36190527-Gapuz-Notes-Day-1-7

NCLEX REVIEW – GAPUZ REVIEW CENTER (31 JANUARY – 17 FEBRUARY 2005, PICC, City of Manila)

DAY 1 (31 JANUARY 05) STEPS IN PASSING       

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

MOSBY – growth and development LIPPINCOTT – care of the Elderly and Communicable Disease DIGOXIN – monitor the creatinine… “ the TV DOESN’T look good to me” (DIGOXIN TOXICITY – nausea/vomiting, abdl cramps) Olive = butter CK – normalize 1 – 3 days after MI LDH - 10 – 14 days ATRIAL FLUTTER – SAW TOOTH PROCESS OF ELIMINATION     

consider MASLOW’s H of NEEDS consider the COMPLICATION whether ACUTE CHRONIC ABCs SAFETY FIRST NSG PROCESS

– ALWAYS prioritize

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

– s/e tinnitus, vertigo, ototoxicity, oliguria

LITHIUM CARBONATE

– for ELDERLY : N level NOT more than 1.0meq/L ADULT : N .5 – 1.2 meq/L

HEPA B diet : low fat, increase CHON

DOWN SYNDROME – large tongue – feeding problem – poor sucking (infants) SAFETY PRINCIPLE 1. when can a child USE ADULT SEAT BELT? - if the infant is 40 lbs and 40 inches in height seat belt location in car: BACK CENTER SEAT 2. TODDLER – falls 3. SUPRATENTORIAL craniotomy – semi fowler’s position INFRATENTORIAL – flat in bed 4. SCATTER RUGS – osteoporosis pts. 5. TRIAGE ; burns, open fx – “SHOCK” Things NOT TO BE DELEGATED by RN: Assessment, Teachings, Evaluation Pt 50y/o and

- mammogram – once a year.

Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl FREE). – therefore LOW CHON Pt with Rocky Mountain Fever – exposure to dog ticks Lyme’s Dses – deer ticks PSYCHE PATIENTS 1. remember to stick to unit rules/policy – be consistent to pt. 2. encourage verbalization – “tel me how…..” 3. sound knowledge of cultural diversity - seek help of interpreter 4. acknowledge pt feelings – “it seems….” “this must be difficult…..” 5. emphatize with your patients’s feelings “ I understand how you feel…..” CATARACT – CAUSES – aging and trauma MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WHEN W/ PT

DAY 2 ( 01 February 05)

TUBES 1. GROSHONG CATHETER HICKMAN BROVIAC

- 2 lumen - 3 lumen - 1 lumen

ALL requires Central Venous Access - sites: cephalic, brachial, basilica and superior vena cava PURPOSE:

For TPN Administration of Chemo Agents, Blood Products, Antibiotics

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

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

2 BOTTLE :

First bottle – drainage bottle (no tube emerge), 2nd bottle - long rod 3-5cm

3 bottle

FREQUENTLY USED

:

1st bottle – drainage 2nd bottle – water sealed 3rd bottle – suction bottle control COMPLICATIONS:

bubbling, breakage, blockage

Nsg ALERT: 

NORMAL : BUBBLING is N in the 3rd bottle – it indicates that suction is ADEQUATE (if no bubbling STOPS in the 3rd bottle, meaning – inadequate suction)



ABNORMAL : if bubbling occurs at the 2nd bottle – indicates LEAKAGE – action, check sealed at air tight container and the pt and bottle connection.

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

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

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

4. PTCA

– enlarge the passageway for bloodflow. problem: spasms that lead to arrhythmia

C-STENT (cardiac-stent) – alternative to PTCA Maintains patency of bld vessels Problem: dislodge IABP (Intra Aortic Balloon Pump) - for Cardiogenic Shock problem: thrombus formation, infection and arrhythmia

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

6. NASO GASTRIC TUBE – stomach and intestine (duodenum) Types:  Levine Tube – for stomach - 1 lumen, for lavage (cleaning) and gavage (feeding) 

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



Miller Abbot – for intestinal (w/ mercury b4 injection) - 2 lumen (insert then inject the mercury)



Cantor – for intestinal - 1 lumen

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

Report the following:

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

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

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

9. HEMOVAC JACKSON-PRATTS (JP)  

BOTH used as close wound drainage suction system BOTH system function on the system of (-) pressure.

JP – compress the container before attaching to the drainage. WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount.

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

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

– 3 lumen

MINESOTTA TUBE

     

– 4 lumen

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

THERAPEUTIC DIET GENERAL CONSIDERATION    



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

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

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

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

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

MOST COMMON DIET 

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



RENAL DIET -

for kidney disorder (renal failure, AGN, Nephrotic syndrome) to maintain fld & e imbalance

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



LOW FAT/CHOLESTEROL RESTRICTED DIET

- for liver disorder, cardiovascular and renal dses ALLOWED: lean meat, fruits, vegs and fish AVOID : Sea foods, fried foods, preserved foods

(cheese cake and custard)



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



SOFT DIET -



PURINE RESTRICTED DIET -



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

HIGH PROTEIN, HIGH CARBO DIET -



for cardiovascular dses, renal, fld & e imbalance ALLOWED: fresh vegs AVOID : processed foods, milk products and salty foods

BLAND DIET -



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

NA RESTRICTED DIET -



for inflammatory conditions: esophagitis, peptic ulcer gastritis pureed foods/ blenderized foods soup

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

ACID ASH DIET -

to decrease the ph of the urine indicated for pt w/ alkaline stone ex struvite ex. 3 C’S – cranberry, cheese, & corn 3 P’S - prunes, plums & pastries



ALKALINE ASH DIET -



GLUTEN-FREE DIET -



for PKU, until age 10 and adolescence only AVOID : CHON rich foods (meat products – luncheon meat)

FULL LIQUID DIET -

“ABGs”

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

PHENYLALANINE DIET -



to increase ph of the urine indicated for acid stone ( uric acid stone, cystine stone) ex. Milk

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

ATERIAL BLOOD GASES

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

Compensatory Mechanism

Uncompensated abnormal Partially compensated abnormal Fully Compensated normal

no change increase or decrease increase or decrease

Diarrhea – metabolic acidosis Vomiting – metabolic alkalosis

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

APGAR SCORING

0 Appearance Pulse Grimace Activity Respiratory

1 pallor

(-) (-) flaccid (-)

2

acrocyanosis 100 grimace vigorous some flexion irregular lusty cry

all pink flexion & extension

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

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

LEVEL 2 “urgent (stable)” 

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

LEVEL 3 

chronic/ minor illness (can be delegated) – dental problems, routine medications and chronic low back pain

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

DELEGATION -

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

CONCEPT OF DELEGATION   

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

MI ATTACK – enzymes to increase IN ORDER - #1 #2 #3 #4

myoglobin troponin CK LDH

RISK FOR INJURY – meniere’s dses INEFFECTIVE BREATHING PATTERN – myasthenia gravis ALTERED TISSUE PERFUSION – pt w/ complete heart block INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing D

DAY 3 ( 02 February 05)

POSITIONING FOR SPECIFIC SURGICAL CONDITION Positioning a. b. c.

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

Post Liver Biopsy

– R side lying – to prevent bleeding

(during the procedure – L side lying). Hiatal Hernia



– upright to prevent reflux.

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



APPENDICITIS Unruptured : any position of comfort

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



BURNS Position is FLAT or Modified Trendelenburg – to prevent shock.

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



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

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

capillary refill – N 1-3 seconds only (complication: altered circulation) note for s/s of infection (when there is musty odor inside the cast) pruritus (inject air using bulb syringe) blood stained – mark and note (if increasing in diameter - report ASAP) tingling sensation – indicate nerve damage



CRANIOTOMY Types:

a. Supratentorial C – semi fowler’s orlow fowler’s position – to prevent accumulation of fluid at surgical site; b. Infratentorial C - flat or supine. Purpose: same



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

position: towards the affected side to stabilize the chest.



GASTRIC RESECTION -



HIATAL HERNIA -



to prevent dumping syndrome – usually for 10 mos only NOT LIFETIME disorder (post gastrectomy) position : LIE FLAT for 1-2hrs post meal

there is damage to esophageal mucosa what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION.

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



LAMINECTOMY -

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

-



LIVER BIOPSY -



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

LOBECTOMY -



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

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

MASTECTOMY -

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

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

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



PNEUMONECTOMY -



RADIUM IMPLANT OF THE CERVIX -



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

keep pt on complete bed rest to prevent dislodge. AVOIDE SEX (may burn penis bec of the implant inside)

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



RETINAL DETACHMENT

-

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

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



VEIN STRIPPING -

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

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

THERAPEUTIC COMMUNICATION 1. DON’T ASK WHY – this put pt on the defensive 2. AVOID PASSING BACK – “I will refer you to….” 3. DON’T GIVE FAKE REASSURANCE – “everything will be alright….” “you’re in the hands of the best” 4. AVOID NURSE CENTERED RESPONSE – “I felt same too…” “I had the same feeling….” In GROUP DISCUSSION – nurse is just a facilitator – let the group decide, he/she channel are concern back to the group. THERAPEUTIC PHRASES – it seems… you seem…. - open ended question - close ended – for manic pt and pt in crisis - direct question- for suicidal pt

ISOLATION PRECAUTION Purpose : to isolate infection transmission TYPE

PRIVATE ROOM

HAND WASHING

GOWN

GLOVE

MASK

STRICT

(airborne dses, direct contact-Diptheria)

RESPIRATORY

OPTIONAL

OPTIONAL

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

TB

OPTIONAL

OPTIONAL

(negative airflow room)

CONTACT

(direct contact – NOT AIRBORNE DSES) eX SCABIES

ENTERIC

X

(fecal contamination)

DISCHARGE X (drainage: pus ex burn pt) UNIVERSAL

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

OPTIONAL

OPTIONAL

OPTIONAL

OPTIONAL

X

TIPS: 

When implementing universal precaution, w/c nsg action require intervention: recapping the needle – this might prick your hand;



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



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



Preventing pediculosis in school age children: avoiding contact w/ hair articles of infected children like clips, head bands, hats – no sharing



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

Essential when a pt w/ meningitis is kept in isolation: isolation precaution remains until 24hrs after initiating antibiotic therapy



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

: : : :

assess for allergy (cleansing enema b4 the procedure) no dye (don’t assess for allergy) 24hr urine specimen no consent required

GENERAL CONSIDERATION

•

-

EXPLAIN the procedure to the pt (initial nsg action) if not ready inform the doctor; pt has the right to refuse procedure; doctor the one who asked for consent

•

Check pt for CONSENT – if INVASIVE – WITH CONSENT NON INVASIVE – NO CONSENT needed

•

CONTRAST MEDIUM – check for allergy

•

For procedure requiring anesthesia – KEEP PT NPO B4 PROCEDURE When local anesthesia used – NPO, 1- 2HRS AFTER General anesthesia – keep NPO at least 8hrd after (check gag reflex before meals)

•

PEDIATRIC PATIENT – use flash cards, games and play to encourage participation

TRANSCULTURAL CONSIDERATION

HISPANIC PATIENT – women prefer same gender health care provider Obtain help of interpreter when explaining procedures – (except or don’t ask family members) For muslim patient - they prefer same sex health care provider however, if procedures require life threatening – they prefer to have male doctor. - they only want good news information of their condition

DELEGATION and DOCUMENTATION

Delegation – assessment, monitoring and evaluation of treatment (cannot be delegated) BUT standard and changing procedures can be delegated ex. – 24hr urine specimen and urine catheter

collection. Documentation – type of treatment and any untoward reactions.

KEYPOINTS FOR NURSES   

Prepare the patient; Monitor for adverse reaction; Report complication to the doctor

FRAMEWORK – includes the Purpose, Special Consideration and Interpretation

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

DAILY FETAL MOVEMENT Purpose : to determine fetal activity by counting fetal movements – usually perform by pt himself

N Fetal Movement



10-12 for 12 hr period (average: 1 movement/hr with average 3fm/hr)

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

monitor the baseline FHR then induce fetal movements by (HOW) : a. ring a bell b. feed the patient

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



CONTRACTION STRESS TEST (oxytocin challenge test) -

correlates FHR with uterine contractions pt on NPO get baseline FHR then induce uterine contraction

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

b. late deceleration – indicates placental insufficiency (REVERSE MIRROR IMAGE) mgt: L Lateral Recumbent Position, Administer O2, Treat Hypotenson

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

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



BIOPHYSICAL PROFILE –

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

fetal breathing movement heart tone reaction to NST amniotic fld volume

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

score below 6, indicates fetal jeopardy



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

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

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

Get sample at chorion (by 10-12wks – The placenta matures, get some sample)

AMNIO Purpose : same w/ CVS

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

can be done on the 2nd wk (14-16 wk) - but not recommended bec. of danger abortion (assess pt age of gestation)

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

or can be done on the 3rd wk (34-36 wk) purpose: to detect fetal maturity (FLM) thru monitoring of L/S Ratio N 2:1 (if mother is (+) DM LS ratio is 3:1) This procedure also check level of alpha-feto Protein – if INCREASE – spina befida; If DECRTEASE – down syndrome

(+) Consent – invasive

(+) Consent

Bladder : Empty

consider the Pt Age of Gestation (if age of gestation :

(+) Consent

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

COMPLICATIONS of CVS, AMNIO & PUBS: a. b. c. d.

infection bleeding abortion fetal death

TIPS

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

• AMNIOCENTESIS – was done @ 35 wks gestation – purpose: to determine fetal lung maturity;

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

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

• after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding; • heart rate;

pt ask the nurse – what deceleration means – it refers to slowing of baby’s

•

before Amniocentesis, what to check – USG DEVICE

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

abdl cramps, steatorrhea, abdl rigidity, abdl distention (if + for CD, gluten free diet will be for life time)

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

BARLOW’S MANUEVER (BM) purpose : same (+) barlow’s click – press downward and w/ click sound

POLYSOMNOGRAPHY or “sleep test” -

EEG is connected to pt when he sleeps Check the brain waves, check for apnea of infancy preparation : No Special prep, HOLD CAFFEINE FOOD – 2days b4 test

SCOLIOMETER -

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

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

HGB ELECTROPOISIS

Purpose: test for sickle cell anemia

Purpose: test for sickle cell anemia

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

Test for Disease

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

SWEAT CHLORIDE TEST -

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

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

TIPS 

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



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



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



pilocarpine – drug used for pt undergoing seat chloride test;



hgb electropoisis – test for sickle cell dses

DAY 4 (3 Feb 2005)

DIAGNOSTIC PROCEDURES I.

CARDIOVASCULAR

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

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

B. CARDIAC CATHETERIZATION -

it determine the structural abnormalities in the heart either L or R sided catheterization site: antecubital, femoral, brachial

common complications: embolism, bleeding, arrythimia “EBA” nsg mgt :  monitor distal pulses (if brachial site: check @ radial if femoral site : check @ dorsalis pedis)  if weak or no pulse – REPORT  if (+) bleeding – report (“sandbag 10-20 lbs” – shld be at bedside)

C. STRESS TEST -

determines the ability of the heart to withstand stress equipment : threadmill & ECG nsg alert : check pulse and BP keep NPO an hr b4 the test NO Jewelries

D. CORONARY ARTERIOGRAPHY -

visualization of the bld vessels w/ contrast medium nsg alert: (+)consent check allergy to contrast medium increase oral fluid intake after to excrete dye epinephrine shld be ready for any untoward reaction

E. SWAN-GANZ CATHETERIZATION -

4 lumen for the ff CVP, Pulmonary Capillary Wedge Pressure (PCWP), Pulmonary Artery Pressure, Bld products, Balloon

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

for SVC – 5-12 Nsg Alert : check pulse and s/s of bleeding

F. BLOOD CHEMISTRIES



SODIUM (135 – 145 meq/L) Addison’s Dses: hyponatremia (dec Na), hyperkalemia (inc K) – “FLD IMBALANCE” Cushing Syndrome: hypernatremia, hypokalemia – “FLD VOL. EXCESS”



POTASSIUM (3.5 – 5 meq/L) Hyperkalemia : Addison’s dses Hypokalemia : Cushing Syndrome Inc or dec in K PT RISK of INJURY Pt w/ digitalis & diuretics – monitor for arrhythmia



CALCIUM (4.5 – 5 meq/L or 9-10mg/dl) Hyperthyroidism – inc CA Renal Calculi Formation – inc CA @ bld







GLUCOSE (80-120) -

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

-

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

Creatinine (.5-1.5) -

most sensitive index of kidney funx (increase BUN but N creatinine – do not report to AP)

-

increase creatinine – kidney failure or renal disorder

BUN (10-20 mg/dl) -



inc. if (+) kidney disorder

LDH (40 – 90 u/L) LDH1 – 27-37% (for heart – check for MI) LDH2 – 17-27% (for heart – check for MI) LDH3 – 8-15% (for respiratory system) LDH4 – 3-8% (for liver & kidney) LDH5 – 0-5% (for liver & kidney) LDH inc for MI for 3-4 days then it returns to N after 10-14 days



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



AST (SGOT)

SGPT (ALT)

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

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

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

PTT

APTT

(11-12 sec)

(60-70 sec)

(30-40 sec)

coumadin – check pt

heparin – PTT

monitor pt 4 bleeding

monitor pt 4 bleeding

HGB – male : 14-18 mg/dl Female : 12-16 mg/dl Dec hgb – anemia (nsg dx: activity intolerance) HCT - 35-45% - determine the adequacy of hydration and the ration of plasma to the cellular component blood inc hct

: hemoconcentration (nsg dx: fld deficit – dehydrated pt)

dec hct

: hemodilution fld excess

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

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

II.

RESPIRATORY 

BRONCHOSCOPY – – – – – –

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

 -

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

-

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

- Viral – thin & watery Bacteria - rusty - blood streaked

BRONCHITIS - gelatinous CHF/ PULMONARY EDEMA - pink stinged

Sputum specimen – sterile container



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

position:

DURING – sitting AFTER - affected or unaffected side

Nsg alert:

NO COUGHING & DEEP BREATHING – during the procedure – coz this may cause puncture of the lungs; Assess for breath sounds after; Complication: bleeding and pneumothorax



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

& out of lung after maximum inspiration. PROCEDURE:



EXHALE then INSERT mouth piece, BREATH iN, HOLD then EXHALE

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



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



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

III.

NERVOUS 

-

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

CT SCAN

dietary modification: WITHOLD CAFFEINE – coffee and tea; WITHOLD 48hrs b4 the procedure : tranquilizers, sedatives, anti-convulsant, alcohol

MRI

PET

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

physiology of psychosis; and to evaluate tx give more detailed impression (ex. Measurement of blocked artery)

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

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

a.

pregnancy;

b. c. d.

obese pt (more than 300 lbs);

e.

claustrophobia (give anti-anxiety b4)

NO METAL OBJECTS - jewelries, insulin pump,

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

pacemaker, hip replacement

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

 -

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

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

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

LUMBAR PUNCTURE

 -

aspiration of CSF for assessment to check for infection or hemorrhage position:

DURING : fetal or C-position AFTER

: FLAT to prevent spinal headache

Needle is inserted between L3 and L4 or L4 and L5 Increase fluid intake after.



CSF ANALYSIS -

Assess for the characteristic of CSF. N amount: 100-200 ml Characteristic : Clear w/ glucose, Na and H2O

like CA Tx

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

MYELOGRAM

 -

test for presence of slip disc or herniated nucleus porposus (HNP).

ALERT:

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

IV. EENT • TONOMETRY -

to measure IOP (N 12-21) - painless but w/ local anesthesia ACUTE GLUACOMA : 50 yo and above CHRONIC GALUCOMA : 25 yo

• CALORIC STIMULATION TEST -

test the presence of Minierre’s Dses (inner ear) involves introduction of warm and cold water then NOTE FOR NYSTAGMUS – jerky lateral movement of the eye. SEVERE NYSTAGMUS – NORMAL MODERATE NYS - Minierre’s Dses NO NYSTAGMUS - Acoustic Neuroma

• GONIOSCOPY -

to differentiate OPEN and close angle galucoma;

-

non-invasive, painless

WEBER TEST

RINNE’S TEST

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

V. 

GASTRO INTESTINAL TRACT UPPER GI SERIES (Barium Swallow)

-

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





BARIUM ENEMA (for Lower GIT) -

involve rectal installation of barium;

-

there is balloon catheter inserted @ anus then barium is instilled and pt is asked to roll-over at different position then xray is taken to detect: hemorrhoids, diverculosis, polyps and lesions;

-

after, give laxative to excrete dye (bec dye is constipating) instruct also patient to inc oral fld intake

GUAIAC TEST -

to detect the presence of bleeding and inflammatory bowel condition like CANCER;

specimen : stool

(this can be refrigerated awaiting laboratory)

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



CHOLANGIOGRAPHY



-

visualization of biliary tree

-

with contrast medium w/s is given thru IV

-

ALERT: assess for allergy (epinephrine/benadryl)

-

Post procedure: inc. oral fld intake –

(includes, hepatic duct & common bile duct) – same with CHOLECYSTOGRAPY – but medium given orally;

to facilitate excretion of dye

GASTRIC ANALYSIS -

analysis of gastric secretion like HYDROCHLORIC ACID Lower Level N : 2-5 meq/hr Upper Limit N: 10-20 meq/hr UPPER LIMIT YPES

a.

WITHOUT TUBE (tubeless gastric analysis)

-

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

b.



-

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

-

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

WITH TUBE – with the use of NGT then aspirate

ULTRASONOGRAPHY -





upper abdl USG to detect abnormalities in the upper abdl area w/ includes biliary tree and Upper GI; painless; gel at abdomen and pt is NPO

LIVER BIOPSY -

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

-

ALERT: Check for Bleeding Time (N – 1-9 mins) and Clotting Time (N – 10-12 mins) – because liver is highly vascular organ

-

WHEN NEDDLE IS INSERTED tell pt to: Inhale then Exhale then Hold Breath – to stabilize liver position

-

Position after : R side-lying position Things to report: s/s of SHOCK – inc PR, dec BP Check v/s

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) -

to visualize common bile duct and pancreatic duct; invasive – (+) consent;

-



NPO – tube insertion; Tell pt that tere will be feeling of soreness a wk after the procedure

COLONOSCOPY -

visualization of colon to detect: inflammatory bowel condition Chron’s Dses Diverticulitis Hemmorhoids Tumor Polyps

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

VI. ENDOCRINE 

GLUCOSE TOLERANCE TEST -



ACTH STIMULATION TEST -



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

DEXAMETHASONE SUPRESSION TEST -



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

to detect endogenous depression – depression resulting thru endocrine disorder pt is given dexa then 24hr urine specimen is collected; a dose of dexa will suppress the release of adrenal hormones; if despite dexa administration still increase adrenal hormones, therefore pt is suffering depression

17 KETOSTEROID & 170 HCS -

use to detect the presence of Addison’s & Cushing’s Dses.

Addison’s – dec secretion of ketones Cushing’s – ince secretion of ketones Specimen: 24 hr urine



VANILLYLMANDELIC ACID TEST – VMA Test -

bi-product of CATHECHOLAMINE Metabolism epinephrine

norepinephrine

inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla

N 2-7 mg/dl / 24hrs – if inc, therefore tumor AVOID: vanilla containing food 3 days b4 test – 

ice cream, coffee, chocolates

RAIU -



pt is given iodine 131 then after 24hr followed by a thyroid scan inc indicates hyperthyroidism, dec hypothyroidism AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include other diagnostic procedures that uses contrast medium (“NO” - angiogram test). – bec it may yield to false (-) result. SULKOWITCH’S TEST -

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

VII. R E NA L 

URINALYSIS -

examine the gross characteristic of the urine

urine amount : 30-60ml/hr color : clear, amber s. gravity : 1.010 – 1.025 abnormality:

lower than 1.005 – diabetic insipidus higher than 1.030 – diabetic mellitus (+) glucose – infection, DM (+) CHON - PIH, kidney dses.

Urine maybe refrigerated if waiting to be examined.



CULTURE & SENSITIVITY -

to detect infection prepare storage container



KUB -

xray of the kidneys, ureter and bladder - NO SPECIAL PREPARATION NEEDED





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

RENAL BIOPSY -

aspiration of tissues at kidney for biopsy to detect: a. malignancy/ Ca b. malignant HPN c. kidney disorder

-

note for s/s of bleeding

CYSTOURETROGRAM -



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

CYSTOSCOPY -



IVP

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

CYSTOMETROGRAM -

to evaluate the sensory and motor funx of bladder; to check if bladder respond to distention after installation of flds; monitor I & O

VIII. MUSCULO-SKELETAL 

ELECTROMYOGRAPHY -



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

ARTHROCENTESIS -

aspiration of fluids at synovial space to detect abnormalities; check for order of analgesic; apply cold pack



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



BONE SCAN -

detect rate of bone destruction or bone resorption for pt w/ osteoporosis; lie still during the procedure; PAINLESS AND NON INVASIVE

IX. MISCELLANEOUS 

BONE MARROW BIOPSY -



to check abnormalities at the b. marrow (eg. Leukemia) site : ILEAC REST (+) consent assess for bleeding sand bag at bedside (post procedure) – for emergency use

SCHILLING’S TEST -

specimen: 24hr urine test for VIT B12 deficiency; for pt w/ PERNICIOUS ANEMEIA; pt is given oral VIT B12 then urine is collected, then NOTE for RATE of EXCRETION of VIT B12 (N – less than 40%); eg. If 100mg Vit b was taken – 60mg shld retain at stomach and 40mg will be excreted.



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



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



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



ERYTHROCYTE FRAGILITY TEST -

use to detect the rate of RBC DESTRUCTION in a hypotonic

(if pt is

solution

(RBC Lifespan: 120 days)

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



HETEROPHIL ANTIBODY TEST -

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

Epstein Virus Infection – causative agent of infectious mononucleousis (“kissing dses”) mgt: AVOID SHARING of utensils and glass



LYMES DSES SEROLOGY -

detect presence of BORRELIA BURGDORFERI –

causative agent of lyme’s

dses. Treatment: tetracycline

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

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

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

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

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

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

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

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

 After liver biopsy, a potential complication: bleeding.  MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques at the brain.

DAY 5 (8 Feb 2005)

PHARMACOLOGY I. GENERAL CONSIDERATIONS •

ONLY RN’s are allowed to administer (to include central line) LPN’s – peripheral IV Line route;

• • • • •

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

II. TRANSCULTURAL ASIANS – are stoicism attitude MIDDLE EASTERNERS -

(they refuse meds if for the 1st time)

they expect meds during first contact w/ hx care provider

JEWISH – no meds restrictions JEHOVAH’S WITNESS – do 

ORIENTAL PAYLOAH (from mexico)

-

treatment for diarrhea; may cause lead toxicity



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



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



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



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

COMMON CONTRAINDICATIONS for HERBAL MEDS:   

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

IV.

THE CHECK PRINCIPLE C– HECK-

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



Lactulose – given to pt with hepatic enceph to dec ammonia absorption - s/e : diarrhea



ANTABUSE (dizulfiram) – most appropriate time to take meds : after 12hrs of alcohol free.



COGENTIN – to prevent pseudoparkinsonism



TETRACYCLINE - can cause staining of teeth, Photosensitivity (use sunscreen when outdoors)



LITHIUM – shld have inc. fluid in the diet

(by decreasing muscle rigidity)

III. DELEGATION AND DOCUMENTATION Document all medical admin record: The following CANNOT be delegated:

time, route, dosage and untoward reaction; treatment, administration, documentation of meds

PSYCHOTROPIC I. ANTIPSYCHOTIC -

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

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

Report ADVERSE EFFECTS of ANTI-PSYCHOTICS – which indicates agranulocytosis a. fever b. body malaise c. sore throat d. chills



hyperpyrexia and muscle rigidity -



this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS) drug of choice: Parlodel, Dantrium

Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM a. mask-like face or expressionless face b. pill-rolling tremors c. cogwheel’s rigidity or lead pipe rigidity

AKATHESIA – “restless leg syndrome” (I feel as if I have ants in my pants) DYSTONIA Avoid direct sunlight – because meds photosensitivity Instruct pt to rise slowly – to avoid orthostatic hypotension

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

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

ex.

L-Dopa Levodopa Levodopa-Carbidopa

 

Effective if decrease in tremors and rigidity within 2-3 days; When to give: AFTER MEALS;



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

IB. ANTICHOLINERGIC -

decrease ACETYLCHOLINE

ex. Benadry Cogentin  

effective: if decrease tremors and rigidity; when to give: AFTER MEALS;



Health Teachings:

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

side effects: blurred vision (no driving); dry mouth – suck on ice chips or hard candy; palpitations – check PR; constipation – inc. roughage at diet; urinary retention NOT urinary frequency decrease BP – rise slowly check BP, PR, ECG

II. ANTI-ANXIETY -

minor tranquilizer decrease Reticular Activity System – center of wakefulness

ex. Valium, diazepam, Librium, Tranxene 

Effective:

Decrease Anxiety, Decrease Muscle Spasm Promote Sleep

(to pt w/ traction)

– because food delays absorption



B4 MEALS



HEALTH TEACHINGS:

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

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

TRICYCLICS MAO STIMULANTS SSRI

PATIENT with DEPRESSION – there is DECREASE norepinephrine and serotonin

A.

TRICYCLICS –

prevents the reabsorption of norepinephrine.

Ex. Tofranil, Elavil Effective:

If adequate sleep (8hrs only) Increase appetite

Best given:

AFTER MEALS

Hx Teachings:



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

 

AVOID : juice – because an acidic medium decrease absorption of drugs REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS – adverse effects of TRICYCLICS



B.

CHECK BP and ECG

MAO INHIBITOR (MonoAmine Oxidase) -

prevents the destruction of NEUROTRANSMITTERs ex. Parnate, Nardil and Marplan

Effective

: if INCREASE SLEEP and APPETITE –

Give AFTER MEALS Hx Teachings:



AVOID – TYRAMINE CONTAINING FOOD (1 day before FIRST DOSE and 14 days AFTER LAST DOSE)

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

ALLOWED: cheese – cottage and cream, FRESH MEAT, VEGETABLES

COLA, CHICKEN LIVER SOY SAUCE RED WINE PICKLES 

Check BP – the drug can cause HYPERTENSIVE CRISIS – occipital headache – “my nape is aching”



2 WKS INTERVAL – when shifting ANTI DEPRESSANT – to avoid HYPERTENSIVE CRISIS ex . after MAO – 2 wks rest then can give ST JOHN’S WORT

C.

STIMULANTS (Ritalin, Dexedrine and Cylert)

-

directly stimulates the CNS. Effective:

Increase Appetite and Adequate sleep

Best to Give: AFTER MEALS -

if b4 meals, it suppresses the appetite; give NOT BEYOND 2pm bec. it causes INSOMNIA – 6 Hrs b4 bedtime; shld be given in the morning – to avoid INSOMNIA

COMPLICATIONS:

growth suppression

Hx Teachings:

 

D.

SSRI

provide intervals or intermittently to avoid growth suppression; check BP and PR

(selective serotonin reuptake inhibitor) Ex. ZOLOFT, Prozac

Adverse effects: s/e:

DECREASE LIBIDO and Impotence

GI

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

A. LITHIUM -

it alters level of neurotransmitters

effective if DECREASE HYPERACTIVITY give AFTER MEALS Hx Teachings: 

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

 Report the ff s/s (NAVDA) Nausea Anorexia Vomiting Diarrhea Abdl Cramps

-

Report also:

FINE HAND TREMORS progressing to COARSE HAND TREMORS, THIRST and ATAXIC - sign of LITHIUM TOXICITY – Dug of

choice: MANNITOL DIAMOX

Hx Teachings:

• • •

Avoid activity that increase perspiration – Na & H2o; Avoid caffeine; Monitor lithium level

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

•

Frequency of Lithium monitoring: ONCE A MONTH; NORMAL LITHIUM LEVEL: ACUTE DOSE Below 65 yo Above 65 yo

MAINTENANCE DOSE

.5 – 1.5 mEq/L .6 – 1.0 mEq/L

.5 – 1.2 mEq/L .4 - .8 mEq/L

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

CONTRAINDICATION OF LITHIUM: • • •

Pregnancy; Lactating; Kidney disorder

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

ANTICONVULSANT (Tegretol and dilantin) -

for seizures, wherein there is abnormal discharge of impulse in the brain action : IT INHIBITS the seizure focus and discharge

effective: if (-) seizure given BEST AFTER MEALS –

(except for sedatives- like valium) MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO.

NSG ALERT: • • • • Check :

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

CHOLINESTERASE INHIBITORS For MYASTHENIA GRAVIS

: Prostigmin (long acting) and Tensillon

For ALZEIMER’s DSES

: Cognex (tacrine) and Aricept

(short acting)

Myasthenia Gravis – there is decrease or absence of Acethylcholine (ACTH) ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contract/move.

Therefore, the drug is given to inhibit cholinesterase in destroying ACTH (so, if dec cholinesterace and inc. ACTH, good muscle contraction)

PROSTIGMIN – long acting – for treatment TENSILLON – short acting – only for 5 mins.

– it increase muscle strength in 30 seconds (therefore, if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS)

Drug Action: • • • •

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

Antidote: ATSO4 – it reverses the effect of anticholinesterase • •

Check for LIVER FUNX TEST; Keep at bedside: endotracheal tube – for resp. problem

ANTICOAGULANT HEPARIN

COUMADIN

For ACUTE CASES of Manic Case

FOR MAINTENANCE or Chronic CASE

Antidote: PROTAMINE SO4

Antidote: VIT K

Given SubQ (Lower Abdl Fat)

Oral

LOVENOX Heparin Derivatives Antidote same w/ Heparin

Onset: 2-5 days (maintenance case) Check PT (N 11-13 sec and INR 24 sec)

Effective if (-) clot Give same time of day Report s/s of bleeding : Hemoptysis Hematemesis

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

COAGULATION PROCESS:

thromboplastin PRO THROMBIN

Vitamin K dependent clotting factors

COUMADIN

THROMBIN

FIBRINOGEN HEPARIN FIBRIN (CLOT)

COUMADIN – act as vit k dependent clotting factors HEPARIN –

converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN

- RAPID ACTING :onset : 24 – 48 hrs

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

can be given together

ANTIARRYTHIMICS Quinidine (quinam)

Ex.

Side notes:

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

ANTIARRYTHMIC (quinidex, pronestyl) -

repolarization – resting phase (k goes out)

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

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

QUINIDINE

PROCAINE

LIDOCAINE Ventricular arrythmia

For VENTRICULLAR & ATRIAL Fibrillation

CARDIAC GLYCOSIDES -

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

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

Effects: (+) INOTROPIC – strengthen the force of contraction (-) CHRONOTROPIC – decrease rate of contraction DIGOXIN EFFECTIVE : ACTION

DIGITOXIN

it increase FORCE OF CONTRACTION :

same

onset : 5 – 20 mins

30 mins – 2hrs

Give after meals due to GI irritation

same

CLIENT TEACHINGS:



Report s/s of TOXICITY : NAVDA

Xanthopsia –

yellowish vision or greenish halos;

Check PR – if BELOW 60/min (adult) – HOLD next dose; if BELOW 70/ min (older child) – HOLD; if BELOW 90- 110 (infants) – HOLD next dose EXCRETION Digoxin – kidney – monitor renal funx test (BUN & Crea) – report if inc;

Digitoxin – liver – AST/ ALT DIGIBIND – antidote for digoxin (lanoxin) THERAPEUTIC LEVEL:

a. Digoxin b. Digitoxin

: .5 – 2 ug/L : 14 – 26 ug/L

NITRATES (nitroglycerine) -

don’t give if pt taking VIAGRA – it will result to FETAL HYPOTENSION dilatation of coronary arteries and arterioles thereby resulting to DECREASE IN PRELOAD & AFTERLOAD.

EFFECTS:

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

• • •

Effective if NEGATIVE ANGINAL PAIN; Give BEFORE any activity; Administered SUBLINGUALLY (+ burning sensation indicates drug is potent) – NO WATER because it

• • • • •

DOSES: 3 doses at 5mins interval; Report if there is persistence of pain; Check BP and PR; Keep meds in dark container (bec light dec potency); Once the bottle is open, use the meds within 3-6 mos

will dilute the meds;

DO NOT REPORT THE FF: (expected s/s) Hypotension, Headache, facial flushing “why is my face red?”

MUCOLYTICS (an antidote also for ACETAMINOPHEN TOXICITY) Ex. Mucomyst -

it decreases the viscosity of secretion; give meds anytime; client teaching: meds can be diluted w/ NSS or cola;

Side effects: NAV + Rashes

-

if no side effects, repeat dose in 1 hr

BRONCHODILATORS (ex. TERBUTALINE – brethine) -

dilates the bronchioles or airways; effective: if (-) bronchospasm; GIVEN in AM to decrease insomnia

-

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

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

EXPECTORANT -

(robitussin)

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

ANTIBIOTICS -

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

I. PENICILLIN : antidote is EPINIPHRINE II. AMINOGLYCOSIDE (gentamycin) -

effective: (-) infection – give B4 meals; report the ff: OTOTOXICITY: “I hear ringing in my ear” NEPHROTOXICITY : ”oliguria” NEUROTOXICITY : “seizures”

-

check BUN, CREA (kidney funx test); check I & O (sign of nephrotoxicity) ANTINEOPLASTIC (adriamycin)

III. -

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

THYROID AGENTS (synthroid, cytomel) -

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

ANTITHYROID

(PTU, LUGOL’S SOLUTION)

-

For GRAVE’S DISEASE or HYPERTHYROIDISM; Effective: Decrease in T3 and T4 (in lab data); Give round the clock;

Health Teachings:

a.

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

ANTIDIABETICS -

(INSULIN)

effective: N Blood sugar (80-120) for DM Type 1 (insulin dependent); give in AM b4 meals; check: a. instruct S/S OF HYPOGLYCEMIA – dizziness/ drowsiness difficulty in problem solving decrease level of consciouness cold clammy skin b. monitor the blood sugar level in early AM and supper time



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



PEAK OF ACTION (refers to – when patient becomes HYPOGLYCEMIA) REGUALR INSULIN - lunch time Intermediate - late in the afternoon – B4 dinner Long Acting - B4 Breakfast

SULFONYLUREAS -

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

ANTACIDS -

(Orinase)

(amphogel, tagamet)

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

LAXATIVES (dulcolax) Colace Metamucil Dulcolax Lactulose -

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

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

be near or stay near CR; s/e: diarrhea; NO lactulose for pt w/ diarrhea; Causes hypokalemia – therefore check electrolytes Increase fld intake – to avoid dehydration

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

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

K-SPARRING (triamterene, aldactone) -

effective: inc. urine output; give in AM; teachings: monitor for HYPERKALEMIA check PR and K

ANTIGOUT

PROBENECID

COLCHICINE

ALLOPURINOL

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

- ONSET: 1-3 wks

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

MIOTICS (timoptic, piloca) -

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

MYDRIATRIC -

(AK-Dilate)

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

CARBONIC ANHYDRASE INHIBITORS (diamox) -

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

ANTI-ACNE (acutane, retin-a) -

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

TOCOLYTICS (Yutopar, MgSO4) -

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

-

give: ORAL – B4 meals and IV – anytime; teachings: a. signs of Ca Intoxication: hypotension, hypothermia and hypocalcemia b. check bld pressure; urine output (N 30ml/hr) c. check RR – at least 12/min d. check patellar reflex – shld be (+) knee jerk

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

OXYTOXIC PITOCIN

METHERGIN

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

PROSTAGLANDIN (cytotec, E2gel) -

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

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

COGNEX – given with AZEIMERS’S DSES – to increase mental functioning



Pt w/ PVC : bedside : XYLOCAINE



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



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



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



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



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



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



Pt is taking LEVODOPA – observe for URINARY RETENTION



ADREAMYCIN – causes hemorrhagic cystitis



DESMOPRESSIN ACETATE – administered INTRANASALLY



FESO4 – shld be given w/ orange juice



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



Pt taking ANCEF – observe for skin rashes



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

TYPES OF PRECAUTION

AIDS

(universal)

DIARRHEA

(enteric)

HEPA

A

H

GL

GW

M

x

yes

yes

yes

yes

x

yes

(enteric)

x

yes

yes

x

yes

x

x

x

B

(universal)

x

yes

yes

yes

yes

C

(universal)

x

yes

yes

yes

yes

MRSA

(contacts)

yes

MENINGITIS/SEPTIC SCABIES TB

P

(contact)

(tb Precaution)

PEDICULOSIS

(contact)

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

(enteric)

x

yes yes

yes

yes

yes

yes

x

x

yes

yes

x

yes

yes

yes

yes

yes

yes

yes

yes

x

yes

yes

yes

Day 6 (Feb 9, 05)

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

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

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

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

REPORTABLE S/S FOR ADULT • •

Palpitation, Pain and Paroxysmal Nocturnal Dyspnea For pediatric patient: observe for PALLOR – if (+) indicates ANEMIA for baby Nocturnal dyspnea – diff. of breathing at night Paroxysmal ND – when pt feels as if he’s drowning

HEART SOUNDS:

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

in assessing S1 & S2 use BELL of steth

S3 - N for Pediatric pt

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

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

SHOCK mp: decrease in circulating blood volume TYPES    

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



SEPTIC – due to systemic infection

(ex. Septicemia)

TRIAD SYMPTOMS OF SHOCK a. Altered level of consciousness b. Hypotension; c. Tachycardia and Tachypnea

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

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

(D5Lr, NSS. Bld Trans – for jehova’s use plasma expander)

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

TYPES:

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

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

IRON DEFICIENCY ANEMIA -

common in infants and children; characteristic of patient: chubby but pale they are also called “milk babies” those baby 5 yo but still taking milk (milk are poor source of iron)

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

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

Oral FeSO4 (take w/ orange juice) if ELIXIR – use straw to avoid staining of teeth if IM (inferon) – “Z” track method (for Z track IM – PULL SKIN LATERALLY, deep IM, wait 10 seconds before pulling the needle)

FeSO4 – evaluate AFTER 4 weeks to check the effect b. Diet: iron rich food – (organ meat, dried foods, “egg yolk” – iron, “egg white” – CHON); c. provide patient with BED REST – due to fatigue

PERNICIOUS ANEMIA -

common in elderly; common in POST GATRIC SURGERY

Main Problem: Lack of INTRINSIC FACTOR at the stomach (intrinsic factor – the one that absorb vit b12)

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

3F (fatigue, fainting, forgetfulness) Beefy Red Tongue or glossitis Peripheral Neuropathy (tingling sensation at lower extremities – usually both legs are affected)

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

(IM, Once a month for lifetime);

FOLIC ACID DEFICIENCY ANEMIA -

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

Main Problem: Deficiency in Folic Acid or VIT B9 or FOLACIN S/S: all symptoms of pernicious anemia EXCEPT P. NEUROPATHY Lab Data: HgB Folic Acid level (N 4mg/day) – green leafy veg. (spinach) Nsg Dx: Activity Intolerance PI:

(NO RISK FOR INJURY coz NO P. NEUROPATHY)

Inc. folic acid in the diet – g. leafy; Bed Rest

SICKLE CELL ANEMIA -

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

STATUS    

N

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

TRAIT TRANS 50% 25%

DSES TRANS

50% 50% 0

0

(SICKLING OF RBC)

0 25% 50%

0

50% 100%

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

(due to dehydration)

+ Pain + Jaundice Hepatomegally

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

b. Spleenic Sequestration Crisis c. Aplastic/ Megaloblastic Crisis –

– massive entrapment of red cells in the spleen & liver

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

Lab Data: Sickledex Test (+) Turbid Solution Nsg Dx:

PI:

Activity Intolerance Fld Volume Deficit Pain – due to vasocclusive crisis

Hydration and relief of pain (inc oral fld intake) Prevent dehydration Meds for Pain – Morphine SO4, acetaminophen Since HEREDITARY – refer to geniticist

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

Activity Intolerance (dec in RBC) Risk for Injury (dec in WBC and Platelet)

Bld transfusion; Reverse Isolation; Genetic Counseling; Bed rest

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

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

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

Activity Intolerance Risk for Injury

PI :

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

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

Anemia (initial) + 3Fs Bleeding Infection

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

PI:

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

IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) or WERLHOF’S DSES -

common in BLACKS; cause: idiopathic

unknown (viral and autoimmune) s/s:

petechiae ecchymosis hemorrhage (all signs of bleeding)

lab data: Platelet Count of less than 20,000

(spontaneous bldg)

(N 150,000 – 450,000)

Nsg Dx: Risk for Injury Fld Vol. Deficit PI :

(due to bldg)

SAFETY –prevent bleeding Give pt platelet, IVF and Bld Transfusion Corticosteroids – “wonder drugs”

HEMOPHILIA -

inherited – bldg disorder

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

(from mother to male)

Von W Dses - Autosomal Dominant – Mother and Father S/S: Hemarthrosis – Hematoma Hematuria Hematemesis

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

(above mentioned are signs of HEMORRHAGE)

Lab Data : PROLONGED CLOTTING TIME Nsg Dx : Risk for Injury PI : SAFETY then RICE

(REST, IMMOBILIZE, COLD COMPRESS, ELEVATE)

For JEHOVAH’S – use plasma expander (cryoprecipitate) instead

TIPS FOR BLOOD DISORDERS 

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



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



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



common manifestation of LYMPHOCYTIC LEUKEMIA is – PETECHIAE;



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



a 7 yo boy with HEMOPHILIA was admitted. MANIFESTATION – HEMARTHROSIS;



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



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



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

w/c of the ff is EXPECTED

CARDIOVASCULAR PEDIATRICS FETAL CIRCULATION 3 FETAL STRUCTRUES

PLACENTA

UMBILICAL VEIN

UMBILICAL ARTERIES

DUCTUS VENUSUS (functionally, closes at birth)

Vena Cava

Right Atrium AORTA

FORAMEN OVALE (functionally, closes at birth)

R Ventricle

L VENTRICLE

L ATRIUM

LIVER

LA

LV

LUNGS

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

P. ARTERY

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

CONGENITAL HEART DISEASE ACYANOTIC HEART DSES

Dec Pulmonary Bld flow

Obstructive CHD

CYANOTIC HEART DISEASE

Decrease Pulmonary

Vent. Septal Defect (most common) Atrial Septal Defect Patent Ductus Arteriosus

Pulmonary Stenosis Aortic Stenosis Coarctation of the Aorta

Tetralogy of Fallot (most common) Transposition of the Great Vein Truncus Arteriosus Tricuspid Atresia

Usually due to: -

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

Signs and Symptoms:     

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

Complication: CH Failure

(check for “murmur”)

CVA

(due to plycythemia – Inc RBC)

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

PATENT DUCTUS ARTERIOSUS -

connection problem : P Artery and Aorta “machinery-like murmur” (+) brow seating (+) retarded growth (+) tachycardia/ tachypnea

LAB DATA : 2 D-Echo CVP

PExam Nsg Dx : Altered Tissue Perfusion PI :

Oxygenation INDOMETHACIN

ACYANOTIC POSITION: ORTHOPNEIC (position for CHF) then SURGERY

TETRALOGY OF FALLOT -

pulmonary stenosis, coarctation of aorta, right vent. Hypertrophy, vent septal defect “boot-shape heart” tet spell – squatting w/ cyanosis

LAB DATA : 2 D-echo Complication : CVA – check for RBC Count Nsg Dx : Risk for Injury PI :

Oxygenation Position the Pt. : SQUATTING Surgery

COARCTATION OF AORTA -

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

Lab Data : BP, 2 D-Echo PI :

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

KAWASAKI’S DISEASE -

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

S/S : High Spiking Fever for 5 Days Lymphadenopathy Strawberry Tongue Palmar and Feet Desquamation

Lab Data :

No Specific Diagnostic test Check ECG

Nsg Dx :

Altered Tissue Perfusion Altered Thermoregulation Altered Skin Integrity

Diet :

High CHON

TIPS FOR CARDIOVASCULAR – PEDIA 

w/ of the ff is an OUTSTANDING SYMPTOM OF CARDIOVASCULAR PROBLEM in children – difficulty in feeding;



w/c of the ff is an appropriate intervention for a child who keeps on squatting because of Tetralogy of Fallot - if LESS THAN 1 yo – flex lower extremities towards the abodomen;



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



the BLD VESSELS INVOLVE in PATENT DUCTUS ARTERIOSUS – pulmonary artery and aorta;



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



when admitting a pt w/ suspected congenital heart disease, w/c intervention is priority – decreasing the metabolic demand of the heart

CORONARY ARTERY DISEASE (CAD) Main Problem :

NARROWING and OBSTRUCTION of Coronary Arteries which could lead to HYPOXIA – reversible (which could further progress to ANGINA) and or ISCHEMIA – irreversible (that could progress also to dev’t. of SCAR FORMATION that can lead to MI).

Risk Factors:

Family History Atherosclerosis Smoking Elevated Cholesterol HPN

Obesity Physical Inactivity Stress

CAD

HYPOXIA

ISCHEMIA NECROSIS

ANGINA Myocardial Infarction – “ jaw pain”

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

PAIN MTOCARDIAL INFACRTION • • • •

Precipitated by 6E’s Pain that resembles “indigestion”, crushing, excruxiating Pain radiates to the L Jaw, L arm, L shoulder Relieved by SO4 Opiods (MORPHINE)

Pain confined at sternal area Pain that resembles “pressure”

•

Pain occurs AFTER MEAL (post cebum) or AFTER ACTIVITY

SAME

•

•

ANGINA

S/S of above mentioned + SHOCK s/s – esp to CARDIOGENIC SHOCK w/c is due to PUMP Failure – that leads to dec cardiac Output that leads further to CHF.

ECG – initial change is ST SEGMENT DEPRESSION w/

SAME

Relieved by rest & NITROGLYCERIN

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

•

SAME

Nsg Dx : PAIN Altered Tissue Perfusion Impaired Gas Exchange

• Priority : Airway (Oxygenation) •

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

HEALTH TEACHINGS: 

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



For patient with MI – focus on complications :

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



CARDIOVERSION

DEFIBRILLATION

- synchronize - esp. for VTACH w/ PULSE

- unsynchronized - for VTACH w/o PULSE



SEX – for pt w/ MI – resume if pt tolerate 2-3 plights of stair w/o pain; - take meds b4 sex; - position during sex : passive – let the girl do her share

 

ACTIVITY – advised pt to have frequent rest period; DIET : avoid PROCESSED FOODS; MILK Salty Sea Foods Pastries – esp. yellow cake

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

Weak or absent PULSE – indicative of VENTRICULLAR FIBRILLATION



Report NECK VEIN DISTENTION – indicative of CHF complication



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

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

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

PUMP FAILURE EFFECTS:  

Backward Effects : backflow of blood – systemic congestion; Forward Effects : decrease cardiac output – dec in tissue O2 perfusion – that leads to overwork respiratory system

LEFT HEART FAILURE – early signs of CHF Therefore, Right Heart Failure – will be the late signs of CHF as complication of LHF Risk Factors to Heart Failure:

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

RIGHT SIDED HF – systemic effect –

distended jugular vein Ankle edema Ascites Hepatomegally

LEFTS SIDED HF Lab Data :

RIGHT SIDED HF

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

CVP (N R – 0-12, V Cava – 5-12)

X-ray

X-ray

Nsg Dx :

Altered Tissue Perfusion Ineffective Breathing Pattern – for LHF Fld Volume Excess – for RHF

PRIORITY :

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

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

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

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

pre hypertensive phase

120/80, therefore N BP : 110/70 Risk Factors:

  



Common in BLACKS; Obesity Stress Smoking

if BP elevated B4 20-24 wks & cont after delivery – CHRONIC HPN Levels of PIH

a. HYPERTENSIVE DISORDER OF PREGNANCY - INC. BP + EDEMA & Proteinuria (s/s of PRE-ECLAMPSIA)

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

TYPES:

- ECLAMPSIA

a. b. c. d.

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

HPN IN PREGNANCY – usually related to generalized spasm of the arteries

PRE-ECLAMPSIA TYPES: a. MILD b. SEVERE

BP 140/90, PROTENURIA is 5mg/hr

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

ECLAMPSIA + BLEEDING = HELP SYNDROME H – emolysis E – levated Liver Enzyme L – ow P- latelet (All are signs of bleeding) S/S of HPN:

-

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

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

Altered Health Maintenance Risk for Injury

PIORITY:

Stabilize BP

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

   

II. PHARMACOLOGIC MEASURES     

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

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

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

Venous Obstruction ruddy (+) & severe N homan’s sign (+) warm wet

(pain @ gastrocnemeus area)

TYPES: BURGER’S DSES

RAYNAUDS

ARTERIOSCLEROSIS OBLITERANS

FEMALE

MALE

(THROMBO ANGITIS OBLITERANS) common

:

MALE

AREA AFFECTED :

MP :

Lower Ext.

Upper Ext – 97% 3% - lower ext

Upper & Lower Ext

Affects arteries and veins

Arteries ONLY

Arteries ONLY

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

S/S:

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

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

LAB DATA : Inc Nsg Dx:

PI : MEDS :

WBC & ESR

DOPPLER USG

Altered Tissue Perfusion same Pain -do-

Relief of Pain

-do-

Inc Cholesterol and Ca

same -do-

-do-

(for all types)   

DIET :

Hardening of arteries due to fatty deposits

Anticoagulants Vasodilators (papaverin – pavabid) Antihypertensive

Low Cholesterol

VARICOSE VEIN

THROBOPHLEBITIS

PHLEBOTHROMBOSIS

weakening of venous valves; CLOT + Inflammation job related (prolong sitting/standing) pregnancy hereditary secondary to existing medical condition

Clot

s/s : dilated tortous vein dragging sensation “heaviness” edema (unilateral/ bilateral) – tape measure to monitor leg circumference Pain Lab data:

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

PAIN Altered Tissue Perfusion

Hx Teachings :

• • •

• • •

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

NO MASSAGE – coz it may dislodge the clots; KNEE HIGH STOCKINGS; COLD COMPRESS

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

of tunica adventitia to bulge

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

Altered Tissue Perfusion Risk for Injury

PRIORITY :

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

CARDIO-PULMONARY RESUSCITATION (CPR) -

indicated for cardiac arrest when pt is BREATHLESS and PULSELESS;    

shake the pt – are you ok? If breathless & pulseless then; ACTIVATE the EMS – Help! CPR (1 or 2 rescuer : 15 : 2) In 1 minute, there will be 80 compression and 15 – 20 rescue breaths Depth of Compression : 11/2” – 2” If too deep - it may fx the liver Effect of CPR : #1 (+) Pulse; #2 skin color

TIPS FOR CARDIOVASCULAR – ADULT

•

A nurse is assigned to a pt with arterial dses of lower extremities, w/c of the ff is expected – calf pain after short walking (intermittent claudication);

•

A pt was diagnosed w/ MI develop atrial fibrillation – this may possibly lead to – CEREBRAL EMBOLISM;

•

A pt w/ CHF was admitted exhibiting confusion, disorientation, visual disorders & hallucination – the nurse best action is to – CALL THE PHYSICIAN;

•

A nurse is assessing a pt w/ MI – w/c of the ff is the characteristic of PAIN – pain radiates to the jaw;

•

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

•

Pt exhibits intermittent claudication – another sign of peripheral dses is w/c of the ff – tropic skin changes;

•

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

•

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

•

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

•

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

•

A pt with R sided HF will manifest – distended jugular vein

RESPIRATORY General Consideration:   

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

Consideration w/ Pediatric Patient: 

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



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

Reportable Signs and Symptoms : common TO ALL RESPIRATORY DISORDERS “RE TACHY TACHY D C”

 

RETRACTIONS - #1 or Early sign for respiratory distress; Tachycardia

  

Tachypnea Dyspnea Cyanosis – late sign of respiratory Distress

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

   

BIOTS – increase in depth followed by apnea; - pt w/ neuro impairement Cheyne-Stroke – increase in rate and depth of breathing followed by apnea; - nero case Kussmauls – deep rapid breathing; Apneustic – forceful inspiration followed by slow expiration – dying patient

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

Cause: Lack of O2

Effect: ACIDOSIS

HYPERVENTILATION ALKALOSIS Cause

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

APNEA OF INFANCY Occurs in Full Term Baby

SIDS/ CRIB DEATH Usually occurs in Pre-term

(37wks onwards)

s/s : episodes of APNEA, TACHYCARDIA and Cyanosis

Risk Factors:

a. b. c. d.

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

Dx Procedures: Cardioneumogram – measures O2 Polysonography ABG Analysis Tx :

• • •

Administer Theophylline (N 10-20 mg/ml) S/Effects: NAV and Insomia Caffeine Assist mother threu grieving process

Hx Teaching : Teach parents CPR

(esp to Apnea of Infancy)

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

WHEEZING sound – due to obstruction Orthopnea Whitish Sputum

Lab Data :

Pulmonary Funx test Incentive Spirometer

Nsg Dx :

Ineffective airway Clearance

PI :

AIRWAY

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

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

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

Aminophylline Steroids Theophylline Histamine Antagonist Mucolytic Antibiotics

Hx Teachings :    

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

CYSTIC FIBROSIS -

multi system dses (GI and Respiratory System) characterized by excessive mucus production by exocrine glands.

Respiratory Hereditary For each pregnancy S/S :

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

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

Common Complications: MALE –

because of thick mucus plug

Aspermia – low sperm count Sterility

FEMALE – Difficulty in conceiving Nsg Dx :

Knowledge Deficit Altered Elimination Altered Sexual Functioning

Lab Data :

Sweat Chloride Test – N (if sweat) 10 – 35 mg/dl – INCREASE IF (+) CF (if serum) 90 – 110 mg/dl -do-

PI : since two system are affected: Respiratory Therapy – blowing of trumpet, Increase Fluid Intake; GI Therapy – Administer Pancreatic Enzyme (pancreatin, pancrease, viocase) GIVEN WITH EACH MEALS

Effective : if (-) fat at stool Hx Teaching : Refer parents to GENETICIST

CROUP DISORDER ACUTE LARYNGITIS

LTB

RSV/ BRONCHIOLITIS

(Laryngotracheal Bronchitis)

(Respiratory Synctial Virus)

common in TODDLER

INFANTS & TODDLER

INFANTS usually (less than 6 mos)

VIRAL

VIRAL or BACTERIAL

VIRAL

Inflammation of LARYNX

Inflam. of LARYNX & TRACHEA Inflam. Of BRONCHIOLES

“barking-metallic cough”

“harsh-brassy cough”

“paroxysmal-hacking cough”

(-) FEVER

(+) FEVER-low grade

(+) FEVER-moderate

(+) STRIDOR

(+) STRIDOR

(+) WHEEZING

STRIDOR – is present when the affected part is LARYNX.

Lab data: Nsg Dx : PI :

P Exam ABG’s

-do-

ELIZA -do-

INEFFECTIVE AIRWAY CLEARANCE

Airway – Endotracheal Tube (Tracheostomy Set - #1) – to facilitate airway; Humidity – place infant in MIST TENT or CROUPETTE Nsg care:



change clothing frequently coz mist will dampen child clothings;

  

TOYS while inside the tent: PLASTIC TOYS “no battery operated & no friction wheel toys” at HOME: we can use NIGHT or MOIST air outside and hot shower mist at the comfort room – for child to inhale

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

Chronic Obstructive Pulmonary Disease (COPD) MP :

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

EMPHYSEMA

BRONCHITIS

ASTHMA

Over distention of Alveoli

Inflammation of Bronchus Gelatinous sputum + “RE TACHY TACHY D C”

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

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

RE TACHY TACHY D C + “barrel-shape test” – there is an INCREASE in ANTERIOR and POSTERIOR DIAMETER of the chest

Lab Data : ABG’s – to check for respiratory acidosis CXrays Nsg Dx : #1 Ineffective Airway Clearance – due to narrowing & obstruction

#2 Ineffective Breathing Pattern PI :  

AIRWAY 1-2 L/min; Meds: Bronchodilator – Atrovent

 

Exercise: Blowing; Rest periods in between activities

During ACUTE attack, the POSITION OF CHOICE : ORTHOPNEIC

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

• • • S/S :

over distention of alveoli

Diminished Breath Sounds – (-) b. sounds to area auscultated; (+) Dyspnea; (+) Restlessness

Nsg Dx :

PI :

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

Impaired Gas Exchange Ineffective Breathing Pattern

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

PNEUMONIA (PNA) MP :

there is INFLAMMATION of ALVEOLAR SPACES that leads to exudation and consolidation of the lungs.

LEGIONARES DSES – acute bronchopneumonia in elderly, alcoholic & Immunosuppressed pt - management same w/ pna

VIRAL PNA

BACTERIAL PNA

Fever :

(+) low-moderate

(+) fever moderate-high

Cough :

(+) Non productive – “thin-watery” (+) Productive – “rusty”

WBC :

No change or slight

Lab Data :

Xray and ABG’s

Nsg Dx :

Impaired Gas Exchange – due to exudation and consolidation of Alveoli

Elevated

PI : • • • • • •

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

TB

HISTOPLASMOSIS

Bacterial

Fungal (from HISTOPLASMA CAPSULATUM)

MYCOBACTERIUM AVIUM COMPLEX Bacterial

from BIRD MANURE – soil & transmitted thru inhalation

Droplets & Airborne Droplets & Airborne

Droplets & Airborne

Risk Factors: ASIAN IMMIGRANT IMMUNOSUPPRESSION MALNUTRITION

S/S :

same: a to e + FOREST RELATED ACTIVITY

same with TB

Ask client if came from AVIARY

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

Histoplasmine Skin Test – for Histoplasmosis

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

Nsg Dx : Infection; Ineffective Breathing Pattern

•

PROPHYLACTIVE TREATMENT OF TB –

MEDS :

Antiviral Meds

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

Rifampicin INH Streptomycin Ethambutol

-

take above meds for 6-12 moths to avoid resistance

TIPS FOR RESPIRATORY 

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



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



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



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



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



a pt is diagnosed w/ emphysema – w/ of the ff s/s would the nurse expect to have – barrel shape chest;



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

DAY 7 (Feb 10, 2005)

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

c. self insulin administration – allowed to child 9 yo and above Reportable S/S : 

skin changes – “have you noticed any change in your skin color”

 

Inc. temperature S/S of Shock

(“bronze skin pigmentation – addison’s dses)

Keypoints :

Specimen characteristic is usually affected by STREE, DIET and

Normal Body Rhythm

PKU -

AUTOSOMAL RECESSIVE PATTERN of transmission (inherited)

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

Initially – asymptomatic For OLDER CHILDREN :

Since (-) melanine: Lab Data :

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



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



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



Phenylalanine level greater than 8mg/dl – diagnostic of PKU

(4mg/dl – indicative)

Nsg Dx :

Knowledge Deficit Altered Thought Process Risk For Injury PI :

Dietary Modification : LOW CHON and Low Phenylalanine Diet until adolescent or til 10 yo – bec b4 this time the brain mature

MEDS :

Lofenalac – 20-30mg/kg/day

Hx Teachings :

  

Inform parents of the foods to be avoided; - prepare special education to parents Provide list of foods allowed;- prepare special education to parents Refer to geneticist

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

LYMPHOCYTIC THYROIDITIS or JUVENILE HYPOTHYROIDISM Cause :

Autoimmune or genetics

MP :

Decrease in T3 and T4

S/S :

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

Nsg Dx :

Knowledge Deficit Activity Intolerance

PI :

no tx because it regresses (only temporary) spontaneously

CRETENISM or CONGENITAL HYPOTHYROIDISM -

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

behavioral s/s

physical s/s –

- apathy – “well behave”

-

large tongue & protrudes from mouth retarded growth intolerance to cold

mental retardation  

Prevention: neonatal screening blood test; Without treatment, mental retardation and developmental delay will occur after age 3 mos;

Lab Data :

Decrease T3 and T4

Nsg Dx :

Knowledge Deficit Risk for Injury

Meds :

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

PI :

correct the deficiency

Hx Teachings :   

Warm environment (bec there is Hypothermia w/ cool extremities); Low calorie diet : since there is decrease metabolism; Special education

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

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

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

Glands

UNDER

OVER

PITUITARY

Diabetes Insipidus

SIADH

THYROID

Hypothroidism (Myxedema)

Hyperthyroidism (Graves, Basedows, Parrys)

PARATHYROID

Hypo

Hyper

Pancreas

DM

ADRENALS

Addison’s Dses

Cushings Conns

PANCREAS Alpha Cells

BETA CELLS

Islets of Langerhans Glucagon

Insulin

(responsible for Decrease in blood sugar)

Responsible in the increase Blood Sugar

Absence (DM Type I) IDDM    

Juvenile Onset – B4 age of 30 Adolescence to Early Adult Stage Pt is THIN Pt is KETOSIS PRONE

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

MODY – DM III -

combines features of DM Type I & 2; Maturity Onset that occurs in young adult; OBESE, b4 age of 30 Non-Ketosis Prone

GESTATIONAL DIABETES

- occurs during pregnancy

Types According to WHITE’S Classification TYPE

ONSET

DURATION

A

CHEMICAL DIABETES

(+) Increase Bld Sugar

B

After the age of 20

10 years

C

Bet 10 – 19 yrs old

10-19 years

D

Before 10 yrs old D1

More than 20 yrs

Before 10 yrs old

D2

>20 yrs

D3

Beginning Retinopathy

D4

w/ calcification of arteries

D5

DM w/ HPN

E

w/ calcification of Pelvic Arteries

F

w/ nephropathy (Diabetes Nephropathy)

H

Diabetes Cardiopathy

R

Diabetes Retinopathy

T

w/ Transplant of the Kidney

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

unknown

R. factors :

Autoimmune Genetic Stress

S/S :

Polydipsia Polyuria Polyphagia Wt loss

Nsg Dx : PI :

– the stave cells send message to the brain to eat more

Knowledge Deficit Altered Nutrition

Correct the deficiency- HOW?

 

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

RAPID

Regular Insulin - BEFORE LUNCH

INTERMEDIATE SLOW INSULIN:

NPH

- LATE IN THE AFTERNOON/ AFTERNOON

Protamine Zinc - DURING NIGHT Ultralente

Best Site is ABDOMEN bec it is a NEUTRAL AREA

SUBQ – 90 degree angle for insulin syringe 40 degree angle if non-insulin syringe Complication of INSULIN ADMINISTRATION:

 

Lipodystropy Dawn’s Phenomenon – hyperglycemia that occurs at dawn –



SOMOGYI Phenomenon – rebound hyperglycemia

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



Antidiabetic Agent;



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



Ensure adequate food intake;



Transplant of Pancreatic Cells;



Exercise – it will decrease insulin requirement



Scrupulous foot care

(tx: administer insulin)

(in pregnancy/stress – Increase insulin req)

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

Modification for Pregnant Pt with DM •

•

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

2:1 for Regular to NPH 1:1 for R:NPH

EFFECTS

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

BABY Hypoglycemia RDS Congenital Defects

COMPLICATION

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

Hyperglycemia (bld sugar level above 120) (Diabetic Coma)

DKA

HHNK

Risk Factors :  

Missed meals; Increase or Overdose of Insulin;

Overeating Decrease Insulin



Too much Activity

Inactivity Stress Infection

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

Administer Simple Sugar (fructose-fruit juice) Hard Candy (not chocolate – it is complex sugar) If unconscious – D50

DKA (Type 1)

HHNK (Type 2) (Hyperglycemic Hyperosmolar Nonketotic Coma)

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

Hyperglycemia “Kussmaul Breathing + 3P’s Thirst and warm skin Lab Data :

Increase Bld Sugar

PI :

#1 AIRWAY #2 Fluid Regular Insulin

Nsg Dx :

Risk for Injury

More pronounced GI Disturbances

2.

MICROANGIOPATHY

3.

ATHEROSCLEROSIS –

4.

NEPHROPATHY

- destruction of small blood vessels; hardening of arteries;

– kidney damage;

5.

OPTHALMOPATHY

6.

Peripheral Neuropathy or Autonomic Neuropathy -

- w/c leads to cataract

(eye exam annually);

there is poor nerve impulse transmission common manifestation : impotence

DIABETES INSIPIDUS

(Pituitary Glands – 3 lobes)

ANTERIOR

POSTERIOR

MIDDLE

Secrete Tropic Hormones

Store Only (does not excrete)

MSH (skin color)



FSH OXYTOCIN (follicle stimulating Hormone) ADH

 ACTH (adrenocorticotropic hormone)



LH (luteinizing hormone);



GH (growth hormone);



Prolactin

PITUITARY GLAND ADH (anti Diuretic Hormone)

Deficiency: lead to D. INSIPIDUS

– retain h20 or flds

Excess : SIADH

(Syndrome of Inappropriate Anti Diuretic Hormone Secretion)

Due to or related to: Pituitary Tumor Head Trauma Injuries

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

Polyuria – 21 L/day Polydypsia

LAB DATA : a. urine - decrease in specific gravity (N 1.010 – 1.025) – in DI its 10mg in 24 hrs

Nsg Dx :

(+) Proteinuria -