THE NURSING

A Study Bundle for Nursing Students

Anatomy
Med-Surg
Pharmacolo
Pediatrics
Maternity
Fundament

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Authors: Fiskvik Antwi, PhDN, RN.
Simon Osei, PhDN, RN
Rachel Antwi, BSN, RN

Copyright © 2021 by NurseBoss Store

All Rights Reserved.
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table of contents
Fundamentals of Nursing............................ 5-41
IV Fluids.......................................................................... 42-51
Anatomy and Physiology............................ 52-82
Medical-Surgical Nursing............................ 83-233
Med-Surg Flashcards...................................... 234-280
Shock............................................................................... 281-299
Hepatitis....................................................................... 300-302
Burns................................................................................ 303-308
Chest Tube Management............................ 309-312
Electrolyte Imbalance.................................... 313-318
EKGs/ECGs.................................................................. 319-344
Lab Values................................................................... 345-349
ABGs.................................................................................. 350
Pharmacology........................................................ 351-426
Drug Calculation................................................... 427-431
Insulin.............................................................................. 432-433
Maternal and Child Health.......................... 434-467
Pediatric Disorders............................................ 468-500
Nursing Health Assessment...................... 501-508
Cranial Nerves......................................................... 509-524
Patient Assessment Template.............. 525-529
Nurse Report Template................................. 530
Nursing Process..................................................... 531-600
FUNDAMENTALS OF
NURSING

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TABLE OF CONTENTS

TABLE OF CONTENTS
1. The Healthcare Delivery System
2. The Nursing Process
3. Nursing Ethics
4. Nursing Concepts
5. Cultural Competence
6. Electrolyte Imbalance
7. Head-to-Toe Assessment
8. Patient Positioning
9. IV Therapy
10. Vital Signs
11. Nutrition
12. Wound Care
13. Medication Administration
14. Infections
15. Transmission Precautions
16. SBAR Communication Tool
17. Blood Groups
18. Oxygen Therapy
19. Nursing Theorists

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The Health Care Delivery System
Definition
A health care delivery system
involves an organization of
people, institutions and
resources to provide health
care services to meet the
needs of a population.
Methods of Healthcare
Delivery
Managed Care System: a
system organized to
manage cost, utilization and
quality.
Case Management: a
collaborative process of care
to meet the patient's
health care needs. The case
managers are nurses.
Primary Healthcare:
provides universal health
care that is accessible to
individuals, families and the
community.
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Components of the HCS
1. The patient (consumer)
2. Professional care providers:
doctor, nurse, etc.
3. Organization: hospital, clinic
4. Economic environment:
regulatory bodies,
Insurance, etc.
Levels of Healthcare
PRIMARY CARE
1. First level of contact
2. Promotive + Preventive care
3. Clinics, etc.
4. Involves disease prevention,
counseling, education, screening
SECONDARY CARE
1. Curative services
2. Diagnosis and treatment of
patients
3. Hospitals, emergency
department etc.
TERTIARY CARE
1. Higher level of care
2. Specialized care + speciality units
3. ICU, cancer treatment, cardiac
surgery, etc.
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The Health Care Delivery System

Type of
Interprofessional Care
Healthcare Settings
Interprofessional/
1. Hospitals
interdisciplinary care involves
2. Ambulatory care centers
the collaboration among
3. Home health healthcare professionals to
4. Primary care centers: offices provide patient-centered care.
5. Schools
6. Daycare centers
7. Mental health centers
8. Rehabilitation centers
9. Hospice
10. Occupational health
Current Trends and
11. Assisted-living
Issues in Healthcare
Finance and Healthcare 1. Nursing shortage
1. Medicare: federal health 2. Healthcare cost
insurance. Coverage: >65 3. Globalization
years and younger people 4. Technology
with disability. 5. Complexity of patient
2. Medicaid: federal and state
care
program for people with
6. Increase of chronic illness
low income
3. Private Insurance
7. Increase of the elderly
population
8. Changing demographics
9. Political influence
10. Increasing diversity

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The Nursing Process

Definition
The nursing process is a
systematic, deliberative and
dynamic method of providing
patient-centered care.
The 5 Sequential Steps
Assessment
Importance
1. It allows the nurse to identify
the patient's needs
2. It allows the nurse and patient
to set mutual goals
3. It provides continuity of care
4. It allows the recognition of
potential risk(s)
5. It provides documentation and
communication among other
health professionals
The 5 Column Care Plan

Assessment
Subjective and objective data
Diagnosis
Nursing Diagnosis
Includes the label, etiology, and
defining characteristics
Planning Expected Outcomes
Short-term and long-term goals
Interventions
List independent and
Implementation
collaborative interventions
Evaluation
Evaluate the expected
outcome. Present evidence that
Evaluation
supports the outcome.
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The Nursing Process
Assessment
Systematic method of collecting
data to determine patient's needs.
Types of Data
1. Subjective data: patient's
feelings, emotions, sensations.
E.g. Dizziness
2. Objective data: Observable and
measurable. E.g. Vital signs
Sources of Data
1. Primary: from the patient
2. Secondary: family, medical
records, healthcare
professionals etc.
Method of Data Collection
1. Interview, 2. Physical
examination, 3. Observation, 4.
Lab tests
Planning
1. Prioritize care
2. Establish short-term and
long-term goals.
3. Establish nursing
interventions: Independent
and collaborative
interventions
Implementation
1. Care plan implementation
SBAR
S- Situation
B- Background
A- Assessment
R- Recommendation
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Diagnosis
A clinical judgment of a patient's
response to an actual or health risk,
which gives a foundation for
interventions toward an outcome.
Parts of a nursing diagnosis
1. Label
2. Etiology
3. Defining characteristics
PRIORITIZING NURSING DIAGNOSIS
Maslows Hierachy of
Needs
Self-
actualization
Self-esteem
Love and Belonging
Safety and Security
Physiological Needs
Evaluation
1. Reassessing the patient's
progress as compared to the
expected outcome
2. Document statements of
evaluation.
3. Establishing an alternative plan
when the outcome was not met.
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Nursing Ethics
Definitions
Values: individual beliefs that
guide and influence behavior.
Ethics: a system of moral
principles that involves
systematizing concepts of right
and wrong conduct
Ethical Principles
1.Autonomy: respecting the
patient's right to make health
decisions.
Nurses' Role: Mutual goal
setting, patient education,
advocacy
2. Fidelity: Keeping promises
and remaining faithful.
Nurses' Role: Being faithful in
the provision of competent and
quality care.
3. Justice: Fairness
Nurses' Role: Avoid
discrimination, bias.
4.Beneficence: promote
good/benefits.
Nurses' Role: Patient advocate,
promote well-being
5. Nonmaleficence: Do no harm
Nurses' Role: Promote patient
safety, prevent risks.
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Ethical Dilemmas
Ethical dilemmas: conflict between
the nurse's ethical values or moral
principles.
Making ethical desicions
Tip: Use the nursing process to make
ethical decisions.
1. Describe the situation and
gather data (assessment)
2. Identify the ethical problem
(recognize conflict of own values)
3. Plan: Identify options,
consequences, and affected
stakeholders. Make a decision
based on ICN code, competence,
or consult with an expert, etc.
4. Implementation
5. Evaluate outcome.
ICN Code of Ethics
International Council of Nurses: a
federation of national nurses
associations. Ensures quality
nursing, advancement of practice,
and policy development
Code of ethics: guide of principles
designed to consider the values and
obligation of the profession.
4 Principles:
1. Nurse and People
2. Nurse and Practice
3. Nurse and the Profession
4. Nurse and Co-worker
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Nursing Ethics
The Nurse Practice Act
Every state has their own Nurse
Practice Act.
Purpose: to ensure that patients are
receiving safe and quality care
Nurse Practice Act outlines
standards for:
1. educational programs
(accreditation)
2. scopes of nursing practice
3. licensure
4. disciplinary actions
5. authority
6. reciprocity: apply and being
endorsed in another state
American Nurses
Association
ANA aims to advance the
nursing profession.
1. Advocate health care issues
2. Promote safe working
environment
3. Promote quality nursing
practice
4. Promote health and
wellness of nurses
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Confidentiality
Patient confidentiality is
protecting and maintaining
patient's privacy.
Health Insurance Portability and
Accountability Act (HIPAA):
federal law to ensure that the
patient’s medical data remains
private and secure.
Informed Consent
A process of seeking patient's
permission before a medical
treatment/intervention.
Components:
1. Describe and educate patient
on proposed intervention
2. Educate patient on their role
in decision making
3. Discuss the risks and benefits
4. Discuss alternative
intervention(s)
5. Assess patient's
understanding
6. Elicit the patient's preference
and decision (through
signature)
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Nursing Concepts
Definitions Roles of a Nurse
ICN definition: 1. Caregiver
Nursing encompasses 2. Educator
autonomous and collaborative
care of individuals of all ages, 3. Leader
families, groups and 4. Collaborator
communities, sick or well and in
all settings. 5. Communicator
6. Advocate
WHO definition of health:
Health is a state of complete 7. Leader
physical, mental and social well- 8. Counselor
being and not merely the
absence of disease or infirmity
Nursing as a Profession

What makes nursing a

Aim of Nursing
profession.
1. To promote health
2. To prevent illness Criteria:
3. To restore health 1. Defined body of
knowledge
4. To alleviate suffering
2. A clear educational
pathway
3. Autonomy
4. Code of ethics
5. Professional
organization that sets
standards
6. Ongoing Research (EBP)
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Nursing Concepts
Professional
Organizations
Nursing Practice
1. International Council of What guides nursing
Nursing (ICN)-a federation of practice?
national nurses associations.
Ensures quality nursing,
1. Standards of Nursing
advancement of practice, and Practice
policy development 2. Nurse Practice Act
2. American Nurses Association:
3. The Nursing Process
aims to advance the nursing
profession.
3. American Association of
Colleges in Nursing (AACN):
focus on quality education.
Trends in Nursing
Performs accreditation of
nursing institutions 1. Evidence-Based Practice
4. The Joint Commission:
accredits and certifies health
2. Aging population
care organizations and 3. Nursing shortage
programs in the USA 4. Diverse population
5. National Student Nurses' 5. Increase chronic illness
Association: professional 6. Primary healthcare
development of nursing
students
7. Cultural competent care
6. Quality and Safety Education 8. Advance practice
for Nurses (QSEN): ensures 9. Health promotion
quality education
7. National League for Nursing
(NLN): professional testing
service in USA for nursing
education

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Cultural Competence
Definitions
Culture: the shared beliefs,
norms and values of a particular
social group.
Race: The distinctive physical
traits/phyisical characteristics
shared by a group of people
(skin pigmentation, hair texture,
etc.)
Ethnicity: culturally defined
group that shares a common
and distinctive culture, religion,
language, etc.
Cultural Competency
Cultural Competence is the
ability for healthcare
professionals to interact and
provide culturally appropriate
care to patients in cross-cultural
communities.
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Cultural Competency
Key components of cultural
competency.
1. Cultural Awareness
2. Cultural Attitude
3. Cultural Knowledge
4. Cultural Skill
Culture,
Health & Healthcare
Culture influences:
1. Patient's perception of
health, illness and death
2. Beliefs of the causes of pain
3. Expression of pain
4. Gender roles
5. Treatment preferences
6. Health promotion/ Nutrition
7. Mental health
8. Physiologic variations:
certain groups are prone to
developing specific diseases
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Cultural Competence
Transcultural Nursing
Transcultural Nursing:
Transcultural nursing is focused
on being aware and sensitive to
cultural differences and focusing
on individual patients, their
needs, and their preferences.
Cultural Care Theories
Leininger Sunrise Model:
Leininger's model assist
healthcare professionals to
provide culturally competent care
and avoid stereotyping.
The model utilizes three concepts:
1. Culture care
maintenance/preservation:
the nursing actions and
provisions that support the
patient's cultural practices.
2. Culture care
negotiation/accommodation:
the provision of support
toward cultural activities that
do not pose threat to the
patient's health/wellbeing.
3. Cultural
restructuring/repatterning:
helping patients modify or
change their cultural activities
that causes harm towards
health.
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Campinha-Bacote Model
Campinha-Bacote's Model views
cultural competency as a process.
1. Cultural Awareness:
Healthcare professionals
consciously examine their own
cultural background, biases,
beliefs and values.
2. Cultural Knowledge:
Understands the cultural
world views.
3. Cultural Skill: Cultural
assessment
4. Cultural Encounters: Cultural
exposure, cultural practice
5. Cultural Desire: motivation to
engage in the cultural
competency process.
Cultural Assessment
Cultural Assessment Includes
assessing
1. Ethnic Background
2. Religious preferences
3. Food preferences/pattern
4. Health Beliefs/Values
5. Health Practices
6. Family patterns
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ELECTROLYTE IMBALANCE
HYPERVOLEMIA HYPOVOLEMIA

Causes: Causes:
1. Heart failure 1. Vomiting
2. Liver cirrhosis 2. Diarrhea
3. Excess fluid/ sodium 3. Continous GI suctioning
4. Hemorrhage
intake 5. DKA
4. Renal failure 6. Burns
7. Adrenal desease
8. Systemic infection
Symptoms: Symptoms:
1. Elevated BP 1. Decreased Bp
2. Bounding pulse 2. Tachycardia/weak pulse
3. Ascites 3. Decreased urinary output
4. JVD 4. Poor skin turgor
5. Edema
6. SOB/crackles 5. Restlessness/Confusion
7. S3 heart sound 6. Dry mucus membranes
8. Urine specification 7. Thirst
<1.010
HYPERNATREMIA HYPONATREMIA
135-145mEq/L

Causes: Causes:
1. Dehydration 1. Diuretics
2. Diabetes insipidus 2. Diarrhea
3. Vomiting
3. Fluid loss-GI 4. Congestive HF
4. Cushing Syndrome 5. Hyperglycemia
5. Increased Na 6. Medication
Intake 7. Continuous gastric suctioning
Symptoms: Symptoms:
1. Cardiac: Tachycardia, 1. Cardiac: Tachycardia,
Increased BP hypotension, thready pulse
2. GI: Thirst 2. GI: Nausea, Vomiting
3. GU: Oliguria 3. GU: Oliguria
4. Neuro: Restlessness, 4. Neuro: Restlessness, headache
dizziness, weakness,seizures
anxiety
5. Skin: Edema
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ELECTROLYTE IMBALANCE
HYPERKALEMIA HYPOKALEMIA
3.5-5.5mEq/L
Causes: Causes:
1. Kidney failure 1. Diarrhea
2. Trauma 2. Vomiting
3. Sepsis 3. Gastric suctioning
4. Potassium-sparing 4. Low potassium diet
diuretics
5. Addison's disease
6. Dehydration
7. Metabolic acidosis
Symptoms: Symptoms:
1. Cardiac: V-fib, T wave 1. Cardiac: Hypotension,
elevation, prolonged PR, Flat Arrhythmias, Flattened T-
P wave, Wide QRS wave, ST depression
2. GI: Abdominal cramps 2. GI: Nausea, Vomiting,
3. GU: Oliguria decreased peristalsis
4. Neuro: Numbness, tingling, 3. GU: Polyuria
4. Neuro: Dizziness, weakness,
hyperreflexia, flaccid decreased reflexes,
paralysis Metabolic Alkalosis
5. Risk: Cardiac arrest
HYPERCALCEMIA HYPOCALCEMIA
8.5-10.5mEq/L
Causes: Causes:
1. Bone cancer 1. Lack of Vitamin D intake
2. Hyperparathyroidis 2. Lack of Calcium intake
m 3. Hypoparathyroidism
3. Hyperthyroidism 4. Hypothyroidism
4. AKI 5. Burns
5. Rhabdomylysis
6. High Vitamin D 6. Sepsis
intake 7. Kidney/liver disease
Symptoms: Symptoms:
1. Cardiac: Increased BP, heart 1. Cardiac: Arrhythmias,
block (may lead to cardiac Bradycardia, Hypotension,
arrest) weak pulse
2. GI: Dehydration, constipation, 2. Neuro: Paresthesia, muscle
polydipsia spasms, seizures, Trousseau
3. GU: Polyuria, kidney pain signs, Chvostek signs
4. Neuro: Confusion, irritability 3. Resp: Dyspnea, Lanryngospasm
5. Musculoskeletal: Bone pain
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ELECTROLYTE IMBALANCE
HYPERMAGNESEMIA HYPOMAGNESEMIA
1.3-2.1mEq/L
Causes: Causes:
1. Laxative use that 1. Chronic alcoholism
contains Mg 2. Hyperaldosteronism
2. Use of antacid 3. Diabetic ketoacidosis
4. Malabsorption,
(containing Mg) Malnutrition
3. Renal dysfunction 5. Chronic diarrhea
4. Decreased adrenal 6. Dehydration
function
Symptoms: Symptoms:
1. Cardiac: Hypotension, 1. Cardiac: Arrhythmias,
bradycardia, weak pulse, Tachycardia, High BP
cardiac arrest 2. Neuro: Seizures, Delusions,
2. Resp: Dyspnea, low RR Hallucinations
3. Neuro: Confusion, dilated pupils, 3. Neuromuscular: Tetany,
lethargy
4. Musculoskeletal: Muscle Chvostek signs,Positive
weakness, facial paresthesia, Trousseau's
decreased reflexes

Functions of Electrolytes.
1. Sodium (Na): found in extracellular fluid. Maintains acid-base
balance, ECF osmolarity, sodium-potassium pump, and
neuromuscular functions.
2. Calcium (Ca): Major cation in teeth and bones. Aids
coagulation, cardiac conduction, and hormonal secretion.
3. Potassium (K): found in the intracellular fluid. Participates in
sodium-potassium pump, and neuromuscular function.
4. Magnesium (Mg): ICF cation. Has an effect on myoneural
junction, skeletal muscles, parathyroid hormones and cardiac
contractions.
5. Phosphorus (P): Main ICF anion. Acts as a hydrogen buffer.
Promotes energy storage.
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HEAD-TO-TOE ASSESSMENT
General Survey
1. Assess physical appearance, mood,
affect and grooming.
2. Assess orientation: Oriented to
Person, Place, Time and Situation.
3. Assess level of consciousness.
4. Assess speech.
Vital Signs
Pulse: 60-100 bpm
Blood Pressure Systolic: 120
Diastolic: 80
Respiratory Rate: 12-18 bpm
O2 Saturation: 95-100%
Temperature: 97.8-99.1 degrees F
36.5-37.5 degrees C
Head/Face
1. Assess head size, shape,
symmetry.
2. Inspect and palpate head, scalp
3. Palpate sinuses and TMJ
Face
1. Assess facial symmetry
2. Assess cranial nerve 7
Eyes/ Ears/ Nose
1. Inspect external eye structures,
conjunctiva and sclera.
2. Test cranial nerve III, IV, VI
3. PERRLA- Pupils are Equal, Round,
Reactive to Light and
Accommodation.
4. Pupil size: 3-5mm
Ears: Assess for redness, drainage.
Test cranial nerve-Vestibulocochlear
Nose: Assess shape, symmetry, size,
patency. Test cranial nerve I
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Mouth
1. Inspect lip color, sores, gums, tongue,
teeth, soft and hard palate, uvula
2. Test cranial nerve 9, 12 and 10
Neck
1. Palpate lymph node, carotid artery,
presence of goiter.
2. Auscultate for bruits.
3. Test cranial nerve 11
Lungs
1. Inspect symmetrical chest movement
2. Palpate for pain and lumps
3. Percuss using the Z-block method
4. Auscultate lung sounds
Heart
1. Auscultate heart sounds (Aortic,
Pumonic, Erb's Point, Tricuspid and
Mitral) using diaphram then bell
Abdomen
1. Inspect, Auscultate, Percuss, Palpate
2. Inspect skin color, contour and aortic
pulsations.
3. Auscultate bowel sounds from RLQ
clockwise.
Skin and Extremities
1. Assess and inspect skin, nails, muscle
strength, ROM, curvature of spine.
2. Palpate pulses
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PATIENT POSITIONING
POSITION EXPLANATION

Supine Lying flat on back without a pillow.

Dorsal Recumbent Lying flat on back. Patient head elevated

on a pillow.
1. Head of bed is elevated 45-90 degrees
Fowlers 2. High fowlers: Head of Bed is at 90
degrees
3. Semi-fowlers: Head of Bed is at 30-45
degrees.
4. Low fowlers: Head of Bed is at 15- 30
degrees
Tripod Sitting at the side of bed and leaning on
the side table.
patient lies on the abdomen with head
Prone turned to one side
patient lies on one side of the body with
Lateral the top leg in front of the bottom leg and
the hip and knee flexed

Trendelenburg HOB is low, foot of bed is raised

Reverse HOB is elevated, foot of bed is lowered.

Trendelenburg

patient is on their back with hips and knees

Lithotomy flexed and thighs apart.

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IV THERAPY
Importance of IV therapy.
Intravenous fluids maintain/restore fluid balance + electrolyte
balance

Types of IV Fluids.
Osmotic pressure is the
Isotonic Solutions
same inside and outside
the cell.

d o not
e cellS ll w ith
Th r swe
k no ent
rin m
sh
d m ove
flu i

ICF ECF
Osmotic pressure draws
Hypertonic Solutions water out of the cell
into the ECF (highly
concentrated)
INKS
L SHR
CEL

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IV THERAPY
Osmotic pressure draws
Hypotonic Solutions
water into the cell from
the ECF (diluted)

ELLS
LL SW
CE

ICF ECF

ISOTONIC SOLUTION.

0.9% saline (NS) 5% dextrose (D5W) Ringer's Lactate (LR)

1. Used with the 1. Used to treat 1. Burns

administration of hypernatremia 2. Electrolyte loss
blood products. 2. Used to treat 3. Hypovolemic shock
2. To replace Na + Cl hypoglycemia (bleeding)
3. Caution: Cardiac 3. Dehydration/Fluid 4. Dehydration
and renal loss
patients. 4. Do not use for
resuscitation.
Nursing Considerations
ICF ECF
1. Assess and monitor vital
3. Monitor for any changes in
signs, lung sounds, lab
fluid balance, electrolyte
values (electrolytes)
concentrations
2. Assess contraindications.
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IV THERAPY

HYPERTONIC SOLUTION.

5% dextrose in 5% dextrose in 10% dextrose in

0.9% saline 0.45% saline water (D10W)
1. Fluid and 1. Maintenance fluid 1. Caloric supply
electrolyte
replenishment
Nursing Considerations
1. Assess and monitor vital 3. Monitor signs of hypervolemia
signs, lung sounds, lab
values (electrolytes)

ICF ECF

HYPOTONIC SOLUTION.

0.45% Saline

1. Fluid replacement
among patients
with hypovolemia

ICF ECF

Nursing Considerations
1. Assess and monitor vital 2. Avoid in patients with liver
signs, lung sounds, lab disease, trauma, risk for
values (electrolytes) increased ICP or burns.

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IV THERAPY
It is important for the nurse to monitor for signs of
IV therapy complications such as pheblitis,
thrombopheblitis, hematoma, air embolism and
hypervolemia.
IV THERAPY
COMPLICATIONS
Pheblitis
Inflammation
of the vein Hematoma
collection/ pooling of
blood outside the blood
Thrombopheblitis vessel.
Clots in the veins

Air Embolism Hypervolemia

blood vessel blockage
Fluid volume overload
caused by one or more
bubbles of air

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VITAL SIGNS

BLOOD PRESSURE TEMPERATURE

120/80 97.8-99.1 degrees F

Blood pressure: the force that 36.5-37.5 degrees C
blood exerts against the inner
walls of blood vessels. 1. Oral-mouth
2. Axillary-armpit
120 Systolic pressure 3. Temporal-
forehead
80 Diastolic Pressure 4. Rectal-rectum
5. Tympanic-ear
1. Elevated BP: >120-129/<80
2. Stage 1 Hypertension: 130-
PULSE OXIMETRY
139/80-89
3. Stage 2 Hypertension: >140/>90
95%-100%
Used to measure the level of 02
saturation in the body.
PULSE COPD Patient normal SPO2:
88%-92%
60-100 bpm
1. Temporal pulse
2. Carotid pulse RESPIRATIONS
3. Brachial pulse
4. Radial pulse
5. Apical pulse
12-18 breaths/min
6. Femoral pulse Assess:
7. Popliteal pulse Respiratory Rate
8. Pedal pulse Respiratory Depth
Pulse:
Respiratory Pattern
Absent= 0
Weak = +1
Normal = +2 Respiratory rate may
Full = +3 increase due to pain, fever,
Bounding = +4
and other medical
conditions.

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NUTRITION
Nutrition Portion Size
Carbohydrates:
1. source of energy.
2. Spares the use of
protein for energy
3. Breakdown of fatty
acids

Proteins
1. Growth and
development of
body tissues. Therapeutic Diets
2. Build and repair
tissues.
1. Clear liquid diet: fluids
(prevent dehydration)
Fats Monitor pt. hydration.
1. Stored energy 2. Full fluid diet:
2. Protect organs Transition after clear
3. Maintain body fluid diet.
temperature
3. Soft diet: soft texture.
Vitamins 4. Low fiber diet
5. High fiber diet: Used
1. Fat-soluble vitamin: for constipation.
A,D,E & K
2. Water soluble:
6. Low fat diet
Vitamin B & C 7. Low sodium diet
8. Low potassium diet
Minerals 9. Diabetic diet
10. DASH diet
1. Growth and
development. 11. Vegan/vegetarian diet
2. Enhance cell
function. Body Mass Index (BMI):
WEIGHT(kg)/HEIGHT (m2)

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NUTRITION
DISORDER DIET
1. Low sodium
RENAL DISEASE: 2. Low potassium
3. Fluid restriction

1. Low sodium
HYPERTENSION: 2. Low fat diet

CONSTIPATION: 1. High fiber diet

BURNS: 1. High protein diet

1. Low carbohydrate
DIABETES: diet
2. Low sugar diet

CELIAC DISEASE: 1. Gluten free diet

1. Low sodium diet

CAD: 2. Low fat diet

PANCREATITIS: 1. Low fat diet

1. Low fat diet

OBESITY: 2. Calorie restriction

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WOUND CARE
Wound Healing Wound Assessment
The wound color, type, size,
1. Hemostasis Phase: first
phase of wound healing. location, tissue type.
Begins at onset of injury. Presence of exudate, tunneling
Goal is to stop bleeding. Symptoms such as pain,
Body activates thrombin, inflammation, odor
platelets (emergency repair Assessment of Wound edges
system). and the surrounding skin for
2. Inflammatory Phase: excoriation or maceration.
Coagulation and WBC
activation
3. Proliferative Phase: fill and
cover the wound with new
connective
tissues(epithelialization)
4. Maturation Phase: collagen Colour Classification
fiber strengthening.
1. Black necrotic (eschar):
debride wound surgically
Stages of Pressure 2. Yellow (sloughy): to de-
Wounds slough, prevent infection.
3. Green (infected): control
Stage 1: Non-blanchable infection and achieve healing.
erythema (redness) of intact 4. Red (granulating): protect
skin and support healing.
Stage 2: Partial-thickness loss 5. Pink (epithelializing): protect
of skin. Affects the epidermis and support healing
and dermis.
Stage 3:Subcutaneous fatty
tissue affected. Muscle,
tendon, ligament, cartilage,
and bone are not exposed.
No tunneling would be
observed.
Stage 4: Muscle, tendon,
ligament, cartilage, and bone
are exposed.
Unstageable: Obscured tissue
damage due to eschar
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MEDICATION ADMINISTRATION
Pharmacokinetics
Pharmacokinetics is the study of
drug movement/action in the
body in terms of absorption,
distribution, metabolism and
excretion.
Absorption
Absorption is the drug movement
from the administration site
to blood stream
Distribution
Drug distribution from one location
to another
Metabolism
Metabolism is the chemical
alteration of a drug in the body.
Excretion
Excretion is the process of
removing a drug & metabolites
from the body.
nursebossstore.com
Drug Administration
Routes
Oral
1. Most frequently used
route.
2. Do not administer to:
patients with dysphagia, or
vomiting.
Transdermal/Topical Route
1. Drug delivery through the
skin
2. Ointment, patches, etc
Rectal/Vaginal
1. Rectal: administered
through the anus into the
rectum
2. Suppository, enema,etc
3. Vaginal: intravaginal
administration
4. Antibacterials and
antifungals, etc
Inhalation Route
1. Patient inhales into their
airway (nasal/oral passage)
Buccal and Sublingual
1. Buccal: gums and cheeks
2. Sublingual: Under the
tongue
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MEDICATION ADMINISTRATION
Drug Administration Parenteral
Routes Routes
Otic Route Parenteral drug administration:
1. Warm solution non-oral route that allows the
2. Have patient tilt head medication to bypass the GI
3. Adults: pull auricle upward system.
and backward
4. >3 years: pull auricular down Types:
and back 1. Intradermal
Ocular Route 2. Subcutaneous
1. given into the eye by drops, 3. intramuscular
gel, or ointment 4. Intravenous

IV route: immediate onset of action

Nasal Route
1. Medication administered
through the nose

Parenteral Route
10-15 Degree Angle 45 Degree Angle

90 Degree Angle 25 Degree Angle

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MEDICATION ADMINISTRATION
Medication
Drug Rights Order
1. Right Drug Date:
Name of Medication:
2. Right Patient Dosage:
3. Right Dose Time and Frequency:
Route of Administration:
4. Right Route Name and Signature of Prescriber:
5. Right Time Patient Information:
6. Right Documentation
7. Right Assessment
Times of Medication
8. Right to Refuse Administeration
9. Right Drug Interaction Before meals: ac
10. Right Education After meals: pc
Twice a day: bid
Three times a day: tid
Four times a day: qid
Types of Drug Orders Every day: daily
1. Routine Order: carried out as Every hour:qh
specified until discontinued Every two hours: q2h
2. P.R.N: As needed
Every four hours: q4h
Every six hours: q6h
3. Single Order: Directive is As needed: prn
carried out only once as As desired: ad lib
specified by physician At bedtime: hs
4. Stat Order: A single order
carried out at once
5. Written Order: inscribed by a
physician on a prescription pad
6. Verbal Order: When receiving
verbal orders, write the order
down exactly as heard,
repeat the order back to the
physician, document, have
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INFECTION
CHAIN OF INFECTION

Causative
Agent
Risk of infection by a
microorganism

Susceptible Reservoir
Host
Impairment of the Humans, plants,
body's natural animals, food, water
defenses

Portal of Entry Portal of Exit

GI tract, Respiratory GI tract, Respiratory
tract, GU tract, blood tract, GU tract, blood

Mode of
Transmission
Direct: Contact
Indirect: Through a vehicle
( surgical instruments,
utensils
Airborne: droplets

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STAGES OF INFECTION

INCUBATION

The time between exposure to pathogen and first symptom.

PRODROMAL

Onset of first symptom to distinct symptoms. The number of

pathogen multiplies and the immune system reacts.

ILLNESS STAGE

Symptoms are pronounced and specific to the infection

CONVALESCENCE

Patient begins to recover gradually. Acute symptoms

disappears.

PERSONAL PROTECTIVE EQUIPMENTS

DONNING PPE REMOVING PPE
REMOVING PPE
1. Gown 1. Gloves

2. Mask 2. Gown

3. Goggles or face shield 3. Mask

4. Gloves 4. Hand hygiene

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TRANSMISSION PRECAUTIONS:
Airborne Precautions Contact Precautions
1. Contact spread occurs
≤
1. Particles are smaller
( 5µm) through direct contact.
2. Diseases: TB, measles, 2. Involves a direct or indirect
varicella transmission.
3. Diseases:
Nursing Actions a. Wounds
1. Negative pressure room
(private room) b. Herpes
2. Masks: N95, respirators c. Scabies
d. Impetigo

Droplet Precautions Nursing Actions

1. Place patient in a private
1. Particles are >5 microns (µm) room
2. Droplet spread is via the 2. Wear gloves and a gown.
upper respiratory tract
(nose, nasal passages and Protective Precautions
pharynx).
Remember:
3. Diseases: Protective precautions are maintained
a. Pneumonia for immunocompromised patients.
b. Influenza 1. Patient is placed in a private room
c. Meningitis 2. Patient wears a mask when they
d. Pertussis leave the room.
e. Mumps 3. The private room should have a
f. Rubella positive pressure ventilation and
Hepa filtered air.
Nursing Actions
1. Place patient in a private Standard Precautions
room Infection prevention and control
2. Wear a surgical mask. measures that applies to all patients.
This includes:
1. Hand hygiene
2. The use of mask, gloves, gown, and
goggles when applicable.

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SBAR COMMUNICATION TOOL

Unit: Room: Name:

DOB: Age: ADM. Date:
Dx: Code:

Situation:
SITUATION

Past Med History:

Allergies:

Medications:

Other:
BACKGROUND

Vital Signs: IV fluids: Neuro:

Tubes/Drains: Resp:

Labs: CV:
Pain:
GI/GU:
Other:
ASSESSMENT
Skin:

Treatment Plan:

Discharge Plan:

RECOMMENDATIONS

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SBAR COMMUNICATION TOOL

SITUATION

BACKGROUND

ASSESSMENT

RECOMMENDATIONS

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BLOOD GROUP
Definitions

1. Antigen: a substance
that stimulates the
immune system to
release antibodies.
2. Antibodies: proteins
that bind to the body's
foreign invaders.
Known as the
"recognizers".

Donor: A, AB Donor: B, AB Universal Universal

Recipient: A, O Recipient: B, O Recipient Donor
Donor: AB Recipient: 0

Antibodies NONE

Antigens NONE

Rh factor
a type of protein found on the
outside of red blood cells
Rh positive: has the protein
Rh negative: do not have the
protein
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OXYGEN THERAPY
Abnormal Breathing
1. Eupnea: normal breathing rate and pattern
2. Tachypnea: increased respiratory rate
3. Bradypnea: decreased respiratory rate
4. Apnea: absence of breathing
5. Hypernea: deep respirations/breathing
6. Cheyne-stokes: increase and decrease in respirations with
apnea
7. Biot's: rapid gasps with short pauses between sets
8. Kussmaul: tachypnea and hyperpnea
9. Apneustic: prolonged inspiration and shortened expiration

OXYGENATION
02 supplementation is used to increase patient's
oxygen saturation and increase oxygen
delivery/tissue perfusion to the vital organs
O2 Masks
Protective Precautions

Simple face mask: Venturi Mask

40% to 60% 24% to 50%
Rate: 5 to 8 L/min Flow rate: 4 to 12 L/min

Nasal Cannula Partial Rebreather

24% to 44% 40% to 70%
Flow rate: 1 to 6 L/min Flow rate:
6 to 10 L/min
Non- Rebreather Standard Precautions
60%-100% Face Tent
Flow rate: 10 to 15 L/min Flow rate: 10 L/min

Prolonged oxygen deprivation causes hypoxia

and damage to the brain and vital organs.
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NURSING THEORISTS

Florence 1. Think environment

Nightingale - 2. Theory focuses on Unsanitary conditions of the
Environment
theory
environment that can affect health.
3. Nurses can control the environment to promote
healing and recovery of patient.
4. Components of the environment: ventilation,
light, warmth, effluvia, noise
1. Think nurse-patient relationship
Hildegard Peplau -
Interpersonal
Phases:
theory 1. Orientation: Patient realizes that they need help.
Nurse gathers data about patient issue(s)/problem.
2. Working phase: Nursing interventions, therapeutic
communication, interdisciplinary interventions.
3. Termination phase: Discharge planning. Termination of
nurse-patient relationship.

1. Think 14 basic needs of a patient

Virginia Henderson 2. Definition of nursing: The unique function of the
- Need Theory
nurse is to assist the individual, sick or well, in the
performance of those activities contributing to
health or its recovery (or to peaceful death) that he
would perform unaided if he had the necessary
strength, will, or knowledge.

Dorothea Orem - 1. Wholly compensatory nursing system-Patient

Self-care theory dependent
2. Partially compensatory- Patient can meet some
needs but needs nursing assistance
3. Supportive educative-Patient can meet self care
requisites, but needs assistance with decision
making or knowledge
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NURSING THEORISTS

SISTER CALISTA 1. The goal of care is adaptation to change

ROY - 2. The nursing care facilitates the adaptation
ADAPTATION
MODEL
3. The person is an open adaptive system with
input (stimuli), who adapts by processes or
control mechanisms (throughput). The output can
be either adaptive responses or ineffective
responses
Leininger's model assist healthcare professionals to
MADELEINE
LEININGER -
provide culturally competent care and avoid stereotyping.
CULTURE CARE
DIVERSITY AND The model utilizes three concepts:
UNIVERSALITY 1. Culture care maintenance/preservation
2. Culture care negotiation/accommodation
3. Cultural restructuring/repatterning

Described 5 levels of nursing experience and

PATRICIA BENNER developed:
- FROM NOVICE
TO EXPERT 1. Novice
2. Advanced beginner
3. Competent
4. Proficient
5. Expert

LYDIA E. HALL -
THE CORE, CARE 1. Core: the patient
AND CURE 2. Care: the role of the nurse
3. Cure: the medical treatment given by health
care professionals.

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KNOW YOUR

IV
FLUIDS
Website: nursebossstore.com

Instagram: nursebossessentials

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BODY FLUID
BODY FLUID
Intracellular fluid: fluid in the cell
Extracellular fluid: fluid outside of the cell

ex
tr FL
ac UID
el
lu
la
intracellular FLUID r

osmosis Function of body fluid

Movement of fluid across a membrane due to 1. Deliver nutrients to cells
differing concentrations 2. Removes waste
3. Temperature regulator
REMEMBER 4. Lubricant

The movement of fluid is from low concentration to a high concentration.

LOW CONCENTRATION HIGH CONCENTRATION

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iv fluids
Importance of IV therapy

Intravenous fluids maintain/restore fluid balance + electrolyte

balance
Types of IV Fluids.

Osmotic pressure is the

Isotonic Solutions
same inside and outside
the cell. Isotonic Solutions

t
ll do no h
ce it
The r swell w
rin ko ement
sh mo v
fluid

ICF ECF
Osmotic pressure draws water
Hypertonic Solutions out of the cell into the ECF
(highly concentrated)

Hypertonic Solutions l
Cel s
ink
Shr

ICF ECF
Hypotonic Solutions Osmotic pressure draws water into
the cell from the ECF (diluted)

Hypotonic Solutions

Swells
l
Cel

ICF ECF

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complications
Phlebitis
Inflammation of the vein.
Causes: the prolong use of an IV site, trauma during IV insertion
Signs and Symptoms: redness, tenderness around the IV site, pain,
warmth

Hematoma
Collection/ pooling of blood outside the blood vessel.
Signs and Symptoms: bruising around the IV site.

Infiltration
Infiltration occurs when IV fluid leak into the surrounding
tissue.
Causes: IV catheter dislodge (or improper placement)
Signs and Symptoms: swelling, burning sensation, cool skin
and blanching

Hypervolemia
Fluid volume overload
Causes: IV infusion rate and volume
Signs and Symptoms: elevated BP, edema, SOB, crackles, bounding
pulse

infection
Local or systemic infection
Signs and Symptoms: elevated temperature, redness at IV site

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iv FLUIDS
isotonic solutions
0.9% 5% LACTATED
NORMAL DEXTROSE RINGER'S
SALINE (D5W)

Isotonic fluid Isotonic fluid Isotonic fluid

HYPOTONIC solutions
0.45%
SALINE

Hypotonic Fluid

HYPERTONIC solutions
5% Dextrose 10% 5% Dextrose
5% Dextrose
in 0.45% Dextrose in in Lactated
in 0.9%
Saline Saline Water Ringer’s
(D10W)

Hypertonic Fluid Hypertonic Fluid

Hypertonic Fluid Hypertonic Fluid

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ISOTONIC FLUIDS
0.9% nORMAL sALINE
type of fluid

0.9%
0.9% Normal saline is an isotonic solution.

used for
NS 1. Used with the administration of blood
products.
Isotonic fluid 2. To replace Na + Cl
remember
1. Caution: Cardiac and renal patients.
2. Monitor for any changes in fluid
balance, electrolyte concentrations

5% DEXTROSE (d5w)
type of fluid
5% Dextrose is an isotonic solution
5%
DEXTROSE used for
(D5W) 1. Patients with hypernatremia
2. Used to treat hypoglycemia
3. Dehydration/Fluid loss
Isotonic fluid
remember
1. Do not use for resuscitation.
2. Contraindicated among patients with head
injury
3. Monitor for any changes in fluid balance
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ISOTONIC FLUIDS
lactated ringer's
type of fluid
LACTATED Ringers lactate is an isotonic solution
RINGER'S
used for
1. Burns, Electrolyte loss
2. Hypovolemic shock (due to significant
amount of blood volume lost)
Isotonic fluid 3. Dehydration
rEMEMBER:
Monitor for any changes in fluid balance,
electrolyte concentrations

HYPOTONIC SOLUTIONS
0.45% sALINE

type of fluid
0.45% 0.45% saline is a hypotonic solution (1/2 NS)
SALINE
used for
1. Fluid replacement among patients with
hypovolemia
Hypotonic Fluid
rEMEMBER
1. Avoid in patients with trauma, risk for
increased ICP or burns.
2. Monitor for hypotension
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HYPERTONIC fluids
5% dextrose in 0.9% saline
type of fluid
5% Dextrose 5% Dextrose in 0.9% Saline is a hypertonic solution
in 0.9% USED FOR
Saline
1. Fluid and electrolyte replenishment
2. Treat hypovolemia
Hypertonic Fluid
rEMEMBER:
1. Monitor signs of hypervolemia

5% dextrose in 0.45% saline

type of fluid
5% Dextrose 5% Dextrose in 0.45% Saline is a hypertonic solution
in 0.45%
Saline used for
1. Maintenance fluid

Hypertonic Fluid
rEMEMBER
1. Monitor signs of hypervolemia

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HYPERTONIC fluids
10% dextrose in water (D10W)
type of fluid
10% dextrose in water (D10W) is a hypertonic solution
10%
Dextrose in USED FOR
Water
1. Caloric supply
(D10W)

Hypertonic Fluid
rEMEMBER:
1. Monitor signs of hypervolemia

5% Dextrose in Lactated Ringer’s

type of fluid
5% Dextrose 5% Dextrose in Lactated Ringer’s is a hypertonic solution
in Lactated
Ringer’s used for
1. Fluid and electrolyte replenishment and
caloric supply
Hypertonic Fluid

rEMEMBER
1. Monitor signs of hypervolemia

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iv catheter gauge
14G ORANGE Trauma, Rapid
infusion

16G GRAY Trauma,

Surgery

18G GREEN Blood

transfusions

20G PINK IV fluids and

medications

22G BLUE Slower infusions, IV

fluids, small veins

24GYELLOW Fragile veins,

elderly,
pediatrics

26GVIOLET
Neonates

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STUDY GUIDE
Anatomy and Physiology Study Guide for
Nursing Students

Website: nursebossstore.com 52 / 601

 Table of Content
1. Cardiovascular System
2. Respiratory System
3. Gastrointestinal System
4. Hepatic System
5. Genitourinary System
6. Nervous System
7. Integumentary System
8. Reproductive System
9. Muscular System
10. Skeletal System
11. Lymphatic System
12. Endocrine System

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Cardiovascular System
Objectives
1. Functions of the cardiovascular system
2. Types of circuits
3. Types of blood vessels
4. Structure of the heart
5. Heart chambers
6. Heart valves
7. Blood flow
8. Electrical conduction
9. Coronary arteries
10. Blood vessels
11. Key terms
Notes...
Key points from this section...

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Functions of the
Cardiovascular System
1. Transports O2 and CO2
2. Transports nutrients
3. Circulation of hormones
4. Removes waste
products
5. Maintenance of body
temperature
6. Circulates antibodies

1.Two Types of Circuits 4. Heart Chambers

Pulmonary Circulation: Upper chamber: Atrium
Transports blood to and from Lower chamber: Ventricles
the lungs. 1. Right atrium- receives deoxygenated blood from
Systemic Circulation: the superior and inferior vena cava
Transports blood to and from
2. Right ventricle- receives blood from the right
the rest of the body
atrium and pumps to the lungs
3. Left atrium- receives oxygenated blood from the
2. Types of Blood Vessels
lungs
Arteries
Arterioles 4. Left ventricle- receives blood from the left atrium
Capillaries and pumps it to the body through the aorta.
Venules
5. Heart Valves
Veins
Atrioventricular valves: tricuspid and
bicuspid valve
3. Structure of the Heart 1. Tricuspid Valve-
a. Location: between the right
The heart is a cone-shaped organ that lies within atrium and right ventricle
the mediastinum between the lungs. 2. Bicuspid Valve (mitral)
The heart is protected by the pericardial sac. The a. Location: between the left
atrium and left ventricle
parietal pericardium is the outer membrane. The Semilunar valves: pulmonary and
visceral pericardium is the inner membrane. The aortic valve
pericardial sac contains 5-20ml of pericardial fluid. 3. Pulmonary valve
a. Location: between
LAYERS OF THE HEART right ventricle and
1. Epicardium: outermost layer of the heart pulmonary artery
2. Myocardium: middle layer of the heart 4. Aortic valve:
a. Location: between left
3. Endocardium: innermost layer of the heart ventricle and aorta
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Blood Flow
1. Deoxygenated blood from the
superior and inferior vena cava goes
into the right atrium (through the
tricuspid valve) and into the right
ventricle. From the right ventricle,
blood flows through the pulmonary
valve into the pulmonary artery and
to the lungs.
2. Oxygenated blood from the lungs
flows through the pulmonary veins
and into the left atrium and left
ventricle through the mitral valve.
From the left ventricle, blood flows
into the aorta through the aortic
valve and to the body.

1.Electrical Conduction 3. Blood Vessels

1. SA (Sinoatrial) Node: 1. Artery: Carries high-pressure blood from the heart
pacemaker of the heart. to the arterioles.
Impulse starts at the SA node.
Beats: 60-100BPM. 2. Arterioles: Controls blood flow from the arteries to
2. AV (Atrioventricular) Node: the capillaries through vasodilation and
Impulse travels from the SA vasoconstriction.
node to the AV node. Known
as the gatekeepers. Causes a
3. Capillary: Allows the exchange of nutrients, gases
delay so that the atrium can and wastes between the blood and tissue fluid.
fully empty into the ventricles. 4. Venule: Connects capillaries to the veins.
Beats: 40-60BPM
5. Veins: Carries low-pressure blood from the venules
3. Bundle of His: The impulse
travels through the Bundle of to the heart.
His which branches out into the 4. Key Terms 5. Key Terms
right and left branch bundles 1. Cardiac Cycle: a
4. Purkinje Fibers: The impulse 1. Blood pressure: the
heartbeat, complete force that blood exerts
travels to the Purkinje fibers.
series of systolic and against the inner walls
Beats: 20-40BPM
diastolic events. of blood vessels.
2. Coronary Arteries 2. Cardiac output: the 2. Systolic pressure:
amount of blood maximum pressure
1. Right coronary artery pumped by the during ventricular
2. Left coronary artery ventricles per minute.
contraction
Coronary arteries supplies blood Formula: SV*heart rate=
3. Diastolic pressure:
CO
to the heart muscles. The heart minimum arterial
3. Stroke volume: the
needs oxygen-rich blood to volume of blood pressure during
function. discharged from the ventricular relaxation.
Plaque formation is usually found ventricle with every 4. Blood pressure: 120/80
in the coronary arteries. contraction 5. Blood volume: 5L
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 Respiratory System
Objectives
1. Functions of the respiratory system
2. Upper respiratory tract
3. Lower respiratory tract
4. Organs of the respiratory system
5. Key terms
6. Inspiration
7. Expiration
8. Respiratory volumes
9. Lung capacity

Notes...
Key points from this section...

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Functions of the Respiratory

System

1. Breathing
2. Gaseous exchange
internally and externally
3. Removes carbon dioxide
4. Speech
5. Olfaction
6. Maintain acid-base
balance
7. Maintain body heat

3. Organs of the Respiratory System

1.Upper Respiratory Tract 1. Nose: filters, moistens, humidifies and warms
1. Nose air, receptors for sense of smell.
2. Paranasal Sinuses 2. Paranasal sinuses: air-filled cavities that
3. Pharynx surrounds the nasal passages.
4. Larynx 3. Pharynx: passageway for food and air
5. Epiglottis (Nasopharynx, laryngopharynx and
oropharynx)
2. Lower Respiratory Tract 4. Larynx: air passageway, voice box, glottis
1. Trachea (plays a role in coughing)
2. Bronchi 5. Epiglottis: a leaf shape flap that prevents
food from entering the lower respiratory
3. Bronchioles
tract.
4. Alveolar duct 6. Trachea: located in front of the esophagus,
5. Alveolar sacs tube running from the larynx and branches
6. Lungs into right and left bronchi. Cleans, warms, and
Trachea moistens incoming air.
Superior lobe 7. Bronchial tree: Consists of right and left main
of left lung bronchi, which divides within the lungs to form
Left main lobar and segmental bronchi and bronchioles.
(primary)
Superior lobe bronchus The bronchi are lined with cilia.
of right lung
Lobar (secondary) 8. Bronchioles: delivers air to the alveolar sacs
bronchus 9. Alveoli: Site for gaseous exchange
10. Lungs: right lung is divided into 3 lobes. The
Segmental left lungs is divided into 2 lobes. The right lung
Middle lobe (tertiary)
of right lung bronchus is larger than the left lung. The lungs is
Inferior lobe located from the clavicle to the diaphragm.
of left lung
Inferior lobe 11. Pleurae: produces lubricating fluid.
of right lung
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Key Terms
1. Breathing: movement of air in and
out of the lungs
2. Gaseous exchange: the diffusion of
oxygen from the lungs to the
bloodstream and the elimination of
carbon dioxide from the blood
stream to the lungs that occurs
between the alveoli and capillaries
within the lungs
3. Perfusion: blood flow to capillaries
4. External respiration: gas exchange
between the capillaries and alveoli.
5. Internal perfusion: gas exchange
between the capillaries and tissues.

1.Inspiration 3. Respiratory Volumes

1. Inspiratory muscles contract (diaphragm
moves downwards; external intercostals
contracts and rib cage moves upwards).
2. Thoracic cavity size increases.
3. Lungs are stretched; intrapulmonary volume
increases.
4. Intrapulmonary pressure decreases to –1
mm Hg.
5. Air flows into lungs until intrapulmonary
pressure is equal to atmospheric pressure.
1. Tidal Volume (TV): volume of air inhaled
and exhaled without effort (resting
condition)
2. Inspiratory Reserve Volume (IRV): the
volume of air that can be forcefully
inhaled beyond tidal volume inhalation.
3. Expiratory Reserve Volume (ERV): the
volume of air that can be forcefully
exhaled beyond tidal volume
exhalation.
4. Residual Volume (RV): the amount of air
that remains in the lungs after full
exhalation.

2.Expiration
1. Inspiratory muscles relax (diaphragm moves
upwards; rib cage moves downwards due
to recoil of costal cartilages).
2. Thoracic cavity size decreases.
3. Elastic lungs recoil passively; intrapulmonary
volume decreases.
4. Intrapulmonary pressure rises (to +1 mm
Hg).
5. Air flows out of lungs until intrapulmonary
pressure is 0
4. Lung Capacity
1. Total Lung Capacity (TLC): the volume of
air in the lungs after maximum
inspiration.
2. Vital Capacity (VC): the volume of air
that can be expired after a maximum
inspiration.
3. Inspiratory Capacity (IC): maximum
volume of air that can be inspired after
expiration
4. Functional Residual Capacity (FRC):
Volume of air remaining in the lungs
after a normal tidal volume expiration

Hyperventilation: fast breathing

Average lung capacity
Hypoventilation: slow breathing
Male: 6L of air Female: 4.8L of air
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Gastrointestinal System
Objectives
1. Functions of the gastrointestinal system
2. Structures of the gastrointestinal system
3. Digestive processes
4. Mouth
5. Esophagus
6. Stomach
7. Small intestines
8. Large intestines
9. Digestive enzymes

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Topic: Gastrointestinal System nursebossstore.com

Functions
1. Digest foods
2. Absorbs nutrients
3. Excrete waste products
4. Synthesize nutrients

Structures
1. Mouth
2. Esophagus
3. Epiglottis
4. Stomach
5. Esophageal sphincter
6. Pyloric sphincter
7. Small intestine
8. Jejunum
9. Ileum
10. Large intestines
11. Colon
12. Ileocecal valve
13. Liver
14. Gallbladder Digestive Processes
15. Pancreas
1. Ingestion: process of taking in food through the
Key Terms mouth.
1. Mastication: chewing 2. Propulsion: movement of food through the
2. Chyme: semi-fluid mass alimentary canal. Swallowing (voluntary),
that is created when food
peristalsis (involuntary, waves of contraction and
is partly digested.
3. Segmentation: rhythmic, relaxation of muscles to move food
localized back and forth downwards).
movement of bolus 3. Mechanical digestion: physical process that does
through contraction and not change the chemical nature of the food.
relaxation of muscles in (Chewing, tongue movement, segmentation)
the intestines
4. Chemical digestion: digestive enzymes that
4. Peristalsis: waves of
contraction and relaxation breaks down complex food molecules
of muscles to move food 5. Absorption: the process of nutrients entering the
downwards. bloodstream.
5. Bolus: ball-like mixture of 6. Defecation: eliminates indigestible substances
food and saliva through the anus as feces.
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Topic: Gastrointestinal System
Mouth
1. Ingest food
2. Mastication
3. Salivary amylase: breakdown
carbohydrates
4. Swallowing
5. Moistens food into a bolus
Esophagus
Esophagus: muscular tube that
carries food from the pharynx to the
stomach
Stomach
1. Mixes food with gastric juices
2. Hydrochloric acid
3. Pepsin: gastric juice that breaks
down protein
4. Carries food into the duodenum
as chyme
5. Secretes intrinsic factor required
for vitamin B12 absorption
Liver: produces bile, emulsify lipids.
Gallbladder: stores and release bile.
Pancreas: secretes insulin,
bicarbonate and digestive enzymes
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Small Intestines
1. Absorption of nutrients
2. Chyme propels at a slower rate to facilitate
absorption
3. Segmentation
Large Intestines
1. Absorption of water, electrolytes and vitamins
2. Propels feces to the rectum.
Rectum: stores feces
Anus: defecation
Digestive Enzymes
1. Salivary amylase: breaks down starch
2. Hydrochloric acid: gastric acid
3. Pepsin: breaks down protein
4. Intrinsic factor: absorption of B12
5. Gastrin: regulates gastric acidity
6. Lactase: breaks down lactose
7. Sucrase: breaks down sucrose to fructose and
glucose
8. Enterokinase: breaks down trypsinogen into trypsin
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 Hepatic System
Objectives
1. Functions of the hepatic system
2. Lobes
3. Hepatic circulation
4. Hepatic disorders

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 Topic: Hepatic System nursebossstore.com

Functions
1. Production of bile
2. Glucose metabolism
3. Bilirubin excretion
4. Drug metabolism
5. Fat and protein metabolism
6. Clotting factors
7. Filters and remove toxins
8. Ammonia conversion

3. Disorders
1.Lobes
1. The liver is divided into 4 lobes 1. Portal hypertension
2. Right lobe 2. Jaundice
3. Left lobe 3. Esophageal Varices
4. Caudate lobe 4. Hepatic Encephalophathy
5. Quadrate lobe 5. Cirrhosis
6. Ascited

2.Hepatic Circulation
The hepatic portal vein is responsible for carrying up to 70% of the blood that
passes through the liver. The hepatic artery is responsible for 30% to 40% of
hepatic oxygenation. The hepatic system is responsible for receiving blood from
the gastrointestinal region and venous drainage from the pancreas and spleen.
One of the functions of the hepatic system is to supply the liver with metabolites
to limit damage that toxins can cause after reaching the systemic circulation.

Blood from the hepatic artery are oxygenated, but nutrient poor . Blood from
the organs of the GI system flows through the portal veins and into the sinusoids
of the liver, allowing for processing of nutrients in the liver. The liver is rich in
specialized immune cells called Kupffer cells to destroy pathogens. Blood collects
in a central vein that drains into the hepatic vein and finally the inferior vena
cava.

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Genitourinary System
Objectives
1. Functions of the genitourinary system
2. Renal parenchyma
3. Nephron
4. Glomerulus
5. Bowman's capsule
6. Acid-base balance
7. Urine formation
8. Tubules
9. Bladder
10. Adrenal gland
11. Renin-angiotensin-aldosterone system

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 Topic: Genitourinary System nursebossstore.com

Functions Cortex
Renal Pyramid
The kidneys are two fist-sized bean
shaped organs situated on either side
of the vertebral column in the Medulla
posterior abdomen. The kidneys are
covered by the renal capsule. On top
of each kidney are the adrenal
glands.
Functions includes:
1. Electrolyte balance
2. Acid-base balance
3. Removes waste
4. Removes water
5. Vitamin D activation
6. Blood pressure control

1.Main Structures 5. Glomerulus

The kidney is divided into 2 main structures. Blood flows into the glomerulus through
1. Renal cortex the afferent arterioles and out via the
2. Renal medulla efferent arterioles. Filtration occurs in the
The renal medulla contains renal pyramids and glomerulus. That includes electrolytes,
renal tubules. The renal column are between each waste, glucose, amino acids.
pyramid.
Glomerular Filtration Rate (GFR):
2.Renal Parenchyma
1. Renal cortex: the outer rim of the kidney. filtration pressure. GFR is a diagnositic
It contains the glomeruli and a portion of method to assess renal function.
the nephron tubules.
2. Medulla: houses the renal pyramids that
hold the collecting ducts, collecting tubules, 5. Bowman's Capsule
and long loops of Henle. It also contains
Houses the glomerulus and receives
blood vessels and nerves.
glomerular filtrate.
3. Renal pelvis: drains urine from the collecting
ducts of the nephrons. The renal pelvis is a
collection area.

3. The Nephron
The nephron is the functional unit of the kidney.
Major functions:
1. Regulates and filters water soluble
substances.
2. Reabsorbs water, nutrients and
electrolytes.
3. Exceretes waste
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 Topic: Genitourinary System nursebossstore.com

Acid-Base Balance

URINE FORMATION
Filtration
Acidosis:
1. Increased secretion and
excretion of hydrogen ions
2. Increase reabsorption of
bicarbonate and decreased Reabsorption
excretion.
3. Increased ammonia production
Alkalosis:
1. Decreased secretion and excretion
of hydrogen ions Secretion
2. Decreased reabsorption of
bicarbonate and increased
excretion
3. Decreased ammonia production
Excretion

1.Tubules 4. Renin-Angiotensin-Aldosterone
Proximal convolated tubules:
System
1. Reabsorbs filtered sodium Decreased The renin-angiotensin-
renal blood
2. Maintains acid-base balance. Reabsorbs flow aldosterone system is a
bicarbonate and and secretes hydrogen. hormone system that is
3. Obligatory water reabsorption essential to regulate
4. Reabsorption of electrolytes
blood pressure and fluid
5. Reabsorption of glucose and amino acids. Renin release volume
Loop of Henle:
1. Dilutes or concentrates urine
2. Ascending limb reabsorbs NaCl (NaCl
active pump).
3. Descending limb reabsorbs water Angiotensino Angiotensin 1
gen
Distal convolated tubules:
1. ADH causes water reabsorption Angiotensin 2
2. Aldosterone causes Na reabsorption
Filtered fluid moves into the collecting duct, Vasoconstriction Aldosterone
renal pelvis into the ureters and then the
bladder.
Na, water
retention
2.Bladder
A muscular sac that provides a holding area for Increased BP
urine until it is excreted through the urethra. It
can contract and relax.
Increased
Organ Perfusion
3. Adrenal Gland
1. The kidneys secretes erythropoietin
Located on top of both kidneys. Influences the 2. Vitamin D synthesis is dependent on
regulation of sodium and water. the kidneys
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 Nervous System
Objectives
1. Functions of the nervous system
2. CNS
3. PNS
4. Neuron
5. Parts of a neuron
6. Reflex arc
7. Parts of the brain
8. Lobes of the cerebrum

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Topic: Nervous System nursebossstore.com

Function
1. Sensory function
2. Transmits information to the brain
3. Processes information in the brain
4. Motor function
5. Maintains homeostasis
6. Controls and coordinate body
organs

1.Nervous System 3. Parts of the Neuron

The nervous system is divided into:
1. Central nervous system
2. Peripheral nervous system.
The peripheral nervous system is divided into:
1. Somatic nervous system (voluntary): sends
and relays information to and from the
skeletal muscles and skin
2. Autonomic nervous system (involuntary):
sends and relays information to internal
organs
1. Dendrite: receives and carries impulse
to the cell body.
2. Cell body: includes the nucleus
3. Axon: carries impulses away from cell
body
4. Schwann Cells: cells produces myelin in
the PNS
5. Myelin sheath: insulates and covers
the axon
6. Node of Ranvier: nodes in the myelin
sheath

The autonomic nervous system is divided into Impulse travels from the
1. Sympathetic nervous system: stress dendrite to cell body to axon
response
2. Parasympathetic nervous system: controls
body when at rest

2.Neuron
The neuron is the basic functional cell of the
nervous system. The neurons transmits impulse.
Types of neurons:
1. Sensory neuron: transmits impulse to the CNS
2. Motor neuron: transmits impulse from the
CNS
3. Interneurons: between sensory & motor
neurons in the CNS
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Topic: Nervous System
Key Terms
1. Stimulus: a change in the
environment that causes a
response.
2. Excitability: the neuron response
to a stimulus to convert to an
impulse.
3. Synapse: a gap between one
neuron's axon and the dendrite of
another
4. Neurotransmitters: chemicals that
cross the gap (synapse) and
continue the impulse
1.Reflex Arc
A reflex is an involuntary action in response to
a stimuli. A reflex action goes through a
process called the reflex arc.
1. Receptor: a reaction to a stimulus occurs
2. Afferent pathway: the sensory neurons
transmits impulses to the CNS
3. Interneurons: includes synapses in the CNS
(mostly in the spine)
4. Efferent pathway: motor neurons
transmits impulses from the CNS to the
effector
5. Effector: a muscle or gland that responds
to the stimulus
2.CNS
Central Nervous System: brain and spinal cord
Meninges: covering of the brain and spinal
cord. The three layers are
1. Dura mater: the outer covering
2. Arachnoid mater: the middle layer
3. Pia mater: the innermost layer
Cerebrospinal fluid: clear, colorless
body fluid found in the brain and spinal cord
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3. Parts of the Brain
1. Cerebellum: movement and motor
learning
2. Cerebrum: activities that includes
planning, perception, emotion,
thought
3. Thalamus: exchanges of information
4. Medulla: involuntary/autonomic
responses
5. Brainstem: (medulla, pons, and
midbrain) involuntary response
6. Hypothalamus: maintain the
homeostasis of the body
4. Lobes of Cerebrum
1. Frontal: planning, movement and
coordination
2. Parietal: processing, language
3. Temporal: auditory, speech and visual
perception
4. Occipital: visual perception
1. Cranial nerve: 12 nerves
2. Spinal nerves: 31
a. Cervical nerve, b. Thoracic nerve
c. Lumbar nerve d. Sacral nerve
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Integumentary System
Objectives
1. Functions of the integumentary system
2. Layers of the skin
3. Accessory organs
4. Epidermis
5. Dermis
6. Hypodermis
7. Accessory organs

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 Topic: Integumentary System nursebossstore.com

1.Functions 5. Dermis
1. Made of fibrous connective tissue that contains
1. Protection
arterioles for supplying nutrients
2. Excretion
2. Contains pili arrector muscles
3. Body temperature regulation
3. Contains nerves and hair follicles
4. Cutaneous sensation
4. Contains sebaceous gland to secrete sebum onto
5. Vitamin D synthesis
skin surface, and sudoriferous glands to secrete
sweat
2. Layers of the Skin
1. Epidermis 6. Hypodermis
2. Dermis 1. Made up of connective tissues and adipose
3. Hypodermis tissues
2. Contains large blood vessels.
3. Accessory Organs
Hair, hair follicles, pili arrector muscle, 7. Accessory Organs
sebaceous gland , sudoriferous gland , nails Hair: Hair roots and hair shaft
, and mammary gland Pili arrector muscle: attached to each hair
follicle
4. Epidermis Sebaceous gland: oil gland
Made of stratified squamous epithelium and no
blood vessels. Sudoriferous gland: sweat gland
Four layer of cells are found in the epidermis of Nails: made of keratin
the body surface:stratum basale , stratum
spinosum , stratum granulosum , and
stratum corneum
Melanocytes: produces melanin
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Reproductive System
Objectives
1. External genitalia of a male
2. Internal genitalia of a male
3. External genitalia of a female
4. Internal genitalia of a female

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Topic: Reproductive System nursebossstore.com

Male
1.External Genitalia of a Male
External genitalia
1. Penis: urinary and reproductive
elimination
2. Scrotum: Houses and protects the
testes
2. Internal Genitalia of a Male
Internal organs:
1. Testes: responsible for producing
testosterone and sperms
2. Ductal system: The vas deferens is the
tube that sperms passes through
3. Seminal vesicle: secretes fluid during
ejaculation
4. Prostate: secretes alkaline fluids that
assist in sperm motility, sperm
protection, sperm nourishment.
Female
1.External Genitalia of a Female
External genitalia:
1. Mons pubis
2. Labia majora and minora
3. Clitoris
4. Vestibule
5. Perineum
Internal organs:
1. Vagina: muscular tube from the vulva to
the uterus
2. Cervix: cylinder-shaped neck of tissue that
connects the vagina and uterus
3. Ovaries: two sex organs on each side of
the uterus
4. Fallopian tubes: three sections (Isthmus,
ampulla and infundibulum)
5. Uterus: the womb, located within the
pelvic cavity. Divided into (cervix, uterine
isthmus, corpus, fundus)

2. Menstrual Cycle
The four main phases of the menstrual cycle
are:
1.Menstruation
2. The follicular phase
3. Ovulation
4. The luteal phase
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 Muscular System
Objectives
1. Functions of the muscular system
2. Skeletal muscles
3. Types of muscle tissues
4. Muscle contraction

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 Topic: Muscular System nursebossstore.com

Functions Types of Muscle Tissue

1. Movement Three basic muscle types
2. Posture •Skeletal muscle
3. Produces heat
4. Stabilize joints •Cardiac muscle
•Smooth muscle

Skeletal muscle:
Terminologies
Most are attached by tendons to bones,
1.Neuromuscular junction: the junction Striated and voluntary movement
between a nerve cell and muscle fiber. Cardiac Muscle
2. Tendons: fibrous connective tissue Found in the heart.
connects bone to muscle Has striation
3. Ligaments: fibrous connective
tissue that connects bone to bone Has a nucleus
Involuntary movement
Smooth Muslce
Has no striation
Involuntary movement
1.Major Parts of Skeletal Muscle
Found in walls of hollow organs
1. Epimysium: surrounds the entire
muscle
2. Perimysium: surrounds a bundle of
muscle fibers
3. Endomysium: surrounds a single
muscle fiber
4. Fascia: on the outside of the
epimysium

2. Microscopic Anatomy of
Skeletal Muscle
1. Sarcolemma: plasma membrane
2. Sarcoplasmic reticulum: smooth
endoplasmic reticulum. Stores calcium
3. Sarcoplasm: cytoplasm fluid in a cell

The Sliding Filament Theory of Muscle

Contraction
1. A muscle fiber contracts when a
nerve impulse causes the
myosin filaments to pull
actin filaments closer together and
thus shorten sarcomeres within a
fiber. When all the sarcomeres in
a muscle fiber shorten, the fiber
contracts.
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 Skeletal System
Objectives
1. Functions of the skeletal system
2. Joints
3. Types of blood tissues
4. Classification of bones
5. Anatomy of a long bone
6. Process of bone formation
7. Healing of a bone fracture

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 Topic: Skeletal System
Functions
1. Support structures
2. Protect organs
3. Formation of blood cells
4. Regulates phosphate and calcium
5. Movement
Parts of the skeletal system
1. Bones, 2. Joints, 3. Ligaments, 4.
Cartilages
Skeleton
1. Axial skeleton
a. Cranium
b. Vertebrae
c. Ribs
2. Appendicular skeleton
a. Limbs
b. Shoulders
c. Hips
1.Types of Bone Tissues
Adult skeleton has a total of 206 bones
Types of bone tissue (osseous):
1. Spongy bone: Has many open spaces
2. Compact bone: Dense
2. Classification of Bones
1. Long bones:femur and humerus
2. Short bones: tarsals, carpals
3. Sesamoid bones: patella
4. Flat bones: sternum, skull, ribs
5. Irregular bones: hips, vertebra
3. Anatomy of a Long Bone
1. Diaphysis: the length of a long bone
2. Epiphysis: spongy bone at the end of
the long bone
3. Periosteum: connective tissue
membrane covering the diaphysis
4. Articular cartilage: covers the
epiphysis
5. Medullary cavity: mostly contains fats
in adults
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Joints
Function:
1. Holds bones together
2. Allows movement
Functional classification of joints
1. Synarthroses – immovable joints
2. Amphiarthroses – slightly moveable
3. Diarthroses – freely moveable joints
Structural classification of joints
1. Fibrous joints: Immovable
2. Cartilaginous joints: Immovable
3. Synovial joints: freely moveable
4. Ball and socket: shoulder joint, hip joint
5. Condyloid: wrist
6. Saddle: carpometacarpal joint
7. Pivot: proximal radioulnar joint
4. Process of Bone Formation
Process of bone formation – ossification done
by bone-forming cells called osteoblasts
Types of Bone Cells:
1. Osteocytes: the mature bone cells
2. Osteoblasts: the bone-forming cells
3. Osteoclasts: Breaks down bone matrix for
remodeling and release of calcium
5. Healing of Bone Fracture
1. Hematoma formation
2. Fibrocartilage callus formation
3. Bony callus formation
4. Bone remodeling (Bone remodeling is a
process by both osteoblasts and osteoclasts)
Tendons: connects muscle to bone
Ligament: connects bone to bone
Cartilage: a soft, gel-like padding
between bones to facilitate movement
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 Lymphatic System
Objectives
1. Functions of the lymphatic system
2. Lymphatic structures
3. Lymphatic circulation
4. Lymphatic vessels
5. Lymph ducts
6. Immunity

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Topic: Lymphatic System nursebossstore.com

Function
1. Returns excess fluid from tissue to
blood
2. Body defense and immunity
3. Maintains and distributes
lymphocytes
4. Hemopoiesis

The lypmhatic system functions with

the circulatory and immune system.
The lymphatic system is a network of
vessels that transports and drains
lymph from the tissues into the blood.

1.Lymphatic Structures 4.Lymph Ducts

1. Lymph: a clear watery fluid
2. Lymphatic nodes and vessels: removes fluids,
bacteria etc.
3. Spleen: largest of the lymphatic organs,
screens blood, removes pathogens, erythrocyte
and platelet destruction, RBC formation in fetus
4. Thymus: primary function is in early life,
Secretes thymosin and thymopoietin
5. Tonsils: Destroy bacteria that breach the
mucosal membrane from outside
1. Right lymphatic duct:
a. Drains lymph from the upper
right quadrant of the body
b. The upper right arm and the
right side of the thorax and
head
2. Thoracic duct:
a. Largest lymphatic vessel
b. Drains lymph from the rest of
the body

2. Lymph Circulation
5.Immunity
→ →
Interstitial fluid Lymph Lymph capillary →
→
Afferent lymph vessel Lymph node Efferent → Adaptive Immunity is also known as

→ →
lymph vessel Lymph trunk Lymph duct
acquired immune system that includes
the processes to eliminate pathogens.
{Right lymphatic duct and Thoracic duct (left
→ →
Two types:
side)} Subclavian vein (right and left) Blood 1. Cell-mediated immunity: involves
→ Interstitial fluid the formation of cytotoxic T cells.
2. Antibody-mediated immunity: also
3. Lymphatic Vessels known as humoral immunity. Involves
antibodies produced by B cells which
Lymphatic capillaries cause the destruction of
Lymphatic vessels microorganisms
Lymphatic collecting vessels
Lymphatic trunks and ducts
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 Endocrine System
Objectives
1. Functions of the endocrine system
2. Structures
3. Endocrine gland and hormones
4. Definitions

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Topic: Endocrine System nursebossstore.com

Functions Structures
The endocrine system is made up of 1. Hypothalamus: Control center of the brain.
glands that produces and secretes Controls the pituitary gland
chemicals, hormones and 2. Pituitary Gland: master gland. Located at
substances. the base of the brain
Functions: 3. Thyroid gland: located at the front of the
1. Growth and development trachea.(metabolism, growth &
2. Control mood development)
3. Metabolism 4. Parathyroids: regulates calcium levels in the
4. Reproduction blood
5. Regulates the way body 5. Adrenal gland: located on top of the
organs functions. kidneys (produces hormones responsible for
metabolism, stress response, blood pressure
regulation, immune system)
6. Pancreas: regulates blood glucose
7. Ovaries: produces eggs, progesterone and
estrogen
8. Testes: produces sperms and testosterone

Endocrine Hormone Definitions

Gland
Pituitary Gland Anterior and posterior pituitary hormone 1.Hormones: chemical
Anterior Pituitary Growth Hormone (GH) messengers that are
Thyroid-Stimulating Hormone (TSH) secreted directly into
Luteinizing Hormone (LH) the blood
ACTH
2. Prostaglandins:
Follicle- Stimulating Hormone (FSH)
lipids made at site of
Prolactin injury that do not enter
bloodstream
Posterior Pituitary ADH, Oxytocin
3. Positive feedback:
Adrenal Gland Aldosterone, cortisol, epinephrine and an action that causes
norepinephrine more of that action to
occur in a positive
Thyroid Gland T3, T4. feedback loop

Insulin, glucagon, somastatin 4. Negative feedback:

Pancreas
actions that are against
the stimulus in a
Ovaries Estrogen, progesterone
negative feedback loop

Testes Testosterone
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A Review Guide For Nursing Students

PART 1

nursebossstore.com 83 / 601
 Table of Content
1. Cardiovascular Disorders

2. Respiratory Disorders

3. Gastrointestinal Disorders

4. Pancreatic Disorders

5. Hepatic Disorders

6. Genitourinary Disorders

7. Neuro Disorders

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 Cardiovascular
TABLE OF CONTENT
1. Coronary Artery Disease
2. Angina
3. Myocardial Infarction
4. Heart Failure
5. Cardiogenic Shock
6. Pericarditis
7. Endocarditis
8. Myocarditis
9. Cardiac Tamponade
10. Aortic Aneurysm
11. Hypertension

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nursebossstore.com

Disease: Coronary Artery Disease Cardiovascular

Risk Factors Pathophysiology
1. Age Coronary artery disease is caused by
2. Gender
3. Family history atherosclerosis (plaque formation) that
4. Hypertension results in the narrowing or occlusion of one
5. High blood cholesterol or more coronary arteries.
level
6. Diabetes
7. Smoking CAD results in decreased myocardial tissue
8. Obesity perfusion and decreased myocardial
Signs and Symptoms oxygenation which leads to angina, MI, HF
or death.
1. Chest pain
2. Dyspnea/SOB
Diagnostic Tests
3. Fatigue
1. Electrocardiography
4. Dizziness
2. Cardiac catheterization
5. Syncope
-may show atherosclerotic lesions.
6. Cough
3. Blood lipids level would be elevated.
7. Normal findings during
asymptomatic period

Treatment
Pharmacology
1. Calcium Channel Blocker
2. Nitrates
3. Cholesterol-lowering
medications
Surgical Interventions
1. Coronary Angioplasty
2. Vascular stent
3. Coronary artery bypass
Nursing Management
Nursing Assessment
1. Pain assessment, vital signs/ECG
Nursing Interventions
1. Administer oxygen
2. Administer medications
3. Promote bed rest
4. Place client in a Semi-Fowler's position.
Patient Education
1. Lifestyle modifications
2. Low-sodium and low-cholesterol diet.
3. Stress management 86 / 601
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Disease: Angina Cardiovascular

Risk Factors Pathophysiology
1. Family history of heart Angina is chest pain due to decreased
disease myocardial oxygenation. This causes
myocardial ischemia.
2. Hypertension Types of angina.
3. High blood cholesterol 1. Stable angina-occurs due to activity.
Pain relieved by rest.
4. Diabetes 2. Unstable angina- unexpected chest pain
5. Smoking that increases in severity, duration and
6. Obesity occurrence (may occur at rest).
3. Variant angina- occurs due to coronary
Signs and Symptoms artery spasm. Occurs at rest.
1. Pain 4. Intractable angina- chronic
5. Preinfarction angina- occurs before an
2. Dyspnea/SOB MI
3. Tachycardia Diagnostic Tests
4. Palpitations 1. Electrocardiography
5. Dizziness 2. Stress test
6. Syncope 3. Cardiac catheterization
7. Diaphoresis
(Sweating)
8. Pallor Nursing Management
9. Elevated BP Nursing Assessment
1. Pain assessment, vital signs/ECG
Treatment
Pharmacology Nursing Interventions
1. Calcium Channel Blocker 1. Administer oxygen
2. Administer nitroglycerin
2. Nitrates 3. Cardiac monitoring
3. Cholesterol-lowering 4. Pain management
medications 5. Promote bed rest
6. Place client in a Semi-Fowler's position.
4. Anti-platelet therapy 7. Establish an IV access.
Surgical Interventions
1. Coronary Angioplasty Patient Education
1. Lifestyle and dietary modifications
2. Vascular stent
3. Coronary artery bypass 87 / 601
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Disease: Myocardial Infarction Cardiovascular

Risk Factors Pathophysiology
1. CAD MI occurs due to myocardial tissue damage
2. Atherosclerosis as a result of oxygen deprivation. Ischemia
3. High cholesterol level may lead to necrosis if myocardial tissue
4. Diabetes oxygenation is not restored.
5. Hypertension Obstruction locations of an MI
6. Smoking 1. Left anterior descending artery
7. Stress 2. Right coronary artery
Signs and Symptoms 3. Circumflex artery
1. Pain- crushing substernal
pain that radiates to the
left arm, jaw or back. Diagnostic Tests
1. Troponin- level rises between 4-6 hours
2. Dyspnea
2. CK-MB- peaks after 18 hours.
3. Dysrhythmias
3. Myoglobin- level rises between 2-3
4. Pallor
hours
5. Cyanosis
4. ECG- May show ST-elevation MI (STEMI)
6. Diaphoresis
-or non-ST-elevation MI (NSTEMI)
7. Anxiety
Nursing Management
Treatment Nursing Assessment
Pharmacology 1. Pain, respiratory status, vital signs, ECG,
1. Morphine peripheral pulse and skin temperature.
2. Nitroglycerin Nursing Interventions
3. Thrombolytic therapy 1. Administer oxygen
4. Beta-blockers 2. Administer aspirin, nitroglycerin and morphine
5. Antidysrhythmic medications 3. Cardiac monitoring
Immediate treatment: 4. Administer thromobolytic therapy,
Oxygen: Increase oxygen antidysrhythmics, beta-blockers.
delivery 5. Monitor BP
Aspirin: reduce blood clotting 6. Monitor intake and output
Nitroglycerin: vasodilation 7. Notify HCP if the systolic pressure is lower than
Morphine: pain reliever 100 mm Hg after medication administration.
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Disease: Heart Failure
Risk Factors
1. CAD
2. MI
3. Myocarditis/Endocarditis
4. Diabetes
5. Hypertension
6. Abnormal heart valves
7. Cardiomyopathy
8. Congenital heart disease
Signs and Symptoms
Right-sided HF (evident in
systemic circulation)
Edema of the extremities,
abdominal distention, JVD,
splenomegaly, hepatomegaly,
weight gain
Left-sided HF (evident in the
pulmonary system)
Dyspnea, crackles, tachypnea,
pulmonary congestion, dry cough
Treatment
Pharmacology
1. Morphine
2. Digoxin
3. ACE-Inhibitors
4. Beta-blockers
5. Diuretics
Cardiovascular
Pathophysiology
HF is the inability of the heart muscle to
pump enough blood to meet the metabolic
demands of the body. Therefore, there is
a decrease in cardiac output.
Types:
Right-sided heart failure and left-sided
heart failure.
Diagnostic Tests
1. Blood tests/ Cardiac bio markers
2. Chest X-ray
3. Electrocardiogram (ECG)
4. Echo cardiogram
5. Stress test
6. Cardiac computerized tomography (CT) scan,
Magnetic resonance imaging (MRI). and
Coronary angiogram.
Nursing Management
Monitor for acute pulmonary edema
1. Place patient in a high Fowler's
position.
2. Oxygen therapy
3. Administer morphine sulfate and
diuretics.
4. Insert Foley's catheter.
5. Intubation and ventilation support if
prescribed.
Other nursing interventions
1. Administer prescribed medication regime.
2. Monitor daily weight
3. Monitor intake and output.
4. Provide balance between rest and
activities.
5. Educate patient on lifestyle and dietary
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Disease: Cardiogenic Shock Cardiovascular

Risk Factors Pathophysiology
1. CAD
Cardiogenic shock is a condition caused by
2. MI
failure of the heart to pump adequately.
3. Myocarditis/Endocarditis
4. Diabetes This results in decreased cardiac output
5. Hypertension and decreased tissue perfusion.
6. Abnormal heart valves
7. Cardiomyopathy
8. Congenital heart disease
Signs and Symptoms
1. Hypotension
2. Tachycardia
3. Chest pain/discomfort Diagnostic Tests
1. Blood tests/ Cardiac bio markers
4. Decreased urine output,
2. Chest X-ray
less than 30ml/hr.
3. Electrocardiogram (ECG)
5. Diminished peripheral 4. Echo cardiogram
pulse 5. Stress test
6. Confusion/disorientation 6. Coronary angiogram

Nursing Management
Assessment
Treatment Orientation, respiratory status, pain, vital
Treatment Goal signs, peripheral pulse, intake and output
To improve the heart's
Interventions
pumping ability and maintain 1. Administer medications (see pharmacologic
tissue perfusion. interventions).
Pharmacology 2. Oxygen therapy
3. Monitor vital signs
1. Morphine sulfate 4. Monitor BP after diuretic and nitrate
2. Diuretics administration.
3. Nitrates 5. Prepare client for procedures to improve
coronary tissue perfusion and cardiac output:
4. Vasopressors and positive PTCA, coronary atery bypass grafting,
inotropes (Improve organ insertion of intraaortic balloon pump, etc.
6. Monitor urinary output
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Disease: Pericarditis
Risk Factors
1. MI
2. Autoimmune diseases
3. Injury
4. Heart surgery
5. Bacterial, viral and fungal
infections
Signs and Symptoms
1. Pain
a. Pain that radiates to
the left side of neck,
shoulders and back
b. Pain experienced during
inspiration
c. Pain experienced when
in a supine position
2. Fever
3. Fatigue
4. Pericardial friction rub
(during auscultation)
Treatment
Pharmacology
1. Analgesics
2. NSAIDS
3. Corticosteroids
4. Antibiotics (for bacterial
infections)
5. Diuretics
6. Digoxin
Surgical Intervention
1. Pericardiectomy
Cardiovascular
Pathophysiology
Pericarditis is an infection of the
pericardium. The pericardium is comprised
of two thin sac layers that surrounds the
heart.
Chronic pericarditis causes thickening of
the pericardium which results in the
accumulation of fluid (and causes a
decrease in pericardial elasticity).
This may result in further complications such
as heart failure and cardiac tamponade.
Diagnostic Tests
1. History and physical examination
2. Chest X-ray
3. Electrocardiogram (ECG)
4. Echo cardiogram
5. Blood culture
Nursing Management
1. Pain assessment
2. Assess for signs of cardiac tamponade.
3. Auscultate lungs (listen for pericardial
friction rub).
4. Position patient in a high Fowler's
position (leaning forward to reduce pain).
5. Blood culture
6. Administer medications
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Disease: Endocarditis
Risk Factors
1. Congenital heart defects.
2. IV illegal drug use
3. Damaged heart valves
4. Valve replacement
5. Prosthetic heart valve
Signs and Symptoms
1. Fever
2. Weight loss
3. Heart murmurs
4. Pallor Diagnostic Tests
5. Clubbing of fingers
6. Petechiae
7. Splenomegaly
8. Red tender lesions on
hands and feet- Osler's
nodes
9. Nontender hemorrhagic
nodular lesions- Janeway
lesions Nursing Management
Treatment
Pharmacology
1. Antibiotics
Cardiovascular
Pathophysiology
Inflammation and infection of the
endocardium, the inner lining of the
heart chambers and heart valves.
Entry:
1. Oral cavity
2. Infection
3. Invasive procedures
1. Blood culture test
2. ECG
3. Chest X-ray
4. Echo-cardiogram
5. CT scan
6. MRI
Assessment
1. Assess skin for petechiae
2. Assess nail beds and clubbing of fingers
3. Assess for Janeway lesios and Osler's nodes
4. Assess blood culture results
Interventions
1. Monitor cardiovascular status
2. Monitor signs of emboli and heart failure.
3. Provide rest and activity balance to prevent
thrombus formation
4. Maintain antiembolism stockings
5. Administer antibiotics
Education
1. Temperature monitoring
2. Oral hygiene
3. Teach client on the signs and symptoms of
complications (emboli and heart failure).
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Disease: Myocarditis Cardiovascular

Risk Factors
1. Previous pericarditis
2. Bacterial, viral or
fungal infection.
3. Allergic response
Pathophysiology
Myocarditis is the inflammation of the
heart muscles (myocardium).
Myocarditis may affect the heart's
pumping ability and cause
arrhythmias.

Signs and Symptoms

1. Fever
2. Chest pain
Diagnostic Tests
3. Pericardial friction rub 1. Blood test (Cardiac enzymes-CPK
4. Tachycardia level)
2. ECG
5. Murmur
3. Chest X-ray
6. Dyspnea 4. Echo-cardiogram
7. Fatigue 5. CT scan
6. MRI

Nursing Management
1. Place client in a comfortable position
Treatment
(Semi-Fowler's position).
Pharmacology
2. Oxygen therapy
1. Analgesics
2. Salicylates 3. Administer medications as prescribed (see
3. NSAIDs pharmacologic therapy)
4. Antidysrhythmic drugs 4. Provide rest periods
5. Antibiotics 5. Avoid activities that causes overexertion
6. Monitor for heart failure,
cardiomyopathy and thrombus as signs of
complications.
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Disease: Cardiac Tamponade
Risk Factors
1. Cancer
2. Tuberculosis
3. Hypothyroidism
4. Kidney failure
5. Chest trauma
6. Pericarditis
Signs and Symptoms
1. Increase central venous
pressure (CVP).
2. Jugular venous distention
3. Muffled heart sound
4. Pulsus paradoxus
5. Decreased cardiac output
Treatment
1. Cardiac tamponade is a
medical emergency
2. Client is managed in a critical
care unit for hemodynamic
monitoring
3. IV fluids are prescribed for
decreased cardiac output.
4. Pericardiocentesis is
performed (a procedure to
remove fluids in the
pericardium).
Cardiovascular
Pathophysiology
Cardiac tamponade is a syndrome caused
by accumulation of fluid in the pericardial
cavity (pericardial effusion). Cardiac
tamponade decreases ventricular filling
and cardiac output.
This may cause complications such as
pulmonary edema, shock, or death.
Diagnostic Tests
1. Chest X-rays (an enlarged, globe-
shaped heart may indicate cardiac
tamponade).
2. Thoracic CT scan (fluid accumulation).
3. Magnetic Resonance Angiogram
(determine cardiac blood flow).
4. Echo cardiography
Nursing Management
1. Place client on hemodynamic monitoring.
2. Administer IV fluids are prescribed.
3. Prepare client for pericardiocentesis
procedure.
4. Monitor client after the procedure for any
recurrence of tamponade.
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Disease: Aortic Aneurysm Cardiovascular

Risk Factors Pathophysiology
1. Tobacco use Aortic aneurysm is an
2. Hypertension
enlargement/dilation of the aorta.
3. Family history
Aneurysm may occur anywhere along
4. Age (65 and older)
5. Gender (male) the abdominal aorta.
6. High blood cholesterol
level
Signs and Symptoms
Thoracic aneurysm:
dyspnea, cyanosis, weakness,
hoarseness, syncope, pain.
Abdominal aneurysm:
Diagnostic Tests
abdominal pain, abdominal 1. Abdominal ultrasound
tenderness, systolic bruit over
aorta, mass above the
2. CT scan
umbilicus. 3. Ateriography
Rupturing aneurysm:
tachycardia, hypotension,
abdominal pain, s/s of shock,
hematoma at the flank
region.
Nursing Management
1. Assess abdominal distension
Treatment
Pharmacology 2. Assess peripheral pulse, temperature,
1. Antihypertensive drugs-to
maintain BP and prevent color and capillary refill.
pressure on the aneurysm. 3. Monitor vital signs
Surgical Intervention 4. Monitor for signs of aneurysm rupture
1. Abdominal aortic aneurysm
resection- section is replaced 5. Administer medication (see
with a graft.
2. Thoracic aneurysm repair- a pharmacologic interventions).
thoractomy procedure is used 6. Prepare client for surgical procedure
to enter the thoracic cavity,
expose the aneurysm and a 7. Implement post operative interventions
graft is sewn on the aorta.

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Disease: Hypertension Cardiovascular

Risk Factors Pathophysiology
1. Obesity Hypertension is the most common lifestyle
2. DM
disease.
3. Physical inactivity
4. Tobacco use Hypertension is multifactorial that causes
5. Alcoholism an increase in peripheral vascular
6. Family history resistance and an increase in blood
7. Secondary hypertension:
caused by underlying
pressure (chronic).
condition
Signs and Symptoms Elevated BP: >120-129/<80
Stage 1 Hypertension: 130-139/80-89
1. Increased BP Stage 2 Hypertension: >140/>90
2. Headache
3. Dizziness Diagnostic Tests
1. History/BP monitoring
4. Chest pain 2. ECG
5. Blurred vision 3. Echocardiography
6. Tinnitus 4. Blood chemistry
5. Urinalysis
6. Lipid panel
Remember: it may be
7. CT scan
asymptomatic 8. Chest xray

Nursing Management
1. Assess and monitor BP
Treatment
Goal of treatment: 2. Obtain family history
1. Reduction of BP 3. Monitor weights
2. Prevention of organ
damage 4. Goal: weight reduction or maintenance
5. Diet: sodium restriction
Lifestyle changes 6. Smoking cessation
1. Diet
2. Exercise 7. Educate patient on pharmacological
treatment
Pharmacology
1. Anti-hypertensive
medications
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 RESPIRATORY
TABLE OF CONTENT
1. Asthma
2. COPD-Chronic Bronchitis
3. COPD-Emphysema
4. Pleural Effusion
5. Hemothorax
6. Pneumothorax
7. Pneumonia

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Disease: ASTHMA Respiratory

Risk Factors/Causes Pathophysiology
1. Allergies
Chronic inflammatory disease of the
2. Stress airway.
3. Hormonal changes Inflammation and hypersensitivity to
a trigger (stimuli).
Smooth muscle constriction of the
bronchi.
Signs and Symptoms
Intermittent airflow obstruction.
1. Chest tightness
2. Wheezing Diagnostic Tests
3. Shortness of breath 1. ABGs
4. Cough 2. Pulmonary function tests
3. Peak expiratory flow
5. Restlessness
4. Spirometry
5. Allergy test
6. Pulse oximetry
7. CBC
Treatment Nursing Management
1. Assess patient's respiratory rate, depth
Pharmacology and pattern
1. Bronchodilators 2. Monitor pulse ox
3. Monitor vital signs
2. Corticosteroids
4. Maintain patent airway
3. Anticholinergics 5. Administer O2 therapy as prescribed
6. Administer medications as ordered.
Patient Education
1. Medication regimen.
2. Identify and avoid triggers.
3. Long term management.
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Disease: COPD- Chronic Bronchitis Respiratory
Risk Factors/Causes Pathophysiology
1. Smoking
Progressive respiratory disease.
2. Exposure to dust Overproduction of mucus due to
and chemicals. inflammatory response.
3. Air pollution Causes airway narrowing and
ventilation-perfusion imbalance.

Signs and Symptoms

1. SOB
2. Cough Diagnostic Tests
3. Sputum production 1. ABGs
4. Fatigue 2. Pulmonary function tests
3. Spirometry
5. Wheezing, crackles
4. Chest X-ray
6. Cyanosis
5. Sputum culture

Treatment Nursing Management

1. Assess respiratory rate, depth and
Pharmacology pattern.
2. Auscultate lungs
1. Bronchodilators 3. Maintain patent airway
2. Glucocorticosteroids 4. Place patient in Fowler's position
3. Anticholinergics 5. Provide O2 therapy as ordered.
6. Increase oral fluids and maintain
4. Mucolytic agents hydration.
7. Perform chest physiotherapy
Patient Education
1. Deep breathing exercises
2. Nutrition and hydration
3. Smoking cessation 99 / 601
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Disease: COPD- EMPHYSEMA Respiratory

Risk Factors/Causes Pathophysiology
1. Smoking
Progressive respiratory disease
2. Exposure to dust characterized by the enlargement of
and chemicals. the alveolar.
3. Air pollution Enlargement causes decrease in
alveolar elasticity, alveolar wall
damage and decrease in alveolar
Signs and Symptoms
surface area.
1. SOB
2. Cough Diagnostic Tests
3. Sputum production 1. ABGs
4. Fatigue 2. Pulmonary function tests
3. Chest X-ray
5. Wheezing, crackles
6. Cyanosis
7. Barrel chest
8. Clubbing of nails
Treatment Nursing Management
1. Assess respiratory rate, depth and
Pharmacology pattern.
2. Auscultate lungs
1. Bronchodilators 3. Maintain patent airway
4. Place patient in Fowler's position
2. Glucocorticosteroids 5. Provide O2 therapy as ordered.
3. Anticholinergics 6. Increase oral fluids and maintain
hydration.
4. Mucolytic agents 7. Perform chest physiotherapy
Patient Education
1. Deep breathing exercises (pursed lip
breathing)
2. Nutrition and hydration
3. Smoking cessation 100 / 601
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Disease: PLEURAL EFFUSION Respiratory

Risk Factors/Causes Pathophysiology
Transudative Effusion
1. Cirrhosis Accumulation of fluid in the pleural
2. Heart failure space.
3. Hypoalbuminemia
Exudative Effusion Fluid accumulates between the
1. Pneumonia
2. Cancer visceral and parietal pleura of the
3. Pulmonary embolism lungs.
4. Tuberculosis
Pleural fluid: transudate or exudate
Signs and Symptoms
1. SOB
2. Chest pain Diagnostic Tests
3. Dry, nonproductive 1. Pleural fluid analysis
cough 2. CT scan
4. Diminished breath 3. Chest radiography
4. Transthoracic ultrasonography
sounds
5. Pain during
inspiration
Treatment Nursing Management
1. Thoracentesis 1. Identify underlying cause
2. Chest tube insertion 2. Assess respiratory rate, depth
3. Pleurectomy
4. Pleurodesis and pattern
5. Treatment of underlying 3. Monitor vital signs
condition
4. Elevate the head of bed
Pharmacology 5. Administer O2 therapy as ordered
(Depends on the underlying 6. Administer medications as
condition)
ordered
1. Diuretics- congestive 7. Prepare patient for possible
heart failure. thoracentesis.
2. Antibiotics
3. Anticoagulants- 8. Chest tube management
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Disease: HEMOTHORAX Respiratory

Risk Factors/Causes Pathophysiology
1. Thoracic/heart surgery
2. Chest trauma Accumulation of blood in the pleural
3. Blood clotting defect cavity.
4. Anticoagulant therapy Causes respiratory distress.
5. Lung cancer
6. Tuberculosis

Signs and Symptoms

1. sOB
2. Tachypnea
3. Chest pain Diagnostic Tests
4. Tachycardia 1. Thoracentesis
5. Hypotension
6. Diminished breath 2. ABGs
sounds on affected 3. CT scan
side
7. Restlessness
8. Cyanosis
9. Anxiety
Treatment Nursing Management
1. Stabilize patient 1. Assess diagnostic test results.
2. Stoppage of bleeding 2. Assess respiratory rate, depth and
3. Thoracentesis
4. Chest tube insertion pattern
3. Monitor vital signs
4. Elevate the head of bed
Surgical Intervention 5. Administer O2 therapy as ordered
1. Thoracotomy
2. VATS-Video assisted 6. Pharmacologic pain management
thoracoscopic surgery 7. Non-pharmacologic pain management
8. Chest tube management/care
9. Administer IV fluids as ordered
10. Administer blood transfusion as ordered
11. Prepare patient for surgery, if indicated.
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Disease: PNEUMOTHORAX
Risk Factors/Causes
1. Chest injury
2. Ruptured air blebs
3. Mechanical ventilation
4. Lung disease: cystic fibrosis
5. Chest surgery
6. Smoking
7. Genetics
8. Invasive procedures
Signs and Symptoms
Spontaneous pneumothorax
1. SOB/ Cyanosis
2. Tachycardia
3. Asymmetrical chest
movement
4. Diminished breath sounds on
affected side
5. Chest pain
Tension pneumothorax
1. Tracheal deviation away
from affected side
2. SOB/ Tachypnea/Cyanosis
3. Hypotension/weak pulse
4. Chest pain
5. Decreased CO
Treatment
1. Oxygen therapy
2. Chest tube insertion
Pharmacology
1. Antibiotics
Surgical Management
1. If 1500 ml of blood is
aspirated initially by
thoracentesis then
thoracotomy is
performed.
Respiratory
Pathophysiology
Air leaks into pleural space. Pleural space is
exposed to positive atmospheric pressure
(pressure is normally negative). Causes
impaired lung expansion.
Results in full lung collapse or partial lung
collapse.
Types
1. Spontaneous pneumothorax
2. Tension pneumothorax
3. Traumatic pneumothorax
Diagnostic Tests
1. ABGs
2. Thoracic CT scan
3. CBC
4. Thoracentesis
5. Chest X-ray
Nursing Management
1. Assess respiratory status
2. Maintain patent airway
3. Monitor vital signs
4. Administer O2 therapy as ordered
5. Chest tube management: monitor for
kinks and bubbling
6. Pain management
7. Maintain bed rest
Patient Education
1. Deep breathing exercises
2. Educate patient on the use of Incentive
spirometer
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Disease: PNEUMONIA
Causes
Community acquired pneumonia
1. Streptococcus pneumoniae
Hospital acquired pneumonia
1. Prolonged hospitalization
2. Mechanical ventilation
3. Chronic illness/co morbid
Aspiration Pneumonia
1. Substance entering the
airway due to vomiting or
impaired swallowing
Signs and Symptoms
1. SOB
2. Productive cough
3. Tachypnea
4. Use of accessory
muscles
5. Fever
6. Cyanosis
7. Pleuritic chest pain
Treatment
1. Hydration (IV fluids)
2. Blood culture
3. Respiratory Management
Pharmacology
1. Antibiotics
2. Antiviral angents
3. Antitussives
4. Antipyretics
5. Analgesics
Patient Education
Respiratory
Pathophysiology
Inflammation of the pulmonary tissue
caused by bacteria, fungi and viruses
Types:
1. Community acquired pneumonia: onset
of pneumonia symptoms that occurs in
the community setting or for the first
48 hours after admission
2. Hospital acquired pneumonia: onset of
pneumonia symptoms after 48 hours of
admission
3. Aspiration pneumonia: bacterial
infection from aspiration
Diagnostic Tests
1. ABGs
2. Sputum culture
3. Chest X-ray
4. CBC-WBC
5. Blood culture
6. Pulmonary function studies
7. Bronchoscopy
Nursing Management
1. Assess respiratory status
2. Maintain patent airway
3. Monitor vital signs
4. Assess swallowing if cause is aspiration
5. NPO status maintained if cause is aspiration
6. Administer O2 therapy as ordered
7. Chest physiotherapy
8. Maintain bed rest/Semi-Flower's position
9. Increase fluid intake
10. High-calorie, protein diet
1. Fluid intake
2. Deep breathing/coughing
3. Medication regimen 104 / 601
 Gastrointestinal
TABLE OF CONTENT
1. Hiatal Hernia
2. Gastroesophageal Reflux Disease
3. Gastritis
4. Appendicits
5. Peptic Ulcer Disease
6. Ulcerative Colitis
7. Crohn's Disease

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Disease: Hiatal Hernia Gastrointestinal

Causes/Risk Factors Pathophysiology
The diaphragm has a small opening
1. Injury
2. Aging (hiatus) through which the esophagus
3. Obesity passes before connecting to the
stomach.

Hiatal hernia occurs when a portion of

the stomach herniates through the
Signs and Symptoms diaphragm and into the thorax.

1. Heart burn
2. Dysphagia Diagnostic Tests
3. Regurgitation
1. Upper endoscopy
4. Epigastric pain
2. Barium swallow (esophagram)

Treatment Nursing Management

Pharmacology 1. Assess pain
1. Antacid 2. Elevate head of bed (HOB)
a. Neutralizes 3. Avoid eating 2 to 3 hours before bedtime
stomach acids 4. Provide small frequent meals
2. Proton pump inhibitors 5. Avoid lying down after eating
a. Blocks acid 6. Administer medications as ordered
production- reduces
stomach acid Patient Education
1. Avoid alcohol, fatty foods, caffeine,
tobacco, and other irritants
Surgical intervention may 2. Avoid eating 2 to 3 hours before bedtime
be required 3. Avoid lying down after eating
4. Avoid anticholinergics
5. Maintain healthy body weight (exercise)
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Disease: GERD Gastrointestinal

Causes/Risk Factors Pathophysiology
A digestive disorder that occurs due to the
1. Hiatal Hernia
2. Pregnancy backflow of gastric content.
3. Pyloric surgery Impaired or dysfunctional lower
4. Smoking esophageal sphincter (LES) causes
5. Obesity
6. Alcohol regurgitation of stomach content into the
7. Fatty foods esophagus.
Complications- esophagitis, Barrett
esophagus, esophageal stricture.
Signs and Symptoms

1. Heart burn
2. Dysphagia Diagnostic Tests
3. Regurgitation
1. Upper endoscopy
4. Epigastric pain
2. Esophageal pH studies
5. Dyspepsia
3. Barium swallow (esophagram)
(indigestion)

Treatment Nursing Management

Pharmacology 1. Assess pain
1. Antacid 2. Elevate head of bed (HOB)
a. Neutralizes stomach 3. Avoid eating 2 to 3 hours before bedtime
acids 4. Avoid lying down after eating
2. Proton pump inhibitors 5. Administer medications as ordered
a. Blocks acid
production- reduces
stomach acid Patient Education
3. Histamine H2 antagonist 1. Avoid alcohol, fatty foods, caffeine, tobacco,
a. Blocks histamine and other irritants
(decreases 2. Avoid eating 2 to 3 hours before bedtime
stimulation of
stomach acid 3. Avoid lying down after eating
production). 4. Avoid NSAIDS and anticholinergics
5. Maintain healthy body weight (exercise)
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Disease: Gastritis Gastrointestinal

Causes/Risk Factors Pathophysiology
Gastritis is the inflammation of the gastric
1. Bacterial infection
2. Autoimmune disease mucosa.
3. Prolong use of NSAIDs
4. Excessive alcohol use Acute gastritis- caused by the overuse of
5. Smoking
6. Dietary factors NSAIDs, aspirin or excessive alcohol intake.
Chronic gastritis-consistent inflammation of
the gastric mucosa. May be caused by H.
pylori bacteria, or autoimmune diseases.
Signs and Symptoms
Acute Gastritis
1. Nausea/vomiting
2. Anorexia
3. Abdominal pain Diagnostic Tests
4. Acid reflux
5. Hiccups
1. Endoscopy
Chronic Gastritis 2. H. pylori test
1. Indigestion 3. Upper GI X-ray
2. Heart burn after meals
3. Vitamin B12 deficiency
4. Anorexia/nausea/vomiting

Treatment Nursing Management

Pharmacology 1. Assess pain
1. Antacid 2. Monitor signs of hemorrhagic gastritis
a. Neutralizes stomach
acids 3. Maintain NPO status until symptoms
2. Proton pump inhibitors subsides
a. Blocks acid 4. Administer medications as ordered.
production- reduces
stomach acid
3. Histamine H2 antagonist Patient Education
a. Blocks histamine 1. Educate patient to avoid irritating
(decreases
stimulation of foods.
stomach acid 2. Educate patient on the importance of
production). medication regime and adherence.
4. Antibiotics: to treat
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Disease: Appendicitis
Risk Factors
1. Abdominal trauma
2. Inflammatory bowel
disease
3. Infection in the
gastrointestinal tract
4. Foreign body
5. Viral infection
Signs and Symptoms
1. Rovsing's sign: pain
experienced at the RLQ
when pressure is applied
and released at the LLQ
2. Periumbilical abdominal
pain
3. RLQ pain
4. Fever
5. Abdominal rigidity
Treatment Nursing Management
1. Appendectomy: surgical
removal of the appendix
2. Pain management
3. IV fluids
Pharmacology
1. Antibiotics
Patient Education
Gastrointestinal
Pathophysiology
Inflammation of the vermiform appendix.
Inflammation causes obstruction of the
appendiceal lumen.
Complications: Prolong inflammation may
cause the appendix to burst/rupture
leading to peritonitis.
Diagnostic Tests
1. CBC (WBC)
2. CT scan
3. Abdominal ultrasound
1. Assess pain
2. Abdominal assessment
3. Monitor VS
4. Pre-operative care: NPO + IVF
5. Post-operative care: Monitor surgical site
+ monitor for signs of infection
1. Post-operative education
a. Early ambulation
b. Deep breathing exercises
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Disease: Peptic Ulcer Disease Gastrointestinal

Risk Factors/Causes Pathophysiology
Ulceration that erodes the gastric or
1. H. pylori bacteria
2. NSAIDS duodenal mucosa.
3. Irritants Mucosal inflammation and ulceration
4. Smoking is caused by H. pylori bacteria.

Complications: GI hemorrhage,
Signs and Symptoms bowel obstruction
1. Epigastric pain after
meals
2. Dark, tarry stools Diagnostic Tests
3. Weight loss 1. Laboratory tests for H. pylori
4. Coffee ground emesis 2. Endoscopy
3. Barium Swallow (Upper
gastrointestinal series)

Treatment Nursing Management

Pharmacology 1. Abdominal Assessment (abdominal
1. Antibiotics sounds)
2. Histamine H2 blockers
2. Monitor vital signs (BP,P)
a. Blocks histamine
(decreases
3. Monitor stools for blood
stimulation of
stomach acid Patient Education
production). 1. Dietary modification: avoid
3. Proton pump inhibitor irritants
a. blocks acid 2. Smoking cessation
production to 3. Avoid NSAIDS
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Disease: Ulcerative Colitis
Risk Factors/Causes
1. Age
2. Family history
Signs and Symptoms
1. Diarrhea with pus or
blood
2. Abdominal pain
3. Abdominal
tenderness
4. Fever
5. Fecal urgency
Treatment
Pharmacology
1. 5-aminosalicylic acid (5-
ASA)
2. Corticosteroids-
moderate to severe
ulcerative colitis
3. Immunosuppresants-
reduces inflammation.
Gastrointestinal
Pathophysiology
Known as an Inflammatory Bowel
Disease.
Characterized by the ulceration and
inflammation of the colon and rectum.
Causes poor nutrient absorption.
Complications: Nutritional deficiencies,
hemorrhage and perforated colon
Diagnostic Tests
1. Colonoscopy
2. Stool specimen analysis
Nursing Management
1. Assess and monitor vital signs
2. Assess pain
3. Monitor fluid balance
4. I/O charting
5. Monitor electrolyte levels (lab studies)
6. Monitor stool frequency and
characteristics
7. Obtain daily weights
8. Pain management
9. Maintain NPO status if indicated (severe
condition)
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Disease: Crohn's Disease
Risk Factors/Causes
1. Autoimmune
2. Heredity
Signs and Symptoms
1. Diarrhea with pus
2. Fever
3. Abdominal pain
4. Abdominal distention
5. Weight loss
6. Reduced appetite
7. Iron deficiency
Treatment
Pharmacology
1. 5-aminosalicylic acid (5-
ASA)
2. Corticosteroids
3. Immunosuppresants-
reduces inflammation.
Gastrointestinal
Pathophysiology
Crohn's disease is a type of
inflammatory bowel disease (IBD) that
causes inflammation in the
gastrointestinal tract (leads to
thickening, scarring and narrowing)
Diagnostic Tests
1. Colonoscopy
2. Stool specimen analysis
3. CT scan
4. MRI
Nursing Management
1. Assess and monitor vital signs
2. Assess pain
3. Monitor fluid balance
4. I/O charting
5. Monitor electrolyte levels (lab studies)
6. Monitor stool frequency and
characteristics
7. Obtain daily weights
8. Pain management
9. Maintain NPO status if indicated (severe
condition)
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 Pancreas & Gallbladder
TABLE OF CONTENT
1. Pancreatitis
2. Cholecystitis
3. Cholelithiasis

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Disease: Pancreatitis
Risk Factors/Causes
1. Hyperlipidemia
2. Hypercacemia
3. Gallstones
4. Abdominal surgery
5. Abdominal trauma
6. Obesity
7. Infection
Signs and Symptoms
1. Left upper abdominal
pain that radiates to the
back
2. Abdominal pain that
worsens after meals
3. Abdominal tenderness
4. Fever
5. Tachycardia
6. Hypotension
7. Steatorrhea: chronic
pancreatitis
Treatment
1. NPO status
2. Pancreatic enzyme
supplements
3. Pain management
4. IV fluids
5. Surgical procedure to
remove bile duct
obstruction.
6. Cholecystectomy (if cause
is gallstones)
7. Pancreatic Jejunostomy
Gastrointestinal
Pathophysiology
Inflammation of the pancreas.
Obstruction of pancreatic secretory
flow, activation and release of
pancreatic enzymes. Digestive
enzymes starts digesting the
pancreas.
Diagnostic Tests
1. Electrolyte levels (Calcium)
2. Elevated level of pancreatic enzymes
3. WBC
4. CT scan
5. Abdominal ultrasound
6. Endoscopic ultrasound
7. MRI
8. stool test: for chronic pancreatitis
Nursing Management
1. Assess pain
2. Provide pharmacologic and non-
pharmacologic pain management
3. Monitor fluid and electrolytes
4. Maintain NPO status as ordered
5. Manage biliary drainage
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Disease: Cholecystitis Gastrointestinal

Risk Factors/Causes Pathophysiology
1. Gallstones Inflammation of the gallbladder.
2. Tumor Acute inflammation: is often due to
3. Infection cholelithiasis.
Chronic inflammation: repeated
acute inflammation that causes the
gallbladder to be thick-walled and
Signs and Symptoms scarred.
1. Epigastric pain that
radiates to the right
shoulder
Diagnostic Tests
1. CBC- WBC
2. Fever
3. Nausea/Vomiting 2. Abdominal ultrasound
4. Murphy's sign 3. Endoscopic ultrasound
5. Belching 4. CT scan
6. Flatulence
7. Abdominal tenderness

Treatment Nursing Management

1. NPO status
2. Pain management 1. Assess pain
2. Provide pharmacologic and non-
3. Antiemetics: for nausea
pharmacologic pain management
and vomiting
3. Maintain NPO status
4. Analgesics: pain
4. Prepare patient for procedures
Surgical intervention
1. Cholecystectomy:
Post operative interventions
removal of the
1. Monitor respiratory complications
gallbladder. 2. Encourage coughing and deep breathing
2. Choledocholithotomy: 3. Encourage early ambulation
removal of gallstones 4. Tube drainage management (if any).
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Disease: Cholelithiasis
Risk Factors/Causes
1. Obesity
2. High cholesterol
levels
3. Women over 40 years
4. Diabetes
5. Cirrhosis
Signs and Symptoms
1. Sudden pain in the right
upper quadrant
2. Abdominal distention
3. Dark urine
4. Abdominal pain after
eating fatty foods.
Treatment
Pharmacology Preoperative Care
1. Analgesics
Postoperative Care
2. Antibiotics
Surgical intervention
1. Cholecystectomy:
removal of the
gallbladder.
Medications to dissolve
stones Patient Education
1. Chenodeoxycholic
2. Ursodeoxycholic acid
Gastrointestinal
Pathophysiology
Gallstones are hard, crystalline
structures that abnormally forms
and obstruct the gallbladder / bile
duct.
Most of cholelithiasis is caused by
cholesterol gallstones.
Diagnostic Tests
1. Cholesterol levels/LDLs
2. Cholecystogram
3. Laparoscopy
4. Abdominal ultrasound
5. Endoscopic ultrasound
6. CT scan
7. MRI
Nursing Management
1. Prepare patient for surgery
1. Monitor vital signs
2. Monitor respiratory status
3. Pain management
4. Monitor drainage/incision site
5. Monitor intake and output
6. Maintain NPO status
7. Deep breathing exercises
8. Early ambulation
1. Ambulation/ 2. Avoid heavy lifting/ 3. Avoid
bathing for 48 hours/ 4. Report fever/ 5. Dietary
modification/ 6. Assess wound site daily.
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 Hepatic Disorders
TABLE OF CONTENT
1. Cirrhosis
2. Portal Hypertension
3. Esophageal Varices

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Disease: Cirrhosis
Risk Factors/Causes
1. Chronic alcoholism
2. Hepatitis
3. Biliary obstruction
4. Right-sided HF
Gastrointestinal
Hepatic Disorders
Pathophysiology
Cirrhosis is a chronic progressive
disease of the liver characterized by
fibrosis (scarring).

Signs and Symptoms

1. Jaundice
2. Edema
3. Splenomegaly
4. Liver enlargement Diagnostic Tests
5. Ascities 1. Liver Function Test
6. Abdominal pain 2. INR/Prothrombin time
7. Steatorrhea
8. Bleeding- decreased Vit K 3. MRI
9. Red palms 4. CT scan
10. Itchiness 5. Liver Biopsy
11. Weight loss/ Loss of
appetite
12. White nails
Treatment Nursing Management
1. Treatment of underlying
1. Identify underlying/precipitating factors
cause 2. Perform daily weights
a. Alcohol dependency 3. Administer vitamin supplements- KADE
b. Hepatitis treatment 4. Monitor for signs of infection
2. Treatment of Cirrhosis 5. Monitor for signs of bleeding
complications- ascites, 6. Nutrition- low sodium
gastric distress, portal
Patient Education
hypertension, etc.
1. Alcohol cessation
3. Liver Transplant- in severe 2. Low sodium diet
cases of Cirrhosis 3. Low saturated fats

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Gastrointestinal
Disease: Portal Hypertension Hepatic Disorders
Causes Pathophysiology
1. Cirrhosis Portal veins carries blood from the
2. Portal vein digestive organs to the liver.
thrombosis Portal hypertension-increased pressure
in the portal veins due to obstruction of
the portal blood flow.

Complications- Hepatic encephalopathy,

Signs and Symptoms
1. Gastrointestinal bleeding ascites, GI bleed, varices rupture.
a. Dark/tarry stools
b. bleeding from varices
2. Ascites Diagnostic Tests
3. Decreased platelets and 1. CBC- low platelets
WBC 2. Hemoccult
4. Splenomegaly
5. Thrombocytopenia 3. Endoscopy
6. Encephalopathy 4. Ultrasound

Treatment Nursing Management

1. Endoscopic therapy
1. Monitor intake and output
2. Dietary/lifestyle
2. Assess level of consciousness
modifications
3. Monitor coagulation studies
3. Transjugular intrahepatic 4. Perform daily weights
portosystemic shunt 5. Administer diuretics as ordered
(TIPS)-radiological 6. Administer Vit K as ordered
procedure
4. Distal splenorenal Patient Education
shunt (DSRS)-surgical 1. Low sodium diet
procedure 2. Alcohol cessation

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Disease: Esophageal Varices
Causes
1. Cirrhosis
2. Thrombosis in the
portal vein
3. Heart failure
4. Schistosomiasis
Signs and Symptoms
1. Jaundice
2. Dark-colored urine
3. Ascites
4. Nausea/Vomiting
5. Spontaneous
bleeding/easy bruising
6. Spider nevi
7. Hypotension
8. Tachycardia
9. Pallor
10. General malaise
11. Pruritus
Treatment
1. Primary goal is to prevent
bleeding.
2. Beta blockers- to reduce
pressure in the portal
veins
3. Vasopressin
4. Somatostatin/Sandostatin
5. Sclerotherapy
6. Endoscopic band ligation
Gastrointestinal
Hepatic Disorders
Pathophysiology
Esophageal varices occurs when there is a
blockage in the blood flow to the liver due to
scarring or clotting in the liver.
This results in an increased pressure from the
portal vein.
The increased pressure causes blood to flow into
smaller veins in the esophagus. The smaller
fragile veins may become distended and
rupture, causing life--threatening hemorrhage.
Diagnostic Tests
1. CBC
2. Coagulation studies
3. Liver function test
4. Endoscopy
5. CT scan
Nursing Management
1. Monitor vital signs
2. Monitor lung sounds
3. Elevate HOB
4. Administer O2 as ordered
5. Administer IV fluids as ordered
6. Monitor lab values-coagulation studies
7. Administer Vit K as ordered
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 Genitourinary
TABLE OF CONTENT
1. Acute Kidney Injury
2. Chronic Kidney Disease
3. Glomerulonephritis
4. Nephrotic Syndrome
5. Renal Calculi
6. Urinary Tract Infection
7. Pyelonephritis

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Disease: Acute Kidney Injury Genitourinary

Causes Pathophysiology
Prerenal-outside the kidney Renal cell damage characterized by a
1. Dehydration, infection outside of
the kidney, decreased cardiac sudden deterioration in kidney function.
output
Intrarenal-parenchyma of the kidney AKI can cause cell death, decompensation
1. Infection within the kidney of renal function and hypoperfusion.
parenchyma, obstruction, tubular
necrosis, renal ischemia
Postrenal-between kidney and
urethral meatus The signs and symptoms of AKI are due to
1. Calculi, cystitis, bladder
cancer/obstruction the retention of fluids, the retention of
nitrogenous waste and electrolyte
Signs and Symptoms
Oliguric Phase imbalances.
1. Urine output: <400mL/d,
pericarditis, excessive
fluid volume, uremia, Diagnostic Tests
metabolic acidosis, 1. Urinalysis
neurological changes. 2. Urine output measurement
Diuretic Phase
1. An increase in urine 3. BUN/ Creatinine
output 5L/day. 4. Kidney ultrasound/Imaging
Recovery Phase
1. Recovery may take 6
months to 2 years.

Treatment Nursing Management

1. Treatment of underlying Oliguric Phase
cause 1. Administer diuretics
2. Treatment of 2. Fluid restriction-if hypertension is
complications present
a. Fluids and Diuretic Phase
electrolytes 1. Administer IV fluids
imbalances 2. Monitor Lab values
3. Pharmacology Recovery Phase
a. Antibiotics 1. Patient education-decrease sodium,
b. NSAIDs protein, fluid and potassium intake
c. Diuretics 2. Monitor intake and output.
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Disease: Chronic Kidney Disease
Causes
1. AKI
2. Hypertension
3. Urinary obstruction
4. Diabetes
Signs and Symptoms
1. Hypertension
2. SOB
3. Kussmaul respirations
4. Oliguria/anuria
5. Uremia
6. Edema
7. Irritability
8. Restlessness
9. Pulmonary edema
10. Pulmonary effusion
11. Body weakness
12. Yellow-gray pallor
13. Proteinuria
Treatment
1. Hemodialysis
2. Peritoneal Dialysis
Kidney transplant
Pharmacology
1. Angiotensin-converting
enzyme (ACE) inhibitors
2. Angiotensin II receptor
blockers
3. Diuretics
4. Corticosteroids
5. Erythropoietin
supplements
Genitourinary
Pathophysiology
Slow, progressive and irreversible loss of kidney
function.(GFR <60mL/min).
Results in uremia, electrolyte imbalances,
hypervolemia (inability to excrete sodium and
water) or hypovolemia (inability to conserve
sodium and water).
Stages of CKD
1. At risk: >90mL/min
2. Mild CKD: 60-89mL/min
3. Moderate CKD: 30-59mL/min
4. Severe CKD: 15-29mL/min
5. ESKD: <15mL/min
Diagnostic Tests
1. Kidney function test-
BUN/Creatinine
2. Glomerular filtration rate
3. CBC
4. Kidney ultrasound
5. Urinalysis
Nursing Management
1. Monitor vital signs
2. Monitor cardiopulmonary system
3. Perform daily weights
4. Monitor lab values
5. Monitor intake and output
6. Low protein/sodium diet
7. Fluid restriction
8. Dialysis treatment
9. Administer medications
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Disease: Glomerulonephritis Genitourinary

Causes
1. Immunological diseases
2. Strep throat
3. Autoimmune diseases
Pathophysiology
A group of renal diseases caused by
immunologic response that triggers
the inflammation of the glomerular
tissue.

Signs and Symptoms

1. Dark colored urine
2. Hematuria
3. Proteinuria
4. Azotemia Diagnostic Tests
5. Oliguria 1. Urinalysis
6. Edema 2. CT Scan
7. Elevated BP
8. JVD 3. MRI
9. Dyspnea 4. Bun-increased
5. Creatinine-increased
6. Decreased GFR
7. Increased Urine Specific Gravity
Treatment Nursing Management
Pharmacology 1. Monitor vital signs
1. Antibiotics 2. Monitor respiratory status
2. Antihypertensive drugs 3. Monitor BP
4. Monitor fluids and electrolytes level
5. Maintain fluid restrictions as ordered
6. Obtain daily weights
Patient Education
1. Medication adherence
2. Fluid restrictions
3. Dietary modifications
4. Increase carbohydrates in diet
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Disease: Nephrotic Syndrome Genitourinary

Causes Pathophysiology
1. Diabetes Mellitus
2. Heart failure Nephrotic syndrome is characterized
3. SLE by excessive excretion of protein in
4. Amyloidosis the urine (proteinuria), leading to
low protein levels in the blood
(hypoproteinemia).
This leads to edema and
hypovolemia.
Signs and Symptoms
1. Periorbital and facial
edema
2. Ascites
3. Peripheral edema Diagnostic Tests
4. Proteinuria 1. Urinalysis
5. Hypoproteinemia 2. BUN, Creatinine
6. Hyperlipidemia
7. Electrolyte imbalance 3. Elevated Albumin
8. Fatigue 4. Blood cholesterol and blood
9. Lethargy triglycerides-increased
5. Electrolytes

Treatment Nursing Management

Pharmacology 1. Monitor vital signs
1. Diuretics 2. Monitor BP
2. ACE-Inhibitors/ ARBS 3. Monitor lab values-protein
3. Corticosteroids 4. Intake and output charting
4. Immunosuppressant 5. Obtain daily weights
6. Low salt/sodium diet/Low cholesterol

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Disease: Renal Calculi
Causes/Risk Factors
1. Dehydration
2. Family history
3. UTI
4. Hypercalcemia
5. Obesity
6. High calcium diet
Signs and Symptoms
1. Pain in the costovertebral
region
2. Fever
3. Persistent need to
urinate
4. Elevated RBC,WBC noted
in urine
Treatment
Treatment depends on the
type, size and cause of the
calculi.
Pharmacology-antibiotics
Small Calculi
1. Increase water intake
2. Pain medications
3. Alpha blockers
Large Calculi
1. Extracorporeal shock
wave lithotripsy (ESWL)
2. Surgical intervention
Genitourinary
Pathophysiology
Renal calculi is also known as kidney
stones. Calculi is made up of minerals and
salt deposits that is found in the urinary
tract.
Types
1. Calcium stones
2. Cystine stones
3. Struvite stones
4. Uric acid stones
Diagnostic Tests
1. 24-hours urine collection
2. Urinalysis
3. CBC
4. Ultrasound
5. KUB radiography
Nursing Management
1. Monitor vital signs
2. Monitor temperature
3. Pain management
4. Encourage fluid intake of 3L/day
5. Encourage ambulation
6. Monitor urine output
7. Strain urine
8. Administer medication as ordered.
Patient Education
1. Increase fluid intake
2. Dietary restrictions
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Disease: Urinary Tract Infection
Causes/Risk Factors
1. Vesicoureteral reflux
2. Urinary catheters-
continuous or long term
use
3. Female
4. Renal calculi
5. Sexual activity
Signs and Symptoms
Acute pyelonephritis
1. Flank pain, Fever, chills,
bacteriuria, pyuria
Cystitis
1. Lower abdominal pain,
burning on urination,
hematuria, frequent
urination, incontinence
Urethritis
1. Lower abdominal pain,
burning on urination,
hematuria, frequent
urination, incontinence
Treatment
Pharmacology
1. Antibiotics
2. Analgesics
3. Antipyretics
Genitourinary
Pathophysiology
UTI is the infection/inflammation of
any part of the urinary system.
1. Acute pyelonephritis:
inflammation of the kidneys
2. Cystitis: Inflammation of the
bladder
3. Urethritis: Inflammation of the
urethra
Diagnostic Tests
1. Urine sample
2. Urine culture
3. Kidney ultrasound
4. CT scan
Nursing Management
1. Monitor vital signs
2. Monitor temperature
3. Encourage fluid intake 3L/day
4. Monitor intake and output
5. Obtain daily weights
6. Administer medications as ordered
Patient Education
1. High calorie, low protein diet
2. Non-pharmacologic pain management
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Disease: Pyelonephritis Genitourinary

Causes/Risk Factors Pathophysiology
1. Vesicoureteral reflux
2. Urinary catheters- Inflammation of the renal pelvis
continuous or long term caused by bacterial infection.
use
3. Female
4. Renal calculi

Signs and Symptoms

1. Fever/chills
2. Flank pain
3. Costovertebral angle
tenderness Diagnostic Tests
4. Hematuria 1. Urine sample
5. Tachypnea 2. Urine culture
6. Tachycardia
7. Nausea 3. Blood culture
8. Cloudy urine 4. Kidney ultrasound
9. Increased urine frequency 5. CT scan
and urgency
10. Pyuria
11. Bacteriuria
Treatment Nursing Management
Pharmacology 1. Monitor vital signs
1. Antibiotics 2. Monitor temperature
2. Analgesics 3. Encourage fluid intake 3L/day
3. Antipyretics 4. Monitor intake and output
4. Antiemetics 5. Obtain daily weights
5. Urinary antiseptics 6. Administer medications as ordered

Patient Education
1. High calorie, low protein diet
2. Non-pharmacologic pain management

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 Neuro
TABLE OF CONTENT
1. Traumatic Head Injury
2. Meningitis
3. Stroke
4. Multiple Sclerosis
5. Seizures
6. Parkinson's Disease

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Disease: TRAUMATIC BRAIN INJURY NEURO

Causes/ Risk Factors Pathophysiology
1. Falls Trauma to the skull that causes brain damage.
2. Sports injury Types:
1. Concussion-injury that causes the head to
3. Vehicular accident move back and forth forcefully
4. Violence 2. Contusion-bruising
3. Epidural hematoma- hematoma between
skull and dura
4. Subdural hematoma-blood between
between the dura and arachnoid
5. Intracerebral hemorrhage-bleeding inside
the brain
Signs and Symptoms 6. Subarachnoid hemorrhage-bleeding into
1. Increased ICP the subarachnoid space
2. LOC changes 7. Skull fractures- break in the cranial bone
3. Confusion/altered mental
status Diagnostic Tests
4. Papilledema 1. GCS
5. Body weakness
6. Seizures
2. Physical Assessment
7. Paralysis 3. CT scan
8. Slurred speech
9. CSF drainage from the ears
or nose

Signs and symptoms depends on Nursing Management

the type of injury and severity.
Treatment
Mild Injury
1. Close monitoring
2. Antibiotics
3. Wound care
Moderate to severe injury
1. Treatment focuses on
increasing cerebral
oxygenation, maintaining BP
and preventing further
injury.
2. Craniotomy
1. Monitor respiratory status
2. Maintain patent airway
3. Initiate seizure precautions
4. Assess neurological changes
5. Assess pupil size
6. Monitor vital signs
7. Monitor for signs of increase
intracranial pressure.
8. Prevent neck flexion
9. Pain management
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Disease: Meningitis
Causes
1. Streptococcus pneumoniae
2. Neisseria meningitidis
3. Haemophilus influenzae
Signs and Symptoms
1. Fever
2. Headache
3. Skin rash
4. Rigidity of the neck
muscles (nuchal rigidity)
5. Positive Kernig's sign and
Brudzinski's sign
6. Decreased LOC
Treatment
Bacterial meningitis
1. Antibiotics
IV fluids: fluids replacement
Antipyretics
Neuro
Pathophysiology
Meningitis is the inflammation of the
meninges. The meninges covers the brain
and spinal cord. Meningitis is mostly
caused by bacterial or viral infection.
Diagnostic Tests
1. Lumbar puncture: CSF fluid is
collected to test for the
pathogen
2. CT scan
3. MRI
4. Blood culture
Nursing Management
1. Infection control precautions
2. Monitor neurological status
3. Assess LOC
4. Monitor vital signs
5. Initiate seizure precautions
6. Administer antipyretics as ordered
7. Encourage and increase hydration
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Disease: Stroke
Risk Factors
1. TIA
2. Hypertension
3. smoking
4. Atherosclerosis
5. Diabetes
6. High cholesterol
Signs and Symptoms
1. Drooping of face
2. One sided weakness
3. Slurred speech
4. Blurred vision
5. Agnosia
6. High BP
7. Unilateral neglect
8. Apraxia
Treatment
1. An IV injection of
recombinant tissue
plasminogen activator
(tPA)-ischemic stroke
2. Hemorrhagic stroke: stop
bleeding. Prevention of
increased ICP
Neuro
Pathophysiology
Stroke is the loss of neurological functions
due to the lack of blood flow to the brain.
Types
1. Ischemic Stroke (Clots)- an obstruction
in the blood vessel that supplies blood
to the brain.
2. Hemorrhagic Stroke (Bleeding)-
weakened blood vessel ruptures.
3. Transient Ischemic Attack- temporary
stroke (a warning stroke)
Diagnostic Tests
1. CT scan
2. MRI
3. Electroencephalography
4. Carotid ultrasound
5. Cerebral arteriography
Nursing Management
1. Maintain patent airway
2. Administer 02
3. Administer tPA
4. Monitor VS-maintain BP @ 150/100
5. Monitor LOC
6. Monitor for signs of increase ICP
7. Elevate HOB
8. Administer IV fluids
9. Insert Foley's catheter
10. Prevention of DVT
11. Assist with self care and ADLs
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Disease: Multiple Sclerosis
Risk Factors
1. Autoimmune disorders
2. Viral infection
Signs and Symptoms
1. Weakness
2. Fatigue
3. Blurred vision
4. Nystagmus
5. Sensory loss
6. Dysphagia
7. Bowel and bladder
dysfunction
8. Electric-shock sensations
9. Neuralgias
Treatment
There is no cure. Treatment
goal is focused on managing
symptoms, acute attacks and
slowing the progression of the
disease.
Neuro
Pathophysiology
Multiple sclerosis is a CNS inflammatory
disease (chronic), characterized by
the demyelination axons. This damage
results in varied neurological dysfunctions.
Diagnostic Tests
1. CT scan
2. MRI
3. Lumbar puncture
Nursing Management
1. Assess muscle function and mobility
2. Pain management
3. Assess sensory function
4. Monitor vision changes
5. Cluster nursing activities
6. Patient's safety measures
7. Encourage independence
8. Encourage bladder and bowel training
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Disease: Seizures Neuro

Risk Factors/Causes Pathophysiology
1. Meningitis Seizures is characterized by a sudden, uncontrolled
electrical disturbance in the brain.
2. Head trauma Epilepsy: chronic seizure activity.
3. Stroke
Types:
4. Fever Generalized Seizures-all areas of the brain are
5. Brain tumor affected
Tonic-Clonic- may begin with an aura.
Tonic phase- muscle rigidity , then loss of
consciousness
Clonic-hyperventilation and jerking
Absence-loss of awareness (stare blankly into
space)
Myoclonic-brief, jerking movement of a
muscle/muscle group
Signs and Symptoms Atonic-sudden loss of muscle strength
The signs and symptoms depends
Partial Seizures-affects one part of the brain
on seizure history and type. Simple partial
Before seizure Complex partial
1. Aura
During seizure
Diagnostic Tests
1. Loss of consciousness during 1. An electroencephalogram
seizures 2. Computerized tomography
2. Uncontrollable involuntary
muscle movements 3. Magnetic resonance imaging
3. Loss of bladder and bowel (MRI)
control
After seizure 4. Neurological exam
1. Headache
2. Confusion
3. Slurred speech
Treatment Nursing Management
Pharmacology 1. Assess time and duration of seizure
1. Anti-seizure medication activity
2. Provide patient safety
3. Turn patient to the side
4. Maintain airway
5. Avoid restraining patient
6. Loosen clothing
7. Administer O2
8. Monitor behavior before and after
seizure activity

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Disease: Parkinson's Disease
Risk Factors
1. Age >65
2. Family history
Signs and Symptoms
1. Bradykinesia
2. Tremors
3. Slow movement
4. Blank facial expression
5. Posture: forward tilt
6. Rigidity of extremities
7. Pill rolling
8. Drooling
Treatment
Pharmacology
1. Carbidopa-levodopa
2. Dopamine agonist
3. Catechol O-
methyltransferase (COMT)
inhibitors
Neuro
Pathophysiology
A progressive neurological disease
characterized by depletion of dopamine
and acetycholine imbalances.
Diagnostic Tests
1. Medical history
2. Signs and symptoms
3. Neurological examination
4. Physical examination
Nursing Management
1. Neuro assessment
2. Assess ability to swallow
3. Provide patient's safety
4. Promote independence
5. Promote physical therapy
6. Diet: high calorie & soft diet
Treatment goal
1. Increase/maintain independence
2. Improve mobility
3. Improve nutritional status
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A Review Guide For Nursing Students

PART 2

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 Table of Content
1. Thyroid Disorders

2. Pancreatic Disorders

3. Adrenal Cortex Disorders

4. Pituitary Gland Disorders

5. Skeletal Disorders

6. Hematology Disorders

7. Reproductive Disorders (F)

8. Reproductive Disorder (M)

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 THYROID DISORDERS
TABLE OF CONTENT
1. Hypothyroidism
2. Hyperthyroidism
3. Hypoparathyroidism
4. Hyperparathyroidism

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Disease: Hypothyroidism Thyroid Disorders

Risk Factors/Causes Pathophysiology
1. Autoimmune diseases The thyroid gland produce hormones that
2. Iodine deficiency or are responsible for regulating the body's
excess metabolic rate (energy).
3. Thyroiditis In hypothyroidism, the thyroid gland is
4. Thyroidectomy underactive (Hyposecretion of thyroid
hormones).
Remember: LOW ENERGY
Signs and Symptoms
1. Fatigue/body weakness
2. Weight gain
Diagnostic Tests
3. Oligomenorrhea
1. Physical examination
4. Hair loss
2. Thyroid Function Test
5. Bradycardia
3. Serum T3/T4
6. Coldness
7. Constipation
8. Myxedema

Nursing Management
1. Monitor HR
Treatment 2. Administer levothyroxine as prescribed.
Pharmacology
1. Levothyroxine Patient Education
1. Educate patient on medication
compliance. Levothyroxine is to be taken
for a life-time.
2. Constipation: High fiber diet and
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Disease: Hyperthyroidism Thyroid Disorders

Risk Factors/Causes
1. Graves' disease
Pathophysiology
The thyroid gland produce hormones that
are responsible for regulating the body's
metabolic rate (energy)
In hyperthyroidism, the thyroid gland is
overactive (Hypersecretion of thyroid
hormones (T3 and T4))
Remember: HIGH ENERGY

Signs and Symptoms Thyroid Storm: acute and life-threatening

1. Exophthalmos: bulging emergency for uncontrolled hyperthyroidism.
eyes
2. Palpitations
3. Tachycardia Diagnostic Tests
4. Weight loss 1. Physical examination
5. Oligomenorrhea
6. Hot flashes
2. Thyroid Function Test
7. Irritability 3. Serum T3/T4
8. Nervousness 4. Thyroid ultrasound
9. Diarrhea

Thyroid Storm
1. Fever
2. Tachycardia Nursing Management
3. Hypertension/Increased RR 1. Monitor BP, P
Treatment 2. Administer medications as prescribed.
3. Obtain daily weights
Pharmacology
1. Propylthiouracil (PTU) Patient Education
1. Educate patient on medication compliance
2. Methimazole 2. Diet: High calorie diet
3. Radioactive iodine 3. Avoid stimulants

therapy Thyroid Storm

1. Maintain patent airway
Surgical Intervention
2. Medications: Antithyroid medication, Beta
1. Thyroidectomy Blockers, Glucocorticoids, Nonsalicylate
antipyretics
3. Cooling blankets
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Disease: Hypoparathyroidism Thyroid Disorders

Risk Factors/Causes
1. Thyroidectomy (and the
removal of the
parathyroid).
Pathophysiology
The parathyroid gland produces the
parathyroid hormone (PTH) that maintains
the serum calcium level in the body.
Hypoparathyroidism is caused by
hyposecretion of parathyroid hormones.

Signs and Symptoms

1. Positive Trousseau's sign
2. Positive Chvostek's sign
3. Hypocalcemia Diagnostic Tests
4. Hyperphosphatemia 1. Calcium and Phosphate serum levels
5. Hypotension 2. Positive Chvostek's and Trousseau's sign
6. Tetany
3. Patient History
7. Muscle cramps
8. Anxiety
9. Numbness and tingling

Nursing Management
1. Monitor BP, P
Treatment 2. Monitor calcium/ phosphorus level
Pharmacology 3. Administer medications as prescribed
4. Diet: high Calcium, low Phosphorus diet
1. IV Calcium Gluconate
5. Seizure precautions-(hypocalcemia)
2. Vitamin D supplements
3. Phosphate binders

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Disease: Hyperparathyroidism
Risk Factors/Causes
1. Chronic kidney failure
Signs and Symptoms
1. Hypercalcemia
2. Hypophosphatemia
3. Weight loss
4. High BP (Hypertension)
5. Bone and joint pain
6. Bone deformities
7. Fatigue
8. Cardiac dysrhythmias
9. Kidney stones
Nursing Management
Treatment
Pharmacology
1. Calcitonin
2. Bisphosphonates (oral/IV)
3. Furosemide
4. Phosphates
Surgical Intervention
1. Parathyroidectomy
Thyroid Disorders
Pathophysiology
The parathyroid gland produces the
parathyroid hormone (PTH) that maintains
the serum calcium level in the body.
Hyperparathyroidism is caused by
hypersecretion of parathyroid hormones.
Diagnostic Tests
1. Calcium and Phosphate serum levels
2. Patient History
3. Bone X-ray
1. Monitor BP
2. Monitor calcium/ phosphorus level
3. Increase fluid intake
4. Promote body alignment
5. Promote safety precautions
6. Administer medications as prescribed
7. Diet: High fiber/ moderate calcium
8. Pre and post operative care
(parathyroidectomy)
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 PANCREATIC DISORDERS
TABLE OF CONTENT
1. Type 1 Diabetes
2. Type 2 Diabetes
3. Diabetes Ketoacidosis
4. Hyperosmolar Hyperglycaemic State
5. Hypoglycemia
6. Hyperglycemia

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Disease: Type 1 Diabetes Pancreas

Risk Factors/Causes Pathophysiology
1. Autoimmune response A chronic condition in which the
2. Genetics pancreas (beta cells) is unable to
3. Onset: childhood produce insulin.

Signs and Symptoms

1. Polyuria: increased
urination
2. Polydipsia: Increased Diagnostic Tests
thirst 1. Fasting blood sugar (FBS)
3. Polyphagia: Increased 2. Glycated hemoglobin
appetite 3. Random blood sugar
4. Weight loss 4. Urinalysis
5. Hyperglycemia
6. Blurred vision
Nursing Management
1. Monitor glucose levels
Treatment 2. Insulin administration
Pharmacology
1. Insulin Patient Education
1. Glucose monitoring
Monitoring
2. Insulin administration technique
1. Continuous glucose
monitoring

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Disease: Type 2 Diabetes Pancreas

Risk Factors/Causes Pathophysiology
1. Obesity Type 2 Diabetes is characterized by
2. Sedentary lifestyle insulin resistance and impaired insulin
3. Hypertension secretion.
4. Hyperglycemia
5. Onset: adulthood
Complication: Hyperosmolar
Hyperglycaemic State
Signs and Symptoms
1. Polyuria: increased
urination
2. Polydipsia: Increased
thirst Diagnostic Tests
3. Polyphagia: Increased 1. Fasting blood sugar (FBS)
appetite
2. Glycosylated hemoglobin (HbA1C)
4. Weight gain
5. Poor wound healing 3. Random blood sugar
6. Fatigue 4. Urinalysis
7. Blurred vision
8. Recurrent infections
9. Numbness and tingling of
hands and feet
10. Dry skin
Nursing Management
1. Monitor glucose levels
Treatment 2. Medication administration
Pharmacology
1. Oral hypoglycemic Patient Education
medications 1. Diabetic Diet
2. Insulin
2. Exercise
3. Medication adherence
Nonpharmacologic therapy
1. Glucose monitoring
2. Dietary plan
3. Exercise regime
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Disease: Diabetic Ketoacidosis (DKA) Pancreas

Risk Factors/Causes
1. Onset: Sudden
2. Infection
3. Complication of Type 1
Diabetes
Signs and Symptoms
1. Fruity breath
2. Kussmaul's respiration
3. Ketosis
4. Acidosis
5. Electrolyte loss
6. Lethargy
7. Coma
Pathophysiology
DKA is a sudden, life-threatening
complication of Type 1 Diabetes.
Characteristics:
1. Hyperglycemia
2. Dehydration
3. Ketosis
4. Acidosis
Diagnostic Tests
1. Serum glucose
2. Serum ketones
3. Osmolarity
4. Electrolyte level
5. BUN level
6. Creatinine level

Nursing Management
1. Monitor glucose levels
Treatment 2. Administer IV insulin as prescribed
1. IV fluid replacement 3. Administer IV fluids
2. IV insulin: treat 4. Monitor potassium levels
5. Monitor cardiac status
hyperglycemia
6. Monitor signs of increased
3. Correct electrolyte intracranial pressure
imbalance: Monitor
potassium levels

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Disease: Hyperosmolar Hyperglycaemic State (HHS) Pancreas

Risk Factors/Causes Pathophysiology
1. Onset: Gradual
2. Infection
3. Complication of Type 2
Diabetes
Signs and Symptoms
1. Dehydration
2. Hyperglycemia
3. Electrolyte loss
4. Dry skin
5. Lethargy
Hyperosmolar Hyperglycaemic State
(HHS) is a complication of Type 2
Diabetes.
Characteristics:
1. Extreme hyperglycemia
2. There is no presence of ketosis or
acidosis
Diagnostic Tests
1. Serum glucose: >800mg/dL
2. Serum ketones: negative
3. Osmolarity
4. Electrolyte level
5. BUN level: elevated
6. Creatinine level: elevated

Nursing Management
1. Monitor glucose levels
Treatment 2. Administer IV fluids
1. IV fluid replacement 3. Monitor electrolyte levels
2. Insulin: If applicable 4. Administer insulin if applicable
3. Correct electrolyte
imbalance

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Disease: Hypoglycemia Pancreas

Risk Factors/Causes Pathophysiology
1. Too much insulin or Hypoglycemia occurs when there is a
diabetic medication sudden decrease of blood glucose level
2. Skipping meals <60 mg/dL.
3. Increased physical
activity
Mild: <60mg/dL
Moderate: <40mg/dL
Signs and Symptoms Severe: <20mg/dL
1. Confusion
2. Palpitations
3. Blurred vision Diagnostic Tests
4. Inability to concentrate
1. Serum glucose
5. Fatigue
2. Physical assessment
6. Body weakness
7. Lightheadedness
8. Diaphoresis
9. Cold and clammy skin
Remember: The symptoms
depends on the level of the
blood glucose.
Nursing Management
1. Assess glucose level
Treatment 2. Administer 15g of simple carbohydrates
1. Simple carbohydrates 3. Recheck blood glucose level in 15 minutes
4. Administer 15 g of simple carbohydrates if
2. Glucagon (IV,IM) necessary.
3. 50% Dextrose (IV) 5. If blood glucose level is still <60mg/dL or in
severe cases (altered LOC): Administer 50%
dextrose (IV)

Unconscious patients:(DO NOT ADMINISTER ORAL

FOOD OR FLUID)
1. Assess glucose level
2. Administer Glucagon (IV,IM) or 50% Dextrose
(IV)
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Disease: Hyperglycemia Pancreas

Risk Factors/Causes Pathophysiology
1. Diet Hyperglycemia occurs when there is an
2. Inactivity increase in blood glucose >200mg/dL
3. Not taking
insulin/diabetic
medication

Signs and Symptoms

1. Polyuria
2. Polyphagia
3. Polydipsia Diagnostic Tests
4. Dehydration 1. Serum glucose
5. Blurred vision 2. Physical assessment
6. Fruity breath 3. Urinalysis
7. Dry skin

Nursing Management
1. Assess glucose level
Treatment 2. Insulin administration as prescribed
1. Insulin
2. Glucose monitoring Education
3. Diabetic diet 1. Educate patient on glucose
monitoring
2. Educate patient on diabetic diet
3. Educate patient on exercise.

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ADRENAL CORTEX DISORDERS
TABLE OF CONTENT
1. Addison's Disease
2. Cushings

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Disease: Addison's Disease Adrenal Cortex

Risk Factors/Causes Pathophysiology
1. Autoimmune disease Addison's disease is the inadequate
production of steroid hormones by the
adrenal cortex.

Addisonian Crisis: life-threatening

condition. Caused by stress, infection or
surgery.
Signs and Symptoms
1. Weight loss
2. Fatigue
3. Lethargy
4. Hypotension
Diagnostic Tests
1. ACTH stimulation test
5. Hyperkalemia
2. Elevated Potassium, Calcium levels
6. Hypercalcemia
3. CT Scan
7. Hyponatremia
8. Hyperpigmentation 4. MRI

Nursing Management
1. Monitor BP
Treatment 2. Monitor daily weights
Pharmacology 3. Monitor intake and output
4. Monitor electrolyte level
1. Glucocorticoid
5. Monitor glucose level
2. Mineralocorticoid 6. Administer medications as prescribed

Addisonian Crisis:
1. Administer glucocorticoids IV

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Disease: Cushings Adrenal Cortex

Risk Factors/Causes Pathophysiology
1. Adrenal tumor Cushing syndrome is the excessive level of
adrenocortical hormones (cortisol).

Remember: Addison's disease is the

hyposecretion of steroids. Cushing
syndrome is the hypersecretion of steroids.

Signs and Symptoms

1. Moon face
2. Buffalo hump
3. Truncal obesity
4. Hypertension
Diagnostic Tests
1. Stimulation test
5. Hyperglycemia
2. Electrolyte levels
6. Hypernatremia
3. CT Scan
7. Hypocalcemia
8. Hypokalemia 4. MRI
9. Masculine features
(Hirsutism)

Nursing Management
1. Monitor BP
Treatment 2. Monitor daily weights
1. Chemotherapeutic 3. Monitor intake and output
4. Monitor electrolyte level
agents: for adrenal
5. Monitor glucose level
tumors 6. Administer medications as prescribed
2. Glucocorticoid 7. Prepare patient for adrenalectomy if
replacement: lifelong applicable

Surgical intervention:
1. Adrenalectomy
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PITUITARY GLAND DISORDERS
TABLE OF CONTENT
1. Hypopituitarism
2. Hyperpituitarism
3. Diabetes Insipidus
4. SIADH

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Disease: Hypopituitarism Pituitary

Risk Factors/Causes Pathophysiology
1. Pituitary tumor Pituitary gland is located at the base of
2. Head injury the brain.
3. Stroke Hypopituitarism is the hyposecretion of
4. Autoimmune pituitary hormones.
5. Encephalitis Hormones that may be affected:
1. Growth hormone (GH)
2. Luteinizing hormone (LH) and follicle-
stimulating hormone (FSH)
3. Thyroid-stimulating hormone (TSH)
Signs and Symptoms 4. Adrenocorticotropic hormone (ACTH)
Signs and symptoms depend 5. Anti-diuretic hormone (ADH)
on the hormone affected.

Growth Hormones: Diagnostic Tests

1. Obesity, Decreased BP 1. Blood test: Hormonal level
TSH
2. ACTH stimulation test
1. Obesity, Fatigue,
decrease BP 3. CT Scan
ACTH 4. MRI
1. Sexual dysfunction
Gonadotropins
1. Sexual dysfunction
ADH
1. Low BP, Decreased CO Nursing Management
1. Daily weights
Treatment 2. Hormonal replacement may be
Pharmacology prescribed
3. Provide emotional support
1. Hormone replacement
4. Allow patient to verbalize feelings

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Disease: Hyperpituitarism/ Acromegaly Pituitary

Risk Factors/Causes Pathophysiology
1. Pituitary Tumors Pituitary gland is located at the base of
the brain.
Hyperpituitarism is caused by the
hypersecretion of growth hormone.

Signs and Symptoms

1. Enlarged Organs
2. Large hands and feet
3. Hypertension
4. Cardiomegaly
Diagnostic Tests
1. Oral Glucose Tolerance Test
5. Oily skin
2. IGF-1
6. Diaphoresis
3. CT Scan
7. Hyperglycemia
8. Husky-sounding voice 4. MRI
9. Sleep apnea
10. Joint pain

Nursing Management
1. Administer medication
Treatment 2. Prepare patient for hypophysectomy if
Pharmacology applicable
3. Provide emotional support
1. Growth Hormone
4. Pain management
Receptor Antagonist
Surgical Intervention
1. Hypophysectomy:
removal of pituitary
tumor

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Disease: Diabetes Insipidus Pituitary

Risk Factors/Causes Pathophysiology
1. Stroke Diabetes Insipidus is characterized by the
2. Trauma hyposecretion of ADH. This results in
3. Craniotomy abnormal increase in urine output.

Remember: Antidiuretic hormone (ADH)

causes the kidneys to release less water.
If ADH level is low, there is an increase in
water loss.
Signs and Symptoms
1. Polyuria
2. Diluted urine
3. Dry mucous membranes
4. Postural hypotension
Diagnostic Tests
1. Water deprivation test
5. Tachycardia
2. Increased BUN
6. Low urinary specific
3. Low urinary specific gravity
gravity
7. Headache
8. Body weakness
9. Fatigue

Nursing Management
1. Monitor fluids and electrolytes
Treatment 2. Monitor weights
Pharmacology 3. Monitor intake and output
4. Monitor skin integrity
1. Desmopressin
5. Administer hypotonic saline (IV)
acetate/Vasopressin 6. Administer medications as prescribed
IV Therapy
1. IV hypotonic saline

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Disease: SIADH Pituitary

Risk Factors/Causes Pathophysiology
1. Stroke Syndrome of Inappropriate Antidiuretics
2. Trauma Hormone Secretion (SIADH) is the secretion
3. Lung disease of ADH in excess levels. This results in
water retention.

Remember: Antidiuretic hormone (ADH)

causes the kidneys to release less water.
If ADH is high, there is an increase in water
retention.
Signs and Symptoms
1. Fluid overload
2. Weight gain
3. Hypertension Diagnostic Tests
4. Hyponatremia 1. Urine osmorality
5. Tachycardia 2. Serum Sodium levels
6. Concentrated urine
7. Low urinary output
8. Nausea/Vomiting

Nursing Management
1. Monitor BP/P
Treatment 2. Monitor serum Na levels
Pharmacology 3. Initiate seizure precautions
1. Loop diuretics 4. Restrict fluid intake
5. Monitor weights
2. Vasopressin
6. Elevate HOB
antagonists 7. Administer medications as
prescribed

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 SKELETAL DISORDERS
TABLE OF CONTENT
1. Gout
2. Rheumatoid Arthritis
3. Osteoarthritis

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Disease: Gout Skeletal

Risk Factors/Causes Pathophysiology
1. Diet Gout is a systemic disorder characterized
2. Obesity by elevated uric acid and urate crystals
3. Kidney disease that accumulate deposits in the joints and
other body tissues.

Stages
1. Asymptomatic stage
2. Acute Gouty arthritis
3. Chronic Gout
Signs and Symptoms
1. Joint pain (Intense) Complications: Kidney stones
2. Inflammation
3. Swelling and redness Diagnostic Tests
4. Low grade fever 1. Uric acid level
5. Pruritus
2. X-ray imaging
6. Tophi
3. Joint fluid test

Nursing Management
1. Assess ROM
Treatment 2. Diet: low-purine
Pharmacology 3. Encourage fluid intake
(2000mL/day)
1. Analgesics
4. Administer medications
2. Anti-inflammatory 5. Provide comfort and
Agents nonpharmacologic interventions

3. Uricosuric Agents

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Disease: Rheumatoid Arthritis Skeletal

Risk Factors/Causes Pathophysiology
1. Higher risk in women Rheumatoid Arthritis is an autoimmune
2. Age: Onset is most disorder.
frequent between the The immune system attacks the joints,
ages of 40-50 leading to dislocation and permanent
deformity.

Signs and Symptoms

1. Joint stiffness
2. Joint tenderness
3. Joint deformity
4. Pain (moderate to
Diagnostic Tests
1. Xray
severe)
5. Rheumatoid nodules 2. Rheumatoid Factor: Blood test
6. Fatigue
(Negative or <60 units/mL)
7. Fever
8. Weight loss

Nursing Management
Treatment
Pharmacology
1. NSAIDs
2. Glucocorticoids
3. DMARDs: Disease-
modifying antirheumatic
drugs
Surgical Intervention
A surgical intervention
would be recommended
to restore function.
1. Assess pain
2. Administer medications as prescribed
3. Assess ROM
4. Provide nonpharmacologic pain
management such as positioning, heat
or cold therapy.
5. Assess and assist patient with self care
6. Promote energy conservation
7. Pre and post operative care if applicable
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Disease: Osteoarthritis Skeletal

Risk Factors/Causes Pathophysiology
1. Aging Osteoarthritis is the most common
2. Obesity form of arthritis.
3. Genetics Osteoarthritis causes deterioration of
joint cartilage.

Signs and Symptoms

1. Joint pain
2. Joint stiffness
3. Crepitus Diagnostic Tests
4. Swelling 1. MRI
5. Limited ROM
2. Joint fluid analysis
Temperature affects
symptom severity.

Nursing Management
1. Assess pain
Treatment 2. Administer medications as
Pharmacology prescribed
1. NSAIDs 3. Assess ROM
2. Acetaminophen 4. Provide non-pharmacologic pain
3. Muscle relaxant management
Therapy 5. Encourage balance between rest
1. Physical therapy and physical therapy (low impact
Surgical Intervention:
exercises).
May be required

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 HEMATOLOGY DISORDERS
TABLE OF CONTENT
1. Iron Deficiency Anemia
2. Thrombocytopenia

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Disease: Iron Deficiency Anemia Hematology

Risk Factors/Causes Pathophysiology
1. Diet Iron deficiency anemia is characterized by
2. Blood loss (GI bleeds) insufficient iron which leads to depletion of
3. Pregnancy red blood cells. This results in decreased
4. Mensuration hemoglobin and decreased oxygen-
5. Inability to absorb iron carrying capacity of the blood.

Signs and Symptoms

1. Fatigue
2. Pallor
3. Brittle nails
Diagnostic Tests
1. CBC
2. Hematocrit
3. Hemoglobin
4. RBC size: smaller
5. Serum iron levels
6. Stool testing
7. Ferritin
Nursing Management
1. Administer Iron supplements as
Treatment prescribed (Oral, IM or IV)
1. Iron supplement 2. Educate patient on the side effects of
2. Treatment of underlying iron supplements: Constipation and black
cause stools
3. Diet: Iron-rich foods 3. Educate patient on iron-rich diet/foods
4. Educate patient to increase vitamin C
consumption in their diet
5. Educate patient to take liquid iron
supplements with a straw to prevent
teeth staining.

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Disease: Thrombocytopenia Hematology

Risk Factors/Causes Pathophysiology
1. Bone marrow disease Platelets (thrombocytes) stops bleeding by
2. Autoimmune disease clumping and forming plugs in the blood
vessel injury site.
3. Splenomegaly
4. Alcoholism Thrombocytopenia is a condition
5. Anemia characterized by low blood platelet count.

Causes:
1. Platelet destruction: autoimmune
2. Platelet sequestration: trapped platelet
Signs and Symptoms in the spleen (enlarged spleen)
3. Decreased platelet production: bone
1. Easy bruising (Purpura) marrow disease.
2. Petechia
3. Prolonged bleeding time
4. Bleeding gums
Diagnostic Tests
1. Platelet count: <150,000
5. Epistaxis (Nose bleeds)
2. Increase INR & PT/PTT
6. Blood in urine or stools
3. Physical examination and patient
7. Heavy menstrual flows
history

Nursing Management
1. Monitor lab values
Treatment 2. Monitor INR, PT/PTT
1. Platelet transfusions 3. Use electric razors
2. Corticosteroid treatment 4. Avoid anticoagulants, aspirin and
3. Bone marrow transplant. thrombolytics
5. Protect patient from falls/injury

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 REPRODUCTIVE DISORDERS
TABLE OF CONTENT
1. PCOS
2. Endometriosis
3. Pelvic Inflammatory Disease

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Disease: PCOS Reproductive

Risk Factors/Causes Pathophysiology
1. Excess androgen Polycystic ovary syndrome (PCOS) is a
2. Heredity hormonal disorder characterized by excess
androgen levels.

The ovaries may develop follicles.

Signs and Symptoms

1. Diabetes
2. Infertility
3. Sleep apnea Diagnostic Tests
4. Irregular periods 1. Pelvic examination
5. Polycystic ovaries 2. Ultrasound

Nursing Management
1. Educate patient on the importance
Treatment of
1. Diet a. Weight loss
2. Weight loss b. Low fat diet
3. Metformin c. Medication adherence
4. Oral contraceptives d. Glucose monitoring
5. Anti-androgens

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Disease: Endometriosis Reproductive

Risk Factors/Causes Pathophysiology
1. No known cause Endometriosis occurs when the tissues
lining the uterus grows outside the uterus.
With endometriosis, the tissues outside
the uterus thickens, breaks down and
bleeds with each menstrual cycle.

Signs and Symptoms

1. Dysmenorrhea
2. Painful intercourse
3. Excessive bleeding
4. Infertility
Diagnostic Tests
1. Ultrasound
2. Laparoscopy

Nursing Management
1. Educate patient on
Treatment a. Pain management
1. Hormone therapy b. Anemia
2. Treatment of anemia c. Hormone therapy

Surgical Intervention
1. Hysterectomy

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Disease: Pelvic Inflammatory Disease Reproductive

Risk Factors/Causes Pathophysiology
1. Being sexually active Pelvic inflammatory disease (PID) is an
2. Having multiple infection of the female reproductive
partners organs
3. Unprotected
intercourse

Signs and Symptoms

1. Fever
2. Pelvic pain
3. Increased vaginal Diagnostic Tests
discharge 1. WBC/Urinalysis
2. Medical history
3. Ultrasound
4. Laparoscopy

Nursing Management
1. Educate patient on
Treatment a. Antibiotic regimen
1. Antibiotics b. Protected intercourse
2. Treatment for partner c. Treatment of partner
3. Temporary abstinence d. Temporary abstinence
until treatment is
complete

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 REPRODUCTIVE DISORDER
TABLE OF CONTENT
1. Varicocele

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Disease: Varicocele
Risk Factors/Causes
1. No known risk factors
Signs and Symptoms
1. Dull pain in scrotum
2. Varicocele may be
visible
3. Swelling
Nursing Management
Treatment
Treatment depends on
the severity and
complications
Reproductive
Pathophysiology
Varicocele is the enlargement of the veins
that transport oxygen-depleted blood
away from the testicles.
Diagnostic Tests
1. Physical examination
2. Scrotal Ultrasound
1. Educate patient to
a. Wear athletic supporter to
relieve pressure
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PART 3

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 Table of Content
1. integumentary Disorders

2. DISORDERS OF THE EYES

3. dISORDERS OF THE EARS

4. cancers

5. IMMUNE DISORDERS

6. skeletal disorders

7. PERIPHERAL VASCULAR DISORDERS

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 INTEGUMENTARY
TABLE OF CONTENT
1. pressure ulcers
2. psoriasis
3. acne vulgaris
4. skin cancer
5. frostbite

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Disease: PRESSURE ULCERS SKIN

Causes/Risk Factors Pathophysiology
1. Malnutrition Pressure ulcers- skin integrity is impaired
2. Friction
due to prolonged pressure.
3. Pressure
4. Shear
5. Prolonged immobility
6. Lack of sensory perception
7. Incontinence

Signs and Symptoms

Stage I
Skin remains intact, redness
Stage II
Partial-thickness loss of the
epidermis and some of the dermis
Stage III Diagnostic Tests
Full-thickness loss of the dermis &
subcutaneous tissue. 1. Skin assessment
Stage IV
Full-thickness loss of the skin
(muscle, bone and tendons are
exposed). Slough, eschar,
undermining and tunneling may
be present.
Suspected Deep-Tissue Injury
Localized area of skin is
discolored. Skin feels "boggy".
Skin is intact but there is ischemic
subcutaneous tissue injury below
skin.
Unstageable Nursing Management
Full-thickness tissue loss covered Prevention
by eschar/necrotic tissue/slough
1. Assess patients at risk for developing pressure
ulcers
Treatment 2. Assess skin integrity
1. Wound care- to promote 3. Initiate measures to prevent the development
wound healing of ulcers: adequate nutrition, positioning and
turning immobilized patients every 2 hours,
2. Pain management passive/active ROM exercises, pressure relief
3. Adequate nutrition devices, keeping patient skin dry, preventing
wrinkled sheets, using lotions to keep skin
lubricated
Nursing Interventions
1. Assess wound (location, size, type/amount of
exudate, undermining, tunneling)
2. Provide appropriate wound care (wound
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Disease: PSORIASIS SKIN

Causes/Risk Factors Pathophysiology
1. Stress A chronic, inflammatory skin disorder
2. Infection that causes rapid buildup of skin cells.
3. Weather
4. Skin injury
5. Autoimmune reaction

Signs and Symptoms

1. Itchy skin (Pruritus)
2. Red patches of skin
3. Silvery-white scales
4. Joint pain observed with
psoriatic arthritis
Diagnostic Tests
1. Skin assessment
2. Skin biopsy

Nursing Management
Patient education
1. Educate patient on medication regimen
Treatment 2. Educate the patient to avoid scratching
Pharmacology 3. Provide emotional support
1. Topical Corticosteroids

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Disease: ACNE VULGARIS SKIN

Causes Pathophysiology
1. Excess sebum A chronic skin disorder characterized
production by skin lesions (usually begins at
2. Bacteria puberty).
3. Inflammation Types
1. Comedones
2. Nodules
Signs and Symptoms 3. Papules
1. Whiteheads (closed 4. Pustules
comedones)
2. Blackheads (open Diagnostic Tests
comedones) 1. Skin assessment
3. Painful, red and pus-
filled (Cystic acne)
4. Painful lumps deep
under the skin (nodules)
5. Red small bumps
(papules)
6. Red small bumps with Nursing Management
pus (Pustules) Patient education
1. Educate patient on the use of
Treatment
Treatment goals: oral and topical medications
1. Avoid or lessen skin 2. Educate patient to avoid
damage squeezing the lesions
2. Acne control

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Disease: SKIN CANCER SKIN

Causes/Risk Factors Pathophysiology
1. Excessive sun exposure Skin cancer is the abnormal
2. Exposure to radiation
(malignant) growth of skin cells.
3. Family history of skin
cancer
Types:
1. Basal cell carcinoma
2. Squamous cell carcinoma
Signs and Symptoms 3. Melanoma.
Basal cell carcinoma
1. Pearly, waxy nodule
Squamous cell carcinoma Diagnostic Tests
1. Red nodule 1. Skin assessment
2. Rough, reddish scaly
patch 2. Skin biopsy
3. Oozing/bleeding
Melanoma
1. Irregular border
2. Color: black, brown,
and tan Nursing Management
3. Circular Prevention
1. Educate patient on the causes/risk
Treatment
Surgical interventions:
factors
1. Cryosurgery 2. Educate patient on preventative
2. Curettage practices (sunscreen, wearing
3. Electrodesiccation protective clothing, self assessment
4. Excisional surgery and reporting skin changes)
Other nursing interventions:
1. Provide nursing care for surgical/
nonsurgical interventions
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Disease: FROSTBITE SKIN

Causes Pathophysiology
1. Cold weather Skin cell and tissue damage caused
by prolonged exposure to extreme
low temperatures.
Areas mostly affected:
1. Fingers
2. Toes
Signs and Symptoms 3. Nose
First-degree 4. Ears
Skin redness + edema
Second-degree Diagnostic Tests
Fluid-filled blisters 1. Skin assessment
Third-degree
Blood-filled blisters +
eschar formation
Fourth-degree
Full-thickness necrosis
Nursing Management
1. Rewarming the area affected
2. To prevent tissue damage, avoid
Treatment
1. Rewarming of the skin massaging the area
2. Protecting skin- sterile 3. Monitor for signs of complications
dressing applied loosely
(compartment syndrome)
Pharmacology 4. Administer medications
1. Analgesics
2. Tetanus prophylaxis
3. Antibiotics Patient education
Other treatment depending on
severity:
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 EYES
TABLE OF CONTENT
1. legal blindness
2. cataract
3. glaucoma
4. retinal detachment

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Disease: LEGAL BLINDNESS
Causes/Risk Factors
1. Eye trauma
2. Diabetic retinopathy
3. Cataracts
4. Glaucoma
5. Age (macular
degeneration)
Signs and Symptoms
1. Inability to see (Vision is
20/200 or less in the
better eye or field of
vision is less than 20
degrees)
Nursing Management
Treatment
1. Patient education on
adaptive products and
learning new skills
EYES
Pathophysiology
Vision is 20/200 or less in the better eye
or field of vision is less than 20 degrees.
Diagnostic Tests
1. Visual acuity test
2. Visual field test
1. Orient the patient to the environment
(using a focal point and allowing the
patient to touch objects)
2. Speak to the patient in a normal tone
3. Ensure that you alert the patient when
approaching (and introduce yourself)
4. Assess patient's level of independence
5. Educate patient on the proper use of a
cane
6. Assist patient during ambulation
7. Provide emotional support
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Disease: CATARACTS
Causes
1. Congenital cataracts
2. Traumatic cataracts-due to
injury
3. Senile cataracts- due to
age
4. Secondary cataracts-
arising from another eye
disease
Signs and Symptoms
Early signs
1. Blurred vision
Late signs
1. Double vision
2. White pupils
3. Vision loss-gradual
Nursing Management
Treatment
1. Cataract surgery
Preoperative Medications
1. Cycloplegics & Mydriatics
(ophthalmic medications
that are used to dilate
the pupil)
Postoperative medications
1. Antibiotic eye drops
2. NSAID eye drops
EYES
Pathophysiology
Cataract is the clouding or opacity of
the lens of eye.
Diagnostic Tests
1. Visual acuity test
2. Retinal exam
3. Slit Lamp
1. Assess patient's visual acuity
2. Prepare patient for cataract surgery
Medications: Cycloplegics & Mydriatics
3. Postoperative care:
Position: Semi-Fowler's
Assist patient during ambulation
Provide patient safety
Maintain eye patch
4. Patient education
Avoid lifting heavy objects
Avoid eye straining & pressure
Prevent constipation
Medication adherence (eye drops)
The use of sunglasses
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Disease: GLAUCOMA EYES

Risk Factors Pathophysiology
1. >60 years of age Glaucoma (a group of eye diseases) is characterized
by increased intraocular pressure (IOP) and
2. Family history subsequently, damage to the optic nerve.
3. increased IOP
4. Diabetes, HTN In glaucoma, there is fluid buildup which causes
increased eye pressure (due to inadequate
drainage of aqueous humor or overproduction of
aqueous humor)
Normal eye pressure (IOP): 10-21 mm Hg
Complication: blindness
Signs and Symptoms Types:
1. Open-angle glaucoma: most common
Open-angle glaucoma 2. Closed-angle glaucoma- AN EMERGENCY
1. No pain
2. Tunnel vision Diagnostic Tests
Closed-angle glaucoma 1. Tonometry: to measure IOP
1. Eye pain 2. Visual acuity test
2. Blurred vision 3. Gonioscopy: observe drainage
3. Eye redness angle
4. Halos around lights 4. Pachymetry: measure the
Other s/s thickness of the eye's cornea.
1. Increased IOP
Nursing Management
1. Educate patient of the importance of
medication adherence (life-long use)
Treatment 2. Educate patient to avoid
Glaucoma damage cannot be
reversed. Anticholinergic medication
The treatment goal is to
1. prevent complication (vision loss) 3. Educate patient to report any vision
and
2. lower intraocular pressure changes + other developing symptoms
Pharmacology
a. Miotics: cause the pupil to 4. Remember to treat closed-angle
constrict
b. Beta-blockers: decrease IOP glaucoma as a medical emergency
c. Carbonic anhydrase
inhibitors: reduce the
production of fluid in the eye
Surgical Management
1. Trabeculectomy
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Disease: RETINAL DETACHMENT
Causes/Risk Factors
1. Trauma
2. Hemorrhage
3. Aging
4. Family history
5. Myopia
Signs and Symptoms
1. Blurred vision
2. Photopsia- flashes of
light
3. Floating spots
4. The feeling of curtain-
like shadow blocking
portion of the visual
5. Loss of peripheral vision
Treatment
Surgical management:
The goal is to repair the
retina detachment.
The surgical interventions
include:
1. Scleral buckling
2. Laser surgery
3. Cryosurgery
4. Diathermy
EYES
Pathophysiology
Retinal detachment is the separation of
the retina from the epithelial layer.
Complete retinal detachment results in
blindness.
Diagnostic Tests
1. Retinal examination
Nursing Management
1. Providing a calm environment
2. Encouraging bed rest
3. Patch both eyes as prescribed
4. Ensure patient safety
5. Patient education: avoid touching the
eyes, medication adherence, avoid
straining activities
Postoperative management
1. Patch both eyes as prescribed
2. Monitor for any complications
3. Encourage bed rest
4. Prevent straining activities that can
increase IOP
5. Educate patient to follow up & at home
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 EARS
TABLE OF CONTENT
1. Otitis media
2. External otitis
3. Meniere's Disease

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Disease: OTITIS MEDIA
Causes/Risk Factors
1. Age (children)
2. Infant feeding (Bottle-
fed)
Signs and Symptoms
1. Ear pain
2. Fever
3. Fluid drainage from
ears
4. Loss of balance
5. Hearing difficulties
6. Tugging on ear
(children)
7. Irritability (children)
Nursing Management
Treatment
1. Pain management
2. Antibiotic therapy
EARS
Pathophysiology
Otitis media is an
infection/inflammation of the middle
ear (common among children)
Diagnostic Tests
1. Ear examination using an
otoscope
2. Pneumatic otoscope
3. Tympanometry
1. Position child sitting upright
(Fowler's) or on unaffected side
2. Encourage mothers to breastfeed
baby
3. For bottle-fed babies, educate
mother to position baby upright
during feeding
4. Educate mother/adult patient on
antibiotic therapy adherence
5. Monitor for signs of complications
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Disease: EXTERNAL OTITIS EARS

Causes/Risk Factors Pathophysiology
1. Age (common in children) Infection of the structure of the
2. Allergies
external ear canal (common among
3. Skin conditions (eczema
children)
or psoriasis)
4. Injury to ear
5. Irritants: hair spray, etc

Signs and Symptoms

1. Pain
2. Redness
3. Edema Diagnostic Tests
4. Ear Tenderness 1. Ear inspection
5. Blocked ear
6. Itching
7. Exudate

Nursing Management
1. Administer medications as prescribed
2. Provide a calm environment & promote
Treatment rest.
Pharmacology
3. Provide non-pharmacologic pain
1. Antibiotics
2. Corticosteroids
management (apply heating pad to
3. Analgesics affected ear)
4. Educate patient to avoid irritants

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Disease: MENIERE'S DISEASE EARS

Causes/Risk Factors Pathophysiology
1. The cause is unknown Meniere's disease is a disorder of the
2. Infection
inner ear caused by the
3. Genetics
overproduction or decreased
absorption of endolymphatic fluid.

Signs and Symptoms

Major Signs and Symptoms
1. Vertigo-dizziness
2. Uni-lateral Diagnostic Tests
sensorineural hearing 1. Medical history to assess the
loss signs and symptoms
3. Tinnitus-ringing in the 2. Audiometric testing
ear
Other Signs and Symptoms
1. Headaches
2. Nausea and vomiting Nursing Management
1. Provide patient safety
2. Provide a calm environment and bed
Treatment rest
There is no cure. Care provided is 3. Administer prescribed medications
supportive.
(see treatment)
Pharmacology: 4. Low salt diet and fluid restriction as
1. Antihistamines
2. Diuretics prescribed
3. Antiemetics 5. Provide pre and post operative care
4. Tranquilizers 5. Anticholinergics Patient Education
Diet:
1. Low salt diet 1. Low salt diet
2. Avoid alcohol, smoking and caffeine
Surgical Management:
1. Labyrinthectomy
2. Endolymphatic sac, or shunt,
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 CANCER
TABLE OF CONTENT
1. cancer
2. pain
3. breast cancer
4. endometrial cancer
5. ovarian cancer
6. cervical cancer
7. testicular cancer
8. prostate cancer
9. bladder cancer
10. pancreatic cancer
11. gastric cancer
12. lung cancer
13. leukemia
14. lymphoma
15. multiple myeloma

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Disease: CANCER CANCER

Risk Factors/Causes Pathophysiology
1. Genetics Cancer is characterized by abnormal
2. Prolonged sun exposure growth of cells (cells mutate + change in
3. Diet their morphology), whereby it
4. Smoking
proliferates and can metastasize.
5. Chemical + radiation
6. Pollutants
7. Or no known cause
Signs and Symptoms
1. C-hanges in bladder or
bowel
2. A-sore that doesn’t heal
3. U-nusual bleeding or
Diagnostic Tests
discharges 1. Biopsy
4. T-hickening or lumps 2. Physical examination
5. I-ndigestion
6. O-bvious changes in the 3. Imaging: CT scan, MRI, Ultrasound
skin 4. Lab test: Urinalysis, CBC
7. N-agging cough or
hoarseness
8. U-nexplained anemia
Nursing Management
9. S-udden weight loss
1. Initiate infection control
2. Treatment of nausea and vomiting
Treatment 3. Patient education on surgical and non
1. Chemotherapy
surgical interventions
2. Radiation therapy
4. Monitor adverse effects of
3. Surgery
4. Hormone therapy chemotherapy and radiation therapy
5. Pre and post operative care
6. Provide emotional support
7. Pain management

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Disease: PAIN
Risk Factors/Causes
1. Inflammation
2. Psychological factors
3. Compression of nerves
4. Obstruction of an organ
Signs and Symptoms
The best indicator of pain is
through verbalization since it
is a subjective experience
Behavioral & Physiologic
Indicators of Pain
1. Facial grimace
2. Crying/screaming
3. Clench eyes
4. Guarding
5. Vital signs: Increased HR, Nursing Management
BP, RR
Treatment
Treat the underlying cause
of pain.
CANCER
Pathophysiology
According to the International
Association for the Study of Pain, pain is
an unpleasant, subjective sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage.
Diagnostic Tests
1. Pain assessment tools
1. Assess pain
2. Assess the underlying cause of pain
3. Provide pharmacologic pain
management as prescribed
(analgesics, opioids)
4. Non-pharmacologic pain management
a. Physical- positioning
b. Environmental- dimming lights,
providing a calm environment
c. Cognitive technique- Guided
imagery
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Disease: BREAST CANCER
Risk Factors/Causes
1. Age (older women)
2. Gender-women
3. Family history of
breast cancer
Signs and Symptoms
1. Mass-firm irregular mass
that is painless (located
in the upper outer
quadrant of the breast)
2. Asymmetry of the breast
3. Nipple discharge (blood
or clear)
4. Lymphedema
5. Skin changes over the
breast- dimpling
6. Scaling & peeling of the
skin around areola
Nursing Management
7. Orange skin over breast
Treatment
Early detection:
1. Patient education on
Breast-self examination For postoperative interventions
Other interventions:
1. Chemotherapy
2. Radiation therapy
Surgical Interventions:
1. Lumpectomy
2. Mastectomy
3. Mammoplasty
CANCER
Pathophysiology
Breast cancer is the most common type
of cancer diagnosed among women.
Breast cancer common sites of
metastasis are the lungs, bone, liver,
and the brain.
Diagnostic Tests
1. Breast examination
2. Mammography
3. Breast biopsy
1. Patient education on surgical and non
surgical interventions
2. Monitor adverse effects of chemotherapy
and radiation therapy
3. Provide emotional support
1. Monitor vital signs
2. Encourage deep breathing and coughing
3. Monitor for signs of infection
4. Drainage management if any
5. Patient education: home care and follow
up care
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Disease: ENDOMETRIAL CANCER CANCER

Risk Factors/Causes
1. Older age
2. Obesity
3. Family history of
endometrial cancer
4. Hormone therapy
5. Polycystic ovary disease
Pathophysiology
Cancer of the uterus. Endometrial
cancer begins from the endometrium
of the uterus.
Common sites of metastasis: ovaries,
pelvis, lungs, liver and bone.

Signs and Symptoms

1. Postmenopausal
bleeding
2. Pelvic pain-late sign Diagnostic Tests
3. Enlarged uterus 1. Endometrial biopsy
4. Vaginal discharge 2. Hysteroscopy

Nursing Management
1. Patient education on surgical and non
surgical interventions
Treatment 2. Providing emotional support
1. Chemotherapy
2. Radiation therapy
3. Pre and post operative care
3. Hormone therapy 4. Patient education: home care and
follow up plan
Surgical Intervention:
1. Total abdominal
hysterectomy (removal of
the uterus) and bilateral
salpingo-oophorectomy
(removal of both of the
fallopian tubes and ovaries)
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Disease: OVARIAN CANCER CANCER

Risk Factors/Causes Pathophysiology
1. Older age Ovarian cancer arises from the ovaries
2. Family history and has a higher mortality rate.
3. Endometriosis Ovarian cancer grows rapidly and
4. Obesity
spreads quickly.

Signs and Symptoms

1. Abdominal swelling
2. Abdominal
discomfort Diagnostic Tests
3. Constipation (and 1. Elevated CA-125 (tumor marker)
other GI 2. Exploratory laparotomy
disturbances) 3. Transvaginal ultrasound
4. Weight loss

Nursing Management
1. Patient education on surgical and non
surgical interventions
Treatment 2. Providing emotional support
1. Chemotherapy
3. Pre and post operative care
2. Radiation therapy
4. Supportive and palliative care
Surgical Intervention:
1. Total abdominal
hysterectomy and
bilateral salpingo-
oophorectomy
Palliative care

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Disease: CERVICAL CANCER
Risk Factors/Causes
1. HPV-Human
papillomavirus
2. Early sexual activity
3. Smoking
4. Multiple sexual partners
Signs and Symptoms
1. Vaginal discharge
(foul odor)
2. Painful urination
(Dysuria)
3. Blood in urine
(hematuria)
4. Pelvic pain
5. Weight loss
Nursing Management
Treatment
1. Chemotherapy
2. Laser therapy
3. Radiation
4. Cryosurgery
Surgical Management
1. Hysterectomy-removal of the
uterus
2. Conization- removal of the
cylindrical part of the cervix
3. Pelvis exenteration-removal of
organs from the urinary,
gastrointestinal, and
reproductive system.
CANCER
Pathophysiology
The cervix connects the vagina and
uterus. Cervical cancer arises from the
cervix.
Common sites of metastasis is confined
in the pelvis or can occur via lymphatic
spread
Diagnostic Tests
Screening:
1. Pap test
Diagnostic tests
1. Colposcopic examination
2. Biopsy
1. Patient education on surgical and non surgical
interventions
2. Providing emotional support
3. Pre and post operative care
Hysterectomy
1. Monitor vital signs
2. Encourage patient to perform deep breathing
exercises
3. Monitor vaginal bleeding
Pelvis exenteration
1. Educate patient on ileal conduit and
colostomy
2. Sexual counseling
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Disease: TESTICULAR CANCER
Risk Factors/Causes
1. History of cryptorchidism
2. Age (men between 15-
35)
3. Family history
Signs and Symptoms
1. Swelling of the
testicles
2. The sensation of
heaviness in the
scrotum
Late signs
1. Abdominal mass
2. Respiratory
symptoms
3. Bone pain
Treatment
1. Chemotherapy
2. Radiation therapy
Surgical Management
1. Radical inguinal
orchiectomy- removal of a
testicle
2. Retroperitoneal lymph
node dissection- removal
of lymph nodes
CANCER
Pathophysiology
Testicular cancer arises from the
testicles.
Common sites of metastasis: liver,
lungs, bone and adrenal glands.
Diagnostic Tests
Early detection:
1. Testicular self-examination
Diagnostic tests:
1. Testicular ultrasound
2. Blood test- determine levels of tumor
markers
Nursing Management
1. Patient education on surgical and non surgical
interventions
2. Providing emotional support
3. Pre and post operative care
Post operative care
1. Monitor vital signs
2. Monitor for signs of bleeding
3. Monitor for signs of infection
4. Pain management
Patient education
1. Reproductive health/options
2. Avoid heavy lifting
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Disease: PROSTATE CANCER
Risk Factors/Causes
1. Age (>50)
2. Family history
3. Smoking
4. Hx of STI
Signs and Symptoms
1. Hematuria
2. Nocturia
3. Urinary retention
4. Increased urinary
frequency
5. Urinary hesitancy
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
3. Hormone therapy
Surgical Management
1. Prostatectomy
2. Orchiectomy- removal of
testicles
CANCER
Pathophysiology
Prostate cancer is cancer that occurs in
the prostate.
Common sites of metastasis:
surrounding tissues + through the
lymphatics and blood vessels (bone,
liver, lungs & kidneys).
Diagnostic Tests
1. Digital rectal exam
2. Prostate-Specific Antigen will be
elevated (but also in BPH. Further
testing needs to be done)
3. Transrectal ultrasound
4. Biopsy of prostate gland
1. Monitor urinary output (red to light pink
urine would be seen for 24 hours) + monitor
for excessive bleeding
2. Monitor vital signs
3. Encourage increase fluid intake
2000mL/day to 3000 mL/day
4. Maintain continuous bladder irrigation-as
indicated
5. Medications such as antibiotics & analgesics
should be administered as prescribed.
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Disease: BLADDER CANCER
Risk Factors/Causes
1. Family history
2. Smoking
3. Older age
4. Gender-males
Signs and Symptoms
1. Hematuria
2. Painful urination
(Dysuria)
3. Urinary frequency
4. Urinary hesitancy
Treatment
1. Chemotherapy
2. Radiation therapy
Surgical Management
1. Transurethral resection of
bladder tumor (TURBT)
2. Cystectomy
3. Ileal conduit
4. Neobladder reconstruction
5. Kock pouch
6. Indiana pouch
7. Ureterostomy
8. Vesicostomy
CANCER
Pathophysiology
Papillomatous growth in the bladder
urothelium that progress to
malignancy.
Common sites of metastasis: bone,
liver & lungs
Diagnostic Tests
1. Cystoscopy
2. Biopsy
Nursing Management
1. Provide preoperative care
2. Educate patient on the post surgical
interventions.
Postoperative care
1. Assess: stoma, incision site, bowel
function
2. Monitor: urinary output, vital signs, signs
of complication (shock, hemorrhage,
peritonitis), skin integrity around
drainage
3. Notify physician: necrosis of the stoma,
urine output is less than 30mL/hr
4. Maintain NPO status as prescribed
5. Provide emotional support
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Disease: PANCREATIC CANCER CANCER

Risk Factors/Causes Pathophysiology
1. Diabetes Pancreas cancer arises from the
2. Smoking pancreatic tissues (pancreatic ductal
3. Older age adenocarcinoma- the most common
4. Family history type of pancreatic cancer)

Signs and Symptoms

1. Jaundice
2. Weight loss
3. Abdominal pain Diagnostic Tests
4. Stools- clay colored 1. Elevated tumor marker- CA19-9
5. Urine- dark colored 2. An endoscopic ultrasound
6. Nausea and vomiting
Poor prognosis

Nursing Management
1. Provide preoperative care
2. Educate patient on the post surgical
Treatment interventions.
1. Chemotherapy
2. Radiation therapy Postoperative care
1. Monitor blood glucose levels
Surgical Management 2. Pain management
1. Pancreaticoduodenectomy
-Whipple procedure

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Disease: GASTRIC CANCER CANCER

Risk Factors/Causes Pathophysiology
1. H. pylori infection Gastric cancer is the malignant growth
2. Smoking of cells in the stomach.
3. Gastric ulcers/gastritis Complications
4. Alcohol 1. Dumping syndrome
5. Men 2. Hemorrhage
6. Diet 3. Metastasis
Signs and Symptoms
Initial symptoms
1. Dyspepsia
2. Gastric fullness/bloated Diagnostic Tests
3. Epigastric pain 1. Endoscopy
4. Indigestion 2. Biopsy
Late symptoms
1. Weight loss
2. Nausea/vomiting
3. Body weakness
4. Gastric obstruction
Nursing Management
5. Ascites 1. Monitor: VS, hematocrit and
hemoglobin
Treatment 2. Administer vitamin supplements
1. Chemotherapy
3. Pain management
2. Radiation therapy
Postoperative management
3. Palliative care
1. Position: Fowler's
2. Administer parenteral Nutrition as
Surgical Management
prescribed
1. Gastrectomy
3. Monitor : NG suction, intake and
output
4. Maintain NPO status
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Disease: LUNG CANCER CANCER

Risk Factors/Causes Pathophysiology
1. Smoking Lung cancer is also known bronchogenic
2. Air pollutant cancer. Bronchogenic cancer originate
3. Family history in the epithelium of the bronchus.
Types:
1. Squamous cell
2. Adenocarcinoma
Signs and Symptoms 3. Small cell lung cancer (SCLC)
1. Cough 4. Non-small cell lung cancer (NSCLC)
2. Dyspnea
3. Wheezing Diagnostic Tests
4. Blood-tinged sputum 1. Chest x-ray
5. Weight loss 2. CT scan
6. Decreased breath 3. MRI
sounds 4. Fiberoptic bronchoscopy
7. Fatigue/body weakness 5. Sputum cytology
8. Chest pain 6. Biopsy
9. Hoarseness
Nursing Management
1. Maintain patent airway
2. Assess respiratory status
Treatment 3. O2 therapy
1. Chemotherapy 4. Positioning: Fowler's
2. Radiation therapy
3. Oxygen therapy
5. Administer medications
Pharmacology- analgesics, 6. Diet: high-protein, high-calorie diet.
expectorants, bronchodilators, 7. Provide a calm environment
corticosteroids
Surgical Management
1. Laser therapy Postoperative management
2. Thoracentesis- to remove pleural
fluid 1. Maintain patent airway
3. Pneumonectomy-removal of an 2. Monitor vital signs and respiratory status
entire lung
4. Lobectomy-removal of the entire 3. Chest tube management
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Disease: LEUKEMIA
Risk Factors/Causes
1. No known cause
2. Risk factors: genetics,
exposure to chemicals
Signs and Symptoms
1. Fever & frequent
infections
2. Easy bleeding and
bruising
3. Petechiae
4. Anemia
5. Pallor, body weakness,
fatigue and weight loss
6. Enlarged liver, spleen
and lymph nodes
7. Tachycardia,
hypotension, dyspnea
8. Bone pain
Treatment
1. Chemotherapy
2. Radiation therapy
3. Transfusions of red
blood cells and platelets
4. Bone marrow transplant
Pharmacology
1. Antibiotics, antifungal
and antiviral
CANCER
Pathophysiology
Leukemia is a type of cancer that affects the white
blood cells and the bone marrow due to the abnormal
overproduction of leukocytes.
Because leukemia affects the bone marrow, there is an
underproduction of red blood cells, platelets (and
overproduction of immature leukocytes). This therefore
causes anemia, leukopenia, thrombocytopenia and
increased risk for infections due to low immunity.
Types of leukemia:
1. Lymphocytic
2. Myelocytic/myelogenous
Classification
1) Acute Lymphocytic Leukemia 2) Acute Myelogenous
Leukemia 3) Chronic Myelogenous Leukemia 4) Chronic
Lymphocytic Leukemia
Diagnostic Tests
1. CBC
2. Bone marrow aspiration and biopsy
Nursing Management
Infection
1. Initiate infection precautions
2. Care for patient in a private room (protective
isolation)
3. Hand washing and strict aseptic technique
4. Monitor for signs of infection
5. Avoid invasive procedures
6. Avoid constipation, diarrhea and rectal trauma
7. Administer antimicrobials
Bleeding
1. Monitor for signs of bleeding
2. Monitor lab values
3. Administer blood components
4. Ensure patient's safety
Nutrition
1. High calorie, high carbohydrates and high
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Disease: LYMPHOMA CANCER

Risk Factors/Causes Pathophysiology
1. Viral infection Two types of lymphomas: Hodgkin's and
2. Family hx non-Hodgkin's

Lymphoma- cancer of the lymph nodes

and lymphocytes

Spreads through the lymphatic system

involving the lymph nodes, spleen and
Signs and Symptoms then through the blood stream.
1. Enlarged lymph nodes,
spleen and liver
2. Fever + chills Diagnostic Tests
3. Night sweats 1. Lymph node biopsy- shows the
4. Weight loss presence of Reed-sternberg giant
cell
2. CT scan

Nursing Management
1. Initiate infection & bleeding
precautions
Treatment 2. Monitor side effects due to
1. Chemotherapy
chemotherapy and radiation therapy
2. Radiation therapy

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Disease: MULTIPLE MYELOMA
Risk Factors/Causes
1. No known cause
2. Risk: Family hx
Signs and Symptoms
1. Bone pain
2. Osteoporosis
3. Thrombocytopenia (low
platelet count)
4. Leukopenia (low white
blood cell count)
5. Anemia
6. Frequent infections
7. Fatigue
Treatment
1. Chemotherapy
2. Radiation therapy
3. Blood transfusion
Pharmacology
1. Antibiotics
2. Analgesics
3. Diuretics: increase the
excretion of Ca
4. Bisphosphonate: slow down
or prevent bone loss
CANCER
Pathophysiology
Multiple myeloma is characterized by
cancerous plasma cells that accumulate
within the bone marrow.
The accumulation of plasma cells in the
bone marrow causes decrease
production of immunoglobulin and
antibodies.
The cancerous plasma cells produces
abnormal proteins.
Diagnostic Tests
1. Blood tests
2. Urinalysis: shows Bence Jones
proteinuria
3. Bone marrow aspiration
4. Elevated calcium and uric acid
Nursing Management
1. Ensure patient's safety: monitor for
skeletal fractures (provide skeletal
support)
2. Initiate infection & bleeding precautions
3. Increase fluid intake
4. Administer medications (see treatment)
Patient education
1. Signs and symptoms of an infection
2. Safety measures at home to prevent
fractures.
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 IMMUNE
TABLE OF CONTENT
1. Allergy
2. Systemic Lupus Erythematosus (SLE)
3. Goodpasture's Syndrome
4. hiv/AIDS
5. Fever

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Disease: ALLERGY IMMUNE

Causes/Risk Factors Pathophysiology
1. Drugs Allergy: An immune response to a
2. Food foreign substance that triggers a
3. Insect reaction.
4. Airborne (pollen)
5. Latex
Latex allergy: hypersensitivity to
latex
Signs and Symptoms Anaphylactic shock: occurs due to a
1. Hives severe allergic reaction (drugs, food,
2. Itching skin insect bite, etc)
3. Sneezing Diagnostic Tests
4. Wheezing 1. Skin test
5. Tearing, red or swollen 2. Blood test
eyes 3. History taking
6. Swelling of the lips,
tongue, face or throat

Nursing Management
1. Identify and remove allergen
2. Maintain patent airway
Treatment 3. Administer medications (see treatment)
Anaphylactic Reaction
Pharmacology 1. Remove allergen, maintain patent
1. Antihistamines airway
2. Corticosteroids 2. Monitor vital signs
3. Administer epinephrine promptly
3. Anti-inflammatory 4. Initiate 02 therapy
agents 5. Initiate IV therapy & monitor urine
output
Anaphylaxis: 6. Position: supine position with leg
1. Epinephrine elevated
Patient education
1. Educate patient to avoid allergen
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Disease: Systemic Lupus Erythematosus (SLE) IMMUNE

Causes/Risk Factors Pathophysiology
1. No known cause Systemic Lupus Erythematosus (SLE) is
Risk factors: a chronic, inflammatory autoimmune
1. Genetics disease where the body attacks
2. Environmental
healthy tissues.
3. Hormonal
4. Medications

Signs and Symptoms

1. Butterfly rash on the
face
2. Joint pain/swollen joints Diagnostic Tests
3. Fever
1. Positive antinuclear antibody (ANA)
4. Fatigue
2. Elevated erythrocyte
5. Sensitivity to sunlight
sedimentation rate and C-reactive
6. Weight loss
7. Hair loss protein level
8. Chest pain when 3. CBC
breathing 4. Urinalysis
9. Edema
Nursing Management
10. Raynaud’s phenomenon 1. Monitor skin integrity, signs of bruising and
bleeding, intake and output, signs of
Treatment complications, BUN and creatinine
There is no cure for SLE. The goal is to 2. Encourage deep breathing exercises.
control symptoms and provide 3. Pain management (pharmacologic and non-
supportive care when major organs pharmacologic management).
are affected.
Pharmacology 4. Administer medications (see treatment)
1. NSAIDs 5. Diet: high-iron, high-protein (unless
2. Topical corticosteroids contraindicated)
3. Systemic Corticosteroids
4. Immunosuppressants (for serious
6. Provide emotional support
cases) Patient Education
5. For anemia: iron, folic acid 1. Avoid prolong exposure to sunlight
6. Antimalarials 2. Healthy diet
(Hydroxychloroquine)
Pain management 3. Adequate rest
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Disease: Goodpasture's Syndrome IMMUNE

Causes/Risk Factors
1. No known cause
Risk factors:
1. Genetics
2. Environmental factors
Pathophysiology
Goodpasture's syndrome is a rare,
autoimmune disease that forms
autoantibodies and attack the
basement membranes of the lungs and
kidneys.

Signs and Symptoms

Lung-related symptoms:
1. Shortness of breath
2. Cough
Diagnostic Tests
3. Chest pain
1. Serum anti-GBM antibody tests
4. Hemoptysis (coughing up
blood) 2. Urinalysis
Kidney-related symptoms 3. CT scan, chest X-ray
1. Edema 4. Bronchoscopy
2. Weight gain 5. Kidney biopsy
3. Oliguria
4. Hematuria
5. Increased BP Nursing Management
6. Increased HR 1. Monitor respiratory status
2. Elevate head of bed
Treatment 3. Oxygen therapy as prescribed
Pharmacology
4. Deep breathing exercises
1. Corticosteroids
5. Administer medications as prescribed
2. Immunosuppressant drugs
6. Monitor weights and I/O, creatinine
Plasma exchange
(plasmapheresis) and BUN
7. Diet: low protein diet

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Disease: HIV/AIDS
Causes/Risk Factors
High risk groups:
1. Use of IV drugs
2. Multiple sexual
partners + unprotected
sex
3. Receiving blood
products
Signs and Symptoms
Primary infection (Acute HIV)
Two to four weeks (up to 3
months)
1. Flu-like illness
Clinical latent infection (Chronic
HIV)
1. Infected person do not have
any symptoms of HIV
infection (can last for 10
years or longer)
Progression to AIDS
1. Fever, weight loss, fatigue
2. Night sweats, chills, swollen
lymph nodes
3. Diarrhea, nausea & vomiting
4. Opportunistic Infections
Treatment
Pharmacology
1. Anteroviral drugs
a. Reverse
trancriptase
inhibitors Patient Education
b. Protease inhibitors 1. Proper nutrition
2. Compliance to treatment
3. Skin care
IMMUNE
Pathophysiology
Acquired immunodeficiency syndrome
(AIDS) is a chronic illness caused by the
human immunodeficiency virus (HIV) which
attacks the T cells.
Mode of transmission:
1. Sexual contact
2. Blood and blood products (& sharing of
needles)
3. Mother to baby- preventive treatment
to reduce the risk of transmission.
Diagnostic Tests
1. ELISA Test & Western Blot
2. Viral load: polymerase chain
reaction (PCR)
3. T lymphocyte and B lymphocyte
subsets; CD4 counts, CD4
percentages
Nursing Management
1. Provide respiratory support (monitor
respiratory status + O2 therapy)
2. Initiate protective isolation
precautions
3. Practice universal/standard precaution
4. Provide emotional support
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Disease: Fever IMMUNE

Causes/Risk Factors Pathophysiology
1. Infections Fever is the elevation in body
2. Inflammatory diseases temperature.
3. Prolong exposure to
hot environment (may Temperature:
cause hyperthermia) Normal: 36.4-37.0 (degrees
celsius)
Fever: >38.0 (degrees celsius)
Signs and Symptoms
1. Temperature: >38.0
(degrees celsius)
2. Skin: warm, flushed Diagnostic Tests
3. Lethargy
1. Increased temperature
4. Chills
5. Sweating 2. High White Blood Cell Count (due
6. Malaise to an infection)

Nursing Management
1. Monitor temperature
2. Assess and treat underlying cause
Treatment 3. Non-pharmacologic management:
Treat underlying cause remove excess clothing, cooling
(infection) measures, sponge bath.
Pharmacology 4. Increase fluid intake
1. Antipyretics 5. Medications: Antipyretics

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 MUSCULOSKELETAL DISORDERS
TABLE OF CONTENT
1. Osteoporosis
2. STRAINS
3. SPRAINS
4. FRACTURES

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Disease: Osteoporosis
Causes/Risk Factors
1. Gender: among
postmenopausal women
2. Age
3. Family history
4. Low calcium intake
5. Sedentary lifestyle
6. Smoking
Signs and Symptoms
1. Asymptomatic during
early stages
2. Back & hip pain
3. Decline in height
4. Kyphosis of the dorsal
spine
Nursing Management
Treatment
1. Diet- increased calcium
and vitamin D
Pharmacology
1. Calcium supplements
2. Bone resorption inhibitor
3. Analgesics Patient education
2. The use of assistive devices
MSD
Pathophysiology
Osteoporosis- a metabolic disorder
that is defined as bone
demineralization.
Bone mass decreases- which causes
the bone to become porous & fragile
(risk for fractures).
Diagnostic Tests
1. Bone mineral density (BMD)
2. Bone x-rays
3. Serum calcium level
1. Ensure patient safety
2. Move patient gently when
repositioning
3. Encourage ROM exercises
4. Diet- high in calcium, vitamin D, protein
and iron
5. Administer medications (see treatment)
1. Proper body mechanics
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Disease: STRAINS MSD

Causes/Risk Factors Pathophysiology
1. Poor body mechanics Strains- Injury to the muscle or
2. Higher risk among
athletes tendons due to overstretching.

Signs and Symptoms

1. Ecchymoses (bruising)
2. Pain or tenderness
3. Swelling Diagnostic Tests
1. Physical examination
2. X-ray
3. MRI

Nursing Management
1. Heat and cold application
2. Encourage the patient to rest to
Treatment promote healing
Pharmacology
3. Administer medications as prescribed
1. Antiinflammatory
medications
2. Analgesics
3. Muscle relaxants
For severe strains- surgical
repair

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Disease: SPRAINS MSD

Causes/Risk Factors Pathophysiology
1. Direct or indirect injury A sprain is a stretching or tearing of
2. Higher risk among
athletes ligaments.

Signs and Symptoms

1. Pain
2. Swelling
3. Limited joint Diagnostic Tests
1. Physical examination
movement
2. Xray
3. MRI

Nursing Management
1. Encourage the patient to rest to
promote healing
Treatment 2. Apply ice packs to affected joint
Management:
3. Elevate limb
Rest, ice, compression and
elevation (RICE) 4. Assist in applying with tape, splint or
Pharmacology cast
1. Antiinflammatory 5. Administer medications as prescribed
medications
2. Analgesics
3. Muscle relaxants
Moderate Sprain- cast
Severe Sprain- Surgery
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Disease: FRACTURES MSD

Causes/Risk Factors Pathophysiology
1. Injury A fracture is a broken bone. There is a break in the continuity of
2. Persons with the bone structure.
Types
osteoporosis 1. Closed fracture: bone break without open wound in skin.
2. Open fracture (compound): fracture with an open wound.
3. Complete fracture: complete break through the bones that
separates into two.
4. Incomplete fracture: the bone doesn't break completely.
5. Comminuted fracture: break into more than two fragments.
6. Greenstick: one side of the bone is broken, the other side is
bent
7. Transverse fractures: fracture straight across the bone.
Signs and Symptoms 8. Oblique: fracture that run at an angle across
9. Spiral: fracture that circles or spirals around the shaft.
1. Pain 10. Impacted: a part of the bone that impact another bone
11. Compression: one bone compresses another bone
2. Loss of
function/deformity Diagnostic Tests
1. X-ray
3. Crepitus
2. CT
4. Edema
3. MRI
5. Ecchymosis (skin
discoloration)

Nursing Management
1. For open fractures, cover wound with sterile
dressing
2. Assess neurovascular status
Treatment 3. Provide pharmacologic and non-pharmacologic
1. Reduction pain management
Traction care:
2. Fixation 1. Ensure that the traction weight bag is hanging
3. Traction freely.
2. Monitor for any complication of immobilization.
4. Cast 3. Assess skin integrity
Pharmacology Casts:
1. Monitor for circulatory impairment
1. Analgesics 2. Assess skin integrity
3. Educate the patient to avoid placing any
object inside the casts.
Prevent and manage potential complications.
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TABLE OF CONTENT
1. PERIPHERAL ARTERIAL DISEASE
2. PERIPHERAL VENOUS DISEASE

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PERIPHERAL
Disease: PERIPHERAL ARTERIAL DISEASE VASCULAR DISORDERS
Causes/Risk Factors Pathophysiology
1. Smoking Arterial narrowing or occlusion
2. Diabetes (arteriosclerosis) which causes O2
3. Hypertension and nutrients to the lower
4. High blood cholesterol extremities.
level
Leads to tissue damage (ischemia +
necrosis)
Signs and Symptoms
1. Pain (sharp)
2. Absent pulse
3. Skin:
a. cool to touch Diagnostic Tests
b. pale skin
c. absent hair + shiny 1. Ankle-brachial index (ABI)
skin 2. Doppler ultrasound
d. thin, dry + scaly skin
e. no edema
4. Lesions:
a. Red sores on the
toes/feet
b. punched out
appearance
5. Gangrene (death of Nursing Management
tissues) 1. HANG (DANGLE) the patient's legs

Treatment
Pharmacology
1. Antiplatelets
2. Cholesterol-lowering
drugs
Surgical Intervention
1. Angioplasty
2. Bypass surgery
3. Endarterectomy
an "a" shape
2.Monitor pain
a= PAD
3.Monitor for any signs of gangrene
4. Provide a warm environment + warm clothing
5. Do NOT apply direct heat to the extremities
(such as heating pads.
6. Administer medications as prescribed
Patient Education
1. Avoid caffeine + smoking (due to vasoconstrictive
effects)
2. Skin assessment
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PERIPHERAL
Disease: PERIPHERAL VENOUS DISEASE VASCULAR DISORDERS
Causes/Risk Factors Pathophysiology
1. Smoking Pooling of blood in the extremities
2. Diabetes
3. Hypertension
due to the inability to bring blood
4. High blood cholesterol back to the heart (vascular
level insufficiency)

Signs and Symptoms

1. Pain (achy + dull)
2. Presence of a strong
pulse
3. Skin:
Diagnostic Tests
a. presence of edema 1. Ankle-brachial index (ABI)
b. Warm legs 2. Doppler ultrasound
c. yellow/brown
ankles
4. Lesions:
a. irregular shaped
sores
5. No presence of Nursing Management
gangrene 1. ELEVATE the patient's legs

Treatment
v= PvD
Pharmacology v shape
1. Antiplatelets
2. Cholesterol-lowering
drugs 2. Administer medications as prescribed
Surgical Intervention
Patient Education
1. Angioplasty 1. Avoid caffeine + smoking (due to
2. Bypass surgery vasoconstrictive effects)
2. Skin assessment
3. Endarterectomy 3. Hydration

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CRITICAL CARE conditions
PART 4

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 Table of Content
1. respiratory disorders

2. neuro disorders

3. cardiovascular disorders

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 RESPIRATORY
TABLE OF CONTENT
1. PULMONARY EMBOLISM
2. ACUTE RESPIRATORY DISTRESS SYNDROME

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Disease: PULMONARY EMBOLISM RESPIRATORY

Causes Pathophysiology
1. Blood clots Pulmonary embolism is the
2. Fat, Tumor obstruction/blockage of a pulmonary
3. Air emboli (due to IV artery mostly caused by blood clots
therapy) (travel from the deep vein in the legs to
Risk Factors: the lungs)
DVT, Surgery, prolonged
immobility, trauma
Signs and Symptoms
1. Sudden SOB
2. Chest pain (sharp)
3. Tachycardia Diagnostic Tests
4. Hypotension 1. Pulmonary angiogram
5. Cool and clammy skin 2. CT pulmonary angiography
6. Cough (bloody 3. Ventilation-perfusion scan
sputum) 4. Chest X-ray
7. Dizziness 5. MRI
8. Fever
Nursing Management
1. Assess respiratory rate, depth and
pattern
Treatment
2. Administer O2 therapy as ordered
Pharmacology
3. Position: High Fowler's
1. Anticoagulants:
4. Active/passive leg exercises
prevent clot formation
5. Monitor thrombolytic and
2. Thrombolytics: dissolve
anticoagulant therapy (coagulation
clots studies)
Surgical Interventions:
1. Surgical embolectomy:
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Disease: ACUTE RESPIRATORY DISTRESS SYNDROME RESPIRATORY

Causes Pathophysiology
Direct Injury ARDS is characterized by the build up of fluid
1. Trauma to the chest in the alveoli. This results in decreased gas
2. Smoke and toxic chemical exchange and leads to deprivation of
inhalation oxygen to the vital organs.
3. Aspiration, drowning
3 PHASES: exudative, proliferative, and
Indirect Injury
1. Sepsis, 2. Pancreatitis, 3. fibrotic
Blood transfusion, 4. Drug 1. Exudative phase: leakage of fluid +
overdose protein to the alveoli lumen (pulmonary
edema)
Signs and Symptoms 2. Proliferative phase: repair of damaged
alveolar structure
1. Rapidly progressive 3. Fibrotic phase: Damage and fibrosis of
dyspnea the alveoli and lung tissues.
2. Tachypnea Diagnostic Tests
3. Hypoxemia 1. Blood test to measure oxygen
4. Crackles level
5. Tachycardia 2. Chest x-ray
6. Altered mental status 3. Echocardiogram- to rule out heart
7. Cyanosis failure

Nursing Management
1. Maintain patent airway
2. Monitor respiratory status
Treatment
3. Administer supplemental oxygen as
1. Mechanical ventilation
prescribed
using PEEP (PEEP
maintains the patient's 4. Position: Prone position
airway pressure) 5. Administer medications as prescribed
2. Supplemental oxygen 6. Prepare patient for intubation &
Pharmacology mechanical ventilation using PEEP
1. Diuretics
2. Anticoagulants
3. Corticosteroids
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 NEURO
TABLE OF CONTENT
1. increased intracranial pressure
2. spinal cord injury
3. AUTONOMIC DYSREFLEXIA
4. cerebral aneurysm
5. traumatic brain injury
6. stroke
7. seizures

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Disease: INCREASED INTRACRANIAL PRESSURE NEURO

Causes Pathophysiology
1. Brain tumor Increased ICP is a rise in the pressure
2. Hydrocephalus inside the skull.
3. Hemorrhage The normal intracranial pressure is
4. Meningitis between 5-15 mmHg.
5. Hematoma
6. Head injury
Signs and Symptoms
1. Altered LOC, Double vision
2. Pupils-dilated, Headache
3. Irregular respiration
4. Vomiting
Diagnostic Tests
Late signs: 1. MRI
1. Increased systolic BP,
decreased HR 2. CT scan
2. Body weakness + decreased
motor function
3. Positive Babinski reflex
4. Posture:
Decorticate/decerebrate
5. Seizures

(Cushing's triad are signs that

indicates increased ICP. This
includes: increased systolic BP,
decreased HR and decreased RR)
Treatment
Pharmacology
1. Antiseizures
2. Antihypertensive
3. Antipyretics
4. Muscle relaxants
5. Corticosteroids
Nursing Management
1. Position: elevate head of bed to 30
degrees (prevent flexion of neck & hips)
2. Monitor respiratory status, neurological
status, vital signs
3. For mechanical ventilation: maintain the
PaCO2 at 30 to 35 mm Hg (this results in
decreased ICP due to vasoconstriction)
4. Monitor ABGs
5. Maintain normal body temperature
Patient Education
1. Avoid Valsalva's maneuver
2. Avoid straining activities
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Disease: SPINAL CORD INJURY NEURO

Causes Pathophysiology
1. Motor vehicle accidents SCI- damage that occurs to any part of the
2. Sporting injuries spinal cord/nerves causing permanent changes
3. Violence (gun shots, (such as loss of motor function, changes in
wounds) sensation, reflexes and strength).
4. Falls
5. Diseases: cancer Tetraplegia (Quadriplegia)- paralysis of all
extremities
6. Fractures/compression of the Paraplegia-paralysis of the lower extremities
spinal cord
Classification
Signs and Symptoms 1. Complete- total loss of sensation & function
1. Loss of motor function and 2. Incomplete (partial)- some sensory & motor
decreased sensation function remains
2. Loss of bladder/bowel
control Diagnostic Tests
3. If C3-C5 are involved, it 1. X-rays
affects breathing
4. Muscle spams 2. MRI
3. CT scan
Remember: the signs and
symptoms is dependent on 4. Neurological examination
the level and severity of
injury
Nursing Management
Emergency management:
1. Immobilize the spine (on spinal backboard
with head in a neutral position)
Treatment 2. Maintain patent airway
3. Use the logrolling technique to maintain
1. Immobilizing the spine alignment.
2. Respiratory management Acute phase
1. Monitor respiratory status
3. Prevention/management 2. Monitor for signs of neurologic shock
3. Monitor for signs of Autonomic dysreflexia
of long-term (damage above T6)
Other nursing care:
complications 1. Turn patient every 2 hours to maintain skin
4. Surgical intervention integrity.
2. Educate patient on physical rehabilitation
3. Range of motion exercises
4. Prevention and management of long-term
complications of SCI
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Disease: AUTONOMIC DYSREFLEXIA NEURO

Causes Pathophysiology
Common causes Autonomic dysreflexia is a sudden
1. Distended bladder uncontrolled sympathetic response
2. Constipation (overreaction) to stimulation.

Autonomic dysreflexia is common among

people with spinal cord injuries (damage
above T6)

Signs and Symptoms This is a medical emergency.

1. Severe high blood
pressure
2. Severe bradycardia Diagnostic Tests
3. Throbbing headache 1. Blood and urine tests
4. Blurred vision
2. CT or MRI scan
5. Flushed skin above
injury level 3. ECG
6. Pale skin below injury
level
7. Goosebumps
8. Nasal congestion Nursing Management
9. Sweating 1. Position: High Fowler's
2. Remove the stimulus
Treatment
Pharmacology 3. Loosen clothing
4. Assess for bladder distention,
1. Antihypertensive drugs
constipation or other stimulus (check
Treatment depends on the
for any kinks if the client has a urinary
cause. catheter).
5. Medication: antihypertensive drug
6. Monitor VS (BP & P every 5 mins)

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Disease: CEREBRAL ANEURYSM NEURO

Causes/ Risk Factors Pathophysiology
1. Hypertension A bulge or ballooning of a weakened
2. Smoking blood vessel in the brain.
3. Older age
4. Excessive alcohol use A brain aneurysm can rupture, resulting
5. Head trauma in hemorrhagic stroke.

Signs and Symptoms

1. Headache
2. Changes in vision
3. Tinnitus Diagnostic Tests
4. Seizures 1. CT scan
5. Nuchal rigidity
2. MRI
3. Cerebral angiogram

Nursing Management
1. Maintain patent airway
2. Monitor VS
Treatment
3. Position: semi-Fowler's
Pharmacology
4. Administer supplemental oxygen as
1. Antiseizure medication prescribed
2. Anti-hypertensive 5. Provide a calm environment
medication 6. Pain management
7. Administer medications as prescribed
(hypertensive patients)
Pain management Patient Education:
1. Educate patient to avoid straining
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Disease: TRAUMATIC BRAIN INJURY NEURO

Causes/ Risk Factors Pathophysiology
1. Falls Trauma to the skull that causes brain damage.
2. Sports injury Types:
1. Concussion-injury that causes the head to
3. Vehicular accident move back and forth forcefully
4. Violence 2. Contusion-bruising
3. Epidural hematoma- hematoma between
skull and dura
4. Subdural hematoma-blood between
between the dura and arachnoid
5. Intracerebral hemorrhage-bleeding inside
the brain
Signs and Symptoms 6. Subarachnoid hemorrhage-bleeding into
1. Increased ICP the subarachnoid space
2. LOC changes 7. Skull fractures- break in the cranial bone
3. Confusion/altered mental
status Diagnostic Tests
4. Papilledema 1. GCS
5. Body weakness
6. Seizures
2. Physical Assessment
7. Paralysis 3. CT scan
8. Slurred speech
9. CSF drainage from the ears
or nose

Signs and symptoms depends on Nursing Management

the type of injury and severity.
Treatment
Mild Injury
1. Close monitoring
2. Antibiotics
3. Wound care
Moderate to severe injury
1. Treatment focuses on
increasing cerebral
oxygenation, maintaining BP
and preventing further
injury.
2. Craniotomy
1. Monitor respiratory status
2. Maintain patent airway
3. Initiate seizure precautions
4. Assess neurological changes
5. Assess pupil size
6. Monitor vital signs
7. Monitor for signs of increase
intracranial pressure.
8. Prevent neck flexion
9. Pain management
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Disease: STROKE
Causes/ Risk Factors
1. TIA
2. Hypertension
3. smoking
4. Atherosclerosis
5. Diabetes
6. High cholesterol
Signs and Symptoms
1. Drooping of face
2. One sided weakness
3. Slurred speech
4. Blurred vision
5. Agnosia
6. High BP
7. Unilateral neglect
8. Apraxia
Nursing Management
Treatment
1. An IV injection of
recombinant tissue
plasminogen activator
(tPA)-ischemic stroke
2. Hemorrhagic stroke: stop
bleeding. Prevention of
increased ICP
10. Prevention of DVT
11. Assist with self care and ADLs
NEURO
Pathophysiology
Stroke is the loss of neurological functions
due to the lack of blood flow to the brain.
Types
Ischemic Stroke (Clots)- an obstruction
in the blood vessel that supplies blood
to the brain.
Hemorrhagic Stroke (Bleeding)-
weakened blood vessel ruptures.
Transient Ischemic Attack- temporary
stroke (a warning stroke)
Diagnostic Tests
1. CT scan
2. MRI
3. Electroencephalography
4. Carotid ultrasound
5. Cerebral arteriography
1. Maintain patent airway
2. Administer 02
3. Administer tPA
4. Monitor VS-maintain BP @ 150/100
5. Monitor LOC
6. Monitor for signs of increase ICP
7. Elevate HOB
8. Administer IV fluids
9. Insert Foley's catheter
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Disease: SEIZURES NEURO

Causes/ Risk Factors Pathophysiology
1. Meningitis Seizures is characterized by a sudden, uncontrolled
electrical disturbance in the brain.
2. Head trauma Epilepsy: chronic seizure activity.
3. Stroke Types:
1. Generalized Seizures-all areas of the brain are
4. Fever affected
a. Tonic-Clonic- may begin with an aura.
5. Brain tumor i. Tonic phase- muscle rigidity , then loss of
consciousness
ii. Clonic-hyperventilation and jerking
b. Absence-loss of awareness (stare blankly into
space)
c. Myoclonic-brief, jerking movement of a
muscle/muscle group
Signs and Symptoms d. Atonic-sudden loss of muscle strength
The signs and symptoms Partial Seizures-affects one part of the brain
depends on seizure history and Simple partial
Complex partial
type.
Before seizure Diagnostic Tests
Aura
During seizure
1. An electroencephalogram
Loss of consciousness during 2. Computerized tomography
seizures
Uncontrollable involuntary 3. Magnetic resonance imaging
muscle movements
Loss of bladder and bowel (MRI)
control
After seizure
4. Neurological exam
Headache Nursing Management
Confusion
Slurred speech Assess time and duration of seizure
activity
Treatment
Provide patient safety
Pharmacology
Turn patient to the side
Anti-seizure medication
Maintain airway
Avoid restraining patient
Loosen clothing
Administer O2
Monitor behavior before and after
seizure activity

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 CARDIOVASCULAR
TABLE OF CONTENT
1. deep vein thrombosis
2. Disseminated intravascular
coagulation

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Disease: DEEP VEIN THROMBOSIS CARDIOVASCULAR

Causes Pathophysiology
1. Age (older age), Deep vein thrombosis (DVT)- thrombus
obesity, smoking (blood clot) forms mostly in the deep vein
2. Prolong immobilization of the lower extremities.
3. Trauma
4. Increased blood Complication:
Pulmonary Embolism (PE)- life-threatening
coagulability
The blood clot in the legs can break and
Signs and Symptoms travel to the lungs causing pulmonary
1. Edema of the embolism
affected extremity
2. Warmth & discolored Diagnostic Tests
skin in the affected 1. D-dimer blood test: a type of
leg protein produced when there is
3. Pain blood clots
4. Tenderness 2. Duplex ultrasound

Nursing Management
Prevention
1. Nursing interventions to prevent DVT
Treatment (see treatment)
Prevention Other nursing interventions:
1. Prevent prolonged
immobilization 1. Administer anticoagulants and
2. Active, passive ROM thrombolytics
3. Compression stockings 2. Prevention of pulmonary embolism
Treatment:
1. Anticoagulants: prevent
further formation of clots
2. Thrombolytics: dissolve
clots
3. Prevention of PE
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DISEASE: DISSEMINATED INTRAVASCULAR COAGULATION

Causes Pathophysiology
1. Blood transfusion Disseminated intravascular coagulation
reaction-major cause (DIC) is characterized by an
2. Cancer overstimulation of the proteins that
3. Pancreatitis control blood clotting which causes
4. Sepsis microclots throughout the body.
5. Pregnancy complications

Signs and Symptoms

1. Bleeding (various
parts in the body)
2. Bruising Diagnostic Tests
3. Blood clots 1. D-dimer
4. Fever 2. Partial thromboplastin time
5. Decreased BP (PTT)
6. SOB 3. Prothrombin time (PT)
7. Confusion 4. CBC

Nursing Management
Treatment
1. Treatment of the
underlying cause
2. Plasma transfusions-
replace blood clotting
factors
Pharmacology
1. Anticoagulants-prevent
further formation of clots
1. Assess respiratory status
2. Monitor VS
3. Monitor coagulation studies
4. Monitor patient's level of
consciousness/mental status
5. Administer O2 as prescribed
6. Administer medications
7. Provide supportive care
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 Bleeding
Thrombolytic drugs dissolve clots by Bleeding
activating plasminogen that forms Hypotension
Hypotension
plasmin. Arrhythmias
Arrhythmias
Hypersensitivity reaction
Hypersensitivity reaction

FLASHCARDS
A Review Guide For Nursing Students PART 1

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table of content
1. Cardiovascular Disorders
2. Respiratory Disorders
3. Gastrointestinal Disorders
4. Pancreatic Disorders
5. Hepatic Disorders
6. Genitourinary Disorders
7. Neurologic Disorders

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CARDIOVASCULAR DISORDERs
1. Coronary Artery Disease
2. Angina
3. Myocardial Infarction
4. Heart Failure
5. Cardiogenic Shock
6. Pericarditis
7. Endocarditis
8. Myocarditis
9. Cardiac Tamponade
10. Aortic Aneurysm
11. Hypertension

CORONARY ARTERY DISEASE

rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Age Coronary artery disease is caused by 1. Chest pain
2. Gender atherosclerosis (plaque formation) that 2. Dyspnea/SOB
3. Family history results in the narrowing or occlusion of 3. Fatigue
4. Hypertension one or more coronary arteries. CAD 4. Dizziness
5. High blood cholesterol results in decreased myocardial tissue
5. Syncope
level perfusion and decreased myocardial
6. Diabetes 6. Cough
oxygenation which leads to angina, MI,
7. Smoking HF or death.
7. Normal findings during
8. Obesity asymptomatic period

NURSING MANAGEMENT Treatment

1. Pain assessment, vital signs, ECG Pharmacology
1. Calcium Channel Blocker
2. Administer oxygen, medications
2. Nitrates
3. Promote bed rest
3. Cholesterol-lowering medications
4. Place client in a Semi-Fowler's position. Surgical Interventions
5. Patient Education- 1. Coronary Angioplasty
a. Lifestyle modifications, Low-sodium and 2. Vascular stent
low-cholesterol diet. 3. Coronary artery bypass
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 ANGINA
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Family history of heart Angina is chest pain due to decreased 1. Pain
myocardial oxygenation. This causes
disease myocardial ischemia.
2. Dyspnea/SOB
2. Hypertension Types of angina. 3. Tachycardia
3. High blood cholesterol Stable angina-occurs due to activity. 4. Palpitations
Pain relieved by rest. 5. Dizziness
4. Diabetes Unstable angina- unexpected chest pain
5. Smoking that increases in severity, duration and 6. Syncope
6. Obesity occurrence (may occur at rest). 7. Diaphoresis (Sweating)
Variant angina- occurs due to coronary 8. Pallor
artery spasm. Occurs at rest.
Intractable angina- chronic 9. Elevated BP

NURSING MANAGEMENT treatment

1. Pain assessment, vital signs/ECG Pharmacology
2. Administer 02, nitroglycerin Calcium Channel Blocker
Nitrates
3. Cardiac monitoring
Cholesterol-lowering medications
4. Pain management Anti-platelet therapy
5. Promote bed rest (Semi-fowler's position) Surgical Interventions
6. Establish an IV access. Coronary Angioplasty
7. Patient Education- Lifestyle and dietary Vascular stent
modifications Coronary artery bypass

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Myocardial Infarction
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. CAD 1. Pain- crushing
MI occurs due to myocardial tissue
2. Atherosclerosis substernal pain that
damage as a result of oxygen radiates to the left
3. High cholesterol level
deprivation. Ischemia may lead to arm, jaw or back.
4. Diabetes 2. Dyspnea
necrosis if myocardial tissue
5. Hypertension 3. Dysrhythmias
oxygenation is not restored. 4. Pallor
6. Smoking
5. Cyanosis
7. Stress 6. Diaphoresis
7. Anxiety
NURSING MANAGEMENT Treatment
Nursing Assessment Pharmacology
1. Pain, respiratory status, vital signs, ECG, peripheral Morphine, Nitroglycerin, Thrombolytic
pulse and skin temperature. therapy, Beta-blockers, Antidysrhythmic
Nursing Interventions medications
1. Administer oxygen Immediate treatment:
2. Administer medications Oxygen: Increase oxygen delivery
3. Cardiac monitoring
4. Monitor BP, intake and output Aspirin: reduce blood clotting
5. Notify HCP if the systolic pressure is lower than 100 Nitroglycerin: vasodilation
mm Hg after medication administration. Morphine: pain reliever
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 Heart Failure
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. CAD Right-sided HF (evident in
HF is the inability of the heart muscle to
2. MI systemic circulation)
pump enough blood to meet the
3. Myocarditis/Endocarditis 1. Edema of the extremities,
metabolic demands of the body.
4. Diabetes abdominal distention, JVD,
Therefore, there is a decrease in cardiac
5. Hypertension splenomegaly,
output.
6. Abnormal heart valves hepatomegaly, weight gain
Types:
7. Cardiomyopathy Left-sided HF (evident in the
Right-sided heart failure and left-sided
8. Congenital heart disease pulmonary system)
heart failure.
1. Dyspnea, crackles,
tachypnea, pulmonary
congestion, dry cough

NURSING MANAGEMENT Treatment

1. Monitor for acute pulmonary edema Pharmacology
2. Place patient in a high Fowler's position.
3. Oxygen therapy
Morphine
4. Administer morphine sulfate and diuretics. Digoxin
5. Insert Foley's catheter. ACE-Inhibitors
Other nursing interventions
1. Administer prescribed medication regime. Beta-blockers
2. Monitor daily weight, intake and output. Diuretics
3. Provide balance between rest and activities.
4. Educate patient on lifestyle and dietary modifications.

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Cardiogenic Shock
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. CAD
1. Hypotension
2. MI
3. Myocarditis/Endocarditis
Cardiogenic shock is a condition 2. Tachycardia
4. Diabetes caused by failure of the heart to 3. Chest pain/discomfort
5. Hypertension 4. Decreased urine output,
6. Abnormal heart valves pump adequately. This results in
less than 30ml/hr.
7. Cardiomyopathy decreased cardiac output and 5. Diminished peripheral
8. Congenital heart disease
decreased tissue perfusion. pulse
6. Confusion/disorientation

NURSING MANAGEMENT Treatment

Assessment Treatment Goal
Orientation, respiratory status, pain, vital signs, To improve the heart's pumping ability and
peripheral pulse, intake and output maintain tissue perfusion.
Pharmacology
Interventions Morphine sulfate
Administer medications Diuretics
Oxygen therapy, Monitor vital signs
Monitor BP after diuretic and nitrate administration. Nitrates
Prepare client for procedures Vasopressors and positive inotropes
Monitor urinary output (Improve organ tissue perfusion.)
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rISK FACTORS/causes
1. MI
2. Autoimmune diseases
3. Injury
4. Heart surgery
5. Bacterial, viral and
fungal infections
Pericarditis
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Pain
Pericarditis is an infection of the a. Pain that radiates to
pericardium. The pericardium is the left side of neck,
comprised of two thin sac layers that shoulders and back
surrounds the heart. b. Pain experienced during
Chronic pericarditis causes thickening of inspiration
the pericardium which results in the c. Pain experienced when
accumulation of fluid (and causes a in a supine position
decrease in pericardial elasticity). 2. Fever
3. Fatigue
This may result in further complications 4. Pericardial friction rub
such as heart failure and cardiac (during auscultation)
tamponade.

NURSING MANAGEMENT Treatment

1. Pain assessment Pharmacology
2. Assess for signs of cardiac tamponade. Analgesics
3. Auscultate lungs (listen for pericardial friction NSAIDS
rub). Corticosteroids
Antibiotics (for bacterial infections)
4. Position patient in a high Fowler's position
Diuretics
(leaning forward to reduce pain). Digoxin
5. Blood culture Surgical Intervention
6. Administer medications Pericardiectomy

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Endocarditis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Congenital heart 1. Fever
Inflammation and infection of the 2. Weight loss
defects. endocardium, the inner lining of the 3. Heart murmurs
2. IV illegal drug use heart chambers and heart valves. 4. Pallor
3. Damaged heart valves 5. Clubbing of fingers
Entry: 6. Petechiae
4. Valve replacement 7. Splenomegaly
Oral cavity
5. Prosthetic heart valve 8. Red tender lesions on hands
Infection and feet- Osler's nodes
Invasive procedures 9. Nontender hemorrhagic
nodular lesions- Janeway
lesions

NURSING MANAGEMENT Treatment

1. Assess skin for petechiae Pharmacology
2. Assess nail beds and clubbing of fingers Antibiotics
3. Assess for Janeway lesios and Osler's nodes Penicillin, nafcillin and ampicillin, are
4. Assess blood culture results the drugs of choice for enterococcal,
5. Monitor cardiovascular status streptococcal, and staphylococcal.
6. Monitor signs of emboli and heart failure.
7. Provide rest and activity balance to prevent
thrombus formation
8. Maintain antiembolism stockings
9. Administer antibiotics
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 Myocarditis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Previous pericarditis Myocarditis is the inflammation of 1. Fever
the heart muscles (myocardium). 2. Chest pain
2. Bacterial, viral or
Myocarditis may affect the heart's 3. Pericardial friction rub
fungal infection.
pumping ability and cause 4. Tachycardia
3. Allergic response
arrhythmias. 5. Murmur
6. Dyspnea
7. Fatigue

NURSING MANAGEMENT Treatment

1. Place client in a comfortable position (Semi-Fowler's Pharmacology
position). Analgesics
2. Oxygen therapy
3. Administer medications as prescribed (see Salicylates
pharmacologic therapy) NSAIDs
4. Provide rest periods Antidysrhythmic drugs
5. Avoid activities that causes overexertion
6. Monitor for heart failure, cardiomyopathy and
Antibiotics
thrombus as signs of complications.

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Cardiac Tamponade
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Cancer Cardiac tamponade is a syndrome 1. Increase central venous
2. Tuberculosis caused by accumulation of fluid in the pressure (CVP).
3. Hypothyroidism pericardial cavity (pericardial effusion). 2. Jugular venous
4. Kidney failure Cardiac tamponade decreases distention
5. Chest trauma ventricular filling and cardiac output. 3. Muffled heart sound
6. Pericarditis 4. Pulsus paradoxus
This may cause complications such as 5. Decreased cardiac
pulmonary edema, shock, or death. output

NURSING MANAGEMENT Treatment

1. Place client on hemodynamic monitoring.
2. Administer IV fluids are prescribed.
3. Prepare client for pericardiocentesis
procedure.
4. Monitor client after the procedure for any
recurrence of tamponade.
Cardiac tamponade is a medical emergency
Client is managed in a critical care unit for
hemodynamic monitoring
IV fluids are prescribed for decreased
cardiac output.
Pericardiocentesis is performed (a
procedure to remove fluids in the
pericardium).

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 Aortic Aneurysm
rISK FACTORS/causes
1. Tobacco use
2. Hypertension
3. Family history
4. Age (65 and older)
5. Gender (male)
6. High blood cholesterol
level
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Thoracic aneurysm:
Aortic aneurysm is an dyspnea, cyanosis, weakness,
enlargement/dilation of the aorta. hoarseness, syncope, pain.
Aneurysm may occur anywhere along Abdominal aneurysm:
abdominal pain, abdominal
the abdominal aorta.
tenderness, systolic bruit over
aorta, mass above the umbilicus.
Rupturing aneurysm:
tachycardia, hypotension,
abdominal pain, s/s of shock,
hematoma at the flank region.

NURSING MANAGEMENT Treatment

1. Assess abdominal distension
2. Assess peripheral pulse, temperature, color and
capillary refill.
3. Monitor vital signs
4. Monitor for signs of aneurysm rupture
5. Administer medication (see pharmacologic
interventions).
6. Prepare client for surgical procedure
7. Implement post operative interventions
Pharmacology
1. Antihypertensive drugs-to maintain BP
and prevent pressure on the aneurysm.
Surgical Intervention
Abdominal aortic aneurysm resection-
section is replaced with a graft.
Thoracic aneurysm repair- a thoractomy
procedure is used to enter the thoracic
cavity, expose the aneurysm and a graft
is sewn on the aorta.
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Hypertension
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Obesity Hypertension is the most common 1. Increased BP
2. DM lifestyle disease. 2. Headache
3. Physical inactivity Hypertension is multifactorial that
4. Tobacco use
3. Dizziness
causes an increase in peripheral vascular
5. Alcoholism resistance and an increase in blood 4. Chest pain
6. Family history pressure (chronic). 5. Blurred vision
7. Secondary hypertension:
caused by underlying Elevated BP: >120-129/<80 6. Tinnitus
condition Stage 1 Hypertension: 130-139/80-89 Remember: it may be
Stage 2 Hypertension: >140/>90 asymptomatic

NURSING MANAGEMENT Treatment

1. Assess and monitor BP Goal of treatment:
2. Obtain family history Reduction of BP
3. Monitor weights Prevention of organ damage
4. Goal: weight reduction or maintenance Lifestyle changes
5. Diet: sodium restriction Diet
6. Smoking cessation Exercise
7. Educate patient on pharmacological Pharmacology
treatment Anti-hypertensive medications
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Respiratory DISORDERs
1. Asthma
2. COPD-Chronic Bronchitis
3. COPD-Emphysema
4. Pleural Effusion
5. Hemothorax
6. Pneumothorax
7. Pneumonia

rISK FACTORS/Causes
1. Allergies
2. Stress
3. Hormonal changes
ASTHMA
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Chronic inflammatory disease of 1. Chest tightness
the airway. 2. Wheezing
3. Shortness of breath
Inflammation and hypersensitivity 4. Cough
to a trigger (stimuli). 5. Restlessness
Smooth muscle constriction of the
bronchi.
Intermittent airflow obstruction.

NURSING MANAGEMENT Treatment

1. Monitor patient's respiratory rate, depth and Pharmacology
pattern, pulse ox, vital signs
2. Maintain patent airway 1. Bronchodilators
3. Administer O2 therapy as prescribed 2. Corticosteroids
4. Administer medications as ordered.
Patient Education 3. Anticholinergics
1. Medication regimen.
2. Identify and avoid triggers.
3. Long term management.

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 COPD- Chronic Bronchitis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Smoking 1. SOB
Progressive respiratory disease.
2. Cough
2. Exposure to dust and Overproduction of mucus due to 3. Sputum production
chemicals. inflammatory response. 4. Fatigue
3. Air pollution Causes airway narrowing and 5. Wheezing, crackles
ventilation-perfusion imbalance. 6. Cyanosis

NURSING MANAGEMENT Treatment

Assess respiratory rate, depth and pattern. Pharmacology
Auscultate lungs
Maintain patent airway 1. Bronchodilators
Place patient in Fowler's position
Provide O2 therapy as ordered. 2. Glucocorticosteroids
Increase oral fluids and maintain hydration.
Perform chest physiotherapy 3. Anticholinergics
Patient Education
Deep breathing exercises 4. Mucolytic agents
Nutrition and hydration
Smoking cessation

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COPD- EMPHYSEMA
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Smoking Progressive respiratory disease 1. SOB
2. Exposure to dust and characterized by the enlargement 2. Cough
chemicals. 3. Sputum production
3. Air pollution of the alveolar.
Enlargement causes decrease in 4. Fatigue
alveolar elasticity, alveolar wall 5. Wheezing, crackles
damage and decrease in alveolar 6. Cyanosis
surface area. 7. Barrel chest
8. Clubbing of nails

NURSING MANAGEMENT Treatment

Assess respiratory rate, depth and pattern.
Auscultate lungs Pharmacology
Maintain patent airway
Place patient in Fowler's position Bronchodilators
Provide O2 therapy as ordered. Glucocorticosteroids
Increase oral fluids and maintain hydration.
Perform chest physiotherapy Anticholinergics
Patient Education
Deep breathing exercises (pursed lip breathing) Mucolytic agents
Nutrition and hydration
Smoking cessation
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 PLEURAL EFFUSION
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Transudative Effusion 1. SOB
Accumulation of fluid in the
1. Cirrhosis 2. Chest pain
2. Heart failure pleural space. 3. Dry, nonproductive
3. Hypoalbuminemia Fluid accumulates between the cough
Exudative Effusion visceral and parietal pleura of 4. Diminished breath
1. Pneumonia
2. Cancer the lungs. sounds
3. Pulmonary embolism Pleural fluid: transudate or 5. Pain during
4. Tuberculosis inspiration
exudate

NURSING MANAGEMENT Treatment

Thoracentesis
1. Identify underlying cause Chest tube insertion
2. Assess respiratory rate, depth and pattern Pleurectomy
3. Monitor vital signs Pleurodesis
Treatment of underlying condition
4. Elevate the head of bed
5. Administer O2 therapy as ordered Pharmacology
6. Administer medications as ordered (Depends on the underlying condition)
Diuretics- congestive heart failure.
7. Prepare patient for possible thoracentesis. Antibiotics
8. Chest tube management Anticoagulants- pulmonary embolism

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HEMOTHORAX
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Thoracic/heart surgery Acculumation of blood in the 1. sOB
2. Chest trauma 2. Tachypnea
pleural cavity. 3. Chest pain
3. Blood clotting defect
4. Anticoagulant Causes respiratory distress. 4. Tachycardia
5. Hypotension
therapy
6. Diminished breath
5. Lung cancer
sounds on affected side
6. Tuberculosis 7. Restlessness
8. Cyanosis
9. Anxiety

NURSING MANAGEMENT Treatment

1. Assess respiratory rate, depth and pattern Stabilize patient
2. Monitor vital signs Stoppage of bleeding
3. Elevate the head of bed
Thoracentesis
4. Administer O2 therapy as ordered
5. Pain management Chest tube insertion
6. Chest tube management/care Surgical Intervention
7. Administer IV fluids as ordered Thoracotomy
8. Administer blood transfusion as ordered
9. Prepare patient for surgery, if indicated. VATS-Video assisted thoracoscopic surgery

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 PNEUMOTHORAX
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY Spontaneous pneumothorax
1. Chest injury Air leaks into pleural space. Pleural space SOB/ Cyanosis, Tachycardia
2. Ruptured air blebs is exposed to positive atmospheric Asymmetrical chest
3. Mechanical ventilation pressure (pressure is normally negative). movement
4. Lung disease: cystic Causes impaired lung expansion. Diminished breath sounds on
Results in full lung collapse or partial lung affected side, Chest pain
fibrosis Tension pneumothorax
collapse.
5. Chest surgery Tracheal deviation away
6. Smoking from affected side
Types SOB/ Tachypnea/Cyanosis
7. Genetics Spontaneous pneumothorax Hypotension/weak pulse
8. Invasive procedures Tension pneumothorax Chest pain, Decreased CO
Traumatic pneumothorax

NURSING MANAGEMENT Treatment

Assess respiratory status Oxygen therapy
Maintain patent airway Chest tube insertion
Monitor vital signs
Administer O2 therapy as ordered Pharmacology
Chest tube management: monitor for kinks and Antibiotics
bubbling
Pain management and maintain bed rest Surgical Management
Patient Education Sometimes surgery may be necessary
Deep breathing exercises to close the air leak.
Educate patient on the use of Incentive spirometer
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rISK FACTORS/causes
Community acquired pneumonia
Streptococcus pneumoniae
Hospital acquired pneumonia
Prolonged hospitalization
Mechanical ventilation
Chronic illness/co morbid
Aspiration Pneumonia
Substance entering the
airway due to vomiting or
impaired swallowing
PNEUMONIA
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Inflammation of the pulmonary tissue 1. SOB
caused by bacteria, fungi and viruses 2. Productive cough
Types: 3. Tachypnea
Community acquired pneumonia: onset 4. Use of accessory muscles
of pneumonia symptoms that occurs in
the community setting or for the first 48 5. Fever
hours after admission 6. Cyanosis
Hospital acquired pneumonia: onset of 7. Pleuritic chest pain
pneumonia symptoms after 48 hours of
admission
Aspiration pneumonia: bacterial
infection from aspiration

NURSING MANAGEMENT Treatment

Assess respiratory status, monitor vital signs Hydration (IV fluids)
Maintain patent airway, O2 therapy Blood culture
Assess swallowing if cause is aspiration
NPO status maintained if cause is aspiration
Respiratory Management
Chest physiotherapy, Increase fluid intake Pharmacology
Maintain bed rest/Semi-Flower's position Antibiotics
High-calorie, protein diet Antiviral angents
Patient Education Antitussives
Fluid intake
Deep breathing/coughing Antipyretics
Medication regimen Analgesics
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Gastrointestinal DISORDERs
1. Hiatal Hernia
2. Gastroesophageal Reflux
Disease
3. Gastritis
4. Appendicits
5. Peptic Ulcer Disease
6. Ulcerative Colitis
7. Crohn's Disease

Hiatal Hernia
rISK FACTORS/Causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Injury The diaphragm has a small opening 1. Heart burn
2. Aging (hiatus) through which the 2. Dysphagia
3. Obesity esophagus passes before connecting 3. Regurgitation
to the stomach. 4. Epigastric pain

Hiatal hernia occurs when a portion

of the stomach herniates through
the diaphragm and into the thorax.

NURSING MANAGEMENT Treatment

1. Assess pain Pharmacology
2. Elevate head of bed (HOB) Antacid
3. Avoid eating 2 to 3 hours before bedtime Neutralizes stomach acids
Proton pump inhibitors
4. Provide small frequent meals Blocks acid production- reduces
5. Avoid lying down after eating stomach acid
6. Administer medications as ordered
Surgical intervention may be required
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 GERD
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Heart burn
1. Hiatal Hernia A digestive disorder that occurs due to
the backflow of gastric content. 2. Dysphagia
2. Pregnancy
Impaired or dysfunctional lower 3. Regurgitation
3. Pyloric surgery
4. Smoking esophageal sphincter (LES) causes 4. Epigastric pain
regurgitation of stomach content into the 5. Dyspepsia (indigestion)
5. Obesity esophagus.
6. Alcohol Complications- esophagitis, Barrett
7. Fatty foods esophagus, esophageal stricture.

NURSING MANAGEMENT Treatment

1. Assess pain Pharmacology
2. Elevate head of bed (HOB) Antacid
3. Avoid eating 2 to 3 hours before bedtime Neutralizes stomach acids
4. Avoid lying down after eating Proton pump inhibitors
Blocks acid production- reduces stomach
Patient Education acid
1. Avoid alcohol, fatty foods, caffeine, tobacco, and Histamine H2 antagonist
other irritants Blocks histamine (decreases stimulation
2. Avoid eating 2 to 3 hours before bedtime of stomach acid production).
3. Avoid lying down after eating
4. Avoid NSAIDS and anticholinergics
5. Maintain healthy body weight (exercise)

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rISK FACTORS/causes
Bacterial infection
Autoimmune disease
Prolong use of NSAIDs
Excessive alcohol use
Smoking
Dietary factors
Gastritis
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Acute Gastritis
Gastritis is the inflammation of the
gastric mucosa. 1. Nausea/vomiting
2. Anorexia
Acute gastritis- caused by the overuse 3. Abdominal pain
of NSAIDs, aspirin or excessive alcohol 4. Acid reflux
intake. 5. Hiccups
Chronic gastritis-consistent inflammation Chronic Gastritis
of the gastric mucosa. May be caused by 1. Indigestion
H. pylori bacteria, or autoimmune 2. Heart burn after meals
diseases.
3. Vitamin B12 deficiency
4. Anorexia/nausea/vomiting

NURSING MANAGEMENT Treatment

1. Assess pain Pharmacology
2. Monitor signs of hemorrhagic gastritis Antacid
3. Maintain NPO status until symptoms subsides Neutralizes stomach acids
4. Administer medications as ordered. Proton pump inhibitors
Blocks acid production- reduces stomach
1. Patient Education acid
Histamine H2 antagonist
2. Educate patient to avoid irritating foods. Blocks histamine (decreases stimulation of
3. Educate patient on the importance of medication stomach acid production).
regime and adherence. Antibiotics: to treat bacterial infection

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rISK FACTORS/causes
1. Abdominal trauma
2. Inflammatory bowel
disease
3. Infection in the
gastrointestinal tract
4. Foreign body
5. Viral infection
NURSING MANAGEMENT
1. Assess pain
2. Abdominal assessment
3. Monitor VS
4. Pre-operative care: NPO + IVF
5. Post-operative care: Monitor surgical site + monitor
for signs of infection
Patient Education
1. Post-operative education
a. Early ambulation
b. Deep breathing exercises
Peptic Ulcer Disease
rISK FACTORS/causes
1. H. pylori bacteria
2. NSAIDS
3. Irritants
4. Smoking
NURSING MANAGEMENT
1. Abdominal Assessment (abdominal sounds)
2. Monitor vital signs (BP,P)
3. Monitor stools for blood
Patient Education
1. Dietary modification: avoid irritants
2. Smoking cessation
3. Avoid NSAIDS
Appendicitis
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Rovsing's sign: pain
Inflammation of the vermiform
experienced at the RLQ
appendix.
when pressure is applied
Inflammation causes obstruction of the
appendiceal lumen. and released at the LLQ
Complications: Prolong inflammation 2. Periumbilical abdominal
may cause the appendix to pain
burst/rupture leading to peritonitis. 3. RLQ pain
4. Fever
5. Abdominal rigidity
Treatment
Appendectomy: surgical removal of
the appendix
Pain management
IV fluids
Pharmacology
Antibiotics
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sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Epigastric pain after meals
Ulceration that erodes the gastric or 2. Dark, tarry stools
duodenal mucosa. 3. Weight loss
Mucosal inflammation and ulceration 4. Coffee ground emesis
is caused by H. pylori bacteria.
Complications: GI hemorrhage,
bowel obstruction
Treatment
Pharmacology
Antibiotics
Histamine H2 blockers
Blocks histamine (decreases stimulation
of stomach acid production).
Proton pump inhibitor
blocks acid production to promote
healing
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 Ulcerative Colitis
rISK FACTORS/causes
1. Age
2. Family history
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Known as an Inflammatory Bowel 1. Diarrhea with pus or
Disease. blood
Characterized by the ulceration and 2. Abdominal pain
inflammation of the colon and rectum.
Causes poor nutrient absorption. 3. Abdominal
tenderness
Complications: Nutritional deficiencies, 4. Fever
hemorrhage and perforated colon
5. Fecal urgency

NURSING MANAGEMENT Treatment

1. Assess and monitor vital signs Pharmacology
2. Assess pain 5-aminosalicylic acid (5-ASA)
3. Monitor fluid balance
4. I/O charting Corticosteroids-moderate to severe
5. Monitor electrolyte levels (lab studies) ulcerative colitis
6. Monitor stool frequency and characteristics Immunosuppresants- reduces
7. Obtain daily weights
8. Pain management inflammation.
9. Maintain NPO status if indicated (severe
condition)
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Crohn's Disease
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Autoimmune Crohn's disease is a type of
1. Diarrhea with pus
2. Heredity 2. Fever
inflammatory bowel disease (IBD) 3. Abdominal pain
that causes inflammation in the 4. Abdominal distention
gastrointestinal tract (leads to 5. Weight loss
thickening, scarring and narrowing) 6. Reduced appetite
7. Iron deficiency

NURSING MANAGEMENT Treatment

1. Assess and monitor vital signs Pharmacology
2. Assess pain 5-aminosalicylic acid (5-ASA)
3. Monitor fluid balance Corticosteroids
4. I/O charting Immunosuppresants-
5. Monitor electrolyte levels (lab studies) reduces inflammation.
6. Monitor stool frequency and characteristics
7. Obtain daily weights
8. Pain management
9. Maintain NPO status if indicated (severe condition)
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Pancreatic DISORDERs
1. Pancreatitis
2. Cholecystitis
3. Cholelithiasis

Pancreatitis
rISK FACTORS/Causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Hyperlipidemia Inflammation of the pancreas. 1. Left upper abdominal
2. Hypercacemia Obstruction of pancreatic secretory pain that radiates to
the back
3. Gallstones flow, activation and release of 2. Abdominal pain that
4. Abdominal surgery pancreatic enzymes. Digestive worsens after meals
3. Abdominal tenderness
5. Abdominal trauma enzymes starts digesting the 4. Fever
6. Obesity pancreas. 5. Tachycardia
6. Hypotension
7. Infection 7. Steatorrhea: chronic
pancreatitis

NURSING MANAGEMENT Treatment

1. Assess pain NPO status
2. Provide pharmacologic and non- Pancreatic enzyme supplements
Pain management
pharmacologic pain management IV fluids
3. Monitor fluid and electrolytes Surgical procedure to remove bile
duct obstruction.
4. Maintain NPO status as ordered Cholecystectomy (if cause is
5. Manage biliary drainage gallstones)
Pancreatic Jejunostomy

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 Cholecystitis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Inflammation of the gallbladder. 1. Epigastric pain that
1. Gallstones
Acute inflammation: is often due to radiates to the right
2. Tumor
cholelithiasis. shoulder
3. Infection
Chronic inflammation: repeated 2. Fever
acute inflammation that causes the 3. Nausea/Vomiting
gallbladder to be thick-walled and 4. Murphy's sign
scarred. 5. Belching
6. Flatulence
7. Abdominal tenderness

NURSING MANAGEMENT Treatment

1. Assess pain NPO status
2. Provide pharmacologic and non-pharmacologic Pain management
pain management Antiemetics: for nausea and vomiting
3. Maintain NPO status Analgesics: pain
4. Prepare patient for procedures Surgical intervention
Post operative interventions
1. Monitor respiratory complications Cholecystectomy: removal of the
2. Encourage coughing and deep breathing gallbladder.
3. Encourage early ambulation Choledocholithotomy: removal of
4. Tube drainage management (if any). gallstones
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Cholelithiasis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Obesity Gallstones are hard, crystalline
1. Sudden pain in the right
2. High cholesterol levels upper quadrant
structures that abnormally forms and 2. Abdominal distention
3. Women over 40 years
obstruct the gallbladder / bile duct. 3. Dark urine
4. Diabetes
5. Cirrhosis Most of cholelithiasis is caused by 4. Abdominal pain after
cholesterol gallstones. eating fatty foods.

NURSING MANAGEMENT Treatment

Postoperative Care Pharmacology
1. Monitor vital signs, respiratory status Analgesics
2. Pain management Antibiotics
3. Monitor drainage/incision site, intake and output Surgical intervention
4. Maintain NPO status Cholecystectomy: removal of the
5. Deep breathing exercises and early ambulation
Patient Education gallbladder.
1. Ambulation/ 2. Avoid heavy lifting/ 3. Avoid bathing Medications to dissolve stones
for 48 hours/ 4. Report fever/ 5. Dietary Chenodeoxycholic
modification/ 6. Assess wound site daily. Ursodeoxycholic acid
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hepatic DISORDERs
1. Cirrhosis
2. Portal Hypertension
3. Esophageal Varices
rISK FACTORS/Causes
1. Chronic alcoholism
2. Hepatitis
3. Biliary obstruction
4. Right-sided HF
NURSING MANAGEMENT
1. Identify underlying/precipitating factors
2. Perform daily weights
3. Administer vitamin supplements- KADE
4. Monitor for signs of infection
5. Monitor for signs of bleeding
6. Nutrition- low sodium
Patient Education
1. Alcohol cessation
2. Low sodium diet
3. Low saturated fats
Cirrhosis
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Cirrhosis is a chronic progressive 1. Jaundice
2. Edema
disease of the liver characterized by 3. Splenomegaly
fibrosis (scarring). 4. Liver enlargement
5. Ascities
6. Abdominal pain
7. Steatorrhea
8. Bleeding- decreased Vit K
9. Red palms
10. Itchiness
11. Weight loss/ Loss of
appetite
12. White nails
Treatment
Treatment of underlying cause
Alcohol dependency
Hepatitis treatment
Treatment of Cirrhosis
complications- ascites, gastric
distress, portal hypertension, etc.
Liver Transplant- in severe cases of
Cirrhosis
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 Portal Hypertension
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Gastrointestinal bleeding
1. Cirrhosis Portal veins carries blood from the
digestive organs to the liver. a. Dark/tarry stools
2. Portal vein b. bleeding from varices
Portal hypertension-increased
thrombosis pressure in the portal veins due to 2. Ascites
obstruction of the portal blood flow. 3. Decreased platelets and
WBC
Complications- Hepatic 4. Splenomegaly
encephalopathy, ascites, GI bleed, 5. Thrombocytopenia
varices rupture. 6. Encephalopathy

NURSING MANAGEMENT Treatment

1. Monitor intake and output Endoscopic therapy
2. Assess level of consciousness Dietary/lifestyle modifications
3. Monitor coagulation studies Transjugular intrahepatic portosystemic
4. Perform daily weights shunt (TIPS)-radiological procedure
5. Administer diuretics as ordered Distal splenorenal shunt (DSRS)-surgical
6. Administer Vit K as ordered procedure
Patient Education
1. Low sodium diet
2. Alcohol cessation
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Esophageal Varices
rISK FACTORS/causes
1. Cirrhosis
2. Thrombosis in the portal
vein
3. Heart failure
4. Schistosomiasis
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Esophageal varices occurs when there is 1. Jaundice
a blockage in the blood flow to the liver 2. Dark-colored urine
3. Ascites
due to scarring or clotting in the liver.
4. Nausea/Vomiting
This results in an increased pressure from 5. Spontaneous bleeding/easy
the portal vein. bruising
6. Spider nevi
The increased pressure causes blood to 7. Hypotension
flow into smaller veins in the esophagus. 8. Tachycardia
The smaller fragile veins may become 9. Pallor
distended and rupture, causing life-- 10. General malaise
threatening hemorrhage. 11. Pruritus

NURSING MANAGEMENT Treatment

1. Monitor vital signs Primary goal is to prevent bleeding.
2. Monitor lung sounds Beta blockers- to reduce pressure in the
3. Elevate HOB portal veins
4. Administer O2 as ordered Vasopressin
Somatostatin/Sandostatin
5. Administer IV fluids as ordered Sclerotherapy
6. Monitor lab values-coagulation studies Endoscopic band ligation
7. Administer Vit K as ordered

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Genitourinary disorders
1. Acute Kidney Injury
2. Chronic Kidney Disease
3. Glomerulonephritis
4. Nephrotic Syndrome
5. Renal Calculi
6. Urinary Tract Infection
7. Pyelonephritis

Acute Kidney Injury

rISK FACTORS/Causes
Prerenal-outside the kidney
1. Dehydration, infection outside
of the kidney, decreased cardiac
output
Intrarenal-parenchyma of the kidney
1. Infection within the kidney
parenchyma, obstruction,
tubular necrosis, renal ischemia
Postrenal-between kidney and
urethral meatus
1. Calculi, cystitis, bladder
cancer/obstruction
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Renal cell damage characterized by a Oliguric Phase
1. Urine output: <400mL/d,
sudden deterioration in kidney function. pericarditis, excessive fluid
AKI can cause cell death, decompensation volume, uremia, metabolic
of renal function and hypoperfusion. acidosis, neurological
changes.
Diuretic Phase
The signs and symptoms of AKI are due to
1. An increase in urine output
the retention of fluids, the retention of 5L/day.
nitrogenous waste and electrolyte Recovery Phase
imbalances. 1. Recovery may take 6 months
to 2 years.

NURSING MANAGEMENT Treatment

Oliguric Phase Treatment of underlying cause
1. Administer diuretics Treatment of complications
2. Fluid restriction-if hypertension is present
Diuretic Phase Fluids and electrolytes
1. Administer IV fluids imbalances
2. Monitor Lab values Pharmacology
Recovery Phase Antibiotics
1. Patient education-decrease sodium, protein, fluid and
potassium intake NSAIDs
2. Monitor intake and output. Diuretics

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 Chronic Kidney Disease
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY 1. Hypertension, SOB
1. AKI Slow, progressive and irreversible loss
of kidney function.(GFR <60mL/min). 2. Kussmaul respirations
2. Hypertension Results in uremia, electrolyte 3. Oliguria/anuria
3. Urinary obstruction imbalances, hypervolemia or 4. Uremia, Edema
4. Diabetes hypovolemia. 5. Irritability, Restlessness
Stages of CKD 6. Pulmonary edema
At risk: >90mL/min 7. Pulmonary effusion
Mild CKD: 60-89mL/min 8. Body weakness
Moderate CKD: 30-59mL/min 9. Yellow-gray pallor
Severe CKD: 15-29mL/min
ESKD: <15mL/min 10. Proteinuria

NURSING MANAGEMENT Treatment

1. Monitor vital signs Hemodialysis
2. Monitor cardiopulmonary system Peritoneal Dialysis
Kidney transplant
3. Perform daily weights Pharmacology
4. Monitor lab values Angiotensin-converting enzyme (ACE)
5. Monitor intake and output inhibitors
6. Low protein/sodium diet Angiotensin II receptor blockers
7. Fluid restriction Diuretics
8. Dialysis treatment Corticosteroids
9. Administer medications Erythropoietin supplements
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Glomerulonephritis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Immunological diseases A group of renal diseases caused 1. Dark colored urine
2. Strep throat 2. Hematuria
by immunologic response that
3. Autoimmune diseases 3. Proteinuria
triggers the inflammation of the 4. Azotemia
glomerular tissue. 5. Oliguria
6. Edema
7. Elevated BP
8. JVD
9. Dyspnea

NURSING MANAGEMENT Treatment

1. Monitor vital signs (Bp), respiratory status Pharmacology
2. Monitor fluids and electrolytes level Antibiotics
3. Maintain fluid restrictions as ordered Antihypertensive drugs
4. Obtain daily weights
Patient Education
1. Medication adherence
2. Fluid restrictions
3. Dietary modifications
4. Increase carbohydrates in diet
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 Nephrotic Syndrome
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Nephrotic syndrome is characterized 1. Periorbital and facial
1. Diabetes Mellitus
by excessive excretion of protein in edema
2. Heart failure 2. Ascites
the urine (proteinuria), leading to low
3. SLE 3. Peripheral edema
protein levels in the blood
4. Amyloidosis (hypoproteinemia). 4. Proteinuria
This leads to edema and hypovolemia. 5. Hypoproteinemia
6. Hyperlipidemia
7. Electrolyte imbalance
8. Fatigue
9. Lethargy
NURSING MANAGEMENT Treatment
1. Monitor vital signs Pharmacology
2. Monitor BP Diuretics
3. Monitor lab values-protein ACE-Inhibitors/ ARBS
4. Intake and output charting Corticosteroids
5. Obtain daily weights Immunosuppressant
6. Low salt/sodium diet/Low cholesterol

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Renal Calculi
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Dehydration Renal calculi is also known as 1. Pain in the
2. Family history costovertebral region
kidney stones. Calculi is made up
3. UTI 2. Fever
of minerals and salt deposits that 3. Persistent need to
4. Hypercalcemia is found in the urinary tract.
5. Obesity urinate
Types 4. Elevated RBC,WBC
6. High calcium diet
Calcium stones noted in urine
Cystine stones
Struvite stones
Uric acid stones

NURSING MANAGEMENT Treatment

1. Monitor vital signs, temperature Treatment depends on the type, size and cause of
2. Pain management the calculi.
3. Encourage fluid intake of 3L/day Pharmacology-antibiotics
4. Encourage ambulation Small Calculi
5. Monitor urine output Increase water intake
6. Strain urine Pain medications
7. Administer medication as ordered. Alpha blockers
Patient Education Large Calculi
1. Increase fluid intake Extracorporeal shock wave lithotripsy (ESWL)
2. Dietary restrictions Surgical intervention

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 Urinary Tract Infection
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY Acute pyelonephritis
UTI is the infection/inflammation of any
1. Vesicoureteral reflux Flank pain, Fever, chills,
part of the urinary system.
2. Urinary catheters- bacteriuria, pyuria
continuous or long Acute pyelonephritis: inflammation of Cystitis
term use the kidneys Lower abdominal pain, burning
3. Female Cystitis: Inflammation of the bladder on urination, hematuria,
Urethritis: Inflammation of the frequent urination, incontinence
4. Renal calculi
urethra
5. Sexual activity Urethritis
. Lower abdominal pain, burning
on urination, hematuria,
frequent urination, incontinence

NURSING MANAGEMENT Treatment

1. Monitor vital signs, temperature Pharmacology
2. Encourage fluid intake 3L/day Antibiotics
3. Monitor intake and output Analgesics
4. Obtain daily weights Antipyretics
5. Administer medications as ordered
Patient Education
1. High calorie, low protein diet
2. Non-pharmacologic pain management

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Pyelonephritis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Vesicoureteral reflux 1. Fever/chills
Inflammation of the renal pelvis 2. Flank pain
2. Urinary catheters- caused by bacterial infection. 3. Costovertebral angle
continuous or long term tenderness
use 4. Hematuria
3. Female 5. Tachypnea
6. Tachycardia
4. Renal calculi 7. Nausea
8. Cloudy urine
9. Increased urine frequency
and urgency
10. Pyuria
11. Bacteriuria

NURSING MANAGEMENT Treatment

1. Monitor vital signs Pharmacology
2. Monitor temperature Antibiotics
3. Encourage fluid intake 3L/day
4. Monitor intake and output Analgesics
5. Obtain daily weights Antipyretics
6. Administer medications as ordered
Antiemetics
Patient Education Urinary antiseptics
1. High calorie, low protein diet
2. Non-pharmacologic pain management
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NEUROLOGICAL disorders
1. Traumatic Head Injury
2. Meningitis
3. Stroke
4. Multiple Sclerosis
5. Seizures
6. Parkinson's Disease

Head Injury
rISK FACTORS/Causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Falls Trauma to the skull that causes brain 1. Increased ICP
damage. 2. LOC changes
2. Sports injury 3. Confusion/altered mental
3. Vehicular accident Types status
4. Violence Contusion 4. Papilledema
Concussion
Intracerebral hematoma 5. Body weakness
Subdural hematoma 6. Seizures
Basilar skull fracture 7. Paralysis
Closed head injury 8. Slurred speech
Complications:
Hematoma, Increased ICP, Signs and symptoms depends on
Cerebral bleed, Seizures, CSF leakage, the type of injury and severity.
infections

NURSING MANAGEMENT Treatment

1. Monitor respiratory status Mild Injury
2. Maintain patent airway Close monitoring
Antibiotics
3. Assess neurological changes Wound care
4. Assess pupil size Moderate to severe injury
5. Monitor vital signs Treatment focuses on increasing cerebral
6. Monitor for signs of ICP oxygenation, maintaining BP and preventing
7. Prevent neck flexion further injury.
8. Monitor CSF drainage Pharmacology
9. Pain management Anti-seizure medication
Mannitol, Dexamethasone, Furosemide.

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 Meningitis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY 1. Fever
Meningitis is the inflammation of the
1. Streptococcus 2. Headache
meninges. The meninges covers the brain
pneumoniae and spinal cord. Meningitis is mostly 3. Skin rash
2. Neisseria meningitidis 4. Rigidity of the neck
caused by bacterial or viral infection.
muscles (nuchal rigidity)
3. Haemophilus 5. Decreased LOC
influenzae

NURSING MANAGEMENT Treatment

1. Infection control precautions Bacterial meningitis
2. Monitor neurological status Antibiotics
3. Assess LOC
4. Monitor vital signs IV fluids: fluids replacement
5. Initiate seizure precautions
6. Administer antipyretics as ordered Antipyretics
7. Encourage and increase hydration

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Stroke
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. TIA Stroke is the loss of neurological 1. Drooping of face
functions due to the lack of blood flow 2. One sided weakness
2. Hypertension 3. Slurred speech
to the brain.
3. smoking 4. Blurred vision
4. Atherosclerosis Types 5. Agnosia
5. Diabetes Ischemic Stroke (Clots)- an 6. High BP
obstruction in the blood vessel that 7. Unilateral neglect
6. High cholesterol supplies blood to the brain. 8. Apraxia
Hemorrhagic Stroke (Bleeding)-
weakened blood vessel ruptures.
Transient Ischemic Attack-
temporary stroke (a warning
stroke)

NURSING MANAGEMENT Treatment

1. Maintain patent airway An IV injection of recombinant tissue
2. Administer 02
3. Administer tPA plasminogen activator (tPA)-ischemic
4. Monitor VS-maintain BP @ 150/100 stroke
5. Monitor LOC
6. Monitor for signs of increase ICP Hemorrhagic stroke: stop bleeding.
7. Elevate HOB Prevention of increased ICP
8. Administer IV fluids
9. Insert Foley's catheter
10. Prevention of DVT
11. Assist with self care and ADLs
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 Multiple Sclerosis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Weakness
1. Autoimmune disorders Multiple sclerosis is a CNS inflammatory 2. Fatigue
disease (chronic), characterized by
2. Viral infection 3. Blurred vision
the demyelination axons. This
damage results in varied neurological 4. Nystagmus
dysfunctions. 5. Sensory loss
6. Dysphagia
7. Bowel and bladder
dysfunction
8. Electric-shock sensations
9. Neuralgias

NURSING MANAGEMENT Treatment

1. Assess muscle function and mobility There is no cure. Treatment goal is
2. Pain management focused on managing symptoms, acute
3. Assess sensory function attacks and slowing the progression of
4. Monitor vision changes the disease.
5. Cluster nursing activities
6. Patient's safety measures
7. Encourage independence
8. Encourage bladder and bowel training

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Seizures
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY The signs and symptoms depends
1. Meningitis Seizures is characterized by a sudden, on seizure history and type.
uncontrolled electrical disturbance in the brain. Before seizure
2. Head trauma
1. Aura
3. Stroke Epilepsy: chronic seizure activity. During seizure
4. Fever 1. Loss of consciousness during
Types: seizures
5. Brain tumor Generalized Seizures 2. Uncontrollable involuntary
Tonic-Clonic muscle movements
Absence 3. Loss of bladder and bowel
Myoclonic control
Atonic After seizure
Partial Seizures 1. Headache
2. Confusion
Simple partial 3. Slurred speech
Complex partial

NURSING MANAGEMENT Treatment

1. Assess time and duration of seizure activity Pharmacology
2. Provide patient safety Anti-seizure medication
3. Turn patient to the side
4. Maintain airway
5. Avoid restraining patient
6. Loosen clothing
7. Administer O2
8. Monitor behavior before and after seizure
activity
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 Parkinson's Disease
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
A progressive neurological disease Bradykinesia
1. Age >65 Tremors
characterized by depletion of
2. Family history Slow movement
dopamine and acetycholine
imbalances. Blank facial expression
Posture: forward tilt
Rigidity of extremities
Pill rolling
Drooling

NURSING MANAGEMENT Treatment

1. Neuro assessment Pharmacology
2. Assess ability to swallow
3. Provide patient's safety
Carbidopa-levodopa
4. Promote independence Dopamine agonist
5. Promote physical therapy Catechol O-methyltransferase (COMT)
6. Diet: high calorie & soft diet
Treatment goal inhibitors
1. Increase/maintain independence
2. Improve mobility
3. Improve nutritional status

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DISORDER:
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY

NURSING MANAGEMENT Treatment

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 Bleeding
Thrombolytic drugs dissolve clots by Bleeding
activating plasminogen that forms Hypotension
Hypotension
plasmin. Arrhythmias
Arrhythmias
Hypersensitivity reaction
Hypersensitivity reaction

FLASHCARDS
A Review Guide For Nursing Students PART 2

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table of content
1. Thyroid Disorders
2. Pancreatic Disorders
3. Adrenal Cortex Disorders
4. Pituitary Gland Disorders
5. Skeletal Disorders
6. Hematology Disorders
7. Reproductive Disorders

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THYROID DISORDERs

1. Hypothyroidism
2. Hyperthyroidism
3. Hypoparathyroidism
4. Hyperparathyroidism

rISK FACTORS/causes
1. Autoimmune diseases
2. Iodine deficiency or
excess
3. Thyroiditis
4. Thyroidectomy
Hypothyroidism
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
The thyroid gland produce hormones 1. Fatigue/body weakness
that are responsible for regulating the 2. Weight gain
body's metabolic rate (energy). 3. Oligomenorrhea
In hypothyroidism, the thyroid gland is 4. Hair loss
underactive (Hyposecretion of thyroid
5. Bradycardia
hormones).
6. Coldness
Remember: LOW ENERGY
7. Constipation
8. Myxedema

NURSING MANAGEMENT Treatment

1. Monitor HR Pharmacology
2. Administer levothyroxine as prescribed. Levothyroxine
Patient Education
1. Educate patient on medication compliance.
Levothyroxine is to be taken for a life-time.
2. Constipation: High fiber diet and increase fluids
3. Diet: low-calorie, high fiber diet
4. Weight reduction: exercise plan
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 Hyperthyroidism
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY 1. Exophthalmos: bulging eyes
1. Graves' disease The thyroid gland produce hormones that 2. Palpitations
are responsible for regulating the body's 3. Tachycardia
metabolic rate (energy) 4. Weight loss
In hyperthyroidism, the thyroid gland is 5. Oligomenorrhea
overactive (Hypersecretion of thyroid 6. Hot flashes
hormones (T3 and T4)) 7. Irritability
Remember: HIGH ENERGY 8. Nervousness
9. Diarrhea
Thyroid Storm: acute and life-threatening
emergency for uncontrolled Thyroid Storm
hyperthyroidism. 1. Fever
2. Tachycardia
3. Hypertension/Increased RR

NURSING MANAGEMENT treatment

1. Monitor BP, P Pharmacology
2. Administer medications as prescribed. Propylthiouracil (PTU)
3. Obtain daily weights
Patient Education Methimazole
1. Educate patient on medication compliance Radioactive iodine therapy
2. Diet: High calorie diet
3. Avoid stimulants Surgical Intervention
Thyroid Storm
1. Maintain patent airway Thyroidectomy
2. Medications: Antithyroid medication, Beta Blockers,
Glucocorticoids, Nonsalicylate antipyretics
3. Cooling blankets

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Hypoparathyroidism
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Thyroidectomy (and 1. Positive Trousseau's
The parathyroid gland produces
sign
the removal of the the parathyroid hormone (PTH) 2. Positive Chvostek's sign
parathyroid). that maintains the serum calcium 3. Hypocalcemia
level in the body. 4. Hyperphosphatemia
5. Hypotension
Hypoparathyroidism is caused by 6. Tetany
hyposecretion of parathyroid 7. Muscle cramps
hormones. 8. Anxiety
9. Numbness and tingling

NURSING MANAGEMENT Treatment

1. Monitor BP, P Pharmacology
2. Monitor calcium/ phosphorus level IV Calcium Gluconate
3. Administer medications as prescribed Vitamin D supplements
4. Diet: high Calcium, low Phosphorus diet Phosphate binders
5. Seizure precautions-(hypocalcemia)

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 Hyperparathyroidism
rISK FACTORS/causes
1. Chronic kidney failure
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY 1. Hypercalcemia
The parathyroid gland produces the 2. Hypophosphatemia
parathyroid hormone (PTH) that 3. Weight loss
maintains the serum calcium level in the 4. High BP (Hypertension)
body. 5. Bone and joint pain
Hyperparathyroidism is caused by 6. Bone deformities
hypersecretion of parathyroid 7. Fatigue
hormones. 8. Cardiac dysrhythmias
9. Kidney stones

NURSING MANAGEMENT treatment

1. Monitor BP Pharmacology
2. Monitor calcium/ phosphorus level Calcitonin
3. Increase fluid intake Bisphosphonates (oral/IV)
4. Promote body alignment Furosemide
5. Promote safety precautions
6. Administer medications as prescribed Phosphates
7. Diet: High fiber/ moderate calcium Surgical Intervention
8. Pre and post operative care Parathyroidectomy
(parathyroidectomy)

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DISORDER:
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY

NURSING MANAGEMENT Treatment

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pancreatic DISORDERs
1. Type 1 Diabetes
2. Type 2 Diabetes
3. Diabetes Ketoacidosis
4. Hyperosmolar
Hyperglycaemic State
5. Hypoglycemia
6. Hyperglycemia

Type 1 Diabetes
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Autoimmune response A chronic condition in which the 1. Polyuria: increased
2. Genetics urination
pancreas (beta cells) is unable to
2. Polydipsia: Increased
3. Onset: childhood produce insulin. thirst
3. Polyphagia: Increased
appetite
4. Weight loss
5. Hyperglycemia
6. Blurred vision

NURSING MANAGEMENT Treatment

1. Monitor glucose levels Pharmacology
2. Insulin administration Insulin
Monitoring
Patient Education Continuous glucose monitoring
1. Glucose monitoring
2. Insulin administration technique

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 Type 2 Diabetes
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Polyuria: increased urination
1. Obesity Type 2 Diabetes is characterized by Polydipsia: Increased thirst
2. Sedentary lifestyle insulin resistance and impaired insulin Polyphagia: Increased
secretion. appetite
3. Hypertension Weight gain
4. Hyperglycemia Complication: Hyperosmolar Poor wound healing
Hyperglycaemic State Fatigue
5. Onset: adulthood Blurred vision
Recurrent infections
Numbness and tingling of
hands and feet
Dry skin

NURSING MANAGEMENT treatment

Pharmacology
1. Monitor glucose levels Oral hypoglycemic medications
2. Medication administration
Insulin
Patient Education Nonpharmacologic therapy
1. Diabetic Diet Glucose monitoring
2. Exercise
3. Medication adherence Dietary plan
Exercise regime

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Diabetic Ketoacidosis (DKA)

rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Onset: Sudden 1. Fruity breath
DKA is a sudden, life-threatening
2. Kussmaul's respiration
2. Infection complication of Type 1 Diabetes. 3. Ketosis
3. Complication of Type 1 Characteristics: 4. Acidosis
Diabetes Hyperglycemia 5. Electrolyte loss
6. Lethargy
Dehydration 7. Coma
Ketosis
Acidosis

NURSING MANAGEMENT Treatment

1. Monitor glucose levels IV fluid replacement
2. Administer IV insulin as prescribed IV insulin: treat hyperglycemia
3. Administer IV fluids Correct electrolyte imbalance: Monitor
4. Monitor potassium levels potassium levels
5. Monitor cardiac status
6. Monitor signs of increased intracranial
pressure

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 Hyperosmolar Hyperglycaemic State (HHS)
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Onset: Gradual Hyperosmolar Hyperglycaemic 1. Dehydration
State (HHS) is a complication of 2. Hyperglycemia
2. Infection 3. Electrolyte loss
Type 2 Diabetes.
3. Complication of Type Characteristics: 4. Dry skin
2 Diabetes Extreme hyperglycemia 5. Lethargy
There is no presence of ketosis
or acidosis

NURSING MANAGEMENT treatment

IV fluid replacement
1. Monitor glucose levels Insulin: If applicable
2. Administer IV fluids Correct electrolyte
3. Monitor electrolyte levels
imbalance
4. Administer insulin if applicable

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rISK FACTORS/causes
Too much insulin or
diabetic medication
Skipping meals
Increased physical
activity
Hypoglycemia
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Hypoglycemia occurs when 1. Confusion
2. Palpitations
there is a sudden decrease of 3. Blurred vision
4. Inability to concentrate
blood glucose level <60 mg/dL. 5. Fatigue
6. Body weakness
7. Lightheadedness
Mild: <60mg/dL 8. Diaphoresis
Moderate: <40mg/dL 9. Cold and clammy skin
Remember: The symptoms
Severe: <20mg/dL depends on the level of the
blood glucose.

NURSING MANAGEMENT Treatment

1. Assess glucose level Simple carbohydrates
2. Administer 15g of simple carbohydrates Glucagon (IV,IM)
3. Recheck blood glucose level in 15 minutes
4. Administer 15 g of simple carbohydrates if necessary. 50% Dextrose (IV)
5. If blood glucose level is still <60mg/dL or in severe
cases (altered LOC): Administer 50% dextrose (IV)
Unconscious patients:(DO NOT ADMINISTER ORAL FOOD
OR FLUID)
1. Assess glucose level
2. Administer Glucagon (IV,IM) or 50% Dextrose (IV)

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 Hyperglycemia
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Diet Hyperglycemia occurs when there 1. Polyuria
2. Polyphagia
2. Inactivity is an increase in blood glucose
3. Polydipsia
3. Not taking >200mg/dL 4. Dehydration
insulin/diabetic 5. Blurred vision
6. Fruity breath
medication 7. Dry skin

NURSING MANAGEMENT treatment

1. Assess glucose level Insulin
2. Insulin administration as prescribed Glucose monitoring
Education Diabetic diet
1. Educate patient on glucose monitoring
2. Educate patient on diabetic diet
3. Educate patient on exercise.

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disorder:
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY

NURSING MANAGEMENT Treatment

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ADRENAL CORTEX DISORDERs

1. Addison's Disease
2. Cushings

Addison's Disease
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Autoimmune disease Addison's disease is the inadequate 1. Weight loss
production of steroid hormones by 2. Fatigue
the adrenal cortex. 3. Lethargy
4. Hypotension
Addisonian Crisis: life-threatening
5. Hyperkalemia
6. Hypercalcemia
condition. Caused by stress,
7. Hyponatremia
infection or surgery.
8. Hyperpigmentation

NURSING MANAGEMENT Treatment

1. Monitor BP Pharmacology
2. Monitor daily weights Glucocorticoid
3. Monitor intake and output
4. Monitor electrolyte level Mineralocorticoid
5. Monitor glucose level
6. Administer medications as prescribed
Addisonian Crisis:
1. Administer glucocorticoids IV

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 Cushings
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Moon face
1. Adrenal tumor Cushing syndrome is the excessive
2. Buffalo hump
level of adrenocortical hormones
3. Truncal obesity
(cortisol).
4. Hypertension
5. Hyperglycemia
Remember: Addison's disease is
6. Hypernatremia
the hyposecretion of steroids.
7. Hypocalcemia
Cushing syndrome is the
8. Hypokalemia
hypersecretion of steroids
9. Masculine features
(Hirsutism)
NURSING MANAGEMENT treatment
Monitor BP Chemotherapeutic agents:
Monitor daily weights for adrenal tumors
Monitor intake and output Glucocorticoid replacement:
Monitor electrolyte level lifelong
Monitor glucose level
Administer medications as prescribed Surgical intervention:
Prepare patient for adrenalectomy if
applicable Adrenalectomy
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DISORDER:
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY

NURSING MANAGEMENT Treatment

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pituitary gland DISORDERs
1. Hypopituitarism
2. Hyperpituitarism
3. Diabetes Insipidus
4. SIADH

Hypopituitarism
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Signs and symptoms depend
1. Pituitary tumor Pituitary gland is located at the base on the hormone affected.
of the brain.
2. Head injury Hypopituitarism is the hyposecretion of Growth Hormones:
pituitary hormones. 1. Obesity, Decreased BP
3. Stroke Hormones that may be affected: TSH
Growth hormone (GH) 1. Obesity, Fatigue,
4. Autoimmune decrease BP
Luteinizing hormone (LH) and ACTH
5. Encephalitis follicle-stimulating hormone (FSH) 1. Sexual dysfunction
Thyroid-stimulating hormone (TSH) Gonadotropins
Adrenocorticotropic hormone 1. Sexual dysfunction
(ACTH) ADH
Anti-diuretic hormone (ADH) 1. Low BP, Decreased CO

NURSING MANAGEMENT Treatment

1. Daily weights Pharmacology
2. Hormonal replacement may be Hormone replacement
prescribed
3. Provide emotional support
4. Allow patient to verbalize feelings

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 Hyperpituitarism/ Acromegaly
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Pituitary gland is located at the 1. Enlarged Organs
1. Pituitary Tumors 2. Large hands and feet
base of the brain.
3. Hypertension
Hyperpituitarism is caused by the 4. Cardiomegaly
hypersecretion of growth 5. Oily skin
hormone. 6. Diaphoresis
7. Hyperglycemia
8. Husky-sounding voice
9. Sleep apnea
10. Joint pain

NURSING MANAGEMENT treatment

Pharmacology
1. Administer medication Growth Hormone Receptor
2. Prepare patient for hypophysectomy Antagonist
if applicable
Surgical Intervention
3. Provide emotional support
Hypophysectomy: removal of
4. Pain management
pituitary tumor

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Diabetes Insipidus
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Stroke Diabetes Insipidus is characterized by 1. Polyuria
the hyposecretion of ADH. This results 2. Diluted urine
2. Trauma 3. Dry mucous membranes
in abnormal increase in urine output.
3. Craniotomy 4. Postural hypotension
Remember: Antidiuretic hormone 5. Tachycardia
(ADH) causes the kidneys to release 6. Low urinary specific
less water. gravity
If ADH level is low, there is an 7. Headache
increase in water loss. 8. Body weakness
9. Fatigue

NURSING MANAGEMENT Treatment

1. Monitor fluids and electrolytes Pharmacology
2. Monitor weights Desmopressin acetate/Vasopressin
IV Therapy
3. Monitor intake and output IV hypotonic saline
4. Monitor skin integrity
5. Administer hypotonic saline (IV)
6. Administer medications as prescribed

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 SIADH
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Stroke Syndrome of Inappropriate 1. Fluid overload
Antidiuretics Hormone Secretion 2. Weight gain
2. Trauma (SIADH) is the secretion of ADH in 3. Hypertension
3. Lung disease excess levels. This results in water 4. Hyponatremia
retention.
5. Tachycardia
Remember: Antidiuretic hormone 6. Concentrated urine
(ADH) causes the kidneys to release 7. Low urinary output
less water. 8. Nausea/Vomiting
If ADH is high, there is an increase in
water retention.

NURSING MANAGEMENT treatment

1. Monitor BP/P Pharmacology
2. Monitor serum Na levels Loop diuretics
3. Initiate seizure precautions Vasopressin antagonists
4. Restrict fluid intake
5. Monitor weights
6. Elevate HOB
7. Administer medications as prescribed

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DISORDER:
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY

NURSING MANAGEMENT Treatment

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SKELETAL DISORDERs
1. Gout
2. Rheumatoid Arthritis
3. Osteoarthritis

Gout
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Diet Gout is a systemic disorder 1. Joint pain (Intense)
characterized by elevated uric acid 2. Inflammation
2. Obesity and urate crystals that accumulate
deposits in the joints and other body 3. Swelling and
3. Kidney disease tissues. redness
Stages 4. Low grade fever
Asymptomatic stage 5. Pruritus
Acute Gouty arthritis
Chronic Gout 6. Tophi
Complications: Kidney stones

NURSING MANAGEMENT Treatment

1. Assess ROM Pharmacology
2. Diet: low-purine Analgesics
3. Encourage fluid intake (2000mL/day) Anti-inflammatory Agents
4. Administer medications Uricosuric Agents
5. Provide comfort and
nonpharmacologic interventions
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 Rheumatoid Arthritis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Rheumatoid Arthritis is an 1. Joint stiffness
1. Higher risk in women 2. Joint tenderness
2. Age: Onset is most autoimmune disorder.
3. Joint deformity
The immune system attacks the 4. Pain (moderate to
frequent between joints, leading to dislocation and severe)
the ages of 40-50 permanent deformity. 5. Rheumatoid nodules
6. Fatigue
7. Fever
8. Weight loss

NURSING MANAGEMENT treatment

1. Assess pain Pharmacology
2. Administer medications as prescribed NSAIDs
3. Assess ROM Glucocorticoids
4. Provide nonpharmacologic pain management DMARDs: Disease-modifying
such as positioning, heat or cold therapy. antirheumatic drugs
5. Assess and assist patient with self care Surgical Intervention
6. Promote energy conservation A surgical intervention would be
7. Pre and post operative care if applicable
recommended to restore function.

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Osteoarthritis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Aging Osteoarthritis is the most common 1. Joint pain
2. Obesity form of arthritis. 2. Joint stiffness
Osteoarthritis causes deterioration of 3. Crepitus
3. Genetics
joint cartilage. 4. Swelling
5. Limited ROM
Temperature affects
symptom severity.

NURSING MANAGEMENT Treatment

1. Assess pain Pharmacology
2. Administer medications as prescribed NSAIDs
3. Assess ROM Acetaminophen
4. Provide non-pharmacologic pain Muscle relaxant
management Therapy
5. Encourage balance between rest and Physical therapy
physical therapy (low impact exercises). Surgical Intervention:
May be required
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HEMATOLOGY DISORDERs
1. Iron Deficiency Anemia
2. Thrombocytopenia

Iron Deficiency Anemia

rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Diet Iron deficiency anemia is characterized 1. Fatigue
2. Blood loss (GI bleeds) by insufficient iron which leads to 2. Pallor
depletion of red blood cells. This 3. Brittle nails
3. Pregnancy
results in decreased hemoglobin and
4. Mensuration decreased oxygen-carrying capacity of
5. Inability to absorb the blood.
iron

NURSING MANAGEMENT Treatment

1. Administer Iron supplements as prescribed (Oral, Iron supplement
IM or IV)
2. Educate patient on the side effects of iron Treatment of underlying
supplements: Constipation and black stools cause
3. Educate patient on iron-rich diet/foods
4. Educate patient to increase vitamin C Diet: Iron-rich foods
consumption in their diet
5. Educate patient to take liquid iron supplements
with a straw to prevent teeth staining.

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 Thrombocytopenia
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Platelets (thrombocytes) stops bleeding by 1. Easy bruising (Purpura)
1. Bone marrow clumping and forming plugs in the blood 2. Petechia
disease vessel injury site. 3. Prolonged bleeding
2. Autoimmune disease Thrombocytopenia is a condition time
characterized by low blood platelet count. 4. Bleeding gums
3. Splenomegaly 5. Epistaxis (Nose bleeds)
Causes: 6. Blood in urine or stools
4. Alcoholism Platelet destruction: autoimmune
Platelet sequestration: trapped 7. Heavy menstrual flows
5. Anemia platelet in the spleen (enlarged spleen)
Decreased platelet production: bone
marrow disease.

NURSING MANAGEMENT treatment

1. Monitor lab values Platelet transfusions
2. Monitor INR, PT/PTT Corticosteroid treatment
3. Use electric razors Bone marrow transplant
4. Avoid anticoagulants, aspirin and
thrombolytics
5. Protect patient from falls/injury

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DISORDER
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY

NURSING MANAGEMENT Treatment

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rEPRODUCTIVE DISORDERs
1. PCOS
2. Endometriosis
3. Pelvic Inflammatory
Disease

PCOS
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Excess androgen Polycystic ovary syndrome (PCOS) is a 1. Diabetes
2. Heredity hormonal disorder characterized by 2. Infertility
excess androgen levels. 3. Sleep apnea
4. Irregular periods
The ovaries may develop follicles.
5. Polycystic ovaries

NURSING MANAGEMENT Treatment

1. Educate patient on the importance of Diet
a. Weight loss Weight loss
b. Low fat diet Metformin
c. Medication adherence Oral contraceptives
d. Glucose monitoring Anti-androgens

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 Endometriosis
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. No known cause Endometriosis occurs when the 1. Dysmenorrhea
tissues lining the uterus grows 2. Painful intercourse
outside the uterus. 3. Excessive bleeding
With endometriosis, the tissues 4. Infertility
outside the uterus thickens,
breaks down and bleeds with
each menstrual cycle.

NURSING MANAGEMENT treatment

1. Educate patient on Hormone therapy
Treatment of anemia
a. Pain management
b. Anemia Surgical Intervention
c. Hormone therapy Hysterectomy

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Pelvic Inflammatory Disease

rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Being sexually active Pelvic inflammatory disease (PID) is 1. Fever
2. Having multiple an infection of the female 2. Pelvic pain
reproductive organs 3. Increased vaginal
partners
discharge
3. Unprotected
intercourse

NURSING MANAGEMENT Treatment

1. Educate patient on Antibiotics
a. Antibiotic regimen Treatment for partner
b. Protected intercourse Temporary abstinence until treatment
c. Treatment of partner is complete
d. Temporary abstinence

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REPRODUCTIVE DISORDERs
1. Varicocele

Varicocele
rISK FACTORS/causes sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. No known risk factors Varicocele is the enlargement of the 1. Dull pain in scrotum
veins that transport oxygen- 2. Varicocele may be
depleted blood away from the visible
testicles. 3. Swelling

NURSING MANAGEMENT Treatment

1. Educate patient to Treatment depends on the
a. Wear athletic supporter to relieve severity and complications
pressure

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sho
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shock
what is shock?
Shock is an acute, life-threatening condition in which the body is not
getting enough blood flow to maintain the normal supply of oxygen
and nutrients for optimal cell function.
This leads to hypoxia (lack of oxygen at the tissue level).

Circulatory failure
COMPLICATIONS
1. Multiple organ
dysfunction syndrome
2. Disseminated Decreased CO
intravascular
coagulation
Lack of blood perfusion to vital organs

summary of the types of shock

CARDIOGENIC SHOCK
Occurs due to the heart's inability to pump enough blood

HYPOVOLEMIC SHOCK
Severe bleeding or fluid loss (burns, trauma)

ANAPHYLACTIC SHOCK
Severe allergic reaction (drugs, food, insect bite)

SEPTIC SHOCK
Occurs due to an infection. Severe complication of sepsis

NEUROGENIC SHOCK
Occurs due to damage to the nervous system
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shock
INITIAL STAGE
OH NO! The body is not getting enough blood!
INITIAL STAGE

The level of oxygen is low! We are experiencing cell hypoxia!

Sorry guys! I need to start performing anaerobic metabolism

Things are getting worse! Lactic acid is accumulating

COMPENSATORY STAGE
The body is here to SAVE THE DAY! We need to work
COMP

together to increase cardiac output and blood volume

PROGRESSIVE STAGE
OH NO! We failed! Now our vital organs are compromised
REFRACT PROG

and the shock cannot be reversed

REFRACTORY STAGE
Brain damage + cell death

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stages of shock
INITIAL STAGE
1. Decreased cardiac output causes the cells to be deprived of
oxygen
2. The cells begin to perform anaerobic metabolism
3. Anaerobic metabolism causes the build up of lactic acid
which leads to metabolic acidosis
4. The liver is unable to remove and breakdown lactic acid
because of the lack of oxygen.

WHAT WILL YOU SEE IN THIS STAGE

1. Decreased cardiac output
2. Decreased mean arterial pressure (MAP)
3. Elevated serum lactate

COMPENSATORY STAGE
1. During this stage, the body is here to SAVE THE DAY!
2. The body tries to compensate and intervene to
stop/overcome the shock.
3. The body tries to increase the CO + blood volume

WHAT WILL YOU SEE IN THIS STAGE

1. Respiratory: Hyperventilation
2. Skin: Cool and clammy or Warm/flushed
3. Cardiac: Increase HR
4. GU: Oliguria may develop

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stages of shock
PROGRESSIVE STAGE
1. The SAVE THE DAY plan did not work and the body's
intervention failed.
2. Vital organs are compromised and the shock cannot be
reversed
3. Anaerobic metabolism continues and metabolic acidosis
increases.
4. Leakage of fluid in the surrounding tissues (capillary
permeability) + blood viscosity increases.

WHAT WILL YOU SEE IN THIS STAGE

1. CNS: Altered mental status
2. RESP: Acute respiratory distress syndrome
3. CARDIAC: Decreased CO+ tissue perfusion,
4. Skin: Cyanosis
5. GU: Oliguria, GI: GI bleeding

REFRACTORY STAGE
1. Vital organs fails and the shock is irreversible
2. Brain damage + cell death

WHAT WILL YOU SEE IN THIS STAGE

1. Unconsciousness
2. Brain damage
3. Cell death
4. Impending death

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cardiogenic shock
cardiogenic shock
Cardiogenic shock occurs due to the heart's
inability to pump enough blood. Pulmonary
edema will occur due to back up of blood.

HEART MI HEART
FAILURE MYOCARDITIS VALVE
DISEASE

causes

cardiogenic shock
signs and symptoms treatment
1. CARDIAC: Fast, weak pulse, 1. Oxygen therapy
decreased systolic blood 2. Pain management
pressure, chest pain 3. Hemodynamic monitoring
2. RESP: Orthopnea, rapid, shallow 4. Intra-aortic balloon pump
respirations, crackles Pharmacology:
3. SKIN: Cool/Clammy Skin, 1. Vasopressors and inotropes
Cyanosis
cyanosis
4. GU: Oliguria, CNS: Confusion

nursing management
1. Monitor patient's vital signs
2. Initiate O2 therapy
3. Administer IV fluids as prescribed and monitor for any signs of fluid overload
4. Place a catheter and monitor urine output
5. Provide supportive care

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hypovolemic shock
hypovolemic shock
Hypovolemic shock occurs when there is a
loss in intravascular blood volume due to
severe bleeding or fluid loss

severe
Internal bleeding,
bleeding vomiting, burns
diarrhea
causes

hypovolemic shock
signs and symptoms treatment
1. CARDIAC: Hypotension, 1. Treat the underlying cause
tachycardia(rapid, weak and thready of the severe blood or fluid
pulse) loss
2. RESP: Rapid, shallow breathing 2. Fluid resuscitation
3. SKIN: Pale, Cool/Clammy Skin
4. GU: Oliguria
5. CNS: Confusion, restlessness, anxiety

nursing management
1. Monitor patient's vital signs, temperature, capillary refill, I/0
2. Monitor patient's level of consciousness
3. Initiate O2 therapy
4. Initiate IV fluid therapy
5. Blood transfusion may be required
6. Patient position: Supine with the legs elevated

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 Distributive shock
Distributive shock results from excessive vasodilation
and the impaired distribution of blood flow.
1. ANAPHYLACTIC SHOCK
2. SEPTIC SHOCK
3. NEUROGENIC SHOCK

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ANAPHYLACTIC SHOCK
anaphylactic shock
Anaphylactic shock occurs due to a severe
allergic reaction (drugs, food, insect bite, etc)
1. Reintroduction to the sensitized allergen
2. IgE binds to the antigen
3. Activation of mast cells + basophils
4. The mast cells then release massive amounts
of histamine + other inflammatory mediators
5. Massive vasodilation occurs + decrease tissue
perfusion
6. Bronchospasm & laryngeal edema may occur

anaphylactic shock
signs and symptoms treatment
1. CARDIAC: Tachycardia, (This is a medical emergency)
hypotension 1. O2 therapy
2. RESP: Shortness of breath, 2. IV therapy
bronchoconstriction Pharmacology:
3. SKIN: Hives, flushed, itching, 1. Epinephrine
localized edema 2. Albuterol
4. GU: Oliguria 3. Antihistamines
5. CNS: Decreased LOC 4. Hydrocortisone (corticosteroids)
nursing management
1. Remove allergen, maintain patent airway
2. Monitor vital signs
3. Administer epinephrine promptly
4. Initiate 02 therapy
5. Initiate IV therapy & monitor urine output
6. Position: supine position with leg elevated

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SEPTIC SHOCK
septic shock
Septic shock occurs due to an infection.
(Severe complication of sepsis). This
results in vasodilation and increased
capillary permeability due to the release of
histamines and proteolytic enzymes.
1. invasive procedures
2. Immunocompromised Patients
3. Malnourishment
4. Elderly people
risk factors

septic shock
signs and symptoms treatment
1. CARDIAC: Hypotension, tachycardia 1. IV fluid therapy
2. RESP: increased respirations 2. Oxygen therapy
3. SKIN: Initial stage-flushed & warm 3. Mechanical ventilation
4. GU: Oliguria (late stage) (intensive care) may be
5. Immune: Fever required
6. CNS: Anxiety, restlessness, Pharmacology
lethargy 1. Antibiotics, Inotropes
nursing management
1. Monitor vital signs
2. Monitor respiratory status
3. Initiate IV fluids and oxygen therapy
4. Administer medication as prescribed
5. Nutritional therapy
6. Fever management

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NEUROGENIC SHOCK
neurogenic shock
Neurogenic shock occurs due to damage to the
nervous system. There is a loss of sympathetic
nerve activity which results in vasodilation.

SPINAL INJURY OF Spinal

CORD THE anesthesia
INJURY BRAIN STEM

cause VASODILATION

neurogenic shock
signs and symptoms treatment
1. IV fluid therapy
1. CARDIAC: Hypotension,
2. O2 therapy
bradycardia
Pharmacology:
2. SKIN: Dry, warm skin
1. Inotropic agents
3. Depending on the type of
2. Atropine: severe bradycardia
injury, patient may have no
bladder control and
diaphragmatic breathing
nursing management
1. Perform neurologic assessment
2. Maintain patent airway
3. Monitor vital signs
4. Initiate O2 therapy and IV fluids as prescribed
5. Foley catheter for patients who do not have bladder control
6. Maintain proper alignment of spine
7. Administer medication as prescribed

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TEMPLATES

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cardiogenic shock
cardiogenic shock

causes

cardiogenic shock
signs and symptoms treatment

nursing management

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hypovolemic shock
hypovolemic shock

causes

hypovolemic shock
signs and symptoms treatment

nursing management

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ANAPHYLACTIC SHOCK
anaphylactic shock

anaphylactic shock
signs and symptoms treatment

nursing management

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SEPTIC SHOCK
septic shock

risk factors

septic shock
signs and symptoms treatment

nursing management

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NEUROGENIC SHOCK
neurogenic shock

cause VASODILATION

neurogenic shock
signs and symptoms treatment

nursing management

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REVISION notes
cardiogenic shock
summary

hypovolemic shock
summary

ANAPHYLACTIC SHOCK
summary

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REVISION notes
SEPTIC SHOCK
summary

NEUROGENIC SHOCK
summary

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Hepatitis is characterized by the inflammation of the liver tissues.

1. Production of bile
2. Glucose metabolism
3. Bilirubin excretion
4. Drug metabolism

1. VIRUS 1. ALCOHOL 5. Fat and protein

2. BACTERIA 2. MEDICATIONS metabolism

3. TOXINS 6. Clotting factors

7. Filters and remove toxins
8. Ammonia conversion

1. Incubation period: virus

multiplies and spreads
(no symptoms)
2. Prodromal (pre-icteric)

FECAL-ORAL (FOOD+WATER) phase: 1-5 days. S/S:

anorexia, malaise,
BLOOD & BODY FLUIDS nausea and vomiting,
RUQ pain

BLOOD & BODY FLUIDS 3. Icteric phase: dark

urine, jaundice, weight
loss, RUQ pain.
OCCURS WITH HEP B 4. Recovery phase: pt
signs and symptoms

FECAL-ORAL (FOOD+WATER) improves.

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1. BLOOD TEST:
a. ALT & AST (elevated) In patients with findings
b. Bilirubin suggesting acute viral
hepatitis, the following
2. STOOL SAMPLE:
studies are done to screen for
a. Hepatitis A hepatitis viruses A, B, and C:
3. URINE SAMPLE: IgM antibody to HAV (IgM
a. Bilirubin anti-HAV)
4. LIVER BIOPSY Hepatitis B surface
antigen (HBsAg)
5. LIVER ULTRASOUND
IgM antibody to hepatitis
B core (IgM anti-HBc)
Antibody to HCV (anti-
1. Prevention: Immunization HCV)
(Vaccines for hepatitis A and Hepatitis C RNA (HCV-
RNA) polymerase chain
hepatitis B)
reaction (PCR)
2. Prevention: hand-hygiene
3. Rest
4. Diet (high carbs, high calories)
(low protein and low fat)
5. Hepatitis B: Antiviral
medications
1. Assess GI status
2. Monitor daily weights
3. Promote high carbs, high calories, low protein and fat diet
4. Pt. Education: hand hygiene, avoid alcohol, avoid sex during
treatment

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Three layers of the skin:

1. Epidermis
2. Dermis
3. Hypodermis
Burns lead to:
1. Infection
2. Hypothermia
3. Disturbed body image
4. Changes in level of
Definition: independence/function

Damage of the layers of the skin caused by heat, chemicals, or radiation

PATHOPHYSIOLOGY of burns:
1. Injured tissue releases vasoactive substances
2. Fluid shift
a. Increased capillary permeability (lasts for 26 hours)
b. Blood vessels dilate and leak fluid into interstitial space
c. Amount of fluid shift depends on extent of injury
d. Body edema
e. Decreased intravascular blood volume
3. Hyper K+ due to cell damage + hypo Na
4. Cardiac: increased HR, decreased CO
5. Respiratory: Airway edema, pulmonary cap. leakage
6. Immune system: diminished response, Increased risk of infection
7. Renal: oliguria
8. GI: Paralytic ileus may occur due to lack of blood flow to the GI system
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Definition: inhales combustion

1. Thermal burn: external heat
during fire.
sources that raise the
temperature of the skin and
Remember: priority is airway
tissues.
management.
2. Radiation burns: prolonged
exposure to ultraviolet rays of
Nursing Assessment:
the sun.
1. Facial burns
3. Chemical burns: caused by
2. SOB, wheezing, cough,
solvents
nasal flaring, stridor
4. Electrical burns: burns caused
by electrical currents
Carbon Monoxide Poisoning
5. Friction burns: caused by heat
1. Carbon monoxide is a
generation through friction
poisonous gas that has no
6. Inhalation: respiratory injury
smell or taste.
(inhales combustion during a
Nursing Assessment: cherry red
fire)
discolouration.

superficial burn:
-Affects the epidermis, mild redness with pain, no blisters

superficial partial-thickness burn:

-Affects the epidermis + dermis, redness, swelling, pain, large blisters

FULL-thickness burn:
-Affects the epidermis + dermis + hypodermis. May appear white, deep
red, yellow, brown or black.
No sensation. Requires skin grafting
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1. The front and back of the head and neck equal 9% of the body's
surface area.
2. The front and back of each arm and hand equal 9% of the body's
surface area.
3. The chest equals 9% and the stomach equals 9% of the body's
surface area.
4. The upper back equals 9% and the lower back equals 9% of the
body's surface area.
5. The front and back of each leg and foot equal 18% of the body's
surface area.
6. The genital area equals 1% of the body's surface area.

The size of a burn

can be quickly
estimated by using
the "rule of nines."
This method divides
the body's surface
area into
percentages.
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remember: Fluid
shift
1. Duration: first 24 hours
2. Maintain patent airway
3. IV fluid therapy 1. Patient will experience
tachycardia, low cardiac
lac

output and low blood

tat

iv pressure.
ids
ed

fl u
rin
ger
s

1. Hgb/Hct…elevated due to fluid loss

2. Glucose…elevated due to stress response
3. Sodium…decreased
4. Potassium…increased due to tissue destruction
5. Albumin…decreased
6. ABG’s
a. pO2…decreased
b. pCO2…increased due to resp injury
c. pH…decreased metabolic acidosis
d. CO…elevated-smoke inhalation

Maintain patent airway Monitor vital signs

Administer IV fluids Monitor output (Foley's
Monitor lab values catheter)
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remember: capillary
permeability is restored

1. Duration: 48-72 hours after injury

2. Goal of care:
a. prevent infection-antibiotics 1. High protein diet
b. nutrition 2. High carbohydrate diet
c. pain management 3. High vitamins in diet
d. wound closure 4. Calories: >5000(severe
burns)
1. Prevent ulcers
a. Antacids, H2 receptor
antagonist
2. Prevent infection
a. Antibiotics
3. Pain management
a. Opioid analgesics (IV)

Goal: remember: Beyond hospitalization

1. Focus on patient reaching maximum level of function.
2. Body image
3. Self esteem
4. Activities of daily living
5. Emotional support
6. Promote wound healing

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respiratory disorders
Chest Tubes
Chest tubes are inserted in the pleural space to remove air, fluid or blood
and restore lung expansion.
UWSD-Under Water Sealed Drains

CONDITIONS THAT REQUIRES CHEST TUBE INSERTION

Pleural effusion: Accumulation of fluid in the pleural space.
Fluid accumulates between the visceral and parietal pleura
of the lungs.
Pleural fluid: transudate or exudate

Hemothorax: Accumulation of blood in the pleural cavity.

Pneumothorax: Air leaks into pleural space. Pleural space is exposed

to positive atmospheric pressure (pressure is normally negative).
Causes impaired lung expansion.
Results in full lung collapse or partial lung collapse.

Types
Spontaneous pneumothorax
Tension pneumothorax
Traumatic pneumothorax

Post-surgical intervention: e.g. cardiac surgery. A chest tube is

inserted to prevent complications. It ensures that fluid and air is
drained fluently from the pleural space.

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CHEST TUBE
types
1. Wet suction system Wet suction system: regulate suction
pressure by the height of the column
2. Dry suction system
of water in the suction control
chamber.
CHAMBERS
Dry suction system: uses a self-
Drainage collection chamber controlled regulator that controls the
1.Drainage collection chamber: amount of suctioning.
collects drainage from the
pleural cavity. Located at the
right side of the system where
the chest tube connects to the
system.

Water seal chamber

2. water seal chamber: the
water in the underwater seal
fluctuate with inspiration and
expiration.
Excessive bubbling: air leak
dry suction system
Suction control chamber
3. Suction control chamber:
In a wet suction system-
controlled by the level of water
in the suction control chamber.
In a dry suction system: self-
regulator controls the amount of
suctioning.
wet suction system
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nursing interventions
nursing interventions
assessment
1. Vital signs-Bp, HR, SPO2, RR
2. Pain assessment
3. Assess respiratory status/auscultate lung sounds
4. Monitor for any signs of infection at the insertion site.
DRAINAGE collection chamber
1. Monitor drainage: Normal (<100mL(cc)/hour). Notify HCP if
drainage is >100mL(cc)/hour)
a. Note the color: unexpected bloody fluids, and cloudiness.

water seal chamber

1. If the water does not fluctuate, there is a kink or the lungs have
reexpanded.
2. Air is removed through the tube, but air is prevented from entering
the lungs.
3. Continuous bubbling: air leakage.
4. Patient with pneumothorax: intermittent bubbling in the water seal
chamber (assess dislodgment and disconnection)

Suction control chamber

1. Wet suction chamber: gentle bubbling is noted.

other nursing considerations

1. Maintain chest tube drainage system below patient's chest
2. Ensure that the connection is secured
3. Keep the tube free from any kinks or obstructions.
4. Do not milk chest tube (unless indicated by physician).
5. Avoid clamping chest tube without prescription.
6. Drainage breaks: insert tubing (1 inch) into a bottle of sterile water.
7. Dislodged chest tube: cover the insertion site (sterile dressing),
tape 3 sides and notify the physician.

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IMBALANCE

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HYPERVOLEMIA
Definition:
Increase in extracellular fluid volume. Fluid and sodium
retention. Also known as fluid overload or excess fluid volume
Function:
Extracellular fluid are body fluid located outside of the cell.
The extracellular fluid provides a medium for exchanges of
substances between the ECF and the cells.

Causes: Symptoms:
1. Heart failure 1. Elevated BP
2. Bounding pulse
2. Liver cirrhosis 3. Ascites
3. Excess fluid/ sodium 4. JVD
5. Edema
intake 6. SOB/crackles
4. Renal failure 7. S3 heart sound
8. Urine specification <1.010
Nursing Interventions
1. Monitor Bp and pulse 6. Obtain daily weight
2. Monitor respiratory status 7. Restrict sodium intake
3. Monitor intake and output 8. Monitor lab values
4. Fluid restriction
5. Diuretics
HYPOVOLEMIA
Definition:
Hypovolemia is the loss of extracellular fluid.

Function:
Extracellular fluid are body fluid located outside of the cell.
The extracellular fluid provides a medium for exchanges of
substances between the ECF and the cells.

Causes:
1. Vomiting
2. Diarrhea
3. Continous GI suctioning
4. Hemorrhage
5. DKA
6. Burns
7. Adrenal desease
8. Systemic infection
Nursing Interventions
1. Monitor Bp and pulse
2. Administer isotonic IV fluids
3. Encourage fluids
4. Monitor intake and output
Symptoms:
1. Decreased Bp
2. Tachycardia/weak pulse
3. Decreased urinary output
4. Poor skin turgor
5. Restlessness/Confusion
6. Dry mucus membranes
7. Thirst
6. Assess skin turgor
7. Assess hydration levels
8. Assess urine specific gravity
9. Monitor lab values
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HYPERNATREMIA 135-145mEq/L
Definition:
Sodium serum level >145 mEq/L

Function:
Sodium is mostly found in the extracellular fluid.
Sodium helps to maintain concentration of extracellular fluid,
neuromuscular function, sodium-potassium pump and acid-base
balance.
Causes: Symptoms:
1. Dehydration Cardiac: Tachycardia,
2. Diabetes insipidus Increased BP
GI: Thirst
3. Fluid loss-GI GU: Oliguria
4. Cushing Syndrome Neuro: Restlessness,
anxiety
5. Increased Na Intake Skin: Edema
Nursing Interventions
1. Monitor Bp 5. Obtain daily weight
2. Monitor respiratory status 6. Monitor serum sodium levels
3. Monitor neurologic status 7. Increase hydration
4. Monitor intake and output 8. Low sodium diet

Na HYPONATREMIA 135-145mEq/L
Definition:
Sodium serum level <135 mEq/L

Function:
Sodium is mostly found in the extracellular fluid.
Sodium helps to maintain concentration of extracellular fluid,
neuromuscular function, sodium-potassium pump and acid-base
balance.
Causes: Symptoms:
1. Diuretics Cardiac: Tachycardia, thready
2. Diarrhea pulse, hypotension
3. Vomiting
4. Congestive HF GI: Nausea, Vomiting
5. Hyperglycemia Neuro: Restlessness, headache
6. Medication
7. Continuous gastric dizziness, weakness,seizure
suctioning
Nursing Interventions
1. Monitor Bp 6. Assess skin turgor
2. Monitor respiratory status 7.Obtain daily weight
3. Monitor neurologic status 8. Monitor serum sodium levels
4. Monitor intake and output 9. Fluid intake restriction
5. Institute seizure 10. High sodium diet
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K
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HYPERKALEMIA 3.5-5.5 mEq/L

Definition:
Potassium serum level >5.5 mEq/L

Function:
Potassium is mostly found in the intracellular fluid. Potassium
participates in potassium-sodium pump and neuromuscular
function.
Causes: Symptoms:
Cardiac: V-fib, T wave elevation,
1. Kidney failure prolonged PR, Flat P wave, Wide QRS
2. Trauma
3. Sepsis GI: Abdominal cramps
4. Potassium-sparing GU: Oliguria
diuretics Neuro: Numbness, tingling,
5. Addison's disease hyperreflexia, flaccid paralysis
6. Dehydration Risk: Cardiac arrest
7. Metabolic acidosis

Nursing Interventions
1. Monitor cardiac status
2. Monitor HR and rhythm
3. Monitor intake and output
4. Low potassium diet

K HYPOKALEMIA 3.5-5.5mEq/L
Definition:
Potassium serum level <3.5 mEq/L

Function:
Potassium is mostly found in the intracellular fluid. Potassium
participates in potassium-sodium pump and neuromuscular
function.
Causes: Symptoms:
1. Diarrhea Cardiac: Hypotension, Arrhythmias,
2. Vomiting Flattened T-wave, ST depression
3. Gastric suctioning GI: Nausea, Vomiting, decreased
4. Low potassium diet peristalsis
GU: Polyuria
Neuro: Dizziness, weakness,
decreased reflexes, Metabolic
Alkalosis

Nursing Interventions
1. Monitor cardiac status 5. Monitor potassium level
2. Monitor HR and rhythm 6. Monitor hydration status
3. Monitor intake and output
4. High potassium diet
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Ca
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HYPERCALCEMIA 8.5-10.5mEq/L
Definition:
Calcium serum level >10.5 mEq/L

Function:
Calcium is a cation that contributes to bone strength,
necessary for hormonal secretion, cardiac conduction and
participates in the sodium-potassium pump.
Causes: Symptoms:
1. Bone cancer Cardiac: Increased BP, heart block
2. Hyperparathyroidism (may lead to cardiac arrest)
3. Hyperthyroidism GI: Dehydration, constipation,
4. AKI polydipsia
5. Rhabdomylysis GU: Polyuria, kidney pain
6. High Vitamin D intake Neuro: Confusion, irritability
Musculoskeletal: Bone pain
Nursing Interventions
1. Monitor cardiopulmonary 4. Monitor cardiac rhythms
status 5. Monitor serum calcium levels
2. Monitor neurologic status 6. Low calcium diet
3. Monitor vital signs

Ca HYPOCALCEMIA 8.5-10.5mEq/L
Definition:
Calcium serum level <8.5 mEq/L

Function:
Calcium is a cation that contributes to bone strength,
necessary for hormonal secretion, cardiac conduction and
participate in the sodium-potassium pump.
Causes: Symptoms:
1. Lack of Vitamin D intake Cardiac: Arrhythmias, Bradycardia,
2. Lack of Calcium intake Hypotension, weak pulse
3. Hypoparathyroidism Neuro: Paresthesia, muscle spasms,
4. Hypothyroidism seizures, Trousseau signs, Chvostek
5. Burns
6. Sepsis signs
7. Kidney/liver disease Resp: Dyspnea, Lanryngospasm

Nursing Interventions
1. Monitor cardiac status 5. Seizure precautions
2. Monitor HR and rhythm 6. Assess neuromuscular movements
3. Monitor respiratory status 7. Increase Vit D and calcium intake
4. Monitor calcium levels
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HYPERMAGNESEMIA 1.3-2.1mEq/L
Definition:
Magnesium serum level >2.1 mEq/L

Function:
Magnesium regulates the intracellular fluid calcium levels.
Magnesium has an effect on the myoneural junction, skeletal
muscles, parathyroid hormone secretion and cardiac contraction.
Causes: Symptoms:
Cardiac: Hypotension, bradycardia,
1. Laxative use that weak pulse, cardiac arrest
contains Mg
2. Use of antacid Resp: Dyspnea, low RR
(containing Mg) Neuro: Confusion, dilated pupils,
3. Renal dysfunction lethargy
4. Decreased adrenal Musculoskeletal: Muscle weakness,
function facial paresthesia, decreased
reflexes
Nursing Interventions
1. Monitor cardiopulmonary 3. Intake and output
status 4. Monitor neurologic status
2. Monitor respiratory status,5. Decrease Mg dietary intake
Bp and P. 6. Avoid laxatives

Mg HYPOMAGNESEMIA 1.3-2.1mEq/L
Definition:
Magnesium serum level <1.3 mEq/L

Function:
Magnesium regulates the intracellular fluid calcium levels.
Magnesium has an effect on the myoneural junction, skeletal
muscles, parathyroid hormone secretion and cardiac contraction.
Causes: Symptoms:
1. Chronic alcoholism Cardiac: Arrhythmias, Tachycardia,
2. Hyperaldosteronism High BP
3. Diabetic ketoacidosis Neuro: Seizures, Delusions,
4. Malabsorption, Hallucinations
Malnutrition Neuromuscular: Tetany, Chvostek
5. Chronic diarrhea signs,Positive Trousseau's
6. Dehydration
Nursing Interventions
1. Assess level of
consciousness 4. Monitor Intake and output
2. Assess VS 5. Monitor cardiopulmonary status
3. Monitor Mg levels 6. Increase Mg dietary intake
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table of content
1. Terminologies
2. Electrical Conduction
3. EKG Breakdown
4. EKG Interpretation
5. 5-Lead Placement
6. Electrolyte Imbalance
7. Normal Sinus Rhythm
8. Sinus Bradycardia
9. Sinus Tachycardia
10. Sinus Arrhythmia
11. Premature Atrial Contractions (PAC)
12. Atrial Fibrillation
13. Atrial Flutter
14. Premature Junctional Contraction (PJC)
15. Premature Ventricular Contractions (PVC)
16. Ventricular Tachycardia
17. Ventricular Fibrillation
18. First-Degree Block
19. Second-Degree AV Block (TYPE 1)
20. Second-Degree AV Block (TYPE 2)
21. Third-Degree AV Block
22. Aystole
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the
basics

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terminologies
ekg/ecg: is a test that measures the electrical signals in the heart.
bradycardia: slow heart beat <60bpm

tachycardia: fast heart beat >100bpm

normal sinus rhythm:

Electrical impulse from the sinus node is properly transmitted.

sinus tachycardia:
SA node firing faster than 100 bpm

sinus bradycardia:
SA node firing at less than 60 bpm

sinus ARRYTHMIA:
A cyclic change associated with respiration.

CARDIOVERSION:
Cardioversion is done by sending electric shocks (lower amount of
energy) to the heart through electrodes placed on the chest.
Synchronized shock, not done with CPR

defibrillation
Defibrillation is the treatment for immediately life-threatening
arrhythmias with which the patient does not have a pulse, ie
ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).
This uses a higher amount of energy, with CPR.

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ELECTRICAL CONDUCTION
PM
SA NODE: -100B
: 60
Sinoatrial Node TS
Pacemaker of the heart. BEA
Impulse starts at the SA node.

PM
AV NODE: 0 B
Atrioventricular Node 0-6
: 4
Impulse travels from the SA node to
TS
EA
the AV node. Known as the B
gatekeepers. Causes a delay so that
the atrium can fully empty into the
ventricles.
PM
0 B
BUNDLE OF HIS: -6
: 40
The impulse travels through the
TS
EA
Bundle of His which branches
B
out into the right and left
branch bundles

purkinje fibers: PM
B
The impulse travels to the
-40
20
purkinje fibers.
S:
AT
BE
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ELECTRICAL CONDUCTION
p wave QRS
COMPLEX
T wave
T wave: represents ventricle
P wave: represents atrial

R
depolarization (contraction)-SA repolarization
NODE IS RESPONSIBLE.
u wave
qrs complex
U wave: U wave may be seen
following the T wave. This is not
common.
ST
QRS complex: represents ventricular SEGMENT

P
depolarization

T
PR

Q
INTERVAL

PR interval
PR segment: Starts at the atrial
contraction and ends at the beginning
of ventricle depolarization.

ST SEGMENT S
ST segment: represents ventricular QT INTERVAL
repolarization.

qt interval
The QT interval represents the time
for both ventricular depolarization
and repolarization to occur.

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ekg interpretation
Steps in EKG Interpretation
1. Determine R-R interval: Regular R-R intervals
2. Calculate the rate: (Atrial & ventricular rates), Bradycardia, Tachycardia
3. Evaluate the P wave: Present, Regular, P wave for each QRS complex.
4. Calculate PR interval: Consistently within the normal range
5. Analyze the QRS complex: <0.12 seconds, QRS complex for every P wave
6. Examine T wave: consistently present and normal
7. Calculate QT interval
8. Look for other characteristics

determining the heart rate

1. Used to determine the HR for

regular and irregular rhythms
2. Count the number of P waves
in six seconds and multiply 10.
3. Ventricular Rate: count the
number of R waves or QRS
complexes in 6 seconds and
multiply by 10.
CHARACTERISTICS
1. Heart Rate: 60-100 bpm
2. PR Interval: 0.12-0.2 sec
3. QRS: 0.06-0.12 sec
4. ST segment: 0.08 sec

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5-lead placement
mnemonic (LEAD PLACEMENT)
1. White on right
2. Smoke (black) over fire (red)
3. Snow (white) on green grass (green)
4. Chocolate close to the heart."

RA lA

rl Ll

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electrolyte imbalance
Potassium
3.5-5.5 mEq/L
Hyperkalemia Hypokalemia
1. T wave elevation 1. Flat/inverted T wave
2. Wide QRS complex 2. ST depression
3. Prolonged PR interval 3. U wave
4. Flat P wave

calcium
8.5-10.5mEq/L
HypercalCemia HypocalCemia
1. Shortened ST segment 1. Prolonged ST segment
2. Shortened QT interval 2. Prolonged QT interval

MAGNESIUM
1.3-2.1mEq/L
HYPERMAGNESEMIA HYP0MAGNESEMIA
1. Prolonged PR interval 1. Flattened/Inverted T wave
2. Widened QRS 2. Prolonged QT interval

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know
your
rhythms

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NORMAL SINUS RHYTHM

normal sinus rhythm

iption
Descr

1. Atrial and ventricular rhythms are regular.

2. Rate: 60-100 beats/min
3. PR interval and QRS width are within normal
limit

1. Normal sinus rhythm refers to the normal heart

beat originating from the sinoatrial node.
2. Slight variations in rhythm regularity may be
noted with the respiratory cycle

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sinus bradycardia
SINUS BRADYCARDIA

iption ses
Descr cau
1. Atrial and ventricular rhythms 1. Medications:
are regular a. Antihypertensive
2. Rate: less than 60 beats/min drugs
3. Normal P wave precedes each
2. Normal among
QRS complex
athletes
4. PR. interval and QRS width
are within normal limits 3. Sleep(at rest)

TREATMENT
1. Patient may be asymptomatic
2. Treatment for symptomatic patients (decreased cardiac
output, altered LOC, SOB)- Administration of atropine.
3. Pacemaker
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sinus TACHYCARDIA
SINUS tACHYCARDIA

iption ses
Descr cau
1. Atrial and ventricular rhythms 1. Increased physical activity
are regular 2. Fever
2. Rate: >100 beats/min 3. Stress/anxiety
3. Normal P wave precedes each 4. Hemorrhage
QRS complex 5. Caffeine/alcohol
4. PR interval and QRS width are 6. Heart failure
7. Electrolyte imbalance
within normal limits
8. Hyperthyroidism

TREATMENT
1. Symptoms: SOB, palpitations, dizziness, syncope.
2. Treatment: treat the underlying cause
3. Medications: Beta blockers, Calcium channel blockers

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sinus Arrhythmia
SINUS ARrhythmia

iption ses
Descr cau

1. Rhythm are irregular A cyclical change in the

2. Rate: 60-100 beats/min heart rate associated
3. P wave: sinus with respirations.
4. PR interval: normal
5. QRS width: normal

TREATMENT
1. No treatment required unless patient is symptomatic.

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premature atrial
contractions (pac)
PAC

iption ses
Descr cau
1. Rhythm are regular (irregular 1. Enlarged atria
with PAC)
2. Rate:Is that of underlying 2. Heart diseases
rhythm. 3. Hyperthyroidism
3. P wave: premature, appears
different than normal. P wave 4. Caffeine
may be buried in the preceding 5. Tobacco
T wave.
4. QRS complex: P wave may not 6. Nicotine
be followed by QRS complex

TREATMENT
1. Increasing number of PAC, (Paroxysmal Atrial
Tachycardia: 3+PAC at 140-250 beats/min
2. Medications: Calcium channel blockers, Beta blockers,
Amiodarone
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atrial fibrillation
ATRIAL FIBRILLATION

iption ses
Descr cau
1. Atrial rhythm is irregular 1. Heart disease
2. Ventricular rhythm is irregular 2. Heart tissue damage
3. Atrial: 350-600bpm 3. Congenital heart
4. Ventricular: less than atrial defects
5. No P wave 4. Hypertension
6. PR interval is not measurable
7. Fibrillatory waves before QRS
complex

TREATMENT
1. Unstable patients: prepare for cardioversion
2. O2 therapy
3. Anticoagulants: to prevent emboli
4. Administer cardiac medications (beta blockers, calcium channel
blockers, digoxin)
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atrial flutter
ATRIAL FLUTTER

iption ses
Descr cau
1. Atrial rhythm is regular 1. Atrioventricular (AV)
2. Atrial: 250-400 bpm valve disease
3. Ventricular: less than atrial 2. Pericarditis
4. P wave: sawtooth 3. Heart failure
5. PR interval: not measurable 4. MI
6. QRS complex: less than or
equal to 0.12s

TREATMENT
1. Unstable patients: prepare for cardioversion
2. Administer medication: Anticoagulant

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premature junctional
contraction (PJC)
pjc

iption ses
Descr cau
1. Rhythm: premature beat 1. MI
2. Rate: is that of underlying 2. Digoxin toxicity
rhythm. 3. Valvular heart disease
3. P wave: premature, inverted,
within, hidden or after QRS
complex.
4. PR: is short on the PJC
5. QRS complex: normal

TREATMENT
1. Treat the underlying cause.
2. Medication: Quinidine
3. Discontinue digoxin if applicable

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PREMATURE VENTRICULAR
CONTRACTIONS
pvc

iption ses
Descr cau
1. Rhythm: Irregular 1. Electrolyte imbalance
2. Rate: is that of underlying 2. Hypoxia
rhythm. 3. Stimulants
3. P wave: absent (no P wave with 4. Withdrawal
PVCs 5. Heart failure
4. PR: not measurable 6. MI
5. QRS complex: QRS complex in PVC 7. Drug toxicity
is premature, wide and abnormal

TREATMENT
1. Treat the underlying cause.
2. Medications: Antiarrhythmics (amiodarone)
3. Management of electrolyte imbalance (hypokalemia)
4. Discontinuation of drug causing toxicity

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Ventricular TACHYCARDIA
VENTRICULAR
TACHYCARDIA

iption ses
Descr cau
1. Rhythm: regular 1. MI
2. Rate: 140-250 beats/min 2. CAD
3. P wave: absent 3. Digoxin toxicity
4. PR: not measurable 4. Caffeine
5. QRS complex: QRS complex is
wide, bizarre

TREATMENT
1. Stable patient with a pulse: Oxygen, antidysrhythmic therapy
2. Unstable patient with VT (with pulse and s/s of decreased CO):
Oxygen, antidysrhythmic therapy, synchronized cardioversion, cough
CPR.
3. Unstable patient without a pulse: Defibrillation, CPR

IMPORTANT: VT can lead to Ventricular Fibrillation and then death.

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Ventricular FIBRILLATION
VENTRICULAR
fibrillation

iption ses
Descr cau
1. Rhythm: chaotic rapid rhythm 1. Untreated VT
2. Rate: Not measurable 2. Drug toxicity
3. P wave: absent 3. Damage to the heart
4. PR: not measurable muscle- Cardiac injury
5. QRS complex: not measurable 4. Cardiomyopathy
Remember: 5. Electrolyte imbalance
-VF is fatal. Patient lacks a pulse,
BP, respiration, and is unconscious

TREATMENT
1. Initiate CPR
2. Defibrillation
3. Oxygen therapy
4. Medication: Antidysrhythmic therapy
Epinephrine
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FIRST-degree block
FIRST-degree
block

iption
Descr
1. Rhythm: Atrial and Ventricular rhythms are regular
2. Rate: Varies
3. P wave: sinus
4. PR interval: prolonged
5. QRS complex: normal

TREATMENT
1. No treatment is required.

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SECOND-DEGREE av bLOCK (TYPE 1)

SECOND-DEGREE
block (TYPE 1)

iption
Descr
1. Rhythm: Atrial (regular),
Ventricular (irregular)
2. Rate: Ventricular rate (less than
atrial rate)
3. P wave: regular
4. PR: lengthens progressively until
QRS drops
5. QRS complex:A QRS complex is
dropped. Normal duration <0.12sec
ition
defin
Second-Degree Block Type 1 is
also known as Wenckebach.
Characterized by progressive
lengthening of the PR
interval until a QRS complex
is dropped.

TREATMENT
1. Patient is usually asymptomatic
2. May not require treatment
3. Decreased cardiac output- administer atropine

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SECOND-DEGREE av bLOCK (TYPE 2)

SECOND-DEGREE
block (TYPE 2)

iption
Descr
1. Rhythm: Atrial (regular),
Ventricular (irregular)
2. Rate: Ventricular rate (less than
atrial rate)
3. P wave: 2 to 3 P waves before QRS
complex
4. PR: Normal and consistent
5. QRS complex:A QRS complex is
dropped. Normal duration <0.12sec
ition
defin
Second-Degree Block Type 2
is also known as MobitzII
A Mobitz Type II heart block is
characterized by an
intermittent dropped QRS.
The PR is normal and
consistent

TREATMENT
1. Pacemaker is the treatment used for second-degree
block (type 2)

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THIRD-DEGREE av bLOCK
THIRD-DEGREE
BLOCK

n gn s &
iptio si
Descr pt oms
sym
1. Rhythm: Regular 1. Confusion
2. Rate: Atrial rate (normal), 2. Syncope
Ventricular rate (<60bpm) 3. Chest pain
3. P wave: no relationship 4. Dyspnea
with QRS complex
4. PR: Varies
5. QRS complex:Normal

TREATMENT
1. Pacemaker is the treatment used for third-degree
block

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aystole
aystole

iption ses
Descr cau

Aystole is characterized by a 1. Hypoxia

flat line. This means that 2. Hypovolemia
there is no rhythm, no rate, 3. Hypo/hyperkalemia
no P wave, No PR interval 4. MI
5. Heart failure
and no QRS complex.

TREATMENT
1. Treatment for aystole
is to perform CPR

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 LAB
VALUES

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LAB VALUES nursebossstore.com
Hematology Electrolytes
WBC: 5,000-10,000 Na+: 135-145 mEq/L
RBC: 4,500-6,000 K+: 3.5-5.0 mEq/L
Hematocrit: (M) 42%-52% Mg+: 1.5-2.5 mEq/L
(F) 37%-47% Ca+: 8.5-10.5 mg/dL
Hemoglobin: (M) 14-18 g/dL PO4: 3.0-4.5 mg/dL
(F) 12-16 g/dL Cl-: 95-105 mEq/L
Platelets: 150,000-400,000 cells/mcL

Coagulation ABGs
Platelets: 150,000-400,000 cells/mcL pH: 7.35-7.45
PT: 10-13 seconds PaCO2: 35-45 mmHg
PTT: 25-35 seconds PaO2: 80-100mmHg
aPTT: 30-40sec-HEPARIN HCO3: 22-26 mmHg
INR: 2-3 seconds SaO2: 95%-100%

Renal Liver
Albumin: 3.4-5.4 g/dL
BUN: 8-25 mg/dL
Bilirubin Total: 0.1-1.2 mg/dL
Creatinine: 0.6-1.2 mg/dL
AST: 10-40 U/L
Creatinine Clearance: (M) 97-137 mL/min
ALT: 7-56 U/L
(F) 88-128 mL/min
ALP: 20-40 U/L
GFR: 90 mL/mmol
Total Protein: 6.2-8.2 g/dL

Blood Glucose
Glucose: 70-100 mg/dL
HgBA1C: 4%-5.6%

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Hematology Electrolytes
WBC:_____________ Na+:__________
RBC:_____________ K+:___________
Hematocrit: (M)__________ Mg+:_________
(F) __________ Ca+:__________
Hemoglobin:(M)__________ PO4:__________
(F) __________ Cl-:___________
Platelets:______________

Coagulation ABGs
Platelets:____________ pH:____________
PT:____________ PaCO2:_________
PTT:___________ PaO2:__________
aPTT:__________ HCO3:_________
INR:___________ SaO2:__________

Renal Liver
Total Protein:__________
BUN:_________________
Albumin:______________
Creatinine:____________
Bilirubin Total:________________
Creatinine Clearance:
Bilirubin Direct:_______________
(M)_______________
AST:_____________
(F)________________
ALT:_____________
GFR:_________________
Alkaline Phosphate
Total:____________

Blood Glucose
Glucose:____________
HgBA1C:____________

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Cardiac Lipid
Troponin I: 0-0.4 ng/mL Cholesterol Total: <200 mg/dL
Myoglobin: 5-70 ng/mL LDL: <100 mg/dL
CK-MB: 0-3ng/mL HDL: >60 mg/dL
CPK-MB: 3%-5% Triglycerides: <150 mg/dL

Therapeutic Drug Levels Other Lab Values

Digoxin: 0.5-2 ng/mL Ammonia: 15-45 U/dL
Theophylline: 10-20 mcg/mL BNP: <125 pg/mL
Phenobarbital: 15-40 mcg/mL CRP: <3.0 mg/L
Lithium: 0.8-1.5 mmol/L D-Dimer: <0.50
Carbamazepine: 4-10 mg/L Folic Acid: 2.7-17.0 ng/mL

Other Lab Values Vital Signs

Glucose Tolerance Test: Heart Rate: 60-100 bpm
Fasting: 60/100 mg/dL Blood Pressure: 90/60- 120/80 mmHg
1 hour: <200 mg/dL O2 Saturation: 95%-100%
2 hours: <140 mg/dL Respiration: 12-18 bpm
Prostate Specific Antigen (PSA): Temperature: 97.8-99.1 F
4.0 ng/mL
Lactic Acid: 0.5-1.0 mmol/L

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LAB VALUES
Cardiac
Troponin I:____________
Troponin T:___________
Myoglobin:____________
CPK-MB:______________
Therapeutic Drug Levels
Digoxin:_____________________
Theophylline:________________
Phenobarbital:_______________
Lithium:____________________
Carbamazepine:______________
Other Lab Values
Glucose Tolerance Test:
Fasting:_____________
1 hour:______________
2 hours:_____________
Prostate Specific Antigen (PSA):
____________________
Lactic Acid: ___________________
nursebossstore.com
Lipid
Cholesterol Total:_____________
LDL:______________
HDL:______________
Triglycerides:________________
Other Lab Values
Ammonia:_______________
BNP:____________________
CRP:____________________
D-Dimer:________________
Folic Acid:_______________
Vital Signs
Heart Rate:__________________
Blood Pressure:______________
O2 Saturation:_______________
Respiration:_________________
Temperature:________________
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Arterial Blood Gases

ABGs is the measurement of the acidity, and the level of oxygen and carbon dioxide in the
blood. ABGs is used to evaluate the acid-base status of a patient.
In order to interpret a patient's ABG status, it is important to:
1.Know the lab values

1 3
2. Determine whether it is a respiratory or metabolic problem
3. Know whether it uncompensated, partially
compensated or fully compensated (evaluate the pH value)

Acidosis Alkalosis Normal Uncompensated:

Values
When the pH value is out of the normal
pH <7.35 >7.45 7.35- range and CO2 or HCO3 is within the
7.45 normal range.
Partially Compensated:
CO2 >45 <35 35-45 The CO2, HCO3 and pH values are out of
range.

HCO3 <22 >26 22-26

Fully Compensated

2
The pH is within the normal range.
ROME
CAUSES:
Respiratory pH CO2 Alkalosis Metabolic Acidosis: DKA, Addison's
disease, renal failure, diarrhea, liver

O pposite pH CO2 Acidosis damage

Metabolic Alkalosis: Continuous gastric
pH HCO3 Alkalosis content suctioning, vomiting, diuretics,
M etabolic antacid
Respiratory Acidosis: Pneumonia, airflow
Equal pH HCO3 Acidosis
obstruction, paralysis, over sedation
Respiratory Alkalosis: Fever, increased
respiratory rate and depth, anemia, CHF

COMPENSATION MECHANISM
The kidneys excretes The lungs compensates
excess acid and HCO3 or through
hyperventilation and
retains hydrogen and hypoventilation
HCO3

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 STUDY GUIDE
A Pharmacology Study Guide for Nursing
Students

Website: nursebossstore.com 351 / 601

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Table Of Content

Introduction
Cardiovascular Drugs
Respiratory Drugs
Gastrointestinal Drugs
Genitourinary Drugs
Antibiotics
Neurological Drugs
Anti-Diabetic Drugs

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Introduction

Terminologies
Medication Rights
Drug Suffixes and Prefixes
Therapeutic Drug Level
Drug Antidotes

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Terminologies To Remember
❖ Pharmacology
Pharmacology is the study of drugs
❖ Drug
A substance, when introduced to the body, causes a physiological
effect.
❖ Pharmacodynamics
The effect (physiological and biochemical) that a drug has on the
human body. Another definition is the body’s biological response to
the drug
❖ Pharmacokinetics
Pharmacokinetics is the study of drug movement/action in the body
in terms of absorption, distribution, metabolism and excretion.
❖ Mechanism of Action
Mechanism of action refers to the biochemical processes in which
yields the drug effect.
❖ Indication
Purpose of administering a certain drug
❖ Contraindication
Reason against administering a certain drug
❖ Absorption
Absorption is the drug movement from the administration site
to blood stream
❖ Duration
Duration is the length of time that a drug is effective.
❖ Onset
Onset is the time taken for a drug effect to take place after
administration
❖ Peak
Peak is the highest level of drug concentration in the blood

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Terminologies To Remember
❖ Therapeutic Effect
Therapeutic effect is the response to a drug that is favorable
(good effect).
❖ Adverse Effect
Adverse Effect is the undesirable effect of the drug (bad
effect)
❖ Systemic Effect
Systemic effect is defined as effects that occur in other
tissues that is distant to administration site
❖ Side Effect
Side effect is the secondary effect of a drug. It may be
therapeutic or adverse
❖ Idiosyncratic effect
Idiosyncratic effect is an unknown effect or cause
❖ Agonist
Agonist drugs bind to a receptor and stimulates the function
of the receptor
❖ Antagonist
Antagonist drugs bind to the receptors and prevent the
function of the receptor
❖ Hypersensitivity
An undesirable reaction produced by the immune system in
response to an antigen or drug
❖ Metabolism
Metabolism is the chemical alteration of a drug in the body.

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10 RIGHTS OF MEDICATION
ADMINISTRATION
Right Drug

Right Patient

Right Dose

Right Route

Right Time

Right Documentation

Right Assessment

Right to Refuse

Right Drug Interaction

Right Education
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Classification of Drugs

Therapeutic Classification: the drug’s therapeutic

usefulness

Anticoagulant: influence blood clotting

Antihypertensive: lowers blood pressure
Antianginals: treat angina
Antihyperlipidemics: lowers blood cholesterol

Pharmacological Classification: how the drug acts

Diuretics: lowers plasma volume

Calcium Channel Blockers: blocks heart calcium
channels

Drug Name

Chemical Name: chemical composition

Generic Name: indicates drug group
Trade Name: name registered by the manufacturer

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Medication Summary
Medication Orders
Date:
Name of Medication:
Dosage:
Time and Frequency:
Route of Administration:
Name and Signature of
Prescriber:
Patient Information:
Factors that affect drug
absorption
1. Route
2. Dosage Formulation
3. Surface Area
4. Blood Flow
5. Lipid solubility
6. Food and Fluids
Remember: some drugs need to
be
taken on an empty stomach.
Other drugs should be taken on
a full stomach or
with food to enhance absorption
or minimize gastric irritation.
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Types of Drug Order
Routine Order:
Carried out as specified until
discontinued
P.R.N: As needed
Single Order: Directive is carried
out only once as specified by
physician
Stat Order: A single order
carried out at once
Written Order: inscribed by a
physician on a prescription pad
Verbal Order: When receiving
verbal orders, write
the order down exactly as
heard, repeat the order back to
the physician,
document, have physician cosign
Telephone Order: Many
institutions do not accept this
order
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Drug Suffixes and Prefixes
Cardiac Drugs
1. ACE Inhibitors: -pril
2. Beta Blockers: -olol
3. Calcium Channel Blockers:
-ipine
4. Loop Diuretics: -semide
5. ARBs: -sartan
Resp Drugs
1. Xantine: -phylline
2. Bronchodilator (beta
agonist): -terol
3. Antihistamine: - tadine, -
iramine
4. Corticosteroid: pred-,
cort-, -asone, -olone
GI Drugs
1. PPIs: -eprazole, oprazole
2. H2 Receptor Antagonists:
-tidine
3. Antiemetics: -setron
4. PEG: peg-
nursebossstore.com
Antibiotics
1. Cephalosporin: cef-,
ceph-
2. Penicillin: -cillin
3. Quinolones: -floxacin
4. Macrolides: -mycin
5. Tetracycline: cycline
6. Antiviral: -vir
Neuro
1. Benzodiazepine: -zepam,
zolam
2. SSRIs: -etine
3.Barbituates: -barbital
4. Tricyclic Antidepressants:
-ipramine
Pain
1. NSAIDs: - fenac, -profen
2. Local anesthetic: -caine
3. General anesthetic: -ane
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Therapeutic Drug Level/Antidote

Therapeutic Drug Levels

Digoxin: 0.5-2 ng/mL
Theophylline: 10-20 mcg/mL
Phenobarbital: 15-40 mcg/mL
Lithium: 0.8-1.5 mmol/L
Carbamazepine: 4-10 mg/L
Phenytoin: 10-20mg/L
Lidocaine: 1.5-5mg/L

Drug: Antidote
Opioids: Nalaxone
Wafarin: Vit K
Heparin: Protamine
Cholinergics: Atropine
Acetaminophen:Acetylcysteine
Benzodiazepines: Flumazenil
Insulin: Glucagon
Digoxin: Digoxin Immune Fab
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Cardiovascular Drugs
Thrombolytic Agents
Antiplatelets
Anticoagulant
Cardiac Glycosides
Thiazide Diuretics
Loop Diuretics
Potassium Sparing Diuretics
ACE-Inhibitors
Angiotensin II Receptor Blocker
Calcium Channel Blocker
Beta Adrenergic Blocker
Adrenergic Agonist
Antianginal

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Drug Class: Thrombolytic Drugs Cardiovascular
Medications
TENECTEPLASE
ALTEPLASE
Mechanism of Action: Adverse/Side Effects:
Thrombolytic drugs dissolve clots 1. Bleeding
by activating plasminogen that
forms plasmin. 2. Hypotension
Three major classes: 3. Arrhythmias
1. Tissue Plasminogen Activator
(tPA)
2. Streptokinase (SK)
3. Urokinase (UK)
The three major classes dissolve
blood clots, however, their
mechanism (process) to do so
differs.
Indications: Contraindications:
1. Acute MI 1. Cerebral hemorrhagic
2. Acute ischemic stroke stroke
3. Pulmonary embolism 2. Trauma injury
3. GI bleeding/active internal
bleeding
Thrombolytic drugs dissolve 4. Known allergy
clots, prevent organ damage, 5. Hypertension
and improve blood flow. 6. Recent surgery

Assessment/ Nursing Considerations/Patient Education

1. Assess coagulation studies 1. Educate patient on tooth
2. Monitor VS: monitor for brushing and shaving.
tachycardia and
hypotension 2. Educate patient on the
3. Monitor for signs of side/adverse effects.
bleeding: petechiae,
bruises, dark-colored stools.
4. Monitor neurological
status/changes
5. Monitor for adverse effects
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Drug Class: Antiplatelet Drugs Cardiovascular
Medications
(ASA) acetylsalicylic acid- Aspirin
Clopidogrel (Plavix)
Mechanism of Action: Adverse/Side Effects:
Antiplatelet drugs prevent 1. Bleeding
the aggregation or adhesion 2. Bruising
of platelets. 3. GI bleeding
4. Dark-tarry stools
5. Hematuria

Indications:
1. MI
2. Stroke
3. Stents
4. Prevention of
cerebrovascular occlusion
Aspirin can be used with
thrombolytic therapy. It is used
for the long term management
of the conditions stated above.
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindications
2. Monitor VS: BP, P
3. Monitor coagulation studies
Contraindications:
1. History of
thrombocytopenia
2. Known allergy
3. Head trauma/injury
4. Recent surgery
5. Active internal bleeding
1. Educate patient on tooth
brushing (soft tooth brush)
and shaving.
2. Educate patient on the
side/adverse effects.
3. Educate patient to take
medication with meals to
avoid GI upset.
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Drug Class: Anticoagulant Drugs Cardiovascular
Medications
Heparin Sodium/ Enoxaparin
Wafarin Sodium
Mechanism of Action: Adverse/Side Effects:
Anticoagulants interfere and 1. Hypotension
prevent the formation of clots by
inhibiting factors in the clotting 2. Bleeding/bleeding gums
cascade. 3. Thrombocytopenia
Heparin Sodium: prevents 4. Hematuria (blood in urine)
thrombin from converting 5. Epistaxis
fibrinogen to fibrin.
Wafarin Sodium: reduces vitamin-K Toxicity S/S: Nausea, hepatic
clotting factors (X, IX, VII, II) dysfunction, GI upset,
Enoxaparin: is a low molecular vomiting, diarrhea
weight heparin
Indications: Contraindications:
1. MI 1. GI ulcers
2. DVT 2. Active internal bleeding
3. Bleeding disorder
3. Pulmonary embolism 4. Hemorrhagic brain injury
4. Angina 5. Liver disease
5. Afib 6. Kidney disease
Drug Interactions
Anticoagulants are used 1. Green-leafy vegetables
among patients who are at 2. NSAIDS/Allopurinol/salicylates
3. Phenytoin/Corticosteroids
risk for developing clots. 4. Sulfonamides/Cimetidine
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindications 1. Educate patient on
2. Monitor coagulation studies tooth brushing (soft
3. Monitor for signs of bleeding
4. Infusion pump should be used tooth brush) and
for accurate rate of delivery shaving.
5. Maintain antidote: Vit K is the 2. Educate patient on
antidote for wafarin,
side/adverse effects.
protamine sulfate is the
antidote for heparin.
6. Maintain patient's safety.
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Drug Class: Cardiac Glycosides Cardiovascular
Medications
Digoxin (Lanoxin)

Mechanism of Action: Adverse/Side Effects:

Cardiac glycosides inhibit Na+/K+ 1. Vision changes: blurred or
ATPase in the myocardium. This
increases the intracellular calcium yellow vision
level in the myocardium. 2. GI upset
Therefore, cardiac glycosides 3. Bradycardia
increase cardiac contractility/the 4. Dysrhythmias
force of myocardial contractions
(positive inotropic effect). 5. Fatigue
Signs of digoxin toxicity:
However, cardiac glycosides also vomiting, diarrhea, irregular
decrease heart rate( negative heart rhythms, confusion,
chronotropic effect).
visual disturbances, fatigue
Indications: Contraindications:
1. Heart failure 1. Hypokalemia
2. Atrial tachycardia 2. Hypothyroidism
3. Atrial fibrillation 3. Ventricular dysrhythmias
4. Atrial flutter 4. Renal disease
5. Heart block

Assessment/ Nursing Considerations/Patient Education

1. Assess contraindications 1. Educate patient of s/s
2. Assess VS (+apical pulse): Count apical
pulse for 60secs. Withhold medication of digoxin toxicity.
if pulse <60beats/min and notify HCP
3. Monitor serum digoxin level (0.5- 2. Educate patient to
2ng/mL) consume a high
4. Monitor electrolyte levels + renal
function potassium diet (if
5. Monitor signs of digoxin toxicity
6. Monitor potassium levels: hypokalemia applicable)
can increase digoxin toxicity
7. Obtain ECG
8. Maintain antidote: Digoxin immune
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Drug Class: Thiazide Diuretics
Medications
Chlorothiazide, Chlorthalidone
Hydrochlorothiazide, Metolazone
Mechanism of Action:
Thiazide diuretics increase
the excretion of Na and
water in the distal
convoluted tubule.
Thiazide is a mild diuresis as
compared to loop diuretics
Indications:
1. Hypertension
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor vital signs: BP,P
3. Monitor electrolytes, glucose
level, BUN & creatinine
4. Monitor urinary output/weight
nursebossstore.com
Cardiovascular
Adverse/Side Effects:
1. Hypotension
2. Hyponatremia
3. Hypokalemia
4. Hyperglycemia
5. Hypercalcemia
6. Hyperuricemia
7. Fatigue/weakness
Tip: the side and adverse
effects are mostly electrolyte
imbalances.
Contraindications:
1. Fluid and electrolyte imbalance
2. Renal failure
3. SLE
Interactions:
Patient taking
1. Digoxin: can cause digoxin
toxicity due to changes in
potassium levels
2. Lithium: can cause lithium
toxicity
3. Corticosteroids
4. Antidiabetic medications
1. Educate patient on
increasing potassium in
diet
2. Educate patient of
preventing orthostatic
hypotension: slowly
change position
3. Diabetic patients
should monitor blood
glucose regularly.
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Drug Class: Loop Diuretics Cardiovascular
Medications
Furosemide
Torsemide
Mechanism of Action: Adverse/Side Effects:
Loop diuretics decrease the 1. Hypotension/orthostatic
reabsorption of sodium and
chloride in the ascending Loop of hypotension
Henle. 2. Hyponatremia
(Hence the name-loop diuretics 3. Hypokalemia
main effect is in the Loop of Henle.)
4. Hearing loss: due to rapid flow
Loop diuretics may cause changes of injection of IV furosemide
in cardiac output and BP due to its
potency as compared to thiazide
diuretics.

Indications: Contraindications:
1. Hypertension 1. Hypersensitivity
2. Anuria
2. Edema due to HF, renal
3. Hepatic coma
disease 4. Severe electrolyte depletion
3. Acute pulmonary edema Interactions:
1. Digoxin
2. Lithium
3. Aminoglycoside
4. Anticoagulants
Assessment/ Nursing Considerations/Patient Education
1. Assess 1. Educate patient of
interactions/contraindications preventing orthostatic
2. Monitor vital signs: BP,P hypotension: slowly
3. Monitor electrolytes, glucose change position
level, BUN & creatinine, uric acid 2. Increase potassium in
4. Monitor urinary output/weight diet.

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Drug Class: Potassium-Sparing Diuretics Cardiovascular

Medications
Spironolactone
Amiloride
Mechanism of Action: Adverse/Side Effects:
Potassium-sparing diuretics 1. Hyperkalemia-major
cause sodium and water
excretion in the distal tubule, concern
whilst promoting potassium
retention (blocks aldosterone 2. Lethargy
receptors) 3. Arrhythmias
Mostly used for patients with a
higher risk of hypokalemia.
However, the major concern of
potassium-sparing diuretics is
monitoring for hyperkalemia
Indications: Contraindications:
1. Hypertension 1. Kidney disease
2. Hepatic Disease
2. Edema 3. Hyperkalemia
3. Fluid retention secondary Interactions:
1. Lithium
to a condition 2. ACE Inhibitors
4. Heart failure Caution:
1. Patient taking potassium
supplements
2. Diabetic Patient
Assessment/ Nursing Considerations/Patient Education
1. Assess 1. Educate patient on
interactions/contraindications
2. Monitor vital signs: BP,P low potassium diet
3. Monitor electrolyte levels (pay and signs of
attention to potassium levels) hyperkalemia
4. Monitor for symptoms of
hyperkalemia
5. Monitor ECG for peaked T wave (a
sign of hyperkalemia) and
dysrhythmia
6. Monitor urinary output/weight
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Drug Class: ACE Inhibitors Cardiovascular

Medications
SUFFIX- PRIL
Captopril, Lisinopril, Enalapril
Mechanism of Action: Adverse/Side Effects:
Angiotensin-Converting 1. Dry cough
Enzyme Inhibitor (ACE
Inhibitors) prevents the 2. Hypotension
conversion of angiotensin I to
angiotensin II which prevents 3. GI distress
vasoconstriction.
4. Tachycardia
Remember: angiotensin II is a 5. Hyperkalemia
vasoconstrictor and stimulates
aldosterone release. 6. Angioedema
Hence, ACE Inhibitors are
antihypertensive drugs.
Indications: Contraindications:
1. Hypertension 1. Hypersensitivity to ACE
Inhibitors
2. Heart failure 2. Renal failure
Interactions:
1. Potassium-sparing diuretics
and supplements due to
the potential of
hyperkalemia
2. NSAIDs
Assessment/ Nursing Considerations/Patient Education
1. Assess 1. Educate patient on
interactions/contraindications low potassium diet
and signs of
2. Monitor vital signs: BP,P
hyperkalemia
3. Monitor potassium serum level 2. Educate patient on
4. Monitor glucose level of diabetic dry cough as a
patients (hypoglycemia may potential side effect
3. Educate patient on BP
occur) monitoring
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Drug Class: Angiotensin II Receptor Blockers Cardiovascular
Medications
SUFFIX- SARTAN
Losartan, Candesartan, Valsartan
Mechanism of Action: Adverse/Side Effects:
ARBs prevent aldosterone 1. Hypotension
release and peripheral 2. Diarrhea
vasoconstriction by selectively
3. Nausea/vomiting
blocking angiotensin II
receptors. 4. Hyperkalemia
5. Fatigue/ weakness
ARBs is primarily an 6. Angioedema
antihypertensive drug

Indications: Contraindications:
1. Hypertension 1. Renal failure
2. Heart failure 2. Hepatic impairment
Interactions:
1. Potassium-sparing diuretics
and supplements due to
the potential of
hyperkalemia

Assessment/ Nursing Considerations/Patient Education

1. Assess 1. Educate patient on
interactions/contraindications low potassium diet
2. Monitor vital signs: BP,P and signs of
3. Monitor potassium serum level hyperkalemia
4. Monitor glucose level of diabetic 2. Educate patient on BP
patients (hypoglycemia may monitoring
occur)
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Drug Class: Calcium Channel Blockers Cardiovascular

Medications
SUFFIX- PINE
Nifedipine, Amlodipine
Mechanism of Action: Adverse/Side Effects:
Calcium channel blockers 1. Hypotension
prevent calcium ions movement
across myocardial cell 2. Bradycardia
membrane.
This causes relaxation of 3. Dysrhythmias
smooth muscle. 4. Dizziness
Therapeutic effects includes: 5. Fatigue
decreased cardiac workload,
decreased myocardial oxygen
consumption and decreased
blood pressure.
Indications: Contraindications/Caution:
1. Hypertension 1. AV block
2. Angina 2. HF
3. Bradycardia-use with
caution

Assessment/ Nursing Considerations/Patient Education

1. Assess
interactions/contraindications
2. Assess liver enzymes level
3. Monitor vital signs: BP,P
1. Educate patient on
side effects of dizziness
and fainting
2. Educate patient on BP,
P monitoring

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Drug Class: Beta Adrenergic Blockers Cardiovascular

Medications
SUFFIX- LOL
Atenolol, Carvedilol
Mechanism of Action: Adverse/Side Effects:
Beta adrenergic blockers block the
effect of epinephrine at the 1. Hypotension
receptor sites. 2. Bradycardia
Therapeutic effects: decrease 3. Dizziness, Weakness
cardiac workload, BP, HR and
myocardial oxygen demands. 4. Fatigue
5. Hyperglycemia
Selective BB: affects only the
beta1 adrenergic sites (heart) 6. Bronchospasm
Nonselective BB: (lungs and heart)
acts on both beta 1 and beta 2 7. Orthostatic hypotension
adrenergic sites

Indications: Contraindications/Caution:
1. Hypertension 1. Asthma- due to side effect
2. Angina of bronchospasm
3. Glaucoma 2. Bradycardia
4. Migraine 3. Renal failure
5. Dysrhythmias 4. AV block
5. Diabetes mellitus (use with
caution)
Assessment/ Nursing Considerations/Patient Education
1. Assess 1. Educate diabetic
interactions/contraindications patients on glucose
2. Assess liver enzymes level monitoring-the effect of
3. Monitor vital signs: BP,P- beta blockers can mask
withhold medication if BP/P is hypoglycemia
2. Monitor BP, P
not within therapeutic
3. Educate patient to
parameters stand up slowly-due to
4. Monitor respiratory status orthostatic hypotension
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Drug Class: Adrenergic Agonist Cardiovascular

Medications
Dobutamine, Dopamine, Epinephrine

Mechanism of Action: Adverse/Side Effects:

Adrenergic agonist stimulates the
adrenergic receptors (both alpha 1. Hypertension
or beta receptors) of target 2. Tachycardia
organs.
Therapeutic effect: 3. Dysrhythmias
1. Heart: increase contractility,
HR, increase cardiac output 4. Palpitations
2. Lungs: bronchodilation
Examples includes:
1. Epinephrine,
2. Dopamine, 3. Dobutamine

Indications: Contraindications/Caution:
1. Epinephrine: acute
hypersensitivity, asthma, 1. Ventricular fibrillation
cardiac arrest
2. Dobutamine: positive
inotropic effect (heart failure)
3. Dopamine: positive inotropic
effect,increase blood flow to
the kidneys

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 7. Monitor adverse effect
2. Monitor vital signs: BP,P 8. Monitor medication effect
3. Monitor respiratory status and patient's response
4. Auscultate lungs for adventitious
sounds
5. Monitor ECG
6. Monitor urine output
Note: Be cautious when preparing,
calculating and administering drug
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Drug Class: Antianginal Agents Cardiovascular

Medications
Nitroglycerin

Mechanism of Action: Adverse/Side Effects:

Nitrates are antianginal 1. Hypotension
agents that relax smooth 2. Reflex tachycardia
muscles, resulting in
3. Pallor
vasodilation, reduced
preload (dilating veins) and 4. Fatigue/body weakness
afterload (dilating arteries)
and decreased myocardial
oxygen demand.

Indications: Contraindications/Caution:
1. Angina pectoris 1. Increase ICP
2. Hypotension
3. Hypovolemia
4. Cerebral hemorrhage
5. Anemia

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 1. Educate patient to place
2. Monitor vital signs: BP,P
3. Monitor respiratory status
4. Assess neurological status
5. Assess ECG
6. Administer type of medication
correctly (sublingual medication,
transdermal patch, topical ointment
and translingual medication)
sublingual medication under
tongue
2. Educate patient on how to
use sublingual medication,
transdermal patch, topical
ointment and translingual
medication.
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 Cardiac Drug Study
Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

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 Respiratory Drugs

Anticholinergics
Antihistamine
Expectorants
Mucolytics
Decongestants
Antitussives
Glucocorticoids
Sympathomimetic Bronchodilators
Methylxanthines Bronchodilators

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Drug Class: Inhaled Anticholinergics Respiratory

Medications
Atrovent (Ipratropium)

Mechanism of Action: Adverse/Side Effects:

Inhaled anticholinergics prevent
1. Cough
the binding of acetylcholine
(neurotransmitter) by blocking 2. Palpitation
muscarinic receptors. 3. Dry mouth
This results in bronchodilation 4. Throat irritation
(relaxation of smooth muscle in
the bronchi).

Indications: Contraindications:
1. COPD-Chronic obstructive 1. Glaucoma
pulmonary disease 2. Hypersensitivity- patient
2. Asthma with peanut allergy should
not take ipratropium

Assessment/ Nursing Considerations/Patient Education

1. Assess 1. Educate patient on
interactions/contraindications increase hydration
2. Monitor urinary output and fiber in diet
3. Increase patient's hydration
4. Increase fiber in diet

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Drug Class: Antihistamine Respiratory

Medications
Brompheniriamine
Chlorpheniramine
Mechanism of Action: Adverse/Side Effects:
Antihistamine selectively 1. Drowsiness/sedation
blocks and prevents the 2. Fatigue
effects of histamine at the
3. GI disturbance
histamine-1 receptor sites.
Therapeutic effect: decrease 4. Dry mouth
bronchial secretions 5. Hypotension
6. Urinary retention

Indications: Contraindications:
1. Allergic rhinitis 1. Use with caution among
2. Common cold COPD clients
3. Nausea and vomiting (due
Interactions:
to motion sickness)
1. Diphenhydramine- may
cause a prolong
anticholinergic effect

Assessment/ Nursing Considerations/Patient Education

1. Assess
interactions/contraindications
2. Proper medication
administration
3. Patient safety due to CNS
effect
4. Monitor urinary output and signs
of urinary retention
1. Educate patient to
avoid alcohol due to
sedation and CNS
effect
2. Educate patient on
side effects such as
dry mouth
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Drug Class: Expectorants Respiratory

Medications
Guaifenesin

Mechanism of Action: Adverse/Side Effects:

Expectorants reduce the 1. Rhinorrhea
surface tension of bronchial 2. Rash
secretion and induce 3. GI irritation
productive cough to promote 4. Throat irritation
patent airway.

Indications: Contraindications:
1. Dry, nonproductive cough 1. Hypersensitivity

Assessment/ Nursing Considerations/Patient Education

1. Assess underlying cause of 1. Educate patient on
coughing deep breathing and
2. Assess contraindication coughing.
3. Assess respiratory status 2. Encourage patient to
4. Assess skin for rashes increase fluid intake
5. Prevent GI irritation by
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Drug Class: Mucolytics Respiratory

Medications
Acetylcysteine

Mechanism of Action: Adverse/Side Effects:

Mucolytics liquefy or thins
respiratory secretions (mucus) for
1. Rhinorrhea
airway clearance (productive 2. Rash
cough). 3. GI irritation
4. Throat irritation
Mucolytics breaks apart disulfide
bonds (disulfide bonds holds mucus
secretions together). This action
results in mucus thinning and
productive cough.

Indications: Contraindications:
1. Dry, nonproductive cough 1. Hypersensitivity
2. COPD- Mucolytic drug with
dextromethorphan
3. Acute bronchospasms
(asthma)

Assessment/ Nursing Considerations/Patient Education

1. Assess underlying cause of 1. Educate patient on
coughing deep breathing and
2. Assess contraindication coughing.
3. Assess respiratory status 2. Encourage patient to
4. Assess skin for rashes
increase fluid intake
5. Prevent GI irritation by advising
patient to have small frequent
meals
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Drug Class: Decongestant Respiratory

Medications
Oxymetazoline, Phenylephrine
Pseudoephedrine
Mechanism of Action: Adverse/Side Effects:
Decongestants cause
vasoconstriction in the upper
1. Palpitations
respiratory system. This leads to 2. Anxiety
shrinking swollen mucous 3. Hyperglycemia
membrane and reduced fluid 4. Restlessness
secretion. 5. Rebound congestion

Types: 1. Topical decongestants,

Oral decongestants and nasal
steroid decongestants

Indications: Contraindications:
1. Common cold 1. Hypertension
2. Sinusitis 2. DM
3. Allergic rhinitis 3. Hyperthyroidism
4. Otitis media
5. Acute coryza

Assessment/ Nursing Considerations/Patient Education

1. Assess contraindications
2. Monitor BP and P
3. Monitor ECG
4. Monitor glucose level in diabetic
patients
1. Educate patient on the
duration of taking
decongestants (no longer
than 2 to 3 days) due to
rebound congestion
(prolong use of
decongestants causes
vasodilation due to nasal
mucosa irritation)
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Drug Class: Antitussives Respiratory

Medications
Benzonatate, Dextromethorphan

Mechanism of Action: Adverse/Side Effects:

Antitussives suppress the
cough reflex by directly
acting on the cough control
center in the medulla.
1. Sedation (antitussives are
centrally acting)
2. Drowsiness (antitussives
are centrally acting)
3. Dry mouth
4. GI upset (nausea and
irritation)
5. Dependency

Indications: Contraindications:
1. Dry cough (nonproductive 1. Head injury
2. Postoperative patients
cough)
2. COPD Interaction
1. Antidepressants
2. Monoamine oxidase
inhibitors

Assessment/ Nursing Considerations/Patient Education

1. Assess contraindication 1. Educate patient on
2. Assess neurological status sedative effect of
3. Encourage increase fluid intake antitussives to avoid
4. Place patient in a Fowler's
injury.
position.
5. Assess for history of addiction 2. Avoid alcohol
(medication dependency may
occur)
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Drug Class: Glucocorticoids (Corticosteroids) Respiratory
Medications
Beclomethasone

Mechanism of Action: Adverse/Side Effects:

Glucocorticoids are anti- 1. Headache
inflammatory agents that 2. Irritability
decrease inflammatory 3. Local infection
response in the airway.

Therapeutic effect: increase

airflow, reduce edema.

Indications: Contraindications:
1. Asthma 1. Hypersensitivity
2. Respiratory infection

Assessment/ Nursing Considerations/Patient Education

1. Assess contraindications
2. Monitor respiratory status
3. Assess adventitious sounds
4. Monitor for signs of infection-
due to prolong use
Educate patient on drug
therapeutic use and side
effects

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Drug Class: Sympathomimetic Bronchodilators Respiratory

Medications
Salmeterol, Isoproterenol

Mechanism of Action: Adverse/Side Effects:

Sympathomimetic affects the
beta-receptors found in the 1. Tachycardia
bronchi which leads to the 2. Dysrhythmias
relaxation of smooth muscle in the
bronchi. 3. Palpitation
Therapeutic effect: airway dilation
4. Restlessness
5. Dry mouth
Other effects: increase BP, HR,
vasoconstriction (due to
sympathomimetic mimicking the
effects of the sympathetic nervous
system.

Indications: Contraindications:
1. COPD 1. Cardiac dysrhythmias
2. Asthma 2. PUD-peptic ulcer disease
3. Hyperthyroidism

Caution:
DM, Glaucoma, HTN

Assessment/ Nursing Considerations/Patient Education

1. Assess contraindication Educate patient on
2. Monitor respiratory status increasing fluid intake
3. Assess adventitious sounds
4. Monitor neurological status

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Drug Class: Methylxanthines Bronchodilators Respiratory

Medications
Theophylline

Mechanism of Action: Adverse/Side Effects:

Xanthines are 1. Tachycardia
bronchodilators that relax 2. Dysrhythmias
the smooth muscles of the 3. Palpitation
respiratory system (bronchi) 4. Restlessness
and blood vessels. 5. Dry mouth
6. Hyperglycemia

Indications: Contraindications:
1. COPD 1. Cardiac dysrhythmias
2. Asthma 2. PUD-peptic ulcer disease
3. Hyperthyroidism

Caution:
HTN, Glaucoma, DM

Assessment/ Nursing Considerations/Patient Education

1. Assess contraindication Educate patient on
2. Monitor respiratory status increasing hydration.
3. Assess adventitious sounds
Educate patient not to
4. Monitor neurological status
5. Monitor glucose level of DM patients crush capsules
6. Monitor theophylline therapeutic
level: 10-20mcg/mL
7. Theophylline cause cause risk for
digoxin toxicity.
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 Resp Drug Study
Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

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 Gastrointestinal Drugs

Proton Pump Inhibitors

Histamine (H2)Receptor Antagonist
Antacid
Antiemetics
Laxatives

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Drug Class: Proton Pump Inhibitor Gastrointestinal

Medications
SUFFIX- ZOLE
Omeprazole, Esomeprazole
Mechanism of Action: Adverse/Side Effects:
Proton pump inhibitors 1. Abdominal pain
suppress the secretion of HCL 2. Headache
in the stomach by inhibiting
3. Nausea
hydrogen-potassium
adenosine triphosphate 4. Vomiting
enzyme (the enzyme that 5. Diarrhea
generates HCL).

Indications: Contraindications:
1. Peptic ulcer 1. Hypersensitivity
2. GERD
3. Erosive esophagitis
4. Zollinger Ellison's
syndrome

Assessment/ Nursing Considerations/Patient Education

1. Assess Educate patient to not
interactions/contraindications crush or chew capsule.
2. Administer drug before meals
3. Schedule drug to avoid
interactions
4. Provide small frequent meals

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Drug Class: Histamine (H2) Receptor Antagonist Gastrointestinal

Medications
SUFFIX- DINE
Ranitidine, Cimetidine
Mechanism of Action: Adverse/Side Effects:
Histamine (H2) receptor 1. Dizziness
antagonist blocks the action 2. Confusion
of histamine, which produces
3. Impotence
HCL secretion.
This action promotes ulcer 4. Rash
healing. 5. Pruritus

Indications: Contraindications:
1. Peptic ulcer 1. Hypersensitivity
2. Erosive esophageal 2. Pregnancy and lactation
3. Zollinger Ellinson's 3. Hepatic or renal
dysfunction
syndrome
4. Prevents stress ulcers

Assessment/ Nursing Considerations/Patient Education

1. Assess Educate patient to take
interactions/contraindications medication with meals or
2. Schedule drugs to avoid
interactions at bedtime.
3. Monitor IV doses carefully
4. Cimetidine and antacid should be
administered 1 to 2 hours apart
(antacid can decrease the
absorption of cimetidine)
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Drug Class: Antacid Gastrointestinal

Medications
Aluminum hydroxide, Calcium carbonate

Mechanism of Action: Adverse/Side Effects:

Antacid are alkaline compounds
that neutralizes acids and
prevents the conversion of
pepsinogen to pepsin in the
stomach.
Types of compounds:
1. Aluminium compounds
2. Magnesium compounds
3. Calcium compound
4. Sodium bicarbonate
Indications:
1. GERD
2. Indigestion
3. Promote ulcer healing
1. Hypokalemia
2. Headache
3. Nausea
4. Vomiting
5. Diarrhea: magnesium
hydroxide retains water which
may cause diarrhea
6. Constipation: aluminium
compound
Adverse/side effect depends on the
specific compound.
Contraindications:
1. Hypersensitivity
2. Pregnancy and lactation
Caution:
1. Electrolyte imbalance
2. Renal dysfunction

Assessment/ Nursing Considerations/Patient Education

1. Assess 1.Educate patient to chew
tablets thoroughly and follow
interactions/contraindications with a glass of water.
2. Monitor electrolyte level 2. Administer antacid apart
3. Monitor for hypermagnesemia: from any other oral
medications to ensure
magnesium-containing antacid adequate absorption of the
should be used with caution due other medications (1 to 2 hours
apart)
to the risk of hypermagnesemia. 3. Shake liquid before pouring

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Drug Class: Antiemetics Gastrointestinal

Medications
Aprepitant, Ondansetron

Mechanism of Action: Adverse/Side Effects:

Antiemetics suppress nausea and 1. Drowsiness
vomiting by acting on the brain's 2. Sedation
control center to stop the nerve 3. Constipation
impulse.
The choice of antiemetic depends on The type of antiemetic contributes
the cause of nausea and vomiting. to the adverse/side effect
TYPES
1. Serotonin antagonist
2. Dopamine Antagonist
3. Antihistamine
4. Glucocorticoids
5. Benzodiazepine
6. Anticholinergics
Indications: Contraindications:
1. Nausea 1. Narrow-angle glaucoma
2. Vomiting 2. Corticosteroids are
3. Gastroenteritis contraindicated with untreated
infections
4. Chemotherapy
5. Motion sickness

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 1.Educate patient when using
2. Monitor intake and output oral antiemetics, to take it one
3. Monitor fluid and electrolyte status
4. Position client in a Flower's position to hour before travel to prevent
prevent aspiration motion sickness.
5. Provide safety precaution if client is
drowsy
6. Administer antiemetics before
treatment/procedure that causes
nausea.
7. Limit oral intake with client nauseated or
vomiting.
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Drug Class: Laxatives Gastrointestinal

Medications
Bulk-forming: Psyllium, Methylcellulose
Stimulant: Senna. Osmotics: Magnesium Hydroxide
Mechanism of Action: Adverse/Side Effects:
Laxatives promote bowel elimination.
1. GI disturbance
Types: 2. Dehydration
1. Bulk-forming laxatives: absorbs 3. Electrolyte Imbalance
water into the intestinal lumen
and feces to increase the size of
the fecal mass and soften stool.
2. Osmotic Laxatives: causes
increased osmotic pressure in the
intestinal lumen (and water
retention). The stool becomes
semifluid.
3. Stimulant laxatives: stimulate
intestinal motility
Indications: Contraindications:
1. Constipation 1. Bowel obstruction
2. Prevent straining in post op
patients
3. Empty bowel in pre op care
4. Obtain stool specimen
5. Orally ingested toxic
compounds

Assessment/ Nursing Considerations/Patient Education

1. Assess 1.Educate patient on
interactions/contraindications high fiber diet
2. Monitor fluids and electrolyte
2. Educate patient on
levels
3. Encourage increased fluid intake exercise
4. Laxative use should be 3.Educate patient on
temporary increasing fluid intake

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Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

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 Genitourinary Drugs
Fluoroquinolones
Sulfonamides
Thiazide Diuretics
Potassium Sparing Diuretics
Loop Diuretics

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Drug Class: Fluoroquinolones Genitourinary Drugs

Medications
levofloxacin, moxifloxacin, ciprofloxacin, ofloxacin

Mechanism of Action: Adverse/Side Effects:

Flouroquinolones interfere with 1. Headache
DNA gryase (an enzyme) needed 2. Drowsiness
by the bacteria for the synthesis 3. Dizziness
of DNA 4. Nausea
5. Vomiting
6. Photosensitivity
7. Bone marrow depression
8. Superinfections

Indications: Contraindications:
1. Treatment of respiratory, skin 1. Hypersensitivity
and urinary infections (caused 2. Seizures
by E. coli) 3. Renal disorders
4. Pregnancy/children
Interaction
1. Antacid
2. Iron
3. Calcium
4. Magnesium
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Monitor allergic reaction a. completing medication
3. Do not administer medication with regimen
antacid, iron, calcium or magnesium b. report if symptoms persist
supplements c. increase fluid intake
4. Encourage increase fluid intake d. avoid medication with
5. Monitor I and O antacid, iron, calcium and
6. Monitor renal lab values magnesium

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Drug Class: Sulfonamides Genitourinary Drugs

Medications
sulfadiazine, sulfasalazine

Mechanism of Action: Adverse/Side Effects:

Sulfonamides Inhibit a metabolic 1. Nausea
process essential for the function 2. Vomiting
and growth of the bacterial cell. 3. Diarrhea
4. Bone marrow depression
5. Hepatotoxicity
Inhibit folic acid synthesis. 6. Nephrotoxicity
7. Photosensitivity
Sulfonamide blocks
paraaminobenzoic acid to prevent 8. Renal damage: a result of
synthesis of folic acid crystalluria
9. Hypersensitivity

Indications: Contraindications:
1. UTI 1. Hypersensitivity
2. Trachoma 2. Renal/hepatic disease
3. Pregnancy

Assessment/ Nursing Considerations/Patient Education

1. Assess culture and sensitivity results Educate patient on
2. Hx of hypersensitivity a. completing medication
3. Monitor intake and output regimen
4. Encourage fluid intake b. report if symptoms persist
c. the use of sunscreen
d. increase fluid intake

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Drug Class: Thiazide Diuretics Genitourinary Drugs
Medications
Chlorothiazide, Chlorthalidone
Hydrochlorothiazide, Metolazone
Mechanism of Action: Adverse/Side Effects:
Thiazide diuretics increase 1. Hypotension
sodium and water excretion 2. Hyponatremia
in the distal tubule. 3. Hypokalemia
4. Hyperglycemia
5. Hypercalcemia
Thiazide is a mild diuresis as 6. Hyperuricemia
compared to loop diuretics 7. Fatigue/weakness

Indications: Contraindications:
1. Hypertension 1. Fluid and electrolyte imbalance
2. Renal failure
2. Edema 3. SLE
Interactions:
Patient taking
1. Digoxin: can cause digoxin
toxicity due to changes in
potassium levels
2. Lithium: can cause lithium
toxicity
3. Corticosteroids
4. Antidiabetic medications
Assessment/ Nursing Considerations/Patient Education
1. Assess 1. Educate patient on
interactions/contraindications increasing potassium in
diet
2. Monitor vital signs: BP,P 2. Educate patient of
3. Monitor electrolytes, glucose preventing orthostatic
level, BUN & creatinine hypotension: slowly
change position
4. Monitor urinary output/weight 3. Diabetic patients
should monitor blood
glucose regularly.
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Drug Class: Potassium-Sparing Diuretics Genitourinary Drugs

Medications
Spironolactone
Amiloride
Mechanism of Action: Adverse/Side Effects:
Potassium-sparing diuretics 1. Hyperkalemia-major
cause sodium excretion in the
distal tubule, whilst promoting concern
potassium retention.
2. Lethargy
Mostly used for patients with a 3. Arrhythmias
higher risk of hypokalemia.
However, the major concern of
potassium-sparing diuretics is
monitoring for hyperkalemia

Indications: Contraindications:
1. Hypertension 1. Kidney disease
2. Hepatic Disease
2. Edema 3. Hyperkalemia
3. Fluid retention secondary Interactions:
1. Lithium
to a condition 2. ACE Inhibitos
Caution:
1. Patient taking potassium
supplements
2. Patient with diabetes
Assessment/ Nursing Considerations/Patient Education
1. Assess 1. Educate patient on
interactions/contraindications
2. Monitor vital signs: BP,P low potassium diet
3. Monitor electrolyte levels (pay and signs of
attention to potassium levels) hyperkalemia
4. Monitor for symptoms of
hyperkalemia
5. Monitor ECG for peaked T wave (a
sign of hyperkalemia) and
dysrhythmia
6. Monitor urinary output/weight
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Drug Class: Loop Diuretics Genitourinary Drugs
Medications
Furosemide
Torsemide
Mechanism of Action: Adverse/Side Effects:
Loop diuretics decrease 1. Hypotension/orthostatic
reabsorption of sodium and
chloride in the ascending Loop of hypotension
Henle. 2. Hyponatremia
(Hence the name-loop diuretics 3. Hypokalemia
main effect is in the Loop of Henle.)
4. Hearing loss: due to rapid flow
Loop diuretics may cause changes of injection of IV furosemide
in cardiac output and BP due to its
potency as compared to thiazide
diuretics.

Indications: Contraindications:
1. Hypertension 1. Hypersensitivity
2. Anuria
2. Edema due to HF, renal
3. Hepatic coma
disease 4. Severe electrolyte depletion
3. Acute pulmonary edema Interactions:
1. Digoxin
2. Lithium
3. Aminoglycoside
4. Anticoagulants
Assessment/ Nursing Considerations/Patient Education
1. Assess 1. Educate patient of
interactions/contraindications preventing orthostatic
2. Monitor vital signs: BP,P hypotension: slowly
3. Monitor electrolytes, glucose change position
level, BUN & creatinine, uric acid
4. Monitor urinary output/weight

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Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

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 Antibiotics
Penicillin
Cephalosporin
Aminoglycosides
Tetracycline
Sulfonamide
Fluoroquinolones
Antimycobacterials

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Drug Class: Penicillin Antibiotics

Medications
Penicillins, Extended-Spectrum Penicillins
Penicillinase-Resistant Antibiotics
Mechanism of Action: Adverse/Side Effects:
Penicillins inhibit bacterial cell wall 1. Allergies
synthesis. Penicillin prevents
2. Superinfections: when
bacteria from using the substance
antibiotics disrupts normal flora
muramic acid peptide that is
essential for the bacteria's outer causing new infections (yeast
cell wall. Therefore, the bacteria's infection)
cell wall swells, ruptures and dies. 3. GI: nausea, vomiting, abdominal
pain, diarrhea, glossitis,
stomatitis, gastritis, furry
tongue, sore mouth
Indications: Contraindications:
1. Treatment of streptococcal 1. Renal disease
infections 2. Hypersensitivity
2. Treatment of meningococcal
meningitis
3. Bacterial Infections

Assessment/ Nursing Considerations/Patient Education

1. Assess culture and sensitivity reports Educate patient on
2. Assess interactions/contraindications a. completing medication regimen
3. Hx of drug allergies b. report if symptoms persist
4. Monitor for hypersensitivity after drug c. signs of superinfections
administration
5. Discontinue drug when an allergic reaction
is noted (notify physician)
6. For mild allergic reaction: diphenhydramine
7. For severe allergic reaction: epinephrine SC
or IV
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Drug Class: Cephalosporin Antibiotics

Medications
1st Generation Ceph: Cefazolin, 2nd Gen Ceph: Cefoxitin
3rd Gen Ceph: Cefoperazone, 4th Gen Ceph: Cefipime
Mechanism of Action: Adverse/Side Effects:
Cephalosporins inhibit bacterial cell wall
synthesis. 1. Superinfections
Classification: 2. GI disturbances
1. First generation cephalosporins:
effective against gram-positive and 3. Nephrotoxicity (especially
gram-negative bacteria.
2. Second generation cephalosporins: among the elderly)
less effective against gram-positive
bacteria.
3. Third generation cephalosporins: Adverse Effect
weak against gram-positive bacteria,
potent against gram-negative bacilli 1. Allergies
4. Fourth generation cephalosporins:
active against gram-negative and
gram-positive organisms

Indications: Contraindications:
1. UTI caused by E. coli 1. Hypersensitivity
2. Surgical wound infection 2. Renal/hepatic impairment
3. Gram-negative bacterial
meningitis
4. Treat multiple resistant gram-
negative infection
5. Bacterial Infections

Assessment/ Nursing Considerations/Patient Education

1. Monitor Educate patient on
hypersensitivity/superinfections a. completing medication
2. Monitor I/O and creatinine levels regimen
(patients with hx of renal insufficiency) b. report if symptoms persist
3. Monitor IV site for thrombopheblitis c. signs of superinfections
(pain, swelling and redness) d. Avoid alcohol

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Drug Class: Aminoglycosides Antibiotics

Medications
amikacin, gentamicin

Mechanism of Action: Adverse/Side Effects:

Aminoglycosides inhibit bacteria
protein synthesis.
They inhibit the translation of
mRNA to protein by irreversibly
binding to bacteria ribosome.
1. Ototoxicity (may lead to deafness)
2. GI effect: nausea, vomiting,
diarrhea, hepatic toxicity, weight
loss, stomatitis
3. Cardiac: hypertension, palpitations,
hypotension
4. Hypersensitivity
5. Nephrotoxicity: hematuria,
proteinuria, increased BUN levels,
decreased urine output
6. Confusion, disorientation

Indications: Contraindications:
1. Serious/life threatening 1. Hypersensitivity
infections 2. Renal/hepatic disease
3. Myasthenia gravis
4. Parkinson
5. Herpes (active infection)
6. Hearing loss

Assessment/ Nursing Considerations/Patient Education

1. Assess culture and sensitivity results Educate patient on
2. Monitor for signs of nephrotoxicity a. completing medication
3. Provide safety measures due to CNS regimen
effects b. report if symptoms persists
4. Monitor renal and hepatic function c. changes in urinary pattern
(toxic effect on kidney)
d. reporting any tinnitus

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Drug Class: Tetracycline Antibiotics

Medications
doxycycline, minocycline

Mechanism of Action: Adverse/Side Effects:

Tetracycline are broad-spectrum 1. Nausea
and inhibits protein synthesis 2. Vomiting
which causes the inability for 3. Epigastric burning
bacterial growth 4. Stomatitis
5. Glossitis
6. Photosensitivity and rash

Indications: Contraindications:
1. Pneumonia 1. Hypersensitivity
2. Lyme disease 2. Renal/hepatic disease
3. Endocervical infections 3. Pregnancy
4. Children below 8
Interactions
1. Penicillin
2. Cephalosporin

Assessment/ Nursing Considerations/Patient Education

1. Assess culture and sensitivity results Educate patient on
2. Do not administer tetracycline to a. completing medication
children under 8- (tetracycline may regimen
cause teeth and bone damage) b. report if symptoms persist
3. Avoid administering tetracycline c. the use of sunscreen
with diary products or antacid

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Drug Class: Sulfonamides Antibiotics

Medications
sulfadiazine, sulfasalazine

Mechanism of Action: Adverse/Side Effects:

Sulfonamides Inhibit the metabolic 1. Nausea
process essential for the function 2. Vomiting
and growth of the bacterial cell. 3. Diarrhea
4. Bone marrow depression
5. Hepatotoxicity
Inhibit folic acid synthesis. 6. Nephrotoxicity
7. Photosensitivity
Sulfonamide blocks
paraaminobenzoic acid to prevent 8. Renal damage: a result of
synthesis of folic acid crystalluria
9. Hypersensitivity

Indications: Contraindications:
1. UTI 1. Hypersensitivity
2. Trachoma 2. Renal/hepatic disease
3. Pregnancy

Assessment/ Nursing Considerations/Patient Education

1. Assess culture and sensitivity results Educate patient on
2. Hx of hypersensitivity a. completing medication
3. Monitor intake and output regimen
4. Encourage fluid intake b. report if symptoms persist
c. the use of sunscreen
d. increase fluid intake

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Drug Class: Fluoroquinolones Antibiotics

Medications
levofloxacin, moxifloxacin, ciprofloxacin, ofloxacin

Mechanism of Action: Adverse/Side Effects:

Flouroquinolones interfere with 1. Headache
DNA gryase (an enzyme) needed 2. Drowsiness
by the bacteria for the synthesis 3. Dizziness
of DNA 4. Nausea
5. Vomiting
6. Photosensitivity
7. Bone marrow depression
8. Superinfections

Indications: Contraindications:
1. Treatment of respiratory, skin 1. Hypersensitivity
and urinary infections (caused 2. Seizures
by E. coli) 3. Renal disorders
4. Pregnancy/children
Interaction
1. Antacid
2. Iron
3. Calcium
4. Magnesium
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Monitor allergic reaction a. completing medication
3. Do not administer medication with regimen
antacid, iron, calcium or magnesium b. report if symptoms persist
supplements c. increase fluid intake
4. Encourage increase fluid intake d. avoid medication with
5. Monitor I and O antacid, iron, calcium and
6. Monitor renal lab values magnesium

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Drug Class: Antimycobacterials Antibiotics

Medications
isoniazid (INH), rifampin, ethambutol, pyrazinamide, and streptomycin

Mechanism of Action: Adverse/Side Effects:

Two main mechanism of action: 1. Peripheral neuropathy
a. inhibition of the cell wall 2. Jaundice
synthesis 3. Discoloration of bodily fluids
b. affects the DNA and/or RNA of 4. Rashes
the bacteria 5. Headache
6. Malaise
The major drugs used in 7. Drowsiness
tuberculosis are isoniazid (INH), 8. Nausea
rifampin, ethambutol, 9. Vomiting
pyrazinamide, and streptomycin. 10. Anorexia,
11. Stomach upset
12. Abdominal pain

Indications: Contraindications:
1. TB 1. Hypersensitivity
2. Leprosy 2. Renal/hepatic disease

Assessment/ Nursing Considerations/Patient Education

1. Encourage patient to comply with Educate patient on
medication regimen a. completing medication
2. Administer vitamin B6 with isoniazid regimen
to prevent peripheral neuropathy b. treatment of TB takes at
3. Monitor for hepatotoxicity (jaundice, least 6 months
dark urine, enlarged liver) c. Diet: high in vitamin B6
4. Monitor for signs of liver damage d. Weight monitoring
(elevated ALT, Elevated AST) e. Avoid alcohol
5. Monitor patient weight
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Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

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 Neuro Drugs
NSAIDs
Salicylates
Acetaminophen
Opioid Analgesics
Morphine Sulphate
Meperidine HCL
Hydromorphone
Anticholinesterases
Benzodiazepines
Hydantoins
Barbiturates

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Drug Class: Nonsteroidal anti-inflammatory drugs
Neurological Drugs
Medications
ibuprofen, diclofenac

Mechanism of Action: Adverse/Side Effects:

NSAIDs have anti-inflammatory, 1. Dysrhythmias
analgesic and antipyretic properties.
2. Dizziness
NSAIDs inhibits prostaglandin
3. GI disturbances/GI bleeding
synthesis
Types: 4. Hypotension
1. First-generation NSAIDs: inhibit 5. Hepatotoxicity
COX-1 and COX-2 and are used 6. Tinnitus
to treat inflammatory disorders.
2. Second generation NSAIDs:
inhibits COX-2 only. Inhibits pain
and inflammation
Indications: Contraindications:
1. Rheumatoid arthritis and 1. Hypersensitivity
osteoarthritis 2. Peptic Ulcer
3. Bleeding disorders
2. Dysmenorrhea 4. Renal or hepatic disease
3. Reduction of fever Interactions
1. Anticoagulant
2. Sulfonamides, phenytoin

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 1. Educate patient the
2. Monitor for edema medication regimen, side
3. Provide supporting care and adverse effects
4. Maintain hydration
5. Monitor for adverse effects

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Drug Class: Salicylates Neurological Drugs
Medications
ASPIRIN (acetylsalicylic acid)

Mechanism of Action: Adverse/Side Effects:

Salicylates inhibit synthesis of 1. Dizziness
prostaglandin. Salicylates have
2. Tinnitus
anti-inflammatory, antipyretic and
3. Mental confusion/drowsiness
analgesic properties.
4. GI disturbance
Aspirin suppresses platelet 5. Visual changes
aggregation by inhibiting 6. Bleeding
synthesis of thromboxane A2 7. Decreased renal function
(causes platelet aggregation)

Indications: Contraindications:
1. Rheumatoid arthritis and 1. Hypersensitivity
osteoarthritis 2. Bleeding disorders
2. Dysmenorrhea 3. Impaired hepatic/renal function
4. Children/adolescents with flu
3. Reduction of fever
symptoms, chicken pox,
4. Suppression of platelet
influenza (risk for Reye's
coagulation syndrome)

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 1. Educate patient on the
2. Monitor for edema medication regimen, side
3. Monitor signs of bleeding and adverse effects
4. Monitor serum salicylate
5. Administer drug with food to
alleviate GI effects

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Drug: Acetaminophen Neurological Drugs
Medications
Acetaminophen

Mechanism of Action: Adverse/Side Effects:

Acetaminophen inhibits 1. Nausea
prostaglandin synthesis (limited to 2. Vomiting
CNS and not periphery) 3. Hepatotoxicity
4. Oliguria
5. Rash

Indications: Contraindications:
1. Pain 1. Hypersensitivity
2. Fever 2. Alcoholism
3. Preferred use in children 3. Impaired hepatic/renal function
4. Replacement for patients with
aspirin toxicity

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 1. Educate patient on the
2. Monitor VS time frame of medication
3. Monitor liver enzymes use.
4. Antidote of acetaminophen:
acetylcysteine

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Drug Class: Opioid Analgesics Neurological Drugs
Medications
Morphine Sulfate, Pethidine, Fentanyl, Tramadol

Mechanism of Action: Adverse/Side Effects:

Centrally acting opioid analgesics
act as agonist by stimulating
specific opioid receptors in the CNS
that results in analgesia,
euphoria, and sedation.
Suppresses pain impulses.
Indications:
1. Pain
2. Preoperative medication
1. Respiratory depression
2. Decreased cough: due to
inhibition of cough reflex
3. Light-headedness, dizziness
4. Nausea and Vomiting
5. Urinary retention
6. Constipation
7. Lethargy and sleep
8. Postural hypotension
9. Sweating
Contraindications:
1. Hypersensitivity
2. Respiratory dysfunction
3. Head Injury
4. Increased ICP
5. Severe hepatic and renal
disease
6. Hemorrhage

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 1. Encourage deep breathing
2. Assess pain
3. Monitor VS (BP, P, RR, SPO2)- Hold and coughing
medication and notify HCP if there is 2. Avoid activities that
bradycardia, hypotension, respiratory
depression requires alertness
4. Auscultate lung sounds
5. Provide non-pharmacologic pain
management with opioids
6. Monitor intake and output.
7. Assess urinary retention
8. Provide safety precautions
9. Have antidote/opioid antagonist on hand.
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Generic Name:
Morphine Sulphate
Trade Name:
Avinza
Drug Class:
Opioid Analgesics
Mechanism of Action:
Centrally acting opioids
analgesics act as agonist by
stimulating specific opioid
receptors in the CNS that
results in analgesia, euphoria,
and sedation.
Therapeutic Use:
Pain
Preoperative medication
Side/Adverse Effects:
1. Respiratory depression
2. Orthostatic hypotension
3. Constipation
4. Sedation, Confusion
5. Urinary retention
Contraindications:
Hypersensitivity
Respiratory dysfunction
Head Injury
Increased ICP
Severe hepatic and renal
disease
Hemorrhage
Nursing Considerations:
1. Monitor VS
2. Monitor signs of
respiratory depression
3. Encourage deep
breathing exercises
4. Encourage deep
breathing and coughing
5. Avoid activities that
requires alertness
6. Antidote: nalaxone
Generic Name:
Meperidine HCL
Trade Name:
Pethidine
Drug Class:
Opioid Analgesics
Mechanism of Action:
Centrally acting opioids
analgesics act as agonist by
stimulating specific opioid
receptors in the CNS that
results in analgesia, euphoria,
and sedation.
Therapeutic Use:
Pain
Preoperative medication
Side/Adverse Effects:
1. Hypotension
2. Dizziness
3. Drowsiness
4. Urinary Retention
Contraindications:
Hypersensitivity
Respiratory dysfunction
Head Injury
Increased ICP
Severe hepatic and renal
disease
Hemorrhage
Nursing Considerations:
1. Monitor VS
2. Monitor signs of
respiratory depression
3. Encourage deep
breathing exercises
4. Encourage deep
breathing and coughing
5. Avoid activities that
requires alertness
NEURO DRUGS
Generic Name:
Hydromorphone
Trade Name:
Dilaudid
Drug Class:
Opioid Analgesics
Mechanism of Action:
Centrally acting opioids
analgesics act as agonist by
stimulating specific opioid
receptors in the CNS that
results in analgesia, euphoria,
and sedation.
Therapeutic Use:
Pain
Side/Adverse Effects:
1. Respiratory depression
2. Constipation
Contraindications:
Hypersensitivity
Respiratory dysfunction
Head Injury
Increased ICP
Severe hepatic and renal
disease
Hemorrhage
Nursing Considerations:
1. Monitor VS
2. Monitor signs of
respiratory depression
3. Encourage deep
breathing exercises
4. Encourage deep
breathing and coughing
5. Avoid activities that
requires alertness
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Drug Class: Anticholinesterases Neurological Drugs
Medications
Ambenonium chloride
Edrophonium
Mechanism of Action: Adverse/Side Effects:
Used to treat muscle weakness in 1. Increased GI motility
myasthenia gravis.
2. Pupillary miosis
Anticholinesterases blocks
3. Bronchospasm
acetylcholine breakdown.
4. Increase bronchial secretion
5. Sweating
6. Hypotension
7. Bradycardia
8. Dizziness

Indications: Contraindications:
1. Myasthenia gravis 1. Hypersensitivity
2. Peritonitis
3. GI obstruction

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications
2. Monitor signs of cholinergic crisis and
myasthenic crisis
3. Assess neuromuscular status
4. Provide safety measures
1. Educate patient on drug
use, side/adverse effect.
2. Educate patient to take
medication with food to
prevent nausea, vomiting
and diarrhea

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DrugClass: Dopaminergic Drugs Neurological Drugs
Medications
Apomorphine, Amantadine

Mechanism of Action: Adverse/Side Effects:

Dopaminergic drugs stimulate 1. Muscle twitching
dopamine receptors and increase
2. Chest pain
dopamine concentration.
3. Nausea and Vomiting
4. Urinary retention
5. Confusion
6. Hallucinations
7. Constipation
8. Orthostatic hypotension

Indications: Contraindications:
1. Parkinson’s disease 1. Hypersensitivity
2. Glaucoma
3. Psychiatric disorder

Assessment/ Nursing Considerations/Patient Education

1. Assess interactions/contraindications 1. Encourage patient to
2. Assess VS change position slowly to
3. Note that carbidopa-levodopa can minimize orthostatic
cause hypertensive crisis hypotension
4. Provide safety precautions 2. Avoid alcohol

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Drug: Benzodiazepines Neurological Drugs
Medications
SUFFIX: PAM. LAM
Diazepam, Lorazepam
Mechanism of Action: Adverse/Side Effects:
Benzodiazepines are used to treat 1. Sedation, drowsiness
absence seizures.
2. BP changes
They enhance the effect of GABA
3. Hypotension
resulting in sedative, sleep-
inducing, anti-anxiety, 4. Blurred vision
anticonvulsant, and muscle 5. Hepatoxicity
relaxant properties 6. Respiratory depression

Indications: Contraindications:
1. Preoperative anxiety 1. Hypersensitivity
2. Seizures 2. Myasthenia gravis
3. Skeletal muscle spams 3. COPD
4. Bronchitis
5. Sleep apnea

Assessment/ Nursing Considerations/Patient Education

1. Antiseizure precautions
2. Provide safety precaution
3. Monitor lab values
4. Monitor renal function test
5. Monitor liver function test
6. Antidote: Flumazenil
1. Educate patient to:
a. Avoid alcohol and OTC
b. Caution when
performing activities that
requires alertness

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Drug: Hydantoins Neurological Drugs

Medications
Phenytoin

Mechanism of Action: Adverse/Side Effects:

Blocks sodium channels and inhibits 1. Sedation, drowsiness
neurons from firing to stabilize
2. Nausea
central nervous system membrane
3. Vomiting
4. Nystagmus
5. Decrease platelet count
6. Increase serum glucose level
7. Hypotension
8. Blurred vision

Indications: Contraindications:
1. Seizures 1. Hypersensitivity
2. Psychoses
3. Impaired renal and hepatic
function
4. Pregnancy
Interactions:
Oral contraceptives

Assessment/ Nursing Considerations/Patient Education

1. Antiseizure precautions
2. Provide safety precaution
3. Monitor lab values
4. Monitor renal function test
5. Monitor liver function test
6. Phenytoin should be given at a slow
rate to prevent hypotension
1. Educate patient to:
a. Avoid alcohol and OTC
b. Caution when
performing activities that
requires alertness

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Drug: Barbiturates Neurological Drugs

Medications
SUFFIX: arbital
Phenobarbital, butabarbital
Mechanism of Action: Adverse/Side Effects:
Stimulates the inhibitory 1. Sedation, drowsiness
neurotransmitter system in the
2. Hypotension
brain.
3. Respiratory depression

Indications: Contraindications:
1. Tonic-clonic seizures 1. Hypersensitivity
2. Intubation/sedation 2. Psychoses
3. Impaired renal and hepatic
function
4. Pregnancy

Assessment/ Nursing Considerations/Patient Education

1. Antiseizure precautions
2. Provide safety precaution
3. Monitor lab values
4. Monitor renal function test
5. Monitor liver function test
6. Monitor ECG
7. Monitor for signs of infection
1. Educate patient to:
a. Avoid alcohol and OTC
b. Caution when
performing activities that
requires alertness

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 Neuro Drug Study
Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

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Anti-Diabetic Drugs
Insulin
Biguanides
Sulphonylureas

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Drug Class: Insulin Anti- Diabetic Drug
Medications
Lispro, Lantus, Regular, NPH

Mechanism of Action: Adverse/Side Effects:

Insulin replaces endogenous insulin. 1. Hypoglycemia
Facilitates the transport of
2. Reaction at injection site
metabolized food nutrients across
cell membranes.

Insulin
Rapid Acting: Lispro Short Acting: Regular (R)
Onset: 15min Onset: 30min
Peak: 1 hour Peak: 2-5 hourS
Indications: Duration: 2-4 hours Duration: 3-6 hours
1. Type 1 diabetes Intermediate Acting: NPH Long Acting: Lantus
2. Type 2 diabetes Onset: 1-2 hours Onset: 1-2 hours
3. Diabetic ketoacidosis Peak: 4--12 hours Peak: no peak time
Duration: 12-18 hours Duration: 24 hours

Contraindications:
1. Hypoglycemia

Assessment/ Nursing Considerations/Patient Education

1. Assess signs and symptoms of 1. Educate patient on
hypoglycemia glucose monitoring
2. Administer medication using 2. Educate patient on insulin
subcutaneous site. self-administration
3. Rotate injection site
4. Store insulin in cool place
5. Do not administer insulin into areas
that are swollen, red or itching
6. Provide good skin care and foot care
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Drug Class: Biguanides: Metformin Anti-Diabetic Drugs

Medications
Metformin

Mechanism of Action: Adverse/Side Effects:

Decrease production of glucose by 1. Decrease appetite
the liver and also reduces insulin
2. Nausea
resistance.
3. Diarrhea
4. Vitamin B12 deficiency

Indications: Contraindications:
1. Type 2 diabetes 1. Hypersensitivity
2. PCOS 2. Type 1 diabetes

Assessment/ Nursing Considerations/Patient Education

1. Assess vital signs and blood glucose 1. Educate patient on signs
level of hypoglycemia
2. Withhold metformin after radiological 2. Educate patient on low
study (with the use of IV dye) carb diet
3. Monitor nutritional status 3. Educate patient on
4. Administer Vitamin B12 supplements glucose monitoring

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Drug Class: Sulphonylureas Anti-Diabetic Drugs

Medications
Chlorpropamide
Glimepiride
Mechanism of Action: Adverse/Side Effects:
Stimulates insulin secretion by the 1. Decrease appetite
beta cells of the pancreas
2. Nausea
3. Diarrhea
4. Hypoglycemia

Indications: Contraindications:
1. Type 2 diabetes 1. Hypersensitivity
2. PCOS 2. Type 1 diabetes

Assessment/ Nursing Considerations/Patient Education

1. Assess vital signs and blood glucose 1. Educate patient on signs
level of hypoglycemia
2. Monitor for hypoglycemia 2. Educate patient on low
3. Instruct patient not ingest alcohol carb diet
with sulfonylureas 3. Educate patient on
4. Monitor nutritional status glucose monitoring

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 Anti-Diabetic Drug Study
Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

Generic Name: Brand Name:

Drug Class: Dosage:

Uses: Nursing Considerations:

Side/ Adverse Effect

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 DRUG
CALCULATION

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The
Medication
Basics
Administration Routes
1. PO: by mouth/orally
2. SubQ: Subcutaneous
3. IM: Intramuscular
4. ID: Intradermal
5. SL: Sublingual
6. PR: per rectum
7. NG: Nasogastric tube
8. IV: Intravenous
9. GT: Gastrostomy tube
10. IVP: IV push
11. IVPB: IV piggyback
10. Right Education
10 Rights of Medication
Administration
1. Right Drug
2. Right Patient
3. Right Dose
4. Right Route
5. Right Time
6. Right Documentation
7. Right Assessment
8. Right to Refuse
9. Right Drug Interaction

1. Before meals: ac
2. After meals: pc
3. Twice a day: bid
Types of Drug 4. Three times a day: tid
Preparation 5. Four times a day: qid
1. Tablet: tab(s) 6. Every day: daily
7. Every hour:qh
2. Drop: gtt
8. Every two hours: q2h
3. Suspension: susp 9. Every four hours: q4h
4. Suppository: supp 10. Every six hours: q6h
5. Enteric coated: EC 11. As needed: prn Times Of
6. Elixir: elix 12. As desired: ad lib Medication
13. At bedtime: hs Administration
7. Controlled release: CR
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Conversion Factors
Remember: Conversions can be based on volume or weight
Conversion WEIGHT
Based on 1 kg = 2.2lbs
Volume 1 lb = 16 oz

Calculation:
From pounds to kg = divide by
2.2
VOLUME From kg to pounds = multiply by
1 mg = 1,000mcg 2.2
1 g = 1,000mg
1 oz = 30mL
8 oz = 1cup
1 oz = 2tbsp
1 tsp = 5mL
1 tbsp = 15mL
Conversion
1 tbsp = 3tsp
Based on
1 mL = 1cc Weight
1 mL = 5gtts Safe nursing care mandates accuracy in the
1L = 1,000mL calculation of dosages and solution rates. In
medication calculations, there is no room for
mistakes.

Measurement Systems
There are three measurement systems used in dosage
calculation/pharmacology. That is: a. metric system, apothecary system and
household system.

a. Metric system: gram (g), milligram (mg), microgram (mcg), kilogram (kg),
milliliter (mL) and milliequivalent (mEq)

b. Apothecary (historical system of volume and mass unit): minim (min), pint
(pt), dram, ounces (oz), grain (gr)

c. Household system (what patients use at home): teaspoon (tsp),

tablespoon (tbsp), gallon (gal), pounds (lb), cups
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Basic Volume-Related Formula
The physician order. Example: 4mg
A physician orders lorazepam 4 mg
Desired Dose Volume IV Push. The nurse has 2 mg/mL vials
on hand. How many mL should be
Have The volume that the given?
Volume
medication is available in: 4mg Desired dose 1mL = 2mL
Example: 2mg/1mL 2mg Have Answer
The dosage that the
medication is available in:
Example: 2mg/1mL

Tablet A physician orders DRUG 50 mg/day

po. The nurse has 100mg/ tab on
Desired Dose Tablet hand. How many tablets should be
Have given?
Tablet
50mg Desired dose 1 tab=0.5 tab
100mg Have Answer

Pediatric Doses
Remember: Pediatric dosage calculations are based on body weight(kgs).
Always convert pounds to Kgs. Formula below is used for safe dose range.

Weight per Kg Dose per Kg = Amount to Administer

Calculate the dose of a drug in mLs for a child weighing 22
lb. The dose required is 40 mg/kg/day divided BID and the
suspension comes in a concentration of 400 mg/5 mL.

Step 1. Convert pounds to kg: 22 lb × 1 kg/2.2 lb = 10 kg

Step 2. Calculate the dose in mg: 10 kg × 40 mg/kg/day =
400 mg/day
Step 3. Divide the dose by the frequency: 400 mg/day ÷ 2
(BID) = 200 mg/dose BID
Step 4. Convert the mg dose to mL: 200 mg/dose ÷ 400 mg/5
mL = 2.5 mL BID
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IV Flow Rate Calculation
Calculating: mL/hr Calculate 1000ml of normal saline
over 2 hours.
mL of amount to be infused
=mL/hr 1000mL 500mL/hr
total hours 2 hours

1. If the question provides liters,

convert to mL. 1L= 1000mL
2. 2. If the question provides
minutes, convert to hours.
60min=1 hour

Calculating: gtt/min (drops/min)

A total of 2000mL normal saline is
mL of amount to be infused drop to infuse at 50mL/hr. Drop factor of
factor
=gtt/min tubing is 10gtt/mL
total minutes

50mL 10 gtt/mL= 8 gtt/min

60min

Calculating: Remaining Time of Infusion

Volume Remaining (mL) Drop
factor
=minutes remaining
Drops per min
Calculation: A patient has IV infusion at 400 mL level. It is
regulated to run for 22 drops per minute using a macrodrip
set with drop factor 20. Calculate the remaining time of
infusion.
400mL
20= 363 mins
22

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 MATERNAL
&
CHILD HEALTH

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table of content
1. Anatomy and Physiology
2. Signs of Pregnancy
3. Naegele's Rule
4. Gravidity and Parity
5. GTPAL
6. Fundal Height
7. Fetal Development
8. Changes During Pregnancy
9. Discomforts During Pregnancy
10. Nutrition During Pregnancy
11. Conditions During Pregnancy
a. Gestational Diabetes
b. Iron Deficiency Anemia
c. Gestational Hypertension
d. Ectopic Pregnancy
e. Placenta Previa
f. Abruptio Placenta
g. Abortion
h. Torch Infections
12. Labor and Delivery
a. Labor
b. True/False Labor
c. Stages of Labor
d. 5Ps
e. VEAL CHOP
f. Labor Complications
i. Preterm Labor
ii. Cord Prolapse
13. Postpartum-Newborn Care
a. Lochia
b. Postpartum Hemorrhage
c. APGAR SCORE
d. Postpartum Infections
i. UTI
ii. Mastitis
iii. Endometritis 435 / 601
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anatomy and physiology
Female Reproductive System
follicle-stimulating hormone
Ovarian hormones:
Luteinizing hormone
Ovarian hormones: are released by the anterior pituitary gland
THE MENSTRUAL CYCLE
The four main phases of the
menstrual cycle are:
1.Menstruation
2. The follicular phase
3. Ovulation
4. The luteal phase
The ovaries secrete two main
hormones—
estrogen and progesterone
INTERNAL ORGANS
1. Vagina: muscular tube from the
vulva to the uterus
2. Cervix: cylinder-shaped neck of
tissue that connects the vagina and
uterus
3. Ovaries: two sex organs on each
side of the uterus
4. Fallopian tubes: three sections
(Isthmus, ampulla and infundibulum)
5. Uterus: the womb, located within
the pelvic cavity. Divided into
(cervix, uterine isthmus, corpus,
fundus)
1. Menstrual cycle: 28 days
(average length)
2. Ovulation: occurs on the
14th day
3. Fertilization: fusion of
the egg + sperm
4. Implantation: occurs 8-9
days after conception.
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SIGNS OF PREGNANCY
PRESUMPTIVE SIGNS PROBABLE SIGNS POSITIVE SIGNS
PRESUMPTIVE SIGNS subjective
1. Amenorrhea (missed period). think "mother"
2. Enlarged breast
3. Quickening: feeling of fetal movement
4. Enlarged breast
5. vomiting
6. Nausea
7. Fatigue

PROBABLE SIGNS THE DOCTOR AND NURSE

1. Positive pregnancy test CAN OBSERVE AND
2. Uterine enlargement DOCUMENT
3. Goodell's sign: softening of cervix
4. Chadwik's sign: bluish coloration of vulva,
cervix and vagina.
5. Hegar's sign: softening of the lower
uterine segment

Positive sign is
POSITIVE SIGNS conclusive (diagnostic)
1. Fetal heart
2. Fetal movement
3. Ultrasound or radiography

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NAEGeLE'S RULE

DEFINITION
Used to calculate the estimated date of delivery (based on a
normal 28-day menstrual cycle).

FIRST DAY OF LAST MENSTRUAL PERIOD

January 10th, 2021

Subtract 3 months
October
October 10th 2020 17th 2021

Add 7 days

October 17th 2020

estimated date of
delivery
Add 1 Year

October 17th 2021

Full term: 40 weeks (average)

The calculation is based on a 28-day cycle.

Remember: practice makes perfect. Do as much practice

test questions using the 4 steps presented above.
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gravidity and parity

GRAVIDITY
Gravida: pregnant woman Nulligravida- never been
pregnant.
Gravidity: the number of pregnancies Primigravida: pregnant
for the first time.
Multigravida: 2+
pregnancies

NULL- NONE
PRIMI-FIRST
MULTI-MULTIPLE

PARITY
Number of times a woman has
given birth to a fetus with a
gestational age of 24 weeks or
more.
Include all babies (living or still
birth)
Nullipara- no births above
20 weeks of gestation.
Primipara: 1 birth after 20
weeks of gestation
Multipara: multiple
pregnancies that reached
the stage of fetal
viability.

NULL- NONE
PRIMI-FIRST
MULTI-MULTIPLE
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gtpal
GTPAL: DESCRIBES PREGNANCY OUTCOMES

1. Number of pregnancies
(twins and triplets are
counted as one)
GRAVIDITY 2. Present pregnancy included.

1. The number born at term

(longer than 37 weeks of
TERM BIRTHS gestation)
2. Twins and triplets are
counted as one.

20-37 weeks of gestation.

(Count twins and triplets as
PRETERM BIRTHS one)
Includes alive and still birth

Less that 20 weeks of

gestation.
ABORTIONS Count twins and triplets as one

also include miscarriages

Current living children.

LIVING CHILDREN Count children individually
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FUNDAL HEIGHT
The fundal height is used to determine the gestational age of a
fetus by determining the distance in centimeters from the symphysis
pubis to the top of the uterine fundus.

t is
me n
MEASURING THE FUNDAL HEIGHT re
easu m
m in c
Position patient to lie back

Start measuring from the symphysis pubis

Run the tape measure along the midline

of the woman’s abdomen to the top of Monitor for
the uterine fundus supine
hypotension

Fundal height (cm)= fetal

gestational age.
(20cm=20weeks)

16 weeks= fundus is located

between the symphysis pubis and
umbilicus
20-22 weeks= fundus is located
at the level of the umbilicus
36 weeks= fundus is at the
xiphoid process
Patient with inaccurate fundal height
measurement should have a serial
assessment of fetal size using
ultrasound
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fetal development
preembryonic PERIOD: Embryonic PERIOD: FETAL period:
first 2 weeks 2-8 weeks 9weeks-birth

week 4/5 week 8 week 12

1. Heart begins to 1. Blood begins to 1. Sex is visible
beat circulate 2. Face is formed
2. Organs are present 3. Heart tones can be
heard using a
Doppler

week 16 week 20 week 24

1. Movement is 1. Heartbeat is 1. Fetus can hear
present detected by fetoscope
2. Lanugo covers body

week 28 week 32 week 36

1. Lungs are 1. Bones are 1. Skin becomes less
developed developed. wrinkled.
2. Skin is pink.
3. Baby position down in
pelvis

week 40 TRIMESTERS
1. The average full- First Trimester: 0-12
term 40- week weeks
Baby is Second Trimester: 13-28
weeks
here! Third Trimester: 29-40
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CHANGES DURING PREGNANCY

cardiovascular
Increased CO
Increased HR
Increased blood volume

Respiratory
Increased O2 consumption
Diaphragm pushes upwards
SOB may be experienced

Gastrointestinal
Nausea, Vomiting
Acid reflux, Constipation
Changes in taste and smell

genitourinary
Increase urination
Bladder sensitivity
Increase bladder capacity

Endocrine
Oxytocin stimulates contractions
Weight gain
Thyroid activity increases
Increased water retention
Prolactin causes the lactation process

SKIN/musculoskeletal
1. Striae
2. Linea nigra
3. Increased hair growth
4. Umbilicus protrudes
5. Abdominal wall stretches

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Discomforts during pregnancy

1.Nausea and Vomiting 2. Fatigue
Intervention: Eating dry crackers Interventions: Frequent naps/rest
before rising up from bed. Relaxation and exercise
3. Heartburn
Intervention: Have small, frequent meals.
Sit upright after meals for 30mins-1hour
4. Increased urination
Intervention: Adequate fluid intake,
Avoid fluid intake before bedtime.
Kegel exercises

5. EDEMA/varicose veins
Intervention: Elevate legs
Supportive stockings
Avoid standing or sitting for
long periods
6. Constipation
Intervention: Increase fiber in
diet. Increase fluid intake

7. uti
Intervention: Consult with
physician. Follow treatment
regimen

8. Hemorrhoids
Intervention: Soaking in a sitz
bath

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NUTRITION during pregnancy

calories PROTEIN
300-500 additional calories Increase protein in diet.
Vitamin B12 is found in animal
WEIGHT GAIN protein.
vit b12
Total weight gain: 25-35lbs PROTEIN = defeciency

FOLIC ACID iron

Recommendation: 600
micrograms (mcg) of folic acid
daily.
CALCIUM
Calcium supplements
Diary foods
Dark, leafy green vegetables
Important for fetus: Bone and
teeth formation
Build hemoglobin for fetus
VITAMINS
Vitamin D: for calcium
absorption
Increase fruits and vegetables
fiber
To prevent/reduce constipation

fluid intake
Recommendation: 2-3L/day
No alcohol, Limit caffeine

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CONDITIONS
RELATED TO
PREGNANCY

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CONDITIONS during pregnancy

GESTATIONAL
DIABETES
pathophysiology
Impaired glucose tolerance that occurs during the 2nd or 3rd
trimester of pregnancy.

RISK FACTORS signs & SYMPTOMS

1. Obesity
2. Multiple pregnancies
3. Family history of DM
DIAGNOSTIC TEST
1. Glucose tolerance test
2. 3-hour oral glucose
tolerance test (OGTT)
1. Polyuria: increased
urination
2. Polydipsia: Increased
thirst
3. Polyphagia: Increased
appetite
4. Blurred vision
5. Glucose in urine
6. Frequent UTIs
7. Excess weight gain

Nursing management
1. Diet, Insulin
2. Glucose monitoring, Low impact exercise
3. Monitor weight
4. Monitor fetal status

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CONDITIONS during pregnancy

Iron Deficiency
Anemia
pathophysiology
Iron deficiency anemia is characterized by insufficient serum
iron. This results in decreased hemoglobin and decreased
oxygen-carrying capacity of the blood.

causes signs & SYMPTOMS

1. Diet: low consumption 1. Fatigue
of iron-rich foods. 2. Pallor
3. Hemoglobin: <10mg/dL
2. Insufficient serum iron.

DIAGNOSTIC TEST Pharmacology

1. Hemoglobin/Hematocrit 1. Ferrous Sulfate
2. Serum iron level 2. Folic acid
3. RBC size: smaller 3. Vitamin C: increase iron
absorption
Nursing management
1. Monitor hemoglobin/hematocrit levels
2. Educate patient on medication regime
3. Encourage iron-rich foods

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CONDITIONS during pregnancy

gestational
Hypertension
Gestational hypertension
Blood pressure >140/90 mm Hg after 20 weeks gestation with
no proteinuria (excess protein in the urine).
Mild preeclampsia: BP >140/90 but <160/110,
preeclampsia Proteinuria: 1+
Severe preeclampsia: BP >160/110, Proteinuria: >3+
Signs of preeclampsia: HYPERTENSION + PROTEINURIA

ECLAMPSIA complications
1. DIC/ fetal death
Seizures in preeclamptic patient 2. Abruptio placentae
3. HELLP syndrome: H-
hemolysis, EL- elevated
liver enzymes, LP- low
Intervention platelet count.

1.BP monitoring
2. Fetal monitoring
3. Bed Rest (lateral position)
4. Antihypertensive medications
5. Administer Magnesium sulfate: prevent seizures.
Monitor for magnesium toxicity (antidote: calcium gluconate)
6. Initiate seizure precaution: preeclampsia/eclampsia
7. Monitor for HELLP

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CONDITIONS during pregnancy

ectopic
pregnancy
pathophysiology
Ectopic pregnancy occurs when an ovum implants outside of the
uterus (mostly in the fallopian tube). Risk for tubal rupture and
hemorrhage.
RISK FACTORS signs & SYMPTOMS
1. Previous ectopic 1. Abdominal pain
pregnancy (stabbing pain)
2. Vaginal spotting
2. Vitro fertilization (IVF)
3. Hemorrhage-
hypotension,
DIAGNOSTIC TEST tachycardia

1. Ultrasound

Treatment
Pharmacology
Methotrexate-used to stop cell growth
Laparotomy procedures
1. Salpingostomy: ectopic pregnancy is removed and the
fallopian tube left to heal.
2. Salpingectomy: ectopic pregnancy and fallopian tube are
removed.
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CONDITIONS during pregnancy

placenta
previa
pathophysiology
Placenta previa occurs when the placenta partially or totally
covers the mother's cervical opening.

TYPES signs & SYMPTOMS

1. Marginal: Placenta is 1. Painless bright red
attached in the lower bleeding
region of the uterus but 2. Bleeding
does not cover cervical 3. Soft uterus
opening.
2. Partial: Placenta covers a Diagnostic test
part of the cervical opening
3. Total: The placenta covers Ultrasound
the entire cervical opening.

Nursing Management
1. Avoid vaginal examination
2. Medication: corticosteroids
3. Continuous monitoring of mother and fetal status
4. Promote rest (left side lying)

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CONDITIONS during pregnancy

abruptio
placenta
pathophysiology
Abruptio placenta is the premature separation of the placenta
from the uterus. RISK FOR: Hemorrhage, shock and fetal
distress.
RISK FACTORS signs & SYMPTOMS
1. Hypertension 1. Abdominal pain
2. Smoking 2. Bleeding: dark red
3. Cocaine 3. Hypovolemic shock (s/s)
4. Abdominal injury 4. Uterine becomes hard
5. Fetal distress

Nursing Management
1. Monitor mother and fetal status
2. O2 therapy as prescribed
3. Monitor bleeding: remember to count the # of pads
4. Side lying
5. Medication: corticosteroids
6. IV fluids/blood as prescribed
7. Prepare for Caesarian section

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CONDITIONS during pregnancy

abortion
pathophysiology
Abortion is the termination of pregnancy before 20 weeks of
gestation (either spontaneously or electively)

Types signs & SYMPTOMS

1. Spontaneous: natural cause 1. Bleeding/Blood clots
2. Complete: all tissues of conception 2. Cramping
leaves the body
3. Missed: tissues of conception
remains in the uterus
4. Threatened: Spotting & cramping
5. Inevitable: Bleeding & dilated
cervix

Nursing Management
1. Monitor VS
2. Monitor bleeding (signs of shock)
3. Count pads
4. Administer IV fluids as prescribed
5. Procedure: prepare for Dilation and Curettage (D&C) for
inevitable /incomplete abortion.

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CONDITIONS during pregnancy

torch
infections
Toxoplasmosis: found in raw meat (or undercooked), cat
feces.
Patient education: Mother should NOT clean litter
boxes. Cook meat well.

OTHER:
Syphilis, Hepatitis A & B, Varicella, HIV

Rubella:
S/S: deafness, congenital defects: heart, eyes and
brain

Cytomegalovirus: droplet transmission

S/S: low birth weight, jaundice, hearing loss,
seizures

Herpes simplex virus:

Transmitted during vaginal delivery (delivery is
usually cesarean section)
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LABOR AND
DELIVERY

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LABOR
signs that precede labor
1. Contractions (Braxton Hicks)
2. Lightening
3. Rupture of membrane
4. Weight loss (1-3 pounds)
5. Increased in energy
6. Cervical ripening
7. Increased vaginal discharge
8. GI disturbance

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TRUE VS LABOR
true labor
1. Contractions:
i. Regular
ii. Stronger
iii. Longer
2. Softening of the cervix
i. Cervical dilation
ii. Effacement
3. Fetus engages in the pelvis
i. Presenting part compresses the bladder

FALSE labor
1. Contractions:
a. Irregular
b. Walking decreases contractions
2. No cervical changes or dilation
3. No effacement

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STAGES OF LABOR

FIRST STAGE second STAGE

From the onset of labor The second stage is
to complete dilation. between full dilation-
birth

Phases:
1. Latent Phase: 0- Third STAGE
3cm (from mild to The third stage is
moderate between the delivery of
contractions) the baby and the
2. Active Phase: 4-7cm delivery of the placenta.
3. Transition phase 8-
10cm dilation FOURTH STAGE
(contractions are
The fourth stage is
very strong)
between placenta
delivery until mother's
stabilization.

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5pS
4 Types of
pelvic shape
Gynecoid (most common),
ASSSAGEWAY android, anthropoid
Remember: birth canal (oval), and platypelloid
(flat)

assenger
Remember: fetus, membranes & placenta

Attitude: The relationship of fetus' body parts to one another.

Normal attitude: general flexion, fetal extension

fetal lie: The relationship between the long axis (spine) of the fetus
with respect to the long axis (spine) of the mother.
Lie: Longitudinal/vertical (cephalic or breech)
Transverse or horizontal- cesarean section is needed

Presentation: Part of the fetus that enters the pelvic inlet first.
Cephalic: head first, Breech: buttocks first, Shoulder:
shoulders first (transeverse)

position: Relationship of presenting part to maternal pelvis

station: Station 0: at ischial spine

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5pS
Contractions causes effacement and
dilation
Effacement: Shortening and thinning
owers of cervix during first stage of labor.
Dilation: Full dilation 10cm
(enlargement of cervix)

Birthing positions.
This includes:
osition 1. Squatting position
2. Lithotomy position
3. Upright position
4. Sitting position

Emotional Response
sychological Anxiety or fear
Response

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VEAL CHOP
A method used to understand the different fetal heart rate patterns

variable deceleration cord compression

early deceleration head compression

acceleration oxygenated or OK

late placental
deceleration insufficiency
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labor Complications
preterm labor
Onset of uterine contractions before 37 weeks of gestation.

signs and symptoms

Signs of true labor (regular contractions, vaginal discharge and
cervical dilation)

Pharmacology
Administer Glucocorticoids (to improve fetal lung maturity)
Administer magnesium sulfate: monitor magnesium sulfate
toxicity.

cord prolapse
Cord prolapse occurs when the cord descends through the
cervix below the presenting part of the fetus.

RISK
Risk for decrease blood flow and oxygenation to the baby.

NURSING INTERVENTIONS
Call for help
Insert 2 fingers in the vagina (lift the fetal head off the cord)
Position: Trendelenburg or knee to chest position
Monitor fetal heart rate

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Postpartum
Newborn care

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lochia
lochia rubra

D
RE
Remember: bright red

HT
Lasts for 1-3 days

IG
BR

n
lochia SEROSA

ow
br
Remember: pink/brown

k/
Lasts: day 4 to day 10
n
pi

lochia alba
te
hi
/w

Remember: yellow/white
ow
ll

Can last up to 6 weeks

ye

ABNORMAL FINDINGS
When pad is soaked within less than 15 minutes.
Increased abdominal pain
Fever
Foul smelling or purulent lochia
Bright red bleeding after 3 days

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POSTPARTUM HEMORRHAGE
POSTPARTUM
HEMORRHAGE
Definition: The mother loses
>500 mL of blood in a normal
delivery and >1000mL of
blood in a cesarean delivery

CAUSES
uterine Atony: The uterus stops contracting
Lacerations
Retained placental fragments

Signs and Symptoms

1. Heavy bleeding
2. Tachycardia
3. Hypotension
4. Tense and rigid uterus
5. Decreased hematocrit

Nursing Interventions
1. Administer O2
2. Assess and monitor vital signs
3. IV replacement + blood products
4. Massage uterine fundus
5. Administer oxytocin, hemabate, & methylergonovine
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APGAR ASSESSMENT

SCORE 0 1 2
HEART RATE <100/MIN >100/MIN

SLOW/ VIGOROUS
RESP RATE ABSENT
WEAK CRY

MUSCLE TONE ABSENT SOME ACTIVE

FLEXION
REFLEX
NONE GRIMACE CRY
IRRITABILITY

PALE OR ACRO-
COLOR CYANOSIS PINK
BLUE

0-3 Severely Distressed

requires medical attention and resuscitation

4-6 Moderately Distressed

clearing of the airway and supplementary oxygen

7-10 Good Condition

Baby is in best possible health

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POSTPARTUM infections
Urinary tract infection
PATHO
Inflammation of any part of the urinary system
causes:
C-section, frequent vaginal examination, catheterization
Interventions:
1. Urine sample, antibiotics, analgesics

mastitis
PATHO
Inflammation/infection of the breast tissue
causes:
Poor feeding technique, block duct
Interventions:
1. Antibiotics 2. Educate patient to breastfeed frequently 3.
Educate patient to empty breast after feeding

endometritis
PATHO
Inflammation/infection of the inner lining of the uterus
causes:
C-section, retained placental fragments, internal fetal monitoring
Interventions:
1. Vaginal+blood culture
2. Antibiotics + analgesics

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PED
IAT
ord RI
dis
ers C
A St
udy
Gui
de f
or N
ursi
ng S
tud
ents

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INTEGUMENTARY DISORDERS

1. ECZEMA
2. SCABIES

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INTEGUMENTARY DISORDERS
ECZEMA
description
Skin inflammation involving the epidermis.
Forms:
1. Infantile: Onset (2-6 months)
2. Childhood: Onset (2-3 years)
3. Preadolescent and Adolescent: Onset (12
years)

Interventions Signs & Symptoms

1. Avoid skin exposure to irritants 1. Redness
2. Lubricate skin 2. Inflammation
3. Soothe skin with cold compressions 3. Itching
4. Medications: Antihistamines, topical 4. Papules
corticosteroids 5. Oozing or crusting.
5. Avoid wet diapers 6. Scaly patches of skin.

SCABIES
description
1. Highly contagious parasitic skin disorder
caused by the human itch mite (Sarcoptes
scabiei).
2. Transmission: skin-to-skin contact

Interventions Signs & Symptoms

1. Itching
1. Monitor skin around wound
2. Rash
2. Medications: topical scabicide- educate the
3. Pruritus
parents on application, Anti-itch topical 4. Burrows in skin: Fine grayish
treatment, antibiotics red lines
3. Change bedding daily 5. Thick crusts on the skin (crust
4. Treat the family scabies)

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HEMATOLOGY DISORDERS
1. SICKLE CELL ANEMIA
2. IRON DEFICIENCY ANEMIA

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Hematology disorders
Sickle Cell Anemia Normal red
blood cells
description
In sickle cell anemia, hemoglobin A is replaced by
abnormal sickle hemoglobin S.
Other characteristics: Sticky sickle cells, sickle cells
block blood flow
SickleD RED
Sickle cell crisis: BLOOD CELLS
Vaso-occlusive crisis, sequestration, aplastic,
hyperhemolytic

Interventions Signs & Symptoms

1. O2 therapy 1. Pain
2. Blood transfusion 2. Anemia
3. Electrolyte replacement
4. Pain management 3. Jaundice
5. Infection prevention: antibiotics 4. Heart
6. Non-pharmacologic pain management: failure/dysrhythmias
positioning
7. Diet: high calorie, high protein diet, folic acid 5. Enlargement of the
supplement bones

iRON DEFICIENCY aNEMIA

description
Iron deficiency anemia is characterized by insufficient
iron which leads to depletion of red blood cells. This
results in decreased hemoglobin and decreased
oxygen-carrying capacity of the blood.

Interventions Signs & Symptoms

Administer Iron supplements 1. Fatigue
Educate on the side effects of iron supplements:
Constipation and black stools 2. Pallor
Educate parents on iron-rich diet/foods 3. Brittle nails
Educate parents to increase vitamin C consumption in 4. Low hemoglobin and
their child's diet hematocrit levels
Educate parents to give the child liquid iron
supplements with a straw to prevent teeth staining. 5. Shortness of breath
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 ENDOCRINE DISORDERS
1. FEVER
2. DEHYDRATION
3. TYPE 1 DIABETES
4. DIABETES KETOACIDOSIS

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endocrine disorders
!!!
fever
!!
description
ER
Fever is the elevation in body
EV
F
temperature.

Temperature:
1. Normal: 36.4-37.0 (degrees celsius)
2. Fever: >38.0 (degrees celsius)

Interventions Signs & Symptoms

1. Monitor temperature 1. Temperature: >38.0
2. Assess underlying cause (degrees celsius)
3. Non-pharmacologic management: remove excess
2. Skin: warm
clothing, cooling measures, sponge bath.
4. Medications: Antipyretics
3. Lethargy
Remember: do not administer Aspirin
4. Chills
due to the risk of reye's syndrome

Dehydration
description
Dehydration is a fluid and electrolyte
imbalance that results from decreased fluid
intake, increased fluid output (vomiting,
diarrhea) or fluid shift (burns and sepsis).

Interventions Signs & Symptoms

1. Monitor vital signs 1. Weight loss
2. Monitor weight 2. Increased pulse
3. Monitor intake and output 3. Tachypnea
4. Treat cause of dehydration 4. Increased thirst
5. Mild dehydration: oral rehydration therapy 5. Oliguria
6. Severe dehydration: maintain NPO, IV therapy
6. Sunken anterior fontanel
7. Remember: signs and symptoms depends on the
7. Sunken eyes
severity of dehydration
8. Irritability
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endocrine disorders
TYPE 1 DIABETES Insulin is an essential
hormone produced by the
description
An autoimmune dysfunction in which the beta pancreas. Its main role is to
cells are being destroyed. The pancreas (beta control glucose levels in the
cells) is unable to produce insulin. body
Risk factor/causes
Autoimmune response
Genetics
Onset: childhood
Interventions Signs & Symptoms
1. Glucose monitoring 1. Polyuria: increased
urination
2. Insulin: diluted insulin for infants 2. Polydipsia: Increased
thirst
3. Balanced diet 3. Polyphagia: Increased
4. Exercise appetite
4. Weight loss
5. Hyperglycemia
co
mp

DIABETIC KETOACIDOSIS
lic
at

description
io
n

DKA is a sudden, life-threatening

complication of Type 1 Diabetes.
Characteristics:
Hyperglycemia, Dehydration, Ketosis,
Acidosis
Interventions Signs & Symptoms
IV fluid replacement 1. Fruity breath
IV insulin: treat hyperglycemia 2. Kussmaul's respiration
Correct electrolyte imbalance: 3. Ketosis
4. Acidosis
Monitor potassium levels
5. Electrolyte loss
O2 therapy 6. Lethargy
7. Confusion/Coma
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RESPIRATORY DISORDERS
1. EPIGLOTTITIS
2. BRONCHITIS
3. ASTHMA
4. CYSTIC FIBROSIS
5. PNEUMONIA
6. BRONCHIOLITIS
7. INFLUENZA
8. TONSILLITIS

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Respiratory disorders
epiglottitis
description
Inflammation and swelling of the
epiglottis.
Cause: Haemophilus influenza

treated as an emergency

Interventions Signs & Symptoms

1. Maintain patent airway (priority) 1. Fever
2. O2 therapy as ordered
2. Severe sore throat
3. Monitor respiratory status
3. Difficulty speaking
4. Maintain NPO
5. Do not place the child in a supine position 4. Drooling
6. Avoid throat culture 5. Tachycardia
7. Medications: antibiotics, antipyretics 6. Difficulty breathing
8. Prepare resuscitation equipment 7. Stridor

bronchitis
description
Inflammation of the lining of the bronchial
tubes.
Causes: viral infection
Bronchitis may be either acute or chronic

Interventions Signs & Symptoms

1. Monitor temperature 1. Fever
2. Monitor respiratory status 2. Nonproductive cough
3. Increase fluid intake 3. Productive cough
4. Medications: antipyretics, cough (after 2 days)
suppressants 4. Chest pain
5. Chills
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Respiratory disorders
asthma
description
Chronic inflammatory disease of the airway.
Inflammation and hypersensitivity to a trigger
(stimuli).
Smooth muscle constriction of the bronchi.
Intermittent airflow obstruction.
Interventions
1. Maintain patent airway
2. Assess respiratory status
3. Administer humidified O2
4. Administer medications
(anticholinergics, corticosteroids,
bronchodilators)
5. Chest physiotherapy
Diagnostic tests:
1. Sweat test: More than 60 mmol/L:
diagnosis of cystic fibrosis
2. Stool analysis and Pulmonary function test
Interventions
Resp- Monitor resp status, chest physiotherapy,
antibiotics, bronchodilators, O2 therapy, mucolytics,
anticholinergics
GI- Diet (Vitamins, high-protein, high calorie diet),
Monitor weight and stool pattern, administer
pancreatic enzymes.
Others- Monitor vital signs, monitor electrolyte levels,
provide emotional support
Signs & Symptoms
1. Dyspnea, wheezing,
chest tightness, non
productive cough
2. Restlessness
3. Hyperresonance on
percussions
Cystic Fibrosis
description
CF is an exocrine gland dysfunction that results to
chronic respiratory infections, pancreatic enzyme
insufficiency, sweat gland dysfunction (results to
increased Na + Cl sweat concentration). Thick mucus
produced by the exocrine gland obstruct organs.
CF is progressive and incurable.
Signs & Symptoms
Resp- barrel chest, clubbing of fingers,
dyspnea, wheezing & cough
GI: Meconium ileus, Steatorrhea, Rectal
prolapse, Bile-stained emesis
Skin: High Na + Cl in sweat,
dehydration, electrolyte imbalance
Reproductive system: Sterility
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Respiratory disorders
pneumonia
description
Inflammation of the pulmonary tissue caused
by bacteria, fungi and viruses.
Viral pneumonia: occurs more frequently than
bacterial pneumonia.
Bacterial pneumonia: serious infection
Aspiration pneumonia: Substance enters the
airway due to vomiting or impaired
swallowing

Interventions Signs & Symptoms

Viral pneumonia: 1. Cough
1. 02 therapy, 2. antipyretics, 3. chest
physiotherapy 4.Increase fluid intake, Iv fluids 2. Wheezing
Bacterial pneumonia: 3. Fever
1. O2 therapy, IV fluids, antibiotics, suction mucus,
promote rest, increase fluid intake 4. Chills
5. Tachypnea

Bronchiolitis
description
Inflammation of the lining of the bronchioles
due to RSV (Respiratory Syncytial Virus).

Interventions Signs & Symptoms

1. Maintain patent airway 1. Rhinorrhea
2. Humidified oxygen 2. Cough
3. Increase fluid intake
3. Fever
4. Place the child at a semi-fowlers position.
5. Periodic suctioning 4. Wheezing
5. Tachypnea

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Respiratory disorders
Influenza
description
Influenza is a viral infection that attacks
the respiratory system.

Highly contagious airborne disease.

Interventions Signs & Symptoms

1. Promote bed rest 1. Cough
2. Administer antiviral medication 2. Fever
3. Increase fluid intake 3. Myalgia
4. Fatigue/body
weakness

Tonsillitis
description
Tonsillitis is the inflammation of the tonsils.
The tonsils are two oval-shaped pads of
tissue at the back of the throat.

Interventions Signs & Symptoms

1. Medications: Antipyretics, Antibiotics 1. Swollen tonsils
2. Surgical intervention: tonsillectomy-the removal of
the tonsils
2. Sore throat
a. Monitor for postoperative bleeding (a sign of 3. Snoring
bleeding is frequent swallowing) 4. Painful swallowing
b. Begin with clear fluids then proceed to soft
diet. 5. Fever
c. Remember: do not administer any red liquids 6. Muffled voice
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NEUROLOGICAL DISORDERS

1. MENINGITIS
2. SEIZURES
3. REYE'S SYNDROME
4. CEREBRAL PALSY
5. HEAD INJURY
6. HYDROCEPHALUS

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NEUROLOGIC disorders
The primary function of the
MENINGITIS meninges and of the
cerebrospinal fluid is to protect
the central nervous system
description
Meningitis is an inflammation of the protective membranes covering the brain
and spinal cord.
Causes Other causes
1. Trauma
2. Cancer
3. Neurosurgery
BACTERIA virus

DIAGNOSTIC TEST
CSF is obtained through lumbar puncture

BACTERIAL Meningitis
Results: Positive gram stain, Appearance (cloudy), WBC (elevated),
Glucose (decreased) Protein (elevated)

VIRAL Meningitis
Results: Negative gram stain, Appearance (clear), WBC (elevated),
Protein (within normal range), Glucose (within normal range)

Interventions Signs & Symptoms

1. Droplet precautions 1. Positive Brudzinski's
2. Assess LOC, increased ICP
sign
3. Medications: IV antibiotics (bacterial
2. Positive Kernig's sign
meningitis), antipyretics, corticosteroids
4. Monitor for hearing loss 3. Fever, headache
4. Irritability
5. Bulging anterior
DROPLET PRECAUTIONS
fontanels
Droplet spread is via the upper respiratory tract (nose,
nasal passages and pharynx). 6. Nuchal rigidity
7. Photophobia
Nursing Actions
1. Place patient in a private room 8. Nausea/vomiting
2. Wear a surgical mask.
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NEUROLOGIC disorders
RISK FACTORS
SEIZURES 1. Fever
description 2. Meningitis
3. Head trauma
Seizures: a sudden, uncontrolled 4. Stroke
electrical disturbance in the brain. 5. Brain tumor
Epilepsy: Chronic seizures 6. Electrolyte imbalances

DIAGNOSTIC TESTS:
seizure types:
Generalized Seizures 1. An electroencephalogram
1. Tonic-Clonic 2. Computerized tomography
2. Absence 3. Magnetic resonance imaging
3. Myoclonic (MRI)
4. Atonic 4. Neurological exam
Partial Seizures
Signs and symptoms
1. Simple partial
2. Complex partial The signs and symptoms depends on seizure
history and type.
Nursing Interventions: Before seizure
Aura
1. Initiate seizure precautions
During seizure
2. Assess time and duration of seizure
Loss of consciousness during seizures
activity
Uncontrollable involuntary muscle
3. Provide patient safety
movements
4. Turn patient to the side
Loss of bladder and bowel control
5. Maintain airway
6. Avoid restraining patient
7. Loosen clothing febrile seizures
8. Administer O2
9. Monitor behavior before and after A febrile seizure is a convulsion in
seizure activity, vital signs a child that's caused by a fever.
10. Maintain NPO status after seizure The fever is often from an
infection.
MEDICATION:
Anti-seizure medication: Types:
e.g.Phenytoin 1. Simple febrile seizures
2. Complex febrile seizures
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neurological disorders
REYE'S SYNDROME
description
Reye's syndrome is characterized by
encephalopathy and fatty changes in
liver
Diagnostic test
Risk factors: Viral infection, Aspirin
1. Liver Biopsy
Aspirin is not used among children due to 2. Liver enzymes: ALT, AST
the risk of Reye's syndrome 3. Blood ammonia level
Interventions Signs & Symptoms
1. Assessment: Hx of viral illness (4-7 days 1. Fever
prior), liver enzymes and blood 2. Vomiting
ammonia level (elevated). 3. Irritability
2. Monitor s/s of increased ICP, LOC 4. Lethargy
3. Positioning: HOB @ 30 degrees
5. Hepatic dysfunction
4. Monitor intake and output

CEREBRAL PALSY
description
Cerebral Palsy is a disorder that
affects movement, posture and muscle
tone.
Spastic cerebral palsy is the most
common type.
Interventions Signs & Symptoms
1. Assessment: developmental and 1. Developmental
growth status delays
2. Physical therapy, speech therapy 2. Delayed growth
3. Braces 3. Abnormal posture
4.Medication: anti-seizure and motor function
4. Opisthotonos
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NEUROLOGIC disorders
HEAD INJURY
description
Trauma to the skull that causes
brain damage.
types:
Open Head Injury:
Object
penetrates skull
Closed Head Injury:
Blunt trauma
Nursing Interventions:
1. Immobilize the neck and spine
2. Elevate head @ 30 degrees (if it is
not a spinal cord injury)
3. Head position: midline position
4. Monitor airway (O2 therapy)
5. Assess vital signs and level of
consciousness
6. Do not suction patient
7. Seizure precautions
8. Educate child to avoid straining
9. Insert urinary catheter
MEDICATION:
1. Antibiotics: laceration
2. Osmotic diuretic (mannitol): decrease
cerebral edema
3. Anticonvulsants: seizures
4. Acetaminophen: headaches
EARLY SIGNS OF INCREASED ICP
1. Infants: High-pitched cry, poor feeding,
irritability, bulging fontanel, setting sun
sign, Macewen's sign (percussion: you will
hear a cracked-pot sound)
2. Children: Blurred vision, seizures,
headaches
Late signs of increased icp
1. Decorticate: flexion
2. Decerebrate: extension
3. Cheyne-Stokes respirations
4. Decreased LOC
5. Abnormal pupil reaction
6. Bradycardia
7. Poor sensory and motor function
Decorticate & decerebrate
Decorticate:
1. The arms are bent in toward the
body
2. wrists and fingers are bent and
held on the chest
3. Legs extended
Decerebrate:
1. The head and neck being arched
backward
2. Arms and legs are extended
COMPLICATIONS:
1. Epidural hemorrhage
2. Subdural hemorrhage
3. Brainstem involvement
4. Leakage of CSF: drainage from
nose/ears is positive for glucose
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NEUROLOGIC disorders
Signs and symptoms: infant
HYDROCEPHALUS 1. Increase head size (circumference)-
description abnormal rate of head growth
Abnormal CSF accumulation due to 2. Bulging fontanelle
3. Setting sun sign
the imbalance of CSF production 4. Dilated scalp veins
and absorption 5. Macewen’s sign (“cracked pot sound”)

types: Signs and symptoms: Children

Communicating: non-obstructive 1. Headache on awakening

hydrocephalus
Non-communicating:
Obstructive
hydrocephalus
Preoperative care
surgical intervention
The goal of the surgical intervention
is to bypass the blockage and
prevent CSF accumulation.
Shunt
1. Surgical insertion of a drainage
system, called a shunt.
Endoscopic third ventriculostomy
1. Treatment of choice for
Postoperative care:
obstructive hydrocephalus
MEDICATION:
1. Antibiotics
2. Analgesics
2. Nystagmus
3. Irritability
4. Vomiting
5. Apathy and confusion
6. Papilledema
1. Assess LOC, head circumference
and increase ICP
2. Support head and neck
3. Provide small and frequent
feeding
1. Assess for signs of increased ICP
2. Assess head circumference
3. Assess for signs of infection
4. Provide shunt care
5. Position: unoperated side to
avoid pressure on shunt valve.
6. Remember: a high, shrill cry in an
infant is a sign of increased ICP.
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CARDIOVASCULAR DISORDERS

1. Defects that increase pulmonary blood flow

2. Defects that decrease pulmonary blood
flow
3. Obstructive defects
4. Mixed Blood Flow
5. Rheumatic Fever

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CARDIOVASCULAR disorders
defects that increase pulmonary blood flow
Atrial Septal Defect:
Pathophysiology: a hole in the septum between the left and
right atria.
Signs and symptoms: Heart murmur, palpitations, tachycardia,
decreased peripheral pulse (other signs of decreased cardiac
output)
Management: Atrial septal defect may be closed using cardiac
catheterization.
VENTRICULAR SEPTAL Defect:

Pathophysiology: a hole in septum that separates the heart's

lower left and right ventricles
Signs and symptoms: Murmur (harsh and loud heard at the left
lower sternal border), other signs of decreased cardiac
output.
Management: Ventricular septal defect may be closed using
cardiac catheterization.

PATENT DUCTUS ARTERIOSUS:

Pathophysiology: This occurs when the ductus arteriosus

fails to close after birth.
Signs and symptoms: Bounding pulse, wide pulse pressure,
machine-like murmur
Medication: Indomethacin

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CARDIOVASCULAR disorders
defects that DECREASE pulmonary blood flow
TETRALOGY OF FALLOT
PATHOPHYSIOLOGY:

Tetralogy of Fallot includes 4 defects:

1. Ventricular septal defect (VSD): a hole in septum that separates
the heart's lower left and right ventricles
2. Pulmonary stenosis: the pulmonary valve is narrow.
3. Overriding aorta:defect in the aorta. The aorta is shifted to the
right and lies directly above the VSD.
4. Right ventricular hypertrophy: right ventricle thickens

SIGNS AND SYMPTOMS:

1. Cyanosis
2. Hypoxia
3. Clubbing of fingers and toes
4. Poor growth

Diagnostic tests:

1. Echocardiography
2. Chest X-ray

sURGICAL MANAGEMENT:

1. Surgical intervention is an effective treatment option for

Tetralogy of Fallot.
2. Surgical intervention: temporary procedure that uses a shunt
3. Surgical intervention: complete repair

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CARDIOVASCULAR disorders
obstructive defects
Aortic STENOSIS:
Pathophysiology: the aortic valve is
narrow
Signs and symptoms: Exercise
intolerance, murmur, chest pain,
hypotension.
Management: Aortic Valvotomy,
Balloon valvuloplasty.
Pulmonary Stenosis:
Pathophysiology: the pulmonary
valve is narrow.
Complications: Right ventricular
hypertrophy, HF, Arrhythmia
Signs and symptoms: Murmurs
Management: Valvotomy

COARCTATION OF THE AORTA

Pathophysiology: Obstruction of blood flow due to narrowing of the aorta
near the ductus arteriosis.
Signs and symptoms: High BP in the upper extremities as compared to the
lower extremities. Bounding pulse at the upper extremities and cool skin
at the lower extremities.
Management: Aortic Valvotomy, Balloon valvuloplasty.

defects that results in MIXED BLOOD FLOW

Truncus Arteriosus:
Pathophysiology: A single arterial
trunk due to failed septation
between the left and right
ventricle
Signs and symptoms: HF, lethargy,
heart murmurs, cyanosis, poor
feeding & growth
Management: Surgical intervention
within first few months of life.
Hypoplastic left heart syndrome:
Pathophysiology: The left side of
the heart is not fully developed.
Signs and symptoms: Heart failure,
lethargy, cyanosis
Management: The procedures are
done in three stages. Norwood
procedure, Glenn procedure, Fontan
procedure.

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CARDIOVASCULAR disorders
Signs and symptoms
RHEUMATIC FEVER 1. Cardiac: Chest pain , Heart murmur,
carditis
Inflammatory autoimmune disease.
2. Musculoskeletal: Painful and tender joints,
Occurs after a throat infection from a
subcutaneous nodules
bacteria called group A
3. Skin: Erythema marginatum (red lesions of
streptococcus. the trunk and extremities)

it affects the: 4. CNS: Uncontrollable involuntary

movements (chorea), fever (+sore throat)
1. Heart
Lab Tests:
2. Blood vessels
1. Elevated anti-streptolysin-O
3. CNS
titer
4. Joints 2. Elevated C-reactive protein level
5. Skin 3. Throat swab test
4. Elevated erythrocyte
sedimentation rate

major criteria (diagnostic tests)

nURSING INTERVENTIONS
1. Pain assessment
2. Non-pharmacologic management
3. Bed rest
4. Educate parents on the need for
antibiotic prophylaxis for any
invasive procedures (& dental
work)
5. Educate parents on the medical
and pharmacologic regime
MEDICATION:
1. Antibiotics
2. Anti-inflammatory agents
1. Carditis: inflammation of the heart
2. Chorea: Uncontrollable involuntary
movements
3. Erythema marginatum: red lesions of
the trunk and extremities
4. Subcutaneous nodules
5. Polyarthritis
minor criteria (diagnostic tests)
1. Fever
2. Arthralgia: joint pain
3. Elevated erythrocyte
sedimentation rate
4. Elevated C-reactive protein level

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GENITOURINARY DISORDERS

1. NEPHROTIC SYNDROME
2. GLOMERULONEPHRITIS
3. CRYPTORCHIDISM
4. EPISPADIAS/HYPOSPADIAS

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GENITOURINARY disorders
NEPHROTIC SYNDROME
description
Nephrotic syndrome is characterized by
excessive excretion of protein in the urine
(proteinuria), leading to low protein levels
in the blood (hypoproteinemia).
This leads to edema and hypovolemia.

Interventions Signs & Symptoms

1. Monitor vital signs 1. Periorbital and facial edema
2. Monitor BP 2. Ascites
3. Monitor lab values-protein 3. Peripheral edema
4. Intake and output charting 4. Proteinuria
5. Hypoproteinemia
5. Obtain daily weights 6. Hyperlipidemia
6. Low salt/sodium diet/Low cholesterol 7. Electrolyte imbalance
7. Medications: Corticosteroids, Diuretics 8. Fatigue
9. Lethargy

glomerulonephritis
description
A group of renal diseases caused by immunologic
response that triggers the inflammation of the
glomerular tissue.
Acute: 2-3 weeks after streptococcal infection
Chronic: after acute phase

Interventions Signs & Symptoms

1. Monitor BP 1. Dark colored urine
2. Monitor fluids and electrolytes level 2. Hematuria
3. Maintain fluid restrictions as ordered 3. Proteinuria
4. Obtain daily weights 4. Azotemia
5. Oliguria
5. Sodium restriction in diet
6. Edema
Medications: Antihypertensive drugs, diuretics, 7. Elevated BP
antibiotics 8. Dyspnea
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GENITOURINARY disorders
cryptorchidism
description
Testes fail to descend into the
scrotum.

Interventions Signs & Symptoms

Surgical Intervention: 1. Can't see or feel the
1. Orchiopexy (1-2 years) testicle in the scrotum.
Postoperative care 2. Scrotum is flat and
1. Monitor for signs of infection
smaller than normal
2. Monitor for bleeding
3. Pain management

epispadias/hypospadias
description
Epispadias and Hypospadias is a birth defect
characterized by an abnormal placement of the
urethra opening.
Epispadias: remember "TOP"
Hypospadias: remember "BOTTOM"

Interventions Signs & Symptoms

Surgical Intervention 1. Epispadias: an abnormal
1. Urinary stent
opening at the top of the
2. Between the ages of 6 and 18 months.
Postoperative care: urethra
1. Monitor intake and output 2. Hypospadias: an
2. Medication: antibiotics abnormal opening at the
Education bottom of the urethra
1. Signs and symptoms of an infection
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GASTROINTESTINAL DISORDERS

1. HIRSCHSPRUNG DISEASE
2. INTUSSUSCEPTION
3. GERD
4. APPENDICITIS
5. CELIAC DISEASE
6. HYPERTROPHIC PYLORIC STENOSIS

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GASTROINTESTINAL disorders
Hirschsprung disease
description
Hirschsprung disease is characterized by
the lack or absence of ganglion cells in some
areas of the colon.
This results in mechanical obstruction &
decreased motility
Complications: Enterocolitis

Interventions Signs & Symptoms

Diagnostic test: Rectal biopsy Newborns
Surgical Intervention 1. No meconium stool
1. Colostomy 2. Abdominal distention
2. Removal of areas of bowel. 3. Vomiting (bile)
Children
Diet: low-fiber, high calorie, high protein diet.
1. Constipation
Remember: Do not take temperature rectally. 2. Ribbon-like stools
3. Growth delay

INTUSSUSCEPTION
description
Intussusception occurs when a segment of the
intestine "telescopes" inside of another.
This results in bowel obstruction.

Interventions Signs & Symptoms

1. IV fluids, Antibiotics and NG tube (used for 1. Abdominal pain (severe)
decompression) 2. Vomiting
Treatment 3. Mass in the abdomen
1. A water soluble contrast or air enema. (sausage-shaped).
4. Stool mixed with blood
and mucus-jelly stools
5. Weakness/lethargy
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GASTROINTESTINAL disorders
GERD
description
Gastroesophageal Reflux Disease is a
digestive disorder that occurs due to the
backflow of gastric content.

Diagnostic tests: Upper endoscopy

Esophageal pH studies

Interventions Signs & Symptoms

Assess pain Infants:
Elevate head of bed (HOB)-children >1 year 1. Irritability
Medications: Proton pump inhibitors, Histamine H2
2. Spits up
antagonist
Teaching
Children:
Avoid infant from lying down after eating 1. Cough
Small, frequent meals 2. Heartburn
Burp infant 3. Poor weight gain

Appendicitis
description
Inflammation of the vermiform appendix.
Inflammation causes obstruction of the appendiceal
lumen.
Complications: Prolong inflammation may cause the
appendix to burst/rupture leading to peritonitis.

Interventions Signs & Symptoms

1. Appendectomy: surgical removal of the appendix
2. Pain management, IV fluids
1. McBurney's point
Pharmacology 2. Periumbilical
1. Antibiotics
Nursing Intervention abdominal pain
1. Assess pain
2. Abdominal assessment 3. RLQ pain
3. Monitor VS
4. Pre-operative care: NPO + IVF 4. Fever
5. Post-operative care: Monitor surgical site + monitor for signs 5. Abdominal rigidity
of infection
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GASTROINTESTINAL disorders
celiac disease
description
Celiac disease is the intolerance of gluten.
Gluten is a protein found in wheat, barley
and rye.

Interventions Signs & Symptoms

1. Educate family on gluten-free diet. 1. Steatorrhea
2. Foods to eat: fruits, corn, rice, gluten- 2. Weight loss
3. Abdominal pain
free flour/cereal, eggs, fish, vegetables.
4. Abdominal
3. Avoid wheat, barley or rye. distention
5. Anemia
6. Fatigue

hypertrophic pyloric stenosis

description
Thickening (hypertrophy) of the pylorus
muscles which results in an obstruction. Food is
blocked from entering duodenum.

Interventions Signs & Symptoms

Surgical Intervention: 1. Projectile vomiting
1. Pyloromyotomy 2. Persistent hunger
Intervention 3. Dehydration
4. Metabolic Alkalosis
1. Obtain daily weights
5. Olive-shaped mass
2. Monitor I/O and episodes of vomiting (RUQ)
3. Postoperative care (pyloromyotomy) 6. Weight loss
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MUSCULOSKELETAL DISORDERS

1. FRACTURES

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musculoskeletal disorders
Signs and Symptoms
FRACTURES 1. Pain
description 2. Loss of function/deformity
A fracture is a broken bone. 3. Crepitus
There is a break in the continuity 4. Edema
of the bone structure. 5. Ecchymosis (skin discoloration)

types: TRACTION CARE

1. Closed fracture: bone break without 1. Ensure that the traction weight bag
open wound in skin. is hanging freely.
2. Open fracture (compound): fracture
with an open wound. 2. Monitor for any complication of
3. Complete fracture: complete break immobilization.
through the bones that separates into 3. Assess skin and neurovascular status
two.
4. Incomplete fracture: the bone doesn't
break completely.
5. Comminuted fracture: break into more casts
than two fragments.
1. Pain assessment
Nursing Interventions: 2. Assess neurovascular status
3. Assess skin integrity
1. Pain assessment
4. Prevent indentation by supporting cast
2. Skin integrity assessment with the palms of hand (plaster casts,
3. Neurovascular status assessment exposed casts).
4. Monitor for immobilization 5. Educate the family and child to avoid
complications placing any object (such as toys) inside
5. Provide pharmacologic and non- the casts.
pharmacologic pain management
6. Encourage patient to change
COMPLICATIONS:
position (as tolerated/as
prescribed)
1. Compartment syndrome
2. Skin breakdown
Compartment Syndrome 3. Pressure ulcers
5Ps:
4. Constipation (lack of mobility)
1. Pain
2. Paresthesia 5. Neurovascular impairment
3. Pulselessness
4. Paralysis
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Assessment

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INTRODUCTION
REMEMBER INTRODUCTION
INSPECTION 1. Introduce yourself.
2. Perform hand hygiene.
3. Provide patient privacy.
PALPATION 4. Verify patient ID and DOB.
5. Explain procedure.
PERCUSSION
VITAL SIGNS
Pulse: 60-100 bpm
AUSCULTATION Blood Pressure Systolic: 90-129
Diastolic: 60-80
Respiratory Rate: 12-18 bpm
ORIENTATION O2 Saturation: 95-100%
Use these questions as guidelines to Temperature: 97.8-99.1 degrees F
assess the patient's orientation.
1. What is your name?
2. What is your date of birth? PAIN ASSESSMENT
3. Where are you now?
Provoking/ Precipitating Factor: What causes

P
4. Who is the current president? the pain to worsen?
5. Can you tell me what month Palliative Factor: What makes the pain better?

Q
it is?
6. What are you doing here? Quality: Describe the pain.

R
Region: Where is the pain located?
Radiation: What other areas do you feel the
pain?

S Severity: Pain scale.

T
Time/Temporal Factors: Does the pain
intensity changes? Is the pain intensity
constant?

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MENTAL STATUS
Add a little bit of body text
1. Assess mood, appearance,
affect and grooming.
2. Assess speech
3. Assess level of consciousness
4. Assess orientation
BALANCE AND COORDINATION
Gait and Balance
1. Observe patient's gait pattern 6. Abducens Nerve: Eye movement
as they walk away from you
and back.
2. Have patient stand from a
sitting position.
3. Instruct patient to hop in place
on each foot.
Coordination
1. Have patient touch nose and
your index finger continuously.
STRENGTH, ROM AND REFLEXES
Assess muscle strength.
Assess reflex using the tendon
reflex grading scale.
Instruct patient to distinguish
between sharp and dull
sensations.
Assess for numbness and tingling
THE NEURO SYSTEM
CRANIAL NERVES
1. Olfactory Nerve: Smell
2. Optic Nerve: Vision
3. Oculomotor Nerve: Pupil
restriction and eye movement
4. Trochlear Nerve: Eye movement
5. Trigeminal Nerve: Touch and pain
of face and head, muscles for
chewing.
7. Facial Nerve: Taste of the
anterior tongue, facial
expression muscles and
somatosensory information from
ear
8. Vestibulocochlear Nerve:
Hearing/ Balance
9. Glossopharyngeal Nerve: Taste
of the posterior tongue,
swallowing muscles.
10.Vagus Nerve: Sensory, motor
and autonomic function of
viscera.
11. Spinal Accessory Nerve: Head
movement
12. Hypoglossal Nerve: Control
tongue muscle.
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HEAD, EYES, EARS, NOSE, MOUTH

HEAD EYES
INSPECTION INSPECTION
1. Skin color. 1. inspect the external eye
2. Head size and shape.
3. Assess facial symmetry. (Cranial nerve 7) structures.
4. Observe abnormal facial movements. 2. Inspect the conjunctiva and sclera.
5. Assess whether the eyes and ears are at 3. Test cranial nerve III, IV and VI (see
the same level. assessment of neuro).
PALPATION 4. Examine pupil reactivity to light.
1. Cranium- Palpate for lesions, masses. 5. Test accommodation.
2. Hair- Palpate for any signs of infestation 3.
and bald spots. PERRLA- Pupils are Equal, Round and
4. Sinuses- Palpate the frontal and maxillary Reactive to Light and
sinuses.
5. TMJ- Palpate for signs of stiffness and
Accommodation.
clicking
Pupil size- 3-5mm and equal in size

EARS NOSE
INSPECTION INSPECTION
1. Redness, drainage and 1. External: Inspect for drainage, size
abnormalities. and symmetry, shape. Inspect the
septum.
2. Internal: Inspect for redness and
PALPATION polyps.
1. Palpate and observe for tenderness,
lesions and masses. TEST
2. Test cranial nerve-Vestibulocochlear. 1. Nare patency
2. Cranial nerve- Olfactory

MOUTH NECK
INSPECTION INSPECTION
1. External: inspect lip color and 1. Inspect trachea (mid-line), JVD,
lesions and lumps.
sores.
PALPATION
2. Internal: Inspect gum, tongue,
1. Palpate lymph nodes.
teeth, lesions, soft and hard
2. Palpate carotid artery and
palate. auscultate for bruits.
3. Palpate and determine the
CRANIAL NERVE presence of a goiter.
Test cranial nerve - Glossopharyngeal
Test cranial nerve- Hypoglossal CRANIAL NERVE
Test cranial nerve- Vagus Test cranial nerve- Accessory.

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THE RESPIRATORY SYSTEM

ASSESSMENT/HISTORY
1. Assess RR, O2
saturation, ABGs
2. Assess for history of:
a. SOB
b. Cough
c. Chest pain
d. Family history
e. Respiratory illness
INSPECTION
1. Symmetrical chest
movement
2. Labored breathing
ABGs
pH: 7.35-7.45
PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
O2 Saturation: 95%-100%
HCO3: 21-28 mEq/L

PALPATION AUSCULTATION
1. Pain and Lumps Auscultate posterior,
anterier and lateral chest.
Listen for:
PERCUSSION 1. Crackles
Use the Z-block method:
2. Wheezes
Resonance: heard over normal
3. Rhonchi
lungs.
Dull sound: solid/ fluid filled
4. Stridor
area 5. Pleural rub
Hyperresonance: Heard over Use the Z-block pattern
hyperinflated lungs from the apex to the base.
Tympany: pneumothorax

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THE CARDIOVASCULAR SYSTEM

1. Assessment
1. Vital signs 2. Inspection
a. BP, HR, RR, O2 1. Pulsation of the chest
saturation wall
2. Assess for
a. Skin temperature Assessment tools
b. Cyanosis Capillary Refill: Normal = <3
c. Moisture Delay = >3
Pulse:
d. Capillary refill Absent= 0
Weak = +1
e. Peripheral pulse Normal = +2
f. Edema Full = +3
Bounding = +4
g. Varicose veins
3. Palpation 4. Auscultation
1. Listen to heart sounds
1. Locate the apical and murmurs.
pulse (PMI) 2. Use the diaphragm of
2. Assess for thrills the stethoscope then
(palpable murmurs). the bell.
3. Assess for heaves

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ABDOMINAL/GI/GU
Remember 1. INSPECTION
1. Skin color, contour
INSPECTION and aortic pulsation

AUSCULTATION

PERCUSSION

PALPATION

2. AUSCULTATION
Auscultate bowel sounds.
Begin with RLQ and
clockwise.

Bowel sounds 3. PERCUSSION

1. Absent- No bowel sound Tympanic Sound: Gas filled
after listening for 5 abdomen (normal)
minutes. Dullness: solid viscera, fluid,
stool predominate, posterior
2. Hypoactive- One bowel
solid structure (e.g. liver)
sound every 3-5 minutes.
3. Normal bowel sound- 4. PALPATION
Gurgles 5-30 every Light palpation followed by deep
minute. palpation.
Palpate and observe for pain,
4. Hyperactive- >30 sounds
rigidity, masses and tenderness
per minute
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EXTREMITIES
UPPER EXTREMITY
INSPECTION
Inspect the skin for
redness or skin
breakdown and LOWER EXTREMITY
color. Inspect palms INSPECTION
and nails. Inspect the skin for redness
or skin breakdown, hair
PALPATE growth, swelling, feet and
Palpate the radial nails.
and brachial pulses
and capillary refill. PALPATE
Assess muscle Palpate pulses- popliteal
strength and ROM. pulse posterior, tibial pulse,
and dorsalis pedis pulse.
Palpate for pitting edema.

Babinski Reflex- create an S

curve under the feet using
a pen and observe curled
toes.
Assess muscle strength
using the Oxford Strength
Grading Scale

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CRA
NIA
LN
ERV
A St
udy
Gui

ES
de f
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ursi
ng S
tud
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Cranial Nerves
CN= CRANIAL NERVE, S=SENSORY
Cranial Nerves Summary M=MOTOR

cn i: Olfactory (on) Function: Smell (s)

cn ii: Optic (occasions) Function: Vision (s)

cn iii:
Pupil
Oculomotor (our) Function: restriction
and eye
(m)
movement

cn iv: Trochlear (trusty) Function: Most eye

movement
(m)

cn v: Function:
Face
Trigeminal (truck) sensation, (both)
Mastication

cn vi: Abducens Function:

Abducts
(acts) the eye (m)

cn vii:
Facial
Facial (funny) Function: expression,
taste
(both)

cn viii: bulocochlear
Vesti-
(very) Function: Hearing/
Balance (s)
Glosso-
cn ix: pharyngeal (good) Function:
Swallowing
Gag reflex (both)
Sensory,

cn x:
motor and
Vagus (vehicle) Function: autonomic
function of
(both)
viscera.
Head

cn xi:
movement,
Accessory (any) Function: Shoulder
shrug
(m)

cn xii:
Control
Hypoglossal (how) Function: tongue
muscle. (m)

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Cranial Nerves
cn i: Olfactory
aSSESSMENT:
1. Ask the client to occlude one
nostril with eyes closed.
2. Place a test odor under each
nostril and ask the client to
identify the smell.
3. Evaluate the patency of the
nasal passages bilaterally
(on) Function: Smell (s)
FINDINGS:
1. The client is able to identify the
test odor with each nostril.
2. Strength of smell with each
nostril is the same.

ABNORMAL FINDINGS:
1. Hyperosmia: heightened sense of smell. Hypoosmia: diminished olfactory acuity.
Anosmia, the inability to recognize odors (unilateral or bilateral)
2. The most common cause is a cold/ nasal allergies or trauma.

cn ii: Optic (occasions) Function: Vision (s)

aSSESSMENT: FINDINGS:
Visual Acuity
1. Assess visual acuity using a Snellen Chart. Visual Acuity
Instruct the client to cover one eye and ask
the client to recite the letters shown and 1. Client is able to read with each
record acuity. eye and both eyes. (20/20
Visual fields
1. Test visual fields via confrontation. vision)
2. At eye level, instruct the client to cover the
left eye (examiner covers the right eye). Fundoscopy
Ask the client to say "now" when the
examiner's fingers enter from out of sight, 1. Normal findings of the optic disc,
into the client's peripheral vision. (Repeat) physiological cup, retinal vessels
Fundoscopy
1. Direct visualization of optic nerve and fovea observed

ABNORMAL FINDINGS:
1. Legally blind-20/200
2. Papilledema in fundus: Loss of venous pulsations, loss of the disc margin
flame shaped hemorrhages, loss of the physiologic cup

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Cranial Nerves
cn iii:
Pupil
Oculomotor (our) Function: restriction
and eye (m)
movement

aSSESSMENT: FINDINGS:
Light Reaction to light
1. In a dimly lit room, ask the client to 1. Both Illuminated and non-illuminated
focus on an object in a distance
2. Swing the penlight from the side pupil should constrict.
towards the pupil. Accommodation:
3. Observe the response of the 1. Pupils- constrict (near object)
illuminated pupil.
4. Note the response of the other pupil. 2. Pupils-dilate (distant object)
3. Pupils-converge (object moves
Accommodation towards nose)
1. Ask client to alternate gaze from the PERRLA (pupils equally round and reactive
near to the far object.
2. Move an object towards the client’s to light and accommodation)
nose.
ABNORMAL FINDINGS:
1. Anisocoria- one pupil is larger than the other. 2. Diplopia ("seeing
double") 3. Ptosis- droopy eyelid. 4.Inability to accommodate

cn iv: Trochlear (trusty) Function: Most eye

movement
(m)

aSSESSMENT: FINDINGS:
1. Stand 1 ft in front of client Both eyes are able to follow
2. Instruct the client to follow the penlight smoothly.
penlight only with their eyes
without moving their head
upward, downward, to the
side and diagonally

ABNORMAL FINDINGS:
1. Gaze palsy: inability to move both eyes together in a single horizontal
or vertical direction.
2. Nystagmus: uncontrolled eye movement.

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Cranial Nerves
cn v:
Face
Trigeminal (truck) Function: sensation, (both)
Mastication

aSSESSMENT: FINDINGS:
Corneal reflex:
1. Using a Q-tip, lightly touch the lateral 1. Client was able to elicit corneal
cornea of eye to elicit blink reflex.
reflex
Sensation 2. Sensitive to stimuli
1. Ask the client to close their eyes and say
"sharp" or "dull" when they feel an 3. Masseter muscle: no weakness
object touch their face.
observed. Normal motor
Masseter muscle: function of mastication.
1. Palpate the temporalis and masseter
muscle as client bites down hard.
2. Ask the client to open their mouth
against resistance of your hands at the
base of chin

ABNORMAL FINDINGS:
1. Absent corneal reflex
2. Sensory deficit
3. Weakness of the jaw

cn vi: Function:
Abducts
Abducens (acts) the eye (m)

aSSESSMENT: FINDINGS:
1. Stand 1 ft away from client 1. Both eyes move in
with a penlight. coordination and parallel
2. Ask the client to follow the alignment observed
penlight through the six
cardinal fields of gaze.

ABNORMAL FINDINGS:
1. Gaze palsy: inability to move both eyes together in a single horizontal
or vertical direction.
2. Nystagmus: uncontrolled movements.

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Cranial Nerves
cn vii: Facial
Facial
(funny) Function: expression,
taste
(both)

aSSESSMENT:
1. Ask the client to perform different
facial expressions (smile, frown,
puff cheeks, close eyes, raise
eyebrows)
2. Ask client to close their eyes and
extend their tongue.
3. Place various taste (sweet, sour,
salty, bitter) and ask client to
identify the different tastes.
FINDINGS:
1. The client is able to perform the
different facial expressions with
ease
2. The client is able to identify the
different tastes.

ABNORMAL FINDINGS:
1. Weakness of muscles to perform facial expressions
2. Facial asymmetry including drooping, sagging or smoothing of normal facial
creases.
3. Client is unable to distinguish the different tastes

cn viii: Vesti-
bulocochlear (very) Function:
Hearing/
Balance (s)
aSSESSMENT: FINDINGS:
Hearing
1. Ask the client to occlude one ear and instruct Hearing
the client to close both eyes. 1. Client is able to hear in both ears.
2. Vigorously rub your fingers, or whisper in one 2. Positive Weber test: client is able to
ear and ask the client to repeat what was
heard.(repeat) hear it in both ears
3. Weber test is a test for lateralization 3. Positive Rinne test: air conduction is
4. Rinne test compares air conduction to bone greater than bone conduction
conduction.
Balance Balance
1. Assess client's gait by instructing them to 1. Upright posture and steady gait.
walk across the room

ABNORMAL FINDINGS:
1. Conductive hearing impairment: bone conduction is equal or greater than air
conduction.
2. Sensineuronal hearing loss: vibration is heard longer in the air than usual.

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Cranial Nerves
Glosso-
cn ix: Function: Swallowing
Gag reflex
(both)
pharyngeal (good)

aSSESSMENT:
1. Ask the client to swallow.
2. Instruct the client to yawn
and observe the soft palate.
3. Ask the client to open their
mouth wide, protrude their
tongue, and say "AHH".
4. Elicit gag response.
FINDINGS:
1. Client is able to swallow without
difficulty
2. Soft palate observed to rise
symmetrically
3. Uvula is observed to remain
midline
4. Client elicited gag reflex

ABNORMAL FINDINGS:
1. Dysarthria-muscles that produces speech are damaged
2. Dysphagia- inability to swallow
3. Uvula deviation

cn x:
Sensory, motor
Vagus (vehicle) Function: and autonomic
function of
(both)
viscera.

aSSESSMENT: FINDINGS:
1. Ask the client to cough 1. Client is able to swallow without
2. Ask the client to swallow and difficulty
speak 2. Client is able to speak audibly

ABNORMAL FINDINGS:
1. Dysarthria-muscles that produces speech are damaged
2. Dysphagia- inability to swallow
3. Hoarseness

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Cranial Nerves
Head

cn xi: Function:
movement,
Accessory (any) Shoulder (m)
shrug

aSSESSMENT: FINDINGS:
1. Sternocleidomastoid: Instruct 1. Client should be able to turn
the client to turn their head head from side to side.
from side to side, and against 2. Client is able to shrug shoulders
resistance (examiner's hands)
2. Trapezius: instruct the client to
shrug their shoulders against
resistance (examiner's hands)

ABNORMAL FINDINGS:
1. Asymmetry
2. Peripheral lesions produce ipsilateral sternocleidomastoid (SCM)
weakness and ipsilateral trapezius weakness.

cn xii:
Control
Hypoglossal (how) Function: tongue
muscle. (m)

aSSESSMENT: FINDINGS:
1. Ask the client to open their 1. Client tongue is midline
mouth and inspect the 2. Client is able to move tongue
from side to side
tongue
2. Ask the client to protrude the
tongue and move from side
to side

ABNORMAL FINDINGS:
1. Deviations of the tongue from midline
2. Inability to protrude the tongue
3. Tongue atrophy and fasciculations

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CRANIAL NERVE
templates

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Cranial Nerves
Cranial Nerves Summary

cn i: Function:

cn ii: Function:

cn iii: Function:

cn iv: Function:

cn v: Function:

cn vi: Function:

cn vii: Function:

cn viii: Function:

cn ix: Function:

cn x: Function:

cn xi: Function:

cn xii: Function:
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Cranial Nerves
cn i: (on) Function: (s)
aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

cn ii: (occasions) Function: (s)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

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Cranial Nerves
cn iii: (our) Function: (m)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

cn iv: (trusty) Function: (m)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

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Cranial Nerves
cn v: (truck) Function: (both)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

cn vi: (acts) Function: (m)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

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Cranial Nerves
cn vii: (funny) Function: (both)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

cn viii: (very) Function: (s)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

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Cranial Nerves
cn ix: (good) Function: (both)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

cn x: (vehicle) Function: (both)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

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Cranial Nerves
cn xi: (any) Function: (m)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

cn xii: (how) Function: (m)

aSSESSMENT: FINDINGS:

ABNORMAL FINDINGS:

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Patient Assessment
Room No. MD:
Name: Age: DOB:
ADM: Code Status:
Allergies: Diet:
HT: WT: BMI:

T: P: RR: BP: SPO2:

NEURO CARDIO
Mental status, GCS, LOC, PERRLA, HR, Heart rhythm, BP, Pulse, Heart Sounds,
Muscle Strength (ROM) Capillary Refill, Skin
tugor/color/temprature/moisture

RESP GU
Respiratory rate/depth/pattern, Use of Urine output/ color/consistency
accessory muscle, Nasal flaring, Anterior & Bladder distention, Voiding method
posterior breath sounds, Spo2

GI SKIN
Bowel sounds on 4 quadrants, Peristalsis, Skin turgor/color/temp/moisture/lesions/
Diet, Stool quantity and appearance breakdown/bruising/dressings

NOTES

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Patient Assessment
Room No. MD:
Name: Age: DOB:
ADM: Code Status:
Allergies: Diet:
HT: WT: BMI:

T: P: RR: BP: SPO2:

NEURO CARDIO
Mental status, GCS, LOC, PERRLA, HR, Heart rhythm, BP, Pulse, Heart Sounds,
Muscle Strength (ROM) Capillary Refill, Skin
tugor/color/temprature/moisture

RESP GU
Respiratory rate/depth/pattern, Use of Urine output/ color/consistency
accessory muscle, Nasal flaring, Anterior & Bladder distention, Voiding method
posterior breath sounds, Spo2

GI SKIN
Bowel sounds on 4 quadrants, Peristalsis, Skin turgor/color/temp/moisture/lesions/
Diet, Stool quantity and appearance breakdown/bruising/dressings

NOTES

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Nursing Care Plan Med Dx: nursebossstore.com
Subjective Data Objective Data

Nursing Diagnosis

Expected Outcomes

Nursing Interventions Rationale Evaluation

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Nursing Care Plan Med Dx: nursebossstore.com
Subjective Data Objective Data

Nursing Diagnosis

Expected Outcomes

Nursing Interventions Rationale Evaluation

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Nursing Care Plan Med Dx: nursebossstore.com
Subjective Data Objective Data

Nursing Diagnosis

Expected Outcomes

Nursing Interventions Rationale Evaluation

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Nurse Report Sheet Patient's Hx:
Room No. MD:
Name: Age: DOB:
ADM: Code Status:
Allergies: Diet: Chief complaint:
HT: WT: BMI:
Isolation: Activity: NPO:
Medical Diagnosis:

ASSESSMENT
Neuro:

Time
Cardiac: TEMP
HR
RR
Resp: BP
SPO2
PAIN
GI/GU:
IV:
IV fluids:
SKIN: O2 Therapy:

Tube Feeding:

LABS FOLEY:
DATE: Last BM:

WBC: Treatment Plan:

RBC:
HGB:
HCT:
PLT:
PTT:
INR:
BUN:
Discharge Plan:
CR:
NA:
K:
MG:
BNP:
TROP:
OUTPUT:
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ALL YOU NEED TO KNOW…

THE
NURSING
PROCESS

Fiskvik Boahemaa Antwi, RN, MN.

Simon Akwasi Osei, RN, MN. 531 / 601
 2

Copyright © 2019 by Fiskvik Boahemaa Antwi

All rights reserved. This book or any portion thereof

may not be reproduced or used in any manner whatsoever
without the express written permission of the publisher
except for the use of brief quotations in a book review.

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 3

Important Disclosure
Please keep in mind that the case studies and care plans are for examples and
educational purposes only. Due to evidence-based practice, some of these
treatments may change over time. Hence, do not base your patient’s treatment
on this care plan. There are different care plans and concept mapping formats
among various nursing institutions. However, it is important to note that the
principles remain the same. The most important aspect of the care plan is the
content, as it serves as the foundation in providing care.

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4

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 5

All You Need to Know…

Grab your pen and paper, because today you are going to learn the necessary
foundation of nursing care…the nursing process. The five steps in the nursing
process include:

Assessment, Diagnosis, Planning, Implementation, and Evaluation.

A nursing care plan is a tool that is utilized in the nursing process as a form
of documentation. Without the nursing care plan, quality and continuity of
care would be lost.

There are many books, journals, and materials that provide a comprehensive
overview of the nursing process. However, this book aims to simplify the
concept of the nursing process as you use other resources as well.

To complete the activities in this book, you would need the NANDA-I, the
NIC, and the NOC list. This book also includes examples, explanations,
images, and areas for you to write your answers.

Happy Care Planning!

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 6

Dear Nursing Students,

Here is a simple case scenario that you would be referred to as you

complete the chapter’s activities.

CASE SCENARIO

Mr. Harry Fernando is a 68-year-old male admitted to the medical-

surgical unit and diagnosed with congestive cardiac failure. The
client states that he has been experiencing shortness of breath for
over three days and has swollen feet. “I am not able to sleep at
night because I cannot breathe.” According to Mr. Fernando’s wife,
he complains of body weakness and the inability to perform daily
tasks.
Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30
years; however, he does not drink alcohol or use recreational drugs.
Mr. Fernando has a family history of cancer, diabetes and
hypertension, and coronary artery disease.
Mr. Fernando loves to eat KFC and burgers. He is currently
concerned about his health status but isn’t sure what to do.
Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp
36.9, RR 24 bpm. Crackles noted in the right lung base upon
auscultation.

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Table of Content

CHAPTER TOPIC PAGE

NUMBER
1 INTRODUCTION 10

2 ASSESSMENT 16

3 DIAGNOSIS 25

4 PLANNING 32

5 IMPLEMENTATION 41

6 EVALUATION 44

7 CONCEPT MAPPING 47

8 ANSWER KEY 57

9 CASE SCENARIOS 66

10 REFERENCES 72

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NURSES DISPENSE COMFORT, COMPASSION, AND

CARING WITHOUT A PRESCRIPTION.
--Val Saintsbury

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 9

O THE NURSING PROCESS

B OBJECTIVES
In this chapter, you would learn:

J 1. The definition of the nursing process.

2. The steps in the nursing process.

3. The importance of the nursing process.

E 4. Nursing care plan.

NOTES
C KEY POINTS FROM THIS CHAPTER…

T
I
V
E
S
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I THE NURSING PROCESS

What is the

N Definition: nursing
process?
A systematic, deliberative and dynamic method
of providing patient-centered care.
T
The 5 Sequential Steps

R • Assessment
• Diagnosis
• Planning
• Implementation ACRONYM:
O • Evaluation

ADPIE
D
Importance of the Nursing Process
• It allows nurses to identify the patient’s needs.

U • It allows nurses and patients to set and communicate goals.

• It allows the recognition of potential risk(s).
• It provides continuity of care.

C • It provides adequate documentation and communication among

other health professionals.

T
Assessment

I
Evaluation The Diagnosis
Nursing

O Process

N Implementation Planning

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The Four Column Care Plan

Nursing Diagnosis Expected Interventions Evaluation
Outcomes
In this column, you would write In this column, you In this column, you In this column, you
the nursing diagnosis, which state your goal and would state the would state
includes a label, etiology, and expected outcome steps that would whether the
defining characteristics. that you want your help the patient expected outcome
patient to meet. reach the expected was met or not.
outcome. This (If the expected
includes nursing outcome was met:
independent and provide evidence.)
collaborative
interventions.
(If the expected
(A Short Sample) outcome was not
met: Present
Activity intolerance related to Patient would 1. Assess the evidence that
an imbalance between oxygen demonstrate the patient’s level of supports this claim.
supply and demand as evidence use of effective physical ability. State the reason
by verbalization of generalized energy- 2. Assess the why the outcome
weakness and inability to conservation factors that cause was not met and
perform activities of daily techniques when activity make mention of
living. performing intolerance. what you would do
activities of daily 3. Monitor the next.)
living after 8 hours patient’s vital signs.
of nursing 4. Encourage the
interventions. patient to perform
activities at a
slower rate.
5. Encourage the
patient to take
intermittent rest
between activities.
6. Gradually
increase patient’s
activities.
7. Cluster task to
be performed by
the patient.
8. Assist the
patient with
activities of daily
living.
9. Etc.

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The Five Column Care Plan: For Students

Nursing Diagnosis Expected Interventions Rationale Evaluation
Outcomes
In this column, you In this column, you In this column, you In this In this column, you
would write the state your goal and would state the column, you would state whether
nursing diagnosis, expected outcome steps that would would the expected outcome
which includes a label, that you want your help the patient include a was met or not.
etiology, and defining patient to meet. reach the rationale for (If the expected
characteristics. expected outcome. every outcome was met:
This includes nursing provide evidence.)
nursing intervention.
independent and This
collaborative includes a (If the expected
interventions. citation outcome was not met:
(A Short Sample) from a book Present evidence that
or journal. supports this claim.
Activity intolerance Patient would 1. Assess the State the reason why
related to an demonstrate the patient’s level of the outcome was not
imbalance between use of effective physical ability. met and make mention
oxygen supply and energy- 2. Assess the of what you would do
demand as evidence conservation factors that cause next.)
by verbalization of techniques when activity
generalized weakness performing intolerance.
and inability to activities of daily 3. Monitor the
perform activities of living after 8 hours patient’s vital
daily living. of nursing signs.
interventions. 4. Encourage the
patient to perform
activities at a
slower rate.
5. Encourage the
patient to take
intermittent rest
between activities.
6. Gradually
increase patient’s
activities.
7. Cluster task to
be performed by
the patient.
8. Assist the
patient with
activities of daily
living.
9. Etc.

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The Six Column Care Plan: For Students

Assessment Nursing Expected Interventions Rationale Evaluation
Diagnosis Outcomes
In this column, In this column, In this column, In this column, In this In this column, you
write the you would write you would state state the steps column, would state whether
subjective and the nursing your goal and that would help include a the expected outcome
objective data. diagnosis, expected the patient reach rationale for was met or not.
which includes outcome that you the expected every nursing (If the expected
a label, want your patient outcome. This intervention. outcome was met:
etiology, and to meet. includes nursing This includes provide evidence.)
defining independent and a citation
characteristics collaborative from a book
. interventions. or journal. (If the expected
(A Short Sample) outcome was not met:
Present evidence that
supports this claim.
State the reason why
Patient would the outcome was not
demonstrate the 1. Assess the met and make mention
Activity use of effective patient’s level of of what you would do
intolerance energy- physical ability. next.)
related to an conservation 2. Assess the
imbalance techniques when factors that
between performing cause activity
oxygen supply activities of daily intolerance.
and demand as living after 8 3. Monitor the
evidence by hours of nursing patient’s vital
verbalization interventions. signs.
of generalized 4. Encourage the
weakness and patient to
inability to perform
perform activities at a
activities of slower rate.
daily living. 5. Encourage the
patient to take
intermittent rest
between
activities.
6. Gradually
increase patient’s
activities.
7. Cluster task to
be performed by
the patient.
8. Assist the
patient with
activities of daily
living.
9. Etc.

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A ACTIVITY 1.

1. What factors can affect the implementation of the nursing process?

I
.
V
2. Using your creativity, draw and label the steps in the nursing process.

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 15

O
ASSESSMENT
B OBJECTIVES
In this chapter, you would learn:

J 1. Definition of assessment.

2. Components of assessment.

3. Types of assessment.

E 4. Elements of a complete health assessment.

5. Techniques to gather and organize data.

C NOTES
KEY POINTS FROM THIS CHAPTER…

T
I
V
E
S
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A ASSESSMENT
Assessment is the first phase of the nursing process.
S Definition

Assessment is a deliberative and systematic method of collecting

information/data to determine the patient's needs.
S Components

o Data collection

E o Data verification
o Data organization
o Data recording/documentation

S 1. DATA COLLECTION

Types of Data Where do I

collect my
Subjective Data: (What the patient’s SAY!) patient’s data?
S
o The client’s perception of health problems.
o What the patient tells you.

M o Feelings, emotions, sensations, etc.

PAIN ANXIETY DIZZINESS

E
Objective Data: (What you OBSERVE!)

o Observable and measurable.

N

T VITAL SIGNS LAB VALUES DIAGNOSTIC

TESTS

SUBJECTIVE DATA VS OBJECTIVE DATA

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A Sources of Data
o Primary Source: From the patient.

o Secondary Source:
S o Family
o Health-care professionals
o Medical records
o Research
S
Method of Data Collection
o Interview
o Physical examination
E o Observation
o Laboratory Test
o Review of Medical Record
S
Interview Technique

S A structured and organized conversation to obtain information on

current health problems and needs from the patient or patient's
relative.

M Phases

Orientation Phase

o Introduction and explanation of the purpose of conducting the

E interview are done. The nurse sets a comfortable environment and
builds rapport.

Working Phase
N o Interview to obtain the health status of the patient. The nurse
uses a variety of communication techniques.

Termination Phase
T o The information obtained is summarized. The patient or nurse
asks questions. The interview ends in a friendly manner.

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A Elements of an Effective Interview

o Clear goals set

o Culturally sensitive
Self-introduction
S o
o Choose an effective communication strategy
o Congruent verbal and non-verbal communication
o Maintain Rapport
S o
o
Confidentiality
Closure

Types of Interview Question Technique

E Open-ended questions

o It allows the patient to describe and explain a given situation.

o Example: How do you feel today?
S Close-ended questions

o This allows the patient to give a direct answer to the question.

o Example: Are you in pain?
S 2. DATA VALIDATION

o This is done to ensure that the data is valid

o Double-checking of data/information
M o Validation of data involves comparing data with other sources.

3. DATA ORGANIZATION

E o Organizing data allows a nurse to cluster and arrange the data

obtained logically and systematically to aid the formulation of
nursing diagnosis.

4. DATA RECORDING
N
o Documentation of data
o If it was not written, it was not done.

T
Types of Assessment

o Comprehensive Assessment
o Focused Assessment
o Ongoing Assessment
o Emergency Assessment

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A COMPLETE HEALTH ASSESSMENT

A complete patient’s health assessment includes:

o patient’s history
S o physical assessment
o diagnostic and laboratory test results
o review of any other health information.

S Past Medical History

This includes both past medical and surgical procedures.

Questions to ask? (Follow up with When/Why)

E 1. Have you ever had surgery?
2. Have you ever been hospitalized?
3. Did you have any childhood illness?
S 4. Do you currently have any illness/problem?
5. What are your current medications?

Family History
S
This includes:

o Illness in the family.

M o Genetic disorders in the family.

Family History Genogram

E Grandfather, 80,
HF
Grandmother,
78, Cancer

Female

N Grandfather, 91,
DM, Stroke
Grandmother,
93, HF

Male Father, 63,

Mother, age 61,
well
hypertension

T
Deceased Female Sister, age 40, Patient, 32, DM,
well HTN

Sister, age
37, Cancer

Deceased Male

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 20

A Activities of daily living

Identify the patient's ability to perform activities of daily living.

S This includes:

1. Diet, food allergies, special diets

2. Sleep habits
3. Exercise
S 4. Urinary and bowel elimination frequency
5. Use of tobacco, marijuana, alcohol, etc.
6. Religious practices
E 7. Sexual practices.

S Socioeconomic Factors

This includes:

S 1. Financial resources.
2. Insurance plan.
3. Financial aid

M Spiritual and Cultural Factors

E This includes:

1. Spiritual needs
2. Religious practices
3. Cultural beliefs
N

T Remember:

Remain nonjudgmental during

the assessment of your
patient’s spiritual beliefs.

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A Physical Assessment

Four basic physical examination techniques

o Inspection: USE YOUR 5 SENSES.

S o Palpation: FEEL
o Percussion: PRODUCE A SOUND
o Auscultation: LISTEN

S Diagnostic Testing Data

o Understand the process to access patient’s diagnostic

test results.
E o Understand the normal and abnormal values.

S ASSESSING GROWTH AND DEVELOPMENTAL STAGES

According to Erikson, there are eight stages in psychosocial

development. Nurses need to assess which stage the patient falls under,

S to better understand whether the developmental task has been met or

whether the patient cannot resolve a conflict expected in the particular
stage.

M
Trust vs Mistrust Stage 1: From birth till age 1
E Autonomy vs. Shame and
Stage 2: Ages 1-3
Doubt

Initiative vs Guilt
Stage 3: Ages 3-6
N Industry vs Inferiority
Stage 4: Ages 6-12

Identity vs. Role confusion

Stage 5: Ages 12-18
T
Intimacy vs. Isolation
Stage 6: Ages 18-40

Generativity vs. Self-absorption

Stage 7: Ages 35-65

Integrity vs. despair

Stage 8: 65and above

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A ACTIVITY 2.

Scenario

C Mr. Harry Fernando is a 68-year-old male admitted to the medical-

surgical unit and diagnosed with congestive cardiac failure. The client
states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
T weakness and the inability to perform daily tasks.

Mr. Fernando has a history of hypertension, diabetes, AF,

hypercholesterolemia for over 20 years. He had a coronary artery

I bypass surgery 10 years ago. He is a known smoker for over 30 years;

however, he does not drink alcohol or use recreational drugs. Mr.
Fernando has a family history of cancer, diabetes and hypertension and
coronary artery disease.

V Mr. Fernando loves to eat KFC and burgers. He is currently concerned

about his health status but isn’t sure what to do.

Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.
I

T SUBJECTIVE DATA OBJECTIVE DATA

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 23

A 2. Quote a phrase that shows that the data was gathered from a
secondary source.

C
3. As a nurse, what other information would you obtain from Mr.
Fernando?

V
_

I
4. What developmental stage does Mr. Fernando belong in? What are
T some of the developmental tasks expected of him?

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 24

O DIAGNOSIS
B OBJECTIVES
In this chapter you would learn:

J 1. Parts of a nursing diagnosis.

2. Types of nursing diagnosis.

3. Nursing diagnosis dos and don’ts.

E 4. Differentiating medical and nursing diagnosis.

5. Prioritizing of nursing diagnosis.

C Notes
Key points from this chapter…

T
I
V
E
S
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D NURSING DIAGNOSIS
The nursing diagnosis is the second step of the nursing process after the
assessment and clustering of the gathered data.
I Definition of Diagnosis
The NANDA (North America Nursing Diagnosis Association) defines
nursing diagnosis as
A a clinical judgment of an individual, family, or community response to an
actual or health problem risk, which gives the foundation for definitive
interventions towards the achievement of an outcome.

G Steps in formulating nursing diagnosis

1. Gather both subjective and objective data from your

assessment.

N 2. Cluster the data that relates to a problem.

3. Develop a list of problems.

4. Prioritize the list of problems.

O 5. Formulate a nursing diagnosis for each problem.

Parts of nursing diagnosis

Example: Decreased cardiac output related to decreased cardiac
contractility to meet the metabolic demands of the body as evidence by
S a pulse of 119, Bp- 98/62, cold and clammy skin, an ejection fraction of
30%.

There are three parts to the nursing diagnosis.

I 1. The label: Decreased cardiac output
This is written from the NANDA-I terminologies. This is the
patient’s problem.
2. The etiology: decreased cardiac contractility to meet the metabolic

S demands of the body

This statement is preceded by the phrase “related to." These are
the related factors that cause and contribute to the patient's problem.

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 26

D 3. The defining characteristics: a pulse of 119, Bp- 98/62, cold and

clammy skin, an ejection fraction of 35%.

This is a list of signs and symptoms that supports the diagnosis.

This statement is preceded by the phrase "as evidence by."
I
Remember:

A
A potential risk diagnosis only

has a label and etiology. (It has

not yet occurred.)

Types of Nursing Diagnosis
G
Actual Diagnosis: Impaired gaseous exchange

N Potential Risk Diagnosis: Risk for infection

Syndrome Diagnosis: Chronic pain syndrome

Wellness Diagnosis: Readiness to enhance family coping

O
Actual Diagnosis (IT IS ALREADY HAPPENING.)
S An actual diagnosis describes an existing problem.

For example, a patient experiencing shortness of breath and medically

diagnosed with asthma may have a nursing diagnosis of an ineffective
I breathing pattern.

Potential Risk Diagnosis (MIGHT OCCUR)

This is a problem that the patient is at risk of developing. The goal is to

S prevent the problem from occurring with proper planning and

implementation of interventions.

For example, a bedridden patient is at risk of developing pressure ulcers.

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D Syndrome Diagnosis

This is a cluster of problems of risk.

Example: Post trauma syndrome, chronic pain syndrome, etc.

I Wellness Diagnosis

A patient’s response to a degree of wellness. This is mostly used among

patients who are healthy but want to maintain or improve the wellness
level.
A Example: a patient who wants to enhance knowledge about a balanced
diet would have a nursing diagnosis of readiness to enhance knowledge.

G Nursing Diagnosis DO’S and DON’TS

DO’s DON’TS

N o Write nursing diagnosis

that nurses are licensed
o Don’t write medical diagnosis
as a label.
to treat. E.g., Heart failure related to
E.g., Decreased cardiac decreased cardiac

O output related to
decreased cardiac
contractility to meet the
metabolic demands of the
contractility to meet the
metabolic needs of the body
as evidence by a pulse of 119,
Bp- 98/62, cold and clammy

S body as evidence by a
pulse of 119, Bp- 98/62,
skin, an ejection fraction of
30%.”
cold and clammy skin, an
ejection fraction of 30%.”
o Let the nursing diagnosis o Don’t let the nursing
I be evidence-based and diagnosis be unclear.
clear.
E.g. Acute pain related to the
E.g., Acute pain related to
inability for oxygen to
decreasing oxygenation to
S the myocardium as
penetrate the myocardium
and cause decrease
evidence by patient
oxygenation as evidence by
verbalization of chest pain
the patient complaining of
of (0-10)8.
chest pain.

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 28

D Include the label, etiology, and Don’t omit any aspect from an
signs and symptoms for all actual nursing diagnosis.
actual nursing diagnosis.
E.g., Acute pain related to

I E.g., Acute pain related to

decreasing oxygenation to the
decreasing oxygenation to the
myocardium.
myocardium as evidence by
patient verbalization of chest
pain of (0-10)8.
A

G Other Common Mistakes

o Don’t write a diagnosis for a diagnostic test or treatment plan

N E.g., Computed tomography scan of the lungs related to
decreased tissue perfusion.
o Don’t repeat the diagnosis
E.g., Ineffective airway clearance related to the inability to
O clear the airway as evidence by coughing.

S Nursing Diagnosis VS Medical Diagnosis

Medical Diagnosis: Disease focused.

I E.g., Pleural Effusion

Nursing Diagnosis: Patient's response to the disease (patient-focused).

E.g., Ineffective breathing pattern related to decreased lung expansion

S secondary to fluid accumulation in the pleura space as evidence by
dyspnoea, nasal flaring, chest x-ray, and the use of accessory muscles.

Note that the nursing diagnosis is the patient's response to having

pleural effusion.

Nursing diagnosis also addresses mental, physical, social, and social

aspects of health, patient education, comfort.
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D Questions to Ask Yourself.

Ask yourself the following questions:

I o Does the label, and NANDA-I definition match the patient's

current problem?
o Does the etiology support the label?
o Do the defining characteristics support the label and etiology?

A Prioritizing Nursing Diagnosis

Remember that nursing care is continuous. You won’t have time to
address all of the patient’s problem. It is important to address the
G highest-priority diagnoses first.

High-priority nursing diagnosis: Involves immediate and emergency

physiological needs.

N Intermediate priority diagnosis: Involves nonemergency or potential risk.

Low-priority nursing diagnosis: Involves a long-term plan.

O Self-
Actualization

Self-Esteem

S Love and Belonging

Safety and Security
I
Physiological Needs
S Prioritization: The use of the Maslow's Hierarchy of
Needs

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A Scenario
ACTIVITY 3

Mr. Harry Fernando is a 68-year-old male admitted to the medical-

surgical unit and diagnosed with congestive cardiac failure. The client
C states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
T Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;
however, he does not drink alcohol or use recreational drugs. Mr.
I Fernando has a family history of cancer, diabetes and hypertension, and
coronary artery disease.

Mr. Fernando loves to eat KFC and burgers. He is currently concerned

V about his health status but isn’t sure what to do.

Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.

I Create 4 nursing diagnosis (Three actual and one potential diagnosis)

1.

T
2.

Y
3.

4.

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O
PLANNING
B
OBJECTIVES
In this chapter, you would learn:
J 1. Identification of expected outcomes.

2. How to formulate patient outcomes.

3. How to utilize NOC.

E 4. How to develop nursing interventions.

5. How to use NIC.

C NOTES

Key points from this chapter…

S
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P PLANNING
L Identifying the Expected Outcome
The goal of nursing care to assist patient reach their highest functional
level. If the patient cannot fully recover, the nursing care goal is to
assist the patient in being comfortable and coping with the declining
health status. Therefore, it is critical to establish an expected outcome

A for nursing care. It is important to remember that expected outcomes

are geared towards the patient's performance and not the nurse's
interventions or actions.

N An Outcome Statement

An outcome statement includes:

o Specific behaviors that denote the patient has reached the goal.
o A criterion to measure the attained behavior.
The condition in which the behavior should occur.
N
o
o A specific timeframe.

Elements of an Outcome Statement

I
B M C T
N Behavior Measure Condition Time Frame

A desired Measuring of Condition in Specific time

behavior that behavior. (How which behavior frame in which

G is observable. much, how

long, etc.)
should take
place.
the behavior
should occur

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P Long-Term and Short-Term Goals

Long-term goals: It takes weeks or months to achieve.

Short-term goals: It takes a lesser amount of time.

Writing Outcome Statements

L o Begin with specific action verbs such as ambulate, perform, state,

verbalize, participate, demonstrate, etc.
o Make sure that the statement is specific
o Avoid the use of unnecessary words
o Only use the accepted abbreviation

A o Include the patient in the participation of goal setting.

Nursing Outcome Classification (NOC)

NOC is a standardized patient outcome categorization that helps nurses

N formulate effective interventions.

Purpose of NOC

o Ensure consistent measurement of the patient's outcome.

o Validate the effectiveness of nursing care to improve quality.

N o Aids in the integration of electronic health database in nursing

care planning.

The NOC has a Likert scale that allows nurses to evaluate patient's
status effectively.

Example of NOC Scales:

I 1 (Extremely Compromised) to 5(Not Compromised)

1(Never Demonstrated) to 5(Consistently Demonstrated)

1(None) to 5(Extensive)

N Example:

Imbalanced nutrition: Less than body requirements related to decreased

oral intake secondary to surgical intervention as evidence by a sudden

G decrease of BMI from 22.5-17.5.

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P
NOC:

Nutritional Status: Food and Fluid Intake (1008)

o (100801) Oral food intake at a level of 4 within 5 days.

o (100803) Oral fluid intake at the level of 4 within 5 days.

L Nursing Intervention
Nursing intervention should be realistic, measurable, and achievable.

Types of Intervention

A Independent Intervention: An independent intervention is within the

scope of nursing practice. For example:

o Patient teaching.
o Self-care and performing activities of daily living.

N Collaborative Intervention

A collaborative intervention includes consultation with another health

care member. For example:

o Administration of medication

N
o Administration of intravenous fluids
o Diagnostic test

How to Write Nursing Interventions

Nursing interventions should be based on the specific nursing diagnosis

and expected outcome. The purpose of the nursing interventions is to be

I comprehensive to achieve the goal.

Nursing interventions should:

o Be Actions (begin with a verb)

Monitor the patient’s temperature.

N Assess respiratory rate, depth, pattern.
Perform passive range of motion exercises.
o Be scientific and evidence-based.
o Include rationale from nursing books, journals, and care plans.
o Have available resources.

G o
o
Include the patient's willingness and consent.
Possess competence to perform the intervention.

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P Nursing Intervention Classification (NIC)

NIC is a standardized evidenced-based nursing intervention. NIC
includes 554 interventions and grouped into 30 classes and 7 domain
groups.

Sample Using NIC and NOC

L Here is a short sample on how to use the NIC and NOC

Nursing Diagnosis

Imbalanced nutrition: Less than body requirements related to decreased

A oral intake secondary to surgical intervention as evidence by a sudden

decrease of BMI from 22.5-17.5 in 30 days.

NOC LABEL

o 100801 Oral food intakes at a level of 4(substantially adequate)

within 5 days.
N o 100803 Oral fluid intakes at the level of 4(substantially adequate)
within 5 days.

NIC LABEL

o Nutrition Management

N o Nutritional Counselling
o Nutritional Monitoring

Tips for writing nursing interventions.

I o
o
Ensure that the nursing interventions are simple to understand.
Clearly, state the action verb.
o Prioritize patient’s safety.
o Interventions should be collaborative between the nurse and
the patient.

N o Follow the institutional policy.

o Ensure all resources are available.
o Focus on independent nursing actions first.

G
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A Scenario
ACTIVITY 4

Mr. Harry Fernando is a 68-year-old male admitted to the medical-

surgical unit and diagnosed with congestive cardiac failure. The client
C states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
T Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;
however, he does not drink alcohol or use recreational drugs. Mr.
I Fernando has a family history of cancer, diabetes and hypertension, and
coronary artery disease.

Mr. Fernando loves to eat KFC and burgers. He is currently concerned

V about his health status but isn’t sure what to do.

Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.

I 1. Create expected outcomes and nursing interventions.

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O IMPLEMENTATION
B OBJECTIVES
In this chapter, you would learn:
J 1. Care plan implementation

2. Documentation.

E Notes
Key points from this chapter…

C
T
I
V
E
S
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I IMPLEMENTATION
Implementation is the fourth step in the nursing process. This phase

M involves putting the care plan into action to achieve the desired set
outcome(s). It includes:

P
o Executing planned intervention.
o Using critical thinking to prioritize needs.
o Assessing and reassessing the patient.

L o Communication, documentation and referrals.

Documentation

E Documentation depends on the facility’s policy. The facility’s policy

dictates the format of documenting interventions.

M
Documentation Format

There are different types of nursing documentation formats that can be

utilized in the clinical setting. This includes:

E The PIE system: Problem-intervention-evaluation.

E.g.

N P- Ineffective Breathing Pattern

I- Patient assessment revealed the use of accessory muscle, RR of

T 25, SPO2 of 95%. The patient is placed on continuous SPO2 and RR

monitoring every 15 minutes. The patient is placed in a semi-
fowlers position and oxygen therapy 4L/min as prescribed ongoing.

A E- After 1 hour of nursing intervention, the patient had an

increase of SP02- 98% and RR of 18.

T
The SOAP Format: Subjective, Objective, Assessment Planning.

E.g.

I S- Patient verbalize chest tightness

O- Use of accessory muscles, RR- 25, SPO2 95%
A- Ineffective Breathing Pattern

O P- Assess and monitor respiratory rate, depth, and pattern.

Administer 02 therapy 4L/min. Place pt. in a semi-fowlers position.

N
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I
The SBAR Format: Situation, Background, Assessment, Recommendation

This type of documentation is done between health care providers.

M Situation: Briefly explaining the situation.

Background: Provide relevant history that relates to the patient’s

current problem.

P Assessment: Assess patient’s problem.

Recommendation: What is requested to be done.

L
ACTIVITY 5
E Question 1.

M Create an SOAP documentation format for any of your nursing

diagnosis.

E
N
T
A
T
I
O
N
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O
EVALUATION
B OBJECTIVES
In this chapter, you would learn:
J 1. The importance of evaluation.

2. The process of evaluation.

E Notes
Key points from this chapter…

C
T
I
V
E
S
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E EVALUATION
Evaluation is the fifth stage in the nursing process. However, it is
essential to remember that, despite it being the fifth stage, it is an

V ongoing process of the first four stages. In includes:

o Reassessing the patient.

o Patient progress as compared to the expected outcome
established.
A o Documenting statements of evaluation.

The purpose of evaluation

o Determine complication
L o
o
Assess patient’s response to intervention
Improve the quality of care
o Determine whether care conform to evidence-based standards

U Reassessment

Reassessment allows the nurse to identify whether the patient’s

condition is improving or whether interventions are effective. Check for:

A
Assessment: Vital signs change, a change in the pain rate.

Nursing diagnosis: Relevancy of diagnosis, new defining characteristics

Planning: Realistic goals, congruence of nursing interventions, and

T
expected outcomes.

Evaluation: Change between expected outcome and current condition.

Evaluating the Expected Outcome

I Achieved Outcome Outcome Not Achieved

Upon evaluation, you may discover Upon evaluation, you may discover
that the patient has met the short- that the patient did not meet the

O term goal. Hence, the intervention

was adequate, and the outcome was
met.
short-term goal. Hence, the
interventions should be reexamined;
goals should be reassessed.

N
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A
ACTIVITY 6

Scenario

Mr. Harry Fernando is a 68-year-old male admitted to the medical-

surgical unit and diagnosed with congestive cardiac failure. The client
C states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
T Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;

I however, he does not drink alcohol or use recreational drugs. Mr.

Fernando has a family history of cancer, diabetes and hypertension, and
coronary artery disease.

Mr. Fernando loves to eat KFC and burgers. He is currently concerned

V about his health status but isn’t sure what to do.

Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.

I 1. Evaluate your nursing care. (Assume that your expected

outcomes/goals were met).

T
Y

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O CONCEPT MAPPING
B OBJECTIVES
In this chapter, you would learn:
J 1. The definition of concept mapping.

2. The use of concept mapping.

E
3. The steps in developing a concept map care plan.

NOTES

C Key points from this chapter…

T
I
V
E
S
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C CONCEPT MAPPING
Concept mapping is an innovative approach in planning patient care.
Concept mapping places “concepts” or ideas of patient’s problems into a

O diagram. Concept care maps are used to:

o Systematically organize the patient's data.

o Create relationships among the data.
Prioritize
N
o
o Provide a holistic approach to care.

Steps in Developing Concept Care Mapping

Preparation
C Prior to step 1, it is important for you to gather all clinical data
(subjective and objective data). The assessment phase must be complete
and accurate.

E Step 1. Develop A Skeleton Diagram

Detail the problems that you assessed and collected. The key problems
are also known as concepts. In the middle, write the medical diagnosis.

P
T Key Problem Key
Problem
Key

M Key Problem Key Problem

Medical Diagnosis

A Priority Assessment

p Key Problem Key Problem Key Problem

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C
Step 2. Analyze and Categorize Data

Analyze and categorize the data from both objective and subjective
data. This provides supportive evidence for the medical diagnosis and
nursing diagnosis. Include abnormal assessment findings, medical history,

O etc.

Key Problem: Key Problem: Key Problem:

N
Data: Data: Data:

C Key Problem: Key Problem:

Medical Diagnosis

E Data:
Priority Assessment
Data:

P Key Problem: Key Problem: Key Problem:

Supporting Data: Supporting Data: Supporting

T Data:

Step 3: Indicate relationships

M Draw lines between problems that relate, then prioritize the problem.
Replace the key problem with the nursing diagnosis.

In the example below, in terms of prioritization, ineffective airway

A clearance is first, followed by ineffective breathing pattern, activity

intolerance, and anxiety.

Secondly, the lines represent the relationship between the problems. For

P example, the line between ineffective breathing pattern and anxiety

shows that respiratory distress causes the patient’s anxiety.

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C Ineffective Breathing Pattern

Supporting Data
2

Dyspnea, RR, SPO2, nasal flaring, use of

accessory muscles, tachypnea, prolong

O
expiration,
4 3
Anxiety Activity
Intolerance
Supporting ASTHMA

N
Data: Supporting Data
Priority Assessment:
Dyspnea
Verbalization of
Airway patency, breathing,
Tachypnea weakness
safety, activity tolerance.
Tired appearance
Verbalization

C
Inability to
of anxiety
1 perform daily
Restlessness tasks.
Ineffective Airway Clearance

Supporting Data:

E Cough

Dyspnea

Respiratory Rate

P SPO2

Step 4: Identify goals and expected outcome and nursing strategies

T (interventions)

This includes a general goal and behavioral outcome at the top of the
template. Nursing strategies are the nursing interventions that would be
implemented.

M Step 5: Evaluate the patient’s outcome/response.

In this step, evaluate the patient's response to the nursing strategies.

For example, under the diagnosis of ineffective breathing pattern,

A assessment of respiratory rate, depth, and pattern would be a nursing

strategy. In the patient's response, you would state the patient's
respiratory rate, depth, and pattern.

P
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C Problem #

Goal:

O Expected Outcome (Behavioral Outcome): The patient will…

N
C Nursing Intervention Patient Response

E
1.

2.

P 3.

4.

T 5.

6.

M 7.

8.

A
Evaluation:

P
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C
Remember that concept care mapping is dynamic, depending on the
institution. The core principle is to establish relationships among the
problems. Follow your teacher's instruction and maintain the core
principles when formulating your care plan.

O Other Concept Care Mapping Templates.

Nursing Dx:

Assessment:

N Expected Outcome:

Interventions:

C Nursing Dx:
Goal Evaluation: Nursing Dx:

Assessment:
Assessment:
E Expected Outcome:
Expected MEDICAL
DIAGNOSIS
P Outcome:
Assessment:
Interventions:

Interventions: Goal Evaluation:

T Goal Evaluation:

Nursing Dx:

M Assessment:

Expected Outcome:

A Interventions:

Goal Evaluation:

P
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A
ACTIVITY 7

Scenario

Mr. Harry Fernando is a 68-year-old male admitted to the medical-

surgical unit and diagnosed with congestive cardiac failure. The client
C states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
T Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;

I however, he does not drink alcohol or use recreational drugs. Mr.

Fernando has a family history of cancer, diabetes and hypertension and
coronary artery disease.

Mr. Fernando loves to eat KFC and burgers. He is currently concerned

V about his health status but isn’t sure what to do.

Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.

I CREATE A CONCEPT MAP FOR ONE OF YOUR DIAGNOSIS.

T
Y

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A
C
T
I
V
I
T
Y

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A Problem #

Goal:

C Expected Outcome (Behavioral Outcome): The patient will…

T
I
Nursing Intervention Patient Response

1.

V 2.

3.

I 4.

5.

T 6.

7.

Y 8.

Evaluation:

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A ANSWERS
N
S
REMEMBER THAT NURSING IS DYNAMIC AND THIS IS JUST A CASE
SCENARIO. THEREFORE, THERE WOULD BE MISSING PIECES. THE

W GOAL OF THIS SECTION IS TO GIVE YOU A GUIDE ON HOW TO

ANSWER THE QUESTION. YOU ARE NOT LIMITED TO THESE
ANSWERS ALONE. AGAIN, REMEMBER, NURSING IS DYNAMIC.

E
R TRY BEFORE YOU TAKE A
PEEK!

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A ACTIVITY 1

1. According to Miskir and Emishaw (2018), the factors that may affect
the implementation of the nursing process includes:

N o
o
o
No writing formats
Lack of follow up and monitoring
Lack of time
o Lack of knowledge
Increasing workload

S
o
o Nursing staff shortage
o Lack of support
o Lack of reference materials.

(You may include other factors that may affect the implementation of

W
the nursing process.)

2. Draw and label the steps in the nursing process. (You may create your
design.)

E 1

ASSESSMENT

R 5
THE NURSING
2

DIAGNOSIS
EVALUATION
PROCESS

S
4 3

IMPLEMENTATION PLANNING

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A 1.
ACTIVITY 2

SUBJECTIVE DATA OBJECTIVE DATA

N
o SOB for 3 days o Vital signs showed: BP
o “I am unable to sleep at night 97/52, irregular pulse 80,
because I cannot breathe.” SaO2 94%, Temp 36.9, RR
o Family history 24 bpm.
o Past medical and surgical o Crackles noted in the right
history lung base upon auscultation.

S
o Known smoker for 30 years o Bilateral pedal edema.
o Diet: KFC and Burger
o Concerned about health

W
2. According to Mr. Fernando’s wife, he complains of body weakness and
the inability to perform daily tasks.

E 3. Additional subjective data: Weight gain, allergies, medication history,

social history, religion, lifestyle habits.

Additional objective data: Degree of pitting (edema), jugular vein

distention, diagnostic test results, ECG, Lab results, blood chemistry,

R peripheral pulse, capillary refill, cyanosis.

4. Mr. Fernando’s stage according to Erik Erikson is Integrity vs Despair.

It includes focusing on one's life and either transitioning to being happy

and satisfied with one's life or experiencing a deep sense of regret.

S
With his medical condition, the nurse must assess whether the patient is
pleased with the life lived or experiencing depression and grief.

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A ACTIVITY 3
(The nursing diagnosis is not limited to the list below.)

1. Ineffective breathing pattern related to decreased lung expansion

secondary to pulmonary congestion as evidence by SaO2 94%, RR 24

N bpm, crackles noted in the right lung base upon auscultation, dyspnea,
SOB, and orthopnea.

2. Decreased cardiac output related to decreased myocardial

contractility as evidence by BP 97/52, irregular pulse 80, pedal edema.

S
3. Excess fluid volume related to increased fluid retention secondary to
decreased myocardial contractility as evidence by bilateral pedal edema,
orthopnea, crackles noted in the right lung base upon auscultation and
dyspnea.

4. Activity intolerance related to an imbalance between oxygen supply

W and demand as evidence by verbalization of generalized weakness and

inability to perform activities of daily living.

5. Disturbed sleep pattern related to decreased lung expansion

secondary to pulmonary congestion as evidence by patient verbalization
of difficulty sleeping, dyspnea, SOB, orthopnea SaO2 94%, and RR 24

E bpm.

6. Deficient knowledge related to lack of understanding of the disease

process as evidence by verbalization of health concern and lifestyle
behaviors.

R 7. Risk for impaired gaseous exchange related to pulmonary congestion.

8. Risk for ineffective tissue perfusion related to decreased stroke

volume secondary to inadequate myocardial contractility.

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A ACTIVITY 4 and 6
(Only three nursing diagnosis were used as a sample.)

Nursing Diagnosis:

N
Ineffective breathing pattern related to decreased lung expansion secondary
to pulmonary congestion as evidence by SaO2 94%, RR 24 bpm, crackles noted
in the right lung base upon auscultation, dyspnea, SOB, and orthopnea.

Expected Outcomes

1. The patient will maintain a blood oxygen saturation level between 95% to

S
100% after 1 hour of nursing intervention.

2. The patient will maintain a respiratory rate within 12-20bpm after 1 hour of
nursing intervention.

2. The patient will demonstrate a diaphragmatic pursed-lip breathing technique

after 1 hour of nursing intervention.

W Interventions

1. Assess respiratory rate, depth, and pattern every 2 hours.

2. Auscultate breath sounds every 4 hours.

3. Monitor the patient’s vital signs every 2 hours.

E 4. Place the patient in a semi-fowlers position.

5. Encourage a diaphragmatic pursed-lip breathing technique.

6. Administer oxygen therapy as per physician order. (Specify)

R
7. Administer medication(s) as prescribed by the physician. (State medication
name, time, dose and route).

8. Monitor any medication(s) side effects.

9. Assist patient to perform relaxation techniques.

S
10. Document nursing interventions and the patient’s response.

Outcome:

The outcome was met. After 1 hour of nursing intervention, the patient
maintained a blood oxygen saturation of 96%, maintained an RR of 20bpm, and
demonstrated diaphragmatic pursed-lip breathing technique every thirty
minutes.

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A Nursing Diagnosis
ACTIVITY 4 and 6

Decreased cardiac output related to decreased myocardial contractility as

evidence by BP 97/52, irregular pulse 80 and bilateral pedal edema.

N Expected Outcome:

1. After 8 hours of nursing intervention, the patient will demonstrate an

increase in cardiac output as evidence by increase in BP within normal systolic

S
range of 110-129 and diastolic range of 60 and less than 80; a regular 3+ pulse
on a graded scale of (0-4+) with a rate ranging from 60-100bpm and a decrease
in bilateral pedal edema of 0-2+ on a graded scale of (0-4+).

Interventions

W 1. Assess apical and peripheral pulses every 2 hours.

2. Assess heart and lung sounds every 4 hours.

3. Place the patient on cardiac monitoring as per the physician's order.

E
4. Monitor fluid input and output.

5. Place the patient in a semi-fowlers position.

6. Encourage periodic rest and assist with ADLs.

7. Administer oxygen therapy as per physician order. (Specify)

R
8. Administer medication(s) as prescribed by the physician. (State medication
name, time, dose and route).

9. Monitor any medication side effects.

10. Document nursing interventions and the patient’s response.

S Outcome:

The outcome was met. After 8 hours of nursing intervention, the patient
demonstrated an increase in cardiac output as evidence by a maintained BP of
115/72, regular 3+ pulse and rate of 88bpm, and a decrease of bilateral pedal
edema of 2+.

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A Nursing Diagnosis
ACTIVITY 4 and 6

Excess fluid volume related to increased fluid retention secondary to

decreased myocardial contractility as evidence by bilateral pedal edema,

N
orthopnea, Crackles noted in the right lung base upon auscultation and dyspnea
and BP 97/52, irregular pulse 80

Expected Outcome:

Patient would regain and maintain fluid balance as evidence by decrease of

bilateral pedal edema on the scale grade of 0-2, increase in BP within normal

S systolic range of 110-129 and diastolic range of 60 and less than 80; a regular
pulse of 3+ on a graded scale of (0-4+) and maintain a regular breathing pattern
after 8 hours of nursing interventions.

Interventions.

W
1. Assess BP, pulse and respiratory rate, depth, and pattern every 2 hours.

2. Auscultate breath sounds every 4 hours.

3. Maintain fluid restriction as per physician order.

4. Maintain a low sodium diet.

E
5. Weigh patient daily and compare to previous weights.

6. Elevate the patient's lower limbs.

7. Administer medication(s) as prescribed by the physician. (State medication

name, time, dose and route).

R
8. Monitor any medication side effects.

9. Document nursing intervention and the patient's response.

Outcome:

The outcome was met. After 8 hours of nursing interventions, the patient

S
demonstrated a maintained fluid balance as evidence by a BP of 115/72, a
regular 3+ pulse of 88bpm, and a decrease of bilateral pedal edema of 2+ and
RR of 20bpm.

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ACTIVITY 5
A
SOAP format:

N S- The Patient verbalized SOB for over 3 days.

O- SaO2 94%, RR 24 bpm. Crackles noted in the right lung base upon
auscultation, dyspnea, SOB, and orthopnea.

S A- Ineffective breathing pattern

P- Assess and monitor respiratory rate, depth, and pattern. Administer

02 therapy. Place pt. in a semi-fowlers position.

W
E
R
S

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A ACTIVITY 7.
The arrows are used to show the relationships between the diagnosis. For example, an
Ineffective breathing pattern can cause disturbed sleep patterns and activity intolerance.
Decreased cardiac output causes excess fluid volume, activity intolerance, disturbed sleep
pattern, and ineffective breathing pattern. This format is shown below.

N
Disturbed sleep pattern 5
Supporting Data:

Patient verbalization of
difficulty sleeping, dyspnea,
SOB, orthopnea SaO2 94%
and RR 24 bpm.

S Ineffective breathing
pattern
1

Decreased cardiac output

2

Supporting Data: Supporting Data:

SaO2 94%, RR 24 bpm. BP 97/52, irregular pulse

W
CONGESTIVE HEART
80, bilateral pedal edema.
Crackles noted in the
right lung base upon FAILURE
auscultation, dyspnea,
Assessment:
SOB, and orthopnea.
Respiration, Cardiac Output,
Activity Tolerance, Fluid
retention

E 3
4
Activity intolerance Excess fluid volume
related

R
Supporting data:
Supporting Data:
Verbalization of
generalized weakness Bilateral pedal edema,
and inability to orthopnea, crackles noted
perform activities of in the right lung base upon
daily living. auscultation and dyspnea.

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C CASE
A
S
STUDIES
E Here are additional case studies. The aim is for you to apply the basic
concepts that you have learned. Remember that these case scenarios

S
sometimes omit other relevant information that might be crucial in
creating a comprehensive care plan. The goal is to critically think like
a nurse and fill in the gaps with the question:

T
U WHAT OTHER INFORMATION
SHOULD I OBTAIN?

D
Y

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C CASE STUDY 2

Mrs. Kathrine George is a 30-year-old female who was admitted with a

A medical diagnosis of pneumonia. She complains of cold for two weeks,

decrease oral intake, dyspnea, orthopnea, and body weakness. “I have

S been coughing up thick pink sputum." The assessment showed dry mucous

membranes, hot and pale skin, decreased breath sounds, and inspiratory

E crackles upon auscultation. Mrs. George has a medical history of asthma.

She has no past surgical history. Mrs. George has no known food or drug

S allergy and does not smoke or abuse alcohol and drugs.

Create a nursing care plan and concept care map for Mrs. George.

T
U
D
Y

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C CASE STUDY 3

A 79-year-old female is admitted with a medical diagnosis of COPD. The

A patient states that she has been experiencing shortness of breath for

the past 24 hours. She is using her accessory muscles, and you noticed

S
nasal flaring. Patient breathing is fast and irregular. Vital signs show

oxygen saturation was 82%, HR 120, BP 160/90, RR 34. Lung sounds are

diminished, and a chest X-ray revealed a hyper-inflated lung and

E flattened diaphragm. The patient oxygen setting is 2L/min; however, she

begins to complain that the oxygen level is too low. ABGS show PCO2 59,

pH 7.24, PO2 52, O2 Sat 82%.

S Create a nursing care plan and concept care map.

T
U
D
Y

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C CASE STUDY 4

A 50-year-old male is admitted with complaints of abdominal pain on a

A pain rating of 9(0-10 scale). He described his pain as intermittent and

stabbing. He also complained of frequent dark tarry stool for the past 4

S days and described a coffee brown looking emesis. He stated that his

current medications are Aspirin and Lisinopril, however, he is unable to

E remember the dosage. He feels dizzy and always tired. The patient has a

dry mucous membrane, is pale and diaphoretic. Vital signs showed BP

S 98/62, HR 115, O2 Sat 99%.

Create a nursing care plan and concept care map.

T
U
D
Y NOTES

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NOTES

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NOTES

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