BULLETS

(Authored from previous board exam questions)

 Chest X ray  painless procedure

 Bronchoscopy
o AtSO4
 Anticholinergic  mimics SNR
 Decreases saliva  dry mouth
o NPO 6 to 8 hours
o Local anesthesia  check gag reflex before feeding

 ABG
o Hyperventilation  decreased CO2  increased blood pH  respiratory alkalosis
o Hypoventilation  increased CO2  decreased blood pH  respiratory acidosis
o Diarrhea  decreased HCO3  decreased blood pH  metabolic acidosis
o Vomiting gastric content  decreased HCL  increased blood pH  metabolic alkalosis
o Vomiting blood  decreased O2  anaerobic metabolism  formation of lactic acid 
decreased blood pH  metabolic acidosis
o Blood pH  normal 7.35 to 7.45  If increased  alkalosis; If decreased  acidosis
o Partial CO2  normal 35 to 45 If increased Respiratory Acidosis; if decreased Respiratory
Alkalosis
o Partial HCO3  normal 22 to 26  If increased Metabolic alkalosis; If decreased metabolic
acidosis

 Cancer of the larynx  CS, alcohol and over usage of voice (choir member)
o A - nterior neck mass
o B – urning sensation with hot beverages / Bad breath
o C - hange in the voice (hoarseness)
o D – ysphagia/dyspnea

 Chronic Obstructive Pulmonary Disease

o Chronic Bronchitis
 Blue bloater
 Excessive mucus production
o Asthma
 Periods of bronchospasm and bronchoconstriction
o Emphysema
 Disequilibrium of elastase and antielastase
 Pink puffer
o Manifestations
 A – LTERATION IN
• LOC  decreased O2
• Thoracic anatomy  over distention of alveoli  TD = APD  barrel chest
• Skin
o Temperature  cool clammy skin
o Color  pale to cyanotic
• ABG  Respiratory acidosis  Increased CO2
 B – reathing  difficulty, purse lip  expiration > inhalation  removal of excess CO2
(diet low CHO)
 C – ough (mucus production); Chronic hypoxia (2 to 3 lpm of O2 therapy, decreased O2
demand by rest and SFF)  clubbing of the fingers and decreased TP to the kidneys
causing polycythemia
 D – ecreased Metabolism
• Anorexia  weight loss (high calorie diet)  fatigue  weakness
 Bronchodilators
o Theophylline and aminophylline
 Primary effect  stimulates beta 2 receptors  smooth muscle relaxation 
bronchodilation
 Side effect  stimulates beta 1 receptors  increases cardiac rate  need not to notify
the physician
  Adverse effect  hypotension  monitor BP  sign of toxicity
 Evaluation  check breath sounds

 Acute Respiratory Distress Syndrome

o Causes
 A – spiration
 R – espiratory trauma (embolism)
• fracture  embolism  ARDS
 D – rug toxicity (ASA)
 S – epsis and shock
• Vomiting, bleeding, dehydration hypovolemia  shock  ARDS
o Syndrome
 Severe hypoxia
 Bilateral infiltrates
 Dyspnea

 Pulmonary embolism
o Restlessness  earliest sign

 Water Seal System

o Drainage Bottle → marked the level every shift
o Water seal bottle
 Presence of fluctuation → normal
 Absence of fluctuation → lungs are fully expanded → assess first patient (X ray →
confirm) OR presence of obstruction
 Intermittent bubbling → normal
• Absent → obstruction
• Continuous → leakage
o Suction Control → continuous bubbling → normal

 Risk factors for cardiovascular disorders

o R – ace  non modifiable
o I – ncreased blood pressure  modifiable
o S – tress  SNR  increased BP and CR, vasoconstriction  modifiable
o K – nowing sedentary life style  modifiable
o F – at foods atherosclerosis  modifiable
o A – lcohol (modifiable) / Age  above 40 (non modifiable)
o C – igarette smoking  vasoconstriction (nicotine)  modifiable / Contraceptive pills  clotting
of blood  thrombus formation
o T – ype A behavior (modifiable)  competitiveness, perfectionist  high stress level
o O – besity
o R – esult of DM  lipolysis  increased fatty acids  atherosclerosis
o S – ex gender  males > female (before menopausal because estrogen decreases PVR)
after menopausal female eversible}[inverted T wave]  Injury [elevated ST segment] > male

 Decreased TP in heart  Ischemia (Angina) {r necrosis (MI) {irreversible}[pathologic Q

wave/permanent in the ECG]

 Eating a heavy meal, strenuous exercise, sex, exposure to cold  Decreased blood flow (heart)
decreased TP (heart) decreased O2 (heart) anaerobic respiration  production of lactic acid 
PAIN  management decreased O2 demand by rest and SFF

 Angina
o Pain relieved by rest and NTG
o NTG
 Vasodilation  orthostatic hypotension  move gradually  Monitor BP
 Store in a dark and amber container
  Effective  tingling sensation  no need to notify physician
 Maximum of 3 tablets with 5 minute interval

 MI
o Pain relieved by Morphine SO4
 Narcotic analgesic
 Can cause respiratory depression  monitor RR and O2 saturation
 Antidote  narcan

 Cardioversion  synchronous

 Defibrillation  unsynchronous

 Buerger’s disease  CS  vasoconstriction  stop CS  common in men

 Raynaud’s  stress and cold  vasoconstriction  common in female

 Congestive heart failure

o Left sided  pulmonary
 Dyspnea
 Crackles
 Polycythemia  due to decrease O2 to the kidneys
 Clubbing of the fingers  due to prolonged hyxia
 Orthopnea
o Right sided  systemic
 Hepatomegaly
 Distended neck veins
 Edema
 Portal hypertension
 Ascites  weight gain
 Varicose veins
o Digoxin
 Cardiac glycoside
 Positive inotrophic effect  increased strength of myocardial contraction
 Negative chronotrophic effect  decreased cardiac rate  monitor CR  never give if
CR below 60 bpm
 Adverse effect
• V – omitting
• A – norexia
• N – ausea
• D – iarrhea
• A – bdominal pain
• REMEMBER: earliest  GI; late  halo vision
• Antidote  Digibind

 Decreased RBC → Activity in tolerance, Fatigue, provide rest, Anemia

 Decreased Platelets → Prone to bleeding, avoid parenteral injection, appl pressure on injection
site, high risk for injury

 Decreased WBC → prone to infection, reverse isolation

 Increased WBC → presence of infection

 First Day/Newly diagnosed → Knowledge deficit

 Diuretic
o D – iet  high K diet except aldactone
o I – input and Output  expected increased output
o U – ndesirable effect electrolyte imbalance (K)
 o R – ecord weight  expected decreased weight
o E – lderly  special precaution
o T – ake in AM and with food
o I – ncreased orthostatic hypotension  monitor BP and move gradually
o C – ancel alcohol because of mild diuretic effect

 Heparin  anticoagulant  prevent further enlargement of clot not dissolve them  monitor
APTT/PTT  antidote protamine SO4

 Coumadin  anticoagulant  prevent further enlargement of clot not dissolve it  monitor PT 

vitamin K is the antidote

 Urokinase/Streptoase → dissolves the clot

 Pernicious anemia  absence of intrinsic factor (gastric surgery) problem in absorption of Vitamin
B12  beefy red tongue schilling’s test  definitive test  24 hour urine collection  life long Vitamin
B12

 Gastritis  LUQ pain

 Gastric ulcer  affected area stomach  pain (precipitated by food intake  increased HCl)  pain
relieved by antacids

 Duodenal ulcer  affected area duodenum  pain (2 hour after eating)  pain relieved by food

 Ulcers  bleeding  (+) occult blood test (guiac) high fiber diet, avoid red meat, iron, steroids,
NSAIDs, indomethacin

 Vagotomy  resection of vagus nerve  decreased cholinergic stimulation  decreased HCl and
gastric movement

 Dumping syndrome  tachycardia and weakness  3 D’s (diarrhea, diaphoresis and dizziness) 
fluids after meals, lie down after meals and SFF

 Appendicitis  RLQ pain  avoid heat pads  cause rupture  signs of ruptured appendix 
sudden cessation of pain, elevation of temperature and WBC

 Diverticulitis  LLQ pain → low fiber diet

 Diverticulosis → high fiber diet

 Ulcerative colitis  bloody diarrhea 15 to 20 times a day  fluid volume deficit, anemia

 Liver cirrhosis  alcohol and malnutrition (laennec’s), infection and drugs (post necrotic), RSCHF
(cardiac) and biliary obstruction (biliary)
o Portal hypertention can lead to
 Blood shifted to the different collateral
• Esophageal varices
• Spider angioma (face and neck)
• Caput medusae (abdomen)
• Hemorrhoids (rectal)
• Management avoid rupture  avoid shouting, valsalva maneuver
 Increased hydstatic pressure  fluid shifting  ascites
o Decreased albumin  decreased oncotic / colloidal osmotic pressure  fluid shifting  ascites
 management high protein diet
o CHON metabolism  by product ammonia  liver cannot convert to urea  increased level of
ammonia in the brain  Alteration of LOC and changes of behavior and asterexis hepatic
encephalopathy  management low CHON diet and lactulose for removal of ammonia

 Hepatitis A  fecal oral  prone plumber

 Hepatitis B  body secretion  prone working in a dialysis

 Cholecystitis  5 F’s (fair, female, fat, fertile and forty)  RUQ pain  after ingestion of fatty food 
demerol to relieved pain

 Cholecystectomy  T tube  level of the incision site  drain excess bile

 Pancreatitis  alcohol  autodigestion  LUQ pain

 Anterior Pituitary gland

o Growth hormone
 Increased before the closure of the epiphysis of the long bones  gigantism  tall
 Increased after the closure of the epiphysis  acromegaly  big hands (big gloves), big
feet (big shoes) and big head (big hat)
 Decreased  dwarfism
o Prolactin
 Increased  galactorrhea
 Decreased  decreased milk production
o ACTH
 Increased  secondary cushing’s
 Decreased  secondary addison’s
o TSH
 Increased  secondary hypethyroidism
 Decreased  secondary hypothyroidism
 Posterior pituitary gland
o ADH
 Increased  water retention  oliguria  edema (fluid volume excess) and weight gain
 concentrated urine  increased urine specific gravity
 Decreased  water excretion  polyuria  dehydration (fluid volume deficit and weight
loss)  diluted urine  decreased urine specific gravity

 Parathyroid gland
o Parathormone
 Increased  increased calcium in the blood and decrease calcium in the bones  stone
formation and decreased bone mass  osteoporosis  management increased water
intake
 Decreased  hypocalcemia  calcium supplement

 Thyroid Gland
o Increased (hyperthyroidism)
 T3 and T4  increased BMR  hyperactive  inability to focus  insomia  increased
catabolism  weight loss  increased appetite  increased peristalsis  Diarrhea 
fluid volume deficit  Increased CR and RR (due to increased BMR)
• Increased T3  heat intolerance
 Calcitonin  decreased calcium in the blood  tetany  compensatory  calcium
withdraws from the bones  bone destruction (complication)
 PTU  decreased synthesis of TH  watch out for SE (similar to signs and symptoms
of hypothyroidism)  watch out for agrunulocytosis (fever, skin rash and sore throat)
 Lugol’s solution  decreased released of TH  before thyroidectomy  decreased
vascularity of the thyroid gland
o Decreased (hypothyroidism)
 T3 and T4  decreased BMR  hypoactive  sleeps a lot  decreased metabolism 
weight gain  anorexia  decreased peristalsis  constipation  decreased CR and
RR due to decreased BMR
 T3  cold intolerance
 Calcitonin  hypercalcemia  stone formation
 Synthroid and Proloid  increased TH

 Adrenal Gland
o Incresead (cushing’s)
 Glucocorticoids  hyperglycemia and decrease wound healing
  Mineral corticoids  increased aldosterone  sodium retention and potassium excretion
 hypernatremia and hypokalemia
• Hypernatremia  water retention  oliguria  edema (moon face,buffalohump,
fluid volume excess and weight gain)  concentrated urine  increased urine
specific gravity  low sodium diet
• Hypokalemia  weakness  Prominent U wave  high potassium diet
 Epinephrine and Norepinephrine  Increased BP and CR
 Sex hormones
• Males  gynecomastia and falling of hair
• Females  hirsutism and deepening of the voice
o Decreased (addisons)
 Glucocorticoids  hypoglycemia and inability to cope with stress
 Mineralcorticoids  decreased aldosterone  sodium excretion and potassium
retention  hyponatremia and hyperkalemia
• Hyponatremia  water excretion  polyuria (dehydration, fluid volume deficit
and weight loss)  diluted urine --. Decreased urine specific gravity  increased
fluids and Na
• Hyperkalemia  weakness  tall or peaked T waves  low K diet
 Epinephrine and Norepinephrine  decreased BP and CR

 Diabetes Mellitus
o Type I  absolutely no insulin  thin  insulin
o Type II  insufficient insulin  obese  OHA
o Diet  50% CHO, 30% Fats, 20% CHON
o Exercise  Increased uptake of glucose  Decreased insulin requirement
o Oral hypoglycemic agent (OHA)
 Stimulates pancreas to produce insulin

o Insulin
 SC; IV if DKA
 Never massage the area
 Never administer cold insulin
 Rotate the site of injection
• PREVENTS LIPODYSTROPHY
 Mix
• Aspirate clear first
• Inject air to cloudy first
o Hypoglycemia
 W – eakness
 H – unger pangs
 A – alteration of LOC
 T – achycardia and tremors

 A – bdominal pain
 B – blurring of vision
 C – ool clammy skin
 D – iaphoresis
 Give  orange juice (simple sugars)
o DKA → increased lipolysis increased ketones
o Hyperglycemia  polyuria, polydipsia, polyphagia, kussmaul breathing, glycosuria, ketonuria
and warm flush skin
o Glycosylated hemoglobin  reflect BSL for the past 3 to 4 months  most accurate
o Foot care
 Podiatrist
 Avoid removing corns and calluses
 Cut toe nails straight across
 Avoid walking bare foot
 Hepatitis A → fecal oral

 Hepatitis B → body and bloody secretions (hemodialysis)

 Peritoneal Dialysis
o Diasylate output is decreased → turn patient from side to side
o Complication → infection → monitor WBC and temperature, diasylate is cloudy → boardlike and
rigid abdomen → peritonitis
o Don’t include diasylate solution in the output of the client
o Expected → decreased weight → monitor weight before and after → decreased createnine and
BUN

 Heart block → decreased tissue perfusion

 Parkinson’s diasease
o Decreased dopamine in the basal ganglia → levodopa to increased dopamine → avoid Vit B6
foods
o Cardinals signs → tremors (non intentional) → muscle rigidity → bradykinesia
o Pill rolling
o Microphonia → ask your client to speak aloud to be aware
o Artane and Cogentin → anticholinergic → decreased muscle rigidity

 Myasthenia Gravis
o Tensilon test → confirmatory test
o Decreased Acetylcholine and increased cholinesterase
o Muscle weakness → priority airway
o NO tranquilizer, Morphine SO4, Muscle relaxant and neomycin
o Cholinergics (mestinon) → increased muscle strength → antidote ATSO4
 Undermedication → myasthenic crisis → give cholinergics
 Over medication → cholinergic crisis → give ATSO4

 Multiple Sclerosis
o Demyelinization of the myelin sheath
o Charcoat’s triad
 Intentional tremors
 Scanning of speech
 Nystagmus
o Visual disturbances → diplopia

 Pancreatitis → autodigestion → alcohol → bleeding → shock

o Elevated amylase

 Rheumatoid Arthritis
o No specific diagnostic test
o NSAID’s and ASA (antipyretic, analgesic and anti-inflammatory)
o Synovitis → Pannus formation → fibrous ankylosis (limited joint movement) → Bony ankylosis
(joint fixation)
o Avoid flexion and promote prone position

 Gouty Arthritis
o Increased uric acid → allopurinol and avoid organ meats (liver) → tophi (ears)

 Osteoarthritis
o Most common → related with aging
o Pain after weight bearing exercise or activity → rest to relieved pain → weight reduction
 Diverticulitis → LLQ pain and low fiber diet

 Cyclophosphamide (Cytoxan) → can cause hemorrhagic cystitis → to avoid increased fluid intake

 Vincristine (Oncovin) → increased fiber in the diet

 Iron supplement →When is the best time to take (empty stomach), How is best taken (with orange
juice)

 Steroids and NSAID’s

o DEATH → inflammation
o BIRTH → side effects
 B – one marrow depression → prone to infection → monitor temperature and WBC
 I – ncreased gastric irritation → take it with food or after meals
 R – enal toxicity
 T – innitus
 H – epato toxic

 Cataract → common cause is aging (senile) → opacity of the lens → position on the unaffected side

 Glaucoma → increased IOP → decreased of peripheral vision first → halo, tunnel and gun barrel vision
→ miotics (constricts pupils) → avoid ATSO4 (dilates pupil)

 Retinal detachment → trauma → blood clots → floating spots → dependent position→ scleral buckling

 Avoid Increased Intraocular pressure → PRIORITY

o Avoid vomiting, coughing, valsalva maneuver, lifting heavy objects, bending, crying

 Meniere’s → Triad → tinnitus, impaired hearing loss and vertigo → low Na diet
o Vertigo → imbalance → high risk for injury → decreased vertigo by focusing on one side of the
room → assume a flat or reclining position

 ASA → 8th cranial nerve damage → tinnitus, impaired hearing loss and vertigo

 Antibiotics → allergic reactions

 Normal Values
o BUN = 10 – 20 mg/dl
o Calcium = 9 to 10.5 mg/dl
o Creatinine = 5 to 1.5 mg/dl
o GTT = 70 to 115 mg/dl
o O2 sat = 97 to 98%

 Signs and Symptoms of Increased Intracranial Pressure

o B – lood pressure and temperature are elevated
o R – espiratory and cardiac rate are decreased
o A – lteration of LOC
o I – rritability
o N – ote for projectile vomiting
o S – eizure