Nursing Board Exam Q&A

Q: How to prevent STD? A: Monogomous relationship Test taking strategies: 1. Process of elimination: 2 correct answers, 2 incorrect answers Q: For 1st/2nd/3rd/4th degree burns, nursing priority? A: #1 INFECTION #2 Dependent on the type of burn 1st & 2nd degree = PAIN 3rd & 4th degree = FLUID & ELECTROLYTE

DEEPENING OF VOICE – late to develop in men Puberty start at age=9 for both Q: Most appropriate food for a toddler (active, playful) A: Spaghetti X-hotdog, X-grapes = both have skin can cause CHOKING X-milk = #1 cause of Iron deficiency

*Best/Most Important/Priority = IMMEDIATELY RELIEVE S/Sx Airway Breathing Circulation Safety First/Initial Nursing Action: Assess Obtain base line data Check Q: Normal physical finding of thyroid gland (anterior of the neck, only 1 gland with 2 lobes) A: Nodular Consistency X-palpable upon swallowing = if client has GOITER, and the only part that can be palpated on the neck is the Thyroid cartilage (Adam’s apple) = Men & women have Adam’s apple but men are more prominent because of MORE FAT PADS, women has more fat pads on the BREAST & HIPS X-Tenderness, X-Marked asymmetry THELARCHE – breast enlargement – 1st to develop in women MENARCHE – late to develop in women ADRENARCHE – pubic, auxillary hair development TESTICULAR, PENILE ENLARGEMENT – 1st to develop in men

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NERVOUS SYSTEM A. 3 DIVISIONS OF N/S 1. CNS a. Brain b. Spinal Cord – H-shaped structure 2. Peripheral N/S (12 pairs of Cranial nerves) I – Olfactory II – Optic III – Occulomotor IV – Trochlear – smallest CN V – Trigeminal – largest CN VI – Abducen VII – Facial VIII – Acoustic IX- Glossalpharyngeal X – Vagus – longest CN XI – Spinal XII – Hypoglossal 3. Autonomic N/S a. Symphatetic N/S b. Parasymphatetic N/S SYMPHATETIC (SNS) “FIGHT or Aggression Response” NOREPINEPHRINE @ Adrenal Medulla ↑Adrenalins VASOCONSTRICTOR All bodily activities ↑ except ↓ GIT - Constipation ADRENERGIC or Parasympatholytic response When under STRESS,blood flows to 3 important organs:

PARASYMPHATETIC (PNS) “FLIGHT or withdrawal response” ACETHYLCHOLINE – neurotransmitter [↑ Acethylcholine = Bipolar Disorder = Lithium ↓ Acethylcholine = M.Gravies] All bodily activities ↓ except ↑GIT - Diarrhea CHOLINERGIC or Vagal or Sympathetic response

#1 Brain - ↑ cerebration = to think #2 Heart – propel blood to systemic circulation #3 Skeletal muscles GIT = least important organ ↓ blood flow ↓ motility CONSTIPATION SYMPHATETIC (SNS) Bodily 1. Eyes – DILATES Mydriasis –aware of surroundings 2. Mouth – DRY ↓ salivation 3. Heart - ↑ HR ↑ BP 4. Lungs – BRONCHODILATION -↑ O2 because under stress -↑ RR 5. GIT – CONSTIPATION 6. Urinary system - URINARY RETENTION

PARASYMPHATETIC (PNS) effects - CONSTRICTS Meiosis - MOIST ↑ salivation - ↓ HR ↓BP - BRONCHOCONSTRICTION -↓ O2 - ↓ RR - DIARRHEA - URINARY FREQUENCY

Correlation to clinical nursing practice: SYMPHATETIC (SNS) PARASYMPHATETIC (PNS) I. Adrenergic Agents I. Cholinergic or Sympatholytic a. Epinephrine, Adrenalins Agents SE: SNS ↑ All except GI a. Beta-adrenergic blocking agents or beta-blockers “LOL” - can not prevent - expectant effect of drug PropranoLOL AtenoLOL - you can lessen/minimize MetropoLOL II. Antipsychotic Agents a. Haloperidol Effects: b. Anti-depressants/Tricylic > Bronchoconstiction/spasm Mono Amine Oxidase Inhibitors > Ellicits ↓ myocardial contraction > 2-4 weeks effects > Treats hypertension ex. PARnate > AV conductor slows down – antiMARplan arrythmic, mild arrhythmic NARdil

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c. Anti-anxiety – Valium Diazepam

Indications: Angina pectoris/MI – to ↓ BP ↓ HR SYMPHATETIC (SNS)

III. Anti-hypertension 1. Beta-blockers “LOL” 2. ACE Inhibitors “PRIL” ending ex: CaptoPRIL EnalaPRIL 3. Ca antagonist ex: Nifedipine IV. Mestinon (Prostigmine) nice to know: COPD 1. Bronchitis 2. Asthma 3. Bronchiectasis 4. Emphysema

- “Blue bloaters”, - Allergens, Hereditary - “Pink puffer”, barrel chest

CENTRAL NERVOUS SYSTEM A. Cells = Neurons = nerve impulse/conduction  Excitability – affected to the external changes in the environment  Conductivity – transmits away of excitation to one cell to another  Permanent cells – once destroyed, not capable of regeneration Types of Cells: According to regenerative cells: 1. LABILE capable of regenerate 2. STABLE 3. PERMANENT

capable of regeneration with limited survival time period once destroyed, can not regenerate

Location GUT, GIT, epidermal, respiratory cells Kidney, Liver, Pancreas, Salivary gland-parotid gland Osteocytes, retina cells, neurons, cardiac cells

nice to know: For shallow wound, scar – suggest to give Vitamin C – precursor collagen, aid in wound healing For stab wound – apply direct pressure to stabbed area using clean cloth -> use CTT For artificial eyes -> dry N/R: use eye drops q30mins

Parotid gland = located below and in front of ear Medulla Oblongata = respiratory center Frontal lobe = motor/speech – head Sceaman creases on foot – normal Artificial eyes = dry = use eye drops q 30 mins when bladder constricts = individual urinates plegia hemiplegia quadriplegia/tetraplegia monoplegia paraplegia

paralysis L/R paralysis 4 limbs paralysis 1 limb paralysis low extremities, with urinary & bowel incontinence -> relaxed bladder ->atony bladder -> urine retention N/R: assist in catheterization There is no upper extremities paralysis B. Neuroglia = acts as support and protection of neurons  majority of brain tumors arises from Neuroglia 1. Types: a. ASTROCYTES – outer surface, 90% astrocytoma -> brain tumor o maintains the integrity of the blood brain barrier o semi-permeable membrane o selective toxic substances can enter: 1) Ammonia = cerebral toxin, 1st toxic substance in the brain ↑ Ammonia ↓ hepatic encephalopathy (end stage) ↓ liver cirrhosis (necrosis of the liver) Primary cause: Malnutrition-Vit B1 Thiamine def. Major cause: Alcoholism Early sign of Hepatic encephalopathy: 1. Asterixis – flapping hand tremors Late signs: 1. Headache

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4) Lead poisoning – 4th toxic substance, Parkinson’s disease; Seizure activity. ANTIDOTE : Calcium EDTA

2. Confusion 3. Fetor hepaticus 4. ↓ LOC leads to hepatic coma

5) Ketone – CNS depressant = by product of fat catabolism Diabetic Ketoacidosis [DKA] –DM I-IDDM early sign: ↓ weight loss ↑ fat catabolism headache ↓ free fatty acid ↓ ↓ Cholesterol Ketones ↓ ↓ Atherosclerosis DKA -> Diabetic coma -> Death HPN ↓ ↓ Late sign: fruity Kaussmaul’s respiration – deep Acetone rapid, shallow, breathing pattern Breath odor

Liver ↓ converts ammonia ↓ Urea ↓ Urine 2) Bilirubin – 2nd toxic substance – yellow pigment irritant to neurons ↑ Bilirubin ↓ Jaundice=icteric sclerae ↓ Hyperbilirubenemia/Kernicterus ↓ Irreversible Brain Damage nice to know: Biliverdin – green pigment Hemoglobin – red pigment Hemosiderin – golden brown pigment Sclerae – white – normal Jaundice – if yellow skin, discololoration & icteric sclerae CAROTENEMIA = tumor in the pituitary gland – if yellow skin but NORMAL eyes HEPATITIS B = from serum – most dangerous, may lead to liver cancer, liver cirrhosis, AIDS HEPA I = from infectious hepa HEPA A = from fecal-oral route 3) Carbon monoxide – 3rd toxic substance, detaches hgb from the oxygen; face = pinkish in color; Parkinson’s disease

b. MICROGLIA = stationary cells – Phagocytosis – cell eating; engulfing of bacteria or cellular debris nice to know: ORGAN BRAIN BLOOD KIDNEYS LUNGS SKIN – subcutaneous tissues c.

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1. 2. 3. 4. 5.

MACROPHAGES Microglia Monocytes – largest WBC Kupffer macrophages Alveolar macrophages Histocytes

EPYNDEMAL CELLS – secretes a glue-like substance that concentrates bacteria = chemoattractants Meninges Microglia (2) Epyndemal cells (1)

defense of CNS

Bacteria

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d. OLIGONDENDROCYTES – produces myelin sheath – covers neurons/fibers; acts as insulator facilitates nerve impulses/conduction Pathognomonic Signs: Asterixis – flapping hand tremors Pill rolling tremors Intentional tremor Low grade fever – afternoon Rusty sputum > needs penicillin Barrel chest Wheezing on expiration Pseudo membrane Koplick spots Chills with step-ladder fever 38-39-40-41oC Petechiae Rose spots on abdomen Rice-watery stool, diarrhea = BRAToast Rebound tenderness (+), flex right leg, palpate R iliac inguinal then remove immediately (+) Cullen’s sign – bluish discoloration umbilicus and (+) Gray-turner – ecchymosis of flank area (+) Cullen’s sign and (+) Homan’s sign – feet dorsiflex with pain (+) Kernig’s - leg pain, and (+) Brudzenski sign – neck pain (+) chevostek’s sign – face spastic; (+) Trouseu’s sign – carpopedal spasm Lock -jaw, sardonic smile, Exopthalmus Butterfly rashes Jaundice Spider angiomas Lion’s face Chipmunk face, over eating, pinge & purge; acid of stomach goes to mouth – teeth cavities

Disease: Hepatic Encephalopathy Parkinson’s Disease Multiple Sclerosis PTB Pneumonia Emphysema Asthma Diphtheria Measles Malaria Dengue Typhoid fever Cholera Appendicitis Pancreatitis OB – Ectopic pregnancy Meningitis Hypocalcemia Tetany, tetanus Hyperthyroidism Hepatitis Liver cirrhosis Leprosy Bulimia nervosa

Bronze like skin pigementation Buffalo humps, moon faced Red beefy tongue Strawberry tongue Protrusion of tongue; Sceaman creases on palm Machine-like murmur, acyanotic Cyanotic, clubbing of fingrs Hypoxemia with cyanosis (+) Levine’s sign = Hand clutching of chest “emote” day light vision hazy vision

Addison’s disease Cushing syndrome Pernicious anemia Kawasaki syndrome Down syndrome Patent ductus arteriosis Tetralogy of Fallot Tet spells Angina pectoris Retinal detachment Glaucoma Cataract

DEMYELINATING DISORDERS: Palliative for s/sx, can not cure 1. ALZHEIMER’S DISEASE = atrophy (shrinkage of an organ) of brain tissue mnesia – partial/total loss of memory gnosia – failure to familiarize praxia – failure to do the purpose of the object ex.combused to brush teeth phasia – expressive &/or receptive RICEPT OR COGNEX – given best @ bedtime nice to know: ANTEROGRADE RETROGRADE EXPRESSIVE APHASIA – Brocca’s RECEPTIVE APHASIA – Wernicke’s

short memory loss long term memory loss inability to speak; FRONTAL = motor speech center inability to understand; TEMPORAL = general interpretative area

2. MULTIPLE SCLEROSIS = chronic intermittent disorder of the CNS, characterized by: WHITE PATCHES of demyelinization in the brain and spinal cord; remission & exacerbation A. Incidence Rate: women 13-25 y.o. B. Predisposing Factors:

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1. Idopathic – unknown cause 2. Viruses 3. Autoimmune – self-killing immunity ex. Glomerulonephritis, Systemic Lupus Erythematous = connective tissue destruction; Pernicious Anemia nice to know: WBC = LYMPHOCYTES & ANTIBODY IgG > pass thru placental barrier = Passive (temporary, preventive action, short acting) ex. IgG to fetus > copies the genetic coding IgA > present in bodily secretion: saliva; tears; sweat; colostrums IgM > largest antibody; acute inflammation IgE > allergic reaction IgD > chronic inflammation C. S/SX of Multiple Sclerosis: 1. BLARING of vision – visual disturbances 2. IMPAIRED SENSATION to touch, pain, pressure, heat & cold, tingling sensation, numbness 3. MOOD SWINGS – euphoria – elated sense of well being 4. IMPAIRED MOTOR ACTIVITY a) Weakness b) Spascity c) Paralysis 5. IMPAIRED CEREBELLAR FUNCTION CHARCOT’S TRIAD: INA Intentional Tremors Nystagmus – abnormal rotation of eyes to head movement Ataxia – unsteady gait 6. Urinary retention/incontinence 7. Constipation 8. Decreased in sexual capacity D. Diagnostic Procedures: 1. CSF Analysis = reveals ↑IgG and ↑Protein thru Lumbar Tap/Spinal tap @ L3-L4 subarachnoid space because spinal cord ends @ L1, L2. Aspirate CSF for microscopic exam nice to know: DURA Subdural Subarachnoid ARACHNOID

SUBARACHNOID

L3-L4 or L4-L5, no more spinal cord

2. Magnetic Resonance Imaging – extent & site of demyelinization with white patches = no nerve impulses; no myelin sheath E. Nursing management – Palliative 1. Administer medication, for acute exacerbation ACTH 2. Provide relaxation techniques = deep breathing 3. Maintain side rails 4. Prevent complications of immobility: Adult – Q2, Elderly Q1 5. Provide catheterization due to urinary incontinence/retention 6. Encourage increase Oral fluid Intake, Forced: 2-3L/day (for constipation) and ↑acid ash in the diet ->acidify urine ↓ prune, grape, cranberry – CGFNS orange, pineapple, vitamin C – local board *avoid bacteria multiplication 7. Avoid heat application nice to know: URINARY TRACT INFECTION UTI – female prone than male (20cm/8inches) Risk factors: 1. Urethra – 3-5cm or 1-1.5 inches 2. Poor perineal care/hygiene = back to front, dirtiest to cleanest 3. Vagina environment = moist, good source of bacterial growth 4. Sexual intercourse without urination after act, leads to urinary retention COMPOSITION OF BRAIN: 1. Brain mass = 80% 2. Blood = 10% 3. Cerebro Spinal Fluid = 10% PARTS OF THE BRAIN: I. CEREBRUM II. DIENCEPHALON III. MIDBRAIN or MESENCEPHALON IV. BRAIN STEM V. CEREBELLUM

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I.

CEREBRUM – largest a) 2 parts: Right and Left Cerebral hemisphere; CORPUS COLLOSUM=bridge between two hemisphere b) 3 functions: Sensory, Motor, Integrative c) 6 LOBES: 1. FRONTAL lobe > motor activity, personality development, controls higher cortical thinking of brain, Brocca’s area = motor/speech center 2. TEMPORAL lobe > hearing, short term memory loss = Anterograde, Wernicke’s area = Receptive 3. PARIETAL lobe > appreciation/discrimination of sensory impulses: pain, touch, pressure, hot, cold -> check if with numbness 4. OCCIPITAL lobe > vision, check if with blindness 5. INSULA or ISLET of REIM > above frontal lobe, controls visceral function/activities of internal organs 6. LIMBIC SYSTEM > controls smell RHINENCEPHALON ANOSMIA = absence of smell, sexual e. Basal Ganglia > areas of Grey matter, located deep within each cerebral hemisphere, produces dopamine = controls gross voluntary movement

NEUROTRANSMITTER: 1. AcH 2. Dopamine

↓ M.Gravies, Ptosis Parkinson

↑ Bipolar Disorder Schizophrenia

II. DIENCEPHALON a) HYPOTHALAMUS > thermoregulator center > controls BP > controls fluids & electrolytes > controls thirst > controls appetite & satiety > controls sleep & wakefulness > controls emotional response > controls some PITUITARY FUNCTION, ex. Adrenergic = Testoterone & Progesterone MENOPAUSE = 40 Female; ANDEPAUSE = Male

> FEAR = known cause, ANXIETY = unknown cause, impending doom , excitement; PHOBIA = extreme fear - desensitization b) THALAMUS > relay station for sensation III. MIDBRAIN or MESENCEPHALON  relay station for sight and hearing  size of pupil Normal = 2-3mm  hearing acuity ISOCORIA = equal size pupil ANISOCORIA = unequal size pupil (+) PERRLA = Normal = pupil equally round reactive to light and accommodation; constricts HEARING ACUITY = 30-40 decibels IV. BRAIN STEM MEDULLA OBLONGATA Function: respiration heart rate vomiting hiccup = SINGULTUS swallowing vasomotor center spinal deccussation *most dangerous if affected

PONS Pneumotaxic center Depth of respiration

V. CEREBELLUM = smallest part of the brain  balance equilibrium  posture, gait coordination a) Cerebellar Test or Romberg’s Test = stand 5 to 10 minutes to: Assume anatomical posture VS Assume normal anatomical posture

(+) Romberg’s Test = ATAXIA: 2 nurses should support in both sides

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b) Finger to Nose Test (FTNT) Individual - faster (+) FTNT = DYMETRIA = inability to stop a movement @ a desired point Doctor and patient:

Alternate Supination Pronation Normal:

Cerebrospinal Fluid 1. Normal Amount = 120-250ml/day Head injury/trauma ↓ Brain compression ↓ Brain herniation ↓ ↑ICP 24-48H – projectile vomiting; irregular RR/HR for monitoring 2. Site of CSF production: CHOROID PLEXUS 3. Composition = Clear, glucose, colorless, protein, WBC, no RBC 4. CSF function = shock absorber, cushions HYDROCEPHALUS = ↑CSF = ↑ICP If postetriorly = there’s early closure of posterior fontanelle Blood Stroke = partial/total brain’s blood supply Circle of Willis = smallest part of artery Collateral Circulation 24-48H – Internal carotid and Middle Cererbral Artery

ABNORMAL (+) Alternate Supination Pronation *if hands do a Kung Fu style Monroe Kellie Hypothesis: Skull – is a close container ICP = 0-15mmHg C1 = Atlas – cervical enlargement, can palpate C2 = Axis, with Foramen Magnum = hole, above Medulla Oblongata, below C1

↑ICP = intracranial bulk brought about ↑ in 1 or the 3 major intracranial components A. Predisposing Factors: 1. Brain trauma/injury 2. Brain tumor 3. Localized abscess 4. Hydrocephalous 5. Meningitis 6. Cerebral edema B. S/Sx: 1. Early Signs ↑ICP: a. Agitation b. Change or ↓ LOC c. Confusion -> restlessness -> agitation -> irritation d. Disorientation -> Lethargy -> stupor -> coma

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LOC: wakefulness = AWAKE Level Of Orientation: 1. Conscious 1. Aware 2. Lethargy 2. Coherent 3. Stupor 3. Alert 4. Coma Late signs ↑ICP: a. Changes in the vital signs: > ↑ BP ↑SBP, diastolic same > Cheyne Stoke’s respiration = normal then with episodes of apnea > HR↓ > ↑ Temperature, Temperature directly proportional BP Example: Patient has 120/80 Pulse pressure = 40mmHg If ↑ICP, BP 140/80, pulse pressure = 60mmHg -> widening of the pulse pressure Brain shock + Cardiac disorder = narrowing of pulse pressure ↓ tissue perfusion ↓ ↓ blood circulation If with seizure = DO NOT restrain, may lead to fracture CUSHING’s reflex = vital signs different that of ↑ICP b. Headache, papilledema, projectile vomiting c. Abnormal posturing d. ♠ Unilateral dilation of pupil – UNCAL HERNIATION e. Possible seizure

3) 4) 5) 6) 7)

Tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis

LATE

Hypoxia -> Cerebral Edema -> ↑ICP Powerful respiratory stimulant = ↑ CO2 b. Assist in mechanical ventilation ↑ CO2 ↓ Negative Feedback @ Medulla Oblongata ↓ Sends impulses ↓ Lungs ↓ Hyperventilation to remove ↓ ↓ CO2 ↓ ↑ Oxygen = maintain homeostasis

C. Nursing Management ↑ICP: 1. Maintain patent airway and adequate ventilation a. Prevention of hypoxia and hypercabia ↓ ↓ ↓ tissue oxygenation ↑ CO2 level ↓ ↓ tissue perfusion LATE sign of HYPOXIA: RAT-BED-C 1) Restlessness 2) Agitation EARLY

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MS 01-21-2006 Guillain Barre Syndrome (GBS) disorder of the CNS, characterized by symmetrical, bi lateral olineuritis, leading to ascending paralysis Polyneuritis>Inflammation of peripheral nerves A.    

Predisposing Factors Idiopathic Autoimmune Antecedent viral infxn Immunizations (best method URTI – Annual flu vaccine) – too costly, not lifetime, yearly, USA 2 doses per year for freely given. Pneumonia (rusty sputum) vaccine every 5 yrs - esp. 65 yrs old. Pyloric stenosis – olive shaped mass.

B.     

Signs and Symptoms Initial sign – CLUMSINESS Dysphagia – can lead to aspiration shld be NGT feeding Ascending muscle paralysis Decreased Deep Tendon Reflex – paralysis (patellar/plantar) Alternate hypotension/hypertension – irregular heart rate – complications- arrythmia Autonomic changes – increased sweating – increased lacrimation / salivation – constipation – give anticholinergic agents (Atropine Sulfate)

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C. Diagnostic Procedures  CSF Analysis : elevated CHON and IgG, (+) Lermic sign (post lumbar tap increased/ forced fluids) CSF opening pressure 50160mmHg. ICP =0-15mmHg D. 1. a. b.

Nursing Mgmt Maintain patent airway and ventilation assist in mechanical ventilation assess pulmonary function test – spirometer – vital lung capacity – Incentive spirometry c. Maintain side rails – due to paralysis d. Prevent complications of immobility every 2 hours, elderly 1 hour e. Institute NGT feeding f. Administer medications as ordered  Anticholinergics- (Autoimmune) Give

Corticosteroids to suppress immune response – BEST GIVEN IN AM 2/3 dose, and PM 1/3 2. Anti-arrhythmic agents >> Lidocaine (Xylocaine) –SE confusion >> Bretyllim SE Blocks the release of norepinephrine vasodilation – hypotension >> Quinidines - anti-arrhythmic and malaria (king of tropical diseases - QUEENS) agents – Anophelus mosquito female with antenna lay in the morning (female needs blood for reproduction) – NIGHT BITING [DAY BITING – Dengue – Aedis Aegypti- 4 oclock habit-wash in the stagnant water, lay in the afternoon or night, Complication: hemorrhage, hypovolemic shocks – INITIAL SIGN: COOL MOIST SKIN RESTLESSNESS, LATE SIGN: ANURIA]. g. Assist in plasmapherresis – removing autoimmune and returned back to the client, other disease who undergoes the same: MG h. Prevent complications. MOST FEARED: Anemia, respiratory arrest – prepare Trach set at bed side. CTT – clamp- to prevent air leakage – prevent pneumothorax & air embolism and extra bottle and petroleum gauze – accidental removal of chest tube – to cover it. Liver cirrhosis – complication esophageal varices veins of esophagus dilate - bleeding – balde balde dugoprepare at bedside: Sengstaken Blakemore Tube to decompress vein – prevent bleeding – may complain of difficulty of breathing, prepare with scissor – to cut the tube and deflate the balloon. Hemodialysis – Bulldog Clip to prevent embolism. 1.

CONVULSIVE DISORDERS – disorder of the CNS characterized by paroxysmal seizures, with or without loss of consciousness, abnormal motor activity, alteration in sensation and perception, and changes in behavior. Is Seizure (1st convulsive attack) and Epilepsy (2nd convulsive attack). Febrile seizure - 5 yrs old – epilepsy

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A. Predisposing factors Head injury secondary to birth trauma CO poisoning antidote: Hyperbaric oxygenation – to remove carbon dioxide and monoxide – poisoning – decrease Oxygen carrying capacity of hemoglobin. (Lead poisoning – Calcium Edta) Genetics

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Brain tumor (Astrocytoma) Nutritional and metabolic deficiencies Sudden withdrawal of anti-convulsive agent – NUMBER 1 CAUSE of status epilepticus – drug of choice – diazepam, valium, glucose – continuous seizure – increased firing in the brain – high metabolism – glucose depletion may cause loss of oxygen – may lead to coma. Oxygen without 5 -10 mins irreversible brain damage B. Types of seizures Generalized a. Grand Mal (tonic clonic) >> with or without AURA highly subjective - with blank stare, flashes, hear voices, smell something, ants crawling in the entire body initial size warning size pending seizure – AURA. Initial sign of AURA (epigastric pain accompanied by visual, auditory, olfactory and tactile sensory experience) >> Epileptic cry – feeling of FALL, Loss of consciousness for 3-5mins. >> Tonic – clonic contractions. Tonic- direct symmetrical extensions of extremities - naninigas, clonic – contractions >> post-ictal sleep un responsive sleep b. Petitmal seizure – (Absence Seizure) – common pediatric clients characterized by: s/sx: >> blank stare >> decreased blinking of the eyes >> twitching of the mouth >> loss of consciousness for 5-10 seconds c. Partial Seizures >> Jacksonian seizure (focal seizures) s/sx: jerky movement of index finger and tongue that spreads to the shoulder and to the other side of the body with jacksonian march >> Psychomotor sezure ( focal- motor seizures) s/sx: -Automatism -stereotype repetitive and non –purposive behavior. - Clouding of consciousness - the client is not in contact with his environment or reality - Mild hallucinating sensory experience (3 types: Visualsevere alcoholism - Korsakoff’s Psychosis, Auditory-Schizo-

Paranoid, I’m Angry – Are you angry?, Tactile hallucination – Substance abuse) >> Status Epilepticus - continuous uninterrupted seizure activity, can lead to coma, drug of choice – diazepam, valium, glucose C. Diagnositc Procedures 1. CT Scan reveals brain lesion 2. EEG - reveals hyperactivity of brain waves. D. Nursing Mgmt: 1. Maintain patent airway and promote safety before seizure activity. a. Clear the site of sharps, blunt objects b. Loosen clothing of the patient c. Avoid use of restraints – can lead to fracture d. Maintain side rails e. Turn client’s head to side to prevent aspiration f. Place tongue guard on the client’s mouth, prevent biting of the tongue, don’t force anything during seizure, during emergency can use of spoon, clean piece of towel 2. Avoid precipitating stimulus – bright/glaring lights – noise 3. drafts 2. Administer medication as ordered: a. Phenytoin (Dilantin) toxic level 20 normal 10-19 – prevent alcoholism may lead to severe PNS b. Diazepam (Valium) c. Carbamazepine (Tegretol) > Treat trigeminal neuralgia d. Phenobarbital (Luminal) 3. Institute seizure and safety precautions post seizure activity by: a. administer O2 inhalation b. provide suction apparatus 4. Monitor and document the following: 4. Onset and duration 5. Type of seizure 6. Duration of post-ictal sleep, the loner post-ictal sleep – danger to lead to status epilepticus 5. Assist in surgical procedure, cortical resection – cortical (pial) incision for frontal lobectomy

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Q: a one year old client is suffering from grandmal seizure. What is the nursing priority? ABC-Safety/ Suffering A. Place mouthpiece – complete set of teeth at 2 -3 yrs old INCORRECT B. Administer O2 inhalation C. Give pillows – CORRECT – prevent banging of the head D. Provide suction apparatus Parkinson Stereotaxic thalamotomy Huntington’s Chorea (pedia) & Parkinson’s disease = decrease dopamine NEUROLOGICAL ASSESSMENT A. Glasgow Coma Scale: Components: 1. Motor Response – 6 2. Verbal Response – 5 3. Eye Opening – 4  Findings 15 15-14 = Conscious/ Conscious - AWAKE 13-12 = Lethargy/Letahargic – Drowsy, sleepy, obtunded 11-9 = Stupor/ Stuporous – client is only awaken by vigorous stimulation, client is (+) generalized body weakness, and decreased bodily reflexes 7 – Coma/ Comatose – LIGHT COMA – (+) all forms to painful stimulation DEEP COMA (-) to all forms of painful stimulation

1. Deep Sternal Pressure/ Stimulation 2. Orbital pressure

3. Pressure on Great toes

LIGHT close fist form a knuckle, press the sternum 3 strokes with response Tip of Thumbs press orbital bones above and below eyes, 3x, with response Press great toes 3x with response

DEEP without response after 3 strokes without response after 3 storkes without response

4. Corneal/ Blinking Pass the cotton tip on Drop saline soln Reflex – Conscious – the eyes when in the eyes it will wisp of cotton – hibla looking straight to blink even closed dulo the nurse, it will blink – light coma, Unconscious – do not if no response use cotton – use one deep drop of saline solution *PRECORDIAL TAP NEVER USED IN THE HOSPITAL – causes: fracture ribs, collapse lungs *do not do CORNEAL PRESSURE – may lead to corneal pressure, cornea punit – may lead to blindness 3 – DEEP COMA B. Comprehensive Neurological Exam 1. Survey of Mental Status and Speech >> LOC >> Test of memory 2. Levels of Orientation 3. Cranial Nerve Assessment 12 Vagus – longest Trigeminal – largest Trochlear - smalles 4. Motor Assessment Movement of larger muscle 0 – no movement plegia 1 – smaller muscle 2– 34– 55. Sensory Assessment 6. Cerebellar Test Romberg Test Finger to nose Test (+) Dymetria 7. DTRs 8. Autonomics Test of memory Short term memory – what did you take this morning for breakfast Anterograde – TEMPORAL lobe affected

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Long term memory – when is your birthday? – validate in the client’s data sheet Retrograde – Diencephalon or Limbic system damage Levels of Orientation Time – Ask for the period of date – Umaga or Hapon or Gabi? Person – Sino po ako? Place – Where po okay? Cranial Nerves Assessment I – Olfactory - S II- Optic -S III- Oculomotor -M IV – Trochlear - M V – Trigeminal - SM VI – Abducen - M VII – Facial - SM VIII – Acoustic –S IX – Glossopharyngeal -SM X- Vagus- SM XI – Accessory -M XII- Hypoglossal -M NOTE: Some says marry money but my brother says bad business marry money CN I – Olfactory nerve  Sensory – smell  Materials used – DO NOT USE ALCOHOL AMMONIA PERFUME – irritating to nasal mucosa highly diffusible easily to evaporate – USE COFFEE granules, VINEGAR, CIGARETTE TAR, BAR SOAP. Procedure: CLOSE HIS EYES, TEST EACH NOSTRIL, BY OCCULDING 1, ask what odor -symmetrical body to check abnormalities >> Hyposmia – decrease sensitivity to smell (matagal vinegar – lumayo – soy sauce) >> Dysosmia - distorted sense of smell >> Anosmia – absence of smell – might indicate: 1. HEAD INJURY 2. INFLAMMATION – sinus – SINUSITIS

CN II - OPTIC NERVE >> Sensory – Vision >> Tests:  Test of Visual Acuity/Central or Distance Vision. Materials used: Snellen’s Chart 1) Snellen’s Alphabet Chart used for literate client who can read 2) Snellen’s E chart – used for illiterate who can not read 3) Snellen’s Animal Chart – used for pediatric clients, children have shorter attention span 1. Findings: 20/20 2. Numerator – FIXED CONSTANT – indicates distance of the person to the snellen’s chart – 20 feet or 6-7 meters 3. Denominator – indicates the distance by which the person can normally see the letters in the chart 4. OD – oculodexter ; right OS oculosinister left OU both eyes, small letters od – once a day 5. ABNORMAL FINDING: 20/200 indicates blindness – can not read the letter E 6. NORMAL FINDINGS: 20/20 - can read at least 2 letters above the shaded red lines 7. If the clients can still read below the shaded red lines perfect vision  Visual Fields/Peripheral vision Where is the examiner when testing the peripheral vision of the client? 1. Superiorly – sa forehead 2. Bitemporally – near ears 3. Nasally - nose 4. Inferiorly – sa baba Instruct client to stare at the nurse’s forehead, occlude right eye – instruct Roxanne to count the numbers of fingers wingling, tapat fingers on areas above. DAMAGE in peripheral vision – Nystagmus 4 COMMON DISORDERS: 1. Glaucoma – increased intraocular pressure Normal=12-21mmHg causes: 1. 40 yrs old 2. Hypertension 3. Obesity

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4. Trauma s/sx:

1. LOSS of peripheral vision “tunnel vision” 2. Halos “rainbow around lights 3. Steamy cornea – cloudy 4. Ocular Pain – eye pain 5. Headache 6. Nausea and Vomiting *Can lead to blindness Diagnostic Procedures: 1. Tonometry 2. Gonioscopy 3. Perimetry Drug of choice: 1. MIOTICS – constricts the pupil Ex. Pilocarpine Sodium, Carbachol 2. Epinephrine eyedrops – decrease aquaeous humor 3. Carbonic anhydrase inhibitor : Acetazolamide-Diamox – promote drainage 4. Timoptics – Timolol Maleate 1. Trabeculectomy 2. Peripheral Iridectomy BOTH-drainage of aquaeous humor *It is preventable, but not curable, treatment is LIFETIME 2. Cataract – opacity of the lens “Degenerative/Senile Cataract causes: 1. 65 yrs old and above 2. Congenital 3. DM 4. Prolong exposure to violent rays s/sx: 1. Loss of central vision – blaring or hazy vision Lens- should be transparent, getting old turns to opaque 2. Milky white appearance at the center of the pupil.

3. Cataract has decreased perception to colors. 4. Diagnostic: opthalmoscopic examination drug of choice: a. MYDRIATICS – ex. Mydriacyl, ATSO4 -dilates the pupil b. Cyclopegics – ex. Cyclogyl – paralyzes the ciliary muscle Surgical procedure: E xtra C apsular C atarat L ens E extraction > partial removal Intra Capsular Cataract Lens Extraction  Total Removal Complication of lens extraction: RETINAL DETACHMENT 3. RETINAL DETACHMENT  means of separation of epithelial cells of the retina CAUSE: 1. FOLLOWING LENS EXTRACTION 2. Myopia – near sightedness – Biconcave lens used as treatment Emmetropia- normal eye Hyperopia – far sightedness – Biconvex lens used as treatment Astigmatism - Distorted vision – Cylindrical lens used as treatment Presbyopia- old sight – loss of - bi-focal lens used as treatment Pathognomonic signs: s/sx: 1. Curtain-veil like vision 2. “Floaters” – due to leakage of red blood cells

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Surgical procedure: 1. Scleral Buckling 2. Cryosurgery – cold application 3. Diathermy – heat application



4. MACULAR DEGENERATION > macula lutea – yellowish spot at the center of the retina - middle layer Fovea centralis - site of perfect vision Optic Disk – covering of retina Pathnognomonic signs: “Black spots”

Q: A client is suffering Trigeminal Neuralgia, the nurse should administer food products? A. hot milk-X, wafer-ok, butter-ok B. bread-ok, cereals-ok & cold drink-X C. potato-OK, toast, gelatin-OK D. gelatin-OK, salad-OK, potato-OK

 

CN III – OCULOMOTOR – 4 EOM–  CONTROLS THE RAISING OF THE UPPER LID  ISOCORIA = Equal  PERRLA = PUPIL CONSTRICTS  CONTROLS THE SIZE OF THE PUPIL 2-3mm CN IV – TROCHLEAR – SO CN VI – ABDUCENS – Lateral Rectus  innervates movement of extrinsic ocular motor EOM= 6 Right eye SR SO LR – MR IO IR

n o s e

Left eye SO SR MR LR IR IO

Follow the direction of my pen according to 6 cardinal gaze PER EYE 4- rectus 2 - oblique 3 cranial nerves CN V – Trigeminal  Ophthalmic branch  Maxillary branch  Mandibular branch  Sensory Motor  Largest CN

Sensory – controls sensation of face and teeth (pain diffused), mucous membrane and corneal reflex Motor – mastication or chewing Damage to CN V – Trigeminal Neuralgia – difficulty in chewing and swallowing

SALAD VS TOAST – which is easy to chew *AVOID EXTREME TEMPERATURES Gelatin is CLEAR LIQUID DIET Porridge is SOFT DIET CN VII – FACIAL NERVE  Sensory – it controls taste anterior 2/3 of tongue. Cotton applicator, pinch of sugar – say ah – place the sugar on the tip of the client’s tongue, don’t allow to taste it- TIP OF THE TONGUE SHOULD BE SWEET  Motor – controls facial expression, instruct the client to smile to frown or raise his eyebrows Bell’s palsy – facial nerve paralysis – temporary – 4 to 6 months Q: What is A. B. C. D.

the most evident clinical sign of facial symmetry? Lips – remove due to cleft lip Cheeks Nasocranial bone – remove due to cleft lip Nasolabial folds – smiling N= face pantay right and left – (+) Bell’s palsy = tabingi- no nasolabial folds

CN VIII – Acoustic/Vestibulocochlear Nerve  inner ear  for balance Kinesthesia “position sense” – movement and orientation of the body in space.

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Cochlear – hearing, organ of corti= TRUE SENSE ORGAN OF HEARING Inner Middle Outer cochlear Hummer Anvil pinna vestibule Stirups external Malleus I-? Stapes Eustachean tube 

Meiner’s disease sensory hearing loss

otitis media Conductive hearing loss

impacted cerumen Conductive hearing loss

Q: laws of physics:a client suffered from MSW multiple stab wound, upon assessment, the client has difficulty of breathing, chest pain. Movement of air in and out of the lungs is carried by what principles: law of PARTIAL pressure of gases. Atmospheric pressure(+) OUTSIDE, lungs = (-) atmospheric pressure NORMAL; (+) atmospheric pressure (higher to lower) - DIFFUSION A. Boyle’s B. Archimedes C. Dalton’s - CORRECT D. Inertia Q pregnant women on her 1st tri of pregnancy, visited a pre natal clinic for check up, UTZ reveals fetus is suspended LAW OF buoyancy – Archimedes



likod ng tonge to initiate gag-reflex, vagal stimulation – eyes constricts, moist mouth, decrease RR, BP, diarrhea HYPOTENSION Damage in cerebral hemisphere

CN XI – SPINAL/ACCESSORY CONTROLS two muscles of  Sternocleidomastoid (neck)  Trapezius (Shoulder) Ask client to shrug, and apply pressure, if he can not hold the pressure paresis, or paralysis CN XII - HYPOGLOSSAL  controls the movement of the tongue  ask client to say AHH, to protrude the tongue, should be straight, if it deviates to left and right, there’s damage to cerebral hemisphere. Ask the client to push tongue against his/her check – he/she might have short frenum/frenulum linguae – located at the back of the tongue “litid” – tongue-tied “bulol” TSE: spontaneous answer, don’t humm, don’t be nervous, use nouns, adjectives, connecting words

Q: A client suffered from vertigo – dizziness due to fasting for 5 days. – INERTIA Law of motion CN IX - GLOSSOPHARYNGEAL  controls taste, posterior 1/3 of tongue CN X – VAGUS  Gag reflex  Tested both, say client to say ah, check the position of uvula, should be at the center or midline, put the tongue depressor sa

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ENDOCRINE SYSTEM Pituitary gland – main organ, (hypophysis cerebri) located at the sella turcica at the base of the brain  master clock, master gland of the body because it secretes hormones that controls or regulates all the metabolic fxn of the body  thyroid  adrenal  gonads  2 DIVISIONS OF pituitary gland 1. Anterior pituitary (Adenohypophysis) 2. Posterior pituitary (neurohypophysis) hormones: 1) Oxytocin – promotes uterine contraction, thereby preventing bleeding or hemorrhage when is the best time to give: after placental delivery to prevent uterine atony that may lead to bleeding and hemorrhage – initiates milk let down reflex by the help of prolactin 2) Antidiuretic Hormone ADH – ADH replacement >> Pitressin (vasopressin) – prevents urination, conserving water Diabetes Insipidus 1. Definition: HYPOSECRETION of ADH ↓ 2. Predisposing Factors: a. Pituitary surgery b. Inflammation c. Trauma d. Tumor

Syndrome of inappropriate ADH HYPERSECRETION OF ADH ↑ 2. Predisposing Factors: a. Head injury b. Bronchogenic cancer.(1.Lung cancer initial: nonproductive cough 2. Liver cancer 3. Prostate cancer -40 4. Testicular cancer – 30, BPH - 50) C. Hyperplasia of

3. S/Sx: Alcohol – inhibits the release of ADH – A. polyuria – excessive urination B. Dehydration - Thirst - Agitation -Poor skin turgor -Dry mucous membrane C. weakness and fatigue D. Hypotension E. Weight loss if left untreated … F. hypovolemic shock – INITIAL: COOL MOIST SKIN, RESTLESSNESS LATE SIGN: ANURIA 4. Diagnostic procedures 1.010 to 1.030 a. Urine specific gravity LOW b. Serum Na 135145meq/L HIGH 5. Nursing Mgmt: a. Forced fluids b. Administer isotonic soln as ordered c. monitor VS and IO d. Administer medications as ordered: Vassopressin

Pituitary gland increased size of the organ due to increased number of cell 3. S/Sx: a. Fluid retention - Hypertension - Weight gain - edema b. Water intoxication may lead to cerebral edema, lead to increased ICP (N=015mmHg), may lead to seizure activity

4. Diagnostic Procedures: a. Urine specific gravity HIGH b. Serum Na LOW 5. Nursing Mgmt. a. Restrict fluid b. Administer medications as ordered Diuretics both osmoticcerebral edema/loopedema GIVEN at AM, 10-15mins, max 6

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–IM Petrissin e. Prevent complications: Hypovolemic shock

hours effect, SD, fast drip, c. 1st monitor VS BP, then I& O d. weight patient daily and assess for edema e. meticulous skin care

ANTERIOR PITUIATARY GLAND 1. Growth hormones/ somatotrophic hormones > promotes elongation of your long bones - DWARFISM - GIGANTISM - ACROMEGALY – box/ squared face distal ends – epiphysis covered by epiphysial plate, shaft – diaphysis – periosteum, center cavity – medullary cavity – covered by endosteum long bones contain bone marrow –RED – epyphysies RBC, WBC, and platelets AND YELLOW – medullary cavity - produces fat cells Q: if there’s a fracture- (loss or break of continuity) of femur, the nurse would expect feared, complications: fat embolism – pulmonary embolism – headache – dizziness – cerebral embolism; second hemorrhage, and compartment syndrome – compression of the arteries and nerves – assess neuro vascular status Puberty as early as 9 as late as 21 yrs old @ age 21 epiphyseal plates closes What to ask for person with Acromegally: Q: what is the sizes of your recent shoes? Drug of choice for Acromegally: Ocreotide – [Sandostatin] 2. ACTH Adenocorticotrophic Hormone – promotes maturation and development of adrenal cortex

Addison hyposecretion and Cushing diseases – hypersecretion 3. PROLACTIN/Lactogenic Hormone – initiates milk let down reflex – development or enlargement of breast 4. MELANOCYTE STIMULATING Hormone (MSH) fxn: for skin pigmentation sufficient amount of melanin – brown skin – can tolerate the heat of the sun - Albinism - Hyposecretion of MSH, complications: blindness and skin cancer - Vitiligo - Hypersecretion of MSH – Dalmatian spots seen in chest 5. LEUTENIZING HORMONE – produces progesterone 6. FOLLICLE STIMULATING HORMONE (FSH) secretes estrogen PINEAL GLAND – secretes MELATONIN  inhibits leutenizing hormone secretion  controls circadian rhythm – body clock THYROID GLAND – palpable only adam’s apple, if palpable you have goiter  nodular consistency = NORMAL  1 thyroid gland continuous, left and right at the back – parathyroid, above-larynx  located anterior to the neck  3 hormones secreted a. T3 – triiodothyronine b. T4 – tetraiodothyronine or thyroxine c. Thyrocalcitonin 1. inhibits the action parathormone – promotes calcium resorption – breaking down 2. T3 and T4 metabolic or calorigenic hormone Brain – increase thinking V/S – high Hypothyroidism – ALL ARE DECREASED except weight and menstruation a. Loss of appetite – but there’s weight gain b. Menorrhagia – excessive menstruation – HIGH estrogen – promotes lipolysis- breakdown of lipids, dislodge to fats, can be

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deposited to arteries, artherosclerosis, hypertension MI, stroke, Increase serum cholesterol Memory impairment Forgetfulness Constipation Lethargy Hypotension Hypothermic Low metabolism, no perspiration, skin dry, cold intolerance Hyperthyroidism – ALL ARE INCREASED except weight and menstruation a. Hyperphagia – increased appetite, weight loss- high metabolim , increased perspiration, heat intolerance b. Amenorrhea – absence of menstruation CNS hyperactivity Irritability Tremors hallucination diarrhea CRITICAL 16 section 3800 final coaching 3200, 340pax UE and ALIW, Araneta PRC- St. Thomas Square Banco De Oro 2nd flr register THYROID DISRODERS: GOITER – enlargement of the thyroid gland due to iodine deficiency 2. Predisposing Factors: a. Goiter belt area - places far from the sea – walang seafoods – no iodine - mountainous regions- cordilleria and Baguio City – increase of goitrogenic foods b. Goitrogenic foods contains pro-goitrin, anti-thyroid agent that has no iodine - metabolism low

ex. Cabbage, radish, singkamas – turnips, all nuts, strawberries, sweet potato, broccoli – planted in mountainous area – soil erosion, iodine is washed away c. Goitrogenic drugs - Anti-thyroid agent (PTU) Prophyllthiuracil given to hyperthyroidism Surgery: Grave’s disease = removal thyroidectomy – subtotal Total thyroidectomy – only to Thyroid Cancer - Lithium toxic 2 N=.6-1.2, forced fluid, increase Na, to prevent dehydration 3. 4. 5. 1. 2. S/sx: a. b. c.

ASA SE: Thrombis, dyspepsia, heart burn CI: Dengue, ulcer antiplatelet Phenylbutazone Cobalt Endemic Goiter caused by goiter belt area Sporadic Goiter caused by 2 goitrogenic food and drugs enlarged thyroid gland mild dysphagia mild restlessness

Diagnostic procedures a. Serum T3 and T4 – may reveal normal and below normal b. Thyroid scan - Enlarge thyroid gland c. Serum TSH is INCREASED – confirms presence of goiter 6. Nursing Management: 1. Administer meds as ordered a. Iodine solution 6. Lugol’s solution – saturated solution of Potassium Iodide- purple or violet – administer with straw to prevent staining of the teeth. (Drugs given with straw: Lugol’s soln, Iron Tetracycline, Nitrofurantoin (Macrodantin) urinary antiseptic drug of choice of pyelonephritis ) 2. Thyroid agents of hormones

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i. Levothryroxine (Synthroid) ii. Liothyronine (Cytomel) iii. Thyroid extracts Nsg Mgmt: 1. best taken in AM – to prevent INSOMNIA 2. Monitor heart rate, most SE: Tachycardia, palpitation hypertension, heat intolerance (due to metabolism) SE: HYPERTHYROIDISM 3. Encourage increased intake of foods rich in iodine. a. seaweeds b. seafoods – oyster #1, clams, crab, lobster, mababa iodine content = SHRIMP c. Iodized salt – too salty – best taken at raw, because heat destroys it. Too much – iodized salt may lead to hyperthyroidism 4. Surgical procedure: partial thyroidectomy MS 01/22/2006 Hypothyroidism 1. Def: hypo secretion of decreased to T3 and T4 7. Myxedema – adult 8. Cretinism – children, the only endocrine disorder can lead to mental retardation 2. Predisposing Factors: a. Iatrogenic cause – disease caused by medical intervention – surgery (Hospital acquired infection – health related infection) b. Atrophy of the Thyroid gland due to: I – rradiation T – umor T – rauma I – nflammation c. Iodine deficiency d. Autoimmune – Hashimoto’s disease

3. S/Sx: low metabolism – hoarseness of voice, anorexia, MI Early signs: a. Weakness and fatigue b. loss of appetite but weight gain c. Dry skin d. Cold intolerance e. Constipation Late signs: a. Brittleness of hair and nails b. Non-pitting edema due to accumulation of mucopolysacchrides in the subcutaneous tissue, hence to adult it’s Myxedema c. Hoarseness of voice d. ↓Libido e. ↓ VS – Hypotension, Bradycardia, Bradypnea, f. CNS Changes – lethargy, memory impairment, psychosis g. Menorrhagia ↑ estrogen 4. a. b. c. 5. a.

Diagnostic Procedures: Serum T3 and T4 are normal or ↓ Radioactive Iodine Uptake ↓ Serum cholesterol ↑ due to weight gain Nursing Mgmt: Monitor VS and IO strictly 9. Myxedema coma – severe form of hypothyroidism, characterized by:  severe hypotension  bradycardia  bradypnea  hypoventilation  hypoglycemia  hyponatremia *that may lead to progressive stupor and coma COMA – # 1. nsg management: - Assist in mechanical ventilation 2. Administer thyroid hormones 3. Forced fluids b. Administer med as ordered – i. Levothryroxine (Synthroid) ii. Liothyronine (Cytomel)

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iii. Thyroid extracts Nsg Mgmt: 1. best taken in AM – to prevent INSOMNIA 2. Monitor heart rate, most SE: Tachycardia, palpitation hypertension, heat intolerance (due to metabolism) SE: HYPERTHYROIDISM c. Provide dietary intake low in calories due to weight gain d. Institute meticulous skin care – due to dry skin e. Provide comfortable and warm environment - due to cold intolerance f. Forced fluids g. Provide health teaching and discharge planning > Avoidance of precipitating factors leading to myxedema coma - Stress - Infection - Cold environment (do not put in air condition room) - Anesthetics, sedatives, and narcotics (lead to respiratory depression)   

Prevent complications: hypertension, MI, CHF, CVA, myxedema coma, hypovolemic shock Hormonal replacement therapy for lifetime Importance of follow up

HYPERTHYROIDISM - hyper secretion of T3 & T4 – GRAVE’S DISEASE – with Exopthalmus - Thyrotoxicosis Predisposing Factors: a. Autoimmune - release of long-acting thyroid stimulator – LATS – autoimmune antibodies responsible of occurrence of exopthalmus b. Increased iodine intake c. Hyperplasia (increase in the number of cells) of thyroid gland Signs/Sympotms: a. Hyperphagia – increase in appetite b. (+) weight loss – T3 & T4 increase, metabolism increase c. Moist skin d. Diarrhea e. Heat intolerance f. ↑ VS -Hypertension, tachycardia, tachypnea, hyperthermia

g. CNS changes – irritability, agitation, tremors, restlessness, insomnia, hallucinations h. Goiter i. Exophtalmos – protrusion of the eye j. Amenorrhea Diagnostic Procedure a. T3 & T4 ↑ b. RAIU ↑ c. Thyroid scan ↑ size of thyroid gland = goiter d. TSH High confirms goiter Nice to know: Enophtalmos- severe dehydration late sign among children, depression in the eye Nursing mgmt: a. Monitor VS and IO strictly – complication of Thyroid storm b. Administer med as ordered – anti-thyroid agents  Prophethiuracil (PTU)  Methimazole (Tapozole) Q: What is the most common SE of anti-thyroidism A: SE: Agranulocytosis – increase WBC Agrunolocytes: Monocytes ↑ and Lymphocytes ↑ = there’s infection Fever, chills = CBC, sore throat – throat swab/culture c. d. e. f. g.

Increased caloric diet to correct the weight loss Institute meticulous skin care due to moist skin Provide comfortable and cool environment Maintain side rails Provide bilateral eye patch to prevent dryness of the eye due to exophtalmos h. Assist in surgical procedure – subtotal thyroidectomy Pre-op Nsg Mgmt: 1. Administer Lugol’s solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage Post-Op Nsg Mgmt: 1. Watch out for signs of Thyroid storm TRIAD: Hyperthermia, Tachycardia, Agitation Nsg mgmt if there’s thyroid storm:

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1. Give medications: a. antipyretics, b. beta blockers – propanolol = SE: PNS 2. WOF: inadvertent or accidental removal of parathyroid gland can lead to hypocalcemia or tetany = trousseua’s sign, chevostek’s sign = administer calcium gluconate IV slowly to prevent cardiac arrest, antidote: magnesium sulfate = toxicity BP low Urine output low RR low Patellar reflex absent – paralysis 2. WOF accidental laryngeal nerve damage – instruct the client to talk and speak after post op – laryngeal nerve cut – notify the physician 3. WOF signs of bleeding – post subtotal thyroidectomy = feeling of fullness at the incisional site – Nurse should check soiled dressing at the back or nape area – Notify the physician 4. WOF signs of laryngeal spasm – difficulty of breathing or shortness of breath – prepare at bedside – trach set 5. Hormonal replacement therpy 6. Follow up care Tonsillectomy – general anesthesia – keeps swallowing may have bleeding – offer ice chips, no straw may add tension to suture line, or provide ice collar PARATHYROID GLAND – pair of small nodules located behind the thyroid gland 1. Secretes parathormone – promotes calcium reabsorption – antagonize –Thyrocalcitonin – calcium reabsorbtion CALCIUM ↑↓ HYPOPARATHYROIDISM 1. Definition: ↓ PARATHORMONE - ↓ calcium ↑ phosphate – hypocalcemia hyperphosphatemia Complications: tetany 2. Predisposing Factors a. Following subtotal throidectomy b. Atrophy of parathyroid  Inflammation  Tumor 3. Signs/ SX

a.         

Acute tetany Tingling sensation Paresthesia Dysphagia – Anorexia Irritability (+) laryngospasm bronchospasm – prepare trach set (+) Trousseu’s sing (+) Chevostek’s sign Complications: Arrhythmia And Seizures

b. CHRONIC TETANY S/Sx:  Cataract and photophobia  Loss of tooth enamel  Anorexia and general body malaise  Irritability and memory impairment 4. Diagnostic Procedures a. Serum Ca ↓ (N=8.5-11mg/100ml) b. Serum phosphate ↑ (N=2.5-4.5mg/100ml) c. X-ray of long bones will show ↑ bone density d. CT scan reveals degeneration of Basal Ganglia 5. Nursing Management: a. Administer med as ordered 1. Ca Gluconate IV slowly- for acute 2. Oral calcium supplement – for chronic ex. Calcium lactate, Calcium carbonate, Calcium Gluconate (facilitate by vitamin) 3. Vit D – sources: (Cholecalciferol) drug, diet (Calcidiol) , sunlight (Calcitriol) (ex. Eat Cheese 5am, 7am-9am sunlight, direct to bones) 4. Phosphate binders - If phosphate is ↑ ex. Aluminum hydroxide gel (Ampho-gel) antacid SE: Constipationbinds phosphate in the intestines promoting it’s excretion in the urine. b. Avoid precipitating stimulus such as bright and glaring lights, due to photophobia result to seizure

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c. d. e. f. g. h. i.

Provide dietary intake ↑ Ca ↓Phosphate – diet of osteoperosis – #1 SALMON, #2 Turnips, #3 Anchovies Institute seizure and safety precaustions Prepare trache set at bedside - for possible laryngeal spasm Encourage the client to breath using paper bag. – Promotes mild respiratory acidosis, that can increased ionized calcium levels Prevent complications: Arrhythmias and Seizures Hormonal replacement Follow up care

Nice to know: Antacids – 2 TYPES A-A-C : Aluminum containing Antacids – SE: Constipation M-A-D : Magnesium containing Antacids (Milk of Magnesia) – SE: Diarrhea Q: What is the most effective antacid with a fewer side effects: A: MAALOX HYPERPARATHYROIDISM 1. Definition: Hypersecretion of parathormone - ↑Calcium ↓Phosphate Hypercalcemia Ca↑ in the blood >– lead to bone demineralization – lead to bone fracture >-lead to kidney stones Calcium = 99%-bones, 1% blood 2. Predisposing factors a. hyperplasia of parathyroid glands b. over compensation of parathyroid gland d/t Vitamin D – deficiency 5. Ricketts – children 6. Osteomalacia – adult 3. S/sx: a. Bone pain especially at the back and bone fracture b. Kidney stones  renal colic – pain  cool moist skin – if with hypovolemic shock c. Ulceration

d. Anorexia and general body malaise e. Irritability and memory impairment 4. a. b. c.

Diagnostic Procedure Serum Ca ↑ Serum Phosphate ↓ Bone x-ray reveals bone demineralization

5. Nursing Management: a. Forced fluids 2-3L – due to kidney stones b. Strain all the urine with gauze pad –can filter the kidney stones or precipitate for the laboratory – for stone analysis: calcium, uric acid c. Provide warm sitz bath – to promote comfort d. Provide acid-ash diet – cranberry, plums, grape juice, prunes, Phils: orage-pineapple-ponkan-Vit C- acidify urine to prevent bacterial multiplication e. Administer med as ordered:  Narcotic analgesic – respiratory depression 1. Morphine Sulfate [antidote= Narcan, (Naloxol – SE: Tremors)] 2. Demerol f. Maintain side rails g. Supervise/ Assist in ambulation h. Diet: lean meat ↑Phosphate ↓Calcium i. Assist in surgical procedure = Parathyroidectomy j. Hormonal replacement for lifetime k. Follow up care l. Prevent complications: kidney stones – ischemia – death of kidneys – may lead to RENAL FAILURE ADRENAL GLAND – located on top of the kidney Cortex – outer part Medulla – inner part Adrenal Medulla – secretes catecholamines – adrenalins a. Epinephrine b. Norepinephrine Vasoconstriction – SNS – All ↑ bodily activities, except GI

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Pheochromocytoma – catecholamine producing tumor -> - > Increased norepinephrine -> HPN (resistant to non-pharmacological agents) -> Hypertensive crisis -> Stroke - disease of adrenal medulla Drug of choice: Beta blockers Adrenal Cortex – outermost - consist of 3 zones or layers: 1. Zona Fasciculata SUGAR -> secretes GLUCOCORTICOIDS hormone ex. Cortisol (steroid) fxn: it promotes glucose metabolism 2. Zona reticularis SEX -> secretes ANDROGENIC hormones ex. FEstrogen (FSH), Progesterone (LH); M-Testosteron fxn: promotes secondary sexual characteristics 3. Zona glomerulosa SALT -> secretes Mineralocorticoids ex. Aldosterone -> promotes Na and water reabsorption, while promoting excretion of K (↑ Na H2O ↓K) Addison – HYPO - ↓SSS Cushing – HYPER ↑ SSS 1. Def: hyposecretion of adrenocortical 1. Def: hypersecretion of hormones leading to: adrenocortical hormones - metabolic disturbances SUGAR - fluid & electrolyte imbalances – SALT - Deficiency of neuromuscular function – SUGAR & SEX 2. Predisposing Factors: 2. Predisposing Factors: a. Atrophy of the Adrenal gland a. Hyperplasia of Adrenal gland b. Fungal infections b. Tubular infection – with TB Q: WHAT do you call the spread of tuberculi bacilli to adjacent organ? A:MILLIARY TUBERCULOSIS 3. S/Sx: 3. S/Sx: a. Hypoglycemia (TIRED) a. Hyperglycemia (PPP) > Tremors > Polyuria > Irritability > Polydipsia > Extreme fatigue > Polyphagia > Diaphoresis & depression Complications: DM b. Decreased tolerance to stress -> b. Increased susceptibility to may lead to Addisonian crisis infection

c. Hyponatremia > hypotension – no water absorption – low salt > Signs of dehydration > Weight loss – no water d. Hyperkalemia > Irritability and agitation > Diarrhea > Arrhythmias – peak T wave e. Decreased libido f. Loss of pubic and axillary hair g. PS: Bronze-like skin pigmentation

c. Hypernatremia > hypertension > edema > weight gain > moonface appearance, buffalo humps, obese trunk, pendulous abdomen, thin extremities d. Hypokalemia > Weakness and fatigue > Constipation > U wave on ECG tracing e. Hirsutism f. Acne and striae, easy bruising g. Increased masculinity in females

4. Diagnostic Procedure a. FBS – low N=18-120mg/dl B. Serum NA low c. Serum K high d. Plasma cortisol low 5. Nursing Mgmt: a. Monitor strictly VS, IO and Addisonian crisis – characterized by: > hyponatremia > hypovolemia > dehydration > weight loss – which may lead to progressive stupor and coma N/R in Addisonian crisis: 1. Assist in mechanical ventilation 2. Administer steroids 3. Forced fluids b. Administer meds as ordered > Corticosteroids – “ONE” - Hydrocortisone, Dexamethasone, Prednisone N/R:

4. Diagnostic Procedure a. FBS high b. Serum high c. Serum K low d. Plasma cortisol high 5. Nursing Mgmt: a. Monitor IO and VS b. Restrict Na and fluids c. weight patient daily and assess for edema d. Measure abdominal girth daily and notify physician e. Diet – low in carbohydrate, high in K, high in protein f. Administer meds as ordered: Provide diuretics: DO NOT GIVE LOOP DIURETICS LASIX : HypoK, HyperGlycemia give only… K-sparing diuretics – Spironolactone (Aldactone)

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1. Best taken 2/3 dose in AM, 1/3 dose in PM, to mimic normal diurnal rhythm. Cortisol ↑ immune response/ strong immune system in AM. 2. Taper the dose – instructs the client to withdraw gradually from the drug. If withhold immediately from drug… 3. Monitor SE: a. Moon-faced appearance, buffalo humps, HPN, edema, hirusitism = increase susceptible to infection = CUSHING syndrome > Mineralocoricoids - Fluorocortisone c. Forced fluids – due to hyponatremia d. maintain patent IV line e. Diet ↑ in calories, ↑ protein ↑Carbohydrates, ↑ Na but ↓ K ex. Ham ↑ Na; French fries ↑ saturated fat f. Meticulous skin care g. Provide health teaching and discharge planning > Avoidance of precipitating factors leading to Addisonian crisis - Stress - Infection - Sudden withdrawal to steroids > Prevent complications: Addisonian crisis –> dehydration –> hypovolemic crisis > Hormonal replacement > Importance of follow up care

– promotes Na excretion, while conserving K. g. Prevent complications: DM h. Assist in surgical procedurebilateral adrenalectomy i. Hormonal replacement j. Importance of follow up care

PANCREAS – located behind the stomach endocrine/exocrine gland Mixed gland: Acinar Cells (exocrine gland) with ducts  secretes pancreatic juices goes through the pancreatic duct to the stomach  aids in digestion

  

Islets of Langerhans (endocrine gland) ductless alpha cells ->secretes glucagons -> hyperglycemia beta cells -> secretes insulin -> hypoglycemia delta cells -> somatostatin -> antagonizes production of GH

Disorders of the Pancreas 1. CANCER or TUMOR of Pancreas 2. Diabetes Mellitus 3. Pancreatitis – autodigestion – self digestion, self-eating - #1 cause = alcoholism, #2 obesity NICE TO KNOW: lipase and amylase – toxic substance in the body right pain – gallstone left pain - pancreatitis GROIN pain – inflammation of testicles (with fever), hernia, stones in the ureters-immobility, limited intake of fluid, concentrated of urine Pain in right iliac region – appendicitis Pain in gallbladder – UTI DM I (IDDM) 1.  2.  3. a. b. c. d. 4. a. b. c. d. e. f. 5. a. b.

Def: Juvenile Onset/ Non-obese Incidence Rate Only 10% of general population Predisposing Factors Hereditary – total destruction of pancreatic cells Viruses Toxicties (carbon tetrachloride CCl4) Drugs, steroids, and loop diuretics (Lasix, and steroids) Signs/Sx: PPP-G Polyuria, polydipsia, polyphagia Glucosuria Weight loss, anorexia, nausea and vomiting Blurring of vision Increased susceptibility to infection Poor/delayed wound healing Treatment: Insulin therapy Exercise

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c. Diet 6. Most feared complications: DKA – give Na Bicarbonate DM II (NIDDM) 1. Def:  Adult Onset/Obese (40 yrs old and above) 2. Incidence Rate  90% of the general population, started to increase in early 80’s 3. Predisposing Factors: a. Obesity – Q:Why obese persons develop DM? A: Obese individuals lack insulin receptor binding sites 4. Signs and Symptoms: a. Usual asymptomatic 5. TREATMENT 1. Oral Hypoglycemic Agents (OHA) 2. Diet 3. Exercise 6. HyperOsmolarNonKitetotic Coma (HONK)

If glucose is low -> cell sends impulses to hypothalamus -> stimulate liver to undergo: a. Glycogenesis = synthesis of glycogen b. Glycogenolysis = breakdown of glycogen -> converts to glucose and undergo the normal function c. Gluconeogenesis = formation of glucose from non-carbohydrate sources: Proteins and Fats DM: I – no insulin II – low insulin Increased glucose -> remains in the circulation – hyperglycemia (because of no or low insulin) -> there’s an increased Osmotic diuresis > polyuria -> cellular dehydration -> stimulate the thirst center (hypothalamus) Polydipsia Osmotic diuresis -> Glycosuria -> cellular starvation -> stimulate appetite center, sense of hunger Polyphagia Cellular starvation -> weight loss

BASIC PATHOGENESIS Main food stuff Anabolism – building up Carbohydrates (CHO) Protein (CHON) Fats

Glucose Amino acids Fatty Acids

Catabolism – breaking down Glycogen Nitrogen Free fatty acids – cholesterol and ketones

Blood circulation – contains nutrients CHO[ ->increase glucose in blood > stimulate pancreas to secrete insulin -> insulin transport glucose inside the cell, but it needs a receptor] blood removed glucose hypoglycemia, CHON, Fats Cell -> will undergo chemical reaction converts glucose to ATP= main fuel of body Some glucose are stored = glycogen, reserved glucose for future use in skeletal muscle and liver

Gluconeogenesis Liver -> release protein -> converted to glucose -> no insulin -> osmotic diuresis Increased CHON catabolism -> (-) nitrogen balance -> tissue wasting/cachexia (client not taking insulin) Increased fat catabolism -> free fatty acids by product -> release cholesterol -> atherosclerosis -> HPN -> MI and Stroke -> Death Free fatty acids -> Ketones -> DKA -> Acetone breath odor and Kussmaul’s respiration -> Diabetic Coma -> Death Q: What is the part of the brain controls thirst and hunger? A: HYPOTHALAMUS Liver –largest gland Pancreas produces insulin DKA – DIABETIC KETOACIDOSIS – acute complication of Type I DM, characterized by severe CNS depression due to hyperglycemia 1. a.

Precipitating Factors: Hyperglycemia

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b. c.

Stress - #1 Infection

2. Signs and Symptoms: a. Polyuria, Polydipsia, Polyphagia b. Glycosuria c. Weight loss *early sign d. N/Vomiting e. Weakness and fatigue * early sign LATE SIGN: a. acetone breath, fruity odor b. Kussmaul’s rapid shallow breathing pattern c. Decreased level of consciousness -> COMA 3. Diagnostic Procedures a. FBS N=80-20 mg/dl b. BUN N=10-20mg/dl due to severe dehydration, the body is compensating c. Creatinine N=.8-1 d. Hematocrit – red cell percentage in whole blood always 3x hemoglobin F=12-14gms% women menstruate M=14-16gms% Hct F=36-42% M=42%-48% average = 42% 4. Nursing Mgmt: a. #1 Airway Assist in mechanical ventilation b. #2 Administer 0.9 NaCl, PNSS, isotonic, followed by 0.45 NaCl hypotonic. c. Monitor VS, IO and neuro check d. Administer meds. As ordered  Insulin Q: What is the type of insulin given to DKA A: Rapid acting insulin – Regular - the  

Sodium bicarbonate Antimicrobial

5. Complication: HONK HO–> increased osmolality -> severe dehydration

NK -> absence of lypolysis -> no ketosis Coma s/sx: Headache, Confusion, Seizure, Decreased LOC Treatment of HONK: the same DKA except NaBicarbonate INSULIN THERAPY 1. Sources  Animal – pork and beef, rarely given because it can cause severe allergic reaction  Human – Humulin – it has less antigenecity property – it can cause less allergic reaction 2. Types of Insulin  Rapid (Short Acting Insulin) – the only clear insulin, peak: 2-4 hours  Intermediate AI - NPH (Non-Protamine Hagedorn) - cloudy, peak: 8-16 hours > Long AI - Ultra lente - cloudy, peak 16-24 hours *DO NOT MEMORIZE THE ONSET AND DURATION, only PEAK HOURS = check for hypoglycemic reaction ex. 5am = 250 mg/dl, give 6 units of Regular A-I due at peak: 79am = check for TIRED CBG N = 80-120mg/dl 3. Nursing Mgmt: a. Administer insulin at room temperature to prevent lipodystrophy (atrophy and hypertrophy of SQ) b. Insulin only refrigerated once opened c. Avoid shaking insulin, roll between palms only d. Accuracy of administration is important e. No need to aspirate after insulin injection f. Administer insulin injection @ 45 (thin individual)-90 (fat individual) degree depending of the amount of tissue deposit g. Gently rotate insulin sites – prevent lipodystrophy

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h. Universal rule: when mixing 2 types of insulin aspirate the clear before the cloudy – to prevent the contaminating the clear insulin and to promote accurate calibration 4. -

Complications: Allergic reactions Lipodystrophy Somogyi Phenomenon> hyperglycemia followed by periods of hypoglycemia

Nice to   

know: Horse – anti tetanus Goat’s brain – anti rabies Chicken – anti-measles (most expensive)

ORAL HYPOGLYCEMICS  for Type II  Mechanism of action: Stimulates the pancreas to secrete insulin 1. Classification of OHA – ending “NASE”  First generation sulfonylureas ex. Chlorpropamide (Diabenase) 1. Tolbutamide (Orinase) 2. Tolazamide (Tolinase)  Second generation sulfonylureas

1. Glipzide (glucotrol) 2. Diabeta (Micronase) 3. Nursing Mgmt in giving OHA: 1. Instruct the client to take it with meals, to lessen GIT irritation and to prevent hypoglycemia 2. Instruct the client to avoid alcohol- because added OHA can result to severe hypoglycemic reactions Diagnostic Procedures for DM: a. FBS – if it is increased 3 consecutive times plus 3 Ps and 1 G, it confir Nice to know: ms Most accessible and most safe: ABDOMEN prese Q: What needle gauge? A: G25-26 small bore needle nce of DM, Use Insulin syringe or tuberculin syringe use (1cc/ml=100units -0.5ml=50units -0.1ml=10units) gluco meter 1ml of tuberculin syringe = 100 units of insulin , prick index *too much insulin -> leads to hypoglycemia -> insulin finger coma -> death – sides only lesser nerve endings – wipe it with saline solution-if no saline soln use dry cotton, don’t use alcohol (fermented sugar = ethyl– it can alter the result) b. Random blood sugar RBS – it is elevated c. Oral Glucose Tolerance Test (OGTT)– it is elevated, most sensitive test d. Alpha Glycosylated Hemoglobin Nursing Management for DM: 1. Monitor for signs and symptoms of hypoglycemia (TIRED)-cold and clammy to touch -> offer hard candies or 1 glass of orange juice => needs simple sugar for easier digestion and easier glucose formation (coke and chocolate =>complex sugar) and hyperglycemia (PPP) – warm and dry to touch -> administer insulin

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Q: A client has history of DM, one morning her body was found in the floor, unconscious A: The brain can tolerate an increase/excessive amount of glucose, but the brain can never tolerate deficiency of glucose->offer simple sugar 2. Monitor strictly VS, Blood sugar, and I/O 3. Diabetic diet CHO 50%, CHON 30%, Fats 20% or offer alternate food products/beverages: glass of orange juice 4. Exercise after meals - to promote increase utilization of glucose 5. Monitor for complications:  atherosclerosis -> HPN -> MI or CVA (Stroke) Neuropathy  Microangiopathies: affects the small capilliaries and arteries of  the eyes: premature cataract -> retinopathy -> blindness and  kidneys -> recurrent pyelonephritis (inflammation of the renal pelvis) -> Nephropathy or Renal Failure  gangrene formation  Shock  Peripheral neuropathy -> diarrhea -> constipation -> sterility/impotence 6. Institute foot care management a. Instruct the client not to walk barefooted b. Encourage client to apply lanolin lotion to prevent skin breakdown c. Instruct the client to cut toenails straight 7. Instruct the client to avoid wearing constrictive garments 8. Encourage annual eye and kidney exam – prevent retinopathy and nephropathy 9. Monitor for signs of DKA or HONK 10. Assist in surgical wound debridement 11. Assist in surgical procedure: a. BKA - Right below the Knee Amputation Procedure b. AKA – above knee amputation

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01/28/2006 Hematology Hematologic System Consists of 3 structures: 1. Blood forming organs: > produces blood cells a. Liver – largest gland – right hypochondriac region b. Thymus – located near the sternum, removed Thymus Myasthemia Gravies – autoimmune antibodies c. Spleen – kills the RBC once it reaches 80-120 days old, proximal to the liver, when hepatomegally occurs, there will be spleenamegally d. Bone marrow- red bone marrow – epiphysis – RBC WBC platelets, yellow bone marrow – long bones humerus, femur, fats cells – most feared complications of fracture of femur: fat embolism – dyspnea & chest pain, hemorrhage, compartment syndrome e. Lymph nodes – f. Lymphoid organ - Salmonella Typhi – Payer’s patches – rose spots in the abdomen – defense mechanism between small and large intestines for Thypoid fever g. Veins – LARGEST: superior & inferior vena cava, jugular veins - towards heart – unoxygenated blood – dark red superficial h. Arteries –LARGEST: aorta & carotid artery – away the heart, scarlet red – oxygenated blood – deep i. Capilliaries NOTE: Alternate expansion and recoil of artery = PULSE Varicosities – venous ulcer – elevate legs Thrombophelbitis – deep vein thrombosis- Homan sign - venous Aneurysm – Abnormal dilation of an artery lead to subarchnoid hemorrhage - arterial Reynaud’s disease – arterial – Female 40 yrs old and above – hands or digits bluish, have intermittent claudication – pain upon walking or excertion, gangrene formation - smoking Buerger’s disease – Thromboanginitis Obliterans –arterial – smoking, Male 40 yrs old and above – feet bluish, have intermittent claudication – pain upon walking or excertion, gangrene formation, III. Blood

a. 55% Plasma – color yellow pigment – bilirubin

NOTE: red cell pigment – hemoglobin, green – biliverdin, golden brown pigment – hemostindirin  

Serum Plasma Proteins a. Albumin  most abundant in plasma protein – maintains osmotic pressure thereby preventing EDEMA b. Globulin 1. Alpha – transports hormones, steroids, and bilirubin 2. Beta – transports iron and copper 3. Gamma – transports antibodies, immunoglobulins 5: G-chronic, maternal circulation A-sweat, tears M-acute E-allergic c. Prothrombin – clotting factors – lead to bleeding and hemorrhage when lack of clotting factors d. Fibrinogen – clotting factors – lack of c & d – Disseminated Intravascular Coagulation

Cellular components: RBC  Normal value=erythrocytes 4-6M cubic mm  biconcave disks NOTE: there’s hemolytic anemia in which the RBC assumes an Sshape structure – SICKLE CELL anemia – immature RBC – easily destroyed by spleen – hemolysis- low rbc, low oxygen. Priority Nsg Mgmt: 1. Airway = avoid deoxygenating activities Q: Sickle cell anemia patient what exercises to indulge: a. Mountain climbing - x b. Hiking - x c. Bowling - √ d. Ice Skiing – x Anti-sickling agent – Hgb-S via IM– can use before flying 2. Force fluids 3. Pain (Comfort) – if too much vaso occlusion – blood flow decreased –> ischemia -> hypoxia o2 low in tissue-> anerobic metabolism -> lactic acid -> irritating to tissue, stimulates mediators, release of prostaglandin->stimulate nociceptor->pain sensation; Give: Mefenamic acid – inhibits prostaglandin

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decreased in RBC – Anemia – early sign: Weakness – low hgb – low oxygen – complete bed rest  increased in RBC – Polycythemia – early sign: Headache; late sign: Pruritus/ Urticaria due to abnormal anti-histamine, can lead to Thrombosis, HPN, CVA, Stroke – TIA early sign: headache A. RBC is anucleated B. Molecules of Hgb (carries oxygen) 

Hgb F = 12-14gm %, lower blood volume due to women have monthly menstruation M = 14-16gm %, blood volume is higher Child = higher blood volume compared to adults C. HEMATOCRIT – RBC percentage, 3x hemogblobin Hct F = 36-42% M = 42-48% Q: A client suffered a 3rd degree burns (Priority: Fluids & electrolytes), the nurse will notice after 24-48 hours that the hct: Pred factor: 3rd deg burn -> hypovolemia->ischemia->Hypoxia->major stimulus for erythropoiesis-> stimulate kidneys->to secrete erythropoietin -produced @ MACULA DENSA -> stimulate one marrow >increased RBC -> increased Hct A: Elevated – compensation √ B: Decreased C: The same D: No change at all Q: a pregnant woman on 1st trimester needs a larger amount of FOLIC ACID to prevent neural tube defect – SPINA BIFIDA/Myelo?-prone position 3rd trimester – needs IRON WBC – Basophil, Neutrophil, Eosinophil with granules – granulocytes In clients with DKA, Acute renal failure, 3rd degree burns – Hct is ALWAYS ELEVATED – due to compensation D. Substances needed for maturation of RBC 1. folic acid 2. iron 3. vit B12 (Cyanocobalamin) 4. vit C (Ascorbic Acid)

5. vit B6 (Pyridoxine) 6. intrinsic factor E. Normal lifespan – 80-120 days F. Spleen – graveyard of RBC at red pulp WBC –phagocytosis (Leukocytes)  Normal value = 5-10,000  Decreased WBC = Leukopnea – increase susceptibility to infxn  Increased WBC = Leukocytosis – (+) to infection A. Granulocytes: (too check how long your infection, use the differential count) 1. Polymorphonuclear Neutrophils > the most abundant of all WBC, constitute 60-70% of WBC > involved in short term phagocytosis-> acute inflammation because lifespan is only good for 3-4Hrs (replaced by MOnocytes) 2. Polymorphonuclear Eosinophils > allergic rxn 3. Polymorphonuclear Basophils > involved in parasitic infxn > involved in the release in chemical mediators for inflammation (Prostaglandin, Histamine, Serotonin, Bradykinins) > *RESPONSIBLE for dissolving or ingesting fat particles after ingestion of high fat meal (presence of cholesterol if too much fats and minimal basophils) B. Monocytes – the largest WBC (Macrophage) > fxn opposite of neutrophils > long term > chronic inflammation > life span 8-12 months > non-granulocytes C. Lymphocytes > non-granulocytes – B cells (arises from bone marrow) – T cells (arises from Thymus) > target site of HIV (incubation period: 6mos to 5 yrs, window period: 6months-subjected to ELISA-inaccurate-enzyme link immunosorbent assay, confirmatory test = Western Blot) > non-granulocytes – NK (Natural killer cells) > have both anti-tumor, and anti-viral property III. Platelets (Thrombocytes) Normal Values =  Promotes hemostatis – prevention of blood loss  Immature/baby platelets – Megakaryoctes, target site of virus = Dengue Virus(Aedis Aegypti) – increased capilliary fragility – Petechiae – internal bleeding

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Signs of Platelet dysfunction: low platelet 1. Petechiae 2. Ecchymoses (purpura-many ecchymoses) 3. Oozing of blood from venipunctured sites Disorder: DIC (provide heplock because it is contraindicated to injection) Hemophilia-pedia = both risk for HEMORRHAGE (Hypovolemic shock) MOST DANGEROUS: Plasmodium Falciparium – may lead to irreversible brain damage, hemorrhage->hypovolemic shock (late sign: anuria) NOTES: HIV complications: 4. Kaposi’s Sarcoma - skin 5. Pneumocystic carini pneumonia 6. Drug of choice: AZT(Zidovudine or Retrovir) Platelets Normal lifespan: 9-12 days 7. Monocytes, Lymphocytes without granules – non granulocytes Platelet – namuo blood clot Note: What is the nsg dx decreased albumin & osmotic pressure? Impaired SKIN INTEGRITY PLASMA protein produce by liver IRON DEFICIENCY ANEMIA – 1. Incidence rate: a. Common on developed countries: USA #1 due to DIET – Increase cereal intake – milk products – less iron #2 Trauma, due to accident -> blood loss -> anemia nice to know: Teenagers Children Infant

Suicide Poisoning-Aspirin SIDS, suffocation

b. Common tropical areas: Philippines – blood sucking parasites

b. Common tropical areas: Philippines 2. Causes: c. inadequate absorption of iron due to: - Chronic diarrhea - r/t increased cereal intake with decreased animal CHON ingestion - malabsorption syndrome d. Inproper cooking of foods  Signs/Sx: a. Usually asymptomatic b. Headache c. Dizziness d. Palpitations - low o2, compensation increase pumping of blood e. Cold sensitivity f. Generalized body malaise g. Pallor h. Brittleness of hair i. Spoon shaped nails – Koilonychia j. Atrophic glossitis – inflammation of the tongue, Stomatitis – mouth sore, dysphagia = collectively known as PLUMMER VINSON’S SYNDROME k. Pica, abnormal appetite, craving for non-edible foods -> cerebral hypoxia->psychosis-> neuronal impairment-> body will find an immediate alternate source of nutrients (oxygen & glucose) NOTES: Nails 180 degrees normal, form a diamond shape, thumb to thumb 4. Diagnostic Procedure: ALL LOW 1. RBC 2. Hgb 3. Hct 4. Reticulocytes 5. Iron 6. Ferritin RBC (80-120days) -> Spleen -> hgb disintegrate into ->>heme & ->> globin ->back to spleen, while heme ->> ferrous & -> bilirubin & >biliverdin , ->>ferretin -> back to spleen

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c. Women 15-35 yrs old-reproductive age d. Common among the poor – nutrition deficiency Chronic       

blood loss due to: heavy trauma menstruation GIT bleeding hematemesis = vomiting of blood melena = passage of black tarry stool – indicates upper GI bleeding – stomach, small intestines hematochezia = fresh blood in stool – indicates lower GI bleeding – large intestines hemoptysis = coughing of blood

Bilirubin-> GIT (N flora) ->>Urine (urobilin), ->>stool (stercobilin) If without bilirubin: urine – tea colored, stool –clay colored Alicia Dionisio – member Psychiatric nursing 200 items Q: What is the most possible cause of death of count Dracula? A. Eczema – skin wounds B. Halitosis – bad breath C. SLE – butter fly rash D. Porphyria – increasing porphyrin (encircles ferritin) rings in the blood – severe photophobia, and psychotic behavior 5. Nursing Management: a. Monitor for signs of bleeding of all hematest including urine, stool and GIT b. Enforce CBR, so as not to overtire the client c. Encourage increased iron diet: Iron - #1 California Raisins, egg yolk, organ: liver, meat, legumes, green leafy vegetables, sweet potato d. Avoid tannates-major substance mixed in coffee & teagives color brown (impairs iron absorption) in tea e. Administer medications as ordered: oral iron preparations: ferrous sulfate, Fe gluconate, Fe fumarate 300mg/OD- take it with meals, to lessen GIT irritation, when diluting to liquid iron preparation: administer with straw to prevent staining in the teeth

f.

Instruct with Vitamin C, orange juice to facilitate absorption. g. Monitor, and inform client of SE: all GIT 1. Anorexia 2. Nausea and vomiting 3. Abdominal pain 4. Diarrhea/constipation 5. Melena h. If the client can not tolerate iron preparation, there’s poor compliance to iron preparation – administer parenteral iron preparations Iron Dextran IM or IV, Sorbitex IM Nsg Mgmt: 1. Administer z-track method to prevent discoloration, discomfort, leakage to tissue 2. Avoid massaging the injection site, instead encourage client to ambulate 3. Monitor and inform client of SE 6. pain at injection site 7. localized abscess 8. Lymphadenopathy 9. Fever and chills 10. Pruirtus and urticaria 11. Hypotension, if (+) Anaphylactic Shock = Epinephrine SE: SNS, all increase except GIT To use straw: Tetracycline Lugos Iron Nitrofurantoin macrolantin Chinese: white : genetic, diet=tea PERNICIOUS ANEMIA – megaloblastic anemia, characterized by macrocytic anemia due to deficiency of intrinsic factor leading to hypochlorhydric (decreased to HCl acid secretion) - most dangerous anemia because of neurological disturbances Pathogenesis: Stomach ↓

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Parietal cells/Oxyntic/Argentaffin ↓ ↓ Secretes Secretes Intrinsic factor hydrochloric acid Fxn: promote ↓ Reabsorption of Aids in digestion VS Indigestion Vitamin B12 ↓ ↓ Dyspepsia promotes of maturation ↓ of RBC ↑ calories CHON 1. Predisposing Factors: a. Subtotal gastrectomy - Billroth I – duodenostomy - Billroth II – Jejunostomy b. Related to hereditary factors c. Inflammatory disorders of the ileum d. Autoimmune e. Strictly vegetarian diet 2. S/SX: 12. headache 13. dizziness 14. dyspnea 15. palpitation 16. cold sensitivity 17. pallor 18. generalized body malaise GIT changes: 19. mouth sores 20. red beefy tongue 21. Dyspepsia 22. Weight loss 23. Immature RBC – jaundice Neurologic changes: 24. Tingling sensation 25. Paresthesia 26. Ataxia 27. Psychosis

Vit B12 – maintains myelin sheath, without it may lead to neurologic impairment 3. Diagnostic Procedures 28. Schilling’s Test – reveals inadequate absorption of Vit B12 a. Injection of nonradioactive vit b12 given at IM Gluteus maximus, or radioactive b12 ingested, Urine samples are collected (water soluble vitamins, easily to excrete through urine)- High vit B12 4. Nursing Management a. Enforce complete bed rest b. Administer Vit B12 injections at monthly intervals for lifetime as ordered, should not be given orally- client may develop resistance, NOT DAILY, major SE: NONE c. Increase caloric intake, CHON, CHO, Fe, and Vit C d. Encourage client to use soft bristled toothbrush and avoid irritating mouthwashes – due to mouth sore, red beefy tongue e. Avoid heat application- can lead to burns Q: What are the sites of Vit B12 injections? A: Ventrogluteal and dorsogluteal APLASTIC ANEMIA It is a stem cell disorder characterized by bone marrow depression -> leading to Pancytopenia (All blood cells are decreased ->> decreased RBC (Anemia) s:weakness, ->>decreased WBC (Leukopenia)s:increased susceptibility to infection, ->> decreased platelets (thrombocytopenia) 1. Predisposing factors a. Chemicals 29. Benzene and its derivatives b. Irradiation c. Immunologic injury d. Drugs 30. Broad spectrum antibiotics  Chloramphenicol  Sulfonamides (Bactrin) co-trimoxazole (UTI) 31. Chemotherapeutic Agents  Nitrogen Mustard (anti-metabolite)  Vincristine (Plant Alkaloids)

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 Methotrexate (Alkylating agent) Signs/Sx: Anemia – Headache Dizziness Dyspnea Palpitations Pallor Cold sensitivity Generalized body malaise Leukopenia – increased susceptibility Thrombocytopenia – PEO 32. Petechiae 33. Ecchymoses 34. Oozing blood 3. Diagnostics 35. CBC – reveals Pancytopenia 36. Bone marrow biopsy or aspiration – reveals fatty streaks in the bone marrow Q: Site of bone marrow aspiration A: posterior iliac crest 2. a. b. c. d. e. f. g. h. i.

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

Nursing Management: Removal of underlying cause BT as ordered Enforce complete BR Administer O2 inhalation Institute reverse isolation Monitor for signs of infection: fever cough Avoid IM, SQ or any venipuncture sites – provide heparin lock Administer medications as ordered: 37. Immunosuppressants: Anti-lymphocyte Globulin – given 6days to 3 weeks via central venous catheter to achieve the maximum effect of the drug

DISSEMINATED INTRAVASCULAR COAGULATION –an acute hemorrhagic syndrome, characterized by wide spread & spontaneous bleeding & thrombosis due to deficiency of prothrombin & fibrinogen -platelet disorder 1. Predisposing Factors a. Rapid BT

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

Massive trauma Massive Burns Neoplasia -New growth of tissue or tumor Anaphylaxis Hemolytic Reactions Pregnancy Septicemia

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

Signs and symptoms: Petechiae – whole body Ecchymoses – whole body Oozing of blood Hemoptysis – scarlet red Hemorrhage Oliguria (late sign)

3. Diagnostic Procedure: 38. CBC reveals thrombocytopenia 39. Stool for occult blood (+) 40. Ophtalmoscopic exam 41. ABG analysis – metabolic acidosis Metabolic acidosis Chronic Diarrhea DM Ileustomy

Metabolic Alkalosis Projective Vomiting Pyloric stenosis Cushing

Respiratory Acidosis Emphysema

Respiratory Alkalosis Hyperventilation

Bronchitis

ROME – respiratory Before ABG, patient should be (+) Allen’s test: determines collateral circulation, press radial & ulnar artery ABG Normal Values 1.35-1.45 35-35 22-26 Polycytemia late sign- pruritus

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Acidic – hematemesis coffee ground, with HCl 4. a. b. c.

Nursing Management Monitor for signs of bleeding of all hema tests Administer IV fluid replacement as ordered isotonic Administer oxygen inhalation as ordered 42. Vitamin K (Aquamephyton) 43. Heparin – short acting 44. Vasopressin, Pitrissin – to prevent urination, conserving water d. Provide heplock, avoid IM SQ or any venipuctured sites e. Institute NGT decompression – gastric lavage 45. iced saline solution 46. cold saline solution f. Prevent complications: Hypovolemic SHOCK, late sign = anuria NOTES: NGT tube kink – closed – for feeding – gavage NGT tube – open –drain sa bed side bottles – lavage – remove gastric contents – decompression Give ice or cold water saline solution instill 1 litter, then decompress BLOOD TRANSFUSIONS 1. FOUR objectives: 1.) To replace circulating blood volume 2.) To increase the oxygen carrying capacity of the blood 3.) To combat infection if decreased WBCs 4.) Prevent bleeding if decreased PLT 2. Nursing Management: 47. proper refrigeration 48. proper blood typing and cross-matching  O - universal donor  AB – universal recipient  85% of general population is Rh (+) 49. Aseptically assemble all materials needed for BT:  Filter set (BT set)  PNSS isotonic to prevent hemolysis  Needle gauge 18-19 large bore needle 50. Instruct another RN to re-check the following  Name of patient

 BT and crossmatching  Expiration date  Serial number 51. check blood unit for presence of bubbles, cloudiness, sediments and dark color – signs of contamination DO NOT DISPOSE, RETURN TO THE BLOOD BANK, for re-exam 52. NEVER WARM BLOOD PRODUCT, it may destroy vital components in the blood, wait for 30 minutes, let room temperature warm the blood product, NEVER WRAP IT 53. WARMING of blood, used only through warming DEVICE, emergency-RAPID BLOOD TRANSFUSION 54. Transfusion should be completed in 4 hours, blood that is exposed more than 2 hours causes blood deterioration, can result to bacterial contamination 55. Avoid mixing or administering drug at BT line – may cause to hemolysis 56. Regulate at KVO (Macro- 10-12gtts/min) at 100cc/hr – to prevent circulatory overload 57. Monitor VS BEFORE, DURING & AFTER transfusion, especially every 15 minutes (majority of transfusion rxn occurs in this period) for the first hour. 3. Signs of BT reaction - HAPCATCH Hemolytic Reaction Signs/sx: 58. dizziness 59. headache 60. dyspnea 61. hypotension 62. flush skin 63. lumbar, flank, sternal pain 64. red colored urine (portwine urine) Nsg. Mgmt: 1. Stop the blood transfusion 2. Notify the physician 3. Flush it with PNSS, to prevent hemolysis 4. Administer isotonic fluid solution as ordered – to counteract shock & prevent acute tubular necrosis –(leads to renal failure) 5. Return the blood unit to the blood bank for re-examination 6. Obtain urine & blood samples to laboratory for re-examination 7. Monitor vital signs

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Allergic Reaction: s/sx: 65. fever, chills 66. dyspnea 67. laryngospasm 68. bronchial wheezing 69. urticaria, pruritus Nursing Mgmt: 1. to 3 same 4. Administer anti-histamines as ordered Diphenhydramide Hcl (Benadryl) drowsiness, avoid driving and operating machineries 5. If (+) hypotension due to anaphylactic reaction 6. Return blood to blood bank (same) Pyrogenic Reaction s/sx: -fever and chills - headache - dyspnea - tachycardia and palpitations - diaphoresis Nursing Mgmt: 1. to 3 same 4. Administer anti-pyretics & antibiotics as ordered 5 to 7th same 8. Provide TSB Circulatory Overload S/Sx: 70. dyspnea 71. rales/crackles 72. orthopnea Nsg Mgmt: 1 to 2 same 3. Administer loop diuretics as ordered: Lasix 10-15mins 6 H, given AM Air embolism Thrombocytopenia

Citrate intoxication – hypocalcemia, tetany, trousseou’s sign Hyperkalemia – indicates that blood is already expired – lead to arrythmia Q: You have 4 patients, who will the nurse help in emergency case? A: Hemolytic reactions √ B: Allergic C: Pyrogenic D: Circulatory Next is Anaphylactic reaction Verbal order – during emergency only, let another doctor to sign it for the other doctor’s order Administer KCl 11.5 meq/L- (should be given 3.5-5.5meq/L) to be given via IV bolus now – (may lead to cardiac arrest, should be given IV drip) Hypotonic solution: what happened to the cell? – SWELL Hypertonic solution: SHRINK Insulin G25-26 RBC 1 unit/pack = 3-6 days refrigeration = 250cc Platelet bag expiration = 3-5 days refrigeration = 110cc Whole blood with plasma= 2-3 months = 500cc Oncology Nursing Differences Differentiation Encapsulation Metastasis Prognosis Tx modality

Benign (Tumor) well differentiated with capsule (-) Good Surgery-most chosen treatment

Malignant (Cancer) poorly differentiated without capsule (+) Poor Chemotherapy Radiation – many side effects Surgery Bone marrow Transplantation Normal growth of cell: by straight line, with structure, pantay Cancer cells: They pile each other, forming mass

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Oldest type of cancer – BREAST CANCER 1. Predisposing Factors (Carcinogenesis) GIVE 73. Genetic history (smoking, drinking, staying late at night=immunocompromised) – with oncogenes 74. Immunologic factors: 75. Viral factors: Epstein barr virus – infectious mononucleuosis KISSING DISEASE (dysphagia, retinopathy, fever & chills, sore throat, spleenic rupture->immediate death); Human papelloma Virus – wart-pre-carcinogenic (same as moles) (if it spreads, tender, 76. Environmental factors  Physical factors  Radiation  UV rays  Nuclear explosion  Chronic irritation  Direct trauma: cervical cancer – (multiple sexual partners or birth)  Chemical factors  Urethrane/hydrocarbons  Food additives (nitrates/nitrites) tocino tapa-salitre  Drugs (stilbestrol, diethylstilbestrol, DES)  Smoking  Hormones 2. Classification (based on tissue type) 77. Carcinoma -epithelial tissue and surface of the granular tissue 78. Sarcoma – connective tissue 79. Multiple Myeloma – arises from bone marrow & plasma cells, hypocalcemia, early sign: back pain especially in AM 80. Lymphoma – arises from lymph glands 81. Leukemia – arises from blood cells, CODE: ANT  Anemia

 Neutropenia  Thrombocytopenia 3. Warning danger signal signs: CAUTION 82. Change in bowel or bladder movements 83. A sore that doesn’t heal 84. Unusual bleeding or discharges 85. Thickening of a lump in breast or elsewhere 86. Indigestion or dysphagia 87. Obvious change in a wart or mole 88. Nagging cough or hoarness 89. Unexplained anemia 90. Sudden weight loss 91. Anemia 92. Loss of weight NOTE: 3 to 4 (+) signs, consult a doctor 4. Therapeutic Modalities 1. Chemo-utilization of various chemotherapeutic agents that kills the cancer cells, and also kills normal rapidly producing cells-GIT, hair follicles, bone marrow.  Antimetabolites  Alkylating agents  Plant alkaloids  Hormones and steroids  Antineoplastic antibiotics 5. Side effect and nursing Management a. Hair follicles – alopecia 93. Encourage use wigs – turban/bandana 94. Inform client that hair loss is temporary, hair will grow back in 4-6months after chemotheraphy b. GIT - Nausea and vomiting: 95. NPO before procedure 96. Administer anti-emetics (Metoclopramide) Plasil 4-6 hours before chemotheraphy 97. Bland diet post-chemo 98. Diarrhea :Administer anti-diarrhea agents 4-6hrs before chemotherapy 99. Stomatitis: provide oral care, offer popsicles 100. Dysgeusia (altered taste sensitivity):

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c. Bone Marrow Depression – Anemia: 101. CBR 102. Provide O2 inhalation 103. Leukopenia: reverse isolation 104. Thrombocytopenia: encourage client to use electric razor when shaving d. Reproductive organs 105. Sterility: encourage client to sperm banking before the start of chemotherapy 106. Genetic counseling e. Renal System 107. Lead to increasd serum uric acid - Allopurinol - Colchicine f. Neurologic Disturbance - Peripheral neuropathy - Paralytic ileus> absence of peristalsis, the only chemotherapeutic agent: Vincristin -plant alkaloid II. Radiation therapy- utilization of electro-magnetic waves that kills the cancer cells and inhibit their growth and also kills the normal rapid producing cells a. Types of energy emitted 108. Alpha – does not penetrate skin tissues 109. Beta – internal radiation; more penetrating 110. Gamma rays – external radiation; penetrates deeper underlying tissues (ex. cobalt)

117. Distance – the farther the distance, the lesser the exposure 118. Shielding – alpha and beta rays can be blocked by rubber gloves; gamma rays can be blocked by thick lead and concrete d. Major SE and nursing management: 119. Skin erythema/redness and sloughing of tissues  Assist in bathing  Force fluids, to flush the radioisotopes, flush water  (-) talcum powder, lotion – may lead to skin irritation & breakdown, use olive oil (NCLEX) or cornstarch (local exam) 1. GIT N/V, diarrhea, stomatitis 2. Bone marrow – anemia, leucopenia, thrombocytopenia Same intervention NOTE: Atrophy of taste buds (decreased taste sensitivity) – 40 yrs old Phils: 95% Filipino males who have cancer are aged European: dominant gene Q: what should be avoided post chemo? A. custard B. milk C. Pork (beef) √ D. Banana

b. Methods of delivery 111. External – utilizes electromagnetic waves 112. Internal – involves injection or implantation / transplantation or injection radioisotopes proximal to the cancer site 113. Sealed implant – radioisotope within a container and does not contaminate body fluids ex. Phosphorus 32 114. Unsealed implant – radioisotope without a container and contaminates body fluids c. Factors affecting Exposure 115. Half life – time required for half of the radioisotope to decay 116. Time – shorter time lesser exposure

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01/29/06 CARDIOVASCULAR SYSTEM Heart – muscular pumping organ of the body A. the only organ located in the midastinum Left B. it resembles like a closed fist C. Weighs 300-400 grams D. This is covered by a continuous sheet – serous membrane – pericardium 3. Parietal –outside 4. Visceral – middle  Pericardial fluid – approx 10-20cc in the middle of parietal & visceral, to prevent pericardial friction E. Layers  Epicardium  Mayocardium  Endocardium III. Chambers a. Atria – collecting or receiving chamber b. Ventricles – pumping or the contracting medium, left ventricleHIGHEST PRESSURE: 180-250mmHg needs pressure to force the blood going to the aorta, going to the systemic circulation TO PREVENT backflow, IV. a.  b. 1. 2. 

Valves atrioventricular valves Tricuspid Mitral closure of the AV valves gives rise to: 1st heartsound S1 “LAB” Semilunar valves Pulmonic Aortic closure of the semilunar valves gives rise to: 2nd heart sound S2 “DAB”  Extra heart sound 1. S3 – ventricular gallop – CHF LEFT 2. S4 – atrial gallop – MI HPN IV Coronary Arteries – both supply the myocardium with blood a. Arises from the base of the aorta b. Right main coronary artery RMCA

c. Left MCA If one of the coronary arteries is blocked, myocardial ischemia -> angina pectoris -> if prolonged myocardial necrosis -> MI (heart attack) V. Cardiac conduction sytem a. SA node – pacemaker, (Keith Flock node) – located at the junction of superior vena cava and right atrium 3.fxn: primary pacemaker of the heart, it is the one that initiates an electrical impulse of 60-100bpm 4.if heart rate is below 60 brady, above 100 tachycardia -> arrythmias b. AV node – (Tawara node) - located at the inter-atrial septum - there’s a delay of electrical impulse NORMAL= 0.08 milliseconds to allow ventricular filling - secondary pacemaker, can initiate electrical impulse only for about 4060bpm c. Bundle of His - R and L main bundle branch - located in the interventricular septum d. Purkinje fibers - located at the walls of the ventricles - leading to ventricular contractions (1 heartbeat) Q: complete heart block = L R bundle of HIS are damaged N/R: needs an artificial pacemaker – made of metal, every 5 years has to be changed Q: sign of malfunction pacemaker= HICCUPS Coronary Artery Disease – Ischemic Heart Disease Stages: 1. Myocardial injury – Artherosclerosis = presence of lipid deposits 2. Myocardial Ischemia – Angina Pectoris =lead to decreased blood flow 3. Myocardial Necrosis – Myocardial infarction, unpredictable disease Atherosclerosis narrowing of artery lipid and fat deposits Tunica intima

Arteriosclerosis hardening of an artery CHON protein and Ca deposits Tunica media

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Layers of the artery : Tunica adventitia/externa- external Tunica media – middle Tunica intima - innermost Coronary Artery Disease – Ischemic Heart Disease 1. Predisposing Factors 5. Sex: male 6. Race: Black 7. Smoking – nicotine vasoconstrictor 8. Hyperlipidemia – genetic 9. Obesity - >20% Overweight >10% prolonged use of oral contraceptives Sedentary lifestyle Diet high in saturated fats – WHOLE MILK DM Hypothyroidism S/sx:  Chest pain  Tachycardia  Palpitations  Diaphoresis 3. Treatment - Percutaneous Transluminal Coronary Angioplasty (PTCA) Objectives: > Revascularized myocardium > prevent angina > increase survival rate 10. 11. 12. 13. 14. 2.

deflate balloon, put KY, pasok sa femoral artery, inject dye (pre-op: check for allergies-seafoods-shellfish – dyes are iodine base), to clearly visualize where to place the catheter, x-ray is used,if near atheroma, syringe 10 cc insert air to inflate balloon to compress the atheroma – PTCA – done to single occluded vessel (post-op: force fluids, flush the dye, dyes are nephrotoxic agents it can destroy the kidneys and dyes are osmotic diuretics-> leads to severe DHN)

If 2 or more blood vessel or artery are occluded -> perform Coronary Arterial Bypass and Graft Surgery (CABG) 1ST GRAFT – give doctor 2-3 hours, get artery in the femur, placed in ice or cold solution, open heart, xyphoid process to umbilicus, open ribs, put valve, coronary artery cut, harvested femoral connected through cauterized CABG – respiratory complications – coughing 4. Same diagnostic/nursing management with Angina pectoris ANGINA PECTORIS 1. Definition: a clinical syndrome characterized by paroxysmal chest pain resulting from temporary myocardial ischemia, relieved by rest or by taking nitroglycerine 2. Predisposing Factors: same as atherosclerosis 3. Precipitating Factors: 4E  Excessive strenuous physical exertion  Extreme emotional response  Exposure to cold environment  Excessive intake of foods rich in saturated fats 4. Signs/Symptoms: > Initial sign: Levin’s sign – hand clutching of the chest > Chest pain – sharp, stabbing, excruciating, crushing substernal pain > Usually radiates from back, shoulder, arms, axilla and jaw muscles > Usually relieved by rest or by taking NTG > Dyspnea > Tachycardia > Palpitations > Diaphoresis 5. Diagnostic Procedure  ECG -reveals ST segment depression ST elevation – MI  Stress test – trendmill abnormal  Serum uric acid and cholesterol HIGH 6. Nursing Management Nsg goal: decrease myocardial demand or workload – REST the heart a. Enforce CBR b. Administer medications as ordered

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Nitroglycerin (NTG) 1. Small doses – dilates lower extremities, venous pulling -> venous stasis -> leg retained can not return to heart -> heart lesser pumping 2. Large doses – vaso dilator – dilates all Nursing Mgmt: (NTG) 1st dose of NTG = 3-5 mins 2nd dose of NTG = 3-5 mins 3rd & last dose of NTG = 3-5 mins STOP giving the dose, notify the physician Given only 3x at 3-5 mins interval, if not relieved by NTG = it is MI 1. Place the drug in a dry - AVOID heat & moisture as it may inactivate the drug 2. Monitor side effects – low BP -> Orthastatic hypotension, transient headache, and dizziness 3. Instruct patient to rise slowly from sitting position 4. If giving transdermal patch, avoid placing near hairy areas – as it may decrease drug absorption, if hairy-shave it when giving NGT, if auscultating put water (+) hairy chest – water is good conductor for sound waves 5. Avoid rotating transdermal patches – decrease drug absorption, avoid placing near microwave ovens during defibrillation-may lead to burns-it contains aluminum foil in the package 6. Beta-blockers – propanolol 7. ACE inhibitors – captopril 8. Ca channel blockers – nifedipine 9. Administer O2 inhalation – low in flow 2-3LPM 

4-5lpm WILL LEAD TO RESPIRATORY ARREST 10. Place client on semi-fowler’s position (lung expansion) 11. Monitor strictly VS, IO and ECG tracing 12. Diet- low in saturated fats, low in sodium, low in caffeine, avoid gas forming foods (prevent valsalva maneuver) 13. Provide health teaching and discharge planning concerning: - Avoidance of precipitating factors: 4Es - Prevent complications: MI - Take medications before activity/exercise Instruct client to take medication before indulging in physical exertion- to achieve maximum therapeutic effect of the drug - Importance of follow up care

MYOCARDIAL INFARCTION (MI) HEART ATTACK 1. Definition: terminal stage of CAD characterized by permanent malocculusion leading to necrosis and scarring 2. Types: (depending on location) 3. Transmural – the most dangerous of all types of MI, characterized by occlusion (blocked) of both R and L coronary arteries 4. Subendocardial – occlusion either the L or R coronary artery 3. Critical period  6-8 hours after MI, majority of arrhythmia occurs during this period, most common or #1 cause of death PVC premature ventricular contraction, if PVCs and conscious – assist in the defibrillation but positive to PVC and unconscious – assist in cardioversion  Ventricular tachycardia -2nd most common cause of death, ventricles are pumping ?180bpm -> lead to arrest N/R: Administer Lidocaine, Xylocaine SE: Confusion  Ventricular Fibrillation NR: Administer epinephrine, assist in defibrillation, perform advance cardiac life support or CPR 4. Predisposing Factors: same as atherosclerosis 5. Signs and symptoms:  Chest pain – excruciating, visceral pain, substernal, rarely precordial  Radiates from back, shoulder, arms, axilla, jaws and abdominal muscles – indigestion “bloated” may signify myocardial infarction, don’t do valsalva maneuver - may have abdominal ischemia  Not relieved by NTG  dyspnea  hyperthermia – high metabolism  initial rise in BP  cool, moist, ashen skin  mild apprehension, restlessness  occasional findings: 1. split S1 and S2 2. pericardial friction rub 3. rales/crackles 4. S4- atrial gallop S3 –CHF Left side 6. Diagnostics  Cardiac Enzymes

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CPK –MB Creatinine Phosphokinase Serum Increased 12-24H – most important 2. LDH –lactic Acid Dehydrogenase Increased 3. SGPT (ALT) serum glutamic pyruvate transaminase – can be found in liver 4. SGOT (AST) Serum oxaloacetic pyruvate transaminase - can be found in liver 5. Troponin Test – Increased (+) MI, result released within 1-2hours only 6. ECG reveals ST segment elevation and widening of QRS complexes – indicative of arrhythmia  If there’s a pathologic Q wave (depressed) indicates infarction  Peak T waves 7. Serum uric acid increased 8. CBC increased WBC 7. Nursing Management: Goal: decrease myocardial workload a. Administer medications as ordere: >First give Morphine sulfate – induces vasodilation respiratory depression antidote- narcan naloxon and relieve anxiety >Administer O2 inhalation, low flow at 2-3 LPM >enforce CBR without BP (not universal abbreviation) – use bedside commode b. instruct client to avoid activities of valsalva maneuver c. place client on semi-fowler’s position d. Diet provide general liquid to soft diet – avoid saturated fats, sodium, caffeine, and gas forming foods e. monitor VS, IO, ECG strictly ST elevation QRS widening f. administer medications as ordered: - Vasodilators for high BP - NTG - ISDN – Isorsorbide dinitrate - Isordil via SL - Anti arrhythmic agents – lidocaine - beta blockers - ACE inhibitors g. Administer medications as ordered - Thrombolytic/Fibrinolytic agents (should be administerd within 12 hours post – MI) > Streptokinase SE: allergic rxn > Urokinase 1.

> Tissue Plasminogen activating factor – SE: chest pain monitor for bleeding time g. administer medications as ordered 9. anticoagulants  heparin  coumadin 10. antiplatelets – PASA aspirin – due to anti-thrombotic  CI: Dengue, ulcer, un known cause of headache h. encourage patient to take 20-30 cc/week of whiskey or brandy to induce vasodilation – red wine- prevent clot of fat i. assist in surgical procedure – CABG j. PROVIDE HEALTH teaching and d/c planning 11. avoidance of precipitating factors 12. prevent complications  arrythmias  cardiogenic shock late sign MI: OLIGURIA  L CHF  Thrombophlebitis – hOman’s sign  DRESSLER’S SYNDROME or post MI syndrome – the client is non-resistant to pharmacological agents  Administer 15-400T units of streptokinase as ordered 13. regular adherence to medications 14. resumption of ADLs especially sexual activity (4-6 weeks post-cardiac rehabilitation CABG) and instruct patient to have sex as appetizer rather than a dessert > have sex before meals, not after meals  assume non-weight bearing position  missionary – normal, 69, 88 CPK –MM – for brain Q: What is the initial question- angina pectoris? A: What did you do prior to having the chest pain? Q: What is the second question to ask? A: is the chest pain radiates? – problem is cardiac in nature If it does not radiate – respiratory in origin – Pneumonia, Emphysema, PTB, Pleural effusion NTG is given sublingually – prick it gel Universal RULE: when given small doses – renal dilator

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02/04/06 PSYCHIATRIC NSG: Thoughts -> Feelings I am not prepared -> nervous -> restless This is not right! -> angry -> frown At last, after 48 years -> excited -> open eyes I’m on a diet -> hungry I lack sleep -> sleepy -> closed eyes, open mouth, drooling Somebody kissed me -> loved -> happy No txt, no luv -> unloved -> sad I am the queen of the world -> ↑ self-esteem -> flamboyant heavy make up Life is empty -> sad -> withdrawn suicide The FBI is out to get me! -> sad scared -> withdrawn violent I am fat. Fat is beautiful ->↑ self-esteem I am fat, Fat is ugly ->↓ self-esteem -> diet, diet, diet Belief determines your feelings Feelings determines your behavior Grandma – slouching, sad, low self-esteem, withdrawn -> talk to her NOTE: 1. Whatever you see, what you say “You seemed sad/happy today.” -> the person seemed interest, the person thinks he/she is important NOTE: 2. Restating: “You are so sad today?” “You don’t want to eat?” *Listening to the client, whatever client she/he says is important NOTE: 3. Recognition “You have done something right. You have combed hair, arranged the bed.” NOTE: 4. Present reality “You are a monster.” -> “Good morning, mam. I’m not a monster, I am wilen. I will be your nurse for today.” Why are they dysfunctional? Why they are not normal? Why are they different from us?

we are the result of whatever happened to us when we were kids  Structure of Personality ID EGO SUPEREGO Impulsive Delays gratification “I want to… impronto” “Should not” Pain avoidance Executive decision Small voice of God Pleasure Principle Reality Principle Conscience MAN Schizophrenia OA Manic Impaired reality Obsessive Compulsive Anti-social perception- ego Anorexia Nervosa Narcissistic disintegration 

The Factory = “Earth” & Factory worker “Mother”  Libido – sexual energy responsible for survival  It began when we were born 0-18 months – survival  want to eat, sleep, urinate, defecate  ID developed – CRY-> mother gives breast – nipple – SUCK -> MOUTH = ORAL STAGE  When the child cries ->>Feed the infant -> important -> happy -> successful  When the child cries ->>If ignore the infant -> not important -> NARCISSISTIC = to meet their needs for the entire lifetime FIXATION= when a person is stuck in a certain developmental stage  Mouth – smoking, eat, talk, bite, suck, drink, gossip, lick, kiss, chew REGRESSION – return to an earlier developmental stage  EGO – 6 MONTHS 18months – 3 years old ANAL STAGE  You should NOT  Toilet Training  SUPEREGO is developed  Ambivalence = Pulled to 2 forces “to stay or not to stay”  TT ->>Good mother -> Successful SuperEgo  TT->> Bad mother ->> Clean, organized, obedient, OBSESSIVECOMPULSIVE = Strong Superego = Anal Retentive

Sigmund Freud – father of psychoanalysis

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

TT-> Bad mother ->> Dirty, disorganized, disobedient ANTISOCIAL = Weak Superego and ID = Anal Expulsive

Q: But who’s anal retentive and anal expulsive? A: Anal expulsive – Anti-Social A: Anal retentive – Obsessive Compulsive         

3-6 years old PHALLIC STAGE Preschooler Penis Vagina Parents Will have a relationship with the opposite sex parent Oedipus Complex - Boy loves mommy, IDENTIFICATION = imitates daddy, afraid of removing his testis – Fear of Castration Electra Complex - Girl loves daddy, IDENTIFICATION = imitates mommy, Penis envy – thinking of somebody cut off your penis, wants to have it

Dr. Karen Horney – disagrees with Dr. S.Freud’s concept of Penis Envy SUPPRESSION = conscious forgetting of an anxiety provoking concept Conscious = there’s a level of awareness Preconscious= tip of the tongue Unconscious = unconscious forgetting of an anxiety provoking concept/idea = REPRESSION= ex. birth traumatic experience =is to be forgotten, not worth recalling, stored place       

6-12 years old School LATENCY – dormant, submissive, TULOG School phobia = Separation anxiety Reading, WRiting, ARithmetic SUBLIMATION = Placing sexual energies toward more productive endeavors 12 – ABOVE = GENITAL STAGE – Gising most important, responsible of sexual intercourse, continuation of human species

PHARMA MOMENTS:

ANTI-ANXIETY V – alium L – ibrium “Liberty” A- tivan – Ate guy S – erax “Sira ulo” T – ranxene “LR -Transit” M –iltown “meal town – down town” E –quanil “aqua/tubig” V –istaril “larVabista” A –tarax “Ang dami rocks” I – nderal “hINDE RALph” B –uspar “Bus pa taRa na” Ex. Childhood – Kurt Cobain 27 years old, when he was 4-8 years old Thanksgiving he performed, bullied, “nobody wants to keep me”= became a successful Nirvana vocalist but killed himself, feeling of emptiness Erik Erikson – there’s more to life than just sex,  hence, the psychosocial theory of development Stage + Factor 0-18 TRUST MISTRUST Feeding months 18mos -3 AUTONOMY SHAME/ Toilet training y/o - stand on his DOUBT own 3 – 6 y/o INITIATIVE GUILT Independence - imitates -anger turned parents inwards - initial steps 6-12 y/o INDUSTRY INFERIORITY INDUStry - many steps in da skul - SCHOOL 12-20 y/o IDENTITY ROLE PEERS The garden of CONFUSION Belief#1 Education is life: valuable Belief #2 Success can Who am I? be achieved by perseverance Belief#3 I have the capability to effect changes in the society

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20-25 y/o 25-45 y/o

45 & above

INTIMACY GENERATIVITY – grab opportunity, learning EGO INTEGRITY - aging - examine life, replay events - embrace all experiences because it contributed to their development

ISOLATION STAGNATION

LOVE PARENTING

DESPAIR

REFLECTION

Abraham Maslow’s Hierarchy of Needs SelfActualization Self-Esteem Love & Belongingness Safety and Security Basic Needs: air, food, shelter, clothing, sex Psychiatric Nursing goals: 1. Love & belongingness 2. Self Esteem 3. Self Actualization As a nurse, the role is to: Acknowledge whatever the client has done - to improve the client’s condition until the client reaches selfactualization Behavioral Models: Ivan Pavlov’s Classical Conditioning  all behavior is learned  1939, laboratory experiment, food = stimulus, has been shown to a dog, dog salivates, he used a bell, followed by the food

BF Skinner – Operant Conditioning  behavior can be repeated  positive reinforcement = reward = result to repetition of behavior  negative reinforcement = punishment = behavior is stopped/extinct Frontal Lobe Language Learning Personality Judgment

Occipital Lobe Vision - eyes

Temporal Lobe Hear Smell

Parietal Lobe Touch Taste

CN Olfactory Optic Oculomotor

ACTION smell of food open eyes - sight move up – light brighten up – eyes constrict, movement of pupil Trochlear look down – food thrown at the floor Trigeminal pray – 3, chewing Abducens look at the sides Facial taste, facial expression Vestibulocochlear balance, hear Glossopharyngeal throat, swallow Vagal/vagus bagal-parasympathetic Accessory move shoulders-happy Hypoglossal movement of tongue-Belat How do you interact with your environment? SIM SENSORY Eyes Nose Ears Tongue INTEGRATION MOTOR->> Voluntary = Voluntary Nervous System = SOMATIC NERVOUS SYSTEM – begins from the brain ->Spinal Cord -> Motor Nerve [Synapse-neurotransmitter: ACETYLCHOLINE = chemical responsible for movement “ON”]->Muscle Fiber ->>Involuntary = AUTOMATIC – AUTONOMIC NERVOUS SYSTEM

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ANS ↓----------------------------------------------↓ Sympathetic-Anticholinergic Parasympathetic-Cholinergic ↓ ↓ ↑heart rate ↓ heart rate ↑ RR ↓ RR ↓ GI Constipation,Dry Mouth ↑ Diarrhea, Moist Mouth ↓ GU Retention ↑ Urinary frequency Dilate pupils DILAT-ALERT Constrict Mydriasis Miotic Vaso constrictor Vaso dilation ↑ BP ↓ BP Neurotransmitter: Epinephrine Norepinephrine Acetycholine Q: The following are anticholinergic side effects of antidepressants exept: a. urinary retention b. Dry mouth c. Constipation Q: The following are anticholinergic side effects of antipsychotic agents except a. Tachyardia b. Urinary retention c. Diarrhea – correct MONOAMINE OXIDASE INHIBITORS - PANAMA M PLAN N AR DIL P NATE Therapeutic Communication Techniques: If a person is withdrawn, will you ignore the person? Offer self: I will be here with you. I will sit with you. I will go with you. Let’s so there. Let’s sit down. Silence: You want the client to think of any topic, and let the client to talk and talk

Making Observations: You seem sad. You have made your bed today. Active Listening: What if you want a person to continue speaking? - nodding - eye contact - lean forward Broad opening: How are you today? How are things going today? How are you? Tell us about yourself? Who are you? How do you make it verbal? General Leads: Go on, I’m listening. And then. What else? Exploring: Who, What, When Restating: I’m sad. “You’re sad?” I’m happy. “you’re happy?” Refocusing: “Dave, I’m not asking what you do, who you are? Deltner/Videbeek/Shives – Psychiatric Nursing Reflect VS Restate “You’re hungry?” VS “You want cheeseburger?” Non-Therapeutic : False reassurance: Everything’s going to be fine Changing topic/subject Ignore the client Value based judgement: Avoid using ADJECTIVE “Nice weather we’re having today” “You have the most wonderful bed in the ward” Why? = putting the client in defensive position Flattery You should do this now = Advising = Commanding

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In my opinion … Arguing = No, you are wrong… Mind – visualize things to happen Fantasy –> mental Reality You have to know where to go You must know what you really want to have in life STRESS – use DEFENSE MECHANISM: 1. Displacement – transfer of feelings to a lesser threatening objects, than the one who provoked it. 2. Denial – failure to acknowledge an unacceptable trait or situation 3. Dissociation - Pschological Flight From Self = amnesia - Raped – traumatic experience = Sino ka? Sino ako? = wants to forget 4. Regression – return to an earlier developmental stage “fetal position” 5. Repression – unconscious forgetting of an anxiety provoking concept 6. Rationalization – illogical reasoning for a socially unacceptable trait. Ex. I drink because I socialize and I socialize everyday 7. Reaction Formation – done the opposite of your intention. Ex. Gusto mo sakalin pero niyakap mo. Plastik, Tupperware, Orocan, Kyowa 8. Undoing – do the opposite of what you have done/action. Ex. You shown your true feelings, frown then other smile. Felt guilty, next time you smiled 9. Identification – assume trait for personal, social, occupational role. Ex. I want to be like my father = Personal goal. I want to be the president = Social role. Occupational role – I want to be an architect. 10. Projection – attribute to others one’s unacceptable trait. PASA LOAD ex. My friends are alcoholic. Not me, but them. 11. Introjection – assume another person’s trait as your own, not just, me too! Ako din. 12. Suppression – conscious forgetting of an anxiety provoking concept. 13. Sublimation – destructive energies/ sexual energies/ hostile energies put towards more productive endeavors:music, poetry, writing lyrics, dance, art, handicraft. 14. Conversion – 15. Compensation – overachievement in one area to cover a defective part

No, I did not feel angry ↓ Anger is repressed ↓ Conversion ↓ Converted to physical symptoms ↓ Nervous system ↓-----------------------------↓ Sensory Motor Numbness Paralysis 16. Substitution – replace difficult goals with more accessible one SNS   

Stop – GABA – Gamma Amino Butyric Acid slow down go – Epinephrine/Norepinephrine

Anxiety ↑SNS – E/NE – axn: bring the GABA ↑ - Anti-Anxiety Agents ↑ ↑ Anticholinergic ↑ ↑ Constipation within 1 week ↑ ↑Urinary ret Seizures ↑ ↑ Rebound Phenomenon ↑ ↑ Abrupt ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ Withdrawal ↑---------------------Anti-anxiety------------------------------------- Dependence ↑ ↓ drowsy ↓ ↑ ↓ can not drink alcohol ↓ ↑ ↓ can not drink coffee Gradual ↑ ↓ Dev.Orthostatic Hypotension Tapered dose Relaxed Anxiety - ↑ RR

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pH 7.35-45 CO2 35-45 HCO3 22-26

Metabolic acidosis ↓ pH ↓ CO2 ↓ HCO3

Respiratory acidosis ↓ pH ↑ CO2 ↑ HCO3

Respiratory Alkalosis ↑ pH ↓ CO2 ↓ HCO3

Metabolic Alkalosis ↑ pH ↑ CO2 ↑ HCO3

 

My thoughts won’t shut off. They’re constantly running, making me worry… If a loved one is ten minutes late, the person with generalized anxiety fears the very worst

Principles: 1. 2. 3. 4.

CO2 is opposite pH = ↓↑ HCO3 is same Ph Compensation: same direction for CO2 HCO3 CO2 HCO3 pH – Normal = Fully, Abnormal = Partially

Interpretation: 1. ph ↓ acidosis ↑ alkalosis 2. CO2 opposite: RESPIRATORY 3. HCO3 same direction with the Ph: METABOLIC

PANIC MILD

MODERATE

+1 Widened perceptual field Restless Enhanced learning capacity

+2 Pacing Prn Meds Valium Librium

NR: 1. Sit 2. Dangle 3. Stand gradually Anticholinergic SE in taking Antianxiety: 1. Constipation 2. Urinary retention 3. dry mouth 4. blurred 02/05/06 Fear – something that protects us Trade off/Price of gift of fear – anxiety Anxiety – vague sense of impending doom Doom - Parasympathetic – SNS Assess – Level of Anxiety Subjective Data:  I just dread being alone at night. I don’t know why, but I do…

Simple words are enough You seem restless

SEVERE

+4 Suicide +3 Safety Don’t know Don’t touch what to do/ the client! say Respiratory Directive: Alkalosis Let’s go to the Breathe into room. bag! Enter the room Sympathetic Stop. Come .here. Anxiety ↓ SNS ↓ ↑ RR ↓ ↓ CO2 ↓ ↑pH ↓ Respiratory Alkalosis

Nx Dx: Ineffective Individual Coping Subjective: Hey, I can not handle things anymore. Nx Dx: Powerlessness Subjective: I have lost control over my life Nx. Dx: Impaired Skin Integrity Objective: keeps of cleaning hands

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Planning/Implementation: 1. Decreased Level of Anxiety 2. Decreased Environmental Stimuli 3. Relaxation Technique  Manipulating the environment Evaluation:Effective Individual Coping 6 months excessive worrying Generalized Anxiety Disorder:GAD Restless Concentration difficulty Sleep problems Palpitations Edge of the seat Easy fatigability  if your worrying affects or interferes with ADLs  may lead to harm to self & others – escape panic attack Panic attack – may happen anytime SNS activation but goes down, difficult to manage  15 to 30 minutes escalation of SNS Agoraphobia – fear of open spaces, they can not go outside 1. can still communicate with other people Social Phobia – fear of public/ other people Victims - trauma, disaster, accident, rape, earthquake ↓ Survivor – victims who were able to cope and emerged as ↓ new people Flashbacks- haunted by the past ↓ Nightmares – disorder happens > 1 month

Post Traumatic Stress Disorder - PTSD 6 yrs old ↓ Assignments Homeworks ↓ No assignment No homework ↓ You think, “Teacher may get angry!”

↑Anxiety ↓ Psychosomatic I am sick ↓ Malingering Somatoform pretending to be sick-conscious ↓ Absent

Escape from teacher ↓ Primary Anxiety Gain

Somatoform no pretension unconscious no organic basis ↓ Nervous system Conversion disorder La belle indifference  No reaction to the s/sx happening

Mama care ↓ Attention Secondary Gain -result of malingering where attention increases Illusion of structural defect Body Dysmorphic disorder

Minor discomfort Interpreted as major illness Hypochondriasis

Favorite pastime: Symptom: Doctor Hopping Nursing Focus: focus on client’s feelings

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Mind – Psychophysiologic/Psychosomatic ↓ Real pains/illness/ Real Symptoms Body ↓ SNS PNS ↓ ↓ Vasoconstriction Bronchoconstriction ↓ ↓ ↓ Cerebral Left Asthma Artery Gastric Spasm Artery ↓ ↓ Migraine ↓ O2 ↓ Mucosal lining ↓ Stress Ulcer * no causative agent Duodenal ulcer Etiologic Agent: H-pylori Thought-> Feelings-> Open ↑Anxiety ↓ Burglar Obsession-> ↑Anxiety->

Behavior -action - return house Compulsion->↓Anxiety

P/I: THOUGHT STOPPING RELAXATION *explore feelings TECHNIQUES

↑*gloves *substitute *schedule *gradual withdrawal

Obsessive-Compulsive Disorder  fear of dirt or contamination  concern with order, symmetry, and exactness

 constantly thinking about certain sounds, images, words, or numbers  fear of harming a family member or friend  fear of thinking evil or sinful COMPULSIONS  excessive hand washing  repeatedly checking that doors are locked and appliances are turned off  arranging items in a precise order  repeatedly counting to the same number  touching certain objects a precise number of times High Obsession High Compulsion PHOBIA  irrational fear  immediate nursing intervention: REMOVAL of the object  ↑ stimulus -> ↑ anxiety  root of the client’s phobia is the stimulus  Aiming for behavioral change: SYSTEMATIC DESENSITIZATION = gradual EXPOSURE to the feared object. Ex: fear of snake- show black & white picture, then colored picture, then show dead snake, let client touch, then show alive snake, let the client touch it. Brain/Mind is conditioned, there’s a change of perception, a new response. Etiology of Phobia: 1. Knowledge 2. Experience

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Psychotherapy: 1. Free Association - Free to talk any ideas 2. Catharsis – allowed to express feelings 3. Transference – client to therapist ex. Client thinks of the healthcare personnel as his father 4. Countertransference – therapist to client

A need for detoxification: Detoxification – withdrawal with MD supervision Withdrawal - Stop taking a drug 1. Alcohol 2. Mouthwash 3. Elixir – alcohol based

ANTI-PARKINSON AGENTS - CAPABLES C ongentin – Cogie Domingo B enadryl A rtane – arte L arodopa – laro dapa P arlodel – ayos sa parlor E ldeprl – elderly A kineton – akin eto S ymmetrel – palit SIM

1st subdivision of Anti-parkinson CAPABLES:

ALCOHOL 1ST Generation – with history of alcoholism 1. can be passed on from generations 2. genetic make up 3. environmental Intergenerational transmission Alcohol ↓ Blackout ↑Risk for injury awake but Memory gap unaware ↓ Confabulation Inventing stories to increase self esteem ↓ Denial Dependence -> Tolerance ↑ substance to maintain desired euphoria ↓ Enabling Significant other tolerates abuser

Anticholinergics-ABC Artane Akineton Bendaryl Cogentin

Dopaminergics-PLEASE Parlodel Larodopa Symmetrel Eldeprl

THERAPY: Avoid alcohol therapy Never Drink Alcohol Aversion Therapy 12-hour interval Alcoholics Anonymous or else, nausea, vomiting and Antabuse-Disulfiram hypotension ↓ B1 vitamin deficiency ↓ Wernicke’s encephalopathy – “Vah”Complications: motor ↓ Korsakoff’s psychosis-memory Delirium Tremens nurse I don’t know my name? -like anxiety/panic attack -illusion, hallucination ↓ Formication – bugs crawling under the skin Family therapy Ask the client: When was your last dose of alcohol? 52

The client must not take Antabuse if the client has just taken alcohol, because there might be effects. 12 HOURS interval needed before giving antabuse 4-6 hours – will experience withdrawal symptoms 24-72 hours – will experience delirium tremens Echolalia - repeats whatever people say, talk to them slowly, they live in their own world = Autism Autistic Savant – gifted child, can concentrate Nobody Nowhere Somebody, Somewhere by Donna Williams Assess: ABC Appearance – Flat Affect – no eye/poor eye contact Consistent movement no emotion, clean OCD Behavior – Repetitive Ritualistic keep on rocking – relaxes them, love bicycles Communication – Echolalia Incomprehensible Nx Dx:

Impaired Verbal Communication Impaired Social Interaction Self mutilation – hurt oneself – internal factors Risk for injury – external factors Planning/Implementation: Maslow’s Hierarchy of Needs: Language-important 1. Use Expressive Therapy – art, music, song, poetry 2. Provide constant environment Evaluation: Enhanced communication Improved Social Interaction Safety

ANTI-PSYCHOTIC AGENTS S telazin – Stella Sin P rolixin S erentil – serena til midnight T horazine – tora T rilafon - tri band phone C lozaril – close na reel M ellaril – milya milya reel H aldol – hahaha ADHD – Attention Deficit Hyperactivity Disorder If eight or more of the following statements accurately describe your child or yourself as a child, particularly before age 7 (ONSET), there may be reason to suspect ADHD. A definitive diagnosis requires further examination. 1. often fidgets or squirms in seat. 2. has difficulty remaining seated 3. is easily distracted 4. has difficulty awaiting turn in groups 5. often blurts out answers to questions 6. has difficulty following instructions 7. has difficulty sustaining attention to tasks 8. Often shifts from one uncompleted activity to another 9. has difficulty playing quietly 10. often talks excessively 11. often interrupts or intrudes on others 12. often does not seem to listen 13. often loses things necessary for tasks 14. often engages in physically dangerous activities without considering consequences.  can not control impulses – ID is the dominant part, always impulsive  7 yrs old and below

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ADHD Onset: 7 yrs old and below Duration: 6 months and above Settings: 2 Assess: ABC Appearance: Dirty Behavior: Clumsy, Hyperactive, Impatient Communication: Talkative, blurts out in class Nx Dx: Risk for Injury – High Impaired Social Interaction ID impulsive - Will not follow the mother, teacher, principal, society-> Antisocial disorder: anger may build up = future criminals Planning/Implementation: S tructure S chedule – time for everything S et limits – providing ample time, extent of what u can do S afety Evaluation: Minimize Risk for injury Improved social Interaction Safety

18 months – 3 yrs 6yrs old -> Class Valedictorian ↓ ↓ Model Student Toilet training Social life inactive ↓ ↓ Clean obedient organized One night, a dream… Eating Disorders Anorexia Diet, diet, diet inc compensation -> up interferes ADLs harm of others

Wait for 2-4 weeks of Lithium Therapy to end Patient teaching: #1 Drug compliance #1 defense mechanism by manic patient: COMPENSATION flamboyant queen of the world, heavy make up, loud voice, overachievement in one area to cover a defective part

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up self esteem -> dec compensation -> down interferes ADLs harm of others How do you increase the self esteem of client? T-A-S-K No – basketball, volleyball No – pingpong – no to competition Yes - Gross motor skills: sweeps the floor, wiping the dining table, watering the plant, Escorted walk outdoors = SUBLIMATION = put energies toward more productive endeavors & DISPLACEMENT – punching bag No - Cross stitch – Fine motor skills SCHIZOPHRENIA  ego disintegration  impaired reality perception  twin – if one suffer, there’s a possibility that other  genetic vulnerability  stress – diathesis model -> stress factor  Biological theory : ↑Dopamine level, exact cause is unknown PROCESS: Assess: Affect –external patient feeling inside & emotion Mood – internal subjective Affect: 1. 2. 3. 4.

Inappropriate Appropriate Flat Blunt

SYMPTOMS NEGATIVE Hypoactive Withdrawn Apathy

POSITVE Hyperactive Sociable Flight of ideas Talkative

Assess: Content of thought Nx Dx: Disturbed Thought Process Planning/Implementation: Present Reality Provide Safety Evaluation: Improved Thought Process Assess: Nx Dx: P/I: E: violence Assess: Nx Dx: P/I: Evaluation:

Suspicious Risk for other directed violence Present Reality, Provide Safety Eliminate/minimize risk for other directed

Assess: Nx. Dx: Planning/I: Evaluation: violence

Suicidal Risk for self-directed violence Present Reality, Provide safety Eliminate/minimize risk for self-directed

Hallucinations/Illusions Disturbed Sensory Perception Present reality, Provide safety Improved Sensory perception

Ambivalence – caught to 2 choices Autism – trap in one world Associative Looseness – 56

I am going to the mall. The mall is big. Big is the tree. Tree is tall.

I am going to the mall. Where is the light? Go here, mineral water. Hurray!

Looseness of Association = two words with association, with common words

Flight of ideas = no common words

Magical Thinking = “I can turn you into a frog.” Ambivalence = 2 opposing thoughts Echolalia = repeat what you say Echopraxia = repeat what you do Word salad = Just words, no rhyme “life, like, lice” Clang Association= Clang Poet with rhyme “life, wife, knife” Neologisms = Plungplang, priskip, sertugil = CLARIFICATION= “What do you mean by this…plungplang?”

“The nurses are talking about me” “People are looking at me” Concrete Association – pilosopo “saan ka pupunta? Eh di sa pupuntahan.”  Give a proverb & have it explained Thought blocking – interruption in the thought/ stream of thought Hallucinations Absent X X X

Illusions Present √ √ √

Stimulus Visual Auditory Tactile Hallucinations Acknowledgment:“I know the voices are real to you.” Reality: “But I don’t hear them” Diversion: “Let’s go to the garden.” But what if nothing in the preceding interventions are seen? Is it appropriate to assess what the voices are saying? Command hallucinations – assess what the voices are saying – to know if the client will commit suicide, or harm others

Delusion – persecutory “The FBI is out to get me.” Delusion – religious “I am Jesus Christ, the savior” Delusion – grandeur “I am the Queen of world” Delusion – Ideas of reference 57

02/11/06

Antipsychotic D High Dopamine = Schizophrenia

TYPES DISORGANIZED -sad but smiles Inappropriate affect -no reaction Flat affect

CATATONIC Ambivalence

PARANOID

No -flight of ideas Disorganized speech

Negativism

-giggling Hebephrenic Positive/Negative S/S

RESIDUAL No more positive Just withdrawn

UNclassified UNdifferentiated Mixed classification Can’t be classified

AcH

Suspicious

Waxy Flexibility

Violent Keep Door Open Near the door Don’t Touch Eye Contact 1 arm away Call Reinforcement

D

ON= Extrapyramidal Effects

AcH D AKATHISIA- Restless, Inability to sit AKINESIA – Muscle Rigidity DYSTONIA Torticollis- wryneck Oculogyric Crisis – fixed stare Opisthotonos – Arched back

MISTRUST->SCARED->WITHDRAWN TRUST 1 TO 1 SHORT INTERACTION FREQUENT FOODS IN SEALED CONTAINER MEDS WRAPPED

AcH- Acetycholine – ON switch of muscle D- Dopamine – OFF switch of muscle ParkinsON disease – Dopamine goes ↓, Acetycholine ↑

Tardive Dyskinesia Lips Smacking Tongue Protruding Cheeks puffing Irreversible Neuroleptic Malignant Syndrome – fever ON = glucose = ATP used = heat Other Side Effects: 1. photosensitivity: a. use sunscreen b. wear shades c. wide brimmed hat 2. Agranulocytosis: ↑ Lymphocytes, Monocytes ↓ neutrophils , Eosinophils, Basophils -> sore throat

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Anticholinergic - minimize side effects of extrapyramidal effects ->↓ Ach Dopaminergic – both are used to keep balance, used as partners->↑ D Anti-psychotic -> ↑ EPSE Anti-parkinson -> ↓ EPSE

Given to restore balance

Antianxiety - > ↑ GABA – drowsy

ANTIDEPRESSANT: A sendin – to go up N orpramin – knorr para mainit T ofranil – lagyan ng tofu S inequan – sine Kuan A nafranil – Ana franing A ventil – aven til midnight V ivactil- bye back til next week E lavil – e lab mo ba ako? P rozac - pero zaka na tayo magpakasal P axil – isa kang taksil Z oloft -mag SOLO ka Task - ↑ esteem of the manic patient

Personality Disorders 1. SCHIZOID – I avoid people. There’s no enjoyment no reaction/flat affect, mechanical, they like computer hacking, cross stitching, they avoid sex, do not engage in play, school activities, don’t have best friends-maybe have pets, no plan of marrying, not dated at all, don’t want people loving other people, people who can live by themselves 2. AVOIDANT - I avoid people. I’m afraid of criticisms – longs for people around them, to care for them 3. ANTI-SOCIAL – used to steal, liars, violating the rules, engage in bank robbery, drug trafficking, easily irritated, drug abuser, dangerous sex, break the law, anti-social, good speakers, serial killers 4. BORDERLINE – my life is an empty glass – (+) Fill Friends, usually feel discontented, likes SPLITTING friends, SPLIT affect happy vs sad – LABILE affect – (-) will commit suicide 5. DEPENDENT – I can’t live if living is without you.

6. HISTRIONIC - wants to be center of attention, manipulative, excited, dramatic – wants to be seen by everyone 7. NARCISSISTIC – I love myself, wants to be center of attention, blessed and cursed only wants the best for him 8. OBSESSIVE – COMPULSIVE – I am so organized – consistency 9. PARANOID – I am suspicious – leads to domestic violence Sensory – Frontal lobe chemical manipulated in the film Integration Motor Serotonin

☺

↓Serotonin -> SAD ↓ Antidepressants

Safest Selective Side effects low Serotonin Reuptake I to 4 weeks Inhibitor

SSRI ↑serotonin

Two-four weeks Two neurotransmitters Tri Cyclic Antidepressant

Mono

Higher Incidence of side effects

Inhibitors

TCA ↑serotonin ↑norepinephrine

Amine Oxidase

Avoid tyramine-rich foods, or else there’ll be Hypertensive Crisis 2-6 weeks Avocado Fermented Aged cheese foods Beer Pickles Chocolate Preserved Soy sauce food

MonoAmine Oxidase KILLS Serotonin ↑ MAO -> ↓Serotonin -> SAD

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How do you bring MonoAmine Oxidase DOWN? MonoAmine Oxidase INHIBITORS or MAOIS ↓ MAO ->↑ Serotonin ->

☺

Anti-depressants Side effects: Male Erectile Dysfunction - IMPOTENT VLASTMEVAIB Anxiety E/NE

Antianxiety

↑↓GABA

Anticholinergic

SEIZURE Rebound Abrupt

S/E Constipation Retention Dry Mouth Blurred Vision WITHDRAWAL

D E P E N D E N C E

Drowsy Do not Drink Alcohol Do not drink Coffee Do not drive Equipment Develop O.H. GRADUAL

Antipsychotic Anticholinergic ↓D

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↓ DOWNERS ABON Much to take IN A lcohol Morph B arbituates Code INE O piates Hero N arcotic M arijuana - ambivalent ASSESS: S/S: Overdose bradycardia bradypnea moist mouth pupils constrict constipation retention hypotension coma, lethargy asleep weight gain

↑ UPPERS CHA CHA C ocaine H allucinogens A mphetamines - shabu

S/S: Overdose Tachycardia tachypnea dry mouth pupils dilate hypertension seizures alertness awake weight loss

Psychological well being of a client - EUPHORIA NARCAN (Naloxone HCl) – Narcotics Antagonist – drug of choice narcotics overdose Alcohol Overdose HR ↓ RR ↓ LOC COMA BP ↓

Cocaine withdrawal – Crash Syndrome – from elation to euphoria, then goes down when withdrawing - may commit suicide Black – crisis Blue – return to original stage White – pure optimist, gotten through troubles in life Gold – ambitious Black – suffering depression DEPRESSION 1. ASSESS Are there things that got LOST? STAGE OF GRIEF PROCESS  DENIAL – No, this can’t be! – 1ST  ANGER – Why me? Why this? Why now? Why God?  BARGAINING – if something happens, then I’ll give something back  DEPRESSION – I’m down – 2 weeks or more s/s = Major Clinical Depression  ACCEPTANCE – Client acts according to situation MELATONIN - ↑“HYPERSOMNIA” responsible for sleep, secreted by pineal gland When aged – pineal gland calcified - ↓”INSOMNIA”

Self-Actualization

Withdrawal – opposite of intoxication ↑ ↑ SEIZURE ↑

Note: Overdose/Intoxication inversely proportional withdrawal METHADONE - drug of choice narcotics detoxification Detoxification is withdrawal with MD Supervision

↓ SELF ESTEEM

T-A-S-K

WITHDRAWN

STAY

RISK FOR SELF-DIRECTED VIOLENCE EAT

SLEEP

HYPOACTIVE

↓ SEX

SENSITIVITY TO CLIENT’S NEEDS

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SUICIDE -> VERBAL I won’t be a problem anymore This is my last day on earth I’ll soon be gone. NON VERBAL Give away valuables Sudden change in mood – be suspicious When the client is suicidal, what will the nurse do? 4. helpless, hopeless the nurse must D irect discuss, Do you plan to commit suicide? I rregular Interval – unpredictable when checking client E ndorsement Period – Early A.M. SAFETY - Avoid giving knife, no jigsaw, give simple task.

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03/04/06 Fundamentals of Nursing Nursing Process > the nursing process provides the framework in which nurses their knowledge and skills to express human caring and to help clients meet their health needs 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation Characteristics of the nursing process 1. It is cyclic and dynamic rather than static 2. It is client-centered – nurse organizes plan of care according to client problems rather than nursing goals. 3. It is interpersonal and collaborative – depends on open and meaningful communication between client and the nurse. 4. It is universally applicable – can be used with clients of any age at any point of wellness-illness continuum; useful in a variety of settings. 5. It is an adaptation of problem-solving techniques and systems theory-based on the scientific method 6. It can be viewed as parallel to but separate from the medical process = focuses on resolving the disease of the patient; Health/nursing problems →human response to the existing to the health condition – disease or wellness state The nursing process diagram in each phase (see handout) Quality assurance = safety in caring out nursing intervention = standards of nursing care Q: volunteer, nursing graduate, what type of nursing care: A: interventions should live up to the standards of nursing profession, even if you are just a volunteer. Evidence based nursing = Research findings Rectal temperature taking = 3-5mins Oral temperature taking = 2-3mins

NGT = testing if the end of tubing submerge in a basin of waterbubbles lungs; distention in stomach = gas; should always be updated Data gathering: 2 sources of data: Primary Secondary client himself/herself significant others chart doctors members of the health team other related literature Methods used in data gathering: Observation – using senses Interviewing – nursing history, therapeutic communication skills Examining – physical examination Nursing history:  using subjective data Data base is more often based on  Gordon’s Typology of 11 Functional Patterns  Health-perception-health management pattern 2. Describes client’s perceived pattern of health and wellbeing and how health is managed  Nutritional-metabolic pattern – describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply  Elimination pattern – describes patterns of excretory function (bowel, bladder, and skin)  Activity-exercise pattern – describes pattern of exercise, activity, leisure and recreation ADL’s healthy lifestyle – household chores Regular -> 3x/week -> 5-10mins warm up; 20-30mins cardiophase; 5-10mins cool down  Cognitive-perceptual pattern – describes sensoryperceptual and cognitive pattern  Sleep-rest pattern – describes pattern of sleep, rest and relaxation

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Self-perception-self-concept pattern – psychosocial interventions; describes self-concept pattern and perceptions of self (e.g. body comfort, body image, feeling state)  Role-relationship pattern – describes pattern of role engagements and relationships  Sexuality reproductive pattern – describes client’s patterns of satisfaction and dissatisfaction with sexuality; describes reproductive patterns  Coping stress tolerance pattern – describes general coping pattern and effectiveness of the pattern in terms of stress tolerance  Value belief pattern – describes patterns of values beliefs, including spiritual; or goals that guide choices or decisions. Sign Sx Treatment Medcl Dx Nsg Dx Restlessness Thirst Passive HyperRisk for ROM tension latex Hematuria Pain exercise allergy violent 3x/day – Acute behavior Reported prevent myocardial Nonweight atrophy, infarction compPain rating loss of contractures liance scale 20 promote Hyper0-no pain pounds circulation thyroidism Impaired 1-2 mild in 3 mos mobility 3-4 moderate Shampoo at Depression 5-6 severe Nausea bedtime Impaired 7-8 very Schizotissue severe Cholecystec- phrenia perfusion 9-10 worst tomy ABG – possible pain Oxygen 

palpation on painful site = (+) tenderness elevated

Self care deficit Anxiety – complicated

Pco3 on ABG

behavior

Vomiting

Impaired parenting

Temperature 38.5 pyrexic, febrile, fever

Decreased cardiac output

diaphoresis Hemoptysis Phase II – NURSING DIAGNOSIS  clinical judgment about individual, family or community responses to actual and potential health problems/life processes; provides a basis for the selection of nursing interventions to achieve outcomes for the which the nurse is accountable. This means that: 1. Professional nurses are responsible for making nursing diagnosis 2. Nursing diagnosis describe a continuum of health states

Actual Health Problems

Potential Health Problems

Nursing Diagnosis Focus on identifying human responses to health and illness Describe problems treated by nurses within the scope of independent nursing practice Changes from day to day as client responses change

Healthy Responses

Medical Diagnosis Identifies disease Describe problems for which the physician directs the primary treatment Remains the same for as long as the disease is present

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Types of Nursing Diagnosis 1. Actual Diagnosis – judgment about a client’s response to a health problem at the time of assessment and is signified by the presence of associated signs and symptoms Formats: 1 part statement – problem format 2 part (problem related to etiology) 3 part (PES format) Problem related to etiology as manifested by s/sx

Effective breastfeeding Anticipatory grieving

2. Risk Nursing Diagnosis – a clinical judgment that a client is more vulnerable to develop the problem than others in the same situation Format: 2 part statement diagnostic label R/T risk factors Ex. 1: Risk for disuse syndrome R/T immobility Ex. 2: High risk for infection R/T compromised immune system

ALFARO’s RULE FOR A COLLABORATIVE PROBLEM To write a diagnostic statement for a collaborative problem, focus on POTENTIAL COMPLICATIONS (PC) of the problem

3. Possible Nursing Diagnosis – evidence about a certain health problem is unclear or the causative factors are unknown; needs collection of more data either to support or refute it; not a real type of nursing diagnosis

Common Errors in Writing Nursing Diagnoses and Recommendations Error Example Correction Example Writing the Needs Write the Self care diagnosis in assistance with diagnosis in deficit: bathing terms of needs bathing related terms of related to and not to bed rest response immobility response rather than need Making legally Noncompliance Use related Non inadvisable due to hostility to rather compliance statements toward nursing than due to related to staff (the words or caused hostility toward due to imply a by to link nursing staff direct cause the etiology (denotes a and effect to the relation relationship) problem between the statement problem and etiology but not necessarily a causal

Format 2 part statement Ex: possible social isolation R/T unknown etiology 4. Wellness Diagnosis – is a clinical judgement about an individual, family or community in transition from a specific level of wellness to a higher level of wellness Format: NANDA has specified that wellness diagnosis should be developed as a one-part statement with: Potential + desired higher level of wellness; readiness for (+) desired higher level of wellness (LeFevre, 2004) Ex. Potential for enhanced parenting Health seeking behaviors Family coping Potential for growth Enhanced Parenting

5. Syndrome Diagnosis – comprises of a cluster of problems Format: one part statement Ex. Rape trauma syndrome Post trauma response Defensive coping

PC+:+complication+related to + etiology Ex. Potential complication: pneumothorax related to fracture ribs

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Spouse abuse related to husband’s immaturity and violent temper

Impaired skin integrity related to client’s lying on back all night

Identifying as a problem a client respond that is not necessarily unhealthy

Mild anxiety related to impending surgery

Identifying as a problem signs and symptoms of illness

Cough related to long history of smoking

Identifying as a

Alterations in

> more alert, normal, motivate to understand

Write diagnosis in legally advisable terms: statements that may be interpreted as libel OR that imply nursing negligence are legally hazardous to all nurses caring for the patient Include in the problem statement of the nursing diagnosis only client responses that are unhealthy or that the client wants to change Avoid including signs and symptoms of illness Express the

relationship) High risk for violence: spouse abuse related to husband’s reported inability to control behavior. Impaired skin integrity related to immobility

No need for nursing diagnosis; mild anxiety before surgery is a healthy response that motivates preoperative self care behavior

Ineffective airway clearance related to 20 year history of smoking Self care

client problem or etiology what cannot be changed

Bowel Elimination: Permanent colostomy related to cancer of the bowel Grieving related to death of spouse

>grieving is a normal response to death > if dysfunctional grieving – 1 year – can not accept death Problem + Etiology Suggest suggest that objective/Goals intervention; eliminate etiology will eventually eliminate problem

Identifying environmental factors rather than client factors as a problem Reversing

client statement and etiologic factors in terms that can be changed; otherwise, nursing energies are being directed to a hopeless task

Cluttered home related to inability to discard anything Knowledge

Avoid

deficit: care of colostomy, related to severe anxiety about cancer and feelings of powerlessness > do not put the medical diagnosis as the etiologic statement but put the human responses only

Inability to accept the death of the spouse. provide psychological support/ emotional support to client High risk for injury related to cluttered home (inability to discard anything) Altered

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clauses

Having both clauses say the same thing

Including value judgments in the nursing diagnosis

Including the medical diagnosis in the diagnostic statement

deficit related to alteration in parenting

Alteration in comfort related to pain (pain is the comfort alteration – what is contributing to the pain?) > describe, location, type of pain Poor home maintenance management related to laziness

Impaired home maintenance management related to arthritis

reversing the problem statement and etiologic statement

Be sure that the two parts of the diagnosis do not mean the same thing

Write the diagnosis without value judgments; avoid words such as poor, inadequate, abnormal unhealthy as much as possible

parenting related to knowledge deficit: OR LACK OF INFORMATION ABOUT child growth and developmental discipline Unrelieved incisional pain related to fear of addiction

Impaired home maintenance management related to low value ascribed to home safety and cleanliness

Impaired home maintenance management related to mobility,

endurance and comfort alterations RIGHT Alteration in oral mucous membranes related to the effects of chemotherapy stomatitis Oral care Increase fluid Risk for injury related to disorientation and impaired judgment > can intervene Self-feeding deficit (Level III) related to joint pain/swelling Impaired physical mobility : level III related to general muscle weakness and spasm in the legs Ineffective airway clearance related to accumulation of tenacious secretions in the airway Hyperthermia Infection Non compliance with renal diet related to the client’s perception of its therapeutic ineffectiveness

WRONG Risk for injury related to frequent falls

Dysfunctional grieving related to death of spouse

Self-feeding deficit (Level III) related to arthritis Patient difficult to get along with related to his frustrations at being in the hospital. Alteration in bowel elimination: stool incontinence related to involuntary passage of stool Elevation in temperature caused by infection Alteration in level of consciousness due to grandmal seizures self-care deficit: bathing related to inability to bathe self Nausea and vomiting related to cancer of the pancreas Poor hygiene related to laziness Alteration in comfort related to chest pain

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Alteration in nutritional intake: less than body requirements related to … as manifested by nausea and vomiting Impaired skin integrity…

Ineffective management of therapeutic regimen: families related to economic difficulties > may intervene because you can refer

Nausea and vomiting related to alteration in nutritional intake

Loss of skin integrity related to prolonged bed rest and infrequent position changes Anger related to knowledge of the diagnosis of cancer

FIRST Ineffective airway clearance related to accumulation of viscous secretions

MEDIUM Anxiety related to difficulty in breathing > because you can resolve it if the 1st priority

LOW Sleep pattern disturbance… Self care deficit… Altered family processes…

Fluid volume deficit: intake insufficient to replace fluid loss related to diaphoresis

Impaired memory related to observed experiences of forgetting Airway, Breathing, Circulation – first priority Three helpful guides – suggested by Atkinson and Murray (1990) for prioritizing client problems are: Maslow’s hierarchy of Human Needs: Physiologic needs – safety needs – love and belonging needs – self actualization needs. Prioritizing nursing Diangnoses: Priority setting – process of establishing a preferential order for nursing strategies  FIRST PRIORITY is any threat to the vital functions of breathing, heartbeat, and blood pressure  MEDIUM PRIORITY – health threatening problems that may result in delayed development or cause destructive physical or emotional changes  LOW PRIORITY – problems that arise from normal developmental needs or those that require minimal nursing support

Goal versus Objective versus Expected Outcome: Goals are broad statements about the effects of nursing intervention Ex. The client’s nutritional status will improve Objectives are more specific statements about the effects of the nursing intervention Ex. The client will gain weight after two weeks. Criteria/Characteristics of objectives:  SMART- specific, measurable->observable, attainable, realistic, time-bound  Client centered  Statement of a single human response-> human condition or behavior -> performance of a procedure taught Expected Outcomes are the more specific, measurable criteria, used to evaluate whether the goal has been met. Ex. The client will have a weight gain of 5 lbs by October 28 SMART After 2 weeks, the client will be able to ambulate in the hall 3x/day.

NOT SMART After 2 weeks, the nurse will assist the client to ambulate in the hall 3x a day.

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After nursing intervention, the client’s lungs will be clear to auscultation. After nursing intervention the client’s RR will be normal by afternoon of March 4, 2006 After 30 minutes of health teaching, the significant others will explain, verbalizes, discuss, enumerate, identify the ways on how to prevent bedsores in the client. if psychomotor = demonstrate, perform, show

After nursing intervention, the client’s lungs will be clear to auscultation and the RR will be normal. > should be of single human response After nursing intervention, the significant others will know how to prevent bedsores in the client actions are not the same as knowing, you will not know unless the client speaks or answer the exam  knowing is not measurable  will know how is cognitive – ask questions

Types of nursing Interventions: 1. Independent interventions – those activities that nurses are licensed to initiate on the basis of their knowledge and skills Ex. Physical care, ongoing assessment, health teachings, emotional support, and comfort

Vital signs wound care Massage assisting to ambulate perineal care position client in bed

administration of medication IV therapy

NGT feeding Passive ROM crutch walking

Writing the Evaluation statement Conclusion + Supporting Data Conclusion: Goal Met Goal Partially Met Goal Not met ND: Ineffective airway clearance related to viscous secretions and shallow chest expansion Expected Outcome: Demonstrates adequate air exchange as evidenced by: 1. absence of pallor and 2. absence of cyanosis (skin and mucous membranes) Evaluation:

2. Dependent Interventions – activities carried out under the physician’s orders or supervision or according to specified routines; Ex. Medication, diagnostic tests, diet, treatment, activity 3. Collaborative interventions – actions nurse carries out in collaboration with other health team members such as physical therapists, social workers, dieticians and physicians INDEPENDENT

DEPENDENT

COLLOBORATIVE

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March 11, 2006 LEGAL DOCTRINES IN NURSING Professional Negligence Definition: failure to do something which are reasonable and prudent nurse should have done something under a particular situation. (e.g. failure to raise side rails when the patient is unconscious) 3 Elements: 1. duty 2. failure to do said duty 3. injury, harm, death – important in negligence, not in malpractice Ms. Ara Mae Quinto, an OR nurse in a government hospital has prior knowledge regarding some defective OR table. It is unsafe to use for heavy patients. Due to some reason she still allows patients to undergo surgery using said defective OR TABLE. One day, a 40 year old obese female patient, will undergo appendectomy, fell and suffered fracture. The case of Humpee Dumpee -drug rehabilitation clinic, he was having withdrawal syndrome, p[sychiatrist provide a safe and calm environment for Humpee. In a room with an open window. One night, while Gloria was about to give medication, Humpee thought that Gloria was a dragon. The patient jumped the window and died. Will the nurse be liable for negligence?

X Negligence

Malpractice

Ex. Prescribing nurse – has already memorized all the contents of her drug handbook. She has a prescription pad bearing her name, hospital that she is employed, license number and contact number. She gives it for free for all her indigent patients.

The “X” stitch An OB Gyn is too tired after having 10 CS operation for the past 10 hours. It is a practice of said physician to delegate the suturing of the last layer of the patient’s abdominal cavity to her OR nurse. Nurse Kristeta being young and aggressive accepted the task and does it well. Normal spontaneous delivery with specific training on suturing of perineal cavity – episiorrhapy – ALLOWED Allowed to do the IE during normal spontaneous delivery, prior to complete delivery: in the absence of maternal fetal aberration/abnormalities: abrupt placenta placenta previa abortion, H-mole and absence of full delivery = DOCTOR Crime Affecting Nurses: 1. Manner of Commission 3. DOLO > crimes committed with deceit (sinadya mo ang crime), real criminal intention 4. CULPA > unintentional, product of negligence (hindi mo sinadya) 2. Stages of Execution 5. CONSUMMATED > when the crime was totally, absolutely commited or perfected 6. FRUSTRATED > when the offender performs everything to consummate the crime but it did not happen 7. ATTEMPTED > no crime done, overt acts = merely showing the intention to commit the crime Degree of Participation 1. Principal – very, very important, indispensable, primary author of the crime 2. Accomplice – dispensable, before & during 3. Accessory – after the crime has been committed – benefiting itself from the product of the crime Q: Referral by a nurse to an abortionist, the nurse is considered to accomplice to an Abortionist, before the committing the act

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RA 7877 – Anti-Sexual Harassment Act Conditions: 1. Any person who exercises authority ex. Doctor-nurse; Head nurse-nurse, Teacher-student 2. Who is asking for sexual favors, in exchange for another favor

mandatory report within 30 days before the Local Civil Registrar’s Office with penalty if beyond 30 days)

Rape – crisis situation 1. Ordinary Rape – a forcible penetration of an organ for copulation to another organ for copulation, Victim is women only 2. Sexual Assault – anything forcible penetration to any body orifice with sexual malice ex. Victims can be male or female

1) ACT 2808 (1919) – 1ST TRUE NURSING LAW  under doctor  removed from the jurisdiction of the doctor and formed Board of Nursing Board of Nursing – appointed 3 man team a) 1 chairman b) 2 members c) ALL nurses

Intervention: SAFETY – physical, emotional REPORT – 48h at barangay - accessibility REFERRAL – DWSD Abortion – expulsion/termination of the product of conception before the age of viability 12-24 weeks or 3-6months AOG Infanticide – crime if you killed a person/infant less than 3 days or 72 hours of life Parricide – killing another person, whom you have a relationship Homicide – killed another person without any relationship, no intention to kill, product of negligence ex. Somera case, wrong drug administration Murder – with an intention to kill another person Simulation of Birth – committed by any person who shall substitute 1 child to another child or alter his identities for the purpose of losing his civil status. (e.g. failure to report the birth of the baby PD 651 Birth Registration Act = requires all person who shall assist in giving birth, OB, midwife, hilot, nurse, to

Pink – baby girl

Blue – baby boy

LAWS AFFECTING NURSES

1920 - 1st nursing licensure examination TRAIDS Iloilo mission hospital (1906) -1st nursing school PGH School of Nursing (1907) St. Luke’s School of Nursing (1907) Mary Johnston School of Nursing (1907) St. Paul-Iloilo (1907) San Juan De Dios (1907) University of the Philippines - 1st college in the Philippines, 4 yrs Bucaullereate degree - Dean Julieta Sotejo 2) RA 7164 (1991) BON = MAFSON PTC M – Man A – Accredited Nursing Organization F – Five Man Team = 1 chairman, 4 members, all NURSES S – Sixty Five y.o. O – One year Interim period N – not convicted of any crime P – Pecuniary Interest (Absence) – monetary consideration T – Ten Years nursing practice C – Citizen of R.P.

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3) RA 9173 (OCT 21, 2002)  Board of Nursing – MASIN PTC M – MAN A – Accredited Nursing Organization S – Seven man team I – Immediately resigned upon appointment N – Not convicted of any crime P – Pecuniary Interest (Absence) T – Ten years Nursing Practice but the last five years must be in the Philippines C – Citizen and resident of the Philippines POWERS AND FUNCTIONS OF BON L – icensure Exam- formulates examination, not the PRC I – ssue Certificate Of Registration = it is a privilege, not a right, PRC – issues of nurse license = it is a privilege = with all the qualification and not disqualification M – onitor standards of Nursing Practice- BON only have the power to inspect or recommend, only the CHED is authorized to open or close the school 30% passing rate consistent for 5 consecutive years E – ducation C – ode of Ethics (2003) H – ear and decides cases of negligence/malpractice A – ccredits different Organizations, training center G – uides Nursing Practice in the Philippines ex. ICU 1:1, Ward 1:8  Dean 1. RN 2. MAN 3. 5 years of nursing experience  CI - AMOR A – ccredited member organization M –ay have MAN or any Other Allied Health courses O – ne year experience R-N  Nursing Administrator

SM – BANT Supervisor/Manager/Head Nurse – per ward, per shift, per department B – BSN RN A – Accredited Organization N – Nine units MAN T – Two years general staff nursing experience C/D – Chief/Director – the whole hospital RN+MAN+ 5 years Supervisory Experience (except: N.B. IF primary hospital = 50 Bed capacity)

COMMUNITY

MILITARY HOSPITAL

ADD ONLY MASTER’S IN PHN OR CHN 5 years supervisory in the Community

MAN + General Staffing Course

 Nurse Licensure Examinees Optional and Mandatory 1. Certificate of Good Moral Character (optional) 2. Proofs of Valid Holder of Filipino Citizenship – given Birth Certificate (Mandatory) 3. Proofs of Valid Holder of A BSN degree only from Schools whose curriculum is approved by the CHED a. TOR with scanned photo b. RLE, MAN, licensure number, Chief Nurse, PNA number, notarized at the back of completion form; only 2 operations are allowed to have the same procedure, filing of PRC deadline May 22 Other Related Laws: 1. PD 223 – PRC Act 2. RA 1080 – Civil Service Act, if you pass Civil Service, PRC, Magna Cum Laude, Summa Cum Laude, Cum Laude = civil service eligible 3. RA 6425 – Dangerous Drugs Act – 2 types of chemical substances:

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a) Prohibited – absolutely, totally, can not be consumed by cannabis, shabu, hallucinogen, cocaine, LSD, opium – can not use it even if there’s physician order b) Regulated – can use the drug, prescription, with appropriate license from BFAD and Dangerous Drugs Board ex. Antipsychotic drugs 4. RA 7600 - Baby Friendly Hospital, early bonding between mother and child – Sen. Flavier a) Rooming in b) Breastfeeding – Galing Sa Ina Sustansya

- Registration and Oath Q: What are the grounds for a nurse not to be registered? D – dishonorable conduct U – unsound mind M – moral turpitude I – indecent, immoral conduct

Q: how can you promote bonding father and newborn? A: cuddling, and embracing 5. E.O. – Milk Code – avoid manufactured or formulated milk, use breast milk HOW TO BE AN RN UNDER RA 9173? 1. Have all qualifications 2. Take the Exam June 11 3. Acquire the Required Ratings “In order to pass the exam, an examinee must obtain a general average of at least seventy five percent with a rating of not below sixty percent in any subject. An examinee who obtains an average rating of seventy-five percent or higher but gets a rating below sixty percent in any subject must take the examination again but only in the subject or subjects where he/she is rated below sixty percent exam, an examinee must obtain a rating of at least seventy-five percent in the subject or subjects repeated.” - absolutely, totally, unconditionally pass = 60, 100, 100, 100, 100 because General Ave 75 higher, with no 4 - above 35  Major Program Policies - Improvement of family welfare with main focus on women’s health, safe motherhood, and child survival - Freedom of choice = informed choice - Promotion of family solidarity and responsible parenthood FAMILY PLANNING METHODS 1. Spacing Methods - Hormones (pills, injectibles) – with systemic effects - Barrier methods: Intrauterine Device (Arabs), 70s plastic, polyutherane – looks like bituka ng manok - Condoms (male, female)- contraindicated to use oilbased ex. baby oil to prevent tearing of condom, cervical cap(Leah’s shield); diaphragm; sponge; spermicides = toxic shock syndrome TSS - Scientific, Natural (Cervical Mucus, Basal Body Temp., Sympto-Thermal, Lactational Amenorrhea Method-exclusive 6 months breastfeeding)-High literacy/education, Standard days Method, white bead = fertile; brown bead = non-fertile 2. Permanent Methods 79

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Tubal Ligation Vasectomy – ejaculate 25-40x to check sterility after procedure

Expanded Program on Immunization Goal EPI: morbidity and mortality reduction of immunizable disease (p.14) Types and Schedule of Vaccines At birth BCG – anti-TB 0.05ml ID (infant) 0.1ml ID (school entrant) Prevent leprosy 1 ½ month DPT1 05ml IM HEP B1 TT OPV1 – trivalent 3 class poliomyelitis virus 1,2,3 2 ½ mos. DPT2 OPV2 HEP2 3 ½ mo DPT3 OPV3 HEP3 9-12mo Measles 0.5ml SQ Side effects: BCG 2-3 weeks abscess will ulcerate then heals leaving a scar (approx 12 weeks from vaccination)

Koch’s Phenomenon – normal inflammation of the site after 2-4 days. NR: warm compression Deep Abscess at site – not normal. NR:incision and drainage; powdered INH, do use alcohol it will kill the vaccine. Indolent Ulceration – ulcer after 12 weeks NR: incision and drainage; INH powder Glandular Enlargement – not normal, treat as abscess Side effects: DPT  Fever for a day – usually  Soreness at site within 3-4 days normal, warm compress  Abscess after a week or more – incision and drainage, use local antiseptic: Betadine solution, or alcohol  Convulsions – do not give next dose and refer for next check up Side Effects: Measles  Fever after 5-7 days usually 1-3 days  Mild rashes Cold Chain  Vaccines destroyed by heat  Viral: BCG, DPT, OPV, TT, MEASLES, HEP B – viral  Most sensitive to heat: OPV, measles  Destroyed by freezing: DPT, TT, HEP B

Control of Diarrheal Diseases: Control of dehydration, Q: what is the reason to deaths due to diarrhea? A: Dehydration Classification of Dehydration VS Diarrhea MILD MODERATE SEVERE 5-10 bouts of 10-15 bouts/day >15 bouts/day watery stool/day - sunken fontanels -lethargic, normal - comatose, 80

and eyeballs - dry lips, child is irritable but conscious - (-) skin fold test

blood pressure - (+) skin fold test

almost (-) urine output - dry tear ducts - (++) skin fold test

> Give ORS for 46 hours treatment Less than 2 years – ½ glass ORS/bout or - ½ cup rice water/bout If 2 yrs & above - 1 glass ORS or - 1 cup of rice water - Reassess after 4-6 hours

Intravenous Fluid ↓ Available ↓ ↓ YES NO ↓ Assess if child can drink ↓ ↓ yes no -> NGT ↓ ↓ ↓ ors yes no ↓ ↓ ↓ REFER via NGT REFER REFER IVF

Supplementary? Give to ensure proper nutrition to avoid malnutrition Weight loss Mild 1 YR 3%

Moderate

10%

6%

Severe

15%

9%

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