NCLEX REVIEW GAPUZ REVIEW CENTER

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

DAY 1 (31 JANUARY 05)

STEPS IN PASSING

Have a Right Attitude

THINK POSITIVELY have a Fresh Start
KNOW what YOU WANT and HOW TO GET IT
OVERVIEW OF ESSENTIAL CONCEPT
TRY OUT
Focus assessment
7 habits of SUCCESSFUL EXAMINEE

MOSBY
growth and development
LIPPINCOTT care of the Elderly and Communicable Disease
DIGOXIN monitor the creatinine the TV DOESNT look good to me
(DIGOXIN TOXICITY nausea/vomiting, abdl cramps)
Olive = butter
CK
normalize 1 3 days after MI
LDH - 10 14 days
ATRIAL FLUTTER SAW TOOTH
PROCESS OF ELIMINATION

consider MASLOWs H of NEEDS

consider the COMPLICATION whether ACUTE
CHRONIC
ABCs
SAFETY FIRST
NSG PROCESS

ALWAYS prioritize

MMR VACCINE only vaccine for HIV pt.

Pt on HEPARIN APTT (N 30-40sec), therefore if INCREASE bleeding
POISON - nursing action in order :
#1 CALL poison control center
# 2 MINIMIZE EXPOSURE of pt to poison pull him/her away from the poison
# 3 IDENTIFY the poison
GENTAMYCIN

s/e tinnitus, vertigo, ototoxicity, oliguria

LITHIUM CARBONATE

for ELDERLY : N level NOT more than 1.0meq/L

ADULT : N .5 1.2 meq/L

HEPA B diet : low fat, increase CHON

DOWN SYNDROME large tongue feeding problem poor sucking (infants)

SAFETY PRINCIPLE
1. when can a child USE ADULT SEAT BELT?
- if the infant is 40 lbs and 40 inches in height
seat belt location in car: BACK CENTER SEAT
2. TODDLER falls
3. SUPRATENTORIAL craniotomy semi fowlers position
INFRATENTORIAL flat in bed
4. SCATTER RUGS osteoporosis pts.
5. TRIAGE ; burns, open fx SHOCK
Things NOT TO BE DELEGATED by RN:
Assessment, Teachings, Evaluation
Pt 50y/o and

- mammogram once a year.

Pt with PKU LOW PHENYLALAMINE DIET (NOT phenyl FREE).

therefore LOW CHON
Pt with Rocky Mountain Fever exposure to dog ticks
Lymes Dses deer ticks
PSYCHE PATIENTS
1. remember to stick to unit rules/policy be consistent to pt.
2. encourage verbalization tel me how..
3. sound knowledge of cultural diversity
- seek help of interpreter
4. acknowledge pt feelings it seems.
this must be difficult..
5. emphatize with your patientss feelings
I understand how you feel..
CATARACT CAUSES aging and trauma
MRSA (methicillin resistant staphyliccocus aureus)
- USE GLOVES AND GOWN WHEN W/ PT

DAY 2 ( 01 February 05)

TUBES
1. GROSHONG CATHETER
HICKMAN
BROVIAC

- 2 lumen
- 3 lumen
- 1 lumen

ALL requires Central Venous Access

- sites: cephalic, brachial, basilica and superior vena cava
PURPOSE:

For TPN
Administration of Chemo Agents,
Blood Products, Antibiotics

COMPLICATION:Thrombosis and Bleeding

2. CHEST TUBES Water Sealed Drainage
Types: Anterior w/c drains AIR
Posterior - w/c drains FLUIDS
Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system
1 BOTTLE :

3 5cm of only (length of tube to be emerge)

2 BOTTLE :

First bottle drainage bottle (no tube emerge),

2nd bottle - long rod 3-5cm

3 bottle

FREQUENTLY USED

1st bottle drainage

2nd bottle water sealed
3rd bottle suction bottle control
COMPLICATIONS:

bubbling, breakage, blockage

Nsg ALERT:

NORMAL : BUBBLING is N in the 3rd bottle it indicates that suction is

ADEQUATE
(if no bubbling STOPS in the 3rd bottle, meaning inadequate suction)

ABNORMAL : if bubbling occurs at the 2nd bottle indicates LEAKAGE

action, check sealed at air tight container and the pt and bottle connection.

In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry of
air and or may use forcep to clamp tube temporarily.
If pt. ambulates, keep bottle LOWER than the patient.
ABSENCE of OSCILLATION at the 2nd Bottle indicates blockage
TOWARDS THE BOTTLE - When MILKING the tubings.
EMERGENCY EQUIPMETS AT BEDSIDE: xtra bottle,clamp, gauze

3. TRACHEOSTOMY TUBE
- to maintain patent airway for pt w/ neurological problems and
musculoskeletal disorders.

nursing care:
1. Suctioning 10-15seconds
- if (+) bradycardia, STOP
- if accidentally dislodge, insert obturator to keep it open
2. AVOID: water sports swimming
3. In changing ties insert new one first BEFORE REMOVING old tie.
4. Ribbon or ties @ side of the neck only to avoid pressure.
5. Before and After suctioning hyperoxygenate the patient.

4. PTCA

enlarge the passageway for bloodflow.

problem: spasms that lead to arrhythmia

C-STENT (cardiac-stent) alternative to PTCA

Maintains patency of bld vessels
Problem: dislodge
IABP (Intra Aortic Balloon Pump)
- for Cardiogenic Shock
problem: thrombus formation, infection and arrhythmia

5. PENROSE DRAIN
- wound drainage system
- doctors the one who removes this.
- remove gradually

6. NASO GASTRIC TUBE stomach and intestine (duodenum)

Types:
Levine Tube for stomach
- 1 lumen, for lavage (cleaning) and gavage (feeding)

Salem Sump for stomach

- 2 lumen (I for suctioning, I for lavage/gavage)
- if pt (infant) is having enteric coated meds, request for
change in form of meds

Miller Abbot for intestinal (w/ mercury b4 injection)

- 2 lumen (insert then inject the mercury)

Cantor for intestinal

- 1 lumen

Nursing Care for NGT:

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

Report the following:

If (-) or decrease drainage,

(+) nausea and vomiting
(+) abdml rigidity
Characteristic of Gastric Residual: more than 50 mo and coffee ground.
Before feeding check for placement.

7. GASTROSTOMY TUBE (GT)

PEG
both for NUTRITIONAL PURPOSES
GT incision (abdomen to stomach)
- for pt (+) lesion at esophagus
- nsg care : report s/s of infection, abdl cramps, n/v
- provide adequate skin care
PEG incision at skin
- long term therapy

8. T TUBE
- to drain excess bile until hearing occurs
- place drainage bag at the level of t-tube
(obstruction of t-tube there will be excess drainage)
500 ml N drainage in 24hrs, if report ASAP.

9. HEMOVAC
JACKSON-PRATTS (JP)

BOTH used as close wound drainage suction system

BOTH system function on the system of (-) pressure.

JP compress the container before attaching to the drainage.

WHEN TO EMPTY: when its usually 1/3 to full then RECORD the amount.

10. THREE-WAY FOLEY

absence of clot effective
Characteristic of drainage 2-3 days after surgery (bloody to pinkish) NO NEED TO
REPORT THIS
it is expected

11. SUPRAPUBIC CATHETER for genito urinary problem

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

3 lumen

MINESOTTA TUBE

4 lumen

SCISSORS important EQUIPMENT AT BEDSIDE FOR ALL TUBES.

HEMOSTAT important instrument that shld be @ bedside for water sealed
drainage.
Persistent bubbling at water drainage bottle for bottle #2 check if tubing is
properly sealed.
NGT IS REMOVED if patient exhibits return of bowel sounds.
BULB SYRINGE use to clean the nares of pt with NGT (child)
To facilitate removal of air at lungs purpose of water sealed chamber in 3 way
bottle system.

THERAPEUTIC DIET
GENERAL CONSIDERATION

Know the DIAGNOSIS of the patient

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

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

TRANSCULTURAL CONSIDERATION
CHINESE like cold desserts after surgery for optimum health
JEWS kosher diet (no meat and diary products at the same time)
EUROPEANS main meal is served at mid day followed by espresso
MUSLIM halal diet no pork
SDA strictly vegs diet (vit B6 and B12 deficiency)
MORMONS
words of wisdom (no caffeine, alcohol and once a month fasting)
the amount due for food is donated to the church

KEY POINTS FOR NURSES

Sodium (Na) source down the soil
Potassium (K) - source up the tree
Low Na Diet : AVOID processed foods, milk products and salty foods
KNOW the serving:

CHO
- 6-11 servings
CHON
- 2-3
FRUITS & Vegs - 3-4
FATS
- sparingly

MOST COMMON DIET

CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT)
- given to pt to relieve thirst, correct fld & electrolyte imbalance
- given also to pt post-op
ex: apple juice, gelatin (strawberry), popsicle, candy

RENAL DIET
-

for kidney disorder (renal failure, AGN, Nephrotic syndrome)

to maintain fld & e imbalance

LOW CHON avoid poultry products

LOW Na
- avoid processed foods, milk products, & salty foods
Low K
- avoid fruits (anything you see in a tree)

LOW FAT/CHOLESTEROL RESTRICTED DIET

- for liver disorder, cardiovascular and renal dses

ALLOWED: lean meat, fruits, vegs and fish
AVOID
: Sea foods, fried foods, preserved foods

(cheese cake and custard)

HIGH FIBER DIET

- to prevent constipation, hemorrhoids & diverticulitis
- vegs, fruits and grain products

SOFT DIET
-

PURINE RESTRICTED DIET

-

for peptic ulcer, inflammatory GI conditions

AVOID: chemically and mechanically irritating foods such as fried foods, fresh
and raw fruits & vegs (EXCEPT: avocado, banana & pinya) and spicy foods
with preservatives

HIGH PROTEIN, HIGH CARBO DIET

-

for cardiovascular dses, renal, fld & e imbalance

ALLOWED: fresh vegs
AVOID
: processed foods, milk products and salty foods

BLAND DIET
-

for gouty arthritis

increase fluid intake
AVOID: preserved foods, sea foods, alcohol,
organ meat (liver, gizzard)

NA RESTRICTED DIET
-

for inflammatory conditions: esophagitis, peptic ulcer gastritis

pureed foods/ blenderized foods
soup

for burns (about 5000 cal/day)

grain products and poultry to aid the healing tissues

ACID ASH DIET

-

to decrease the ph of the urine

indicated for pt w/ alkaline stone ex struvite
ex. 3 CS cranberry, cheese, & corn
3 PS - prunes, plums & pastries

ALKALINE ASH DIET

-

GLUTEN-FREE DIET
-

for PKU, until age 10 and adolescence only

AVOID : CHON rich foods (meat products luncheon meat)

FULL LIQUID DIET

-

ABGs

for celiac dses

ALLOWED : rice, corn, cereals, soy beans
AVOID (LIFETIME): barley, rye, oats, wheat

PHENYLALANINE DIET
-

to increase ph of the urine

indicated for acid stone ( uric acid stone, cystine stone)
ex. Milk

opaque
transitional diet from liquid
ex : cream soup, ice cream, milk, leche flan, pumpkin cake

ATERIAL BLOOD GASES

Ph
7.35 7.45
PCO2 - 35 35
HCO3 - 22 26 meq/L
Ph

Compensatory Mechanism

Uncompensated
abnormal
Partially compensated
abnormal
Fully Compensated normal

no change
increase or decrease
increase or decrease

Diarrhea metabolic acidosis

Vomiting metabolic alkalosis

PRIORITIZING of case:
Med.-Surg abc
Psyche
- safety first
Fire
- race
Triage
- pt evaluation system (prioritizing)

APGAR SCORING

0
Appearance
Pulse
Grimace
Activity
Respiratory

1
pallor

(-)
(-)
flaccid
(-)

acrocyanosis
<100
>100
grimace
vigorous
some flexion
irregular
lusty cry

all pink
flexion & extension

T.R.I.A.G.E -prioritizing
LEVEL 1 emergency

severe shock, cardiac arrest, cervical spine injury, airway compromise, altered
level of consciousness, multiple system trauma, eclampsia

LEVEL 2 urgent (stable)

can be delegated (fever, minor burns, lacerations, dizziness)

LEVEL 3

chronic/ minor illness (can be delegated) dental problems, routine medications

and chronic low back pain

TIPS ON PRIORITIZING
1. PT @ ER sleeping pills overdose;
2. pt bp 80/30 & mother died of CVA
1st priority : assess pt for addtl risk factor;
3. pt ask what procedure: Rn Action : notify the doctor
4. MI attack 1st action : report ASAP (esp. presence of vent. Fibrillation)
5. pt on NGT check patency of tube

DELEGATION
-

do not delegate Assessment, Teaching and Evaluation

do not delegate meds preparation, administration, documentation

CONCEPT OF DELEGATION

consider the competence of personnel

5 Rs in delegating (RIGHT task, person, circumstances, direction/communication supervision)
RN may delegate feeding client, routine vital sign (pt w/ no complications)
and hygiene care

MI ATTACK enzymes to increase IN ORDER - #1

#2
#3
#4

myoglobin
troponin
CK
LDH

RISK FOR INJURY menieres dses

INEFFECTIVE BREATHING PATTERN myasthenia gravis
ALTERED TISSUE PERFUSION pt w/ complete heart block
INEFFECTIVE AIRWAY CLEARANCE pt w/ kussmauls breathing
D

DAY 3 ( 02 February 05)

POSITIONING FOR SPECIFIC SURGICAL CONDITION

Positioning
a.
b.
c.

independent nsg function

know the purpose of the position
to prevent or promote soothing;
what to prevent or promote;
know your anatomy & physiology

Post Liver Biopsy

R side lying to prevent bleeding

(during the procedure L side lying).

Hiatal Hernia

upright to prevent reflux.

AMPUTATION
complication: hemorrhage (keep tourniquet @ bedside)
1st 24hr goal: to decrease edema elevate the stump at foot part w/
the use of pillow
AFTER 24hr goal : to prevent contracture deformity (keep leg extended)

APPENDICITIS
Unruptured : any position of comfort

Ruptured : semi to high fowlers position to prevent the upward

spread of infection
complication: peritonitis
Ruptured appendicitis indication: pain decreases or go away.
(pt say, I want to go home pain is gone)

BURNS
Position is FLAT or Modified Trendelenburg to prevent shock.

SHOCK occurs w/in 24-48hrs (immediate post burn phase).

Complication: infection

CAST, EXTREMITY
Elevate the Extremity to prevent edema (use rubber pillow)

Nsg care:
a.
b.
c.
d.
e.

capillary refill N 1-3 seconds only (complication: altered circulation)

note for s/s of infection (when there is musty odor inside the cast)
pruritus (inject air using bulb syringe)
blood stained mark and note (if increasing in diameter - report ASAP)
tingling sensation indicate nerve damage

CRANIOTOMY
Types:

a. Supratentorial C semi fowlers orlow fowlers position to prevent

accumulation of fluid at surgical site;
b. Infratentorial C - flat or supine. Purpose: same

FLAIL CHEST
(+) Traumatic Injury paradoxical chest movement areas of chest GOES IN
inspiration and OUT on Expiration

position: towards the affected side to stabilize the chest.

GASTRIC RESECTION
-

HIATAL HERNIA
-

to prevent dumping syndrome usually for 10 mos only NOT LIFETIME

disorder (post gastrectomy)
position : LIE FLAT for 1-2hrs post meal

there is damage to esophageal mucosa

what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION.

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

LAMINECTOMY
-

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

ALIGNMENT

LIVER BIOPSY
-

before LB : supine or L side lying to expose the part

during LB :
- doafter LB : R side lying w/ small pillow under the coastal margin to
prevent bleeding.

LOBECTOMY
-

AVOID: hyperflexion, hyperextension and prone it causes

hyperextension of the spine.

removal of Lobe (N R lobe 3, L lobe 2)

position : semi fowlers position to promote lung expansion

MASTECTOMY
-

removal of breast
elevate or extend affected arm to prevent lymp edema (or elevate higher
that the level of the heart.
AVOID: venipuncture, specimen taking, blood pressure ON THE AFFECTED
ARM coz there is no more lymph node w/c predispose pt to bleeding.
Post mastectomy Exercises:

squeezing exercises, finger wall climbing, flexionextension (folding of clothing, washing face,
vacuuming the house)

Due to removal of axillary lymph node, avoid also gardening and hand sewing

PNEUMONECTOMY
-

RADIUM IMPLANT OF THE CERVIX

-

either L or R lung. Position pt on the AFFECTED SIDE to promote

lung expansion.

keep pt on complete bed rest to prevent dislodge.

AVOIDE SEX (may burn penis bec of the implant inside)

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

RETINAL DETACHMENT

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

Ex. If operation is on the R outer of the R eye, place pt on the R position.

If operation is on the L inner of the R eye, position pt on the L side
AVOID: sudden head movement.

VEIN STRIPPING
-

keep extremities extended then elevate the legs at level of the heart to
promote venous return

TIPS
liver biopsy is done on a pt. during 1st 24hrs after the procedure, turn the pt
on his abdomen w/ pillow under the subcoastal area;
when draining the L lower lobe of the lung the pt shld be positioned on his R
side w/ hip higher or slightly higher than the head;
after tonsillectomy position: prone
a pt is about to go on thoracenthesis - how shld the nurse position the pt?
sitting w/ a arms resting on the overbed table;
to maintain the integrity of pt w/ hip prosthesis abduction splints
immediately after supratentorial craniotomy- fowlers position
best position for pt in shock supine w/ lower extremities elevated

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

ISOLATION PRECAUTION
Purpose : to isolate infection transmission
TYPE

PRIVATE ROOM

HAND WASHING

GOWN

GLOVE

MASK

STRICT

(airborne dses, direct contact-Diptheria)

RESPIRATORY

OPTIONAL

OPTIONAL

(AIRBORNE: BEYOND 3FT

DROPLET : W/IN 3FT)

TB

OPTIONAL

OPTIONAL

(negative airflow room)

CONTACT

(direct contact NOT AIRBORNE DSES)

eX SCABIES

ENTERIC

(fecal contamination)

DISCHARGE
X
(drainage: pus ex burn pt)
UNIVERSAL

(AIDS, HEPA b TRANSMITTED

BY BLD AND DODY FLUIDS)

OPTIONAL

OPTIONAL

OPTIONAL

OPTIONAL

TIPS:

When implementing universal precaution, w/c nsg action require intervention:

recapping the needle this might prick your hand;

When discarding the contents of the bed pan use by a pt under enteric precaution
GLOVE IS NECESSARY;

A nurse is giving health teaching to the parents of child with scabies: family
member must be treated;

Preventing pediculosis in school age children: avoiding contact w/ hair articles

of infected children like clips, head bands, hats no sharing

Patient with full blown AIDS is placed on isolation precaution pt ask nurse why his
visitors is wearing mask response: it will help in the prevention of
infection;

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

remains until 24hrs after initiating antibiotic therapy

DIAGNOSTIC PROCEDURES
side notes:
pt for IVP
pt for KUB
schilling test
USG

:
:
:
:

assess for allergy (cleansing enema b4 the procedure)

no dye (dont assess for allergy)
24hr urine specimen
no consent required

GENERAL CONSIDERATION

EXPLAIN the procedure to the pt (initial nsg action)

if not ready inform the doctor;
pt has the right to refuse procedure;
doctor the one who asked for consent

Check pt for CONSENT if INVASIVE WITH CONSENT

NON INVASIVE NO CONSENT needed

CONTRAST MEDIUM check for allergy

For procedure requiring anesthesia KEEP PT NPO B4 PROCEDURE

When local anesthesia used NPO, 1- 2HRS AFTER
General anesthesia keep NPO at least 8hrd after
(check gag reflex before meals)

PEDIATRIC PATIENT use flash cards, games and play to encourage

participation

TRANSCULTURAL CONSIDERATION

HISPANIC PATIENT women prefer same gender health care provider

Obtain help of interpreter when explaining procedures (except or dont ask family
members)
For muslim patient - they prefer same sex health care provider however, if
procedures require life threatening they prefer to have
male doctor.
- they only want good news information of their condition

DELEGATION and DOCUMENTATION

Delegation assessment, monitoring and evaluation of treatment

(cannot be delegated) BUT standard and changing procedures can
be delegated ex. 24hr urine specimen and urine catheter

collection.
Documentation type of treatment and any untoward reactions.

KEYPOINTS FOR NURSES

Prepare the patient;

Monitor for adverse reaction;
Report complication to the doctor

FRAMEWORK includes the Purpose, Special Consideration and Interpretation

DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND WELL-BEING)

DAILY FETAL MOVEMENT

Purpose : to determine fetal activity by counting fetal movements
usually perform by pt himself

N Fetal Movement

10-12 for 12 hr period (average: 1 movement/hr with

average 3fm/hr)

NON STRESS TEST (NST) correlates fetal heart rate w/ fetal movement
-

monitor the baseline FHR then induce fetal movements by (HOW) :

a. ring a bell
b. feed the patient

then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseline. (ex. 140 FHB
baseline, then after challenge it increase to 155)
POSITIVE result means, BABY is REACTIVE (good condition) and no need for contraction stress
test/oxytocin challenge test coz baby is OK and doing well.

CONTRACTION STRESS TEST (oxytocin challenge test)

-

correlates FHR with uterine contractions

pt on NPO
get baseline FHR then induce uterine contraction

HOW:
Thru breast stimulation it triggers the release of oxytocin from pituitary gland If (-) patient
is given Oxytocin onset is 20-30 minutes. Then check FHR and note the presence of
DECELERATION (slowing of FHR)
types of deceleration
a. early deceleration indicates head compression (MIRROR IMAGE)

b. late deceleration indicates placental insufficiency (REVERSE MIRROR IMAGE)

mgt: L Lateral Recumbent Position, Administer O2, Treat Hypotenson

c. variable deceleration due to cord (image: U or W shape) and slowing of FHR can occur
anytime.

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

BIOPHYSICAL PROFILE

to determine fetal well being w/ the use of 5 CRITERIA

fetal breathing
movement
heart tone
reaction to NST
amniotic fld volume

2 points
2 points
2 points
2 points
2 points
10 points

score below 6, indicates fetal jeopardy

ULTRASOUND
- provide data on placenta (age and location)
gender of baby
structural abnormalities
position of baby
- for pregnant: site is lower abdominal USG

types:
a. Upper USG NPO
b. Lower USG - NPO
- preparation: increase fluid intake (oral)
NO consent needed
If pt ask if it is painful: NO PAIN;
Pt shld have full bladder
CHORIONIC VILLI SAMPLING CVS
AMNIOCENTESIS AMNIO
PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING PUBS

CVS
Purpose: to detect chromosomal
Aberration
(eg. Down syndrome, Trisomy 21)
Done in 1st trimester
(can be done as early as 5th wk but
can be done on 8-10th wk)

Get sample at chorion (by 10-12wks

The placenta matures, get some sample)

AMNIO
Purpose : same w/ CVS

PUBS
Purpose: to check chromosomal
aberrations, & presence of RH
Incompatibility

can be done on the 2nd wk (14-16 wk)

- but not recommended bec. of danger
abortion (assess pt age of gestation)

Extract blood at umbilical cord

then it is tested if it really comes
from the umbilical cord (can be
done on either 2nd or 3rd tri.

or can be done on the 3rd wk (34-36 wk)

purpose: to detect fetal maturity (FLM)
thru monitoring of L/S Ratio N 2:1
(if mother is (+) DM LS ratio is 3:1)
This procedure also check level of alpha-feto
Protein if INCREASE spina befida;
If DECRTEASE down syndrome

(+) Consent invasive

(+) Consent

Bladder : Empty

consider the Pt Age of Gestation

(if age of gestation :

(+) Consent

is higher than 20wks and above : empty bladder,

if AOG is 20wks and below : full bladder

COMPLICATIONS of CVS, AMNIO & PUBS:

a.
b.
c.
d.

infection
bleeding
abortion
fetal death

TIPS

EARLY DECELERATION expected in the fetal monitor when there is fetal head
compression;

AMNIOCENTESIS was done @ 35 wks gestation purpose: to determine fetal

lung maturity;

A mother asked the nurse what will amniocentesis provide during pregnancy:
it will show as whether the baby lungs are developed enough for the baby to be born;

a nurse is preparing pt for lower abdl usg w/c of the following done by the pt
needs further teaching pt voids b4 the procedure;

after amniocentesis w/c of the following manifestation if observed by the nurse

on the patient that needs to be reported : bleeding;

heart rate;

pt ask the nurse what deceleration means it refers to slowing of babys

before Amniocentesis, what to check USG DEVICE

DIAGNOSTIC TESTS (to evaluate pediatric patients)

CARDIOPNEUMOGRAM
use to diagnose apnea of infancy
assess HR, RR, nasal airflow and O2 saturation N 95-98%
below 85 report ASAP
GLUTEN CHALLENGE
- detect presence of Celiac Disease (CD) - intolerance to gluten;
- pt is given gluten rich food for 3-4 months the observe s/s of CD
s/s of CD:

abdl cramps, steatorrhea, abdl rigidity, abdl distention

(if + for CD, gluten free diet will be for life time)

ORTOLANIS TEST (OT)

purpose: test developmental dysplacia of the hip or
congenital hip dislocation
(+) if w/ click sound (lateral)

BARLOWS MANUEVER (BM)

purpose : same
(+) barlows click press downward and w/ click sound

POLYSOMNOGRAPHY or sleep test

-

EEG is connected to pt when he sleeps

Check the brain waves, check for apnea of infancy
preparation : No Special prep,
HOLD CAFFEINE FOOD 2days b4 test

SCOLIOMETER
-

measure the degree or angle of scoliosis

check for: (+) scoliosis if uneven hemline
uneven waist
more prominent iliac rest and scapula on one side
presence of rib hump

test for pre-teen : bend over test bend and touch the toe;
(+) scoliosis if presence of rib hump, therefore x-ray then scoliometer.
SICKLEDEX TEST

HGB ELECTROPOISIS

Purpose: test for sickle cell anemia

Purpose: test for sickle cell anemia

Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + electropoiesis, if sickling of RBC
Therefore TRAIT CARRIER
(S or C shape RBC), therefore + for SC Dses
Test for TRAIT

Test for Disease

GUTHRIE CAPILLARY BLOOD TEST (GCBT)

- to detect PKU
(in PKU there is absence of PHENYLALAMINE HYDROXYLASE- PH)
Phenylalamine hydroxylase is an enzyme that converts PH to Tyroxine the one that
gives color to hair, eyes and skin.
If absent PH, no one will convert PH to Tyroxine, therefore it will accumulates to brain
and can cause mental retardation.
PH came from CHON rich food. At birth, it is usually negative, so give CHON food first for
3wks then retest.
Before test, give chon rich food for 1-4 days before test. (adult)
N PH level - >2mg/dl
(if 4mg/dl indicative of PKU, 8mg/dl confirms PKU)

SWEAT CHLORIDE TEST

-

to detect Cystic Fibrosis (in CF, the skin becomes impermeable to Na.
meaning cannot reabsorb Na and it accumulates outside of the skin);
Mother complain that her baby taste salty;
PILOCARPINE used in the test to induce sweating;

Types:
a. sweat chloride test N 10-35 meq/L (above 40 meq/L (+)
b. serum chloride test N 90-110 meq/L (above 140 meq/L (+)

TIPS

pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is adequate
CHON in the diet;

mother complains that her baby taste salty which test is to be performed : sweat chloride
test;

9 yo pt has (+) result for sweat test this indicates possible dx of Cystic Fibrosis;

pilocarpine drug used for pt undergoing seat chloride test;

hgb electropoisis test for sickle cell dses

DAY 4 (3 Feb 2005)

DIAGNOSTIC PROCEDURES
I.

CARDIOVASCULAR

A. ELECTROCARDIOGRAPHY records the electrical activity of the HEART

P wave
atrial depolarization
QRS complex ventricular depolarization
ST
- repolarization
Rhythm appearance of wave and distance
Rate
- N 60-100 bpm check on # of QRS then divide it by 300 (k)
ABNORMALITIES

a. atrial fibrillation p waves halos magkadikit.

(no discernable p waves)
b. atrial flutter saw tooth flutter waves
c. ventricular check on QRS (N - .8-.12)
ANGINA st segment elevation, t wave inversion
MI
- st segment elevation or depression, t wave inversion

B. CARDIAC CATHETERIZATION
-

it determine the structural abnormalities in the heart

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

common complications: embolism, bleeding, arrythimia EBA

nsg mgt :
monitor distal pulses (if brachial site: check @ radial
if femoral site : check @ dorsalis pedis)
if weak or no pulse REPORT
if (+) bleeding report (sandbag 10-20 lbs shld be at bedside)

C. STRESS TEST
-

determines the ability of the heart to withstand stress

equipment : threadmill & ECG
nsg alert : check pulse and BP
keep NPO an hr b4 the test
NO Jewelries

D. CORONARY ARTERIOGRAPHY
-

visualization of the bld vessels w/ contrast medium

nsg alert: (+)consent
check allergy to contrast medium
increase oral fluid intake after to excrete dye
epinephrine shld be ready for any untoward reaction

E. SWAN-GANZ CATHETERIZATION
-

4 lumen for the ff CVP, Pulmonary Capillary Wedge Pressure

(PCWP), Pulmonary Artery Pressure,
Bld products, Balloon

CVP measure R side pressure of the heart

PCWP L side of the heart
N Pressure CVP: for R Atrium 0-12

for SVC 5-12

Nsg Alert : check pulse and s/s of bleeding

F. BLOOD CHEMISTRIES

SODIUM (135 145 meq/L)

Addisons Dses: hyponatremia (dec Na), hyperkalemia (inc K) FLD IMBALANCE
Cushing Syndrome: hypernatremia, hypokalemia FLD VOL. EXCESS

POTASSIUM (3.5 5 meq/L)

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

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

Hyperthyroidism inc CA
Renal Calculi Formation inc CA @ bld

GLUCOSE (80-120)
-

Higher than 140 hyperglycemia (acidosis may lead to ineffective breathing pattern
and airway is the main problem)

below 50 hypoglycemia (pt prone to injury & altered thought process)

Creatinine (.5-1.5)
-

most sensitive index of kidney funx

(increase BUN but N creatinine do not report to AP)

increase creatinine kidney failure or renal disorder

BUN (10-20 mg/dl)

-

inc. if (+) kidney disorder

LDH (40 90 u/L)

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

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

AST (SGOT)

SGPT (ALT)

- N 8-20 u/L
- for liver (inc. for liver dses)

N 8-20 u/L
more on HEART (inc for cardiac dses)

G. HEMATOLOGIC STUDIES
RBC (4.5 5.5 million)
- inc RBC polycythemia risk for injury complication CVA
- dec RBC anemia activity intolerance
WBC (5-10 thousand)
- to detect presence of infection, bld disorders like leukemia
- dec WBC pt prone to infection
- inc WBC hyperleukocytosis (+) to pt w/ leukemia risk for infxn
PLATELET (150,000-450,000)
- spontaneous bleeding occurs when platelet dec
(pt also prone to injury)
PT

PTT

APTT

(11-12 sec)

(60-70 sec)

(30-40 sec)

coumadin check pt

heparin PTT

monitor pt 4 bleeding

monitor pt 4 bleeding

HGB male : 14-18 mg/dl

Female : 12-16 mg/dl
Dec hgb anemia (nsg dx: activity intolerance)
HCT - 35-45%
- determine the adequacy of hydration and the ration of plasma to
the cellular component blood
inc hct

: hemoconcentration (nsg dx: fld deficit dehydrated pt)

dec hct

: hemodilution fld excess

DOPPLER USG
- to detect the patency of bld vessels arteries & veins esp of lower
extremities;
- painless, non invasive, NO SMOKING 30 min-1hr b4 the test

PULSE OXIMETRY
- determines the O2 saturation at blood
- N 95-98 attach to finger or earlobe (do not expose e light)

II.

RESPIRATORY

BRONCHOSCOPY

visualization of b. tree or airway passages;

to gather specimen for biopsy;
NPO b4 & after
Gag reflex return after 1-2hrs;
Pt may expect a sore feeling (PINK STINGED SPUTUM)
Report (+) stridor
CHEST X-RAY

to determine abnormalities of lungs and thoracic cavity;

no preparation;
ABSOLUTE CONTRAINDICATED TO PREGNANCY
Check pt for radiation indicator
Determine effectiveness of tx and whether pt is active or
non-active

SPUTUM STUDIES
to determine the gross characteristic of the sputum (refers
to the amount, color, abnormal particles, consistency and
characteristic)
TYPE OF SPUTUM
PNEUMONIA
TB

- Viral
thin & watery
Bacteria - rusty
- blood streaked

BRONCHITIS - gelatinous
CHF/ PULMONARY EDEMA - pink stinged

Sputum specimen sterile container

THORACENTESIS
- aspiration of fld at thoracic cavity
(for diagnostic & therapeutic purpose)

position:

DURING sitting
AFTER - affected or unaffected side

Nsg alert:

NO COUGHING & DEEP BREATHING during the procedure coz

this may cause puncture of the lungs;
Assess for breath sounds after;
Complication: bleeding and pneumothorax

PULMONARY FUNCTION TEST

- thru the use of incentive spirometer
- vital capacity (4-5 L of air) refers 2 N amt of air that goes in

& out of lung after maximum inspiration.

PROCEDURE:

EXHALE then INSERT mouth piece, BREATH iN, HOLD

then EXHALE

LUNG SCAN
- to identify the presence of blockage in the pulmonary bld
vessels;
- with contrast medium;
- (+) consent;
- assess for rxn to allergy

MANTOUX TEST
- test for POSSIBLE TB EXPOSURE;
- using PPD (purified chon derivatives)
- angle 10-15, BEVEL UP then read 48-72hrs after
5mm in duration (+) for HIV, multiple sex, previously (+) pt;
10mm
- (+) for immigrants, children below 3yo and for
pt w/ medical condition DM & Alcoholism
15mm
- (+) for general population

LUNG BIOPSY
- aspiration of tissues at lungs for dx of tumors, malignancy
- assess for bleeding, breath sounds & report for s/s of dyspnea

III.

NERVOUS

EEG
shampoo hair B4 (to remove chemicals)
and AFTER to remove electrode gel (shampoo or acetone)
measures electrical activity of the brain (gray matter)
non invasive, (-) consent
detect the ff: brain tumors, space occupying lessions
alcohol brain waves and seizures
nursing alert:

CT SCAN

dietary modification: WITHOLD CAFFEINE coffee and tea;

WITHOLD 48hrs b4 the procedure : tranquilizers, sedatives, anti-convulsant, alcohol

MRI

PET

Use radiation to determine

use electromagnetic field
use gamma rays or positron electron
tissue density
to detect abnormality of tissue density
to detect abnormality of tissue density;
(detect cancer and tumor)
also to detect O2 saturation @ tissue;

physiology of psychosis; and to evaluate tx

give more detailed impression
(ex. Measurement of blocked artery)

NSG ALERT:
(w/ or w/out dye)
CONTRAINDICATION

CONTRAINDICATION
(same w/ ct scan BUT w/ addtl)

a.

pregnancy;

b.
c.
d.

obese pt (more than 300 lbs);

e.

claustrophobia (give anti-anxiety b4)

NO METAL OBJECTS
- jewelries, insulin pump,

pt w/ unstable v/s (arrhythmic & HPN);

pt w/ allergy to dye

pacemaker, hip replacement

clicking sound will be heard & lie still during the procedure
lie still
lie still during the procedure
and thumping sound will be heard

CEREBRAL ANGIOGRAM
involves visualization of bld vessels @ vein w/ the use of
contrast medium.
CONTRAINDICATED IN:
pt w/ allergy; pregnant pt.; bleeding

Nursing Alert:
a.
b.
c.
d.
e.

keep pt NPO;
assess pt for allergy;
monitor for signs of bldg;
inc oral fld intake to excrete dye;
keep epinephrine and or benadryl at bedside for emergency

LUMBAR PUNCTURE

aspiration of CSF for assessment to check for infection or

hemorrhage
position:

DURING : fetal or C-position

AFTER

: FLAT to prevent spinal headache

Needle is inserted between L3 and L4 or L4 and L5

Increase fluid intake after.

CSF ANALYSIS
-

Assess for the characteristic of CSF.

N amount: 100-200 ml
Characteristic : Clear w/ glucose, Na and H2O

like CA Tx

If REDDISH hemorrhage
If Yellowish infection
Ear licking w/ fluid test if (+) glucose bec. CSF has glucose.

MYELOGRAM

test for presence of slip disc or herniated nucleus

porposus (HNP).

ALERT:

Know the type of dye use:

a. water based called AMIPAQUE
b. oil base called PANTOPAQUE
type of dye will determine the position of pt AFTER the procedure.
If water based, the HEAD OF BED ELEVATED;
If oil based, FLAT after
Rationale for both oil and water based dye is TO PREVENT the upward dispersal of dye
w/c can cause electrical meningitis (s/s includes: (+) seizure, headache)

IV. EENT
TONOMETRY
-

to measure IOP (N 12-21)

- painless but w/ local anesthesia
ACUTE GLUACOMA : 50 yo and above
CHRONIC GALUCOMA : 25 yo

CALORIC STIMULATION TEST

-

test the presence of Minierres Dses (inner ear)

involves introduction of warm and cold water then NOTE
FOR NYSTAGMUS jerky lateral movement of the eye.
SEVERE NYSTAGMUS NORMAL
MODERATE NYS
- Minierres Dses
NO NYSTAGMUS
- Acoustic Neuroma

GONIOSCOPY
-

to differentiate OPEN and close angle galucoma;

non-invasive, painless

WEBER TEST

RINNES TEST

To determine lateralization of sound;

To determine air and bone conduction
If pt hears vibration better in GOOD EAR,
Place tuning fork 2inches from the ear
Problem would be SENSORINEURAL LOSS;
place at mastoid bone or in teeth then.
if pt hear better in POOR EAR, - refers to if AIR CONDUCTION is LONGER, therefore
CONDUCTIVE HEARING LOSS
SENSORINEURAL HEARING LOSS;
If BONE CONDUCTION IS LONGER, therefore
CONDUCTIVE HEARING LOSS

V.

GASTRO INTESTINAL TRACT

UPPER GI SERIES (Barium Swallow)

xray visualization with contrast medium

- Contrast Medium:
a. Gastrografin water soluble, use straw
b. Barium - swallow milk shake like (use feeding bottle of pt)
- then pt is ask to assume different positions to
distribute dye @ esophagus
purpose: to detect disorders of esophagus
feces : chalky-white
after: instruct pt to take laxative to excrete dye

BARIUM ENEMA (for Lower GIT)

-

involve rectal installation of barium;

there is balloon catheter inserted @ anus then barium is instilled and pt is

asked to roll-over at different position then xray is taken to detect:
hemorrhoids, diverculosis, polyps and lesions;

after, give laxative to excrete dye (bec dye is constipating)

instruct also patient to inc oral fld intake

GUAIAC TEST
-

to detect the presence of bleeding and inflammatory bowel condition like

CANCER;

specimen : stool

(this can be refrigerated awaiting laboratory)

AVOID the following 3 days B4 the test bec it can yield to FALSE (+)
RESULT : Red Meat, Fish and Horse Radish

CHOLANGIOGRAPHY

visualization of biliary tree

with contrast medium w/s is given thru IV

ALERT: assess for allergy (epinephrine/benadryl)

Post procedure: inc. oral fld intake

(includes, hepatic duct & common bile duct) same with

CHOLECYSTOGRAPY but medium given orally;

to facilitate excretion of dye

GASTRIC ANALYSIS
-

analysis of gastric secretion like HYDROCHLORIC ACID

Lower Level N : 2-5 meq/hr
Upper Limit N: 10-20 meq/hr
UPPER LIMIT YPES

a.

WITHOUT TUBE (tubeless gastric analysis)

using DIAGNEX BLUE (specimen: urine);

if urine colors turns BLUE, therefore (+) HCL Acid;
if urine (-) blue color, therefore (-) HCL Acid

b.

if (-) HCL Acid at stomach (achlorhydia), therefore Gastric CA;

if Increase HCL Acid therefore ZOLLINGER-ELLISON SYNDROME (+) Gastric Tumor

WITH TUBE with the use of NGT then aspirate

ULTRASONOGRAPHY
-

upper abdl USG to detect abnormalities in the upper abdl area w/

includes biliary tree and Upper GI;
painless;
gel at abdomen and pt is NPO

LIVER BIOPSY
-

aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis;

ALERT: Check for Bleeding Time (N 1-9 mins) and

Clotting Time (N 10-12 mins) because liver is highly
vascular organ

WHEN NEDDLE IS INSERTED tell pt to:

Inhale then Exhale then Hold Breath to stabilize liver position

Position after : R side-lying position

Things to report: s/s of SHOCK inc PR, dec BP
Check v/s

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

-

to visualize common bile duct and pancreatic duct;

invasive (+) consent;

NPO tube insertion;

Tell pt that tere will be feeling of soreness a wk after the procedure

COLONOSCOPY
-

visualization of colon to detect:

inflammatory bowel condition
Chrons Dses
Diverticulitis
Hemmorhoids
Tumor
Polyps

- (+) Consent
- NPO b4
- clear liquid diet 2days b4 the procedure
position: Lateral or side lying position or L Lateral Sims

VI. ENDOCRINE

GLUCOSE TOLERANCE TEST

-

ACTH STIMULATION TEST

-

to detect presence of Addisons Dses

specimen: blood
pt is given dose of ACTH (not nore than 40ug/dl)
if still dec despite ACTH administration, therefore Adrenal Insufficiency
Addisons Dses

DEXAMETHASONE SUPRESSION TEST

-

to provide measure of bld sugar level at blood;

Inform pt to have high CHO diet 2 days b4 the test;
Instruct NPO a day b4 the test (npo post midnoc);
Inc sugar level, therefore Diabetes

to detect endogenous depression depression resulting thru endocrine disorder

pt is given dexa then 24hr urine specimen is collected;
a dose of dexa will suppress the release of adrenal hormones;
if despite dexa administration still increase adrenal hormones, therefore pt is
suffering depression

17 KETOSTEROID & 170 HCS

-

use to detect the presence of Addisons & Cushings Dses.

Addisons dec secretion of ketones

Cushings ince secretion of ketones
Specimen: 24 hr urine

VANILLYLMANDELIC ACID TEST VMA Test

-

bi-product of CATHECHOLAMINE Metabolism

epinephrine

norepinephrine

inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla

N 2-7 mg/dl / 24hrs if inc, therefore tumor

AVOID: vanilla containing food 3 days b4 test

ice cream, coffee, chocolates

RAIU
-

pt is given iodine 131 then after 24hr followed by a thyroid scan

inc indicates hyperthyroidism, dec hypothyroidism
AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include
other diagnostic procedures that uses contrast medium (NO - angiogram
test). bec it may yield to false (-) result.
SULKOWITCHS TEST
-

detect amount of calcium excreted at urine;

if to test for hypercalcemia and hyperthyroidism - gather specimen b4 meals;
to test for hypocalcemia and hypothyroidism gather after meals

VII. R E NA L

URINALYSIS
-

examine the gross characteristic of the urine

urine amount : 30-60ml/hr

color
: clear, amber
s. gravity
: 1.010 1.025
abnormality:

lower than 1.005 diabetic insipidus

higher than 1.030 diabetic mellitus
(+) glucose infection, DM
(+) CHON - PIH, kidney dses.

Urine maybe refrigerated if waiting to be examined.

CULTURE & SENSITIVITY

-

to detect infection
prepare storage container

KUB
-

xray of the kidneys, ureter and bladder

- NO SPECIAL PREPARATION NEEDED

visualization of urinary bladder

after : monitor I & O;
note for s/s of bleeding

RENAL BIOPSY
-

aspiration of tissues at kidney for biopsy to detect:

a. malignancy/ Ca
b. malignant HPN
c. kidney disorder

note for s/s of bleeding

CYSTOURETROGRAM
-

- xray of the kidneys, ureter and bladder

- uses contrast medium/ dye
- assess for allergy, then inc. oral fld intake after
- benadryl or epinephrine at bedside for allergic rxn
- NPO POST MIDNOC, cleansing enema in AM

CYSTOSCOPY
-

IVP

to check the patency of the ureter and bladder;

monitor I & O

CYSTOMETROGRAM
-

to evaluate the sensory and motor funx of bladder;

to check if bladder respond to distention after installation of flds;
monitor I & O

VIII. MUSCULO-SKELETAL

ELECTROMYOGRAPHY
-

to detect electrical activity of the muscle;

(+) consent;
to alternately contract and release the muscle as needle is inserted
HOLD muscle relaxant b4 the test

ARTHROCENTESIS
-

aspiration of fluids at synovial space to detect abnormalities;

check for order of analgesic;
apply cold pack

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

BONE SCAN
-

detect rate of bone destruction or bone resorption for pt w/ osteoporosis;

lie still during the procedure;
PAINLESS AND NON INVASIVE

IX. MISCELLANEOUS

BONE MARROW BIOPSY

-

to check abnormalities at the b. marrow (eg. Leukemia)

site : ILEAC REST
(+) consent
assess for bleeding
sand bag at bedside (post procedure) for emergency use

SCHILLINGS TEST
-

specimen: 24hr urine

test for VIT B12 deficiency;
for pt w/ PERNICIOUS ANEMEIA;
pt is given oral VIT B12 then urine is collected, then NOTE for RATE of
EXCRETION of VIT B12 (N less than 40%);
eg. If 100mg Vit b was taken 60mg shld retain at stomach and
40mg will be excreted.

URINE UROBILINOGEN
to detect HEMOLYTIC DSES
WITHOLD ALL MEDS 24hrs b4 the test

BENCE-JONES PROTEIN
detect presence of MULTIPLE MYELOMA (malignancy of plasma cells);
RELEASED by destroyed or damage bones

ROMBERGS TEST
check FUNX of CEREBELLUM;
stand erect, close eyes, and observe for inability to maintain posture
Swaying, therefore TUMOR at cerebellum)

ERYTHROCYTE FRAGILITY TEST

-

use to detect the rate of RBC DESTRUCTION in a hypotonic

(if pt is

solution

(RBC Lifespan: 120 days)

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

HETEROPHIL ANTIBODY TEST

-

detect presence of IgM w/c is related to Epstein Virus infection

Epstein Virus Infection causative agent of infectious mononucleousis (kissing dses)

mgt: AVOID SHARING of utensils and glass

LYMES DSES SEROLOGY

-

detect presence of BORRELIA BURGDORFERI

causative agent of lymes

dses.
Treatment: tetracycline

TIPS FOR DIAGNOSTIC PROCEDURE

2 moths old infant suspected of brocholitis is treated with oxygen therapy. Which result indicates
that tx was effective : 02 SATURATION OF 98%.

Pt is scheduled for liver biopsy. What shld the nurse instruct pt to do during needle insertion? hold breath during the procedure upon insertion of the needle.

Staff nurse is observing a nurse caring for pt w/ cvp. W/c action of the nurse require intervention?
touching the edge of the soiled dressing using clean gloves.

Pt undergoing ERCP important prep for nurse to make would be: keep pt NPO b4 the
procedure.

Pt w/ coronary angiogram, the catheter was inserted at the L femoral artery. w/c intervention is
appropriate after the procedure: palpate the popliteal and pedal pulses.

In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize.
A mantoux test is (+) if the nurse assesses w/c of the following: in duration.
w/c of the ff will yield an accurate reading of CVP: when the zero level of the manometer is at
the level of R atrium.

w/c responses made by the pt indicates that he understands the procedure to be done in a CT scan:
a dye will be injected to me.

A pt is to have an upper GI series which statement shows that he understood the instruction given
: I will drink the dye.

After liver biopsy, a potential complication: bleeding.

MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques
at the brain.

DAY 5 (8 Feb 2005)

PHARMACOLOGY
I. GENERAL CONSIDERATIONS

ONLY RNs are allowed to administer (to include central line)

LPNs peripheral IV Line route;

ELDERLY PT provide with memory aid

PEDIATRIC PT do not mix w/ milk (dosage depends on wt, age and size)
For SIDE EFFECTS GI symptoms (mostly)
For AD. EFFECTS always consider bone marrow (leukocytopenia all PENIA)
3 COMMON DRUGS with patients over 65 y/o
a. LITHIUM if above 65 yo, dose shld not more than 1.0mEq
b. HALDOL if above 65 yo, dose shld not more than 6mg/day
c. MEPERIDINE if above 65 yo, shld not 50 mg

II. TRANSCULTURAL
ASIANS are stoicism attitude
MIDDLE EASTERNERS -

(they refuse meds if for the 1st time)

they expect meds during first contact w/ hx care provider

JEWISH no meds restrictions

JEHOVAHS WITNESS do

ORIENTAL PAYLOAH (from mexico)

treatment for diarrhea;

may cause lead toxicity

ECHINECEA
- use to boost the immune system;
- for pt. with cancer

ST JOHNS WORT
- anti-depressant (it funx like MAO inhibitor);
- do not give to pt taking MAO

VALERIAN
- sedative (used also as anti-anxiety agent)
- adverse effects GI Irritation

GINGCO BILOBA
- blood thinner;
- use to enhance bld circulation;
- for pt w/ alzeimers
- CONTRAINDICATED to pt with bleeding disorders

COMMON CONTRAINDICATIONS for HERBAL MEDS:

NO HERBAL MEDS for pregnant client;

NO HERBAL to lactating pt;
NO HERBAL for those with severe kidney and liver disorder

IV.

THE CHECK PRINCIPLE

C
HECK-

lassification (FOR WHAT?)

ow will you know that he meds if effective (evaluation)
xactly what time are you going to give it
lient teaching tips
eys to giving it safely

Lactulose given to pt with hepatic enceph to dec ammonia absorption

- s/e : diarrhea

ANTABUSE (dizulfiram) most appropriate time to take meds : after

12hrs of alcohol free.

COGENTIN to prevent pseudoparkinsonism

TETRACYCLINE - can cause staining of teeth,

Photosensitivity (use sunscreen when outdoors)

LITHIUM shld have inc. fluid in the diet

(by decreasing muscle rigidity)

III. DELEGATION AND DOCUMENTATION

Document all medical admin record:
The following CANNOT be delegated:

time, route, dosage and untoward reaction;

treatment, administration, documentation of meds

PSYCHOTROPIC
I. ANTIPSYCHOTIC
-

major tranquilizer;
for SCHIZOPHRENIA (pt has EXCESS DOPAMINE);
plays as treatment to the symptoms NOT CURE to schizo meaning it modify
the symptoms (target symptom: to decrease dopamine)

ex.
Haldol
Chlorpromazine
Clozapine (chlozaril)
Olanzapine (zyprexa)
Risperdon
BETS TO GIVE: after meals
DOPAMINE neurotransmitter (facilitate the transmission of neurons)
In SCHIZO there in INCREASE NEUROTANSMITTER.
Signs & Symptoms:
a. DELUSION FALSE BELIEF
b. HALUCINATION - hearing sounds
c. LOOSENES OF ASSOCIATION shifting of topic
CLIENT TEACHINGS:

Report ADVERSE EFFECTS of ANTI-PSYCHOTICS

which indicates agranulocytosis
a. fever
b. body malaise
c. sore throat
d. chills

hyperpyrexia and muscle rigidity

-

this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS)

drug of choice: Parlodel, Dantrium

Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM

a. mask-like face or expressionless face
b. pill-rolling tremors
c. cogwheels rigidity or lead pipe rigidity

AKATHESIA restless leg syndrome (I feel as if I have ants in

my pants)
DYSTONIA
Avoid direct sunlight because meds photosensitivity
Instruct pt to rise slowly to avoid orthostatic hypotension

Check: CBC, BP, AST/ALT

To prevent pseudoparkinsonism, administer ANTIPARKINSONIAN agents

IA. DOPAMINERGICS - ANTIPARKINSONIAN

in schizo there is increase dopamine, therefore give antipsychotic to dec dopamine then dec dopamine causes
pseudoparkinsonism. Therefore give dopaminergic.

ex.

L-Dopa
Levodopa
Levodopa-Carbidopa

Effective if decrease in tremors and rigidity within 2-3 days;

When to give: AFTER MEALS;

Health Teachings:
a. dietary modification: AVOID CHON and Vit B6
- bec it decreases drug absorption
b. check for ORTHOSTATIC HYPOTENSION and PALPITATION;
c. check BP and PR

IB. ANTICHOLINERGIC
-

decrease ACETYLCHOLINE

ex. Benadry
Cogentin

effective: if decrease tremors and rigidity;

when to give: AFTER MEALS;

Health Teachings:

a.
b.
c.
d.
e.
f.
g.

side effects: blurred vision (no driving);

dry mouth suck on ice chips or hard candy;
palpitations check PR;
constipation inc. roughage at diet;
urinary retention NOT urinary frequency
decrease BP rise slowly
check BP, PR, ECG

II. ANTI-ANXIETY
-

minor tranquilizer
decrease Reticular Activity System center of wakefulness

ex. Valium, diazepam, Librium, Tranxene

Effective:

Decrease Anxiety,
Decrease Muscle Spasm
Promote Sleep

(to pt w/ traction)

because food delays absorption

B4 MEALS

HEALTH TEACHINGS:

a. report ADVERSE EFFECT:

PARADOXICAL REACTION opposite of side effects
b. Danger of Dependency
c. AVOID:
Caffeine, Alcohol it increase the depressant effect of the drug
d. check RR it causes respiratory depression
e. administer VALIUM separately because it is incompatible with any drug
use different syringe.

III. ANTI-DEPRESSANT/MANIC
a.
b.
c.
d.

TRICYCLICS
MAO
STIMULANTS
SSRI

PATIENT with DEPRESSION

there is DECREASE norepinephrine and serotonin

A.

TRICYCLICS

prevents the reabsorption of norepinephrine.

Ex. Tofranil, Elavil

Effective:

If adequate sleep (8hrs only)

Increase appetite

Best given:

AFTER MEALS

Hx Teachings:

The INITIAL EFFECT

2-3 wks after
FULL THERAPEUTIC EFFCET 3-4 wks
ONSET EFFECT
in a WK

AVOID : juice because an acidic medium decrease absorption of drugs

REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS adverse effects of
TRICYCLICS

B.

CHECK BP and ECG

MAO INHIBITOR (MonoAmine Oxidase)

-

prevents the destruction of NEUROTRANSMITTERs

ex. Parnate, Nardil and Marplan

Effective

: if INCREASE SLEEP and APPETITE

Give AFTER MEALS

Hx Teachings:

AVOID TYRAMINE CONTAINING FOOD

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

Avocado,
banana,
cheese (cheddar, aged and swiss)

ALLOWED: cheese cottage and cream,

FRESH MEAT, VEGETABLES

COLA, CHICKEN LIVER

SOY SAUCE
RED WINE
PICKLES

Check BP the drug can cause HYPERTENSIVE CRISIS

occipital headache my nape is aching

2 WKS INTERVAL when shifting ANTI DEPRESSANT

to avoid HYPERTENSIVE CRISIS
ex . after MAO 2 wks rest then can give ST JOHNS WORT

C.

STIMULANTS
(Ritalin, Dexedrine and Cylert)

directly stimulates the CNS.

Effective:

Increase Appetite and Adequate sleep

Best to Give: AFTER MEALS

-

if b4 meals, it suppresses the appetite;

give NOT BEYOND 2pm bec. it causes INSOMNIA 6 Hrs b4 bedtime;
shld be given in the morning to avoid INSOMNIA

COMPLICATIONS:

growth suppression

Hx Teachings:

D.

SSRI

provide intervals or intermittently to avoid growth suppression;

check BP and PR

(selective serotonin reuptake inhibitor)

Ex. ZOLOFT, Prozac

Adverse effects:
s/e:

DECREASE LIBIDO and Impotence

GI

III.1 ANTIMANIC
Lithium (lithane, lithobid, escalith)
Tegretol
Depakine/ Depakote

A. LITHIUM
-

it alters level of neurotransmitters

effective if DECREASE HYPERACTIVITY

give AFTER MEALS
Hx Teachings:

diet:
High Na (6-10 gms) and High Fluid (3-4L)
N Na 3 gms, N fluid intake 3L
Basically, Lithium is a salt

Report the ff s/s (NAVDA)

Nausea
Anorexia
Vomiting
Diarrhea
Abdl Cramps

Report also:

FINE HAND TREMORS progressing to COARSE HAND TREMORS,

THIRST and ATAXIC - sign of LITHIUM TOXICITY Dug of

choice: MANNITOL
DIAMOX

Hx Teachings:

Avoid activity that increase perspiration Na & H2o;

Avoid caffeine;
Monitor lithium level

(specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the last dose)

Frequency of Lithium monitoring: ONCE A MONTH;

NORMAL LITHIUM LEVEL:
ACUTE DOSE
Below 65 yo
Above 65 yo

MAINTENANCE DOSE

.5 1.5 mEq/L
.6 1.0 mEq/L

.5 1.2 mEq/L
.4 - .8 mEq/L

Lithium is effective with 10 14 DAYS before it will reach its therapeutic level.

CONTRAINDICATION OF LITHIUM:

Pregnancy;
Lactating;
Kidney disorder

- if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DEPAKOTE
tegretol a/e : alopecia
dopakine/ depakote - gingivitis

ANTICONVULSANT (Tegretol and dilantin)

-

for seizures, wherein there is abnormal discharge of impulse in the brain

action : IT INHIBITS the seizure focus and discharge

effective: if (-) seizure

given BEST AFTER MEALS

(except for sedatives- like valium)

MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO.

NSG ALERT:

Check :

Report GINGIVITIS;
Report S/S of Bone Marrow Depression pancytopenia
(dec RBC & WBC);
Instruct pt to use SOFT BRISTTLED TOOTHBRUSH;
Instruct pt to MASSAGE GUMS and frequent oral hygiene
CBC due to pancytopenia
RBC, WBC and Platelet label

CHOLINESTERASE INHIBITORS
For MYASTHENIA GRAVIS

: Prostigmin (long acting) and Tensillon

For ALZEIMERs DSES

: Cognex (tacrine) and Aricept

(short acting)

Myasthenia Gravis there is decrease or absence of Acethylcholine (ACTH)

ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contract/move.

Therefore, the drug is given to inhibit cholinesterase in destroying ACTH

(so, if dec cholinesterace and inc. ACTH, good muscle contraction)

PROSTIGMIN long acting for treatment

TENSILLON short acting only for 5 mins.

it increase muscle strength in 30 seconds

(therefore, if muscle weakness disappear within 30 seconds it is MYASTHENIA GRAVIS)

Drug Action:

Increase muscle strength (ex. Increase chewing ability or able to chew food forcefully)
GIVE B4 MEALS or any activity;
Meds is FOR LIFE;
Report s/s of HEPATOXICITY RUQ pain of abdomen and JAUNDICE

Antidote: ATSO4 it reverses the effect of anticholinesterase

Check for LIVER FUNX TEST;

Keep at bedside: endotracheal tube for resp. problem

ANTICOAGULANT
HEPARIN

COUMADIN

For ACUTE CASES of Manic Case

FOR MAINTENANCE or Chronic CASE

Antidote: PROTAMINE SO4

Antidote: VIT K

Given SubQ (Lower Abdl Fat)

Oral

LOVENOX
Heparin Derivatives
Antidote same w/ Heparin

Onset: 2-5 days (maintenance case)

Check PT (N 11-13 sec and INR 24 sec)

Effective if (-) clot

Give same time of day
Report s/s of bleeding : Hemoptysis
Hematemesis

HEPARIN: AVOID green leafy vegetables bec it is rich in Vit K and will counteract the effect of anti coagulant.
Therefore, diet of patient no appropriate.
NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD
INR refers to the upper limit of meds from N value to the maximum dose

COAGULATION PROCESS:

thromboplastin
PRO THROMBIN

Vitamin K dependent clotting factors

COUMADIN

THROMBIN

FIBRINOGEN
HEPARIN
FIBRIN (CLOT)

COUMADIN act as vit k dependent clotting factors

HEPARIN

converts PROTHROMBIN to THROMBIN and

FIBRINOGEN to FIBRIN

- RAPID ACTING :onset : 24 48 hrs

Coumadin and Heparin

NOT to dissolve clot
(only as THROMBOLYTIC meaning it prevents ENLARGEMENT and FORMATION of CLOTS)
-

can be given together

ANTIARRYTHIMICS
Quinidine (quinam)

Ex.

Side notes:

Characteristics of HEART MUSCLE:

a. CONDUCTIVITY ability to propagate impulses;
b. AUTOMATICITY - ability of heart to initiate contraction;
c. REFRACTORINESS ability of t heart to respond to stimulus while in the state of contraction;
d. EXCITTABILITY - ability of the heart to be stimulated
Inotropic effect
- force of contraction or strength of myocardial contraction;
Chromotropic Effect
conduction of impulses;
CHRONOTROPIC Effect
- rate of contraction

ANTIARRYTHMIC (quinidex, pronestyl)

-

repolarization resting phase (k goes out)

depolarization stimulating phase (Na goes in)

(therefore the depolarization and repolarization of heart muscle depends on Na and K pump.)
K once it increase or decrease, it affects the repo and depo of heart muscle
which causes arrhythmia.
And so, to maintain the balance in the Na and K pump give antiarrythmia because it
decreases the automaticity of the heart.
Antiarrythmia is effective if (-) arrhythmia;
Give meds anytime;

Health teachings:
a. report CNS confusion, ataxia and headache
GI - nausea, anorexia and vomiting
b.
RASH therefore SKIN TEST FIRST
c. REPORT s/s of QUINIDINE TOXICITY tinnitus, hearing loss and visual disturbances
d. check pt PR and ECG waves, rate and rhythm

QUINIDINE

PROCAINE

LIDOCAINE
Ventricular arrythmia

For VENTRICULLAR & ATRIAL Fibrillation

CARDIAC GLYCOSIDES
-

increase force of contraction;

affects the automaticity and excitability of the heart muscle;
K shld be monitored when in this meds therapy

(The heart contraction is regulated by Na and K pump. If K decreases, Calcium enters and it will result to a
more increase force of contraction due to Na and Ca pump conversion.)

Effects: (+) INOTROPIC strengthen the force of contraction

(-) CHRONOTROPIC decrease rate of contraction
DIGOXIN
EFFECTIVE :
ACTION

DIGITOXIN

it increase FORCE OF CONTRACTION

:

same

onset : 5 20 mins

30 mins 2hrs

Give after meals due to GI irritation

same

CLIENT TEACHINGS:

Report s/s of TOXICITY : NAVDA

Xanthopsia

yellowish vision or greenish halos;

Check PR if BELOW 60/min (adult) HOLD next dose;

if BELOW 70/ min (older child) HOLD;
if BELOW 90- 110 (infants) HOLD next dose
EXCRETION
Digoxin kidney monitor renal funx test (BUN & Crea) report if inc;

Digitoxin liver AST/ ALT

DIGIBIND antidote for digoxin (lanoxin)
THERAPEUTIC LEVEL:

a. Digoxin
b. Digitoxin

: .5 2 ug/L
: 14 26 ug/L

NITRATES (nitroglycerine)
-

dont give if pt taking VIAGRA it will result to FETAL HYPOTENSION

dilatation of coronary arteries and arterioles thereby resulting to
DECREASE IN PRELOAD & AFTERLOAD.

EFFECTS:

Decrease in Preload decrease in the amount of blood that goes to the LV;
AFTERLOAD amount of resistance offered by blood vessels that heart shld overcome
when pumping blood

Effective if NEGATIVE ANGINAL PAIN;

Give BEFORE any activity;
Administered SUBLINGUALLY (+ burning sensation indicates drug is potent) NO WATER because it

DOSES: 3 doses at 5mins interval;

Report if there is persistence of pain;
Check BP and PR;
Keep meds in dark container (bec light dec potency);
Once the bottle is open, use the meds within 3-6 mos

will dilute the meds;

DO NOT REPORT THE FF: (expected s/s)

Hypotension, Headache, facial flushing why is my face red?

MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY)

Ex. Mucomyst
-

it decreases the viscosity of secretion;

give meds anytime;
client teaching: meds can be diluted w/ NSS or cola;

Side effects: NAV + Rashes

if no side effects, repeat dose in 1 hr

BRONCHODILATORS (ex. TERBUTALINE brethine)

-

dilates the bronchioles or airways;

effective: if (-) bronchospasm;
GIVEN in AM to decrease insomnia

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

Theophylline - N 10-20;
- for ACUTE ATTACK and PREVENTION of ASTMA

EXPECTORANT
-

(robitussin)

stimulates productive coughing;

effective : (+) COUGHING & SECRETIONS
give ANYTIME;
sideffects: NAV + DIZZINESS or drowsiness avoid activity
that required alertness (ex. Driving)

ANTIBIOTICS
-

bactericidal;
effective: (-) infection;
give ON EMPTY STOMACH B4 MEALS;
Hx teachings: REPORT rash, urticaria and STRIDOR indicates
airway obstruction;
side effects: NAVDA + GI Irritation

I. PENICILLIN : antidote is EPINIPHRINE

II. AMINOGLYCOSIDE (gentamycin)
-

effective: (-) infection give B4 meals;

report the ff:
OTOTOXICITY: I hear ringing in my ear
NEPHROTOXICITY : oliguria
NEUROTOXICITY : seizures

check BUN, CREA (kidney funx test);

check I & O (sign of nephrotoxicity)
ANTINEOPLASTIC (adriamycin)

III.
-

for breast and ovarian CA;

effective: (-) tumor size;
GIVE IN ARM to prevent HEMMORRHAGIC CYSTITIS
Hx Teachings:
a. inc oral fluid intake (2-3L/day) cytotoxic prevention;
b. monitor kidney funx I & O;

THYROID AGENTS (synthroid, cytomel)

-

for HYPOTHYROIDSM;
effective: if Inc in T3 and T4 and NORMAL SLEEP;
pt always sleep, therefore give meds in AM to avoid insomnia;
REPORT HE FOLLOWING: insomnia, nervousness; palpitations
Take meds LIFETIME (same w/ meds 4 neuro);
Check HR, PR and kidney funx test;

ANTITHYROID

(PTU, LUGOLS SOLUTION)

For GRAVES DISEASE or HYPERTHYROIDISM;

Effective: Decrease in T3 and T4 (in lab data);
Give round the clock;

Health Teachings:

a.

Report sore throat, fever, chills, body malaise because meds

cause AGRANULOCUYTOSIS;
b. Report lethargy, bradycardia, and INCREASE SLEEP indicates
that pt is having HYPERTHYROIDISM;
c. Diarrhea with metallic taste sign of IODINE TOXICITY

ANTIDIABETICS
-

(INSULIN)

effective: N Blood sugar (80-120)

for DM Type 1 (insulin dependent);
give in AM b4 meals;
check:
a. instruct S/S OF HYPOGLYCEMIA
dizziness/ drowsiness
difficulty in problem solving
decrease level of consciouness
cold clammy skin
b. monitor the blood sugar level in early AM and supper time

INJECT AIR FIRST to NPH then inject air and WITHDRAW FIRST with REGULAR.

PEAK OF ACTION (refers to when patient becomes HYPOGLYCEMIA)

REGUALR INSULIN - lunch time
Intermediate
- late in the afternoon B4 dinner
Long Acting
- B4 Breakfast

SULFONYLUREAS
-

for DM type 2;
stimulate pancreas to produce insulin;
effective N bld sugar level;
give b4 meals regularly;
teachings:
a. s/s of hypoglycemia;
b. monitor renal funx test;
c. antidote for hypoglycemia ORANGE JUICE

ANTACIDS
-

(Orinase)

(amphogel, tagamet)

ALUMINUM HYDROXIDE GEL antacid and it also dec phosphate level in pt

renal failure;
Effective: dec phosphate
(-) pain
give on EMPTY STOMACH (1 hr b4 or 2hrs after meals);
instruct pt to REPORT: muscle weakness in lower extremities
indicates HYPOPHOSPATHEMIA
administer with glass of water;
check phosphate level and renal funx test;
assess for constipation

LAXATIVES (dulcolax)
Colace
Metamucil
Dulcolax
Lactulose
-

stool softener
- bulk forming
- rapid acting
- 15-30 mins

effective : (+) BM;

give AT HS (if NOT diagnostic procedure);
give AFTER MEALS for dyspepsia;
meds is given in short duration only because of dependency
teachings:
a.
b.
c.
d.
e.

be near or stay near CR;

s/e: diarrhea;
NO lactulose for pt w/ diarrhea;
Causes hypokalemia therefore check electrolytes
Increase fld intake to avoid dehydration

DIURETICS
Target Organs
a. Diamox exerts effect at Proximal Convuluted Tubules;
b. Lasix at Loop of Henle;
c. Diuril at Distant Con. Tubules
LOOP DIURETICS (lasix)
- effetctive: incrase urine output;
- give in morning to prevent nocturia;
- teachings:
a. monitor for hypokalemia level and I & O;
b. report muscle weakness;
c. give K rich food banana, orange
THIAZIDE (diuril)
-

give in AM;
monitor for hypokalemia;
check I & O, K level, PR and BP

K-SPARRING (triamterene, aldactone)

-

effective: inc. urine output;

give in AM;
teachings: monitor for HYPERKALEMIA
check PR and K

ANTIGOUT

PROBENECID

COLCHICINE

ALLOPURINOL

- URICOSURIC
- for ACUTE GOUT
- for CHRONIC GOUT
- promotes excretion of uric acid
- has anti-inflammatory effect by
- prevents or dec formation
preventing deposition of u.acid
of u. acid
@ joints
- s/effects: NAV +
- NAV + Bldg and Bruising
- dizziness/drowsiness
Hypersensitivity
agranulocytosis (check CBC)
- ONSET: 8-12 wks

- ONSET: 1-3 wks

TEACHINGS:
a. Increase ORAL FLUID INTAKE;
b. Monitor uric acid levels;

MIOTICS (timoptic, piloca)

-

DECREASE IOP (N12-21) for pt w/ glaucoma;

Give ANYTIME but for LIFETIME;
Teachings:
a. it causes blurring of vision and brow pain;
b. administer meds at lower conjunctival sac;
c. press the inner canthus for 1-2 mins to prevent systemic side
effects (hyperglycemia and hypotension)

MYDRIATRIC
-

(AK-Dilate)

effective: pupillary dilatation;

give ANYTIME (but if pt for surgery, give b4);
teachings: may cause blurring of vision
lower conjuctival sac

CARBONIC ANHYDRASE INHIBITORS (diamox)

-

for GALAUCOMA lifetime;

to decrease production of acqueous humor;
effective: N IOP and Inc. urine output;
effective to pt with MENIERES DSES dec vertigo
teachings:
a. check urine output;
b. report: s/s of dehydration bec of diuretic effect
c. blurred vision
d. monitor I & O and IOP

ANTI-ACNE (acutane, retin-a)

-

decrease sebaceous gland size;

given in AM to prevent insomnia;
avoid sunlight: photosensitivity
pregnancy: fetotoxic - therefore check if pt is pregnant;
check if pt has skin irritation may burn the skin

TOCOLYTICS (Yutopar, MgSO4)

-

relax the uterus;

drug of choice for pre-term labor;
effective: (-) pre-term or relaxed uterus;

give: ORAL B4 meals and IV anytime;

teachings:
a. signs of Ca Intoxication:
hypotension, hypothermia and hypocalcemia
b. check bld pressure; urine output (N 30ml/hr)
c. check RR at least 12/min
d. check patellar reflex shld be (+) knee jerk

HOLD if RR 10/min and urine output: 15ml/hr

Antidote: Calcium Gluconate

OXYTOXIC
PITOCIN

METHERGIN

To induce labor
To prevent post partum hemorrhage
Effective: Firm and Contracted Uterus
Give anytime
If IV, use piggy back
Teachings:
a. REPORT the ff: HYPOTENSION (due to inactivation of ANS neurological effect of drug);
b. Headache
c. Hypertension (cardiovascular effect of the drug)
d. Check BP, Uterine Contraction especially the duration N 30-90 sec
- report if beyond 90 sec sign of uterine hypertonicity
e. Check Force, Duration and Frequency of Uterine Contraction

PROSTAGLANDIN (cytotec, E2gel)

-

anti ulcer drug to dec gastric acidity;

decrease ripening of the cervix w/c leads to effacement then dilatation then
abortion;
give after meals;
assess for diarrhea and gastric irritation;
check for pregnancy bec it may cause abortion

TIPS ON PHARMACOLOGY
Patient receiving DIAZEPAM, the nurse notice that there is no change in patient
behavior. What shld the nurse do? VERIFY THE PT DIET

COGNEX given with AZEIMERSS DSES to increase mental functioning

Pt w/ PVC : bedside : XYLOCAINE

Pt w/ COMPLETE HEART BLOCK: give ATSO4 it increases HR

Pt w/ DIVERTICULITIS (pt has diarrhea) the ff meds were given: what meds the nurse
shld question : LACTULOSE

Morphine S04 given to pt with Pul. Edema to decrease anxiety

Pt ask the nurse on why she will take COUMADIN when shes already taking HEPARIN
Heparin is given for ACUTE CASES while Coumadin for maintenance

Pt on CHEMOTHERAPY complains of nausea and vomiting, w/c meds can be given

ZOFRAN

Expected side effects of STEROIDS : wt gain, obesity and Inc appetite

Pt is taking LEVODOPA observe for URINARY RETENTION

ADREAMYCIN causes hemorrhagic cystitis

DESMOPRESSIN ACETATE administered INTRANASALLY

FESO4 shld be given w/ orange juice

ASPIRIN I s given to pt w/ TIA to decrease platelet aggregation

Pt taking ANCEF observe for skin rashes

Pt to receive NPH at 7:30am, the nurse shld expect for hypoglycemia LATE in the
AFTERNOON

TYPES OF PRECAUTION

AIDS

(universal)

DIARRHEA

(enteric)

HEPA

GL

GW

yes

yes

yes

yes

yes

(enteric)

yes

yes

yes

(universal)

yes

yes

yes

yes

(universal)

yes

yes

yes

yes

MRSA

(contacts)

yes

MENINGITIS/SEPTIC
SCABIES
TB

(contact)

(tb Precaution)

PEDICULOSIS

(contact)

P private room
H handwashing
GL - gloves
GW gown
M - mask
AIDS universal
Norwalk Virus respiratory
Hepa A contact
MRSA contact
Scabies contact

(enteric)

yes
yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

Day 6 (Feb 9, 05)

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

Priority: Oxygenation
The disorders result as alteration in the function of HEART (pump), BLOOD
(transport mechanism of oxygen, nutrients, hormones & CO2) and BLOOD
VESSELS (passageway).

PEDIATRIC CONSIDERATION
a. all factors necessary for appropriate cardiovascular functioning are
present at birth EXCEPT VIT. K (w/c is produced by intestinal mucosa);
b. there are structures which are present at birth that may alter the route of blood
circulation (present at birth: foramen ovale, ductus arteriosus, ductus venosus)
c. note the CARDIAC RATE of pediatric pt

(minimum $ y. children 90-110, older c. 70)

REPORTABLE S/S FOR ADULT

Palpitation, Pain and Paroxysmal Nocturnal Dyspnea

For pediatric patient: observe for PALLOR if (+) indicates ANEMIA for baby
Nocturnal dyspnea diff. of breathing at night
Paroxysmal ND when pt feels as if hes drowning

HEART SOUNDS:

S1 - normal lubb
S2 - -do- dub
-

in assessing S1 & S2 use BELL of steth

S3 - N for Pediatric pt

(ABNORMAL for adult pt it indicates CHF or Aortic Stenosis)

Steth - BELL for LOW PITCH SOUND (ex. Murmur)

Diaphragm for HIGH PITCH SOUND

SHOCK
mp: decrease in circulating blood volume
TYPES

CARDIOGENIC pump failure (CHF, MI, Atherosclerosis Heart Dses, Mitral Valve Dses)
HYPOVOLEMIC - related to fluid loss (pt w/ open wound, traumatic injury, burn)
ANAPHYLACTIC - cause by allergic reaction (laB procedure w/ dye, asthma, poison)
NEUROGENIC - caused by vasomotor collapse
(vasomotor located @ medulla oblongata w/c is responsible for dilatation & constriction of bld vessels)

SEPTIC due to systemic infection

(ex. Septicemia)

TRIAD SYMPTOMS OF SHOCK

a. Altered level of consciousness
b. Hypotension;
c. Tachycardia and Tachypnea

(dec bld circulation result to dec o2 in the brain);

Patient in shock- there is also (+) pallor and

(+) oliguria due to dec bld circulation & narrowing of bld vessels
Lab Data (to check bld volume circulation) check HEMATOCRIT (N-35-45%)
- check Urine Output
- check CVP
Nsg Dx: FLD VOLUME DEFICIT rel to dec in Circ Vol.
Priority Intervention: Fld replacement

(D5Lr, NSS. Bld Trans for jehovas use plasma expander)

ANEMIA
MP: Decrease RBC due to decrease production or increase destruction
Risk Factors:
Age
Gender
Surgery
Secondary to existing medical condition (ex. Renal Failure)
Kidney produce erythropoiten that stimulates bone marrow to produce RBC

TYPES:

a.
b.
c.
d.
e.
f.

Iron Deficiency Anemia (IDA)

Pernicious Anemia (PA)
Folic Acid Deficiency Anemia (FADA)
Sickle Cell Anemia (SCA)
Aplastic/ Fanconis Anemia (AA)
Talasemia Anemia (TA)

IRON DEFICIENCY ANEMIA

-

common in infants and children;

characteristic of patient: chubby but pale
they are also called milk babies
those baby 5 yo but still taking milk
(milk are poor source of iron)

MP: Nutritional Deficiency

S/S : Fatigue
Fainting
Forgetfulness
Pallor, cold clammy skin
Dyspnea (due to dec RBC)
Lab data:
Decrease in HgB (N male: 14-18, Female: 12-16)
Characteristic of RBC: HYPOCHROMIC & MICROCYTIC

Nsg Dx: Activity Intolerance

Priority Intervention:
a. Correct the deficiency by administering iron supplements,
- IRON RDA 15-30 mgs/ day
eg.

Oral FeSO4 (take w/ orange juice)

if ELIXIR use straw to avoid staining of teeth
if IM (inferon) Z track method
(for Z track IM PULL SKIN LATERALLY, deep IM,
wait 10 seconds before pulling the needle)

FeSO4 evaluate AFTER 4 weeks to check the effect

b. Diet: iron rich food (organ meat, dried foods, egg yolk iron, egg white CHON);
c. provide patient with BED REST due to fatigue

PERNICIOUS ANEMIA
-

common in elderly;
common in POST GATRIC SURGERY

Main Problem: Lack of INTRINSIC FACTOR at the stomach

(intrinsic factor the one that absorb vit b12)

In elderly, there is that GASTRIC ATROPHY w/c leads to dec in the Intrinsic factor
S/S:

3F (fatigue, fainting, forgetfulness)

Beefy Red Tongue or glossitis
Peripheral Neuropathy (tingling sensation at lower extremities usually both legs are affected)

Lab Data:
a. check Hgb
b. SCHILLINGS TEST (24hr urine)
c. RBC characteristic : MACROCYTIC & HYPERCHROMIC
Nsg Dx: Activity Intolerance
Risk for Injury due to p. neuropathy
Priority Intervention:
a. Correct the deficiency give Vit B12
b. Bed rest due to fatigue

(IM, Once a month for lifetime);

FOLIC ACID DEFICIENCY ANEMIA

-

common in infants, adolescents, pregnant, lactating and overcooked food;

Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN

S/S: all symptoms of pernicious anemia EXCEPT P. NEUROPATHY
Lab Data: HgB
Folic Acid level (N 4mg/day) green leafy veg. (spinach)
Nsg Dx:
Activity Intolerance
PI:

(NO RISK FOR INJURY coz NO P. NEUROPATHY)

Inc. folic acid in the diet g. leafy;

Bed Rest

SICKLE CELL ANEMIA

-

autosomal recessive
hereditary
presence of S or C shape Hgb due to dec O2

STATUS

1 PARENT W/ TRAIT
BOTH PARENTS w/ TRAIT
I parent TRAIT, 1 DSES
BOTH parents w/ Disease

TRAIT TRANS
50%
25%

DSES TRANS

50%
50%
0

(SICKLING OF RBC)

0
25%
50%

50%
100%

Risk Factors:
Dehydration (dec in circ bld volume result in sickling of RBC);
Infections
Conditions that lead to SHOCK
S/S:
3Fs + Fever

(due to dehydration)

+ Pain + Jaundice Hepatomegally

Complications:
a. Vasocclusive Crisis (hallmark of the dses)
- bld vessels obstruction by rigid and tangled cells w/c causes tissue anoxia and possible necrosis

b. Spleenic Sequestration Crisis

c. Aplastic/ Megaloblastic Crisis

massive entrapment of red cells in the spleen & liver

bone marrow depression w/c resulted to DEC RBC, WBC & PLATELET

Lab Data: Sickledex Test

(+) Turbid Solution
Nsg Dx:

PI:

Activity Intolerance
Fld Volume Deficit
Pain due to vasocclusive crisis

Hydration and relief of pain (inc oral fld intake)

Prevent dehydration
Meds for Pain Morphine SO4, acetaminophen
Since HEREDITARY refer to geniticist

APLASTIC ANEMIA
MP: Hereditary (there is DECREASE IN RBC, WBC & PLATELET)
Autosomal Recessive
S/S: 3Fs + Pallor + Dyspnea
Risk for Infection (dec in RBC)
Bleeding (dec in Platelet)
Lab Data: HgB, CBC, Clotting Factors Platelet, Bleeding & Clotting time
Nsg Dx:
PI:

Activity Intolerance (dec in RBC)

Risk for Injury (dec in WBC and Platelet)

Bld transfusion;
Reverse Isolation;
Genetic Counseling;
Bed rest

THALASEMIA
Risk Factors:
Common in Blacks, Italian, Greeks, Chinese, Indians
MP: Hereditary
Autosomal Dominant common in female and male
There is a defect in polypeptide
Chain of HgB ALPA and ETA Chain there is RBC destruction

Types:
a. Minor Thalasemia Anemia mild anemia: 3Fs

b. Intermedia TA more severe anemia + Speenomegally

Jaundice
(inc deposition of iron @ tissue) Hemosidorosis
c. Major TA severe anemia + Spleenomegally
Lab Data:
HgB
Clotting and Bleeding Time
Nsg Dx:

Activity Intolerance
Risk for Injury

PI :

Bld Transfusion,
IVF
Dietary supplements of Folic Acid and Iron
Surgery (last resort)

LEUKEMIA
MP: proliferation of immature WBC
Characterized by Remission and Exacerbation
Types:
a. LYMPHOCYTIC common in young children (proliferation of lymphocytes)
b. MYELOGENOUS adolescent and adult (proliferation of granulocytes)
TRAID S/S:

Anemia (initial) + 3Fs

Bleeding
Infection

Lab Data:
WBC hyperleukocytosis (150 500,000K) expected
NDx:

PI:

Risk for Injury

Activity Intolerance
Risk for infection
Bed rest
Avoid Contact Sports
Reverse Isolation
Blood transfusion
Bone marrow transplant

IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or

WERLHOFS DSES
-

common in BLACKS;
cause: idiopathic

unknown (viral and autoimmune)

s/s:

petechiae
ecchymosis
hemorrhage
(all signs of bleeding)

lab data: Platelet Count of less than 20,000

(spontaneous bldg)

(N 150,000 450,000)

Nsg Dx: Risk for Injury

Fld Vol. Deficit
PI :

(due to bldg)

SAFETY prevent bleeding

Give pt platelet, IVF and Bld Transfusion
Corticosteroids wonder drugs

HEMOPHILIA
-

inherited bldg disorder

TYPES:
a. Hemo. A - deficiency in factor 8
b. Hemo. B - deficiency in Factor 9
c. Von Willebrands Dses common in male and female
HEMPPHILIA A and B - Autosomal Recessive Link

(from mother to male)

Von W Dses - Autosomal Dominant Mother and Father

S/S:
Hemarthrosis
Hematoma
Hematuria
Hematemesis

bldg between joints that usually affects ankle, knee and elbow joints;

(above mentioned are signs of HEMORRHAGE)

Lab Data : PROLONGED CLOTTING TIME

Nsg Dx : Risk for Injury
PI : SAFETY then RICE

(REST, IMMOBILIZE, COLD COMPRESS, ELEVATE)

For JEHOVAHS use plasma expander (cryoprecipitate) instead

TIPS FOR BLOOD DISORDERS

If all of the ff data were obtained by the nurse, w/c one is MOST SUGGESTIVE of
CARDIOGENIC SHOCK - Inc. HRate from 84 to 122 bpm;

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

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

EXERTION;

common manifestation of LYMPHOCYTIC LEUKEMIA is PETECHIAE;

a mother of 15 mos old child with IDA makes the ff comment. w/c one is related to
child condition - MY CHILD DRINKS 2 QUARTS OF MILK/DAY;

a 7 yo boy with HEMOPHILIA was admitted.

MANIFESTATION HEMARTHROSIS;

pt w/ IDA has NSG DX of ALTERED NUTRITION LESS THAN BODY REQUIREMENTS.

w/c of the ff shld the nurse instruct the pt to do - INCLUDE VEGS. AND MEAT in
your diet at least 1 meal a day;

w/c of the ff is the priority intervention for pt w/ IDA PROVIDE BED REST
ALTERNATING w/ activities;

w/c of the ff is indicative of thrombocytopenia - HEMATURIA

w/c of the ff is EXPECTED

CARDIOVASCULAR PEDIATRICS
FETAL CIRCULATION
3 FETAL STRUCTRUES

PLACENTA

UMBILICAL VEIN

UMBILICAL ARTERIES

DUCTUS VENUSUS
(functionally, closes at birth)

Vena Cava

Right Atrium
AORTA

FORAMEN OVALE
(functionally, closes at birth)

R Ventricle

L VENTRICLE

L ATRIUM

LIVER

LA

LV

LUNGS

DUCTUS ARTERIOSUS (functionally closes by 3-4 days at birth)

AORTA

P. ARTERY

Therefore, if these 3 fetal structures will not close, CONGENITAL HEART DISEASE

CONGENITAL HEART DISEASE

ACYANOTIC HEART DSES

Dec Pulmonary Bld flow

Obstructive CHD

CYANOTIC HEART DISEASE

Decrease Pulmonary

Vent. Septal Defect (most common)

Atrial Septal Defect
Patent Ductus Arteriosus

Pulmonary Stenosis
Aortic Stenosis
Coarctation of the Aorta

Tetralogy of Fallot (most common)

Transposition of the Great Vein
Truncus Arteriosus
Tricuspid Atresia

Usually due to:

-

Maternal Infection measles, c. pox

Age 40 and above
Medical Conditions DM
Alcoholism

Signs and Symptoms:

Difficulty feeding
Retarded Growth
Tachypnea/Tachycardia
Frequent URTI
ANS brow seating

Complication: CH Failure

(check for murmur)

CVA

(due to plycythemia Inc RBC)

Lab Data: 2 D Echo

Nsg Dx: Altered Tissue Perfusion
PI : Oxygenation
Surgery
If < 2yrs old prepare the patient the moment the diagnosis was confirmed/ determined;
For 2-7 yrs old surgery is equal to child age ( ex 3yo, therefore prepare the child 3 days prior to surgery)
If > 7yo parents decision

PATENT DUCTUS ARTERIOSUS

-

connection problem : P Artery and Aorta

machinery-like murmur
(+) brow seating
(+) retarded growth
(+) tachycardia/ tachypnea

LAB DATA : 2 D-Echo

CVP

PExam
Nsg Dx : Altered Tissue Perfusion
PI :

Oxygenation
INDOMETHACIN

ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then SURGERY

TETRALOGY OF FALLOT
-

pulmonary stenosis, coarctation of aorta, right vent. Hypertrophy, vent

septal defect
boot-shape heart
tet spell squatting w/ cyanosis

LAB DATA : 2 D-echo

Complication : CVA check for RBC Count
Nsg Dx : Risk for Injury
PI :

Oxygenation
Position the Pt. : SQUATTING
Surgery

COARCTATION OF AORTA
-

Higher BP in the Upper Extremities and Lower BP in the Lower Ext.

Lab Data : BP, 2 D-Echo

PI :

Oxygenation
Position the patient: Orthopneic or semi fowlers position

KAWASAKIS DISEASE
-

due to acute vasculitis (inflammation of bld vessels) of the heart;

especially to JAPANESE children and toddler 5yo and below

S/S : High Spiking Fever for 5 Days

Lymphadenopathy
Strawberry Tongue
Palmar and Feet Desquamation

Lab Data :

No Specific Diagnostic test

Check ECG

Nsg Dx :

Altered Tissue Perfusion

Altered Thermoregulation
Altered Skin Integrity

Diet :

High CHON

TIPS FOR CARDIOVASCULAR PEDIA

w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in

children difficulty in feeding;

w/c of the ff is an appropriate intervention for a child who keeps on squatting

because of Tetralogy of Fallot - if LESS THAN 1 yo flex lower extremities
towards the abodomen;

a child who was brought in to a well baby clinic turns cyanotic while crying
REFER to the physician;

the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS pulmonary artery

and aorta;

w/c of the ff data in mother health history indicates a risk factor for congenital
heart disease ADVANCE AGE;

when admitting a pt w/ suspected congenital heart disease, w/c intervention is

priority decreasing the metabolic demand of the heart

CORONARY ARTERY DISEASE (CAD)

Main Problem :

NARROWING and OBSTRUCTION of Coronary Arteries which

could lead to HYPOXIA reversible (which could further progress to ANGINA)
and or ISCHEMIA irreversible (that could progress also to devt. of SCAR
FORMATION that can lead to MI).

Risk Factors:

Family History
Atherosclerosis
Smoking
Elevated Cholesterol
HPN

Obesity
Physical Inactivity
Stress

CAD

HYPOXIA

ISCHEMIA
NECROSIS

ANGINA
Myocardial Infarction jaw pain

this leads to decrease O2 and will result to the conversion of aerobic metabolism to
anerobic thereby resulting to the production of LACTIC ACID that will stimulate the nerve ending of the
heart w/ will produce/ result to PAIN that is precipitated by:
EATING
Elimination due to valsalva manuever
Exercise/effort/ exertion
Emotion
Extreme Temperature cool temp vasoconstriction
sEx

PAIN
MTOCARDIAL INFACRTION

Precipitated by 6Es
Pain that resembles indigestion, crushing, excruxiating
Pain radiates to the L Jaw, L arm, L shoulder
Relieved by SO4 Opiods (MORPHINE)

Pain confined at sternal area

Pain that resembles pressure

Pain occurs AFTER MEAL (post cebum) or AFTER ACTIVITY

SAME

ANGINA

S/S of above mentioned + SHOCK s/s esp to CARDIOGENIC

SHOCK w/c is due to PUMP Failure that leads to dec cardiac
Output that leads further to CHF.

ECG initial change is ST SEGMENT DEPRESSION w/

SAME

Relieved by rest & NITROGLYCERIN

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

SAME

Nsg Dx :
PAIN
Altered Tissue Perfusion
Impaired Gas Exchange

Priority : Airway (Oxygenation)

Goal of CARE
a. To decrease oxygen metabolic demand
- position : SEMI-FOWLERS
- administer O2 as ordered
- administer meds:
MI : Morphine SO4 monitor RR, effective : (-) pain,
ANTIDOTE : Naloxone HCL Narcan
ANGINA : Nitroglycerine
dark container
give b4 activity
maximum of 3 doses, 5 mins interval
effective: tingling sensation, sublingual
provide rest due to pain
b. Diet : Low Na and Low Cholesterol

HEALTH TEACHINGS:

Identify types of Angina:

Stable Angina predictable angina that occurs w/ activity;
Unpredictable relieved by Nitroglycerin;
Variant/ Prinzmetal severe form of Angina;
Nocturnal Angina occurs at night;
Decubitus Angina when pt is lying down
Intractable Angina unresponsive to tx
Post MI Angina

For patient with MI focus on complications :

a. PVC or PVBeats defibrillation/ cardioversion

b. Ventricullar Fibrillation Lidocaine s/e rashes

CARDIOVERSION

DEFIBRILLATION

- synchronize
- esp. for VTACH w/ PULSE

- unsynchronized
- for VTACH w/o PULSE

SEX for pt w/ MI resume if pt tolerate 2-3 plights of stair w/o pain;

- take meds b4 sex;
- position during sex : passive let the girl do her share

ACTIVITY advised pt to have frequent rest period;

DIET : avoid PROCESSED FOODS;
MILK
Salty
Sea Foods
Pastries esp. yellow cake

FOR ANGINA APIN instruct patient to report pain that last more than 2o minutes (indicative of MI);

Weak or absent PULSE indicative of VENTRICULLAR FIBRILLATION

Report NECK VEIN DISTENTION indicative of CHF complication

Report BLEEDINGs especially to pt on THROMBOLYTICS t-PA and Streptokinase

CONGESTIVE HEART FAILURE

main problem : PUMP FAILURE inability of the heart to pump an adequate
amount of blood to meet the metabolic
demands of the body
how will the heart compensate?

The HEART will pump harder- Inc HR (tachycardia) that will result to enlargement
of the heart muscle (hypertrophy) w/c can lead to dilatation and congestion of the
cardiac muscles - thereby resulting to decrease in the cardiac output.

PUMP FAILURE EFFECTS:

Backward Effects : backflow of blood systemic congestion;

Forward Effects : decrease cardiac output dec in tissue O2
perfusion that leads to overwork respiratory
system

LEFT HEART FAILURE early signs of CHF

Therefore, Right Heart Failure will be the late signs of CHF as
complication of LHF
Risk Factors to Heart Failure:

- Arrythmias
- Coronary Dses & HPN
- Renal Failure
LEFT SIDED HF dyspnea and other pulmonary s/s crackles

RIGHT SIDED HF systemic effect

distended jugular vein

Ankle edema
Ascites
Hepatomegally

LEFTS SIDED HF
Lab Data :

RIGHT SIDED HF

Swan Ganz
PAP (N 20-30)
PCWP (N 8-13)

CVP (N R 0-12, V Cava 5-12)

X-ray

X-ray

Nsg Dx :

Altered Tissue Perfusion

Ineffective Breathing Pattern for LHF
Fld Volume Excess for RHF

PRIORITY :

Oxygenation
Position: Semi-Fowlers
Administer: Digoxin absorb in GI
Vasodilators
Diuretics
Morphine for CHF it causes pheriperal vasodilation by
Decreasing the amount blood going back to the heart.

DIET : LOW Na NO PMS

HEALTH TEACHINGS :
a. Activity rest
b. dietary counseling NO PMS
c. report s/s of complications
DIGITALIS D. Toxicity: yellow vision;
Muscle weakness (hypokalemia) that can lead to arrythmia
Dyspnea s/s of pulmonary edema;

HYPERTENSION
MP : blood pressure higher than
140/90 (hypertensive state)

PREGNANCY INDUCED HPN

Elevation of BP that occurs after 20-24
(5 mos- age of viability) wks of gestation

pre hypertensive phase

120/80, therefore N BP : 110/70

Risk Factors:

Common in BLACKS;
Obesity
Stress
Smoking

if BP elevated B4 20-24 wks & cont after delivery CHRONIC

HPN
Levels of PIH

a. HYPERTENSIVE DISORDER OF PREGNANCY

- INC. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA)

b. PRE-ECLAMPSIA S/S + convulsion,

Abdl pain & Headache
PHASE
c. ECLAMPSIA + Bleeding = HELP SYNDROME

TYPES:

- ECLAMPSIA

a.
b.
c.
d.

ESSENTIAL HPN cause unknown

BENIGN usually of long duration, onset is CHRONIC
MALIGNANT acute or abrupt onset, short in duration
SECONDARY related to existing medical condition

HPN IN PREGNANCY usually related to generalized spasm of the arteries

PRE-ECLAMPSIA TYPES:
a. MILD
b. SEVERE

BP 140/90, PROTENURIA is <5mg/hr (N - .5-1GM)

BP 160/90, PROTENURIA is >5mg/hr

HEADACHE and ABDOMINAL PAIN s/s of ECLAMPSIA, indicative of impending convulsion.

ECLAMPSIA + BLEEDING = HELP SYNDROME

H emolysis
E levated Liver Enzyme
L ow
P- latelet
(All are signs of bleeding)
S/S of HPN:

Headache
Retinal Hemorrhage
Edema
above s/s can further lead to complications: Coronary artery dses
CHF
Chronic Renal Failure
CVA

LAB DATA:
Blood Pressure
Elevated Cholesterol
For PIH : (+) Proteinuria, Inc BP and Inc Cholesterol
Nsg Dx:

Altered Health Maintenance

Risk for Injury

PIORITY:

Stabilize BP

How?
I. Non-Pharmacologic Features
Stress Management
Deep breathing
Diet : Low Na/ Cholesterol
Position : if inc BP supine position

II. PHARMACOLOGIC MEASURES

Antihypertensive
Diuretics
Aspirin
Antilipimic - simvastatin & lovastatin give after meal nighttime
Monitor liver Funx test meds above are hepatotoxic

Pts w/ PIH meds:

a. MgSo4 antidote is CAgluconate
b. Darkened room to dec stimulus thereby preventing convulsion

PERIPHERAL VASCULAR DISEASE

Arterial Obstruction
Color
pallor
Edema
(-) or mild
Nails
brittle nails
Pain
intermittent claudication
Pulse
(-)
Temperature
cold
Ulcer
dry & necrotic

Venous Obstruction
ruddy
(+) & severe
N
homans sign
(+)
warm
wet

(pain @ gastrocnemeus area)

TYPES:
BURGERS DSES

RAYNAUDS

ARTERIOSCLEROSIS OBLITERANS

FEMALE

MALE

(THROMBO ANGITIS OBLITERANS)

common

MALE

AREA
AFFECTED :

MP :

Lower Ext.

Upper Ext 97%

3% - lower ext

Upper & Lower Ext

Affects arteries
and veins

Arteries ONLY

Arteries ONLY

Angitis inflam. of
Spasm of Arteries
Arteries & veins of lower ext of Upper & lower
ACUTE

S/S:

INTERMITTENT
CHRONIC
- (+) pain usually related to
- (+) pain that
narrowing of blood vessels.
accompanied by color changes: PALLOR that
progresses to CYANOSIS then REDNESS &
aggravated by exposure to cold NO
SHOVELING OF SNOW & COLD BATH & exposure to cold wear gloves

Outstanding s/s
is INTERMITTENT CLAUDICATION pain that worsens w/ activity or pain that is relieved by rest.
- aggravated by smoking causes further narrowing of bld vessels

LAB DATA : Inc

Nsg Dx:

PI :
MEDS :

WBC & ESR

DOPPLER USG

Altered Tissue Perfusion same

Pain
-do-

Relief of Pain

-do-

Inc Cholesterol and Ca

same
-do-

-do-

(for all types)

DIET :

Hardening of arteries due to fatty deposits

Anticoagulants
Vasodilators (papaverin pavabid)
Antihypertensive

Low Cholesterol

VARICOSE VEIN

THROBOPHLEBITIS

PHLEBOTHROMBOSIS

weakening of venous valves;

CLOT + Inflammation
job related (prolong sitting/standing)
pregnancy
hereditary
secondary to existing medical condition

Clot

s/s : dilated tortous vein

dragging sensation heaviness
edema (unilateral/ bilateral) tape measure to monitor leg circumference
Pain
Lab data:

1. conservative test TRENDELENBURG TEST pt lie down, elevate/ raise the legs then
stand up and observe for bulging of vein;
2. DOPPLER USG
Nsg Dx :

PAIN
Altered Tissue Perfusion

Hx Teachings :

Elevate the legs above the heart;

Use support stockings;
Surgery vein ligation & stripping
Sclero therapy injection of sclerosing agents to make wall stronger
thereby preventing veins to bulge.

NO MASSAGE coz it may dislodge the clots;

KNEE HIGH STOCKINGS;
COLD COMPRESS

ABDOMINAL AORTIC ANEURYSM (AAA)

- weakening of portion of abdl aorta leading to dilation;
- could be related to aging and HPN
TYPES:
Fusiform - entire wall is affected
Dissecting - part of inner intima and media was dissected w/c lead to the pushing
Saccular

of tunica adventitia to bulge

S/S:
Pulsating Abdl Mass
Low Back Pain
Higher BP in Upper Extremities
If RUPTURE occurs could lead to SHOCK
LAB DATA :

Altered Tissue Perfusion

Risk for Injury

PRIORITY :

NO ABDOMINAL PALPATION
bec it may lead to rupture PLACE WARNING AT THE DOOR OF THE PT.
Prepare pt for Surgery

CARDIO-PULMONARY RESUSCITATION (CPR)

-

indicated for cardiac arrest when pt is BREATHLESS

and PULSELESS;

shake the pt are you ok? If breathless & pulseless then;

ACTIVATE the EMS Help!
CPR (1 or 2 rescuer : 15 : 2)
In 1 minute, there will be 80 compression and
15 20 rescue breaths
Depth of Compression : 11/2 2
If too deep - it may fx the liver
Effect of CPR : #1 (+) Pulse;
#2 skin color

TIPS FOR CARDIOVASCULAR ADULT

A nurse is assigned to a pt with arterial dses of lower extremities, w/c of the ff is

expected calf pain after short walking (intermittent claudication);

A pt was diagnosed w/ MI develop atrial fibrillation this may possibly lead to

CEREBRAL EMBOLISM;

A pt w/ CHF was admitted exhibiting confusion, disorientation, visual disorders &

hallucination the nurse best action is to CALL THE PHYSICIAN;

A nurse is assessing a pt w/ MI w/c of the ff is the characteristic of PAIN pain

radiates to the jaw;

In utilizing mind over body principle for pt w/ HPN w/c intervention is appropriate
- relaxation and stress mgt;

Pt exhibits intermittent claudication another sign of peripheral dses is w/c of the

ff tropic skin changes;

Ff MI, when shall I resume sexual activity? when you can climb 2 plights of
stairs w/o shortness of breath then sexual activity is safe;

A pt has R sided CHF, w/c of the ff is expected hepatomegally;

Apt w/ CHF who is taking diuretics exhibits the ff, w/c requires further investigation
(not expected to pt) wt gain of 3 lbs in 2 days;

In addition to assessing a pt w/ Burgers Dses, w/c of the ff data supports the Dx.
smoking;

A pt with R sided HF will manifest distended jugular vein

RESPIRATORY
General Consideration:

use the DIAPHRAGM of the steth when assessing breath sounds;

use steth directly on pt. skin because clothing my interfere w/ auscultation;
when the pt chest is hairy, wet the hair w/ dump cloth because dry hair interfere
w/ auscultation

Consideration w/ Pediatric Patient:

when assessing pediatric pt, RR is affected when therefore check RR FIRST;

Note for chest indrawing (if +, may indicate Pneumonia) and rapid breathing

Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS

RE TACHY TACHY D C

RETRACTIONS - #1 or Early sign for respiratory distress;

Tachycardia

Tachypnea
Dyspnea
Cyanosis late sign of respiratory Distress

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

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

Cheyne-Stroke increase in rate and depth of breathing followed by apnea; - nero case
Kussmauls deep rapid breathing;
Apneustic forceful inspiration followed by slow expiration dying patient

At birth, the child can maintain temperature by burning brown fat and increase burning bi products
is Increase fatty acids that will cause acidosis that can worsen the Resp. Distress Syndrome a
group of symptoms (mgt: maintain temperature).
HYPOVENTILATION

Cause: Lack of O2

Effect: ACIDOSIS

HYPERVENTILATION
ALKALOSIS
Cause

: lack of CO2 the pt will decrease rate of breathing to save CO2.

co2 then combine with H2O to form carbonic acid if inc, can
lead to acidosis and the brain will compensate by
hyperventilating and increase elimination of CO2 will cause
ALKALOSIS.

APNEA OF INFANCY
Occurs in Full Term Baby

SIDS/ CRIB DEATH

Usually occurs in Pre-term

(37wks onwards)

s/s : episodes of APNEA, TACHYCARDIA

and Cyanosis

Risk Factors:

a.
b.
c.
d.

Pre-Term;
Those w/ episodes of Apparent Life Threatening Events
Siblings of those who died w/ SIDS
(usually 2-3 sis/ bro died)
Hypoventilation

Dx Procedures:
Cardioneumogram measures O2
Polysonography
ABG Analysis
Tx :

Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia

Caffeine
Assist mother threu grieving process

Hx Teaching : Teach parents CPR

(esp to Apnea of Infancy)

ASTHMA
MP : Inflammation of bronchioles that leads to excessive mucus production that resulted to
narrowing and obstruction.
Risk Factors :
Environmental factors
Emotion
Effort/ Exercise
S/S :

WHEEZING sound due to obstruction

Orthopnea
Whitish Sputum

Lab Data :

Pulmonary Funx test

Incentive Spirometer

Nsg Dx :

Ineffective airway Clearance

PI :

AIRWAY

Intervention :
Bronchodilators theophylline
Rest
Oxygen low flow (1-2 l/min)

higher than this will result to decrease in the stimulus for breathing
w/c is CO2

Nebulization
Chest Physiotherapy b4 meals or at bed time
High Fowlers
Intermittent Positive Pressure Breathing
Aerosol
Liberal Fluid Intake
Meds :

Aminophylline
Steroids
Theophylline
Histamine Antagonist
Mucolytic
Antibiotics

Hx Teachings :

Appropriate rest;
Activity avoid those that will expose pt to allergens;
AVOID PROPANOLOL and ASPIRIN causes BRONCHOSPASM;
Exercise blowing exercises bubbles, trumpet

CYSTIC FIBROSIS
-

multi system dses (GI and Respiratory System) characterized by excessive

mucus production by exocrine glands.

Respiratory
Hereditary
For each pregnancy S/S :

GI
Autosomal Recessive
TRAIT TRANSMISSION 50%
Chance for DISEASE TRANSMISSION 25%

MECONIUM ILEUS within the 1st 24-36 hrs if baby fail to defecate suspect for CF;
ABDL DISTENTION
Malabsorption Syndrome STEATORRHEA foul-smelling stool w/ Inc Fats & Bulky
Salty to Kiss bec skin becomes impermeable to Na

Common Complications:
MALE

because of thick mucus plug

Aspermia low sperm count

Sterility

FEMALE Difficulty in conceiving

Nsg Dx :

Knowledge Deficit
Altered Elimination
Altered Sexual Functioning

Lab Data :

Sweat Chloride Test N (if sweat) 10 35 mg/dl INCREASE IF (+) CF

(if serum) 90 110 mg/dl -do-

PI : since two system are affected:

Respiratory Therapy blowing of trumpet, Increase Fluid Intake;
GI Therapy Administer Pancreatic Enzyme (pancreatin, pancrease, viocase)
GIVEN WITH EACH MEALS

Effective : if (-) fat at stool

Hx Teaching : Refer parents to GENETICIST

CROUP DISORDER
ACUTE LARYNGITIS

LTB

RSV/ BRONCHIOLITIS

(Laryngotracheal Bronchitis)

(Respiratory Synctial Virus)

common in TODDLER

INFANTS & TODDLER

INFANTS usually (less than 6 mos)

VIRAL

VIRAL or BACTERIAL

VIRAL

Inflammation of LARYNX

Inflam. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES

barking-metallic cough

harsh-brassy cough

paroxysmal-hacking cough

(-) FEVER

(+) FEVER-low grade

(+) FEVER-moderate

(+) STRIDOR

(+) STRIDOR

(+) WHEEZING

STRIDOR is present when the affected part is LARYNX.

Lab data:
Nsg Dx :
PI :

P Exam
ABGs

-do-

ELIZA
-do-

INEFFECTIVE AIRWAY CLEARANCE

Airway Endotracheal Tube (Tracheostomy Set - #1) to facilitate airway;

Humidity place infant in MIST TENT or CROUPETTE
Nsg care:

change clothing frequently coz mist will dampen child clothings;

TOYS while inside the tent: PLASTIC TOYS

no battery operated & no friction wheel toys
at HOME: we can use NIGHT or MOIST air outside
and hot shower mist at the comfort room for child to inhale

Antibiotics Antiviral Ribavirin

Hx Teachings :
SYRUP OF IPECAC for Croup it induces vomiting- bec it will stop the spam thereby preventing
further coughing.

Chronic Obstructive Pulmonary Disease (COPD)

MP :

group of disorders of respiratory system that lead to obstruction or

narrowing of airways.

EMPHYSEMA

BRONCHITIS

ASTHMA

Over distention of Alveoli

Inflammation of Bronchus
Gelatinous sputum + RE TACHY TACHY D C

Risk Factors:
(+)
(+)
(+)
(+)
(+)
S/S:

Allergy
Environmental factors
Pollen
Elevated Immunoglobulin E (IgE)
Smoking (esp to passive smokers)

RE TACHY TACHY D C + barrel-shape test there is an INCREASE in ANTERIOR and POSTERIOR

DIAMETER of the chest

Lab Data : ABGs to check for respiratory acidosis

CXrays
Nsg Dx : #1 Ineffective Airway Clearance due to narrowing & obstruction

#2 Ineffective Breathing Pattern

PI :

AIRWAY 1-2 L/min;

Meds: Bronchodilator Atrovent

Exercise: Blowing;
Rest periods in between activities

During ACUTE attack, the POSITION OF CHOICE : ORTHOPNEIC

PNEUMOTHORAX
MP : partial or total collapse of lungs due to:
Types :

S/S :

over distention of alveoli

Diminished Breath Sounds (-) b. sounds to area auscultated;

(+) Dyspnea;
(+) Restlessness

Nsg Dx :

PI :

Open Pneumothorax TRAUMA

Spontaneous Pneumothorax - due to rupture of BLEB
Tension Pneumothorax due to INCREASE IN TENSION

Impaired Gas Exchange

Ineffective Breathing Pattern

Chest Tube Drainage System restores the (-) pressure within the thoracic cavity
Anterior chest tube drains the AIR
Posterior chest tube drains FLUIDS

PNEUMONIA (PNA)
MP :

there is INFLAMMATION of ALVEOLAR SPACES that leads to

exudation and consolidation of the lungs.

LEGIONARES DSES acute bronchopneumonia in elderly, alcoholic &

Immunosuppressed pt
- management same w/ pna

VIRAL PNA

BACTERIAL PNA

Fever :

(+) low-moderate

(+) fever moderate-high

Cough :

(+) Non productive thin-watery (+) Productive rusty

WBC :

No change or slight

Lab Data :

Xray and ABGs

Nsg Dx :

Impaired Gas Exchange due to exudation and consolidation of Alveoli

Elevated

PI :

Airway O2
Position : Semi-fowlers or Orthopneic
Bed Rest
Inc Oral fluid intake
Antibiotics
TCDB (turning, coughing, & deep breathing)

TB

HISTOPLASMOSIS

Bacterial

Fungal (from HISTOPLASMA CAPSULATUM)

MYCOBACTERIUM
AVIUM COMPLEX
Bacterial

from BIRD MANURE soil & transmitted thru

inhalation

Droplets & Airborne Droplets & Airborne

Droplets & Airborne

Risk Factors:
ASIAN IMMIGRANT
IMMUNOSUPPRESSION
MALNUTRITION

S/S :

same: a to e + FOREST RELATED ACTIVITY

same with TB

Ask client if came from AVIARY

a. initially asymptomatic;
b. low grade fever that occurs in the afternoon;
c. body malaise or weakness;
d. coughing w/ bld streaked sputum;
e. weight loss
Lab Data :

Histoplasmine Skin Test for Histoplasmosis

Mantoux Test
Xray confirmatory test
Sputum - @ least 2 (-) to be effective

Nsg Dx :
Infection;
Ineffective Breathing Pattern

PROPHYLACTIVE TREATMENT OF TB

MEDS :

Antiviral Meds

INH for TWO WKS (take Vit B6 to avoid NEUROPATHY)

Antibiotics

Rifampicin
INH
Streptomycin
Ethambutol

take above meds for 6-12 moths to avoid resistance

TIPS FOR RESPIRATORY

you observed a nurse caring for a child in a CROUPETTE, if you are the nurse incharge, what would be your #1 PRIORITY? changing the linens & clothings to
keep child always dry;

which data in the past medical history of the pt. supports a dx of cystic fibrosis
MECOMIUM ILEUS in the neonate;

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

expenditure;

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

a client w/ TB will experience - low grade fever;

a pt is diagnosed w/ emphysema w/ of the ff s/s would the nurse expect to have

barrel shape chest;

a nurse caring for a pt w R Lower Lobe PNA shld put the pt in w/c of the ff position
to enhance postural drainage L Lateral w/ the Head Lower than the Trunk

DAY 7 (Feb 10, 2005)

ENDOCRINE
General Consideration
Explain to the pt the MOST COMMON METHOD of assessment:
a. Direct methods specimen : blood and urine
b. Explain the methods of gathering the specimen
Consideration for PEDIATRIC PATIENT
a. Involve the parents of the child;
b. Incorporate food preferences
2 servings of popcorn HOW MANY RICE TO GIVE UP = 1
if sandwich = 1 rice

c. self insulin administration allowed to child 9 yo and above

Reportable S/S :

skin changes have you noticed any change in your skin color

Inc. temperature
S/S of Shock

(bronze skin pigmentation addisons dses)

Keypoints :

Specimen characteristic is usually affected by STREE, DIET and

Normal Body Rhythm

PKU
-

AUTOSOMAL RECESSIVE PATTERN of transmission (inherited)

MP :
There is Absence of Phenylalamine Hydroxylase (the one that converts
Phenylalamine to Thyroxine ( a precursor to Melanin).
Therefore (-) PH leads to accumulation of phenylalanine at the brain that leads to
Mental Retardation.
S/S :

Initially asymptomatic
For OLDER CHILDREN :

Since (-) melanine:

Lab Data :

Diarrhea
Anorexis
Lethargy
Anemia
Skin Rashes and seizure
Musty odor of urine (due to phenyl pyruvic acid)
hair : blonde
Eyes: blue
Fair Skin

GUTHRIE CAPILLARY BLD TEST initial screening done after the infant has ingested CHON
for a minimum of of 24 hrs.

Secondary screening : done when the infant is about 6wks old test fresh urine w/
PHENISTIX WHICH CHANGE COLOR

Phenylalanine level greater than 8mg/dl diagnostic of PKU

(4mg/dl indicative)

Nsg Dx :

Knowledge Deficit
Altered Thought Process
Risk For Injury
PI :

Dietary Modification : LOW CHON and Low Phenylalanine Diet until

adolescent or til 10 yo bec b4 this time the brain mature

MEDS :

Lofenalac 20-30mg/kg/day

Hx Teachings :

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

Provide list of foods allowed;- prepare special education to parents
Refer to geneticist

Untreated PKU can result in failure to thrive, vomiting and eczema and by about 6 mos,
signs of brain involvement appear.

LYMPHOCYTIC THYROIDITIS or
JUVENILE HYPOTHYROIDISM
Cause :

Autoimmune or genetics

MP :

Decrease in T3 and T4

S/S :

Dysphagia
Enlarge thyroid
All s/s of hypothyroidism (decrease metabolism)

Nsg Dx :

Knowledge Deficit
Activity Intolerance

PI :

no tx because it regresses (only temporary) spontaneously

CRETENISM or CONGENITAL HYPOTHYROIDISM

-

disorders related to absent or non-functioning thyroid;

newborns are supplied with maternal thyroid hormones that last up to 3 mos;
initially asymptomatic
s/s begins 2 3 months

behavioral s/s

physical s/s

- apathy well behave

large tongue & protrudes

from mouth
retarded growth
intolerance to cold

mental retardation

Prevention: neonatal screening blood test;

Without treatment, mental retardation and developmental delay will occur after age 3 mos;

Lab Data :

Decrease T3 and T4

Nsg Dx :

Knowledge Deficit
Risk for Injury

Meds :

Single morning dose of Synthroid for LIFE oral thyroxine and Vit D as
ordered to prevent M. retardation
(adverse effect of meds : insomnia, tachycardia, and nervousness REPORT ASAP)

PI :

correct the deficiency

Hx Teachings :

Warm environment (bec there is Hypothermia w/ cool extremities);

Low calorie diet : since there is decrease metabolism;
Special education

ENDOCRINE GLANDS
1.
2.
3.
4.
5.
6.
7.
8.

8 glands (ductless)- they secrete the hormone directly to bld stream

Pineal Gland
Pituitary Gland
Thyroid Gland
Parathyroid Gland
Thymus Gland
Pancreas
Adrenals
Gonads (testes & ovaries)

Glands

UNDER

OVER

PITUITARY

Diabetes Insipidus

SIADH

THYROID

Hypothroidism
(Myxedema)

Hyperthyroidism
(Graves, Basedows, Parrys)

PARATHYROID

Hypo

Hyper

Pancreas

DM

ADRENALS

Addisons Dses

Cushings
Conns

PANCREAS
Alpha Cells

BETA CELLS

Islets of Langerhans
Glucagon

Insulin

(responsible for Decrease in blood sugar)

Responsible in the increase Blood Sugar

Absence
(DM Type I)
IDDM

Juvenile Onset B4 age of 30

Adolescence to Early Adult Stage
Pt is THIN
Pt is KETOSIS PRONE

Deficiency
(DM Type II)
NIDDM
Maturity Onset After age of 30;
Pt is Obese
NON-KETOSIS PRONE

MODY DM III
-

combines features of DM Type I & 2;

Maturity Onset that occurs in young adult;
OBESE, b4 age of 30
Non-Ketosis Prone

GESTATIONAL DIABETES

- occurs during pregnancy

Types According to WHITES Classification

TYPE

ONSET

DURATION

CHEMICAL DIABETES

(+) Increase Bld Sugar

After the age of 20

10 years

Bet 10 19 yrs old

10-19 years

Before 10 yrs old

D1

More than 20 yrs

Before 10 yrs old

D2

>20 yrs

D3

Beginning Retinopathy

D4

w/ calcification of arteries

D5

DM w/ HPN

w/ calcification of Pelvic Arteries

w/ nephropathy (Diabetes Nephropathy)

Diabetes Cardiopathy

Diabetes Retinopathy

w/ Transplant of the Kidney

DIABETES MELLITUS
MP : Deficiency in INSULIN either absence or deficiency of insulin that leads
to alteration in the metabolism of CHO, CHON
and FATS.
Cause:

unknown

R. factors :

Autoimmune
Genetic
Stress

S/S :

Polydipsia
Polyuria
Polyphagia
Wt loss

Nsg Dx :
PI :

the stave cells send message to the brain to eat more

Knowledge Deficit
Altered Nutrition

Correct the deficiency- HOW?

Diet : well balance diet CHO 50-70% (main source of energy and sugar for DM pt.)
Insulin for Type 1
Hypoglycemia Most Approximately to Occur

RAPID

Regular Insulin - BEFORE LUNCH

INTERMEDIATE
SLOW
INSULIN:

NPH

- LATE IN THE AFTERNOON/ AFTERNOON

Protamine Zinc - DURING NIGHT

Ultralente

Best Site is ABDOMEN bec it is a NEUTRAL AREA

SUBQ 90 degree angle for insulin syringe

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

Lipodystropy
Dawns Phenomenon hyperglycemia that occurs at dawn

SOMOGYI Phenomenon rebound hyperglycemia

Early AM
- due to over secretion growth hormone
treatment: GIVE INSULIN NPH at 10 PM to prevent hyperglycemia at early AM

Antidiabetic Agent;

Blood Sugar Monitoring in AM and supper time (2x a day);

Ensure adequate food intake;

Transplant of Pancreatic Cells;

Exercise it will decrease insulin requirement

Scrupulous foot care

(tx: administer insulin)

(in pregnancy/stress Increase insulin req)

check up w/ podiatrist
- foot powder, snugly fitting shoes, cut toe nail straight across
- cut toe nail across
- avoid going barefoot
- always dry in between toes

Modification for Pregnant Pt with DM

+300Kcal;
Insulin Requirement (dose will be adjusted on 2nd & 3rd Trimester);
AM Dose:
PM Dose:

2:1 for Regular to NPH

1:1 for R:NPH

EFFECTS

MOTHER
Macrosomia
Hyperglycemia
Therefore pre-term birth
Complication: Uterine Atony

BABY
Hypoglycemia
RDS
Congenital Defects

COMPLICATION

1. Hypoglycemia
(Insulin Reaction)
- BLD SUGAR BELOW 50

Hyperglycemia (bld sugar level above 120)

(Diabetic Coma)

DKA

HHNK

Risk Factors :

Missed meals;
Increase or Overdose of Insulin;

Overeating
Decrease Insulin

Too much Activity

Inactivity
Stress
Infection

S/S :
Dizziness
Drowsiness
Difficulty Problem Solving
Decrease Level of Consciousness
+ Cold Clammy Skin, Diaphoresis
Lab Data : Below 50 Blood Sugar Level
PI :

Administer Simple Sugar (fructose-fruit juice)

Hard Candy (not chocolate it is complex sugar)
If unconscious D50

DKA (Type 1)

HHNK (Type 2)
(Hyperglycemic Hyperosmolar Nonketotic Coma)

S/S : 3 Ps + Signs of Dehydration thirst & warm skin

Hyperglycemia
Kussmaul Breathing + 3Ps
Thirst and warm skin
Lab Data :

Increase Bld Sugar

PI :

#1 AIRWAY
#2 Fluid
Regular Insulin

Nsg Dx :

Risk for Injury

More pronounced GI Disturbances

2.

MICROANGIOPATHY

3.

ATHEROSCLEROSIS

4.

NEPHROPATHY

- destruction of small blood vessels;

hardening of arteries;

kidney damage;

5.

OPTHALMOPATHY

6.

Peripheral Neuropathy or Autonomic Neuropathy

-

- w/c leads to cataract

(eye exam annually);

there is poor nerve impulse transmission

common manifestation : impotence

DIABETES INSIPIDUS

(Pituitary Glands 3 lobes)

ANTERIOR

POSTERIOR

MIDDLE

Secrete Tropic Hormones

Store Only (does not excrete)

MSH (skin color)

FSH
OXYTOCIN
(follicle stimulating Hormone)
ADH

ACTH
(adrenocorticotropic hormone)

LH (luteinizing hormone);

GH (growth hormone);

Prolactin

PITUITARY GLAND
ADH (anti Diuretic Hormone)

Deficiency: lead to D. INSIPIDUS

retain h20 or flds

Excess : SIADH

(Syndrome of Inappropriate Anti Diuretic Hormone Secretion)

Due to or related to:

Pituitary Tumor
Head Trauma
Injuries

MP : Deficiency in ADH leads to fld excretion, therefore s/s same with DM EXCEPT : POLYPHAGIA

Polyuria 21 L/day
Polydypsia

LAB DATA :
a. urine - decrease in specific gravity (N 1.010 1.025) in DI its <1.005;
b. FLUID DEPRIVATION Test - pt on NPO 24hrs B4;
Nsg Dx :

FLUID VOLUME DEFICIT

PI :

Administer IV Fluids
Meds - Synthetic ADH - Vasopressin IM
Desmopressin INTRANASALLYLypressin -doHow :

Given as pt exhale to the mouth then

inhale thru the nose then EXHALE to the
mouth then give meds.

Evaluate the effect of meds :

one hole of nose only

Check Specific Gravity of Urine;

Monitor I & O;
Monitor V/S : assess for hypovolemic shock

SIADH
-

excess ADH;

MP : Fluid Retention result to DILUTIONAL HYPONATREMIA or H2O INTOXICATION

S/S :

due to DECREASE NA this could lead to the ff:

convulsion;
seizure;
HPN

Above s/s could lead to decrease LOC

LAB DATA : Decrease Na Level (<120 mEq/L) hyponatremia
Nsg Dx :

FLUID VOLUME EXCESS

PI :

FLUID RESTRICTION
Drugs DIURETICS + ANTIHPN

if cause by TUMOR PREPARE PT FOR SURGERY

IF after surgery POLYURIA report ASAP sign of DI

PITUITARY
GROWTH HORMONE
DEFICIENCY
DWARFISM
- congenital
ex. MAHAL

NANUS SYNDROME (hereditary)

Lab Data :

EXCESS
B4 Closure of Growth Plate
- gigantism
- long, slender extremities and Inc. in Height
ex. Marlo Aquino

After the Closer of Growth Plate

- acromegally
- there is coarsening of facial features +
enlargement of the digits (inc. shoe size)
ex. Balingit

INCREASE HUMAN GROWTH HORMONE

Increase Blood Sugar

Nsg Dx :

Risk for Injury

PI :

Safety
Meds - Parlodel decrease secretion of growth hormone
If related to tumor : surgery

GIGANTISM
(long slender extremity)

MARFAN SYNDROME
(hereditary)
MP : Cardio & Eye disorder
Scoliosis

KLINEFELTERS
(chromosomal aberrations)
MP : XXY Pattern (an extra X chromosome)

(complication)

X chromosome FEMALE COMPONENT

of HUMAN BODY
Problem is NON-DEVELOPMENT of SEX ORGAN

ADRENAL/SUPRARENAL

CORTEX (OUTER)
RESPONSIBLE FOR SECRETION OF:

GLUCOCORTICOIDS

MINERALOCORTICOIDS

MEDULLA

(INNER)
SECRETES THE FF:

EPINEPHRINE

NOREPINEPHRINE

(ALDOSTERONE)
GLUCONEOGENESIS
STRESS RESPONSE fight or flight
- formation of sugar from
Responsible for Na Retention
new sources
and K Excretion

DEFICIENCY IN GLUCO & MINERALO :

ADDISONS Dses

EXCESS of GLUCO & MINERALO :

CUSHINGS Dses/ syndrome

EXCESS of MINERALOCORTICOIDS ONLY : CONNS SYNDROME

ADDISONS

CUSHING

MP : Underactivity of the Adrenal Glands Overactivity of A. Glands

(there is DEC G, M & SEX HORMONES) (there is INCREASE G & M)
ADRENOCORTICAL INSUFFICIENCY

CONNS
INC. MINERALOCORTICOIDS
- w/c cause K EXCRETION &
Na RETENTION

Excessive SECRETION of
- coticosteriods especially the
GLUCOCORTICOID CORTISOL

Common: Male and Female

Excessive ALDOSTERONE
Secretion from A. Cortex

Female (bet. Age 30-60)

Female (30-50)

RF : Could be related to Surgery removal Related to Tumors

Related to Tumor

Of Adrenal Gland and or

Auto Immune Reaction

S/S: Dec Bld Sugar (hypoglycemia)

INC BP, NA
ALL S/S OF CUSHINGS
DEC K
+
EXCEPT HYPERGLYCEMIA
Moonface, Hirsutism,
Buffalo Hump, Pendulous Abdomen Hypertension
Lability of Mood (mood swings)
Polyuria, Polydipsia
Depression
Cardiac Arrythmias due
COMPENSATORY of MSH Inc w/c
Trunkal Obesity / thin Extremities
to dec K
Leads to Bronze-Like Skin Pigmentation Hypertension
Decrease Resistance to Infxn
Hypotension, Weak Pulse
Weight loss, Fatigue, Muscle weakness
Nausea, Anorexia, Vomiting
Hx of frequent Hypoglycemic Rxn
Dec Na (hyponatremia)
Dec BP
INC K (hyperkalemia)

Lab Data : Decrease Cortisol Level

Increase Cortisol Level

Hypernatremia
Hyperglycemia
Hypokalemia

Hyponatremia
Hypoglycemia
Hyperkalemia

Hypokalemia due
metabolic Alkalosis
Inc Urinary Aldosterone Level
Decrease K

Nsg Dx :
Fluid Vol. Deficit
Fld & E imbalance

Fld Vol. Excess

Fld & E imbalance

ADDISONS

Risk for Injury

Fld & E Imbalance

CUSHINGS

CONNS

PI :

Correct the imbalance IV

Diet: Inc Na Dec K
Administer Steroids (Fludocortisone)
Admin. Hormone Replacement Therapy
Cortisone give 2/3 of dose in AM
1/3 in afternoon

Meds are FOR LIFE

Correct the imbalance

DIET : Low in Calories & Na

High in CHON, K, Ca
& Vit D

Prevent accident & Falls

Prevent exposure to Infxn

Diet : Low Na, Inc K

Minimize stress in environment

MIO & weigh Daily

Provide small, frequent feeding high in

CHO, Na and CHON to prevent
Hypoglycemia & Hyponatremia

Use of Table salt tablets (if Rx) or ingestion Surgery prepare pt if cause
Of salty foods (potato chips)
by pituitary tumor or hyperplasia
if experiencing Inc. sweating
Post Surgery:
poor wound healing;
report s/s of Addisonian Crisis
severe HYPOTENSION

Avoidance of strenuous exercise esp

in HOT WEATHER

Monitor V/S, observe for HPN &

edema

Meds: FOR LIFE

Glucocorticoids Synthesis Inhibitors
- Lysodren and Cytodren
- prevents formation of Gluco

Administer SPIRONOLACTONE
(aldactone) & K supplements

As Rx

ADDISONIAN CRISIS

Limit the flds

Protect client exposure to Infxn

Provide rest periods prevent fatigue

Monitor I & O, weigh Daily

Check BP give antiHPN

- limit fld intake

severe exacerbation of Addisons dses caused by acute adrenal insuffieciency

causes:

strenuous activity, infection, trauma, stress, failure to take RX Meds

s/s:

severe generalized muscle weakness

severe hypotension
hypovolemia, shock

PI :

administer flds to treat vascular collapse

IV glucocorticoids - Solu-Cortef and Vasopressors
Maintain strict bed rest and eliminate all forms of stressful stimuli
MIO and weigh daily
Protect client from Infxn
Other Hx teachings: same with Addisons

THYROID
T3 & T4
- responsible for maintenance of

Calcitonin

METABOLISM

DEFICIENCY
HYPOTHYROIDISM
Adult: Myxedema
Children: Cretenism

- deposit Ca @ bones

EXCESS
HYPERTHYROIDISM
Graves Disease, Basedows or Parrys Dses

Main Problem:
Slowing of metabolic process caused by hypofunction of the
Secretion of excessive amount of Thyroid Thyroid Gland
with decrease thyroid hormone secretion (T3 & T4)
Hormone in the blood causes in the INC
Of metabolic process
DEFICIENCY in T3 and T4

Excess in T3 and T4

Causes:

congenital
surgery
autoimmune

genetic
autoimmune
tumor

S/S :
FACIAL EDEMA
INTOLERANCE to COLD
DECREASE v/s
DECREASE GI Motility constipation
HYPOactivity
Increase Sleep hypersomnia
Wt Gain in the presence of Dec Appetite
Dry scaly skin, dry sparse hair, brittle nails

EXOPTHALMUS
(+) Goiter
Hypermetabolic State
INTOLERANCE to HEAT
Inc V/S
INC GI Motility - DIARRHEA
Insomnia
HYPERactivity
WT LOSS even INC Appetite
Warm smooth skin, fine soft hair
Pliable nails
Irritability, restlessness, agitation

LAB DATA :
Check TSH (increase)
DECREASE T3 & T4
DECREASE RAIU (131)
INCREASE Serum Cholesterol Level

DECREASE TSH
INCREASE T3 & T4
INCREASE RAIU

RADIOACTIVE IODINE UPTAKE (RAIU) administration of 123I or 131I orally;

- performed to determine thyroid function (increase uptake indicated
hyperthyroidism, minimal uptake may indicate hypothyroidism);
nsg consideration : take a thorough history thyroid meds must be D/C 7-10 days b4 the test meds containing iodine
cough preparations, and intake of iodine rich foods and test using iodine eg IVP can invalidate the test

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

Risk for Injury (bec of hyper)

Promote a EUTHYROID STATE

HOW :

same

a. THYROID SUPPLEMENT
Synthroid, Cytomel lifetime
s/e: insomnia, palpitation
nervousness
b. DIET: low calorie

Admin AntiThyroid Meds for LIFE

ex. PTU & Lugols
Assign to private room away from excessive activity

c. Maintain vital funx: correct hypothermia maintain

adequate ventilation
d. Provide comfortable, warm environment
e. Increase flds and high fiber foods to prevent
constipation,. Admin stool softener as Rx
f. Meds: thyroid hormone replacement take daily
dose in AM to avoid insomnia
Monitor THYROTOXICOSIS tachycardia
Palpitations, nausea, vomiting, diarrhea,
Sweating, tremors, dyspnea

Quite & relaxing Activity

Provide a COOL ENVIRONMENT
DIET : High in CHO, CHON, CALORIES
Vit & Minerals w/ supplemental
feedings bet meals & at HS
NO STIMULANTS
tears

Protect eyes w/ dark glasses & artificial

Monitor for AGRANULOCYTOSIS (fever,

Sore throat & skin rashes) if taking
antithyroid meds.
Prepare pt for surgery 2wks before
SURGERY give LUGOLS SOLUTION
- it decrease size and vascularity of thyroid gland;
- give w/ straw to avoid staining teeth;
- can be diluted w/ H2O or orange/ apple juice;
- report diarrhea & metallic state

Meds:

a.

Antithyroid Drugs Prophythiouracil and Tapazole

- block synthesis of thyroid hormone;
- toxic effect include AGRANULOCYTOSIS

b. Radioactive Isotope of Iodine (131) Radioactive Iodine Thrapy

- given to destroy the thyroid gland thereby decreasing
Thyroid hormone production

COMPLICATIONS OF THYROID SURGERY:

MEMORRHAGE whether the dressing is dry or intact its not a confirmatory that there
is no bleeding.
To check, slip your hands at the back of the neck (bec of principle of gravity)

Damage Laryngeal Nerve to assess, ask pt to talk past surgery and if pt has APHONIA provide
communication aids paper and pencil

LARYNGOSPASM accidental removal of parathyroid gland therefore will lead to dec

parathormones w/c lead to dec Calcium and laryngospasm KEEP TRACHEO SET at bedside.

TETANY due to decrease in CA characterized by:

a. tingling sensation fingers & lips
b. Chvosteks Sign facial muscle twitching on percussion of facial nerve
c. Trousseau Sign carpopedal spasm

THYROID CRISIS due to rebound hyperthyroidism

Increase thyroid hormone
Increase HRate/palpitation
Inc Temp - hyperthermia

PARATHYROID
Parathormone

Deficiency

HYPOPARATHYROIDISM

Inc CA in the Blood

EXCESS

withdraws Ca @ bone to the bld

MP : Dec Ca (hypocalcemia) maybe hereditary,

Or caused by accidental damage to or removal
Of parathyroid glands during surgery eg thyroidectomy

HYPERPARATHYROIDISM

Increased secretion of PTH that result

in altered state of Ca, Phospate & bone
metabolism

S/S :
Initial S/S:
-

Tingling lips & Fingers

Chvosteks

Bone Pain (esp Back Bone)

Kidney Disorder kidney stones
renal colic

Trousseau

NAV, Constipation

Late S/S
-

personality changes
cardiac arrythmias
muscle pains

Lab Data : Decrease Ca

Serum Phospate Inc
Skeletal Xray reveal Inc Bone density
Nsg Dx :
PI :

RISK FOR INJURY

Inc Ca (N 4.5-5.5 mg/dl)

Dec Serum Phospate Level
xray reveal Bone Demineralization
same

a. Safety

same

b. Keep Ca supplement at Bedside

c. Diet: Inc Ca spinach, sardines, seafoods
d. Tracheo set deu to dec Ca Laryngospasm

Inc Oral Fld intake due to renal

calculi of having INC Ca
Diet; Low Ca
Surgery if due to tumor

TIPS FOR ENDOCRINE

a child w/ PKU was admitted, w/c of the ff statements made by the mother
indicates a need for further instruction my child loves to drink milkshakes
chon- w/c has INCREASE Phenylalanine;

w/c of the ff if manifested by a child could be indicative of diabetes bed

wetting;

a common manifestation of HYPOGLYCEMIA shaky tremors;

a pt post thyroidectomy develops tetany, the nurse anticipates that the doctor will
most likely order Ca Gluconate;

rapid & deep breathing that occurs in diabetic pt is indicative of KETOACIDOSIS

a pt is to receive NPH Insulin at 8AM, when shld the nurse expect to have
hypoglycemia in the late afternoon;

to determine the effect of PTU, the expected outcome is Dec HR;

what would be the question to support the Dx of Hypothyroidism do you tire

easily?;

w/c of the ff statements made by the diabetic pt would indicate the need for
further teaching I will be hypoglycemic if I experience emotional stress.

GENITO-URINARY
General Consideration

when performing assessment of Genito-urinary system, use open-ended question- bec some pt are
not comfortable talking genitals;
explain the meaning of terminologies;
ask the patient what symptoms bother him/her the most;

Consideration for Pediatric Patient

assess for history of sorethroat;

bladder capacity increase with age
infants about 65ml
toddler 300-400 ml
school age 800 1000 ml

infants are unable to concentrate urine until the age of 1 therefore adequate milk intake if baby
has 6-8 diapers /day;

bladder sphincter control develop at around 2 yo (therefore, bladder trng comes after bowel trng
15-18 mos of age)

S/S common to all Disorders of GU:

a. frequency
b. urgency
c. hesitancy
Reportable s/s :

peri orbital edema

BP
Oliguria
Hematuria Early Stream Hematuria indicate lesion at Urethra
Late Stream indicate lesion at bladder

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

d. Increase glucose UTI

e. Elevated CHON Nephrotic Syndrome or PIH
Epispadias opening at DORSAL portion
Hypospadias opening at VENTRAL portion

WILMS TUMOR
S/S :

congenital tumor at the kidney

common in L Kidney and
children below 5 yo

Unilateral Abdml Mass

Hematuria
HPN

Lab Data :
CT Scan
IVP
NO INAVSIVE LAB/ Procedure
NO BIOPSY
Nsg Dx :
PI :

Knowledge Deficit
Risk for Injury

AVOID/ NO ABDOMINAL PALPATION

Prepare pt for Surgery and Chemotherapy

NEPHROTIC SYNDROME

AGN

MP : Altered Kidney Funx related to inability to retain CHON Destruction of Kidney Tissues related
(therefore there is PROTEINURAI)
causes: Autoimmune
congenital

to Group A Beta Hemolytic Streptococus

sorethroat

S/S
EDEMA: Peri-orbital Edema but subside
at the end of the day

Periorbital but progresses to generalized

at the end of the day

BP :

Decrease or N

INCREASE BP

URINE :

Frothy

Tea colored or Cola colored or Smoky

LAB DATA
(+) Proteinuria, severe - >10mg in 24 hrs

Nsg Dx :

(+) Proteinuria - <10 mg/ 24hrs urine

Fld Volume Excess

Impaired Skin Integrity

PI :
Check BP
Maintain Fld Balance
Meds : NO Antihypertensive
(+) Steroids
(+) Antibiotics

Antihypertensive
Diuretics

DIET :
INCREASE CHON, Low Na

LOW CHON and Na

POSITIONING :
Turn Patient frequently because pt w/ edema are prone to skin integrity like pressure sore formation

CYSTITIS
-

Infection of the bladder

Ascending infection caused by E. Coli (from feces) or Pseudomonas

RF :
Wearing silk underwear (does not absorb moist); - use COTTON
Bubble bath
Prolong driving
Common in FEMALE due to size (short) urethra
S/S:
FREQUENCY, URGENCY & HESISTANCY + Burning sensation on urination (dysuria)
LAB DATA :

Urinalysis to check for microorganism

Nsg Dx :

Altered Elimination Pattern

Infection

PI :

Treat for Infection antibiotics for 10-15 days

Diet :

ACID-ASH DIET give lemon juice or VIT C

Bladder Analgesic (ex. PYRIDIUM ch can cause ORANGE COLORED URINE, effective : (-) pain)

Hx Teachings: Avoid bubble Bath

No Silk underwear
Inc. Fld Intake

RENAL FAILURE
ACUTE
MP

CHRONIC

Sudden or Acute, Usually Reversible loss of

Kidney Funx

IRREVERSIBLE kidney damage that

leads to scar formation

There is inability of kidney to maintain fld & E balance

PHASES

Causes

Pre-renal Factors those that dec bld circulating vol. SHOCK;Phase I: RENAL INSUFFICIENCY
Intra-Renal dses condition of the kidney eg. AGN
Post-Renal those that causes obstruction eg. Kidney stones
Polyuria
Nocturia
Polydipsia

Phases of ARF

OLIGURIC PHASE
- decrease urine output that is less than 400 ml/24hr
- Dec NA & Inc K
DIURETIC PHASE
- Inc urine output (4-5L/day)
- Dec Na & K
RECOVERY PHASE
- renal funx normalizes

PHASE II : MILD RENAL DAMAGE

(OLIGURIA)

There will be INC BUN & Crea

RENAL FAILURE
All s/s + Anemia & HPN
ESRD

(1-2 yrs)

LAB DATA
Increase BUN and
Crea most sensitive Index

Azotemia & Uremia

accumulation
of waste products
uremic frost skin pruritus
same

Nsg Dx
Fld and E Imbalance

PI :

Fld & E Imbalance

Activity Intolerance

TO CORRECT THE IMBALANCE

A.
B.

Fluid restriction;
Meds : Diuretics
Cardiac Glycosides Digitalis
Antihypertensive

Fld restriction
Amphogel to promote excretion of
Phospate
Epogen Inc RBC synthesis
Diuretics
AntiHPN
Diet: same

C. DIET : Low CHON NO PMS

DIALYSIS
PERITONEAL

HEMODIALYSIS

Semi-permeable membrane: Abdomen (peritoneum)

Use of Tenchkoff Catheter
Teachings:

Dialyzing machine
Use of fistula or shunt

anastomosis of artery & vein (internal access) less prone to infxn

Report Infxn (abdomen: rigid, Solution : cloudy)

Check BT and CT

external access

Check Temp of dialyzing solution

(more prone to infxn)

Complications of dialysis (report ASAP):

1.

DISEQUILIBRIUM SYNDROME due to rapid removal of solutes (electrolytes and CHON)

s/s:
GI nausea, vomiting, headache
CNS - convulsion, seizures

2. DIALYSIS ENCEPHALOPATHY due to aluminum toxicity

s/s:
(+) dementia
muscle abnormalities twitching
seizures
RENAL TRANSPLANT s/s of complication : FLANK PAIN, FEVER, TENDERNESS, HPN - REPORT

BPH
-

glandular enlargement of the prostrate

common in males above 40 yrs old

S/S :
Decrease size and force of urinary stream
Nocturia
Frequency, hesitancy and urgency
LAB DATA:

Digital rectal exam once a yr for pt 40yo and above

gloves, ky jelly
position: Sims

Nsg Dx :

Altered Elimination Pattern

PI :

Prepare pt for surgery

TURP no incision
Suprapubic Prostatectomy
Retropubic -do Perineal
-do- - common complication: IMPOTENCE due to
nerve damage
I am eager to have sex again cannot be bec pt is impotence

nsgcare :

CBR for 2-3 days post surgery;

NO LONG DRIVE/ SITTING;
Ff up check up (if INC ACID PHOSPATASE: Prostate CA)

TIPS FOR GENITOR-URINARY

A common sign of ARF OLIGURIA;

After peritoneal dialysis, w/c of the ff is appropriate action turn pt to side;

To prevent cystitis, w/c of the ff the nurse must instruct to the pt to do take a
bath using the shower rather than bubble bath;

For early detection of prostrate CA the nurse shld emphasized digital rectal
exam annually to screen for prostrate CA in men 40 yo and above;

In a pt with BPH, the nurse shld expect that the pt will probably have the
symptoms residual urine of more than 50 ml;

A male pt has an arteriovenous fistula in his L forearm, w/c behavior would indicate
that the pt needs further instruction in self care he wears a watch on his L
wrist;

w/c of the ff indicates complication of peritoneal dialysis cloudy dialysate

DAY 8 (Feb 11, 2005)

EENT
General Consideration

Explain to the patient there there will be no or little discomfort when performing EENT exam;
Explain the methods of assessment to the patient;

Consideration to Pediatric Patients

Obtain feeding history (bec the type & techniques differs)

Obtain the diet hx of the pt and hx to URTI
Involve the parents in the assessment of the baby

Reportable Signs and Symptoms

TINNITUS - ringing, buzzing or sea shell sound in the ear

VERTIGO - Objective the room is spinning
Subjective I feel that I am revolving/rotating

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

Keypoints for Assessment

Note for abnormal findings

Document the subjective and objective complaints

OTITIS MEDIA
-

infection of the middle ear

RF :
Faulty feeding practices
Swimming in dirty waters
Upper Resp. Tract Infection
S/S :
PAIN Pulling
Tugging
Crying when lying on the affected ear
Absence of pain indicates rupture of Tympanic Membrane ear drum
Lab Data :
OTOSCOPY revealed reddened, bulging tympanic membrane

Nsg Dx :
PI :

Infection
Sensory Perception Alteration

Treat Infection (antibiotics 7-10 days) if does not heal possible MYRINGOTOMY

Hx Teaching : RIGHT POSITION while feeding

RETINOBLASTOMA
S/S :

congenital tumor of the retina;

genetically transmitted;
autosomal dominant (common in MALE and FEMALE)
LEUKOCORIA cats eye reflex
- whitish or grayish discoloration of the pupil
Diplopia and or Strabismus

LAB DATA :

PE
Opthalmoscopy

Nsg Dx :

Knowledge Deficit

Tx :

Surgery Inoculation done b4 age of 3 (chemotherapy after surgery)

Genticist

RETINAL DETACHMENT

GLAUCOMA

CATARACT

Aging (above 40)

Aging (above 40)

Aging (above 70)

Related to trauma

Common in Blacks
Related to Trauma
Familial Predisposition
Rel. to Diabetes
Rel. to Steroids
Rel. to Chromosomal Abberation
- those with D. Syndrome are prone

RF:

RETINAL DETACHMENT
MP : There is separation of sensory and pigment portion of the retina therefore it will allow fluids to go in
between which give rise to OUSTANDING manifestation as:
VISUAL FLOATERS pt says: I see light structures
Curtain like
Floating spots
Cobwebs
S/S :

NO Pain
Blurring of vision because of floaters

Lab Data :

Opthalmoscopy

Nsg Dx :

Risk for Injury

PI :

Immediate Bed rest AFFECTED SIDE TOWARDS THE BED to allow the connection of
DETACHED PART
NO SUDDEN HEAD MOVEMENT
AVOID reading (TV ALLOWED)
Prepare Pt for Surgery:

SCLERAL BUCKLING use of laser to reduce inflammation and

when inflammation subside, the
detached retina portion will be attached
thru scar formation.

POST SURGERY :

AVOID activity that requires BENDING, LIFTING, COUGHING;

(No Bowling & shampooing of hair at sink)

REPORT SUDDEN eye pain indicative of bleeding/ hemorrhage

GLAUCOMA
MP :

INCRASE IOP due to obstruction in the outflow of acqeous humor or could be related to
forward displacement of the iris.
TREATABLE but NOT CURABLE
If Obstruction related :

could lead to CHRONIC OPEN ANGLE.

If due to Forward displacement: can lead to ACUTE CLOSE ANGLE

S/S :
TUNNEL or Gun Barrel Vision wherein there is loss of Peripheral Vision
Halos around lights rounded rings around eyes
CLOSED ANGLE GLAUCOMA (+) pain
OPEN ANGLE GLAUCOMA minimal or (-) pain
LAB DATA:
Tonometry measures IOP (N12-21) PAINLESS
ACUTE G as high as 25;
Chronic G - as high as 50

Nsg Dx :
PI :

Gonioscopy
Opthalmoscopy
Perimetry measures visual field
Risk for Injury

TO DECREASE IOP
How:
a. Administer MIOTICS (Pilocarpine, Tomolol, Diamox) for LIFE
- it decrease the production of ACQEOUS HUMOR admin. At lower conjunctival sac

b. Prepare pt for Surgery : TRABECULOPLASTY a new pathway was created for the passage of
the blocked fluids;
- Out-patient only (use of laser only)

TRABECULECTOMY
Hx Teachings : same w/ retinal detachment

requires hospital admission for 1-2 days

CATARACT
MP : Opacity of the Crystalline Lense
S/S :

Blurred Vision (Poor Color Perception)

NO PAIN

LAB DATA:
a. SLIT LAMP TEST test for red light reflex
(this reflex is absent in cataract pt due to presence of milky white lens)

b. Opthalmoscopy
Nsg Dx :
PI :

Risk for Injury

Prepare for SURGERY

CATARACT EXTRACTION

Extra Capsular Cataract Extraction (ECCE)

Intra Capsular Cataract Extraction (ICCE)

ECCE removal of anterior part

ICCE removal of entire capsule

PHACOEMULSIFICATION - needle is inserted to lens and send vibration thereby crushing

the cataract then suction it out

PERIPHERAL IRIDECTOMY a whole is created then suctioning

Post Cataract Surgery NO SEX for 4-6 weeks

Health teachings same w/ R. Detachment

MENIERES DSES

OTOSCLEROSIS
(hardening of the ears)

RF :

High altitudes
Aging
Ototoxic Drugs

MP :

Cause by an imbalance of EndoLymphatic Fluids in the inner ear

S/S :

Aging

Overgrowth of the stapes

Sensori-neural hearing loss since

Inner ear was affected

Conductive Hearing Loss

- since middle ear was affected

Tinnitus
Hearing Loss +
VERTIGO (only for M. DSES)

same

Lab Data:

Caloric Stimulant test

same

Webers test lateralization of sound

Rinnes bone conduction
Audiometry
(above test use of TUNING FORK)

Nsg Dx :

Risk for Injury

PI :

SAFETY
(to prevent pt from falling:
bedrest or supine danger of falls)

Sensory Perceptualalteration
Establish Communication
Surgery : STAPEDECTOMY mobilization of
stape

DIET :

LOW NA (AVOID Alcohol & Caffeine containing food)

Meds :
Effective :

AntiVertigo Diamox, Bonamine

(-) Vertigo/ Falls
AVOID - driving
PMS
Sudden Head Movement

Post Surgery Hx Teachings:

AVOID diving
Small airplane
Coughing
Blowing of Nose
Bending

TIPS FOR EENT

A pt who underwent cataract surgery w/ intraocular implantation is scheduled for

discharge, the nurse shld instruct the pt to do w/c of the ff when pain occurs
notify the AP;

w/c Nsg Dx is considered a priority for a pt with Menieres Dses Risk for Injury

a Tonometer is used for the purpose to determine IOP;

Post Cataract Extraction : how shld the nurse position the pt UNAFFECTED SIDE
to minimize edema;

w/c of the ff is a common manifestation of Retinoblastoma Cats Eye Reflex;

The parents of the pt w/ retinoblastoma must be referred to - GENETICIST

GASTROINTESTINAL
GENERAL CONSIDERATION

Provide privacy
Ask the pt when he 1st notice the S/S
Eg. LIVER CIRRHOSIS when did you notice that your eyes turns yellow?

PEDIATRIC CONSIDERATION

Introduction of FOOD: (shld be in order)

Cereals
Fruits
Vegetables
Meat
Table foods
Obtain child Dietary History
Assess for over-intake of milk poor source of iron (IDA)

REPORTABLE S/S
Vomiting
Abdl Pain (if more than 6hrs) R/O rupture of the bowel
Tarry Stool indicates bldg (upper GI)
Fever, Tachycardia, Dehydration indicative of SHOCK
Hypotention
KEPOINTS
Bowel Sounds (check all 4 quadrants- N 5-35 bowel sounds/min)
- to assess, use DIAPHRAGM of Steth to listen for normal sounds
BELL part of Steth to listen for abnormal bowel sound
Ex. bruit abnormal vascular sound w/c indicate abdml aortic aneurysm

DIARRHEA/ AGE
-

usually asso w/ NORWALK

(common in ship),

ROTAVIRUS and CLOSTRIDIUM DEFFICELE

MP : Passage of watery and loose stools (BEST judge in the consistency)

S/S :
Frequent stools
Sign of DHN sunken fontannels
Poor Skin Turgor
Absence of Tears (for more than 2 MONTHS old infant)
Check for complication : Metabolic Acidosis
If excess fluid loss, it will progress to shock due to K loss (hypokalemia)
LAB DATA :
Stool Exam to check for bacteria
Nsg Dx :

PI :

Diarrhea
Fluid Volume Deficit
Place pt on ENTERIC ISOLATION PRECAUTION
while waiting for lab result

(handwashing & gloves ONLY)

CHALASIA

GERD

CONGENITAL WEAKNESS OF THE CARDIAC SPHINCTER

S/S:

vomiting - NON-BILE-STAINED

Hear-burn due to Reflux of Acid

Complication :

METABOLIC Acidosis
BARRETTS ESOPHAGUS

same
same

- damage to mucosal lining of lower esophageal mucosa w/c can lead to esophageal CA

LAB DATA :
Upper GI Series (Ba Swallow)
Gastroscopy
Esophagoscopy

do

do

do

Nsg Dx : Altered Nutrition Less Than Body Requirement

Flds & E Imbalance
PI :

Insure Adequate Nutrition

Position: Place pt in UPRIGHT to avoid vomiting
(if BABY: use HARNESS or PRONE w/ HEAD UP POSITION)

Administer flds
Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, therefore X100)
Health teachings crackers, juice, water
Feeding : Thickened
Prepare pt for surgery : NISSINFUNDOPLICATION part of fundus will be sutured to
esophageal area to tighten
Effective: if (-) vomiting and(-) reflux and heartburn

POISONING
INTERVENTION:
a. CALL poison control center;
b. MINIMIZE EXPOSURE remove pt from the scene
c. IDENTIFY the type of poison
if unknown substance was taken bring bottle or foil for proper identification
TYPES:

CORROSIVE DO NOT INDUCE VOMITING

Management: NEUTRALIZE the poison
If STRONG ACID give WEAK BASE

(eg. ACID give MILK)

IF STRONG BASE use weak ACID by using vinegar

NON-CORROSIVE induce vomiting by stimulating GAG REFLEX

How:

a.

b.

Use fingers or tongue blade

Syrup of Ipecac administer w/ glass of H2O make sure that all taken will be
vomited bec it is cardiotoxic (after 1hr can repeat)
dosage:

CHILDREN 15 ML
ADULT
- 30 ML

CLEFT

LIP
MP:

PALATE

Non-fusion of facial process

Non-fusion of Palative Processess (soft & hard)

(congenital)

(congenital)

Nsg Dx : Altered Nutrition

Risk for Aspiration
Body Image Disturbance
PI :

Nutrition
Safety
Prepare for Surgery

Surgery :
Chiloplasty

Palate Uranoplasty

- for 10wks old

10 lbs
10gms/hgb
10,000 WBC

- if child is 15-18 mos

Post Surgery:

CRYING shld be minimize bec it will put pressure at suture line;

LOGAN BAR/ BOW it decrease tension at suture line;
ELBOW RESTRAINT prevent child from touching the suture line;
FEEDING DEVICE C CLIP use dropper, C PALATE use Breck Feeder/ cup
Refer pt to:
SPEECH THERAPIST, AUDIOLOGIST & PSYCHOLOGIST

PYLORIC STENOSIS
-

congenital
hypertrophy

(kumapal)

of the pyloric sphincter (bet stomach & intestine)

S/S :

PROJECTILE VOMITING

(INITIALLY, NON-BILE STAINED but eventually it PROGRESSESS TO bile-stained)

If sitting
: 4-5 ft
If lying down : 1 foot
Feeding should be thickened then AFTER FEEDING, place to RIGHT SIDE LYING SEATED
at car seat to facilitate the entry of food from stomach to duodenum

OLIVE-SHAPE MASS
VISCIBLE PERISTALTIC MOVEMENT usually from L to R of the abdomen w/c can lead to DHN

LAB DATA :
Ba Swallow (+) string sign
NSg Dx :

Altered Nutrition
Fluid Vol Deficit
Fld and E imbalance

PI :

Nutrition
Surgery FREDET-RAMSTEDT or PYLOROMYOTOMY

CELIAC DISEASE
-

GLUTEN INDUCED ENETEROPATHY

incision at pyloric sphincter

MP :

Genetic predisposition
Life-time disorder
Intolerance to GLUTEN

OUTSTANDING S/S :
Malabsorption Syndrome-crisis
Abdl Enlargement this can be triggered by INFECTION & Fld and E imbalance
Anorexia
Anemia
- there will be SEVERE DHN
LAB DATA :

Diagnostic Test : GLUTEN CHALLENGE 3-4 mos give gluten rich food
And if there is malabsorption, therefore (+) CDses

Nsg Dx :

Altered Nutrition

PI :

Dietary Modification :

AVOID GLTUEN RICH FOOD :

ALLOWED :

Barley, rice, oats, wheat

Rice, cereals, corn, soy beans

Commercially prepared cakes are made of wheat AVOID

Ok or allowed: if pt say I will prepare a homemade cake
AVOID : spaghetti, macaroni, sausage, luncheon meat, hotdog

HIRSCHPRUNGS DISEASE
MP :

(AGANGLIONIC MEGACOLON)

Absence of parasympathetic nerve fibers in a portion of a colon dilation, abdominal

distention and pellet-like or ribbon-like stool.
Patient meconium ileus & constipation HALLMARK SIGN

LAB DATA : BA Enema

Nsg Dx :

Altered Ellimination

Diet :

High Fiber
Increase fluids

Tx :

Give Enema

Meds :

Laxative
Surgery SOAVE Surgery resection with end to end pull through

INTUSSUCEPTION
MP : There is telescoping of a part of a colon which leads to inflammation and edema

S/S :

sausage-shape mass
Abdominal distention
Dance sign the R lower portion of the colon becomes empty
Vomiting : BILE-STAINED
Constipation
LAB DATA : Ba Enema: if for DIAGNOSTIC
: it outlines the area involve
if for THERAPEUTIC : it reduces intussuception by means of hydrostatic pressure
Nsg Dx :

Constipation
Altered Elimination

Diet :

Inc. Flds.
High Fiber

Tx :

wonder drugs steroid

surgery

TRACHEOESOPHAGEAL FISTULA (TEF)

MP : Failure of the esophagus to develop as a continous process
Types :

AF1
AF2
AF3
AF4
AF5
AF6

esophagus NOT connected w/ abdomen/stomach

esophagus attached to trachea (when pt eat, it goes to the lungs)
stomach connects w/ trachea
stomach & esophagus connected
stomach, eso and trachea are connected
separated properly

Atresia narrowing
Fistula connection
S/S :

Excessive Drooling danger in aspiration

(avoid glucose water as initial feeding use sterile H2O instead.)

Coughing, Chocking
Cyanosis
LAB DATA :

Lateral Neck Xray to check the esophagus

Nsg Dx :

Risk for Aspiration

PI :

Safety
Airway
Keep child NPO just give pacifier

Tx :

(if feeding OK use sterile H2o instead NOT GLUCOSE)

Surgery

TIPS FOR GASTRO PEDIA

w/c of the ff signs if manifested by a child post tonsillectomy needs to be reported

FREQUENT SWALLOWING;

a child who has had several episodes of diarrhea is likely to develop metabolic
acidosis;

in relation to dx of p. stenosis, w/c of the ff actions of the nurse is important

weighing pt daily for wt loss;

w/c of the ff will the nurse expect to observe in a child who loss fluid due to
diarrhea flushed dry skin;

the most appropriate feeding device for a child post cleft palate paper cup;

the priority nsg care for a child on NPO is offer a pacifier regularly;

a common manifestation of pyloric stenosis is visible peristaltic wave;

the priority nsg dx for a pt w/ rotavirus infection is diarrhea;

w/c of the ff is expected in a child suffering from celiac dses intolerance to

gluten

PEPTIC ULCER
RF :

Stress
Smoking
Salicylates or NSAIDS
Helicobacter Pylori
Zollinger-Ellison Syndrome (gastinoma) tumor of the stomach
GASTRIC

ESOPHAGEAL

due to increase HCL acid

DUODENAL

RF :

same

same

MP :

Weakened Mucosa
Common in Female
Below 65
Inc risk for CA

Excessive HCL Acid

Common in Male
65 yo & above

OUSTANDING S/S: PAIN aching, burning, gnawing

PAIN 30mins 1hr post meal
PAIN at daytime
Pain relieved by vomiting

2-3hrs after meal

Nightime
Pain relieved by eating
Also related as hyperacidity

HEMATEMESIS (vomiting of blood)

- severe bleeding shock

LAB DATA :

GASTRIC Analysis (diamox blue urine)

Gastroscopy
BA Swallow
HgB
Hct
Nsg Dx :

PAIN

PI :

Relief of Pain

Meds :

ANTACIDS:

Maalox
it NEUTRALIZE HCL Acid;
RANITIDINE - it DECREASE HCL Acid;
SUCRALFATE - it COATS the GIT

NO ASPIRIN
Diet :

BLAND DIET NO SPICY, fried, raw fruits and vegetables

(EXCEPT: avocado, banana & pineapple)

GASTRIC SURGERY

VAGOTOMY
PARTIAL GATRECTOMY Billroth I (BI) and Billroth II (BII)
TOATAL GASTRECTOMY

BI gastrodoudenostmy duodenum and stomach

BII gastrojejunostomy stomach and jejunum
COMPLICATIONS:

PERNICIOUS ANEMIA due to decrease INTRINSIC FACTOR w/c came from stomach;
DUMPING SYNDROME (occur usually for

10-12 mos post surgery)

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

GASTRO-COLIC REFLEX is usually due to increase CHO INTAKE in the diet
- NO PANCAKE, NO UPRIGHT SITTING AFTER MEALS

S/S OF Dumping Syndrome :

Diarrhea
Diaphoresis
Dizziness/drowsiness

Management:
NO FLUIDS after meals instead in between meals
DIET: High Fats because it delays the emptying of the stomach
LOW CHO
Lie down after eating

INFLAMMATORY BOWEL CONDITION

ULCERATIVE COLITIS

DIVERTICULITIS

CROHNS DSES
(Regional Enteritis)

RF : With familial Predisposition

Common in those LOW FIBER Diet Related to Genetics
Smoking as Protective Effect
Common in Aging
Common in Obsessive-Compulsive
Or Stress Related or to perfectionist
MP :
Inflammation @ large Intestine
Inflam @ L Intes.
Specifically @ recto-sigmoid colon
at DIVERTICULUM
S/S :

Inflam of small &

large intestine

same

same

DIARRHEA

(15-20x/day)
bloody mucoid

diarrhea & constipation

3-4x/day

FEVER

(+)

(+)

(+)

CRAMPY ABDL PAIN

LLQ
(Rigidity (REPORT ASAP) sign of colon rupture)
LAB DATA:

BA ENEMA
Colonoscopy
Stool Exam

Nsg Dx :

PAIN
Altere Elimination: Diarrhea

PI :

Relieve Pain
Meds:

Steroids

LLQ

RLQ

Anticholinergic
Antidiarrheals
Antispasmodic
DIET :

Low Fiber and Low Residue for Ulcerative and Chrons

Diverticulosis High Fiber/residue allowed: vegetables
Low residue (no vegetables)

SURGERY :

Colostomy irrigate
Ileostomy no need for irrigation

Characteristic of N Colostomy

REDDISH or PINKISH
EDEMATOUS
MOIST
N elevation from skin: 2.5 cm
Diameter : 5cm

When to empty colostomy: when 1/3 full (EMPTY DO NOT CHANGE)

When to change C. Bag : 48hrs or 3x a wk
BEST TIME TO DO COLOSTOMY CARE at home, while in the bathroom
STOP colostomy irrigation if patient (+) ABDOMINAL CRAMPS

HEMORRHOIDS
MP

Varicosities of the ANAL SPINCHTER

RF
PREGNANCY
PROLONGED STANDING
PORTAL HPN hepatic enceph and liver cirrhosis

GRADE
I
II
III
IV

Small Area
Large Area reduces spontaneously
Entire Area manual reduction
Entire Area irreducible

TYPES
INTERNAL H above the spinchter
EXTERNAL H below the spinchter

S/S

Pruritus
Pain
Bleeding

LAB DATA

Sigmoidoscopy
Proctoscopy
P Exam

Nsg Dx

Altered Elimination

PI

Diet :

High Fiber
Avoid Spicy

PAIN use SITZ BATH (48 degree C temp of H2o)

- emerge up to pelvic area with ice pack at head to prevent dizziness
STOOL SOFTENER
SURGERY

PANCREATITIS
-

AUTODESTRUCTION OR AUTODIGESTION of the pancreas

RF

#1 Alcoholism
#2 autoimmune
High Fat Diet
Biliary Dses

SS

PAIN @ peri-umbilical area or epigastric that radiates to peri-umbilical area

GREY TURNER SIGN pain w/ bluish discoloration at flank area;

CULLENS SIGN pain w/ bluish discoloration @ umbilicus
NAUSEA & VOMITING
SHOCK as complication
LAB DATA

Elevated Serum Amylase (N56-190 u/L that normalize in 2 wks)

Nsg Dx

PAIN

PI

Relieve PAIN
Meds: DEMEROL DRUG OF CHOICE
AVOID MORPHINE it causes more pain bec it will causes spasm to the spinchter of oddi

DIET

LOW FAT
AVOID alcohol

CHOLELITHIASIS

CHOLECYSTITIS

Combine or usually come together in a pt

Stone in gall bladder

Inflammation of the G. bladder

RF

Fat
Female
Fertile
Forty
flatulence

same

S/S

R UQ Pain radiating to R shoulder or R Scapula usually precipitated by FATTY INTAKE

GI S/S NAV diarrhea and Jaundice
URINE: dark colored
STOOL : clay-colored or grayish alcoholic stool

LAB DATA

Increase AMYLASE, WBC, FATS

Increase Liver Fnx test
USG

Nsg Dx

PAIN

PI

Relief of Pain
meds : DEMEROL
diet:
LOW FAT
surgery :

1) LAP. CHOLE 4 small incision, CO2 insufflation

2-3 days after discharge pt and back to ADL
1 WK after pt can lift weight
2) CHOLECYSTECTOMY R SUBCOASTAL
- complication: Pneumonia
report rusty-colored sputum
hx teaching: TURNING, COUGHING, DEEP BREATHING

HEPATITIS
MP

Inflammation of the Liver

TYPES
A

Infectious

SERUM

POST TRANSFUSION

DELTA HEPA

ENTERICALLY-TRANSMITTED

Fecal-oral

bld, body flds

Non A & B

Post Hepa B

Fecal-oral

2-6 wks

6wks-6mos

70-80 days

6wks-6mos

(Hepa A & B Combination

STAGES OF HEPA B

PRE-ICTERIC - 1-2 days : S/S NAVDA NO jaundice yet;

ICTERIC
- 2-4 wks w/ jaundice;
POST ICTERIC - 2-4 mos s/s subside

Lab data

Increase Liver Funx Test (Inc AST/ ALT)

Hepa A Inc HaV
Hepa B HbsAg

Nsg Dx

Infection
Alt Skin Integrity
Body Image Disturbance

PI

Tx for Infection
a. Meds : HEPATOPROTECTORS
DIURETICS
b. Diet : High Calorie
Low Fat
Isolation : A & E Enteric
B, C, D Universal

COMPLICATION Liver Cirrhosis

LIVER CIRRHOSIS
- scarring of liver tissues
TYPES
LAENNES

BILIARY

Due to alcoholism

CARDIAC

Due to biliary Disorder

POST NECROTIC

due to CHF

due to Hepatitis

S/S are related to 3 FUNXs of the LIVER

MANUFACTURES :

bile, immunoglubolin, & clotting factors

METABOLIZES:

CHO, Fats, CHON, Alcohol and Drugs

STORES :

Vitamins & Minerals

Signs and symptoms

a.
b.
c.
d.

pt prone to bleeding;
malnutrition no cho metabolize
edema due to fld retention (bec of dec albumin)
Flds & e imbalance

LAB DATA

Increase Liver Funx Test

Liver Biopsy

Nsg Dx

Risk for Injury

Fld & E imbalance
Fld Vol Excess
Altered Nutrition

PI

SAFETY
HOW?

Meds:

Diuretics due to fld retention

ANTIHPN due to portal HPN
Clotting factors : Coagulants give Vit K (to avoid bleeding)

Diet :

LOW CHON or CHON to Tolerance

Or High Biologic Value CHON good quality CHON (eg poultry products)

SURGERY :

Liver Transplant

COMPLICATIONS:

a. HEPATIC EBCEPHALOPATHY accumulation of ammonia toxic to brain

s/s:

PERSONALITY CHANGES
DECREASE LOC or irritability/ restlessness

DRUG OF CHOICE : Neomycin, Lactulose

- facilitate excretion of ammonia by acidifying the colon
- common s/e : DIARRHEA

b. ASCITIS accumulation of fluids at the abdomen

s/s :

wt gain
Increase abdl girth I cannot button my pants anymore
(fluids)

management: abdominal paracentesis aspiration of fluids from the peritoneum

- complication: chance for infection & shock
pt preparation:

#1 instruct pt to void;
#2 position: sitting the evaluate the WEIGHT, ABDL GIRTH & REPSIRATION

effective if : Pt decrease wt of 5 lbs and decrease or N RR

c. BLEEDING ESOPHAGEAL VARICES DUE TO portal HPN

Lab data

Sengstaken Blakemore Tube 48 hrs inflated, scissors at bed side

(Balloon Tamponade)
- effective if (-) hematemesis

TIPS GASTRO ADULT

A pt w/ appendicitis was admitted, of ALL the ff written orders, w/c shld the nurse
prioritize Administration of Antibiotics;
w/c statement if made by a pt w/ cirrhosis is a risk factor for having the disease
I drink 2 glasses of alcohol /day;
which of the ff indicates a ruptured appendix absence of pain;

 ff subtotal gastrectomy, the nurse shld expect gastric drainage for the 1st 12 hrs to
be reddish brown;
the priority nsg care post common bile duct exploration preventing hypostatic
PNA;

w/c question during nsg assessment would confirm the Dx of L Cirrhosis

- how long have you noticed the white in your eyes turns yellow;

the priority nsg dx for a pt w/ Hepa B altered Nutrition

the priority nsg dx for for pt w/ acute pancreatitis Altered nutrition less
than body requirements

NEUROLOGY
DECORTICATE abnormal FLEXION
DECEREBRATE abnormal EXTENSION
Opistotonous back arching
GENERAL CONSIDERATION
When assessing the neurological system, pay attention to the ff:

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

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

PEDIATRIC CONSIDERATION
a. Check for bowel and bladder funx indicates neurological maturity
15-18 months START BOWEL TRAINING
2 yo start bladder training
b. Assess for their habits
security blankets ex. Stuff toys, mother wallet
Associate mothers time w/ child activity (children has NO DEFINITE TIME)
Ex. Your mom will be back after you have eaten your lunch.

c. Assess for presence of URTI could be sign of Meningitis, Hemophilus influenza, Otitis Media
d. Assess child for S/S of anxiety
-

bed wetting
nail biting (N up to 4 yo)
head banging
excessive thumb sucking

e. CONTUSSION more severe, fatal and could even lead to death

CONCUSSION jarring of the brain, na-alog w/c could lead to s/s of LOC in 24-48 hrs
DECORTICATE abnormal flexion which indicates damage to the cortex
s/s :

#1 Decrease LOC
#2 widening pulse pressure (increase systolic BUT diastole is N)
#3 Convulsion & seizures
ABOVE ARE S/S OF INCREASE ICP.

DECEREBRATE more serious

- abnormal extension w/c indicates damage to brain stem

GLASGOW COMA SCALE

EYE OPENING (4)

4
3
2
1

VERBAL RESPONSE (5)

5
4

OPEN SPONTANEOUSLY
OPENS TO VERBAL COMMAND
OPEN TO PAIN
2
NO RESPONSE
1
SCORE OF 3

SCORE OF 15
Score of 8

INCOMPREHENSIBLE
NO RESPONSE

6
5
4
3
2
1

OBEYS COMMAND
LOCALIZES PAIN
WITHDRAWS FROM PAIN
INAPPROPRIATE
3 - DECORTICATE RIGIDITY
DECEREBRATE RIGIDITY
NO RESPONSE

NO response (DEAD) Doctor will the one to pronounce

:

ORIENTED
CONFUSED

MOTOR (6)

pt is awake
50-50, MONITOR THE PT

7 and BELOW

pt is COMA

CRANIAL NERVES
I.

OLFACTORY :

SENSORY :

II .

OPTIC

III.
IV.
VI.

OCCULOMOTOR
TROCHLEAR
ABDUCENS

V.

TRIGEMINAL

SIGHT

smell -

Abnoxious smell
Anosmia no smell
Perfume

snellens chart 20/20 usually by age 3-6 yo

Eye movement - 6 cardinal direction of gaze

(if abnormal look for DIPLOPIA)

: SENSORY :

responsible for FACIAL SENSATION

(to check, use cotton & needle and run across the cheek)

AND MOTOR :

ability of pt to chew

Reflex: CORNEAL REFLEX (+) if both eyes can blink

VII.

FACIAL

SENSORY :
and

VIII.

MOTOR

sense of taste @ anterior 2/3 of the tongue

Facial Expression

ACOUSTIC or VESTIBULOCOCHLEAR

- Sense of hearing and balance

TEST : ROMBERGS TEST - stand erect, close eyes, observe for balance

IX.
X.

GLOSSOPHARYNGEAL
VAGUS

SENSORY
MOTOR

XI.

SPINAL ACCESSORY

XII.

HYPOGLOSSAL

Posterior Taste 1/3 Of The Tongue

- swallowing and gag reflex

- motor movement of shoulder muscle

TONGUE MOVEMENT

DUCHENES MUSCULAR DYSTROPHY (DMD)

X linked RECESSIVE (only mother transmit to SON)
(-) Father

Mother (+ carrier)

Son - 50% chance

Daughter as Carrier 25% chance

DMD

Erb Duchennes Paralysis (EDP)

Klumpke Palsy (KP)

Related to Birth Injuries affecting the BRACHIAL PLEXUS nerves at axilla portion
HEREDITARY

EDP upper plexus

KP - lower plexus

w/c leads to paralysis.

Prognosis : complete recovery in 3 months
Treatment : splint and cast for 3 mos leads to nerve

regeneration

X-linked RECESSIVE DIRORDER

MP

characterized by progressive muscle atrophy

w/c apparent in male at the age of 3

S/S

a) GOWERS SIGN inability to stand up

- use arms to brace the body
b) WADDLING GAIT - duck-like gait
c) impaired mobility
d) difficulty in running and climbing

COMPLICATIONs

Respiratory Paralysis for young children

Cardio-Resp. Arrest - for adolescent

LAB DATA

Muscle Biopsy
PExam

Nsg Dx

Ineffective Breathing Pattern

Impaired Physical Mobility

PI

AIRWAY
(keep TRACHEO at bedside)

TX
a.
b.

Supportive - leg brace, crutches

Refer parents to geneticist
Target: Mothers or FEMALES bec they are the source of transmission
Ex. Aunt, Female Sibling, mothers, female members of the family (bec transmission: X linked recessive)

CEREBRAL PALSY
- Permanent, Fix (non-progressive) neuromuscular disorder characterized by abnormal
muscle movement.
Cause

Unknown

S/S

Exaggerated Reflexes
Protrusion of the tongue or tongue thrusting
Early pattern of hand dominance
Back Arching
Scissors-gait

LAB DATA

Neurological Assessment
PExam

Nsg Dx

Risk for Injury

Impaired Physical Mobility

PI

SAFETY
a.

Leg braces

b.
c.
d.

Meds : Anticunvulsants, Muscle Relaxants

Prepare child for SURGERY release of TENDON OF ACHILLES to promote mobility
Refer child to :

PT for gross motor movement walking

OT - for fine motor to open a bottle of soft drinks

HYDROCEPHALUS
NOT A DISEASE but a manifestation of an existing disorder

Related to ARNOLD CHIARI MALFORMATION

DANDY WALKER SYNDROME

there is ELONGATION of the BRAIN STEM or Medulla

- characterized by ATRESIA of
and it protrudes to Foramen magnum
Foramen of Luschka & Magendie
SIDE NOTES:

FLOW OF CSF (N amt : 100- 200 ml) rich in glucose

From Lateral Ventricle it goes to Foramen of Munroe then to 3rd Ventricle then to Aqueduct of Sylvius then it moves
to F. of Luschka and Magendie going to 4th Ventricle then it goes back to subarachnoid spaces of brain.
S/S OF HYDROCEPHALUS

PROJECTILE VOMITING
IRRITABILITY
ENLARGED HEAD N Head Circumference : 33-35 cm (chest circum: 31-35 cm)
SEPARATION OF SKULL BONES
SEIZURES

SUNKEN EYES Can Progress To Bossing Sign

MACEWEN SIGN crack pot sound upon knocking the head

LAB DATA

CT Scan
MRI
PExam focus on head circumference
(tape measure at bedside to measure H Circumference)

NSG DX

Risk for Injury

PI

SAFETY

Position

Semi Fowlers to prevent increase in ICP

Meds

Diuretics
Anticonvulsants

Surgery

Ventriculo-Peritoneal Shunt progressive procedures

(AS CHILD AGE PROGRESSES, the surgery is revised)

SPINA BIFIDA

failure of a PORTION of spinal cord to fuse

TYPES

SB OCULTA
NO SAC
W/ DIMPLE or TUFT OF HAIR

SB CYSTICA
W/ SAC
SUB TYPES:
Meningocele w/ sac that contains CSF and meninges;
Meningomyelocele CSF, meninges and portion of
spinal nerves

LAB DATA

Amniocetesis test for ALFA FETO CHON if INCREASE Neural Tube Defect
If DECREASE Down Syndrome
CT SCAN
PExam

NSG DX

Risk for Injury

PI

Protect the sac

a.
b.
c.

SURGERY

Position: Prone or side lying (NEVER SUPINE);

Wet sterile gauze to cover the skin;
DOUGHNUT ring

WITHIN 24-48 HRS

COMPLICATION

Bladder and Bowel Problem

Paralysis of Lower Extremities

Post Surgery Complication

Hydrocephalus (tape measure- at bed side)

INCREASE ICP

ICP above 15mmhg (N 0-10)

Mild elevation : 11 20
Moderate
: 21 - 30
Severe
: 31 and above

With the use of INTRAVENTRICULAR or SUBDURAL MONITORING DEVICE to monitor ICP

RF

Hydrocephalus
Space Occupying Lessions
Brain Tumor
Trauma

S/S
1. INITIAL: Behavioral Changes irritability,
restlessness,
decrease LOC drowsiness or pt becomes sleepy
2. Vital Signs Changes widening pulse pressure
DECREASE RR and PR
INCREASE temperature
3. Vomiting
4. Monitor Abnormalities decorticate, decerebrate

Nsg Dx
PI

Risk for injury

To decrease ICP

Head of Bed ELEVATED

Evaluate Neuro Status Glasgow
AIRWAY
Discharge Meds Instruction

Seizure precaution DARKENED ROOM

Anticonvulsants, Steroids, Diuretics (mannitol to dec amt of cerebral edema)

MENINGITIS
Inflammation of meninges w/c could be related to
the presence of bacteria esp the H. Influenza, and
Neisseria Meningitidis
disorder
S/S of

MENINGISMUS
Inflammation of meninges but WITHOUT
infection
Usually accompany w/ resp.

INC ICP + Kernigs Sign pain on extension of lower extremities

+ Brudzinkis
- flexion of neck would lead to flexion of lower ext.

- sign of MENINGEAL IRRITATION

LAB DATA

Lumbar Puncture
CSF Analysis

Nsg Dx

Infection
Risk For Injury

PI

Safety
Seizure Precaution
Tx the Infection
Type of Infcetion:

a. Bacterial Meningitis respiratory of droplet precaution

b. Viral Meningitis - enteric precaution
MEDS

Antibiotics

to AUDIOLOGIST

For Bacterial Meningitis - may cause hearing impairment - refer

REYES SYNDROME
Non inflammatory, non recurring but TOXIC ENCEPHALOPATY and HEPATOPATHY
(CNS)

RF

Presence of Viral Infection

Use of Aspirin

TRIAD S/S

Fever
Impaired Liver Funx
Impaired Consciousness w/c could lead to convulsion

STAGES

I
II
III
IV
V

LAB DATA

Bleeding and Clotting Time

Liver Biopsy
Neurological Assessment

Nsg DX

Risk for Injury

Altered Thought Process
Altered Thermoregulation
Impaired Physical Mobility

PI

Treatment symptomatic assess neuro status

Bleeding give Vit K
AVOID ASPIRIN when there is VIRAL INFECTION

pt becomes lethargic
confusion
decorticate rigidity
decerebrate rigidity
seizure or coma

CVA/ STROKE
MP

Decrease Oxygen to brain cells

TYPES
THROMBOSIS
EMBOLISM
HEMORRHAGE
INFARCTION

(LIVER)

RF
atherosclerosis
hpn
obesity
smoking
stress
age/ gender
SIGNS & SYMPTOMS:
1. DEPENDS ON THE PROGRESSION

a. TIA brief period of neurologic dysfunction that last less than 24 hrs (between episode, pt is
N);

b. STROKE IN EVOLUTION there s/s like: facial paralysis

Muscle weakness
- above s/s could last 2-3 days
c. COMPLETE STROKE there is FOCAL s/s
if R side of Brain Affected L Eye - R Face L Body
if L Brain R Eye L face R body
2. RELATED TO LOBES

FRONTAL if affected PERSONALITY CHANGES

TEMPORAL - memory disturbances

BROCAS AREA (expressive aphasia mouth

opening);

WERNICKS LANGUAGE AREA (choice of words, understanding - RECEPTIVE APHASIA);

PARIETAL - DISORIENTATION especially SPATIAL orientation;

OCCIPITAL - VISUAL disturbances

3. SIGNS AND SYMPTOMS INDICATIVE OF COMPLICATIONS

Hemianopsia

loss of half of the visual field (eg. Pt consumes half of the food at plate);

Hemiphlegia

paralysis of one side of the body;

Emotional Lability
Aphasia

mood swing
Expressive inability to find right words to say (damage to Brockas Area);
- pt can say right words mgt: picture board
and Receptive - inability to understand spoken words (Wernicks area)
mgt: talk to pt slowly

Dysphagia

instruct the pt to swallow twice to prevent aspiration

LAB DATA

Increase Cholesterol

Diagnostic Test

CT Scan
MRI
EEG

Nsg DX

Unilateral Neglect inability to care half of the body

Impaired Physical Mobility
Risk for Injury

PI

SAFETY
Position

Semi-fowlers
Elevated

Meds

Antihypertensive
Diuretics
Antilipimic Agents
Anticonvulsants
Thrombolytics if (+) thrombus to dissolve clots
Low Na and Cholesterol

DIET
Activity

Range of Motion Exercises

Surgery

Craniotomy
Infratentorial Cranio FLAT
Supratentorial
- Semi-fowlers

DISEASES OF NEUROMUSCULAR :

GBS

Guillain Barre Syndrome (GBS)

Myastenia Gravis (MG)
Multiple Sclerosis (MS)
Amyotrophic Lateral Sclerosis (ALS)

MG

Descending paralysis start @ upper ext.

NO gender related factor but could be related to viral infxn
Reversible

Common in Male and Female

Early onset : 20-30 yo (Female)
Early onset : above 50 yo (male)

MP Inflammation that leads to destruction of Peripheral Nerves

90%
w/c leads to:
ASCENDING GBS
neurotransmitter
DESCENDING GBS
Mixed Type GBS

Deficiency in ACTH Receptor Sites

Or Def. in ACTH

ASCENDING GBS - #1 Clumsiness that eventually lead to

S/S Muscle weakness w/c begins at

face
muscle weakness & resp. depression
which

therefore, Diplopia and Ptosis

progresses to MASK-LIKE face which lead

to

respiratory depression
(descending paralysis start at face NO

telebabad)

LAB DATA

CSF Increase CHON

TENSILLON TEST 5 mins

(to all neuromusco disorders)

Nsg Dx

Ineffective Breathing Pattern (ALL)

PI

AIRWAY (tracheostomy bed side) ALL

MEDS

Steroids

same
same
Neostigmine ATSO4 - antidote

Avoid crowded areas : viral infection

Refer to NEUROLOGIST, PULMOLOGIST and PT

MYASTHENIA GRAVIS
COMPLICATIONS

Myasthenia Crisis (MC)

- due to under medication or lack of meds;

Cholinergic Crisis (CC)

- due to over medication overdose

Signs and symptoms of above complication:

MUSCLE WEAKNESS in MC due to ACTH Deficiency while in
CC due to or as adverse effect of the drug
Treatment : TENSILLON effective in MC it INCREASE MUSCLE STRENGTH
Effect in CC it worsens muscle weakness once given give ATSO4
NEOSTIGMINE for MC as TREATMENT

MULTIPLE SCLEROSIS
Common among women especially white
There is destruction of MYELIN SHEET at CNS , therefore generalized muscle
weakness
Eg. I know I will be eventually confined in the wheelchair
s/s of generalized muscle weakness:

LAB DATA

FACIAL diplopia
Impaired Cerebellar Funx
Ataxic Gait lasing
Impaired Sensation NO HOT/COLD BATH
Impaired Sensory Funx impotence

#1 MRI specific test for MS it localizes the area of plaque formation or the area of

dyemlination

#2 CT SCAN

NSG DX

same with GBS & MG

DRUGS

STEROIDS
Anticonvulsants dilantin
Muscle relaxant Baclofen
Bladder Stimulants Urecholine (bethanicol)

HX TEACHINGS

AVOID : HOT COLD SHOWER

Refer to PT: ROM Exercises

AMYOTHROPIC LATERAL SCLEROSIS

(LON GAHRIGS DISEASE)
MP

Destruction of Upper and Lower Motor Neurons;

Genetically Transmitted: AUTOSOMAL DOMINANT common in Male & Female
More Pronounce is DYSPHAGIA
The muscle weakness will eventually lead to RESPIRATORY DEPRESSION

LABDATA

CSF Increase CHON

EMG contract and relax needle insertion
Muscle biopsy

NSG DX

Ineffective Breathing Pattern

PI

AIRWAY (tracheostomy)
SUPPORTIVE
Refer to Geneticist

SIDE NOTES:

DSES

A Recessive :

Cystic Fibro, Sickle Cell, Apalstic/Fanconis either or both parents are (+) for trait NOT

A Dominant :

Retinoblastoma, ALS either father or mother (+) for disease or trait

X Link Recessive : Hemophilia, Color Blindness, Duchennes Muscular, G6PD Dses mother (+) trait NOT DSES
and transmit to SON

SPINAL CORD INJURY

Destruction of S. Cord related to TRAUMA
TYPES

PI

CERVICAL
THORACIC
LUMBAR
SACRAL
COCCYGEAL
SAFETY

8 most serious quadriphlegia

12
5
5
1
- immobilize, surgery

LUMBOSACRAL AREA if affected, therefore PARAPHLEGIA bowel and bladder problem

THORACIC

- paraphlegia + bowel and bladder problem

CERVICAL c1 c4
C5 C8

- incomplete or partial quadriphlegia

- Complete quadriphlegia

LAB DATA

Myelogram
CT Scan
Xray

Nsg Dx

Risk for Injury

Impaired Physical Mobility

PI

SAFETY
a.
b.

Immobilize the spine side lying w/ pillows bet legs

Surgery

COMPLICATIONS OF SPINAL INJURY : AUTONOMIC DYSREFLXIA due to full bladder and bowel
s/s : #1 INITIAL : HPN
#2 Diaphoresis
#3 slight fever
what to keep at bedside: CATHETER - TO KEEP THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS

TIPS FOR NEURO

A 10 yo is to undergo EEG, w/c comment made by a pt demonstrate that she

understands the procedure I will wash my hair after the procedure;

A pt w/ tumor of the frontal lobe will most likely manifest difficulty in

concentrating;

A pt w/ M. Sclerosis has urinary incontinence. To achieve voiding, w/c nsg

care shld the nurse give establishing regular voiding sked;

While interviewing a pt. w/ Myasthenia gravis, w/c of the ff statements

confirm the dx I have difficulty in swallowing;

A male pt w/ CVA is observed by the nurse to have consumed half of his

meal, the PRIORITY Nsg Dx Unilateral Neglect;

When taking care of pt w/ C4 Spinal Injury, w/c equipment shld the nurse
keep @ the b.side Urinary Catheterization Set;

The PRIORITY NSG DX for pt w/ Myasthenic Crisis Ineffective Breathing

Pattern

MUSCULO
CLUBFOOT DEFORMITY
MP

Congenital
Foot twisted out of place

Types
Talipes Varus inversion
Talipes Valgus eversion
Talipes Equinus tiptoe
LAB DATA
Nsg Dx
PI

PE
Xray
Impaired Physical Mobility
Promote Mobility

#1 MANUAL MANIPULATION
#2 SEREAL CASTING every 1-2 wks til position normalizes
#3 DENNIS BROWN SPLINT 2-3 months
CAST : assess for s/s of neurological damage:
REPORT

Capillary refill if more than 3 sec. EDEMA

Skin Color/ nailbed

CONGENITAL HIP DISLOCATION

MP

Maldevelopment of the Hips that involves the acetabulum, head of femur or both

S/S

Extra Gluteal Fold at affected side;

Ortolonis Sign (+) Click
Trendelenburg Sign or Pelvic Dropping
Allis Sign or Galleazis Sign

LAB DATA

Nsg Dx
PI

when child stand in one foot toward the affected side,

then there is change in length
shortening of the affected leg

PExam
Barlows Manuever press leg downward (+) click
Ortolanis abduct leg sideward (+) click
Impaired Physical Mobility
#1 Double or triple diaper to keep legs in abducted position;
#2 PAVLIK Harness - for 2-3 mos
#3 Hip Spica Cast LAST RESORT
NO ADDUCTION OF LEGS!

FRACTURES
MP

Break in the continuity of the bone

TYPES

Open (compound) bone tears the skin therefore open: risk for infection
CLOSE skin intact

S/S

AVULSION tear in the tendon

COMMINUTED - fragmented
COMPRESSED crushed
IMPACTED driven to each other
DEPRESSED pressed
SPIRAL goes around the bone
GREENSTICK incomplete
#1 Deformity
#2 Pain
#3 Edema

#4 CREPITUS sound created when two bone surface rob each other
NSG DX

Impaired Physical Mobility

PI

MOBILITY immobilize the fx

a. Splinting;
b. Casting check for edema elevate the affected areas;
- check skin color capillary refill time
- check for presence of blood stained

c. After cast, - CRUTCH WALKING

2 point gait indicated if both lower extremities has partial wt bearing;

4 point gait indicated for partial wt bearing;
3 point gait - indicated if 1 leg is allowed partial wt bearing and
the other one is N;
swing through - when both legs need to moved past the level of the crutches
swing to when both legs need to be moved AT THE LEVEL OF THE CRUTHES

going upstairs unaffected then crutch (goodleg crutch bad)

going down crutch then bad leg then good leg

SCOLIOSIS
MP

Lateral Deviation of the Spine

RF

STRUCTURAL non correctible

FUNCTIONAL - correctible

OUSTANDING S/S

Uneven Hemline;
Uneven waistline;
Uneven shoulder
(+) Rib Hump
Prominent Iliac Crest

LAB DATA

Bend Over test instruct to touch the toes and note for rib hump
Xray

Nsg Dx

Impaired Physical Mobility - child

Body Image Disturbance - adolesence

TX

a. To decrease curvature wear BOSTON or MILWAUKEE Brace

for 23 hrs/day except bathing
b.

SURGERY HARRINGTON ROD

- LUQUE

HX Teaching
Avoid :

Bending
Jumping Rope
Playing Tennis
Trampoline

Allowed:

Brisk Walking
Swimming
Cheer Leading

OSTEOPOROSIS/ HUNGRY BONE

MP

Loss of Bone Density

RF

#1 smoking
AGING
IMMOBILITY
MENOPAUSE decrease Estrogen
Secondary to Existing Condition as secondary Hyperparathyroidism

S/S

PAIN
Dowagers Hump
Short Stature
Progressive Decrease in Height

LAB DATA

Decrease in Calcium
Bone Densinometry
Bone Scan
Xray

Nsg Dx

SAFETY

How?

DIET : High Ca especially 4 those with OSTEOPOROSIS

- spinnach
- seafoods
- sardines
ACTIVITY : Partial Weight Bearing (NO SWIMMING)
jumping rope
- bicycle reading
- brisk walking
MEDS : Ca Supplement - alendronate
Fosomax SIT UPRIGHT AFTER

ARTHRITIS
RHEUMATOID

GOUTY

OSTEOARTHRITIS

Common

FEMALE

MALE

MALE/FEMALE

Affected Part

Upper Extremities

Lower Extremities

wt bearing joint

MP
Chronic, systemic inflammation of connective tissues
Synovial joints and joints of Upper extremities

S/S

PAIN
Inflammation
Morning Stifness

Stages of Rheumatoid A.

 STAGE 1 no Disability
STAGE 2 with Interference To ADL
STAGE 3 - with major compromise of funx
STAGE 4 - incapacitation
ULNAR DRIFT

SWAN NECK DEFORMITY

LAB DATA

Decrease HgB
Increase ESR

Nsg Dx

PAIN
Impaired Physical Mobility

PI

Relief of Pain
a. Warm Bath;
b. MEDS :
ASA - Antiinflammatory
STREROIDS
c. exercise: ROM

GOUTY ARTHRITIS
MP

Metabolic disorder of purine w/c leads to deposition or uric acid at joints

site: THE GREAT BIG TOE

S/S

(+) PAIN usually aggravated by pressure

(+) Inflammation
-

above s/s affects the LOWER EXTREMITIES

LAB DATA

Increase Uric Acid

NSG DX

PAIN
Impaired Physical Mobility

PI

Relief of PAIN
Meds : Allupurinol, Probenecid
Diet : Low Purine/ Purine Restricted: AVOID : Organ Meats
SEAFOODS
Alcohol
ALLOWED: Cheese (EXCEPT fermented and Aged)

Increase ORAL Fluid Intake

OSTEOARTHRITIS
A degenerative joint disease that involves the weight bearing joints elbows & knees
S/S

PAIN NO inflammation
Bouchards Nodes (distal)
Heberdenes Node (proximal)

LAB DATA
xRAY
Nsg Dx

PAIN
Impaired Physical Mobility

PI

Weight Control

Health Teaching

Hot or Cold Compress

ASA
Trunk Assistive Device (cane)

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Autoimmune multi system dses characterized by inflammation of connective tissues
JOINT
CARDIOVASCULAR
CNS
OUTSTANDING S/S

:
:
:

(+) pain, (+) morning stiffness;

(+) chest pain;
(+) s/s of dec LOC, Irritability, Headache

BUTTERFLY RASH

(also present in pt in PROCAINAMIDE TOXICITY)

LAB DATA

Increase ESR

Nsg Dx

PAIN
Altered Tissue Perfusion
Risk For Injury

TX

Symptomatic/ Supportive meaning, treat available s/s

Drugs

Steroids

TRACTION
PRINCIPLES

T rapeze bar
R equires free hanging weights
A nalgesic
C iculation monitoring
T emperature monitoring
I - nfection prevention
O utput and input monitoring
N utrition
S kin Assessment

TIPS FOR MUSCULO

the priority nsg care for the pt w/ bucks extension traction shld be ensure that
the traction applied to the affected leg is always attached to the weight;

pt in russels traction is being taken cared of by the nurse, it would be necessary

for the nurse to intervene if the pt feet are pressed against the foot board;

a pt is using CRUTCHES for the first time, w/c action reflects a need for further
instruction the pt bears his/her wt with his/her axial;

a pt on bucks traction of the R femur ask the nurse how he can possibly move
around. What can the nurse advise the pt you can hold on to the trapeze bar
while moving;

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

adolescent uneven hemline scoliosis;

when assessing an infant, w/c of the ff needs to be reported extra gluteal folds;

post spinal fusion ROBAXIN is given for w/c of the ff purpose

muscle spasm;

a child has hip spica cast upon discharge, w/c statement of the father indicates
further instruction I will hold on to the bar bet his legs to help move
him

INTEGUMENTARY SYSTEM
Burn triage : face and perineum (priority)

BURNS
Traumatic injury to the skin brought about by :
FIRE
CHEMICALS
PROLONGED EXPOSURE TO SUN
ELECTRICAL CURRENT
HOT H2O
CLASSSIFICATION:

- to decrease

According to Damage

2ND DEGREE

PARTIAL THICKNESS FIRST DEGREE

EPIDERMIS

EPIDERMIS & PART OF DERMIS

Pain
Redness

Redness
Blister Formation

Eg sunburn

pain

THIRD DEGREE

4TH DEGREE

FULL THICKNESS

SUB Q FATS
MUSCLES
LEATHERY APPEARANCE
NO Pain

SUB Q FATS
MUSCLES & BONES
CHARRED APPEARANCE
No Pain

MINOR

MODERATE

PARTIAL TICKNESS

less than 15%

15-25%

FULL THICKNESS

NONE

<10%

MAJOR
25%
>10%

RULE OF 9 CHECK NOTE day 9 page115

BURN TRIAGE
Priority : Burns of FACE
PERIMEUM
UPPER & LOWER EXT
Burn related to Child Abuse
Chemical Fire
THINK:

R escue
A larm
C onfine the Fire
E xtinguish the Fire

PRINCIPLES OF NSG CARE FOR BURN PTS:

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

DIET

DAT (High CHON, Ca, Vit C)

Complication

FIRST 24HRS SHOCK

72Hrs
- INFECTION

Pt Preparation :Bed Craddle

Fever

LYMES DISEASE

caused by BORRELIA BURGDORFERI

dog ticks

Rocky Mountain

(deer ticks)

Dermacentor/ Variabilis

3-30 days

or Dermacentor Andersori (wood)

2-3 wks

s/s :

Fever, Pain, Chills, Rashes

RASHES: Bulls Eye Rash or Rounder Rings

At moist body parts

Generalized rashes

Complications
Cardio, Musculoskeletal and CNS
- which can lead to paralysis
TX

Avoid wooded area have you been to the woods?

PI

Vaccination
Use long sleeve
Remove ticks w/ twizers upward straight motion

Meds

Chloramphenicol
Tetracycline

DERMATITIS
DIAPER (contact)
Peak
patients
S/S

ATOPIC ECZEMA

(adult)

: During infancy 9-12 mos

Due to prolonged exposure to urine, soap & excreta

Cause : Hereditary
Prone to asthmatic

RASH + scaling,

RASH

Crusting
Pruritus or itching
Viscicles
Management: Hydrate the skin w/ cold compress
Meds: Benadryl (antihistamine)

ROSEOLA

RUBEOLA

RUBELLA

Exanthem

MEASLES

GERMAN MEASLES

Causative Agent
INC PERIOD

Herpez Virus

Unknown

10 -20 days

s/s
RASH

Measle Virus

Rubella Virus
14 -21 days

FEVER and RASH

Non Pruritic
Rose pink begins w/ trunk

Begins w/ face & downwards

Face & downwards

Progressing outward

With KOPLICKS SPOTS

3 Cs : Coryza
Cough
Conjuctivitis

same

MANAGEMENT: (to all types)

Bed rest
Antibiotics
Antipyretic

C Agent
I. Period

SYPHYLLIS

GONORRHEA

T Pallidum

N Gonorrhea

10-13 wks

HERPEZ
Zoster

Simplex

2-7 days
Vericella Zoster Virus

Abdominal

Genital H

Herpes Simplex Viruz

Oral Herpez

2-12 days vesicle

Steroids

Around the mouth

Inner thigh
Buttocks
Genitals

Acyclovir
Cervical Ca complication of
Herpez

Annual pap smear

TRICHOMONIASIS

MONILIASIS/CANDIDIASIS

Caused by TRICHOMONAS Vaginalis

Albicans

Both are STDs

Charac of discharge : Greenish/ Yellowish
With FOUL ODOR

WHITISH-CHEESELIKE discharge

Inc Period

2 5 days

Druf pf Choice

4 20 days
Flagyl

Amphotericin

TIPS

A nurse admits 8yo brought by her mother. Upon assessment, the nurse finds
rounded rings of rash. This is indicative of lymes dses;

During the immediate 24hrs pot burn, w/c of the ff is the priority administration
of fluis;

A pt tells the nurse that he notice small blisters on his private parts. This is
indicative of HERPEZ

A pt with CA of the cervix was admitted with the ff data: w/c one indicates a
possible risk factor previous tx for herpes;

w/c of the ff indicates effective tx of gonorrhea (-) purulent discharge;

a pt is diagnosed w/ herpes zoster, w/c of the ff is the priority nsg dx PAIN;

w/c of the ff is indicative of CHLAMYDIASIS burning on urination

CANCER
Cause
RF

Unknown Theory of USE - Overuse, Underuse, and Abuse

Smoking :

Lung, Bladder and Laryngeal or Oral CA

RACE

Jewish Breast
Blacks - Cervix and Prostrate
Whites Testes

PARITY :

Nulliparity breast having baby after 35 yo

Multiparity cervix

DIET

High Fat and Low Fiber CA of Colon

Spicy Ca of Prostrate

Raw Ca of Stomach
LABDATA

Screening Exams
Male:
a. Testicular Self Exam mothly begins age 16 yo- target are high school
Female:
a. Pap smear at age of 18 (if sexually active) - anually
b. Breast self exam beginning age 20 monthly
c. Mamography baseline : 35-40 yo : AFTER 40 yo once every 2years
After age 50 annually
BOTH MALE AND FEMALE

Nsg Dx

Digital Rectal Exam

Sigmoidoscopy
STOOL FOR OCCULT BLD

Initial
If pt is TERMINALLY ILL
If pt has some wishes or
Unfulfilled needS :

:
:

40 and above ANUALLY

ANUALLY after age 50yo
Annually after age 50 yo
Knowledge deficit
HOPELESSNESS

Powerlessness

Nsg Care Principles :

C hemotherapy target cells : those rapidly dividing cells;
A sess Body Image
N tuition/diet : high CHON, well balance
C aution pt on s/s
E xercise
R est
COMMON S/S
LARYNX
LUNGS
STOMACH
BREAST
OVARIAN
CERVICAL
PROSTRATE
COLON
Hodgkins Dses
TESTICULAR

change in VOICE or Hoarseness

changing cough or smokers cough (productive)
dyspepsia
a lump or a discharge
complains feeling of fullness or indigestion
bleeding
elevated acid phosphatase, nocturia
change in bowel habits
painless enlargement of lymph nodes
crytorchidism, spongy testes or lump (N smooth unequal)

TIPS FOR CANCER

w/c nsg dx is a priority for a pt undergoing chemotherapy SOCIAL ISOLATION;

when undergoing chemotheraphy, w/c solution is used for mouth care

HYDROGEN PEROXIDE;

w/c of the ff is an appropriate diet for pt undergoing chemo bland diet;

the most common sign of Breast Ca is in upper outer quadrant;

pt w/ CA of esophagus will manifest DYSPHAGIA

TIPS FOR

PSYCHE

A pt w/ chronic depression is to undergo ECT, the purpose is to relieve the

symptoms of depression;

A nurse shld assess the pt w/ ALZEIMERS DSES for possible change in

orientation;

A pt w/ bipolar episodes is ready for discharge when she can comply with
units activities;

The nurse would suspect that the child is a victim of abuse if he keeps quiet
while an IV is inserted;

w/c of the ff situations reflects an increase in self-esteem of an abuse child - when

he ask the nurse for a plastic cup to drink;

the initial care plan for a pt with Anorexia Nervosa would require the pt to
remain in public place 1 hour after meals;

where shld the nurse put the pt on early alcoholic withdrawal well-lighted room
near nurses station

TIPS FOR OB-GYNE

A Mother Is Crying Besides her baby, she said I feel so sorry I couldnt hold her
let her stroke the baby;

6wks pregnant woman ask the nurse about the signs of pregnancy w/c one is
expected at this time frequent urination;

the nurse notes mirror image in the fetal monitor this could be related to
FETAL HEAD COMPRESSION;

which of the ff is related to trauma ABRUPTIO PLACENTA;

A nurse is caring for a woman in first stage of labor, she is timing the duration of
contraction she is correct when she times it from the beginning of one
contraction to the end of same contraction

TIPS PEDIA

w/c of the ff is expected by 6mos of age sits w/ minimal support;

the most appropriate toy for 18 mos old child carriage w/ a doll;

the appropriate room mate for an 8yo girl w/ leukemia is 6 yo with hemophilia;

in a 3yo child w/c of the ff shld the nurse assess during admission special
words used for objects and routines;

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

the child where she would like the injecvtion to be given

Paralysis of Lower