Le

Not My Notes:
NCLEX

Delegation

RN LPN UAP/NC
Specialized Care (Inc. Level of skill, Newly recovered) Routine Care Activities of Daily Living
Severe Cases Chronic cases
Sterile Procedure Stable clients
Newly Diagnosed
Unstable clients
With Complications (acute, life threatening)
Assessment, Teaching, Evaluation

o Latex Allergy = Kiwi fruit allergy

o History of MVA(head trauma)  Polyuria  Diabetes Insipidus
o Cushing’s triad: 1.) wide pulse pressure
2.) Dec. RR
3.) Dec. PR
* Note a dec. in LOC before Cushing’s triad
o Saw Palmetto = Same as Finasteride  prevents dysuria  given to clients with BPH to dec. the size of
prostate.
o Ma Huang = Same as ephedra  substitute of Sudafed  Shabu or amphetamine like effect
o Di Huang = Dec. blood sugar for DM
o Black Cohosh = Inc. Estrogen  for menopause  relieves hot flushes
o Blue Cohosh = a uterine tonic for starting labor  also after delivery for uterine contraction
o Chamomile = CI in asthma  causes bronchospasm
= CI with gingkobiloba
o Heart Block = Atropine Sulfate
o Tachycardia = Lidocaine
o How many servings of milk, fruit and vegetables a day = 3-4/meal

Chemotherapeutic Agents
1. Cisplastin = causes stomatitis
2. Azathioprine =
3. Methotrexate = Psychotropic precautions

Conversion Disturbances

Primary Gain Secondary Gain Tertiary Gain

Motivation Behind the s/sx The attention that they get Extent to w/c the s/sx is
manifested in order to please
the health care provider
o Goal on Pre-eclampsia = To prevent seizure
o Ileostomy  Normal  2-3 days after (-) discharge

Fat embolism
1.) Dyspnea
2.) Chest pain
3.) Petechiae on the chest
o Priority administer O2  To dec. surface tension of fat globules

DIC = Disseminated Intravascular Coagulation

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 o Systemic clotting  bleeding
o Priority = Prevent systemic clotting
o Normal Fibrinogen level = 180-340mg/dl  < 100  bleeding

Narcotic Withdrawal Syndrome Fetal Alcohol Syndrome

• Hypertonicity Hypotonicity
• Hyperactivity Irritability
• Irritability Poor Sucking
• Poor Sucking Facial Deformity
• Sleepiness Microcephaly
• Shrill cry
• High pitched cry

o Priority = Physiologic Integrity  Vitals signs  Give Valium

Macular Degeneration
o CMV = Cytomegalovirus infection
o Loss of central & peripheral vision  blindness

Erb’s Palsy
o Attained during delivery  reversible  complete recovery after 3 months

Steps of Heimlich Maneuver

= stand behind
=wrap arms around the client
= fist over xiphoid process
= upward abdominal thrust

Septic Shock
o Systemic infection
o Centralized vasodilation
o Dec. BP
o Inc. Temperature

Cleft Palate
o Post surgery = prone
o Post feeding = side lying

Cleft Lip & Palate

o Post surgery = side lying
o Cleft lip is 1st done followed by the repair of the palate
o Must first satisfy the rule of 10:
1.) 10 weeks
2.) 10 lbs.
3.) 10 Hgb

Situation in which consent of parents are not needed:

1.) STD’s
2.) Delivery
3.) Substance abuse

Diabetic Clients
o 50-70% CHO
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 o Raisin  best to bring during travel
o 1 rice is equal to 2 servings of popcorn

MI

Sequence of enzymes that increases during MI:

1.) Myoglobin = 30 min-1hr post MI

2.) Troponin = 3-6hrs upto 3 weeks
3.) CK MB = Inc 4 – 8 hrs post MI, back to normal in 3 – 4 days
4.) AST = 8 – 20 u/L normal, Inc 6 – 10 hrs post MI, back to normal a week later
5.) LDH = Inc 2 – 3 days post MI, back to normal by 10 – 14 days
LDH = 45 – 90 u/ml Normal
LDH 1 = Heart
LDH 2 = RES
LDH 3 = Lungs
LDH 4 = Kidney & Pancreas
LDH 5 = Liver

Pilocarpine sweat Test (Induce Sweating)  Cystic Fibrosis (Autosomal recessive)

Dysthemia  Less severe form of depression

Incentive Spirometer  Inhale

Peak Flowmeter  Blow as hard as fast as possible

Gentamycin Toxic Effects:

1.) Ototoxic
2.) Nephrotoxic
3.) Neurotoxic

Influenzae vaccine

Varivax  Do not give Aspirin  may lead to Reye’s Syndrome

Kwell  CI to pt with seizure

Dx Procedures:

1.) ABG
2.) Amniocentesis
3.) Thoracocentesis
4.) Bronchoscopy
5.) MRI

Angiogram:

1.) Capillary Refill time

2.) Distal Pulses
3.) Puncture site for bleeding
= If the site is on the femoral  Keep leg extended for 24 hrs.

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Respiratory Alkalosis  breath to a paper bag
Respiratory Acidosis  Deep Breathing

Commonly asked drugs:

1.) Lanoxin
2.) Heparin
3.) Acetaminophen
4.) MgSO4
5.) Cytoxan
6.) Synthroid
7.) Vaccines

Do the CHECK method

Theophylloine = 10-20mg/dl – adult

= 5-10mg/dl – pedia

Acetaminophen SE = Hard stools

Commonly asked diseases:

1.) Alzeihmenrs
2.) Sickle Cell Anemia
3.) Pancreatitis
4.) Bipolar Disorders
5.) Liver Cirrhosis
6.) Hemophilia
7.) AIDS
8.) DM
9.) Cystic Fibrosis

Droplet  within 3 feet

Airborne  Beyond 3 feet
Informed consent
o For adult or minor with capacity
o Require full understanding of procedure
o Protects the client, nurse, surgeon and hospital
o For emancipated minors:
o Married minors
o Military service
o Living away from home
o Had a child
Procedures requiring consent:
1. Surgical Procedure
2. Invasive that requires entry to a body cavity
3. Visualization or radiologic procedure with contrast medium
4. General Anaesthesia, local infiltration and regional block

Conditions that doesn’t need parents consent:

15 y/o = antibiotics for acne
16 y/o = pelvic exam
17 y/o = request for contraceptives
18 y/o = Dx exam for recurrent H/A
19 y/o = surgery for bone tumor

Assesment
o Empowering children to the greatest extent feasible
ELEMENTS
o Explain to the child his condition and the reason why the procedure has to be done in lay man’s term
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 o Clinical assessment of patient’s understanding
o Solicit child’s willingness
o Expectation

Ethical Care Concept

1.) Autonomy = Living will, freedom of choice, self determination and privacy.

a. Advance Directive = List of don’t’s (client’s with progressive chronic illness in which death is expected)
b. Durable Power of Attorney for health Care= appoints a proxy that will decide for the patient.
2.) Beneficence = duty to promote well being of others
Ideal Beneficence = “Nag kusa”

3.) Non-Maleficence = Restrained self from doing something that might harm someone. “Do not harm”.

4.) Justice = Fairness

Clinical Issues

1. Unsafe nurse/pt ratio

Intervention:
o Address verbally and document.
o Report to charge nurse  Supervisor  director

2. No response by Physician
Promote Safety:
o Side rails up
o Move pt near nurses station
o Use restraints appropriately (last resort)

3. Inappropriate order
o Document it
o Notify the charge nurse
o Notify the physician

Legal Issues

Malpractice = Negligent conduct in rendering prof. service

= did not exercise care

Respondeat Superior = Superior is responsible to the actions of subordinates.

Referral Agencies for special care during admission

Pt advocate = Empower pt to know his/her rights and privileges

1.) social worker

2.) Children’s protective services
3.) Adult protective services
4.) Organizations

Care of the hospitalized clients

Mantoux Test

15mm = gen. population

10mm = DM, Alcoholism

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5mm = HIV

Areas where bruises are indicative of child abuse:

1. Lower Back
2. Upper Back
3. Side of the abdomen

Special Considerations

Infants

o Greatest risk for fluid and electrolyte imbalance

o Hypothermia and infections
o Approach them in non-threatening manner

Toddler

o Increased separation anxiety

o Briefly prepare them for procedures due to short attention span
o Describe sensation that they may feel during procedure

Preschooler

o Fear of physical harm

o Believe that illnesses is a form of punishment
o Explanations must be brief, honest and in natural terms
o Use demonstrations and play in providing health teaching
o Can use adult seatbelt if  40lbs or 40 inches tall, also if he could look at the window in sitting position

School Age

o Realistic understanding of death = 9 -10

o Needs more detailed teachings
o Allow them to make some choices

Adolescence

o Developed abstract thinking and ability to problem solve

o Logic and reasoning
o Full and honest explanation
o Primary concern are with the present time
o Focus on appearance

Elderly

o Nutrition is a primary concern

o Muscle atrophy
o Dec body water, BMR
o Dec renal, CV, GIT function
o Dec taste, smell, visual acuity (cataract, arcuc senilis = fatty deposits around pupil_)
o With multiple medications due to chronic diseases  OH, Nephrotoxic

Triage = a system of client evaluation to establish priorities

PRINCIPLES

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Emergency Situation = greatest risk receives priority
Major Disasters = those requiring minimal care are treated first
= Those requiring specialized care may be given minimal care or no care

Tree of Strategy for Prioritizing

Ask  Where  Disaster Area = Least injured

 Emergency Area = Most injured

Look  Case

Same Area Various Areas

= all OB Physiologic vs. Psychological
= all Psycho Acute vs. Chronis
= all MS Unstable vs. Stable
= all Pedia

Evaluate and look for

= Complications
= Immediate need
= Adverse effects

Prioritizing Signs and symptoms

Consider
= Symptoms related to ABC
= symptoms which are indicative of complications

Prioritizing Nursing Diagnosis

Consider
= Tyoe of N. Dx
= Actual (Problem)
= Risk (Vulnerable)
= Possible (Inadequate data)
= Wellness

Prioritizing Interventions

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Diagnostic  Verify the Dx  Assessment
Therapeutic  Assess pt
Teaching  Informing the patient
Referral  Involves a member of the health team
Independent  Decision Making

Level’s of prioritizing

Level 1: Emergent
S = evere shcock
C = ardiac arrest, Cervical Spine Injury
A = irway compromise, altered LOC
M = ulti system
E = clampsia

Level 2: Urgent (stable)

Fe = ver
Mi = nor burn less 10%
Mi = nor musculo Skeletal d/o
La = creation
Di = zziness

Level 3: Chronic / Minor Injuries

Dental problems
Routine Medications
Missed Menses
Chronic Low Back Pain

Prioritize
Cardiovascular = Neurological Cases
Acute Complications
Consider = Age and Dx of the pt
Fort MS Cases: Think “ABC”

For Psyche: Safety First

In case of fire: ARCE (new)
: RACE  If caused by O2, turn off O2 first

DELEGATION: Transfer of responsibility for the performance of an activity from one individual to another.

Direct: Identified by the RN

Indirect: Task based on the families list

Complex task = never delegated

= requires judgment on how to proceed

Non-complex task: can be safely performed recording to exact directions

: can be delegated

Task that cannot be delegated (HOSPITAL)

1. Administration of:
= Investigational drugs
= Cancer Drugs
= IV push drugs
= Blood and blood products
= TPN
= Implanted device

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2. Hemodialysis Functions
Task that cannot be delegated (HOME HEALTH)

a.) initial set up of pt controlled analgesic pump

= changing of flow rates
= changing medications reservoir
= filling the reservoir

b.) NGT feeding

KNOW THE RULES

1.) Do not delegate:

o Assessment
o Teaching
o Evaluation
o Preparation and administration of meds

2.) Delegate
o ADL
o Routine
o Standard Procedures

Know the 5 rights of delegation

1.) Right Task
2.) Right Circumstances
3.) Right Person
4.) Right Person/Communication
5.) Right Supervision

Social Therapeutic
Relationship

Goals: Socialization Goal: Mental Health

trust

Phases:
1. Pre-interaction – self awareness of nurses
2. Orientation – contract  do’s and don’ts
3. Working phase – identification & resolution of problems
4. Termination phase – evaluation

Therapeutic Communication

1. Don’t ask why

2. Avoid passing the buck
3. Don’t give false reassurance
4. Avoid nurse centered response
5. Recognize the pt’s feelings

CORE CONCEPTS

o Therapeutic phrases
o Open ended questions are
o Generally Therapeutic
o Closed ended effective for manic and pt’s in crisis
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 o Direct questions for suicidal pts

Bruit = high pitched

Murmur = low pitched

20/20 = Vision  attained at 3-6 years old

Decorticate Decerebrate

Flexed Arms Flexed

Adducted Abducted

Plantar- Legs Plantar-

Flexed Flexed
Extended Extended

How to attack the questions?

1. Consider the pt’s dx

2. Know what is normal
3. Some conditions have inherent and expected changes in the normal values
4. Minimal deviation from normal values are not reportable

Sodium = 135-145 Meq/L

Dilutional Hyponatremia = < 120  Inc reisk for seizure

= 115  Seizure Precaution

Addison – Hyponatremia, Hyperkalemia

Cushings – Hypernatremia, Hypokalemia

Potassium = 3.5-4.5 Meq/L Normal

= < 3.5  Muscle weakness

Calcium = 4.5 – 5.5 Meq/L Normal

= 9 – 10 mg/dl
Hypercalcemia  Inc H2O intake
Multiple Myeloma  Inc serum calcium level
Hypoparathyroid  Dec Ca
Levels in blood
Thyrocalcitonin  Deposits Ca to bones
Parathyroid Hormone  Bone Ca to blood

Glucose
= < 50  Hypoglycemia
= > 140  Hyperglycemia

CREATININE = .5 – 1.5 Meq/L

= Best indicator for kidney function
= Inc creatinine  Kidney failure
BUN = 10 – 20 mg/dl
= Also an indicator for kidney function
= Inc BUN  Kidney failure

RBC = 4.5 – 5.5

= Dec  bleeding, shock, anemia
= Inc in polycythemia
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 = Phlebotomy  removal of 500ml of blood
= Dec RBC  Activity intolerance
= Inc RBC  CVA  Risk for injury

WBC = 5,000 – 10,000

= Post partum  > 15,000
= Leukemia  > 150,000  Hyperleukocytosis  Risk for injury

Platelets = 150,000 – 450,000

= < 150,000  Thrombocytepenic precaution
= < 20,000  bleeding precaution
= > 500,000  bleeding d/o
= Risk for Injury

PT = 11 – 12 seconds
INR = 24 seconds X 20
= > 24  bleeding

PTT = 60 – 70 seconds
INR = 175 seconds X 25

APTT = 30 – 40 seconds
INR = 100 seconds X 25
Monitored  Heparin
= > INR  bleeding

Hbg
Female = 12 – 16
Male = 14 – 18
Newborn = 14 – 24
Pregnant = 10 – 12
= < 10  report
= Results to Anemia  Activity Intolerance

Hematocrit = 35 – 45
Danger of hydration
= < 35  Overhydration  Fluid Volume excess
= > 45  Underhydration  Fluid Volume deficit

Acid – Base Imbalance

Respiratory Metabolic

Alkalosis Acidosis Alkalosis Acidosis

Def in CO2 Excess CO2 Excess HCO3 Def HCO3

Hyper ventilation Lung Disease Cushings Ketone overload

Hypermetabolism Airway obstruction Hypokalemia Lactic Acid production
Hypoxia Resp Depression Excessive loss of acids Kidney Disease
Hypotension Neurological & Muscular dse GI vomiting GI disease

s/sx s/sx s/sx s/sx

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Restlessness Restlessness Cyanosis Confusion
Anxiety Apprehension Hypotension Hyponatremia
Tachycardia Tachycardia Apathy Anorexia
Syncope Dec LOC Weakness Weakness
Dec DTR Dull H/A
Kaussmaul’s breathing

Breath thru paper bag Deep breathing Administer Ammonium Cl Mechanical ventilator
Breath thru cupped hand

ABG determination

Alkalosis Acidosis

PH  7.35 – 7.45 Inc Dec

Hco3  22 – 26 Inc Dec
CO2  35 – 45 Dec Inc

HCO3  determinant for Metabolic d/o

CO2  determinant for respiratory d/o

RAMS = Respiratory d/o, Alternate arrow direction

= Metabolic d/o, Same arrow direction
Compensation

Compensation PH Compensatory
Mechanism
Uncompensated Abnormal No Change
Partially Abnormal Change
compensates
Fully Normal Change
compensated

APGAR

1 minte  Assess cardio, pulmonary and neurological status of the baby

5 minutes  adjustment to extrauterine life
10 minutes  when 2nd apgar is below 6

7 – 10  admission
4 – 6  O2 and warm
0 – 3  Resuscitation

0 1 2
A-ppearance All blue Acrocyanosis Pink
P-ulse Absent < 100 > 100
G-rimace No rxn Weak cry Vigorous cry
A-ctivity Flaccid Some flexion and extension Spontaneous flexion &
extension
R-espiratory effort Abnormal Irregular Lusty

Computation:

1.) D
S

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2.) Vol. in cc X gtt factor
# of hrs. X 60

3.) IV fluid replacement in pediatric pt

Weight
< 10 kg  X 100/kg
11 – 20 kg  1000ml/10kg
 In excess X 50
2 kgs  1,500ml/20kg
 in excess X 20

Isolation Precaution

HW PR Mask, goggles Gloves Gown

I. Standard √ X √ (surgical) √ √
II. Transmission
Based
a. Doplet √ √ √ X X
b. Airborne √ √ √(PRM) X X
c. Contact √ √ X √ √

• PRM (particulate Respirator Mask)

I. Standard  AiDS, HIV, Hepa, Roseola

II. Transmission Based:
A. Droplet  Mumps, Mycoplasmal Pneumonia, Rubella
B. Airborne  Measles (Rubeola), TB, Varicella
C. Contact  Clostridium deficile, Respiratory borne, scabies, Sarcoidosis, RSV
• Hepa with bowel incontinence  Contact precaution

Principles:
1. If patient goes out from the room  let the patient wear mask
2. Coherting  Same illness  Share room
3. Standard Precaution  exemption in pedia  diapered, incontinent, < 6 y/o  contact precaution
HERBAL REMEDIES
Saw Palmetto
o Stops progression of BPH like Finasteride
o Ease urinary difficulty
o Interferes with iron absorption
o CI: pregnancy and lactation
o SE: stomach ache

Blue Cohosh
o Uterine tonic
o Used in the last 2 – 4 weeks
o To ease labor pains
o Jump start stalled labor
o Deliver retained placenta
o Stop bleeding after delivery

Black Cohosh
o Sppress LH but not FSH
o Relieves symptoms of menopause
o Not habit forming
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 o Does not cause cancer
o Limit use to 6 months  alters the normal hormonal balance

Ma-Huang
o CNS Stimulant
o Causes addiction
o Withdrawal symptoms: depression, fatigue, irritability
o With ephedra like effect
o Used to treat asthma
o Can cause weight loss
o Not given inpatients with DM  alters the blood sugar level

Chamomile
o For diarrhea, anti-bacterial, anti-viral
o CI: Bronchial asthma, anticoagulant therapy

Cranberry
o For UTI and asthma
o Not for DM
o Safe in pregnancy
o Use with caution in DM

Echinacea
o Immune system stimulant
o Not used for more than 14 days
o Store it away from direct light
o Not given in TB and chronic conditions

Ginger
o Anti-emetic, tx for colic and flatulence
o Report bleeding and CNS depression

Ginseng
o Fatigue, atherosclerosis, depression, Ca
o Report ginseng abuse syndrome, Diarrhea, nervousness, edema, insomnia

Gingko Biloba
o Improves blood circulation
o Used in Alzheimer’s Disease
o CI  pregnancy, lactation and clotting d/o
Gotu Kova
o Improves memory
o For UTI, snake bites, rheumatism
o CI: pregnancy, lactation and use of sedatives

KAVA
o Anxiety, menstrual problem, leprosy
o AE: CNS depression, hepatotoxicity
o Not given to pts with antipsychotic  inc sedative effects of drugs

VALERIAN
o Tranquilizer, sedative
o Not given with valium
o Uses: insomnia, mm. spasm

DRUGS

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Iron Supplements  FeSO4

C= Mineral Supplement  Anemia

H= Relief of fatigue / Inc strength
E= Best before meals, after meals if with GI irritation
C= takes effect after 2-3 weeks, Inc absorption with orange juice
K= Elixiform  use straw
Injectable  Z track method (laterally stretch the skin, 10 seconds)
SE: Constipation and black stools
Antidote: Deferoxamine HCL (Desferal)

RHOGAM

C= Prevents RH sensitization
H= ( - ) Hemolytic reaction
E= 27-28 weeks AOG, ideally 72 hrs after delivery of baby with Rh (+) and ( - ) Coomb’s
C= Pain in injection site
K= Check Coombs test only in ( - )

OXYTOCIN
Pitocin Methergine

C= Induce Labor Contracts uterus after placental delivery

Increase force of
Uterine contraction
H= firmly contracted uterus
E= As prescribed
C= Report prolonged duration of contraction
K= Avoid: Blue cohosh
Check BP

o Pitocin initially causes Hypotension then rebound hypertension

o Methergine initially causes Hypertension then rebound Hypotension

TOCOLYTICS

C= Relaxes the uterine mm. during preterm labor

H= ( - ) contractions / relaxed uterus
Ritodrine HCl (Yutopar)
E= Onset of preterm labor
C= Report maternal tachycardia
HR > 130  Arrhythmia
K= Prepare antidote  Propanolol

Magnesium Sulfate

C= Anticonvulsant, NS depressant

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H= ( - ) Seizure
E= As prescribed PIH
C= Report MgSO4 intoxication  Hypotension, hypocalcemia and H/A
K= Check BP, urine output, RR, Patellar reflex  if Dec  antidote  Ca Gluconate
Therapeutic level:
o Loading dose  4 – 7 Meq/L
o Maintenance  1.5 – 3 Meq/L
o Depression of DTR if  8 Meq/L
o Dec RR if  10 – 12 Meq/L

Coagulation Process

Vit K dependent clotting Factors

Thromboplastin Fibrinogen  Fibrin (clot)

Prothrombin Thrombin

Coumadin Heparin

Coumadin / Heparin

Coumadin Heparin
(Oral) (Injectable)
C= Anticoagulant
H= ( - ) Clot formation
E= Onset: 2 – 5 days 1 -2 days
C= Report signs of bleeding
K= Avoid green leafy Vegetable (contains Vit K)
Avoid hard bristle toothbrush
Antidote: Vit K Protamine Sulfate
Lab: PT PTT

CHEMOTHERAPY

CELL CYCLE

G0 Mitosis
Interphase

Resting G1 S G2 Cell division

RNA production DNA synthesis RNA synthesis

Alkalating Agents Anti-metabolites Antibiotic Plant Alkaloid Hormones

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Interferes DNA Interferes DNA & Inhibit DNA & Interferes DNA Interferes RNA
replication RNA Replication RNA synthesis synthesis synthesis

* CYTOXAN *METHOTREXATE *ADRIAMYCIN *ONCOVIN *TAMOXIFEN

* MUSTARGEN (antidote: Leucoverin) GLENOXANE

C= ANTI-PSYCHOTIC

Typical Atypical
Anti-emetic
Mania
Schizophrenia
Bipolar d/o
Haloperidol (Haldol) Clozapine (Clozaril)
Dec ( + ) symptoms Dec ( + ) and ( - ) symptoms
(wala sa normal being)

H= Hallucinations Apathy
Delusion Alogia
Looseness of Association Avolition
Anhidonia

Dec dopamine levels

E= pc = after meals

C= Side effects: Anticholinergic Side Effects:

1.)Agranulocytosis Tachycardia Leukopenia (<3,500 = signs of infxn)
Fever, sore throat Dry mouth (if < 2,00 = protective isolation)
2.) NMS Blurred Vision
Fever, mm rigidity Constipation
3.) EPS Dec BP
Mm rigidity

EPS = Cogentin
Akineton
Artane
Malignant Hyperthermia = Parlodel
Muscle rigidity = Dantrolene, Dantrium

K= Liver Fxn Test

No direct exposure to sunlight = Photosensitivity
Anti-Parkinsonian at hand
CI = St. John’s wort

C= ANTI-PARKINSONIAN AGENT

Dopaminergic Anticholinergic
Inc Dopamine Dec Ach

L-Dopa Congentin
Carbidopa Benadryl
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 (Sinimet)

H= Dec mm rigidity
Dec pill rolling
(after 2-3 weeks)
E= after meals

C= H/A, Irritability, Restlessness

K= No to Vit B6 = dec absorption of drug

Check BP and HR
No CHON
C= ANTI-ANXIETY

Valium
Librium = Acute alcohol withdrawal syndrome
= dec tremors

H= Dec center of wakefulness

E= Before meals

C= Dizziness
Drowsiness
Dry Mouth

K= Avoid Alcohol and Caffeine

Administer Valium separately = incompatible with any other drugs
Avoid KAVA & VALERIAN = Inc Resp depression

C= ANTI-DEPRESSANT

SSRI TCA MAOI Stimulant

ZOLOFT VIVACTIL PARNATE RITALIN

CETAVIL NARDIL
TOFRANIL MARPLAN

H= Dec re-uptake of Prevents re-absorption Prevents the destruction Directly stimulates

Serotonin of Norepinephrine of serotonin & the CNS
Norepinephrine

E= After meals

C= Inc appetite
Adequate sleep
Initial effect = 2-3 weeks
Full effect = 3-4 weeks

Side effects:
Dec libido Cardiac Arrhythmias Hypertensive Crisis Growth suppression
Impotence

K= Check the BP
Avoid Citrus juices  Dec absorption of anti-depressants
Observe dietary modifications
Avoid St. John Wort
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 Avoid Tyramine containing foods:
Cheddar, Swiss, Cottage and Aged cheese
Cola, coffee, soy sauce

C= ANTI-MANIC AGENTS

LITHIUM TEGRETOL DEPAKENE

(Carbamazipine) (Valproic Acid)
Anti-Convulsant
Alternative drug for pregnant
Women
H= Dec Hyperactivitywithin 2 – 3 weeks
Acute Mania = Give Anti-Psychotic with anti-manic

E= After meals – pc

C= Check signs of toxicity:

Mild Moderate Severe
1.5 Meq/L 2.5 Meq/L > 2.5 Meq/L
Thirst Nausea
Ataxia Anorexia
H/A Vomiting
Irritability Diarrhea
Beginning Fine hand tremors Coarse hand tremors
Abdominal Cramps
Coma  Death

K= Monitor Lithium Level  early morning (before breakfast)

Out patient at least once a month
Drug of choice for toxicity  Diamox, Mannitol
CI:
1.) Pregnancy
2.) Lactation
3.) Renal Failure
Dietary Modification  Inc Na (6 – 10 gm) and Inc Fluid ( 3L or more)
Acute Dose: .5 – 1.5 Meq/L
Maintenance: .5 – 1.2 Meq/L
Elderly : not exceed 1.0 Meq/L  due to poor renal excretion

MUSCULOSKELETAL DRUGS

C= Focus: Gold Therapy

Suppresses Arthritis

H= ( - ) Inflammation

E= IM  weekly
Lie supine for 10 mins to prevent OH

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C= Check:
Signs of Stomatitis
Dermatitis
Unusual Bleeding
Unusual Bruising
Fever
Sore Throat

K= Monitor Renal Function Test

C= ANTI-INFLAMMATORY

Ibuprofen Aspirin
(NSAID’s)

Anti-Inflammatory Anti-Inflammatory
Anti-pyretic Anti-pyretic
Analgesic Analgesic
For RA & OA Anti-Platelet aggregate
Anti-rheumatic

H= ( - ) Inflammation, ( - ) pain, ( - ) RA
( - ) fever, ( - ) platelet aggregation

E= pc – after meals

C= Report:
Visual disturbances Ringing in the ears
Allergy Nausea & Vomiting
Sore throat Rapid breathing
Fever Hyperpnea  toxicity
Black Stool

K= Annual eye exam

Check bleeding time

C= ANTI-GOUT AGENTS

Probenecid Colchicine Allopurinol

Acute Chronic
(8-12 hrs) (1-3 weeks)
Excretion of u.a. Prevent deposition of u.a. Prevent formation of u.a.
Anti-inflammatory

H= Decrease uric acid

E= Given with food

C= NAVDA Bruising H/A, drowsiness

Allergy Agranulocytosis

K= Inc fluid intake 2 – 3 L/day

Frequently check serum uric acid level
20
 CARDIAC DRUGS

NITRATE

A. Nitroglycerine
Sublingual
Trans-mucosal = between gums, cheecks and lips

B. Isordil
Sustained release, with water and don’t crush
Patch
Nasal Spray
C= Caridac drug (Nitrate)
Dilate coronary arteries and arterioles  Dec pre-load

H= ( - ) Anginal Pain

E= Give before onset of pain

3 X at 5 mins interval
After 15 mins ( + ) pain  report  May indicate MI
C= 1. Ointment = Cover with plastic and put adhesive tape
2. Patch = Non-Hairy part
3. Oral spray = 3 sprays in 15 mins

S.E. Facial flushing, H/A, Hypotension

K= Rise slowly to prevent OH

Tablet on dry, dark container
6 months  Discard
Burning Sensation  Indication that the drug is still potent

C= CARDIAC GLYCOSIDE
Digoxin Digitoxin

H= Strengthen Myocardial Contraction

Na-K-pump is converted to Na-Ca-pump
Thus increasing force of contraction

E= Onset 5 – 20 mins Onste 30 mins – 2 hrs

Observe GI irritation

C= Excreted by kidneys Excreted by the liver

Normal level 14 – 26 Anti-dote: Digibive

Normal level 5 -2 ug/dl

K= Check HR = Adult 60
Older Children = 70
Infants = 90 – 110

DOPAMINE and DOBUTAMINE

21
 DOPAMINE DOBUTAMINE
Inc force of contraction
Correct Hemodynamic
For Emergency Situation

H= Adequate Urine Output

E= Emergency Situation

C= Always in diluted form

K= Compute the drugs properly

C= ANTI-ARRYTHMICS
Lidocaine Quinidine
(Xylocaine) Atrial Fibrillation
For PVC’s
H= ( - ) Arrythmia
Slow ventricular rate
Slow atrial rate

E= Given as prescribed

C= Rash Blurring of Vision

Convulsion Tinnitus/Ototoxicity
K= Check HR
Evaluate ECG

C= THROMBOLYTICS

Streptokines
TPA
Dissolves the clot by preventing the formation of fibrin (fibrinolysis)
H= ( - ) Clot formation
Clot Dissolved

E= Effective within 6 hours

After MI  within 24 hrs

C= Report Bleeding
Monitor VS

K= Contraindicated to clients that are prone to bleeding

C= ANTI-LIPEMIC AGENTS

LOVASTATIN QUESTRAN
(Tablet) (Powder)

H= Dec LDL = 30 – 80
22
 (HDL should be > 80 and LDL < 80)

E= Before meals or at night time

C= Caution: Hepatotoxic

K= Questran  1 pack of powder + 4 – 6 oz of fluid (water, milk or juice)

Check liver function test
Rash and bleeding

C= PERIPHERAL VASODILATOR

Paracid
Smooth muscle relaxant  Facilitates blood circulation
H= ( - ) Ischemia
E= After Meals
C= Instruct patient that drug may cause H/A and SOB
K= Long term use is individual

C= BETA-BLOCKER
(Timolol, Esmolol, Nadolol)
H= Dec BP, for Hyperthyroidism, Dec sympathetic (Autonomic) nervous system stimulation

E= Before meals

C= Rise slowly: Lie down for 30 mins after medication.

Instruct patient that meds may cause bronchospasm
K= Do not give chamomile and aspirin

C= ANTICHOLINERGIC

Atropine Sulfate
Vasolytic Agent

H= Inc heart rate (check complete heart rate)

E= Before meals

C= Avoid hot environments

K= Check for rashes and SOB

NEURO-DRUGS
C= Anticonvulsants
(Dilantin)

H= Decrease Seizure Threshold

E= After Meals

C= Epilepsy  Maintenance
Chronis Use  Gingivitis
Visit dentist at least once a year
Soft bristle toothbrush, massage the gums
Urine is pink tinged

K= SAS ( Saline Flush  Administer drug  Saline Flush

23
 To Prevent precipitate

C= CHOLINESTERASE

Neostigmine Tensilon Cognex

Myasthenia Gravis Alzeihmers

Long Acting Short Acting Maintenance

Treatment Diagnostic Treatment

H= Inc muscle strength Inc mental functioning

E= Before Activity At bedtime
Before meals  Use muscles of mastication

C= Chewing becomes stronger Dec dizziness

Medication is lifetime
Report S/Sx of hepatotoxicity

K= Check liver fxn test

Keep at bedside  Neostigmine  Antidote: atropine sulfate
Do not give echinicea
Prepare Tracheostomy

C= ANTI-TB

Rifampicin INH Streptomycin Ethambutol

H= ( - ) Infection

E= Before Meals

C= Red orange urine Peripheral Neuritis Oto, nephro, neuro- Hepatotoxic

Don’t use contact lenses (Give B6) TOXIC Psychotic like Sx

K= Take the complete treatment as prescribed by the doctor ( 6 – 12 months )

Incomplete TB treatment  Lead to MDRTB

C= ANTI-ASTHMA
Theophylline Cromolyn Na
Adult = 10 – 20 mg/dl Prevents anti-histamine release
Pedia = 5 – 10 mg/dl
Dilates bronchioles

H= Ease breathing

E= In the morning  because it causes insomnia

C= Nausea and vomiting Rashes

Theophylline toxicity

K= Check the pulse rate

Avoid Chamomile  cause bronchospasm
Avoid aspirin --? Cause bronchospasm

24
 Inhaler  Acute
Steroid  Chronic

C= MUCOLYTICS
(Mucomyst)

H= Antidote for aspirin toxicity

Dec viscosity of mucous
Loose phlegm

E= No specific time

C= Inc OFI
S.E.  bronchospasm

K= Suction
Medication has a foul odor that resemble rotten egg

C= EMETIC
Syrup of Ipecac

H= To induce vomiting  non-corrosive

Pedia below 6 months  ( - ) vomiting

E= Dose depends on age

6 mos – 1 yr = 10ml
1 – 12 yrs = 15ml
> 12 yrs = 30ml

C= Administer with glass of water to enhance effects of ipecac

Cardiotoxic = Ensure that child vomits the entire amount

C= ANTACIDS
Peptic Ulcer Disease
Maalox Ranitidine Sucralfate
1-2 hrs 4-6 wks 8 wks

Neutralizes HCl Dec HCl secretion Coats GIT

Normal HCL 2 – 5
Maximum 10

H= ( - ) Pain, dec HCl

E= Usually on an empty stomach

1 hour before meals
2 hours after meals
C= Shake liquid
SE: diarrhea
Constipation

K= Short term therapy  Electrolyte imbalance

25
 ENDOCRINE DISEASE

C= INSULIN OHA

Type 1 Diabetes Mellitus Type 2

Regular – Humulin Orinase

Intermediate – NPH Diabinase
Long-acting – ultra lente Metformin

H= Inc transfer of glucose to cell membrane Pancreas to secrete insulin

E= Before breakfast

C= Report Hypoglycemia:
Dizziness
Dec LOC
Diff. of problem solving

K= Hypo occurs usually occurs at the peak of action of meds:

Before lunch
In the afternoon or before dinner
In midnight or next day

Rank: 4 – 8 – 12/16

C= THYROID DRUGS
Synthroid PTU
(supplement) Tapazole ( 10 times greater than PTU)
For Hypothyroidism For Hyperthyroidism

H= Normal BMR Dec T3 and T4, Adequate appetite and sleep

E= In morning to prevent insomnia Round the clock

C= Report signs of overdose: Report:
Insomnia, palpitation & Nervousness Fever, sore throat, body malaise

K= Life time Monitor HR & BP

C= STEROID

Cortisone Floricef
Replacement Therapy
Addision’s Disease

H= Correct Fluid and electrolyte Imbalance

E= In the morning

C= Given intramuscularly
Avoid abrupt withdrawal
AE: Bruising  Bone marrow depression

K= Avoid salty foods  edema

Maintain a balance diet  obesity

26
 Avoid crowded areas  Infection

C= RENAL DRUGS
EPOGEN
Inc RBC production  for Chronic Renal Failure

H= Normal Hemoglobin

E= As prescribed

C= Report Polycythemia  Inc production of RBC  CVA

Check Complete Blood Count

C= DIURETIC
Loop Diuretic Thiazide Diuretic K – Sparring Diuretic
(Lasix) (Hydrochlorothiazide) (Spirinolactone)
Duiril Aldactone

Loop of Henle Distal Tubule Blocks aldosterone

Prevent Na absorption Prevents Na absorption Retains water

H= Increase urine output and decrease pt’s weight

E= Early morning  prevent nocturia

C= Hypokalemia Hypokalemia
Dec K Dec K Inc K
Dec na Dec Na Dec Na
Dec Ca
Dec mg

K= Inc Sodium in diet

Check Electrolyte level
Check BP

IMMUNUREN
(Azathioprine)

C= Immunosuppressant
H= ( - ) rejection of organs
E= As prescribed
C= Report:
Nausea, vomiting
Thrombocytopenia
Bruising
Infection

K= Check CBC
Frequent Handwashing

C= MIOTICS MYDRIATICS
(Pilocarpine) (ATSO4)
For Glaucoma CI for Glaucoma
For eye exam

H= Normal IOP Dilatation of pupils

27
E= Lifetime in glaucoma As prescribed

C= Lower conjunctival sac Report: eye pain & blurring of vision

Press inner canthus 1 – 2 mins to Avoid alertness after medication
prevent systemic SE

K= Check BP and Blood sugar

C= ANTIBIOTICS

Vancomycin Penicillin Tetracycline

MRSA Gonorrhea Lymes
Syphillis Rocky Mountain Fever

H= ( - ) Infection

E= Before meals
With GI irritation  After meals

C= Ototoxic, Nephrotoxic, Allergy Hepatotoxic

Neurotoxic

K= Check I and O

Peak Level = 15 – 30 mins after administration

Trough level = 15 – 30 mins before the next dose

Antidote: Epinephrine Deep IM and check CBC

Given with probenecid

Guidelines on Gross Cultural Orientation and adjustment

Try to get to know as much as you can about:

o Social customs
o Family Life
o Class structure
o Religion
o Economics
o Value System

Some Areas of Culture Differences

1. Communication
o Message interpretation
o Personal Space
o Eye contact
o Touch

2. View of Time
o Present oriented (Hispanics, Africans)
o Future oriented (Europeans, Americans)
o Past Oriented (Tribal/Traditional)

3. Family Type
28
 o Nuclear
o Extended

4. Nutrition = kosher diet, jalal

5. Religion
o Catholics
o Jehova’s Witnesses
o 7th day Adventist
o Mormons

Culture Bound Syndrome

Black  Inc blood

Chinese  Koro
Hispanics  Pasmo
Whites  Anorexia, Bullimia

Death and Dying

ASIANS
Family and friends of same sex will prepare and wash the body

MUSLIM
1. Washing of the body
- women – cleanse women
- men – cleanse men
2. After washing 3 time the body is wrapped in 3 pieces of clean white cloth
3. Special prayers
4. Bury the body with the head facing mecca
5. Burial of fetus = < 130 days  discard like tissue
= > 130 days  proper burial rites

JEHOVA’S WITNESS
o Autopsy is accepted if required by law
o The parts to be removed from the body
o Cremation is permitted

FRAMEWORK

Main Problem: SIADH  Neuroendocrine

Most common / initial manifestations = SIADH  Oliguria
Laboratory Data = Dec Na, Inc BP
Nursing Diagnosis  Dec Na  N. Dx. Fluid and Electrolyte imbalance
Priority Intervention = Dec Na  115 meq/L  Implement seizure precaution

Leukemia

Main Problem: Proliferation of Immature WBC

Periods of remission and exacerbation
Remission = Absence of s/sx  Lymphycytic  Lymphocytes  Pedia
Exacerbation = Active s/sx  Myelogenous  Granulocytes  Adults
S/Sx Initial: Anemia
Bleeding  severe / unexplained
Infection
29
Lab. Data: WBC  Hyperleukocytosis  WBC 150,000

N. Dx: Priority  Safety

Reverse, Isolation precaution  relative wear mask
Thrombocytopenic precaution
Cytotoxic Precaution
Bleeding Precaution
Standard Precaution

HEMOPHILIA

Main Problem  Inherited disorder

Type A Type B Von Willebrands disease

X-linked X-linked Autosomal dominant
Recessive recessive Male & Female
50% male offspring 50% male oofspring
( - ) Factor 8 ( - ) factor 9

S/Sx: Hemarthrosis  Hallmark  elbow, wrist, ankles, knees

Hematoma
Hematuria
Hematemesis
Hemmorhage

Lab Data: Clotting time

N. Dx: Risk for injury, altered growth
Priority: Safety

Blood Transfusion, Plasma Expanded

1. Rest
2. Immobilize
3. Cold compress
4. Elevate

30
 SICKLE CELL ANEMIA

IRON PERNICIOUS FOLIC ACID SICKLE CELL APLASTIC OR THALASSEMIAS

DEFICIENCY ANEMIA DEFICIENCY ANEMIA FANCONIS 1. Minor
ANEMIA ANEMIA 2. Intermediate
3. Major

Inc. def. of iron Lack of Vit. B12 Deficiency in Inherited  31Autosomal Pancytopenia Due to defect in polypeptide chains
Dec absorption Absence of Folic Acid Recessive  status of Hemolytic of RBC
Excessive loss intrinsic factor Parents
In stomach: (See Table A.1 below)

Baby  chubby Aging  atrophy Pregnant RBC C/S shape Dec RBC, wbc and RBC destruction
but pale Surgery  Breast feeding  thrombus  occlude bv platelet Common in blacks, Indians, Greeks,
Due to over intake removal Infant Vasoclusive Crisis  due to DHN Chinese & Italians
of milk Adolescent Aplastic Crisis (hemolytic anemia) 
Women  Alcoholic dec RBC, WBC & platelets
menstruation Poor feeding Spleenic sequestration crisis 
practice spleen destroys rbc rapidly
Over cooking of
veggie
S/Sx: 3 F’s: S/Sx: 3 F’s + S/Sx: 3 F’s S/Sx: Fever, joint pain, S/Sx: 3 F’s, Inc S/Sx: Depends in types
Fatigue, Fainting, beefy red With peripheral paralysis & weakness infection, Inc Mild: Mild anemia
Forgetfulness Tongue neuritis CVA bleeding Intermediate: Anemia, spleeno-
(glossitis) megaly, hemosiderosis,
Peripheral accumulation of iron in tissues
neuritis Major: severe anemia with
hepatomegaly
N. Dx: Lab: schillings Lab: Folic Acid Lab data: Lab Data: Dec Hgb, Lab Data: Dec Hgb
Activity Intolerance test < 4 mg/dl *Sickle dex test – trait wbc & platelet N. Dx: Activity Intolerance
Priority: N. Dx. Risk for N. Dx: Fatigue *Hgb electrophoresis – Confirms the N. Dx: Risk for injury, Priority: Bedrest, steroids,
Bedrest, injury Injury disease Infection, activity spleenectomy
supplement Iron 2 Priority: Priority: Rest N. Dx: Activity Intolerance, Risk for intolerance
wks, Rest FA supplement injury, unilateral neglect Priority: protect form
Inc iron diet  B12 supplement Green Leafy Priority: Pain relief & hydration infection, CBR, BT
organ meats, *Absence of veg  Blood transfusion  refer to
Green leafy beefy red Spinach, geneticists
vegetables, dried tongue broccoli 
fruits Help RBC
Relief of Fatigue production
*Desferral 
Antidote

31
Table A.1: Autosomal Recessive
Normal Trait Disease
A. 1 parent with trait 50% 50& 0%
B. 2 parents with trait 25% 50% 25%
C. 1 parent with trait the 0% 50% 50%
The other with disease
D. Both parents with disease )% 0% 100%

Neoplastic Thrombocytopenia

Purpura  Dec Platelet  due to viral infection  autoimmune reaction  drug use
S/sx: Petechiae, ecchymosis, hematoma
Lab Data: Platelet < 20,000, Dec Hgb
N. DX: Risk for injury
Priority: Safety, prevent bleeding
Supplement with folic acid
Blood transfusion

CHD
ACYANOTIC CYANOTIC
(Left to right shunting) (Right to left shunting)

Inc pulmonary blood flow Obstructive conditions Dec pulmonary blood flow

Ventricular septal defect Pulmonary stenosis Tetralogy of Fallot

Atrial septal defect Aortic stenosis Truncus arteriosus
Patent ductus arteriousus Coarctation of the aorta Transposition of great vessels
Tricuspid atresia
Hypoplastic left heart syndrome

Risk factors:
Maternal infection (14 mos)
Age (> 40)
Medical Condition (DM)
Alcoholism

Brow seating (feeding)  due to activation of ANS

Baby sleeps after 3 minutes of sucking

Difficulty in feeding
Tachycardia
Tachypnea
Frequent URTI

Heart Failure Retarded Growth Cyanotic (tet spell) 

Semi Fowlers Priority: provide warmth CVA
Initial: L sided heart failure  dyspnea & O2 & surgery If walking  squat
Late: R sided heart failure If not walking  knee chest
< 2 y/o = O2
2 – 7 y/o = Surgery> 7 = Surgery as soon as possible

32
RHEUMATIC FEVER

Systemic inflammation of connective tissues (joints, CNS, heart)

Risk Factors: (conditions 2-4 weeks before diagnosis)

Sore throat
Impetigo
Scarlet Fever

S/Sx:
Major: Minor:
Carditis  tachycardia at rest Fever
Arthritis  migratory Murmur
Sub Q nodules  painless Tachycardia
Eryythema Marginatum  rashes
Chorea  Abnormal movement

Lab: Inc ESR = Male (1-2 mm/hr, Female 20 mm/hr), Inc ASI titer
N.Dx: Altered tissue perfusion, Dec CO, Pain
Diet: Inc fluid intake, Inc CHON
Meds: ASA, Penicillin to prevent heart valvular damage
Complications: Cardiac Valvular Disease  stenosis and regurgitation
Stenosis  narrowing, fusion of leaflets
Regurgitataion  incomplete closure

STENOSIS REGURGITATION

Mitral Aortic Mitral Aortic

Dec pitch High pitch High pitch Blowing diastolic
Diastolic murmur Systolic murmur Systolic murmur murmur

Treatment:
Antibiotics
Anticoagulants

Pregnant Clients Classifications:

I II III IV

No Limitation of activities Symptoms with activities Symptoms with less Symptoms even at
of daily living than ordinary ADL’s rest

ARRYTHMIAS

= Abnormal cardiac rhythm

ATRIAL VENTRICULAR
Flutter Fibrillation PVC Fibrillation

Sawtooth patter  Pwave  P:QRS ratio 2:1-4:1-6:1 Extra QRS Widened QRS

Quinidine Epinephrine Lidocaine

33
Defibrillation Defibrillation Defibrillation
CPR CPR, Quinidine CPR
QRS = < .10, 2 squares
PR = .12-.20 = 35 small squares

ABNORMAL CARDIAC RHYTM

Heart Block  PR interval

Primary  prolonged PR Interval

= No intervention

Secondary  Progressively prolonged PR Interval

= Atropine Sulfate

Tertiary  P & R wave are independent of each other

= Pacemaker
= HR < 5 beats below the limit
= Hiccups  Failure
= Belching  decreasing heart rate
= Signs of shock  weak pulse
= Stay away from electromagnetic field

CAD

o Narrowing and obstruction of coronary arteries

o Dec O2  Hypoxia  Angina
o ( - ) O2  Neurosis
o Risk Factors:
CAD
Atherosclerosis
Smoking
Elevated Cholesterol
HPN
Obesity
Physical inactivity
Stress

Angina MI

Stable  Pattern is predictable             Anterior Wall

Unstable  Pattern is unpredictable
Variant (Printzmetal)  Severe form          Posterior Wall
Nocturnal __> @ night
Decubitus  when lying down             Lateral Wall
Intractable  Unresponsive to treatment
Post MI  After MI

Pain Precipitates: Pain

< 20 min > 20 min
Upper sternum Eating Lower sternum
Pressure Elimination Crushing, Excruciating
Relieved by rest Extreme temp Not relieved by rest
Nitroglycerine Emotion Morphine (Check RR)  Antidote  Naloxone
Effort

Associated S/sx:
34
 Agitation
Restlessness
Cold clammy skin
HPN

Lab Data:
Inc cholesterol < 200 Inc cardiac enzymes
ECG changes Inc ST segment
Inc ESR

N. Dx: Pain
Position in Semi Fowlers
Administer drugs as ordered
Diet:
Cholesterol restricted diet

Percutaneous Transluminal CardioAngioplasty

= Done if 50% of blood supply to heart is impended

= Insertion of a balloon tipped catheter  ballooning  cardiac stent

Coronary Artery Bypass Graft

= Done if 50% of blood supply to heart is impended

= Placing a new blood vessel

Health Teaching:
o Avoid strenuous activities
o Can resume sexual activity  if can climb 2 – 3 flights of stairs with no dyspnea
o Provide frequent rest periods
o Discharge Instructions  Avoid life threatening conditions

HEART FAILURE

= Inability of the heart to pump adequate amount of blood to meet the metabolic demand of the body.

Risk Factors:
MI
Heart valvular disease
RHD
HPN
Arrhythmia

S/Sx:
Left sided:
Dyspnea, pink sputum, productive cough, pulmonary edema
Right sided:
Distended neck veins, ascites, ankle edema, hepatomegaly

Lab Data:
Left cardiac function  Swan Ganz
Right Cardiac Function  CVP
N. Dx:
Altered tissue perfusion and dec CO
Priority:
To Inc CO
35
Position in semi fowlers
Administer drugs as prescribed  Digitalis, Vasodilators, Diuretics
*Morphine  dec venous return to the heart  peripheral vasodilating effects
Diet  Low Na, Low Cholesterol
Assess breath sounds, edema, heart sounds

HYPERTENSION
= Silent Killer disease

Hypertensive disorders of pregnancy

= Persistent elevation of BP above 140/90
= 120/80  Pre-hypertensive
= 110/70  normal

Risk Factors:
Family Hx
Age
Blacks
Obesity
Stress
Smoking

Types:

1.) Essential  Unknown

2.) Benign  Unknown / Long duration
3.) Malignant  Acute, short duration
4.) Secondary --? Due to medical condition

Complications: 4 common complications:

Occipital HA CAD
Retinal Hemorrhage CVA
Pedal Edema CRF
CHF

Lab: Inc in cholesterol, Inc LDL, Inc TAG

N. Dx: Altered health maintenance  Tx is prolonged
= Vasodilator, Anti-lipemic agents
* Common cause of concern  Bronchospasm, Dec libido
Diet  Dec Na, Dec cholesterol

NON-PHARMACOLOGIC REGIMEN

Stress Mx: Exercise  deep breathing, walking, stress free hobbies (like walking by the bay)

HPN in pregnancy  Unknown

= Generalized vasospasm  due to virus  H. Lualba
= 2nd trimester
= B4 20 wks AOG  H. Mole / GTD
= after 20 wks AOG  PIH
= Before and after pregnancy  chronic hypertension

HYPERTENSIVE D/O OF PREGNANCY

o Inc BP

36
PRE-ECLAMPSIA
o Inc BP
o Edema
o Proteinuria:
Mild : BP  140/90
Protein  < 5gm/24hrs
Severe: BP  160/110 & above
Protein  > 5 gm/24hrs
o Mx: Darkened room
Inc CHON diet
MgSO4: Antidote --> Ca Gluconate

ECLAMPSIA
o Inc BP
o Edema
o Proteinuria
o Convulsion  bleeding  HELLP Syndrome (hemolysis, elevated liver enzyme, low platelet  manifested with
petechiae

PVD

Arterial Occlusion Venous Occlusion

Color Pallor Ruddy
Edema ( - ) or minimal Severe
Nails Thick & brittle Normal
Pain *Intermittent Claudication Homan’s sign
Pulse (-) Normal
Temperature Cold Warm
Ulcer Dry Wet

BUERGER’S RAYNAUD’S ARTERIOSCLEROSIS

(Thromboantgitis Obliterans) DISEASE OBLITERANS
- Acute - Intermittent - Chronic
-A&V - arteries - arteries
- Male - Female - Male
- Lower ex - Upper ex (97%) toes, ears, LE (3%) - Upper & Lower ex
- Smoking - Cold
- Inflammation of arteries and veins - Vasospasm of arteries - hardening arteries

Pain
Intermittent Claudication – Intermittent color changes
(Pallor, Cyanosis, Redness)
Lab data: Painless Doppler UTZ
N. Dx: Pain & altered tissue perfusion
Priority: Anti HPN, Vasodilator, Anticoagulants
Instructions: Avoid smoking, swimming in cold water

37
PULMONARY EMBOLISM

- A clot lodges in one of the pulmonary arteries

Risk Factors:
1.) VA  Trauma
2.) Hypercoagulation
3.) Arrhythmia
4.) Thombosis

S/Sx: Anxiety / Agitation

Dyspnea
Restlessness
Tachycardia
Tachypnea
Chest Pain
*Crackles
Lab Data: Perfusion Lung Scan
N. Dx: Pain, Ineffective breathing pattern
Priority: Positioning Right sidelying
Administer Anticoagulant

ABDOMINAL AORTIC ANEURYSM

- Weakening of the walls of the aorta

- Congenital
- Angina
- Chronic HPN
Types:
1.) Fusiform – bulging of both sides of bv
2.) Disecting – Dissected inner wall of bv
3.) Saccular – forms a pouch or sac

S/Sx: Assymptomatic
Pulsating Abdominal mass
Low Back Pain
Inc BP of Ue, Dec BP in LE

Lab data: Aortography, X-Ray

N. Dx: Risk Poor injury  altered tissue perfusion
Safety  Most Abdominal Palpation
Prepare pt for surgery that will involve grafting
After surgery  assess for distal pulses

KAWASAKI’S DISEASE
- Acute systemic inflammation of the vascular system
- Heart & blood Vessels
- Common in Japanese, toddler & pre-schooler
- Unknown
S/Sx: High spiking fever for 5 days of more
Strawberru tongue, palmar desquamation

38
Lab Data: 2 D-Echo, ECG
N. Dx: Altered tissue perfusion, Dec Cardiac output
Priority: Tx is supportive, ASA
Diet: Clear Liquid
Discharge Infection: Teach Pt. CPR
5:1  Pedia
15:2  Adult
30:2

1. To Assess risk of developing mitral valve stenosis in pt. What should the nurse ask the pt?
A: Did you have streptococcal infection
2. How to assess intermittent Claudication:
A: Ask the pt to walk and note presence of pain
3. What should the nurse prepare at bedside with PVC
A: Xylocaine
4. Priority in pt with complete heart block
A: Altered tissue perfusion
5. Goal of Care with atrial fibrillation
A: Inc CO
6. Coomon complication of sickle cell anemia?
A: CVA
7. Signs of left sided heart failure
A: Dyspnea on excretion
8. When planning an exercise program in pt with HPN, Nurse should ask?
A: How do you spend your leisure time

CYSTIC FIBROSIS

- Inherited multi system disease affecting the exocrine gland

- Autosomal recessive  each pregnancy  (Disease 25%, trait 50%)
- Excessive Mucous production  Made = Sterility, Female = Diff. in concerning

S/Sx: Initial: Abdominal distention

Malabsorption Syndrome  Steatorrhea  Foul smelling fatty, stool
Salty when kissed

Lab: Pilocarpine Sweat test

Respiratory Therapy: Blowing Exercise  Trumpet  Blowing Bubbles

GI Therapy: Pancreatic Enzyme  Pancreas  Viokase  with each meal & snacks
Refer pt’s prevents  geneticist
Pt. Grows  OB

PNEUMONIA

- Mycoplasma Pneumonia (pedia), Legionnaires disease (elderly, alcoholic, immunosuppresion)

- Inflammation  Allveoli  Exudate, Consolidation
- Viral, Bacterial, Rickettsia

S/Sx: 5 Cardinal signs & symptoms

1. Fever
2. Sputum
3. Pleuritic Chest Pain
4. Chills
5. Cough

39
 PNEUMONIA

Viral:
- Low grade fever
- Thin & watery sputum
- WBC either normal or slightly increased

Bacterial
- High grade fever
- Rusty sputum
- WBC severely increased

Lab data: Chest X-ray, sputum exam, ABG analysis

N. Dx: Impaired Gas Exchange
Ineffective Airway clearance
Ineffective Breathing pattern
Priority: Bed Rest, Inc OFI, Administer meds as ordered: antibiotics

CROUP

ACUTE LARYNGITIS LTB BRONCHIOLITIS

Toddler Infant & toddler Infant < 6 mos

Viral & Bacterial (RSV)

Larynx Inflammation of the Larynx and trachea Bronchioles

S/Sx:
Cough: Barking, metallic Harsh & Brasky Paroxysmal & Hacking
Stridor: Present Present Present
Wheezing: Absent Absent Present
Fever: Absent Low Grade Moderate to high grade

Lab Data:
Throat Swab X-ray X-ray
PE Throat swab ELISA
X-ray PE Throat swab
PE

N. Dx: Infection, Ineffective breathing pattern

Priority: Tx of infection
Multi-drug therapy

OPD (Obstructive Pulmonary Disease)

Narrowing and obstruction of the airway

Emphysema Bronchitis Asthma

40
-overdistended alveoli - inflammation of bronchioles -excessive mucus

Smoking

RE,TACY,TACHY DC

Barrel Chest Gelatinous Sputum Whitish sputum

Inc coughing Orthopnea

Lab Data: X-ray, ABG Analysis

N. Dx: Ineffective Breathing Pattern
Ineffective Airway Clearance

Orthopneic Bronchodilators Activity: Soft ball

Semi-Fowlers Baseball

Principles in Nursing Care:

Bronchodilator Aminophylline
Rest Steroid
Oxygen low flow Theophylline
Nebulize Histamine Antagonist
Chest Physiotherapy Mucolytic
High Fowlers Antabuse
IPPB – Intermittent Positive Pressure Breathing
Aerosol
Liberal Fluid Intake

Complication:
Cor Pulmonale
Right Ventricular Hypertrophy

Pneumothorax

Spontaneous Open Tension

Ruptured Chest injury Trauma

Bullae/alveoli

Increase tension and pressure

Thoracic cavity
Lung collapse
( - ) breath sounds
Dyspnea
Pain
3 way bottle sys

Pointers for Respiratory:

1.) Mist  Priority?

A: Change the linen and clothing to keep the pt dry.
2.) Goal of care for child with bronchiolitis?
A: Minimize O2 expenditure
3.) Pancrease is given with meal
4.) Patient with TB  What is the purpose of NGT?
41
 A: To aspirate swallowed sputum
5.) S/Sx that indicates emphysema?
A: Barrel shaped chest
6.) Development of Edema?
A: Moist and noisy breathing
7.) Common risk factor for Legionnaire’s disease?
A: Immunosuppression
8.) Mycoplasmal Pneumonia is manifested by?
A: Fever & productive cough

PKU
o Inherited disorder characterized by absence of phenylalanine hydroxylase (PH) which converts phenylalanine
to tyrosine (precursor)  melanin for hair, eyes, skin
o Normal level = 2mg/dl, 4mg may indicate PKU, 8mg confirms PKU
o Autosomal recessive
o Phenylalanin is toxic to the brain and causes MR

S/Sx: Asymptomatic at birth: Diarrhea, Anorexia, Lethargy, Anemia, skin rashes

N. Dx: Knowledge deficit
Altered nutrition
Risk for injury  seizure

Health Teachings:
Low Phenylalanine  up to adolescence  9-10 y/o
Refer to Geneticists and nutritionist
Produce list of foods that’s is allowed and not allowed

HASHIMOTO DISEASE

o Congenital deficiency in T3 and T4

o S/sx  Asymptomatic  maternal hormonal transfer
o 2 – 3 mos s/sx appear
o Behavioral: Apathy, well behaved baby
o Physical: Large tongue, short structure, retarded growth  MR

Lab data: Dec T3 and T4

N. Dx: Knowledge deficit
Risk for activity intolerance
Altered growth & development
Priority: Administer Synthroid, single morning dose forever
Report: Tachycardia (palpitations)
Insomnia
Nervousness
*Provide warm environment
* Refer to special education center

PANCREAS
ALPHA CELLS BETA CELLS
Glucagon Insulin

MODY Absence Deficiency

(Maturity onset Diabetes in young adults) IDDM (Type I) NIDDM (Type II)

42
Combination of IDDM & NIDDM Juvenile onset Maturity onset after 35
Pregnancy 2nd trimester Ketosis prone Non Ketosis form
Developed placenta secretes HPL Thin Obese
(Human placental lactogel  counteracts
insulin

Gestational: (White’s classification)

Types:

A: Chemical DM:
B: onset: >20 y/o
C: 10 – 19 y/o
D: < 10 y/o
D1: < 10 y/o
D2: > 20 y/o
D3: Beginning retinopathy
D4: Hardening arteries
D5: HPN
E: Pelvic arteries
F: Retinopathy
H: Cardiopathy
R: Retinopathy
T: Transplant kidney

- Absence or deficiency in insulin affects, CHO, Fats & CHON metabolism

- Insulin facilitates entry of glucose into the cell
- If there is no insulin  glucose remains outside the cell  hyperglycemia  fluids are attracted to cell & blood
- Cells dehydrated (brain)  compensatory mechanism  Polydipsia
- Cells dehydrated (brain)  Inc glomerular filtration rate  Poly uria  leads to weight loss  cell stones  brain 
polyphagia

Lab Data: FBS, Glycosylated Hgb, Hemogluco test

N. Dx: Knowledge deficit
Altered Nutrition
Altered Elimination
Risk for Infection
Priority: To maintain normal blood sugar
Diet: 50 -70 % CHO, 20 – 30% Fats, 10 – 20% CHON
Well balanced diet
Insulin: Type I, pregnant 2nd trimester  Inc dose
Anti-Diabetic Agents  sulfonylreas  CI --> sulfa Drugs
Blood sugar  am and pm
Ensure Adequate food intake
Transplant of pancreatic cells
Exercise  Moderate
Scrupulous Foot care  Avoid barefoot, avoid synthetic shoes  Indicated: Foot powder, snuggly fitting shoes, cotton
socks, visit podiatrist atleast once a year

Complications:

Hypoglycemia: Blood Sugar  < 150mg/dl Hyperglycemia: Blood sugar  > 140mg/dl
RF: too much insulin, missed meal, exercise RF: Too little insulin, Inc food intake, pregnancy,
Infection, stress, surgery
S/Sx:
Diaphoresis Type I type II
Decreased LOC DKA HHNK
Diff in problem solving Acetone breath Inc GI s/sx
De H2O DeH2O
Warm skin Inc serum Osmolality
43
 3 P’s 3 P’s
Kussmauls breathing
Tx: Simple sugar TX: Airway, Fluid and Insulin  rapid acting insulin

Other Complications:
1.) Microangiography  damage to small retinal blood vessels
2.) Atherosclerosis  hardening of arteries  HPN
3.) Neuropathy  Kidney damage
4.) Retinopathy  Opthalmopathy  damage to nerves
5.) Peripheral / Autonomic  Dec nerve impulse transmission

PITUITARY GLAND

ADH
Fluid Retention

Deficiency Exercise
Diabetes Insipidus SIADH

Risk Factor Trauma Trauma

Surgery Tumor
S/sx: Polyuria (21L/day)
Polydipsia

Lab Data: Fluid deprivation test

NPO X 12 hrs
Concentrated urine
Specific Gravity: < 1.005

Vasopressin Check specific Gravity

Depressin
Lepressin

Monitor and output and specific gravity of urine Fluid retention

Goal of care: Excretion of fluid  Diuretics and anti-HPN Dilutional Hyponatremia
Check Sodium

Growth Hormone

Ant. Pituitary Gland

Promotes growth

Deficiency Excess
Dwarfism  Mahal *Before closure of growth plate  Gigantism  Taller, slender
Achondroplasia  “Nanus Syndrome”  Dagul  Marfans’ Syndrome  Genetic d/o, a. Dominant  spine d/o
 Scoliosis  Cardiac problem
*After closure of growth plate  Acromegally  enlargement of
Extremities
* Inc growth hormone and glucose

ADRENAL

Outer Middle
Cortex Medulla

44
Glucocorticoids Mineralocorticoids Epinephrine
Gluconeogenesis Na retention Nor-epinephrine

Def. Excess Excess fight/flight response

Addison’s Cushings Conn’s Syndrome Tumor
Pheochromocytoma  excess epi and
Commons syndrome  norepinephrine
Aldosteronism HPN, H/A
Inc hyperglycemia
Hypermetabolism
Lab Data: Inc VMA  2 – 7 mg/dl in 24 hrs
Avoid vanilla containing foods, 14 hrs before the test

ADDISON’S CUSHING’S CONN’S

Deficiency Excess Excess

Glucocorticoids Mineralocoticoids Glucocorticoids Mineralocoticoids Mineralocoticoids
RF: Autoimmune Tumor tumor
Surgery

S/Sx: Hypoglycemia Hyperglycemia Hypertesnsion

Hyponatremia Hypernatremia Hypernatremia
Hyperkalemia Hypertension Hypertension
Hypotension – shock like
Brown skin pigmentation Truncal Obesity Truncal Obesity
Truncal Obesity Mood swings Mood swings
Mood swings Facial hirsutism Facial hirsutism
Facial hirsutism Buffalo hump Buffalo hump
Buffalo hump Moon Facie Moon Facie
Moon Facie

Maintain Fluid and electrolyte Balance inc Na & dec K, Inc BP

Steroids steroids inhibitor Anti-HPN
*Fludrocotisone Florinef Mitotaine Diuretics
Dec s/sx:
Normal Na and blood sugar
Diet: Inc Na, Dec K Dec Na, Inc K Dec Na, Inc K
Client Teachings:
Meds for life Prone to osteoporosis
Avoid crowded areas Excessive poor wound healing

THYROID

T3, T4 CALCITONIN
BMR Deposition of Ca in the bones

Deficiency Excess

Hypothyroidism Hyperthyroidism
- Cretinism - Grave’s disease
- Myxedema - Basedow’s disease
- Parry’s disease

RF: Autoimmune, tumor

45
S/Sx:
Facial edema Exopthalmos
Intolerance to cold Goiter
Hypometabolism Hypermetabolism
Intolerance to cold

Lab Data:
Dec T3, T4, Inc TSH Inc T3, T4, Dec TSH
- Activity intolerance - Risk for injury
-Uthyroid state  Normal - Uthyroid state
- Give thyroid supplement - Anti thyroid drugs
- Synthroid - Propylthiouracil
SE:
- Insomnia - Agranulocytosis (Fever, Soar throat)
- Nervousness -
- Palpitation
Diet:
- Dec Calories - Inc Calories
- Warm environment - Cold environment

THYROID SURGERY

Preparation Post operative

- Lugol’s solution (2 wks before surgery) - Monitor complication

- Dec size & vascularity of thyroid gland
- Give in straw and diluted in water or apple juice
- S/sx of iodism  Metallic taste
1. Hemmorrhage – bruises
2. Laryngospasm – tracheostomy
3. Damage to laryngeal – inability to speak, aphonia
4. Tetany – Dec in Ca > Tingling, chvostek, Trouseau sign
5. Thyroid crisis
Complications: Fever, Inc HR, check VS

PARATHYROID
- Inc Ca in the blood

Hypothyroidism Hyperthyroidism

Surgery Tumor

S/Sx;
Early: Tingling, chvostek, Trouseau sign - Pain, bone destruction, fracture / osteoporosis
- Von Recklinghausen disease

N. Dx:
Risk for injury Renal calculi formation
- Give Ca supplements Lab Data: Inc Ca in blood
- Inc Ca in diet N. Dx: Risk for injury
Priority: Surgery
Mx: Inc OFI
Pointers:
1. Manifestations of Ketoacidosis:
A: Rapid and deep breathing
2. Post thyroidectomy  Tetany of hands, feet and muscle twitching, the nurse knows the doctor would order?
A: Ca Gluconate
3. W/c of the ff. indicates hypothyroidism?
A: Intolerance to cold
4. In PKU, which is not indicated?
A: Milk Shake

46
5. Which of the ff. manifestation indicates a complication post thyroidectomy?
A: Tachycardia
6. Which of the ff. interventions is appropriate for a pt with Addison’s disease?
A: Monitor the BP
7. Insulin was given at 8 am, when do you expect hypoglycemia?
A: Before lunch
8. In PTU an expected outcome is a?
A: Dec in PR
9. Hypothyroidism  best question?
A: Do you tire?
10. Which of the ff. data needs to be assured in head injury?
A: Dec urine specific Gravity

NEPHROTIC SYNDROME ACUTE GLOMERULONEPHRITIS

Congenital Acquired  sore throat
Autoimmune Autoimmune

- Inability of the kidneys to maintain fluid balance - Kidney damage

*hyponatremia

S/Sx:
- Normal or dec in BP - Inc BP
- Peripheral Edema subsides at the end of the day - Progressive peripheral edema at the end of the day
- Frothy urine color - tea colored urine / cola

Lab Data:
- Most significant data  Proteinuria = > 10mg/24hrs - Proteinuria = < 10mg/24hrs
- ( - ) Colloid osmotic pressure  edema - Inc ASOT
N.Dx:
- Fluid Volume excess
- Risk for impaired skin integrity
Mx:
- Goal of care  promote fluid balance
- Restricted fluid
- Frequently turn client
- Steroids - AGN: Anti-HPN
- Dec Na, Inc CHON - Dec Na, Dec CHON

WILM’S TUMOR
- Congenital tumor of kidneys
- unilateral left kidney
- palpable on abdomen
- common in children < 5y/o
- ( + ) HPN, Hematuria
- Risk for injury
- Promote Safety
- Prepare pt for surgery & chemotherapy
- Avoid abdominal palpation

CYSTITIS
- Ascending infection

47
- Bladder  Ureters  Kidneys  pyelonephritis  CVA tendency
RF:
- bubble bath
- Silk underwear
- Prolonged driving
- Catheterization
S/Sx:
- Burning sensation
Lab Data:
- Urinalysis
- Inc WBC
- Inc glucose
Tx:
- Treat infection
- antibiotics
- Acid ash diet
- Inc OFI
- Avoid risk factors

RENAL FAILURE

ACUTE CHRONIC

- Sudden cessation of kidney function - Progressive/ irreversible destruction of kidney tissues

- Scar formation
RF:
Pre- Intra- Post- - AGN, NS
Renal Renal Renal
-Dec circulation of -disease of kidney - obstruction
Blood volume -stone

S/sx;
Oliguric Diuretic Recovery 1. Dec renal reserve – polyuria, nocturia, polydipsia
Phase Phase Phase 2. Renal insufficiency – Inc BUN & creatinine
3. Renal Failure – HPN, Renal Damage
-Dec urine output -polyuria, dec Na & K - 1-2 yrs 4. ESRD – Azotemia, uremia
- < 400ml Lab Data:
- Inc BUN & Crea
N. Dx:
- Fluid & electrolyte imbalance N. Dx:
Priority: Restore circulating fluids - Fluid & electrolyte imbalance
- Monitor intake and output Priority: Fluid restrictions
- Response of client on therapy – output, BP Meds: Epogen to prevent anemia
Meds: Diuretics, Dec Na diet, Anti-HPN, digoxin - Amphogel – prevent hyper phosphatemia
- Diuretics, Anti-HPN, Digitalis
Diet: Dec Chon
Mx: Dialysis: 3 X a week or every 48 hours

DIALYSIS

Hemodialysis Peritoneal
Dialyzing agent - Dialyzing Machine - Dialyzing agent – Peritoneum
Access Access
Fistula shunt - Ten khoff catheter
-internal access - external access - assess rigid abdomen  peritonitis
-anastomisis of a & v
- palpate for thrills and auscultate bruit

Complications
48
Disequilibrium Dialysis Encephalopathy

Rapid removal of waste product -Aluminum toxicity

Fluids and electrolytes -S/Sx: dementia, dizziness
GI CNS -Report to MD
NAVDA H/A
Dizziness
Restlessness
- Report to MD

BPH
- Glandular enlargement of the prostate
- After age 40, male
S/Sx: - Dec size & force of urinary stream
- Nocturia
- Dysuria
- Frequency, urgency, hesitancy
Lab Data:
DRE  @ age 40
Priority: Promote Urinary elimination  Prepare for surgery
TURP  no incision
Suprapubic Retropubic Perineal
-above the bladder -below the bladder -causes impotence

Pointers
1. An elderly with oliguria and flank pain may indicate a problems caused by?
A: Intake of neomycin
2. Which laboratory data needs to be reported?
A: urine specific gravity of 1.004
3. 12 hrs after TURP – the pt complains of spasm
A: Check patency of retention catheter.
4. A 2 y/o boy with Nephrotic Syndrome with periorbital edema & frontal edema what will be the essential nursing
measure: A: turn pt frequently
5. Which of the ff is a common complication of chronic renal failure?
A: Anemia
6. A pt with Nephrotic Syndrome asks “Why am I gaining weight?” the best reponse is?
A: you have sodium retention that attracts water
7. During hemolysis, pt with HA and vomiting, restless and confused, he is having?
A: Disequilibrium syndrome
8. After peritoneal dialysis the return flow with dialyzate solution is inadequate, What should the nurse do?
A: Turn pt from side to side.
9. A Priority N. dx to a pt with renal stones?
A: Pain

OTITIS MEDIA
- Infection of middle ear
- URTI
- Faulty feeding

49
- swimming in dirty waters
- Pain, fever, earache
Lab Data: PE, otoscope, bulging tympanic membrane
N. Dx: Pain  antibiotic, decongestant, Pseudafed
Chronic: myringotomy tube insertion

RETINAL DETECHMENT
o Separation
o Sensory pigment  retina
o Aging  40 y/o
o Trauma
o S/sx: visual floaters  painless
Cobwebs, veil like, floating spots
o Lab Data: Opthalmoscopy, PE
o N. Dx: Risk for injury
o Priority: Safety, bedrest, affected side towards the bed
o Scleral buckling  using laser to create a scar
o Avoid sudden head movement, bending and blowing of nose
o Surgery:
Trabeculoplasty  trabecular meshwork  laser  out pt
Ttrabeculectomy  trabecular meshwork  removal  in pt for 1 -2 days
o Avoid bending and sudden eye movement
o Report: eye pain and bleeding

GLAUCOMA
o Inc IOP
o Open Angle: Chronic  Inc aqueous humor
o Closed Angle: Acute  forward displacement of iris
o Aging > 40 y/o
o Familial
o “tunnel vision”
o “Gun barrel vision”
o “halos around lights”
o “Loss of peripheral vision”
o Blindness
o Lab Data: Tonometry, (gonioscopy  differentiate open from closed angle glaucoma), perimetry -> visual fields
o N. Dx: risk for injury, safety, dec IOP
o Meds: Myotics  pilocarpine
o CI: Midriatics

CATARACT
o Opacity of lenses
o Poor color perception
o Painless
o Aging > 40 y/o
o Prolonged steroids
o Lab Data: Opthalmoscopy  ( - ) red light reflex
o N. Dx: Risk for injury
o Surgery:
Peripheral iridectomy  hole in lens  cataract is suctioned
Photoemulsification  needle like structure inserted into the lens -> crush cataract
o Avoid bending and sudden eye movement
o Report: eye pain and bleeding

50
MENIERE’S DISEASE OTOSCLEROSIS
- Imbalance in the endolymphatic fluids - Hardening of the bones in the inner ear
- inner ear - affected  stapes
- RF:
-High altitudes (pilots and divers) -Aging
- s/sx:
-Hearing loss -diff in communicating
-Tinnitus -tinnitus
-Vertigo – revolving motion -conductive hearing loss
- Lab Data:
- Caloric stimulation test - Weber and Rhine’s test
- N. Dx:
- Risk for injury - Impaired communication
- Intervention:
- Safety - establish communication
- Position  supine or flat - stapedectomy  mobilize stapes
- Diet: Low Na - post surgery: avoid blowing of nose
- CI: Streptomycin  ototoxic - avoid deep diving
- Meds: DIAMOX - avoid flying in small airplanes

Pointers:

1. Post trabeculoplasty  eye pain.

A: Call MD
2. Pt with tunnel vision, N. Dx?
A: Inc risk for injury
3. Which drug will help dec aqueous humor?
A: DIAMOX
4. Post Cataract extraction, what is the position?
A: On unaffected side to dec edema
5. Which intervention will help prevent loss of vision in glaucoma?
A: Taking the meds correctly as ordered
6. Which describes trabeculoplasty?
A: Surgical intervention that aims to create a passageway for the blocked fluid.

DUCHENNE’S MUSCULAR DYSTROPHY ERB DUCHENNE PARALYSIS

- genetically transmitted - acquired

- X-linked recessive (mother to son – 50% disease, - Birth trauma (hyperextension of shoulder)
Mother to daughter – 25% trait) - Brachial Plexus – upper plexus
S/sx: - Reversible, recovery after 3 mos
- Gower’s sign  arms used to push body to stand up - Klumpke’s paralysis – lower plexus
- Waddling gait
- Difficulty in running and climbing  1 ½ to 2 ½
- Progressive weakness  respiratory paralysis
- Lab Data: EMG, PE
N. Dx: Ineffective breathing pattern
Impaired physical mobility
- Prepare tracheostomy set
- Refer parents to geneticists
- refer to PT
- Treat symptoms

CEREBRAL PALSY

51
- non- progressive (fixed) d/o
- neuromuscular system
- uncoordinated movements
- related to brain anoxia and prolonged labor
S/sx:
- Exaggerated reflexes
- Early pattern of hand dominance  10 – 12 months
- poor posture
- Arching of back
- Frequent tongue thrusting
- scissor gait
Lab Data:
- CT Scan
- Muscle biopsy
N. Dx:
- Risk for injury
- Improved Physical integrity
- Altered nutrition
Priority: Promote Safety & mobility
Assist ambulation
Support: crutches, cane, walker, leg braces
- Drugs – muscle relaxants, anti-convulsants
- Surgery – release of tendon of Achilles
- Foods that sticks on spoon

CSF FLOW
Lateral Ventricles  Foramen of Monroe  3rd Ventricle  Aqueduct of Sylvius  Foramen of Lushka & Magendie  4th
Ventricle  Sub-arachnoid spaces

HYDROCEPHALUS

- Interruption of CSF flow

- Not a disease
- Manifestation  d/o
- Arnold Chiari Malformation  Elongation of brainstem  Obstructs the flow of CSF
- Dandy Walker  atresia  narrowing of foramen of Lushka & Magendie  CSF flow
- Excessive production (communicating) or obstruction of CSF (non-communicating)
S/Sx: Projectile vomiting, irritability, enlarged head (Normal  33-35 cm), Sunset eyes, separation of sutures, seizure)
Bossing sign  pronounced forehead
Macewen’s sign  cracked pot percussion of head
Lab data: CT Scan, MRI
N. Dx: Risk for injury
Priority: Safety, Seizure precaution
Meds: Anti-convulsants
Position: Semi-Fowlers
Low-fowlers
Surgery: Insertion of ventriculoperitoneal shunt
- Check  Inc in ICP
- Measure head frequently

SPINA BIFIDA

- Failure of spinal processes to fuse

- neural tube defects
- Occulta: Dimpling, tuff of hair, lumbo-sacral area
- Cystica: Meningocel  CSF & meniges, Myelomeningocele  CSF, meninges, spinal cord
52
Lab Data: PE, MRI
Alpha Feto CHON analysis  Increased
Normal  15 – 30
N. Dx: Risk for infection, Impaired mobility
- Sidelying or prone  best position
- Cover with wet sterile gauze
- Surgery  within 48hrs  prevent paralysis of LE
 After sac is closed  may lead to hydrocephalus
- Tape measure  @ bedside to measure head

Increase ICP
- ICP more than 15mmHg
-Normal 0 – 10
- 11 – 20  mild
- 21 – 30  moderate
- 31 and above  severe
- Maybe due to trauma
- Space occupying lesion
- A congenital defect
S/Sx:
Early: Decreasing LOC
Late: VS changes, Cushing’s triad, widened PP, Dec PR, Dec RR
Lab Data: Subdural / intravascular monitoring
N. Dx: Risk for injury
Priority: Safety, head of bed elevated, evaluate LOC, promote a patent airway
Discharge instutions: meds, mitoring, seizure precaution

BACTERIAL MENIGITIS
- Infections  inflammation with menigitis
- N. Menigitides
- Influenze Virus
- HIB Vaccine
S/Sx: Inc ICP, Brudzinski’s sign, Kernig’s sign
Lab Data: CSF, Dec Sugar, Inc WBC, Inc Protein
N Dx: Risk for injury, Risk for injection
Meds: Antibiotics as prescribed
Precaution: Respiratory Droplet
Complication: Hearing Impairment
Audiologist Screening and testing

REYES SYNDROME
- Toxic
- Encephalopathy & Hepatopathy
- Fatty infiltration
- CNS and Liver
- V. Vax related to Reye’s
- Triad Symptoms: Fever, Dec LOC, Bleeding tendencies
Stages:
1.) Stage 1 = Confused
2.) Stage 2 = Lehargic
3.) Stage 3 = Decorticate
4.) Stage 4 = Decerebrate
5.) Stage 5 = Comma
Diagnostic: Biliary fxn test, bleeding time, clotting time, Neuro assessment GCS
N Dx: Risk for injury
53
Priority: Safety
 Bleeding precaution, clotting time, Neuro-assessment GCS
 Vivax ( + ) chickenpox  Reye’s

SEIZURE
- Abnormal discharge of electrical impulse in the brain
RF: Metabolic d/o  Delirium
Alcoholism  withdrawal symptoms
Intake of drugs & trauma
S/Sx:
Types
1.) Absence / petitmal  brief periods of non-activity
2.) Jacksonian  Starts on body parts  to whole body
3.) Grandmal  Tonic: gen. contractions, Clonic: alternating contraction & relaxation
S/Sx: Dura  feeling of uneasiness before seizure and LOC and convulsion.
N. Dx: Ineffective Airway Clearance
Risk for injury
Smal pillow at the back of head or lap
Meds: Anti-convulsants, Dilantin
- Refer to Neorologist
- Subs. Abuse screening
- EEG, MRI, CT Scan
Precaution: Avoid extremes
Avoid emotional stress
Lifetime anti-convulsants

CVA
- Sudden cessation of brain functions due to dec O2
RF: Thrombosis, embolism, hemorrhage & infarction
Progression:
1.) TIA  brief neurologic deficits  30 secs  24 hrs
2.) Stroke in evolution  body weakness / facial weakness
3.) Completed stroke
Frontal Lobe  personality, speech changes  Broca’s aphasia
 Expressive Aphasia  Inability to say the right words
Temporal  Memory, Wernicke’s Aphasia  Inability to comprehend
Parietal Lobe  sensation & orientation
Occipital  Visual disturbance
S/Sx: Indicative of Complication
Hemiplegia  Paralysis of right or left side of body
Homonymous Hemianopsia
Emotional Lability  Mood swings
Aphasia  Expressive and receptive
Dysphagia  Swallow food at least twice
- C4-C5 deccusation of spinal cord
- Right lesion  Left eye, right face , Left body affectation
 Unilateral Neglect
Lab Data: Inc cholesterol  Normal 200
EEG, MRI, CT-scan
N.Dx: Ineffective breathing pattern
- Head of bed elevated
- Refer to PT & OT
Diet: Low Na, Low Fat
Meds: Anti-convulsants, vasodilator, diuretics

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GBS
PNS
- Inflammation & destruction of PNS
- Autoimmune  viral infection
- No gender related factors
S/Sx:
- Ascending or descending muscle
paralysis
- Mixture
- Respiratory Depression
- Lab. CSF Analysis  Inc CHON
N.Dx:
- Ineffective breathing pattern
Priority:
- Promote patent airway
- Prepare tracheotomy set @ bedside
- steroids
- Refer to Respiratory Therapist
NEUROMUSCULAR DISEASE
MG MS ALS (Lou-Gehrig)
NMJ CNS Upper & Lower Motor Neuron
- Autoimmune (early – male 20 – 40 - Whites/females - Autosomal dominant
y/o, late – female > 50 y/o) - Demyelination of neurons in CNS - Male & Female
- Deficiency in acetylcholine receptor - Brain and Spinal Cord
sites
- descending muscle weakness
-from face downward
- Ptosis - Diplopia - Dysphagia
- Difficulty in chewing - Ptosis
- Decrease voice - Impaired sensation
- Impaired sexual function
- General muscle paralysis
CI: Talking long  respiratory Lab: MRI, localizes areas of plaque Lab: EMG, CT Scan, MRI
depression formation
Diagnostic: N.Dx: N.Dx:
Tensilon  short 30 secs  lasts for 5 - Ineffective breathing pattern Ineffective breathing pattern
mins - Sensory perceptual alteration Priority:
Drugs: Priority: - Airway
Neostigmine  lifetime  Antidote  - Maintain patent airway - Prepare tracheostomy set
ATSO4 Meds:
- steroids
- Muscle relaxants
- Bladder stimulant
Complications: - Avoid hot or cold shower - Supportive and preventive
- Crisis - Assist diet in ambulation - Advance directive & living will
- Myesthenic: Dec Meds  * Bladder retraining program – self
Neostigmine catheterization
- Cholinergic: Inc Meds  ATSO4 - Handwashing  to prevent
ascending infection
-Refer to PT & OT
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