Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Meningitis
Hyperactive deep tendon reflexes, tachy, red macular
rash
CSF- cloudy bacterial, clear viral Protein, WBC, CSF
pressure glucose (bacterial)
DROPLET
Kernig Sign: + w/ meningitis = resistance and pain w/
extension of the clients leg from a flex position
Brudzinski Sign: + w/ meningitis = flexion of
extremities occurring with deliberate flexion of the
clients neck
Seizures
Tonic-Clonic Seizures
-usually lasts 1 to 2 min. but no more than 5 min.
Tonic Phase: episode of stiffening of muscle, loss of
consciousness, cessation of breathing, dilated pupils,
and development of cyanosis
Clonic Phase: episode of rhythmic jerking of the
extermitis, irregular resp, bitting of the cheek or tongue
and bladder and bowel loss.
Postictal Phase: may last for several hours.
Unconsciousness may last for 30 min. client wakes up
confused doesnt know what happened. s/s
headache, fatigue, muscle aches
Simple Partial Seizures:
consciousness maintained
dj vu, changes in HR, abnormal flushing, offensive
smells
Parkinsons
Parkinsons Stages:
Stage 1: unilateral shaking or termor of one limb
Stage 2: bilateral limb involvement occurs, making
walking and balance difficult
Stage 3: physical movements slow down significantly,
affecting walking more
Stage 4: tremors may decrease, but akinesia and
rigidity make day-to-day task difficult
Stage 5: client unable to stand or walk, is dependent
for all care, and may exhibit dementia.
Bradykinesia: slow movements
Stroke
LEFT: responsible for language, mathematic skills, and
analytic thinking.
-expressive and receptive aphasia (abilty to speech
and understand language)
-agnosia (unable to recognize familiar objects)
-alexia (reading difficult)
-Agraphia (writing difficulty)
-right extremity hemiplegia (paralysis) or hemiparesis
(weakness)
-slow, cautious behavior
-depression, anger, and quick to become frustrated
-visual changes
RIGHT: visual and spatial awareness and
proprioception
-alter perception of deficits
-one-sided neglect syndrome
-loss of depth perception
-poor impulse control and judgement
-left hemiplegia or hemiparesis
-visual changes, such as hemianopsia
Myasthenia Gravis
autoimmune disorder w/ severe muscle weakness
Tensilon Testing: measurement of the cranial muscle
strength. Medication Edrophonium (Tensilon) adm
(antidote is Atropine) + when muscle strength
improves.
Myasthenic Crisis (undermedicated): resp muscle
weakness mechanical ventilation, weakness,
incontinence, fatigue, hypertension
Cholinergic Crisis (overmedicated): muscle
twitching to the point of resp weakness,
hypersecretions (nausea, dirreaha, resp sections.),
hypotension, ATROPINE
Head injury
s/s: deteriorating LOC, restlessness, irritability, dilated,
pinpoint or asymmetrical puplis slow to react or
nonreactive, abnormal posturing (decerebrate,
decorticate or flaccidity), cushing reflex severe
hypertension w/ widening pulse pressure and
bradycardia. CSF halo sign from nose or ears.
1 hr golden window for best tx. Brain function
diminishes after 3 min w/o O2
HOB 30 degrees.
ICP pressure has not exceeded 25 mmHG for 30 min,
30 mmHG for 15 min, or 40 mmHG for 1 min.
Disorders of the Eye
cataracts: in vision and sensitivity to light
open-angle glaucoma: loss of peripheral vision
Macular Degeneration: loss of central vision
Angle-closure glaucoma: nausea and severe pain
*never turn on op side
Ear
Menieres Disease: vestibular disease characterized
by a triad of manifestations: tinnuitus, unilateral
sensorineural hearing loss, and vertigo
-FLUID restrictions
-limit freq position changes
-dark room
-administer antiemetic
Multiple Sclerosis:
-hyperactive deep-tendon reflexes
-risk for motor dysfunction, intention tremors, poor
coordination, and loss of balance
-double vision
Guillain-Barre Syndrome
-Ascending paralysis
Myasthenia Gravis
-Increased lacrimation (tearing of the eyes)
-Tensilon test (determines myasthenic crisis or
cholinergic crisis)
-double vision
Carbidopa-levodopa
-orthostatic hypotension
-high protein reduces the absorption
-saliva, urine and sweat can be darker color
-takes weeks to months to work
Rheumatoid Arthritis
-Ulnar deviation
-increased sedimentation
-spongy joint tissue
-celecoxib (Celebrex)
Osteoarthritis
-unilateral joint involvement
-compression fractures of the spine
-crepitus
-decrease range of motion
-affects larger joints
-joint pain resolves with rest
Increased Intracranial pressure
-maintain PaCO2 at approx. 35 mmHg
Post-op Craniotomy
-no suction ; only when necessary
-report wound drainage greater than 50ml/8hr
-elevated HOB 30 degrees
-neuros q15-30 min for 4-6 hr after 24 hr post op q2-4
hr
Right-sided homonymous hemianopia
Recombinant tissue plasminogen activator
thrombolytic dissolves blood clots
Recombinant factor VIII
manages symptoms of hemophilia
Amyotrophic Lateral Sclerosis
-rest periods
-adm pain meds
-MONITOR O2 SAT progressive paralysis of resp
muscles
Viral Meningitis
-neuros q4hrs
-standard precautions
-cap refill q4 hrs
-photophobia or light sensitivity
Continuous Passive Motion
-8 12 hr per day
-wear elastic stockings thromboemboli can occur 6
mo post
Subluxation: incomplete or partial dislocation of a
bone in a joint. Limb appears shorter
Atrophy: casted extremity is smaller due to the
wasting of the muscles that occur secondary to the
lack of use
Dislocated hip
-shortening of the leg
Decerebrate Posture
-rigidly extend all four extermities
Decorticate Posture
-internally flex the arms and extend the legs
-internally rotate arms and legs
Arteriovenous Malformation
CARDIO
Bradydysrhythmia: s/s confusion, hypotension,
diaphoresis
Pericarditis: friction rub
Cardiac tamponade: pulses paradoxus, - systolic BP
is 10 mmHg higher on expiration or inspiration
endocarditis: valvular disease common complication
total cholesterol is less than 200 mg/dl
HDL above 40 mg/dl
LDL less than 100 mg/dl
25% of fat intake is okay
2 bottles of beer / day is okay moderate
-Claudication occurs with arterial ulcers
CABG mediastinal drainage 150ml/hr okay
-report elevated blood pressure
Dilated cardiomyopathy activity intolerance left
ventricular failure
Iron Deficiency anemia: ferrous sulfate
supplementation
Megaloblastic Anemia: increase folic acid
Pernicious Anemia: Vitamin B12 injections
CHF: sudden onset of SOB, air hungry, coughing
frothy, pink sputum crackles in lungs, pitting edema
Respiratory Masks:
rebreather mask:
L/min)
Simple face mask:
L/min)
Venturi Mask:
Nonrebreather Mask:
40% to 70% (6 to 10
40% to 60% (5 to 8
24% to 60% (4 to 12 L/min)
60% to 100% (10 to 15 L/min)
RESP
-pH 7.47 Po2 94 PCo2 30 HCo3 25 = respiratory
alkalosis hyperventilation; have client breathe slowly
into paper bag. -metabolic alkalosis = vomiting and diarrhea
-resp acidosis = decreased exhalation of carbon
dioxide as in COPD
absence of breath sounds: pneumothorax
expiratory wheezing: asthma
inspiratory stridor: narrowed upper airway
rhonchi: partial obstruction of large airways
Chest tubes:
-below level of chest
-suction control chamber should bubble continuously
-water seal chamber should not bubble
-change the whole drainage system when emptying.
-drainage greater than 100 ml in 1 hr needs
interventions
-small, dark-red clots are expected
GI
Paracentesis: increased HR (hypovolemia) potential
complication
-weight should decrease after procedure
-decreased SOB post procedure
Ileostomy:
-pts often experience intolerance to high-fiber foods.
-loose liquid output
-NHP of dark purple stoma = bowel ischemia
-sensation of burning during bowel elimination is
normal.
Ulcerative Colitis exacerbations teaching to
reduce risk
-use progressive relaxation techniques
-arrange activities to allow for daily rest periods
-restrict intake of carbonated beverages
AVOID fiber (causes diarrhea and cramping), milk
(poorly tolerated)
Acute pancreatitis:
-elevated serum glucose
-increased serum amylase
-elevated WBC
-increased bilirubin
ENDO
Diabetes insipidus
-limit fluid intake: no more than 3 L per day
-daily weights
-report weight gain or loss of 1 lb per week
-occurrence of nocturia indicates dosage adjustment.
-tachycardia
-increased hematocrit (r/t dehydration)
-increased urine output leads to dilute urine and low
specific gravity
-increased BUN (r/t dehydration)
-polyuria increased urination
-polydipsia increased thirst
hyperglycemic-hyperosmolar state (HHS)
Thyroid storm:
-Propranolol = reduction of the effects of thyroid
hormone on the heart. = decreases the rapid heart
rate caused by excessive thyroid stimulation.
Hypoglycemic: cool, clammy skin, diaphoresis,
blurred vision, tremor
Hyperglycemia: rapid, deep respirations, abdominal
cramping, urinary frequency, anorexia, dry mouth,
thirst
Early manifestations of hypoglycemia: drowsiness,
fatigue, headache, shakiness, and nausea
hyperthyroidism (Graves disease): heat
intolerance, restless, and irritable, tremors,
diaphoresis, and insomnia, exophthalmos (wide-eyed
startled appearance)
Hypothyroidism: cold intolerance, lethargy, sunken
eyes, weight gain, constipation, bradycardia,
hypotension
Thyroid replacement drugs: take medication on an
empty stomach do not eat or drink anything for 30 to
60 after taking it
Cushings Disease
-elevated blood pressure
-weight gain
-hirsutism
-Thinning of the skin
Propylthiouracil (PTU): treatment goals are to
increase weight with medication
Hypocalcemia: weak, thready pulse, increased bowel
sounds, tingling and numbness of the hands and feet,
hyperactive deep-tendon reflexes
Preop pheochromocytoma:
-avoid palpating the abdomen (causes hypertensive
crisis)
-will get a adrenalectomy loss of cortisol will need
glucocorticoid post op hormones must be replaced
-monitor client for extreme hypertension b/c
phenchromocytoma is a tumor of the adrenal glands
that causes excessive release of catecholamines
epinephrine and norepinephrine regulates HR and BP.
-Tumor usually benign
Glycosylated hemoglobin levels: or hemoglobin
A1C RBC lifespan approx. 4 mo hemoglobin
attached to glucose
Addisons Disease
-hormone deficiency caused by damage to the outer
layer of the adrenal gland (adrenal cortex)
-do not produce enough cortisol and aldosterone
-diet high in salt, carbohydrates, and protein
-low in potassium
Prolactin: hormone of pituitary gland and is
responsible for lactation
IMMUNE
Breast exam:
normal findings: asymmetrical breast size, presence
of Montgomerys tubercles on the areola, moveable
mass in the left-lower breast quadrant.
Abnormal Findings: breast tissue with an orangepeel appearance
Clindamycin:
PID report watery diarrhea to provider immediately.
Risk for pseudomembranous colitis.
Erythema at the IV insertion site
-extravasation and infection.
Uterine Cancer: transvaginal US, endometrial biopsy
screening
Cervical Cancer: Pap test
Ovarian Cyst: screening; pelvic exam, along with
transvaginal US
Fibroids: vaginal exam, transvaginal US
Leukemia
-WBC
-Hgb levels
-Hct
-platelet
Systemic lupus erythematosus SLE
- urine output
-butterfly rash
-joint inflammation
-wear SPF of at least 30
-should wear gloves when its cold outside painful
vasoconstriction in fingers
-apply moisturizer after bathing skin lesions with warm
water
Lupus Nephritis
-renal calculi
Rheumatoid Arthritis
-subcutaneous nodules
Multiple Myeloma: overgrowth of B-lymphocyte
plasma cells
Hodgkins Lymphoma: Reed-Sternberg cells found in
lymph
Burkitts Lymphoma: Epstein-Barr Virus
leukemia: overproduction of blast phase cells
HIV
-low or decreasing CD4/CD8 indicates disease
progression
- viral load = + response to the therapy
Arteriovenous Shunt
-auscultate for bruits every 4 hours
-elevated the shunted arm on pillows postop
-DO NOT take BP in that arm
-palpate distal pulses of the shunted arm
Acute Glomerulonephritis
-weight the client daily
-daily fluid allowance by adding 500 to 600 ml to the
clients previous 24-hr urine output
-client should rest
-periobital edema
-dry, itchy skin
-anuria or oliguria
-hypertension
Troponin I
Myoglobin
Cholesterol
HDL
LDL
Triglycerides
RBC
WBC
MCV
MCH
TIBC
Iron
Platelets
Hgb
Hct
PT
aPTT
INR
D-dimer
Fibrinogen
Sodium
potassium
Chloride
Calcium
Magnesium
Phosphorus
AST
ALT
ALP
Amylase
Lipase
Bilirubin
Albumin
Ammonia
BUN
Creatinine
Creatinine Clearance
Urine specific Gravity
pH
PaO2
PaCO2
HCO3
SaO2
CK-MB
Troponin T
7.35 7.45
80 100
35 45
21 28
95 100 %
0% (30 170 units/L)
< 0.2 ng/L
1.010 10.25
Prealbumin 12 mg/dl
below expected reference range protein status is
inadequate = delayed wound healing
-snack as part of bedtime routine can help clients relax
and prepare for sleep
old adult skin changes:
-thick and scaly
-round and reddish-purple (psoriasis)
-small, brown, and located randomly over the body
(moles)
Melanoma: variegated color and irregular borders
metoclopramide: half hour before meals for
gastroesophageal reflux
amputation of the left lower extremity
-elevated no more than 24 hr to prevent contractures
-rewrap the compression dressing three times daily to
promote proper fit of prostehesis and reduce edema
-anchor the residual limb dressing at the nearest joint
proximal to the amputation
pneumococcal: every 3 to 5 years
head injury: low fowlers head in midline position
MS: plan to exercise daily, avoid excessive heat
hyperactive bowel sounds: 30 gurgles and clicks
per minute
normal bowel sounds: 5 to 30 gurgles and clicks per
min
Caloric Test: client lie supine while irrigating with cold
and then warm solution in each ear. An expected
response for a client who has Meniere Disease is
vertigo, nausea, and vomiting.
TB: negative air flow room
Calcium channel blockers: headaches are common
,dumping syndrome: low fiber diet
Dehydration manifestations: tenting of the skin,
increased respiratory rate, urine output 20 ml/hr,
tachycardia, decreased BP