CHRONIC RENAL FAILURE STAGE I: POLYURIA AND NOCTURIA

II- OLIGURIA AND SWELLING IN ANKLE AND LEGS

III DIALYSIS-END STAGE RENAL DISEASE

Acute renal failure

I- oliguria

Strep infection Not infectious after 24hrs of antibiotic therapy-

indicator to be able to care
Heart failure- ventricular gallop -s3 sound is the Sodium 2g/day, fluid restriction, Lasix, O2,weigh
first sign daily, i/o
Best indicator of effective diuretic: WEIGHT
1pound lost = 500ml
RHF
LHF
ACUTE CORONARY SYNDROME-Unstable angina, O2, iv access for nitro, morphine, hep, fibrinolytic
myocardial infarction/ischemia
Shock: increase pulse, light headedness, cold and Shock is priority than hypoglycemia, bleeding, early
clammy, high resp labour fracture

GERD RISK Caucasian, female, age more than 45, obese,

smoking, NG tube
Sickle cell crisis Hydration then oxygen
Fluids 200cc/hr
Prevent inf .. URI and blood borne pathogens
Coumadin Carry cell phone, bandages, dressing
Long term med, incorporate into lifestyle
Degenerative joint disease- risk of contractures Keep in functional position
For back pain elevate legs 8-10 inches
Donot use big pillows
Fundus level in pregnancy 10 to 12 weeks fundus slightly above symphysis
pubis
2434 weeks, fundal height correlates well 16 weeks fundus halfway between symphysis
with weeks of gestation pubis and umbilicus
20 to 22 weeks fundus at the level of the
umbilicus
28 weeks fundus three fingerbreadths above the
 umbilicus
36 weeks fundus just below ensiform cartilage

TURP WITH CBI PAIN, leg with cath should be straight

Urinary retention Crede maneuver-cupped hand on bladder inward
and downward pressure
Urinary incontinence Toilet whn awaken and before and after meals
Hemolytic reaction: n/v,back pain, high pulse, low Stop infusion, ns iv,o2, airway, Benadryl, draw
bp, decrease urine output, hematuria blood, urine specimen, send blood bag to lab
Body mechanics Determine if help required
Then position close to the pt and use arms and legs
and encourage pts to help
Horners syndrome lung tumor that invades ribs Miosis, partial ptosis, anhidrosis of the affected
and affects the sympathetic nerve ganglia side
Pancoast tumor first thoracic and 8th cranial nerve Arm and shoulder pain and atrophy of arm and
hand muscles on affected side
Pleural tumor Chest pain, cough, dyspnea, fever,weight loss
SLE-proteinuria, hyperlipidemia Dec s. complement, positive antinuclear test,
increased anti DNA levels, positive lupus erth. Cell
Pregnancy Primi: effaces then dilates
Multi: both at same time
Newborn respiration Calories, respiratory center, nerves in brain and
chest, patent airway
Parasympathetic nervous system Constricts pupil, increases heart rate,constricts
Constricts and stimulates bronchi, increases GI motility and bile secretion,
stimulates saliva, stimulates /contract urine/urine
retention, relaxes rectum
Sympathetic nervous system Dilates pupil, slows heart, decreases GI motility,
Dilates and inhibits inhibit saliva, relaxes urinary muscles, contracts
rectum, increases glucose by liver, epi and nor epi
by kidney, dilates bronchi
p. jairoveci pneumonia-opportunistic AIDS inf Can cause hypoxemia and cyanosis
Crohns disease Corticosteroids, antidiarrheals
Donot give protein, fibre and milk[causes diarhea]
Circumcision care Should void before discharge
Dont bathe, dont remove crust
Small amount of bleeding expected
Care for 2-4 days required for healing
Lubricant/ Vaseline jelly over glans penis

Nurse client relationship Orientation phase:

Realistic limits, trust , rapport
Prepare for termination
Assess client, identify problems, discuss plan for
visit
Identification phase:
Clarification and goal setting

Sign of prevention of infection in COPD
Sign of infection In COPD
Pulmonary embolism- serious emergency
PNEUMONIA
t.b.
Atrial fibrillation-emergency
Sinus tachy and PVC are not emergency
Hypokalemia
Sprue [celiac disease]
CONTINOUS PASSIVE MOVEMENT DEVICE
Jaundice within 24 hrs- life threatening
Jaundice after 24-72 hrs
ACIDOSIS
ALKALOSIS
Nurse practice act
Involuntary admission
Working phase:
Identify problems
Ask questions
Nurse was beneficial
Termination phase
Problem solved
Reaches established goals,
Relationship ended- sadness normal for nurse pt.
Dependent personalities require help- reflect on
positives and growth
Fear of abandonment,
Decrease in O2 requirements
Increase in O2 req, fever, fatigue, sputum increase,
shortness of breath
Petechia on chest, shortness of breath, chest
pain,anxiety
Give Oxygen first then notify doc. Wil prescribe hep
and analgesics can be given.
Crackles, pleuritic pain, fever
Anorexia, fever, night sweats, weight loss
Can cause clots from atria and lead to stroke
Ventricular tachycardia
Diarrhea and constipation, bloating, flatulence, no
imp vitamins minerals and nutrition absorbed,
malnourished, less albumin and clotting factors,
GLUTEN FREE DIET: WHEAT, OATS, RYE, BARLEY,
BEER, COUSCOUS, GRAVY, BROTH, PROCESSED
AND BATTERED FOOD, FLOUR,
SPRUE FOUND MORE IN TROPICAL REGION
Needed even if physical therapy is given
Prevents adhesions
Bleeding is a complication
Monitor skin intergrity
Can be hemolytic disease, rh /abo incompatability,
sepsis
Physiologic jaundice
Hyperkalemia: during periods of hyperglycemia K
leaves the cell along with glucose
Hypokalemia: when the treatment is initiated and
the glucose goes back to the cell K also goes back
causing hypokalemia-watch out for arrhythmias-
v.tach
Regulates the scope of nursing practice enacted
and outlined by state legislature
Harm to self /others
 Should have a suicide plan
Threatening to kill
Schizos with hallu and delu are ok to live alone
Advanced directive Includes living will
Should be reviewed with doc at every admission
Should be informed at admission and taken

Neck radiation Dysgeusia: absence of taste

Xerostomia: dry mouth and xerophthalmia
Stomatitis: irritation of oral mucosa
Internal pelvic radiation Cystitis
Internal radiation Leukopenia, thrombocytopenia
Head Cognitive decline
Externalradiation Nausea, infertility, hair loss, dry skin, pink sore skin,
lymphedema, gastric ulcers,
Pyelonephritis: infection from blood, cath, Give more fluids
procedures Acid ash diet-prune, cranberrry,tomato, buillon,
no milkand citrus fruits-orange and lemon
No sitz bath
Myxedema coma [hypothyroidism] Resp depressed so patent airway imp-most critical
Severe hypothermia: gradual heating or will cause
vasodilation and shock
Bradycardia- prolonged QT interval
Thyroid replacement given IV
Diabetes insipidus[pyelonephritis] Deficient volume related to inability to conserve
water
BIOPHYSICAL PROFILE[USG] Non stress test, fetal tone, fetal movement,
amniotic fluid volume
1st trimester Crown rump length for gestational age
2nd n 3rd trimester Biparietal diameter, femur length for gestational
age
Rheumatic fever-non pruritic rash, fever, joint pain Ask previous sore throat with strep
Not infectious
Affects heart, joints and CNS
HYPOGLYCEMIA If confused but conscious give orange juice
If unconscious glucagon IM or dextrose 50%
Epidural anesthesia RESPIRATORY DISTRESS-CNS DEPRESSION-
decreased heart rate and blood pressure,
Decreased sensation to the lower extremities
Urine retention, hypotension, allergic reaction,
Hypophsysectomy Head elevated, no coughing, sneezing, blowing
nose for sutures, increase fluid because of diabetes
insipidus and visual disturbances

Parkinsons crisis-confined to bed, risk for Ineffective airway clearance related to

pneumonia and aspiration drooling[airway obstruction]
PARKINSONISM Shuffling gait, stooped posture, drooling, muscle
 rigidity, flat face, tremors
Akasthisia Inability to stay still, pacing, restlessness
BIB BABY SYNDROME Reason: insulin acts as a growth hormone for fetus
Bone marrow Depression in 7-14 days noticed
Recovery in 21-28days
HCG Maintains pregnancy till placenta intact
Monitored for knowing the status of pregnancy
Relaxin Makes mommy tired to seek rest
Progesterone Thickens the uterine lining before pregnancy and
nurtures the fetus during pregnancy-supportive
envt
Estrogen For breast tissues and breast feeding and nurturing
the fetus
Stoma after surgery: danger signs Dusky stoma
-Edema in 24hrs if ok Stomal protrusion out of the skin
Abdominal rigidity and pain

Most common complication of influenza Pneumonia-bacterial /influenza

Others-exacerbation of COPD, reye syndrome,
myositis
Hypocalcemia Trousseau sign, cardiac arrhythmias, diarrhea,
increased clotting time, irritation, anxiety,
pathological fractures,
Rombergs test Assess cerebellar function
Rinne test Air and bone conduction
Pulmonary emboli risk factors Immobility, pelvic fractures, obesity
Mononucleosis- flu, sore throat, fever No contact for 3months, no need of isolation, no
sharing of cups and glasses

Premature labour control Hydration

Sickle cell crisis Hydration, o2
Hyperglycemia Fluid volume deficit
Burns Fluid volume deficit
ECT Vitals for every 15mins for first 1hr, left side
position for aspiration, orientation, no ambulation
until oriented and awake
Multiple myeloma Preventing bone injuries, hydration, pain control
Chronic bronchitis Diaphragmatic pursed lip breathing-exhalation
more than inhalation to prevent collapse of
bronchioles
Medication administration in infant[liquid] Verify order
Right drug , dose, route, time
Right pt.
Position in the crook and raise 45 degree head
Give through the corner of the mouth b/w gums
and cheek
Hemolytic reaction Stop transfusion,
give NS,
Notify doc,
collect urine sample,
send blood to lab
Insulin administration air in syringe
air in NPH
air in regular
withdraw regular then NPH
Dont shake but rotate gently, not need to keep in
fridge
Herniated disc Comfortable position
Give pain med
Assess and teach non pharmacological measures
Notify doc if pain unrelieved
UPPER GI ENDOSCOPY Nbm for 6-12hrs
Conscious sedative
Gag and cough reflex gone for 2hrs
Lower endoscopy GI cleansing with enema and golytely
Clear liquid diet
Mother negative baby positive Rh immunization at 28 weeks and after within 72
hrs-no antibodies will b formed if given
Negative rubella antibodies during pregnancy Immediate rubella vaccine post delivery and
counseling
Hypoxia test ABG
Cardiac tamponade Decrease in amplitude of QRS complex
Insulin unit Its a measure of effect and not standard weight or
quantity
Apothecary system Grain and minim
Avoirdupois system Ounce and pound
Metric Liter, gram