NCLEX REVIEW GAPUZ REVIEW CENTER

(31 JANUARY 17 FEBRUARY 2005, PICC, City of Manila)

DAY 1 (31 JANUARY 05) STEPS IN PASSING

Have a Right Attitude THINK POSITIVELY
ve a Fresh Start KNOW what YOU WANT and HOW TO GET IT OVERVIEW OF ESSENTIAL CONC
EPT TRY OUT Focus assessment 7 habits of SUCCESSFUL EXAMINEE

MOSBY growth and development LIPPINCOTT care of the Elderly and Communicable Dis
ease DIGOXIN monitor the creatinine the TV DOESNT look good to me (DIGOXIN TOXICITY
nausea/vomiting, abdl cramps) Olive = butter CK normalize 1 3 days after MI LDH
- 10 14 days ATRIAL FLUTTER SAW TOOTH PROCESS OF ELIMINATION
consider MASLOWs
of NEEDS consider the COMPLICATION whether ACUTE CHRONIC ABCs SAFETY FIRST NSG P
ROCESS
ALWAYS prioritize
MMR VACCINE only vaccine for HIV pt. Pt on HEPARIN APTT (N 30-40sec), therefore
if INCREASE bleeding POISON - nursing action in order : #1 CALL poison control c
enter # 2 MINIMIZE EXPOSURE of pt to poison pull him/her away from the poison #
3 IDENTIFY the poison
GENTAMYCIN
s/e tinnitus, vertigo, ototoxicity, oliguria for ELDERLY : N level NOT more than
1.0meq/L ADULT : N .5 1.2 meq/L
LITHIUM CARBONATE
HEPA B diet : low fat, increase CHON

DOWN SYNDROME large tongue feeding problem poor sucking (infants) SAFETY PRINCIP
LE 1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inc
hes in height seat belt location in car: BACK CENTER SEAT 2. TODDLER falls 3. SU
PRATENTORIAL craniotomy semi fowlers position INFRATENTORIAL flat in bed 4. SCATT
ER RUGS osteoporosis pts. 5. TRIAGE ; burns, open fx SHOCK Things NOT TO BE DELEGA
TED by RN: Assessment, Teachings, Evaluation Pt 50y/o and - mammogram once a yea
r.

Pt with PKU LOW PHENYLALAMINE DIET (NOT phenyl FREE). therefore LOW CHON Pt with
Rocky Mountain Fever exposure to dog ticks Lymes Dses deer ticks PSYCHE PATIENTS
1. remember to stick to unit rules/policy be consistent to pt. 2. encourage ver
balization tel me how.. 3. sound knowledge of cultural diversity - seek help of int
erpreter 4. acknowledge pt feelings it seems. this must be difficult.. 5. emphatize w
th your patientss feelings I understand how you feel.. CATARACT CAUSES aging and tr
auma MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WH
EN W/ PT
DAY 2 ( 01 February 05)

TUBES
1. GROSHONG CATHETER HICKMAN BROVIAC - 2 lumen - 3 lumen - 1 lumen
ALL requires Central Venous Access - sites: cephalic, brachial, basilica and sup
erior vena cava
PURPOSE:
For TPN Administration of Chemo Agents, Blood Products, Antibiotics
COMPLICATION:Thrombosis and Bleeding 2. CHEST TUBES Water Sealed Drainage Types:
Anterior w/c drains AIR Posterior - w/c drains FLUIDS Water Sealed Drainage : 1
bottle, 2 bottle and Three bottle system 1 BOTTLE : 2 BOTTLE : 3 bottle : 3 5cm
of only (length of tube to be emerge) First bottle drainage bottle (no tube eme
rge), 2nd bottle - long rod 3-5cm FREQUENTLY USED 1st bottle drainage 2nd bottle
water sealed 3rd bottle suction bottle control COMPLICATIONS: Nsg ALERT:
NORMAL
: BUBBLING is N in the 3rd bottle it indicates that suction is ADEQUATE (if no
bubbling STOPS in the 3rd bottle, meaning inadequate suction) ABNORMAL : if bubb
ling occurs at the 2nd bottle indicates LEAKAGE action, check sealed at air tigh
t container and the pt and bottle connection. bubbling, breakage, blockage

In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry
of air and or may use forcep to clamp tube temporarily. If pt. ambulates, keep b
ottle LOWER than the patient. ABSENCE of OSCILLATION at the 2nd Bottle indicates
blockage
TOWARDS THE BOTTLE - When MILKING the tubings. EMERGENCY EQUIPMETS AT BEDSIDE: x
tra bottle,clamp, gauze
3. TRACHEOSTOMY TUBE - to maintain patent airway for pt w/ neurological problems
and musculoskeletal disorders.

nursing care: 1. Suctioning 10-15seconds - if (+) bradycardia, STOP - if acciden

tally dislodge, insert obturator to keep it open 2. AVOID: water sports swimming
3. In changing ties insert new one first BEFORE REMOVING old tie. 4. Ribbon or
ties @ side of the neck only to avoid pressure. 5. Before and After suctioning h
yperoxygenate the patient.
4. PTCA
enlarge the passageway for bloodflow. problem: spasms that lead to arrhythmia
C-STENT (cardiac-stent) alternative to PTCA Maintains patency of bld vessels Pro
blem: dislodge IABP (Intra Aortic Balloon Pump) - for Cardiogenic Shock problem:
thrombus formation, infection and arrhythmia
5. PENROSE DRAIN - wound drainage system - doctors the one who removes this. - r
emove gradually
6. NASO GASTRIC TUBE stomach and intestine (duodenum) Types:
Levine Tube for sto
mach - 1 lumen, for lavage (cleaning) and gavage (feeding) Salem Sump for stomac
h - 2 lumen (I for suctioning, I for lavage/gavage) - if pt (infant) is having e
nteric coated meds, request for change in form of meds Miller Abbot for intestin
al (w/ mercury b4 injection) - 2 lumen (insert then inject the mercury) Cantor f
or intestinal - 1 lumen

Nursing Care for NGT: 1. tip of nose to earlobe to xyphoid process (for stomach)
2. tip of nose to earlobe to XP + 7-10 inches for intestinal NGT 3. accurate me
ans to verify correct placement: ALWAYS consider Two checking criteria: ASPIRATI
ON and Gurgling Sounds

Report the following:

If (-) or decrease drainage, (+) nausea and vomiting (+) abdml rigidity Characte
ristic of Gastric Residual: more than 50 mo and coffee ground. Before feeding ch
eck for placement.
7. GASTROSTOMY TUBE (GT) PEG both for NUTRITIONAL PURPOSES GT incision (abdomen
to stomach) - for pt (+) lesion at esophagus - nsg care : report s/s of infectio
n, abdl cramps, n/v - provide adequate skin care PEG incision at skin - long ter
m therapy
8. T TUBE - to drain excess bile until hearing occurs - place drainage bag at th
e level of t-tube (obstruction of t-tube there will be excess drainage) 500 ml N
drainage in 24hrs, if report ASAP.
9. HEMOVAC JACKSON-PRATTS (JP)
BOTH used as close wound drainage suction system
BOTH system function on the system of (-) pressure.
JP compress the container before attaching to the drainage. WHEN TO EMPTY: when
its usually 1/3 to full then RECORD the amount.
10. THREE-WAY FOLEY absence of clot effective Characteristic of drainage 2-3 day
s after surgery (bloody to pinkish) NO NEED TO REPORT THIS it is expected

11. SUPRAPUBIC CATHETER for genito urinary problem - inserted directly at the bl
adder wall - check if properly anchored 12. URETHRAL CATHETER to drain urine. never clamp because it can only hold 4-8 ml of urine. - keep open to drain urine
from kidney pelvis. SENGSTAKEN BLAKEMORE TUBE - 3 lumen ( for esophageal balloo
n, gastric balloon, for meds) - for pt w/ esophageal varices - balloon tamponade
- 48 hrs keep balloon inflated for 10 minutes to decrease bleeding
LINTON TUBE
3 lumen 4 lumen
MINESOTTA TUBE

SCISSORS important EQUIPMENT AT BEDSIDE FOR ALL TUBES. HEMOSTAT

ment that shld be @ bedside for water sealed drainage. Persistent
ter drainage bottle for bottle #2 check if tubing is properly
OVED if patient exhibits return of bowel sounds. BULB SYRINGE
ares of pt with NGT (child) To facilitate removal of air at lungs
er sealed chamber in 3 way bottle system.

important instru
bubbling at wa
sealed. NGT IS REM
use to clean the n
purpose of wat

THERAPEUTIC DIET
GENERAL CONSIDERATION
Know the DIAGNOSIS of the patient Identify & incorporate t
he pt. dietary preferences Instruct pt on what to avoid For pregnant pt, note di
etary changes: a. addtl calories (300 cal/day) average of 2400 - 2700 b. addtl o
f 10gms/day for CHON c. IRON : 15-30mg/day d. CALCIUM : RDA is 1000 then +200mg/
day (broccoli,tuna,cheese) e. Galactogogues increase production of milk

PEDIATRIC pt by 4-6 mos START iron supplement due to iron depletion and (-) extr
usion reflex. - cereals, fruits, vegetables,meat and table foods - egg yolk (6mo
s), egg white (1yr)

TRANSCULTURAL CONSIDERATION
CHINESE like cold desserts after surgery for optimum
health JEWS kosher diet (no meat and diary products at the same time) EUROPEANS m
ain meal is served at mid day followed by espresso MUSLIM halal diet no pork
SDA
trictly vegs diet (vit B6 and B12 deficiency)
MORMONS words of wisdom (no caffei
ne, alcohol and once a month fasting) the amount due for food is donated to the
church
KEY POINTS FOR NURSES Sodium (Na) source down the soil Potassium (K) - source up
the tree Low Na Diet : AVOID processed foods, milk products and salty foods KNO
W the serving: CHO - 6-11 servings CHON - 2-3 FRUITS & Vegs - 3-4 FATS - sparing
ly
MOST COMMON DIET
CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT) - given to pt to
relieve thirst, correct fld & electrolyte imbalance - given also to pt post-op
ex: apple juice, gelatin (strawberry), popsicle, candy
RENAL DIET for kidney dis
order (renal failure, AGN, Nephrotic syndrome) to maintain fld & e imbalance
LOW CHON avoid poultry products LOW Na - avoid processed foods, milk products, &
salty foods Low K - avoid fruits (anything you see in a tree)

LOW FAT/CHOLESTEROL RESTRICTED DIET

- for liver disorder, cardiovascular and renal dses ALLOWED: lean meat, fruits,
vegs and fish AVOID : Sea foods, fried foods, preserved foods
(cheese cake and custard)

HIGH FIBER DIET - to prevent constipation, hemorrhoids & diverticulitis - vegs,

fruits and grain products SOFT DIET for inflammatory conditions: esophagitis, pe
ptic ulcer gastritis pureed foods/ blenderized foods soup

PURINE RESTRICTED DIET for gouty arthritis increase fluid intake AVOID: preserve
d foods, sea foods, alcohol, organ meat (liver, gizzard)

NA RESTRICTED DIET for cardiovascular dses, renal, fld & e imbalance ALLOWED: fr
esh vegs AVOID : processed foods, milk products and salty foods

BLAND DIET for peptic ulcer, inflammatory GI conditions AVOID: chemically and mechanically
irritating foods such as fried foods, fresh and raw fruits & vegs (EXCEPT: avoca
do, banana & pinya) and spicy foods with preservatives

HIGH PROTEIN, HIGH CARBO DIET for burns (about 5000 cal/day) grain products and
poultry to aid the healing tissues

ACID ASH DIET to decrease the ph of the urine indicated for pt w/ alkaline stone
ex struvite ex. 3 CS cranberry, cheese, & corn 3 PS - prunes, plums & pastries

ALKALINE ASH DIET to increase ph of the urine indicated for acid stone ( uric ac
id stone, cystine stone) ex. Milk

GLUTEN-FREE DIET for celiac dses ALLOWED : rice, corn, cereals, soy beans AVOID
(LIFETIME): barley, rye, oats, wheat

PHENYLALANINE DIET for PKU, until age 10 and adolescence only AVOID : CHON rich
foods (meat products luncheon meat)

FULL LIQUID DIET opaque transitional diet from liquid ex : cream soup, ice cream
, milk, leche flan, pumpkin cake
ABGs
ATERIAL BLOOD GASES
Ph 7.35 7.45 PCO2 - 35 35 HCO3 - 22 26 meq/L Ph Compensatory Mechanism no change
increase or decrease increase or decrease
Uncompensated abnormal Partially compensated abnormal Fully Compensated normal D
iarrhea metabolic acidosis Vomiting metabolic alkalosis
PRIORITIZING of case: Med.-Surg abc Psyche - safety first Fire - race Triage - pt
evaluation system (prioritizing)
APGAR SCORING

0 Appearance Pulse Grimace Activity Respiratory pallor (-) (-) flaccid (-)
1
2 all pink flexion & extension
acrocyanosis <100 >100 grimace vigorous some flexion irregular lusty cry
T.R.I.A.G.E -prioritizing LEVEL 1 emergency
severe shock, cardiac arrest, cervical
spine injury, airway compromise, altered level of consciousness, multiple syste
m trauma, eclampsia
LEVEL 2 urgent (stable) LEVEL 3
chronic/ minor illness (can be delegated) dental p
roblems, routine medications and chronic low back pain can be delegated (fever,
minor burns, lacerations, dizziness)
TIPS ON PRIORITIZING
1. PT @ ER sleeping pills overdose; 2. pt bp 80/30 & mother died of CVA 1st prio
rity : assess pt for addtl risk factor; 3. pt ask what procedure: Rn Action : no
tify the doctor 4. MI attack 1st action : report ASAP (esp. presence of vent. Fi
brillation) 5. pt on NGT check patency of tube
DELEGATION
do not delegate Assessment, Teaching and Evaluation do not delegate meds prepara
tion, administration, documentation
CONCEPT OF DELEGATION
consider the competence of personnel 5 Rs in delegating (RIGHT task, person, circ
umstances, direction/communication supervision) RN may delegate feeding client,
routine vital sign (pt w/ no complications) and hygiene care

MI ATTACK enzymes to increase IN ORDER - #1 #2 #3 #4

myoglobin troponin CK LDH
RISK FOR INJURY menieres dses INEFFECTIVE BREATHING PATTERN myasthenia gravis ALT
ERED TISSUE PERFUSION pt w/ complete heart block INEFFECTIVE AIRWAY CLEARANCE pt
w/ kussmauls breathing D
DAY 3 ( 02 February 05)
POSITIONING FOR SPECIFIC SURGICAL CONDITION
Positioning a. b. c. independent nsg function know the purpose of the position t
o prevent or promote soothing; what to prevent or promote; know your anatomy & p
hysiology R side lying to prevent bleeding
Post Liver Biopsy

(during the procedure L side lying).

Hiatal Hernia
upright to prevent reflux.

AMPUTATION complication: hemorrhage (keep tourniquet @ bedside) 1st 24hr goal: t

o decrease edema elevate the stump at foot part w/ the use of pillow AFTER 24hr
goal : to prevent contracture deformity (keep leg extended)

APPENDICITIS Unruptured : any position of comfort

Ruptured : semi to high fowlers position to prevent the upward spread of infectio
n complication: peritonitis Ruptured appendicitis indication: pain decreases or
go away. (pt say, I want to go home pain is gone) BURNS Position is FLAT or Modifi
ed Trendelenburg to prevent shock. SHOCK occurs w/in 24-48hrs (immediate post bu
rn phase). Complication: infection

CAST, EXTREMITY Elevate the Extremity to prevent edema (use rubber pillow)
Nsg care: a. b. c. d. e. capillary refill N 1-3 seconds only (complication: alte
red circulation) note for s/s of infection (when there is musty odor inside the
cast) pruritus (inject air using bulb syringe) blood stained mark and note (if i
ncreasing in diameter - report ASAP) tingling sensation indicate nerve damage

CRANIOTOMY
Types:
a. Supratentorial C semi fowlers orlow fowlers position to prevent accumulation of
fluid at surgical site; b. Infratentorial C - flat or supine. Purpose: same

FLAIL CHEST (+) Traumatic Injury paradoxical chest movement areas of chest GOES
IN inspiration and OUT on Expiration
position: towards the affected side to stabilize the chest.

GASTRIC RESECTION to prevent dumping syndrome usually for 10 mos only NOT LIFETI
ME disorder (post gastrectomy) position : LIE FLAT for 1-2hrs post meal

HIATAL HERNIA there is damage to esophageal mucosa what to prevent: gastric refl
ux therefore FEEP PT IN UPRIGHT POSITION.

HIP PROSTHESIS Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use
of wedge pillow or triangular pillow from perinium to the knees.
dumping syndrome : flat

LAMINECTOMY log-roll the patient (3 nurses) KEEP SPINE IN STRAIGHT ALIGNMENT

AVOID: hyperflexion, hyperextension and prone it causes hyperextension of the sp

ine.

LIVER BIOPSY before LB : supine or L side lying to expose the part during LB : doafter LB : R side lying w/ small pillow under the coastal margin to prevent b
leeding.

LOBECTOMY removal of Lobe (N R lobe 3, L lobe 2) position : semi fowlers position

to promote lung expansion

MASTECTOMY removal of breast elevate or extend affected arm to prevent lymp edema (or eleva
te higher that the level of the heart. AVOID: venipuncture, specimen taking, blo
od pressure ON THE AFFECTED ARM coz there is no more lymph node w/c predispose p
t to bleeding.
Post mastectomy Exercises:
squeezing exercises, finger wall climbing, flexionextension (folding of clothing
, washing face, vacuuming the house)
Due to removal of axillary lymph node, avoid also gardening and hand sewing PNEU
MONECTOMY either L or R lung. Position pt on the AFFECTED SIDE to promote lung e
xpansion.

RADIUM IMPLANT OF THE CERVIX keep pt on complete bed rest to prevent dislodge. A
VOIDE SEX (may burn penis bec of the implant inside)

RESPIRATORY DISTRESS Adult : Orthopneic position over bed table then lean forwar
d Pedia : TRIPOD lean forward and stick out tongue to maximize the Airflow RETIN
AL DETACHMENT

to prevent further detachment, place pt on the AFFECTED SIDE.

Ex. If operation is on the R outer of the R eye, place pt on the R position. If
operation is on the L inner of the R eye, position pt on the L side AVOID: sudde
n head movement.

VEIN STRIPPING keep extremities extended then elevate the legs at level of the h
eart to promote venous return
TIPS
liver biopsy is done on a pt. during 1st 24hrs after the procedure, turn the pt
on his abdomen w/ pillow under the subcoastal area;
when draining the L lower lo
be of the lung the pt shld be positioned on his R side w/ hip higher or slightly
higher than the head; after tonsillectomy position: prone
a pt is about to go o
n thoracenthesis - how shld the nurse position the pt? sitting w/ a arms resting
on the overbed table; to maintain the integrity of pt w/ hip prosthesis abducti
on splints immediately after supratentorial craniotomy- fowlers position
best pos
ition for pt in shock supine w/ lower extremities elevated

THERAPEUTIC COMMUNICATION
1. DONT ASK WHY this put pt on the defensive 2. AVOID PASSING BACK I will refer yo
u to. 3. DONT GIVE FAKE REASSURANCE everything will be alright. youre in the hands
e best 4. AVOID NURSE CENTERED RESPONSE I felt same too I had the same feeling. In G
P DISCUSSION nurse is just a facilitator let the group decide, he/she channel ar
e concern back to the group. THERAPEUTIC PHRASES it seems you seem. - open ended q
uestion - close ended for manic pt and pt in crisis - direct question- for suici
dal pt

ISOLATION PRECAUTION
Purpose : to isolate infection transmission
TYPE PRIVATE ROOM HAND WASHING GOWN GLOVE MASK
STRICT
(airborne dses, direct contact-Diptheria)
RESPIRATORY
(AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT)
OPTIONAL
OPTIONAL
TB CONTACT
OPTIONAL (negative airflow room)
OPTIONAL
(direct contact NOT AIRBORNE DSES) eX SCABIES
ENTERIC
(fecal contamination)
X
OPTIONAL
OPTIONAL
DISCHARGE X (drainage: pus ex burn pt) UNIVERSAL X
OPTIONAL
OPTIONAL
(AIDS, HEPA b TRANSMITTED BY BLD AND DODY FLUIDS)
TIPS:
When implementing universal precaution, w/c nsg action require intervention: rec
apping the needle this might prick your hand; When discarding the contents of th
e bed pan use by a pt under enteric precaution GLOVE IS NECESSARY; A nurse is gi
ving health teaching to the parents of child with scabies: family member must be
treated; Preventing pediculosis in school age children: avoiding contact w/ hai
r articles of infected children like clips, head bands, hats no sharing Patient
with full blown AIDS is placed on isolation precaution pt ask nurse why his visi
tors is wearing mask response: it will help in the prevention of infection;

Essential when a pt w/ meningitis is kept in isolation: isolation precaution rem

ains until 24hrs after initiating antibiotic therapy
DIAGNOSTIC PROCEDURES
side notes: pt for IVP pt for KUB schilling test USG : : : : assess for allergy
(cleansing enema b4 the procedure) no dye (dont assess for allergy) 24hr urine sp
ecimen no consent required
GENERAL CONSIDERATION

EXPLAIN the procedure to the pt (initial nsg action) if not ready inform the doc
tor; pt has the right to refuse procedure; doctor the one who asked for consent
Check pt for CONSENT if INVASIVE WITH CONSENT NON INVASIVE NO CONSENT needed CON
TRAST MEDIUM check for allergy For procedure requiring anesthesia KEEP PT NPO B4
PROCEDURE When local anesthesia used NPO, 1- 2HRS AFTER General anesthesia keep
NPO at least 8hrd after (check gag reflex before meals)

PEDIATRIC PATIENT use flash cards, games and play to encourage participation
TRANSCULTURAL CONSIDERATION
HISPANIC PATIENT women prefer same gender health care provider Obtain help of in
terpreter when explaining procedures (except or dont ask family members) For musl
im patient - they prefer same sex health care provider however, if procedures re
quire life threatening they prefer to have male doctor. - they only want good ne
ws information of their condition
DELEGATION and DOCUMENTATION
Delegation assessment, monitoring and evaluation of treatment (cannot be delegat
ed) BUT standard and changing procedures can be delegated ex. 24hr urine specime
n and urine catheter

collection. Documentation type of treatment and any untoward reactions.

KEYPOINTS FOR NURSES
Prepare the patient; Monitor for adverse reaction; Report c
omplication to the doctor
FRAMEWORK includes the Purpose, Special Consideration and Interpretation
DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND WELL-BEING)
DAILY FETAL MOVEMENT Purpose : to determine fetal activity by counting fetal mov
ements usually perform by pt himself
N Fetal Movement
10-12 for 12 hr period (average: 1 movement/hr with average 3fm/hr)

NON STRESS TEST (NST) correlates fetal heart rate w/ fetal movement monitor the
baseline FHR then induce fetal movements by (HOW) : a. ring a bell b. feed the p
atient
then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseli
ne. (ex. 140 FHB baseline, then after challenge it increase to 155) POSITIVE res
ult means, BABY is REACTIVE (good condition) and no need for contraction stress
test/oxytocin challenge test coz baby is OK and doing well. CONTRACTION STRESS T
EST (oxytocin challenge test) HOW: Thru breast stimulation it triggers the relea
se of oxytocin from pituitary gland If (-) patient is given Oxytocin onset is 2030 minutes. Then check FHR and note the presence of DECELERATION (slowing of FHR
)
types of deceleration a. early deceleration indicates head compression (MIRROR I
MAGE)

correlates FHR with uterine contractions pt on NPO get baseline FHR then induce
uterine contraction
b. late deceleration indicates placental insufficiency (REVERSE MIRROR IMAGE)
mgt: L Lateral Recumbent Position, Administer O2, Treat Hypotenson
c. variable deceleration due to cord (image: U or W shape) and slowing of FHR ca
n occur
anytime.

If (+) CST, meaning there is deceleration, baby is NOT OK coz there is decrease
FHR and during labor he/she may stand the labor process.

BIOPHYSICAL PROFILE to determine fetal well being w/ the use of 5 CRITERIA 2 poi
nts 2 points 2 points 2 points 2 points 10 points
fetal breathing movement heart tone reaction to NST amniotic fld volume score be
low 6, indicates fetal jeopardy

ULTRASOUND - provide data on placenta (age and location) gender of baby structur
al abnormalities position of baby - for pregnant: site is lower abdominal USG
types: a. Upper USG NPO b. Lower USG - NPO - preparation: increase fluid intake
(oral) NO consent needed If pt ask if it is painful: NO PAIN; Pt shld have full
bladder
CHORIONIC VILLI SAMPLING CVS AMNIOCENTESIS AMNIO PERCUTANEOUS UMBILICAL CORD BLO
OD SAMPLING PUBS
CVS
Purpose: to detect chromosomal Aberration (eg. Down syndrome, Trisomy 21) Done i
n 1st trimester (can be done as early as 5th wk but can be done on 8-10th wk)
AMNIO
Purpose : same w/ CVS
PUBS
Purpose: to check chromosomal aberrations, & presence of RH Incompatibility Extr
act blood at umbilical cord then it is tested if it really comes from the umbili
cal cord (can be done on either 2nd or 3rd tri.
can be done on the 2nd wk (14-16 wk) - but not recommended bec. of danger aborti
on (assess pt age of gestation) or can be done on the 3rd wk (34-36 wk) purpose:
to detect fetal maturity (FLM) thru monitoring of L/S Ratio N 2:1 (if mother is
(+) DM LS ratio is 3:1) This procedure also check level of alpha-feto Protein i
f INCREASE spina befida; If DECRTEASE down syndrome
Get sample at chorion (by 10-12wks The placenta matures, get some sample)
(+) Consent invasive Bladder : Empty
(+) Consent consider the Pt Age of Gestation (if age of gestation :
(+) Consent

is higher than 20wks and above : empty bladder, if AOG is 20wks and below : full
bladder
COMPLICATIONS of CVS, AMNIO & PUBS: a. b. c. d. infection bleeding abortion feta
l death
TIPS
EARLY DECELERATION expected in the fetal monitor when there is fetal head compre
ssion;
AMNIOCENTESIS was done @ 35 wks gestation purpose: to determine fetal lung matur
ity;
A mother asked the nurse what will amniocentesis provide during pregnancy: it wi
ll show as whether the baby lungs are developed enough for the baby to be born;
a nurse is preparing pt for lower abdl usg w/c of the following done by the pt n
eeds further teaching pt voids b4 the procedure;
after amniocentesis w/c of the following manifestation if observed by the nurse
on the patient that needs to be reported : bleeding; heart rate;
pt ask the nurse what deceleration means it refers to slowing of babys before Amn
iocentesis, what to check USG DEVICE
DIAGNOSTIC TESTS (to evaluate pediatric patients)
CARDIOPNEUMOGRAM use to diagnose apnea of infancy assess HR, RR, nasal airflow a
nd O2 saturation N 95-98% below 85 report ASAP GLUTEN CHALLENGE - detect presenc
e of Celiac Disease (CD) - intolerance to gluten; - pt is given gluten rich food
for 3-4 months the observe s/s of CD s/s of CD: abdl cramps, steatorrhea, abdl
rigidity, abdl distention (if + for CD, gluten free diet will be for life time)

ORTOLANIS TEST (OT)

purpose: test developmental dysplacia of the hip or congenital hip dislocation (
+) if w/ click sound (lateral)
BARLOWS MANUEVER (BM)
purpose : same (+) barlows click press downward and w/ click sound
POLYSOMNOGRAPHY or sleep test EEG is connected to pt when he sleeps Check the brai
n waves, check for apnea of infancy preparation : No Special prep, HOLD CAFFEINE
FOOD 2days b4 test
SCOLIOMETER measure the degree or angle of scoliosis check for: (+) scoliosis if
uneven hemline uneven waist more prominent iliac rest and scapula on one side p
resence of rib hump
test for pre-teen : bend over test bend and touch the toe; (+) scoliosis if presen
ce of rib hump, therefore x-ray then scoliometer. SICKLEDEX TEST
Purpose: test for sickle cell anemia
HGB ELECTROPOISIS
Purpose: test for sickle cell anemia
Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + ele
ctropoiesis, if sickling of RBC Therefore TRAIT CARRIER (S or C shape RBC), ther
efore + for SC Dses Test for TRAIT Test for Disease
GUTHRIE CAPILLARY BLOOD TEST (GCBT) - to detect PKU (in PKU there is absence of
PHENYLALAMINE HYDROXYLASE- PH) Phenylalamine hydroxylase is an enzyme that conve
rts PH to Tyroxine the one that gives color to hair, eyes and skin. If absent PH
, no one will convert PH to Tyroxine, therefore it will accumulates to brain and
can cause mental retardation. PH came from CHON rich food. At birth, it is usua
lly negative, so give CHON food first for 3wks then retest. Before test, give ch
on rich food for 1-4 days before test. (adult) N PH level - >2mg/dl (if 4mg/dl i
ndicative of PKU, 8mg/dl confirms PKU)

SWEAT CHLORIDE TEST Types: a. sweat chloride test N 10-35 meq/L (above 40
+) b. serum chloride test N 90-110 meq/L (above 140 meq/L (+) to detect
ibrosis (in CF, the skin becomes impermeable to Na. meaning cannot reabsorb
nd it accumulates outside of the skin); Mother complain that her baby taste
y; PILOCARPINE used in the test to induce sweating;

meq/L (
Cystic F
Na a
salt

TIPS
pt w/ PKU would more likely to have (+) result in gluten capillary bld test if t
here is adequate CHON in the diet; mother complains that her baby taste salty wh
ich test is to be performed : sweat chloride test; 9 yo pt has (+) result for sw
eat test this indicates possible dx of Cystic Fibrosis; pilocarpine drug used fo
r pt undergoing seat chloride test; hgb electropoisis test for sickle cell dses

DAY 4 (3 Feb 2005)

DIAGNOSTIC PROCEDURES
I. CARDIOVASCULAR
A. ELECTROCARDIOGRAPHY records the electrical activity of the HEART P wave atria
l depolarization QRS complex ventricular depolarization ST - repolarization Rhyt
hm appearance of wave and distance Rate - N 60-100 bpm check on # of QRS then di
vide it by 300 (k)
ABNORMALITIES

a.
al

atrial fibrillation p waves halos magkadikit. (no discernable p waves) b. atri

flutter saw tooth flutter waves c. ventricular check on QRS (N - .8-.12) ANGINA
st segment elevation, t wave inversion MI - st segment elevation or depression,
wave inversion

B. CARDIAC CATHETERIZATION it determine the structural abnormalities in the hear

t either L or R sided catheterization site: antecubital, femoral, brachial

common complications: embolism, bleeding, arrythimia EBA nsg mgt :

monitor distal
pulses (if brachial site: check @ radial if femoral site : check @ dorsalis pedi
s) if weak or no pulse REPORT
if (+) bleeding report (sandbag 10-20 lbs shld be a
bedside)
C. STRESS TEST determines the ability of the heart to withstand stress equipment
: threadmill & ECG nsg alert : check pulse and BP keep NPO an hr b4 the test NO
Jewelries
D. CORONARY ARTERIOGRAPHY visualization of the bld vessels w/ contrast medium ns
g alert: (+)consent check allergy to contrast medium increase oral fluid intake
after to excrete dye epinephrine shld be ready for any untoward reaction
E. SWAN-GANZ CATHETERIZATION 4 lumen for the ff CVP, Pulmonary Capillary Wedge P
ressure (PCWP), Pulmonary Artery Pressure, Bld products, Balloon
CVP measure R side pressure of the heart PCWP L side of the heart N Pressure CVP
: for R Atrium 0-12

for SVC 5-12 Nsg Alert : check pulse and s/s of bleeding
F. BLOOD CHEMISTRIES SODIUM (135 145 meq/L)
Addisons Dses: hyponatremia (dec Na), hyperkalemia (inc K) FLD IMBALANCE Cushing Sy
ndrome: hypernatremia, hypokalemia FLD VOL. EXCESS

POTASSIUM (3.5 5 meq/L)

Hyperkalemia : Addisons dses Hypokalemia : Cushing Syndrome Inc or dec in K PT RI
SK of INJURY Pt w/ digitalis & diuretics monitor for arrhythmia

CALCIUM (4.5 5 meq/L or 9-10mg/dl)

Hyperthyroidism inc CA Renal Calculi Formation inc CA @ bld

GLUCOSE (80-120) Higher than 140 hyperglycemia (acidosis may lead to ineffective
breathing pattern and airway is the main problem) below 50 hypoglycemia (pt pro
ne to injury & altered thought process)

Creatinine (.5-1.5)
most sensitive index of kidney funx (increase BUN but N creatinine do not report
to AP) increase creatinine kidney failure or renal disorder

BUN (10-20 mg/dl)

inc. if (+) kidney disorder

LDH (40 90 u/L)

LDH1 27-37% (for heart check for MI) LDH2 17-27% (for heart check for MI) LDH3 8
-15% (for respiratory system) LDH4 3-8% (for liver & kidney) LDH5 0-5% (for live
r & kidney) LDH inc for MI for 3-4 days then it returns to N after 10-14 days

CPK or CK
Male 12-70 u/L Female - 10-55 u/L Increase CPK 3-6hrs post MI then it normalize
3-4 dyas

AST (SGOT)
- N 8-20 u/L - for liver (inc. for liver dses)
SGPT (ALT)
N 8-20 u/L more on HEART (inc for cardiac dses)
G. HEMATOLOGIC STUDIES RBC (4.5 5.5 million) - inc RBC polycythemia risk for inj
ury complication CVA - dec RBC anemia activity intolerance WBC (5-10 thousand) to detect presence of infection, bld disorders like leukemia - dec WBC pt prone
to infection - inc WBC hyperleukocytosis (+) to pt w/ leukemia risk for infxn P
LATELET (150,000-450,000) - spontaneous bleeding occurs when platelet dec (pt al
so prone to injury) PT
(11-12 sec)
PTT
(60-70 sec)
APTT
(30-40 sec)
coumadin check pt monitor pt 4 bleeding
heparin PTT monitor pt 4 bleeding
HGB male : 14-18 mg/dl Female : 12-16 mg/dl Dec hgb anemia (nsg dx: activity int
olerance) HCT - 35-45% - determine the adequacy of hydration and the ration of p
lasma to the cellular component blood inc hct dec hct : hemoconcentration (nsg d
x: fld deficit dehydrated pt) : hemodilution fld excess
DOPPLER USG - to detect the patency of bld vessels arteries & veins esp of lower
extremities; - painless, non invasive, NO SMOKING 30 min-1hr b4 the test

PULSE OXIMETRY - determines the O2 saturation at blood - N 95-98 attach to finge

r or earlobe (do not expose e light)
II.
RESPIRATORY
BRONCHOSCOPY
visualization of b. tree or airway passages; to gather specimen
biopsy; NPO b4 & after Gag reflex return after 1-2hrs; Pt may expect a sore fee
ling (PINK STINGED SPUTUM) Report (+) stridor CHEST X-RAY
to determine abnormalities of lungs and thoracic cavity; no preparation; ABSOLUT
E CONTRAINDICATED TO PREGNANCY Check pt for radiation indicator Determine effect
iveness of tx and whether pt is active or non-active
SPUTUM STUDIES to determine
the gross characteristic of the sputum (refers to the amount, color, abnormal p
articles, consistency and characteristic)
TYPE OF SPUTUM PNEUMONIA TB - Viral thin & watery Bacteria - rusty - blood strea
ked
BRONCHITIS - gelatinous CHF/ PULMONARY EDEMA - pink stinged
Sputum specimen sterile container

THORACENTESIS - aspiration of fld at thoracic cavity (for diagnostic & therapeut

ic purpose) DURING sitting AFTER - affected or unaffected side
position:
Nsg alert:
NO COUGHING & DEEP BREATHING during the procedure coz this may cause puncture of
the lungs; Assess for breath sounds after; Complication: bleeding and pneumotho
rax PULMONARY FUNCTION TEST - thru the use of incentive spirometer - vital capac
ity (4-5 L of air) refers 2 N amt of air that goes in

& out of lung after maximum inspiration.

PROCEDURE:
EXHALE then INSERT mouth piece, BREATH iN, HOLD then EXHALE

LUNG SCAN - to identify the presence of blockage in the pulmonary bld vessels; with contrast medium; - (+) consent; - assess for rxn to allergy MANTOUX TEST test for POSSIBLE TB EXPOSURE; - using PPD (purified chon derivatives) - angle
10-15, BEVEL UP then read 48-72hrs after 5mm in duration (+) for HIV, multiple s
ex, previously (+) pt; 10mm - (+) for immigrants, children below 3yo and for pt
w/ medical condition DM & Alcoholism 15mm - (+) for general population LUNG BIOP
SY - aspiration of tissues at lungs for dx of tumors, malignancy - assess for bl
eeding, breath sounds & report for s/s of dyspnea

III.
NERVOUS
EEG shampoo hair B4 (to remove chemicals) and AFTER to remove electrode gel (sha
mpoo or acetone) measures electrical activity of the brain (gray matter) non inv
asive, (-) consent detect the ff: brain tumors, space occupying lessions alcohol
brain waves and seizures nursing alert:
dietary modification: WITHOLD CAFFEINE coffee and tea; WITHOLD 48hrs b4 the proc
edure : tranquilizers, sedatives, anti-convulsant, alcohol
CT SCAN
MRI
PET
Use radiation to determine use electromagnetic field use gamma rays or positron
electron tissue density to detect abnormality of tissue density to detect abnorm
ality of tissue density; (detect cancer and tumor) also to detect O2 saturation
@ tissue;

physiology of psychosis; and to evaluate tx give more detailed impression (ex. M

easurement of blocked artery)
like CA Tx
NSG ALERT: (w/ or w/out dye) CONTRAINDICATION a. pregnancy; obese pt (more than
300 lbs); claustrophobia (give anti-anxiety b4) pt w/ unstable v/s (arrhythmic &
HPN); pt w/ allergy to dye
CONTRAINDICATION (same w/ ct scan BUT w/ addtl) NO METAL OBJECTS - jewelries, in
sulin pump, pacemaker, hip replacement
b. c. d.
e.
clicking sound will be heard & lie still during the procedure lie still lie still
during the procedure and thumping sound will be heard
CEREBRAL ANGIOGRAM involves visualization of bld vessels @ vein w/ the use of co
ntrast medium.
CONTRAINDICATED IN:
pt w/ allergy; pregnant pt.; bleeding
Nursing Alert: a. b. c. d. e. keep pt NPO; assess pt for allergy; monitor for si
gns of bldg; inc oral fld intake to excrete dye; keep epinephrine and or benadry
l at bedside for emergency
LUMBAR PUNCTURE
aspiration of CSF for assessment to check for infection or hemorrhage
position:
DURING : fetal or C-position AFTER : FLAT to prevent spinal headache
Needle is inserted between L3 and L4 or L4 and L5 Increase fluid intake after.

CSF ANALYSIS Assess for the characteristic of CSF. N amount: 100-200 ml Characte
ristic : Clear w/ glucose, Na and H2O

If REDDISH hemorrhage If Yellowish infection Ear licking w/ fluid test if (+) gl

ucose bec. CSF has glucose.
MYELOGRAM test for presence of slip disc or herniated nucleus porposus (HNP).
ALERT:
Know the type of dye use: a. water based called AMIPAQUE b. oil base called PANT
OPAQUE
type of dye will determine the position of pt AFTER the procedure.
If wat
er based, the HEAD OF BED ELEVATED; If oil based, FLAT after Rationale for both
oil and water based dye is TO PREVENT the upward dispersal of dye w/c can cause
electrical meningitis (s/s includes: (+) seizure, headache)
IV. EENT
TONOMETRY to measure IOP (N 12-21) - painless but w/ local anesthesia
ACUTE GLUACOMA : 50 yo and above CHRONIC GALUCOMA : 25 yo
CALORIC STIMULATION TEST test the presence of Minierres Dses (inner ear) involves
introduction of warm and cold water then NOTE FOR NYSTAGMUS jerky lateral movem
ent of the eye.
SEVERE NYSTAGMUS NORMAL MODERATE NYS - Minierres Dses NO NYSTAGMUS - Acoustic Neu
roma
GONIOSCOPY to differentiate OPEN and close angle galucoma;

non-invasive, painless RINNES TEST

WEBER TEST
To determine lateralization of sound; To determine air and bone conduction If pt
hears vibration better in GOOD EAR, Place tuning fork 2inches from the ear Prob
lem would be SENSORINEURAL LOSS; place at mastoid bone or in teeth then. if pt he
ar better in POOR EAR, - refers to if AIR CONDUCTION is LONGER, therefore CONDUC
TIVE HEARING LOSS SENSORINEURAL HEARING LOSS; If BONE CONDUCTION IS LONGER, ther
efore CONDUCTIVE HEARING LOSS
V.
GASTRO INTESTINAL TRACT
UPPER GI SERIES (Barium Swallow) xray visualization with contrast medium - Contr
ast Medium: a. Gastrografin water soluble, use straw b. Barium - swallow milk sh
ake like (use feeding bottle of pt) - then pt is ask to assume different positio
ns to distribute dye @ esophagus purpose: to detect disorders of esophagus feces
: chalky-white after: instruct pt to take laxative to excrete dye

BARIUM ENEMA (for Lower GIT) involve rectal installation of barium; there is bal
loon catheter inserted @ anus then barium is instilled and pt is asked to roll-o
ver at different position then xray is taken to detect: hemorrhoids, diverculosi
s, polyps and lesions; after, give laxative to excrete dye (bec dye is constipat
ing) instruct also patient to inc oral fld intake
-

GUAIAC TEST to detect the presence of bleeding and inflammatory bowel condition
like CANCER;
(this can be refrigerated awaiting laboratory)
specimen : stool
AVOID the following 3 days B4 the test bec it can yield to FALSE (+) RESULT : Re
d Meat, Fish and Horse Radish

CHOLANGIOGRAPHY

visualization of biliary tree

(includes, hepatic duct & common bile duct) same with CHOLECYSTOGRAPY but medium
given orally;
with contrast medium w/s is given thru IV ALERT: assess for allergy (epinephrine
/benadryl) Post procedure: inc. oral fld intake
to facilitate excretion of dye

GASTRIC ANALYSIS analysis of gastric secretion like HYDROCHLORIC ACID Lower Leve
l N : 2-5 meq/hr Upper Limit N: 10-20 meq/hr
UPPER LIMIT YPES a. WITHOUT TUBE (tubeless gastric analysis)
using DIAGNEX BLUE (specimen: urine); if urine colors turns BLUE, therefore (+)
HCL Acid; if urine (-) blue color, therefore (-) HCL Acid
if (-) HCL Acid at stomach (achlorhydia), therefore Gastric CA; if Increase HCL
Acid therefore ZOLLINGER-ELLISON SYNDROME (+) Gastric Tumor
b.
WITH TUBE with the use of NGT then aspirate

ULTRASONOGRAPHY upper abdl USG to detect abnormalities in the upper abdl area w/
includes biliary tree and Upper GI; painless; gel at abdomen and pt is NPO

LIVER BIOPSY aspiration of sample tissue from the liver to detect: Hepatic CA an
d Cirrhosis; ALERT: Check for Bleeding Time (N 1-9 mins) and Clotting Time (N 10
-12 mins) because liver is highly vascular organ WHEN NEDDLE IS INSERTED tell pt
to: Inhale then Exhale then Hold Breath to stabilize liver position Position af
ter : R side-lying position Things to report: s/s of SHOCK inc PR, dec BP Check
v/s
-

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) to visualize common bile d

uct and pancreatic duct; invasive (+) consent;

NPO tube insertion; Tell pt that tere will be feeling of soreness a wk after the
procedure

COLONOSCOPY visualization of colon to detect: inflammatory bowel condition Chrons

Dses Diverticulitis Hemmorhoids Tumor Polyps
- (+) Consent - NPO b4 - clear liquid diet 2days b4 the procedure position: Late
ral or side lying position or L Lateral Sims
VI. ENDOCRINE
GLUCOSE TOLERANCE TEST
to provide measure of bld sugar level at blood; Inform pt
to have high CHO diet 2 days b4 the test; Instruct NPO a day b4 the test (npo p
ost midnoc); Inc sugar level, therefore Diabetes
ACTH STIMULATION TEST to detect presence of Addisons Dses specimen: blood pt is g
iven dose of ACTH (not nore than 40ug/dl) if still dec despite ACTH administrati
on, therefore Adrenal Insufficiency Addisons Dses

DEXAMETHASONE SUPRESSION TEST to detect endogenous depression depression resulti

ng thru endocrine disorder pt is given dexa then 24hr urine specimen is collecte
d; a dose of dexa will suppress the release of adrenal hormones; if despite dexa
administration still increase adrenal hormones, therefore pt is suffering depre
ssion

17 KETOSTEROID & 170 HCS use to detect the presence of Addisons & Cushings Dses.

Addisons dec secretion of ketones Cushings ince secretion of ketones Specimen: 24

hr urine

VANILLYLMANDELIC ACID TEST VMA Test bi-product of CATHECHOLAMINE Metabolism

epinephrine norepinephrine
inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla
N 2-7 mg/dl / 24hrs if inc, therefore tumor AVOID: vanilla containing food 3 day
s b4 test
RAIU pt is given iodine 131 then after 24hr followed by a thyroid scan
inc indicates hyperthyroidism, dec hypothyroidism AVOID: iodine rich-food (sea
foods, sea shells, sea weeds) 7-10 days b4 and to include other diagnostic proce
dures that uses contrast medium (NO - angiogram test). bec it may yield to false (
-) result. SULKOWITCHS TEST detect amount of calcium excreted at urine; if to tes
t for hypercalcemia and hyperthyroidism - gather specimen b4 meals; to test for
hypocalcemia and hypothyroidism gather after meals ice cream, coffee, chocolates

VII. R E NA L
URINALYSIS examine the gross characteristic of the urine
urine amount : 30-60ml/hr color : clear, amber s. gravity : 1.010 1.025
abnormality: lower than 1.005 diabetic insipidus higher than 1.030 diabetic mell
itus (+) glucose infection, DM (+) CHON - PIH, kidney dses. Urine maybe refriger
ated if waiting to be examined.

CULTURE & SENSITIVITY to detect infection prepare storage container

KUB xray of the kidneys, ureter and bladder - NO SPECIAL PREPARATION NEEDED
IVP
- xray of the kidneys, ureter and bladder - uses contrast medium/ dye - assess f
or allergy, then inc. oral fld intake after - benadryl or epinephrine at bedside
for allergic rxn - NPO POST MIDNOC, cleansing enema in AM

CYSTOSCOPY visualization of urinary bladder after : monitor I & O; note for s/s
of bleeding

RENAL BIOPSY aspiration of tissues at kidney for biopsy to detect: a. malignancy

/ Ca b. malignant HPN c. kidney disorder note for s/s of bleeding
-

CYSTOURETROGRAM to check the patency of the ureter and bladder; monitor I & O

CYSTOMETROGRAM to evaluate the sensory and motor funx of bladder; to check if bl

adder respond to distention after installation of flds; monitor I & O
VIII. MUSCULO-SKELETAL
ELECTROMYOGRAPHY to detect electrical activity of the muscle; (+) consent; to al
ternately contract and release the muscle as needle is inserted HOLD muscle rela
xant b4 the test

ARTHROCENTESIS aspiration of fluids at synovial space to detect abnormalities; c

heck for order of analgesic; apply cold pack

ARTHROSCOPY - visualization of joints - KEEP TORNIQUET, ICE PACK and ANALGESIC a

t bedside BONE SCAN detect rate of bone destruction or bone resorption for pt w/
osteoporosis; lie still during the procedure; PAINLESS AND NON INVASIVE

IX. MISCELLANEOUS
BONE MARROW BIOPSY
to check abnormalities at the b. marrow (eg. Leukemia) site :
ILEAC REST (+) consent assess for bleeding sand bag at bedside (post procedure)
for emergency use
SCHILLINGS TEST specimen: 24hr urine test for VIT B12 deficiency; for pt w/ PERNI
CIOUS ANEMEIA; pt is given oral VIT B12 then urine is collected, then NOTE for R
ATE of EXCRETION of VIT B12 (N less than 40%);
eg. If 100mg Vit b was taken 60mg shld retain at stomach and 40mg will be excret
ed.

URINE UROBILINOGEN
to detect HEMOLYTIC DSES
WITHOLD ALL MEDS 24hrs b4 the test B
ENCE-JONES PROTEIN detect presence of MULTIPLE MYELOMA (malignancy of plasma cel
ls); RELEASED by destroyed or damage bones

ROMBERGS TEST
check FUNX of CEREBELLUM;
inability to maintain posture
Swaying, therefore TUMOR at cerebellum)

stand erect, close eyes, and observe for

(if pt is

ERYTHROCYTE FRAGILITY TEST use to detect the rate of RBC DESTRUCTION in a hypoto
nic

solution
(RBC Lifespan: 120 days)
if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA (EX. SICKLE CELL)

HETEROPHIL ANTIBODY TEST detect presence of IgM w/c is related to Epstein Virus
infection
Epstein Virus Infection causative agent of infectious mononucleousis (kissing dse
s) mgt: AVOID SHARING of utensils and glass

LYMES DSES SEROLOGY detect presence of BORRELIA BURGDORFERI

dses. Treatment: tetracycline causative agent of lymes
TIPS FOR DIAGNOSTIC PROCEDURE
2 moths old infant suspected of brocholitis is treated with oxygen therapy. Whic
h result indicates
that tx was effective : 02 SATURATION OF 98%.
Pt is scheduled for liver biopsy. What shld the nurse instruct pt to do during n
eedle insertion? hold breath during the procedure upon insertion of the needle.
Staff nurse is observing a nurse caring for pt w/ cvp. W/c action of the nurse r
equire intervention?
touching the edge of the soiled dressing using clean gloves.
Pt undergoing ERCP important prep for nurse to make would be: keep pt NPO b4 the
procedure.
Pt w/ coronary angiogram, the catheter was inserted at the L femoral artery. w/c
intervention is
appropriate after the procedure: palpate the popliteal and pedal pulses.
In explaining to the pt about
will be visualize.
A mantoux
wing: in duration. w/c of the
zero level of the manometer is
the level of R atrium.

cystoscopy the nurse shld say : the bladder lining

test is (+) if the nurse assesses w/c of the follo
ff will yield an accurate reading of CVP: when the
at

w/c responses made by the pt indicates that he understands the procedure to be d

one in a CT scan:
a dye will be injected to me.
A pt is to have an upper GI series which statement shows that he understood the
instruction given
: I will drink the dye.
After liver biopsy, a potential complication: bleeding.
MRI is the primary diagn
ostic tool for multiple scelosis bec it promotes visualization of plaques
at the brain.

DAY 5 (8 Feb 2005)

PHARMACOLOGY
I. GENERAL CONSIDERATIONS ONLY RNs are allowed to administer (to include central
line) LPNs peripheral IV Line route; ELDERLY PT provide with memory aid PEDIATRIC
PT do not mix w/ milk (dosage depends on wt, age and size) For SIDE EFFECTS GI
symptoms (mostly) For AD. EFFECTS always consider bone marrow (leukocytopenia all
PENIA) 3 COMMON DRUGS with patients over 65 y/o a. LITHIUM if above 65 yo, dose
shld not more than 1.0mEq b. HALDOL if above 65 yo, dose shld not more than 6mg/
day c. MEPERIDINE if above 65 yo, shld not 50 mg II. TRANSCULTURAL ASIANS are st
oicism attitude MIDDLE EASTERNERS (they refuse meds if for the 1st time)
they expect meds during first contact w/ hx care provider
JEWISH no meds restrictions JEHOVAHS WITNESS do

ORIENTAL PAYLOAH (from mexico)

treatment for diarrhea; may cause lead toxicity

ECHINECEA - use to boost the immune system; - for pt. with cancer ST JOHNS WORT anti-depressant (it funx like MAO inhibitor); - do not give to pt taking MAO VA
LERIAN - sedative (used also as anti-anxiety agent) - adverse effects GI Irritat
ion GINGCO BILOBA - blood thinner; - use to enhance bld circulation; - for pt w/
alzeimers - CONTRAINDICATED to pt with bleeding disorders

COMMON CONTRAINDICATIONS for HERBAL MEDS:

NO HERBAL MEDS for pregnant client; NO HERBAL to lactating pt; NO HERBAL for tho
se with severe kidney and liver disorder
IV.
THE CHECK PRINCIPLE C HECKlassification (FOR WHAT?) ow will you know that he meds
if effective (evaluation) xactly what time are you going to give it lient teach
ing tips eys to giving it safely

Lactulose given to pt with hepatic enceph to dec ammonia absorption - s/e : diar
rhea ANTABUSE (dizulfiram) most appropriate time to take meds : after 12hrs of a
lcohol free. COGENTIN to prevent pseudoparkinsonism
(by decreasing muscle rigidity)

TETRACYCLINE - can cause staining of teeth, Photosensitivity (use sunscreen when

outdoors) LITHIUM shld have inc. fluid in the diet

III. DELEGATION AND DOCUMENTATION Document all medical admin record: The followi
ng CANNOT be delegated:
time, route, dosage and untoward reaction; treatment, administration, documentat
ion of meds

PSYCHOTROPIC
I. ANTIPSYCHOTIC
major tranquilizer; for SCHIZOPHRENIA (pt has EXCESS DOPAMINE); plays as treatme
nt to the symptoms NOT CURE to schizo meaning it modify the symptoms (target sym
ptom: to decrease dopamine) Haldol Chlorpromazine Clozapine (chlozaril) Olanzapi
ne (zyprexa) Risperdon BETS TO GIVE: after meals DOPAMINE neurotransmitter (faci
litate the transmission of neurons) In SCHIZO there in INCREASE NEUROTANSMITTER.
Signs & Symptoms: a. DELUSION FALSE BELIEF b. HALUCINATION - hearing sounds c. LO
OSENES OF ASSOCIATION shifting of topic CLIENT TEACHINGS:
Report ADVERSE EFFECTS
of ANTI-PSYCHOTICS which indicates agranulocytosis a. fever b. body malaise c.
sore throat d. chills hyperpyrexia and muscle rigidity this indicates NEUROLEPTI
C MALIGNANT SYNDROME (NMS)
drug of choice: Parlodel, Dantrium
ex.

Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM

a. mask-like face or expressionless face b. pill-rolling tremors c. cogwheels rig
idity or lead pipe rigidity
AKATHESIA restless leg syndrome (I feel as if I have ants in my pants) DYSTONIA Av
oid direct sunlight because meds photosensitivity Instruct pt to rise slowly to
avoid orthostatic hypotension

Check: CBC, BP, AST/ALT To prevent pseudoparkinsonism, administer ANTIPARKINSONI

AN agents
IA. DOPAMINERGICS - ANTIPARKINSONIAN
in schizo there is increase dopamine, therefore give antipsychotic to dec dopami
ne then dec dopamine causes pseudoparkinsonism. Therefore give dopaminergic.
ex.
L-Dopa Levodopa Levodopa-Carbidopa

Effective if decrease in tremors and rigidity within 2-3 days; When to give: AFT
ER MEALS; Health Teachings: a. dietary modification: AVOID CHON and Vit B6 - bec
it decreases drug absorption b. check for ORTHOSTATIC HYPOTENSION and PALPITATI
ON; c. check BP and PR
IB. ANTICHOLINERGIC
decrease ACETYLCHOLINE
ex. Benadry Cogentin
AFTER MEALS;
Health Teachings:

effective: if decrease tremors and rigidity; when to give:

a. b. c. d. e. f. g.
side effects: blurred vision (no driving); dry mouth suck on ice chips or hard c
andy; palpitations check PR; constipation inc. roughage at diet; urinary retenti
on NOT urinary frequency decrease BP rise slowly check BP, PR, ECG
II. ANTI-ANXIETY
minor tranquilizer decrease Reticular Activity System center of wakefulness
ex. Valium, diazepam, Librium, Tranxene
Effective:
Decrease Anxiety, Decrease Muscle Spasm Promote Sleep
(to pt w/ traction)

B4 MEALS
because food delays absorption
HEALTH TEACHINGS:

a. report ADVERSE EFFECT: PARADOXICAL REACTION opposite of side effects b. Dange

r of Dependency c. AVOID: Caffeine, Alcohol it increase the depressant effect of
the drug d. check RR it causes respiratory depression e. administer VALIUM sepa
rately because it is incompatible with any drug use different syringe.
III. ANTI-DEPRESSANT/MANIC
a. b. c. d. TRICYCLICS MAO STIMULANTS SSRI
PATIENT with DEPRESSION there is DECREASE norepinephrine and serotonin
A.
TRICYCLICS
prevents the reabsorption of norepinephrine.
Ex. Tofranil, Elavil
Effective:
If adequate sleep (8hrs only) Increase appetite AFTER MEALS
Best given:
Hx Teachings:

The INITIAL EFFECT 2-3 wks after FULL THERAPEUTIC EFFCET 3-4 wks ONSET EFFECT in
a WK AVOID : juice because an acidic medium decrease absorption of drugs REPORT
PALPITATION and TACHYCARDIA and ARRYTHMIAS adverse effects of
TRICYCLICS

CHECK BP and ECG

B.
MAO INHIBITOR (MonoAmine Oxidase)
prevents the destruction of NEUROTRANSMITTERs ex. Parnate, Nardil and Marplan
Effective
: if INCREASE SLEEP and APPETITE
Give AFTER MEALS
Hx Teachings:

AVOID TYRAMINE CONTAINING FOOD

(1 day before FIRST DOSE and 14 days AFTER LAST DOSE)

Avocado, banana, cheese (cheddar, aged and swiss) COLA, CHICKEN LIVER SOY SAUCE
RED WINE PICKLES
ALLOWED: cheese cottage and cream, FRESH MEAT, VEGETABLES
Check BP the drug can cause HYPERTENSIVE CRISIS
occipital headache my nape is aching
2 WKS INTERVAL when shifting ANTI DEPRESSANT
to avoid HYPERTENSIVE CRISIS ex . after MAO 2 wks rest then can give ST JOHNS WOR
T
C.
STIMULANTS
(Ritalin, Dexedrine and Cylert)
directly stimulates the CNS.
Effective:
Increase Appetite and Adequate sleep
Best to Give: AFTER MEALS
if b4 meals, it suppresses the appetite; give NOT BEYOND 2pm bec. it causes INSO
MNIA 6 Hrs b4 bedtime; shld be given in the morning to avoid INSOMNIA
COMPLICATIONS:
growth suppression
Hx Teachings:

provide intervals or intermittently to avoid growth suppression; check BP and PR

D.
SSRI
(selective serotonin reuptake inhibitor) Ex. ZOLOFT, Prozac
Adverse effects: s/e:
DECREASE LIBIDO and Impotence
GI
III.1 ANTIMANIC
Lithium (lithane, lithobid, escalith)

Tegretol

Depakine/ Depakote

A. LITHIUM
it alters level of neurotransmitters effective if DECREASE HYPERACTIVITY give AF
TER MEALS Hx Teachings:
diet: High Na (6-10 gms) and High Fluid (3-4L)
N Na 3 gms, N fluid intake 3L Basically, Lithium is a salt
Report the ff s/s (NAVDA) Nausea Anorexia Vomiting Diarrhea Abdl Cramps
Report also:
FINE HAND TREMORS progressing to COARSE HAND TREMORS, THIRST and ATAXIC - sign o
f LITHIUM TOXICITY Dug of
choice: MANNITOL DIAMOX
Hx Teachings:

Avoid activity that increase perspiration Na & H2o; Avoid caffeine; Monitor lith
ium level Frequency of Lithium monitoring: ONCE A MONTH;
(specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the
last dose)
NORMAL LITHIUM LEVEL:
ACUTE DOSE Below 65 yo Above 65 yo .5 1.5 mEq/L .6 1.0 mEq/L
MAINTENANCE DOSE
.5 1.2 mEq/L .4 - .8 mEq/L
Lithium is effective with 10 14 DAYS before it will reach its therapeutic level.
CONTRAINDICATION OF LITHIUM: Pregnancy; Lactating; Kidney disorder
- if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DE
PAKOTE tegretol a/e : alopecia dopakine/ depakote - gingivitis
ANTICONVULSANT (Tegretol and dilantin)
for seizures, wherein there is abnormal discharge of impulse in the brain action
: IT INHIBITS the seizure focus and discharge

effective: if (-) seizure given BEST AFTER MEALS

(except for sedatives- like valium) MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AF
TER MEALS TOO.
NSG ALERT: Check : Report GINGIVITIS; Report S/S of Bone Marrow Depression pancy
topenia (dec RBC & WBC); Instruct pt to use SOFT BRISTTLED TOOTHBRUSH; Instruct
pt to MASSAGE GUMS and frequent oral hygiene CBC due to pancytopenia RBC, WBC an
d Platelet label
CHOLINESTERASE INHIBITORS
For MYASTHENIA GRAVIS For ALZEIMERs DSES
: Prostigmin (long acting) and Tensillon : Cognex (tacrine) and Aricept
(short acting)
Myasthenia Gravis there is decrease or absence of Acethylcholine (ACTH)
ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contrac
t/move.
Therefore, the drug is given to inhibit cholinesterase in destroying ACTH
(so, if dec cholinesterace and inc. ACTH, good muscle contraction)
PROSTIGMIN long acting for treatment TENSILLON short acting only for 5 mins.
it increase muscle strength in 30 seconds (therefore, if muscle weakness disappe
ar within 30 seconds it is MYASTHENIA GRAVIS)
Drug Action: Increase muscle strength (ex. Increase chewing ability or able to c
hew food forcefully) GIVE B4 MEALS or any activity; Meds is FOR LIFE; Report s/s
of HEPATOXICITY RUQ pain of abdomen and JAUNDICE
Antidote: ATSO4 it reverses the effect of anticholinesterase Check for LIVER FUN
X TEST; Keep at bedside: endotracheal tube for resp. problem
ANTICOAGULANT
HEPARIN
For ACUTE CASES of Manic Case Antidote: PROTAMINE SO4 Given SubQ (Lower Abdl Fat
)
COUMADIN
FOR MAINTENANCE or Chronic CASE Antidote: VIT K Oral
LOVENOX
Heparin Derivatives Antidote same w/ Heparin

Effective if (-) clot Give same time of day Report s/s of bleeding : Hemoptysis
Hematemesis
Onset: 2-5 days (maintenance case) Check PT (N 11-13 sec and INR 24 sec)
HEPARIN: AVOID green leafy vegetables bec it is rich in Vit K and will counterac
t the effect of anti coagulant. Therefore, diet of patient no appropriate. NSG A
LERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD INR refer
s to the upper limit of meds from N value to the maximum dose
COAGULATION PROCESS: Vitamin K dependent clotting factors
thromboplastin PRO THROMBIN
THROMBIN
COUMADIN HEPARIN
FIBRINOGEN
FIBRIN (CLOT)
COUMADIN act as vit k dependent clotting factors HEPARIN
converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN
- RAPID ACTING :onset : 24 48 hrs
Coumadin and Heparin
NOT to dissolve clot (only as THROMBOLYTIC meaning it prevents ENLARGEMENT and F
ORMATION of CLOTS) can be given together
ANTIARRYTHIMICS
Ex. Quinidine (quinam)
Side notes:
Characteristics of HEART MUSCLE: a. CONDUCTIVITY ability to propagate impulses;
b. AUTOMATICITY - ability of heart to initiate contraction; c. REFRACTORINESS ab
ility of t heart to respond to stimulus while in the state of contraction; d. EX
CITTABILITY - ability of the heart to be stimulated
Inotropic effect - force of contraction or strength of myocardial contraction; C
hromotropic Effect conduction of impulses; CHRONOTROPIC Effect - rate of contrac
tion
ANTIARRYTHMIC (quinidex, pronestyl) repolarization resting phase (k goes out)

depolarization stimulating phase (Na goes in) (therefore the depolarization and
repolarization of heart muscle depends on Na and K pump.)
K once it increase or decrease, it affects the repo and depo of heart muscle whi
ch causes arrhythmia. And so, to maintain the balance in the Na and K pump give
antiarrythmia because it decreases the automaticity of the heart. Antiarrythmia
is effective if (-) arrhythmia; Give meds anytime;
Health teachings: a. report CNS confusion, ataxia and headache GI - nausea, anor
exia and vomiting b. RASH therefore SKIN TEST FIRST c. REPORT s/s of QUINIDINE T
OXICITY tinnitus, hearing loss and visual disturbances d. check pt PR and ECG wa
ves, rate and rhythm
QUINIDINE
PROCAINE
LIDOCAINE
Ventricular arrythmia
For VENTRICULLAR & ATRIAL Fibrillation
CARDIAC GLYCOSIDES
increase force of contraction; affects the automaticity and excitability of the
heart muscle; K shld be monitored when in this meds therapy
(The heart contraction is regulated by Na and K pump. If K decreases, Calcium en
ters and it will result to a more increase force of contraction due to Na and Ca
pump conversion.)
Effects: (+) INOTROPIC strengthen the force of contraction (-) CHRONOTROPIC decr
ease rate of contraction
DIGOXIN
EFFECTIVE : ACTION it increase FORCE OF CONTRACTION : onset : 5 20 mins same
DIGITOXIN
same 30 mins 2hrs
Give after meals due to GI irritation
CLIENT TEACHINGS:

Report s/s of TOXICITY : NAVDA

Xanthopsia
yellowish vision or greenish halos;
Check PR if BELOW 60/min (adult) HOLD next dose; if BELOW 70/ min (older child)
HOLD; if BELOW 90- 110 (infants) HOLD next dose EXCRETION Digoxin kidney monitor
renal funx test (BUN & Crea) report if inc;

Digitoxin liver AST/ ALT DIGIBIND antidote for digoxin (lanoxin)

THERAPEUTIC LEVEL:
a. Digoxin b. Digitoxin
: .5 2 ug/L : 14 26 ug/L
NITRATES (nitroglycerine)
EFFECTS:
dont give if pt taking VIAGRA it will result to FETAL HYPOTENSION dilatation of c
oronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTER
LOAD.
Decrease in Preload decrease in the amount of blood that goes to the LV; AFTERLO
AD amount of resistance offered by blood vessels that heart shld overcome when p
umping blood

Effective if NEGATIVE ANGINAL PAIN; Give BEFORE any activity; Administered SUBLI
NGUALLY (+ burning sensation indicates drug is potent) NO WATER because it
will dilute the meds;
DOSES: 3 doses at 5mins interval; Report if there is persistence of pain; Check
BP and PR; Keep meds in dark container (bec light dec potency); Once the bottle
is open, use the meds within 3-6 mos
DO NOT REPORT THE FF: (expected s/s) Hypotension, Headache, facial flushing why i
s my face red?
MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY)
Ex. Mucomyst it decreases the viscosity of secretion; give meds anytime; client
teaching: meds can be diluted w/ NSS or cola;
Side effects: NAV + Rashes
if no side effects, repeat dose in 1 hr
BRONCHODILATORS (ex. TERBUTALINE brethine)
dilates the bronchioles or airways; effective: if (-) bronchospasm; GIVEN in AM
to decrease insomnia

REPORT THE FF: insomnia, tachycardia, palpitation-PR, + NAV

Theophylline - N 10-20; - for ACUTE ATTACK and PREVENTION of ASTMA
EXPECTORANT
(robitussin)
stimulates productive coughing; effective : (+) COUGHING & SECRETIONS give ANYTI
ME; sideffects: NAV + DIZZINESS or drowsiness avoid activity that required alert
ness (ex. Driving)
ANTIBIOTICS
bactericidal; effective: (-) infection; give ON EMPTY STOMACH B4 MEALS; Hx teach
ings: REPORT rash, urticaria and STRIDOR indicates airway obstruction; side effect
s: NAVDA + GI Irritation
I. PENICILLIN : antidote is EPINIPHRINE II. AMINOGLYCOSIDE (gentamycin) effectiv
e: (-) infection give B4 meals; report the ff:
OTOTOXICITY: I hear ringing in my ear NEPHROTOXICITY : oliguria NEUROTOXICITY : seizu
res
III. check BUN, CREA (kidney funx test); check I & O (sign of nephrotoxicity) ANTINEO
PLASTIC (adriamycin) for breast and ovarian CA; effective: (-) tumor size; GIVE
IN ARM to prevent HEMMORRHAGIC CYSTITIS Hx Teachings: a. inc oral fluid intake (
2-3L/day) cytotoxic prevention; b. monitor kidney funx I & O;
THYROID AGENTS (synthroid, cytomel)
for HYPOTHYROIDSM; effective: if Inc in T3 and T4 and NORMAL SLEEP; pt always sl
eep, therefore give meds in AM to avoid insomnia; REPORT HE FOLLOWING: insomnia,
nervousness; palpitations Take meds LIFETIME (same w/ meds 4 neuro); Check HR,
PR and kidney funx test;
ANTITHYROID
(PTU, LUGOLS SOLUTION)

For GRAVES DISEASE or HYPERTHYROIDISM; Effective: Decrease in T3 and T4 (in lab d

ata); Give round the clock; a. Report sore throat, fever, chills, body malaise b
ecause meds cause AGRANULOCUYTOSIS; b. Report lethargy, bradycardia, and INCREAS
E SLEEP indicates that pt is having HYPERTHYROIDISM; c. Diarrhea with metallic t
aste sign of IODINE TOXICITY
Health Teachings:
ANTIDIABETICS
(INSULIN)
effective: N Blood sugar (80-120) for DM Type 1 (insulin dependent); give in AM
b4 meals; check: a. instruct S/S OF HYPOGLYCEMIA dizziness/ drowsiness difficult
y in problem solving decrease level of consciouness cold clammy skin b. monitor
the blood sugar level in early AM and supper time

INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR. PEAK OF
ACTION (refers to when patient becomes HYPOGLYCEMIA) REGUALR INSULIN - lunch ti
me Intermediate - late in the afternoon B4 dinner Long Acting - B4 Breakfast
SULFONYLUREAS
(Orinase)
for DM type 2; stimulate pancreas to produce insulin; effective N bld sugar leve
l; give b4 meals regularly; teachings: a. s/s of hypoglycemia; b. monitor renal
funx test; c. antidote for hypoglycemia ORANGE JUICE
(amphogel, tagamet)
ANTACIDS
ALUMINUM HYDROXIDE GEL antacid and it also dec phosphate level in pt renal failu
re; Effective: dec phosphate (-) pain give on EMPTY STOMACH (1 hr b4 or 2hrs aft
er meals); instruct pt to REPORT: muscle weakness in lower extremities indicates
HYPOPHOSPATHEMIA administer with glass of water; check phosphate level and rena
l funx test; assess for constipation

LAXATIVES (dulcolax)
Colace Metamucil Dulcolax Lactulose stool softener - bulk forming - rapid acting
- 15-30 mins
effective : (+) BM; give AT HS (if NOT diagnostic procedure); give AFTER MEALS fo
r dyspepsia; meds is given in short duration only because of dependency teaching
s: a. b. c. d. e. be near or stay near CR; s/e: diarrhea; NO lactulose for pt w/
diarrhea; Causes hypokalemia therefore check electrolytes Increase fld intake t
o avoid dehydration
DIURETICS
Target Organs a. Diamox exerts effect at Proximal Convuluted Tubules; b. Lasix a
t Loop of Henle; c. Diuril at Distant Con. Tubules LOOP DIURETICS (lasix) - effe
tctive: incrase urine output; - give in morning to prevent nocturia; - teachings
: a. monitor for hypokalemia level and I & O; b. report muscle weakness; c. give
K rich food banana, orange THIAZIDE (diuril) give in AM; monitor for hypokalemi
a; check I & O, K level, PR and BP
K-SPARRING (triamterene, aldactone) effective: inc. urine output; give in AM; te
achings: monitor for HYPERKALEMIA check PR and K
ANTIGOUT

PROBENECID
COLCHICINE
ALLOPURINOL
- URICOSURIC - for ACUTE GOUT - for CHRONIC GOUT - promotes excretion of uric ac
id - has anti-inflammatory effect by - prevents or dec formation preventing depo
sition of u.acid of u. acid @ joints - s/effects: NAV + - NAV + Bldg and Bruisin
g - dizziness/drowsiness Hypersensitivity agranulocytosis (check CBC) - ONSET: 8
-12 wks - ONSET: 1-3 wks
TEACHINGS: a. Increase ORAL FLUID INTAKE; b. Monitor uric acid levels;
MIOTICS (timoptic, piloca)
DECREASE IOP (N12-21) for pt w/ glaucoma; Give ANYTIME but for LIFETIME; Teachin
gs: a. it causes blurring of vision and brow pain; b. administer meds at lower c
onjunctival sac; c. press the inner canthus for 1-2 mins to prevent systemic sid
e effects (hyperglycemia and hypotension)
MYDRIATRIC
(AK-Dilate)
effective: pupillary dilatation; give ANYTIME (but if pt for surgery, give b4);
teachings: may cause blurring of vision
lower conjuctival sac
CARBONIC ANHYDRASE INHIBITORS (diamox)
for GALAUCOMA lifetime; to decrease production of acqueous humor; effective: N I
OP and Inc. urine output; effective to pt with MENIERES DSES dec vertigo teaching
s: a. check urine output; b. report: s/s of dehydration bec of diuretic effect c
. blurred vision d. monitor I & O and IOP
ANTI-ACNE (acutane, retin-a)
decrease sebaceous gland size; given in AM to prevent insomnia; avoid sunlight:
photosensitivity pregnancy: fetotoxic - therefore check if pt is pregnant; check
if pt has skin irritation may burn the skin
TOCOLYTICS (Yutopar, MgSO4)
relax the uterus; drug of choice for pre-term labor; effective: (-) pre-term or
relaxed uterus;

give: ORAL B4 meals and IV anytime; teachings: a. signs of Ca Intoxication: hypo

tension, hypothermia and hypocalcemia b. check bld pressure; urine output (N 30m
l/hr) c. check RR at least 12/min d. check patellar reflex shld be (+) knee jerk
HOLD if RR 10/min and urine output: 15ml/hr Antidote: Calcium Gluconate
OXYTOXIC
PITOCIN METHERGIN
To induce labor To prevent post partum hemorrhage Effective: Firm and Contracted
Uterus Give anytime If IV, use piggy back Teachings: a. REPORT the ff: HYPOTENSIO
N (due to inactivation of ANS neurological effect of drug); b. Headache c. Hyper
tension (cardiovascular effect of the drug) d. Check BP, Uterine Contraction esp
ecially the duration N 30-90 sec - report if beyond 90 sec sign of uterine hyper
tonicity e. Check Force, Duration and Frequency of Uterine Contraction
PROSTAGLANDIN (cytotec, E2gel)
anti ulcer drug to dec gastric acidity; decrease ripening of the cervix w/c lead
s to effacement then dilatation then abortion; give after meals; assess for diar
rhea and gastric irritation; check for pregnancy bec it may cause abortion

TIPS ON PHARMACOLOGY
Patient receiving DIAZEPAM, the nurse notice that there is no change in patient
behavior. What shld the nurse do? VERIFY THE PT DIET
COGNEX given with AZEIMERSS
DSES to increase mental functioning Pt w/ PVC : bedside : XYLOCAINE Pt w/ COMPLE
TE HEART BLOCK: give ATSO4 it increases HR Pt w/ DIVERTICULITIS (pt has diarrhea
) the ff meds were given: what meds the nurse shld question : LACTULOSE Morphine
S04 given to pt with Pul. Edema to decrease anxiety Pt ask the nurse on why she
will take COUMADIN when shes already taking HEPARIN Heparin is given for ACUTE
CASES while Coumadin for maintenance Pt on CHEMOTHERAPY complains of nausea and
vomiting, w/c meds can be given ZOFRAN Expected side effects of STEROIDS : wt ga
in, obesity and Inc appetite Pt is taking LEVODOPA observe for URINARY RETENTION
ADREAMYCIN causes hemorrhagic cystitis DESMOPRESSIN ACETATE administered INTRAN
ASALLY FESO4 shld be given w/ orange juice ASPIRIN I s given to pt w/ TIA to dec
rease platelet aggregation Pt taking ANCEF observe for skin rashes Pt to receive
NPH at 7:30am, the nurse shld expect for hypoglycemia LATE in the AFTERNOON

TYPES OF PRECAUTION
P AIDS
(universal) x
H
yes
GL
yes
GW
yes
M
yes
DIARRHEA HEPA B C MRSA
(enteric)
x
yes
yes
x
x
A
(enteric) x x
x yes yes
yes yes yes
yes yes yes
x yes yes
x
(universal) (universal)
(contacts) (enteric)
yes x
yes yes
yes yes
yes x
yes x
MENINGITIS/SEPTIC SCABIES TB
(contact)

yes
yes
yes
yes
yes
(tb Precaution)
yes
yes
x
x
yes
PEDICULOSIS
P private room H handwashing GL - gloves GW gown M - mask
(contact)
yes
yes
yes
yes
yes
AIDS universal Norwalk Virus respiratory Hepa A contact MRSA contact Scabies con
tact

Day 6 (Feb 9, 05)

D.I.S.E.A.S.E.S
(MEDICAL-SURGICAL NURSING)
GENERAL CONSIDERATION

Priority: Oxygenation The disorders result as alteration in the function of HEAR
T (pump), BLOOD (transport mechanism of oxygen, nutrients, hormones & CO2) and B
LOOD VESSELS (passageway).
PEDIATRIC CONSIDERATION
a. all factors necessary for appropriate cardiovascular functioning are present
at birth EXCEPT VIT. K (w/c is produced by intestinal mucosa); b. there are stru
ctures which are present at birth that may alter the route of blood circulation
(present at birth: foramen ovale, ductus arteriosus, ductus venosus) c. note the
CARDIAC RATE of pediatric pt
(minimum $ y. children 90-110, older c. 70)
REPORTABLE S/S FOR ADULT
Palpitation, Pain and Paroxysmal Nocturnal Dyspnea For pediatric patient: observ
e for PALLOR if (+) indicates ANEMIA for baby Nocturnal dyspnea diff. of breathi
ng at night Paroxysmal ND when pt feels as if hes drowning
HEART SOUNDS:
S1 - normal lubb S2 - -do- dub
in assessing S1 & S2 use BELL of steth
(ABNORMAL for adult pt it indicates CHF or Aortic Stenosis)
S3 - N for Pediatric pt
Steth - BELL for LOW PITCH SOUND (ex. Murmur) Diaphragm for HIGH PITCH SOUND

SHOCK
mp: decrease in circulating blood volume TYPES
CARDIOGENIC pump failure (CHF, MI
, Atherosclerosis Heart Dses, Mitral Valve Dses) HYPOVOLEMIC - related to fluid
loss (pt w/ open wound, traumatic injury, burn) ANAPHYLACTIC - cause by allergic
reaction (laB procedure w/ dye, asthma, poison) NEUROGENIC - caused by vasomoto
r collapse
(vasomotor located @ medulla oblongata w/c is responsible for dilatation & const
riction of bld vessels)

SEPTIC due to systemic infection

(ex. Septicemia)
TRIAD SYMPTOMS OF SHOCK a. Altered level of consciousness b. Hypotension; c. Tac
hycardia and Tachypnea
(dec bld circulation result to dec o2 in the brain);
Patient in shock- there is also (+) pallor and (+) oliguria due to dec bld circu
lation & narrowing of bld vessels Lab Data (to check bld volume circulation) che
ck HEMATOCRIT (N-35-45%) - check Urine Output - check CVP Nsg Dx: FLD VOLUME DEF
ICIT rel to dec in Circ Vol. Priority Intervention: Fld replacement
(D5Lr, NSS. Bld Trans for jehovas use plasma expander)
ANEMIA
MP: Decrease RBC due to decrease production or increase destruction Risk Factors
: Age Gender Surgery Secondary to existing medical condition (ex. Renal Failure)
Kidney produce erythropoiten that stimulates bone marrow to produce RBC
TYPES:
a. b. c. d. e. f.
Iron Deficiency Anemia (IDA) Pernicious Anemia (PA) Folic Acid Deficiency Anemia
(FADA) Sickle Cell Anemia (SCA) Aplastic/ Fanconis Anemia (AA) Talasemia Anemia
(TA)

IRON DEFICIENCY ANEMIA common in infants and children; characteristic of patient

: chubby but pale they are also called milk babies those baby 5 yo but still takin
g milk
(milk are poor source of iron)
MP: Nutritional Deficiency S/S : Fatigue Fainting Forgetfulness Pallor, cold cla
mmy skin Dyspnea (due to dec RBC) Lab data: Decrease in HgB (N male: 14-18, Fema
le: 12-16)
Characteristic of RBC: HYPOCHROMIC & MICROCYTIC
Nsg Dx: Activity Intolerance Priority Intervention: a. Correct the deficiency by
administering iron supplements, - IRON RDA 15-30 mgs/ day eg. Oral FeSO4 (take
w/ orange juice) if ELIXIR use straw to avoid staining of teeth if IM (inferon) Z
track method
(for Z track IM PULL SKIN LATERALLY, deep IM, wait 10 seconds before pulling the
needle)

FeSO4 evaluate AFTER 4 weeks to check the effect b. Diet: iron rich food (organ
meat, dried foods, egg yolk iron, egg white CHON); c. provide patient with BED REST
due to fatigue
PERNICIOUS ANEMIA common in elderly; common in POST GATRIC SURGERY
(intrinsic factor the one that absorb vit b12)
Main Problem: Lack of INTRINSIC FACTOR at the stomach
In elderly, there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic fact
or S/S:
3F (fatigue, fainting, forgetfulness) Beefy Red Tongue or glossitis Peripheral N
europathy (tingling sensation at lower extremities usually both legs are affecte
d)

Lab Data: a. check Hgb b. SCHILLINGS TEST (24hr urine) c. RBC characteristic : MA
CROCYTIC & HYPERCHROMIC Nsg Dx: Activity Intolerance Risk for Injury due to p. n
europathy Priority Intervention: a. Correct the deficiency give Vit B12 b. Bed r
est due to fatigue
(IM, Once a month for lifetime);
FOLIC ACID DEFICIENCY ANEMIA common in infants, adolescents, pregnant, lactating
and overcooked food;
Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN S/S: all symptoms of
pernicious anemia EXCEPT P. NEUROPATHY Lab Data: HgB Folic Acid level (N 4mg/da
y) green leafy veg. (spinach) Nsg Dx: Activity Intolerance PI:
(NO RISK FOR INJURY coz NO P. NEUROPATHY)
Inc. folic acid in the diet g. leafy; Bed Rest
SICKLE CELL ANEMIA autosomal recessive hereditary presence of S or C shape Hgb due
to dec O2 N TRAIT TRANS
50% 25% 0 0 0 50% 50% 50% 100%
(SICKLING OF RBC)
STATUS
DSES TRANS
0 25% 50%
1 PARENT W/ TRAIT BOTH PARENTS w/ TRAIT I parent TRAIT, 1 DSES BOTH parents w/ D
isease
Risk Factors: Dehydration (dec in circ bld volume result in sickling of RBC); In
fections Conditions that lead to SHOCK S/S: 3Fs + Fever
(due to dehydration)
+ Pain + Jaundice Hepatomegally

Complications: a. Vasocclusive Crisis (hallmark of the dses)

- bld vessels obstruction by rigid and tangled cells w/c causes tissue anoxia an
d possible necrosis
b. Spleenic Sequestration Crisis c. Aplastic/ Megaloblastic Crisis

massive entrapment of red cells in the spleen & liver

bone marrow depression w/c resulted to DEC RBC, WBC & PLATELET
Lab Data: Sickledex Test (+) Turbid Solution Nsg Dx: Activity Intolerance Fld Vo
lume Deficit Pain due to vasocclusive crisis
PI:
Hydration and relief of pain (inc oral fld intake) Prevent dehydration Meds for
Pain Morphine SO4, acetaminophen Since HEREDITARY refer to geniticist
APLASTIC ANEMIA MP: Hereditary (there is DECREASE IN RBC, WBC & PLATELET) Autoso
mal Recessive S/S: 3Fs + Pallor + Dyspnea Risk for Infection (dec in RBC) Bleedi
ng (dec in Platelet) Lab Data: HgB, CBC, Clotting Factors Platelet, Bleeding & C
lotting time Nsg Dx: PI: Activity Intolerance (dec in RBC) Risk for Injury (dec
in WBC and Platelet)
Bld transfusion; Reverse Isolation; Genetic Counseling; Bed rest
THALASEMIA Risk Factors: Common in Blacks, Italian, Greeks, Chinese, Indians MP:
Hereditary Autosomal Dominant common in female and male There is a defect in po
lypeptide Chain of HgB ALPA and ETA Chain there is RBC destruction
Types: a. Minor Thalasemia Anemia mild anemia: 3Fs

b. Intermedia TA more severe anemia + Speenomegally Jaundice (inc deposition of

iron @ tissue) Hemosidorosis c. Major TA severe anemia + Spleenomegally Lab Data
: HgB Clotting and Bleeding Time Nsg Dx: PI : Activity Intolerance Risk for Inju
ry Bld Transfusion, IVF Dietary supplements of Folic Acid and Iron Surgery (last
resort)
LEUKEMIA
MP: proliferation of immature WBC Characterized by Remission and Exacerbation Ty
pes: a. LYMPHOCYTIC common in young children (proliferation of lymphocytes) b. M
YELOGENOUS adolescent and adult (proliferation of granulocytes) TRAID S/S: Anemi
a (initial) + 3Fs Bleeding Infection
Lab Data: WBC hyperleukocytosis (150 500,000K) expected NDx: Risk for Injury Act
ivity Intolerance Risk for infection Bed rest Avoid Contact Sports Reverse Isola
tion Blood transfusion Bone marrow transplant
PI:
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or WERLHOFS DSES
common in BLACKS; cause: idiopathic

unknown (viral and autoimmune) s/s: petechiae ecchymosis hemorrhage

(all signs of bleeding) (spontaneous bldg)
lab data: Platelet Count of less than 20,000
(N 150,000 450,000)
Nsg Dx: Risk for Injury Fld Vol. Deficit PI :
(due to bldg)
SAFETY prevent bleeding Give pt platelet, IVF and Bld Transfusion Corticosteroids
wonder drugs
HEMOPHILIA
inherited bldg disorder
TYPES: a. Hemo. A - deficiency in factor 8 b. Hemo. B - deficiency in Factor 9 c
. Von Willebrands Dses common in male and female HEMPPHILIA A and B - Autosomal R
ecessive Link
(from mother to male)
Von W Dses - Autosomal Dominant Mother and Father S/S: Hemarthrosis Hematoma Hem
aturia Hematemesis
bldg between joints that usually affects ankle, knee and elbow joints;
(above mentioned are signs of HEMORRHAGE)
Lab Data : PROLONGED CLOTTING TIME Nsg Dx : Risk for Injury PI : SAFETY then RIC
E
(REST, IMMOBILIZE, COLD COMPRESS, ELEVATE)
For JEHOVAHS use plasma expander (cryoprecipitate) instead
TIPS FOR BLOOD DISORDERS
If all of the ff data were obtained by the nurse, w/c one is MOST SUGGESTIVE of
CARDIOGENIC SHOCK - Inc. HRate from 84 to 122 bpm;

The nurse admitted a 4 yo child with SICKLE CELL DSES the priority for the patie
nt is HYDRATION;

w/c of the ff is TYPICAL for patient w/ ANEMIA - SHORTNESS OF BREATH ON EXERTION

; common manifestation of LYMPHOCYTIC LEUKEMIA is PETECHIAE; a mother of 15 mos
old child with IDA makes the ff comment. w/c one is related to child condition MY CHILD DRINKS 2 QUARTS OF MILK/DAY; a 7 yo boy with HEMOPHILIA was admitted. MA
NIFESTATION HEMARTHROSIS; w/c of the ff is EXPECTED

pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS. w/c of th
e ff shld the nurse instruct the pt to do - INCLUDE VEGS. AND MEAT in your diet
at least 1 meal a day;

w/c of the ff is the priority intervention for pt w/ IDA PROVIDE BED REST ALTERN
ATING w/ activities; w/c of the ff is indicative of thrombocytopenia - HEMATURIA

CARDIOVASCULAR PEDIATRICS
FETAL CIRCULATION
3 FETAL STRUCTRUES

PLACENTA
UMBILICAL VEIN
DUCTUS VENUSUS (functionally, closes at birth)
LIVER
UMBILICAL ARTERIES
Vena Cava
Right Atrium AORTA
FORAMEN OVALE (functionally, closes at birth) LA
R Ventricle
L VENTRICLE
LUNGS
LV
L ATRIUM
P. ARTERY
DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth) AORTA
Therefore, if these 3 fetal structures will not close, CONGENITAL HEART DISEASE
CONGENITAL HEART DISEASE
ACYANOTIC HEART DSES CYANOTIC HEART DISEASE
Dec Pulmonary Bld flow
Obstructive CHD
Decrease Pulmonary

Vent. Septal Defect (most common) Atrial Septal Defect Patent Ductus Arteriosus
Pulmonary Stenosis Aortic Stenosis Coarctation of the Aorta
Tetralogy of Fallot (most common) Transposition of the Great Vein Truncus Arteri
osus Tricuspid Atresia
Usually due to:
Maternal Infection measles, c. pox Age 40 and above Medical Conditions DM Alcoho
lism
Signs and Symptoms:
Difficulty feeding Retarded Growth Tachypnea/Tachycardia Frequent URTI ANS brow
seating (check for murmur)
Complication: CH Failure Lab Data: 2 D Echo
CVA
(due to plycythemia Inc RBC)
Nsg Dx: Altered Tissue Perfusion PI : Oxygenation Surgery
If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determ
ined; For 2-7 yrs old surgery is equal to child age ( ex 3yo, therefore prepare
the child 3 days prior to surgery) If > 7yo parents decision
PATENT DUCTUS ARTERIOSUS
connection problem : P Artery and Aorta machinery-like murmur (+) brow seating (+)
retarded growth (+) tachycardia/ tachypnea
LAB DATA : 2 D-Echo CVP

PExam Nsg Dx : Altered Tissue Perfusion PI : Oxygenation INDOMETHACIN

ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then SURGERY
TETRALOGY OF FALLOT
pulmonary stenosis, coarctation of aorta, right vent. Hypertrophy, vent septal d
efect boot-shape heart tet spell squatting w/ cyanosis
LAB DATA : 2 D-echo Complication : CVA check for RBC Count Nsg Dx : Risk for Inj
ury PI : Oxygenation Position the Pt. : SQUATTING Surgery
COARCTATION OF AORTA
Higher BP in the Upper Extremities and Lower BP in the Lower Ext.
Lab Data : BP, 2 D-Echo PI : Oxygenation Position the patient: Orthopneic or sem
i fowlers position
KAWASAKIS DISEASE
due to acute vasculitis (inflammation of bld vessels) of the heart; especially t
o JAPANESE children and toddler 5yo and below
S/S : High Spiking Fever for 5 Days Lymphadenopathy Strawberry Tongue Palmar and
Feet Desquamation

Lab Data : Nsg Dx :

No Specific Diagnostic test Check ECG Altered Tissue Perfusion Altered Thermoreg
ulation Altered Skin Integrity High CHON
Diet :
TIPS FOR CARDIOVASCULAR PEDIA
w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children dif
ficulty in feeding; w/c of the ff is an appropriate intervention for a child who
keeps on squatting because of Tetralogy of Fallot - if LESS THAN 1 yo flex lowe
r extremities towards the abodomen; a child who was brought in to a well baby cl
inic turns cyanotic while crying REFER to the physician; the BLD VESSELS INVOLVE
in PATENT DUCTUS ARTERIOSUS pulmonary artery and aorta; w/c of the ff data in m
other health history indicates a risk factor for congenital heart disease ADVANC
E AGE; when admitting a pt w/ suspected congenital heart disease, w/c interventi
on is priority decreasing the metabolic demand of the heart

CORONARY ARTERY DISEASE (CAD)

Main Problem :
NARROWING and OBSTRUCTION of Coronary Arteries which could lead to HYPOXIA rever
sible (which could further progress to ANGINA) and or ISCHEMIA irreversible (tha
t could progress also to devt. of SCAR
FORMATION that can lead to MI).
Risk Factors:
Family History Atherosclerosis Smoking Elevated Cholesterol HPN

Obesity Physical Inactivity Stress

CAD
HYPOXIA
ISCHEMIA
NECROSIS
ANGINA Myocardial Infarction jaw pain
this leads to decrease O2 and will result to the conversion of aerobic metabolis
m to anerobic thereby resulting to the production of LACTIC ACID that will stimu
late the nerve ending of the heart w/ will produce/ result to PAIN that is preci
pitated by: EATING Elimination due to valsalva manuever Exercise/effort/ exertio
n Emotion Extreme Temperature cool temp vasoconstriction sEx
PAIN
MTOCARDIAL INFACRTION

ANGINA
Pain confined at sternal area Pain that resembles pressure Relieved by rest & NITR
OGLYCERIN SAME
Precipitated by 6Es Pain that resembles indigestion, crushing, excruxiating Pain ra
diates to the L Jaw, L arm, L shoulder Relieved by SO4 Opiods (MORPHINE) Pain oc
curs AFTER MEAL (post cebum) or AFTER ACTIVITY

S/S of above mentioned + SHOCK s/s esp to CARDIOGENIC SHOCK w/c is due to PUMP F
ailure that leads to dec cardiac Output that leads further to CHF. SAME

ECG initial change is ST SEGMENT DEPRESSION w/

T WAVE INVERSION Increase CHOLESTEROL SAME HDL good or Healthy liver for metabolis
m 30-80 LDL - bad peripheral vascular system bld vessels- 60-80 CARDIAC ENZYMES #1
Myoglobin Troponin CK within 2-3 days LDH 1&2 within 10-14 days SAME

Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange

Priority : Airway (Oxygenation) Goal of CARE a. To decrease oxygen metabolic dem
and - position : SEMI-FOWLERS - administer O2 as ordered - administer meds: MI :
Morphine SO4 monitor RR, effective : (-) pain, ANTIDOTE : Naloxone HCL Narcan AN
GINA : Nitroglycerine dark container give b4 activity maximum of 3 doses, 5 mins
interval effective: tingling sensation, sublingual provide rest due to pain b.
Diet : Low Na and Low Cholesterol
HEALTH TEACHINGS:
Identify types of Angina:
Stable Angina predictable angina that occurs w/ activity; Unpredictable relieved
by Nitroglycerin; Variant/ Prinzmetal severe form of Angina; Nocturnal Angina o
ccurs at night; Decubitus Angina when pt is lying down Intractable Angina unresp
onsive to tx Post MI Angina
For patient with MI focus on complications :

a. PVC or PVBeats defibrillation/ cardioversion b. Ventricullar Fibrillation Lid

ocaine s/e rashes
CARDIOVERSION - synchronize - esp. for VTACH w/ PULSE DEFIBRILLATION - unsynchro
nized - for VTACH w/o PULSE

SEX for pt w/ MI resume if pt tolerate 2-3 plights of stair w/o pain; - take med
s b4 sex; - position during sex : passive let the girl do her share ACTIVITY adv
ised pt to have frequent rest period; DIET : avoid PROCESSED FOODS; MILK Salty S
ea Foods Pastries esp. yellow cake

FOR ANGINA APIN instruct patient to report pain that last more than 2o minutes (
indicative of MI);
Weak or absent PULSE indicative of VENTRICULLAR FIBRILLATION
Report NECK VEIN DISTENTION indicative of CHF complication Report BLEEDINGs espe
cially to pt on THROMBOLYTICS t-PA and Streptokinase
CONGESTIVE HEART FAILURE
main problem : PUMP FAILURE inability of the heart to pump an adequate amount of
blood to meet the metabolic demands of the body
how will the heart compensate?
The HEART will pump harder- Inc HR (tachycardia) that will result to enlargement
of the heart muscle (hypertrophy) w/c can lead to dilatation and congestion of
the cardiac muscles - thereby resulting to decrease in the cardiac output.
PUMP FAILURE EFFECTS:
Backward Effects : backflow of blood systemic congestion;
Forward Effects : decrease cardiac output dec in tissue O2 perfusion that leads
to overwork respiratory system
LEFT HEART FAILURE early signs of CHF Therefore, Right Heart Failure will be the
late signs of CHF as complication of LHF
Risk Factors to Heart Failure:
- Arrythmias - Coronary Dses & HPN - Renal Failure LEFT SIDED HF dyspnea and oth
er pulmonary s/s crackles

RIGHT SIDED HF systemic effect

distended jugular vein Ankle edema Ascites Hepatomegally
LEFTS SIDED HF
Lab Data : Swan Ganz PAP (N 20-30) PCWP (N 8-13) X-ray Nsg Dx :
RIGHT SIDED HF
CVP (N R 0-12, V Cava 5-12)
X-ray
Altered Tissue Perfusion Ineffective Breathing Pattern for LHF Fld Volume Excess
for RHF Oxygenation Position: Semi-Fowlers Administer: Digoxin absorb in GI Vaso
dilators Diuretics Morphine for CHF it causes pheriperal vasodilation by Decreas
ing the amount blood going back to the heart.
PRIORITY :
DIET : LOW Na NO PMS HEALTH TEACHINGS : a. Activity rest b. dietary counseling N
O PMS c. report s/s of complications
DIGITALIS D. Toxicity: yellow vision;
Muscl
e weakness (hypokalemia) that can lead to arrythmia
Dyspnea s/s of pulmonary ede
ma;
HYPERTENSION
MP : blood pressure higher than 140/90 (hypertensive state)
pre hypertensive phase
PREGNANCY INDUCED HPN
Elevation of BP that occurs after 20-24 (5 mos- age of viability) wks of gestati
on
120/80, therefore N BP : 110/70
Risk Factors:
if BP elevated B4 20-24 wks & cont after delivery CHRONIC HPN
Levels of PIH

Common in BLACKS; Obesity Stress Smoking

a. HYPERTENSIVE DISORDER OF PREGNANCY
- INC. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA)
b. PRE-ECLAMPSIA S/S + convulsion, Abdl pain & Headache PHASE c. ECLAMPSIA + Ble
eding = HELP SYNDROME
- ECLAMPSIA
TYPES:

a. b. c. d.
ESSENTIAL HPN cause unknown BENIGN usually of long duration, onset is CHRONIC MA
LIGNANT acute or abrupt onset, short in duration SECONDARY related to existing m
edical condition
HPN IN PREGNANCY usually related to generalized spasm of the arteries
PRE-ECLAMPSIA TYPES: a. MILD b. SEVERE BP 140/90, PROTENURIA is <5mg/hr (N - .51GM) BP 160/90, PROTENURIA is >5mg/hr
HEADACHE and ABDOMINAL PAIN s/s of ECLAMPSIA, indicative of impending convulsion
.
ECLAMPSIA + BLEEDING = HELP SYNDROME H emolysis E levated Liver Enzyme L ow P- l
atelet (All are signs of bleeding) S/S of HPN:
Headache Retinal Hemorrhage Edema above s/s can further lead to complications: C
oronary artery dses CHF Chronic Renal Failure CVA Blood Pressure Elevated Choles
terol For PIH : (+) Proteinuria, Inc BP and Inc Cholesterol
LAB DATA:
Nsg Dx:
Altered Health Maintenance Risk for Injury
PIORITY: How?
Stabilize BP
I. Non-Pharmacologic Features
Stress Management Deep breathing Diet : Low Na/ Ch
olesterol Position : if inc BP supine position
II. PHARMACOLOGIC MEASURES
Antihypertensive Diuretics Aspirin Antilipimic - simv
astatin & lovastatin give after meal nighttime Monitor liver Funx test meds abov
e are hepatotoxic

Pts w/ PIH meds: a. MgSo4 antidote is CAgluconate b. Darkened room to dec stimul
us thereby preventing convulsion
PERIPHERAL VASCULAR DISEASE
Arterial Obstruction Color pallor Edema (-) or mild Nails brittle nails Pain int
ermittent claudication Pulse (-) Temperature cold Ulcer dry & necrotic TYPES:
BURGERS DSES
(THROMBO ANGITIS OBLITERANS) common : MALE FEMALE MALE
Venous Obstruction ruddy (+) & severe N homans sign (+) warm wet
(pain @ gastrocnemeus area)
RAYNAUDS
ARTERIOSCLEROSIS OBLITERANS

AREA AFFECTED :
Lower Ext.
Upper Ext 97% 3% - lower ext Arteries ONLY
Upper & Lower Ext
Affects arteries and veins
Arteries ONLY
MP :
Angitis inflam. of Spasm of Arteries Arteries & veins of lower ext of Upper & lowe
r
ACUTE
Hardening of arteries due to fatty deposits
INTERMITTENT CHRONIC - (+) pain usually related to - (+) pain that narrowing of
blood vessels. accompanied by color changes: PALLOR that progresses to CYANOSIS
then REDNESS & aggravated by exposure to cold NO SHOVELING OF SNOW & COLD BATH &
exposure to cold wear gloves
S/S:
Outstanding s/s is INTERMITTENT CLAUDICATION pain that worsens w/ activity or pa
in that is relieved by rest. - aggravated by smoking causes further narrowing of
bld vessels WBC & ESR DOPPLER USG Inc Cholesterol and Ca
LAB DATA : Inc Nsg Dx:
Altered Tissue Perfusion same Pain -dosame -doPI : MEDS :
Relief of Pain (for all types)
-do-doAnticoagulants Vasodilators (papaverin pavabid) Antihypertensive
DIET :
Low Cholesterol
VARICOSE VEIN
THROBOPHLEBITIS
PHLEBOTHROMBOSIS
Clot
weakening of venous valves; CLOT + Inflammation job related (prolong sitting/sta
nding) pregnancy hereditary secondary to existing medical condition

s/s : dilated tortous vein dragging sensation heaviness edema (unilateral/ bilater
al) tape measure to monitor leg circumference Pain Lab data:
1. conservative test TRENDELENBURG TEST pt lie down, elevate/ raise the legs the
n
stand up and observe for bulging of vein; 2. DOPPLER USG Nsg Dx : PAIN Altered T
issue Perfusion

Hx Teachings :

Elevate the legs above the heart; Use support stockings; Surgery vein ligation &
stripping Sclero therapy injection of sclerosing agents to make wall stronger t
hereby preventing veins to bulge.

NO MASSAGE coz it may dislodge the clots; KNEE HIGH STOCKINGS; COLD COMPRESS
ABDOMINAL AORTIC ANEURYSM (AAA)
- weakening of portion of abdl aorta leading to dilation; - could be related to
aging and HPN TYPES: Fusiform - entire wall is affected Dissecting - part of inn
er intima and media was dissected w/c lead to the pushing Saccular S/S: Pulsatin
g Abdl Mass Low Back Pain Higher BP in Upper Extremities If RUPTURE occurs could
lead to SHOCK LAB DATA : PRIORITY : Altered Tissue Perfusion Risk for Injury NO
ABDOMINAL PALPATION bec it may lead to rupture PLACE WARNING AT THE DOOR OF THE
PT. Prepare pt for Surgery
of tunica adventitia to bulge
CARDIO-PULMONARY RESUSCITATION (CPR)
indicated for cardiac arrest when pt is BREATHLESS and PULSELESS;
shake the pt a
re you ok? If breathless & pulseless then; ACTIVATE the EMS Help! CPR (1 or 2 re
scuer : 15 : 2) In 1 minute, there will be 80 compression and 15 20 rescue breat
hs Depth of Compression : 11/2 2 If too deep - it may fx the liver Effect of CPR :
#1 (+) Pulse; #2 skin color
TIPS FOR CARDIOVASCULAR ADULT


A nurse is assigned to a pt with arterial dses of lower extremities, w/c of the
ff is expected calf pain after short walking (intermittent claudication); A pt w
as diagnosed w/ MI develop atrial fibrillation this may possibly lead to CEREBRA
L EMBOLISM; A pt w/ CHF was admitted exhibiting confusion, disorientation, visua
l disorders & hallucination the nurse best action is to CALL THE PHYSICIAN; A nu
rse is assessing a pt w/ MI w/c of the ff is the characteristic of PAIN pain rad
iates to the jaw; In utilizing mind over body principle for pt w/ HPN w/c interv
ention is appropriate - relaxation and stress mgt; Pt exhibits intermittent clau
dication another sign of peripheral dses is w/c of the ff tropic skin changes; F
f MI, when shall I resume sexual activity? when you can climb 2 plights of stair
s w/o shortness of breath then sexual activity is safe; A pt has R sided CHF, w/
c of the ff is expected hepatomegally; Apt w/ CHF who is taking diuretics exhibi
ts the ff, w/c requires further investigation (not expected to pt) wt gain of 3
lbs in 2 days; In addition to assessing a pt w/ Burgers Dses, w/c of the ff data
supports the Dx. smoking; A pt with R sided HF will manifest distended jugular v
ein
RESPIRATORY
General Consideration:
use the DIAPHRAGM of the steth when assessing breath soun
ds; use steth directly on pt. skin because clothing my interfere w/ auscultation
; when the pt chest is hairy, wet the hair w/ dump cloth because dry hair interf
ere w/ auscultation
Consideration w/ Pediatric Patient:
when assessing pediatric pt, RR is affected when therefore check RR FIRST;
Note for chest indrawing (if +, may indicate Pneumonia) and rapid breathing
Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS
RE TACHY TACHY D C

RETRACTIONS - #1 or Early sign for respiratory distress; Tachycardia

Tachypnea Dyspnea Cyanosis late sign of respiratory Distress

Key Points for Assessment - note for abnormalities in RATE, RHYTHM & DEPTH
Common CHARACTERISTIC in Breathing

BIOTS increase in depth followed by apnea; - pt w/ neuro impairement Cheyne-Stro

ke increase in rate and depth of breathing followed by apnea; - nero case Kussma
uls deep rapid breathing; Apneustic forceful inspiration followed by slow expira
tion dying patient
At birth, the child can maintain temperature by burning brown fat and increase b
urning bi products is Increase fatty acids that will cause acidosis that can wor
sen the Resp. Distress Syndrome a group of symptoms (mgt: maintain temperature).
HYPOVENTILATION
Cause: Lack of O2
Effect: ACIDOSIS
HYPERVENTILATION ALKALOSIS
Cause
: lack of CO2 the pt will decrease rate of breathing to save CO2. co2 then combi
ne with H2O to form carbonic acid if inc, can lead to acidosis and the brain wil
l compensate by hyperventilating and increase elimination of CO2 will cause ALKA
LOSIS.
APNEA OF INFANCY
Occurs in Full Term Baby
(37wks onwards)
SIDS/ CRIB DEATH
Usually occurs in Pre-term Risk Factors:
s/s : episodes of APNEA, TACHYCARDIA and Cyanosis
a.
b. c. d.
Pre-Term; Those w/ episodes of Apparent Life Threatening Events Siblings of thos
e who died w/ SIDS (usually 2-3 sis/ bro died) Hypoventilation
Dx Procedures: Cardioneumogram measures O2 Polysonography ABG Analysis Tx :

Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia Caffeine Assi
st mother threu grieving process
(esp to Apnea of Infancy)
Hx Teaching : Teach parents CPR

ASTHMA
MP : Inflammation of bronchioles that leads to excessive mucus production that r
esulted to narrowing and obstruction. Risk Factors : Environmental factors Emoti
on Effort/ Exercise S/S : WHEEZING sound due to obstruction Orthopnea Whitish Sp
utum Pulmonary Funx test Incentive Spirometer Ineffective airway Clearance AIRWA
Y
Lab Data : Nsg Dx : PI :
Intervention : Bronchodilators theophylline Rest Oxygen low flow (1-2 l/min)
higher than this will result to decrease in the stimulus for breathing w/c is CO
2
Nebulization Chest Physiotherapy b4 meals or at bed time High Fowlers Intermitte
nt Positive Pressure Breathing Aerosol Liberal Fluid Intake Meds : Aminophylline
Steroids Theophylline Histamine Antagonist Mucolytic Antibiotics
Hx Teachings :
Appropriate rest; Activity avoid those that will expose pt to all
ergens; AVOID PROPANOLOL and ASPIRIN causes BRONCHOSPASM; Exercise blowing exerci
ses bubbles, trumpet
CYSTIC FIBROSIS
multi system dses (GI and Respiratory System) characterized by excessive mucus p
roduction by exocrine glands. GI
Autosomal Recessive TRAIT TRANSMISSION 50% Chance for DISEASE TRANSMISSION 25%
Respiratory
Hereditary For each pregnancy S/S :
MECONIUM ILEUS within the 1st 24-36 hrs if baby fail to defecate suspect for CF;
ABDL DISTENTION Malabsorption Syndrome STEATORRHEA foul-smelling stool w/ Inc F
ats & Bulky Salty to Kiss bec skin becomes impermeable to Na

Common Complications: MALE

because of thick mucus plug
Aspermia low sperm count Sterility
FEMALE Difficulty in conceiving Nsg Dx : Knowledge Deficit Altered Elimination A
ltered Sexual Functioning Sweat Chloride Test N (if sweat) 10 35 mg/dl INCREASE
IF (+) CF (if serum) 90 110 mg/dl -doLab Data :
PI : since two system are affected: Respiratory Therapy blowing of trumpet, Incr
ease Fluid Intake; GI Therapy Administer Pancreatic Enzyme (pancreatin, pancreas
e, viocase)
GIVEN WITH EACH MEALS
Effective : if (-) fat at stool Hx Teaching : Refer parents to GENETICIST
CROUP DISORDER
ACUTE LARYNGITIS LTB
(Laryngotracheal Bronchitis)
RSV/ BRONCHIOLITIS
(Respiratory Synctial Virus)
common in TODDLER VIRAL Inflammation of LARYNX barking-metallic cough (-) FEVER (+
) STRIDOR
INFANTS & TODDLER VIRAL or BACTERIAL
INFANTS usually (less than 6 mos) VIRAL
Inflam. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES harsh-brassy cough (+) FEVER-lo
w grade (+) STRIDOR paroxysmal-hacking cough (+) FEVER-moderate (+) WHEEZING
STRIDOR is present when the affected part is LARYNX.
Lab data: Nsg Dx : PI :
P Exam ABGs
-do-doELIZA
INEFFECTIVE AIRWAY CLEARANCE
Airway Endotracheal Tube (Tracheostomy Set - #1) to facilitate airway; Humidity
place infant in MIST TENT or CROUPETTE Nsg care:

change clothing frequently coz mist will dampen child clothings;

TOYS while inside the tent: PLASTIC TOYS no battery operated & no friction wheel
toys at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the co
mfort room for child to inhale
Antibiotics Antiviral Ribavirin Hx Teachings : SYRUP OF IPECAC for Croup it indu
ces vomiting- bec it will stop the spam thereby preventing further coughing.
Chronic Obstructive Pulmonary Disease (COPD)
MP : group of disorders of respiratory system that lead to obstruction or narrow
ing of airways.
BRONCHITIS ASTHMA
EMPHYSEMA
Over distention of Alveoli Risk Factors: (+) (+) (+) (+) (+) S/S:
Inflammation of Bronchus Gelatinous sputum + RE TACHY TACHY D C
Allergy Environmental factors Pollen Elevated Immunoglobulin E (IgE) Smoking (es
p to passive smokers)
RE TACHY TACHY D C + barrel-shape test there is an INCREASE in ANTERIOR and POSTER
IOR DIAMETER of the chest
Lab Data : ABGs to check for respiratory acidosis CXrays Nsg Dx : #1 Ineffective
Airway Clearance due to narrowing & obstruction
#2 Ineffective Breathing Pattern PI :
ovent

AIRWAY 1-2 L/min; Meds: Bronchodilator Atr

Exercise: Blowing; Rest periods in between activities

During ACUTE attack, the POSITION OF CHOICE : ORTHOPNEIC
PNEUMOTHORAX
MP : partial or total collapse of lungs due to:
Types :

S/S :
Open Pneumothorax TRAUMA Spontaneous Pneumothorax - due to rupture of BLEB Tensi
on Pneumothorax due to INCREASE IN TENSION
over distention of alveoli
Diminished Breath Sounds (-) b. sounds to area auscultated; (+) Dyspnea; (+) Res
tlessness Impaired Gas Exchange Ineffective Breathing Pattern
Nsg Dx :
PI :
Chest Tube Drainage System restores the (-) pressure within the thoracic cavity
Anterior chest tube drains the AIR Posterior chest tube drains FLUIDS
PNEUMONIA (PNA)
MP : there is INFLAMMATION of ALVEOLAR SPACES that leads to exudation and consol
idation of the lungs.
LEGIONARES DSES acute bronchopneumonia in elderly, alcoholic & Immunosuppressed
pt - management same w/ pna
VIRAL PNA
Fever : Cough : WBC : Lab Data : Nsg Dx : PI : (+) low-moderate
BACTERIAL PNA
(+) fever moderate-high

(+) Non productive thin-watery (+) Productive rusty No change or slight Xray and ABG
Impaired Gas Exchange due to exudation and consolidation of Alveoli Airway O2 P
osition : Semi-fowlers or Orthopneic Bed Rest Inc Oral fluid intake Antibiotics T
CDB (turning, coughing, & deep breathing) Elevated

TB
HISTOPLASMOSIS
MYCOBACTERIUM AVIUM COMPLEX
Bacterial
Bacterial
Fungal (from HISTOPLASMA CAPSULATUM)
from BIRD MANURE soil & transmitted thru inhalation
Droplets & Airborne Droplets & Airborne
Risk Factors: ASIAN IMMIGRANT IMMUNOSUPPRESSION MALNUTRITION
Droplets & Airborne
S/S :
same: a to e + FOREST RELATED ACTIVITY
Ask client if came from AVIARY
same with TB
a. initially asymptomatic; b. low grade fever that occurs in the afternoon; c. b
ody malaise or weakness; d. coughing w/ bld streaked sputum; e. weight loss Lab
Data : Histoplasmine Skin Test for Histoplasmosis
Mantoux Test Xray confirmatory test Sputum - @ least 2 (-) to be effective
Nsg Dx : Infection; Ineffective Breathing Pattern

MEDS :
PROPHYLACTIVE TREATMENT OF TB Antiviral Meds
INH for TWO WKS (take Vit B6 to avoid NEUROPATHY) Antibiotics
Rifampicin INH Streptomycin Ethambutol
take above meds for 6-12 moths to avoid resistance
TIPS FOR RESPIRATORY
you observed a nurse caring for a child in a CROUPETTE, if you are the nurse inc
harge, what would be your #1 PRIORITY? changing the linens & clothings to keep c
hild always dry; which data in the past medical history of the pt. supports a dx
of cystic fibrosis MECOMIUM ILEUS in the neonate;

the primary goal of care for pt w/ bronchiolitis is to minimize oxygen expenditu

re;

w/c of the ff intervention being carried out by LPN would require immediate inte
rvention suctioning the pt for 20 seconds;

a client w/ TB will experience - low grade fever; a pt is diagnosed w/ emphysema

w/ of the ff s/s would the nurse expect to have barrel shape chest; a nurse car
ing for a pt w R Lower Lobe PNA shld put the pt in w/c of the ff position to enh
ance postural drainage L Lateral w/ the Head Lower than the Trunk

DAY 7 (Feb 10, 2005)

ENDOCRINE
General Consideration Explain to the pt the MOST COMMON METHOD of assessment: a.
Direct methods specimen : blood and urine b. Explain the methods of gathering t
he specimen Consideration for PEDIATRIC PATIENT a. Involve the parents of the ch
ild; b. Incorporate food preferences c. self insulin administration allowed to c
hild 9 yo and above Reportable S/S :
skin changes have you noticed any change in
your skin color
(bronze skin pigmentation addisons dses) 2 servings of popcorn HOW MANY RICE TO GI
VE UP = 1 if sandwich = 1 rice
Inc. temperature S/S of Shock Specimen characteristic is usually affected by STR
EE, DIET and
Keypoints :

Normal Body Rhythm

PKU
MP : There is Absence of Phenylalamine Hydroxylase (the one that converts Phenyl
alamine to Thyroxine ( a precursor to Melanin). Therefore (-) PH leads to accumu
lation of phenylalanine at the brain that leads to Mental Retardation. S/S : Ini
tially asymptomatic For OLDER CHILDREN : AUTOSOMAL RECESSIVE PATTERN of transmis
sion (inherited)
Since (-) melanine: Lab Data :
Diarrhea Anorexis Lethargy Anemia Skin Rashes and seizure Musty odor of urine (d
ue to phenyl pyruvic acid) hair : blonde Eyes: blue Fair Skin
Nsg Dx :
GUTHRIE CAPILLARY BLD TEST initial screening done after the infant has ingested
CHON for a minimum of of 24 hrs.
Secondary screening : done when the infant is about 6wks old test fresh urine w/
PHENISTIX WHICH CHANGE COLOR Phenylalanine level greater than 8mg/dl diagnostic
of PKU
(4mg/dl indicative)
Knowledge Deficit Altered Thought Process Risk For Injury PI :
MEDS : Hx Teachings :
Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or t
il 10 yo bec b4 this time the brain mature
Lofenalac 20-30mg/kg/day

Inform parents of the foods to be avoided; - prepare special education to parent

s Provide list of foods allowed;- prepare special education to parents Refer to
geneticist
Untreated PKU can result in failure to thrive, vomiting and eczema and by about
6 mos, signs of brain involvement appear.
LYMPHOCYTIC THYROIDITIS or JUVENILE HYPOTHYROIDISM
Cause : MP : S/S : Autoimmune or genetics Decrease in T3 and T4 Dysphagia Enlarg
e thyroid All s/s of hypothyroidism (decrease metabolism)

Nsg Dx : PI :
Knowledge Deficit Activity Intolerance no tx because it regresses (only temporar
y) spontaneously
CRETENISM or CONGENITAL HYPOTHYROIDISM
disorders related to absent or non-functioning thyroid; newborns are supplied wi
th maternal thyroid hormones that last up to 3 mos; initially asymptomatic s/s b
egins 2 3 months
behavioral s/s
- apathy well behave
physical s/s
large tongue & protrudes from mouth retarded growth intolerance to cold
mental retardation
Prevention: neonatal screening blood test; Without treatment,
mental retardation and developmental delay will occur after age 3 mos; Decrease
T3 and T4 Knowledge Deficit Risk for Injury Single morning dose of Synthroid fo
r LIFE oral thyroxine and Vit D as ordered to prevent M. retardation
(adverse effect of meds : insomnia, tachycardia, and nervousness REPORT ASAP)
Lab Data : Nsg Dx :
Meds :
PI :
correct the deficiency
Hx Teachings :
Warm environment (bec there is Hypothermia w/ cool extremities);
Low calorie diet : since there is decrease metabolism; Special education
ENDOCRINE GLANDS
1. 2. 3. 4. 5. 6. 7. 8. 8 glands (ductless)- they secrete the hormone directly t
o bld stream
Pineal Gland Pituitary Gland Thyroid Gland Parathyroid Gland Thymus Gland Pancre
as Adrenals Gonads (testes & ovaries)
Glands
PITUITARY THYROID
UNDER
Diabetes Insipidus Hypothroidism
(Myxedema)
OVER
SIADH Hyperthyroidism
(Graves, Basedows, Parrys)

PARATHYROID Pancreas ADRENALS

Hypo DM Addisons Dses
Hyper
Cushings Conns
PANCREAS Alpha Cells BETA CELLS
Islets of Langerhans
Glucagon Insulin
(responsible for Decrease in blood sugar)
Responsible in the increase Blood Sugar
Absence (DM Type I) IDDM
Juvenile Onset B4 age of 30 Adolescence to Early Adult Stage Pt is THIN Pt is KE
TOSIS PRONE
Deficiency (DM Type II) NIDDM
Maturity Onset After age of 30; Pt is Obese NON-KETOSIS PRONE
MODY DM III
combines features of DM Type I & 2; Maturity Onset that occurs in young adult; O
BESE, b4 age of 30 Non-Ketosis Prone
GESTATIONAL DIABETES
- occurs during pregnancy
Types According to WHITES Classification TYPE ONSET DURATION

A B C D
CHEMICAL DIABETES
(+) Increase Bld Sugar After the age of 20 Bet 10 19 yrs old Before 10 yrs old 1
0 years 10-19 years More than 20 yrs
D1 D2 D3 D4 D5
Before 10 yrs old >20 yrs Beginning Retinopathy w/ calcification of arteries DM
w/ HPN w/ calcification of Pelvic Arteries w/ nephropathy (Diabetes Nephropathy)
Diabetes Cardiopathy Diabetes Retinopathy w/ Transplant of the Kidney
E F H R T
DIABETES MELLITUS
MP : Deficiency in INSULIN either absence or deficiency of insulin that leads to
alteration in the metabolism of CHO, CHON and FATS. Cause:
unknown Autoimmune Genetic Stress Polydipsia Polyuria Polyphagia Wt loss
R. factors :
S/S :
the stave cells send message to the brain to eat more
Nsg Dx : PI :
Knowledge Deficit Altered Nutrition
Correct the deficiency- HOW?

Diet : well balance diet CHO 50-70% (main source of energy and sugar for DM pt.)
Insulin for Type 1
Hypoglycemia Most Approximately to Occur
RAPID INTERMEDIATE SLOW INSULIN:
Regular Insulin - BEFORE LUNCH NPH - LATE IN THE AFTERNOON/ AFTERNOON
Protamine Zinc - DURING NIGHT Ultralente
Best Site is ABDOMEN bec it is a NEUTRAL AREA

SUBQ 90 degree angle for insulin syringe 40 degree angle if non-insulin syringe
Complication of INSULIN ADMINISTRATION:

Lipodystropy Dawns Phenomenon hyperglycemia that occurs at dawn

Early AM - due to over secretion growth hormone treatment: GIVE INSULIN NPH at 1
0 PM to prevent hyperglycemia at early AM (tx: administer insulin)
Antidiabetic Agent;
SOMOGYI Phenomenon rebound hyperglycemia
Blood Sugar Monitoring in AM and supper time (2x a day); Ensure adequate food in
take; Transplant of Pancreatic Cells; Exercise it will decrease insulin requirem
ent Scrupulous foot care
(in pregnancy/stress Increase insulin req)
check up w/ podiatrist - foot powder, snugly fitting shoes, cut toe nail straigh
t across - cut toe nail across - avoid going barefoot - always dry in between to
es
Modification for Pregnant Pt with DM

+300Kcal; Insulin Requirement (dose will be adjusted on 2nd & 3rd Trimester); AM
Dose: PM Dose: EFFECTS 2:1 for Regular to NPH 1:1 for R:NPH
MOTHER
Macrosomia Hyperglycemia Therefore pre-term birth Complication: Uterine Atony
BABY
Hypoglycemia RDS Congenital Defects
COMPLICATION
1. Hypoglycemia (Insulin Reaction) - BLD SUGAR BELOW 50
DKA
Risk Factors :
Missed meals; Increase or Overdose of Insulin;
Hyperglycemia (bld sugar level above 120) (Diabetic Coma)
HHNK
Overeating Decrease Insulin

S/S :
Too much Activity
Inactivity Stress Infection
Dizziness Drowsiness Difficulty Problem Solving Decrease Level of Consciousness
+ Cold Clammy Skin, Diaphoresis Lab Data : Below 50 Blood Sugar Level PI : Admin
ister Simple Sugar (fructose-fruit juice) Hard Candy (not chocolate it is comple
x sugar) If unconscious D50
DKA (Type 1)
HHNK (Type 2)
(Hyperglycemic Hyperosmolar Nonketotic Coma)
S/S : 3 Ps + Signs of Dehydration thirst & warm skin
Hyperglycemia Kussmaul Breathing + 3Ps Thirst and warm skin Lab Data : PI : Increa
se Bld Sugar #1 AIRWAY #2 Fluid Regular Insulin Risk for Injury
More pronounced GI Disturbances
Nsg Dx :
2. 3. 4. 5. 6.
MICROANGIOPATHY
- destruction of small blood vessels; hardening of arteries;
ATHEROSCLEROSIS NEPHROPATHY OPTHALMOPATHY
kidney damage; - w/c leads to cataract
(eye exam annually);
Peripheral Neuropathy or Autonomic Neuropathy
there is poor nerve impulse transmission common manifestation : impotence
DIABETES INSIPIDUS

(Pituitary Glands 3 lobes)

ANTERIOR
Secrete Tropic Hormones
POSTERIOR
Store Only (does not excrete)
MIDDLE
MSH (skin color)

FSH OXYTOCIN (follicle stimulating Hormone) ADH

ACTH (adrenocorticotropic hormone)

LH (luteinizing hormone); GH (growth hormone); Prolactin

PITUITARY GLAND
ADH (anti Diuretic Hormone)
retain h20 or flds
Deficiency: lead to D. INSIPIDUS
Excess : SIADH
(Syndrome of Inappropriate Anti Diuretic Hormone Secretion)
Due to or related to: Pituitary Tumor Head Trauma Injuries
MP : Deficiency in ADH leads to fld excretion, therefore s/s same with DM EXCEPT
: POLYPHAGIA
LAB DATA : a. urine - decrease in specific gravity (N 1.010 1.025)
in DI its <1.005; b. FLUID DEPRIVATION Test - pt on NPO 24hrs B4; Nsg Dx : PI :
FLUID VOLUME DEFICIT Administer IV Fluids Meds - Synthetic ADH - Vasopressin IM
Desmopressin INTRANASALLYLypressin -doHow : Polyuria 21 L/day Polydypsia
one hole of nose only
Given as pt exhale to the mouth then inhale thru the nose then EXHALE to the mou
th then give meds.
Evaluate the effect of meds :
Check Specific Gravity of Urine; Monitor I & O; Mo
nitor V/S : assess for hypovolemic shock

SIADH
excess ADH; MP : Fluid Retention result to DILUTIONAL HYPONATREMIA or H2O INTOXI
CATION
S/S : due to DECREASE NA this could lead to the ff:
convulsion; seizure; HPN
Above s/s could lead to decrease LOC LAB DATA : Decrease Na Level (<120 mEq/L) h
yponatremia Nsg Dx : PI : FLUID VOLUME EXCESS FLUID RESTRICTION Drugs DIURETICS
+ ANTIHPN
if cause by TUMOR PREPARE PT FOR SURGERY IF after surgery POLYURIA report ASAP s
ign of DI
PITUITARY
GROWTH HORMONE DEFICIENCY
DWARFISM - congenital ex. MAHAL
EXCESS
B4 Closure of Growth Plate - gigantism - long, slender extremities and Inc. in Hei
ght ex. Marlo Aquino
NANUS SYNDROME (hereditary)
After the Closer of Growth Plate - acromegally - there is coarsening of facial fea
tures + enlargement of the digits (inc. shoe size) ex. Balingit
Lab Data :
INCREASE HUMAN GROWTH HORMONE

Increase Blood Sugar Nsg Dx : PI : Risk for Injury Safety Meds - Parlodel decrea
se secretion of growth hormone If related to tumor : surgery
GIGANTISM
(long slender extremity)
MARFAN SYNDROME (hereditary) MP : Cardio & Eye disorder Scoliosis
(complication)
KLINEFELTERS (chromosomal aberrations) MP : XXY Pattern (an extra X chromosome)
X chromosome FEMALE COMPONENT of HUMAN BODY Problem is NON-DEVELOPMENT of SEX OR
GAN
ADRENAL/SUPRARENAL
CORTEX (OUTER) RESPONSIBLE FOR SECRETION OF:
MEDULLA
(INNER) SECRETES THE FF:
GLUCOCORTICOIDS
MINERALOCORTICOIDS
(ALDOSTERONE)
EPINEPHRINE
NOREPINEPHRINE
GLUCONEOGENESIS STRESS RESPONSE fight or flight - formation of sugar from Responsi
ble for Na Retention new sources and K Excretion

DEFICIENCY IN GLUCO & MINERALO : EXCESS of GLUCO & MINERALO :

ADDISONS Dses CUSHINGS Dses/ syndrome
EXCESS of MINERALOCORTICOIDS ONLY : CONNS SYNDROME
ADDISONS
CUSHING
CONNS
INC. MINERALOCORTICOIDS - w/c cause K EXCRETION & Na RETENTION
MP : Underactivity of the Adrenal Glands Overactivity of A. Glands
(there is DEC G, M & SEX HORMONES) (there is INCREASE G & M) ADRENOCORTICAL INSU
FFICIENCY

Excessive SECRETION of - coticosteriods especially the GLUCOCORTICOID CORTISOL

Excessive ALDOSTERONE Secretion from A. Cortex Female (30-50) Related to Tumor
Common: Male and Female
Female (bet. Age 30-60)
RF : Could be related to Surgery removal Related to Tumors
Of Adrenal Gland and or Auto Immune Reaction
S/S: Dec Bld Sugar (hypoglycemia)
Dec Na (hyponatremia) Dec BP INC K (hyperkalemia)
INC BP, NA ALL S/S OF CUSHINGS DEC K + EXCEPT HYPERGLYCEMIA Moonface, Hirsutism,
Buffalo Hump, Pendulous Abdomen Hypertension Lability of Mood (mood swings) Pol
yuria, Polydipsia Depression Cardiac Arrythmias due COMPENSATORY of MSH Inc w/c
Trunkal Obesity / thin Extremities to dec K Leads to Bronze-Like Skin Pigmentatio
n Hypertension Decrease Resistance to Infxn Hypotension, Weak Pulse Weight loss,
Fatigue, Muscle weakness Nausea, Anorexia, Vomiting Hx of frequent Hypoglycemic
Rxn Increase Cortisol Level Hypernatremia Hyperglycemia Hypokalemia Hypokalemia
due metabolic Alkalosis Inc Urinary Aldosterone Level Decrease K
Lab Data : Decrease Cortisol Level
Hyponatremia Hypoglycemia Hyperkalemia
Nsg Dx :
Fluid Vol. Deficit Fld & E imbalance Fld Vol. Excess Fld & E imbalance Risk for
Injury Fld & E Imbalance
ADDISONS
PI :
CUSHINGS
CONNS

Correct the imbalance IV Diet: Inc Na Dec K Administer Steroids (Fludocortisone)

Admin. Hormone Replacement Therapy Cortisone give 2/3 of dose in AM 1/3 in afte
rnoon
Correct the imbalance - limit fld intake DIET : Low in Calories & Na High in CHO
N, K, Ca & Vit D
Check BP give antiHPN
Limit the flds

Meds are FOR LIFE

Prevent accident & Falls
Diet : Low Na, Inc K

Prevent exposure to Infxn Provide rest periods prevent fatigue Monitor I & O, we
igh Daily
Protect client exposure to Infxn Minimize stress in environment MIO & weigh Dail
y As Rx Monitor V/S, observe for HPN & edema Administer SPIRONOLACTONE (aldacton
e) & K supplements
Provide small, frequent feeding high in CHO, Na and CHON to prevent Hypoglycemia
& Hyponatremia

Use of Table salt tablets (if Rx) or ingestion Surgery prepare pt if cause Of sa
lty foods (potato chips) by pituitary tumor or hyperplasia if experiencing Inc.
sweating Post Surgery: poor wound healing; report s/s of Addisonian Crisis sever
e HYPOTENSION Avoidance of strenuous exercise esp in HOT WEATHER Meds: FOR LIFE
Glucocorticoids Synthesis Inhibitors - Lysodren and Cytodren - prevents formatio
n of Gluco

ADDISONIAN CRISIS

causes: s/s:
severe exacerbation of Addisons dses caused by acute adrenal insuffieciency
strenuous activity, infection, trauma, stress, failure to take RX Meds severe ge
neralized muscle weakness severe hypotension hypovolemia, shock administer flds
to treat vascular collapse IV glucocorticoids - Solu-Cortef and Vasopressors Mai
ntain strict bed rest and eliminate all forms of stressful stimuli MIO and weigh
daily Protect client from Infxn Other Hx teachings: same with Addisons
PI :
THYROID
T3 & T4
- responsible for maintenance of
METABOLISM
Calcitonin
- deposit Ca @ bones
DEFICIENCY HYPOTHYROIDISM
Adult: Myxedema Children: Cretenism Main Problem:
EXCESS HYPERTHYROIDISM
Graves Disease, Basedows or Parrys Dses
Slowing of metabolic process caused by hypofunction of the Secretion of excessiv
e amount of Thyroid Thyroid Gland with decrease thyroid hormone secretion (T3 &
T4) Hormone in the blood causes in the INC Of metabolic process DEFICIENCY in T3
and T4 Causes: Excess in T3 and T4
S/S :
congenital surgery autoimmune
genetic autoimmune tumor
FACIAL EDEMA INTOLERANCE to COLD DECREASE v/s DECREASE GI Motility constipation
HYPOactivity Increase Sleep hypersomnia Wt Gain in the presence of Dec Appetite
Dry scaly skin, dry sparse hair, brittle nails
EXOPTHALMUS (+) Goiter Hypermetabolic State INTOLERANCE to HEAT Inc V/S INC GI M
otility - DIARRHEA Insomnia HYPERactivity WT LOSS even INC Appetite Warm smooth
skin, fine soft hair Pliable nails Irritability, restlessness, agitation
LAB DATA : Check TSH (increase) DECREASE T3 & T4 DECREASE RAIU (131) INCREASE Se
rum Cholesterol Level DECREASE TSH INCREASE T3 & T4 INCREASE RAIU
RADIOACTIVE IODINE UPTAKE (RAIU) administration of 123I or 131I orally; - perfor
med to determine thyroid function (increase uptake indicated hyperthyroidism, mi
nimal uptake may indicate hypothyroidism); nsg consideration : take a thorough h
istory thyroid meds must be D/C 7-10 days b4 the test meds containing iodine cou
gh preparations, and intake of iodine rich foods and test using iodine eg IVP ca
n invalidate the test

NSG DX : Activity Intolerance due to Fatigue (fatigue due to hypometabolism) PI

: HOW : Promote a EUTHYROID STATE a. THYROID SUPPLEMENT Synthroid, Cytomel lifet
ime s/e: insomnia, palpitation nervousness b. DIET: low calorie c. Maintain vita
l funx: correct hypothermia maintain adequate ventilation d. Provide comfortable
, warm environment e. Increase flds and high fiber foods to prevent constipation
,. Admin stool softener as Rx f. Meds: thyroid hormone replacement take daily do
se in AM to avoid insomnia Monitor THYROTOXICOSIS tachycardia Palpitations, naus
ea, vomiting, diarrhea, Sweating, tremors, dyspnea Risk for Injury (bec of hyper
)
same Admin AntiThyroid Meds for LIFE ex. PTU & Lugols Assign to private room awa
y from excessive activity Quite & relaxing Activity Provide a COOL ENVIRONMENT D
IET : High in CHO, CHON, CALORIES Vit & Minerals w/ supplemental feedings bet me
als & at HS NO STIMULANTS tears Protect eyes w/ dark glasses & artificial
Monitor for AGRANULOCYTOSIS (fever, Sore throat & skin rashes) if taking antithy
roid meds. Prepare pt for surgery 2wks before SURGERY give LUGOLS SOLUTION - it d
ecrease size and vascularity of thyroid gland; - give w/ straw to avoid staining
teeth; - can be diluted w/ H2O or orange/ apple juice; - report diarrhea & meta
llic state
Meds:
a.
Antithyroid Drugs Prophythiouracil and Tapazole - block synthesis of thyroid hor
mone; - toxic effect include AGRANULOCYTOSIS
b. Radioactive Isotope of Iodine (131) Radioactive Iodine Thrapy - given to dest
roy the thyroid gland thereby decreasing Thyroid hormone production
COMPLICATIONS OF THYROID SURGERY:
MEMORRHAGE whether the dressing is dry or intact its not a confirmatory that the
re is no bleeding. To check, slip your hands at the back of the neck (bec of pri
nciple of gravity)
Damage Laryngeal Nerve to assess, ask pt to talk past surgery
and if pt has APHONIA provide communication aids paper and pencil LARYNGOSPASM
accidental removal of parathyroid gland therefore will lead to dec parathormones
w/c lead to dec Calcium and laryngospasm KEEP TRACHEO SET at bedside. TETANY du
e to decrease in CA characterized by: a. tingling sensation fingers & lips b. Ch
vosteks Sign facial muscle twitching on percussion of facial nerve c. Trousseau S
ign carpopedal spasm THYROID CRISIS due to rebound hyperthyroidism Increase thyr
oid hormone Increase HRate/palpitation Inc Temp - hyperthermia

PARATHYROID
Parathormone
HYPOPARATHYROIDISM
Deficiency
Inc CA in the Blood
withdraws Ca @ bone to the bld
EXCESS
HYPERPARATHYROIDISM
MP : Dec Ca (hypocalcemia) maybe hereditary,
Or caused by accidental damage to or removal Of parathyroid glands during surger
y eg thyroidectomy
Increased secretion of PTH that result in altered state of Ca, Phospate & bone m
etabolism
S/S : Initial S/S:
Tingling lips & Fingers Chvosteks Trousseau personality changes cardiac arrythmia
s muscle pains
Late S/S
Bone Pain (esp Back Bone) Kidney Disorder kidney stones renal colic
NAV, Constipation
Lab Data : Decrease Ca Serum Phospate Inc Skeletal Xray reveal Inc Bone density
Nsg Dx : PI : RISK FOR INJURY a. Safety b. Keep Ca supplement at Bedside c. Diet
: Inc Ca spinach, sardines, seafoods d. Tracheo set deu to dec Ca Laryngospasm s
ame same
Inc Ca (N 4.5-5.5 mg/dl) Dec Serum Phospate Level xray reveal Bone Demineralizati
on
Inc Oral Fld intake due to renal calculi of having INC Ca Diet; Low Ca Surgery i
f due to tumor

TIPS FOR ENDOCRINE

a child w/ PKU was admitted, w/c of the ff statements made by the mother indicat
es a need for further instruction my child loves to drink milkshakes chon- w/c has
INCREASE Phenylalanine; w/c of the ff if manifested by a child could be indicat
ive of diabetes bed wetting; a common manifestation of HYPOGLYCEMIA shaky tremor
s; a pt post thyroidectomy develops tetany, the nurse anticipates that the docto
r will most likely order Ca Gluconate; rapid & deep breathing that occurs in dia
betic pt is indicative of KETOACIDOSIS a pt is to receive NPH Insulin at 8AM, wh
en shld the nurse expect to have hypoglycemia in the late afternoon; to determin
e the effect of PTU, the expected outcome is Dec HR; what would be the question
to support the Dx of Hypothyroidism do you tire easily?; w/c of the ff statement
s made by the diabetic pt would indicate the need for further teaching I will be
hypoglycemic if I experience emotional stress.

GENITO-URINARY
General Consideration
when performing assessment of Genito-urinary system, use o
pen-ended question- bec some pt are not comfortable talking genitals; explain th
e meaning of terminologies; ask the patient what symptoms bother him/her the mos
t;
Consideration for Pediatric Patient
assess for history of sorethroat; bladder ca
pacity increase with age infants about 65ml toddler 300-400 ml school age 800 10
00 ml infants are unable to concentrate urine until the age of 1 therefore adequ
ate milk intake if baby has 6-8 diapers /day; bladder sphincter control develop
at around 2 yo (therefore, bladder trng comes after bowel trng 15-18 mos of age)

S/S common to all Disorders of GU: a. frequency b. urgency c. hesitancy Reportab

le s/s :
peri orbital edema BP Oliguria Hematuria Early Stream Hematuria indicat
e lesion at Urethra Late Stream indicate lesion at bladder

Key points : a. check for wt gain if >1lb/day indicative of fld retention b. cha
racteristic of urine: color N - amber if pinkish bldg brownish flagyl orange rif
ampicin c. s. gravity (N 1.010 1.025) - if INCREASE - D. Insipidus DECREASE D. M
ellitus

d. Increase glucose UTI e. Elevated CHON Nephrotic Syndrome or PIH Epispadias op

ening at DORSAL portion Hypospadias opening at VENTRAL portion
WILMS TUMOR
S/S : congenital tumor at the kidney common in L Kidney and children below 5 yo
Unilateral Abdml Mass Hematuria HPN
Lab Data : CT Scan IVP NO INAVSIVE LAB/ Procedure NO BIOPSY Nsg Dx : PI : Knowle
dge Deficit Risk for Injury
AVOID/ NO ABDOMINAL PALPATION Prepare pt for Surgery and Chemotherapy
NEPHROTIC SYNDROME
(therefore there is PROTEINURAI) causes: Autoimmune congenital
AGN
to Group A Beta Hemolytic Streptococus sorethroat
MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidn
ey Tissues related
S/S EDEMA: Peri-orbital Edema but subside
at the end of the day Periorbital but progresses to generalized at the end of th
e day INCREASE BP Tea colored or Cola colored or Smoky
BP : URINE :
Decrease or N Frothy
LAB DATA
(+) Proteinuria, severe - >10mg in 24 hrs (+) Proteinuria - <10 mg/ 24hrs urine
Nsg Dx :
Fld Volume Excess Impaired Skin Integrity
PI :
Check BP Maintain Fld Balance Meds : NO Antihypertensive (+) Steroids (+) Antibi
otics
Antihypertensive Diuretics
DIET :
INCREASE CHON, Low Na LOW CHON and Na

POSITIONING : Turn Patient frequently because pt w/ edema are prone to skin inte
grity like pressure sore formation
CYSTITIS
RF : Wearing silk underwear (does not absorb moist); - use COTTON Bubble bath Pr
olong driving Common in FEMALE due to size (short) urethra S/S: FREQUENCY, URGEN
CY & HESISTANCY + Burning sensation on urination (dysuria) LAB DATA : Nsg Dx : P
I :
Diet :
Infection of the bladder Ascending infection caused by E. Coli (from feces) or P
seudomonas
Urinalysis to check for microorganism Altered Elimination Pattern Infection
Treat for Infection antibiotics for 10-15 days
ACID-ASH DIET give lemon juice or VIT C
Bladder Analgesic (ex. PYRIDIUM ch can cause ORANGE COLORED URINE, effective : (
-) pain)
Hx Teachings: Avoid bubble Bath No Silk underwear Inc. Fld Intake
RENAL FAILURE
ACUTE
MP
Sudden or Acute, Usually Reversible loss of Kidney Funx There is inability of ki
dney to maintain fld & E balance
CHRONIC
IRREVERSIBLE kidney damage that leads to scar formation
Causes
PHASES
:

Phases of ARF
Pre-renal Factors those that dec bld circulating vol. SHOCK;Phase I: RENAL INSUF
FICIENCY Intra-Renal dses condition of the kidney eg. AGN Post-Renal those that
causes obstruction eg. Kidney stones Polyuria Nocturia Polydipsia PHASE II : MIL
D RENAL DAMAGE (OLIGURIA) RENAL FAILURE All s/s + Anemia & HPN ESRD (1-2 yrs) Az
otemia & Uremia accumulation of waste products uremic frost skin pruritus same The
re will be INC BUN & Crea
OLIGURIC PHASE - decrease urine output that is less than 400 ml/24hr - Dec NA &
Inc K DIURETIC PHASE - Inc urine output (4-5L/day) - Dec Na & K RECOVERY PHASE renal funx normalizes
LAB DATA
Increase BUN and Crea most sensitive Index

Nsg Dx Fld and E Imbalance Fld & E Imbalance Activity Intolerance

PI :
TO CORRECT THE IMBALANCE A. B. Fluid restriction; Meds : Diuretics Cardiac Glyco
sides Digitalis Antihypertensive Fld restriction Amphogel to promote excretion o
f Phospate Epogen Inc RBC synthesis Diuretics AntiHPN Diet: same
C. DIET : Low CHON NO PMS
DIALYSIS
PERITONEAL
Semi-permeable membrane: Abdomen (peritoneum) Use of Tenchkoff Catheter Teaching
s:
HEMODIALYSIS
Dialyzing machine Use of fistula or shunt
anastomosis of artery & vein (internal access) less prone to infxn
Report Infxn (abdomen: rigid, Solution : cloudy) Check BT and CT Check Temp of d
ialyzing solution external access (more prone to infxn)

Complications of dialysis (report ASAP):

1. DISEQUILIBRIUM SYNDROME due to rapid removal of solutes (electrolytes and CHO
N) s/s:
GI nausea, vomiting, headache CNS - convulsion, seizures
2. DIALYSIS ENCEPHALOPATHY due to aluminum toxicity s/s:
(+) dementia muscle abnormalities twitching seizures RENAL TRANSPLANT s/s of com
plication : FLANK PAIN, FEVER, TENDERNESS, HPN - REPORT
BPH
S/S : Decrease size and force of urinary stream Nocturia Frequency, hesitancy an
d urgency LAB DATA: Digital rectal exam once a yr for pt 40yo and above gloves,
ky jelly position: Sims Altered Elimination Pattern Prepare pt for surgery
TURP n
o incision Suprapubic Prostatectomy
Retropubic -do Perineal -do- - common complic
ation: IMPOTENCE due to nerve damage I am eager to have sex again cannot be bec pt
is impotence glandular enlargement of the prostrate common in males above 40 yr
s old
Nsg Dx : PI :

nsgcare :
CBR for 2-3 days post surgery; NO LONG DRIVE/ SITTING; Ff up check up (if INC AC
ID PHOSPATASE: Prostate CA)
TIPS FOR GENITOR-URINARY
A common sign of ARF OLIGURIA; After peritoneal dialysis, w/c of the ff is appro
priate action turn pt to side; To prevent cystitis, w/c of the ff the nurse must
instruct to the pt to do take a bath using the shower rather than bubble bath;
For early detection of prostrate CA the nurse shld emphasized digital rectal exa
m annually to screen for prostrate CA in men 40 yo and above; In a pt with BPH,
the nurse shld expect that the pt will probably have the symptoms residual urine
of more than 50 ml; A male pt has an arteriovenous fistula in his L forearm, w/
c behavior would indicate that the pt needs further instruction in self care he
wears a watch on his L wrist; w/c of the ff indicates complication of peritoneal
dialysis cloudy dialysate

DAY 8 (Feb 11, 2005)

EENT
General Consideration
Explain to the patient there there will be no or little di
scomfort when performing EENT exam; Explain the methods of assessment to the pat
ient;
Consideration to Pediatric Patients
Obtain feeding history (bec the type & techn
iques differs) Obtain the diet hx of the pt and hx to URTI Involve the parents i
n the assessment of the baby
Reportable Signs and Symptoms

TINNITUS - ringing, buzzing or sea shell sound in the ear VERTIGO - Objective the
room is spinning Subjective I feel that I am revolving/rotating

Hearing Loss Pain if pain subside or (-) rupture of ear drum

Keypoints for Assessment
objective complaints

Note for abnormal findings Document the subjective and

OTITIS MEDIA
RF : Faulty feeding practices Swimming in dirty waters Upper Resp. Tract Infecti
on S/S : PAIN Pulling Tugging Crying when lying on the affected ear Absence of p
ain indicates rupture of Tympanic Membrane ear drum Lab Data : OTOSCOPY revealed
reddened, bulging tympanic membrane infection of the middle ear
Nsg Dx : PI :
Infection Sensory Perception Alteration
Treat Infection (antibiotics 7-10 days) if does not heal possible MYRINGOTOMY
Hx Teaching : RIGHT POSITION while feeding

RETINOBLASTOMA
S/S : congenital tumor of the retina; genetically transmitted; autosomal dominan
t (common in MALE and FEMALE) LEUKOCORIA cats eye reflex - whitish or grayish disco
loration of the pupil Diplopia and or Strabismus LAB DATA : Nsg Dx : Tx : PE Opt
halmoscopy Knowledge Deficit Surgery Inoculation done b4 age of 3 (chemotherapy
after surgery) Genticist
RETINAL DETACHMENT RF:
Aging (above 40) Related to trauma
GLAUCOMA
Aging (above 40)
CATARACT
Aging (above 70)
Common in Blacks Related to Trauma Familial Predisposition Rel. to Diabetes Rel.
to Steroids Rel. to Chromosomal Abberation - those with D. Syndrome are prone
RETINAL DETACHMENT
MP : There is separation of sensory and pigment portion of the retina therefore
it will allow fluids to go in between which give rise to OUSTANDING manifestatio
n as: VISUAL FLOATERS pt says: I see light structures Curtain like Floating spots
Cobwebs S/S : NO Pain Blurring of vision because of floaters Opthalmoscopy Risk
for Injury Immediate Bed rest AFFECTED SIDE TOWARDS THE BED to allow the connect
ion of DETACHED PART NO SUDDEN HEAD MOVEMENT AVOID reading (TV ALLOWED) Prepare
Pt for Surgery: SCLERAL BUCKLING use of laser to reduce inflammation and when in
flammation subside, the detached retina portion will be attached thru scar forma
tion.
Lab Data : Nsg Dx : PI :
POST SURGERY :
AVOID activity that requires BENDING, LIFTING, COUGHING;
(No Bowling & shampooing of hair at sink)

REPORT SUDDEN eye pain indicative of bleeding/ hemorrhage

GLAUCOMA
MP : INCRASE IOP due to obstruction in the outflow of acqeous humor or could be
related to forward displacement of the iris. TREATABLE but NOT CURABLE If Obstru
ction related : could lead to CHRONIC OPEN ANGLE.
If due to Forward displacement: can lead to ACUTE CLOSE ANGLE S/S : TUNNEL or Gu
n Barrel Vision wherein there is loss of Peripheral Vision Halos around lights r
ounded rings around eyes CLOSED ANGLE GLAUCOMA (+) pain OPEN ANGLE GLAUCOMA mini
mal or (-) pain LAB DATA:
Tonometry measures IOP (N12-21) PAINLESS ACUTE G as hi
gh as 25; Chronic G - as high as 50
Nsg Dx : PI : Gonioscopy Opthalmoscopy Perim
etry measures visual field Risk for Injury
TO DECREASE IOP How: a. Administer MIOTICS (Pilocarpine, Tomolol, Diamox) for LI
FE - it decrease the production of ACQEOUS HUMOR admin. At lower conjunctival sa
c
b. Prepare pt for Surgery : TRABECULOPLASTY a new pathway was created for the pa
ssage of
the blocked fluids; - Out-patient only (use of laser only)
TRABECULECTOMY Hx Teachings : same w/ retinal detachment
requires hospital admission for 1-2 days

CATARACT
MP : Opacity of the Crystalline Lense S/S : Blurred Vision (Poor Color Perceptio
n) NO PAIN
LAB DATA: a. SLIT LAMP TEST test for red light reflex
(this reflex is absent in cataract pt due to presence of milky white lens)
b. Opthalmoscopy Nsg Dx : PI : Risk for Injury
Prepare for SURGERY

CATARACT EXTRACTION
Extra Capsular Cataract Extraction (ECCE) Intra Capsular Cataract Extraction (IC
CE)
ECCE removal of anterior part ICCE removal of entire capsule
PHACOEMULSIFICATION
- needle is inserted to lens and send vibration thereby crushing the cataract t
hen suction it out PERIPHERAL IRIDECTOMY a whole is created then suctioning

Post Cataract Surgery NO SEX for 4-6 weeks Health teachings same w/ R. Detachmen
t
MENIERES DSES
RF : High altitudes Aging Ototoxic Drugs Cause by an imbalance of EndoLymphatic
Fluids in the inner ear Sensori-neural hearing loss since Inner ear was affected
S/S : Tinnitus Hearing Loss + VERTIGO (only for M. DSES) Caloric Stimulant test
OTOSCLEROSIS
(hardening of the ears)
Aging
MP :
Overgrowth of the stapes
Conductive Hearing Loss - since middle ear was affected same same
Lab Data:
Webers test lateralization of sound Rinnes bone conduction Audiometry
(above test use of TUNING FORK)
Nsg Dx : PI :
Risk for Injury SAFETY
(to prevent pt from falling: bedrest or supine danger of falls)
Sensory Perceptualalteration Establish Communication
Surgery : STAPEDECTOMY mobilization of
stape

DIET : Meds : Effective :

LOW NA (AVOID Alcohol & Caffeine containing food) AntiVertigo Diamox, Bonamine (
-) Vertigo/ Falls AVOID - driving PMS Sudden Head Movement Post Surgery Hx Teach
ings:
AVOID diving Small airplane Coughing Blowing of Nose Bending
TIPS FOR EENT
A pt who underwent cataract surgery w/ intraocular implantation is scheduled for
discharge, the nurse shld instruct the pt to do w/c of the ff when pain occurs
notify the AP; w/c Nsg Dx is considered a priority for a pt with Menieres Dses Ri
sk for Injury a Tonometer is used for the purpose to determine IOP;

Post Cataract Extraction : how shld the nurse position the pt UNAFFECTED SIDE to
minimize edema; w/c of the ff is a common manifestation of Retinoblastoma Cats E
ye Reflex; The parents of the pt w/ retinoblastoma must be referred to - GENETIC
IST

GASTROINTESTINAL
GENERAL CONSIDERATION

Provide privacy Ask the pt when he 1st notice the S/S Eg. LIVER CIRRHOSIS when d
id you notice that your eyes turns yellow?
PEDIATRIC CONSIDERATION
Introduction of FOOD: (shld be in order) Cereals Fruits
Vegetables Meat Table foods Obtain child Dietary History Assess for over-intake
of milk poor source of iron (IDA) REPORTABLE S/S Vomiting Abdl Pain (if more tha
n 6hrs) R/O rupture of the bowel Tarry Stool indicates bldg (upper GI) Fever, Ta
chycardia, Dehydration indicative of SHOCK Hypotention KEPOINTS Bowel Sounds (che
ck all 4 quadrants- N 5-35 bowel sounds/min) - to assess, use DIAPHRAGM of Steth
to listen for normal sounds BELL part of Steth to listen for abnormal bowel sou
nd Ex. bruit abnormal vascular sound w/c indicate abdml aortic aneurysm
DIARRHEA/ AGE
usually asso w/ NORWALK
(common in ship),
ROTAVIRUS and CLOSTRIDIUM DEFFICELE
MP : Passage of watery and loose stools (BEST judge in the consistency) S/S : Fr
equent stools Sign of DHN sunken fontannels Poor Skin Turgor Absence of Tears (f
or more than 2 MONTHS old infant) Check for complication : Metabolic Acidosis If
excess fluid loss, it will progress to shock due to K loss (hypokalemia) LAB DA
TA : Stool Exam to check for bacteria Nsg Dx : Diarrhea Fluid Volume Deficit Pla
ce pt on ENTERIC ISOLATION PRECAUTION while waiting for lab result
(handwashing & gloves ONLY)
PI :

CHALASIA
GERD
CONGENITAL WEAKNESS OF THE CARDIAC SPHINCTER
S/S:
vomiting - NON-BILE-STAINED
Hear-burn due to Reflux of Acid
Complication :
METABOLIC Acidosis BARRETTS ESOPHAGUS LAB DATA : Upper GI Series (
Ba Swallow) Gastroscopy Esophagoscopy do do do same same
- damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal
CA
Nsg Dx : Altered Nutrition Less Than Body Requirement Flds & E Imbalance PI : In
sure Adequate Nutrition Position: Place pt in UPRIGHT to avoid vomiting
(if BABY: use HARNESS or PRONE w/ HEAD UP POSITION)

Administer flds Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, theref

ore X100) Health teachings crackers, juice, water Feeding : Thickened Prepare pt
for surgery : NISSINFUNDOPLICATION part of fundus will be sutured to esophageal
area to tighten Effective: if (-) vomiting and(-) reflux and heartburn
POISONING
INTERVENTION: a. CALL poison control center; b. MINIMIZE EXPOSURE remove pt from
the scene c. IDENTIFY the type of poison if unknown substance was taken bring bot
tle or foil for proper identification TYPES:

CORROSIVE DO NOT INDUCE VOMITING Management: NEUTRALIZE the poison If STRONG ACID
give WEAK BASE
(eg. ACID give MILK)
IF STRONG BASE use weak ACID by using vinegar

NON-CORROSIVE induce vomiting by stimulating GAG REFLEX

How:
a.
b.
Use fingers or tongue blade Syrup of Ipecac administer w/ glass of H2O make sure
that all taken will be vomited bec it is cardiotoxic (after 1hr can repeat) dos
age: CHILDREN 15 ML ADULT - 30 ML
CLEFT

LIP
MP: Non-fusion of facial process
PALATE
Non-fusion of Palative Processess (soft & hard)
(congenital) Nsg Dx : Altered Nutrition Risk for Aspiration Body Image Disturban
ce PI : Nutrition Safety Prepare for Surgery Chiloplasty - for 10wks old 10 lbs
10gms/hgb 10,000 WBC Post Surgery:
(congenital)
Surgery : Palate Uranoplasty - if child is 15-18 mos
CRYING shld be minimize bec it will put pressure at suture line; LOGAN BAR/ BOW
it decrease tension at suture line; ELBOW RESTRAINT prevent child from touching
the suture line; FEEDING DEVICE C CLIP use dropper, C PALATE use Breck Feeder/ c
up Refer pt to: SPEECH THERAPIST, AUDIOLOGIST & PSYCHOLOGIST
PYLORIC STENOSIS
S/S :
congenital hypertrophy
(kumapal)
of the pyloric sphincter (bet stomach & intestine)

PROJECTILE VOMITING
(INITIALLY, NON-BILE STAINED but eventually it PROGRESSESS TO bile-stained)
If sitting : 4-5 ft If lying down : 1 foot Feeding should be thickened then AFTE
R FEEDING, place to RIGHT SIDE LYING SEATED at car seat to facilitate the entry
of food from stomach to duodenum OLIVE-SHAPE MASS VISCIBLE PERISTALTIC MOVEMENT
usually from L to R of the abdomen w/c can lead to DHN
LAB DATA : Ba Swallow (+) string sign NSg Dx : Altered Nutrition Fluid Vol Deficit
Fld and E imbalance Nutrition Surgery FREDET-RAMSTEDT or PYLOROMYOTOMY
PI :
incision at pyloric sphincter
CELIAC DISEASE
GLUTEN INDUCED ENETEROPATHY

MP :
Genetic predisposition Life-time disorder Intolerance to GLUTEN
OUTSTANDING S/S : Malabsorption Syndrome-crisis Abdl Enlargement this can be tri
ggered by INFECTION & Fld and E imbalance Anorexia Anemia - there will be SEVERE
DHN LAB DATA : Nsg Dx : PI : Diagnostic Test : GLUTEN CHALLENGE 3-4 mos give gl
uten rich food And if there is malabsorption, therefore (+) CDses Altered Nutrit
ion Dietary Modification : AVOID GLTUEN RICH FOOD : ALLOWED :
Rice, cereals, corn, soy beans Barley, rice, oats, wheat
Commercially prepared cakes are made of wheat AVOID Ok or allowed: if pt say I wi
ll prepare a homemade cake AVOID : spaghetti, macaroni, sausage, luncheon meat, h
otdog
HIRSCHPRUNGS DISEASE
MP :
(AGANGLIONIC MEGACOLON)
Absence of parasympathetic nerve fibers in a portion of a colon dilation, abdomi
nal distention and pellet-like or ribbon-like stool.
Patient meconium ileus & constipation HALLMARK SIGN
LAB DATA : BA Enema Nsg Dx : Diet : Tx : Meds : Altered Ellimination High Fiber
Increase fluids Give Enema Laxative Surgery SOAVE Surgery resection with end to
end pull through
INTUSSUCEPTION
MP : There is telescoping of a part of a colon which leads to inflammation and e
dema

S/S :
sausage-shape mass Abdominal distention Dance sign the R lower portion of the colon
becomes empty Vomiting : BILE-STAINED Constipation LAB DATA : Ba Enema: if for D
IAGNOSTIC : it outlines the area involve if for THERAPEUTIC : it reduces intussu
ception by means of hydrostatic pressure Nsg Dx : Diet : Tx : Constipation Alter
ed Elimination Inc. Flds. High Fiber wonder drugs steroid surgery
TRACHEOESOPHAGEAL FISTULA (TEF)
MP : Failure of the esophagus to develop as a continous process Types :
AF1 AF2
AF3 AF4 AF5 AF6 esophagus NOT connected w/ abdomen/stomach esophagus attached to
trachea (when pt eat, it goes to the lungs) stomach connects w/ trachea stomach
& esophagus connected stomach, eso and trachea are connected separated properly

Atresia narrowing Fistula connection S/S : Excessive Drooling danger in aspiration

(avoid glucose water as initial feeding use sterile H2O instead.)
Coughing, Chocking Cyanosis LAB DATA : Nsg Dx : PI : Lateral Neck Xray to check
the esophagus Risk for Aspiration Safety Airway Keep child NPO just give pacifie
r Surgery
(if feeding OK use sterile H2o instead NOT GLUCOSE)
Tx :
TIPS FOR GASTRO PEDIA
w/c of the ff signs if manifested by a child post tonsillectomy needs to be repo
rted FREQUENT SWALLOWING;

a child who has had several episodes of diarrhea is likely to develop metabolic
acidosis; in relation to dx of p. stenosis, w/c of the ff actions of the nurse i
s important weighing pt daily for wt loss; w/c of the ff will the nurse expect t
o observe in a child who loss fluid due to diarrhea flushed dry skin; the most a
ppropriate feeding device for a child post cleft palate paper cup; the priority
nsg care for a child on NPO is offer a pacifier regularly; a common manifestatio
n of pyloric stenosis is visible peristaltic wave; the priority nsg dx for a pt
w/ rotavirus infection is diarrhea; w/c of the ff is expected in a child sufferi
ng from celiac dses intolerance to gluten

PEPTIC ULCER
RF : Stress Smoking Salicylates or NSAIDS Helicobacter Pylori Zollinger-Ellison
Syndrome (gastinoma) tumor of the stomach GASTRIC
RF : MP : same Weakened Mucosa Common in Female Below 65 Inc risk for CA
due to increase HCL acid
ESOPHAGEAL
same
DUODENAL
Excessive HCL Acid Common in Male 65 yo & above
OUSTANDING S/S: PAIN aching, burning, gnawing PAIN 30mins 1hr post meal PAIN at
daytime Pain relieved by vomiting
- severe bleeding shock
2-3hrs after meal Nightime Pain relieved by eating HEMATEMESIS (vomiting of bloo
d)
Also related as hyperacidity
LAB DATA :
GASTRIC Analysis (diamox blue urine) Gastroscopy BA Swallow HgB Hct Nsg Dx : PI
: PAIN Relief of Pain
Meds :
ANTACIDS:
Maalox it NEUTRALIZE HCL Acid; RANITIDINE - it DECREASE HCL Acid; SUCRALFATE - i
t COATS the GIT
NO ASPIRIN Diet : BLAND DIET NO SPICY, fried, raw fruits and vegetables

(EXCEPT: avocado, banana & pineapple)

GASTRIC SURGERY
VAGOTOMY PARTIAL GATRECTOMY Billroth I (BI) and Billroth II (BII) TOATAL GASTREC
TOMY
BI gastrodoudenostmy duodenum and stomach BII gastrojejunostomy stomach and jeju
num COMPLICATIONS:
PERNICIOUS ANEMIA due to decrease INTRINSIC FACTOR w/c came from stomach;
G SYNDROME (occur usually for
10-12 mos post surgery)

DUMPIN

due to rapid emptying of the stomach and stimulation of gastro-colic reflex

GASTRO-COLIC REFLEX is usually due to increase CHO INTAKE in the diet - NO PANCA
KE, NO UPRIGHT SITTING AFTER MEALS
S/S OF Dumping Syndrome :
Diarrhea Diaphoresis Dizziness/drowsiness
Management: NO FLUIDS after meals instead in between meals DIET: High Fats becau
se it delays the emptying of the stomach LOW CHO Lie down after eating
INFLAMMATORY BOWEL CONDITION
ULCERATIVE COLITIS DIVERTICULITIS CROHNS DSES (Regional Enteritis)
RF : With familial Predisposition Common in those LOW FIBER Diet Related to Gene
tics Smoking as Protective Effect Common in Aging Common in Obsessive-Compulsive
Or Stress Related or to perfectionist MP : Inflammation @ large Intestine Inflam
@ L Intes. Specifically @ recto-sigmoid colon at DIVERTICULUM S/S : DIARRHEA FEV
ER (15-20x/day) bloody mucoid (+) same diarrhea & constipation (+) LLQ Inflam of
small & large intestine same 3-4x/day (+) RLQ
CRAMPY ABDL PAIN LLQ (Rigidity (REPORT ASAP) sign of colon rupture) LAB DATA: BA
ENEMA Colonoscopy Stool Exam PAIN Altere Elimination: Diarrhea
Nsg Dx :
PI :
Relieve Pain Meds: Steroids

Anticholinergic Antidiarrheals Antispasmodic DIET : Low Fiber and Low Residue fo

r Ulcerative and Chrons Diverticulosis High Fiber/residue allowed: vegetables Low
residue (no vegetables) SURGERY : Colostomy irrigate Ileostomy no need for irri
gation
Characteristic of N Colostomy

REDDISH or PINKISH EDEMATOUS MOIST N elevation from skin: 2.5 cm Diameter : 5cm
When to empty colostomy: when 1/3 full (EMPTY DO NOT CHANGE) When to change C. B
ag : 48hrs or 3x a wk BEST TIME TO DO COLOSTOMY CARE at home, while in the bathr
oom STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS
HEMORRHOIDS
MP RF
PREGNANCY PROLONGED STANDING PORTAL HPN hepatic enceph and liver cirrhosis Varic
osities of the ANAL SPINCHTER
GRADE
I II III IV Small Area Large Area reduces spontaneously Entire Area manual reduc
tion Entire Area irreducible
TYPES
INTERNAL H above the spinchter EXTERNAL H below the spinchter
S/S
Pruritus Pain Bleeding Sigmoidoscopy Proctoscopy P Exam Altered Elimination
LAB DATA
Nsg Dx PI
Diet :
High Fiber Avoid Spicy
PAIN use SITZ BATH (48 degree C temp of H2o) - emerge up to pelvic area with ice
pack at head to prevent dizziness STOOL SOFTENER SURGERY
PANCREATITIS
RF AUTODESTRUCTION OR AUTODIGESTION of the pancreas
#1 Alcoholism #2 autoimmune High Fat Diet Biliary Dses PAIN @ peri-umbilical are
a or epigastric that radiates to peri-umbilical area
SS

GREY TURNER SIGN pain w/ bluish discoloration at flank area; CULLENS SIGN pain w/
bluish discoloration @ umbilicus NAUSEA & VOMITING SHOCK as complication LAB DA
TA Nsg Dx PI Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks) PAIN R
elieve PAIN Meds: DEMEROL DRUG OF CHOICE
AVOID MORPHINE it causes more pain bec it will causes spasm to the spinchter of
oddi DIET LOW FAT AVOID alcohol
CHOLELITHIASIS
Combine or usually come together in a pt
CHOLECYSTITIS
Stone in gall bladder
Inflammation of the G. bladder
RF
Fat Female Fertile Forty flatulence
same
S/S
R UQ Pain radiating to R shoulder or R Scapula usually precipitated by FATTY INT
AKE GI S/S NAV diarrhea and Jaundice URINE: dark colored STOOL : clay-colored or g
rayish alcoholic stool
LAB DATA
Increase AMYLASE, WBC, FATS Increase Liver Fnx test USG PAIN Relief of Pain meds
: DEMEROL diet: LOW FAT surgery : 1) LAP. CHOLE 4 small incision, CO2 insufflat
ion 2-3 days after discharge pt and back to ADL 1 WK after pt can lift weight 2)
CHOLECYSTECTOMY R SUBCOASTAL - complication: Pneumonia report rusty-colored sputu
m hx teaching: TURNING, COUGHING, DEEP BREATHING
Nsg Dx PI
HEPATITIS
MP TYPES A
Infectious Fecal-oral
Inflammation of the Liver
B
SERUM
C
D
POST TRANSFUSION Non A & B
E
DELTA HEPA Post Hepa B ENTERICALLY-TRANSMITTED Fecal-oral
bld, body flds

2-6 wks
6wks-6mos
70-80 days
6wks-6mos
(Hepa A & B Combination
STAGES OF HEPA B

PRE-ICTERIC - 1-2 days : S/S NAVDA NO jaundice yet; ICTERIC - 2-4 wks w/ jaundic
e; POST ICTERIC - 2-4 mos s/s subside Increase Liver Funx Test (Inc AST/ ALT) He
pa A Inc HaV Hepa B HbsAg Infection Alt Skin Integrity Body Image Disturbance Tx
for Infection a. Meds : HEPATOPROTECTORS DIURETICS b. Diet : High Calorie Low F
at Isolation : A & E Enteric B, C, D Universal
Lab data
Nsg Dx
PI
COMPLICATION Liver Cirrhosis
LIVER CIRRHOSIS
- scarring of liver tissues TYPES LAENNES
Due to alcoholism
BILIARY
CARDIAC
POST NECROTIC
due to Hepatitis
Due to biliary Disorder
due to CHF
S/S are related to 3 FUNXs of the LIVER

MANUFACTURES : METABOLIZES: STORES :

bile, immunoglubolin, & clotting factors CHO, Fats, CHON, Alcohol and Drugs Vita
mins & Minerals
Signs and symptoms
a.
b. c. d. LAB DATA
pt prone to bleeding; malnutrition no cho metabolize edema due to fld retention
(bec of dec albumin) Flds & e imbalance Increase Liver Funx Test Liver Biopsy

Nsg Dx
Risk for Injury Fld & E imbalance Fld Vol Excess Altered Nutrition SAFETY HOW?
PI

Meds:
Diuretics due to fld retention ANTIHPN due to portal HPN Clotting factors : Coag
ulants give Vit K (to avoid bleeding) LOW CHON or CHON to Tolerance Or High Biol
ogic Value CHON good quality CHON (eg poultry products)

Diet :

SURGERY :
Liver Transplant
COMPLICATIONS:
a. HEPATIC EBCEPHALOPATHY accumulation of ammonia toxic to brain
s/s: PERSONALITY CHANGES DECREASE LOC or irritability/ restlessness
- facilitate excretion of ammonia by acidifying the colon - common s/e : DIARRHE
A
DRUG OF CHOICE : Neomycin, Lactulose
b. ASCITIS accumulation of fluids at the abdomen
s/s : wt gain Increase abdl girth I cannot button my pants anymore
(fluids)
management: abdominal paracentesis aspiration of fluids from the peritoneum - co
mplication: chance for infection & shock
pt preparation: #1 instruct pt to void; #2 position: sitting the evaluate the WE
IGHT, ABDL GIRTH & REPSIRATION
effective if : Pt decrease wt of 5 lbs and decrease or N RR
c. BLEEDING ESOPHAGEAL VARICES DUE TO portal HPN
Lab data Sengstaken Blakemore Tube 48 hrs inflated, scissors at bed side (Balloo
n Tamponade) - effective if (-) hematemesis
TIPS GASTRO ADULT
A pt w/ appendicitis was admitted, of ALL the ff written orders, w/c shld the nu
rse prioritize Administration of Antibiotics;
w/c statement if made by a pt w/ c
irrhosis is a risk factor for having the disease I drink 2 glasses of alcohol /da
y; which of the ff indicates a ruptured appendix absence of pain;

ff subtotal gastrectomy, the nurse shld expect gastric drainage for the 1st 12 h
rs to be reddish brown;
the priority nsg care post common bile duct exploration
preventing hypostatic PNA; w/c question during nsg assessment would confirm the
Dx of L Cirrhosis - how long have you noticed the white in your eyes turns yello
w;

the priority nsg dx for a pt w/ Hepa B altered Nutrition the priority nsg dx for
for pt w/ acute pancreatitis Altered nutrition less than body requirements
NEUROLOGY
DECORTICATE abnormal FLEXION DECEREBRATE abnormal EXTENSION Opistotonous back arc
hing GENERAL CONSIDERATION When assessing the neurological system, pay attention
to the ff:

#1 LEVEL OF CONSCIOUSNESS #2 BEHAVIOR #3 REFLEX When assessing MUSCULO SYSTEM:

#1 Range of Motion #2 Joint Stiffness #3 POSTURES

PEDIATRIC CONSIDERATION a. Check for bowel and bladder funx indicates neurologic
al maturity 15-18 months START BOWEL TRAINING 2 yo start bladder training b. Ass
ess for their habits
security blankets ex. Stuff toys, mother wallet Associate mothers time w/ child act
ivity (children has NO DEFINITE TIME) Ex. Your mom will be back after you have e
aten your lunch.
c. Assess for presence of URTI could be sign of Meningitis, Hemophilus influenza
, Otitis Media
d. Assess child for S/S of anxiety bed wetting nail biting (N up to 4 yo) head b
anging excessive thumb sucking
e. CONTUSSION more severe, fatal and could even lead to death CONCUSSION jarring
of the brain, na-alog w/c could lead to s/s of LOC in 24-48 hrs DECORTICATE abnor
mal flexion which indicates damage to the cortex s/s : #1 Decrease LOC #2 wideni
ng pulse pressure (increase systolic BUT diastole is N) #3 Convulsion & seizures
ABOVE ARE S/S OF INCREASE ICP. DECEREBRATE more serious - abnormal extension w/
c indicates damage to brain stem
GLASGOW COMA SCALE
EYE OPENING (4) VERBAL RESPONSE (5) 5 4 MOTOR (6) 6 5 4 3 2 1 OBEYS COMMAND LOCALI
ZES PAIN WITHDRAWS FROM PAIN INAPPROPRIATE 3 - DECORTICATE RIGIDITY DECEREBRATE
RIGIDITY NO RESPONSE
4 3 2 1
OPEN SPONTANEOUSLY OPENS TO VERBAL COMMAND OPEN TO PAIN 2 NO RESPONSE 1 SCORE OF
3 SCORE OF 15 Score of 8 : : :
ORIENTED CONFUSED INCOMPREHENSIBLE NO RESPONSE
NO response (DEAD) Doctor will the one to pronounce pt is awake 50-50, MONITOR T
HE PT

7 and BELOW
:
pt is COMA
CRANIAL NERVES
I. OLFACTORY : SENSORY :
smell Abnoxious smell Anosmia no smell Perfume
II . III. IV. VI.
OPTIC
:
SIGHT
snellens chart 20/20 usually by age 3-6 yo
OCCULOMOTOR TROCHLEAR ABDUCENS
Eye movement - 6 cardinal direction of gaze (if abnormal look for DIPLOPIA)
V.
TRIGEMINAL
: SENSORY :
responsible for FACIAL SENSATION (to check, use cotton & needle and run across t
he cheek)
AND MOTOR :
ability of pt to chew
Reflex: CORNEAL REFLEX (+) if both eyes can blink
VII.
FACIAL
:
SENSORY :
and
sense of taste @ anterior 2/3 of the tongue Facial Expression
MOTOR
:
VIII.
ACOUSTIC or VESTIBULOCOCHLEAR
- Sense of hearing and balance

TEST : ROMBERGS TEST - stand erect, close eyes, observe for balance
IX. X.
GLOSSOPHARYNGEAL VAGUS
SENSORY MOTOR
Posterior Taste 1/3 Of The Tongue
- swallowing and gag reflex
XI.
XII.
SPINAL ACCESSORY HYPOGLOSSAL
- motor movement of shoulder muscle
TONGUE MOVEMENT
DUCHENES MUSCULAR DYSTROPHY (DMD)
X linked RECESSIVE (only mother transmit to SON) (-) Father Mother (+ carrier) So
n - 50% chance Daughter as Carrier 25% chance
DMD
Erb Duchennes Paralysis (EDP)
Klumpke Palsy (KP)
Related to Birth Injuries affecting the BRACHIAL PLEXUS nerves at axilla portion
HEREDITARY EDP upper plexus KP - lower plexus
w/c leads to paralysis. Prognosis : complete recovery in 3 months Treatment : sp
lint and cast for 3 mos leads to nerve

X-linked RECESSIVE DIRORDER MP characterized by progressive muscle atrophy w/c a

pparent in male at the age of 3 a) GOWERS SIGN inability to stand up - use arms t
o brace the body b) WADDLING GAIT - duck-like gait c) impaired mobility d) diffi
culty in running and climbing COMPLICATIONs LAB DATA Nsg Dx Respiratory Paralysi
s for young children Cardio-Resp. Arrest - for adolescent Muscle Biopsy PExam In
effective Breathing Pattern Impaired Physical Mobility AIRWAY (keep TRACHEO at b
edside)
regeneration
S/S
PI TX a. b.
Supportive - leg brace, crutches Refer parents to geneticist Target: Mothers or
FEMALES bec they are the source of transmission Ex. Aunt, Female Sibling, mother
s, female members of the family (bec transmission: X linked recessive)
CEREBRAL PALSY
- Permanent, Fix (non-progressive) neuromuscular disorder characterized by abnor
mal muscle movement.
Cause S/S Unknown Exaggerated Reflexes Protrusion of the tongue or tongue thrust
ing Early pattern of hand dominance Back Arching Scissors-gait Neurological Asse
ssment PExam Risk for Injury Impaired Physical Mobility SAFETY a. Leg braces Med
s : Anticunvulsants, Muscle Relaxants Prepare child for SURGERY release of TENDO
N OF ACHILLES to promote mobility Refer child to : PT for gross motor movement w
alking OT - for fine motor to open a bottle of soft drinks
LAB DATA
Nsg Dx
PI
b. c. d.
HYDROCEPHALUS
NOT A DISEASE but a manifestation of an existing disorder
Related to ARNOLD CHIARI MALFORMATION
DANDY WALKER SYNDROME
there is ELONGATION of the BRAIN STEM or Medulla - characterized by ATRESIA of a
nd it protrudes to Foramen magnum Foramen of Luschka & Magendie SIDE NOTES: FLOW
OF CSF (N amt : 100- 200 ml) rich in glucose

From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then t
o Aqueduct of Sylvius then it moves to F. of Luschka and Magendie going to 4th V
entricle then it goes back to subarachnoid spaces of brain. S/S OF HYDROCEPHALUS
PROJECTILE VOMITING IRRITABILITY ENLARGED HEAD N Head Circumference : 33-35 cm
(chest circum: 31-35 cm) SEPARATION OF SKULL BONES SEIZURES SUNKEN EYES Can Prog
ress To Bossing Sign MACEWEN SIGN crack pot sound upon knocking the head CT Scan
MRI PExam focus on head circumference (tape measure at bedside to measure H Cir
cumference) Risk for Injury SAFETY Semi Fowlers to prevent increase in ICP Diuret
ics Anticonvulsants Ventriculo-Peritoneal Shunt progressive procedures (AS CHILD
AGE PROGRESSES, the surgery is revised)

LAB DATA
NSG DX PI Position Meds Surgery
SPINA BIFIDA
TYPES
failure of a PORTION of spinal cord to fuse
SB OCULTA
NO SAC W/ DIMPLE or TUFT OF HAIR W/ SAC
SB CYSTICA
SUB TYPES: Meningocele w/ sac that contains CSF and meninges; Meningomyelocele C
SF, meninges and portion of spinal nerves
LAB DATA
Amniocetesis test for ALFA FETO CHON if INCREASE Neural Tube Defect If DECREASE
Down Syndrome CT SCAN PExam
NSG DX
Risk for Injury

PI
Protect the sac
a. b.
c.
Position: Prone or side lying (NEVER SUPINE); Wet sterile gauze to cover the ski
n; DOUGHNUT ring
SURGERY
WITHIN 24-48 HRS
COMPLICATION
Bladder and Bowel Problem Paralysis of Lower Extremities Hydrocephalus (tape mea
sure- at bed side)
Post Surgery Complication
INCREASE ICP
ICP above 15mmhg (N 0-10) Mild elevation : 11 20 Moderate : 21 - 30 Severe : 31
and above
With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP RF
Hydrocephalus Space Occupying Lessions Brain Tumor Trauma
S/S 1. INITIAL: Behavioral Changes irritability, restlessness, decrease LOC drow
siness or pt becomes sleepy 2. Vital Signs Changes widening pulse pressure DECRE
ASE RR and PR INCREASE temperature 3. Vomiting 4. Monitor Abnormalities decortic
ate, decerebrate
Nsg Dx PI
Risk for injury To decrease ICP
Head of Bed ELEVATED Evaluate Neuro Status Glasg
ow AIRWAY Discharge Meds Instruction
Anticonvulsants, Steroids, Diuretics (mannitol to dec amt of cerebral edema)
Seizure precaution DARKENED ROOM
MENINGITIS
Inflammation of meninges w/c could be related to the presence of bacteria esp th
e H. Influenza, and Neisseria Meningitidis disorder S/S of
MENINGISMUS
Inflammation of meninges but WITHOUT infection Usually accompany w/ resp.
INC ICP + Kernigs Sign pain on extension of lower extremities + Brudzinkis - flex
ion of neck would lead to flexion of lower ext.

- sign of MENINGEAL IRRITATION

LAB DATA Nsg Dx PI
Lumbar Puncture CSF Analysis Infection Risk For Injury Safety Seizure Precaution
Tx the Infection Type of Infcetion:
a. Bacterial Meningitis respiratory of droplet precaution b. Viral Meningitis enteric precaution
MEDS Antibiotics
to AUDIOLOGIST For Bacterial Meningitis - may cause hearing impairment - refer
REYES SYNDROME
Non inflammatory, non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY
(CNS) (LIVER)
RF TRIAD S/S
Presence of Viral Infection Use of Aspirin Fever Impaired Liver Funx Impaired Co
nsciousness w/c could lead to convulsion I II III IV V pt becomes lethargic conf
usion decorticate rigidity decerebrate rigidity seizure or coma
STAGES
LAB DATA
Bleeding and Clotting Time Liver Biopsy Neurological Assessment Risk for Injury
Altered Thought Process Altered Thermoregulation Impaired Physical Mobility Trea
tment symptomatic assess neuro status Bleeding give Vit K AVOID ASPIRIN when the
re is VIRAL INFECTION
Nsg DX
PI
CVA/ STROKE
MP Decrease Oxygen to brain cells
TYPES THROMBOSIS EMBOLISM HEMORRHAGE INFARCTION

RF atherosclerosis hpn obesity smoking stress age/ gender SIGNS & SYMPTOMS: 1. D
EPENDS ON THE PROGRESSION
a. TIA brief period of neurologic dysfunction that last less than 24 hrs (betwee
n episode, pt is
N);
b. STROKE IN EVOLUTION there s/s like: facial paralysis Muscle weakness - above
s/s could last 2-3 days c. COMPLETE STROKE there is FOCAL s/s if R side of Brain
Affected L Eye - R Face L Body if L Brain R Eye L face R body 2. RELATED TO LOB
ES

FRONTAL if affected PERSONALITY CHANGES
opening);
BROCAS AREA (expressive aphasia mouth
TEMPORAL - memory disturbances
WERNICKS LANGUAGE AREA (choice of words, understanding - RECEPTIVE APHASIA);
PARIETAL - DISORIENTATION especially SPATIAL orientation; OCCIPITAL - VISUAL distu
rbances
3. SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS Hemianopsia Hemiphlegia Emotio
nal Lability Aphasia
loss of half of the visual field (eg. Pt consumes half of the food at plate); pa
ralysis of one side of the body; mood swing Expressive inability to find right wor
ds to say (damage to Brockas Area); - pt can say right words mgt: picture board a
nd Receptive - inability to understand spoken words (Wernicks area) mgt: talk to
pt slowly
Dysphagia LAB DATA Diagnostic Test
instruct the pt to swallow twice to prevent aspiration
Increase Cholesterol CT Scan MRI EEG Unilateral Neglect inability to care half o
f the body Impaired Physical Mobility Risk for Injury
Nsg DX

PI Position Meds
SAFETY Semi-fowlers Elevated Antihypertensive Diuretics Antilipimic Agents Antico
nvulsants Thrombolytics if (+) thrombus to dissolve clots Low Na and Cholesterol
Range of Motion Exercises Craniotomy
Infratentorial Cranio FLAT Supratentorial - Semi-fowlers
DIET Activity Surgery
DISEASES OF NEUROMUSCULAR :
Guillain Barre Syndrome (GBS) Myastenia Gravis (MG) Multiple Sclerosis (MS) Amyo
trophic Lateral Sclerosis (ALS)
GBS
Descending paralysis start @ upper ext. NO gender related factor but could be re
lated to viral infxn Reversible
MG
Common in Male and Female Early onset : 20-30 yo (Female) Early onset : above 50
yo (male) Deficiency in ACTH Receptor Sites Or Def. in ACTH
MP Inflammation that leads to destruction of Peripheral Nerves 90% w/c leads to:
ASCENDING GBS neurotransmitter DESCENDING GBS Mixed Type GBS ASCENDING GBS - #1 C
lumsiness that eventually lead to face muscle weakness & resp. depression
which to telebabad)
S/S Muscle weakness w/c begins at therefore, Diplopia and Ptosis
progresses to MASK-LIKE face which lead respiratory depression (descending paral
ysis start at face NO
LAB DATA Nsg Dx PI MEDS
CSF Increase CHON
(to all neuromusco disorders)
TENSILLON TEST 5 mins same same Neostigmine ATSO4 - antidote
Avoid crowded areas : viral infection
Ineffective Breathing Pattern (ALL) AIRWAY (tracheostomy bed side) ALL
Steroids
Refer to NEUROLOGIST, PULMOLOGIST and PT
MYASTHENIA GRAVIS
COMPLICATIONS

Myasthenia Crisis (MC) Cholinergic Crisis (CC)
- due to under medication or lack of meds; - due to over medication overdose

Signs and symptoms of above complication: MUSCLE WEAKNESS in MC due to ACTH Defi
ciency while in CC due to or as adverse effect of the drug Treatment : TENSILLON
effective in MC it INCREASE MUSCLE STRENGTH Effect in CC it worsens muscle weak
ness once given give ATSO4 NEOSTIGMINE for MC as TREATMENT
MULTIPLE SCLEROSIS
Common among women especially white There is destruction of MYELIN SHEET at CNS
, therefore generalized muscle weakness
Eg. I know I will be eventually confined in the wheelchair s/s of generalized mus
cle weakness: FACIAL diplopia Impaired Cerebellar Funx Ataxic Gait lasing Impaired
Sensation NO HOT/COLD BATH Impaired Sensory Funx impotence
dyemlination
LAB DATA
#1 MRI specific test for MS it localizes the area of plaque formation or the are
a of #2 CT SCAN
NSG DX DRUGS
same with GBS & MG STEROIDS Anticonvulsants dilantin Muscle relaxant Baclofen Bl
adder Stimulants Urecholine (bethanicol) AVOID : HOT COLD SHOWER Refer to PT: RO
M Exercises
HX TEACHINGS
AMYOTHROPIC LATERAL SCLEROSIS
(LON GAHRIGS DISEASE) MP Destruction of Upper and Lower Motor Neurons; Geneticall
y Transmitted: AUTOSOMAL DOMINANT common in Male & Female More Pronounce is DYSP
HAGIA
The muscle weakness will eventually lead to RESPIRATORY DEPRESSION
LABDATA
CSF Increase CHON EMG contract and relax needle insertion Muscle biopsy Ineffectiv
e Breathing Pattern AIRWAY (tracheostomy) SUPPORTIVE Refer to Geneticist
NSG DX PI
SIDE NOTES:

DSES
A Recessive : A Dominant :
Cystic Fibro, Sickle Cell, Apalstic/Fanconis either or both parents are (+) for
trait NOT Retinoblastoma, ALS either father or mother (+) for disease or trait
X Link Recessive : Hemophilia, Color Blindness, Duchennes Muscular, G6PD Dses mo
ther (+) trait NOT DSES and transmit to SON
SPINAL CORD INJURY
Destruction of S. Cord related to TRAUMA TYPES

PI
CERVICAL THORACIC LUMBAR SACRAL COCCYGEAL SAFETY
8 most serious quadriphlegia 12 5 5 1 - immobilize, surgery
LUMBOSACRAL AREA if affected, therefore PARAPHLEGIA bowel and bladder problem TH
ORACIC CERVICAL c1 c4 C5 C8 LAB DATA Myelogram CT Scan Xray Risk for Injury Impa
ired Physical Mobility SAFETY a. b.
Immobilize the spine side lying w/ pillows bet legs Surgery
- paraphlegia + bowel and bladder problem - incomplete or partial quadriphlegia
- Complete quadriphlegia
Nsg Dx PI
COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA due to full bladder and bo
wel
s/s : #1 INITIAL : HPN #2 Diaphoresis #3 slight fever what to keep at bedside: C
ATHETER - TO KEEP THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS
TIPS FOR NEURO
A 10 yo is to undergo EEG, w/c comment made by a pt demonstrate that she underst
ands the procedure I will wash my hair after the procedure;


A pt w/ tumor of the frontal lobe will most likely manifest difficulty in concen
trating; A pt w/ M. Sclerosis has urinary incontinence. To achieve voiding, w/c
nsg care shld the nurse give establishing regular voiding sked; While interviewi
ng a pt. w/ Myasthenia gravis, w/c of the ff statements confirm the dx I have dif
ficulty in swallowing; A male pt w/ CVA is observed by the nurse to have consumed
half of his meal, the PRIORITY Nsg Dx Unilateral Neglect; When taking care of p
t w/ C4 Spinal Injury, w/c equipment shld the nurse keep @ the b.side Urinary Ca
theterization Set; The PRIORITY NSG DX for pt w/ Myasthenic Crisis Ineffective B
reathing Pattern

MUSCULO
CLUBFOOT DEFORMITY
MP Types Talipes Varus inversion Talipes Valgus eversion Talipes Equinus tiptoe L
TA Nsg Dx PI PE Xray Impaired Physical Mobility Promote Mobility Congenital Foot
twisted out of place

#1 MANUAL MANIPULATION #2 SEREAL CASTING every 1-2 wks til position normalizes #
3 DENNIS BROWN SPLINT 2-3 months CAST : assess for s/s of neurological damage: R
EPORT Capillary refill if more than 3 sec. EDEMA Skin Color/ nailbed
CONGENITAL HIP DISLOCATION
MP S/S Maldevelopment of the Hips that involves the acetabulum, head of femur or
both Extra Gluteal Fold at affected side; Ortolonis Sign (+) Click Trendelenburg
Sign or Pelvic Dropping Allis Sign or Galleazis Sign LAB DATA
when child stand in one foot toward the affected side, then there is change in l
ength shortening of the affected leg
PExam Barlows Manuever press leg downward (+) click Ortolanis abduct leg sideward
(+) click Impaired Physical Mobility #1 Double or triple diaper to keep legs in
abducted position; #2 PAVLIK Harness - for 2-3 mos #3 Hip Spica Cast LAST RESORT
NO ADDUCTION OF LEGS!
Nsg Dx PI
FRACTURES
MP TYPES Break in the continuity of the bone
Open (compound) bone tears the skin therefore open: risk for infection CLOSE ski
n intact

S/S
AVULSION tear in the tendon COMMINUTED - fragmented COMPRESSED crushed IMPACTED
driven to each other DEPRESSED pressed SPIRAL goes around the bone GREENSTICK in
complete #1 Deformity #2 Pain #3 Edema

#4 CREPITUS sound created when two bone surface rob each other NSG DX PI Impaire
d Physical Mobility MOBILITY immobilize the fx a. Splinting; b. Casting check fo
r edema elevate the affected areas; - check skin color capillary refill time - c
heck for presence of blood stained
c. After cast, - CRUTCH WALKING

2 point gait indicated if both lower extremities has partial wt bearing; 4 point
gait indicated for partial wt bearing; 3 point gait - indicated if 1 leg is all
owed partial wt bearing and the other one is N;
swing through - when both legs n
eed to moved past the level of the crutches swing to when both legs need to be m
oved AT THE LEVEL OF THE CRUTHES
going upstairs unaffected then crutch (goodleg crutch bad) going down crutch the
n bad leg then good leg
SCOLIOSIS
MP RF Lateral Deviation of the Spine STRUCTURAL non correctible FUNCTIONAL - cor
rectible
OUSTANDING S/S
Uneven Hemline; Uneven waistline; Uneven shoulder (+) Rib Hump Pr
ominent Iliac Crest Bend Over test instruct to touch the toes and note for rib h
ump Xray Impaired Physical Mobility - child Body Image Disturbance - adolesence
a. To decrease curvature wear BOSTON or MILWAUKEE Brace for 23 hrs/day except ba
thing b. SURGERY HARRINGTON ROD - LUQUE Avoid : Bending Jumping Rope Playing Ten
nis Trampoline Brisk Walking Swimming Cheer Leading
LAB DATA Nsg Dx
TX
HX Teaching
Allowed:
OSTEOPOROSIS/ HUNGRY BONE

MP RF
Loss of Bone Density #1 smoking AGING IMMOBILITY MENOPAUSE decrease Estrogen Sec
ondary to Existing Condition as secondary Hyperparathyroidism PAIN Dowagers Hump
Short Stature Progressive Decrease in Height Decrease in Calcium Bone Densinomet
ry Bone Scan Xray SAFETY
S/S
LAB DATA
Nsg Dx How?
DIET : High Ca especially 4 those with OSTEOPOROSIS
- spinnach - seafoods - sardines
ACTIVITY : Partial Weight Bearing (NO SWIMMING)
jumping rope - bicycle reading - brisk walking
MEDS : Ca Supplement - alendrona
te Fosomax SIT UPRIGHT AFTER
ARTHRITIS
RHEUMATOID Common Affected Part MP
Chronic, systemic inflammation of connective tissues Synovial joints and joints
of Upper extremities
FEMALE Upper Extremities
GOUTY
MALE Lower Extremities
OSTEOARTHRITIS
MALE/FEMALE wt bearing joint
S/S
PAIN Inflammation Morning Stifness
Stages of Rheumatoid A.

STAGE 1 no Disability
STAGE 2 with Interference To ADL
STAGE 3 - with major compromise of funx
STAGE 4 - incapacitation ULNAR DRIFT LAB
DATA Nsg Dx PI Decrease HgB Increase ESR PAIN Impaired Physical Mobility Relief
of Pain a. Warm Bath; b. MEDS : ASA - Antiinflammatory STREROIDS c. exercise: R
OM SWAN NECK DEFORMITY
GOUTY ARTHRITIS
MP S/S Metabolic disorder of purine w/c leads to deposition or uric acid at join
ts site: THE GREAT BIG TOE (+) PAIN usually aggravated by pressure (+) Inflammat
ion
above s/s affects the LOWER EXTREMITIES
LAB DATA NSG DX PI
Increase Uric Acid PAIN Impaired Physical Mobility Relief of PAIN Meds : Allupur
inol, Probenecid Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats SEAFO
ODS Alcohol
ALLOWED: Cheese (EXCEPT fermented and Aged)
Increase ORAL Fluid Intake
OSTEOARTHRITIS
A degenerative joint disease that involves the weight bearing joints elbows & kn
ees S/S PAIN NO inflammation Bouchards Nodes (distal) Heberdenes Node (proximal)
LAB DATA xRAY Nsg Dx PI PAIN Impaired Physical Mobility Weight Control Hot or Co
ld Compress
Health Teaching

ASA Trunk Assistive Device (cane)

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Autoimmune multi system dses characterized by inflammation of connective tissues
JOINT CARDIOVASCULAR CNS OUTSTANDING S/S LAB DATA Nsg Dx : : : (+) pain, (+) mo
rning stiffness; (+) chest pain; (+) s/s of dec LOC, Irritability, Headache
(also present in pt in PROCAINAMIDE TOXICITY)
BUTTERFLY RASH
Increase ESR PAIN Altered Tissue Perfusion Risk For Injury Symptomatic/ Supporti
ve meaning, treat available s/s Steroids
TX Drugs
TRACTION
PRINCIPLES T rapeze bar R equires free hanging weights A nalgesic C iculation mo
nitoring T emperature monitoring I - nfection prevention O utput and input monit
oring N utrition S kin Assessment
TIPS FOR MUSCULO
the priority nsg care for the pt w/ bucks extension traction shld be ensure that
the traction applied to the affected leg is always attached to the weight; pt i
n russels traction is being taken cared of by the nurse, it would be necessary fo
r the nurse to intervene if the pt feet are pressed against the foot board; a pt
is using CRUTCHES for the first time, w/c action reflects a need for further in
struction the pt bears his/her wt with his/her axial; a pt on bucks traction of t
he R femur ask the nurse how he can possibly move around. What can the nurse adv
ise the pt you can hold on to the trapeze bar while moving;

w/c of the ff can possibly indicate the presence of abnormality in an adolescent

uneven hemline scoliosis;

when assessing an infant, w/c of the ff needs to be reported extra gluteal folds
; post spinal fusion ROBAXIN is given for w/c of the ff purpose muscle spasm;
- to decrease

a child has hip spica cast upon discharge, w/c statement of the father indicates
further instruction I will hold on to the bar bet his legs to help move him
INTEGUMENTARY SYSTEM
Burn triage : face and perineum (priority)
BURNS
Traumatic injury to the skin brought about by : FIRE CHEMICALS PROLONGED EXPOSUR
E TO SUN ELECTRICAL CURRENT HOT H2O CLASSSIFICATION:

According to Damage

PARTIAL THICKNESS FIRST DEGREE

EPIDERMIS Pain Redness Eg sunburn
2ND DEGREE
EPIDERMIS & PART OF DERMIS Redness Blister Formation pain

FULL THICKNESS
THIRD DEGREE
SUB Q FATS MUSCLES LEATHERY APPEARANCE NO Pain
4TH DEGREE
SUB Q FATS MUSCLES & BONES CHARRED APPEARANCE No Pain
MINOR PARTIAL TICKNESS FULL THICKNESS less than 15% NONE
MODERATE 15-25% <10%
MAJOR 25% >10%
RULE OF 9 CHECK NOTE day 9 page115
BURN TRIAGE
Priority : Burns of FACE PERIMEUM UPPER & LOWER EXT Burn related to Child Abuse
Chemical Fire THINK:
R escue A larm C onfine the Fire E xtinguish the Fire
PRINCIPLES OF NSG CARE FOR BURN PTS:

B reathing Airway U rine output monitoring R esuscitation of Fluids N utrition S

ilvadene Ointment
DIET
DAT (High CHON, Ca, Vit C) FIRST 24HRS SHOCK 72Hrs - INFECTION
Complication
Pt Preparation :Bed Craddle
Fever
dog ticks
LYMES DISEASE
Rocky Mountain
caused by BORRELIA BURGDORFERI

(deer ticks)
Dermacentor/ Variabilis

3-30 days
or Dermacentor Andersori (wood) 2-3 wks
s/s :
Fever, Pain, Chills, Rashes Generalized rashes
RASHES: Bulls Eye Rash or Rounder Rings At moist body parts Complications Cardio,
Musculoskeletal and CNS - which can lead to paralysis TX PI
Avoid wooded area have you been to the woods? Vaccination Use long sleeve Remove t
icks w/ twizers upward straight motion Chloramphenicol Tetracycline
Meds
DERMATITIS
DIAPER (contact)
Peak patients S/S : During infancy 9-12 mos Due to prolonged exposure to urine,
soap & excreta
ATOPIC ECZEMA
(adult)
Cause : Hereditary Prone to asthmatic
:
RASH
RASH + scaling, Crusting Pruritus or itching Viscicles Management: Hydrate the s
kin w/ cold compress Meds: Benadryl (antihistamine)
ROSEOLA
Exanthem
Causative Agent INC PERIOD
RUBEOLA
MEASLES Measle Virus
10 -20 days
RUBELLA
GERMAN MEASLES Rubella Virus
14 -21 days
Herpez Virus
Unknown
s/s
RASH
FEVER and RASH
Begins w/ face & downwards Face & downwards
Non Pruritic Rose pink begins w/ trunk

Progressing outward
With KOPLICKS SPOTS 3 Cs : Coryza Cough Conjuctivitis MANAGEMENT: (to all types) B
ed rest Antibiotics Antipyretic
+
same
SYPHYLLIS
C Agent I. Period T Pallidum 10-13 wks
GONORRHEA
N Gonorrhea 2-7 days Zoster
HERPEZ
Simplex
Vericella Zoster Virus
Herpes Simplex Viruz
Genital H
Abdominal
Oral Herpez
Steroids
2-12 days vesicle
Around the mouth
Inner thigh Buttocks Genitals
Acyclovir Cervical Ca complication of Herpez Annual pap smear
TRICHOMONIASIS
Caused by TRICHOMONAS Vaginalis Both are STDs Charac of discharge : Greenish/ Ye
llowish With FOUL ODOR Inc Period Druf pf Choice 4 20 days Flagyl
MONILIASIS/CANDIDIASIS
Albicans
WHITISH-CHEESELIKE discharge 2 5 days Amphotericin

TIPS
A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds round
ed rings of rash. This is indicative of lymes dses; During the immediate 24hrs po
t burn, w/c of the ff is the priority administration of fluis; A pt tells the nu
rse that he notice small blisters on his private parts. This is indicative of HE
RPEZ A pt with CA of the cervix was admitted with the ff data: w/c one indicates
a possible risk factor previous tx for herpes; w/c of the ff indicates effectiv
e tx of gonorrhea (-) purulent discharge; a pt is diagnosed w/ herpes zoster, w/
c of the ff is the priority nsg dx PAIN; w/c of the ff is indicative of CHLAMYDI
ASIS burning on urination

CANCER
Cause RF Unknown Theory of USE - Overuse, Underuse, and Abuse Smoking : RACE : L
ung, Bladder and Laryngeal or Oral CA Jewish Breast Blacks - Cervix and Prostrat
e Whites Testes Nulliparity breast having baby after 35 yo Multiparity cervix Hi
gh Fat and Low Fiber CA of Colon Spicy Ca of Prostrate
PARITY : DIET :

Raw Ca of Stomach LABDATA

egins age 16 yo- target are
xually active) - anually b.
phy baseline : 35-40 yo :
TH MALE AND FEMALE

Screening Exams Male: a. Testicular Self Exam mothly b

high school Female: a. Pap smear at age of 18 (if se
Breast self exam beginning age 20 monthly c. Mamogra
AFTER 40 yo once every 2years After age 50 annually BO

Nsg Dx
Digital Rectal Exam Sigmoidoscopy STOOL FOR OCCULT BLD : :
40 and above ANUALLY ANUALLY after age 50yo Annually after age 50 yo Knowledge d
eficit HOPELESSNESS
Initial If pt is TERMINALLY ILL If pt has some wishes or Unfulfilled needS :
Powerlessness
Nsg Care Principles : C hemotherapy target cells : those rapidly dividing cells;
A sess Body Image N tuition/diet : high CHON, well balance C aution pt on s/s E
xercise R est COMMON S/S LARYNX LUNGS STOMACH BREAST OVARIAN CERVICAL PROSTRATE
COLON Hodgkins Dses TESTICULAR change in VOICE or Hoarseness changing cough or s
mokers cough (productive) dyspepsia a lump or a discharge complains feeling of fu
llness or indigestion bleeding elevated acid phosphatase, nocturia change in bowel
habits painless enlargement of lymph nodes crytorchidism, spongy testes or lump
(N smooth unequal)
TIPS FOR CANCER
w/c nsg dx is a priority for a pt undergoing chemotherapy SOCIAL ISOLATION; when
undergoing chemotheraphy, w/c solution is used for mouth care HYDROGEN PEROXIDE
; w/c of the ff is an appropriate diet for pt undergoing chemo bland diet; the m
ost common sign of Breast Ca is in upper outer quadrant; pt w/ CA of esophagus w
ill manifest DYSPHAGIA

TIPS FOR
PSYCHE
A pt w/ chronic depression is to undergo ECT, the purpose is to relieve the symp
toms of depression; A nurse shld assess the pt w/ ALZEIMERS DSES for possible cha
nge in orientation; A pt w/ bipolar episodes is ready for discharge when she can
comply with units activities; The nurse would suspect that the child is a victi
m of abuse if he keeps quiet while an IV is inserted; w/c of the ff situations r
eflects an increase in self-esteem of an abuse child - when he ask the nurse for
a plastic cup to drink; the initial care plan for a pt with Anorexia Nervosa wo
uld require the pt to remain in public place 1 hour after meals; where shld the
nurse put the pt on early alcoholic withdrawal well-lighted room near nurses sta
tion

TIPS FOR OB-GYNE

A Mother Is Crying Besides her baby, she said I feel so sorry I couldnt hold her le
t her stroke the baby; 6wks pregnant woman ask the nurse about the signs of preg
nancy w/c one is expected at this time frequent urination; the nurse notes mirro
r image in the fetal monitor this could be related to FETAL HEAD COMPRESSION; wh
ich of the ff is related to trauma ABRUPTIO PLACENTA;

A nurse is caring for a woman in first stage of labor, she is timing the duratio
n of contraction she is correct when she times it from the beginning of one cont
raction to the end of same contraction
TIPS PEDIA
w/c of the ff is expected by 6mos of age sits w/ minimal support; the most appro
priate toy for 18 mos old child carriage w/ a doll; the appropriate room mate fo
r an 8yo girl w/ leukemia is 6 yo with hemophilia;
in a 3yo child w/c of the ff shld the nurse assess during admission special word
s used for objects and routines;

w/c of the ff is appropriate way of administering pre-op meds to 4 yo child ask

the child where she would like the injecvtion to be given

Paralysis of Lower