History of Nursing in the Philippines

The Earliest Hospitals Established were the following:

a. Hospital Real de Manila (1577). It was established mainly to care for the Spanish Kings

soldiers, but also admitted Spanish civilians.Founded by Gov. Francisco de Sande

b. San Lazaro Hospital (1578) built exclusively for patients with leprosy. Founded by Brother Juan
Clemente

The Earliest Hospitals Established

a. Hospital de Indio (1586) Established by the Franciscan Order; Service was in general

supported by alms and contribution from charitable persons.

b. Hospital de Aguas Santas (1590). Established in Laguna, near a medicinal spring, Founded by

Brother J. Bautista of the Franciscan Order.

c. San Juan de Dios Hospital (1596) Founded by the Brotherhood de Misericordia and support was
derived from alms and rents. Rendered general health service to the public.

Nursing During the Philippine Revolution

The prominent persons involved in the nursing works were:

a. Josephine Bracken wife of Jose Rizal. Installed a field hospital in an estate house in Tejeros. Provided
nursing care to the wounded night and day.

b. Rosa Sevilla De Alvero converted their house into quarters for the filipino soldier,during the
Philippine-American war that broke out in 1899.

c. Dona Hilaria de Aguinaldo Wife of Emilio Aguinaldo; Organized the Filipino Red Cross under the
inspiration of Apolinario Mabini.

d. Dona Maria de Aguinaldo- second wife of Emilio Aguinaldo.Provided nursing care for the Filipino
soldier during the revolution. President of the Filipino Red Cross branch in Batangas.

e. Melchora Aquino (Tandang Sora) Nurse the wounded Filipino soldiers and gave them shelter and
food.

f. Captain Salome A revolutionary leader in Nueva Ecija; provided nursing care to the wounded when
not in combat.

g. Agueda Kahabagan Revolutionary leader in Laguna, also provided nursing services to her troop.
h. Trinidad Tecson Ina ng Biac na Bato, stayed in the hospital at Biac na Bato to care for the wounded
soldier.

Hospitals and Nursing Schools

1.Iloilo Mission Hospital School of Nursing (Iloilo City, 1906)

It was ran by the Baptist Foreign Mission Society of America.

Miss Rose Nicolet, a graduate of New England Hospital for woman and children in Boston,
Massechusettes, was the first superintendent.

Miss Flora Ernst, an American nurse, took charge of the school in 1942.

2. St. Pauls Hospital School of Nursing (Manila, 1907)

The hospital was established by the Archbishop of Manila, The Most Reverend Jeremiah Harty, under
the supervision of the Sisters of St. Paul de Chartres.

It was located in Intramuros and it provided general hospital services.

3. Philippine general Hospital School of Nursing (1907)

In 1907, with the support of the Governor General Forbes and the Director of Health and among
others, she opened classes in nursing under the auspices of the Bureau of Education.

Anastacia Giron-Tupas, was the first Filipino to occupy the position of chief nurse and superintendent
in the Philippines, succeded her.

4.St. Lukes Hospital School of Nursing (Quezon City, 1907)

The Hospital is an Episcopalian Institution. It began as a small dispensary in 1903. In 1907, the school
opened with three Filipino girls admitted.

Mrs. Vitiliana Beltran was the first Filipino superintendent of nurses.

5. Mary Johnston Hospital and School of Nursing (Manila, 1907)

It started as a small dispensary on Calle Cervantes (now Avenida)

It was called Bethany Dispensary and was founded by the Methodist Mission.

Miss Librada Javelera was the first Filipino director of the school.

6. Philippine Christian mission Institute School of Nursing.

The United Christian Missionary of Indianapolis, operated Three schools of Nursing:

1. Sallie Long Read Memorial Hospital School of Nursing (Laoag, Ilocos Norte,1903)
2. Mary Chiles Hospital school of Nursing (Manila, 1911)

3. Frank Dunn Memorial hospital

7. San Juan de Dios hospital School of Nursing (Manila, 1913)

8. Emmanuel Hospital School of Nursing (Capiz,1913)

9. Southern Island Hospital School of Nursing (Cebu,1918)

The hospital was established under the Bureau of Health with Anastacia Giron-Tupas as the organizer.

The First Colleges of Nursing in the Philippines

University of Santo Tomas .College of Nursing (1946)

Manila Central University College of Nursing (1948)

University of the Philippines College of Nursing (1948). Ms.Julita Sotejo was its first Dean

Health and Illness

The Basic Human Needs

Each individual has unique characteristics, but certain needs are common to all people.

A need is something that is desirable,useful or necessary.

Human needs are physiologic and psychologic conditions that an individual must meet to achieve a
state of health or well-being.

Maslows Hierarchy of Basic Human Needs

Physiologic

1. Oxygen

2. Fluids

3. Nutrition

4. Body temperature

5. Elimination

6. Rest and sleep

7. Sex

Safety and Security

1. Physical safety

2. Psychological safety

3. The need for shelter and freedom from harm and danger

Love and belonging

1. The need to love and be loved

2. The need to care and to be cared for.

3. The need for affection: to associate or to belong

4. The need to establish fruitful and meaningful relationships with people,institution, or organization

Self-Esteem Needs

1. Self-worth

2. Self-identity

3. Self-respect

4. Body image

Self-Actualization Needs

1. The need to learn, create and understand or comprehend

2. The need for harmonious relationships

3. The need for beauty or aesthetics

4. The need for spiritual fulfillment

Characteristics of Basic Human Needs

1. Needs are universal.

2. Needs may be met in different ways

3. Needs may be stimulated by external and internal factor

4. Priorities may be deferred

5. Needs are interrelated

Concepts of health and Illness

HEALTH

1. is the fundamental right of every human being. It is the state of integration of the body and mind

2. Health and illness are highly individualized perception. Meanings and descriptions of health and
illness vary among people in relation to geography and to culture.

3. Health - is the state of complete physical, mental, and social well-being, and not merely the absence
of disease or infirmity. (WHO)

4. Health is the ability to maintain the internal milieu. Illness is the result of failure to maintain the
internal environment.(Claude Bernard)

5. Health is the ability to maintain homeostasis or dynamic equilibrium. Homeostasis is regulated by

the negative feedback mechanism.(Walter Cannon)

6. Health is being well and using oness power to the fullest extent. Health is maintained through
prevention of diseases via environmental health factors.(Florence Nightingale)

7. Health is viewed in terms of the individuals ability to perform 14 components of nursing care
unaided. (Henderson)

8. Positive Health symbolizes wellness. It is value term defined by the culture or individual. (Rogers)

9. Health is a state of a process of being becoming an integrated and whole as a person.(Roy)

10. Health is a state the characterized by soundness or wholeness of developed human structures and
of bodily and mental functioning.(Orem)

11. Health- is a dynamic state in the life cycle;illness is an interference in the life cycle. (King)

12. Wellness is the condition in which all parts and subparts of an individual are in harmony with the
whole system. (Neuman)

13. Health is an elusive, dynamic state influenced by biologic,psychologic, and social factors.Health is
reflected by the organization, interaction, interdependence and integration of the subsystems of the
behavioral system.(Johnson)

Illness and Disease

Illness

is a personal state in which the person feels unhealthy.

Illness is a state in which a persons physical, emotional, intellectual, social, developmental,or spiritual
functioning is diminished or impaired compared with previous experience.

Illness is not synonymous with disease.

Disease

An alteration in body function resulting in reduction of capacities or a shortening of the normal life
span.

Common Causes of Disease

1. Biologic agent e.g. microorganism

2. Inherited genetic defects e.g. cleft palate

3. Developmental defects e.g. imperforate anus

4. Physical agents e.g. radiation, hot and cold substances, ultraviolet rays

5. Chemical agents e.g. lead, asbestos, carbon monoxide

6. Tissue response to irritations/injury e.g. inflammation, fever

7. Faulty chemical/metabolic process e.g. inadequate insulin in diabetes

8. Emotional/physical reaction to stress e.g. fear, anxiety

Stages of Illness

1. Symptoms Experience- experience some symptoms, person believes something is wrong

3 aspects physical, cognitive, emotional

2. Assumption of Sick Role acceptance of illness, seeks advice

3. Medical Care Contact

Seeks advice to professionals for validation of real illness,explanation of symptoms, reassurance

or predict of outcome

4. Dependent Patient Role

The person becomes a client dependent on the health professional for help.

Accepts/rejects health professionals suggestions.

Becomes more passive and accepting.

5. Recovery/Rehabilitation
Gives up the sick role and returns to former roles and functions.

Risk Factors of a Disease

1. Genetic and Physiological Factors

For example, a person with a family history of diabetes mellitus, is at risk in developing the disease
later in life.

2. Age

Age increases and decreases susceptibility ( risk of heart diseases increases with age for both sexes

3. Environment

The physical environment in which a person works or lives can increase the likelihood that certain
illnesses will occur.

4. Lifestyle

Lifestyle practices and behaviors can also have positive or negative effects on health.

Classification of Diseases

1. According to Etiologic Factors

a. Hereditary due to defect in the genes of one or other parent which is transmitted to the

i. offspring

b. Congenital due to a defect in the development, hereditary factors, or prenatal infection

c. Metabolic due to disturbances or abnormality in the intricate processes of metabolism.

d. Deficiency results from inadequate intake or absorption of essential dietary factor.

e. Traumatic- due to injury

f. Allergic due to abnormal response of the body to chemical and protein substances or to physical
stimuli.

g. Neoplastic due to abnormal or uncontrolled growth of cell.

h. Idiopathic Cause is unknown; self-originated; of spontaneous origin

i. Degenerative Results from the degenerative changes that occur in the tissue and organs.

j. Iatrogenic result from the treatment of the disease

2. According to Duration or Onset

a. .Acute Illness An acute illness usually has a short duration and is severe. Signs and symptoms
appears abruptly, intense and often subside after a relatively short period.

b. Chronic Illness chronic illness usually longer than 6 months, and can also affects functioning in any
dimension. The client may fluctuate between maximal functioning and serious relapses and may be life
threatening. Is is characterized by remission and exacerbation.

Remission- periods during which the disease is controlled and symptoms are not obvious.

Exacerbations The disease becomes more active given again at a future time, with recurrence of
pronounced symptoms.

c. Sub-Acute Symptoms are pronounced but more prolonged than the acute disease.

3. Disease may also be described as:

a. Organic results from changes in the normal structure, from recognizable anatomical changes in an
organ or tissue of the body.

b. Functional no anatomical changes are observed to account from the symptoms present, may result
from abnormal response to stimuli.

c. Occupational Results from factors associated with the occupation engage in by the patient.

d. Venereal usually acquired through sexual relation

e. Familial occurs in several individuals of the same family

f. Epidemic attacks a large number of individuals in the community at the same time. (e.g. SARS)

g. Endemic Presents more or less continuously or recurs in a community. (e.g. malaria, goiter)

h. Pandemic An epidemic which is extremely widespread involving an entire country or continent.

i. Sporadic a disease in which only occasional cases occur. (e.g. dengue, leptospirosis)

Leavell and Clarks Three Levels of Prevention

a. Primary Prevention seeks to prevent a disease or condition at a prepathologic state ; to stop

something from ever happening.

Health Promotion

-health education

-marriage counseling
-genetic screening

-good standard of nutrition adjusted to

developmental phase of life

Specific Protection

-use of specific immunization

-attention to personal hygiene

-use of environmental sanitation

-protection against occupational hazards

-protection from accidents

-use of specific nutrients

-protections from carcinogens

-avoidance to allergens

b. Secondary Prevention also known as Health Maintenance.Seeks to identify specific

illnesses or conditions at an early stage with prompt intervention to prevent or limit disability;

to prevent catastrophic effects that could occur if proper attention and treatment are not

provided

Early Diagnosis and Prompt Treatment

-case finding measures

-individual and mass screening survey

-prevent spread of communicable disease

-prevent complication and sequelae

-shorten period of disability

Disability Limitations

- adequate treatment to arrest disease process and prevent further complication and

sequelae.
-provision of facilities to limit disability and prevent death.

c. Tertiary Prevention occurs after a disease or disability has occurred and the recovery

process has begun; Intent is to halt the disease or injury process and assist the person in

obtaining an optimal health status.To establish a high-level wellness.

To maximize use of remaining capacitiess

Restoration and Rehabilitation

-work therapy in hospital

- use of shelter colony

NURSING

As defined by the INTERNATIONAL COUNCIL OF NURSES as written by Virginia Henderson.

the unique function of the nurse is to assist the individual, sick or well, in the performance of those
activities contributing to health, its recovery, or to a peaceful death the client would perform unaided if
he had the necessary strength, will or knowledge.

Help the client gain independence as rapidly as possible.

CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE

A. NIGHTANGLES THEORY ( mid-1800)

Focuses on the patient and his environment.

Developed the described the first theory of nursing. Notes on Nursing: What It Is, What It Is Not. She
focused on changing and manipulating the environment in order to put the patient in the best possible
conditions for nature to act.

She believed that in the nurturing environment, the body could repair itself. Clients environment is
manipulated to include appropriate noise, nutrition, hygiene, socialization and hope.

B. PEPLAU, HILDEGARD (1951)

Defined nursing as a therapeutic, interpersonal process which strives to develop a nurse- patient
relationship in which the nurse serves as a resource person, counselor and surrogate.

Introduced the Interpersonal Model. She defined nursing as an interpersonal process of therapeutic
between an individual who is sick or in need of health services and a nurse especially educated to
recognize and respond to the need for help. She identified four phases of the nurse client relationship
namely:

1. Orientation: the nurse and the client initially do not know each others goals and testing the role each
will assume. The client attempts to identify difficulties and the amount of nursing help that is needed;

2. Identification: the client responds to help professionals or the significant others who can meet the
identified needs. Both the client and the nurse plan together an appropriate program to foster health;

3. Exploitation: the clients utilize all available resources to move toward a goal of maximum health
functionality;

4. Resolution: refers to the termination phase of the nurse-client relationship. it occurs when the clients
needs are met and he/she can move toward a new goal. Peplau further assumed that nurse-client
relationship fosters growth in both the client and the nurse.

C. ABDELLAH, FAYE G. (1960)

Defined nursing as having a problem-solving approach, with key nursing problems related to health
needs of people; developed list of 21 nursing-problem areas.

Introduced Patient Centered Approaches to Nursing Model She defined nursing as service to
individual and families; therefore the society. Furthermore, she conceptualized nursing as an art and a
science that molds the attitudes, intellectual competencies and technical skills of the individual nurse
into the desire and ability to help people, sick or well, and cope with their health needs.

D. ORLANDO, IDA

She conceptualized The Dynamic Nurse Patient Relationship Model.

E. LEVINE, MYRA (1973)

Believes nursing intervention is a conservation activity, with conservation of energy as a primary

concern, four conservation principles of nursing: conservation of client energy, conservation of
structured integrity, conservation of personal integrity, conservation of social integrity.

Described the Four Conversation Principles. She Advocated that nursing is a human interaction and
proposed four conservation principles of nursing which are concerned with the unity and integrity of the
individual. The four conservation principles are as follows:

1. Conservation of energy. The human body functions by utilizing energy. The human body needs energy
producing input (food, oxygen, fluids) to allow energy utilization output.
2. Conservation of Structural Integrity. The human body has physical boundaries (skin and mucous
membrane) that must be maintained to facilitate health and prevent harmful agents from entering the
body.

3. Conservation of Personal Integrity. The nursing interventions are based on the conservation of the
individual clients personality. Every individual has sense of identity, self worth and self esteem, which
must be preserved and enhanced by nurses.

4. Conservation of Social integrity. The social integrity of the client reflects the family and the
community in which the client functions. Health care institutions may separate individuals from their
family. It is important for nurses to consider the individual in the context of the family.

F. JOHNSON, DOROTHY (1960, 1980)

Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can
move more easily through recovery.

Viewed the patients behavior as a system, which is a whole with interacting parts.

The nursing process is viewed as a major tool.

Conceptualized the Behavioral System Model. According to Johnson, each person as a behavioral system
is composed of seven subsystems namely:

1. Ingestive. Taking in nourishment in socially and culturally acceptable ways.

2. Eliminative. Ridding the body of waste in socially and culturally acceptable ways.

3. Affiliative. Security seeking behavior.

4. Aggressive. Self protective behavior.

5. Dependence. Nurture seeking behavior.

6. Achievement. Master of oneself and ones environment according to internalized standards of

excellence.

7. Sexual role identity behavior

G. ROGERS, MARTHA

Considers man as a unitary human being co-existing with in the universe, views nursing primarily as a
science and is committed to nursing research.

H. OREM, DOROTHEA (1970, 1985)

 Emphasizes the clients self-care needs, nursing care becomes necessary when client is unable to fulfill
biological, psychological, developmental or social needs.

Developed the Self-Care Deficit Theory. She defined self-care as the practice of activities that
individuals initiate to perform on their own behalf in maintaining life, health well-being. She
conceptualized three systems as follows:

1. Wholly Compensatory: when the nurse is expected to accomplish all the patients therapeutic self-
care or to compensate for the patients inability to engage in self care or when the patient needs
continuous guidance in self care;

2. Partially Compensatory: when both nurse patient engage in meeting self care needs;

3. Supportive-Educative: the system that requires assistance decision making, behavior control and
acquisition knowledge and skills.

I.IMOGENE KING (1971, 1981)

Nursing process is defined as dynamic interpersonal process between nurse, client and health care
system.

Postulated the Goal Attainment Theory. She described nursing as a helping profession that assists
individuals and groups in society to attain, maintain, and restore health. If not possible, nurses help
individuals die with dignity.

In addition, King viewed nursing as an interaction process between client and nurse whereby during
perceiving, setting goals, and acting on them transactions occurred and goals are achieved.

J. BETTY NEUMAN

Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary,
secondary or tertiary level of prevention.

K. SIS CALLISTA ROY (Adaptation Theory) (1979, 1984)

Views the client as an adaptive system. The goal of nursing is to help the person adapt to changes in
physiological needs, self-concept, role function and interdependent relations during health and illness.

Presented the Adaptation Model. She viewed each person as a unified biopsychosocial system in
constant interaction with a changing environment. She contended that the person as an adaptive
system, functions as a whole through interdependence of its part. The system consist of input, control
processes, output feedback.
L.LYDIA HALL (1962)

The client is composed of the ff. overlapping parts: person (core), pathologic state and treatment
(cure) and body (care).

Introduced the model of Nursing: What Is It? focusing on the notion that centers around three
components of CARE, CORE and CURE. Care represents nurturance and is exclusive to nursing. Core
involves the therapeutic use of self and emphasizes the use of reflection. Cure focuses on nursing
related to the physicians orders. Core and cure are shared with the other health care providers.

M. Virginia Henderson (1955)

Introduced The Nature of Nursing Model. She identified fourteen basic needs.

She postulated that the unique function of the nurse is to assist the clients, sick or well, in the
performance of those activities contributing to health or its recovery, the clients would perform unaided
if they had the necessary strength, will or knowledge.

She further believed that nursing involves assisting the client in gaining independence as rapidly as
possible, or assisting him achieves peaceful death if recovery is no longer possible.

N. Madaleine Leininger (1978, 1984)

Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific
mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices)
to improve or maintain a health condition.

O. Ida Jean Orlando (1961)

Conceptualized The Dynamic Nurse Patient Relationship Model.

She believed that the nurse helps patients meet a perceived need that the patient cannot meet for
themselves. Orlando observed that the nurse provides direct assistance to meet an immediate need for
help in order to avoid or to alleviate distress or helplessness.

She emphasized the importance of validating the need and evaluating care based on observable
outcomes.

P. Ernestine Weidanbach (1964)

Developed the Clinical Nursing A Helping Art Model.

She advocated that the nurses individual philosophy or central purpose lends credence to nursing
care.
 She believed that nurses meet the individuals need for help through the identification of the needs,
administration of help, and validation that actions were helpful. Components of clinical practice:
Philosophy, purpose, practice and an art.

Q. Jean Watson (1979-1992)

Introduced the theory of Human Becoming. She emphasized free choice of personal meaning in
relating value priorities, co creating the rhythmical patterns, in exchange with the environment, and co
transcending in many dimensions as possibilities unfold.

R. Joyce Travelbee (1966,1971)

She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing
individual or family in preventing or coping with illness, regaining health finding meaning in illness, or
maintaining maximal degree of health.

She further viewed that interpersonal process is a human-to-human relationship formed during illness
and experience of suffering

She believed that a person is a unique, irreplaceable individual who is in a continuous process of
becoming, evolving and changing.

S. Josephine Peterson and Loretta Zderad (1976)

Provided the Humanistic Nursing Practice Theory. This is based on their belief that nursing is an
existential experience.

Nursing is viewed as a lived dialogue that involves the coming together of the nurse and the person to
be nursed.

The essential characteristic of nursing is nurturance. Humanistic care cannot take place without the
authentic commitment of the nurse to being with and the doing with the client. Humanistic nursing also
presupposes responsible choices.

T. Helen Erickson, Evelyn Tomlin, and Mary Ann Swain (1983)

Developed Modeling and Role Modeling Theory. The focus of this theory is on the person. The nurse
models (assesses), role models (plans), and intervenes in this interpersonal and interactive theory.

They asserted that each individual unique, has some self-care knowledge, needs simultaneously to be
attached to the separate from others, and has adaptive potential. Nurses in this theory, facilitate,
nurture and accept the person unconditionally.

U. Margaret Newman

Focused on health as expanding consciousness. She believed that human are unitary in whom disease
is a manifestation of the pattern of health.
 She defined consciousness as the information capability of the system which is influenced by time,
space movement and is ever expanding.

V. Patricia Benner and Judith Wrudel (1989)

Proposed the Primacy and Caring Model. They believed that caring central to the essence of nursing.
Caring creates the possibilities for coping and creates the possibilities for connecting with and concern
for others.

W. Anne Boykin and Savina Schoenhofer

Presented the grand theory of Nursing as Caring. They believed that all person are caring, and nursing
is a response to a unique social call. The focus of nursing is on nurturing person living and growing in
caring in a manner that is specific to each nurse-nursed relationship or nursing situation. Each nursing
situation is original.

They support that caring is a moral imperative. Nursing as Caring is not based on need or deficit but is
egalitarian model helping.

Moral Theories

1. Freud (1961)

Believed that the mechanism for right and wrong within the individual is the superego, or conscience.
He hypothesized that a child internalizes and adopts the moral standards and character or character
traits of the model parent through the process of identification.

The strength of the superego depends on the intensity of the childs feeling of aggression or
attachment toward the model parent rather than on the actual standards of the parent.

2. Erikson (1964)

Eriksons theory on the development of virtues or unifying strengths of the good man suggest that
moral development is continuous throughout life. He believed that if the conflicts of each psychosocial
developmental stages are favorably resolved, then an ego-strength or virtue emerges.

3. Kohlberg

Suggested three levels of moral development. He focused on the reason for the making of a decision,
not on the morality of the decision itself.

1. At first level called the premolar or the preconventional level, children are responsive to cultural rules
and labels of good and bad, right and wrong. However children interpret these in terms of the physical
consequences of the actions, i.e., punishment or reward.

2. At the second level, the conventional level, the individual is concerned about maintaining the
expectations of the family, groups or nation and sees this as right.
3. At the third level, people make postconventional, autonomous, or principal level. At this level, people
make an effort to define valid values and principles without regard to outside authority or to the
expectations of others. These involve respect for other human and belief that relationship are based on
mutual trust.

Peter (1981)

Proposed a concept of rational morality based on principles. Moral development is usually considered
to involve three separate components: moral emotion (what one feels), moral judgment (how one
reasons), and moral behavior (how one acts).

In addition, Peters believed that the development of character traits or virtues is an essential aspect or
moral development. And that virtues or character traits can be learned from others and encouraged by
the example of others.

Also, Peters believed that some can be described as habits because they are in some sense automatic
and therefore are performed habitually, such as politeness, chastity, tidiness, thrift and honesty.

Gilligan (1982)

Included the concepts of caring and responsibility. She described three stages in the process of
developing an Ethic of Care which are as follows.

1. Caring for oneself.

2. Caring for others.

3. Caring for self and others.

She believed the human see morality in the integrity of relationships and caring. For women, what is
right is taking responsibility for others as self-chosen decision. On the other hand, men consider what is
right to be what is just.

Spiritual Theories

Fowler (1979)

Described the development of faith. He believed that faith, or the spiritual dimension is a force that
gives meaning to a persons life.
 He used the term faith as a form of knowing a way of being in relation to an ultimate environment.
To Fowler, faith is a relational phenomenon: it is an active made-of-being-in-relation to others in which
we invest commitment, belief, love, risk and hope.

ROLES AND FUNCTIONS OF THE NURSE

Selected Expanded Career Roles of Nurses

1. Nurse Practitioner

A nurse who has an advanced education and is a graduate of a nurse practitioner program.

These nurses are in areas as adult nurse practitioner, family nurse practitioner, school nurse
practitioner, pediatric nurse practitioner, or gerontology nurse practitioner.

They are employed in health care agencies or community based settings. They usually deal with non-
emergency acute or chronic illness and provide primary ambulatory care.

2. Clinical Nurse Specialist

A nurse who has an advanced degree or expertise and is considered to be an expert in a specialized
area of practice (e.g., gerontology, oncology).

The nurse provides direct client care, educates others, consults, conducts research, and manages care.

The American Nurses Credentialing Center provides national certification of clinical specialists.

3. Nurse Anesthetist

A nurse who has completed advanced education in an accredited program in anesthesiology.

The nurse anesthetist carries out pre-operative visits and assessments, and Administers general
anesthetics for surgery under the supervision of a physician prepared in anesthesiology.

The nurse anesthetist also assesses the postoperative of clients

4. Nurse Midwife

An RN who has completed a program in midwifery.

The nurse gives pre-natal and post-natal care and manages deliveries in normal pregnancies.

The midwife practices the association with a health care agency and can obtain medical services if
complication occurs.

The nurse midwife may also conduct routine Papanicolaou smears, family planning, and routine breast
examination.
5. Nurse Educator

Nurse educator is employed in nursing programs, at educational institutions, and in hospital staff
education.

The nurse educator usually ha a baccalaureate degree or more advanced preparation and frequently
has expertise in a particular area of practice. The nurse educator is responsible for classroom and of ten
clinical teaching.

6. Nurse Entrepreneur

A nurse who usually has an advanced degree and manages a health-related business.

The nurse may be involved in education, consultation, or research, for example.

COMMUNICATION IN NURSING

COMMUNICATION

1. Is the means to establish a helping-healing relationship. All behavior communication influences

behavior.

2. Communication is essential to the nurse-patient relationship for the following reasons:

3. Is the vehicle for establishing a therapeutic relationship.

4. It the means by which an individual influences the behavior of another, which leads to the successful
outcome of nursing intervention.

Basic Elements of the Communication Process

1. SENDER is the person who encodes and delivers the message

2. MESSAGES is the content of the communication. It may contain verbal, nonverbal, and symbolic
language.

3. RECEIVER is the person who receives and decodes the message.

4. FEEDBACK is the message returned by the receiver. It indicates whether the meaning of the senders
message was understood.

Modes of Communication

1. Verbal Communication use of spoken or written words.

2. Nonverbal Communication use of gestures, facial expressions, posture/gait, body movements,

physical appearance and body language

Characteristics of Good Communication

1. Simplicity includes uses of commonly understood, brevity, and completeness.

2. Clarity involves saying what is meant. The nurse should also need to speak slowly and enunciate
words well.

3. Timing and Relevance requires choice of appropriate time and consideration of the clients interest
and concerns. Ask one question at a time and wait for an answer before making another comment.

4. Characteristics of Good Communication

5. Adaptability Involves adjustments on what the nurse says and how it is said depending on the
moods and behavior of the client.

6. Credibility Means worthiness of belief. To become credible, the nurse requires adequate knowledge
about the topic being discussed. The nurse should be able to provide accurate information, to convey
confidence and certainly in what she says.

Communicating With Clients Who Have Special Needs

1.Clients who cannot speak clearly (aphasia, dysarthria, muteness)

1. Listen attentively, be patient, and do not interrupt.

2. Ask simple question that require yes and no answers.

3. Allow time for understanding and response.

4. Use visual cues (e.g., words, pictures, and objects)

5. Allow only one person to speak at a time.

6. Do not shout or speak too loudly.

7. Use communication aid:

-pad and felt-tipped pen, magic slate, pictures denoting basic needs, call bells or alarm.

2. Clients who are cognitively impaired

1. Reduce environmental distractions while conversing.

2. Get clients attention prior to speaking

3. Use simple sentences and avoid long explanation.

4. Ask one question at a time

5. Allow time for client to respond

6. Be an attentive listener

7. Include family and friends in conversations, especially in subjects known to client.

3. Client who are unresponsive

1. Call client by name during interactions

2. Communicate both verbally and by touch

3. Speak to client as though he or she could hear

4. Explain all procedures and sensations

5. Provide orientation to person, place, and time

6. Avoid talking about client to others in his or her presence

7. Avoid saying things client should not hear

4. Communicating with hearing impaired client

1. Establish a method of communication (pen/pencil and paper, sign-language)

2. Pay attention to clients non-verbal cues

3. Decrease background noise such as television

4. Always face the client when speaking

5. It is also important to check the family as to how to communicate with the client

6. It may be necessary to contact the appropriate department resource person for this type of disability

4. Client who do not speak English

1. Speak to client in normal tone of voice (shouting may be interpreted as anger)

2. Establish method for client o signal desire to communicate (call light or bell)

3. Provide an interpreter (translator) as needed

4. Avoid using family members, especially children, as interpreters.

5. Develop communication board, pictures or cards.

6. Have dictionary (English/Spanish) available if client can read.

Reports
 Are oral ,written, or audiotaped exchanges of information between caregivers.

Common reports:

1. Change-in-shift report

2. Telephone report

3. Telephone or verbal order only RNs are allowed to accept telephone orders.

4. Transfer report

5. Incident report

Documentation

1. Is anything written or printed that is relied on as record or proof for authorized person.

2. Nursing documentation must be:

3. accurate

4. comprehensive

5. flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and
reflects current standards of nursing practice

6. Effective documentation ensures continuity of care, saves time and minimizes the risk of error.

7. As members of the health care team, nurses need to communicate information about clients
accurately and in timely manner

8. If the care plan is not communicated to all members of the health care team, care can become
fragmented, repetition of tasks occurs, and therapies may be delayed or omitted.

9. Data recorded, reported, or c0mmunicated to other health care professionals are CONFIDENTIAL and
must be protected.

CONFIDENTIALITY

1. nurses are legally and ethically obligated to keep information about clients confidential.

2. Nurses may not discuss a clients examination, observation, conversation, or treatment with other
clients or staff not involved in the clients care.

3. Only staff directly involved in a specific clients care have legitimate access to the record.

4. CONFIDENTIALITY
5. Clients frequently request copies of their medical record, and they have the right to read those
records.

6. Nurses are responsible for protecting records from all unauthorized readers.

7. when nurses and other health care professionals have a legitimate reason to use records for data
gathering, research, or continuing education, appropriate authorization must be obtained according to
agency policy.

8. Confidentiality

9. Maintaining confidentiality is an important aspect of profession behavior.

10. It is essential that the nurse safe-guard the client right to privacy by carefully protecting information
of a sensitive, private nature.

11. Sharing personal information or gossiping about others violates nursing ethical codes and practice
standards.

12. It sends the message that the nurse cannot be trusted and damages the interpersonal relationships.

Guidelines of Quality Documentation and Reporting

1.Factual

1. a record must contain descriptive, objective information about what a nurse sees, hears, feels, and
smells.

2. The use of vague terms, such as appears, seems, and apparently, is not acceptable because these
words suggests that the nurse is stating an opinion.

Example: the client seems anxious (the phrase seems anxious is a conclusion without supported
facts.)

2. Accurate

1. The use of exact measurements establishes accuracy. (example: Intake of 350 ml of water is more
accurate than the client drank an adequate amount of fluid

2. Documentation of concise data is clear and easy to understand.

3. It is essential to avoid the use of unnecessary words and irrelevant details

3. Complete

1. The information within a recorded entry or a report needs to be complete, containing appropriate
and essential information.
Example:

The client verbalizes sharp, throbbing pain localized along lateral side of right ankle, beginning
approximately 15 minutes ago after twisting his foot on the stair. Client rates pain as 8 on a scale of 0-
10.

4. Current

1. Timely entries are essential in the clients ongoing care. To increase accuracy and decrease
unnecessary duplication, many healthcare agencies use records kept near the clients bedside, which
facilitate immediate documentation of information as it is collected from a client

5. Organized

1. The nurse communicates information in a logical order.

For example, an organized note describes the clients pain, nurses assessment, nurses interventions,
and the clients response

Legal Guidelines for recording

1. Draw single line through error, write word error above it and sign your name or initials. Then

record note correctly.

2. Do not write retaliatory or critical comments about the client or care by other health care
professionals.

Enter only objective descriptions of clients behavior; clients comments should be quoted.

3. Correct all errors promptly

errors in recording can lead to errors in treatment

Avoid rushing to complete charting, be sure information is accurate.

4. Do not leave blank spaces in nurses notes.

Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at
end.

5. Record all entries legibly and in blank ink

Never use pencil, felt pen.

Blank ink is more legible when records are photocopied or transferred to microfilm.

Legal Guidelines for Recording

6. If order is questioned, record that clarification was sought.

If you perform orders known to be incorrect, you are just as liable for prosecution as the physician is.

7. Chart only for yourself

Never chart for someone else.

You are accountable for information you enter into chart.

8. Avoid using generalized, empty phrases such as status unchanged or had good day.

Begin each entry with time, and end with your signature and title.

Do not wait until end of shift to record important changes that occurred several hours earlier. Be sure
to sign each entry.

9. For computer documentation keep your password to yourself.

maintain security and confidentiality.

Once logged into the computer do not leave the computer screen unattended.

Assessment of Vital Signs

Assessing Vital Signs

Vital Signs or Cardinal Signs are:

Body temperature

Pulse

Respiration

Blood pressure

Pain

I. Body Temperature

The balance between the heat produced by the body and the heat loss from the body.

Types of Body Temperature

Core temperature temperature of the deep tissues of the body.

Surface body temperature

Alteration in body Temperature

 Pyrexia Body temperature above normal range( hyperthermia)

Hyperpyrexia Very high fever, 41C(105.8 F) and above

Hypothermia Subnormal temperature.

Normal Adult Temperature Ranges

Oral 36.5 37.5 C

Axillary 35.8 37.0 C

Rectal 37.0 38.1 C

Tympanic 36.8 37.9C

Methods of Temperature-Taking

1. Oral most accessible and convenient method.

a. Put on gloves, and position the tip of the thermometer under the patients tongue on either of the
frenulum as far back as possible. It promotes contact to the superficial blood vessels and ensure a more
accurate reading.

b. Wash thermometer before use.

c. Take oral temp 2-3 minutes.

d. Allow 15 min to elapse between clients food intake of hot or cold food, smoking.

e. Instruct the patient to close his lips but not to bite down with his teeth to avoid breaking the
thermometer in his mouth.

Contraindications

Young children and infants

Patients who are unconscious or disoriented

Who must breath through the mouth

Seizure prone

Patient with N/V

Patients with oral lesions/surgeries

2. Rectal- most accurate measurement of temperature

a. Position- lateral position with his top legs flexed and drape him to provide privacy.

b. Squeeze the lubricant onto a facial tissue to avoid contaminating the lubricant supply.

c. Insert thermometer by 0.5 1.5 inches

d. Hold in place in 2minutes

e. Do not force to insert the thermometer

Contraindications

Patient with diarrhea

Recent rectal or prostatic surgery or injury because it may injure inflamed tissue

Recent myocardial infarction

Patient post head injury

3. Axillary safest and non-invasive

a. Pat the axilla dry

b. Ask the patient to reach across his chest and grasp his opposite shoulder. This promote skin contact
with the thermometer

c. Hold it in place for 9 minutes because the thermometer isnt close in a body cavity

Note:

Use the same thermometer for repeat temperature taking to ensure more consistent result

Store chemical-dot thermometer in a cool area because exposure to heat activates the dye dots.

4. Tympanic thermometer

a. Make sure the lens under the probe is clean and shiny

b. Stabilized the patients head; gently pull the ear straight back (for children up to age 1) or up and back
(for children 1 and older to adults)

c. Insert the thermometer until the entire ear canal is sealed

d. Place the activation button, and hold it in place for 1 second

5. Chemical-dot thermometer

a. Leave the chemical-dot thermometer in place for 45 seconds

b. Read the temperature as the last dye dot that has change color, or fired.

Nursing Interventions in Clients with Fever

a. Monitor V.S

b. Assess skin color and temperature

c. Monitor WBC, Hct and other pertinent lab records

d. Provide adequate foods and fluids.

e. Promote rest

f. Monitor I & O

g. Provide TSB

h. Provide dry clothing and linens

i. Give antipyretic as ordered by MD

II. Pulse Its the wave of blood created by contractions of the left ventricles of the

heart.

Normal Pulse rate

1 year 80-140 beats/min

2 years 80- 130 beats/min

6 years 75- 120 beats/min

10 years 60-90 beats/min

Adult 60-100 beats/min

Tachycardia pulse rate of above 100 beats/min

Bradycardia- pulse rate below 60 beats/min

Irregular uneven time interval between beats.

What you need:

a. Watch with second hand

b. Stethoscope (for apical pulse)

c. Doppler ultrasound blood flow detector if necessary

Radial Pulse

a. Wash your hand and tell your client that you are going to take his pulse

b. Place the client in sitting or supine position with his arm on his side or across his

chest

c. Gently press your index, middle, and ring fingers on the radial artery, inside the patients wrist.

d. Excessive pressure may obstruct blood flow distal to the pulse site

e. Counting for a full minute provides a more accurate picture of irregularities

Doppler device

a. Apply small amount of transmission gel to the ultrasound probe

b. Position the probe on the skin directly over a selected artery

c. Set the volume to the lowest setting

d. To obtain best signals, put gel between the skin and the probe and tilt the probe 45 degrees from the
artery.

e. After you have measure the pulse rate, clean the probe with soft cloth soaked in antiseptic. Do not
immerse the probe

III. Respiration - is the exchange of oxygen and carbon dioxide between the atmosphere

and the body

Assessing Respiration

Rate Normal 14-20/ min in adult

The best time to assess respiration is immediately after taking clients pulse

Count respiration for 60 second

 As you count the respiration, assess and record breath sound as stridor, wheezing, or stertor.

Respiratory rates of less than 10 or more than 40 are usually considered abnormal and should be
reported immediately to the physician.

IV. Blood Pressure

Adult 90- 132 systolic

60- 85 diastolic

Elderly 140-160 systolic

70-90 diastolic

a. Ensure that the client is rested

b. Use appropriate size of BP cuff.

c. If too tight and narrow- false high BP

d. If too lose and wide-false low BP

e. Position the patient on sitting or supine position

f. Position the arm at the level of the heart, if the artery is below the heart level, you may get a false
high reading

g. Use the bell of the stethoscope since the blood pressure is a low frequency sound.

h. If the client is crying or anxious, delay measuring his blood pressure to avoid false-high BP

Electronic Vital Sign Monitor

a. An electronic vital signs monitor allows you to continually tract a patients vital

sign without having to reapply a blood pressure cuff each time.

b. Example: Dinamap VS monitor 8100

c. Lightweight, battery operated and can be attached to an IV pole

d. Before using the device, check the client7s pulse and BP manually using the same arm youll using for
the monitor cuff.

e. Compare the result with the initial reading from the monitor. If the results differ call the supply
department or the manufacturers representative.
V. Pain

How to assess Pain

a. You must consider both the patients description and your observations on his behavioral responses.

b. First, ask the client to rank his pain on a scale of 0-10, with 0 denoting lack of pain and 10 denoting
the worst pain imaginable.

c. Ask:

d. Where is the pain located?

e. How long does the pain last?

f. How often does it occur?

g. Can you describe the pain?

h. What makes the pain worse

i. Observe the patients behavioral response to pain (body language, moaning, grimacing, withdrawal,
crying, restlessness muscle twitching and immobility)

j. Also note physiological response, which may be sympathetic or parasympathetic

Managing Pain

1. Giving medication as per MDs order

2. Giving emotional support

3. Performing comfort measures

4. Use cognitive therapy

Height and weight

a. Height and weight are routinely measured when a patient is admitted to a health care facility.

b. It is essential in calculating drug dosage, contrast agents, assessing nutritional status and determining
the height-weight ratio.

c. Weight is the best overall indicator of fluid status, daily monitoring is important for clients receiving a
diuretics or a medication that causes sodium retention.

d. Weight can be measured with a standing scale, chair scale and bed scale.
e. Height can be measured with the measuring bar, standing scale or tape measure if the client is
confine in a supine position.

Pointers:

a. Reassure and steady patient who are at risk for losing their balance on a scale.

b. Weight the patient at the same time each day. (usually before breakfast), in similar clothing and using
the same scale.

c. If the patient uses crutches, weigh the client with the crutches or heavy clothing and subtract their
weight from the total determined patient weight.

Laboratory and Diagnostic examination

I. Urine Specimen

1.Clean-Catch mid-stream urine specimen for routine urinalysis, culture and sensitivity test

a. Best time to collect is in the morning, first voided urine

b. Provide sterile container

c. Do perineal care before collection of the urine

d. Discard the first flow of urine

e. Label the specimen properly

f. Send the specimen immediately to the laboratory

g. Document the time of specimen collection and transport to the lab.

h. Document the appearance, odor, and usual characteristics of the specimen.

2. 24-hour urine specimen

a. Discard the first voided urine.

b. Collect all specimen thereafter until the following day

c. Soak the specimen in a container with ice

d. Add preservative as ordered according to hospital policy

3. Second-Voided urine required to assess glucose level and for the presence of albumen in the urine.

a. Discard the first urine

b. Give the patient a glass of water to drink

c. After few minutes, ask the patient to void

4. Catheterized urine specimen

a. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate
specimen can be collected.

b. Clamping the drainage tube and emptying the urine into a container are contraindicated after a
genitourinary surgery.

II. Stool Specimen

1. Fecalysis to assess gross appearance of stool and presence of ova or parasite

a. Secure a sterile specimen container

b. Ask the pt. to defecate into a clean , dry bed pan or a portable commode.

c. Instruct client not to contaminate the specimen with urine or toilet paper( urine inhibits bacterial
growth and paper towel contain bismuth which interfere with the test result.

2. Stool culture and sensitivity test

To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics.

3. Fecal Occult blood test

are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer,

detecting melena stool

a. Hematest- (an Orthotolidin reagent tablet)

b. Hemoccult slide- (filter paper impregnated with guaiac)

Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours.

c. Colocare a newer test, requires no smear

Instructions:

a. Advise client to avoid ingestion of red meat for 3 days

b. Patient is advise on a high residue diet

c. avoid dark food and bismuth compound

d. If client is on iron therapy, inform the MD

e. Make sure the stool in not contaminated with urine, soap solution or toilet paper
f. Test sample from several portion of the stool.

Venipuncture

Pointers

a. Never collect a venous sample from the arm or a leg that is already being use d for I.V therapy or
blood administration because it mat affect the result.

b. Never collect venous sample from an infectious site because it may introduce pathogens into the
vascular system

c. Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular injury.

d. Dont wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine.

e. If the patient has a clotting disorder or is receiving anticoagulant therapy, maintain pressure on the
site for at least 5 min after withdrawing the needle.

Arterial puncture for ABG test

a. Before arterial puncture, perform Allens test first.

b. If the patient is receiving oxygen, make sure that the patients therapy has been underway for at least
15 min before collecting arterial sample

c. Be sure to indicate on the laboratory request slip the amount and type pf oxygen therapy the patient
is having.

d. If the patient has just receive a nebulizer treatment, wait about 20 minutes before collecting the
sample.

IV. Blood specimen

a. No fasting for the following tests:

- CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes

b. Fasting is required:

- FBS, BUN, Creatinine, serum lipid ( cholesterol, triglyceride)

V. Sputum Specimen

1.Gross appearance of the sputum

a. Collect early in the morning

b. Use sterile container

c. Rinse the mount with plain water before collection of the specimen

d. Instruct the patient to hack-up sputum

2. Sputum culture and sensitivity test

a. Use sterile container

b. Collect specimen before the first dose of antibiotic

3. Acid-Fast Bacilli

a. To assess presence of active pulmonary tuberculosis

b. Collect sputum in three consecutive morning

4. Cytologic sputum exam-

-to assess for presence of abnormal or cancer cells.

Diagnostic Test

1. PPD test

a. read result 48 72 hours after injection.

b. For HIV positive clients, induration of 5 mm is considered positive

2. Bronchography

a. Secure consent

b. Check for allergies to seafood or iodine or anesthesia

c. NPO 6-8 hours before the test

d. NPO until gag reflex return to prevent aspiration

3. Thoracentesis aspiration of fluid in the pleural space.

a. Secure consent, take V/S

b. Position upright leaning on overbed table

c. Avoid cough during insertion to prevent pleural perforation

d. Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity
e. Check for expectoration of blood. This indicate trauma and should be reported to MD immediately.

4.Holter Monitor

a. it is continuous ECG monitoring, over 24 hours period

b. The portable monitoring is called telemetry unit

5. Echocardiogram

a. ultrasound to assess cardiac structure and mobility

b. Client should remain still, in supine position slightly turned to the left side, with HOB elevated

15-20 degrees

6. Electrocardiography-

a. If the patients skin is oily, scaly, or diaphoretic, rub the electrode with a dry 4x4 gauze to enhance
electrode contact.

b. If the area is excessively hairy, clip it

c. Remove client`s jewelry, coins, belt or any metal

d. Tell client to remain still during the procedure

7. Cardiac Catheterization

a. Secure consent

b. Assess allergy to iodine, shelfish

c. V/S, weight for baseline information

d. Have client void before the procedure

e. Monitor PT, PTT, ECG prior to test

f. NPO for 4-6 hours before the test

g. Shave the groin or brachial area

h. After the procedure: bed rest to prevent bleeding on the site, do not flex extremity

i. Elevate the affected extremities on extended position to promote blood supply back to the heart and
prevent thrombplebities

j. Monitor V/S especially peripheral pulses

k. Apply pressure dressing over the puncture site

l. Monitor extremity for color, temperature, tingling to assess for impaired circulation.

8. MRI

m. secure consent,

n. the procedure will last 45-60 minute

o. Assess client for claustrophobia

p. Remove all metal items

q. Client should remain still

r. Tell client that he will feel nothing but may hear noises

s. Client with pacemaker, prosthetic valves, implanted clips, wires are not eligible for MRI.

t. Client with cardiac and respiratory complication may be excluded

u. Instruct client on feeling of warmth or shortness of breath if contrast medium is used during the
procedure

9.UGIS Barium Swallow

a. instruct client on low-residue diet 1-3 days before the procedure

b. administer laxative evening before the procedure

c. NPO after midnight

d. instruct client to drink a cup of flavored barium

e. x-rays are taken every 30 minutes until barium advances through the small bowel

f. film can be taken as long as 24 hours later

g. force fluid after the test to prevent constipation/barium impaction

10.LGIS Barium Enema

a. instruct client on low-residue diet 1-3 days before the procedure

b. administer laxative evening before the procedure

c. NPO after midnight

d. administer suppository in AM
e. Enema until clear

f. force fluid after the test to prevent constipation/barium impaction

11. Liver Biopsy

a. Secure consent,

b. NPO 2-4 hrs before the test

c. Monitor PT, Vit K at bedside

d. Place the client in supine at the right side of the bed

e. Instruct client to inhale and exhale deeply for several times and then exhale and hold breath while the
MD insert the needle

f. Right lateral post procedure for 4 hours to apply pressure and prevent bleeding

g. Bed rest for 24 hours

h. Observe for S/S of peritonitis

12. Paracentesis

a. Secure consent, check V/S

b. Let the patient void before the procedure to prevent puncture of the bladder

c. Check for serum protein. excessive loss of plasma protein may lead to hypovolemic shock.

13. Lumbar Puncture

a. obtain consent

b. instruct client to empty the bladder and bowel

c. position the client in lateral recumbemt with back at the edge of the examining table

d. instruct client to remain still

e. obtain specimen per MDs order

NURSING PROCEDURES

1. Steam Inhalation

a. It is dependent nursing function.

b. Heat application requires physicians order.

c. Place the spout 12-18 inches away from the clients nose or adjust the distance as necessary.

2. Suctioning

a. Assess the lungs before the procedure for baseline information.

b. Position: conscious semi-Fowlers

c. Unconscious lateral position

d. Size of suction catheter- adult- fr 12-18

e. Hyper oxygenate before and after procedure

f. Observe sterile technique

g. Apply suction during withdrawal of the catheter

h. Maximum time per suctioning 15 sec

3. Nasogastric Feeding (gastric gavage)

Insertion:

a. Fowlers position

b. Tip of the nose to tip of the earlobe to the xyphoid

Tube Feeding

a. Semi-Fowlers position

b. Assess tube placement

c. Assess residual feeding

d. Height of feeding is 12 inches above the tubes point of insertion

e. Ask client to remain upright position for at least 30 min.

f. Most common problem of tube feeding is Diarrhea due to lactose intolerance

4. Enema

a. Check MDs order

b. Provide privacy

c. Position left lateral

d. Size of tube Fr. 22-32

e. Insert 3-4 inches of rectal tube

f. If abdominal cramps occur, temporarily stop the flow until cramps are gone.

g. Height of enema can 18 inches

5. Urinary Catheterization

a. Verify MDs order

b. Practice strict asepsis

c. Perineal care before the procedure

d. Catheter size: male-14-16 , female 12 14

e. Length of catheter insertion

male 6-9 inches ,female 3-4 inches

For retention catheter:

Male anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure

Female- inner aspect of the thigh

6. Bed Bath

a. Provide privacy

b. Expose, wash and dry one body part a time

c. Use warm water (110-115 F)

d. Wash from cleanest to dirtiest

e. Wash, rinse, and dry the arms and leg using Long, firm strokes from distal to proximal area to
increase venous return.

7. Foot Care

a. Soaking the feet of diabetic client is no longer recommended

b. Cut nail straight across

8. Mouth Care

a. Eat coarse, fibrous foods (cleansing foods) such as fresh fruits and raw vegetables
b. Dental check every 6 mounts

9. Oral care for unconscious client

a. Place in side lying position

b. Have the suction apparatus readily available

10. Hair Shampoo

c. Place client diagonally in bed

d. Cover the eyes with wash cloth

e. Plug the ears with cotton balls

f. Massage the scalp with the fatpads of the fingers to promote circulation in the scalp.

11. Restraints

g. Secure MDs order for each episode of restraints application.

h. Check circulation every 30 min

i. Remove restraints at least every 2 hours for 30 minutes

COMMON THERAPEUTIC DIETS

1. CLEAR-LIQUID DIET

Purpose:

relieve thirst and help maintain fluid balance.

Use:

post-surgically and following acute vomiting or diarrhea.

Foods Allowed:

carbonated beverages; coffee (caffeinated and decaff.); tea; fruit-flavored drinks; strained fruit juices;
clear, flavored gelatins; broth, consomme; sugar; popsicles; commercially prepared clear liquids; and
hard candy.

Foods Avoided:

milk and milk products, fruit juices with pulp, and fruit.

2. FULL-LIQUID DIET
Purpose:

provide an adequately nutritious diet for patients who cannot chew or who are too ill to do so.

Use:

acute infection with fever, GI upsets, after surgery as a progression from clear liquids.

Foods Allowed:

clear liquids, milk drinks, cooked cereals, custards, ice cream, sherbets, eggnog, all strained fruit juices,
creamed vegetable soups, puddings, mashed potatoes, instant breakfast drinks, yogurt, mild cheese
sauce or pureed meat, and seasoning.

Foods Avoided:

nuts, seeds, coconut, fruit, jam, and marmalade

SOFT DIET

Purpose:

provide adequate nutrition for those who have troubled chewing.

Use:

patient with no teeth or ill-fitting dentures; transition from full-liquid to general diet; and for those

who cannot tolerate highly seasoned, fried or raw foods following acute infections or gastrointestinal

disturbances such as gastric ulcer or cholelithiasis.

Foods Allowed:

very tender minced, ground, baked broiled, roasted, stewed, or creamed beef, lamb, veal, liver,

poultry, or fish; crisp bacon or sweet bread; cooked vegetables; pasta; all fruit juices; soft raw fruits;

soft bread and cereals; all desserts that are soft; and cheeses.

Foods Avoided:

coarse whole-grain cereals and bread; nuts; raisins; coconut; fruits with small seeds; fried foods; high

fat gravies or sauces; spicy salad dressings; pickled meat, fish, or poultry; strong cheeses; brown or

wild rice; raw vegetables, as well as lima beans and corn; spices such as horseradish, mustard, and

catsup; and popcorn.

SODIUM-RESTRICTED DIET

Purpose:

reduce sodium content in the tissue and promote excretion of water.

Use:

heart failure, hypertension, renal disease, cirrhosis, toxemia of pregnancy, and cortisone therapy.

Modifications:

mildly restrictive 2 g sodium diet to extremely restricted 200 mg sodium diet.

Foods Avoided:

table salt; all commercial soups, including bouillon; gravy, catsup, mustard, meat sauces, and soy

sauce; buttermilk, ice cream, and sherbet; sodas; beet greens, carrots, celery, chard, sauerkraut, and

spinach; all canned vegetables; frozen peas;

all baked products containing salt, baking powder, or baking soda; potato chips and popcorn; fresh or

canned shellfish; all cheeses; smoked or commercially prepared meats; salted butter or margarine;

bacon, olives; and commercially prepared salad dressings.

RENAL DIET

Purpose:

control protein, potassium, sodium, and fluid levels in the body.

Use:

acute and chronic renal failure, hemodialysis.

Foods Allowed:

high-biological proteins such as meat, fowl, fish, cheese, and dairy products- range between 20 and

60 mg/day.

Potassium is usually limited to 1500 mg/day.

Vegetables such as cabbage, cucumber, and peas are lowest in potassium.

Sodium is restricted to 500 mg/day.

 Fluid intake is restricted to the daily volume plus 500 mL, which represents insensible water loss.

Fluid intake measures water in fruit, vegetables, milk and meat.

Foods Avoided:

Cereals, bread, macaroni, noodles, spaghetti, avocados, kidney beans, potato chips, raw fruit, yams,
soybeans, nuts, gingerbread, apricots, bananas, figs, grapefruit, oranges, percolated coffee, Coca-Cola,
orange crush, sport drinks, and breakfast drinks such as Tang or Awake

HIGH-PROTEIN, HIGH CARBOHYDRATE DIET

Purpose:

to correct large protein losses and raises the level of blood albumin. May be modified to include low-

fat, low-sodium, and low-cholesterol diets.

Use:

burns, hepatitis, cirrhosis, pregnancy, hyperthyroidism, mononucleosis, protein deficiency due to poor

eating habits, geriatric patient with poor intake; nephritis, nephrosis, and liver and gall bladder

disorder.

Foods Allowed:

general diet with added protein.

Foods Avoided:

restrictions depend on modifications added to the diet. The modifications are determined by the
patients condition.

PURINE-RESTRICTED DIET

Purpose:

designed to reduce intake of uric acid-producing foods.

Use:

high uric acid retention, uric acid renal stones, and gout.

Foods Allowed:

general diet plus 2-3 quarts of liquid daily.

Foods Avoided:
 cheese containing spices or nuts, fried eggs, meat, liver, seafood, lentils, dried peas and beans, broth,

bouillon, gravies, oatmeal and whole wheat, pasta, noodles, and alcoholic beverages. Limited

quantities of meat, fish, and seafood allowed.

BLAND DIET

Purpose:

provision of a diet low in fiber, roughage, mechanical irritants, and chemical stimulants.

Use:

Gastritis, hyperchlorhydria (excess hydrochloric acid), functional GI disorders, gastric atony, diarhhea,
spastic constipation, biliary indigestion, and hiatus hernia.

Foods Allowed:

varied to meet individual needs and food tolerances.

Foods Avoided:

fried foods, including eggs, meat, fish, and sea food; cheese with added nuts or spices; commercially

prepared luncheon meats; cured meats such as ham; gravies and sauces; raw vegetables;

potato skins; fruit juices with pulp; figs; raisins; fresh fruits; whole wheats; rye bread; bran cereals;

rich pastries; pies; chocolate; jams with seeds; nuts; seasoned dressings; caffeinated coffee; strong tea;

cocoa; alcoholic and carbonated beverages; and pepper.

LOW-FAT, CHOLESTEROL-RESTRICTED DIET

Purpose:

reduce hyperlipedimia, provide dietary treatment for malabsorption syndromes and patients having

acute intolerance for fats.

Use:

hyperlipedimia, atherosclerosis, pancreatitis, cystic fibrosis, sprue (disease of intestinal tract

characterized by malabsorption), gastrectomy, massive resection of small intestine, and cholecystitis.

Foods Allowed:

nonfat milk; low-carbohydrate, low-fat vegetables; most fruits; breads; pastas; cornmeal; lean meats;
nsaturated fats

Foods Avoided:

remember to avoid the five Cs of cholesterol- cookies, cream, cake, coconut, chocolate; whole milk

and whole-milk or cream products, avocados, olives, commercially prepared baked goods such as

donuts and muffins, poultry skin, highly marbled meats

butter, ordinary margarines, olive oil, lard, pudding made with whole milk, ice cream, candies with

chocolate, cream, sauces, gravies and commercially fried foods.

DIABETIC DIET

Purpose:

maintain blood glucose as near as normal as possible; prevent or delay onset of diabetic
complications.

Use:

diabetes mellitus

Foods Allowed:

choose foods with low glycemic index compose of:

a. 45-55% carbohydrates

b. 30-35% fats

c. 10-25% protein

coffee, tea, broth, spices and flavoring can be used as desired.

exchange groups include: milk, vegetable, fruits, starch/bread, meat (divided in lean, medium fat, and

high fat), and fat exchanges.

the number of exchanges allowed from each group is dependent on the total number of calories

allowed.

non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight diabetics.

Foods Avoided:
 concentrated sweets or regular soft drinks.

ACID AND ALKALINE DIET

Purpose:

Furnish a well balance diet in which the total acid ash is greater than the total alkaline ash each day.

Use:

Retard the formation of renal calculi. The type of diet chosen depends on laboratory analysis of the
stone.

Acid and alkaline ash food groups:

a. Acid ash: meat, whole grains, eggs, cheese, cranberries, prunes, plums

b. Alkaline ash: milk, vegetables, fruits (except cranberries, prunes and plums.)

c. Neutral: sugar, fats, beverages (coffee, tea)

Foods allowed:

Breads: any, preferably whole grain; crackers; rolls

Cereals: any, preferable whole grains

Desserts: angel food or sunshine cake; cookies made without baking powder or soda; cornstarch,

pudding, cranberry desserts, ice cream, sherbet, plum or prune desserts; rice or tapioca pudding.

Fats: any, such as butter, margarine, salad dressings, Crisco, Spry, lard, salad oil, olive oil, ect.

fruits: cranberry, plums, prunes

Meat, eggs, cheese: any meat, fish or fowl, two serving daily; at least one egg daily

Potato substitutes: corn, hominy, lentils, macaroni, noodles, rice, spaghetti, vermicelli.

Soup: broth as desired; other soups from food allowed

Sweets: cranberry and plum jelly; plain sugar candy

Miscellaneous: cream sauce, gravy, peanut butter, peanuts, popcorn, salt, spices, vinegar, walnuts.

Restricted foods:

no more than the amount allowed each day

1. Milk: 1 pint daily (may be used in other ways than as beverage)

2. Cream: 1/3 cup or less daily

3. Fruits: one serving of fruits daily( in addition to the prunes, plums and cranberries)

4. Vegetable: including potatoes: two servings daily

5. Sweets: Chocolate or candies, syrups.

6. Miscellaneous: other nuts, olives, pickles.

HIGH-FIBER DIET

Purpose:

Soften the stool

exercise digestive tract muscles

speed passage of food through digestive tract to prevent exposure to cancer-causing agents in food

lower blood lipids

prevent sharp rise in glucose after eating.

Use: diabetes, hyperlipedemia, constipation, diverticulitis, anticarcinogenics (colon)

Foods Allowed:

recommended intake about 6 g crude fiber daily

All bran cereal

Watermelon, prunes, dried peaches, apple with skin; parsnip, peas, brussels sprout, sunflower seeds.

LOW RESIDUE DIET

Purpose:

Reduce stool bulk and slow transit time

Use:

Bowel inflammation during acute diverticulitis, or ulcerative colitis, preparation for bowel surgery,

esophageal and intestinal stenosis.

Food Allowed:

eggs; ground or well-cooked tender meat, fish, poultry; milk, cheeses; strained fruit juice (except
prune): cooked or canned apples, apricots, peaches, pears; ripe banana; strained vegetable juice:

canned, cooked, or strained asparagus, beets, green beans, pumpkin, squash, spinach; white bread;

refined cereals (Cream of Wheat)

PRINCIPLES OF MEDICATION ADMINISTRATION

I - Six Rights of drug administration

1. The Right Medication when administering medications, the nurse compares the label of the
medication container with medication form.

The nurse does this 3 times:

a. Before removing the container from the drawer or shelf

b. As the amount of medication ordered is removed from the container

c. Before returning the container to the storage

2. Right Dose when performing medication calculation or conversions, the nurse should have another

qualified nurse check the calculated dose

3. Right Client an important step in administering medication safely is being sure the medication is

given to the right client.

a. To identify the client correctly:

b. The nurse check the medication administration form against the clients identification bracelet and
asks the client to state his or her name to ensure the clients identification bracelet has the correct
information.

4. RIGHT ROUTE if a prescribers order does nor designate a route of administration, the nurse consult
the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the
prescriber immediately.

5. RIGHT TIME

a. the nurse must know why a medication is ordered for certain times of the day and whether the

time schedule can be altered

b. each institution has are commended time schedule for medications ordered at frequent interval

c. Medication that must act at certain times are given priority (e.g insulin should be given at a
precise interval before a meal )

6. RIGHT DOCUMENTATION Documentation is an important part of safe medication administration

a. The documentation for the medication should clearly reflect the clients name, the name of the
ordered medication,the time, dose, route and frequency

b. Sign medication sheet immediately after administration of the drug

CLIENTS RIGHT RELATED TO MEDICATION ADMINISTRATION

A client has the following rights:

a. To be informed of the medications name, purpose, action, and potential undesired effects.

b. To refuse a medication regardless of the consequences

c. To have a qualified nurses or physicians assess medication history, including allergies

d. To be properly advised of the experimental nature of medication therapy and to give written consent
for its use

e. To received labeled medications safely without discomfort in accordance with the six rights of
medication administration

f. To receive appropriate supportive therapy in relation to medication therapy

g. To not receive unnecessary medications

II Practice Asepsis wash hand before and after preparing the medication to reduce transfer of
microorganisms.

III Nurse who administer the medications are responsible for their own action. Question any order that
you considered incorrect (may be unclear or appropriate)

IV Be knowledgeable about the medication that you administer

A FUNDAMENTAL RULE OF SAFE DRUG ADMINISTRATION IS: NEVER ADMINISTER AN UNFAMILIAR

MEDICATION
V Keep the Narcotics in locked place.

VI Use only medications that are in clearly labeled containers. Relabelling of drugs are the responsibility
of the pharmacist.

VII Return liquid that are cloudy in color to the pharmacy.

VIII Before administering medication, identify the client correctly

IX Do not leave the medication at the bedside. Stay with the client until he actually takes the
medications.

X The nurse who prepares the drug administers it.. Only the nurse prepares the drug knows what the
drug is. Do not accept endorsement of medication.

XI If the client vomits after taking the medication, report this to the nurse in-charge or physician.

XII Preoperative medications are usually discontinued during the postoperative period unless ordered
to be continued.

XIII- When a medication is omitted for any reason, record the fact together with the reason.

XIV When the medication error is made, report it immediately to the nurse in-charge or physician. To
implement necessary measures immediately. This may prevent any adverse effects of the drug.

Medication Administration

1. Oral administration

Advantages

a. The easiest and most desirable way to administer medication

b. Most convenient

c. Safe, does nor break skin barrier

d. Usually less expensive

Disadvantages

a. Inappropriate if client cannot swallow and if GIT has reduced motility

b. Inappropriate for client with nausea and vomiting

c. Drug may have unpleasant taste

d. Drug may discolor the teeth

e. Drug may irritate the gastric mucosa

f. Drug may be aspirated by seriously ill patient.

Drug Forms for Oral Administration

a. Solid: tablet, capsule, pill, powder

b. Liquid: syrup, suspension, emulsion, elixir, milk, or other alkaline substances.

c. Syrup: sugar-based liquid medication

d. Suspension: water-based liquid medication. Shake bottle before use of medication to properly mix it.

e. Emulsion: oil-based liquid medication

f. Elixir: alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before
giving water. This allows maximum absorption of the medication.

NEVER CRUSH ENTERIC-COATED OR SUSTAINED RELEASE TABLET

Crushing enteric-coated tablets allows the irrigating medication to come in contact with the oral or
gastric mucosa, resulting in mucositis or gastric irritation.

Crushing sustained-released medication allows all the medication to be absorbed at the same time,
resulting in a higher than expected initial level of medication and a shorter than expected duration of
action

2. SUBLINGUAL

a. A drug that is placed under the tongue, where it dissolves.

b. When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the
capsule and placed under the tongue.

c. A medication given by the sublingual route should not be swallowed, or desire effects will not be
achieved

Advantages:

a. Same as oral
b. Drug is rapidly absorbed in the bloodstream

Disadvantages

a. If swallowed, drug may be inactivated by gastric juices.

b. Drug must remain under the tongue until dissolved and absorbed

3. BUCCAL

a. A medication is held in the mouth against the mucous membranes of the cheek until the drug
dissolves.

b. The medication should not be chewed, swallowed, or placed under the tongue (e.g sustained release
nitroglycerine, opiates,antiemetics, tranquilizer, sedatives)

c. Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation

Advantages:

a. Same as oral

b. Drug can be administered for local effect

c. Ensures greater potency because drug directly enters the blood and bypass the liver

Disadvantages:

If swallowed, drug may be inactivated by gastric juice

4. TOPICAL Application of medication to a circumscribed area of the body.

1. Dermatologic includes lotions, liniment and ointments, powder.

a. Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking
an involved site, or locally debriding tissue.

b. Use surgical asepsis when open wound is present

c. Remove previous application before the next application

d. Use gloves when applying the medication over a large surface. (e.g large area of burns)

e. Apply only thin layer of medication to prevent systemic absorption.

2. Opthalmic - includes instillation and irrigation

a. Instillation to provide an eye medication that the client requires.

b. Irrigation To clear the eye of noxious or other foreign materials.

c. Position the client either sitting or lying.

d. Use sterile technique

e. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the
inner to the outer canthus

f. Instill eye drops into lower conjunctival sac.

g. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops need to be administered.
This is for proper absorption of the medication.

h. Avoid dropping a solution onto the cornea directly, because it causes discomfort.

i. Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication.

j. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds
to prevent systemic absorption of the medication.

3. Otic

Instillation to remove cerumen or pus or to remove foreign body

a. Warm the solution at room temperature or body temperature, failure to do so may cause vertigo,
dizziness, nausea and pain.

b. Have the client assume a side-lying position ( if not contraindicated) with ear to be treated facing up.

c. Perform hand hygiene. Apply gloves if drainage is present.

d. Straighten the ear canal:

0-3 years old: pull the pinna downward and backward

Older than 3 years old: pull the pinna upward and backward

e. Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust
to body temperature

f. Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the
ear canal.
g. Ask the client to remain in side lying position for about 5 minutes

h. At times the MD will order insertion of cotton puff into outermost part of the canal.Do not press
cotton into the canal. Remove cotton after 15 minutes.

4. Nasal Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous
membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or
sinuses. Decongestants, steroids, calcitonin.

a. Have the client blow the nose prior to nasal instillation

b. Assume a back lying position, or sit up and lean head back.

c. Elevate the nares slightly by pressing the thumb against the clients tip of the nose. While the client
inhales, squeeze the bottle.

d. Keep head tilted backward for 5 minutes after instillation of nasal drops.

e. When the medication is used on a daily basis, alternate nares to prevent irritations

5. Inhalation use of nebulizer, metered-dose inhaler

a. Simi or high-fowlers position or standing position. To enhance full chest expansion allowing deeper
inhalation of the medication

b. Shake the canister several times. To mix the medication and ensure uniform dosage delivery

c. Position the mouthpiece 1 to 2 inches from the clients open mouth. As the client starts inhaling, press
the canister down to release one dose of the medication. This allows delivery of the medication more
accurately into the bronchial tree rather than being trapped in the oropharynx then swallowed

d. Instruct the client to hold breath for 10 seconds. To enhance complete absorption of the medication.

e. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second interval. Administer

bronchodilator before other inhaled medication. This opens airway and promotes greater absorption of
the medication.

f. Wait at least 1 minute before administration of the second dose or inhalation of a different
medication by MDI

g. Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.

6. Vaginal drug forms: tablet liquid (douches). Jelly, foam and suppository.

a. Close room or curtain to provide privacy.

b. Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal
canal, also allows suppository to dissolve without escaping through orifice.

c. Use applicator or sterile gloves for vaginal administration of medications.

Vaginal Irrigation is the washing of the vagina by a liquid at low pressure. It is also called douche.

a. Empty the bladder before the procedure

b. Position the client on her back with the hips higher than the shoulder (use bedpan)

c. Irrigating container should be 30 cm (12 inches) above

d. Ask the client to remain in bed for 5-10 minute following administration of vaginal suppository,
cream, foam, jelly or irrigation.

7. RECTAL can be use when the drug has objectionable taste or odor.

a. Need to be refrigerated so as not to soften.

b. Apply disposable gloves.

c. Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal
sphincter.

d. Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4
inches) in adults, 5 cm (2 in) in children and infants. May need to apply gentle pressure to hold buttocks
together momentarily.

e. Discard gloves to proper receptacle and perform hand washing.

f. Client must remain on side for 20 minute after insertion to promote adequate absorption of the
medication.

8. PARENTERAL- administration of medication by needle.

Intradermal under the epidermis.

a. The site are the inner lower arm, upper chest and back, and beneath the scapula.

b. Indicated for allergy and tuberculin testing and for vaccinations.

c. Use the needle gauge 25, 26, 27: needle length 3/8, 5/8 or

d. Needle at 1015 degree angle; bevel up.

e. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or bleb.
f. Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the
drug into the subcutaneous.

Subcutaneous vaccines, heparin, preoperative medication, insulin, narcotics.

The site:

outer aspect of the upper arms

anterior aspect of the thighs

Abdomen

Scapular areas of the upper back

Ventrogluteal

Dorsogluteal

a. Only small doses of medication should be injected via SC route.

b. Rotate site of injection to minimize tissue damage.

c. Needle length and gauge are the same as for ID injections

d. Use 5/8 needle for adults when the injection is to administer at 45 degree angle; is use at a 90
degree angle.

e. For thin patients: 45 degree angle of needle

f. For obese patient: 90 degree angle of needle

g. For heparin injection:

h. do not aspirate.

i. Do not massage the injection site to prevent hematoma formation

j. For insulin injection:

k. Do not massage to prevent rapid absorption which may result to hypoglycemic reaction.

l. Always inject insulin at 90 degrees angle to administer the medication in the pocket between the
subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.
m. For other medications, aspirate before injection of medication to check if the blood vessel had been
hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the
medication and equipment.

Intramuscular

a. Needle length is 1, 1 , 2 to reach the muscle layer

b. Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area.

c. Inject the medication slowly to allow the tissue to accommodate volume.

Sites:

Ventrogluteal site

a. The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it
less contaminated.

b. Position the client in prone or side-lying.

c. When in prone position, curl the toes inward.

d. When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and
minimize discomfort during injection.

e. To locate the site, place the heel of the hand over the greater trochanter, point the index finger
toward the anterior superior iliac spine, then abduct the middle (third) finger. The triangle formed by
the index finger, the third finger and the crest of the ilium is the site.

Dorsogluteal site

a. Position the client similar to the ventrogluteal site

b. The site should not be use in infant under 3 years because the gluteal muscles are not well developed
yet.

c. To locate the site, the nursedraw an imaginary line from the greater trochanter to the posterior
superior iliac spine. The injection site id lateral and superior to this line.

d. Another method of locating this site is to imaginary divide the buttock into four quadrants. The upper
most quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is high
enough.

e. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.

Vastus Lateralis
a. Recommended site of injection for infant

b. Located at the middle third of the anterior lateral aspect of the thigh.

c. Assume back-lying or sitting position.

Rectus femoris site located at the middle third, anterior aspect of thigh.

Deltoid site

a. Not used often for IM injection because it is relatively small muscle and is very close to the radial
nerve and radial artery.

b. To locate the site, palpate the lower edge of the acromion process and the midpoint on the lateral
aspect of the arm that is in line with the axilla. This is approximately 5 cm (2 in) or 2 to 3 fingerbreadths
below the acromion process.

IM injection Z tract injection

a. Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent
staining of the skin.

b. Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is
withdrawn

c. Do not massage the site of injection to prevent leakage into the subcutaneous.

GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION OF MEDICATIONS

1. Check doctors order.

2. Check the expiration for medication drug potency may increase or decrease if outdated.

3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful.client
may have anxiety, which can increase the pain.

4. Practice asepsis to prevent infection. Apply disposable gloves.

5. Use appropriate needle size. To minimize tissue injury.

6. Plot the site of injection properly. To prevent hitting nerves, blood vessels, bones.

7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.

8. Introduce air into the vial before aspiration. To create a positive pressure within the vial and allow
easy withdrawal of the medication.
9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.

10. Introduce the needle in quick thrust to lessen discomfort.

11. Either spread or pinch muscle when introducing the medication. Depending on the size of the client.

12. Minimized discomfort by applying cold compress over the injection site before introduction of
medicati0n to numb nerve endings.

13. Aspirate before the introduction of medication. To check if blood vessel had been hit.

14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling
tissues as needle is withdrawn.

15. Massage the site of injection to haste absorption.

16. Apply pressure at the site for few minutes. To prevent bleeding.

17. Evaluate effectiveness of the procedure and make relevant documentation.

Intravenous

The nurse administers medication intravenously by the following method:

1. As mixture within large volumes of IV fluids.

2. By injection of a bolus, or small volume, or medication through an existing intravenous infusion line or
intermittent venous access (heparin or saline lock)

3. By piggyback infusion of solution containing the prescribed medication and a small volume of IV
fluid through an existing IV line.

a. Most rapid route of absorption of medications.

b. Predictable, therapeutic blood levels of medication can be obtained.

c. The route can be used for clients with compromised gastrointestinal function or peripheral circulation.

d. Large dose of medications can be administered by this route.

e. The nurse must closely observe the client for symptoms of adverse reactions.

f. The nurse should double-check the six rights of safe medication.

g. If the medication has an antidote, it must be available during administration.

h. When administering potent medications, the nurse assesses vital signs before, during and after
infusion.
Nursing Interventions in IV Infusion

a. Verify the doctors order

b. Know the type, amount, and indication of IV therapy.

c. Practice strict asepsis.

d. Inform the client and explain the purpose of IV therapy to alleviate clients anxiety.

e. Prime IV tubing to expel air. This will prevent air embolism.

f. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to
prevent infection.

g. Shave the area of needle insertion if hairy.

h. Change the IV tubing every 72 hours. To prevent contamination.

i. Change IV needle insertion site every 72 hours to prevent thrombophlebitis.

j. Regulate IV every 15-20 minutes. To ensure administration of proper volume of IV fluid as

ordered.

k. Observe for potential complications.

Types of IV Fluids

Isotonic solution has the same concentration as the body fluid

a. D5 W

b. Na Cl 0.9%

c. plainRingers lactate

d. Plain Normosol M

Hypotonic has lower concentration than the body fluids.

a. NaCl 0.3%

Hypertonic has higher concentration than the body fluids.

a. D10W

b. D50W
c. D5LR

d. D5NM

Complication of IV Infusion

1. Infiltration the needle is out of nein, and fluids accumulate in the subcutaneous tissues.

Assessment:

Pain, swelling, skin is cold at needle site, pallor of the site, flow rate has decreases or stops.

Nursing Intervention:

Change the site of needle

Apply warm compress. This will absorb edema fluids and reduce swelling.

2. Circulatory Overload -Results from administration of excessive volume of IV fluids.

Assessment:

Headache

Flushed skin

Rapid pulse

Increase BP

Weight gain

Syncope and faintness

Pulmonary edema

Increase volume pressure

SOB

Coughing

Tachypnea

shock

Nursing Interventions:

Slow infusion to KVO

 Place patient in high fowlers position. To enhance breathing

Administer diuretic, bronchodilator as ordered

3. Drug Overload the patient receives an excessive amount of fluid containing drugs.

Assessment:

Dizziness

Shock

Fainting

Nursing Intervention

Slow infusion to KVO.

Take vital signs

Notify physician

4. Superficial Thrombophlebitis it is due to o0veruse of a vein, irritating solution or drugs, clot

formation, large bore catheters.

Assessment:

Pain along the course of vein

Vein may feel hard and cordlike

Edema and redness at needle insertion site.

Arm feels warmer than the other arm

Nursing Intervention:

Change IV site every 72 hours

Use large veins for irritating fluids.

Stabilize venipuncture at area of flexion.

Apply cold compress immediately to relieve pain and inflammation; later with warm compress to
stimulate circulation and promotion absorption.
 Do not irrigate the IV because this could push clot into the systemic circulation

5. Air Embolism Air manages to get into the circulatory system; 5 ml of air or more causes air

embolism.

Assessment:

Chest, shoulder, or backpain

Hypotension

Dyspnea

Cyanosis

Tachycardia

Increase venous pressure

Loss of consciousness

Nursing Intervention

Do not allow IV bottle to run dry

Prime IV tubing before starting infusion.

Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of the heart.
This prevent pulmonary embolism.

6. Nerve Damage may result from tying the arm too tightly to the splint.

Assessment

Numbness of fingers and hands

Nursing Interventions

Massage the are and move shoulder through its ROM

Instruct the patient to open and close hand several times each hour.

Physical therapy may be required

Note: apply splint with the fingers free to move.

7. Speed Shock may result from administration of IV push medication rapidly.

To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3 to 5 minutes.
BLOOD TRANSFUSION THERAPY

Objectives:

1. To increase circulating blood volume after surgery, trauma, or hemorrhage

2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia

3. To provide selected cellular components as replacements therapy (e.g clotting factors, platelets,
albumin)

Nursing Interventions:

a. Verify doctors order. Inform the client and explain the purpose of the procedure.

b. Check for cross matching and typing. To ensure compatibility

c. Obtain and record baseline vital signs

d. Practice strict Asepsis

e. At least 2 licensed nurse check the label of the blood transfusion

Check the following:

Serial number

Blood component

Blood type

Rh factor

Expiration date

Screening test (VDRL, HBsAg, malarial smear)

- this is to ensure that the blood is free from blood-carried diseases and therefore, safe from
transfusion.

f. Warm blood at room temperature before transfusion to prevent chills.

g. Identify client properly. Two Nurses check the clients identification.

h. Use needle gauge 18 to 19. This allows easy flow of blood.

j.Use BT set with special micron mesh filter. To prevent administration of blood clots and particles.

k. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually
occurs during the first 15 to 20 minutes.
l. Monitor vital signs. Altered vital signs indicate adverse reaction.

Do not mixed medications with blood transfusion. To prevent adverse effects

Do not incorporate medication into the blood transfusion

Do not use blood transfusion line for IV push of medication.

m. Administer 0.9% NaCl before, during or after BT. Never administer IV fluids with dextrose. Dextrose
causes hemolysis.

n. Administer BT for 4 hours (whole blood, packed rbc). For plasma, platelets, cryoprecipitate, transfuse
quickly (20 minutes) clotting factor can easily be destroyed.

Complications of Blood Transfusion

1. Allergic Reaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with
recipient antigen.

Assessments

Flushing

Rush, hives

Pruritus

Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells, platelets or plasma

proteins. This is the most symptomatic complication of blood transfusion

Assessments:

Sudden chills and fever

Flushing

Headache

Anxiety

3. Septic Reaction it is caused by the transfusion of blood or components contaminated with bacteria.

Assessment:

Rapid onset of chills

Vomiting
 Marked Hypotension

High fever

4. Circulatory Overload it is caused by administration of blood volume at a rate greater than the
circulatory system can accommodate.

Assessment

Rise in venous pressure

Dyspnea

Crackles or rales

Distended neck vein

Cough

Elevated BP

5. Hemolytic reaction. It is caused by infusion of incompatible blood products.

Assessment

Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.

Chills

Feeling of fullness

Tachycardia

Flushing

Tachypnea

Hypotension

Bleeding

Vascular collapse

Acute renal failure

Nursing Interventions when complications occurs in Blood transfusion

1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.

2. Start IV line (0.9% Na Cl)

3. Place the client in fowlers position if with SOB and administer O2 therapy.

4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often
as every 5 minutes.

5. Notify the physician immediately.

6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and
steroids as per physicians order or protocol.

7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result
of RBC hemolysis.

8. Blood container, tubing, attached label, and transfusion record are saved and returned to the
laboratory for analysis

Diagnostic Exam For Students

1. Ella, is a nurse working in Mayamot Hospital and has an order to obtain a 24 hour urine collection on
a client with a renal disorder. Nurse Ella avoids which of the following to ensure proper collection of the
24 hour specimen?

A. Have the client void at the start time and place this specimen in the container

B. Save all subsequent voidings during the 24 hour period

C. Place the container on ice, or in a refrigerator

D. Have the client void at the end time and place this specimen in the container

2. Nurse Ella is inserting an indwelling urinary catheter into a male client. As she inflates the balloon, the
client complains of discomfort. The nurse:

A. Removes the syringe from the balloon because discomfort is normal and temporary

B. Aspirates the fluid, advances the catheter farther, then reinflates the balloon

C. Aspirates the fluid, withdraws the catheter slightly and then reinflates the balloon

D. Aspirates the fluid, removes the catheter and reinsert a new catheter

3. Nurse Carlito is caring for a client who has returned to a surgical unit from a critical care unit after
having pelvic exenteration. The client complains of pain in the calf area. Nurse Carlito would:

A. Administer meperidine hydrochloride ( Demerol ) As prescribed

B. Check the calf for temperature, color and size

C. Lightly massage the area to relieve the pain

D. Ask the client to walk and observe the gait

4. A nurse assesses the peripheral IV site dressing and notes that it is damp and the tape is loose. The
first most appropriate nursing action is to:

A. Stop the infusion immediately and notify the physician

B. Check that the tubing is securely attached to the catheter and redress the site

C. Increase the IV flor rate to assess for further leaking

D. Remove the tape, slow the IV rate and then discontinue the IV

5. A nurse has just inserted an indwelling foley catheter into the bladder of a post operative client who
has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection
bag is hung on the bed frame, the nurse notices that 750 ml of urine has drained into the collection bag.
To ensure safety of the client is is best to:

A. Clamp the tubing for 30 minutes and then release

B. Provide suprapubic pressure to maintain a steady flow of urine

C. Check the urine specific gravity

D. Raise the collection bag high enough to slow the rate of drainage

6. A nurse is giving bed bath to a client who is on strict bed rest. To increase venous return, the nurse
bathes the clients extremities using:

A. Long firm stroke, from distal to proximal areas

B. Firm circular stroke, from proximal to distal areas

C. Short patting strokes, from distal to proximal areas

D. Smooth light strokes, back and forth from proximal to distal areas
7. A nurse is preparing to give an intramuscular injection that is irritating to the subcutaneous tissues.
The drug reference recommends that it be given using the Z-Track technique. The nurse avoids which of
the following with this administration technique.

A. Prepares a 0.2mL air lock in the syringe after drawing up the medication

B. Massage the site after injecting the medication

C. Attach a new sterile needle to the syringe after drawing up the medication

D. Retract the skin to the side before piercing the skin with the needle

8. A nurse has an order to infuse a unit of blood. The nurse checks the clients IV line to make sure that
the gauge of the intravenous catheter is atleast:

A. 14 B. 19 C. 22 D. 24

9. The Gauge of an IV catheter determines the:

A. The external circumference of the tube C. the length of the tube

B. The internal diameter of the tube D. the tubes volumetric capacity

10. The nurse is correct in performing suctioning when she applies the suction intermittently during:

A. Insertion of the suction catheter

B. Withdrawing of the suction catheter

C. both insertion and withdrawing of the suction catheter

D. When the suction catheter tip reaches the bifurcation of the trachea

11. The purpose of the cuff in Tracheostomy during mechanical ventilation is:

A. Separate the upper and lower airway

B. Separate trachea from the esophagus

C. Separate the larynx from the nasopharynx

D. Secure the placement of the tube

12. A nurse is developing a plan of care for an elderly client and includes strategies that will facilitate
effective communication. The nurse would include which strategy to accomplish this goal?

A. Use an authoritarian approach C. React enthusiastically during the conversation

B. Use active listening D. React only to the facts during conversation

13. When examining a client with abdominal pain, the nurse should assess:

A. any quadrant first. C. the symptomatic quadrant last.

B. the symptomatic quadrant first. D. the symptomatic quadrant either second or third.

14. When performing an abdominal assessment, the nurse should follow which examination sequence?

A. Inspection, auscultation, percussion, and palpation

B. Inspection, percussion, palpation, and auscultation

C. Inspection, auscultation, palpation, and percussion

D. Inspection, palpation, percussion, and auscultation

15. Which of the following factors would have the most influence on the outcome of a crisis situation?

A. Age C. Previous coping skills

B. Self esteem D. Perception of the problem

16. A client's blood test results are as follows: white blood cell (WBC) count is 10,000/l; hemoglobin
(Hb) level, 14 g/dl; hematocrit (HCT), 42%, Platelet count is : 100,000/l. Which of the following goals
would be most important for this client?

A. Promote fluid balance. B. Prevent infection. C. Promote rest. D. Prevent injury.

17. Luisito Geron is a client who suffered a cerebrovascular accident (CVA) has a nursing diagnosis of
Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which
intervention would help meet this goal?
A. Repositioning the client every 2 hours

B. Administering oxygen by cannula as ordered

C. Restricting fluids to 1,000 ml/24 hours

D. Keeping the head of the bed at a 30-degree angle

18. Aling Lorena is a client with terminal breast cancer is being cared for by a long-time friend who's a
physician. The client has identified her twin sister as the agent in her durable power of attorney. The
client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different
physician caring for my sister now. I've dismissed her friend." In response, the nurse should:

A. inform the sister that she doesn't have the power to assign a different physician.

B. ask the dismissed physician if the client ever stated she wanted a different physician.

C. Abide by the wishes of the sister who is the durable power of attorney agent.

D. politely ignore the sister's statement and continue to call the dismissed physician for orders.

19. For the past few days, a client has been having calf pain and notices that the painful calf is larger
than the other one. The right calf is red, warm, achy, and tender to touch. Which of the following
questions about the pain should the nurse include in the assessment?

A. "Does the pain worsen in the morning upon rising?"

B. "Does the pain increase with activity and lessen with rest?"

C. "Is the pain relieved by position changes?"

D. "Is the pain worse with the toes pointed toward the knee?"

20. For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of
600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which
nursing diagnosis?

A. Impaired urinary elimination C. Imbalanced nutrition

B. Deficient fluid volume D. Excessive fluid volume

21. Mr. Medrano is a client who received general anesthesia returns from surgery. Postoperatively,
which nursing diagnosis takes highest priority for this client?

A. Pain related to surgery

B. Deficient fluid volume related to blood and fluid loss from surgery

C. Impaired physical mobility related to surgery

D. Risk for aspiration related to anesthesia

22. As a nurse must verify the client's identity before administering medication. The safest way to verify
identity is to:

A. ask the client his name.

B. state the client's name aloud and have the client repeat it.

C. check the client's identification band.

D. check the room number and the client's name on the bed.

23. A medication order reads "Meperidine 1 ml I.M. stat." The nurse responsible for administering the
drug should base the next action on which understanding?

A. The order should specify the exact time to give the drug.

B. The ordered route is inappropriate for this drug.

C. The order should be clarified with the physician.

D. The order is correct and valid.

24. Meperidine will cause which of the following side effect?

A. Lethargy B. Tachypnea C. Diarrhea D. Spastic bladder

25. The physician orders chest physiotherapy for a client with respiratory congestion. When should the
nurse plan to perform chest physiotherapy?

A. After meals C. Before meals

B. When the client has time D. When the nurse has time

26. You are the assigned nurse to care for a client with a tracheostomy tube. How can the nurse
communicate with this client?

A. By providing a tracheostomy plug to use for verbal communication

B. By placing the call button under the client's pillow

C. By supplying a magic slate or similar device

D. By suctioning the client frequently

27. A client with a fecal impaction frequently exhibits which clinical manifestation?

A. Liquid or semiliquid stools C. Loss of urge to defecate

B. Hard, brown, formed stools D. Increased appetite

28. In recording the clients Temperature and Pulse, the nurse uses forms that allows her to record
specific measurements or observation on repeated basis. The best way to record this is using which of
the following?

A. Kardex C. SOAPIER

B. Flowsheets D. Problem Oriented Record

29. Which of the following is not true with regards to the nursing kardex?

A. A concise method of organizing data consisting of series of cards kept in portable index file

B. Consists of nursing care plan

C. Has a list of diagnostic procedures to be done

D. The entries are in pencil if kardex is decided to be a permanent part of the clients record

30. SOAP format is used to write progress notes. Which of the following is not included in SOAP
charting?

A. S for subjective cues C. A for Adequate data base

B. O for objective cues D. P for Plan

31. To give nursing care to a client, the nurse must first:

A. Understand the clients emotional conflict

B. Develop rapport with the clients physician

C. Recognize personal feelings toward this client

D. Talk with the clients family or significant others

32. Which of the following statement is true with regards to the nursing process?

A. It is useful mainly in outpatient setting

B. It focuses on the patient, not the nurse

C. It progresses in separate unrelated steps

D. It provides solution to all patient health problems

33. The patient is to have an X-ray study of the gallbladder, the nurse tells the patient that he will be
having a:

A. Cholangiography C. Cholecystography

B. Cholecystectomy D. Choledocolithotomy

34. The nurse is aware that in wound dehiscence:

A. Wounds are completely healed

B. Opened, showing the internal organs

C. Opening of a previously intact suture line

D. Purulent drainage coming from it

35. A quality assurance nurse performs a chart review to determine how many facility patients with
surgical incisions are currently experiencing wound infections. This chart review is an example of which
kind of nursing audit?

A. Concurrent C. Terminal

B. Retrospective D. Prospective

36. Which of the following is an incorrect assessment documentation?

A. Client states It hurts right here C. BP of 120/80 mmHg

B. Client is febrile D. Hemovac output of 40 ml

37. Which of the following is a correctly written actual nursing diagnosis?

A. Impaired physical mobility as evidenced by decreased range of motion in left shoulder from 180
degrees to 190 degrees of flexion and extension related to left shoulder pain

B. Ineffective airway clearance related to thickened bronchial secretions as evidenced by adventitious

lung sounds over the periphery of the right and left lung field

C. Potential for altered nutrition less than body requirements as evidenced by a 15 lb weight loss in 3
weeks

D. Risk for injury related to decreased oxygen level in the blood as evidenced by irritability and
restlessness

38. Which intervention is an example of primary prevention?

A. Administering digoxin (Lanoxicaps) to a client with heart failure

B. Administering a measles, mumps, and rubella immunization to an infant

C. Obtaining a Papanicolaou (PAP) test to screen for cervical cancer

D. Using occupational therapy to help a client cope with arthritis

39. The nurse is revising a client's plan of care. During which step of the nursing process does such
revision take place?
A. Assessment B. Planning C. Implementation D. Evaluation

40.What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

A. Deficient fluid volume C. Decreased cardiac output

B. Excessive fluid volume D. Ineffective tissue perfusion

41. A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which
nursing diagnosis takes highest priority for this client?

A. Excessive fluid volume related to intracellular fluid shift

B. Imbalanced nutrition: Less than body requirements related to decreased intake

C. Deficient fluid volume related to nausea and vomiting

D. Ineffective cardiopulmonary tissue perfusion related to hyperventilation

42. Mr. Gapos is a blind client, and is admitted for treatment of gastroenteritis. Which nursing diagnosis
takes highest priority for this client?

A. Anxiety C. Risk for injury

B. Activity intolerance D. Impaired physical mobility

43. Each morning, the nurse-manager assigns clients and additional tasks for the staff nurses to
complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the
additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to
explain, the nurse-manager interrupts, saying that the tasks should have been completed anyway.
Which leadership style is the nurse-manager exhibiting?

A. Authoritarian B. Democratic C. Participative D. Laissez faire

44. A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells
the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurse should
formulate which nursing diagnosis?

A. Deficient knowledge related to food restrictions associated with anesthesia

B. Fear related to surgery

C. Risk for impaired skin integrity related to upcoming surgery

D. Ineffective individual coping related to the stress of surgery

45. Mr Miguel Delos Angeles is a client who received general anesthesia returns from surgery.
Postoperatively, which nursing diagnosis takes highest priority for this client?

A. Pain related to surgery

B. Deficient fluid volume related to blood and fluid loss from surgery

C. Impaired physical mobility related to surgery

D. Risk for infection related to anesthesia

46. A client receiving care from a home health agency asks the visiting nurse about a living will. The
client is unsure about what is included in this document. The nurse understands that living will is a:

A. Legally binding contract between a client and the physician

B. Document that establishes who will make health care decisions for you if you are not able

C. Document that verifies the client wish for do not resuscitate status while under the care of a health
care provider

D. Document that allows the client to express any wishes regarding health care decision

47. The nurse is aware that a durable power of attorney for health care allows the designated decision-
maker to:

A. Refuse treatment for the client

B. Access clients finances to assure payment for health care

C. Be the executor of the clients estate

D. Agree to active euthanasia when there is no chance of recovery for the client
48. The nurses home-care client is returning from skilled nursing care facility following rehabilitation
from CVA and now walks with a walker. The nurse rearranges the furniture, remove throw rugs and has
grab bars installed in the clients bathroom. These actions reflect the nurses attention to which ethical
principle?

A. Beneficence B. Nonmaleficence C. Fidelity D. Justice

49. The nurse knows that informed consent is based in the ethical principle of:

A. Paternalism and fidelity C. Autonomy and benificence

B. Veracity and nonmaleficence D. Justice and legal obligation

50. An imbecile, insane or a child below 9 years of age who commits a crime cannot be held liable
because of what circumstance?

A. Aggravating circumstance C. Justifying circumstance

B. Exempting circumstance D. Mitigating circumstance

51. Marnie killed her 1 year old infant. She told the police that it is the best thing to do since she cannot
feed the baby anymore because she got laid off from her work. You know that Marnie is guilty of which
crime?

A. Parricide B. Homicide C. Infanticide D. Murder

52. You committed a mistake in your entry in the nurses progress notes. Which of the following
measures should you observe?

A. Cross out the incorrect entry with a vertical line and write the word error on top

B. Erase the entry and write the word error

C. Cross out the incorrect entry with a single horizontal line and write the word error on top

D. Erase the entry with a liquid corrector

53. When making an occupied bed, which of the principles should you observe in maintaining a proper
body mechanics?

A. Use the weight of your body to help pull the patient

B. Spread your legs to provide a narrow support base

C. Bend at your back when lifting the patient

D. When lifting an object, stand far from the object

54. When teaching a client with peripheral vascular disease about foot care, the nurse should include
which instruction?

A. Avoid using cornstarch on the feet. C. avoid using a nail clipper to cut toenails

B. Avoid wearing cotton socks. D. avoid wearing canvas shoes

55. A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The
nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the
following items?

a. Tightness of tubing connections C. expiration date on bag

b. Client's temperature D. time of last dressing change

56. How long will a nurse obtain an accurate reading of temperature via oral route?

A. 1 minute C. 5 minutes

B. 3 minutes D. 8 minutes

57. If a document such as the patient chart will be needed in the court to prove the commission of
negligence by the nurse, the court will be issuing which order?

A. Subpoena C. Subpoena Duces Tecum

B. Subpoena Ad Testificandum D. Summon

58. The one filing the criminal case against an accused party is said to be the:

A. Defendant C. Accused

B. Witness D. Plaintiff

59. If Agatha, an OB nurse refer Christina to an abortionist, she will be considered as a/an:

A. Accomplice C. Co-principal

B. Principal D. Accessory

60. Nestor hid the evidences after the abortion has been committed, in his act, he committed a felony
and he is classified as the:

A. Accomplice C. Co-principal

B. Principal D. Accessory

61. If a criminal act is incompletely performed due to factors other than his own determination, the act
is said to be:

A. Consummated C. Attempted

B. Frustrated D. Converted

62. This quality is being demonstrated by a Nurse who raise the side rails of a confuse and disoriented
patient?

A. Autonomy B. Responsibility C. Prudence D. Resourcefulness

63. Nurse Joel and Ana is helping a 16 year old Nursing Student in a case filed against the student. The
case was frustrated homicide. Nurse Joel and Ana are aware of the different circumstances of crimes.
They are correct in identifying which of the following Circumstances that will be best applied in this
case?
A. Justifying B. Aggravating C. Mitigating D. Exempting

64. Mrs. Marquez, 50 year old and member of the Board of nursing leaked the questions to her daughter
Ivy, who managed to enter the topnotcher list ranking 4th with a rating of 86% among 50,000
examinees. You understand that the circumstance of this said act is:

A. Mitigating C. Aggravating

B. Exempting D. Justifying

65. Mang Carlos has been terminally ill for 5 years. He asked his wife to decide for him when he is no
longer capable to do so. As a Nurse, You know that this is called:

A. Last will and testament C. living will

B. DNR D. durable power of attorney

66. Mang Carlos has a standing DNR order. He then suddenly stopped breathing and you are at his
bedside. You would:

A. Give extraordinary measures to save Mang Carlos

B. Stay with Mang Carlos and Do nothing

C. Call the physician

D. Activate Code Blue

67. Mr. BBB was diagnosed with Alzheimer s disease. He specified his wishes regarding health care
decision because he fears that he will unable to make a decision due to the terminal state of his Disease.
The nurse knows that this kind of advance directive is called:

A. Durable Power Of Attorney C. last will and testament

B. A Will D. living will

68. In an attempt to be a change agent of an Alcoholic client, Which of the following is the most
important?
A. Awareness of the problem and how it negatively affects his life

B. The ability to change his lifestyle and increase his level of wellness

C. The client stated I will stop drinking alcohol from now on

D. Financial capability and Support system

69. You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and
tell you that the client from the other room was in Pain. The best intervention in such case is:

A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in
pain to give the PRN medication

B. Tell the nursing assistant to give the pain medication to the client complaining of pain

C. Tell the nursing assistant to go the clients room and tell the client to wait

D. Finish the bed bath quickly then rush to the client in Pain

70. Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the following is
the best nursing intervention to prevent future falls?

A. Tell Angie not to get up from bed unassisted

B. Put the call bell within her reach

C. Put bedside commode at the bedside to prevent Angie from getting up

D. Put the bed in the lowest position

71. In conflict resolution, when one person neglects his own need to give way to another party, the
conflict resolution used was:

A. Accomodation B. Collaboration C. Compromise D. Avoidance

72. Which of the following conflict resolution method creates a LOSE LOSE scenario?

A. Accomodation B. Collaboration C. Compromise D. Competition

73. Setting up organizational structure, identifying groupings, roles and relationships are all included in
which phase of the management process?

A. Planning B. Organizing C. Directing D. Controlling

74. Coordinating nursing personnel, supervising and harmonizing goals thru guidance are all seen in
which phase of the management process?

A. Planning B. Organizing C. Directing D. Controlling

75. In assessing and monitoring services utilizing various methods and applying correct discipline, the
nurse manager is utilizing which phase of the managerial process?

A. Planning B. Organizing C. Directing D. Controlling

76. All of the following are not an example of a structure standard except:

A. Nurses should be BSN with atleast 1 year experience and 80% board rating

B. Patient should answer a retrospective nursing audit after discharge

C. The nurse should weigh the client every morning

D. The nurse should utilize the nursing process when caring for the clients in all health settings

77. As a Nurse Manager, DSJ enjoys his staff of talented and self motivated individuals. He knew that the
leadership style to suit the needs of this kind of people is called:

A. Autocratic B. Participative C. Democratic D. Laissez Faire

78. A fire has broken in the unit of DSJ R.N. The best leadership style suited in cases of emergencies like
this is:

A. Autocratic B. Participative C. Democratic D. Laissez Faire

79. Which step of the management process is concerned with Policy making and Stating the goals and
objective of the institution?
A. Planning B. Organizing C. Directing D. Controlling

80. In the management process, the periodic checking of the results of action to make sure that it
coincides with the goal of the institution is termed as:

A. Planning B. Evaluating C. Directing D. Organizing

81. The Vision of a certain agency is usually based on their beliefs, Ideals and Values that directs the
organization. It gives the organization a sense of purpose. The belief, Ideals and Values of this Agency is
called:

A. Philosophy B. Mission C. Vision D. Goals and Objectives

82. Mr. CKK is unconscious and was brought to the E.R. Who among the following can give consent for
CKKs Operation?

A. Doctor B. Nurse C. Next of Kin D. The Patient

83. Mr. CKK is now comatose after 5 days of hospital stay. If Mr. CKKs Thumb mark was obtained as his
signature, how should you consider this signature?

A. It has no meaning C. It is a valid signature

B. It is not a valid signature D. Verification is needed

84. The law which regulated the practice of nursing profession in the Philippines is:

A. R.A 9173 C. LOI 949

B. Patients Bill of Rights D. Code of Ethics for Nurses

85. Which of the following best describes Primary Nursing?

A. Is a form of assigning a nurse to lead a team of registered nurses in care of patient from admission to
discharge

B. A nurse is responsible in doing certain tasks for the patient

C. A registered nurse is responsible for a group of patients from admission to discharge

D. A registered nurse provides care for the patient with the assistant of nursing aides

86. The best and most effective method in times of staff and financial shortage is:

A. Functional Method C. Primary Nursing

B. Team Nursing D. Modular Method

86. The ideal number of patients suitable for Primary Nursing is:

A. 1 patient B. 3 to 4 C. 10 to 12 D. 15 to 20

87. Which of the following describes an advantage of Primary Nursing?

A. Provides continuity of care and Increase rapport and trust between the patient and the nurse

B. The care given is fragmented, making the nursing interventions faster and easier

C. The team leader develops accountability, increased autonomy and expertise in caring for clients with
similar condition

D. Primary Nursing provides an excellent way of increasing staffing cost

88. Why is there a need for secondary nurses in Primary nursing?

A. They are responsible for the care of the patient when the primary nurse if off duty

B. They report the progress of the client to the primary nurse

C. They assist the primary nurse in doing nursing care and procedures

D. They provide secondary level of prevention when primary level of prevention fails

89. This quality is being demonstrated by a Nurse who raise the side rails of a confuse and disoriented
patient?

A. Autonomy B. Responsibility C. Prudence D. Resourcefulness

90. If you a to conduct a research, arrange the following in sequence from the first step of the research
process to the last:

1. Select sample 4. Identify the problem 7. Select the design

2. Communicate findings 5. Determine the purpose 8. Review of literature

3. Analyze the data 6. Collect data 9. Formulate hypothesis

A. 4,5,8,7,9,1,6,3,2 C. 6,3,4,5,7,8,9,1,2

B. 4,5,8,9,7,1,6,3,2 D. 6,4,5,3,1,7,8,9,2

DSJ is about to conduct a research entitled Relationship of self motivation and passing the nurse
licensure examination among the June 2008 board examinees. The hypothesis developed was :
Increase in self motivation increases the chance of passing the nurse licensure examination. DSJ
performs the sampling by going to the review class of the 4th year board exam candidates of OLFU.
Questions 41 to 45 refer to this.

91. Which is the dependent variable?

A. Self motivation C. Passing the NLE

B. June 2008 board examinees D. Relationship

92. Which is the independent variable?

A. Self motivation C. Passing the NLE

B. June 2008 board examinees D. Relationship

93. The type of hypothesis developed was:

A. Simple, non directional research hypothesis

B. Simple, directional research hypothesis

C. Complex, directional research hypothesis

D. Null hypothesis

94. BDK R.N is conducting a research on his unit about the effects of effective nurse-patient
communication in decreasing anxiety of post operative patients. Which of the following step in nursing
research should he do next?

A. Review of related literature

B. Ask permission from the hospital administrator

C. Determine the research problem

D. Formulate ways on collecting the data

95. Before BDK perform the formal research study, what do you call the pre testing, small scale trial run
to determine the effectiveness of data collection and methodological problem that might be
encountered?

A. Sampling B. Pre testing C. Pre Study D. Pilot Study

96. On the study effects of effective nurse-patient communication in decreasing anxiety of post
operative patients What is the Independent variable?

A. Effective Nurse-patient communication C. Communication

B. Decreasing Anxiety D. Post operative patient

97. On the study effects of effective nurse-patient communication in decreasing anxiety of post
operative patients What is the Dependent variable?

A. Effective Nurse-patient communication

B. Communication

C. Anxiety level

D. Post operative patient

98. In the recent technological innovations, which of the following describe researches that are made to
improve and make human life easier?

A. Pure research C. Basic research

B. Applied research D. Experimental research

99. Which of the following is Qualitative research design?

A. Effects of morphine dose on the blood pressure of the client

B. Relationship of Age in the salary rate of Makati workers

C. A Study on the effects of culture in breastfeeding practice

D. A comparative analysis between the length of stay in the hospital and the dependence of clients with

MEDICAL SURGICAL

Reynaldo A. Donghit, Jr.

Overview of the Structures & Functions of Nervous System

Central NS PNS ANS

Brain & spinal cord 31 spinal & cranial sympathetic NS

Parasympathetic NS

Somatic NS

C- 8

T- 12

L- 5

S- 5
C- 1

ANS (or adrenergic of parasympatholitic response)

SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic)

1. Dilate pupil to be aware of surroundings

Release of norepinephrine (adrenaline cathecolamine) - medriasis

Adrenal medulla (potent vasoconstrictor)

2. Dry mouth

Increases body activities VS = Increase

3. BP & HR= increased

Except GIT decrease GIT motility bronchioles dilated to take more oxygen

4. RR increased

* Why GIT is not increased = GIT is not important!

5. Constipation & urinary retention

Increase blood flow to skeletal muscles, brain & heart.

I. Adrenergic Agents Epinephrine (adrenaline)

SE: SNS effect

II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in lol)

- Blocks release of norepinephrine.

- Decrease body activities except GIT (diarrhea)

Ex. Propanolol, Metoprolol

SE:

B broncho spasm (bronchoconstriction)

E elicits a decrease in myocardial contraction

T treats HPN

A AV conduction slows down

Given to angina & MI beta-blockers to rest heart

Anti HPN agents:

1. Beta blockers (-lol)

2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL

3. Calcium antagonist

ex CALCIBLOC or NiFEDIPINE

Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)

- Involved in fly or withdrawal response 1. Meiosis contraction of pupils

- Release of acetylcholine (ACTH) 2. Increase salivation

- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased

4. RR decrease broncho constriction

I Cholinergic agents 5. Diarrhea increased GI motility

ex 1. Mestinon 6. Urinary frequency

Antidote anti cholinergic agents Atropine Sulfate S/E SNS

S/E- of anti-hpn drugs:

1. orthostatic hpn

2. transient headache & dizziness.

-Mgt. Rise slowly. Assist in ambulation.

CNS (brain & spinal cord)

I. Cells A. neurons

Properties and characteristics

a. Excitability ability of neuron to be affected in external environment.

b. Conductivity ability of neuron to transmit a wave of excitation from one cell to another

c. Permanent cells once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)

Regenerative capacity

A. Labile once destroyed cant regenerate

- Epidermal cells, GIT cells, resp (lung cells). GUT

B. Stable capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver,
kidney cells

C. Permanent cells retina, brain, heart, osteocytes cant regenerate.

3.) Neuroglia attached to neurons. Supports neurons. Where brain tumors are found.

Types:

1. Astrocyte

2. Oligodendria

Astrocytoma 90 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.

Astrocyte maintains integrity of blood brain barrier (BBB).

BBB semi permeable / selective

-Toxic substance that destroys astrocyte & destroy BBB.

Toxins that can pass in BBB:

1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide seizure & parkinsons.

3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.

4. 4. Ketones DM.

OLIGODENDRIA Produces myelin sheath wraps around a neuron acts as insulator facilitates rapid
nerve impulse transmission.

No myelin sheath degenerates neurons

Damage to myelin sheath demyellenating disorders

DEMYELLENATING DSE

1.)ALZHEIMERS DISEASE atrophy of brain tissue due to a deficiency of acetylcholine.

S&Sx:

A amnesia loss of memory

A apraxia unable to determine function & purpose of object

A agnosia unable to recognize familiar object

A aphasia

- Expressive broccas aphasia unable to speak

- Receptive wernickes aphasia unable to understand spoken words

Common to Alzheimer receptive aphasia

Drug of choice ARICEPT (taken at bedtime) & COGNEX.

Mgt: Supportive & palliative.

Microglia stationary cells, engulfs bacteria, engulfs cellular debris.

II. Compositions of Cord & Spinal cord

80% - brain mass

10% - CSF

10% - blood

MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase
ICP.

Normal ICP: 0-15mmHg

Brain mass

1. Cerebrum largest - Connects R & L cerebral hemisphere

- Corpus collusum

Rt cerebral hemisphere, Lt cerebral hemisphere

Function:

1. Sensory

2. Motor

3. Integrative

Lobes

1.) Frontal

a. Controls motor activity

b. Controls personality development

c. Where primitive reflexes are inhibited

d. Site of development of sense of umor

e. Broccas area speech center

Damage - expressive aphasia

2.) Temporal

a. Hearing

b. Short term memory

c. Wernickes area gen interpretative or knowing Gnostic area

Damage receptive aphasia

3.) Parietal lobe appreciation & discrimation of sensory imp

- Pain, touch, pressure, heat & cold

4.) Occipital - vision

5.) Insula/island of reil/ Central lobe- controls visceral fx

Function: - activities of internal organ

6.) Rhinencephalon/ Limbec

- Smell, libido, long-term memory

Basal Ganglia areas of gray matte located deep within a cerebral hemisphere

- Extra pyramidal tract

- Releases dopamine-

- Controls gross voluntary unit

Decrease dopamine (Parkinsons) pin rolling of extremities & Huntingtons Dse.

Decrease acetylcholine Myasthenia Gravis & Alzheimers

Increased neurotransmitter = psychiatric disorder Increase dopamine schizo

MID BRAIN relay station for sight & hearing

Controls size & reaction of pupil 2 3 mm

Controls hearing acuity

CN 3 4

Isocoria normal size (equal)

Anisocoria uneven size damage to mid brain

PERRLA normal reaction

DIENCEPHALON- between brain

Thalamus acts as a relay station for sensation

Hypothalamus (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center,
emotional responses, controls pituitary function.

BRAIN STEM- a. Pons or pneumotaxic center controls respiration

Cranial 5 8 CNS

MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus

Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12

CEREBELLUM lesser brain

- Controls posture, gait, balance, equilibrium

Cerebellar Tests:

a.) R Rombergs test- needs 2 RNs to assist

- Normal anatomical position 5 10 min

(+) Rombergs test (+) ataxia or unsteady gait or drunken like movement with loss of balance.

b.) Finger to nose test

(+) To FTNT dymetria inability to stop a movement at a desired point

c.) Alternate pronation & supination

Palm up & down . (+) To alternate pronation & supination or damage to cerebellum dymentrium

Composition of brain - based on Monroe Kellie Hypothesis

- Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP

Normal ICP 0 15 mmHg

Foramen Magnum

C1 atlas

C2 axis

(+) Projectile vomiting = increase ICP

Observe for 24 - 48 hrs

CSF cushions the brain, shock absorber

Obstruction of flow of CSF = increase ICP

Hydrocephalus posteriorly due to closure of posterior fontanel

CVA partial/ total obstruction of blood supply

INCREASED ICP increase ICP is due to increase in 1 of the Intra Cranial components.

Predisposing factors:

1.) Head injury

2.) Tumor

3.) Localized abscess

4.) Hemorrhage (stroke)

5.) Cerebral edema

6.) Hydrocephalus

7.) Inflammatory conditions - Meningitis, encephalitis

B. S&Sx change in VS = always late symptoms

Earliest Sx:

a.) Change or decrease LOC Restlessness to confusion Wide pulse pressure: Increased ICP

- Disorientation to lethargy Narrow pp: Cardiac disorder, shock

- Stupor to coma

Late sign change in V/S

1. BP increase (systolic increase, diastole- same)

2. Widening pulse pressure

Normal adult BP 120/80 120 80 = 40 (normal pulse pressure)

Increase ICP = BP 140/80 = 140 80= 60 PP (wide)

3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)

4. Temp increase

Increased ICP: Increase BP Shock decrease BP

Decrease HR Increase HR CUSHINGS EFFECT

Decrease RR Increase RR

Increase Temp Decrease temp

b.) Headache

Projectile vomiting
Papilledima (edema of optic disk outer surface of retina)

Decorticate (abnormal flexion) = Damage to cortico spinal tract /

Decerebrate (abnormal extension) = Damage to upper brain stem-pons/

c.) Uncal herniation unilateral dilation of pupil. (Bilateral dilation of pupil tentorial herniation.)

d.) Possible seizure.

Nursing priority:

1.) Maintain patent a/w & adequate ventilation

a. Prevention of hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).

Hypoxia cerebral edema - increase ICP

Hypoxia inadequate tissue oxygenation

Late symptoms of hypoxia

B bradycardia

E extreme restlessness

D dyspnea

C cyanosis

Early symptoms R restlessness

A agitation
T tachycardia

Increase CO2 retention/ hypercarbia cerebral vasodilatation = increase ICP

Most powerful respiratory stimulant increase in CO2

Hyperventilate decrease CO2 excrete CO2

Respiratory Distress Syndrome (RDS) decrease Oxygen

Suctioning 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.

Ambu bag pump upon inspiration

c. Assist in mechanical ventilation

1. Maintain patent a/w

2. Monitor VS & I&O

3. Elevate head of bed 30 45 degrees angle neck in neutral position unless contra indicated to promote
venous drainage

4. Limit fluid intake 1,200 1,500 ml/day

(FORCE FLUID means:Increase fluid intake/day 2,000 3,000 ml/day)- not for inc ICP.

5. Prevent complications of immobility

6. Prevent increase ICP by:

a. Maintain quiet & comfy environment

b. Avoid use of restraints lead to fractures

c. Siderails up

d. Instruct patient to avoid the ff:

-Valsalva maneuver or bearing down, avoid straining of stool

(give laxatives/ stool softener Dulcolax/ Duphalac)

- Excessive cough antitussive

Dextrometorpham

-Excessive vomiting anti emetic (Plasil Phil only)/ Phenergan

- Lifting of heavy objects

- Bending & stooping

e. Avoid clustering of nursing activities

7. Administer meds as ordered:

1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue

Nursing considerations:

1.) Mannitol

1. Monitor BP SE of hypotension

2. Monitor I&O every hr. report if < 30cc out put

3. Administer via side drip

4. Regulate fast drip to prevent formation of crystals or precipitate

2.) Loop diuretic - Lasix (Furosemide)

Nursing Mgt: Lasix

Same as Mannitol except

- Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt
will urinate at 7:15

Immediate effect of Lasix within 15 minutes. Max effect 6 hrs due (7am 1pm)

S/E of Lasix

Hypokalemia (normal K-3.5 5.5 meg/L)

S&Sx

1. Weakness & fatigue

2. Constipation
3. (+) U wave in ECG tracing

Nursing Mgt:

1.) Administer K supplements ex Kalium Durule, K chloride

Potassium Rich food:

ABCs of K

Vegetables Fruits

A asparagus A apple

B broccoli (highest) B banana green

C carrots C cantalope/ melon

O orange (highest) for digitalis toxicity also.

Vit A squash, carrots yellow vegetables & fruits, spinach, chesa

Iron raisins,

Food appropriate for toddler spaghetti! Not milk increase bronchial secretions

Dont give grapes may choke

S/E of Lasix:

1.) Hypokalemia

2.) Hypocalcemia (Normal level Ca = 8.5 11mg/100ml) or Tetany:

S&Sx

weakness

Paresthesia

(+) Trousseau sign pathognomonic or carpopedal spasm. Put bp cuff on arm=hand spasm.

(+) Chevosteks sign

Arrhythmia
Laryngospasm

Administer Ca gluconate IV slowly

Ca gluconate toxicity: Sx seizure administer Mg SO4

Mg SO4 toxcicity administer Ca gluconate

B BP decrease

U urine output decrease

R RR decrease

P patellar reflexes absent

3.) Hyponatremia Normal Na level = 135 145 meg/L

S/Sx Hypotension

Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.

Early signs Adult: thirst and agitation / Child: tachycardia

Mgt: force fluid

Administer isotonic fluid sol

4.) Hyperglycemia increase blood sugar level

P polyuria

P polyphagia

P polydipsia

Nsg Mgt:

a. Monitor FBS (N=80 120 mg/dl)

5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in joint.

Gouty arthritis kidney stones- renal colic (pain)

Cool moist skin

Sx joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritis

a.) Cheese (not sardines, anchovies, organ meat)

(Not good if pt taking MAO)

b.) Force fluid

c.) Administer meds Allopurinol/ Zyloprim inhibits synthesis of uric acid drug of choice for gout

Colchicene excretes uric acid. Acute gout drug of choice.

Kidney stones renal colic (pain). Cool moist skin

Mgt:

1.) Force fluid

2.) Meds narcotic analgesic

Morphine SO4

SE of Morphine SO4 toxicity

Respiratory depression (check RR 1st)

Antidote for morphine SO4 toxicity Narcan (NALOXONE)

Naloxone toxicity tremors

Increase ICP meds:

3.) Corticosteroids - Dexamethsone decrease cerebral edema (Decadrone)

4.) Mild analgesic codeine SO4. For headache.

5.) Anti consultants Dilantin (Phenytoin)

Question: Increase ICP what is the immediate nsg action?

a. Administer Mannitol as ordered

b. Elevate head 30 45 degrees

c. Restrict fluid

d. Avoid use of restraints

Nsg Priority ABC & safety

Pt suffering from epiglotitis. What is nsg priority?

a. Administer steroids least priority

b. Assist in ET temp, a/w

c. Assist in tracheotomy permanent (Answer)

d. Apply warm moist pack? Least priority

Rationale: Wont need to pass larynx due to larynx is inflamed. ET cant pass. Need tracheostomy only-

Magic 2s of drug monitoring

Drug N range Toxicity Classification Indication

D digoxin .5 1.5 meq/L 2 cardiac glycosides CHF

L - lithium .6 1.2 meq/L 2 antimanic bipolar

A aminophylline 10 19 mg/100ml 20 bronchodilator COPD

D Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures

A acetaminophen 10 30 mg/100ml 200 narcotic analgesic osteoarthritis

Digitalis increase cardiac contraction = increase CO

Nursing Mgt

1. Check PR, HR (if HR below 60bpm, dont giveDigoxin)

Digitalis toxicity antidote - Digivine

a. Anorexia -initial sx.

b. n/v GIT

c. Diarrhea

d. Confusion

e. Photophobia

f. Changes in color perception yellow spots

(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)

L lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine

Antimanic agent

Lithium toxicity

S/Sx -
a.) Anorexia

b.) n/s

c.) Diarrhea

d.) Dehydration force fluid, maintain Na intake 4 10g daily

e.) Hypothyroidism

(CRETINISM the only endocrine disorder that can lead to mental retardation)

A aminophyline (theophylline) dilates bronchioles.

Take bp before giving aminophylline.

S/Sx : Aminophylline toxicity:

1. Tachycardia

2. Hyperactivity restlessness, agitation, tremors

Question: Avoid giving food with Aminophylline

a. Cheese/butter food rich in tyramine, avoided only if pt is given MAOI

b. Beer/ wine -

c. Hot chocolate & tea caffeine CNS stimulant tachycardia

d. Organ meat/ box cereals anti parkinsonian

MAOI antidepressant

m AR plan

n AR dil can lead to CVA or hypertensive crisis

p AR nate

3 4 weeks - before MAOI will take effect

Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa

D dilatin (Phenytoin) anti convulsant/seizure

Nursing Mgt:

1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate

- Do sandwich method

- Give NSS then Dilantin, then NSS!

2. Instruct the pt to avoid alcohol bec alcohol + dilantin can lead to severe CNS depression

Dilantin toxicity:

S/Sx:

G gingival hyperplasia swollen gums

i. Oral hygiene soft toothbrush

ii. Massage gums

H hairy tongue

A - ataxia

N nystagmus abnormal movement of eyeballs

A acetaminophen/ Tylenol non-opoid analgesic & antipyretic febrile pts

Acetaminophen toxicity :

1. Hepato toxicity

2. Monitor liver enzymes

SGPT (ALT) Serum Glutamic Piruvate Tyranase

SGOT- Serum Glutamic Acetate Tyranase

3. Monitor BUN (10 20)

Crea (.8-1)

Acetaminophen toxicity can lead to hypoglycemia

T tremors, Tachycardia

I irritability

R restlessness

E extreme fatigue

D depression (nightmares) , Diaphoresis

Antidote for acetaminophen toxicity Acetylcesteine = causes outporing of secretions. Suction.

Prepare suctioning apparatus.

Question: The following are symptoms of hypoglycemia except:

a. Nightmares

b. Extreme thirst hyperglycemia symptoms

c. Weakness d. Diaphoresis

PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of

dopamine producing cells in substancia nigra at mid brain & basal ganglia

- Palliative, Supportive

Function of dopamine: controls gross voluntary motors.

Predisposing Factors:

1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA

2. Hypoxia

3. Arteriosclerosis

4. Encephalitis

High doses of the ff:

a. Reserpine (serpasil) anti HPN, SE 1.) depression - suicidal 2.) breast cancer

b. Methyldopa (aldomet) - promote safety

c. Haloperidol (Haldol)- anti psychotic

d. Phenothiazide - anti psychotic

SE of anti psychotic drugs Extra Pyramidal Symptom

Over meds of anti psychotic drugs neuroleptic malignant syndrome char by tremors (severe)

S/Sx: Parkinsonism

1. Pill rolling tremors of extremities early sign

2. Bradykinesia slow movement

3. Over fatigue

4. Rigidity (cogwheel type)

a. Stooped posture

b. Shuffling most common

c. Propulsive gait

5. Mask like facial expression with decrease blinking eyes

6. Monotone speech

7. Difficulty rising from sitting position

8. Mood labilety always depressed suicide

Nsg priority: Promote safety

9. Increase salivation drooling type

10. Autonomic signs:

- Increase sweating

- Increase lacrimation

- Seborrhea (increase sebaceous gland)

- Constipation

- Decrease sexual activity

Nsg Mgt

1.) Anti parkinsonian agents

- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)

Mechanism of action

Increase levels of dopa relieving tremors & bradykinesia

S/E of anti parkinsonian

- Anorexia

- n/v

- Confusion

- Orthostatic hypotension

- Hallucination

- Arrhythmia

Contraindication:

1. Narrow angled closure glaucoma

2. Pt taking MAOI (Parnate, Marplan, Nardil)

Nsg Mgt when giving anti-parkinsonian

1. Take with meals to decrease GIT irritation

2. Inform pt urine/ stool may be darkened

3. Instruct pt- dont take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
- Cause B6 reverses therapeutic effects of levodopa

Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.

2.) Anti cholinergic agents relieves tremors

Artane mech inhibits acetylcholine

Cogentin action , S/E - SNS

3.) Antihistamine Diphenhydramine Hcl (Benadryl) take at bedtime

S/E: adult drowsiness, avoid driving & operating heavy equipt. Take at bedtime.

Child hyperactivity CNS excitement for kids.

4.) Dopamine agonist

Bromotriptine Hcl (Parlodel) respiratory depression. Monitor RR.

Nsg Mgt Parkinson

1.) Maintain siderails

2.) Prevent complications of immobility

- Turn pt every 2h

Turn pt every 1 h elderly

3.) Assist in passive ROM exercises to prevent contractures

4.) Maintain good nutrition

CHON in am

CHON in pm to induce sleep due Tryptopan Amino Acid

5.) Increase fluid in take, high fiber diet to prevent constipation

6.) Assist in surgery Sterotaxic Thalamotomy

Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis
MULTIPLE SCLEROSIS (MS)

Chronic intermittent disorder of CNS white patches of demyelenation in brain & spinal cord.

- Remission & exacerbation

- Common women, 15 35 yo cause unknown

Predisposing factor:

1. Slow growing virus

2. Autoimmune (supportive & palliative treatment only)

Normal Resident Antibodies:

Ig G can pass placenta passive immunity. Short acting.

Ig A body secretions saliva, tears, colostrums, sweat

Ig M acute inflammation

Ig E allergic reactions

IgD chronic inflammation

S & Sx of MS: (everything down)

1. Visual disturbances

a. Blurring of vision

b. Diplopia/ double vision

c. Scotomas (blind spots) initial sx

2. Impaired sensation to touch, pain, pressure, heat, cold

a. Numbness

b. Tingling

c. Paresthesia
3. Mood swings euphoria (sense of elation )

4. Impaired motor function:

a. Weakness

b. Spasiticity tigas

c. Paralysis major problem

5. Impaired cerebellar function

Triad Sx of MS

I intentional tremors

N nystagmus abnormal rotation of eyes Charcots triad

A Ataxia

& Scanning speech

6. Urinary retention or incontinence

7. Constipation

8. Decrease sexual ability

Dx MS

1. CSF analysis thru lumbar puncture

- Reveals increase CHON & IgG

2. MRI reveals site & extent of demyelination

3. Lhermittes response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.

Nsg Mgt MS

- Supportive mgt

1.) Meds

a. Acute exacerbation

ACTH adenocorticotopic

Steroids to reduce edema at the site of demyelination to prevent paralysis

Spinal Cord Injury

Administer drug to prevent paralysis due to edema

a. Give ACTH steroids

b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)

To decrease muscle spasticity

c. Interferone to alter immune response

d. Immunosuppresants

2. Maintain siderails

3. Assist passive ROMexercises promote proper body alignment

4. Prevent complications of immobility

5. Encourage fluid intake & increase fiber diet to prevent constipation

6. Provide catheterization die urinary retention

7. Give diuretics

Urinary incontinence give Prophantheline bromide (probanthene)

Antispasmodic anti cholinergic

8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.

9. Provide acid-ash diet to acidify urine & prevent bacteria multiplication

Grape, Cranberry, Orange juice, Vit C

MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from nerve to muscle cell at neuro
muscular

junction.

Common in Women, 20 40 yo, unknown cause or idiopathic

Autoimmune release of cholenesterase enzyme

Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine

Descending muscle weakness

(Ascending muscle weakness Guillain Barre Syndrome)

Nsg priority:

1) a/w

2) aspiration

3) immobility

S/ Sx:

1.) Ptosis drooping of upper lid ( initial sign)

Check Palpebral fissure opening of upper & lower lids = to know if (+) of MG.

2.) Diplopia double vision

3.) Mask like facial expression

4.) Dysphagia risk for aspiration!

5.) Weakening of laryngeal muscles hoarseness of voice

6.) Resp muscle weakness lead respiratory arrest. Prepare at bedside tracheostomy set

7.) Extreme muscle weakness during activity especially in the morning.

Dx test

1. Tensilon test (Edrophonium Hcl) temporarily strengthens muscles for 5 10 mins. Short term-
cholinergic. PNS effect.

Nsg Mgt

1. Maintain patent a/w & adequate vent by:

a.) Assist in mechanical vent attach to ventilator

b.) Monitor pulmonary function test. Decrease vital lung capacity.

2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)

3. Siderails

4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.

5. NGT feeding
Administer meds

a.) Cholinergics or anticholinesterase agents

Mestinon (Pyridostigmine)

Neostignine (prostigmin) Long term

- Increase acetylcholine

s/e PNS

b.) Corticosteroids to suppress immune resp

Decadron (dexamethasone)

Monitor for 2 types of Crisis:

Myastinic crisis Cholinergic crisis

A cause 1. Under medication

2. Stress

3. Infection

B S&Sx 1. Unable to see Ptosis & diplopia

2. Dysphagia- unable to swallow.

3. Unable to breath

C Mgt adm cholinergic agents Cause: 1 over meds

S/Sx - PNS

Mgt. adm anti-cholinergic

- Atropine SO4
- SNS dry mouth

7. Assist in surgical proc thymectomy. Removal of thymus gland. Thymus secretes auto immune
antibody.

8. Assist in plasmaparesis filter blood

9. Prevent complication respiratory arrest

Prepare tracheostomy set at bedside.

GBS Guillain Barre Syndrome

- Disorder of CNS

- Bilateral symmetrical polyneuritis

- Ascending paralysis

Cause unknown, idiopathic

- Auto immune

- r/t antecedent viral infection

- Immunizations

S&Sx

Initial :

1. Clumsiness

2. Ascending muscle weakness lead to paralysis

3. Dysphagia

4. Decrease or diminished DTR (deep tendon reflexes)

- Paralysis
5. Alternate HPN to hypotension lead to arrhythmia - complication

6. Autonomic changes increase sweating, increase salivation.

Increase lacrimation

Constipation

Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)

Nsg Mgt

1. Maintain patent a/w & adequate vent

a. Assist in mechanical vent

b. Monitor pulmonary function test

2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia

3. Siderails

4. Prevent compl immobility

5. Assist in passive ROM exercises

6. Institute NGT feeding due dysphagia

7. Adm meds (GBS) as ordered: 1. Anti cholinergic atropine SO4

2. Corticosteroids to suppress immune response

3. Anti arrhythmic agents

a.) Lidocaine /Xylocaine SE confusion = VTach

b.) Bretyllium

c.) Quinines/Quinidine anti malarial agent. Give with meals.

- Toxic effect cinchonism

Quinidine toxicity

S/E anorexia, n/v, headache, vertigo, visual disturbances

8. Assist in plasmaparesis (MG. GBS)

9. Prevent comp arrhythmias, respiratory arrest

Prepare tracheostomy set at bedside.

INFL CONDITONS OF BRAIN

Meninges 3-fold membrane cover brain & spinal cord

Fx:

Protection & support

Nourishment

Blood supply

3 layers

1. Duramater sub dural space

2. Arachmoid matter

3. Pia matter sub arachnoid space where CSF flows L3 & L4. Site for lumbar puncture.

MENINGITIS inflammation of meningitis & spinal cord

Etiology Meningococcus

Pneumococcus

Hemophilous influenza child

Streptococcus adult meningitis

MOT direct transmission via droplet nuclei

S&Sx
- Stiff neck or nuchal rigidity (initial sign)

- Headache

- Projectile vomiting due to increase ICP

- Photophobia

- Fever chills, anorexia

- Gen body malaise

- Wt loss

- Decorticate/decerebration abnormal posturing

- Possible seizure

Sx of meningeal irritation nuchal rigidity or stiffness

Opisthotonus- rigid arching of back

Pathognomonic sign (+) Kernigs & Brudzinski sign

Leg pain neck pain

Dx:

1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or
L4 & L5

Aspirate CSF for lumbar puncture.

Nsg Mgt for lumbar puncture invasive

1. Consent / explain procedure to pt

- RN dx procedure (lab)

- MD operation procedure

2. Empty bladder, bowel promote comfort

3. Arch back to clearly visualize L3, L4

Nsg Ngt post lumbar

1. Flat on bed 12 24 h to prevent spinal headache & leak of CSF

2. Force fluid

3. Check punctured site for drainage, discoloration & leakage to tissue

4. Assess for movement & sensation of extremeties

Result

1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose

b. Decrease glucose

Confirms meningitis c. increase CSF opening pressure

N 50 160 mmHg

d. (+) Culture microorganism

2. Complete blood count CBC reveals increase WBC

Mgt:

1. Adm meds

a.) Broad-spectrum antibiotic penicillin

S/E

1. GIT irritation take with food

2. Hepatotoxicity, nephrotoxcicity

3. Allergic reaction

4. Super infection alteration in normal bacterial flora

- N flora throat streptococcus

- N flora intestine e coli

Sx of superinfxn of penicillin = diarrhea

b.) Antipyretic

c.) Mild analgesic

2. Strict resp isolation 24h after start of antibiotic therapy

A Cushings synd reverse isolation - due to increased corticosteroid in body.

B Aplastic anemia reverse isolation - due to bone marrow depression.

C Cancer anytype reverse isolation immunocompromised.

D Post liver transplant reverse isolation takes steroids lifetime.

E Prolonged use steroids reverse isolation

F Meningitis strict respiratory isolation safe after 24h of antibiotic therapy

G Asthma not to be isolated

3. Comfy & dark room due to photophobia & seizure

4. Prevent complications of immobility

5. Maintain F & E balance

6. Monitor vs, I&O , neuro check

7. Provide client health teaching & discharge plan

a. Nutrition increase cal & CHO, CHON-for tissue repair. Small freq feeding

b. Prevent complication hydrocephalus, hearing loss or nerve deafness.

8. Prevent seizure.

Where to bring 2 yo post meningitis

- Audiologist due to damage to hearing- post repair myelomeningocele

- Urologist -Damage to sacral area spina bifida controls urination

9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor
development.
CEREBRO VASCULAR ACCIDENT stroke, brain attack or cerebral thrombosis, apoplexy

- Partial or complete disruption in the brains blood supply

- 2 largest & common artery in stroke

Middle cerebral artery

Internal carotid artery

- Common to male 2 3x high risk

Predisposing factor:

1. Thrombosis clot (attached)

2. Embolism dislodged clot pulmo embolism

S/Sx: pulmo embolism

Sudden sharp chest pain

Unexplained dyspnea, SOB

Tachycardia, palpitations, diaphoresis & mild restlessness

S/Sx: cerebral embolism

Headache, disorientation, confusion & decrease in LOC

Femur fracture complications: fat embolism most feared complication w/in 24hrs

Yellow bone marrow produces fat cells at meduallary cavity of long bone

Red bone marrow provides WBC, platelets, RBC found at epiphisis

2.) Hemorrhage

3.) Compartment syndrome compression of nerves/ arteries

Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery mitral valve
replacement
Lifestyle: 1. Smoking nicotine potent vasoconstrictor

2. Sedentary lifestyle

3. Hyperlipidemia genetic

4. Prolonged use of oral contraceptives

- Macro pill has large amt estrogen

- Mini pill has large amt of progestin

- Promote lipolysis (breakdown of lipids/fats) artherosclerosis HPN - stroke

5. Type A personality

a. Deadline driven person

b. 2 5 things at the same time

c. Guilty when not dong anything

6. Diet increase saturated fats

7. Emotional & physical stress

8. Obesity

S & Sx

1. TIA- warning signs of impending stroke attacks

- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or
plegia (monoplegia 1 extreme)

Increase ICP

2. Stroke in evolution progression of S & Sx of stroke

3. Complete stroke resolution of stroke

a.) Headache

b.) Cheyne-Stokes Resp

c.) Anorexia, n/v

d.) Dysphagia
e.) Increase BP

f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke

g.) Focal & neurological deficit

1. Phlegia

2. Dysarthria inability to vocalize, articulate words

3. Aphasia

4. Agraphia diff writing

5. Alesia diff reading

6. Homoninous hemianopsia loss of half of field of vision

Left sided hemianopsia approach Right side of pt the unaffected side

Dx

1. CT Scan reveals brain lesion

2. Cerebral arteriography site & extent of mal occlusion

- Invasive procedure due to inject dye

- Allergy test

All graphy invasive due to iodine dye

Post

1.) Force fluid to excrete dye is nephrotoxic

2.) Check peripheral pulses - distal

Nsg Mgt

1. Maintain patent a/w & adequate vent

- Assist mechanical ventilation

- Administer O2
2. Restrict fluids prevent cerebral edema

3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.

4. Monitor vs., I&O, neuro check

5. Prevent compl of immobility by:

a. Turn client q2h

Elderly q1h

- To prevent decubitus ulcer

- To prevent hypostatic pneumonia after prolonged immobility.

b. Egg crate mattress or H2O bed

c. Sand bag or foot board- prevent foot drop

6. NGT feeding if pt cant swallow

7. Passive ROM exercise q4h

8. Alternative means of communication

- Non-verbal cues

- Magic slate. Not paper and pen. Tiring for pt.

- (+) To hemianopsia approach on unaffected side

9. Meds

Osmotic diuretics Mannitol

Loop diuretics Lasix/ Furosemide

Corticosteroids dextamethazone

Mild analgesic

Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.

Streptokinase

Urokinase

Tissue plasminogen activating

Monitor bleeding time

Anticoagulants Heparin & Coumadin sabay

Coumadin will take effect after 3 days

Heparin monitor PTT partial thromboplastin time if prolonged bleeding give Protamine SO4-
antidote.

Coumadin Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K Aquamephyton-
antidote.

Antiplatelet PASA aspirin paraanemo aspirin, dont give to dengue, ulcer, and unknown headache.

Health Teaching

1. Avoidance modifiable lifestyle

- Diet, smoking

2. Dietary modification

- Avoid caffeine, decrease Na & saturated fats

Complications:

Subarachnoid hemorrhage

Rehab for focal neurological deficit physical therapy

1. Mental retardation

2. Delay in psychomotor development

CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or
without loss of consciousness, abnormal motor activity, alteration in sensation & perception & change in
behavior.

Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack

Febrile seizure Normal if < 5 yo Epilepsy 2nd and with history of seizure
Pathologic if > 5 yo

Predisposing Factor

Head injury due birth trauma

Toxicity of carbon monoxide

Brain tumor

Genetics

Nutritional & metabolic deficit

Physical stress

Sudden withdrawal to anticonvulsants will bring about status epilepticus

Status epilepticus drug of choice: Diazepam & glucose

S & Sx

I. Generalized Seizure

a.) Grand mal / tonic clonic seizures

With or without aura warning symptoms of impending seizure attack- Epigastric pain- associated with
olfactory, tactile, visual, auditory sensory experience

- Epileptic cry fall

- Loss of consciousness 3 5 min

- Tonic clonic contractions

- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC

- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic

b.) Petimal seizure (same as daydreaming!) or absent seizure.

- Blank stare
- Decrease blinking eye

- Twitching of mouth

- Loss of consciousness 5 10 secs (quick & short)

II. Localized/partial seizure

a.) Jacksonian seizure or focal seizure tingling/jerky movement of index finger/thumb & spreads to
shoulder & 1 sideof the body with janksonian march

b.) Psychomotor/ focal motor - seizure

-Automatism stereotype repetitive & non-purposive behavior

- Clouding of consciousness not in control with environment

- Mild hallucinatory sensory experience

HALLUCINATIONS

1. Auditory schitzo paranoid type

2. Visual korsakoffs psychosis chronic alcoholism

3. Tactile addict substance abuse

III. Status epilecticus continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia
coma death

Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and
O2=dec glucose, dec O2.

Tx:Diazepam (drug of choice), glucose

Dx-Convulsion- get health history!

1. CT scan brain lesion

2. EEG electroencephalography

- Hyperactivity brain waves

Nsg Mgt
Priority Airway & safety

1. Maintain patent a/w & promote safety

Before seizure:

1. Remove blunt/sharp objects

2. Loosen clothing

3. Avoid restraints

4. Maintain siderails

5. Turn head to side to prevent aspiration

6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at
home.

7. Avoid precipitating stimulus bright glaring lights & noises

8. Administer meds

a. Dilantin (Phenytoin) ( toxicity level 20 )

SE Ginguial hyperplasia

H-hairy tongue

A-ataxia

N-nystagmus

A-acetaminophen- febrile pt

Mix with NSS

- Dont give alcohol lead to CNS depression

b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia

c. Phenobarbital (Luminal)- SE: hallucinations

2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration

- Type of seizure

- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having
status epilepticus!

4. Assist in surgical procedure. Cortical resection

5. Complications: Subarachnoid hemorrhage and encephalitis

Question: 1 yo grand mal immediate nursing action = a/w & safety

a. Mouthpiece 1 yr old little teeth only

b. Adm o2 inhalation post!

c. Give pillow safety (answer)

d. Prepare suction

Neurological assessment:

1. Comprehensive neuro exam

2. GCS - Glasgow coma scale obj measurement of LOC or quick neuro check

3 components of ECS

M motor 6

V verbal resp 5

E eye opening 4

15

15 14 conscious

13 11 lethargy

10 8 stupor

7 coma
3 deep coma lowest score

Survey of mental status & speech (Comprehensice Neuro Exam)

1.) LOC & test of memory

2.) Levels of orientation

3.) CN assessment

4.) Motor assessment

5.) Sensory assessment

6.) Cerebral test Romhberg, finger to nose

7.) DTR

8.) Autonomics

Levels of consciousness (LOC)

1. Conscious (conscious) awake levels of wakefulness

2. Lethargy (lethargic) drowsy, sleepy, obtunded

3. Stupor (stuporous) awakened by vigorous stimulation

Pt has gen body weakness, decrease body reflex

4. Coma (Comatose) light (+) all forms of painful stimulations

Deep (-) to painful stimulation

Question: Describe a conscious pt ?

a. Alert not all pt are alert & oriented to time & place

b. Coherent

c. Awake- answer

d. Aware
Different types of pain stimulation

- Dont prick

1. Deep sternal stimulation/ pressure 3x fist knuckle

With response light coma

Without response deep coma

2. Pressure on great toe 3x

3. Orbital pressure pressure on orbits only below eye

4. Corneal reflex/ blinking reflex

Wisp of cotton used to illicit blinking reflex among conscious patients

Instill 1-drop saline solution unconscious pt if (-) response pt is in deep coma

5. Test of memory considered educational background

a.) Short term memory

- What did you eat for breakfast?

Damage to temporal lobe (+) antero grade amnesia

b.) Long term memory

(+) Retrograde amnesia damage to limbic system

6. Levels of orientation

Time Place Person

Graphesthesia- can identify numbers or letters written on palm with a blunt object.

Agraphesthesia cant identify numbers or letters written on palm with a blunt object.

CN assessment:

I Olfactory s

II Optic s
III Oculomotor m

IV Trocheal m smallest CN

V Trigeminal b largest CN

VI Abducens m

VII Facial b

VIII Acustic/auditory s

IX Glassopharyngeal b

X Vagus b longest CN

XI Spinal accessory m

XII Hypoglossal m

I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa use coffee, bar soap, vinegar,
cigarette tar

- Hyposmia decrease sensitivity to smell

- Diposmia distorted sense of smell

- Anosmia absence of sense of smell

Either of 3 might indicate head injury damage to cribriform plate of ethmoid bone where olfactory
cells are located or indicate inflammation condition sinusitis

II optic- test of visual acuity Snellens chart central or distance vision

Snellens E chart used for illiterate chart

N 20/20 vision distance by w/c person can see letters- 20 ft

Numerator distance to snellens chart

Denominator distance the person can see the letters

OD Rt eye 20/20 20/200 blindness cant read E biggest

OS left eye 20/20

OU both eye 20/20

2. Test of peripheral vision/ visual field

a. Superiority

b. Bitemporally

c. Inferiorly

d. Nasally

Common Disorders see page 85-87 for more info on glaucoma, etc.

1. Glaucoma Normal 12 21 mmHg pressure

- Increase IOP - Loss of peripheral vision tunnel vision

2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision

3. Retinal detachment curtain veil like vision & floaters

4. Macular degeneration black spots

III, IV, VI tested simultaneously

- Innervates the movementt of extrinsic ocular muscle

6 cardinal gaze EOM

Rt eye N left eye

IO SO O

LR MR E

SR
3 4 EOM

IV sup oblique

VI lateral rectus

Normal response PERRLA (isocoria equal pupil)

Anisocoria unequal pupil

Oculomotor

1. Raising of eyelid Ptosis

2. Controls pupil size 2 -3 cm or 1.5 2 mm

V Trigeminal Largest consists of - ophthalmic, maxillary, mandibular

Sensory controls sensation of the face, mucus membrane; teeth & cornea reflex

Unconscious instill drop of saline solution

Motor controls muscles of chewing/ muscles of mastication

Trigeminal neuralgia diff chewing & swallowing extreme food temp is not recommended

Question: Trigeminal neuralgia, RN should give

a. Hot milk, butter, raisins

b. Cereals

c. Gelatin, toast, potato all correct but

d. Potato, salad, gelatin salad easier to chew

VI Facial: Sensory controls taste ant 2/3 of tongue test cotton applicator put sugar.

-Put applicator with sugar to tip to tongue.

-Start of taste insensitivity: Age group 40 yrs old

Motor- controls muscles of facial expression, smile frown, raise eyebrow

Damage Bells palsy facial paralysis

Cause bells palsy pedia R/T forcep delivery

Temporary only

Most evident clinical sign of facial symmetry: Nasolabial folds

VIII Acoustic/ vestibule cochlear (controls hearing) controls balance (kenesthesia or position sense)

- Movement & orientation of body in space

- Organ of Corti for hearing true sense organ of hearing

Outer tympanic membrane, pinna, oricle (impacted cerumen), cerumen

Middle hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media

- Eustachean ear

Inner ear- meniere dse, sensory hearing loss (research parts! & dse)

Remove vestibule menieres dse disease inner ear

Archimedes law buoyancy (pregnancy fetus)

Daltons law partial pressure of gases

Inertia law of motion (dizziness, vertigo)

1.) Pt with multiple stab wound - chest

- Movement of air in & out of lungs is carried by what principle?

- Diffusion Daltons law

2.) Pregnant check up ultrasound reveals fetus is carried by amniotic fluid

- Archimedes

3.) Severe vertigo due- Inertia

Test for acoustic nerve:

- Repeat words uttered

IX Glossopharyngeal controls taste posterior 1/3 of tongue

X Vagus controls gag reflex

Test 9 10

Pt say ah check uvula should be midline

Damage cerebral hemisphere is L or R

Gag reflex place tongue depression post part of tongue

Dont touch uvula

XI Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)

- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia

XII Hypoglossal controls movement of tongue say ah. Assess tongue position=midline

L or R deviation

- Push tongue against cheek

- Short frenulum lingue

Tongue tied bulol

ENDOCRINE

Fx of endocrine ductless gland

Main gland Pituitary gland located at base of brain of Stella Turcica

Master gland of body

Master clock of body

Anterior pituitary gland adenohypophysis

Posterior pituitary gland neurohypophysis

Posterior pituitary:

1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage.

- Give after placental delivery to prevent uterine atony.

b.) Milk letdown reflex with help of prolactin.

2.) ADH antidiuretic hormone (vasopressin) -Prevents urination conserve H2O

A. DIABETIS INSIPIDUS (DI- dalas ihi) hyposecretion of ADH

Cause: idiopathic/ unknown

Predisposing factor:

1. Pituitary surgery

2. Trauma/ head injury

3. Tumor

4. Inflammation

* alcohol inhibits release of ADH

S & Sx:

1. Polyuria

2. Sx of dehydration (1st sx of dehydration in children-tachycardia)

- Excessive thirst (adult)

- Agitation

- Poor skin turgor

- Dry mucus membrane

3. Weakness & fatigue

4. Hypotension if left untreated -

5. Hypovolemic shock

Anuria late sign hypovolemic shock

Dx Proc:

1. Decrease urine specific gravity- concentrated urine

N= 1.015 1.035

2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia

Mgt:

1. Force fluid 2,000 3,000ml/day

2. Administer IV fluid replacement as ordered

3. Monitor VS, I&O

4. Administer meds as ordered

a.) Pitresin (vasopressin) IM

5. Prevent complications

Most feared complication Hypovolemic shock

B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone

- Increase ADH

- Idiopathic/ unknown

Predisposing factor

1. Head injury

2. Related to Bronchogenic cancer or lung caner-

Early Sign of Lung Ca - Cough 1. non productive 2. productive

3. Hyperplasia of Pit gland

Increase size of organ

S&Sx

1. Fluid retention

2. Increase BP HPN

3. Edema
4. Wt gain

5. Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure

Dx Proc:

1. Urine specific gravity increase diluted urine

2. Hyponatremia Decreased Na

Nsg Mgt:

1. Restrict fluid

2. Administer meds as ordered eg. Diuretics: Loop and Osmotic

3. Monitorstrictly V/S, I&O, neuro check increase ICP

4. Weigh daily

5. Assess for presence edema

6. Provide meticulous skin care

7. Prevent complications increase ICP & seizures activity

Anterior Pituitary Gland adeno

1. Growth hormone (GH) (Somatotropic hormone)

Fx: Elongation of long bones

Decrease GH dwarfism children

Increase GH gigantism

Increase GH acromegaly adult

Puberty 9 yo 21 yo

Epiphyseal plate closes at 21 yo

Square face

Square jaw

Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness

- Somatostatin Hormone antagonizes the release of of GH

2. Melanocytes stimulating hormone - MSH

- Skin pigmentation

3. Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland

(Oxytocin-Initiates milk letdown reflex)

4. Adrenocorticotropic hormone ACTH - Development & maturation of adrenal cortex

5. Luteinizing hormone produces progesterone.

6. FSH- produces estrogen

PINEAL GLAND

1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion

THYROID GLAND (TG)

Question: Normal physical finding on TG:

a. With tenderness thyroid never tender

b. With nodular consistency- answer

c. Marked asymmetry only 1 TG

d. Palpable upon swallowing - Normal TG never palpable unless with goiter

TG hormones:

T3 T4 Thyrocalcitonin

- Triodothyronine -Tetraiodothyronine/ Tyroxine FX antagonizes effects of parathormone

- 3 molecules of iodine - 4 molecules of iodine

Metabolic hormone

Increase metabolism brain inc cerebration, inc v/s all v/s down, constipation

Hypo T3 T4 - lethargy & memory impairment

Hyper T3 T4 - agitation, restlessness, and hallucination

7. Increase VS, increase motility

HYPOTHYROIDISM all decreased except wt & menstruation, loss of appetite but with wt gain
menorrhagia increase in mens

HYPERTHYROIDISM - Increase appetite wt loss, amenorrhea

SIMPLE GOITER enlarged thyroid gland - iodine deficiency

Predisposing factors

1. Goiter belt area - Place far from sea no iodine. Seafoods rich in iodine
2. Mountainous area increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake)

Cabbage has progoitrin an anti thyroid agent with no iodine

Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops),
all nuts.

3. Goitrogenic drugs:

Anti thyroid agents :(PTU) prephyl thiupil

Lithium carbonate, Aspirin PASA

Cobalt, Phenyl butasone

Endemic goiter cause # 1

Sporadic goiter caused by #2 & 3

S & Sx enlarged TG

Mild restlessness

Mild dysphagia

Dx Proc.

1. Thyroid scan reveals enlarged TG

2. Serum TSH increase (confirmatory)

3. Serum T3, T4 N or below N

Nsg Mgt:

1. Administer meds

a.) Iodine solution Logols solution or saturated sol of K iodide SSKI

Nsg Mgt Lugols sol violet color

1. use straw prevent staining teeth

2. Prophylaxis 2 -3 drops Treatment 5 to 6 drops

Use straw to prevernt staining of teeth

1. Lugols sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron

solution.

B. Thyroid h / Agents

1. Levothyroxine (Synthroid)

2. Liothyronine (cytomel)

3. Thyroid extract

Nsg Mgt: for TH/agents

1. Monitor vs. HR due tachycardia & palpitation

2. Take it early AM SE insomnia

3. Monitor s/e

Tachycardia, palpitations

Signs of insomnia

Hyperthyroidism restlessness agitation

Heat intolerance

HPN

3. Encourage increase intake iodine iodine is extracted from seaweeds (!)

Seafood- highest iodine content oysters, clams, crabs, lobster

Lowest iodine shrimps

Iodized salt easily destroyed by heat take it raw not cooked

4. Assist surgery- Sub total thyroidectomy-

Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision
site.Check nape for wet blood. 4.Laryngeal spasm DOB, SOB trache set ready at bedside.

2.) HYPOTHYROIDISM decrease secretion of T3, T4 can lead to MI / Atherosclerosis

Adult myxedema

Child- cretinism only endocrine dis lead to mental retardation

Predisposing factor:

1. `Iatrogenic causes caused by surgery

2. Atrophy of TG due to:

a. Irradiation

b. Trauma

c. Tumor, inflammation

3. Iodine def

4. Autoimmune Hashimoto disease

S&Sx everything decreased except wt gain & mens increase)

Early signs weakness and fatigue

Loss of appetite increased lypolysis breakdown of fats causing atherosclerosis = MI

Wt gain

Cold intolerance myxedema - coma

Constipation

Late Sx brittle hair/ nails

Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema

Horseness voice

Decrease libido
Decrease VS hypotension bradycardia, bradypnea, and hypothermia

Lethargy

Memory impairment leading to psychosis-forgetfulness

Menorrhagia

Dx:

1. Serum T3 T4 decrease

2. Serum cholesterol increase can lead to MI

3. RA IU radio iodine uptake decrease

Nsg Mgt:

1. Monitor strictly V/S. I&O to determine presence of myxedema coma!

Myxedema Coma - Severe form of hypothyroidism

Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia

Might lead to progressive stupor & coma

Impt mgt for Myxedema coma

1. Assist mech vent priority a/w

2. Adm thyroid hormone

3. Adm IVF replacement force fluid

Mgt myxedema coma

1. Monitor VS, I&O

2. Provide dietary intake low in calories due to wt gain

3. Skin care due to dry skin

4. Comfortable & warm environment due to cold intolerance

5. Administer IVF replacements

6. Force fluid

7. Administer meds take AM SE insomia. Monitor HR.

Thyroid hormones

Levothyroxine(Synthroid), Liothyronine (cytomel)

Thyroid extracts

8. Health teaching & discharge plan

a. Avoidance precipitating factors leading to myxedema coma:

1. Exposure to cold environment

2. Stress 3. Infection

4. Use of sedative, narcotics, anesthetics not allowed CNS depressants V/S already down

Complications:

9. Hypovolemic shock, myxedema coma

10. Hormonal replacement therapy - lifetime

11. Importance of follow up care

HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens)

-Increased T3 & T4

Predisposing factors:

1. Autoimmune disease release of long acting thyroid stimulator (LATS)

Exopthalmos

Enopthalmos severe dehydration depressed eye

2. Excessive iodine intake

3. Hyperplasia of TG
S&Sx:

1. Increase in appetite hyperphagia wt loss due to increase metabolism

2. Skin is moist - perspiration

3. Heat intolerance

4. Diarrhea increase motility

5. All VS increase = HPN, tachycardia, tachypnea, hyperthermia

6. CNS changes

8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations

7. Goiter

8. Exopthalmos pathognomonic sx

9. Amenorrhea

Dx:

1. Serum T3 & T4 - increased

2. Radio iodine uptake increase

3. Thyroid scan reveals enlarged TG

Nsg Mgt:

1. Monitor VS & I & O determine presence of thyroid storm or most feared complication:
Thyrotoxicosis

2. Administer meds

a. Antithyroid agents

1. Prophylthiuracil (PTU)

2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab
culture

Most feared complication : Thrombosis stroke CVS

3. Diet increase calorie to correct wt loss

4. Skin care

5. Comfy & cool environment

6. Maintain siderails- due agitation/restlessness

7. Provide bilateral eye patch to prevent drying of eyes- exopthalmos

8. Assist in surgery subtotal thyroidectomy

Nsg Mgt: pre-op

Adm Lugols solution (SSKI) K iodide

9. To decrease vascularity of TG

10. To prevent bleeding & hemorrhage

Mgt post op:

Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis

Triad signs of thyroidstorm;

a. Tachycardia /palpitation

b. Hyperthermia

c. Agitation

Nsg Mgt Thyroid Storm:

1. Monitor VS & neuro check

Agitated might decrease LOC

2. Antipyretic fever
Tachycardia - blockers (-lol)

3. Siderails agitated

Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland

Secretes Para hormone

If removed, hypocalcemia - classic sign tetany 1. .(+) Trousseau sign/ 2. Chvostecks sign

Nsg Mgt:

Adm calcium gluconate slowly to prevent arrhythmia

Ca gluconate toxicity antidote MgSO4

3.Laryngeal (voice box) nerve damage (accidental)

Sx: hoarseness of voice

***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage

Notify physician!

4. Signs of bleeding post subtotal thyroidectomy

- Feeling of fullness at incision site

Nsg mgt:

Check soiled dressing at nape area

5. Signs of laryngeal spasm

a. DOB

b. SOB

Prepare at bedside tracheostomy

6. Hormonal replacement therapy - lifetime

7. Importance of follow up care

(Liver cirrhosis bedside scissor if pt complaints of DOB)

(Cut cystachean tube to deflate balloon)

Parathyroid gland pair of small nodules located behind the TG

11. Secrets parathyroid hormone promotes Ca reabsorption

Thyrocalcitonin antagonises secretion of parathyroid hormone

1. Hypoparthroidism decrease of parathyroid hormone

2. Hyperparathroidsm

HYPOPARATHYROIDISM decreased parathormone

Hypocalcemia Hyperphosphatemia

(Or tetany)

[If Ca decreases, phosphate increases]

A. Predisposing, factors:

1. Following subtotal thyroidectomy

2. Atrophy of parathyroid gland due to

a. Irradiation

b. Trauma

S&Sx:

1. Acute tetany

a. Tingling sensation

b. Paresthesia

c. Dysphagia

d. Laryngospasm

e. Bronchospasm

Pathognomonic Sign of tetany:

a. (+) Trousseaus or carpopedial spasm

b. (+) Chvostecks sign

f. Seizure most feared complication

g. Arrhythmia

2. Chronic tetany

a. Loss of tooth enamel

b. Photophobia & cataract formation

c. GIT changes anorexia, n/v, general body malaise

d. CNS changes memory impairment, irritability

Dx:

1. Serum calcium decrease (N 8.5 11 mg/100ml)

2. Serum phosphate increase (N 2.5 4.5 mg/100ml)

3. X-ray of long bone decrease bone density

4. CT Scan reveals degeneration of basal ganglia

Nsg Mgt:

1. Administration of meds:

a.) Acute tetany

Ca gluconate IV, slowly

b.) Chronic tetany

1. Oral Ca supplements

Ex. Ca gluconate

Ca carbonate

Ca lactate

Vit D (Cholecalceferol)

Drug diet sunlight

Cholecalceferol calcidiol calcitriol 7am 9am

2. Phosphate binder

Alumminum DH gel (ampho gel)

SE constipation

Antacid

AAC MAD

Aluminum containing acids Mg containing antacids

Ex. Milk or magnesia

Aluminum OH gel Diarrhea

Constipation Maalox magnesium & aluminum - Less s/e

2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure

3. Diet increase Ca & decrease phosphorus

- Dont give milk due to increase phosphorus

Good = anchovies increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.

4. Bedside tracheostomy set due to laryngospasm

5. Encourage to breath with paper bag in order to produce mild respiratory acidosis to promote
increase ionized Ca levels

6. Most feared complication : Seizure & arrhythmia

7. Hormonal replacement therapy - lifetime

8. Important fallow up care

HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure

Hypercalcemia can lead to Hypophosphatemia

Bone dse - kidney stones

Mineralization

Leading to bone fracture

Ca 99% bones

1% serum blood

Predisposing Factors:

1. Hyperplasia parathyroid gland (PTG)

2. Over compensation of PTG due to Vit D deficiency

Children Rickets Vit D

Adults Osteomalacia deficiency

Sippys diet Vit D diet not good for pt with ulcer

2 -4 cups of milk & butter

Karrels diet Vit D diet not good for pt with ulcer

6 cups of milk & whole cream

Food rich in CHON eggnog combination of egg & milk

S/Sx:

Bone fracture

1. Bone pain (especially at back), bone fracture

2. Kidney stone
a. Renal colic

b. Cool moist skin

3. GIT changes anorexia, n/v, ulcerations

4. CNS involvement irritability, memory impairment

Dx Proc:

1. Serum Ca increase

2. Serum phosphorus decreases

3. X-ray long bones reveals bone demineralization

Nsg Mgt: Kidney Stone

1. Force fluids 2,000 3,000/day or 2-3L/day

2. Isotonic solution

3. Warm sitz bath for comfort

4. Strain all urine with gauze pad

5. Acid ash diet cranberry, plum, grapefruit, vit C, calamansi to acidify urine

6. Adm meds

a. Narcotic analgesic Morphine SO4, Demerol (Meperidine Hcl)

S/E resp depression. Monitor RR)

Narcan/ Naloxone antidote

Naloxone toxicity tremors

7. Siderails

8. Assist in ambulation
9. Diet low in Ca, increase phosphorus lean meat

10. Prevent complication

Most feared renal failure

11. Assist surgical procedure parathyroidectomy

12. Impt ff up care

13. Hormonal replacement- lifetime

ADRENAL GLAND

12. Atop of @ kidney

13. 2 parts

Adrenal cortex outermost layer

Adrenal medulla - innermost layer

14. Secrets cathecolamines

a.) Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP

Adrenal Medullas only disease:

PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla

-increase nor/epinephrine

-with HPN and resistant to drugs

-drug of choice: beta blockers

-complication: HPN crisis = lead to stroke

-no valsalva maneuver

Adrenal Cortex
1. Zona fasiculata secrets glucocorticoids

Ex. Cortisol - Controls glucose metabolism (SUGAR)

2. Zona reticularis secrets traces of glucocorticoids & androgenic hormones

M testosterone

F estrogen & progesterone

Fx promotes development of secondary sexual characteristics

3. Zona glomerulosa - secretes mineralcortisone

Ex. Aldosterone

Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)

ADDISONS DISEASE Steroids-lifetime

Decreased adrenocortical hormones leading to:

a.) Metabolic disturbances (sugar)

b.) F&E imbalances- Na, H2O, K

c.) Deficiency of neuromuscular function (salt & sex)

Predisposing Factors:

1. Atrophy of adrenal gland

2. Fungal infections

3. Tubercular infections

S/Sx:

1. Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol

T tremors, tachycardia

I - irritability

R - restlessness

E extreme fatigue

D diaphoresis, depression

2. Decrease plasma cortisol

Decrease tolerance to stress lead to Addisonians crisis

3. Decrease salt Hyponatermia Decreased mineralocorticoids - Aldosterone

Hypovolemia

a.) Hypotension

b.) Signs of dehydration extreme thirst, agitation

c.) Wt loss

4. Hyperkalemia

a.) Irritability

b.) Diarrhea

c.) Arrhythmia

5. Decrease sexual urge or libido- Decreased Androgen

6. Loss of pubic and axillary hair

To Prevent STD Local practice monogamous relationship

CGFNS/NCLEX condom

7. Pathognomonic sign bronze like skin pigmentation due to decrease cortisol will stimulate pituitary
gland to release melanocyte stimulating hormone.
Dx Proc:

1. FBS decrease FBS (N 80 120 mg/dL)

2. Plasma cortisol decreased

Serum Na decreased (N 135 145 meg/L)

3. Serum K increased (N 3.5 5.5 meg/L)

Nsg Mgt:

1. Monitor VS, I&O to determine presence of Addisonian crisis

15. Complication of Addisons dse : Addisonian crisis

16. Results the acute exacerbation of Addisons dse characterized by :

Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia

17. Lead to progressive stupor & coma

Nsg Mgt Addisonian Crisis (Coma)

1. Assist in mechanical ventilation

2. Adm steroids

3. Force fluids

2. Administer meds

a.) Corticosteroids - (Decadron) or Dexamethazone

- Hydrocortisone (cortisone)- Prednisone

Nsg Mgt with Steroids

1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.

2. Taper the dose (w/draw, gradually from drug) sudden withdrawal can lead to addisonian crisis
3. Monitor S/E (Cushings syndrome S/Sx)

a.) HPN

b.) Hirsutism

c.) Edema

d.) Moon face & buffalo hump

e.) Increase susceptibility to infection sue to steroids- reverse isolation

b.) Mineralocorticoids ex. Flourocortisone

3. Diet increase calorie or CHO

Increase Na, Increase CHON, Decrease K

4. Force fluid

5. Administer isotonic fluid as ordered

6. Meticulous skin care due to bronze like

7. HT & discharge planning

a) Avoid precipitating factors leading to Addisonian crisis

1. Sudden withdrawal crisis

2. Stress

3. Infection

b) Prevent complications

Addisonian crisis & Hypovolemic shock

8. Hormonal replacement therapy lifetime

9. Important: follow up care

CUSHINGS SYNDROME increase secretion of adrenocortical hormone

Predisposing Factors:

1. Hyperplasia of adrenal gland

2. Tubercular infection milliary TB

S/Sx

1. Increase sugar Hyperglycemia

3 Ps

1. Polyuria

2. Polydipsia increase thirst

3. Polyphagia increase appetite

Classic Sx of DM 3 Ps & glycosuria + wt loss

2. Increase susceptibility to infection due to increased corticosteroid

3. Hypernatrermia

a. HPN

b. Edema

c. Wt gain

d. Moon face

Buffalo hump

Obese trunk classic signs

Pendulous abdomen

Thin extremities

4. Hypokalemia

a. Weakness & fatigue

b. Constipation

c. ECG (+) U wave

5. Hirsutism increase sex

6. Acne & striae

7. Increase muscularity of female

Dx:

1. FBS increase (N: 80-120mg/dL)

2. Plasma cortisol increase

3. Na increase (135-145 meq/L)

4. K- decrease (3.5-5.5 meq/L)

Nsg Mgt:

1. Monitor VS, I&O

2. Administer meds

a. K- sparing diuretics (Aldactone) Spironolactone

- promotes excretion of NA while conserving potassium

Not lasix due to S/E hypoK & Hyperglycemia!

3. Restrict Na

4. Provide Dietary intake low in CHO, low in Na & fats

High in CHON & K

5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.

6. Reverse isolation

7. Skin care due acne & striae

8. Prevent complication

- Most feared arrhythmia & DM

(Endocrine disorder lead to MI Hypothyroidism & DM)

9. Surgical bilateral Adrenolectomy

10. Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid!

PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland

Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless)

Secrete pancreatic juices at pancreatic ducts. cells

Aids in digestion (in stomach) secrets glucagon

Fxn: hyperglycemia (high glucose)

Cells

Secrets insulin

Fxn: hypoglycemia

Delta Cells

Secrets somatostatin
Fxn: antagonizes growth hormone

3 disorders of the Pancreas

1. DM

2. Pancreatic Cancer

3. Pancreatitis

Overview only:

PANCREATITIS (check page 72) acute inflammation of pancreas leading to pancreatic edema,
hemorrhage & necrosis due to

Autodigestion self-digestion

Cause: unknown/idiopathic

18. Or alcoholism

Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa

(+) Grey turners sign ecchymosis of flank area

Both sx means hemorrhage

CHRONIC HEMORRHAGIC PANCREATITIS- bangugot

Predisposing factors - unknown

Risk factor:

1. History of hepatobiliary disorder

2. Alcohol

3. Drugs thiazide diuretics, oral contraceptives, aspirin, penthan

4. Obesity

5. Hyperlipidemia

6. Hyperthyroidism

7. High intake of fatty food saturated fats

DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat
metabolism

Classification:

I. Type I DM (IDDM) Juvenile onset, common in children, non-obese brittle dse

-Insulin dependent diabetes mellitus

Incidence rate

1.) 10% of population with DM have Type I

Predisposing Factor:

1. 90% hereditary total destruction of pancreatic dells

2. Virus

3. Toxicity to carbon tetrachloride

4. Drugs Steroids both cause hyperglycemia

Lasix - loop diuretics

S/Sx:

3 PS + G

1.) Polyuria

2.) Poydipsia

3.) Polyphagia

4.) Glycosuria

5.) Weight loss

6.) Anorexia

7.) N/V

8.) Blurring of vision

9.) Increase susceptibility to infection

10.) Delayed/ poor wound healing

Mgt:

1. Insulin Therapy

Diet

Exercise

Complications Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis (DKA) due to increase fat catabolism or breakdown of fats

DKA (+) fruity or acetone breath odor

Kassmauls respiration rapid, shallow breathing

Diabetic coma (needs oxygen)

II. Type II DM (NIDDM)

Adult/ maturity onset type age 40 & above, obese

Incidence Rate

1. 90% of pop with DM have Type II

Mid 1980s marked increase in type II because of increase proliferation of fast food chains!

Predisposing Factor:

1. Obesity obese people lack insulin receptors binding site

2. Hereditary

S/Sx:

1. Asymptomatic

2. 3 Ps and 1G

Tx:

1. Oral Hypoglycemic Agents (OHA)

2. Diet

3. Exercise

Complication: HONKC

H hyper

O osmolar
N non

K ketotic

C coma

III. GESTATIONAL DM occurs during pregnancy & terminates upon delivery of child

Predisposing Factors:

1. Unknown/ idiopathic

2. Influence of maternal hormones

S/Sx :

Same as type II

1. Asymptomatic

2. 3 Ps & 1G

Type of delivery CS due to large baby

Sx of hypoglycemia on infant

1. High pitched shrill cry

2. Poor sucking reflex

IV. DM ASSOCIATED WITH OTHER DISORDER

a.) Pancreatic tumor

b.) Cancer

c.) Cushings syndrome

3 MAIN FOOD GROUPS

Anabolism Catabolism
1. CHON glucose glycogen

2. CHON amino acids nitrogen

3. Fats fatty acids free fatty acids (FFA) Cholesterol & Ketones

Pancreas glucose ATP (Main fuel/energy of cell )

Reserve glucose glycogen

Liver will undergo glucogenesis synthesis of glucagons

& Glycogenolysis breakdown of glucagons

& Gluconeogenesis formation of glucose form CHO sources CHON & fats

Hyperglycemia pancreas will not release insulin. Glucose cant go to cell, stays at circulation causing
hyperglycemia.

increase osmotic diuresis glycosuria

Lead to cellular starvation

Lead to wt loss stimulates the appetite/ satiety center polyuria

(Hypothalamus)

Cellular dehydration

Polyphagia

Stimulates thirst center (hypothalamus)

Polydipsia

Increased CHON catabolism

Lead to (-) nitrogen balance

Tissue wasting (cachexia)

Increase fat catabolism

Free fatty acids

Cholesterol ketones DKA

Atherosclerosis coma
HPN death

MI stroke

DIABETIC KETOACIDOSIS (DKA)

- Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.

- Ketones- a CNS depressant

Predisposing factor:

1. Stress between stress and infection, stress causes DKA more.

2. Hyperglycemia

3. Infection

S/Sx: 3 Ps & 1G

1. Polyuria

2. Polydipsia

3. Polyphagia

4. Glycosuria

5. Wt loss

6. Anorexia, N/V

7. (+) Acetone breath odor- fruity odor pathognomonic DKA

8. Kussmaul's resp-rapid shallow respiration

9. CNS depression
10. Coma

Dx Proc:

1. FBS increase, Hct increase (compensate due to dehydration)

N =BUN 10 -20 mg/100ml --increased due to severe dehydration

Crea - .8 1 mg/100ml

Hct 42% (should be 3x high)-nto hgb

Nsg Mgt:

1. Can lead to coma assist mechanical ventilation

2. Administer .9NaCl isotonic solution

Followed by .45NaCl hypotonic solution

To counteract dehydration.

3. Monitor VS, I&O, blood sugar levels

4. Administer meds as ordered:

a.) Insulin therapy IV push

Regular Acting Insulin clear (2-4hrs, peak action)

b.) To counteract acidosis Na HCO3

c.) Antibiotic to prevent infection

Insulin Therapy

A. Sources:

1. Animal source beef/ pork-rarely used. Causes severe allergic reaction.

2. Human has less antigenecity property

Cause less allergic reaction. Humulin

If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo.

3. Artificially compound

B. Types of Insulin

1. Rapid Acting Insulin - Ex. Regular acting I

2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)

3. Long acting I - Ex. Ultra lente

Types of Insulin color & consistency onset peak duration

1. Rapid clear - 2-4h -

2. Intermediate cloudy - 6-12h -

3. Long acting cloudy - 12-24h -

Ex. 5am Hemoglucose test (HGT)

250 mg/dl

Adm 5 units of RA I

Peak 7-9am monitor hypoglycemic reaction at this time- TIRED

Nsg Mgt: upon injection of insulin:

1.Administer insulin at room temp! To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues

2. Insulin is only refrigerated once opened!

3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles.
4. Use gauge 25 26needle tuberculin syringe

5. Administer insulin at either 45(for skinny pt) or 90 (taba pt)depending on the client tissue deposit.

6. Dont aspirate after injection

7. Rotate injection site to prevent lipodystrophy

8. Most accessible site abdomen

9. When mixing 2 types of insulin, aspirate

1st regular/ clear before cloudy to prevent contaminating clear insulin & to promote accurate
calibration.

10. Monitor signs of complications:

a. Allergic reactions lipodystrophy

b. Somogyis phenomenon hypoglycemia followed by periods of hyperglycemia or rebound effect of

insulin.

11. 1ml or cc of tuberculin = 100 units of insulin

- - 1 cc = 100 units

- - .5cc = 50 units

- - .1 cc = 10 units
6 units RA

Most Feared Complication of Type II DM

Hyper osmolarity = severe dehydration

Osmolar

Non - absence of lipolysis

Ketotic - no ketone formation

Coma S/Sx: headache, restlessness, seizure, decrease LOC = coma

Nsg Mgt; - same as DKA except dont give NaHCO3!

1.Can lead to coma assist mechanical ventilation

2. Administer .9NaCl isotonic solution

Followed by .45NaCl hypotonic solution

To counteract dehydration.

3.Monitor VS, I&O, blood sugar levels

4.Administer meds

a.) Insulin therapy IV

b.) Antibiotic to prevent infection

Tx:

O ral

H ypoglycemic
A gents

19. Stimulates pancreas to secrete insulin

Classifications of OHA

1. First generation Sulfonylurear

a. Chlorpropamide (diabenase)

b. Tolbutamide (orinase)

c. Tolazamide (tolinase)

2. 2nd generation sulfonylurear

a. Diabeta (Micronase)

b. Glipside (Glucotrol)

Nsg Mgt or OHA

1. Administer with meals to lessen GIT irritation & prevent hypoglycemia

2. Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-

Disufram

Dx for DM

1. FBS N 80 120 mg/dl = Increased for 3 consecutive times =confirms DM!!

+ 3 Ps & 1G

2. Oral glucose tolerance (OGTT) - Most sensitive test

3. Random blood sugar increased

4. Alpha Glucosylated Hgb elevated

Nsg Mgt;

1. Monitor for PEAK action of OHA & insulin

Notify Doc

2. Monitor VS, I&O, neurocheck, blood sugar levels.

3. Administer insulin & OHA therapy as ordered.

4. Monitor signs of hyper & hypoglycemia.

Pt DM hinimatay

20. You dont know if hypo or hyperglycemia.

Give simple sugar

(Brain can tolerate high sugar, but brain cant tolerate low sugar!)

Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin

5. Provide nutritional intake of diabetic diet:

CHO 50%

CHON 30%

Fats 20%

-Or offer alternative food products or beverage.

-Glass of orange juice.

6. Exercise after meals when blood glucose is rising.

7. Monitor complications of DM

a. Atherosclerosis HPN, MI, CVA

b. Microangiopathy small blood vessels

Eyes diabetic retinopathy , premature cataract & blindness

Kidneys recurrent pyelonephritis & Renal Failure

(2 common causes of Renal Failure : DM & HPN)

c. Gangrene formation

d. Peripheral neuropathy

1. Diarrhea/ constipation

2. Sexual impotence

e. Shock due to cellular dehydration

8. Foot care mgt

a. Avoid waking barefooted

b. Cut toe nails straight

c. Apply lanolin lotion prevent skin breakdown

d. Avoid wearing constrictive garments

9. Annual eye & kidney exam

10. Monitor urinalysis for presence of ketones

Blood or serum more accurate

11. Assist in surgical wound debridement

12. Monitor signs or DKA & HONKC

13. Assist surgical procedure

BKA or above knee amputation

Overview: HEMATOLOGICAL SYSTEMS

I Blood

II Blood vessels

III Blood forming organs

1. Thymus removed myasthenia gravis

2. Liver largest gland

3. Lymph nodes

4. Lymphoid organs payers patch

5. Bone marrow

6. Spleen destroys RBC

Blood vessels

1. Veins SVC, IVC, Jugular vein blood towards the heart

2. Artery carries blood away from the

21. Aorta, carotid

3. Capillaries

Blood 45% formed elements 55% plasma fluid portion of vlood. Yellow color.

Serum Plasma CHONs (Produced in Liver)

1. Albumin- largest, most abundant plasma

Maintains osmotic pressure preventing edema

FXN: promotes skin integrity

2. Globulins alpha transports steroids Hormones & bilirubin

- Transports iron & copper

Gamma transport immunoglobulins or antibodies

3. Prothrombin fibrinogen clotting factor to prevent bleeding

Formed Elements:
1. RBC (erythrocytes) Spleen life span = 120 days

(N) 3 6 M/mm3

- Anucleated

- Biconcave discs

- Has molecules of Hgb (red cell pigment)

Transports & carries O2

SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired circulation of RBC.

-immature cells=hemolysis of RBC=decreased hgb

3 Nsg priority

1. a/w avoid deoxygenating activities

- High altitude is bad

2. Fluid deficit promote hydration

3. Pain & comfort

Hgb ( hemoglobin)

F= 12 14 gms %

M = 14-16 gms %

Hct 3x hgb 12 x 3 = 36

(hamatocrit) F 36 42% 14 x 3 = 42

M 42 48%
Average 42%

- Red cell percentage in whole red

Substances needed for maturation of RBC

a.) Folic acid

b.) Iron

c.) Vit C

d.) Vit B12 (cyanocobalamin)

e.) Vit B6 (Pyridoxine)

f.) Intrinsic factor

Pregnant: 1st trimester- Folic acid prevent neural tube deficit

3rd tri iron

Life span of rbc 80 120 days. Destroyed at spleen.

WBC leucocytes 5,000 10,000/mm3

GRANULOCYTES

1. Polymorphonuclearneutrophils

Most abundant 60-70% WBC

- fx short term phagocytosis

For acute inflammation

2. PM Basophils

-Involved in Parasitic infection

- Release of chem. Mediator for inflammation

Serotonin, histamine, prostaglandin, bradykinins

3. PM eosinophils

- Allergic reactions NON-GRANULOCYTES

1. Monocytes (macrophage) - largest WBC

- involved in long term phagocytes

- For chronic inflammation

- Other name macrophage

Macrophage in CNS- microglia

Macrophage in skin Histiocytes

Macrophage in lungs alveolar macrophage

Macrophage in Kidneys Kupffer cells

2. Lymphocytes
B Cell L bone marrow or bursa dependent

T cell devt of immunity- target site for HIV

NK cell natural killer cell

Have both antiviral & anti-tumor properties

3.Platelets (thrombocytes)

N- 150,000 450, 000/ mm3

it promotes hemostasis prevention of blood loss by activating clotting

- Consists of immature or baby platelets known as megakaryocytes target of virus dengue

- Normal lifespan 9 12 days

Drug of choice for HIV Zidovudine (AZT or Retrovir)

Standard precaution for HIV gloves, gown, goggles & mask

Malaria night biting mosquito

Dengue day biting mosquito

Signs of platelet dis function:

a.) Petecchiae

b.) Ecchemosis/ bruises

c.) Oozing or blood from venipuncture site

ANEMIA

Iron deficiency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate
absorption of iron leading to hypoxemic injury.
Incidence rate:

1. Common developed country due to high cereal intake

Due to accidents common on adults

2. Common tropical countries blood sucking parasites

3. Women 15 35yo reproductive yrs

4. Common among the poor poor nutritional intake

Suicide - common in teenager

Poisoning common in children (aspirin)

Aspiration common in infant

Accidents common in adults

Choking common in toddler

SIDS common in infant in US

22. Common in tropical zone Phil due blood sucks

Predisposing factor:

1. Chronic blood loss

a. Trauma

b. Mens

c. GIT bleeding:

i. Hematemesis-

ii. Melena upper GIT duodenal cancer

iii. Hematochezia lower GIT large intestine fresh blood from rectum

2. Inadequate intake of food rich in iron

3. Inadequate absorption of iron due to :

a. Chronic diarrhea

b. Malabsorption syndrome celiac disease-gluten free diet. Food for celiac pts- sardines

c. High cereal intake with low animal CHON ingestion

d. Subtotal gastrectomy

4. Improper cooking of food

S/Sx:

1. Asymptomatic

2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor

3. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells

4. Atropic glossitis, dysphagia, stomatitis

5. Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic
behavior)

Brittle hair, spoon shaped nail atrophy of epidermal cells

N = capillary refill time < 2 secs

N = shape nails biconcave shape, 180

Atrophy of cells Plummer Vinsons Syndrome due to cerebral hypoxia

1. Atropic glossiti inflammation of tongue due to atrophy of pharyngeal and tongue cells

2. Stomatitis mouth sores

3. Dysphagia

Dx Proc:

1. RBC
2. Hgb

3. Reticulocyte

4. Hct

5. Iron

6. Ferritin

Nsg Mgt

1. Monitor signs of bleeding of all hema test including urine & stool

2. Complete bed rest dont overtire pt =weakness and fatigue=activity intolerance

3. Encourage iron rich food

23. Raisins, legumes, egg yolk

4. Instruct the pt to avoid taking tea - impairs iron absorption

5. Administer meds

a.) Oral iron preparation

Ferrous SO4

Fe gluconate

Fe Fumarate

Nsg Mgt oral iron meds:

1. Administer with meals to lessen GIT irritation

2. If diluting in iron liquid prep adm with straw

Straw

1. Lugols

2. Tetracycline

3. Oral iron
4. Macrodantine

3. Give Orange juice for iron absorption

4. Monitor & inform pts S/E

a. Anorexia

b. n/v

c. Abdominal pain

d. Diarrhea or constipation

e. Melena

If pt cant tolerate oral iron prep administer parenteral iron prep example:

1. Iron dextran (IV, IM)

2. Sorbitex (IM)

Nsg Mgt parenteral iron prep

1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues.

2. Dont massage injection site. Ambulate to facilitate absorption.

3. Monitor S/E:

a.) Pain at injury site

b.) Localized abscess (nana)

c.) Lymphadenopathy

d.) Fever/ chills

e.) Urticaria itchiness

f.) Hypotension anaphylactic shock

Anaphylactic shock give epinephrine

PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to

Hypochlorhydria decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.

Predisposing factor

1. Subtotal gastrectomy removal stomach

2. Hereditary

3. Infl dse of ileum

4. Autoimmune

5. Strict vegetable diet

STOMACH

Parietal or ergentaffen Oxyntic cells

Fxn produce intrinsic factor Fxn secrets Hcl acid

For reabsorption of B12 Fx aids in digestion

For maturation of RBC

Diet high caloric or CHO to correct wt loss

S/Sx:

1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor

2. GIT changes

a. Red beefy tongue PATHOGNOMONIC mouth sores

b. Dyspepsia indigestion

c. Wt loss

d. Jaundice

3. CNS

Most dangerous anemia: pernicious due to neuroglogic involvement.

a. Tingling sensation

b. Paresthesia

c. (+) Rombergs test

Ataxia

d. Psychosis

Dx:- Shillings test

Nsg Mgt Pernicious anemia

1. Enforce CBR

2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or
ventrogluteal. Not given oral due pt might have tolerance to drug

3. Diet high calorie or CHO. Increase CHON, iron & Vit C

4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged.

5. Avoid applying electric heating pads can lead to burns

APLASTIC ANEMIA stem cell disorder due to bone marrow depression leading to pancytopenia all
RBC are decreased

Decrease RBC decrease WBC decrease platelets

Anemia leukopenia thrombocytopenia

Increase WBC leukocytocys

Increase RBC polycythemia vera complication stroke, CVA, thrombosis

Predisposing factors leading to Aplastic Anemia

1. Chemicals Banzene & its derivatives

2. radiation

3. Immunologic injury

4. Drugs cause bone marrow depression

a. Broad spectrum antibiotic - Chlorampenicol

- Sulfonamides bactrim

b. Chemo therapeutic agents

Methotrexate alkylating agents

Nitrogen mustard anti metabolic

Vincristine plant alkaloid

S/Sx:

1. Anemia:

a. Weakness & fatigue

b. Headache, dizziness, dyspnea

c. cold sensitivity, pallor

d. palpitations

2. Leucopenia increase susceptibility to infection

3. Thrombocytopenia

a. Peticchiae

b. Oozing ofblood from venipuncture site

c. ecchymosis

Dx:

1. CBC pancytopenia

2. Bone marrow biopsy/ aspiration at post iliac crest reveals fatty streaks in bone marrow

Nsg Mgt:

1. Removal of underlying cause

2. Blood transfusion as ordered

3. Complete bed rest

4. O2 inhalation

5. Reverse isolation due leukopenia

6. Monitor signs of infection

7. Avoid SQ, IM or any venipuncture site = HEPLOCK

8. Use electric razor when shaving to prevent bleeding

9. Administer meds

Immunosuppresants

Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max
therapeutic effect of drug.

BLOOD TRANSFUSION:
Objectives:

1. To replace circulating blood volume

2. To increase O2 carrying capacity of blood

3. To combat infection if theres decrease WBC

4. To prevent bleeding if theres platelet deficiency

Nsg Mgt & principles in Blood Transfusion

1. Proper refrigeration

2. Proper typing & crossmatching

Type O universal donor

AB universal recipient

85% of people is RH (+)

3. Asceptically assemble all materials needed:

a.) Filter set

b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis

Hypotonic sol swell or burst

Hypertonic sol will shrink or crenate

c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis.

d.) Instruct another RN to recheck the following .

Pts name, blood typing & cross typing expiration date, serial number.

e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments indicates bacterial
contamination. Dont dispose. Return to blood bank.

f.) Never warm blood products may destroy vital factors in blood.

- Warming is done if with warming device only in EMERGENCY! For multiple BT.

- Within 30 mins room temp only!

g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h
causes blood deterioration.

h.) Avoid mixing or administering drug at BT line leads to hemolysis

i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent circulatory overload

j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for
1st 15min.

- Majority of BT reaction occurs within 1h.

BT reactions S/Sx Hemolytic reaction:

H hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain,

A allergic Reaction hypotension, flushed skin , (red) port wine urine.

P pyrogenic Reaction

C circulatory overload

A air embolism

T - thrombocytopenia

C citrate intoxication expired blood =hyperkalemia

H hyperkalemia

Nsg Mgt: Hemolytic Reaction:

1. Stop BT

2. Notify Doc

3. Flush with plain NSS

4. Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock

5. Send blood unit to blood bank for reexamination

6. Obtain urine & blood samples of pt & send to lab for reexamination
7. Monitor VS & Allergic Rxn

Allergic Reaction:

S/Sx

1. Fever/ chills

2. Urticaria/ pruritus

3. Dyspnea

4. Laryngospasm/ bronchospasm

5. Bronchial wheezing

Nsg Mgt:

1. Stop BT

2. Notify Doc

3. Flush with PNSS

4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness.

Child-hyperactive

If (+) Hypotension anaphylactic shock administer epinephrine

5. Send blood unit to blood bank

6. Obtain urine & blood samples send to lab

7. Monitor VS & IO

8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension indicates anaphylactic shock

24. administer epinephrine

9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB

Pyrogenic Reaction:

S/Sx
a.) Fever/ chills d. tachycardia

b.) Headache e. palpitations

c.) Dyspnea f. diaphoresis

Nsg Mgt:

1. Stop BT

2. Notify Doc

3. Flush with PNSS

4. Administer antipyretics, antibiotics

5. Send blood unit to blood bank

6. Obtain urine & blood samples send to lab

7. Monitor VS & IO

8. Tepid sponge bath offer hypothermic blanket

Circulatory Overload:

Sx

a. Dyspnea

b. Orthopnea

c. Rales or crackles

d. Exertional discomfort

Nsg Mgt:

1. Stop BT

2. Notify Doc. Dont flush due pt has circulatory overload.

3. Administer diuretics
Priority cases:

Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage

Allergic 3rd

Pyrogenic 4th

Circulatory 2nd

Hemolytic 2nd

Anaphylitic 1st priority

DIC DISSEMINATED INTRAVASCULAR COAGULATION

25. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting
factors (Prothrombin & Fibrinogen).

Predisposing factor:

1. Rapid BT

2. Massive trauma

3. Massive burns

4. Septicemia

5. Hemolytic reaction

6. Anaphylaxis

7. Neoplasia growth of new tissue

8. Pregnancy

S/Sx

1. Petechiae widespread & systemic (lungs, lower & upper trunk)

2. Ecchymosis widespread

3. Oozing of blood from venipunctured site

4. Hemoptysis cough blood

5. Hemorrhage

6. Oliguria late sx

Dx Proc

1. CBC reveals decrease platelets

2. Stool for occult blood (+)

Specimen stool

3. Opthalmoscopic exam sub retinal hemorrhage

4. ABG analysis metabolic acidosis

pH HCO3

R pH PCO2 respiratory alkalosis

O ph PCO2 respiratory acidosis

M ph HCO3 metabolic alkalosis

E ph HCO3 metabolic acidosis

Diarrhea met acidosis

Vomitting met alk

Pyloric stenosis met alkalosis vomiting

Ileostomy or intestinal tubing met acidosis

Cushings met alk

DM met acid

Chronic bronchitis resp acid with hypoxemia, cyanosis

Nsg Mgt DIC

1. Monitor signs of bleeding hema test + urine, stool, GIT

2. Administer isotonic fluid solution to prevent shock.

3. Administer O2 inhalation

4. Administer meds

a. Vit K aquamephyton

b. Pitressin or vasopressin to conserve water.

5. NGT lavage

- Use iced saline lavage

6. Monitor NGT output

7. Provide heplock

8. Prevent complication: hypovolemic shock

Late signs of hypovolemic shock : anuria

Oncologic Nsg:

Oncology study of neoplasia new growth

Benign (tumor) Malignancy (cancer)

Diff - well differentiated poorly or undifferentiated

Encapulation (+) (-)

Metastasis (-) (+)

Prognosis good poor

Therapeutic modality surgery 1. Chemotherapy plenty S/E

2. Radiation

3. Surgery most preferred treatment

4. Bone marrow transplant - Leukemia only

Predisposing factors: (carcinogenesis)

G genetic factors

I immunologic factors

V viral factors

a. Human papiloma virus causing warts

b. Epstein barr virus

E environmental Factors 90%

a. Physical irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma

b. Chemical factors

- Food additives (nitrates

- Hydrocarbon vesicants, alkalies

- Drugs (stillbestrol)

- Uraehane

- Hormones

- Smoking

Male

3.) Prostate cancer - common 40 & above (middle age & above)
BPH 50 & above

1.) Lung cancer

2.) Liver cancer

Female

1. Breast cancer 40 yrs old & up mammography 15 20 mins (SBE 7 days after mens)

2. Cervical cancer 90% multi sexual partners

5% early pregnancy

3. Ovarian cancer

Classes of cancer

Tissue typing

1. Carcinoma arises from surface epithelium & glandular tissues

2. Sarcoma- from connective tissue or bones

3. Multiple myeloma from bone marrow

Pathological fracture of ribs & back pain

4. Lymphoma from lymph glands

5. Leukemia from blood

Warning / Danger Sx of CA

C change in bowel /bladder habits

A a sore that doesnt heal

U unusual bleeding/ Discharge

T thickening of lump breast or elsewhere

I indigestion? Dysphagia
O obvious change in wart/ mole

N nagging cough/ hoarseness

U unexplained anemia A - anemia

S sudden wt loss L loss of wt

Therapeutic Modality:

1. Chemotherapy use various chemotherapeutic agents that kills cancer cells & kills normal rapidly
producing cells GIT, bone marrow, and hair follicle.

Classification:

a.) Alkylating agents

b.) Plant alkaloids vincristine

c.) Anti metabolites nitrogen mustard

d.) Hormones DES

Steroids

e.) Antineoplastic antibiotics

S/E & mgt

GIT - -Nausea & vomiting

Nsg Mgt:

1. Administer anti emetic 4 6h before start of chemo

Plasil

2. Withhold food/ fluid before start of chemo

3. Provide bland diet post chemo

26. Non irritating / non spicy

- Diarrhea

1. Administer anti diarrheal 4 6h before start of chemo

2. Monitor urine, I&O qh

- Stomatitis/ mouth sores

1. Oral care offer ice chips/ popsickles

2. Inform pt hair loss temporary alopecia

Hair will grow back after 4 6 months post chemo.

-Bone marrow depression anemia

1. Enforce CBR

2. O2 inhalation

3. Reverse isolation

4. Monitor signs of bleeding

Repro organ sterility

1. Do sperm banking before start of chemo

Renal system increase uric acid

1. Administer allopurinol/ xyloprin (gout)

27. Inhibits uric acid

28. Acute gout colchicines

29. Increase secretion of uric acid

Neurological changes peristalsis paralytic ileus

Most feared complication ff any abdominal surgery

Vincristine plant alkaloid causes peripheral neuropathy

2. Radiation therapy involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill
N rapidly producing cells.
Types of energy emitted

1. Alpha rays rarely used doesnt penetrate skin tissues

2. Beta rays internal radiation more penetration

3. Gamma ray external radiation penetrates deeper underlying tissues

Methods of delivery

1. External radiation- involves electro magnetic waves

Ex. cobalt therapy

2. Internal radiation injection/ implantation of radioisotopes proximal to CA site for a specific period of
time.

2 types:

a.) Sealed implant radioisotope with a container & doesnt contaminate body fluid.

b.) Unsealed implant radioisotope without a container & contaminates body fluid.

Ex. Phosphorus 32

3 Factors affecting exposure:

A.) Half life time period required for half of radioisotopes to decay.

- At end of half life less exposure

B.) Distance the farther the distance lesser exposure

C. ) Time the shorter the time, the lesser exposure

D.) Shielding rays can be shielded or blocked by using rubber gloves & gamma use thick lead on
concrete.

S/E & Mgt:

a.) Skin errythema, redness, sloughing

1. Assist in battling pt

2. Force fluid 2,000 3,000 ml/day

3. Avoid lotion or talcum powder skin irritation

4. Apply cornstarch or olive oil

b.) GIT nausea / vomiting -

1. Administer antiemetic 4 6h before start of chemo - Plasil

2 Withhold food/ fluid before start of chemo

3. Provide bland diet post chemo

Non irritating / non spicy

Dysglusia decrease taste sensitivity

-When atrophy papilla (taste buds) 40 yo

Stomatitis

c.) Bone marrow depression

1. Enforce CBR

2. O2 inhalation

3. Reverse isolation

4. Monitor signs of bleeding

Overview of function & structure of the heart

HEART

- Muscular, pumping organ of the body

- Left mediastinum

- Weigh 300 400 grams

- Resembles a closed fist

- Covered by serous membrane pericardium

Pericardium

Parietal layer Pericardial Visceral layer

Fluid prevent

Friction rub

Layer

1. Epicardium outermost

2. Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock

3. Endocardium innermost layer

Chambers

1. Upper collecting/ receiving chamber - Atria

2. Lower pumping/ contracting chamber - Ventricles

Valves

1. Atrioventricular valves - Tricuspid & mitral valve

Closure of AV valves gives rise to 1st heart sound or S1 or lub

2. Semi lunar valve

a.) Pulmonic

b.) Aortic

Closure of semilunar valve gives rise to 2nd heart sound or S2 or dub

Extra heart Sound

S3 ventricular Gallop CHF

S4 atrial gallop MI, HPN

Heart conduction system

1. Sino atrial node (SA node) (or Keith-Flock node)

Loc junction of SVC & Rt atrium

Fx- primary pace maker of heart

-Initiates electric impulse of 60 100 bpm

2. Atrioventicular node (AV node or Tawara node)

Loc inter atrial septum

Delay of electric impulse to allow ventricular filling

3. Bundle of His location interventricular septum

Rt main Bundle Branch

Lt main Bundle Branch

4. Purkenjie Fiber

Loc- walls of ventricles-- Ventricular contractions

SA node

Purkenjie Fibers

Bundle of His

Complete heart block insertion of pacemaker at Bundle Branch

Metal Pace Maker change q3 5 yo

Prolonged PR atrial fib T wave inversion MI

ST segment depression angina widening QRS arrhythmia

ST elev MI

CAD coronary artery dse or Ischemic Heart Dse (IHD)

Atherosclerosis Myocrdial injury

Angina Pectoris Myocardial ischemia

MI- myocardial necrosis

ATHEROSCLEROSIS ARTEROSCLEROSIS

- Hardening or artery due to fat/ lipid deposits at tunica intima. - Narrowing or artery due to calcium &
CHON deposits at tunica media.

Artery tunica adventitia outer

- Tunica intima innermost

- Tunica media middle

ATHEROSCLEROSIS

Predisposing Factor

1. Sex male

2. Black race

3. Hyperlipidemia
4. Smoking

5. HPN

6. DM

7. Oral contraceptive- prolonged use

8. Sedentary lifestyle

9. Obesity

10. Hypothyroidism

Signs & Symptoms

1. Chest pain

2. Dyspnea

3. Tachycardia

4. Palpitations

5. Diaphoresis

Treatment

P percutaneous

T tansluminar

C coronary

A angioplasty

Obj:

1. To revascularize the myocardium

2. To prevent angina

3. Increase survival rate

PTCA done to pt with single occluded vessel .

Multiple occluded vessels

C coronary

A arterial

B bypass

A and

G graft surgery

Nsg Mgt Before CABAG

1. Deep breathing cough exercises

2. Use of incentive spirometer

3. Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST
or NGT nitroglycerin, resulting fr temp myocardial ischemia.

Predisposing Factor:

1. sex male

2. black raise

3. hyperlipidemia

4. smoking

5. HPN

6. DM

7. oral contraceptive prolonged

8. sedentary lifestyle

9. obesity

10.hypothyroidism

Precipitating factors
4 Es

1. Excessive physical exertion

2. Exposure to cold environment - Vasoconstriction

3. Extreme emotional response

4. Excessive intake of food saturated fats.

Signs & Symptoms

1. Initial symptoms Levines sign hand clutching of chest

2. Chest pain sharp, stabbing excruciating pain. Location substernal

-radiates back, shoulders, axilla, arms & jaw muscles

-relieve by rest or NGT

3. Dyspnea

4. Tachycardia

5. Palpitation

6.diaphoresis

Diagnosis

1.History taking & PE

2. ECG ST segment depression

3. Stress test treadmill = abnormal ECG

4. Serum cholesterol & uric acid - increase.

Nursing Management

1.) Enforce CBR

2.) Administer meds

NTG small doses venodilator

Large dose vasodilator

1st dose NTG give 3 5 min

2nd dose NTG 3 5 min

3rd & last dose 3 5 min

Still painful after 3rd dose notify doc. MI!

55 yrs old with chest pain:

1st question to ask pt: what did you do before you had chest pain.

2nd question: does pain radiate? If radiate heart in nature. If not radiate pulmonary origin

Venodilator veins of lower ext increase venous pooling lead to decrease venous return.

Meds:

A. NTG- Nsg Mgt:

1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.

2. Monitor S/E:

orthostatic hypotension dec bp

transient headache

dizziness

3. Rise slowly from sitting position

4. Assist in ambulation.

5. If giving NTG via patch:

i. avoid placing it near hairy areas-will dec drug absorption

ii. avoid rotating transdermal patches- will dec drug absorption

iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch

B. Beta blockers propanolol

C. ACE inhibitors captopril

D. Ca antagonist - nefedipine

3.) Administer O2 inhalation

4.) Semi-fowler

5.) Diet- Decrease Na and saturated fats

6.) Monitor VS, I&O, ECG

7.) HT: Discharge planning:

a. Avoid precipitating factors 4 Es

b. Prevent complications MI

c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug

d. Importance of follow-up care.

MI MYOCARDIAL INFARCTION hear attack terminal stage of CAD

- Characterized by necrosis & scarring due to permanent mal-occlusion

Types:

1. Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery

2. Sub-endocardial MI mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI 48 to 72h

- Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors Signs & symptoms Diagnostic Exam

1. sex male

2. black raise
3. hyperlipidemia

4. smoking

5. HPN

6. DM

7. oral contraceptive prolonged

8. sedentary lifestyle

9. obesity

10. hypothyroidism 1. chest pain excruciating, vice like, visceral pain located substernal or precodial
area (rare)

- radiates back, arm, shoulders, axilla, jaw & abd muscles.

- not usually relived by rest r NTG

2. dyspnea

3. erthermia

4. initial increase in BP

5. mild restlessness & apprehensions

6. occasional findings

a.) split S1 & S2

b.) pericardial friction rub

c.) rales /crackles

d.) S4 (atrial gallop) 1. cardiac enzymes

a.) CPK MB Creatinine Phosphokinase

b.) LDH lactic acid dehydrogenase

c.) SGPT (ALT) Serum Glutanic Pyruvate Transaminase- increased

d.) SGOT (AST) Serum Glutamic Oxalo-acetic - increased

2. Troponin test increase

3. ECG tracing ST segment increase,

widening or QRS complexes means arrhythmia in MI indicating PVC

4. serum cholesterol & uric acid - increase

5. CBC increase WBC

Nursing Management

1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety.

2. Administer O2 inhalation low inflow (CHF-increase inflow)

3. Enforce CBR without BP

a.) Bedside commode

4. Avoid valsalva maneuver

5. Semi fowler

6. General liquid to soft diet decrease Na, saturated fat, caffeine

7. Monitor VS, I&O & ECG tracings

8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.

9. Assist in surgical; CABAG

10. Provide pt HT

a.) Avoid modifiable risk factors

b.) Prevent complications:

1. Arrhythmias PVC

2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria

3. thrombophlebitis - deep vein

4. CHF left sided

5. Dresslers syndrome post MI syndrome

-Resistant to medications
-Administer 150,000 450,000 units of streptokinase

c.) Strict compliance to meds

- Vasodilators

1. NTG

2. Isordil

- Antiarrythmic

1. Lydocaine blocks release of norepenephrine

2. Brithylium

- Beta-blockers lol

1. Propanolol (inderal)

- ACE inhibitors - pril

1. Captopril (enalapril)

- Ca antagonist

1. Nifedipine

- Thrombolitics or fibrinolytics to dissolve clots/ thrombus

S/E allergic reactions/ uticaria

1. Streptokinase

2. Urokinase

3. Tissue plasminogen adjusting factor

Monitor for bleeding:

- Anticoagulants

1. Heparin 2. Caumadin delayed reaction 2 3 days

PTT PT

If prolonged bleeding prolonged bleeding

Antidote antidote Vit K

Protamine sulfate

- Anti platelet PASA (aspirin)

d.) Resume ADL sex/ activity 4 to 6 weeks

Post-cardiac rehab

1.)Sex as an appetizer rather then dessert

Before meals not after, due after meals increase metabolism heart is pumping hard after meals.

2.) Position non-weight bearing position.

When to resume sex/ act: When pt can already use staircase, then he can resume sex.

e.) Diet decrease Na, Saturated fats, and caffeine

f.) Follow up care.

CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.

- Backflow

1.) Left sided heart failure:

Predisposing factors:
1.) 90% mitral valve stenosis due RHD, aging

RHD affects mitral valve streptococcal infection

Dx: - Aso titer anti streptolysine O > 300 total units

- Steroids

- Penicillin

- Aspirin

Complication: RS-CHF

Aging degeneration / calcification of mitral valve

Ischemic heart disease

HPN, MI, Aortic stenosis

S/Sx

Pulmonary congestion/ Edema

1. Dyspnea

2. Orthopnea (Diff of breathing sitting pos platypnea)

3. Paroxysmal nocturnal dysnea PNO- nalulunod

4. Productive cough with blood tinged sputum

5. Frothy salivation (from lungs)

6. Cyanosis

7. Rales/ crackles due to fluid

8. Bronchial wheezing

9. PMI displaced lateral due cardiomegaly

10. Pulsus alternons weak-strong pulse

11. Anorexia & general body malaise

12. S3 ventricular gallop

Dx

1. CXR cardiomegaly

2. PAP Pulmonary Arterial Pressure

PCWP Pulmonary CapillaryWedge Pressure

PAP measures pressure of R ventricle. Indicates cardiac status.

PCWP measures end systolic/ diastolic pressure

PAP & PCWP:

Swan ganz catheterization cardiac catheterization is done at bedside at ICU

(Trachesostomy bedside) - Done 5 20 mins scalpel & trachesostomy set

CVP indicates fluid or hydration status

Increase CVP decrease flow rate of IV

Decrease CVP increase flow rate of IV

3. Echocardiography reveals enlarged heart chamber or cardiomayopathy

4. ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor

1. 90% - tricuspid stenosis

2. COPD

3. Pulmonary embolism
4. Pulmonic stenosis

5. Left sided heart failure

S/Sx

Venous congestion

- Neck or jugular vein distension

- Pitting edema

- Ascites

- Wt gain

- Hepatomegalo/ splenomegaly

- Jaundice

- Pruritus

- Esophageal varies

- Anorexia, gen body malaise

Diagnosis:

1. CXR cardiomegaly

2. CVP measures the pressure at R atrium

Normal: 4 to 10 cm of water

Increase CVP > 10 hypervolemia

Decrease CVP < 4 hypovolemia

Flat on bed post of pt when giving CVP

Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular
filling.

3. Echocardiography enlarged heart chamber / cardiomyopathy

4.Liver enzyme

SGPT ( ALT)

SGOT AST

Nsg mgt: Increase force of myocardial contraction = increase CO

3 6L of CO

1. Administer meds:

Tx for LSHF: M morphine SO4 to induce vasodilatation

A aminophylline & decrease anxiety

D digitalis (digoxin)

D - diuretics

O - oxygen

G - gases

a.) Cardiac glycosides

Increase myocardial = increase CO

Digoxin (Lanoxin). Antidote: digivine

Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.

b.) Loop diuretics: Lasix effect with in 10-15 min. Max = 6 hrs

c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine

d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety

e.) Vasodilators NTG

f.) Anti-arrythmics Lidocaine

2. Administer O2 inhalation high! @ 3 -4L/min via nasal cannula

3. High fowlers

4. Restrict Na!

5. Provide meticulous skin care

6. Weigh pt daily. Assess for pitting edema.

Measure abdominal girth daily & notify MD

7. Monitor V/S, I&O, breath sounds

8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to

promote decrease venous return

9. Diet decrease salt, fats & caffeine

10. HT:

a) Complications :shock

Arrhythmia

Thrombophlebitis

MI

Cor Pulmonale RT ventricular hypertrophy

b.) Dietary modifications

c.) Adherence to meds

PERIPHERAL MUSCULAR DISEASE

Arterial ulcers venous ulcer

1. Thromboangiitis Obliterans male/ feet 1. Varicose veins

2. Reynauds female/ hands 2. Thrombophlebitis

1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to
medium sized arteries & veins of lower extremities. Male/ feet

Predisposing factors:

- Male

- Smokers

S/Sx

1. Intermittent claudication leg pain upon walking - Relieved by rest

2. Cold sensitivity & skin color changes

White bluish red

Pallor cyanosis rubor

3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis

4. Tropic changes

5. Ulcerations

6. Gangrene formation

Dx:

1. Oscillometry decrease peripheral pulse volume.

2. Doppler UTZ decrease blood flow to affected extremities.

3. Angiography reveals site & extent of mal-occulsion.

Nsg Mgt:

1. Encourage a slow progression of physical activity

a.) Walk 3 -4 x / day

b.) Out of bed 2 3 x a / day

2. Meds

a.) Analgesic

b.) Vasodilator

c.) Anticoagulant

3. Foot care mgt like DM

a.) Avoid walking barefoot

b.) Cut toe nails straight

c.) Apply lanolin lotion prevent skin breakdown

d.) Avoid wearing constrictive garments

4. Avoid smoking & exposure to cold environment

5. Surgery: BKA (Below the knee amputation)

2.)REYNAUDS PHENOMENON acute episodes of arterial spasm affecting digits of hands & fingers

Predisposing factors:

1. Female, 40 yrs
2. Smoking

3. Collagen dse

a.) SLE pathognomonic sign butterfly rash on face

Chipmunk face bulimia nervosa

Cherry red skin carbon monoxide poisoning

Spider angioma liver cirrhosis

Caput medusae leg & trunk umbilicus- Liver cirrhosis

Lion face leprosy

b.) Rheumatoid arthritis

4. Direct hand trauma piano playing, excessive typing, operating chainsaw

S/Sx:

1. Intermittent claudication - leg pain upon walking - Relieved by rest

2. Cold sensitivity

Nsg Mgt:

a. Analgesics

b. Vasodilators

c. Encourage to wear gloves especially when opening a refrigerator.

d. Avoid smoking & exposure to cold environment

VENOUS ULCERS

1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext & trunk

- Due to:
a.) Incompetent valves leading to

b.) Increase venous pooling & stasis leading to

c.) Decrease venous return

Predisposing factors:

a. Hereditary

b. Congenital weakness of veins

c. Thrombophlebitis

d. Heart dse

e. Pregnancy

f. Obesity

g. Prolonged immobility - Prolonged standing

S/Sx:

1. Pain especially after prolonged standing

2. Dilated tortuous skin veins

3. Warm to touch

4. Heaviness in legs

Dx:

1. Venography

2. Trendelenbergs test vein distend quickly < 35 secs

Nsg Mgt:

1. Elevate legs above heart level to promote venous return 1 to 2 pillows

2. Measure circumference of leg muscles to determine if swollen.

3. Wear anti embolic or knee high stockings. Women panty hose

4. Meds: Analgesics

5. Surgery: vein sweeping & ligation

Sclerotherapy spider web varicosities

S/E thrombosis

THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation

Predisposing factors:

1. Smoking

2. Obesity

3. Hyperlipedemia

4. Prolonged use of oral contraceptives

5. Chronic anemia

6. DM

7. MI

8. CHF

9. Postop complications

10. Post cannulation insertion of various cardiac catheters

S/Sx:

1. Pain at affected extremities

2. Cyanosis

3. (+) Homans sign - Pain at leg muscles upon dorsiflexion of foot.

Dx:

1. Angiography
2. Doppler UTZ

Nsg Mgt:

1. Elevate legs above heart level.

2. Apply warm, moist packs to decrease lymphatic congestion.

3. Measure circumference of leg muscles to detect if swollen.

4. Use anti embolic stockings.

5. Meds: Analgesics.

Anticoagulant: Heparin

6. Complication:

Pulmonary Embolism:

- Sudden sharp chest pain

- Dyspnea

- Tachycardia

- Palpitation

- Diaphoresis

- Mild restlessness

OVERVIEW OF RESPIRATORY SYSTEM:

I. Upper respiratory tract:

Fx:

1. Filtering of air

2. Warming & moistening

3. Humidification

a. Nose cartilage

- Parts: Rt nostril separated by septum

Lt nostril

- Consists of anastomosis of capillaries

Kessel Bach Plexus site of epistaxis

b. Pharynx (throat) muscular passageway for air& food

Branches:

1. Oropharynx

2. Nasopharynx

3. Layngopharynx

c. Larynx voice box

Fx:

1. For phonation

2. Cough reflex

Glottis opening

Opens to allow passage of air

Closes to allow passage of food

II. Lower Rt Fx for gas exchange

a. Trachea windpipe

- has cartillagenous rings

- site for permanent/ artificial a/w tracheostomy

b. Bronchus R & L main bronchus

c. Lungs R 3 lobes = 10 segments

L 2 lobes 8 segments

Post pneumonectomy - position affected side to promote expansion of lungs

Post segmental lobectomy position unaffected side to promote drainage

Lungs covered by pleural cavity, parietal lobe & visceral lobe

Alveoli acinar cells

- site of gas exchange (O2 & CO2)

- diffusion: Daltons law of partial pressure of gases

Ventilation movement of air in & out of lungs

Respiration movement of air into cells

Type II cells of alveoli secrets surfactant

Surfactant - decrease surface tension of alveoli

Lecithin & spinogometer

L/S ratio 2:1 indicator of lung maturity

If 1:2 adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.

I. PNEUMONIA inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled

with exudates.

Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)

2. Hemophilus pneumoniae(Bronchopneumonia)

3. Escherichia coli

4. Klebsiella P.

5. Diplococcus P.

High risk elderly & children below 5 yo

Predisposing factors:

1. Smoking

2. Air pollution

3. Immuno-compromised

a. AIDS PLP

b. Bronchogenic CA - Non-productive to productive cough

4. Prolonged immobility CVA- hypostatic pneumonia

5. Aspiration of food

6. Over fatigue

S/Sx:

1. Productive cough pathognomonic: greenish to rusty sputum

2. Dyspnea with prolonged respiratory grunt

3. Fever, chills, anorexia, gen body malaise

4. Wt loss

5. Pleuritic friction rub

6. Rales/ crackles

7. Cyanosis

8. Abdominal distension leading to paralytic ileus

Sputum exam could confirm presence of TB & pneumonia

Dx:

1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.

2. CXR pulmo consolidation

3. CBC increase WBC

Erythrocyte sedimentation rate

4. ABG PO2 decrease

Nsg Mgt:

1. Enforce CBR

2. Strict respiratory isolation

3. Meds:

a.) Broad spectrum antibiotics

Penicillin or tetracycline

Macrolides ex azythromycin (zythromax)

b.) Anti pyretics

c.) Mucolytics or expectorants

4. Force fluids 2 to 3 L/day

5. Institute pulmonary toilet-

a.) Deep breathing exercise

b.) Coughing exercise

c.) Chest physiotherapy cupping

d.) Turning & reposition - Promote expectoration of secretions

6. Semi-fowler

7. Nebulize & suction

8. Comfy & humid environment

9. Diet: increase CHO or calories, CHON & vit C

10. Postural drainage - To drain secretions using gravity

Mgt for postural drainage:

a.) Best done before meals or 2 4 hrs after meals to prevent Gastroesophageal Reflux

b.) Monitor VS & breath sounds

Normal breath sound bronchovesicular

c.) Deep breathing exercises

d.) Adm bronchodilators 15 30 min before procedure

e.) Stop if pt cant tolerate procedure

f.) Provide oral care it may alter taste sensation

g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)

Normal IOP 12 21 mmHg

11. HT:

a.) Avoidance of precipitating factors

b.) Complication: Atelectacies & meningitis

c.) Compliance to meds

PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of

mycobacterium TB or tubercle bacilli or acid fast bacilli gram (+) aerobic, motile & easily destroyed by
heat or sunlight.
Predisposing factors:

1. Malnutrition

2. Overcrowding

3. Alcoholism

4. Ingestion of infected cattle (mycobacterium BOVIS)

5. Virulence

6. Over fatigue

S/Sx:

1. Productive cough yellowish

2. Low fever

3. Night sweats

4. Dyspnea

5. Anorexia, general body malaise, wt loss

6. Chest/ back pain

7. Hempotysis

Diagnosis:

1. Skin test mantoux test infection of Purified CHON Derivative PPD

DOH 8-10 mm induration

WHO 10-14 mm induration

Result within 48 72h

(+) Mantoux test previous exposure to tubercle bacilli

Mode of transmission droplet infection

2. Sputum AFB (+) to cultured microorganism

3. CXR pulmonary infiltrate caseosis necrosis

4. CBC increase WBC

Nursing Mgt:

1. CBR

2. Strict resp isolation

3. O2 inhalation

4. Semi fowler

5. Force fluid to liquefy secretions

6. DBCE

7. Nebulize & suction

8. Comfy & humid environment

9. Diet increase CHO & calories, CHON, Vit, minerals

10. Short course chemotherapy

- Intensive phase

INH isoniazide - give before meals for absorption

Rifampicin - given within 4 months, given simultaneously to prevent resistance

-S/E: peripheral neutitis vit B6

Rifampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears.
PZA Pyrazinamide given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity

Standard regimen

1. Injection of streptomycin aminoglycoside

Ex. Kanamycin, gentamycin, neomycin

S/E:

a.) Ototoxicity damage CN # 8 tinnitus hearing loss

b.) Nephrotoxicicity monitor BUN & Crea

HT:

a.) Avoid pred factors

b.) Complications:

1.) Atelectasis

2.) Miliary TB spread of Tb to other system

c.) Compliance to meds

- Religiously take meds

HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma
capsulatum transmitted to birds manure.

S/Sx: Same as pneumonia & PTB like

1. Productive cough

2. Dyspnea

3. Chest & joint pains

4. Cyanosis

5. Anorexia, gen body malaise, wt loss

6. Hemoptysis
Dx:

1. Histoplasmin skin test = (+)

2. ABG pO2 decrease

Nsg Mgt:

1. CBR

2. Meds:

a.) Anti fungal agents

Amphotericin B (Fungizone)

S/E :

a.) Nephrotoxcicity check BUN

b.) Hypokalemia

b.)Corticosteroids

c.) Mucolytic/ or expectorants

3. O2 force fluids

4. Nebulize, suction

5. Complications:

a.) Atelectasis

b.) Bronchiectasis COPD

6. Prevent spread of histoplasmosis:

a.) Spray breading places or kill the bird.

COPD Chronic Obstructive Pulmonary Disease

1. Chronic bronchitis
2. Bronchial asthma

3. Bronchiectasis

4. Pulmonary emphysema terminal stage

CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or

hyperplasia of goblet mucus producing cells leading to narrowing of smaller airways.

Predisposing factors:

1. Smoking all COPD types

2. Air pollution

S/Sx:

1. Prod cough

2. Dyspnea on exertion

3. Prolonged expiratory grunt

4. Scattered rales/ rhonchi

5. Cyanosis

6. Pulmo HPN a.)Leading to peripheral edema

b.) Cor pulmonary respiratory in origin

7. Anorexia, gen body malaise

Dx:

1. ABG

PO2 PCO2 Resp acidosis

Hypoxemia causing cyanosis

Nsg Mgt:
(Same as emphysema)

2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to
narrowing of smaller airway.

Predisposing factor:

1. Extrinsic Asthma called Atropic/ allergic asthma

a.) Pallor

b.) Dust

c.) Gases

d.) Smoke

e.) Dander

f.) Lints

2. Intrinsic Asthma-

Cause:

Herediatary

Drugs aspirin, penicillin, b blockers

Food additives nitrites

Foods seafood, chicken, eggs, chocolates, milk

Physical/ emotional stress

Sudden change of temp, humidity &air pressure

3. mixed type: combi of both ext & intr. Asthma

90% cause of asthma

S/Sx:

1. C cough non productive to productive

2. D dyspnea

3. W wheezing on expiration

4. Cyanosis

5. Mild apprehension & restlessness

6. Tachycardia & palpitation

7. Diaphoresis

Dx:

1. Pulmo function test decrease lung capacity

2. ABG PO2 decrease

Nsg Mgt:

1. CBR all COPD

2. Meds-

a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids

b.) Corticosteroids due inflammatory. Given 10 min after adm bronchodilator

c.) Mucolytic/ expectorant

d.) Mucomist at bedside put suction machine.

e.) Antihistamine

3. Force fluid

4. O2 all COPD low inflow to prevent resp distress

5. Nebulize & suction

6. Semifowler all COPD except emphysema due late stage

7. HT

a.) Avoid pred factors

b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators

- Emphysema

c.) Adherence to med

BRONCHIECTASIS abnormal permanent dilation of bronchus resulting to destruction of muscular &

elastic tissues of alveoli.

Predisposing factors:

1. Recurrent upper & lower RI

2. Congenital anomalies

3. Tumors

4. Trauma

S/Sx:

1. Productive cough

2. Dyspnea

3. Anorexia, gen body malaise- all energy are used to increase respiration.

4. Cyanosis

5. Hemoptisis

Dx:

1. ABG PO2 decrease

2. Bronchoscopy direct visualization of bronchus using fiberscope.

Nsg Mgt: before bronchoscopy

1. Consent, explain procedure MD/ lab explain RN

2. NPO
3. Monitor VS

Nsg Mgt after bronchoscopy

1. Feeding after return of gag reflex

2. Instruct client to avoid talking, smoking or coughing

3. Monitor signs of frank or gross bleeding

4. Monitor of laryngeal spasm

- DOB

- Prepare at bedside tracheostomy set

Mgt: same as emphysema except Surgery

Pneumonectomy removal of affected lung

Segmental lobectomy position of pt unaffected side

PULMONARY EMPHYSEMA irreversible terminal stage of COPD

- Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.

- Body will compensate over distension of thoracic cavity

- Barrel chest

Predisposing factor:

1. Smoking

2. Allergy

3. Air pollution

4. High risk elderly

5. Hereditary - a 1 anti trypsin to release elastase for recoil of alveoli.

S/Sx:
1. Productive cough

2. Dyspnea at rest due terminal

3. Anorexia & gen body malaise

4. Rales/ rhonchi

5. Bronchial wheezing

6. Decrease tactile fremitus (should have vibration) palpation 99. Decreased - with air or fluid

7. Resonance to hyperresonance percussion

8. Decreased or diminished breath sounds

9. Pathognomonic: barrel chest increase post/ anterior diameter of chest

10. Purse lip breathing to eliminated PCO2

11. Flaring of alai nares

Diagnosis:

1. Pulmonary function test decrease vital lung capacity

2. ABG

a.) Panlobular / centrolobular emphysema

pCO2 increase

pO2 decrease hypoxema resp acidosis Blue bloaters

b.) Panacinar/ Centracinar

pCO2 decrease

pO2 increase hyperaxemia resp alkalosis Pink puffers

Nursing Mgt:

1. CBR

2. Meds

a.) Bronchodilators
b.) Corticosteroids

c.) Antimicrobial agents

d.) Mucolytics/ expectorants

3. O2 Low inflow

4. Force fluids

5. High fowlers

6. Neb & suction

7. Institute

P posture

E end

E expiratory to prevent collapse of alveoli

P pressure

8. HT

a.) Avoid smoking

b.) Prevent complications

1.) Cor pulmonary R ventricular hypertrophy

2.) CO2 narcosis lead to coma

3.) Atelectasis

4.) Pneumothorax air in pleural space

9. Adherence to meds

RESTRICTIVE LUNG DISORDER

PNEUMOTHORAX partial / or complete collapse of lungs due to entry or air in pleural space.

Types:

1. Spontaneous pneumothorax entry of air in pleural space without obvious cause.

Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions

Eg. open pneumothorax air enters pleural space through an opening in chest wall

-Stab/ gun shot wound

2. Tension Pneumothorax air enters plural space with @ inspiration & cant escape leading to over
distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.

Eg. flail chest paradoxical breathing

Predisposing factors:

1.Chest trauma

2.Inflammatory lung conditions

3.Tumor

S/Sx:

1. Sudden sharp chest pain

2. Dyspnea

3. Cyanosis

4. Diminished breath sound of affected lung

5. Cool moist skin

6. Mild restlessness/ apprehension

7. Resonance to hyper resonance

Diagnosis:

1. ABG pO2 decrease

2. CXR confirms pneumothorax

Nursing Mgt:

1. Endotracheal intubation

2. Thoracenthesis

3. Meds Morphine SO4

- Anti microbial agents

4. Assist in test tube thoracotomy

Nursing Mgt if pt is on CPT attached to H2O drainage

1. Maintain strict aseptic technique

2. DBE

3. At bedside

a.) Petroleum gauze pad if dislodged Hemostan

b.) If with air leakage clamp

c.) Extra bottle

4. Meds Morphine SO4

Antimicrobial

5. Monitor & assess for oscillation fluctuations or bubbling

a.) If (+) to intermittent bubbling means normal or intact

- H2O rises upon inspiration

- H2o goes down upon expiration

b.) If (+) to continuous, remittent bubbling

1. Check for air leakage

2. Clamp towards chest tube

3. Notify MD

c.) If (-) to bubbling

1. Check for loop, clots, and kink

2. Milk towards H2O seal

3. Indicates re-expansion of lungs

When will MD remove chest tube:

1. If (-) fluctuations
2. (+) Breath sounds

3. CXR full expansion of lungs

Nursing Mgt of removal of chest tube

1. DBE

2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.

3. Apply vaselinated air occlusive dressing

- Maintain dressing dry & intact

GIT

I. Upper alimentary canal - function for digestion

a. Mouth

b. Pharynx (throat)

c. Esophagus

d. Stomach

e. 1st half of duodenum

II. Middle Alimentary canal Function: for absorption

- Complete absorption large intestine

a. 2nd half of duodenum

b. Jejunum

c. Ileum

d. 1st half of ascending colon

III. Lower Alimentary Canal Function: elimination

a. 2nd half of ascending colon

b. Transverse

c. Descending colon
d. Sigmoid

e. Rectum

IV. Accessory Organ

a. Salivary gland

b. Verniform appendix

c. Liver

d. Pancreas auto digestion

e. Gallbladder storage of bile

I. Salivary Glands

1. Parotid below & front of ear

2. Sublingual

3. Submaxillary

- Produces saliva for mechanical digestion

- 1200 -1500 ml/day - saliva produced

PAROTITIS mumps inflammation of parotid gland

-Paramyxo virus

S/Sx:

1. Fever, chills anorexia, gen body malaise

2. Swelling of parotid gland

3. Dysphagia

4. Ear ache otalgia

Mode of transmission: Direct transmission & droplet nuclei

Incubation period: 14 21 days

Period of communicability 1 week before swelling & immediately when swelling begins.

Nursing Mgt:

1. CBR

2. Strict isolation

3. Meds: analgesic

Antipyretic

Antibiotics to prevent 2 complications

4. Alternate warm & cold compress at affected part

5. Gen liquid to soft diet

6. Complications

Women cervicitis, vaginitis, oophoritis

Both sexes meningitis & encephalitis/ reason why antibiotics is needed

Men orchitis might lead to sterility if it occur during / after puberty.

VERNIFORM APPENDIX Rt iliac or Rt inguinal area

- Function lymphatic organ produces WBC during fetal life - ceases to function upon birth of baby

APENDICITIS inflamation of verniform appendix

Predisposing factor:

1. Microbial infection

2. Feacalith undigested food particles tomato seeds, guava seeds

3. Intestinal obstruction

S/Sx:

1. Pathognomonic sign: (+) rebound tenderness

2. Low grade fever, anorexia, n/v

3. Diarrhea / & or constipation

4. Pain at Rt iliac region

5. Late sign due pain tachycardia

Diagnosis:

1. CBC mild leukocytosis increase WBC

2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)

3. Urinalysis

Treatment: - appendectomy 24 45

Nursing Mgt:

1. Consent

2. Routinary nursing measures:

a.) Skin prep

b.) NPO

c.) Avoid enema lead to rupture of appendix

3. Meds:

Antipyretic

Antibiotics

*Dont give analgesic will mask pain

- Presence of pain means appendix has not ruptured.

4. Avoid heat application will rupture appendix.

5. Monitor VS, I&O bowel sound

Nursing Mgt: post op

1. If (+) to Pendrose drain indicates rupture of appendix

Position- affected side to drain

2. Meds: analgesic due post op pain

Antibiotics, Antipyretics PRN

3. Monitor VS, I&O, bowel sound

4. Maintain patent IV line

5. Complications- peritonitis, septicemia

Liver largest gland

- Occupies most of right hypochondriac region

- Color: scarlet red

- Covered by a fibrous capsule Glissons capsule

- Functional unit liver lobules

Function:

1. Produces bile

Bile emulsifies fats

- Composed of H2O & bile salts

-Gives color to urine urobilin

Stool stircobilin
2. Detoxifies drugs

3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins

Hypevitaminosis vit D & K

Vit A retinol

Def Vit A night blindness

Vit D cholecalciferon

- Helps calcium

- Rickets, osteoarthritis

4. It destroys excess estrogen hormone

5. For metabolism

A. CHO

1. Glycogenesis synthesis of glycogens

2. Glycogenolysis breakdown of glycogen

3. Gluconeogenesis formation of glucose from CHO sources

B. CHON-

1. Promotes synthesis of albumin & globulin

Cirrhosis decrease albumin

Albumin maintains osmotic pressure, prevents edema

2. Promotes synthesis of prothrombin & fibrinogen

3. Promotes conversion of ammonia to urea.

Ammonia like breath fetor hepaticus

C. FATS promotes synthesis of cholesterol to neutral fats called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Early sign hepatic encephalopathy

1. Asterixis flapping hand tremors

Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.

Nursing priority assist in mechanical ventilation

Predisposing factor:

Decrease Laennacs cirrhosis caused by alcoholism

1. Chronic alcoholism

2. Malnutrition decreaseVit B, thiamin - main cause

3. Virus

4. Toxicity- eg. Carbon tetrachloride

5. Use of hepatotoxic agents

S/Sx:

Early signs:

a.) Weakness, fatigue

b.) Anorexia, n/v

c.) Stomatitis

d.) Urine tea color

Stool clay color

e.) Amenorrhea

f.) Decrease sexual urge

g.) Loss of pubic, axilla hair

h.) Hepatomegaly
i.) Jaundice

j.) Pruritus or urticaria

2. Late signs

a.) Hematological changes all blood cells decrease

Leukopenia- decrease

Thrombocytopenia- decrease

Anemia- decrease

b.) Endocrine changes

Spider angiomas, Gynecomastia

Caput medusate, Palmar errythema

c.) GIT changes

Ascitis, bleeding esophageal varices due to portal HPN

d.) Neurological changes:

Hepatic encephalopathy - ammonia (cerebral toxin)

Late signs: Early signs:

Headache asterexis

Fetor hepaticus (flapping hand tremors)

Confusion

Restlessness

Decrease LOC

Hepatic coma
Diagnosis:

1. Liver enzymes- increase

SGPT (ALT)

SGOT (AST)

2. Serum cholesterol & ammonia increase

3. Indirect bilirubin increase

4. CBC - pancytopenia

5. PTT prolonged

6. Hepatic ultrasonogram fat necrosis of liver lobules

Nursing Mgt

1. CBR

2. Restrict Na!

3. Monitor VS, I&O

4. With pt daily & assess pitting edema

5. Measure abdominal girth daily notify MD

6. Meticulous skin care

7. Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON

Well balanced diet

8. Complications:

a.) Ascites fluid in peritoneal cavity

Nursing Mgt:

1. Meds: Loop diuretics 10 15 min effect

2. Assist in abdominal paracentesis - aspiration of fluid

- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted

b.) Bleeding esophageal varices

- Dilation of esophageal veins

1. Meds: Vit K

Pitrisin or Vasopresin (IM)

2. NGT decompression- lavage

- Give before lavage ice or cold saline solution

- Monitor NGT output

3. Assist in mechanical decompression

- Insertion of sengstaken-blackemore tube

- 3 lumen typed catheter

- Scissors at bedside to deflate balloon.

c.) Hepatic encephalopathy

1. Assist in mechanical ventilation due coma

2. Monitor VS, neuro check

3. Siderails due restless

4. Meds Laxatives to excrete ammonia

HEPATITIS- jaundice (icteric sclera)

Bilirubin
Kernicterus/ hyperbilirubinia

Irreversible brain damage

Pancreas mixed gland (exocrine & endocrine gland)

PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage &
necrosis due to auto digestion.

Bleeding of pancreas - Cullens sign at umbilicus

Predisposing factors:

1. Chronic alcoholism

2. Hepatobilary disease

3. Obesity

4. Hyperlipidemia

5. Hyperparathyroidism

6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)

7. Diet increase saturated fats

S/Sx:

1. Severe Lt epigastric pain radiates from back &flank area

- Aggravated by eating, with DOB

2. N/V

3. Tachycardia

4. Palpitation due to pain

5. Dyspepsia indigestion

6. Decrease bowel sounds

7. (+) Cullens sign - ecchymosis of umbilicus hemorrhage

8. (+) Grey Turners spots ecchymosis of flank area

9. Hypocalcemia

Diagnosis:

1. Serum amylase & lipase increase

2. Urine lipase increase

3. Serum Ca decrease

Nursing Mgt:

1. Meds

a.) Narcotic analgesic - Meperidine Hcl (Demerol)

Dont give Morphine SO4 will cause spasm of sphincter.

b.) Smooth muscle relaxant/ anti cholinergic

- Ex. Papavarine Hcl

Prophantheline Bromide (Profanthene)

c.) Vasodilator NTG

d.) Antacid Maalox

e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation

f.) Ca gluconate

2. Withold food & fluid aggravates pain

3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation

Complications of TPN

1. Infection

2. Embolism

3. Hyperglycemia
4. Institute stress mgt tech

a.) DBE

b.) Biofeedback

5. Comfy position - Knee chest or fetal like position

6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON

7. Complications: Chronic hemorrhagic pancreatitis

GALLBLADDER storage of bile made up of cholesterol.

CHOLECYSTITIS/ CHOLELITHIASIS inflammation of gallbladder with gallstone formation.

Predisposing factor:

1. High risk women 40 years old

2. Post menopausal women undergoing estrogen therapy

3. Obesity

4. Sedentary lifestyle

5. Hyperlipidemia

6. Neoplasm

S/Sx:

1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night

2. Fatty intolerance

3. Anorexia, n/v

4. Jaundice

5. Pruritus

6. Easy bruising

7. Tea colored urine

8. Steatorrhea
Diagnosis:

1. Oral cholecystogram (or gallbladder series)- confirms presence of stones

Nursing Mgt:

1. Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol

b.) Anti cholinergic - Atropine SO4

c.) Anti emetic

Phenergan Phenothiazide with anti emetic properties

2. Diet increase CHO, moderate CHON, decrease fats

3. Meticulous skin care

4. Surgery: Cholecystectomy

Nursing Mgt post cholecystectomy

-Maintain patency of T-tube intact & prevent infection

Stomach widest section of alimentary canal

- J shaped structures

1. Anthrum

2. Pylorus

3. Fundus

Valves

1. 1.cardiac sphincter

2. Pyloric sphincter

Cells
1. Chief/ Zymogenic cells secrets

a.) Gastric amylase - digest CHO

b.) Gastric lipase digest fats

c.) Pepsin CHON

d.) Rennin digests milk products

2. Parietal / Argentaffin / oxyntic cells

Function:

a.) Produces intrinsic factor promotes reabsorption of vit B12 cyanocobalamin promotes maturation
of RBC

b.) Secrets Hcl acid aids in digestion

3. Endocrine cells - Secrets gastrin increase Hcl acid secretion

Function of the stomach

1.Mechanical

2.Chem. Digestion

3.Storage of food

-CHO, CHON- stored 1 -2 hrs. Fats stored 2 3 hrs

PEPTIC ULCER DISEASE (PUD) excoriation / erosion of submucosa & mucosal lining due to:

a.) Hypercecretion of acid pepsin

b.) Decrease resistance to mucosal barrier

Incidence Rate:

1. Men 40 55 yrs old

2. Aggressive persons
Predisposing factors:

1. Hereditary

2. Emotional

3. Smoking vasoconstriction GIT ischemia

4. Alcoholism stimulates release of histamine = Parietal cell release Hcl acid = ulceration

5. Caffeine tea, soda, chocolate

6. Irregular diet

7. Rapid eating

8. Ulcerogenic drugs NSAIDS, aspirin, steroids, indomethacin, ibuprofen

Indomethacin - S/E corneal cloudiness. Needs annual eye check up.

9. Gastrin producing tumor or gastrinoma Zollinger Ellisons sign

10. Microbial invasion helicobacter pylori. Metromidazole (Flagyl)

Types of ulcers

Ascending to severity

1. Acute affects submucosal lining

2. Chronic affects underlying tissue heals & forms a scar

According to location

1. Stress ulcer

2. Gastric ulcer

3. Duodenal ulcer most common

Stress ulcers common among eritically ill clients

2 types

1.Curings ulcer cause: trauma & birth

hypovolemia

GIT schemia

Decrease resistance of mucosal barriers to Hcl acid

Ulcerations

2.Cushings ulcer cause stroke/CVA/ head injury

Increase vagal stimulation

Hyperacidity

Ulcerations

GASTRIC ULCER DUODENAL ULCER

SITE Intrum or lesser curvature Duodenal bulb

PAIN -30 min 1 hr after eating

- epigastrium
- gaseous & burning

- not usually relieved by food & antacid -2-3 hrs after eating

- mid epigastrium

- cramping & burning

- usually relieved by food & antacid

- 12 MN 3am pain

HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion

VOMITING Common Not common

HEMORRHAGE Hematemeis Melena

WT Wt loss Wt gain

COMPLICATIONS a. stomach cause

b. hemorrhage a. perforation

HIGH RISK 60 years old 20 years old

Diagnosis:

1. Endoscopic exam

2. Stool from occult blood

3. Gastric analysis N gastric

Increase duodenal

4. GI series confirms presence of ulceration

Nursing Mgt:

1. Diet bland, non irritating, non spicy

2. Avoid caffeine & milk/ milk products

Increase gastric acid secretion

3. Administer meds

a.) Antacids

AAC

Aluminum containing antacids Magnesium containing antacids

Ex. aluminum OH gel ex. milk of magnesia

(Ampho-gel) S/E diarrhea

S/E constipation

Maalox (fever S/E)

b.) H2 receptor antagonist

Ex

1. Ranitidine (Zantac)

2. Cimetidine (Tagamet)

3. Tamotidine (Pepcid)

- Avoid smoking decrease effectiveness of drug

Nursing Mgt:

1. Administer antacid & H2 receptor antagonist 1hr apart

-Cemetidine decrease antacid absorption & vise versa

c.) Cytoprotective agents

Ex

1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Cytotec

d.) Sedatives/ Tranquilizers - Valium, lithium

e.)Anticholinergics

1. Atropine SO4

2. Prophantheline Bromide (Profanthene)

(Pt has history of hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large
amount of Na.

4. Surgery: subtotal gastrectomy - Partial removal of stomach

Billroth I (Gastroduodenostomy)

-Removal of of stomach & anastomoses of gastric stump to the duodenum. Billroth II

(Gastrojejunostomy)

- removal of -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.

Nursing Mgt:

1. Monitor NGT output

a.) Immediately post op should be bright red

b.) Within 36- 42h output is yellow green

c.) After 42h output is dark red

2. Administer meds:

a.) Analgesic

b.) Antibiotic

c.) Antiemetics
3. Maintain patent IV line

4. VS, I&O & bowel sounds

5. Complications:

a.) Hemorrhage hypovolemic shock

Late signs anuria

b.) Peritonitis

c.) Paralytic ileus most feared

d.) Hypokalemia

e.) Thromobphlebitis

f.) Pernicious anemia

7.)Dumping syndrome common complication rapid gastric emptying of hypertonic food solutions
CHYME leading to hypovolemia.

Sx of Dumping syndrome:

1. Dizziness

2. Diaphoresis

3. Diarrhea

4. Palpitations

Nursing mgt:

1. Avoid fluids in chilled solutions

2. Small frequent feeding s-6 equally divided feedings

3. Diet decrease CHO, moderate fats & CHON

4. Flat on bed 15 -30 minutes after q feeding

BURNS direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)

Head burn-priority- a/w

2nd priority for 1st & 2nd - pain

2nd priority for 3rd - F&E

Thermal- direct contact flames, hot grease, sunburn.

Electric, wires

Chem. direct contact corrosive materials acids

Smoke gas / fume inhalation

Stages:

1. Emergent phase Removal of pt from cause of burn. Determine source or loc or burn

2. Shock phase 48 - 72. Characterized by shifting of fluids from intravascular to interstitial space

S/Sx:

- BP decrease

- Urine output

- HR increase

- Hct increase

- Serum Na decrease

- Serum K increase

- Met acidosis

3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular
space

4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue
injury.
Class:

I. Partial Burn

1. 1st degree superficial burns

- Affects epidermis

- Cause: thermal burn

- Painful

- Redness (erythema) & blanching upon pressure with no fluid filled vesicles

2. 2nd degree deep burns

- Affects epidermis & dermis

- Cause chem. burns

- very painful

- Erythema & fluid filled vesicles (blisters)

II Full thickness Burns

1. Third & 4th degrees burn

- Affects all layers of skin, muscles, bones

- Cause electrical

- Less painful

- Dry, thick, leathery wound surface known as ESCHAR devitalized or necrotic tissue.

Assessment findings

Rule of nines

Head & neck = 9%

Ant chest = 18%

Post chest = 18%

@ Arm 9+9 = 18%

@ leg 18+18 = 18%

Genitalia/ perineum= 1%

Total 100%

Nursing Mgt

1. Meds

a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany

Tetany

Tetanolysin tetanospasmin

Hemolysis muscle spasm

b.) Morphine SO4

c.) Systemic antibiotics

1. Ampicillin

2. Cephalosporin

3. Tetracyclin

4. Topical antibiotic :

1. Silver Sulfadiazene (silvadene)

2. Sulfamylon

3. Silver nitrate

4. Povidone iodine (betadine)

2. Administer isotonic fluid sol & CHON replacements

3. Strict aseptic technique

4. Diet increase CHO, increase CHON, increase Vit C, and increase K- orange

5. If (+) to burns on head, neck, face - Assist in intubation

6. Assist in hydrotherapy

7. Assist in surgical wound debridement. Administer analgesic 15 30 minutes before debridement

8. Complications:

a.) Infection

b.) Shock

c.) Paralytic ileus - due to hypovolemia & hypokalemia

d.) Curlings ulcer H2 receptor antagonist

e.) Septicemia blood poisoning

f.) Surgery: skin grafting

GUT genito-urinary tract

Function:

1. Promote excretion of nitrogenous waste products

2. Maintain F&E & acid base balance

1. Kidneys pair of bean shaped organ

- Retro peritonially (back of peritoneum) on either side of vertebral column. Encased in Bowmanss
capsule.

Parts:

1. Renal pelvis pyenophritis infl

2. Cortex

3. Medulla

Nephrones basic living unit

Glomerulus filters blood going to kidneys

Function of kidneys:

1. Urine formation

2. Regulation of BP

Urine formation 25% of total CO (Cardiac Output) is received by kidneys

1. Filtration

2. Tubular Reabsorption

3. Tubular Secretion

Filtration Normal GFR/ min is 125 ml of blood

Tubular reabsorption 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)

Tubular secretion 1 ml is excreted in urine

Regulation of BP:

Predisposing factor:

Ex CS hypovolemia decrease BP going to kidneys

Activation of RAAS

Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus

Angiotensin I mild vasoconstrictor

Angiotensin II vasoconstrictor

Adrenal cortex increase CO increase PR

Aldosterone

Increase BP

Increase Na &

H2O reabsorption

Hypervolemia

Ureters 25 35 cm long, passageway of urine to bladder

Bladder loc behind symphisis pubis. Muscular & elastic tissue that is distensible

- Function reservoir or urine

1200 1800 ml Normal adult can hold

200 500 ml needed to initiate micturition reflex

Color amber

Odor aromatic

Consistency clear or slightly turbid

pH 4.5 8

Specific gravity 1.015 1.030

WBC/ RBC (-)

Albumin (-)
E coli (-)

Mucus thread few

Amorphous urate (-)

Urethra extends to external surface of body. Passage of urine, seminal & vaginal fluids.

- Women 3 5 cm or 1 to 1

- Male 20cm or 8

UTI

CYSTITIS inflammation of bladder

Predisposing factors:

1. Microbial invasion E. coli

2. High risk women

3. Obstruction

4. Urinary retention

5. Increase estrogen levels

6. Sexual intercourse

S/Sx:

1. Pain flank area

2. Urinary frequency & urgency

3. Burning upon urination

4. Dysuria & hematuria

5. Fever, chills, anorexia, gen body malaise

Diagnosis:

1. Urine culture & sensitivity - (+) to E. coli

Nursing Mgt:

1. Force fluid 2000 ml

2. Warm sitz bath to promote comfort

3. Monitor & assess for gross hematuria

4. Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication

5. Meds: systemic antibiotics

Ampicillin

Cephalosporin

Sulfonamides cotrimaxazole (Bactrim)

- Gantrism (ganthanol)

Urinary antiseptics Mitropurantoin (Macrodantin)

Urinary analgesic- Pyridum

6. Ht

a.) Importance of Hydration

b.) Void after sex

c.) Female avoids cleaning back & front

Bubble bath, Tissue paper, Powder, perfume

d.) Complications:

Pyelonephritis

PYELONEPHRITIS acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction,
interstitial abscess formation.

- Lead to Renal Failure

Predisposing factor:

1. Microbial invasion

a.) E. Coli

b.) Streptococcus

2. Urinary retention /obstruction

3. Pregnancy

4. DM

5. Exposure to renal toxins

S/Sx:

Acute pyelonephritis

a.) Costovertibral angle pain, tenderness

b.) Fever, anorexia, gen body malaise

c.) Urinary frequency, urgency

d.) Nocturia, dsyuria, hematuria

e.) Burning on urination

Chronic Pyelonephritis

a.) Fatigue, wt loss

b.) Polyuuria, polydypsia

c.) HPN

Diagnosis:

1. Urine culture & sensitivity (+) E. coli & streptococcus

2. Urinalysis

Increase WBC, CHON & pus cells

3. Cystoscopic exam urinary obstruction

Nursing Mgt:

1. Provide CBR acute phase

2. Force fluid

3. Acid ash diet

4. Meds:

a.) Urinary antiseptic nitrofurantoin (macrodantin)

SE: peripheral neuropathy

GI irritation

Hemolytic anemia

Staining of teeth

b.) Urinary analgesic Peridium

5. Complication- Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract

- calcium , oxalate, uric acid

milk cabbage anchovies

cranberries organ meat

nuts tea nuts

chocolates sardines

Predisposing factors:

1. Diet increase Ca & oxalate

2. Hereditary gout

3. Obesity

4. Sedentary lifestyle

5. Hyperparathyroidism

S/Sx:

1. Renal colic

2. Cool moist skin (shock)

3. Burning upon urination

4. Hematuria

5. Anorexia, n/v

Diagnosis:

1. IVP intravenous pyelography. Reveals location of stone

2. KUB reveals location of stone

3. Cytoscopic exam- urinary obstruction

4. Stone analysis composition & type of stone

5. Urinalysis increase EBC, increase CHON

Nursing Mgt:

1.Force fluid

2.Strain urine using gauze pad

3.Warm sitz bath for comfort

4.Alternate warm compress at flank area

5. a.) Narcotic analgesic- Morphine SO4

b.) Allopurinol (Zyeoprim)

c.) Patent IV line

d.) Diet if + Ca stones acid ash diet

If + oxalate stone alkaline ash diet - (Ex milk/ milk products)

If + uric acid stones decrease organ meat / anchovies sardines

6. Surgery

a.) Nephectomy removal of affected kidney

Litholapoxy removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones

b.) Extracorporeal shock wave lithotripsy

- Non - invasive

- Dissolve stones by shock wave

7. Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to

a.) Hydro ureters dilation of ureters

b.) Hydronephrosis dilation of renal pelvis

c.) Kidney stones

d.) Renal failure

Predisposing factor:

1. High risk 50 years old & above

60 70 (3 to 4 x at risk)

2. Influence of male hormone

S/Sx:

1.Decrease force of urinary stream

2.Dysuria

3.Hematuria

4.Burning upon urination

5.Terminal bubbling

6.Backache

7.Sciatica

Diagnosis:

1. Digital rectal exam enlarged prostate gland

2. KUB urinary obstruction

3. Cystoscopic exam obstruction

4. Urinalysis increase WBC, CHON

Nursing Mgt:

1. Prostatic message promotes evacuation of prostatic fluid

2. Limit fluid intake

3. Provide catheterization

4. Meds:

a. Terazozine (hytrin) - Relaxes bladder sphincter

b. Fenasteride (Proscar) - Atrophy of Prostate Gland

5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision

-Assist in cystoclysis or continuous bladder irrigation.

Nursing mgt:

c. Monitor symptoms of infection

d. Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h.

3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention
ACUTE RENAL FAILURE sudden immobility of kidneys to excrete nitrogenous waste products &
maintain F&E balance due to a decrease in GFR. (N 125 ml/min)

Predisposing factor:

Pre renal cause- decrease blood flow

Causes:

1. Septic shock

2. Hypovolemia

3. Hypotension decrease flow to kidneys

4. CHF

5. Hemorrhage

6. Dehydration

Intra-renal cause involves renal pathology= kidney problem

1. Acute tubular necrosis-

2. Pyelonephritis

3. HPN

4. Acute GN

Post renal cause involves mechanical obstruction

1. Stricture

2. Urolithiasis

3. BPH

CHRONIC RF irreversible loss of kidney function

Predisposing factors:

1. DM

2. HPN

3. Recurrent UTI/ nephritis

4. Exposure to renal toxins

Stages of CRF

1. Diminished Reserve Volume asymptomatic

Normal BUN & Crea, GFR < 10 30%

2. Renal Insufficiency

3. End Stage Renal disease

S/Sx:

1.) Urinary System

a.) polyuria

b.) nocturia

c.) hematuria

d.) Dysuria

e.) oliguria 2.) Metabolic disturbances

a.) azotemia (increase BUN & Crea)

b.) hyperglycemia

c.) hyperinulinemia

3.) CNS

a.) headache

b.) lethargy
c.) disorientation

d.) restlessness

e.) memory impairment 4.) GIT

a.) n/v

b.) stomatitis

c.) uremic breath

d.) diarrhea/ constipation

5.) Respiratory

a.) Kassmauls resp

b.) decrease cough reflex 6.) hematological

a.) Normocytic anemia

bleeding tendencies

7.) Fluid & Electrolytes

a.) hyperkalemia

b.) hypernatermia

c.) hypermagnesemia

d.) hyperposphatemia

e.) hypocalcemia

f.) met acidosis 8.) Integumentary

a.) itchiness/ pruritus

b.) uremic frost

Nursing Mgt:

1. Enforce CBR

2. Monitor VS, I&O

3. Meticulous skin care. Uremic frost assist in bathing pt

4. Meds:

a.) Na HCO3 due Hyperkalemia

b.) Kagexelate enema

c.) Anti HPN hydralazine

d.) Vit & minerals

e.) Phosphate binder

(Amphogel) Al OH gel - S/E constipation

f.) Decrease Ca Ca gluconate

5. Assist in hemodialysis

1.) Consent/ explain procedure

2.) Obtain baseline data & monitor VS, I&O, wt, blood exam

3.) Strict aseptic technique

4.) Monitor for signs of complications:

B bleeding

E embolism

D disequilibrium syndrome

S septicemia

S shock decrease in tissue perfusion

Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to:

a.) n/v

b.) HPN

c.) Leg cramps

d.) Disorientation

e.) Paresthesia
5. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.

6. Maintain patency of shunt by:

i. Palpate for thrills & auscultate for bruits if (+) patent shunt!

ii. Bedside- bulldog clip

- If with accidental removal of fistula to prevent embolism.

- Infersole (diastole) common dialisate used

7. Complication

- Peritonitis

- Shock

8. Assist in surgery:

Renal transplantation : Complication rejection. Reverse isolation

EYES

External parts

1. Orbital cavity made up of connective tissue protects eye form trauma.

2. EOM extrinsic ocular muscles involuntary muscles of eye needed for gazing movement.

3. Eyelashes/ eyebrows esthetic purposes

4. Eyelids palpebral fissure opening upper & lower lid. Protects eye from direct sunlight

Meibomean gland secrets a lubricating fluid inside eyelid

b.) Stye/ sty or Hordeolum- inflamed Meibomean gland

5. Conjunctiva

6. Lacrimal apparatus tears

Process of grieving

a. Denial

b. Anger

c. Bargaining

d. Depression

e. Acceptance

2. Intrinsic coat

I. sclerotic coat outer most

a.) Sclera white. Occupies post of eye. Refracts light rays

b.) Canal of schlera site of aqueous humor drainage

c.) Cornea transparent structure of eye

II/ Uveal tract nutritive care

Uveitis infl of uveal tract

Consist of:

a.) Iris colored muscular ring of eye

2 muscles of iris:

1. Circular smooth muscle fiber - Constricts the pupil

2.radial smooth muscle fiber - Dilates the pupil

2 chambers of the eye

1. Anterior

a.) Vitereous Humor maintains spherical shape of the eye

b.) Aqueous Humor maintains intrinsic ocular pressure

Normal IOP= 12-21 mmHg

II. Retina (innermost layer)

i. Optic discs or blind spot nerve fibers only

No auto receptors

cones (daylight/ colored vision) rods night twilight vision

phototopic vision scotopic vision = vit A deficiency rods insufficient

ii. Maculla lutea yellow spot center of retina

iii. Fovea centralis area with highest visual acuity oracute vision

Physiology of vision

4 Physiological processes for vision to occur:

1. Refraction of light rays bending of light rays

2. Accommodation of lens

3. Constriction & dilation of pupils

4. Convergence of eyes

Unit of measurements of refraction diopters

Normal eye refraction emmetropia

ERROR of refraction
1. Myopia near sightedness Treatment: biconcave lens

2. Hyperopia/ or farsightedness Treatment: biconvex lens

3. Astigmatisim distorted vision Treatment: cylindrical

4. Prebyopia old slight inelasticity of lens due to aging Treatment: bifocal lens or double vista

Accommodation of lenses based on thelmholtz theory of accommodation

Near vision = far vision=

Ciliary muscle contracts= ciliary muscle dilates / relaxes=

Lens bulges lens is flat

Convergence of the eye:

Error:

1. Exotropia 1 eye normal

2. Esophoria corrected by corrective eye surgery

3. Strabismus- squint eye

4. Amblyopia prolong squinting

GLAUCOMA increase IOP if untreated, atrophy of optic nerve disc blindness

Predisposing factors:

1. High risk group 40 & above

2. HPN

3. DM

4. Hereditary
5. Obesity

6. Recent eye trauma, infl, surgery

Type:

1. Chronic (open angle G.) most common type

Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema

2. Acute (close angle G.) Most dangerous type

Forward displacement of iris to cornea leading to blindness.

3. Chronic (closed angle) - Precipitated by acute attack

S/Sx:

1. Loss of peripheral vision tunnel vision

2. Halos around lights

3. Headache

4. n/v

5. Steamy cornea

6. Eye discomfort

7. If untreated gradual loss of central vision blindness

Diagnosis:

1. Tonometry increase IOP >12- 21 mmHg

2. Perimetry decrease peripheral vision

3. Gonioscopy abstruction in anterior chamber

Nursing mgt:
1. Enforce CBR

2. Maintain siderails

3. Administer meds

a.) Miotics lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)

b.) Epinephrine eye drops decrease secretion of aqueous humor

c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)

- Promotes increase out flow of aquaeous humor

d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor

4. Surgery:

Invasive:

a.) Trabeculectomy eyetrephining removal of trabelar meshwork of canal or schlera to drain aqueous
humor

b.) Peripheral Iridectomy portion of iris is excised to drain aqueous humor

Non-invasive:

Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery

1. Apply eye patch on unaffected eye to force weaker eye to become stronger.

Nursing Mgt post op all types of surgery

1. Position unaffected/ unoperated side - to prevent tension on suture line.

2. Avoid valsalva maneuver

3. Monitor symptoms of IOP

a.) Headache

b.) n/v
c.) Eye discomfort

d.) Tachycardia

4. Eye patch both eyes - post op

CATARACT partial/ complete opacity of lens

Predisposing factor:

1. 90-95% - aging (degenerative/ senile cataract)

2. Congenital

3. Prolonged exposure to UV rays

4. DM-

S/Sx:

1. Loss of central vision - Hazy or blurring of vision

2. Painless

3. Milky white appearance at center of pupil

4. Decrease perception of colors

Diagnosis: Opthalmoscopic exam (+) opacity of lens

Nsg Mgt:

1. Reorient pt to environment due opacity

2. Siderails

3. Meds a.) Mydriatics dilate pupil not lifetime

Ex. Mydriacyl

c.) Cyslopegics paralyzes ciliary muscle. Ex. Cyclogye

4. Surgery

E extra

C - capsular

C cataract partial removal of lens

L - lens

E extraction

I - intra

C - capsular

C cataract total removal of lens &

L lens surrounding capsules

E extraction

Nursing Mgt:

1.Position unaffected/ unoperated side - to prevent tension on suture line.

2.Avoid valsalva maneuver

3.Monitor symptoms of IOP

a.) Headache
b.) n/v

c.) Eye discomfort

d.) Tachycardia

4.Eye patch both eyes - post op

RETINAL DETACHMENT- separation of 2 layers of retina

Predisposing factors:

1. Severe myopia nearsightedness

2. Diabetic Retinopathy

3. Trauma

4. Following lens extraction

5. HPN

S/Sx:

1. Curtain veil like vision

2. Flashes of lights

3. Floaters

4. Gradual decrease in central vision

5. Headache

Diagnosis- opthaloscopic exam

Nursing Mgt:

1. Siderails (all visual disease)

2. Surgery:

a.) Cryosurgery

b.) Scleral buckling

EAR

1. Hearing

2. Balance (Kinesthesia or position sense)

Parts:

1. Outer-

a.) Pinna/ auricle protects ear from direct trauma

b.) Ext. auditory meatus has ceruminous gland. Cerumen

c.) Tympanic membrane transmits sound waves to middle ear

Disorders of outer ear

Entry of insects put flashlight to give route of exit

Foreign objects beans (bring to MD)

H2O - drain

2. Middle ear

a.) Ear osssicle

1. Hammer -malleus

2. Anvil -Incus for bone conduction disorder conductive hearing loss

3. Stirrups -stapes
b. Eustachian tube - Opens to allow equalization of pressure on both ears

- Yawn, chew, and swallow

Children straight, wide, short

c.) Otitis media

Adult long, narrow & slanted

c. Muscles

1. Stapedius

2. Tensor tympani

3. Inner ear

a. Bony labyrinth for balance, vestibule

Utricle & succule

Otolithe or ear stone has Ca carbonate

Movement of head = Righting reflex = Kinesthesia

b. Membranous Labyrinth

1. Cochlea ( function for hearing) has organ of corti

2. Endolymph & perilymph for static equilibrium

3. Mastoid air cells air filled spaces in temporal bone in skull

Complications of Mastoditis meningitis

Types of hearing loss:

1. Conductive hearing loss transmission hearing loss

Causes:

a.) Impacted cerumen tinnitus & conduction hearing loss- assist in ear irrigaton

b.) Immobility of stapes OTOSCLEROSIS

d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility
of stapes

e.) Stapes cant transmit sound waves

Surgery

Stapedectomy removal of stapes, spongy bone & implantation of graft/ ear prosthesis

Predisposing factor:

1. Familiar tendency

2. Ear trauma & surgery

S/Sx:

1. Tinnitus

2. Conductive hearing loss

Diagnosis:

1. Audiometry various sound stimulates (+) conductive hearing loss

2. Webers test Normal AC> BC

result BC > AC
Stapedectomy

Nursing Mgt post op

1. Position pt unaffected side

2. DBE

No coughing & blowing of nose

- Night lead to removal of graft

3. Meds:

a.) Analgesic

b.) Antiemetic

c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)

4. Assess motor function facial nerve - (Smile, frown, raise eyebrow)

5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS

Cause:

1. Tumor on cocheal

2. Loud noises (gun shot)

3. Presbycusis bilateral progressive hearing loss especially at high frequencies elderly

Face elderly to promote lip reading

4. Menieres disease endolymphatic hydrops

f.) Inner ear disease char by dilation of endo lympathic system leading to increase volume of endolin

Predisposing factor of MENIERES DISEASE

Smoking

Hyperlipidemia

30 years old

Obesity (+) chosesteatoma

Allergy

Ear trauma & infection

S/Sx:

1. TRIAD symptoms of Menieres disease

a.) Tinnitus

b.) Vertigo

c.) Sensory neural hearing loss

2. Nystagmus

3. n/v

4. Mild apprehension, anxiety

5. Tachycardia

6. Palpitations

7. Diaphoresis

Diagnosis:

1. Audiometry (+) sensory hearing loss

Nursing mgt:

1. Comfy & darkened environment

2. Siderails
3. Emetic basin

4. Meds:

a.) Diuretics to remove endolymph

b.) Vasodilator

c.) Antihistamine

d.) Antiemetic

e.) Antimotion sickness agent

f.) Sedatives/ tranquilizers

5. Restrict Na

6. Limit fluid intake

7. Avoid smoking

8. Surgery endolymphatic sac decompression- Shunt anorexia nervosa.

MATERNAL/OB NOTES

Human Sexuality

A. Concepts

1. A persons sexuality encompasses the complex behaviors, attitudes emotions and preferences that
are related to sexual self and eroticism.

2. Sex basic and dynamic aspect of life

3. During reproductive years, the nurse performs as resource person on human sexuality.

B. Definitions related to sexuality:

Gender identity sense of femininity or masculinity

2-4 yrs/3 yrs gender identity develops.

Role identity attitudes, behaviors and attributes that differentiate roles

Sex biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual
intercourse.

Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change.

- developed at the moment of conception.

II. Sexual Anatomy and Physiology

A. Female Reproductive System

1. External value or pretender

a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at
puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis.

Stages of Pubic Hair Development

Tannerscale tool - used to determine sexual maturity rating.

Stage 1 Pre-adolescence. No pubic hair. Fine body hair only

Stage 2 Occurs between ages 11 and 12 sparse, long, slightly pigmented & curly hair at pubis
symphysis

Stage 3 occurs between ages 12 and 13 darker & curlier at labia

Stage 4 occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so
thick and does no appear to the inner aspect of the upper thigh.

Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh .

b. Labia Majora - large lips longitudinal fold, extends symphisis pubis to perineum

c. Labia Minora 2 sensitive structures

clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual arousal
(Greek-key)
fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during
delivery.

Site episiotomy.

d. Vestibule an almond shaped area that contains the hymen, vaginal orifice and bartholenes glands.

1. Urinary Meatus small opening of urethra, serves for urination

2. Skenes glands/or paraurethral gland mucus secreting subs for lubrication

3. hymen covers vaginal orifice, membranous tissue

4. vaginal orifice external opening of vagina

5. bartholenes glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs secrets
alkaline subs.

Alkaline neutralizes acidity of vagina

Ph of vagina - acidic

Doderleins bacillus responsible for acidity of vagina

Carumculae mystiformes-healing of torn hymen

e. Perineum muscular structure loc lower vagina & anus

Internal:

A. vagina female organ of copulation, passageway of mens & fetus, 3 4inches or 8 10 cm long,
dilated canal

Rugae permits stretching without tearing

B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights.

Size- 1x2x3

Shape: nonpregnant pear shaped / pregnant - ovoid

Weight - nonpregnant 50 -60 kg- pregnant 1,000g

Pregnant/ Involution of uterus:

4th stage of labor - 1000g

2 weeks after delivery - 500g

3 weeks after delivery - 300 g

5-6 weeks after delivery - returns to original, state 50 60

Three parts of the uterus

1. fundus - upper cylindrical layer

2. corpus/body - upper triangular layer

3. cervix - lower cylindrical layer

* Isthmus lower uterine segment during pregnancy

Cornua-junction between fundus & interstitial

Muscular compositions: there are three main muscle layers which make expansion possible in every
direction.

1. Endometrium- inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs
during menstruation.

Decidua- thick layer.

Endometriosis-proliferation of endometrial lining outside uterus. Common site: ovary.

S/sx: dysmennorhea, low back pain.

Dx: biopsy, laparoscopy

Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation

2. Lupreulide (Lupron) inhibit FSH/LH production

2. Myometrium largest part of the uterus, muscle layer for delivery process

Its smooth muscles are considered to be the living ligature of the body.

- Power of labor, resp- contraction of the uterus

3. Perimetrium protects entire uterus

C. ovaries 2 female sex glands, almond shaped. Ext- vestibule int ovaries

Function: 1. ovulation

2. Production of hormones

d. Fallopian tubes 2-3 inches long that serves as a passageway of the sperm from the uterus to the
ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus.

4 significant segments

1. Infundibulum distal part of FT, trumpet or funnel shaped, swollen at ovulation

2. Ampulla outer 3rd or 2nd half, site of fertilization

3. Isthmus site of sterilization bilateral tubal ligation

4. Interstitial site of ectopic pregnancy most dangerous

B. Male Reproductive System

1. External

penis the male organ of copulation and urination. It contains of a body of a shaft consisting of 3
cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the
clitoris in the female the glands penis.

3 Cylindrical Layers

2 corpora cavernosa

1 corpus spongiosum

Scrotum a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs,
each of which contains a testes.

- cooling mechanism of testes

- < 2 degrees C than body temp.

- Leydig cell release testosterone

2. Internal

The Process of Spermatogenesis maturation of sperm

Male and Female homologues

Male Female

Penile glans Clitoral glans

Penile shaft Clitorial shaft

Testes ovaries

Prostate Skenes gands

Cowpers Glands Bartholin's glands

Scrotum Labia Majora

III. Basic Knowledge on Genetics and Obstetrics

1. DNA carries genetic code

2. Chromosomes threadlike strands composed of hereditary material DNA

3. Normal amount of ejaculated sperm 3 5 cc., 1 tsp

4. Ovum is capable of being fertilized with in 24 36 hrs after ovulation

5. Sperm is viable within 48 72 hrs, 2-3 days

6. Reproductive cells divides by the process of meiosis (haploid)

Spermatogenesis maturation of sperm

Oogenesis process - maturation of ovum

Gematogenesis formation of 2 haploid into diploid 23 + 23 = 46 or diploid

7. Age of Reproductivity 15 44yo

8. Menstruation-

Menstrual Cycle beginning of mens to beginning of next mens

Average Menstrual Cycle 28 days

Average Menstrual Period - 3 5 days

Normal Blood loss 50cc or cup

Related terminologies:
Menarche 1st mens

Dysmenorrhea painful mens

Metrorrhagia bleeding between mens

Menorhagia excessive during mens

Amenorrhea absence of mens

Menopause cessation of mens/ average : 51 years old

9. Functions of Estrogen and Progestin

* Estrogen Hormone of the Woman

Primary function: development secondary sexual characteristic female.

Others:

1. inhibit production of FSH ( maturation of ovum)

2. hypertrophy of myometrium

3. Spinnbarkeit & Ferning ( billings method/ cervical)

4. development ductile structure of breast

5. increase osteoblast activities of long bones

6. increase in height in female

7. causes early closure of epiphysis of long bones

8. causes sodium retention

9. increase sexual desire

*Progestin Hormone of the Mother

Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous
(twisted)

Secondary Function: uterine contractility (favors pregnancy)

Others: 1.inhibit prod of LH (hormone for ovulation)

2.inhibit motility of GIT

3. mammary gland development

4. increase permeability of kidney to lactose & dextrose causing (+) sugar

5. causes mood swings in moms

6. increase BBT

10. Menstrual Cycle

4 phases of Menstrual Cycle

1. Phases of Menstrual Cycle:

1. Proliferative

2. Secretory

3. Ischemic

4. Menses

Parts of body responsible for mens:

1. hypothalamus

2. anterior pituitary gland master clock of body

3. ovaries

4. uterus

Initial phase 3rd day decreased estrogen

13th day peak estrogen, decrease progesterone

14th day Increase estrogen, increase progesterone

15th day Decrease estrogen, increase progesterone

I. On the initial 3rd phase of menstruation , the estrogen level is decreased, this level stimulates the
hypothalamus to release GnRH or FSHRF

II. GnRH/FSHRF stimulates the anterior pituitary gland to release FSH

Functions of FSH:

1. Stimulate ovaries to release estrogen

2. Facilitate growth primary follicle to become graffian follicle (secrets large amt estrogen & contains
mature ovum.)

III. Proliferative Phase proliferation of tissue or follicular phase, post mens phase. Pre-ovularoty.

-phase of increase estrogen.

Follicular Phase causing irregularities of mens

Postmenstrual Phase

Preovulatory Phase phase increase estrogen

IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these
stimulates the hypothalamus to release GnRF on LHRF

1.) Mittelschmerz slight abdominal pain on L or RQ of abdomen, marks ovulation day.

2.) Change in BBT, mood swing

V. GnRF/LHRF stimulates the ant pit gland to release LH.

Functions of LH:

1. (13th day-decreased progesterone) LH stimulates ovaries to release progesterone

2. hormone for ovulation

VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of
graffian follicle on process of ovulation.

VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus
luteum (secrets large amount of progesterone)

VIII. Secretory phase-

Lutheal Phase

Postovulatory PhaseIncreased progesterone

Premenstrual Phase

IX. 24th day if no fertilization, corpus luteum degenerate ( whitish corpus albicans)

X. 28th day if no sperm in ovum endometrium begins to slough off to begin mens

Cornix- where sperm is deposited

Sperm- small head, long tail, pearly white

Phonones-vibration of head of sperm to determine location of ovum

Sperm should penetrate corona radiata and zona pellocida.

Capacitation- ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona
pellocida.

11. Stages of Sexual Responses (EPOR)

Initial responses:

Vasocongestion congestion of blood vessels

Myotonia increase muscle tension

1. Excitement Phase (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple
erection) erotic stimuli cause increase sexual tension, lasts minutes to hours.

2. Plateau Phase (accelerated V/S) increasing & sustained tension nearing orgasm. Lasts 30 seconds
3 minutes.
3. Orgasm (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with
physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 10 sec- most
affected are is pelvic area.

4. Resolution (v/s return to normal, genitals return to pre-excitement phase)

Refractory Period the only period present in males, wherein he cannot be restimulated for about 10-
15 minutes

A. Fertilization

B. Stages of Fetal Growth and Development

3-4 days travel of zygote mitotic cell division begins

*Pre-embryonic Stage

a. Zygote- fertilized ovum. Lifespan of zygote from fertilization to 2 months

b. Morula mulberry-like ball with 16 50 cells, 4 days free floating & multiplication

c. Blastocyst enlarging cells that forms a cavity that later becomes the embryo. Blastocyst covering of
blastocys that later becomes placenta & trophoblast

d. Implantation/ Nidation- occurs after fertilization 7 10 days.

Fetus- 2 months to birth.

placenta previa implantation at low side of uterus

Signs of implantation:

1. slight pain

2. slight vaginal spotting

- if with fertilization corpus luteum continues to function & become source of estrogen &
progesterone while placenta is not developed.

3 processes of Implantation
1. Apposition

2. Adhesion

3. Invasion

C. Dicidua thickened endometrium ( Latin falling off)

* Basalis (base) part of endometrium located under fetus where placenta is delivered

* Capsularies encapsulate the fetus

* Vera remaining portion of endometrium.

C. Chorionic Villi- 10 11th day, finger life projections

3 vessels=

A unoxygenated blood

V O2 blood

A unoxygenated blood

Whartons jelly protects cord

Chorionic villi sampling (CVS) removal of tissue sample from the fetal portion of the developing
placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex
missing digits/toes.

E. Cytotrophoblast inner layer or langhans layer protects fetus against syphilis 24 wks/6 months life
span of langhans layer increase. Before 24 weeks critical, might get infected syphilis

F. Synsitiotrophoblast synsitial layer responsible production of hormone

1. Amnion inner most layer

a. Umbilical Cord- FUNIS, whitish grey, 15 55cm, 20 21. Short cord: abruptio placenta or inverted
uterus.

Long cord:cord coil or cord prolapse

b. Amniotic Fluid bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly
alkaline.

*Function of Amniotic Fluid:

1. cushions fetus against sudden blows or trauma

2. facilitates musculo-skeletal development

3. maintains temp

4. prevent cord compression

5. help in delivery process

normal amt of amniotic fluid 500 to 1000cc

polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid

oligohydramnios- decrease amt of fluid kidney disease

Diagnostic Tests for Amniotic Fluid

A. Amniocentesis empty bladder before performing the procedure.

Purpose obtain a sample of amniotic fluid by inserting a needle through the abdomen into the
amniotic sac; fluid is tested for:

1. Genetic screening- maternal serum alpha feto-protein test (MSAFP) 1st trimester

2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity 3rd
trimester

Testing time 36 weeks

decreased MSAFP= down syndrome

increase MSAFP = spina bifida or open neural tube defect

Common complication of amniocenthesis infection

Dangerous complications spontaneous abortion

3rd trimester- pre term labor

Important factor to consider for amniocentesis- needle insertion site

Aspiration of yellowish amniotic fluid jaundice baby

Greenish meconium

A. Amnioscopy direct visualization or exam to an intact fetal membrane.

B. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured
amniotic fluid)

C. Nitrazine Paper Test diff amniotic fluid & urine.

Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid.

1. Chorion where placenta is developed

Lecithin Sphingomyelin L/S

Ratio- 2:1 signifies fetal lung maturity not capable for RDS

Shake test amniotic + saline & shake

Foam test

Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity

a. Placenta (Secundines) Greek pancake, combination of chorionic villi + deciduas basalis. Size: 500g
or kg
-1 inch thick & 8 diameter

Functions of Placenta:

1. Respiratory System beginning of lung function after birth of baby. Simple diffusion

2. GIT transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If
mom hypoglycemic, fetus hypoglycemic

3. Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.

4. Circulating system achieved by selective osmosis

5. Endocrine System produces hormones

Human Chorionic Gonadrophin maintains corpus luteum alive.

Human placental Lactogen or sommamommamotropin Hormone for mammary gland development.

Has a diabetogenic effect serves as insulin antagonist

Relaxin Hormone- causes softening joints & bones

estrogen

progestin

6. It serves as a protective barrier against some microorganisms HIV,HBV

Fetal Stage Fetal Growth and Development

Entire pregnancy days 266 280 days 37 42 weeks

Differentiation of Primary Germ layers

* Endoderm

1st week endoderm primary germ layer

Thyroid for basal metabolism

Parathyroid - for calcium

Thymus development of immunity

Liver lining of upper RT & GIT

* Mesoderm development of heart, musculoskeletal system, kidneys and repro organ

* Ectoderm development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth

First trimester:

1st month - Brain & heart development

GIT& resp Tract remains as single tube

1. Fetal heart tone begins heart is the oldest part of the body

2. CNS develops dizziness of mom due to hypoglycemic effect

Food of brain glucose complex CHO pregnant womans food (potato)

Second Month

1. All vital organs formed, placenta developed

2. Corpus luteum source of estrogen & progesterone of infant life span end of 2nd month

3. Sex organ formed

4. Meconium is formed

Third Month

1. Kidneys functional
2. Buds of milk teeth appear

3. Fetal heart tone heard Doppler 10 12 weeks

4. Sex is distinguishable

Second Trimester: FOCUS length of fetus

Fourth Month

1. lanugo begins to appear

2. fetal heart tone heard fetoscope, 18 20 weeks

3. buds of permanent teeth appear

Fifth Month

1. lanugo covers body

2. actively swallows amniotic fluid

3. 19 25 cm fetus,

4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks multi

5. fetal heart tone heard with or without instrument

Sixth Month

1. eyelids open

2. wrinkled skin

3. vernix caseosa present

Third trimester: Period of most rapid growth. FOCUS: weight of fetus

Seventh Month development of surfactant lecithin

Eighth Month

1. lanugo begin to disappear

2. sub Q fats deposit

3. Nails extend to fingers

Ninth Month

1. lanugo & vernix caseosa completely disappear

2. Amniotic fluid decreases

Tenth Month bone ossification of fetal skull

Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus

A. Drugs:

Streptomycin anti TB & or Quinine (anti malaria) damage to 8th cranial nerve poor hearing &
deafness

Tetracycline staining tooth enamel, inhibit growth of long bone

Vitamin K hemolysis (destr of RBC), hyperbilirubenia or jaundice

Iodides enlargement of thyroid or goiter

Thalidomides Amelia or pocomelia, absence of extremities

Steroids cleft lip or palate

Lithium congenital malformation

B. Alcohol lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by
microcephaly

C. Smoking low birth rate

D. Caffeine low birth rate

E. Cocaine low birth rate, abruption placenta

TORCH (Terratogenic) Infections viruses

CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend
through birth canal and adversely affect fetal growth and development. These infections are often
characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice
(hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have
devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes
simples virus.

T toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat

O others. Hepa A or infectious heap oral/ fecal (hand washing)

Hepa B, HIV blood & body fluids

Syphilis

R rubella German measles congenital heart disease (1st month) normal rubella titer 1:10

<1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Dont get pregnant
for 3 months. Vaccine is terratogenic

C cytomegalo virus

H herpes simplex virus

VI. Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes
1. Cardiovascular System increase blood volume of mom (plasma blood) 30 50% = 1500 cc of blood

- easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to hyperemia
of nasal membrane palpitation,

Physiologic Anemia pseudo anemia of pregnant women

Normal Values

Hct 32 42%

Hgb 10.5 14g/dL

Criteria

1st and 3rd trimester.- pathologic anemia if lower

HCT should not be 33%, Hgb should not be < 11g/dL

2nd trimester Hct should not <32%

Hgb Shdn't < 10.5% pathologic anemia if lower

Pathogenic Anemia

- iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant
women.

- Assessment reveals:

Pallor, constipation

Slowed capillary refill

Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia
Nursing Care:

Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetable-
alugbati,saluyot, malunggay, horseradish, ampalaya

Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly administered, hematoma.

Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs
after, black stool, constipation

Monitor for hemorrhage

Alert:

Iron from red meats is better absorbed iron form other sources

Iron is better absorbed when taken with foods high in Vit C such as orange juice

Higher iron intake is recommended since circulating blood volume is increased and heme is required
from production of RBCs

Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip
level.

Varicosities pressure of uterus

- use support stockings, avoid wearing knee high socks

- use elastic bandage lower to upper

Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under
hips or modified knee chest position

Thrombophlebitis presence of thrombus at inflamed blood vessel

- pregnant mom hyperfibrinogenemia

- increase fibrinogen

- increase clotting factor

- thrombus formation candidate

outstanding sign (+) Homan's sign pain on cuff during dorsiflexion

milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens

Mgt:

1.) Bed rest

2.) Never massage

3.) Assess + Homan sign once only might dislodge thrombus

4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)

5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate

6.) Avoid aspirin! Might aggravate bleeding.

2. Respiratory system common problem SOB due to enlarged uterus & increase O2 demand

Position- lateral expansion of lungs or side lying position.

3. Gastrointestinal 1st trimester change

Morning Sickness nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30
minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg emesisgravida.

Metabolic alkalosis, F&E imbalance primary med mgt replace fluids.

Monitor I&O
constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet

- fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.

Except guava has pectin thats constipating veg petchy, malungay.

- exercise

-mineral oil excretion of fat soluble vitamins

* Flatulence avoid gas forming food cabbage

* Heartburn or pyrosis reflux of stomach content to esophagus

- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body
mechanical

increase salivation ptyalsim mgt mouthwash

*Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort

4. Urinary System frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos
mgt for nocturia

Acetyace test albumin in urine

Benedicts test sugar in urine

5. Musculoskeletal

Lordosis pride of pregnancy

Waddling Gait awkward walking due to relaxation causes softening of joints & bones

Prone to accidental falls wear low heeled shoes

Leg Cramps causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while
pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus

Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head
of fish,

Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.

Vit D for increased Ca absorption

dorsiflexion

B. Local Changes

Local change: Vagina:

V Chadwicks sign blue violet discoloration of vagina

C Goodel's sign change of consistency of cervix

I Hegar's change of consistency of isthmus (lower uterine segment)

LEUKORRHEA whitish gray, mousy odor discharge

ESTROGEN hormone, resp for leucorrhea

OPERCULUM mucus plug to seal out bacteria.

PROGESTERONE hormone responsible for operculum

PREGNANT acidic to alkaline change to protect bacterial growth (vaginitis)

Problems Related to the Change of Vaginal Environment:

a. Vaginitits trichomonas vaginalis due to alkaline environment of vagina of pregnant mom

Flagellated protozoa wants alkaline

S&Sx:
Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema

Mgt:

FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so dont give at 1st trimester

1. treat dad also to prevent reinfection

2. no alcohol has antibuse effect

VAGINAL DOUCHE IQ H2O : 1 tbsp white vinegar

b. Moniliasis or candidiasis due to candida albecans, fungal infection.

Color white cheese like patches adheres to walls of vagina.

Signs & Symptoms:

Management antifungal Nistatin, genshan violet, cotrimaxole, canesten

Gonorrhea -Thick purulent discharge

Vaginal warts- condifoma acuminata due to papilloma virus

Mgt: cauterization

2. Abdominal Changes striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q
tissue avoid scratching, use coconut oil, umbilicus is protruding

3. Skin Changes brown pigmentation nose chin, cheeks chloasma melasma due to increased
melanocytes.

Brown pinkish line- linea nigra- symphisis pubis to umbilicus

4. Breast Changes increase hormones, color of areola & nipple

pre colostrums present by 6 weeks, colostrums at 3rd trimester

Breast self exam- 7 days after mens supine with pillow at back

quadrant B upper outer common site of cancer

Test to determine breast cancer:

1. mammography 35 to 49 yrs once every 1 to 2 yrs

50 yrs and above 1 x a yr

6. Ovaries rested during pregnancy

7. Signs & symptoms of Pregnancy

A. Presumptive s/s felt and observed by the mother but does not confirm positive diagnosis of
pregnancy . Subjective

B. Probable signs observed by the members of health team. Objective

C. Positive Signs undeniable signs confirmed by the use of instrument.

Ballotment sign of myoma

* + HCG sign of H mole

- trans vaginal ultrasound. Empty bladder

- ultrasound full bladder

placental grading rating/grade

o immature

1 slightly mature

2 moderately mature

3 placental maturity
What is deposited in placenta which signify maturity - there is calcium

Presumptive Probable Positive

Breast changes

Urinary freq

Fatigue

Amenorrhea

Morning sickness

Enlarged uterus

Cloasma

Linea negra

Increased skin pigmentation

Striae gravidarium

Quickening Goodel's- change of consistency of cervix

Chadwicks- blue violet discoloration of vagina

Hegar's- change of consistency of isthmus

Elevated BBT due to increased progesterone

Positive HCG or (+)preg test

Ballottement bouncing of fetus when lower uterine is tapped sharply

Enlarged abdomen

Braxton Hicks contractions painless irregular contractions

Ultrasound evidence (sonogram) full bladder

Fetal heart tone

Fetal movement

Fetal outline

Fetal parts palpable

VII. Psychological Adaptation to Pregnancy (Emotional response of mom Reva Rubin theory)

First Trimester: No tanginal signs & sx, surprise, ambivalence, denial sign of maladaptation to
pregnancy. Developmental task is to accept biological facts of pregnancy

Focus: bodily changes of preg, nutrition

Second Trimester tangible S&Sx. mom identifies fetus as a separate entity due to presence of
quickening, fantasy. Developmental task accept growing fetus as baby to be nurtured.

Health teaching: growth & development of fetus.

Third Trimester: - mom has personal identification on appearance of baby

Development task: prepare of birth & parenting of child. HT: responsible parenthood babys Layette
best time to do shopping.

Most common fear let mom listen to FHT to allay fear

Lamaze classes

VII. Pre-Natal Visit:

1. Frequency of Visit: 1st 7 months 1x a month

8 9 months 2 x a month

10 once a week

post term 2 x a week

2. Personal data name, age (high risk < 18 & >35 yrs old) record to determine high risk HBMR. Home
base moms record. Sex ( pseudocyesis or false pregnancy on men & women)
Couvade syndrome dad experiences what mom goes through lihi)

Address, civil status, religion, culture & beliefs with respect, non judgmental

Occupation financial condition or occupational hazards, education background level knowledge

3. Diagnosis of Pregnancy

1.) urine exam to detect HCG at 40 100th day. 60 70 day peak HCG. 6 weeks after LMP- best to get
urine exam.

2.) Elisa test test for preg detects beta subunit of HCG as early as 7 10days

3.) Home preg kit do it yourself

4. Baseline Data: V/S esp. BP, monitor wt. (increase wt 1st sign preeclampsia)

Weight Monitoring

First Trimester: Normal Weight gain 1.5 3 lbs (.5 1lb/month)

Second trimester: normal weight gain 10 12 lbs (4 lbs/month) (1 lb/wk)

Third trimester: normal weight gain 10 12 lbs (4 lbs/ month) ( 1lb/wk)

Minimum wt gain 20 25 lbs

Optimal wt gain 25 35 lbs

5. Obstetrical Data:

nullipara no pregnancy

a. Gravida- # of pregnancy

b. Para - # of viable pregnancy

Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age.

age of viability - 20 24 wks

Term 37 42 wks,

Preterm -20 37 weeks

abortion <20 weeks

Sample Cases:

1 abortion GTPAL

1 2nd mo 2 0 01 0

G2

P0

1 40th AOG GT P A L

1 36th AOG 6 1 2 2 4

2 misc

1 twins 35 AOG

1 4th month G6 P3

1 39th week

1 miscarriage GP GTPAL

1 stillbirth 33 AOG (considered as para) 4 2 4 11 1 1

1 preg 3rd wk

1 33 P

1 41st L

1 abort A

1 still 39 GP GTPAL

1 triplet 32 6 4 6 2 2 15

1 4th mon

c. Important Estimates:
1. Nageles Rule use to determine expected date of delivery

Get LMP -3+ 7 +1 Apr-Dec LMP Jan Feb Mar

M D Y +9 +7 no year

LMP Jan 25, 04

+9 +7

10 / 32 / 04

-1

add 1 month to month

11/31/04 EDD

2. McDonalds Rule to determine age of gestation IN WEEKS

FUNDIC HT X 7/8=AOG in WK

Fundic Ht X 7 = AOG in weeks

Fr sypmhisis pubis to fundus 24 X 7 =21 wks

3. Bartholomews Rule to determine age of gestation by proper location of fundus at abdominal cavity.

3 months above sym pub

5 months level of umbilicus

9 months below zyphoid

10 months level of 8 months due to lightening

4. Haases rule to determine length of the fetus in cm.

Formula: 1st of preg , square @ month

2nd of preg, x @ month by 5

3mos x 3 = 9cm

4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st of preg

5 x 5 = 25 cm

6 x 5 = 30 cm

7 x 5 = 35 cm 2nd of preg

8 x 5 = 40 cm

9 x 5 = 45 cm

d. tetanus immunizations prevents tetanus neonatum

-mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3

TT1 any time during pregnancy

TT2 4 wks after TT1 3 yrs protection

TT3 6 months after TT2 5 yrs protection

TT4 1 yr after TT3 10 yrs protection

TT5 yr after TT4 lifetime protection

5. Physical Examination:

A. Examine teeth: sign of infection

Danger signs of Pregnancy

C - chills/ fever - infection

Cerebral disturbances ( headache preeclampsia)

A abdominal pain ( epigastric pain aura of impending convulsions

B boardlike abdomen abruption placenta

Increase BP HPN

Blurred vision preeclampsia

Bleeding 1st trimester, abortion, ectopic pre/2nd H mole, incompetent cervix

3rd placental anomalies

S sudden gush of fluid PROM (premature rupture of membrane) prone to inf.

E edema to upper ext. (preeclampsia)

6. Pelvic Examination internal exam

1. empty bladder

2. universal precaution

EXT OS of cervix site for getting specimen

Site for cervical cancer

Pap Smear cervical cancer

- composed of squamous columnar tissue

Result:
Class I - normal

Class IIA acytology but no evidence of malignancy

B suggestive of infl.

Class III cytology suggestive of malignancy

Class IV cytology strongly suggestive of malignancy

Class V cytology conclusive of malignancy

Stages of Cervical Cancer

Stage 0 carcinoma insitu

1 cancer confined to cervix

2 - cancer extends to vagina

3 pelvis metastasis

4 affection to bladder & rectum

7. Leopolds Maneuver

Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an
estimate of the size, and number of fetuses, position, fetal back & fetal heart tone

- use palm! Warm palm.

Prep mom:

1. Empty bladder

2. Position of mom-supine with knee flex (dorsal recumbent to relax abdominal muscles)

Procedure:

1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right
hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of
the part to determine presentation
2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound)
where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff
fundic souffl (FHR) & uterine souffl.

Uterine souffl maternal H rate

3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.

To determine degree of engagement.

Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be
movable).

4th Maneuver: the Examiner changes the position by facing the patients feet. With two hands, assess
the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude
relationship of fetus to 1 another.

When the brow is on the same side as the back, the head is extended. When the brow is on the same
side as the small parts, the head will be flexed and vertex presenting.

Attitude relationship of fetus to a part or degree of flexion

Full flexion when the chin touches the chest

8.Assessment of Fetal Well-Being-

A. Daily Fetal Movement Counting (DFMC) begin 27 weeks

Mom- begin after meal - breakfast

a. Cardiff count to 10 method one method currently available

(1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal
movement, noting how long it takes to count 10 fetal movements (FMs)

(2) Expected findings 10 movements in 1 hour or less

3) Warning signs

a.) more then 1 hour to reach 10 movements

b.) less then 10 movements in 12 hours(non-reactive- fetal distress)

c.) longer time to reach 10 FMs than on previous days

d.) movement are becoming weaker, less vigorous

Movement alarm signals - < 3 FMs in 12 hours

4.) warning signs should be reported to healthcare provider immediately; often require further testing.
Examples: nonstress test (NST), biographical profile (BPP)

B. Nonstress test to determine the response of the fetal heart rate to activity

Indication pregnancies at risk for placental insufficiency

Postmaturity

a.) pregnancy induced hypertension (PIH), diabetes

b.) warning signs noted during DFMC

c.) maternal history of smoking, inadequate nutrition

Procedure:
Done within 30 minutes wherein the mother is in semi-fowlers position (w/ fetal monitor); external
monitor is applied to document fetal activity; mother activates the mark button on the electronic
monitor when she feels fetal movement.

Attach external noninvasive fetal monitors

1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)

2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected

3. monitor until at least 2 FMs are detected in 20 minutes

if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through
abdomen

if no FM after 1 hour further testing may be indicated, such as a CST

Result:

Noncreative

Nonstress

Not Good

Reactive

Responsive is

Real Good

Interpretation of results

i. reactive result

1. Baseline FHR between 120 and 160 beats per minute

2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a
10 to 20 minute period as a result of FM

3. Good variability normal irregularity of cardiac rhythm representing a balanced interaction between
the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an
uneven line on the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system

ii. Nonreactive result

1. Stated criteria for a reactive result are not met

2. Could be indicative of a compromised fetus.

Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)

9. Health teachings

a. Nutrition do nutritional assessment daily food intake

High risk moms:

1. Pregnant teenagers low compliance to heath regimen.

2. Extremes in wt underweight, over wt candidate for HPN, DM

3. Low socio economic status

4. Vegetarian mom decrease CHON needs Vit B12 cyanocobalamin formation of folic acid
needed for cell DNA & RBC formation. (Decrease folic acid spina bifida/open neural tube defect)

How many Kcal CHO x4,CHON x4, fats x 9

Recommended Nutrient Requirement that increases During Pregnancy

Nutrients Requirements Food Source

Calories

Essential to supply energy for

- increased metabolic rate

- utilization of nutrients

- protein sparing so it can be used for

- Growth of fetus
- Development of structures required for pregnancy including placenta, amniotic fluid, and tissue
growth. 300 calories/day above the prepregnancy daily requirement to maintain ideal body weight and
meet energy requirement to activity level

- Begin increase in second trimester

- Use weight gain pattern as an indication of adequacy of calorie intake.

- Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis
has been associated with fetal damage.

Caloric increase should reflect

- Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits)

- Variety of foods representing foods sources for the nutrients requiring during pregnancy

- No more than 30% fat

Protein

Essential for:

- Fetal tissue growth

- Maternal tissue growth including uterus and breasts

- Development of essential pregnancy structures

- Formation of red blood cells and plasma proteins

* Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH) 60
mg/day or an increase of 10% above daily requirements for age group

Adolescents have a higher protein requirement than mature women since adolescents must supply
protein for their own growth as well as protein t meet the pregnancy requirement

Protein increase should reflect

- Lean meat, poultry, fish

- Eggs, cheese, milk

- Dried beans, lentils, nuts

- Whole grains

* vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of
sufficient quantities of all amino acids

Calcium-Phosphorous

Essential for

- Growth and development of fetal skeleton and tooth buds

- Maintenance of mineralization of maternal bones and teeth

- Current research is :

Demonstrating an association between adequate calcium intake and the prevention of pregnancy
induce hypertension

Calcium increases of

- 1200 mg/day representing an increase of 50% above prepregnancy daily requirement.

- 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it
enhances absorption of both calcium and phosphorous Calcium increases should reflect:

- dairy products : milk, yogurt, ice cream, cheese, egg yolk

- whole grains, tofu

- green leafy vegetables

- canned salmon & sardines w/ bones

- Ca fortified foods such as orange juice

- Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood

Iron

Essential for

- Expansion of blood volume and red blood cells formation

- Establishment of fetal iron stores for first few months of life 30 mg/day representing a doubling of the
pregnant daily requirement
- Begin supplementation at 30- mg/day in second trimester, since diet alone is unable to meet
pregnancy requirement

- 60 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin
values prior to pregnancy or who have iron deficiency anemia.

- 70 mg/day of vitamin C which enhances iron absorption

- inadequate iron intake results in maternal effects anemia depletion of iron stores, decreased energy
and appetite, cardiac stress especially labor and birth

- fetal effects decreased availability of oxygen thereby affecting fetal growth

* iron deficiency anemia is the most common nutritional disorder of pregnancy. Iron increases should
reflect

- liver, red meat, fish, poultry, eggs

- enriched, whole grain cereals and breads

- dark green leafy vegetables, legumes

- nuts, dried fruits

- vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage, potatoes

- iron from food sources is more readily absorbed when served with foods high in vit C

Zinc

Essential for

* the formation of enzymes

* maybe important in the prevention of congenital malformation of the fetus. 15mcg/day representing
an increase of 3 mg/day over prepreganant daily requirements. Zinc increases should reflect

- liver, meats

- shell fish

- eggs, milk, cheese

- whole grains, legumes, nuts

Folic Acid, Folacin, Folate

Essential for

- formation of red blood cells and prevention of anemia

- DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects (spina
bifida), abortion, abruption placenta 400 mcg/day representing an increase of more then 2 times the
daily prepregnant requirement. 300mcg/day supplement for women with low folate levels or dietary
deficiency

4 servings of grains/day Increases should reflect

- liver, kidney, lean beef, veal

- dark green leafy vegetables, broccoli, legumes.

- Whole grains, peanuts

Additional Requirements

Minerals

- iodine

- Magnesium

- Selenium

175 mcg/day

320 mg/day

65 mcg/day Increased requirements of pregnancy can easily be met with a balanced diet that meets the
requirement for calories and includes food sources high in the other nutrients needed during pregnancy.

Vitamins

Thiamine

Riborlavin

Pyridoxine ( B6)

B12

Niacin
10 mg/day

1.5 mg/day

1.6 mg/day

2.2 mg/day

2.2 mg day

17 mg/day Vit stored in body. Taking it not needed fat soluble vitamins. Hard to excrete.

2.Sexual Activity

a.) should be done in moderation

b.) should be done in private place

c.) mom placed in comfy pos, sidelying or mom on top

d.) avoided 6 weeks prior to EDD

e.) avoid blowing or air during cunnilingus

f.) changes in sexual desire of mom during preg- air embolism

Changes in sexual desire:

a.) 1st tri decrease desire due to bodily changes

b.) 2nd trimester increased desire due to increase estrogen that enhances lubrication

c.) 3rd trimester decreased desire

Contraindication in sex:

1. vaginal spotting

1st trimester threatened abortion

2nd trimester placenta previa

2. incompetent cervix

3. preterm labor
4. premature rupture of membrane

3. Exercise to strengthen muscles used during delivery process

- principles of exercise

1.) Done in moderation. 2.) Must be individualized

Walking best exercise

Squatting strengthen muscles of perineum. Increase circulation to perineum. Squat feet flat on floor

Tailor Sitting 1 leg in front of other leg ( Indian seat)

Raise buttocks 1st before head to prevent postural hypotension dizziness when changing position

- shoulder circling exercise- strengthen chest muscles

- pelvic rocking/pelvic tilt- exercise relieves low back pain & maintain good posture

- * arch back standing or kneeling. Four extremities on floor

Kegel Exercise strengthen pulococcygeal muscles

- as if hold urine, release 10x or muscle contraction

Abdominal Exercise strengthens muscles of abdominal done as if blowing candle

4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that
can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth
experience.

a. Psychophysical

1. Bradley Method Dr. Robert Bradley advocated active participation of husband at delivery process.
Based on imitation of nature.

Features:

1.) darkened rm

2.) quiet environment

3.) relaxation tech

4.) closed eye & appearance of sleep

2. Grantly Dick Read Method fear leads to tension while tension leads to pain

b. Psychosexual

1. Kitzinger method preg, labor & birth & care of newborn is an impt turning pt in womans life cycle

- flow with contraction than struggle with contraction

c. Psychoprophylaxis prevention of pain

1. Lamaze: Dr. Ferdinand Lamaze

req. disciple, conditioning & concentration. Husband is coach

Features:

1. Conscious relaxation

2. Cleansing breathe inhale nose, exhale mouth

3. Effleurage gentle circular massage over abdominal to relieve pain

4. imaging sensate focus

5. Different Methods of delivery:

1.) birthing chair bed convertible to chair semifowlers

2.) birthing bed dorsal recumbent pos

3.) squatting relives low back pain during labor pain

4.) leboyers warm, quiet, dark, comfy room. After delivery, baby gets warm bath.

5.) Birth under H20 bathtub labor & delivery warm water, soft music.

IX. Intrapartal Notes inside ER

A. Admitting the laboring Mother:

Personal Data: name, age, address, etc

Baseline Data: v/s esppecially BP, weight

Obstetrical Data: gravida # preg, para- viable preg, 22 24 wks

Physical Exams,Pelvic Exams

B. Basic knowledge in Intrapartum.

b. 1 Theories of the Onset of Labor

1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content)
contraction action

2.) oxytocin theory post pit gland releases oxytocin. Hypothalamus produces oxytocin

3.) prostaglandin theory stimulation of arachidonic acid prostaglandin- contraction

4.) progesterone theory before labor, decrease progesterone will stimulate contractions & labor
5.) theory of aging placenta life span of placenta 42 wks. At 36 wks degenerates (leading to contraction
onset labor).

b.2. The 4 Ps of labor

1. Passenger

a. Fetal head is the largest presenting part common presenting part of its length.

Bones 6 bones S sphenoid F frontal - sinciput

E ethmoid O occuputal - occiput

T temporal P parietal 2 x

Measurement fetal head:

1. transverse diameter 9.25cm

- biparietal largest transverse

- bitemporal 8 cm

2. bimastoid 7cm smallest transverse

Sutures intermembranous spaces that allow molding.

1.) sagittal suture connects 2 parietal bones ( sagitna)

2.) coronal suture connect parietal & frontal bone (crown)

3.) lambdoidal suture connects occipital & parietal bone

Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis

Fontanels:

1.) Anterior fontanel bregma, diamond shape, 3 x 4 cm,( > 5 cm hydrocephalus), 12 18 months
after birth- close
2.) Posterior fontanel or lambda triangular shape, 1 x 1 cm. Closes 2 3 months.

4.) Anteroposterior diameter -

suboccipitobregmatic 9.5 cm, complete flexion, smallest AP

occipitofrontal 12cm partial flexion

occipitomental 13.5 cm hyper extension submentobragmatic-face presentation

2. Passageway

Mom 1.) < 49 tall

2.) < 18 years old

3.) Underwent pelvic dislocation

Pelvis

4 main pelvic types

1. Gynecoid round, wide, deeper most suitable (normal female pelvis) for pregnancy

2. Android heart shape male pelvis- anterior part pointed, posterior part shallow

3. Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse narrow

4. Platypelloid flat AP diameter narrow, transverse wider

b. Pelvis

2 hip bones 2 innominate bones

3 Parts of 2 Innominate Bones

Ileum lateral side of hips

- iliac crest flaring superior border forming prominence of hips

Ischium inferior portion

- ischial tuberosity where we sit landmark to get external measurement of pelvis

Pubes ant portion symphisis pubis junction between 2 pubis

1 sacrum post portion sacral prominence landmark to get internal measurement of pelvis

1 coccyx 5 small bones compresses during vaginal delivery

Important Measurements

1. Diagonal Conjugate measure between sacral promontory and inferior margin of the symphysis
pubis.

Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC 11.5 cm=true conjugate)

2. True conjugate/conjugate vera measure between the anterior surface of the sacral promontory and
superior margin of the symphysis pubis. Measurement: 11.0 cm

3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or more.

Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial tuberosity approximated with
use of fist 8 cm & above.

3. Power the force acting to expel the fetus and placenta myometrium powers of labor

a. Involuntary Contractions

b. Voluntary bearing down efforts

c. Characteristics: wave like

d. Timing: frequency, duration, intensity

4. Psyche/Person psychological stress when the mother is fighting the labor experience

a. Cultural Interpretation

b. Preparation

c. Past Experience
d. Support System

Pre-eminent Signs of Labor

S&Sx:

- shooting pain radiating to the legs

- urinary freq.

1. Lightening setting of presenting part into pelvic brim - 2 weeks prior to EDD

* Engagement- setting of presenting part into pelvic inlet

2. Braxton Hicks Contractions painless irregular contractions

3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase
epinephrine

4. Ripening of the Cervix butter soft

5. decreased body wt 1.5 3 lbs

6. Bloody Show pinkish vaginal discharge blood & leukorrhea

7. Rupture of Membranes rupture of water. Check FHT

Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse

Contraction drop in intensity even though very painful

Contraction drop in frequently

Uterus tense and/or contracting between contractions

Abdominal palpations

Nursing Care;

Administer Analgesics (Morphine)

Attempt manual rotation for ROP or LOP most common malposition

Bear down with contractions

Adequate hydration prepare for CS

Sedation as ordered

Cesarean delivery may be required, especially if fetal distress is noted

Cord Prolapse a complication when the umbilical cord falls or is washed through the cervix into the
vagina.

Danger signs:

PROM

Presenting part has not yet engaged

Fetal distress

Protruding cord form vagina

Nursing care:

1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery &
prevent cord compression causing cerebral palsy.

2. Slip cord away from presenting part

3. Count pulsation of cord for FHT

4. Prep mom for CS

Positioning trendelenberg or knee chest position

Emotional support

Prepare for Cesarean Section

Difference Between True Labor and False Labor

False Labor True Labor

Irregular contractions

No increase in intensity

Pain confined to abdomen

Pain relived by walking

No cervical changes Contractions are regular

Increased intensity

Pain begins lower back radiates to abdomen

Pain intensified by walking

Cervical effacement & dilatation * major sx

of true labor.

Duration of Labor

Primipara 14 hrs & not more than 20 hrs

Multipara 8 hrs & not > 14 hrs

Effacement softening & thinning of cervix. Use % in unit of measurement

Dilation widening of cervix. Unit used is cm.

Nursing Interventions in Each Stage of Labor

2 segments of the uterus

1. upper uterine - fundus

2. lower uterine isthmus

1. First Stage: onset of true contractions to full dilation and effacement of cervix.

Latent Phase:

Assessment: Dilations: 0 3 cm mom excited, apprehensive, can communicate

Frequency: every 5 10 min

Intensity mild

Nursing Care:

1. Encourage walking - shorten 1st stage of labor

2. Encourage to void q 2 3 hrs full bladder inhibit contractions

3. Breathing chest breathing

Active Phase:

Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self

Frequency q 3-5 min lasting for 30 60 seconds

Nursing Care:

M edications have meds ready

A ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.

D dry lips oral care (ointment)

dry linens

B abdominal breathing

Transitional Phase: intensity: strong Mom mood changes with hyperesthesia

Assessment: Dilations 8 10 cm

Frequency q 2-3 min contractions

Durations 45 90 seconds
Hyperesthesia increase sensitivity to touch, pain all over

Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain

keep informed of progress

controlled chest breathing

Nursing Care:

T ires

I nform of progress

R estless support her breathing technique

E ncourage and praise

D iscomfort

Pelvic Exams

Effacement

Dilation

a. Station landmark used: ischial spine

- 1 station = presenting part 1cm above ischial spine if (-) floating

- 2 station = presenting part 2 cm above ischial spine if (-) floating

0 station = level at ischial spine engagement

+ 1 station = below 1 cm ischial spine

+3 to +5 = crowning occurs at 2nd stage of labor

b. Presentation/lie the relationship of the long axis (spine) of the fetus to the long axis of the mother

-spine of mom and spine of fetus

Two types:
b.1. Longitudinal Lie ( Parallel)

cephalic - Vertex complete flexion

Face

Brow Poor Flexion

Chin

Breech - Complete Breech thigh breast on abdomen, breast lie on thigh

Incomplete Breech thigh rest on abdominal

Frank legs extend to head

Footling single, double

Kneeling

b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.

c. Position relationship of the fatal presenting part to specific quadrant of the mothers pelvis.

Variety:

Occipito LOA left occipito ant (most common and favorable position) side of maternal pelvis

LOP left occipito posterior

LOP most common mal position, most painful

ROP squatting pos on mom

ROT

ROA

Breech- use sacrum LSA left sacro anterior

- put stet above umbilicus LST, LSP, RSA, RST, RSP

Shoulder/acromniodorso

LADA, LADT, LADP, RADA

Chin / Mento

LMA, LMT, LMP, RMP, RMA, RMT, RMP

Monitoring the Contractions and Fetal heart Tone

Spread fingers lightly over fundus to monitor contractions

Parts of contractions:

Increment or crescendo beginning of contractions until it increases

Acme or apex height of contraction

Decrement or decrescendo from height of contractions until it decreases

Duration beginning of contractions to end of same contraction

Interval end of 1 contraction to beginning of next contraction

Frequency beginning of 1 contraction to beginning of next contraction

Intensity - strength of contraction

Contraction vasoconstriction

Increase BP, decrease FHT

Best time to get BP & FHT just after a contraction or midway of contractions

Placental reserve 60 sec o2 for fetus during contractions

Duration of contractions shouldnt >60 sec

Notify MD
Mom has headache check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia

Health teachings

1.) Ok to shower

2.)NPO GIT stops function during labor if with food- will cause aspiration

3.)Enema administer during labor

a.)To cleanse bowel

b.)Prevent infection

c.)Sims position/side lying

12 18 inch ht enema tubing

Check FHT after adm enema

Normal FHT= 120-160

Signs of fetal distress-

1.) <120 & >160

2.) mecomium stain amnion fluid

3.) fetal thrushing hyperactive fetus due to lack O2

2. Second Stage: fetal stage, complete dilation and effacement to birth.

7 8 multi bring to delivery room

10cm primi bring to delivery room

Lithotomy pos put legs same time up

Bulging of perineum sure to come out

Breathing panting ( teach mom)

Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2nd stage of labor.

Episiotomy median less bleeding, less pain easy to repair, fast to heal, possible to reach rectum (
urethroanal fistula)

Mediolateral more bleeding & pain, hard to repair, slow to heal

-use local or pudendal anesthesia.

Ironing the perineum to prevent laceration

Modified Ritgens maneuver place towel at perineum

1.)To prevent laceration

2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled.
Pull shoulder down & up. Check time, identification of baby.

Mechanisms of labor

1. Engagement -

2. Descent

3. Flexion

4. Internal Rotation

5. Extension

6. External rotation

7. Expulsion

Three parts of Pelvis 1. Inlet AP diameter narrow, transverse diameter wider

2. Cavity

Two Major Divisions of Pelvis

1. True pelvis below the pelvic inlet

2. False pelvis above the pelvic inlet; supports uterus during pregnancy

Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false
and true pelvis.

Nursing Care:

To prevent puerperal sepsis - < 48 hours only vaginal pack

Bolus of Ptocin can lead to hypotension.

3. Third Stage: birth to expulsion of Placenta -placental stage placenta has 15 28 cotyledons

Placenta delivered from 3-10 minutes

Signs of placental separation

1. Fundus rises becomes firm & globular Calkins sign

2. Lengthening of the cord

3. Sudden gush of blood

Types of placental delivery

Shultz shiny begins to separate from center to edges presenting the fetal side shiny

Dunkan dirty begin to separate form edges to center presenting natural side beefy red or dirty

Slowly pull cord and wind to clamp BRANDT ANDREWS MANEUVER

Hurrying of placental delivery will lead to inversion of uterus.

Nsg care for placenta:

4. Check completeness of placenta.

5. Check fundus (if relaxed, massage uterus)

6. Check bp

7. Administer methergine IM (Methylergonovine Maleate) Ergotrate derivatives

8. Monitor hpn (or give oxytocin IV)

9. Check perineum for lacerations

10. Assist MD for episiorapy

11. Flat on bed

12. Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to
regain energy.

4. Fourth Stage: the first 1-2 hours after delivery of placenta recovery stage. Monitor v/s q 15 for 1 hr.
2nd hr q 30 minutes.

Check placement of fundus at level of umbilicus.

If fundus above umbilicus, deviation of fundus

1.) Empty bladder to prevent uterine atony

2.) Check lochia

a. Maternal Observations body system stabilizes

b. Placement of the Fundus

c. Lochia

d. Perineum

R - edness

E- dema

E - cchemosis
D ischarges

A approximation of blood loss. Count pad & saturation

Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc

e. Bonding interaction between mother and newborn rooming in types

1.) Straight rooming in baby: 24hrs with mom.

2.) Partial rooming in: baby in morning , at night nursery

Complications of Labor

Dystocia difficult labor related to:

Mechanical factor due to uterine inertia sluggishness of contraction

1.) hypertonic or primary uterine inertia

- intense excessive contractions resulting to ineffective pushing

- MD administer sedative valium,/diazepam muscle relaxant

2.) hypotonic secondary uterine inertia- slow irregular contraction resulting to ineffective pushing.
Give oxytocin.

Prolonged labor normal length of labor in primi 14 20 hrs

Multi 10 -14 hrs

> 14 hrs in multi & > 20 hrs in primi

- maternal effect exhaustion. Fetal effect fetal distress, caput succedaneum or cephal hematoma

- nsg care: monitor contractions and FHR

Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with
bleeding.

Earliest sign: tachycardia & restlessness

Late sign: hypotension

Outstanding Nursing dx: fluid volume deficit

Post of mom modified trendelenberg

IV fast drip due fluid volume def

Signs of Hypovolemic Shock:

Hypotension

Tachycardia

Tachypnea

Cold clammy skin

Inversion of the uterus situation uterus is inside out.

MD will push uterus back inside or not hysterectomy.

Factors leading to inversion of uterus

1.) short cord

2.) hurrying of placental delivery

3.) ineffective fundal pressure

Uterine Rupture

Causes: 1.)

1.)Previous classical CS
2.)Large baby

3.) Improper use of oxytocin (IV drip)

Sx:

a.) sudden pain

b.) profuse bleeding

c.) hypovolemic shock

d.) TAHBSO

Physiologic retraction ring

- Boundary bet upper/lower uterine segment

BANDLS pathologic ring suprapubic depression

a.) sign of impending uterine rupture

Amniotic Fluid Embolism or placental embolism amniotic fluid or fragments of placenta enters natural
circulation resulting to embolism

Sx:

dyspnea, chest pain & frothy sputum

prepare: suctioning

end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body eyes, nose,
etc.

Trial Labor measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor

Multi: 8 14, primi 14 20

Preterm Labor labor after 20 37 weeks) ( abortion <20 weeks)

Sx:

1. premature contractions q 10 min

2. effacement of 60 80%

3. dilation 2-3 cm

Home Mgt:

1. complete bed rest

2. avoid sex

3. empty bladder

4. drink 3 -4 glasses of water full bladder inhibits contractions

5. consult MD if symptoms persist

Hosp:

1. If cervix is closed 2 3 cm, dilation saved by administer Tocolytic agents- halts preterm
contractions.YUTOPAR- Yutopar Hcl)

150mg incorporated 500cc Dextrose piggyback.

Monitor: FHT > 180 bpm

Maternal BP - <90/60

Crackles notify MD pulmo edema administer oral yutopar 30 minutes before d/c IV

Tocolytic (Phil)

Terbuthaline (Bricanyl or Brethine) sustained tachycardia

Antidote propranolol or inderal - beta-blocker

If cervix is open MD steroid dextamethzone (betamethazone) to facilitate surfactant maturation

preventing RDS

Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.

X. Postpartal Period 5th stage of labor

after 24hrs :Normal increase WBC up to 30,000 cumm

Puerperium covers 1st 6 wks post partum

Involution return of repro organ to its non pregnant state.

Hyperfibrinogenia

- prone to thrombus formation

- early ambulation

Principles underlying puerperium

1. To return to Normal and Facilitate healing

A. Physiologic Changes

a.1. Systemic Changes

1. Cardiovascular System

- the first few minutes after delivery is the most critical period in mothers because the increased in
plasma volume return to its normal state and thus adding to the workload of the heart. This is critical
especially to gravidocardiac mothers.

2. Genital tract

a. Cervix cervical opening

b. Vaginal and Pelvic Floor

c. Uterus return to normal 6 8 wks. Fundus goes down 1 finger breath/day until 10th day no longer
palpable due behind symphisis pubis
3 days after post partum: sub involuted uterus delayed healing uterus with big clots of blood- a
medium for bacterial growth- (puerperal sepsis)- D&C

after, birth pain:

1. position prone

2. cold compress to prevent bleeding

3. mefenamic acid

d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.

1. Ruba red 1st 3 days present, musty/mousy, moderate amt

2. Serosa pink to brown 4 9th day, limited amt

3. Alba crme white 10 21 days very decreased amt

dysuria

- urine collection

- alternate warm & cold compress

- stimulate bladder

3. Urinary tract: Bladder freq in urination after delivery- urinary retention with overflow

4. Colon: Constipation due NPO, fear of bearing down

5. Perineal area painful episiotomy site sims pos, cold compress for immediate pain after 24 hrs,
hot sitz bath, not compress

sex- when perineum has healed

II. Provide Emotional Support Reva Rubia

Psychological Responses:

a. Taking in phase dependent phase (1st three days) mom passive, cant make decisions, activity is to
tell child birth experiences.

Nursing Care: - proper hygiene

b. Taking hold phase dependent to independent phase (4 to 7 days). Mom is active, can make
decisions

HT:

1.) Care of newborn

2.) Insert family planting method

common post partum blues/ baby blues present 4 5 days 50-80% moms overwhelming feeling of
depression characterized by crying, despondence- inability to sleep & lack of appetite. let mom cry
therapeutic.

c. Letting go interdependent phase 7 days & above. Mom - redefines new roles may extend until
child grows.

III. Prevent complications

1. Hemorrhage bleeding of > 500cc

CS 600 800 cc normal

NSD 500 cc

I. Early postpartum hemorrhage bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding
uterine atony. Complications: hypovolemic shock.

Mgt:

1.) massage uterus until contracted

2.) cold compress

3.) modified trendelenberg

4.) IV fast drip/ oxytocin IV drip

1st degree laceration affects vaginal skin & mucus membrane.

2nd degree 1st degree + muscles of vagina

3rd degree 2nd degree + external sphincter of rectum

4th degree 3rd degree + mucus membrane of rectum

Breast feeding post pit gland will release oxytocin so uterus will contract.

Well contracted uterus + bleeding = laceration

- assess perineum for laceration

- degree of laceration

- mgt episiorapy

DIC Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.

- bleeding to any part of body

- hysterectomy if with abruption placenta

mgt: BT- cryoprecipitate or fresh frozen plasma

II. Late Postpartum hemorrhage bleeding after 24 hrs retained placental fragments

Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta,
percreta,

Acreta attached placenta to myometrium.

Increta deeper attachment of placenta to myometrium hysterectomy

Percreta invasion of placenta to perimetrium

Hematoma bluish or purple discoloration of SQ tissue of vagina or perineum.

- too much manipulation

- large baby

- pudendal anesthesia

Mgt:

1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs

2.) shave

3.) incision on site, scraping & suturing

Infection- sources of infection

1.)endogenous from within body

2.) exogenous from outside

1.) anaerobic streptococci most common - from members health team

2.) unhealthy sexual practices

General signs of inflammation:

1. Inflammation calor (heat), rubor (red), dolor (pain) tumor(swelling)

2. purulent discharges

3. fever

Gen mgt:

1.) supportive care CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity for
antibiotic

prolonged use of antibiotic lead to fungal infection

inflammation of perineum see general signs of inflammation

2 to 3 stitches dislocated with purulent discharge

Mgt:

Removal of sutures & drainage, saline, between & resulting.

Endometriosis inflammation of endometrial lining

Sx:

Abdominal tenderness, pos.

Fowlers to facilitate drainage & localize infection oxytocin & antibiotic

IV. Motivate the use of Family Planning

1.) determine ones own beliefs 1st

2.) never advice a permanent method of planning

3.) method of choice is an individuals choice.

Natural Method the only method accepted by the Catholic Church

Billings / Cervical mucus test spinnbarkeit & ferning (estrogen)

- clear, watery, stretchable, elastic long spinnbarkeit

Basal Body Temperature 13th day temp goes down before ovulation no sex

- get before arising in bed

LAM lactation amenorrheal method hormone that inhibits ovulation is prolactin.

breast feeding- menstruation will come out 4 6 months

bottle fed 2 3 months

disadvantage of lam might get pregnant

Symptothermal combination of BBT & cervical. Best method

Social Method 1.) coitus interuptus/ withdrawal - least effective method

2. coitus reservatus sex without ejaculation

3. coitus interfemora ipit

4. calendar method

OVULATION count minus 14 days before next mens (14 days before next mens)

Origoknause formula

- monitor cycle for 1 year

- -get short test & longest cycle from Jan Dec

- shortest 18

- longest 11

June 26 Dec 33

- 18 -11

8 - 22 unsafe days

21 day pill- start 5th day of mens

28day pill- start 1st day of mens

missed 1 pill take 2 next day

Physiologic Method-

Pills combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland
production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9%
effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.
Alerts on Oral Contraceptive:

-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she
would wait for at least 3 months before attempting to conceive to provide time for the estrogen and
progesterone levels to return to normal.

- if a new oral contraceptive is prescribed the mother should continue taking the previously prescribed
contraceptive and begin taking the new one on the first day of the next menses.

- discontinue oral contraceptive if there is signs of severe headache as this is an indication of

hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.

Signs of hypertension

Immediate Discontinuation

A abdominal pain

C chest pain

H - headache

E eye problems

S severe leg cramps

If mom HPN stop pills STAT!

Adverse effect: breakthrough bleeding

Contraindicated:

1.) chain smoker

2.) extreme obesity

3.) HPN

4.) DM

5.) Thrombophlebitis or problems in clotting factors

- if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If
forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the
start again.

DMPA depoproveda has progesterone inhibits LH inhibits ovulation

Depomedroxy progesterone acetate IM q 3 months

- never massage injected site, it will shorten duration

Norplant has 6 match sticks like capsules implanted subdermally containing progesterone.

- 5 yrs disadvantage if keloid skin

- as soon as removed can become pregnant

Mechanism and Chemical Barriers

Intrauterine Device (IUD)

Action: prevents implantation affects motility of sperm & ovum

- right time to insert is after delivery or during menstruation

primary indication for use of IUD

- parity or # of children, if 1 kid only dont use IUD

HT:

1.) Check for string daily

2.) Monthly checkup

3.) Regular pap smear

Alerts;

- prevents implantation

- most common complications: excessive menstrual flow and expulsion of the device (common problem)

- others:

P eriod late (pregnancy suspected)

Abnormal spotting or bleeding

A bdominal pain or pain with intercourse

I nfection (abnormal vaginal discharge)

N ot feeling well, fever, chills

S trings lost, shorter or longer

Uterine inflammation, uterine perforation, ectopic pregnancy

Condom latex inserted to erected penis or lubricated vagina

Adv; gives highest protection against STD female condom

Alerts:

Disadvantage:

- it lessen sexual satisfaction

- it gives higher protection in the prevention of STDs

Diaphragm rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus.
REVERSABLE

Ht:

1.) proper hygiene

2.) check for holes before use

3.) must stay in place 6 8 hrs after sex

4.) must be refitted especially if without wt change 15 lbs

5.) spermicide chem. Barrier ex. Foam (most effective), jellies, creams

S/effect: Toxic shock syndrome

Alerts: Should be kept in place for about 6 8 hours

Cervical Cap most durable than diaphragm no need to apply spermicide

C/I: abnormal pap smear

Foams, Jellies, Creams

Surgical Method BTL , Bilateral Tubal Ligation can be reversed 20% chance. HT: avoid lifting heavy
objects

Vasectomy cut vas deferense.

HT: >30 ejaculations before safe sex

O zero sperm count, safe

XI. High Risk Pregnancy

1. Hemorrhagic Disorders

General Management

1.) CBR

2.) Avoid sex

3.) Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc)

4.) Ultrasound to determine integrity of sac

5.) Signs of Hypovolemic shock

6.) Save discharges for histopathology to determine if product of conception has been expelled or
not

First Trimester Bleeding abortion or eptopic

A. Abortions termination of pregnancy before age of viability (before 20 weeks)

Spontaneous Abortion- miscarriage

Cause: 1.) chromosomal alterations

2.) blighted ovum

3.) plasma germ defect

Classifications:

a. Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed

b. Inevitable moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)

Types:

1.) Complete all products of conception are expelled. No mgt just emotional support!

2.) Incomplete Placental and membranes retained. Mgt: D&C

Incompetent cervix abortion

McDonalds procedure temporary circlage on cervix

S/E; infection. During delivery, circlage is removed. NSD

Sheridan permanent surgery cervix. CS

c. Habitual 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
Present 2nd trimester

d. Missed fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy
cease. (-) preg test, scanty dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction

5.) Induced Abortion therapeutic abortion to save life of mom. Double effect choose between lesser
evil.

C. Ectopic Pregnancy occurs when gestation is located outside the uterine cavity. common site: tubal
or ampular

Dangerous site - interstitial

Unruptured Tubal rupture

- missed period

- abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)

- scant, dark brown, vaginal bleeding

Nursing care:

Vital signs

Administer IV fluids

Monitor for vaginal bleeding

Monitor I & O - sudden , sharp, severe pain. Unilateral radiating to shoulder.

shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve)

+ Cullens Sign bluish tinged umbilicus signifies intra peritoneal bleeding

syncope (fainting)

Mgt:

Surgery depending on side

Ovary: oophrectomy

Uterus : hysterectomy
Second trimester bleeding

C. Hydatidiform Mole bunch or grapes or gestational trophoblastic disease. with fertilization.

Progressive degeneration of chorionic villi. Recurs.

- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed
form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm
duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.

Use: methotrexate to prevent choriocarcinoma

Assessment:

Early signs - vesicles passed thru the vagina

Hyperemesis gravidarium increase HCG

Fundal height

Vaginal bleeding( scant or profuse)

Early in pregnancy

High levels of HCG

Preeclampsia at about 12 weeks

Late signs hypertension before 20th week

Vesicles look like a snowstorm on sonogram

Anemia

Abdominal cramping

Serious complications hyperthyroidism

Pulmonary embolus

Nursing care:

Prepare D&C

Do not give oxytoxic drugs

Teachings:
a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus
and rising titer could indicative of choriocarcinoma

b. Avoid pregnancy for at least one year

Third Trimester Bleeding Placenta Anomalies

D. Placenta Previa it occurs when the placenta is improperly implanted in the lower uterine segment,
sometimes covering the cervical os. Abnormal lower implantation of placenta.

- candidate for CS

Sx: frank

Bright red

Painless bleeding

Dx:

Ultrasound

Avoid: sex, IE, enema may lead to sudden fetal blood loss

Double set up: delivery room may be converted to OR

Assessment:

Engagement (usually has not occurred)

Fetal distress

Presentation ( usually abnormal)

Surgeon in charge of sign consent, RN as witness

- MD explain to patient

complication: sudden fetal blood loss

Nursing Care

NPO
Bed rest

Prepare to induce labor if cervix is ripe

Administer IV

E. Abruptio Placenta it is the premature separation of the placenta form the implantation site. It
usually occurs after the twentieth week of pregnancy.

Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:

Concealed bleeding (retroplacental)

Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to
hemorrhage.

Severe abdominal pain

Dropping coagulation factor (a potential for DIC)

Complications:

Sudden fetal blood loss

-placenta previa & vasa previa

Nursing Care:

Infuse IV, prepare to administer blood

Type and crossmatch

Monitor FHR

Insert Foley

Measure blood loss; count pads

Report s/sx of DIC

Monitor v/s for shock

Strict I&O
F. Placenta succenturiata 1 or 2 more lobes connected to the placenta by a blood vessel may lead to
retained placental fragments if vessel is cut.

G. Placenta Circumvalata fetal side of placenta covered by chorion

H. Placenta Marginata fold side of chorion reaches just to the edge of placenta

I. Battledore Placenta cord inserted marginally rather then centrally

J. Placenta Bipartita placenta divides into 2 lobes

K. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta

L. Vasa Previa velamentous insertion of cord has implanted in cervical OS

2. Hypertensive Disorders

I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.

1.) Gestational hypertension - HPN without edema & protenuria H without EP

2.) Pre-eclampsia HPN with edema & protenuria or albuminuria HE P/A

3.) HELLP syndrome hemolysis with elevated liver enzymes & low platelet count

II. Transissional Hypertension HPN between 20 24 weeks

III. Chronic or pre-existing Hypertension HPN before 20 weeks not solved 6 weeks post partum.

Three types of pre-eclampsia

1.) Mild preeclampsia earliest sign of preeclampsia

a.) increase wt due to edema

b.) BP 140/90

c.) protenuria +1 - +2
2.) Severe preeclampsia

Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually
indicates an impending convulsion. BP 160/110 , protenuria +3 - +4

3.) Eclampsia with seizure! Increase BUN glomerular damage. Provide safety.

Cause of preeclampsia

1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi

2.) common in multiple pre (twins) increase exposure to chorionic villi

3.) common to mom with low socioeconomic status due to decrease intake of CHON

Nursing care:

P romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to
urinate.

P- prevent convulsions by nursing measures or seizure precaution

1.) dimly lit room . quiet calm environment

2.) minimal handling planning procedure

3.) avoid jarring bed

P- prepare the following at bedside

- tongue depressor

- turning to side done AFTER seizure! Observe only! for safely.

E ensure high protein intake ( 1g/kg/day)

- Na in moderation
A anti-hypertensive drug Hydralazine ( Apresoline)

C convulsion, prevent Mg So4 CNS depressant

E valuate physical parameters for Magnesium sulfate

Magnesium SO4 Toxicity:

1. BP decrease

2. Urine output decrease

3. Resp < 12

4. Patella reflex absent 1st sigh Mg SO4 toxicity. antidote Ca gluconate

3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas)

Function: of insulin facilitates transport of glucose to cell

Dx: 1 hr 50gr glucose tolerance test GTT

Normal glucose 80 120 mg/dl < 80 hypoclycemic

( euglycemia) > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL

maternal effect DM

1.) Hypo or hyperglycemia 1st trimester hypo, 2nd 3rd trim hyperglycemic

2.) Frequent infection- moniliasis

3.) Polyhydramnios

4.) Dystocia-difficult birth due to abnormalities in fetus or mom.

5.) Insulin requirement, decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd 3rd trimester.

Post partum decrease 25% due placenta out.

Fetal effect

1.) hyper & hypoglycemia

2.) macrosomia large gestational age baby delivered > 400g or 4kg

3.) preterm birth to prevent stillbirth

Newborn Effect : DM

1.) hyperinsulinism

2.) hypoglycemia

normal glucose in newborn 45 55 mg/dL

hypoglycemic < 40 mg/dL

Heel stick test get blood at heel

Sx:

Hypoglycemia high pitch shrill cry tremors, administer dextrose

3.) hypocalcemia - < 7mg%

Sx:

Calcemia tetany

Trousseau sign

Give calcium gluconate if decrease calcium

Recommendation

Therapeutic abortion

If push through with pregnancy

1.) antibiotic therapy- to prevent sub acute bacterial endocarditis

2.) anticoagulant heparin doesnt cross placenta

Class I & II- good progress for vaginal delivery

Class III & IV- poor prognosis, for vaginal delivery, not CS!

NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver

Regional anesthesia!

Low forcep delivery due to inability to push. It will shorten 2nd stage of labor.

Heart disease

Moms with RHD at childhood

Class I no limit to physical activity

Class II slight limitation of activity. Ordinary activity causes fatigue & discomfort.

Recommendation of class I & II

1.) sleep 10 hrs a day

2.) rest 30 minutes & after meal

Class III - moderate limitation of physical activity. Ordinary activity causes discomfort

Recommendation:

1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.

Recommendation: Therapeutic abortion

XII. Intrapartal complications

1. Cesarean Delivery Indications:

a. Multiple gestation
b. Diabetes

c. Active herpes II

d. Severe toxemia

e. Placenta previa

f. Abruptio placenta

g. Prolapse of the cord

h. CPD primary indication

i. Breech presentation

j. Transverse lie

Procedure:

a. classical vertical insertion. Once classical always classical

b. Low segment bikini line type aesthetic use

VBAC vaginal birth after CS

INFERTILITY - inability to achieve pregnancy. Within a year of attempting it

- Manageable

STERILITY - irreversible

Impotency inability to have an erection

2 types of infertility

1.) primary no pregnancy at all

2.) Secondary 1st pregnancy, no more next preg

test male 1st

- more practical & less complicated

- need: sperm only

- sterile bottle container ( not plastic has chem.)

- Sims Huhner test or post coital test. Procedure: sex 2 hours before test

mom remains supine 15 min after ejaculation

Normal: cervical mucus must be stretchable 8 10 cm with 15 20 sperm. If >15 low sperm count

Best criteria- sperm motility for impotency

Factors: low sperm count

1.) occupation- truck driver

2.) chain smoker

administer: clomid ( chomephine citrate) to induce spermatogenesis

Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count

Implant sperm in ampula

1.) Mom: anovulation no ovulation. Due to increase prolactin hyperprolactinemia

Administer; parlodel ( Bromocryptice Mesylate)

Action; antihyper prolactineuria

Give mom clomid: action: to induce oogenesis or ovulation

S/E: multiple pregnancy

2.) Tubal Occlusion tubal blockage Hx of PID that has scarred tubes

- use of IUD

- appendicitis (burst) & scarring

= dx: hysterosalphingography used to determine tubal patency with use of radiopaque material

Mgt: IVF invitrofertilization (test tube baby)

England 1st test tube baby

To shorten 2nd stage of labor!

1.) fundal pressure

2.) episiotomy

3.) forcep delivery

Growth and Development

Growth- increase in physical size of a structure or whole.

-quantitative change.

Two parameters of Growth

1. weight- most sensitive measure of growth, especially low birth rate.

Wt doubles 6 months

3x 1yr

4x 2-2 yrs

2. Height- increase by 1/mo during 1st 6 months

- average increase in ht - 1st year = 50%

stoppage of ht coincide with eruption of wisdom tooth.

Development- increase skills or capability to function

- qualitative

How to measure development

1. Observe child doing specific task.

2. Role description of childs progress

3. DDST- Denver development screening test.

MMDST (Phil) Metro Manila Developmental Screening Test.

DDST measures mental

4 main rated categories of DDST

1. Language communication

2. personal social-interaction

3. fine motor adaptive- ability to use hand movement

4. gross motor skills- large body movement

maturation- same with development readiness

Cognitive development ability to learn and understand from experience to acquire and retain
knowledge. To respond to a new situation and to solve problems.

IQ test- test to determine cognitive development

Mental age x 100 = IQ

Chronological age

Average IQ 90-100

Gifted child- > 130 IQ

Basic Divisions of Life

I. Prenatal stage from conception- birth

II. Period of infancy

1. Neonatal- 1st 28 days or 1st 4 weeks of life

2. Formal infancy- 29 day 1 year

III. Early childhood

1. Toddler 1-3 yrs

2. Pre school 4-6 years

IV. Middle childhood

1. School age- 7 12 yrs

V. Late childhood

1. Pre adolescent 11 13 yrs

2. Adolescent 12 - 18 21

Principles of G & D

1. G&D is a continuous process

-begins form conception- ends in death

- womb to tomb principles

2. not all parts of the body grow at the same time or at same rate.

- asynchronism
Patterns of G&D

1. )renal

digestive grows rapidly during childhood

circulatory

musculoskeletal

2. )Neuromuscular tissue (CNS, brain, S. cord)

- grow rapidly 1-2 years of life

- brain achieved its adult proportion by 5 years.

3. )Lymphatic system- lymph nodes, spleen grows rapidly- infancy and childhood to provide protection -
infection

- tonsil adult proportion by 5 years

4. )Repro organ- grows rapidly at puberty

Rates of G&D

1. fetal and infancy most rapid G&D

2. adolescent- rapid G&D

3. toddler- slow G period

4. Toddler and preschool- alternating rapid and slow

5. school age- slower growth

fetal and infancy- prone to develop anemia

3. Each child is unique

2 primary factors affecting G&D

A. Heredity - R race

I intelligence

S sex

N - nationality

Females are born less in weight than males by 1 oz.

Females are born less in length than males by 1 inch

B. Environment

Q quality of nutrition

S socio eco. status

H health

O ordinal pos in family

P parent child relationship

Eldest- skillful in language and social skills

Younger- toilet trained self

4.G&D occurs in a regular direction reflecting a definitive and predictable patterns or trends.
Directional trends- occur in a regular direction reflecting the development of neuromuscular function.
These apply to physical, mental, social and emotional development and includes.

a. cephalo-caudal head to tail

- occurs along bodies long axis in which control over head, mouth and eye movements and precedes
control over upper body torso and legs.

b. proximo- distal Centro distal

- progressing form center of body to extremities.

c. Symmetrical- at side of body develop on same direction at same time at same rate.

d. Mass specific differentiation

- child learns form simple operations before complex function of move from a broad general pattern of
behavior. To a bore refined pattern.

B. Sequential- involves a predictable sequence of G&D to which the child no9rmally passes.

a. locomotion- creep than crawls, sit then stand.

b. socio and language skills- solitary games, parallel games

C. Secular- worldwide trend of maturing earlier and growing larger as compared to succeeding
generations.

5.Behavioral in the most compressive indicator of developmental status.

6. universal language of child- play

7. great deal of skill and behavior is learned by practice. Practice makes perfect.

9. neonatal reflexes us must be lost before one can proceed.

-plantar reflex should disappear before baby can walk

-moro reflex should disappear before baby can roll

persistent primitive infantile reflexes- case of cerebral palsy

Theories of G&D

Developmental tasks- different form chronological age

-skill or growth responsibility arising at a particular time in the individuals life.

The successful achievement of which will ------- a foundation for the accomplishments of future tasks.

Theorists

1. Sigmund Freud 1856-1939 Austrian neurologists. Founder of psychoanalysis

- offered personality development

Psychosexual theory

a.) Oral Phase 0-18 months

- mouths site of gratification

-activity of infant- biting, sucking crying.

-why do babies suck?- enjoyment and release of tension.

-provide oral stimulation even if baby was placed on NPO.

-pacifier.

-never discourage thumb sucking.

b.) ANAL- 18 months-3 years

-site of gratification- anus

-activity- elimination, retention or defecation of feces make take place

- principle of holding on or letting go.

-mother wins or child wins

-child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins)
-mother wins- obedient, kind, perfectionist, meticulous

OC-anal phase

-help child achieve bowel and bladder control even if child is hospitalized.

c.) Phallic- 3-6 years

site of gratification -genitals

activity- may show exhibitionism

-increase knowledge of a sexes

-accept child fondling his/her own genitalia as normal exploration

-answer Childs question directly.

Right age to introduce sexuality preschool

d.) Latent- 7-12 years

-period of suppression- no obvious development.

-Childs libido or energy is diverted to more concrete type of thinking

-helps child achieve (+) experience so ready to face conflict of adolescence

e.) Genital- 12-18 years

-site of gratification -genitals

-achieve sexual maturity

-learns to establish relationships with opposite sex.

-give an opportunity to relate to opposite sex.

ERIC ERICKSON- psychoanalysis theory

- stresses important of culture and society to the development of ones personality

- environment

- culture

stages of psychosocial

a.) trust vs mistrust 0-18 months.

-foundations of all psychosocial task

-to give and receive is the psychosocial theme

-know to develop trust baby

1. satisfy needs on time

- breastfeed

2. care must be consistent and adequate

-both parents- 1st 1 year of life

3.) give an experience that will add to security- touch, eye to eye contact, soft music.

b.) Autonomy vs shame and doubt 18-3 years --- independence /self govt

develop autonomy on toddler

1. give an opportunity of decision making like offer choices.

2. encourage to make decision rather then judge.

3. set limits

c. initiative vs guilt- 4-6 years

-learns how to do basic things

-let explore new places and events

-activity recommended- modeling clay, finger painting will enhance imagination and creativity and
facilitate fine motor devt
d. industry vs inferiority 7-12 yrs

-child learns how to do things well

-give short assignments and projects

e. Identity vs role confusion or diffusion 12-18 yrs

- learns who he/she is or what kind of person he/ she will become by adjusting to new body image and
seeking emancipation form parents

-freedom form parents.

f. Intimacy vs isolation 20-40 yrs -looking for a lifetime partner and career focus

g. generatively vs stagnation 40- 60 45-65 yrs

h. ego integrity vs, despair 60-65

JEAN PIAGET- Swiss psychologists

-develop reasoning power

STAGES OF COGNITIVE DEVELOPMENT

A-Sensory motor 0-2 yrs

-practical intelligence- words and symbols not yet available baby communicates through senses and
reflexes.

(sub div.)
Schema Age Behavior

1.) neonate reflex 1 month All reflexes

2.) primary circular 1-4 months -Activity related to body

-repetition of behavior

ex. thumb sucking

3.) secondary circular reaction 4-8 months -activity not related to body

-discover obj and persons permanence

-memory traces present

-anticipate familiar events.

Coordination of secondary reaction 8-12 months -exhibit goal directed behavior

-increase of separateness (will search of lost toy, knows mom)

Tertiary circular reaction 12-18 months -use trial and error to discover places and events

- invention of new means

-capable of space and time perception

(hits fork, spoon on table or drops fork)

Invention of new means there mental combination 18-24 months -transitional phase to the pre
operational thought period.
Preoperational thought 2-7 years

Schema age Behavior

Preconceptual 2-4 yrs -thinking basically complete literal and static

-egocentric- unable to view others interrupt

-concept of dying is only now

-concept of distance is only as fat as they can see.

-concept of amenism inanimate object is alive

-not aware of concept of r3eversibility- in every action theories an opposite reaction or cause and effect

Initiative 4-7 yrs Beginning of causation

Concrete Operational thought 7-12 years

1. able to find solution to everyday problems which systematic reasoning.

2. have concept of reversibility- cause and effect

3. have concept of longer uation constancy despite of transformation.

4. 4. activity recommended- collecting and classifying

5. stamps stationeries, dolls, rubber band markers.

Formal Operational thought 12 and up.

1. Cognition achieved its final form

2. can deal with past present and future

3. have abstract and mature thoughts.

4. can find solutions to hypothetical problems with scientific reasoning.

5. activity ------- will sort out opinions and current events.

KOHLBERG- recognized the theory of moral devt as considered to closely approximate cognitive stages
of devt

-sabay with cognitive dev;t

Stages of Moral devt

Infancy premoral, prereligious, amoral stage

AGE STAGE DESCRIPTION

Pre-conventional Level 1

2-3 yrs 1 -Punishment/ obedience oriented (heteronymous morality) child does right cause a parent tells
him or her to and to avoid punishment

4-7 2 -Individualism. Instrumental purpose and exch. Carries out action to satisfy own needs rather than
society.

-Will do something for another if that person does something for the child.

Conventional Level

7-10 3 -Orientation to interpersonal relations of mutuality. Child followers rules cause of a need to be a
good person in own eyes and eyes of others.

10-12 4 -Maintenance of social order fixed rules and authority. Child finds ff. rules satisfying. Follows
rules of authority figures.

Post-conventional Level III

Above 12 yrs 5 -Social contract, utilitarian level making perspectives. Followers standards of society.

6 Universal ethical principle orientation. Follows internalized standards of conduct.

E. DEVT MILESTONES-major markers of growth and devt

1. Period of infancy- universal language of child-play

a.) Play- Infancy- solitary plays

-solo, mom interactive

-facilitate motor and sensory devt

-safety- important age appropriate

solitary play- mobile, teeter, music box, rattle

b.) fear of infancy- stranger anxiety begin 6-7 months peak 8 months diminishes 9 months

1 month- dance reflex disappears looks at mobile

2 months- holds head up when in prone,

social smile,

baby coos doing sound

cry with tears

-closure of frontal fontanel 2-3 months

head lag when pulled to sitting position.

3 months- holds head and chest up when prone

follows obj. past midline

grasp and tonic neck reflex fading

hand regard (looks at hand)

4 months turns form front to back

head control complete

needs space to turn

Laugh aloud, bubbling sounds

5 months- turn both ways roll over

-teething rings

-handles rattle well

-moro reflex disappears ( 4-5 months)

6 months- reaches out in anticipatory of being picked up

-sits with support

-uses palmar grasp

-eruption of 1st temp teeth 6-8 months 2 lower incisors

-say vowel sounds ah, oh

-handles bottle well

7 months- transfer obj. hand to hand

-likes obj that are good size

8 months- sits without support

-peak of stranger anxiety

-planters reflex disappears 8-9 months in prep for walking

9 months - creeps or crawls

-neat finger grasp reflex

- combine 2 syllables mama and papa

- needs space for creeping

10 months pull self to stand

-understands no
-responds to own name

-peak a boo, pat a cake

-can clap

11 months- cruisse

- stands with assistance

12 months- stand alone take 1st step

-walk with assistance

-drink from cup, cooperate in dressing

-says 2 words mama and dada

-pots and pans, pull tay, nursery rhymes

Toddler- parallel play- 2 toddlers playing separately

-provide with similar toys

-squeaky frog to squeeze

waddling duck to pull

trucks to push-push pull toy

building blocks, pounding peg

toys to ride on

fear- separation anxiety

begin 9 months

peak 18 months

3 phases of separation anxiety (in order)

1. P- protect

2. d despair

3. d- denial

-dont prolong goodbye

-say goodbye firmly to develop trust- say when ul be back

15 months plateau stage

walks alone

lateness in walking- mild mental retardation

-puts small pellets into small bowl

-holds spoon well

- seats self on chair

-creeps up stairs

- 4 - 6 words

18 months- height of possessiveness

favorite word- mine

bowel control achieved (bowel 1st before bladder)

-no longer rotates spoon

-can run and jump in place

walks up and down stairs holding railing or persons hand

-1-20 words

-name, body part

-puts both feet on 1 step before advancing.

24 months- terrible two

-can open doors by turning door knobs

-unscrew lids

-can walk upstairs alone using both feet on same step at same time

-50-200 words ( 2 words sentences)

-daytime bladder control achieved ( daytime 1st- next nighttime bladder control)

30 months or 2 years makes simple lines or stroke for crosses with a pencil

-can jump down from chairs

-knows full name

- copy a circle

- holds up finger to show age

- temp teeth complete

post molar- last temp teeth to appear

how many deciduous teeth -20

beginning of toothbrush 2-2 yrs

tooth brushing with little assistance 3 yrs

tooth brushing alone 6 yrs

right time to bring to dentist- when temp teeth complete

36 months or 3 yrs- trusting 3

- unbutton buttons (unbutton before learn to button)

-draw a +
- learns how to share

-knows full name and sex (gender identity)

- speaks fluently

-nighttime bladder control

-300-900 words

-ride a tricycle

Characteristic Traits of toddler

negativistic- NO! -way to search for independence

limit questions

modify questions to a statement

2.) rigid, ritualistic and stereotype

ritualism- for mastering

3.)Temper tantrums- head banging, screaming, stamping feet, holds breath

ignore behavior

scaffoid abdominal-due to underdeveloped abdominal muscles

physiologic anorexia- due to preoccupation with environment- food jag that last for short period of time

loves rough and tumbling play

loves toilet training-

failure of toilet training- unreadiness

Clues of toilet readiness:

1.) can stand, squat walk alone

2.) can communicate toilet needs

3.) can maintain dry for 2 hours

Pre schoolers- associative or cooperative play

1.) bahay-bahayan play house

2.) role playing

3.) fear-body mutilation or castration

fear of dark places witches

fear of thunder and lightning

fear of ghosts

Milestones

4years old- furious 4 , noisy, aggressive, stormy

-can button buttons

-copy a square

-jumps and skips

-laces shoes

-vocabulary 1,500

-knows four basic colors

5 years old- frustrating 5

-copy a triangle

-draw a 6 part man

-imaginary playmates
-2,100 words

Character Traits of Pre-schooler:

1.) curious, creative imaginative, imitative

2.) 2. favorite words- why and how

3.) complexes- word identification to parent of same sex and attachment to parent of opposite sex

ex. Oedipal complex- boy to mom

Electra complex- girl to dad

Cause of incest marital discord

Death-sleep only

Behavior problems Preschool

1. telling tall tales-over imagination

2. imaginary friend- to release tension and anxieties

3. sibling rivalry- jealousy to newly delivered baby.

4. regression- going back to early stage

-thumb sucking (should be oral stage only)

-baby talk

-bed wetting

-fetal position

5. masturbation- sign of boredom

-divert attention- offer a toy

School Age

Play- competitive play

Ex. Tug of war, track and field, basket ball

Fear. 1.) school phobia

-orient to new environment

2.) displacement from school

-teacher and peer of same sex

3. loss of privacy

-wants bra

4.) fear of death

-7-9yrs death is personified

-death- permanent loss of life

Significant Development

a. boys- prone to bone fracture

b. mature vision 20/20

6 years- temp teeth begin to fall

perm teeth appear- 1st molar

1st temp teeth- 5 months

1st perm teeth- 6 yrs

-yr of constant motion

clensy mout

recognize all shapes

-1st grade teacher becomes authority figure

-nail biting

-begin interest in God.

7 yrs- assimilation age

-copy a diamond

-enjoys teasing and playing alone

-quieting down period

8 yrs- expansive age

-smoother mouth

-loves to collect objects

-count backwards

9 yrs coordination improves

-tells time correctly

-hero worship

-stealing and lying are common

-takes care of body needs completely

-teacher finds this group difficult to handle

10 yrs- age of special talent

-writes legibly

-ready for competitive games

-more considerate and cooperative

-joins orgs.

-well mannered with adult

-critical of adults

11-12 yrs pre adolescents

-full of energy and constantly active

-secret language are common

-share with friends secrets

-sense of humor present

-social and cooperative

Character Traits School Age

1. industrious-

2. modest

3. cant bear to lose- will cheat

4. love collections- stamps

Signs of sexual maturity

GIRLS:

I-inc size breast and genitalia (pelarche- 1st sign sexual mat.

W- widening of hips

A- appearance axillary, pubic ( adrenarch)

M- menarche- last sign sexual mat. Girls

BOYS:

A-appearance axillary, pubic hair ( 1st sign sexual mat)

D-deepening voice

D- development of muscles

I--inc in testes and penis size

P- prod of viable sperm ( last sign sexual maturity)

Adolescent

Fear

1. obesity

2. acne

3. homosexuality

4. death

5. replacement from friends

6. significant person- opp sex.

Significant devt

1. experiences conflict bet his needs for sexual satisfaction and societies expectation

2. change of body image and acceptance of opp/sex

3. nocturnal emission wet dreams

4. distinctive odor- due to stimulation apocrine glands

5. sperm is viable by 17 yrs

6. testes & scrotum increase until age 17

7. breast and female genitalia increase until age 18

Personality Traits Adolescents

1. idealistic

2. rebellious

3. reformers

4. conscious with body image

5. adventuresome

Problems:

1. vehicular accident

2. smoking

3. alcoholism

4. drug addiction

5. pre marital sex

IMMEDIATE CARE OF NEWBORN

1st days of life

1. initiation and maintenance of respiration

2. establishment of extra uterine circulation

3. control of body temp

4. intake of adequate nourishment

5. establishment of waste elimination

6. prevention of infection

7. establishment of an infant parent relationship

8. devt care that balances rest and stimulation or mental devt

1.) Initiation and maintenance of respiration

2nd stage of labor- initial airway

-initiation of a /w is a crucial adjustment

-most neonatal deaths with in 24 h caused by inability to initiate a/w

-lung function begins after birth only

How to initiate a/w

a.) remove secretions bulb syringe

B. Catheter Suctioning

1.) place head to side to facilitate drainage

2,) suction mouth 1st before nose

-neonates are nasal breathers

3.) period of time

-5-10 sec suctioning, gentle and quick

prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation
vagal nerve

4.) evaluate for patency

-cover nostril and baby struggles theres a need for additional suctioning

C. If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal
tube can be inserted and oxygen can be administered by an (+) pressure bag and mask with 100%
oxygen at 40-60b/m.
Nsg alert:

1. No smoking

2. Always humidify to prevent drying of mucosa

3. Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or
retinopathy of prematurity)

4. When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push
mecomium inside)

2.) Establishing extra uterine circulation

- circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord.

FETO PLACENTAL CIRCULATION

-Placenta(simple diffusion) oxygenated blood is carried by the umbilical vein- passes liver-ductus
venousus- IVC- RT atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve LT ventricle-
aorta-lower extremities.

-Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition) (vasoconstriction
of lungs pushes blood to ductus arteriousus to aorta to supply upper extremities.

SHUNTS-shortcuts

Ductus venosus- -shunts from liver to IVF

Foramen ovale- shunts bet 2 atrias

Ductus arteriosus- from pulmonary artery to aorta

What will sustain 1st breath- decreased artery pressure

What will initiate lung circulation-lung expansion

What will complete circulation- cutting of cord

4.) 2 way to facilitate closure of foramen ovale

a.) Tangential Footstep- slap foot of baby

-never stimulate baby to cry if secretions not fully drained to prevent aspiration

-check characteristic of cry

normal cry- strong, vigorous and lusty cry

cri-du-chat syndrome-chromosomal obliteration cat like cry

b.) proper position -right side lying pos.

-will increase pressure on left and foramen ovale will close

Foramen Ovale and Ductus arteriosus will begin to close within 24h
Obliteration-complete closure

Structure Appropriate time of obliteration Structure remaining Failure to close

F. Ovale 1yr Fossa Ovalis Atrial Septal Defect

Ductus Arteriosus 1 month Ligamentum Arteriosum Patent ductus arteriosus

Ductus Venosus 2 months Ligamentum venosum

Umbilical artery 2-3 months 1.) lateral umb. Ligament

2.) interior iliac artery

Umbilical vein 2-3 months -ligamentum teres ( round ligament of liver)

Position of infant immediately after birth:

NSD-trendelenberg/ T position for drainage

contraindication of trendelenberg position - increase ICP

CS- supine or crib level position

Signs of increased ICP

1.) abnormally large head

2.) bulging and tense fontanel

3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of

4.) Decreased RR, decreased PR ICP

5.) projective vomiting- sure sign of cerebral irritation

6.) high deviation diplopia sign of ICP older child

4-6 months- normal eye deviation

>6 months- lazy eyes

7.) High pitch shrill cry-late sign of ICP

Temp Regulation

- goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)

- maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to
hypothermia or cold stress

A. factors leading to devt of HYPOTHERMIA

1. preterms are born poi kilo thermic- cold blooded

- babies easily adapt to temp of environment due to immaturity of thermo regulating system of body.
Hypothalamus

2. inadequate SQ tissue

3. baby is not capable of shivering

4. babies are born wet

PROCESS OF HEAT LOSS

1. evaporation-body to air (TSB)

2. conduction- body to cold solid object (cold compress)

3. convection-body to cooler surrounding air (aircon)

4. radiation- body to cold object not in contact with body

earliest sign of hypothermia- increase in RR

Effects of Hypothermia ( Cold stress)

1.) Hypoglycemia- 45-55 mg/dl normal

50- borderline

2.) met acidosis- catabolism of brown fats (best insulator of newborns body)

will form ketones

3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy

4.) additional fatigue to allergy stressful heart

To Prevent Hypothermia

1. dry and wrap baby

2. mechanical pressure radiant warmer

pre-heated first isolette (or square acrylic sided incubator)

3. prevent an necessary exposure cover baby

4. cover baby with tin foil or plastic

5. embrace the baby- kangaroo care

A. Establish Adequate Nutritional Intake

CS- breastfeeding after 4 hours

NSD- breastfeeding asap

Physiology breast milk production

As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior Posterior Gland (APG)
releases prolactin acts on

acinar cells (or alveoli) produce foremilk stored in lactiferous tubules ( or collecting tubules)

where breast milk is produced alveoli post-pit.gland

Sucking- PPG oxytocin contraction of lactiferous tubules - milk ejection reflex- let down reflex.

Advantages of Breastfeeding

1. Economical

2. Always available

3. Breastfed babies have higher IQ than bottle fed babies.

4. It facilitates rapid involution

5. Decrease incidence of breast cancer.

6. Has antibodies- IgA

7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT

8. Has macrophages

Store milk- plastic storage container

Store milk good for 6 months from freezer- put rm temp. dont heat

Disadvantages:

1. Possibility of transfer HEP B, HIV, cytomegalo virus.

2. No iron

3. Father cant feed & bond as well

Stages of Breastmilk:

1. Colostrum- 2-4 days present

content: decrease fats, increase IgA, dec CHO, dec CHON, inc minerals,

inc fat soluble minerals

2. Transitional milk- 4 14 days

content: inc lactose, inc water soluble vit., inc minerals

3. Mature milk- 14 & up

content: inc fats (linoleic acid) resp for devt of brain & integrity of skin

inc CHO- lactose easily digested, baby not constipated.

- resp of sour milk smelling odor of stool.

Lactose intolerance- deficiency of enzyme LACTASE that digest LACTOSE

Decrease CHON- lactalbumin

Cows milk inc fats-

Dec CHO

Inc CHON casing- has curd thats hard to digest.

Inc mineralstraumatic effect on kidneys of babies. Can trigger stone formation.

Inc phosphorus

Health Teachings:

1. Proper hygiene- proper hand washing

Care of breast - cotton balls with lukewarm water

Caked colostrum- dry milk on breast

2. Best position in breastfeeding upright sitting -avoid tension!

3. Stimulate & evaluate feeding reflexes

a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6
weeks- by 6 weeks baby can focus. Reflex will be gone

- Purpose rooting- to look for food.

b.) Sucking when you touch middle of lips then baby will suck

- Disappears by 6 months

- When not stimulated sucking will stop.

c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed

d.) Extrusion/ Protrusion reflex

-when food touches anterior portion of tongue then food will be extruded.

Purpose: to prevent from poisoning

Disappear by 4 months & baby can already spit out by 4 months.

Criteria Effective Sucking

a.) Babys mouth is hiked up to areola

b.) Mom experiences after pain.

c.) Other nipple is also flowing with milk.

To prevent from crack nipples & initiate proper production of oxytocin.

- begin 2-3 min at @ breast ( 5 7 min other authors)

to initiate production of oxytocin

- increase 1 min/ day until reaching 10 mins @ breast or 20 mins/ feeding.

For proper emptying & continuous milk production / feeding

-feed baby on last breast that you feed her with, alternately ( if not emptied - mastitis)
Problems experienced in Breastfeeding :

3RD day changes in breast post partum

a.)Engorged- feeling of fullness & tension in breast.

- sometimes accompanied by fever known as MILK FEVER.

Mgt: Warm compress- for breastfeeding mom

Cold compress for bottle feeding & wear supportive bra.

When is involution of breast- 4 weeks

b.) Sore nipple cracked with painful nipple

Mgt: 1.) exposure to air remove bra & wear dress, if not, expose to 20 Watt bulb

avoid wearing plastic liner bra

- will create moisture, cotton only

c.) Mastitis- inflammation of breast : staphylococcus aureus

Factors:

1. Improper breast emptying

2. Unhealthy sexual practices

-contraindicated for breast feeding

- manually express inflamed breast

feed on unaffected breast

- give antibiotics can still feed on unaffected breast

Contra Indications in Breast Feeding:

Maternal Conditions:

1. HIV CMV
Hepa B Coumadin

Newborn Condition - Inborn errors of metabolism

Erythrobastosis Fetalis Rh incompatibility

Hydrops Fetalis

Phenylketonuria

Galactosemia

Tay Sachs disease

5. Establish of waste elimination

A. Diff stools

1. Meconium - physiologic stool

- black green, sticky, tar like, odorless (Sterile intestine)

will pass with in 24 36 hrs

failure to pass mecomium after 24h- GIT obstruction

ex. Hirschsprungs disease

imperforate anus

mecomium ileus due to Cystic Fibrosis

2. Transitional stool -

- green loose & shiny, like diarrhea to the untrained eye

3. Breastfed stool - golden yellow, soft, mushy with sour milk smell, frequently passed

- recur every feeding

4. Bottlefed stool

- pale yellow, formed hard with typical offensive odor, seldom passed, 23 x/day
- with food added -brown & odorous

Jaundice baby light stool

Under phototherapy bright green

Mucus mixed with stool - milk allergy

Clay colored stool obstruction to bile duct

Chalk clay stool after barium enema

Black stool GIT bleeding (melena)

Blood flecked stool - anal fissure.

Currant jelly stool instussusection

Ribbon like stool hirschsprung disease

Steatorrhea stool fatty, bulky foul smelling odor stool

- malabasorption syndrome ( celiac disease or cystic fibrosis)

Cult blood stool exam

III Assessment for Wellbeing

APGAR SCORE Dr. Virginia Apgar

Special Considerations:

1st 1 min determine general condition of baby

Next 5 min- determine babys capabilities to adjust extra uterinely

Next 15 min dependent on the 5 min

A- appearance- color slightly cyanotic after 1st cry baby becomes pink.

P- pulse rate apical pulse left lower nipple

G- grimace reflex irritability- tangential foot slap, catheter insertion

A activity degree of flexion or muscle tone

R respiration

Baby cry within 30 secs

Failure to cry after 30 secs asphyxia near the neatorum

Resp. depression due mom given Demerol. Administer Naloxone

APGAR Scoring Chart:

012

HR -absent <100 >100

Resp effort -absent - slow, irreg, weak -good strong cry

Muscle tone - flaccid extremities - some flexion - well flexed

Reflex irritability

Catheter - no response - grimace - cough, sneeze

Tangential Footslap - NR - grimace - cry

Color - blue/pale - acrocyanosis

(body- pink

extremities-blue) - pinkish

APGAR result
0 3 = severely depressed, need CPR, admission NICU

4 6 = moderately depressed, needs addl suctioning & O2

7 - 10 =good/ healthy

CPR cardio pulmonary resuscitation or CPR

Cardio pulmonary cerebral resuscitation

5 min no O2 irreversible brain damage

1. shake, no resp, call for help

2. flat on head

3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway

Breathing ( ventilating the lungs)

1. check for breathlessness

if breathless, give 2 breaths- ambu bag

> 1 yr old- mouth to mouth, pinch nose

< 1 yr mouth to nose

force different between baby & child

infant puff

Circulation

Check for pulslessness :carotid- adult

Brachial infants

CPR breathless/pulseless

Compression inf 1 finger breath below nipple line or 2 finger breaths or thumb
CPR inf 1:5

Adults 2:15

Assessment tool determines respiration of baby

Silvermann Anderson Index

Respiration Evaluation lowest score best

Criteria 0 1 2

Chest movement synchronized Lag on respiration See - saw

Intercostal retraction No retraction Just visible Marked

Xiphoid retraction None Just visible Marked

Nares dilatation None Minimal Marked

Expiratory grunt None Heard on stet only Heard on naked ear

Interpretation result:

0 -3 normal, no RDS

4 6 moderate RDS

7 10 severe RDS

Assessment of Gestational Age

-Ballards & Dobowitz

Findings Less 36 weeks (Preterm) 37 - 38 39 and up

Sole creases Anterior transverse crease only Occasional creases 2/3 in Covered with creases

Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm

Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky

Ear lobe Pliable Some cartilage Thick cartilage

Testes and Scrotum testes in lower canal

Scrotum small few rugae Some intermediate Testes pendulus

Scrotum full extensive rugae

Signs of Preterm Babies

Born after 20 weeks, after 37 weeks

-frog leg or laxed positon

-hypotonic muscle tone- prone resp problem

-scarf sign elbow passes midline pos.

- square window wrist 90 degree angle of wrist

- heal to ear sign-

abundant lanugo-

Signs of Post term babies:

> 42 weeks

- classic sign old mans face

- desquamation peeling of skin

- long brittle finger nails

- wide & alert eyes

Neonates in Nursery

Nsg responsibility upon receiving baby- proper identification

- foot printing, affixing mother thumb print

- take anthropometic measurement

normal length- 19.5 21 inch or 47.5 53.75cm, average 50 cm

head circumference 33- 35 cm or 13 14

Hydrocephalus - >14

Chest 31 33 cm or 12 13

Abd 31 33 cm or 12 13

Bathing

- oil bath initial

- to cleanse baby & spread vernix caseosa

Fx of vernix caseosa

1. insulator

2. bacterio- static

Babies of HIV + mom immediately give full bath to lessen transmission of HIV

- 13 39% possibly of transmission of HIV

Full bath safely given when cord fall

Dressing the Umbilical Cord strict asepsis to prevent tetanus

3 cleans in community
1. clean hand

2. clean cord

3. clean surface

betadine or povidone iodine to clean cord

check AVA, then draw 3 vessel cord

If 2 vessel cord- suspect kidney malformation

- leave about 1 of cord

- if BT or IV infusion leave 8 of cord best access - no nerve

- check cord every 15 min for 1st 6 hrs bleeding .> 30 cc of blood

bleeding of cord Omphalagia suspect hemophilia

Cord turns black on 3rd day & fall 7 10 days

Faiture to fall after 2 weeks- Umbilical granulation

Mgt: silver nitrate or catheterization

- clean with normal saline solution not alcohol

- dont use bigkis air

- persistent moisture-urine, suspect patent uracus fistula bet bladder and normal umbilicus

dx: nitrazine paper test yellow urine

mgt: surgery

Credes Prophylaxis Dr. Crede

-prevent opthalmia neonatorum or gonorrheal conjunctivitis

- how transmitted mom with gonorrhea

drug: erythromycin ophthalmic ointment- inner to outer

silver nitrate (used before) 2 drops lower conjunctiva (not used now)

Vit-K to prevent hemorrhage R/T physiologic hypoprothrombinemia

- Aquamephyton, phytomenadione or konakion

- .5 1.5 ml IM, vastus lateral or lateral ant thigh

- 5 ml preterm baby

Vit K synthesized by normal flora of intestine

Vit K meds is synthetic due intestine is sterile

Weight: Normal wt 3.000 3400 gms/ 3 3.4 kg / 6.5 - 7.5 lbs

Arbitrary lower limit 2500 gm

Low birth wt baby delivered < 2500g

Small for gestational age (SGA) < 10th % rank or born small

Large for gestational age > 90th % rank or macrosomia >4000 g

Appropriate for GA within 2 standard deviation of mean

Physiologic wt loss 5 10% wt loss few days after birth

Small GA < (less) 10

Large GA > (more) 90

Physical Exam and Deviations fr Normal

1. if client is new born, cover areas not being examined

2. if client is infant the 1st yr of life - get VS take RR 1st

- begin fr least intrusive to the most intrusive area

3. if client is a toddler and preschool, let them handle an instrument like:

- play syringe or stet, security blanket favorite article. Let baby hold it.

4. Explain procedure and respect their modesty - school age and adolescent

V/S:

Temp: rectal- newborn to rule out imperforate anus

- take it once only, 1 inch insertion

Imperforate anus

1. atretic no anal opening

2. agenetic no anal opening

3. stenos has opening

4. membranous has opening

Earliest sign:

1. no mecomium

2. abd destention

3. foul odor breath

4. vomitous of fecal matter

5. can aspirate resp problem

Mgt:

Surgery with temporary colostomy

Cardiac rate: 120 160 bpm newborn

Apical pulse left lower nipple

Radial pulse normally absent. If present PDA

Femoral pulse normal present. If absent- COA - coartation of aorta

Congenital Heart Dse

Common in girls PDA, ASD atrial septal

Common in boys TOGA ( transportation of great arteries)

TA tronchus arteriosus

TOF tetralogy of fallot

Causes:

1. familial

2. exposure to rubella 1st month

3. failure of strucute to progress

acyanotic L to R

cyanotic R L

Acyanotic heart defects L to R

1. ventricular septal defect - opening between 2 ventricles

S&Sx

1. systolic murmurs at lower border of sternum and no other significant sign

2. cardiac catheterization reveals increased o2 saturation @ R side of heart

3. ECG reveals hypertrophy of R side of heart

Nsg Care:

Cardiac catheterization: site Rt femoral vein

1. NPO 6 hrs before procedure

2. protect site of catheterization. Avoid flexion of joints proximal to site.

3. assess for complication infection, thrombus formation check pedal pulses

( dorsalis pedis)

Mgt.

1.) long term antibiotic to prevent subacute bacterial endocarditis

2.) open heart surgery-

2.) ASD failure of foramen ovale to close

S&SX

1. systolic murmur @ upper border of sternum

2. result of cardiac catheterization & ECG same with VSD

Mgt: open heart surgery

3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve

Dx confirmed by cardiac catheterization

Mgt: - open heart surgery

Antibiotics to prevent subacute bacterial endocarditis

4.) PDA - failure of ductus arteriosus to close

- should close within 24 h -complete close 1 month

S&Sx

1. continuous machinery like murmurs

2. prominent radial pulse

3. ECG- hypertrophy Left ventricle

Drug:

1. endomethazine prostaglandin inhibitor - facilitate closing of PDA

2. ligation of PDA by 3-4 yo

3. thoracotomy procedure- nakadapa child

5.)Pulmunary Stenosis- narrowing of valve of pulmo artery

S &Sx: 1.) typical systolic ejection murmur

2. S2 sound widely split

3. ECG- Lt ventricular hypertrophy

6.)Aortic Stenosis narrowing of valve of aorta

S & Sx: 1. inactive, sx sme with angina

2. typical murmur

3. rough systolic sound and thrill

4. ECG- Left ventricular hypertrophy

Mgt Pulmo Stenosis & Aortic Stenosis

1.) balloon stenostomy

2.) surgery

Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus
S&Sx : 1. dysphagia 2. dyspnea

3. left ventricular hypertrophy

Mgt: - close heart surgery

8.) Coartation of Aorta narrowing of arch of aorta

outstanding Sx : absent femoral pulse

BP increased on upper extremities and decreased on lower extremities

ECG hypertrophy Lft ventricle

Mgt: close heart surgery

CYANOTIC HEART DEFECTS R to L

1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle pulmo artery arising form Lt
ventricle

Outstanding Sx:

1. cyanosis after 1st cry (due no exygenation)

2. polycythemia increased RBC =compensatory due to O2 supply=viscous blood

=thrombus = embolus = stroke

3. ECG cardiomegaly

Cardiac cath decreased O2 saturation

Palliative repair rashkind procedure

Complete repair mustard repair

2.) Total Anomalous Pulmonary

venous return pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC

Increased pressure on Rt so blood goes to Lft

Outstanding Sx: Open foramen ovale

Mild to moderate cyanosis

Polycythemia = thrombus = embolus = stroke

asplenia- absent spleen

Mgt: restructuring of heart

3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD

S & Sx 1. cyanosis

2. polycythemia thrombus = embolus = stroke

Mgt: Heart transplant

4.) Hypoplastic Left heart syndrome non fx Left ventricle

1. cynosis

2. polycythemia throm, emb, stroke

Mgt: heart transplant

5.) Tricuspid atresia failure of tricuspid valve to open

S&SX: open foramen ovale

(R to L shunting goes to Lt atrium)

cynosis, polycythemia

Mgt: fontan procedure open tricuspid valve

6.) Tetralogy of Fallot

P pulmonary stenosis

V ventricular SD

O overriding or dextroposition of aorta

R Rt ventricular hypertrophy

S &Sx:

1. Rt ventricular hypertrophy

2. high degree of cyanosis

3. polycythemia

4. severe dyspnea squatting position relief , inhibit venous return facilitate lung expansion.

5. growth retardation due no O2

6. tet spell or blue spells- short episodes of hypoxia

7. syncope

8. clubbing of fingernails due to chronic tissue hypoxia

9. mental retardation due decreased O2 in brain

10. boot shaped heart x-ray

Mgt:

1. O2

2. no valsalva maneuver , fiber diet laxative

3. morphine hypoxia

4. propranolol decrease heart spasms

5. palliative repair

BLT blalock taussig procedure

Brock procedure complete procedure

ACQUIRED HEART DSE

1. RHD Rheumatic Heart Disease

- inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus

Affected body cardiac muscles and valves , musculoskeletal , CNS, Integumentary

Sorethroat before RHD

Aschoff rounded nodules with nucleated cells and fibroblasts stays and occludes mitral valve.

Jones Criteria

Major Minor

1. polyarthritis multi joint pain 1. arthralgia joint pain

2. chorea sydenhamms chores or

st. vetaus dance-purposeless involuntary hand and shoulder with grimace 2. low grade fever

3. carditis tachycardia

erythema marginatum - macular rashes

SQ nodules 3. all lab results

increase antibody

C reactive protein

erythrocyte sedimentation rate

anti streptolysin

o titer (ASO)
Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx.

Nsg Care:

1. CBR

2. throat swab culture and sensitivity

3. antibiotic mgt to prevent recurrence

4. aspirin anti-inflammatory. Low grade fever dont give aspirin.

S/E of aspirin:

- Reyes syndrome encephalopathy- fatty infiltration of organs such as liver and brain

Respiration

Newborn resp 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis.

< 15 secs normal apnea newborn

Resp Check

Newborn 40 90

1 yr - 20 40

2-3yr 20 30

5 yrs 20 25

10 yrs 17 22

15 & above 12- 20

BREATH SOUNDS HEARD DURING ASCULTATION:

1.) VESICULAR soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -
Normal
2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp.
Normal

3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration.
Normal

4.) RHONCHI snoring sound made by air moving through mucus in bronchi. Normal

5.) RALES-or crackles like cellophane made by air moving through fluid in alveoli.

Abnormal- asthma, foreign body obstruction.

6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal
asthma, foreign body obstruction

7.) STRIDOR- crowing or ropster life sound air being pulled through a constricted larynx. Abnormal
resp obstruction

Asthma- pathognomonic sign expiratory wheezing

Pet fish. Sport swimming

Drugs amynophylline monitor bp, may lead to hypotension

Laryngo Tracheo Bronchitis LTB

- inspiratory stridor pathognomonic sign

RDS respiratory dist synd or hyaline membrane dis

Cause- lack of surfactant for lung expansion

Hypotonia, Post surgery, Common to preterm

Fibrine hyaline

Sx definite with in 1st of life

Increase RR with retraction

Inspiratory grunting pathognomonic

7 10 severe RDS (silvermenn Anderson index)

cyanosis due to atelectasis

Mgt:

1. surfactant replacement and rescue

2. pos- head elevated

3. proper suctioning

4. o2 with increase humidity- to prevent drying of mucosa

5. monitor V/S skin color , ABG

6. CPAP- continuous + a/w pressure

7. PEEP - + end expiratory pressure

Purpose of #6-7- to maintain alveoli partially open and alveoli collapse

LARYNGOTRACHEOBRONCHITIS

LTB most common Creup -viral infection of larynx, trachea & bronchi

outstanding sx - croupy cough or barking

pathognomonic - stridor

- labored resp

- resp acidosis

- end stage death

Lab:

1. ABG

2. neck and throat culture

3. dx- neck x-ray to rule out epiglotitis

Nsg Mgt:

1. bronchodilators

2.increase o2 with humidity

3. prepair tracheostomy set

BRONCHOLITIS- Inflammation of bronchioles tenatious mucus

Causative agaent RSV - Resp sincytial viruses

Sx: flu like sx

Increased RR

Drug: Antiviral Ribavirin

End stage epiglotitis

EPIGLOTITIS - infl of epiglottis

- emer. Condition of URTI

Sx: sudden onset

Tripod position leaning forward with tongue protrusion

- never use tongue depressor

prepare tracheotomy set

< 5 yo unable to cough out, put on mist tent (humidifier o2) or croupe tie

Nsg Care: check edges tucked on mist tent

Provide washable plastic material

No toys with friction due O2 on

No hairy toys due moist environment medium for bacterial growth

BP 80/46 mmHg newborn

BP after 10 days- 100/50

BP taking begins by 3 yo

COA take BP on 4 extremities

SKIN:

Acrocyanosis

BIRTHMARKS:

1. Mongolian spots stale gray or bluish discoloration patches commonly seen across the sacrum or
buttocks due to accumulation of melanocytes. Disappear by 1 yr old

2. MIlla plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek.

3. Lanugo fine, downy hair common preterm

4. Desquamation peeling of newborn, extreme dryness that begin sole and palm.

5. Stork bites (Talengeictasi nevi) pink patches nape of neck

hair will grow as child grows old

6. Erythema Toxicum (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to
time & place.

7. Harlequin sign dependent part is pink, independent part is blue

(side lying bottom part is dependent pink)

8. Cutis Marmorato transitory mottling of neonates skin when exposed to cold.

9. Hemangiomas vascular tumors of the skin

3 types Hemangiomas

a.) Nevus Flammeus port wine stain macular purple or dark red lesions seen on face or thigh. NEVER
disappear. Can be removed surgically

b.) Strawberry hemangiomas nevus vasculosus dilated capillaries in the entire dermal or subdermal
area. Enlarges, disappears at 10 yo.
c.) Cavernous hemangiomas communication network of venules in SQ tissue that never disappear with
age. - MOST DANGERIOUS intestinal hemorrhage

Skin color blue cyanosis or hypoxia

White edema

Grey inf

Yellow jaundice , carotene

Vernix Caseosa white cheese like for lubrication, insulator

BURN TRAUMA injury to body tissue caused by excessive heat.

INFANT 5-9 yo

ANTERIOR POSTERIOR Ant Post

Head 9.5 9.5 6.5 6.5

Neck 1 1 1 1

Upper arm 2 2 2 2

Lower arm 1.5 1.5 1.5 1.5

Hand 13 1.25 1.25 1.25

Trunk 13 13

Back 13 13

Genital 1 1

@ buttocks 2.5@ 2.5 @

Thigh 2.75 2.75 4 4

Leg 2.5 2.5 3 3

foot 1.75 1.75 1.75 1.75

DEPTH

1st degree partial thickness superficial epidermis - erythema, dryness, PAIN

-sunburn, heals by regeneration from 1 10 days

2nd degree epidermis & dermis- erythema, blisters, moist, extremely painful

scalds

3rd degree full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone

lethargy, white or black, not painful nerve endings destroyed

ex. lava burns

Mgt:

1.) 1st aid a.) put out flames by rolling child on blanket

b.) immerse burned part on cold H2o

c.) remove burned clothing of with sterile material

d.) cover burn with sterile dressing

2.) a/w

a.) suction PRN, o2 with increased humidity

b.) endotracheal intubation

c.) tracheostomy

3.) Preventiuon of shock & F&E imbalance

a. colloids to expand bld volume

b. isotonic saline to replace electrolytes

c. dextrose & H2o to provide calories

4.) Tetanus toxoid booster

5.) Relief of pain IV analgesic MORPHINE SO4 needed for 2nd degree very painful

6.) 1st defense of body intact skin

prevention of wound infection

a.) cleaning & debriding of wound

b.) open or close method of wound care

c.) whirlpool therapy drum with solution

7.) skin grafting 3rd degree thigh or buttocks (autograft), pigs/ animals xenograft

frozen cadaver hallow graft

8,) diet increase CHON, increase calories.

ATOPIC DERMATITIS- infantile eczema (galis)

Papulo vesicular erythematus lesions with weeping & crusting

Cause food allergies: milk, citrus juice, eggs, tomatoes, wheat

Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white lechenification

Goal of care: decrease pruritus avoid food allergens

Diet: Prosobi or Isomil

Hydrate skin, borow solution 1% hydrocortisone cream

Prevent infection proper handwahsing, trim nails

IMPETIGO- skin disease.

Causative agent grp A beta Hemolytic streptococcus

- papulovesicular surrounded by localized erythema becomes purulent , oozes a honey colored crust

Pediculosiscapitis KUTO

- Mgt: proper hygiene wash soap and H2o, oral penicillin bactroban ointment
Can lead to acute glomerulonephritis AGN

ACNE- adolescent problem

- self limiting infl dis sebaceous gland comedones sebum causing white heads

- sebum- lipids causing acne bulgaris

Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi

ANEMIA-pallor

Causes:

1.)early cutting of cord preterm cut umb cord ASAP

fullterm cut umb cord when pulsation stops

2.) Bleeding disorders blood dyscrasias

HEMOPHILIA deficiency of clotting factor. X linked recessive inherited

If mom carrier, son affected

If father carrier- transmitted to daughter

Hemophilia A deficiency of coagulation component factor 8

Hemophilia B or christmas disease, deficiency of clotting factor 9

Hemophilia C deficiency of clotting factor 11

Assessment:

- umphalagia earliest sign

- newborn receive maternal clotting factor

- newborn growing sudden bruising on bump area- marks earliest sign

- continuous bleeding hematrosis damage or bleeding synovial membrane

Dx test :

PTT. Partial thromboplastin time reveals deficiency in clotting factor

Long Term Goal- prevention of injury

Nsg Dx- increase risk of injury

HT: avoid contact sport, swimming only, dont stop immunization just change gauge of needle

Falls immobilized , elevate affected part, apply pressure-not more then 10 min

cold compress

-determine case before doing invasive procedure

LEUKEMIA- grp of malignant disease

- rapid proliferation of immature WBC

- WBC protection from infection, soldiers of body

Classification :

1. Lympho affects lymphatic system

2. Myelo affects bone marrow

3. acute / blastic- affects immature cells

4. chronic/ cystic- affects mature cells

MOST COMMON CANCER (ALL) Acute Lymphocytic Leukemia

S&Sx:

1. from invasion of bone marrow

signs of infection

a.) fever

b.) poor wound healing

c.) bone weakness & causes fracture

signs of bleeding

a.) petecchiae-small, round, flat, dark red spot

b.) epistaxis

c.) blood in urine/ emesis

signs of anemia

a.) pallor , body malaise , constipation

2. from invasion of body organ- hepato spenomegaly abd pain ,

CNS affectation, increase ICP

Dx Tests:

1. PBS- peripheral blood smear determine immature RBC

2. CBC determine anemia, leukocytosis, thrombocytopenia neutropenia

3. lumbar puncture (LP) determine CNS involvement. Before LP, fetal pos.- avoid flexion of neck will
cause a/w obstruction.C position or shrimp position only.

4. bone marrow aspiration determine blast cells,

- common site- iliac crest

- post BMA s/effect bleeding

- apply pressure. Put pt on affected side to prevent hemorrhage

5. Bone scan determine bone involvement

6. CT scan determine organ involvement

Therapeutic Mgt:
TRIAD:

1. surgery

2. irradiation

3. chemotheraphy

Focus Nsg Care: prevent infection

4 LEVELS OF CHEMOTHERAPHY

1. induction goal of tx; to achieve remission

meds: IV vincristine

L- agpariginase

Oral predinisone

2. Sanctuary- treat leukemic cells that invaded testes & CNS

give: methotrixate- adm intrathecally via CNS or spine

cytocine, Arabinoside, steroids with irradiation

3. maintenance- to continue remission

give: oral methotrisate check WBC

-adm of methotrisate do weekly WBC check

4. Reinductin treat leukemic cells after relapse occurs. Meds same as induction

- give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy.

Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement.

Based on Maslows heirarchy

S/Effect of Chemotherapy

1. N/V adm antiemetic drugs 30 mins before chemo until 1 day after chemo

2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req)

- oral care alcohol free mouthwash , betadine mouthwash

- dont brush use cotton pledgets

- topical xylocaine before meals

diet- soft, bland diet according to childs preference

Temporary S/E of chemo:

Alopecia altered body image

Hirsutism hair

-give emotional support to parents

ABO incompatibility

Most common incompatibility ( mom) O ( fetus) A

Most severe incompatibility (Mom) O (Fetus) B

Can affect 1st pregnancy

Hydrops (h20) Fetalis edematous on lethal state with pathologic jaundice

Within 24 h

Mgt:

1. initiate breastfeeding to get colostrum

2. Temp suspension of breastfeeding

- content breast milk pregnanedioles that delays action of glucoronil transferees

liver enzymes converts in direct bilirubin to become direct bilirubin

3. Needs phototherapy

4. needs exchange therapy

Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term

Normal 0-3 mg/dL

- bilirubin encephalopathy

- Kemicterus - > 20 mg/dL among full term &

>12 mg /dl of indirect preterm

=can lead to cerebral palsy-

Physiologic jaundice jaundice within 48 -72 h (2-3 days) expose morning sunlight

Pathologic Jaundice within 24h. Jaundice during delivery.

Breastfeeding jaundice caused by pregnanediole

Assessment of Jaudice :

1. Blanching neonates forehead, nose or sternum

- yellow skin & sclera

- color of stool light stool

- color of urine dark urine

Mgt: Phototheraphy photo oxygenation

Nsg Resp:
1. cover eyes prevent retinal damage

2. cover genitals prevent priapism painful continuous erection

3. change position regularly even exposed to light

4. increase fld intake due prone to dehydration

5. monitor I&O weigh baby

6. monitor V/S avoid use of oil or lotion due- heat at phototherapy

= bronze baby syndrome-transient S/E of phototherapy

weigh diaper 1gm = 1cc

Head largest part of baby

of its length

Craniostenosis or craniosinustosis premature closing of fontanel

Hydrocephalus ant fontanel open after 18 mos

Microcephaly small growing brain due- alcohol & HIV mom

Anencepahly absence of cerebral hemisphere

Craniotabes localized softening cranial bone. Common 1st born child

-due early lightening (2 weeks prior to EDD)

Rickets of Vit B deficiency soft cranial bone in older children

Caput Succedaneum edema of scalp due prolonged pressure at birth

Char:

1. present at birth

2. crosses suture lines

3. disappear after 2-3 days

Cephalhematoma- collection of blood due to rapture of pericostal capillaries

Char :

1. present after 24 h

2. never cross suture line

3. disappear after 4-6 weeks

4. monitor for developing jaundice

Seborrheic Dermatitis craddle cap

Scaling, greasy appearing salmon colored patches seen on scalp behind ears and umbilicus

Cause: - improper hygiene

Mgt:

1. proper hygiene

2. put oil night before shampoo

- baby oil

Hydrocephalus excessive accumulation of CSF

1. communicating extra ventricular hydrocephalus

2. non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus

due to tumor obstruction

Sx ICP abnormally large head, bulging fontanel

- cushings triad

- high pitched cry

older child diplopia eye deviation, projectile vomiting

- fontanel bossing prominent forehead

- - prominent skull vein

- sunset eyes

Mgt: position to lessen ICP low semi-fowlers 30 degree angle

Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam

Decrease CSF production

Shunting AV shunt or Vp shunt (ventriculoperitoneal shunt)

Shave hair in OR to prevent growth of micro org.

Nsg Care:

1.) post VP shunt side lying on non operated site - to prevent increase ICP

-monitor for good drainage - sign sunken fontanel

-bulging fontanel blocked shunt

-change fontanel as child is growing

SENSES

EYES: Assessment

1. check for symmetry

2. sclera normal color light blue then become dirty white

pupil round- adult size

coloboma- part of iris is missing

sign: key hole pupil

-whiteness & opacity of lens congenital cataract

cornea round & adult size

large congenital glaucoma

Test for blindness common tests

1. newborn general appearance

- can only see 10 12

- visual acuity 20 /200 to 20/ 800

Dolls eyes test- test for blindness

- done 10th day

- pupil goes opposite to direction when head is moved

Globellars test test for blink reflex. Points near nose baby should blink

2. Infant & children

- appearance

- ability to follow object past midline

3. 3 yrs school age

- general appearance

Allen cards test for visual acuity. Show picture 20 ft away

Ishiharas plates test for color blindness

Prechool E chart - test for stereopsi of depth perception

Cover testing test cover 1 eye for 10 15 min. Then remove. Test for strabismus

4. School age adult

- general appearance

- snellens test

Retinobastoma malignant tumor of retina

Outstanding sign : oats eye reflex-whitish glow of pupil

- red painful eye

- blindness

surgery Enucliation removal of eyeball put artificial aye

NOSE:

1. flaring alenase case of RDS

2. cyanosis at rest choanal atresia - post nares obstructed with bone or membrane

Sx:

1. resistance during catheter insertion

2. emer. Surgery within 24 h

normal color nasal membrane pinkish

rhinitis presence of creases & pale

check sense of smell blindfold smell

Hair in nose cilia

Adolescent no hair with ulceration of nasal mucosa suspect cocaine user

Epistaxis nosebleed

- sit upright, head slightly forward to facilitate drainage

- cold compress , apply gentle pressure, epinephrine

most developed sense of newborn sense of touch

1st sense to develop & last to disappear hearing

EARS:

1. Properly aligned with outer cantus of eyes

low set ear kidney malformation

ex. Renal aginesis absence of kidney

sign in uterus : oligohydramnios

sign in newborn: 2 vessel cord

failure to void within 24 h

Mgt: kidney transplant

Chromosomal aberrations : -advance maternal age

1. non disjunction uneven division

Trisomy 21 - down syndrome - extra chromosome

47xx + 21 - related to advance paternal age

Sx:

Mongolian slant

Broad flat nose

Protruding neck

Puppys neck

Hypotonic prone to resp problem

Simean crease single transverse line on palm.

Trisomy 18 edward syndrome

Trisomy 13- patau syndrome

Turner Monosomy of X synd.

- 45x0

- affected girls

- signs evident during puberty

- has poorly developed 2dary sexual char.

- Sterile

Klinefelters Syndrome- has male genitalia - 47 XXY

- poorly devt secpndary sexual characteristics

- no deepening of voice

-small testes, penis -sterile

Klinefelter Calvin Kline male

Turner Tina Turner female

Otitis Media inflammation of middle ear. Common children due to wider & shorter Eustachian tube

Causes

1.) bottle propping

2.) Cleft lip/ cleft palate

Sx: Otitis

1. bulging tympanic membrane, color pearly gray

2. absence light reflex

3. observe for passage of milky, purulent foul smelling odor discharge

4. observe for URTI

Nsg Care:

1. position side lying on affected aside to facilitate drainage

2. supportive care- bedrest, increase fld intake

Med Mgt:

1. Massive dosage antibiotic

Complication bacterial meningitis

2. Apply ear ointment

School age up and down

< 3 yo down & back

> 3 yo up & back

Small child down & back ( no age)

surgery (to prevent permanent hearing loss) otitis media myringotmy with tympanostomy tube

post surgery position affected side for drainage

both put ear plug

if tympanous tube falls healed na

Bells Palsy- facial nerve #7 paralysis R/T forcep delivery

Sx.

1. Continuous drooling saliva

2. inability to open , eye & close either eye

Mgt:

Refer to PT

TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach

Outstanding Sx Coughing

Choking

Continuous drooling

Cyanosis

Mgt:: Emergency surgery

Epstein pearl white glistering cyst at palate & gums related to hypercalcemia

Hypervitaminosis

Natal tooth tooth at birth. Move with gauze

Neonatal tooth tooth within 28days of life

Moniliasis oral candidiasis

- white cheese like, curd like patches that coats tongue

- oral thrush

- Nsg Care dont remove, wash with cold boiled H2o

Meds nystatin / Mysnastatin antifungal

Kawasaki Dse--strawberry tongue - originated in Korea

- Dr. Kawasaki discovered it

- common in Japan

- mucocutaneous Lymphnode Syndrome

Sx:

-persistent fever 5 days

-strawberry tongue ,

-desquamation of palm & sole

- lymph adenopathy > 1.5 cm

Drug: aspirin

Can lead to MI

LIPS- symmetrical

Cleft lip failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy

- common to boys

- unilateral

Cleft Palate- Failed palate to fuse by 9 12 wks of pregnancy

- common to girls

- unilateral or bilateral

Sx:

1. evident at birth

2. milk escapes to nostril during feeding

3. frequent colic & otitis media or URTI

Mgt:

1. Surgery

cleft lip repair Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months )

Cleft Palate- uranoplasty = done 4-6 months to save speech

Pre op care

1. emotional support especially to mom

2. proper nutrition

3. prevent colic

feed upright seating or prone pos

burp frequently 2x at middle and after feeding-lower to upper tap

4. orient parents to type of feeding

rubber tipped syringe cheiloplasty

paper cup/ soup spoon/ plastic cup urano plasty

5. apply restraints elbow restraints

so baby can adjust post op

Condition that warrants suspension of operation

- colds & pharyngitis = can lead to generalized infection septicemia

Post Op Nsg Care :

1. airway positon post cheilopasty side lying for drainage

post uranoplasty (tonsillectomy)- prone

2. assess for RDS sx bleeding

3. assess for bleeding freq swallowing. 6-7 days after surgery bleeding

4. proper nutrition

- clear liquids- ( gelatin except red or brown color due may mask bleeding)

- ( popsicle- not ice cream)

full liquid

soft diet
regular diet

5. Maintain integrity of suture line such as:

Logan bar wash strength Hydrogen Peroxide & saline solution- Bubbling effect

traps microorganism

- prevent baby form crying

for pain- analgesic

NECK-

1.) check symmetry

Congenital torticolis- wryneck-burn injury of sternocleidomsstoid muscle during

delivery due to excessive traction at cephalic delivery

Mgt: passive stretching exercise , Surgery

Complication scoliosis

THYROID gland for basal metabolism

Congenial cretinism absence or non functioning thyroid glands

reasons for delaying dx:

1. Thyroid glands covered by sternocleidomastoid muscles in newborn

2. baby received maternal thyroxine

3. baby sleeps 16 20 h a day

earliest sign:

1. change in crying

2. change in sucking
3. sleep excessively

4. constipation

5. edema moon face

late sign

1. mental retardation

prognosis : mental retardation preventable when Dx is early

Dx:

1. PPI-protein

2. radioimmunoassay test

3. radioactive iodine uptake

Mgt: synthroid sodium Levothyrosine -synthetic thyroid given lifetime

- check pulse rate before giving synthroid

- tachycardia Sx of hyperthyroidism

CHEST

1. symmetry

2. breast - transparent fluid coming out from newborn related to hormonal changes-

3. chest has retroactive RDS

4. sternum sunken pectus excavation

ABDOMEN (in order)

1. inspection I

2. Auscultation A

3. percussion P
4. Palpation P = Will change bowel sounds, so do last

Normal contour of abd slightly protruding

Sunken abd- diaphramatic hernia protrusion of stomach content through a defective diaphragm due to
failure of puroperitoneal canal to close.

Sx:

1. sunken abd

2. Sx of RDS

3. R to L shunting

Mgt:

Emergency surgery within 24h

Omphalocele protrusion of stomach contents in between junction of abd wall and umbilicus.

Mgt- very small surgery

If large suspension surgery

Nsg Mgt: protect sac- sterile wet dressing

Gastrochisis absence of abd wall

Nsg Mgt: sterile wet dressing

Fx of GIT

1. assists in maintaining F&E & acid base balance

2. Processes & absorbs nutrients to maintain metabolism & support G & D

3. excrete waste products from digestive process

Recommended Daily Allowance

Calories : 120 cal / Kbw/day (kilo body wt)

360 380 cal/ day

CHON_ 2.2g /Kbw/day

Principles in Supplementary Feeding

Supplementary Feeding usually 6 mos

Supplementary feeding given 4 mos.

a.) solid food offered to ff sequence!

1. cereals rich in iron

2. fruits

3. veg

4. meat

b.) begin with small quantities

c,) finger foods offered 6 months

d.) soft table food modified family menu given 1 yr

e.) dilute fruit juices 6 mos

f.) never give half cooked eggs usually causes of salmoneliosis

g.) dont give honey infant botulism

h.) offered new food one at a time interval of 4 7days or 1 week determines food allergens

Total Body Fluids- comprises 65 - 85% of body wt of infants & children

Where fluids are greater in infants

Extracellular fld prone to develop dehydration

Acid Base Balance dependent on the ff:

a. chemical buffers

b. renal & resp system involvement

c. dilution of strong acids and bases in bld

Resp Acidosis carbonic acid excess

- hypoventilation

- RDS

- COPD

- Laryngotracheobronchitis (LTB)

Resp Alkalosis carbonic acid deficit

- hyperventilation

- fever

- encephalopathy

Met. Acidosis base HCO3 deficit

- diarrhea

- severe dehydration

- malnutrition

- ciliac crisis

Met Alkalosis base HCO3 excess

- uncontrolled vomiting

- NGT aspiration

- Gastric lavage
PROBLEMS LEADIING TO F&E IMBALANCE

1. vomiting forceful expulsion of stomach content

Sx:

1. nausea

2. dizziness

3. facial flushing

4. abd cramping

assess: amt, freq, force

projectile vomiting= increase ICP or pyloric stenosis

Mgt: BRAT diet - banana, rice cereal, apple sauce, toast

2. Diarrhea exaggerated excretion of intestinal contents

Types:

Acute diarrhea related to gastroenteritis, salmoneliosis

- dietary indiscretions

- antibiotic use

Chronic non specific diarrhea

Cause:

1. food intolerance

2. excessive fld intake

3. CHO, CHON malabsorption

Assess: freq, consistency, appearance of given colored stool.

Best criteria to determine diarrhea : consistency

Complication = dehydration

Mild dehydration 5% wt loss

Moderate dehydration 10% wt loss

Severe dehydration 15 % wt loss

Earliest sx of dehydration

tachycardia increase temp weight loss

tachypnea sunken fontanel & eyeballs scanty urine

hypotension absence of tears

Severe dehydration:

Oliguria , Prolonged capillary refill time

Mgt:

Acute NPO ( rest the bowel )

- with fluid replacement IV

- prone to Hypokalemia give K chloride

before adm of K chloride check if baby can void, if cant void hypokalemia

Drug: Na HCO3 adm slowly to prevent cardiac overload

Gastric Motility Disorder:

HIRSCHPRUNGS DISEASE congenital aganglionic megacolon

Aganglionic absence of ganglion cells needed for peristalis

Earliest sign

1. failure to pass mecomium after 24h

2. abd distension

3. vomitus of fecal material

early childhood ribbon like stool

foul smelling stool

constipations

diarrhea

Dx:

1. Barium enema reveals narrowed portion of bowel

2. Rectal Biopsy reveals absence of ganglionic cells

3. abd x-ray reveals dilated loops on intestine

4. rectal manometry revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care

1. NGT feeding measure tube fr nose to ear to midline of xyphoid & umbilicus

2. surgery

a.) temp colostomy

b.) anastomosis & pull through procedure

Diet:

Increase CHON, increase calories , decrease residue pasta

GER- Gastroesophageal Reflux

Chalasia presence of stomach contents to esophagus

Will lead to esophagitis complication aspiration pneumonia

Esophageal cancer

Assessment :

1. chronic vomiting

2. faiture to thrive syndrome

3. organic organ affected

4. melena or hematemesis esophageal bleeding

Dx procedure

1. barium esophogram reveals reflux

2. esophageal manometry reveals lower esophageal sphincter pressure

3. intra esophageal pH content reveals pH of distal esophagus.

Meds of GERD

Anti-cholinergic

a.) Betanicol ( urecholine) increase esophageal tone & peristaltic activity

b.) Metachloporomide (Reglam) decrease esophageal pressure by relaxing pyloric & duodenal
segments

- increase peristalsis without stimulating secretions

c.) H2 Histamine Receptor Antagonist decrease gastric acidity & pepsin secretion

- Zimetidine, Ranitidine (Zantac) take 30 min before meals

d.) antacid neutralizes gastric acid between feedings - Maalox

Surgery: Nissen funduplication :

Chronic vomiting

- thickened feeding with baby cereals - effective if without vomiting

- feed slowly, burp often every 1 ounce

- positioning

< 9 months infant sit with infant supine

> 9 months prone with head of mattress slightly elevated 30 degree angle

OBSTRUCTIVE DISORDERS

A. PYLORIC STENOSIS hypertrophy of muscles of pylorus causing narrowing &

obstruction.

1.) outstanding Sx- projectile vomiting

- vomiting is an initial sx of upper GI obstruction

- vomitus of upper GI can be blood tinged not bile streaked. (with blood)

- vomitus of lower GI is bilous ( with pupu)

- projectile vomiting increase ICP or GI obstruction

- abd distension major sx of lower GIT obst

2.) met alk

3.) failure to gain wt

4.) olive shaped mass on palpation

5.)serum electrolyte increase Na & K, decrease chloride

6.) ultrasound

7.) x ray of upper abd with barium swallow reveal string sign
Mgt:

1. Pyleromyotomy

2. Fredet Ramstedt procedure

INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another

Common site ilio-secal junction

Prone pt: person who eats fat

Complication peritonitis emergency

Sx:

1.) persistent paroxysmal abd pain

2.) vomiting

3.) currant jelly stool- dye bleeding & inflammation

- palpate sausage shaped mass

Mgt:

1.) Hydrostatic reduction with barium enema

2.) Anastomosis & pull thru procedura

Inborn Errors of Metabolism- deficient liver enzymes

PHENYLKETONURIA (PKU) deficiency of liver enzymes (PHT)

Phenylalaninehydroxylase Transferase liver enzyme that converts CHON to amino acid

9 amino acids:

valine isolensine tryptophase

lysine phenylalanine
Thyronine decrease malanine production

1.) fair complexion

2.) blond hair

3.) blue eyes

Thyroxine decrease basal metabolism

- accumulation of Phenyl Pyruvic acid

4.) Atopic dermatitis

5.) musty / mousy odor urine

6.) seizure mental retardation

Test GUTHRIE TEST specimen blood

- preparation increase CHON intake

- test if CHON will convert to amino acid

specimen and urine

mixed with pheric chloride, presence of green spots at diaper a sign of PKU

DIET:

Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts

Give Lofenalac- milk with synthetic protein

Galactosemia deficiency of liver enzyme

- GUPT Galactose Urovil Phosphatetranferase

- Converts galactose to phosphate tranferace glucose

Galactose will destroy brain cells if untreated death within 3 days

Dx:
Beutler test get blood -done after 1st feeding

presence of glucose in blood sign of galactosemia

galactose free diet lifetime

neutramigen milk formula

CELIAC DISEASE gluten enteropathy

Common gluten food:

Intolerance to food with brow

B- barley

R- rye

O- oat

W- wheat

Early Sx:

1. diarrhea failure to gain wt ff diarrheal episodes

2. constipation

3. vomiting

Late Sx:

1. abd pain protruberant abd even if with muscle wasting

2. steatorrhea
Celiac Crisis- exaggerated vomiting with bowel inflammation

Dx:

1. lab studies stool analysis

2. serum antiglyadin confirmatory of disease

gluten free diet lifetime

all BROW not allowed

ok rice & corn

Mgt:

1. vitamin supplements

2. mineral supplements

3. steroids

POISONING- common in toddlers. (falls- common to infant)

1. determine substance taken, assess LOC

2. unless poison is corrosive, caustic (strong alkali such as lye) or a hydrocarbon, vomiting is the most
effective way to remove poison.

- Give syrup 1 pecac to induce vomiting

3. 1 pecac oral emetic

- 15 ml adolescent, school age & pre school

- 10 ml to infant

4. UNIVERSAL ANTIDOTE- charcoal, milk of magnesia & burned toast

5. Never adm charcoal before 1 pecac

6. antidote for acetaminophen poisoning acetylsysterine ( mucomyst)

7. caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Dont vomit prepare
tracheostomy set

8. Gas- mineral oil will coat intestine

Lead poisoning

Lead = Destroy RBC functioning = Hypochornic Microcytic Anemia = Destroy kidney functioning

Accumulation of anemia = Encepalopathy

Sx:

1. beginning sx of lethargy

2. impulsiveness, learning difficulties

3. as lead increases, severe encepalopathy with seizure and permanent mental retardation

Dx:

1. Blood smear

2. abd x ray

3. long bones

Mgt:

1. remove child from source

2. if > 20 ug/dL need chelation therapy = binds with led & excreted by kidney

=nephrotoxic

Amogenital

Female:

Pseudomenstration slight bleeding on vagina related to hormonal changes

Tearing of fourchette with blood rape/ child abuse

Rape- Report within 48 h

Shape pubic hair in inverted triangle ( female)

Male:

Undescended testes cyrptorchidism -common to preterm

surgery orchidopexy

assess scrotum- warm room & hands

baby pee within 24 h

-check for arch of urination

Epispadias- urinary meatus located dorsal or above glans penis

Hypospadias- urinary meauts loc ventral or below glans penis

Hypospadias with chordee- fibrous band causing penis to curb downward

Mgt:

Surgery

Phimosis- tight foreskin

Balanitis-infection of glands penis due smegma

Mgt:

Circumsicion
Hydrocele fld filled scrotum

Tst of Dx:

Transillumination with use of flashlight - glowing sign

Varicocele enlarged vein of epididimis ( girls- vulvular varicosities)

BACK- check for flatness & symmetry

Open Neural Tube Defect- decreased Folic Acid intake

SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to fuse

Sx: dimpling of back , Abnormal tufts of hair

SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac

Types:
1. Meningocele protrusion of CSF & Meninges

2. Myelomeningocele protrusion of CSF & Meninges & spinal cord ( most dangerous)

3. Encephalocele ( CNS complication hydrocephalus) cranial meningocele or myelomeningocele

Most common problem

- rupture of sac

- prone pos

- sterile wet dressing

Most common complication - infection

Myelomeningocele genitourinary complication- urinary & fecal incontinence

Nsg care: always check diaper

Orthopedic complication paralysis of lower extremities

Surgery to prevent infection

Post op prone position

SCOLIOSIS- lateral curvature of the spine

2 types:

1. structural rye neck

2. postural improper posture

Dx:

1. uneven hemline

2. bend forward- 1 hip higher

1 shoulder blade more prominent

Nsg care:

1. conservative avoid obesity, exercise

2. preventive Milwaukee brace - worn 23 h a day

3. corrective surgery insert Harrington rod

post op- how to move

log rolling- move client as 1 unit

EXTREMITIES:

check # of digits = 20

1. syndactyly webbing of digits

2. polydactyly extra digits

3. olidactyly lack of digits

4. Amelia total absence of digits

5. pocoamelia- absence of distal part of extremities

ErQ duchennes paralysis- brachial plexus injury or brachial palsy

- birth injury caused by lateral & excessive traction during a breech injury

Sx:

1. unable to abduct arms from shoulders, rotate arm externally or supinate forearm

2. absence or asymetrical moro reflex

Mgt:

1. abduct arm from shoulders with elbow flex.

CONGENITAL HIP DISLOCATION head of femur is outside acetabulum

Types;

1. subluxated most common type

2. dislocated

Sx:

1. shortening of affected leg

2. asymmetrical gluteal fold

3. limited movement earliest sx

4. (+) ortolanis sign abnormal clicking sound

5. when able to walk child limps late sx- trendelenburg sign

Goal of Mgt:

Facilitate abduction

Mgt.

1. triple diaper

2. carry baby astride

3. Frejka splint

4. Pavlik harness

5. Hip Spica Cast

TALIPES clubfoot

a.) Equinos plantar flexion horsefoot

b.) Calcaneous dorsiflexion heal lower that foot anterior posterior of foot flexed towards anterior leg

c.) Varus- foot turns in

d.) Valgus- foot turns out

Equino varus- most common

Assessment:

1. Straighten legs & flexing them at midline pos

Mgt:

1. Corrective shoe- Dennis brown shoe, spica cast

Fx: of cast

- to immobilize

- bone alignment

- prevent muscle spasm

lead pencil mark area to be amputated

cold H20 hasten setting process

hot H20- slow setting process

After cast application how to move pt:

- use open palm not fingers- fingers will cause indention

- dry cast natural air not blower

- priority check : neurovascular check

C- circulation

M- motion S- sensation

Cast with bleeding

- mask with ball pen edge of blood to know if bleeding is on going

sign cast is dry = resonant sound, cast cold to touch

do petaling making rough surface of cast smooth

CRUTCHES

Fx: To maintain balance

- To support weakened leg

Principles in crutches

- wt of body on palm!

- Brachial pulsing if wt of body in axila

Renal Disorder Cause Sx Tx NSG CARE

NEPHROTIC

SYNDROME infectious 1. Anasarca- gen edema

2. massive protenuria

3. microscopic or no hematuria

4. serum CHON decreased

5. serum lipid increased

6. fatigue

7. normal or decreased BP Prednisone

Diuretic Focus of care: monitor edema

-weigh daily

Diet:

Increase CHON

Increase K- OJ, beef broth, banana

Decrease Na

AGN ( acute Glomerulo Nephritis)

3As;

AGN,

autoimmune,
Grp A Autoimmune

Grp A beta hemolytic streptococcus 1. (PPP) primary peripheral periobital edema

2. moderate protenuria

3. gross hematuria ( smokey urine)

4. serum K increased

5. fatigue

6. increase BP

Complication :

1. hypersensive encephalopathy

2. anemia 1. anti HPN drug

- hydralazine or apresoline

2. iron 1. weigh daily

2. monitor BP & neurologiuc status

3. Diet: decrease K, decrease Na

- Do palm exercise- squeeze ball

Different crutch Gaits:

1. Swing Through

2. Swing to

- no weight bearing are allowed into lower ext

3. Three point Gait

- wt bearing is allowed in 1 ext

4. Four point gait

5. Two point Gait

- wt bearing allowed in 2 lower ext

PSYCHIATRIC NURSING

BeliefsFeelingsBehavior

Sigmund Freud Father of Psychoanalysis

-structure of personality

Id- impulsive part, pleasure principle

-eat, urinate, have sex

-its all I

Superego small voice of God

-conscience

-should not eat yet, should not eat yet

Ego- arbiter, decision maker

-in touch with reality

Id___________________Superego

EGO

ID DOMINANT needs a superego-needs a conscience

M- manic

A- antisocial serial killer

N- narcissistic

SUPEREGO DOMINANT needs an Id

O- Obsessive Compulsive

A- Anorexia nervosa

EGO impaired reality perception (RN will present reality)

S- schizophrenia- cant distinguish fact from reality

Libido- sexual energy

FREUD - PSYCHOSEXUAL THEORY

ORAL 0-18 months

Cry, suck mouth- survival

Id dominant

Maternal deprivation if not feed, not given milk/water, not kept warm.

Narcissistic seeks the Id I love myself

Regression return to an earlier stage or earlier level

Fixation stopped in a stage

ANAL- 18 mos-3yrs

Toilet training

Mom is superego.

Superego is being formed

Child is caught in ambivalence pulled in 2 opposing factors

Too much toilet training with punishment will result to a child who is:

Obedient, organized, clean Rebel, dirty, disobedient

= OC =Anti-social

=anal retentive =anal expulsive

PHALLIC 3-6 yrs old

-penis & vagina

-love of parent of opposite sex

Oedipal-boy loves mom

Electra-girl loves dad

Identification- boy imitates dad

Castration fears- fear that dad is angry at him and will cut off penis

Penis envy- girls envy little boys

Dr. Karen Horney- detractor of Freud, didnt believe in penis envy. Freud said that it is maybe in her
unconscious mind.

Or repressed.

Conscious- highest level of awareness

Pre-conscious- at tip of tongue

Unconscious forgotten

Repression-kept in unconscious. Unconscious forgotten.

Suppression conscious forgetting

LATENT- 6-12 years old Latent- Logtu = sexual energy asleep

School age School phobia- 1st time to go to school Separation anxiety

Child is busy with Reading, writing, arithmetic.

Sublimation putting anger into something more productive

putting all energies into schooling

Ex. Angry at life, pour anger in singing.

GENITAL 12 years old Genital-Gising sexual energy

Sexual intercourse most important in this stage!!

PHARMA MOMENTS

Anti-anxiety Drugs (used also for alcohol withdrawal)

Valium Librium Ativan Serax Tranxene

Miltown Equanil Vistaril Atarax Inderal Buspar

ERIK ERIKSON

STAGE (+) (-) FACTOR

0-18 months (Oral) Trust vs Mistrust Feeding

18 mos- 3yrs old (Anal) Autonomy vs

Au-(anal)

To-ilet training

No-No! Favorite word.

My Shame/doubt Toilet training

3-6 yrs old (Phallic) Initiative vs

(Initiate 1st steps)

Phallic-oedipal,electra Guilt anger turned inward

Independence

6-12 yrs old (Latent) Industry vs Inferiority Industry

Induskul

12-20 (Genital) Identity vs Role confusion Peers

20-25 Intimacy vs Isolation Love

25-45 Generativity vs Stagnation Parenting

45 up Ego Integrity vs Despair Reflection

Newly admitted pt- develop trust 1st

-pts are dependent=self care deficit

-develop/teach autonomy

-then pt will develop initiative

-etc

Frontal lobe- personality, learning, judgment, language

Occipital- vision
Temporal- hearing, smell

Parietal-taste, touch

Sensory Integration Motor

Somatic nervous system- voluntary movements

Acetylcholine- responsible for voluntary movements

- on switch of movement

Autonomic nervous system- involuntary movements

-Sympathetic(Anti cholinergic) and parasympathetic (cholinergic)

SYMPATHETIC (alert) PARASYMPATHETIC (relax)

Heart tachycardia bradycardia

Respiratory tachypnea bradypnea

GI (opposite effect) Slow, constipation diarrhea

GU (opposite effect) Slow, oliguria, retention Polyuria, frequency

Dry mouth Moist mouth

Neurotransmitter Epinephrine, Norepinephrine Acetylcholine (AcH)

Pupils Dilated (dilat when alert) (Midriasis) Constricted (Myotic)

Blood vessels vasoconstriction vasodilated

BP increased decreased

Anti-cholinergic / anti-parasympathetic =effect is sympathetic!

Sympathetic drug classifications:

A- anxiety

P- psychotic

Anti C- cholinergic

D- depressants

MONO AMINE OXIDASE INHIBITORS:

mARplan

nARdil

pARnate
DEFENSE MECHANISMS: coping mechanism from stress:

DISPLACEMENT- -------------Your boss shouts at you, you shout at your subordinate.

SUBLIMATION - ---------------putting anger into something more productive or +

putting all energies into schooling

Ex. Angry at life, pour anger in singing.

DENIAL- ----------------------I am not an alcoholic!

DISSOCIATION --------------psychological flight from self. Amnesia. Ex. Rape, trauma

REGRESSION ----------------RETURN to an earlier developmental stage

FIXATION ---------------------stuck in a stage of development

REPRESSION -----------------unconscious forgetting

SUPPRESSION ---------------conscious forgetting. Avoidance. I dont want to talk about it. I dont want
to remember it.

RATIONALIZATION -------uses because. Has illogical reasoning. I drink because I dont want to waste
the beer in the ref.

REACTION FORMATION----plastic. Doing opposite of intention.

UNDOING- ----------------------show true feeling/color then feels guilty after.

IDENTIFICATION -----------models a certain behavior from a certain role model.

PROJECTION -----------------blame other people, pass load to others. Looks for a scapegoat. Not me, but
them.

INTROJECTION --------------assume another persons trait as your own. Not just you, me too. Ako din,
gusto ko yan.

CONVERSION repression. Anger turned inward to herself. Converted to physical symptoms.

Sensory-numbness. Motor-paralyzed, tremors.

COMPENSATION -----------defects of the person, overachieve to cover a defective part.

SUBSTITUTION -----------when you replace a difficult role with a more accessible one.

Ex.Wants to go to Disneyland but cant afford it. Went to Enchanted Kingdom instead.

Defense mechanism: Affects/interferes with ADL

Harm to self or others

Behavior Model Ivan Pavlov

Classical Conditioning -behavior learned-repeated (+)

BF Skinner operant conditioning-reinforcement

Confront (-) behavior to make it extinct.

MASLOWS HEIRARCHY OF NEEDS:

5. Self-actualization

4. Self-esteem

3. Love and belonging

2. Safety and security

1. Air, food, water, shelter, clothing, sex Basic physiologic needs

LEVELS OF PREVENTION

PRIMARY SECONDARY TERTIARY

Healthy ill Relapse avoidance

Community teaching Crisis intervention Rehab centers

Community demographics Treatment and diagnosis Al anon

STAGES OF INTERACTION

ORIENTATION WORKING TERMINATION

Assessment Problem solving Evaluation

Establishment of trust Discussion Summarize

Tell patient about termination Patient is most cooperative Say goodbye

Set contract Grief-ANGER-focus of RN

Patient is resistant Pt might become violent/suicidal

ANTI-PARKINSON DRUGS (Capables) used with anti-psychotics

Anti-cholinergic Dopaminergic ABC PLSE

C- Cogentin

A- Artane

P- Parlodel

A- Akineton

B- Benadryl

L- Larodopa
E- Eldepryl

S- Symmetrel

THERAPEUTIC COMMUNICATION NON- THERAPEUTIC

1. Offer self- Ill stay/sit with you. Dont worry, be happy.

2. Explores use what, when, where, how Why? Puts pt in defensive position.

3. Silence Change the subject.

4. Active listening-nodding, eye contact, leaning

forward-show active participation. Everythings going to be alright. giving

False reassurance.

5. Make observations. You see/ I have observed/

I have noticed Ignore the patient.

6. Broad opening- How are you?

You have combed your hair today. Prejudicial. Nice weather today. value based judgment.

7. Clarification-What do you mean by

ploopplank? Flattery dont use too much adjectives. You have the most beautiful hair in the ward.

8. Restating-I dont want to eat. (Word per word repetition!) You dont want to eat? Arguing with
the patient

Dont impose your opinion.

9. General leads- And then/What else/Go on

10. Refocusing-We were talking abt the exam

11. Focusing-Tell me more abt this.

ABG ANALYSIS

Ph & PCO2-Respiratory-opposite signs

Ph & HC02-Metabolic same signs

Compensation: Ph is normal=Fully compensated.

C02 & HC03 same signs = Partially compensated

ANXIETY

-vague sense of impending doom. Sympathetic activation.

Assessment: Level of anxiety

MILD-------------------sit restlessly, widened perceptual field, enhanced learning experience. You seem
anxious.

MODERATE----------patient is pacing, selective inattention. Give PRN meds-Anti-anxiety drugs-valium

SEVERE----------------patient cant make decisions. I dont know what to do or say. RN directs patient.
Sit down on the

chair. Directive.

PANIC- highest level of anxiety. Suicidal. Priority: safety. Stay with patient. Dont touch pt. Sympathetic
activation.

I think Im having a heart attack!

Nrs Dx: -----------------Ineffective Individual Coping

P/I: Decrease anxiety, decrease stimuli

HT: relaxation technique

E: Effective Individual Coping

GENERALIZED ANXIETY DISORDER 6 months excessive worrying. Patient knows what the problem is.

Cant sleep, concentrate, seat

Fatigue and palpitations

PANIC ATTACK ------------------------------15-30 minutes, happens without warning. SNS activation.

-with or without agoraphobia -------------------- fear of open space

-social phobia ------------------------------------- fear of public

-provide safety

-Alkalosis-brown bag

-stay with patient

-be directive

POST TRAUMATIC STRESS DISORDER

Victims rape, accident, war zone, disaster, trauma

1. Survivor

2. Flashback > 1 month

3. Memory nightmares

MALINGERING------------------------------------- no organic basis (no tissue change)

-pretending to be sick, conscious

-decrease anxiety for primary gain

-increase attention from RN secondary gain

SOMATOFORM DISORDER ------------------unconscious, not pretending, no organic basis

- goes doctor hopping

Nervous system Minor discomfort BODY DYSMORPHIC DISORDER

CONVERSION -Feels like illness -illusion of structural defect

-loss of sensory/motor fx -HYPOCHONDRIASIS -S/sx not real

-s/sx real (biglang nabulag)

PSYCHOSOMATIC DISORDER (Psychophysiologic) real illness, real s/sx, real pain, with organic basis
(with change in tissue)

- stress ulcers, migraine, HPN

PHOBIA---------------------------------------------------------- irrational fear

Etiology knowledge, experience

Immediate nsg intervention: Remove object of fear

(Increase stimuli=increase level of anxiety)

(Decrease stimuli=decrease anxiety)

Belief Feeling Behavior

Object will hurt patient Scared Avoidant=interferes with ADL

Gradual exposure to feared object- SYSTEMATIC DESENSYTHEZATION

Individual Therapy

1. Hypnosis --------------relaxed state

2. Free association ------ ideas shared to psychoanalyst

3. Catharsis --------------free to express feeling

4. Transterence- -----------patient feels something for psychoanalyst

5. Countertransterence --RN feels something for patient

Green light-Go Epi & Norepinephrine

Red light Stop G-gamma

A-amino

B-butyric

A- acid

Anxiety

Increase GABA Anti-cholinergic S/E

GI-constipation

GU-retention

Effect of GABA:
Drowsy, drink, dont drive, orthostatic hypotension

Anti-anxiety drug

Withdrawal from drug abrupt REBOUND PHENOMENA leads to seizures. 1 week effect.

Gradual withdrawal tapered dose

Dependence- Cant live without valium

ANTI-PSYCHOTIC AGENTS Sympathetic effect.

Effect 2-4 weeks

STELAZINE CLOZARIL

SERENTIL MELLARIL

THORAZINE HALDOL

TRILAFON PROLIXIN

SCHIZOPHRENIA-------------------------------impaired reality perception. Ego disintegration. Genetic

vulnerability. Stress.

-Chose fantasy over reality. Increase dopamine theory. Cause: unknown.

Increase dopamine, increase schizophrenia.

4 As:

1. Affect---------------------------------------------feelings & emotions (smiles, laughs). External, readily

observable.

Mood, internal, does not match affect. (sad inside)

2. Ambivalence-------------------------------------pulled between 2 opposing forces

3. Autism --------------------------------------------self absorbed. Trapped in his own world.Attached to odd

objects.Poor eye contact.
4. Associative looseness---------------------------talk about so many things but unrelated ideas.

Disturbed thought process-------------------------Nsg dx

Content of thought---------------Hallucinations/Illusions------------ADL----------------------------Harm

Disturbed thought process

Disturbed sensory Self care deficit Self Other

Perception Directed Violence

P/I: Reality/Orient/Safety

Eval: Improved thought process

S & Sx of Schizophrenia:

(-)neg sx (+) positive sx

hypoactive hyperactive flight of ideas

withdrawn restless hallucinations

quiet, flat affect talkative delusions many ideas

poverty of words queen of the world illusions

Types of schizophrenia:

1. Disorganized schizo---------------------------------sad inside, happy outside inappropriate affect (+)

flat affect no affect (-)

disorganized manner/speech flight of ideas (+)

Hebephrenic- giggling (+)

Sx: both (+) and (-).

2. Catatonic ---------------------------------------------ambivalence anal stage (-)

No! Negativisim-rebel-anal (-)

Waxy flexibility--------------raise arm of patient. Patients arm remains up for a long time. (-)

(-) > (+)

3. Paranoid ----------------------------------------------uses projection.

Mistrust Scared/withdrawn/violent Based on history

Develop trust: orientation -Leave door open

-1:1 interaction -Distance from pt: 1 arms length

-consistent approach -stay near door not window

-short/frequent interaction -have visibility:stand halfway in & out

-food: sealed container to be able to call for reinforcement.

-meds: wrapped in tamper resistant foil -calm and firm

4. Unclassified/ Undifferentiated-----------------------cant be classified anymore.

5. Residual-------------------------------------------------no more (+), (-). Social withdrawal

THOUGHT PROCESS DISTURBANCE

1. LOOSENESS OF ASSOCIATION----------------topics have connection but no thought. I am going to the

mall. The mall is in

town. The town flies. Flies are here.

2. FLIGHT OF IDEAS ---------------------------------New unrelated topics. I am going to the mall. Where is the
light? I treasure this

chalk. Hurray!

3. AMBIVALENCE-------------------------------------Pulled by 2 opposing forces.

4. MAGICAL THINKING----------------------------- believes he has magical powers. I can turn you into a
frog.

5. ECHOLALIA------------------------------------------repeat what is said. Parrots.

6. ECHOPRAXIA----------------------------------------repeats what you do. Repeats what is seen.

7. WORD SALAD----------------------------------------mixes words that dont rhyme.

8. CLANG ASSOCIATION----------------------------uses words that rhyme. Flank, blank, prank.

9. NEOLOGISM------------------------------------------invents new words not in the dictionary. Ploopplank,

pisnok.

10. DELUSIONS-----------------------------------------false belief

Grandeur--------------I am a queen/ king/millionaire!

Persecution------------NBI out to get me!

Ideas of reference-----They talk and write about me!

11. CONCRETE ASSOCIATION-----------------------pilosopo. What will you wear tomorrow? Clothes!

12. HALLUCINATIONS----------------------ILLUSIONS (with stimuli)

Stimuli N Y

Visual N Y

Auditory N Y

Tactile N Y
Present reality!!! H A R D-Directive. Lets go in the garden.

Acknowledge: I know the voices are real to you. Present reality. But I cant hear them.

=Assess what voices are saying to know if patient will harm himself.

Increase Dopamine = increase schizo

Decrease dopamine = decrease schizo

Extra Pyramidal Side Effects (EPSE) (Happens when acetylcholine is up and dopamine is down)

1. AKATHISIA-------------------------- restless, inability to sit still.

2. AKINISIA ---------------------------- rigidity

3. DYSTONIA--------------------------- affects neck

TORTICOLLIS -------------wry neck

OCULOGYRIC CRISIS fixed stare

OPISTHOTONUS ---------arched back, contracted

4. TARDIVE DYSKINESIA------------lip smacking, tongue is protruding, puffy cheeks. Irreversible!

5. NEUROLEPTIC MALIGNANT SYNDROME- hyperthermia, unstable BP, increase CPK, diaphoresis, pallor

-discontinue meds, medical emergency.

6. PHOTOSENSITIVITY------------------wear shades, sunscreen

7. WBC- Agranulocytosis---------------sore throat, fever, malaise, leukopenia

AUTISM- boys > girls. 1:100 kids gift-autistic savants

-echolalis, poor eye contact, cant express verbally.

Assess:

A- appearance- neat, OC, wants constancy

B- behavior- ritualistic behavior, flat affect, repetitive

C- communication difficulty communicating

Nsg Dx: Impaired social interaction cant form IPR (Interpersonal relationship)

Impaired verbal communication

Self mutilation cant express anger. Express it inward.

Risk for injury

P/I: constancy, promote safety

Expressive therapy uses art, music, poetry, decreasing risk for injury, improved social interaction, be
able to express feelings.

E: -Safety

ADHD- ATTENTION DEFICIT HYPERACTIVITY DISORDER (can progress to conduct disorder to anti-social
behavior)

Cant focus on anything.

Onset 7 yrs old and below

Duration >6 months

Setting: House & school

ID dominant: Mom or RN will act as superego

Assessment:
A- appearance: dirty

B- behavior: clumsy, impatient, easily distracted

C- talkative

Nsg Dx: High risk for injury

Safety

Structure- provide place to study, eat, play,bath,etc.

Schedule time for everything

Set limits

Residual ADHD grows up not anti-social

Meds: Ritalin, Dexedrine,Pemoline, Adderal

Best time to give meds: If once a day give AFTER MEALS- to prevent loss of appetite.

Dont give at bedtime-its a stimulant-will cause insomia. Can be given 6hours before bedtime (if q2d)

ANOREXIA NERVOSA diet, underweight < 85% of expected fat, 3 months amenorrhea, failure to
recognize problem.

BULIMIA NERVOSA induce vomiting, takes laxative, normal weight, irregular menstruation, dental
carries, diarrhea

- knows problem but ashamed and embarrassed,

Priority: Fluid volume balance

Weight gain monitor weight, eating pattern, stay 1 hour after eating, accompany in toilet

Problem: Body image Disturbance

NI: 1. Establish nutrition pattern

2. Teach stress management, journal keeping

3. Monitor eating pattern and weight.

4. Anti-depressant

MANIA needs mood stabilizing agents- Lithium. Group therapy

L- 0.5-1.5 mEq/L (If level is near 2.5-3 mEq/L will cause ataxia and mental confusion)

I- increase urination

T- tremors

H- H20- 3L/d

I- increase

T- uu

M- mouth dry

N- Na- 135-145 mEq/L to hold water

Check kidney(blood level) before administration of Lithium BUN, CREA, electrolyte

Lithium toxicity n/v, diarrhea = Diamox

BIPOLAR DISORDER 2 poles, happy (more dominant) & sad

-female, >20 yrs old, stress, obese

Self actualization

Task to decrease self esteem

Family therapy

Risk for injury, risk for other directed violence

Decrease eat, decreased sleep, hyperactive, increase sex masturbate in front of others

Nsg Dx: High risk for self or other directed violence

Risk for injury

Give task, no group games, any competition will increase anxiety, water the plants, activities using gross
motor skills, escorted walk, punching bag-displacement.

3 or more signs confirms disorder:

G grandiose, increase risk activities

F flt of ideas

S - sleeplessness

P pressured speech

E exaggerated SE

E extraneous stimuli (easily distracted)

D distractability

PERSONALITY DISORDER

1. Schizoid --------doesnt care about people, believes that he can stand on his own, never had a best
friend

avoid groups & activities no enjoyment

cares more about computers, pets

2. Avoidant ----------avoid group fear criticism, have talent but no confidence.

3. Anti-social ------as child steal, lie, always get reprimanded

Adult grand robbery, illegal activities against the law.

drug addiction, drives fast, unsafe sex, thrill seeker.

Good talker, charmer, witty, manipulator. Motto I will break the law

4. Borderline -------Favorite line life is an empty glass. Splitting, suicidal, superficial relationship,
labile-sudden change of

Mood, self mutilation.

(+) (-)

fill glass with friends suicide

have happy moments LABILE AFFECT sad moment

labile- change from good to bad in a split moment

5. Dependent ---------Decrease self esteem, dependent

Poor decision making skills

I cant live if living is without you

6. Histrionics ----------excited, dramatic, manipulative

- CENTER OR ATTENTION

7. Narcissistic----------I love myself insensitive, arrogant, self absorbed

- exaggerated Self esteem, ambitious I am the best

8. OC ------------------ perfectionist, organized, constancy in environment. Provide time to do rituals.

9. Paranoid ----------- always jealous, suspicious, violent

10. Passive aggressive ------always say yes, but resistance is hidden.

Nsg Intervention: Improve IPR, build trust

A-LCOHOL ABUSE ----------------------happy socializing Narcotic oversode-give Narcan

-escape from problem Narcotic detox- Methadone

-peer pressure Aversion therapy-Antabuse

B-blackout ---------------- awake but unaware

C-confabulation ---------- invent stories to increase Self-Esteem

D-denial ------------------- I am at not an alcoholic.

D-dependence ------------ I cant live without alcohol.

a. physical tremors, tachycardia, restless

b. psychological craving

E-enabling/codependency (significant others tolerate abusers)

DISULFIRAM

voids alcohol beer

version therapy
ntabuse (DISULFIRAM)

lcoholics anonymous n/v

hypotension

interval of alcohol & antabuse:

12h interval after alcohol intake

B1 Thiamine

Complications wernickes

Encephalopathy

Korsakoff psychosis

Wernickes VROOM Motor sx effect

Korsakoff memory- confabulation

24 72h after alcohol intake

Delirium tremors happens due SNS activation

Tremors, hallucinations, illusions. Well lit room to avoid hallucinations

ANTI DEPRESSANTS decrease serotonin problem

Anti depressants full stomach

All meds take on a full stomach, except anti anxiety.

ASENDIN TCA

NORPRAMIN TCA

TOFRANIL TCA

SINEQUAN TCA
ANAPRANIL TCA - OC

AVENTYL TCA

VIVACTIL TCA

ELAVIL TCA

PROZAC SSRI

PAXIL SSRI

ZOLOFF SSRI

LUVOX SSRI

Serotonin ---------makes us happy

Decrease serotonin pt becomes sad depression

Increase serotonin antidepressant

SSRI:

Selective S

Serotonin S (decrease S/E)

Reuptake R

Inhibitors I (1 4 weeks)

If SSRI dont work, give TCA

Tri Cyclic Antidepressants ( TCA) ----------2 4 wks has increased S/E

increased Serotonin & Norephinephrine

MAOI-------------------------- effect 2 6wks

Increase E, NE, serotonin kills serotonin - MAOI

increase MAO = decrease serotonin

* decrease MAO = increase serotonin

give MAOI

Most dangerous, most S/E

Diet avoid tyramine food eat SARIWA, fresh foods

HPN crisis dangerous! Increase CR, diaphoresis

Tyramine rich food:

Avocado Pickles

Alcohol Fermented foods

Beer Eggplant

Chocolate preservatives tocino, bologna,canned meat etc.

Cheese mozerella, swiss cheese

W ine

S soysauce

Anticholinergic = antidepressants antiparasympathetic

Dry, constipation, retention, tachycardia

Male erectile dysfunction

MAOI

mARplan

NARdil

PARnate
DEPRESSION decrease serotonin. If unresponsive to drugs, ECT-electroconvulsive therapy

Assess:

1. Denial this cant be happening. This cant be real.

2. Anger Why me, why now, why God?!

3. Bargaining If returned, I will give reward.

4. Depression 2 wks or more of sx = clinical depression

5. Acceptance client acts according to situation. Pt prepares living will.

Increase risk for self directed violence.

Maslows:

4 decrease Self-esteem give TASK

3 Pt is withdrawn

2 Risk for self directed violence suicide

1 eat (wt gain) or not eat(wt loss), sleep or not sleep, hypoactive, decrease sex

SUICIDE CUES:

I wont be a problem any longer

Remember me when Im gone

This is my last day

This is my wedding ring. Give it to my son

- Sudden change in mood.

Pt is suicidal, RN should: D d irect question Are you going to commit suicide?

I irregular interval of visit to pt room

E early am & endorsement period - time pts commit suicide.

Who will commit suicide?

S sex male (more successful)/female (hesitant)

A age 15 24yo or above 45

D depression

P pt with previous attempts will try again

E ETOH (Ethanol) alcoholics

R irrational

S lacks social support

O organized plan greater risk

N no family

S sickness, terminal

Suicide Triad:

- Loss of spouse

- Loss of job

- Aloneness

Best approach for suicide: Direct approach

Nursing Mgt: close surveillance

Hospital area majority suicide happens at: weekends 1 3 am Sunday

Weekend less staff personnel

Early am every one is asleep

Give simple task. Dont give complex task no jigsaw puzzle

Water the plants

Wash the dishes except sharp objects

SUBSTANCE ABUSE

Type of Addict:

1. Nervous -----tremors

Give downers

Sx of overdose

1. Identify if drug is upper or downer

2. Check effect

3. Sx of withdrawal

If patient takes a downer, all vital signs are down! If he stops taking it (during withdrawal), patient will
experience the opposite effect of a downer. All his vital signs will shoot up! Same with uppers.

Ex: Pt had cocaine intoxication. Pt will manifest hyperactivity, tachypnea, seizure. During withdrawal, pt
will manifest bradypnea or coma.
Substance Abuse Moments

(downer)

A alcohol

B barbiturates

O opiates Antidote

N narcotics - Narcan (narcotic antagonist)

M marijuana

Morph

CODE

HERO

(uppers)

C cocaine

H Hallucinogens

A amphetamines

Uppers Downers

Seizure decrease RR, decrease HR

Tachypnea Para constricted pupil

Moist mouth

Dilated Blood Vessels

Coma
Asleep

Decreased GI constriction

Decrease GU retention

Decrease BP

State of euphoria

Sx of withdrawal reverse of effect

1. Know if upper or downer

2. Opposite of effect

Overdose Withdrawal (opposite of withdrawal is overdose)

Alcohol coma seizure

Morphine bradypnea tachypnea

Detox withdrawal with MD supervision

Methadone

2. Depressed - Sits down on chair

Uppers

Codeine increased heart increase - BP increase, awake

Hallucinogen sympathetic HR increase seizure

Amphetamine pupils- dilate GI - diarrhea

Mouth dry

Decrease appetite - thin

Stop uppers

Tremors crash syndrome Depressed Suicide

Fatigue

LEVELS OF MENTAL RETARDATION

Profound severe moderate mild borderline normal

IQ 20 35 50 70 90 110

Profound Mental retardation IQ <20 =thinks like an INFANT. Cant be trained. Stay with patient.

Severe MR 20-35

Moderate 35-50 = Can be trained. Mental age is 2-7yo. Pre-operational stage.

Mild 50-70 = (mild 7) Mental age is 7-12. Educable. Can go to school.

Borderline- 70-90

Normal- 90-110

JOHN PIAGET COGNITIVE THEORY

0-2 yrs old S-ensory motor. Baby can sense, see, perceive and hear. Object permanence

2-4 yo- P-reconceptual- language.

4-7 yo- I-ntuitive stage. Unidimentional classification or unidimentional characteristic.

Child can fix toys according to size, color, height=one at a time only.

7-12 yo- C-conservation/concrete association. Multidemensional

12yo- F-ormal operation good in abstract thinking. Can interpret proverbs.

CHILD ABUSE

B=burns, bruises, bone fractures, bungi

Dont bathe child. Dont brush teeth. Body of evidence will be lost.

Bantay Bata 163

ALZHEIMER

Anomia- dont know name of object

Agnosia problem with senses (smell, taste, hear, touch)

Aphasia cant say it

Apraxia cant do it

Dissociative Fugue- takes a new personality from a tar away place. New place new identity.

Dissociative Identity Disorder multiple personality

Dissociative Amnesia dont know who/where I am.

DEPERSONALIZATION- believe that they are not persons anymore

PERSEVERATION- kulit. I want to talk about something because this is something that I want to do. It is
something that I need to talk about. This is something that I want to do.

ELECTROCONVULSIVE THERAPY- sign informed consent. For depressed pt. If meds dont work, use ECT.

Pre-ECT

N-npo 6 hours

A-atropine sulfate dry mouth

B-barbiturate

S- succinylcholine chloride to relax muscles

Post-ECT

Side-lying- lateral

S/E headache, dizziness, temporary memory loss (distinct sx)=RN-orient pt.

EXAMS:

Nsg intervention:

Look for words like:

S=safety, support, stay, set limits, assist

Provide safety. Mobilize support system. I will stay with you. Assist in activity.
Set limit- dont allow patient to misbehave.

Look for words like:

Orient=orient pt post delirium, ECT, pt with dementia

Accept

Seem, observed, noticed, comment, feelings

Group therapy- facilitator is RN.

Rape, battered pt

ALTRUISM Victim becomes a counselor, shares experience to new victim.

Self-help group=facilitator is the pt themselves. AL ANON groups Alcoholics Anonymous