MAP (mean arterial pressure) Calculation

((2x diastolic) + systolic) / 3 ) A MAP of greater than 60 65 mm Hg is necessary to

perfuse organ
-

Furosemide is potassium wasting dangerous for ppl with heart failure d/t
dysrhythmias
o Need potassium supplements
Potassium tak with plenty of water (at least 4 oz), sit upright for a bit after
ingestion to prevent pill from lodging in esophagus and eroding over time or
pill induced esophagitis
Methylphenidate admin in divided doses 2-3 times daily, 30-45min before
meals
o It is a stimulant so it may interfere with sleep so do not give later
than 6pm
o Monitor closely initially for tics
Adalimbumab (TNF inhibitor) = immunosuppressant
o Increases risk of new infection, including reactivation of previous
infection (e.g. latent TB, hep B)
Lithium carbonate = mood stabilizer for schizophrenia and bipolar
o Narrow therapeutic index (0.6-1.2 mEq/L), levels > 1.5 are
toxic
o Acute toxicity = GI sx (n/v, diarrhea)
o Chronic toxicity = neuro manifestations (ataxia, confusion, agitation,
neuromusc excitability) and as diabetes insidpius (polyuria, polydipsia)
Heparin
o Risk is herparin induced thrombocytopenia (HIT)
o Normal platelet range = 150 000 400 000 u/L
o aPTT 46-70 sec when on heparin therapy (1.5-2.5x normal range)
ACE inhibitors (e.g. Lisinopril)
o Teratogenic, esp in first 13 weeks gestation
o Produce non-productive cough
Nitroglycerin
o Vasodilation, can lower BP, make sure BP > 80 mmhg systolic
Phenytoin
o Gingival hyperplasia or hypertrophy is a side effect
Warfarin
o Desired result is a therapeutic range rather than a normal value when
not on drug
o Therapeutic range is 1.5-2.5 x control (INR of 2-3) but up to 3-4 x (INR
2.5-3.5) the control in high risk situations (ie. Artificial heart valve)
o Antidote = vit K
Gs Ginseng, garlic, green tea, gingko biloba, grapefruit
Cranberry juice
Watch out for leafy green vegetables (rich in vit k)
Atropine = anticholinergic
o Anticholinergic dries things out (eyes, mouth) use it for death rattle
to dry secretions in mouth
Metoclopramide = for GERD and antiemetic

Associated with EPS, including tardive dyskinesia

Call if tardive dyskinesia sx (uncontrollable mvements)
Protruding and twisting of tongue
Lip smacking
Puff cheeks
Chewing movements
Frowning or blinking of eyes
Twisting fingers
Twisted or rotated neck (torticollis)
ASA / aspirin toxicity
o Activated charcoal is the antidote for ASA poisoning
(disorientation, vomiting, hyperpnea, diaphoresis, restelessness)
Activated charcoal binds to salicylates to reduce absorption in
intestine
o Sodium bicarb appropriate after admin of activated charcoal
Makes blood and urine more alkaline to promote urinary
excretion of salicylate
Methadone
o Narcotic, long half life (up to 50+ hrs)
o Early signs of toxicity = N/V, lethargy and sedation precedes resp
depression
o Itching (pruritus) expected with narcotic use
o Occasional PVCs are common, also risk of QT prolongation
Saw palmetto
o Use to tx benign prostatic hyperplasia
St johns wort
o For depression tx
Ginkgo biloba
o Can cause bleeding , be careful in ppl with clotting disorders or blood
thinners
o Tx for dementia, axiety, schizophrenia, cerebral insufficiency
Pancrelipase
o Provides digestive enzymes
o Give with snack and meal
Rifampin for TB
o Turns body fluids (urine, sweat, tears) red
o Wear eyeglasses
Calcium channel blockers (nifedipine, amlodipine)
o Vasodilators tx of HTN, chronic stable angina -> relaxes vascular
smooth muscles
o Most important side effect
Dizziness
Flushing
Headache
Peripheral edema
Constipation
Corticosteroids (methylpredisoloe, prednisone, dexamethasone)
o
o

All glucocorticoids can cause increase in BS/hyperglycemia (may need

higher insulin dose) may see incr urine, hunger, thirsp
o Can cause immunosuppression and infection can develop; can mask
signs of infection, so be concerned with low grade fever
o Increase dose during stress b/c it can cause sudden cdecrease in
cortisol level, triggering addisonian crisis
o Can cause gastric irritation, take w food
o Cataracts = side fx
o Never discontinue medications abruptly - it could precipitate an acute
crisis
o Take medication with breakfast - corresponds to biorhythms and
reduces gastric irritation
o Take higher dose in morning and lower doses in evening
o Always take medication with a meal or a snack
o increased sensitivity to sunlight
o Avoid other people with infections
o steroid use masks the signs of infection
o Be aware of the anticipated side effects of (long-term) steroid therapy,
including
o weight gain, swelling of face, hands, ankles, skin changes,
excess hair growth on face, hands, arms, back, legs,
easy
bruising, thinning of skin, acne of the face, back and chest (teens and
young adults),
mood swings and depression,
increase in blood
sugar levels - client may need to take insulin
Spironolactone
o K+ sparing diuretic , generally weak
o Often used in combo with thiazide diuretics to reduce K+ loss
Thiazides inhibit reabsorption of sodium choride NaCl
Because thiazides take out sodium, which also tkes out
potassium
o Desired effect is to prevent hypokalemia, sodium level should be lower
than normal because of the exchange (Na / K pump)
Theophylline (bronchodilator for COPD)
o Level 10-20 mcg/mL nomal range
Vancomycin
o Can cause nephrotoxicity therefore monitor serum creatinine levels
Cushing Traid indicates increase intracranial pressure
o Increase BP, decreased HR/RR
Shock is opposite of this
Cushings disease
o ACTH overproduction leads adrenal gland to overproduce cortisone
Diabetes insipidus (DI)
o Decrease ADH
o Central DI (hypothalamus or pituitary gland)
o Nephrogenic DI (physical damage to kidneys)
o Findings:
Excessive thirst
Polyuria (excessive urine)
o

Nocturia (excessive urine at night)

Signs of dehydration
Constipation
Syndrome of inappropriate antidiuretic hormone (SIADH)
o hypersecretion of ADH with water intoxication with decrease in sodium
concentration
o Causes are Nervous, neoplasia, pulmonary diseases, drug-induced
o Symptoms
Changes in LOC, tachycardia, hyponatremia (due to increase in
water retention), weight gain, hypertension
o Management
Diuretics
o restrict water intake as ordered and seizure precautions - with
hyponatremia
o
myxedema crisis/coma: a loss of brain function as a result of severe,
longstanding hypothyroidism; usually precipitated by a secondary insult
(hypothermia, infection, or another systemic condition, or drug therapy)
o require mechanical ventilation, tx infection, IV thyroid hormone
replacement
Hypothyroidism

Management
synthetic thyroid hormone: levothyroxine sodium (give on empty
stomach one hour before meal, drink a lot of water, can cause
dysrhythmias)
protect client from cold
Hyperthyroidism
o Overactive thyroid
o Thyrotoxic crisis (thyroid storm) precipitated by factors like stress,
infection, pregnancy
o Graves disease: leads to exophthalmos (bulging eyes), heat
intolerance, anxiety.
Accounts for most cases of hyperthy
o Causes: too much iodine, thyroiditis, overdosage of thyoid hormone
o Findings: difficulty concentrating, fatigue, wt loss, heat intolerance,
tachycardia, insomnia,
o Drugs: sodium 131 (radioactive iodine), methimazole, propanolol
o Care of post-thyroidectomy: assess for excessive swallowing or pooling
of blood behind neck, report changes in voice or findings of
hypocalcemia (b/c it is close to parathyroid, which regulates
calcium), avoid fowlers position (due to strain on incision) but 30
degree fowler to prevent blockage of airway
Hypoparathyroidism
o parathyroid produces too little parathyroid hormone; results in
hypocalcemia
o Findings : irritability, personality changes, muscular weakness,
numbness of fingers, carpopedal spasms, laryngospam, seizure, hair
loss, dry, abdominal cramp
o positive Chvostek's sign (facial muscle twitching when cheek is
stroked)
o positive Trousseau's sign (carpal spasm as inflated BP cuff is released)
o Drug: calcium replacement, vitamin D
o Decrease phosphorus intake (fish, eggs, cheese, and cereals)
Hyperparathyroidism
o

increased serum calcium (hypercalcemia) and development of kidney

stones
o Findings : gastrointestinal, constipation, nausea, vomiting, anorexia,
demineralization, kidney stones, blurred vision, muscle weakness,
fatigue, depression
Symptoms of hyperparathyroidism can be remembered as:
"moans, groans, stones, and bones... with psychic overtones."
o Management : drink more fluids (to dilute calcium levels), surgery, diet
rich in calcium and vit D,
Neck surgery can increase laryngeal edema/tracheal obstruction monitor
respiratory distress
o Increased risk of hypocalcaemia
Addisons disease
o Destruction of adrenal cortex decrease cortisol and aldosterone
(also called primary adrenal insufficiency)
o Causes: autoimmune, infections (tb, hiv, fungal), hemorrhage,
tumours, anticoags
o

o
o

Management: glucocorticoid treatment (hydrocortisone),

mineralocorticoid (fludrocortisone acetate), diet high in protein
o Tx of addisonian crisis: IV hydrocortisone
o Teach client
Add sodium to diet
Avoid extra potassium
Have quick sugar source available
Increase fluid intake
Cushing syndrome
o Secretes too much cortisol

o
o

Causes: long term tx of corticosteroid e.g. prednisolone,

Makes too much ACTH (pituitary) increased cortisol

o
o Striae (purple marks)
o Management: slowly decrease corticosteroid medication
o Monitor for hypokalemia and hypernatremia
Diabetes Mellitus (DM)
o a chronic condition in which the pancreas produces too little insulin, or
cells stop responding to insulin; results in hyperglycemia
o Findings:
Hyperglycemia, fatigue, weight loss (diabetes type 1), blurred
vision, slow wound healing
3 polys of diabetes mellitus
Polydipsia (increased thirst)
Polyuria (increased urine production)
Polyphagia ( increased hunger)
o type 1 DM
hypertensive medications, including angiotensin-converting
enzyme (ACE) inhibitors or angiotensin II receptor blockers
(ARBs)
cholesterol-lowering drugs (the statins)
o oral hypoglycemic medications - sulfonylureas, meglitinides,
biguanides, thiazolidinediones and alpha-glucosidase inhibitors
for type 2 diabetes
same with metformin only given to type 2 diabetes
Hypoglycemia (insulin shock)
o Blood sugar below 50 mg/dl

Due to too much insulin, too little food and excessive physical activity
Findings: diaphoresis, cold, clammy skin, anxiety, tremor, slurred
speech, weakness, nausea, mental confusion, headache
o Management
Give 15 -20 grams of carbohydrates, 4 ounces of juice
If unconscious 1 mg glucagon IM
Diabetic ketoacidosis in type 1 diabetes
o Severe Insulin deficiency
o Sudden onset
o Finding: blood sugar level greater 300 mg/dl
Elevated ketone levels sweating or odour , sweet odor to
breath
Metabolic acidosis pH less than 7.35, dry skin, kussmauls
respirations
Thirst, polyuria, drowsiness, anorexia, shock/coma
o Management
Correct fluid (IV fluid), electrolyte depletion (especially K),
correct metabolic acidosis (regular) insulin IV
Hyperosmolar hyperglycemic state in type 2 diabetes
o Gradual onset, more in old ppl
o Findings
Severe hyperglycemia > 600 mg/dl
pH > 7.4
negative ketones
profound dehydration
altered LOC
o precipitated by physical stress like infection
o for non-diabetics d/t tube feedings without supplemental water or too
rapid rate of infusion for parenteral nutrition
diabetic triopathy
o retinopathy impairs retinal circulation, causes hemorrhage
o nephropathy decline in kidney fx
o neuropathy - deteriorates nervous system, nonhealing foot ulcers
macorvascular complications
o CAD, peripheral vascular disease,
medication interactions with insulin and oral hypoglycemic medications
o medications that can increase blood glucose levels: glucocorticoids,
thiazide diuretics, thyroid agents, oral contraceptives, estrogen
o medications that can further decrease blood glucose levels: aspirin,
alcohol, oral anticoagulants, beta blockers, tricyclic antidepressants,
tetracycline, monoamine oxidase inhibitors
exercise decrease blood sugar but increases insulin sensitivity
Illness can increase the need for insulin and raise blood sugar
Glycated hemoglobin (HbA1c) predicator of diabetes management for past 2
to 3 months Normal value less than 6% and diabetics should keep it
below 7%
Target blood glucose for diabetics -- 90 to 130 mg/dl (before meal) and
less than 180 mg/dl (after 1 or 2hr meal)
o
o

70-110 mg/dl for non-diabetics (normal sugar level)

CDV
Plasma proteins
o Albumin & globulin assess nutrition
Pericarditis
o Inflammation of pericardial sac due to viral, heart attack, influenza,
pneumonia
o Findings: Chest pain, pericardial friction rub, dyspnea, fever,
dysrhythmias, pulsus paradoxus (decrease in systolic BP during
inspiration), cant lie flat
o Changes in ST segment, sedimentation rate (marker for inflammation)
o Medication: anti-inflammatory avoid anticoagulant (risk of bleeding)
o Semi-fowler position
o Assess respiratory, cardiovascular and renal
Myocarditis
o Inflammation of myocardium
o Findings: chest pain, fatigue, dyspnea, congestive heart failure signs
(edema, crackles in lungs), abnormal heart sounds
o Changes in troponin and creatine kinase (myocardial enzyme)
o Medication
Corticosteroids (decrease inflammation)
Cardiovascular medication tx heart failure ( ACE inhibitors, betablockers, vasodilators, digoxin)
Diuretics to tx fluid overload (furosemide)
o Signs of fluid overload
Orthopnea (inability to breathe while lying flat), peripheral
edema, increase in daily weights, crackles, jugular venous
distention, worsening heart murmur
Endocarditis
o Infection of endocardium, heart valves, or heart valve prosthesis
(from bac or fungal)
Can cause emboli
Infection most likely in heart valves, ppl with murmurs, and
illegal iv druggies
o Findings
Most common = murmurs , usually a new one that develops
with fever
Hx of dmg to heart valve
Fever, chills, night sweats, with no obvious source (Fever NYD)
Pericardial friction rub
Fatigue, anorexia
Petechiae of skin, splinter hemorrhage
Signs of infarction r/t emboli
Infarction of spleen, abdo organs (will see pain, rigidity,
signs of ileus)
In kidney (hematuria, pyuria, flank pain, decr u/o)
In brain (hemiparesis, aphasia, neuro deficits )

In lung (cough, pleuritic pain, pleural rub, dyspnea)

Peripheral vascular occlusion (numb, tingling, cyanosis in
arm, leg, finger, toe)
ESR elevated (erythrocyte sedimentation rate)
o Give oxygen to prevent tissue hypoxia
o Start long term IV access for IV abx and plan for home IV therapy
o Prophylactic abx befoe dental work and other procedures
o Tell ppl to report fever, tachy cardia, dyspnea, SOB (signs of embolus +
infection)
Rheumatic heart disease
o Damage to the heart by one or more episodes of rheumatic fever
caused by infection
o Rheumatic endocarditis damages the heart, valves and causes
stenosis (tricuspid and mitral)
o Findings
Sudden sore throat, swollen lymph nodes, headache, fever (40C)
Polyarthritis (warm and swollen joints)
Heart problems and SOB, chest pain, heart murmurs and
pericaridal rubs
Chorea (emotional instability, jerky movements in face, feet)
Rash erythema marginatum (ring like or snake shaped rash)
o Test using antistreptolysin O (ASO) (strep infection) and ESR
o Help clients with Chorea to grasp objects to prevent falls
o Avoid exposure to respiratory infections
o Teach them to look for strept infection (like strept throat)
Valve disorders
Mitral stenosis: mitral valve thickens, gets narrow, decr blood flow from L
atrium to L ventricle
o mostly caused by rheumatic fever
o findings:
if mild, asymptomatic heart murmur
if moderate severe, will see sx of L sided heart failure b/c of
blood backing up into lungs + poor cardiac output
heart murmur
dyspnea on exertion, cough
orthopnea (dyspnea when supine), ppl wil sleep in recliner
or prop up pillows to sleep
paroxysmal nocturnal dyspnea (sudden waking due to
sob)
crackles in lungs
mild wt gains
weakness, fatigue, parpitations
o Management: DO-ABLE
D diuretics (for pulmonary congestion)
O oxygen for hpoxia
A ace inhibitors to reduce preload and afterload
B beta blockers, prevents arrhythmias, reduces workload

L low sodium (prevent fluid retention) 2000 mg / day

E exercise as tolerated
o Nursing assessment: CARDIALVLS (cardiac levels)
C chest discomfort
A activity tolerance
R response to drug therapy
D depression and anxiety
I increased wt due to fluid buildup / periph edema
A arrhythmia
L light headed
V vital sign changes
L- decreased LOC
S SOB
o If valve surgery, watch for hypotension and arrhythmias, administer
and titrate anticoags, use PTT for heparin, INR for warfarin
If on long term anticoag, periodic INR teting, maintain steady vit
K
Mitral valve insufficiency (regurgitation)
o Back flow into left atrium during ventricular systole
o To handle backflow, atrium enlarges but left ventricle also enlarges to
make up for cardiac output
o From birth defects (like transposition of aorta and pulmonary artery)
or can be from calcification
o Findings
Asymptomatic
Orthopnea, dyspnea, fatigue, weakness, wt loss
Peripheral edema
Chest pain, palpitations
Systolic murmur at apex, or blowing murmur
JVP distension
Hepatomegaly
o Same mgmt as for heart failure (DO-ABLE) and surgery
o Same monitoring as above (CARDIAC LEVELS) and same mgmt. as
above (anticoag, etc)
Tricuspid stenosis
o Narrowing of tricuspid valve between R atrium and R ventricle
o Caused by rheumatic fever
o Findings:
Dyspnea, fatigue, weakness, syncope (fainting)
Peripheral edema
Jaundice and ascites
May appear malnourished
Distended jugular vein
o DO-ABLE used for management of failure
o Same monitoring as above (CARDIAC LEVELS) and same mgmt. as
above (anticoag, etc)
Ticuspid Valve insufficiency (regurgitation)

Doesnt close properly during ventricular systole allowing blood to leak

from the righ ventricle to the right atrium
o Findings
Dyspnea, fatigue, weakness and syncope, peripheral edema,
ascites, pulmonary edema
o Same mgmt as for heart failure (DO-ABLE) and surgery
o Same monitoring as above (CARDIAC LEVELS) and same mgmt. as
above (anticoag, etc)
Pulmonary stenosis
o Narrowing of pulmonic valve b/w right ventricle and pulmonary artery
o From tetralogy of fallot, rare in elderly
o Findings
Cyanosis, dyspnea, syncope, right heart failure sx
Cyanosis in babies, failure to thrive (baby cant do shit)
o Same mgmt. (DO ABLE) and surgery
o Same assessment (CARDIAC LEVELS, anticoags)
Pulmonary valve insufficiency (pulm valve fail to close, blood flows back into
right ventricle)
o Findings
Dyspnea, fatigue, cp, syncope
Peripheral edema
Jaundice with ascites,
o Same mgmt. and assessment
o Tx for pulmonary edema MDOG
M morphine
D diruetics
O oxygen
G blood gases
Aortic stenosis
o Poor cardiac output, increased left heart pressures
o Most significant in old ppl
o Usually leads to L sided heart failure, L ventricular hypertrophy,
cardiomyopathy
o Findings
Classic triad dyspnea, syncope, angina
Palpitations, fatigue,
Orthopnea, paroxysmal nocturnal dyspnea, crackles in lungs
Systolic murmur into carotid arteries
o Mgmt. DO-ABLE
Nitrates for chest discomfort
o Assessment is the same (Cardiac levels)
Aortic insufficiency
o Cause hypertrophy of L ventricle
o Most common in males
Can be due to Marfans syndrome, ankylosing spondylitis,
syphilis, essential hypertension or defect of the ventricular
septum
o

MI

o
o
o
o
o

Findings:
Pectus excavatum , arachnodactyly, dilation of aorta, more
aware of heartbeat
If nail tip is pressed, the root will flush and then pale
(Quinckes sign)
High pitched diastolic murmur
Pulsus bisferiens double beat pulse
Widened pulse pressure
Chest pain unrelieved by sublingual nitroglycerin
Same mgmt. (DO ABLE) and surgery
Same assessment (CARDIAC LEVELS, anticoags)
Can be sudden/gradual, total event can take b/w 3-6h
Equal b/w men and women
Findings
Classic: persistent, crushing substernal chest pain
Pain radiates from LEFT arm jaw, neck, shoulders with
feeling of impending doom
Pain doesnt resolve with rest
Some pts report no pain or think its mild indigestion
(mostly in older adults or ppl with diabetes)
Silent MI heart failure, change in mental status,
unexplained abdo pain, dyspnea, fatigue
Some older women = only fatigue, n/v, SOB, flu like
symptoms
Sudden death
May get HTN within first hour
Others can get hypotension with signs of shock
ST elevation on ECG
Diagnosis
CK-MB isoenzyme rise 4-6 degrees after acute MI (goes back to
normal 3-4 days)
Troponin rises quickly, elevated for 2 weeks
Immediate administration (M.O.N.A) morphine, oxygen,
nitrates, aspirin
Goal is resolution of symptoms as quickly as possible think
time is muscle
Emergency coronary angiogram with revascularization
Cardiac catheterization stent insertion
Thrombolytic agents such as tPa (tissue plasminogen
activator) to dissolve the thrombus in the coronary
artery and reperfuse the myocardium
Induce hypothermia after return of spontaneous circulation
Pharmacologic agents
Antiplatelets and or anticoagulants (aspirin, heparin) to
prevent recurrent thrombosis

Nitrates to decrease pain and decrease preload and

afterload resulting in increase in myocardial oxygen
supply
Narcotic analgesics acute episodes of chest discomfort
or pulmonary edeme and reduces the workload of heart
Beta-blockers decrease myocardial tissue oxygen
consumption and decrease the risk of arrhythmias
ACE inhibitors decrease pressue in heart and reducing
risk of cardiac remodelling
Diuretics pulmonary edema
Sedative decrease anxiety and decrease workload of
heart
Stool softeners to decrease workload of heart caused by
straining leading to vagal stimulation producing
bradycardia and arrhythimas
*note the lack of Calcium channel blockers
OH BATMAN!"
O = Oxygen
H = Heparin
B = Beta blocker
A = ASA (aspirin)
T = Thrombolytics
M = Morphine
A = ACE (especially for those with heart failure or a lower
ejection fraction)
N = Nitroglycerin
Nursing management elevate head of bed (improves chest
expansion)
Monitor for cough, tachypnea, and crackles which may
indicate pulmonary edema due to LVF
To prevent venostasis and thrombophlebitis stockings
and intermittent pneumatic compression devices
Gradual resumption of sexyimes. Sildenafil (Viagra)
contraindicated or else severe hypotension

Heart failure
o Inability to pump fluid overload
o Left sided
Systolic heart failure, LV ejection fraction < 40% (cant contract
properly)
Diastolic heart failure, LV ejection fraction > 50% (normal) so
its also called heart failure with normal ejection fraction; cant
relax properly
o Heart muscle dmg = cardiomyopathy

Right heart failure

Left heart failure

Significant weight gain

Fatigue and activity intolerance

Cough (often dry initially)
Mild weight gain that leads to early pulmonary
symptoms
Shortness of breath/orthopnea
Paroxysmal nocturnal dyspnea
Tachypnea
Crackles
S3 heart sound
Cardiac cachexia and muscle weakness in
advanced stage

Jugular vein distention

Bilateral dependent peripheral edema
Liver engorgement (hepatomegaly with
abdominal pain, anorexia, and nausea)
Ascites

Acute pulmonary edema:

Frothy sputum (may be blood-tinged)
Restlessness, irritability, hostility, agitation, anxiety
Prominent crackles throughout lung fields
Diaphoresis
Cyanosis

o
-

Diagnostics look at CBC, electrolytes, brain natriuretic peptide;

hemodynamic monitoring in cardiogenic shock (arterial BP, pulmonary
artery pressure, wedge pressure, cardiac output)
- Mgmt: DO-ABLE
Pharmacology: digitalis, vasodilators, nitrates, anti
HTN, cardiac glycosides, diuretics, ace inh, beta
blockers, inotropes (to change muscular contractions)
Oxygen, intra aortic balloon counterpulsation, ventricular
assist pumping, biventricular pacing
Surgery (partial left ventriculectomy)
Cardiac tamponade
- Fluid fills pericardial sac and minimizes cardiac output, requiring
emergency care to avoid cardiac arrest (compression of heart due
to fluid accumulation within the pericardium)
- Finding classic triad 1) hypotension 2) muffled heart
sounds 3) marked jugular vein distension if no hypovolemia
And pulsus paradoxus (systolic BP lower on inspiration than
expiration)
Narrowed pulsepressure (difference b/w sys + dys BP)
showing poor cardiac output
Tachypnea, tachycardia, restlessness, lightheadedness, or
decreased LOC REQUIRES emergency care

Hypertension

Category

Systolic BP

Optimal

< 120

and

< 80

Normal

< 130

and

< 85

High-Normal

130-139

or

85-89

Hypertension - stage 1

140-159

or

90-99

Hypertension - stage 2

160-179

or

100-109

Hypertension - stage 3

180 or higher

or

110 or higher

Diastolic BP

Chronic hypertension of pregnancy present before week 20 of gestation

Hypertensive crisis when blood pressure rises very rapidly BP usually
greater than 180/120 mm Hg and mean arterial pressure more than 150
mmHG
Primary hypertension 90 95% unknown
- Hormonal contraceptives
Secondary hypertension
- Renal disease, drugs (decongestants, immunosuppressants),
cushing syndrome, pregnancy related hormones, neurologic
disorders, congenital aortic narrowing
Usually asymptomatic unless end-organ damage
- Findings
Dizziness, TIA, stroke, retinal arteriole abnormalities, chest
pain, signs of heart failure, intermittent claudication (leg pain
with exercise relieved by rest), vascular bruits, elevated
serum creatinine, urine positive for protein
Hypertensive crisis : sudden blood pressure elevation
Hypertensive encephalopathy (first sign), severe
headache, nausea, papilledema (swelling of eyes), MI,
angina, renal insufficiency
Diagnosed through taking average of three or more blood pressure
readings and two minutes apart at each of three or more visits after an
initial screening visit
Management
- If preHTN or uncomplicated stage 1: lifestyle modifications (wt
reduction, phys activity, DASH diet fruits, veggies, low fat milk
products, fish, grains,limit sodium ( 2 grams), limit alcohol,
smoking cessation, stress reduction)
- Pharmacological initial therapy is using diuretic or beta-adrenergic
blocking agent, oxygen is used in acute crisis, ACE inhibitors are

used to treat left side heart failure and to protect kidney

(diabetics)
Coronary artery disease (CAD)
- Fat deposits in coronary arteries (atheroma or plaque) narrows the
artery by 75% reduce flow of blood and o2 to heart
- Epidemic in western world, in a lot of men, most common cause is
atherosclerosis
- Findings: early stages asymptomatic
If >70% narrowed, angina, chest discomfort
Women, ppl with diabetes, those who are v old have
atypical sx like dyspnea, lightheadedness, GI
complaints or pain in atypical locations
- Labs: LDH cholesterol, triglycerides, C-reactive protein (general
inflammation), homocysteine levels (assess cardiac risk)
Reduced HDL cholesterol
Cardiac stress test with ST segment changes
Nuclear perfusion test to show poor perfusion
Cardiac catheterization with angiography
- Med mgmt.
Pharmacological
Nitrates (vasodilator) short acting nitroglyc tabs or
spray
Beta blockers (to reduce oxygen demand)
Antiplatelet agents (aspirin 81mg) to prevent
thrombotic event
Antilipemics to treat hyperlipidemia, statin drugs,
reduce risk of atherosclerotic plaque rupture
Oxygen during aginal events
Coronary angioplasty (PTCA)
CABG bypass graft
- Nursing mgmt.
MONA
Post-cardiac cath: maintain heparin, monitor for chest pain,
hypotension, bleeding, hematoma from catheter site,
coronary artery spasm, keep affected leg straight and
immobile for 6-12 h, check distal pulses to detect
arterial occlusion, give IV fluids, serum creatinine,
potassium levels for arrythmias
Hyperlipidemia
- Diagnosis Increased: Total cholesterol, LDL, triglycerides;
decreased HDL
- Medications statins, bile acid sequestrants (colestipol,
cholestyramine), niacin
Cardiac arrhythmias
- Types: supraventricular, ventricular,
- Findings:

Note all new or symptomatic arrhythmias need continuous

cardiac monitoring, IV access for meds, vital signs +
symptom monitoring if client not tolerating rhythm
Asymptomatic : no findings, means client tolerating well
Mild: palpitations, fatigue, mild reduction in cardiac otutput
Moderate: lightheaded, low BP, chest discomfort, dyspnea or
indicators of poor cardiac output/// bedrest if unstable, 12
lead ECG, frequent BP monitoring, call rapid response team
at risk for cardiac arrest soon
Severe: unresponsive, slow/absent pulse, no or v low BP,
emergency
- ABCD of A fib mgmt.
A anticoagulate with heparin or warfarin
B beta blocker
C cardioversion if beta blocker ineffective or ccb
D digoxin
- Supraventricular arrhythmias (too fast) give adenosine,
CCB, beta blockers, do cardioversion, ablation
- Ventricular arrhythmias ABCDs of life support, prepare for
cardioversion or implantable cardioverter if indicated
- Atrioventricular conduction disturbances too slow- may
need atropine, maybe pacemaker
Aneurysms dilation of an artery due to weakness in arterial wall ( from
atherosclerosis)
- Common locations abdominal aorta
Usually asymptomatic
Vague abdo or back pain if severe, may be a sign of
active dissection, requiring emergency care
Tenderness + pulsation on palpation
Hypotension
Diminished pulses in lower extremities
- Thoracic aorta
Findings: may be asymptomatic, vague chest pain (sudden,
severe may signal dissecting aneurysm), dyspnea, distended
neck veins
Occlusive arterial disease
- insufficient blood supply in arteries, usually in legs
- acute findings
pain in affected limb, esp with walking or activity
cyanosis and paresthesia in affected limb
gangrene if untreated
6 Ps Pain, pallor, paralysis, paresthesia,
pulselessness, poiklithermia,
- management
IV heparin based on PTT
Surgery embolectomy, bypass, amputation of limb, PTCA
- Chronic

Findings: intermittent claudication, (pain with walking,

relieved with rest, indicating mild to moderate obstruction)
Pain at rest indicates severe arterial obstruction
Affected limb shows:
o Skin waxy, hairless, cool, pale, cyanotic
o Weak or absent pulses
o Paresthesia
o Non-healing wounds
o IN MEN- IMPOTENCE
Pharmacologic anticoagulants, vasodilators, antiplatelets,
pentoxifylline to promote blood flow by making blood
cells more slippery
Nursing: foot care, monitor peripheral pulses, blanch test
Place legs in dependent position to increase blood
flow, avoid constrictive clothing on legs, avoid crossing
legs
Raynauds Phenomenon (arteriospactic disease)
- Episodic vasospasm that results in intermittent pallor or cyanosis of
the skin usually affects the fingers bilaterally but occasionally
affects the (toes, nose or tongue) leading pallor and cyanosis of the
skin due to severe constriction of cutaneous vessels followed by
vessel dilation
- More common in woman
- Finding the 6 Ps
- Management promote perfusion
Calcium channel blockers, alpha-adrenergic blocking agents,
vasodilators, analgesics for pain relief
- Protect self from cold and avoid temperature extremes
Thromboangiitis obliterans (buergers disease)
- Inflammatory disease of the arteries (vasculitis) usually affecting
the legs and feet
- Findings pain, numbness and tingling of toes, weak or absent
peripheral pulses (6 Ps), ischemic ulcerations
- Nursing interventions: blanch test (Cap refill)
Varicose veins
- Dilation of superficial veins of the legs and feet
- Etiology : found in greater saphenous vein, incompetent, increased
pressure in veins, due to long periods of standing and pregnancy
- Findings: pain after period of standing, foot and ankle swelling,
distended legs veins
- Management: medical sclerotherapy ( injection of sclerosing agent
that causes vein thrombosis)
- Vein ligation (vein stripping) surgical
- Teach client
Not to cross legs, elevate legs, avoid prolonged
sitting/standing
Thrombophlebitis
- Thrombus (clot) with inflammation of wall of superficial blood vessel

DVT
-

Findings: redness, swelling, tenderness, warmth, complication

thromboembolism
Diagnostic D-dimer
Mgmt.: bed rest with elastic stockings, elevate extremity,
anticoagulatns, analgesics
Nursing
Vitals, peripheral pulses, look for PE, look for vascular
impairment

Virchows triad hypercoagulability, hemodynamic changes (stasis,

turbulence), endothelial injury
- Sepsis, CHF, MI, obesity
- Findings: unilateral edema of an extremity with warmth,
tenderness, redness at site
- Mgmt anticoagulant therapy (clot prevention), thrombolytic
therapy (dissolve)
- Nursing
Drug therapy monitoring (aPTT heparin, PT/INR warfarin),
look for bleeding (bruises, blood in urine/stool)
Venous stasis ulcers
- skin and subcut ulcers on legs, ankles, feet
Sickle cell disease
- Autosomal recessive
- 1 in 12 african americans carry the trait
- Generalized microvascular occlusion
- Findings (d/t obstruction from sickled RBCs ad RBC destruction)
Hypoxia
Organ dysfuction (spleen, liver, kidney) from ischemia and
infarction
Crises
Vaso-occlusive painful distal ischemic usually hands
and feet
Sequestration crisis pool blood in liver and spleen
Aplastic crisis diminished RBC production
Hyperhemolytic crisis increased destruction of RBC
- Mgmt
Hydration
Oxygen
Pharmacologic
Analgesics (narcotics)
Antibiotics (prophylaxis)
Folate
High dose IV steroids
Blood transfusions
Vaccines, annual influenza vaccine
Nursing
Encourage fluids

Accurate I+O

B-thalassemia
- Inherited blood disorder characterized by deficiencies in rate of
production of specific globin chains in Hb
- Auto recessive, Mediterranean people
- Findings
Severe anemia, pallor
Microcytic RBCs
Impaired growth
Splenomegaly
- Diagnostic Hb and Hct, Hb electrophoresis
- Mgmt.
Iron chelating agent to counteract hemosiderosis
Splenectomy
Chronic transfusion therapy
Bone marrow transplantation
Bleeding disorders
Idiopathy thrombocytopenic purpura
- Acquired hemorrhagic disease
- Unknown etiology but occurs one to two weeks after febrile viral
illness
- Patho: autoimmune disorder, platelets killed and fewer made, can
be acute/chronic
- findings
excessive bruising, petechiae, internal bleeding
- mgmt.
pharmacologic corticosteroids, IV immunoglobins,
immunosuppression
immunoabsorption apheresis (to filter abx from
bloodstream)
splenectomy for chronic disease
- nursing interventions
monitor for bleeding
do not use aspirin use Tylenol for pain
dont do contact sports
Von Willebrands disease
- Clotting protein (von willebrand factor) deficient or defective
- Findings: easy bruising, nosebleeds, menstrual periods, blood in
stool, urine
- Mgmt
Doesnt require tx if findings mild
Avoid blood-thinning eds, like aspirin and some NSAIDs,
clopidogrl, warfarin, heparin, antidepressants
replace missing clotting factors or administer antidiuretic
desmopressin acetate (DDAVP) after surgery, tooth
extraction or accident
Aplastic anemia
- Body stops producing enough new blood cells

Findings: petechiae, bruising, pallor, fatigue, headache,

myelosuppression
- Mgmt.
Corticosteroids (for granulocyte production)
Antibiotics (for infection)
Androgens (stimulate bone marrow)
Remove causative agent
Bone marrow transplant, transfusion, hemorrhagic
precautions
Hemophilia
- Grp of bleeding disorders where there is a deficiency of onefactor
needed for blood coagulation
- X-linked recessive
- Findings: mild severe prolonged bleeding, most often in muscles
and joints (hemarthrosis), long term loss of range of motion
- Diagnostic partial thromboplastin time (PTT)
- Management: replacement of missing clotting factor,
descompression acetate (DDAVP)( an antidiuretic that aids blood
clotting) , prophylactic tx with clotting and pressure to bleeding site
- Nursing intervention: prevent bleeding that may occur as result of
trauma
Disseminated intravascular coagulation (DIC)
- Disorder of coagulation clotting followed by bleedin
- Fibrin deposition in blood vessels causes obstruction and necrosis
- Findings
Bleeding, bruising petechiae
Altered serum levels of cloting related factors (increased PT,
PTT decreased plts, degraded fibrinogen)
- Management
Factor replacement
Platelets, fresh frozen plasma, RBC transfusion
Vitamin K
Oxygen

Neurological
-

Parkinson disease
- due to decrease in dopamine levels
- mental function is still intact
- Findings:
Resting tremors, bradykinesia/akinesia, fatigue, drooling
T- tremors, R- rigidity, A- akinesia/bradykinesia, P- postural
instability (TRAP)
- Meds:
Anticholinergics minimize extrapyramidal effects
Dopamine hydrochloridergics and agonist
MAO inhibitors

Huntington disease

Progressive atrophy of basal ganglia and some parts of cerebral cortex

Findings: involuntary movement and decline cognitive function
- Effects chewing, decline in speech, memory loss, personality
changes and depression, chorea (jerky movements)
Meds: psychotropic agents to manage cognitive changes

Amyotrophic lateral sclerosis (ALS, Lou gehrigs)

-

Neurological disease in which progressive degeneration of the motor

neurons of the anterior horn cells of the spinal cord, brain stem and motor
cortex causes muscle weakness, disability and eventually death
Findings: muscle wasting, speech disorders, death due to respiratory
failure, cognitive remains intact
Meds: muscle relaxants and riluzole (neuroprotector)

Dementia
-

Antipsychotics, mood stabilizers, serotonin-affecting drugs, stimulants

Findings: difficulty naming objects (agnosia), language disturbance
(aphasia), difficulty with motor activities (apraxia)
Drugs that inhibit the breakdown of acetylcholine in the brain

Cerebrovascular accident (CVA, stroke, Cerebral infarction)

-

Decreased blood supply to the brain

Five classes of stroke
- Transient ischemic attach (TIA) angina
Warning sign of stroke short term
- Reversible ischemic neurological deficit (RIND)
Symptom last for 24 to 3 week
- Non progressing stroke
Some damage
- Progressing stroke
Neurological status is effected
- Complete stroke
Permanent neurological deficit
Two types of strokes
- Ischemic (occlusive) stroke slower onset
Inadequate blood flow leads to thrombosis or embolism
Leading causes due to atherosclerosis
Pharmacologic
o Thrombolytics, anticoagulants, antiplatetet
therapy, platelet aggregation inhibitor, steroids
o Maintain MAP at 70 mmHg
- Hemorrhagic stroke (bleeding) abrupt onset
Intracerebral hemorrhagic stroke
Rupture of blood vessel in the brain can occur during
anticoagulant or thrombolytic therapy
Subarachnoid hemorrhage (SAH)
Rupture of saccular intracranial aneurysm

Epidural bleeds
Cerebral arterial vessel and loss of transient
unconsciousness
Subdural bleeds
Veins involved take months to be evident
o Pharmacologic
Antihypertensive agents, systemic
steroids, osmotic diuretics,
antifibrinolytic, anticonvulsant
ICP treatment
- Elevate the head of the bed 15-30
- Monitor respiratory status
- Maintain body temperature
- Limit fluid to 1200 ml/day
- Avoid straining activities
Changes in ICP
Altered LOC, headache, abnormal respirations, rise in
blood pressure, slowing pulse, elevated temperature,
vomiting, pupil changes, changes in motor function
Observe for herniation syndrome
Irregular breathing/pulse, loss of brainstem reflexes
(blinking, gagging), respiratory arrest, cardiac
Meningitis
- Acute or chronic inflammation of the meninges
Bacterial, viral, or fungal
Findings: severe headache, sudden high fever/chills, changes
in LOC, petechial rash
Positive kernigs sign = 90 flexion of hip/knee extension of
knee causes pain
Positive Brudziski sign flexion of neck causes flexion of hip
and knee
Nursing
Provide care for ICP, seizure,
Parameningeal infections
- Localized collection of exudate in the brain or in the spinal cord
- Findings: headache, fever, stiff neck, decrease in LOC
Encephalitis
- Inflammation of the parenchyma of the brain or spinal cord
Findings: sudden fever, severe headache, changes in LOC, flu
like symptoms
Botulism
- Acute flaccid paralysis due to bacteria in food
Findings: blurred vision, diplopia, lethargy, vomiting and
dysphagia (weakness of difficulty speaking)

Multiple sclerosis
- Demyelination of white matter throughout brain and spinal cord

Findings: blurred vision, dysphagia, diplopia, muscle weakness,

tremor, incoordination, cognitive issues, loss of bowel control,
urinary retention
- Pharmacologic: adrenocorticotropic hormone (ACTH), beta
interferon
Prevent injuries from difficulties of walking, prevent
complications of immobility
Guillain-Barre syndrome (postinfectious polyneuropathy)
- Autoimmune peripheral neuropathies resulting in symmetric and
ascending motor paralysis, an acute condition death can occur
due to respiratory distress
- Findings: muscle weakness, leads to paralysis of voluntary
muscles, respiratory failure, paralysis
Prevent complication of paralysis until it is reversed
Immunoglobulin therapy and morphine
Provide ventilator support to maintain respiratory
status
Myasthenia gravis (MG)
- Autoimmune disorder causes progressive weakness and
exhaustibility of voluntary muscles without atrophy/sensory
disturbance
- Findings: muscle weakness, sensation remain intact, Facial is
effected(weak smile, diplopia, swallowing disorders, weakness of
facial muscles)
Pharmacologic : immunosuppressants, anticholinesterase
agent, corticosteroid therapy
Myasthenic crisis : due to stress or infection sudden
inability to swallow and difficulties with breathing
- Cholinergic crisis
Caused by overdose of pyridostigmine result in increased
acetylcholine
Profound weakness, GI distress, Respiratory failure
Stop anticholinesterase agent and restart gradually
Epilepsy : chronic disorder of abnormal recurring, electrical discharge
-

Partial Seizures
Focal motor, client remains conscious
Simple partial
o Motor finding, autonomic findings, no loss of
conscious
Complex partial
o Psychomotor seizure, impairment of
consciousness
Generalized seizures both hemispheres
Absence petit mal
Less than 10 sec loss of consciousness and blank
starring
Myoclonic

Sudden uncontrollable jerking movements in

morning

Clonic
Violent bilateral muscle movements
o Hyperventilation, face contortion, salivation,
tachycardia
Tonic
Loses consciousness and muscle contract bilaterally
Opisthotonos position, jaws clenched, pupils dilated
and unresponsive
Less than a minute
Tonic clonic (grand mal) most common type
Movements bilaterally
Last 2 to 3 mins
Incontinent bowel/bladder unresponsive for 5 mins
Disorientation / confusion
Atonic sudden loss of postural muscle tone with collapse
Status epilepticus
Rapid sequence of seizures without interruption
Medical emergency
Postictal state
Due to stop of maintenance anticonvulsant
Severe organ and muscle hypoxia
Pharmacologic
o Benzodiazepines (active seizures),
anticonvulsants, barbiturates, succinimides
Contusion bruising on the surface of the brain
Intracerebral- bleeding directly in the brain tissue; secondary to invasive
skull trauma
Epidural damaged artery b/w skull and dura mater risk of death
- Loss consciousness lucid LOC drop quickly in 24 hrs
Subdural damaged veins b/w subdural space secondary to closed head
injury
- Acute 24 to 74 rapid neurologic deterioration
- Subacute 72 to 2 week will slower progression
- Chronic gradual clot formation minimal deterioration

Head injury complication s

- Cerebral edema
Increased intracranial pressure
- Diabetes insipidus (DI)
Decreased release of ADH and body excreting too much fluid
Low specific gravity due to increase urine output acute
phase
- Stress ulcer
Due to gastric ischemia and vasoconstriction

Syndrome of inappropriate antidiuretic hormone (SIADH)

Too much ADH
Water retained urinary output decreased urine specific
gravity increased chronic phase
- Seizure 6. Infection 7. Hyperthermia/hypothermia
Neurogenic shock
- Imbalance in the autonomic nervous system lead to hypotension,
bradycardia, change in mental status, lower body temperature

Cardiac Disease
-

Antianginal agents
- Nitrates (i.e. nitroglycerin)
Relaxes vascular smooth muscles through vasodilation
Tx: angina given 3 dose w/ 15mins
S/E: severe hypotension, dizziness, edema, flushing
Contraindications: Sildenafil (viagara), hypovolemia,
hypotension, heart failure, increased ICP
Nursing: alcohol intoxication can occur, avoid tolerance by
having nitrate free period
- Isosorbide
Vasodilation by relaxing arterial muscle
Tx: prevent acute attack and angina pectoris
Maintance therapy for angina, CAD
- Beta-adrenergic blocking agent beta blocker
Ex: Atenolol, metoprolol, propranolol
Slower heart rate, decreased vasoconstriction heart failure,
hypertension, migraine headache prophylaxis
S/E: bradycardia, bronchospasm, hypotension
Most common: fatigue, dizziness, constipation,
depression, impotence, disorientation, weakness,
nausea
Dont give to cardiogenic shock, AV block, bronchial asthma,
thioridazine
May hide symptoms of hypoglycemia or cause asthma
symptoms
Taken at bedtime
- Calcium channel blocker
Amlodipine, diltiazem, verapamil
Use: hypertension, angina, arrhythmias
S/E: hypotension bradycardia, AV block, heart failure
Monitor BUN, creatinine, liver enzyme
Avoid Grapefruit and older clients
Change position slowly can cause dizziness
Anticoagulants (i.e. warfarin)
- Prevents the formation of clots
- S/E: hemorrhage, purple toe syndrome, bruising

Contraindication: pregnancy, hepatic or renal disease

Antidote : Vitamin K
Avoid alcohol, NSAIDs, green tea, licorice, ginseng, spinach,
broccoli and onions
- Look at PT and INR, liver enzyme tests
Low molecular weight (LMW) heparin (i.e. dalteparin, enoxaparin)
- Affecting thrombin or prothrombin used prophylaxisly
- S/E: hemorrhage, thrombocytopenia, epidural/spinal hematoma
- Contraindication: sensitive to pork products, active bleeding
- Doesnt effect PT, INR, aPTT levels
Unfractionated heparin
- Prevents fibrin formation, prevent clot formation in DVT, DIC, PE
- S/E: heparin induced thrombosis (HIT)
- Nursing: monitor aPTT, blood count, platelets
- Antidote: protamine sulfate
Antiarrhythmic agents
- To tx premature ventricular contractions
- Sodium channel blocking
Ex: Lidocaine, quinidine gluconate
Tx: ventricular and supraventricular arrhythmia
S/E: ventricular fibrillation, seizures, hypotension,
bradycardia, pruritus
Contraindication: AV block, myasthenia graves
Nursing: avoid citrus juice, antacids and milk products
- Beta blockers
- Potassium channel blocking agents
Use: ventricular arrhythmia
Ex: amiodarone, sotalol
Protect skin and eye from UV rays
- Anticholinergic agent
Ex: Atropine (i.e. every 3 to 5 mins)
Use: bradycardia
S/E: anaphylaxis, heat stroke,
Headache, dry mouth, insomnia
- Acetylcholine potassium current activator
Use on supraventricular tachycardia
S/E: bradycardia, ventricular fibrillation, heart block
Bronchospasm, flushing, dyspnea, chest pressure,
nausea, lightheadedness
Antihypertensive agents
- Use for heart failure and hypertension
- S:e orthostatic hypotension, tachycardia, bradycardia, dizziness,
weakness, sexual dysfunction, nausea, vomiting, diarrhea
- Contraindications: severe deficiencies in serum electrolytes,
hypovolemia
- Nursing: monitor potassium, fluid, renal function
Change position slowly
- Angiotension-converting enzyme (ACE) inhibitors
Ex: enalapril, Lisinopril

Use hypertension or heart failure inhibits angiotension 1 or

11 conversion leading to vasodilation and lower bp
S/E: steven-johnson syndrome, angioedema of head, cough
Dont give in pregnancy - teratogenic
Taken on empty stomach
ACE can lower WBC so watch for infection
Monitor for cough or hypotension or angioedema
Avoid electrolyte fortified food: can cause hyperkalemia
Angiotension II receptor blockers (ARB)
Release aldosterone to block vasoconstriction
Ex: Iosartan, Valsartan
Use hypertension and heart failure
S/E: angioedema, hyperkalemia
Dont give in pregnancy teratogenic, hyponatremia
Avoid food with potassium
Beta blocker and calcium blocker
Alpha-adrenergic blocking agents
Ex: phentolamine
Use hypertension crisis, extravasation necrosis
prevention/treatment
S/E: myocardial infarction
Tachycardia, weakness, dizziness, hypotension, nasal
congestion
Alpha-blocking agents
Ex: prazosin, terazosin, tamsulosin
Use for hypertension, benign prostatic hypertrophy (BPH)
S/E: angioedema, hypotension
Dont take with amiodarone
Alpha-agonist
Ex: clonidine
Use hypertension, cancer pain
S/E: dry mouth, drowsiness, dizziness, sedation, orthostatic
hypotension, weakness, constipation
DONT give with MOAIs and beta blocker

Respiratory anatomy & physiology

-

Increased hydrogen level (acidosis) lead to increased respiratory

rate/volume
Neutral pH level 7.4 (7.35 7.45)
Maintain pH through CO2 (35-45) (rapid) in lung and in renal through
HCO3 (22-26) (slow)
Arterial blood gases
- 1. Compensated v.s. uncompensated (based normal pH limits)
- 2. Acid or alkaline (based on pH value)
- 3. CO2 (respiratory) or HCO3 (metabolic)

pH

HCO3

PaCO2

(< 7.35)

(> 26)

(> 45)

respirator
y alkalosis

(> 7.45)

(< 22)

(< 35)

metabolic
acidosis

(< 7.35)

(< 22)

(< 35)

metabolic
alkalosis

(> 7.45)

(> 26)

(> 45)

respirator
y acidosis

Rhinitis
-

Nasal congestion, itching, sneezing due hay fever or infection, allergy

S/S: nasal drainage, congestion itchiness, watery eyes, fever, headache
Drugs: antihistamine, decongestant, NSAIDs
- Fluids, salt water, vit c, zinc

Sinusitis
-

Inflammation of paranasal sinuses due resp. infection, underwater

swimming, defects of nose

S/S: frontal headache, fever, tooth pain, malaise, tenderness in sinus area
Fluid intake, hot shower, nasal irrigation (saline)

Upper airway obstruction partial or complete

-

Medical emergency due to aspiration/trauma/laryngeal edema

S/S: stridor, restlessness, inability, tachycardia, pallor, cyanosis
hypoxemia can lead to cardiac arrest

Pharyngitis
-

Inflammation of mucous membranes of pharynx

S/S: scratchy throat, worsened by swallowing redness or patchy white or
yellow exudates
Increase fluid intake of cool and bland liquid

Tonsillitis and adenoiditis

-

Inflammation of tonsils
S/S: sore throat, fever, difficulty swallowing, foul smelling breath
(halitosis), ear infection
Post-op
- Position prone and head to side
- Hemorrhage or airway obstruction
- Semi-liquid diet 48 to 72 hr postoperative

Peritonsillar abscess
-

Complication acute tonsillitis or pharyngitis spread to surrounding

tissues
S/S: inability to swallow saliva, hot potato muffled voice, fever, increase
WBC, swelling

Lower respiratory system obstructive

Chronic obstructive pulmonary disease (COPD)
-

Asthma

Chronic irreversible airway obstruction slow exhalation

Emphysema alveoli enlarge and loses elasticity and decrease capacity of
vital gas exchange
Chronic bronchitis inflammation of bronchioles
- Cor pulmonale RT heart failure
S/S: dyspnea, sputum production, cough, barrel chest (increase
anterior/posterior diameter)
Medication:
- inhaled bronchodilator: albuterol/ipratropium
- corticosteroids prednisoe
- expectorants guaifenesin
- oxygen saturation around 90%
- avoid extreme temperatures

absence of wheeze may indicate absence of airflow need emergency

respiratory care
Medication
- Long acting
inhaled corticosteroids (ICS) fluticasone/beclomethasone
Salmeterol, tiotropium
- Short acting rescue
SABA albuterol inhaler or nebulizer or corticosteroids

Restrictive Respiratory disorder

-

Intrapulmonary restrictive conditions lung or pleura effected

- Lung expansion restricted lung tissue collapse due to fluid leading
to (pneumothorax, hemothorax, pleural effusion, empyema)
- Pulmonary fibrosis lung stiffening
S/S: Dyspnea, non productive chronic cough, crackles, nail
clubbing
- Sarcoidosis granulmoas in the lung as well heart
S/S: asymptomatic, chest pain, cough
- Corticosteroid therapy, immunization (risk of pneumonia)
Lung tissue collapse
- Pleural space abnormally occupied by air or fluid reduced lung
capacity
Pneumothorax air in the pleural space
Open (hole in chest wall), closed (hole in lung tissue),
tension (rapid accumulation of air increase pressure)
o compress the heart cardiac tamponade
(pulseless electrical activity) EMERgency
crepitus air in subcutaneous space
vocal fremitus (99) increased over area of
consolidation
chest tube treatment
o semi-fowler (pneumothorax), high-fowler
(hemothorax)
o Water seal (2 cm), Suction (20 cm)
o Report drainage at 100 ml, bright red, free
flowing
o Less than 150 ml drained within 24hr remove
chest tube
Pleural effusion fluid (transudate or exudate)
Hemothorax blood in pleural space
Empyema purulent drainage in pleural space
Chylothorax white lymphatic fluid
S/S: worsening respiratory distress asymmetrical chest
movement, tachycardia, chest pain, cyanosis
Extrapulmonary restrictive conditions lung are normal, respiratory
muscle weakness/compression of chest well
- Neuromuscular myasthenia gravis, guillain-barre, polio, sclerosis

CNS impair due to brain injury

Guillain barre syndrome due to immunization, HIV, infection
Motor paralysis an acute condition, fatal if respiratory
muscle
S/S: tingling sensation in extremites, ascending paralysis
begins lower extremities, pain, weakness of respiratory
muscles
Pneumonia
- Pleuritic chest pain, crackles, egophony, whispered pectoriloquy
(indicating consolidation), SOB, respiratory acidosis
SARS
- Droplet
Pulmonary embolism
- Bed of the arteries hypoxemia due to blood clot, fat, amniotic
fluid, air
- S/S: dyspnea, low oxygen saturation, pleuritic chest pain,
impending doom
Acute respiratory distress syndrome (ARDS)
- Pulmonary edema or acute injury
- Ill appearance, restlessness, anxiety
- Oxygen therapy is not effective causes hypoxemia and respiratory
acidosis
- Mechanical ventilation
Cor pulmonale
- Right heart failure develops due to sustained lung resistance in
COPD
- S/S: fatigue, tachypnea, dyspnea, cough, chest pain
Restrict fluid intake
Respiratory failure
- PaCO2 > 50 mmHg
- PaO2 < 60 mmHg
- Three Hs hypoventilation, hypoxemia, hypercapnia
- Control anxiety
- 10 to 15 liters of oxygen via non-rebreather mask

Bronchodilators
-

most effective are short acting beta adrenergic (SABA)

xanthines (effect CNS and prevents inflammatory)
- Ex: aminophylline, theophylline (5 to 15 mcg/ml)
- Used for COPD and asthma
- S/E: dermatitis, nausea, vomiting, headache, insomnia, irritability,
restlessness
Dont give if seizures, heart failure, hepatic issues, cor
pulomonale
- Avoid caffeine
Anticholinergic
- Bronchodilation and decreased secretion
- Ex: ipratropium bromide , tiotropium

Uses for COPD or asthma

S/E: anaphylaxis, angioedema, cough, nervousness
A- anorexia, B-blurry vision, C-constipation, D-dry
mouth, S-sedation
- Dont use for rescue therapy or acute spams, rinse mouth
Mucolytics (nebulizer)
- Mobilizes secretion
- Ex: acetylcysteine
- Tx pulmonary complications, bronchopulmonary disease, Tylenol
overdose
- S/E: unpleasant odor, hypersensitivity, stomatitis
Dont give if cough, GI bleed
Expectorants
- Liquefies respiratory secretion
- Ex: guaifenesin
Tx chest congestion
- S/E: nephrolithiasis, rash, vomiting
- Avoid dairy and caffeine
Benzonatate reduces cough no effect on CNS S/E: sedation, headache,
pruritus, rash, constipation, confusion, dizziness
Dextromethorphan cough suppression no effect on CNS
- S/E: serotonin syndrome, dizziness, drowsiness, fatigue
Dont give if on MOI or child under 6
Antituberculars
- Ex: isoniazid (i.e. tingling, take on empty stomach), rifampin (i.e.
reddish orange body fluid and avoid soft contacts), ethambutol,
streptomycin (first line)
Ethionamide, pyrazinamide, cycloserine
- S/E: hepatotoxicity, optic neuritis, aplastic anemia,
thrombocytopenia, peripheral neuropathy
- Avoid alcohol, tyramine (protein as food ages Ex: aged cheese,
cured meat, smoked fish) and histamine (Ex: tuna, yeast extract)
- Take vit B6
- Latent for 9 to 12 months
- Active 6 to 9 months
- No longer able to transfer TB after 2 to 3 weeks on drugs
Anti-inflammatory agents
- Glucocorticoid (steroid)
S/E: nasal septal, nasal ulcer, nasal irritation, headache,
nausea, lightheadness, epitaxis (bleeding from nose)
Can cause Thrush and blood glucose testing
Use bronchodilator first then use the steroid inhaler
Mast cell stabilizer
- Prevents histamine allergic rhinitis
- Ex: cromolyn nasal S/E: sneezing, nasal burning, epitaxis
Leukotriene receptor antagonist
- Stop bronchospasm and airway edema tx asthma, exercise
induced bronchospasm
- Ex: zafirlukast, montelukast

S/E: angioedema, anaphylaxis, churg-strauss syndrome, hepatic,

aggressive
- Give after meal
- Report finding : jaundice, dark urine or stool
Antihistamine
- First generation
Block the effects of histamine
Ex: azelastine nasal blow nose before taking it
S/E: bitter taste, headache, nasal buring, dry mouth,
dizziness, nausea
Dont take with alcohol
Monitor respiratory system congestion and drowsiness
- Second generation
Block mast cell and histamine
Ex: loratadine, fexofenadine, desloratadine, cetirizine
S/E: hepatotoxicity, severe hypotension drowsiness, fatigue,
abdominal pain, headache, dry mucous
Avoid alcohol and CNS depressents
Decongestant
- Stimulates SNS Causing vasoconstriction of nasal mucus reduces
nasal congestion
- Ex: tetrahydrozoline, oxymetazoline
- S/E: can cause arrhythmias or angina sneezing, restlessness,
elevated BP, lack of sleep
Dont give for CDV, MAO inhibitor, diabetes
- Client upright position
Oral decongestants
- Ex: Pseudoephedrine hydrochloride
S/E: insomnia, nausea, dizziness, anxiety, tremor, urinary
retention
- Dont give if urinary retention, CDV, diabetes, MAO inhibitor
- Stop taking if restlessness
Nicotine withdrawal: headache, fatigue, drowsiness, irritability, severe
cravings
Nicotine toxicity: hypotension, dyspnea, abdominal issues, blurred vision,
tinnitus
- No nicotine for cardio ppl
- Patch apply daily and rotate site
- Chew gum slowly for 30 mins
- NOOO smoking

RPN can collect data but cannot evaluate it

Pneumonia -> Improve Secretion
-

Maintain fluid, teaching coughing (huff coughing- most effective),

ambulation, fowler position (45-60 degree)

Endotracheal tube auscultate the lung sounds for the placement of tube

Obstructive sleep apnea

-

Partial or complete airway obstruction during sleep

- Common symptoms: frequent periods of sleep disturbance,
snoring, daytime sleepiness, difficulty concentrating,
forgetfulness, mood changes, morning headache
- Intervention: continuous positive airway pressure, limit
alcohol, weight loss, avoiding sedating medication
- Ex: medication modafinil shouldnt taken at bedtime as it
will cause insomnia
Sedative at bedtime can relax ur muscle making it
difficult to breath

Respiratory failure

PaCO2 greater than 50mmHg increase leads to respiratory acidosis

PaO2 less than 60mmHg
Paradoxical breathing inward movement of the chest on inspiration and
outward movement on expiration
Change in mentation status
Silent chest and absence of wheezing
Single word dyspnea

Allen test
-

When doing ABG to ensure patency of ulnar artery through allen test

Pursed-Lip breathing technique

Bronchoscopy
-

Post-op
- After the procedure : No smoking, gargle with salt water and low
grade fever
- Notify HCP if chest, cough or frank blood sputum, shortness of
breath

Hyperpnea increased depth breathing

Cheyne stokes respiration alternating b/w apnea (no breathing) and tachypnea
(fast breathing)

Kussmauls breathing deep labored breathing during metabolic acidosis

Biot respiration quick shallow respiration
Retraction physical sinking of the chest wall muscles with respiratory difficulty (in
children

Genitourinary
BPH
-

Enlargement of prostate, impedes urine flow

Findings: difficulty stopping or starting stream; stream smaller than usual,
frequency, dribbling; nocturia
Management if symptomatic
- Antihypertensives (to relax smooth muscles in prostate and
bladder)
E.g. prazosin, doxazosin, terazosin
- Hormonal manipulation to decrease prostate size + urinary
changes (dribbling etc)
E.g. finasteride
- CAM: saw palmetto
- Balloon dilation
- Surgery : transurethral resection of prostate (TURP), open
prostatectomy
Complications
- UTI, urinary retention, hydronephrosis (distention of kidneys due to
obstruction in flow of urine), gross hematuria
Nursing
- Assess for post-void residuals and take I+O
- Post op surgical tx: maintain continuous bladder irrigation system
with normal saline, Kegels exercises

Cystocele (Female disorders)

-

Bladder herniates into vaginal canal

Findings:
- Asymptomatic early on
- Pelvic pressure
- Changes in frequency, urgency, stress incontinence, cant empty
bladder
- Frequent UTI
Mgmt
- Postmenopausal women estrogen replacement therapy
Nursing
- Assess for hx of obs trauma, abdo surgery, menopause, estrogen
therapy
- Pain
- Bulge from vagina when standing upright or bearing down
- Post op 6 weeks of pelvic rest

Pelvic Inflammatory Disease (PID)

-

Infection of cervix up to fallopian tubes and broad ligaments

Causes: STDs, IUDs, hx of multiple sexual partners, hx of therapeutic
abortion
Findings
- N/V, acute abdomen
- Cervical bleeding and tenderness and abnormal discharge
- Fever and pelvic pain
- Dysuria, frequency
Mgmt
- Antibiotics, analgesics
- Drain abscess
Complications
- Ectopic pregnancy
- Infertility
- Sepsis and rupture of abscess
Nursing
- Assess for hypotension, hypovolemia, fever
- Restore fluid balance

Endometriosis
-

Endometrium tissue gorws in cysts at diff sites throughout pelvis and / or

abdo wall
More in white vs Africanamerican women
Findings
- Pelvic pain before/during menstruation
- Dyspareunia (pain during sexual intercourse)
- Painful defecaion
- Abnormal bleeding (uterine, hematuria)
- Infertility
Mgmt
- Pharm: OCs, danazol (to atrophy endometrial tissue), leuprolide
acetate (reduces pain/lesions), progestins
- Laparoscopic surgery
- Hysterectomy
Nursing
- Bleeding in uterus, pain pelvis and during intercourse and
defecation

Urinary Tract Infections

-

Findings
- Dysuria (painful urination), frequency, urgency, nocturia,
suprapubic pain
- If kidney involved, then hematuria
Mgmt
- Uncomplicated infections
Co-trimoxazole (1st line)
Quinolones

Nitrofurantoin
- Complicated: IV, oral antimicrobials
Complications
- Pyelonephritis
- Sepsis
Nursing
- Assess hx of UTI, voiding and hygiene habits, hx of vaginal issues
- Manage pain
- Prevention: to females, void after intercourse and wear cotton
underpants
- Nutrition: increase water intake, avoid carbonated and caffeinated
fluids

Renal calculi (kidney stones, renal lithiasis)

-

Causes: hypercalcemia, hyperuricemia, high purine diet (meats, yeast),

chronic dehydration,
Epidemiology: more in men, aged 20-30, and in those with prev hx of 2+
stones
Findings
- Severe pain
- Increased hydrostatic pressure
- Renal and ureteral colic (pain)
- With obstruction stones block urine flow signs of UTI
with fever and chills
- GI issues n/v/d

Mgmt
- Pharm: diuretics to prevent calcium stones and control
hypercalciuria
Allopurinol (prevent calc stones)
Opioids, abx
Complications

Obstruction from fragments, infection from bacteria, chronic

impairment of renal function
Nursing
- Assess for family hx of kidney stones and UTIs
- Increase fluid intake and maintain urine flow
- Increase intake of foods high in calcium; calcium
supplements should be avoided (can incr risk of stones)

Acute kidney injury

-

Abrupt loss of kidney fx retain urea and other nitrogenous waste

products and dysregulation of volume and electrolytes
Phases :
- Oliguric/anuric : <500 mL/24h
- Diuretic phase: > 500 mL/24h and no longer rise in serum BUN and
creatinine
- Recovery: several months to one year/ more likely to leave scar
tissue remnants / loss of renal function usually not clinicaly
significant
Findings
-

Mgmt.
- Discontinue all nephrotoxic drugs
Ex. Aminoglycosides, ACE inhibitors, NSIADs
- post renal causes are obstructing from kidney due to: tumors,
neurogenic bladder, prostatic hypertrophy.
- Tx Life threatening issues:
IV fluids
Control potassium: calcium, glucose, sodium polystyrene
sulfonate (controls hyperkalemia)
Restore calcium levels (low calcium levels)

- Hemodialysis
Complications
- Infection, arrhythmias due to hyperkalemia, electrolyte imbalance,
multiple organ system failure, GI bleed due to ammonia
Nursing intervention
- Monitor 24hr urine, neurologic function
- Regulate protein intake offer high carbohydrate options
- Restrict foods in high potassium, phosphorus and sodium

Chronic kidney disease

-

Progressive, irreversible deteroration in renal function

- Causes uremia (blood poisoning due to renal waste building up in
body)

3. Findings
System

Findings of Chronic Renal Failure

Respiratory

Pulmonary edema, pleural effusions, pleural rub

Cardiovascular

Hypertension, hyperkalemia with subsequent EKG changes,

pericardial effusion, tamponade

Neuromuscular

Sleep disorders, headache, lethargy, peripheral

neuropathies, seizures, coma

Metabolicendocrine

Hyperlipidemia, decreased libido, impotence, amenorrhea,

glucose intolerance

Acid-base

Water retention, metabolic acidosis, hyperkalemia,

hypocalcemia, hypermagnesemia, hyperphosphatemia

Gastrointestina
l

Anorexia, nausea, vomiting, gastric, ulcerations and/or

hemorrhage

Blood

Anemia from decreased or no erythropoietin production,

increased bleeding, platelet defects

Skeletal

Renal osteodystrophy, osteomalacia from decreased serum

calcium levels

Skin

Pruritus, uremic frost, hyperpigmentation, ecchymoses,

xerosis, half-and-half nails

Psychosocial

Changes in cognition, behavior, personality

Elevated creatinine, potassium, phosphorus, BUN

Decreased bicarbonate, calcium, protein (albumin)

Tx hypertension ACE inhibitors, angiotensin II receptor blockers

Lower cholesterol: statins
Anemia epoetin (erythropoietin)
Reduce swelling diurectics
Protect bones: calcium and Vit D
Nutrition
- Low protein, low salt food, restrict potassium/phosphorus (i.e.
chicken, milk, legumens, carbonated drinks)
Dialysis

Mgmt

Nursing intervention
-

Hemodialysis fistula for thrill and bruit

Watch for nutritional status, neurologic status, peripheral edema
Implement seizure precautions

Chlamydia
-

Most common sexually transmitted disease bacteria

Findings: silent epidemic
- Women asymptomatic lower abdominal pain, burning pain,
vaginal discharge
- Men no symptoms discharge from penis, pain from urination,
infection of testicles
Do nucleic acid amplification test (NAAT) for females
Mgmt:
- Azithromycin, doxycycline
Complication:
- Women pelvic inflammatory disease, chronic pelvic pain, ectopic,
infertility
- Men sexually reactive arthritis, swelling of testes
Nursing intervention
- Check yearly if sexually active for women

Gonorrhea
-

Most common and oldest STD

Findings:
- Women: asymptomatic itching/burning, thick yellow-green
discharge, sore throat, rectal pain
- Men pain during urination, yellow penile discharge, sore throat,
infection of prostate gland
Mgmt
- Cephalosporins
Complication: meningitis, arthritis
- Women: Pelvic inflammatory disease, ectopic pregnancy, infertility

- Men: may develop sexually acquired arthritis, testicles, epididymitis

Nursing intervention
- Pap smears and pelvic examination

Syphilis
-

The greater impostor can mimic other infections chronic STD

Findings:
- Primary phase: sore (chancre) at the site of infection
- Secondary phase: 4 -10 weeks appearance of chancres fever, joint
pain, muscle aches, headache, rash, patchy hair loss
- Latent (dormant) phase 1 year or more after first chancre with
occasional relapses back
- Tertiary syphilis 4 -20 years after primary phase, cardio issues or
neurological issues
Mgmt
- Penicillin drug of choice, tetracyclines
- Prognosis: first 2 stages, most ppl are cure with abx
Nursing
- Abstain from sex until cleared
- Follow up testing

Genital herpes (Virus) HSV2

-

Findings
- Clustered painful vesicles or ulcers on / around genitals or rectum
- Mild lymphadenopathy
- Reactivation can be due to stress, infection, pregnancy,
sunburn
Prognosis: chronic, life long viral infection
- Recurrent genital sores
- Pregnant woman with active genital lesions may need c
section b/c can be fatal to newborn and fetus
Nursing
- Avoid tight clothing

Genital warts
-

Caused by HPV, highly contagious, most sexually transmitted disease

Findings
- Flesh coloured or grey growths on/around genitals / rectum
- Mostly painless bumps, itching, discharge
Mgmt
- HPV vaccination (Gardasil)
- Tx cryotherapy, laser tx, electrodessication
- Prognosis no single effective cure or tx
Nursing
- Tell them that this disease is FOREVER IN YOUR BODY

Hep B
-

More infectious than HIV or HCV

Incubation time (exposure to onset of sx) is 6 wk to 6 months

Can be self-limited or chronic
Findings
- Half of them have no sx
- Anorexia, fatigue, n/v, itching , liver area pain, jaundice, dark
urine and pale stools
Mgmt routine vaccination
- If acute, then tx is supportive
- If chronic, suppress hep b replication and remission of liver disease
Prognosis most improve, others become chronic, get cirrhosis,
LIVER CANCER, liver failure, death
Nursing
- Transmission teaching dont share toothbrushes, razors, cover
open cuts/scrapes, clean blood spills with bleach

HIV
-

Depletes CD4 lymphocytes

When CD 4 < 200cells/uL, then at risk for AIDS and other opportunistic
infections
Transmission : bodily fluids (blood, semen, vaginal, breast milk)
Findings
- Can be asymptomatic for >10 years
- May take up to 6mo after exposure to test +ve
- Commonly: no energy, wt loss, fever, sweats, persistent skin
rashes / flaky skin, short term memory loss, mouth, genital,
anal sores (from herpes infections)
- When CD4 count < 200,
Cough, SOB
Seizures and lack of coordination
Difficulty and painful swallowing
Mental sx confusion, forgetful
n/v/cramps/severe + persistent diarrhea
neck stiffness
Kaposi sarcoma : malignant tumour of endothelium lining
heart, blood vessles, lymphatic system, serous cavities.
Benign if limited to skin
PCP (penumocysticis carinii pneumonia)
Mgmt
- Antivirals
- Postpexposure prophylaxis for HCPs after exposure to body
fluids/sharps injury
- Pneumocystis trimethoprim/sulfamethoxazole
- HAART (highly active antiretroviral therapy) combo of at least 3
antiretroviral drugs at attack different parts of HIV or stop entry
Nb: HIV is a reportable drug
Nursing

Standard precautions wear gloves, eye and face protection if

performing aerosol generating procedure or contact with resp
secretions
Initiate airborne if cough, fever, pulmonary infiltrate
PPE if splashing of bodily fluids

Family planning
-

Three common methods for fertility

- Calendar method
- Basal body temperature charting
- Cervical mucous method
- Combined they are known as symptothermal method
Mechanical barriers diaphragm, condom, cervical cap- use with
spermicides
Hormonal contraceptives birth control pill (progestin or
(estrogen/progestin)),
- morning after pill
taken 120 hrs after sex for progestin (2 pills))
combined oral pills 2 pills 72 to 120 after sex than 12 hrs
again
Effected by rifampin, St John wort and anti seizures meds)
Can cause 24 hr vomiting and nausea or breast tenderness
Before pregnancy and during first trimester give folic acid at 400 mcg
and if iron deficiency take 1 mg/day
Morning sickness due to human chorionic gonadotropin (hCG) test for
pregnancy
- 6 day in blood
- 26 days in urine

Risk factor for pregenacy

-

Age of under 17 (anemia) or over 35 years old (diabetes/high BP)

Weight (less than 100 pounds), and height (less than 5)
Infection, disorders, 5 or more pregnancies
Potential teratogens
- Medications, including isotretinoin (used to treat severe acne),
some anticonvulsants, lithium, some antibiotics (such as
streptomycin, kanamycin, and tetracycline), thalidomide, warfarin,
and angiotensin-converting enzyme (ACE) inhibitors

First trimester
-

Fertilization to 12 weeks
- Able to know the sex of the child
Findings of pregnancy
- Presumptive/possible subjective/objective findings
Nausea/vomiting, skin, basal body temperature
- Probable signs observed

Chadwick sign bluish purple hue of the cervix, vagina and

vulva
Hegar sign softening of the uterine isthmus
Goodell sign cervical softening due to stimulation from
estrogen/progesterone
- Positive
Presence of fetus heart tones, visualization, fetal movement
Rh factor
- If mother (Rh -) and father (Rh +)
Give immune globulin(RHoGram) (given at 24 to 28
weeks)
If negative (indirect) coombs test woman can be given
RHoGAM
Dont give if
(Rh +) women
Women (Rh -) had baby (Rh -)
positive indirect combs test for Rh negative women
ultrasound to confirm date
Nursing:
- Naegels rule
1st day of last normal period + 7 3 months + 1 year
- Breast tenderness firm/supportive bra
- Fatigue rest and balanced diet and iron
- Nausea small meal dry crackers avoid fired foods
Watch out for bleeding, pain, long period of vomiting, high temperature,
exposure to infection

Second trimester
-

Palpate fetal outline using leopold maneuver

Ultrasound Doppler fetal heart rate ( 12 to 14 weeks)
Fundus check
Chromosomal check
Diabetes screening (24 to 28 weeks)
Amniocentesis
Watch out for:
- Heartburn, bleeding gums, leg cramps, constipation
Warning signs
- Bleeding, pain, unrelenting N/V, pulse rate, fever, sudden weight
gain (>4lbs)

Third trimester
-

Fundal height, fetal assessment, kick counts

fetal heart rate
- full term 120 160 bpm
- During contraction increase/decrease by 30 bpm
- Should decrease at end of contraction if it doesnt warning sign
Pelvic examination
Look for generalized edema

- Preeclampsia ( pregnancy induced hypertension)

Five things that effect the process of labour and delivery
1. Passenger presentation of fetus (cephalic (head) or breech (no
head)), position, size of fetus
2. Passage (birth canal)
3. Power (contractions)
4. Placenta
5. Psychology
Signs of early labour
1. Braxton-Hicks contractions - irregular uterine contractions / may
come and go
2. Dropping of the baby, blood show, nesting instinct (burst of
energy), weight loss, backache, upset stomach
Left Lateral position for sleeping on the left after birth
Four stage of labour
1. First stage
Dilating stage (cervix at 10 cm)
Latent (early) or prodromal (primipara (8hrs) and
multipara (4-5hrs)
o 30 to 45 sec contraction and frequency (5 to 20
min)
o Dilation 0 to 3 cm
o Bloody show
o Mother able to talk and walk
Active or accelerated (primipara (4hrs) and multipara
(2hrs)
o Contraction stronger (45 to 60 sec) and
frequency (3 to 5 min)
o Dilation to 4 to 7 cm
o Mother in not able to walk and need
encouragement
Transient or transitional (10 to 15 mins)
o Contraction sharp (60 to 90 sec) and frequency
(2 to 3 min)
o Dilation 8 to 10 cm
o Increase in bloody show
o Mother has urge to push
Epidural can be given at the is stage up to 4 cm, watch for
respiratory distress monitor fetal and mother (initial for 5
min every 30 mins)
Signs are: headache, shivering, backache, nausea
2. Second stage (primipare (30 to 50mins) and multipara (20mins))
Delivery or expulsive stage complete dilation to birth
Crowning, delivery of head, anterior shoulder, trunk
Clamping and cutting umbilical cord
Imminent sign
Bloody show, bear down, bulging of perineum, dilation
of anal orifice

Impending signs
Nausea, irritability, severe discomfort
3. Third stage (5 to 30 mins)
Placental stage birth of baby and delivery of placenta
Placental separation
o Uterus becomes globular in shape, rises in
abdomen, sudden gush of blood
4. Fourth stage (1 to 2 hrs after birth)
Recovery
Delivery of placenta to uterus no longer tends to relax
Prevent hemorrhage due uterine atony, cervical or vaginal
lacerations
Massage fundus if boggy
Ice to perineum area
Give oxytocic (stimulates uterine contraction), try
breastfeeding, void within 1 hr
Mechanisms of labour
1. Engagement, descent, flexion
2. Internal rotation
3. Extension
4. External rotation
5. Expulsion
Normal active labour progresses for primipara is (1.2cm) and multipara
(1.5cm)
Safest time to give analgesics when woman is dilated b/w 4 to 7 cm

Normal Postpartum
-

birth to 6 weeks
1. fundus (above umbilics on day 1) moves downward (firm grapefruit
decrease to nonpalpable in 10 days), lochia (minimal clots),
perineal healing
2. estrogen and progesterone decrease
3. oxytocin and prolactin (milk production) increase
Maternal Postpartum assessment BUBBLE-HE
1. B Breast
Nipples, tissue, temperature, colour
2. U- Uterus
Location mildline or deviated
Tone firm or boggy
3. B- bladder
Last time emptied
4. B bowel
Last bowel movement
Flatus and hunger
5. L lochia
Colour, amount, presence of clots free flow of lochia
Rubra (red) 1 to 3 days
Serosa (pink to brown) 3 to 7 days

6.

7.
8.
9.

Alba (creamy white) 10th day

E Incision (episiotomy
Type and tissue trauma
Assess REEDA ( Redness, Edema, Ecchymosis,
discharge, approximation)
L/H Legs (homans sign)
Pain, varicosities, warmth
Pedal pulses
E emotions
B bonding (taking in phase)

High temperature in first 24 hours may due to dehydration

After 6 hours apart after 24 hours for 2 day may be infection

Newborn assessment
-

Direct coombs test for newborn to assess if RH positive

Appearance lanugo, milia, mottling
Apgar (0 to 10)
1. 8 10 = normal
2. 5-7 = mild depression stimulate the baby or provide oxygen
3. 3-4 = moderate depression = provide oxygen and feeding tube to
decompress
4. 0 -2 = severe depression life support

Temperature (36.6 to 37.7)

Heart rate (110 to 160 BPM)
Blood pressure (50 to 75 mmHg)
Respirations (30 to 60 per min)
Reflexes
1. Rooting head to side when cheek touched = stops by 3 to 4
months
2. Extrusion touch/depress tongue causing it to be forced outward stop 4 month
3. Babinski/plantar grasp disappear by 12 to 18 months
4. Moro or startle reflex sudden jarring stop by 2 months
5. Stepping reflex 3 to 4 weeks
Bilirubin levels
1. Jaundice after first day
15mg or greater (term)
10 mg or greater (preterm)
Initial weight loss 10% within first 10 days

Growth and development

-

Cephalocaudal head to tail

Proximodistal near to far
Differentiation simple to complex activities/function

Infancy (1 month to 12 months)

-

Double the birth weight and triple by 1 year

Posterior fontanel closes at 6 to 8 weeks
Anterior closes at 12 to 18 months

Sit without by 6 to 8 months

Rolls at 6 month
Vocalization at 8 months
Pincer grasp at 9 to 11 months
Crawling at 6 to 7 months
Stands alone 10 to 12 months
Walking at 12 to 15 months

1. Primary care- Prevent

2. Secondary care - Screen
3. Tertiary care Treat
Percussion sounds
-

Dullness over solid organs

Flatness over muscles
Hyperreasonance presence of trapped air (lung)
Resonance lung
Tympany space containing air stomach

Hearing test
-

Weber test vibrating tuning fork midline of the skull/face (bone

conduction only)
1. Normal hearing when tone produced by the tuning fork sounds at
the same volume in each ear
Rinne test compares sound conduction of air (more) v.s. bone (less)
1. Latter (auditory canal) sound should be heard twice as long as that
of mastoid sound

Right-sided heart murmurs are louder on Inspiration. Left-sided heart murmurs

are louder on Expiration

Abdomen assessment
-

Ascites fluid filled belly associated with liver failure

Paralytic ileus no motility in bowel after abdominal surgery
Borborygmus stomach growling
Inspect -> auscultation -> percussion -> palpation

Musculoskeletal
-

Kyphosis curving of the spine bowing of the back leading to hump

back
Lordosis sway back
Scoliosis curve of spin sideways (away from midline)
1. Uneven shoulders, curve in spine, uneven hip

Cranial nerves
On Old Olympus Towering Tops A Fin And GermanViewed Some Hops
(S=sensory, M=motor, B=both): Some Say Marry Money But MyBrother Says Big Business Makes
Money
Motor nerve function

Psychosocial intergrity
-

Congnitive behavioral therapy (CBT)

1. Person thoughts control their behaviour tx involves replaces the
current thoughts with ones that produce a more desirable outcome
Behavioural theory
1. Through use of positive and negative reinforcement unacceptable
learned behaviour can be replace with more desired behaviour
2. Used to treat phobias, sexual dysfunction and eating disorder
3. Involves assertiveness training and desensitization
Kubler-Ross Five stage of Grief
1. Denial
2. Anger
3. Bargaining
4. Depression and withdrawal
5. Acceptance

Focus on actual objective behaviour, description, share information and

explore alternatives, focus on how and what, ask opened question
1. Dont ask why
2. Dont offer solution
3. No subjective inferences

Aphasia
-

Global aphasia most severe cannot read, write, and understand speech
Broca aphasia (non-fluent) limited mainly to short utterances of less than
four words and limited writing but able to understand speech/read
Wernickes aphasia (fluent) inability to understand then meaning of
spoken words, reading and writing able to speak but speech is not
consistent
Ask yes and no questions

Clients Post-CVA
-

Come from side of intact field of vision

Ask client to turn head in direction of visual loss to make up for loss of
visual field
Tell client about objects near them and put items near them
Reorient to 3x

Client with dementia

-

Be calm and unhurried

Dont ask client to make decisions and avoid distractions
Use orientation techniques

Anxiety disorders
-

Excessive fear and anxiety and related behavioural disturbances can

include panic disorder or generalized anxiety disorder
Findings
1. Frequent worry or tension for at least 6 months
2. Problem concentrating, fatigue, irritability, restless sleep,
restlessness, upset stomach, sweating, difficulty breathing
Tx talk therapy and antidepressants, anxiety, beta blockers,
benzodiazepines
Nursing: provide distracting activities, use relaxation techniques

Bipolar & Related disorders

-

Person has episoders of depression and periods of being extremely happy

or being cross and irritable and extremely happy
1. Episodes of depression are more common than mania
Findings:
1. Manic easily distracted, little need for sleep, poor judgment,
reckless behaviour, lack of control, racing thought, talking a lot,
false beliefts about self or abilities, very involved in activities
2. Depressive daily low mood or sadness, difficulty concentrating,
eating problems, fatigue or lack of energy, feeling worthless, loss of
pleasure in activities
Tx:
1. Medication:
Mood stabilizers, antidepressants, atypical antipsychotics,
electoconvulsive therapy (ECT)
Nursing intervention
1. Prevent suicide
2. Mania
Offer high protein, high calorie, supplements
Set limits on manipulative behaviour
Positive reinforcement
Reduce stimuli
Bipolar and related disorders are characterized by mood swings;
depressive episodes are more common than mania.
Know the therapeutic lab values for the mood stabilizer, lithium
carbonate (Lithane): 0.8 to 1.2 mEq/L; overdose symptoms may include
nausea, vomiting, diarrhea, drowsiness, muscle weakness, tremor, lack of
coordination, blurred vision or tinnitus.

Depressive disorder
-

Presence of sad, empty or irritable mood somatic/cognitive changes

Findings
1. Agitation, restlessness, irritability, anger, lack of energy, fatigue,
loss of interest, self-hate, sudden change in appetite thoughts of
death and suicide, trouble sleeping

2. Can have hallucinations and delusions

Medications:
1. Antidepressant
Talk therapy
1. Cognitive behavioural therapy teach how to fight off negative
thoughts
2. Psychotherapy help to understand the issues that may be behind
the thoughts and feelings
Electroconvulsive therapy (ECT)
Light therapy for seasonal affective disorder
Avoid natural remedies John wort

Feeding & Eating disorders

-

Persistent disturbance of eating leading to altered consumption or

absorption of food
1. Anorexia severe malnutrition, low potassium level, heart problems
and confusion
Severely limiting food intake, cutting food into small pieces,
refusing to eat, exercising all the time, depression, dry
mouth, sensitivity to cold, muscle wasting
Tx antidepressants, group therapy, family therapy, support
groups
2. Bulimia nervosa constipation, dehydration, dental cativies,
electrolyte imbalance, hemorrhoids, tears of esophagus
Eat large amout of food of high calorie foods, usually in
secret, forced vomiting, excessive exercise, dry mouth,
Russell sign small cuts and calluses on the tops of
finger joint (due to making urself vomit)
Tx stepped approach CBT, support groups, nutritional
therapy
Antidepressants
3. Nursing intervention
Improve self-esteem,

Neurodevelopmental disorders
-

Produces impairements of personal, social, academic or occupational

functioning
Autism spectrum disorder
1. Difficulties in pretend play, social interaction, verbal and nonverbal
communication
Attention deficit hyperactivity disorder (ADHD)
1. Inattentiveness, hyperactivity, impulsivity

Obsessive compulsive related disorders

-

An anxiety disorder in which people have unwanted and repeated

thoughts, feelings, ideas, sensation (obsessions) or behaviour that make
them feel driven to do something (compulsion)

Cause a great amount of anxiety

1. Tx: antidepressants trcyclic, SSRI, antipsychotics, mood stabilizers

Personality disorders
-

Enduring pattern of inner experience and behaviour that deviates

markedly from the expectations of the individual culture
Findings: act witty and charming, good at flattery, break the law,
manipulating others, lie, steal and fight often
Protect client and others from harm, provide structure

Schizophrenia spectrum and other psychotic disorders

-

Lifelong condition that makes it hard to think clearly, to the difference b/w
real or not real to have normal emotional responses and to act normally in
social situations
1. Leads to delusions, hallucinations, disorganized speech, flat affect
Early symptoms irritable, tense feeling, trouble concentrating, trouble
sleeping
Later symptoms involve thinking, emotions/behaviour. Isolation,
problems paying attention. Delusions. Loose associations
Antipsychotic
1. Typical and atypical
2. Give antiparkinsoism agent to counteract the extrapyramidal side
effects (tardive dyskinesia)
Build trust, be honest, dependable

Substance-related and addictive disorders

Though the clients statements are not typical of logical communication, the second
and third remark contain elements of the preceding sentence (moon, walk).
Neologisms refers to making up words that have personal meaning to the client.
Flight of ideas defines nearly continuous flow of speech, jumping from one
unconnected topic to another. Word salad refers to stringing together real words
into nonsense sentences that have no meaning for the listener.

Nutrition and Hydration

-

Fluid needs
1. 6 to 8 wet diapers per day for baby
2. Infant need 2.2 gm/kg/day protein
3. Breast milk for 1st 6 months of life and milk around 1 year
Pre-pregnancy add 400 ug/day folic acid
Pregnancy add per day 300 calories, 15 mg iron, 30 g protein, 400 g
calcium, 400 folic acid for 1st trimester
Lactation add 500 calories and 2 quarts extra fluid per day
3500 kcal = 1 lb

Carbohydrates
1.
2.
3.
4.
5.

Sugars, starches, and fibers (cellulose)

Simple sugar most easily metabolized
Starches are most complex
Excessive carbohydrate calories are stored as fat
Functions:
Quickest source of energy (4 kcal/gram)
Main source of fuel for brain, peripheral nerves, WBC, RBC
Protein sparer
50 to 60% of total calories of daily intake

Lipids
1. Lack of it leads to problems with skin, blood and arteries
2. Functions:
Most concentrated source of energy ( 9 kcal/gram)
Insulation, cell membrane ,
Carries fat soluble vit A, D, E and K
Total fat intake shouldnt exceed 30% of daily calories and
saturated fat not exceeding 10% of total daily caloric intake
Proteins
1. Amino acids
2. 8 essential amino acids not produced by body
3. Function:
Secondary energy source = 4 kcal/gram
Only source of nitrogen
0.8 g per kg of body weight per day
Vitamins
1. Body cant synthesize vitamins
2. Types:
Water soluble
Vit c, b complex ( thiamin, riboflavin, niacin,
pantothenic acid, biotin, B6, folate, B12)
Cant be stored- daily intake required
Excess is eliminated daily little risk of toxicity
Fat soluble
A, D,E, K
Stored in liver and adipose tissue
Minerals
1. Inorganic substances essential as catalyst in biochemical reactions
2. Regulation of acid-base balance and heart muscle respond
3. Major minerals
Calcium, magnesium, sodium, potassium, phosphorus, sulfur,
chlorine
4. Trace minerals
Iron, copper, iodine, manganese, cobalt, zin
Water
1. 60 to 70% of total body weight and (70 to 75% of total body weight
of children)

2. Require 2 to 3 liters a day

Sodium
1. Low level cause mental confusion, hostility, hallunications
2. High levels cause hypertension or generalized edema called
anasarca
Potassium
1. High/low can lead to fast or slow heart rhythm or muscle with
results of cramping in abdomen or legs
Calcium
1. Hypercalcemia
Due to: hyperparathyroidism, metastasis of cancer, paget
disease, prolonged immobilization
Signs/symptoms: weakness, paralysis, decreased deep
tendon reflexes
2. Hypocalcemia
Due to: rickets, vit D deficiency, renal failure, pancretitis,
chelation therapy, hypoparathyrodism
S/S: muscle tingling, twitching, tetany
Magnesium
1. Hypermagesemia
Due to: chronic renal disease, antacid Maalox/Mylanta,
Addison disease, diabetes
S/S: lethargy, nausea, vomiting, slurred speech, muscle
weakness, paralysis, decreased deep tendon reflexes
2. Hypomagnesemia
Due to: malnutrition, toxemia in pregnancy, malabsorption,
alcoholism, diabetic acidosis
S/S: mood irritability, cardiac irritability, muscle tingling,
twitching, delirium, convulsions

Aldosterone
-

Decrease in sodium (ECF) or increase in Potassium

1. Increase reabsorption of Sodium
2. decrease reabsorption of potassium
leading to increased blood volume

Renin/angiotensin effect reabsorption of water in renal

Atrail natriuretic peptide (ANP) effect reabsorption of water in renal
Parathyroid
-

release calcium from bone

when calcium is low PTH increase
When calcium is high PTH falls
High Vit. D inhibits PTH
Low magnesium increases PTH
Low calcium high phosphorus
High calcium low phosphorus

Diabetic diet
-

50-60% carbohydrates, 20-30% fat and 10-20% protein

Carbohydrate is a key component

Stop hypertension (DASH) diet

-

Sodium reduction and eating food rich in potassium, calcium and

magnesium
DASH diet 2,300 mg sodium/day
Lower Na DASH diet 1500 mg sodium/day
Low in saturated fat, cholesterol and total fat

Low protein diet

-

For renal disease such as pyelnophritis, uremia, kidney failure

Limit protein to less than 40 g/day (0.5 g/kg/day)
Restricted food
1. Meats and other food high in protein (legumes, fish, dairy)

High protein diet

-

Condition for burns, anemia, malabsorption syndrome, ulcerative colitis

High protein supplement sustagen
More protein than 60 g/day (1.5 g/kg/day)

Low purine diet

-

Prevent uric acid stone for client with gout

1. Gout diet
High complex carbohydrate, low in protein
Restrict:
1. Glandular meats, gravies, fowl, anchovies, beer and wine

Low calcium diet

-

Limit to 400 mg per day instead of 800 mg

Restrict:
1. Dried fruits and vegetables, shell fish, cheese, nuts

Acid ash diet

-

Prevent kidney stone formation

Restrict:
1. Carbonated beverage, dried fruits, banana, figs, chocolate, nuts,
olives, pickles

Gluten free
-

Sensitivity to gluten in wheat, oats, rye and barley

May eat rice, corn and millet products

Low cholesterol
-

To reduce high cholesterol levels

Normal amount of cholesterol intake 250 to 300 mg/day

Restricts egg, beef, liver, lobster, ice cream

High fiber
-

To correct constipation, prevent diverticulitis, lower risk of colon cancer

30 to 40 gram fiber/daily

Low residue
-

For diarrhea, acute diverticulitis

Reduce fiber intake, canned fruit, refined carhodyrates, pasta, strained
vegetables
Increase ground meat, fish, broiled chicken w/o skin, white bread

Gastric tube
-

Head of bed at 30 degree for abt 1 hr afterward to prevent aspiration

Assess stoma for signs of infection
Flush tube with 30 ml every 4 hrs
Limit infuse to 8 hrs and changing tube every 24 hrs

Orthostatic hypotension
-

Change position slowly

Highest risk is from supine to standing postion

Increased cardiac workload

-

Avoid bearing down (Valsalva maneuver)

Minimize coughing
Limiting sitting in high fowler position to 1 2 hrs

Thrombus/emboli formation
-

Apply stocking or intermittent pneumatic compression devices

Turn every 2 hrs
Assist with dorsiflexion and plantar flexion of the foot
Limit sitting with feet in dependent position to 1 2 hrs

Mechanical aids
-

Crutches provide support for people that have weight bearing

restrictions

1. Keep tips of crutches 8 to 12 inches to side of feet

2. Adjust length to 3 to 4 fingers width from axilla
3. Adjust handbars to allow for 15 to 30 degree elbow flexion
Cane relieve pressure on weight bearing joints
1. Handle at level of greater trochanter elbow flexed at 30 degree
angle
2. Hold to close to body and on stronger side
3. Move cane at same time as the weaker side
Walker support, stability and balance for people without weigh bearing
restrictions
1. Client must be strong enough to pick up walker and move forward
2. Dont allow client to place hands on the walker from sitting position
Gait belt
1. Over client clothing
2. Safety device

Urine : Minimum 30 ml/hr

Bowel : no more than 3 movement per day to 3 times a week
Diarrhea: 3 or more loose stool per day
Urinary incontinence
-

Stress sudden increase in pressure (sneezing, coughing) causes urine to

leak
Overflow (reflex) bladder empties incompletely urine dribbles
constantly
Urge uncontrolled contraction of the bladder results in leakage of urine
Functional impaired mobility may prevent the client from reach the
bathroom in time
Tx:
1. Antispasmodics and anticholinergics relax/increase capacity of
bladder
2. Alpha-adrenergic increases urethral resistance
Reversible causes of urinary incontinence D.R.I.P
1. D delirium
2. R- restricted mobility ( or retention)
3. I infection
4. P pharmaceuticals (or polyuric states)

Catheterization
-

Only irrigated when an obstruction

1. After prostate or bladder surgery when blood clots are anticipated

Ileostomy
-

Semi-formed stool
Effect potassium and sodium levels
Digestive enzyme in stool irritate skin
Dont give laxatives
Lavage can be done to clear food blockage

Colostomy
-

Ascending semi-liquid stool

Transverse semi-formed stool
Loop stoma
1. Proximal end functioning stoma
2. Distal end drains mucous
3. Usually temporary
Double barrel
1. 2 stomas
Sigmoid
1. Formed stool
2. May be irrigated
Nursing assessment
1. Colour stoma will always stay red
2. Edema common after surgery for 48 to 72 hrs
3. Bleeding some after 48 to 72 hrs

Theories of pain
-

Specificity theory pain can be initiated only by painful stimuli

Pattern theory stimulus goes to receptors in the spinal cord signal to
perceive pain
Gate control theory pain impulses can be altered or regulated by gating
mechanism along nerve pathways how past and present experiences
can influence the perception of pain

St John wort
-

Interact with a lot of drugs

Makes drugs less effective digoxin, cycolosporine tamoxifen, high active
antiretroviral therapies and combined oral contraceptives

No massage for phlebitis, thrombosis, varicose veins, diabetes, pitting edema

Pediatrics
- Cardio
-

Congenital heart defects

1. Findings: child small for age, physiological failure to thrive, exercise

intolerance, dyspnea while feeding, squatting position, clubbing
finger, cyanosis
Increase workload, pulmonary hypertension, cyanotic defect,
thrombus w/ embolus
Acyanotic defect pink but may become cyanotic
1. Hole in heart internal wall
Increased pulmonary blood flow
Atrial septal defect (ASD)- asymptomatic or mild heart
failure (Right heart effected) (systolic murmur)
Ventricular septal defect (VSD) into the lungs
Patent ductus arteriosus (PDA) asymptomatic during
infancy, mild HF, increased pulse, dyspnea, bounding
rapid pulse on exertion
Decreased pulmonary blood flow
Coarctation of aorta
Aortic stenosis
Pulmonary stenosis
o Increased BP in head and arm and lower in
feet/legs, exercise intolerance, narrowing of
pulmonary artery, asymptomatic or mild
cyanosis
Cyanotic defect usually is blue but child may appear pink
1. Unoxygenated blood mixes with oxygenate via right to left shunt
2. Can be due to decreased pulmonary bold flow
3. Also due to mixed blood flow ( transposition of the great vessels)
Cyanosis, cardiomegaly
4. 4 main defects
Tetraology of fallot, truncus arteriosus, tricuspid atresia,
transportation of the great vessels
Heart failure
1. S/S: cyanosis, pallor, rapid respiration, increased respiratory
infection, tachycardia, edema, fatigue, feeding difficulties, poor
weigh gain
2. Cardiac catheterization
Post procedure diaper rash can occur
Difficulty with correct position post procedure
3. Improve cardiac function, remove accumulated fluid, decrease
cardiac demands, improve tissue oxygenation
4. Position : slanting position with head elevated
Older babies in infant seat or knee-chest position

Pediatric respiratory
-

Respiratory distress syndrome

1. due to lack of protective substance called surfactant prevent air
sacs from collapsing
2. S/S: tachypnea, increased respiratory effort, paradoxical seesaw
respiration, nasal flaring, substernal retractions, expiratory grunt,
cyanosis, hypnoxa
Bronchopulmonary dysplasia (BPD)
1. Chronic lung condition that requires the newborn to be on a
ventilator
2. S/S: tachycardia, tachypnea, increased work of breathing, pallor,
cyanosis, restlessness
3. Watch out for pulmonary edema and respiratory assessment
Apnea
1. Breathing stop for 20 secs
2. Types:
Central absence of respiratory effort and air movement
Obstructive respiratory effort but no air movement
Mixed first central then obstructive
3. S/S: child may appear to stop breathing, changed colour or become
limp apparent life threatening event (ALTE)
Respiratory failure
1. Inability to maintain adequate oxygenation
2. S/S: restlessness, mood changes, changes in LOC, increase rate of
RR/pulse
3. If apneic rub the trunk or pat gently
Post op tonsillectomy
1. Assess for frequent swallowing due to bleeding risk
2. Assess any vomitus
3. Place child on side

4. Avoid fluid with red, brown or acidic

5. Soft food
6. Recovers takes 1 to 2 week, no school for 7 to 10 days and no
exercise/swimming for 3 weeks
Croup syndrome (laryngitis, trancheitis, epiglottitis)
1. Airway blocking infections
2. Edema narrows the airway
3. S/S: barky harsh cough, stridor, hoarsenss, fever, purulent
secretion, dyspnea if severe, child looks sicker
Epiglottitis four Ds
Drooling
Dysphagia (difficulty swallowing)
Dysphonia (hoarse voice)
Distressed inspiratory effort

Pertussis life threatening complication Tdap vaccine is given to pregnant

females b/w 27 to 36 weeks. One dose only
-

HPV cant be given due to live virus

MMR cant be given since it can cause miscarriage can be only given
after postpartum or 4 weeks before pregnancy
Influenza nasal spray cant be given due to live virus
1. But IM injection is fine

Late decelerations occurs after the onset of a uterine contraction and continue
beyond its end
-

This due to uteroplacental insufficiency

This is fixed by:
1. Giving oxygen via facemask
2. Repositioning client right or left
3. Oxytocin stopped
4. IV fluid bolus given

Acceleration and moderate variability is normal it is when the wave is upwards

Naegele rule of expected birth is = last menstrual cycle 3 months + 7 days
-

If LMP in January, February, or March then birth will occur the current year

Fetal heart rate (FHR) 10 to 12 weeks

Urination frequency common symptom during first trimester
Empty bladder before checking uterine growth (I.e. fundus)

Fetal movement at (18 to 20 weeks primigravida) and (14-16 weeks in

multigravidas)

Hyperemesis gravidarum disorder that causes pregnant clients to have severe

nausea and vomiting
-

Cause fluid and electrolyte imbalance, nutritional deficiencies, ketonuria

and weight loss
Signs of dehydration, low blood pressure, urine specific gravity (>1.030)
and blood urea nitrogen (>20mg/dl)

Abnormalities in newborn
-

Normal head is 32 to 37 cm anything low or high is abnormal

Jaundice
Not voiding in 24 hours
Nasal flaring, chest wall retraction and grunting signs of respiratory
distress

Preeclampsia hypertension and multisystem disorder that occurs at 20

weeks of pregnancy
-

Causes proteinuria and hypertension

Headache and visual changes
Eclampsia (on set of seizure, coma) to grand mal seizures
1. Monitor seizure using deep tendon reflex
Leads to HELLP syndrome (severe form of preeclampsia)
1. Hemolysis, elevated liver enzyme, low platelet count
Epigastric pain, nausea, vomiting
But no proteinuria or hypertension
Use magnesium sulfate ( 5 to 8) to treat seizure
1. Reverse the effects using calcium gluconate

2. Can cause respiratory distress, low urine output (< 30ml/hr), no

tendon reflex (earliest sign)
Suction the client and side lying position
Delivery of the child only treatment

Oxytocin Is used to induce labour however it can reduce placental blood flow
leading to irregular non reassuring FHR this leads to need for emergency
caesarean birth
-

Oxytocin increases the risk for

1. Postpartum hemorrhage
2. Placental abruption
3. Uterine rupture
Monitor for:
1. FHR pattern
2. Contraction pattern
3. Vital signs hypotension
4. Intake and output water intoxication hyponatremia/seizure
5. Cervical dilation after membrane rupture stop oxytocin
Uterine hyperstimulation 5 contraction in 10 min or resting tone more
than 20 mmHg
1. Reassuring pattern of FHR
Side lying positon/bolus of IV fluid
Consider oxytocin dose
2. Non reassuring pattern of FHR
Late deceleration, fetal bradycardia, tachycardia, decreased
variability
Stop oxytocin
Side lying position
Apply oxygen 10 L/min via face mask

IV fluid bolus
Consider terbutaline

Circumcision:
-

After 24 hours yellow exudate occurs and dark red dont remove this
normal healing process
1. Redness, swelling, odor and discharge indicate infection
2. If bleeding greater than a quarter also a worry

Diabetic mother put the child at risk for hypoglycemia or hypocalcemia

-

Newborn hypoglycemia is blood glucose less than 40 mg/dl

1. S/S: jitterness, irritability, hypotonia, apnea, lethargy and
temperature instability

Normal neonatal heart rate is 120-160

-

Tachycardia signs of sepsis, respiratory distress, congenital heart

abnormality
Bradycardia possible sign of sepsis, increased ICP, hypoxia

Apgar score = 7 to 10 normal

-

Taken after birth 1 min and 5 mins

If score less than 7
1. Recheck every 5 up to 20 mins
2. Score at >7 (no intervention), 4 to 6 (supportive or
resuscitative), <3 (need resuscitative)

Supine hypotensive syndrome compression of vena cava due to weight

leading to:
-

S/S: Hypotension and tachycardia, dizziness, pallor, cold and clammy skin
Tx: reposition to right or left side
1. If supine place a wedge under the client hip

Opoid can be given during the active phase of stage 1

-

Before giving it:

1. The vital signs have to be stable
2. Fetus heart rate 110 160
3. Well established labor contractions
4. Cervix dilated to 4 to 5 cm in primipara and 4 cm in multipara
No more than 3 doses due to ceiling effect
Precipitate withdrawal in opioid dependent client so give then epidural

Monitor for maternal hypotension

Deep tendon reflexes (DTR) is monitored during the administration of

magnesium sulfate to reduce seizure activity in preeclampsia/eclampsia
-

Normal DTRs are 2+ ( scale of 0 -4)

Leopold maneuver is palpation of abdomen to identify the positon of fetus

Single Transverse crease : Extends across the palm of the hand and is a classic
sign of down syndrome

Prolapse umbilical cord lies below the presenting part of the fetus
-

Fetus is at risk of occluded circulation

1. Need caesarean section
Position client in knee chest or Trendelenburg position
Sterile glove hand remain in the vagina to prevent it from occuluding
Provide oxygen and IV fluids

McRobert maneuver used to straighten the sacrum used for shoulder dystocia
Green amniotic fluid indicates the presence of meconium
-

Meconium aspiration syndrome could occur require immediate care

Vaginal hematoma trauma to perineum during delivery during use of

forceps, vacuum assisted birth or episiotomy leading to severe vaginal
bleeding, pain and feeling of fullness

Uterine atony boggy uterus and deviated to right indicates distended

bladder
-

Leading to excessive postpartum bleeding

1. Thus ask person to urinate to correct the bladder distention
2. Then uterine massage
3. Then oxytocin
Due to:
1. Uterine overdistension
2. Uterine fatigue (prolonged labour)
3. Grand multiparity
4. Uterine relaxants or anesthesia

During pregnancy should avoid:

-

Smoked seafood, unpasteurized milk, unwashed fruits and vegetables, deli

meat, hot dogs and raw fish/meat avoid caffeine and fish high in
mercury

During pregnancy white blood count increase to 5000 15000

Blood glucose abnormal If over 140 mg/dl
Leaking amniotic fluid is test through nitrazine paper test
-

If the pH is 7 to 7.5 and turns blues it indicates presence of amniotic fluid

It is positive during active labour

Boggy uterus should massage the fundus to prevent blood loss after child birth
-

After birth uterus is b/w symphysis pubic and umbilicus

Bisphophonates decrease bone resorption

-

Take in morning on empty stomach and 30 mins before other drugs

Full glass of water

Stay upright for 30 min prevent esophageal irritation

Postpartum endometritis infection

-

Fever, chills, uterine tenderness and foul smelling lochia

Uterus (hegar) Cervix (goodell) Vagina (chadwick)

Braxton contraction at 6 weeks

Placenta previa placenta is implanted over or very near the cervix risk for
hemorrhage
-

Get client type and screen

Biophysical profile 1x or 2x a week
Asymptomatic client cesearean birth planned after 36 weeks
1. If bleeding done immediately
Bed rest and pelvic rest
No corticosteroids after 34 weeks of gestation

M indicate multiple gestation

NSAIDs should be avoided during pregnancy
-

Category C until 29 weeks

Category D at 30 weeks become dangerous for the fetus

Knee chest position during episode of hypoxia and cyanosis in infants with
tetralogy of fallot (TOF)
Hypovolemic shock (hemorrhage) due to ectopic pregnancy
-

Dizziness, hypotension, tachycardia, decreased urinary output less than

30ml/hr
Due to blood pooling can lead to shoulder pain

Bishop score rate the inducibility of cervix score less than 8 indicate labor
induction will be successful (vaginal birth)
-

Cervix is scored (0,1,2, or 3)

1. Consistency
2. Position
3. Dilation
4. Effacement
5. Station

Heart rate less than 60 do chest compression

Breast self examination
-

Should be done 5 to 7 days after menstrual cycle end

Oral contraceptive should perform it when they start a new pack
Same day each month

From JP in first 24 hours 80 to 120 ml drainage is expected

Inflammatory breast cancer aggressive form of cancer
-

Breast tissue the becomes red, warm, has orange peel (peau dorange)
and pitting appearance

Drug not to give during pregnancy

-

Doxycycline , isotretinoin, Iisinopril (ACE inhibitor), NSAIDs

Constipation during is pregnancy is common

-

Tx: excerise, water intake, vegetables and fruits and bulk forming fibre
(psyllium)
1. Avoid laxatives as it can lead to preterm labour and dehydration
2. Avoid coffee during pregnancy

Breastfeeding
-

On demand
8 to 12 times a day
15 to 20 mins per breast

Nasal stuffiness, epistaxis (nosebleeds), deepening of voice, fullness in ears and

earache, copious/clear vaginal discharge are common during pregnancy
Deep vein thrombosis (DVT) check for redness, tenderness or warmth in calf
High temperature and WBC and incisional discomfort are common after first 24hrs
of birth

Mastitis common infection in postpartum

-

Frequent drainage of milk

Every 2 to 3 hours breastfeeding

Cleft palate risk for aspiration and inadequate nutrition due difficulties with eating
-

Upright position
Point down and away from cleft
Special bottles and nipples
Burped often
Feed slowly over 20 to 30 mins
Feed every 3 to 4 hours

Sudden infant death syndrome

-

Prevent by:
1. Firm surface
2. Avoid soft objects
3. Avoid bumper crib pads
4. Avoid overheating

5. Use pacifier
6. Breastfeeding
7. Use sleeping sack or a thin tucked blanket
Infant assessment
-

Auscultation first palpation percussion traumatic procedures

(eyes, ear, mouth) general reflexes (grasping, Babinski moro reflex
(startle) causes the baby to wake up

2 month infant cant roll they only start at 4 months

Separation or stranger anxiety
-

Starts at 6 months
Peaks at 10 to 18 months
Reaction is normal resolves by age 3
1. More stress (then pain, injury)
3 stage
1. Protest refuse attention from other and crises
2. Despair withdraw and quiet
3. Detachment happy and building relationships
Provide calm environment build trust and connection with family
1. Favorite toy, daily schedule, calming presence, phone calls, play
activities

Failure to thrive (FTT) state of undernutrition and inadequate growth

-

Due to preterm birth, breatfeeding issues, GI, cleft palate, SES factors
Less than 80% of ideal weight so observing the child feeding is
important

Fine motor skills

-

3 months reflex grasp something placed in the hands

5 months voluntary grasp objects using the palm
7 months transfer object from one hand to another
8 10 month palamar grasp turns into crude pincer grasp
11 months neat pincer grasp
12 months turn pages of the book and stack 2 blocks
1. Cant place object into narrow openings
2. Head and chest are equal size
3. Weight is tripled
4. 6 teeth

Toddler (12 months to 3 years) - show behaviour of negativism and ritualism they
seek autonomy
-

2 years high risk of Foreign body aspiration due to food

1. Hot dogs, hard candies, whole grapes, cherries
Bowel control by 18 to 24 months (2 years) start toilet training
1. Bladder control by 2 to 3 years

2. Should be able to communicate and follow direction and pull up

clothing
Average weight gain of 4 to 6 lb 4x the birth weight
Head circumference increase by 1 in (2.5) cm during 2 years slow to 0.5
in until 5 years of age
Avoid giving options or avoid asking
Limiting opportunities that child has to say no
If child refuse dont force it wait until next meal time
1. Period slow growth
Use time outs
15 to 30 min calm down period before meals
Parallel play children play independently near another ppl
1. No group organization or common goal
2. May share toys
Emotional display (tantrums) and separation anxiety
1. Home routine is important in hospitalization to prevent regression

Preschool children (3 to 6 age) magical thinkers

-

Night fears are common

Need 11 hours of sleep at age 5

School-age year (6 to 12)

-

Need 9 hours of sleep at age 12

Bed times should be established to prevent fatigue
Growth is slowed down
Puberty start around 9.5 age
1. First sign testicular size increases
2. Then pubic, axillary hair grows
3. Height and weight is around mid puberty

3 to 4 months of life infant cry for 1 to 3 hours

-

Important to assess the pattern and frequency of crying

Pacifier can be used to calm the child down

9 year old have same understanding of death as a adult

Numerical pain scale at age of 5

ADHD children require

-

Calm, structured, organized and consistent environment

Written chart or list of daily activities

Autism limited social interaction and communication, pattern of behaviour

(restricted and repetitive)
CO-operative play develop during preschool years
PKU inborn error of metabolism can lead to irreversible neurologic damage
-

Require to be PKU diet

1. Monitor levels
2. Synthetic protein and special formulas
3. NO high protein diet (meat, eggs, milk)
4. More fruits and vegetables
Safe level (2 to 6 mg level for children under 12)
Life time dietary restrictions

Expected number of teeth (24 months)

-

Age of child (in months) 6 = expected number of teeth

By age 30 months all primary teeth (20) are there

Regression during hospitalization is normal response to stress in an unfamiliar

environment
Nocturnal enuresis involuntary bed wetting
-

Primary enuresis never had issue before

Secondary previously had a bladder issue
Tx:
1. Restrict fluids in evening, void before bed, bed alarms
2. Positive reinforcement and motivation
3. Avoid punishing, use of Pull-up
4. Ask the child to assist with wet linen
5. Awaken child to void at night
Over the age of 5 use medications
1. Desmopressin and tricyclic antidepressants (amitriptyline)

Shaken baby syndrome (SBS)

-

Bleeding within eye and brain

Vomiting, irritability, lethargy, inability to suck or eat, seziures and
inconsolable crying
Multiple SBS lead to difficulty breathing and lifelessness

6 months Be DR HIP

Hematological/Oncological
Lymphedema accumulation of lymph fluid in soft tissue due to lymph node
removal or radiation treatment
-

Client arm may feel heavy, painful and motor function can be impaired
increases the risk of infection and injury to limb
Tx:
1. Decongestive therapy (massage to mobilize fluid)
2. Compression bandaging to increase distal pressure
3. Elevation of arm level with heart
4. Isometric exercise

5. Injury prevention (limb less sensitive to temperature) NOO ice

packs
6. Infection prevention and avoiding venipunctures
Lymph nodes shouldnt be palpable
1. If is palpable it should be superficial, small (0.5 -1 cm), mobile, firm
and non tender
This normal

Enoxaparin check CBC for thrombocytopenia

Heparin check PTT
-

Therapeutic range is 1.5 to 2.0 (46 to 70 sec) times the control value - it
remain there until the infusion stops
So infiltration can lead to drop in PTT levels to control value
Low platelets increase the risk for clot formation due to HIT NOT
bleeding
Reverse heparin through Protamine
Platelets count less than 40,000 is life threatening autoimmune
stop heparin due HIT
1. Changes with LOC are emergency situation (indicates increase
bleeding and ICP)

Warfarin check PT/INR therapeutic range is 1.5 to 2.0x the control value
Brachytherapy ( internal radiation) implant of radioactive at the site of tumor
-

Tx endometrial or cervical cancer

Client emits radiation use forceps to move it
Protection:
1. Limit time to 30 mins per shift
2. Wear a radiation badge
3. No pregnant or under age of 18 in the room
4. Maintain distance of at least 6 feet
5. Pt should be in private room and keep door closed and have signs
6. Bedrest to prevent dislodgment
7. Shielding with lead wear a lead apron

Sickle cell vaso occlusive crisis (pain crisis)

-

Due to destruction of RBC cause occlusion of blood vessels

It triggered due to dehydration, infection, high attitudes, extremes in
temperature cause ischemia or damage to organs
S/S:
1. brownish urine,
2. jaundice
3. ischemia
4. severe pain
Increase in:

1. bilirubin (due to breakdown of hemoglobin),

2. reticulocytes (bone marrow)
3. acute anemia
Potassium level might be hyperkalemia due to destruction of cells
Tx: provide
1. constant opioids,
2. IV fluids for hydration,
3. bed rest
4. decrease energy/oxygen demands oxygenation
5. Low stimulating activites watching tv, reading, music , warm
soaks, gentla massage
6. Diet high protein, high calorie diet
7. Folic acid BUT not Iron

7 Warning signs for CANCER = CAUTION

-

C Change in bowel (black stool)/bladder habits (hematuria)

A a sore that doesnt heal
U unusual bleeding or discharge i.e. vagina
T thickening or lump in breast or elsewhere (hard, fixed, not soft/mobile)
I indigestion or difficulty swallowing
O obvious change in wart or mole (size, colour or shape)
N nagging cough or hoarseness (cough that lingers)
Weight loss greater than 10%
Nausea, anorexia and dysgeusia (altered taste sensation)

Megaloblastic/macrocytic anemia lack of B12 or folic acid in vegans

Microcytic anemia - Iron deficiency in elderly can be caused by GI bleeding (i.e.
colonoscopy)
-

Children due to excessive milk

Preterm babies run out of iron by 2 to 3 months ( thus need iron
supplements)
Term babies run out of iron by 5 to 6 months solid foods contain iron
fortified foods
1. Formula already contains iron

Thalassemia inadequate production of hemoglobin asymptomatic

Benign prostatic hyperplasia (BPH) is normal part of aging
Transdermal patches are placed at upper back (not at site of pain) and careful with
it so fold it in half fentanyl
Topical patches (i.e. lidocaine) are placed near site of pain and can be cut in half
Spinal cord compression due to metastatic tumor in epidural space
-

S/S: localized, persistent back pain, motor weakness and sensory changes
(numbness, paresthesia), bowel or bladder dysfunction

Alopecia (loss of hair) and ulcer/mucositis are common with chemotherapy

Iron deficiency anemia lack of dietary intake, premature birth, delayed

introduction of solid food, cow milk before age 1
-

Excessive milk intake over 24 oz/day in children common cause in client

over age of 1
Iron from mother is depleted after 5 to 6 months then child require iron
from food

Hemophilia A bleeding disorder due to deficiency in coagulation proteins no

factor VIII and hemophilia B (Christmas disease no factor IX)
-

Lead to internal/external bleeding Bleeding mostly occurs at joints and

knees
1. Avoid NSAIDs , IM injections, contact sports and safety hazards
2. Dental hygiene is important, non activities are ok (swimming),
prevent injuries
3. Medicalert bracelets
No risk of dehydration or malnutrition

Physical changes of dying person/process:

-

Coolness and paleness or mottling of extremities

A slack, relaxed jaw and open mouth due to loss of facial muscle tone
Difficulty maintaining body posture or positions
Eyelids half-open
Cheyne stokes or uneven respirations with periods of apnea
Urine output decrease and become darkened (concentrated) due to
dehydration

Hematocrit (Hct) % in of RBC in volume of whole blood (3x Hgb = Hct %)

-

Hgb carries oxygen if there is decrease in Hgb it will lead to decrease in

Hct
1. This leads to shortness of breath, tachypnea, tachycardia

Brain natriuretic peptide (BNP) increase is associated with heart failure leading to
dyspnea (shortness breathing)
Polycythemia vera (PV) bone marrow produces an abnormally high number of
RBCs
-

Secondary polycythemia can occur in an individual with chronic

hypoxemia
1. Due to chronic obstructive pulmonary disease or chronic lung
disease
Increased risk of blood clots and decreasing tissue perfusion
TX: periodic phlebotomy remove blood to reduce RBC and reduce hct
(45%)
Avoid transfusion
Drink 3 L fluids and avoid dehydration

TNF inhibitor drugs (etanercept, infliximab, adalimumab) trigger inflammatory

response of body
-

Reduce rheumatoid arthritis (RA), slow progression of joint damage

Cause immunosuppression leading to increased risk of infection
Tulerculin skin test (TST) should be done before start of drug

CRP- C-reactive protein used to detect acute or chronic inflammation in the body
-

Used in RA

Impetigo common highly contagious bacterial skin infection

-

Creates a honey colored crust

Cisplatin is an antineoplastic medication that causes renal toxicity

-

BUN indicates decreased kidney function and dehydration

Creatinine increased may indicate kidney injury
Urine output is best indicator of renal function

Pulmonary embolism postoperative at risk due to:

-

Abdominal caesarean section surgery (endothelial damage)

Engorged pelvic vessels from pregnancy (venous stasis,

hypercoagulability of blood)
Inactivity/immobility >6hrs (venous stasis)
Postpartum state (hypercoagulbility of blood)

Teletherapy (external beam radiation therapy) skin care is important to prevent

infection and promote healing
-

Protect the skin from infection by not rubbing

Cleanse the skin daily by taking a lukewarm shower
Only cream approved by HCP
Shield skin from sun
Avoid extremes in skin temperature

Chemotherapy suppression of rapidly reproducing cells and bone marrow

suppression
-

Cause low RBC, WBC, platelets

Lowest nadir count after 7 to 10 days
Destruction of tumor lead to tumor lysis syndrome an increase in
nucleic acid and metabolic products
1. The uric acid leads to kidney injury due hyperuricemia
Lead to hypocalceima, hyperphostatemia, hyperkalemia
2. Test uric acid levels ( 4 to 8.5)
Prevented through allopurionol and IV hydration
Also used to prevent gout

Filgrastim and pegfilgrastim stimulate neutrophil production

Epoetin used to stimulate RBC to prevent anemia
Mastecotomy restoring arm function is important
-

Client should be semi-fowler and elevate the arm

Flexing and extending the fingers
No blood pressure, venipuncture or injection second step

Oral mucositis inflammation or ulceration of the oral mucosa due to

chemotherapy
-

Clean mouth with NS after meal/bedtime

Soft toothbrush
Use lidocaine to reduce oral pain
Water soluble lubricating agent to moisten the mouth tissues
Avoid hot, spicy food, antiseptic mouthwash

Xerostomia (dry mouth) due to radiation therapy to head/neck

-

Chew sugar free gum and lemon juice or hard candy, ice, fruit juices
1. Increases saliva and thin thick mucus
2. Avoid anything causes dryness and thickness mucus

Infectious Disease

Red man syndrome due to rapid IV vancomycin administration

-

S/S: flushing, erythema, and pruritus (face, neck, chest), muscle pain,
spasms, dyspnea, hypotension
It is a infusion reaction not allergic
Tx: by reducing the infusion rate of vancomycin to minimum 60 mins

Anaphylaxis
-

S/S: hives, angioedema, wheezing, respiratory distress, flushing,

hypotension, light-headedness
Tx: high flow O2 via non-rebreather mask, epinephrine IM, elevate legs, IV
fluids, bronchodilator, antihistamine, corticosteroids

Rheumatic fever (RF)

-

Acute inflammatory disease of the heart occurs due to Streptococcal

pharyngitis
1. Autoimmune reaction
Effects heart, skin, joints and CNS
2 major or 1 major/2 minor with infection indicate RF

Influenza incubation 1 to 4 days and lasting up to 5 to 7 days after (illness stage)

-

Droplet protection

Vancomycin and aminoglycosides (i.e. gentamicin, tobramycin, amikacin)

-

Cause nephrotoxicity and ototoxicity (tinnitus and vertigo)

Monitor BUN, creatinine and urinary output
IV vancomycin
1. Assess skin for flushing and red rash (Red man syndrome)
2. Draw prescribed trough serum concentration levels before
infusing 4th dose
3. Infuse over 60 minutes
4. Monitor BP during infusion (red man syndrome)
5. Obsever for pain, redness, or swelling at IV site for 30 mins
6. Monitor for allergic reaction (rash, edema, wheezing)
7. Through central catheter

Oral thrush milk lesion in the mouth

-

In immunosuppressed patient
1. Taking corticosteroids (Latent TB), chemotherapy/radiation, AIDS,
prolonged high dose of antibiotic (since it reduces normal flora),
dentures, uncontrolled diabetes
Treat with oral hygiene, proper nutrition and antifungal medication
(nystatin) swish/swallow it

Systemic lupus erythematosus (SLE) autoimmune disorder chronic inflammation

of different body parts
-

Mild (skin, muscle and joints) severe (kidneys, heart, lung, blood vessels,
CNS)
Butterfly shape across the bridge of the nose and cheeks
Monitor increased

1. Creatinine
2. BUN
3. Urinalysis
To assess for lupus nephritis (kidney damage) serious
complication
4. They may also have increase erythrocyte sedimentation,
antinuclear antibody, anemia, mild leukopenia, thrombocytopenia
Tx: Hydroxychoroquine
1. Reduces fatigue and treat skin and arthritics
2. Treats inactive and mild disease take months to see therapeutic
effect
3. Adverse effect:
Retinal toxicity and visual disturbance require examination
eye every 6 months
4. Should be taken with food
Severe SLE treated through corticosteroid to prevent organ damage

C.difficile - tx through metronidazole, - severe cases use oral vancomycin

Pediculosis capitis (head lice) cant survive away from host for 48 hours
-

They live on hairbrushes, carpets, hat for 10 days

Treated with pediculicide
Nit comb for 2 to 3 day for 2 weeks
Vaccum the carpet, rugs, furniture
Bedding should be washed with hot water and dried
Non washable can be sealed in bag for 2 weeks to kill the lice
Boiling water effective at killing the lice in 10 minutes
Household pet dont transfer or require treatment

Amoxicillin/clavulanate tx respiratory infections

-

Can be taken with food or without

Nausea, vomiting, diarrhea side effects
Shake the liquid and take at evenly spaced time

Fibromyalgia abnormal central nervous system pain transmission and processing

-

s/s: chronic, bilateral muscoskeletal pain, multiple tender points, fatigue

and sleep disturbance
Tx: duloxetine, pregabalin, amitriptyline: antidepressant and pain-relieving
effects
1. Relieve chronic pain
Reduce fatigue, improves sleep

Vaccines
-

Immunocompromised shouldnt receive vaccines (corticosteroids,

chemotherapy, AIDs)
1. Live vaccines
Measles, rubella, rotavirus, intranasal influenza, yellow fever,
varicella-zoster

Allergy to vaccine components

1. Eggs, neomycin, gelatin, yeast
2. Allergy to latex (lips swell with banana, kiwis, avocados,
tomatoes, peaches, grapses)
Allergic contact dermatitis and anaphylaxis indicates allergy
to latex

Sulfasalazine sulfonamide used for RA, IBD

-

Urine and skin can turn orange-yellow this normal finding

Side effects: crystalluria (kidney injury) drink a lot of water
1. Photosensitivity and risk of sunburn
2. Folic acid deficiency
3. Agranulocytosis (leukopenia)
4. Stevens-Johnson syndrome

Reye syndrome
-

Develop as result of child have a recent viral infection (i.e. chicken pox,
flu)
S/S: fever, lethargy, acute encephalopathy and altered hepatic function
1. Elevated ammonia
Risk increase due to aspirin and salicylate especially in client with
Kawasaki

Chicken pox (varicella) airborne

-

Most contagious 1 to 2 days not contagious after all lesion are crusted
over
Immunization side effects: discomfort, redness, few vesicles
1. Cover with small bandage to reduce risk of transmission

Rotavirus leading cause of diarrhea in children less than 5 age

-

Fecal to oral route spread

Contact through food, toys, diaper, hands
S/S: foul smelling diarrhea, last 5 to 7 days, fever, vomiting, dehydration
Vaccination to be given before the child is 8 months old
Breastfeeding should continue

Scabies skin infestation

-

Spread via person to person contact

S/S: intense itching (night a lot more)
Long incubation period of 30 to 60 days so everyone in contact has to
treated
Dont survive away from human skin for more than 2 to 3 days
1. Washing all clothes, stuffed animals in hot water or leaving them in
plastic bag

Febrile seizures

Occur b/w the age of 6 month to 6 years

Reassurance to the parents, safety precaution, antipyretics
Applying cool and damp compresses to lower fever
Prevent shivering can lead to increase metabolic rate (NO tepid water or
ice bags)

Sjogren syndrome autoimmune condition inflammation of exocrine glands

-

Decreased production of tears and saliva

Dry eyes (xerophthalmia) and dry mouth (xerostomia)
Use artificial tears and artificial saliva, use humidifier and NO fans
1. Removes dryness, burning, itching, irritation, pain, gritty sensation

UTI- wipe from front to back

-

Urinary stasis (incomplete emptying of the bladder) most common factor

to UTI
Constipation
Avoid holding it in
Scented soaps or commercial prepared bubble bath should be avoided
Cotton should be worn

Cystitis near the bladder

-

Community acquired
Infection of lower urinary tract
S/S: hyperemia, tissue hemorrhage, pus formation
1. Burning, dysuria, frequency and urgency, hematuria and suprapubic
discomfort

Pyelonephritis infection of urinary tract to the ureters and kidneys

-

S/S: seriously ill, nausea, vomiting, fever, chills, flank pain

Client could become septic

Kawasaki disease tx with aspirin and IVIG to prevent coronary artery aneurysm
-

Antibodies wil be in body for 11 month thus live vaccines shouldnt be

given
1. Varicella and MMR

Macrolide antibiotics (i.e. azithromycin, erythromycin, clarithromycin)

-

Can cause QT interval

Hepatotoxicity due elevated liver enzyme
1. Be caution when giving Tylenol

Hepatitis A fecal oral route

-

Hand hygiene most important

Sepsis inflammatory response to infection when 2 out 4 criteria present

-

Heart rate >90

Temp > 38.3

BP < 90 mmHg
Change in mental status
Hyperglycemia > 140 mg
WBC > 12,000, <4000
Respiration >20
Absent bowel sounds, cap refill > 5 sec
Assess oxygenation, airway , breathing, circulation, tissue perfusion and
urine output
Tx: through IV fluids and antibiotics
Development of cold and clammy skin will indicate progressive septic
shock requires immediate intervention

Fat embolism (pulmonary embolism) life threatening

-

Due to fracture in long bones and pelvis, bowel resection

Cause changes in LOC, respiratory distress, SOB, chest pain
Main sign petechiae (pin sized red/purple spots)
1. Chest, axillae and soft palate
Death can occur in minutes to hours 1st priority

Diabetic ketoacidosis - in type 1 diabetes

-

Nausea, vomiting, abdominal pain, polyuria

Rapid respirations (kussmaul signs)

Aortic dissection moving, ripping back pain, tearing, worst ever, due to
uncontrolled hypertension

LPN limited to lung, bowel sounds and neurovascular checks cant perform initial
assessment
-

Stable and have expected outcomes

UAP assist with ROM exercise after taught by RN, remind about Incentive
spirometer, remind pt to use overhead trapeze, notify RN of client reports/states,
report observations, remind client to change position

Assist with treatment/prevention of aspiration (oral non sterile

suctioning/positioning)

RN does peripheral circulation, neurovascular and skin assessments

-

Use assertive statement towards UAP use I- be given as a directive

Nursing process (assessment, diagnosis, planning, implementation,
evaluation)

New graduate nurse perform wound care (assessment, documentation, sterile

dressing change), provide diabetic teaching
Case management assessing, planning, facilitating and advocating
-

Decrease fragmentation, helps coordinate care/communication, makes

referrals, arranges for home health and placement

IN emergency situation greatest good for greatest number of people

-

START simple triage and rapid transport look at airway, breathing and
circulation
Priority goes to client that going to survive

Aphasia inability to express thoughts and comprehend language requires advance

directive
Abdominal aneurysm pulsatile mass in the periumbilical area
-

Bruit may be ausculated and back/abdominal pain

Medical emergency

Graves disease autoimmune condition enlarged thyroid gland and excessive

thyroid hormone secretion
-

Bounding, rapid pulse expected CDV symptoms not urgent

Acute pyelonephritis can be life threatening due to kidney damage

-

Require patent IV access

Children under 10 are given a higher priority in emergency situation

Epiglottitis inflammation of the epiglottis life threatening airway obstruction

due Hib inlfuenzea
-

S/S: high grade fever, severe sore throat,

1. 4 Ds drooling, dysphonia (difficulty speaking), dysphagia and
distressed airway (stridor)
2. Tripoding (sitting up and learning forward)

Infectious mononucleosis due to Epstein-Barr virus

Cause spleen rupture

S/S upper quadrant abdominal pain

time frame, when change in condition happened,

Bacterial meningitis high fever, LOC, nuchal rigidity and meningeal sign (positive
kernigs and brudzinski sign)

Orthopaedics