1

NCLEX REVIEW GAPUZ REVIEW CENTER

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

DAY 1 (31 JANUARY 05)

STEPS IN PASSING

Have a Right Attitude

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

MOSBY
growth and development
LIPPINCOTT care of the Elderly and Communicable Disease
DIGOXIN monitor the creatinine the TV DOESNT look good to me
(DIGOXIN TOXICITY nausea/vomiting, abdl cramps)
Olive = butter
CK
LDH

normalize 1 3 days after MI

- 10 14 days

ATRIAL FLUTTER SAW TOOTH

PROCESS OF ELIMINATION

consider MASLOWs H of NEEDS

consider the COMPLICATION whether ACUTE

ALWAYS prioritize
CHRONIC

ABCs

SAFETY FIRST

NSG PROCESS

MMR VACCINE only vaccine for HIV pt.

Pt on HEPARIN APTT (N 30-40sec), therefore if INCREASE
bleeding

2.
TODDLER falls
3.
SUPRATENTORIAL craniotomy semi fowlers
position
INFRATENTORIAL flat in bed
4.
5.

SCATTER RUGS osteoporosis pts.

TRIAGE ; burns, open fx SHOCK

Things NOT TO BE DELEGATED by RN:

Assessment, Teachings, Evaluation

POISON - nursing action in order :

#1 CALL poison control center
# 2 MINIMIZE EXPOSURE of pt to poison pull him/her
away from the poison
# 3 IDENTIFY the poison

Pt 50y/o and

GENTAMYCIN s/e tinnitus, vertigo, ototoxicity, oliguria

Pt with Rocky Mountain Fever exposure to dog ticks

Lymes Dses deer ticks

LITHIUM CARBONATE for ELDERLY : N level NOT more

than 1.0meq/L
ADULT : N .5 1.2 meq/L
HEPA B diet : low fat, increase CHON
DOWN SYNDROME large tongue feeding problem poor
sucking (infants)
SAFETY PRINCIPLE
1. when can a child USE ADULT SEAT BELT?
- if the infant is 40 lbs and 40
inches in height
seat belt location in car: BACK CENTER
SEAT

- mammogram once a year.

Pt with PKU LOW PHENYLALAMINE DIET (NOT phenyl

FREE).
therefore LOW CHON

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

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COMPLICATIONS: bubbling, breakage, blockage
Nsg ALERT:
TUBES
1. GROSHONG CATHETER
HICKMAN
BROVIAC

- 2 lumen
- 3 lumen
- 1 lumen

ALL requires Central Venous Access

sites: cephalic, brachial, basilica and superior
vena cava
PURPOSE: For TPN
Administration of Chemo Agents,
Blood Products, Antibiotics
COMPLICATION: Thrombosis and Bleeding
2. CHEST TUBES Water Sealed Drainage
Types: Anterior w/c drains AIR
Posterior - w/c drains FLUIDS
Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle
system
1 BOTTLE
emerge)

2 BOTTLE
emerge),

3 bottle

3 5cm of only (length of tube to be

NORMAL : BUBBLING is N in the 3rd bottle it

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

ABNORMAL : if bubbling occurs at the 2nd

bottle indicates LEAKAGE action, check sealed at air tight
container and the pt and bottle connection.
In case there BREAKAGE, have extra bottle and emerge
tube ASAP to prevent entry of air and or may use forcep to
clamp tube temporarily.
If pt. ambulates, keep bottle LOWER than the patient.
ABSENCE of OSCILLATION at the 2nd Bottle indicates
blockage
TOWARDS THE BOTTLE - When MILKING the tubings.
EMERGENCY EQUIPMETS AT BEDSIDE: xtra
bottle,clamp, gauze
3.
TRACHEOSTOMY TUBE
to maintain patent airway for pt w/ neurological
problems and musculoskeletal disorders.
nursing care:

First bottle drainage bottle (no tube

2nd bottle - long rod 3-5cm
FREQUENTLY USED
1st bottle drainage
2nd bottle water sealed
3rd bottle suction bottle control

1. Suctioning 10-15seconds
- if (+) bradycardia, STOP
- if accidentally dislodge, insert obturator to
keep it open
2. AVOID: water sports swimming
3. In changing ties insert new one first BEFORE
REMOVING old tie.

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4. Ribbon or ties @ side of the neck only to avoid pressure.
5. Before and After suctioning hyperoxygenate the patient.

4. PTCA
enlarge the passageway for bloodflow.
problem: spasms that lead to arrhythmia
C-STENT (cardiac-stent) alternative to PTCA
Maintains patency of bld vessels
Problem: dislodge
IABP (Intra Aortic Balloon Pump)
- for Cardiogenic Shock
problem: thrombus formation, infection and
arrhythmia

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

6. NASO GASTRIC TUBE stomach and intestine

(duodenum)
Types:

Levine Tube for stomach

- 1 lumen, for lavage (cleaning) and
gavage (feeding)
Salem Sump for stomach
- 2 lumen (I for suctioning, I for
lavage/gavage)
- if pt (infant) is having enteric
coated meds, request for
change in form of meds

Miller Abbot for intestinal (w/ mercury b4

injection)
- 2 lumen (insert then inject the
mercury)

Cantor for intestinal

- 1 lumen

Nursing Care for NGT:

1.
tip of nose to earlobe to xyphoid process (for stomach)
2.
tip of nose to earlobe to XP + 7-10 inches for
intestinal NGT
3.
accurate means to verify correct placement: ALWAYS
consider Two checking criteria: ASPIRATION and Gurgling
Sounds
Report the following:
If (-) or decrease drainage,
(+) nausea and vomiting
(+) abdml rigidity
Characteristic of Gastric Residual: more than 50 mo and
coffee ground.
Before feeding check for placement.

7. GASTROSTOMY TUBE (GT)

PEG

both for NUTRITIONAL PURPOSES

n/v

GT incision (abdomen to stomach)

for pt (+) lesion at esophagus
nsg care : report s/s of infection, abdl cramps,

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-

provide adequate skin care

PEG incision at skin

long term therapy

Characteristic of drainage 2-3 days after surgery (bloody to

pinkish) NO NEED TO REPORT THIS
it is expected

8. T TUBE
- to drain excess bile until hearing occurs
- place drainage bag at the level of t-tube
(obstruction of t-tube there will be excess drainage)

11. SUPRAPUBIC CATHETER for genito urinary problem

- inserted directly at the bladder wall
- check if properly anchored

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)

system

pressure.

BOTH used as close wound drainage suction

BOTH system function on the system of (-)

JP compress the container before attaching to the

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

10. THREE-WAY FOLEY

absence of clot effective

SENGSTAKEN BLAKEMORE TUBE

3 lumen ( for esophageal balloon, gastric
balloon, for meds)
for pt w/ esophageal varices
balloon tamponade
48 hrs keep balloon inflated for 10 minutes to
decrease bleeding
LINTON TUBE 3 lumen
MINESOTTA TUBE 4 lumen

SCISSORS important EQUIPMENT AT BEDSIDE

FOR ALL TUBES.

HEMOSTAT important instrument that shld be @

bedside for water sealed drainage.

Persistent bubbling at water drainage bottle for

bottle #2 check if tubing is properly sealed.

NGT IS REMOVED if patient exhibits return of bowel

sounds.

BULB SYRINGE use to clean the nares of pt with NGT

(child)

To facilitate removal of air at lungs purpose of water

sealed chamber in 3 way bottle system.

THERAPEUTIC DIET
GENERAL CONSIDERATION

Know the DIAGNOSIS of the patient

Identify & incorporate the pt. dietary preferences

Instruct pt on what to avoid

For pregnant pt, note dietary changes:

a.
addtl calories (300 cal/day) average of 2400 2700
b.
addtl of 10gms/day for CHON
c.
IRON : 15-30mg/day
d.
CALCIUM : RDA is 1000 then +200mg/day
(broccoli,tuna,cheese)
e.
Galactogogues increase production of milk

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

TRANSCULTURAL CONSIDERATION

CHINESE like cold desserts after surgery for

optimum health

JEWS kosher diet (no meat and diary products

at the same time)

EUROPEANS main meal is served at mid day

followed by espresso

MUSLIM halal diet no pork

SDA strictly vegs diet (vit B6 and B12 deficiency)

MORMONS

words of wisdom (no caffeine, alcohol and

once a month fasting)

the amount due for food is donated to the

church

KEY POINTS FOR NURSES

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

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

MOST COMMON DIET

CLEAR LIQUID DIET (light can pass thru it,

meaning TRANSPARENT)

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- given to pt to relieve thirst, correct fld & electrolyte
imbalance
- given also to pt post-op
ex: apple juice, gelatin (strawberry), popsicle, candy

RENAL DIET

for kidney disorder (renal failure, AGN,

Nephrotic syndrome)
to maintain fld & e imbalance

LOW CHON avoid poultry products

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

PURINE RESTRICTED DIET

for gouty arthritis

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

NA RESTRICTED DIET

salty foods

LOW FAT/CHOLESTEROL RESTRICTED DIET

for liver disorder, cardiovascular and renal dses

ALLOWED: lean meat, fruits, vegs and fish
AVOID
: Sea foods, fried foods, preserved foods (cheese
cake and custard)

HIGH FIBER DIET

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

for cardiovascular dses, renal, fld & e imbalance

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

BLAND DIET

for peptic ulcer, inflammatory GI conditions

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

tissues

HIGH PROTEIN, HIGH CARBO DIET

for burns (about 5000 cal/day)
grain products and poultry to aid the healing

SOFT DIET

for inflammatory conditions: esophagitis, peptic

ulcer gastritis
pureed foods/ blenderized foods
soup

ACID ASH DIET

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-

to decrease the ph of the urine

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

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

ALKALINE ASH DIET

to increase ph of the urine

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

GLUTEN-FREE DIET

PHENYLALANINE DIET

FULL LIQUID DIET

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

ABGs

Uncompensated
abnormal
Partially compensated abnormal
decrease
Fully Compensated
normal
decrease

no change
increase or
increase or

Diarrhea metabolic acidosis

Vomiting metabolic alkalosis

for celiac dses

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

for PKU, until age 10 and adolescence only

AVOID : CHON rich foods (meat products
luncheon meat)

Compensatory

Mechanism

ATERIAL BLOOD GASES

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

APGAR SCORING

Appearance
pink
Pulse
>100
Grimace
vigorous

pallor

acrocyanosis

all

(-)

<100

(-)

grimace

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Activity
flaccid
flexion & extension
Respiratory
(-)
lusty cry

some flexion
irregular

T.R.I.A.G.E -prioritizing

3.
pt ask what procedure: Rn Action : notify the
doctor
4.
MI attack 1st action : report ASAP (esp. presence
of vent. Fibrillation)
5.

pt on NGT check patency of tube

LEVEL 1 emergency

severe shock, cardiac arrest, cervical spine injury,

airway compromise, altered level of consciousness, multiple
system trauma, eclampsia
LEVEL 2 urgent (stable)

can be delegated (fever, minor burns, lacerations,

dizziness)
LEVEL 3

chronic/ minor illness (can be delegated) dental

problems, routine medications and chronic low back pain

DELEGATION
do not delegate Assessment, Teaching and
Evaluation
do not delegate meds preparation,
administration, documentation
CONCEPT OF DELEGATION

consider the competence of personnel

5 Rs in delegating (RIGHT task, person,

circumstances, direction/communication supervision)

RN may delegate feeding client, routine vital sign

(pt w/ no complications)
and hygiene care

TIPS ON PRIORITIZING
1.
2.

PT @ ER sleeping pills overdose;

pt bp 80/30 & mother died of CVA
1st priority : assess pt for addtl risk factor;

MI ATTACK enzymes to increase IN ORDER #1

myoglobin
#2 troponin
#3 CK
#4 LDH

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RISK FOR INJURY
menieres dses
INEFFECTIVE BREATHING PATTERN myasthenia gravis
ALTERED TISSUE PERFUSION pt w/ complete heart block
INEFFECTIVE AIRWAY CLEARANCE pt w/ kussmauls
breathing
D

APPENDICITIS

Unruptured : any position of comfort

Ruptured : semi to high fowlers position to prevent the
upward
spread of infection
complication: peritonitis
Ruptured appendicitis indication: pain decreases or go away.
(pt say, I want to go home pain is gone)

POSITIONING FOR SPECIFIC SURGICAL CONDITION

Positioning independent nsg function
know the purpose of the position
a.
to prevent or promote soothing;
b.
what to prevent or promote;
c.
know your anatomy & physiology
Post Liver Biopsy R side lying to prevent
bleeding
(during the procedure L side lying).

BURNS

Position is FLAT or Modified Trendelenburg to prevent

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

Hiatal Hernia upright to prevent reflux.

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

CAST, EXTREMITY

Elevate the Extremity to prevent edema (use rubber pillow)

Nsg care:
a. capillary refill N 1-3 seconds only (complication:
altered circulation)
b. note for s/s of infection (when there is musty odor inside
the cast)
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.

CRANIOTOMY

Types:
a.
Supratentorial C semi fowlers orlow fowlers
position to prevent
accumulation of fluid at surgical
site;
b.

Position: to prevent subloxation (KEEP LEG ABDUCTED) with

the
use of wedge pillow or triangular pillow from
perinium to
the knees.
dumping syndrome : flat

Infratentorial C - flat or supine. Purpose: same

HIP PROSTHESIS

FLAIL CHEST

(+) Traumatic Injury paradoxical chest movement areas

of chest GOES IN inspiration and OUT on Expiration

LAMINECTOMY

STRAIGHT

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

ALIGNMENT
AVOID: hyperflexion, hyperextension and prone
it causes
hyperextension of the spine.

position: towards the affected side to stabilize the chest.

GASTRIC RESECTION

to prevent dumping syndrome usually for 10

mos only NOT LIFETIME disorder (post gastrectomy)
position : LIE FLAT for 1-2hrs post meal

LIVER BIOPSY

before LB : supine or L side lying to expose the

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

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LOBECTOMY

inside)

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

position : semi fowlers position to promote
lung expansion

MASTECTOMY

removal of breast
elevate or extend affected arm to prevent lymp
edema (or elevate higher that the level of the heart.
AVOID: venipuncture, specimen taking, blood pressure
ON THE AFFECTED
ARM coz there is no more lymph node w/c predispose pt
to bleeding.
Post mastectomy Exercises: squeezing exercises, finger
wall climbing, flexionextension (folding of clothing,
washing face,
vacuuming the house)
Due to removal of axillary lymph node, avoid also gardening
and hand sewing

RESPIRATORY DISTRESS

Adult : Orthopneic position over bed table then lean

forward
Pedia : TRIPOD lean forward and stick out tongue to
maximize the
Airflow

RETINAL DETACHMENT

to prevent further detachment, place pt on the

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

PNEUMONECTOMY

either L or R lung. Position pt on the AFFECTED

SIDE to promote
lung expansion.

AVOIDE SEX (may burn penis bec of the implant

RADIUM IMPLANT OF THE CERVIX

dislodge.

keep pt on complete bed rest to prevent

VEIN STRIPPING

keep extremities extended then elevate the

legs at level of the heart to promote venous return

TIPS

liver biopsy is done on a pt. during 1st 24hrs after

the procedure, turn the pt on his abdomen w/ pillow under
the subcoastal area;

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a pt is about to go on thoracenthesis - how shld the

nurse position the pt? sitting w/ a arms resting on the
overbed table;

1.
DONT ASK WHY this put pt on the defensive
2.
AVOID PASSING BACK I will refer you to.
3.
DONT GIVE FAKE REASSURANCE everything will be
alright.
youre in the
hands of the best
4.
AVOID NURSE CENTERED RESPONSE I felt same
too
I had the
same feeling.

to maintain the integrity of pt w/ hip prosthesis

abduction splints

In GROUP DISCUSSION nurse is just a facilitator let the

group decide, he/she channel are concern back to the group.

immediately after supratentorial craniotomy- fowlers

position

THERAPEUTIC PHRASES
it seems you seem.
- open ended question
- close ended for manic pt and pt in crisis
- direct question- for suicidal pt

when draining the L lower lobe of the lung the pt

shld be positioned on his R side w/ hip higher or
slightly higher than the head;

after tonsillectomy position: prone

best position for pt in shock supine w/ lower

extremities elevated

THERAPEUTIC COMMUNICATION
ISOLATION PRECAUTION
RESPIRATORY
OPTIONAL

OPTIONAL

Purpose : to isolate infection transmission

(AIRBORNE: BEYOND 3FT
DROPLET : W/IN 3FT)
TYPE
WASHING

GOWN

PRIVATE ROOM
HAND
GLOVE
MASK

STRICT
(airborne dses, direct contact-Diptheria)

TB
OPTIONAL

OPTIONAL
(negative airflow room)

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CONTACT
(direct contact NOT AIRBORNE DSES)
eX SCABIES
ENTERIC
X
OPTIONAL
OPTIONAL
(fecal contamination)
DISCHARGE

X
OPTIONAL
(drainage: pus ex burn pt)
UNIVERSAL
X
(AIDS, HEPA b TRANSMITTED
BY BLD AND DODY FLUIDS)

OPTIONAL

TIPS:

When implementing universal precaution, w/c nsg

action require intervention: recapping the needle this
might prick your hand;

When discarding the contents of the bed pan use by a

pt under enteric precaution GLOVE IS NECESSARY;

A nurse is giving health teaching to the parents of

child with scabies: family member must be treated;

Preventing pediculosis in school age children:

avoiding contact w/ hair articles of infected children
like clips, head bands, hats no sharing

Patient with full blown AIDS is placed on isolation

precaution pt ask nurse why his visitors is wearing mask
response: it will help in the prevention of infection;

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

isolation precaution remains until 24hrs after
initiating antibiotic therapy

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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:
pt for IVP :
assess for allergy (cleansing enema
b4 the procedure)
pt for KUB :
no dye (dont assess for allergy)
schilling test
:
24hr urine specimen
USG
:
no consent required
GENERAL CONSIDERATION

EXPLAIN the procedure to the pt (initial nsg action)

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

WITH CONSENT

Check pt for CONSENT if INVASIVE

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

NON INVASIVE NO CONSENT

needed

CONTRAST MEDIUM check for allergy

For procedure requiring anesthesia

KEEP PT NPO B4 PROCEDURE

DELEGATION and DOCUMENTATION

Delegation assessment, monitoring and evaluation of
treatment

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

monitor the baseline FHR then induce fetal

movements by (HOW) :

Documentation type of treatment and any untoward

reactions.

then check FHR, NST is (+) if FHR increase at least 15

beats/min than the baseline. (ex. 140 FHB baseline, then
after challenge it increase to 155)

KEYPOINTS FOR NURSES

Prepare the patient;

Monitor for adverse reaction;
Report complication to the doctor

FRAMEWORK includes the Purpose, Special Consideration

and Interpretation

DIAGNOSTIC TESTS (to evaluate FETAL GROWTH AND

WELL-BEING)

DAILY FETAL MOVEMENT

Purpose : to determine fetal activity by counting fetal

movements
usually perform by pt himself
N Fetal Movement 10-12 for 12 hr period (average: 1
movement/hr with
average 3fm/hr)

NON STRESS TEST (NST) correlates fetal heart

rate w/ fetal movement

a.
b.

ring a bell
feed the patient

POSITIVE result means, BABY is REACTIVE (good condition)

and no need for contraction stress test/oxytocin challenge
test coz baby is OK and doing well.

CONTRACTION STRESS TEST (oxytocin challenge

test)
correlates FHR with uterine contractions
pt on NPO
get baseline FHR then induce uterine
contraction
HOW:
Thru breast stimulation it triggers the release of
oxytocin from pituitary gland If (-) patient is given Oxytocin
onset is 20-30 minutes. Then check FHR and note the
presence of DECELERATION (slowing of FHR)
types of deceleration
a.
early deceleration indicates head compression
(MIRROR IMAGE)
b.
late deceleration indicates placental insufficiency
(REVERSE MIRROR IMAGE)
mgt: L Lateral Recumbent Position, Administer O2,
Treat Hypotenson
c.
variable deceleration due to cord (image: U or W
shape) and slowing of FHR can occur
anytime.

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

AMNIOCENTESIS AMNIO
PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING PUBS
CVS
PUBS

BIOPHYSICAL PROFILE

CRITERIA

to determine fetal well being w/ the use of 5

fetal breathing
movement
heart tone
reaction to NST
amniotic fld volume

2
2
2
2
2

points
points
points
points
points
10 points

score below 6, indicates fetal jeopardy

AMNIO

Purpose: to detect chromosomal

Purpose : same
w/ CVS
Purpose: to check chromosomal
Aberration
aberrations, & presence of RH
(eg. Down syndrome, Trisomy 21)
Incompatibility
Done in 1st trimester
can be done on the
2nd wk (14-16 wk)
Extract blood at umbilical cord
(can be done as early as 5th wk but
- but not
recommended bec. of danger
then it is tested if it really
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
structural abnormalities
position of baby
- for pregnant: site is lower abdominal USG
types:
a.
b.
-

Upper USG NPO

Lower USG - NPO
preparation: increase fluid intake (oral)
NO consent needed
If pt ask if it is painful: NO PAIN;
Pt shld have full bladder

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

purpose: to detect fetal
maturity (FLM)
Get sample at chorion (by 10-12wks
thru
monitoring of L/S Ratio N 2:1
The placenta matures, get some sample)
(if mother is
(+) DM LS ratio is 3:1)
This procedure also check level
of alpha-feto
Protein if
INCREASE spina befida;
If DECRTEASE down
syndrome

CHORIONIC VILLI SAMPLING CVS

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(+) Consent invasive
(+) Consent
Bladder : Empty
Gestation

(+) Consent

consider the Pt Age of

(if age of gestation :

is higher than
20wks and above : empty bladder,
if AOG is 20wks
and below : full bladder

after amniocentesis w/c of the following

manifestation if observed by the nurse on the patient that
needs to be reported : bleeding;

pt ask the nurse what deceleration

means it refers to slowing of babys heart rate;

USG DEVICE

before Amniocentesis, what to check

COMPLICATIONS of CVS, AMNIO & PUBS:

a.
b.
c.
d.

infection
bleeding
abortion
fetal death

TIPS

EARLY DECELERATION expected in the

fetal monitor when there is fetal head compression;

AMNIOCENTESIS was done @ 35 wks

gestation purpose: to determine fetal lung maturity;

A mother asked the nurse what will

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

a nurse is preparing pt for lower abdl

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

DIAGNOSTIC TESTS (to evaluate pediatric patients)

CARDIOPNEUMOGRAM

use to diagnose apnea of infancy

assess HR, RR, nasal airflow and O2

saturation N 95-98%
below 85 report ASAP
GLUTEN CHALLENGE

19
detect presence of Celiac Disease (CD) intolerance to gluten;
pt is given gluten rich food for 3-4 months the
observe s/s of CD
s/s of CD:
distention

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

abdl cramps, steatorrhea, abdl rigidity, abdl

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

SICKLEDEX TEST
ELECTROPOISIS

HGB

Purpose: test for sickle cell anemia

Purpose: test for sickle cell anemia
ORTOLANIS TEST (OT)
MANUEVER (BM)

BARLOWS

purpose: test developmental dysplacia of the hip or

purpose : same
congenital hip dislocation

Specimen : Blood : (blood + solution, if (+) TURBID

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

Test for Disease

(+) if w/ click sound (lateral)

(+)
barlows click press downward and w/ click sound

POLYSOMNOGRAPHY or sleep test

infancy
-

EEG is connected to pt when he sleeps

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

SCOLIOMETER
-

measure the degree or angle of scoliosis

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

GUTHRIE CAPILLARY BLOOD TEST (GCBT)

to detect PKU
(in PKU there is absence of PHENYLALAMINE HYDROXYLASEPH)

20
Phenylalamine hydroxylase is an enzyme that converts PH
to Tyroxine the one that gives color to hair, eyes and skin.
If absent PH, no one will convert PH to Tyroxine, therefore it
will accumulates to brain and can cause mental retardation.
PH came from CHON rich food. At birth, it is usually
negative, so give CHON food first for 3wks then retest.
Before test, give chon rich food for 1-4 days before test.
(adult)
N PH level - >2mg/dl
(if 4mg/dl indicative of PKU, 8mg/dl confirms PKU)

mother complains that her baby taste salty which

test is to be performed : sweat chloride test;

9 yo pt has (+) result for sweat test this indicates

possible dx of Cystic Fibrosis;

pilocarpine drug used for pt undergoing seat

chloride test;

hgb electropoisis test for sickle cell dses

SWEAT CHLORIDE TEST

to detect Cystic Fibrosis (in CF, the skin
becomes impermeable to Na. meaning cannot reabsorb Na
and it accumulates outside of the skin);
Mother complain that her baby taste salty;
PILOCARPINE used in the test to induce
sweating;
Types:
a.
sweat chloride test N 10-35 meq/L (above 40
meq/L (+)
b.
serum chloride test N 90-110 meq/L (above 140
meq/L (+)

DIAGNOSTIC PROCEDURES
I.

CARDIOVASCULAR

A. ELECTROCARDIOGRAPHY records the electrical

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

TIPS

a.

pt w/ PKU would more likely to have (+) result in

gluten capillary bld test if there is adequate CHON in the
diet;

atrial fibrillation p waves halos magkadikit.

(no discernable p waves)

b.

atrial flutter saw tooth flutter waves

21
c.

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

D.

ANGINA st segment elevation, t wave inversion

MI
- st segment elevation or depression, t wave
inversion

CORONARY ARTERIOGRAPHY

medium
-

visualization of the bld vessels w/ contrast

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

heart
-

it determine the structural abnormalities in the

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

common complications: embolism, bleeding, arrythimia

EBA
nsg mgt :

monitor distal pulses (if brachial site: check @

radial
if femoral site : check @ dorsalis
pedis)

if weak or no pulse REPORT

if (+) bleeding report (sandbag 10-20 lbs

shld be at bedside)

C.
stress
-

STRESS TEST

E.

SWAN-GANZ CATHETERIZATION

4 lumen for the ff CVP, Pulmonary Capillary

Wedge Pressure
(PCWP), Pulmonary Artery Pressure,
Bld products, Balloon
CVP measure R side pressure of the heart
PCWP L side of the heart
N Pressure CVP: for R Atrium 0-12
for SVC 5-12
Nsg Alert : check pulse and s/s of bleeding

F.

BLOOD CHEMISTRIES

SODIUM (135 145 meq/L)

determines the ability of the heart to withstand

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

Addisons Dses: hyponatremia (dec Na),

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 : Addisons 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)

Hyperthyroidism inc CA
Renal Calculi Formation inc CA @ bld

LDH5 0-5% (for liver & kidney)

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
main problem)

Male 12-70 u/L

Female - 10-55 u/L

below 50 hypoglycemia (pt prone to injury &

altered thought process)

dyas

Increase CPK 3-6hrs post MI then it normalize 3-4

Creatinine (.5-1.5)

most sensitive index of kidney funx

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

disorder

increase creatinine kidney failure or renal

BUN (10-20 mg/dl)

inc. if (+) kidney disorder

AST (SGOT)

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

G.

SGPT (ALT)
N 8-20 u/L
more on HEART (inc

HEMATOLOGIC STUDIES
RBC (4.5 5.5 million)

23
- inc RBC polycythemia risk for injury complication CVA
- dec RBC anemia activity intolerance
WBC (5-10 thousand)
to detect presence of infection, bld disorders
like leukemia
dec WBC pt prone to infection
inc WBC hyperleukocytosis (+) to pt w/
leukemia risk for infxn
PLATELET (150,000-450,000)
spontaneous bleeding occurs when platelet dec
(pt also prone to injury)

DOPPLER USG
to detect the patency of bld vessels arteries &
veins esp of lower
extremities;
painless, non invasive, NO SMOKING 30 min-1hr
b4 the test
PULSE OXIMETRY
determines the O2 saturation at blood
N 95-98 attach to finger or earlobe (do not
expose e light)
II.

PT
(11-12 sec)
sec)

PTT
(60-70 sec)

coumadin check pt

heparin PTT

monitor pt 4 bleeding

monitor pt 4 bleeding

APTT
(30-40

HGB male : 14-18 mg/dl

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

: hemodilution fld excess

SPUTUM)

RESPIRATORY
BRONCHOSCOPY
visualization of b. tree or airway passages;
to gather specimen for biopsy;
NPO b4 & after
Gag reflex return after 1-2hrs;
Pt may expect a sore feeling (PINK STINGED
Report (+) stridor
CHEST X-RAY

to determine abnormalities of lungs and

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

SPUTUM STUDIES

24
to determine the gross characteristic of the
sputum (refers
to the amount, color, abnormal particles, consistency
and
characteristic)
TYPE OF SPUTUM
PNEUMONIA
TB

PROCEDURE:
BREATH iN, HOLD

then EXHALE

- Viral
thin & watery
Bacteria - rusty

BRONCHITIS - gelatinous

Sputum specimen sterile container

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

position: DURING sitting

AFTER - affected or unaffected side
Nsg alert:
NO COUGHING & DEEP BREATHING during the procedure
coz
this may cause puncture of the lungs;
Assess for breath sounds after;
Complication: bleeding and pneumothorax

PULMONARY FUNCTION TEST

- thru the use of incentive spirometer

- vital capacity (4-5 L of air) refers 2 N amt of air
that goes in
& out of lung after maximum inspiration.

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

- blood streaked

CHF/ PULMONARY EDEMA - pink stinged

EXHALE then INSERT mouth piece,

MANTOUX TEST
- test for POSSIBLE TB EXPOSURE;
- using PPD (purified chon derivatives)
- angle 10-15, BEVEL UP then read 48-72hrs after

5mm in duration (+) for HIV, multiple sex, previously (+)

pt;
10mm
- (+) for immigrants, children below 3yo
and for
pt w/ medical condition DM &
Alcoholism
15mm
- (+) for general population

LUNG BIOPSY

- aspiration of tissues at lungs for dx of tumors,

malignancy
- assess for bleeding, breath sounds & report for s/s of
dyspnea

25
CONTRAINDICATION
III.

NERVOUS
EEG

shampoo hair B4 (to remove chemicals)

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

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

a. pregnancy;
b. obese pt (more than 300 lbs);
OBJECTS
c. claustrophobia (give anti-anxiety b4)
insulin pump,
d. pt w/ unstable v/s (arrhythmic & HPN);
hip replacement
e. pt w/ allergy to dye
clicking sound will be heard &
procedure
lie still
lie still during the procedure
sound will be heard

NO METAL
- jewelries,
pacemaker,

lie still during the

and thumping

nursing alert:

dietary modification: WITHOLD

CAFFEINE coffee and tea;

WITHOLD 48hrs b4 the procedure :

tranquilizers, sedatives, anti-convulsant, alcohol
CT SCAN

MRI

PET

Use radiation to determine

use electromagnetic
field
use gamma rays or positron electron
tissue density
to detect abnormality of tissue
density
to detect abnormality of tissue density;
(detect cancer and tumor)
also to detect O2 saturation @ tissue;
physiology of psychosis; and to evaluate tx
like CA Tx
give more detailed impression
(ex. Measurement of blocked artery)
NSG ALERT:
(w/ or w/out dye)

CEREBRAL ANGIOGRAM

involves visualization of bld vessels @ vein w/

the use of
contrast medium.
CONTRAINDICATED IN:
pt w/ allergy; pregnant pt.; bleeding
Nursing Alert:
a.
keep pt NPO;
b.
assess pt for allergy;
c.
monitor for signs of bldg;
d.
inc oral fld intake to excrete dye;
e.
keep epinephrine and or benadryl at
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.

LUMBAR PUNCTURE

MYELOGRAM

nucleus

test for presence of slip disc or herniated

porposus (HNP).

ALERT:
Know the type of dye use:
aspiration of CSF for assessment to check for
infection or
hemorrhage

DURING : fetal or C-position

: FLAT to prevent spinal headache

Needle is inserted between L3 and L4 or L4 and L5

Increase fluid intake after.

water based called AMIPAQUE

oil base called PANTOPAQUE

type of dye will determine the position of pt

AFTER the procedure.

position:

AFTER

a.
b.

If water based, the HEAD OF BED ELEVATED;

If oil based, FLAT after

Rationale for both oil and water based dye is TO PREVENT

the upward dispersal of dye w/c can cause electrical
meningitis (s/s includes: (+) seizure, headache)

CSF ANALYSIS
Assess for the characteristic of CSF.

IV.

EENT

27
CONDUCTIVE HEARING

LOSS

TONOMETRY

to measure IOP (N 12-21)

- painless but w/ local anesthesia
ACUTE GLUACOMA : 50 yo and above
CHRONIC GALUCOMA : 25 yo
CALORIC STIMULATION TEST
test the presence of Minierres Dses (inner ear)
involves introduction of warm and cold water
then NOTE
FOR NYSTAGMUS jerky lateral movement of the eye.
SEVERE NYSTAGMUS NORMAL
MODERATE NYS
- Minierres Dses
NO NYSTAGMUS
- Acoustic Neuroma

GONIOSCOPY

V.

to differentiate OPEN and close angle galucoma;

non-invasive, painless
WEBER TEST

RINNES TEST

To determine lateralization of sound;

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

GASTRO INTESTINAL TRACT

UPPER GI SERIES (Barium Swallow)

xray visualization with contrast medium

- Contrast Medium:

a. Gastrografin water soluble, use straw

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

28

BARIUM ENEMA (for Lower GIT)

involve rectal installation of barium;

ALERT: assess for allergy (epinephrine/benadryl)

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

inflammatory bowel condition like CANCER;
specimen : stool (this can be refrigerated awaiting
laboratory)
AVOID the following 3 days B4 the test bec it can
yield to FALSE (+)
RESULT : Red Meat, Fish and Horse Radish

CHOLANGIOGRAPHY

visualization of biliary tree (includes, hepatic

duct & common bile duct) same with CHOLECYSTOGRAPY
but medium given orally;
-

with contrast medium w/s is given thru IV

GASTRIC ANALYSIS

analysis of gastric secretion like

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

WITHOUT TUBE (tubeless gastric analysis)

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

if (-) HCL Acid at stomach (achlorhydia),

therefore Gastric CA;
if Increase HCL Acid therefore ZOLLINGERELLISON 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)

ULTRASONOGRAPHY

upper abdl USG to detect abnormalities in the

upper abdl area w/
includes biliary tree and Upper GI;
painless;
gel at abdomen and pt is NPO

LIVER BIOPSY

aspiration of sample tissue from the liver to

detect: Hepatic CA and Cirrhosis;
and

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

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

vascular organ
-

WHEN NEDDLE IS INSERTED tell pt to:

Inhale then Exhale then Hold Breath to stabilize liver
position
-

to visualize common bile duct and pancreatic

duct;
invasive (+) consent;
NPO tube insertion;
Tell pt that tere will be feeling of soreness a wk
after the procedure

Position after : R side-lying position

COLONOSCOPY

visualization of colon to detect:

inflammatory bowel condition
Chrons Dses
Diverticulitis
Hemmorhoids
Tumor
Polyps
- (+) Consent
- 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

VI.

ENDOCRINE
GLUCOSE TOLERANCE TEST

test;
midnoc);

17 KETOSTEROID & 170 HCS

use to detect the presence of Addisons &

Cushings Dses.

to provide measure of bld sugar level at blood;

Inform pt to have high CHO diet 2 days b4 the

Addisons dec secretion of ketones

Cushings ince secretion of ketones

Instruct NPO a day b4 the test (npo post

Specimen: 24 hr urine

Inc sugar level, therefore Diabetes

ACTH STIMULATION TEST

to detect presence of Addisons Dses

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

VANILLYLMANDELIC ACID TEST VMA Test

bi-product of CATHECHOLAMINE Metabolism
epinephrine

norepinephrine

31
abnormality:
inc if there is TUMOR
(pheocromocytoma) of Adrenal Medulla

lower than 1.005 diabetic insipidus

higher than 1.030 diabetic

mellitus
(+) 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

pt is given iodine 131 then after 24hr followed

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

SULKOWITCHS TEST
detect amount of calcium excreted at urine;
if to test for hypercalcemia and hyperthyroidism
- gather specimen b4 meals;
to test for hypocalcemia and hypothyroidism
gather after meals
VII.

CULTURE & SENSITIVITY

RAIU

to detect infection
prepare storage container
KUB

IVP

- xray of the kidneys, ureter and bladder

xray of the kidneys, ureter and bladder
- NO SPECIAL PREPARATION NEEDED
- uses
contrast medium/ dye
- assess for allergy,
then inc. oral fld intake after
- benadryl or
epinephrine at bedside for allergic rxn
- NPO POST MIDNOC,
cleansing enema in AM

R E NA L
URINALYSIS
examine the gross characteristic of the urine

urine amount : 30-60ml/hr

color
: clear, amber
s. gravity
: 1.010 1.025

CYSTOSCOPY
visualization of urinary bladder
after : monitor I & O;
note for s/s of bleeding

32

RENAL BIOPSY

detect:
a.
b.
c.

aspiration of tissues at kidney for biopsy to

note for s/s of bleeding

malignancy/ Ca
malignant HPN
kidney disorder

to alternately contract and release the muscle

as needle is inserted
HOLD muscle relaxant b4 the test

aspiration of fluids at synovial space to detect

abnormalities;
check for order of analgesic;
apply cold pack

CYSTOURETROGRAM
to check the patency of the ureter and bladder;
monitor I & O
CYSTOMETROGRAM

to evaluate the sensory and motor funx of

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

VIII.

BONE SCAN

detect rate of bone destruction or bone

resorption for pt w/ osteoporosis;
lie still during the procedure;
PAINLESS AND NON INVASIVE

MUSCULO-SKELETAL
ELECTROMYOGRAPHY

ARTHROSCOPY

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

IX.

ARTHROCENTESIS

to detect electrical activity of the muscle;

(+) consent;

MISCELLANEOUS
BONE MARROW BIOPSY

Leukemia)

to check abnormalities at the b. marrow (eg.

33
emergency

site : ILEAC REST

(+) consent
assess for bleeding
sand bag at bedside (post procedure) for
use

SCHILLINGS TEST

specimen: 24hr urine

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

URINE UROBILINOGEN

use to detect the rate of RBC DESTRUCTION in a

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

detect presence of MULTIPLE MYELOMA

(malignancy of plasma cells);

RELEASED by destroyed or damage bones

HETEROPHIL ANTIBODY TEST

detect presence of IgM w/c is related to Epstein

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

to detect HEMOLYTIC DSES

WITHOLD ALL MEDS 24hrs b4 the test
BENCE-JONES PROTEIN

ERYTHROCYTE FRAGILITY TEST

mgt: AVOID SHARING of utensils and glass

LYMES DSES SEROLOGY

detect presence of BORRELIA BURGDORFERI

causative agent of lymes
dses.

ROMBERGS TEST

check FUNX of CEREBELLUM;

stand erect, close eyes, and observe for

inability to maintain posture (if pt is Swaying, therefore
TUMOR at cerebellum)

Treatment: tetracycline

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

2 moths old infant suspected of brocholitis is treated

with oxygen therapy. Which result indicates that tx was
effective : 02 SATURATION OF 98%.

Pt is scheduled for liver biopsy. What shld the nurse

instruct pt to do during needle insertion? - hold breath
during the procedure upon insertion of the needle.

Staff nurse is observing a nurse caring for pt w/ cvp.

W/c action of the nurse require intervention? touching the
edge of the soiled dressing using clean gloves.

Pt undergoing ERCP important prep for nurse to

make would be: keep pt NPO b4 the procedure.

Pt w/ coronary angiogram, the catheter was inserted

at the L femoral artery. w/c intervention is appropriate after
the procedure: palpate the popliteal and pedal pulses.

In explaining to the pt about cystoscopy the nurse

shld say : the bladder lining will be visualize.

A mantoux test is (+) if the nurse assesses w/c of

the following: in duration.

w/c of the ff will yield an accurate reading of CVP:

when the zero level of the manometer is at the level
of R atrium.

w/c responses made by the pt indicates that he

understands the procedure to be done in a CT scan: a dye
will be injected to me.

After liver biopsy, a potential complication: bleeding.

MRI is the primary diagnostic tool for multiple scelosis

bec it promotes visualization of plaques at the brain.

35
LPNs peripheral IV Line route;

ELDERLY PT provide with memory aid

PEDIATRIC PT do not mix w/ milk (dosage depends

on wt, age and size)

For SIDE EFFECTS GI symptoms (mostly)

For AD. EFFECTS always consider bone marrow

(leukocytopenia all PENIA)

3 COMMON DRUGS with patients over 65 y/o

a. LITHIUM if above 65 yo, dose shld not more than 1.0mEq
b. HALDOL if above 65 yo, dose shld not more than
6mg/day
c. MEPERIDINE if above 65 yo, shld not 50 mg
II. TRANSCULTURAL
ASIANS are stoicism attitude (they refuse meds if for
the 1 time)
st

MIDDLE EASTERNERS - they expect meds during first

contact w/ hx care provider
JEWISH no meds restrictions
JEHOVAHS WITNESS do
-

ORIENTAL PAYLOAH (from mexico)

treatment for diarrhea;
may cause lead toxicity

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

I. GENERAL CONSIDERATIONS

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

ONLY RNs are allowed to administer (to include

central line)

VALERIAN
sedative (used also as anti-anxiety agent)

DAY 5 (8 Feb
2005)
PHARMACOLOGY

36
-

adverse effects GI Irritation

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

COMMON CONTRAINDICATIONS for HERBAL MEDS:

liver

NO HERBAL MEDS for pregnant client;

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

Lactulose given to pt with hepatic enceph to dec

ammonia absorption
- s/e : diarrhea

ANTABUSE (dizulfiram) most appropriate time to

take meds : after
12hrs of alcohol free.

COGENTIN to prevent pseudoparkinsonism (by

decreasing muscle rigidity)
TETRACYCLINE - can cause staining of teeth,
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.
C
HECK-

THE CHECK PRINCIPLE

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

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

37
ex.
Haldol
Chlorpromazine
Clozapine (chlozaril)
Olanzapine (zyprexa)
Risperdon
BETS TO GIVE: after meals
DOPAMINE neurotransmitter (facilitate the transmission of
neurons)
In SCHIZO there in INCREASE NEUROTANSMITTER.
Signs & Symptoms:
a.
DELUSION FALSE BELIEF
b.
HALUCINATION - hearing sounds
c.
LOOSENES OF ASSOCIATION shifting
of topic

hyperpyrexia and muscle rigidity

this indicates NEUROLEPTIC MALIGNANT

SYNDROME (NMS)
drug of choice: Parlodel, Dantrium

Assess SIGNS and SYMPTOMS of

PSEUDOPARKINSONISM
a.
b.
c.

mask-like face or expressionless face

pill-rolling tremors
cogwheels rigidity or lead pipe rigidity

AKATHESIA restless leg

syndrome (I feel as if I have ants in my pants)

DYSTONIA

Avoid direct sunlight because meds photosensitivity

Instruct pt to rise slowly to avoid orthostatic

hypotension
Check: CBC, BP, AST/ALT
To prevent pseudoparkinsonism, administer
ANTIPARKINSONIAN agents

IA. DOPAMINERGICS - ANTIPARKINSONIAN

CLIENT TEACHINGS:

a.
b.
c.
d.

Report ADVERSE EFFECTS of ANTI-PSYCHOTICS

which indicates agranulocytosis
fever
body malaise
sore throat
chills

in schizo there is increase dopamine, therefore give

antipsychotic to dec dopamine then dec dopamine causes
pseudoparkinsonism. Therefore give dopaminergic.
ex.

L-Dopa
Levodopa
Levodopa-Carbidopa

38

Effective if decrease in tremors and rigidity within 2-3

days;

When to give: AFTER MEALS;

Health Teachings:

dietary modification: AVOID CHON and Vit B6

- bec it decreases drug absorption
b. check for ORTHOSTATIC HYPOTENSION and PALPITATION;
c. check BP and PR

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

dry mouth suck on ice chips or hard candy;

palpitations check PR;
constipation inc. roughage at diet;
urinary retention NOT urinary frequency
decrease BP rise slowly
check BP, PR, ECG

a.

II. ANTI-ANXIETY
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.

IB. ANTICHOLINERGIC
-

decrease ACETYLCHOLINE

ex. Benadry
Cogentin

effective: if decrease tremors and rigidity;

when to give: AFTER MEALS;

Health Teachings:

a.

side effects: blurred vision (no driving);

report ADVERSE EFFECT:

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

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

TRICYCLICS
MAO
STIMULANTS

39
d.

SSRI

PATIENT with DEPRESSION

there is DECREASE norepinephrine and

serotonin

40

A.
TRICYCLICS prevents the reabsorption of
norepinephrine.
Ex. Tofranil, Elavil
Effective: If adequate sleep (8hrs only)
Increase appetite

Avocado,
banana,
cheese (cheddar, aged and swiss) ALLOWED: cheese
cottage and cream,
FRESH MEAT, VEGETABLES
COLA, CHICKEN LIVER
SOY SAUCE
RED WINE
PICKLES

Best given: AFTER MEALS

Hx Teachings:

The INITIAL EFFECT

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

AVOID : juice because an acidic medium

decrease absorption of drugs

REPORT PALPITATION and TACHYCARDIA and

ARRYTHMIAS adverse effects of TRICYCLICS

CHECK BP and ECG

B.

Check BP the drug can cause

HYPERTENSIVE CRISIS
occipital headache my nape
is aching

DEPRESSANT

2 WKS INTERVAL when shifting ANTI

to avoid HYPERTENSIVE

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

MAO INHIBITOR (MonoAmine Oxidase)

prevents the destruction of

NEUROTRANSMITTERs
ex. Parnate, Nardil and Marplan

C.

Effective : if INCREASE SLEEP and APPETITE

STIMULANTS
(Ritalin, Dexedrine and Cylert)

Give AFTER MEALS

Hx Teachings:

Effective: Increase Appetite and Adequate sleep

AVOID TYRAMINE CONTAINING FOOD

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

Best to Give: AFTER MEALS

if b4 meals, it suppresses the appetite;
give NOT BEYOND 2pm bec. it causes INSOMNIA
6 Hrs b4 bedtime;

directly stimulates the CNS.

41
INSOMNIA

shld be given in the morning to avoid

N Na 3 gms, N fluid intake 3L

Basically, Lithium is a
salt

COMPLICATIONS: growth suppression

provide intervals or intermittently to

avoid growth suppression;

check BP and PR

D.

Report also:

Hx Teachings:

SSRI (selective serotonin reuptake inhibitor)

Ex. ZOLOFT, Prozac

Adverse effects: DECREASE LIBIDO and Impotence

s/e: GI

Report the ff s/s (NAVDA)

Nausea
Anorexia
Vomiting
Diarrhea
Abdl Cramps

FINE HAND TREMORS progressing to COARSE HAND

TREMORS,
THIRST and ATAXIC - sign of LITHIUM TOXICITY Dug of
choice: MANNITOL
DIAMOX
Hx Teachings:

III.1 ANTIMANIC

Lithium (lithane, lithobid, escalith)

Tegretol
Depakine/ Depakote

A.
-

LITHIUM
it alters level of neurotransmitters

effective if DECREASE HYPERACTIVITY

give AFTER MEALS
Hx Teachings:

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

Avoid activity that increase perspiration Na & H2o;

Avoid caffeine;

Monitor lithium level

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

Frequency of Lithium monitoring: ONCE A MONTH;

NORMAL LITHIUM LEVEL:
ACUTE DOSE
Below 65 yo
mEq/L

MAINTENANCE DOSE
.5 1.5 mEq/L

Above 65 yo .6 1.0 mEq/L

.5 1.2
.4 - .8 mEq/L

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
TEGRETOL, DOPAKINE/ DEPAKOTE
tegretol a/e : alopecia

CHOLINESTERASE INHIBITORS
For MYASTHENIA GRAVIS : Prostigmin (long acting)
and Tensillon (short acting)

dopakine/ depakote - gingivitis

For ALZEIMERs DSES

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
action : IT INHIBITS the seizure focus and
discharge

ACTH is a neurotransmitter the delivers the order ex. Brain

to muscle to contract/move.

effective: if (-) seizure

given BEST AFTER MEALS (except for sedatives- like
valium)

MOST DRUGS THAT AFFECT CNS ARE BEST

GIVEN AFTER MEALS TOO.
NSG ALERT:

Report GINGIVITIS;

Report S/S of Bone Marrow Depression

pancytopenia
(dec RBC & WBC);

Instruct pt to use SOFT BRISTTLED

TOOTHBRUSH;

Instruct pt to MASSAGE GUMS and frequent oral

hygiene

: Cognex (tacrine) and

Therefore, the drug is given to inhibit cholinesterase in

destroying ACTH
(so, if dec cholinesterace and inc. ACTH, good muscle
contraction)
PROSTIGMIN long acting for treatment
TENSILLON short acting only for 5 mins. it increase
muscle strength in 30 seconds
(therefore, if muscle weakness disappear within 30 seconds
it is MYASTHENIA GRAVIS)
Drug Action:

Increase muscle strength (ex. Increase chewing ability

or able to chew food forcefully)

GIVE B4 MEALS or any activity;

43

Meds is FOR LIFE;

Report s/s of HEPATOXICITY RUQ pain of abdomen

and JAUNDICE

INR refers to the upper limit of meds from N value to the

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
LOVENOX

COUMADIN

For ACUTE CASES of Manic Case

MAINTENANCE or Chronic CASE

FOR
Heparin Derivatives

Antidote: PROTAMINE SO4

Antidote: VIT
K
Antidote same w/ Heparin
Given SubQ (Lower Abdl Fat)

Oral
Onset: 2-5 days

COAGULATION PROCESS:
Vitamin K dependent clotting factors
THROMBIN
COUMADIN
FIBRINOGEN

(maintenance case)

HEPARIN

Check PT (N 11-13 sec

and INR 24 sec)
Effective if (-) clot
Give same time of day
Report s/s of bleeding : Hemoptysis
Hematemesis
HEPARIN: AVOID green leafy vegetables bec it is rich in
Vit K and will counteract the effect of anti coagulant.
Therefore, diet of patient no appropriate.
NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if
more than INR - HOLD

thromboplastin
PRO THROMBIN

FIBRIN (CLOT)

COUMADIN act as vit k dependent clotting factors

HEPARIN converts PROTHROMBIN to THROMBIN and
FIBRINOGEN to FIBRIN
- RAPID ACTING :onset : 24 48 hrs
Coumadin and Heparin

44
NOT to dissolve clot
(only as THROMBOLYTIC meaning it prevents
ENLARGEMENT and FORMATION of CLOTS)

which causes arrhythmia.

And so, to maintain the balance in the Na and K pump
give antiarrythmia because it
decreases the automaticity of the heart.

Antiarrythmia is effective if (-) arrhythmia;

can be given together

Give meds anytime;

ANTIARRYTHIMICS
Ex.

Quinidine (quinam)

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

a. report CNS confusion, ataxia and headache

GI - nausea, anorexia and vomiting
b.
RASH therefore SKIN TEST FIRST
c.
REPORT s/s of QUINIDINE TOXICITY tinnitus,
hearing loss and visual disturbances
d. check pt PR and ECG waves, rate and rhythm
QUINIDINE
LIDOCAINE

PROCAINE

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.)
K once it increase or decrease, it affects the repo and depo
of heart muscle

CARDIAC GLYCOSIDES
-

increase force of contraction;

45
affects the automaticity and excitability of the
heart muscle;
K shld be monitored when in this meds
therapy
(The heart contraction is regulated by Na and K pump.
If K decreases, Calcium enters and it will result to a
more increase force of contraction due to Na and
Ca pump conversion.)

Digitoxin liver AST/ ALT

DIGIBIND antidote for digoxin (lanoxin)
THERAPEUTIC LEVEL:
a.
b.

Digoxin
Digitoxin

: .5 2 ug/L
: 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
ACTION
mins 2hrs

onset : 5 20 mins

Give after meals due to GI irritation

same

CLIENT TEACHINGS:

Report s/s of TOXICITY : NAVDA

Xanthopsia yellowish vision or greenish halos;

Check PR if BELOW 60/min (adult)

HOLD next dose;
if BELOW 70/ min (older child) HOLD;
if BELOW 90- 110 (infants) HOLD next dose

EXCRETION

Digoxin kidney monitor renal funx test (BUN &

Crea) report if inc;

NITRATES (nitroglycerine)
30

dont give if pt taking VIAGRA it will result to

FETAL HYPOTENSION
EFFECTS: dilatation of coronary arteries and arterioles
thereby resulting to
DECREASE IN PRELOAD & AFTERLOAD.
Decrease in Preload decrease in the amount of blood
that goes to the LV;
AFTERLOAD amount of resistance offered by blood
vessels that heart shld overcome
when pumping blood

Effective if NEGATIVE ANGINAL PAIN;

Give BEFORE any activity;

Administered SUBLINGUALLY (+ burning sensation

indicates drug is potent) NO WATER because it will dilute
the meds;

DOSES: 3 doses at 5mins interval;

Report if there is persistence of pain;

Check BP and PR;

Keep meds in dark container (bec light dec potency);

46

Once the bottle is open, use the meds within 3-6 mos

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

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

MUCOLYTICS (an antidote also for ACETAMINOPHEN

TOXICITY)
Ex. Mucomyst
cola;

it decreases the viscosity of secretion;

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

Side effects: NAV + Rashes

-

if no side effects, repeat dose in 1 hr

that required alertness

(ex. Driving)
ANTIBIOTICS
bactericidal;
effective: (-) infection;
give ON EMPTY STOMACH B4 MEALS;
Hx teachings: REPORT rash, urticaria and
STRIDOR indicates
airway obstruction;
side effects: NAVDA + GI Irritation
I. PENICILLIN : antidote is EPINIPHRINE
II. AMINOGLYCOSIDE (gentamycin)
effective: (-) infection give B4 meals;
report the ff:
OTOTOXICITY: I hear ringing in my ear
NEPHROTOXICITY : oliguria
NEUROTOXICITY : seizures

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

III.

ANTINEOPLASTIC (adriamycin)

CYSTITIS
-

for breast and ovarian CA;

effective: (-) tumor size;
GIVE IN ARM to prevent HEMMORRHAGIC

Theophylline - N 10-20;
for ACUTE ATTACK and PREVENTION of ASTMA
EXPECTORANT (robitussin)
stimulates productive coughing;
effective : (+) COUGHING & SECRETIONS
give ANYTIME;
sideffects: NAV + DIZZINESS or
drowsiness avoid activity

a.
prevention;
b.

Hx Teachings:
inc oral fluid intake (2-3L/day) cytotoxic
monitor kidney funx I & O;

THYROID AGENTS (synthroid, cytomel)

47
for HYPOTHYROIDSM;
effective: if Inc in T3 and T4 and NORMAL
SLEEP;
pt always sleep, therefore give meds in AM to
avoid insomnia;
REPORT HE FOLLOWING: insomnia,
nervousness; palpitations
Take meds LIFETIME (same w/ meds 4 neuro);
Check HR, PR and kidney funx test;
ANTITHYROID
-

(PTU, LUGOLS SOLUTION)

For GRAVES DISEASE or HYPERTHYROIDISM;

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

Health Teachings:
a.
Report sore throat, fever, chills, body
malaise because meds
cause AGRANULOCUYTOSIS;
b.
Report lethargy, bradycardia, and
INCREASE SLEEP indicates
that pt is having HYPERTHYROIDISM;
c.
Diarrhea with metallic taste sign of IODINE
TOXICITY

b.
monitor the blood sugar level in early AM
and supper time

INJECT AIR FIRST to NPH then inject air and

WITHDRAW FIRST with REGULAR.

PEAK OF ACTION (refers to when patient becomes

HYPOGLYCEMIA)
REGUALR INSULIN
Intermediate
Long Acting

- lunch time
- late in the afternoon B4 dinner
- B4 Breakfast

SULFONYLUREAS (Orinase)
a.
b.
c.
JUICE

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

ANTACIDS (amphogel, tagamet)

ANTIDIABETICS (INSULIN)
a.

effective: N Blood sugar (80-120)

for DM Type 1 (insulin dependent);
give in AM b4 meals;
check:
instruct S/S OF HYPOGLYCEMIA
dizziness/ drowsiness
difficulty in problem solving
decrease level of consciouness
cold clammy skin

ALUMINUM HYDROXIDE GEL antacid and it

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

48
a.
b.
c.

teachings:
monitor for hypokalemia level and I & O;
report muscle weakness;
give K rich food banana, orange
THIAZIDE (diuril)

LAXATIVES (dulcolax)
Colace
Metamucil
Dulcolax
Lactulose
dependency
a.
b.
c.
d.
electrolytes
e.
dehydration

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

effective : (+) BM;

give AT HS (if NOT diagnostic procedure);
give AFTER MEALS for dyspepsia;
meds is given in short duration only because of
teachings:
be near or stay near CR;
s/e: diarrhea;
NO lactulose for pt w/ diarrhea;
Causes hypokalemia therefore check
Increase fld intake to avoid

DIURETICS
Target Organs
a.
Diamox exerts effect at Proximal Convuluted
Tubules;
b.
Lasix at Loop of Henle;
c.
Diuril at Distant Con. Tubules

give in AM;
monitor for hypokalemia;
check I & O, K level, PR and BP
K-SPARRING (triamterene, aldactone)

effective: inc. urine output;

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

ANTIGOUT
PROBENECID
ALLOPURINOL

- URICOSURIC
- for ACUTE GOUT
- for CHRONIC GOUT
- promotes excretion of uric acid
- has anti-inflammatory
effect by
- prevents or dec formation
preventing deposition of u.acid
of u. acid
@ joints
- s/effects: NAV +
- NAV + Bldg and Bruising
- dizziness/drowsiness
Hypersensitivity
agranulocytosis (check CBC)
- ONSET: 8-12 wks
ONSET: 1-3 wks

LOOP DIURETICS (lasix)

effetctive: incrase urine output;
give in morning to prevent nocturia;

COLCHICINE

TEACHINGS:

49
a.
b.

Increase ORAL FLUID INTAKE;

Monitor uric acid levels;

MIOTICS (timoptic, piloca)

DECREASE IOP (N12-21) for pt w/ glaucoma;
Give ANYTIME but for LIFETIME;
Teachings:
a.
it causes blurring of vision and brow
pain;
b.
administer meds at lower conjunctival
sac;
c.
press the inner canthus for 1-2 mins
to prevent systemic side effects (hyperglycemia and
hypotension)
MYDRIATRIC (AK-Dilate)
-

effective: pupillary dilatation;

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

ANTI-ACNE (acutane, retin-a)

pregnant;
skin

decrease sebaceous gland size;

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

TOCOLYTICS (Yutopar, MgSO4)

a.

relax the uterus;

drug of choice for pre-term labor;
effective: (-) pre-term or relaxed uterus;
give: ORAL B4 meals and IV anytime;
teachings:
signs of Ca Intoxication:
hypotension, hypothermia and hypocalcemia
b.
check bld pressure; urine output (N
30ml/hr)
c.
check RR at least 12/min
d.
check patellar reflex shld be (+)
knee jerk
HOLD if RR 10/min and urine output: 15ml/hr

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 MENIERES DSES dec
vertigo
teachings:
a.
check urine output;
b.
report: s/s of dehydration bec of
diuretic effect
c.
blurred vision
d.
monitor I & O and IOP

OXYTOXIC
PITOCIN
To induce labor
prevent post partum hemorrhage
Effective: Firm and Contracted Uterus
Give anytime
If IV, use piggy back

METHERGIN
To

50
Teachings:
a.
REPORT the ff: HYPOTENSION (due to
inactivation of ANS neurological effect of drug);
b.
Headache
c.
Hypertension (cardiovascular effect of the drug)
d.
Check BP, Uterine Contraction especially the
duration N 30-90 sec
- report if beyond 90 sec sign of uterine
hypertonicity
e. Check Force, Duration and Frequency of Uterine
Contraction

TIPS ON PHARMACOLOGY
Patient receiving DIAZEPAM, the nurse notice that there is
no change in patient behavior. What shld the nurse do?
VERIFY THE PT DIET
COGNEX given with AZEIMERSS DSES to increase
mental functioning

PROSTAGLANDIN (cytotec, E2gel)

effacement
-

Pt w/ COMPLETE HEART BLOCK: give ATSO4 it

increases HR

anti ulcer drug to dec gastric acidity;

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

Pt w/ PVC : bedside : XYLOCAINE

Pt w/ DIVERTICULITIS (pt has diarrhea) the ff meds were

given: what meds the nurse shld question : LACTULOSE
Morphine S04 given to pt with Pul. Edema to decrease
anxiety
Pt ask the nurse on why she will take COUMADIN when
shes already taking HEPARIN Heparin is given for ACUTE
CASES while Coumadin for maintenance
Pt on CHEMOTHERAPY complains of nausea and vomiting,
w/c meds can be given ZOFRAN
Expected side effects of STEROIDS : wt gain, obesity
and Inc appetite
Pt is taking LEVODOPA observe for URINARY
RETENTION

ADREAMYCIN causes hemorrhagic cystitis

DESMOPRESSIN ACETATE administered

INTRANASALLY

51

DIARRHEA (enteric)
yes
x
x

FESO4 shld be given w/ orange juice

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

aggregation

Pt taking ANCEF observe for skin rashes

Pt to receive NPH at 7:30am, the nurse shld expect for

hypoglycemia LATE in the AFTERNOON

HEPA A (enteric)
yes
x

yes

C (universal)
yes

yes

GW
M
AIDS (universal)
yes

yes

yes

GL
yes

yes

yes

yes

yes

yes

yes

yes

yes

MENINGITIS/SEPTIC (enteric)
yes
x
x

SCABIES (contact)
yes
yes

yes

yes

TB (tb Precaution)
x
yes

yes

yes

PEDICULOSIS (contact)
yes
yes
yes

yes

yes

TYPES OF PRECAUTION
H

yes

B (universal)
yes

MRSA (contacts)
yes
yes

P private room
H handwashing
GL - gloves
GW gown
M - mask
AIDS universal

yes

yes
x

52
Norwalk Virus respiratory
Hepa A contact
MRSA contact
Scabies contact

The disorders result as alteration in the function of

HEART (pump), BLOOD (transport mechanism of oxygen,
nutrients, hormones & CO2) and BLOOD VESSELS
(passageway).

PEDIATRIC CONSIDERATION
a.
all factors necessary for appropriate cardiovascular
functioning are
present at birth EXCEPT VIT. K (w/c is produced by
intestinal mucosa);
b.
there are structures which are present at birth that
may alter the route of blood circulation (present at birth:
foramen ovale, ductus arteriosus, ductus venosus)
c.
note the CARDIAC RATE of pediatric pt (minimum $ y.
children 90-110, older c. 70)
REPORTABLE S/S FOR ADULT

Palpitation, Pain and Paroxysmal Nocturnal

Dyspnea

For pediatric patient: observe for PALLOR if (+)

indicates ANEMIA for baby
Day 6 (Feb 9, 05)

Nocturnal dyspnea diff. of breathing at

night
Paroxysmal ND when pt feels as if hes

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

drowning
HEART SOUNDS:

GENERAL CONSIDERATION

S1 - normal lubb
S2 - -do- dub

Priority: Oxygenation

in assessing S1 & S2 use BELL of steth

53
S3 - N for Pediatric pt (ABNORMAL for adult pt it
indicates CHF or Aortic Stenosis)
Steth - BELL for LOW PITCH SOUND (ex. Murmur)
Diaphragm for HIGH PITCH SOUND

c.

Tachycardia and Tachypnea

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

(+) oliguria due to dec bld
circulation & narrowing of bld vessels
Lab Data (to check bld
HEMATOCRIT (N-35-45%)

volume

circulation)
-

check

check Urine

Output
- check CVP
Nsg Dx: FLD VOLUME DEFICIT rel to dec in Circ Vol.
Priority Intervention: Fld replacement (D5Lr, NSS. Bld Trans
for jehovas use plasma expander)
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)

HYPOVOLEMIC - related to fluid loss (pt w/ open

wound, traumatic injury, burn)

ANAPHYLACTIC cause by allergic reaction (laB

procedure w/ dye, asthma, poison)

NEUROGENIC - caused by vasomotor collapse

(vasomotor located @ medulla oblongata w/c is
responsible for dilatation & constriction of bld vessels)
SEPTIC due to systemic infection (ex. Septicemia)
TRIAD SYMPTOMS OF SHOCK
a.
Altered level of consciousness (dec bld circulation
result to dec o2 in the brain);
b.
Hypotension;

Age
Gender
Surgery
Secondary to existing medical condition (ex. Renal
Failure)
Kidney produce erythropoiten that stimulates
bone marrow to produce RBC
TYPES:
a.
b.
c.
d.
e.
f.

Iron Deficiency Anemia (IDA)

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

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
(milk

b. Diet: iron rich food (organ meat, dried foods, egg

yolk iron, egg white CHON);
c. provide patient with BED REST due to fatigue

common in infants and children;

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

PERNICIOUS ANEMIA

MP: Nutritional Deficiency

S/S : Fatigue
Fainting
Forgetfulness
Pallor, cold clammy skin
Dyspnea (due to dec RBC)

common in elderly;
common in POST GATRIC SURGERY

Main Problem: Lack of INTRINSIC FACTOR at the stomach

(intrinsic factor the one that absorb vit
b12)
In elderly, there is that GASTRIC ATROPHY w/c leads to
dec in the Intrinsic factor

Lab data:
Decrease in HgB (N male: 14-18, Female: 1216)
Characteristic

of

RBC:

HYPOCHROMIC

&

MICROCYTIC
Nsg Dx: Activity Intolerance

S/S:
3F (fatigue, fainting, forgetfulness)
Beefy Red Tongue or glossitis
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.
b.

check Hgb
SCHILLINGS TEST (24hr urine)

55
c.

RBC characteristic : MACROCYTIC & HYPERCHROMIC

Nsg Dx: Activity Intolerance

Risk for Injury due to p. neuropathy

presence of S or C shape Hgb due to dec O2

(SICKLING OF RBC)
STATUS
TRANS

TRAIT TRANS

DSES

Priority Intervention:

a.
Correct the deficiency give Vit B12 (IM, Once a
month for lifetime);
b.
Bed rest due to fatigue

FOLIC ACID DEFICIENCY ANEMIA

common in infants, adolescents, pregnant, lactating
and overcooked food;
Main Problem: Deficiency in Folic Acid or VIT B9 or
FOLACIN
S/S: all symptoms of pernicious anemia EXCEPT P.
NEUROPATHY
Lab Data: HgB
Folic Acid level (N 4mg/day) green leafy veg.
(spinach)
Nsg Dx:
Activity Intolerance (NO RISK FOR INJURY coz NO P.
NEUROPATHY)
PI:

Inc. folic acid in the diet g. leafy;

Bed Rest

SICKLE CELL ANEMIA

-

autosomal recessive
hereditary

1 PARENT W/ TRAIT
0
BOTH PARENTS w/ TRAIT
25%
I parent TRAIT, 1 DSES
50%
BOTH parents w/ Disease
100%

50%

50%

25%

50%

50%

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

Complications:
a.
Vasocclusive Crisis (hallmark of the dses)
- bld vessels obstruction by rigid and tangled cells w/c
causes tissue anoxia and possible necrosis
b.
Spleenic Sequestration Crisis massive entrapment of
red cells in the spleen & liver
c.
Aplastic/ Megaloblastic Crisis

bone marrow depression w/c resulted to DEC RBC,

WBC & PLATELET

56
Lab Data: Sickledex Test
(+) Turbid Solution

MP:

Hereditary
Autosomal Dominant common in female and

male
Nsg Dx:

PI:

Activity Intolerance
Fld Volume Deficit
Pain due to vasocclusive crisis

There is a defect in polypeptide

Chain of HgB ALPA and ETA Chain there is RBC
destruction

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 &

PLATELET)
Autosomal Recessive

a.
Minor Thalasemia Anemia mild anemia: 3Fs
b.
Intermedia
TA

more
severe
anemia
+
Speenomegally
Jaundice
(inc deposition of iron @ tissue)
Hemosidorosis

S/S: 3Fs + Pallor + Dyspnea

Risk for Infection (dec in RBC)
Bleeding (dec in Platelet)

c. Major TA severe anemia + Spleenomegally

Lab Data:
HgB, CBC, Clotting Factors Platelet,
Bleeding & Clotting time
Nsg Dx:

Lab Data:

Activity Intolerance (dec in RBC)

Risk for Injury (dec in WBC and Platelet)

PI:
Bld transfusion;
Reverse Isolation;
Genetic Counseling;
Bed rest

HgB
Clotting and Bleeding Time
Nsg Dx:

Activity Intolerance
Risk for Injury

PI :

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

THALASEMIA
Risk Factors:
Common
Chinese, Indians

in

Blacks,

Italian,

Greeks,

LEUKEMIA

57
MP: proliferation of immature WBC

unknown (viral and autoimmune)

Characterized by Remission and Exacerbation

s/s:

Types:
a.
LYMPHOCYTIC

common
in
young
children
(proliferation of lymphocytes)
b.
MYELOGENOUS adolescent and adult (proliferation of
granulocytes)

lab data:
Platelet Count of less than
(spontaneous bldg)
(N 150,000 450,000)

TRAID S/S:

petechiae
ecchymosis
hemorrhage
(all signs of bleeding)
20,000

Nsg Dx: Risk for Injury

Fld Vol. Deficit (due to bldg)

Anemia (initial) + 3Fs

Bleeding
Infection

PI :

Lab Data:

SAFETY prevent bleeding

Give pt platelet, IVF and Bld Transfusion
Corticosteroids wonder drugs

WBC hyperleukocytosis (150 500,000K) expected

NDx:

PI:

Risk for Injury

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

HEMOPHILIA
-

inherited bldg disorder

TYPES:

a.
b.
c.

Hemo. A - deficiency in factor 8

Hemo. B - deficiency in Factor 9
Von Willebrands Dses common in male and female

HEMPPHILIA A and B mother to male)

Autosomal Recessive Link (from

Von W Dses - Autosomal Dominant Mother and Father

IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or
WERLHOFS DSES
-

common in BLACKS;
cause: idiopathic

S/S:
Hemarthrosis bldg between joints that usually
affects ankle, knee and elbow joints;
Hematoma
Hematuria

58
Hematemesis
(above mentioned are signs of HEMORRHAGE)
Lab Data : PROLONGED CLOTTING TIME
Nsg Dx : Risk for Injury
PI : SAFETY then RICE (REST, IMMOBILIZE, COLD COMPRESS,
ELEVATE)
For
JEHOVAHS
(cryoprecipitate) instead

use

plasma

pt w/ IDA has NSG DX of ALTERED NUTRITION LESS

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

w/c of the ff is the priority intervention for pt w/ IDA

PROVIDE BED REST ALTERNATING w/ activities;

w/c of the ff is indicative of thrombocytopenia HEMATURIA

expander

TIPS FOR BLOOD DISORDERS

If all of the ff data were obtained by the nurse, w/c

one is MOST SUGGESTIVE of CARDIOGENIC SHOCK - Inc.
HRate from 84 to 122 bpm;

The nurse admitted a 4 yo child with SICKLE CELL

DSES the priority for the patient is HYDRATION;

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

common manifestation of LYMPHOCYTIC LEUKEMIA is

PETECHIAE;

a mother of 15 mos old child with IDA makes the ff

comment. w/c one is related to child condition - MY CHILD
DRINKS 2 QUARTS OF MILK/DAY;

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

ff is EXPECTED MANIFESTATION HEMARTHROSIS;

CARDIOVASCULAR PEDIATRICS
FETAL
CIRCULATION

59
3

FETAL

STRUCTRUES
PLACENTA
DUCTUS VENUSUS

UMBILICAL
VEIN
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

CONGENITAL HEART DISEASE

structures

will

not

close,

60

CONGENITAL HEART DISEASE

ACYANOTIC HEART DSES
CYANOTIC HEART DISEASE

Signs and Symptoms:

Difficulty feeding

Retarded Growth

Tachypnea/Tachycardia

Frequent URTI

ANS brow seating

Complication: CH Failure (check for murmur)
CVA (due to plycythemia Inc RBC)
Lab Data: 2 D Echo
Nsg Dx: Altered Tissue Perfusion

Dec Pulmonary Bld flow

Decrease Pulmonary

Obstructive CHD

PI : Oxygenation
Surgery
If < 2yrs old prepare the patient the moment the
diagnosis was confirmed/ determined;

Vent. Septal Defect (most common)

Pulmonary
Stenosis
Tetralogy of Fallot (most common)
Atrial Septal Defect
Aortic Stenosis
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

For 2-7 yrs old surgery is equal to child age ( ex

3yo, therefore prepare the child 3 days prior to surgery)
If > 7yo parents decision

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

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

Higher BP in the Upper Extremities and Lower BP in

the Lower Ext.

LAB DATA : 2 D-Echo

CVP
PExam
Nsg Dx : Altered Tissue Perfusion
PI :

Oxygenation
INDOMETHACIN

ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then

SURGERY

TETRALOGY OF FALLOT
pulmonary stenosis, coarctation of aorta, right vent.
Hypertrophy, vent septal defect
boot-shape heart

Lab Data : BP, 2 D-Echo

PI :

Oxygenation
Position the patient: Orthopneic or semi
fowlers position

62
KAWASAKIS DISEASE
due to acute vasculitis (inflammation of bld vessels)
of the heart;
especially to JAPANESE children and toddler 5yo and
below

w/c of the ff data in mother health history indicates a

risk factor for congenital heart disease ADVANCE AGE;

when admitting a pt w/ suspected congenital heart

disease, w/c intervention is priority decreasing the
metabolic demand of the heart

S/S : High Spiking Fever for 5 Days

Lymphadenopathy
Strawberry Tongue
Palmar and Feet Desquamation
Lab Data : No Specific Diagnostic test
Check ECG
Nsg Dx :

Altered Tissue Perfusion

Altered Thermoregulation
Altered Skin Integrity

Diet :

High CHON

TIPS FOR CARDIOVASCULAR PEDIA

w/ of the ff is an OUTSTANDING SYMPTOM OF

CARDIOVASCULAR PROBLEM in children difficulty in
feeding;

w/c of the ff is an appropriate intervention for a child

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

a child who was brought in to a well baby clinic turns

cyanotic while crying REFER to the physician;

the BLD VESSELS INVOLVE in PATENT DUCTUS

ARTERIOSUS pulmonary artery and aorta;

CORONARY ARTERY DISEASE (CAD)

Main Problem : NARROWING and OBSTRUCTION of
Coronary Arteries which
could lead to HYPOXIA reversible (which
could further progress to ANGINA)
and or ISCHEMIA irreversible
(that could progress also to devt. of SCAR
FORMATION that can lead to MI).
Risk Factors:
Family History
Atherosclerosis
Smoking
Elevated Cholesterol
HPN

63
Obesity
Physical Inactivity
Stress

CAD

HYPOXIA

ISCHEMIA
NECROSIS

ANGINA

PAIN
Myocardial Infarction jaw

pain

MTOCARDIAL INFACRTION

ANGINA

this leads to decrease O2 and will result to the

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

Precipitated by 6Es
Pain confined at sternal area

Pain that resembles indigestion, crushing,

excruxiating
Pain that resembles pressure

Pain radiates to the L Jaw, L arm, L shoulder

Relieved by SO4 Opiods (MORPHINE)

Relieved by rest & NITROGLYCERIN

Pain occurs AFTER MEAL (post cebum) or AFTER

ACTIVITY
SAME

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

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

64
ECG initial change is ST SEGMENT DEPRESSION w/
SAME
T WAVE INVERSION

b.

Diet : Low Na and Low Cholesterol

Increase CHOLESTEROL
SAME
HDL good or Healthy liver for metabolism 30-80
LDL - bad peripheral vascular system bld vessels60-80
CARDIAC ENZYMES #1 Myoglobin
SAME
Troponin
CK within 2-3 days
LDH 1&2 within 10-14 days

HEALTH TEACHINGS:

Nsg Dx :
PAIN
Altered Tissue Perfusion
Impaired Gas Exchange

Identify types of Angina:

Stable Angina predictable angina that occurs

w/ activity;

Priority : Airway (Oxygenation)

Unpredictable relieved by Nitroglycerin;

Goal of CARE

Variant/ Prinzmetal severe form of Angina;

a.
To decrease oxygen metabolic demand
- position : SEMI-FOWLERS
- administer O2 as ordered
- administer meds:

Nocturnal Angina occurs at night;

MI : Morphine SO4 monitor RR, effective : (-) pain,

ANTIDOTE : Naloxone HCL Narcan
ANGINA : Nitroglycerine

dark container
give b4 activity
maximum of 3 doses, 5

mins interval

Decubitus Angina when pt is lying down

Intractable Angina unresponsive to tx
Post MI Angina

For patient with MI focus on complications :

a.
PVC or PVBeats defibrillation/ cardioversion
b.
Ventricullar Fibrillation Lidocaine s/e
rashes

effective: tingling
sensation, sublingual
provide rest due to pain

CARDIOVERSION
DEFIBRILLATION

65
- synchronize
unsynchronized
- esp. for VTACH w/ PULSE
PULSE

- for VTACH w/o

SEX for pt w/ MI resume if pt tolerate 2-3 plights

of stair w/o pain;
- take meds b4 sex;
- position during sex : passive let the girl do
her share

ACTIVITY advised pt to have frequent rest period;

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

FOR ANGINA APIN instruct patient to report pain that

last more than 2o minutes (indicative of MI);

Weak or absent PULSE indicative of

VENTRICULLAR FIBRILLATION

Report NECK VEIN DISTENTION indicative of CHF

complication

Report BLEEDINGs especially to pt on

THROMBOLYTICS t-PA and Streptokinase

CONGESTIVE HEART FAILURE

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

how will the heart compensate?

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

PUMP FAILURE EFFECTS:

Backward Effects : backflow of blood systemic

congestion;

Forward Effects : decrease cardiac output dec

in tissue O2
perfusion that leads to overwork
respiratory
system
LEFT HEART FAILURE early signs of CHF
Therefore, Right Heart Failure will be the late signs of CHF
as
complication of LHF
Risk Factors to Heart Failure:
- Arrythmias
- Coronary Dses & HPN
- Renal Failure
LEFT SIDED HF dyspnea and other pulmonary s/s
crackles
RIGHT SIDED HF systemic effect

distended jugular vein

Ankle edema
Ascites
Hepatomegally

66
LEFTS SIDED HF
HF

RIGHT SIDED

Lab Data : Swan Ganz

12, V Cava 5-12)
PAP (N 20-30)
PCWP (N 8-13)

CVP (N R 0-

X-ray
Nsg Dx :

HYPERTENSION
INDUCED HPN
X-ray

MP : blood pressure higher than Elevation of BP that occurs

after 20-24
140/90 (hypertensive state)
(5 mos- age of
viability) wks of gestation

Altered Tissue Perfusion

Ineffective Breathing Pattern for LHF
Fld Volume Excess for RHF

PRIORITY : Oxygenation
Position: Semi-Fowlers
Administer: Digoxin absorb in GI
Vasodilators
Diuretics
Morphine for CHF it causes
pheriperal vasodilation by
Decreasing the amount
blood going back to the heart.
DIET : LOW Na NO PMS
HEALTH TEACHINGS :
a.
Activity rest
b.
dietary counseling NO PMS
c.
report s/s of complications

DIGITALIS D. Toxicity: yellow vision;

Muscle weakness (hypokalemia) that can

lead to arrythmia

Dyspnea s/s of pulmonary edema;

PREGNANCY

pre hypertensive phase

120/80, therefore N BP : 110/70 if BP elevated B4 20-24 wks
& cont after delivery CHRONIC HPN
Risk Factors:

Levels of PIH

Common in BLACKS;
a.
HYPERTENSIVE DISORDER OF PREGNANCY

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

Stress

Smoking
b. PRE-ECLAMPSIA
S/S + convulsion,
Abdl pain & Headache - ECLAMPSIA PHASE
c. ECLAMPSIA +
Bleeding = HELP SYNDROME
TYPES:
a.
b.
c.
d.

ESSENTIAL HPN cause unknown

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

67
HPN IN PREGNANCY usually related to generalized spasm
of the arteries
PRE-ECLAMPSIA TYPES:
a. MILD
- .5-1GM)
b. SEVERE

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

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

PIORITY:

HEADACHE and ABDOMINAL PAIN s/s of ECLAMPSIA,

indicative of impending convulsion.

Stabilize BP

How?
I. Non-Pharmacologic Features

ECLAMPSIA + BLEEDING = HELP SYNDROME

H emolysis
E levated Liver Enzyme
L ow
P- latelet
(All are signs of bleeding)
S/S of HPN:
Headache
Retinal Hemorrhage
Edema
above s/s can further lead to complications:
Coronary artery dses
CHF
Chronic Renal Failure
CVA
LAB DATA:
Blood Pressure
Elevated Cholesterol
For PIH : (+) Proteinuria, Inc BP and Inc
Cholesterol
Nsg Dx:
Altered Health Maintenance
Risk for Injury

Stress Management
Deep breathing
Diet : Low Na/ Cholesterol
Position : if inc BP supine position

II. PHARMACOLOGIC MEASURES

Antihypertensive

Diuretics

Aspirin

Antilipimic - simvastatin & lovastatin give after

meal nighttime

Monitor liver Funx test meds above are hepatotoxic

Pts w/ PIH meds:
a.
MgSo4 antidote is CAgluconate
b. Darkened room to dec stimulus thereby preventing
convulsion

68

PERIPHERAL VASCULAR DISEASE

Arterial Obstruction

Venous

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

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

TYPES:
BURGERS DSES
RAYNAUDS
ARTERIOSCLEROSIS OBLITERANS
(THROMBO ANGITIS OBLITERANS)
common
:
MALE

MALE

AREA
Lower Ext.
Lower Ext
AFFECTED :

FEMALE
Upper Ext 97%
3% - lower ext

Affects arteries
Arteries ONLY
and veins
MP :

Upper &

Arteries ONLY

Angitis inflam. of
Spasm of Arteries
Hardening of arteries due to fatty deposits
Arteries & veins of lower ext
of Upper & lower
ACUTE
CHRONIC

INTERMITTENT
- (+) 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
S/S:

Outstanding s/s
is INTERMITTENT CLAUDICATION pain that worsens
w/ activity or pain that is relieved by rest.
- aggravated by smoking
causes further narrowing of bld vessels
LAB DATA : Inc WBC & ESR
Inc Cholesterol and Ca

DOPPLER USG

Nsg Dx: Altered Tissue Perfusion

same
Pain
-doPI :

Relief of Pain

-do-

same
-do-do-

MEDS : (for all types)

Anticoagulants
Vasodilators (papaverin pavabid)
Antihypertensive

DIET : Low Cholesterol

VARICOSE VEIN
PHLEBOTHROMBOSIS

THROBOPHLEBITIS

weakening of venous valves;

CLOT + Inflammation
Clot
job related (prolong sitting/standing)
pregnancy
hereditary
secondary to existing medical condition
s/s : dilated tortous vein
dragging sensation heaviness
edema (unilateral/ bilateral) tape measure to monitor
leg circumference
Pain
Lab data:
1.
conservative test TRENDELENBURG
TEST pt lie down, elevate/ raise the legs then stand up and
observe for bulging of vein;
2.
Nsg Dx :

DOPPLER USG
PAIN
Altered Tissue Perfusion

Hx Teachings :

Elevate the legs above the heart;

70

Use support stockings;

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

NO MASSAGE coz it may dislodge the clots;

KNEE HIGH STOCKINGS;
COLD COMPRESS

ABDOMINAL AORTIC ANEURYSM (AAA)

- weakening of portion of abdl aorta leading to dilation;
- could be related to aging and HPN
TYPES:

Prepare pt for Surgery

CARDIO-PULMONARY RESUSCITATION (CPR)

indicated for cardiac arrest when pt is
BREATHLESS
and PULSELESS;

shake the pt are you ok? If breathless &

pulseless then;

ACTIVATE the EMS Help!

CPR (1 or 2 rescuer : 15 : 2)

In 1 minute, there will be 80 compression

and
15 20 rescue breaths
Depth of Compression : 11/2 2

Fusiform - entire wall is affected

Dissecting - part of inner intima and media was dissected
w/c lead to the pushing
of tunica adventitia to bulge
Saccular

If too deep - it may fx the liver

Effect of CPR : #1 (+) Pulse;
#2 skin color

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

Altered Tissue Perfusion

Risk for Injury

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

TIPS FOR CARDIOVASCULAR ADULT

A nurse is assigned to a pt with arterial dses of lower

extremities, w/c of the ff is expected calf pain after short
walking (intermittent claudication);

A pt was diagnosed w/ MI develop atrial fibrillation

this may possibly lead to CEREBRAL EMBOLISM;

A pt w/ CHF was admitted exhibiting confusion,

disorientation, visual disorders & hallucination the nurse
best action is to CALL THE PHYSICIAN;

71

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

characteristic of PAIN pain radiates to the jaw;

In utilizing mind over body principle for pt w/ HPN

w/c intervention is appropriate - relaxation and stress
mgt;

Pt exhibits intermittent claudication another sign of

peripheral dses is w/c of the ff tropic skin changes;

Ff MI, when shall I resume sexual activity? when

you can climb 2 plights of stairs w/o shortness of
breath then sexual activity is safe;

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

hepatomegally;

Apt w/ CHF who is taking diuretics exhibits the ff, w/c

requires further investigation (not expected to pt) wt gain
of 3 lbs in 2 days;

In addition to assessing a pt w/ Burgers Dses, w/c of

the ff data supports the Dx. smoking;

A pt with R sided HF will manifest distended

jugular vein

use steth directly on pt. skin because clothing my

interfere w/ auscultation;

when the pt chest is hairy, wet the hair w/ dump cloth

because dry hair interfere w/ auscultation
Consideration w/ Pediatric Patient:

when assessing pediatric pt, RR is affected when

therefore check RR FIRST;

Note for chest indrawing (if +, may indicate

Pneumonia) and rapid breathing
Reportable Signs and Symptoms : common TO ALL
RESPIRATORY DISORDERS
RE TACHY TACHY D C

RETRACTIONS - #1 or Early sign for respiratory

distress;

Tachycardia

Tachypnea

Dyspnea

Cyanosis late sign of respiratory Distress

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

RESPIRATORY
General Consideration:

use the DIAPHRAGM of the steth when assessing

breath sounds;

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

neuro impairement

Cheyne-Stroke increase in rate and depth of

breathing followed by apnea; - nero case

Kussmauls deep rapid breathing;

Apneustic forceful inspiration followed by slow

expiration dying patient

72
At birth, the child can maintain temperature by burning
brown fat and increase burning bi products is Increase
fatty acids that will cause acidosis that can worsen the
Resp. Distress Syndrome a group of symptoms (mgt:
maintain temperature).
HYPOVENTILATION

Cause: Lack of O2

a.
b.
of Apparent Life Threatening Events
c.
who died w/ SIDS
(usually 2-3 sis/ bro died)
d.
Dx Procedures:

Pre-Term;
Those w/ episodes
Siblings of those
Hypoventilation

Cardioneumogram measures O2
Polysonography
ABG Analysis

Effect:

ACIDOSIS
Tx :

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

NAV and Insomia

Caffeine

Assist mother threu grieving process

HYPERVENTILATION
ALKALOSIS
Cause : lack of CO2 the pt will decrease rate of
breathing to save CO2.
co2 then combine with H2O to form carbonic
acid if inc, can
lead to acidosis and the brain will
compensate by
hyperventilating and increase elimination of
CO2 will cause
ALKALOSIS.

Hx Teaching : Teach parents CPR (esp to Apnea of Infancy)

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

APNEA OF INFANCY

SIDS/ CRIB DEATH

Occurs in Full Term Baby (37wks onwards)

occurs in Pre-term

Usually

s/s : episodes of APNEA, TACHYCARDIA

Factors:
and Cyanosis

Risk

S/S :

WHEEZING sound due to obstruction

Orthopnea
Whitish Sputum

Lab Data : Pulmonary Funx test

Incentive Spirometer

73
Nsg Dx :

Ineffective airway Clearance

PI :

AIRWAY

Intervention :
Bronchodilators theophylline
Rest
Oxygen low flow (1-2 l/min) higher than this will
result to decrease in the stimulus for breathing
w/c is CO2
Nebulization
Chest Physiotherapy b4 meals or at bed time
High Fowlers
Intermittent Positive Pressure Breathing
Aerosol
Liberal Fluid Intake
Meds :

Aminophylline
Steroids
Theophylline
Histamine Antagonist
Mucolytic
Antibiotics

multi system dses (GI and Respiratory System)

characterized by excessive mucus production by exocrine
glands.
Respiratory

GI

Hereditary

Autosomal Recessive

For each pregnancy -

TRAIT TRANSMISSION 50%

Chance for DISEASE TRANSMISSION

25%
S/S : MECONIUM ILEUS within the 1st 24-36 hrs if baby
fail to defecate suspect for CF;
ABDL DISTENTION
Malabsorption Syndrome STEATORRHEA foulsmelling stool w/ Inc Fats & Bulky
Salty to Kiss bec skin becomes impermeable to Na
Common Complications: because of thick mucus plug
MALE
Aspermia low sperm count
Sterility
FEMALE Difficulty in conceiving
Nsg Dx :

Hx Teachings :

Appropriate rest;

Activity avoid those that will expose pt to allergens;

AVOID PROPANOLOL and ASPIRIN causes

BRONCHOSPASM;

Exercise blowing exercises bubbles, trumpet

CYSTIC FIBROSIS

Knowledge Deficit
Altered Elimination
Altered Sexual Functioning

Lab Data : Sweat Chloride Test N (if sweat) 10 35 mg/dl

INCREASE IF (+) CF
(if serum) 90 110 mg/dl -doPI : since two system are affected:
Respiratory Therapy blowing of trumpet, Increase
Fluid Intake;
GI Therapy Administer Pancreatic Enzyme
(pancreatin, pancrease, viocase)

74
GIVEN WITH
EACH MEALS
Effective : if (-) fat at stool

(-) FEVER
(+) FEVER-low grade
(+) FEVER-moderate
(+) STRIDOR
WHEEZING

(+) STRIDOR

(+)

Hx Teaching : Refer parents to GENETICIST

STRIDOR is present when the affected part is LARYNX.
Lab data:

P Exam
ABGs

Nsg Dx :

-do-

ELIZA
-do-

INEFFECTIVE AIRWAY CLEARANCE

PI :
Airway Endotracheal Tube (Tracheostomy Set - #1)
to facilitate airway;
Humidity place infant in MIST TENT or CROUPETTE
Nsg care:
CROUP DISORDER
ACUTE LARYNGITIS
LTB
RSV/ BRONCHIOLITIS
(Laryngotracheal Bronchitis)
(Respiratory Synctial Virus)
common in TODDLER
INFANTS & TODDLER
INFANTS usually (less than 6 mos)
VIRAL

VIRAL or BACTERIAL
VIRAL

Inflammation of LARYNX
Inflam. of LARYNX &
TRACHEA
Inflam. Of BRONCHIOLES
barking-metallic cough
harsh-brassy cough
paroxysmal-hacking cough

change clothing frequently coz

mist will dampen child clothings;

TOYS while inside the tent:

PLASTIC TOYS

no battery operated & no friction

wheel toys

at HOME: we can use NIGHT or

MOIST air outside
and hot shower mist at the comfort room for child to
inhale
Antibiotics Antiviral Ribavirin
Hx Teachings :
SYRUP OF IPECAC for Croup it induces vomitingbec it will stop the spam thereby preventing
further coughing.

75
Over distention of Alveoli
Bronchus

Inflammation of
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 : ABGs to check for respiratory acidosis
CXrays
Nsg Dx : #1 Ineffective Airway Clearance due to
narrowing & obstruction
#2 Ineffective Breathing Pattern
PI :

Chronic Obstructive Pulmonary Disease (COPD)

MP : group of disorders of respiratory system that lead to
obstruction or
narrowing of airways.

AIRWAY 1-2 L/min;

Meds: Bronchodilator Atrovent
Exercise: Blowing;
Rest periods in between activities

During ACUTE attack, the POSITION OF CHOICE :

ORTHOPNEIC

PNEUMOTHORAX
EMPHYSEMA

BRONCHITIS
ASTHMA

MP : partial or total collapse of lungs due to:

76
Types :

BLEB over

TENSION

Open Pneumothorax TRAUMA

Spontaneous Pneumothorax - due to rupture of
distention of alveoli
Tension Pneumothorax due to INCREASE IN

S/S :
Diminished Breath Sounds (-) b. sounds to
area auscultated;
(+) Dyspnea;
(+) Restlessness
Nsg Dx :

Impaired Gas Exchange

Ineffective Breathing Pattern

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

PNEUMONIA (PNA)
MP : there is INFLAMMATION of ALVEOLAR SPACES
that leads to
exudation and consolidation of the lungs.
LEGIONARES DSES acute bronchopneumonia in elderly,
alcoholic &
Immunosuppressed pt
- management same w/ pna

VIRAL PNA

BACTERIAL

PNA
Fever :
moderate-high

(+) low-moderate

(+) fever

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

(+)

WBC :

Elevated

No change or slight

Lab Data :

Xray and ABGs

Nsg Dx :
Impaired Gas Exchange due to exudation and
consolidation of Alveoli
PI :

TB

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

HISTOPLASMOSIS
MYCOBACTERIUM
AVIUM

COMPLEX
Bacterial
CAPSULATUM)
thru

Fungal
(from HISTOPLASMA
Bacterial
from BIRD MANURE soil & transmitted

77
inhalation
Droplets & Airborne
Droplets & Airborne
Droplets & Airborne
Risk Factors:

Rifampicin
INH
Streptomycin
Ethambutol
take above meds for 6-12 moths to avoid
resistance

ASIAN IMMIGRANT
IMMUNOSUPPRESSION
MALNUTRITION
S/S :
ACTIVITY

same: a to e + FOREST RELATED

same with TB
Ask client if came from AVIARY

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

Histoplasmine Skin Test for

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

TIPS FOR RESPIRATORY

you observed a nurse caring for a child in a

CROUPETTE, if you are the nurse in-charge, what would be
your #1 PRIORITY? changing the linens & clothings to
keep child always dry;

which data in the past medical history of the pt.

supports a dx of cystic fibrosis MECOMIUM ILEUS in the
neonate;

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

minimize oxygen expenditure;

w/c of the ff intervention being carried out by LPN

would require immediate intervention suctioning the pt
for 20 seconds;

Nsg Dx :
Infection;
Ineffective Breathing Pattern

PROPHYLACTIVE TREATMENT OF TB INH for TWO

WKS (take Vit B6 to avoid NEUROPATHY)
MEDS :
Antibiotics

Antiviral Meds

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

a pt is diagnosed w/ emphysema w/ of the ff s/s

would the nurse expect to have barrel shape chest;

a nurse caring for a pt w R Lower Lobe PNA shld put

the pt in w/c of the ff position to enhance postural drainage
L Lateral w/ the Head Lower than the Trunk

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 addisons dses)

Inc. temperature

S/S of Shock
Keypoints : Specimen characteristic is usually affected by
STREE, DIET and
Normal Body Rhythm

DAY

(Feb

10, 2005)

PKU
AUTOSOMAL
transmission (inherited)

RECESSIVE

PATTERN

of

MP :
ENDOCRINE
General Consideration
Explain to the pt the MOST COMMON METHOD of
assessment:
a.
b.

Direct methods specimen : blood and urine

Explain the methods of gathering the specimen

There is Absence of Phenylalamine Hydroxylase (the

one that converts
Phenylalamine to Thyroxine ( a precursor to Melanin).
Therefore (-) PH leads to accumulation of phenylalanine at
the brain that leads to
Mental Retardation.
S/S :
Initially asymptomatic
For OLDER CHILDREN :

Consideration for PEDIATRIC PATIENT

a.
b.

Involve the parents of the child;

Incorporate food preferences
2 servings of popcorn HOW MANY RICE TO GIVE UP

=1
if sandwich = 1 rice

Diarrhea
Anorexis
Lethargy
Anemia
Skin
Rashes

and

seizure
Musty odor of urine
(due to phenyl pyruvic acid)
Since (-) melanine: hair : blonde

79
Eyes: blue
Fair Skin

LYMPHOCYTIC THYROIDITIS or
JUVENILE HYPOTHYROIDISM

Lab Data :

GUTHRIE CAPILLARY BLD TEST initial

screening done after the infant has ingested CHON for a
minimum of of 24 hrs.

Cause :

Autoimmune or genetics

MP :

Decrease in T3 and T4

Secondary screening : done when the infant is

about 6wks old test fresh urine w/ PHENISTIX WHICH
CHANGE COLOR

S/S :

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

Phenylalanine level greater

diagnostic of PKU (4mg/dl indicative)

Nsg Dx :

Knowledge Deficit
Activity Intolerance

than

8mg/dl

PI :
no tx because it regresses (only temporary)
spontaneously

Nsg Dx :
Knowledge Deficit
Altered Thought Process
Risk For Injury
PI :
Dietary Modification : LOW CHON and Low
Phenylalanine Diet until
adolescent or til 10 yo bec b4 this time the
brain mature
MEDS :

Lofenalac 20-30mg/kg/day

Hx Teachings :

Inform parents of the foods to be avoided; - prepare

special education to parents

Provide list of foods allowed;- prepare special

education to parents

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

CRETENISM or CONGENITAL HYPOTHYROIDISM

disorders related to absent or non-functioning
thyroid;
newborns are supplied with maternal thyroid
hormones that last up to 3 mos;
initially asymptomatic
s/s begins 2 3 months

behavioral s/s
physical s/s large tongue & protrudes
- apathy well behave
from
mouth
retarded growth
- intolerance to cold
mental retardation

80

Prevention: neonatal screening blood test;

Without treatment, mental retardation and

developmental delay will occur after age 3 mos;
Lab Data : Decrease T3 and T4
Nsg Dx :

Knowledge Deficit
Risk for Injury

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

correct the deficiency

Hx Teachings :

Warm environment (bec there is

Hypothermia w/ cool extremities);

Low calorie diet : since there is decrease

metabolism;

Special education
ENDOCRINE GLANDS
8 glands (ductless)- they secrete the hormone
directly to bld stream
1.
2.
3.
4.
5.
6.

Pineal Gland
Pituitary Gland
Thyroid Gland
Parathyroid Gland
Thymus Gland
Pancreas

7.
8.

Adrenals
Gonads (testes & ovaries)

Glands

UNDER

OVER

PITUITARY

Diabetes Insipidus

SIADH

THYROID
Hypothroidism
Hyperthyroidism
(Myxedema)
Basedows, Parrys)
PARATHYROID
Pancreas
ADRENALS
Cushings

Hypo

(Graves,
Hyper

DM
Addisons Dses
Conns

81
- Non-Ketosis Prone
GESTATIONAL DIABETES - occurs during pregnancy
Types According to WHITES Classification
PANCREAS
TYPE
Alpha Cells

BETA CELLS

ONSET
DURATION
A CHEMICAL DIABETES

(+) Increase Bld Sugar

Islets of Langerhans
B

After the age of 20

C
10-19 years

Bet 10 19 yrs old

D
More than 20 yrs

Before 10 yrs old

D1

Before 10 yrs old

10

years
Glucagon
Insulin
(responsible for Decrease in blood sugar)
Responsible in the increase Blood Sugar
Absence
Deficiency
(DM Type I)
IDDM

(DM Type II)

NIDDM

Juvenile Onset B4 age of 30

Maturity Onset After age of 30;

Adolescence to Early Adult Stage

Pt
is Obese

Pt is THIN

Pt is KETOSIS PRONE
NONKETOSIS PRONE
MODY DM III
- combines features of DM Type I & 2;
- Maturity Onset that occurs in young adult;
- OBESE, b4 age of 30

D2

>20 yrs

D3
Beginning Retinopathy
D4

w/ calcification of arteries

D5

DM w/ HPN

E
F
Nephropathy)

w/ calcification of Pelvic Arteries

w/ nephropathy (Diabetes

Diabetes Cardiopathy

Diabetes Retinopathy

82
T

w/ Transplant of the Kidney

INTERMEDIATE
NPH
AFTERNOON/ AFTERNOON
SLOW

LATE IN THE

Protamine Zinc - DURING NIGHT

Ultralente

INSULIN:
NEUTRAL AREA
DIABETES MELLITUS

Best Site is ABDOMEN bec it is a

SUBQ 90 degree angle for insulin

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

unknown

R. factors : Autoimmune
Genetic
Stress
S/S :

Polydipsia
Polyuria
Polyphagia the stave cells send message to
the brain to eat more
Wt loss
Nsg Dx :

Knowledge Deficit
Altered Nutrition

PI :
Correct the deficiency- HOW?

Diet : well balance diet CHO 50-70% (main

source of energy and sugar for DM pt.)

Insulin for Type 1

Hypoglycemia Most Approximately to Occur
RAPID

Regular Insulin - BEFORE LUNCH

40 degree angle if noninsulin syringe

Complication of INSULIN ADMINISTRATION:

Lipodystropy

Dawns Phenomenon hyperglycemia

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

SOMOGYI Phenomenon rebound

hyperglycemia (tx: administer insulin)

Antidiabetic Agent;

(2x a day);

Blood Sugar Monitoring in AM and supper time

Ensure adequate food intake;

Transplant of Pancreatic Cells;

Exercise it will decrease insulin requirement

(in pregnancy/stress Increase insulin req)
Scrupulous foot care check up w/ podiatrist
- foot powder, snugly fitting shoes,
cut toe nail straight across

83
- cut toe nail across
- avoid going barefoot
- always dry in between toes

(Insulin Reaction)
Coma)
- BLD SUGAR BELOW 50

(Diabetic

DKA

HHNK

Risk Factors :
Modification for Pregnant Pt with DM

+300Kcal;

Insulin Requirement (dose will be adjusted on 2 nd & 3rd

Trimester);
AM Dose:
PM Dose:

2:1 for Regular to NPH

1:1 for R:NPH

Missed meals;

Increase or Overdose of Insulin;

Insulin

Too much Activity

Stress
Infection
S/S :

BABY

Lab Data : Below 50 Blood Sugar Level

Macrosomia
Hyperglycemia
Hypoglycemia
Therefore pre-term birth
RDS
Complication: Uterine Atony Congenital Defects

COMPLICATION

1. Hypoglycemia
sugar level above 120)

Inactivity

Dizziness
Drowsiness
Difficulty Problem Solving
Decrease Level of Consciousness
+ Cold Clammy Skin, Diaphoresis

EFFECTS

MOTHER

Overeating
Decrease

Hyperglycemia (bld

PI :

Administer Simple Sugar (fructose-fruit juice)

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

84
DKA (Type 1)
HHNK (Type 2)
(Hyperglycemic Hyperosmolar Nonketotic Coma)
S/S : 3 Ps + Signs of Dehydration thirst & warm

DIABETES INSIPIDUS
(Pituitary Glands 3 lobes)

skin

Hyperglycemia
pronounced GI Disturbances
Kussmaul Breathing + 3Ps
Thirst and warm skin

More

ANTERIOR
MIDDLE

POSTERIOR

Secrete Tropic Hormones

excrete)
MSH (skin color)

Store Only (does not

Lab Data : Increase Bld Sugar

PI :

#1 AIRWAY
#2 Fluid
Regular Insulin

Nsg Dx :

Risk for Injury

2.
3.

ATHEROSCLEROSIS hardening of

arteries;
NEPHROPATHY kidney damage;

5.
OPTHALMOPATHY - w/c leads to cataract (eye exam
annually);
6.
-

ACTH
(adrenocorticotropic hormone)

LH (luteinizing hormone);

GH (growth hormone);

Prolactin

MICROANGIOPATHY - destruction of small

blood vessels;

4.

FSH
OXYTOCIN
(follicle stimulating Hormone) ADH

Peripheral Neuropathy or Autonomic Neuropathy

there is poor nerve impulse transmission
common manifestation : impotence

85
PITUITARY GLAND

Lypressin -

-doHow : Given

ADH (anti Diuretic Hormone)

retain h20 or flds

as pt exhale to the mouth then

inhale thru the nose then EXHALE to the
mouth then give meds.
Evaluate the effect of meds :

Deficiency: lead to D. INSIPIDUS

Excess : SIADH

(Syndrome of Inappropriate Anti Diuretic Hormone Secretion)

Due to or related to:

Pituitary Tumor
Head Trauma
Injuries
MP : Deficiency in ADH leads to fld excretion, therefore
s/s same with DM EXCEPT : POLYPHAGIA

Polyuria 21 L/day
Polydypsia

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

FLUID VOLUME DEFICIT

Administer IV Fluids
Meds Synthetic ADH - Vasopressin IM
Desmopressin
INTRANASALLY- one hole of nose only

Check Specific Gravity of Urine;

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

86

DWARFISM
of Growth Plate
- congenital
gigantism
ex. MAHAL
slender extremities and Inc. in Height

SIADH
excess ADH;

MP : Fluid Retention result to DILUTIONAL HYPONATREMIA

or H2O INTOXICATION
S/S :

B4 Closure
- long,
ex. Marlo

Aquino

due to DECREASE NA this could lead to the ff:

NANUS SYNDROME (hereditary)
convulsion;
seizure;
HPN

After the Closer

of Growth Plate
acromegally
- there is

Above s/s could lead to decrease LOC

coarsening of facial features +

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

hyponatremia

enlargement of the digits (inc. shoe size)

Nsg Dx :

ex. Balingit

FLUID VOLUME EXCESS

PI :

FLUID RESTRICTION
Drugs DIURETICS + ANTIHPN if cause by
TUMOR PREPARE PT FOR SURGERY
IF after surgery
POLYURIA report ASAP sign of DI

Lab Data : INCREASE HUMAN GROWTH HORMONE

Increase Blood Sugar
Nsg Dx :

Risk for Injury

PI :

Safety
Meds - Parlodel decrease secretion of growth

hormone
If related to tumor : surgery
PITUITARY
GROWTH HORMONE
DEFICIENCY

EXCESS

87
GLUCOCORTICOIDS
MINERALOCORTICOIDS
EPINEPHRINE
NOREPINEPHRINE
(ALDOSTERONE)
GLUCONEOGENESIS
STRESS RESPONSE fight or flight
- formation of sugar from
Responsible for Na
Retention
new sources
and K Excretion

GIGANTISM
(long slender extremity)

DEFICIENCY IN GLUCO & MINERALO :

ADDISONS Dses

EXCESS of GLUCO & MINERALO :

CUSHINGS Dses/ syndrome

EXCESS of MINERALOCORTICOIDS ONLY : CONNS

SYNDROME

MARFAN SYNDROME
KLINEFELTERS
(hereditary)
(chromosomal aberrations)
MP : Cardio & Eye disorder (complication)
XXY Pattern (an extra X chromosome)
Scoliosis
chromosome FEMALE COMPONENT

MP :
X
of

HUMAN BODY
Problem is NON-DEVELOPMENT of SEX ORGAN

ADDISONS

the
CORTEX (OUTER)

MEDULLA

RESPONSIBLE FOR SECRETION OF:

SECRETES THE FF:

CONNS

MP : Underactivity of the Adrenal Glands Overactivity

of A. Glands
INC. MINERALOCORTICOIDS
(there is DEC G, M & SEX HORMONES) (there is
INCREASE G & M)
- w/c cause K EXCRETION &
ADRENOCORTICAL INSUFFICIENCY
Na RETENTION

ADRENAL/SUPRARENAL

(INNER)

CUSHING

Excessive SECRETION of
Excessive ALDOSTERONE
- coticosteriods especially
Secretion from A. Cortex
GLUCOCORTICOID CORTISOL

Common: Male and Female

Age 30-60)
Female (30-50)

Female (bet.

RF : Could be related to Surgery removal

Tumors
Related to Tumor

Related to

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
Dec BP
Moonface, Hirsutism,
INC K (hyperkalemia)
Buffalo Hump,
Pendulous Abdomen
Hypertension
Lability of Mood (mood
swings)
Polyuria, Polydipsia
Depression
Cardiac Arrythmias due
COMPENSATORY of MSH Inc w/cTrunkal Obesity / thin
Extremities
to dec K
Leads to Bronze-Like Skin Pigmentation Hypertension
Decrease Resistance to
Infxn
Hypotension, Weak Pulse
Weight loss, Fatigue, Muscle weakness
Nausea, Anorexia, Vomiting
Hx of frequent Hypoglycemic Rxn
Lab Data : Decrease Cortisol Level
Increase
Cortisol Level
Hypokalemia due
Hyponatremia
Hypernatremia
metabolic Alkalosis
Hypoglycemia
Hyperglycemia
Inc Urinary Aldosterone Level
Hyperkalemia
Hypokalemia
Decrease K
Nsg Dx :
Fluid Vol. Deficit
Risk for Injury
Fld & E imbalance
Fld & E Imbalance

Fld Vol. Excess

Fld & E imbalance

ADDISONS

CUSHINGS
CONNS

PI :
Correct the imbalance IV
Correct the imbalance
Check BP give antiHPN
Diet: Inc Na Dec K
- limit fld intake
Administer Steroids (Fludocortisone)
DIET : Low in Calories & Na
Limit the flds
Admin. Hormone Replacement Therapy
High
in CHON, K, Ca
Cortisone give 2/3 of dose in AM
& Vit D
1/3 in afternoon
Meds are FOR LIFE
Prevent accident &
Falls
Diet : Low Na, Inc K

Prevent exposure to Infxn

Protect client
exposure to Infxn

Provide rest periods prevent fatigue

Minimize
stress in environment
Administer SPIRONOLACTONE

Monitor I & O, weigh Daily

MIO & weigh
Daily
(aldactone) & K supplements
As Rx
Provide small, frequent feeding high in
observe for HPN &
CHO, Na and CHON to prevent
Hypoglycemia & Hyponatremia

Monitor V/S,
edema

Use of Table salt tablets (if Rx) or ingestion Surgery

prepare pt if cause

89
Of salty foods (potato chips)
or hyperplasia
if experiencing Inc. sweating

by pituitary tumor
Post Surgery:
poor wound

healing;
report s/s of
Addisonian Crisis

THYROID
severe

HYPOTENSION
Avoidance of strenuous exercise esp
Meds: FOR LIFE
in HOT WEATHER
Glucocorticoids
Synthesis Inhibitors
- Lysodren and Cytodren
- prevents formation of
Gluco

ADDISONIAN CRISIS
severe exacerbation of Addisons dses caused by
acute adrenal insuffieciency
causes: strenuous activity, infection, trauma, stress, failure
to take RX Meds
s/s:

PI :

severe generalized muscle weakness

severe hypotension
hypovolemia, shock
administer flds to treat vascular collapse
IV glucocorticoids - Solu-Cortef and Vasopressors

Maintain strict bed rest and eliminate all forms of

stressful stimuli
MIO and weigh daily
Protect client from Infxn
Other Hx teachings: same with Addisons

T3 & T4
Calcitonin
- responsible for maintenance of METABOLISM
- deposit Ca @ bones
DEFICIENCY
HYPOTHYROIDISM
HYPERTHYROIDISM
Adult: Myxedema
Graves Disease, Basedows or Parrys Dses
Children: Cretenism

EXCESS

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

congenital

surgery
autoimmune

genetic

90

autoimmune

tumor

- performed to determine thyroid

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

S/S :
FACIAL EDEMA
EXOPTHALMUS
INTOLERANCE to COLD
(+) Goiter
DECREASE v/s
Hypermetabolic State
DECREASE GI Motility constipation
INTOLERANCE to HEAT
HYPOactivity
Increase Sleep hypersomnia
INC GI Motility - DIARRHEA
Wt Gain in the presence of Dec Appetite
Insomnia
Dry scaly skin, dry sparse hair, brittle nails
HYPERactivity

NSG DX :
Activity Intolerance due to Fatigue
Risk for Injury (bec of hyper)
(fatigue due to hypometabolism)

Inc V/S

PI :
Promote a EUTHYROID STATE
same
WT LOSS

even INC Appetite

Warm
smooth skin, fine soft hair
Pliable
nails
Irritability, restlessness, agitation
LAB DATA :
Check TSH (increase)
DECREASE TSH
DECREASE T3 & T4
INCREASE T3 & T4
DECREASE RAIU (131)
INCREASE RAIU
INCREASE Serum Cholesterol Level
RADIOACTIVE
IODINE
UPTAKE
administration of 123I or 131I orally;

(RAIU)

HOW :
a. THYROID SUPPLEMENT
Admin AntiThyroid Meds for LIFE
Synthroid, Cytomel lifetime
ex. PTU & Lugols
s/e: insomnia, palpitation
nervousness
b. DIET: low calorie
Assign to private room away
from excessive activity
c. Maintain vital funx: correct hypothermia maintain
Quite & relaxing Activity
adequate ventilation
d. Provide comfortable, warm environment
Provide a COOL ENVIRONMENT
e. Increase flds and high fiber foods to prevent
constipation,. Admin stool softener as Rx
DIET : High in CHO, CHON, CALORIES
f. Meds: thyroid hormone replacement take daily
Vit & Minerals w/ supplemental
dose in AM to avoid insomnia
feedings bet meals & at HS
Monitor THYROTOXICOSIS tachycardia
NO STIMULANTS

91
Palpitations, nausea, vomiting, diarrhea,
Sweating, tremors, dyspnea
Protect eyes w/ dark glasses & artificial
tears
Monitor
for AGRANULOCYTOSIS (fever,
Sore
throat & skin rashes) if taking
antithyroid meds.
Prepare
pt for surgery 2wks before
SURGERY give LUGOLS SOLUTION
- it decrease size and vascularity of thyroid
gland;

MEMORRHAGE whether the dressing is dry or intact

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

Damage Laryngeal Nerve to assess, ask pt to talk

past surgery and if pt has APHONIA provide communication
aids paper and pencil

LARYNGOSPASM accidental removal of parathyroid

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

TETANY due to decrease in CA characterized by:

- can be diluted w/

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

- report diarrhea &

- give w/ straw to
avoid staining teeth;
H2O or orange/ apple juice;
metallic state
Meds: a. Antithyroid Drugs
Prophythiouracil and Tapazole
- block synthesis of thyroid hormone;
- toxic effect include AGRANULOCYTOSIS
b. Radioactive Isotope of
Iodine (131) Radioactive Iodine Thrapy
- given to destroy
the thyroid gland thereby decreasing
Thyroid hormone production
COMPLICATIONS OF THYROID SURGERY:

THYROID CRISIS due to rebound hyperthyroidism

Increase thyroid hormone
Increase HRate/palpitation
Inc Temp - hyperthermia

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

same

PI :

a. Safety
same

PARATHYROID
Parathormone

Deficiency
Inc CA in the Blood
EXCESS
HYPOPARATHYROIDISM
withdraws Ca @
bone to the bld
HYPERPARATHYROIDISM
MP : Dec Ca (hypocalcemia) maybe hereditary,
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
Disorder kidney stones
Chvosteks
renal colic
Trousseau
Constipation
Late S/S
personality changes
cardiac arrythmias
muscle pains

Kidney

NAV,

b. Keep Ca supplement at Bedside

Inc Oral Fld intake due to renal
c. Diet: Inc Ca spinach, sardines, seafoods
calculi of having INC Ca
d. Tracheo set deu to dec Ca Laryngospasm
Diet; Low Ca
Surgery
if due to tumor

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

indicative of KETOACIDOSIS

a pt is to receive NPH Insulin at 8AM, when shld the

nurse expect to have hypoglycemia in the late
afternoon;

to determine the effect of PTU, the expected outcome

is Dec HR;

what would be the question to support the Dx of

Hypothyroidism do you tire easily?;

w/c of the ff statements made by the diabetic pt would

indicate the need for further teaching I will be
hypoglycemic if I experience emotional stress.

GENITO-URINARY
General Consideration

when performing assessment of Genito-urinary

system, use open-ended question- bec some pt are not
comfortable talking genitals;

explain the meaning of terminologies;

ask the patient what symptoms bother him/her the

most;
Consideration for Pediatric Patient

assess for history of sorethroat;

bladder capacity increase with age

infants about 65ml

94
toddler 300-400 ml
school age 800 1000 ml

infants are unable to concentrate urine until the age

of 1 therefore adequate milk intake if baby has 6-8
diapers /day;

d.
e.

Increase glucose UTI

Elevated CHON Nephrotic Syndrome or PIH

Epispadias opening at DORSAL portion

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.
b.
c.

frequency
urgency
hesitancy

Reportable s/s :

peri orbital edema

BP

Oliguria

Hematuria Early Stream Hematuria indicate lesion

at Urethra
Late Stream indicate lesion at bladder

WILMS TUMOR
congenital tumor at the kidney
common in L Kidney and
children below 5 yo
S/S : Unilateral Abdml Mass
Hematuria
HPN
Lab Data :
CT Scan
IVP
NO INAVSIVE LAB/ Procedure
NO BIOPSY

Key points :
a.

check for wt gain

if >1lb/day indicative of fld retention

b.

characteristic of urine: color N - amber

if pinkish bldg
brownish flagyl
orange rifampicin

c.
s. gravity (N 1.010 1.025) - if INCREASE - D.
Insipidus
DECREASE D. Mellitus

Nsg Dx : Knowledge Deficit

Risk for Injury
PI :

AVOID/ NO ABDOMINAL PALPATION

Prepare pt for Surgery and Chemotherapy

NEPHROTIC SYNDROME

AGN

95
MP : Altered Kidney Funx related to inability to retain CHON
Destruction of Kidney Tissues related
(therefore there is PROTEINURAI)
to
Group A Beta Hemolytic Streptococus

DIET :

causes: Autoimmune
sorethroat
congenital

POSITIONING :

INCREASE CHON, Low Na

CHON and Na

LOW

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
end of the day
BP :

at the

Decrease or N
INCREASE BP

URINE : Frothy
colored or Cola colored or Smoky
LAB DATA
(+) Proteinuria, severe - >10mg in 24 hrs
(+) Proteinuria - <10 mg/ 24hrs urine

Tea

CYSTITIS
Infection of the bladder
Ascending infection caused by E. Coli (from
feces) or Pseudomonas
RF :

Nsg Dx : Fld Volume Excess

Impaired Skin Integrity
PI :
Check BP
Maintain Fld Balance
Meds : NO Antihypertensive
Antihypertensive
(+) Steroids
Diuretics
(+) Antibiotics

Wearing silk underwear (does not absorb moist); - use

COTTON
Bubble bath
Prolong driving
Common in FEMALE due to size (short) urethra
S/S:
FREQUENCY, URGENCY & HESISTANCY + Burning
sensation on urination (dysuria)
LAB DATA :

Urinalysis to check for microorganism

Nsg Dx :

Altered Elimination Pattern

96
Infection
PI :

Treat for Infection antibiotics for 10-15 days

Bladder Analgesic (ex. PYRIDIUM ch can cause
ORANGE COLORED URINE, effective : (-) pain)
Diet : ACID-ASH DIET give lemon juice or VIT C
Hx Teachings:
Avoid bubble Bath
No Silk underwear
Inc. Fld Intake
RENAL FAILURE
ACUTE
CHRONIC
MP

OLIGURIC PHASE
- decrease urine output that is less than 400 ml/24hr
(OLIGURIA)
There will be INC BUN & Crea
- Dec NA & Inc K
RENAL
FAILURE
DIURETIC PHASE
- Inc urine output (4-5L/day)
All s/s + Anemia & HPN
- Dec Na & K
ESRD
RECOVERY PHASE
- renal funx normalizes (1-2 yrs)
Azotemia & Uremia
accumulation
of waste products

Sudden or Acute, Usually Reversible loss of

IRREVERSIBLE kidney damage that
Kidney Funx
leads to scar formation

uremic frost
skin pruritus
LAB DATA

There is inability of kidney to maintain fld & E balance

Causes
PHASES

Nsg Dx

Pre-renal Factors those that dec bld circulating vol.

SHOCK;
Phase I: RENAL INSUFFICIENCY

Intra-Renal dses condition of the kidney eg. AGN

Post-Renal those that causes obstruction eg. Kidney

stones
Polyuria
Nocturia
Polydipsia
Phases of ARF
PHASE
II : MILD RENAL DAMAGE

Increase BUN and

same
Crea most sensitive Index

Fld and E Imbalance

Fld & E Imbalance
Activity
Intolerance
PI :

TO CORRECT THE IMBALANCE

A.
Fluid restriction;
restriction
B.
Meds : Diuretics
Amphogel to promote excretion of
Cardiac Glycosides Digitalis
Phospate

Fld

97
Antihypertensive
Inc RBC synthesis
C. DIET : Low CHON NO PMS
same

Epogen
Diuretics
AntiHPN
Diet:

muscle abnormalities twitching

seizures
RENAL TRANSPLANT s/s of complication : FLANK PAIN,
FEVER, TENDERNESS, HPN - REPORT

DIALYSIS
BPH
-

PERITONEAL
HEMODIALYSIS

glandular enlargement of the prostrate

common in males above 40 yrs old

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

Semi-permeable membrane: Abdomen (peritoneum)

Dialyzing machine
Use of Tenchkoff Catheter
fistula or shunt

Use of

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

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

Report Infxn (abdomen: rigid, Solution : cloudy)

Check BT and CT
external access
Check Temp of dialyzing solution
(more prone to infxn)

Complications of dialysis (report ASAP):

DISEQUILIBRIUM SYNDROME due to rapid removal of
solutes (electrolytes and CHON)
s/s:
GI nausea, vomiting, headache
CNS - convulsion, seizures
1.

2. DIALYSIS ENCEPHALOPATHY due to aluminum toxicity

s/s:
(+) dementia

gloves, ky jelly
position: Sims
Nsg Dx :

Altered Elimination Pattern

PI :
Prepare pt for surgery

TURP no incision

Suprapubic Prostatectomy

Retropubic -do
Perineal
-do- - common
complication: IMPOTENCE due to nerve damage
I am eager to have sex again cannot
be bec pt is impotence
nsgcare :

CBR for 2-3 days post

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

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;

w/c of the ff indicates complication of

peritoneal dialysis cloudy dialysate

DAY 8 (Feb 11, 2005)

EENT
General Consideration

Explain to the patient there there will be no or little

discomfort when performing EENT exam;

Explain the methods of assessment to the patient;

Consideration to Pediatric Patients

99

Obtain feeding history (bec the type & techniques

differs)

Obtain the diet hx of the pt and hx to URTI

Involve the parents in the assessment of the baby

Reportable Signs and Symptoms
TINNITUS - ringing, buzzing or sea shell sound in the

ear

VERTIGO - Objective the room is spinning

Subjective I feel that I am revolving/rotating

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

Absence of pain indicates rupture of Tympanic

Membrane ear drum
Lab Data :
OTOSCOPY revealed reddened, bulging
tympanic membrane
Nsg Dx :

Infection
Sensory Perception Alteration

PI :
Treat Infection (antibiotics 7-10 days) if does not
heal possible MYRINGOTOMY
Hx Teaching :

RIGHT POSITION while feeding

Keypoints for Assessment

Note for abnormal findings

Document the subjective and objective complaints

OTITIS MEDIA

RETINOBLASTOMA

FEMALE)

infection of the middle ear

RF :
Faulty feeding practices
Swimming in dirty waters
Upper Resp. Tract Infection
S/S :
PAIN Pulling
Tugging
Crying when lying on the affected ear

congenital tumor of the retina;

genetically transmitted;
autosomal dominant (common in MALE and

S/S :
LEUKOCORIA cats eye reflex
- whitish or grayish
discoloration of the pupil
Diplopia and or Strabismus
LAB DATA :

PE
Opthalmoscopy

100
Nsg Dx :

Knowledge Deficit

Lab Data : Opthalmoscopy

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

Nsg Dx :

Risk for Injury

PI :
Immediate Bed rest AFFECTED SIDE TOWARDS
THE BED to allow the connection of
DETACHED PART

RETINAL DETACHMENT
CATARACT
RF:
Aging (above 40)
Aging (above 70)
Related to trauma
Related to Trauma

GLAUCOMA
NO SUDDEN HEAD MOVEMENT
AVOID reading (TV ALLOWED)
Aging (above 40)

Prepare Pt for Surgery:

SCLERAL BUCKLING
use of laser to reduce inflammation and

Common in Blacks

when inflammation subside, the

Familial Predisposition

Rel. to

Diabetes
Rel. to Steroids
Rel. to

detached retina portion will be attached

thru scar formation.

Chromosomal Abberation
- those with D. Syndrome are prone

POST SURGERY :

AVOID activity that requires BENDING,

LIFTING, COUGHING;
(No Bowling & shampooing of hair at
sink)

RETINAL DETACHMENT
MP : There is separation of sensory and pigment portion of
the retina therefore it will allow fluids to go in
between which give rise to OUSTANDING manifestation
as:

REPORT SUDDEN eye pain indicative of

bleeding/ hemorrhage

VISUAL FLOATERS pt says: I see light

structures
Curtain like
Floating spots
Cobwebs
S/S : NO Pain
Blurring of vision because of floaters

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

101
If Obstruction related :
OPEN ANGLE.

could lead to CHRONIC

If due to Forward displacement: can lead to ACUTE

CLOSE ANGLE

b.
Prepare pt for Surgery : TRABECULOPLASTY a
new pathway was created for the passage of
the blocked fluids;
- Out-patient only (use of laser only)
TRABECULECTOMY requires
hospital admission for 1-2 days

S/S :
TUNNEL or Gun Barrel Vision wherein there is loss of
Peripheral Vision

Hx Teachings : same w/ retinal detachment

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
Chronic G

as high as 25;
- as high as 50
Gonioscopy
Opthalmoscopy
Perimetry measures visual field

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

Blurred Vision (Poor Color Perception)

NO PAIN

LAB DATA:
Nsg Dx :
PI :

Risk for Injury

TO DECREASE IOP
How:

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

a.

SLIT LAMP TEST test for red light reflex

(this reflex is absent in cataract pt due to presence of
milky white lens)
b.

Opthalmoscopy

Nsg Dx :
PI :

Risk for Injury

Prepare for SURGERY

102

CATARACT EXTRACTION Extra Capsular Cataract

Extraction (ECCE)
Intra Capsular Cataract Extraction (ICCE)

Hearing Loss +
VERTIGO (only for M. DSES)
Lab Data:

same

Caloric Stimulant test

Webers test

ECCE removal of anterior part

lateralization of sound
Rinnes bone

ICCE removal of entire capsule

conduction
Audiometry
(above test

PHACOEMULSIFICATION - needle is inserted to lens

and send vibration thereby crushing
the cataract then suction it out

use of TUNING FORK)

PERIPHERAL IRIDECTOMY a whole is created then

suctioning

Nsg Dx :
Risk for Injury
Perceptualalteration

Sensory

PI :
SAFETY
Communication
(to prevent pt from falling:
bedrest or supine danger of falls)
Surgery :
STAPEDECTOMY mobilization of

Establish

Post Cataract Surgery NO SEX for 4-6 weeks

Health teachings same w/ R. Detachment
MENIERES DSES

OTOSCLEROSIS
(hardening

stape

of the ears)
RF :

High altitudes
Aging
Ototoxic Drugs

Aging

S/S : Tinnitus

LOW NA (AVOID Alcohol & Caffeine containing

Meds :
AntiVertigo Diamox, Bonamine
Post Surgery Hx Teachings:

MP : Cause by an imbalance of EndoOvergrowth of the stapes

Lymphatic Fluids in the inner ear
Sensori-neural hearing loss since
Conductive Hearing Loss
Inner ear was affected
middle ear was affected

DIET :
food)

Effective : (-) Vertigo/ Falls

AVOID diving
Small

airplane
- since

same

Coughing
AVOID - driving
Blowing of Nose
PMS
Sudden Head Movement

Bending

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;
GASTROINTESTINAL

w/c Nsg Dx is considered a priority for a pt with

Menieres Dses Risk for Injury

a Tonometer is used for the purpose to determine

IOP;

Post Cataract Extraction : how shld the nurse position

the pt UNAFFECTED SIDE to minimize edema;

w/c of the ff is a common

Retinoblastoma Cats Eye Reflex;

manifestation

of

The parents of the pt w/ retinoblastoma must be

referred to - GENETICIST

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

PEDIATRIC CONSIDERATION

Introduction of FOOD: (shld be in order)

Cereals
Fruits
Vegetables
Meat
Table foods
Obtain child Dietary History
Assess for over-intake of milk poor source of iron
(IDA)
REPORTABLE S/S
Vomiting
Abdl Pain (if more than 6hrs) R/O rupture of the
bowel

104
Tarry Stool indicates bldg (upper GI)
Fever, Tachycardia, Dehydration indicative of SHOCK
Hypotention
KEPOINTS
Bowel Sounds (check all 4 quadrants- N 5-35 bowel
sounds/min)
to assess, use DIAPHRAGM of Steth to listen
for normal sounds
BELL part of Steth to listen for
abnormal bowel sound

Nsg Dx :
Diarrhea
Fluid Volume Deficit
PI :
Place pt on ENTERIC ISOLATION PRECAUTION
(handwashing & gloves ONLY)

while waiting for lab result

CHALASIA

GERD

Ex. bruit abnormal vascular sound w/c indicate abdml

aortic aneurysm

SPHINCTER

DIARRHEA/ AGE

S/S:
vomiting - NON-BILE-STAINED
burn due to Reflux of Acid

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

and CLOSTRIDIUM DEFFICELE
MP : Passage of watery and loose stools (BEST judge in
the consistency)
S/S :
Frequent stools
Sign of DHN sunken fontannels
Poor Skin Turgor
Absence of Tears (for more than 2 MONTHS old infant)
Check for complication : Metabolic Acidosis
If excess fluid loss, it will progress to shock due to K loss
(hypokalemia)

CONGENITAL WEAKNESS OF THE CARDIAC

Complication :
METABOLIC Acidosis
same
BARRETTS ESOPHAGUS
same
- damage to mucosal lining of lower esophageal mucosa
w/c can lead to esophageal CA

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

Stool Exam to check for bacteria

do
do
do

Nsg Dx : Altered Nutrition Less Than Body Requirement

Flds & E Imbalance
PI :

LAB DATA :

Hear-

Insure Adequate Nutrition

Position: Place pt in UPRIGHT to avoid vomiting

105
(if BABY: use HARNESS or PRONE w/ HEAD UP
POSITION)

Administer flds

Antibiotics/ Antidiarrheals ( dosage: if less than 10 kg,

therefore X100)

Health teachings crackers, juice, water

Feeding : Thickened

Prepare pt for surgery : NISSINFUNDOPLICATION part

of fundus will be sutured to

NON-CORROSIVE induce vomiting by stimulating

GAG REFLEX
How:
a.
Use fingers or tongue blade
b.
Syrup of Ipecac administer w/ glass of H2O
make sure that all taken will be
vomited bec it is cardiotoxic (after 1hr
can repeat)
dosage:
ADULT

esophageal area to tighten

Effective: if (-) vomiting and(-) reflux and heartburn

CHILDREN 15 ML
- 30 ML
CLEFT

LIP
POISONING
INTERVENTION:
a.
b.
c.

CALL poison control center;

MINIMIZE EXPOSURE remove pt from the scene
IDENTIFY the type of poison

if unknown substance was taken bring bottle or foil for

proper identification

MP:
Non-fusion of facial process
Palative Processess (soft & hard)
(congenital)
Nsg Dx :

Altered Nutrition
Risk for Aspiration
Body Image Disturbance

PI :

Nutrition
Safety
Prepare for Surgery

TYPES:

CORROSIVE DO NOT INDUCE VOMITING

Management: NEUTRALIZE the poison
If STRONG ACID give WEAK BASE (eg. ACID

give MILK)
IF STRONG BASE use weak ACID by using
vinegar

PALATE

Surgery :
Chiloplasty
Uranoplasty
- for 10wks old
18 mos
10 lbs
10gms/hgb
10,000 WBC
Post Surgery:

Non-fusion of
(congenital)

Palate
- if child is 15-

106

CRYING shld be minimize bec it will put pressure at

suture line;

LOGAN BAR/ BOW it decrease tension at suture line;

ELBOW RESTRAINT prevent child from touching the

suture line;

FEEDING DEVICE C CLIP use dropper, C PALATE

use Breck Feeder/ cup

Refer pt to: SPEECH THERAPIST, AUDIOLOGIST &

PSYCHOLOGIST

PYLORIC STENOSIS
congenital
hypertrophy (kumapal) of the pyloric sphincter (bet
stomach & intestine)
S/S :

PI :

Nutrition
Surgery FREDET-RAMSTEDT or
PYLOROMYOTOMY incision at pyloric sphincter

CELIAC DISEASE
-

GLUTEN INDUCED ENETEROPATHY

Genetic predisposition
Life-time disorder

MP :

PROJECTILE VOMITING (INITIALLY, NON-BILE STAINED

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

OLIVE-SHAPE MASS

VISCIBLE PERISTALTIC MOVEMENT usually from L to R

of the abdomen w/c can lead to DHN
LAB DATA :
Ba Swallow (+) string sign
NSg Dx :

Fluid Vol Deficit

Fld and E imbalance

Altered Nutrition

Intolerance to GLUTEN

OUTSTANDING S/S :
Malabsorption Syndrome-crisis
Abdl Enlargement this can be triggered
by INFECTION & Fld and E imbalance
Anorexia
Anemia
- there will be SEVERE DHN
LAB DATA :
Diagnostic Test : GLUTEN CHALLENGE
3-4 mos give gluten rich food
And if there is
malabsorption, therefore (+) CDses
Nsg Dx :

Altered Nutrition

PI :
Dietary Modification :
FOOD : Barley, rice, oats, wheat

AVOID GLTUEN RICH

ALLOWED : Rice, cereals,

corn, soy beans

107
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
HIRSCHPRUNGS DISEASE (AGANGLIONIC
MEGACOLON)

MP : There is telescoping of a part of a colon which leads to

inflammation and edema

MP :
Absence of parasympathetic nerve fibers in a
portion of a colon dilation, abdominal
distention and pellet-like or ribbon-like stool.

S/S : sausage-shape mass

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

Patient meconium ileus & constipation

HALLMARK SIGN
LAB DATA : BA Enema
Nsg Dx :

Altered Ellimination

Diet :

High Fiber
Increase fluids

Tx :

Give Enema

Nsg Dx :
Diet :
Meds :

Laxative
Surgery SOAVE Surgery resection with end
to end pull through

Tx :

Constipation
Altered Elimination
Inc. Flds.
High Fiber
wonder drugs steroid
surgery

TRACHEOESOPHAGEAL FISTULA (TEF)

108
MP : Failure of the esophagus to develop as a continous
process
Types :

AF1 esophagus NOT connected w/

abdomen/stomach

AF2 esophagus attached to trachea (when pt

eat, it goes to the lungs)

AF3 stomach connects w/ trachea

AF4 stomach & esophagus connected

AF5 stomach, eso and trachea are connected

AF6 separated properly

Atresia narrowing
Fistula connection
S/S : Excessive Drooling danger in aspiration
(avoid glucose water as initial
feeding use sterile H2O instead.)
Coughing, Chocking
Cyanosis
LAB DATA :

Lateral Neck Xray to check the esophagus

Nsg Dx :

Risk for Aspiration

PI :

Safety
Airway
Keep child NPO just give pacifier (if feeding OK
use sterile H2o instead NOT GLUCOSE)
Tx :

Surgery

TIPS FOR GASTRO PEDIA

w/c of the ff signs if manifested by a child post

tonsillectomy needs to be reported FREQUENT
SWALLOWING;

a child who has had several episodes of diarrhea is

likely to develop metabolic acidosis;

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

the nurse is important weighing pt daily for wt loss;

w/c of the ff will the nurse expect to observe in a child

who loss fluid due to diarrhea flushed dry skin;

the most appropriate feeding device for a child post

cleft palate paper cup;

the priority nsg care for a child on NPO is offer a

pacifier regularly;

a common manifestation of pyloric stenosis is

visible peristaltic wave;

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

diarrhea;

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

dses intolerance to gluten

PEPTIC ULCER

109
RF :

Stress
Smoking
Salicylates or NSAIDS
Helicobacter Pylori
Zollinger-Ellison Syndrome (gastinoma) tumor of the
stomach due to increase HCL acid
GASTRIC
DUODENAL
RF :

Nsg Dx :

PAIN

PI :

Relief of Pain

ESOPHAGEAL

same

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

same

MP : Weakened Mucosa
Excessive HCL Acid
Common in Female
in Male
Below 65
above
Inc risk for CA

Common
65 yo &

NO ASPIRIN
Diet :
vegetables

BLAND DIET NO SPICY, fried, raw fruits and

(EXCEPT: avocado, banana &

pineapple)
OUSTANDING S/S: PAIN aching, burning,
gnawing

GASTRIC SURGERY

PAIN 30mins 1hr post meal

3hrs after meal
PAIN at daytime
Nightime
Pain relieved by vomiting
Pain relieved by eating

2-

Also
related as hyperacidity
HEMATEMESIS (vomiting of blood)
- severe bleeding shock
LAB DATA :
GASTRIC Analysis (diamox blue urine)
Gastroscopy
BA Swallow
HgB
Hct

(BII)

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

BI gastrodoudenostmy duodenum and stomach

BII gastrojejunostomy stomach and jejunum
COMPLICATIONS:

PERNICIOUS ANEMIA due to decrease

INTRINSIC FACTOR w/c came from stomach;

110

DUMPING SYNDROME (occur usually for 10-12

mos post surgery)
due to rapid emptying of the stomach and
stimulation of gastro-colic reflex
GASTRO-COLIC REFLEX is usually due to
increase CHO INTAKE in the diet
- NO PANCAKE, NO UPRIGHT
SITTING AFTER MEALS
S/S OF Dumping Syndrome : Diarrhea
Diaphoresis
Dizziness/drowsiness
Management:
NO FLUIDS after meals instead in
between meals
DIET: High Fats because it delays the
emptying of the stomach
LOW CHO
Lie down after eating

MP :
Inflammation @ large Intestine Inflam @ L Intes.
Inflam of small &
Specifically @ recto-sigmoid colon
at
DIVERTICULUM
large intestine
S/S :

same
same

DIARRHEA (15-20x/day)
3-4x/day
bloody mucoid

diarrhea & constipation

FEVER

(+)

(+)
(+)

CRAMPY ABDL PAIN LLQ

LLQ
RLQ
(Rigidity (REPORT ASAP) sign of colon rupture)
LAB DATA: BA ENEMA
Colonoscopy
Stool Exam

INFLAMMATORY BOWEL CONDITION

ULCERATIVE COLITIS
CROHNS DSES

Nsg Dx :

PAIN
Altere Elimination: Diarrhea

DIVERTICULITIS

(Regional Enteritis)
RF : With familial Predisposition
Common in
those LOW FIBER Diet
Related to Genetics
Smoking as Protective Effect
Common in
Aging
Common in Obsessive-Compulsive
Or Stress Related or to perfectionist

PI :

Relieve Pain
Meds:
Steroids
Anticholinergic
Antidiarrheals
Antispasmodic

DIET :
Low Fiber and Low Residue for Ulcerative
and Chrons

111
Diverticulosis High Fiber/residue allowed:
vegetables
Low residue (no vegetables)

III Entire Area manual reduction

IV Entire Area irreducible
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
PINKISH
EDEMATOUS
MOIST
N elevation from skin: 2.5
cm
Diameter : 5cm

S/S

LAB DATA

Sigmoidoscopy
Proctoscopy
P Exam

When to empty colostomy: when 1/3 full (EMPTY

DO NOT CHANGE)

Nsg Dx

Altered Elimination

PI

Diet : High Fiber

Avoid Spicy

When to change C. Bag : 48hrs or 3x a wk

Pruritus
Pain
Bleeding

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

CRAMPS

- emerge up to pelvic area with

ice pack at head to prevent dizziness
STOOL SOFTENER
SURGERY

HEMORRHOIDS
MP

Varicosities of the ANAL SPINCHTER

RF
PREGNANCY
PROLONGED STANDING
PORTAL HPN hepatic enceph and liver cirrhosis

PANCREATITIS
AUTODESTRUCTION OR AUTODIGESTION of the
pancreas
RF

GRADE
I Small Area
II Large Area reduces spontaneously

#1 Alcoholism
#2 autoimmune
High Fat Diet
Biliary Dses

112
SS
PAIN @ peri-umbilical area or epigastric that radiates
to peri-umbilical area
GREY TURNER SIGN pain w/ bluish
discoloration at flank area;
CULLENS SIGN pain w/ bluish discoloration @
umbilicus

Forty
flatulence
S/S R UQ Pain radiating to R shoulder or R Scapula
usually precipitated by FATTY INTAKE
GI S/S NAV diarrhea and Jaundice
URINE: dark colored

NAUSEA & VOMITING

SHOCK as complication

STOOL : clay-colored or grayish alcoholic stool

LAB DATA
Elevated Serum Amylase (N56-190 u/L that
normalize in 2 wks)
Nsg Dx
PI

Increase AMYLASE, WBC, FATS

Increase Liver Fnx test
USG

Nsg Dx

PAIN

PI

Relief of Pain
meds : DEMEROL
diet:
LOW FAT

PAIN
Relieve PAIN

Meds: DEMEROL DRUG OF CHOICE

AVOID MORPHINE it causes more pain bec it will
causes spasm to the spinchter of oddi
DIET

LAB DATA

surgery :
incision, CO2 insufflation

LOW FAT
AVOID alcohol

1) LAP. CHOLE 4 small

2-3 days after discharge pt and back to ADL

1 WK after pt can lift weight
CHOLELITHIASIS

CHOLECYSTITIS

Combine or usually come together in a pt

2) CHOLECYSTECTOMY R
SUBCOASTAL
complication: Pneumonia
report rusty-colored sputum
hx teaching:

Stone in gall bladder

Inflammation of the G. bladder
RF

Fat
Female
Fertile

TURNING, COUGHING, DEEP BREATHING

same

113
HEPATITIS
MP

Isolation : A & E Enteric

B, C, D Universal

Inflammation of the Liver

COMPLICATION Liver Cirrhosis

TYPES
A

Infectious
SERUM
POST TRANSFUSION
DELTA HEPA ENTERICALLY-TRANSMITTED

LIVER CIRRHOSIS
- scarring of liver
tissues
TYPES

Fecal-oral
bld, body flds
Post Hepa B Fecal-oral

Non A & B

(Hepa A & B Combination

2-6 wks
6wks-6mos 70-80 days
6mos

LAENNES
NECROTIC
6wks-

STAGES OF HEPA B

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

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

Lab data

Increase Liver Funx Test (Inc AST/ ALT)

Hepa A Inc HaV
Hepa B HbsAg

Nsg Dx

Infection
Alt Skin Integrity
Body Image Disturbance

BILIARY

Due to alcoholism
CHF due to Hepatitis

CARDIAC

Due to biliary Disorder

POST
due to

S/S are related to 3 FUNXs of the LIVER

MANUFACTURES :
bile, immunoglubolin, &
clotting factors

METABOLIZES:
CHO, Fats, CHON, Alcohol
and Drugs

STORES :
Vitamins & Minerals
Signs and symptoms

PI

Tx for Infection
a. Meds : HEPATOPROTECTORS
DIURETICS

a.
b.
c.
d.

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

LAB DATA
b. Diet : High Calorie
Low Fat

Increase Liver Funx Test

Liver Biopsy

114
Nsg Dx

Risk for Injury

Fld & E imbalance
Fld Vol Excess
Altered Nutrition

PI

SAFETY
HOW?

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

Increase abdl girth I cannot button my pants

anymore
(fluids)
management:
abdominal paracentesis aspiration of
fluids from the peritoneum
- complication: chance
for infection & shock

Diet : LOW CHON or CHON to Tolerance

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

SURGERY :

Liver Transplant

COMPLICATIONS:
a.
HEPATIC EBCEPHALOPATHY accumulation of
ammonia toxic to brain
s/s:

PERSONALITY CHANGES
DECREASE LOC or irritability/ restlessness

DRUG OF CHOICE : Neomycin, Lactulose

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

ASCITIS accumulation of fluids at the abdomen

wt gain

pt preparation:
#1 instruct pt to void;
#2 position: sitting the evaluate
the WEIGHT, ABDL GIRTH & REPSIRATION
effective if : Pt decrease wt of 5 lbs and
decrease or N RR
c.
HPN

BLEEDING ESOPHAGEAL VARICES DUE TO portal

Lab data
Sengstaken Blakemore Tube 48 hrs inflated,
scissors at bed side
(Balloon Tamponade)
- effective if (-)
hematemesis

115
TIPS GASTRO ADULT

A pt w/ appendicitis was admitted, of ALL the ff written

orders, w/c shld the nurse prioritize Administration of
Antibiotics;

w/c statement if made by a pt w/ cirrhosis is a risk

factor for having the disease I drink 2 glasses of
alcohol /day;

which of the ff indicates a ruptured appendix

absence of pain;

ff subtotal gastrectomy, the nurse shld expect gastric

drainage for the 1st 12 hrs to be reddish brown;

the priority nsg care post common bile duct

exploration preventing hypostatic PNA;

w/c question during nsg assessment would confirm

the Dx of L Cirrhosis
how long have you noticed the white in
your eyes turns yellow;

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

Nutrition

the priority nsg dx for for pt w/ acute pancreatitis

Altered nutrition less than body requirements

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

#1 LEVEL OF CONSCIOUSNESS

116

#2 BEHAVIOR
#3 REFLEX

When assessing MUSCULO SYSTEM:

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

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

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

PEDIATRIC CONSIDERATION
a. Check for bowel and bladder funx indicates neurological
maturity
15-18 months START BOWEL TRAINING
2 yo start bladder training

#1 Decrease LOC
#2 widening pulse pressure (increase
systolic BUT diastole is N)
#3 Convulsion & seizures
ABOVE ARE S/S OF INCREASE ICP.
DECEREBRATE more serious
- abnormal extension w/c indicates
damage to brain stem

b. Assess for their habits

security blankets ex. Stuff toys, mother wallet
Associate mothers time w/ child activity
(children has NO DEFINITE TIME)
Ex. Your mom will be back after you have
eaten your lunch.
c. Assess for presence of URTI could be sign of Meningitis,
Hemophilus influenza, Otitis Media
d. Assess child for S/S of anxiety
-

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

GLASGOW COMA SCALE

EYE OPENING (4)
MOTOR (6)

VERBAL RESPONSE (5)

6

OBEYS COMMAND
5 ORIENTED
LOCALIZES PAIN
4 OPEN SPONTANEOUSLY
CONFUSED
4 WITHDRAWS FROM PAIN
3 OPENS TO VERBAL COMMAND
INAPPROPRIATE
3 - DECORTICATE RIGIDITY
2 - OPEN TO PAIN
2 - INCOMPREHENSIBLE
DECEREBRATE RIGIDITY
1 - NO RESPONSE
1 - NO RESPONSE
RESPONSE

54
3
21 - NO

117
AND MOTOR : ability of pt to
chew
SCORE OF 3 :
the one to pronounce

NO response (DEAD) Doctor will

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

SCORE OF 15

pt is

awake
Score of 8

7 and BELOW

50-50, MONITOR THE PT

:

VII.
FACIAL
:
SENSORY : sense of taste @
anterior 2/3 of the tongue

pt is COMA
and MOTOR

CRANIAL NERVES
I.

OLFACTORY : SENSORY
Abnoxious smell

: Facial Expression

VIII. ACOUSTIC or VESTIBULOCOCHLEAR - Sense of

hearing and balance

: smell

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

Anosmia no
smell
Perfume
II .
OPTIC
: SIGHT snellens chart
20/20 usually by age 3-6 yo

IX.
GLOSSOPHARYNGEAL
X.
VAGUS
SENSORY
Posterior Taste 1/3 Of The Tongue
MOTOR - swallowing and

III.
OCCULOMOTOR
IV.
TROCHLEAR
Eye movement - 6 cardinal
direction of gaze
VI.
ABDUCENS
(if
abnormal look for DIPLOPIA)

gag reflex
XI.
SPINAL ACCESSORY - motor movement of
shoulder muscle
XII.

V.
TRIGEMINAL : SENSORY :
FACIAL SENSATION

responsible for
(to check,

use cotton & needle and run across the cheek)

HYPOGLOSSAL TONGUE MOVEMENT

118
DUCHENES MUSCULAR DYSTROPHY (DMD)
X linked RECESSIVE (only mother transmit to SON)

COMPLICATIONs
young children

Respiratory Paralysis for

Cardio-Resp. Arrest

for

adolescent
(-) Father

Mother (+ carrier) Son - 50% chance

LAB DATA

Muscle Biopsy
PExam

Nsg Dx

Ineffective Breathing Pattern

Impaired Physical Mobility

PI

AIRWAY
(keep TRACHEO at bedside)

Daughter as Carrier 25%

chance
DMD

Erb Duchennes Paralysis (EDP)

Klumpke Palsy (KP)

Related to Birth Injuries affecting the

BRACHIAL PLEXUS nerves at axilla portion
HEREDITARY

EDP upper plexus

KP - lower plexus

w/c leads to

TX
a.
b.

Supportive - leg brace, crutches

Refer parents to geneticist

paralysis.
Prognosis : complete
recovery in 3 months

Target: Mothers or FEMALES bec they are the

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

S/S

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.

a) GOWERS SIGN inability to stand up

- use arms to brace the body

Cause

b) WADDLING GAIT - duck-like gait

S/S

c) impaired mobility
d) difficulty in running and climbing

Unknown

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

119
LAB DATA

Neurological Assessment
PExam

Nsg Dx

Risk for Injury

Impaired Physical Mobility

From Lateral Ventricle it goes to Foramen of

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

PI

SAFETY

a.
Leg braces
b.
Meds : Anticunvulsants, Muscle Relaxants
c.
Prepare child for SURGERY release of TENDON
OF ACHILLES to promote mobility
d.
Refer child to : PT for gross motor movement
walking
OT - for fine motor to open a bottle
of soft drinks

PROJECTILE VOMITING

IRRITABILITY

ENLARGED HEAD N Head Circumference : 3335 cm (chest circum: 31-35 cm)

SEPARATION OF SKULL BONES

SEIZURES

SUNKEN EYES Can Progress To Bossing Sign

MACEWEN SIGN crack pot sound upon

knocking the head
LAB DATA

HYDROCEPHALUS
NOT A DISEASE but a manifestation of an existing disorder

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

Related to ARNOLD CHIARI MALFORMATION

DANDY WALKER SYNDROME
there is ELONGATION of the BRAIN STEM or Medulla
- characterized by ATRESIA of
and it protrudes to Foramen magnum
Foramen of Luschka & Magendie
SIDE NOTES:
rich in glucose

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

Position
in ICP
Meds

to

Risk for Injury

SAFETY
Semi Fowlers to prevent increase
Diuretics
Anticonvulsants

Surgery
Ventriculo-Peritoneal
progressive procedures

Shunt

(AS

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.
b.
c.

Position: Prone or side lying (NEVER SUPINE);

Wet sterile gauze to cover the skin;
DOUGHNUT ring

SURGERY

WITHIN 24-48 HRS

SPINA BIFIDA failure of a PORTION of spinal cord to fuse

COMPLICATION

TYPES

Post Surgery Complication

measure- at bed side)

SB OCULTA
NO SAC
W/ DIMPLE or TUFT OF HAIR

Bladder and Bowel Problem

Paralysis of Lower Extremities
Hydrocephalus (tape

SB CYSTICA
W/ SAC

INCREASE ICP

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
RF

MENINGITIS
MENINGISMUS

Hydrocephalus
Space Occupying Lessions
Brain Tumor
Trauma

Inflammation of meninges w/c could be related to

Inflammation of meninges but WITHOUT
the presence of bacteria esp the H. Influenza, and
infection
Neisseria Meningitidis
Usually accompany w/ resp. disorder

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

S/S of INC ICP + Kernigs Sign pain on extension

of lower extremities
+ Brudzinkis
- flexion of neck
would lead to flexion of lower ext.
- sign of MENINGEAL
IRRITATION
LAB DATA

Lumbar Puncture
CSF Analysis

Nsg Dx

Infection
Risk For Injury

PI

Safety
Seizure Precaution
Tx the Infection

3. Vomiting
4. Monitor Abnormalities decorticate,
decerebrate

Nsg Dx
PI

Risk for injury

To decrease ICP

Head of Bed ELEVATED

Evaluate Neuro Status Glasgow
AIRWAY
Discharge Meds Instruction
Anticonvulsants, Steroids, Diuretics (mannitol to
dec amt of cerebral edema)

Seizure precaution DARKENED ROOM

Type of Infcetion:
a.
b.

Bacterial Meningitis respiratory of droplet precaution

Viral Meningitis - enteric precaution

MEDS
Antibiotics

For Bacterial Meningitis - may cause hearing

impairment - refer to AUDIOLOGIST

122

REYES SYNDROME

CVA/ STROKE

Non inflammatory, non recurring but TOXIC ENCEPHALOPATY

and HEPATOPATHY
(CNS)

(LIVER)

RF

Presence of Viral Infection

Use of Aspirin

TRIAD S/S Fever

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

I
II
III
IV
V

pt becomes lethargic
confusion
decorticate rigidity
decerebrate rigidity
seizure or coma

LAB DATA

Bleeding and Clotting Time

Liver Biopsy
Neurological Assessment

Nsg DX

Risk for Injury

Altered Thought Process
Altered Thermoregulation
Impaired Physical Mobility

PI

Treatment symptomatic assess neuro

status
Bleeding give Vit K
AVOID ASPIRIN when there is VIRAL
INFECTION

MP

Decrease Oxygen to brain cells

TYPES
THROMBOSIS
EMBOLISM
HEMORRHAGE
INFARCTION
RF
atherosclerosis
hpn
obesity
smoking
stress
age/ gender
SIGNS & SYMPTOMS:
1. DEPENDS ON THE PROGRESSION

a.
TIA brief period of neurologic dysfunction that last
less than 24 hrs (between episode, pt is N);
b.
STROKE IN EVOLUTION there s/s like: facial paralysis
Muscle weakness
- above s/s could
last 2-3 days
c. COMPLETE STROKE there is FOCAL s/s
if R side of Brain Affected L Eye - R Face L Body
if L Brain R Eye L face R body
2. RELATED TO LOBES

123

FRONTAL if affected PERSONALITY CHANGES

BROCAS AREA (expressive aphasia mouth opening);

TEMPORAL - memory disturbances

WERNICKS LANGUAGE AREA (choice of
words, understanding - RECEPTIVE APHASIA);

PARIETAL - DISORIENTATION especially SPATIAL

orientation;

mgt: talk
to pt slowly
Dysphagia
swallow twice to prevent aspiration

instruct the pt to

LAB DATA

Increase Cholesterol

Diagnostic Test

CT Scan
MRI
EEG

OCCIPITAL - VISUAL disturbances

Nsg DX
care half of the body

Unilateral Neglect inability to

Impaired Physical Mobility
Risk for Injury

PI

3. SIGNS AND SYMPTOMS INDICATIVE OF

COMPLICATIONS
Hemianopsia
loss of half of the
visual field (eg. Pt consumes half of the food at plate);
Hemiphlegia

paralysis of one side

mood swing

Aphasia
Expressive inability
to find right words to say (damage to Brockas Area);
- pt can say
right words mgt: picture board
and Receptive inability to understand spoken words (Wernicks area)

Position

Semi-fowlers
Elevated

Meds

Antihypertensive
Diuretics
Antilipimic Agents
Anticonvulsants
Thrombolytics if (+) thrombus

to dissolve clots
DIET

of the body;
Emotional Lability

SAFETY

Low Na and Cholesterol

Activity

Range of Motion Exercises

Surgery

Craniotomy
Infratentorial Cranio FLAT
Supratentorial
- Semi-

fowlers

124
DISEASES OF NEUROMUSCULAR
Barre Syndrome (GBS)

Guillain

LAB DATA CSF Increase CHON

TENSILLON TEST 5 mins
(to all neuromusco disorders)

Myastenia Gravis (MG)

Multiple Sclerosis (MS)
Amyotrophic Lateral Sclerosis (ALS)
GBS
MG

Descending paralysis start @ upper ext.

Common in Male and Female

NO gender related factor but could be related to viral

infxn
Early onset : 20-30 yo (Female)

Reversible
Early onset : above 50 yo (male)
MP
Inflammation that leads to destruction of Peripheral
Nerves
Deficiency in ACTH Receptor Sites 90%
w/c leads to:
ASCENDING GBS
Or Def. in ACTH neurotransmitter
DESCENDING GBS
Mixed Type GBS
ASCENDING GBS - #1 Clumsiness that eventually lead
S/S Muscle weakness w/c begins at face
muscle weakness & resp. depression
therefore, Diplopia and Ptosis which

Nsg Dx
Ineffective Breathing Pattern (ALL)
same
PI
AIRWAY (tracheostomy bed side) ALL
same
MEDS
Steroids
Neostigmine ATSO4 - antidote
Avoid crowded areas : viral infection
Refer to NEUROLOGIST,
PULMOLOGIST and PT
MYASTHENIA GRAVIS
COMPLICATIONS

Myasthenia Crisis (MC) - due to under

medication or lack of meds;

Cholinergic Crisis (CC) - due to over medication

overdose
Signs and symptoms of above
complication:
MUSCLE WEAKNESS in MC due to
ACTH Deficiency while in
CC due to or as
adverse effect of the drug

to

progresses to MASK-LIKE face which lead to

respiratory depression
(descending paralysis start at face NO
telebabad)

Treatment : TENSILLON effective in

MC it INCREASE MUSCLE STRENGTH
Effect in CC it
worsens muscle weakness once given give ATSO4
NEOSTIGMINE for MC as
TREATMENT

125
(LON GAHRIGS DISEASE)
MULTIPLE SCLEROSIS
Common among women
especially white
There is destruction of MYELIN
SHEET at CNS , therefore generalized muscle weakness

MP

Destruction of Upper and Lower Motor Neurons;

Genetically Transmitted: AUTOSOMAL
DOMINANT common in Male & Female
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
Impaired Cerebellar Funx

LABDATA

CSF Increase CHON

EMG contract and relax

needle insertion
Muscle biopsy

Ataxic Gait lasing

Impaired Sensation NO HOT/COLD BATH

NSG DX

Ineffective Breathing Pattern

PI

AIRWAY (tracheostomy)
SUPPORTIVE
Refer to Geneticist

Impaired Sensory Funx impotence

LAB DATA #1 MRI specific test for MS it localizes
the area of plaque formation or the area of dyemlination
#2 CT SCAN
NSG DX

same with GBS & MG

DRUGS

STEROIDS
Anticonvulsants dilantin
Muscle relaxant Baclofen
Bladder Stimulants Urecholine

(bethanicol)
HX TEACHINGS

AVOID : HOT COLD SHOWER

Refer to PT: ROM Exercises

SIDE NOTES:
A Recessive :
Cystic Fibro, Sickle Cell,
Apalstic/Fanconis either or both parents are (+) for
trait NOT DSES
A Dominant :
Retinoblastoma, ALS
either father or mother (+) for disease or trait
X Link Recessive : Hemophilia, Color
Blindness, Duchennes Muscular, G6PD Dses mother (+)
trait NOT DSES
and transmit to SON
SPINAL CORD INJURY
Destruction of S. Cord

AMYOTHROPIC LATERAL SCLEROSIS

related to TRAUMA

126
TYPES
CERVICAL
8 most serious quadriphlegia
THORACIC 12
LUMBAR
5
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
LAB DATA Myelogram
CT Scan
Xray

a.

Nsg Dx

Risk for Injury

Impaired Physical Mobility

PI

SAFETY

Immobilize the spine side lying w/ pillows bet

legs
b.

Surgery

COMPLICATIONS OF SPINAL INJURY :

AUTONOMIC DYSREFLXIA due to full bladder and bowel
s/s : #1
INITIAL : HPN
#2
Diaphoresis

#3
slight fever
what to keep at bedside: CATHETER - TO KEEP
THE BLADDER EMPTY, BEC IF FULL IT WILL TRIGGER THE ANS

TIPS FOR NEURO

A 10 yo is to undergo EEG, w/c comment made by a pt

demonstrate that she understands the procedure I will
wash my hair after the procedure;

A pt w/ tumor of the frontal lobe will most likely

manifest difficulty in concentrating;

A pt w/ M. Sclerosis has urinary incontinence. To

achieve voiding, w/c nsg care shld the nurse give
establishing regular voiding sked;

While interviewing a pt. w/ Myasthenia gravis, w/c of

the ff statements confirm the dx I have difficulty in
swallowing;

A male pt w/ CVA is observed by the nurse to have

consumed half of his meal, the PRIORITY Nsg Dx
Unilateral Neglect;

When taking care of pt w/ C4 Spinal Injury, w/c

equipment shld the nurse keep @ the b.side Urinary
Catheterization Set;

The PRIORITY NSG DX for pt w/ Myasthenic Crisis

Ineffective Breathing Pattern

127
MP
Maldevelopment of the Hips that involves the
acetabulum, head of femur or both
S/S

MUSCULO
CLUBFOOT DEFORMITY
MP
Congenital
Foot twisted out of place
Types

LAB DATA
Talipes Varus inversion
Talipes Valgus eversion
Talipes Equinus tiptoe

LAB DATA

PE
Xray

Nsg Dx
PI

Extra Gluteal Fold at affected side;

Ortolonis Sign (+) Click
Trendelenburg Sign or Pelvic Dropping when
child stand in one foot toward the affected side,
then there is
change in length
Allis Sign or Galleazis Sign shortening of the
affected leg

click
Ortolanis abduct leg sideward (+) click
Nsg Dx

Impaired Physical Mobility

Promote Mobility

PExam
Barlows Manuever press leg downward (+)

Impaired Physical Mobility

PI
#1 Double or triple diaper to keep legs in
abducted position;
#2 PAVLIK Harness - for 2-3 mos
#3 Hip Spica Cast LAST RESORT

#1 MANUAL MANIPULATION
#2 SEREAL CASTING every 1-2 wks til
position normalizes
#3 DENNIS BROWN SPLINT 2-3 months
CAST : assess for s/s of neurological damage:
Capillary refill if more than 3 sec. - REPORT

NO ADDUCTION OF LEGS!

EDEMA
FRACTURES
Skin Color/ nailbed

CONGENITAL HIP DISLOCATION

MP
Break in the continuity of the bone
TYPES
Open (compound) bone tears the skin
therefore open: risk for infection
CLOSE skin intact

AVULSION tear in the tendon

128

COMMINUTED
- fragmented
COMPRESSED crushed
IMPACTED driven to each other
DEPRESSED pressed
SPIRAL goes around the bone
GREENSTICK incomplete

#1 Deformity
#2 Pain
#3 Edema
#4 CREPITUS sound created when two bone
surface rob each other

S/S

NSG DX

Impaired Physical Mobility

PI

MOBILITY immobilize the fx

a.
Splinting;
b.
Casting check for edema elevate the affected
areas;
- check skin color capillary refill time
- check for presence of blood stained
c.

OUSTANDING S/S

Uneven Hemline;
Uneven waistline;
Uneven shoulder
(+) Rib Hump
Prominent Iliac Crest

LAB DATA
Bend Over test instruct to touch the
toes and note for rib hump
Xray
Nsg Dx

Impaired Physical Mobility - child

Body Image Disturbance - adolesence

After cast, - CRUTCH WALKING

2 point gait indicated if both lower extremities has

partial wt bearing;

4 point gait indicated for partial wt bearing;

3 point gait - indicated if 1 leg is allowed partial wt

bearing and
the other one is N;

swing through - when both legs need to moved past

the level of the crutches

swing to when both legs need to be moved AT THE

LEVEL OF THE CRUTHES
going upstairs unaffected then crutch
(goodleg crutch bad)
going down crutch then bad leg then good
leg

SCOLIOSIS
Lateral Deviation of the Spine
STRUCTURAL non correctible
FUNCTIONAL - correctible

MP
RF

TX
a. To decrease curvature wear BOSTON or
MILWAUKEE Brace
for 23 hrs/day except
bathing
b. SURGERY HARRINGTON ROD
- LUQUE
HX Teaching
Avoid :

Bending
Jumping Rope
Playing Tennis
Trampoline

Allowed: Brisk Walking

Swimming

129
Cheer Leading
OSTEOPOROSIS/ HUNGRY BONE
MP

Loss of Bone Density

RF

#1 smoking
AGING
IMMOBILITY
MENOPAUSE decrease Estrogen
Secondary to Existing Condition as
secondary Hyperparathyroidism
S/S

PAIN
Dowagers Hump
Short Stature
Progressive Decrease in Height

LAB DATA

Nsg Dx

Decrease in Calcium
Bone Densinometry
Bone Scan
Xray
SAFETY

ARTHRITIS
RHEUMATOID
OSTEOARTHRITIS
Common

GOUTY

FEMALE
MALE/FEMALE

Affected Part
Upper Extremities
Extremities wt bearing joint

MALE
Lower

How?
MP

DIET : High Ca especially 4 those with

OSTEOPOROSIS
- spinnach
- seafoods
- sardines

ACTIVITY : Partial Weight Bearing (NO SWIMMING)

jumping rope
- bicycle reading
- brisk walking

MEDS : Ca Supplement - alendronate

Fosomax SIT UPRIGHT AFTER

Chronic, systemic inflammation of connective

tissues
Synovial joints and joints of Upper
extremities
S/S

PAIN
Inflammation
Morning Stifness

Stages of Rheumatoid A.

STAGE 1 no Disability
STAGE 2 with Interference To ADL

130
STAGE 3 - with major compromise of funx
STAGE 4 - incapacitation

Diet : Low Purine/ Purine Restricted:

AVOID : Organ Meats
SEAFOODS

ULNAR DRIFT

SWAN NECK

DEFORMITY
LAB DATA

Decrease HgB
Increase ESR

Nsg Dx

PAIN
Impaired Physical Mobility

PI
a. Warm Bath;
b. MEDS :

Relief of Pain
ASA - Antiinflammatory
STREROIDS
c. exercise: ROM

Alcohol
ALLOWED: Cheese (EXCEPT
fermented and Aged)
Increase ORAL Fluid Intake

OSTEOARTHRITIS
A degenerative joint disease that involves the weight bearing
joints elbows & knees
S/S

GOUTY ARTHRITIS

PAIN NO inflammation
Bouchards Nodes (distal)
Heberdenes Node (proximal)

MP
Metabolic disorder of purine w/c leads to deposition or
uric acid at joints
site: THE GREAT BIG TOE

LAB DATA

S/S

Nsg Dx

PAIN
Impaired Physical Mobility

PI

Weight Control

(+) PAIN usually aggravated by pressure

(+) Inflammation
above s/s affects the LOWER EXTREMITIES

LAB DATA

Increase Uric Acid

NSG DX

PAIN
Impaired Physical Mobility

PI

Relief of PAIN
Meds : Allupurinol, Probenecid

xRAY

Health Teaching

Hot or Cold Compress

ASA
Trunk Assistive Device (cane)

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

131
Autoimmune multi system dses characterized by
inflammation of connective tissues
JOINT
:
stiffness;
CARDIOVASCULAR :
CNS
:
Irritability, Headache

(+) pain, (+) morning

TIPS FOR MUSCULO
(+) chest pain;
(+) s/s of dec LOC,

OUTSTANDING S/S BUTTERFLY RASH (also present in pt in

PROCAINAMIDE TOXICITY)

the priority nsg care for the pt w/ bucks extension

traction shld be ensure that the traction applied to the
affected leg is always attached to the weight;

LAB DATA

Increase ESR

pt in russels traction is being taken cared of by the

nurse, it would be necessary for the nurse to intervene if
the pt feet are pressed against the foot board;

Nsg Dx

PAIN
Altered Tissue Perfusion
Risk For Injury

a pt is using CRUTCHES for the first time, w/c action

reflects a need for further instruction the pt bears his/her
wt with his/her axial;

TX
available s/s

Symptomatic/ Supportive meaning, treat

Drugs

Steroids

a pt on bucks traction of the R femur ask the nurse

how he can possibly move around. What can the nurse
advise the pt you can hold on to the trapeze bar while
moving;

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

abnormality in an adolescent uneven hemline
scoliosis;

TRACTION
PRINCIPLES

T rapeze bar
R equires free hanging weights
A nalgesic
C iculation monitoring
T emperature monitoring
I - nfection prevention
O utput and input monitoring
N utrition
S kin Assessment

when assessing an infant, w/c of the ff needs to be

reported extra gluteal folds;

post spinal fusion ROBAXIN is given for w/c of the ff

purpose - to decrease muscle spasm;

a child has hip spica cast upon discharge, w/c

statement of the father indicates further instruction I will
hold on to the bar bet his legs to help move him

132
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
DERMIS

Pain

Redness

Eg sunburn

FULL THICKNESS
THIRD DEGREE

4TH DEGREE
SUB Q

MUSCLES
MUSCLES & BONES
LEATHERY APPEARANCE
CHARRED APPEARANCE
NO Pain

Pain

Burn triage : face and perineum (priority)

Redness
Blister Formation
pain

SUB Q FATS

FATS

INTEGUMENTARY SYSTEM

EPIDERMIS & PART OF

MODERATE
PARTIAL TICKNESS
15-25%

MINOR
MAJOR
less than 15%
25%

No

133
FULL THICKNESS
>10%

NONE

<10%
LYMES DISEASE
Mountain Fever

Rocky

RULE OF 9 CHECK NOTE day 9 page115

caused by BORRELIA BURGDORFERI (deer
Dermacentor/ Variabilis dog ticks

ticks)
BURN TRIAGE
Priority : Burns of

THINK:

FACE
PERIMEUM
UPPER & LOWER EXT
Burn related to Child Abuse
Chemical Fire

R escue
A larm
C onfine the Fire
E xtinguish the Fire

3-30 days
or Dermacentor Andersori (wood)
2-3 wks

s/s :

Fever, Pain, Chills,

Rashes
RASHES: Bulls Eye Rash or Rounder Rings
Generalized rashes
At moist body parts

PRINCIPLES OF NSG CARE FOR BURN PTS:

B reathing Airway
U rine output monitoring
R esuscitation of Fluids
N utrition
S ilvadene Ointment

Complications
Cardio, Musculoskeletal and CNS
- which can lead to paralysis
TX
been to the woods?
PI

DIET DAT (High CHON, Ca, Vit C)

Complication

FIRST 24HRS SHOCK

72Hrs
- INFECTION

Pt Preparation : Bed Craddle

Avoid wooded area have you

Vaccination
Use long sleeve
Remove ticks w/ twizers upward

straight motion
Meds

Chloramphenicol
Tetracycline

134
Causative Agent Herpez Virus
Rubella Virus

DERMATITIS

INC PERIODUnknown
14 -21 days

DIAPER (contact)
ATOPIC ECZEMA (adult)
Peak : During infancy 9-12 mos
Cause : Hereditary
Due to prolonged exposure to urine, soap &
excreta
Prone to asthmatic patients

Measle Virus
10 -20 days

s/s

FEVER and RASH

RASH
Non Pruritic
Begins w/
face & downwards
Face & downwards
Rose pink begins w/ trunk
Progressing outward

S/S
:
RASH
RASH + scaling,
Crusting

With KOPLICKS
Pruritus or itching

SPOTS +

same
3 Cs : Coryza
Cough
Conjuctivitis

Viscicles
Management: Hydrate the skin w/ cold compress

MANAGEMENT: (to all types)

Bed rest
Antibiotics
Antipyretic

Meds:
Benadryl (antihistamine)

ROSEOLA
RUBELLA

RUBEOLA

Exanthem
GERMAN MEASLES

MEASLES

SYPHYLLIS
HERPEZ
C Agent

T Pallidum
Zoster

GONORRHEA
N Gonorrhea
Simplex

135
I. Period

10-13 wks

Vericella Zoster Virus

2-7 days

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
WHITISH-CHEESELIKE discharge
With FOUL ODOR

Steroids
Around the mouth

Inner thigh

Inc Period

4 20 days

5 days
Buttocks
Genitals

Druf pf Choice
Amphotericin

Flagyl

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 lymes dses;

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

the priority administration of fluis;

136

A pt tells the nurse that he notice small blisters on his

private parts. This is indicative of HERPEZ

A pt with CA of the cervix was admitted with the ff

data: w/c one indicates a possible risk factor previous tx for
herpes;

w/c of the ff indicates effective tx of gonorrhea (-)

purulent discharge;

a pt is diagnosed w/ herpes zoster, w/c of the ff is the

priority nsg dx PAIN;

w/c of the ff is indicative of CHLAMYDIASIS burning

on urination

RF
Laryngeal or Oral CA

Smoking :

Lung, Bladder and

RACE

Jewish Breast
Blacks - Cervix and

Prostrate
Whites Testes
PARITY
breast having baby after 35 yo

Nulliparity

Multiparity cervix
DIET

High Fat and Low

Fiber CA of Colon
Spicy Ca of
Prostrate
Raw Ca of Stomach
LABDATA

Screening Exams
Male:

a. Testicular Self Exam mothly

begins age 16 yo- target are high school
Female:
a. Pap smear at age of 18 (if
sexually active) - anually
b. Breast self exam beginning
age 20 monthly
c. Mamography baseline : 35-40
yo : AFTER 40 yo once every 2years
After age 50 annually
CANCER
Cause
Unknown Theory of USE Overuse, Underuse, and Abuse

BOTH MALE AND FEMALE

Digital Rectal Exam

ANUALLY

40 and above

137

Sigmoidoscopy
age 50yo

STOOL FOR OCCULT BLD

Nsg Dx
Knowledge deficit

ANUALLY after

TESTICULAR
testes or lump (N smooth unequal)

crytorchidism, spongy

Annually after age 50 yo

Initial

If pt is TERMINALLY ILL

TIPS FOR CANCER

HOPELESSNESS
If pt has some wishes or
Unfulfilled needS :
Powerlessness

w/c nsg dx is a priority for a pt undergoing

chemotherapy SOCIAL ISOLATION;

when undergoing chemotheraphy, w/c solution is used

for mouth care HYDROGEN PEROXIDE;

Nsg Care Principles :

C hemotherapy target cells :
those rapidly dividing cells;
A sess Body Image
N tuition/diet : high CHON, well
balance
C aution pt on s/s
E xercise
R est

w/c of the ff is an appropriate diet for pt undergoing

chemo bland diet;

the most common sign of Breast Ca is in upper

outer quadrant;

pt w/ CA of esophagus will manifest DYSPHAGIA

COMMON S/S
LARYNX
VOICE or Hoarseness
LUNGS
cough or smokers cough (productive)
STOMACH
BREAST
discharge
OVARIAN
fullness or indigestion
CERVICAL
PROSTRATE
phosphatase, nocturia
COLON
bowel habits
Hodgkins Dses
enlargement of lymph nodes

change in
changing
dyspepsia
a lump or a
complains feeling of
bleeding
elevated acid
change in
painless

TIPS FOR

PSYCHE

A pt w/ chronic depression is to undergo ECT, the

purpose is to relieve the symptoms of depression;

A nurse shld assess the pt w/ ALZEIMERS DSES for

possible change in orientation;

A pt w/ bipolar episodes is ready for discharge when

she can comply with units activities;

138

The nurse would suspect that the child is a victim of

abuse if he keeps quiet while an IV is inserted;

w/c of the ff situations reflects an increase in selfesteem of an abuse child - when he ask the nurse for a
plastic cup to drink;

the initial care plan for a pt with Anorexia Nervosa

would require the pt to remain in public place 1 hour
after meals;

the nurse notes mirror image in the fetal monitor

this could be related to FETAL HEAD COMPRESSION;

which of the ff is related to trauma ABRUPTIO

PLACENTA;

A nurse is caring for a woman in first stage of labor,

she is timing the duration of contraction she is correct
when she times it from the beginning of one contraction
to the end of same contraction

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;

TIPS FOR OB-GYNE

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

so sorry I couldnt hold her let her stroke the baby;

6wks pregnant woman ask the nurse about the signs

of pregnancy w/c one is expected at this time frequent
urination;

w/c of the ff is appropriate way of administering preop meds to 4 yo child ask the child where she would
like the injecvtion to be given

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Paralysis of Lower