Professional Documents
Culture Documents
P R E PA R E D B Y: B e e n a S i b y
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INDEX
1. CARDIOVASCULAR SYSTEM 02
2. RESPIRATORY SYSTEM 29
4. ENDOCRINE SYSTEM 64
6. NERVOUS SYSTEM 83
9. DERMATOLOGY 109
15.OBG 205
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MEDICAL SURGICAL NURSING
CARDIO VASCULAR SYSTEM
Heart is situated on the left side of the thoracic cavity. If it present in the right side of the body is
known as dextrocardia
3 layers – pericardium ( outer) , mayocardium ( middle ), endo cardium( inner ) . normal pericardial
fluid in pericardium 10 -30 ml
✔ Right coronary artery – is supplying to right atrium & ventricles, inferior portion of left
ventricle, posterior septal wall & SA node and AV node
✔ Left coronary artery
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● Left anterior desending - anterior wall of left ventricle, anterior ventricular
septum,apex of the left ventricle
● Circumflex artery - ls supplying blood to left atrium, lateral and posterior surface of
the left ventricle
HEART SOUNDS
GALLOP
⮚ S3 gallop (ventricular gallop) cause systolic heart failure
Auscultation apex, pt position left lateral ( because is not clearly audible in supine position ).
⮚ S4 gallop (atrial gallop) cause diastolic heart failure.
Auscultation apex, patient position left lateral.
HEART MURMURS
⮚ DIASTOLIC MURMUR: Causes: aortic and pulmonic regurgitation mitral and tricuspid
stenosis
⮚ BRUIT AND THRILL SOUND : Bruit is vascular murmur . Causes : PVD, renal artert
stenosis, carotid artery stenosis, aneurysm, COA, atherosclerosis, AV fistula, thrill is tremor
or vibration felt on palpation AV fistula
CARDIAC OUTPUT
STROKE VOLUME
⮚ Is the volume of blood pumped from the ventricle per beat.
⮚ Normal: 70 ml per beat
⮚ Stroke volume = EDV - ESV volume of blood pumped by the left or right (ESV = 140ml,
EDV =70 ml)
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PRELOAD OR EDV & AFTER LOAD
⮚ Preload is the end diastolic volume that stretches the right and left ventricle of the heart to its
greatest dimension under variable physiology dimension.
⮚ After load is the pressure against which the heart must work to eject blood during systole
⮚ Ejection fraction is the percentage of blood ejected from a chamber with each contraction
⮚ Normal: 50% to 65%
⮚ Cardiac reserve: is the difference between the rate at which the heart pumps blood and its
maximum capacity for pumping blood at any given time
⮚ Normal 25 to 30 L per mit
PULSE PRESSURE
⮚ Difference between systolic and diastolic blood pressure.
⮚ Normal value 120 – 80 = 40 mm of hg
PULSE DEFICIT
⮚ is the difference between apical pulse and peripheral pulse. ( always epical pulse is higher
than peripheral pulse)
PULSE PARADOXUS
⮚ Is an abnormally large decrease in stroke volume, systolic bp ( minimum less than 10
mmofhg ) and pulse wave amplitude during inspiration
⮚ Causes- COPD, Asthma, Cardiac taponade, Croup syndrome
CARDIAC TAMPONIDE
⮚ Increased fluid collection in pericardial space. ( C/M is BECKS TRIAD
{hypotension,jvd,muffled heart sound } )
CHEST LEADS
Elements of chest leads
Lead Positive electrode placement View of heart
V1 4th intercostal space to right sternum Septum
V2 4th intercostal space to left sternum Septum
V3 Directly between V2 and V4 Anterior
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V4 5th intercostal space at left midclavicular line Anterior
V5 Level with V4 at left anterior axillary line Lateral
V6 Level with V5 at left midaxillary line lateral
⮚ It is a level of medical care which is used for victims of life threatening illness or injuries
until they can be given full medical care at a hospital . it can be given any one
⮚ STEPS
❖ Seen safety
Shout for help
Check the responsiveness of the client by shouting or shaking
No response - call for help
To get an automatic external defibrillator
❖ Monitor pulse ( time 5- 10 second only ) - No pulse start CPR
❖ Site of compression lower 2/3rd of sternum toward nipple line
⮚ Inside the hospital if client undergone cardiac arrest the professional team is treating the
client with the help of an medicine.
⮚ Common difference in BLS & ACLS -drug adrenaline and aminodarone is using in ACLS
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⮚ Common steps- CPR, airway, defibrillation
Waveform Capnography
⮚ It is the mechanical obstruction at the flow of air from the environment in to the lungs.
Chocking prevents breathing and can be partial or complete.
⮚ Adult chocking
✔ C/M the person tightly hold the neck
✔ Management – first ask the client are you chocking
✔ Followed by Heimlich maneuver ( abdominal thrust )
✔ Abdominal thrust is contra indicated in pregnancy and post partum women,abdominal
surgery – in this perform chest thrust and instruct the client to forcefully cough.
⮚ Infant chocking
✔ Place the infant on prone position on your left arm and give five back blows then
chest thrust
HYPERTENSION
Definition of blood pressure: blood pressure is pressure exerted by blood on walls of arteries.
Hypertension: blood pressure more than 140/90 mm of hg.
Blood pressure=CO × TPVR (total pulmonary vascular resistance )
Reason for false high bp – cuff is small & rapid deflation
Reason for false low bp – cuff is large
Causes of hypertension
⮚ CLINICAL FEATURES
● Early morning Headache
● Vertigo
● Tinnitus
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● Blurring of vision
⮚ DIAGNOSTIC EVALUATION
● ECH – LVH is present
● Monitor the BP at different position
MANAGEMENT OF HYPERTENSION
● Diet low sodium ( it will help to decrease pre load ), low saturated fat, high potassium ( blood
vessel is dilated & sodium is excreting) , high soluble fiber
● Identify the cause and treat them
● Exercise – aerobic exercise
● For immediate reduction of BP administer- NTG, AMINODEPINE, SODIUM NITRO-
PRUSIDE
ACE INHIBITOR (enlapril)
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DIURETICS
❖ MODE OF ACTION - Increases urine output >reduces blood volume> reduces preload>
reduces cardiac output >reduces systolic blood pressure.
LOOP DIURETICS
● MODE OF ACTION : dilate veins reduces preload, dilates the artery reduce afterload.
● Use; HTN , angina.
● Side effects; chest pain, palpitation, headache, nausea dizziness, flushing, hypotension
tachycardia.
● Interaction; sildenafil (Viagra)
VASODILATORS CLASSIFICATION
HYPOTENSION
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● Blurred vision
● Fatigue
● Weakness
● Fainting
MANAGEMENT
✔ Crystalloids: are solutions of salt and water with variable electrolyte composition and
contain no protein or colloids
✔ Colloids: contain larger insoluble molecules, which act to retain existing fluid and
promote increase in blood volume
TYPES OF IV FLUIDS
1. CRYSTALLOIDS
● Isotonic
o 0.9 % sodium chloride (NS)
o Lactate ringers
o Dextrose 5% in water (D5W)
● Hypotonic
o 0.45% sodium chloride
● Hypertonic
o 5% dextrose in NS
o 5% dextrose in lactated ringers
o 5% dextrose in 0.45% ½ NS
o 10% dextrose in water
2. COLLOIDS (plasma expanders)
● Albumin
● Plasma protein fraction
● Dextran,Hetastarch
CRYSTALLOID VS COLLOIDS
Crystalloids Colloids
Low molecular weight high molecular weight
Iso/hypo/hypertonic hypertonic
Increase hydrostatic pressure increase oncotic pressure
Expands interstitial volume expands plasma volume
Time ½-30 minutes time ½-2 hrs
Replacement ratio- 3:1 replacement ratio 1:1
Allergic reaction- rare allergic reaction common
Cheap expensive
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INFLAMATORY DISOREDERS OF HEART
PERICARDITIS
⮚ MANAGEMENT
✔ High fowlers or sitting upright position
✔ Drug- analgesics. NSAID, corticosteroid, diuretcs
✔ Check blood culture to identify the organism
✔ S/M pericardiectomy
⮚ COMPLICATION
✔ Cardiac tamponade – excessive accumulation of pericardial fluid in the pericardium
o C/ M – becks traid ( hypotension with narrow pulse pressure, jugular vein
distension, muffled heart sound )
o Management – peri cardiosynthesis
✔ Pericardial effusion – moderate accumulation pericardial fluid in pericardial sac C/M
– hiccups due to phrenic nerve compression
✔ Pulsus paradoxus
✔ Decrease cardiac output
ENDO CARDITIS
⮚ Inflammation of the endocardium ( inner lining of the heart )
⮚ CAUSE
✔ Group A- beta haemolytic streptococci ( always first priority )
✔ Staphylococci
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✔ Valvular disorder
✔ Dental procedures (H/O 3-6 month before )
✔ IV drug abusers / lack of aseptic technique during IV therapy
⮚ PATHOPHYSIOLOGY
✔ Vegetation formation ( right side vegetation can cause pulmonary embolism. Left side
vegetation can cause – CAD, stroke , gangrene & cellulites in the extremities, liver &
kidney injury )
⮚ CLINICAL FEATURES ( cross check the picture from net )
✔ Petechiae or echmosis
✔ Splinter haemorrhage
✔ Oslers node – painful, tender, red colour pea shape lesion found on finger tips or toes
✔ Janeways lesion – flat , painless, small red spot may be found on the palms and soles
✔ Roths spot – fundoscopic examination may reveal hemorrhagic retinal lesion
✔ Fever, fatigue, clubbing of finger.
⮚ D/E - increased – WBC,ESR,CRP
Positive blood culture
⮚ MANAGEMENT
✔ Bed Rest to prevent cardiac complication
✔ Anti embolism stocking
✔ Antibiotics
✔ Maintain aseptic technique
✔ Encourage oral hygiene
✔ Take medication at correct time
SHOCK
● Shock is a systemic state of low tissue of perfusion which is inadequate for normal cellular
respiration
⮚ COMMON FEATURES OF SHOCK
● Initially tachycardia followed by bradycardia
● Hypotension
● Poor peripheral pulse
● Extremities clammy and cold
● Oliguria
● Dyspnoea
● Altered LOC
● Pedal oedema
● In septic shock additionally fever present
● In anaphylactic shock – rashes, swelling, wheezing.
TYPES OF SHOCK
PACEMAKER
⮚ SA node is the pace maker of the heart is producing 60-100 impulses /minute
⮚ Client education after pacemaker insertion
✔ Teach the sign and symptoms of pace maker failure
✔ Hiccups, swelling of ankles, dizziness, weakness, fatigue, chest pain, dyspnoea
✔ Monitor any infection – redness, swelling, discharge
✔ Monitor pulse & BP on the opposite side of the pacemaker
✔ Wear loose cloth & use mobile phone on the opposite side of the pacemaker
✔ THINGS CONTRAINDICATED
● MRI
● Tens
● Electric trimmer
● Radiation
● Metal detector
● Anti-theft device
● Contact sports, electric mixer
COMPLICATION
VALVULAR DISORDER
⮚ Three problems occur in to the valve-
⮚ atresia, ( absence of opening )
⮚ stenosis, ( narrowing of the valve )
⮚ Regurgitation ( back flow )
CLINICAL FEATURES
● Right side valvular problems that can cause right side heart failure
● Left side valvular problems that can cause left side heart failure
D/E
● 2D ECHO
MANAGEMENT
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● Jugular vein distension ● Initially dyspnoea
● Kussmaul sign (high JVP during ● Tachycardia, tachypnoea
inspiration), ● dyspnoea, orthopnoea
● hepatojugular reflux, ● PND,
● weight gain, edema ● haemoptysis, dry cough
● Abdominal distension ● pulse alternance
● fatigue, ascites, hepatomegaly, ● clubbing of finger (Hippocratic
anorexia, nocturia. finger)
● Initially hypertension F/BY ● rales (fine crackles), oliguria,
hypotension ● S3 or S4, high PCWP (normal 2-15
MM OF HG)
● Pedal edema
DIAGNOSIS
● BNP (brain natriuretic peptide) more than(100pg/ml). ANP increased ( nomal less than 27
● ECHO (EF less than 40%).
MANAGEMENT
CARDIAC GLYCOSIDES
● Use for systolic heart failure, arrhythmia.
● Drug digoxin.
● Moa: positive inotrope, negative chronotropic, negative dromotropic.
● Therapeutic range 0.5-2 ng/ml.
ADULT CHILD
● Features Anorexia, nausea vomiting, ● Poor feeding
diarrhoea ● Brady cardia
● fatigue, abdominal pain,
● delirium, ● Child ( less than 70 )
● halo yellow or green, hypotension, ● Infant ( less than 90 )
● bradycardia ( less than 60 ) ● Headache
● heart block, PVC, VT, VF. ● vomiting
● ECG changes ST Depression, T
inversion, PR prolongation.
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● CAUSE OF TOXICITY: hypokalemia, hypomagnesaemia, hypocalcemia, renal impairment
MANAGEMENT OF DIGOXIN TOXICITY.
⮚ ANGINA PECTORIS
● Chest pain or pressure due to myocardial ischemia.
● Word meaning (strangling feeling in the chest).
● Due to high o2 demand and low supply.
● Pain triggering factors (physical mental stress, high altitude, cold exposure).
● Clinical features: chest pain
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o Left sub sternal crushing, squeezing pain radiating to the neck ,jaw, left
shoulder and back
o Pain intensity is not increased or decreased during respiration
o Time - 15 sec to 15 minute.
o Pain is relieved by rest or NTG
o nausea, dyspnoea, anxiety, sweating, palpitation, dizziness, tachycardia.
o HTN
CLASSIFICATION
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WARFARIN
● Coumadin
● Route; oral
● Antidote; vitamin. k
● Monitor lab value (PT, INR ) normal 9.5 -12 sec (2 -3.5 sec )
● With held 3 days before surgery
● Contraindicated in (pregnancy)
ASPRIN
● Acetylsalicylic acid.
● Routes (oral, rectal, iv, im).
● With held 1 days before surgery
● Antidote (sodium bicarbonate, vitamin k, FFP, , charcoal).
● Side effects: ulcer, bleeding, hyperuricemia, Reye’s syndrome, tinnitus, hyperkalemia,
rashes, headache, dizziness
● Contraindication (Reye’s syndrome,3rd trimester pregnancy)
CABG ( coronary artery bypass graft )
● Graft
● Most commonly using Great saphenous vein 80%
● LIMA ( left internal mammary artery )
MYOCARDIAL INFARCTION
⮚ Heart attack (blockage of coronary artery leads to death of heart muscles).
⮚ MI occurs when myocardial tissue is abruptly and severely deprived of oxygen
CLINICAL FEATURES
AWMI LAD V3 V4
PWMI RPD V7 V8 V9
IWMI RPD II,III,AVF
LWMI Left circumflex AVL, V5, V6
SMI LAD V1 V2
ECG
Post MI complications
● Cardiac Arrhythmias
● pericarditis
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● Congestive heart failure – right or left . but most of the time left ventricular failure is occur.
Because the majority branches of the coronary artery is supplying blood to the left ventricle.
● Pulmonary edema due to left side heart failure
● Cardiogenic shock
SURGICAL MANAGEMENT of CAD
⮚ Cardiac catheterisation
✔ Coronary angiogram ( Nsg intervention – ask sea food allergy, monitor serum
creatinine and nephro toxicity, with held metformin 48 hours prior for to
prevent lactic acidosis,when injecting die metallic taste occur i mouth ,before
procedure monitor peripheral pulse for post procedure comparison)
✔ Percutaneous trans luminal coronary angioplasty
✔ Laser assisted angioplasty
✔ Stent application
✔ Atherectomy
⮚ Coronary artery by pass graft
✔ Most commonly safenous vein is using or internal mammary artery
✔ Normal drain amount – 70-100 ml per hour
✔ Priority nursing diagnosis – impaired gas exchange & acute pain
✔ At the time of discharge teach the sign and symptoms of complication.
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ELECTRO CARDIO GRAM
⮚ ECG paper consist of 1500 small boxes and 300 large boxes
⮚ Horizontal line denoting time & vertical line denoting voltage
ECG COMPOSES OF
P – WAVE Arterial depolarisation 0.11 second
QRS – Ventricular depolarisation 0.12 second
COMPLEX
PR INTERVAL The time need for sinus node stimulation, 0.12 – 0.20
arterial depolarisation, conduction through second
AV node before ventricular depolarisation
T – WAVE Ventricular repolarisation
ST SEGMENT Early ventricular repolarization
QT – Total time need for ventricular contraction
INTERVAL and relaxation
PP – To determine arterial rhythm
INTERVAL
RR – To determine ventricular rhythm
INTERVAL
U – WAVE Repolarisation of purkinje fibers & papillary
muscles
ARRHYTHMIA OR DYSRHYTHMIA
SINUS BRADYCARDIA
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✔ Rectal temperature monitoring
● ECG CHANGE
● Management
● Oxygen administration
● Treat the exact cause
● Drug of choice (atropine) side effect – pupil dilation, all body secretion decreased
● Epinephrine
SINUS TACHYCARDIA
⮚ atrial and ventricular rate are 100- 180 beats per minute ( rhythm regular )
⮚ cause
✔ hyperthyroidism
✔ hyperthermia
✔ stress & tension
✔ pain
✔ exercise
⮚ ECG
⮚ Management
✔ Drug of choice beta blocker – propanalol
✔ Treat the exact cause
ATRIAL FLUTTER
● Atrial flutter occurs in the atrium and creates impulses at a regular rate between 240-340
beats / minute
● Cause – CAD, HTN, Mitral valve disorder
● ECG
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Abnormal P WAVE
Name – saw tooth
ECG
MANAGEMENT
● Beta blocker
● Calcium channel blocker, adenosine 6 mg IV
● Cardio version
● RFA- radio frequency ablation
ATRIAL FIBRILLATION
● MANAGEMENT
A(ANTICOAGULANT)
B(BETABLOCKR)
C(CALCIUM CHANNEL BLOCKER)
D(DIGOXIN)
E(ELECTRIC Cardio Version).
Aminodarone for to stabilize unstable rhythm to stable rhythm
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MANAGEMENT
● Adenosine
● Vagal maneuvers
● Beta blocker
● Cardio version
● RFA
● Amiodarone
● BIGEMINY
● TRIGEMINY
● QUADRIGEMINY
● COUPLETS
● TRIPLETS
● ECG CHANGES
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● BETABLOCKER
● CALCIUM CHANNEL BLOCKER
● MAGNESIUM SUPPLEMENT
● RFA – radio frequency ablation
● ICD – implantable cardioverter defibrillator
VENTRICULAR TACHYCARDIA
● ECG
WIDE
QRS.complex,
Pwave not
visible ,
PR not
measurable
VENTRICULAR FIBRILLATION
● Impulses from many irritable foci in the ventricles fire in a totally disorganised manner
● VF is fatal if not successfully terminated within 3-5 minutes
● Cause – CAD
● CLIENT LACKS vitals and heart sound
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ECG
● DEFIBRILLATION
● CPR
● adrenaline
● AMIODARONE (CLASS III ANTIARRHYTHMIC DRUG)- DOSE 300 MG
HEART BLOCK
FIRST DEGREE AV BLOCK
⮚ Is a disease of the electrical conduction system in which pr intervals more than 0.20 seconds.
⮚ Cause (delay in conduction through av node)
SECOND DEGREE AV BLOCK
TYPE 1
● Block above AV
● Ecg progressive prolongation of PR and dropped qrs.
TYPE 2
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VASCULAR DISORDER
TYPES
✔ CLINICAL FEATURES
● Homans sign ( dorsiflexion of the foot indicate pain in calf muscles )
● pain, tenderness, swelling, warmth, redness, edema over the area.
✔ DIAGNOSIS
● D dimmer (fibrin degradation product),
● Venous ultrasound
● History collection
● physical examination
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MANAGEMENT
✔ COMPLICATION
● Pulmonary embolism
● Chronic venous insufficiency
ANEURYSM
✔ Abnormal dilatation of arterial wall
✔ CAUSES- syphilis, HTN , hyperlipidemia, smoking, pregnancy, monckberg’s
sclerosis. Most common disease atherosclerosis
✔ Classification
● Fusiform – bilateral dilatation
● Secular – one side dilatation
● Aortic dissecting
● Pseudo aneurysm or false aneurysm
INTERMITTENT CLAUDICATION PAIN MGNT – severe leg pain due to arterial insufficiency.
● CILOSTAZOL
● PENTOXIFILLINE (Trental)
● Leg in dependent position.
RAYNAUD PHENOMENON
● Vasospasm of the arterioles and arteries of the upper and lower extremities
CAUSES
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● Secondary SLE, scleroderma, prolonged vibration, oral contraceptives, frozen food
packing, Lyme disease.
MANAGEMENT
Key points
koilonichia
RESPIRATORY SYSTEM
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Functions of respiratory system
Primary functions
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● Lungs – right lung is larger than left because for to accommodate heart in the left side of the
thoracic cavity. Right lung 3 lobes and left lung 2 lobes. The upper lobe of the lung having
too much air circulation and lower lobe containing blood circulation
● Pleural cavity - covering of lungs. Outer layer parietal pleura and inner layer visceral pleura.
In between pleural fluid present
Respiratory nerves
● INSPECTION
● PALPATION
● PERCUSSION
● AUSCULTATION
INSPECTION :
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PALPATION ( NOT MANDATORY )
• crepitation
• tracheal deviation
• tactile fremitus ( increased in pneumonia and decreased in pneumothorax and pleural effusin )
• vocal fremitus ( vibration feeling increased in pneumonia and decreased in COPD )
• tussive fremitus ( is a vibration felt on the chest when the patient cough )
PURCUSSION
• Resonance
• Dull or flat ( if fluid )
• Hyper resonance
• Tympanic ( if gas occur )
AUSCULTATION
• STRIDOR : a harsh vibrating shrill sound produced during respiration when there is completely
airway obstruction. Management – intubation or tracheostomy.
• WHEEZES : a musical sound or whistling sound commonly heard during expiration ,when air is
passing through the partially obstructed airway passage. Example asthma.
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• Beta 2 Agonists : Terbutaline, Ritodrine, Salbutamol, Fomoterol.
• CRACKLES : sound heard when air is passing through the fluid filled alveoli example-
pulmonary edema. C/M cyanosis. Management – diuretics and mechanical ventilation
• FRICTION RUBS ( heard in pleurisy . C/M knife like chest pain during respiration ) )
Chest X – ray
Suctioning
Bronchoscophy - visualisation of the larynx, trachea and bronchi with the help of an fiberoptic
bronchoscope
CHEST PHYSIOTHERAPY – applying percussion or vibration over the thoracic area and
loosening the lung secretion
POSTURAL DRAINAGE – use of gravity to drain secretion from segments of the lungs may be
combined with CPT
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● PH 7.35-7.45 HCO3- 22-26meq/l
● PCO2 35-45mm of Hg
● PO2 80-100mm of H
1. RESPIRATORY ACIDOSIS
❖ Causes; Hypoventilation, Copd, Pulmonary Oedema, ARDS.
❖ Ph Less Than 7.35
❖ Pco2 More Than 45
❖ P02 Less Than 80
❖ Hco3 More Than 26
❖ Management- treat the exact cause , mechanical ventilation position ( semi fowlers of
high fowlers )
2. RESPIRATORY ALKALOSIS
❖ Cause - Hyperventilation, Excessive Mechanical Ventilation, Anxiety, Pain, Panic,.
❖ Ph More Than 7.45
❖ Pco2 Less Than 35
❖ P02 More Than 80
❖ Hco3 Less Than 22
❖ Management – treat the exact cause and use re breather mask
3. METABOLIC ACIDOSIS
Causes- Lactic Acidosis, Keto acidosis (Dm, Starvation,), Kidney Failure, Diarrhoea, Addison’s
Disease , Ileostomy, Heat Stroke, Sepsis, INH, Rhabdomyolysis. Dehydration, liver cirrhosis. Over
intake of aspirin.
4. METABOLIC ALKALOSIS
❖ Causes- Vomiting, Bulimia Nervosa, Pyloric stenosis, Ng Tube, Laxatives, Loop
Thiazide Hypokalemia.
❖ Ph More Than 7.45
❖ Hco3 More Than 26
❖ Pco2 More Than 45
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❖ Management – drug carbonic an-hydrate inhibitor or HCL and treat the actual
cause
⮚ Step 1 – look at the PH . less than 7.35 acidosis and more than 7.45 alkalosis
⮚ Step 2 – look at the Pco2 . it is elevated or decreased. If the pco2 reflects opposite to ph then
its respiratory imbalance.
⮚ Step 3 – look at the Hco3- it is elevated or decreased . Hco3 reflects corresponding to ph then
its metabolic imbalance
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▪ PRINCIPLES OF THE CHEST TUBE - Gravity, Under Water Seal, Suction.
▪ Monitor the chest drain is properly functioning. Water oscillate is denoting the tube is
properly functioning. Also known as ( fluctuation of the tube ). The exact meaning is
bubbles present inside tube move inward during inspiration and move outward during
expiration. if water oscillates is absent that means the tube is obstructed or blocked.
Immediately reported to the doctor
▪ The expected drain amount is 70 – 100 ml per hour . normal colour is dull red in
colour. Bright red abnormal
▪ If the chest drain is inserted for removal of air: intermittent bubbling,tidalling,
fluctuation indicate properly functioning but continuous bubbling indicate air leakage
and report to the doctor.
▪ Apply pressure dressing over the incision area.
▪ Instruct the client to practice deep breathing and coughing exercise.
▪ Keep petroleum gauze pad dressing and artery forceps always at the bedside
▪ During care accidentally if the tube is come out the best nursing intervention is
immediately cover the area with petroleum gauze pad dressing and then report to the
doctor
▪ If Icd is detatched from water seal chamber, dip the distal end in sterile water.
▪ When ever shifting for x ray place the drainage bag below the body level and during the
time of x- ray unclamp the tube.
▪ During chest tube removal instruct the client to practice valsalva maneuver
▪ Monitor complication
▪ 1. Tension pneumothorax
▪ 2. Subcutaneous emphysema- accumulation of air beneath the skin. C/M crepitus on
palpation. Management needle puncturing.
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TUBERCULOSIS
• Cause - Mycobacterium Tuberculosis ( group – acid fast bacilli ) it is a Aerobic bacteria.
• Epidemic disease
Location – can occur anywhere in the body example spine ( pots spine ), meanings, kidney, bone ,
intestine. Because for the growth of organism only oxygen is needed . in lungs infection most
commonly affect upper lobe where oxygen concentration is high.
CLINICAL FEATURES
• Fever, Night Sweats, Productive Cough, client shows rales respiration/ popping sound
DIGNOSIS
• HISTORY & Physical examination
• MANTOUX TEST
⮚ It is a intra-dermal skin sensitivity test ( site – inner surface of upper 1/3 rd of the forearm on
the left hand )
⮚ Using 26 G NEEDLE
⮚ Amount 0.1 ML
⮚ If redness or itching occur that means allergy with PPD not positive mantoux test
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⮚ Palpable Raised Area denoting positive
● 5mm 0r More; HIV , Person With Recent Contac With A Tb Pt, Organ Transplanted, X –Ray
Findings.
● 10mm Or More; Drug Abuser, Dm , CKD ,Low Body Weight, Child Less Than 4,Health
Care Workers.
● 15mm Or More; Person With No Risk Factor.
⮚ Reason for false positive test – expected those who are taken BCG. AND after TB attack
mantoux remain positive for life long.
PREVENTION
• Isolation - NEGATIVE PRESSURE ROOM ( always close the doors and windows ) & use
N95 MASK ( when ever suspecting use the patient and its confirmation situation both
patient and health care provider )
TREATMENT
● DAILY DOSE
✔ Streptomycin, rifampicin
✔ Ethambutol, pyrazinamide
✔ isoniazid
RIFAMBICIN -Instruct the client to take the tablet in early morning with
empty stomach.
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- urine colour become orange on next day onwards
- Hepatic toxic drug so monitor LFT frequently
ETHAMBUTOL Side effect – optic neuritis, colour vision, red- green colour
blindness
PYRAZINAMIDE -hepatotoxic
- instruct the client to take much more water otherwise gout
like symptoms develop
Second line drug - gentamycin ( oto-toxic and nephrotoxic ), amikacin ( nephrotoxic in old age ),
tetracycline ( in less than 12 year can cause nephro toxicity and oral syrup can cause tooth stain.
) tetracycline side effect – visual changes,blurred vision,decrease colour perception
● Nursing diagnosis-
● Impaired gas exchange
● ineffective airway clearance
PNEUMONIA
• Inflammation of the Lung parenchyma cells.
• Risk group - immune suppressed ( old age , under five children , performed organ
transplantation because they are taking immune suppressed tablet for to prevent rejection )
TYPES OF PNEUMONIA
1. CHEMICAL PNEUMONIA
• It is two types
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⮚ ventilators associated pneumonia (VAP) – PRECAUTIONS ( head end elevation, closed
suction, mouth care, use anti- embolism stockings, H2receptor or PPI , avoid administer
humidified oxygen
⮚ iatrogenic pneumonia – health care induced pneumonia due to lack of aseptic technique
• Risk group - over crowded population . the cause is mycoplasma pneuminae (no cell wall )
5. HYPOSTATIC PNEUMONIA
Mainly occur in bed ridden patient due to pooling of secretion in the lungs. Management is use
spirometry and change position frequently.
PREVENTION
• Pneumococcal Vaccine ( administer every five yearly . this vaccine safe in old age )
• Streptococcus Pneumonia
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MANAGEMENT
PULMONARY EMBOLISM
❖ Any obstruction or block in to the pulmonary artery ot its branch
❖ CAUSES –
❖ thrombus , emboli,
❖ fat, air, vegetation,
❖ tumour . the main reason for emboli is DVT.
❖ ASSESSMENT-
✔ initial feature is restlessness, apprehension
✔ cough, chest pain
✔ cyanosis, crackles
✔ haemoptysis ( pink colour frothy sputum)
✔ petechia or ecchymosis present at below the axila or over the
chest.
❖ Diagnosis- pulmonary angiography.
❖ MANAGEMENT ( order is important )
▪ Inform to the rapid response team or cord blue or doctor.
▪ High fowlers position
▪ Oxygen administration
▪ Monitor lung sound
▪ Monitor ABG – result respiratory acidosis
✔ Administer anti coagulant- heparin followed by warfarin
✔ Surgical management – embolectomy
✔ Nursing diagnosis- impaired gas exchange
Effect
⮚ 1. Rib fracture
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❖ Single rib fracture . it result from blunt trauma
❖ 5-10 ribs most vulnerable. Because least protected by muscles.
❖ Clinical features – pain at the site that increases with inspiration, client splint the site ,
shallow respiration
❖ Management – high fowlers position. Pain medication. Ribs usually unite
spontaneously . perform splint the chest during breathing.
⮚ 2. Flail chest
❖ Multiple Adjacent Rib Are Broken In Multiple Places
❖ Signs & Symptoms - Dyspnoea, Chest Pain, Paradoxical Chest Wall Movement,
Poor Air Movement
❖ MANAGEMENT- Definitive management, Positive –pressure ventilation may be
needed ( mechanical ventilation )
PNEUMOTHORAX
Accumulation of air in pleural space
TYPES
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DIAGNOSTIC TEST – X- ray
RESPIRATORY FAILURE
✔ It is condition due to other lung disease or disorder
✔ Occurs when insufficient o2 is transported to the blood or inadequate co2 is removed
from the lungs and the clients compensatory mechanism fail.
✔ pao2 less than 60mm of hg. hypoxemia (normal 95-100) and Paco2 more than 45
hypercapnia
✔ management. – treat the exact cause . intubation and mechanical ventilation
Clinical features
Clinical features
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❖ Productive Cough ❖ Cough
❖ Dyspnoea ❖ Barrel Chest
❖ Clubbing ❖ Tripod Position
❖ Crackles ❖ JVD
❖ Dull ❖ Clubbing
❖ High Fremitus ❖ Tachycardia
❖ Cyanosis ❖ Wheezing
❖ JVD ❖ Dyspnoea
❖ PFT ❖ Weight Loss
❖ Pursed Lip Breathing
❖ Anxious
❖ Hyper resonant
❖ Hoover’s Sign Inward Movement Of
Lower Rib Cage During Inspiration.
COMPLICATION
✔ Pulmonary insufficiency
✔ Pulmonary hypertension
✔ Cor-pulmonale ( enlargement and weakness of the right side of the heart )
✔ Cardiac dysrhythmias
✔ Respiratory acidosis
MANAGEMENT
✔ Administer 1-2 L oxygen via nasal canula if the Spo2 is less than 90% ( normal SPO2 in
COPD 88-92 % and normal person 94-98% ). If more oxygen is administered it will
suppress the hypoxic drive.
✔ Position – in COPD – High fowlers and in emphysema – semi fowlers position
✔ Chest physiotherapy followed by postural drainage or suctioning
✔ Take more water. It will help to loosening the secretion
✔ Administer bronchodilator followed by steroid. When ever the symptoms is subside first
stop steroid then bronchodilator. After oral steroid administration clean the mouth with
water otherwise steroid can precipitate in the mouth that can cause fungal infection .
example oral candidiasis .clinical feature is white patches in the mouth . drug of choice
is nystatin
✔ Instruct the client to practice pursed lip breathing./ diaphragmatic or abdominal
✔ Avoid smoking
✔ Avoid allergens and early treatment of respiratory tract infections.
✔ VACCINATION- every five yearly pneumo cocci vaccine and yearly influenza vaccine
✔ DIET - high caloric, high protein and avoid hot cold spicy and gas forming food
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BRONCHIAL ASTHMA
⮚ It is a intermittent reversible airway disease
⮚ Cause – allergy ( antigen antibody reaction or hypersensitivity. )
⮚ Example of allergen ( antigen ) - exercise, occupational exposure, pollens, dust, drugs. –
aspirin NSAID, Beta adrenergic blockers
⮚ Pathophysiology –
o 1. Allergen is entering the body
o 2. our immune cell especially mast cell is releasing the antibody like histamine for to
destroy the allergen.
o 3. Antigen and antibody reaction occur. Due to this reason the bronchial inflammation
and broncho spasm develop
o 4. So the airway is partially obstructed and breathing difficulty develop
⮚ Clinical features
o Wheezing
o Pulses paradoxes ( a large fall in systolic BP ,and pulse volume when the patient
breath in minimum 10 mmhg or more . )
o IgE level elevated
o Increase eosinophil count
o Child maintain tripod position
o Cough, chest tightness, cyanosis
o Absent or diminished lung sound
CLASSIFICATION
⮚ Mild intermittent – symptom less or equal to 2 times per week. Exacerbations are brief
.hours to days .intensity of exacerbations vary. Nocturnal symptoms occur twice a month.
⮚ Mild persistent – symptoms greater than 2 times per week. But less than one time /day.
exacerbations may affect activity. Night time symptoms more than 2 times per month .
⮚ Moderate persistent – daily symptoms. Exacerbations at least 2 times per week and may last
for days. Night time symptoms more than one time per week. Exacerbations affect activity.
⮚ Severe persistent. – continous symptoms. Limited physical activity. Frequent exacerbations.
Frequent night time symptoms.
MANAGEMENT
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GOAL – short term goal- maintain SPo2 more than 96% and maintain the patent airway
STEROIDS
⮚ Example - Dexamethasone
⮚ Action - Anti Inflammatory
⮚ Adverse Effects; Acne, Weight Gain, Depression, Hypertension, Cataract, Peptic Ulcer,
Osteoporosis, Hyperglycaemia, Psycosis, Candidiasis, Hypokalemia, Hypocalcaemia,
Hypernatremia, Cushing Syndrome.
Key points
✔ Pleural effusion means pleural fluid more than 200ml at pleural cavity
✔ Collection of pus in the pleural cavity is known as emphyma. The pus converted to solid form
is known as fibrothorax. The management is decortications
✔ Inflammation of pleural cavity is known as pleurisy. Management high fowlers and turn
towards the affected side and splint the chest while coughing and breathing.
✔ Legionnaires disease- acute bacterial lung infection caused by legionella pneumophilia. It is a
waterborne disease. Drug of choice erythromycin.
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✔ Influenza – two types H5N1 & H1NI. Drug of choice tamiflu or oseltamavir.
✔ Histoplasmosis – fungal lung infection caused by histoplasma capsulatum. Infection same
like pneumonia. Drug of choice amphotericin-B . side effect of the drug is nephrotoxicity.
✔ Mononucleosis 0r kissing disease – acute viral infection caused by ebstain barr
virus.infection affected to lungs and spread through saliva. Main clinical feature night
swetting.lumphedema. complication splenomegaly so take precaution to prevent splenic
rupture
✔ ARDS – collection of fluid in the alveoli. Priority nsg diagnosis is impaired gas
exchange.
GASTROINTESTINAL SYSTEM
FUNCTIONS
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ANATOMY
❖ UPPER GI TRACT – mouth to stomach ( it include lip, teeth, tongue, palate, pharynx.
Salivary gland ( saliva contain ptyalin enzyme), Epiglottis )
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1. Inspection
2. Auscultation
3. Percussion
4. Palpation – palpate the right lower quadrant
first and palpate the painful area at last
► STOOL CHARACTER
⮚ Malena – it means black color stool denoting dark bleeding(upper)
⮚ Hematochezia-it means fresh blood in stool or bright bleeding(lower)
⮚ Fecal Occult Blood (Guaiac Test)- to rule out occult blood.
⮚ Red Currant Jelly Stool- intussuception
⮚ Ribbon Like Stool- hirschpung’s disease
⮚ Steatorrhea- fat in the stool
⮚ Blood And Mucosa
⮚ Gray Or Clay ( colicystitis and colilithiasis )
⮚ Rice Water stool - cholera
⮚ Pea Soup stool - typhoid
► Asterixis (Flapping Tremor)- liver cirrhosis
► Xanthelasma (is a deposition of yellowish cholesterol rich material that can appear around
eye )
► Xanthoma ( is a deposition of yellowish cholesterol rich material that can appear anywhere in
the body )
► Caput Meduca- dilated veins in abdomen
► Spider Angioma(Spider Naevus)
► Gynecomastia
► Palmar Erythema
► Jaundice
► Cullen Sign- ecchymosis in peri umbilical area
► Turner’s Sign- ecchymosis in flank area
► Edema
AUSCULTATION
PERCUSSION
ENEMA
❖ Administration of solution in to the rectal area,
❖ Purpose – laxative , nutrient, analgesic , antipyretic, sedation.
❖ Position –left lateral position with right knee hyperflexed or left sims position (purpose is to
drain the enema fluid by its gravity
❖ Self enema position- lithotomy ( supine with hip and knee flexed) or semi prone position.
❖ Oil enema position trendelenberg position.
❖ Enema solution temperature ( adult = 40 – 43degree )and ( infant 37 degree )
❖ Large volume enema (maximum 100-250 ml at atime )
● The rectal tube should insert 6.6 – 8.8 CM or (3 - 4 inch )
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● The enema bag should be hang at a height of 18 – 22 inch.
● During enema if pain occur - 1. Reduce the height of enema solution.2. Stop or clamp
the enema tube
● After subsiding pain slowly restart.
Example - height 6 feet 8 inch. Weight 120 lbs( pound ) find the BMI
ABDOMINAL
QUADRANTS
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GASTRO ESOPHAGEAL REFLEX DISEASE
⮚ Stomach content regurgitate in to the oesophagus
⮚ Causes – poor development of cardiac sphincter, stimulant food items, abnormal intestinal
contraction ( motility disorder )
⮚ Clinical features
● Pyrosis ( heart burn )
● Globus ( something in throat feeling )
● Dyspepsia, regurgitation
● Hypersalivation/ water brash
● Odenophagia ( painful swallowing )
● Vomiting
Management
GASTRITIS
⮚ Inflammation of the mucous membrane of the stomach
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⮚ DIAGNOSTIC evaluation - endoscopy
o Left lateral position
o Administer atropine ( for to decrease the secreation ) and glucagon ( as a muscle
relaxant )priorly
o After procedure before giving anything to mouth check the gag reflex
⮚ MANAGEMENT
o Put The Client NPO till symptom subside.
o After symptom subside Initially administer clear water
o Avoid administer stimulants to the client.
o Antibiotics- clarythromycin and metrogel
o Administer syrup sucrafen – it work as a mucosal barrier protectant
o H2receptor ( rantac ) or PPI (omiprazole ) both drug will help to decrease the
production of HCL OR administer antacid ( gelucil ) it will neutralise the gastric
secretion.
o Bismuth salt or pepto-bismol
o SURGERY – gastrectomy or billroth 1 & 2 procedure
► GASTRIC
► DUODINAL
► OESOPHAGEAL
► CURLING ULCER ( is an acute gastric erosion resulting as a complication of burn. Due to
decreased plasma volume leads to ischemia and necrosis )
► CUSHING ULCER. ( due to increased ICP )
DIGNOSIS
Post operative intervention after abdominal surgeries ( both adult and child )
Most commonly surgery is perform under general anaesthesia.
First 24 hour complete bed rest. After that the client can ambulate.
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► Bleeding( bleeding is the most common complication after any surgeries ) , diarrhoea,
hypoglycemia
► DUMPING SYNDROME
⮚ The rapid emptying of the gastric content in to the small intestine leads vertigo,
palpitation and giddiness
⮚ Clinical features – symptoms occur after 30 minutes meal
o Borborgymi ( loud gurgles in the abdomen indicate hyper peristalsis )
o Abdominal cramping, feeling of abdominal fullness
Management.
Lie down after the meals
Avoid fluid between the meals
Provide high fat, high protein & low carbohydrate diet
Administer anticholinergic drugs
► PERNICIOUS ANEMIA ( vitamin B12 deficiancy ) ( refer pediatric hematology page
no 152 )
CHOLECYSTITIS
⮚ Inflammation of the gall bladder
⮚ Cause – cholelithiasis( stone present in the gall bladder )
⮚ Risk factor for cholelithiasis – fatty, female, fertile client, after forty age, ( due to increase
estrogens) Pregnancy, use of oral contraceptives, diabetes mellitus ( because in DM bile
production is high )
CLINICAL FEATURES
⮚ Right hypochondral pain radiating to the right scapula 2- 4 hours after fatty meal that
persist up to 6 hours ( BOAS SIGN )
⮚ Positive Murphy sign- when palpating lower liver border, patient shows breathing
difficulty
⮚ steatorrhoea ( accumulation of fat in stool )
⮚ indigestion, jaundice with prurities
⮚ grey or clay coloured stool
⮚ hypo active bowel sound
⮚ fever with chills
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⮚ nausea, vomiting, anorexia, dehydration
DIAGNOSIS – ERCP ( endoscopic retrograde cholangio pancreatography ) ,USG ,CT- scan
MANAGEMENT
APPENDICITIS
⮚ Inflammation of vermiform appendix
⮚ Cause - any kinking or obstruction in to the appendix
⮚ Clinical features
● Mild fever
● Constipation or diarrhea
● nausea, vomiting, anorexia, dehydration.
● Hamberger sign-physician provides favorite food for the patient, if patient consumes
the food it is consider other than appendicitis, a positive sign indicates patient decline
the food
● kochers sign – peri-umbilical pain that descent to the right lower quadrant or pain at
the MC-burneys point .
● positive dunphy sign – coughing can causing abdominal pain.
● Rovsing sign – when palpating to the left side of abdomen pain present at the right
side
● Psoas sign- forceful extension of thigh leads to severe right lower abdominal pain
● Rebound tenderness – applying pressure on the abdomen ,and after releasing pressure
abdominal pain will be develop .
● Murphys traid – fever, N/V, pain in right lower abdomen.
● Obturator sign
DIAGNOSIS EVALUATION
PANCREATITIS
● Inflammation Of The Pancreas
MANAGEMENT
⮚ Diagnosis (Serum Lipaseis increased )
⮚ High Protein Diet. Avoid heavy meal
⮚ Administer pancreatic enzyme with each meal
⮚ Do not administerpancreatic enzyme in NPO perio
⮚ H2 receptor / PPI
⮚ P- PAIN : avoid morphine because chances of metabolic acidosis,( dilaudid, tramadol
can give
⮚ A- antispasmodic drug
⮚ N – NPO/NGT suction – pancreas to rest and TPN ( total parenteral nutrition )
⮚ C – calcium replacement
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⮚ R- replacement of fluid and electrolyte
⮚ E – endocrine (insulin ) exocrine (amylase and lipase with food ) replacement
⮚ A- antibiotics
⮚ S – steroids during acute attack
⮚ Surgical management – pancreactectomy and wipples procedure ( complication –
hyperglycemia
⮚ Complication of pancreatitis is – acute pneumonia
LIVER CIRRHOSIS
Nodule formation and scaring of the liver
Clinical features
Azotemia(high Ammonia) COMPLICATIONS
Asterixis,
fetor hepaticas ⮚ Hypertension
spider angioma ⮚ Pleural effusion
oedema ( generalized ) ⮚ Ascitis
⮚ Metabolic acidosis
⮚ Bleeding
⮚ anemia
⮚ Portal hypertension
⮚ Esophageal varices ( C/M – black tarry
stool )
⮚ Hemorrhoids
⮚ Caput meducae
⮚ Hepatic encephalopathy due to peak
ammonium concentration
DIAGNOSTIC EVALUATION
⮚ Hypernatremia
⮚ Heperkalemia
⮚ Hypercalcemia
⮚ Increase bilirubin
⮚ Increase ammonium
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MANAGEMENT
HEMORROIDS
⮚ Dilated varicose veins of the anal canal
⮚ Cause – portal hypertension, constipation, pregnancy.
⮚ Clinical feature – bright red rectal bleeding with defecation, rectal pain and itching.
⮚ Management
● Encourage high fiber and fluid
● Administer stool softeners
● Avoid prolonged sitting
⮚ Surgery ( hemorrhoidectomy, sclerotherapy, minimally invasive procedure of
hemorrhoids ) – during surgery provide lithotomy position
⮚ Post operative intervention
● Position- prone or lateral and avoid supine position
● First 24 hour cold application
● After 24 hour hot sits bath ( temperature 43degre or 110 degree Fahrenheit)
● Instruct the client to limit sitting for a short period
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⮚ Management
● Drug - anti diarrheal, antibiotics, antispasmodic.
● Maintain NPO
● IVF + Electrolyte,
● complete bed rest
● Total parenteral nutrition ( TPN ) - always on IV controller, and frequently
monitor hyperglycemias. Tubing use single use ( maximum 24 hour) & monitor
daily weight .
● Following acute phase diet progress from clear liquids to low fibre. Instruct the client
to avoid gas forming food, milk products, whole wheat, grains, nuts, raw fruits,
vegetables , pepper and alcohol should be avoid.
● Diet elementary diet – it means diet containing all micronutrients and easily
absorbing
● Close monitoring any complication
● Monitor complication- bowel perforation leads to peritonitis ( for detail refer
appendicitis )
COLOSTOMY AND ILEOSTOMY
❖ An stoma create in to large intestine is known as colostomy. In to the small intestine is
known as ileostomy.
❖ PRE OPERATIVE INTERVENTION.
✔ Administer laxative or enema.
✔ Instruct the client to eat a lower fiber diet for 1 – 2 days before surgery.
✔ Administer intestinal antiseptics and antibiotics ( metrogel )as prescribed to clean the
bowel and to decrease the bacterial content of the colon. ( continuous antibiotic
administration can cause bleeding in post operative period due to damages of the
intestinal flora )
❖ POST OPERATIVE INTERVENTION
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✔ Initially performing hydrocolloid dressing or wet dressing ( below wet above dry
cotton ) for moisture.
✔ Place a pouch system in the stoma as soon as possible.
✔ Monitor the stoma daily.
● Normal stoma colour is bright red, pink or shiny.
● White colour indicate fungal infection
● Pale pink , peach colour indicate anaemia.
● Purple, black or blanching colour indicate decrease circulation to the stoma
indicate tissue necrosis. Immediately report to the doctor.
✔ Give priority for ileostomy patients ( extra skin layer protection). And apply skin
barrier protecting agent over the stoma. Example karayagum powder or Zinc Oxide.
✔ Post operatively avoid gas forming food and odour forming food. ( cabbage. Broccoli,
cauliflower, egg yolk). During colostomy care if smell occur first ask the client what
type of food he is taken
✔ Colostomy irrigation
● Character – Luke warm tap water ( temperature 106- 110 )
● Amount- 500 to 1000 ml. colostomy irrigation stimulate bowel emptying.
● Position of the client- ambulatory same position sitting in toilet. Bed redden
towards affected side.
● Irrigation tube insert 2-3 inch inside the stoma. And irrigation perform after 1
hour meal.
● For getting the better result of colostomy irrigation slightly massage the
abdomen.
● Avoid frequent irrigation it leads to fluid and electrolyte imbalance.
● During irrigation if pain occur immediately clamp the tube.
● After colostomy the client can perform all normal activities including
swimming.
● Oral feeding can start 4-6 days later colostomy ( this is the minimum time for
stoma setting.)
● Take 6-8 week time for complete maturation of stoma.
● Should not apply antibiotics directly over the stoma.
● Nursing diagnosis- disturbed body image.
HEPATITIS
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DIGNOSIS
Hepatitis B- serum hepatitis . most highly occur and most commonly occur through blood .
incubation period 6-24 weeks .complication- cirrohosis, hepatocellular carcinoma, fulminant
hepatitis.
Hep D- it is the complication of hep B. and occur co infection along with hepatitis B
PARACENTESIS
⮚ Draining of fluid from the abdominal cavity . it is the management of ascitis
⮚ Pre procedure intervention. Empty the bladder before procedure
⮚ Bedredden patient provide fowlers position and conscious patient positioned upright on the
edge of the bed with the back supported and feet resting on a stool
⮚ Before and after procedure monitor the weight
⮚ After procedure observe hematuria. It indicate blader puncture
⮚ Large amount of fluid will drain at a time this can cause hypovolemic shock
Key points
● Intetestinal obstruction – the clinical feature is silent abdomen or absent peristaltic
movement. priority management fluid and electrolyte management.
● Anoscophy position – left lateral or knee chest
● Proctoscophy – visualisation of the sigmoid colon. position providing during examination is
left lateral with right leg bend
ENDOCRINE SYSTEM
Functions of endocrine system
Note - three glands is equally responsible for to maintain the hormone become normal .
HYPOTHALAMUS- it is situated at the base of the brain. ( master of master gland ) is producing
all type of releasing and inhibiting hormone
GROWTH DISOREDER
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THYROID GLAND (situated at the anterior part of the neck )
� It produces:
� Thyrocalcitonin- which helps in deposition of calcium in bones ( ie decrease blood calcium level
)
THYROID DISORDERS
� HYPOTHYROIDISM � HYPERTHYROIDISM
� Condition due to hypo secretion of thyroid � Condition due to hyper secretion of thyroid
hormones (decrease BMR) hormones (INCREASED BMR)
� TYPES
� Types � Primary- increase –T3,T4 &decrease
� Primary- decrease T3,T4 & INCREASE TSH,TRH
TSH,TRH � Secondary- increase T3,T4,TSH &decrease
TRH
� Secondary- decrease T3,T4,TSH &increase � Tertiary- increase – T3,T4,TSH,TRH
TRH � CAUSES
� Manipulation during thyroidectomy
� Tertiary- decrease T3,T4,TSH,TRH
� Thyroid tumour
� CAUSES � Iodine deficiency
� S/S
� Autoimmune or hashimotor thyroididtis � Increase T3 &T4
� Decrease TSH
� Use of lithium & aminodarone
� Weight loss, soft skin, silky hair
� S/S � Intolerance to heat
� Decrease T3 &T4 � Hypertension & tachypnoea
� Increase TSH � Tachycardia & palpitation
� Weight gain ,fatigue ,hard skin � Diarrhoea
� Intolerance to cold � Insomnia, goitre
� Hypotension � Tremors, diaphoresis, diplopia
� Bradycardia & bradypnoea � Chemosis (redcolour eye )
� Memory changes � Personality changes
� Menstrual irregularities � Exophthalmos (protrusion of eyeball)
� Chances of abortion in pregnancy
� Cardiac enlargement prone to develop CHF
� Constipation
� Dry coarse hair.
� Myxoedema (puffiness over face and Around
eyes) � MGT
� MGT � Thyroidectomy
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� Safety. � Provide cool environment
� Provide warm environment � Decrease the fibre intake.
� Increase the fibre intake. � Administer iodides, beta blocker, propyl
� Administer levothyroxine sodium lifelong.( thiouracil (PTU)
should take in early morning with empty � S/E of PTU
stomach. Long term use can cause � Agranulocytosis
osteoporosis ) � Bradycardia
� S/E
� Tachycardia, Palpitation
� Complication � Complication
� Myxoedema coma- life threatening due to � Thyroid storm- life threatening due to extreme
extreme low thyroid hormones high thyroid hormones
� Hypothyroidism is not treating early then � Causes – manipulation of thyroid gland during
chances of mental retardation surgery,infection and stress
� Causes – infection, surgery,sudden stoppage � C/M –fever, tachycardia, nausea
of LTS, use of sedatives& anesthetics vomiting,irritability
� C/M – above said clinical features & features � MGT
of shock � Administer iodides, beta blocker, propyl
thiouracil (PTU) and glucocorticoids before
� MGT thyroidectomy
� Priority for airway � Permanent management thyroidectomy.
� Administer warm IV isotonic solution
� Iv – LTS
� PRE-OP intervention
� Administer PTU, POTASIUM IODIDE, beta blocker and glucocorticoids to prevent thyroid
storm during surgery
� POST OP intervention
� Monitor Respiratory status ( first priority for airway), Keep O2,suction tracheostomy set at the
bed side
� Semi fowlers position & avoid supine position ( supine position can cause laryngeal oedema )
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� Tetany or hypocalcaemia due to accidental injury to the parathyroid gland. If occur prepare to
administer calcium gluconate.
HYPOPARATHYROIDISM HYPERPARATHYROIDISM
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1. Glucocorticoids (cortisol, cortisone,corticosterone)- 1. regulate or decrease carbohydrate,
protein metabolism. ( which means increase blood glucose ) 2. suppresses immune
response.
� CAUSES � CAUSES
� Removal of pituitary or adrenal gland � Pituitary tumour.
� S/S � Overuse of steroid
� Hypoglycaemia
� Weight loss � S/S
� Fatigue, weakness. � Hyperglycaemia
� Hyponatremia-hypotension.
� Hypovolemia
� Hyperkalaemia
� Hypercalcemia
� Bronze pigmentation of skin � Weight gain, muscle wasting and weakness
� Menstrual irregularities in female &impotence in � Moon face, buffalo hump
men � Truncal obesity or centralised obesity with thin
� MGT extrimities
� Administer steroid lifelong.(side effect – � Pendulous abdomen
hyperglycemia,cataract,osteoporosis ) � Hirsutism( abnormal growth of hair in female
� Diet –high calorie ,protein,CHO faces )
� Protect the client from infection � Plethora ( redness over cheek )
� Avoid sedatives ,anesthetics,barbuterates � Hypernatremia-hypertension.
� Hypervolemia-oedema
COMPLICATION-
� Hypokalaemia
Addisonian crisis ( absolute deficiency due to � Hypocalcaemia- tetany
surgery, infection,sudden stoppage of steroids ) � Fragile skin that easily bruises
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ADRENAL MEDULLA ( inner core of adrenal gland )
It produces catecholamines (epinephrine and norepinephrine), it is the part of sympathetic
nervous system which helping for vaoconstruction and increase HR & BP and which helps in
regulating vitals
PHEOCHROMOCYTOMA
� Condition due to hyper secretion of catecholamines by adrenal medulla
� CAUSES
� Adrenal tumour
� S/S
� Paroxysmal sustained hypertension
� Tachycardia.
� Hyperglycaemia.
� Palpitation
� D/E - VMA URINE TEST (VANILLYLMANDELIC ACID) in 24hrs urine ( normal value
14mcg/100 ml more than this value pheochromocytoma )
� Biopsy is contra indicated because chance for rupture
� Can take CT,MRI
� MGT
� Avoid beta blockers ( because this can cause hyperglycemia )
� Administer calcium channel blocker and alfa adrenergic receptor blockers
� Adrenalectomy
⮚ Beta cells – secrete insulin ( function – it decrease blood glucose level by shifting
blood glucose in to cells. Shift potassium in to cells. It helps for glycogenolysis –
conversion of glycogen in to glucose )
⮚ Delta cells – produce somatostatin – which suppresses alfa cell and beta cells
DIABETES MELLITUS
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� Metabolic disorder ( decrease level of CHO,FAT,PROTEIN metabolism ) due to decrease or
absence of production of insulin by the pancreas.
� TYPES
� TYPE-I (IDDM) or juvenile DM . auto immune disorder. Mainly occur less than 13 years. In
this absolute deficiency of insulin
� TYPE-II (NIDDM) – in this type insulin production is present either adequate ( if adequate the
demand of body is high eg. Obese condition ) or the production of insulin is relatively less. So
anyway with the help of an that insulin FAT & PROTEIN METABOLISM 0ccur but CHO
metabolism is interrupted .mainly occur after 35 years ( middle adulthood ), hereditary
� R/f of type II DM
� S/S
� Polydipsia.
� Polyphagia.
� Delayed wound healing ( because the glucose mediated chamber is promoting bacterial growth ).
& decreased circulation to the feet ( due to increased blood viscosity )
� Blurred vision
� Recurrent infection
� D/E
� HBA1C- to detect at least 3 months of glucose control level.( it is the confirmatory test )
� ABOVE 6.5 DM
� MGT
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� Exercise at least 3 times in a week ( applicable only in type 2 )
� Diet ( low CHO, FAT and adequate protein )
� OHA-eg: orinase, tolbutamide, METFORMIN
� Contraindication of OHA
INSULIN
ꟷ Hypoglycemia
ꟷ Allergic reactions
● Local inflammatory reaction
ꟷ Lipodystrophy
● Hypertrophy or atrophy of SQ tissue r/t frequent use of same injection site.
Management- rotate the site of insulin injection
COMPLICATION OF INSULIN
� MGT- Administer extra snacks at bedtime or decrease the dose of bed time insulin .
COMPLICATION OF DM
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� HYPOGLYCEMIA
� CAUSE
� Excessive thirst
� Some drugs can cause hypoglycemia – aspirin, alcohol, sulphonamide, oral contraceptives,
monoamine oxidize inhibitors, ACE-inhibitors
� S/S
� Excessive hunger.diplopia,altered LOC
� Sweating, headache, palpitation.
� Slurred speech, tremors,
� Headache, confusion, seizure
� MGT
� Check the blood glucose level
� If conscious or shaky or responding administer 10-15gm of fast acting CHO (6-10 hard candies,
1 cup of a juice, 4 tsp of sugar, 1 tbsp. of honey)
� If the patient is not responding or unshaiky DEXTROSE 50 % 30-50ml
� If unconscious administers s/c or IM glucagon
COMPLICATIONS OF DM
TYPE 2 TYPE 1
● Retinopathy ● DKA
● Nephropathy
● Neuropathy
● CAD
● Cholilithiasis
● HGHNKS
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� CAUSES
� Illness, infection
� S/S
� Hyperglycaemia(300-800mg/dl)
� Ketonuria
� Cellular Dehydration
Precipitating factors
Infection, renal failure, MI, CVA, GI hemorrhage, Pancreatitis, CHF, TPN, Surgery, dialysis,
steroids
S/SX
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CLIENT EDUCATION
TYPE-I patient education.-1. Teach the patient how to adminster insulin.
FUNCTIONS
❖ maintain homeostasis of the blood and acid base balance
❖ excrete end product of protein metabolism
❖ control fluid & electrolyte balance
❖ excrete bacterial toxins ,water soluble drugs
❖ secrete rennin and erythropoietin ( rennin is produced from juxta glomerular kidney cell
& erythropoetinin is produced by fibroblast in the kidney )
IMPORTANT POINTS
● nephrons is the functional units of the kidney
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● the totalbladder capacity – 1 litre
● normal adult urine output – 1.5 litre/day ( have to maintain 30-50ml /hour )
● the inner lining of urinary bladder is covered by transitional epithelium
● creatinine is the end product of protein & muscle metabolism . increased level in the
blood indicate renal failure ( normal value – 0.5 – 1.5 mg/dl )
● BUN by product of proten metabolism in liver
● Normal urine specific gravity – 1.010 to 1.030
● Normal urine color- amber
● Urine specimen collect early morning. Amount 10 – 20 ml
● For urine culture sensitivity collect midstream urine specimen in a sterile container
● Cystocele – prolapsed urinary bladder, management kegel exercise
● Catheterisation
✔ Position ( male supine. Female – lithotomy )
✔ Over foleys catheter pseudo membrane occur, it’s a fungal infection. Drug of
choice fluconazole,cotrimoxazole
● 24 hour urine sample any one sample is missed again restart the procedure
● Renal biopsy position – prone ( after procedure – supine position, post procedure
monitor bleeding at ythe back of the body )
GLOMERULO NEPHRITIS
● destruction,inflamation, and sclerosis of glomeruli of both kidney occurs
● CAUSE - group a beta hemolytic streptococcus.
● Clinical features
✔ Proteinuria, edema
✔ Hematuria ( dark smoky cola colored red brown urine )
✔ Peri orbital edema
✔ H/O throat infection 2-3 week before
● COMPLICATION – pleural effusion, CHF, pulmonary edema,
● Management
✔ Anti- biotic
✔ Fluid restriction – 500-600 ml
✔ Daily weight and I/O charting
✔ Diet – high calorie, low protein, low sodium, low potassium
✔ Nursing diagnosis – fluid volume excess
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MANAGEMENT
● Anticolinergic
● Example-
● Atropine or benztropine
● Kegels exercise
MANAGEMENT
RENAL CALCULI
TYPES – nephro-lithiasis ( inside the kidney ) ,uro-lithiasis ( inside the ureter ) , cysto-lithiasis (
inside the urinary bladder )
Causes – purine food, increase calcium,increase vit,D, increase uric acid, immobilisation
Clinical features
● Renal colic which originates in the lumbar region and radiates around the side and down to
the testicles in men and to the bladder in women
● Ureteric colic which radiates towards the genitaliaband thighs
● Nausea and vomiting
● Diaphoresis and hematuria
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MANAGEMENT
MANAGEMENT
● ANTIBIOTICS –
SULFONAMIDE
● CITRUS JUICE
● INCREASE FLUID
● CLEAN PERINEUM
FROM FRONT TO
BACK
● USE COTTON
UNDERWEAR
❖ CAUSES
● AGE ABOVE 60, HIGH DHT ( dy-hydroxy testosterone ), OBESITY, DM.
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❖ DIGNOSIS - PSA ( prostate specific antigen more than 4 nanogram/dl ) – blood sample
❖ MANAGEMENT
✔ alpha adrenergic receeptor blocker (tamsulosin) or terazocin. It can inhibit the
contraction of smooth muscles.
✔ anti antrogen(finasteridin). It will help to decrease hormonal stimulation
❖ S/M - TURP
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RENAL FAILURE
It is slow progressive irreversible loss in kidney function with GFR less than or equal to 60ml/mt.
For 3 month or longer
TYPES
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MANAGEMENT – DIALYSIS
RENAL TRANSPLANTATION
Dietary restriction
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DIALYSIS PRINCIPLES
OSMOSIS movement of
solvent from
lower
concentration
to higher
concentration.
DIFFUSION diffusion
movement of
solute from
higher
concentration
to lower
concentration
ULTRA Pressure
FILTRATION needed for
shifting the
fluid
● Maximun No of dialysis in week – 3 .
● Complication of dialysis - diseqilibrium syndrome, air embolism, dialysis
encephalopathy
RENAL TRANSPLANTATION
Key points
⮚ Cystitis means inflammation of the gall bladder, causes – E-coli, enterobacter
⮚ Urethritis is inflammation of urethra
NERVOUS SYSTEM
CLASSIFICATION
⮚ Central nervous system
● Brain
● Spinal cord
⮚ Peripheral nervous system
● Spinal nerves ( 31 pairs )
● Cranial nerves (12 )
⮚ Autonomic nervous system
● Sympathetic nervous system
● Parasympathetic nervous system
a. Cerebrum
b. Brainstem
c. Cerebellum
Cerebrum:
Neuro transmitters
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⮚ Acetylcholine
⮚ Dopamine
⮚ Nor-epinephrine
⮚ Polypeptides
⮚ Serotonin
⮚ Amino acids
NEUROLOGICAL ASSESSMENT
Cranial nerves assessment
⮚ Normal pupil reaction – PERRLA ( pupils equally round and reacting to light and
accommodation
⮚ 3-5 mm pupil dilation considered as normal
⮚ Unilateral dilation of pupil indicate compression of third cranial nerve
⮚ Bilateral dilation of pupil indicate midbrain injury ( ominous sign )
⮚ Pin pointed or constricted pupil indicate Pons damage or poison or drug toxicity.
Assessment of posture
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Reason for decorticate posture
1. Non- functioning of
cortex
Diagnostic tests
a. CT- if contrast is used, must be assessed for allergy to iodine or sea food
Lumbar puncture
Myelogram
⮚ if gas is injected provide Trendelenburg position after procedure and if it is liquid based dye
elevate head and thorax
⮚ Cerebral arteriogram- assess the bilateral pedal pulses
EMG-
EEG (electroencephalography)
● Avoid stimulants and sedatives during the procedure, HEAD SHAMPOOING ( for
removal of oil
INCREASE ICP
Adult Children
Early signs Early signs
● Altered sensorium (restlessness, ● excessive vomiting
confusion, disorientation) or ● high shrill cry
altered LOC. ● tense bulged anterior
● Headache fontanels
● Projectile vomiting
● Irritation
● Cheyne stroke respiration
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Late signs Late signs
● cushing traid ● seizure
✔ systolic hypertension
✔ bradycardia
✔ increase pulse pressure
● Positive Babinski reflex
● Abnormal posture (decorticate,
decerebrate, opisthotonos
posture)
● Seizure
⮚ MANAGEMENT
✔ PRIORITY FOR AIRWAY
✔ Can administer morphine to the client. but the client should be on mechanical
ventilator. (because morphine is respiratory depressants.)
✔ Maintain the PAC02 normal or below normal. Hyper ventilation helps to this process
✔ Avoid nasal suctioning and hypoxia.
✔ Maintain the body temperature normal .because shivering can worsening icp.
✔ Limit fluid intake 1.2 litre per day
✔ Decrease environmental stimuli.
✔ Avoid Valsalva maneuver. & avoid coughing,sneezing,straining
✔ Elevate head of the bed 15- 30 degree not much more
✔ Avoid hip flexion and neck flexion
✔ Avoid Trendelenburg position
✔ Drug fibre rich for to prevent constipation
⮚ PHARMACOLOGY
✔ Drug of choice – osmotic diuretics eg. mannitol
✔ Anticonvulsive, corticosteroid for to decrease cerebral oedema.
✔ Muscle relaxant for prevent shivering
✔ Administer hypertonic solution and avoid hypotonic solution
✔ Syp. Defolac or lactulose for to prevent constipation
⮚ SURGICAL MANAGEMENT
✔ V P shunt, spinal tapping, endoscopic third ventriculostomy
⮚ NURSING DIAGNOSIS
✔ INEFFECTIVE CEREBRAL TISSUE PERFUSION
Causes
Transient Ischemic Attack (TIA)- it is a mini stroke with no dead brain tissue . it the warning sign
of stroke .and it is a temporary focal loss of neurological function caused by ischemia of one of the
vascular territories of the brain. Symptoms last for 24 hour and minimum for 5 minutes
Types of stroke
Signs/Symptoms
ASSESSMENT
F- fascial dropping
A- arm weakness
S- slurred speech
● Dysphagia
● Hemiplegia-one side body paralysis
● Unilateral neglect-avoiding affected side
● Homonymous hemianopsia-blindness on the same side of paralysis (management – instruct
the client to scan the room )
● Agnosia- inability to recognize familiar objects or person
● Apraxia-inability to carry out voluntary and skillful movements
● Proprioception alteration- client maintain abnormal posture so risk for injury.
● Aphasia-impaired communication
✔ Expressive – unable to understand what we said (management – provide one pen and
paper)
✔ Receptive – unable to understand what we said (management – often a written word
or use communication board)
✔ mixed
● Right side brain stroke – left side body paralysis
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● Left side brain stroke – right side body paralysis
Diagnosis- CT scan
Management
PREVENTIVE
COLLABORATIVE
Craniotomy
● prevention of infection
● monitor ICP and neurological status, HR
● provide midline neutral position of head
● prevent neck and hip flexion
● expect periorbital edema and ecchymosis of one or both eyes. if so apply cold compress.
● monitor the drain (30-50ml/Shift).
● provide range of motion exercises.
● administer coumadin for 3-6months
SEIZURES
⮚ Abnormal electrical discharge of the brain from the cerebral hemisphere
⮚ Type
● Generalized seizures (Tonic Clonic) Adult.- tonic clonic, Absent Seizure(Children),
myoclonic, atonic, febrile
● Partial – simple and complex partial
⮚ Stages
● Pre-ictal( aura) - before develop seizure the client body produce warning symptoms(
mainly in sensory form )
● Tonic spasm phase – stiffness of the body . the C/M are – client fall the ground from
sitting or standing position, opisthotonous posture, frothy discharge from mouth,
cayanosis, cease the breath,
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● Clonic spasm phase – jerking of the body C/M are – involuntary passage of urine and
stool, tongue or cheek bite with loss of consciuosness
● Post ictal phase - one sleep like stage , headache present
MULTIPLE SCLEROSIS
⮚ Demyelization Of Neurons Or CNS. It is a slow progressive disease
⮚ Causes – auto immune disorder, viral infection, usually occurs 20 – 40 years
⮚ Triggering factor- exposure to hot
⮚ Clinical features
⮚ MANAGEMENT
● To help relieve muscle spasm in a pt who has multiple sclerosis the nurse should
administer baclofen . side effect is tremor
● Avoid Hot Bath & perform regular exercise
● Exercise - Yoga In Ac Room
● Dignostic evaluation EMG
● Drug during exacerbation steroid eg:Iv Prednisone
● Administer immune modulators Interferon Beta 1 A(Betaferon)
● Client should avoid hot temperature it should exacerbate the condition
● Immune suppressants- avonex, betaserone,copaxone
● Diet- increase fluid, low fat, high fibre, food high in potassium, vit B12 , vit.c
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MYASTHENIA GRAVIS
⮚ Diagnostic test
o EMG CONFERMATORY TEST
● Ice test
● Tensilon test (Edrophonium chloride) – when ever administer tensilon if the
muscle strength is improving it means myasthenia gravis. If the client condition
is deteriorating that mean cholinergic crisis
● Tensilon - Atropine sulphate is the antidote for tensilon and is given to treat
cholinergic crisis
● Tensilon test side effect – ventricular fibrillation . so keep defibrillator at the bed
side before test
⮚ MANAGEMENT
⮚ Myasthenia gravis worsens with exercise and improvement with rest
⮚ Intubation & mechanical ventilation
⮚ Plasmapheresis
⮚ Drug of choice- Anti cholinesterase eg:Pyridostigmine, neostigmine, prostigmine
⮚ Antidote of anticholinestrase- Atropine sulphate.
⮚ Steroid
⮚ Immune suppressants
⮚ Exercise – blowing bubble exercise
⮚ Complication – myasthenia crisis , c/m – tachycardia,tachypnoea,cayanosis, boweland
bladder incontinence
PARKINSON’S DISEASE
⮚ Its a degenerative disease caused by depletion of dopamine
⮚ It is a basal ganglia disorder. Parkinson’s disease is usually caused by deficiency of
dopamine in the substantia nigra nerve
⮚ Risk factor – Wilsons disease( accumulation of copper in the cells ), encephalitis, repeated
head injury, encephalitis
⮚ Clinical features
a. Parkinson’s main signs are RAT (rigidity, akinesia, and tremors),
b. Resting Tremor, ( pill rolling )-
c. Mask Like Face,
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d. Festinating Gate.
e. Drooling of saliva from mouth
f. Bradykinesia( slow movement )
g. cogwheel rigidity( passive movement of limbs can cause severe joint pain ).
h. Monotonic speech ( speech quality is soft )
i. Camptocormia-bent spine syndrome(kyphosis).
j. Bladder incontinence (mgnt. Bladder retraining exercise )
k. Akinesia ( loss of muscle power )
⮚ MANAGEMENT
● SINEMET ( levo dopa+ carbi dopa ), bromocriptine, amantadine. Levodopa-
sideeffect is on-off phenomenon
● PHYSIOTHERAPY – passive range of motion exercise
● Prone position to facilitate posture
● Those who are taking anti Parkinson medicine should avoid vitamin B6 food
( pyridoxine ).
● Should avoid MAOI – chance for hypertensive crisis
● Increase fluid intake
● Diet – high caloric, protein, fibre rich soft diet
● Chances of depression associated with immobility
● Nursing diagnosis - impaired physical mobility, risk for injury
TRIGEMINAL NEURALGIA
⮚ Pain present in the fifth cranial nerve
⮚ Causes – compression of blood vessels, herpes virus infection, infection of teeth
⮚ Clinical features- dysphasia, severe pain on gums, nose, across the cheeks, situations that
stimulate symptoms like cold, hot, face washing
⮚ Management.
● Avoid hot or cool foods and administer fluids
● DRUG CARBAMAZIPINE
● Priority nursing diagnosis - acute pain.
BELL’S PALSY
⮚ Temporary paralysis of one side of the face due to injury to the seventh cranial
nerve(7th) cranial nerve . facial nerve
⮚ Cause – birth injury, trauma, meningitis
⮚ Clinical features – dysphasia, inability to close the eyes, loss of taste
⮚ management
● The major complication of bell’s palsy is keratitis (corneal inflammation) which
results from incomplete eye closure on the affected side.
● DARK ROOM
● STEROID & fascial exercise
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⮚ H/ O respiratory or GI infection2-3 week before
⮚ Ascending to descending paralysis
⮚ Diagnosis nerve conduction velocity
⮚ Management - Iv immune globulin IgG, PLASMAPHERESIS, INTUBATE
⮚ ALS is a condition in which there is a degeneration of motor neurons in both the upper and
lower motor neuron systems.
ENCEPHALITIS
⮚ Inflammation of brain parenchymal cells
⮚ Cause urbo virus
⮚ Drug of choice- Acyclovir (zovirax) is the drug of choice for herpes encephalitis
MENINGITIS
⮚ Inflammation of covering of brain
⮚ TYPES
⮚ PAYOGENIC – BACTERIAL – streptococcus, neisseria, hemophilus influenza type B
⮚ ASEPTIC – VIRUL – entero virus, varicella zoaster,
⮚ FUNGAL &PROTOZOAL
⮚ Risk factor- craniotomy, skull fracture, those who are living in crowded areas . eg dormitory
and prison
⮚ Mode of transmission: bacteria ( airborn/droplet ) virus ( direct contact )
⮚ Clinical features
Signs of meningeal irritation seen in meningitis include nuchal rigidity,
positive Brudzinki’s sign and
positive Kerning’s sign
seizure, increase ICP
⮚ Lumbar puncture
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HEADACHE ( common clinical feature along with neurological disease )
⮚ MIGRAINE. (high in Female. Increase In Morning, Unilateral, Aura, N/V, Photo & Phono
Phobia, 4-72 Hrs)
● DRUG OF CHOICE SUMATRIPTAN.
⮚ STATUS MIGRANITUS ( head ache more than 72 hours. Avoid –coffee , wine, pickle,
chocolate, cheese, sausage
HEAD INJURIES
⮚ It is trauma to the skull resulting in mild to extensive damage to the brain
⮚ Types
a. Open – scalp lacerations
b. Closed - concussion, contusion ( coup and counter coup injury )
c. Hematoma- EDH,SDH, ICH
d. EDH- it is associated with treating of the middle meningeal artery (most severe )
e. SDH- it is associated with tearing of vein
⮚ Clinical features
✔ Altered level of consciousness
✔ Increase ICP features
✔ Battle sign (post auricular or mastoid echymosis )
✔ Racoon eye (purple discoloration around the eye – management- cold application )
⮚ DIAGNOSIS
✔ CT,MRI
✔ If otorrhoea or rhinorrhoea occur perform – HALO RING/ CONCENTRIC RING
TEST (bloody discharge)
✔ If clear discharge perform beta transferin test
⮚ Management
✔ First aid
P-PROTECT
R- REST
I – ICE
C – COMPRESSION
E – ELEVATION
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SPINAL CORD INJURY
⮚ Trauma to the spinal cord causes partial or complete disruption of the nerve tract and neurons
⮚ EFFECTS OF SPINAL CORD INJURY
✔ Spinal shock- flaccid paralysis, loss of activity below level of the injury.
✔ Neurogenic Shock; C/M Hypotension, Bradycardia
✔ Autonomic dysreflexia- sudden increase in ICP in patients with spinal cord injury
above the level of T6 .it is due to full bladder or constipation.
✔ Features: severe thrombing headache,severe hypertension and bradycardia, flushing
above the level of injury, dilated pupil, sweating,.
✔ Management; 1. Assess for full bladder.2 provide semi to high fowlers position
✔ Quadriplegia
✔ Cervical injuries
● C2-C3 is usually fatal
● C4- respiratory difficulty
✔ Thoracic injuries- paraplegia
✔ Lumbar injuries- paraplegia
✔ Sacral injuries- neurogenic bladder
✔ Below the level of injury no sensation , no reflexes, no movement
✔ S2 injury ejaculation problem. S2-S4 erection and ejaculation problem
Priority nursing action
MUSCULOSKELETAL DISORDERS
OSTEOPOROSIS
⮚ Demineralization of bone is known as osteoporosis.
⮚ Osteoporosis is characterized by decreased bone mass and increased bone fragility.
⮚ Most commonly occur in to the wrist, hip, and vertebral column.
⮚ The condition same as hypercalcemia.
⮚ TYPES /CAUSES
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o PRIMARY- the causes are decreased calcium intake, poor vitamin D , old age ( males
due to deficiency of testosterone and in menopausal women due to deficiency of
estrogen).
o SECONDARY – the causes are alcoholism, drug induced ( steroids, LevoThyroxine
Sodium, anticonvulsants, aluminum containing antacids ) , malabsorption syndrome.
⮚ Clinical features
o Back pain occurs after lifting or bending.
o Back pain that increases with palpation
o Decline in height from vertebral compression
o Dowagers hump.( kyphosis).
o hypercalcemia
o pathological fracture
o renal stones
⮚ Management
o Drug of choice – calcitonin
o Bisphonates – example alendronate.
Action- it inhibit osteoclast mediated bone resorption there by increasing total bone
mass.
Side effect – esophagitis, ocular problems.
Contra indication – esophageal disorder, person who do not sit or stand.
Nursing responsibility- should be administered in empty stomach with one glass of
water and should remain sitting or standing and can take food after 30 minutes.
o Instruct the client to perform weight bearing activities for to reduce weight .eg
walking exercise.
o Diet high calcium , protein and vitamin D .
PLANTAR FASCITIS
Inflammation of plantar skin commonly seen in marathon runners due to
prolonged use of heal of the foot
Management - leg stretching exercises, use cushion shoes
RHEUMATOID ARTHRITIS
⮚ DIAGNOSTIC TEST
o X – ray ( joint deterioration )
o Blood test – RA factor
o Synovial tissue biopsy ( showing pannus tissue or granulation tissue)
⮚ MANAGEMENT
o NSAID, steroid, methotrexate ( methotripsin)
o Monitor medication related blood loss through GUAIAC TEST ( stool for occult
blood ).
o Surgery – synovectomy , TKR .
OSTEO ARTHRITIS
⮚ It is progressive degeneration of the joint. Marked by progressive deterioration of the
articular cartilage in peripheral and axial joints.
⮚ CAUSE – trauma. Obesity. Fracture. Infection.
⮚ ASSESSMENT- CROSS CHECHK THE PICTURE FROM NET
o Initially pain during activity and will be relieved by rest.
o Difficulty getting up from prolonged sitting.
o Heberdens node- a hard or bony swelling that can develop in the distal inter
phalangeal joints.
o Bouchards node- are hard bony outgrowth on the proximal interphalangeal joints.
⮚ MANAGEMENT
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o Corticosteroid directly in to the joints.( intra articular) . after medication continues hot
application.
o NSAID and muscle relaxants.
o Immobilize the affected joints.
o Maintain weight within normal range with a normal well balanced diet.
⮚ Indication – amputation
⮚ Hold the crutch on the unaffected side and during ambulation the nurse should stand on the
affected side
⮚ Measurement-
⮚ Walking up the stairs- first move unaffected leg then affected leg and crutch.
⮚ Down the stairs- first crutch, then affected leg and then un affected leg.
CANE
⮚ Indication- weakness in to the lower extremities
⮚ Hold the cane on the unaffected side, so that the cane and weaker leg can work together with
each step.
⮚ During ambulation the nurse should stand on the affected side.
ROLLER WALKER
⮚ Indication- those who are weakness in to the upper extremities
FRACTURE
⮚ It is a break in to the continuity of the bone.
⮚ TYPES.
● Closed or simple
● Comminuted- the bone crushed with three or more fragments.
● Compression- a fractured bone is compressed by other bone
● Depressed – bone fragments are driven inward.
● Green stick – common in children .one side of the bone is Brocken and the other
part is bent.
● Impacted – a part of the fracture bone is driven in to another bone.
● Incomplete
● Oblique – the fracture line runs at an angle across the axis of the bone.
● Open or compound fracture – the bone is exposed to air. Sterile dressing is needed
● Spiral- the break partially encircles bone
● Transverse
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● Pathological fracture
⮚ MANAGEMENT
● Immediate intervention is immobilization ( for to prevent further damage and
immobilization is basic requirement for bone healing)
● SPLINT & SLINGS
● Reduction – it restores the bone to proper alignment. Types open and closed.
● Fixation - it provide immediate bone strength. And immobilization. Types internal
and external.
● CAST- Nursing intervention
✔ Keep the cast extremity elevated.
✔ Monitor the distal area – if having poor peripheral pulse, numbness,
tingling sensation, cyanosis, and swelling occur that means cast
compression present . the best nursing intervention is immediately report
to the doctor or cut the cast
✔ Instruct the client to keep the cast clean and dry. And avoid stick any object
inside the cast.
✔ If any foul discharge, smell occur from inside the cast or hot spot over the
cast indicate inside the cast infection is present
✔ EXERCISE- during cast – isometric exercise or passive exercise. After
cast removal – active assistive range of motion exercise.
● TRACTION- traction provides proper bone alignment and reduce muscle spasm.
✔ Nursing intervention- maintain proper body alignment.
✔ Ensure that the weight hang freely and do not touch the floor.
✔ Do not remove or lift the weight without a physician order.
✔ Ensure that pulleys are not obstructed and ropes in the pulleys move
freely.
✔ TYPES :
o Skeletal traction – priority pin site care with chlorohexidine
o Skin traction
1. Cervical skin traction - it relieve compression and muscle spasm of
neck & extremity.
2. Bucks extension – use fracture in to the lower limbs or tibial bone.
3. Russels or brayands traction- use fracture in to the femur.
4. Dunlops traction- horizontal traction is applying to clear humorous
fracture.
COMPLICATIONS OF FRACTURE
6. COMPARTMENT SYNDROME
✔ It occurs when pressure increases within one or more compartment leading to tough
fascia surrounds muscle group.
✔ Assessment- 5P( Pain, paleness , pulselessness, parasthesia, paralysis) and
edema.
✔ Management – notify, fasciotomy
7. DISUSE SYNDROME- is the generic name for a physical state caused by bed rest ,
immobility or a lack of physical activity.
8. AVASCULAR NECROSIS- when a fracture interrupts the blodd supply to a section of bone
leading to bone death.
AMPUTATION
⮚ It is the surgical removal of a lower limb or part of the limp
⮚ Classification – 1, traumatic amputation . 2. Surgical amputation.
⮚ Types – 1. Above knee amputation, 2. Below knee amputation, 3. Syme amputation, 4. Mid
foot amputation, 5. Toe amputation.
⮚ POST OP INTERVENTION
❖ After surgery first 24 hour elevate the extremity to prevent hip contracture.
❖ After 24 hour to provide supine position to prevent hip contracture
❖ After 24 hour every day 20 minutes to provide prone position to prevent hip
contracture
❖ The second post operative day onwards massage toward the site to make as
cylindrical shape to prepare for prosthesis. It will help to decrease pain and
mobilizing the scar. but the massaging is performing the 15th day for prosthesis
preparation.
❖ Use triangular pillows inside and out side the thigh to prevent internal and external
rotation of the thigh.
❖ After 24 hour avoid hip flexion.
❖ Use anti embolism stockings or TED HOSE.
❖ Monitor complications.
1. Bleeding – if occur first mark the area and report to the doctor.
2. Neuroma
3. Infection
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4. Phantom limb sensation pain – it is a neurogenic pain treated with high dose
analgesics ( both pre and post operatively ) or with the help of an mirror box
therapy . mirror box therapy will help to convert the sensory perception to
visual perception.
❖ Prepare for prosthesis
SPINE DEFORMITIES
1 KYPHOSIS - posterior or convex curvature or outward curvature of the spine . commonly
seen in osteoporosis, and parkinsonism
2 LORDOSIS – forward or upward or inward curvature of spine. Also known as concave
model. Can seen in pregnancy.
3 SCOLIOSIS – lateral curvature of spine
4 Management – physiotherapy, brace application, spinal fusion surgery
P- Protection.
R-Rest
I-Ice
C-Compression.
E-Elevation
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2 . commonly affected parts - pelvis, femur, lumbar vertebrae and skullbones.
3 . causes - family history, aging, more common in males, associated with viral infections such as
respiratory synctialvirus
4 . C/M - severe bone pain, joint distraction, fracture, arthritis, spine deformities, loss of hearing in
one /both ears
Management
⮚ No permanent cure
⮚ Administer NSAID, calcitonin, bishopnates
⮚ Promote safety measures
⮚ Monitor hearing loss
⮚ Provide vitamin D suppliments
⮚ Surgery – osteotomy
⮚ Exercise – weight bearing exercise
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EYE DISORDERS
ANISOCORIA
⮚ It is a condition characterized by an unequal size of the pupils.
⮚ Cause- 1. Physiological – it is normal
2. Mechanical -- previous trauma or eye surgery or inflammations
3. Oculo motor nerve palsy
4. Pharmacological agent – anticolinergic example atrophine sulphate.
⮚ Management- administer miotics
ADIES SYNDROME
⮚ It is a neurological disorder characterized by a tonicaly dilated pupil that reacts slowly to
light but shows a more definite response to accommodation
⮚ Cause – damage of post ganglionic fibers of the parasympathetic intervention of the eye.
⮚ Pilocarpine drugs for constrict pupil.
REFRACTIVE ERRORS
⮚ MYOPIA – a condition in which close objects apear clearly. But far ones don’t. management
– concave lens.
⮚ HYPEROPIA – long site present .management use convex lens.
⮚ PRESBYOPIA- vision loss due to aging. Due to decreasing elasticity in the lens. To check
refractive errors with the help of ansnellens chart.
CATARACT
⮚ Opacity of the lens
⮚ TYPES / CAUSES
✔ SENILE CATARACT- due to aging process
✔ INHERITED – congenital
✔ TRAUMATIC – due to ant other eye injury
✔ SECONDARY – due to another eye disease or drugs eg long term use of steroids
⮚ CLINICAL FEATURE
✔ Early features: blurred vision (floaters) and decreased color perception
✔ Diplopia, decreased color perception, presence of white pupil, redness of eye ( only in
senile
Management - Administer mydriatrics pre operatively - to dilate the pupil eg:atropine. S/E-
dry mouth, constipation, tachycardia
⮚ Surgical management:
✔ Extra capsular extraction of the lens ( phacoemulsification is the principle )
✔ Intra capsular extraction ( total lens and capsule are removed )
⮚ Post operative intervention
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✔ Elevate the head of the bed at 45 degree and turn the client from supine to non
operative side.
✔ Avoid getting strain to the eye.
✔ Clean the eyes from inner canthus to the outer canthus.
✔ Monitor complication. Decreased vision and pain
✔ The final best vision will not be present until 4-6 week following cataract removal
.because this is the time should take for wound healing
⮚ Nursing diagnosis : disturbed sensory perception related to ocular lens opacity.
GLAUCOMA
⮚ A group of ocular diseases resulting in increased intra ocular pressure. increase IOP result
from inadequate drainage of aqueous humor from the canal of schlemm or over production of
aqueous humor. So increase IOP will compress the optic nerve and the pupil is dilated that
result blindness.
⮚ Normal IOP Is 10-21 mmof hg . tonometer is using for measure IOP
⮚ Aseesment
✔ Early features- increase IOP, tunnel vision or decreased accommodation
✔ Headache, halos around light , loss of peripheral vision
⮚ Management
✔ Vision problem is not corrected with lenses.
✔ Administer drugs for to decrees IOP. Eg. Timilol , xalatan.
✔ Administer diamox for to decrease the production of aqueous humor
✔ Atropine is contra indicated in this disease (anti colinergics) or mydriatrics (
drugs which is using for to dilate pupil
✔ Administer miotics for to constrict pupil eg. pilocarpine S/E- bradycardia,
hypotension
✔ S/m - trabeculectomy and iridectomy
✔ Eye surgery position – towards the un affected side
RETINAL DETACHMENT
⮚ Detachment or separation of the retina from the epithelial eye wall.
⮚ It occurs when the layers of the retina separate because of accumulation of fluid between
them or tumors.
⮚ When detachment become complete blindness occurs.
⮚ Assessment : flashes of light, sense of curtain being drawn over the eye, floaters or black
spot
⮚ MANAGEMENT
✔ Provide bed rest. Cover both eyes to prevent further damage.
✔ Avid jerky head movement
✔ Cryosurgery : nitrous oxide is injecting into the epithelial eye wall and to freeze the
cells
✔ Vitrectomy : after surgery prone position
✔ Drainage of fluid from sub retinal space
✔ Sclera buckling, laser therapy .
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EAR DISORDERS
Anatomy and physiology
EAR ASSESSMENT
⮚ Autoschopic examination – less than 3 year pinna down and back more than 3 year up and
back for to visualize the auditory canal . Normal character of tympanic membrane is grey
color , opaque .
⮚ TUNING FORK TEST
✔ Webers test _ place the vibrating tuning fork at the middle of the for head or in front
of the nose, if patient get conduction equally in both ears(normal). if the conduction is
louder in one ear it denotes conductive hearing loss to that ear. this is performing to
detect conductive hearing loss.
✔ Rinne test – place the vibrating tuning fork at the mastoid process patient get
vibration to an extent through the bone. after the vibration is stopped place the fork in
front of ear to get vibration through air If air conduction is more than bone conduction
it indicates positive test or normal hearing . air conduction is two times longer than
bone conduction
⮚ Vestibular assessment
✔ Caloric test- is a test of the vestibulo-ocular reflex that involves irrigating cold or
warm water or air into the external auditory canal. Ice cold or warm water or air is
irrigated into the external auditory canal, usually using a syringe. If the water is warm
(44 °C or above) is used horizontal nystagmus towards irrigated ear. If the water is
cold, relative to body temperature (30 °C or below) horizontal nystagmus away from
irrigated ear.
✔ Romberg test-Romberg's test, Romberg's sign, or the Romberg maneuver is a test
used in an exam of neurological function for balance. Ask the subject to stand erect
with feet together and eyes closed. Watch the movement of the body in relation to a
perpendicular object behind the subject. Romberg'stest is positive if the patient falls
while the eyes are closed.
✔ Hallpikes maneuver-The client starts on sitting position, the examiner lowers the
client to the exam table and rather quickly turns the client's head to 45 degree
position. If after about 30 seconds there is no nystagmus, the client is returned to a
sitting position and the test is repeated on the other side.
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✔ Gaze nystagmus evaluation- client's eyes are examined as the client looks straight
ahead, 30 degrees to each side, upward and downward.Any spontaneous nystagmus-
an involuntary, rhythmic, rapid twitching of eyeballs- represent a problem with the
vestibular system.
⮚ TERMINOLOGIES
✔ Otalgia – ear pain
✔ Cholesteatoma - tumor of the middle ear and mastoid process that contain
cholesterol.
✔ Labyrinthitis – inflammation of the labyrinth membrane
✔ Cerumen – ear vax
✔ Otosclerosis – a condition characterized by abnormal spongy bone formation around
the stapes . this is a middle ear problem can cause conductice hearing loss.
Management stapedectomy.
✔ Presbycusis- progressive hearing loss associated with aging process
✔ Myringitis – inflammation of the tympanic membrane.
✔ Ototoxic drugs- aminoglycoside antibiotics( streptomycin, gentamycin, amikacin,
tobramycin. )
- Anti neoplastic ( cisplatin vincristine)
- Diuretics eg. Lasix
- Others Eg. Quinine, aspirin and salicylate.
⮚ MANAGEMENT
✔ Anti-histamine
✔ Diuretics – lasix
✔ Anti emetics and vestibulosupressants ( haloperidol )
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✔ Sedative eg. Diazepam
✔ Cryosurgery and endolymphatic drainage
✔ Complete bed rest ,provide assistance for walking.
✔ Initiate sodium and water restriction
OTITIS MEDIA
⮚ Inflammation of the middle ear. Mainly occur in children. It is occurring as a result of a
blocked Eustachian tube. It is a common complication of acute respiratory infection.
⮚ Infants and children are more prone to otitis media because their eustachian tubes are shorter
wider and straighter
⮚ Cause:
● The common cause is streptococcus pneumonia.
● Hemophilus influenza
● Moraxella catarrhalis
● High risk: child not maintain up right position for feeding, bottle feeding baby,
acute respiratory infection.
⮚ CLINICAL FEATURE
● Excessive crying, fever, irritability
● Older children complaint otalgia
● Rolling of head from side to side and pulling on or rubbing the ear
● Otorrhea
⮚ MANAGEMENT
● ENCOURAGE fluid intake and avoid chewing because it increases pain
● Position – affected side down.
● Administer analgesics or antibiotic ear drops for 14 days
● Surgery – myringotomy and insertion of tympanoplasty tubes into the middle ear to
equalize pressure and keep the ear aerated. It is a surgical procedure for facilitating
drainage in otitis media.
● Post-operative intervention
▪ Avoid – Airplane travelling, nose blowing, pinch the nose trills, vigorous
coughing and sneezing, and avoid take water through straw
▪ Keep the ear clean and dry
▪ Use ear plug during shampooing
▪ Instruct the parents that if the tubes fall outs it is not an emergency but the
physician should be notified.
⮚ PREVENTION
● MAINTAIN UPRIGHT POSITION FOR FEEDING
● Promote breast feeding and avoid bottle feeding
● Keep immunization up to date
● Early treat upper respiratory infection
ACOUSTIC NEUROMA
⮚ Benign tumor in the distal portion of the eight cranial nerve ( aquastic nerve)
⮚ Clinical feature - tinnitus, vertigo, and sensory neural hearing loss
⮚ Management- surgery through craniotomy
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DERMATOLOGY
BURNS
⮚ Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolyte
⮚ Types – 1. Thermal burn
2. electrical burn
3. chemical burn
4. inhalation
5. radiation
⮚ CLASSIFICATION
COMPLICATION
R RESCUE
A ALARM
C CONFINE
E EXTINGUSH
P PULLED UP
A AIM AT BASE
S SQUEEZE
S SWEEP
● Emergency phase management- priority for ABC & calculate the percentage of
burn
● Resuscitative phase – administer fluid to prevent hypovolemic shock . mainly using
parkland formula
● Medication only IM
● Reverse isolation/ PPI
● Diet High Protein, Calorie,
Vit-C, D, Zinc.
nursing diagnosis
⮚ burn present in face , neck, chest – ineffective airway clearance
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⮚ 80% burn all over the body – fluid volume deficit
⮚ 80% burn priority nursing diagnosis at the time of discharge – disturbed body image
PHEMPHIGUS
⮚ It is an auto immune disease commonly affecting oral cavity .
⮚ C/M – it present as oral blisters especially in the buccal and the palate mucosa
- Weight loss, mal nutrition
- It also affect conjunctiva, nose, esophagus, vulva, vagina, pelvis, anus
- Blister can leads to ulcerative lesion
PRESSURE ULCER
⮚ Causes – immobility. Mal
nutrition, sensory deprivation
⮚ STAGES;
⮚ Stage 1; non blanchable redness.
⮚ Stage 2; blister, red, shallow
crater.
⮚ Stage3; deep crater,
subcutanious tissue affected.
⮚ Stage 4; bone tendon muscle.
⮚ Stage 5; unstageable, escar.
1. Sensory perception.
2. Activity
3. Mobility
4. Nutrition
5. Moisture
6. Friction/shear
Management
Preventive Collaborative
● Every 2 hourly change the position ● Avoid massage over the red area
of the client ● Antibiotics
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● Use air bed or water bed ● Skin grafting
● Be sheet is wrinkle free ● Perform hydrocolloid dressing or wet
● Keep skin clean and dry dressing
● Use cream and lotions to lubricate ● DIET HIGH PROTEIN HIGH CALORIE
the skin VIT-C ( but first priority for protein )
● ROM every 8 hourly
Sero sanguineous Pale, Pink, watery mixture of clear and red fluid.
PSORIASIS
⮚ It is a long lasting auto immune disease characterized by silverey patches of the skin.
⮚ Causes – long term stress, hormonal change, medication.
⮚ Clinical features.
❖ Red dry itchy wound
❖ Skin scaling lesion - silver colored in center red boundary
❖ Yellow discoloration, pitting, and thickening of the nail
❖ Psoriatic arthritis
❖ Koebner phenomenon – is the development of psoriatic lesion at the of injury. such as
scratched or sunburn area
⮚ Management
❖ Topical medication – coal tar, gluco-corticoid, anthralin
❖ Systemic medication – 1. Acitretin – slowing cell production 2. Cyclosporine and
methotrexate
LYME DISEASE
Causative organism-Borrelia burgodeferi
signs/symptoms
1. asymptomatic
2. symptoms appear days to months after bite.
3. a small pimple develops that progress into a ring shape rash (bullseye rash) ( picture from net )
4. flu like symptoms.
5. neurological and cardiac manifestation
Management
● Gently remove the tick with tweezer and flush it in toilet.
● administer antibiotics & avoid wooden and grassy area.
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SHINGLES
⮚ it is an acute viral infection of dorsal nerve route of ganglion caused by herpes zoaster
virus
⮚ it can be caused by reactivation of varizella zoaster with history of chicken pox or
immune suppressive condition
⮚ MOT – airborn, droplets, direct contact
⮚ C/M – fever, crusted skin vesicles along the peripheral sensory nerves of the
trunk,thorax,anf face, burning sensation, pruritis or itching.
⮚ Management - isolation, maintain standard and contact isolation, antiviral ( acyclovir or
zovinax ) and analgesics& corticosteroid
⮚ Vaccination – varicella
PAEDIATRIC NURSING
GROWTH AND DEVELOPMENT
Growth Increase the size of the body. It can measure in the form of KG, cm, lbs
Development It is defined as progression towards maturity. Thus the terms are used together to
describe the physical mental, and emotional processes associated with the growing up of children.
Height 45- 55 cm
GROWTH PERIODS
New Born Birth – 28 days
Adolescence – 12 – 18 year
GROWTH CHART
Appropriate for Gestational Age (AGA) – between 10th and 90th percentiles
It can be presumed to have grown at a normal rate regardless of the time of birth-preterm, term or post-term
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Hold head in midline
4 – 5month
Grasps object
6 – 7month Creeps
Crawls
10 – 11 month
Stand securely
3 year- rides tricycle, throw a ball overhead. 4 years- hop on one foot.
● Respiratory system
● Cardiovascular system
● Integumentary system
OR
Scoring - 7 – 10 normal
4 -6 mild depression
0 -3 severe depression
Note : - Evaluation of all fine categories are made on 1 – 5 minutes after birth.
Step II
1. Skin
● Normally bright red smooth with lanugos and white cheesy substances or vernix caseosa
● Abnormal findings ( cross check the picture from net )
● Milia
● Mongolian spot
● Erythema toxicum
● Harlequin coloration and mottling
2. Head
● Anterior fontanel or Bregma– diamond in shape
close at 18 month.
Posterior fontanel or lamda-triangular in shape
close at 1 ½ - 3 month
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Monitor any abnormality
a) Craniosynostosis / Brachycephaly
→ It is a condition in which one or more of a fibrous sutures in an infant skull permanently fuses
their by changing the growth pattern of the skull.
b) Caput succedaneum
→ It is the edema of the soft tissue over bone
c) Cephalohematoma
→ It is swelling caused by bleeding in to an area between the bone and its periosteum.
a) Bell’s PalsyTemporary paralysis of one side of the face due to injury to the seventh cranial
nerve that is facial nerve.
b) Erb’s Palsy Upper brachial plexus injury can cause Erb’s palsy. It is also called waiters tip hand
c) Klumpke Palsy Lower plexus injury can cause Klumpke palsy.
d) Neck - Tonic neck reflex present. Abnormalities in neck – Torticollis or torticose neck syndrome.
It may be due to injury to the sternocleidomastoid muscle
4. Chest
5. Umbilicus
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1. Sucking and Rooting
● Touch the new born lip, cheek or corner of the mouth with a nipple. The new born turn head
towards the nipple, opens the mouth takes hold of the nipple and sucks. Disappear after 3 – 4
month old. But persist up to 1 year.
● If sucking is absent, to give spoon feeding
● As the new born faces the left side, the left arm and leg extend outward while the right arm and
leg flex
● Disappear 3 – 4 month old
● Placing object or finger beneath the toes causes curling of toes around the object.
● Disappear 8 – 12 month old
● Elicited by pulling the baby halfway to sitting position from supine and suddenly let the head fall
back.
● Consist of rapid abduction and extension of arms with the opening of bands, tensing of the back
muscles. Flexion of the leg and crying.It is used to defect hearing in infants.
TEETH ERUPTION
● 6– 8 month lower incisors
● 8 – 12 month Upper incisors
● 13 – 19 month Pre –molars and molars
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● 16 – 23 month Canine and cuspid
● At 28 month 20 temporary teeth.
● Oral care started at 1 year
● Toilet training start at 2 – 3 year(bowel training at 2 year bladder training at 3 year)
Play Therapy
BREAST FEEDING
● According to the WHO and AAP breast feeding is the normal way of providing young infants
with the nutrients they need for healthy growth and development.
● Breast feeding helps defiance against infections, prevent allergies and protect against a number of
chronic conditions.
● BFHI 1991
Physiology of Lactation
2. Lactogenesis Synthesis and secreting of milk in the breast alveolar cells. Prolactin is helping
for
this stage.
3. Galactokinases Ejection of milk. Oxytocin is helping to stimulate the breast alveolar cells to
eject
the milk.
4. Galactopoesis Maintenance of lactation. hormone responsible for this stage is prolactin and
adequate sucking.
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Benefits of Breast feeding – maternal
Nursing Intervention
CONTRA INDICATION
Maternal
Neonatal
→ Birth Asphyxia, Increase lCP, lactose intolarance, Galactosemia
GENETIC DISORDERS
Types
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● If One parent is affected(getting 50% chance of inheritance)or Both parent should affected–
(getting100% chance of inheritance ).
Eg:- Achondroplacia or congenital dwarfism, Adult PKD
Example 1:- Father has no hemophilia. But mother is the carrier. The result is
Example 2:-Father hemophilic positive. But mother not in carrier stage the result become
NOTE- but rarely the disease is affecting to the female. (if father is hemophilic and mother
is the carrier situation)
RESPIRATORY DISORDER
CROUP SYNDROME
● It is Laryngeotracheobronchitis
● Risk group 3 month – 5 years
● Cause allergy/ Para influenza virus.mycoplasma, respiratory synctyl virus ( droplet infection )
Clinical Features
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● Mild fever
● Barking cough due to laryngeal edema
● Wheezing
● Diaphoresis
● Stridor
Types
Management
Drugs
Nursing Diagnosis
EPIGLOTITIS
● Inflammation of the epiglottis
● Risk group 2 years – 5 years
● Cause
→ Homophiles influenza type B
→ Streptococcus pneumonia
Clinical Feature
● High fever
● Absence of spontaneous cough
● Dysphonic
● Drooling of saliva from mouth
● Child maintain tripod position
Prevention
Management
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● Priority for airway clearance
● Maintain lateral position and avoid supine position
● Provide cool mist oxygen therapy
● Provide NPO till gag reflex return.
● Avoid oral temperature monitoring, and throat swab culture because this can cause spasm and
stridor.
● When monitor oral temperature place the thermometer bulb at the lateral side of the frenulum of
the tongue.
Nursing Diagnosis
CYSTIC FIBROSIS
● It is an autosomal recessive trait genetic disorder
● It is a multisystem, genetic fatal disorder
● The disease is affecting to the exocrine glands.
Eg :- Pancreas, liver, salivary gland, mammary gland sweat gland etc
Pathology
Due to abnormal gene transmission ( CFTR) the mucous produced by the exocrine gland is
abnormally thick, tenuous and copious causing obstruction of the small passage ways of the
affected organs particularly in the respiratory, GI, reproductive system
Note :-It is an incurable disorder and respiratory failure is a common cause of death.
Clinical features
1. Respiratory system
Complication
● Pneumonia
● Emphysema
● Atelectasis
2.G.I System
3. Integumentary System
● Dehydration
● Electrolyte imbalance
4. Reproductive System
● Delay puberty
● Infertility
Diagnostic Test
Result
2. Stool Examination’
3. Chest X-ray
Management
Respiratory Management
G.I Management
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TRANSIENT TACHYPNOEA OF THE NEW BORN (TTNB)
1. Temporary increased respiratory rate in new born.
2. It results from incomplete re-absorption of fetal lung fluid in full –term new born.
3. Usually disappears within 24 – 48 hours.
4. Risk factor LSCS, preterm
5. Clinical feature
● Respiration more than 60 times/mt
● Expiratory grunting, crackles, cyanosis
● Chest x-ray shows interstitial edema and pleural effusion( normal after 48 hours)
Management
● O2 administration
● Supportive care.
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Diagnostic Evaluation
Result – Both score are widely used for the categorization of respiratory distress in
neonates.
Score of 4 or more for at least 2 hours during the first 8 hours of life denotes clinical RD
and require assessment of the infant by a physician. An RD score of 6 or more is an
indication for ventilator support.
Management
Prevention
Administer Betamethasone to the pregnant ladies those who are expecting preterm labor
for early maturity of fetal lung .
Nursing Diagnosis
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TONSILITIS
1. Inflammation of tonsils
2. Cause
● Group A. Beta hemolytic streptococci
● Pneumococcal, H. influenza
3. Clinical Feature
● Redness, pain, swallowing difficulty
● Enlargement of lymph nodes
● Mouth breathing and unpleasant mouth odor.
4. Management
● Position
→ Prone or lateral position
→ Avoid supine position
→ If breathing difficulty occur to give semi fowlers position
● Child having frequent swallowing it means bleeding from the surgical site.
● Can be seen old dried blood clot in vomits is normal.
● Post operatively give clear cold water or ice chips. It will help to decrease pain and bleeding.
● Post operatively avoid
→ Milk or milk product
→ Ice-cream
→ Red color food
→ Citrus fruit and carbonated beverages
→ Gargling
● Discourage coughing
● Monitor complication
→ Eustachian tube obstruction
→ Ear pain
1. Acynotic CHD
2. Cyanotic CHD
Acynotic Heart Disease – It means mixing of oxygenated and deoxygenated blood and the mixed
blood is going in to the deoxygenated area.
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Eg:- ASD, VSD, PDA, coarctation of aorta
Cyanotic Heart Disease – It means mixing of oxygenated and deoxygenated blood and mixed
blood is going in to the oxygenated area. That can cause cyanosis.
HEART MURMERS
1. VSD
2. Pulmonary stenosis
3. Right ventricular hypertrophy
4. Over riding of aorta
Clinical features
Management
RHEUMATIC FEVER
● It means inflammation at the all layers of heart. (Pericarditis + Myocarditis + Endocarditis)
● RHD is the first complication of Rheumatic fever. ie, inflammation is affecting to the valves of
the heart. eg:- Mitral valve
Cause
Risk factor
Pathological Change
Clinical Features
1. jhone’s criteria
Major
● Carditis
● Poly arthritis
● Chorea (Involuntary movement of face and extremity during mental stress)
● Erythema marginatum – It is a pink color macules seen mainly trunk and extremities.
● Subcutaneous nodules –Non tender movable nodules on the bony prominence especially joint
area
Minor
● Fever
● Polyarthralgia
● Increase WBC, ESR
● +ve CRP
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● ECG Prolonged PR interval
Confirmatory Test
ASO Titer
Management
Azithromycin or erythromycin If allergic ( azithromycin side effect- diarrhoea, chest pain,
nausea, itching, loss of appetite, dark urine, clay colored stool )
KAWASAKI DISEASE
● It is also known as mucocutaneous lymph node syndrome
● It is an autoimmune disease in which the medium sized blood vessels throughout the body
become inflamed
● The disease mainly affecting the endothelium of coronary artery
● Mostly occur in under 5 year children
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● Mainly it including blood vessels, skin, mucous membrane and lymph nodes
Clinical Features
● Remittent fever
● Red throat
● Swollen hands
● Bilateral conjunctivitis
● Enlargement of cervical lymph nodes
● Desquamation of skin or peeling of skin.
● Strawberry tongue.
● Thrombocytosis.
Management
▪ IV immune globulin.
▪ Salicylate or aspirin may be prescribed
▪ Do not administer aspirin or aspirin containing product if the child has exposed to viral infection
along with Kawasaki disease for the prevention of Reye’s syndrome.
▪ Symptoms may last 2 months
▪ Monitor the sign and symptoms of aspirin toxicity
Eg:- Headache, tinnitus, Bruising
▪ Avoid administer live attenuated vaccine for 11 month after IV immune globulin therapy
Eg:- MMR, Varicella, etc
HOME CARE INSTRUCTION FOR DIGOXIN ADMINISTRATION
NERVOUS SYSTEM
HYDROCEPHALUS
It is a medical condition in which there is an abnormal collection of CSF. This may cause
increase ICP and progressive enlargement of head.
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Types
Assessment
1. Infant
● Macewen’s sign
● Increased head circumference
● Anterior fontanels tense, Bulging and non pulsating
● Frontal bossing or prominent forehead
2. Child
Medical Management
● Mannitol.
● Anticonvulsant
● Tab. Diamox – It will help to decrease CSF production
Surgical Management
● If ICP is normal keep the child flat as prescribed to avoid rapid reduction of intracranial fluid.
● Observe for increase ICP, If increase ICP occurs elevate the head of the bed 15 – 30 degree to
enhance gravity.
● Turn the patient from supine to non-operative side to prevent pressure on shunt.
● Daily monitoring of head circumference.
● Strict intake and output charting.
● During VP shunt if ICP increases( high pitched shrill cry), provide ventricular tapping.
● Monitor the complication
ꟷ Frequent manipulation of shunting procedure can cause infection.
ꟷ Latex allergy (When collecting history ask about nut’s allergy).
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BOTULISM
� It is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium
Botulinum.
� Mode of Transmission
● Organism are found in the soil.
● Spread through food, air or wound.
● incubation period 12 hour – 72 hour
Pathology
The toxin destroys the Neurotransmitter Acetylcholine that leads to muscle weakness or paralysis.
Assessment
Management
Prevention
CEREBRAL PALSY
● It is a general term for a group of permanent movement problem due to injury to the extra
pyramidal or pyramidal motor system.
● They cause physical disability mainly in the areas of body movement there may also be
problems with sensation perception and communication ability.
● In this condition according to chronological age physical development present. But there is no
mental and cognitive development.
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Causes
Fetal distress
Clinical Features
Management
SPINA BIFIDA
● It is a neural tube defect. ie, failure to close the neural tube during embryonic period.
● Cause – Folic acid deficiency in pregnancy
ꟷ Daily intake -200 mcg
ꟷ In pregnancy – 400 mcg ( a lady delivered her first baby with spina bifida for to prevent
spina bifida in her second baby she should take 4000 mcg folic acid daily )
Types
⮚ Meningocele - Lumbosacral area one protrusion is present. It involves meanings, CSF, not
involved the neural tube, the protrusion is covered with a sac
ꟷ Neurological deficit are absent
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⮚ myelomeningocele
ꟷ Lumbosacral area one protrusion. The protrusion is covered by as thin membrane prone to
leakage or rupture. The protrusion involves meninges, CSF, and spinal cord.
ꟷ Neurological deficit are present
Clinical Manifestation
Note: -Perform credes maneuver ( apply firm pressure over the bladdef ) for to eliminate
urine
● Hydrocephalus
Management
Surgical Management
❖ Laminectomy.
Cause
Risk Factor
Clinial Features
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▪ Grey spot on iris (BRUSHFIELD SPOT)
▪ Over curved helix
▪ Protruding or large tongue
▪ Single transverse palmer creases(SIMIAN LINE)
▪ Low set ears
▪ Brachycephaly
▪ Speech delay
▪ Separated eyebrows
▪ Poor eye contact during feeding
▪ High risk for leukemia due to immune dysfunction
▪ Leg sandle sign (Separated wide gap between big toe and 2nd)
Diagnostic Evaluation
Management
▪ Positive re-enforcement
▪ Supportive management and safety and Correcting structural deformities
CRYPTORCHIDISM
It is also known as undescended testis- failure to descend the testis in to the scrotal cavity.
Cause
● Absence of testis
● Prematurity
Management
Surgical Management
● Orchiopexy – Should be perform in between 1 year – 2 year. If the testis do not descend
spontaneously.
● At the time of discharge counseling the parents regarding future fertility of the child.
WILMS TUMOR
● It is also known as nephroblastoma or kidney tumor of childhood.
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● Peak incidence 3 years of age.
● Boys and left kidney are more affected
● Wilms tumor associated syndrome
W – Wilms tumor
A – Aniridia (Absence of iris)
G – Genito urinary defect
R – Mental retardation
STAGES
Stage I- tumor is within the kidney and can be completely resected.
stageII- tumor extend beyond the kidney and can be completely resected.
Stage III- tumor extend through the lymph nodes and cannot be resected.
Clinical Features
1. Initially painless, non pulsating abdominal mass. (But later pain present)
2. Increase abdominal girth
3. Anemia due to
● Rupture and hemorrhage
● Decreased erythropoietin
4. Hypertension due to Renin Angiotensin reaction
5. Urinary retention /hematuria
6. Symptoms like dyspnoea, chest pain occur it means metastasis occur in lungs
Diagnosis
1. CT
2. MRI
3. Biopsy is contraindicated because chance for rupture and metastasis
Management
Pre-operative intervention
● Monitor vitals
● Avoid abdominal palpation. because palpation can cause rupture of the tumor
● Measure abdominal girth daily
● Administer antihypertensive medication
Surgical Management
● Nephrectomy
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● First 24 hour complete bed rest
● Turn the client from supine to non-operative side
● Monitor bleeding at the back of the body
● Monitor bowel sound. because increase chance of intestinal obstruction
● Monitor color of urine and any infection.
Management
❖ Surgery is done before the age of toilet training preferably between 16 – 18 month of age.
❖ Circumcision is not perform on a newborn with epispadiasis and hypospadiasis because the fore
skin may be used in surgical reconstruction of the defect.
Clinical Features
Management
Surgical Management
Complication
❖ Easophagitis
❖ Aspiration pneumonia
❖ Sudden infant death syndrome
Nursing Diagnosis
Clinical Features
● Projectile vomiting
● Dehydration
● Electrolyte imbalance
● Metabolic alkalosis
● Olive shaped mass is in the epigastrium just right of the umbilicus
● Visible waves of peristalsis
● Bulging in the lower part of the rib (at right side)
Complication
● Malnutrition
● Failure to thrive
Management
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Surgery
Nursing Diagnosis
Management
Surgical Management
● Thoracotomy
● Wait up to one year for surgical closure
● Post operatively – maintain mechanical ventilation
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● Neck neutral position
● Avoid head and neck movement
● Inspect the surgical site have any infection
● Provide proper chest drain care
● Before giving oral feeding perform Barium swallow examination to detect any obstruction in the
upper GI tract
● When ever provide first feed monitor any feed content in the chest drain. If present it denotes
anastomotic leaks
Cleft Palate It is a midline fissure of the palate that result from failure of the two sides to fuse.
Cause
● Genetic / Hereditary
● Rarely due to folic acid deficiency
● Anti-convulsant during pregnancy
● Maternal smoking
● Teratogenic factor
Management (surgery)
Cleft Lip Cheiloplasty – timing 3 – 6 month ( post operatively provide LATERAL position
and use elbow restraints )
or Rule of 10
-- 10 Ibs weight
ꟷ 10 gm Hb
ꟷ 10 week old
Cleft Palate Palatoplasty timing 6 -18 month (PRONE position post operatively )
Complication
● Otitis media
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● Nasal speech
● Difficult feeding
INTUSSUCEPTION
Telescoping of one portion of the bowel into another portion. The condition results in obstruction
to the passage of intestinal contents.
Clinical Feature
Diagnostic Evaluation
▪ usg
Management
▪ Antibiotics
▪ Insert NG tube – It should be open
▪ Administer hydrostatic reduction enema with barium or NS.
▪ Monitor for the passage of normal brown stool which indicate that the intussusceptions has
reduced itself.
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● OmphaloceleHerniation of the abdominal contents through the umbilical ring. The
protrusion is covered by a translucent sac that may contain bowel or other abdominal organ.
● Gastroschisis Occurs when the herniation of the intestine is lateral to the umbilical ring. No
membrane covers the exposed bowel.
● Bladder exstrophy or Ectopia vesicleIt is characterized by extrusion of the urinary bladder
to the outside of the body through a defect in the lower abdominal wall.
Management
▪ The affected area is covered with a saline gauze piece or perform hydrocolloid dressing or wet
dressing. A layer of plastic wrap is placed over the gauze to provide additional protection against
moisture loss.
▪ Avoid getting the sac is rupture.
▪ Protect the client from infection and hypothermia.
▪ Surgical management skin grafting.
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HIRSCHPRUNGS DISEASE
● It is also known as congenital a ganglionic
mega colon.
● It occurs due to congenital absence of the
parasympathetic ganglionic nerve cell that
regulate to the activities of the colon.
● The affected segment of the colon cannot relax
and pass stool through the colon, creating an
obstruction.
● Defect mainly affecting recto sigmoid colon.
Clinical Features
Diagnostic Evaluation
Management
DIARRHOEA
Loose or watery stool.
Cause
● Acute diarrhea
ꟷ Rota virus
ꟷ Antibiotic therapy
ꟷ Parasite infection
● Chronic diarrhea
ꟷ Malabsorption syndrome
ꟷ IBS
ꟷ Immune deficiency. eg:- AIDS
Clinical Features
Management
● Contact isolation
● Monitor skin integrity
● IVF and electrolyte
● Antibiotics
Prevention
DEHYDRATION
● It is a common fluid and electrolyte imbalance in infants and children.
● In infants the organs that conserve water are immature, placing then at risk for fluid volume
deficit.
Cause
Clinical Feature
● Weight loss more than 10% – Daily 1kg weight loss indicate 1 litre water loss present in the
body.
● Poor skin turgor (In children check – Abdomen, Adult – Forehead, fore arm)
● Depressed anterior fontanels (Only in less than 18 month babies)
● Absent or decreased tears during crying
● Kussmaul respiration (Deep and rapid)
● Behavior – lethargic
● Sunken eye
● Capillary refilling more than 4 seconds
● Oliguria
1. Vitals stable
2. Urine is clear
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3. Good skin integrity
Management
CELIAC DISEASE
● It is an auto immune disorder.
● Intolerance to gluten, the protein component of wheat, Barley, RYE
● Gluten is a endosperm protein. It contains amino acid.
● It results in the accumulation of the amino acid glutamine which is toxic to intestinal mucosal cell.
● Intestinal Villi atrophy occurs, which affect absorption of ingested nutrients.
● Willi atrophy can see through endoscopic examination.
● Symptoms occurs most often between 1 – 5 years.
● There is usually an internal of 3 – 6 month between the introduction of gluten in the diet and the
onset of symptoms.
Clinical Features
● Malnutrition
● Vitamin deficiency
● Acidic diarrhea
● Rapid dehydration
● Abdominal pain and distention
Management
Lifelong elimination of gluten sources
B – Barley
R – RYE
W – Wheat
PHENYLKETONURIA
● PKU is an inborn error of metabolism involving impaired metabolism of phenylalanine one of
the Amino acid.
● PKU is a autosomal recessive trait genetic disorder that result in central nervous system damage
from toxic level of phenylalanine in the blood.
● Phenylalanine more than 2mg/dl is considered as PKU.
● Phenylalanine present in protein rich food.
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Cause
Deficiency of hepatic enzyme phenylalanine hydroxylase, which convert phenylalanine in to
Tyrosine which is again metabolized in to dopamine and melanin.
Clinical Features
1. Digestive problem and vomiting
2. Seizure
3. If not treating early mental retardation
4. Eczema
5. Hypertonic
6. Liver cirrhosis
7. Fare skin
8. Blue eye
9. Hypo pigmentation of hair (Red color) due to absence of melanin.
Diagnostic Evaluation
⮚ Metabolic Screening or Guthrie test or heal prick test
● The infant should have begun formula or breast milk feeding before specimen collection.
● First sample should send 48 – 72 hours
● Repeat sample on the 7th day
● Most accurate sample on the 3rd day
Management
Restrict phenylalanine intake or protein rich food. But not completely avoid because it is an
essential amino acid
HEMATOLOGICAL DISORDER
ANEMIA
It means – Decrease Hemoglobin – less than 12gm
Types
Clinical Features
Management
Clinical Features
Diagnostic Evaluation
● CBC
● Sr. Ferritin monitoring
● Peripheral smear Hypo chromic and microcytic cell
Management
APLASTIC ANEMIA
● Decrease RBC, WBC, Platelet
Types / Causes
● CBC
Management
NOTE – dyscrasis means decrease platelet & increase WBC . can seen in leukemia and
haemophilia
PERNICIOUS ANEMIA
It is also known as vitamin B12 deficiency or vegetarian anemia
Causes
Clinical features
1) Smooth red beefy tongue
2) Paleness
3) Gait problems
4) Slight jaundice
Diagnostic evaluation
1) Peripheral smear – normochromic, macrocytic cell
2) Confirmatory test- shrilling test
Management
● Administer vitamin B12 injection cyanocobalamin lifelong if the cause is deficiency of intrinsic
factor
● Those who are taking vitamin B12 injection frequently monitor CBC or reticulocyte count
● Instruct the client to take vitamin B12 rich food. Eg: brewer’s yeast, green leafy
vegetables,organ meat, citrus fruit
● Complication – gastric ulcer and gastric cancer
THALASSEMIA
● It is an autosomal recessive trait genetic disorder
● It is characterized by the reduced production of one of the globins chain in the synthesis of
hemoglobin
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● Increased level of iron in the blood is deposited in to the organs(hemosiderosis or
hemochromatosis) that can cause organ damage
Clinical features
1) Frontal bossing
2) Maxillary prominence
3) Hepato splenomegaly
4) Severe Anemia
Diagnostic evaluation
1) Prenatal – amniocentesis
Chronic villus sampling
2) CBC
ꟷ Peripheral smear- microcytic hypochromic cell
ꟷ Hb electrophoresis is the confirmatory test
Management
● No specific treatment
● Monthly blood transfusion
● Administer the antidote of iron deferoxamine (working as chelating therapy. And monitor
nephrotoxicity)
● s/m – splenectomy to relieve abdominal pressure
●
HEMOPHILIA (royal disease)
Clinical Features
Management
❖ Same as hemophilia
BLOOD TRANSFUSION
Types of blood component Indication Timing
1. Packed RBC Anemia 3-4 hours
2. Platelet Thrombocytopenia 15-30 mnt
3. Fresh frozen plasma or Clotting factor replacement Over 2 hour
cryoprecipitate
4. Whole blood Aplastic anemia 3-4 hour
Hemorrhage
Hypovolemic shock
5. Albumin Hypoalbuminemia 2-3 hour
Nursing Intervention
1. consent
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2. RN – nurse is permitted to give blood transfusion
3. The blood bag should collect 30 minute before transfusion from the blood bank
4. Large volume of refrigerate blood infused rapidly cause cardiac dysrhythmia
5. Medication never added to blood component
6. The first 15 minute administer too slowly under close supervision
7. Infusion should not exceed more than 4 hour. Because hemolysis can occur that leads to
hyperkalemia
8. Monitor any reaction , if reaction is occur
● Stop the transfusion
● Keep the IV line open with NS
● Be along with the pt bedside and instruct another nurse to contact the physician
● Return the bag and tubing’s to the blood bank
Complication
TYPES OF IV FLUID
1. ISOTONIC SOLUTION
● Same osmolality as body fluid
● Increase ECF volume volume
Eg:- i) 0.9 %. NS - indication ischemic shock, contra indication CHF
ii) RL - content potassium.
2. HYPOTONIC SOLUTION
● More dilute solution and have as lower osmolality than body fluid
● Cause the movement of water enter in to the cell
● Administer slowly to prevent cellular edema. Eg: 0.45% NS, 0.33%NS,
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3. HYPERTONIC SOLUTION
● More concentrated solution and have a higher osmolality than body fluid
● Cause movement of water from cells into extra cellular fluid
● Administer slowly for to prevent, organ shrinkage
● Example 3%NS , D10%, mannitol, DNS
CALCULATION
MEDICATION DOSE FORMULA
Eg: a physician has prescribed an antibiotic Inj.Taxim 625 mg IV 8 hourly. The medication available
at pharmacy 10 ml= 1000 mg. Then how many ml administer to the child.
Answer:
Eg: a physician has prescribed an antibiotic for a child. The average adult dose is 250 mg. the child
has a body surface area of 0.41 m2. What is the dose of child?
Answer:
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Eg: a physician has prescribed an IV fluid NS 800ml over 6 hour through micro drip set. Then how
many drops per minutes you should administer to the client
Answer:
Exercise - : a physician has prescribed an IV fluid NS 1.5 l over 24 hour through micro drip set. Then
how many drops per minutes you should administer to the client
Step I:
Step II:
Eg: 500ml D5 % with 20000 unit of heparin sodium. Physician ordered administer 1000 unit/hour.
Then how many ml/hours you should administer to the client.
Exercise
1. A physician prescribed administer RL 800 ml over 4 hour. Then how many ml/hour you should
administer to the client?
a. 800/4 = 200 ml/hour
2. A physician has prescribed an antibiotic for a child is 50 mg/ kg/ day divided into 2 doses. The
child has a body weight of 66 lbs (pound). The medication available at pharmacy 1gm= 10ml.
then how many ml you should administer at one dose?
a. Step I: convert the child weight from pound (lbs) to kg
1.2 lbs = 1 kg
= 66/2.2= 30 kg
b. Step II : calculating one day dose
50mg/ kg/day
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Ie, 50 X 30= 1500 mg/day
1500/2 = 750 mg each dose
c. Step III: volume (ml) should administer at one dose
Dose prescribed/ dose in hand X total ml
Ie, 750(mg)/ 1 (gm) X 10
= 750 mg/1000 mg X 10 = 7.5 ml/dose
ELECTROLYTE IMBALANCE
SODIUM (NA+)= CNS symptoms
Hyponatremia Hypernatremia
⮚ decrease 135 meq/lt ⮚ increase 145 meq/lt
cause Cause
1. diarrhea 1. Sodium intake
2. diuretics administration 2. Renal failure
3. water toxicity 3. Corticosteroid
eg: drowning, bladder irrigation 4. Fasting(Increased H2O intake)
5. Diabetes insipidus
4. oxytocin overdose 6. Cushing
5. Addisons disease Clinical manifestation
clinical manifestation ● Altered cerebral function
● Headache personality change ● Agitation, confusion
● Confusion ● Extreme thirst
● Seizure ● Oliguria
● Abdominal cramp ● Dry skin
● Hypotension ● Increased urine specific gravity
● Polyuria ● Hyper tension
● Decreased urine specific gravity Management
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Management ● Monitor vitals
● Monitor vitals ● Administer diuretics
● Administer hypertonic saline. eg :- 3%.Ns ● Restrict sodium
● Increase sodium intake ● If the cause is fluid loss prepare to
Eg:- Butter, Canned food, Cheese, Milk, administer IV infusion
mustard
Hypokalemia Hyperkalemia
⮚ Less than 3.5 ⮚ More than 5
Cause Cause
● Diuretics – Lasix ● DKA
● Alkalosis / Hyperinsulinism ● Renal failure
● Cushing Syndrome ● Spironolactone
● Vomiting/ Diarrhea ● Acidosis
● NG suction ● Tumor lysis syndrome
● Water intoxication ● Addison's disease
● Digoxin toxicity
Clinical Features
Clinical Features
● Slow weak irregular HR
● Thread, Weak irregular pulse ● Hypotension
● Orthostatic hypotension ● Muscle cramps
● Shallow respiration ● Hyperactive bowel sound
● Paresthesia ● Diarrhea
● Absent bowel sound
● Paralytic Ileus
ECG Changes
ECG Changes
● Flat P – wave
● ST- depression ● Wide QRS complex
● Shallow flat or inverted T –wave ● Tall peaked T – Wave
● Prominent u-wave
Management
Management
● Monitor vitals and ECG
● Monitor vitals and ECG ● Treat the exact cause
● Administer injection potassium over ● IV regular insulin + Dextrose
dilution administer slowly under cardiac ● Administer Albuterol
monitoring. ● Dialysis
● Maximum recommended infusion rate is 5
10 mEg/ hour. Not exceed more than 20
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● Increase potassium intake.
Eg:- Banana, Orange, Carrot, Spinach and
fresh fruits.
Hypocalcemia/Tetany Hypercalcemia
⮚ Calcium less than 8.6mg/dl ⮚ Calcium more than 10mg/dl
Cause Cause
● Decrease intake of calcium ● Kidney disease
● Lactose intolerance ● Use of thiazide diuretics
● Malabsorption ● Hyperparathyroidism
● Inadequate intake of vitamin D ● Use of gluco-corticoid
● End stage kidney disease ● Dehydration
● Acute pancreatitis ● Use of Lithium
● Immobility
● Removal of parathyroid gland Clinical Features
● Increased heart rate
● Hypertension
Clinical Features ● Bone destruction
● Increased heart rate ● Profound muscle weakness
● Hypotension ● Disorientation
● Bronchospasm ● Formation of Renal Calculi
● Positive – Trousseau’s sign ● Abdominal distention
● Positive Chvostek’s sign ● Constipation
● Hyperactive bowel sound ● Decreased bowel sound
● Leg cramps
Management
Management ● Monitor vital/
● Monitor vitals/ ● ECG
● ECG ● Short ST segment
● Prolonged ST interval ● Wide T –wave
● Prolonged QT interval ● Administer Calcitonin
● Administer calcium orally or IV ● Route intranasal
● Prewarm the medication
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● Vitamin D supplements ● Increase water intake
● Initiate seizure precaution ● Movement with caution because chance for
● Increase calcium food pathological fracture
Eg:- Milk or its products, egg yolk, yogurt
Function
Hypomagnesemia Hypermagnesemia
⮚ Less than 1.6 mg/dl ⮚ More than 2.6 mg/dl
Cause Cause
● Malnutrition ● Mg containing antacid and
● Vomiting / Diarrhea laxatives
● Celiac disease ● MgSO4 administration
● Crohn’s disease ● Renal failure
● Drug – Diuretics
● Chronic alcohol
● Hyperglycemia
● Insulin administration
COMMUNICABLE DISEASE
MEASELS OR RUBEOLA
● Agent – Paramyxovirus / Morbillivirus
● Incubation period 10 – 20days
● Mode of transmission
ꟷ Airborne/Droplet/contact/Tran placental
Clinical Feature
● Fever
● Coryza
● Cough
● Conjunctivitis
● Kolpik’s spot- small red spot with a bluish white center and a red base located on the
buccal mucosa .( cross check the picture from net )
Management
● Isolation
● Dark room/humidified room
RUBELLA
● Agent Rubella virus.
● Incubation period 14 -21 days
● Mode of transmission
ꟷ Airborne/Droplet/Contact/Tran placental
● Communicable period 7 days before to about 5 days after the rash appear.
Clinical Feature
Pinkish red maculopapular rash that begins on the face and spread of the entire body within
1 – 3 days.
Sources of Infection
Management
● Isolation
● Special attention in pregnancy – Infection in pregnancy can cause CHD, cataract, growth
retardation, pneumonia, congenital defect in ear and brain.
Prevention
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● Vaccine is available
● It is a live attenuated vaccine
● Vaccine contra indicated in pregnancy
● Women should conceive at least 3 month after Rubella vaccination
MUMPS OR RUBULA
● Agent Paramyxovirus
● Incubation period 14 – 21days
● Mode of transmission – Droplet/ Direct contact
Clinical Feature
Management
● Droplet precaution
● Hot or Cold application
● Liquid diet.
Clinical Feature
● Respiratory infection
● Cough
● Cyanosis
● Toung protrusion
Management
● Isolation
● Antimicrobial therapy
● Pertussis Immune globulin.
DIPHTERIA
● Agent Corny bacterium diphtheria
● Incubation period 2 – 5days
● Mode of transmission
ꟷ More droplet
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Clinical Feature
Diagnostic Test
Management
● Isolation
● Administer diphtheria antitoxin
● Tracheostomy with mechanical ventilation.
CHICKEN POX
Agent Varicella zoster
Clinical Feature
Macular rash that first appear trunk and scalp and moves to the face and extremities.
Management
TETANUS
⮚ Agent Clostridium tetani
⮚ Mode of transmission – Direct contact
⮚ Incubation period 7 – 10 days
Clinical Features
Management
⮚ Isolation
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⮚ Antitoxin
⮚ Symptomatic treatment
Prevention
⮚ T.T vaccine
⮚ Booster dose of TT every 10 yearly
RABIES
⮚ Causative agent – Lyza virus
⮚ Infected from – Dog, Monkey, Fox, Bat, Raccoon
⮚ NEGRI BODIES
SCARLET FEVER
⮚ Agent Group A Beta hemolytic streptococcus
⮚ Incubation period 1 -7 days
⮚ Mode of transmission Direct contact/Droplet
Clinical Feature
⮚ High fever
⮚ Vomiting
⮚ Headache
⮚ Enlarged lymph nodes in the neck
⮚ Red fine sand paper like rash develop in the Axilla, groin and neck that spread to cover the
entire body except face
⮚ White strawberry tongue followed by red strawberry tongue
Management
⮚ Antibiotic
⮚ Isolation
Clinical Feature
● Opportunistic infection
● Chronic cough leads to pneumonia
● TB
● Pneumocystis pneumonia
● Diarrhea & Oral candidacies
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Diagnostic Evaluation
● ELISA
● Confirmatory test is Western Blot test – In this CD4+ cell is less than 200(Normal 500 –
1200)
Complication
Management
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99
2. VITAMIN B –COMPLEX
● B1 – Thiamine
DeficiencyBeriberi
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Sources Bran, Spinach, Rice, legumes
● B2 – Riboflavin
Function It is required by the body for cellular respiration
Deficiency Dermatitis, glossitis, Cheliosis
SourcesLegumes, cereals, egg, milk, green leafy vegetables
● B3 – Niacin
DeficiencyPellagra
Sources Chicken, peanut, mushroom, liver, beef, Avocado, seafood
● B6 – Pyridoxine
Function It is needed to maintain the health of nerves, skin, and RBC
Deficiency Peripheral neuropathy and neuritis
Sources Yeast, corn, meat, poultry, fish
● B9 – Folic acid
Function Help in DNA synthesis and formation of blood tissue and cell division.
Deficiency In pregnancy – Neural tube defect
Non pregnancy – Megaloblastic anemia
Sources Green leafy vegetables, liver, grape fruit, Orange
Daily intake In pregnancy – 400mg , Non pregnancy 200 mcg
Vitamin B12 – Cyanocobalamin
● Vitamin A (Retinol)
ꟷ Helps for vision
ꟷ Deficiency Night blindness/ Keratomalacia, or Xerophthalmia
ꟷ C/M Bitot spots
ꟷ Sources Liver, egg yolk, whole milk, green leafy vegetables, Orange
● Vitamin D (Calcitrol)
ꟷ Helps for absorb calcium
ꟷ Deficiency Rickets
ꟷ Sources Fortified milk, fish oil, sunlight
ꟷ
● Vitamin E (Tocoferol)
ꟷ It is beauty vitamin
ꟷ Helps for fertility
Sources Almonds, Spinach, sweet potato, Avocado
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● Vitamin K (Menadiol)
ꟷ Helps for blood clotting
ꟷ Deficiency bleeding
ꟷ Sources Green leafy vegetables, Broccoli, Spinach, Cauliflower, Cabbage
LACTODEX POWDER
Indications
1. Vitamin A deficiency
2. Eye problems
3. Skin disease
4. Scurvy
5. Cell damage
6. Wound healing
7. RBC production
8. Vitamin D deficiency
9. Growth & Development
HYPERBILIRUBENEMIA
→ Jaundice is the yellow color of the skin and sclera caused by deposit of Bilirubin.
→ Normal Bilirubin in newborn- less than 5 mg/dl in pre term and less than 12mg/dl in term
babies
Types
● Note that Jaundice starts at the head first spread to the chest, abdomen and then the arms and
legs followed by the hands and feet.
● Poor sucking reflex.
● Poor muscle tone.
● Enlarged liver.
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Clinical Assessment of Jaundice
Management
● Complication of Phototherapy
● Eye damage
● Dehydration
● Impotency
● Sensory deprivation
4. Intravenous Immunoglobulin
5. Exchange transfusion
6. Drug phenobarbitone
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MUSKULOSKELETAL DISORDER
Assessment
● Allis sign or Galeazzi sign (shortening of the affected limb) - this also can seen in femur
fracture
● Positive Ortolani test
● Positive Barlow test
● Positive Trendelenburg sign
Management
❖ Types
● Talipus Varus An inversion or bending inward.
● Talipus valgus An eversion or bending outward.
● Talipus Equinus Toes are lower than heal.
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● Talipus Calcaneus Toes are higher than heal.
Risk Factors
● Spina Bifida
● Oligohydramnios
● Smoking during pregnancy
Management
Complication of IV Therapy
1. Air embolism.
2. Circulatory overload.
3. Electrolyte overload.
4. Hematoma
● Collection of blood in to the tissue
● Clinical Feature: - Ecchymosis, immediate swelling, leakage of blood at the site painful lump at
the site.
5. Infection.
6. Phlebitis.
7. Infiltration.
● It is seepage of the IV fluid out of the vein and in to the surrounding interstitial spaces.
● Clinical Feature: -Edema, Pain, coolness of the site may or may not have blood return.
8. Tissue damage
● Damage the skin, vein, S/C tissue
● Clinical Feature :-Skin color change, Discomfort at the site
Complication of Tracheostomy
1. Tracheomalacia Constant pressure exerted by the cuff causes tracheal dilation and erosion
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of cartilage.
2. Tracheal stenosis Due to scar formation from irritation of tracheal mucosa by the cuff.
3. Tube obstruction
4. Tube dislodgement
5. TEF Cuff pressure causes erosion of the posterior wall of the trachea.
2. Convection- the flow of heat from the body surface to cooler surrounding air.(eliminating drafts
such as windows or air con, reduces convection).
3. Evaporation –loss of heat through conversion of a liquid to vapor.
4. Radiation – the transfer of heat to a cooler object not in contact with the baby.
Conversion
● 1 litter = 1000 ml
● 1 gm = 1000 mg
● 1 mg = 1000 mcg
● 1 gm = 15 grain (gr)
● 1/150 gr = 0.4 mg
● 1 ounce = 30 ml
● OD = Right eye
● OE = Left eye
● OU = Both eye
● 1 kg = 2.2 lbs
● 1 teaspoon = 5 ml
● 1 table spoon = 15 ml
● PC = After meal
● AC = Before meal
● 1 inch = 2.5 cm
● 1 feet = 30 cm
● 1 lbs = 453g
PSYCHIATRIC NURSING
ANXIETY DISORDER
1. Mild: mild occurs due to tension of everyday life. This type of anxiety may be motivating and
enhances growth. HIGH PERCEPTION
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2. Moderate: It focus on immediate concern, it narrows the perception
3. Severe: pt is feeling that something bad is about to happen. They need direction to focus
4. Panic attack: sudden onset of feeling with intense apprehension, tremors and dis organized
personality. They have inability to focus
Signs and symptoms of anxiety: -
1. Restlessness
2. Inability to focus
3. Sleep problems
4. Physical discomfort
Panic attack
- Chocking
- Chest pain
- Laboured breathing
- Dizziness
- Blurred vision
- Feeling of anxiety
Mgt of anxiety
Benzodiazepines
1. Diazepam (Valium)
2. Midazolam
3. Lorazepam
s/e of anti-anxiety drugs : - daytime sedation
- Dizziness
- Headache
- Blurred vision
- Hypotension
- Amnesia
- Antidote flumazenil
Contraindication- angle closure glaucoma
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POST-TRAUMATIC STRESS DISORDER (PTST)
After experiencing a psychologically traumatic event- the individual is prone to re- experience the
event and has recurrent and intuitive dreams or flashback
Causes:
- Natural disaster
- Murder
- Accident
- Rape
- Terrorist attack
- Violence
- Physical, emotional or sexual abuse
Symptoms
DEFENCE MECHANISM
It is an unconscious process that defense a person against anxiety. It is a coping mechanism
that enable a person to reduce stress or anxiety
1. DENIAL: when we refuse to accept or believe the existence of something that is very
unpleasant to us. Disowning consciously intolerable thoughts and impulses.
2. RATIONALIZATION: it is a defence mechanism in which the individual justify the failure
and socially acceptable behaviour, by giving socially approved reasons
It operates by 2 mechanisms
a) Sour grape: (unskilled worker blames always the tool)
b) Sweet lemon: (a poor man says, he doesn’t want to earn money because, money is the
root cause of many evil event)
3. CONVERSION: expression of emotional conflict through physical symptoms
4. PROJECTION: transferring one’s internal feelings, thoughts, unacceptable ideas to another
person
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5. DISPLACEMENT: feeling towards one person are direct to another person who is less
powerful or less threatening
6. SUPPRESSION: conscious deliberate for getting of painful thoughts, ideas and feeling.
They will be ….
7. REPRESSION: unconscious process in which client black undesirable and unacceptable
thoughts
8. COMPENSATION: putting forth extra effort to achieve in areas where one has a real or
imagined deficiency.
9. FANTACT : gratification by imaginary achievements and wishful thinking
10. REGRESSION : returning to an earlier developmental stage to express an impulse to deal
with anxiety
PHOBIA
Phobia is irrational fear of an object, for a situation that persist. Defense mechanism commonly used
in phobia is repression and displacement
Types
FLOODING – some times referred to as in vivo exposure therapy, is a form of behavior therapy
and desensitization or exposure therapy. based on the principles of respondent conditioning. As a
psychotherapeutic technique, it is used to treat phobia and anxiety disorders including post traumatic
stress disorder
Causes
Causes
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Symptoms
(Physical characteristics)
- Mistrust
- Hostility (viewing the centric world as enemy)
- Helplessness
- Hopelessness
- Anxiety
- Anger
- Guilt
- Depression
- Ambivalence (status of having mixed fooling or ideas about something or someone (-ve
feeling)
⮚ Grandeour delusions: false beliefs that one’s is a powerful and important person
⮚ Jealousy: false beliefs that one’s partner going out with another person
⮚ Persecution: false belief that somebody is going harm them
Mgt of Delusion
Types
1. Auditory
2. Visual
3. Tactile
4. Olfactory
5. Gustatory
Management.
1. Paranoid: -in which a person loses touch with reality. C/M including suspiciousness, hostility,
delusion, auditory hallucination, anxiety, anger/ violence
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2. Catatonic: - problem with movement or psychomotor disturbances. Most dangerous. very
less movement and does not respond to instructions
i. Stupor
ii. Immobility
iii. Waxy flexibility
iv. Purposeless unwanted movement
v. Echolalia
3. Residual – have previous history of schizophrenia pt shows intermittent signs of
schizophrenia negative symptoms.
4. Disorganized- Extreme social withdrawal, disorganized speech behaviour
Selfishness- stereotyped behaviour, inability to perform activity of daily living
5. simple [ no positive symptoms)
Management
Action: Improve the thought process and behavior of the client with psychotic symptoms. It affect
dopamine receptors in the brain
Side effect: - anti-cholinergic effect. Eg. atropine drug- dry mouth, Tachycardia, Urinary Retention,
constipation, hypertension
- Rigidity
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- Bradykinesia
- Tremors at rest
- Mask like face
- Drooling/ dysphagia
- Dystonia (muscle tone movement disorder) characterized by prolonged involuntary
movement
It is a potential fatal condition that occurs any time during antipsychotic medication
Symptoms
- Dyspnoea
- Tachypnoea
- Tachycardia
- Fever
- Altered LOC
- Difficulty swallowing
- Sever EPS
- Seizure
- Oculogyric crisis
- Treatment benztropine
GRIEF
D – Depression – after bargaining leads to depression and especially to good tasty acceptance
MANIA DEPRESSION
Cause – increased nor-epinephrine Cause – decreased nor-epinephrine and
serotonin
: extroverted – highly energetic It affects feeling, thoughts and behaviors
Symptoms Symptoms
- Become angry quickly - Hopelessness
- Extraverted personality - Powerlessness
- Grandeur delusion - Helplessness
- Persecutory delusion - Low self esteem
- Flight of ideas - Introverted
- Unlimited energy - Sleep disturbance
- Loss of appetite - Lack of interest in physical appearance
- Distracted by stimulus - Decreased speech
- Buffoon like appearance - Increased or decreased appetite
- Restlessness - Somatic complaint
- Low mood
- Low mood with high energy high
chance for suicide
MANAGEMENT - MANIA
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- Fatigue
- Alopecia
- Hypothyroidism
Lithium antidote- diamox or acetazolamide
NURSING MANAGEMENT
1. Reuptake inhibitor
Action: It inhibit serotonin uptake + elicit a anti-depressants action
Class -
C. A typical anti-depressant
Eg: Bupropion (Zyban), mirtazapine, nefazodone, trazodone
S/E: - dry mouth
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o Dry mouth
o Urinary retention
o Constipation
o Blurred vision
o Tachycardia
o Dilated pupils
Nsg responsibility
- Inform the client that anti-depression it may take several weeks for desired effect (2 to 4
weeks)
- Take with food on milk
- Instruct the client to avoid alcohol and driving, avoid alcohol consumption
Contraindications: should not be used with levodopa, OHA, dopamine, epinephrine, nor-
epinephrine, tyramine containing food, nasal decongestion. Because it cause hypertensive crisis. Eg:
phenelzine, isocarboxazid
S/E: - insomnia
- Dizziness
- Anti-cholinergic effect
THYRAMIN…. Containing food
- Major depression
- Mania pt resistant to lithium
- Schizophrenia
s/e:
- Confusion
- Disorientation
- Short term memory loss
Note – the usual course is 6-12 treatment, 2-3 times per week
1. Consent
2. Explain the procedure to the client and teach the client and family what to expect.
3. Maintain NPO status midnight or at least 4 hour.
4. Monitor vitals
5. Empty bladder, and bowel before procedure
6. Remove dentures, lenses, hairpins, etc.
7. Administer atropine sulphate before procedure ( it will help to decrease secretion and
bradycardia during procedure )
Nursing intervention – during procedure
1. Priority for airway and keep emergency tray always at the bedside
2. Monitor vitals
3. Once the client is awake talk to the client and take the vitals
4. Reorient the client frequently
5. Before giving anything to mouth check the gag reflex.
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EATING DISORDERS-
ANOREXIA NERVOSA: BULIMIA NERVOSA
It is associated with stressful life event. Client Client indulges in eating plenty, followed by parking
initially fear obesity and body image to distorted. behavior. Client will remain in the normal weight of
It can be life threatening because death can occur range, but things that the life are noted by eating
due to starvation, suicide, electrolyte imbalance. related conflict
Symptoms Symptoms
- Refuse to eat - Attempt to loss the weight through diet,
- Appetite loss vomiting, compulsive exercise
- Feeling of lack of control - Consumption high caloric food
- Self-induce vomiting - Poor inter personal relationship
- Self-administered enema - Low self esteem
- Compulsive exercise - Mood swing
Physical - Metabolic alkalosis
- Weight loss (BMI less than 18) - Loss of tooth enamel and dental decay
- Decrease temperature, pulse, BP - BMI 18.5 -24.9
- Constipation - RUSSELL SIGN ( calluses on the knuckles
- Metabolic acidosis or back of the hand due to repeated self
- Hyperkalemia induced vomiting over long period of time )
- Dry scaly skin
- Sleep disturbance
- Bone dehydration
Management.
DEMENTIA
It is an organic disorder with progressive deterioration functioning. It may result in self-care deficit
1) Alzheimer’s disease:
It is irreversible form of senile dementia memory. It affects the cerebral cortex
Incidence: - More common in female gender with genetic history
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Stages: recent memory impaired remote intact
Stage
S/E:
- Dizziness
- Headache
- Nausea
- Diarrhoea
- Confusion
Nursing diagnosis - risk for injury , impaired physical mobility
DELIRIUM
Altered level of consciousness. Sudden onset of confusion
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Causes
- Alcohol withdrawal
- Head injury
- Stroke
- Toxic levels of medicines or chemicals
Signs
- Confusion
- Disorientation
- Language deficit
- Hallucination
- Illusion
SUBSTANCE ABUSE
It is a mal adoptive pattern of a substance, use that impaired the cell in board senses
ALCOHOL ABUSE
- Slurred speech
- Unsteady gait
- Restlessness
- Confusion
- Binge drinking
- Arguments
Antidote - fomepizole
Psychological symptoms
- Depression
- Hostility (viewing the world has enemy)
- Rationalization
- Suspiciousness
- Irritability
- Isolation
Complication of alcohol abuse- vitamin B1 deficiency. Wernicke’s exophalopathy and Korsakoff
psychosis
Withdrawal symptoms
- It is a medical emergency because death can occur, MI, aspiration, fat embolism on
electrolyte changes
- Assess vital signs, neurological symptoms every 5 minutes, seizure precautions
- Administer multivitamins
- Prepare for therapy
● Marijuana, cocaine, heroin, codeine, are C1 classification of drug abus
ANAL stage: - (1 to 3 years) Toilet training begins in the period child from elimination or focus and
form their no tension
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PHALLIC stage: - (3 to 6 years) child experience pleasure and conflict feeling ….. with genital
organs
GENITAL stage: - (12 years to beyond) development of puberty. Individual develop satisfaction
from sexual emotional relationship to opposite sex
Milieu’s therapy: - milieu refers to physical and social environment in which client receive
treatment. It uses the safe environment to meet the client needs
THERAPEUTIC COMMUNICATIONS
1. Silence – client able to think about their problems doesn’t feel pressure or obligation to speak
2. Offering calls- offer to provide comfort to the client by presence eg: nursing staff tells that I
will sit with you and I will walk with you
3. Accepting- (listening) indicate non-judgemental acceptance of clients and this perception by
nodding and following what client says or demands
4. Give recognition: - indicate to the client you are aware of him and his behaviour. Eg: nurse
says good morning John; you have combed your hair this morning
5. Making observation- verbalize what you perceive. Eg: nurse: I notice that you can’t seeing
to sick skill
6. Encouraging description- ask the client to verbalize the perception. Eg: what is happening
to you now
7. Used broad openings- encourage the client to introduce topic of conversation eg: what are
you thinking about?
8. Offering general needs- to encourage the client to continue discussing the topic eg: tell me
more about that
9. Re-statting – repeat what client was said. Eg: client: I don’t want to take this medicine.
Nurse: you don’t want to take this medicine
10. Reflecting – direct client questions all statements back to encourage expressions of ideas and
feelings eg: client: do you think I should call my father. Nurse: what do you want to do?
11. Focussing- encourage client to stay on a topic or a point and eg: nurse- you were talking
about identify the based on
12. Exploiting – encourage the client to express feeling or idea. Eg: tell me more about
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13. Clarification- encourage the client to make ideas or feelings more expressed or
understandable eg: nurse: I don’t understand and that’s what you mean? Would you explain
to me?
14. Presenting reality- report events or situation as they really are. Eg: client: I don t get to talk
to my doctor. Nurse: I saw your doctor talking to you today morning
15. Translating into feelings- encourage the client verbalize feelings, expressed in another way.
Client: I will never be got better. Nurse: you sound rather helpless and hopeless
16. Suggesting collaboration- offer to work with client towards the goal. Client: I fail at
everything I try.
Nurse: we can collaborate or work together to achieve the goals
Features:
● Eye blinking
● Throat clearing
● Facial movements
● Shrinking of shoulders
● Chorea
● Dystonia
Management
Behavioral modification
Features
Management
CHILD ABUSE
It is a non-accidental physical injury or act of avoiding care by a parent or person responsible
for the child
TYPES
1. Neglect
2. Physical.
3. Emotional
4. Sexual.
Shaken Baby syndrome: it is a form of physical abuse characterized by violent shaking of
infant younger than 1yr, which results in intracranial haemorrhage casuing cerebral edema and
death.
Management;
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NURSING PROCESS
It is a systematic process of providing nursing care
Steps
● Assessment
● Nursing diagnosis
● Planning
● Implementation
● Evaluation
I. Assessment
Types of assessment.
1Initial assessment - it is performed when a person enters health care facility for the first time.
3.Time lapsed Assessment-is scheduled to compare a patient's current status to baseline data
obtained earlier.
4.Focus Assessment- assessment in which more detailed information are collected on. an already
identified problem.
Techniques of Assessment
Types of Data
● Subjective data-what the patient says or it is the symptoms eg: patient complaints of stomach
pain
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● Objective data-what the nurse find from examination or it is the signs eg: urine is cloudy
B.Physical Examination
Steps
1. Inspection
2. palpation
3. percussion
4. Auscultation.
1.Actual nursing Diagnosis- it indicates current problem. Eg: Acute pain related to surgical incision.
1. Asthma,Copd,Pulmonary embolism
3. Hypervolemia
4. Hypovolemia,dehydration
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Fluid volume deficit
5. Burns, bedsore,
6. Stroke, Parkinson,
Impaired swallowing
7.HIV/AIDS
III. Planning
Goals to be achieved
Short term goals- it is achieved within short period of time or within hospital stay.it focus on
immediate need of the patient.
Long term goals- it is to improve the functional ability and decrease disability.it is achieved at home
or in health care centre.
IV. Implementation
V. Evaluation
Checking the effectiveness and efficacy of intervention or checking whether the goals are
achieved or not.
Stages of sleep
Stages duration
stage1(NREM) = very light 5-15mts
sleep, sense of falling common
stage2(NREM) = Light sleep, 5-15mts
body temperature drops, heart
rate slows
Stage 3&4(NREM)=slow 5-15mts each
brain waves delta develops
stage 4 slightly deeper, body
repairs itself
stage5 (REM) = dreaming 10mts in first cycle (Up to 1hr in subsequent
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occurs, brain activity similar to cycle)
waking levels
sleep cycle restart after REM
Does not recall the event the may vividly remember the dream
next morning
Health is a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity.
EPIDEMIOLOGICAL TRIAD
● Clinician
● Educator
● Advocate
● Managerial
● Collaborator
● Leader
● Research
Disease occurrence in populations
Total number of deaths due to a disease (eg: cancer) in a defined area during a specified period /
mid-year population X1000
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Types of mortality rates
Crude death rate: number of deaths in an area in a year per 1000 population counted at midyear
Total no. of Deaths from all causes in 1 year/ no. of persons in the population at mid-yearX1000
EXAMPLE
Calculate specific death rate and crude death rate from the following table
CVD - 4200
Cancer- 3500
TB - 2500
Total = 10200
Solution:
Prevalence: refers to the total number of individuals in a population who have disease or health
condition at a specific period of time, usually expressed as a percentage of the population.
Incidence: refers to the number of individuals who develop a specific disease or experience a
specific health-related event during a particular time period (such as month or year)
MNEMONIC:
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Disease during a given time period
NURSING ADMINISTRATION
Roles of professional nurse
● Care provider
● Researcher
● Educator
● Leader
● Advocate
● Collaborator
● Manager
DELEGATION
Transferring the responsibility of performing a nursing activity to another person, while retaining
accountability for the outcome. Sources: American Nurses Association (ANA)/ National Council of
state Boards of Nursing (NCSBN) 2006
Scope of practice
RN LPN/LVN UAP
● Clinical assessment ● Monitoring RN findings ● Activities of daily living
● Initial client education ● Reinforcing education ● Hygiene
● Discharge education ● Routine procedures ● Linen change
● Clinical judgement (catheterization) ● Routine, stable vitals
● Initiating blood ● Most medication ● Documenting input/output
transfusion administrations except IV ● Positioning
● Psychological support ● Ostomy care
● Tube patency & enteral
feeding
● Specific assessments
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BENNER’S MODEL
ADVANCED BEGINNER: can note recurrent meaningful situational components, but not prioritize
between them
EXPERT: has intuitive grasp of the situation and zeros in on the accurate region of the problem
● Autonomy-self-determination, freedom
● Justice-Fairness to all people. Equal treatment
● Fidelity-faithful to commitments made to self and others
● Beneficence-Doing good
● Non maleficence- do not harm
● Veracity- Truthfulness
TORT
● Tort = a civil wrong; damage to property or a personal injury cause by another person
● Unintentional Torts = injuries that are the result of an accident or an action that was not
intended to cause harm
● Negligence = careless conduct that causes foreseeable harm to another person
o This is the most common unintentional tort
o Eg: pushing a friend into a pool- they hit their head and have a concussion and cannot
work for 2 days
o Your actions were negligent – you should have foreseen that your actions might cause
an injury
Intentional Torts
● Any intentional acts that are reasonably foreseeable to cause harm to an individual, and that
do so.
⮚ ASSAULT- verbal harassment by showing objrcts or by fearful contact.
⮚ BATTERY – intentional touching of others without their consent.
⮚ INVASION OF PRIVACY- intruding into private matters
⮚ FALSE IMPRISONMENT – restraining the patient without clinical evidence. And
detaining the pt.
⮚ DEFAMMATION OF CHARACTER- gossiping about others
▪ Slander- speaking bad about others
▪ Libel-writing bad about others
LEADERSHIP STYLES
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⮚ DEMOCRATIC (PARTICIPATIVE) – In this style leader and each member of the group is
important. Leader seek suggestions from the group. It is not suitable during emergency
situation.
⮚ LAISSEZ- FAIRE (FREE- REIGN) in the style leader assume a passive role and all decisions
are taken by members
Confidentiality
Accountability is a legal obligation in health care which is also an ethical and moral responsibility. It
is important to assume responsibility for one’s own nursing practice. The American Nursing
Association (ANA) has a code that states, the nurse will assume accountability for nursing
judgement and actions.
REPORTS
Incident Reports
● Used to documents any unusual occurrence or accident in the delivery of client care
● The incident report is not part of the medical record, but it may be used later in litigation.
ADVANCE DIRECTIVES
The most common classification uses the internationally accepted four colour system.
Red: indicates high priority treatment or transfer. Eg: massive Haemorrhage, Tension Pneumothorax.
Black: for dead or those minimal chance of survival, eg, massive head injuries, 95% coverage with
third degree burns.
COHORT STUDY
� In this study cohorts are identified prior to the occurrence of the disease
� For a medical entry, initial health examination was conducted and recorded from 1995-
2016.some of them are having BMI more than 25 so the Researcher planned to conduct a study to
find out the relationship of development of CAD in people with BMI more than 25. which among
the following is the most suitable study?
CASE CONTROL
� Case are people already with suspected disease are compared with control, are people who are
exposed to suspected cause
� In a community 100 males who are residing near to a power station were diagnosed with
hypertension. The researcher found that people living in this area are more prone for
hypertension, so planned to compare these patients with 100 males from the same area without
hypertension. Based on this situation which design the researcher will conduct to find out the
association?
ODD’ S RATIO
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Calculating Odds Ratio (OR)
Disease No Disease
(Case) (Control)
Exposed A B
Unexposed C D
= AD
BC
yes no
Yes 56(a) 274(b)
no 18(c) 390(d)
◻ Understand linkages and relationships among two or more variables without introducing any
intervention.
◻ Generate hypothesis that can be tested in experimental research.(Polit & Beck, 2004)
Estrogen
◻ Using correlational analysis, researcher determines:
◻ Strength type (Positive or Negative)
CROSS SECTIONAL
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� In this study design researcher collects date from the samples only one-time i.e one period of data
collection.
� Eg: researcher collects awareness about swine flu among people in a population
STATISTICS
MEASURES OF CENTRAL TENDENCY
Symbolically,
=∑
= 15+13+18+16+14+17+12
= 105/7 = 15
MEDIAN
5,8,10,11,13,15,17,18,22
Median =13
MODE
● The mode
● This is the value that occurs most frequently in a data set
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● Example:
● Find the mode
● 6, 7, 2, 3, 4, 6, 2, 6 mode is 6
● 6,7, 2, 3, 4, 5, 9, 8 no mode
RANGE
Definition :
The range of a set of data values is the difference between the maximum data value and the
minimum data value.
It is very sensitive to extreme values; therefore not as useful as other measures of variation.
PROBABILITY DISTRIBUTION
EXAMPLE:
Total amount collected from 10 persons are 90 rupees with standard deviation ( =4). Express this
in form of probability distribution
Solution
SD = 4
Total persons
= 90/10 = 9
3 4
Probability Distribution = Mean+-SD 4
So 9 +-4
Z-SCORE
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EXAMPLE:
A study was conducted among 100 people for Hypertension. Out of it 75% of people have high BP
and expressed as 175 +-10. Find the % of BP ranging between 165 – 185mmHg
Solution:
Z = 165 -175
10
= -10/10 = -1
X =185 µ = 175 Ꝺ = 10
Z = 185 -175
10
= 10/10 = 1
-1 to +1 µ +- 1 Ꝺ = 68%
Exercise 2. Inorder to find the the probability distribution 81 apple is collected from 9 trees . and the
standard deviation is 2.
OBG
ANATOMY – UTERUS
Weight-50-60. Gram
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SHAPE- pear shape
Weight in pregnancy -1 kg
FERTILIZATION
IMPLANTATION
The zygote is propelled towards the uterus. Fertilization to implantation timing is 7-10 days
PLACENTA
UMBILICAL CORD
● It contains two artery and one vein. artery carry deoxygenated blood and vein carries
oxygenated blood.
PELVIS
● Gynecoid pelvis-normal female pelvis. most favorable for successful labor and birth.
● Anthropoid pelvis-oval shape, adequate outlet with a narrow pubic arch.
● Android pelvis- heart shaped resembles male pelvis.
● Platypelloid- flat with an oval inlet. wide transfers diameter but short anterior posterior
diameter making labor and birth difficulty.
AMNIOTIC FLUID
⮚ 2-3 week. Blood circulation begins and heart is tubular and begins to beat.
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⮚ 3-5 weeks. Double heart chambers are visible.
⮚ 8weeks.every organ system is present.
⮚ 12 weeks. Kidney begins to form urine. And sex is visually recognizing
⮚ 16 weeks. fetus is 100 grams. lanugo begins to develop. fetal ossification occurs.
⮚ 24 weeks. Fetus has ability to hear.
⮚ 28 weeks. Fetus is 1.1Kg. brain is developing rapidly and if born neonate can breathe at this
time.
⮚ 32 weeks. bones fully developed
⮚ 6 weeks. Skin is pink and less wrinkled.
⮚ 40 weeks. weight.3.2KG length 40 CM .skin pink and smooth. testis is in the scrotum, and
labia majora are well developed.
NAGELES RULE-
GTPAL SCORE
Example - a lady is pregnant for the sixth time .she had one cutaneous abortion in the first trimester.
She deliverd twin daughter at 37 week gestation and twin boy at 35 week gestation. Also delivered
twin boy at 38 week gestation and girl after completion of 37 weeks .before one year one daughter
was expired due to pneumonia apply GTPAL score – G6T2P2A1L6
PRESUMPTIVE SIGN:
⮚ Amenorrhea
⮚ Nausea and vomiting due to increased HCG hormone (placenta is producing HCG hormone)
⮚ Increase size and increased feeling of fullness in breast. (due to increased estrogen and
progesterone)
⮚ Pronounced nipples.
⮚ Urinary frequency. (because the enlarged uterus is compressing the urinary bladder)
⮚ Quickening. - the first fetal perception feels by the mother itself. it occur 20 weeks in
primigravida and 16 week in multi Para
⮚ Fatigue
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PROBABLE SIGN:
⮚ Uterine enlargement
⮚ Chadwick sign- violet discoloration of the vagina, vulva and cervix occur at about week 4.
⮚ Goodle sign- softening of the cervix that occur at beginning of the second month.
⮚ Hegar sign. Compressibility and softening of the lower uterine segment occur at about week 6
⮚ Ballottement-rebounding of the fetus against the examiners figure on palpation.
⮚ Braxton hick’s contraction- irregular painless contraction that may occur intermittently
throughout pregnancy.
⮚ Positive UPT
POSITIVE SIGN:
⮚ FHR is detected by electronic device at 10-12 week. and through fetoscope by 20 weeks.
⮚ Active fetal movement.
⮚ Outline of the fetus via USG.
BEST POSITION IN PREGNANCY – left lateral (especially in second and third trimester) for
to prevent vena cava syndrome
FHR
DISCOMFORT CAUSES
Nausea and vomiting Increase HCG Hormone
Syncope Increase blood volume
Anemia
Sudden position changes
Breast tenderness Increase estrogen and progesterone
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Increased vaginal discharge Hypertrophy and thickening of the vaginal
mucosa
Nasal stiffness Increase estrogen
Heart burn Increase progesterone
Head ache Changes in blood volume
hemorrhoids Increase venous pressure and constipation
constipation Increase progesterone
Decrease intestinal motility
Displacement of the intestine due to pressure
of the uterus
Back pain Due to abnormal posture
Leg cramps Altered calcium and pressure on the uterus on
the nerves
AMNIOCENTESIS:
ANOTHER TEST
● Fern test
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● Non stress test
● Contraction stress test
● Hemoglobin and HCT
● GTT
NORMAL LABOUR
EUTOCIA – NORMAL LABOUR
STAGES OF LABOUR
✔ FIRST STAGE - It starts from the onset of true labour pain and ends with full
dilatation of cervix. average duration in primi 8-12 hours and in multi 4-6 hours
✔ SECOND STAGE - it starts from the full dilatation of cervix and ends with expulsion of
the fetus from the birth canal. Timing 2 hours in primi and 30 minutes in multi.
✔ THIRD STAGE - It begins after expulsion of the fetus and ends with expulsion of he
placenta. and membranes. is about 15 minutes in both primi and multi. sign and symptoms
of third stage of labor. -gush of vaginal bleeding, uterus feels hard to touch,
lengthening of umblical cord.
✔ FOURTH STAGE – it is the stage of observation for at least one hour after expulsion of the
placenta.
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Active phase 4-7 cm 3-5 minutes 30-60 seconds Every 30 minutes
NOTE: early deceleration of FHR, it is due to head compression late deceleration of FHR
indicate fetal distress. management give left lateral position and administer oxygen.
MECHANISM OF LABOR
▪ ENGAGEMENT/LIGHTENING/DROPPING
▪ DESCENT
▪ FLEXION
▪ INTERNAL ROTATION OF HEAD
▪ CROWNING
▪ EXTENTION
▪ RESTITUTION
▪ EXTERNAL ROTATION OF THE SHOULDER AND INTERNAL RATATION OF THE
BODY
▪ EXPULSION
2. ABRUPTIO PLACENTA
⮚ Premature separation of the placenta from the uterine wall after the 20 week of
gestation and before the fetus is delivered
⮚ Causes
● Trauma
● Short cord (normal length 45-50 CM)
● Sick placenta
● Cocaine abuse
● Previous history of longitudinal C.S
⮚ Clinical features
● Dark red painful vaginal bleeding.
● Severe abdominal pain
● Uterine rigidity
● Sign of fetal distress
● sign of maternal shock if bleeding is excess.
● DIC
⮚ MANAGEMENT
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⮚ Monitor maternal vitals and FHR.
⮚ Administer oxygen, IVF, and blood products.
⮚ Place the client in a extremely Trendelenburg position.
⮚ Prepare for delivery of fetus as quickly as possible with vaginal delivery, preferably if
the fetus is healthy and stable and the presenting part is in the pelvis.
⮚ Emergency C.S is performed if the fetus is alive but shows sign of distress.
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⮚ Risk factor
● Primigravida
● Family history
● Placental abnormality
● Incompatibility
● Age less than 19 and more than 40
⮚ Clinical features
● Alarming features- early morning head ache. Disturbed sleep. Oliguria. Epigastric pain.
Diminished vision
● Late features- hypertension. Edema (pitting edema over ankles persist at early morning) and
proteinuria
⮚ Complication
● Maternal- eclampsia
HELLP syndrome
H – hemolysis
EL – elevated liver enzyme
LP- law platelet count
Accidental hemorrhage
Preterm labor and PPH and sepsis
● Fetal- fetal distress, IUD, IUGR, Prematurity. And asphyxia
⮚ Management
⮚ Drugs- methyl dopamine, labetalol, nifedipine, hydralazine
⮚ Diuretics.
⮚ Complete bed rest to prevent cardiac complication
⮚ Diet- high caloric high protein adequate sodium and adequate water. or balanced diet.
⮚ Legumes can give (rich sources of protein daily 100gram )
⮚ Administer MgSo4 to prevent eclampsia and preterm labor.
⮚ Frequently monitor neurological status and magnesium toxicity.(MGSO4 TOXIC(BURP)-
decrease BP, decrease u/o, decrease respiration, decrease platellar reflex.)
BREAST CANCER
⮚ RISK FACTOR
✔ Age after 40 years
✔ Nulliparity
✔ First delivery after 35 years
✔ Previous history of uterus, ovary and fallopian tube
⮚ Clinical feature
✔ Initially painless lump over the nipple, over breast or below the axilla. But later pain present.
✔ Asymmetry of the breast. Ie affected breast being higher.
✔ Clear to mucoid purulent nipple discharge
✔ Orange peal skin
⮚ Diagnostic evaluation
✔ Early detection
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● 1. Mammogram- should perform after 40 years every early
● 2. Breast self examination
If the lady has every 28th day cycle should perform 7-10 days after menstruation.
Menopausal women or after hysterectomy should perform every month in a day
✔ Confirmatory test
● Biopsy
● CT, MRI, PET scan
● (CA15-3, CA27-29)
⮚ Management
✔ Chemotherapy- vincristine, cisplatin
● Side effect- reversible alopecia
● Nausea and vomiting – so give anti emetic prior to chemotherapy
● Anemia-so frequently monitor CBC
● Leucopenia and fever
● Tumor lysis syndrome- it include hyperkalemia, hyperphosphatemia, hypocalcemia, and
increase BUN and azotemia.
● Gastritis
✔ Radiation therapy
✔ Modified radical mastectomy
✔ Post operative intervention
● Semi fowlers position to work the drain effectively
● Affected hand should be elevate to prevent lymphedema.
● No IV line, no injection, no BP measurement on the affected hand.
● Exercise- morning mastectomy done the evening exercise is just movement of the wrist and
figures
● First exercise- ball squeezing or wall climbing exercise.
● Flowed by combing of hair and put up the hair
● Avoid over usage of the affected arm for several month
● Avoid wear tight jewelers or cloth on the affected hand
● Avoid get sunlight on the affected area
● For hormonal manipulation instruct the client to take tamoxifen tablet(nolvadex)
✔ Nursing diagnosis
● At the time of discharge – disturbed body image.
OVARIAN CANCER
It grows rapidly ,spread fast and is often bilateral.metastasis can occur due to organs in the pelvis or
through other organs,including lining of abdomen, lymph nodes,lung and liver
R/F – nulliparity , hormone therapy after menopause, use of fertility medication,obesity,women B/W
55-65 years
S/S – asymptomatic in early stage, abdominal discomfort & bloating, dysfunctional vaginal bleeding,
abdominalor pelvic or back pain, frequent urination, elevated tumour marker ( ca 125 )
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● Monitor fetus status closely for sign of distress and, it noted prepare the client for immediate
C.S
● Carefully regulate insulin and provide glucose IV as prescribed because labor depletes
glycogen that cause hypoglycemia
⮚ Intervention during post-partum period
● Observe the mother closely for a hypoglycemic reaction because a precipitous decline in
insulin requirement normally occurs (the mother may not require insulin for the first 24 hours.)
● Regulate insulin needs as prescribed after the first day, according to blood glucose testing.
SURGERY
CESSARIAN SECTION
Elective Emergency
1. Placenta previa 1. Abruption placenta
2. Previous cesarean 2.Occult/cord prolapse
3. CPD and previous uterine surgeries 3.Fetal distress
Shoulder Dystocia
⮚ Suprapubic pressure
⮚ Cleidotomy-One or both clavicles may cut with scissors to reduce the shoulder girth.
⮚ Surgery do not do in living fetus
DRUGS
PROM-Monitor FHR
IMPORTANT ANTIDOTE
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⮚ Heparin : protamine sulphate
⮚ Warfarin : VITAMIN k
⮚ Potassium : regular insulin+ glucose / albuterol
⮚ Organon phosphate : atropine sulphate
⮚ Insulin : dextrose 50%
⮚ Dopamine : phentolamine
⮚ Digoxin : Digi bind/Digifab
⮚ Cyclophosphamide : mesna
⮚ Cyanide : sodium thio sulphate
⮚ Lithium : Diamox
⮚ Beta blocker : glucagon
⮚ Midazolam/diazepam : flumazenil
⮚ Anti-cholinergic : physostigmine
⮚ PCM/acetaminophen : mucomilt/N -acetyl cystine
⮚ Morphine : naloxone hydrochloride
⮚ Iron : deferoxamine
⮚ Led : succimer/dimercaprol
⮚ Penicillin : adrenaline
⮚ Thrombolytic : amino carporicacid
⮚ Magnesiumsulphate : calsiumgluconate
⮚ Universal antidote : activated charcoal
⮚ OPOIDS ; NALAXONE
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