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NCLEX 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 development


LIPPINCOTT – 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 MI


LDH - 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 – falls
3. 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 interpreter
4. 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)


TUBES

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 – drainage


2nd bottle – water sealed
3rd 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 NGT
3. 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 - 2700
b. addtl of 10gms/day for CHON
c. IRON : 15-30mg/day
d. 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-op
ex: 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 dses
ALLOWED: 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 – 7.45
PCO2 - 35 – 35
HCO3 - 22 – 26 meq/L

Ph Compensatory Mechanism

Uncompensated abnormal no change


Partially compensated abnormal increase or decrease
Fully Compensated normal increase or decrease

Diarrhea – metabolic acidosis


Vomiting – 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 pink


Pulse (-) <100 >100
Grimace (-) grimace vigorous
Activity flaccid some flexion flexion & extension
Respiratory (-) 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 dses


INEFFECTIVE BREATHING PATTERN – myasthenia gravis
ALTERED TISSUE PERFUSION – pt w/ complete heart block
INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing

DAY 3 ( 02 February 05)

POSITIONING FOR SPECIFIC SURGICAL CONDITION

Positioning – independent nsg function


- know the purpose of the position
a. 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

TIPS
 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 defensive


2. 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 – TRANSMITTED
BY 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 specimen
USG : 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 bell
b. 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 deceleration
a. 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 points
amniotic fld volume 2 points

10 points
score 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 USG


types:

a. Upper USG – NPO


b. 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 – CVS


AMNIOCENTESIS – AMNIO
PERCUTANEOUS 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 comes
can 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 2:1
The 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. infection
b. bleeding
c. abortion
d. fetal death

TIPS
• 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 depolarization


QRS complex – ventricular depolarization
ST - repolarization

Rhythm – appearance of wave and distance


Rate - 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 inversion


MI - 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 heart


PCWP – 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 dses


Hypokalemia : 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 CA
Renal 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 electron
tissue 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 OBJECTS
c. claustrophobia (give anti-anxiety b4) - jewelries, insulin pump,
d. pt w/ unstable v/s (arrhythmic & HPN); pacemaker, hip replacement
e. pt w/ allergy to dye

“clicking sound” will be heard & lie still during the procedure lie still
lie 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 – hemorrhage
If 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 above
CHRONIC 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 – NORMAL
MODERATE NYS - Minierre’s Dses
NO 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 conduction


If 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, therefore
CONDUCTIVE 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 condition
Chron’s Dses
Diverticulitis
Hemmorhoids
Tumor
Polyps

- (+) 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 ketones
Cushing’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

 RAIU

-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/hr


color : clear, amber
s. 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
 KUB 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/ Ca
b. malignant HPN
c. 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 it
C- lient teaching tips
K- 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.
Haldol
Chlorpromazine
Clozapine (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 sounds
c. LOOSENES OF ASSOCIATION – shifting of topic

CLIENT TEACHINGS:

 Report ADVERSE EFFECTS of ANTI-PSYCHOTICS


– which indicates agranulocytosis
a. fever
b. body malaise
c. sore throat
d. 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 face
b. pill-rolling tremors
c. 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-Dopa
Levodopa
Levodopa-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 absorption
b. 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 frequency
f. decrease BP – rise slowly
g. 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 Dependency
c. 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. TRICYCLICS
b. MAO
c. STIMULANTS
d. 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 LIVER
SOY SAUCE
RED WINE
PICKLES

 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 pancytopenia


RBC, 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 (-) clot
Give same time of day
Report 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 FIRST


c. REPORT s/s of QUINIDINE TOXICITY – tinnitus, hearing loss and visual disturbances
d. 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/L
b. 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/ drowsiness
difficulty in problem solving
decrease level of consciouness
cold 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 acting
Lactulose - 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 electrolytes
e. Increase fld intake – to avoid dehydration

DIURETICS
Target Organs
a. 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 effect
c. blurred vision
d. 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 hypocalcemia
b. check bld pressure; urine output (N 30ml/hr)
c. check RR – at least 12/min
d. 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 hemorrhage


Effective: Firm and Contracted Uterus
Give anytime
If IV, use “piggy back”
Teachings:
a. REPORT the ff: HYPOTENSION (due to inactivation of ANS – neurological effect of drug);
b. Headache
c. 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 hypertonicity
e. 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 M
AIDS (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 room
H – handwashing
GL - gloves
GW – gown
M - mask

AIDS – universal
Norwalk Virus – respiratory
Hepa A – contact
MRSA – contact
Scabies – 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 night


Paroxysmal 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:

Age
Gender
Surgery
Secondary 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
Forgetfulness
Pallor, cold clammy skin
Dyspnea (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 glossitis
Peripheral 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);


Infections
Conditions 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: Hereditary
Autosomal Dominant – common in female and male
There is a defect in polypeptide

Chain of HgB – ALPA and ETA Chain – there is RBC destruction

Types:

a. Minor Thalasemia Anemia – mild anemia: 3Fs


b. 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 transfusion
Bone marrow transplant

IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or


WERLHOF’S DSES

- common in BLACKS;
- cause: idiopathic
unknown (viral and autoimmune)

s/s: petechiae
ecchymosis
hemorrhage
(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 bleeding


Give pt platelet, IVF and Bld Transfusion
Corticosteroids – “wonder drugs”

HEMOPHILIA

- inherited – bldg disorder

TYPES:

a. Hemo. A - deficiency in factor 8


b. Hemo. B - deficiency in Factor 9
c. 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;
Hematoma
Hematuria
Hematemesis
(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 Vein
Patent 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 : Oxygenation
Position the Pt. : SQUATTING
Surgery

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 Days


Lymphadenopathy
Strawberry Tongue
Palmar and Feet Desquamation
Lab Data : No Specific Diagnostic test
Check ECG

Nsg Dx : Altered Tissue Perfusion


Altered Thermoregulation
Altered 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 History
Atherosclerosis
Smoking
Elevated Cholesterol
HPN
Obesity
Physical Inactivity
Stress

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:

EATING
Elimination – due to valsalva manuever
Exercise/effort/ exertion
Emotion
Extreme 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 CARDIOGENIC


SHOCK w/c is due to PUMP Failure – that leads to dec cardiac
Output 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 interval
effective: 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 CHF


Therefore, 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 vein
Ankle edema
Ascites
Hepatomegally

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 : Oxygenation
Position: Semi-Fowler’s
Administer: 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 – rest
b. dietary counseling – NO PMS
c. 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 – unknown
b. BENIGN – usually of long duration, onset is CHRONIC
c. MALIGNANT – acute or abrupt onset, short in duration
d. 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 Enzyme
L – ow
P- latelet
(All are signs of bleeding)

S/S of HPN:
Headache
Retinal Hemorrhage
Edema
- above s/s can further lead to complications: Coronary artery dses
CHF
Chronic Renal Failure
CVA

LAB DATA:
Blood Pressure
Elevated Cholesterol
For PIH : (+) Proteinuria, Inc BP and Inc Cholesterol

Nsg Dx:
Altered Health Maintenance
Risk 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 (+) & severe
Nails brittle nails N
Pain intermittent claudication homan’s sign (pain @ gastrocnemeus area)
Pulse (-) (+)
Temperature cold warm
Ulcer 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 Ext
AFFECTED : 3% - lower ext

Affects arteries Arteries ONLY Arteries ONLY


and 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 Perfusion same 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 : PAIN
Altered 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 Mass


Low Back Pain
Higher BP in Upper Extremities

If RUPTURE occurs – could lead to SHOCK

LAB DATA : Altered Tissue Perfusion


Risk 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

RESPIRATORY

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 Events
c. Siblings of those who died w/ SIDS
(usually 2-3 sis/ bro – died)
d. Hypoventilation
Dx Procedures:

Cardioneumogram – measures O2
Polysonography
ABG 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 factors


Emotion
Effort/ Exercise

S/S : WHEEZING sound – due to obstruction


Orthopnea
Whitish Sputum

Lab Data : Pulmonary Funx test


Incentive Spirometer

Nsg Dx : Ineffective airway Clearance

PI : AIRWAY

Intervention :

Bronchodilators – theophylline
Rest
Oxygen – low flow (1-2 l/min) – higher than this will result to decrease in the stimulus for breathing –
w/c is CO2
Nebulization
Chest Physiotherapy – b4 meals or at bed time
High Fowlers
Intermittent Positive Pressure Breathing
Aerosol
Liberal Fluid Intake

Meds : Aminophylline
Steroids
Theophylline
Histamine Antagonist
Mucolytic
Antibiotics

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 & Bulky
Salty to Kiss – bec skin becomes impermeable to Na
Common Complications: because of thick mucus plug

MALE – Aspermia – low sperm count


Sterility

FEMALE – Difficulty in conceiving

Nsg Dx : Knowledge Deficit


Altered Elimination
Altered 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 Bronchus


Gelatinous 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 Exchange


Ineffective Breathing Pattern

PI : Chest Tube Drainage System – restores the (-) pressure within the thoracic cavity

Anterior chest tube – drains the AIR


Posterior 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 IMMIGRANT
IMMUNOSUPPRESSION
MALNUTRITION

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 Test
Xray – confirmatory test
Sputum - @ 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

Rifampicin
INH
Streptomycin
Ethambutol
- 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 urine


b. 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 – asymptomatic
For OLDER CHILDREN : Diarrhea
Anorexis
Lethargy
Anemia
Skin Rashes and seizure
Musty odor of urine (due to phenyl pyruvic acid)
Since (-) melanine: hair : blonde
Eyes: blue
Fair 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 Deficit
Altered Thought Process
Risk 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 or
JUVENILE HYPOTHYROIDISM
Cause : Autoimmune or genetics

MP : Decrease in T3 and T4

S/S : Dysphagia
Enlarge thyroid
All s/s of hypothyroidism (decrease metabolism)
Nsg Dx : Knowledge Deficit
Activity 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 Deficit


Risk 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 Gland
2. Pituitary Gland
3. Thyroid Gland
4. Parathyroid Gland
5. Thymus Gland
6. Pancreas
7. Adrenals
8. 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 Cushings


Conns

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 : Polydipsia
Polyuria
Polyphagia – the stave cells send message to the brain to eat more
Wt loss

Nsg Dx : Knowledge Deficit


Altered 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 hormone
treatment: 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 NPH


PM Dose: 1:1 for R:NPH

EFFECTS

MOTHER BABY

Macrosomia
Hyperglycemia Hypoglycemia
Therefore pre-term birth RDS
Complication: 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
Stress
Infection
S/S :

Dizziness
Drowsiness
Difficulty Problem Solving
Decrease 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’s
Thirst and warm skin

Lab Data : Increase Bld Sugar

PI : #1 AIRWAY
#2 Fluid
Regular 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 Tumor
Head Trauma
Injuries

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 Fluids
Meds - 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 RESTRICTION
Drugs – 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 HORMONE


Increase Blood Sugar

Nsg Dx : Risk for Injury

PI : Safety
Meds - Parlodel – decrease secretion of growth hormone
If 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. Cortex
GLUCOCORTICOID 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, Polydipsia
Depression 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 flds
Admin. 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 weakness


severe hypotension
hypovolemia, 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 EXOPTHALMUS


INTOLERANCE to COLD (+) Goiter
DECREASE v/s Hypermetabolic State
DECREASE GI Motility – constipation INTOLERANCE to HEAT
HYPOactivity Inc V/S
Increase Sleep – hypersomnia INC GI Motility - DIARRHEA
Wt Gain in the presence of Dec Appetite Insomnia
Dry scaly skin, dry sparse hair, brittle nails HYPERactivity
WT LOSS even INC Appetite
Warm smooth skin, fine soft hair
Pliable nails
Irritability, restlessness, agitation

LAB DATA :

Check TSH (increase) DECREASE TSH


DECREASE T3 & T4 INCREASE T3 & T4
DECREASE 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 ENVIRONMENT
e. 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 & lips


b. Chvostek’s Sign – facial muscle twitching on percussion of facial nerve
c. 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 65ml


toddler – 300-400 ml
school 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. frequency
b. urgency
c. 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 – UTI
e. 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 Mass


Hematuria
HPN

Lab Data :

CT Scan
IVP
NO INAVSIVE LAB/ Procedure
NO BIOPSY

Nsg Dx : Knowledge Deficit


Risk for Injury

PI : AVOID/ NO ABDOMINAL PALPATION


Prepare 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 BP
Maintain Fld Balance
Meds : 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 bath
Prolong driving
Common 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 Pattern


Infection

PI : Treat for Infection – antibiotics for 10-15 days


Bladder 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 Bath


No Silk underwear
Inc. Fld Intake

RENAL FAILURE
ACUTE 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
Nocturia
Polydipsia
Phases of ARF
PHASE 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 FAILURE
DIURETIC PHASE
- Inc urine output (4-5L/day) All s/s + Anemia & HPN
- Dec Na & K
ESRD
RECOVERY PHASE
- renal funx normalizes (1-2 yrs) Azotemia & Uremia –
accumulation
of waste products

“uremic frost” – skin pruritus


LAB DATA

Increase BUN and same


Crea – most sensitive Index
Nsg Dx

Fld and E Imbalance Fld & E Imbalance


Activity Intolerance

PI : TO CORRECT THE IMBALANCE

A. Fluid restriction; Fld restriction


B. Meds : Diuretics Amphogel – to promote excretion of
Cardiac Glycosides – Digitalis Phospate
Antihypertensive Epogen – Inc RBC synthesis
Diuretics
AntiHPN
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, headache
CNS - convulsion, seizures

2. DIALYSIS ENCEPHALOPATHY – due to aluminum toxicity


s/s:
(+) dementia
muscle abnormalities – twitching
seizures

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 stream
Nocturia
Frequency, 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)

EENT
General 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 practices


Swimming in dirty waters
Upper 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 Trauma


Familial Predisposition Rel. to Diabetes
Rel. to Steroids
Rel. 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 spots
Cobwebs”

S/S : NO Pain
Blurring 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 MOVEMENT


AVOID 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 Aging


Aging
Ototoxic Drugs

MP : Cause by an imbalance of Endo- Overgrowth of the stapes


Lymphatic 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 same


Hearing Loss + same
VERTIGO (only for M. DSES)

Lab Data: Caloric Stimulant test


Weber’s test – lateralization of sound
Rinne’s – bone conduction
Audiometry
(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)

Cereals
Fruits
Vegetables
Meat
Table foods

Obtain child Dietary History


Assess for over-intake of milk – poor source of iron (IDA)

REPORTABLE S/S

Vomiting
Abdl Pain (if more than 6hrs) – R/O rupture of the bowel
Tarry Stool – indicates bldg (upper GI)
Fever, Tachycardia, Dehydration – indicative of SHOCK
Hypotention

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 stools
Sign of DHN – sunken fontannels
Poor Skin Turgor
Absence 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 :
Diarrhea
Fluid 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) do


Gastroscopy do
Esophagoscopy do

Nsg Dx : Altered Nutrition Less Than Body Requirement


Flds & 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 scene
c. 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 blade
b. 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 Nutrition


Risk for Aspiration
Body Image Disturbance

PI : Nutrition
Safety
Prepare 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 ft
If 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 Nutrition


Fluid Vol Deficit
Fld and E imbalance

PI : Nutrition
Surgery – 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-crisis


Abdl Enlargement – this can be triggered by INFECTION & Fld and E imbalance
Anorexia
Anemia
- 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 Fiber


Increase fluids

Tx : Give Enema

Meds : Laxative
Surgery – 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 empty
Vomiting : BILE-STAINED
Constipation
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, Chocking
Cyanosis

LAB DATA : Lateral Neck Xray – to check the esophagus

Nsg Dx : Risk for Aspiration

PI : Safety
Airway
Keep 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 : Stress
Smoking
Salicylates or NSAIDS
Helicobacter 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 Acid


Common in Female Common in Male
Below 65 65 yo & above
Inc risk for CA

OUSTANDING S/S: PAIN – aching, burning, gnawing

PAIN – 30mins – 1hr post meal 2-3hrs after meal


PAIN at daytime Nightime
Pain relieved by vomiting Pain relieved by eating
Also related as hyperacidity
HEMATEMESIS (vomiting of blood)
- severe bleeding – “shock”
LAB DATA :
GASTRIC Analysis (diamox blue – urine)
Gastroscopy
BA Swallow
HgB
Hct

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 stomach


BII – 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 : Diarrhea


Diaphoresis
Dizziness/drowsiness

Management: NO FLUIDS after meals – instead in between meals


DIET: High Fats – because it delays the emptying of the stomach
LOW CHO
Lie 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 ENEMA


Colonoscopy
Stool Exam

Nsg Dx : PAIN
Altere Elimination: Diarrhea

PI : Relieve Pain

Meds: Steroids
Anticholinergic
Antidiarrheals
Antispasmodic

DIET : Low Fiber and Low Residue – for Ulcerative and Chron’s

Diverticulosis – High Fiber/residue – allowed: vegetables


Low residue – (no vegetables)

SURGERY : Colostomy – irrigate


Ileostomy – no need for irrigation

Characteristic of N Colostomy – REDDISH or PINKISH


EDEMATOUS
MOIST
N elevation from skin: 2.5 cm
Diameter : 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
PREGNANCY
PROLONGED STANDING
PORTAL HPN – hepatic enceph and liver cirrhosis

GRADE
I Small Area
II Large Area – reduces spontaneously
III Entire Area – manual reduction
IV Entire Area – irreducible

TYPES

INTERNAL H – above the spinchter


EXTERNAL H – below the spinchter

S/S Pruritus
Pain
Bleeding

LAB DATA Sigmoidoscopy


Proctoscopy
P Exam

Nsg Dx Altered Elimination

PI Diet : High Fiber


Avoid 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 SOFTENER
SURGERY

PANCREATITIS
- AUTODESTRUCTION OR AUTODIGESTION of the pancreas

RF #1 Alcoholism
#2 autoimmune
High Fat Diet
Biliary 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 & VOMITING


SHOCK – 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 FAT


AVOID alcohol

CHOLELITHIASIS CHOLECYSTITIS
Combine or usually come together in a pt

Stone in gall bladder Inflammation of the G. bladder

RF Fat same
Female
Fertile
Forty
flatulence

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, FATS


Increase Liver Fnx test
USG

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 HaV
Hepa B – HbsAg

Nsg Dx Infection
Alt Skin Integrity
Body Image Disturbance

PI Tx for Infection
a. 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 metabolize
c. edema – due to fld retention (bec of dec albumin)
d. Flds & e imbalance

LAB DATA Increase Liver Funx Test


Liver Biopsy

Nsg Dx Risk for Injury


Fld & E imbalance
Fld Vol Excess
Altered Nutrition

PI SAFETY

HOW?

 Meds: Diuretics – due to fld retention


ANTIHPN – due to portal HPN
Clotting factors : Coagulants – give Vit K (to avoid bleeding)

 Diet : LOW CHON or CHON to Tolerance


Or 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 CHANGES
DECREASE 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 gain
Increase 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. OCCULOMOTOR
IV. TROCHLEAR Eye movement - 6 cardinal direction of gaze
VI. 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 plexus


KP - 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 children


Cardio-Resp. Arrest - for adolescent

LAB DATA Muscle Biopsy


PExam

Nsg Dx Ineffective Breathing Pattern


Impaired Physical Mobility

PI AIRWAY
(keep TRACHEO at bedside)

TX

a. Supportive - leg brace, crutches


b. 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 thrusting
Early pattern of hand dominance
Back Arching
Scissors-gait

LAB DATA Neurological Assessment


PExam

Nsg Dx Risk for Injury


Impaired Physical Mobility

PI SAFETY

a. Leg braces
b. Meds : Anticunvulsants, Muscle Relaxants
c. Prepare child for SURGERY – release of TENDON OF ACHILLES – to promote mobility
d. 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 Scan


MRI
PExam – 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 Diuretics
Anticonvulsants

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/ SAC
W/ 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 SCAN
PExam

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 Problem


Paralysis 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 Hydrocephalus
Space Occupying Lessions
Brain Tumor
Trauma

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 WITHOUT


the 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 Puncture


CSF Analysis

Nsg Dx Infection
Risk For Injury

PI Safety
Seizure Precaution
Tx the Infection

Type of Infcetion:

a. Bacterial Meningitis – respiratory of droplet precaution


b. 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 Infection


Use of Aspirin

TRIAD S/S Fever


Impaired Liver Funx
Impaired Consciousness w/c could lead to convulsion

STAGES I pt becomes lethargic


II confusion
III decorticate rigidity
IV decerebrate rigidity
V seizure or coma

LAB DATA Bleeding and Clotting Time


Liver Biopsy
Neurological Assessment

Nsg DX Risk for Injury


Altered Thought Process
Altered Thermoregulation
Impaired Physical Mobility

PI Treatment – symptomatic – assess neuro status


Bleeding – give Vit K
AVOID ASPIRIN when there is VIRAL INFECTION

CVA/ STROKE
MP Decrease Oxygen to brain cells

TYPES
THROMBOSIS
EMBOLISM
HEMORRHAGE
INFARCTION
RF
atherosclerosis
hpn
obesity
smoking
stress
age/ 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 paralysis
Muscle 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 Scan


MRI
EEG

Nsg DX Unilateral Neglect – inability to care half of the body


Impaired Physical Mobility
Risk for Injury
PI SAFETY

Position Semi-fowler’s
Elevated

Meds Antihypertensive
Diuretics
Antilipimic Agents
Anticonvulsants
Thrombolytics – if (+) thrombus – to dissolve clots
DIET Low Na and Cholesterol

Activity Range of Motion Exercises

Surgery Craniotomy

Infratentorial Cranio – FLAT


Supratentorial - 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 GBS
Mixed 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 - antidote


Avoid 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 white
There 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 BATH
Impaired 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 STEROIDS
Anticonvulsants – dilantin
Muscle relaxant – Baclofen
Bladder Stimulants – Urecholine (bethanicol)

HX TEACHINGS AVOID : HOT COLD SHOWER


Refer 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 CHON


EMG – “contract and relax” – needle insertion
Muscle 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 Injury


Impaired 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 Congenital
Foot twisted out of place

Types
Talipes Varus – “inversion”
Talipes Valgus – “eversion”
Talipes Equinus – “tiptoe”

LAB DATA PE
Xray

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 – (+) Click
Trendelenburg 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 PExam


Barlow’s Manuever – press leg downward – (+) click
Ortolani’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 infection
CLOSE – 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 correctible


FUNCTIONAL - 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 hump
Xray

Nsg Dx Impaired Physical Mobility - child


Body 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 Teaching
Avoid : Bending
Jumping Rope
Playing Tennis
Trampoline

Allowed: Brisk Walking


Swimming
Cheer Leading

OSTEOPOROSIS/ HUNGRY BONE


MP Loss of Bone Density

RF #1 smoking
AGING
IMMOBILITY
MENOPAUSE – decrease Estrogen
Secondary to Existing Condition – as secondary Hyperparathyroidism

S/S PAIN
Dowager’s Hump
Short Stature
Progressive Decrease in Height

LAB DATA Decrease in Calcium


Bone Densinometry
Bone Scan
Xray

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 tissues


Synovial joints and joints of Upper extremities

S/S PAIN
Inflammation
Morning 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 HgB


Increase ESR

Nsg Dx PAIN
Impaired Physical Mobility

PI Relief of Pain
a. 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 joints


site: 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 PAIN
Impaired 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 Compress


ASA
Trunk 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 Dx PAIN
Altered Tissue Perfusion
Risk For Injury

TX Symptomatic/ Supportive – meaning, treat available s/s

Drugs Steroids

TRACTION
PRINCIPLES T – rapeze bar
R – equires free hanging weights
A – nalgesic
C – iculation monitoring
T – emperature monitoring
I - nfection prevention
O – utput and input monitoring
N – utrition
S – 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


CHEMICALS
PROLONGED EXPOSURE TO SUN
ELECTRICAL CURRENT
HOT 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 FACE
PERIMEUM
UPPER & LOWER EXT
Burn related to Child Abuse
Chemical – 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 – SHOCK


72Hrs - 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 Vaccination
Use long sleeve
Remove ticks w/ twizers – upward straight motion

Meds Chloramphenicol
Tetracycline

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,

Crusting
Pruritus or itching
Viscicles

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 & downwards
Rose pink – begins w/ trunk
Progressing outward

With KOPLICK’S SPOTS + same


3 C’s : Coryza
Cough
Conjuctivitis

MANAGEMENT: (to all types)

Bed rest
Antibiotics
Antipyretic

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 – Breast


Blacks - Cervix and Prostrate
Whites – Testes

PARITY : Nulliparity – breast having baby after 35 yo


Multiparity – cervix

DIET : High Fat and Low Fiber – CA of Colon


Spicy – Ca of Prostrate
Raw – 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) - anually


b. Breast self exam – beginning age 20 – monthly
c. 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 deficit


If pt is TERMINALLY ILL : HOPELESSNESS
If pt has some wishes or
Unfulfilled needS : Powerlessness

Nsg Care Principles :

C hemotherapy – target cells : those rapidly dividing cells;


A sess Body Image
N tuition/diet : high CHON, well balance
C aution pt on s/s
E xercise
R est

COMMON S/S

LARYNX change in VOICE or Hoarseness


LUNGS changing cough or smoker’s cough (productive)
STOMACH dyspepsia
BREAST a lump or a discharge
OVARIAN complains feeling of fullness or indigestion
CERVICAL “bleeding”
PROSTRATE elevated acid phosphatase, nocturia
COLON change in bowel habits
Hodgkin’s Dses painless enlargement of lymph nodes
TESTICULAR 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

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