carbs, restricted to biological ↑protein & ↓ sodium, ↓ potassium,
↓phosphorus; Drink 1-2L of water/day.
Avoid foods high in potassium: oranges, beet, bananas, Spinach, Broccoli, Milk , yogurt
Biological protein: eggs, lean meat, fish, and poultry, are high biological protein that contain a
sufficient amount of all the amino acids. (low biological value: peanut butter nuts and veggies.)

Central Nervous System Alterations

Bacterial Meningitis
Acute bacterial meningitis usually occurs when bacteria enter the bloodstream and migrate to
the brain and spinal cord. But it can also occur when bacteria directly invade the meninges, as a
result of an ear or sinus infection, or a skull fracture, or rarely, after some surgeries.
S/SY
 Severe headache
 Nuchal rigidity – kerning’s sign
 Nausea
 Photophobia
 Stiffness in neck
 Cloudy CSF
 ↑WBC (Infection)
 petechial rashon trunk
 + Brudzinki sign (knees to chest)
o Gently flex head and neck into chest; + Brudzinki response (flexion of the hips &
knees)
 It needs to be treated right away to prevent brain damage and death.
 In young children, the fever may cause vomiting and they may refuse to eat. Young
children may become very irritable and cry. There may be seizures.

**The onset of symptoms is fast, within 24 hours. If allowed to progress, you can die from
bacterial meningitis.

How is bacterial meningitis treated?

Bacterial meningitis is treated with antibiotics. A general intravenous antibiotic with a
corticosteroid to bring down the inflammation may be prcribed even before all the test results
are in. When the specific bacteria are identified, your doctor may decide to change antibiotics.
In addition to antibiotics, it will be important to replenish fluids lost from loss of appetite,
sweating, vomiting and diarrhea.

Viral Meningitis
Viral meningitis is more common than the bacterial form and generally -- but not always -- less
serious. It can be triggered by a number of viruses, including several that can cause diarrhea.
People with viral meningitis are much less likely to have permanent brain damage after the
infection resolves. Most will recover completely. (most common in children)
 S/SY

 Fever
 Headache
 Stiff neck
 Fatigue.
 Rash, sore throat
 Intestinal symptoms may also occur.
 CSF is clear , ↑WBC (not as high as bacterial)
 In severe cases, it can cause prolonged fever and seizures.
 Symptoms generally appear within 1 week of exposure.

Hepatic Alterations (Liver)

Portal Hypertension
Portal hypertension is the increased pressure throughout the portal venous system that results
from obstruction of the blood through the damaged liver. Commonly associated with hepatic
cirrhosis, it can also occur with non-cirrhotic liver disease. Although splenomegaly (enlarged
spleen) with possible hypersplenism is a common manifestation of portal hypertension, the two
major consequences of portal hypertension are ascites and varices.

Ascites
The failure of the liver to metabolize aldosterone increases ↑ sodium (Na) & water retention by
the kidney, leading to increased ↑intravascular fluid volume, ↑lymphatic flow, and decreased
↓synthesis of albumin by the damaged liver all contribute to the movement of fluid from
vascular system into the peritoneal space.
Clinical manifestations
 ↑abdominal girth & rapid wt. gain are common presenting symptoms
 SOB and uncomfortable from the enlarged abdomen, and striae and distended veins
may be visible over the abdominal wall.
 Umbilical hernias also occur frequently in those pt. w/ cirrhosis
 Fluid & Electrolyte imbalances are common

Esophageal Varices
Develop in majority of pt. with cirrhosis; that develops from elevated ↑ pressure in the veins
that drain into the portal system. They are prone to rupture and often are the source of massive
hemorrhages from the upper GI tract and the rectum. In addition, blood clotting abnormalities,
often seen in pt. with severe liver disease, increases ↑ the likelihood of bleeding and significant
blood loss.

Hepatic Encephalopathy & Coma

Life threatening complication of liver disease- may lead to Hepatic Coma. Two major alterations
underlie its development, in acute and chronic liver disease.
1st, hepatic insufficiency may result in encephalopathy b/c of the inability of the liver to detoxify
toxic byproducts of metabolism. 2nd, portal-systemic shunting, in which collateral vessels
develop as a result of portal HTN, allows elements of the portal blood to enter systemic
circulation.
  Major Toxin involved – nitrogenous ammonia, which crosses blood-brain barrier
producing neurologic toxic manifestations  stimulates GABA in the brain causing
depression of CNS.
 The ingestion of ammonium salts also increase the blood ammonia level. Conversely,
serum ammonia is decreased by the elimination of protein from the diet and by
antibiotic agents such as Neomycin sulfate (Mycifradin, Neo-fradin)
 Other factors unrelated to increased serum ammonia levels that can cause hepatic
encephalopathy in susceptible pts include: excessive diuresis, dehydration, infections,
surgery, fever and some medications (sedatives, tranquilizers, analgesics, and diuretics
that cause potassium loss).

Clinical Manifestations
The onset is often insidious and subtle, and initially the disease is termed subclinical or minimal
hepatic encephalopathy.
 Early symptoms: Minor mental changes and motor disturbances. Pt. appears slightly
confused
o Pt. tends to sleep during the day
o Difficult to awaken
o Pt. can lapse into frank coma and may have seizures
 Asterixis – flapping tremor of hands; simple tasks such as handwriting becomes difficult.
Handwriting or drawing sample (star figure)
o Inability to reproduce a simple figure – constructional apraxia
 In the Early stages – DTR ↑ hyperactive; with worsening of the encephalopathy these
reflexes disappear and the extremities become flaccid.
 Hyperventilation, hypothermia, tachycardia
 Fetor hepaticus – a sweet, slightly fecal odor to the breath that is presumed to be of
intestinal origin may be noticed. It’s described as freshly mowed grass, acetone, or old
wine.

Medical Management
Goal: reduction of ammonia formation
 Lactulose (Cephulac)– reduces serum ammonia levels; promotes excretion of ammonia
in the stool

Cirrhosis of the Liver

Chronic progressive disease of the liver characterized by replacement of normal liver tissue with
diffuse fibrosis that disrupts the structure and function of the liver
Pathological Classifications
1. Alcoholic or Laennec’s –
2. Postnecrotic- (viral hepatitis, drugs, toxins) – broad bands of scar tissue; this is a late
result of previous bout of acute viral hepatitis.
3. Billiary- (biliary obstruction) – scarring occurs in the liver around the bile ducts; this
results from chronic biliary obstruction and infection (cholangitis).
S/SY
Signs and symptoms of cirrhosis increase in severity as the disease progresses.
Compensated Decompensated
 Intermittent mild fever  Ascites
 Vascular spiders  Jaundice
 Unexplained epistaxis (nose bleed)  Weakness
 Palmar erythema (reddened palms)  Muscle wasting
 Ankle edema  Weight loss
 Vague morning indigestion  Continuous mild fever
 Flatulent dyspepsia  Clubbing of fingers
 Abdominal pain  Purpura (due to decreased platelet count)
 Firm, enlarged liver  Spontaneous bruising
 Splenomegaly  Epistaxis
 Sparse body hair
 White nails
 Gonadal atrophy

Nutritional status – nurse encourages pt. to eat

 Pt. w/ cirrhosis w/o ascites, edema, or signs of impending hepatic coma should receive a
nutritious, high-protein diet, if tolerated, supplemented by vitamins of the B complex,
as well as A, C, K. The nurse encourages the pt to eat.
 If ascites is present, small, frequent meals may be better tolerated than 3 large meals
b/c of the abdominal pressure exerted by ascites.
 Pt. w/ prolonged or severe anorexia and vomiting or eating poorly may receive nutrients
by the enteral or parenteral route.
 Pt. w/ fatty stools (steatorrhea) should receive water-soluble forms of fat-soluble
vitamins A, D, and E (Aquasol A, D, E).
 Folic acid & iron are prescribed to prevent anemia
 Protein is decreased temporarily if signs of impeding or advancing coma appear
 Protein is restricted if encephalopathy develops (Brain disease: altered mental state,
dementia, seizure, coma)
 Incorporating vegetable protein to meet protein needs may decrease the risk of
encephalopathy.
 Sodium restriction is also indicated to prevent ascites.

Neuromuscular System Alterations

Systemic Lupus Erythematosus (SLE) Is an autoimmune disease in which the body's immune
system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other
organs

- African American women- risk factor

Symptoms
 Joint pain & swelling.
 The joints of the fingers, hands, wrists, and knees are often affected.
 Butterfly Rash- on face, gets worse in sun
 Chest pain when taking a deep breath
  Swollen lymph nodes
 Fatigue
 Fever with no other cause
 General discomfort, uneasiness, or ill feeling (malaise)
 Hair loss
 Mouth sores
 Sensitivity to sunlight
 ↑Proteinuria & ↑ hyperlipidemia

Amyotrophic Lateral Sclerosis (ALS)

Loss of motor neurons (nerve cells controlling muscles) in the anterior horns of the spinal cord
and the motor nuclei of the lower brain stem. Referred as Lou Gehrig’s disease.
Clinical manifestations
Depends on the location of the affected motor neurons. The chief symptoms are fatigue,
progressive muscle weakness, cramps, fasciculations (twitching), and incoordination.
- progressive weakness and atrophy of the muscles of the arms, trunk, and legs.
- Spasticity usually is present, and the deep tendon stretch reflexes become brisk and
overactive.
- Anal and bladder sphincters remain INTACT, spinal nerves that control muscles of the
rectum and urinary bladder are NOT affected.
- Weakness starts in the muscles supplied by the cranial nerves, and difficulty in talking,
swallowing, and ultimately breathing
- When the pt. ingests liquids, soft palate and upper esophageal weakness causes the
liquid to be regurgitated through the nose.
- If bulbar muscles are impaired, speaking and swallowing are progressively difficult, and
aspiration becomes a risk. The voice assumes a nasal sound, and articulation becomes
so disrupted that speech is unintelligible.
- Have difficulty w/ dysphagia and aspiration; other early symptoms are fatigue while
talking, tongue atrophy, weakness of the hands and arms

Multiple Sclerosis Myasthenia Gravis

An immune-mediated, progressive demyelinating disease of the Autoimmune disorder affecting the myoneural junction,
CNS characterized by varying degrees of weakness of the
voluntary muscles.
 Acetylcholine (ACh), ↑ cholinesterase

Primary symptoms  Primary symptoms 

 Weakness and fatigue  Weakness and fatigue
 Memory changes & confusion  Difficulty chewing
 Ataxia & vertigo  Dysphagia
 Tremors and spasticity of the lower extremities  Ptosis (eye drooping)
 Parasthesia  Diplopia
 Blurred vision, diplopia, transient blindness  Weak, hoarse voice
 Nystagmus  Difficulty breathing
 Decreased perception to pain touch, temperature  Respiration paralysis and failure
 Bladder and bowel disturbances
 Abnormal reflexes: hyperflexia, absent reflex’s, Complications
+Babinski reflex Respiratory failure:
 Emotional changes: apathy, euphoria, irritability, - Myasthenic crisis – exacerbation of the disease
depression process
o Sudden, severe generalized muscle
Interventions weakness and respiratory and bulbar
 Avoid over exposure to heat or cold (neck/throat) weakness that may result in
 Avoid over exertion of muscles respiratory failure.
 Encourage ROM exercises o Crisis may result from diseases
 Sleeping prone may minimize spasms exacerbation, inadequate medication,
infection, pregnancy, fatigue or stress.
o Treatment- administer IV Neostigmine

- Cholinergic crisis – severe muscle weakness,

respiratory failure, plus GI symptoms due to
overmedication with anti-cholinesterase
o Atropine sulfate should be at hand to treat
bradycardia or respiratory distress

DX: + Tensolin test= will improve symptoms

Parkinson’s disease
Slowly progressing neurologic movement disorder that eventually leads to disability.
Symptoms usually appear in 5th decade of life
- ↑acetylcholine (excitatory) and ↓dopamine (inhibitory)
S/SY
Gradual onset and symptoms progress slowly over a chronic prolonged course. The cardinal
signs are tremor, rigidity, bradykinesia (abnormally slow movements), and postural
instability.
 Tremor – slow, unilateral resting tremor is present in majority of pts. at the time of
diagnosis. Resting tremor.
 o Tremor manifests as a rhythmic, slow turning motion (pronation-
supination) of the forearm and the hands and a motion of the thumb against
the fingers as if rolling a pill between the fingers.
 Rigidity –moving in jerking increments, referred to as lead-pipe or cog-wheel
movements.
o Stiffness of the arms, legs, face, and posture
o Early in the disease pt. may complain of shoulder pain due to rigidity
 Bradykinesia –slowing of active movements. Pt. takes longer to complete activities
and have difficulty initiating movements, such as rising form a sitting position or
turning in bed.
 Postural instability – loss of postural reflexes occurs, and the pt. stands with the
head bent forward and walks with a propulsive gait
o Shuffling gait
o Propulsive gait (a walk with forward momentum)
o Difficulty in pivoting (turning) causes loss of balance (either forward or
backward)
Stage 4 Parkinson’s
 Client is immobile

Guillain-Barre Syndrome (MEDICAL EMERGENCY!)

A. Definition
1. GB is an autoimmune attack on the peripheral nerve myelin. The result is acute, rapid
segmental demyelination of peripheral nerves and some cranial nerves, producing
ascending weakness with dyskinesia, hypo-reflexia, and paresthesias. Full recovery may
take up to two years.
2. The syndrome is usually preceded by a recent viral infection, such as an upper
respiratory infection or gastroenteritis.
1. .
B. Clinical Manifestations (DOES NOT affect LOC or cognition)
1. Acute progressive muscle weakness and paralysis
a. Ascending (Initially bilateral lower extremity muscles are affected then
progresses upward through the arms and thorax.)
b. Recovery is in descending order (initially, facial muscles recover, the
improvement progresses downward.)
2. Decreased/absent deep tendon reflexes
3. Pain (sensory)
4. Paresthesias of the hands and feet (sensory)
5. Neuromuscular respiratory failure & bulbar weakness. (*** The major concern in GB is
difficulty breathing; monitor respiratory status closely!!)
6. If the optic nerve is affected, it can result in blindness.
7. If the vagus nerve is affected, it can result in autonomic dysfunction. This leads to
instability of the cardiovascular system. (It is very labile and requires continuous ECG
monitoring!!)
a. Tachycardia
b. Hypertension
c. Bradycardia
d. Orthostatic hypotension
e. Dysrhythmias
 8. If the glossopharyngeal and vagus nerves are affected, it can result in inability to
clear/swallow secretions.
9. Dysarthria (difficulty saying words)

Diabetes Mellitus (DM)

A normal fasting blood glucose target range for an individual without diabetes is 70-105 mg/dL).
Normal non-fasting BS BG- <126mg/dl

Diagnostic test findings

 Random blood glucose level 200mg/dl or more
 Fasting serum glucose 126 mg/dl or more at least two occasion
 Glycosylated HB assay increase
 Blood chemistry increase K, CL, ketones, Cholesterol, and triglycerides, decrease carbon
dioxide, PH less than 7.

Hypoglycemia BS <60 Hyperglycemia >300

Cold and clammy need some candy Warm and dry sugar is high

Caused by too much insulin or oral hypoglycemic agents, too little  Extreme thirst
food or excessive exercise pt needs to carry fast carry in simple  Dry skin
carbohydrate with them  Drowsiness
High fat food slow the absorption of glucose and hypoglycemia may  3 P’s ↑
not resolve quickly, so do not give this food when pt has low BS to o Polyuria- excessive urinating
help increased o Polydipsia- excessive thirst
Mild hypoglycemia <60 o Polyphagia- excessive hunger
 Nervousness/ shaky  Sick to stomach
 Palpitation  Slow healing wounds
 Sweating & tachycardia  Glycosuria (glucose into the urine)
 Hunger  Osmotic diuresis (increased urination due to
 Tremors
the presence of certain substances in the fluid
 Irritability
filtered by the kidneys.)
 Loss of water and electrolytes
Intervention
 Give fast acting carbohydrate (hard candy, 4tsp of sugar, 1tsp
honey, and 8 oz of milk, fruits, and saltine crackers or Intervention: Hydrate, and regular insulin (Humalin
orange/apple juice) R)
 Recheck glucose in 15 minutes

Moderate hypoglycemia <40 Complications: DKA, HHNS

 Cold and clammy
 Confusion
 Diplopia
 Drowsiness
 Diaphoresis
 Emotional changes
 Headache
  Impaired coordination
 Inability to concentrate
 Memory lapses
 Numbness of lips and tongue
 Slurred speech
Interventions
 Fast acting simple carbohydrate, low fat milk or cheese, also
orange juice
 Recheck glucose in 15 minutes

Severe hypoglycemia <20

 Pt is unable to swallow
 Unconscious or experiences seizures

Intervention
 25- 50ml of 50% dextrose in water use (IM Glucagon 50)

Diabetes ketoacidosis (DKA)

DKA is an acute life threatening condition characterized by hyperglycemia (>300) resulting in the
breakdown of body fat for energy and accumulation of ketones in the blood and urine.
 Sever insufficiency of insulin, undiagnosed and unthreaded type 1
 Hyperglycemia
 Confusion
 Hot flushed skin
 Dehydration
 Electrolytes loss
 Acidosis
 Presence of ketones in the urine
 Acetone breathe (fruity odor)
 Anorexia, nausea, vomiting, abdominal pain, blurred vision, headache, hypotension,
kussmaul resp, polydipsia, polyuria,, weak rapid pulse, weakness.
 BS 300-800
 Decrease serum bicarbonate and decrease PH
 Na and K may below, depend of dehydration
 Kussumal respirations- deep and labored breathing

Treatment
 Restore circulating volume treat dehydration (IV rapid infusion of 0.9 or 0.45 Normal
Saline (NS), insulin-Regular-- remember that glucose is added to IV when pt’s blood
sugar is 250-300 & conscious.
 Correct electrolyte imbalance (K level may be increase ass a result of dehydration and
acidosis)
 Monitor K level after treatment because K decreases (may need K replacement).
Ensure adequate renal function before adm K.
 Flush the insulin solution and discard the first 50ml before adm to the pt
  Insulin infuse continuously until SubQ insulin resume, monitor VS and BS frequent,
urinary out put or sign of increase ICP
 If BS fall too fast can cause cerebral edema
Pt education
 Test BS and ketones every 3-4 hours
 After insulin always eat
 If vomiting or fever consume liquids every 30 minutes to prevent dehydration
 Notified MD if BS 250-300

Hyperglycemic Hyperosmolar Non-ketonic Syndrome (HHNS)

 BS 600-1200mg/dl
 Extreme hyperglycemia without ketosis or acidosis
 Often type 2 DM
 Onset is slow occurs to hours to days to develop
 Dehydration
 Tachycardia
 Mental status changes
 Neurological deficit
 Seizure
 Hypotension
 Glycosuria – glucose in urine
 Hypernatremia – high in sodium deficit in water
 Can be caused by infection in ppl w/o hx of diabetes
 Common in ppl 50-70 yrs old

Treatment
Similar to DKA but need to treat dehydration first that is an emergency Fluid replacement,
correction of electrolyte and insulin administration.

Dawn Phenomenon results from reduced tissue sensitivity to insulin that develops between 5
and 8 am (dawn). Pre-breakfast hyperglycemia occurs.
So you'll wake up hyper at dawn.
Tx: Administer an evening dose of intermediate-acting insulin at 10 pm.

Somogi's phenomenon- hypoglycemia occurs at 2 to 3 am. By 7 am the blood glucose rebounds

significantly to the hyperglycemic range.
- I remember this with (I have a brother named Yogi who's a musician), the club closes at 2-3 in
the morning, Yogi is low so off to breakfast he goes.

Tx: Decrease the evening (pre-dinner or bedtime) dose of intermediate-acting insulin (NPH) or
increase the bedtime snack.

Foot care
 Inspect feet daily;
 Avoid thermal injuries from hot water, heating pads, and bath.
  Avoid foot soak,
 Do not cross legs,
 Do not treat blister, cut toenails carefully,
 Apply moisture lotion but not between the toes,
 No shoes with straps between the toes
 Have each foot measured when buying new shoes
 Wear loss sock and well fitting shoes, clean cotton socks,
 do not wear same pair of shoes two day s consecutive
 Leather shoes are recommend because they “breathe”
 No smoking
 Adm med for pain
 Operative pt diabetic withholding hypoglycemic med or insulin, some long actin are
discontinue 24-48 hours before surgery (metformin)
 Post op
 IV glucose and regular insulin until pt tolerate PO
 Glucose fasting PT NPO 8 hours
 Client should eat a snack before exercising to prevent hypoglycemia
 Always take insulin even on sick days

Insulin administration
Mixing Draw Method:
1. Gently roll the vial of insulin to mix (never shake)
2. Sanitize the rubber port of insulin vials using alcohol, and then allow to dry.
3. Draw up air into the syringe equal to how much insulin you need then inject air into the
(NPH) cloudy insulin bottle. Do not draw up the insulin yet.
4. Draw up air into the syringe equal to how much insulin you need then inject air into the
(R) clear insulin vial.
5. Turn the vial upside down and draw up the (R) clear insulin.
6. Turn the vial of the (NHP) cloudy insulin upside down and insert the needle of the
syringe into the bottle. Draw up the dose of the cloudy insulin very, very slowly to
prevent air from coming in.
7. You are now ready to give your injection.

Sexually transmitted diseases (STD’s)

Human papilloma virus (HPV)à condylomata acuminata
Signs & symptoms- (genital warts-painless)
 Transmission: sexually transmitted, latent, skin-to-skin
o Increased incidence of cervical cancer à pap smear every 6 months to check
for cervical dysplasia
  Risk for cervical cancer and PID
 Dx tests: r/o other STD with VDRL, culture for chlamydia, gonorrhea, colposcopy
with bx,
 Rx:
o Topical of podophyllin (Podofin, Podocon), trichloroacetic acid, liquid
nitrogen
o Chemo: interferon (injection)
o Electrocautery, laser
** Cervical dysplasia refers is abnormal changes in the cells on the surface of the cervix. The
changes are not cancer. However, they can lead to cancer of the cervix if not treated.

HERPES VIRUS TYPE 2 (herpes vaginalis, herpes simplex)

 Life-long viral infection, STD & self-transmitted
 May spread to other part of the body eg. eye
 Recurrent with stress conditions, less pain
Signs & Symptoms:
o Red,
o Swollen blisters,
o May have inguinal lymphadenopathy
 Transmission even without symptoms (subclinical shedding)
 Rx: Topical or IV of acyclovir (Zovirax), valcyclovir (Valtrex), famciclovir (Famvir)

CHLAMYDIA & GONORRHEA

 Often coexist, common causes of endocervicitis, PID, and risk for ectopic pregnancy,
vulnerable for HIV
 Neisseria Gonorrheae à Gonorrheaà dysuria (painful urination), vaginal discharge,
risk for PID
Dx test: gram stained smear found dipplococci, culture
Rx: ceftriazone (Rocephin), ciprofloxacin (Cipro), ofloxacin ( Floxin)

 Chlamydia trachomatis à Chlamydiaà women may be asymptomatic, post partum

endometriosis, infertility, bleeding, and painful intercourse.
Dx test: gram stained smear and culture
Rx: doxycyclin (Vibramycin), azithromycin (Zithromax), Alt. Rx: erythromycin,
oflxacin (Floxin), levofloxacin (Levaquin)
SYPHILIS
Definition: acute & chronic disease caused by the spirochete Treponema pallidum
 Pathophysiology: three stages
o Primary syphilis: (2-3 wk after inoculation), a chancre (papular, blood
less, and painless skin lesion) -resolved spontaneously in 2 months.
Communicability is from chancre and blood
o Secondary syphilis: original chancre spreads by blood-borne bacteria to
generalized infection e.g. lymphadnopathy, arthritis, meningitis, hair loss,
fever, malaise, and wt. loss (2-8 wks after chancre). Communicability is from
skin & mucus membrane
o
 Latent period: no signs or symptoms, or recurrent 2 nd stage.
Noninfectious after 4 years, but possible placental transmission
o Tertiary (late) syphilis: affecting multiple organs, noninfectious,
organism may be in spinal fluid. S/Sy are dementia, psychosis, paresis,
stroke and meningitis.

Management
 Rx:
o Penicillin G benzathine (observe 30 min for allergic reaction)
o Doxycycline if allergic to PCN
 o **Lesions of primary and secondary syphilis is may be highly infective, wear
gloves and gown when in direct contact w/ lesions.
o Report to local public health
o Refrain from sexual contact until partners are treated
o Condom can significantly reduce the risk
o Gloves and hand hygiene
o No isolation in a private room is required

Syphilis – chancre develops within 2-6 weeks; appears at point entry; starts as a small
papule in the vaginal area; develops into painless ulcer.

Herpes- cluster of painful blisters on the genital area may have difficulty voiding,
recurrence during times of stress, infection, and menses.

Herpes Zoster (shingles)- is a reactivation of latent varicella (chickenpox), which has a

increased frequency rate among adults with a weakened immune system; Pain, tenderness,
and pruritus over the affected region
o Is contagious to anyone that has NOT had the chicken pox or who is immuno-
compromised.
o Not a sexually transmitted disease
o Airborne precautions
o Standard precautions if it is localized.

HIV
Transmission: contact with body and oral fluids
 Primary symptoms:
 Flu like,
 Progressive weight loss,
 Decreased CD4 count

High risk: IV drug users,multiple sexual partners,contaminated blood prdcts, perinatal

transmission

 Diagnostics:
 1. ELISA detects dvpt of antibodies. test is positive or negative
 2. Western blot detects HIV infection and viral load. It confirms positive or negative
 CD4 and viral load levels indicate response to treatment.
 Management:
 Antiretroviral- taken daily and on time to avoid replication and mutation
 megace for apetite stimulation
 Immunization against disease is encouraged
 Small frequent high calori meals.
 PLASTIC UTENSILS USED instead of metal ones to avoid altered food perception not
to prevent spread of disease.
 Confidentiality a must, periodic evaluations, lab works always
Like?
AIDS
DX:
  CD4 count of <200m/mm3
 plus an AIDS related disease. eg Kaposis Sarcoma, PCP, CMV, TB, invasive cervical
cancer, non Hodgkins Lymphoma, histoplasmosis, wasting syndrome
,oropharyngeal candida infections, HIV related dementia
MEDS:
Antiretroviral, zinc supplements to help with altered taste, Megace, antibiotics, pain meds,
antiemetics and antifungals.

Nursing mgt:
 F/E momitor r/t vomitting and diarhea. hyponatremia is common
 Small frequent meals.
 Educate client on how disease and symptoms are managed
 Evaluate support system
 Emphasize on confidentiality and responsible sexual behavior
 Emphasize on medical regimen compliance since client is taking multiple drugs
qday.
 Do not share razors
Muscle skeletal Disorders
Arthritis

Characteristi Osteoarthritis Rheumatoid Arthritis

c
Disease Aka degenerative joint disease. Progressive Chronic progressive autoimmune connective tissue
process deterioration and loss of Cartilage in one or disorder primarily affecting Synovial joints
more joints.
Symptoms  Pain w/ activity that improves at rest  Morning stiffness
 Crepitus  Pain at rest or after immobility
 Chronic pain and stiffness  Swelling, redness,
 Warmth,
 Bilateral joint inflammation w/ decreased
range of motion
 Dry eyes and moth (Sjogrens syndrome)
Effusions Localized inflammatory response All joints
Body size Over weight Under weight
Nodes Heberdens and Bouchards nodes Swan neck and boutonniere deformities of the
hands

Systemic No; articular Yes: lungs, heart, skin, and extra- articular
involvement
Symmetrical No Symmetrical
DX tests X-rays X-rays, and positive Rheumatoid factor
Interventions  Use ice r heat for comfort
 Warm up exercises prior to
exercising
 Range of motion (ROM)
 Large joints should be encourages to
use instead of small joints
 Encourage adequate rest and sleep to
relieve pain
 Severely painful joints should NOT be
exercised
 Perform Range of motion (ROM) exercises
 Encourage client to continue exercises and
point out small accomplishments
 Active exercises are better than passive or
active-assistive exercises
 Take warm showers, walking, swimming
 Monitor for fatigue
 Balance rest and activity; do not allow
long rest periods btw exercises as it
reverses gains

OSTEOPEROSIS
Osteoporosis is the most common metabolic bone disorder resulting in low bone density.
Risk Factors
 Females
 Age over 60 (over 75 if male)
 Post-menapausal estrogen deficiency
 Hx of smoking & high alcohol intake
 Thin lean body build
 Asian/Caucasian-small framed- non-obese
 Sedentary life style (lack of physical exercise)
 Hx of fractures
Symptoms
 Decrease in height
 Kyphosis (curve at upper T spine)
 Change in BMI
 Frequent falls
 Acute back pain after lifting or bending

HEALTH PROMOTION & DISEASE PREVENTION

 Ensure the clients diet includes adequate amounts of calcium and vitamin D,
especially before age 35.
 Encourage the client to take calcium supplement + vitamin D if dietary intake is
inadequate (lactose intolerant)
 Expose areas of the skin to sun 5 to 30 min twice a week
 Discuss pros and cons of hormone replacement therapy
 Engage in weight bearing exercises

Complications
 Fractures are the leading complication of osteoporosis
 Ensure proper screening with a DEXA scan.
Nursing Care
 Instruct the client and family about calcium supplementation (take with food)
 Adequate amounts of protein, magnesium, vit K, and other trace mineral needed for
bone formation
  The need of sun exposure to Vit D (sunlight, fortified milk)
 Reinforce daily exercise and weight bearing activities. Ensure proper screening with
a DEXA scan.
Medication
 Calcium needed
o Young adults- 1300mg/day
o 19-50 yrs- 1000mg/day
o >15 yrs- 1200mg/ day
o Menopausal women w/o HRT – 1500mg/day
Diet
 Foods high in protein
 Green leafy veggies (turnip, Mustard, and Dandelion Greens)
 Yogurt/ cheese
 Calcium + Vit D,
 Tofu, almonds, flax seeds, sesame seeds.
 Herring (fish)

Gout
Gout is a type of arthritis. It occurs when uric acid builds up in blood and causes
inflammation in the joints.
Contributing factors
 Excessive alcohol intake
 High intake of foods w/ purines (organ meats, yeast, sardines, spinach)
 Obesity
 Comorbid DM/ kidney disease
S/SY
• Only one or a few joints are affected. The big toe, knee, or ankle joints are most often
affected.
• The pain starts suddenly, often during the night
• Pain is often described as throbbing, crushing, or excruciating.
• The joint appears warm and red. It is usually very tender and swollen (it hurts to put a
sheet or blanket over it)
• There may be a fever.
• Appearance of tophi (deposit of sodium urate crystals)
Interventions
 Diet: low-purine diet: avoid red organ meats, shellfish or oily fish w/ bones, alcohol
 High carbohydrate increases uric excretion
 Eliminate alcohol
 Drink lots of fluids to excrete uric acid
 Encourage Partial weight bearing exercises to relieve pressure and stress on leg
 ROM exercises would aggravate the pain

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a hand and arm condition that causes numbness, tingling and
other symptoms. Caused by a pinched nerve in your wrist.

S/SY
• Clumsiness of the hand when gripping objects
• Numbness or tingling in the thumb and next two or three fingers of one or both hands
• Numbness or tingling of the palm of the hand
• Pain extending to the elbow
• Pain in the wrist or hand in one or both hands
• Problems with fine finger movements (coordination) in one or both hands
• Wasting away of the muscle under the thumb (in advanced or long-term cases)
• Weak grip or difficulty carrying bags (a common complaint)
• Weakness in one or both hands

DX test
 + Phalen’s test: You hold your arms out in front of you and then flex your wrists,
letting your hands hang down for about 60 seconds. If you feel tingling, numbness,
or pain in the fingers within 60 seconds, you may have carpal tunnel syndrome.

 + Tinel sign: numbness, tingling, and pain felt when nurse percusses slightly iver
the median nerve on inner wrist.

TYPES OF IMMIBOLIZATION
Traction-Traction uses pulling force to promote and maintain alignment to the injured
area.
3 types: skin, skeletal or manual traction.
1. Skin (Bucks traction)- the pulling force is applied by weights that are attached by
rope to the client with tape, straps, boots, or cuffs.
-Eg. Bucks traction- used for hip fractures preoperatively
-Eg. Russell- for lower leg fractures
 - The weights can be removed when moving the pt. up and down in
bed for skin traction (Buck’s and Russell)
Interventions
 Turn client to unaffected side every 2 hrs
 Elevate HOB 15-30 degrees
 Strict bed rest
 Footboard on the bed would interfere with traction
 If client is sliding down on bed; Elevate the foot of the bed on blocks; keeps
leg straight and counter the pull of weights

2. Skeletal- applied directly to the bone by use or metal pin or wire

- Make sure, weights hang free and that the knots in the rope are tied
securely
 Never interrupt skeletal traction and do not remove Weights
 Pin site care
  The goal is avoid infection and development of osteomyelitis.
 Monitor: drainage (color, amount , odor)
 Loosening of pins
 Tenting at the skin at pin site
 Pin care is provide 1-2 times a day
 Crusting of the pin should not be removed
 Inspect pin site every 8 hrs for inflammation, evidence of infection
and reaction (redness, warmth, and serous sanguinous drainage at
site)
Nursing actions
 Pt is in the center with good alignment
 Skeletal fraction is never interrupted
 Ropes must be unobstructed
 Ensure Weights hang freely
 Knots are not touched the pulley, or the foot of the bed
 Avoid lifting or removing weights
 Monitor skin integrity
Complication
 Pressure, pneumonia, constipation, urinary stasis-> UTI, DVT

FRATURE COMPLICATIONS:
 Compartment syndrome
o CS, occurs when pressure within one or more muscle compartments of the
extremity compromises circulation, resulting in ischemia-edema cycle.
o Pressure can result from external resources, such as tight cast or a
constructive bulky dressing
o Internal sources such as accumulation of blood or fluid in the muscle
compartment can cause pressure as well
o Finding include
 Hallmark sign: Sever pain that occurs or intensifies with passive
ROM. (Muscle is swollen and hard)
 Deep, throbbing, unrelenting pain despite use of opioids and out of
proportion to injury and increases with passive stretching.
 Peripheral pulses; normal or decreased (early)
 Increased pain unrelieved with elevation
 Intense pain when passively moved
 Paresthesia or numbness
 Color of the tissue is pale (pallor)
 Severe pain caused by nerve damage, takes a long time to heal
o Later manifestations
 Cyanosis (blue color)
 Pain that occurs or intensifies with passive ROM (hallmark sign)
 Parenthesis
 Severe pain
 Renal failure
 Motor weakness late sign of nerve ischemia
 Pulselessness (lack of distal tissue perfusion)

o Nursing actions
  Cutting cast on one side (univalve) or both sides (bivalve)
 Loosening the constructive dressing or cutting the bandage or tape
 Elevating the extremity at heart level (not above heart level)
 Applying ice
 Volkmann contracture
o is a permanent shortening of forearm muscles, usually resulting from injury,
that gives rise to a claw-like deformity of the hand, fingers, and wrist.
o Cannot straighten fingers, severe pain
o This is a type of compartment syndrome.

 Fat Embolism-
o Fat embolism occurs with blockage of small blood vessels that supply the
brain, lungs kidneys, and other organs
o Sudden onset usually occurring 12- 48hrs but may occur up to 10 days after
injury
o More common in pts w/ multiple fractures
o Common in fractures w/ long bones
o Manifestations include
 Confusion related to arterial oxygen level (earliest sign)
 Hypoxia (reduced O2)
 Respiratory distress
 Tachycardia
 Tachypnea (rapid breathing)
 Dyspnea (SOB)
 Crackles
 Wheezes
 Cough w/ white sputum
 Precordial chest pain
 Fever
 petechia (from transcient thrombocytopenia)- petechia small (1-
2mm) red or purple spot on the body, caused by a minor
hemorrhage (broken capillary blood vessels)

o NURSING ACTIONS
 Prevention includes immobilization of fracture of the long bones
and minimal manipulation during turning if immobilization
procedure has not yet been performed
 Treatment includes:
 Oxygen
 Corticosteroids for cerebral edema
 Vasopressors and fluid replacement for shock
 Pain and anxiety meds
  VQ scan
 Neuro check

 Osteomyelitis- is an inflammation with in bone secondary to penetration by

infections organisms (trauma, surgery).
o Open fractures poses risks for osteomyelitis, tetanus and gas gangrene
o Manifestations include:
 Bone pain that is worse within movement
 Erythema and edema at the site of the infection
 Fever
 Leukocytosis and possible elevated sedimentation rate
 Many of these signs will disappear if the infection becomes chronic
o Dx procedures & TMT
 Bone Bx
 Cultures fpr detecton of microbes
 Antibiotics (long 3 month TMT of IV and oral therapy)
 Surgical debriment may be indicated. Bone graft may be necessary
 Unsuccessful treatment can resut in amputation
o NURSING ACTIONS
 Administer antibiotics and maintain blood level
 Analgesics for pain
 Neurovascular assessment if debridement is done

 Shock- hypovolemic shock (loss of blood) resulting from hemorrhage is more

frequently noted in trauma patients with pelvic fractures and in pts w/ a displaced
oropen femoral fracture.
 Deep Vein Thrombosis (DVT)-most common complication following trauma, y or
disability related to immobility
o NURSING ACTIONS
 Administer anticoagulants
 Encourage Intake of fluids
 Instruct client to rotate fee at the ankles and perform lower
extremity exercises

Total Hip Replacement

Nursing intervention
 After sx: place thigh-high TED hose (anti-embolic hose) or sequential compression
devices (SCD)
o Promotes venous return
 Prevent dislocation of the hip prosthesis by using abduction pillow (between legs)
 No turning on affected side
 Never flex the hip > 90 degree
 HOB up no more than 60 degree
 Use fracture bedpan (read pt. instruction)
 Use high-seats, raised toilet seats
 Hip should be higher than the knees when sitting
 Affected leg should not be elevated when sitting
 Avoid: internal or external rotation, hyperextension, acute flexion
  May use cradle boot (prevent leg rotation and keep heel off pressure)
 Avoid crossing legs
 Avoid sitting or standing for long periods of time
 No bending at waist level e.g. put on shoes
 Transferring from bed to chair
o Assist pt to stand on unaffected leg and pivot to a straight-backed chair,
flexing hips slightly
o Nurse stands on affected side
o Should not bear weight on affected side

Signs of dislocation
 Increasing pain, swollen, immobilization
 Groin pain
 Shortening of the leg
 Abnormal external-internal rotation
 Report “popping” sensation in the hip
 *Must be reported to the surgeon
 Check CMS

Below the Knee Amputation (BKA)

 After procedure; elevate the limb for 24 hrs
o Do not elevate for more than 24hrs bc of hip flexion
 In order to prevent hip flexion; during the first 24 hrs, the pt may lie prone for short
period of time.
 After the first day; client should lay prone for 30 mins 3 times per day
 Should perform active range of motion to strengthen the leg

Above the Knee Amputation (AKA)

 Elevate for 24 hrs on pillow
 Position prone daily to provide hip extension
 Expose stump to air dry to facilitate healing
 Stump should be inspected daily for pressure areas, dermatitis and blisters
 Infection= persistent pain

Cancer
7 Warning Signs of Cancer
1. Change in bowel habits
2. Sore that doesn't heal
3. Unusual bleeding or discharge from body orifices
4. Thickening or a lump in the breast or elsewhere
5. Indigestion or difficulty swallowing
6. Obvious change in a wart or mole
7. Nagging cough or hoarseness.

Breast cancer signs

 Inverted nipples
 Pear d' orange skin, drainage from nipples
Masectomy
  After procedure: position semi-fowlers w/ affected arm elevated
 No injections, bp, VP on unaffected side
 Avoid deodorants on affected side
 No not hang affected arm dependently, put on sling while ambulating
 Drainage system
o Unite should be fastened to gown w/o applying tension on the drainage tubing
o After emptying drain, reestablish vacuum that creates suction
o Sterile gauze to clean the drainage evacuators spout and plug prior to
reestablishing the vacuum
o Rapid re-inflation indicates air leak; if it occurs; compress unt again and check
plug for a secure fit
Prostate cancer
Risk Factors:
 Age : 50 and over
 Race: African American
 Hx of prostate cancer in family
 Employment: exposure to carcinogens found in urban areas, fertilizer, rubber,
textile industries, & places with heavy metals,

The Elderly
 Elderly pts have lower temperature due to lower basic metabolic rate
 They are intolerant to cold
 Increase ↑ protein intake – to slow down degeneration process of aging
 ↑ soluble and insoluble fiber; eat 2-4 servings of fruit per day, 3-5 of vegetables
 8-10 glasses of fluids daily
 Tongue will reflect hydration status since it in not affected by the adding process
 Instruct change position slowly
 Instruct how to call for help if in a hospital to promote rest
 Tachypnea (rapid breathing), tachycardia, and confusion may be signs of infection in
elderly pts.

Elderly abuse findings: over/undernourished, absence of needed dentures or glasses, poor

nutritional status, dehydration, urine burns, excoriations (injuries), pressure ulcers.

Glaucoma:
A condition of increased pressure within the eyeball, causing gradual loss of sight. This disease
damages to the optic nerve leads to progressive, irreversible vision loss.
S/Sy:
Cloudy blurry vision, loss of peripheral vision, artificial lights appear to have rainbows or halos
around them, pain H/A, N/V
 Teach client to return for periodic tonometer readings; 1-2 times a year
 - It is important to note whether the patient takes any β-adrenergic blockers
(Lopressor/metoprolol) because this category of medications also is used to treat
glaucoma, and there may be an increase in adverse effects.
  Patients should be instructed that eye discomfort and visual blurring are expected side
effects of the ophthalmic drops {timolol (Timoptic)} but that the drops must be used to
prevent further visual-field loss.

Cataracts
A condition in which the lens of the eye becomes progressively opaque (clouded), resulting in
blurred vision.
S/SY
• Vision that is cloudy, blurry, foggy, or filmy
• Progressive nearsightedness in older people often called "second sight" because they may
no longer need reading glasses.
• Changes in the way you see color because the discolored lens acts as a filter.
• Loss of acuity
• Problems driving at night such as glare from oncoming headlights.
• Glare during the day.
• Pupil changes from black to milky white
• Double vision (like a superimposed image).
• Sudden changes in glasses prescription.

Cataract Surgery
 The eye patch is usually on over the dressing for the first 24 hours.
 Prevent activities that can cause intraocular pressure
o Do not hold head in a defendant position (hanging down)
o Utilize dry shampoo for several weeks
o Avoid flexion ,jerky, or rapid movements like vacuuming or golfing
 Should lie in semi-fowlers position or on the none operative side
 Sleep on unaffected side w/ night shield 1-4 weeks
 Prevent fast eye movements or rotating the affected eye
 May need glasses after surgery unless a lens is implanted
 Mild eye itching caused by the stitches is normal; acetaminophen used as a mild
analgesic if necessary
 Avoid aspirin; eyes should not be rubbed or pressed

Detached Retina
 Bright flashes of light
 Loss of a portion of visual field
o Client states part of the visual field is dark
 Photophobia- eye discomfort in bright light

Corneal abrasion
Eye itching and pain suggest a possible corneal abrasion or ulcer,

Emergency Care
SHOCK
Hypovolemic Shock
An emergency condition in which severe blood and fluid loss make the heart unable to pump
enough blood to the body. This type of shock can cause many organs to stop working.
Loss of fluid from vomiting or diarrhea could cause dehydration and hypervolemia.

S/SY
Fist stages of shock S/SY: ↓ decreased urine output, even when there is normal fluid intake. It is
especially important for the nurse to elicit information about fluid intake and output during the
preceding 24 hrs.
• Anxiety or agitation
• Cool, clammy skin
• Confusion
• ↓ urine output; or none
• ↓ BP
• ↓ Body temp
• General weakness
• Pale skin color (pallor)
• ↑ rapid breathing
• ↑ HR
• Thready pulse
• Sweating, moist skin
• Unconsciousness

Nursing Interventions
 Elevate the lower extremities (modified Trendelenburg)
o Improves circulation to the brain and vital organs w/o increasing cardiac
workload and respiratory effort.
 Monitor CVP of water- Normal (CVP 3-12 cm water pressure) 8=good
o Indicates response to fluid replacement
o Decreased w/ hypovolemic shock
o Increased w/ over hydration

Cardiogenic Shock (Fluid overload)

S/SY of fluid overload
 Restlessness
 Dyspnea
 Crackles in the lungs
 HF symptoms (dyspnea, orthopnea, dependent edema, weight gain)
 Chest pain or pressure
 Decreased urination
 ↑BP
 ↑ rapid pulse
 ↑ rapid breathing
 Cool pale skin
 Rapid weight gain
Intervention
 Elevate HOB
 Stop IV fluids
 May administer Diuretics

Toxic Shock Syndrome

 Sudden onset fever, hypotension, and rash
 Change tampon every 3-6hrs
 Don’t use extra absorbent tampons
 Use sanitary napkins at night

Chest Trauma
-Flail chest- caused by fracture of multiple adjacent ribs, causing the chest wall to become
unstable and respond paradoxically.
The chest on the affected side is pulled inward during inspiration and bulges outward during
expiration.
- - During inspiration, chest expands, the detached part of the rib segment moves in a
paradoxical manner (pendelluft movement) in that it’s pulled inward during inspiration,
reducing amt. of air that can be drawn into the lungs.

-Pneumothorax- Absent or restricted movement on the affected side.

S/SY
Dyspnea, Tachycardia, sudden Pleural pain, anxiety, asymmetrical chest wall expansion, ↓
breath sounds

-Sucking Chest Wound- a sucking sound on inspiration and expiration

o Place a sterile dressing loosely over the wound, which will allow air to escape but not re-
enter to the pleural space; this is an open pneumothorax.

-Tension pneumothorax - is a complete collapse of the lung. It occurs when air enters the
pleural space, but cannot escape.
S/sy-
 Left –sided tracheal shift from midline- 1st sign
 Chest expansion might be diminished or fixed in a hyper-expansion state,
 Diminished/absent breath sounds (on affected side),
 Percussion to affected side is hyper-resonant,
 Air hunger, agitation, ↑ hypoxemia, central cyanosis, hypotension, tachycardia, and
profuse diaphoresis.

BURNS
• HEAD = 9% - front & back
• TRUNK = 18% front & back
• EACH ARM = 4.5%, front & back (9%)
• EACH LEG = 18%, front & back (9%)
• GENITALIA = 1%
  Superficial: skin appears pink, or red blotchy, increased sensitivity to heat, some
swelling, healing occurs w/o treatment
 Partial thickness: only part of skin is damaged or destroyed, large thick walled
blisters develop, fluid filled vesicles; underlying tissue is deep red, appears wet and
shiny, painful with increased sensitivity to heat; healing occurs with evolution of
undamaged basal cells, takes about 21-22 days
 Full thickness: all skin is destroyed and muscle and bone may be involved;
substance that remains is eschar, dry to touch, does not heal spontaneously,
requires grafting
STAGES OF BURNS:

• Hypovolemic state - begins at the onset of burn and lasts for the first 48 hours - 72
hours
 Rapid fluid shifts - from the vascular compartments into the interstitial spaces
 Capillary permeability with burns increases with vasodilation
 Fluid loss deep in wounds
 Initially Sodium and H2O
 Protein loss - hypoproteninemia
 Hemoconcentration - Hct increases
 Low blood volume, oliguria
 Hyponatremia - loss of sodium with fluid
 Hyperkalemia - damaged cells release K, oliguria
 Metabolic acidosis

• Diuretic Stage - begins 48 - 72 hours after burn injury:

 Capillary membrane integrity returns
 Edema fluid shifts back into vessels - blood volume increases
 Increase in renal blood flow - result in diuresis (unless renal damage)
 Hemodilution - low Hct, decreased potassium as it moves back into the cell or is
excreted in urine with the diuresis
 Fluid overload can occur due to increased intravascular volume
 Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism

Complications
-Hypokalemia can occur in the 3rd day after burn. Hypokalemia is caused by diuresis; muscle
weakness, lethargy

Wound grafting
Pt. w/ deep partial-thickness or full-thickness burns may be candidate for skin grafting
- After fire is out, remove clothing & wrap pt in a clean sheet- prevents infection
-Auto graft – pt. own skin
 Immobilization of the graft is critical; takes 7-10 days for the graft to really adhere
 Manage pain

Spinal Cord injuries

 After any spinal cord injury the priority is to prevent flexion or hyperextension of
the spine
 Flaccid bladder may develop after spinal cord injury
o Encourage beverages that promotes acidic urine to prevent UTI’s: cranberry
 juice, prune juice, tomato juice, bouillon

Autonomic Dysreflexia is a potentially dangerous clinical syndrome that develops in

individuals with spinal cord injury, resulting in acute, uncontrolled hypertension. Develops
in individuals with a neurologic level of spinal cord injury at or above the sixth thoracic
vertebral level (T6).
S/SY
 Pounding Headache (caused by the elevation in blood pressure)
 Hypertension (blood pressure greater than 200/100)
 Blurred vision
 Piloerection (Goose flesh)
 Profuse Sweating above the level of injury (especially forehead)
 Nasal Congestion
 Slow Pulse
 Blotching of the Skin
 Restlessness
 Flushed (reddened) face
 Red blotches on the skin above level of spinal injury
 Sweating above level of spinal injury
 Nausea
 Slow pulse (< 60 beats per minute), ↑BP
 Cold, clammy skin below level of spinal injury
Interventions
 Place pt. in sitting position should be done immediately
o To help decrease BP and prevent increased intracranial pressure w/ cerebral
hemorrhages and seizures
 Asses for distended bladder after pt is sitting up

What can trigger autonomic dysreflexia? Some of the stimuli that may trigger autonomic
dysreflexia are as follows: 
 Distended bladder or rectum (too full)
 Pelvic, rectal, or urologic exam 
 Uterine contractions, especially during labor and delivery 
 Urinary tract infection 
 Pelvic infection 
 Pressure ulcer 
 Clots in your leg veins

Head Injury
 Position clients neck in a midline position and HOB 30 degrees (neutral position)
 Do NOT give narcotic analgesics; Morphine for pain; causes CNS and respiratory
depression and can mask signs of ICP.
 Can use stool softeners (Ducosate)
 Monitor for ICP
 Early signs: change of LOC, restlessness, slowing of speech, Fixed/dilated Pupils
delayed responses, restlessness, and confusion.
 Late signs LOC continues to deteriorate until pt is comatose, Cheyne-Stokes
respirations (deep breathing; marked by periods f apnea lasting 10-60 secs; followed
 by hyperventilation), decortication and decerebration, bilateral flaccidity, loss of gag
reflexes, pulse and resp decrease or become erratic, BP and temp increase, pulse
fluctuate form bradi to tachy fast, widening pulse pressure, projectile vomiting.
Interventions
 Elevate HOB 15-30 degrees
 Assess cough and gag reflex
 Avoid frequent suctioning
 Keep head from rotating or flexing

Pediatrics
Characteristics based on age
 Weight doubles by 6 months and triples by 12
 Newborn pulse 100-160 RR: 30-60
 Posterior fontanelle should be closed by 2-3 months
 Anterior fontanelle is generally the last to close between 1-3 years of age
 1-3 – grasp reflex is strong; disappears after 3 months
 3 months- holds head erect while sitting
 4-6 brings objects to the mouth
 6 months- Sitting up with support
 7-9 months- sits without support
 9 months – a present pincher grasp ; can say momma dadda
 10-12 months- the infant eats with his fingers
 13-15 months- walking w/o help
 15 months- the infant assumes standing position with out assistance
 18 months- building tower blocks
 1 year- Tripling of the birth weight
 20 months begin toilet training; by 24 months may be able to achieve daytime
Bladder control
 2 yrs (24 months)- uses 2-3 word phrases
 3 yrs (30 months)- has a steady gait, stands on one foot momentarily, can walk up
and down the steps. Jumps with both feet.
 Infants head circumference: 33-35cm
 Infant chest circumference: 30.5-33 cm
 Infant Heart rate: 120 (sleeping) to 180 (crying); respirations 30-60 breaths/min

Age Fine motor Gross Motor

Infancy: 3 mo Lifts head and chest in prone position;
1mo-1yr Follows objects with eyes moves arms and legs simultaneously
6 mo Rolls from side to side well; sits with
Transfers objects from hand to hand assistance
9 mo sits well w/o assistance; crawls; stands w/
Uses pincer grasp
assistance; say momma dada
12 mo Turn pages in books; attempts to stack
walks w/ assistance; stand w/o assistance
blocks
Toddler:
1-3yrs 15 mo Builds tower of 2 blocks Walks w/o assistance
24 mo Removes clothes, build tower of 6 blocks, Walks up and down stairs, crawls; runs
 turns doorknob, sphincter control after ball
36 mo Dresses and undresses; holds pencil with Runs well, jumps from a step, rides
(3yrs) tripod grip tricycle, walks on tip toes

Pre-School: 3-6 yrs Kicks well; uses alternative feet on stairs;

3-6yrs
Copies a triangle; threads beads; uses
scissors; draws a person;
catches a ball; skips and hops on one foot
by 4 yrs; balances on alternative feet by 5
yrs;

School- 6-12 yrs Physical skills maximized; rides bike; runs;

Cursive writing, craft projects, play cards
Aged: swim; dances; jump rope; neatly ties shoe
and board games
6-12yrs laces by 6

Adolescent: 12-18 yrs

Maximized fine motor Maximized strength
12-18yrs

Play Methods
 Infants (birth-1 year)- Solitary play; interest centered on own activity but enjoys
presence of others. Ex. Touching/ examining toys and putting it in their mouths
 Toddlers (1-3 yrs)- Parallel play; playing alongside but NOT with others; Ex 2 toddlers
tend to play with similar objects side by side
 Pre-school (3-6)- Associative play; no group goals, often follows a leader; Ex 3 kids
playing tag
 School age (6-12)- Cooperative play; organized rules, leader/follower relationship, Ex. 4
kids playing doge ball
o The child learns to compete and cooperate with others
 Adolescent (12-18)-
Safety Concerns
 Infants (birth-1yr)- aspiration
 Toddlers (1-3)- water safety
o Encourage finger foods
 Pre-school (3-6)- water safety
 School age (6-12)- sports related injuries
o Encourage proper nutrition b/c risk in obesity

 Adolescent (12-18) – suicide prevention

New Born Rexles

 Root reflex. This reflex begins when the corner of the baby's mouth is stroked or
touched. The baby will turn his or her head and open his or her mouth to follow and
"root" in the direction of the stroking. This helps the baby find the breast or bottle to
begin feeding.
 Suck reflex. Rooting helps the baby become ready to suck. When the roof of the baby's
mouth is touched, the baby will begin to suck. This reflex does not begin until about the
32nd week of pregnancy and is not fully developed until about 36 weeks. Premature
 babies may have a weak or immature sucking ability because of this. Babies also have a
hand-to-mouth reflex that goes with rooting and sucking and may suck on fingers or
hands.
 Moro reflex (Startle). The Moro reflex is often called a startle reflex because it usually
occurs when a baby is startled by a loud sound or movement. In response to the sound,
the baby throws back his or her head, extends out the arms and legs, cries, then pulls
the arms and legs back in. A baby's own cry can startle him or her and begin this reflex.
This reflex is strongest at 2 months and should disappear after 3-4 months.

 Tonic neck reflex. When a baby's head is turned to one side, the arm on that side
stretches out and the opposite arm bends up at the elbow. This is often called the
"fencing" position. The tonic neck reflex lasts about six to seven months.
 Grasp reflex. Stroking the palm of a baby's hand causes the baby to close his/her fingers
in a grasp. The grasp reflex lasts only a couple of months and is stronger in premature
babies.
 Babinski reflex. When the sole of the foot is firmly stroked, the big toe bends back
toward the top of the foot and the other toes fan out. This is a normal reflex up to about
2 years of age.
 Step reflex (dancing). This reflex is also called the walking or dance reflex because a
baby appears to take steps or dance when held upright with his or her feet touching a
solid surface.
 Extrusion Reflex: the tongue moving outward when the tongue is touched; disappears
between 3-4 months of age.

Normal Assessment Findings

 Milia- Exposed sebaceous glands appear as raised white spots on the face especially
around the nose. Disappears in a few days or weeks; no treatment required.

 Telangiectatic Nevi (stork bites)- go away by the 2nd birthday. Pale pink or red spots
(birthmark) and are frequently found on eyelids, nose, lower occipital bone, and nape of
the neck

 Mongolian Spots- Macular areas or black or bluish-gray pigmentation on the dorsal area
and the buttocks (sacral area). Gradually fades over a period of months or years
(birthmark).(Asian, Hispanic, and African descent)

 Nevus vasculosus (strawberry mark)- It is a raised, clearly delineated, dark red, rough-
surfaced nodules. Commonly found in the head region (birthmark).

 Port-wine stains (nevus flammeus)-. Large-irregular, flat macular patch reddish-purplish

discoloration of the skin. Are found on the face, neck, scalp, arms, or legs. (Usually does
not go away)

Abnormal Findings
 Jaundice- Yellow Discoloration due to High Bilirubin. Jaundice appears first in the head,
progresses cephalocuadal (from head to toe); jaundice with in the 1 st 24hrs indicates
hemolytic disease of newborn.
 o If receiving phototherapy for treatment of jaundice, vital signs are checked every
2 to 4 hours because hyperthermia can occur due to the phototherapy lights.
o Phototherapy is considered for infants w/ Bilirubin > 15 mg/dl at 72 hrs of age

Feeding
 Infants are less likely to be allergic to rice cereal than to any other solid food; usually
started between 4 and 5 months of age; breast- fed infants may be started on solids
even later.
 Breast feeding mothers should increase her daily caloric intake by 500 calories; milk
production requires an increase of 500 calories per day

Infant (Birth to 1 Year)

Play:
Infants spend much of their time engaging in Solitary Play/Onlooker, or playing by
themselves. The play often begins in a reflexive manner. The next phase of infant play
focuses on manipulative behavior (examining toys, touching them, and placing them in
mouth)
***TOYS include:
Birth to 3 Months 6 Months 9 Months 9-12 Months
*Music Box *Rattle *Rattle *Push and Pull
*Mobile *Soft toys *Soft toys *Cloth books
*Mirror *Bright colors *Bright colors *Surprise toys
*first teething rings *Ball

*Toddler (1 to 3 Years)
Play:
Toddlers find the company of other children pleasurable, even though socially
interactive play may not occur. Two toddlers tend to play with similar objects side by
side, occasionally trading toys and words, Parallel Play. This play time helps develop
social skills. They engage in play activities seen at home. Both gross and fine motor
activities are enhances during this period. ****TOYS include:
12 months 15- 18 Months 24 Months 36 Months
*Push and Pull *Push and Pull *Push and Pull *Tricycle
*Cloth books *Blocks *Riding toys *Dress up clothes
*Surprise toys *Jack in the Box *Crayons
*Large blocks *Blocks *Puzzles
*Ball *finger paints *Books
*Water play *Videos

*Preschool Child (4 to 6 Years)

Play:
The preschooler has begun to play in a different way, Associative Play (ex. One child
cuts the paper and another glues the paper).The preschooler enjoys large motor
activities such as swinging, riding a tricycle, and throwing a ball. Because fantasy life is
so powerful at this age, the preschooler readily uses props to engage in Dramatic Play
(The living out the drama of human life). Play is highly Imitative (imitates dad on the
telephone) , dramatic, and imaginative and reflects sex role standards. May also have
imaginary playmate. TOYS include:
3 to 6 Years
*Videos *Arts and Crafts *Story time *Ball *Tricycle *Puppets *Play House *Clay *Coloring Books

*School-Age Child (6 to 12 Years)

Play:
The characteristics of play exhibited by the school-age child are cooperation with others
and the ability to play a part in order to contribute to a unified whole, Cooperative
Play/ Group oriented, mainly with same sex.
TOYS/Activities include:
6 to 12 Years
*Board/Video Games *Card games *Team activities *Sports *Dance *Musical instruments

*Adolescent (12-18 Years)

Play:
Adolescents become more dependent on parents for transportation on parents and
spend more with friends. Activities include participation in sports and extracurricular
school activities, as well as “hanging out” and attending movies or concerts with friends.
Peer groups become the focus of activities, and are important in establishing identity.
TOYS/Activities include:
12 to 18 Years
*Video games *Sports (Team) *School activities *Quiet activities Ex. reading

Respiratory Syncytial Virus (RSV)

A virus that causes infections of the lungs and respiratory tract. It's so common that most
children have been infected with the virus by age 2. Respiratory syncytial (sin-SISH-ul)
virus can also infect adults.

S/SY
Typically appear about 4-6 days after exposure to the virus. In adults and older children,
RSV usually causes mild cold-like signs and symptoms. These include:

• Congested or runny nose

• Dry cough
• Wheezing
• Low-grade fever
• Poor feeding
• Sore throat
• Mild headache
• Diarrhea & vomiting
• Severe symptoms: tachypnea, > than 70 breaths/min, grunting , increased wheezing,
retractions, nasal flaring, irritability, lethargy, poor fluid intake, and distended abdomen
from over expanded lungs.
Nursing considerations
 Contact precautions- gown, gloves
 Place pt in private room
 Humidified oxygen to maintain SpO2 greater than 90%.

Infant Meningitis
s/sy: fever, poor feeding, irritability and bulging fontanel
-Droplet precautions

Sickle Cell Anemia

SCD is a serious disorder in which the body makes sickle-shaped red blood cells. “Sickle-
shaped” means that the red blood cells are shaped like a crescent. Red blood cells carry
oxygen to the body.
 Sickle cell anemia is an autosomal recessive disorder
If both parents have the trait, with each pregnancy the risk of having a child with the
disease is 25%.
• The abnormal cells deliver less oxygen to the body's tissues.
They can also easily get stuck in small blood vessels and break into pieces. This can
interrupt healthy blood flow and cut down even more on the amount of oxygen flowing to
body tissues.

Risk factors
 Primarily in Blacks
 Mediterranean decent
Triggers of sickling
 INFECTION – highest trigger
 May be triggered by fever and emotional or physical stress, hypoxia
 Hypoxia can be caused by hypoventilation, vasoconstriction in cold weather, high
altitudes and emotional or stressful event.
 Any condition that increases the body's need for oxygen or alters the transportation
of oxygen such as infection, trauma or dehydration may result in sickle cell crisis.
S/SY
 Symptoms do not occur until after 4th months
 Hematuria
 splenic infarction (necrosis)
 Fatigue
 Paleness
 Rapid heart rate
 Shortness of breath
 Yellowing of the eyes and skin (jaundice)
• Sickle cell crisis
  Severe pain (chest, back, arms, legs, and abdomen. Pain can occur anywhere in the
body)
 Anemia
 Chest pain and difficulty breathing
 Strokes
 Joint pain and arthritis and bone infarctions 
 Blockage of blood flow in the spleen or liver
 Severe infections
Interventions
 Administer oxygen as priority (b/c of hypoxia)
 Hydration s priority
 Pain relief
 May use a patient -controlled analgesia (PCA):
o Itching is a common side effect
 The IV fluids used before and after a blood transfusion must be saline rather than
D5W, monitor for reaction to the transfusion.
 Encourage rest and help avoid emotional stress.
 Many activities result in tissue hypoxia, so you must schedule caregiving activities
and play.
 Help the child assume a comfortable position and avoid putting stress on painful
joints (you may use warm packs for joint pain).
 Administer acetaminophen (Tylenol) or ibuprofen (Advil) for moderate pains and
opioids for severe pain
 Aspirin is contraindicated in a sickle cell crisis
 Vaccinate for influenza and pneumonia to prevent with future sickling

Croup Syndromes
 Croup is a term applied to a broad classification of upper airway illnesses that result
from swelling of the epiglottis and larynx.
 The swelling usually extends into the trachea and bronchi.
 Initial symptom of all 3 conditions include:
o Respiratory stridor (high-pitched, musical sound that is created by narrowing of
the airway)
o “Seal-like” barking cough
o Hoarseness
o Laryngotracheobronchitis (LTB) is the most common disorder but Epiglottitis
and Bacterial Tracheitis are more serious.

Summary of Croup Syndromes

Viral Syndromes Bacterial Syndromes
Acute Laryngotracheitis/ Bacterial Epiglottitis (supraglottitis)
Spasmodic Laryngotracheobronchi Tracheitis
Laryngitis tis
(Spasmodic
Croup)
Severity Least serious Serious; progresses if Guarded; requires Most life-threatening
untreated close observation (medical emergency)
Age 3 months -3 yrs 3mos-8 yrs 1 mo-13 yrs 2yrs- 8yrs
Affected
Onset Abrupt onset; Gradual onset, starts as Progressive from Progresses rapidly (hours);
peaks at night; URI, progresses to URI (1-2 days) may progress to complete
resolves by symptoms of respiratory airway obstruction
morning distress; symptoms worse
(recurs) at night
Clinical Afebrile; mild Early: mild fever (less than High fever (higher High fever (higher than 39
Manifest respiratory 40 degrees C (102.2 degrees than 39 degrees C degrees C (102.2 degrees F);
ations distress; F) barking-seal, brassy, (102.2 degrees F); URI; intense sore throat,
barking-seal croupy cough, rhinorrhea, URO appears as dysphagia, drooling,
cough sore throat, stridor viral croupy cough increased pulse rate; prefers
(inspiratory); and croup initially, upright position (tripod
apprehension; restless or stridor (tracheal); position w/chin thrust);
irritable purulent secretions; cherry red epiglottis.
Progressing to retractions often prefers to lie *Tacypnea (↑rep rate/ rapid
(progressive); increasing flat breathig) is an early sign of
stridor; cyanosis hypoxia, also for tachycardia
Etiology Uknown; Para influenza, type I and Staphylococcus, Haemophilus influenza,
allergic II, RSV, or influenza; may Moraxella streptococcus,
response to develop a bacterial catarrhalis, and no- staphylococcus
viral antigens superinfection typeable
rather than a Haemophilus
direct infection influenza; may
is suspected; follow viral LTB
emotional
influences
Clinical Maintaining and Antibiotics are Immediate clinical therapy
Therapy improving respiratory given for a full 10- usually involves insertion of
effort w/meds & 14 day course. an ET tube to maintain
supplemental oxygen Most children need airway.
when the SpO2 level is intubation until Abx effective for gram-
<92%. swelling diminishes. positive organisms & H.
Children w/mod. to influenza are given until the
severe symptoms after culture sensitivities are
nebulizer meds are available.
admitted for further Racemic epinephrine &
observation & tx. corticosteroids are not
effective.
Rifampin prophylaxis (once a
day for 4 days) should be
given to any child contact
that is immunocompromised
or under age 48 months with
incomplete Hib
immunization.
Antipyretics
(acetaminophen, ibuprofen)
may be useful in managing
fever and sore throat pain.

If a child cries, obstruction of

 the airway can occur.

TMT: moist air and IV

antibiotics

Cystic Fibrosis
 A common inherited autosomal recessive disorder of the exocrine glands that results in
physiologic alterations in the respiratory, GI, and reproductive organs.
 Children develop a classic cough bc the respiratory cilia in the lungs cannot clear the
thick mucus.
 This collection of sticky mucus results in life-threatening lung infections and serious
digestion problems
Clinical Manifestations
 One of the first sings noticed by parents Salty taste to skin
 Meconium ileus (1st stool an infant has) may be found in newborns
 Stool characteristics
o Steatorrhea (fat or greasy)
o Frothy (bulky and large quantities)
o Foul smelling
o Floating
 Constipation is common
 Intestinal obstruction in older children
 Rectal prolapse, resulting from the large, bulky, difficult-to-pass stools.
 Respiratory signs and symptoms:
o Chronic, moist, productive cough
o Fx respiratory infections
o Wheezing
o SOB
o A child can have a barrel chest or clubbing of he fingers
 Signs of chronic sinus infection
o Frontal headaches
o Facial tenderness
o Purulent nasal discharge
 Nasal polyps
 Clubbing –develops over time
 Barrel chest – develops over time

DX test
Sweat Chloride test: measures the amount of chloride in skin sweat. Abnormally high
concentration of Sodium and Chloride are found in CF.
Management
 Clinical therapy focuses on maintaining respiratory function, managing infection,
promoting optimal nutrition and exercise, and preventing GI blockage.
 Frequent prolonged courses of antibiotics for infections may be prescribed to improve
pulmonary function, exercise tolerance, and quality of life.
 Perform Chest physiotherapy done before meals
 The diet of someone with cystic fibrosis should be high in ↑ calories, high ↑ protein,
low fat as they will not be able to digest all the food they eat. Salty snacks are
recommended for salt depletion.
 A dietitian may recommend salt supplements for a child with cystic fibrosis, especially
in hot weather or if they are going on holiday to a country with a warm climate, where
sweating may cause a loss of salt (Na). - “Hence salty skin”
 Anti-inflammatory tx is sometimes prescribed.
 Vitamins and pancreatic enzymes are also provided to improve the child’s nutritional
status.
o Administer pancreatic enzymes w/ meals and snacks
o Instruct the child/family that the capsules can be swallowed whole or opened
to sprinkle the contents on a small amount of food
 End-stage lung disease is the cause of death in 80% of patients with CF
 Do postural drainage after meals
Complications
CF causes
o COPD
o Pancreatic exocrine deficiency

Myelomeningocele
A birth defect in which the backbone and spinal canal do not close before birth. The
condition is a type of spina bifida.

S/SY
A newborn may have a sac sticking out of the mid to lower back. The doctor cannot see
through the sac when shining a light behind it. Symptoms include:
• Loss of bladder or bowel control
• Partial or complete lack of sensation
• Partial or complete paralysis of the legs
• Weakness of the hips, legs, or feet of a newborn
-Other symptoms may include:

• Abnormal feet or legs, such as clubfoot

• Build up of fluid inside the skull (hydrocephalus)
• Hair at the back part of the pelvis called the sacral area
• Dimpling of the sacral area
Interventions
 Position: On their abdomen with their face turned to the
side
 Monitor for temperature, irritability and lethargy
 Infant is at risk to develop infection (meningitis) b/c of myelomeningocele sac; change
dressings every 2-4 hrs using aseptic technique. Keep moist before sx.
 Keep perineal area clean and dry; place on pressure reducing surface; risk for infection
takes priority
 Monitor occipitofrontal circumference daily; risk for impaired circulation of
cerebrospinal fluid (hydrocephalus )

Hemophilia
  Hemophilia usually is inherited. It is a rare bleeding disorder in which the blood
doesn't clot normally.
 if you have hemophilia, you have little or no clotting factor.
 you may bleed for a long time after an injury or accident. You also may bleed into
your knees, ankles, and elbows.
 Bleeding in the joints causes pain and, if not treated, can lead to arthritis. Bleeding in
the brain, a very serious complication of hemophilia, requires emergency treatment.
 Hemophilia affects males much more often than females.

There are two types of inherited hemophilia:

 Type A, the most common type, is caused by a deficiency of factor VIII (8), one of
the proteins that helps blood to form clots.
 Type B hemophilia is caused by a deficiency of factor IX.
S/Sy
 Joint pain (may indicate bleeding)
 Prolonged external bleeding
 Bruising that occurs easily or for no apparent reason
 May have any type of internal bleeding (inside the body), but most often in the
muscles and joints, such as the elbows, knees, hips, shoulders, and ankles
 Joint may become hot to the touch, swollen, and painful to move
Interventions
 Codeine phosphate (Paveral)- for pain , Percocet (oxycodone w/ acetaminophen)
 Contraindicated: Aspirin, NSAIDS, oxycodone, Motrin , Percodan (oxy w/asp)

Increased Intracranial Pressure (ICP)

 High-pitched cry- 1st sign of ICP in infants
 Pupils respond to light slowly

CELIAC DISEASE (Gluten-sensitive enteropathy)

 -It’s a chronic malabsortion syndrome
 4-17% of Down Syndrome have celiac disease
 Immunologic disorder characterized by gluten intolerance: Inability to digest
glutenin and gliadin (protein factors) results in the accumulation of the amino acid
glutamine, which is toxic to mucosal cells in the intestine
-In the first stages fat absorption is affected and you can see fat in the stool (steatorrhea).
Stools are greasy, foul smelling, frothy, and excessive -
Impairment of the absorption of:
-Protein
-Carbohydrates
-Calcium
-Iron
-Folate
-Vitamins: A, D, E, K and B12

SIGNS AND SYMPTOMS:

-When solid foods are introduced to the child between 6mo to 2 y/o
-Chronic diarrhea
-Growth impairment
 -Abdominal distention
-Poor appetite
-Lack of energy
-Muscle wasting w hypotonia
(decreased muscle tone)
-Delayed onset of the disease (5-7 y/o): nausea, vomiting, recurrent abdominal pain, and
bloating, delayed growth, iron deficiency, defects in tooth enamel and abnormal liver
function tests

Diet Gluten free

NO BROW (Bread, Rye, Oats, Wheat) Diet

FOODS ALLOWED FOODS PROHIBITED

Meats such as: Commercially prepared:
 Beef  Ice cream
 Pork  Chocolate
 Poultry  Soups
 Fish  Condiments/ starch
 Eggs  Malted milk
 Milk and dairy pdts  Prepared: puddings/meats
 Vegetables  Grains including anything made from wheat,
 Rice rye, oats, or barley such as:
 Corn *Breads *rolls
 Gluten-free flour, puffed rice, cornflakes, *Cookies *cakes
cornmeal, and precooked gluten-free *Crackers *cereal
cereals *Spaghetti *macaroni noodles
*Beer *Ale

Fetal Alcohol Syndrome

Physical characteristics- infant with a small head circumference, low birth weight, and
undeveloped cheekbones. May have feeding difficulties and poor sucking ability.
 Replace vitamins depleted as a result of poor maternal diet; adequate intake of B
complex vitamins are necessary for normal CNS function.

PKU (Phenylketonuria)
Phenylketonuria (also called PKU) is a condition in which your body can’t break down an
amino acid called phenylalanine. Amino acids help build protein in your body.

What problems can PKU cause?

Babies born with PKU seem normal for the first few months of life. But without treatment,
they begin to have signs and symptoms of the illness at about 6 months of age. These
include:

 Jerky movements in arms and legs

 Lighter skin and eyes (Babies with PKU can’t properly make melanin, the pigment in
the body that’s responsible for skin and hair color.)
  Musty body smell
 Seizures
 Skin rashes
 Small head size
 Taking longer than expected to sit, crawl or walk
 Losing interest in surroundings
 Delays in mental and social skills
 Intellectual disabilities
 Behavior problems, like being hyperactive

Testing
A phenylketonuria (PKU) screening test is done to see whether a newborn baby has the
enzyme needed to use phenylalanine in his or her body.
 If initial specimen is collected before newborn is 48 hrs old, a repeat test should be
done by 2 weeks of age
PKU Diet
Meal plan that is low in phenylalanine. It’s best to start this meal plan as soon as possible,
ideally within the first 7 to 10 days of life.

 At first, your baby gets a special protein formula (Lofenalac) that has reduced
phenylalanine.
o Lofenalac is low in phenylalanine but contains minerals and vitamins
required by the infant.
 When your baby is ready to eat solid foods, she can eat vegetables, fruits, some
grains (like low-protein cereals, breads and pasta) and other low-phenylalanine
foods.
 If your baby has PKU, she should not eat:
 Milk, cheese, ice cream and other dairy products
 Eggs
 Meat and poultry
 Fish
 Nuts
 Beans
 Food or drinks that contain aspartame. This is an artificial sweetener that has
lots of phenylalanine in it. It’s sold as NutraSweet and Equal.

Ophthalmic complications
If the Red reflex is absent in the newborns eye it may indicate an ophthalmic emergency
bc light is not being transmitted to the retina and this can cause blindness.

Down syndrome
Newborns ears are low-set bilaterally. Flat occiput, broad nasal bridges, yes that have
epicanthal folds and slant upwards, large tongue, high palate, small chin

MUMPS
S/sY : fever, headache, malaise, anorexia, sore throat, ear ache when chewing, swelling of the
parotid glands (btw ear and jaw). Communicability greatest immediately before and after
swelling begins.

Tonsillectomy
 Observe for frequent swallowing; early sign of bleeding; observe when awake and
asleep
 Other signs of bleeding are increased pule& pallor, and vomiting bright red blood
 Restrict fluids until there is no sign of hemorrhage then offer clear fluids; avoid fluids
with red or brown color.
 White patches on the throat indicates healing

Cyanotic heart defect- the patient has lack of oxygen going to the body usually because of an
abnormal blockage or malformation of blood flowing from the right part of the heart into the
lungs. Since not enough blood flow gets to the lungs, the pt may turn blue or "cyanotic".

Acyanotic heart defects - usually involving the left part of the heart there is usually abnormal
blood flow going from the left part of the heart to body. This doesn't cause the person to turn
blue "acyanotic"- but may lead to congestive heart failure.

Acyanotic Cyanotic
LEFT TO RIGHT SHUNT; increased pulm blood flow; RIGHT TO LEFT SHUNT; decreased pulm blood
obstructive defects flow; mixed blood

Ventricular Septal Defect (VSD) – Hole between
ventricle; may close spontaneously; may cause HF
Atrial Septal Defect (ASD) – hole between atria; sx
closure before school age to avoid CHF; not as
serious
Patent Ductus Arteriosus (PDA)– opening between
aorta and pulm artery; usually closes w/in 72 hrs
after birth; if it remains patent, oxygenated blood
from aorta returns to pulm artery; may cause pulm
HTN
- Indocin to close it
- Prostaglandin E to keep open
Coarctation of the Aorta – obstructive narrowing in
aorta; HTN in upper extremities, decreased in lower
extremities
Aortic Stenosis – narrowing at aortic valve;
oxygenated blood into systemic circulation is
diminished; low cardiac output
Tetralogy of Fallot – (PROV) VSD, overriding
aorta (aorta is over and above the VSD),
pulmonary stenosis (obstructs right vent
outflow), right ventricular hypertrophy (b/c of
pulm stenosis);
- Cyanosis b/c unoxygenated blood is
pumped into systemic
- Tet spells (hypoxic episodes) –
squatting/knee to chest helps relieve
- Staged surgery
Truncus Arteriosus – pulm artery and aorta do
not separate; one main vessel receives blood
from both ventricles; needs a large VSD to stay
alive at birth
Transposition of Great Vessels – great vessels are
reversed; pulm circulation comes from left vent
and systemic circulation from the right vent;
needs VSD, ASD and/or PDA to survive at birth
- Needs prostaglandin E to keep
open!!!
Maternity

Signs of pregnancy
Presumptive signs – Subjective symptoms felt by the women
 Amenorrhea: The cessation of Menses. It suggests pregnancy has occurred, but not
uncommon for a woman to miss her period
 N/V (Morning sickness): This is associated with increased HCG levels
 Breast Changes
 Urinary Frequency
 Fatigue
 Quickening (Fetal Movement)
 Fatigue
 Darkened areola and tingling in the nipples

Probable signs – Signs observed by the examiner

 Positive urine pregnancy test
 Uterine enlargement
 Soufflé and contractions
 Goodell's Sign- Softening of the cervical tip
 Hegars sign- softening and compressibility of lower uterus
 Chadwick sign- deepened violet-bluish color of vaginal mucosa secondary to
increased vascularity of the area
 Ballottement- rebound of unengaged fetus
 Braxton Hick's Contractions- false and painless contractions; irregular contractions
o Palpated after 28th week
o Lie down
o Drink water
o Elevate legs
o Relieved by walking
 Fetal Outline (palpated by examiner) =Leopold’s maneuver
Positive signs-These are positive signs attributed to the presence of the fetus.
 Auscultation of the fetal heart rate (Audible at about 10-12 weeks)using Doppler;
using stethoscope audible at 20 weeks.
o Fetal parts and movement seen at 8 weeks in U/S
 Fetal Movements- Visualization of the fetus by a sonogram .

 First trimester- week 1-12, or about 3 months.

 Second trimester- week 13 -27
 Third trimester - week 28 to birth.

 NulliGravida- A woman who has never been pregnant.

 Nullipara- A woman who has never delivered a live child; also seen as “para 0."
 Primigravida - A woman who is pregnant for the first time.
 Multigravida is the term for a woman who has had more than one pregnancy.
 Primipara- A woman who has given birth to 1 child.
 Multipara-A woman who has given birth to more than one viable infant

Obstetrical History GP TPAL: (P.384) (ATI-25)

 Gravida (G) - any pregnancy, regardless of duration, including present pregnancy
 Para (P) - births after 20weeks gestation regardless of whether the infant is born alive or
dead
 T: number of TERM infants born after 37 weeks gestation or more
 P: number of PRETERM infants born, born after 20 weeks but before the completion of
37 weeks
 A: number of All pregnancies ending in either spontaneous or therapeutic ABORTION
 L: number of currently LIVING children

Naegele Rule:
add 7 days to the first day of the last menstrual period and subtract 3 months.
Eg. Last menstrual period began May 8. The estimated date of confinement is February
15.
May 8 LMP + 7 days = 15
– 3 months = February 15

Signs that Labor is Approaching

 Lightening. Lightening is the settling of the fetus into the pelvis. people often say,
“the baby has dropped.” Lightening usually occurs 2 to 3 weeks before the onset of
labor in primigravidas (women having their first child). If the client is a multigravida
(has had more than one pregnancy), lightening may not occur until labor begins.
Although lightening allows the pregnant woman to breathe more easily, she will
 notice an increase in pelvic pressure and urinary frequency and may also have leg
cramps and increased leg edema.

 Braxton-Hicks Contractions. During pregnancy’s late stages, the uterine muscles

prepare for labor and delivery by tightening and relaxing at intervals. They are
usually painless, short, and irregular. They are also known as false labor. As labor
approaches, these contractions may become stronger and somewhat regular. She
may experience false labor anytime in the last trimester, but more often during the
final 2 or 3 weeks of pregnancy.
 Show. A mucous plug seals the cervix during pregnancy. Just before labor, the cervix
opens slightly and this plug dislodges. At the same time, some capillaries of the
cervix rupture, staining the sticky mucus a pinkish color. This process is called the
show, or bloody show, and indicates that labor is about to begin.

Fetus Characteristics
8 weeks- baby has heart beat and arms and legs start to form
16 weeks- determine gender of baby
38 weeks- baby can hear and breathe

 Pre-term characteristics- Extremities are Flexed in a term infant at rest: in a Preterm

infant, extremities are in extension.

 Full term: Fine hair covering (lanugo); greatest at 28 weeks gestation; disappears first
from face and then from trunk; indicates a full tern infant.
 Elbow creases contain vernix (white skin coating)
 Nipple bud measures 0.5-1 cm

Fetal Monitoring
Internal Fetal monitor- Monitors the oxygen status of the fetus during labor. Goal is early
detection of mild fetal hypoxia.

Amniotic Fluid analysis

Amniocentesis is a procedure used to obtain amniotic fluid for genetic testing (early in
pregnancy or between 14 to 16 weeks) for fetal abnormalities or to determine fetal lung
maturity in the 3rd (2:1).
This procedure is also done for:
 Maternal age 35 older
 Previous child with a chromosomal abnormality
 Parent carrying a chromosomal abnormality
 Mother carrying an X-linked disease
 Parents carrying an inborn error of metabolism that can be diagnosed in utero
 Both parents carrying an autosomal recessive disease
 Family history of neural tube defects
 Alfa fetoprotein abnormal
 Lung maturity
During the procedure the physician does an US to scan for the fetal position and to Identify
adequate pockets of AMF, cleaned with betadine solution, 22 gauge needle (local anesthetic
optional),
Complications include:
 Hemorrhage
 Infection
 Fetal death
 Preterm labor
 PROM

Alpha fetoprotein – between 15-22 wks –

↑ Elevated AFA-neural tube defect, (encephalopathy)
↓ Low AFA -may be chromosomal defects (down syndrome)

Rh factor
An Rh-negative woman who conceives whit an Rh + positive man will most likely have an
incompatibility problem. b/c the woman has Rh antibodies.
o Rh immune globin is given to Rh - negative mother who delivers Rh +positive baby
when the baby has a negative - direct Coombs test.
o If the mother is RH- negative, the mother will receive a RhoGam injection at around 28
weeks and also an injection at 72 hours post delivery.
o RhoGAM is given when the Rh- negative mother has a miscarriage or abortion of an
Rh+positive fetus.

Leopold’s Maneuver- determines fetal position by palpation

1. Have mother empty bladder
2. Palpate upper abdomen w/ both hands
3. Palpate fetal back
4. Palpate head or breech
5. Down sides of uterus toward pubis

McRobert’s Maneuver- done if there is shoulder dystocia

Sharp flexion of the thighs towards his and abdomen; apply downward supra-pubic
pressure

Contractions:
 Contractions continuously lasting every 5mins for an hour indicate labor- contact Dr if
this happens
 Contractions every 3-4 mins indicate active labor
 Mucus plug can expel up to 2 weeks before onset of labor, client may not notice

Stages of Labor
1st stage: from onset of true labor to complete dilatation of the cervix
 Latent/Early Phase (0-3 cm)
  Freq 5-30min, dur 30-45 secs
 Client is talkative and excited
 Active Phase (4-7 cm)
 Freq 3-5min, dur 40-75 secs
 Anxious and in pain
 Epidural can be given
 Transition phase (8-10 cm)
 Freq 2-3min, dur 45-90 secs
 Complete effacement; increased pressure in pelvis causes intense desire to
urinate.
 You might experience hot flashes, chills, nausea, vomiting, or gas
 May have N/V and irritable
 Encourage Pursed lip breathing

2nd stage: from complete dilatation to birth of the infant

 Start to PUSH

3rd stage: from birth to delivery of the placenta

4th stage: From delivery of the placenta up to four hours after birth
o Palpate the fundus 3 fingers under the umbilicus
o “Shaking chills” felt at the end of pregnancy

Boggy uterus deviated to right indicates a full bladder; encourage client to void

Epidurals
 Empty bladder
 Positing sitting or side laying
 Bolus IV fluids
 Ongoing monitoring of mother and baby

Medications
 Pitocin/ oxytocin
o Used to induce labor
o Given after birth to stimulate contractions
Complications
TORCH
Groups of infections that cross placenta and affect fetus
 Toxoplasmosis- protozoal infection caused by eating undercooked meat, or
contact w/ cat feces or lter.
 Other infections: HIV, hepatitis, GBS, syphilis, varicella
 Rubella- causes fetal infection, abortion, hearing impairment, congenital
heart disease, retardation
 Cytomegalovirus- retardation, auditory impairments
 Herpes Simplex- can be contracted through vaginal delivery process. Causes
SAB,IUGR.
Gestational Diabetes
-Gestational diabetes can occur between the 16th and 28th week of pregnancy
- usually disappears after infant is born
- Risk factors
o Obesity
o Maternal age over 25
o Family Hx of DM
-S/SY
o Hypoglycemia
o Hyperglycemia
o Increase in: thirst, intake of fluids, and hunger

-Diagnosis usually is made with oral glucose tolerance testing (OGTT)

o +Positive blood glucose of 140 mg/dL or greater
-Urine analysis
o Urine test is positive for Glucose and acetone
-Complications
o Hypoglycemia after birth
o Spontaneous abortions
o Macrosomia: birth trauma and dystocia (shoulder of the infant cannot pass)

Hyperemesis Gravidarum- Excessive vomiting in the first trimester (but mostly seen after the
1st trimester) that leads to dehydration, alkalosis, starvation and ultimately death of the mother
and fetus.
Management
 NPO for 24-48 hrs
 From NPO clear fluidssoft diet regular diet
 TPN if necessary
 Vit B6 – correct deficiencies
 Reglan – controls N/V

Pregnancy Induced Hypertension (PIH) –

 Blurred vision, double vision
 Headache,
 Epigastric pain,
 Systemic edema (upper body, face)
 Excessive nausea and vomiting.
- An increase in systolic blood pressure > 30 mm/hg from baseline or an increase in diastolic
blood pressure > 15 mm/hg from baseline on at least two occasions > six hours apart. If no
baseline data is available then 140/90. There are two categories: Pre-eclampsia and eclampsia

Pre-eclampsia- Hypertension, facial swelling, proteinuria, oliguria (<400ml/24hr)

Management
 Seizure Management – Mg so4

Eclampsia- Convulsions, Coma, more protein in the urine 1+, Edema – can lead to edema in the
brain, S/SY – epigastric pain (referred pain from the liver), An increase in reflexes.
Management
  Seizure Management – Mg so4
 Safety Precautions – Padded tongue blade above bed, padded side rails.,
 Get the baby out,
 Put pt on Mg SO4 – may decrease BP, but stops seizure activity
o Assess ↓ respirations & ↓ urine output
o (MG toxicity: absent deep tendon reflexes)
o Antidote: Calcium gluconate
 After delivery, the pt can be on Mg SO4 for up to 24-48 hours
 NEVER GIVE DIURETICS when pregnant and retaining fluids
 Use position changes to increase urination
 Give high protein diet (due to protein loss in urine)
 Reduce stimulation (lights, noise), to decrease seizure possibility
 I/O, May give meds to decrease HTN

Hydatidiform mole- An abnormal formation of the placenta into fluid filled, grape-like clusters.
Gestational trophoblastic disease (a molar disease – fetus does not develop but the placenta
continues to grow, sometimes as a mass of abnormal cells). This does not mean that the pt has
cancer and the pt may be able to have a normal baby in the future.
 grapelike looking structure.
 Uterine enlargement greater than expected gestational age.
 Absence of fetal heart tones –because there is no fetus.
 Hyperemesis Gravidarum
 PIH (pregnancy induced HTN) in the 2nd trimester – where BP is usually at its lowest.

Abortion: Expulsion of the fetus prior to viability (age of viability is 24 weeks), 20 weeks
gestation. Two types: Spontaneous (occurring naturally) and Induced
S/SY of abortion: Unexplained bleeding, cramping, backache
Types of Spontaneous abortion: frank re bleeding w/ moderate cramps
 Threatened – Pt has been bleeding
 Imminent – Pt is bleeding, cervical os is open, cramping.
 Complete – Fetus and placenta are expelled
 Incomplete – Fetus is expelled and placenta is left inside.
 Missed – Fetus dies before the 20th week of gestation
 Habitual – Pt has 3 abortions between 14-16 weeks (usually due to incompetent cervix –
cerclage performed)
Bleeding : Before 12 weeks: Abortion, ectopic pregnancy
 After 12 weeks: Placenta previa, placenta abruptio,

Placenta Previa: Placenta implantation in the lower uterine segment. The placenta is coming
before the baby because it is implanted too low. If becomes completely unconnected then it
becomes placenta abruptio. Can cause a decrease in O2 for the baby. Painless bleeding.
*If the placenta is blocking the vagina (complete), pt must be c-sectioned.
 Quite onset bright red bleeding - # 1 symptom:
 Painless vag bleeding
 Abdomen soft, palpable
 Labor pains – pt will go into labor after bleeding episode.
Interventions
 Bed Rest- complete bed rest as long as she is bleeding
 Monitor blood loss (pad count)
 hydration
 No vaginal exams

Placenta Abruptio: Premature separation of the placenta (it should only separate after baby is
delivered). Emergency because it cuts the baby’s O2 and nutrients. It can happen because of
trauma to the abdomen.
 Dark venous blood
 **Pain with bleeding
 Rigid-board like abdomen, hard, Severe pain
 Sudden onset
 Prepare for an emergency C-Section
 Check for Fetal heart sounds
 No vaginal exam
 Nsg Dx: fluid volume deficit R/T bleeding

Ectopic pregnancy: Implantation of the blastocyst in a site other than the endometrial lining of
the uterus. Most common site is in the fallopian tube (tubal pregnancy).
 Unilateral pain
 Dull abdominal pain

Pre-mature Rupture of Membranes (PROM)- Spontaneous rupture of membranes prior to

onset of labor at the end of 37 weeks. Usually labor will start within 24 hours of rupture of
membranes.
Interventions:
 Asses for cord prolapse
 Remember: Amniotic fluids is continually produced
 Hospitalized
 Bed Rest
 Trendelenberg position

Cord prolapse:
-Occurs when loop of the umbilical cord gets inform of presenting part
-Most likely occurs when there is rupture of membranes (ROM)
 Perfusion., # 1
 Do not pack and stuff!, Wrap cord with sterile gauze soaked in sterile saline to keep the
cord moist.
 Give Oxygen
 Position change – knees to chest and butt in the air or (Trendelenburg)
 IV fluids
 Check FHR by feeling the cord for heartbeat with a sterile gloved hand.
 Assess for variable decelerations
Pre-term Labor: Onset of labor between 20 and 37 completed weeks of pregnancy
S/SY: Cramping, backache, Spontaneous contractions
Management
 Bed rest
 Hydration – place IV or drink a pitcher of water. Contraction can be caused by
dehydration
 Empty bladder – Check for bacteria for UTI – it can cause pre-term labor. If UTI, give
antibiotics.,
 Tocolytics – Toco = contractions, Lysis = to kill (stops contractions)
 Terbutaline (Brethene) – bronchodilator, stops contractions (give sub-Q Q15 –20 min x
4)
o Side effects: Tachycardia if HF >120 hold drug. Perfect drug choice if the pt is
having difficulty breathing and contractions
o Antedote: Propranolol (Inderol) – Beta Blocker
 Magnesium Sulfate (Mg SO4) – Relaxes the uterus. MgSO4 is not used to decrease BP in
this case
o Assess for: Decrease in ↓ Respirations (MgSO4 can decrease ↓ resp muscles)
o Magnesium toxicity (nausea, muscle weakness, loss of reflexes)
o Check Reflexes – should not be slow (Normal reflexes is +2) Mg SO4 relaxes
reflexes.
o **When a person comes close to seizing, they become hyperexcitable /
hyperflexive., Check labs
o Decrease stimulation for this patient – dim lights, place pt away from the nursing
station.,
o Check LOC, Antedote: Calcium Gluconite, You can give Solestom (Steroid) Beta
Methadone with Mg SO4 to mature the baby if pre-term.
 Administer Abx – Infection (if PROM),
 If pt. bleeding – DO NOT PERFORM PHYSICAL VAGINAL CHECK
 Perform and reinforce perineal care – for infection
 Teach mother signs of labor: It may be pressure, cramping, it is rhythmic
 Nitrazine test for amniotic fluid – urine is acid, amniotic fluid is base
o Amniotic fluid is Alkaline (7.0) & urine and purulent material is Acidic (5.5)
 Ferning test – performed by MD – fluid placed under microscope to check (+) for
amniotic fluid
 Possible grief counseling
 Place pt. left side lying
 If PROM occurs and mother is Rh Neg, Rhogam will be given if it has not been already
given during the pregnancy.

Rapid Labor
-Is a risk factor for early postpartum hemorrhage and also for amniotic fluid embolism; it is
defined as labor pattern which progresses quickly and ends in less than 3 hrs from when it
began.
Risk factors
 Multipara status
 Small fetus in favorable position
 Hx of previous rapid labors
Fetal Monitoring
 Baseline – average of FHR 120-160
o Tachycardia- > 160 bpm
o Bradycardia- <120 bpm
 Decelerations
o Early- Head Compression
 Monitor FHR
 Reposition mom on Left lateral side

o Variable- Cord Compression (caused by ROM)

-Persistent fetal bradycardia indicates cord compression

 Reposition mom knees to chest

 Give O2 w/ face mask
 IV fluids
o Late- Placental Insufficiency
 STOP Pitocin
 Give O2
 Reposition on left lateral side
 IV fluids
 Prepare for C-section

Postpartum
FUNDUS. Immediately after childbirth, the uterus rapidly contracts to facilitate compression of
the intra myometrial blood vessels..
 Within an hour, the uterus settles in the midline at the level of the umbilicus. Over the
course of days, the uterus descends into the pelvis at a rate of about 1 cm/day (one
fingerbreadth)
 After 10 days, the uterus has descended into the pelvis and is no longer palpable. The
fundus is assessed for consistency (firm, soft, or boggy), location (should be midline),
and height (measured in finger breadths).
 During the fundal assessment, the nurse notes whether it is located midline or deviated
to one side.
** If uterus is boggy and to the left of midline, encourage mom to urinate or offer bed pan. A
full bladder can prevent the uterus from contracting and lead to bleeding.
Signs and Symptoms Segment
Postpartum
- May be given stadol (Butorphanol ) IM injection is used to relieve moderate to severe
pain
- monitor RR

Position. Position refers to the relationship between standardized points on the presenting part
of the fetus to a designated point on one of four quadrants of the woman’s pelvis. The
standardized or assigned points can include the occipital bone (O), the chin or mentum (M), the
buttocks or sacrum (S), and the scapula or acromion process (A). The presenting part (occiput,
mentum, sacrum, or acromion) is labeled in relationship to a designated point of one of the four
quadrants of the maternal pelvis: right anterior, left anterior, right posterior, and left posterior.
There are several positions for a fetus in any presentation.
•    Complete breech: The fetus has both legs drawn up, bent at both the hip and the knee.
 Frank breech: The fetus has the hips bent, but the knees are extended
 Kneeling breech: Either one or both legs are extended at the hip, flexed at the knee
 Footling breech: Either one or both legs are extended both at the hip and knee.
**In all types of breech presentation positions, the sacrum is the assigned point.

APGAR APGAR is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute
score determines how well the baby tolerated the birthing process. The 5-minute score tells the
doctor how well the baby is doing outside the mother's womb.

Breast Feeding
Breast-feeding
 Use side-lying, sitting upright, or infant facing mother (tailor position); rotate breast
feeding positions; position nipple so that infants mouth covers a large portion of the
areola and release infants mouth from nipple by inserting finger to break suction.
 Allow baby to feed on one breast for 10 mins until satisfied then on the alternate breast.
 To clean use water on breast b/c soap can be drying, dry thoroughly; expose to air
 Oral contraception suppresses milk producton and should not be taken if you want to
breast feed.
Woman who Do not wish to breast feed
 Wear a tight-fitting bra for 72hrs after deliver;
 Ice packs on breasts help relieve discomfort and engorgement
 Avoid warm water over breast; increases milk production, causing engorgement

Psych
PSYCHOLOGICAL – ERIKSON “Psychosocial Stages of Development”
Trust vs. Mistrust (birth – 18m) INFANT: basic trust in the mothering figure and be able to
generalize it to others.
Achievement – self-confidence, optimism, faith in the gratification of needs and desires, and
hope for the future. Infant learns to trust when basic needs are met consistently.
Nonachievement – emotional dissatisfaction with the self and others, suspiciousness, and
difficulty with interpersonal relationships. A task is unresolved when primary caregivers fail to
respond to the infant’s distress signal promptly and consistently.

Autonomy vs. Shame and Doubt (18m – 3yrs) TODDLER: gain some self-control and
independence within the environment.
Achievement – sense of self-control and the ability to delay gratification, and a feeling of self-
confidence in one’s ability to perform. Autonomy is achieved when parents encourage and
provide opportunities for independent activities.
Nonachievement – lack of self-confidence, a lack of pride in the ability to perform a sense of
being controlled by others, and a rage against self. Unresolved if parent restricts independent
behaviors, or set the child up for failure w/ unrealistic expectations.

Initiative vs. Guilt (3-6 yrs.) PRE-SCHOOL: develop a sense of purpose and the ability to initiate
and direct one’s own activities.
Achievement – ability to exercise restraint and self-control of inappropriate social behaviors.
Assertiveness and dependability increase, and the child enjoys learning and personal
achievement.
Nonachievement – feelings of inadequacy and a sense of defeat; guilt is experienced to an
excessive degrees, even to the point of accepting liability in situations for which one is not
responsible.

Industry vs. Inferiority (6-12 yrs.) SCHOOL-AGED: achieve a sense of self-confidence by learning,
competing, performing successfully, and receiving recognition from significant others, peers,
and acquaintances.
Achievement – sense of satisfaction and pleasure in the interaction and involvement with
others. Masters reliable work habits and develops attitudes of trustworthiness.
Nonachievement – difficulty in interpersonal relationships b/c of feelings of personal
inadequacy. Individual can neither cooperate nor compromise with others in group activities nor
problem solve or complete tasks successfully.
o The child learns to compete and cooperate with others

Identity vs. Role Confusion (12-20 yrs.) ADOLESCENT: integrate the tasks mastered in the
previous stages into a secure sense of self.
Achievement – confidence, emotional stability, and a view of the self as a unique individual.
Nonachievement – sense of self-consciousness, doubt, and confusion about one’s role in life.

Intimacy vs. Isolation (20-30 yrs.): form an intense, lasting relationship or a commitment to
another person, a cause, an institution, or a creative effort.
Achievement – capacity for mutual love and respect between 2 people and the ability of an
individual to pledge a total commitment to another. Intimacy goes far beyond the sexual contact
between 2 people.
Nonachievement – withdrawal, social isolation, and aloneness. Unable to form lasting intimate
relationships, often seeking intimacy through numerous superficial sexual contacts.

Generativity vs. Stagnation (30-65 yrs.): achieve the life goals established for oneself while also
considering the welfare of future generations.
Achievement – sense of gratification from personal and professional achievements and from
meaningful contributions to others. They express satisfaction with this stage in life and
demonstrate responsibility for leaving the world a better place.
Nonachievement – lack of concern for the welfare of others and total preoccupation with the
self. They become withdrawn, isolated, and highly self-indulgent, with no capacity for giving of
the self to others.
** Self-questioning occurs, reappraises the past, discards unrealistic goals, Potential mid-life
crisis.

Ego Integrity vs. Despair (65 –death): goal is to review one’s life and derive meaning from both
positive and negative events, while achieving a positive sense of self.
Achievement – sense of self-worth and self-acceptance as one reviews life goals, accepting that
some were achieved and some were not.
Nonachievement – sense of self-contempt and disgust with how life has progressed. They would
like to start over and have a second chance of life.

Defense Mechanisms
 Sublimation: Rechanneling of drives or impulses that are personally or socially
unacceptable into activities that are constructive. Putting your energy into good use.

 Humor: using humor instead of confrontation; it’s not healthy to joke too much when
there needs to be a serious conversation.
 Suppression: this is done consciously; voluntary blocking of unpleasant feelings and
experiences from one’s awareness. Can be good if you put it aside but come back to it to
deal with the problem and don’t just always suppress your problems.

 Compensation: Covering up a real or perceived weakness by emphasizing a trait one

considers more desirable. Making up for what you may lack.

 Introjection: Integrating the beliefs and values of another individual into one’s own ego
structure. For example when kids integrate their parents value system into process of
conscience formation; child says to friend “Don’t cheat. It’s wrong”.
  Identification: An attempt to increase self-worth by acquiring certain attributes and
characteristics of an individual one admires. It’s good to identify with someone but only
to an extent. Practice empathy not sympathy.

 Repression: done unconsciously; Involuntarily blocking unpleasant feelings and

experiences from one’s awareness. Not dealing with something.
o This is commonly seen w/ Conversion disorder
o Conversion disorder is a mental health condition in which a person has blindness,
paralysis, or other nervous system (neurologic) symptoms that cannot be
explained by medical evaluation.

 Displacement: The transfer of feelings from one target to another that is considered less
threatening or that is neutral. We put on someone else what we can’t do for ourselves.

 Reaction Formation: Preventing unacceptable or undesirable thoughts or behaviors

from being expressed by exaggerating opposite thoughts or types of behaviors. Doing or
saying the opposite of what we really feel.

 Somatization: physical reaction to an emotional situation

 Undoing: Symbolically negating or canceling out an experience that one finds

intolerable. It’s like saying something inappropriate and then saying you didn’t mean to
say that. This is not good if done constantly.

 Rationalization: Attempting to make excuses or formulate logical reasons to justify

unacceptable feelings or behaviors.

 Regression: Responding to stress by retreating to an earlier level of development and

the comfort measures associated with that level of functioning. This is not healthy;
going back in time to when you suck you thumb or wet the bed.

 Projection: attributing to others feelings, impulses, thoughts, or wishes (blaming or

scape-goating). (eg. I wouldn’t drink so much if my wife didn’t irritate me)
EATING DISORDERS

ANOREXIA NERVOSA [morbid fear of obesity] features…

 Individual weight is less than 85% of normal
 Intense fear of becoming fat
 Body image disturbance – they see a fat person in the mirror. They have an accurate
perception of others but not of themselves.
 Strenuous exercising and particular food handling patterns – only eat about 200 calories
per day yet they still do activities that burn the little calories they ate.
 Lack of sense of control in any area of life besides weight control – they try to keep the
control that they have over their wt. by not eating. Isolates self and denies that there is
a problem
ASSESSMENT - PHYSICAL SYMPTOMS
- Less than 85% of the expected weight
- Bradycardia, hypotension, Arrhythmias, Hypokalemia & Hypocalcemia
- Dehydration and electrolyte imbalance
- Amenorrhea – one of the 1st thing that happens; we need a little fat for hormones
- Hypoglycemia, Lanugo, dry skin, hair loss [hair is thin and brittle], edema
- Hypothermia – they wear several layers of clothing to keep warm and to hide how
skinny they are.
- Osteoporosis – muscles are wasting and bone mass is decreased. Provide calcium
supplements & adequate nutrition
- Constipation and bloating

PLANNING/IMPLEMENTATION
 Monitor daily caloric intake – stay to see how much they really ate. Don’t just leave their
tray they could throw away food to mislead that they ate “all” their food. Stay with pt.
during meals and for 1 hr. following meals.
 Observe for signs of purging – NO bathroom breaks until after 2 hours after meal
 Monitor activity level- monitor for over exercising
 Weigh daily – pt. should have back to scale so that they don’t see their wt. b/c this can
cause them anxiety
 Plan for dietician to meet with patient – increase calories slowly
 Monitor electrolytes and other labs often
 Encourage to verbalize feelings
 “Matter of fact approach” – be straight- forward and objective… Don’t judge. Don’t
bargain; explain how privileges and consequences are based on compliance with
therapy and wt. gain.
 Someone on a 200 cal diet for several years can not start automatically eating 1200 cal a
day . they have to start slowly increasing the amount of food.
 Slow, Steady weight gain of no more than 2lb per week; rapid weight gain can put
undue stress on the heart, which already has diminished output from starvation.
** Women of average age and height need approximately 1200 cal per/day

BULIMIA NERVOSA
Recurrent episodes of uncontrolled compulsive, rapid ingestion of large qualities of food over a
short period of time [binging], followed by inappropriate compensatory behaviors to rid the
body of the excess calories [purging] with the use of laxatives, self-induced vomit, diuretics,
enemas, fasting and excessive exercise…

ASSESSMENT - SYMPTOMS
 Secretive eating [Frequency of binge varies] – binge is set off by a stressor and then they
feel guilty that causes them to purge (Abuse of laxative and diuretics among other
things)
 Close to normal weight maintained or may even be a little under or over wt.

PHYSICAL SYMPTOMS
o Bradycardia, hypotension, arrhythmias, Hypokalemia, hyponatremia
 o Excessive vomiting and laxative or diuretic abuse may lead to problems with
dehydration and electrolyte imbalance. Low potassium, magnesium, and sodium.
o Irregular menses, hypoglycemia
o Gastric acid in the vomitus also contributes to the erosion of tooth enamel.
o Hoarseness due to acid on vocal cords, esophagitis, tears in gastric and esophageal
mucosa
 At risk for treacheal-esophgeal fistula from esophageal tear; laryngitis is a
danger sign
o Dental caries, enlarged parotid glands, sore throat, irritated, can tear and rupture, blood
in vomit
o Grey or black eroded teeth w/ foul odor; signs of vomiting; gastric acid erodes teeth.
o Constipation, bloating, diarrhea, and abdominal cramping
o Acne vulgaris related to bingeing on junk food

NURSING CARE - BULIMIA

 More motivated for treatment
 Set limits - very manipulative
 Create trust – non-judgmental
 Help to identify feelings BEFORE binge-eating – triggers that cause the binge eating
 Help to increase self-esteem
 Teach patients and family about bulimia
 Administer medication as ordered

Antisocial personality Disoder

They are manipulative and act out; to establish trust and avoid power struggles, limits
should be set in non-punitive matter.
They express unconscious feelings or conflicts through actions.

SCHIZOPHRENIA
Primary problem: difficulty-forming relationships with marked inability to trust others
COMMON SYMPTOMS
 DELUSIONS – false beliefs; deal with “thinking”
 LOOSE ASSOCIATIONS – inability to communicate effectively; some thread of sense but
they aren’t really connected. You need to clarify what they say when they aren’t making
sense.
 HALLUCINATIONS – deal with the 5 senses; see, feel, hear, taste, or smell
 ILLUSIONS – you think you see or you think you hear. Like when you look at your desk
and you think you see a bug but in reality it is an eraser.
 DEPERSONALIZATION/DEREALIZATION – separation from reality; “out of body
experience” sometimes in our dreams we experience this. These pt. experience this
while awake and alert.
 AFFECTIVE FLATTENING/ INAPPROPIATE – there is either no emotion or it doesn’t
correlate with what they are feeling. “that is so funny” while showing NO emotion. They
are smiling while asking you if your mother died.
 AMBIVALENCE – don’t care about anything; brushing teeth/hair, feeling love/hate
relationship.
  AVOLITION - no motivation to do anything; common in pt. with severe depression.
 ECHOPRAXIA – “Copy cat” of posture and actions.
 CRONCRETE THINKING – they are only able to think concrete and narrow; they aren’t
able to comprehend abstract thoughts.

POSITIVE SYMPTOMS +- Hallucinations, delusions, loose associations, bizarre or disorganized

behavior. *** Are seen when the pt. is “positively crazy”. If these
symptoms are seen they commonly have schizophrenia***
 I can see or hear these; I can see them do something bizarre or hear them speak in loose
association.

NEGATIVE SYMPTOMS- Flat affect, anhedonia (no pleasure), avolition (no motivation), attention
impairment and social withdrawal, alogia (not speaking).
*If these are present it doesn’t mean that the pt. has schizophrenia b/c they can also accompany
other disorders*
 Less difficult to see and more difficult to treat.

DELUSIONS (false beliefs):

 IDEAS OF REFERENCE – when pt. believes that the radio is talking to him or that a singer
is singing the song to them only.
 SOMATIC – they believe they have some physical defect, disorder, or disease. For
example, they think they smell, have roaches crawling up their leg inside [infestation of
insects in/on skin], has an internal parasite, has misshapen or ugly body parts, and
dysfunctional body parts.
 PERSECUTION – believe someone is out to get them; they think they are being conspired
against, cheated, followed, poisoned or drugged, harassed, or obstructed. Repeated
complains may be directed at legal authorities, lack of satisfaction from which may
result in violence toward the object of the delusion.
 GRANDEUR – they think they are better then they are; they have irrational ideas
regarding their own worth, talent, knowledge, or power. Thinking they are a celebrity,
Jesus Christ, undercover FBI/ CIA agent
 JEALOUSY – idea that their sexual partner is unfaithful; irrational and w/o cause, but pt.
will search for evidence to justify the belief.
 CONTROL – they believe that someone else is in control of them. Eg. Being abducted by
aliens, the CIA/FBI is controlling them

DISORGANIZED SPEECH
 ECHOLALIA – they repeat what you say
 CLANG ASSOCIATION – rhyming of words
 NEOLOGISMS – make up words; that word consistently means something to them
 WORD SALAD – nothing they say make sense

DISORGANIZED BEHAVIOR
 ECHOPRAXIA – copy what you do , movement or behavior wise [you put your hands on
you hips then they put their hands on their hips]
 STEREOTYPED BEHAVIOR- they could be rocking back and forth
 NEGATIVISM – being negative about everything
 POSTURING – weird positions, they can just stay in that position
TYPES OF SCHIZOPHRENIA
 PARANOID: may be dangerous due to the persecution state; at any given time they can
turn on the nurse due to the believe that she is out to get him. Pt. is often tense,
suspicious, and guarded, and may be argumentative, hostile, and aggressive. These pt’s
are at risk for violence
 DISORGANIZED: not dangerous they just have a disorganized mind; the more
disorganized the harder it is for them to participate in group and for them to get better.
 CATATONIC: maybe manifested in the form of stupor or excitement. They may sit in a
corner not doing anything in a mild state and fall into a full coma with no reason to be in
that state in which they come out of 3-5 days. Can also be weird bizarre movements.
Waxy flexibility may be exhibited; this is a type of posturing or voluntary assumption of
bizarre positions, in which individual may remain for long periods of time.
 UNDIFFERENTIATED
 RESIDUAL

PLANNING/IMPLEMENTATION
Nursing Actions depend on Outcome…
 Observe client behavior closely.
 Set limits on inappropriate behavior.
 Present reality when hallucinates. Voice doubt; DON’T say “there is no girl on that
couch” SAY “I don’t see a girl”.. “
 Do not argue or try to convince with logic when delusional use ‘reasonable doubt.’ This
is there reality. You can say “I understand that you believe this is true, but personally I
find it hard to accept”.
 Do not touch without warning; some pt. may perceive touch as threatening.
 Do not question client about false ideas, it will cause the client to defend the idea and
encourages the client to engage in further distortion of reality.
 Don’t whisper to others in pt. presence.
 Offer foods that are not easily contaminated. If they are paranoid you should give them
“sealed food”

 PSYCHOPHARMACOLOGY
ANTIPSYCHOTICS [1st line] – major tranquilizers
 STANDARD/ TYPICAL – are older drugs like thorazine, prolixin, mellaril, stelazine. Bring
the positive symptoms down. They are dopamine receptor blockers. Decrease agitation,
behaviors. They have a lot of EPS symptoms that are parkinsonian like. Severe anti-
cholinergic side effects.
 A-TYPICAL – newer drugs; they address positive and negative symptoms. They are more
functional. They are weaker dopamine receptor antagonists, but are more potent
agonists of serotonin receptors.

ANTIPARKINSON: given with antipsychotic for the side effects they may cause
_ Anti-Parkinson agents are given when pt is on typical/standard (older) anti-psychotics
-COGENTIN & ARTANE are given with typical anti-psychotics daily.
TMT of SIDE EFFECTS Nursing considerations
Schizophrenia &
psychotic disorders
ANTIPSYCHOTICS ANTICHOLINERGIC: Dry Mouth, Blurred vision, Urinary NEUROLEPTIC MALIGNANT SYNDROME*
[1st line] Retention, Constipation, Photosensitivity, Dry eyes. Potentially fatal
TYPICAL .* 1st signs – significantly acute/ abrupt
Thorazine EXTRAPYRADIMAL SIDE EFFECTS (EPS) [these are not increase of EPS symptoms
Haldol adverse effects] o ↑CPK
Mellaril PSEUDOPARKINSON: Drooling, lack of facial o Fever
Navane responsiveness, shuffling gait, and fine intentional tremors. o HYPERTHERMIA 102° AND ABOVE
Prolixin ACUTE DYSTONIA: Muscle spasms of the jaw, tongue, neck o Muscle rigidity
Trilafon or eyes.(oculogyric crisis- eyes locked upward) Laryngeal o TACHYCARDIA
Serentil spasms possible. Need to be treated immediately with IM o FLUCTUATING B.P. and other VS
Stelazine Benadryl. o DIAPHORESIS
Perphenazine TARDIVE DYSKINESIA: Bizarre facial and tongue
o Incontinence
movements, chewing, tongue from side to side. Involuntary
o STUPOR AND COMA
tonic muscular spasms of extremities.
AKASTHISIA: Motor restlessness, pacing, rocking TMT
 Stop medication
 Cool body
TMT: IM (Benztropine Mesylate), or Trihexyphenidyl
 Administer Bromocriptine to treat
(Artane)- anti-Parkinson agents
muscle rigidity and dantrolene to
reduce muscle spasms

A-TYPICAL o Orthostatic Hypotension NURSING IMPLICATIONS

Clozaril (clozopine), o Decreased Libido  MONITOR B.P. B4 giving MEDS
Risperdal, Zyprexa o Agranulocytosis especially w/ Clozapine)-  CHECK CBC, CPK, LIVER FUNCTIONS
(olanzapine), AND VISION regularly
 Low fever,
Seroquel, Geodon, &  EVALUATE 4 SIDE EFFECTS
 Sore throat
Abilify  Give 1 -2 Hrs B4 BEDTIME
 Malaise  MIX LIQUIDS W/ 60CC FRUIT JUICE
 Low ↓ WBC  Avoid extreme temperatures
 Hypotension  Change position slowly
 Potentially fatal
o Weight gain
o Tachycardia
o Edema
o Report any suicidal thoughts

ANTIPARKINSON
AGENTS
_ Anti-Parkinson -COGENTIN (Benzatropin) & ARTANE are given with
agents are given typical anti-psychotics daily
when pt is on
typical/standard -Akineton (Biperiden)
(older) anti-
psychotics
BIPOLAR DISORDER - Chronic mood disorder that manifests as alternating and recurring mood
episodes throughout a person’s life that may begin with either a manic or depressive disorder
that are recurrent with levels of function that vary. Alternating mood episodes are characterized
by mania, hypomania [slight milder degree of mania], depression, and concurrent mania and
depression (mixed episodes) alternating with periods of normal functioning [when they take
their meds].
 Classic mania is evidenced by elevated mood, speech is loud and rapid, they can speak
vulgar, they have wt. loss b/c they don’t like to eat, grandiose, delusions, distracted, and
they don’t need much sleep.
 Depression episodes
 Pt. alternates between mania and depression. Sometimes it takes longer to diagnose b/c
they are seeking treatment for depression most of the time.
 They feel as though they are all powerful and put themselves in riskful situations due to
the lack of sleep, decrease food intake…

 Bipolar 1 – full mania alternating with depression

o Acute mania- agitation, grandiose delusions, euphoria, difficulty concentrating.
 Bipolar 2 – hypomanic episodes alternating with recurrent bouts of major depression.
This is harder to diagnose b/c they seek treatment only when they are in the depressive
state. There hypomanic episodes are quite functional they don’t go into full mania.
 Cyclothymia – hypomanic episodes alternating with dysthymia; probably never in crisis
state. That last at least 2 yrs. they are never w/o symptoms for more than 2 months.

NURSING INTERVENTION
 Firm and calm approach w/ Short and concise explanations.
 Remain neutral, avoid power struggles – these pt. tend to be very hyper and
manipulative as well as quick to anger. Don’t confront them; you as a nurse need to
control your own behaviors around these pts.
 Be consistent in approach.
 Set limits and tell in concrete terms consequences of inappropriate behavior.
 Firmly redirect energy into appropriate channels. Redirect violent behavior –
EX. pt. is running in the hallway and you allow him to go play basketball instead. They
can go out and walk.
 Hear and act on legitimate complaints.
 Low level of stimulation in environment.
 Structured solitary activities with staff.
 High- calorie protein “finger foods” snacks and drinks. Avoid caffeine. Finger foods are
those that they can eat on the go. They will not have time to sit and eat while in manic
state.
 Provide frequent rest periods.
 Make sure patient takes prescribed meds.
 When violent or extreme agitation use antipsychotics and seclusion w/ aggressive
behavior
 Protect client from giving away money and possessions.
 Monitor lithium levels and observe for signs of toxicity.
 Supervise hygiene and choice of clothing.
  Give simple step-by-step directions.
 When able to learn teach about disorder, medication and community agencies.
 Manic Phase: distract the client; redirect behaviors

ANXIETY
PANIC DISORDER
Characterized by recurrent, unpredictable attacks of intense apprehension or terror that can
render a client unable to control a situation or to perform simple tasks.
Panic attack characteristics:
 Palpitations, ↑HR
 Chest pain
 SOB
 Decreased perceptual field,
 Diaphoresis
 Fear of going crazy.

-Somatoform (hypochondriac)- concern with physical and emotional healh with bodily
complaints with no physical basis.

Mood Disorders
Depression
o Inability to enjoy play masked by this typical statement is a hallmark sign of depression
in children. “8 year old says: No one will play with me ”
o Infants and toddlers have no concept of death
o School aged -might show signs of regression and temper tantrums

NURSING INTERVENTION FOR THE DEPRESSED CLIENT

o Safety!!! Prevent suicide! Take away all harmful objects, put pt. on suicide precautions,
need to be checked often depending on level of suicide precaution, provide 1-to-1
contact, constant visual observation, or Q15. Formulate a no harm contract.
o Assist through grief process.
o Increase self-esteem; focus on strengths minimize failures.
o Increase reality testing, Decrease anxiety
o Confronting anger
o Teaching coping mechanisms to pt. and family.
o Ensuring all basic needs are met
o Approach: Caring, supportive, and firm

SUICIDE
Psychological Theories
- Anger Turned Inward
- Hopelessness
- Desperation and Guilt
- History of Aggression and Violence
- Shame and Humiliation
 - Developmental Stressors

ASSESSING SUICIDAL POTENTIAL

 Admits to suicide thoughts? Clues? “Do you feel like hurting yourself?”
 Has a plan? Means? Assessing if they have a plan is the most crucial, this shows how
much they have been thinking of this. If they tell you they plan to shot themselves you
must find out if they have the means to carry out this plan, such as do they have a gun?
 Support systems
 Past or family history of suicide?
 Coping strategies?
 Alcohol or drug abuse
 Anxiety, agitation
 Depression, hopelessness, isolation, withdrawal

NURSING INTERVENTION OF SUICIDAL PATIENT

 One to One, Nurse-client relationship
 Stay with the person
 “No suicide” contract or no harm contract; pt. promises they wont harm themselves.
 Non- judgmental, accepting attitude. Nurse need to accept that their situation is bigger
then there coping strategies.
 Listen and be attentive
 Encourage to verbalize, provide hope
 Safety in the environment
 Assist in meeting basic needs
 Provide activity

Medication Side effects Used for Teaching

Classificatio
n

SSRI’s Agitation, Anxiety, Sleep disturbance IN ADDITION TO - Take in the morning

PROZAC (fluoxetine) (insomnia), Tremor, Sexual dysfunction, DEPRESSION, THEY ARE - Rinse mouth freq/oral
Tension headache, dry mouth Initial USED SUCCESSFULLY IN: hygiene
CELEXA (citalopram) autonomic reactions, Rare toxic effect: - ANXIETY - Do NOT stop abruptly
LUVOX Serotonin Syndrome. ***Should be taken DISORDERS - Medication interaction: 14-
(fluvoxamine) in the mornings*** - PD, OCD, GAD, Day clearance from MAOI’s
PTSD & SAD [don’t take with MAOI’s];
PAXIL (paroxetine) - PMDD - Check Liver/Renal/Blood
ZOLOFT (sertraline) - BULIMIA count periodically
- SLEEPING - Get up slowly
LEXAPRO
DISORDERS
(escitalopram)
- ALCOHOLISM
- SCHIZOPHRENIA
SNRI (Atypical) - Wellbutrin (Bupropion) (Zyban) -Do not perform activities
novel -seizures, insomnia requiring alertness until drug
Wellbutrin, Zyban - Serzone (Nefazodone) effects realized
(buproprion) Hypotension, sedation, ↑ -Perception of taste and
cardiotoxic effects with allergy appetite may change, weigh
Remeron weekly and report changes
(mertazapine) meds, such as Seldane and -May take up to 3 weeks to
Ludiomil Hismanal work (all antideprresants)
(maproptiline) - Desyrel (Trazadone) Priapism -Get up slowly
Desyrel (trazodone) risk, sedation, ↑ risk of digitalis -Do not drink alcohol or other
Serzone toxicity with digoxin. CNS depressants
(nefazodone) - Effexor (Venlafaxine)
Effexor (venlafaxine) Hypertension
Cymbalta - Remeron (Mirtazapine)
(duloxetine)
Anticholinergic ,sedation

TRICYCLICS (TCA’S) ANTICHOLINERGIC are more DRUG INTERACTIONS

ELAVIL pronounced. Cannot be used with: Alcohol,
(amitriptyline) - DRY MOUTH, BLURRED VISION, MAOI’s, Barbiturates,
ASENDIN URINARY RETENTION, Disulfiram, Oral
(amoxapine) CONSTIPATION contraceptives
NORPRAMIN - TACHYCARDIA [↓effectiveness],
(desipramine) OTHER Anticoagulants
SINEQUAN (doxapin) - HYPERTENSION, ARRYTHMIAS
TOFRANIL  Full effect may take 4
- PHOTOSENSITIVITY, ANOREXIA,
(imipramine) to 6 weeks.
ANAFRANIL(clomipr NAUSEA  Wear sunblock
amine) - SEXUAL DYSFUCNTION,  Contraindicated with
PAMELOR FATIGUE, SEDATION, CV disease, glaucoma,
(nortriptyline) SEROTONIN SYNDROME BPH, liver and renal
VIVACTIL - SEIZURES, OVERDOSE diseases.
(protriptyline)  Should be given at
TOFRANIL (imipramine) SE: sore throat night
fever, increased fatige, vomiting ,  Used in caution w/
diarreah. elderly

Monoamineoxidade Hypertensive crisis resulting from intake Best for depression MAOI’S CLIENT TEACHING
Inhibitors (MAOI’S) of dietary tyramine. (H/A, nausea, associated with acute  May take 4-6 weeks to
MARPLAN, NARDIL, increased HR & BP) anxiety attacks, phobic reach therapeutic
& PARNATE & -Orthostatic hypotension attacks, or many level
ELAVIL -Anxiety, agitation, mania
physical complaints  Avoid tyramine
containing foods
(aged cheese,
chocolate, red wines,
processed meats, soy
sauce, coffee, yogurt)
 Watch BP if pt cheats
on diet for HTN crisis
 Should be
discontinued 2 weeks
before surgery

Monoamineoxidade Inhibitors (MAOI’S)

Medication blocks monoamineoxydase (an enzyme- MAO ) from destroying
neurotransmitters therefore increasing their availability at the synapses. It also blocks the
metabolism of “Tyramine” resulting in a danger for hypertensive crisis.
 - Best for depression associated with acute anxiety attacks, phobic attacks, or many
physical complaints.

Examples of MAOI’S:
PA-PARNATE (Tranylcypromine)
NA-NARDIL (Phenelzine)
MA-MARPLAN (Isocarboxazid)
MAOI’S CLIENT TEACHING
 May take 4-6 weeks to reach therapeutic level
 Report any hypertensive episodes
 Diet restrictions and Medication interactions
 Avoid tyramine containing foods
 Put on sunscreen
 Watch blood pressure if pt cheats on diet bc it can cause a hypertension crisis;
severe headache
 Should be discontinued 2 weeks before surgery
 Danger!! Failure to follow diet/med restrictions may result in hypertensive crisis.

High tyramine content [AVOID] Moderate tyramine content Low tyramine content
[OCCASIOINAL]
Aged cheeses (cheddar, swiss, camembert, Gouda cheese, processed American Pasteurized cheese
blue cheese, parmesan, provolone, romano, cheese, and mozzarella. [cream cheese, cottage
brie). Yogurt, sour cream cheese, and ricotta]
Raisins, fava beans, flat Italian beans, Chinese avocados, bananas Figs
pea pods. beer, white wine, coffee, colas, tea, Distilled spirits
Red wines, smoked and processed meats hot chocolate
(salami, bologna, pepperoni, summer meat extracts.
sausage.
Caviar, corned beef, chicken or beef liver. soy
sauce and MSG.
DISORDERS of COGNITION
Delirium: Confusion, excitement, disorientation, and clouding of consciousness.
Hallucinations and illusions are common. Can be secondary to a physical illness. Rapid
onset.

Dementia: loss of previous levels of cognition, executive, and memory function in a state of full
alertness. Insidious onset.
Characteristics:
 Memory deficit
 Poor judgment
 Irritability
 Apathy or indifference (lack of interest)
 Pacing
 Restlessness and agitation.
  This pt. has intellectual impairment; ex. the accountant may not be able to add numbers
without a calculator.
 Disregard for conventional rule of social conduct – go to the grocery store in pjs.
 Neglect of personal appearance and hygiene
 Wandering – they lose sight of where they are
 Language may or not be affected
 Personality change is common
 Irreversible- they tend to progress

INTERVENTION
- Positive attitude, be patient and understanding.
- Facilitate highest level of functioning – Try to get them to function as well as they can
- Speak slowly in a face to face position
- Provide low stimulation environment (e.g. quiet, soothing music, non-demanding)
- Remove environmental dangers.
- ID bracelet is very important
- Consistency in environment and routine.
- Introduce self, simple one step directions.
- Use distraction rather than confrontation – approach carefully, no confronting behaviors
- Provide simple structured activities that the patient can complete – give positive
feedback

ALZHEIMER’S DISEASE
Onset of s/s is slow and insidious; course of disorder is usually progressive and deteriorating
- Acetylcholine alterations (ACh) ↓- decrease of Ach reduces the amt. of
neurotransmitters released in cells.
STAGES OF ALZHEIMER’S
STAGE 1: MILD
 Forgetfulness, loss in short term memory (uses memory aids) – write down everything in
order to remember things
 Insidious loss of intelligence
 Loss of energy and motivation, depression. Difficulty learning new things
 May continue to work, not diagnosable at this time but some changes are seen

STAGE 2: MODERATE
 Memory loss progressive- confabulation. Memory gaps
 Deterioration becomes evident labile & needs care or in home assistance
 Denial, fear, depression activities become hazardous
 Decline in ADL’s: personal hygiene; dress such as a stain on shirt
STAGE 3: MODERATE TO SEVERE
 ADL’s- loss of grooming, dressing and communication skills
 Loss of reasoning ability & language skills – can’t do things for themselves
 Severe agnosia (inability to recognize common objects, people, or sounds ), apraxia
 Total care
o Wandering
o Danger to self/others
o Incontinent
 o Keeps family awake
 Institutional care needed

STAGE 4: LATE
 Does not recognize self or family
 Mute or screams – can’t express self
 Forgets how to eat, chew or swallow: they regress to oral stage  they put everything
in their mouth like babies
 Agraphia
 Hyperorality
 Hypermetamorphosis
 Inability to talk and walk
 Stupor, seizures, coma
 Death

Standard Precautions and Transmission-Based Precautions P6 69 ATI

Standard precautions Contact Precautions

 Hand hygiene – cleaning hands with soap and water Used for pt,s that have an infection that can be spread by
or an alcohol-based hand rub to prevent contact with the person’s skin, mucous membranes, feces,
transmission of germs to others vomit, urine, wound drainage, or other body fluids, or by
 Lyme disease contact with equipment or environmental surfaces that may
 Pneumonia caused by staphylococcus aureus be contaminated by the pt or by his/her secretions and
 Kawasaki disease (acute systemic vasculitis) excretions.
 Mononucleosis  Wear a gown and gloves upon room entry of a patient
 Anthrax exposure on contact precautions.
 HIV  RSV
Personal protective equipment –  C. diff
Face mask/face shield/eye protection (goggles)- Worn if  MRSA
contact with blood or body fluids may occur, especially  Norovirus
during suctioning and intubation.  Draining wounds,
 Croup
Gloves -Worn if contact with blood, body fluids, mucous  Cellulitis
membranes, non-intact skin, or contaminated items in the  (HEP A infants w/ diapers/or incontinent pts)
pt’s environment.  skin infectons : impetigo, scabies, herpers simplex
 Uncontrolled secretions,
Gown- Worn if contact with blood or body fluids may  Pressure ulcers, or presence of ostomy tubes and/or
occur. bags draining body fluids

Droplet precautions Airborne Precautions

Used for pt’s , that have an infection that can be spread
through close respiratory or mucous membrane contact
with respiratory secretions.
 Wash hands, & wear mask, private air rooms
 Instruct patient to wear a facemask when exiting
the exam room, avoid coming into close contact
with other patients, and practice respiratory
hygiene and cough etiquette
 Respiratory viruses (e.g., influenza, parainfluenza
virus, adenovirus, human metapneumovirus)
 Influenza N. (one of the causes of meningitis),
 Streptococcal Pneumonia
 Pertussis (also known as “whooping cough”)
 Rhinovirus (also known as the “common cold”)
 Meningococcal Meningitis
 MUMPS
 Rubella
 Sepsis
 Wash hands, remove mask, throw it in the
container in the room
Used for pt’s , that have an infection that can be spread over
long distances when suspended in the air. These disease
particles are very small and require special respiratory
protection and room ventilation.
 In addition to standard precautions:
 Wear a N95 mask or respirator prior to room entry,
depending on the disease-specific
recommendations. Most diseases will require N95
or higher respiratory protection.
 Tuberculosis (TB)
 Measles
 Varicella (chickenpox)
 Disseminated Herpes Zoster (shingles)/+ contact
precautions
**MyChickenHezTB
 Electrolyte Imbalances

Electrolyte Hypo Hyper

Na (Sodium) Na- Hyponatremia : confusion, lethargy, restlessness,
135- 145 headaches, seizures ,Muscle weakness/ twitching,
fatigue, hypotension, N/V, apprehension.
Cause: GI loss, SIADH, adrenal insufficiency, Addisons,
CHF, lithium
Hypernatremia: fever, swollen dry tongue,
hallucinations, sticky mucous membrane,
tachycardia, lethargy, restlessness, hypertension,
seizures.
Causes: Water deficit, GI loss, DI, Burns,
Hypertonic tube feedings

K (Potassium) Hypokalemia: Cardiac Dysrhythmias (PVC’s) ; can rapidly Hyperkalemia: peaked T waves (ECG), muscle
3.5- 5.0 deteriorate to ventricular tachycardia or sudden death.
Muscle weakness, leg cramping, confusion, N/V, leg
weakness. Inverted T waves, ST depression, prominent U
waves on ECG.
Causes: SE of; Diuretics, digitalis, laxatives; diarrhea,
vomiting, diaphoresis, NG suctioning
Ca (Calcium) Hypocalcemia: Tetany; involuntary spasms of the hands
8.4- 10.5 and feet, cramps, spasm of the voice (stridor), face
(facial twitching/hand tremors). Numbness/ tingling of
extremities and mouth, Seizures.
o B + Trousseau’s sign- neuromuscular
hyperreflexia. Evidenced a few seconds after the
sphygmomanometer cuff was inflated to more than the
systolic blood pressure on the left upper arm. Wrist
flexes & fingers adduct.
o A +Chvostek’s sign- clinical sign of existing nerve
hyperexcitability (tetany). When the facial nerve is
tapped at the angle of the jaw, the facial muscles
on the same side of the face will contract
momentarily (typically a twitch of the nose or lips).
Cause: Hypoparathyroidism, kidney failure,
Hypomagnesemia, acute pancreatitis, insufficient Vit D,
gastrix sx, bone cancer, diarrhea.
Mg++ Hypomagnesia: parasthesias, dysrhythmias,
(Magnesium) hyperreflexia, hypertension, agitation, confusion
1.5- 2.0 o + Trousseau’s sign- neuromuscular hyperreflexia.
o +Chvostek’s sign- nerve hyperexcitability (tetany).
Causes: GI loss, hyperparathyroidism, Hypocalcemia,
Hypokalemia, DKA, hyperparathyroidism, acute MI,
chronic alcohol abuse.
(PO4) Hypophosphatemia: generalized muscle weakness
Phosphorus which may lead to muscle breakdown (Rhabdomyolysis),
3.0- 4.5 parethesia, bone pain and deformities, nystagmus
**PO4 has a inverse relationship w/ calcium
(Cl) Chloride Hypochloremia: Excessive perspiration associated with
95-105 a fever, dehydration, slow shallow respirations,
hyperactive DTR
twitching/ paresthesia, Nausea, Slow, weak, or
irregular pulse, Sudden collapse
**Avoid taking salt substitutes while on potassium
supplements. Many salt substitutes are high in potassium
and may result in hyperkalemia.
Cause: Aldosterone deficiency, Acidosis, sodium
depletion
TMT: Kayexalate (Sodium Polystyrene Sulfonate)
Hypercalcemia-Hypercaluria/kidney stones,
hyporeflexia, ↓muscle weakness, flaccidity,
dysrhythmias, ↓DTR, lethargy/coma.
Cause: Hyperparathyroidism, Vit D excess,
malignant disease, prolonged immobilization,
over use of Ca supplements
Hypermagnesia: Hypotension, drowsiness,
bradycardia, bradypnnea, coma, cardiac arrest,
hyporeflexia, facial flushing, (MG toxicity: absent
deep tendon reflexes)
Causes: adrenal insufficiency, renal failure,
laxative over use, lithium toxicity.
Hyperphosphatemia: hyperreflexia, tetany,
cramps, dysrhythmias
Hyperchloredemia: Weight gain & edema caused
by hypernatremia, Kussmaul respirations,
tachypnea, & other s/s of acidosis
 Causes: forms of fluid loss, such as diarrhea, or vomiting Causes: Weight gain & edema caused by
hypernatremia, Kussmaul respirations,
tachypnea, & other s/s of acidosis

*** IV admiration of KCL should be no faster than KCL 20 mEq/hr

** IV calcium gluconate can cause severe chemical burn; check patency of vein b4 giving it
**Products high in sodium: canned meats or soups, smoked fish, Chinese food uses soy & MSG,
smoked , pickled or cured should be avoided.

Hormones & Actions

Epinephrine – Preparing the body for “fight or flight “

Norepinephrine- Enhancing muscle skeletal activity
Cortisol – converting proteins and fat into glucose; also an anti-inflammatory agent.
Parathyroid hormone (PTH) & Parathormone- regulating the calcium metabolism.

Neutropenia Pecautions
 Private room
 Visitors/ staff should wear, gloves, gown and mask
 No fresh fruits or vegetables allowed
 No fresh flowers allowed
 Limit visitors to healthy adults
 Inspect mouth, mucous membrane and skin every 8 hrs
 Limit number of health care workers entering the room

Fall Prevention
 Remove items you might trip over (such as papers, books, clothes, and shoes) from
stairs and places where you walk.

 Remove small throw rugs or use double-sided tape to keep the rugs from slipping.

 Keep items you use often within easy reach, so you can avoid using a ladder or step
stool.

 Have grab bars installed next to your toilet, and install grab bars in your tub or shower.

 Use non-slip mats in the bathtub and on shower floors.

 Improve the lighting in your home. As you get older, you'll need brighter lights to see
well. Use lamp- shades or frosted bulbs to reduce glare.

 Make sure all stairways have handrails and sufficient lighting.

 If you are a senior or have a disability, it's best to wear shoes that give good support and
have thin non-slip soles.
 Avoiding lightweight slippers (especially backless styles) or athletic shoes with deep
treads, which can reduce your feeling of control.
 Tai chi exercises improve balance and coordination
  Review all medication with doctor; meds can cause lightheadedness or drowsy side
effects

PROCEDURES
Personal Protective Equipment (PPE)
Order of PPE Application Order of PPE Removal
1. Gown 1. Gloves
2. Mask 2. Goggles/ face shield
3. Goggles/face shield 3. Gown
4. Gloves 4. Mask
5. Perform hand hygiene

Radiation
Internal Radiation (implant):
- client is on strict bed rest
- place on a low-residue diet; bowel movements lan dislodge radium implant
- evaluate position of applicator ever 8 hrs
- plan your tasks, work efficiently to reduce your time exposed.
Localized radiation
AE: altered taste sensations

Anaphylactic reaction
Anaphylaxis is a severe, potentially life-threatening allergic reaction. It can occur within
seconds or minutes of exposure to something you're allergic to, such as a peanut or the
venom from a bee sting.
S/SY
• Skin reactions, including hives along with itching, and flushed or pale skin (almost always
present with anaphylaxis)
• A feeling of warmth
• The sensation of a lump in your throat
• Constriction of the airways and a swollen tongue or throat, which can cause wheezing
and trouble breathing
• A weak and rapid pulse
• Nausea, vomiting or diarrhea
• Dizziness or fainting
Interventions
1. Give Epi SubQ- Epi is the only thing that is going to immediately stop the reaction
2. Open patient's airway
3. Place on NRB O2
4. Notify physician
5. Start IV
6. VS
7. Give Benadryl
8. Give Solumedrol (steroid)
**You always give EPI 1st, then benadryl, and finally steroids. Mainly d/t onset and length of
action of each one.

Blood Transfusions
 Allergic reaction- respiratory wheezing, urticarial (hives), pruritus, fever, facial flushing,
and itching.
o TMT: STOP blood transfusion, give Benadryl, and oxygen.
 Hemolytic reaction (blood not compatible)- hypotension, lower backache, fever, chills,
dyspnea, headache, Nausea & vomiting.
o TMT: STOP Blood transfusion, obtain urine specimen, maintain blood volume
and renal perfusion.
o Most dangerous reaction
 Febrile reaction- fever, headache, chills, nausea
o TMT: STOP blood, give aspirin
 Circulatory overload: Dyspnea, Neck vein distention, cough, edema, hemoptysis
o TMT: STOP blood, position upright, give Oxygen
Nurses Role
1. Check MD order
2. Obtain consent
3. Verify Blood is ready in blood bank (lab)
4. Make sure IV site present and patent(use a large 20-22 gauge)
5. Ask pt about allergies and previous reactions to blood products
6. Follow institution guidelines (consent forms)
7. Obtain baseline vital signs
8. Administer premeds if ordered
9. Assemble equipment, prime tubing

After you obtain from the blood bank

1. Inspect blood product for s/s of leakage, clots, bubbles, purplish color
2. Two licensed nurses must compare blood with cross match slip and with ID band

Items to be compared prior to Blood admin.

1. Client name
2. ID number
3. Blood type
4. Donor number on blood container
5. Expiration date

Steps to hang and begin admin of Blood product

1. Don gloves
2. Prepare tubing with NS
3. Spike blood bag to tubing
4. Run blood slowly per institution protocol for first 10-15min
5.If no adverse reaction occurs in first 15 min. Continue at infused rate 125-175ml/hr or
Other Order by MD
6. Recheck Vitals at 10min, 30min and at stop time.
Setting up a blood transfusion (kaplan)

1. Obtain consent
2. Ensure IV patency
3. Double verify compatibility
4. Identify pt
5. Start infusion
6. Evauate for transfusion reactions

If you suspect a transfusion reaction, take these immediate actions:

• Stop the transfusion.

• Keep the I.V. line open with normal saline solution.
• Notify the physician and blood bank.
• Intervene for signs and symptoms as appropriate. (urine sample)
• Monitor the patients vital signs.

Sterile (Aseptic) Technique

a. Obtain the necessary equipment and supplies. All articles required for the procedure, which
will be within the sterile field must be sterile.
 
b. Perform patient care hand wash.
 
c. Locate a suitable surface. Set up the field on a surface that is clean, flat, dry, and free from
drafts.
 
d. Create a sterile field using one of the two methods given below.
(1) Preferred method. The preferred method is to use a double-wrapped sterile package. Do not
let your hands pass over the sterile field or the wrapped sterile object while you are establishing
the field.

(a) Set up sterile field ABOVE waist level

Lay the package so that the flaps are on top

(b) Open the outer layer, usually a paper or plastic cover. This layer forms a barrier between the
work surface and the inner wrapper.
(c) Open the inner wrapper.
1 Using one hand lift the distal flap up and away from the package (figure 3-2). Let this flap drop
gently.
Figure 3-2. Distal flap

2. Open the left flap (figure 3-3

3. Open the right flap (figure 3-4).

open Figure 3-5. Near flap.

5. Open the wrapper so your hand and arm do not pass over any part of the inside of the wrapper
that has been exposed.
(d) Use the inside of inner wrapper as the sterile field. The object that was wrapped is now
located inside a sterile field and is removed from the sterile field using sterile technique.

Perform a Wet-to-Dry dressing

1. Assess comfort level; may require pain medication b/c removing dressing may be
painful
2. Remove gauze dressing; wear clean disposable gloves; be careful to remove
drains or tubs; do not moisten dressing if it sticks to wound.
3. Observe the appearance of the wound: inspect wound for color, character of
drainage, and presence of drains.
4. Clean wound with saline solution; clean from least contaminated area to most
contaminated area of the wound to decrease potential for infection.
5. Apply moist gauze in a single layer to the wound; absorbs drainage and adheres
to wound; cover moist dressing with dry sterile dressing
6. On the tape, record the date and time dressing was applied

Using a Cane
Up the stairs: advance strong leg, then weak leg, then cane
Down the Stairs: client leads with the cane, followed by the weak leg, then strong leg.
**Memory trick: the good goes up the bad comes down

Walking: hold cane with strong arm, move cane forward, followed by the weak leg, and then
strong leg .

The nurse: Stands slightly behind the client on strong side

o Use gait belt to assist the pt; do not place hands on pts arms

"When you walk, the cane and your injured leg swing and strike the ground at the same time. To
start, position your cane about one small stride ahead and step off on your injured leg. Finish
the step with your normal leg.
Crutches (pg 28 Kaplan review)
3-point crutch-walk gait
- Weak leg and crutches are moved forward at the same time, followed by the strong leg;
describes the 3 point crutch-walk gait
o -Arms should be bent at a 35-degree angle; weight should be placed on hands and arms
o Crutches should be placed 8-10in front w/ each step
o Shoes should have nonslip soles (leather soled shoes are bad)
o Crutch tips should be inspected regurlar for cracks , wear and tightness of fit, and
replaced immediately if any problems are found
Stairs
- Up stairs: Strong leg leads up first , then crutches and weak leg
- Down Stairs: the crutches are advanced to the lower step, the weak leg is advanced and
then the longer leg follows
(“up with the good and down with the bad”)

Colostomy care
sigmoid
The colostomy irrigations should be done at the same time each day to assist in
establishing a normal pattern of elimination.
 Bags Should be changed once a week
 Irrigate once a day
Ileostomy
 Measure out put after sx
 Report if stoma is tight, and decreased amount of stool
 Ileostomies are not irrigated
 Wear pouch around stoma at all times
 Empty drainage when it 1/3 full
 Do not use moisturizers

IV Infiltration
Characteristics of IV insertion site: Cool to touch, pale, swollen, edema and blanching at
the site, burning pain.
Cause: devise is dislodged from vein or perforated vein
Intervention:
1. Stop the infusion
2. Remove IV and Elevate extremity on pillow
3. Apply cold compress
4. Insert new IV on opposite extremity

Phlebitis
Inflammation of the vein
-Causes: prolonged use of same site, injury during venipuncture, needle size is too large
for vein.
-Characteristics: IV site is reddened, red streaks, pain, vein is sore and hard/cord like,
warm to touch, signs of infection
Intervention
1. Stop infusion
2. Remove IV
3. Apply pressure to stop bleeding
4. Apply Warm soaks

Pacemaker
Any time the pulse rate drops below the present rate on the pacemaker, the pacemaker
s malfunctioning.
The pulse rate should be maintained at a minimal rate set on on the pacemaker.
o Measure apical pulse

Care after Surgery

Abdominal hysterectomy
 Early ambulation as soon as possible to prevent thromboembolism formation
and to increase peristalsis
o Ambulation helps to expel flatus (gas pains)
 Show how to splint the abdomen when deep breathing and coughing
 Use of incentive spirometry
 Avoid heavy lifting or strenuous activity

Paracentesis
The client is usually positioned semi fowlers position in bed or sitting upright on the bed
w/ feet supported
 Empty bladder before procedure

Complications
 Peritonitis: abdominal pain, rigidity, distention, N/V
Thoracentesis
A procedure to remove fluid from the space between the lining of the outside of the lungs
(pleura) and the wall of the chest.

Complications
SOB, faintness, chest pain, bloody sputum
 Pulmonary edema, hypoxia, hemothorax, pneumothorax, subcutaneous emphysema,
spleen and liver puncture

Lumber puncture
 Following Lumbar Puncture- client will remain supine, flat for 8 hours to prevent spinal
headache
 Children /infants must be retrained to prevent trauma

Liver Biopsy
 Position supine with arms raised above head
 After biopsy position pt on right side
 Have a lab result for prothrombin time PT
Thyroidectomy
 After sx, position semi fowlers, supported head, neck, shoulders.

Bronchoscopy
 After bronchoscopy:
 Assess for S/SY of respiratory distress
o Tachypnea, tachycardia, resp stridor, and retractions
 The nurse keeps the client on NPO status until the gag reflex returns
o the preoperative sedation and local anesthesia impair swallowing and the
protective laryngeal reflexes for a number of hours.
 Additional fluids are unnecessary because no contrast dye is used that would need
flushing from the system.

Pneumonectomy
A surgical procedure to remove a lung.
 On surgical side, breath sounds will be absent
 Assess position of trachea- should be mid-line

Central Venous Line
A central venous catheter, also called a central line, is a long, thin, flexible tube used to give
medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks
or more. A catheter is often inserted in the arm or chest through the skin into a large vein.
Position: pt is supine w/ head low and turned away from the insertion site
Complications:
 If Iv tubing becomes disconnected from pts central line it can cause an air embolism
 Air Embolism
s/sy:
o Restlessness
o Dyspnea
o Tachycardia, sudden onset of pallor
o Diaphoretic
o Coughing
o Hypotension
o Chest pain
o Weak rapid pulse
o Shoulder and low back pain depending on the location of the embolus.
 Priority: place pt on left side and lower HOB. Trendelenburng position (head lower than
feet), initiate oxygen therapy, and notify the physician
 Placing the pt in this position will increase the likelihood that the air will pass into
through right atrium and be disbursed by the pulmonary artery.
Enemas
Position the pt on LEFT side laying (Sim’s) with knee flexed.
- Warm water
- Insert irrigation tube 3-4 inches into rectum
- Hold irrigation set 12-18 in above client’s rectum; a high level may cause rapid
distention and pressure in the intestine.
-

Barium Swallow (Upper GI series)

Pre-procedure:
 Client drinks barium sulfate
 NPO after midnight before the test

Intra-procedure
Post- procedure
 A laxative may be prescribed
 Advise client to increase oral fluid intake to help pass the barium
 Monitor stools for the passage of barium (stools will appear chalky white)

Barium Enema (Lower GI series)

An X-ray exam that can detect changes or abnormalities in the large intestine (colon)
Pre-procedure:
 Clear liquid diet before the test
 NPO after midnight before the test
Intra-procedure
 Rectal instillation of barium sulfate
 During the test, tell client to take slow, deep breaths through mouth
o Client may have urge to defecate

Post- procedure
 Advise client to increase oral fluid intake to help pass the barium
 Administer mild laxative
 Advise client stools may be light colored for 2-3 after test

Clean Intermittent- Self catheterization

A urinary catheter tube drains urine from your bladder. You may need a catheter because you
have urinary incontinence (leakage), urinary retention (not being able to urinate), prostate
problems, lower motor neuron disorders (multiple sclerosis) or surgery that made it necessary.
-Can be done using clean techniques (not sterile).

1. Wash your hands with soap and water.

2. Collect your supplies: catheter (open and ready to use), towelette or other cleaning
wipe, lubricant, and a container to collect urine if you are not planning to sit on the
toilet.
3. You may use clean disposable gloves, . The gloves do not need to be sterile, unless your
doctor says so.
4. With one hand, gently pull the labia open, and find the urinary opening. You can use a
mirror to help you at first.
5. With your other hand, wash your labia 3 times from front to back, up and down the
middle, and on both sides. Use a fresh antiseptic towelette or baby wipe each time. Or,
you may use cotton balls with mild soap and water. Rinse well and dry if you use soap
and water.
6. Apply the K-Y Jelly or other gel (water-soluble lubricant ) to the tip and top 2 inches of
the catheter. (Some catheters come with gel already on them.)
7. While you continue to hold your labia with your first hand, use your other hand to slide
the catheter gently up into your urethra until urine starts to flow. Do not force the
catheter. Start over if it is not going in well. Try to relax and breathe deeply.
8. Let the urine flow into the toilet or container.
9. When urine stops flowing, slowly remove the catheter. Pinch the end closed to avoid
getting wet.
10. Wipe around your urinary opening and labia again with a towelette/ baby wipe.
11. If you are using a container to collect urine, empty it into the toilet. Always close the
toilet lid before flushing to prevent germs from spreading.
12. Wash your hands with soap and water.

Cleaning your catheter

1. Wash your hands well.

2. Rinse out the catheter with a solution of 1 part white vinegar and 4 parts water. Or, you
can soak it in hydrogen peroxide for 30 minutes. You can also use warm water and soap.
The catheter does not need to be sterile, just clean.
3. Rinse it again with cold water.
4. Hang the catheter over a towel to dry.
5. When it is dry, store the catheter in a new plastic bag.
6. Throw away the catheter when it becomes dry and brittle.

Mechanical Ventilation
 Tidal volume: volume of air inspired and expired in a normal breath
 No water should be in the tubing; check tubing for presence of water and remove;
humidifier is used
 Settings should be 1.5 times the tidal volume and occur every 1-3 hrs
 Settings are based on findings of ABG
 Machine is adjusted to deliver the lowest concentration of oxygen to maintain
normal ABG
Nursing Interventions
  Assess BP immediately after initiation of mechanical ventilation
 Report a cough that does got go away
 Position Supine, HOB at 30 - 45 degrees (to prevent aspiration)
 Monitor for sighs of ventilator associated pneumonia (VAP)
o Elevated temp and WBCs.
o Purulent sputum. Odorous sputum.
o Crackles or rhonchi on auscultation.
o Pulmonary infiltrates on X-ray
 Assess for symptoms of hypoxia: confusion, agitation, cyanosis, anxiety,
tachycardia, increased RR,
o Nurse should ventilate at 100% oxygen

Endotracheal tubing-
- if the abdomen is distended and food like material is in the ET tube, it indicates that the ET
tube is in the stomach

-After the removal of ET tube- Stridor indicates airway edema and places the client at risk
for airway obstruction. This is a high-pitched, coarse sound that is heard with the
stethoscope over the trachea.

Tube Suctioning (sterile)

1. Pt. in semi-fowlers position
2. Set up sterile field
3. Always hyper-oxygenate w/ 100% O2 before suctioning
4. Use suctions 90-120 Hg and #12 or #14 French suction catheter
5. Insert the suction catheter until resistance is met without applying suction,
withdraw 0.4- 0.8 inches (1-2cm),
6. Apply intermittent suction with twirling motion. Never suction more than 10-15
seconds.
7. Always suction trachea 1st then suction mouth
8. Hyper-oxygenate w/ 100% O2 after suctioning

**If side effects develop, especially cardiac irregularities, the procedure is stopped and the
client is re-oxygenated.

Tracheostomy care (sterile)

 Always use pre-cut 4X4 gaze
o never ever cut or detach the old trach ties until you have the new ones
secured
 If there is water in the tubing; the fluid can be empties from the tubing
 If tracheostomy tube becomes dislodged;
o Immediately replace tube
o Grasp the retention sutures to spread the opening. Head does not need to
elevated for suctioning
 o Check for bilateral breath sounds

Chest Tubes
After a Thoracotomy:
Pluer-Evac Drainage
 The water should be continuous gentle, slow be steady bubbling in the suction
control chamber.
o Constant bubbling in water seal chamber; indicates air leak
 There should be air bubbles in the water seal chamber when patient exhales (on
expiration phase or respiration cycle) and when coughing or sneezing; these
bubbles indicate the system is removing air from the pleural space
 First 24 hrs after the chest surgery as much as 500-1000ml of drainage can occur,
with 100-300ml being in the first 2 hours and then a progressive decline in amount.
o Drainage over 100/hr should be notified
 The fluid in the water seal chamber should fluctuate with respirations of the patient,
rising with inspiration and falling with expiration.
 **Absence of fluctuations indicates that either the lung has re-expanded (which is
desired) or that there is an obstruction of the chest drainage tubes (NOT desired); the
most common cause of obstruction is the patient lying on the tubing; other causes
are kinking, clots, dependent loops, or fibrin.
o Chest x-ray will confirm re-expansion
 If the chest drainage system is disconnected, the end of the tube is placed in a bottle
of sterile water held below the level of the chest
 NEVER clamp a chest tube during transportation or ambulation; should only be
clamped during a draining system change or by a DR evaluating the readiness for
removal

Nasogastric Tube (NG): intubation procedures. Saunders 237

To decompress the stomach by removing fluids
1. Explain procedure and potential discomfort
2. Position client upright w/ pillows behind shoulders
3. Determine which nostril is more patent
4. Measure the length of the tube from the bridge of the nose to the earlobe to the
xiphoid process. Indicate this length w/ a piece of tape on the tube
5. If the pt is conscious alert and awake have him swallow or drink water
6. Lubricate the tip of tube w/ water-soluble lubricant.
7. Gently insert the tube into the nasopharynx and advance tube.
8. When tube nears he back of the throat (first black measurement on the tube) instruct
the client to swallow or drink sips of water. If resistant is met , then slowly rotate
and aim the tube downward and toward the ear
9. Immediately withdraw the tube is any change is notes in the pts respiratory status
10. Following insertion, obtain an abdominal x-ray to confirm placement
11. Connect the tube to suction, to either intermittent or continuous
12. Secure the tube to clients nose w/ adhesive tape and to the client gown
13. Observe for N/V, abdominal fullness or distention. Monitor output
14. If residual amount is more than > 100ml , with hold feeding
15. Before the instillation of any substance through tube (irrigation, meds, feeding)
o Confirm placement of tube by aspirating
 o Aspirate stomach contents and test PH (pH < 3.5 indicates tip of the tube is in
gastric location)
o Flush NG tube with 30ml of air before aspirating fluids

** Tube feeding w/ decreased LOC

o Position pt on right side (promotes gastric emptying of the stomach)
o Elevate HOB
** if these is abdominal distention or nausea; check NG patency and draining
o Patency is checked b aspirating gastric contents
**Salem sump tube: Hissing sound indicates that air is freely exiting the airway, purpose is
to provide continuous steady suction, w/o pulling gastric mucosa.

Enteral feeding
o Aspirate stomach contents and check pH
o The tube feeding is given at room temperature
o Enteral tube is flushed with 30ml of water after feeding

Incentive Spirometry
 Inhalation and holding of breathe for 3-5 seconds; deep inhalations expand
the alveoli and therefore prevent atelectasis.

1. Sit on the edge of your bed if possible, or sit up as far as you can in bed.
2. Hold the incentive spirometer in an upright position.
3. Place the mouthpiece in your mouth and seal your lips tightly around it.
4. Breathe in slowly and as deeply as possible.
o Notice the yellow piston rising toward the top of the column. The yellow
indicator should reach the blue outlined area.
5. Hold your breath as long as possible. Then exhale slowly and allow the piston to fall
to the bottom of the column.
6. Rest for a few seconds and repeat steps one to five at least 10 times every hour.
7. Position the yellow indicator on the left side of the spirometer to show your best
effort. Use the indicator as a goal to work toward during each slow deep breath.
8. After each set of 10 deep breaths, cough to be sure your lungs are clear. If you have
an incision, support your incision when coughing by placing a pillow firmly against
it.
9. Once you are able to get out of bed safely, take frequent walks and practice the
cough.
** Always splint incision before using spirometer

Total Parental Nutrition TPN

Total parenteral (IV) nutrition (TPN) Parental Nutrition (PN) is a method of providing
nutrients to the body by an IV route. The nutrients are a complex admixture containing
proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water in a
single container. Typically the subclavian vein or superior vena cava is the preferred site.
-Indications for PN: inability to ingest adequate or oral food or liquids for 7 days. Enteral
Nutrition should be considered before parenteral support.
 TPN will drip through a needle or catheter placed in your vein for 10 to 12 hours,
once a day or five times a week.
 TPN is used for patients who cannot or should not get their nutrition through eating.
Your TPN may include a combination of sugar and carbohydrates (for energy),
proteins (for muscle strength), lipids (fat), electrolytes, and trace element.
 Assist pt to remain in Trendelenburg (head down /feet up) position during
catheter insertion, to prevent pneumothorax.
 Do NOT tamper off medication, slowly stop infusion.
 Never abruptly STOP TPN
o Insulin levels remain high and glucose levels decline; results in Hypoglycemia;
o Tachycardia
o Confusion
o Diaphoresis
o Restlessness
o Headache
o Weakness
o Lack of muscle coordination
o Apprehension /irritability

 Do NOT use TPN line for other IV bolus fluids and meds
 DO NOT infuse rapidly; would cause hyperglycemia and hyperosmolar diuresis
 Hang no longer than 24 hrs; slowing rate will cause rebound hypoglycemia
 If TPN is not in stock it can be replaced with D5W (10% dextrose in water)
(D10W)
 10% Dextrose in water (D10W) is also given to wean off from TPN
 Monitor urine output of at least 30ml/hr
o Determines clients tolerance to treatment and also determines proper
hydration status
 Insulin is the only medication that can be given, that is compatible with TPN
 Check capillary glucose every 4-6 hr for the first 24 hrs.
 Clients receiving TPN frequently need supplemental Regular insulin until
pancreas can increase its endogenous production of insulin.
 Side effects= Hyperglycemia = an excessive amount of glucose
 If pt is not on TPN, they need to be on a diet
o High protein
o High fat
o Low- mod carb diet
o Small frequent meals
o No milk
o No concentrated sugars or sweets
o Drink only 1hr before or 2 hrs after meals.
o Teach to lie down about 30 mins after meals

 NURSING DX
 Risk for infection
 Maintain aseptic technique and wear sterile gloves to clean the area
 The area is checked for leakage, bloody or purulent drainage, a kinked
catheter, and skin reactions such as inflammation, swelling, redness, or
tenderness.
 Change tubing and solution bag every 24 hrs.
 Unused solution is ALWAYS discarded
  Imbalanced nutrition
o Dumping syndrome
o Gastric surgery
o Bowel obstruction
o Pt. with colostomy
o Irritable Bowel Syndrome
Complications:
 Pneumothorax
o TMT- place pt in fowlers position
 Air embolism
o TMT- clamp catheter, place pt in left side Trendelengerg’s position
o Give O2
o S/SY of air embolism: Restlessness, dyspnea, Tachycardia, sudden onset of pallor,
pdiaphoresis
 If resistance is met when flushing the distal lumen
o Secure the lumen with a Leur-Lock cap, and notify Dr.
o Streptokinase may be used to dissolve clot, if unsuccessful, lumen is labeled
as clotted off.
 Clotted or displaced catheter
 Sepsis
 Hyperglycemia,
 Rebound hypoglycemia,
 Fluid over load

Respiratory Alkalosis:
Client is hyperventilating: increased RR
 Have client to breath in paper bag;
 having him breath in his CO2 will reverse the imbalance
 Give O2 only if he is hypoxic

Solutions
 Hypotonic:
o ½ NS
o 0.45% NaCl
o Used for Dehydration
o (Little salt Less than Normal saline)
 Hypertonic:
o 10% Dextrose in water (D10W)
o (lots salt more than Normal saline)
 Isotonic:
o Ringers lactate: effective as volume expander
o 0.9% NaCl: used for fluid replacement /replaces electrolyes
o (Normal saline) 0.9% normal saline

EKG Dysrhythmias and Medication

Eg. 8 QRS complex in 30 large squares for a 6 sec strip EKG, calculate HR.
30 large squares on EKG represents 6 secnds.
Multiply the numer of QRS complex by 10 (8x10= 80 beats/min)
  Bradycardia
o Atropine IV
 Heart block & ventricular dysrhythmias
o Isoproterenol IV
o Pace maker -HB
 Premature ventricular contractions (PVC’s)
o Lidocaine IV- for PVC’s occurring in 6- 10 per minute

Peritoneal Dialysis
Goals are to remove toxic substances and metabolic wastes and to reestablish normal F&E
balance.

- PD usually takes 36-48 hrs. to achieve what hemodialysis accomplishes in 6-8hrs.

Prepping pt.
-Explain procedure to pt. and obtain signed consent
-Take baseline VS; BP, pulse, weight., and serum electrolyte levels.
- Evaluate abdomen for placement of cath.; usually placed on non-dominant side to
allow pt. easier access to the cath. connection site.
- Broad-spectrum antibiotic agents may be administered to prevent infection

Preparing equipment
Nurse must consult with Dr. on concentrations of dialysate to be used and meds to be
added to it.
- Heparin may be added to prevent fibrin formation resulting in occlusions
- Potassium chloride may be added to prevent hypokalemia
- Antibiotics may be added to treat peritonitis caused by infection.
- Reg. insulin may be added for pt. with diabetes

Aseptic technique is super important when adding meds.

o Dialysate is warmed to body temp. to prevent pt. discomfort and abdominal pain
and to dilate vessels of the peritoneum to increase urea clearance.
 This is done with dry heat [heating pad]. Not recommended to soak bag in
warm water b/c this may introduce bacteria.

Performing exchange
An exchange is the infusion [fill], dwell, and drainage of the dialysate. Cycle is repeated
throughout course of dialysis.
 - Dialysate is infused by gravity into the peritoneal cavity. Takes 5-10 min to infuse 2-
3L of fluid.
- At the end of the dwell time, the drainage portion of the exchange begins. Tube is
unclamped and the solution drains by gravity through a closed system. Drainage is
completed in 10-20min.
- The # of cycles or exchanges and their frequency are prescribed based on monthly
lab values and presence of uremic symptoms.
- Dialysate has a high dextrose concentration, the higher the dextrose concentration;
the greater the osmotic gradient and the more water will be removed.

Nursing management
- Teach patient/family – teach differences of Hemodialysis/Peritoneal Dialysis
- Provide psychological support – this will cause a life style change
- Monitor VS before, during and after procedure
- Monitor I & O
- Monitor Lab values
- If you see outflow is inadequate
1. Turn client from side to side
2. Assess for kinks in tubing
3. Milk tube if fibrin clot is confirmed
- Assess for physiological & psychological changes

Complications
 Infection
 Possible bowel and bladder perforation leading to Peritonitis and septicemia
 Peritonitis
o Cloudy or opaque dialysate is the earliest sign of peritonitis
o Normal out flow drainage (effluent) is relatively clear and light yellow
o Abdominal pain or tenderness
o Bloating or a feeling of fullness (distention) in your abdomen
o Fever
o Nausea and vomiting
o Loss of appetite
o Diarrhea
o Low urine output
o Thirst

Conditions
Heat stroke- lie flat w/ legs elevated

Disseminated intravascular coagulation (DIC)

Is a serious disorder in which the proteins that control blood clotting become over active.
Over time, the clotting proteins in your blood are consumed or "used up." When this
happens, you have a high risk of serious bleeding, even from a minor injury or without
injury.

TMT: Heparin
Risk factors for DIC include:

• Blood transfusion reaction

• Cancer, especially certain types of leukemia
• Inflammation of the pancreas (pancreatitis)
• Infection in the blood, especially by bacteria or fungus
• Liver disease
• Pregnancy complications (such as placenta that is left behind after delivery)
• Recent surgery or anesthesia
• Severe tissue injury (as in burns and head injury)
• Large hemangioma (a blood vessel that is not formed properly)

S/SY
 Prolonged bleeding from sites of minor trauma
o Oozing blood from venipuncture site or incision
 Blood clots
 Bruising
 Drop in blood pressure

Pituitary Dwarfism – have delicate features- they appear younger than

chronological age.

Buerger's Disease: (Thromboangiitis obliterans)

a rare disease of the arteries and veins in the arms and legs. Buerger's disease is
characterized by a combination of inflammation and clots in the blood vessels, which
impairs blood flow. This eventually damages or destroys tissues and may lead to infection
and gangrene.
Buerger's disease usually begins in the hands and feet and may progress to affect larger
areas of the limbs. More common in men btw 20-35 yrs old.
S/SY:
• Pain and weakness in legs and feet or arms and hands
• Swelling in feet and hands
• Fingers and toes that turn pale when exposed to cold (Raynaud's phenomenon**)
• Pain at rest and coldness
• Open sores on fingers and toes
• Nurses must check for ulcer formations and gangrene

Tests to confirm diagnosis:

Include Allen's test, arteriogram, and blood tests to r/o other possible causes, such as lupus,
scleroderma, blood clotting disorders, and diabetes mellitus

Raynaud's Phenomenon:
Is a condition resulting in a particular series of discolorations of the fingers and/or the toes
after exposure to changes in temperature (cold or hot) or emotional events.
S/SY
Strong emotions or exposure to the cold bring on the changes.

• First, the fingers, toes, ears, or nose to become white, then turn blue.
• When blood flow returns, the area becomes red and then later returns to normal color.
• The attacks may last from minutes to hours
• Tingling & numbness

Treatment
Taking these steps may help control Raynaud's phenomenon:

• Stop smoking. Smoking causes blood vessels to narrow even more.

• Avoid caffeine.
• Avoid taking medicines that cause blood vessels to tighten or spasm.
• Keep the body warm. Avoid exposure to cold in any form. Wear mittens or gloves
outdoors and when handling ice or frozen food.
• Avoid getting chilled, which may happen after any active recreational sport.
• Wear comfortable, roomy shoes and wool socks.
• When outside, always wear shoes.

Wernicke Syndrome - is a brain disorder due to thiamine (Vitamin B1) deficiency.

• Confusion and loss of mental activity that can progress to coma and death
• Loss of muscle coordination (ataxia) that can cause leg tremor  
• Vision changes such as abnormal eye movements (Nystagmus: back/ fourth movements)
• Double vision, eyelid drooping

Korsakoff Syndrome- a chronic memory disorder caused by severe deficiency of

thiamine (vitamin B-1).
 Problems learning new information
 Inability to remember recent events and long-term memory gaps
 Confabulate- or make up, information they can't remember.

Meirner's syndrome-
Ménière’s disease is a disorder of the inner ear that causes severe dizziness (vertigo),
ringing in the ears (tinnitus), hearing loss, and a feeling of fullness or congestion in the ear.
Ménière’s disease usually affects only one ear.
 Vertigo, Fall Risk prevention
 Low sodium diet

Hantavirus Pulmonary Syndrome (HPS)

-Severe, sometimes fatal, respiratory disease in humans caused by infection with a
Hantavirus.
- Caused by rodents
- Airborne transmission
Early S/SY
 Fever
 Aching
 Nausea
Late S/SY
 Coughing
 SOB
 Chest tightening
Interventions
 Assess for thrombocytopenia, hematuria, hematemesis (vomiting blood), bleeding
gums, melena (black tarry stool)

Laws & Regulations

 Negligence is the omission of an action, resulting in an undesirable outcome.
o The nurse checks the pedal pulses of her patient 2 hrs after cardiac
catheterization.
o Checking pedal pulses should be done immediately after the procedure and
repeated every 15 mins for several hrs to detect changes in circulation; act of
omission.
 Malpractice is a direct action that creates an undesirable outcome .
o Applying a cooling blanket or heating pad directly to the skin with no barrier and
then the patient ends up with blisters that further breaks down into a bedsore. Your
actions resulted in injury.

 Advance directives (living will) are legal documents that allow you to spell out
your decisions about end-of-life care ahead of time. They give you a way to tell your
wishes to family, friends, and health care professionals and to avoid confusion later
on.

 Durable power of attorney for health care is a document that names your health
care proxy. Your proxy is someone you trust to make health decisions for you if you
are unable to do so.
IMPORTANT QUESTIONS
 Individuals at risk for Latex Allergy
 Spina bifida
 Congenital or urogenital defects
 Hx of indwelling catheters
 Hx of using condom catheters
 High latex exposure (eg. Health care workers, housekeepers, food handlers,
tire manufactures, workers)
 Hx of multiple childhood surgeries
 Hx of food allergies
 Materials: IV cath, IV tubing, Iv ports, rubber stoppers, adhesive tape, ace
bandages, ambu bag, bp cuff.
 Individuals allergic to: kiwis, papaya, bananas, pineapple, avocado, tropical
fruits, grape, potatoes, hazelnuts, and water chest nuts, watermelon,
tomato’s, celery.. also consider: spinach, broccoli, apples, squash family,
pumpkin, beans, legumes, mango, spices , mint, and cinnamon.

Levels of latex reactions

 Irritant dermatitis- skin redness and itching
 Type IV hypersensitivity: redness itching, and hives
 Type I allergic reaction: life threatening: hives, generalized edema, itching ,
rhinitis, rash, wheezing, bronchospasm, difficulty breathing , hypotension,
tachycardia or cardiac arrest

Random Facts

Examples of Clients to see FIRST

1. Client with forceful bleed from head- indicates arterial bleed, could go into shock
2. Client expectorating pink tinged mucous- pulmonary edema
3. Client receiving blood begins to vomit- hemolytic reaction
4. Client with burns to the face- airway compromise
5. Client with a crush injury to the chest with RR of 10- ABC's
6. Client with swollen lips after an ant bite- could be anaphylactic reaction
7. Client admitted with status asthmaticus- life threatening
8. Child with croup and RR rate of 35
9. Client who delivered by C-Section 1 hour ago with 3 soaked pads- active bleed

 If it come out your ass= Metabolic Acidosis...

 By mouth (vomiting)= Metabolic Alkalosis...

Mother/baby stuff
 1. rh negative mom gets rhogam if baby rh positive. mom also gets rhogam after
aminocentesis, ectopic preganancy, or miscarriages.

3. prolasped cord position knee chest or trend.. call for help!! get that bottom off the cord!
support cord with ya hand

4. Decelerations early vs late----always good to be early but dont ever show up late. early
mirrors the contraction, late comes after the contraction

5. lochia sequence...lochia rubra- red, clotty....lochia serosa...pink, brown....lochia

alba..white.........should never have a foul odor!

 Mydriatic: with a D= Dilate pupils

 Miotic:with an O= cOnstrict pupils
 aniticholinergic SE:
 can't see
 can't pee
 can't spit
 can't sh*t

 Hyperkalemia "MACHINE"- causes of incr serup K+
 M-medications (ace inhibitors, Nsaids)
 A-acidosis (Metabolic and respiratory)
 C-cellular destrx-burns, traumatic injury
 H-hypoaldosteronism, hemolysis
 N-nephrons, renal failure
 E- excretion-impaired

 Signs and symptoms of incr serum K+= MURDER
 M-muscle weakness
 U-urine, oliguria, anuria
 R-respiratory distress
 D-decr cardiac contractility
 E-ECG changes
 R- reflexes, hyperreflexia, or flaccid

 HYPERNATREMIA-you are fried
 F-fever (low grade), flushed skin
 R-restless (irritable)
 I-incr fluid retention and incr BP
 E-edema ( peripheral and pitting)
 D-decr urinary output, dry mouth

 Hypocalcemia-"CATS"
 C-convulsions
 A-arrythmias
 T-tetany
 S-spasms and stridor

**Don’t give non selective Beta Blockers to anyone with respiratory problems i.e asthma, copd.
(eg, Propranolol is contraindicated in CHF)

Nursing Fact: Bulge Test- to check fluid in knees, have pt lie down w/ legs straight

TKO: to keep open (IV fluid runs at a slow rate to keep the vein open)

**IVPB should be hung higher than primary line/bag. the pump does not know which fluid to
run with Y tubing connected above the pump.

** Albumin is the best indicator of long tern nutritional status. Liver function.
 Low albumin levels can be an indicator of chronic malnutrition or protein losing
enteropathy.
 Hypoalbuminemia may cause generalized edema (swelling) via a decrease in oncotic
pressure.
 The serum albumin level is part of a standard panel of liver function tests

Hematocrit is a blood test that measures the percentage of the volume of whole blood that is
made up of red blood cells
 ↓Low hematocrit may be due to
o Anemia
o Bleeding
o Destruction of red blood cells
o Leukemia
o Malnutrition
o Nutritional deficiencies of iron, folate, vitamin B12, and vitamin B6
o Overhydration

 High hematocrit may be due to:

Congenital heart disease
o Failure of the right side of the heart (cor pulmonale)
o Dehydrayoin
o Abnormal increase in red blood cells (erythrocytosis)
o Low blood oxygen levels (hypoxia)
o Scarring or thickening of the lungs (pulmonary fibrosis)
o Bone marrow disease that causes abnormal increase in RBCs
(polycythemia vera)

**Hemoglobin is the molecule in red blood cells that carries oxygen.

 ↓Low Hgb indicates less circulating oxygen; increased respirations & pulse
 Apply oxygen to a pt with critically low Hgb
**Platelets, also called "thrombocytes", are blood cells whose function is to stop bleeding.
(150,000 – 450,000)
 ↓Low count causes problems with blood clotting; risk for injuries; check for bleeding
gums

WBC, help fight infections. They are also called leukocytes (5-10,000)
 ↓Low count is called leukopenia
o Bone marrow deficiency or failure (for example, due to infection, tumor, or abnormal
scarring)
o Leukopenia causes susceptibility to infection
o Cancer treating drugs, or other medicines (see list below)
o Certain autoimmune disorders such as lupus
o Disease of the liver or spleen
o Radiation treatment for cancer
o Certain viral illnesses, such as Mono
o Cancers that damage the bone marrow
o Very severe bacterial infections

 ↑High count is called leukocytosis

o Infection
o Anemia
o Certain drugs or medications (see list below
o Cigarette smoking
o Infections, most often those caused by bacteria
o Inflammatory disease (such as rheumatoid arthritis or allergy)
o Leukemia
o Severe mental or physical stress
o Tissue damage (for example, burns)

BUN is an indication of renal health (kidney). (10-20) 

 ↑High levels indicate, water and salt depletion
o High BUN can cause; confusion, convulsions, disorientation, which could easily
lead to fall
 The main causes of an increase in BUN are: high protein diet, decrease in Glomerular
Filtration Rate (GFR) (suggestive of renal failure) and in blood volume (hypovolemia),
congestive heart failure, gastrointestinal hemorrhage,[3] fever and increased
catabolism.

Specific gravity (1.010- 1.030) -Urine specific gravity is a laboratory test that measures the
concentration of all chemical particles in the urine.
 ↑Increased urine specific gravity may be due to different conditions such as:
o Diarrhea that causes dehydration
o Heart failure
o Loss of body fluids (dehydration)
o Narrowing of the kidney artery (renal artery stenosis)
 o Sugar, or glucose, in the urine
o Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

 ↓ Decreased urine specific gravity may be due to:

o Damage to kidney tubule cells (renal tubular necrosis)
o Diabetes insipidus
o Drinking too much fluid
o Kidney failure
o Severe kidney infection (pyelonephritis)

ESR indicates inflammatory or degenerative tissue destruction. (0-20)

 ↑High levels may indicate an acute febrile disease and therefore become lethargic,
confused, and weak.

HU RATT as a mnemonic for the early adaptations of hypoxia:


 Hypertension
 Use of accessory muscles (while breathing)

 Restlessness
 Anxiety
 Tachycardia
 Tachypnea

 The (early) RAT- restlessness, anxiety, tachycardia & tachypnea.

 (Late) to BED- bradycardia, extreme restlessness, dyspnea

For Pediatrics
 F- feeding difficulty
 I- Inspiratory stridor
 N- nares flare
 E- Expiratory grunting
 S- sternal retractions
 Cyanosis

WBC
Decreased (leukopenia) causes susceptibility to infection

T-cells
5000-100,000 below 400= immunocomprised

Normal urine output= at least 30ml/hr; 1500ml/24hr