Hesi Comprehensive Review for Nclex-RN exam

Lab Values
Blood Gases
o PH: 7.35-7.45
o CO2: 23-30
o HCO3: 21-28
Serum electrolytes:
o Sodium (Na-): 135-145
o Potassium (K+): 3.5-5
o Calcium (C+): 8.5-10.5
o Chloride (Cl-): 95-105
o Magnesium: 1.5-2.5 (<0.5 or >3 is toxic and critical)
o Phosphorus: 2.5-4.5
Hematology
o WBC: 5,000-10,000
o RBC: 4.5-6 million
o Platelets: 150,000-400,000
o Hemoglobin: (women: 12-16) (men: 14-18)
Chemistry
o Glucose: 70-110 mg/dL
o Urine specific gravity: normal is 1.005-1.030
Low urine specific gravity: <1.005
It may be due to excessive loss of urine such as DI, damage to kidney,
drinking lot of fluids
High urine specific gravity: > 1.030
It may be due to dehydration, diarrhea, heart failure, glucosuria
o BUN: 5-18
o Creatinine: 0.5-1.2
o Cholesterol: normal <200 (anything greater is ABNORMAL)
o LDH: < 100 (anything greater is bad)
o HDL: > 60 (anything <60 is bad)
o Serum amylase: 80-180 (serum amylase > 200 think pancreatitis)
Therapeutic drug Levels
o Cardiac Output: 4-8 L/min
o CVP: 2-6 mmHg
o Digoxin: 0.5-2
o Lithium: 0.6-1.4
o Dilantin: 10-20
o Theophylline: 10-20
o Valporic acid: 50-70
Clotting Factors
o INR: 1.5-2 or 2-3.5 (goes with Coumadin)/PT: 1.5-2 (goes with Coumadin)
If low, patient is at RISK FOR CLOTTING
If high, patient is at RISK FOR BLEEDING

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 Antidote: vitamin K
o PTT: 60-70 secs (goes with heparin)
If short ==> patient is at RISK FOR CLOTTING
If prolonged ==> patient is at RISK FOR BLEEDING
o Facts:
PT/PTT are the clotting factors found in the liver
Coumadin and Heparin are given to prevent clot formation
When measuring I&O (normal intake is about 1200-1800ml a day and
output should be close to the amount intake when released out)
o Other
CPK = cardiac enzymes (indicative for MI; especially CPK=MB)
Troponin: <0.6 is normal (1.4 = bad and indicative of an MI)
Hemoglobin A1C = <6 is a good indicator that diabetes is well controlled
ESR = if elevated, there is a problem
Rheumatoid arthritis and Rheumatic fever will have elevated ESR
Degenerative arthritis will have decreased ESR
Maslows Hierarchy of Needs
Biological and physiological needs
o Basic life needs: air, food, drink, shelter, warmth, sex, sleep
Safety needs
o Protection, security, order, law, limits, stability
Belongings and love needs
o Family, affection, relationship, work groups
Esteem needs
o Achievement, status, responsibility, reputation
Self-actualization
o Personal growth and fulfillment
IV Fluids
IV solution administration
o Hypotonic solutions = goes into vascular space, hydrates, goes out
0.22% or 0.33% or 0.45 normal saline
o Isotonic solutions = replaces fluids lost from vomiting and diarrhea and
increases intravascular volume
0.9% normal saline
5% dextrose
o Hypertonic solutions = pulls fluid from outside into vascular space
3% or 5% normal saline
Drugs:
Facts:
o Most antibiotics cause GI effects
o NEVER STOP USING A DRUGS ABRUPTLY
o AVOID ALCOHOL with use of drugs
o PREGNANT WOMAN SHOULD AVOID USE OF OTC (ASK DOCTOR FIRST)
Pain medications

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 o NSAIDs = salicylates
o Tylenol = too much causes liver failure
o Ketoralac (Toradol)/ Ibuprofen (Motrion) or other pain medications= AVOID
taking with the 3 Gs (ginko, ginger, and garlic) because they are anti-
platelet agents and can increase risk for bleeding
o Morphine = given for pain; given for anxiety if patient has an MI; also
decreases preload and afterload (side effect: respiratory depression)
Blood coagulant medications
o Anti-coagulants
Anticoagulants are used to prevent formation of clots
Example of anti-coagulant:
Heparin (given IV or SQ),
o Antidote for heparin: Protamine Sulfate
o When a person is on heparin, monitor aPTT and INR
aPPT = monitors clotting time (normal = 1.5-2.5)
INR = monitors risk of bleeding (normal = 2-3.5)
High = risk for bleeding; Low = risk for clotting
Wafarin (PO medication that patient can use at home)
o Antidote for warfarin: Vitamin K
o When tapering off heparin, give warfarin 3-4 days prior to
discontinuation (heparin and warfarin can be taken together if
tapering off heparin)
Lovenox (used in hospital) = has less adverse effects
o It is often given to post-op surgery patients who had hip surgery,
fracture, or are on complete bed rest to prevent DVT
o When using lovenox, PTT is not required b/c of its lack of effects
Side effect for anticoagulants: BLEEDING
o Anti-platelet drugs
Anti-platelet drugs are given to prevent platelet-aggregation (blood from
sticking together to form clots) = also known as a blood thinner
Example of antiplatelet: Aspirin
Side effect: Bleeding
Nurse management: teach patient to stop taking aspirin 7-10 days before
surgery to prevent bleeding
o Thrombolytics
Thrombolytics are used to dissolve or break down formed clots
Examples: streptokinase, tPA, urokinase
Administration of thrombolytics
For MI = give within 6 hours
For Stroke = give within 3 hours
Side effects: bleeding
Cardiac medications
o Beta-blockers = end with lol
Beta-blockers work by blocking the effects of epinephrine which
therefore decreases heart contractility and lowers BP

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 Beta-blockers affect your heart and sometimes blood vessels
Examples of beta-blockers: propranolol, metoprolol, atenolol, and more
Side effects of beta-blockers: jittery, anxious, may cause confusion
Why would you not give a beta-blocker to a diabetic patient?
Because it would mask the S/S of hypoglycemia
o Calcium channel blocker
Calcium channel blockers work by preventing calcium from entering the
heart and blood vessels thereby slowing heart contractility, lowers blood
pressure, decreases heart rate, and relieves angina
CCB are VERY NICE DRUGS (Verapamil, Nifidipine, Diltiazem)
Side effects: bradycardia, drowsiness, light-headedness
Nurse management:
Before giving CCB, check the patient HR prior to giving drug because it
can increase HR and cause SVT
Teach patient to avoid grapefruit juice while taking CCB
o Ace inhibitors = end with pril
Ace inhibitors work by converting angiotensin I to angiontensin II (found
in the kidneys); thereby, decrease blood pressure
Examples of Ace inhibitors: Captopril, Enalapril, lisinopril, and more
Side effects: dry hacky cough, hyperkalemia, rapid heart beats
Nurse management:
Teach patient to avoid foods high in potassium such as: potatoes,
pears, bananas, and other fruits
Teach patient to report any dry hacky cough
Do not give drug to people with impaired renal function
o Vasodilators
Vasodilators are given to patients with hypertensive crisis
Examples of vasodilators: Nitroprusside; Hydralazine
o Dopamine
Dopamine works by dilating renal tubules to increase kidney perfusion; it
is also used to increase blood pressure
o Atropine
Atropine is used for symptomatic bradycardia;
Atropine is an anti-cholinergic so it can be used to decrease secretions
during surgical procedures
Cholesterol drugs
o Bile acid sequentials
o Statin drugs
Simvastatin
Side effects: rhabdomylosis (break down of muscles)
Avoid grapefruit juice
Muscle relaxants
o Drugs that treat muscle spasms
Baclofen or Flexeril = can Rx multiple sclerosis
o Drugs that treat muscle contractures

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 Dantrolene or Botulinum
Dantrolene can cause liver damage
Anti-migraines
o Ergotamine or Sumatriptans (sumatriptans can be given up to 3 doses upon
onset of migraine = allow to dissolve in mouth)
Antibiotics ==> most ALL antibiotics cause GI problems
o Aminoglycosides
Gentamicin = causes photosensitivity
Adverse effects: hearing loss and tinnitus
Avoid direct sunlight when on medication
o Penicillin = they go hand in hand with cephalosporin = Rx gram (+)/(-)
Penicillin includes: penicillin G or amoxicillin
PT may develop a super-infection while using drug (ex: stomatitis)
Use cautiously in renal failure patients
o Cephalosporins
Cephalosporins include: Cefaclor, Cefitixime, etc
May cause phlebitis at IV site (monitor for that)
o Sulfonamides
Bactrim = avoid sunlight or use sunscreen when outside
o Tetracycline = mycin drugs
Vancomycin = causes ototoxicity
Monitor use of drug because it can cause renal failure?
o TB drugs
Rifampin = used to treat TB
Patient will be on long-term treatment = assess compliance
Rifampin turns bodily fluids orange/red (tears, sweat, urine)
Teach patient to avoid using contact lenses
Seizure drugs
o Dilantin (Phenytoin) = 10-20
Adverse effects: causes swollen bleeding gums (gingival hyperplasia)
Nurse management: rinse mouth, soft-bristle tooth brush
o Phenobarbital = 15-40
o Valporic acid = 50-70
o Lorazepam is used to treat recurring seizures if patient has an IV line;
however, if no IV line, give rectal Diazepam (Valium)
Other
o Neupogen = helps the blood make WBCs = flush with dextrose 5%
o Cytoxan = chemotherapy medication = monitor WBC count because this drug
causes immunosupperssion
Nutrition
Vitamin A = colorful fruits
o Liver, sweet potatoes, carrots, spinach, peaches, and apricot
Vitamin B
o B1 = thiamine (used to reduce nerve pain)= pork, beef, liver
o B2 = riboflavin

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 o B3 = nicotinic acid
o B6 = pyridoxine (meats, poultry, grains, seeds, and seafood)
o B12 = Rx perniscious anemia = shellfish, liver, fish, and lean meat
Folic acid
o Liver, beans, peas, spinach, yeast
Vitamin C
o Citrus fruits (oranges, strawberries, tomatoes, peppers, spinach)
Vitamin D = good for bones = obtain from sunlight or supplement
o Fortified dairy products (milk), fish oil, sunlight
Vitamin E
o Vegetable oils and their products (salad oil, margarine, avocado)
Vitamin K = helps clot
o Green leafy vegetables
Iron = green leafy vegetables
o Green leafy vegetables (spinach), meats, eggs, whole grain, legume
Iodine
o Fish, shellfish, dairy products, iodized salt, and some breads
Calcium = found inside bone
o Milk, cheese, dark green vegetables (spinach), soy, legumes
Potassium
o Citrus fruits, dried fruit, bananas, pears, apples, peanut butter, potatoes
o When taking potassium supplements, take it with food because it causes GI
upset; also, AVOID use of salt substitutes when taking potassium
supplements because it can increase risk for hyperkalemia
Gluten ==> PEOPLE WITH CELIAC DISEASE NEED TO AVOID THIS
o Oats, wheat, rye, barley, dried fruits and some fresh fruits, dairy products
Immunoglobulin
IgA = found in the eyes, ears, nose, digestive tract, and vagina
IgG = transferred from mother to fetus via placenta
IgM = found in blood and lymph (develop antibodies form vaccine)
IgE = found in lungs, skin, mucus membranes (allergies)
IgD = found in chest and lining around belly
Womens health
How frequent should you visit the clinic
o First trimester (1-12 weeks) = every month
o Second trimester (13-28 weeks) = every 2 weeks
o Third trimester (28 weeks and more) = every week
Understand GTPAL
o Gravida = number of pregnancies
o Term = number of children born after 37 weeks
o Para = number of children living
o Abortions = number of children that died before 20 weeks
o Living = number of children that survived birth
Naegele Rule

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 o Subtract 3 months, add 7 days, add 1 year if after march 1st
o ALWAYS give February 28 days in the month
During pregnancy
o First trimester = the fetus should be under the umbilical cord
o At 20 weeks = fetus should be at umbilicus
o After 20 weeks = fetus should start rising up by 1cm until 25 weeks
o Place pregnant woman on left side to avoid vena cava compression
Checking for FHR
o The fetus heart starts beating at 8 weeks
o 10-12 weeks = heard with doppler
o 15-20 weeks = heard by fetoscope
Signs of pregnancy:
o Presumptive signs ==> signs that the woman experience
Consistent nausea and vomiting (morning sickness)
Breast tenderness and enlargement
Fatigue
Urinary frequency
Amenorrhea
Hyperpigmentation
Uterine enlargement
o Probable signs ==> signs examined by the doctor
Positive pregnancy test
Hegars sign = softening of lower uterine isthmus
Chadwick sign = purplish coloring of cervix or vagina
Goodell sign= softening of cervix
Ballottement = when the doctor pushes against cervix during exam
and the fetus bounces back (floating fetus)
o Positive signs ==> signs confirmed = 100% confirmed pregnancy
Fetus verified by ultrasound
Fetal movement felt upon palpation
Fetal heart sounds heard with doppler
X-ray of fetus
Testing for fetal techniques
o Ultrasound
First trimester: used to check for fetal movement and heart beat at 8
weeks, gestational age, and uterine abnormalities
Second and Third trimester: used to check for fetal size and maturity
o Amniocentesis
First trimester: used to check for fetal gender at 12 weeks
Second trimester: used to check for lung maturity
Third trimester: used to check for fetal well-being
It is only done when the uterus rises above the umbilicus
o Alpha Fetoprotein (AFP)
Used to check for down syndrome or neural tube defect
Patients needs to have a full bladder

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 o Chorionic Villi Sampling (CVS)
Used to check for genetic disorders (down syndrome)
Patient needs to void before the test
Complications: spontaneous abortions; fetal anomaly (limbs)
o Additional test
Nonstress test
Used to determine fetal well-being
Healthy fetus responds with movement and 15/15 accelerations
Contraction test (oxytocin challenge)
Used to determine if fetus can withhold stress of labor
It is tested by stimulating the nipples (rolling the nipples for 10
minutes) = she should have 3 contractions in 10 minutes
If stimulation of the nipples does not occur, use oxytocin
If the baby does not move ==> the baby cannot survive labor
A negative result (nonreactive result) is a normal finding
because it indicates that there is no late decels during contraction
A positive result (reactive result) is abnormal = late decels
Biophysical profile (BPP)
When an ultrasound is used to assess fetal health
True labor vs. False Labor
o False Labor = last > 30 seconds but < 60 seconds, abdominal pain,
and relieved by walking, change position, or drinking water
o True labor = last > 60 seconds, low back pain that radiates to
abdomen, and unrelieved with walking or taking a sip of water
Vaginal Examination
o Used to assess cervical dilation, cervical effacement, cervical consistency,
fetal station, fetal presentation, position, lie, and attitude
o Usually done when the woman is cervically dilated 3cm ==> do not
perform a vaginal assessment if the pregnant woman is bleeding*
o IT IS A STERILE PROCEDURE*
o If the infants head is floating ==> WATCH FOR PROLAPSE CORD
o CONTINUE TO ASSESS AND MAINTAIN FHR
Amniotomy = rupturing of membrane
o Once the membranes rupture ==> ASSESS FHR then
o HOW DO YOU KNOE MEMBRANES HAVE RUPTURED?
Test with Nitrazine paper = it will turn blue-green
Perform the fern test = amniotic fluid will fern under microscope
o Amniotic fluid should be CLEAR (straw-colored) and odorless (if it is
cloudy or has an odor ==> this may indicate INFECTION)
o If a pregnant woman comes in and the membranes are ruptured, ask
her how long it has been ruptured to assess for exposure to infection
o Meconium-stain fluid is usually yellow-green or gold-yellow and
may indicate fetal distress ==> fetus will need OXYGEN when born
Continuous Electronic Fetal Monitoring
o Externally = it is done using the tocodynamometer

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 o Internally = needs to be done by doctor or practitioner/midwife
The purpose of the internal fetal monitor is to monitor the
oxygenation status of the fetus during labor
Antepartum
o Pica
When the woman experiences pica ==> inform the doctor about it
because it can be very dangerous to the mother and fetus
Even if the pica craving is just as simple as ice because it
usually places the woman at risk for nutrition imbalance
Stages of Labor
o Stage 1
When the contractions start and mother is ambivalent
Nesting occurs = when the mother gets a burst of energy (the woman
does house chores to prepare for the baby)
There are 3 stages of labor:
Latent phase = 1-3 cm dilated = 0-20% effaced
o The woman might be anxious and nesting
Active phase = 4-7 cm dilated = 20-80% effaced
o Hyperventilation may occur during this phase ==> which can
lead to respiratory alkalosis ==> manage by making the
woman breathe into the paper bag so she can retain CO2
o Normal maternal temperature may be elevated
Transition phase = 8-10 cm dilated = 80-100% effaced
o Most difficult and shortest phase of labor
o The woman might be diaphoretic and say things like I cant
take this any longer
o REMEMBER ==> ONLY ENCOURAGE THE MOTHER TO PUSH
ONCE SHE IS 10CM DILATED and 100% EFFACED
o Stage 2
Birth of the infant
There are 2 phases:
Pelvic phase: when fetal head negotiates to pelvis
Perineal phase: when crowning occurs
COACH THE MOTHER ON HOW TO BREATHE AND PUSH
o Stage 3
Birth of the placenta
There are 2 phases:
Placental separation = when the placenta separates form uterus
Placental expulsion = when the placenta comes out
Continue to give Pitocin after the birth of the placenta t o help the
uterus contract (in case there are pieces of placenta fragment still
remaining inside that can cause hemorrhage or infection)
After birth of baby and placenta, you can apply Perineal pads

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 Monitor for uterine atony (loss of uterine muscle tone which can
cause severe hemorrhage; this is why you give Pitocin to allow the
uterus to contract and prevent bleeding)
Uterine stimulants ==> Pitocin, Oxytocin, Synthocin,
Methylergonovine (Methergine), and Prostaglandin (Hemabate)
o Stage 4
The stage when the mother rests = usually takes up to 1-4 hours
Assess the fundus q15mins for 1st hour, q30mins for 2 hours if normal
Post-Pregnancy
o Normal post-partum vital signs
Temperature 100.4 F
Temperature may be increased due to excessive loss of fluids
during labor ==> force fluids after birth to decrease temperature
Pulse can be 50-70 (anything > 100 indicates hemorrhage)
BP should be normal (suspect hypovolemia if decreased)
Respirations should be normal (tachypnea indicates hemorrhage)
o Lochia drainage
Lochia rubra = red, blood-tinged discharge = lasts 2-3 days
Lochia serosa = pale, pinkish or brownish discharge = lasts 7 days
Lochia alba = thick, white-yellowish discharge = lasts 4 weeks
Lochia drainage usually stops one the placenta site has healed
o Urinary
Palpate for spongy bladder = have patient void if distended
PATIENT SHOULD VOID WITHIN 4 HOURS OF DELIVERY
Teach kegel exercises
o Bowel
Bowel returns within 3 days after delivery
Assess for ability to pass flatus = Give Colace or enema if needed
Encourage increase in fiber and roughage
Encourage early ambulation = prevents DVT as well
o Diet
Add 500 calories to pre-pregnant diet
Increase fluid intake (AVOID CAFFEINE or SMOKING)
o RHOGAM
Rhogam is given when the woman has an abortion or any procedure
or complication that increases risk for maternal-fetal blood exchange
It is routinely given to Rh negative mothers at 28 weeks and 72
hours after birth of child
Combs tests = checks for positive antibodies
o Rubella titer
Mother is immune if titer > 0.10 ==> however, anything < 0.10 is not
immune so they will NEED A BOOSTER
DO NOT GIVE DURING PREGNACY (RUBELLA IS A LIVE VACCINE)
You will need to obtain an informed consent before giving

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 Rubella titer booster is usually given after pregnancy before the
woman goes home ==> Do not give if family is immunosuppressed
After admin of rubella vaccine, avoid pregnancy for 2-3 months
She can still breast-feed after rubella titer
If the woman is exposed ==> her titer needs to be checked
o Psychosocial
Post-partum blues
When the mother is tearful, feeling down, or decreased appetite
There is no need for Rx; Just supportive environment
Post-partum depression
When mother becomes depressed with feelings of hopelessness
Rx: antidepressants
Post-partum psychosis
When mother is delusional about child
Rx: she will need to be institutionalized
Striae Gravidarum
Also known as stretch marks ==> they may be present after birth
Anesthesia
o Regional block
Pudendal block = used for episiotomy to relief Perineal/Uterine pain
Peridural (epidural) block = given at T10 S5 = used to block pain
during labor and delivery of baby
REMEMBER
Anesthesia causes decreased blood pressure and respiratory rate
Prevent decreased blood pressure by hydrating patient
Nausea and vomiting are the first signs of hypotension
If there is a SUDDEN drop in BP = Change position
o General Anesthesia = given for C-SECTION = causes rapid LOC
After pregnancy = Breast feeding vs. Non breast-feeding
o Fundus
Fundus should be at the umbilical region and slowly start going up
1cm per day till day 10 it should NOT be palpable
o Umbilical cord care (cord has 2 arteries and one vein)
Wash with mild soap and dry with every diaper change
Do not allow the diaper to cover the cord area
Allow to air-dry
o Circumcision for boys
There will be a yellow crusting around it = leave it in place
o Breast-feeding
Apply warm compressions to breasts to stimulate milk
Breast feed baby more frequently or use pump to empty frequently
Prolactin stimulates production of milk
MOTHERS ARE AT RISK FOR AFTERPAINS

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 Cramps during breastfeeding is normal because oxytocin is being
released with causes the uterus to contract**
o Not-breast-feeding
Wear good supportive bra
Avoid breast stimulation ==> use ice packs for pain or cabbage
DO NOT USE WARM OR HOT WATER
o Mastitis
Mastitis is inflammation of the breast (it can occur at any time)
S/S: patient will have a red swollen lump in breast, sore or cracked
nipples, and flu-like symptoms
Rx: wear a supportive bra, continue to breast feed (empty breast
frequently), increase fluid intake, wash nipples with just water
o Subinvolution
Assess for subinvolution (when the uterus does not go back to original
size) ==> this could mean that placental fragments are still in uterus
o Cesarean Section delivery
They are prone to developing: paralytic ileus, infection,
thrombophlebitis (DVT), respiratory complication, and impaired
maternal-infant bonding
Pregnancy complications
o Hematoma
Hematoma occurs when there is accumulation of blood in one area (it
can be a build up of up to 500ml worth of blood)
S/S: swelling, blue-black discoloration on perineum, s/s of shock
If a hematoma is suspected = prepare the patient for surgery to
STOP the bleeding
o Abortions
Spontaneous abortion
Bleeding that occurs within 20 weeks of pregnancy
Patient will exhibit S/S of shock (cold, clammy, pallor, tachycardia,
hypotension, rapid thread pulse)
Rx: monitor vitals, start IV, give RhoGAM, support for loss of child
Inevitable abortion
Moderate to severe bleed with mild cramping and cervical dilation
= usually not preventable
Incomplete abortion
Heavy bleeding, cervical dilation, severe cramping and the passage
of large clots
Threatened abortion
Bleeding that occurs without dilation
Septic abortion
Bleeding with odor, fever, and cervical dilation
Recurrent/Habitual
Loss of 3 or more pregnancies
Rx: prophylactiv cerclage

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 o Ectopic pregnancy**
Ectopic pregnancy is the pregnancy that occurs in fallopian tubes
S/S: missed period, signs of shock, vaginal spotting (small amount
of bleeding_, unilateral or bilateral abdominal pain, full feeling in
lower abdomen or tenderness
Rx: MEDICAL EMERGENCY**
Post-partum complications
o Post-partum infection
S/S: fever 101-104 F (38.3-40 C), tachycardia, foul-smelling lochia,
uterine fundal tenderness, etc
Prevent infection by: encouraging early ambulation, voiding within
the first 4 hours after birth, reporting danger signs
o Post-partum hemorrhage
Post-partum hemorrhage usually occurs when blood loss is > 500
after vaginal birth or > 1000 after C-section (each 1gm lost = 1cc)
Causes of hemorrhage
Uterine tone = caused by loss of muscle tone of uterus
Tissue = caused by fragmented parts of placenta still being stuck
in the uterus that it prevents uterus from contracting to stop
bleeding so it continually causes woman to lose blood
Trauma = caused by uterine laceration or scar from C-section
Thrombosis = caused by formation of clots or bleed disorder
S/S: tachycardia, cold, clammy, diaphoresis, hypotension
Rx: massage the fundus to stop bleeding and to help uterus contract,
monitor vitals, keep the bladder empty, increase Pitocin or oxytocin
to help uterus contract and stop bleeding, cross match blood type
For hypovolemic shock: give IV fluids, O2 at 10L, and place supine
o Prolapse cord
Occurs when the umbilical cord becomes alongside or wrapped
around the fetus presenting part (may be the head)
Risk factors: malpresentation, growth restrictions, prematurity,
ruptured membrane with fetus in a high station, hydriamnios
Assessment: check for this when uterine membranes RUPTURE
Nurse management: assess for this through vaginal exam (unless you
see bleeding), place on left side to prevent vena cava compression,
monitor FHR, place on bed rest, or emergency C-section (if needed)
o Placenta Previa (often seen in 2nd trimester)
Occurs when there is
S/S: bright red blood that is PAINLESS, soft uterus, normal FHR
Rx: patient needs to be on bed rest for the remaining pregnancy
until fetal lungs mature (L/S ratio of at least 2:1)
Once achieved, start IV, place in side-lying, prepare for C-section
o Placenta Abruptio (often seen in 3rd trimester pregnancy)
Occurs when there is an early separation of the placenta from uterus

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 Risk factors: PIH, high gravida (too many pregnancies), abdominal
trauma (car accident), short umbilical cord, cocaine abuse
S/S: dark red blood and PAINFUL, rigid and board-like abdomen
Rx: C-Section if baby is alive; Vaginal birth if baby is dead
Monitor for DIC (bleeding gums, bleeding at injection site)
o STDs
Chlamydia = causes stillbirth or opthalmia neonatorum (blindness)
HPV = causes chronic respiratory problems = mom needs C-section
TORCH includes:
Gonorrhea, Syphilis, Toxoplasmosis (transferred from cat feces,
gardening, and raw meats), Hepatitis, Rubella (mother will need to
be vaccinated after pregnancy NOT BEFORE= she can continue to
breastfeed), Cytomegalovirus, Herpes Simplex virus (cannot give
birth to baby vaginally while vesicles are present), HIV, and AIDS
o Pre-Term Labor Risks
Pre-term labor occurs when the baby is born before 37 weeks
It usually can be stopped of cervical dilation <4, <50% effacement,
membranes are intact and NOT bulging
Risk factors: gestational diabetes, PIH, multiple gestation, low SES,
alcohol or drug use, smoking, infections, or placental previa/abruptio
S/S: cervical dilation and effacement before 37 weeks
Management:
Give tocolytic (terbutalline) to stop preterm labor
o Terbutalline can cause tachycardia*
Give betamethasone (steroid) to allow lungs to mature and
surfactant production if fetus is < 35 weeks (because
surfactant is produced in fetal lungs at 35 weeks)
Give magnesium sulfate to decrease uterine activity and relax
smooth muscle cells
Place pregnant woman on bed rest with fetus off the cervix
Place on left side to prevent vena cava compression
Monitor FHR
Babies that are born pre-term are at risk for: infection, maternal-fetal
distress, bleeding, and stretching
o Post-Term Labor Risks
Post-term occurs when babies are born over 40 weeks
Babies that are born post-term are at risk for: being be too large, IUGR
o Dystocia
Dystocia results from difficult labor (labor being too slow or fast)
Dystocia should be suspected if there is: lack of cervical dilation, lack
of fetal descent, and lack of change in uterine contractions
They will need to augment (induce/stimulate) the labor with dystocia
Give oxytocin infusion for the induction and stimulation of labor
The goal of augmentation of labor is to have contractions that are
firm that occur every 2-3 minutes and last 60-70 seconds

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o Amniotic fluid emboli
Occurs when amniotic fluid enters maternal circulation and damages
pulmonary vessels
S/S: difficulty breathing, hypotension, hypoxia, tachycardia, DIC
Rx: give 100% oxygen, IV fluids, control hemorrhage (give oxytocin to
contract the uterus), seizure precaution
o Hypertension
Types:
Gestational hypertension
o When the mother has hypertension with NO proteinuria
Preeclampsia
o Preeclampsia is the elevation is BP and proteinuria
o Risk factors: gestational diabetes, age < 17 or > 35, low SES,
previous hypertension, multiple gestation (pregnancies),
hydratidiform mole, poor pregnancy, and family history
o Types:
Mild preeclampsia
BP 140/90, proteinuria > 300mg in 24 hours,
weigh gain >2lbs/week, proteinuria 1+ dipstick,
edema (around eyes, face, fingers), reflexes 2+,
mild headache, and IUGR
Severe preeclampsia
BP 160/100, proteinuria > 500mg, proteinuria
2+/3+ dipstick, generalized edema (puffy face and
hands), DTR 3+ (hyperreflexia), oliguria, eye pain,
visual changes (blurred vision, blind spots,
photophobia), and pulmonary edema
Eclampsia
Eclampsia is when the patient is at risk for seizures
S/S: hyperreflexia (3+/4+),
Rx: give Magnesium Sulfate (normal levels: 1.6-2.6)
Monitor patient for toxicity (mag sulfate levels >4)
Magnesium Sulfate can cause decreased
respirations, hyporreflexia (absent DTR), and
decreased urine output so make sure you
MONITOR patient BP, HR, and Urine output (must
be 30 ml or greater per hour)
HELLP SYNDROME (High blood glucose, Elevated Liver
enzymes, and Low platelet)
o At risk for bleeding (because of low platelet count and high
blood pressure, the large baby, multiparity (having too

15
 many pregnancies puts you at risk for hemorrhage), DIC,
and seizures
Rx for Preeclampsia, Eclampsia, and HELLP Syndrome
Preeclampsia:
o Place on bed rest with bathroom privileges
o Have client weigh self daily; report weight gain >2lb/week
o Teach to test urine for protein
o Teach to report any: headache, visual changes, edema,
hyperreflexia, convulsions, absent fetal movement, vaginal
bleeding, or any abdominal pain
o Teach to add protein to their diet
o Give oxygen if needed
Eclampsia:
o Give magnesium sulfate (monitor for decreased
respirations (<12), hyporreflexia, decreased urine output)
o Provide environment with minimal stimulation
o Assess DTRs frequently
HELLP Syndrome:
o Assess blood coagulation (PT/PTT)
o Assess for bleeding
o Monitor liver enzymes (AST/ALT)
o Prepare for C-Section
o Pre-gestational diabetes
Pre-gestational diabetes occurs when hormonal changes (HPL) bocks
the production of insulin during pregnancy which increases maternal
resistance to insulin so an abundant amount of glucose is available in
the blood stream which affects the mother and the fetus well-being
Usually:
In first trimester = patient is at risk for hypoglycemia
In second and third trimester = patient is at risk for hyperglycemia
Risk Factors: family history, hydramnios (too much amniotic fluid),
obesity, glucosuria, high parity (too many pregnancies)
Dx: elevated 1-hour glucose test (> 140)
S/S: patient will have S/S of hyperglycemia (3 Ps)
Nurse Management:
Patient need to change diet
Maintain close to normal glucose level
Monitor for changes and REPORT if patient has symptoms
Patient will be at risk for preeclampsia, infection, hydramnios
Infant
Infant will be at risk for being an LGA (assess the baby for
hypoglycemia immediately after the baby is born; do a heel
stick on the lateral side of the foot (do not do on the ball of the
foot because it can cause nerve damage)

16
 S/S of hypoglycemia in infant: jittery and shaking, fatigue, high cry
Rx for hypoglycemia: put the babys hat on, swaddle the baby,
feed the baby, and THERMOREGULATION (do not allow the
baby to shiver because they loose glucose and it causes
breakdown of brown fat = loss of energy)
If having difficulty feeding baby = stimulate the mouth by stroking
the side of the mouth = if not working ==> CALL DOCTOR*
Newborn care
o Care provided immediately
Cut the umbilical cord first
Then suction mouth first then nose
Dry to newborn after they come out the womb to prevent heat loss
Apply the cap unto newborns head then place them on the warmer
o Vital signs
Respirations = assessed first = normal: 30-60
Heart rate = 120-160
Temperature = 97.7-99.4F (36.5-37.5 C)
Blood pressure = 80/50 mmHg
o Measurements
Weight = 7lb 8oz is average (2700-4000 gm)
Length = 46-52 cm (18-21 inches)
Head circumference = 33-35cm = always slightly larger than chest
Chest circumference = 31-33cm
o Apgar Assessment = done at 1 minute then 5 minutes
Good = 7-10
Moderate and needs resuscitative efforts = 4-6 (retest in 5 minutes)
Severe resuscitation = 0-3
IF THE NEONATE IS COMPROMISED ==> DO NOT WAIT 1 MINUTE TO
START APGAR TEST
o Hypothermia
Prevent hypothermia because hypothermia leads to depletion of
glucose and leads to use brown fat (energy); breakdown of brown fat
causes ketoacidosis which places patient at risk for shock (dehydration)
Keep the newborn dry and warm
Apply cap on the newborns head (greatest area that loses most heat)
Place on radiant warmer (isolette)
o Hypoglycemia
Perform a heel stick glucose for all SGA and LGA babies whose
mothers had gestational diabetes or any baby that is jittery and shaky
Normal infant glucose = 40-80 (report blood glucose under 40)
o Vitamin K administration
Vitamin K is given to prevent blood disorders

17
 Vitamin K is an injection given in the vastus lateralis to prevent
the newborn from bleeding (because the intestines are not formed
yet to produce vitamin K that helps with clotting yet)
o Gentamicin administration
Gentamicin is an antibiotic ointment given to prevent neonatal
blindness caused by gonorrhea
It is usually given within the first hour after birth
The ointment is usually squeezed in the eye from the inner cantus to
the out cantus (then close the newborn eyes so it can be absorbed)
o Physiological jaundice
Physiologic jaundice occurs normally in 2-3 days after birth due
to the immature liver not being able to keep up bilirubin production
resulting from normal RBC destruction
If jaundice occurs in babies in the first 24 hours and or persist
over 7 days = it becomes pathologic = this is abnormal*
Jaundice in a newborn can occur due to excessive bilirubin in blood
Risk factors: cephalhematoma (because of excessive build up of
bilirubin in the blood that accumulates in the circulatory system)
Rx: phototherapy, give adequate fluids, feed frequently to promote
elimination of stooling, and monitor bilirubin levels
o Moro reflex
Moro reflex also known as startle reflex
Usually done by making a loud noise to stimulate the newborn
Newborns hands will form a C
o Evaluating urine output
The best way to evaluate an infants urine output is by weighing
the diapers after infant has voided (1g = 1ml)
o Calculating calories
Normally you multiply 50 calories by the infants weight in lbs
(convert the ounce into lbs to multiply by the 50 calories too)
Once you get that, divide by the calories per ounce which is normally
20 calories per ounce) ==> P. 267
High-Risk Newborn
o LGA baby
A large for gestational age baby is at risk for shoulder dystocia and
brachial nerve plexus
o Hypoglycemia
Hypoglycemia occurs in babies of women with gestational diabetes
S/S: jitteriness
Rx:
FEED THE INFANT (if unable to feed, give IV glucose 5%)
Avoid shivering because that increases breakdown of brown fat
(energy) and can cause ketoacidosis
Perform heel stick glucose test (report if < 40)
o Neonatal smoking

18
 These infants are at risk for being small, IUGR, and retardation
Teach woman not to smoke or be around smoke during pregnancy
o Alcohol Intake
These infants are at risk for fetal alcohol syndrome (developmental
delays, mental retardation, attention deficits, poor coordination,
strabismus, facial abnormality, behavioral deviations (irritability),
cardiac and joint abnormalities)
o Sepsis in newborns
S/S: high or low temperature, lethargy, difficulty feeding,
behavioral changes, and hyperbilirubinemia
Rx: antibiotics, place in incubator or isolette, maintain nutrition
o Acute Respiratory Distress Syndrome
ARDS occurs in children due to lack of surfactant in lungs
It is caused by hypoxia (low O2) and hypercapnia (too much CO2)
S/S: tachypnea, grunting, retractions, cyanosis
Rx:
Give Surfactant replacement therapy via endotracheal tube
Keep infant under radiant warmer to prevent chilling
Feed infant by gavage feeding to decrease use of energy
Criteria for mechanical vent for infant: PO2 < 50 and PCO2 > 60
If HR drops below 100 ==> begin oxygenation by bag and mask
If HR drops below 60 ==> START COMPRESSIONS
THINGS TO REMEMBER:
o The lower the score of the Silverman Anderson, the better the
respiratory distress of the neonate
o Always start with the lowest oxygen concentration with
infants because too much or too little oxygen is BAD!!
o Monitor for adverse effects of O2 toxicity
Retinopathy of prematurity = baby have glasses
Bronchopulmonary dysplasia
o Monitor infant for adverse effects caused by hypoxia such as:
Necrotizing enterocolitis (NEC) = lack of absorption of
intestines = caused by hypoxia
Patent Ductus Arteriosus (PDA) = Rx with indomethacin
Intraventricular hemorrhage = vessel damage

Pediatrics
Theories of growth and development
o Erikson (8 stages of psychosocial development)
Infant (birth 1 years old): Trust vs. mistrust
Toddler (1-3 years old): Autonomy vs. shame and doubt
Preschool (3-6 years old): Initiative vs. guilt
School age (6-12 years old): Industry vs. inferiority
Adolescent (12-19 years old): Identity vs. role confusion

19
 Young Adulthood (20-44 years old): Intimacy vs. isolation
Middle Adulthood (45-65 years old): Generativity vs. stagnation
Late Adulthood (65 and older): Integrity vs. despair
o Piaget
Sensorimotor
Preoperational thought
Concrete operation
Formal operation
o Kohlberg Moral Development
Vitals
o Pulse (HR) = 120-160 bpm
o Blood pressure (BP) = 60-70/40 (80/50 is normal)
o Respirations = 40-60 bpm
Developmental milestones
o 2 months = infant can smile
o 3 months = turn head
o 4 months = look back and forth
o 5 months = roll on back
o 6 month = rolls on
o 7 months = tripod
o 8 months = infant sits unsupported at 10 months
o 9 = mama/dama
o 10 months = infant crawls at 10 months
o 11 months = gliding
o 12 months = infant should be able to walk
o 18 months = throw ball over head
o 24 months (2-3 years) = kicks ball
o 4 -5 years = hop on one foot; can ride a bicycle
Growth and development
o Infant = birth 1 year = trust vs. mistrust
After birth, weight doubles in 6 months, triples in 12 months
Posterior fontanel closes at 8 weeks; anterior closes at 12 weeks
Moro reflex disappears at 4 months; Babinski disappear at 12-18 months
Stranger anxiety from 7-9 months
Solitary play
Nurse management:
The infant may be inconsolable if parents are not there (they may not
cry if they are distracted when parent leaves)
Include parents in plan of care of infant
They can use rattle toys, pictures, balls, activity books
o Toddler = 1 - 3 years old = autonomy vs. shame and doubt
How do they look: swaddle walk, rounded abdomen
A child achieves 50% of adult height at 2 years old and can speak 2-3
word sentences

20
 Temper tantrums is common for this age group = ignore child if they
throw a temper tantrum; that will teach them not to do it
Start bladder training at 2, and bowel control is at age 3
Parallel play
Nurse management:
Give choices; usually give them two choices to choose from (ex:
would you like turkey or ham?)
Give basic explanations on how to do things (demonstrate on doll first
before doing it on them)
Prepare for surgery on the day of surgery
Can use pull toys, toy telephone, storybook, pictures, mallets/boards
o Preschool = 3 - 6 years old = initiative vs. guilt
Child can use scissors and swim at age 4; child can tie shoe laces at 5
Visual acuity is 20/20; half adult height
Magical thinkers
Nurse management:
Explain to child they did not cause illness to self or others
because of being bad
Be cautious of what you say around them (magical thinkers)
Use play to interact with child and demonstrate before you do it on
them (allow them to play with medical equipment)
Answer all asked questions to their level of understanding
They can use coloring books, puzzles, cutting and pasting, building
blocks, clay
Let them know a few days prior to procedure; allow child to play with
equipment to feel comfortable
o School-age = 6 - 12 years old = industry vs. inferiority
Each year, the child grows 4-6lbs and about 2 inches in height
Girls may experience menarche towards the end
Fine and gross skills are mature; molars erupt
Child can tell time (past, present, future); dress themselves
Thy can write a script at age 8 (use concrete words)
They seek their peers approval = allow friends to come visit
They play with their friends (group-play to reach a common goal)
Before a procedure = tell them a few days in advance
Nurse management:
Allow child to maintain contact with peers and school activity
Explain all procedures to them and allow to handle equipment
Provide privacy and modesty during hospitalization
Give choices or options if any
o Adolescent = 12 - 19 years old = identity vs. role confusion
Girls = = boys =
Adult-like thinking develops at age 15
Family conflict may occur due to hormonal changes
Seek approval from peers

21
 They care a lot about their BODY IMAGE
Before a procedure = tell them a week before
Nurse management:
Allow to stay in contact with peers and school
They may share rooms with other adolescents
Teach about the procedure weeks in advance (allow to watch a video
over it or something they can interact with)
Give choices and options f any
Pain assessment in children
o Children as young as age 3 can report pain
o Observe the child for nonverbal signs of pain such as: grimacing, irritability,
restlessness, difficulty sleeping, diaphoresis, decreased O2
o Pain scales to use:
How do you tell an infant is in pain?
Difficulty eating, difficulty sleeping, grunting, grimacing
CRIES = infants 32-60 weeks (9 -15 months)
Pain Rating Scale = children age 1 36 months)
FACES = preschool and older
Numeric pain scale = school age (age 9 and adolescents)
Oucher pain scale = used on children culturally sensitive age 3-12
o Pharmacological measures
Use appropriate meds (avoid giving Tylenol to children to prevent Reye
Syndrome which causes liver damage)
Prior to giving pain medication, calculate dose and ensure safety
Monitor vital signs when child is receiving opioid
o Non-pharmacological measures
Infants may respond to pacifier, holding, or rocking to relieve pain
Toddlers and preschoolers may respond to distraction (coloring, blowing
bubbles, books, music, and television)
School age and adolescent may respond to guided imagery
Other measures: application of heat and cold, massage, deep breathing
exercises
Child health promotion
o Vaccines
Types
Live attenuated vaccine (when the virus is weakened to where it
cannot cause illness; used to build immunity, cannot be given with
other vaccines)
Inactivated vaccine (when the virus is dead so vaccine is the made up
of dead cells; can be given with other vaccines)
Vaccines
MMR = assess for anaphylactic reaction to eggs or neomycin
DTaP = assess for history of reactions, seizures, or neurological
symptoms after previous vaccine or allergies
Hesi hints:

22
 o Children can receive vaccinations with a common cold (runny
nose and low-grade fever)
o Irritation, fever (<102F), redness, soreness, at injection site for 2-
3 days are normal side effects for DTaP and IPV
o Call the healthcare provider if seizures occur, high fever (fever
>102F), or high-pitched crying
o Tylenol is given every 4-6 hours orally (10-15mg/kg)
o Immunization schedule
Sites:
Infants get vaccines on the vastus lateralis; Child get ventrogluteal
Live vaccines are SQ; inactivated vaccines = IM
Vaccines that are given:
MMR/Chicken pox = 12-15 months and 4-6 years
o NEVER give MMR to pregnant
DTaP = 1-2, 4-6, 6-8, 12mo-6 years
o Low grade fever child can receive vaccine
o High grade fever or neurological disorder (because it can cause
encephalopathy) = do not give
Ages
2 mo = DR HIP
4 mo = H DR HIP
6 mo = Hi DR HIP
8 mo = M3 IM VIP
12 mo = M3 IM D VIP
16-18 mo = H2 I2
18-23 mo =
4-6 years = influenza
TB needle
Intradermal = 15 degree angle
0.1-0.001
Positive MMR titer = IMMUNE (<10 to be immune)

Pediatric Diseases and Illnesses
Communicable diseases
o Rubeola (measles)
S/S: photophobia, koplik spots, rash starts on face and spread down
Isolation: droplet
o Varicella (chickenpox)
S/S: vesicles that weep and crust
Isolation: direct contact or droplet
Nurse Management: the child can return back to school when the vesicles
have crusted, avoid scratching (place mitten on fingers), place mittens
o Rubella (german measles)
S/S: maculopapular rash that starts on face then spreads down
Isolation: direct contact or droplet

23
 Nurse management: child should get vaccine, but mother cannot get
vaccine
o Pertussis
S/S: characterized by prolonged cough, crowing, and whooping
Isolation: direct contact droplet
Prevention: DTaP
Nurse Management: erythromycin
o Paramyxovirus (Mumps)
S/S: fever, malaise, parotid gland swelling, redness, orchititis
Isolation: direct contact or droplet
Nurse management: BED REST, antiseptic, and analgesics
Complications: it can lead to infertility in the future with men
o AVOID GIVING TYLENOL FOR ANYTHING = REYE SYNDROME
Common Issues
o Diarrhea
It occurs when the patient has an increase number or decreased
consistency of stools (usually can be fatal in infants)
Causes:
Infection (bacteria, viral, parasitic), Malabsorption problems,
Inflammatory disease, and Dietary factors
S/S:
Poor skin turgor, absent tears, weight loss, depressed fontanel
Nurse Management:
Assess hydration, assess vitals, monitor intake and output (weigh
diapers), REHYDRATE (peidialyte), give antibiotics if needed,
monitor labs/urine, DO NOT GIVE ANTIDIARRHEAL (immodium)
Complications:
Dehydration or Metabolic acidosis
o Dehydration
S/S: dark yellow (amber urine), decreased fontanels in infants, decreased
tear production, dry mucus membranes
Nurse management: do not give citric acids (orange juice)
o Burns
Rule of nine cannot be used on infants
Know how to calculate fluid replacement using parkland formula
Partial-thickness
1st degree = redness
2nd degree = blisters
Full thickness burn
3rd degree = involve muscles and nerves
4th degree = involve bone
Parkland formula = 4 x weight in kg x TBSA%
o Poisoning
Most poisoning occur in children ages 2-6 years old
Curiosity and explorative behavior is what place them at risk

24
 Nurse management:
Place cleaning supplies or chemicals in locked cabinets away from
reach of children, be cautious of the childs surrounding, if they do
ingest poison (call poison control to see what next to do); if poison is
corrosive, it is better diluting it than vomiting it back out because it
may cause more damage coming out
o Lead poisoning
Nurse Management: if BLL is high for lead poisoning, patient may need
chelation therapy (help patient poop it out) or EDTA
Respiratory Disorders
o Pneumonia
Pneumonia is the inflammation of lung parenchyma (fluid in lungs)
S/S: fever, SOB, cough (with purulent sputum), crackles, chest pain
Nurse management:
Encourage patient to lie on the affected side
Give antibiotics
Give oxygen
Increase fluids
Perform breathing Rx
Prevent by (turn q2h, cough/deep breath 10x q hour, use spirometer)
Treatment:
Bacterial pneumonia = Rx with antibiotics
Viral pneumonia needs supportive therapy
Teaching points:
Teach patient proper hand hygiene
Teach patient to avoid smoking or exposure to URI
Teach patient to get vaccinated (elderly or immunosuppressed)
o Asthma
Asthma occurs when the airways become edematous, congested with
mucus, and the bronchi and bronchioles constrict
S/S:
Recurrent SOB, wheezes, tight chest, and cough
Silent wheezes = DANGEROUS = wheezes should be audible
Treatment:
Acute attacks = beta-adrenergic agonist (albuterol) or bronchodilator
(ipratropium)
Maintenance = corticosteroids (advair, flovent)
Complications of asthma
Pneumothorax, pneumonia, atelectasis, and status asthmaticus
Nurse Management:
Rx with bronchodilators for acute attacks
Use corticosteroids for maintenance (prevention of episodes) = gargle
mouth after use of corticosteroids to prevent yeast growth in mouth
If exercising, use meds 30 minutes prior to exercise
Avoid triggers (pests, pollen, pet dander, dust mites, roaches)

25
 When using inhaler, shake inhaler, breathe out all the way, then
breathe in slowly, hold, squeeze medication, hold breath for 10
seconds, then breath out = if you need to repeat, take 1 min before
restarting the treatment again
To monitor patient status ==> use peak flow
o Green (stable) = 80-100 = within good standing so continue to
use the preventative measures
o Yellow (caution) = 50-80 = will have frequent s/s so you need to
increase dose or change medication
o Red (danger) = 50 or below = use bronchodilator or
corticosteroid therapy and call EMS
o Cystic fibrosis
Cystic fibrosis is the autosomal recessive disorder that affects the
exocrine glands; it causes accumulation of mucus in the lungs
Causes:
Exocrine dysfunction: lung insufficiency, pancreatic insufficiency, and
loss of sodium and chloride in sweat
S/S:
Pulmonary congestion (excessive mucus production), steatorrhea
(fatty stool), foul-bulky-smelling stool, delayed growth and poor
weight gain, and salty skin
Nurse Management:
They need fat soluble vitamins for digestion (A, D, E, K)
Monitor respiratory status, give antibiotics, give pancreatic enzymes
for digestion (pancrease = you know its working if patient has
formed stools), give vitamin A,D,E,K in water form for fat digestion,
give O2 and pulmozyne (D-Nase) to thin mucus
Prevent infection = child may need yearly immunization
o Epiglottitis
Epiglottitis occurs when there is inflammation of the tissue that covers
the trachea ==> it is LIFE-THREATENING
Causes:
Haemophilus influenza type B
S/S:
High fever, sore throat, stridor, voice changes (hoarseness)
Nurse Management:
Encourage prevention by getting with Hib vaccine, elevate the HOB,
give antibiotics/steroids, DO NOT USE TONGUE BLADE TO DEPRESS
THE TONGUE B/C IT CAN FURTHER BLOCK AIRWAY
MAY NEED INTUBATION WITH HUMIDIFIED OXYGEN
o Croup
S/S: barking cough, stridor, low-grade fever, and hoarseness
Nurse Management: oxygen tent, corticosteroids, and epinephrine
When giving the oxygen via oxygen tent, make sure that the flow is
directed toward the patient

26
o Bronchiolitis (RSV)
RSV is a viral infection of the bronchioles
It is often transferred by hands (washing hands is important)
Nurse Management:
Place child on isolation (only need gown and gloves; no mask) =
child can be placed in room with another child that has RSV
Keep on bed-rest, give antibiotics for over 21 days, and give
prophylaxis palivizumab (Synagis)
Provide cool humidified oxygen via tent
Nurses caring for patient with RSV cannot care for other high risk
children to prevent infection of other children (why? Maybe
because it is caused by a virus)
o Otitis media
Otitis media occurs when there is an inflammation (infection) of the
middle ear often caused by recurrent respiratory infections
Why are children at risk:
Because they have a short Eustachian tube
Risk factors: smoke, bottle-feeding, exposure to other children, and
congenital defect (cleft lip/cleft palate)
S/S:
Fever, pain, infant pulling on ear, enlarged lymph nodes, discharge
from ears, and upper respiratory infection
Nurse Management:
Give antibiotics (tepid baths for high fever or Tylenol), monitor
hearing loss, and teach preventative care (avoid prolonged bottle
feedings, untreated respiratory infection, smoking, or sticking objects
inside ears); avoid cotton-tipped ear cleaner
Patient is at risk for conductive hearing loss
Place patient on affected side so infection can drain out
Myringotomy tube coming out is NOT an emergency
o Tonsillitis
Tonsillitis is the inflammation of the tonsils
S/S:
Sore throat, difficulty swallowing, enlarged tonsils (kissing tonsils),
positive throat culture for bacterial or viral
Why is it important to treat strep?
o To prevent rheumatic heart disease, glomerulonephritis
Nurse Management:
Give antibiotics, manage fever, and monitor for bleeding
Rx: tonsillectomy (usually done when pt has recurrent respiratory
infection)
Pre-op
o Check PT and PTT (to check to see if a patient is at risk for bleed
because a complication is hemorrhage)
o If patient is at risk for bleeding the PTT will be prolonged

27
 Post-op tonsillectomy:
o Patient is at risk for hemorrhage
o Bad mouth odor = normal
o Place patient in prone or side-lying to help with drainage
o For pain relief, patient can suck on ice chip
o Teach patient to avoid clearing of throat, coughing, frequent
swallowing; teach to also avoid fruit juices (red or brown) b/c it
can disguise blood
o Avoid clearing of throat or things that may cause patient to clear
throat (ex: milk, citric juices, etc)
Avoid suctioning patient (only prn basis) and NO throat culture
Cardiovascular disorders
o Take an infant pulse using the BRACHIAL artery
o Most of all the disorders usually recover, if not, then surgery is needed
o MOST COMMON S/S with the children: failure to thrive (poor feeding)
o Acyanotic defect
VSD, PDA, ASD (blood flows from left to right)
o Atrial septal defect
Opening between left atrium to right atrium (leads to CHF)
Increase in blood flow to the
o Ventricular septal defect (blood flows from left to right)
Hollow-systolic murmur
It can lead to eisenmenger syndrome
o PDA usually resolves, if not, give indomethacin
S/S: machine like murmur
Rx: indomethacin to cl
o Coarctation of the Aorta
Stenosis of the aorta (narrowing of the aorta)
Obstruction of blood flow
You will see hypertension (because blood flow is in the upper body
but now lower
They will decreased or absent pulse on lower extremities
You will need to do a four-point
o Tetralogy fallot = cyanotic one because it shunts right to left
It causes right to left blood flow (increased pulmonary blood flow to the
lungs but the blood that is being pumped is not oxygenated)
They have three things going on:
Pulmonary stenosis, aorta is on the ventricle, VSD, right ventricular
hypertrophy (blood goes into
Child will be in knee-chest position with hypercyanotic spells
(increased RR, increased hypoxia); will require surgery to fix
o Nurse management:
Digoxin, diuretics, prophylaxis antibiotics after surgery to decrease risk
for heart disease), small frequent meals
Since patient is at

28
 o CHF
S/S:
Rx: digoxin; If child is taking digoxin, hold drug if HR < 90
Normal HR in infant is 120-160**
Normal digoxin level = 0.8-2 for infants==> digoxin toxicity: headache,
vomiting, visual changes
K+ is messed up with digoxin (it is increased (hyperkalemia)
o Rheumatic fever
Rheumatic fever is the heart disease that affects the valve
S/S: chorea, rash, joint pain, increase ESR, elevated ASO titer, elevated
C-reactive protein, presence of aschoff bodies
Rx: bed rest, antibiotics (penicillin G or erythromycin for a month)
Complication: patient will be at risk for endocarditis (janesway nodules,
osler nodes, splinter hemorrhage, etc)
o Kawasaki Disease
Kawasaki disease is an autoimmune disease that affects blood vessels
(affect japanese and korean children)
S/S:
Acute stage: red eyes (conjunctival hyperemia), red throat, swollen
hands, rash, enlarged cervical lymph nodes
Late stage: peeling of the skin (dequamation of the skin), cracking
lips, and joint pain
Rx: IV immunoglobulin & aspirin (avoid Tylenol bc Reye syndrome)
o Sudden Infant Death Syndrome (SIDS)
Prevention: place infant to sleep on back ==> AVOID placing on stomach
to decrease risk for SIDS
Eye problems
o Strabismus
Strabismus is the lack of coordination of the eye
S/S: headaches, squinting, and tilting the head to see
Rx: use of patch (on the unaffected eye) to strengthen the weak eye
Neurological problems
o Down syndrome
Trisomy 21 is missing
Characteristics: epicanthal folds on the eyes, semian lines on hands, short
neck, small ears and low-set
They will have developmental delay (IQ less than 60) or mental
retardation
At risk for cardiac, respiratory problems and endocrine dysfunction
Ultimate goal: help them reach level of functioning
o Cerebral palsy
S/S: persistent reflexes (Moro, Babinski, plantar reflex), scissor legs,
seizures, poor tongue thrust, plantar flexion
Seen when the mother has infection during pregnancy or lack of oxygen
going to the tissues during pregnancy

29
 Position child upright and support the lower jaw.
o
o Increased Intracranial Pressure (ICP)
Occurs when there is increase id CSF in the brain
S/S
Early S/S: decreased LOC, headache, nausea, bulging fontanel or
dilated scalp vein
Late S/S: abnormal posturing (decorticate/decerebrate), dolls eye
maneuver, change in pupil size, bradycardia, cheyne stokes
Rx: Internal Ventricular Shunt or External Ventricular shunt
Nurse Management:
Elevate the HOB, decrease stimulation,
o Hydrocephalus
Hydrocephalus occurs when there is accumulation of CSP fluid in the
ventricles of the brain (caused by obstruction of spina bifida)
S/S: change in LOC, headache, irritability, bulging fontanels, widened
sutures, high pitch cry, and increased head circumference
Rx: placement of shunt (monitor shunt for malfunction or infection)
Nurse management: reposition frequently, decrease stimuli,
o Spina bifida =neurological disorder
Caused by lack of folic acid in diet of pregnant woman
Meningolecele = bubble on the back = baby will have to lay on abdomen =
will need to be straight catheter
S/S: dimple on back without hair tuff at the base of spine
It can cause: hydrocephalus, neurogenic bladder, congenital dislocated
hips, club feet, skin problems, and scoliosis
Nurse management:
Keep the sac free of stool and urine (maintain skin integrity), cover
the sac with moist sterile dressing, elevate the foot of the bed, position
child on abdomen with legs abducted, measure head circumference
every 8 hours, monitor for infection, monitor neurological status, and
promote parent-bonding
o Bacterial Meningitis
S/S: fever, chills, diplopia, stiff neck, opisthotonos, photophobia, positive
kernig (when you raise the legs with knee flexed and then extending the
leg at the knee and assessing for pain) and burdinski sign (when flexion
of neck causes flexion of the hip and knee)
Nurse management:
Place patient on isolation for 24 hours (droplet) until it is ruled out to
be bacterial or viral, culture first then give antibiotics, keep
environment quiet and darkened to prevent overstimulation, monitor
vitals and status of patient
o Procedures:
Lumbar puncture
Lumbar Puncture is used to analyze CSF fluid (dx meningitis)

30
 During procedure, the patient will be placed in lateral recumbent
position (leaning forward on stand) or with head resting on the chest
and the knee flexed to abdomen
Do not perform lumbar puncture if PT has Increased ICP
After procedure, patient will have to lie supine (flat) to prevent
leaking of CSF fluid and headache
o Abnormal postures
Decorticate = damage to the cerebral hemisphere = the patient will have
hands flexed
Decerebrate = damage to the brainstem (diencephalon, pons, and
midbrain) which affects breathing = the patient will have hands extended
ad pronation
Renal Disorders
o Acute Glomerulonephritis
Causes: recent streptococcal infection (beta-strep)
S/S:
Hypertension, dark-colored urine, proteinuria, elevated ASO titer,
elevated BUN and Creatinine, and oliguria
Nurse Management:
Provide low-sodium and low potassium diet, encourage bed rest
during acute phase, give antihypertensives, monitor vitals, monitor
for seizures, CHF, and renal failure
o Nephrotic Syndrome (Nephrosis)
S/S: severe generalized edematous (child looks like marshmallow),
pallor, frothy urine, massive proteinuria, decreased protein, and elevated
serum lipids
Nurse Management:
Weight child daily, provide a low-sodium and normal protein diet,
give corticosteroids for edema, maintain skin integrity, prevent
infection, and measure abdominal girth
o Wilms tumor
Don't palpate abdomen because the tumor may release something
o Cleft Lip/Cleft-palate
Cleft-lip = surgery done first week f life; cleft palate = in 6 months
Complication: hearing loss (can cause otitis media)
Suction infants for only 5 seconds
Nurse Management:
Burp child frequently, feed child in upright position, promote family
bonding, use soft nipples or rubber prosthetic syringe for feedings,
support breast feeding if possible
Post-op surgery:
o Cleft-lip: keep infant on side or upright position
o Cleft-palate: keep infant on side or abdomen
o Prevent the incision site from being altered (place elbow
restraints on infant, minimizeinfant crying), clean the site

31
 (use peroxide or sterile water to clean the site), perform
ROM on elbow (do one at a time)
o TEF
S/S: 3 Cs (coughing, choking, cyanosis)
Nurse management:
Patient will be NPO, administer IV fluids, patient will have gastronomy
tube, provide pacifier
o Pyloric stenosis
S/S: projectile vomiting, fretful and hungry, weight loss (failure to thrive),
dehydration, metabolic alkalosis, palpable olive-shaped mass in right
upper quadrant, and visible peristaltic movement
Rx: surgery
o Imperforated anus
Occurs when there is no butt hole
S/S: failure to pass meconium first 24 hours after birth, unusual anal
dimple, meconium in urine
Rx: surgery, continue Iv fluids; post-op: burp frequently, small frequent
meals, and place child on right side after feedings
o Hirshsprung disease
Occurs when there is fecal impaction (constipation)
S/S: failure to pass meconium first 24 hours after birth, chronic
constipation, distended abdomen
Rx: surgery (pre-op: perform bowel prep or enema, teach about
colostomy for temporary measures); (post-op: assess use of colostomy;
surgery is done late to correct it in later age)
o Intussusseption
S/S: jelly-like stool
Hematological Disorders
o Iron-Deficiency Anemia
S/S: pallor, fatigue, low iron levels, and pica
Causes: blood loss, inadequate diet, malnutrition, less intake iron
Rx: iron supplements (take with vitamin C); frozen RBC if too low
o Hemophilia
Occurs when the person lacks factor 8 for clotting factors
S/S: prolonged bleeding with any injury
Rx: apply pressure, will need to call ambulance to get patient factor 8
replacement, may need frozen packed RBC if platelets too low; use soft
bristle toothbrush to prevent bleeding, wear medic-alert bracelet
o Sickle-cell anemia
S/S: exercise intolerance, fatigue, pallor, sickling pain
Rx: pain medication, blood transfusion
Complications: sickle cell crisis which occurs when the RBC clump up
together in one area causing sickling pain (triggered by infection)
Nurse management:

32
 Give pain medication, prevent infections or treat them ASAP, increase
fluids, give oxygen, patient may need transfusion
o Pernicious anemia
Lack of vitamin B12
o Vitamin B12 Deficiency (Cobalamin deficiency)
Lack of intrinsic factor to digest cobalamin
Dx: Shilling test
Rx: need B12 for life
o Leukemia
Leukemia occurs when there are too much WBC in bone marrow, spleen,
or lymph system
Classification of leukemia
Acute; production of immature WBCs
Chronic: too much mature WBCs
Types of Leukemia:
ALL = common in children
AML = adults
CLL = adults (patient will have lymph node enlargement)
CML = adults (patient will have Philadelphia chromosomes)
Dx: biopsy (bone marrow aspiration)
S/S: fever, weakness, fatigue, pallor, petechiae, infection, bone pain,
anorexia, anemia, bleeding
Rx: chemotherapy (the aim is to achieve remission)
Side effects of chemo: anorexia, N/V, fatigue, mucositis, bone marrow
suppression, alopecia, and neuropathy
Nurse management:
Place patient in private room = REVERSE ISOLATION
Monitor for bone marrow failure*
Patient may have neutropenia (abnormal low # WBC) or
thrombocytopenia (abnormal low platelet)
Neutropenia = prevent infection
Place in private room, place patient on reverse isolation, remove
plants from room, limit visitors, avoid crowded areas, avoid uncooked
foods (meat, seafood, eggs, fruits, and veggies), bathe and shower
daily, notify doctor (fever > 100F, chills, cold)
Thrombocytopenia = prevent bleed
Use electric razor, avoid falls, use soft bristle tooth brush, avoid
contact sports, avoid SQ injection, watch for dry mouth
Fractures
o DDH
S/S: positive ortalani sign (clicking with abduction), unequal folds of
skin on buttocks and thighs, limited abduction, unequal leg length
Diagnoses: ortalani maneuvers (used to check for hip instability)
Rx: will have traction and cast
o Scoliosis

33
 Mild scoliosis (<20 degrees) = do nothing
Moderate scoliosis (25 -40 degrees) = need braces (remove brace 1hr a
day to shower); wear brace under clothes (wear baggy clothes to make it
less obvious)
Severe scoliosis (>45) = need surgery (after surgery, log-roll patient to
avoid messing up the spine)
o Celiac Disease
S/S: indigestion, steatorrhea
Nurse management: obtain gluten-free diet, they can have rice
o
Fundamentals
Terms to remember
o Ethics is when your doing what you are supposed to do
o Moral = doing what is right or wrong
o Nonmaleficent = causing no harm
o Beneficience = promoting good
o Fidelity = telling the truth
o Justice = keeping promises
o Civil law = consist of unintentional and intentional laws
Unintentional:
Negligence = carelessness
Malpractice = carelessness that leads to patient injury
Intentional:
Battery = threatening to harm patient
Assault = touching or causing harm to patient

Mental Health
Anxiety
o Types of anxiety: mild, moderate, severe, and panic
o Benzodiapines are used as last resort?
o Rx: anti-anxiety and antidepressants
Somatization disorders = form of anxiety disorders
o Somatoform disorder
Having physical complaints
o Conversion disorder
The belief that one has an impairment (ex: patient goes blind = you will
need to treat patient like they have the illness and care for the patient
until they recover)
o Body dysmorphic disorder
The belief that the person has facial defect or body defect
o Hypochondriasis
Fear of getting an illness (ex: mole on arm mistaken for a tumor)
o Rx: antidepressants and anti-anxiety
Bipolar

34
 o Mania = when they are in a hyperactive state
These patients often forget to eat and are too hyperactive, they lose tons
of weight, they may not be sleeping, or getting adequate rest
Rx: give lithium or antidepressants
Nurse management: test TSH levels first to make sure it is not
hyperthyroidism, FEED WITH FINGER FOODS, decrease stimuli
o Hypomania = a low manic state with more depression
Depression
o S/S: may have insomnia or sleep too much, low self-esteem, hopelessness,
fatigue, lack of appetite,
Schizophrenia
o Schizophrenia is when the person loses touch with reality (psychosis)
o They may hallucinate (maybe visual or auditory hallucinations) or be
delusional (grandiose thinking, paranoid)
o S/S:
Positive: hallucinations, delusions
Negative = blunt affect, alogia, a
o They may have:
Grandiose (when they think they are a god, angel, evangelism)
Loose associations (mixing two different topics together)
Neologism (making up new words = ask patient what they mean) =
NEVER encourage neologism or pretend like you know meaning
o Rx: antipsychotic drugs (typical = positive; atypical = positive/negative)
o Nurse management: ALWAYS reorient patient (if they are hallucinating, you
can say: I know these things are real to you but I do not see them)
Substance Abuse
o CNS depressants = they depress CNS system
Alcohol
Use CAGE test to screen for alcohol
If family is upset with patient ==> ask the patient how their
family feels about their drinking
Rx of addiction:
o Librium is used for alcohol withdrawal symptoms
Alcohol withdrawal symptoms: tremors, diaphoresis,
increased BP or pulse, hallucinations, nausea, vomiting,
headache, seizures
o Antabuse (avoid alcohol with drug; must sign consent)
If you use alcohol with drug, patient will be nauseous; it
can cause: respiratory or cardiac collapse,
unconsciousness, convulsions, and DEATH
o Detoxification
Drugs used: chlordiazepoxide (Librium), diazepam
(Valium), and Lorazepam (Ativan)
Keep the patient hydrated ==> give IV fluids
Take seizure precautions

35
 Place cool cloth on forehead in cause of diaphoresis
Give vitamins (Thiamine and Vitamin B12)
Barbiturates
Major cause of overdose death from accidental poison or suicide
Benzodiapines
Used to treat anxiety disorders (safer to used than barbiturates)
When used with alcohol can cause sudden DEATH
o CNS Stimulants = they excite the CNS system
Amphetamine
Methamphetamines (meth) = prolonged use can lead to psychosis
Cocaine = PT may have drug seeking behavior = can cause death
Opiates (Narcotics)
It includes: opium, heroine, meperidine, morphine, codeine,
methadone ( a patient addicted to opiates cannot have stadol)
Narcotic or opioid addiction = pin-point pupils
Overdose can lead to coma, respiratory depression, death
Marijuana (Cannabis)
Marijuana is the most common used drug = gateway drug
Hallucinogens
Includes: LSD, peyote, mescaline, psilocybin
Patients may experience hallucinations or bad trips (flashbacks
or psychotic episodes)
MDMA (Ecstacy)
Most recreational drug used in RAVE culture
Phencyclidine (PCP)
In high doses can cause the person to become very violent
towards themselves or others
Inhalants
Includes: residue from paint, glue, markers
Signs of inhalant use: cold symptoms (runny nose), pimples or sores
around the mouth or nose caused by chemicals on skin
Nicotine/Caffeine
Date-Rape Drug = Rophypnol = illegal in U.S.
o Nurse Management for substance abuse patients
Encourage the patient to stay positive about treatment
If they speak about their experiences and benefits from being on the drug
==> REDIRECT their conversations to better realistic ones
Personality Disorders
o Cluster A = odd and eccentric people
Paranoid
Characteristics: fearful, distrustful, suspicious, jealous, hyper-vigilant
(scanning eyes), controlling behavior
Nurse management: gain trust, give food from vending machine
Schizoid
Characteristics: they isolate themselves and avoid people

36
 Schizotypal = similar to patient with schizo
Characteristics: magical thinkers
o Cluster B = they are manipulative, impulsive, and
Antisocial
Characteristics: manipulative, break rules and law, commit crimes,
cheat, and lack remorse for others
Nurse management: be consistent with patient and set limits
Borderline
Characteristics: fear abandonment, use of splitting, often clingy,
impulsive, dependent on others, angry when needs are not met,
Nurse management: keep appointments (if unable to make it, let them
know ahead of time), be consistent, prevent clinginess
Histrionic disorder
Characteristics: attention-seeking, promiscuous, seductive, lack
insight, and loves to be the center of attention
Nurse management: decrease stimuli
Narcissistic
Characteristics: self-obsession, self-absorbed, grandiose, lack empathy
for others, lack criticism
o Cluster C = fearful
Avoidant
Characteristics: fear close relationships with others, fear rejection
Dependent
Characteristics: highly dependent on others, very clingy, emotionally
indecisive, unable to make decision without approval of others, fear of
abandonment, at risk for being abused
Obsessive-compulsive behavior
Characteristics: perfectionists, focused on rules and control, they
focus so much on details that they may not complete task, they
complain about others weaknesses
o Rx for all clusters
Cluster A
May need antipsychotics
Cluster B
May need mood-stabilizers (borderline needs DBT)
Cluster C
May need anti-anxiety SSRI
Eating disorders
o Anorexia
Anorexia is the fear of gaining weight (they often starve themselves)
These people are the perfectionists and they deny hunger
They think they are overweight when really they are underweight
Nurse management: may need to be checked into a facility to be
monitored, include patient in meal planning, watch patient eat food, if

37
 they do exercise (must be light exercise), be supportive if they do refuse
to eat, patient may need tube feedings
Rx: cognitive behavioral therapy
o Bulimia
Bulimia is when a person binges (eats excessive) and purges (vomits)
They rarely stick to a diet plan (most times, they eat in secret)
Nurse management: monitor their bathroom trips after eating
Rx: give fluid and electrolytes
o Binge-eating
Cognitive disorder
o Delirium = MEDICAL EMERGENCY
Delirium is the SUDDEN change in mental status
Mostly occurs in the hospitals ICU, geriatric, and emergency units
S/S: decreased in LOC, hallucinations (tactile), change in vitals (fever
or electrolyte imbalance), assaultive/combative behavior
Causes: fever, medication toxicity, or illness
Rx: treat the cause
Nurse management: allow family to be with patient (someone familiar) to
decrease combative behavior, interact with patent often
o Dementia = IRREVERSIBLE
Dementia is a slow-onset decline in memory and cognitive functions
It often affects: attention, memory, judgment, decision-making, abstract
thinking, and personality
It occurs due to lack of dopamine in the brain
S/S: normal LOC, slow behavior, personality changes, forgetful, amnesia
(memory loss), poor judgment, sundowning, poor abstract thoughts,
normal perception (no hallucinations), incoherent speech, and
confabulation (when they make up a response to a question)
NOT ASSOCIATED WITH AGING
Sundowning syndrome = night-time agitation
It usually occurs due to lack of interaction with patient
Management: provide calm environment, dim the lights, open the
windows a little, feed the patient, and RE-ORIENT patient
Rx: donepezil (Aricept) = once a day treatment
Aggressive behaviors
o Use calm tone when talking to aggressive patient
o SAFETY FIRST of patients and yourself with aggressive outburst = move
people from the area then address the situation
o ALWAYS call for help
o When you separate people in conflict = redirect them to a stimuli that will
help allow them to release frustration (ex: allow use of punching bag)
Violent and sexual assault
o Sexual assault
A sexual assault nurse or special examiners are used to collect evidence
o Rape

38
 Teach patient not to shower until evidence is collected to avoid evidence
being destroyed
After you are done assessing patient = offer prophylactics STI/STD Rx
Drugs
o Benzodiapines
o Antidepressants
SSRI/SNRI
SSRI: Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine
(Prozac), Fluvoxamine (Luvox), Sertraline (Zoloft)
SNRI: duloxetine (Cymbalta), venlafaxine (Effexor)
Toxicity can cause Serotonin syndrome (due to excess serotonin)
o S/S: fever
o RX: DISCONTINUE SSRI AND NEVER INTRODUCE AGAIN
MAOIs = NO POPULAR MEDS
Nardil, Parnate, Marplan
Side effect: hypertension crisis
AVOID FOODS containing tyramine (soy, dry or aged fruits, pickled or
smoked fish, avocados, dairy products, etc)
TCAs
Amitryptilline (Elavil) (all end with vil); Imipramime (Tofranil)
Side effects: EKG changes, increase risk for suicide
If a patient is at risk for suicide = do not give them a large supply
of medication because that will give them enough drugs to kill
themselves; limit supply to a week worth
o Mood stabilizing drugs
Lithium = may see fine tremors which is normal
Therapeutic level: 0.6-1.4
S/S of toxicity:
o Prodrome: coarse tremors, slurred speech, muscle spasms
o Intoxication: coarse tremors, fever, decreased urine output,
decreased BP, irregular pulse, ECG changes, Seizures/Coma
Diet: encourage patient to maintain normal sodium diet (any
electrolyte imbalance can cause toxicity)
Carbamazepine (Tegretol)
Calcium channel blockers = verapamil
o Antipsychotics
Typical = Rx positive symptoms = zines
Chlorpromazine (Thorazine), Fluphenazine (Prolixin/Prolixin D)
Side effects: Extrapyramidal syndrome (EPS), Tardive Dyskinesia
(TD), and Neuromalignant Syndrome (NMS)
o EPS is characterized by:
Akinesia (motor inertia)
Akathisia (restlessness)
Dystonia (neck stiffness)
Parkisonianism (mask-like face, stiff, stooped posture)

39
 o TD is characterized by:
Involuntary movements: tongue protrusion, lip smacking,
chewing, blinking, grimacing, foot tapping
There is NO treatment for TD
o NMS causes: fever, tachycardia, sweating, muscle rigidity
Atypical = Rx positive and negative symptoms = dones, zoles, pines
Drugs: aripiprazole (Abilify), risperidone (Risperidal Consta),
Haloperidol, clozapine (Clozaril), ziprasidone (Geodon), Zyprexa
Side effects:
o Clozapine causes agranulocytoses (decreased WBC = S/S: fever,
malaise, sore throat, leukopenia)
o Zyprexa causes weight gain
o Risperidone causes EPS (extrapyramidal movements = S/S:

Medical Surgical
Imbalances
o Hyponatremia = low sodium (due to too much water that makes you dilute)
Causes: polydipsia (drinking too much water), vomiting, sweating
S/S: neurological changes, headache, seizures, coma
Rx:
Give IV fluids (NS 3-5%) = hypertonic solutions
DO NOT GIVE WATER
o Hypernatremia = high sodium (due to not enough water)
Causes: heat stroke, dehydration, and diabetes insipidus (loss of excess fluid)
S/S: dry mouth, thirsty (dehydrated), swollen tongue, neurological changes
Rx:
Restrict sodium intake
Dilute patient with IV fluids = NS 0.45 percent = hypotonic solution
because it goes into the vascular space to rehydrate but comes back out
Strict intake and output
Monitor daily weights
Give feeding tube (because most these patients are dehydrated due to not
enough water; and feeding tubes have the most nutrients)
o Hypokalemia = low potassium
Causes: vomiting, NG suction, diuretics (Lasix/HCTZ), not eating
S/S: arrhythmias, muscle cramps, and weakness
Rx: give potassium, eat potassium
o Hyperkalemia = high potassium
Causes: kidney problems (not being able to excrete potassium), Aldactone
S/S: arrhythmias, muscle twitching, weakness, then flaccid
Rx:
Dialysis
Give calcium gluconate = it will decrease potassium
Glucose and Insulin (insulin carries glucose and potassium)
Kayexalate (exchanges Na for K+) = K and Na have inverse relationship

40
 o Hypocalcemia/Hypomagnesemia= NOT ENOUGH SEDATIVE
Hypocalcemia = low calcium levels Hypomagnesemia = low magnesium levels
o Causes: Hypoparathyroidism, radical o Causes: diarrhea and alcoholism
neck, and thyroidectomy
o Signs and symptoms:
o Awake but may respond inappropriately
o Hyperreflexia (increase deep tendon reflexes)
o Positive chevostek (tap cheek) and trousseau sign (pump up BP cuff)
o Arrhythmias ==> because heart is a muscle
o Muscle spasms and tetany (muscles are rigid
o STRIDOR/LARYNGOSPASM ==> because airway is a muscle
o Treatment o Treatment
o Place patient on heart monitor o Give magnesium ==> check kidney
o Give IV calcium function to make sure kidney can
excrete magnesium because too
much can cause renal failure

o Hypercalcemia/Hypermagnesium = ACTS LIKE A SEDATIVE

Hypercalcemia = high calcium levels Hypermagnesemia = high magnesium levels

o Too much calcium causes o Too much magnesium is causes renal

hyperparathyroidism, inability to bare failure
weight on legs (due to loss of calcium o Magnesium makes you vasodilate
from the bones), kidney stones (lowers your blood pressure)
o Signs and symptoms
o Decrease level of consciousness
o Loss of muscle tone (weak or flaccid muscles)
o Hyporreflexia (decreased deep tendon reflexes)
o Decreased respirations (may need to intubate patient if respirations are < 8)
o Arrhythmias
o
o Treatment o Treatment
o Encourage patient to ambulate o Place patient on ventilator
o Give IV fluids to dilute calcium o Dialysis to excrete excess
o Give phosphate or fleet enema magnesium
(phosphate will lower calcium) o Give Calcium gluconate (because
o Give steroids (decrease calcium) calcium and magnesium inactivates
o Give calcitonin (calcitonin will help each other)
put calcium back into the bone)
o Give vitamin D products
o Add phosphate to diet (act inversely)
o
o Serum osmolarity
Serum osmolality test usually measures the amount of chemicals dissolved in
the liquid part of the blood.
If low = indicates fluid overload = retention

41
 If high = indicates loss of excess fluid = dehydration
Cardiovascular
o The cardiovascular system
The heart is located in the 2nd 5th intercostal space slightly to the left
(the base is on the 2nd intercostal, apex is a the 5th intercostal)
The right side of the heart carries oxygenated blood and tries to shunt it
to the lungs to get oxygenated so that it can become oxygenated and go
to the left side of the heart so it can be pumped throughout the body
If the right side is unable to shunt blood to the lungs, it backs up
systemically into the body = systemic edema (right-side HF (RHF)
If the left side is unable to shunt oxygenated blood out of the lungs to the
body, it backs up into the lungs causing pulmonary edema (LHF)
o Blood flow
Superior vena cava Right Atrium Tricuspid valve Right Ventricle
Pulmonary valve Pulmonary artery Lungs Pulmonary veins
Left Atrium Mitral valve Left Ventricle Aortic valve Aorta
Body
o Neck Vessels
Carotid artery = corresponds with S1
S1 is the first sound heard when AV valve closes (tricuspid or
mitral) to prevent blood from back-flowing to the atria; during this
time, semilunar valves (aortic and pulmonary valve) open to allow
blood to flow into the vessels and go into the lungs or out the body;
then when SL valve closes, S2 is heard
o Heart sounds
S1 heard when AV valve closes (tricuspid/mitral) = loud at apex
S2 heard when SL valve closes (pulmonary/aortic) = loud at base
SA is the pacemaker of the heart
o Abnormal heart sounds
S3 (ventricular gallop) = occurs when ventricles resist to filling but
AV valves are open = OCCURS WITH FLUID OVERLOAD = heard right
after S1 = occurs due to MI or left heart failure
S4 (atria gallop) = occurs when ventricles are not compliant (heard
right after S1)
Murmurs
Murmurs are gentle, swooshing, blowing sounds = turbulent blood
flow (chaotic blood flow)
Innocent murmurs occurs normally in children
Grades of murmur:
o I = murmur barely audible
o II = murmur clearly audible but faint
o III = murmur is easy to hear
o IV = murmur is heard with thrill palpable on chest wall
o V = murmur heard with one side stethoscope lifted off chest
o VI = murmur is heard without stethoscope being on chest

42
 o Cardiac output
Cardiac output is the amount of blood the heart pumps in 1 minute
It normally depends on: preload, afterload, contractility, and HR
Normal cardiac output is 4-6 liters (6-8 in an active patient)
Low CO = not enough blood flow; High Co = too much blood
CO determinants:
Heart rate
o The faster the HR = the more blood pumps = increased CO
o The lower the HR = the less blood pumps = decreased CO
Contractility
o Increased CO = increased contractility
o Decreased CO = decreased contractility
Preload: amount of blood filled in atria when heart is relaxing
o
Afterload: amount of pressure in ventricles when atria is relaxed
o Cardiac Drugs
Ace-inhibitors
Ace-inhibitors
Side effects: cough, hyperkalemia
Beta-blockers
Beta-blockers
Side effects: tachycardia
Teaching: do not use beta blockers if you are a diabetic (may mask
S/S of hypoglycemia) or have asthma
Calcium-Channel Blockers
CCB decrease myocardial contractility (how much the heart
contracts) but increases cardiac output (the amount of blood
pumped per minute)
It is used to decrease blood pressure
Teaching = avoid grapefruit juice
Digoxin
Give for HF
Hold if HR < 60 for child and adult; hold if HR < 90 for infants
Cardiac conduction pathway
o P-wave = atrial depolarization
o PR-interval = if prolonged = signal a heart block maybe
o QRS complex = atrial repolarization; ventricular depolarization
o ST-Segment = if elevated = signal MI (if depressed = unstable angina)
o T-wave = ventricular repolarization
Dysrhythmias (look up) = KNOW WHAT THEY SOUND LIKE
o Sinus bradycardia
NSR with HR < 60
o Sinus Tachycardia
NSR with HR > 100
The ventricular and atrial rates are > 100

43
o Junctional rhythm
HR is between 20-40 bpm
There are no p-waves; only QRS complex
o Atrial flutter

The p-waves have a saw-tooth pattern with QRS complexes

Treatment: calcium channel blocker (bolus of 0.25mg/kg is given slowly
over 2 mins; with continuous IV infusion for up to 24 hours)
o Atrial fibrillation

There are no p-waves, but there are fibrillatory waves before each QRS
complex
Controlled A-fib is < 100; uncontrolled A-fib > 100
Treatment: is patient has a pulse, cardiovert; if patient does not have a
pulse, start CPR?
You can give patient heparin and warfarin to prevent clot formation
o Ventricular Fibrillation

There are no p-waves, no QRS complexes, and coarse wavy lines

Treatment: if patient does not have a pulse, and is unconscious, start
CPR; if there is a pulse = defibrillate patient (make sure that
synchronize is turned off and ensure that the pattern showing on the
EKG strip is a ventricular-fibrillation)
In case of emergency, if this occurs, start CPR until defib is available
Complications: Fatal dysrhythmias

44
 o Ventricular Tachycardia (can lead to cardiac arrest f untreated)

There are no p-waves, and QRS complexes are wide

Treatment: If patient has a pulse, Rx by giving lidocaine; if no pulse, Rx
patient with unsynchronized defibrillation of 300 joules with
Complication: Cardiac arrest
o Hyperkalemia = Peaked T-waves, widened QRS Complex, short QT interval
o Hypokalemia = T-waves are flattened, ST-segment depression, and U-waves
may be visible
Defibrillators
o There are two types:
Monophasic defibrillator
Delivers energy in one direction
Delivers shock at 360 joules
Biphasic defibrillator
Delivers energy in two directions
Delivers energy at 120-200 joules
The ACLS (advanced cardiac life support) are usually placed on the
patient between the right of the sternum, just below the clavicle and left
of the precordium
o Hypertension
Stages of hypertension
Prehypertension = 120/80 and higher (120-139/80-89)
Stage 1 = 140/90 and higher (140-159/90-99)
Stage 2 = 160/100 and higher (160-179/100-109)
Hypertensive crisis = 180/110 and higher
Hypertensive emergency = BP > 200/110 = organ failure
Recommended blood pressure maintenance should be close to normal
o Cardiac Tamponade
Cardiac tamponade occurs when there is pressure on the heart caused
by blood or fluid build up in the space that allows the heart to expand
Cardiac tamponade is caused by MI, pericarditis, or wounds in heart
S/S: tachycardia, distant or muffled heart sounds, jugular vein distention,
and falling blood pressure (pulses paradoxus)
o Endocarditis
Ineffective endocarditis occurs when there is infection of the endocardial
layer of the heart
It is caused by staphylococcus or streptococcus (recent strep infection)

45
 S/S: fever (high fever of 100.4F), petechiae, janesway nodes, osler nodes,
roths spots, clubbing of fingers
Rx: antibiotics (culture first)
Nurse management: teach the patient to use prophylaxis before going to
a procedure (dentist, endoscopy, colonoscopy, or any surgery); teach to
Rx strep infections early ahead of time
o Heart Failure
HF occurs when the heart fails to effectively pump blood forward
Types:
Right-side HF (Cor Pulmonale): fluid backs up to the body
o S/S: distended jugular vein, peripheral edema (weight gain),
hepatomegaly, splenomegaly, and tiredness
Left-side HF: fluids backs up to lungs (can eventually affect right)
o S/S: cough with sputum, crackles, dyspnea, nocturia, orthopnea
Risk factors: older adults, diabetes, obesity, high cholesterol, A.A.
Nurse management for HF:
o Elevate the HOB (fowlers to improve ventilation)
o Give diuretics, beta blocker, BNP, Nitrates, and Morphine
o Give digoxin (monitor for toxicity = dig + hypokalemia = toxicity)
o Restrict sodium and water intake
o Angina
Chronic Stable Angina
Chest pain that occurs due to a certain stimuli or activity
Treat by using nitroglycerin prophylaxis or other drug prescribed
Unstable Angina
Chest pain that occurs randomly
Treat with nitroglycerin (take up to 3 times; call 911 if unrelieved)
Prinzmetal Angina
Chest pain at night (causes vasospasms)
Treat with calcium channel blocker
o Myocardial Infarction (MI) = HEART ATTACK
MI occurs when there is injury or ischemia (death) to the heart cells
S/S: chest pain that last > 30 minutes (not relieved with rest), pain
that radiates to the back, nausea/vomiting, tachycardia
Dx: high troponin levels (>1.4), CKMB, and elevated ST segment
Nurse Management:
o Give fibrolytics within 6 hours of occlusion
o Place patient on EKG monitor
o Give morphine, oxygen, nitroglycerin, aspirin, and beta-blocker
o Give stool softeners to prevent straining
o Monitor for re-occlusion => REAPPEARANCE OF CHEST PAIN
o A PCI is done if after 6 hours = done within 12 hours
o A CABG is done when ALL measures have failed
o Shock
Shock occurs due to lack of oxygen supply to the cells

46
 Types of shock:
Cardiogenic shock
o Cardiogenic shock occurs when heart cannot pump enough blood
to meet the bodys need ==> results in decreased cardiac output
o Risk factors: older adults > 65, history of HF and CAD
o S/S: cold, clammy, diaphoretic, tachycardia, hypotension, weak
pulses, decreased urine output, confusion
o Nurse Management:
Medications: Aspirin, Thrombolytics, Heparin, and Dopamine
Procedures: Angiogram/Stenting, Balloon Pump, CABG, Heart
pumps (Ventricular Assist Device), Heart transplant
Hypovolemic shock
o Hypovolemic shock occurs due to low blood volume in the
vascular space or rapid loss of blood in the vascular space
o Causes: bleeding from cuts, burns, diarrhea, and vomiting
o S/S: cool, clammy, diaphoretic, pallor, tachycardia, hypotension,
decreased urine output, decreased LOC, weak or thread pulse
o Nurse Management:
Give IV fluids = Isotonic solutions (0.9% NS or LR for
burns)
Keep patient flat with feet elevated 12 inches to increase
circulation
Give Dopamine, Dobutamine, Epi/Norepi to increase BP
Insert Swan Ganz catheter (monitor CVP for fluid overload
because you will be giving large volumes of fluid)
Neurogenic shock
o Neurogenic shock occurs due to spinal cord injury
o S/S: hypotension, bradycardia, and
o Nurse management:
If patient fell, stabilize the head, neck, and cervical spine
ASSESS AIRWAY
Give IV fluids
Give high doses of steroids => Methylprednisone
Give vasopressors (epi/norepi, dopamine, dobutamine)
Give atropine for bradycardia
Anaphylactic shock
o Anaphylactic shock occurs due to allergic reaction
o S/S: chest-tightness, difficulty breathing, stridor, palpitations,
swelling in face, eyes, or tongue, hives, loss of consciousness
o Nurse Management:
If airway is closing up => perform intubation, tracheostomy,
or cricothyrotomy to assist with breathing
Give antihistamines (relief allergic reaction)
Give corticosteroids (decrease inflammation)
Give Epinephrine

47
 Septic shock
o Septic shock occurs due to infection
o S/S: cool, clammy, diaphoretic, high or low temperature, chills,
hypotension, tachycardia, restlessness, SOB, little/no urine
o Nurse management:
Treat the cause => get rid of infection => give antibiotics
Give IV fluids
Give oxygen or use mechanical vent if patient has SOB
Peripheral vascular diseases
o Deep vein thrombosis (DVT of venous thrombosis)
DVT occurs when there is a blockage in the blood vessels by a clot
Risk factors: immobility, smoking, some oral contraceptives or
hormonal therapy, obesity, dehydration, old age
S/S: pain and tenderness on calf, swelling of calf, warm and red calf
Dx: homans sign, calf circumference, ultrasound, x-ray
Prevention: use of anticoagulants (warfarin (PTT[ ]/INR [2-3.5]),
heparin (PT), lovenox (do not need clotting time), compression socks,
and EARLY AMBULATION!!!
Rx: elevate the leg (used to promote venous return a.k.a. blood flow),
thrombolytic therapy
o Pulmonary embolism
PE occurs when the clot has broken off from a DVT and travelled and
become stuck in the lungs
Risk factors: DVT, recent surgery, HF, stroke, birth control, smoking
S/S: SOB, chest pain,
Dx: based on symptoms
Prevention: Rx of DVT
Rx: place leg in dependent position, give oxygen, thrombolytic to
dissolve clot, and anticoagulants to prevent new clots from forming
Nurse management: WATCH FOR BLEEDING!!!!
Arterial Insufficiency
o Occurs when there is lack of blood flow through the arteries (increases the
chance of clots forming in the leg)
The person will develop claudication (cramp) on foot
o The persons pulse will be decreased or absent
o Color: legs will be pale upon elevation
o Temperature: legs are cool and clammy
o Edema = NO EDEMA
o Skin = skin is shiny (absence of hair on legs); ulcers on toes
o Sensation: leg pain worsens with movement; and relieved with rest
o Rx: lay patient down (allow to rest leg to increase blood flow)
Venous Stasis
o Occurs when bloods flows from legs to the heart slowly (pooling in legs)
o Color: legs are pink or cyanotic
o Temperature: legs are warm

48
 o Edema = PRESENT (swelling of ankles)
o Skin = skin has brown pigmentation; ulcers on ankles
o Sensation = leg pain is aggravated by sitting down; relieved with elevating,
lying down, and walking (because this promotes blood flow)
o Rx: will need to walk or lay flat to promote blood flow throughout body)
Procedures
o Cardiac Catherization
Cardiac catherization is a medical procedure that Dx and Rx heart conditions
It is performed by inserting a catheter into the femoral artery then
advancing it into the coronary artery of the heart
Pre-op
Before procedure, assess allergy to iodine
Patient will be NPO for 6-18 hours before
Teach patient about the procedure (they may feel warm flush hot
flash as dye is being injected into the body)
Assess and mark pedal pulses
Intra-op
During procedure, dye is inserted into the heart arteries to make
them visible => then a balloon catheter is inserted into the coronary
artery to compress the blockage in the artery => After blockage has
been compressed, a stent may be placed to keep vessel open
Post-op
Patient will need to keep leg straight for 4-6 hours
Assess pedal pulses (use doppler if diminished or absent)
Observe for bleeding => if bleed occur, apply pressure above the site
FORCE FLUIDS => give fluids to flush dye out the patient system
Respiratory
o Lung sounds
Normal lung sounds
Vesicular = heard across peripheral chest = sounds like wind blowing
Bronchovesicular = heard at middle area of chest
Bronchial = loudest (heard at the neck)
Crackles
It is a high-pitch popping noise (sounds like pop rocks; fire crackers)
Heard with fluid in lungs (upper) ==> Ex: Heart failure
Wheezes
High pitch musical sound (occurs when airway is inflamed/closing)
Sounds like someone is whistling
Rhonchi
Low pitch, coarse, rattling noise (snoring or moaning sounds)

49
 Occurs due to large amount of fluid in lower lobes (thick mucus)
Pleurisy
Pleural friction rub sounds like fluid is rubbing against something
Stridor
Loud high-pitch crowing sound
Indication that the airway is narrowing
o Pharyngitis
Inflammation of the pharynx
Nurse management: teach patient to consume cool clear fluids, ice chips,
or ice pops to sooth the pain; avoid citrus juices, spicy foods or over
seasoned food to prevent irritation and throat clearing that could irritate
the pharynx
o Tonsillectomy
The removal of the tonsils
Reason for removal? having frequent upper respiratory infections
Nurse management: avoid red, orange, or brown fruits juices to prevent
misinterpretation that it could be blood
o Pulmonary embolism
PE occurs when a clot forms in the lungs (or when clot travels to lungs)
S/S: SOB, chest pain, dyspnea, restlessness
Rx: give oxygen (raising the HOB, coughing, and suctioning does not
solve the problem)
o Fat embolism
Fat embolism occurs due to long bone fractures (within 24 hours)
S/S: Petechiae, dyspnea, SOB
Rx: give oxygen and ventilation, hydration
o Pulmonary edema
Occurs when there is swelling in the lungs
Risk factors: immobile patients (post-op or impaired physical mobility),
hypercoagulation, endothelial disease, and advanced age
S/S: crackles, dyspnea, cough, frothy pink sputum, pain with deep
breathing (give analgesics for that)
Rx: give steroids (decrease inflammation); oxygen, raise HOB, give
diuretics if fluid is in lungs as well (used to remove fluids)
o COPD
COPD occurs when there is airway limitation
It includes:
Emphysema (air trapped in the lungs) = barrel chest*
Chronic bronchitis (mucus build up in the lungs)
Risk factors:
Smoking (biggest one), infection, hereditary
S/S:
Dyspnea at rest, use of accessory muscles with retractions,
clubbing, prolonged expiratory breathing (due to retention of CO2),
and increased respiratory rate

50
 Diet:
Small frequent meals (high calories, low carbs (low carbs because
the carbohydrates break down to CO2)
Treatment:
Give bronchodilators, inhaled corticosteroids, O2 therapy
o Theophylline (bronchodilator) = therapeutic level (10-20) = if
low, the patient needs more meds
Perform chest physiotherapy (bronchitis)
Perform postural drainage (bronchitis)
Maintain nutritional therapy = high calorie, low cards
Nurse Management:
Sit patient in tripod position to assist w/ breathing (emphysema)
Teach patient to breath through pursed-lips (both)
The standard oxygen that you give a COPD patient is 1-2L
o Why ==> because oxygen triggers their need to breathe; you also
do not want to decrease patient oxygen drive; give oxygen with
humidified air
Complications:
Cor Pulmonale = s/s: crackles, dyspnea, distended neck veins
o Flail chest
It occurs when multiple ribs are fractured
The patient will have pain during inspiration (breathing in)
S/S: the person will have paradoxical chest movement (when you
breath in and chest goes in, breathe out, chest goes out)
Once this occurs and flail chest is suspected ==> apply firm
pressure to the flial segments of the ribs to stabilize the chest wall
and help the respirations
o Tuberculosis
Airborne/Droplet infection transmitted through prolonged exposure to
infected persons (when diagnosed, PT will be on meds for 6-9 months)
A person is not contagious anymore after 2-3 weeks of medication
The person can return to work after 3 negative sputum results
When caring for the client, you will need a respirator mask (N-95 mask)
that is specially fitted, gown, and gloves
Diagnosis:
Mantoux skin test = test results are read in 48-72 hours
o Induration > 5cm for HIV patients = positive
o Induration > 10 = those at high risk (homeless, healthcare
workers, assisted living, being foreign born)
o Induration > 15 = regular people (ex: post office worker)
o After a positive result, contact doctor for CXR
Chest X-ray (also used on patient who had BCG vaccine)
Culture = most definite diagnoses for TB
S/S:

51
 Cough with rust-colored sputum, chills, night sweats, dyspnea,
chest discomfort or pain, low-grade fever, fatigue, weight loss
Rx: Rifampin is given for treatment (orange in color); INH, and more
Nurse management:
Patient will need to be placed on airborne precaution
Place patient in negative pressure room
Nurse will need to wear HEPA mask
Teach patient cover mouth with tissue and dispose in bag
Teach patient to be consistent with taking medication for 6-9 months
= follow up care is most important
o Acute Respiratory Failure
ACF occurs when oxygen and carbon dioxide functions are inadequate
Two types:
Hypoxemic failure = patient is receiving oxygen, yet O2 is still low =
VQ mismatch (ventilation perfusion mismatch)
Hypercapneic failure = when CO2 is still high = insufficient removal
of CO2 = paCO2 > 45
S/S: change in mental status, respiratory acidosis, shallow breathing,
patient sitting in tripod position, retraction of the intercostal
o Acute Respiratory Distress = 60/60 rule
It occurs when there is damage to the alveolar capillaries; it causes
lack of surfactant and oxygen exchange
The person will have refractory hypoxemia (the person may be receiving
oxygen (60%) and CO2 (60%) ==> the oxygen is not oxygenating the
lungs; they will have low O2 (hypoxemia)
Fibrotic phase is the irreversible phase (there is no going back); it
causes excessive scarring and the person develops pulmonary htn
Complications: lung collapse, pneumonia, barotrauma, renal failure
o Pneumothorax
Pneumothorax occurs when there is air, fluid, or blood, in the
pleural space of the lungs that causes lung collapse (pleural space is
the space that separates the lungs form the chest wall)
There are two types: open pneumothorax and closed pneumothorax
Causes: stabbing wound to chest
S/S: dyspnea or SOB, sudden sharp chest pain, diminish breath
sounds (usually on the side that the lungs collapsed)
o Tension pneumothorax
When there is accumulation of air in the pleural space
S/S: mediastinal shift toward unaffected side, shallow breathing
Rx: insert chest tube
o Silicosis
Lung disease that occur due to long-term exposure to silica dust
In mild cases, the patient will be asymptomatic ==> upon examination,
chest x-ray will reveal mild case of fibrosis in the lungs and mild
ventilation restriction

52
 Major cases, the patient will experience: malaise, anorexia, weight loss,
and severe dyspnea ==> it also causes massive fibrosis to the lungs
(which can be seen on the chest x-ray)
o Procedures
Endotracheal tube
Used to maintain patent airway and provide mechanical ventilation
for patients
Make sure the cuff in inflated;
To check for placement, use an ambu bag to give breathes then
auscultate for bilateral breath sounds; after that, you chest x-ray
Tracheostomy
Care for skin around tracheostomy site
Suction for no more than 10 seconds (ensure that you hyper-
oxygenate before suctioning)
Avoid suctioning unnecessarily; only on as needed bases
To ensure that the trach is not too tight on the neck = you should be
able to insert two fingers between the tie and neck
If a patient has a trach, in emergency situations, always have an
obturator at the bedside so in case the patient decannulates
themselves you can insert that in to keep the airway secure
o Ventilation settings
Settings on the ventilator
SIM-V
o Patient breathes on their own; if it falls too short, ventilator kicks
in; used for weaning patient off vent
Assist Control
o When the ventilator is pre-set to how much breathes the patient
will take per minute
Controlled
o When the ventilator breathes for the patient
Pressure alarms:
High pressure alarms: kinks, ventilation tube obstruction, fighting
the vent, biting, coughing, and gagging, increased secretions in
airway, bronchial spasms
Low pressure alarms: leaks, patient stops breathing spontaneously,
and disconnection and displacement
If the alarm goes off and you cannot determine the problem,
mechanically ventilate the patient until the problem is
determined
o Chest Tubes and Drains
Only a doctor or nurse practitioner can insert the chest tube
The minimum amount of water in drain must be at least 2cm
If chest tube accidently pulls out = apply occlusive dressing
If chest tube accidently disconnects = immerse in sterile water
During the first few hours, the drainage should be bloody

53
 Teach patient to cough and deep breathe with chest tube to promote lung
reexpansion
Bubbling in chest drainage
If the chest drain is connected, intermittent or continuous bubbling is
okay (bubbling in inspiratory and falling on expiratory means that
the drainage is PATENT)
Bubbling in the chest tube that rises in inspiration and
expiration signals a leak
If bubbling stops = this means OBSTRUCTION!
Removal of chest tube
Use CXR to confirm placement of tube
Perform re-expansion of lungs
Items you need: petrolatum gauze and sterile gauze 4x4
o Oxygen administration
Room air = 21%
Nasal cannula = 24-44% FiO2
1L = 0.24; 2L = 0.28; 3L = 0.32; 4L = 0.36; 5L = 0.40; 6L = 0.44
Venturi mask = 24-40 % FiO2
Simple face mask = 30-40% FiO2
Face masks with reservoirs = 60% FiO2
Nonrebreather mask = 80-100% FiO2
o Extras
Pulse oximetry may give inaccurate readings if the patient has
hypotension because there is no blood flow going to the lungs so the
tissues when being read by the pulse oximetry will not give accurate
reading because there is no blood to measure
The use of an incentive spirometer is to maintain inflation of the
bronchioles and alveoli to promote better gas exchange
Postural drainage positions are used to drain secretions from the lobe
When it says decrease the work of breathing = it means what will
decrease the amount of effort a person will have to put to breathe; ex:
bronchodilation = with bronchodilation, the airway will be dilated,
allowing the client to breathe
What will increase the work of breathing (increase the amount effort a
person will need to out to breathe = increased mucus)
Gas exchange occur through diffusion
When body temperature increase = respiratory rate increase to
compensate for the increased body temperature
Gastrointestinal
o Introduction
Abdominal assessment
Inspect
Auscultate
Percuss
Palpate

54
 Abdominal Regions
Right Hypochondriac Epigastric Left Hypochondriac
Right Lumbar Umbilical Left Lumbar
Right Iliac Hypogastric Left Iliac

Abdominal Quadrants
Right Upper Quadrant Left Upper Quadrant
Liver Stomach
Head of pancreas Spleen
Duodenum Left kidney and adrenal
Right kidney and adrenal gland
gland Left lobe of liver
Part of ascending colon and Body of pancreas
transverse colon Part of transverse colon
and descending colon
Right Lower Quadrant Left Lower Quadrant
Cecum Part of descending colon
Appendix Sigmoid colon
Right ovary, ureter, and Left ovary, ureter, and
spermatic cord spermatic cord
o REMEMBER:
Antibiotics cause GI distress (N/V, constipation, diarrhea)
NSAIDS, Alcohol, and Smoking causes ulcers
o Bleeding
Cullen sign = bluish/purplish = signal intra-abdominal bleeding
Flank bleed = retroperitoneal bleed = patient will have S/S of shock
Costovertebral angle tenderness = used to the assess kidneys
It is conducted by percussing the 12th rib on the back (striking the
ulnar edge of your fist on hand that is on back)
If sharp pain is present, the kidneys are inflamed
Rebound tenderness
Used to check for an enlarged abdominal organ
Murphys sign
Used to check if gallbladder is inflamed
Iliopsoas muscle test
Used to check if patient has appendicitis
Spleen
THE SPLEEN IS NEVER PALPABLE unless enlarged
Dullness = indicate fluid or enlarged organ
o Bowel sounds
If no bowel sounds = listen to each quadrant for 5 minutes before
declaring absent bowel sounds
Hyperactive bowel sounds= often high-pitched and tinkling
Borborygmus = hyperperistalsis (sound when stomach growls)
Hypoactive bowel sounds = absent = usually occurs after surgery

55
o Hiatal hernia
Occurs when a part of the stomach is merged into the esophagus; or
when there is a hiatus (break) in the diaphragm
Risk factors: large abdomen, obesity, pregnancy
S/S: heartburn, indigestion
Rx: lose weight, PPI, H2 receptor, etc
o GERD
Occurs when there is reflux of gastric contents in the esophagus
Risk factors: obesity, pregnancy, cigarette smoker, hiatal hernia
S/S:
Heartburn (pyrosis), burning or tight sensation below lower
sternum, dyspepsia (indigestion)
Rx:
Lifestyle modification (avoid triggers such as chocolate, fatty or spicy
foods, tomatoes, peppermint, tea, coffee, milk at bedtime)
Drugs: PPI and H2 receptors
Avoid laying down after eating (wait 2-3 hours before laying)
Raise HOB to 30 degrees
Take PPI (Prilosec) first before first meal of the day
Teach patient to eat foods that lower esophageal sphincter (non-fat)
o Ulcer
Types of ulcer:
Gastric ulcer = pain is aggravated by food; relieved by vomit
Duodenal ulcer = pain is aggravated by empty stomach; food makes
stomach feel better
Risk factors/Causes:
H. pylori, stress, caffeine, nicotine from smoking, alcohol, NSAIDS
S/S:
Burning pain in mid-epigastric area, N/V, bloating, belching, GI bleed
Rx:
Drugs: Protonix, PPI (Prilosec), Nexium, Prevacid, Sucralfate (these
are given to decrease amount of acid in stomach)
Antacids/Carafate
Give antibiotics if ulcer is caused by h. pylori
Nurse management:
Avoid spicy foods, caffeine, milk, or any other irritant
Teach patient to adhere to medication and diet because treatment
last for a long time
Give foods with neutral ingredients (avoid foods with extreme temp)
Decrease stress and stop smoking
Complications:
Hemorrhage
Perforation ==> peritonitis can occur in 6-12 hours if ulcer erodes
the gastric mucosa wall
Obstruction

56
o Appendicitis
Inflammation of the appendix that may eventually rupture
Causes: usually occurs due to low fiber diet
S/S: generalized pain in RLQ, n/v, elevated WBC, rebound tenderness
Rx: removal of appendix (you can live without your appendix)
o Dumping syndrome
Dumping syndrome occurs when the stomach empties quickly and
patient has uncomfortable side effects
S/S: sweating, pallor, tachycardia, palpitations, vertigo, fullness,
abdominal cramping, diarrhea, and the desire to lie down
Nurse management:
Teach patient to eat in semi-recumbent position
Teach patient to lie down immediately following meals
No fluids with meals (only drink in-between; before or after meals)
Decrease carbs (eat low-carb foods)
Eat small meals and several meals per day
o Crohns Disease
Involves the ileum of the small intestine or anywhere in intestine
Risk factors: occurs in younger people
S/S: diarrhea, abdominal pain, weight loss
Rx:
Surgery may be done to remove the affected parts
Avoid high fiber foods to avoid overstimulation of the intestines, give
anti-inflammatory, antibiotics, antimicrobials, sulfasalazine drugs,
and immunosuppressants
o Irritable Bowel Syndrome
Involves the large intestine
Risk factors: occurs in older people
S/S: bloody diarrhea, abdominal pain
Rx:
May need a colostomy (if they do a colectomy = removal of the colon)
Avoid high fiber foods to avoid overstimulation of the intestines, give
anti-inflammatory, antibiotics, antimicrobials, sulfasalazine drugs,
and immunosuppressants (also monitor blood count)
o Nurse management for crohns and IBS
Place patient on Low fiber diet ==> teach patient to avoid fiber foods
(wheat, grains, nuts, and fresh fruit) to prevent stimulation of colon
Give antibiotics
Give antimicrobial (flagyl or budesonide)
Give corticosteroids to decrease inflammation
Give antidiarrheal (only for mild S/S)
Maintain fluid and electrolytes, avoid spicy foods,
o Ileostomy vs. Colostomy
Ileostomy is the removal of the ileum of the small intestine (the stool will
be loose and watery)

57
 Colostomy is the removal of the colon (the lower the part of the colon
removed, the more formed the stool will be)
Stool characteristics
The upper colon (ascending colon) = liquid stool
The middle part of colon (transverse) = semi-soft stool
The lower colon (descending colon) = solid and formed stool
Usually drains liquid stool (the further up the
o Colon Cancer
Risk factor: most common in men
The most common type is adenocarcinoma
S/S: rectal bleeding
Rx: surgery, chemotherapy, radiation
o Procedures:
Urogram
Need to do bowel prep before procedure
It involves dye so assess for allergy to iodine or shellfish
Barium enema
Place patient on NPO starting at midnight
Patient will need to use enema until colon is empty
Prior to doing procedure, ensure that patient has a BM
Endoscopy (EGD)
After the procedure, ensure that swallow study is done = do not give
patient food or drinks until gag reflex returns
Renal and Urinary
o What is the best way to assess fluid status or fluid balance in a person
Measure daily weights or intake and output
o Renal Calculi (Kidney stones)
Risk factors
Metabolite (oxalate, purines and citric acid)
Climate (extreme hot weather that increase fluid loss)
Diet
o Excess calcium (milk, cheese, spinach)
o Oxalate (asparagus, roast-beef, chocolate, strawberries)
o Uric acid (purines = sardines, fish, liver)
o Tea, or fruit juices
Family history
Sedentary lifestyle
S/S:
Abdominal flank pain, hematuria, colic pain, N/V, chills, fever
Dx:
Urinalysis, urine culture, Intravenous Pyelogram (has dye in it), CT
Scan, Retrograde Pyelogram, Ultrasound
Rx:
Pain relief = give narcotics = morphine
Lithotripsy (ESWL) = shock that breaks stone into fine sand

58
 Nurse management:
Depending on cause, teach about diet changes
Strain all urine for stones
Increase fluid intake to flush out stones
o Renal cancer
Cancer in the kidney
S/S: painless hematuria
Rx: chemotherapy, surgery, radiation
If a patient gets a nephrectomy, they will be in intense pain and may
have difficulty performing post-op measures (cough and deep
breathe)
o Cholecystitis and Cholithiasis
Cholecystitis = infection of gall bladder; Cholelithiasis = gallstones
Risk factors: 4 Fs (fat, forty, female, fertile)
S/S:
Flank pain (that radiates to shoulder), fever, jaundice, (signals if
stone has obstructed common bile duct)
Diet: low calorie, low fat, high fiber, and high calcium
Complications:
Cholelithiatis (when stone have obstructed common bile duct)
Treatment:
Give PAIN medication (toradol), avoid foods high in fat or caffeine,
avoid rapid weight loss,
Cholecyctectomy (removal of the stones) = patient will have greenish
drainage (about 500-1000 ml is normal)
Lithotripsy can also be done (break down of stones)
Nurse management:
o Teach patient to avoid fatty or greasy foods such as: gravy, fatty
meats, products with cream and dessert
o Pyelonephritis
Pyelonephritis is the infection of one or both kidneys
It can be bacterial or viral (mostly caused by E. Coli)
Risk factors: diabetics, hypotension, renal calculi, urinary catheter
S/S: fever, chills, vomiting, flank pain, frequent urination
Rx: Antibiotics
o Glomerulonephritis
Glomerulonephritis occurs when there is damage to glomeruli (the
glomeruli is the part of the kidney that filters waste; if damaged, toxin
are not getting filtered out especially protein b/c it is large)
Caused by Beta-step (streptococcus infection) = seen in children
S/S:
Hematuria, proteinuria, increased BUN and Creatinine,
edema, and hypertension, dark colored urine
Dx: biopsy, labs, urinalysis
Rx:

59
 TREAT WITH ANTIBIOTICS
Low protein diet, give antihypertensives
Monitor for CHF or rheumatic heart disease
Treat the symptoms of the disease
o Provide medication for hypertension
o Decrease protein intake for proteinuria
Encourage adequate rest
Perform good hand hygiene
o Nephrotic Syndrome (Nephrosis)
S/S: severe generalized edematous (patient looks like a marshmallow),
pallor, frothy urine, massive proteinuria, decreased protein, and elevated
serum lipids
Nurse Management:
Weight patient daily
Provide a low-sodium and normal protein diet
Give corticosteroids for edema
Maintain skin integrity
Prevent infection
Measure abdominal girth
Increase and decrease activity level according to edema
o Benign Prostatic Hyperplasia
S/S:
Decreased force in the stream of urine (first sign), difficulty
starting urine stream (b/c of inflammation blocking the ureter),
nocturia, incontinence, dribbling, sexual dysfunction, inability to stop
urinating
LATE SIGN: HEMATURIA (BECAUSE DAMAGE)
Dx:
PSA, DRE/TUS, Cystourethroscopy
Transurectal ultrasound is used to check PSA levels to rule out if
patient has cancer or not
Rx:
Watchful waiting = if patient does not have symptoms
Drug Therapy
o Proscar, Hytrin, Cardura (doxazocin)
Invasive Therapy
o TURP (removal of prostate tissue)
After procedure, a 3-way catheter will be in place; for the
first few hours the drainage is pale pink; if you see bright
red blood and clots = increase the rate of flow; if continuous =
call the doctor
o Prostatectomy
After a prostatectomy, AVOID valsalva maneuver (when you
bear down lie you are trying to have a bowel movement)
because it increase risk for bleed,

60
 AVOID lifting object > 20 lbs
Increase fluids 2-3 L a day
Teach patient to void every 2-3 hours
Decrease alcohol and caffeine intake
After TURP, patient is at risk for hyponatremia (monitor
patient for confusion and disorientation = if this does occur,
notify the doctor)
Critical care Renal
o Acute Renal Failure
Types of renal failure
Pre-renal = decrease in blood flow to kidneys = oliguria
Intra-renal = damage to internal kidney = ATN (check myoglobin
levels to assess for ATN)
o Ex: use of drugs (myocin drugs)
Post-renal = obstruction to kidney = anuria (< 50)
S/S: Kussmaul respirations (because patient has metabolic acidosis)
o Chronic Renal Failure
Occurs when the patient kidneys in unable to filter properly and are
unable to make erythropoietin for RBC
S/S: patient will have anemia, proteinuria, hematuria
Diet: low protein (to decrease break down of uremic acid)
Rx: dialysis (during dialysis, all fluids are electrolytes are lost such as
sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium,
phosphate); HOWEVER, if RBCs are lost = this is NOT good because it
further worsens anemia
o Dialysis
Dialysis is required when patients body is unable to excrete waste
The fluid used is made of clear water and chemicals from medications or
metabolic waster (it is NOT sterile water)
Types of dialysis
Hemodialysis
o Removes fluid and waste from body since the kidneys are not
able to
o If a patient experiences cramping during dialysis, decrease
the infusion rate or give hypertonic or isotonic solution
Peritoneal dialysis
o Removes fluid from pleural space of abdomen
o It contains glucose that helps increase osmotic pressure causing
the solution to be hypertonic and cells to shrink and excrete fluids
through ultrafiltration
o Used mostly on diabetic patients and people with severe
cardiovascular diseases such as CHF
o Do not place peritoneal dialysis on patient who had abdominal
surgery, diverticuli, ruptured disk

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 o Usually, peritoneal dialysis infuses in 10 minutes and dwells
(drains out the patient) in 20 minutes
o Types of peritoneal dialysis
CAPD (continuous ambulatory dialysis)
CAPD is the type of dialysis that does not require the
patient to carry the device
The patient will be required to dialyze self several times a
day; it is done manually and does not interfere with usual
activity
This dialysis is surgically place in the abdomen and
cannot me moved further in

o Problems with dialysis:
MAJOR COMPLICATION with Peritoneal dialysis =
infection = Peritonitis = prevent this by using strict
aseptic technique
The main reasons why a patient may have poor flow is:
constipation, catheter kink, bad position
To fix the poor flow: reposition patient, ensure that patient
gets laxative if constipated, make sure that the drainage bag is
lower than patient abdomen, and check and fix kinks

o Before dialysis, withhold some medication to prevent is from
being dialyzed from patient until after dialysis
o DO NOT DOUBLE UP ON DOSES before dialysis
o Diabetic patients may need to increase insulin dose before
dialysis because (dwell time) increases the risk for hyperglycemia
because of reabsorption of glucose from the dialysate
Criteria for receiving dialysis
Patient needs dialysis when GFR levels fall below or CKD
During dialysis
If the diasylate slows down, or not enough amount coming out of
patient = CHANGE patient position or move side-to-side
If patient expeirnces pain during dialysis, explain that pain will
subside after a few exchanges or give a bolus of NS
Too rapid removal = slow down; not enough removal = speed
After dialysis
Patient may have a slight higher temperature because the dialysate
given was warm = if patient have high temperature, monitor the
patient first
After dialysis = CHECK VITAL SIGNS AND WEIGHT!
Complications of Dialysis:
Disequilibrium
o Disequilibrium syndrome is caused by rapid removal of
solutes = it is LIFE-threatening

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 o S/S: decreased LOC, headache, N/V, restlessness, seizures
o Rx: decrease infusion, give anticonvulsants/barbiturates for
seizures, or CALL DOCTOR
o Circulatory devices used for dialysis
AV fistula = used short term
Complications: arterial steal syndrome (S/S: pallor, decrease pulse,
and pain on the affected arm with the fistula)
AV graft = preferred b/c theyre less likely to clot = use long-term
AVOID these things with AV graft: performing BP on the arm with a
graft, exercising, blood draws, inserting IV, lifting heavy objects
To assess patency, auscultate for bruit, and palpate for thrills**
o Facts about Renal
The kidneys often receive 20-25% of cardiac output when patient is
resting (1200-1500 ml of fluid per min
Dopamine is used to dilate renal tubules (increase blood flow to the
kidneys and increase blood pressure) = even in low levels it increases
blood flow to the kidneys by causing vasodilation
Osmotic vs. Hydrostatic pressure
Osmotic pressure is the pressure developed by solutes dissolved in
the water in the membrane (it is generated by the dissolved solutes:
salt, nutrients and protein)
Hydrostatic pressure is the pushing force (pushes fluid out the blood,
tissues, and capillaries)
Oncotic Pressure is the pulling force (pulls fluid into the blood,
tissues, and capillaries)
If colloidal osmotic pressure is higher than hydrostatic, more solutes
are being pulled into the capillary; if hydrostatic is higher = vice
versa
Since the kidneys make erythropoietin, when the kidneys have failed or
are damaged, erythropoietin needed to make RBC is scarce so a patient
may develop anemia
Urinary
o Types of incontinence = look up
Stress incontinence = occurs when patient voids in small increments
before they go to the restroom
Urge incontinence = occurs when the patient feels involuntary loss of
urine after urgency
Relax incontinence = occurs when patient voids at predictable times
when a certain bladder volume is achieved
Total incontinence = when the patent voids unpredictably and
continuously
o Bladder cancer
S/S: painless hematuria
REMEMBER: damage to bladder will be felt as shoulder pain
o Urinary Tract Infection (UTI)

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 Most common cause is E. Coli
Risk factors:
Immunosuppressed, short ureter (women), use of foley catheter,
kidney stones or urinary retention, people with constipation, people
with diabetes or HIV, menopause
S/S:
Upper UTI: frequency, fever, chills, flank pain
Lower UTI: hematuria, dysuria, cloudy urine
Rx:
Antimicrobial/Antibiotic therapy
Nurse Management:
Teach patient preventative measures (wipe front to back, empty
bladder and bowel regularly, drink fluids 2-3L daily)
Avoid caffeine, alcohol, citrus juices, chocolate, and spicy food
Apply heat to suprapubic area or lower back pain
Encourage drinking cranberry juice
o Cystitis
Inflammation of the bladder NOT caused by infection
Nurse management:
Encourage patient to have sitz baths
Avoid spicy foods, alcohol, and caffeine
o Urinary diversion
Incontinent diversion
It is the creation of a stoma = it requires a colostomy bag
Ex:
Continent diversion
It is an ileal duct reservoir that does NOT require any external bag=
patient will need to self-catherize self
Ex: kock pouch, Indiana pouch
o Procedures:
Urinalysis
Obtain urinalysis from a catheter using a syringe (wipe the port,
aspirate the urine, close port and wipe again)
Cystoscopy
After a cystoscopy, expect pink-stained urine the first 2 days
Normal urine osmolarity = 300-800 in 24 hours
If below 300 = urine is dilute = due to fluid overload causing solutes
to become dilute = hyponatremia
If above 800 = urine is concentrated = due to fluid deficit which is not
enough to dilute solutes = hypernatremia
Endocrine
o Diabetes
Hypoglycemia = not enough glucose
S/S: cold, clammy, diaphoresis, fatigue, irritability, tremors,
confusion, N/V, blurred vision, nervousness

64
 Hyperglycemia = too much glucose
S/S: 3 Ps (polyuria, polydipsia, polyphagia) fruity breath,
agitation, weight loss (anorexia), ketones in urine, confusion,
The patient will be at risk for deficient fluid volume because
with the high levels of glucose, the kidneys will be forced to
excrete the glucose releasing high levels of fluids so causing
electrolyte imbalance
Type 1 Diabetes complication = DKA;
DKA = blood sugar > 300 (ketone formation = fat metabolism)
Patient will need to be given continuous infusion of regular insulin
with normal saline to prevent dehydration
After the blood glucose goes down to 250300, the nurse can start
infusing IV fluids with 5% dextrose
Type 2 Diabetes complication HHNK
HHNK = blood sugar > 600 ==> you should anticipate that regular
insulin should be administered via IV route (also give potassium
while infusing insulin because the insulin causes potassium come out
cells and decreased potassium concentration)
Diagnosis
Oral glucose tolerance test
o When the patient is told to fast from midnight till the test (the
patient will have to eat 15g of carbs then tested later)
o Results must be
o Teach patient o avoid coffee, tea, and alcohol 12 hours before the
test is conducted
Hemoglobin A1C
o < 7 means that patient has be compliant with medication
Treatment for diabetes
Type 1: use insulin
Type 2: oral hypoglycemic or insulin
o These drugs are used to facilitate use of blood sugar in patients
body
o Do not give oral hypoglycemic to patients with chronic kidney,
liver, or lung disease
o Inserting insulin at sites of lipodystrophy can affect absorption of
insulin and cause hypo-hyperglycemia
o If patient vomits while you give insulin = INFORM DOCTOR*
Nurse management:
Diet
o DASH diet = a balanced diet with a portion of fruits and
vegetables and diet drinks
o DIABETICS SHOULD AVOID USING BETA BLOCKER
Exercising
o Prior to exercise, check blood glucose
o AVOID exercising when glucose peaks in

65
 o Have a snack before exercising to prevent hypoglycemia
Grooming
o When cutting toes, cut toe nails straight across
o Apply lotion on feet but avoid applying in between toes
o Wear snug loose-fitted shoes at all time (no bare-foot)
o Never soak feet in water
REMEMBER:
It is better to treat hypoglycemia than hyperglycemia
A diabetic patient need to check blood sugar before each meal
Rotate insulin injection site in the same area just different spot (right
arm = use all upper spots of right arm)
Teach diabetic patient to eat meals around the same time every
day to maintain adequate control of blood sugar
NEVER GIVE A DIABETIC A BETA BLOCKER B/C IT MASKS S/S OF
HYPOGLYCEMIA IS IF WERE TO OCCUR
o SIADH
Syndrome of Inappropriate Diuretic Hormone = too much ADH (water
intoxication) = fluid overload
S/S: hyponatremia, high urine osmolarity, high urine specific
gravity (why? Because they do not have enough urine in bladder to
be excreted so the urine in bladder becomes concentrated)
Rx:
o Fluid restriction; may need diuretics to excrete the fluids
o Diabetes Insipidus
Diabetes Insipidus = not enough ADH (water) = fluid retention
S/S: polyuria, polydipsia (excessive thirst), low urine specific
gravity (1.010), and low urine osmolarity (< 50-200)
o Cushings Syndrome
Too much ACTH (pituitary gland secretes too much cortisol)
S/S:
Weight gain, moon-face, buffalo hump, purple straie on abdomen,
truncal obesity, hypernatremia hypokalemia, hyperglycemia,
elevated WBC, hypocalcemia
Dx: ACTH test (done in the morning at 5 a.m.)
Rx:
Adrenalectomy
o After adrenalectomy, monitor patient for S/S of adrenal
insufficiency (fever, hypotension, mental status changes)
o Patient will be at risk for hypovolemia
o Will need to give the person cortisol
o Addisons Disease (Adrenal Insufficiency)
Not enough ACTH
S/S:
Hyponatremia, Hyperkalemia, hypercalcemia, hypoglycemia
Treatment:

66
 Life-long medication of cortisol
Teach patient not to stop using drug abruptly, monitor for infection
(because cortisol causes immunosuppression), monitor glucose
(patient is at risk for hypoglycemia), patient may need an increased
dose during stress or illness
Complications:
Addisonian crisis = life-threatening
o S/S: weakness, SEVERE back or leg pain
o Hypothyroidism
Not enough thyroid hormone
S/S:
Cold-intolerance, weight gain, constipation, dry coarse hair, dry skin,
bradycardia, bradypnea
Complications:
Myxedema Coma
o Hyperthyroidism
Too much thyroid hormone
S/S:
Heat-intolerance, sweating, weight loss, diarrhea, fine-thin hair,
bulging eye (exophthalmoses), tachycardia, tachypnea
Complications:
Graves Disease (exophthalmoses)
o For exophthalmoses, keep the eyes lubricated, sit patient with
head of bed elevated for easy drainage)
Thyroid storm (Thyrotoxicosis)
o Life-threatening ==> may develop causing: fever (> 106F),
tachycardia, mental status changes (coma), restlessness, and
hypertension
Treatment:
PTU = monitor patient for side effect: hypotension after admin
Thyroidectomy
o Pre-op thyroidectomy
Patient will need to drink radioactive iodine (it is not harmful
to patient) to make sure that they will have enough iodine
after surgery
o Post-op thyroidectomy
Monitor patient for hypocalcemia (numbness or tingling,
tetany); keep calcium gluconate & trach kit at bedside ==> if
hypocalcemia, bag the patient first before inserting trach
Monitor for STRIDOR = insert trach for stridor
Measure neck circumference to ensure that there is no
edema that can affect breathing
Hoarseness right after thyroidectomy is normal
Teach patient how to support neck when coughing or
changing position

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 Avoid tension on neck or straining
o Pheochromocytoma
Tumor of the adrenal medulla that secretes catecholamines which
excretes NE and Epinephrine that causes the increase in vital signs
S/S: severe hypertension, headache, tachycardia, increased CO
Dx: normal levels are < 14; if > 20 it is HIGH than normal
Diet: avoid fatty foods b/c they can precipitate hypertensive crisis
Rx: demeclocycline (chemo drug)
o Hypophysectomy (removal of part of adrenal gland)
Adrenal gland is composed of 3 parts
Adrenal medulla
o Stimulates hypothalamus to secrete NE and Epinephrine
Adrenal cortex
o Mineralocorticoids = responsible for aldosterone secretion
o Glucocorticoids = responsible for aldosterone and cortisol
o Androgen = responsible for sex cells
Post-op Hypophysectomy
After surgery, patient will not be able to brush teeth
The patient is at risk for DI because the route that they go through
surgery takes place in the head (transphenoidal bone)
o Hyperparathyroidism
Hyperparathyroidism (too much calcium = sedation = flaccidity)
When the person has excessive amount of calcium in the body
S/S: polyuria (because your kidneys are trying to excrete all the excess
calcium in the blood stream), joint pain (calcium loss from bone causes
demineralization of the bones causing joint pain or fracture),
Rx:
Drugs: give calcitonin (calcitonin is used to put the calcium back into
the bones) or oral phosphate (because it binds to calcium to balance
it out)
Aluminum phosphate = type of phosphate drug that helps reduce
phosphate in the blood ( if too much, it can cause aluminum
intoxication)
Surgery: parathyroidectomy (watch for stridor; maintain trach kit at
bedside and calcium gluconate)
Exercise or walk (also helps with facilitation of putting calcium back
into the bone
Increase fluids to stimulate kidney to excrete excess calcium
o Hypoparathyroidism
Hypoparathyroidism (not enough calcium = no sedation = rigidity)
Dx: trousseau (look up) and chevostek (numbness and tingling of cheek
in front on ear)
S/S: tetany, numbness and tingling
Rx: give calcium gluconate
o Hepatitis

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 Hepatitis is the inflammation of the liver (can be viral or non-viral
(caused by drugs (NSAIDs), alcohol, or immune disease)
Types:
Hepatitis A:
o Hepatitis A is transmitted fecal-oral route
o Often transmitted by not washing hands when preparing food, sharing
foods within family members (eating out someone else),
contaminated foods and drinking water, and poor sanitary conditions
o Lab test:
Patient will have elevated AST/ALT
You will see IgM in acute infection (IgG in past infection)
o Rx: give immunoglobulin to infected patient and all the patients
family members to prevent spear of the disease
Hepatitis B:
o Hepatitis B is transmitted perinatally (infected mothers), breast
milk, accidental needle stick, and exposure to blood, semen,
vaginal secretions and saliva
o Lab test:
Patient will have elevated AST/ALT
You will see HBsAG surface antigen in active infection (anti-
HB if patient responds to vaccine)
o Rx: give immunoglobulin for prevention; if infected, give Hepatitis
B Immunoglobulin (HBIG shot) to promote active immunity
Hepatitis C: transmitted through IV drug use
o Lab test:
Patient will have elevated AST/ALT
You will see Anti-HCV is patient has been infected
Patient will need genotyping to figure out what kind of
treatment will be done
o Rx: no preventative method; give interferon and ribavirin for Rx
o Pancreatitis
Pancreas is responsible for production of insulin and digestive enzymes
Pancreatitis occurs when there is inflammation of the pancreas that
causes severe pain and is very life-threatening because pancreatic cells
may begin to eat through pancreas and other organs around it
Causes: alcohol (teach patient to abstain from alcohol)
S/S: severe pain in LUQ (mid-epigastric pain that radiates to the
back), , increased blood sugar, N/V, abdominal distention,
hypotension
Dx: serum amylase > 200 (normal is 0-80), serum amylase > 180
increased serum lipase (normal 100-170), calcium <8.5, increased
glucose (pancreas is messed up so it cannot make insulin to lower BS)
Rx:
In acute stages
o Patient will be NPO (strictly enforced)

69
 o NG tube will be inserted to suction (because you want stomach
empty and dry to prevent pancreas from eating itself)
o Bed-rest (because bed-rest decreases stomach secretions)
o Control pain (give Demerol) => NO MORPHINE OR CODEINE
o Give steroids (decrease inflammation), Anticholinergics,
(decrease secretions), Protonix/PPI/Antacids (decrease acid),
Insulin (decrease BS)
In chronic pancreatitis
o Add digestive enzymes to food (Viokase); sprinkle in food; patient
will have formed stools in Viokase is working
o Cirrhosis
Cirrhosis occurs when liver cells are destroyed and replaced with
connective scar tissue which alters circulation within liver
Causes: alcohol, hepatitis
S/S: firm nodular liver that is palpable (normally the liver is not
palpable), abdominal pain, chronic dyspepsia (indigestion), ascites,
splenomegaly, decreased albumin, increased SGOT/SGPT, anemia,
portal hypertension (s/s: jugular vein distension, crackles, bounding
pulse), weight loss, spider angiomas, endocrine problems
Rx:
Abstinence from alcohol (to prevent more damage)
Antacids
Banana bag (thiamine, vitamin B12, folic acid)
Nurse management:
Measure abdominal girth (if patient has ascites)
Prevent bleeding => no intramuscular injections or aspirin
AVOID NARCOTICS (all drugs used should be decreased doses)
Restrict sodium (prevents ascites and additional fluid retention)
Diet: decrease protein (to prevent build up of ammonia; normally, liver
breaks down protein which releases ammonia; causes encephalopathy)
o Ascites
Ascites is when there is accumulation of fluid in the abdominal cavity
Causes: decrease colloidal pressure, hyperaldosteronism (increase
retention of sodium and water), increased hepatic flow
Rx: diuretics, decreased sodium intake, Paracentesis (the insertion of a
needle to relieve fluids from the abdominal cavity; monitor BP)
o Esophageal varices
Esophageal varices are enlarged veins that can easily bleed in the
esophagus and occlude the airway
THE MAIN GOAL IS TO AVOID BLEEDING AND HEMORRHAGE
Commonly occurs in patients with cirrhosis or alcoholic patients
PRIORITY ==> MONITOR PATIENT AIRWAY FOR ASPIRATION
Rx:
When bleeding does occur, stabilize the patient and ASSESS AIRWAY
Start IV therapy with fluids or blood products

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 Give drugs to stop bleeding: Vasopressin, Sandostatin, Neomycin
(decrease ammonia), Vitamin K, Beta blocker, H2 receptor/PPI,
and Nitroglycerin
Insert Sengstaken Blakemore tube (used to hold pressure on varices
and stop bleeding; if the balloon is deflated, watch for hematemesis)
Enema (to flush out any blood)
If drugs do not work to stop bleeding, the patient may need a non-
surgical or surgical shunt
o Hepatic Encephalopathy (Hepatic Coma)
Hepatic encephalopathy occurs due to excess build up of ammonia in the
blood (caused by protein breakdown); the excess causes chemical build
up in the blood which travels to brain and cause neurological problems
S/S: decreased LOC, asterixis (flapping of the hands or tremors;
usually signals brain damage), fetor (ammonia breath)
Rx:
Neomycin/Lactulose (these liver drugs decreases ammonia levels)
Cleansing enema
Decreased protein in diet (monitor ammonia levels)
Neurological
o Stroke
Right-Side stroke = affects left side of body (paralysis on left side)
Left-Side stroke = affects right side of body (paralysis on right side)
o Hemiparesis
Musculoskeletal
o Rheumatoid Arthritis
RA is an autoimmune disorder that causes inflammation of the lining of
the joints (autoimmune = when the body attacks it immune system)
RA occurs bilaterally
RA causes stiffness in the morning (pain decrease w/ movement)
S/S: heat, redness, swelling, ulnar drifts (fingers drift to ulnar sides),
subcutaneous nodules (raised, non-tender nodules), swan-neck or
boutonniere deformity on fingers, crepitus (audible/palpable
crunching or grating with movement)
Rx:
Give NSAIDS (helps with pain)
Give steroids (used to decrease inflammation)
Give immunosuppressants (Imuran, Sandimmune, Gangref)
o Osteoarthritis
Osteoarthritis in a non-inflammatory joint disease that causes
deterioration of cartilages on joint surfaces
OA can occur asymmetrically (can involve hands, knees, hips)
OA causes pain that worsens later in day (especially with motion)
Pain lasts for about 30 minutes
S/S: hard, non-tender heberden (distal phalanges) and bouchard
(proximal phalanges) nodes

71
 Rx: give pain medication
o Carpal tunnel syndrome
Occurs due to compression of the median nerve
Dx:
Phalen test (hold hands back while flexing wrist at 90 degrees for 60
seconds) = pain/tingling = positive
Tinel signs (percuss the median nerve) = pain/tingling = positive
o Casts
Allow casts to air dry (do not use blow dryer to dry cast)
If the cast is itching on the inside, use a blow dryer on cool settings to
soothe the itch (never place objects in the cast because it can break the
skin and cause infection)
If the patient loses pulses = need a bivalve
Upon cast removal, provide reassurance that blade will not break
through the skin; and it will be yellowish after cast is removed and will
fade off as time goes away
o Compartment syndrome
Compartment syndrome is a life-threatening condition where there is
excessive pressure in the area that causes lack of blood flow and can lead
to muscle and nerve damage
5 Ps
Pulselessness, Pallor, Pain, Paresthesia (cant feel),
Paralysis (cant move)

o Osteoporosis
Osteoporosis is the chronic degeneration of bone tissue
Risk factors: white and Asian decent
Prevention:
Diet high in calcium (whole milk, spinach, skim milk, yogurt) and
vitamin D (sunlight exposure or some milk that is fortified)
Ways to reduce the risk of developing osteoporosis is = engage in
weight bearing exercises
o Parkinsons Disease
The patient will have muscle weakness, muscle rigidity, and foot
contractures
S/S: tremors, rigidity, bradykinesia
Complications: dysphagia, dyskinesia, and neurological problems
Rx: Dopamine (levodopa)
Nurse management:
Add thicken to food when feeding especially with dysphagia
Cut food into small bites (avoid foods that require a lot chewing)
Provide small frequent meals per day
Be patient with the client and allow enough time, exercise muscle to
prevent stiffness and build strength

72
 Encourage deep breaths before speaking
Use elevated toilet seats, watch for risk for falls, keep room lit
o Multiple sclerosis
MS is a chronic degenerative disorder of the myelin sheaths of brain and
the spinal cord (it is autoimmune)
Risk factors: women and people age 15-50
S/S: weakness, paralysis of the limb, blurred vision, vertigo, tinnitus,
numbness and tingling, paresthesia, decreased hearing, nystagmus,
ataxia, dysphagia, and SEVERE FATIGUE
Rx: symptoms relieve and management ==> AVOID INFECTION
o Myasthenia gravis
Myasthenia gravis is an autoimmune disease characterized by weakness
of the skeletal muscles (strength is restored with rest)
Dx: Tensilon test (positive tensilon test confirms that person has the
disease because with medication, the person will have more energy)
Complications: myasthenic crisis triggered by (infection, stress)
Nurse management: watch the muscle areas for breathing and
swallowing for weakness
o Rx: thyroidectomy
Lymphatic system
o Systematic lupus
The patient with lupus will have decreased CBC count ==> why? Because
since lupus is autoimmune, the immune system attacks its own cells
decreasing all cell types (RBC, WBC, and platelets)
Eyes
o Cataract
Cataract is the abnormal clouding of the eye
It is the leading cause of blindness in the U.S.
Risk factors: UV light exposure, maternal rubella, and corticosteroids
S/S: abnormal color perception and glare (light scattering; worse at
night)
Rx: the only cure is surgical removal
Post-op:
After surgery, patient needs antibiotic eye drops, NSAID eye drops,
and corticosteroids eye drops
The patient should feel no pain ==> SHARP PAIN = PROBLEM
Eye patch may be worn at night and removed post-op morning
o Glaucoma
Glaucoma is characterized by increased intraocular pressure
It is the second leading cause of blindness in African Americans
Types of glaucoma:
Primary open-angled glaucoma = patient has no eye pain
o Rx: B-adrenergic blockers, mitotics, mannitol are all used to
decrease eye pressure and fluid build up
Primary-closed angled glaucoma = patient reports eye pain

73
 o Rx: surgery and mannitol
Secondary glaucoma
o Retinal Detachment
Retinal detachment is the separation of the sensory retina and the
pigmented epithelium (caused by accumulation of fluid in both layers)
S/S: light flashes, floaters, cobweb/hairnet, painless peripheral or
central vision like curtain across the field of vision
Dx: visual acuity
Rx: surgery (one eye will be patched)
o Menieres disease
Has to do with hearing?
Integumentary
o Eczema (atopic dermatitis)
Usually triggered by allergens
Will need to keep skin moist with skin treatment
Avoid oils, creams, detergent, perfumes, etc
o Pruritis
Pruritis is excessive itching of the skin
Nurse management: encourage oatmeal bath to help reduce skin itching
o Wounds
Stages of Ulcer
Stage 1 = involves epidermis (erythema, swelling)
Stage 2 = involves epidermis and dermis = blisters, skin may be
broken (redness around the area)
Stage 3 = involves epidermis, dermis, subcutaneous fat
Stage 4 = involves epidermis, dermis, subcutaneous, and bone
How to perform dressing change
Dry
Wet-to-Dry
Wound Drains (surgical inserted drains)
Penrose drain (drain that has a flexible rubber tube)
o Watch for infection**
JP Drain (active drain) = small bulb that is compressed
Hemovac = larger drain that looks square
Hematology
o Anemia
S/S: SOB (due to decreased ability of the blood to carry oxygen to the
tissues to meet metabolic demands), tachycardia
o Iron-Deficiency Anemia
S/S: pallor, fatigue, low iron levels, and pica
Causes: blood loss, inadequate diet, malnutrition, less intake iron
Rx: iron supplements (take with vitamin C); frozen RBC if too low
o Hemophilia
Occurs when the person lacks factor 8 for clotting factors
S/S: prolonged bleeding with any injury

74
 Rx: apply pressure, will need to call ambulance to get patient factor 8
replacement, may need frozen packed RBC if platelets too low; use soft
bristle toothbrush to prevent bleeding, wear medic-alert bracelet
o Sickle-cell anemia
S/S: exercise intolerance, fatigue, pallor, sickling pain
Rx: pain medication, blood transfusion
Complications: sickle cell crisis which occurs when the RBC clump up
together in one area causing sickling pain (triggered by infection)
Nurse management:
Give pain medication, prevent infections or treat them ASAP, increase
fluids, give oxygen, patient may need transfusion
o Pernicious anemia
Lack of vitamin B12
o Vitamin B12 Deficiency (Cobalamin deficiency)
Lack of intrinsic factor to digest cobalamin
Dx: Shilling test
Rx: need B12 for life
Blood and lines to draw blood
o Lines
ART line blood draw = hold pressure for 5 minutes
Femoral ART line blood draw = hold pressure for 10 minutes
o Administration of blood
Check compatibility first before dispensing blood from blood bank
Need 2 nurses to verify blood received
Once blood arrives, it must be hanged using y-tubing with normal saline
for piggy; blood must be given within 30 mins arrival to the patients
room; must be administer 1-4 hours
Monitor patient or adverse effect while receiving the blood and stay with
patient the whole time; including 15 minutes after admin
IV tubing
o Hypotonic solution
o Isotonic solution
o Hypertonic solution
Peripheral vs. Central line
o Peripheral IV
Peripheral IV are inserted
o Central line
Central line IV are usually inserted surgically (will need consent form)
Sites used: jugular, subclavian, and femoral
Dressing changes are done every 72 hours (sterile technique) = the nurse will
need mask, sterile gloves, and 10ml syringe for flushing
After you discontinue the IV line, make sure you clamp the access line to
prevent air embolus from getting in; use sterile caps to close ports
Fire safety

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 o R = remove all patients, visitors, and staff safely
o A = activate emergency response
o C = confine the disaster as much as possible
o E = evaluate the appropriate method of handling the disaster
o To use the fire extinguisher
P = pull the pin
A = aim at the base of the fire
S = squeeze the handle
S = spray in sweeping motion
Prioritization
o WHO to ASSESS FIRST**
ABC (Airway, Breathing, Circulation)
LABS (abnormal labs that deal with lungs or heart)
Lungs ==> if ABGs off, are lung sounds diminished or absent
o Ex: patient with sepsis after lung procedure
o Ex: patient with ABG that shows respiratory acidosis
Heart
o Ex: patient with high troponin, chest pain, or abdominal pain
SECOND PRIORITY ==> if no ABC problems then look for these
SAFETY ==> altered level of consciousness (at risk for falls)
NEW DX OR INEFCTION (new Dx, conditions that got worse)
o New post-op patient should be seen first, Asthma, or Neutropenic
patients (low WBC patient; risk for infection)
o Even if patient has been on floor for days ==> any change?
THIRD PRIORITY ==> after 1st and 2nd priority is taken care of
Patients in PAIN
o Any type of pain that is in the abdominal area or
Elimination problems, Skin problems, Nutrition problems
Patient teaching and Psychosocial ==> LAST prioritization
Delegation
o Patients that GOES TO WHO ==> RN, LVN, UAP/ULP
RN
Any patient that EATs (needs assessment, teaching, and evaluation) and
interpretation
Restraining patients or Triage
Newly admitted patients or patient with new/acute problems
First day post-op patients (ambulate for first time post-op, eating first
time post-op)
LVN
They get the STABLE patients
They get the patients that need routine care (giving medications, inserting
an NG tube, foley catheter, urine collection, sterile dressing changes, tube
feeding, and FOLLOW-UP teaching)
THEY CANNOT START IV, HANGING IV FLUIDS, GIVING
BLOOD

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 UAP/ULP
They get the MOST STABLE patients
They do ADLs such as bathing the patient, dressing the patient, feeding,
PASSIVE ROM, and can assist them
They also help transport STABLE patients
Floating nurses
Give the floating nurses the most stable patients**
Give them patients that they have training on caring for (ex: assigning an
L&D nurse to a newborn) ==> also, if unsure that they can perform the
task, ask them to show you their checklist or have them demonstrate the
car to you to ensure they can perform task
Room Assignments
Place patients with like patients (ex: patient with staph infection ==> they
will l need isolation so place them with another patient that have an
infection or is in isolation)
DO NOT place a patient with an infection in a room with patient with
broken leg or wounds or sores or immunosuppressed
A depressed patient should be in the room with another depressed patient
==> NEVER place them in a room with a manic patient
o FACTS
Usually when the charged nurse is delegating tasks, delegate patients to the
nurse that has experience in that field. Ex: if a nurse who works OB is to be
delegated a patient, the charged nurse can delegate the RN to a patient with a
hysterectomy or a patient who has had an abortion
Delegate another nurse patients that are STABLE!
When performing care nurse, the same nurse must finish the care or
assessment. For Example, if a patient falls, the nurse that witnessed the fall
should provide care t the patient; do not re-delegate to new nurse
LVNs can only take care of a stable patient, no assessment (only RNs can
do admission and discharge assessment), no teaching, no action requiring
follow up assessment, no readings of EKG strips or interpretation of pressure
waveforms, and no starting IVs
Nurse techs cannot do anything invasive (they cannot do finger stick glucose
or anything else invasive)
Screening
o Prostate cancer = do every year for age 50
Screen at age 45 if African American of have a family history
Screen at age 50 if not at risk
o Testicular cancer screening (TSE)
Boys should start screening from age 9-35
Teach to conduct screening during or after a warm shower because that is
when the scrotum is most relaxed
They can conduct by using their fingers to roll on the scrotum
o Breast cancer (BSE)
Done monthly 7-12 days after

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 If menopause or hysterectomy, encourage patient to pick a date out the
calendar to perform exam
Usually done right after a warm shower (you can lay or sit)
o Mammograms
Recommended for age 40 and up (age 35 for family history)
Teach patient that before a mammogram, they should not wear lotions,
deodorants, powder, or perfumes
o Clinical breast exam
Usually can be done every 3 years for women > 40
o Colorectal cancer
Colonoscopy can be screened at age 50 for both men and women (q10 years)
o Paps smear
Start screening 3 years after sexual contact or screen at age 21 if no sex
o Cholesterol
Normal total cholesterol is < 200
Cancer
o Seven warning signs of cancer = CAUTION
C = change in bowel or bladder habits
A = a sore that does not heal
U = unusual bleeding or discharge from body opening
T = thickening or lump in breast or elsewhere
I = indigestion or difficulty swallowing
O = obvious change in mole or wart
N = nagging cough or hoarseness
o Types of cancer:
Laryngeal cancer (head and neck cancer)
S/S:
o Early signs: hoarseness (1st sign), painless growth in mouth, otalgia,
(ear pain), lump feeling in throat
o Late signs: pain, dysphagia, airway obstruction, leukoplakia (white
patches), erythroplakia (red patches)
Rx:
o Surgery
Cordectomy (removeal of one vocal cord)
Hemilaryngectomy (patient will need temp trach)
Suproglottic laryngectomy (removal of voicebox)
Total laryngectomy (removal of larynx)
Teaching point regarding trach:
o Patient cannot go swimming with this
o NEVER COVER TRACH AREA with anything
o Radiation
o Chemotherapy
Testicular Cancer
S/S: back pain, painless scrotum pain, and heaviness of scrotum
Leukemia
Leukemia is when there is accumulation of WBC in bone marrow

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 Dx: bone marrow aspiration
Types:
o ALL = common in children
o AML = adults
o CML =
o CLL = s/s: lymphadenopathy (enlarged lymph nodes)
Multiple myeloma
Myeloma occurs when calcium deposits leave the bone and is in the
blood concentration (patient will have hypercalcemia)
PRIORITY IS TO MONITOR CALCIUM LEVELS
Bladder Cancer
Bladder cancer is more common in men than females
S/S: painless hematuria, frequency and urgency,
Dx: Biopsy (definitive), IVP, Ultrasound
Rx:
o Surgery
o Radiation
o Chemotherapy
o Depending on severity, patient may get urinary diversion
Continent urinary diversion = indiana pouch
Patient will have reservoir system for urine storage = they
will need to self-catherize themselves every 4-6 hours
Incontinent urinary diversion = urostomy
Patient will have a stoma
Stoma should be red and moist (slight edema)
Purple stoma (lack or circulation); Gray or Black stoma
(ischemia or necrosis)
Nurse management:
Maintain meticulous skin care
Increase fluid intake
MUCUS IS URINE IS NORMAL
Prostate cancer
It occurs when cancer forms in the tissues of prostate
Screening:
o Screen at age 50 (age 45 for A.A. or family history)
S/S:
o Frequency, dribbling, difficulty urinating, nocturia, hematuria,
incontinence, and pain
Rx:
o Drug Therapy
Patient will need androgen cells for maintenance and growth
of prostate cells (if the cells are cancerous, androgen should
be avoided ==> this is why you would give them hormone
therapy to limit the amount of androgen so that the prostate

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 cells will not regenerate; this will cause regression of the
disease)
o Radiation therapy
o Radical Prostatectomy
Nurse management:
o Teach kegel exercise to help control incontinence
o Teach to avoid sexual intercourse or driving for 2-3 months for
bladder to heal
o Cancer treatments
Surgery
Debulking = controls cancer by reducing the size of tumor
Chemotherapy
Side effects of chemotherapy: anorexia, stomatitis (if a patient
develops, encourage patient to avoid alcohol-based mouthwash,
brush teeth with soft bristle brush, avoid spicy foods, eat neutral
foods at normal temperature; use weak salt water to rinse mouth),
immunosuppression
Radiation
Internal
o If it comes out, put on gloves, pick it up and place in container, call
for help => NEVER leave with it
o Patients with implants should be placed on bed rest to prevent
movement of the radiation source; body should be aligned, avoid
place patient on side
External
o Stand about 6 feet away from client
o Nurse and visitors can be with patient only 30 minutes per
day to limit exposure
o If not necessary to go in, nurse can stand by the patients door to
assist patient
o Pregnant women or children < 16 years of age are not allowed to
be in the room with the radiation patient
Side effects of radiation:
o General signs and symptoms of radiation syndrome include
nausea, vomiting, anorexia, and malaise
o Often localized to area where radiation is being applied
o Radiation for cervical cancer may cause nausea and foul
smelling odor and discharge may occur from destruction of
cancerous cells
Drugs
Hormone therapy may be prescribed (it is used to limit the amount of
circulating androgen)
Allopurinol = this drug can be given to decrease uric acid
production in the urine
o Cancer diet

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 High protein, high calorie foods
o Nurse management for Cancer:
Maintain hydration ==> increase fluids (especially with multiple
myeloma patients to dilute excessive calcium)
Monitor fluid and electrolytes
Provide analgesics for pain
HIV
o HIV is a retroviral disease that can kill an individual (RNA to DNA)
o HIS is transmitted through:
Sexual contact, contact with blood or blood products, or perinatal
o AIDS is diagnosed when CD4 T cell count goes < 200
Surgery
o Preoperative instructions
Get informed consent
Ensure that patient does nto have any more questions
Obtain baseline vital signs
Teach about post-op requirements (turn, cough, deep breath)
o Postoperative instructions
Ensure that patient turns q2h, cough and deep breath (10x q hour)
If the patient has a chest drain, the first few hours patient should have a
bloody drainage
If post-op wound, the drainage should be serosanguinous
o Criteria for discharge
Patient must be awake
All vital signs STABLE (even if temperature is off = NO!)
No excessive bleed or drainage
Patient must have O2 of 90% or greater
Report must be given
Triage = USED TO SAVE AS MANY PEOPLE AS YOU CAN**
o Triage is the sorting out of patients according to their emergency
o It is often used to prioritize who gets care first in emergency situation (car
crash, war zone, natural disaster (earthquake, hurricane)
o Triage works by using color coding such as:
Red = 1st priority = needs immediate attention
It includes: critical life-threatening injury
These people are usually transported first when help arrives
Yellow = 2nd priority = moderate = serious injuries needing help
It includes: semi-critical injuries
These people may be transported first because they have a higher
chance of survival or recovery
Green = 3rd priority = delayed = less serious or minor injuries
It includes: broken bones, minor cuts, wounds, or pain
These people will eventually need help but can wait
White = not injured
Black = deceases or mortally wounded

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 These people are not necessarily dead but they have a less chance of
surviving
o In an emergency setting or accident scene, triage works by color
coding: green, red, yellow, black
Precaution
o Standard precaution
Used on all patients and contact with bodily fluids, blood, or mucus
o Airborne precaution
Measles
Tuberculosis
Varicella
o Droplet precaution
Diphtheria (pharyngeal)
Pertussis
Plague
Streptococcal pharyngitis, Pneumonia, Scarlet fever
Influenza
Mumps/Rubella
o Contact precaution
Clostridium difficile,
RSV
Skin infections (herpes simplex, diphtheria, impetigo, cellulitis,
pediculosis, scabies, staphylococcus infections, conjunctivitis, ebola)

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