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NCLEX REVIEW – GAPUZ REVIEW CENTERNCLEX REVIEW – GAPUZ REVIEW CENTER(31 JANUARY – 17 FEBRUARY 2005, PICC, City of Manila)
DAY 1 (31 JANUARY 05)
STEPS IN PASSING
Have a Right Attitude THINK POSITIVELY … have a Fresh Start KNOW what YOU WANT and HOW TO GET IT OVERVIEW OF ESSENTIAL CONCEPT TRY OUT Focus assessment 7 habits of SUCCESSFUL EXAMINEE
MOSBY – growth and developmentLIPPINCOTT – care of the Elderly and Communicable Disease
DIGOXIN – monitor the creatinine… “ the TV DOESN’T look good to me” (DIGOXIN TOXICITY – nausea/vomiting, abdl cramps)
Olive = butter
CK – normalize 1 – 3 days after MILDH - 10 – 14 days
ATRIAL FLUTTER – SAW TOOTH
PROCESS OF ELIMINATION
consider MASLOW’s H of NEEDS consider the COMPLICATION whether ACUTE – ALWAYS prioritize CHRONIC ABCs SAFETY FIRST NSG PROCESS
MMR VACCINE – only vaccine for HIV pt.
Pt on HEPARIN – APTT (N 30-40sec), therefore if INCREASE – bleeding
POISON - nursing action in order : #1 CALL poison control center # 2 MINIMIZE EXPOSURE of pt to poison – pull him/her away from the poison
# 3 IDENTIFY the poison
GENTAMYCIN – s/e tinnitus, vertigo, ototoxicity, oliguria
LITHIUM CARBONATE – for ELDERLY : N level NOT more than 1.0meq/L ADULT : N .5 – 1.2 meq/L
HEPA B diet : low fat, increase CHON
DOWN SYNDROME – large tongue – feeding problem – poor sucking (infants)
SAFETY PRINCIPLE
1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inches in height seat belt location in car: BACK CENTER SEAT
2. TODDLER – falls3. SUPRATENTORIAL craniotomy – semi fowler’s position
INFRATENTORIAL – flat in bed
4. SCATTER RUGS – osteoporosis pts.5. TRIAGE ; burns, open fx – “SHOCK”
Things NOT TO BE DELEGATED by RN: Assessment, Teachings, Evaluation
Pt 50y/o and - mammogram – once a year.
Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl FREE). – therefore LOW CHON
Pt with Rocky Mountain Fever – exposure to dog ticks Lyme’s Dses – deer ticks
PSYCHE PATIENTS
1. remember to stick to unit rules/policy – be consistent to pt.2. encourage verbalization – “tel me how…..”3. sound knowledge of cultural diversity
- seek help of interpreter4. acknowledge pt feelings – “it seems….”
“this must be difficult…..”5. emphatize with your patients’s feelings
“ I understand how you feel…..”
CATARACT – CAUSES – aging and trauma
MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WHEN W/ PT
DAY 2 ( 01 February 05)
T U B E S
1. GROSHONG CATHETER - 2 lumen HICKMAN - 3 lumen BROVIAC - 1 lumen
ALL requires Central Venous Access- sites: cephalic, brachial, basilica and superior vena cava
PURPOSE: For TPN Administration of Chemo Agents, Blood Products, Antibiotics
COMPLICATION:Thrombosis and Bleeding
2. CHEST TUBES – Water Sealed Drainage
Types: Anterior – w/c drains AIR Posterior - w/c drains FLUIDS
Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system
1 BOTTLE : 3 – 5cm of only (length of tube to be emerge)
2 BOTTLE : First bottle – drainage bottle (no tube emerge), 2nd bottle - long rod 3-5cm
3 bottle : FREQUENTLY USED
1st bottle – drainage2nd bottle – water sealed3rd bottle – suction bottle control
COMPLICATIONS: bubbling, breakage, blockage
Nsg ALERT:
NORMAL : BUBBLING is N in the 3rd bottle – it indicates that suction is ADEQUATE
(if no bubbling STOPS in the 3rd bottle, meaning – inadequate suction)
ABNORMAL : if bubbling occurs at the 2nd bottle – indicates LEAKAGE – action, check sealed at air tight container and the pt and bottle connection.
In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry of air and or may use forcep to clamp tube temporarily.
If pt. ambulates, keep bottle LOWER than the patient.
ABSENCE of OSCILLATION at the 2nd Bottle – indicates blockage
TOWARDS THE BOTTLE - When MILKING the tubings.EMERGENCY EQUIPMETS AT BEDSIDE: xtra bottle,clamp, gauze
3. TRACHEOSTOMY TUBE - to maintain patent airway for pt w/ neurological problems and
musculoskeletal disorders.
nursing care:
1. Suctioning – 10-15seconds - if (+) bradycardia, STOP
- if accidentally dislodge, insert obturator to keep it open
2. AVOID: water sports – swimming
3. In changing ties – insert new one first BEFORE REMOVING old tie.
4. Ribbon or ties @ side of the neck only to avoid pressure.
5. Before and After suctioning – hyperoxygenate the patient.
4. PTCA – enlarge the passageway for bloodflow. problem: spasms that lead to arrhythmia
C-STENT (cardiac-stent) – alternative to PTCA Maintains patency of bld vessels Problem: dislodge
IABP (Intra Aortic Balloon Pump)- for Cardiogenic Shock
problem: thrombus formation, infection and arrhythmia
5. PENROSE DRAIN - wound drainage system
- doctors the one who removes this. - remove gradually
6. NASO GASTRIC TUBE – stomach and intestine (duodenum) Types:
Levine Tube – for stomach - 1 lumen, for lavage (cleaning) and gavage (feeding)
Salem Sump – for stomach - 2 lumen (I for suctioning, I for lavage/gavage)
- if pt (infant) is having enteric coated meds, request for change in form of meds
Miller Abbot – for intestinal (w/ mercury b4 injection) - 2 lumen (insert then inject the mercury)
Cantor – for intestinal - 1 lumen
Nursing Care for NGT:
1. tip of nose to earlobe to xyphoid process (for stomach)2. tip of nose to earlobe to XP + 7-10 inches for intestinal NGT3. accurate means to verify correct placement: ALWAYS consider Two checking
criteria: ASPIRATION and Gurgling Sounds
Report the following:
If (-) or decrease drainage, (+) nausea and vomiting (+) abdml rigidity
Characteristic of Gastric Residual: more than 50 mo and coffee ground.
Before feeding check for placement.
7. GASTROSTOMY TUBE (GT) PEG
both for NUTRITIONAL PURPOSES
GT – incision (abdomen to stomach)- for pt (+) lesion at esophagus- nsg care : report s/s of infection, abdl cramps, n/v- provide adequate skin care
PEG – incision at skin- long term therapy
8. T TUBE - to drain excess bile until hearing occurs - place drainage bag at the level of t-tube
(obstruction of t-tube – there will be excess drainage)
500 ml – N drainage in 24hrs, if report ASAP.
9. HEMOVAC JACKSON-PRATTS (JP)
BOTH used as close wound drainage suction system BOTH system function on the system of (-) pressure.
JP – compress the container before attaching to the drainage.
WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount.
10. THREE-WAY FOLEY
absence of clot – effective
Characteristic of drainage – 2-3 days after surgery (bloody to pinkish) – NO NEED TO REPORT THIS – it is expected
11. SUPRAPUBIC CATHETER – for genito urinary problem- inserted directly at the bladder wall- check if properly anchored
12. URETHRAL CATHETER – to drain urine.- never clamp because it can only hold 4-8 ml of urine.- keep open to drain urine from kidney pelvis.
SENGSTAKEN BLAKEMORE TUBE- 3 lumen ( for esophageal balloon, gastric balloon, for meds)- for pt w/ esophageal varices- balloon tamponade- 48 hrs – keep balloon inflated for 10 minutes to decrease bleeding
LINTON TUBE – 3 lumen
MINESOTTA TUBE – 4 lumen
SCISSORS – important EQUIPMENT AT BEDSIDE FOR ALL TUBES. HEMOSTAT – important instrument that shld be @ bedside for water sealed
drainage. Persistent bubbling at water drainage bottle – for bottle #2 – check if tubing is
properly sealed. NGT IS REMOVED – if patient exhibits return of bowel sounds. BULB SYRINGE – use to clean the nares of pt with NGT (child) To facilitate removal of air at lungs – purpose of water sealed chamber in 3 way
bottle system.
THERAPEUTIC DIET
GENERAL CONSIDERATION
Know the DIAGNOSIS of the patient Identify & incorporate the pt. dietary preferences Instruct pt on what to avoid For pregnant pt, note dietary changes:
a. addtl calories (300 cal/day) average of 2400 - 2700b. addtl of 10gms/day for CHONc. IRON : 15-30mg/dayd. CALCIUM : RDA is 1000 then +200mg/day (broccoli,tuna,cheese) e. Galactogogues – increase production of milk
PEDIATRIC pt – by 4-6 mos – START iron supplement due to iron depletion and (-) extrusion reflex.- cereals, fruits, vegetables,meat and table foods- egg yolk (6mos), egg white (1yr)
TRANSCULTURAL CONSIDERATION
CHINESE – like cold desserts after surgery for optimum health
JEWS – “kosher diet” (no meat and diary products at the same time)
EUROPEANS – main meal is served at mid day followed by espresso
MUSLIM – “halal diet” – no pork
SDA – strictly vegs diet (vit B6 and B12 deficiency)
MORMONS– words of wisdom (no caffeine, alcohol and once a month fasting) – the amount due for food is donated to the church
KEY POINTS FOR NURSES
Sodium (Na) – source down the soil Potassium (K) - source up the tree
Low Na Diet : AVOID processed foods, milk products and salty foods
KNOW the serving: CHO - 6-11 servings CHON - 2-3
FRUITS & Vegs - 3-4 FATS - sparingly
MOST COMMON DIET
CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT)
- given to pt to relieve thirst, correct fld & electrolyte imbalance - given also to pt post-opex: apple juice, gelatin (strawberry), popsicle, candy
RENAL DIET
- for kidney disorder (renal failure, AGN, Nephrotic syndrome)- to maintain fld & e imbalance
LOW CHON – avoid poultry products LOW Na - avoid processed foods, milk products, & salty foods Low K - avoid fruits (anything you see in a tree)
LOW FAT/CHOLESTEROL RESTRICTED DIET
- for liver disorder, cardiovascular and renal dsesALLOWED: lean meat, fruits, vegs and fish
AVOID : Sea foods, fried foods, preserved foods (cheese cake and custard)
HIGH FIBER DIET - to prevent constipation, hemorrhoids & diverticulitis- vegs, fruits and grain products
SOFT DIET
- for inflammatory conditions: esophagitis, peptic ulcer gastritis- pureed foods/ blenderized foods- soup
PURINE RESTRICTED DIET
- for gouty arthritis- increase fluid intake- AVOID: preserved foods, sea foods, alcohol, organ meat (liver, gizzard)
NA RESTRICTED DIET
- for cardiovascular dses, renal, fld & e imbalance- ALLOWED: fresh vegs- AVOID : processed foods, milk products and salty foods
BLAND DIET
- for peptic ulcer, inflammatory GI conditions- AVOID: chemically and mechanically irritating foods such as fried foods, fresh
and raw fruits & vegs (EXCEPT: avocado, banana & pinya) and spicy foods with preservatives
HIGH PROTEIN, HIGH CARBO DIET
- for burns (about 5000 cal/day)- grain products and poultry – to aid the healing tissues
ACID ASH DIET
- to decrease the ph of the urine- indicated for pt w/ alkaline stone ex struvite- ex. 3 C’S – cranberry, cheese, & corn 3 P’S - prunes, plums & pastries
ALKALINE ASH DIET
- to increase ph of the urine- indicated for acid stone ( uric acid stone, cystine stone)
- ex. Milk
GLUTEN-FREE DIET
- for celiac dses- ALLOWED : rice, corn, cereals, soy beans- AVOID (LIFETIME): barley, rye, oats, wheat
PHENYLALANINE DIET
- for PKU, until age 10 and adolescence only- AVOID : CHON rich foods (meat products – luncheon meat)
FULL LIQUID DIET
- opaque- transitional diet from liquid- ex : cream soup, ice cream, milk, leche flan, pumpkin cake
“ABGs” ATERIAL BLOOD GASES
Ph – 7.35 – 7.45PCO2 - 35 – 35HCO3 - 22 – 26 meq/L
Ph Compensatory Mechanism
Uncompensated abnormal no changePartially compensated abnormal increase or decreaseFully Compensated normal increase or decrease
Diarrhea – metabolic acidosisVomiting – metabolic alkalosis
PRIORITIZING of case: Med.-Surg – “abc” Psyche - safety first Fire - race Triage - pt evaluation system (prioritizing)
APGAR SCORING
0 1 2
Appearance pallor acrocyanosis all pinkPulse (-) <100 >100
Grimace (-) grimace vigorousActivity flaccid some flexion flexion & extensionRespiratory (-) irregular lusty cry
T.R.I.A.G.E -prioritizing
LEVEL 1 “emergency”
severe shock, cardiac arrest, cervical spine injury, airway compromise, altered level of consciousness, multiple system trauma, eclampsia
LEVEL 2 “urgent (stable)”
can be delegated (fever, minor burns, lacerations, dizziness)
LEVEL 3
chronic/ minor illness (can be delegated) – dental problems, routine medications and chronic low back pain
TIPS ON PRIORITIZING
1. PT @ ER – sleeping pills overdose;
2. pt bp 80/30 & mother died of CVA 1st priority : assess pt for addtl risk factor;
3. pt ask what procedure: Rn Action : notify the doctor
4. MI attack – 1st action : report ASAP (esp. presence of vent. Fibrillation)
5. pt on NGT – check patency of tube
DELEGATION
- do not delegate Assessment, Teaching and Evaluation- do not delegate meds preparation, administration, documentation
CONCEPT OF DELEGATION
consider the competence of personnel 5 R’s in delegating (RIGHT task, person, circumstances, direction/communication supervision) RN may delegate – feeding client, routine vital sign (pt w/ no complications) and hygiene care
MI ATTACK – enzymes to increase IN ORDER - #1 myoglobin #2 troponin
#3 CK #4 LDH
RISK FOR INJURY – meniere’s dsesINEFFECTIVE BREATHING PATTERN – myasthenia gravisALTERED TISSUE PERFUSION – pt w/ complete heart blockINEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing
D
DAY 3 ( 02 February 05)
POSITIONING FOR SPECIFIC SURGICAL CONDITION
Positioning – independent nsg function- know the purpose of the positiona. to prevent or promote soothing;b. what to prevent or promote;c. know your anatomy & physiology
Post Liver Biopsy – R side lying – to prevent bleeding(during the procedure – L side lying).
Hiatal Hernia – upright to prevent reflux.
AMPUTATION complication: hemorrhage (keep tourniquet @ bedside)
1st 24hr – goal: to decrease edema – elevate the stump at foot part w/
the use of pillow
AFTER 24hr – goal : to prevent contracture deformity (keep leg extended)
APPENDICITIS
Unruptured : any position of comfort
Ruptured : semi to high fowler’s position to prevent the upward spread of infection
complication: peritonitis
Ruptured appendicitis indication: pain decreases or go away. (pt say, “I want to go home pain is gone”)
BURNS
Position is FLAT or Modified Trendelenburg – to prevent shock.
SHOCK occurs w/in 24-48hrs (immediate post burn phase).
Complication: infection
CAST, EXTREMITY
Elevate the Extremity – to prevent edema (use rubber pillow)
Nsg care: a. capillary refill – N 1-3 seconds only (complication: altered circulation)b. note for s/s of infection (when there is musty odor inside the cast)c. pruritus (inject air using bulb syringe)d. blood stained – mark and note (if increasing in diameter - report ASAP)e. tingling sensation – indicate nerve damage
CRANIOTOMY
Types:
a. Supratentorial C – semi fowler’s orlow fowler’s position – to prevent accumulation of fluid at surgical site;
b. Infratentorial C - flat or supine. Purpose: same
FLAIL CHEST
(+) Traumatic Injury – paradoxical chest movement – areas of chest GOES IN inspiration and OUT on Expiration
position: towards the affected side to stabilize the chest.
GASTRIC RESECTION
- to prevent dumping syndrome – usually for 10 mos only NOT LIFETIME disorder (post gastrectomy)
- position : LIE FLAT for 1-2hrs post meal
HIATAL HERNIA
- there is damage to esophageal mucosa- what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION.
HIP PROSTHESIS
Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use of wedge pillow or triangular pillow from perinium to the knees.
dumping syndrome : “flat”
LAMINECTOMY
- “log-roll the patient” (3 nurses) – KEEP SPINE IN STRAIGHT ALIGNMENT- AVOID: hyperflexion, hyperextension and prone – it causes hyperextension of the spine.
LIVER BIOPSY
- before LB : supine or L side lying to expose the part
- during LB : - do- - after LB : R side lying w/ small pillow under the coastal margin to prevent bleeding.
LOBECTOMY
- removal of Lobe (N R lobe – 3, L lobe – 2)- position : semi fowler’s position – to promote lung expansion
MASTECTOMY
- removal of breast- elevate or extend affected arm to prevent lymp edema (or elevate higher
that the level of the heart. AVOID: venipuncture, specimen taking, blood pressure – ON THE AFFECTED
ARM coz there is no more lymph node w/c predispose pt to bleeding.
Post mastectomy Exercises: squeezing exercises, finger wall climbing, flexion- extension (folding of clothing, washing face, vacuuming the house)
Due to removal of axillary lymph node, avoid also gardening and hand sewing
PNEUMONECTOMY
- either L or R lung. Position pt on the AFFECTED SIDE to promote lung expansion.
RADIUM IMPLANT OF THE CERVIX
- keep pt on complete bed rest to prevent dislodge.- AVOIDE SEX (may burn penis bec of the implant inside)
RESPIRATORY DISTRESS
Adult : Orthopneic position – over bed table then lean forward
Pedia : TRIPOD – lean forward and stick out tongue to maximize the Airflow
RETINAL DETACHMENT
- to prevent further detachment, place pt on the AFFECTED SIDE.
Ex. If operation is on the R outer of the R eye, place pt on the R position. If operation is on the L inner of the R eye, position pt on the L side
AVOID: sudden head movement.
VEIN STRIPPING
- keep extremities extended then elevate the legs at level of the heart to promote venous return
T I P S
liver biopsy is done on a pt. – during 1st 24hrs after the procedure, turn the pt on his abdomen w/ pillow under the subcoastal area;
when draining the L lower lobe of the lung – the pt shld be positioned on his R side w/ hip higher or slightly higher than the head;
after tonsillectomy – position: prone
a pt is about to go on thoracenthesis - how shld the nurse position the pt? – sitting w/ a arms resting on the overbed table;
to maintain the integrity of pt w/ hip prosthesis – abduction splints
immediately after supratentorial craniotomy- fowler’s position
best position for pt in shock – supine w/ lower extremities elevated
THERAPEUTIC COMMUNICATION
1. DON’T ASK WHY – this put pt on the defensive2. AVOID PASSING BACK – “I will refer you to….”3. DON’T GIVE FAKE REASSURANCE – “everything will be alright….” “you’re in the hands of the best”4. AVOID NURSE CENTERED RESPONSE – “I felt same too…” “I had the same feeling….”
In GROUP DISCUSSION – nurse is just a facilitator – let the group decide, he/she channel are concern back to the group.
THERAPEUTIC PHRASES – it seems… you seem….- open ended question- close ended – for manic pt and pt in crisis- direct question- for suicidal pt
ISOLATION PRECAUTION
Purpose : to isolate infection transmission
TYPE PRIVATE ROOM HAND WASHING GOWN GLOVE MASK
STRICT(airborne dses, direct contact-Diptheria)
RESPIRATORY OPTIONAL OPTIONAL
(AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT)
TB OPTIONAL OPTIONAL (negative airflow room)
CONTACT (direct contact – NOT AIRBORNE DSES) eX SCABIES
ENTERIC X OPTIONAL OPTIONAL(fecal contamination)
DISCHARGE X OPTIONAL OPTIONAL
(drainage: pus ex burn pt)
UNIVERSAL X(AIDS, HEPA b – TRANSMITTEDBY BLD AND DODY FLUIDS)
TIPS:
When implementing universal precaution, w/c nsg action require intervention: recapping the needle – this might prick your hand;
When discarding the contents of the bed pan use by a pt under enteric precaution – GLOVE IS NECESSARY;
A nurse is giving health teaching to the parents of child with scabies: family member must be treated;
Preventing pediculosis in school age children: avoiding contact w/ hair articles of infected children like clips, head bands, hats – no sharing
Patient with full blown AIDS is placed on isolation precaution – pt ask nurse why his visitors is wearing mask – response: it will help in the prevention of infection;
Essential when a pt w/ meningitis is kept in isolation: isolation precaution remains until 24hrs after initiating antibiotic therapy
DIAGNOSTIC PROCEDURES
side notes:
pt for IVP : assess for allergy (cleansing enema b4 the procedure)pt for KUB : no dye (don’t assess for allergy)schilling test : 24hr urine specimenUSG : no consent required
GENERAL CONSIDERATION
EXPLAIN the procedure to the pt (initial nsg action)- if not ready inform the doctor;- pt has the right to refuse procedure;- doctor the one who asked for consent
Check pt for CONSENT – if INVASIVE – WITH CONSENT NON INVASIVE – NO CONSENT needed
CONTRAST MEDIUM – check for allergy
For procedure requiring anesthesia – KEEP PT NPO B4 PROCEDURE
When local anesthesia used – NPO, 1- 2HRS AFTER General anesthesia – keep NPO at least 8hrd after (check gag reflex before meals)
PEDIATRIC PATIENT – use flash cards, games and play to encourage participation
TRANSCULTURAL CONSIDERATION
HISPANIC PATIENT – women prefer same gender health care provider
Obtain help of interpreter when explaining procedures – (except or don’t ask family members)
For muslim patient - they prefer same sex health care provider however, if procedures require life threatening – they prefer to have male doctor.
- they only want good news information of their condition
DELEGATION and DOCUMENTATION
Delegation – assessment, monitoring and evaluation of treatment (cannot be delegated) BUT standard and changing procedures can be delegated ex. – 24hr urine specimen and urine catheter collection.
Documentation – type of treatment and any untoward reactions.
KEYPOINTS FOR NURSES
Prepare the patient; Monitor for adverse reaction; Report complication to the doctor
FRAMEWORK – includes the Purpose, Special Consideration and Interpretation
DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND WELL-BEING)
DAILY FETAL MOVEMENT
Purpose : to determine fetal activity by counting fetal movements – usually perform by pt himself
N Fetal Movement 10-12 for 12 hr period (average: 1 movement/hr with average 3fm/hr)
NON STRESS TEST (NST) – correlates fetal heart rate w/ fetal movement
- monitor the baseline FHR then induce fetal movements by (HOW) :
a. ring a bellb. feed the patient
then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseline. (ex. 140 FHB baseline, then after challenge it increase to 155)
POSITIVE result means, BABY is REACTIVE (good condition) and no need for contraction stress test/oxytocin challenge test – coz baby is OK and doing well.
CONTRACTION STRESS TEST (oxytocin challenge test)
- correlates FHR with uterine contractions- pt on NPO- get baseline FHR then induce uterine contraction
HOW: Thru breast stimulation – it triggers the release of oxytocin from pituitary gland… If (-) patient is given Oxytocin – onset is 20-30 minutes. Then check FHR and note the presence of DECELERATION (slowing of FHR)
types of decelerationa. early deceleration – indicates head compression (MIRROR IMAGE)
b. late deceleration – indicates placental insufficiency (REVERSE MIRROR IMAGE) mgt: L Lateral Recumbent Position, Administer O2, Treat Hypotenson
c. variable deceleration – due to cord (image: U or W shape) and slowing of FHR can occur anytime.
If (+) CST, meaning there is deceleration, baby is NOT OK coz there is decrease FHR and during labor he/she may stand the labor process.
BIOPHYSICAL PROFILE
– to determine fetal well being w/ the use of 5 CRITERIA
fetal breathing 2 points movement 2 points heart tone 2 points
reaction to NST 2 pointsamniotic fld volume 2 points
10 pointsscore below 6, indicates fetal jeopardy
ULTRASOUND
- provide data on placenta (age and location) gender of baby structural abnormalities
position of baby
- for pregnant: site is lower abdominal USGtypes:
a. Upper USG – NPOb. Lower USG - NPO
- preparation: increase fluid intake (oral) NO consent needed If pt ask if it is painful: NO PAIN; Pt shld have full bladder
CHORIONIC VILLI SAMPLING – CVSAMNIOCENTESIS – AMNIOPERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING – PUBS
CVS AMNIO PUBS
Purpose: to detect chromosomal Purpose : same w/ CVS Purpose: to check chromosomal Aberration aberrations, & presence of RH(eg. Down syndrome, Trisomy 21) Incompatibility
Done in 1st trimester can be done on the 2nd wk (14-16 wk) Extract blood at umbilical cord(can be done as early as 5th wk but - but not recommended bec. of danger then it is tested if it really comescan be done on 8-10th wk) abortion (assess pt age of gestation) from the umbilical cord (can be
done on either 2nd or 3rd tri. or can be done on the 3rd wk (34-36 wk)
purpose: to detect fetal maturity (FLM)Get sample at chorion (by 10-12wks – thru monitoring of L/S Ratio N 2:1The placenta matures, get some sample) (if mother is (+) DM LS ratio is 3:1)
This procedure also check level of alpha-feto Protein – if INCREASE – spina befida; If DECRTEASE – down syndrome
(+) Consent – invasive (+) Consent (+) Consent
Bladder : Empty consider the Pt Age of Gestation (if age of gestation : is higher than 20wks and above : empty bladder, if AOG is 20wks and below : full bladder
COMPLICATIONS of CVS, AMNIO & PUBS:
a. infectionb. bleedingc. abortiond. fetal death
T I P S
EARLY DECELERATION – expected in the fetal monitor when there is fetal head compression;
AMNIOCENTESIS – was done @ 35 wks gestation – purpose: to determine fetal lung maturity;
A mother asked the nurse what will amniocentesis provide during pregnancy: it will show as whether the baby lungs are developed enough for the baby to be born;
a nurse is preparing pt for lower abdl usg – w/c of the following done by the pt needs further teaching – pt voids b4 the procedure;
after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding;
pt ask the nurse – what deceleration means – it refers to slowing of baby’s heart rate;
before Amniocentesis, what to check – USG DEVICE
DIAGNOSTIC TESTS (to evaluate pediatric patients)
CARDIOPNEUMOGRAM – use to diagnose apnea of infancy– assess HR, RR, nasal airflow and O2 saturation – N 95-98% below 85 – report ASAP
GLUTEN CHALLENGE- detect presence of Celiac Disease (CD) - intolerance to gluten;- pt is given gluten rich food for 3-4 months the observe s/s of CD
s/s of CD: abdl cramps, steatorrhea, abdl rigidity, abdl distention (if + for CD, gluten free diet will be for life time)
ORTOLANI’S TEST (OT) BARLOW’S MANUEVER (BM)
purpose: test developmental dysplacia of the hip or purpose : same congenital hip dislocation
(+) if w/ click sound (lateral) (+) barlow’s click – press downward and w/ click sound
POLYSOMNOGRAPHY or “sleep test”
- EEG is connected to pt when he sleeps
- Check the brain waves, check for apnea of infancy- preparation : No Special prep, HOLD CAFFEINE FOOD – 2days b4 test
SCOLIOMETER
- measure the degree or angle of scoliosis- check for: (+) scoliosis if uneven hemline
uneven waist more prominent iliac rest and scapula on one side presence of rib hump
test for pre-teen : “bend over test” – bend and touch the toe;
(+) scoliosis – if presence of rib hump, therefore x-ray then scoliometer.
SICKLEDEX TEST HGB ELECTROPOISIS
Purpose: test for sickle cell anemia Purpose: test for sickle cell anemia
Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + electropoiesis, if sickling of RBC Therefore TRAIT CARRIER (S or C shape RBC), therefore + for SC Dses
Test for TRAIT Test for Disease
GUTHRIE CAPILLARY BLOOD TEST (GCBT)
- to detect PKU (in PKU there is absence of PHENYLALAMINE HYDROXYLASE- PH)
Phenylalamine hydroxylase – is an enzyme that converts PH to Tyroxine – the one that gives color to hair, eyes and skin.
If absent PH, no one will convert PH to Tyroxine, therefore it will accumulates to brain and can cause mental retardation.
PH came from CHON rich food. At birth, it is usually negative, so give CHON food first for 3wks then retest.
Before test, give chon rich food for 1-4 days before test. (adult)
N PH level - >2mg/dl (if 4mg/dl – indicative of PKU, 8mg/dl – confirms PKU)
SWEAT CHLORIDE TEST
- to detect Cystic Fibrosis (in CF, the skin becomes impermeable to Na. meaning cannot reabsorb Na and it accumulates outside of the skin);
- Mother complain that her baby taste salty;- PILOCARPINE – used in the test to induce sweating;
Types:a. sweat chloride test – N 10-35 meq/L (above 40 meq/L– (+)b. serum chloride test – N 90-110 meq/L (above 140 meq/L – (+)
TIPS
pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is – adequate CHON in the diet;
mother complains that her baby taste salty – which test is to be performed : sweat chloride test;
9 yo pt has (+) result for sweat test – this indicates possible dx of Cystic Fibrosis;
pilocarpine – drug used for pt undergoing seat chloride test;
hgb electropoisis – test for sickle cell dses
DAY 4 (3 Feb 2005)
DIAGNOSTIC PROCEDURES
I. CARDIOVASCULAR
A. ELECTROCARDIOGRAPHY – records the electrical activity of the HEART
P wave – atrial depolarizationQRS complex – ventricular depolarization ST - repolarization
Rhythm – appearance of wave and distanceRate - N 60-100 bpm – check on # of QRS then divide it by 300 (k)
ABNORMALITIES
a. atrial fibrillation – p waves “halos magkadikit. (no discernable p waves)
b. atrial flutter – “saw tooth” flutter waves
c. ventricular – check on QRS (N - .8-.12)
ANGINA – st segment elevation, t wave inversionMI - st segment elevation or depression, t wave inversion
B. CARDIAC CATHETERIZATION
- it determine the structural abnormalities in the heart- either L or R sided catheterization- site: antecubital, femoral, brachial
common complications: embolism, bleeding, arrythimia “EBA”
nsg mgt : monitor distal pulses (if brachial site: check @ radial if femoral site : check @ dorsalis pedis) if weak or no pulse – REPORT if (+) bleeding – report (“sandbag 10-20 lbs” – shld be at bedside)
C. STRESS TEST
- determines the ability of the heart to withstand stress- equipment : threadmill & ECG- nsg alert : check pulse and BP keep NPO an hr b4 the test
NO Jewelries
D. CORONARY ARTERIOGRAPHY
- visualization of the bld vessels w/ contrast medium- nsg alert: (+)consent check allergy to contrast medium
increase oral fluid intake after to excrete dye epinephrine shld be ready for any untoward reaction
E. SWAN-GANZ CATHETERIZATION
- 4 lumen for the ff CVP, Pulmonary Capillary Wedge Pressure (PCWP), Pulmonary Artery Pressure, Bld products, Balloon
CVP – measure R side pressure of the heartPCWP – L side of the heart
N Pressure CVP: for R Atrium – 0-12 for SVC – 5-12
Nsg Alert : check pulse and s/s of bleeding
F. BLOOD CHEMISTRIES
SODIUM (135 – 145 meq/L)
Addison’s Dses: hyponatremia (dec Na), hyperkalemia (inc K) – “FLD IMBALANCE”
Cushing Syndrome: hypernatremia, hypokalemia – “FLD VOL. EXCESS”
POTASSIUM (3.5 – 5 meq/L)
Hyperkalemia : Addison’s dsesHypokalemia : Cushing Syndrome
Inc or dec in K PT RISK of INJURY
Pt w/ digitalis & diuretics – monitor for arrhythmia
CALCIUM (4.5 – 5 meq/L or 9-10mg/dl)
Hyperthyroidism – inc CARenal Calculi Formation – inc CA @ bld
GLUCOSE (80-120)
- Higher than 140 – hyperglycemia (acidosis – may lead to ineffective breathing pattern and airway is the main problem)
- below 50 – hypoglycemia (pt prone to injury & altered thought process)
Creatinine (.5-1.5)
- most sensitive index of kidney funx (increase BUN but N creatinine – do not report to AP)
- increase creatinine – kidney failure or renal disorder
BUN (10-20 mg/dl)
- inc. if (+) kidney disorder
LDH (40 – 90 u/L)
LDH1 – 27-37% (for heart – check for MI)
LDH2 – 17-27% (for heart – check for MI)
LDH3 – 8-15% (for respiratory system)
LDH4 – 3-8% (for liver & kidney)
LDH5 – 0-5% (for liver & kidney)
LDH inc for MI for 3-4 days then it returns to N after 10-14 days
CPK or CK
Male – 12-70 u/L Female - 10-55 u/L
Increase CPK 3-6hrs post MI then it normalize 3-4 dyas
AST (SGOT) SGPT (ALT)
- N 8-20 u/L N 8-20 u/L- for liver (inc. for liver dses) more on HEART (inc for cardiac dses)
G. HEMATOLOGIC STUDIES
RBC (4.5 – 5.5 million)- inc RBC – polycythemia – risk for injury – complication CVA- dec RBC – anemia – activity intolerance
WBC (5-10 thousand)- to detect presence of infection, bld disorders like leukemia- dec WBC – pt prone to infection- inc WBC – hyperleukocytosis – (+) to pt w/ leukemia – risk for infxn
PLATELET (150,000-450,000)- spontaneous bleeding occurs when platelet dec (pt also prone to injury)
PT PTT APTT(11-12 sec) (60-70 sec) (30-40 sec)
coumadin – check pt heparin – PTT
monitor pt 4 bleeding monitor pt 4 bleeding
HGB – male : 14-18 mg/dl Female : 12-16 mg/dl
Dec hgb – anemia (nsg dx: activity intolerance)
HCT - 35-45% - determine the adequacy of hydration and the ration of plasma to the cellular component blood
inc hct : hemoconcentration (nsg dx: fld deficit – dehydrated pt)
dec hct : hemodilution fld excess
DOPPLER USG- to detect the patency of bld vessels – arteries & veins esp of lower
extremities;- painless, non invasive, NO SMOKING 30 min-1hr b4 the test
PULSE OXIMETRY- determines the O2 saturation at blood- N 95-98 – attach to finger or earlobe (do not expose e light)
II. RESPIRATORY
BRONCHOSCOPY
– visualization of b. tree or airway passages;– to gather specimen for biopsy;– NPO b4 & after– Gag reflex return after 1-2hrs;– Pt may expect a sore feeling (PINK STINGED SPUTUM)
– Report (+) stridor
CHEST X-RAY
- to determine abnormalities of lungs and thoracic cavity;- no preparation;- ABSOLUTE CONTRAINDICATED TO PREGNANCY- Check pt for radiation indicator- Determine effectiveness of tx and whether pt is active or
non-active
SPUTUM STUDIES
- to determine the gross characteristic of the sputum (refers to the amount, color, abnormal particles, consistency and characteristic)
TYPE OF SPUTUM
PNEUMONIA - Viral – thin & watery Bacteria - rusty
TB - blood streaked
BRONCHITIS - gelatinous
CHF/ PULMONARY EDEMA - pink stinged
Sputum specimen – sterile container
THORACENTESIS - aspiration of fld at thoracic cavity
(for diagnostic & therapeutic purpose)
position: DURING – sitting AFTER - affected or unaffected side
Nsg alert:
NO COUGHING & DEEP BREATHING – during the procedure – coz this may cause puncture of the lungs;
Assess for breath sounds after;
Complication: bleeding and pneumothorax
PULMONARY FUNCTION TEST
- thru the use of incentive spirometer - vital capacity (4-5 L of air) – refers 2 N amt of air that goes in
& out of lung after maximum inspiration.
PROCEDURE: EXHALE then INSERT mouth piece, BREATH iN, HOLD then EXHALE
LUNG SCAN
- to identify the presence of blockage in the pulmonary bld vessels; - with contrast medium;
- (+) consent; - assess for rxn to allergy
MANTOUX TEST
- test for POSSIBLE TB EXPOSURE; - using PPD (purified chon derivatives)
- angle 10-15, BEVEL UP then read 48-72hrs after
5mm in duration – (+) for HIV, multiple sex, previously (+) pt; 10mm - (+) for immigrants, children below 3yo and for pt w/ medical condition – DM & Alcoholism 15mm - (+) for general population
LUNG BIOPSY
- aspiration of tissues at lungs for dx of tumors, malignancy - assess for bleeding, breath sounds & report for s/s of dyspnea
III. NERVOUS
EEG
- shampoo hair B4 (to remove chemicals) and AFTER to remove electrode gel (shampoo or acetone)
- measures electrical activity of the brain (gray matter)- non invasive, (-) consent- detect the ff: brain tumors, space occupying lessions
alcohol brain waves and seizures
nursing alert:
dietary modification: WITHOLD CAFFEINE – coffee and tea; WITHOLD 48hrs b4 the procedure : tranquilizers, sedatives, anti-convulsant, alcohol
CT SCAN MRI PET
Use radiation to determine use electromagnetic field use gamma rays or positron electrontissue density to detect abnormality of tissue density to detect abnormality of tissue density;(detect cancer and tumor) also to detect O2 saturation @ tissue;
physiology of psychosis; and to evaluate tx like CA Tx
give more detailed impression (ex. Measurement of blocked artery)
NSG ALERT: (w/ or w/out dye)
CONTRAINDICATION CONTRAINDICATION(same w/ ct scan BUT w/ addtl)
a. pregnancy;b. obese pt (more than 300 lbs); NO METAL OBJECTSc. claustrophobia (give anti-anxiety b4) - jewelries, insulin pump,d. pt w/ unstable v/s (arrhythmic & HPN); pacemaker, hip replacemente. pt w/ allergy to dye
“clicking sound” will be heard & lie still during the procedure lie stilllie still during the procedure and “thumping sound” will be heard
CEREBRAL ANGIOGRAM
- involves visualization of bld vessels @ vein w/ the use of contrast medium.
CONTRAINDICATED IN: pt w/ allergy; pregnant pt.; bleeding
Nursing Alert:
a. keep pt NPO;b. assess pt for allergy;c. monitor for signs of bldg;d. inc oral fld intake to excrete dye;e. keep epinephrine and or benadryl at bedside for emergency
LUMBAR PUNCTURE
- aspiration of CSF for assessment to check for infection or hemorrhage
position:
DURING : fetal or C-position
AFTER : FLAT to prevent spinal headache
Needle is inserted between L3 and L4 or L4 and L5
Increase fluid intake after.
CSF ANALYSIS
- Assess for the characteristic of CSF.- N amount: 100-200 ml- Characteristic : Clear w/ glucose, Na and H2O
If REDDISH – hemorrhageIf Yellowish – infection
Ear licking w/ fluid – test if (+) glucose bec. CSF has glucose.
MYELOGRAM
- test for presence of slip disc or herniated nucleus porposus (HNP).
ALERT:
Know the type of dye use:
a. water based – called AMIPAQUE
b. oil base – called PANTOPAQUE
type of dye will determine the position of pt AFTER the procedure.
If water based, the HEAD OF BED ELEVATED; If oil based, FLAT after
Rationale for both oil and water based dye is TO PREVENT the upward dispersal of dye w/c can cause electrical meningitis (s/s includes: (+) seizure, headache)
IV. EENT
TONOMETRY
- to measure IOP (N 12-21) - painless but w/ local anesthesia
ACUTE GLUACOMA : 50 yo and aboveCHRONIC GALUCOMA : 25 yo
CALORIC STIMULATION TEST
- test the presence of Minierre’s Dses (inner ear)- involves introduction of warm and cold water then NOTE
FOR NYSTAGMUS – jerky lateral movement of the eye.
SEVERE NYSTAGMUS – NORMALMODERATE NYS - Minierre’s DsesNO NYSTAGMUS - Acoustic Neuroma
GONIOSCOPY
- to differentiate OPEN and close angle galucoma;- non-invasive, painless
WEBER TEST RINNE’S TEST
To determine lateralization of sound; To determine air and bone conductionIf pt hears vibration better in GOOD EAR, Place tuning fork 2inches from the ear Problem would be SENSORINEURAL LOSS; place at mastoid bone or in teeth then….if pt hear better in POOR EAR, - refers to if AIR CONDUCTION is LONGER, therefore CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS;
If BONE CONDUCTION IS LONGER, thereforeCONDUCTIVE HEARING LOSS
V. GASTRO INTESTINAL TRACT
UPPER GI SERIES (Barium Swallow)
- xray visualization with contrast medium
- Contrast Medium:
a. Gastrografin – water soluble, use straw
b. Barium - swallow – milk shake like (use feeding bottle of pt)
- then pt is ask to assume different positions to distribute dye @ esophagus
purpose: to detect disorders of esophagus
feces : “chalky-white”
after: instruct pt to take laxative to excrete dye
BARIUM ENEMA (for Lower GIT)
- involve rectal installation of barium;
- there is balloon catheter inserted @ anus then barium is instilled and pt is asked to roll-over at different position then xray is taken to detect: hemorrhoids, diverculosis, polyps and lesions;
- after, give laxative to excrete dye (bec dye is constipating)instruct also patient to inc oral fld intake
GUAIAC TEST
- to detect the presence of bleeding and inflammatory bowel condition like CANCER;
specimen : stool (this can be refrigerated awaiting laboratory)
AVOID the following 3 days B4 the test – bec it can yield to FALSE (+) RESULT : Red Meat, Fish and Horse Radish
CHOLANGIOGRAPHY
- visualization of biliary tree (includes, hepatic duct & common bile duct) – same with CHOLECYSTOGRAPY – but medium given orally;
- with contrast medium w/s is given thru IV
- ALERT: assess for allergy (epinephrine/benadryl)
- Post procedure: inc. oral fld intake – to facilitate excretion of dye
GASTRIC ANALYSIS
- analysis of gastric secretion like HYDROCHLORIC ACID- Lower Level N : 2-5 meq/hr- Upper Limit N: 10-20 meq/hr
UPPER LIMIT YPES
a. WITHOUT TUBE (tubeless gastric analysis)
- using DIAGNEX BLUE (specimen: urine);
if urine colors turns BLUE, therefore (+) HCL Acid; if urine (-) blue color, therefore (-) HCL Acid
- if (-) HCL Acid at stomach (achlorhydia), therefore Gastric CA;
- if Increase HCL Acid – therefore ZOLLINGER-ELLISON SYNDROME – (+) Gastric Tumor
b. WITH TUBE – with the use of NGT then aspirate
ULTRASONOGRAPHY
- upper abdl USG to detect abnormalities in the upper abdl area w/ includes biliary tree and Upper GI;- painless;- gel at abdomen and pt is NPO
LIVER BIOPSY
- aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis;
- ALERT: Check for Bleeding Time (N – 1-9 mins) and Clotting Time (N – 10-12 mins) – because liver is highly vascular organ
- WHEN NEDDLE IS INSERTED tell pt to: Inhale then Exhale then Hold Breath – to stabilize liver position
- Position after : R side-lying position- Things to report: s/s of SHOCK – inc PR, dec BP
Check v/s
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
- to visualize common bile duct and pancreatic duct;- invasive – (+) consent;- NPO – tube insertion;- Tell pt that tere will be feeling of soreness a wk after the procedure
COLONOSCOPY
- visualization of colon to detect:inflammatory bowel conditionChron’s DsesDiverticulitisHemmorhoidsTumorPolyps
- (+) Consent - NPO b4
- clear liquid diet – 2days b4 the procedure
position: Lateral or side lying position or L Lateral Sims
VI. ENDOCRINE
GLUCOSE TOLERANCE TEST
- to provide measure of bld sugar level at blood;- Inform pt to have high CHO diet 2 days b4 the test;- Instruct NPO a day b4 the test (npo post midnoc);- Inc sugar level, therefore Diabetes
ACTH STIMULATION TEST
- to detect presence of Addison’s Dses- specimen: blood- pt is given dose of ACTH (not nore than 40ug/dl)- if still dec despite ACTH administration, therefore Adrenal Insufficiency –
Addison’s Dses
DEXAMETHASONE SUPRESSION TEST
- to detect endogenous depression – depression resulting thru endocrine disorder
- pt is given dexa then 24hr urine specimen is collected;- a dose of dexa will suppress the release of adrenal hormones;- if despite dexa administration still increase adrenal hormones, therefore pt is
suffering depression
17 KETOSTEROID & 170 HCS
- use to detect the presence of Addison’s & Cushing’s Dses.
Addison’s – dec secretion of ketonesCushing’s – ince secretion of ketones
Specimen: 24 hr urine
VANILLYLMANDELIC ACID TEST – VMA Test
- bi-product of CATHECHOLAMINE Metabolism
epinephrine norepinephrine
inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla
N 2-7 mg/dl / 24hrs – if inc, therefore tumor
AVOID: vanilla containing food 3 days b4 test – ice cream, coffee, chocolates
R A I U
- pt is given iodine 131 then after 24hr followed by a thyroid scan- inc indicates hyperthyroidism, dec hypothyroidism- AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include
other diagnostic procedures that uses contrast medium (“NO” - angiogram test). – bec it may yield to false (-) result.
SULKOWITCH’S TEST
- detect amount of calcium excreted at urine;- if to test for hypercalcemia and hyperthyroidism - gather specimen b4 meals;- to test for hypocalcemia and hypothyroidism – gather after meals
VII. R E NA L
URINALYSIS
- examine the gross characteristic of the urine
urine amount : 30-60ml/hrcolor : clear, ambers. gravity : 1.010 – 1.025
abnormality: lower than 1.005 – diabetic insipidus higher than 1.030 – diabetic mellitus
(+) glucose – infection, DM (+) CHON - PIH, kidney dses.
Urine maybe refrigerated if waiting to be examined.
CULTURE & SENSITIVITY
- to detect infection- prepare storage container
K U B IVP
- xray of the kidneys, ureter and bladder - xray of the kidneys, ureter and bladder- NO SPECIAL PREPARATION NEEDED - uses contrast medium/ dye
- assess for allergy, then inc. oral fld intake after - benadryl or epinephrine at bedside for allergic rxn - NPO POST MIDNOC, cleansing enema in AM
CYSTOSCOPY
- visualization of urinary bladder- after : monitor I & O;- note for s/s of bleeding
RENAL BIOPSY
- aspiration of tissues at kidney for biopsy to detect:a. malignancy/ Cab. malignant HPNc. kidney disorder
- note for s/s of bleeding
CYSTOURETROGRAM
- to check the patency of the ureter and bladder;- monitor I & O
CYSTOMETROGRAM
- to evaluate the sensory and motor funx of bladder;- to check if bladder respond to distention after installation of flds;- monitor I & O
VIII. MUSCULO-SKELETAL
ELECTROMYOGRAPHY
- to detect electrical activity of the muscle;- (+) consent;- to alternately contract and release the muscle as needle is inserted- HOLD muscle relaxant b4 the test
ARTHROCENTESIS
- aspiration of fluids at synovial space to detect abnormalities;- check for order of analgesic;- apply cold pack
ARTHROSCOPY
- visualization of joints- KEEP TORNIQUET, ICE PACK and ANALGESIC at bedside
BONE SCAN
- detect rate of bone destruction or bone resorption for pt w/ osteoporosis;- lie still during the procedure;- PAINLESS AND NON INVASIVE
IX. MISCELLANEOUS
BONE MARROW BIOPSY
- to check abnormalities at the b. marrow (eg. Leukemia)
- site : ILEAC REST- (+) consent - assess for bleeding- sand bag at bedside (post procedure) – for emergency use
SCHILLING’S TEST
- specimen: 24hr urine- test for VIT B12 deficiency;- for pt w/ PERNICIOUS ANEMEIA;- pt is given oral VIT B12 then urine is collected, then NOTE for RATE of
EXCRETION of VIT B12 (N – less than 40%);
eg. If 100mg Vit b was taken – 60mg shld retain at stomach and 40mg will be excreted.
URINE UROBILINOGEN
to detect HEMOLYTIC DSES WITHOLD ALL MEDS – 24hrs b4 the test
BENCE-JONES PROTEIN
detect presence of MULTIPLE MYELOMA (malignancy of plasma cells); RELEASED by destroyed or damage bones
ROMBERG’S TEST
check FUNX of CEREBELLUM; stand erect, close eyes, and observe for inability to maintain posture (if pt is
Swaying, therefore TUMOR at cerebellum)
ERYTHROCYTE FRAGILITY TEST
- use to detect the rate of RBC DESTRUCTION in a hypotonic solution (RBC Lifespan: 120 days)
if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA (EX. SICKLE CELL)
HETEROPHIL ANTIBODY TEST
- detect presence of IgM w/c is related to Epstein Virus infection
Epstein Virus Infection – causative agent of infectious mononucleousis (“kissing dses”) mgt: AVOID SHARING of utensils and glass
LYMES DSES SEROLOGY
- detect presence of BORRELIA BURGDORFERI – causative agent of lyme’s dses.
Treatment: tetracycline
TIPS FOR DIAGNOSTIC PROCEDURE
2 moths old infant suspected of brocholitis is treated with oxygen therapy. Which result indicates that tx was effective : 02 SATURATION OF 98%.
Pt is scheduled for liver biopsy. What shld the nurse instruct pt to do during needle insertion? - hold breath during the procedure upon insertion of the needle.
Staff nurse is observing a nurse caring for pt w/ cvp. W/c action of the nurse require intervention? – touching the edge of the soiled dressing using clean gloves.
Pt undergoing ERCP – important prep for nurse to make would be: keep pt NPO b4 the procedure.
Pt w/ coronary angiogram, the catheter was inserted at the L femoral artery. w/c intervention is appropriate after the procedure: palpate the popliteal and pedal pulses.
In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize.
A mantoux test is (+) – if the nurse assesses w/c of the following: in duration.
w/c of the ff will yield an accurate reading of CVP: when the zero level of the manometer is at the level of R atrium.
w/c responses made by the pt indicates that he understands the procedure to be done in a CT scan: “a dye will be injected to me”.
A pt is to have an upper GI series – which statement shows that he understood the instruction given : “I will drink the dye”.
After liver biopsy, a potential complication: bleeding.
MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques at the brain.
DAY 5 (8 Feb 2005)
PHARMACOLOGY
I. GENERAL CONSIDERATIONS
ONLY RN’s are allowed to administer (to include central line)LPN’s – peripheral IV Line route;
ELDERLY PT – provide with memory aid PEDIATRIC PT – do not mix w/ milk (dosage depends on wt, age and size) For SIDE EFFECTS – GI symptoms (mostly) For AD. EFFECTS – always consider bone marrow (“leukocytopenia – all PENIA”)
3 COMMON DRUGS – with patients over 65 y/o
a. LITHIUM – if above 65 yo, dose shld not more than 1.0mEq
b. HALDOL – if above 65 yo, dose shld not more than 6mg/day
c. MEPERIDINE – if above 65 yo, shld not 50 mg
II. TRANSCULTURAL
ASIANS – are stoicism attitude (they refuse meds if for the 1st time)
MIDDLE EASTERNERS - they expect meds during first contact w/ hx care provider
JEWISH – no meds restrictions
JEHOVAH’S WITNESS – do -
ORIENTAL PAYLOAH (from mexico)- treatment for diarrhea;- may cause lead toxicity
ECHINECEA- use to boost the immune system;- for pt. with cancer
ST JOHN’S WORT- anti-depressant (it funx like MAO inhibitor);- do not give to pt taking MAO
VALERIAN- sedative (used also as anti-anxiety agent)- adverse effects – GI Irritation
GINGCO BILOBA - blood thinner;- use to enhance bld circulation;- for pt w/ alzeimers- CONTRAINDICATED to pt with bleeding disorders
COMMON CONTRAINDICATIONS for HERBAL MEDS:
NO HERBAL MEDS for pregnant client; NO HERBAL to lactating pt; NO HERBAL for those with severe kidney and liver disorder
IV. THE CHECK PRINCIPLE
C – lassification (FOR WHAT?)H - ow will you know that he meds if effective (evaluation)E - xactly what time are you going to give itC - lient teaching tipsK - eys to giving it safely
Lactulose – given to pt with hepatic enceph to dec ammonia absorption - s/e : diarrhea
ANTABUSE (dizulfiram) – most appropriate time to take meds : after 12hrs of alcohol free.
COGENTIN – to prevent pseudoparkinsonism (by decreasing muscle rigidity)
TETRACYCLINE - can cause staining of teeth, Photosensitivity (use sunscreen when outdoors)
LITHIUM – shld have inc. fluid in the diet
III. DELEGATION AND DOCUMENTATION
Document all medical admin record: time, route, dosage and untoward reaction;
The following CANNOT be delegated: treatment, administration, documentation of meds
PSYCHOTROPIC
I. ANTIPSYCHOTIC- major tranquilizer;- for SCHIZOPHRENIA (pt has EXCESS DOPAMINE);- plays as treatment to the symptoms NOT CURE to schizo – meaning it modify
the symptoms (target symptom: to decrease dopamine)
ex. HaldolChlorpromazineClozapine (chlozaril)Olanzapine (zyprexa)Risperdon
BETS TO GIVE: after meals
DOPAMINE – neurotransmitter (facilitate the transmission of neurons)
In SCHIZO there in INCREASE NEUROTANSMITTER.
Signs & Symptoms:
a. DELUSION – “FALSE BELIEF”b. HALUCINATION - hearing soundsc. LOOSENES OF ASSOCIATION – shifting of topic
CLIENT TEACHINGS:
Report ADVERSE EFFECTS of ANTI-PSYCHOTICS – which indicates agranulocytosis a. feverb. body malaisec. sore throatd. chills
hyperpyrexia and muscle rigidity
- this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS) drug of choice: Parlodel, Dantrium
Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM
a. mask-like face or expressionless faceb. pill-rolling tremorsc. cogwheel’s rigidity or lead pipe rigidity
AKATHESIA – “restless leg syndrome” (I feel as if I have ants in my pants)
DYSTONIA
Avoid direct sunlight – because meds photosensitivity
Instruct pt to rise slowly – to avoid orthostatic hypotension
Check: CBC, BP, AST/ALT
To prevent pseudoparkinsonism, administer ANTIPARKINSONIAN agents
IA. DOPAMINERGICS - ANTIPARKINSONIAN
in schizo there is increase dopamine, therefore give antipsychotic to dec dopamine then dec dopamine causes pseudoparkinsonism. Therefore give dopaminergic.
ex. L-DopaLevodopaLevodopa-Carbidopa
Effective if decrease in tremors and rigidity within 2-3 days; When to give: AFTER MEALS;
Health Teachings :
a. dietary modification: AVOID CHON and Vit B6 - bec it decreases drug absorptionb. check for ORTHOSTATIC HYPOTENSION and PALPITATION;c. check BP and PR
IB. ANTICHOLINERGIC
- decrease ACETYLCHOLINE
ex. Benadry Cogentin
effective: if decrease tremors and rigidity; when to give: AFTER MEALS;
Health Teachings:
a. side effects: blurred vision (no driving);b. dry mouth – suck on ice chips or hard candy;c. palpitations – check PR;d. constipation – inc. roughage at diet;e. urinary retention NOT urinary frequencyf. decrease BP – rise slowlyg. check BP, PR, ECG
II. ANTI-ANXIETY
- minor tranquilizer- decrease Reticular Activity System – center of wakefulness
ex. Valium, diazepam, Librium, Tranxene
Effective: Decrease Anxiety, Decrease Muscle Spasm (to pt w/ traction)
Promote Sleep
B4 MEALS – because food delays absorption
HEALTH TEACHINGS :
a. report ADVERSE EFFECT: PARADOXICAL REACTION – opposite of side effects
b. Danger of Dependencyc. AVOID: Caffeine, Alcohol – it increase the depressant effect of the drug
d. check RR – it causes respiratory depression
e. administer VALIUM separately – because it is incompatible with any drug – use different syringe.
III. ANTI-DEPRESSANT/MANIC
a. TRICYCLICSb. MAOc. STIMULANTSd. SSRI
PATIENT with DEPRESSION – there is DECREASE norepinephrine and serotonin
A. TRICYCLICS – prevents the reabsorption of norepinephrine.
Ex. Tofranil, Elavil
Effective: If adequate sleep (8hrs only) Increase appetite
Best given: AFTER MEALS
Hx Teachings:
The INITIAL EFFECT 2-3 wks after FULL THERAPEUTIC EFFCET 3-4 wks ONSET EFFECT in a WK
AVOID : juice – because an acidic medium decrease absorption of drugs
REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS – adverse effects of TRICYCLICS
CHECK BP and ECG
B. MAO INHIBITOR (MonoAmine Oxidase)
- prevents the destruction of NEUROTRANSMITTERs
ex. Parnate, Nardil and Marplan
Effective : if INCREASE SLEEP and APPETITE –
Give AFTER MEALS
Hx Teachings:
AVOID – TYRAMINE CONTAINING FOOD (1 day before FIRST DOSE and 14 days AFTER LAST DOSE)
Avocado, banana, cheese (cheddar, aged and swiss) ALLOWED: cheese – cottage and cream,
FRESH MEAT, VEGETABLES
COLA, CHICKEN LIVERSOY SAUCERED WINEPICKLES
Check BP – the drug can cause HYPERTENSIVE CRISIS – occipital headache – “my nape is aching”
2 WKS INTERVAL – when shifting ANTI DEPRESSANT – to avoid HYPERTENSIVE CRISIS
ex . after MAO – 2 wks rest then can give ST JOHN’S WORT
C. STIMULANTS (Ritalin, Dexedrine and Cylert)
- directly stimulates the CNS.
Effective: Increase Appetite and Adequate sleep
Best to Give: AFTER MEALS - if b4 meals, it suppresses the appetite;- give NOT BEYOND 2pm bec. it causes INSOMNIA – 6 Hrs b4 bedtime;- shld be given in the morning – to avoid INSOMNIA
COMPLICATIONS: growth suppression
Hx Teachings:
provide intervals or intermittently to avoid growth suppression; check BP and PR
D. SSRI (selective serotonin reuptake inhibitor)
Ex. ZOLOFT, Prozac
Adverse effects: DECREASE LIBIDO and Impotence
s/e: GI
III.1 ANTIMANIC
Lithium (lithane, lithobid, escalith) Tegretol Depakine/ Depakote
A. LITHIUM - it alters level of neurotransmitters
effective if DECREASE HYPERACTIVITY
give AFTER MEALS
Hx Teachings:
diet: High Na (6-10 gms) and High Fluid (3-4L)
N Na – 3 gms, N fluid intake 3L Basically, Lithium is a salt
Report the ff s/s (NAVDA)- Nausea- Anorexia- Vomiting- Diarrhea- Abdl Cramps
Report also:
FINE HAND TREMORS progressing to COARSE HAND TREMORS,THIRST and ATAXIC - sign of LITHIUM TOXICITY – Dug of choice: MANNITOL
DIAMOX
Hx Teachings:
Avoid activity that increase perspiration – Na & H2o; Avoid caffeine;
Monitor lithium level (specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the last dose)
Frequency of Lithium monitoring: ONCE A MONTH;
NORMAL LITHIUM LEVEL:
ACUTE DOSE MAINTENANCE DOSE
Below 65 yo .5 – 1.5 mEq/L .5 – 1.2 mEq/L
Above 65 yo .6 – 1.0 mEq/L .4 - .8 mEq/L
Lithium is effective with 10 – 14 DAYS before it will reach its therapeutic level.
CONTRAINDICATION OF LITHIUM:
Pregnancy; Lactating; Kidney disorder
- if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DEPAKOTE
tegretol – a/e : alopecia
dopakine/ depakote - gingivitis
ANTICONVULSANT (Tegretol and dilantin)
- for seizures, wherein there is abnormal discharge of impulse in the brain- action : IT INHIBITS the seizure focus and discharge
effective: if (-) seizure
given BEST AFTER MEALS (except for sedatives- like valium) – MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO.
NSG ALERT:
Report GINGIVITIS; Report S/S of Bone Marrow Depression – pancytopenia
(dec RBC & WBC); Instruct pt to use SOFT BRISTTLED TOOTHBRUSH; Instruct pt to MASSAGE GUMS and frequent oral hygiene
Check : CBC – due to pancytopeniaRBC, WBC and Platelet label
CHOLINESTERASE INHIBITORS
For MYASTHENIA GRAVIS : Prostigmin (long acting) and Tensillon (short acting)
For ALZEIMER’s DSES : Cognex (tacrine) and Aricept
Myasthenia Gravis – there is decrease or absence of Acethylcholine (ACTH) ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contract/move.
Therefore, the drug is given to inhibit cholinesterase in destroying ACTH (so, if dec cholinesterace and inc. ACTH, good muscle contraction)
PROSTIGMIN – long acting – for treatment
TENSILLON – short acting – only for 5 mins. – it increase muscle strength in 30 seconds (therefore, if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS)
Drug Action:
Increase muscle strength (ex. Increase chewing ability or able to chew food forcefully)
GIVE B4 MEALS or any activity; Meds is FOR LIFE; Report s/s of HEPATOXICITY – RUQ pain of abdomen and JAUNDICE
Antidote: ATSO4 – it reverses the effect of anticholinesterase
Check for LIVER FUNX TEST; Keep at bedside: endotracheal tube – for resp. problem
ANTICOAGULANT
HEPARIN COUMADIN LOVENOX
For ACUTE CASES of Manic Case FOR MAINTENANCE or Chronic CASE Heparin Derivatives
Antidote: PROTAMINE SO4 Antidote: VIT K Antidote same w/ Heparin
Given SubQ (Lower Abdl Fat) Oral Onset: 2-5 days (maintenance case) Check PT (N 11-13 sec and INR 24 sec)
Effective if (-) clotGive same time of dayReport s/s of bleeding : Hemoptysis Hematemesis
HEPARIN: AVOID – green leafy vegetables – bec it is rich in Vit K and will counteract the effect of anti coagulant.
Therefore, diet of patient – no appropriate.
NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD
“INR” – refers to the upper limit of meds from N value to the maximum dose
COAGULATION PROCESS: thromboplastin
Vitamin K dependent clotting factors PRO THROMBIN THROMBIN
COUMADIN FIBRINOGEN
HEPARIN
FIBRIN (CLOT)
COUMADIN – act as vit k dependent clotting factors
HEPARIN – converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN
- RAPID ACTING :onset : 24 – 48 hrs
Coumadin and Heparin
– NOT to dissolve clot (only as THROMBOLYTIC – meaning it prevents ENLARGEMENT and FORMATION of CLOTS)
- can be given together
ANTIARRYTHIMICS
Ex. Quinidine (quinam)
Side notes:
Characteristics of HEART MUSCLE:
a. CONDUCTIVITY – ability to propagate impulses;b. AUTOMATICITY - ability of heart to initiate contraction;c. REFRACTORINESS – ability of t heart to respond to stimulus while in the state of contraction;d. EXCITTABILITY - ability of the heart to be stimulated
Inotropic effect - force of contraction or strength of myocardial contraction;Chromotropic Effect – conduction of impulses;CHRONOTROPIC Effect - rate of contraction
ANTIARRYTHMIC (quinidex, pronestyl)
- repolarization – resting phase (k goes out)depolarization – stimulating phase (Na goes in)
(therefore the depolarization and repolarization of heart muscle depends on Na and K pump.)
K – once it increase or decrease, it affects the repo and depo of heart muscle which causes arrhythmia. And so, to maintain the balance in the Na and K pump give antiarrythmia because it decreases the automaticity of the heart.
Antiarrythmia is effective if (-) arrhythmia;
Give meds anytime;
Health teachings:
a. report CNS – confusion, ataxia and headache GI - nausea, anorexia and vomiting
b. RASH – therefore SKIN TEST FIRSTc. REPORT s/s of QUINIDINE TOXICITY – tinnitus, hearing loss and visual disturbancesd. check pt PR and ECG – waves, rate and rhythm
QUINIDINE PROCAINE LIDOCAINE
Ventricular arrythmia
For VENTRICULLAR & ATRIAL Fibrillation
CARDIAC GLYCOSIDES
- increase force of contraction;- affects the automaticity and excitability of the heart muscle;- K – shld be monitored when in this meds therapy
(The heart contraction is regulated by Na and K pump. If K decreases, Calcium enters and it will result to a more increase force of contraction due to Na and Ca pump conversion.)
Effects: (+) INOTROPIC – strengthen the force of contraction
(-) CHRONOTROPIC – decrease rate of contraction
DIGOXIN DIGITOXIN
EFFECTIVE : it increase FORCE OF CONTRACTION same
ACTION : onset : 5 – 20 mins 30 mins – 2hrs
Give after meals due to GI irritation same
CLIENT TEACHINGS:
Report s/s of TOXICITY : NAVDA Xanthopsia – yellowish vision or greenish halos;
Check PR – if BELOW 60/min (adult) – HOLD next dose; if BELOW 70/ min (older child) – HOLD; if BELOW 90- 110 (infants) – HOLD next dose
EXCRETION
Digoxin – kidney – monitor renal funx test (BUN & Crea) – report if inc;
Digitoxin – liver – AST/ ALT
DIGIBIND – antidote for digoxin (lanoxin)
THERAPEUTIC LEVEL:
a. Digoxin : .5 – 2 ug/Lb. Digitoxin : 14 – 26 ug/L
NITRATES (nitroglycerine)
- don’t give if pt taking VIAGRA – it will result to FETAL HYPOTENSION EFFECTS: dilatation of coronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTERLOAD.
Decrease in Preload – decrease in the amount of blood that goes to the LV;
AFTERLOAD – amount of resistance offered by blood vessels that heart shld overcome when pumping blood
Effective if NEGATIVE ANGINAL PAIN; Give BEFORE any activity; Administered SUBLINGUALLY (+ burning sensation indicates drug is potent) – NO WATER because it
will dilute the meds; DOSES: 3 doses at 5mins interval; Report if there is persistence of pain;
Check BP and PR; Keep meds in dark container (bec light dec potency); Once the bottle is open, use the meds within 3-6 mos
DO NOT REPORT THE FF: (expected s/s)
Hypotension, Headache, facial flushing “why is my face red?”
MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY)
Ex. Mucomyst
- it decreases the viscosity of secretion;- give meds anytime;- client teaching: meds can be diluted w/ NSS or cola;
Side effects: NAV + Rashes
- if no side effects, repeat dose in 1 hr
BRONCHODILATORS (ex. TERBUTALINE – brethine)
- dilates the bronchioles or airways;- effective: if (-) bronchospasm;- GIVEN in AM to decrease insomnia- REPORT THE FF: insomnia, tachycardia, palpitation-PR, + NAV
Theophylline - N 10-20;- for ACUTE ATTACK and PREVENTION of ASTMA
EXPECTORANT (robitussin)
- stimulates productive coughing;- effective : (+) COUGHING & SECRETIONS- give ANYTIME;- sideffects: – NAV + DIZZINESS or drowsiness – avoid activity that required alertness (ex. Driving)
ANTIBIOTICS
- bactericidal;- effective: (-) infection;- give ON EMPTY STOMACH – B4 MEALS;- Hx teachings: REPORT rash, urticaria and “STRIDOR” – indicates airway obstruction;- side effects: NAVDA + GI Irritation
I. PENICILLIN : antidote is EPINIPHRINE
II. AMINOGLYCOSIDE (gentamycin)
- effective: (-) infection – give B4 meals;- report the ff:
OTOTOXICITY: “I hear ringing in my ear”NEPHROTOXICITY : ”oliguria”NEUROTOXICITY : “seizures”
- check BUN, CREA (kidney funx test);- check I & O (sign of nephrotoxicity)
III. ANTINEOPLASTIC (adriamycin)
- for breast and ovarian CA;- effective: (-) tumor size;- GIVE IN ARM – to prevent HEMMORRHAGIC CYSTITIS- Hx Teachings:
a. inc oral fluid intake (2-3L/day) – cytotoxic prevention;b. monitor kidney funx – I & O;
THYROID AGENTS (synthroid, cytomel)
- for HYPOTHYROIDSM;- effective: if Inc in T3 and T4 and NORMAL SLEEP;- pt always sleep, therefore give meds in AM – to avoid insomnia;- REPORT HE FOLLOWING: insomnia, nervousness; palpitations- Take meds LIFETIME (same w/ meds 4 neuro);- Check HR, PR and kidney funx test;
ANTITHYROID (PTU, LUGOL’S SOLUTION)
- For GRAVE’S DISEASE or HYPERTHYROIDISM;- Effective: Decrease in T3 and T4 (in lab data);- Give round the clock;
Health Teachings:
a. Report sore throat, fever, chills, body malaise because meds cause AGRANULOCUYTOSIS;b. Report lethargy, bradycardia, and INCREASE SLEEP – indicates that pt is having HYPERTHYROIDISM;c. Diarrhea with metallic taste – sign of IODINE TOXICITY
ANTIDIABETICS (INSULIN)
- effective: N Blood sugar (80-120)- for DM Type 1 (insulin dependent);- give in AM b4 meals;- check:
a. instruct S/S OF HYPOGLYCEMIA –
dizziness/ drowsinessdifficulty in problem solvingdecrease level of consciounesscold clammy skin
b. monitor the blood sugar level in early AM and supper time
INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR.
PEAK OF ACTION (refers to – when patient becomes HYPOGLYCEMIA)
REGUALR INSULIN - lunch time Intermediate - late in the afternoon – B4 dinner Long Acting - B4 Breakfast
SULFONYLUREAS (Orinase)
- for DM type 2;- stimulate pancreas to produce insulin;- effective – N bld sugar level;- give b4 meals regularly;- teachings:
a. s/s of hypoglycemia;b. monitor renal funx test;c. antidote for hypoglycemia – ORANGE JUICE
ANTACIDS (amphogel, tagamet)
- ALUMINUM HYDROXIDE GEL – antacid and it also dec phosphate level in pt renal failure;
- Effective: dec phosphate (-) pain
- give on EMPTY STOMACH (1 hr b4 or 2hrs after meals);- instruct pt to REPORT: muscle weakness in lower extremities – indicates HYPOPHOSPATHEMIA - administer with glass of water;- check phosphate level and renal funx test;- assess for constipation
LAXATIVES (dulcolax)
Colace – stool softener Metamucil - bulk forming
Dulcolax - rapid actingLactulose - 15-30 mins
- effective : (+) BM;- give AT HS (if NOT diagnostic procedure);- give AFTER MEALS –for dyspepsia;- meds is given in short duration only because of dependency- teachings:
a. be near or stay near CR;b. s/e: diarrhea;c. NO lactulose for pt w/ diarrhea;d. Causes hypokalemia – therefore check electrolytese. Increase fld intake – to avoid dehydration
DIURETICS
Target Organsa. Diamox – exerts effect at Proximal Convuluted Tubules;b. Lasix – at Loop of Henle;
c. Diuril – at Distant Con. Tubules
LOOP DIURETICS (lasix)- effetctive: incrase urine output;- give in morning to prevent nocturia;- teachings:
a. monitor for hypokalemia level and I & O;b. report muscle weakness;c. give K rich food – banana, orange
THIAZIDE (diuril)
- give in AM;- monitor for hypokalemia;- check I & O, K level, PR and BP
K-SPARRING (triamterene, aldactone)
- effective: inc. urine output;- give in AM;- teachings: monitor for HYPERKALEMIA check PR and K
ANTIGOUT
PROBENECID COLCHICINE ALLOPURINOL
- URICOSURIC - for ACUTE GOUT - for CHRONIC GOUT- promotes excretion of uric acid - has anti-inflammatory effect by - prevents or dec formation
preventing deposition of u.acid of u. acid @ joints
- s/effects: NAV + - NAV + Bldg and Bruising - dizziness/drowsiness Hypersensitivity agranulocytosis (check CBC)
- ONSET: 8-12 wks - ONSET: 1-3 wks
TEACHINGS:
a. Increase ORAL FLUID INTAKE;b. Monitor uric acid levels;
MIOTICS (timoptic, piloca)
- DECREASE IOP (N12-21) for pt w/ glaucoma;- Give ANYTIME – but for LIFETIME;- Teachings:
a. it causes blurring of vision and brow pain;b. administer meds at lower conjunctival sac;c. press the inner canthus for 1-2 mins to prevent systemic side
effects (hyperglycemia and hypotension)
MYDRIATRIC (AK-Dilate)
- effective: pupillary dilatation;- give ANYTIME (but if pt for surgery, give b4);- teachings: may cause blurring of vision
lower conjuctival sac
CARBONIC ANHYDRASE INHIBITORS (diamox)
- for GALAUCOMA – lifetime;- to decrease production of acqueous humor;- effective: N IOP and Inc. urine output;- effective to pt with MENIERE’S DSES – dec vertigo- teachings:
a. check urine output;b. report: s/s of dehydration bec of diuretic effectc. blurred visiond. monitor I & O and IOP
ANTI-ACNE (acutane, retin-a)
- decrease sebaceous gland size;- given in AM to prevent insomnia;- avoid sunlight: photosensitivity- pregnancy: fetotoxic - therefore check if pt is pregnant;- check if pt has skin irritation – may burn the skin
TOCOLYTICS (Yutopar, MgSO4)
- relax the uterus; - drug of choice for pre-term labor;- effective: (-) pre-term or relaxed uterus;- give: ORAL – B4 meals and IV – anytime;- teachings:
a. signs of Ca Intoxication: hypotension, hypothermia and hypocalcemiab. check bld pressure; urine output (N 30ml/hr)c. check RR – at least 12/mind. check patellar reflex – shld be (+) knee jerk
HOLD if RR – 10/min and urine output: 15ml/hr
Antidote: Calcium Gluconate
OXYTOXIC
PITOCIN METHERGIN
To induce labor To prevent post partum hemorrhageEffective: Firm and Contracted UterusGive anytimeIf IV, use “piggy back”Teachings:
a. REPORT the ff: HYPOTENSION (due to inactivation of ANS – neurological effect of drug);b. Headachec. Hypertension (cardiovascular effect of the drug)
d. Check BP, Uterine Contraction – especially the duration – N 30-90 sec - report if beyond 90 sec – sign of uterine hypertonicitye. Check Force, Duration and Frequency of Uterine Contraction
PROSTAGLANDIN (cytotec, E2gel)
- anti ulcer drug to dec gastric acidity;- decrease ripening of the cervix w/c leads to effacement then dilatation then
abortion;- give after meals;- assess for diarrhea and gastric irritation;
- check for pregnancy bec it may cause abortion
TIPS ON PHARMACOLOGY
Patient receiving DIAZEPAM, the nurse notice that there is no change in patient behavior. What shld the nurse do? – VERIFY THE PT DIET
COGNEX – given with AZEIMERS’S DSES – to increase mental functioning
Pt w/ PVC : bedside : XYLOCAINE
Pt w/ COMPLETE HEART BLOCK: give ATSO4 – it increases HR
Pt w/ DIVERTICULITIS (pt has diarrhea) – the ff meds were given: what meds the nurse shld question : LACTULOSE
Morphine S04 given to pt with Pul. Edema – to decrease anxiety
Pt ask the nurse on why she will take COUMADIN when shes already taking HEPARIN – Heparin is given for ACUTE CASES while Coumadin for maintenance
Pt on CHEMOTHERAPY complains of nausea and vomiting, w/c meds can be given – ZOFRAN
Expected side effects of STEROIDS : wt gain, obesity and Inc appetite
Pt is taking LEVODOPA – observe for URINARY RETENTION
ADREAMYCIN – causes hemorrhagic cystitis
DESMOPRESSIN ACETATE – administered INTRANASALLY
FESO4 – shld be given w/ orange juice
ASPIRIN I s given to pt w/ TIA – to decrease platelet aggregation
Pt taking ANCEF – observe for skin rashes
Pt to receive NPH at 7:30am, the nurse shld expect for hypoglycemia – LATE in the AFTERNOON
TYPES OF PRECAUTION
P H GL GW MAIDS (universal) x yes yes yes yes
DIARRHEA (enteric) x yes yes x x
HEPA A (enteric) x yes yes x x
B (universal) x yes yes yes yes
C (universal) x yes yes yes yes
MRSA (contacts) yes yes yes yes yes
MENINGITIS/SEPTIC (enteric) x yes yes x x
SCABIES (contact) yes yes yes yes yes
TB (tb Precaution) yes yes x x yes
PEDICULOSIS (contact) yes yes yes yes yes
P – private roomH – handwashingGL - glovesGW – gownM - mask
AIDS – universalNorwalk Virus – respiratoryHepa A – contactMRSA – contactScabies – contact
Day 6 (Feb 9, 05)
D.I.S.E.A.S.E.S(MEDICAL-SURGICAL NURSING)
GENERAL CONSIDERATION
Priority: Oxygenation The disorders result as alteration in the function of HEART (pump), BLOOD
(transport mechanism of oxygen, nutrients, hormones & CO2) and BLOOD VESSELS (passageway).
PEDIATRIC CONSIDERATION
a. all factors necessary for appropriate cardiovascular functioning are present at birth EXCEPT VIT. K (w/c is produced by intestinal mucosa);
b. there are structures which are present at birth that may alter the route of blood circulation (present at birth: foramen ovale, ductus arteriosus, ductus venosus)
c. note the CARDIAC RATE of pediatric pt (minimum $ y. children – 90-110, older c. – 70)
REPORTABLE S/S FOR ADULT
Palpitation, Pain and Paroxysmal Nocturnal Dyspnea For pediatric patient: observe for PALLOR – if (+) indicates ANEMIA for baby
Nocturnal dyspnea – diff. of breathing at nightParoxysmal ND – when pt feels as if he’s drowning
HEART SOUNDS:
S1 - normal – “lubb”S2 - -do- - “dub”
- in assessing S1 & S2 use BELL of steth
S3 - N for Pediatric pt (ABNORMAL for adult pt – it indicates CHF or Aortic Stenosis)
Steth - BELL – for LOW PITCH SOUND (ex. Murmur) Diaphragm – for HIGH PITCH SOUND
SHOCK
mp: decrease in circulating blood volume
TYPES
CARDIOGENIC – pump failure (CHF, MI, Atherosclerosis Heart Dses, Mitral Valve Dses)
HYPOVOLEMIC - related to fluid loss (pt w/ open wound, traumatic injury, burn)
ANAPHYLACTIC - cause by allergic reaction (laB procedure w/ dye, asthma, poison)
NEUROGENIC - caused by vasomotor collapse (vasomotor – located @ medulla oblongata w/c is responsible for dilatation & constriction of bld vessels)
SEPTIC – due to systemic infection (ex. Septicemia)
TRIAD SYMPTOMS OF SHOCK
a. Altered level of consciousness (dec bld circulation – result to dec o2 in the brain);b. Hypotension;c. Tachycardia and Tachypnea
Patient in shock- there is also (+) pallor and (+) oliguria – due to dec bld circulation & narrowing of bld vessels
Lab Data (to check bld volume circulation) – check HEMATOCRIT (N-35-45%) - check Urine Output
- check CVP
Nsg Dx: FLD VOLUME DEFICIT rel to dec in Circ Vol.
Priority Intervention: Fld replacement (D5Lr, NSS. Bld Trans – for jehova’s use plasma expander)
ANEMIA
MP: Decrease RBC due to decrease production or increase destruction
Risk Factors:
AgeGenderSurgerySecondary to existing medical condition (ex. Renal Failure) Kidney – produce erythropoiten that stimulates bone marrow to produce RBC
TYPES:
a. Iron Deficiency Anemia (IDA)b. Pernicious Anemia (PA)c. Folic Acid Deficiency Anemia (FADA)d. Sickle Cell Anemia (SCA)e. Aplastic/ Fanconis Anemia (AA)f. Talasemia Anemia (TA)
IRON DEFICIENCY ANEMIA
- common in infants and children;- characteristic of patient: chubby but pale- they are also called “milk babies”- those baby 5 yo but still taking milk
(milk are poor source of iron)
MP: Nutritional Deficiency
S/S : Fatigue Fainting
ForgetfulnessPallor, cold clammy skinDyspnea (due to dec RBC)
Lab data:Decrease in HgB (N male: 14-18, Female: 12-16)Characteristic of RBC: HYPOCHROMIC & MICROCYTIC
Nsg Dx: Activity Intolerance
Priority Intervention:
a. Correct the deficiency – by administering iron supplements, - IRON RDA – 15-30 mgs/ day
eg. Oral FeSO4 (take w/ orange juice) if ELIXIR – use straw to avoid staining of teeth
if IM (inferon) – “Z” track method (for Z track IM – PULL SKIN LATERALLY, deep IM, wait 10 seconds before pulling the needle)
FeSO4 – evaluate AFTER 4 weeks to check the effect
b. Diet: iron rich food – (organ meat, dried foods, “egg yolk” – iron, “egg white” – CHON);
c. provide patient with BED REST – due to fatigue
PERNICIOUS ANEMIA
- common in elderly;- common in POST GATRIC SURGERY
Main Problem: Lack of INTRINSIC FACTOR at the stomach (intrinsic factor – the one that absorb vit b12)
In elderly, there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic factor
S/S:3F (fatigue, fainting, forgetfulness)
Beefy Red Tongue or glossitisPeripheral Neuropathy (tingling sensation at lower extremities – usually both legs are affected)
Lab Data:
a. check Hgb b. SCHILLING’S TEST (24hr urine)c. RBC characteristic : MACROCYTIC & HYPERCHROMIC
Nsg Dx: Activity Intolerance Risk for Injury due to p. neuropathy
Priority Intervention:
a. Correct the deficiency – give Vit B12 (IM, Once a month for lifetime);
b. Bed rest – due to fatigue
FOLIC ACID DEFICIENCY ANEMIA
- common in infants, adolescents, pregnant, lactating and overcooked food;
Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN
S/S: all symptoms of pernicious anemia EXCEPT P. NEUROPATHY
Lab Data: HgB Folic Acid level (N 4mg/day) – green leafy veg. (spinach)
Nsg Dx: Activity Intolerance (NO RISK FOR INJURY coz NO P. NEUROPATHY)
PI: Inc. folic acid in the diet – g. leafy; Bed Rest
SICKLE CELL ANEMIA
- autosomal recessive- hereditary- presence of “S or C” shape Hgb due to dec O2 (SICKLING OF RBC)
STATUS N TRAIT TRANS DSES TRANS
1 PARENT W/ TRAIT 50% 50% 0 BOTH PARENTS w/ TRAIT 25% 50% 25% I parent TRAIT, 1 DSES 0 50% 50% BOTH parents w/ Disease 0 0 100%
Risk Factors:
Dehydration (dec in circ bld volume – result in sickling of RBC);
InfectionsConditions that lead to SHOCK
S/S: 3Fs + Fever (due to dehydration) + Pain + Jaundice Hepatomegally
Complications:
a. Vasocclusive Crisis (hallmark of the dses) - bld vessels obstruction by rigid and tangled cells w/c causes tissue anoxia and possible necrosis
b. Spleenic Sequestration Crisis – massive entrapment of red cells in the spleen & liver
c. Aplastic/ Megaloblastic Crisis – bone marrow depression w/c resulted to DEC RBC, WBC & PLATELET
Lab Data: Sickledex Test (+) Turbid Solution
Nsg Dx: Activity Intolerance Fld Volume Deficit Pain – due to vasocclusive crisis
PI: Hydration and relief of pain (inc oral fld intake) Prevent dehydration
Meds for Pain – Morphine SO4, acetaminophen Since HEREDITARY – refer to geniticist
APLASTIC ANEMIA
MP: Hereditary (there is DECREASE IN RBC, WBC & PLATELET)
Autosomal Recessive
S/S: 3Fs + Pallor + Dyspnea Risk for Infection (dec in RBC)
Bleeding (dec in Platelet)
Lab Data: HgB, CBC, Clotting Factors Platelet, Bleeding & Clotting time
Nsg Dx: Activity Intolerance (dec in RBC)
Risk for Injury (dec in WBC and Platelet)
PI: Bld transfusion; Reverse Isolation; Genetic Counseling;
Bed rest
THALASEMIA
Risk Factors:Common in Blacks, Italian, Greeks, Chinese, Indians
MP: HereditaryAutosomal Dominant – common in female and maleThere is a defect in polypeptide
Chain of HgB – ALPA and ETA Chain – there is RBC destruction
Types:
a. Minor Thalasemia Anemia – mild anemia: 3Fsb. Intermedia TA – more severe anemia + Speenomegally
Jaundice (inc deposition of iron @ tissue) Hemosidorosis
c. Major TA – severe anemia + Spleenomegally
Lab Data:
HgB Clotting and Bleeding Time
Nsg Dx: Activity Intolerance Risk for Injury
PI : Bld Transfusion, IVF Dietary supplements of Folic Acid and Iron Surgery (last resort)
LEUKEMIA
MP: proliferation of immature WBC
Characterized by Remission and Exacerbation
Types:
a. LYMPHOCYTIC – common in young children (proliferation of lymphocytes)
b. MYELOGENOUS – adolescent and adult (proliferation of granulocytes)
TRAID S/S:
Anemia (initial) + 3Fs Bleeding Infection
Lab Data:
WBC – hyperleukocytosis (150 – 500,000K) – expected
NDx: Risk for Injury Activity Intolerance Risk for infection
PI: Bed rest Avoid Contact Sports Reverse Isolation
Blood transfusionBone marrow transplant
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) orWERLHOF’S DSES
- common in BLACKS;- cause: idiopathic unknown (viral and autoimmune)
s/s: petechiaeecchymosishemorrhage
(all signs of bleeding)
lab data: Platelet Count of less than 20,000 (spontaneous bldg) (N 150,000 – 450,000)
Nsg Dx: Risk for Injury Fld Vol. Deficit (due to bldg)
PI : SAFETY –prevent bleedingGive pt platelet, IVF and Bld TransfusionCorticosteroids – “wonder drugs”
HEMOPHILIA
- inherited – bldg disorder
TYPES:
a. Hemo. A - deficiency in factor 8b. Hemo. B - deficiency in Factor 9c. Von Willebrand’s Dses – common in male and female
HEMPPHILIA A and B - Autosomal Recessive Link (from mother to male)
Von W Dses - Autosomal Dominant – Mother and Father
S/S: Hemarthrosis – bldg between joints that usually affects ankle, knee and elbow joints;
HematomaHematuriaHematemesis(above mentioned are signs of HEMORRHAGE)
Lab Data : PROLONGED CLOTTING TIME
Nsg Dx : Risk for Injury
PI : SAFETY then RICE (REST, IMMOBILIZE, COLD COMPRESS, ELEVATE)
For JEHOVAH’S – use plasma expander (cryoprecipitate) instead
TIPS FOR BLOOD DISORDERS
If all of the ff data were obtained by the nurse, w/c one is MOST SUGGESTIVE of CARDIOGENIC SHOCK - Inc. HRate from 84 to 122 bpm;
The nurse admitted a 4 yo child with SICKLE CELL DSES – the priority for the patient is – HYDRATION;
w/c of the ff is TYPICAL for patient w/ ANEMIA - SHORTNESS OF BREATH ON EXERTION;
common manifestation of LYMPHOCYTIC LEUKEMIA is – PETECHIAE;
a mother of 15 mos old child with IDA makes the ff comment. w/c one is related to child condition - “MY CHILD DRINKS 2 QUARTS OF MILK/DAY”;
a 7 yo boy with HEMOPHILIA was admitted. w/c of the ff is EXPECTED MANIFESTATION – HEMARTHROSIS;
pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS. w/c of the ff shld the nurse instruct the pt to do - INCLUDE VEGS. AND MEAT in your diet at least 1 meal a day;
w/c of the ff is the priority intervention for pt w/ IDA – PROVIDE BED REST ALTERNATING w/ activities;
w/c of the ff is indicative of thrombocytopenia - HEMATURIA
CARDIOVASCULAR PEDIATRICS
FETAL CIRCULATION
3 FETAL STRUCTRUES
PLACENTA UMBILICAL VEIN DUCTUS VENUSUS LIVER(functionally, closes at birth)
Vena Cava UMBILICAL ARTERIES
Right Atrium FORAMEN OVALE (functionally, closes at birth)
AORTA R Ventricle LA
LV
LUNGS L VENTRICLE
DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth) L ATRIUM P. ARTERY AORTA
Therefore, if these 3 fetal structures will not close, CONGENITAL HEART DISEASE
CONGENITAL HEART DISEASE
ACYANOTIC HEART DSES CYANOTIC HEART DISEASE
Dec Pulmonary Bld flow Obstructive CHD Decrease Pulmonary
Vent. Septal Defect (most common) Pulmonary Stenosis Tetralogy of Fallot (most common)Atrial Septal Defect Aortic Stenosis Transposition of the Great VeinPatent Ductus Arteriosus Coarctation of the Aorta Truncus Arteriosus
Tricuspid Atresia
Usually due to: - Maternal Infection – measles, c. pox - Age 40 and above
- Medical Conditions – DM - Alcoholism
Signs and Symptoms: Difficulty feeding Retarded Growth Tachypnea/Tachycardia Frequent URTI ANS – brow seating
Complication: CH Failure (check for “murmur”) CVA (due to plycythemia – Inc RBC)
Lab Data: 2 D Echo
Nsg Dx: Altered Tissue Perfusion
PI : Oxygenation Surgery
If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determined;
For 2-7 yrs old – surgery is equal to child age ( ex 3yo, therefore prepare the child 3 days prior to surgery)
If > 7yo – parents decision
PATENT DUCTUS ARTERIOSUS
- connection problem : P Artery and Aorta- “machinery-like murmur”- (+) brow seating
(+) retarded growth(+) tachycardia/ tachypnea
LAB DATA : 2 D-Echo CVP PExam
Nsg Dx : Altered Tissue Perfusion
PI : Oxygenation INDOMETHACIN
ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then SURGERY
TETRALOGY OF FALLOT
- pulmonary stenosis, coarctation of aorta, right vent. Hypertrophy, vent septal defect
- “boot-shape heart”- tet spell – squatting w/ cyanosis
LAB DATA : 2 D-echo
Complication : CVA – check for RBC Count
Nsg Dx : Risk for Injury
PI : OxygenationPosition the Pt. : SQUATTINGSurgery
COARCTATION OF AORTA
- Higher BP in the Upper Extremities and Lower BP in the Lower Ext.
Lab Data : BP, 2 D-Echo
PI : Oxygenation Position the patient: Orthopneic or semi – fowler’s position
KAWASAKI’S DISEASE
- due to acute vasculitis (inflammation of bld vessels) of the heart;- especially to JAPANESE children and toddler 5yo and below
S/S : High Spiking Fever for 5 DaysLymphadenopathyStrawberry TonguePalmar and Feet Desquamation
Lab Data : No Specific Diagnostic testCheck ECG
Nsg Dx : Altered Tissue PerfusionAltered ThermoregulationAltered Skin Integrity
Diet : High CHON
TIPS FOR CARDIOVASCULAR – PEDIA
w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children – difficulty in feeding;
w/c of the ff is an appropriate intervention for a child who keeps on squatting because of Tetralogy of Fallot - if LESS THAN 1 yo – flex lower extremities towards the abodomen;
a child who was brought in to a well baby clinic turns cyanotic while crying – REFER to the physician;
the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS – pulmonary artery and aorta;
w/c of the ff data in mother health history indicates a risk factor for congenital heart disease – ADVANCE AGE;
when admitting a pt w/ suspected congenital heart disease, w/c intervention is priority – decreasing the metabolic demand of the heart
CORONARY ARTERY DISEASE (CAD)
Main Problem : NARROWING and OBSTRUCTION of Coronary Arteries which could lead to HYPOXIA – reversible (which could further progress to ANGINA)
and or ISCHEMIA – irreversible (that could progress also to dev’t. of SCAR FORMATION that can lead to MI).
Risk Factors:Family HistoryAtherosclerosisSmokingElevated CholesterolHPNObesityPhysical InactivityStress
CAD
HYPOXIA ISCHEMIA
NECROSIS
ANGINA
Myocardial Infarction – “ jaw pain”
this leads to decrease O2 – and will result to the conversion of aerobic metabolism to anerobic thereby resulting to the production of LACTIC ACID – that will stimulate the nerve ending of the heart w/ will produce/ result to PAIN that is precipitated by:
EATINGElimination – due to valsalva manuever
Exercise/effort/ exertionEmotionExtreme Temperature – “cool temp” – vasoconstriction
sEx
PAIN
MTOCARDIAL INFACRTION ANGINA
Precipitated by 6E’s Pain confined at sternal area Pain that resembles “indigestion”, crushing, excruxiating Pain that resembles “pressure” Pain radiates to the L Jaw, L arm, L shoulder Relieved by SO4 Opiods (MORPHINE) Relieved by rest & NITROGLYCERIN
Pain occurs AFTER MEAL (post cebum) or AFTER ACTIVITY SAME
S/S of above mentioned + SHOCK s/s – esp to CARDIOGENICSHOCK w/c is due to PUMP Failure – that leads to dec cardiacOutput that leads further to CHF.
ECG – initial change is ST SEGMENT DEPRESSION w/ SAME T WAVE INVERSION
Increase CHOLESTEROL SAME HDL – “good” or Healthy – liver for metabolism – 30-80 LDL - “bad” – peripheral vascular system – bld vessels- 60-80
CARDIAC ENZYMES #1 Myoglobin SAME Troponin CK – within 2-3 days LDH 1&2 – within 10-14 days
Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange
Priority : Airway (Oxygenation)
Goal of CARE
a. To decrease oxygen metabolic demand- position : SEMI-FOWLER’S- administer O2 as ordered- administer meds:
MI : Morphine SO4 – monitor RR, effective : (-) pain, ANTIDOTE : Naloxone HCL – Narcan
ANGINA : Nitroglycerine – dark container give b4 activity
maximum of 3 doses, 5 mins intervaleffective: tingling sensation, sublingual
provide rest – due to pain
b. Diet : Low Na and Low Cholesterol
HEALTH TEACHINGS:
Identify types of Angina:
Stable Angina – predictable – angina that occurs w/ activity;
Unpredictable – relieved by Nitroglycerin;
Variant/ Prinzmetal – severe form of Angina;
Nocturnal Angina – occurs at night;
Decubitus Angina – when pt is lying down
Intractable Angina – unresponsive to tx
Post MI Angina
For patient with MI – focus on complications : a. PVC or PVBeats – defibrillation/ cardioversion
b. Ventricullar Fibrillation – Lidocaine – s/e “rashes”
CARDIOVERSION DEFIBRILLATION
- synchronize - unsynchronized- esp. for VTACH w/ PULSE - for VTACH w/o PULSE
SEX – for pt w/ MI – resume if pt tolerate 2-3 plights of stair w/o pain; - take meds b4 sex; - position during sex : passive – let the girl do her share
ACTIVITY – advised pt to have frequent rest period; DIET : avoid PROCESSED FOODS; MILK Salty Sea Foods Pastries – esp. yellow cake
FOR ANGINA APIN – instruct patient to report pain that last more than 2o minutes (indicative of MI);
Weak or absent PULSE – indicative of VENTRICULLAR FIBRILLATION
Report NECK VEIN DISTENTION – indicative of CHF complication
Report BLEEDINGs – especially to pt on THROMBOLYTICS – t-PA and Streptokinase
CONGESTIVE HEART FAILURE
main problem : PUMP FAILURE – inability of the heart to pump an adequate amount of blood to meet the metabolic demands of the body
how will the heart compensate?
The HEART will pump harder- Inc HR (tachycardia) – that will result to enlargement of the heart muscle (hypertrophy) – w/c can lead to dilatation and congestion of the cardiac muscles - thereby resulting to decrease in the cardiac output.
PUMP FAILURE EFFECTS:
Backward Effects : backflow of blood – systemic congestion; Forward Effects : decrease cardiac output – dec in tissue O2 perfusion – that leads to overwork respiratory system
LEFT HEART FAILURE – early signs of CHFTherefore, Right Heart Failure – will be the late signs of CHF as complication of LHF
Risk Factors to Heart Failure:- Arrythmias- Coronary Dses & HPN- Renal Failure
LEFT SIDED HF – dyspnea and other “pulmonary s/s” – “crackles”
RIGHT SIDED HF – systemic effect – distended jugular veinAnkle edemaAscitesHepatomegally
LEFTS SIDED HF RIGHT SIDED HF
Lab Data : Swan Ganz CVP (N R – 0-12, V Cava – 5-12) PAP (N 20-30) PCWP (N 8-13)
X-ray X-ray
Nsg Dx : Altered Tissue Perfusion Ineffective Breathing Pattern – for LHF
Fld Volume Excess – for RHF
PRIORITY : OxygenationPosition: Semi-Fowler’sAdminister: Digoxin – absorb in GI
Vasodilators Diuretics Morphine – for CHF – it causes pheriperal vasodilation by
Decreasing the amount blood going back to the heart.
DIET : LOW Na – NO PMS
HEALTH TEACHINGS :
a. Activity – restb. dietary counseling – NO PMSc. report s/s of complications
DIGITALIS – D. Toxicity: yellow vision; Muscle weakness (hypokalemia) – that can lead to arrythmia
Dyspnea – s/s of pulmonary edema;
HYPERTENSION PREGNANCY INDUCED HPN
MP : blood pressure higher than Elevation of BP that occurs after 20-24
140/90 (hypertensive state) (5 mos- age of viability) wks of gestation
pre hypertensive phase
120/80, therefore N BP : 110/70 if BP elevated B4 20-24 wks & cont after delivery – CHRONIC HPN
Risk Factors: Levels of PIH
Common in BLACKS; a. HYPERTENSIVE DISORDER OF PREGNANCY Obesity - INC. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA)
Stress Smoking b. PRE-ECLAMPSIA S/S + convulsion,
Abdl pain & Headache - ECLAMPSIA PHASE
c. ECLAMPSIA + Bleeding = HELP SYNDROME
TYPES:
a. ESSENTIAL HPN – cause – unknownb. BENIGN – usually of long duration, onset is CHRONICc. MALIGNANT – acute or abrupt onset, short in durationd. SECONDARY – related to existing medical condition
HPN IN PREGNANCY – usually related to generalized spasm of the arteries
PRE-ECLAMPSIA TYPES:
a. MILD BP 140/90, PROTENURIA is <5mg/hr (N - .5-1GM) b. SEVERE BP 160/90, PROTENURIA is >5mg/hr
HEADACHE and ABDOMINAL PAIN – s/s of ECLAMPSIA, indicative of impending convulsion.
ECLAMPSIA + BLEEDING = HELP SYNDROME H – emolysis
E – levated Liver EnzymeL – owP- latelet
(All are signs of bleeding)
S/S of HPN:HeadacheRetinal HemorrhageEdema
- above s/s can further lead to complications: Coronary artery dses CHF Chronic Renal Failure CVA
LAB DATA:Blood PressureElevated CholesterolFor PIH : (+) Proteinuria, Inc BP and Inc Cholesterol
Nsg Dx:Altered Health MaintenanceRisk for Injury
PIORITY: Stabilize BP
How?
I. Non-Pharmacologic Features
Stress Management Deep breathing Diet : Low Na/ Cholesterol Position : if inc BP – supine position
II. PHARMACOLOGIC MEASURES
Antihypertensive Diuretics Aspirin Antilipimic - simvastatin & lovastatin – give after meal nighttime Monitor liver Funx test – meds above are hepatotoxic
Pts w/ PIH meds:a. MgSo4 – antidote is CAgluconate
b. Darkened room – to dec stimulus thereby preventing convulsion
PERIPHERAL VASCULAR DISEASE
Arterial Obstruction Venous Obstruction
Color pallor ruddy
Edema (-) or mild (+) & severeNails brittle nails NPain intermittent claudication homan’s sign (pain @ gastrocnemeus area)
Pulse (-) (+)Temperature cold warmUlcer dry & necrotic wet
TYPES:
BURGER’S DSES RAYNAUDS ARTERIOSCLEROSIS OBLITERANS (THROMBO ANGITIS OBLITERANS)
common : MALE FEMALE MALE
AREA Lower Ext. Upper Ext – 97% Upper & Lower ExtAFFECTED : 3% - lower ext
Affects arteries Arteries ONLY Arteries ONLYand veins
MP : “Angitis” – inflam. of Spasm of Arteries Hardening of arteries due to fatty deposits Arteries & veins of lower ext of Upper & lower
ACUTE INTERMITTENT CHRONIC - (+) pain usually related to- (+) pain that narrowing of blood vessels.
accompanied by color changes: PALLOR that progresses to CYANOSIS then REDNESS & aggravated by exposure to cold – NO SHOVELING OF SNOW & COLD BATH & exposure to cold – wear gloves
S/S: Outstanding s/s is INTERMITTENT CLAUDICATION – pain that worsens w/ activity or pain that is relieved by rest.
- aggravated by smoking – causes further narrowing of bld vessels
LAB DATA : Inc WBC & ESR DOPPLER USG Inc Cholesterol and Ca
Nsg Dx: Altered Tissue Perfusionsame same Pain -do- -do-
PI : Relief of Pain -do- -do-
MEDS : (for all types)
Anticoagulants Vasodilators (papaverin – pavabid) Antihypertensive
DIET : Low Cholesterol
VARICOSE VEIN THROBOPHLEBITIS PHLEBOTHROMBOSIS weakening of venous valves; CLOT + Inflammation Clot job related (prolong sitting/standing)
pregnancy hereditary secondary to existing medical condition
s/s : dilated tortous vein dragging sensation “heaviness” edema (unilateral/ bilateral) – tape measure to monitor leg circumference Pain
Lab data:
1. conservative test – TRENDELENBURG TEST – pt lie down, elevate/ raise the legs then stand up and observe for bulging of vein;
2. DOPPLER USG
Nsg Dx : PAINAltered Tissue Perfusion
Hx Teachings :
Elevate the legs above the heart; Use support stockings; Surgery – vein ligation & stripping Sclero therapy – injection of sclerosing agents to make wall stronger thereby preventing veins to bulge.
NO MASSAGE – coz it may dislodge the clots; KNEE HIGH STOCKINGS; COLD COMPRESS
ABDOMINAL AORTIC ANEURYSM (AAA)
- weakening of portion of abdl aorta – leading to dilation;- could be related to aging and HPN
TYPES:
Fusiform - entire wall is affected
Dissecting - part of inner intima and media was dissected w/c lead to the pushing of tunica adventitia to bulge
Saccular
S/S:
Pulsating Abdl MassLow Back PainHigher BP in Upper Extremities
If RUPTURE occurs – could lead to SHOCK
LAB DATA : Altered Tissue PerfusionRisk for Injury
PRIORITY : NO ABDOMINAL PALPATION bec it may lead to rupture – PLACE WARNING AT THE DOOR OF THE PT.
Prepare pt for Surgery
CARDIO-PULMONARY RESUSCITATION (CPR)
- indicated for cardiac arrest when pt is BREATHLESS and PULSELESS;
shake the pt – are you ok? If breathless & pulseless then; ACTIVATE the EMS – Help! CPR (1 or 2 rescuer : 15 : 2) In 1 minute, there will be 80 compression and
15 – 20 rescue breaths
Depth of Compression : 11/2” – 2”
If too deep - it may fx the liver
Effect of CPR : #1 (+) Pulse; #2 skin color
TIPS FOR CARDIOVASCULAR – ADULT
A nurse is assigned to a pt with arterial dses of lower extremities, w/c of the ff is expected – calf pain after short walking (intermittent claudication);
A pt was diagnosed w/ MI develop atrial fibrillation – this may possibly lead to – CEREBRAL EMBOLISM;
A pt w/ CHF was admitted exhibiting confusion, disorientation, visual disorders & hallucination – the nurse best action is to – CALL THE PHYSICIAN;
A nurse is assessing a pt w/ MI – w/c of the ff is the characteristic of PAIN – pain radiates to the jaw;
In utilizing mind over body principle for pt w/ HPN – w/c intervention is appropriate - relaxation and stress mgt;
Pt exhibits intermittent claudication – another sign of peripheral dses is w/c of the ff – tropic skin changes;
Ff MI, when shall I resume sexual activity? – when you can climb 2 plights of stairs w/o shortness of breath then sexual activity is safe;
A pt has R sided CHF, w/c of the ff is expected – hepatomegally;
Apt w/ CHF who is taking diuretics exhibits the ff, w/c requires further investigation (not expected to pt) – wt gain of 3 lbs in 2 days;
In addition to assessing a pt w/ Burger’s Dses, w/c of the ff data supports the Dx. – smoking;
A pt with R sided HF will manifest – distended jugular vein
R E S P I R A T O R Y
General Consideration:
use the DIAPHRAGM of the steth when assessing breath sounds; use steth directly on pt. skin – because clothing my interfere w/ auscultation; when the pt chest is hairy, wet the hair w/ dump cloth – because dry hair interfere
w/ auscultation
Consideration w/ Pediatric Patient:
when assessing pediatric pt, RR is affected when – therefore check RR FIRST; Note for chest indrawing (if +, may indicate Pneumonia) and rapid breathing
Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS
“RE TACHY TACHY D C”
RETRACTIONS - #1 or Early sign for respiratory distress; Tachycardia Tachypnea Dyspnea Cyanosis – late sign of respiratory Distress
Key Points for Assessment - note for abnormalities in RATE, RHYTHM & DEPTH
Common CHARACTERISTIC in Breathing
BIOTS – increase in depth followed by apnea; - pt w/ neuro impairement
Cheyne-Stroke – increase in rate and depth of breathing followed by apnea; - nero case
Kussmauls – deep rapid breathing; Apneustic – forceful inspiration followed by slow expiration – dying patient
At birth, the child can maintain temperature by burning brown fat – and increase burning – bi products is Increase fatty acids that will cause acidosis – that can worsen the Resp. Distress Syndrome – a group of symptoms (mgt: maintain temperature).
HYPOVENTILATION
Cause: Lack of O2 Effect: ACIDOSIS
HYPERVENTILATION
ALKALOSIS
Cause : lack of CO2 – the pt will decrease rate of breathing to save CO2. co2 then combine with H2O to form carbonic acid – if inc, can lead to acidosis – and the brain will compensate by hyperventilating – and increase elimination of CO2 will cause ALKALOSIS.
APNEA OF INFANCY SIDS/ CRIB DEATH
Occurs in Full Term Baby (37wks onwards) Usually occurs in Pre-term
s/s : episodes of APNEA, TACHYCARDIA Risk Factors: and Cyanosis
a. Pre-Term;b. Those w/ episodes of Apparent Life Threatening Eventsc. Siblings of those who died w/ SIDS (usually 2-3 sis/ bro – died)d. Hypoventilation
Dx Procedures:
Cardioneumogram – measures O2
PolysonographyABG Analysis
Tx :
Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia
Caffeine Assist mother threu grieving process
Hx Teaching : Teach parents CPR (esp to Apnea of Infancy)
ASTHMA
MP : Inflammation of bronchioles that leads to excessive mucus production that resulted to narrowing and obstruction.
Risk Factors : Environmental factorsEmotionEffort/ Exercise
S/S : WHEEZING sound – due to obstructionOrthopneaWhitish Sputum
Lab Data : Pulmonary Funx testIncentive Spirometer
Nsg Dx : Ineffective airway Clearance
PI : AIRWAY
Intervention :
Bronchodilators – theophyllineRestOxygen – low flow (1-2 l/min) – higher than this will result to decrease in the stimulus for breathing –
w/c is CO2NebulizationChest Physiotherapy – b4 meals or at bed timeHigh FowlersIntermittent Positive Pressure BreathingAerosolLiberal Fluid Intake
Meds : AminophyllineSteroidsTheophyllineHistamine AntagonistMucolyticAntibiotics
Hx Teachings :
Appropriate rest; Activity – avoid those that will expose pt to allergens; AVOID PROPANOLOL and ASPIRIN – causes BRONCHOSPASM; Exercise – “blowing exercises” – bubbles, trumpet
CYSTIC FIBROSIS
- multi system dses (GI and Respiratory System) characterized by excessive mucus production by exocrine glands.
Respiratory GI
Hereditary Autosomal Recessive
For each pregnancy - TRAIT TRANSMISSION – 50% Chance for DISEASE TRANSMISSION – 25%
S/S : MECONIUM ILEUS – within the 1st 24-36 hrs – if baby fail to defecate – suspect for CF;ABDL DISTENTION Malabsorption Syndrome – STEATORRHEA – foul-smelling stool w/ Inc Fats & BulkySalty to Kiss – bec skin becomes impermeable to Na
Common Complications: because of thick mucus plug
MALE – Aspermia – low sperm countSterility
FEMALE – Difficulty in conceiving
Nsg Dx : Knowledge DeficitAltered EliminationAltered Sexual Functioning
Lab Data : Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl – INCREASE IF (+) CF (if serum) 90 – 110 mg/dl - -do-
PI : since two system are affected:
Respiratory Therapy – blowing of trumpet, Increase Fluid Intake;
GI Therapy – Administer Pancreatic Enzyme (pancreatin, pancrease, viocase) GIVEN WITH EACH MEALS
Effective : if (-) fat at stool
Hx Teaching : Refer parents to GENETICIST
CROUP DISORDER
ACUTE LARYNGITIS LTB RSV/ BRONCHIOLITIS(Laryngotracheal Bronchitis) (Respiratory Synctial Virus)
common in TODDLER INFANTS & TODDLER INFANTS usually (less than 6 mos)
VIRAL VIRAL or BACTERIAL VIRAL
Inflammation of LARYNX Inflam. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES
“barking-metallic cough” “harsh-brassy cough” “paroxysmal-hacking cough”
(-) FEVER (+) FEVER-low grade (+) FEVER-moderate
(+) STRIDOR (+) STRIDOR (+) WHEEZING
STRIDOR – is present when the affected part is LARYNX.
Lab data: P Exam -do- ELIZA ABG’s -do-
Nsg Dx : INEFFECTIVE AIRWAY CLEARANCE
PI : Airway – Endotracheal Tube (Tracheostomy Set - #1) – to facilitate airway; Humidity – place infant in MIST TENT or CROUPETTE
Nsg care:
change clothing frequently coz mist will dampen child clothings; TOYS while inside the tent: PLASTIC TOYS “no battery operated & no friction wheel toys” at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the comfort room – for child to inhale
Antibiotics – Antiviral – Ribavirin
Hx Teachings :
SYRUP OF IPECAC – for Croup – it induces vomiting- bec it will stop the spam thereby preventing further coughing.
Chronic Obstructive Pulmonary Disease (COPD)
MP : group of disorders of respiratory system that lead to obstruction or narrowing of airways.
EMPHYSEMA BRONCHITIS ASTHMA
Over distention of Alveoli Inflammation of BronchusGelatinous sputum + “RE TACHY TACHY D C”
Risk Factors:
(+) Allergy(+) Environmental factors(+) Pollen(+) Elevated Immunoglobulin E (IgE)(+) Smoking (esp to passive smokers)
S/S: RE TACHY TACHY D C + “barrel-shape test” – there is an INCREASE in ANTERIOR and POSTERIOR DIAMETER of the chest
Lab Data : ABG’s – to check for respiratory acidosis CXrays
Nsg Dx : #1 Ineffective Airway Clearance – due to narrowing & obstruction #2 Ineffective Breathing Pattern
PI : AIRWAY 1-2 L/min; Meds: Bronchodilator – Atrovent Exercise: Blowing; Rest periods in between activities
During ACUTE attack, the POSITION OF CHOICE : ORTHOPNEIC
PNEUMOTHORAX
MP : partial or total collapse of lungs due to:
Types :
Open Pneumothorax – TRAUMA Spontaneous Pneumothorax - due to rupture of BLEB – over distention of alveoli
Tension Pneumothorax – due to INCREASE IN TENSION
S/S : Diminished Breath Sounds – (-) b. sounds to area auscultated;(+) Dyspnea;(+) Restlessness
Nsg Dx : Impaired Gas ExchangeIneffective Breathing Pattern
PI : Chest Tube Drainage System – restores the (-) pressure within the thoracic cavity
Anterior chest tube – drains the AIRPosterior chest tube – drains FLUIDS
PNEUMONIA (PNA)
MP : there is INFLAMMATION of ALVEOLAR SPACES that leads to exudation and consolidation of the lungs.
LEGIONARES DSES – acute bronchopneumonia in elderly, alcoholic & Immunosuppressed pt
- management same w/ pna
VIRAL PNA BACTERIAL PNA
Fever : (+) low-moderate (+) fever moderate-high
Cough : (+) Non productive – “thin-watery” (+) Productive – “rusty”
WBC : No change or slight Elevated
Lab Data : Xray and ABG’s
Nsg Dx : Impaired Gas Exchange – due to exudation and consolidation of Alveoli
PI :
Airway – O2 Position : Semi-fowler’s or Orthopneic Bed Rest Inc Oral fluid intake Antibiotics TCDB (turning, coughing, & deep breathing)
TB HISTOPLASMOSIS MYCOBACTERIUM AVIUM COMPLEX
Bacterial Fungal (from HISTOPLASMA CAPSULATUM) Bacterial from BIRD MANURE – soil & transmitted thru
inhalation
Droplets & Airborne Droplets & Airborne Droplets & Airborne
Risk Factors:
ASIAN IMMIGRANTIMMUNOSUPPRESSIONMALNUTRITION
S/S : same: a to e + FOREST RELATED ACTIVITY same with TB Ask client if came from AVIARY
a. initially asymptomatic;b. low grade fever that occurs in the afternoon;c. body malaise or weakness;d. coughing w/ bld streaked sputum;e. weight loss
Lab Data : Histoplasmine Skin Test – for Histoplasmosis
Mantoux TestXray – confirmatory testSputum - @ least 2 (-) to be effective
Nsg Dx :Infection;Ineffective Breathing Pattern
PROPHYLACTIVE TREATMENT OF TB – INH for TWO WKS (take Vit B6 to avoid NEUROPATHY)
MEDS : Antiviral Meds Antibiotics
RifampicinINHStreptomycinEthambutol
- take above meds for 6-12 moths to avoid resistance
TIPS FOR RESPIRATORY
you observed a nurse caring for a child in a CROUPETTE, if you are the nurse in-charge, what would be your #1 PRIORITY? – changing the linens & clothings to keep child always dry;
which data in the past medical history of the pt. supports a dx of cystic fibrosis – MECOMIUM ILEUS in the neonate;
the primary goal of care for pt w/ bronchiolitis is to – minimize oxygen expenditure;
w/c of the ff intervention being carried out by LPN would require immediate intervention – suctioning the pt for 20 seconds;
a client w/ TB will experience - low grade fever;
a pt is diagnosed w/ emphysema – w/ of the ff s/s would the nurse expect to have – barrel shape chest;
a nurse caring for a pt w R Lower Lobe PNA shld put the pt in w/c of the ff position to enhance postural drainage – L Lateral w/ the Head Lower than the Trunk
DAY 7 (Feb 10, 2005)
ENDOCRINE
General Consideration
Explain to the pt the MOST COMMON METHOD of assessment:
a. Direct methods – specimen : blood and urineb. Explain the methods of gathering the specimen
Consideration for PEDIATRIC PATIENT
a. Involve the parents of the child;b. Incorporate food preferences 2 servings of popcorn – HOW MANY RICE TO GIVE UP = 1
if sandwich = 1 rice
c. self insulin administration – allowed to child 9 yo and above
Reportable S/S :
skin changes – “have you noticed any change in your skin color” (“bronze skin pigmentation – addison’s dses)
Inc. temperature S/S of Shock
Keypoints : Specimen characteristic is usually affected by STREE, DIET and Normal Body Rhythm
PKU- AUTOSOMAL RECESSIVE PATTERN of transmission (inherited)
MP : There is Absence of Phenylalamine Hydroxylase (the one that converts Phenylalamine to Thyroxine ( a precursor to Melanin).
Therefore (-) PH leads to accumulation of phenylalanine at the brain that leads to Mental Retardation.
S/S :Initially – asymptomaticFor OLDER CHILDREN : Diarrhea
AnorexisLethargyAnemiaSkin Rashes and seizureMusty odor of urine (due to phenyl pyruvic acid)
Since (-) melanine: hair : blondeEyes: blueFair Skin
Lab Data :
GUTHRIE CAPILLARY BLD TEST – initial screening – done after the infant has ingested CHON for a minimum of of 24 hrs.
Secondary screening : done when the infant is about 6wks old – test fresh urine w/ PHENISTIX – WHICH CHANGE COLOR
Phenylalanine level greater than 8mg/dl – diagnostic of PKU (4mg/dl – indicative)
Nsg Dx :Knowledge DeficitAltered Thought ProcessRisk For Injury
PI : Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or til 10 yo – bec b4 this time the brain mature
MEDS : Lofenalac – 20-30mg/kg/day
Hx Teachings :
Inform parents of the foods to be avoided; - prepare special education to parents
Provide list of foods allowed;- prepare special education to parents
Refer to geneticist
Untreated PKU can result in failure to thrive, vomiting and eczema – and by about 6 mos, signs of brain involvement appear.
LYMPHOCYTIC THYROIDITIS orJUVENILE HYPOTHYROIDISM
Cause : Autoimmune or genetics
MP : Decrease in T3 and T4
S/S : Dysphagia
Enlarge thyroidAll s/s of hypothyroidism (decrease metabolism)
Nsg Dx : Knowledge DeficitActivity Intolerance
PI : no tx because it regresses (only temporary) spontaneously
CRETENISM or CONGENITAL HYPOTHYROIDISM
- disorders related to absent or non-functioning thyroid;- newborns are supplied with maternal thyroid hormones that last up to 3 mos;- initially asymptomatic
s/s begins 2 – 3 months
behavioral s/s physical s/s – large tongue & protrudes - apathy – “well behave” from mouth
- retarded growth
- intolerance to cold
mental retardation
Prevention: neonatal screening blood test; Without treatment, mental retardation and developmental delay will occur after age 3 mos;
Lab Data : Decrease T3 and T4
Nsg Dx : Knowledge DeficitRisk for Injury
Meds : Single morning dose of Synthroid for “LIFE” – oral thyroxine and Vit D as ordered to prevent M. retardation
(adverse effect of meds : insomnia, tachycardia, and nervousness – REPORT ASAP)
PI : correct the deficiency
Hx Teachings :
Warm environment (bec there is Hypothermia w/ cool extremities); Low calorie diet : since there is decrease metabolism; Special education
ENDOCRINE GLANDS
- 8 glands (ductless)- they secrete the hormone directly to bld stream
1. Pineal Gland2. Pituitary Gland3. Thyroid Gland4. Parathyroid Gland5. Thymus Gland6. Pancreas7. Adrenals8. Gonads (testes & ovaries)
Glands UNDER OVER
PITUITARY Diabetes Insipidus SIADH
THYROID Hypothroidism Hyperthyroidism
(Myxedema) (Graves, Basedows, Parrys)
PARATHYROID Hypo Hyper
Pancreas DM
ADRENALS Addison’s Dses CushingsConns
PANCREAS
Alpha Cells BETA CELLS
Islets of Langerhans
Glucagon Insulin (responsible for Decrease in blood sugar)
Responsible in the increase Blood Sugar
Absence Deficiency (DM Type I) (DM Type II) IDDM NIDDM
Juvenile Onset – B4 age of 30 Maturity Onset – After age of 30; Adolescence to Early Adult Stage Pt is Obese Pt is THIN Pt is KETOSIS PRONE NON-KETOSIS PRONE
MODY – DM III
- combines features of DM Type I & 2; - Maturity Onset that occurs in young adult; - OBESE, b4 age of 30 - Non-Ketosis Prone
GESTATIONAL DIABETES - occurs during pregnancy
Types According to WHITE’S Classification
TYPE ONSET DURATION
A CHEMICAL DIABETES (+) Increase Bld Sugar
B After the age of 20 10 years
C Bet 10 – 19 yrs old 10-19 years
D Before 10 yrs old More than 20 yrs
D1 Before 10 yrs old
D2 >20 yrs
D3 Beginning Retinopathy
D4 w/ calcification of arteries
D5 DM w/ HPN
E w/ calcification of Pelvic Arteries
F w/ nephropathy (Diabetes Nephropathy)
H Diabetes Cardiopathy
R Diabetes Retinopathy
T w/ Transplant of the Kidney
DIABETES MELLITUS
MP : Deficiency in INSULIN – either absence or deficiency of insulin that leads to alteration in the metabolism of CHO, CHON and FATS.
Cause: unknown
R. factors : Autoimmune Genetic
Stress
S/S : PolydipsiaPolyuriaPolyphagia – the stave cells send message to the brain to eat more
Wt loss
Nsg Dx : Knowledge DeficitAltered Nutrition
PI :Correct the deficiency- HOW?
Diet : well balance diet – CHO – 50-70% (main source of energy and sugar for DM pt.)
Insulin – for Type 1
Hypoglycemia Most Approximately to Occur
RAPID Regular Insulin - BEFORE LUNCH
INTERMEDIATE NPH - LATE IN THE AFTERNOON/ AFTERNOON
SLOW Protamine Zinc - DURING NIGHT Ultralente
INSULIN: Best Site is ABDOMEN bec it is a NEUTRAL AREA
SUBQ – 90 degree angle for insulin syringe 40 degree angle if non-insulin syringe
Complication of INSULIN ADMINISTRATION:
Lipodystropy Dawn’s Phenomenon – hyperglycemia that occurs at dawn – Early AM
- due to over secretion growth hormonetreatment: GIVE INSULIN – NPH at 10 PM to prevent hyperglycemia at early AM
SOMOGYI Phenomenon – rebound hyperglycemia (tx: administer insulin)
Antidiabetic Agent;
Blood Sugar Monitoring – in AM and supper time (2x a day);
Ensure adequate food intake;
Transplant of Pancreatic Cells;
Exercise – it will decrease insulin requirement (in pregnancy/stress – Increase insulin req)
Scrupulous foot care – check up w/ podiatrist - foot powder, snugly fitting shoes, cut toe nail straight across - cut toe nail across
- avoid going barefoot - always dry in between toes
Modification for Pregnant Pt with DM
+300Kcal; Insulin Requirement (dose will be adjusted on 2nd & 3rd Trimester);
AM Dose: 2:1 for Regular to NPHPM Dose: 1:1 for R:NPH
EFFECTS
MOTHER BABY
MacrosomiaHyperglycemia Hypoglycemia Therefore pre-term birth RDSComplication: Uterine Atony Congenital Defects
COMPLICATION
1. Hypoglycemia Hyperglycemia (bld sugar level above 120)
(Insulin Reaction) (Diabetic Coma)- BLD SUGAR BELOW 50
DKA HHNK
Risk Factors :
Missed meals; Overeating Increase or Overdose of Insulin; Decrease Insulin Too much Activity Inactivity
StressInfection
S/S :
DizzinessDrowsinessDifficulty Problem SolvingDecrease Level of Consciousness
+ Cold Clammy Skin, Diaphoresis
Lab Data : Below 50 Blood Sugar Level
PI : Administer Simple Sugar (fructose-fruit juice)Hard Candy (not chocolate – it is complex sugar)
If unconscious – D50
DKA (Type 1) HHNK (Type 2) (Hyperglycemic Hyperosmolar Nonketotic Coma)
S/S : 3 P’s + Signs of Dehydration – thirst & warm skin
Hyperglycemia More pronounced GI Disturbances “Kussmaul Breathing + 3P’sThirst and warm skin
Lab Data : Increase Bld Sugar
PI : #1 AIRWAY#2 FluidRegular Insulin
Nsg Dx : Risk for Injury
2. MICROANGIOPATHY - destruction of small blood vessels;
3. ATHEROSCLEROSIS – hardening of arteries;
4. NEPHROPATHY – kidney damage;
5. OPTHALMOPATHY - w/c leads to cataract (eye exam annually);
6. Peripheral Neuropathy or Autonomic Neuropathy
- there is poor nerve impulse transmission- common manifestation : impotence
DIABETES INSIPIDUS(Pituitary Glands – 3 lobes)
ANTERIOR POSTERIOR MIDDLE
Secrete Tropic Hormones Store Only (does not excrete) MSH (skin color)
FSH OXYTOCIN (follicle stimulating Hormone) ADH
ACTH (adrenocorticotropic hormone)
LH (luteinizing hormone);
GH (growth hormone);
Prolactin
PITUITARY GLAND
ADH (anti Diuretic Hormone) – retain h20 or flds
Deficiency: lead to D. INSIPIDUS Excess : SIADH (Syndrome of Inappropriate Anti Diuretic Hormone Secretion)
Due to or related to:
Pituitary TumorHead TraumaInjuries
MP : Deficiency in ADH leads to fld excretion, therefore s/s same with DM EXCEPT : POLYPHAGIA
Polyuria – 21 L/day Polydypsia
LAB DATA :
a. urine - decrease in specific gravity (N 1.010 – 1.025) – in DI its <1.005;b. FLUID DEPRIVATION Test - pt on NPO 24hrs B4;
Nsg Dx : FLUID VOLUME DEFICIT
PI : Administer IV FluidsMeds - Synthetic ADH - Vasopressin – IM
Desmopressin – INTRANASALLY- one hole of nose only
Lypressin - -do-
How : Given as pt exhale to the mouth then inhale thru the nose then EXHALE to the mouth then give meds.
Evaluate the effect of meds :
Check Specific Gravity of Urine; Monitor I & O; Monitor V/S : assess for hypovolemic shock
SIADH- excess ADH;
MP : Fluid Retention – result to DILUTIONAL HYPONATREMIA or H2O INTOXICATION
S/S : due to DECREASE NA – this could lead to the ff:
convulsion; seizure; HPN
Above s/s could lead to decrease LOC
LAB DATA : Decrease Na Level (<120 mEq/L) – hyponatremia
Nsg Dx : FLUID VOLUME EXCESS
PI : FLUID RESTRICTIONDrugs – DIURETICS + ANTIHPN – if cause by TUMOR – PREPARE PT FOR SURGERY
IF after surgery – POLYURIA – report ASAP – sign of DI
PITUITARY
GROWTH HORMONE
DEFICIENCY EXCESS
DWARFISM B4 Closure of Growth Plate - “congenital” - “gigantism” ex. MAHAL - long, slender extremities and Inc. in Height
ex. Marlo Aquino
NANU’S SYNDROME (hereditary) After the Closer of Growth Plate - “acromegally” - there is coarsening of facial features +
enlargement of the digits (inc. shoe size) ex. Balingit
Lab Data : INCREASE HUMAN GROWTH HORMONEIncrease Blood Sugar
Nsg Dx : Risk for Injury
PI : SafetyMeds - Parlodel – decrease secretion of growth hormoneIf related to tumor : surgery
GIGANTISM (long slender extremity)
MARFAN SYNDROME KLINEFELTERS (hereditary) (chromosomal aberrations)
MP : Cardio & Eye disorder (complication) MP : XXY Pattern (an extra X chromosome) Scoliosis X chromosome – FEMALE COMPONENT
of HUMAN BODY
Problem is NON-DEVELOPMENT of SEX ORGAN
ADRENAL/SUPRARENAL
CORTEX (OUTER) MEDULLA (INNER) RESPONSIBLE FOR SECRETION OF: SECRETES THE FF:
GLUCOCORTICOIDS MINERALOCORTICOIDS EPINEPHRINE NOREPINEPHRINE (ALDOSTERONE)
GLUCONEOGENESIS STRESS RESPONSE – “fight or flight” - formation of sugar from Responsible for Na Retention new sources and K Excretion
DEFICIENCY IN GLUCO & MINERALO : ADDISON’S Dses EXCESS of GLUCO & MINERALO : CUSHING’S Dses/ syndrome EXCESS of MINERALOCORTICOIDS ONLY : CONN’S SYNDROME
ADDISON’S CUSHING CONN’S
MP : Underactivity of the Adrenal Glands Overactivity of A. Glands INC. MINERALOCORTICOIDS (there is DEC G, M & SEX HORMONES) (there is INCREASE G & M) - w/c cause K EXCRETION & ADRENOCORTICAL INSUFFICIENCY Na RETENTION
Excessive SECRETION of Excessive ALDOSTERONE - coticosteriods especially the Secretion from A. CortexGLUCOCORTICOID CORTISOL
Common: Male and Female Female (bet. Age 30-60) Female (30-50)
RF : Could be related to Surgery – removal Related to Tumors Related to Tumor Of Adrenal Gland and or Auto Immune Reaction
S/S: Dec Bld Sugar (hypoglycemia) INC BP, NA ALL S/S OF CUSHINGS Dec Na (hyponatremia) DEC K + EXCEPT HYPERGLYCEMIA Dec BP Moonface, Hirsutism, INC K (hyperkalemia) Buffalo Hump, Pendulous Abdomen Hypertension
Lability of Mood (mood swings) Polyuria, PolydipsiaDepression Cardiac Arrythmias – due
COMPENSATORY of MSH – Inc w/c Trunkal Obesity / thin Extremities to dec K Leads to “Bronze-Like Skin Pigmentation” Hypertension
Decrease Resistance to Infxn Hypotension, Weak Pulse Weight loss, Fatigue, Muscle weakness Nausea, Anorexia, Vomiting Hx of frequent Hypoglycemic Rxn
Lab Data : Decrease Cortisol Level Increase Cortisol Level Hypokalemia – due Hyponatremia Hypernatremia metabolic Alkalosis Hypoglycemia Hyperglycemia Inc Urinary Aldosterone Level Hyperkalemia Hypokalemia Decrease K
Nsg Dx : Fluid Vol. Deficit Fld Vol. Excess Risk for Injury Fld & E imbalance Fld & E imbalance Fld & E Imbalance
ADDISON’S CUSHINGS CONN’S
PI :
Correct the imbalance – IV Correct the imbalance Check BP – give antiHPN Diet: Inc Na Dec K - limit fld intake Administer Steroids (Fludocortisone)
DIET : Low in Calories & Na Limit the fldsAdmin. Hormone Replacement Therapy High in CHON, K, Ca
Cortisone – give 2/3 of dose in AM & Vit D 1/3 in afternoon
Meds are FOR LIFE Prevent accident & Falls Diet : Low Na, Inc K Prevent exposure to Infxn Protect client exposure to Infxn Provide rest periods – prevent fatigue Minimize stress in environment Administer SPIRONOLACTONE Monitor I & O, weigh Daily MIO & weigh Daily (aldactone) & K supplements
As Rx Provide small, frequent feeding high in Monitor V/S, observe for HPN & CHO, Na and CHON to prevent edema Hypoglycemia & Hyponatremia
Use of Table salt tablets (if Rx) or ingestion Surgery – prepare pt if cause Of salty foods (potato chips) by pituitary tumor or hyperplasia if experiencing Inc. sweating
Post Surgery: poor wound healing; report s/s of Addisonian Crisis – severe HYPOTENSION Avoidance of strenuous exercise esp Meds: FOR LIFE in HOT WEATHER Glucocorticoids Synthesis Inhibitors
- Lysodren and Cytodren - prevents formation of Gluco…
ADDISONIAN CRISIS
- severe exacerbation of Addison’s dses caused by acute adrenal insuffieciency
causes: strenuous activity, infection, trauma, stress, failure to take RX Meds
s/s: severe generalized muscle weaknesssevere hypotensionhypovolemia, shock
PI : administer flds to treat vascular collapse IV glucocorticoids - Solu-Cortef and Vasopressors Maintain strict bed rest and eliminate all forms of stressful stimuli MIO and weigh daily Protect client from Infxn
Other Hx teachings: same with Addison’s
THYROID
T3 & T4 Calcitonin - responsible for maintenance of METABOLISM - deposit Ca @ bones
DEFICIENCY EXCESS HYPOTHYROIDISM HYPERTHYROIDISM Adult: Myxedema Grave’s Disease, Basedow’s or Parry’s Dses Children: Cretenism
Main Problem:
Slowing of metabolic process caused by hypofunction of the Secretion of excessive amount of Thyroid Thyroid Gland with decrease thyroid hormone secretion (T3 & T4) Hormone in the blood causes in the INC
Of metabolic process
DEFICIENCY in T3 and T4 Excess in T3 and T4
Causes:
congenital genetic surgery autoimmune autoimmune tumor
S/S :
FACIAL EDEMA EXOPTHALMUSINTOLERANCE to COLD (+) GoiterDECREASE v/s Hypermetabolic StateDECREASE GI Motility – constipation INTOLERANCE to HEATHYPOactivity Inc V/SIncrease Sleep – hypersomnia INC GI Motility - DIARRHEAWt Gain in the presence of Dec Appetite InsomniaDry scaly skin, dry sparse hair, brittle nails HYPERactivity
WT LOSS even INC AppetiteWarm smooth skin, fine soft hairPliable nailsIrritability, restlessness, agitation
LAB DATA :
Check TSH (increase) DECREASE TSHDECREASE T3 & T4 INCREASE T3 & T4DECREASE RAIU (131) INCREASE RAIU
INCREASE Serum Cholesterol Level
RADIOACTIVE IODINE UPTAKE (RAIU) – administration of 123I or 131I orally; - performed to determine thyroid function (increase uptake – indicated
hyperthyroidism, minimal uptake may indicate – hypothyroidism);nsg consideration : take a thorough history – thyroid meds must be D/C 7-10 days b4 the test – meds containing iodine cough preparations, and intake of iodine rich foods and test using iodine – eg IVP can invalidate the test
NSG DX :
Activity Intolerance – due to Fatigue Risk for Injury (bec of hyper) (fatigue – due to hypometabolism)
PI :Promote a EUTHYROID STATE same
HOW : a. THYROID SUPPLEMENT Admin AntiThyroid Meds – for LIFE Synthroid, Cytomel – lifetime ex. PTU & Lugols s/e: insomnia, palpitation
nervousness b. DIET: low calorie Assign to private room away from excessive activity
c. Maintain vital funx: correct hypothermia – maintain Quite & relaxing Activity adequate ventilation
d. Provide comfortable, warm environment Provide a COOL ENVIRONMENTe. Increase flds and high fiber foods to prevent
constipation,. Admin stool softener as Rx DIET : High in CHO, CHON, CALORIES
f. Meds: thyroid hormone replacement – take daily Vit & Minerals w/ supplemental dose in AM to avoid insomnia feedings bet meals & at HS
Monitor THYROTOXICOSIS – tachycardia NO STIMULANTS Palpitations, nausea, vomiting, diarrhea, Sweating, tremors, dyspnea Protect eyes w/ dark glasses & artificial
tears
Monitor for AGRANULOCYTOSIS (fever, Sore throat & skin rashes) – if taking
antithyroid meds.
Prepare pt for surgery – 2wks before SURGERY give LUGOL’S SOLUTION
- it decrease size and vascularity of thyroid gland; - give w/ straw to avoid staining teeth; - can be diluted w/ H2O or orange/ apple juice;
- report diarrhea & metallic state
Meds: a. Antithyroid Drugs – Prophythiouracil and Tapazole - block synthesis of thyroid hormone; - toxic effect include AGRANULOCYTOSIS
b. Radioactive Isotope of Iodine (131) – Radioactive Iodine Thrapy - given to destroy the thyroid gland thereby decreasing
Thyroid hormone production
COMPLICATIONS OF THYROID SURGERY:
MEMORRHAGE – whether the dressing is dry or intact – its not a confirmatory that there is no bleeding.
To check, slip your hands at the back of the neck (bec of principle of gravity)
Damage Laryngeal Nerve – to assess, ask pt to talk past surgery and if pt has APHONIA – provide communication aids – paper and pencil
LARYNGOSPASM – accidental removal of parathyroid gland – therefore will lead to dec parathormones – w/c lead to dec Calcium and laryngospasm – KEEP TRACHEO SET at bedside.
TETANY – due to decrease in CA – characterized by:
a. tingling sensation – fingers & lipsb. Chvostek’s Sign – facial muscle twitching on percussion of facial nervec. Trousseau Sign – carpopedal spasm
THYROID CRISIS – due to rebound hyperthyroidism Increase thyroid hormone
Increase HRate/palpitation Inc Temp - hyperthermia
PARATHYROID
Parathormone
Deficiency Inc CA in the Blood EXCESS HYPOPARATHYROIDISM withdraws Ca @ bone to the bld HYPERPARATHYROIDISM
MP : Dec Ca (hypocalcemia) maybe hereditary, Increased secretion of PTH that result Or caused by accidental damage to or removal in altered state of Ca, Phospate & bone Of parathyroid glands during surgery eg thyroidectomy metabolism
S/S :
Initial S/S: Bone Pain (esp Back Bone)- Tingling lips & Fingers Kidney Disorder – kidney stones- Chvostek’s renal colic- Trousseau NAV, Constipation
Late S/S- personality changes- cardiac arrythmias- muscle pains
Lab Data : Decrease Ca Inc Ca (N 4.5-5.5 mg/dl) Serum Phospate Inc Dec Serum Phospate Level Skeletal Xray – reveal Inc Bone density xray –reveal Bone Demineralization
Nsg Dx : RISK FOR INJURY same
PI : a. Safety same
b. Keep Ca supplement at Bedside Inc Oral Fld intake – due to renal c. Diet: Inc Ca – spinach, sardines, seafoods calculi of having INC Ca d. Tracheo set – deu to dec Ca – Laryngospasm Diet; Low Ca
Surgery – if due to tumor
TIPS FOR ENDOCRINE
a child w/ PKU was admitted, w/c of the ff statements made by the mother indicates a need for further instruction – “my child loves to drink milkshakes” – chon- w/c has INCREASE Phenylalanine;
w/c of the ff if manifested by a child could be indicative of diabetes – bed wetting;
a common manifestation of HYPOGLYCEMIA – shaky tremors;
a pt post thyroidectomy develops tetany, the nurse anticipates that the doctor will most likely order – Ca Gluconate;
rapid & deep breathing that occurs in diabetic pt is indicative of – KETOACIDOSIS
a pt is to receive NPH Insulin at 8AM, when shld the nurse expect to have hypoglycemia – in the late afternoon;
to determine the effect of PTU, the expected outcome is – Dec HR;
what would be the question to support the Dx of Hypothyroidism – do you tire easily?;
w/c of the ff statements made by the diabetic pt would indicate the need for further teaching – “I will be hypoglycemic if I experience emotional stress”.
GENITO-URINARY
General Consideration
when performing assessment of Genito-urinary system, use open-ended question- bec some pt are not comfortable talking genitals;
explain the meaning of terminologies; ask the patient what symptoms bother him/her the most;
Consideration for Pediatric Patient
assess for history of sorethroat; bladder capacity increase with age
infants – about 65mltoddler – 300-400 mlschool age – 800 – 1000 ml
infants are unable to concentrate urine until the age of 1 – therefore – adequate milk intake if baby has 6-8 diapers /day;
bladder sphincter control develop at around 2 yo (therefore, bladder trng comes after bowel trng – 15-18 mos of age)
S/S common to all Disorders of GU:
a. frequencyb. urgencyc. hesitancy
Reportable s/s :
peri orbital edema BP Oliguria Hematuria – Early Stream Hematuria – indicate lesion at Urethra Late Stream – indicate lesion at bladder
Key points :
a. check for wt gain
if >1lb/day – indicative of fld retention
b. characteristic of urine: color N - amber if pinkish – bldg brownish – flagyl orange – rifampicin
c. s. gravity (N 1.010 – 1.025) - if INCREASE - D. Insipidus DECREASE – D. Mellitus
d. Increase glucose – UTIe. Elevated CHON – Nephrotic Syndrome or PIH
Epispadias – opening at DORSAL portion
Hypospadias – opening at VENTRAL portion
WILM’S TUMOR- congenital tumor at the kidney
- common in L Kidney and children below 5 yo
S/S : Unilateral Abdml MassHematuriaHPN
Lab Data :
CT ScanIVPNO INAVSIVE LAB/ ProcedureNO BIOPSY
Nsg Dx : Knowledge Deficit Risk for Injury
PI : AVOID/ NO ABDOMINAL PALPATIONPrepare pt for Surgery and Chemotherapy
NEPHROTIC SYNDROME AGN
MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidney Tissues related (therefore there is PROTEINURAI) to Group A Beta Hemolytic Streptococus
causes: Autoimmune sorethroat congenital
S/S
EDEMA: Peri-orbital Edema but subside Periorbital but progresses to generalized at the end of the day at the end of the day
BP : Decrease or N INCREASE BP
URINE : Frothy Tea colored or Cola colored or Smoky
LAB DATA
(+) Proteinuria, severe - >10mg in 24 hrs (+) Proteinuria - <10 mg/ 24hrs urine
Nsg Dx : Fld Volume Excess Impaired Skin Integrity
PI :
Check BPMaintain Fld BalanceMeds : NO Antihypertensive Antihypertensive
(+) Steroids Diuretics (+) Antibiotics
DIET :
INCREASE CHON, Low Na LOW CHON and Na
POSITIONING :
Turn Patient frequently – because pt w/ edema are prone to skin integrity like pressure sore formation
CYSTITIS- Infection of the bladder- Ascending infection caused by E. Coli (from feces) or Pseudomonas
RF : Wearing silk underwear (does not absorb moist); - use COTTON
Bubble bathProlong drivingCommon in FEMALE – due to size (short) urethra
S/S:FREQUENCY, URGENCY & HESISTANCY + Burning sensation on urination (dysuria)
LAB DATA : Urinalysis – to check for microorganism
Nsg Dx : Altered Elimination PatternInfection
PI : Treat for Infection – antibiotics for 10-15 daysBladder Analgesic (ex. PYRIDIUM – ch can cause ORANGE COLORED URINE, effective : (-) pain)
Diet : ACID-ASH DIET – give lemon juice or VIT C
Hx Teachings: Avoid bubble BathNo Silk underwearInc. Fld Intake
RENAL FAILUREACUTE CHRONIC
MP Sudden or Acute, Usually Reversible loss of IRREVERSIBLE kidney damage that Kidney Funx leads to scar formation
There is inability of kidney to maintain fld & E balance
Causes PHASES :
Pre-renal Factors – those that dec bld circulating vol. – SHOCK;Phase I: RENAL INSUFFICIENCY Intra-Renal – dses condition of the kidney eg. AGN Post-Renal – those that causes obstruction eg. Kidney stones Polyuria
NocturiaPolydipsia
Phases of ARFPHASE II : MILD RENAL DAMAGE
OLIGURIC PHASE - decrease urine output that is less than 400 ml/24hr (OLIGURIA) There will be INC BUN & Crea - Dec NA & Inc K
RENAL FAILUREDIURETIC PHASE - Inc urine output (4-5L/day) All s/s + Anemia & HPN - Dec Na & K
ESRDRECOVERY PHASE
- renal funx normalizes (1-2 yrs) Azotemia & Uremia – accumulation
of waste products
“uremic frost” – skin pruritusLAB DATA
Increase BUN and same Crea – most sensitive Index
Nsg Dx
Fld and E Imbalance Fld & E ImbalanceActivity Intolerance
PI : TO CORRECT THE IMBALANCE
A. Fluid restriction; Fld restrictionB. Meds : Diuretics Amphogel – to promote excretion of Cardiac Glycosides – Digitalis Phospate
Antihypertensive Epogen – Inc RBC synthesisDiureticsAntiHPN
C. DIET : Low CHON – NO PMS Diet: same
DIALYSIS
PERITONEAL HEMODIALYSIS
Semi-permeable membrane: Abdomen (peritoneum) Dialyzing machine
Use of Tenchkoff Catheter Use of fistula or shunt
Teachings: anastomosis of artery & vein (internal access) – less prone to infxn
Report Infxn (abdomen: rigid, Solution : cloudy) Check BT and CT external access Check Temp of dialyzing solution (more prone to infxn)
Complications of dialysis (report ASAP):
1. DISEQUILIBRIUM SYNDROME – due to rapid removal of solutes (electrolytes and CHON) s/s:
GI – nausea, vomiting, headacheCNS - convulsion, seizures
2. DIALYSIS ENCEPHALOPATHY – due to aluminum toxicitys/s:
(+) dementiamuscle abnormalities – twitchingseizures
RENAL TRANSPLANT – s/s of complication : FLANK PAIN, FEVER, TENDERNESS, HPN - REPORT
BPH- glandular enlargement of the prostrate- common in males above 40 yrs old
S/S :Decrease size and force of urinary streamNocturiaFrequency, hesitancy and urgency
LAB DATA:Digital rectal exam – once a yr for pt 40yo and above
gloves, ky jelly position: Sim’s
Nsg Dx : Altered Elimination Pattern
PI : Prepare pt for surgery TURP – no incision Suprapubic Prostatectomy Retropubic -do- Perineal -do- - common complication: IMPOTENCE due to
nerve damage“I am eager to have sex again” – cannot be bec pt is impotence
nsgcare : CBR for 2-3 days post surgery;NO LONG DRIVE/ SITTING;Ff up check up (if INC ACID PHOSPATASE: Prostate CA)
TIPS FOR GENITOR-URINARY
A common sign of ARF – OLIGURIA;
After peritoneal dialysis, w/c of the ff is appropriate action – turn pt to side;
To prevent cystitis, w/c of the ff the nurse must instruct to the pt to do – take a bath using the shower rather than bubble bath;
For early detection of prostrate CA the nurse shld emphasized – digital rectal exam annually to screen for prostrate CA in men 40 yo and above;
In a pt with BPH, the nurse shld expect that the pt will probably have the symptoms – residual urine of more than 50 ml;
A male pt has an arteriovenous fistula in his L forearm, w/c behavior would indicate that the pt needs further instruction in self care – he wears a watch on his L wrist;
w/c of the ff indicates complication of peritoneal dialysis – cloudy dialysate
DAY 8 (Feb 11, 2005)
EENTGeneral Consideration
Explain to the patient there there will be no or little discomfort when performing EENT exam; Explain the methods of assessment to the patient;
Consideration to Pediatric Patients
Obtain feeding history (bec the type & techniques differs) Obtain the diet hx of the pt and hx to URTI Involve the parents in the assessment of the baby
Reportable Signs and Symptoms
TINNITUS - ringing, buzzing or sea shell sound in the ear VERTIGO - Objective – “the room is spinning”
Subjective – “I feel that I am revolving/rotating”
Hearing Loss Pain – if pain subside or (-) – rupture of ear drum
Keypoints for Assessment
Note for abnormal findings Document the subjective and objective complaints
OTITIS MEDIA
- infection of the middle ear
RF :
Faulty feeding practicesSwimming in dirty watersUpper Resp. Tract Infection
S/S :PAIN – Pulling
Tugging Crying when lying on the affected ear
Absence of pain indicates rupture of Tympanic Membrane – ear drum
Lab Data : OTOSCOPY – revealed – reddened, bulging tympanic membrane
Nsg Dx : Infection Sensory – Perception Alteration
PI : Treat Infection (antibiotics – 7-10 days) – if does not heal – possible MYRINGOTOMY
Hx Teaching : RIGHT POSITION while feeding
RETINOBLASTOMA
- congenital tumor of the retina;- genetically transmitted;- autosomal dominant (common in MALE and FEMALE)
S/S :LEUKOCORIA – “cat’s eye reflex”
- whitish or grayish discoloration of the pupil
Diplopia and or Strabismus
LAB DATA : PE
Opthalmoscopy
Nsg Dx : Knowledge Deficit
Tx : Surgery – Inoculation – done b4 age of 3 (chemotherapy – after surgery)Genticist
RETINAL DETACHMENT GLAUCOMA CATARACT
RF: Aging (above 40) Aging (above 40) Aging (above 70)
Related to trauma Common in Blacks Related to TraumaFamilial Predisposition Rel. to Diabetes
Rel. to SteroidsRel. to Chromosomal Abberation
- those with D. Syndrome are prone
RETINAL DETACHMENT
MP : There is separation of sensory and pigment portion of the retina – therefore it will allow fluids to go in between which give rise to OUSTANDING manifestation as: VISUAL FLOATERS – pt says: “I see light structures Curtain like
Floating spotsCobwebs”
S/S : NO PainBlurring of vision – because of floaters
Lab Data : Opthalmoscopy
Nsg Dx : Risk for Injury
PI : Immediate Bed rest – AFFECTED SIDE TOWARDS THE BED – to allow the connection of DETACHED PART
NO SUDDEN HEAD MOVEMENTAVOID reading (TV – ALLOWED)
Prepare Pt for Surgery: SCLERAL BUCKLING – use of laser to reduce inflammation and when inflammation subside, the detached retina portion will be attached thru scar formation.
POST SURGERY :
AVOID activity that requires BENDING, LIFTING, COUGHING;(No Bowling & shampooing of hair at sink)
REPORT SUDDEN eye pain – indicative of bleeding/ hemorrhage
GLAUCOMA
MP : INCRASE IOP due to obstruction in the outflow of acqeous humor or could be related to forward displacement of the iris.
TREATABLE but NOT CURABLE
If Obstruction related : could lead to CHRONIC OPEN ANGLE.
If due to Forward displacement: can lead to ACUTE CLOSE ANGLE
S/S :
TUNNEL or Gun Barrel Vision – wherein there is loss of Peripheral Vision
Halos around lights – rounded rings around eyes
CLOSED ANGLE GLAUCOMA – (+) pain
OPEN ANGLE GLAUCOMA – minimal or (-) pain
LAB DATA:
Tonometry – measures IOP (N12-21) – PAINLESS
ACUTE G – as high as 25;Chronic G - as high as 50
Gonioscopy Opthalmoscopy Perimetry – measures visual field
Nsg Dx : Risk for Injury
PI : TO DECREASE IOP
How:
a. Administer MIOTICS (Pilocarpine, Tomolol, Diamox) – for LIFE- it decrease the production of ACQEOUS HUMOR – admin. At lower conjunctival sac
b. Prepare pt for Surgery : TRABECULOPLASTY – a new pathway was created for the passage of the blocked fluids; - Out-patient only (use of laser only)
TRABECULECTOMY – requires hospital admission for 1-2 days
Hx Teachings : same w/ retinal detachment
CATARACT
MP : Opacity of the Crystalline Lense
S/S : Blurred Vision (Poor Color Perception) NO PAIN
LAB DATA:
a. SLIT LAMP TEST – test for red light reflex (this reflex is absent in cataract pt due to presence of milky white lens)
b. Opthalmoscopy
Nsg Dx : Risk for Injury
PI : Prepare for SURGERY
CATARACT EXTRACTION – Extra Capsular Cataract Extraction (ECCE) Intra Capsular Cataract Extraction (ICCE)
ECCE – removal of anterior part
ICCE – removal of entire capsule
PHACOEMULSIFICATION - needle is inserted to lens and send vibration thereby crushing the cataract then suction it out
PERIPHERAL IRIDECTOMY – a whole is created then suctioning
Post Cataract Surgery – NO SEX for 4-6 weeks
Health teachings – same w/ R. Detachment
MENIERE’S DSES OTOSCLEROSIS (hardening of the ears)
RF : High altitudes AgingAgingOtotoxic Drugs
MP : Cause by an imbalance of Endo- Overgrowth of the stapesLymphatic Fluids in the inner ear
Sensori-neural hearing loss – since Conductive Hearing Loss Inner ear was affected - since middle ear was affected
S/S : Tinnitus sameHearing Loss + sameVERTIGO (only for M. DSES)
Lab Data: Caloric Stimulant testWeber’s test – lateralization of soundRinne’s – bone conductionAudiometry(above test – use of TUNING FORK)
Nsg Dx : Risk for Injury Sensory Perceptualalteration
PI : SAFETY Establish Communication(to prevent pt from falling: bedrest or supine – danger of falls) Surgery : STAPEDECTOMY – mobilization of stape
DIET : LOW NA (AVOID – Alcohol & Caffeine containing food)
Meds : AntiVertigo – Diamox, Bonamine Post Surgery Hx Teachings:
Effective : (-) Vertigo/ Falls AVOID – diving Small airplane Coughing
AVOID - driving Blowing of Nose PMS Bending Sudden Head Movement
TIPS FOR EENT
A pt who underwent cataract surgery w/ intraocular implantation is scheduled for discharge, the nurse shld instruct the pt to do w/c of the ff when pain occurs – notify the AP;
w/c Nsg Dx is considered a priority for a pt with Meniere’s Dses – Risk for Injury
a Tonometer is used for the purpose – to determine IOP;
Post Cataract Extraction : how shld the nurse position the pt – UNAFFECTED SIDE to minimize edema;
w/c of the ff is a common manifestation of Retinoblastoma – Cat’s Eye Reflex;
The parents of the pt w/ retinoblastoma must be referred to - GENETICIST
GASTROINTESTINAL
GENERAL CONSIDERATION
Provide privacy Ask the pt when he 1st notice the S/S Eg. LIVER CIRRHOSIS – when did you notice that your eyes turns yellow?
PEDIATRIC CONSIDERATION
Introduction of FOOD: (shld be in order)
CerealsFruitsVegetablesMeatTable foods
Obtain child Dietary HistoryAssess for over-intake of milk – poor source of iron (IDA)
REPORTABLE S/S
VomitingAbdl Pain (if more than 6hrs) – R/O rupture of the bowelTarry Stool – indicates bldg (upper GI)Fever, Tachycardia, Dehydration – indicative of SHOCKHypotention
KEPOINTS…
Bowel Sounds (check all 4 quadrants- N 5-35 bowel sounds/min)- to assess, use DIAPHRAGM of Steth – to listen for normal sounds- BELL part of Steth – to listen for abnormal bowel sound
Ex. “bruit” – abnormal vascular sound w/c indicate abdml aortic aneurysm
DIARRHEA/ AGE
- usually asso w/ NORWALK (common in ship), ROTAVIRUS and CLOSTRIDIUM DEFFICELE
MP : Passage of watery and loose stools (BEST judge in the consistency)
S/S :
Frequent stoolsSign of DHN – sunken fontannelsPoor Skin TurgorAbsence of Tears (for more than 2 MONTHS old infant)
Check for complication : Metabolic Acidosis
If excess fluid loss, it will progress to shock – due to K loss (hypokalemia)
LAB DATA :
Stool Exam – to check for bacteria
Nsg Dx :DiarrheaFluid Volume Deficit
PI : Place pt on ENTERIC ISOLATION PRECAUTION (handwashing & gloves ONLY)
– while waiting for lab result
CHALASIA GERD
CONGENITAL WEAKNESS OF THE CARDIAC SPHINCTER
S/S: vomiting - NON-BILE-STAINED Hear-burn due to Reflux of Acid
Complication :
METABOLIC Acidosis same BARRETT’S ESOPHAGUS same
- damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal CA
LAB DATA :
Upper GI Series (Ba Swallow) doGastroscopy doEsophagoscopy do
Nsg Dx : Altered Nutrition Less Than Body RequirementFlds & E Imbalance
PI : Insure Adequate Nutrition
Position: Place pt in UPRIGHT – to avoid vomiting
(if BABY: use HARNESS or PRONE w/ HEAD UP POSITION)
Administer flds Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, therefore X100) Health teachings – crackers, juice, water Feeding : Thickened Prepare pt for surgery : NISSINFUNDOPLICATION – part of fundus will be sutured to esophageal area to tighten Effective: if (-) vomiting and(-) reflux and heartburn
POISONING
INTERVENTION:
a. CALL poison control center;b. MINIMIZE EXPOSURE – remove pt from the scenec. IDENTIFY the type of poison
“if unknown substance was taken” – bring bottle or foil for proper identification
TYPES:
CORROSIVE – “DO NOT INDUCE VOMITING”
Management: NEUTRALIZE the poison
If STRONG ACID – give WEAK BASE (eg. ACID – give MILK)
IF STRONG BASE – use weak ACID by using vinegar
NON-CORROSIVE – induce vomiting by stimulating GAG REFLEX
How: a. Use fingers or tongue bladeb. Syrup of Ipecac – administer w/ glass of H2O – make sure that all taken will be vomited – bec it is cardiotoxic (after 1hr – can repeat)
dosage: CHILDREN – 15 ML ADULT - 30 ML
CLEFT
LIP PALATE
MP: Non-fusion of facial process Non-fusion of Palative Processess (soft & hard) (congenital) (congenital)
Nsg Dx : Altered NutritionRisk for AspirationBody Image Disturbance
PI : NutritionSafetyPrepare for Surgery
Surgery :Chiloplasty Palate Uranoplasty
- for 10wks old - if child is 15-18 mos 10 lbs
10gms/hgb 10,000 WBC
Post Surgery:
CRYING shld be minimize – bec it will put pressure at suture line; LOGAN BAR/ BOW – it decrease tension at suture line; ELBOW RESTRAINT – prevent child from touching the suture line; FEEDING DEVICE – C CLIP – use dropper, C PALATE – use Breck Feeder/ cup
Refer pt to: SPEECH THERAPIST, AUDIOLOGIST & PSYCHOLOGIST
PYLORIC STENOSIS- congenital- hypertrophy (“kumapal”) of the pyloric sphincter (bet stomach & intestine)
S/S :
PROJECTILE VOMITING (INITIALLY, NON-BILE STAINED but eventually it PROGRESSESS TO bile-stained)
If sitting : 4-5 ftIf lying down : 1 foot
Feeding should be thickened then AFTER FEEDING, place to RIGHT SIDE LYING SEATED at car seat – to facilitate the entry of food from stomach to duodenum
OLIVE-SHAPE MASS VISCIBLE PERISTALTIC MOVEMENT – usually from L to R of the abdomen – w/c can lead to DHN
LAB DATA :
Ba Swallow – (+) “string sign”
NSg Dx : Altered NutritionFluid Vol DeficitFld and E imbalance
PI : NutritionSurgery – FREDET-RAMSTEDT or PYLOROMYOTOMY – incision at pyloric sphincter
CELIAC DISEASE
- GLUTEN –INDUCED ENETEROPATHY- Genetic predisposition- Life-time disorder
MP : Intolerance to GLUTEN
OUTSTANDING S/S : Malabsorption Syndrome-crisisAbdl Enlargement – this can be triggered by INFECTION & Fld and E imbalance
AnorexiaAnemia - there will be SEVERE DHN
LAB DATA : Diagnostic Test : GLUTEN CHALLENGE – 3-4 mos – give gluten rich food And if there is malabsorption, therefore (+) CDses
Nsg Dx : Altered Nutrition
PI : Dietary Modification : AVOID GLTUEN RICH FOOD : Barley, rice, oats, wheat
ALLOWED : Rice, cereals, corn, soy beans
Commercially prepared cakes are made of wheat – AVOID
Ok or allowed: if pt say “I will prepare a homemade cake”
AVOID : spaghetti, macaroni, sausage, luncheon meat, hotdog
HIRSCHPRUNG’S DISEASE (AGANGLIONIC MEGACOLON)
MP : Absence of parasympathetic nerve fibers in a portion of a colon dilation, abdominal distention and pellet-like or ribbon-like stool.
Patient – meconium ileus & constipation – HALLMARK SIGN
LAB DATA : BA Enema
Nsg Dx : Altered Ellimination
Diet : High FiberIncrease fluids
Tx : Give Enema
Meds : LaxativeSurgery – SOAVE Surgery – resection with end to end pull through
INTUSSUCEPTION
MP : There is telescoping of a part of a colon which leads to inflammation and edema
S/S : “sausage-shape mass”Abdominal distention“Dance sign” – the R lower portion of the colon becomes emptyVomiting : BILE-STAINEDConstipation
LAB DATA : Ba Enema: if for DIAGNOSTIC : it outlines the area involve
if for THERAPEUTIC : it reduces intussuception by means of hydrostatic pressure
Nsg Dx : Constipation Altered Elimination
Diet : Inc. Flds. High Fiber
Tx : wonder drugs – steroid surgery
TRACHEOESOPHAGEAL FISTULA (TEF)
MP : Failure of the esophagus to develop as a continous process
Types :
AF1 - esophagus NOT connected w/ abdomen/stomach AF2 - esophagus attached to trachea (when pt eat, it goes to the lungs)
AF3 - stomach connects w/ trachea AF4 - stomach & esophagus connected
AF5 - stomach, eso and trachea are connected AF6 - separated properly
Atresia – “narrowing”Fistula – connection
S/S : Excessive Drooling – danger in aspiration (avoid glucose water as initial feeding – use sterile H2O instead.)
Coughing, ChockingCyanosis
LAB DATA : Lateral Neck Xray – to check the esophagus
Nsg Dx : Risk for Aspiration
PI : SafetyAirwayKeep child NPO – just give pacifier (if feeding OK – use sterile H2o instead NOT GLUCOSE)
Tx : Surgery
TIPS FOR GASTRO – PEDIA
w/c of the ff signs if manifested by a child post tonsillectomy needs to be reported – FREQUENT SWALLOWING;
a child who has had several episodes of diarrhea is likely to develop – metabolic acidosis;
in relation to dx of p. stenosis, w/c of the ff actions of the nurse is important – weighing pt daily for wt loss;
w/c of the ff will the nurse expect to observe in a child who loss fluid due to diarrhea – flushed dry skin;
the most appropriate feeding device for a child post cleft palate – paper cup;
the priority nsg care for a child on NPO is – offer a pacifier regularly;
a common manifestation of pyloric stenosis is – visible peristaltic wave;
the priority nsg dx for a pt w/ rotavirus infection is – diarrhea;
w/c of the ff is expected in a child suffering from celiac dses – intolerance to gluten
PEPTIC ULCER
RF : StressSmokingSalicylates or NSAIDSHelicobacter Pylori
Zollinger-Ellison Syndrome (gastinoma) – tumor of the stomach – due to increase HCL acid
GASTRIC ESOPHAGEAL DUODENAL
RF : same same
MP : Weakened Mucosa Excessive HCL AcidCommon in Female Common in MaleBelow 65 65 yo & aboveInc risk for CA
OUSTANDING S/S: PAIN – aching, burning, gnawing
PAIN – 30mins – 1hr post meal 2-3hrs after mealPAIN at daytime NightimePain relieved by vomiting Pain relieved by eating
Also related as hyperacidityHEMATEMESIS (vomiting of blood) - severe bleeding – “shock”
LAB DATA : GASTRIC Analysis (diamox blue – urine)GastroscopyBA SwallowHgBHct
Nsg Dx : PAIN
PI : Relief of Pain
Meds : ANTACIDS: Maalox – it NEUTRALIZE HCL Acid;RANITIDINE - it DECREASE HCL Acid;SUCRALFATE - it COATS the GIT
NO ASPIRIN
Diet : BLAND DIET – NO SPICY, fried, raw fruits and vegetables (EXCEPT: avocado, banana & pineapple)
GASTRIC SURGERY
VAGOTOMY PARTIAL GATRECTOMY – Billroth I (BI) and Billroth II (BII) TOATAL GASTRECTOMY
BI – gastrodoudenostmy – duodenum and stomachBII – gastrojejunostomy – stomach and jejunum
COMPLICATIONS:
PERNICIOUS ANEMIA – due to decrease INTRINSIC FACTOR w/c came from stomach;
DUMPING SYNDROME (occur usually for 10-12 mos post surgery) – due to rapid emptying of the stomach and stimulation of gastro-colic reflex
GASTRO-COLIC REFLEX – is usually due to increase CHO INTAKE in the diet - NO PANCAKE, NO UPRIGHT SITTING AFTER MEALS
S/S OF Dumping Syndrome : DiarrheaDiaphoresisDizziness/drowsiness
Management: NO FLUIDS after meals – instead in between mealsDIET: High Fats – because it delays the emptying of the stomach
LOW CHOLie down – after eating
INFLAMMATORY BOWEL CONDITION
ULCERATIVE COLITIS DIVERTICULITIS CROHN’S DSES(Regional Enteritis)
RF : With familial Predisposition Common in those LOW FIBER Diet Related to Genetics Smoking as Protective Effect Common in Aging Common in Obsessive-Compulsive Or Stress Related or to “perfectionist”
MP :
Inflammation @ large Intestine Inflam @ L Intes. – Inflam of small & Specifically @ recto-sigmoid colon at DIVERTICULUM large intestine
S/S : same same
DIARRHEA (15-20x/day) diarrhea & constipation 3-4x/day bloody mucoid
FEVER (+) (+) (+)
CRAMPY ABDL PAIN LLQ LLQ RLQ(Rigidity (REPORT ASAP) –sign of colon rupture)
LAB DATA: BA ENEMAColonoscopyStool Exam
Nsg Dx : PAINAltere Elimination: Diarrhea
PI : Relieve Pain
Meds: SteroidsAnticholinergicAntidiarrhealsAntispasmodic
DIET : Low Fiber and Low Residue – for Ulcerative and Chron’s
Diverticulosis – High Fiber/residue – allowed: vegetablesLow residue – (no vegetables)
SURGERY : Colostomy – irrigateIleostomy – no need for irrigation
Characteristic of N Colostomy – REDDISH or PINKISHEDEMATOUSMOISTN elevation from skin: 2.5 cmDiameter : 5cm
When to empty colostomy: when 1/3 – ½ full (EMPTY DO NOT CHANGE)
When to change C. Bag : 48hrs or 3x a wk
BEST TIME TO DO COLOSTOMY CARE – at home, while in the bathroom
STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS
HEMORRHOIDS
MP Varicosities of the ANAL SPINCHTER
RF PREGNANCYPROLONGED STANDINGPORTAL HPN – hepatic enceph and liver cirrhosis
GRADE
I Small AreaII Large Area – reduces spontaneouslyIII Entire Area – manual reductionIV Entire Area – irreducible
TYPES
INTERNAL H – above the spinchterEXTERNAL H – below the spinchter
S/S PruritusPainBleeding
LAB DATA SigmoidoscopyProctoscopyP Exam
Nsg Dx Altered Elimination
PI Diet : High FiberAvoid Spicy
PAIN – use SITZ BATH (48 degree C – temp of H2o) - emerge up to pelvic area with ice pack at head to prevent dizziness
STOOL SOFTENERSURGERY
PANCREATITIS- AUTODESTRUCTION OR AUTODIGESTION of the pancreas
RF #1 Alcoholism#2 autoimmuneHigh Fat DietBiliary Dses
SS PAIN @ peri-umbilical area or epigastric that radiates to peri-umbilical area
GREY TURNER SIGN – pain w/ bluish discoloration at flank area;CULLEN’S SIGN – pain w/ bluish discoloration @ umbilicus
NAUSEA & VOMITINGSHOCK – as complication
LAB DATA Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks)
Nsg Dx PAIN
PI Relieve PAIN
Meds: DEMEROL – DRUG OF CHOICE AVOID MORPHINE – it causes more pain bec it will causes spasm to the spinchter of oddi
DIET LOW FATAVOID alcohol
CHOLELITHIASIS CHOLECYSTITIS
Combine or usually come together in a pt
Stone in gall bladder Inflammation of the G. bladder
RF Fat sameFemaleFertileFortyflatulence
S/S R UQ Pain radiating to R shoulder or R Scapula – usually precipitated by FATTY INTAKE
GI S/S – NAV diarrhea and Jaundice
URINE: dark colored
STOOL : “clay-colored” or grayish – alcoholic stool
LAB DATA Increase AMYLASE, WBC, FATSIncrease Liver Fnx testUSG
Nsg Dx PAIN
PI Relief of Pain meds : DEMEROL diet: LOW FAT
surgery : 1) LAP. CHOLE – 4 small incision, CO2 insufflation 2-3 days after – discharge pt and back to ADL 1 WK after – pt can lift weight
2) CHOLECYSTECTOMY – R SUBCOASTAL - complication: “Pneumonia”
– report rusty-colored sputum hx teaching: TURNING, COUGHING, DEEP BREATHING
HEPATITIS
MP Inflammation of the Liver
TYPES
A B C D E
Infectious SERUM POST TRANSFUSION DELTA HEPA ENTERICALLY-TRANSMITTED
Fecal-oral bld, body flds Non A & B Post Hepa B Fecal-oral (Hepa A & B Combination
2-6 wks 6wks-6mos 70-80 days 6wks-6mos
STAGES OF HEPA B
PRE-ICTERIC - 1-2 days : S/S NAVDA – NO jaundice yet; ICTERIC - 2-4 wks w/ jaundice; POST ICTERIC - 2-4 mos s/s subside
Lab data Increase Liver Funx Test (Inc AST/ ALT)Hepa A – Inc HaVHepa B – HbsAg
Nsg Dx InfectionAlt Skin IntegrityBody Image Disturbance
PI Tx for Infectiona. Meds : HEPATOPROTECTORS
DIURETICS
b. Diet : High Calorie Low Fat
Isolation : A & E – Enteric B, C, D – Universal
COMPLICATION Liver Cirrhosis
LIVER CIRRHOSIS - scarring of liver tissues
TYPES
LAENNE’S BILIARY CARDIAC POST NECROTIC
Due to alcoholism Due to biliary Disorder due to CHF due to Hepatitis
S/S – are related to 3 FUNXs of the LIVER
MANUFACTURES : bile, immunoglubolin, & clotting factors METABOLIZES: CHO, Fats, CHON, Alcohol and Drugs STORES : Vitamins & Minerals
Signs and symptoms
a. pt prone to bleeding;b. malnutrition – no cho metabolizec. edema – due to fld retention (bec of dec albumin)d. Flds & e imbalance
LAB DATA Increase Liver Funx TestLiver Biopsy
Nsg Dx Risk for InjuryFld & E imbalanceFld Vol ExcessAltered Nutrition
PI SAFETY
HOW?
Meds: Diuretics – due to fld retentionANTIHPN – due to portal HPNClotting factors : Coagulants – give Vit K (to avoid bleeding)
Diet : LOW CHON or CHON to ToleranceOr High Biologic Value CHON – good quality CHON (eg poultry products)
SURGERY : Liver Transplant
COMPLICATIONS:
a. HEPATIC EBCEPHALOPATHY – accumulation of ammonia – toxic to brain
s/s: PERSONALITY CHANGESDECREASE LOC or irritability/ restlessness
DRUG OF CHOICE : Neomycin, Lactulose - facilitate excretion of ammonia by acidifying the colon
- common s/e : DIARRHEA
b. ASCITIS – accumulation of fluids at the abdomen
s/s : wt gainIncrease abdl girth – “I cannot button my pants anymore”(fluids)
management: abdominal paracentesis – aspiration of fluids from the peritoneum - complication: chance for infection & shock
pt preparation: #1 instruct pt to void;#2 position: sitting the evaluate the WEIGHT, ABDL GIRTH & REPSIRATION
effective if : Pt decrease wt of 5 lbs and decrease or N RR
c. BLEEDING ESOPHAGEAL VARICES – DUE TO portal HPN
Lab data Sengstaken Blakemore Tube – 48 hrs inflated, scissors at bed side
(Balloon Tamponade) - effective if (-) hematemesis
TIPS GASTRO – ADULT
A pt w/ appendicitis was admitted, of ALL the ff written orders, w/c shld the nurse prioritize – Administration of Antibiotics;
w/c statement if made by a pt w/ cirrhosis is a risk factor for having the disease – “I drink 2 glasses of alcohol /day”;
which of the ff indicates a ruptured appendix – absence of pain;
ff subtotal gastrectomy, the nurse shld expect gastric drainage for the 1st 12 hrs to be – reddish brown;
the priority nsg care post common bile duct exploration – preventing hypostatic PNA;
w/c question during nsg assessment would confirm the Dx of L Cirrhosis - how long have you noticed the white in your eyes turns yellow;
the priority nsg dx for a pt w/ Hepa B – altered Nutrition
the priority nsg dx for for pt w/ acute pancreatitis – Altered nutrition less than body requirements
NEUROLOGY
DECORTICATE – abnormal FLEXION
DECEREBRATE – abnormal EXTENSION
Opistotonous – “back arching”
GENERAL CONSIDERATION
When assessing the neurological system, pay attention to the ff:
#1 LEVEL OF CONSCIOUSNESS #2 BEHAVIOR #3 REFLEX
When assessing MUSCULO SYSTEM:
#1 Range of Motion #2 Joint Stiffness #3 POSTURES
PEDIATRIC CONSIDERATION
a. Check for bowel and bladder funx – indicates neurological maturity
15-18 months – START BOWEL TRAINING
2 yo – start bladder training
b. Assess for their habits
“security blankets” – ex. Stuff toys, mother wallet
Associate mother’s time w/ child activity (children has NO DEFINITE TIME) Ex. Your mom will be back after you have eaten your lunch.
c. Assess for presence of URTI – could be sign of Meningitis, Hemophilus influenza, Otitis Media
d. Assess child for S/S of anxiety
- bed wetting- nail biting (N up to 4 yo)- head banging- excessive thumb sucking
e. CONTUSSION – more severe, fatal and could even lead to death CONCUSSION – jarring of the brain, “na-alog” w/c could lead to s/s of LOC in 24-48 hrs
DECORTICATE – abnormal flexion which indicates damage to the cortex
s/s : #1 Decrease LOC #2 widening pulse pressure (increase systolic BUT diastole is N)#3 Convulsion & seizures
ABOVE ARE S/S OF INCREASE ICP.
DECEREBRATE – more serious - abnormal extension w/c indicates damage to brain stem
GLASGOW COMA SCALE
EYE OPENING (4) VERBAL RESPONSE (5) MOTOR (6)
6 – OBEYS COMMAND
5 – ORIENTED 5 - LOCALIZES PAIN
4 – OPEN SPONTANEOUSLY 4 – CONFUSED 4 – WITHDRAWS FROM PAIN
3 – OPENS TO VERBAL COMMAND 3 – INAPPROPRIATE 3 - DECORTICATE RIGIDITY
2 - OPEN TO PAIN 2 - INCOMPREHENSIBLE 2 - DECEREBRATE RIGIDITY
1 - NO RESPONSE 1 - NO RESPONSE 1 - NO RESPONSE
SCORE OF 3 : NO response (DEAD) – Doctor will the one to pronounce
SCORE OF 15 : pt is awake
Score of 8 : 50-50, MONITOR THE PT
7 and BELOW : pt is COMA
CRANIAL NERVES
I. OLFACTORY : SENSORY : smell - Abnoxious smell Anosmia – no smell
Perfume
II . OPTIC : SIGHT – snellen’s chart – 20/20 usually by age 3-6 yo
III. OCCULOMOTORIV. TROCHLEAR Eye movement - 6 cardinal direction of gazeVI. ABDUCENS (if abnormal look for DIPLOPIA)
V. TRIGEMINAL : SENSORY : responsible for FACIAL SENSATION (to check, use cotton & needle and run across the cheek)
AND MOTOR : ability of pt to chew
Reflex: CORNEAL REFLEX – (+) if both eyes can blink
VII. FACIAL : SENSORY : sense of taste @ anterior 2/3 of the tongue
and MOTOR : Facial Expression
VIII. ACOUSTIC or VESTIBULOCOCHLEAR - Sense of hearing and balance
TEST : ROMBERG’S TEST - stand erect, close eyes, observe for balance
IX. GLOSSOPHARYNGEAL X. VAGUS SENSORY – Posterior Taste 1/3 Of The Tongue
MOTOR - swallowing and gag reflex
XI. SPINAL ACCESSORY - motor movement of shoulder muscle
XII. HYPOGLOSSAL – TONGUE MOVEMENT
DUCHENE’S MUSCULAR DYSTROPHY (DMD)
X –linked RECESSIVE (only mother transmit to SON)
(-) Father Mother (+ carrier) Son - 50% chance
Daughter as Carrier – 25% chance
DMD Erb Duchenne’s Paralysis (EDP) Klumpke Palsy (KP)
Related to Birth Injuries affecting the BRACHIAL PLEXUS – nerves at axilla portion
HEREDITARY EDP – upper plexusKP - lower plexus w/c leads to paralysis.
Prognosis : complete recovery in 3 months Treatment : splint and cast for 3 mos – leads to nerve
regeneration X-linked RECESSIVE DIRORDER
MP characterized by progressive muscle atrophy w/c apparent in male at the age of 3
S/S a) GOWER’S SIGN – inability to stand up - use arms to brace the body
b) WADDLING GAIT - duck-like gait
c) impaired mobility
d) difficulty in running and climbing
COMPLICATIONs Respiratory Paralysis – for young childrenCardio-Resp. Arrest - for adolescent
LAB DATA Muscle BiopsyPExam
Nsg Dx Ineffective Breathing PatternImpaired Physical Mobility
PI AIRWAY(keep TRACHEO at bedside)
TX
a. Supportive - leg brace, crutchesb. Refer parents to geneticist
Target: Mothers or FEMALES – bec they are the source of transmission
Ex. Aunt, Female Sibling, mothers, female members of the family – (bec transmission: X linked recessive)
CEREBRAL PALSY
- Permanent, Fix (non-progressive) neuromuscular disorder characterized by abnormal muscle movement.
Cause Unknown
S/S Exaggerated Reflexes
Protrusion of the tongue or tongue thrustingEarly pattern of hand dominanceBack ArchingScissors-gait
LAB DATA Neurological AssessmentPExam
Nsg Dx Risk for InjuryImpaired Physical Mobility
PI SAFETY
a. Leg bracesb. Meds : Anticunvulsants, Muscle Relaxantsc. Prepare child for SURGERY – release of TENDON OF ACHILLES – to promote mobilityd. Refer child to : PT – for gross motor movement – walking
OT - for fine motor – to open a bottle of soft drinks
HYDROCEPHALUS
NOT A DISEASE but a manifestation of an existing disorder
Related to ARNOLD CHIARI MALFORMATION DANDY WALKER SYNDROME- there is ELONGATION of the BRAIN STEM or Medulla - characterized by ATRESIA of
and it protrudes to Foramen magnum Foramen of Luschka & Magendie
SIDE NOTES: FLOW OF CSF (N amt : 100- 200 ml) – rich in glucose
From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then to Aqueduct of Sylvius then it moves to F. of Luschka and Magendie going to 4th Ventricle then it goes back to subarachnoid spaces of brain.
S/S OF HYDROCEPHALUS
PROJECTILE VOMITING IRRITABILITY ENLARGED HEAD – N Head Circumference : 33-35 cm (chest circum: 31-35 cm) SEPARATION OF SKULL BONES SEIZURES SUNKEN EYES – Can Progress To Bossing Sign MACEWEN SIGN – crack pot sound upon knocking the head
LAB DATA CT ScanMRIPExam – focus on head circumference
(tape measure – at bedside to measure H Circumference)
NSG DX Risk for Injury
PI SAFETY
Position Semi Fowler’s – to prevent increase in ICP
Meds DiureticsAnticonvulsants
Surgery Ventriculo-Peritoneal Shunt – progressive procedures (AS CHILD AGE PROGRESSES, the surgery is revised)
SPINA BIFIDA – failure of a PORTION of spinal cord to fuse
TYPES
SB OCULTA SB CYSTICA
NO SAC W/ SACW/ DIMPLE or TUFT OF HAIR SUB TYPES:
Meningocele – w/ sac that contains CSF and meninges;
Meningomyelocele – CSF, meninges and portion of spinal nerves
LAB DATA Amniocetesis – test for ALFA FETO CHON – if INCREASE – Neural Tube Defect If DECREASE – Down Syndrome
CT SCANPExam
NSG DX Risk for Injury
PI Protect the sac
a. Position: Prone or side lying (NEVER SUPINE);b. Wet sterile gauze to cover the skin;c. DOUGHNUT ring
SURGERY WITHIN 24-48 HRS
COMPLICATION Bladder and Bowel ProblemParalysis of Lower Extremities
Post Surgery Complication Hydrocephalus (tape measure- at bed side)
INCREASE ICP
ICP above 15mmhg (N 0-10) Mild elevation : 11 – 20
Moderate : 21 - 30 Severe : 31 and above
With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP
RF HydrocephalusSpace Occupying LessionsBrain TumorTrauma
S/S
1. INITIAL: Behavioral Changes – irritability, restlessness, decrease LOC – drowsiness or pt becomes sleepy
2. Vital Signs Changes – widening pulse pressure DECREASE RR and PR INCREASE temperature
3. Vomiting
4. Monitor Abnormalities – decorticate, decerebrate
Nsg Dx Risk for injury
PI To decrease ICP
Head of Bed ELEVATED Evaluate Neuro Status – Glasgow AIRWAY Discharge Meds Instruction Anticonvulsants, Steroids, Diuretics (mannitol – to dec amt of cerebral edema) Seizure precaution – DARKENED ROOM
MENINGITIS MENINGISMUS
Inflammation of meninges w/c could be related to Inflammation of meninges but WITHOUTthe presence of bacteria esp the H. Influenza, and infection Neisseria Meningitidis Usually accompany w/ resp.
disorder
S/S of INC ICP + Kernig’s Sign – pain on extension of lower extremities + Brudzinkis - flexion of neck would lead to flexion of lower ext.
- sign of MENINGEAL IRRITATION
LAB DATA Lumbar PunctureCSF Analysis
Nsg Dx InfectionRisk For Injury
PI SafetySeizure PrecautionTx the Infection
Type of Infcetion:
a. Bacterial Meningitis – respiratory of droplet precautionb. Viral Meningitis - enteric precaution
MEDS Antibiotics For Bacterial Meningitis - may cause hearing impairment - refer to AUDIOLOGIST
REYE’S SYNDROME
Non inflammatory, non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY (CNS) (LIVER)
RF Presence of Viral InfectionUse of Aspirin
TRIAD S/S FeverImpaired Liver Funx Impaired Consciousness w/c could lead to convulsion
STAGES I pt becomes lethargicII confusionIII decorticate rigidityIV decerebrate rigidityV seizure or coma
LAB DATA Bleeding and Clotting TimeLiver BiopsyNeurological Assessment
Nsg DX Risk for InjuryAltered Thought ProcessAltered ThermoregulationImpaired Physical Mobility
PI Treatment – symptomatic – assess neuro statusBleeding – give Vit KAVOID ASPIRIN when there is VIRAL INFECTION
CVA/ STROKE
MP Decrease Oxygen to brain cells
TYPES THROMBOSIS EMBOLISM HEMORRHAGE INFARCTION
RFatherosclerosishpnobesitysmokingstressage/ gender
SIGNS & SYMPTOMS:
1. DEPENDS ON THE PROGRESSION
a. TIA – brief period of neurologic dysfunction that last less than 24 hrs (between episode, pt is N);
b. STROKE IN EVOLUTION – there s/s like: facial paralysisMuscle weakness - above s/s could last 2-3 days
c. COMPLETE STROKE – there is FOCAL s/s
if R side of Brain Affected – L Eye - R Face – L Body
if L Brain – R Eye – L face – R body
2. RELATED TO LOBES
FRONTAL – if affected – PERSONALITY CHANGES – BROCA’S AREA (expressive aphasia – mouth opening);
TEMPORAL - memory disturbances – WERNICK’S LANGUAGE AREA (choice of words, understanding - RECEPTIVE APHASIA);
PARIETAL - DISORIENTATION – especially SPATIAL orientation;
OCCIPITAL - VISUAL disturbances
3. SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS
Hemianopsia loss of half of the visual field (eg. Pt consumes half of the food at plate);
Hemiphlegia paralysis of one side of the body;
Emotional Lability “mood swing”
Aphasia Expressive – inability to find right words to say (damage to Brocka’s Area); - pt can say right words – mgt: picture board
and Receptive - inability to understand spoken words (Wernick’s area)
mgt: talk to pt slowly
Dysphagia instruct the pt to swallow twice to prevent aspiration
LAB DATA Increase Cholesterol
Diagnostic Test CT ScanMRIEEG
Nsg DX Unilateral Neglect – inability to care half of the bodyImpaired Physical MobilityRisk for Injury
PI SAFETY
Position Semi-fowler’sElevated
Meds AntihypertensiveDiureticsAntilipimic AgentsAnticonvulsantsThrombolytics – if (+) thrombus – to dissolve clots
DIET Low Na and Cholesterol
Activity Range of Motion Exercises
Surgery Craniotomy
Infratentorial Cranio – FLATSupratentorial - Semi-fowler’s
DISEASES OF NEUROMUSCULAR: Guillain Barre Syndrome (GBS)Myastenia Gravis (MG)Multiple Sclerosis (MS)Amyotrophic Lateral Sclerosis (ALS)
GBS MG
Descending paralysis – start @ upper ext. Common in Male and Female NO gender related factor but could be related to viral infxn Early onset : 20-30 yo (Female) Reversible Early onset : above 50 yo (male)
MP Inflammation that leads to destruction of Peripheral Nerves Deficiency in ACTH Receptor Sites – 90%
w/c leads to: ASCENDING GBS Or Def. in ACTH – “neurotransmitter”
DESCENDING GBSMixed Type GBS
ASCENDING GBS - #1 Clumsiness that eventually lead to S/S Muscle weakness w/c begins at face
muscle weakness & resp. depression therefore, Diplopia and Ptosis – which progresses to MASK-LIKE face which lead to
respiratory depression(descending paralysis – start at face – “NO
telebabad”)
LAB DATA CSF – Increase CHON TENSILLON TEST – 5 mins(to all neuromusco disorders)
Nsg Dx Ineffective Breathing Pattern (ALL) same
PI AIRWAY (tracheostomy – bed side) – ALL same
MEDS Steroids Neostigmine – ATSO4 - antidoteAvoid crowded areas : viral infection
Refer to NEUROLOGIST, PULMOLOGIST and PT
MYASTHENIA GRAVIS
COMPLICATIONS
Myasthenia Crisis (MC) - due to under medication or lack of meds; Cholinergic Crisis (CC) - due to over medication – overdose
Signs and symptoms of above complication:
MUSCLE WEAKNESS – in MC due to ACTH Deficiency while in CC due to or as adverse effect of the drug
Treatment : TENSILLON – effective in MC – it INCREASE MUSCLE STRENGTH Effect in CC – it worsens muscle weakness once given – give ATSO4
NEOSTIGMINE – for MC as TREATMENT
MULTIPLE SCLEROSIS
Common among women – especially whiteThere is destruction of MYELIN SHEET at CNS , therefore generalized muscle
weakness
Eg. “I know I will be eventually confined in the wheelchair
s/s of generalized muscle weakness: FACIAL – diplopia Impaired Cerebellar Funx Ataxic Gait – “lasing”
Impaired Sensation – NO HOT/COLD BATHImpaired Sensory Funx – impotence
LAB DATA #1 MRI – specific test for MS – it localizes the area of plaque formation or the area of dyemlination
#2 CT SCAN
NSG DX same with GBS & MG
DRUGS STEROIDSAnticonvulsants – dilantinMuscle relaxant – BaclofenBladder Stimulants – Urecholine (bethanicol)
HX TEACHINGS AVOID : HOT COLD SHOWERRefer to PT: ROM Exercises
AMYOTHROPIC LATERAL SCLEROSIS(LON GAHRIG’S DISEASE)
MP Destruction of Upper and Lower Motor Neurons;Genetically Transmitted: AUTOSOMAL DOMINANT – common in Male & Female
More Pronounce is DYSPHAGIA
The muscle weakness – will eventually lead to RESPIRATORY DEPRESSION
LABDATA CSF – Increase CHONEMG – “contract and relax” – needle insertionMuscle biopsy
NSG DX Ineffective Breathing Pattern
PI AIRWAY (tracheostomy)SUPPORTIVE Refer to Geneticist
SIDE NOTES:
A Recessive : Cystic Fibro, Sickle Cell, Apalstic/Fanconis – either or both parents are (+) for trait NOT DSES
A Dominant : Retinoblastoma, ALS – either father or mother (+) for disease or trait
X Link Recessive : Hemophilia, Color Blindness, Duchennes Muscular, G6PD Dses – mother (+) trait NOT DSES and transmit to SON
SPINAL CORD INJURY
Destruction of S. Cord related to TRAUMA
TYPES
CERVICAL 8 – most serious – quadriphlegia THORACIC 12 LUMBAR 5 SACRAL 5 COCCYGEAL 1
PI SAFETY - immobilize, surgery
LUMBOSACRAL AREA – if affected, therefore PARAPHLEGIA – bowel and bladder problem
THORACIC - paraphlegia + bowel and bladder problem
CERVICAL c1 – c4 - incomplete or partial quadriphlegia
C5 – C8 - Complete quadriphlegia
LAB DATA Myelogram CT Scan
Xray
Nsg Dx Risk for InjuryImpaired Physical Mobility
PI SAFETY
a. Immobilize the spine – side lying w/ pillows bet legs
b. Surgery
COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA – due to full bladder and bowel
s/s : #1 INITIAL : HPN #2 Diaphoresis #3 slight fever
what to keep at bedside: CATHETER - TO KEEP THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS
TIPS FOR NEURO
A 10 yo is to undergo EEG, w/c comment made by a pt demonstrate that she understands the procedure – “I will wash my hair after the procedure”;
A pt w/ tumor of the frontal lobe will most likely manifest – difficulty in concentrating;
A pt w/ M. Sclerosis has urinary incontinence. To achieve voiding, w/c nsg care shld the nurse give – establishing regular voiding sked;
While interviewing a pt. w/ Myasthenia gravis, w/c of the ff statements confirm the dx – “I have difficulty in swallowing”;
A male pt w/ CVA is observed by the nurse to have consumed half of his meal, the PRIORITY Nsg Dx – Unilateral Neglect;
When taking care of pt w/ C4 Spinal Injury, w/c equipment shld the nurse keep @ the b.side – Urinary Catheterization Set;
The PRIORITY NSG DX for pt w/ Myasthenic Crisis – Ineffective Breathing Pattern
MUSCULO
CLUBFOOT DEFORMITY
MP CongenitalFoot twisted out of place
TypesTalipes Varus – “inversion”Talipes Valgus – “eversion”Talipes Equinus – “tiptoe”
LAB DATA PEXray
Nsg Dx Impaired Physical Mobility
PI Promote Mobility
#1 MANUAL MANIPULATION#2 SEREAL CASTING – every 1-2 wks til position normalizes#3 DENNIS BROWN SPLINT – 2-3 months
CAST : assess for s/s of neurological damage: Capillary refill – if more than 3 sec. - REPORT
EDEMA Skin Color/ nailbed
CONGENITAL HIP DISLOCATION
MP Maldevelopment of the Hips – that involves the acetabulum, head of femur or both
S/S Extra Gluteal Fold – at affected side;Ortoloni’s Sign – (+) ClickTrendelenburg Sign or Pelvic Dropping – when child stand in one foot toward the affected side,
then there is change in length Alli’s Sign or Galleazi’s Sign – shortening of the affected leg
LAB DATA PExamBarlow’s Manuever – press leg downward – (+) clickOrtolani’s – abduct leg sideward – (+) click
Nsg Dx Impaired Physical Mobility
PI #1 Double or triple diaper – to keep legs in abducted position;#2 PAVLIK Harness - for 2-3 mos#3 Hip Spica Cast LAST RESORT
NO ADDUCTION OF LEGS!
FRACTURES
MP Break in the continuity of the bone
TYPES Open (compound) – bone tears the skin – therefore open: risk for infectionCLOSE – skin intact
AVULSION – tear in the tendon COMMINUTED - fragmented COMPRESSED – crushed IMPACTED – driven to each other DEPRESSED – pressed SPIRAL – goes around the bone GREENSTICK – incomplete
S/S #1 Deformity#2 Pain#3 Edema#4 CREPITUS – sound created when two bone surface rob each other
NSG DX Impaired Physical Mobility
PI MOBILITY – immobilize the fx
a. Splinting;b. Casting – check for edema – elevate the affected areas; - check skin color – capillary refill time
- check for presence of blood stained
c. After cast, - CRUTCH WALKING
2 point gait – indicated if both lower extremities has partial wt bearing; 4 point gait – indicated for partial wt bearing; 3 point gait - indicated if 1 leg is allowed partial wt bearing and
the other one is N; swing through - when both legs need to moved past the level of the crutches swing to – when both legs need to be moved AT THE LEVEL OF THE CRUTHES
going upstairs – unaffected then crutch (goodleg – crutch – bad)
going down – crutch then bad leg – then good leg
SCOLIOSIS
MP Lateral Deviation of the Spine
RF STRUCTURAL – non correctibleFUNCTIONAL - correctible
OUSTANDING S/S
Uneven Hemline; Uneven waistline; Uneven shoulder (+) Rib Hump Prominent Iliac Crest
LAB DATA Bend Over test – instruct to touch the toes and note for rib humpXray
Nsg Dx Impaired Physical Mobility - childBody Image Disturbance - adolesence
TX a. To decrease curvature – wear BOSTON or MILWAUKEE Brace – for 23 hrs/day except bathing
b. SURGERY – HARRINGTON ROD - LUQUE
HX TeachingAvoid : Bending
Jumping RopePlaying TennisTrampoline
Allowed: Brisk WalkingSwimmingCheer Leading
OSTEOPOROSIS/ HUNGRY BONE
MP Loss of Bone Density
RF #1 smokingAGINGIMMOBILITYMENOPAUSE – decrease EstrogenSecondary to Existing Condition – as secondary Hyperparathyroidism
S/S PAINDowager’s HumpShort StatureProgressive Decrease in Height
LAB DATA Decrease in CalciumBone DensinometryBone ScanXray
Nsg Dx SAFETY
How?
DIET : High Ca especially 4 those with – OSTEOPOROSIS - spinnach- seafoods- sardines
ACTIVITY : Partial Weight Bearing (NO SWIMMING)– jumping rope- bicycle reading- brisk walking
MEDS : Ca Supplement - alendronate Fosomax – SIT UPRIGHT AFTER
ARTHRITIS
RHEUMATOID GOUTY OSTEOARTHRITIS
Common FEMALE MALE MALE/FEMALE
Affected Part Upper Extremities Lower Extremities wt bearing joint
MP
Chronic, systemic inflammation of connective tissuesSynovial joints and joints of Upper extremities
S/S PAINInflammationMorning Stifness
Stages of Rheumatoid A.
STAGE 1 – no Disability STAGE 2 – with Interference To ADL STAGE 3 - with major compromise of funx STAGE 4 - incapacitation
ULNAR DRIFT SWAN NECK DEFORMITY
LAB DATA Decrease HgBIncrease ESR
Nsg Dx PAINImpaired Physical Mobility
PI Relief of Paina. Warm Bath;b. MEDS : ASA - Antiinflammatory
STREROIDS c. exercise: ROM
GOUTY ARTHRITIS
MP Metabolic disorder of purine w/c leads to deposition or uric acid at jointssite: THE GREAT BIG TOE
S/S (+) PAIN – usually aggravated by pressure(+) Inflammation
- above s/s affects the LOWER EXTREMITIES
LAB DATA Increase Uric Acid
NSG DX PAINImpaired Physical Mobility
PI Relief of PAIN
Meds : Allupurinol, Probenecid Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats
SEAFOODS Alcohol
ALLOWED: Cheese (EXCEPT fermented and Aged)
Increase ORAL Fluid Intake
OSTEOARTHRITIS
A degenerative joint disease that involves the weight bearing joints – elbows & knees
S/S PAIN – NO inflammation
Bouchard’s Nodes (distal)Heberdene’s Node (proximal)
LAB DATA
xRAY
Nsg Dx PAIN Impaired Physical Mobility
PI Weight Control
Health Teaching Hot or Cold CompressASATrunk Assistive Device (cane)
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Autoimmune multi system dses characterized by inflammation of connective tissues
JOINT : (+) pain, (+) morning stiffness; CARDIOVASCULAR : (+) chest pain;
CNS : (+) s/s of dec LOC, Irritability, Headache
OUTSTANDING S/S BUTTERFLY RASH (also present in pt in PROCAINAMIDE TOXICITY)
LAB DATA Increase ESR
Nsg DxPAINAltered Tissue PerfusionRisk For Injury
TX Symptomatic/ Supportive – meaning, treat available s/s
Drugs Steroids
TRACTION
PRINCIPLES T – rapeze barR – equires free hanging weightsA – nalgesicC – iculation monitoringT – emperature monitoringI - nfection preventionO – utput and input monitoringN – utritionS – kin Assessment
TIPS FOR MUSCULO
the priority nsg care for the pt w/ bucks extension traction shld be – ensure that the traction applied to the affected leg is always attached to the weight;
pt in russel’s traction is being taken cared of by the nurse, it would be necessary for the nurse to intervene if – the pt feet are pressed against the foot board;
a pt is using CRUTCHES for the first time, w/c action reflects a need for further instruction – the pt bears his/her wt with his/her axial;
a pt on buck’s traction of the R femur ask the nurse how he can possibly move around. What can the nurse advise the pt – you can hold on to the trapeze bar while moving;
w/c of the ff can possibly indicate the presence of abnormality in an adolescent – uneven hemline – scoliosis;
when assessing an infant, w/c of the ff needs to be reported – extra gluteal folds;
post spinal fusion –ROBAXIN –is given for w/c of the ff purpose - to decrease muscle spasm;
a child has hip spica cast upon discharge, w/c statement of the father indicates further instruction – “ I will hold on to the bar bet his legs to help move him”
INTEGUMENTARY SYSTEM
Burn – triage : face and perineum (priority)
BURNS
Traumatic injury to the skin brought about by : FIRE
CHEMICALSPROLONGED EXPOSURE TO SUNELECTRICAL CURRENTHOT H2O
CLASSSIFICATION:
According to Damage
PARTIAL THICKNESS – FIRST DEGREE 2ND DEGREE
EPIDERMIS EPIDERMIS & PART OF DERMIS Pain Redness Redness Blister Formation Eg sunburn pain
FULL THICKNESS THIRD DEGREE 4TH DEGREE
SUB Q FATS SUB Q FATS MUSCLES MUSCLES & BONES LEATHERY APPEARANCE CHARRED APPEARANCE NO Pain No Pain
MINOR MODERATE MAJOR
PARTIAL TICKNESS less than 15% 15-25% 25%
FULL THICKNESS NONE <10% >10%
RULE OF 9 – CHECK NOTE day 9 page115
BURN TRIAGE
Priority : Burns of FACEPERIMEUMUPPER & LOWER EXTBurn related to Child AbuseChemical – Fire
THINK: R escue
A larm
C onfine the Fire
E xtinguish the Fire
PRINCIPLES OF NSG CARE FOR BURN PTS :
B – reathing – Airway U – rine output monitoring R – esuscitation of Fluids N – utrition S – ilvadene Ointment
DIET DAT (High CHON, Ca, Vit C)
Complication FIRST 24HRS – SHOCK72Hrs - INFECTION
Pt Preparation :Bed Craddle
LYME’S DISEASE Rocky Mountain Fever
caused by BORRELIA BURGDORFERI (deer ticks) Dermacentor/ Variabilis – dog ticks
3-30 days or Dermacentor Andersori (wood)2-3 wks
s/s : Fever, Pain, Chills, Rashes
RASHES: Bull’s Eye Rash or Rounder Rings Generalized rashes At moist body parts
Complications
Cardio, Musculoskeletal and CNS- which can lead to paralysis
TX Avoid wooded area – “have you been to the woods?”
PI VaccinationUse long sleeveRemove ticks w/ twizers – upward straight motion
Meds ChloramphenicolTetracycline
DERMATITIS
DIAPER (contact) ATOPIC ECZEMA (adult)
Peak : During infancy – 9-12 mos Cause : Hereditary Due to prolonged exposure to urine, soap & excreta Prone to asthmatic
patients
S/S : RASH RASH + scaling,
CrustingPruritus or itchingViscicles
Management: Hydrate the skin w/ cold compress
Meds: Benadryl (antihistamine)
ROSEOLA RUBEOLA RUBELLA
Exanthem MEASLES GERMAN MEASLES
Causative Agent Herpez Virus Measle Virus Rubella Virus
INC PERIOD Unknown 10 -20 days 14 -21 days
s/s FEVER and RASH
RASH Non Pruritic Begins w/ face & downwards Face & downwardsRose pink – begins w/ trunk
Progressing outward
With KOPLICK’S SPOTS + same3 C’s : Coryza Cough Conjuctivitis
MANAGEMENT: (to all types)
Bed restAntibioticsAntipyretic
SYPHYLLIS GONORRHEA HERPEZ
C Agent T Pallidum N Gonorrhea Zoster Simplex
I. Period 10-13 wks 2-7 days
Vericella Zoster Virus Herpes Simplex Viruz
Abdominal Oral Herpez Genital H
2-12 days vesicle Steroids
Around the mouth Inner thigh Buttocks Genitals
Acyclovir
Cervical Ca – complication of Herpez
Annual pap smear
TRICHOMONIASIS MONILIASIS/CANDIDIASIS
Caused by TRICHOMONAS Vaginalis Albicans
Both are STDs
Charac of discharge : Greenish/ Yellowish WHITISH-CHEESELIKE discharge With FOUL ODOR
Inc Period 4 – 20 days 2 – 5 days
Druf pf Choice Flagyl Amphotericin
TIPS
A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds rounded rings of rash. This is indicative of – lyme’s dses;
During the immediate 24hrs pot burn, w/c of the ff is the priority – administration of fluis;
A pt tells the nurse that he notice small blisters on his private parts. This is indicative of – HERPEZ
A pt with CA of the cervix was admitted with the ff data: w/c one indicates a possible risk factor – previous tx for herpes;
w/c of the ff indicates effective tx of gonorrhea – (-) purulent discharge;
a pt is diagnosed w/ herpes zoster, w/c of the ff is the priority nsg dx – PAIN;
w/c of the ff is indicative of CHLAMYDIASIS – burning on urination
CANCER
Cause Unknown Theory of USE - Overuse, Underuse, and Abuse
RF Smoking : Lung, Bladder and Laryngeal or Oral CA
RACE : Jewish – BreastBlacks - Cervix and ProstrateWhites – Testes
PARITY : Nulliparity – breast having baby after 35 yoMultiparity – cervix
DIET : High Fat and Low Fiber – CA of ColonSpicy – Ca of ProstrateRaw – Ca of Stomach
LABDATA Screening Exams
Male:
a. Testicular Self Exam – mothly – begins age 16 yo- target are high school
Female:
a. Pap smear – at age of 18 (if sexually active) - anuallyb. Breast self exam – beginning age 20 – monthlyc. Mamography – baseline : 35-40 yo : AFTER 40 yo – once every 2years
After age 50 – annually
BOTH MALE AND FEMALE
Digital Rectal Exam 40 and above – ANUALLY Sigmoidoscopy ANUALLY after age 50yo STOOL FOR OCCULT BLD Annually after age 50 yo
Nsg Dx Initial : Knowledge deficitIf pt is TERMINALLY ILL : HOPELESSNESSIf pt has some wishes or
Unfulfilled needS : Powerlessness
Nsg Care Principles :
C hemotherapy – target cells : those rapidly dividing cells;A sess Body ImageN tuition/diet : high CHON, well balanceC aution pt on s/sE xerciseR est
COMMON S/S
LARYNX change in VOICE or HoarsenessLUNGS changing cough or smoker’s cough (productive)STOMACH dyspepsiaBREAST a lump or a dischargeOVARIAN complains feeling of fullness or indigestionCERVICAL “bleeding”PROSTRATE elevated acid phosphatase, nocturiaCOLON change in bowel habitsHodgkin’s Dses painless enlargement of lymph nodesTESTICULAR crytorchidism, spongy testes or lump (N – smooth unequal)
TIPS FOR CANCER
w/c nsg dx is a priority for a pt undergoing chemotherapy – SOCIAL ISOLATION;
when undergoing chemotheraphy, w/c solution is used for mouth care – HYDROGEN PEROXIDE;
w/c of the ff is an appropriate diet for pt undergoing chemo – bland diet;
the most common sign of Breast Ca is in – upper outer quadrant;
pt w/ CA of esophagus will manifest – DYSPHAGIA
TIPS FOR PSYCHE
A pt w/ chronic depression is to undergo ECT, the purpose is to – relieve the symptoms of depression;
A nurse shld assess the pt w/ ALZEIMER’S DSES for possible change in – orientation;
A pt w/ bipolar episodes is ready for discharge when – she can comply with units activities;
The nurse would suspect that the child is a victim of abuse if he – keeps quiet while an IV is inserted;
w/c of the ff situations reflects an increase in self-esteem of an abuse child - when he ask the nurse for a plastic cup to drink;
the initial care plan for a pt with Anorexia Nervosa would require the pt to – remain in public place 1 hour after meals;
where shld the nurse put the pt on early alcoholic withdrawal – well-lighted room near nurses station
TIPS FOR OB-GYNE
A Mother Is Crying Besides her baby, she said “I feel so sorry I couldn’t hold her” – let her stroke the baby;
6wks pregnant woman ask the nurse about the signs of pregnancy – w/c one is expected at this time – frequent urination;
the nurse notes mirror image in the fetal monitor – this could be related to FETAL HEAD COMPRESSION;
which of the ff is related to trauma – ABRUPTIO PLACENTA;
A nurse is caring for a woman in first stage of labor, she is timing the duration of contraction – she is correct when she times it from the beginning of one contraction to the end of same contraction
TIPS PEDIA
w/c of the ff is expected by 6mos of age – sits w/ minimal support;
the most appropriate toy for 18 mos old child – carriage w/ a doll;
the appropriate room mate for an 8yo girl w/ leukemia is – 6 yo with hemophilia;
in a 3yo child – w/c of the ff shld the nurse assess during admission – special words used for objects and routines;
w/c of the ff is appropriate way of administering pre-op meds to 4 yo child – ask the child where she would like the injecvtion to be given
Paralysis of Lower
