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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 DOESN’T 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
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 consider MASLOW’s H of NEEDS

 consider the COMPLICATION whether ACUTE – 2. TODDLER – falls
ALWAYS prioritize 3. SUPRATENTORIAL craniotomy – semi fowler’s
CHRONIC position
 ABCs INFRATENTORIAL – flat in bed
 SAFETY FIRST
 NSG PROCESS 4. SCATTER RUGS – osteoporosis pts.
5. TRIAGE ; burns, open fx – “SHOCK”

MMR VACCINE – only vaccine for HIV pt.

Things NOT TO BE DELEGATED by RN:
Pt on HEPARIN – APTT (N 30-40sec), therefore if INCREASE – Assessment, Teachings, Evaluation
bleeding

POISON - nursing action in order : Pt 50y/o and - mammogram – once a year.

#1 CALL poison control center
# 2 MINIMIZE EXPOSURE of pt to poison – pull him/her Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl
away from the poison FREE). –
# 3 IDENTIFY the poison therefore LOW CHON

GENTAMYCIN – s/e tinnitus, vertigo, ototoxicity, oliguria Pt with Rocky Mountain Fever – exposure to dog ticks
Lyme’s Dses – deer ticks
LITHIUM CARBONATE – for ELDERLY : N level NOT more
than 1.0meq/L
ADULT : N .5 – 1.2 meq/L PSYCHE PATIENTS

1. remember to stick to unit rules/policy – be

HEPA B diet : low fat, increase CHON consistent to pt.
2. encourage verbalization – “tel me how…..”
DOWN SYNDROME – large tongue – feeding problem – poor 3. sound knowledge of cultural diversity
sucking (infants) - seek help of interpreter
4. acknowledge pt feelings – “it seems….”
“this must be difficult…..”
SAFETY PRINCIPLE 5. emphatize with your patients’s feelings
“ I understand how you feel…..”
1. when can a child USE ADULT SEAT BELT?
- if the infant is 40 lbs and 40 CATARACT – CAUSES – aging and trauma
inches in height
MRSA (methicillin resistant staphyliccocus aureus)
seat belt location in car: BACK CENTER - USE GLOVES AND GOWN WHEN W/ PT
SEAT
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COMPLICATIONS: bubbling, breakage, blockage

Nsg ALERT:
TUBES
 NORMAL : BUBBLING is N in the 3rd bottle – it
indicates that suction is ADEQUATE
1. GROSHONG CATHETER - 2 lumen (if no bubbling STOPS in the 3rd bottle, meaning –
HICKMAN - 3 lumen inadequate suction)
BROVIAC - 1 lumen
 ABNORMAL : if bubbling occurs at the 2nd
ALL requires Central Venous Access bottle – indicates LEAKAGE – action, check sealed at air tight
- sites: cephalic, brachial, basilica and superior container and the pt and bottle connection.
vena cava
In case there BREAKAGE, have extra bottle and emerge
PURPOSE: For TPN tube ASAP to prevent entry of air and or may use forcep to
Administration of Chemo Agents, clamp tube temporarily.
Blood Products, Antibiotics
If pt. ambulates, keep bottle LOWER than the patient.
COMPLICATION: Thrombosis and Bleeding
ABSENCE of OSCILLATION at the 2nd Bottle – indicates
blockage
2. CHEST TUBES – Water Sealed Drainage
TOWARDS THE BOTTLE - When MILKING the tubings.
Types: Anterior – w/c drains AIR EMERGENCY EQUIPMETS AT BEDSIDE: xtra
Posterior - w/c drains FLUIDS bottle,clamp, gauze

Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle 3. TRACHEOSTOMY TUBE
system - to maintain patent airway for pt w/ neurological
problems and musculoskeletal disorders.
1 BOTTLE : 3 – 5cm of only (length of tube to be
emerge) nursing care:

2 BOTTLE : First bottle – drainage bottle (no tube 1. Suctioning – 10-15seconds

emerge), - if (+) bradycardia, STOP
2nd bottle - long rod 3-5cm - if accidentally dislodge, insert obturator to
keep it open
3 bottle : FREQUENTLY USED
2. AVOID: water sports – swimming
1st bottle – drainage
2nd bottle – water sealed 3. In changing ties – insert new one first BEFORE
3rd bottle – suction bottle control REMOVING old tie.
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4. Ribbon or ties @ side of the neck only to avoid pressure.  Miller Abbot – for intestinal (w/ mercury b4
injection)
5. Before and After suctioning – hyperoxygenate the patient. - 2 lumen (insert then inject the
mercury)

 Cantor – for intestinal

4. PTCA – enlarge the passageway for bloodflow. - 1 lumen
problem: spasms that lead to arrhythmia

C-STENT (cardiac-stent) – alternative to PTCA

Maintains patency of bld vessels Nursing Care for NGT:
Problem: dislodge
1. tip of nose to earlobe to xyphoid process (for stomach)
IABP (Intra Aortic Balloon Pump) 2. tip of nose to earlobe to XP + 7-10 inches for
- for Cardiogenic Shock intestinal NGT
problem: thrombus formation, infection and 3. accurate means to verify correct placement: ALWAYS
arrhythmia consider Two checking criteria: ASPIRATION and Gurgling
Sounds

Report the following:

5. PENROSE DRAIN
- wound drainage system If (-) or decrease drainage,
- doctors the one who removes this. (+) nausea and vomiting
- remove gradually (+) abdml rigidity

Characteristic of Gastric Residual: more than 50 mo and

coffee ground.
6. NASO GASTRIC TUBE – stomach and intestine
(duodenum) Before feeding check for placement.

Types:
 Levine Tube – for stomach
- 1 lumen, for lavage (cleaning) and 7. GASTROSTOMY TUBE (GT)
gavage (feeding) PEG
 both for NUTRITIONAL PURPOSES
 Salem Sump – for stomach
- 2 lumen (I for suctioning, I for GT – incision (abdomen to stomach)
lavage/gavage) - for pt (+) lesion at esophagus
- if pt (infant) is having enteric - nsg care : report s/s of infection, abdl cramps,
coated meds, request for n/v
change in form of meds
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- provide adequate skin care Characteristic of drainage – 2-3 days after surgery (bloody to
pinkish) – NO NEED TO REPORT THIS
PEG – incision at skin
- long term therapy – it is expected

8. T TUBE 11. SUPRAPUBIC CATHETER – for genito urinary problem

- to drain excess bile until hearing occurs - inserted directly at the bladder wall
- place drainage bag at the level of t-tube - check if properly anchored
(obstruction of t-tube – there will be excess drainage)

500 ml – N drainage in 24hrs, if report ASAP. 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.
9. HEMOVAC
JACKSON-PRATTS (JP)
SENGSTAKEN BLAKEMORE TUBE
 BOTH used as close wound drainage suction - 3 lumen ( for esophageal balloon, gastric
system balloon, for meds)
 BOTH system function on the system of (-) - for pt w/ esophageal varices
pressure. - balloon tamponade
- 48 hrs – keep balloon inflated for 10 minutes to
JP – compress the container before attaching to the decrease bleeding
drainage.

WHEN TO EMPTY: when its usually 1/3 to ½ full then LINTON TUBE – 3 lumen
RECORD the amount.
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
10. THREE-WAY FOLEY bottle #2 – check if tubing is properly sealed.
 NGT IS REMOVED – if patient exhibits return of bowel
absence of clot – effective sounds.
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 BULB SYRINGE – use to clean the nares of pt with NGT  JEWS – “kosher diet” (no meat and diary products
(child) at the same time)
 To facilitate removal of air at lungs – purpose of water
sealed chamber in 3 way bottle system.  EUROPEANS – main meal is served at mid day
followed by espresso

 MUSLIM – “halal diet” – no pork

THERAPEUTIC DIET  SDA – strictly vegs diet (vit B6 and B12 deficiency)

 MORMONS
GENERAL CONSIDERATION – words of wisdom (no caffeine, alcohol and
once a month fasting)
 Know the DIAGNOSIS of the patient – the amount due for food is donated to the
 Identify & incorporate the pt. dietary preferences church
 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 KEY POINTS FOR NURSES
c. IRON : 15-30mg/day
d. CALCIUM : RDA is 1000 then +200mg/day Sodium (Na) – source down the soil
(broccoli,tuna,cheese) Potassium (K) - source up the tree
e. Galactogogues – increase production of milk
Low Na Diet : AVOID processed foods, milk products and
salty foods

 PEDIATRIC pt KNOW the serving: CHO - 6-11 servings

– by 4-6 mos – START iron supplement due to iron depletion CHON - 2-3
and (-) FRUITS & Vegs - 3-4
extrusion reflex. FATS - sparingly
- cereals, fruits, vegetables,meat and table foods
- egg yolk (6mos), egg white (1yr)

TRANSCULTURAL CONSIDERATION MOST COMMON DIET

 CHINESE – like cold desserts after surgery for

optimum health  CLEAR LIQUID DIET (light can pass thru it,
meaning TRANSPARENT)
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- given to pt to relieve thirst, correct fld & electrolyte

imbalance  PURINE RESTRICTED DIET
- given also to pt post-op
ex: apple juice, gelatin (strawberry), popsicle, candy - for gouty arthritis
- increase fluid intake
 RENAL DIET - AVOID: preserved foods, sea foods, alcohol,
organ meat (liver, gizzard)
- for kidney disorder (renal failure, AGN,
Nephrotic syndrome)
- to maintain fld & e imbalance  NA RESTRICTED DIET

- for cardiovascular dses, renal, fld & e imbalance

- ALLOWED: fresh vegs
LOW CHON – avoid poultry products - AVOID : processed foods, milk products and
LOW Na - avoid processed foods, milk products, & salty foods
salty foods
Low K - avoid fruits (anything you see in a tree)
 BLAND DIET

- for peptic ulcer, inflammatory GI conditions

 LOW FAT/CHOLESTEROL RESTRICTED DIET - AVOID: chemically and mechanically irritating
foods such as fried foods, fresh and raw fruits & vegs
- for liver disorder, cardiovascular and renal dses (EXCEPT: avocado, banana & pinya) and spicy foods with
ALLOWED: lean meat, fruits, vegs and fish preservatives
AVOID : Sea foods, fried foods, preserved foods (cheese
cake and custard)

 HIGH PROTEIN, HIGH CARBO DIET

 HIGH FIBER DIET
- to prevent constipation, hemorrhoids & - for burns (about 5000 cal/day)
diverticulitis - grain products and poultry – to aid the healing
- vegs, fruits and grain products tissues

 SOFT DIET

- for inflammatory conditions: esophagitis, peptic

ulcer gastritis
- pureed foods/ blenderized foods  ACID ASH DIET
- soup
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- to decrease the ph of the urine

- indicated for pt w/ alkaline stone ex struvite Ph – 7.35 – 7.45
- ex. 3 C’S – cranberry, cheese, & corn PCO2 - 35 – 35
3 P’S - prunes, plums & pastries HCO3 - 22 – 26 meq/L

Ph Compensatory
 ALKALINE ASH DIET Mechanism

- to increase ph of the urine Uncompensated abnormal no change

- indicated for acid stone ( uric acid stone, Partially compensated abnormal increase or
cystine stone) decrease
- ex. Milk Fully Compensated normal increase or
decrease

 GLUTEN-FREE DIET Diarrhea – metabolic acidosis

Vomiting – metabolic alkalosis
- for celiac dses
- ALLOWED : rice, corn, cereals, soy beans
- AVOID (LIFETIME): barley, rye, oats, wheat

PRIORITIZING of case:
 PHENYLALANINE DIET Med.-Surg – “abc”
Psyche - safety first
- for PKU, until age 10 and adolescence only Fire - race
- AVOID : CHON rich foods (meat products – Triage - pt evaluation system (prioritizing)
luncheon meat)

 FULL LIQUID DIET

APGAR SCORING
- opaque
- transitional diet from liquid 0 1 2
- ex : cream soup, ice cream, milk, leche flan,
pumpkin cake Appearance pallor acrocyanosis all
pink
Pulse (-) <100
>100
“ABGs” ATERIAL BLOOD GASES Grimace (-) grimace
vigorous
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Activity flaccid some flexion 3. pt ask what procedure: Rn Action : notify the
flexion & extension doctor
Respiratory (-) irregular
lusty cry 4. MI attack – 1st action : report ASAP (esp. presence
of vent. Fibrillation)

T.R.I.A.G.E -prioritizing 5. pt on NGT – check patency of tube

LEVEL 1 “emergency”

 severe shock, cardiac arrest, cervical spine injury,

airway compromise, altered level of consciousness, multiple
system trauma, eclampsia

LEVEL 2 “urgent (stable)”

DELEGATION
 can be delegated (fever, minor burns, lacerations,
dizziness) - do not delegate Assessment, Teaching and
Evaluation
LEVEL 3 - do not delegate meds preparation,
administration, documentation
 chronic/ minor illness (can be delegated) – dental
problems, routine medications and chronic low back pain
CONCEPT OF DELEGATION

 consider the competence of personnel

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

TIPS ON PRIORITIZING
MI ATTACK – enzymes to increase IN ORDER - #1
1. PT @ ER – sleeping pills overdose; myoglobin
#2 troponin
2. pt bp 80/30 & mother died of CVA #3 CK
1st priority : assess pt for addtl risk factor; #4 LDH
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RISK FOR INJURY – meniere’s dses  APPENDICITIS

INEFFECTIVE BREATHING PATTERN – myasthenia gravis
ALTERED TISSUE PERFUSION – pt w/ complete heart block Unruptured : any position of comfort
INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s
breathing Ruptured : semi to high fowler’s position to prevent the
upward
spread of infection
D complication: peritonitis

Ruptured appendicitis indication: pain decreases or go away.

(pt say, “I want to go home pain is gone”)

POSITIONING FOR SPECIFIC SURGICAL CONDITION  BURNS

Positioning – independent nsg function Position is FLAT or Modified Trendelenburg – to prevent

- know the purpose of the position shock.
a. to prevent or promote soothing;
b. what to prevent or promote; SHOCK occurs w/in 24-48hrs (immediate post burn phase).
c. know your anatomy & physiology
Complication: infection
Post Liver Biopsy – R side lying – to prevent
bleeding
(during the procedure – L side lying).

Hiatal Hernia – upright to prevent reflux.

 CAST, EXTREMITY

 AMPUTATION Elevate the Extremity – to prevent edema (use rubber pillow)

complication: hemorrhage (keep tourniquet @ bedside)
Nsg care:
1st 24hr – goal: to decrease edema – elevate the
stump at foot part w/ a. capillary refill – N 1-3 seconds only (complication:
the use of pillow altered circulation)
b. note for s/s of infection (when there is musty odor inside
AFTER 24hr – goal : to prevent contracture deformity the cast)
(keep leg extended) c. pruritus (inject air using bulb syringe)
d. blood stained – mark and note (if increasing in diameter
- report ASAP)
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e. tingling sensation – indicate nerve damage  HIATAL HERNIA

- there is damage to esophageal mucosa

- what to prevent: gastric reflux therefore FEEP
PT IN UPRIGHT POSITION.


  HIP PROSTHESIS

 CRANIOTOMY Position: to prevent subloxation (KEEP LEG ABDUCTED) with
the
Types: use of wedge pillow or triangular pillow from
perinium to
a. Supratentorial C – semi fowler’s orlow fowler’s the knees.
position – to prevent
accumulation of fluid at surgical dumping syndrome : “flat”
site;

b. Infratentorial C - flat or supine. Purpose: same

 LAMINECTOMY

- “log-roll the patient” (3 nurses) – KEEP SPINE IN

 FLAIL CHEST STRAIGHT
ALIGNMENT
(+) Traumatic Injury – paradoxical chest movement – areas - AVOID: hyperflexion, hyperextension and prone
of chest GOES IN inspiration and OUT on Expiration – it causes
hyperextension of the spine.
position: towards the affected side to stabilize the chest.

 LIVER BIOPSY
 GASTRIC RESECTION
- before LB : supine or L side lying to expose the
- to prevent dumping syndrome – usually for 10 part
mos only NOT LIFETIME disorder (post gastrectomy) - during LB : - do-
- position : LIE FLAT for 1-2hrs post meal - after LB : R side lying w/ small pillow under
the coastal margin to
prevent bleeding.
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 LOBECTOMY - AVOIDE SEX (may burn penis bec of the implant

inside)
- removal of Lobe (N R lobe – 3, L lobe – 2)
- position : semi fowler’s position – to promote
lung expansion
 RESPIRATORY DISTRESS

Adult : Orthopneic position – over bed table then lean

 MASTECTOMY forward

- removal of breast Pedia : TRIPOD – lean forward and stick out tongue to
- elevate or extend affected arm to prevent lymp maximize the
edema (or elevate higher that the level of the heart. Airflow
AVOID: venipuncture, specimen taking, blood pressure –
ON THE AFFECTED
ARM coz there is no more lymph node w/c predispose pt  RETINAL DETACHMENT
to bleeding.
- to prevent further detachment, place pt on the
Post mastectomy Exercises: squeezing exercises, finger AFFECTED SIDE.
wall climbing, flexion-
extension (folding of clothing, Ex. If operation is on the R outer of the R eye, place pt on
washing face, the R position.
vacuuming the house) If operation is on the L inner of the R eye, position pt
on the L side
Due to removal of axillary lymph node, avoid also gardening
and hand sewing AVOID: sudden head movement.

 PNEUMONECTOMY
 VEIN STRIPPING
- either L or R lung. Position pt on the AFFECTED
SIDE to promote - keep extremities extended then elevate the
lung expansion. legs at level of the heart to promote venous return

 RADIUM IMPLANT OF THE CERVIX TIPS

- keep pt on complete bed rest to prevent  liver biopsy is done on a pt. – during 1st 24hrs after
dislodge. the procedure, turn the pt on his abdomen w/ pillow under
the subcoastal area;
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1. DON’T ASK WHY – this put pt on the defensive

 when draining the L lower lobe of the lung – the pt 2. AVOID PASSING BACK – “I will refer you to….”
shld be positioned on his R side w/ hip higher or 3. DON’T GIVE FAKE REASSURANCE – “everything will be
slightly higher than the head; alright….”
“you’re in the
 after tonsillectomy – position: prone hands of the best”
4. AVOID NURSE CENTERED RESPONSE – “I felt same
 a pt is about to go on thoracenthesis - how shld the too…”
nurse position the pt? – sitting w/ a arms resting on the “I had the
overbed table; same feeling….”

 to maintain the integrity of pt w/ hip prosthesis – In GROUP DISCUSSION – nurse is just a facilitator – let the
abduction splints group decide, he/she channel are concern back to the group.

 immediately after supratentorial craniotomy- fowler’s THERAPEUTIC PHRASES

position – it seems… you seem….
- open ended question
 best position for pt in shock – supine w/ lower - close ended – for manic pt and pt in crisis
extremities elevated - direct question- for suicidal pt

THERAPEUTIC COMMUNICATION

ISOLATION PRECAUTION
RESPIRATORY
OPTIONAL OPTIONAL
Purpose : to isolate infection transmission
(AIRBORNE: BEYOND 3FT
DROPLET : W/IN 3FT)
TYPE PRIVATE ROOM HAND
WASHING GOWN GLOVE MASK
TB OPTIONAL
OPTIONAL
STRICT (negative airflow room)
(airborne dses, direct contact-Diptheria)
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CONTACT
(direct contact – NOT AIRBORNE DSES)
eX SCABIES

ENTERIC X
OPTIONAL OPTIONAL
(fecal contamination)

DISCHARGE X OPTIONAL
OPTIONAL
(drainage: pus ex burn pt)

UNIVERSAL X
(AIDS, HEPA b – TRANSMITTED
BY BLD AND DODY FLUIDS) 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
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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

DIAGNOSTIC PROCEDURES

side notes:
TRANSCULTURAL CONSIDERATION
pt for IVP : assess for allergy (cleansing enema
b4 the procedure)
pt for KUB : no dye (don’t assess for allergy) HISPANIC PATIENT – women prefer same gender health
schilling test : 24hr urine specimen care provider
USG : no consent required
Obtain help of interpreter when explaining procedures –
(except or don’t ask family members)
GENERAL CONSIDERATION
For muslim patient - they prefer same sex health care
 EXPLAIN the procedure to the pt (initial nsg action) provider however, if
- if not ready inform the doctor; procedures require life threatening –
- pt has the right to refuse procedure; they prefer to have
- doctor the one who asked for consent male doctor.

 Check pt for CONSENT – if INVASIVE – - they only want good news information
WITH CONSENT of their condition
NON INVASIVE – NO CONSENT
needed

 CONTRAST MEDIUM – check for allergy DELEGATION and DOCUMENTATION

 For procedure requiring anesthesia – Delegation – assessment, monitoring and evaluation of

KEEP PT NPO B4 PROCEDURE treatment
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(cannot be delegated) BUT standard and - monitor the baseline FHR then induce fetal
changing procedures can movements by (HOW) :
be delegated ex. – 24hr urine specimen and
urine catheter a. ring a bell
collection. b. feed the patient

Documentation – type of treatment and any untoward then check FHR, NST is (+) if FHR increase at least 15
reactions. beats/min than the baseline. (ex. 140 FHB baseline, then
after challenge it increase to 155)

POSITIVE result means, BABY is REACTIVE (good condition)

KEYPOINTS FOR NURSES and no need for contraction stress test/oxytocin challenge
test – coz baby is OK and doing well.
 Prepare the patient;
 Monitor for adverse reaction;
 Report complication to the doctor  CONTRACTION STRESS TEST (oxytocin challenge
test)
FRAMEWORK – includes the Purpose, Special Consideration
and Interpretation - correlates FHR with uterine contractions
- pt on NPO
- get baseline FHR then induce uterine
contraction
HOW:
DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND Thru breast stimulation – it triggers the release of
WELL-BEING) 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)
 DAILY FETAL MOVEMENT
types of deceleration
Purpose : to determine fetal activity by counting fetal a. early deceleration – indicates head compression
movements – (MIRROR IMAGE)
usually perform by pt himself
b. late deceleration – indicates placental insufficiency
N Fetal Movement 10-12 for 12 hr period (average: 1 (REVERSE MIRROR IMAGE)
movement/hr with mgt: L Lateral Recumbent Position, Administer O2,
Treat Hypotenson
average 3fm/hr)
c. variable deceleration – due to cord (image: U or W
 NON STRESS TEST (NST) – correlates fetal heart shape) and slowing of FHR can occur
rate w/ fetal movement anytime.
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If (+) CST, meaning there is deceleration, baby is NOT OK AMNIOCENTESIS – AMNIO

coz there is decrease FHR and during labor he/she may PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING – PUBS
stand the labor process.

CVS AMNIO
PUBS

 BIOPHYSICAL PROFILE Purpose: to detect chromosomal Purpose : same

w/ CVS Purpose: to check chromosomal
– to determine fetal well being w/ the use of 5 Aberration
CRITERIA aberrations, & presence of RH
(eg. Down syndrome, Trisomy 21)
fetal breathing 2 points Incompatibility
movement 2 points
heart tone 2 points
reaction to NST 2 points Done in 1st trimester can be done on the
amniotic fld volume 2 points 2nd wk (14-16 wk) Extract blood at umbilical cord
(can be done as early as 5th wk but - but not
10 points recommended bec. of danger then it is tested if it really
score below 6, indicates fetal jeopardy comes
can be done on 8-10th wk) abortion
(assess pt age of gestation) from the umbilical cord (can
be
 ULTRASOUND
done on either 2nd or 3rd tri.
- provide data on placenta (age and location)
gender of baby or can be done on the 3rd wk (34-36 wk)
structural abnormalities purpose: to detect fetal
position of baby maturity (FLM)
Get sample at chorion (by 10-12wks – thru
- for pregnant: site is lower abdominal USG monitoring of L/S Ratio N 2:1
types: The placenta matures, get some sample) (if mother is
(+) DM LS ratio is 3:1)
a. Upper USG – NPO
b. Lower USG - NPO
- preparation: increase fluid intake (oral) This procedure also check level
NO consent needed of alpha-feto
If pt ask if it is painful: NO PAIN; Protein – if
Pt shld have full bladder INCREASE – spina befida;
If DECRTEASE – down
syndrome
CHORIONIC VILLI SAMPLING – CVS
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(+) Consent – invasive (+) Consent  after amniocentesis w/c of the following
(+) Consent manifestation if observed by the nurse on the patient that
needs to be reported : bleeding;

Bladder : Empty consider the Pt Age of  pt ask the nurse – what deceleration
Gestation means – it refers to slowing of baby’s heart rate;
(if age of gestation :
is higher than  before Amniocentesis, what to check –
20wks and above : empty bladder, USG DEVICE
if AOG is 20wks
and below : full bladder

COMPLICATIONS of CVS, AMNIO & PUBS:

a. infection
b. bleeding
c. abortion
d. fetal death

TIPS

 EARLY DECELERATION – expected in the

fetal monitor when there is fetal head compression;

 AMNIOCENTESIS – was done @ 35 wks DIAGNOSTIC TESTS (to evaluate pediatric patients)
gestation – purpose: to determine fetal lung maturity;

CARDIOPNEUMOGRAM
 A mother asked the nurse what will – use to diagnose apnea of infancy
amniocentesis provide during pregnancy: it will show as – assess HR, RR, nasal airflow and O2
whether the baby lungs are developed enough for the saturation – N 95-98%
baby to be born; below 85 – report ASAP

 a nurse is preparing pt for lower abdl

usg – w/c of the following done by the pt needs further GLUTEN CHALLENGE
teaching – pt voids b4 the procedure;
 19

- detect presence of Celiac Disease (CD) - test for pre-teen : “bend over test” – bend and touch the toe;
intolerance to gluten;
- pt is given gluten rich food for 3-4 months the (+) scoliosis – if presence of rib hump, therefore x-ray then
observe s/s of CD scoliometer.

s/s of CD: abdl cramps, steatorrhea, abdl rigidity, abdl

distention SICKLEDEX TEST HGB
(if + for CD, gluten free diet will be for life time) ELECTROPOISIS

Purpose: test for sickle cell anemia

Purpose: test for sickle cell anemia

ORTOLANI’S TEST (OT) BARLOW’S Specimen : Blood : (blood + solution, if (+) TURBID
MANUEVER (BM) Specimen : Blood : bld + electropoiesis, if sickling of
RBC
purpose: test developmental dysplacia of the hip or Therefore TRAIT CARRIER
purpose : same (S or C shape RBC), therefore + for SC Dses
congenital hip dislocation
Test for TRAIT Test for Disease
(+) if w/ click sound (lateral) (+)
barlow’s 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 GUTHRIE CAPILLARY BLOOD TEST (GCBT)
- check for: (+) scoliosis if uneven hemline
uneven waist - to detect PKU
more prominent iliac rest and scapula on one side (in PKU there is absence of PHENYLALAMINE HYDROXYLASE-
presence of rib hump PH)
 20

Phenylalamine hydroxylase – is an enzyme that converts PH

to Tyroxine – the one that gives color to hair, eyes and skin.  mother complains that her baby taste salty – which
test is to be performed : sweat chloride test;
If absent PH, no one will convert PH to Tyroxine, therefore it
will accumulates to brain and can cause mental retardation.  9 yo pt has (+) result for sweat test – this indicates
possible dx of Cystic Fibrosis;
PH came from CHON rich food. At birth, it is usually
negative, so give CHON food first for 3wks then retest.  pilocarpine – drug used for pt undergoing seat
chloride test;
Before test, give chon rich food for 1-4 days before test.
(adult)
 hgb electropoisis – test for sickle cell dses
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 DIAGNOSTIC PROCEDURES

becomes impermeable to Na. meaning cannot reabsorb Na
and it accumulates outside of the skin);
- Mother complain that her baby taste salty; I. CARDIOVASCULAR
- PILOCARPINE – used in the test to induce
sweating;
A. ELECTROCARDIOGRAPHY – records the electrical
Types: activity of the HEART
a. sweat chloride test – N 10-35 meq/L (above 40
meq/L– (+) P wave – atrial depolarization
b. serum chloride test – N 90-110 meq/L (above 140 QRS complex – ventricular depolarization
meq/L – (+) ST - repolarization

Rhythm – appearance of wave and distance

Rate - N 60-100 bpm – check on # of QRS then divide it
by 300 (k)

ABNORMALITIES

TIPS a. atrial fibrillation – p waves “halos magkadikit.

(no discernable p waves)
 pt w/ PKU would more likely to have (+) result in
gluten capillary bld test if there is – adequate CHON in the b. atrial flutter – “saw tooth” flutter waves
diet;
 21

c. ventricular – check on QRS (N - .8-.12)

D. CORONARY ARTERIOGRAPHY

ANGINA – st segment elevation, t wave inversion - visualization of the bld vessels w/ contrast
MI - st segment elevation or depression, t wave medium
inversion - nsg alert: (+)consent
check allergy to contrast medium
increase oral fluid intake after to excrete
dye
B. CARDIAC CATHETERIZATION epinephrine shld be ready for any untoward
reaction
- it determine the structural abnormalities in the
heart
- either L or R sided catheterization
- site: antecubital, femoral, brachial E. SWAN-GANZ CATHETERIZATION

common complications: embolism, bleeding, arrythimia - 4 lumen for the ff CVP, Pulmonary Capillary
“EBA” Wedge Pressure
(PCWP), Pulmonary Artery Pressure,
nsg mgt : Bld products, Balloon
 monitor distal pulses (if brachial site: check @
radial CVP – measure R side pressure of the heart
if femoral site : check @ dorsalis PCWP – L side of the heart
pedis)
 if weak or no pulse – REPORT N Pressure CVP: for R Atrium – 0-12
 if (+) bleeding – report (“sandbag 10-20 lbs” – for SVC – 5-12
shld be at bedside)
Nsg Alert : check pulse and s/s of bleeding

C. STRESS TEST
F. BLOOD CHEMISTRIES
- determines the ability of the heart to withstand
stress
- equipment : threadmill & ECG  SODIUM (135 – 145 meq/L)
- nsg alert : check pulse and BP
keep NPO an hr b4 the test Addison’s Dses: hyponatremia (dec Na),
NO Jewelries hyperkalemia (inc K) – “FLD IMBALANCE”

Cushing Syndrome: hypernatremia, hypokalemia

– “FLD VOL. EXCESS”
 22

 LDH (40 – 90 u/L)

 POTASSIUM (3.5 – 5 meq/L)
LDH1 – 27-37% (for heart – check for MI)
Hyperkalemia : Addison’s dses
Hypokalemia : Cushing Syndrome
LDH2 – 17-27% (for heart – check for MI)
Inc or dec in K PT RISK of INJURY
LDH3 – 8-15% (for respiratory system)
Pt w/ digitalis & diuretics – monitor for arrhythmia
LDH4 – 3-8% (for liver & kidney)

 CALCIUM (4.5 – 5 meq/L or 9-10mg/dl) LDH5 – 0-5% (for liver & kidney)

Hyperthyroidism – inc CA
Renal Calculi Formation – inc CA @ bld LDH inc for MI for 3-4 days then it returns to N after
10-14 days

 GLUCOSE (80-120)
 CPK or CK
- Higher than 140 – hyperglycemia (acidosis –
may lead to ineffective breathing pattern and airway is the Male – 12-70 u/L
main problem) Female - 10-55 u/L

- below 50 – hypoglycemia (pt prone to injury & Increase CPK 3-6hrs post MI then it normalize 3-4
altered thought process) dyas

 Creatinine (.5-1.5)
 AST (SGOT) SGPT (ALT)
- most sensitive index of kidney funx
(increase BUN but N creatinine – do not report to AP) - N 8-20 u/L N 8-20 u/L
- for liver (inc. for liver dses) more on HEART (inc
- increase creatinine – kidney failure or renal for cardiac dses)
disorder

 BUN (10-20 mg/dl) G. HEMATOLOGIC STUDIES

- inc. if (+) kidney disorder

RBC (4.5 – 5.5 million)
 23

- inc RBC – polycythemia – risk for injury – complication CVA

- dec RBC – anemia – activity intolerance DOPPLER USG
- to detect the patency of bld vessels – arteries &
veins esp of lower
WBC (5-10 thousand) extremities;
- to detect presence of infection, bld disorders - painless, non invasive, NO SMOKING 30 min-1hr
like leukemia b4 the test
- dec WBC – pt prone to infection
- inc WBC – hyperleukocytosis – (+) to pt w/
leukemia – risk for infxn PULSE OXIMETRY
- determines the O2 saturation at blood
- N 95-98 – attach to finger or earlobe (do not
PLATELET (150,000-450,000) expose e light)
- spontaneous bleeding occurs when platelet dec
(pt also prone to injury)
II. RESPIRATORY

PT PTT APTT  BRONCHOSCOPY

(11-12 sec) (60-70 sec) (30-40
sec) – visualization of b. tree or airway passages;
– to gather specimen for biopsy;
coumadin – check pt heparin – PTT – NPO b4 & after
– Gag reflex return after 1-2hrs;
monitor pt 4 bleeding monitor pt 4 bleeding – Pt may expect a sore feeling (PINK STINGED
SPUTUM)
– Report (+) stridor
HGB – male : 14-18 mg/dl
Female : 12-16 mg/dl 
 CHEST X-RAY
Dec hgb – anemia (nsg dx: activity intolerance)
- to determine abnormalities of lungs and
thoracic cavity;
HCT - 35-45% - no preparation;
- determine the adequacy of hydration and the ration of - ABSOLUTE CONTRAINDICATED TO PREGNANCY
plasma to - Check pt for radiation indicator
the cellular component blood - Determine effectiveness of tx and whether pt is
active or
inc hct : hemoconcentration (nsg dx: fld deficit – non-active
dehydrated pt)
 SPUTUM STUDIES
dec hct : hemodilution fld excess
 24

- to determine the gross characteristic of the

sputum (refers PROCEDURE: EXHALE then INSERT mouth piece,
to the amount, color, abnormal particles, consistency BREATH iN, HOLD
and then EXHALE
characteristic)

TYPE OF SPUTUM  LUNG SCAN

PNEUMONIA - Viral – thin & watery - to identify the presence of blockage in the pulmonary bld
Bacteria - rusty vessels;
- with contrast medium;
TB - blood streaked - (+) consent;
- assess for rxn to allergy
BRONCHITIS - gelatinous

CHF/ PULMONARY EDEMA - pink stinged  MANTOUX TEST

Sputum specimen – sterile container - test for POSSIBLE TB EXPOSURE;

- using PPD (purified chon derivatives)
 THORACENTESIS - angle 10-15, BEVEL UP then read 48-72hrs after
- aspiration of fld at thoracic cavity
(for diagnostic & therapeutic purpose) 5mm in duration – (+) for HIV, multiple sex, previously (+)
pt;
position: DURING – sitting 10mm - (+) for immigrants, children below 3yo
AFTER - affected or unaffected side and for
pt w/ medical condition – DM &
Nsg alert: Alcoholism
15mm - (+) for general population
NO COUGHING & DEEP BREATHING – during the procedure
– coz
this may cause puncture of the lungs;  LUNG BIOPSY
Assess for breath sounds after;
- aspiration of tissues at lungs for dx of tumors,
Complication: bleeding and pneumothorax malignancy
- assess for bleeding, breath sounds & report for s/s of
dyspnea
 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.
 25

CONTRAINDICATION CONTRAINDICATION
(same w/ ct scan BUT w/ addtl)
a. pregnancy;
III. NERVOUS b. obese pt (more than 300 lbs); NO METAL
OBJECTS
c. claustrophobia (give anti-anxiety b4) - jewelries,
 EEG insulin pump,
d. pt w/ unstable v/s (arrhythmic & HPN); pacemaker,
- shampoo hair B4 (to remove chemicals) hip replacement
and AFTER to remove electrode gel e. pt w/ allergy to dye
(shampoo or acetone)
- measures electrical activity of the brain (gray
matter) “clicking sound” will be heard & lie still during the
- non invasive, (-) consent procedure lie still
- detect the ff: brain tumors, space occupying lie still during the procedure and “thumping
lessions sound” will be heard
alcohol brain waves and seizures

nursing alert:

 dietary modification: WITHOLD

CAFFEINE – coffee and tea;  CEREBRAL ANGIOGRAM
 WITHOLD 48hrs b4 the procedure :
tranquilizers, sedatives, anti-convulsant, alcohol - involves visualization of bld vessels @ vein w/
the use of
contrast medium.
CT SCAN MRI PET
CONTRAINDICATED IN:
Use radiation to determine use electromagnetic
field use gamma rays or positron electron pt w/ allergy; pregnant pt.; bleeding
tissue density to detect abnormality of tissue
density to detect abnormality of tissue density;
(detect cancer and tumor) Nursing Alert:
also to detect O2 saturation @ tissue;
physiology of psychosis; and to evaluate tx like CA Tx a. keep pt NPO;
b. assess pt for allergy;
give more detailed impression c. monitor for signs of bldg;
(ex. Measurement of blocked artery) d. inc oral fld intake to excrete dye;
NSG ALERT: e. keep epinephrine and or benadryl at
(w/ or w/out dye) bedside for emergency
 26

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

If REDDISH – hemorrhage
If Yellowish – infection

Ear licking w/ fluid – test if (+) glucose bec. CSF has glucose.



 
 
 
  MYELOGRAM

 LUMBAR PUNCTURE - test for presence of slip disc or herniated
nucleus
porposus (HNP).

ALERT:

Know the type of dye use:

- aspiration of CSF for assessment to check for
infection or a. water based – called AMIPAQUE
hemorrhage b. oil base – called PANTOPAQUE

position:  type of dye will determine the position of pt

AFTER the procedure.
DURING : fetal or C-position
 If water based, the HEAD OF BED ELEVATED;
AFTER : FLAT to prevent spinal headache  If oil based, FLAT after

Needle is inserted between L3 and L4 or L4 and L5 Rationale for both oil and water based dye is TO PREVENT
the upward dispersal of dye w/c can cause electrical
Increase fluid intake after. meningitis (s/s includes: (+) seizure, headache)

 CSF ANALYSIS

- Assess for the characteristic of CSF. IV. EENT

 27

CONDUCTIVE HEARING
 TONOMETRY LOSS

- 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 Minierre’s 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 - Minierre’s Dses
NO NYSTAGMUS - Acoustic Neuroma

 GONIOSCOPY
V. GASTRO INTESTINAL TRACT
- to differentiate OPEN and close angle galucoma;
- non-invasive, painless
 UPPER GI SERIES (Barium Swallow)

WEBER TEST RINNE’S TEST - xray visualization with contrast medium

- Contrast Medium:
To determine lateralization of sound; To determine
air and bone conduction a. Gastrografin – water soluble, use straw
If pt hears vibration better in GOOD EAR, Place tuning
fork 2inches from the ear b. Barium - swallow – milk shake like (use feeding
Problem would be SENSORINEURAL LOSS; place bottle of pt)
at mastoid bone or in teeth then…. - then pt is ask to assume different
if pt hear better in POOR EAR, - refers to if AIR positions to
CONDUCTION is LONGER, therefore distribute dye @ esophagus
CONDUCTIVE HEARING LOSS
SENSORINEURAL HEARING LOSS; purpose: to detect disorders of esophagus
If BONE CONDUCTION IS
LONGER, therefore feces : “chalky-white”

after: instruct pt to take laxative to excrete dye

 28

 BARIUM ENEMA (for Lower GIT) - ALERT: assess for allergy (epinephrine/benadryl)

- involve rectal installation of barium; - Post procedure: inc. oral fld intake – to facilitate
excretion of dye
- 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  GASTRIC ANALYSIS

inflammatory bowel condition like CANCER;
- analysis of gastric secretion like
specimen : stool (this can be refrigerated awaiting HYDROCHLORIC ACID
laboratory) - Lower Level N : 2-5 meq/hr
- Upper Limit N: 10-20 meq/hr
AVOID the following 3 days B4 the test – bec it can
yield to FALSE (+) UPPER LIMIT YPES
RESULT : Red Meat, Fish and Horse Radish
a. WITHOUT TUBE (tubeless gastric analysis)
- using DIAGNEX BLUE (specimen: urine);

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

 CHOLANGIOGRAPHY if urine (-) blue color, therefore (-) HCL Acid

- visualization of biliary tree (includes, hepatic - if (-) HCL Acid at stomach (achlorhydia),
duct & common bile duct) – same with CHOLECYSTOGRAPY – therefore Gastric CA;
but medium given orally;
- if Increase HCL Acid – therefore ZOLLINGER-
- with contrast medium w/s is given thru IV ELLISON SYNDROME – (+) Gastric Tumor
 29

b. WITH TUBE – with the use of NGT then aspirate - 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;
 ULTRASONOGRAPHY - invasive – (+) consent;
- NPO – tube insertion;
- upper abdl USG to detect abnormalities in the - Tell pt that tere will be feeling of soreness a wk
upper abdl area w/ after the procedure
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;  COLONOSCOPY

- ALERT: Check for Bleeding Time (N – 1-9 mins) - visualization of colon to detect:
and inflammatory bowel condition
Clotting Time (N – 10-12 mins) – because liver is highly Chron’s Dses
vascular organ Diverticulitis
Hemmorhoids
- WHEN NEDDLE IS INSERTED tell pt to: Tumor
Inhale then Exhale then Hold Breath – to stabilize liver Polyps
position
- (+) Consent
- Position after : R side-lying position - NPO b4
 30

- clear liquid diet – 2days b4 the procedure

position: Lateral or side lying position or L Lateral Sims  DEXAMETHASONE SUPRESSION TEST

- 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

VI. ENDOCRINE
- use to detect the presence of Addison’s &
 GLUCOSE TOLERANCE TEST Cushing’s Dses.

- to provide measure of bld sugar level at blood; Addison’s – dec secretion of ketones
- Inform pt to have high CHO diet 2 days b4 the Cushing’s – ince secretion of ketones
test;
- Instruct NPO a day b4 the test (npo post Specimen: 24 hr urine
midnoc);
- Inc sugar level, therefore Diabetes

 ACTH STIMULATION TEST  VANILLYLMANDELIC ACID TEST – VMA Test

- to detect presence of Addison’s Dses - bi-product of CATHECHOLAMINE Metabolism

- specimen: blood
- pt is given dose of ACTH (not nore than 40ug/dl)
- if still dec despite ACTH administration, epinephrine norepinephrine
therefore Adrenal Insufficiency – Addison’s Dses
 31

abnormality: lower than 1.005 – diabetic insipidus

higher than 1.030 – diabetic
inc if there is TUMOR mellitus
(pheocromocytoma) of Adrenal Medulla
(+) glucose – infection, DM
(+) CHON - PIH, kidney dses.
N 2-7 mg/dl / 24hrs – if inc, therefore tumor
Urine maybe refrigerated if waiting to be examined.
AVOID: vanilla containing food 3 days b4 test –
ice cream, coffee, chocolates

 CULTURE & SENSITIVITY

 RAIU
- to detect infection
- pt is given iodine 131 then after 24hr followed - prepare storage container
by a thyroid scan
- inc indicates hyperthyroidism, dec
hypothyroidism  KUB IVP
- AVOID: iodine rich-food (sea foods, sea shells,
sea weeds) 7-10 days b4 and to include other diagnostic - xray of the kidneys, ureter and bladder -
procedures that uses contrast medium (“NO” - angiogram xray of the kidneys, ureter and bladder
test). – bec it may yield to false (-) result. - NO SPECIAL PREPARATION NEEDED - uses
 SULKOWITCH’S TEST contrast medium/ dye
- assess for allergy,
- detect amount of calcium excreted at urine; then inc. oral fld intake after
- if to test for hypercalcemia and hyperthyroidism - benadryl or
- gather specimen b4 meals; epinephrine at bedside for allergic rxn
- to test for hypocalcemia and hypothyroidism – - NPO POST MIDNOC,
gather after meals cleansing enema in AM

VII. R E NA L

 URINALYSIS

- examine the gross characteristic of the urine  CYSTOSCOPY

urine amount : 30-60ml/hr - visualization of urinary bladder

color : clear, amber - after : monitor I & O;
s. gravity : 1.010 – 1.025 - note for s/s of bleeding
 32

- to alternately contract and release the muscle

 RENAL BIOPSY as needle is inserted
- HOLD muscle relaxant b4 the test
- aspiration of tissues at kidney for biopsy to
detect:
a. malignancy/ Ca  ARTHROCENTESIS
b. malignant HPN
c. kidney disorder - aspiration of fluids at synovial space to detect
abnormalities;
- note for s/s of bleeding - check for order of analgesic;
- apply cold pack

 ARTHROSCOPY

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

- to check the patency of the ureter and bladder;

- monitor I & O  BONE SCAN

- detect rate of bone destruction or bone

 CYSTOMETROGRAM resorption for pt w/ osteoporosis;
- lie still during the procedure;
- to evaluate the sensory and motor funx of - PAINLESS AND NON INVASIVE
bladder;
- to check if bladder respond to distention after
installation of flds;
- monitor I & O

VIII. MUSCULO-SKELETAL

IX. MISCELLANEOUS
 ELECTROMYOGRAPHY
 BONE MARROW BIOPSY
- to detect electrical activity of the muscle;
- (+) consent; - to check abnormalities at the b. marrow (eg.
Leukemia)
 33

- site : ILEAC REST

- (+) consent
- assess for bleeding
- sand bag at bedside (post procedure) – for  ERYTHROCYTE FRAGILITY TEST
emergency use
- use to detect the rate of RBC DESTRUCTION in a
 SCHILLING’S TEST hypotonic
solution (RBC Lifespan: 120 days)
- specimen: 24hr urine
- test for VIT B12 deficiency; if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA
- for pt w/ PERNICIOUS ANEMEIA; (EX. SICKLE CELL)
- 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  HETEROPHIL ANTIBODY TEST
stomach and
40mg will be excreted. - detect presence of IgM w/c is related to Epstein
Virus infection

Epstein Virus Infection – causative agent of infectious

 URINE UROBILINOGEN mononucleousis (“kissing dses”)

 to detect HEMOLYTIC DSES mgt: AVOID SHARING of utensils and glass

 WITHOLD ALL MEDS – 24hrs b4 the test

 BENCE-JONES PROTEIN
 LYMES DSES SEROLOGY
 detect presence of MULTIPLE MYELOMA
(malignancy of plasma cells); - detect presence of BORRELIA BURGDORFERI –
 RELEASED by destroyed or damage bones causative agent of lyme’s

dses.

 ROMBERG’S TEST Treatment: tetracycline

 check FUNX of CEREBELLUM;

 stand erect, close eyes, and observe for
inability to maintain posture (if pt is Swaying, therefore
TUMOR at cerebellum)
 34

 A pt is to have an upper GI series – which statement

shows that he understood the instruction given : “I will
drink the dye”.

TIPS FOR DIAGNOSTIC PROCEDURE  After liver biopsy, a potential complication: bleeding.

 2 moths old infant suspected of brocholitis is treated  MRI is the primary diagnostic tool for multiple scelosis
with oxygen therapy. Which result indicates that tx was bec it promotes visualization of plaques at the brain.
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”.
 35

LPN’s – 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 (they refuse meds if for

st
the 1 time)

MIDDLE EASTERNERS - they expect meds during first

contact w/ hx care provider

JEWISH – no meds restrictions

JEHOVAH’S WITNESS – do -

 ORIENTAL PAYLOAH (from mexico)

- treatment for diarrhea;
DAY 5 (8 Feb - may cause lead toxicity
2005)
 ECHINECEA
- use to boost the immune system;
PHARMACOLOGY - for pt. with cancer

 ST JOHN’S WORT
- anti-depressant (it funx like MAO inhibitor);
I. GENERAL CONSIDERATIONS - do not give to pt taking MAO

 ONLY RN’s are allowed to administer (to include  VALERIAN

central line) - sedative (used also as anti-anxiety agent)
 36

- adverse effects – GI Irritation

 Lactulose – given to pt with hepatic enceph to dec
 GINGCO BILOBA ammonia absorption
- blood thinner; - s/e : diarrhea
- use to enhance bld circulation;
- for pt w/ alzeimers  ANTABUSE (dizulfiram) – most appropriate time to
- CONTRAINDICATED to pt with bleeding disorders take meds : after
12hrs of alcohol free.
COMMON CONTRAINDICATIONS for HERBAL MEDS:
 COGENTIN – to prevent pseudoparkinsonism (by
 NO HERBAL MEDS for pregnant client; decreasing muscle rigidity)
 NO HERBAL to lactating pt;
 NO HERBAL for those with severe kidney and  TETRACYCLINE - can cause staining of teeth,
liver disorder Photosensitivity (use sunscreen when
outdoors)

 LITHIUM – shld have inc. fluid in the diet

III. DELEGATION AND DOCUMENTATION

Document all medical admin record: time, route,

dosage and untoward reaction;

The following CANNOT be delegated: treatment,

administration, documentation of meds

IV. THE CHECK PRINCIPLE PSYCHOTROPIC

I. ANTIPSYCHOTIC
C– lassification (FOR WHAT?) - major tranquilizer;
H- ow will you know that he meds if effective (evaluation) - for SCHIZOPHRENIA (pt has EXCESS DOPAMINE);
E- xactly what time are you going to give it - plays as treatment to the symptoms NOT CURE
C- lient teaching tips to schizo – meaning it modify the symptoms (target
K- eys to giving it safely symptom: to decrease dopamine)
 37

ex.  hyperpyrexia and muscle rigidity

Haldol
Chlorpromazine - this indicates NEUROLEPTIC MALIGNANT
Clozapine (chlozaril) SYNDROME (NMS)
Olanzapine (zyprexa) drug of choice: Parlodel, Dantrium
Risperdon
 Assess SIGNS and SYMPTOMS of
BETS TO GIVE: after meals PSEUDOPARKINSONISM

DOPAMINE – neurotransmitter (facilitate the transmission of a. mask-like face or expressionless face

neurons) b. pill-rolling tremors
c. cogwheel’s rigidity or lead pipe rigidity
In SCHIZO there in INCREASE NEUROTANSMITTER.
 AKATHESIA – “restless leg
syndrome” (I feel as if I have ants in my pants)
Signs & Symptoms:
a. DELUSION – “FALSE BELIEF”  DYSTONIA
b. HALUCINATION - hearing sounds
c. LOOSENES OF ASSOCIATION – shifting  Avoid direct sunlight – because meds photosensitivity
of topic
 Instruct pt to rise slowly – to avoid orthostatic
hypotension

Check: CBC, BP, AST/ALT

To prevent pseudoparkinsonism, administer

ANTIPARKINSONIAN agents

IA. DOPAMINERGICS - ANTIPARKINSONIAN

CLIENT TEACHINGS: in schizo there is increase dopamine, therefore give
antipsychotic to dec dopamine then dec dopamine causes
 Report ADVERSE EFFECTS of ANTI-PSYCHOTICS pseudoparkinsonism. Therefore give dopaminergic.
– which indicates agranulocytosis
a. fever ex. L-Dopa
b. body malaise Levodopa
c. sore throat Levodopa-Carbidopa
d. chills
 38

 Effective if decrease in tremors and rigidity within 2-3 b. dry mouth – suck on ice chips or hard candy;
days; c. palpitations – check PR;
 When to give: AFTER MEALS; d. constipation – inc. roughage at diet;
e. urinary retention NOT urinary frequency
 Health Teachings: f. decrease BP – rise slowly
g. check BP, PR, ECG
a. dietary modification: AVOID CHON and Vit B6
- bec it decreases drug absorption
b. check for ORTHOSTATIC HYPOTENSION and PALPITATION; II. ANTI-ANXIETY
c. check BP and PR
- minor tranquilizer
- decrease Reticular Activity System – center of
wakefulness

ex. Valium, diazepam, Librium, Tranxene

 Effective: Decrease Anxiety,

Decrease Muscle Spasm (to pt w/ traction)
Promote Sleep

 B4 MEALS – because food delays absorption

 HEALTH TEACHINGS:

a. report ADVERSE EFFECT:

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

 effective: if decrease tremors and rigidity;

 when to give: AFTER MEALS; III. ANTI-DEPRESSANT/MANIC

 Health Teachings: a. TRICYCLICS

b. MAO
a. side effects: blurred vision (no driving); c. STIMULANTS
 39

d. SSRI

PATIENT with DEPRESSION

– there is DECREASE norepinephrine and
serotonin
 40

Avocado,
A. TRICYCLICS – prevents the reabsorption of banana,
norepinephrine. cheese (cheddar, aged and swiss) ALLOWED: cheese –
cottage and cream,
Ex. Tofranil, Elavil FRESH MEAT, VEGETABLES
COLA, CHICKEN LIVER
Effective: If adequate sleep (8hrs only) SOY SAUCE
Increase appetite RED WINE
PICKLES
Best given: AFTER MEALS
 Check BP – the drug can cause
Hx Teachings: HYPERTENSIVE CRISIS –
occipital headache – “my nape
 The INITIAL EFFECT 2-3 wks after is aching”
FULL THERAPEUTIC EFFCET 3-4 wks
ONSET EFFECT in a WK  2 WKS INTERVAL – when shifting ANTI
DEPRESSANT
 AVOID : juice – because an acidic medium – to avoid HYPERTENSIVE
decrease absorption of drugs CRISIS
 REPORT PALPITATION and TACHYCARDIA and
ARRYTHMIAS – adverse effects of TRICYCLICS ex . after MAO – 2 wks rest then can give ST JOHN’S
 CHECK BP and ECG WORT

B. MAO INHIBITOR (MonoAmine Oxidase)

- prevents the destruction of

NEUROTRANSMITTERs

ex. Parnate, Nardil and Marplan

C. STIMULANTS
Effective : if INCREASE SLEEP and APPETITE – (Ritalin, Dexedrine and Cylert)

Give AFTER MEALS - directly stimulates the CNS.

Hx Teachings: Effective: Increase Appetite and Adequate sleep

 AVOID – TYRAMINE CONTAINING FOOD Best to Give: AFTER MEALS

(1 day before FIRST DOSE and 14 days AFTER LAST - if b4 meals, it suppresses the appetite;
DOSE) - give NOT BEYOND 2pm bec. it causes INSOMNIA
– 6 Hrs b4 bedtime;
 41

- shld be given in the morning – to avoid N Na – 3 gms, N fluid intake 3L

INSOMNIA Basically, Lithium is a
salt
COMPLICATIONS: growth suppression
 Report the ff s/s (NAVDA)
Hx Teachings: - Nausea
- Anorexia
 provide intervals or intermittently to - Vomiting
avoid growth suppression; - Diarrhea
 check BP and PR - Abdl Cramps

D. SSRI (selective serotonin reuptake inhibitor) Report also:

Ex. ZOLOFT, Prozac

FINE HAND TREMORS progressing to COARSE HAND
TREMORS,
Adverse effects: DECREASE LIBIDO and Impotence THIRST and ATAXIC - sign of LITHIUM TOXICITY – Dug of
choice: MANNITOL
s/e: GI
DIAMOX

Hx Teachings:
III.1 ANTIMANIC
 Avoid activity that increase perspiration – Na & H2o;
 Lithium (lithane, lithobid, escalith)  Avoid caffeine;
 Tegretol  Monitor lithium level
 Depakine/ Depakote (specimen: blood drawn in the morning b4 breakfast or at
least 12 hrs after the last dose)
A. LITHIUM  Frequency of Lithium monitoring: ONCE A MONTH;
- it alters level of neurotransmitters
NORMAL LITHIUM LEVEL:
effective if DECREASE HYPERACTIVITY
ACUTE DOSE MAINTENANCE DOSE
give AFTER MEALS
Below 65 yo .5 – 1.5 mEq/L .5 – 1.2
Hx Teachings: mEq/L

 diet: Above 65 yo .6 – 1.0 mEq/L .4 - .8 mEq/L

High Na (6-10 gms) and High Fluid (3-4L)
 42

Lithium is effective with 10 – 14 DAYS before it will reach its

therapeutic level. Check : CBC – due to pancytopenia
RBC, WBC and Platelet label
CONTRAINDICATION OF LITHIUM:

 Pregnancy;
 Lactating;
 Kidney disorder
- if above s/s are (+) to patient, instead of lithium use CHOLINESTERASE INHIBITORS
TEGRETOL, DOPAKINE/ DEPAKOTE
For MYASTHENIA GRAVIS : Prostigmin (long acting)
tegretol – a/e : alopecia and Tensillon (short acting)

dopakine/ depakote - gingivitis For ALZEIMER’s DSES : Cognex (tacrine) and

Aricept

ANTICONVULSANT (Tegretol and dilantin) Myasthenia Gravis – there is decrease or absence of

Acethylcholine (ACTH)
- for seizures, wherein there is abnormal
discharge of impulse in the brain ACTH is a neurotransmitter the delivers the order ex. Brain
- action : IT INHIBITS the seizure focus and to muscle to contract/move.
discharge
Therefore, the drug is given to inhibit cholinesterase in
effective: if (-) seizure destroying ACTH
(so, if dec cholinesterace and inc. ACTH, good muscle
given BEST AFTER MEALS (except for sedatives- like contraction)
valium)
– MOST DRUGS THAT AFFECT CNS ARE BEST PROSTIGMIN – long acting – for treatment
GIVEN AFTER MEALS TOO.
TENSILLON – short acting – only for 5 mins. – it increase
NSG ALERT: muscle strength in 30 seconds
(therefore, if muscle weakness disappear within 30 seconds
– it is MYASTHENIA GRAVIS)
 Report GINGIVITIS;
 Report S/S of Bone Marrow Depression –
pancytopenia Drug Action:
(dec RBC & WBC);
 Instruct pt to use SOFT BRISTTLED  Increase muscle strength (ex. Increase chewing ability
TOOTHBRUSH; or able to chew food forcefully)
 Instruct pt to MASSAGE GUMS and frequent oral  GIVE B4 MEALS or any activity;
hygiene
 43

 Meds is FOR LIFE;

 Report s/s of HEPATOXICITY – RUQ pain of abdomen “INR” – refers to the upper limit of meds from N value to the
and JAUNDICE maximum dose

Antidote: ATSO4 – it reverses the effect of anticholinesterase

 Check for LIVER FUNX TEST;

 Keep at bedside: endotracheal tube – for resp.
problem

ANTICOAGULANT

HEPARIN COUMADIN
LOVENOX
COAGULATION PROCESS:
For ACUTE CASES of Manic Case FOR
thromboplastin
MAINTENANCE or Chronic CASE Heparin Derivatives
Vitamin K dependent clotting factors PRO THROMBIN
THROMBIN
Antidote: PROTAMINE SO4 Antidote: VIT
K Antidote same w/ Heparin
COUMADIN
Given SubQ (Lower Abdl Fat) Oral
FIBRINOGEN
Onset: 2-5 days
(maintenance case)
HEPARIN
Check PT (N 11-13 sec
and INR 24 sec)
FIBRIN (CLOT)
Effective if (-) clot
Give same time of day
Report s/s of bleeding : Hemoptysis
Hematemesis
COUMADIN – act as vit k dependent clotting factors
HEPARIN: AVOID – green leafy vegetables – bec it is rich in
HEPARIN – converts PROTHROMBIN to THROMBIN and
Vit K and will counteract the effect of anti coagulant.
FIBRINOGEN to FIBRIN
Therefore, diet of patient – no appropriate.
- RAPID ACTING :onset : 24 – 48 hrs
NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if
more than INR - HOLD
Coumadin and Heparin
 44

which causes arrhythmia.

– NOT to dissolve clot And so, to maintain the balance in the Na and K pump
(only as THROMBOLYTIC – meaning it prevents give antiarrythmia because it
ENLARGEMENT and FORMATION of CLOTS) decreases the automaticity of the heart.

- can be given together Antiarrythmia is effective if (-) arrhythmia;

Give meds anytime;

ANTIARRYTHIMICS

Ex. Quinidine (quinam)

Side notes:
Health teachings:
Characteristics of HEART MUSCLE:
a. report CNS – confusion, ataxia and headache
a. CONDUCTIVITY – ability to propagate impulses; GI - nausea, anorexia and vomiting
b. AUTOMATICITY - ability of heart to initiate
contraction; b. RASH – therefore SKIN TEST FIRST
c. REFRACTORINESS – ability of t heart to respond to c. REPORT s/s of QUINIDINE TOXICITY – tinnitus,
stimulus while in the state of contraction; hearing loss and visual disturbances
d. EXCITTABILITY - ability of the heart to be d. check pt PR and ECG – waves, rate and rhythm
stimulated

Inotropic effect - force of contraction or strength QUINIDINE PROCAINE

of myocardial contraction; LIDOCAINE
Chromotropic Effect – conduction of impulses;
CHRONOTROPIC Effect - rate of contraction
Ventricular arrythmia

ANTIARRYTHMIC (quinidex, pronestyl)

For VENTRICULLAR & ATRIAL Fibrillation
- 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.)
CARDIAC GLYCOSIDES
K – once it increase or decrease, it affects the repo and depo
of heart muscle - increase force of contraction;
 45

- affects the automaticity and excitability of the Digitoxin – liver – AST/ ALT
heart muscle;
- K – shld be monitored when in this meds DIGIBIND – antidote for digoxin (lanoxin)
therapy
(The heart contraction is regulated by Na and K pump.
If K decreases, Calcium enters and it will result to a THERAPEUTIC LEVEL:
more increase force of contraction due to Na and
Ca pump conversion.) a. Digoxin : .5 – 2 ug/L
b. Digitoxin : 14 – 26 ug/L
Effects: (+) INOTROPIC – strengthen the force of
contraction
(-) CHRONOTROPIC – decrease rate of contraction

DIGOXIN DIGITOXIN

EFFECTIVE : it increase FORCE OF CONTRACTION

same NITRATES (nitroglycerine)

ACTION : onset : 5 – 20 mins 30 - don’t give if pt taking VIAGRA – it will result to

mins – 2hrs FETAL HYPOTENSION

Give after meals due to GI irritation EFFECTS: dilatation of coronary arteries and arterioles
same thereby resulting to
DECREASE IN PRELOAD & AFTERLOAD.

Decrease in Preload – decrease in the amount of blood

CLIENT TEACHINGS: that goes to the LV;

 Report s/s of TOXICITY : NAVDA AFTERLOAD – amount of resistance offered by blood

Xanthopsia – yellowish vision or greenish halos; vessels that heart shld overcome
when pumping blood
 Check PR – if BELOW 60/min (adult) –
HOLD next dose;  Effective if NEGATIVE ANGINAL PAIN;
if BELOW 70/ min (older child) – HOLD;  Give BEFORE any activity;
if BELOW 90- 110 (infants) – HOLD next dose  Administered SUBLINGUALLY (+ burning sensation
indicates drug is potent) – NO WATER because it will dilute
 EXCRETION the meds;
 DOSES: 3 doses at 5mins interval;
Digoxin – kidney – monitor renal funx test (BUN &  Report if there is persistence of pain;
Crea) – report if inc;
 Check BP and PR;
 Keep meds in dark container (bec light dec potency);
 46

 Once the bottle is open, use the meds within 3-6 mos that required alertness
(ex. Driving)
DO NOT REPORT THE FF: (expected s/s)
ANTIBIOTICS
Hypotension, Headache, facial flushing “why is my
face red?” - bactericidal;
- effective: (-) infection;
- give ON EMPTY STOMACH – B4 MEALS;
- Hx teachings: REPORT rash, urticaria and
MUCOLYTICS (an antidote also for ACETAMINOPHEN “STRIDOR” – indicates
TOXICITY) airway obstruction;
- side effects: NAVDA + GI Irritation
Ex. Mucomyst
I. PENICILLIN : antidote is EPINIPHRINE
- it decreases the viscosity of secretion;
- give meds anytime;
- client teaching: meds can be diluted w/ NSS or II. AMINOGLYCOSIDE (gentamycin)
cola;
- effective: (-) infection – give B4 meals;
Side effects: NAV + Rashes - report the ff:
OTOTOXICITY: “I hear ringing in my ear”
- if no side effects, repeat dose in 1 hr NEPHROTOXICITY : ”oliguria”
NEUROTOXICITY : “seizures”

BRONCHODILATORS (ex. TERBUTALINE – brethine) - check BUN, CREA (kidney funx test);
- check I & O (sign of nephrotoxicity)
- dilates the bronchioles or airways;
- effective: if (-) bronchospasm;
- GIVEN in AM to decrease insomnia III. ANTINEOPLASTIC (adriamycin)
- REPORT THE FF: insomnia, tachycardia,
palpitation-PR, + NAV - for breast and ovarian CA;
- effective: (-) tumor size;
Theophylline - N 10-20; - GIVE IN ARM – to prevent HEMMORRHAGIC
- for ACUTE ATTACK and PREVENTION of ASTMA CYSTITIS
- Hx Teachings:
EXPECTORANT (robitussin)
a. inc oral fluid intake (2-3L/day) – cytotoxic
- stimulates productive coughing; prevention;
- effective : (+) COUGHING & SECRETIONS b. monitor kidney funx – I & O;
- give ANYTIME;
- sideffects: – NAV + DIZZINESS or
drowsiness – avoid activity THYROID AGENTS (synthroid, cytomel)
 47

b. monitor the blood sugar level in early AM

- for HYPOTHYROIDSM; and supper time
- effective: if Inc in T3 and T4 and NORMAL
SLEEP;  INJECT AIR FIRST to NPH then inject air and
- pt always sleep, therefore give meds in AM – to WITHDRAW FIRST with REGULAR.
avoid insomnia;
- REPORT HE FOLLOWING: insomnia,  PEAK OF ACTION (refers to – when patient becomes
nervousness; palpitations HYPOGLYCEMIA)
- Take meds LIFETIME (same w/ meds 4 neuro);
- Check HR, PR and kidney funx test; REGUALR INSULIN - lunch time
Intermediate - late in the afternoon – B4 dinner
Long Acting - B4 Breakfast
ANTITHYROID (PTU, LUGOL’S SOLUTION)

- For GRAVE’S DISEASE or HYPERTHYROIDISM;

- Effective: Decrease in T3 and T4 (in lab data); SULFONYLUREAS (Orinase)
- Give round the clock;
- for DM type 2;
Health Teachings: - stimulate pancreas to produce insulin;
a. Report sore throat, fever, chills, body - effective – N bld sugar level;
malaise because meds - give b4 meals regularly;
cause AGRANULOCUYTOSIS; - teachings:
b. Report lethargy, bradycardia, and a. s/s of hypoglycemia;
INCREASE SLEEP – indicates b. monitor renal funx test;
that pt is having HYPERTHYROIDISM; c. antidote for hypoglycemia – ORANGE
c. Diarrhea with metallic taste – sign of IODINE JUICE
TOXICITY
ANTACIDS (amphogel, tagamet)

ANTIDIABETICS (INSULIN) - ALUMINUM HYDROXIDE GEL – antacid and it

also dec phosphate level in pt renal failure;
- effective: N Blood sugar (80-120) - Effective: dec phosphate
- for DM Type 1 (insulin dependent); (-) pain
- give in AM b4 meals; - give on EMPTY STOMACH (1 hr b4 or 2hrs after meals);
- check: - instruct pt to REPORT: muscle weakness in lower
a. instruct S/S OF HYPOGLYCEMIA – extremities –
indicates HYPOPHOSPATHEMIA
dizziness/ drowsiness - administer with glass of water;
difficulty in problem solving - check phosphate level and renal funx test;
decrease level of consciouness - assess for constipation
cold clammy skin
 48

- 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;
LAXATIVES (dulcolax) - check I & O, K level, PR and BP

Colace – stool softener K-SPARRING (triamterene, aldactone)

Metamucil - bulk forming
Dulcolax - rapid acting - effective: inc. urine output;
Lactulose - 15-30 mins - give in AM;
- teachings: monitor for HYPERKALEMIA
- effective : (+) BM; check PR and K
- give AT HS (if NOT diagnostic procedure);
- give AFTER MEALS –for dyspepsia;
- meds is given in short duration only because of ANTIGOUT
dependency
- teachings: PROBENECID COLCHICINE
ALLOPURINOL
a. be near or stay near CR;
b. s/e: diarrhea;
c. NO lactulose for pt w/ diarrhea; - URICOSURIC - for ACUTE GOUT
d. Causes hypokalemia – therefore check - for CHRONIC GOUT
electrolytes - promotes excretion of uric acid - has anti-inflammatory
e. Increase fld intake – to avoid effect by - prevents or dec formation
dehydration preventing deposition of u.acid
of u. acid
DIURETICS @ joints
- s/effects: NAV + - NAV + Bldg and Bruising
Target Organs - dizziness/drowsiness
a. Diamox – exerts effect at Proximal Convuluted Hypersensitivity
Tubules; agranulocytosis (check CBC)
b. Lasix – at Loop of Henle;
c. Diuril – at Distant Con. Tubules - ONSET: 8-12 wks -
ONSET: 1-3 wks
LOOP DIURETICS (lasix)
- effetctive: incrase urine output; TEACHINGS:
- give in morning to prevent nocturia;
 49

a. Increase ORAL FLUID INTAKE; ANTI-ACNE (acutane, retin-a)

b. Monitor uric acid levels;
- decrease sebaceous gland size;
- given in AM to prevent insomnia;
- avoid sunlight: photosensitivity
MIOTICS (timoptic, piloca) - pregnancy: fetotoxic - therefore check if pt is
pregnant;
- DECREASE IOP (N12-21) for pt w/ glaucoma; - check if pt has skin irritation – may burn the
- Give ANYTIME – but for LIFETIME; skin
- Teachings:
a. it causes blurring of vision and brow
pain; TOCOLYTICS (Yutopar, MgSO4)
b. administer meds at lower conjunctival
sac; - relax the uterus;
c. press the inner canthus for 1-2 mins - drug of choice for pre-term labor;
to prevent systemic side effects (hyperglycemia and - effective: (-) pre-term or relaxed uterus;
hypotension) - give: ORAL – B4 meals and IV – anytime;
- teachings:
a. signs of Ca Intoxication:
MYDRIATRIC (AK-Dilate) hypotension, hypothermia and hypocalcemia
b. check bld pressure; urine output (N
- effective: pupillary dilatation; 30ml/hr)
- give ANYTIME (but if pt for surgery, give b4); c. check RR – at least 12/min
- teachings: may cause blurring of vision d. check patellar reflex – shld be (+)
lower conjuctival sac knee jerk

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

CARBONIC ANHYDRASE INHIBITORS (diamox)
Antidote: Calcium Gluconate
- for GALAUCOMA – lifetime;
- to decrease production of acqueous humor;
- effective: N IOP and Inc. urine output;
- effective to pt with MENIERE’S DSES – dec OXYTOXIC
vertigo
- teachings:
a. check urine output; PITOCIN METHERGIN
b. report: s/s of dehydration bec of
diuretic effect To induce labor To
c. blurred vision prevent post partum hemorrhage
d. monitor I & O and IOP Effective: Firm and Contracted Uterus
Give anytime
If IV, use “piggy back”
 50

Teachings:
a. REPORT the ff: HYPOTENSION (due to
inactivation of ANS – neurological effect of drug);
b. Headache TIPS ON PHARMACOLOGY
c. Hypertension (cardiovascular effect of the drug)
d. Check BP, Uterine Contraction – especially the
duration – N 30-90 sec  Patient receiving DIAZEPAM, the nurse notice that there is
- report if beyond 90 sec – sign of uterine no change in patient behavior. What shld the nurse do? –
hypertonicity VERIFY THE PT DIET
e. Check Force, Duration and Frequency of Uterine
Contraction  COGNEX – given with AZEIMERS’S DSES – to increase
mental functioning

PROSTAGLANDIN (cytotec, E2gel)  Pt w/ PVC : bedside : XYLOCAINE

- anti ulcer drug to dec gastric acidity;  Pt w/ COMPLETE HEART BLOCK: give ATSO4 – it
- decrease ripening of the cervix w/c leads to increases HR
effacement then dilatation then abortion;
- give after meals;  Pt w/ DIVERTICULITIS (pt has diarrhea) – the ff meds were
- assess for diarrhea and gastric irritation; given: what meds the nurse shld question : LACTULOSE
- check for pregnancy bec it may cause abortion
 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
 51

DIARRHEA (enteric) x yes

 FESO4 – shld be given w/ orange juice yes x x

 ASPIRIN I s given to pt w/ TIA – to decrease platelet

aggregation HEPA A (enteric) x yes
yes x x
 Pt taking ANCEF – observe for skin rashes
B (universal) x yes yes
 Pt to receive NPH at 7:30am, the nurse shld expect for yes yes
hypoglycemia – LATE in the AFTERNOON
C (universal) x yes yes
yes yes

MRSA (contacts) yes yes

yes yes yes

MENINGITIS/SEPTIC (enteric) x yes

yes x x

SCABIES (contact) yes yes

yes yes yes

TB (tb Precaution) yes yes x

x yes

PEDICULOSIS (contact) yes yes

yes yes yes
TYPES OF PRECAUTION

P H GL P – private room
GW M H – handwashing
AIDS (universal) x yes yes GL - gloves
yes yes GW – gown
M - mask

AIDS – universal
 52

Norwalk Virus – respiratory  The disorders result as alteration in the function of

Hepa A – contact HEART (pump), BLOOD (transport mechanism of oxygen,
MRSA – contact nutrients, hormones & CO2) and BLOOD VESSELS
Scabies – contact (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

Day 6 (Feb 9, 05) night
Paroxysmal ND – when pt feels as if he’s
drowning
D.I.S.E.A.S.E.S
(MEDICAL-SURGICAL NURSING) HEART SOUNDS:

S1 - normal – “lubb”
GENERAL CONSIDERATION S2 - -do- - “dub”

 Priority: Oxygenation - in assessing S1 & S2 use BELL of steth

 53

S3 - N for Pediatric pt (ABNORMAL for adult pt – it c. Tachycardia and Tachypnea

indicates CHF or Aortic Stenosis)
Patient in shock- there is also (+) pallor and
Steth - BELL – for LOW PITCH SOUND (ex. Murmur) (+) oliguria – due to dec bld
Diaphragm – for HIGH PITCH SOUND 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 jehova’s use plasma expander)

SHOCK
ANEMIA
mp: decrease in circulating blood volume
MP: Decrease RBC due to decrease production or
increase destruction
TYPES
Risk Factors:
 CARDIOGENIC – pump failure (CHF, MI, Atherosclerosis
Heart Dses, Mitral Valve Dses) Age
 HYPOVOLEMIC - related to fluid loss (pt w/ open Gender
wound, traumatic injury, burn) Surgery
 ANAPHYLACTIC - cause by allergic reaction (laB Secondary to existing medical condition (ex. Renal
procedure w/ dye, asthma, poison) Failure)
 NEUROGENIC - caused by vasomotor collapse Kidney – produce erythropoiten that stimulates
(vasomotor – located @ medulla oblongata w/c is bone marrow to produce RBC
responsible for dilatation & constriction of bld vessels)
 SEPTIC – due to systemic infection (ex. Septicemia) TYPES:

TRIAD SYMPTOMS OF SHOCK a. Iron Deficiency Anemia (IDA)

b. Pernicious Anemia (PA)
a. Altered level of consciousness (dec bld circulation – c. Folic Acid Deficiency Anemia (FADA)
result to dec o2 in the brain); d. Sickle Cell Anemia (SCA)
b. Hypotension; e. Aplastic/ Fanconis Anemia (AA)
f. Talasemia Anemia (TA)
 54

(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

IRON DEFICIENCY ANEMIA b. Diet: iron rich food – (organ meat, dried foods, “egg
yolk” – iron, “egg white” – CHON);
- common in infants and children; c. provide patient with BED REST – due to fatigue
- 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) PERNICIOUS ANEMIA

MP: Nutritional Deficiency - common in elderly;

- common in POST GATRIC SURGERY
S/S : Fatigue
Fainting Main Problem: Lack of INTRINSIC FACTOR at the stomach
Forgetfulness (intrinsic factor – the one that absorb vit
Pallor, cold clammy skin b12)
Dyspnea (due to dec RBC)
In elderly, there is that GASTRIC ATROPHY w/c leads to
Lab data: dec in the Intrinsic factor
Decrease in HgB (N male: 14-18, Female: 12-
16)
Characteristic of RBC: HYPOCHROMIC & S/S:
MICROCYTIC 3F (fatigue, fainting, forgetfulness)
Beefy Red Tongue or glossitis
Nsg Dx: Activity Intolerance Peripheral Neuropathy (tingling sensation at lower
extremities – usually both legs are affected)
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 Lab Data:
teeth
if IM (inferon) – “Z” track method a. check Hgb
b. SCHILLING’S TEST (24hr urine)
 55

c. RBC characteristic : MACROCYTIC & HYPERCHROMIC - presence of “S or C” shape Hgb due to dec O2
(SICKLING OF RBC)
Nsg Dx: Activity Intolerance
Risk for Injury due to p. neuropathy STATUS N TRAIT TRANS DSES
TRANS
Priority Intervention:
 1 PARENT W/ TRAIT 50% 50%
a. Correct the deficiency – give Vit B12 (IM, Once a 0
month for lifetime);  BOTH PARENTS w/ TRAIT 25% 50%
b. Bed rest – due to fatigue 25%
 I parent TRAIT, 1 DSES 0 50%
50%
 BOTH parents w/ Disease 0 0
100%
FOLIC ACID DEFICIENCY ANEMIA
Risk Factors:
- common in infants, adolescents, pregnant, lactating
and overcooked food; Dehydration (dec in circ bld volume – result in sickling
of RBC);
Main Problem: Deficiency in Folic Acid or VIT B9 or Infections
FOLACIN Conditions that lead to SHOCK

S/S: all symptoms of pernicious anemia EXCEPT P. S/S:

NEUROPATHY 3Fs + Fever (due to dehydration) + Pain + Jaundice
Hepatomegally
Lab Data: HgB
Folic Acid level (N 4mg/day) – green leafy veg.
(spinach)

Nsg Dx:
Activity Intolerance (NO RISK FOR INJURY coz NO P. Complications:
NEUROPATHY)
a. Vasocclusive Crisis (hallmark of the dses)
PI: Inc. folic acid in the diet – g. leafy; - bld vessels obstruction by rigid and tangled cells w/c
Bed Rest causes tissue anoxia and possible necrosis

b. Spleenic Sequestration Crisis – massive entrapment of

SICKLE CELL ANEMIA red cells in the spleen & liver
c. Aplastic/ Megaloblastic Crisis
- autosomal recessive – bone marrow depression w/c resulted to DEC RBC,
- hereditary WBC & PLATELET
 56

Lab Data: Sickledex Test MP: Hereditary

(+) Turbid Solution Autosomal Dominant – common in female and
male
Nsg Dx: Activity Intolerance There is a defect in polypeptide
Fld Volume Deficit
Pain – due to vasocclusive crisis Chain of HgB – ALPA and ETA Chain – there is RBC
destruction
PI: Hydration and relief of pain (inc oral fld intake)
Prevent dehydration
Meds for Pain – Morphine SO4, acetaminophen
Since HEREDITARY – refer to geniticist

APLASTIC ANEMIA Types:

MP: Hereditary (there is DECREASE IN RBC, WBC & a. Minor Thalasemia Anemia – mild anemia: 3Fs
PLATELET) b. Intermedia TA – more severe anemia +
Autosomal Recessive Speenomegally
Jaundice
S/S: 3Fs + Pallor + Dyspnea (inc deposition of iron @ tissue)
Risk for Infection (dec in RBC) Hemosidorosis
Bleeding (dec in Platelet)
c. Major TA – severe anemia + Spleenomegally
Lab Data: HgB, CBC, Clotting Factors Platelet,
Bleeding & Clotting time Lab Data:

Nsg Dx: Activity Intolerance (dec in RBC) HgB

Risk for Injury (dec in WBC and Platelet) Clotting and Bleeding Time

PI: Bld transfusion; Nsg Dx: Activity Intolerance

Reverse Isolation; Risk for Injury
Genetic Counseling;
Bed rest PI : Bld Transfusion,
IVF
Dietary supplements of Folic Acid and Iron
THALASEMIA Surgery (last resort)

Risk Factors:
Common in Blacks, Italian, Greeks, LEUKEMIA
Chinese, Indians
 57

MP: proliferation of immature WBC unknown (viral and autoimmune)

Characterized by Remission and Exacerbation s/s: petechiae

ecchymosis
Types: hemorrhage
(all signs of bleeding)
a. LYMPHOCYTIC – common in young children
(proliferation of lymphocytes) lab data: Platelet Count of less than 20,000
b. MYELOGENOUS – adolescent and adult (proliferation of (spontaneous bldg)
granulocytes) (N 150,000 – 450,000)

TRAID S/S: Nsg Dx: Risk for Injury

Fld Vol. Deficit (due to bldg)
 Anemia (initial) + 3Fs
 Bleeding
 Infection
PI : SAFETY –prevent bleeding
Lab Data: Give pt platelet, IVF and Bld Transfusion
Corticosteroids – “wonder drugs”
WBC – hyperleukocytosis (150 – 500,000K) – expected

NDx: Risk for Injury HEMOPHILIA

Activity Intolerance
Risk for infection - inherited – bldg disorder

PI: Bed rest TYPES:

Avoid Contact Sports
Reverse Isolation a. Hemo. A - deficiency in factor 8
Blood transfusion b. Hemo. B - deficiency in Factor 9
Bone marrow transplant c. Von Willebrand’s 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

IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or

WERLHOF’S DSES S/S:
Hemarthrosis – bldg between joints that usually
- common in BLACKS; affects ankle, knee and elbow joints;
- cause: idiopathic Hematoma
Hematuria
 58

Hematemesis
(above mentioned are signs of HEMORRHAGE)  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
Lab Data : PROLONGED CLOTTING TIME diet at least 1 meal a day;

Nsg Dx : Risk for Injury  w/c of the ff is the priority intervention for pt w/ IDA –
PROVIDE BED REST ALTERNATING w/ activities;
PI : SAFETY then RICE (REST, IMMOBILIZE, COLD COMPRESS,
ELEVATE)  w/c of the ff is indicative of thrombocytopenia -
HEMATURIA

For JEHOVAH’S – 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 CARDIOVASCULAR PEDIATRICS
DRINKS 2 QUARTS OF MILK/DAY”;

 a 7 yo boy with HEMOPHILIA was admitted. w/c of the FETAL

ff is EXPECTED MANIFESTATION – HEMARTHROSIS; CIRCULATION
 59

3 FETAL
STRUCTRUES

PLACENTA UMBILICAL VEIN

DUCTUS VENUSUS LIVER
(functionally,
closes at birth)

Vena Cava
UMBILICAL ARTERIES

Right Atrium
FORAMEN OVALE
(functionally,
closes at birth)

AORTA
R Ventricle
LA

LV
LUNGS
L VENTRICLE

DUCTUS
ARTERIOSUS (functionally closes by 3-4 days at birth)
L ATRIUM P. ARTERY
AORTA

Therefore, if these 3 fetal structures will not close,

CONGENITAL HEART DISEASE
 60

Signs and Symptoms:

 Difficulty feeding
 Retarded Growth
 Tachypnea/Tachycardia
 Frequent URTI
CONGENITAL HEART DISEASE  ANS – brow seating

Complication: CH Failure (check for “murmur”)

ACYANOTIC HEART DSES CVA (due to plycythemia – Inc RBC)
CYANOTIC HEART DISEASE
Lab Data: 2 D Echo

Nsg Dx: Altered Tissue Perfusion

Dec Pulmonary Bld flow Obstructive CHD PI : Oxygenation
Decrease Pulmonary 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

Vent. Septal Defect (most common) Pulmonary Stenosis 3yo, therefore prepare the child 3 days prior to surgery)
Tetralogy of Fallot (most common)
Atrial Septal Defect Aortic Stenosis If > 7yo – parents decision
Transposition of the Great Vein
Patent Ductus Arteriosus Coarctation of the
Aorta Truncus Arteriosus
Tricuspid
Atresia

Usually due to:

- Maternal Infection – measles, c. pox
- Age 40 and above
- Medical Conditions – DM
- Alcoholism
 61

- 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

PATENT DUCTUS ARTERIOSUS COARCTATION OF AORTA

- connection problem : P Artery and Aorta - Higher BP in the Upper Extremities and Lower BP in
- “machinery-like murmur” the Lower Ext.
- (+) brow seating
(+) retarded growth
(+) tachycardia/ tachypnea Lab Data : BP, 2 D-Echo

LAB DATA : 2 D-Echo PI : Oxygenation

CVP Position the patient: Orthopneic or semi –
PExam fowler’s position

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”
 62

KAWASAKI’S DISEASE  w/c of the ff data in mother health history indicates a

risk factor for congenital heart disease – ADVANCE AGE;
- due to acute vasculitis (inflammation of bld vessels)
of the heart;  when admitting a pt w/ suspected congenital heart
- especially to JAPANESE children and toddler 5yo and disease, w/c intervention is priority – decreasing the
below metabolic demand of the heart

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 CORONARY ARTERY DISEASE (CAD)

 w/ of the ff is an OUTSTANDING SYMPTOM OF Main Problem : NARROWING and OBSTRUCTION of

CARDIOVASCULAR PROBLEM in children – difficulty in Coronary Arteries which
feeding; could lead to HYPOXIA – reversible (which
could further progress to ANGINA)
 w/c of the ff is an appropriate intervention for a child and or ISCHEMIA – irreversible
who keeps on squatting because of Tetralogy of Fallot - if (that could progress also to dev’t. of SCAR
LESS THAN 1 yo – flex lower extremities towards the
abodomen; FORMATION that can lead to MI).

 a child who was brought in to a well baby clinic turns Risk Factors:
cyanotic while crying – REFER to the physician; Family History
Atherosclerosis
 the BLD VESSELS INVOLVE in PATENT DUCTUS Smoking
ARTERIOSUS – pulmonary artery and aorta; Elevated Cholesterol
HPN
 63

Obesity
Physical Inactivity
Stress

CAD

HYPOXIA ISCHEMIA

NECROSIS

ANGINA PAIN
Myocardial Infarction – “ jaw
pain” MTOCARDIAL INFACRTION ANGINA

 Precipitated by 6E’s
Pain confined at sternal area
 Pain that resembles “indigestion”, crushing,
excruxiating Pain that resembles “pressure”
this leads to decrease O2 – and will result to the  Pain radiates to the L Jaw, L arm, L shoulder
conversion of aerobic metabolism to anerobic thereby
 Relieved by SO4 Opiods (MORPHINE)
resulting to the production of LACTIC ACID – that will
Relieved by rest & NITROGLYCERIN
stimulate the nerve ending of the heart w/ will produce/
result to PAIN that is precipitated by:
 Pain occurs AFTER MEAL (post cebum) or AFTER
EATING ACTIVITY SAME
Elimination – due to valsalva
manuever
Exercise/effort/ exertion  S/S of above mentioned + SHOCK s/s – esp to
Emotion CARDIOGENIC
Extreme Temperature – SHOCK w/c is due to PUMP Failure – that leads to dec cardiac
“cool temp” – vasoconstriction Output that leads further to CHF.
sEx
 64

 ECG – initial change is ST SEGMENT DEPRESSION w/ b. Diet : Low Na and Low Cholesterol
SAME
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

SAME
Troponin
CK – within 2-3 days
LDH 1&2 – within 10-14 days HEALTH TEACHINGS:

 Identify types of Angina:

 Nsg Dx : PAIN
Altered Tissue Perfusion Stable Angina – predictable – angina that occurs
Impaired Gas Exchange w/ activity;

 Priority : Airway (Oxygenation) Unpredictable – relieved by Nitroglycerin;

 Goal of CARE Variant/ Prinzmetal – severe form of Angina;

a. To decrease oxygen metabolic demand Nocturnal Angina – occurs at night;

- position : SEMI-FOWLER’S
- administer O2 as ordered Decubitus Angina – when pt is lying down
- administer meds:
Intractable Angina – unresponsive to tx
MI : Morphine SO4 – monitor RR, effective : (-) pain,
ANTIDOTE : Naloxone HCL – Narcan Post MI Angina

ANGINA : Nitroglycerine – dark container  For patient with MI – focus on complications :

give b4 activity a. PVC or PVBeats – defibrillation/ cardioversion
maximum of 3 doses, 5 b. Ventricullar Fibrillation – Lidocaine – s/e
mins interval “rashes”
effective: tingling
sensation, sublingual
CARDIOVERSION
provide rest – due to pain DEFIBRILLATION
 65

- synchronize -
unsynchronized
- esp. for VTACH w/ PULSE - for VTACH w/o how will the heart compensate?
PULSE
The HEART will pump harder- Inc HR (tachycardia) –
 SEX – for pt w/ MI – resume if pt tolerate 2-3 plights that will result to enlargement of the heart muscle
of stair w/o pain; (hypertrophy) – w/c can lead to dilatation and congestion of
- take meds b4 sex; the cardiac muscles - thereby resulting to decrease in the
- position during sex : passive – let the girl do cardiac output.
her share

 ACTIVITY – advised pt to have frequent rest period;

 DIET : avoid PROCESSED FOODS;
MILK PUMP FAILURE EFFECTS:
Salty
Sea Foods  Backward Effects : backflow of blood – systemic
Pastries – esp. yellow cake congestion;
 Forward Effects : decrease cardiac output – dec
 FOR ANGINA APIN – instruct patient to report pain that in tissue O2
last more than 2o minutes (indicative of MI); perfusion – that leads to overwork
respiratory
 Weak or absent PULSE – indicative of system
VENTRICULLAR FIBRILLATION
LEFT HEART FAILURE – early signs of CHF
 Report NECK VEIN DISTENTION – indicative of CHF Therefore, Right Heart Failure – will be the late signs of CHF
complication as
complication of LHF
 Report BLEEDINGs – especially to pt on
THROMBOLYTICS – t-PA and Streptokinase Risk Factors to Heart Failure:
- Arrythmias
- Coronary Dses & HPN
- Renal Failure

CONGESTIVE HEART FAILURE LEFT SIDED HF – dyspnea and other “pulmonary s/s” –
“crackles”

main problem : PUMP FAILURE – inability of the heart to RIGHT SIDED HF – systemic effect – distended jugular vein
pump an adequate Ankle edema
amount of blood to meet the Ascites
metabolic Hepatomegally
demands of the body
 66

LEFTS SIDED HF RIGHT SIDED

HF

Lab Data : Swan Ganz CVP (N R – 0-

12, V Cava – 5-12) HYPERTENSION PREGNANCY
PAP (N 20-30) INDUCED HPN
PCWP (N 8-13)
MP : blood pressure higher than Elevation of BP that occurs
X-ray X-ray after 20-24
140/90 (hypertensive state) (5 mos- age of
viability) wks of gestation
Nsg Dx : Altered Tissue Perfusion
Ineffective Breathing Pattern – for LHF pre hypertensive phase
Fld Volume Excess – for RHF
120/80, therefore N BP : 110/70 if BP elevated B4 20-24 wks
PRIORITY : Oxygenation & cont after delivery – CHRONIC HPN
Position: Semi-Fowler’s
Administer: Digoxin – absorb in GI Risk Factors: Levels of PIH
Vasodilators
Diuretics  Common in BLACKS; a.
Morphine – for CHF – it causes HYPERTENSIVE DISORDER OF PREGNANCY
pheriperal vasodilation by  Obesity - INC. BP +
Decreasing the amount EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA)
blood going back to the heart.  Stress
 Smoking b. PRE-ECLAMPSIA
DIET : LOW Na – NO PMS S/S + convulsion,
Abdl pain & Headache - ECLAMPSIA PHASE
HEALTH TEACHINGS :
c. ECLAMPSIA +
a. Activity – rest Bleeding = HELP SYNDROME
b. dietary counseling – NO PMS
c. report s/s of complications TYPES:
 DIGITALIS – D. Toxicity: yellow vision;
 Muscle weakness (hypokalemia) – that can a. ESSENTIAL HPN – cause – unknown
lead to arrythmia b. BENIGN – usually of long duration, onset is CHRONIC
 Dyspnea – s/s of pulmonary edema; c. MALIGNANT – acute or abrupt onset, short in duration
d. SECONDARY – related to existing medical condition
 67

HPN IN PREGNANCY – usually related to generalized spasm

of the arteries

PRE-ECLAMPSIA TYPES:

a. MILD BP 140/90, PROTENURIA is <5mg/hr (N

- .5-1GM)
b. SEVERE BP 160/90, PROTENURIA is >5mg/hr PIORITY: Stabilize BP

HEADACHE and ABDOMINAL PAIN – s/s of ECLAMPSIA, How?

indicative of impending convulsion.
I. Non-Pharmacologic Features

ECLAMPSIA + BLEEDING = HELP SYNDROME  Stress Management

 Deep breathing
H – emolysis  Diet : Low Na/ Cholesterol
E – levated Liver Enzyme  Position : if inc BP – supine position
L – ow
P- latelet
(All are signs of bleeding) II. PHARMACOLOGIC MEASURES

 Antihypertensive
S/S of HPN:  Diuretics
Headache  Aspirin
Retinal Hemorrhage
 Antilipimic - simvastatin & lovastatin – give after
Edema
meal nighttime
- above s/s can further lead to complications:
 Monitor liver Funx test – meds above are hepatotoxic
Coronary artery dses
CHF
Chronic Renal Failure
CVA Pts w/ PIH meds:
a. MgSo4 – antidote is CAgluconate
LAB DATA: b. Darkened room – to dec stimulus thereby preventing
Blood Pressure convulsion
Elevated Cholesterol
For PIH : (+) Proteinuria, Inc BP and Inc
Cholesterol

Nsg Dx:
Altered Health Maintenance
Risk for Injury
 68

PERIPHERAL VASCULAR DISEASE

Arterial Obstruction Venous

Obstruction

Color pallor ruddy

Edema (-) or mild (+) & severe
Nails brittle nails N
Pain intermittent claudication homan’s sign
(pain @ gastrocnemeus area)
Pulse (-) (+)
Temperature cold warm
Ulcer dry & necrotic wet

TYPES:

BURGER’S DSES RAYNAUDS

ARTERIOSCLEROSIS OBLITERANS
(THROMBO ANGITIS OBLITERANS)

common : MALE FEMALE

MALE

AREA Lower Ext. Upper Ext – 97% Upper &

Lower Ext
AFFECTED : 3% - lower ext

Affects arteries Arteries ONLY

Arteries ONLY
and veins

MP : “Angitis” – inflam. of Spasm of Arteries

Hardening of arteries due to fatty deposits
Arteries & veins of lower ext of Upper & lower

ACUTE INTERMITTENT
CHRONIC - (+) pain usually related to
 69

- (+) 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
VARICOSE VEIN THROBOPHLEBITIS
S/S: Outstanding s/s PHLEBOTHROMBOSIS
is INTERMITTENT CLAUDICATION – pain that worsens
w/ activity or pain that is relieved by rest. weakening of venous valves; CLOT + Inflammation
- aggravated by smoking – Clot
causes further narrowing of bld vessels job related (prolong sitting/standing)
pregnancy
LAB DATA : Inc WBC & ESR DOPPLER USG hereditary
Inc Cholesterol and Ca secondary to existing medical condition

s/s : dilated tortous vein

Nsg Dx: Altered Tissue Perfusion same dragging sensation “heaviness”
same edema (unilateral/ bilateral) – tape measure to monitor
Pain -do- -do- leg circumference
Pain

PI : Relief of Pain -do- -do- Lab data:

MEDS : (for all types) 1. conservative test – TRENDELENBURG

TEST – pt lie down, elevate/ raise the legs then stand up and
 Anticoagulants observe for bulging of vein;
 Vasodilators (papaverin – pavabid)
 Antihypertensive 2. DOPPLER USG

DIET : Low Cholesterol

Nsg Dx : PAIN
Altered Tissue Perfusion

Hx Teachings :

 Elevate the legs above the heart;

 70

 Use support stockings;

 Surgery – vein ligation & stripping Prepare pt for Surgery
Sclero therapy – injection of sclerosing agents
to make wall stronger
thereby preventing veins to
bulge. CARDIO-PULMONARY RESUSCITATION (CPR)

 NO MASSAGE – coz it may dislodge the clots; - indicated for cardiac arrest when pt is
BREATHLESS
 KNEE HIGH STOCKINGS;
and PULSELESS;
 COLD COMPRESS
 shake the pt – are you ok? If breathless &
pulseless then;
 ACTIVATE the EMS – Help!
ABDOMINAL AORTIC ANEURYSM (AAA)
 CPR (1 or 2 rescuer : 15 : 2)
- weakening of portion of abdl aorta – leading to dilation;  In 1 minute, there will be 80 compression
- could be related to aging and HPN and
15 – 20 rescue breaths
TYPES:
Depth of Compression : 11/2” – 2”
Fusiform - entire wall is affected
Dissecting - part of inner intima and media was dissected If too deep - it may fx the liver
w/c lead to the pushing
of tunica adventitia to bulge Effect of CPR : #1 (+) Pulse;
Saccular #2 skin color

S/S:

Pulsating Abdl Mass TIPS FOR CARDIOVASCULAR – ADULT

Low Back Pain
Higher BP in Upper Extremities  A nurse is assigned to a pt with arterial dses of lower
extremities, w/c of the ff is expected – calf pain after short
If RUPTURE occurs – could lead to SHOCK walking (intermittent claudication);

 A pt was diagnosed w/ MI develop atrial fibrillation –

LAB DATA : Altered Tissue Perfusion this may possibly lead to – CEREBRAL EMBOLISM;
Risk for Injury
 A pt w/ CHF was admitted exhibiting confusion,
PRIORITY : NO ABDOMINAL PALPATION disorientation, visual disorders & hallucination – the nurse
bec it may lead to rupture – PLACE best action is to – CALL THE PHYSICIAN;
WARNING AT THE DOOR OF THE PT.
 71

 A nurse is assessing a pt w/ MI – w/c of the ff is the  use steth directly on pt. skin – because clothing my
characteristic of PAIN – pain radiates to the jaw; interfere w/ auscultation;
 when the pt chest is hairy, wet the hair w/ dump cloth
 In utilizing mind over body principle for pt w/ HPN – – because dry hair interfere w/ auscultation
w/c intervention is appropriate - relaxation and stress
mgt; Consideration w/ Pediatric Patient:

 Pt exhibits intermittent claudication – another sign of  when assessing pediatric pt, RR is affected when –
peripheral dses is w/c of the ff – tropic skin changes; therefore check RR FIRST;
 Note for chest indrawing (if +, may indicate
 Ff MI, when shall I resume sexual activity? – when Pneumonia) and rapid breathing
you can climb 2 plights of stairs w/o shortness of
breath then sexual activity is safe;
Reportable Signs and Symptoms : common TO ALL
 A pt has R sided CHF, w/c of the ff is expected – RESPIRATORY DISORDERS
hepatomegally;
“RE TACHY TACHY D C”
 Apt w/ CHF who is taking diuretics exhibits the ff, w/c
 RETRACTIONS - #1 or Early sign for respiratory
requires further investigation (not expected to pt) – wt gain
of 3 lbs in 2 days; distress;
 Tachycardia
 In addition to assessing a pt w/ Burger’s Dses, w/c of  Tachypnea
the ff data supports the Dx. – smoking;  Dyspnea
 Cyanosis – late sign of respiratory Distress
 A pt with R sided HF will manifest – distended
jugular vein
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
RESPIRATORY breathing followed by apnea; - nero case
 Kussmauls – deep rapid breathing;
 Apneustic – forceful inspiration followed by slow
General Consideration: expiration – dying patient

 use the DIAPHRAGM of the steth when assessing

breath sounds;
 72

At birth, the child can maintain temperature by burning a. Pre-Term;

brown fat – and increase burning – bi products is Increase b. Those w/ episodes
fatty acids that will cause acidosis – that can worsen the of Apparent Life Threatening Events
Resp. Distress Syndrome – a group of symptoms (mgt: c. Siblings of those
maintain temperature). who died w/ SIDS
(usually 2-3 sis/ bro – died)
HYPOVENTILATION d. Hypoventilation
Dx Procedures:

Cardioneumogram – measures O2
Cause: Lack of O2 Effect: Polysonography
ACIDOSIS ABG Analysis

Tx :

 Administer Theophylline (N 10-20 mg/ml) S/Effects:

NAV and Insomia
HYPERVENTILATION  Caffeine
 Assist mother threu grieving process
ALKALOSIS
Hx Teaching : Teach parents CPR (esp to Apnea of Infancy)
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 ASTHMA
lead to acidosis – and the brain will
compensate by MP : Inflammation of bronchioles that leads to excessive
hyperventilating – and increase elimination of mucus production that resulted to
CO2 will cause narrowing and obstruction.
ALKALOSIS.
Risk Factors : Environmental factors
Emotion
Effort/ Exercise
APNEA OF INFANCY SIDS/ CRIB DEATH S/S : WHEEZING sound – due to obstruction
Orthopnea
Occurs in Full Term Baby (37wks onwards) Usually Whitish Sputum
occurs in Pre-term
Lab Data : Pulmonary Funx test
s/s : episodes of APNEA, TACHYCARDIA Risk Incentive Spirometer
Factors:
and Cyanosis
 73

Nsg Dx : Ineffective airway Clearance - multi system dses (GI and Respiratory System)
characterized by excessive mucus production by exocrine
PI : AIRWAY glands.

Intervention : Respiratory GI

Bronchodilators – theophylline Hereditary Autosomal Recessive

Rest
Oxygen – low flow (1-2 l/min) – higher than this will For each pregnancy - TRAIT TRANSMISSION – 50%
result to decrease in the stimulus for breathing – Chance for DISEASE TRANSMISSION –
w/c is CO2 25%
Nebulization
Chest Physiotherapy – b4 meals or at bed time S/S : MECONIUM ILEUS – within the 1st 24-36 hrs – if baby
High Fowlers fail to defecate – suspect for CF;
Intermittent Positive Pressure Breathing ABDL DISTENTION
Aerosol Malabsorption Syndrome – STEATORRHEA – foul-
Liberal Fluid Intake smelling stool w/ Inc Fats & Bulky
Salty to Kiss – bec skin becomes impermeable to Na
Meds : Aminophylline
Steroids Common Complications: because of thick mucus plug
Theophylline
Histamine Antagonist MALE – Aspermia – low sperm count
Mucolytic Sterility
Antibiotics
FEMALE – Difficulty in conceiving

Nsg Dx : Knowledge Deficit

Altered Elimination
Hx Teachings : Altered Sexual Functioning

 Appropriate rest; Lab Data : Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl
 Activity – avoid those that will expose pt to allergens; – INCREASE IF (+) CF
 AVOID PROPANOLOL and ASPIRIN – causes (if serum) 90 – 110 mg/dl -
BRONCHOSPASM; -do-
 Exercise – “blowing exercises” – bubbles, trumpet
PI : since two system are affected:

Respiratory Therapy – blowing of trumpet, Increase

CYSTIC FIBROSIS Fluid Intake;

GI Therapy – Administer Pancreatic Enzyme

(pancreatin, pancrease, viocase)
 74

GIVEN WITH (-) FEVER (+) FEVER-low grade

EACH MEALS (+) FEVER-moderate

Effective : if (-) fat at stool (+) STRIDOR (+) STRIDOR (+)

WHEEZING
Hx Teaching : Refer parents to GENETICIST
STRIDOR – is present when the affected part is LARYNX.

Lab data: P Exam -do- ELIZA

ABG’s -do-

Nsg Dx : INEFFECTIVE AIRWAY CLEARANCE

PI : Airway – Endotracheal Tube (Tracheostomy Set - #1) –

to facilitate airway;
Humidity – place infant in MIST TENT or CROUPETTE

Nsg care:

 change clothing frequently coz

CROUP DISORDER mist will dampen child clothings;
 TOYS while inside the tent:
PLASTIC TOYS
ACUTE LARYNGITIS LTB  “no battery operated & no friction
RSV/ BRONCHIOLITIS wheel toys”
(Laryngotracheal Bronchitis)  at HOME: we can use NIGHT or
(Respiratory Synctial Virus) MOIST air outside
and hot shower mist at the comfort room – for child to
inhale
common in TODDLER INFANTS & TODDLER
INFANTS usually (less than 6 mos) Antibiotics – Antiviral – Ribavirin

VIRAL VIRAL or BACTERIAL Hx Teachings :

VIRAL
SYRUP OF IPECAC – for Croup – it induces vomiting-
Inflammation of LARYNX Inflam. of LARYNX & bec it will stop the spam thereby preventing
TRACHEA Inflam. Of BRONCHIOLES further coughing.

“barking-metallic cough” “harsh-brassy cough”

“paroxysmal-hacking cough”
 75

Over distention of Alveoli Inflammation of

Bronchus
Gelatinous sputum + “RE
TACHY TACHY D C”

Risk Factors:

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

S/S: RE TACHY TACHY D C + “barrel-shape test” – there is

an INCREASE in ANTERIOR and POSTERIOR
DIAMETER of
the chest

Lab Data : ABG’s – 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

Chronic Obstructive Pulmonary Disease (COPD) During ACUTE attack, the POSITION OF CHOICE :
ORTHOPNEIC
MP : group of disorders of respiratory system that lead to
obstruction or
narrowing of airways.
PNEUMOTHORAX

MP : partial or total collapse of lungs due to:

EMPHYSEMA BRONCHITIS
ASTHMA
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Types :

 Open Pneumothorax – TRAUMA VIRAL PNA BACTERIAL

 Spontaneous Pneumothorax - due to rupture of PNA
BLEB – over distention of alveoli
 Tension Pneumothorax – due to INCREASE IN Fever : (+) low-moderate (+) fever
TENSION moderate-high

S/S : Diminished Breath Sounds – (-) b. sounds to Cough : (+) Non productive – “thin-watery” (+)
area auscultated; Productive – “rusty”
(+) Dyspnea;
(+) Restlessness WBC : No change or slight Elevated

Nsg Dx : Impaired Gas Exchange

Ineffective Breathing Pattern Lab Data : Xray and ABG’s

Nsg Dx : Impaired Gas Exchange – due to exudation and

PI : Chest Tube Drainage System – restores the (-) consolidation of Alveoli
pressure within the thoracic cavity
PI :
Anterior chest tube – drains the AIR  Airway – O2
Posterior chest tube – drains FLUIDS  Position : Semi-fowler’s or Orthopneic
 Bed Rest
 Inc Oral fluid intake
 Antibiotics
 TCDB (turning, coughing, & deep breathing)

PNEUMONIA (PNA) TB HISTOPLASMOSIS

MYCOBACTERIUM
MP : there is INFLAMMATION of ALVEOLAR SPACES AVIUM
that leads to COMPLEX
exudation and consolidation of the lungs.

LEGIONARES DSES – acute bronchopneumonia in elderly, Bacterial Fungal (from HISTOPLASMA

alcoholic & CAPSULATUM) Bacterial
Immunosuppressed pt from BIRD MANURE – soil & transmitted
- management same w/ pna thru
 77

inhalation Rifampicin
INH
Droplets & Airborne Droplets & Airborne Streptomycin
Droplets & Airborne Ethambutol
- take above meds for 6-12 moths to avoid
Risk Factors: resistance

ASIAN IMMIGRANT
IMMUNOSUPPRESSION
MALNUTRITION

S/S : same: a to e + FOREST RELATED TIPS FOR RESPIRATORY

ACTIVITY same with TB
Ask client if came from AVIARY  you observed a nurse caring for a child in a
CROUPETTE, if you are the nurse in-charge, what would be
a. initially asymptomatic; your #1 PRIORITY? – changing the linens & clothings to
b. low grade fever that occurs in the afternoon; keep child always dry;
c. body malaise or weakness;
d. coughing w/ bld streaked sputum;  which data in the past medical history of the pt.
e. weight loss supports a dx of cystic fibrosis – MECOMIUM ILEUS in the
neonate;
Lab Data : Histoplasmine Skin Test – for
Histoplasmosis  the primary goal of care for pt w/ bronchiolitis is to –
minimize oxygen expenditure;
Mantoux Test
Xray – confirmatory test  w/c of the ff intervention being carried out by LPN
Sputum - @ least 2 (-) to be effective 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

Nsg Dx : would the nurse expect to have – barrel shape chest;
Infection;
Ineffective Breathing Pattern  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 –
 PROPHYLACTIVE TREATMENT OF TB – INH for TWO L Lateral w/ the Head Lower than the Trunk
WKS (take Vit B6 to avoid NEUROPATHY)

MEDS : Antiviral Meds

Antibiotics
 78

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”
(“bronze skin pigmentation – addison’s dses)
 Inc. temperature
 S/S of Shock

Keypoints : Specimen characteristic is usually affected by

STREE, DIET and
Normal Body Rhythm

PKU
- AUTOSOMAL RECESSIVE PATTERN of
DAY 7 (Feb transmission (inherited)
10, 2005)
MP :
There is Absence of Phenylalamine Hydroxylase (the
ENDOCRINE one that converts
Phenylalamine to Thyroxine ( a precursor to Melanin).

General Consideration Therefore (-) PH leads to accumulation of phenylalanine at

the brain that leads to
Explain to the pt the MOST COMMON METHOD of Mental Retardation.
assessment:
S/S :
a. Direct methods – specimen : blood and urine Initially – asymptomatic
b. Explain the methods of gathering the specimen For OLDER CHILDREN : Diarrhea
Anorexis
Consideration for PEDIATRIC PATIENT Lethargy
Anemia
a. Involve the parents of the child; Skin Rashes and
b. Incorporate food preferences seizure
2 servings of popcorn – HOW MANY RICE TO GIVE UP Musty odor of urine
=1 (due to phenyl pyruvic acid)
if sandwich = 1 rice Since (-) melanine: hair : blonde
 79

Eyes: blue
Fair Skin LYMPHOCYTIC THYROIDITIS or
Lab Data : JUVENILE HYPOTHYROIDISM

 GUTHRIE CAPILLARY BLD TEST – initial Cause : Autoimmune or genetics

screening – done after the infant has ingested CHON for a
minimum of of 24 hrs. MP : Decrease in T3 and T4

 Secondary screening : done when the infant is S/S : Dysphagia

about 6wks old – test fresh urine w/ PHENISTIX – WHICH Enlarge thyroid
CHANGE COLOR All s/s of hypothyroidism (decrease metabolism)

 Phenylalanine level greater than 8mg/dl – Nsg Dx : Knowledge Deficit

diagnostic of PKU (4mg/dl – indicative) Activity Intolerance

PI : no tx because it regresses (only temporary)

Nsg Dx : spontaneously
Knowledge Deficit
Altered Thought Process
Risk For Injury
CRETENISM or CONGENITAL HYPOTHYROIDISM
PI : Dietary Modification : LOW CHON and Low
Phenylalanine Diet until - disorders related to absent or non-functioning
adolescent or til 10 yo – bec b4 this time the thyroid;
brain mature - newborns are supplied with maternal thyroid
hormones that last up to 3 mos;
MEDS : Lofenalac – 20-30mg/kg/day - initially asymptomatic

Hx Teachings : s/s begins 2 – 3 months

 Inform parents of the foods to be avoided; - prepare

special education to parents
 Provide list of foods allowed;- prepare special behavioral s/s physical s/s – large tongue & protrudes
education to parents - apathy – “well behave” from
 Refer to geneticist mouth
-
Untreated PKU can result in failure to thrive, vomiting and retarded growth
eczema – and by about 6 mos, signs of brain involvement
appear. - intolerance to cold

mental retardation
 80

7. Adrenals
 Prevention: neonatal screening blood test; 8. Gonads (testes & ovaries)
 Without treatment, mental retardation and
developmental delay will occur after age 3 mos;
Glands UNDER OVER
Lab Data : Decrease T3 and T4
PITUITARY Diabetes Insipidus SIADH
Nsg Dx : Knowledge Deficit
Risk for Injury THYROID Hypothroidism
Hyperthyroidism
(Myxedema) (Graves,
Meds : Single morning dose of Synthroid for “LIFE” – Basedows, Parrys)
oral thyroxine and Vit D as
ordered to prevent M. retardation PARATHYROID Hypo Hyper

(adverse effect of meds : insomnia, tachycardia, Pancreas DM

and nervousness – REPORT ASAP)
ADRENALS Addison’s Dses
PI : correct the deficiency Cushings
Conns
Hx Teachings :

 Warm environment (bec there is

Hypothermia w/ cool extremities);
 Low calorie diet : since there is decrease
metabolism;
 Special education

ENDOCRINE GLANDS

- 8 glands (ductless)- they secrete the hormone

directly to bld stream

1. Pineal Gland
2. Pituitary Gland
3. Thyroid Gland
4. Parathyroid Gland
5. Thymus Gland
6. Pancreas
 81

- Non-Ketosis Prone

GESTATIONAL DIABETES - occurs during pregnancy

Types According to WHITE’S Classification

PANCREAS

TYPE ONSET
Alpha Cells BETA CELLS DURATION

A CHEMICAL DIABETES (+) Increase Bld Sugar

Islets of Langerhans
B After the age of 20 10
years
Glucagon Insulin
(responsible for Decrease in blood sugar) C Bet 10 – 19 yrs old
10-19 years

Responsible in the increase Blood Sugar D Before 10 yrs old

More than 20 yrs

Absence D1 Before 10 yrs old

Deficiency
(DM Type I) (DM Type II) D2 >20 yrs
IDDM NIDDM
D3
 Juvenile Onset – B4 age of 30 Beginning Retinopathy
Maturity Onset – After age of 30;
 Adolescence to Early Adult Stage Pt D4 w/ calcification of arteries
is Obese
 Pt is THIN D5 DM w/ HPN
 Pt is KETOSIS PRONE NON-
KETOSIS PRONE E w/ calcification of Pelvic Arteries

F w/ nephropathy (Diabetes
MODY – DM III Nephropathy)

- combines features of DM Type I & 2; H Diabetes Cardiopathy

- Maturity Onset that occurs in young adult;
- OBESE, b4 age of 30 R Diabetes Retinopathy
 82

T w/ Transplant of the Kidney

INTERMEDIATE NPH - LATE IN THE
AFTERNOON/ AFTERNOON

SLOW Protamine Zinc - DURING NIGHT

Ultralente

INSULIN: Best Site is ABDOMEN bec it is a

NEUTRAL AREA
DIABETES MELLITUS SUBQ – 90 degree angle for insulin
syringe
MP : Deficiency in INSULIN – either absence or deficiency of 40 degree angle if non-
insulin that leads insulin syringe
to alteration in the metabolism of
CHO, CHON Complication of INSULIN ADMINISTRATION:
and FATS.
 Lipodystropy
Cause: unknown  Dawn’s Phenomenon – hyperglycemia
that occurs at dawn – Early AM
R. factors : Autoimmune - due to over secretion growth hormone
Genetic treatment: GIVE INSULIN – NPH at 10 PM to prevent
Stress hyperglycemia at early AM

S/S : Polydipsia  SOMOGYI Phenomenon – rebound

Polyuria hyperglycemia (tx: administer insulin)
Polyphagia – the stave cells send message to
the brain to eat more  Antidiabetic Agent;
Wt loss
 Blood Sugar Monitoring – in AM and supper time
Nsg Dx : Knowledge Deficit (2x a day);
Altered Nutrition
 Ensure adequate food intake;
PI :
Correct the deficiency- HOW?  Transplant of Pancreatic Cells;
 Diet : well balance diet – CHO – 50-70% (main
 Exercise – it will decrease insulin requirement
source of energy and sugar for DM pt.)
(in pregnancy/stress – Increase insulin req)
 Insulin – for Type 1
 Scrupulous foot care – check up w/ podiatrist
Hypoglycemia Most Approximately to Occur
- foot powder, snugly fitting shoes,
cut toe nail straight across
RAPID Regular Insulin - BEFORE LUNCH
 83

- cut toe nail across (Insulin Reaction) (Diabetic

- avoid going barefoot Coma)
- always dry in between toes - BLD SUGAR BELOW 50

DKA HHNK

Risk Factors :

Modification for Pregnant Pt with DM  Missed meals; Overeating

 Increase or Overdose of Insulin; Decrease
 +300Kcal; Insulin
 Insulin Requirement (dose will be adjusted on 2 nd & 3rd  Too much Activity Inactivity
Trimester); Stress
Infection
AM Dose: 2:1 for Regular to NPH S/S :
PM Dose: 1:1 for R:NPH
Dizziness
EFFECTS Drowsiness
Difficulty Problem Solving
Decrease Level of Consciousness
+ Cold Clammy Skin, Diaphoresis

MOTHER BABY
Lab Data : Below 50 Blood Sugar Level
Macrosomia
Hyperglycemia Hypoglycemia PI : Administer Simple Sugar (fructose-fruit juice)
Therefore pre-term birth RDS Hard Candy (not chocolate – it is complex sugar)
Complication: Uterine Atony Congenital Defects
If unconscious – D50

COMPLICATION

1. Hypoglycemia Hyperglycemia (bld

sugar level above 120)
 84

DKA (Type 1) HHNK (Type 2)

(Hyperglycemic Hyperosmolar Nonketotic Coma)

S/S : 3 P’s + Signs of Dehydration – thirst & warm DIABETES INSIPIDUS

skin (Pituitary Glands – 3 lobes)

Hyperglycemia More ANTERIOR POSTERIOR

pronounced GI Disturbances MIDDLE
“Kussmaul Breathing + 3P’s
Thirst and warm skin Secrete Tropic Hormones Store Only (does not
excrete) MSH (skin color)
Lab Data : Increase Bld Sugar
 FSH OXYTOCIN
PI : #1 AIRWAY (follicle stimulating Hormone) ADH
#2 Fluid
Regular Insulin  ACTH
(adrenocorticotropic hormone)
Nsg Dx : Risk for Injury
 LH (luteinizing hormone);

 GH (growth hormone);
2. MICROANGIOPATHY - destruction of small
blood vessels;  Prolactin

3. ATHEROSCLEROSIS – hardening of
arteries;

4. NEPHROPATHY – kidney damage;

5. OPTHALMOPATHY - w/c leads to cataract (eye exam

annually);

6. Peripheral Neuropathy or Autonomic Neuropathy

- there is poor nerve impulse transmission

- common manifestation : impotence
 85

PITUITARY GLAND Lypressin - -do-

How : Given
as pt exhale to the mouth then
ADH (anti Diuretic Hormone) – inhale thru the nose then EXHALE to the
retain h20 or flds mouth then give meds.

Evaluate the effect of meds :

 Check Specific Gravity of Urine;

 Monitor I & O;
Deficiency: lead to D. INSIPIDUS Excess : SIADH  Monitor V/S : assess for hypovolemic shock

(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 –
INTRANASALLY- one hole of nose only
 86

DWARFISM B4 Closure
of Growth Plate
- “congenital” -
SIADH “gigantism”
- excess ADH; ex. MAHAL - long,
slender extremities and Inc. in Height
MP : Fluid Retention – result to DILUTIONAL HYPONATREMIA ex. Marlo
or H2O INTOXICATION Aquino

S/S : due to DECREASE NA – this could lead to the ff:

NANU’S SYNDROME (hereditary)
 convulsion; After the Closer
 seizure; of Growth Plate
 HPN -
“acromegally”
Above s/s could lead to decrease LOC - there is
coarsening of facial features +
LAB DATA : Decrease Na Level (<120 mEq/L) –
hyponatremia enlargement of the digits (inc. shoe size)

Nsg Dx : FLUID VOLUME EXCESS ex. Balingit

PI : FLUID RESTRICTION
Drugs – DIURETICS + ANTIHPN – if cause by Lab Data : INCREASE HUMAN GROWTH HORMONE
TUMOR – PREPARE PT FOR SURGERY Increase Blood Sugar
IF after surgery –
POLYURIA – report ASAP – sign of DI Nsg Dx : Risk for Injury

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

GROWTH HORMONE

DEFICIENCY EXCESS
 87

GLUCOCORTICOIDS MINERALOCORTICOIDS
EPINEPHRINE NOREPINEPHRINE
(ALDOSTERONE)

GLUCONEOGENESIS
STRESS RESPONSE – “fight or flight”
GIGANTISM - formation of sugar from Responsible for Na
(long slender extremity) Retention
new sources and K Excretion

 DEFICIENCY IN GLUCO & MINERALO :

MARFAN SYNDROME ADDISON’S Dses
KLINEFELTERS  EXCESS of GLUCO & MINERALO :
(hereditary) CUSHING’S Dses/ syndrome
(chromosomal aberrations)  EXCESS of MINERALOCORTICOIDS ONLY : CONN’S
SYNDROME
MP : Cardio & Eye disorder (complication) MP :
XXY Pattern (an extra X chromosome)
Scoliosis X
chromosome – FEMALE COMPONENT ADDISON’S CUSHING CONN’S
of
HUMAN BODY MP : Underactivity of the Adrenal Glands Overactivity
of A. Glands INC. MINERALOCORTICOIDS
Problem is NON-DEVELOPMENT of SEX ORGAN (there is DEC G, M & SEX HORMONES) (there is
INCREASE G & M) - w/c cause K EXCRETION &
ADRENOCORTICAL INSUFFICIENCY
Na RETENTION

Excessive SECRETION of
Excessive ALDOSTERONE
ADRENAL/SUPRARENAL - coticosteriods especially
the Secretion from A. Cortex
GLUCOCORTICOID CORTISOL

CORTEX (OUTER) MEDULLA Common: Male and Female Female (bet.

(INNER) Age 30-60) Female (30-50)
RESPONSIBLE FOR SECRETION OF:
SECRETES THE FF:
RF : Could be related to Surgery – removal Related to
Tumors Related to Tumor
 88

Of Adrenal Gland and or

Auto Immune Reaction

S/S: Dec Bld Sugar (hypoglycemia) INC BP, NA

ALL S/S OF CUSHINGS
Dec Na (hyponatremia) DEC K +
EXCEPT HYPERGLYCEMIA ADDISON’S CUSHINGS
Dec BP Moonface, Hirsutism, CONN’S

INC K (hyperkalemia) Buffalo Hump,

Pendulous Abdomen Hypertension PI :
Lability of Mood (mood
swings) Polyuria, Polydipsia  Correct the imbalance – IV Correct the imbalance
Depression Check BP – give antiHPN
Cardiac Arrythmias – due  Diet: Inc Na Dec K - limit fld intake
COMPENSATORY of MSH – Inc w/cTrunkal Obesity / thin  Administer Steroids (Fludocortisone)
Extremities to dec K DIET : Low in Calories & Na
Leads to “Bronze-Like Skin Pigmentation” Hypertension Limit the flds
Decrease Resistance to Admin. Hormone Replacement Therapy High
Infxn in CHON, K, Ca
Hypotension, Weak Pulse Cortisone – give 2/3 of dose in AM & Vit D
Weight loss, Fatigue, Muscle weakness 1/3 in afternoon
Nausea, Anorexia, Vomiting
Hx of frequent Hypoglycemic Rxn  Meds are FOR LIFE Prevent accident &
Falls Diet : Low Na, Inc K
 Prevent exposure to Infxn Protect client
Lab Data : Decrease Cortisol Level Increase exposure to Infxn
Cortisol Level Hypokalemia – due  Provide rest periods – prevent fatigue Minimize
Hyponatremia Hypernatremia stress in environment Administer SPIRONOLACTONE
metabolic Alkalosis  Monitor I & O, weigh Daily MIO & weigh
Hypoglycemia Hyperglycemia Daily (aldactone) & K supplements
Inc Urinary Aldosterone Level
Hyperkalemia Hypokalemia As Rx
Decrease K  Provide small, frequent feeding high in Monitor V/S,
observe for HPN &
CHO, Na and CHON to prevent edema
Nsg Dx :
Hypoglycemia & Hyponatremia
Fluid Vol. Deficit Fld Vol. Excess
Risk for Injury
 Use of Table salt tablets (if Rx) or ingestion Surgery –
Fld & E imbalance Fld & E imbalance
prepare pt if cause
Fld & E Imbalance
 89

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 – THYROID
severe
HYPOTENSION
T3 & T4
 Avoidance of strenuous exercise esp Meds: FOR LIFE Calcitonin
in HOT WEATHER Glucocorticoids - responsible for maintenance of METABOLISM
Synthesis Inhibitors - deposit Ca @ bones
- Lysodren and Cytodren
- prevents formation of
Gluco… DEFICIENCY EXCESS
HYPOTHYROIDISM
HYPERTHYROIDISM
Adult: Myxedema
ADDISONIAN CRISIS Grave’s Disease, Basedow’s or Parry’s Dses
Children: Cretenism
- severe exacerbation of Addison’s dses caused by
acute adrenal insuffieciency
Main Problem:
causes: strenuous activity, infection, trauma, stress, failure
to take RX Meds Slowing of metabolic process caused by hypofunction of the
Secretion of excessive amount of
s/s: severe generalized muscle weakness Thyroid Thyroid Gland with decrease thyroid hormone
severe hypotension secretion (T3 & T4) Hormone in the blood causes in the
hypovolemia, shock INC
Of
PI : administer flds to treat vascular collapse metabolic process
IV glucocorticoids - Solu-Cortef and Vasopressors
DEFICIENCY in T3 and T4
Maintain strict bed rest and eliminate all forms of Excess in T3 and T4
stressful stimuli
MIO and weigh daily Causes:
Protect client from Infxn
 congenital genetic
Other Hx teachings: same with Addison’s  surgery
autoimmune
 90

 autoimmune tumor - performed to determine thyroid

function (increase uptake – indicated
S/S : hyperthyroidism, minimal
uptake may indicate – hypothyroidism);
FACIAL EDEMA nsg consideration : take a thorough history – thyroid meds
EXOPTHALMUS must be D/C 7-10 days b4 the test – meds containing iodine
INTOLERANCE to COLD cough preparations, and intake of iodine rich foods and test
(+) Goiter using iodine – eg IVP can invalidate the test
DECREASE v/s
Hypermetabolic State
DECREASE GI Motility – constipation NSG DX :
INTOLERANCE to HEAT
HYPOactivity Inc V/S Activity Intolerance – due to Fatigue
Increase Sleep – hypersomnia Risk for Injury (bec of hyper)
INC GI Motility - DIARRHEA (fatigue – due to hypometabolism)
Wt Gain in the presence of Dec Appetite
Insomnia PI :
Dry scaly skin, dry sparse hair, brittle nails Promote a EUTHYROID STATE
HYPERactivity same
WT LOSS
even INC Appetite HOW : a. THYROID SUPPLEMENT
Warm Admin AntiThyroid Meds – for LIFE
smooth skin, fine soft hair Synthroid, Cytomel – lifetime
Pliable ex. PTU & Lugols
nails s/e: insomnia, palpitation
nervousness
Irritability, restlessness, agitation b. DIET: low calorie Assign to private room away
from excessive activity
c. Maintain vital funx: correct hypothermia – maintain
LAB DATA : Quite & relaxing Activity
adequate ventilation
Check TSH (increase) d. Provide comfortable, warm environment
DECREASE TSH Provide a COOL ENVIRONMENT
DECREASE T3 & T4 e. Increase flds and high fiber foods to prevent
INCREASE T3 & T4 constipation,. Admin stool softener as Rx
DECREASE RAIU (131) DIET : High in CHO, CHON, CALORIES
INCREASE RAIU f. Meds: thyroid hormone replacement – take daily
INCREASE Serum Cholesterol Level Vit & Minerals w/ supplemental
dose in AM to avoid insomnia
feedings bet meals & at HS
RADIOACTIVE IODINE UPTAKE (RAIU) – Monitor THYROTOXICOSIS – tachycardia
administration of 123I or 131I orally; NO STIMULANTS
 91

Palpitations, nausea, vomiting, diarrhea,  MEMORRHAGE – whether the dressing is dry or intact –
Sweating, tremors, dyspnea its not a confirmatory that there
Protect eyes w/ dark glasses & artificial is no bleeding.
tears
To check, slip your hands at the back of the
Monitor neck (bec of principle of gravity)
for AGRANULOCYTOSIS (fever,
Sore  Damage Laryngeal Nerve – to assess, ask pt to talk
throat & skin rashes) – if taking past surgery and if pt has APHONIA – provide communication
aids – paper and pencil
antithyroid meds.
 LARYNGOSPASM – accidental removal of parathyroid
gland – therefore will lead to dec parathormones – w/c lead
Prepare to dec Calcium and laryngospasm – KEEP TRACHEO SET at
pt for surgery – 2wks before bedside.

SURGERY give LUGOL’S SOLUTION  TETANY – due to decrease in CA – characterized by:

- it decrease size and vascularity of thyroid
gland; a. tingling sensation – fingers & lips
- give w/ straw to b. Chvostek’s Sign – facial muscle twitching on
avoid staining teeth; percussion of facial nerve
- can be diluted w/ c. Trousseau Sign – carpopedal spasm
H2O or orange/ apple juice;
- report diarrhea &  THYROID CRISIS – due to rebound hyperthyroidism
metallic state Increase thyroid hormone
Increase HRate/palpitation
Inc Temp - hyperthermia
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:

 92

Lab Data : Decrease Ca

Inc Ca (N 4.5-5.5 mg/dl)
Serum Phospate Inc
Dec Serum Phospate Level
Skeletal Xray – reveal Inc Bone density
xray –reveal Bone Demineralization

Nsg Dx : RISK FOR INJURY

PARATHYROID same

PI : a. Safety
Parathormone same

b. Keep Ca supplement at Bedside

Inc Oral Fld intake – due to renal
Deficiency Inc CA in the Blood c. Diet: Inc Ca – spinach, sardines, seafoods
EXCESS calculi of having INC Ca
HYPOPARATHYROIDISM withdraws Ca @ d. Tracheo set – deu to dec Ca – Laryngospasm
bone to the bld HYPERPARATHYROIDISM Diet; Low Ca
Surgery –
MP : Dec Ca (hypocalcemia) maybe hereditary, if due to tumor
Increased secretion of PTH that result
Or caused by accidental damage to or removal
in altered state of Ca, Phospate & bone
Of parathyroid glands during surgery eg
thyroidectomy metabolism

S/S :

Initial S/S:
Bone Pain (esp Back Bone)
- Tingling lips & Fingers Kidney
Disorder – kidney stones
- Chvostek’s
renal colic
- Trousseau NAV,
Constipation
Late S/S
- personality changes
- cardiac arrythmias
- muscle pains
 93

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 GENITO-URINARY

indicative of – KETOACIDOSIS
General Consideration
 a pt is to receive NPH Insulin at 8AM, when shld the
nurse expect to have hypoglycemia – in the late  when performing assessment of Genito-urinary
afternoon; system, use open-ended question- bec some pt are not
comfortable talking genitals;
 to determine the effect of PTU, the expected outcome  explain the meaning of terminologies;
is – Dec HR;  ask the patient what symptoms bother him/her the
most;
 what would be the question to support the Dx of
Hypothyroidism – do you tire easily?; Consideration for Pediatric Patient

 w/c of the ff statements made by the diabetic pt would  assess for history of sorethroat;
indicate the need for further teaching – “I will be  bladder capacity increase with age
hypoglycemic if I experience emotional stress”.
infants – about 65ml
 94

toddler – 300-400 ml
school age – 800 – 1000 ml d. Increase glucose – UTI
e. Elevated CHON – Nephrotic Syndrome or PIH
 infants are unable to concentrate urine until the age
of 1 – therefore – adequate milk intake if baby has 6-8 Epispadias – opening at DORSAL portion
diapers /day;
Hypospadias – opening at VENTRAL portion
 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 WILM’S TUMOR
- congenital tumor at the kidney
Reportable s/s : - common in L Kidney and
children below 5 yo
 peri orbital edema
 BP S/S : Unilateral Abdml Mass
 Oliguria Hematuria
 Hematuria – Early Stream Hematuria – indicate lesion HPN
at Urethra
Late Stream – indicate lesion at bladder Lab Data :

Key points : CT Scan

IVP
a. check for wt gain NO INAVSIVE LAB/ Procedure
NO BIOPSY
if >1lb/day – indicative of fld retention
Nsg Dx : Knowledge Deficit
b. characteristic of urine: color N - amber Risk for Injury
if pinkish – bldg
brownish – flagyl PI : AVOID/ NO ABDOMINAL PALPATION
orange – rifampicin Prepare pt for Surgery and Chemotherapy

c. s. gravity (N 1.010 – 1.025) - if INCREASE - D.

Insipidus
DECREASE – D. Mellitus NEPHROTIC SYNDROME AGN
 95

MP : Altered Kidney Funx related to inability to retain CHON DIET :

Destruction of Kidney Tissues related
(therefore there is PROTEINURAI) to INCREASE CHON, Low Na LOW
Group A Beta Hemolytic Streptococus CHON and Na

causes: Autoimmune POSITIONING :

sorethroat
congenital Turn Patient frequently – because pt w/ edema are
prone to skin integrity like pressure sore formation
S/S

EDEMA: Peri-orbital Edema but subside

Periorbital but progresses to generalized
at the end of the day at the
end of the day

BP : Decrease or N
INCREASE BP

URINE : Frothy Tea

colored or Cola colored or Smoky

LAB DATA CYSTITIS

- Infection of the bladder
(+) Proteinuria, severe - >10mg in 24 hrs - Ascending infection caused by E. Coli (from
(+) Proteinuria - <10 mg/ 24hrs urine feces) or Pseudomonas

RF :
Nsg Dx : Fld Volume Excess Wearing silk underwear (does not absorb moist); - use
Impaired Skin Integrity COTTON
Bubble bath
PI : Prolong driving
Common in FEMALE – due to size (short) urethra
Check BP
Maintain Fld Balance S/S:
Meds : NO Antihypertensive FREQUENCY, URGENCY & HESISTANCY + Burning
Antihypertensive sensation on urination (dysuria)
(+) Steroids
Diuretics LAB DATA : Urinalysis – to check for microorganism
(+) Antibiotics
Nsg Dx : Altered Elimination Pattern
 96

Infection OLIGURIC PHASE

- decrease urine output that is less than 400 ml/24hr
PI : Treat for Infection – antibiotics for 10-15 days (OLIGURIA) There will be INC BUN & Crea
Bladder Analgesic (ex. PYRIDIUM – ch can cause - Dec NA & Inc K
ORANGE COLORED URINE, effective : (-) pain) RENAL
FAILURE
Diet : ACID-ASH DIET – give lemon juice or VIT C DIURETIC PHASE
- Inc urine output (4-5L/day)
Hx Teachings: Avoid bubble Bath All s/s + Anemia & HPN
No Silk underwear - Dec Na & K
Inc. Fld Intake ESRD
RECOVERY PHASE
- renal funx normalizes (1-2 yrs)
RENAL FAILURE Azotemia & Uremia –

ACUTE accumulation
CHRONIC
of waste products
MP Sudden or Acute, Usually Reversible loss of
IRREVERSIBLE kidney damage that “uremic frost” –
Kidney Funx skin pruritus
leads to scar formation LAB DATA

There is inability of kidney to maintain fld & E balance Increase BUN and
same
Crea – most sensitive Index
Causes
PHASES : Nsg Dx

 Pre-renal Factors – those that dec bld circulating vol. – Fld and E Imbalance
SHOCK; Phase I: RENAL INSUFFICIENCY Fld & E Imbalance
 Intra-Renal – dses condition of the kidney eg. AGN Activity
 Post-Renal – those that causes obstruction eg. Kidney Intolerance
stones Polyuria
PI : TO CORRECT THE IMBALANCE
Nocturia
A. Fluid restriction; Fld
Polydipsia restriction
Phases of ARF B. Meds : Diuretics
PHASE Amphogel – to promote excretion of
II : MILD RENAL DAMAGE Cardiac Glycosides – Digitalis
Phospate
 97

Antihypertensive Epogen – muscle abnormalities – twitching

Inc RBC synthesis seizures
Diuretics
AntiHPN RENAL TRANSPLANT – s/s of complication : FLANK PAIN,
C. DIET : Low CHON – NO PMS Diet: FEVER, TENDERNESS, HPN - REPORT
same

DIALYSIS
BPH
- glandular enlargement of the prostrate
PERITONEAL - common in males above 40 yrs old
HEMODIALYSIS
S/S :
Decrease size and force of urinary stream
Semi-permeable membrane: Abdomen (peritoneum) Nocturia
Dialyzing machine Frequency, hesitancy and urgency

Use of Tenchkoff Catheter Use of LAB DATA:

fistula or shunt Digital rectal exam – once a yr for pt 40yo and
above
Teachings: anastomosis of artery & vein gloves, ky jelly
(internal access) – less prone to infxn position: Sim’s

 Report Infxn (abdomen: rigid, Solution : cloudy) Nsg Dx : Altered Elimination Pattern
 Check BT and CT
external access PI : Prepare pt for surgery
 Check Temp of dialyzing solution  TURP – no incision
(more prone to infxn)  Suprapubic Prostatectomy
 Retropubic -do-
Complications of dialysis (report ASAP):  Perineal -do- - common
complication: IMPOTENCE due to nerve damage
1. DISEQUILIBRIUM SYNDROME – due to rapid removal of “I am eager to have sex again” – cannot
solutes (electrolytes and CHON) be bec pt is impotence
s/s:
GI – nausea, vomiting, headache nsgcare : CBR for 2-3 days post
CNS - convulsion, seizures surgery;
NO LONG DRIVE/ SITTING;
2. DIALYSIS ENCEPHALOPATHY – due to aluminum toxicity Ff up check up (if INC ACID
s/s: PHOSPATASE: Prostate CA)
(+) dementia
 98

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; DAY 8 (Feb 11, 2005)

 w/c of the ff indicates complication of EENT

General Consideration
peritoneal dialysis – cloudy dialysate
 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

 99

 Obtain feeding history (bec the type & techniques Absence of pain indicates rupture of Tympanic
differs) Membrane – ear drum
 Obtain the diet hx of the pt and hx to URTI
 Involve the parents in the assessment of the baby Lab Data :
OTOSCOPY – revealed – reddened, bulging
Reportable Signs and Symptoms tympanic membrane

 TINNITUS - ringing, buzzing or sea shell sound in the Nsg Dx : Infection

ear Sensory – Perception Alteration
 VERTIGO - Objective – “the room is spinning”
PI : Treat Infection (antibiotics – 7-10 days) – if does not
Subjective – “I feel that I am revolving/rotating” heal – possible MYRINGOTOMY

 Hearing Loss Hx Teaching : RIGHT POSITION while feeding

 Pain – if pain subside or (-) – rupture of ear drum

Keypoints for Assessment

 Note for abnormal findings

 Document the subjective and objective complaints

OTITIS MEDIA RETINOBLASTOMA

- infection of the middle ear - congenital tumor of the retina;
- genetically transmitted;
RF : - autosomal dominant (common in MALE and
FEMALE)
Faulty feeding practices
Swimming in dirty waters S/S :
Upper Resp. Tract Infection LEUKOCORIA – “cat’s eye reflex”
- whitish or grayish
discoloration of the pupil
S/S :
PAIN – Pulling Diplopia and or Strabismus
Tugging
Crying when lying on the affected ear LAB DATA : PE
Opthalmoscopy
 100

Nsg Dx : Knowledge Deficit Lab Data : Opthalmoscopy

Tx : Surgery – Inoculation – done b4 age of 3 Nsg Dx : Risk for Injury

(chemotherapy – after surgery)
Genticist PI : Immediate Bed rest – AFFECTED SIDE TOWARDS
THE BED – to allow the connection of

DETACHED PART
RETINAL DETACHMENT GLAUCOMA
CATARACT NO SUDDEN HEAD MOVEMENT
AVOID reading (TV – ALLOWED)
RF:
Aging (above 40) Aging (above 40) Prepare Pt for Surgery: SCLERAL BUCKLING –
Aging (above 70) use of laser to reduce inflammation and

Related to trauma Common in Blacks when inflammation subside, the

Related to Trauma
Familial Predisposition Rel. to detached retina portion will be attached
Diabetes
Rel. to Steroids thru scar formation.
Rel. to
Chromosomal Abberation POST SURGERY :
- those with D. Syndrome are prone
 AVOID activity that requires BENDING,
LIFTING, COUGHING;
(No Bowling & shampooing of hair at
RETINAL DETACHMENT sink)

MP : There is separation of sensory and pigment portion of  REPORT SUDDEN eye pain – indicative of
the retina – therefore it will allow fluids to go in bleeding/ hemorrhage
between which give rise to OUSTANDING manifestation
as:

VISUAL FLOATERS – pt says: “I see light

structures GLAUCOMA
Curtain like
Floating spots MP : INCRASE IOP due to obstruction in the outflow
Cobwebs” of acqeous humor or could be related to
forward displacement of the iris.
S/S : NO Pain
Blurring of vision – because of floaters TREATABLE but NOT CURABLE
 101

If Obstruction related : could lead to CHRONIC b. Prepare pt for Surgery : TRABECULOPLASTY – a

OPEN ANGLE. new pathway was created for the passage of
the blocked fluids;
If due to Forward displacement: can lead to ACUTE - Out-patient only (use of laser only)
CLOSE ANGLE
TRABECULECTOMY – requires
S/S : hospital admission for 1-2 days

TUNNEL or Gun Barrel Vision – wherein there is loss of Hx Teachings : same w/ retinal detachment
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; CATARACT

Chronic G - as high as 50
MP : Opacity of the Crystalline Lense
 Gonioscopy
 Opthalmoscopy S/S : Blurred Vision (Poor Color Perception)
 Perimetry – measures visual field NO PAIN

LAB DATA:
Nsg Dx : Risk for Injury
a. SLIT LAMP TEST – test for red light reflex
PI : TO DECREASE IOP (this reflex is absent in cataract pt due to presence of
milky white lens)
How:
b. Opthalmoscopy
a. Administer MIOTICS (Pilocarpine, Tomolol, Diamox)
– for LIFE Nsg Dx : Risk for Injury
- it decrease the production of ACQEOUS HUMOR
– admin. At lower conjunctival sac PI : Prepare for SURGERY
 102

 CATARACT EXTRACTION – Extra Capsular Cataract Hearing Loss + same

Extraction (ECCE) VERTIGO (only for M. DSES)
Intra Capsular Cataract Extraction (ICCE)
Lab Data: Caloric Stimulant test
ECCE – removal of anterior part Weber’s test –
lateralization of sound
ICCE – removal of entire capsule Rinne’s – bone
conduction
 PHACOEMULSIFICATION - needle is inserted to lens Audiometry
and send vibration thereby crushing (above test –
the cataract then suction it out use of TUNING FORK)

 PERIPHERAL IRIDECTOMY – a whole is created then Nsg Dx : Risk for Injury Sensory
suctioning Perceptualalteration

PI : SAFETY Establish
Post Cataract Surgery – NO SEX for 4-6 weeks Communication
(to prevent pt from falling:
Health teachings – same w/ R. Detachment bedrest or supine – danger of falls) Surgery :
STAPEDECTOMY – mobilization of

MENIERE’S DSES OTOSCLEROSIS stape

(hardening
of the ears)

RF : High altitudes Aging

Aging DIET : LOW NA (AVOID – Alcohol & Caffeine containing
Ototoxic Drugs food)

Meds : AntiVertigo – Diamox, Bonamine

MP : Cause by an imbalance of Endo- Post Surgery Hx Teachings:
Overgrowth of the stapes
Lymphatic Fluids in the inner ear Effective : (-) Vertigo/ Falls AVOID – diving
Small
Sensori-neural hearing loss – since airplane
Conductive Hearing Loss
Inner ear was affected - since Coughing
middle ear was affected AVOID - driving
Blowing of Nose
PMS Bending
S/S : Tinnitus same Sudden Head Movement
 103

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 GASTROINTESTINAL

Meniere’s Dses – Risk for Injury

 a Tonometer is used for the purpose – to determine GENERAL CONSIDERATION

IOP;
 Provide privacy
 Post Cataract Extraction : how shld the nurse position  Ask the pt when he 1st notice the S/S
the pt – UNAFFECTED SIDE to minimize edema; Eg. LIVER CIRRHOSIS – when did you notice that your
eyes turns yellow?
 w/c of the ff is a common manifestation of
Retinoblastoma – Cat’s Eye Reflex; PEDIATRIC CONSIDERATION

 The parents of the pt w/ retinoblastoma must be  Introduction of FOOD: (shld be in order)

referred to - GENETICIST
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
 104

Tarry Stool – indicates bldg (upper GI) Nsg Dx :

Fever, Tachycardia, Dehydration – indicative of SHOCK Diarrhea
Hypotention Fluid Volume Deficit

PI : Place pt on ENTERIC ISOLATION PRECAUTION

KEPOINTS… (handwashing & gloves ONLY)
– while waiting for lab result
Bowel Sounds (check all 4 quadrants- N 5-35 bowel
sounds/min)
- to assess, use DIAPHRAGM of Steth – to listen
for normal sounds CHALASIA GERD
- BELL part of Steth – to listen for
abnormal bowel sound

Ex. “bruit” – abnormal vascular sound w/c indicate abdml CONGENITAL WEAKNESS OF THE CARDIAC
aortic aneurysm SPHINCTER

S/S: vomiting - NON-BILE-STAINED Hear-

DIARRHEA/ AGE burn due to Reflux of Acid

- usually asso w/ NORWALK (common in ship), ROTAVIRUS Complication :

and CLOSTRIDIUM DEFFICELE
 METABOLIC Acidosis same
MP : Passage of watery and loose stools (BEST judge in  BARRETT’S ESOPHAGUS same
the consistency) - damage to mucosal lining of lower esophageal mucosa
w/c can lead to esophageal CA
S/S :
LAB DATA :
Frequent stools
Sign of DHN – sunken fontannels Upper GI Series (Ba Swallow) do
Poor Skin Turgor Gastroscopy do
Absence of Tears (for more than 2 MONTHS old infant) Esophagoscopy do
Check for complication : Metabolic Acidosis
Nsg Dx : Altered Nutrition Less Than Body Requirement
If excess fluid loss, it will progress to shock – due to K loss Flds & E Imbalance
(hypokalemia)
PI : Insure Adequate Nutrition
LAB DATA :
 Position: Place pt in UPRIGHT – to avoid vomiting
Stool Exam – to check for bacteria
 105

(if BABY: use HARNESS or PRONE w/ HEAD UP  NON-CORROSIVE – induce vomiting by stimulating
POSITION) GAG REFLEX

 Administer flds How:

 Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg, a. Use fingers or tongue blade
therefore X100) b. Syrup of Ipecac – administer w/ glass of H2O –
 Health teachings – crackers, juice, water make sure that all taken will be
 Feeding : Thickened vomited – bec it is cardiotoxic (after 1hr
 Prepare pt for surgery : NISSINFUNDOPLICATION – part – can repeat)
of fundus will be sutured to
dosage: CHILDREN – 15 ML
esophageal area to tighten ADULT - 30 ML
 Effective: if (-) vomiting and(-) reflux and heartburn
CLEFT

LIP PALATE

POISONING MP: Non-fusion of facial process Non-fusion of

Palative Processess (soft & hard)
INTERVENTION: (congenital) (congenital)

a. CALL poison control center;

b. MINIMIZE EXPOSURE – remove pt from the scene Nsg Dx : Altered Nutrition
c. IDENTIFY the type of poison Risk for Aspiration
Body Image Disturbance
“if unknown substance was taken” – bring bottle or foil for
proper identification PI : Nutrition
Safety
TYPES: Prepare for Surgery

 CORROSIVE – “DO NOT INDUCE VOMITING” Surgery :

Chiloplasty Palate
Management: NEUTRALIZE the poison Uranoplasty

If STRONG ACID – give WEAK BASE (eg. ACID – - for 10wks old - if child is 15-
give MILK) 18 mos
10 lbs
IF STRONG BASE – use weak ACID by using 10gms/hgb
vinegar 10,000 WBC

Post Surgery:
 106

 CRYING shld be minimize – bec it will put pressure at Fluid Vol Deficit
suture line; Fld and E imbalance
 LOGAN BAR/ BOW – it decrease tension at suture line;
 ELBOW RESTRAINT – prevent child from touching the PI : Nutrition
suture line; Surgery – FREDET-RAMSTEDT or
 FEEDING DEVICE – C CLIP – use dropper, C PALATE – PYLOROMYOTOMY – incision at pyloric sphincter
use Breck Feeder/ cup
 Refer pt to: SPEECH THERAPIST, AUDIOLOGIST &
PSYCHOLOGIST

PYLORIC STENOSIS
CELIAC DISEASE
- congenital
- hypertrophy (“kumapal”) of the pyloric sphincter (bet - GLUTEN –INDUCED ENETEROPATHY
stomach & intestine) - Genetic predisposition
- Life-time disorder
S/S :
MP : Intolerance to GLUTEN
 PROJECTILE VOMITING (INITIALLY, NON-BILE STAINED
OUTSTANDING S/S : Malabsorption Syndrome-crisis
but eventually it PROGRESSESS TO bile-stained)
Abdl Enlargement – this can be triggered
by INFECTION & Fld and E imbalance
If sitting : 4-5 ft
Anorexia
If lying down : 1 foot
Anemia
- there will be SEVERE DHN
Feeding should be thickened then AFTER FEEDING,
place to RIGHT SIDE LYING SEATED
at car seat – to facilitate the entry of food from stomach
LAB DATA : Diagnostic Test : GLUTEN CHALLENGE –
to duodenum
3-4 mos – give gluten rich food
And if there is
 OLIVE-SHAPE MASS
malabsorption, therefore (+) CDses
 VISCIBLE PERISTALTIC MOVEMENT – usually from L to R
of the abdomen – w/c can lead to DHN Nsg Dx : Altered Nutrition
LAB DATA : PI : Dietary Modification : AVOID GLTUEN RICH
FOOD : Barley, rice, oats, wheat
Ba Swallow – (+) “string sign”
ALLOWED : Rice, cereals,
NSg Dx : Altered Nutrition corn, soy beans
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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

INTUSSUCEPTION

HIRSCHPRUNG’S DISEASE (AGANGLIONIC MP : There is telescoping of a part of a colon which leads to

MEGACOLON) inflammation and edema

MP : Absence of parasympathetic nerve fibers in a S/S : “sausage-shape mass”

portion of a colon dilation, abdominal Abdominal distention
distention and pellet-like or ribbon-like stool. “Dance sign” – the R lower portion of the colon
becomes empty
Vomiting : BILE-STAINED
Patient – meconium ileus & constipation – Constipation
HALLMARK SIGN LAB DATA : Ba Enema: if for DIAGNOSTIC : it outlines
the area involve
if for THERAPEUTIC : it reduces
LAB DATA : BA Enema intussuception by means of hydrostatic pressure

Nsg Dx : Altered Ellimination

Nsg Dx : Constipation
Diet : High Fiber Altered Elimination
Increase fluids
Diet : Inc. Flds.
Tx : Give Enema High Fiber

Meds : Laxative Tx : wonder drugs – steroid

Surgery – SOAVE Surgery – resection with end surgery
to end pull through

TRACHEOESOPHAGEAL FISTULA (TEF)

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MP : Failure of the esophagus to develop as a continous

process

Types :

 AF1 - esophagus NOT connected w/

abdomen/stomach TIPS FOR GASTRO – PEDIA
 AF2 - esophagus attached to trachea (when pt
eat, it goes to the lungs)  w/c of the ff signs if manifested by a child post
 AF3 - stomach connects w/ trachea tonsillectomy needs to be reported – FREQUENT
 AF4 - stomach & esophagus connected SWALLOWING;
 AF5 - stomach, eso and trachea are connected
 AF6 - separated properly  a child who has had several episodes of diarrhea is
likely to develop – metabolic acidosis;
Atresia – “narrowing”
Fistula – connection  in relation to dx of p. stenosis, w/c of the ff actions of
the nurse is important – weighing pt daily for wt loss;
S/S : Excessive Drooling – danger in aspiration
(avoid glucose water as initial  w/c of the ff will the nurse expect to observe in a child
feeding – use sterile H2O instead.) who loss fluid due to diarrhea – flushed dry skin;
Coughing, Chocking
Cyanosis  the most appropriate feeding device for a child post
cleft palate – paper cup;
LAB DATA : Lateral Neck Xray – to check the esophagus
 the priority nsg care for a child on NPO is – offer a
Nsg Dx : Risk for Aspiration pacifier regularly;

PI : Safety  a common manifestation of pyloric stenosis is –

Airway visible peristaltic wave;
Keep child NPO – just give pacifier (if feeding OK
– use sterile H2o instead NOT GLUCOSE)  the priority nsg dx for a pt w/ rotavirus infection is –
diarrhea;
Tx : Surgery
 w/c of the ff is expected in a child suffering from celiac
dses – intolerance to gluten

PEPTIC ULCER
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RF : Stress
Smoking Nsg Dx : PAIN
Salicylates or NSAIDS
Helicobacter Pylori PI : Relief of Pain
Zollinger-Ellison Syndrome (gastinoma) – tumor of the
stomach – due to increase HCL acid

GASTRIC ESOPHAGEAL
DUODENAL Meds : ANTACIDS: Maalox – it
NEUTRALIZE HCL Acid;
RF : same same RANITIDINE - it DECREASE HCL
Acid;
MP : Weakened Mucosa SUCRALFATE - it COATS the GIT
Excessive HCL Acid
Common in Female Common NO ASPIRIN
in Male
Below 65 65 yo & Diet : BLAND DIET – NO SPICY, fried, raw fruits and
above vegetables
Inc risk for CA (EXCEPT: avocado, banana &
pineapple)

OUSTANDING S/S: PAIN – aching, burning,

gnawing GASTRIC SURGERY

PAIN – 30mins – 1hr post meal 2-  VAGOTOMY

3hrs after meal  PARTIAL GATRECTOMY – Billroth I (BI) and Billroth II
PAIN at daytime (BII)
Nightime  TOATAL GASTRECTOMY
Pain relieved by vomiting
Pain relieved by eating
Also BI – gastrodoudenostmy – duodenum and stomach
related as hyperacidity BII – gastrojejunostomy – stomach and jejunum
HEMATEMESIS (vomiting of blood)
- severe bleeding – “shock”
LAB DATA : COMPLICATIONS:
GASTRIC Analysis (diamox blue – urine)
Gastroscopy  PERNICIOUS ANEMIA – due to decrease
BA Swallow INTRINSIC FACTOR w/c came from stomach;
HgB
Hct
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 DUMPING SYNDROME (occur usually for 10-12

mos post surgery) MP :
– due to rapid emptying of the stomach and
stimulation of gastro-colic reflex Inflammation @ large Intestine Inflam @ L Intes. –
Inflam of small &
Specifically @ recto-sigmoid colon at
GASTRO-COLIC REFLEX – is usually due to DIVERTICULUM large intestine
increase CHO INTAKE in the diet
- NO PANCAKE, NO UPRIGHT S/S : same
SITTING AFTER MEALS same

DIARRHEA (15-20x/day) diarrhea & constipation

S/S OF Dumping Syndrome : Diarrhea 3-4x/day
Diaphoresis bloody mucoid
Dizziness/drowsiness
FEVER (+) (+)
Management: NO FLUIDS after meals – instead in (+)
between meals
DIET: High Fats – because it delays the CRAMPY ABDL PAIN LLQ LLQ
emptying of the stomach RLQ
LOW CHO (Rigidity (REPORT ASAP) –sign of colon rupture)
Lie down – after eating

LAB DATA: BA ENEMA

Colonoscopy
Stool Exam
INFLAMMATORY BOWEL CONDITION
Nsg Dx : PAIN
Altere Elimination: Diarrhea

ULCERATIVE COLITIS DIVERTICULITIS

CROHN’S DSES
PI : Relieve Pain
(Regional Enteritis)
Meds: Steroids
Anticholinergic
RF : With familial Predisposition Common in Antidiarrheals
those LOW FIBER Diet Related to Genetics Antispasmodic
Smoking as Protective Effect Common in
Aging DIET : Low Fiber and Low Residue – for Ulcerative
Common in Obsessive-Compulsive and Chron’s
Or Stress Related or to “perfectionist”
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Diverticulosis – High Fiber/residue – allowed: III Entire Area – manual reduction

vegetables IV Entire Area – irreducible
Low residue – (no vegetables)
TYPES
SURGERY : Colostomy – irrigate
Ileostomy – no need for irrigation INTERNAL H – above the spinchter
EXTERNAL H – below the spinchter

Characteristic of N Colostomy – REDDISH or S/S Pruritus

PINKISH Pain
EDEMATOUS Bleeding
MOIST
N elevation from skin: 2.5 LAB DATA Sigmoidoscopy
cm Proctoscopy
Diameter : 5cm P Exam

When to empty colostomy: when 1/3 – ½ full (EMPTY Nsg Dx Altered Elimination
DO NOT CHANGE)

When to change C. Bag : 48hrs or 3x a wk PI Diet : High Fiber

Avoid Spicy
BEST TIME TO DO COLOSTOMY CARE – at home,
while in the bathroom PAIN – use SITZ BATH (48 degree C – temp
of H2o)
STOP colostomy irrigation if patient (+) ABDOMINAL - emerge up to pelvic area with
CRAMPS ice pack at head to prevent dizziness

STOOL SOFTENER
SURGERY
HEMORRHOIDS

MP Varicosities of the ANAL SPINCHTER PANCREATITIS

RF - AUTODESTRUCTION OR AUTODIGESTION of the

PREGNANCY pancreas
PROLONGED STANDING
PORTAL HPN – hepatic enceph and liver cirrhosis
RF #1 Alcoholism
GRADE #2 autoimmune
High Fat Diet
I Small Area Biliary Dses
II Large Area – reduces spontaneously
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SS PAIN @ peri-umbilical area or epigastric that radiates Forty

to peri-umbilical area flatulence

GREY TURNER SIGN – pain w/ bluish S/S R UQ Pain radiating to R shoulder or R Scapula –
discoloration at flank area; usually precipitated by FATTY INTAKE
CULLEN’S SIGN – pain w/ bluish discoloration @
umbilicus GI S/S – NAV diarrhea and Jaundice

URINE: dark colored

NAUSEA & VOMITING
SHOCK – as complication STOOL : “clay-colored” or grayish – alcoholic stool

LAB DATA Elevated Serum Amylase (N56-190 u/L that LAB DATA Increase AMYLASE, WBC, FATS
normalize in 2 wks) Increase Liver Fnx test
USG
Nsg Dx PAIN
Nsg Dx PAIN
PI Relieve PAIN
PI Relief of Pain
Meds: DEMEROL – DRUG OF CHOICE meds : DEMEROL
AVOID MORPHINE – it causes more pain bec it will diet: LOW FAT
causes spasm to the spinchter of oddi
surgery : 1) LAP. CHOLE – 4 small
DIET LOW FAT incision, CO2 insufflation
AVOID alcohol
2-3 days after – discharge pt and back to ADL

1 WK after – pt can lift weight

2) CHOLECYSTECTOMY – R
CHOLELITHIASIS CHOLECYSTITIS SUBCOASTAL
-
Combine or usually come together in a pt complication: “Pneumonia”

– report rusty-colored sputum

hx teaching:
Stone in gall bladder TURNING, COUGHING, DEEP BREATHING
Inflammation of the G. bladder

RF Fat same
Female
Fertile
 113

HEPATITIS Isolation : A & E – Enteric

B, C, D – Universal
MP Inflammation of the Liver
COMPLICATION Liver Cirrhosis

TYPES

A B C D E LIVER CIRRHOSIS
- scarring of liver
Infectious SERUM POST TRANSFUSION tissues
DELTA HEPA ENTERICALLY-TRANSMITTED
TYPES
Fecal-oral bld, body flds Non A & B
Post Hepa B Fecal-oral LAENNE’S BILIARY CARDIAC POST
NECROTIC
(Hepa A & B Combination
2-6 wks 6wks-6mos 70-80 days 6wks- Due to alcoholism Due to biliary Disorder due to
6mos CHF due to Hepatitis

STAGES OF HEPA B S/S – are related to 3 FUNXs of the LIVER

 PRE-ICTERIC - 1-2 days : S/S NAVDA – NO jaundice yet;  MANUFACTURES : bile, immunoglubolin, &
 ICTERIC - 2-4 wks w/ jaundice; clotting factors
 POST ICTERIC - 2-4 mos s/s subside  METABOLIZES: CHO, Fats, CHON, Alcohol
and Drugs
Lab data Increase Liver Funx Test (Inc AST/ ALT)  STORES : Vitamins & Minerals
Hepa A – Inc HaV
Hepa B – HbsAg
Signs and symptoms
Nsg Dx Infection
Alt Skin Integrity a. pt prone to bleeding;
Body Image Disturbance b. malnutrition – no cho metabolize
c. edema – due to fld retention (bec of dec albumin)
PI Tx for Infection d. Flds & e imbalance
a. Meds : HEPATOPROTECTORS
DIURETICS
LAB DATA Increase Liver Funx Test
b. Diet : High Calorie Liver Biopsy
Low Fat
 114

Increase abdl girth – “I cannot button my pants

Nsg Dx Risk for Injury anymore”
Fld & E imbalance (fluids)
Fld Vol Excess
Altered Nutrition
management: abdominal paracentesis – aspiration of
PI SAFETY fluids from the peritoneum
- complication: chance
HOW? for infection & shock

 Meds: Diuretics – due to fld retention

ANTIHPN – due to portal HPN pt preparation: #1 instruct pt to void;
Clotting factors : Coagulants – give Vit K #2 position: sitting the evaluate
(to avoid bleeding) the WEIGHT, ABDL GIRTH & REPSIRATION

 Diet : LOW CHON or CHON to Tolerance effective if : Pt decrease wt of 5 lbs and

Or High Biologic Value CHON – good decrease or N RR
quality CHON (eg poultry products)

 SURGERY : Liver Transplant c. BLEEDING ESOPHAGEAL VARICES – DUE TO portal

HPN

Lab data Sengstaken Blakemore Tube – 48 hrs inflated,

COMPLICATIONS: scissors at bed side
(Balloon Tamponade) - effective if (-)
a. HEPATIC EBCEPHALOPATHY – accumulation of hematemesis
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
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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

NEUROLOGY
Nutrition
DECORTICATE – abnormal FLEXION
 the priority nsg dx for for pt w/ acute pancreatitis –
Altered nutrition less than body requirements
DECEREBRATE – abnormal EXTENSION

Opistotonous – “back arching”

GENERAL CONSIDERATION

When assessing the neurological system, pay

attention to the ff:

 #1 LEVEL OF CONSCIOUSNESS
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 #2 BEHAVIOR e. CONTUSSION – more severe, fatal and could even lead to

 #3 REFLEX death

CONCUSSION – jarring of the brain, “na-alog” w/c could

When assessing MUSCULO SYSTEM: lead to s/s of LOC in 24-48 hrs

 #1 Range of Motion
 #2 Joint Stiffness DECORTICATE – abnormal flexion which indicates
 #3 POSTURES damage to the cortex

s/s : #1 Decrease LOC

PEDIATRIC CONSIDERATION #2 widening pulse pressure (increase
systolic BUT diastole is N)
a. Check for bowel and bladder funx – indicates neurological #3 Convulsion & seizures
maturity
ABOVE ARE S/S OF INCREASE ICP.
15-18 months – START BOWEL TRAINING
DECEREBRATE – more serious
2 yo – start bladder training - abnormal extension w/c indicates
damage to brain stem
b. Assess for their habits

“security blankets” – ex. Stuff toys, mother wallet

Associate mother’s time w/ child activity GLASGOW COMA SCALE

(children has NO DEFINITE TIME)
Ex. Your mom will be back after you have
eaten your lunch. EYE OPENING (4) VERBAL RESPONSE (5)
MOTOR (6)
c. Assess for presence of URTI – could be sign of Meningitis,
Hemophilus influenza, Otitis Media 6–
OBEYS COMMAND
d. Assess child for S/S of anxiety 5 – ORIENTED 5-
LOCALIZES PAIN
- bed wetting 4 – OPEN SPONTANEOUSLY 4–
- nail biting (N up to 4 yo) CONFUSED 4 – WITHDRAWS FROM PAIN
- head banging 3 – OPENS TO VERBAL COMMAND 3–
- excessive thumb sucking INAPPROPRIATE 3 - DECORTICATE RIGIDITY
2 - OPEN TO PAIN 2 - INCOMPREHENSIBLE 2-
DECEREBRATE RIGIDITY
1 - NO RESPONSE 1 - NO RESPONSE 1 - NO
RESPONSE
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AND MOTOR : ability of pt to

chew
SCORE OF 3 : NO response (DEAD) – Doctor will
the one to pronounce
Reflex: CORNEAL REFLEX – (+) if both eyes can blink
SCORE OF 15 : pt is
awake

Score of 8 : 50-50, MONITOR THE PT VII. FACIAL : SENSORY : sense of taste @

anterior 2/3 of the tongue
7 and BELOW : pt is COMA
and MOTOR : Facial Expression

CRANIAL NERVES VIII. ACOUSTIC or VESTIBULOCOCHLEAR - Sense of

hearing and balance

I. OLFACTORY : SENSORY : smell - TEST : ROMBERG’S TEST -

Abnoxious smell stand erect, close eyes, observe for balance
Anosmia – no
smell
Perfume IX. GLOSSOPHARYNGEAL
X. VAGUS SENSORY –
II . OPTIC : SIGHT – snellen’s chart – Posterior Taste 1/3 Of The Tongue
20/20 usually by age 3-6 yo
MOTOR - swallowing and
III. OCCULOMOTOR gag reflex
IV. TROCHLEAR Eye movement - 6 cardinal
direction of gaze XI. SPINAL ACCESSORY - motor movement of
VI. ABDUCENS (if shoulder muscle
abnormal look for DIPLOPIA)

XII. HYPOGLOSSAL – TONGUE MOVEMENT

V. TRIGEMINAL : SENSORY : responsible for

FACIAL SENSATION
(to check,
use cotton & needle and run across the cheek)
 118

DUCHENE’S MUSCULAR DYSTROPHY (DMD)

COMPLICATIONs Respiratory Paralysis – for
X –linked RECESSIVE (only mother transmit to SON) young children
Cardio-Resp. Arrest - for
adolescent
(-) Father Mother (+ carrier) Son - 50% chance
LAB DATA Muscle Biopsy
Daughter as Carrier – 25% PExam
chance
Nsg Dx Ineffective Breathing Pattern
Impaired Physical Mobility
DMD Erb Duchenne’s Paralysis (EDP)
Klumpke Palsy (KP)
PI AIRWAY
(keep TRACHEO at bedside)
Related to Birth Injuries affecting the
BRACHIAL PLEXUS – nerves at axilla portion TX

HEREDITARY EDP – upper plexus a. Supportive - leg brace, crutches

KP - lower plexus w/c leads to b. Refer parents to geneticist
paralysis.
Prognosis : complete Target: Mothers or FEMALES – bec they are the
recovery in 3 months source of transmission
Treatment : splint
and cast for 3 mos – leads to nerve Ex. Aunt, Female Sibling, mothers, female members of
the family – (bec transmission: X linked recessive)
regeneration
X-linked RECESSIVE DIRORDER
CEREBRAL PALSY
MP characterized by progressive muscle atrophy
w/c apparent in male at the age of 3 - Permanent, Fix (non-progressive) neuromuscular
disorder characterized by abnormal
muscle movement.
S/S a) GOWER’S SIGN – inability to stand up
- use arms to brace the body Cause Unknown

b) WADDLING GAIT - duck-like gait S/S Exaggerated Reflexes

Protrusion of the tongue or tongue thrusting
c) impaired mobility Early pattern of hand dominance
Back Arching
d) difficulty in running and climbing Scissors-gait
 119

From Lateral Ventricle it goes to Foramen of

LAB DATA Neurological Assessment Munroe then to 3rd Ventricle then to Aqueduct of Sylvius
PExam then it moves to F. of Luschka and Magendie going to 4th
Ventricle then it goes back to subarachnoid spaces of
brain.
Nsg Dx Risk for Injury
Impaired Physical Mobility
S/S OF HYDROCEPHALUS

PI SAFETY  PROJECTILE VOMITING

 IRRITABILITY
a. Leg braces  ENLARGED HEAD – N Head Circumference : 33-
b. Meds : Anticunvulsants, Muscle Relaxants 35 cm (chest circum: 31-35 cm)
c. Prepare child for SURGERY – release of TENDON  SEPARATION OF SKULL BONES
OF ACHILLES – to promote mobility  SEIZURES
d. Refer child to : PT – for gross motor movement  SUNKEN EYES – Can Progress To Bossing Sign
– walking  MACEWEN SIGN – crack pot sound upon
OT - for fine motor – to open a bottle
knocking the head
of soft drinks

LAB DATA CT Scan

MRI
PExam – focus on head circumference
HYDROCEPHALUS
(tape measure – at bedside to
measure H Circumference)
NOT A DISEASE but a manifestation of an existing disorder
NSG DX Risk for Injury

PI SAFETY
Related to ARNOLD CHIARI MALFORMATION
Position Semi Fowler’s – to prevent increase
DANDY WALKER SYNDROME
in ICP
- there is ELONGATION of the BRAIN STEM or Medulla
- characterized by ATRESIA of
Meds Diuretics
and it protrudes to Foramen magnum
Anticonvulsants
Foramen of Luschka & Magendie
Surgery Ventriculo-Peritoneal Shunt –
progressive procedures
SIDE NOTES: FLOW OF CSF (N amt : 100- 200 ml) –
(AS
rich in glucose
CHILD AGE PROGRESSES, the surgery is revised)
 120

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. Position: Prone or side lying (NEVER SUPINE);

b. Wet sterile gauze to cover the skin;
c. DOUGHNUT ring

SURGERY WITHIN 24-48 HRS

SPINA BIFIDA – failure of a PORTION of spinal cord to fuse COMPLICATION Bladder and Bowel Problem
Paralysis of Lower Extremities

TYPES Post Surgery Complication Hydrocephalus (tape

measure- at bed side)

SB OCULTA SB CYSTICA

NO SAC W/ SAC INCREASE ICP

W/ DIMPLE or TUFT OF HAIR
SUB TYPES:  ICP above 15mmhg (N 0-10)
 Mild elevation : 11 – 20
Moderate : 21 - 30
 121

Severe : 31 and above

With the use of INTRAVENTRICULAR or SUBDURAL

MONITORING DEVICE to monitor ICP MENINGITIS
MENINGISMUS
RF Hydrocephalus
Space Occupying Lessions Inflammation of meninges w/c could be related to
Brain Tumor Inflammation of meninges but WITHOUT
Trauma the presence of bacteria esp the H. Influenza, and
infection
S/S Neisseria Meningitidis
Usually accompany w/ resp. disorder
1. INITIAL: Behavioral Changes – irritability,
restlessness,
decrease LOC – S/S of INC ICP + Kernig’s Sign – pain on extension
drowsiness or pt becomes sleepy of lower extremities
+ Brudzinkis - flexion of neck
2. Vital Signs Changes – widening pulse would lead to flexion of lower ext.
pressure - sign of MENINGEAL
DECREASE RR and PR IRRITATION
INCREASE temperature
LAB DATA Lumbar Puncture
3. Vomiting CSF Analysis

4. Monitor Abnormalities – decorticate, Nsg Dx Infection

decerebrate Risk For Injury

PI Safety
Seizure Precaution
Nsg Dx Risk for injury Tx the Infection

PI To decrease ICP Type of Infcetion:

 Head of Bed ELEVATED a. Bacterial Meningitis – respiratory of droplet precaution

 Evaluate Neuro Status – Glasgow b. Viral Meningitis - enteric precaution
 AIRWAY
 Discharge Meds Instruction MEDS Antibiotics
Anticonvulsants, Steroids, Diuretics (mannitol – to  For Bacterial Meningitis - may cause hearing
dec amt of cerebral edema) impairment - refer to AUDIOLOGIST
 Seizure precaution – DARKENED ROOM
 122

REYE’S SYNDROME CVA/ STROKE

Non inflammatory, non recurring but TOXIC ENCEPHALOPATY MP Decrease Oxygen to brain cells
and HEPATOPATHY
TYPES
(CNS) (LIVER)  THROMBOSIS
 EMBOLISM
 HEMORRHAGE
RF Presence of Viral Infection  INFARCTION
Use of Aspirin
RF
TRIAD S/S Fever atherosclerosis
Impaired Liver Funx hpn
Impaired Consciousness w/c could lead to obesity
convulsion smoking
stress
age/ gender
STAGES I pt becomes lethargic
II confusion
III decorticate rigidity SIGNS & SYMPTOMS:
IV decerebrate rigidity
V seizure or coma 1. DEPENDS ON THE PROGRESSION

a. TIA – brief period of neurologic dysfunction that last

less than 24 hrs (between episode, pt is N);
LAB DATA Bleeding and Clotting Time b. STROKE IN EVOLUTION – there s/s like: facial paralysis
Liver Biopsy Muscle weakness
Neurological Assessment - above s/s could
last 2-3 days
Nsg DX Risk for Injury c. COMPLETE STROKE – there is FOCAL s/s
Altered Thought Process
Altered Thermoregulation if R side of Brain Affected – L Eye - R Face – L Body
Impaired Physical Mobility
if L Brain – R Eye – L face – R body
PI Treatment – symptomatic – assess neuro
status 2. RELATED TO LOBES
Bleeding – give Vit K
AVOID ASPIRIN when there is VIRAL
INFECTION
 123

 FRONTAL – if affected – PERSONALITY CHANGES – mgt: talk

BROCA’S AREA (expressive aphasia – mouth opening); to pt slowly

 TEMPORAL - memory disturbances – Dysphagia instruct the pt to

WERNICK’S LANGUAGE AREA (choice of swallow twice to prevent aspiration
words, understanding - RECEPTIVE APHASIA);

 PARIETAL - DISORIENTATION – especially SPATIAL LAB DATA Increase Cholesterol

orientation;
Diagnostic Test CT Scan
MRI
 OCCIPITAL - VISUAL disturbances
EEG

Nsg DX Unilateral Neglect – inability to

care half of the body
Impaired Physical Mobility
Risk for Injury

PI SAFETY

Position Semi-fowler’s
Elevated

Meds Antihypertensive
3. SIGNS AND SYMPTOMS INDICATIVE OF
Diuretics
COMPLICATIONS
Antilipimic Agents
Anticonvulsants
Hemianopsia loss of half of the
Thrombolytics – if (+) thrombus –
visual field (eg. Pt consumes half of the food at plate);
to dissolve clots
DIET Low Na and Cholesterol
Hemiphlegia paralysis of one side
of the body;
Activity Range of Motion Exercises
Emotional Lability “mood swing”
Surgery Craniotomy
Aphasia Expressive – inability
Infratentorial Cranio – FLAT
to find right words to say (damage to Brocka’s Area);
Supratentorial - Semi-
- pt can say
fowler’s
right words – mgt: picture board

and Receptive -
inability to understand spoken words (Wernick’s area)
 124

DISEASES OF NEUROMUSCULAR : Guillain LAB DATA CSF – Increase CHON

Barre Syndrome (GBS) TENSILLON TEST – 5 mins
(to all neuromusco disorders)
Myastenia Gravis (MG)
Nsg Dx Ineffective Breathing Pattern (ALL)
Multiple Sclerosis (MS) same
PI AIRWAY (tracheostomy – bed side) – ALL
Amyotrophic Lateral Sclerosis (ALS) same
MEDS Steroids
Neostigmine – ATSO4 - antidote
GBS Avoid crowded areas : viral infection
MG Refer to NEUROLOGIST,
PULMOLOGIST and PT
 Descending paralysis – start @ upper ext.
Common in Male and Female MYASTHENIA GRAVIS
 NO gender related factor but could be related to viral COMPLICATIONS
infxn Early onset : 20-30 yo (Female)  Myasthenia Crisis (MC) - due to under
 Reversible medication or lack of meds;
Early onset : above 50 yo (male)  Cholinergic Crisis (CC) - due to over medication
– overdose
MP Inflammation that leads to destruction of Peripheral
Nerves Deficiency in ACTH Receptor Sites – 90% Signs and symptoms of above
w/c leads to: ASCENDING GBS complication:
Or Def. in ACTH – “neurotransmitter”
DESCENDING GBS MUSCLE WEAKNESS – in MC due to
Mixed Type GBS ACTH Deficiency while in
CC due to or as
ASCENDING GBS - #1 Clumsiness that eventually lead adverse effect of the drug
to S/S Muscle weakness w/c begins at face
muscle weakness & resp. depression
therefore, Diplopia and Ptosis – which Treatment : TENSILLON – effective in
MC – it INCREASE MUSCLE STRENGTH
progresses to MASK-LIKE face which lead to
Effect in CC – it
respiratory depression worsens muscle weakness once given – give ATSO4

(descending paralysis – start at face – “NO

telebabad”) NEOSTIGMINE – for MC as
TREATMENT
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(LON GAHRIG’S DISEASE)

MULTIPLE SCLEROSIS
Common among women – MP Destruction of Upper and Lower Motor Neurons;
especially white Genetically Transmitted: AUTOSOMAL
There is destruction of MYELIN DOMINANT – common in Male & Female
SHEET at CNS , therefore generalized muscle weakness
More Pronounce is DYSPHAGIA
Eg. “I know I will be
eventually confined in the wheelchair The muscle weakness – will eventually
lead to RESPIRATORY DEPRESSION
s/s of generalized muscle
weakness: FACIAL – diplopia LABDATA CSF – Increase CHON
EMG – “contract and relax” –
Impaired Cerebellar Funx needle insertion
Muscle biopsy
Ataxic Gait – “lasing”
NSG DX Ineffective Breathing Pattern
Impaired Sensation – NO HOT/COLD BATH
PI AIRWAY (tracheostomy)
Impaired Sensory Funx – impotence SUPPORTIVE
Refer to Geneticist
LAB DATA #1 MRI – specific test for MS – it localizes
the area of plaque formation or the area of dyemlination
#2 CT SCAN SIDE NOTES:

NSG DX same with GBS & MG A Recessive : Cystic Fibro, Sickle Cell,
Apalstic/Fanconis – either or both parents are (+) for
DRUGS STEROIDS trait NOT DSES
Anticonvulsants – dilantin
Muscle relaxant – Baclofen A Dominant : Retinoblastoma, ALS –
Bladder Stimulants – Urecholine either father or mother (+) for disease or trait
(bethanicol)
X Link Recessive : Hemophilia, Color
HX TEACHINGS AVOID : HOT COLD SHOWER Blindness, Duchennes Muscular, G6PD Dses – mother (+)
Refer to PT: ROM Exercises trait NOT DSES

and transmit to SON

SPINAL CORD INJURY

Destruction of S. Cord
AMYOTHROPIC LATERAL SCLEROSIS related to TRAUMA
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TYPES #3
 CERVICAL 8 – most serious – quadriphlegia slight fever
 THORACIC 12
 LUMBAR 5 what to keep at bedside: CATHETER - TO KEEP
THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS
 SACRAL 5
 COCCYGEAL 1
PI SAFETY - immobilize, surgery
LUMBOSACRAL AREA – if affected, therefore
PARAPHLEGIA – bowel and bladder problem
THORACIC - paraphlegia + bowel and
bladder problem
CERVICAL c1 – c4 - incomplete or partial
quadriphlegia
C5 – C8 - Complete quadriphlegia TIPS FOR NEURO
LAB DATA Myelogram
CT Scan
 A 10 yo is to undergo EEG, w/c comment made by a pt
Xray
demonstrate that she understands the procedure – “I will
wash my hair after the procedure”;
Nsg Dx Risk for Injury
Impaired Physical Mobility  A pt w/ tumor of the frontal lobe will most likely
manifest – difficulty in concentrating;
PI SAFETY  A pt w/ M. Sclerosis has urinary incontinence. To
achieve voiding, w/c nsg care shld the nurse give –
a. Immobilize the spine – side lying w/ pillows bet establishing regular voiding sked;
legs  While interviewing a pt. w/ Myasthenia gravis, w/c of
b. Surgery 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 –
COMPLICATIONS OF SPINAL INJURY : Ineffective Breathing Pattern
AUTONOMIC DYSREFLXIA – due to full bladder and bowel

s/s : #1
INITIAL : HPN
#2
Diaphoresis
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MP Maldevelopment of the Hips – that involves the

acetabulum, head of femur or both

S/S Extra Gluteal Fold – at affected side;

Ortoloni’s Sign – (+) Click
Trendelenburg Sign or Pelvic Dropping – when
child stand in one foot toward the affected side,
MUSCULO then there is
change in length
CLUBFOOT DEFORMITY Alli’s Sign or Galleazi’s Sign – shortening of the
MP Congenital affected leg
Foot twisted out of place

Types LAB DATA PExam

Talipes Varus – “inversion” Barlow’s Manuever – press leg downward – (+)
Talipes Valgus – “eversion” click
Talipes Equinus – “tiptoe” Ortolani’s – abduct leg sideward – (+) click

LAB DATA PE
Xray Nsg Dx Impaired Physical Mobility

Nsg Dx Impaired Physical Mobility PI #1 Double or triple diaper – to keep legs in

abducted position;
PI Promote Mobility #2 PAVLIK Harness - for 2-3 mos
#3 Hip Spica Cast LAST RESORT
#1 MANUAL MANIPULATION
#2 SEREAL CASTING – every 1-2 wks til NO ADDUCTION OF LEGS!
position normalizes
#3 DENNIS BROWN SPLINT – 2-3 months
CAST : assess for s/s of neurological damage:
Capillary refill – if more than 3 sec. - REPORT

EDEMA
FRACTURES
Skin Color/ nailbed
MP Break in the continuity of the bone
TYPES Open (compound) – bone tears the skin –
therefore open: risk for infection
CONGENITAL HIP DISLOCATION CLOSE – skin intact

 AVULSION – tear in the tendon

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 COMMINUTED - fragmented
 COMPRESSED – crushed
 IMPACTED – driven to each other
SCOLIOSIS
 DEPRESSED – pressed
MP Lateral Deviation of the Spine
 SPIRAL – goes around the bone
RF STRUCTURAL – non correctible
 GREENSTICK – incomplete FUNCTIONAL - correctible

S/S #1 Deformity OUSTANDING S/S

#2 Pain
#3 Edema  Uneven Hemline;
#4 CREPITUS – sound created when two bone  Uneven waistline;
surface rob each other  Uneven shoulder
 (+) Rib Hump
NSG DX Impaired Physical Mobility
 Prominent Iliac Crest
PI MOBILITY – immobilize the fx

a. Splinting; LAB DATA Bend Over test – instruct to touch the

b. Casting – check for edema – elevate the affected toes and note for rib hump
areas; Xray
- check skin color – capillary refill time
- check for presence of blood stained Nsg Dx Impaired Physical Mobility - child
Body Image Disturbance - adolesence
c. After cast, - CRUTCH WALKING

 2 point gait – indicated if both lower extremities has TX a. To decrease curvature – wear BOSTON or
MILWAUKEE Brace
partial wt bearing;
– for 23 hrs/day except
 4 point gait – indicated for partial wt bearing;
bathing
 3 point gait - indicated if 1 leg is allowed partial wt
bearing and b. SURGERY – HARRINGTON ROD
the other one is N; - LUQUE
 swing through - when both legs need to moved past
the level of the crutches HX Teaching
 swing to – when both legs need to be moved AT THE Avoid : Bending
LEVEL OF THE CRUTHES Jumping Rope
Playing Tennis
going upstairs – unaffected then crutch Trampoline
(goodleg – crutch – bad)
Allowed: Brisk Walking
going down – crutch then bad leg – then good Swimming
leg
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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
Dowager’s Hump
Short Stature ARTHRITIS
Progressive Decrease in Height
RHEUMATOID GOUTY
LAB DATA Decrease in Calcium OSTEOARTHRITIS
Bone Densinometry
Bone Scan Common FEMALE MALE
Xray MALE/FEMALE

Nsg Dx SAFETY Affected Part Upper Extremities Lower

Extremities wt bearing joint
How?
MP
 DIET : High Ca especially 4 those with –
OSTEOPOROSIS Chronic, systemic inflammation of connective
- spinnach tissues
- seafoods Synovial joints and joints of Upper
- sardines extremities

 ACTIVITY : Partial Weight Bearing (NO SWIMMING) S/S PAIN

– jumping rope Inflammation
- bicycle reading Morning Stifness
- brisk walking
Stages of Rheumatoid A.
 MEDS : Ca Supplement - alendronate
Fosomax – SIT UPRIGHT AFTER  STAGE 1 – no Disability
 STAGE 2 – with Interference To ADL
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 STAGE 3 - with major compromise of funx Diet : Low Purine/ Purine Restricted:
 STAGE 4 - incapacitation AVOID : Organ Meats

SEAFOODS
ULNAR DRIFT SWAN NECK
DEFORMITY Alcohol

LAB DATA Decrease HgB ALLOWED: Cheese (EXCEPT

Increase ESR fermented and Aged)

Nsg Dx PAIN Increase ORAL Fluid Intake

Impaired Physical Mobility

PI Relief of Pain
a. Warm Bath; OSTEOARTHRITIS
b. MEDS : ASA - Antiinflammatory
STREROIDS A degenerative joint disease that involves the weight bearing
c. exercise: ROM joints – elbows & knees

S/S PAIN – NO inflammation

Bouchard’s Nodes (distal)
GOUTY ARTHRITIS Heberdene’s Node (proximal)

MP Metabolic disorder of purine w/c leads to deposition or LAB DATA

uric acid at joints
site: THE GREAT BIG TOE xRAY

S/S (+) PAIN – usually aggravated by pressure Nsg Dx PAIN

(+) Inflammation Impaired Physical Mobility
- above s/s affects the LOWER EXTREMITIES
PI Weight Control

LAB DATA Increase Uric Acid Health Teaching Hot or Cold Compress
ASA
NSG DX PAIN Trunk Assistive Device (cane)
Impaired Physical Mobility

PI Relief of PAIN

Meds : Allupurinol, Probenecid SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

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Autoimmune multi system dses characterized by

inflammation of connective tissues

JOINT : (+) pain, (+) morning

stiffness; TIPS FOR MUSCULO
CARDIOVASCULAR : (+) chest pain;
CNS : (+) s/s of dec LOC,  the priority nsg care for the pt w/ bucks extension
Irritability, Headache traction shld be – ensure that the traction applied to the
affected leg is always attached to the weight;
OUTSTANDING S/S BUTTERFLY RASH (also present in pt in
PROCAINAMIDE TOXICITY)  pt in russel’s traction is being taken cared of by the
nurse, it would be necessary for the nurse to intervene if –
LAB DATA Increase ESR the pt feet are pressed against the foot board;

Nsg Dx PAIN  a pt is using CRUTCHES for the first time, w/c action
Altered Tissue Perfusion reflects a need for further instruction – the pt bears his/her
Risk For Injury wt with his/her axial;

TX Symptomatic/ Supportive – meaning, treat  a pt on buck’s traction of the R femur ask the nurse
available s/s how he can possibly move around. What can the nurse
advise the pt – you can hold on to the trapeze bar while
Drugs Steroids moving;

 w/c of the ff can possibly indicate the presence of

abnormality in an adolescent – uneven hemline –
TRACTION scoliosis;
PRINCIPLES T – rapeze bar  when assessing an infant, w/c of the ff needs to be
R – equires free hanging weights reported – extra gluteal folds;
A – nalgesic
C – iculation monitoring  post spinal fusion –ROBAXIN –is given for w/c of the ff
T – emperature monitoring
purpose - to decrease muscle spasm;
I - nfection prevention
O – utput and input monitoring
 a child has hip spica cast upon discharge, w/c
N – utrition
statement of the father indicates further instruction – “ I will
S – kin Assessment
hold on to the bar bet his legs to help move him”
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BURNS

Traumatic injury to the skin brought about by : FIRE

CHEMICALS
PROLONGED
EXPOSURE TO SUN
ELECTRICAL CURRENT
HOT H2O

CLASSSIFICATION:

According to Damage

 PARTIAL THICKNESS – FIRST DEGREE

2ND DEGREE

 EPIDERMIS EPIDERMIS & PART OF

DERMIS
 Pain Redness
 Redness Blister Formation
 Eg sunburn pain

 FULL THICKNESS
THIRD DEGREE 4TH DEGREE

 SUB Q FATS SUB Q

FATS
 MUSCLES
MUSCLES & BONES
 LEATHERY APPEARANCE
CHARRED APPEARANCE
 NO Pain No
Pain

MINOR
INTEGUMENTARY SYSTEM MODERATE MAJOR

Burn – triage : face and perineum (priority) PARTIAL TICKNESS less than 15%
15-25% 25%
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FULL THICKNESS NONE <10%

>10%
LYME’S DISEASE Rocky
Mountain Fever
RULE OF 9 – CHECK NOTE day 9 page115

caused by BORRELIA BURGDORFERI (deer

ticks) Dermacentor/ Variabilis – dog ticks
BURN TRIAGE
3-30 days
Priority : Burns of FACE or Dermacentor Andersori (wood)
PERIMEUM
UPPER & LOWER EXT 2-3 wks
Burn related to Child Abuse
Chemical – Fire

THINK: R escue s/s : Fever, Pain, Chills,

A larm Rashes
C onfine the Fire
E xtinguish the Fire RASHES: Bull’s Eye Rash or Rounder Rings
Generalized rashes
At moist body parts
PRINCIPLES OF NSG CARE FOR BURN PTS:

 B – reathing – Airway Complications

 U – rine output monitoring
 R – esuscitation of Fluids Cardio, Musculoskeletal and CNS
 N – utrition - which can lead to paralysis
 S – ilvadene Ointment
TX Avoid wooded area – “have you
been to the woods?”

PI Vaccination
DIET DAT (High CHON, Ca, Vit C) Use long sleeve
Remove ticks w/ twizers – upward
Complication FIRST 24HRS – SHOCK straight motion
72Hrs - INFECTION
Meds Chloramphenicol
Pt Preparation : Bed Craddle Tetracycline
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Causative Agent Herpez Virus Measle Virus

DERMATITIS Rubella Virus

INC PERIODUnknown 10 -20 days

DIAPER (contact) 14 -21 days
ATOPIC ECZEMA (adult)

Peak : During infancy – 9-12 mos

Cause : Hereditary s/s FEVER and RASH
Due to prolonged exposure to urine, soap &
excreta Prone to asthmatic patients
RASH Non Pruritic Begins w/
face & downwards Face & downwards
S/S : RASH Rose pink – begins w/ trunk
RASH + scaling, Progressing outward

Crusting
With KOPLICK’S
Pruritus or itching SPOTS + same
3 C’s : Coryza
Viscicles Cough
Conjuctivitis

Management: Hydrate the skin w/ cold compress MANAGEMENT: (to all types)

Meds: Bed rest

Benadryl (antihistamine) Antibiotics
Antipyretic

SYPHYLLIS GONORRHEA
ROSEOLA RUBEOLA HERPEZ
RUBELLA
C Agent T Pallidum N Gonorrhea
Exanthem MEASLES Zoster Simplex
GERMAN MEASLES
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I. Period 10-13 wks 2-7 days

Vericella Zoster Virus Herpes Simplex Viruz

TRICHOMONIASIS
MONILIASIS/CANDIDIASIS

Abdominal Oral Herpez Genital H Caused by TRICHOMONAS Vaginalis

Albicans

Both are STDs

2-12 days vesicle
Charac of discharge : Greenish/ Yellowish
Steroids WHITISH-CHEESELIKE discharge
With FOUL ODOR

Around the mouth Inner thigh Inc Period 4 – 20 days 2

– 5 days
Buttocks
Druf pf Choice Flagyl
Genitals Amphotericin

Acyclovir

Cervical Ca – complication of Herpez

Annual pap smear

TIPS

 A nurse admits 8yo brought by her mother. Upon

assessment, the nurse finds rounded rings of rash. This is
indicative of – lyme’s dses;

 During the immediate 24hrs pot burn, w/c of the ff is

the priority – administration of fluis;
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 A pt tells the nurse that he notice small blisters on his

private parts. This is indicative of – HERPEZ RF Smoking : Lung, Bladder and
Laryngeal or Oral CA
 A pt with CA of the cervix was admitted with the ff
data: w/c one indicates a possible risk factor – previous tx for RACE : Jewish – Breast
herpes; Blacks - Cervix and
Prostrate
 w/c of the ff indicates effective tx of gonorrhea – (-) Whites – Testes
purulent discharge;
PARITY : Nulliparity –
 a pt is diagnosed w/ herpes zoster, w/c of the ff is the breast having baby after 35 yo
priority nsg dx – PAIN; Multiparity – cervix

 w/c of the ff is indicative of CHLAMYDIASIS – burning DIET : High Fat and Low
on urination 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

CANCER
BOTH MALE AND FEMALE
Cause Unknown Theory of USE -
Overuse, Underuse, and Abuse  Digital Rectal Exam 40 and above –
ANUALLY
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 Sigmoidoscopy ANUALLY after TESTICULAR crytorchidism, spongy

age 50yo testes or lump (N – smooth unequal)
 STOOL FOR OCCULT BLD Annually after age 50 yo

Nsg Dx Initial :
Knowledge deficit
If pt is TERMINALLY ILL :
HOPELESSNESS TIPS FOR CANCER
If pt has some wishes or
Unfulfilled needS :  w/c nsg dx is a priority for a pt undergoing
Powerlessness chemotherapy – SOCIAL ISOLATION;

Nsg Care Principles :  when undergoing chemotheraphy, w/c solution is used

for mouth care – HYDROGEN PEROXIDE;
C hemotherapy – target cells :
those rapidly dividing cells;  w/c of the ff is an appropriate diet for pt undergoing
A sess Body Image chemo – bland diet;
N tuition/diet : high CHON, well
balance  the most common sign of Breast Ca is in – upper
C aution pt on s/s outer quadrant;
E xercise
R est  pt w/ CA of esophagus will manifest – DYSPHAGIA

COMMON S/S

LARYNX change in
VOICE or Hoarseness
LUNGS changing TIPS FOR PSYCHE
cough or smoker’s cough (productive)
STOMACH dyspepsia
BREAST a lump or a  A pt w/ chronic depression is to undergo ECT, the
discharge purpose is to – relieve the symptoms of depression;
OVARIAN complains feeling of
fullness or indigestion  A nurse shld assess the pt w/ ALZEIMER’S DSES for
CERVICAL “bleeding” possible change in – orientation;
PROSTRATE elevated acid
phosphatase, nocturia  A pt w/ bipolar episodes is ready for discharge when –
COLON change in she can comply with units activities;
bowel habits
Hodgkin’s Dses painless
enlargement of lymph nodes
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 The nurse would suspect that the child is a victim of

abuse if he – keeps quiet while an IV is inserted;  the nurse notes mirror image in the fetal monitor –
this could be related to FETAL HEAD COMPRESSION;
 w/c of the ff situations reflects an increase in self-
esteem of an abuse child - when he ask the nurse for a  which of the ff is related to trauma – ABRUPTIO
plastic cup to drink; PLACENTA;

 the initial care plan for a pt with Anorexia Nervosa  A nurse is caring for a woman in first stage of labor,
would require the pt to – remain in public place 1 hour she is timing the duration of contraction – she is correct
after meals; when she times it from the beginning of one contraction
to the end of same contraction
 where shld the nurse put the pt on early alcoholic
withdrawal – well-lighted room near nurses station

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
TIPS FOR OB-GYNE

 A Mother Is Crying Besides her baby, she said “I feel

so sorry I couldn’t 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;
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Paralysis of Lower