Conversion: anxiety repressed and converted into a physical symptom.

Show psychological stress in

physical symptoms.
Creatinine renal function
ESR: inflammation
ABG: acid base balance
Volkmann Contracture- compartment syndrome from obstruction of arterial blood flow to the forearm
and hand. Cant straighten fingers, severe pain, diminished circulation. Fingers and wrist contracted
Abdominal aortic aneurysm- encourage client to drink move and increase fiber to avoid straining.
Would not elevate legs because that would add more pressure to abdomen.
Having an immediate family member increases chances of prostate cancer
HIV patient should be aware of bacteria, such as in cat, fish, and reptiles.
With inflamed gallbladder, avoid food high in fat, such as fatty meat, fried food, full fat milk, pizza in
ranch, cheese omelet, potato chips with French dip.
FTT: fatigued from malnutrition (wake them to feed them), feeding every 2 hours is too often, should be
3-4 hours 6 oz
Nothing in mouth when patient having seizure.
HF: hardly peeing could be sign of kidney insufficiency due to lack of perfusion, fluid changes, bruise
easily because not coagulating properly.
Testicular checks should be done in shower because all muscles relaxed.
Infiltration- remove IV and elevate arm to increase reabsorption of the fluid.
Extrusion reflex when baby pushed the food with their tongue out their mouth. disappears 3-4 months.
Hallmark of aseptic technique- Handwashing!
Penrose drain- prevents build up of fluid uses soft rubber.
Never give morphine or a narcotic analgesic when there is a head injury because can cause CNS and
resp depression. Masks signs of ICP
Ranitidine reduces acid production in stomach and prevents stress ulcers
Fluid volume overload sx: bounding pulse, elevated BP, distended neck veins, edema, headache,
polyuria, diarrhea, liver enlargement
 Should be 5 months at least in remission before getting pregnant with Lupus. Recommended a woman
wait two years following diagnosis to get pregnant with lupus.
Kussmaul respirations are a sign of HYPERglycemia
HYPOglycemia- diaphoresis and trembling.
Patient in suspension traction and other leg is externally rotated: place trochanter roll on outer aspect
of thigh. Adduction does not change external rotation. Normal rotation is required.
Fixed and dilated pupils represents a neurological EMERGENCY. Contact HCP immediately
Strabismus- visual axes are not parallel, so brain receives two images- child closes one eye to see a
poster on the wall
Myopia- nearsightedness, see things at close range
Refractory error in eyes when child rubs eyes frequently
Respiratory rate of 8 is too low, respiratory depression-administer narcan to reverse respiratory
depression
When a child ingests a hydrocarbon (lighter fluid) would not induce vomiting because danger of
aspiration
Dawn phenomena (high BS in the morning), tmt is to adjusting evening diet, bedtime snack, insulin
dose, and exercise to prevent morning HYPERglycemia. Give or increase NPH insulin dose
Clear fluid coming out of someones ear indicates rupture of meninges and presents a potential to
meningitis
complete nursing history includes biopsychosocial data; client's psychosocial and physical status are
evaluated along with an assessment of the client's family system and social support network;
evaluation of the client's cognitive ability is important during the physiological status assessment
Compazine is incompatible with all other medications in a syringe. Draw up in a different syringe
Patient is seeking attn. and angry when attn. not given. Award the patient with unsolicited attn. when
the patient is exhibiting acceptable behaviors.
Gastric contents for NG tube ph should be 0-4.
Introjection: blaming oneself when angry with another
Drawing picture to explain surgery- school aged child
Use of dolls or puppets to explain for surgery- 4 year old
Read an age appropriate illustrated book- school aged child
9 months can pull self up and assume a sitting position at 8 months, can say few words.
Albumin level are best indicators of long term nutritional status
HYDRATION is priority for any client with sickle cell
Basic guideline to teach a postgastrectomy are measures to prevent dumping syndrome: lying down for
30 min after meals, drinking fluids between meals, and reducing intake of carbohydrates and spicy
foods
Glipizide: oral hypoglycemic for type 2 diabetics who produce minimal amounts of insulin
Placenta Previa: painless bleeding
The need for restraints is based on patients behavioral status and condition, not their voluntary or
involuntary status
Hemiophilia A contraindicated pain meds: oxy (Percodan) contains aspirin, ibuprofen, and aspirin.
Codeine phosphate (Paveral) is okay to use for patients with hemophilia A.
Dysplasia of the hip of infant: uneven gluteal fold and thigh creases, decrease in limb length on
affected side, abduction. Folds and creases are longer and deeper on affected side. Ortolanis sign click
sound heard. Use pavlik harness
maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness,
tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and
hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on
blood pressure. Hold medication if HR is elevated
Infant has hep A. put in private room and contact precautions and standard precautions for diapered or
incont. Clients. Diet high in carbs and protein. Low in fat.
Haloperidol (Haldol D): give deep IM in large muscle mass because very irritating to the subq tissue.
Use 2 in 21 g needle. Antipsychotic also controls tourettes. SE: galctorrhea (excessive or spontaneous
flow of milk), lactation, gynecomastia (excessive growth of male mammary glands)
o Monitor BP every 30 minutes, monitoring vital signs is of utmost importance to ensure client
safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used
to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic
blockade of peripheral vascular system lowers BP and causes postural hypotension
 Coupled PVCs greater than 6-10/min or PVCs that could turn into v-tach administer lidocaine
hydrochloride.
Antidysrhythmic- used for brady, heart block, v dystrhythmias.
AntiHTN-CCB
most important priority in the nursing management of an assaultive client is to maintain milieu safety
by restoring the client's self-control; a quick assessment of situation, psychological intervention,
chemical intervention, and possibly physical control are important when managing the physically
assaultive client
When packing wounds: should clean from the center of wound to the outside, dressings should be
soaked before application, pack wet gauze in the incision without overlapping it onto the skin, remove
gauze when dry that wound debris and necrotic tissue are removed with the old dressing.
Expected of 3 month old: holds head erect, turns head to locate sound, smiles spontaneously when
sees mother. Does not grasp for toy until 6 months
Partial thickness burns (2nd degree): remove clothing and wrap patient in clean sheet to prevent
infection.
If there is a fever after a DPaT (diphtheria, pertussis and tetanus shot) it is usually low grade and
presents within 48 hours.
Perphenazine (Trilafon)-antipsychotic (schizo) extrapyramidal sx: head turned to side, neck arched,
stiff, and muscle spasms in neck. Give Biperiden (Akineton) which is a antiparkinsonian agent used for
the extrapyramidal effects.
Promazine (Sparine), Thiothixene, and Haldol all antipsychotics
Education for a newly diagnosed TB patient: airborne precautions at hospital, can send home with
family because they are already exposed, will be on medication for 6-9 months
Delirium Tremens: severe alcohol withdrawal sx shaking, confusion, hallucinations. Steadily increasing
VS needs additional sedation to avoid the effects of withdrawal.
Postcholecystectomy who has t tube removal (holds bile). When removed there will be dark, greenish-
yellow drainage, which is bile not infection!! Remove the dressing, and replace it with a more
absorbent dressing. Dont reinforce because that could cause infection instead replace with new
clean gauze.
After bronchoscopy place client in semi-fowlers. Would not extend neck because tongue could fall in
back of mouth and obstruct airway. Would not put in prone position with head to side because would
limit resp. excursion. Supine never a good position after surgery.
Major nursing concern with abruptio placentae (premature separation of a normally implanted placenta
leading to hemorrhage) is fluid vol deficit.
Sx with subdural hematoma and cerebral edema: decrease LOC, ipsilateral pupil dilation (pupil dilation
on same side of hematoma) HEADACHE IS FIRST SX!!
Procainamide HCl (Pronestyl) given to treat PVC or atrial tachy. Adv. Rxn: severe hypotension or brady.
Candidiasis: Yeast infection. Tmt: Ketoconazole ( Nizoral).
Flagyl is an anti-infective used in tmt of intestinal amebiasis, trichomoniasis, IBS
Bactrim: Tmt for PCP, sx of dyspnea, tachypnea, persistent dry cough, fever, fatigue
Rifampin (Rifadin) tmt for tuberculosis, sx: fever, chills, night sweats, weight loss, anorexia.
Dissociative Disorder: characterized by either a sudden or a gradual disruption in the integrative
functions of identity, memory, or consciousness; disruption may be transient or may become a well-
established pattern; development of these disorders is often associated with exposure to a traumatic
event
somatoform disorder (or hypochondria) is concerned with physical and emotional health, accompanied
by various bodily complaints for which there is no physical basis
Sx of hyponatremia: muscle twitching, convulsions, diarrhea, fingerprinting of skin, headache,
apprehension, lethargy.
Sx of hypernatremia: along with restlessness, weakness, coma, tachy, flushed skin, oliguria, fever,
sticky mucus membranes, decreased UO, and firm rubbery tissues.
After appendectomy: take deep breaths, hold incision, and then cough. Most effect way of deep
breathing and coughing, dilates airway and expands lung SA.
Myelogram: diagnostic imaging to look in spinal canal. Nursing interventions: encourage fluid intake for
dye excretion, lie flat for several hours prevent headaches, monitor vital and neurological signs identify
abnormalities early.
Should hold can on strong side, widens base of support, reduces stress on affected side, flex no more
than 30 degree.
Disoriented, requires immediate assessment to determine underlying cause. Who to see first?
 Right sided failure: peripheral edema caused by heart pumping action accumulating fluid, malaise
causing anorexia, polycythemia increased RBC as compensation for decreased oxygenation, distended
neck veins related to HF
Gemfibrozil: cholesterol medication. Monitor AST and ALT which is liver function. normal 10-40 units/L;
lipid-lowering agent used with patients with high serum triglyceride levels, side effects include
abdominal pain, cholelithiasis; take 30 minutes before breakfast and supper
Hydrochloride (Zantac) best results when taking once a day.
Stockings should be worn the entire hospital visit, during the day, when nonambulatory, before getting
out of bed
Acute gout: should be on low-purine diet, avoid red and organ meats, shellfish, oily fish with bones
When the dialysate outflow is cloudy indicates peritonitis, also will see NV, anorexia, abdominal pain,
tenderness, rigidity. During peritoneal dialysis, a cleansing fluid (dialysate) is circulated through a tube (catheter)
inside part of your abdominal cavity (peritoneal cavity). The dialysate absorbs waste products from blood vessels in
your abdominal lining (peritoneum) and then is drawn back out of your body and discarded.
Child has to be restrained during lumbar puncture to prevent injury
SX of uterine fibroids: benign tumor arising from muscle tissue of uterus, menorrhagia (excessive
bleeding) backache, constipation, dysmennorhea
Warfarin duration is 2-5 days. If stop taking client at risk for repeat stroke
Phlebitis: inflammation and reddened areas around site and up length of vein.
Infiltration increased swelling at the insertion site.
Education on steroid replacement is the most important info the client with Addisons disease needs to
know.
Protein: decreased production of urea nitrogen can be achieved by restricting protein, metabolic wastes
cannot be excreted by the kidneys.
When tetracycline HCL (Achromycin) wear sunscreen and a hat when outdoors because
photosensitivity. Take medication on empty stomach
Prozac is an energizing antidepressant
Allergic SX of blood transfusion: uticaria, pruritus, fever
Febrile reaction of blood transfusion: fever, chills, nausea, headache
Acute hemolytic reaction: most dangerous type of transfusion reaction sx: NV, pain in back, hematuria
Turn, cough, and deep breathe represents preventative care for resp congestion resulting from
anesthesia and shallow resps due to abdominal incision. This is priority in preventing complications
after a c-section.
What to have at bedside after subtotal thyroidectomy for tmt of hyperthyroidism: calcium gluconate
because of possible damage to parathyroid glands, trach, suction equipment. Do not need potassium
chloride because not expected after this surgery.
Pinworm collection: collect the specimen in the early morning with a piece of scotch tape touched to
the childs anus. Pinworms crawl outside the anus early in the morning to lay their eggs.
Nitroglycerin: can cause hypotension so avoid abrupt changes in posture.
CMV (Cytomegalovirus): fever, sore throat, fatigue, swollen glands. Which RN should not be with CMV
patient: nurse who is CMV negative (increased risk), pregnant, immunocompromised.
3 signs of a broken leg: shorter leg, adducted, externally rotated
Penrose Drain: remove dressing layers one at a time to avoid dislodging drain, clean wound from
incisional area toward the drain, do not pull on drain.
Intermittent self-cath at home: store in a plastic food storage bag to decrease risk of contamination,
use clean (not sterile) technique, encourage fluids, perform cath every 2-3 hours initially and increased
6-8 hours.
Most at risk for developing herpes zoster: transplant pts, immunocompromised.
Severe head injury position patients neck in a midline position and head of bed elevated 30. DO NOT:
high fowlers because increase ICP, semi fowlers because should remain in neutral position, side lying
with the clients head extended because decreased venous blood return.
 When should get flu shot: people over 65, recommended for exposure
to general public, people around young children, people with chronic
respiratory, CVD
Cleaning for AIDs patients: if lesions open and draining, clean and
dressed daily to prevent infection, shower daily using a mild soap from
pump dispenser, and pat the skin dry.
Peritoneal Dialysis: check weight daily because peritoneum empty to
assess fluid vol status, strict aseptic technique required to prevent
contamination, dont milk catheter (drainage by gravity only),
encourage a high protein diet because of protein loss with CAPD. is a
type of dialysis that uses the peritoneum in a person's abdomen as the
membrane through which fluid and dissolved substances are exchanged with the
blood. It is used to remove excess fluid, correct electrolyte problems, and remove
toxins in those with kidney failure.
o Can warm the dialysate solution with heating pad to decrease pain cause
RA: assist client with heat application and ROM to reduce swelling, increase circulation, diminish
stiffness while preserving joint mobility. Dont massage because with add to inflammation and pain.
Nonstress test for pregnant women: noninvasive test to evaluate the response of the fetal heart rate to
the stress of fetal movement. Push button when feels fetal movement
MI nursing diagnoses: altered tissue perfusion related to decreased heart pumping action.
Myxedema: slowing of all body functions: decreased temp, decrease pulse, severe hypothyroidism
Sucralfate(Carafate) best given on empty stomach, digoxin (Lanoxin) given two hours after.
Transplant patients require protective isolation following surgery so people cant visit at least 72 hours
post op.
When administering antipsychotic meds: check postural BP because of postural hypotension.
o Nurse should know sign and symptoms of neuroleptic malignant syndrome (pallor, tachycardia,
hypertension or hypotension, diaphoresis, fever, convulsions, loss of bladder control,
respiratory distress, severe muscle stiffness, tiredness); identify it early; notify health care
provider; administer emergency care as needed nurse should know sign and symptoms of
neuroleptic malignant syndrome (pallor, tachycardia, hypertension or hypotension, diaphoresis,
fever, convulsions, loss of bladder control, respiratory distress, severe muscle stiffness,
tiredness); identify it early; notify health care provider; administer emergency care as needed
Parenteral nutrition (PN): tolerance of tmt: UO of at least 30 ml/h- if client being properly hyrdrated with
hypertonic IV such as PN, also check glucose levels. Bad signs of tolerance for PN: increase in HR could
mean fluid overload, decrease in diastolic pressure: shock or lack of blood volume, temp should remain
in normal limits.
Laryngectomy removal of the larynx and separation of the airway from the mouth, nose, and
esophagus. Client swallows air and then eructates it while forming words with his mouth (esophageal
speech). Covering stoma and moves lips (TEF), Battery powered device (electric larynx), finger over the
trach forcing air up through vocal cords (method of speech for ppl with trach)
Scleral buckling procedure: treat retinal detachment. Assessment: prevent NV because would increase
ICP causing damage to area repaired
Hodgkins: reed sternburg cells. Not as bad as non-hodgkins.
Test for diabetes: 24-28 weeks at pregnancy
High pitched cry is first sign of ICP in infant.
Any suspicion of child abuse should be reported to the child protection agency.
Fractured femur elderly: suspiciousness results from interference with communication, very hard of
hearing.
Ewald tube is a larger, orogastric tube designed for rapid lavage (irrigation); insertion often causes
gagging and vomiting, suction equipment must be immediately available to reduce the risk of
aspiration. Have suction near bedside.
Do not use aspirin because fetal hemorrhage during pregnancy
Safe administration of oxytocin: palpate the uterus frequently, oxytocin stimulates the uterus to
contract, which necessities freq. assessment of the uterus; prolonged tetanic contraction can lead to
ruptured uterus.
Withdrawal from narcotics is like flu sx: runny nose, yawning, fever, muscle, joint pain, diarrhea.
Withdrawal from cocaine: severe cravings, depression, fatigue, hypersomnia
Withdrawal from amphetamine: depression, disturbed sleep, restlessness, disorientation
Withdrawal from barbiturate: NV, tachy, coarse tremors, seizures
 Insulin needs decrease after birth of baby
Saunders:
o Clients with trauma, chest pain, severe resp distress, cardiac arrest, limb amputation, and acute
neurological deficits treated first. Clients with simple fracture, asthma without resp distress, fever,
HTN, abdominal pain, renal stones are second. Finally minor laceration, sprain, or cold sx are treated
last.
o Guidelines for making shift assignments are focused on the client and their needs not on the staff and
convenience (like clustering rooms).
o Clear liquids: gelatin, desert, popsicle, tea, ginger ale, boullion, fruit juice without pulp. Usually for
post-op.
o Full Liquid diet: milkshake, custard, soups, all clear liquids. For GI upset. Not allowed jam, fruit, solid
foods, nuts
o Premature infants: less than 2500 g and less than 37 weeks. Feeding is usually PN until oral feeding
can be established, gavage feedings because poor sucking, vitamin K as prophylaxis to prevent
clotting.
o Introduction to solid foods:
o 1-4 months: liquid vitamins
o 4-5 months: cereal, usually rice is first and strained fruit
o 5-6 months: strained vegetables, strained meat
o 7-9 months: chopped meat, hard breads, and finger foods, baked potato
o Toddlers: 6-8 months teeth have erupted
o Enteral nutrition: alternative feeding required because of inability to use GI route. Use NG, PEG or PEJ
tube. Liquid food delivered to stomach, distal duodenum, or proximal jejunum through these tubes
o PN: is through vein through a peripheral IV or PICC, atrial. Do not catch up the rate if was slowed, do
not discont. Immediately.
o Toilet training: never begin before 18 month of life, 2-3 years bladder reflex control achieved, 3 years
regular voiding habits established, 4 years independent bathroom activity, 5 years nighttime control
expected
o Congenital malformations of urinary tract:
o Epispadias: urethral opening on dorsal surface of the penis.
o Hypospadias: male urethral opeinig on the ventral surface of penis, or female urethral
opening in vagina
o Bladder exstrophy: posterior and lateral surfaces of the bladder are exposed.
o Cystitis: inflammation of the bladder
o Prostatic hypertrophy (BPH):
o Dribbling, weak urinary stream, frequency, urgency, dysuria, nocturia, hematuria before or
after voiding, retention.
o Enlargement of the prostate gland, causes urinary flow obstruction, incont, possible
infection, BUN and Creat, PSA normal is less than 4.
o Hemodialysis: through the vein. Peritoneal dialysis: through the stomach.
o Early complication of hypoxemia: HR of 148 bpm, throwing toys and kicking the bed, nasal flaring with
activity.
o 0.45% NaCl: to correct dehydration because shifts fluid into intracellular space
o hypertonic solutions are contraindicated in dehydration.
o Isotonic replace electrolytes not best for dehydration
o Establish a trusting relationship with client is first step in pain relief.
o Psych patient can vote
o Hypotension is a significant side effect of nitroglycerin. Watch BP closely
o Night before surgery of an abdominal cholecystectomy: place the pillow against your abdomen, take
three deep breaths, hold you breath, and then cough 2-3x. should be done every 3 hours to prevent
resp. complications
o NG tube drains stomach, T tube drains common bile duct
o Physical needs take priority.
o Person going for skin biopsy what to tell provider: taking aspirin: can increase bleeding time and
should not be taken prior to a surgical procedure
o When the bowel perforates because of increased intraluminal pressure within the gut, intestinal
contents, are released into peritoneum, leading to peritonitis.
o What to check before giving piperacillin: check for known allergies, obtain specimen for culture and
sensitivity, obtain clients current creat. clearance results (dosage by creat levels)
o Tranylcypromine sulfate is an MAOI must avoid food with tyramine to prevent HTN crisis.
o Second degree thermal injury: which observation is most important to report? Gastric pH less than 5.0
because client is at risk for Curlings ulcer which may develop 24 hours after severe burn
o Hct elevates with burn
o Minimize side effects of a DTaP: administer acetaminophen for discomfort, place a cold cloth on the
injection site for 15 minutes, wrap and comfort child for signs of irritability.
o Dont milk the finger after sticking it for a blood glucose check
o Nifedipine is a CCB used as an antiHTN, brady is untoward effect, withhold medication.
o Pregnant lady Breasts sensitive and sore: apply cool compresses to sides of breasts and well fitting bra
(decreases feeling of pulling). Dont apply warm compress because increase circulation and increase
discomfort.
o Hematuria (blood in urine) is a sign of urinary tract calculi. Hyperparathyroidism- hematuria a sx of
o Multiple sclerosis: education: ambulate as tolerated every day, avoid overexposure to heat and cold,
perform stretching and strengthening exercises, participate in social activities.
o Patient has pneumonectomy: position of the trachea in the sternal notch needs to be checked because
with a tracheal shift, an increase in pressure could occur on the operative side. Breath sounds are
absent on the surgical side
o Rales (abnormal rattling sound) and tachy indicate CV overload
o Psychiatric patients can communicate with outside world, their location may be given out with
prearranged codes.
o Increase calorie intake by 300 for fetal growth in a pregnant woman.
o NSAIDs can cause GI bleed so stool can turn very dark. Take NSAIDs with food, milk, or antacid to
decrease GI upset.
o During labor, pushing should be discouraged until the second stage of labor
o Moist to dry dressing change: gently free dressing, dry skin surrounding wound, moisten prescribed
number and size of gauze, apply moist gauze as a single layer, cover with dry dressings.
o Before administering calcium gluconate check patency of vein, if injected into extravascular tissues
can cause chemical burn.
o Positive sweat test (CF) administer replacement enzymes, social service referral, unrestricted fat diet
because malabsorption of fat.
o Patient with Sengstaken-Blakemore tube in place found in resp distress: cut the balloon and remove
tube caused by upward displacement of esophageal balloon.
o Take prenatal vitamins with orange juice at bedtime because increase absorption of iron. Taking at
night decreases nausea.
o Risperidone education: may gain weight, avoid extreme temps, wear long sleeves when out in sun,
change positions slowly.
o Sucralfate on an empty stomach
o HPV return to get a pap in 6 months because associated with cervical cancer
o MONA- heart
o Internal radiation: time in room is limited for all care providers, verbal exchange at doorway
o Patient with dementia: direct conversation toward assisting the client to reminisce and talk about
important past events in life because they have memory loss.
o Hemorrhage is most important after vagina delivery: look at lochial flow.
o Patient keeps sliding down in bed with buck traction: elevate the foot of the bed on blocks.
o Psych pt asks for antipsych med has torticollis arched back and rapid movement of eyes: administer
PRN trihexyphenidyl IM immediately. Dont give haloperidol because will exacerbate sx
o Isoniazid: SE: hands and feet tingle-neuropathy
o Child has freq. gastroenteritis: ask if the child attends daycare because promote infections.
o Normal CVP is 3-12. Normal range means good fluid replacement
o Lumbar puncture: remain in bed for 8 hours after test, may feel discomfort in leg when needle
inserted, have analgesics if have a headache.
o Hx of alcohol abuse and being treated for chronic cirrhosis. Sx of early stages of hepatic
encephalopathy: client has difficulty describing what he does at work (impaired thought), states
difficulty sleeping (insomnia), change in hand writing (hand tremors)
o When asking a child if they have pain, look at other details first because child could be avoiding
getting another IM injection for pain relief.
o Could develop AKI: hypovolemic or HF patient.
o Weighing self daily is good for overhydration, not dehydration
o Turn patient on left if suspected PE so air goes into RA.
o Lay baby on right after eating
o Oxytocin should always be a secondary infusion controlled by an IV pump!!!
o Sickle cell: dont give cold compress because will vasoconstrict limiting blood flow.
o Bismuth subsalicylate absorbs PO meds so separate med administration.
o Salem sump tube (NG) hissing sound is normal because indicative that air is freely exiting the airway,
purpose is to provide continuous steady suction.
o For baby with PKU: give Lofenalax formula because low in Pheylalanine.
o Breathing into bag for respiratory alkalosis
o To decrease flatulence: walk pt in hall to increase peristalsis which decrease development of flatus.
o Excessive thirst and weight loss are two notable sx of type 1
o Education for mom who is bottle feeding: take acetaminophen as directed, apply cool packs to
decrease milk production, wear well supported bra, be patient milk will resolve in 5-7 days.
o Advice for patient with chronic constipation: establish daily exercise, plan day to be home around time
of defecation, increase intake of cereals, fruits, and vegetables
o Amphotericin increases BUN and Creat because causes renal toxicity
o Signs of respiratory distress: tachypnea, tachy, respiratory stridor, retractions
o Take probiotics with cephalexin because destroying good bacteria in stomach
o Normal head circumference is 32-36 cm of baby
o Constant bubbling in water seal chamber indicates air leak
o Hepatitis A is not infectious about 1 week after onset of jaundice
o Bulge test confirms presence of fluid in the knee, clients leg should be extended and supported on
the bed.
o Exophthalmous: requires eye drops on a regular basis.
o Suctioning increases ICP
o When assessing child do invasive tests last to not change cardiopulmonary assessment of child
o Levothyroxine increases UO. Increases metabolic processes of body.
o 5-30 sounds a minute for bowels is normal
o dye injection for a pyelogram could make pt feel hot and skin become flushed, nausea
o drip rate: total volxdrop factor/ total time in minutes
o 5 mm induration for someone that is immunocompromised is positive for TB
o 10mm for someone who is healthy indicates TB
o continuous bubbling should occur in chamber
o oral corticosteroids should be given with food because gastric irritation
o pentamidine is a antiprotozoal agent used to prevent and or treat pneumoncystitis which is in AIDs
patients. Therapeutic results are decreased crackles and dyspnea
o lung cancer is common sign of SIADH
o predigested formula is best for babies allergic to cow milk. Would not give soy because possible cross
reactivity.
o Rinse mouth with warm water each time after use of beclomethasone
o Mask not required for stage 3 pressure ulcer.
o Babies with RSV and bronchiolitis: parents need to be given bulb syringes because airway can become
blocked.
Random Diseases:
Menieres Disease: Inner ear disorder
causes vertigo
o Vertigo, tinnitus, dilation of
membrane of labyrinth
o Pressure or fullness in ear
o Nystagmus
o Slow down body movements
Trigeminal Neuralgia: chronic pain
affecting the trigeminal nerve in the face.
o Stabbing/burning facial pain
 o Twitching, grimacing of face muscle
o From sinus infection, teeth, mouth, or
irritation
Bells Palsy: sudden weakness on one side of the
face.
o Inability to close eye
o Speech difficulty
o Decreased corneal reflex
o Increased lacrimation
o Distorted side of face

Systemic Lupus Erythema: inflammatory

disease caused when the immune system
attacks its own tissues
o assessment:
Pain in the muscles
Anemia
Fatigue
Hair loss alopecia
Ulcers or dry mouth
Sharp pains in chest
Cough
Weight loss
Butterfly rash
Pericarditis, pleural effusion
Hematuria, proteinuria, renal
failure
Psychosis
Lymphadenopathy, papular
purple lesions
raynauds
Guillen Barre Syndrome: immune system attacks the nerves
o Paresthesia
o Motor losses symmetrical beginning in lower part
of body and moving way up
o Absent or diminished deep tendon reflexes
o Autonomic dysfunction:
Hypotension, tachy, vasomotor flushing,
profuse sweating
Paralytic ileus (inability of intestine to
contract normally)
Distended neck veins
Vasodilation above level of injury and
vasoconstriction below level of injury
o Interventions: symptomatic, mechanical vent,
raise HOB, suction, plasma exchange, IVIG
Meningitis: inflammation of the brain and spinal cord from
infection
o Fever, photophobia, headache
o Nuchal Rigidity- stiff neck
o Kernigs sign: when hip flexed to 90-painful
o Brudinski sign: attempts to flex neck will produce
flexion at knee and thigh
o Opisthotonic position: arc with trunk, legs hyperflexed
 o Seizure, changes in LOC
o Infants: refuse feeding, high pitched cry, bulging fontanelle,
vacant stare
Myesthenia Gravis: a weakness and rapid fatigue of muscles under
voluntary control
o muscle weakness
o drooping of upper eyelid
o difficulty swallowing
o double vision
o fatigue
o SOB
o impaired voice
Care of patient in traction: Using weights to pull up broken bone or
skin traction
Temperature- extremity infection
Ropes hang freely
Alignment
Circulation Check
Increase fluid intake
Overhead trapeze
No weights on bed or floor
Fluids:

Hepatitis:
Jaundice, anorexia, RUQ pain and tenderness, malaise, clay colored stools, tea colored urine,
pruritus: accumulation of bile salts under the skin, prolonged PT, liver fxn tests all elevated
 Kidney FXNS:

Hepatic Encephalopathy:
GI Bleed:

Liv
er:

Acid base balance:

pH: acidosis-7.35-7.45-basic
PaCO2: basic-35-45-acidosis
HCO3: Acidic-22-26-basic
Uncompensated: one system normal
Fully compensated: 2 systems off, pH normal
Partially compensated: 2 systems off, pH off
Diabetes

Alterations
in Protein

metabolism:
-Phenylkeonuria (PKU)- at birth error of phenylalanine utilization. Amino buildup
Test done 1-2 days after birth. Stick on heel
Nursing:
o Specially prepared milk substitutes-Lofenalac
o Low protein diet
-Gout: inborn error of purine metabolism
Disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones
of the feet, deposition of chalkstones, and episodes of acute pain.
High uric acid level- turns into joint deterioration
Nursing:
o Low purine diet no fish or organ meats

-Renal Failure: kidneys lose ability to remove waste and balance fluids.
 Increased protein and albumin losses in urine
that leads to protein deficiency
Nursing Considerations:
o High calorie, low protein diet as
allowed by kidney function

Alterations in Fat Metabolism

-Hepatobiliary Disease: Decreased bile leads to fat
malabsorption
includes a heterogeneous group
of diseases of the liver and biliary system
caused by viral, bacterial, and parasitic
infections, neoplasia, toxic chemicals, alcohol
consumption, poor nutrition, metabolic
disorders, and cardiac failure.
Nursing:
o Low fat, high protein diet, vitamins
-Cystic Fibrosis: inherited life threatening disorder that damages lungs and digestive system. Mucus blocks
airways
Absence of pancreatic enzymes leads to
malabsorption of fat and fat soluble vitamins,
weight loss
Infection and lung disesase lead to increased
need for cals and protein
Nursing:
o Pancreatic enzyme replacement (cotazym
pancreas) before or with meals.
o High protein diet, high cal diet in advanced
stages
-Atherosclerosis: thickening and hardenign of the arteries
Associated with high blood cholesterol and
triglyceride levels
Risk factors- diet, high BP, diabetes, stress,
sedentary life, and smoking
Nursing:
o Low saturated fat diet
o Cholesterol lowering agents given before meals
Infections of GI tract:
-E. Coli: get from undercooked beef.
Nursing:
o Causes rapid and sever dehyration
-Salmonella: from eggs and poultry
Nursing:
o Causes gastroenteritis, systemic infection
-Campylobactr: From poultry, beef, pork
Giardia lambia: from protozoan, contaminated water
Nursing:
o Treat with metronidazole
-Shigella: fecal contamination
Affects pediatric populations, antimicrobial therapy
Hiatal Hernia: part of stomach bulges into chest
Assessment: heartburn, regurgitation, dyspepsia
Diagnose: opening in diaphragm through which the eosphagus passes
become enlarged, part of the upper stomach comes up into the lower
portion of the thorax
Plan:
o Meds
o Cimetadine, rantidine
o Antacids
o Sucralfate
o Pantoprazole
o Surgery to tighten sphincter-fundolipication
o Do not lie down for atleast one hour after meals. HOB elevated
4-8 in when sleeping
Pyloric stenosis: Condition in which the opening between the stomach and
small intestine thickens.
Assessment:
o Vomiting
o Epigastric fullness
o Irritability in infants
o Infant always hungry
o Infant fails to gain weight
o Palpable olive shaped tumor in epigastrium- infant
o Peristalic waves
Diagnose:
o Adults: narrowing or obstruction of pyloric sphincter caused by
scarring from healing ulcers
Inflammation and edema can reduce the size of the
opening until complete destruction
o Infants: obstruction caused by complete obstruction
Dont show symptoms until second to fourth week after
birth. Then symptoms show. Male white full term infants
most likely
o Obstruction in adults usually caused by peptic ulcers
o Surgical:
Infant: pyloromyotomy: incision through circular muscles
of the pylorus
Vagotomy and antrectomy: remoe gastrin which is the secreting portion of the
stomach and severing of vagus nerve
Gastritis: stomach lining inflammed
Assessment:
o Uncomfortable feeling in abdomen
o Anorexia
o Possible bloody vomit
o Hiccuping
o Causes: alcohol abuse, corrosive drinks or food, extreme stress, aspirin
Plan:
 o NPO slowly progress to bland diet
o Antacids often relieve pain
GI Ulcer: forms on lining of stomach, small
intestine, esophagus.
Chronic Duodenal Ulcer
o Risks: COPD, renal failure, alcohol,
stress, smoking, cirrohsis
o Hypersecretion of gastric
secretions
o 2-3 hours after meal get pain.
Nightime in early sleeping hours.
FOOD INTAKE RELIEVES PAIN
o vomiting, malignancy, and
hemmorhage is rare
Chronic Gastric Ulcer:
o Risks: gastritis, alcohol, smoking,
NSAIDs, stress
o Normal- to a little secretion of
gastric secretions
o Pain comes .5-1 hour after meal or
when fasting. RELIEVED BY
VOMITING. eating food does not
help
o Plan:
Avoid oversecretion and hypermotility in the
GI Tract. Avoid coffee, alcohol, and
caffeinated beverages, milk, cream.
Reduce stress
Stop smoking
Meds:
Antacids
-tidine.
Anticholinergics 1 hours after meals
Sucralfate- 1 hour before meals
Omeprazole
Surgical:
Gastrectomy: removal of stomach and attachment to upper portion of
duodenum
Vagotomy: cutting the vagus nerve= decrease HCL secretion
Billroth I: partial removal. Billroth II: full removal
Esophageal Atresia and Tracheoesphageal Fistula:
Esophageal atresia: congenital defect- occurs before birth. Upper esophagus ends and does not
connect with the lower esophagus and stomach.
Tracheoesophageal Fistula: abnormal connection in one or more places between the esophagus
(tube leading from throat to stomach) and trachea (tube leads throat to windpipe and lungs).
Usually not connected.
o Assessment:
Excessive saliva, drooling
Stomach distention
Choking, coughing, sneezing
Cyanosis
o Diagnoses: failure of esophagus to
develop as a continuous tube. Often
occurs with anomlaties of heart or
GU or musculoskeletal
o Plan:
Surgical repair
Chrons Disease: inflammatory condition of the
colon characterized by eroded areas of the mucous membrane and tissues beneath it
UC: inflammatory condition of the colon characterized by eroded areas of the mucous membrane and
tissues beneath it.

Plan:
Diet high in protein, calories. Low fat and fiber. PN used for bowel rest
Meds: analgesics, anticholinergics, antibiotics, corticosteroids (reduce inflammation)
immune modulators, salicylate containing compounds.
ileostomy
Appendicits: appendix becomes
inflammed and filled with pus causing
pain.
Assessment
o Pain in right lower
quadrant
o Muscle guarding
o Low grade fever
Plan:
o No heating pads,
enemas, or laxatives
o Maintain NPO, IV fluids to
prevent dehydration
o Ice pack
o Observe for signs and
symptoms of peritonitis
(inflammation of the
membrane lining the
abdomen wall and
covering the abdominal
organs
Diverticular Disease: small, bulging
pouches develop in the digestive tract.
Assessment:
o Cramping in left lower quadrant. Relieved by passage of stool or gas.
o Fever, increased WBC, constipation alternating with diarrhea
Diagnose: infection, inflammation, obstruction of diverticula (sacs or pouches in intestinal wall).
Associated with deficency in fiber
Plan: antispasmodics, bulk laxatives, high fiber diet, Surgery( drain abcess, resect obstruction
Peritonitis: inflammation of the membrane lining the abdominal wall and abdominal organs.
Assessment:
o Abdominal pain, ascites
o Increased temp, leukocytosis
o Paralytic ileus (paralysis of the intestinal muscles)
Diagnose:
o Inflammation of part or all of the parietal and visceral surgaces of the abdominal cavity.
o Causes: ruptured appendix, ectopic pregnancy, perforated ulcer, bowel or bladder
Plan:
o Gastric decompression: monitor NG drainage
o Antibiotics, fluids, NPO, analgesics, semi fowlers position
Hirschusprungs Disease: Condition of the large intestine (colon) that casues difficulty passing stool.
Ganglionic disease of the intestinal tract, inadequate motility-
mechanic obstruction of intestine. Can be congenital defect.
Assessment:
o Newborn: doesnt pass meconium, refuse to suck,
abdominal distention
o Child: failure to gain weight, delayed growth,
constipation, alternate with diarrgea, foul smelling poop,
abdominal distention, peristalsis
Enemas, low fiber, high cal and protein diet
 Oral antibiotics
Measure abdominal girth at level of umbilicus
Colostomy
Intussusception: part of the intestine telescopes into itself. Usually
the ileum into the cecum and colon
Assessment:
o Colicky abdominal pain, child screasms and draws
knees to abdomen
o Currant jelly like stools containing blood or mucus
o Tender distended abdomen
o Palpable sausage shaped mass in upper abdomen
o Usually happens in 3 months-3 years old
Plan:
o Nonsurgical:
Water soluble contrast, air pressure to push it out
o Surgical: manually reducing the telescoped part. Remove any damaged part of the bowels
Intestioal obstruction
Assessment:
o high pitched bowel sounds above area of obstruction and absent bowel sounds below area of
obstruction.
o Colicky abdominal pain and distention
o Obstipation- abesence of stool and gas
Diagnose:
o Mechanical obstruction: hernia, tumor, adhesions, strictures, intussception, vovlulus
(twisting of bowel)
o Nonmechanical: abdominal trauma, spinal injury, peritonitis, appendicitis, would
dishecience.
Plan:
o Instestinal decompression- may remove fluid or air
o Tubes
o Bowel surgery
Exploratory laprotomy: possible adhesion removal
Resection and anastomosis: disease portion of bowel removed and join the remaining
parts
Abdominal perineal resection: abdominal incision
Intestinal ostomies
o Fowlers position to facilitate breathing
Intestinal Ostomies for Fecal Diversion
Assessment: cancer of colon or rectum,
diverticulitis, intestinal obstruction
Diagnose: ostomy Is opening into colon to allow
passage of intestinal contents. Stoma is an
opening on abdomen where intestine is sutured
to skin
Plan:
o Observe and record condition of stoma:
first few days appears beefy red and
swollen
o Gradually becomes pink or red
 o Notify HCP if
becomes black
or purple-
perfusion
problem
Colostomy irrigations
for sigmoid colostomy:
o Purpose is to
stimulate
emptying of
colon at
scheduled
times to avoid
need for
appliance.
Begins 5-7 days
postop
o Sit upright on
toilet performed
after meals.
Cirrhosis: Chronic liver
damage from scarring and liver failure. Diseased liver and pain and edema in leg
Assessment:
o Digestive disturbances: indigestion,
dyspepsia (stomach pain), flutulence,
constipation, diarrhea, anorexia, weight
loss
o Circulatory: esophageal varices,
hematemesis, hemmorhage, ascites,
hemmorhoids, increased bleeding
tendencies, hemmorhoids, anemia,
edmea, spider anginomas
o Biliary: jaundice, pruritus, dark urine, clay
colored stools, increased abdominal girth
(distance around abdomen
o Compensated: vasuclar spiders, ankle
edema, indigestion, flatulence, abdominal
pain, enlarged liver
o Decompensated: ascites, jaundice, weight loss, purpura, epistaxis
Diagnose: normal liver tissue replaced with fibrosis and nodule formation
o Alcoholic Cirrhosis: due to alcoholism and poor nutrition
o Biliary Cirrhosis: result of chronic billart obstruction and infection
o Postnecrotic Cirrhosis: resuly of previous viral hepatitis
Complications: portal HTN with esophageal varices because of elevated pressure. Hemmorhage-
leading cause of death in clients with cirrhosis. Edema, ascites (accumulation of serous fluid in
periotoneal and abdomen from dehydration and hypokalemia, hepatic encephalopathy (coma)-
occurs with liver disease from accumulation of ammonia and other toxic metabolites in the blood,
sx asterixis (flapping tremor of hand when arm extended) jaundice. Hepatorenal syndrome: renal
failure, azotemia (elevated BUN), ascites
Plan:
o shunts to relieve portal HTN
o reduce ascites: sodium and fluid restrictions, diuretics
o TMT of bleeding esophageal varices
Balloon tamponade
Ensocopic sclerotherapy- causes varices to be fibrotic
Administer vasopressin or propanolol to lower pressure
Surgical bypass
Saline lavage
TIPS
Esophageal banding
Reyes Syndrome : causes confusion, swelling in the brain, and liver damage
Assessment:
o Fever, increased ICP, decreaed LOC, coma, decreased hepatic fxn, diagnosed by liver biopsy
o Link between use of aspirin with viral illness, assoc with URI and gastroenteritis
Cholecystitis (inflammation of the gallbladder, dont
eat fatty foods) Cholelithiasis (presence of stones in
gallbladder):
Risk factors: obesity, women (multiparous),
40+ years old usually, pregnancy,
hypothyroidism, increased serum cholesterol
Avoid fried foods, cheese, pork, alcohol
Laproscopic laser cholecystectomy: removal of
gallbladder by a laser.
Pancreatitis: inflammation of pancreas
Assessment: abdominal pain, vomiting 24-48
hours after heavy meal or alcohol, pain relief
with positioning, hypotension, acute renal
failure, grey blue discoloration around
umbilicus
From: alcoholism, bacterial or viral infection,
trauma, complication of mumps, meds-
thiazide diuretics, corticosteroids,
contraceptives
Plan:
o NPO, gastric decompression, meds (avoid meperdine because of toxicity), semifowlers
position, monitor for shock and hyperglycemia.

Periop Care:
Stress: vasovagal response (fainting)
Teaching:
Toddler: simple directions
Preschool and school-aged: allow to play with
equipment
Adolescent: expect resistance
Prevent or minimize the effects of separation on the
child:
Assign same nurse to care for the child
Bring toys from home
Table 2: prep for children
Supplements not to be taken near time of
surgery may affect anesthesia:
o echinacea
o garlic
o gingko
o ginseng
o Kava
o St. johns wort
o Eliminate all dietary supplements at least 2-3
wks before surgery
Intraop care:
 Malignant hyperthermia:
inherited muscle disorder
chemically induced by
anesthesia, stop surery, treat
with 100% Oxygen, skeletal muscle relaxant, sodium bicarb
Postop care:
CV surgery after: monitor VS every 15 min x 4, q 30 minutes x2, q 1 hour x2, then PRN
Bowel surgery after: check bowels- if high pitched tympany=abnormal, keep NPO till bowel sounds are
present, check for distention, passage of flatus and stool.
GI tubes: upper: gastric decompression, lower: decompress bowel
Potential Complications of Surgery:
Hemmorhage: decreased BP, increased pulse, cold, clammy skin. Nursing: replace blood vol.
monitor VS
Shock: decreased BP, increased pulse, cold and clammy skin. Nursing: treat cause, oxygen, IV
fluids,
Atelectasis and pneumonia: dyspnea, cyanosis, cough, tachy, elevated temp, pain on affected side.
Nursing: experienced second day postop, suctioning, postural drainage, antibiotics, cough and turn
Embolism: dyspnea, pain, hemoptysis, restlessness, ABG- low O2, high CO2. Nursing: oxygen,
anticoagulant (heparin), IV fluids
Venous thromboembolism: positive ultrasound. Nursing: experiences 6-14 days up to 1 year later.
Anticoag therapy
Paralytic ileus: absent bowel sounds, no flatus or stool. Nursing: NG suction, IV fluids,
decompression tubes
Evisceration: protrusion of wound contents. Nursing: low fowlers no coughing, NPO, cover viscera
with sterile saline or wax paper

Diagnostic Test:
Arterial Diagnostic Tests:
Oscillometry: abnormal findings help to pinpoint the level of arterial occlusion
Angiography (arteriography): indicates abnormalities of blood flow due to arterial obstruction or
narrowing. Use contrast dye injected into arteries and x ray films are taken of vascular tree.
Venous Diagnostic Tests:
Phlebography: lack of filling of a vein is indicative of venous occlusion due to a thrombus. Insert dye
into vein
Isotope studies: helpful in diagnosing early formation of thrombi.
Respiratory/Cardiac Tests:
Pulmonary function: detects impaired pulm function. No smoking 4 hours before tests. Withhold
bronchodilators, breathe into machine.
Bronchoscopy: allows visualization of larynx, trachea, and mainstem bronchi. Possible to obtain
tissue biopsy, apply med, aspirate secretions for lab exam, aspirate a mucus plug causing airway
obstruction, remove aspirated foreign objects. Maintain NPO 6 hours before test.
 Thoracentesis: aspiration of fluid or air from pleural space. To obtain specimen for analysis, relieve
lung compression, obtain lung tissue for biopsy, instill medications into pleural space.
Echo: noninvasive sound waves used to determine cardiac structures.
Cardiac cath: usually used with angiography. Evaluate ventricular function and obtain chamber
pressures. NPO 8-12 hours, signed permit, empty bladder
Neurological Tests:
Cerebral angiography: identifies aneurysms, vascular malformations, narrowed vessels. Dye
injected into femoral artery.
CT: detects hemorrhage, infarction, abcesses, and tumors
Myelogram: visualizes spinal column and subarachnoid space. Injects dye so make sure to check
allergies.
PET: used to assesses metabolic and physiologic fxn of brain, diagnose stroke, brain tumor,
epilepsy, PD, head injury.
Liver Function Tests:
Protein studies Serum albumin: proteins are produced by the liver, levels may diminish in hepatic
disease, severely decreased serum albumin results in generalized edema.
PT and PTT: may be prolonged in hepatic disease, in liver disease PTT prolonged due to lack of
vitamin K
Liver enzymes: AST and ALT and LDH are released into the bloodstream.
Blood ammonia: liver converts ammonia to urea. With liver disease, ammonia levels rise.
Bilirubin: detect presence of bilirubin due to hemolytic or liver disease.
GI Tests:
Stomach/esophagus endoscopy: visualization of esophagus by tube through the mouth to stomach
looking for ulcers, tumors, or obtain tissue or fluid samples.
Sigmoidoscopy/Proctoscopy: direct visualization of the sigmoid colon, rectum, and anal canal.
Amylase: diagnose pancreatitis and acute cholecystitis. Normal 6-160
Lipase: diagnose pancreatitis, biliary obstruction, hepatitis, cirrhosis.
Gastric aspirate: aspiration of gastric contents to evaluate for presence of abnormal constituents
such as blood, abnormal bacteria, abnormal pH, malignant cells.
Paracentesis: needle aspiration of fluid in abdominal cavity used for diagnostic exam of ascetic fluid
and tmt of massive ascites resistant to other therapies.
Reproductive Tests:
Culdoscopy: visualization of ovaries, fallopian tubes, uterus via vagina.
Urinary System Diagnostic Tests:
Cystometrogram: identify bacteria in urine.
Cystomertrogram: test of muscle tone.
Cystoscopy: bladder and urethra visualization
Schilling Test: diagnoses vit B12 deficiency (pernicious anemia)

Therapeutic Procedures:
Chest physiotherapy:
o Diaphragmatic or abdominal breathing: client positioned on back with knees bent, place
hands no abdomen
o Pursed lip breathing
o Postural drainage use gravity to facilitate removal of bronchial secretions
o Percussion and vibration, IS
Suctioning:
o Hyperoxygenate before, during, and after suctioning.
o Semi-fowlers
o Complications:
Hypoxia, bronchospasm, vagal stimulation, tissue trauma, cardiac dysrhythmias,
infection
Trach Care:
o Perform every 8 hours and as needed.
o Hyperoxygenate or deep breathe
o Clean cannula with hydrogen peroxide if reusable cannula
o Purpose of cuff: prevents aspiration of fluids, inflated during cont. mechanical ventilation,
during and after eating, during and 1 hour after a tube feeding, when client is unable to oral
secretions, check cuff pressure every 8 hours, maintain at less than 25 cm.
 o Complications:
Airways obstruction, infection, trachial necrosis
Chest Tubes:
o Intrapleural drainage system with one or more chest catheters held in pleural space by
suture to chest wall.
o Fill water seal chamber with sterile water
o Chest tubes are only clamped momentarily to check for air leaks and change the drainage
apparatus.
o Gently milk tubing in direction of drainage as needed if agency allows.
o Fluctuations of fluid in water seal chamber., stops fluctuating when:
Lung re-expands
Tubing is obstructed
Loop hangs below rest of tubing. Suction is not working.
o Complications:
Observe for constant bubbling in the water-seal chamber, indicates air leak in
drainage system
NG tubes:
o Levin, salem sump, sengstaken-Blackemore, Keofeed/Dobhoff,cantor, miller-abbott, harris
o Instill 15-30 ml of saline before and after each dose of medication and tube feeding, after
checking residuals, every 46 hours with cont. feedings, when feeding discont.
Surgical Drains:
o Penrose: simple latex drain.
o T Tube: used after gallbladder surgery. Placed in common bile duct to allow passage of bile.
Monitor drainage, keep below waist, may have bile secretions.
o Jackson Pratt: portable wound self suction device with reservoir.
o Hemovac: larger portable wound self suction device within reservoir. Used after mastectomy.

Medical Emergencies!
Upper airway obstruction:
If conscious: 5 back blows between shoulder blade with heel of hand, Heimlich maneuver, alternate
Unconscious: CPR, remove visible object.
Airway intubation:
o ET tube: passed through nose or mouth into trachea.
o Trach: surgical incision made into trachea through throat. Cuff is used to prevent aspiration
and facilitate mechanical ventilation. Indications: noisy respirations, restlessness, increased
pulse, increased resps, presence of mucus in the airway.
Cardiopulmonary Arrest:
Failure to institute ventilation within 4-6 minutes will result in cerebral anoxia and brain damage.
BLS. Compression rate at least 100 minute
o Compression depth: adults at least 2 in. children at least anterior posterior diameter or 2
in. infants at least diameter or about 1.5 in.
o Compression to ventilation: 30:2 adult. 30:2 with single rescuer. 15:2 2 HCP
Croup Syndromes: Acute Epiglottis, Acute Laryngotracheobronchitits
Bark like cough, use of accessory muscle, dyspnea, inspiratory stridor, cyanosis, decrease in noisy
respirations may indicate decompensation.
Viral infection in the area of larynx
Narrowed airway in children
MI:
Chest pain: severe crushing, prolonged, unrelieved by rest or nitros. Women may present with
atypical symptoms (fatigue, SOB)
Shock: systolic BP below 80, gray facial color, lethargy, cold diaphoresis, peripheral cyanosis, tachy,
brady, weak pulse.
Oliguria
Low grade fever
ESR-elevated
CK-MB first enzyme to be elevated after MI
LDH appears
Myoglobin rise within 1 hour
EKG: ST segment elevation, T wave inversion, Q wave formation
 Plan:
o Provide thrombolytic therapy TPA: to dissolve thrombus in coronary artery
o Watch intake to not facilitate CHF or too little-dehyrdation
o Prevent complications: dysrhythmias, shock, CHF, rupture of heart muscle, PE, recurrent MI
Healing not complete 6-8 weeks
Dysrhythmias:
Dizziness, syncope, chest pain, abnormal pulse rate
Sinus Dysrhythmias: originate in SA node.
o Tachy. HR increased. Causes- pain, exercise, hypoxia, PE, hemorrhage, hyperthyroidism,
fever. SX: dizzy, dyspnea, hypotension, palpitations
TMT: BB, CCB, cardioversion
o Brady: vagal stimulation causes SA node to depress. HR decreased. Causes: MI, Valsalva
maneuver, vomiting, arteriosclerosis, ischemia, hyperkalemia, Digitalis or propranolol. SX:
pale, cool, hypotension, syncope, dyspnea, weak
TMT: atropine or pacemaker
Atrial Dysrhythmias: stimulation outside of SA node but within the atria
o PAC: ectopic focus within one of the atria fires prematurely. Causes: emotional disturbances,
tobacco, fatigue, caffeine, normal in some ppl. SX: sense of skipped beat
o Atrial Flutter: ectopic focus in atrial wall causing atrium to contract 250-400xmin. Causes:
stress, hypoxia, drugs, chronic heart disease, HTN. SX: chest discomfort, hypotension.
sawtooth
TMT: vagal maneuvers, adenosine, cardioversion or ablation
o Atrial fibrillation: rapid disorganized twitching of atrial muscle. Cause: chronic lung disease,
HF< rheumatic heart disease, HTN. SX: stroke symptoms, hypotension, syncope, dyspnea.
TMT: CCP (diltizem) BB (-olol) digoxin, cardioversion, warfarin
Ventricular Dysrhythmias: occur when one or more ectopic foci arise within the ventricles
o PVC: Causes: ischemia due to MI, infxn, mechanical damage due to pump failure, deviations
of electrolyte imbalances, nicotine, caffeine, tea, alcohol, drugs (dig, resperine) anxiety, lung
disease. SX: angina, SOB, heart flip feeling
TMT: amiodarone, BB, procainamide
o V-tach: 3 or more PVCs occurring in a row at a rate exceeding 100 bpm (severe myocardial
irritability). Causes: large MI, low ejection. SX: hypotension, PE, confusion, cardiac aresst
TMT: procainamide, sotalol, amiodarone, mag, isoproterenol, CPR, defibrillation, epi,
amiodarone.
o V-fib: very rapid rate. Most serious of all dysrhythmias because of potential cardiac
standstill. Causes: acute MI, HTN, rheumatic or arteriosclerotic heart disturbances or
hypoxia. SX: unresponsive, pulseless, apneic.
TMT: CPR; unless blood flow is restored by CPR and the dysrhythmia is interrupted by
defibrillation, death will occur within 90s-5 minutes
o Heart Block: delay in conduction of impulses within AV system
First degree: AV junction conducts all impulses, but slower than normal HR. Causes:
digitalsis, CCB, BB, MI, increased vagal tone. SX: asymptomatic
Second Degree: AV junction conducts only some impulses arising in the atria. Causes:
infections, digitalsis toxicity, CAD. SX: may note hypotension, dyspnea, syncope.
Tmt: atropine, pacemaker
Third degree heart block: Blocks all impulses to the ventricles, causing the atria and
ventricles to dissociate and beat independently. V- rate is low 20-40 bpm. Causes:
congenital defects, vascular insufficiency, fibrosis of myocardial tissue, MI. SX: shock,
syncope
TMT: pacemaker, atropine, epi. Treat immediately because could lead to
death.
Diagnostic Tests: EKG, ABGs, Holter recorder (24 hour continuous EKG tracing, client keeps diary of
activities), Cardiac cath and angiography, Echo, stress test.
Medications: Antiarrythmias (lidocaine, quinidine, procanimide), antilipid (lovastatin,
cholestyramine), defibrillation, pacemakers
Head injury:
o Skull fracture: Battles sign (ecchymosis over mastoid bone), raccoon eyes, rhinorrhea, otorrhea
(middle ear infxn.
o Concussion: mental confusion or LOC, headache, no residual neurological deficit, possible loss of
memory surrounding event, long term effects-lack of concentration, personality changes.
 o Contusion: varies from slight depression of consciousness to coma, decorticate posturing,
decerebrate posturing (deeper dysfxn), cerebral edema.
o Laceration: penetrating trauma with bleeding
o Hematoma:
o Epidural: short period of unconsciousness, ipsilateral pupillary dilation, weakness of
extremities
o Subdural: decreased LOC, ipsilateral dilation, weakness, personality changes.
o Plan/Implementation:
o Hypothermia- to decrease metabolic demands
o Barbiturate therapy: to decrease cerebral metabolic rate
Chest trauma:
o Flail Chest: affected side goes down with inspiration and up during expiration. Segment of rib cage
breaks. Monitor for shock.
o Open Pneumothorax: sucking sound on both inspiration and expiration, pain, hyperresonance,
diminished breath sounds on affected side. Penetrating chest wound causing interpleural space to
open to atmospheric pressure=collapsed lung. Thoracentesis, chest tubes
o Pneumothorax: dyspnea, pleuritic pain, cyanosis, absent or restricted movement on affected side.
Collapse of lung due to air in the pleural space
o Spontaneous
o Tension-pressure builds up; shifting of heart and great vessels
o Hemothorax: blood in pleural space
Abdominal Injuries
o Penetrating: sx of hemorrhage. Open wound resulting in hemorrhage, increased risk of infxn.
o Blunt: abdominal pain, distention, shock, ecchymosis (around umbilicus- Cullens sign), bruits
indicating renal artery injury, Balances sign (resonance over spleen with client on left side-
indicates rupture of spleen. IV with large bore needle in upper extremity.
Shock:
o Cool, clammy skin, cyanosis, decreased cap refill, restlessness, weakness, metabolic acidosis,
tachy, respirations shallow, increased muscle weakness, oliguria, increased urine specify.
o Sudden reduction of oxygen and nutrients, decreased blood volume causing reduction in venous
return, decreased CO, decrease in arterial pressure
o Types of shock:
o Hypovolemic: loss of fluid from circulation
Hemmorhagic shock
Cutaneous shock-burns resulting in external fluid loss
DKA
Diabetes insipidus
GI obstruction
Excessive use of diuretics
o Cardiogenic shock: inadequate vascular tone
MI
Dysrhythmias
Pump failure
o Distributive Shock: inadequate vascular tone
Neural: induced loss of vascular tone: anesthesia, pain, insulin shock, spinal cord
injury
Chemical: induced loss of vascular tone: toxic shock, anaphylaxis, capillary leak-
burns, decreased serum protein levels
o Plan:
Low dose-corticosteroids for septic shock
Medications to vasoconstrict and improve myocardial contractility.
Medications used to restore BP, adrenergic/sympathomimetic (dobutamine
hydrochloride)
Increased Intracranial pressure
o Earliest sign- altered LOC, restlessness, confusion, pupillary changes.
o Late signs: increased BP, decreased pulse
o Glasgow: 3-8 indicates severe head trauma; score of 15 indicates client is alert and oriented
o Diagnostic tests: lumbar puncture, EEG, myelogram
o Causes: cerebral edema, hemorrhage, space occupying lesions
o Complications: cerebral hypoxia, decreased cerebral perfusion, herniation-pupil constriction
 o Plan:
o Monitor VS hourly: be alert for increased systolic pressure, widening pulse pressure, and
brady (Cushings triad)
o Monitor pupillary changes
o Glasgow
o Elevate head 30-45 degree to promote venous drainage from brain
o Avoid neck flexion, head rotation, coughing, sneezing, bending fwd
o Reduce environmental stimuli
o Prevent valsava maneuver, teach client to exhale while turning or moving
o Restrict fluids 1200-1500
o Administer meds:
Osmotic diuretics: reduce fluid vol (mannitol)
Corticosteroids: reduce cerebral edema (dexamethasone)
Antiseizure meds (diazepam, phenytoin, phenobarbital)
Seizures:
o Causes: epilepsy, fever, head injury, HTN, CNS infxn, brain tumor, drug withdrawal, stroke
o Plan:
o raise side rails
o ease client to floor
o loosen restrictive clothing
o do not insert anything by mouth!
o Types of seizures:
o Tonic-Clonic: aura. Starts with tonic (stiffening) clonic (jerking). May have bladder incont.
Hard to arouse. Fall asleep. All age groups
o Absence: staring spell, lip smacking, chewing. Children.
o Myoclonic: brief muscular contraction involving one or more limbs, trunk. Children
o Infantile Spasms: gross flexion, extension of limbs treated with ACTH. Infants and children
o Atonic Seizures: sudden loss of muscle tone and posture control, child drops to floor. (infants
and children).
o Tonic seizure: stiffening of limbs. Infants and children
o Partial seizures: Jacksonian, focal seizure, starting at one location, may spread. All ages
o Sensory: tingling, numbness of body part, visual, olfactory, taste sx. All ages
o Affective: inappropriate fear, laughter, depersonalization. All ages
o After seizure:
o Provide description of seizure in record:
Circumstances surrounding seizure
How seizure started (location of first tremors)
Type of body movements
Areas of body involved
Incont
Duration of each phase
o To prevent seizures:
o Administer anticonvulsant (phenytoin, phenobarbital)
o Avoid seizure triggers: alcohol, stress, caffeine, fever, hyperventilation
o Alternative therapies:
Ketogenic diet to prevent seizures:
High in fat, low in carbs. Mimics effect of fasting
Suppresses many seizures
Stroke
o Confusion
o Bladder
o Aphasia
o Hemiphlegia
o Bladder and bowel incont.
o Hemianopia: loss of half of visual field
o Emotional lability (changes easy)
o Dysphagia
o Causes: thrombosis, embolism, hemorrhage
 o Risk factors: age, HTN, diabetes mellitus, TIAs, smoking, elevated blood lipids, oral contraceptives,
atrial fibrillation
o Plan:
o Immediate Care: maintain patent airway, minimize activity, keep head elevated 15-30
degree to prevent increases intracranial pressure, administer thrombolytic within 3 hours of
onset sx.
o Intermediate: place food on unaffected side of mouth, semisolid food- easiest to swallow,
maintain upright position for 30-45 minutes after eating, monitor elimination, do not
approach from visually impaired side, encourage use of affected side
Spinal cord injury
o Loss of motor and sensory function below level of injury.
o Spinal shock sx:
o Flaccid paralysis of skeletal muscles, complete loss of all sensation, decreased pulses, brady,
suppression of somatic and visceral reflexes, postural hypotension, edema
o Diagnose:
o Categories of neurological deficit:
Complete: no voluntary motor activity or sensation below level of injury
Incomplete: some voluntary motor activity or sensation below level of injury
Tetraplegia (quadriplegia)
o Causes: trauma due to accidents, occurs predominately in young white males (15-30),
substance abuse, neoplasms
o Immobilize cervical spine:
Skeletal traction: Gardner-Wells, Crutchfield, Vinke tongs, halo traction
Surgical stabilization: reduction and stabilization by fusion, wires, and plates
o Administer steroid therapy and antispasmodics (baclofen, diazepam)
o Prevent complications of autonomic hyperreflexia (dysreflexia)
Occurs in clients with spinal cord lesions above T6 after spinal shock
Sx: pounding headache, profuse sweating, especially of forehead, nasal congestion,
piloerection (goose flesh, hair sticks up on arms), brady, HTN
Give hydralazine may be given slowly IV (to decrease BP)

Fluid and Electrolyte Imbalances

-Volume Deficit:
o Isotonic loss, V/D, GI suction, sweating, decreased intake, hemorrhage, third spacing
o Plan: provide isotonic IV fluid; LR or .9%NaCl
-Volume Overload:
o Isotonic gain, increase in intestinal compartment, intravascular compartment, CHF, Renal
failure- cirrhosis of liver, excessive ingestion of sodium
o Plan: diuretics, restrict fluids, edema, semi-fowlers position if dyspneic.
-ADH Disorders:
o Diabetes Insipidus (decreased ADH)
o Excessive urine output, chronic dehydration, excessive thirst, anorexia
o Causes: Head trauma, brain tumor, meningitis, encephalitis, deficiency of ADH, low urine
specific gravity, urinary osmolality below, high sodium
o Watch I/O. monitor urine specific gravity, skin condition, weight, BP, pulse, temp, administer
Pitressin (hormone for DI)
o SIADH (Syndrome of Inappropriate ADH Secretion (increased ADH)
o Anorexia, NV, lethargy, headaches, change in LOC, decreased deep tendon reflexes, tachy,
increased circulating blood vol., decreased UO
o Causes: small cell carcinoma of lung, pneumonia, positive pressure ventilation, brain tumors,
head trauma, stroke, meningitis, encephalitis, ADH is released even when plasma hypo-
osmolality is present
o Diagnostic Test: serum sodium decreased, plasma osmolality decreased, increased urine
specific gravity
o Restrict water intake, administer diuretics to promote excretion of water, hypertonic saline,
administer demeclocycline, weight daily, monitor sodium levels, assess LOC
-Potassium Imbalance:
o Hypokalemia:
o Anorexia, NV, dysrhythmias (increased sensitivity to digitalsis), muscle weakness,
paresthesia
 o Potassium: main intracellular ion, involved in cardiac rhythm, nerve transmission
o Causes: vomiting, gastric secretions, diarrhea, diuretics, steroids
o Plan: administer oral potassium. Dilute in juice to avoid gastric irritation, increase dietary
intake (raisins, bananas, apricots, oranges, beans, potatoes, carrots, and celery) increase
risk of digoxin toxicity
o Hyperkalemia:
o EKG changes, dysrhythmias, cardiac arrest, muscle weakness, paralysis, ND
o Causes: renal failure, burns, crushing injuries
o Plan: restrict dietary potassium, give sodium polystyrene sulfonate (causes diarrhea), in
emergency give IV sodium bicarbonate, peritoneal or hemodialysis, diuretics
-Sodium Imbalances:
o Hyponatremia:
o Nausea, muscle cramps, increased intracranial pressure, confusion, muscular twitching,
convulsions
o Diagnose: sodium- main extracellular ion; responsible for water balance.
o Causes: vomiting, diuretics, excessive administration of dextrose and water IVs, prolonged
low sodium diet, excessive water intake
o Plan: water restriction, LR, beef broth, tomato juice
o Hypernatremia:
o Elevated temp, weakness, disoriented, delusion, hallucination, thirst, dry swollen tongue,
sticky mucus membranes, postural hypotension and decreaed ECF, HTN with normal or
increased ECF, tachy
o Causes: hypertonic tube feedings without supplements, diarrhea, hyperventilation, DI,
inhaling large amounts of salt water, inadequate water ingestion
o Plan: decrease sodium in diet, offer fluids at regular intervals, hypotonic solution
Calcium Imbalances:
o Hypocalcemia:
o Nervous system becomes increasingly excitable,
seizures, confusion, paresthesia, irritability
o Tetany:
Trousseus sign: inflate BP cuff on upper
arm, carpal spasms within 2-5 minutes
indicate tetany
Chvosteks sign: tap facial nerve,
twitching of face indicates tetany
o Calcium is needed for blood clotting, skeletal
muscle contraction. Regulated by parathyroid
hormone and vitamin D, facilitates reabsorption
of calcium from bone and enhances absorption
from the GI tract
o Causes: hypoparathyroidism, pancreatitis, renal
failure, steroids and loop diuretics, inadequate
intake, post thyroid surgery.
o Plan: use caution with digitalized clients because
both are cardiac depressants, administer
phosphate binding antacids, calcitrol, vit d,
maintain safety for confusion because decrease
in calcium, maintain airway because laryngeal stridor can occur
o Hypercalcemia:
o Sedative effect on central and peripheral nervous system, muscle weakness, lack of
coordination constipation, abdominal pain, distention, confusion, depressed, absent tendon
reflexes, dysrhythmias
o Causes: malignant neoplastic diseases, hyperthyroidism, excessive intake, immobility,
excessive intake, immobility, and excessive intake of calcium carbonate antacids.
o Plan: encourage fluids, Lasix, calcitonin- decrease calcium level, prevent development of
renal calculi, increased fluid, maintain acidic urine, prevent UTI, surgical intervention, injury
prevention, limit intake of antacids
Magnesium Imbalances:
o Hypomagnesemia:
 o Magnesium acts as a depressant. Dysrhythmias, tremors, tetany, depression, dysphagia,
depression, seizures
o Causes: alcoholism, GI suction, diarrhea, intestinal fistulas, abuse of diuretics or lax
o Plan: increase intake of dietary Mg: green vegetables, nuts, bananas, oranges, PB,
chocolate, monitor cardiac rhythm and reflexes to detect depressive effects of mag., monitor
for dig toxicity, seizures, test ability to swallow because of dysphagia
o Hypermagnesemia:
o Depresses the CNS, depresses cardiac impulse transmission, hypotension, facial flushing,
muscle weakness, absent deep tendon reflexes, paralysis, shallow resp
o Causes: renal failure, excessive mag, administration of antacids, cathartics)
o Plan: emergency, support ventilation, hemodialysis, monitor reflexes, teach about OTC drugs
containing Mg, monitor cardiac rhythm

Adrenal Disorders
o Adrenal cortex: glucocorticoids, mineralcoritcoids, androgen
and estrogen
o Adrenal medulla: norepi,epi
o Addisons: hypocorticolism- adrenal glands dont produce
enough hormones (mineralcorticoids, glucocorticoids,
androgens)
o High protein, high carb, high sodium, low K diet
o Monitor for hypoglycemia, hyponatremia
o Avoid factors that precipitate Addisonian crisis (NV,
abdominal pain, fever, extreme weakness, severe
hypoglycemia, hyperkalemia, dehydration, BP falls-
leading to shock and coma): stress, inadequate steroid
replacement
o Fatigue, weakness, dehydration, decrease BP,
hyperpigmentation, decrease resistance to stress,
alopecia, weight loss, depression, lethargy, emotional
lability
o Decrease sodium, blood vol+shock, blood sugar+insulin
shock
o Increased potassium
o Diagnose: CT, MRI, Hyperkalemia, hyponatremia, decrease plasma cortisol, urinary, ACTH
o TMT: hormone replacement
o TMT of Addisonian Crisis: administer hydrocortisone therapy, IV glucose, glucagon, insulin
with dextrose in normal saline
o Cushings Disease(hypercortisolism): Adrenal gland produces too much cortisol
o Fatigue, weakness, osteoporosis, muscle wasting, cramps, edema, increase BP, purple skin
striations, hirsutism, emaciation, depression, decreased resistance to infxn, moon face,
buffalo hump, obese trunk, mood swings, masculinization in females, blood sugar imbalance.
o Hypersecretion of adrenal hormone (mineralcocorticoids, glucocorticoids, androgens),
increase sodium, blood vol, BP, BS+ketoacidosis
o Decrease potassium
o Diagnose: skull films, BS analysis, hypokalemia, hypernatremia, plasma cortisol level
o TMT: hypophysectomy, adrenalectomy
o TMT: assure client most physical changes are reversible with TMT, observe for hyperactivity,
GI bleeding, FVO, administer aminoglutethimide or metyrepaone to decrease cortisol
production, monitor for shock, HTN
Pheochrmocytoma
o Intermittent HTN, increase HR, NV, weightloss, hyperglycemia, glucosuria, polyuria, diaphoresis,
pallor, tremor, pounding headache, weakness, visual disturbance during hypertensive episodes,
pain, urinary vanillymandelic acid (VMA) test (24 hr urine for VMA- breakdown product of
catecholamine metabolism-food affecting VMA excretion excluded 3 days before test- coffee, tea,
bananas, chocolate, vanilla.
o Diagnose: hypersecretion of catecholamines (epi and norepi) activate fight or flight response due to
secreting tumors.
o Plan: avoid stress, avoid chilling, avoid caffeine, tea, cola, foods containing tyramine, limit activity,
administer adrenergic blocking agents, apresoline for hypertensive crisis,
 o TMT: adrenalectomy or medullectomy

Alterations in Body Systems

-COPD:
o Change in skin color- cyanosis or reddish color, weakness, weight loss, use of accessory muscles of
breathing, dyspnea, cough, adventitious breath sounds, changes in sensorium, memory impairment
o Risks: smoking tobacco, passive tobacco smoke, occupational exposure, air pollution, coal, gas,
asbestos exposure
o Diagnose: most common cause of lung disease,
o Asthma: chronic disease with episodic attacks of breathlessness
o Emphysema (over inflation of alveoli resulting in destruction of alveolar walls)- predisposing
factors: smoking, chronic infxns, and environmental pollution
o Chronic bronchitis: inflammation of bronchi with productive cough
o CF: causes: sweat gland dysfxn, respiratory dysfxn, GI, dysfxn
o Diagnoses: GI enzyme evaluation: pancreatic enzyme deficiency, sweat chloride analysis
test- elevated levels of sodium and chloride
o Client teaching: avoid hot/cold air, allergens, avoid ppl with colds or flu, stop smoking, avoid
crowds
-Congenital Heart Anomalies:
o Diagnose: HX predisposing factors:
o Maternal rubella during pregnancy, alcoholism, maternal age over 40 years, IDDM, siblings
with heart disease, parent with congenital heart disease
o General effects of heart malformation:
o Increased workload: overloading of chambers results in hypertrophy and tachy
o Pulm. HTN: increased vascular resistance results in dyspnea, tachypnea, and recurrent resp.
infxns.
o Inadequate systemic CO results in exercise intolerance and growth failure
o Arterial desat from shunting of deoxy blood directly into the systemic circulation results in
polycythemia, cyanosis, cerebral changes, clubbing, squatting
o Murmurs due to abnormal shunting of blood between two heart chambers or between
vessels.
o Types of Defects:
o Increased pulmonary blood flow (acyanotic)
Increased septal defect (VSD)-
abnormal opening between right and
left ventricles. Characterized by loud
harsh murmur, may close
spontaneously by age 3- surgery may
be indicated
Atrial septal defect (ASD) abnormal opening between the two atrial severity depends
on size and location. Small defects high on sputum may not cause clinical sx, murmur
audible and distinct for defect.
Patent Ductus Arteriosus (PDA) failure of fetal structure to close after birth. PDA
allows blood to be shunted from aorta (high pressure) to pulmonary artery (low
pressure) causing additional blood to be reoxygenated in the lungs; result is
increased pulm vascular congestion and right ventricular hypertrophy. Characteristic
murmur, widened pulse pressure, bounding pulse, tachy. TMT: surgical
o Obstruction to blood flow from ventricles (Acyanotic)
Coarctation of the aorta- narrowing of aorta: High BP and bounding pulses in areas
receiving blood from vessels proximal to defect; weak or absent pulses distal to
defect, cool extremities, muscle cramps. Murmur may or may not be present. TMT:
surgical.
Pulmonic stenosis: narrowing at entrance to the pulmonary artery. Resistance to
blood flow causes right ventricular hypertrophy, common with PDA, TMT: pulmonary
valvotomy
Aortic stenosis: narrowing of aortic valve causes decreased CO. murmur usually hear,
surgery recommended
o Decreased pulmonary blood flow (cyanotic)
Tetralogy of Fallot- four defects=ventricular septal defect, pulmonic stenosis,
overriding aorta, r. ventricular hypertrophy. Cyanosis, clubbing fingers, delayed
 physical growth and development, child often squats or assumes knee position. TMT:
surgical
o Mixed Blood flow (cyanotic)
Transposition of great vessles
Truncus Arteriosus: failure of normal septation and embryonic division of pulm artery
and aorta, resulting in a single vessel that overrides both ventricles, giving rise to
pulm and systemic circulations.
Blood from both ventricles enters the common artery, cyanosis, left
ventricular hypertrophy, dyspnea, activity intolerance, growth retardation,
harsh audible murmur. TMT: close ventricular septal defect.
Total anomalous Venous return: absence of direct communication between pulm
veins and left atrium. Cyanosis, murmur, pulm congestion, HF
Compensatory mechanisms observed in cyanotic heart disease: tachy, polycythemia,
posturing-squatting, knee chest position
o Plan: prevent congenital heart disease: prenatal care, immunization against rubella in
females, recognize early sx (cyanosis, poor weight gain, poor feeding, exercise intolerance,
unusual posturing), meds (dig, iron, diuretics, potassium)
Heart Failure:
o Failure of the cardiac muscle to pump sufficient blood to meet the bodys metabolic needs.
Ventricles cant empty completely, backup of circulation
o Left sided HF:
o Dyspnea, paraoxysmal nocturnal dyspnea, orthopnea, PE, Cheyne-stokes respirations, pulm
edema, rales (crackles), cough with frothy blood tinged sputum, decreased renal fxn,
elevated BUN, albuminuria, edema, cerebral anoxia (changes in mental status), fatigue,
muscle weakness, s3 gallop
o Right sided HF:
o Dependent edema (ankle), liver enlargement, abdominal pain, anorexia, nausea, bloating,
coolness of extremities, anxiety, depression, dear, weight gain
o Plan: digoxine-fundamental drug in the tmt of HF.
o Two categories of dosages:
Rapid digitalization: aimed at administering the drug rapidly to achieve detectable
effect
Gradual digitalization: client placed on smaller amounts, designed to replace the
digoxin lost be excretion while maintain optimal cardiac functioning
o Diuretics-thiazides, carbonic anyhydrase inhibitors, loop diuretics
o Vasodilators: decrease afterload and improve contractility
o Morphine: decrease afterload
o Inotropic agents: improve cardiac contractility
o Restricted sodium diet, low cal, bland, low residue- avoid foods that cause gastric distention
and heartburn.
o Causes:
o Hypertensive disease: vessels become narrowed; peripheral resistance increases. Cardiac
muscle enlarges beyond its oxygen supply
o Arteriosclerosis: degenerative changes in arterial walls cause permanent narrowing of
coronary arteries. Cardiac muscle enlarges beyond oxygen supply.
o Valvular heart disease: stenosed valves dont open freely; scarring and retraction of valve
leaflets result in incomplete closure. Workload increases until heart falls
o Rheumatic heart disease: infection causes damage to heart valves, making them
incompetent or narrowed. Cause blood to regurgitate backwards, workload increases until
heat fails.
o Ischemic heart disease: coronary arteries are sclerosed or thrombosed. Blood supply is
insufficient to nourish heart
o Constrictive pericarditis: inflamed pericardial sac becomes scarred and constricted causing
obstruction to blood flow. Low CO and increased venous pressure, decreases heart filling
o Circulatory overload: excessive fluid in circulatory system. Overwhelms hearts ability to
pump.
o Pulmonary Disease: damage to arterioles of lungs causes vascular constriction; increases
workload of heart. Right ventricular enlargement and failure.
o Tachydysrhythmias: decreases ventricular filling time. Decreased CO
Angina Pectoris:
 o Pain relieved with rest and nitroglycerins
o Risk factors for CAD:
o Non-modifiable: client has no control
Increasing age, family hx, men more likely, race
o Modifiable: client can exercise control
Elevated cholesterol, smoking, HTN, diabetes mellitus, lazy, obesity, depression,
chronic stress, oral contraceptive, meth, cocaine
o Significance- warning sign of ischemia
o Plan:
o No smoking, follow balanced diet limiting fat and sodium
o Vasodilators, aspirin, glycoprotein, BB, angiotensin receptor blockers, CCB
o Percutaneous transluminal coronary angioplasty (PTCA) and stent placement.
Balloon tipped catheter inserted. Plaque compressed against open lumen of vessel. IV
heparin continuous infusion to prevent clots and IV nitro to prevent coronary
vasospasms. Monitor for closure of vessels, bleeding, reaction to dye, hypotension,
hypokalemia, dysrhythmias.
o CABG: to increase blood flow to heart muscle in clients with severe angina. Saphenous vein
or internal mammary artery used for graft. Up to 5 arteries may be bypassed.
Peripheral Vascular Disease:
o Arterial (arteriosclerosis, Raynauds, Buergers)
o Dependent rubor, cool shiny skin, cyanosis, ulcers, gangrene, impaired sensation,
intermittent claudication, decreased peripheral pulses, pallor with extremity elevation
o Risks factors: smoking, exposure to cold, stress, diabetes mellitus, high fat diet, HTN, obese
o TMT: do not cross legs, transluminal angioplasty, arterial bypass, endartectomy amputation,
vasodilators, anticoagulants, antiplatelet meds.
o Venous (varicose veins, thrombophlebitis)
o Cool, brown skin, edema, ulcers, pain, normal or decreased pulses
o Risk factors: immobility, pregnancy, hereditary, obesity, CHF, injury to vein wall,
hypercoagulability
o TMT: thrombectomy, avoid extreme temperatures, elastic stockings, TED hose, intermittent
pneumatic compression devices, anticoagulants, bedrest 4-7 days, elevate legs, warm moist
packs
HTN: Persistent elevation of BP
o Anginal pain, intermittent claudication (impairment in walking, pain tirededness in legs), retinal
hemorrhage and exudates, severe occipital headaches, polyuria, nocturia, anxiety, protein and
RBCs in the urine, diminished ability of kidneys to concentrate urine, dyspnea on exertion- L. HF,
edema of extremities R. HF
o Risk factors:
o Family hx, excessive sodium, excessive intake of cals, lazy, excessive alcohol intake stress,
hx of renal and CVD, age,
o Primary: 90% of all cases; may be benign (gradual onset) or malignant (abrupt onset-rapidly
fatal if not treated).
o Secondary: develops because of another disease of the CV system, renal system, adrenal
glands, neurological symptoms, meds.
o Complications: Renal failure, stroke, TIA, retinal hemorrhage
o Plan: administer antiHTN meds- diuretics, CCB, ACE inhibitors, angiotensin receptor blockers, BB,
aldosterone blockers, central alpha antagonists
o Teaching: weight control, dietary restrictions of fat and sodium, moderate alcohol intake, stop
smoking, change positions slowly- orthostatichypotension.
Anemia: decrease in number of erythrocytes or a reduction in hgb
o Mild: hgb 13-18 usually asymptomatic. Sx: usually follow strenuous exertion; palpitations, dyspnea,
diaphoresis
o Moderate: dyspnea, palpitations, diaphoresis, chronic fatigue
o Severe: pale, exhausted all the time, severe palpitations, sensitivity to cold, loss of appetite,
profound weakness, dizziness, syncope, CHF, angina pectoris
o Plan: frequent rest periods, frequent turning and repositioning, diet high in protein, iron, vits, small
easily digestible meals, good oral hygiene
Iron deficiency anemia: most common type.
o Fatigue, decreased albumin, gamma globulin, and transferrin, glossitis, spoon nails (Koilonychia),
impaired cognition
 o Causes: decreased dietary intake, malabsorption after gastric resection, blood loss due to ulcers,
gastritis, GI tumors, menorrhagia (excessvie menstrual bleeding), poor absorption due to high fiber
diet
o Plan: iron supplements preferred is IV route because IM causes pain, skin staining, and higher
incidence of anaphylaxis, take oral supplements with meals if GI upset, use straw if taking by liquid
because stains teeth.
Vitamin B12 Anemia and Pernicious Anemia: gastric mucuosa fails to secrete sufficient intrinsic factor
required for absorption of vit B12.
o Diagnose by Schilling Test
o Pallor, fatigue, weight loss, sore red tongue, balance and gait disturbances, parethesias in hands
and feet.
o Causes: inadequate dietary intake (vegans who eat no meat), bone marrow produces fewer, larger
RBC
o Plan: initial IM administration. Then 1-2 months or cyanocobalamin nasal spray
Sickle Cell Disease: severe hemolytic anemia resulting form defective hgb. Hgb becomes sickle shaped in
presence of low oxygen. SX caused by hemolysis and thrombosis
o Pain, swelling of joints during crisis, fever, jaundice (esp. of sclera), tachy, murmur, hgb 7-10 on
blood smear
o Plan: check joints for pain and swelling, check for signs of infection (osteomyelitis and pneumonia
common), avoid high altitudes and extreme temps, promote fluids, administer folic acid everyday,
during crisis provide analgesics, administer hydroxyurea
o Hydration is key because dehydration will cause crisis
Hemophilia: sex linked, transmitted to male by female carrier, recessive trait, factor VII deficiency-
hemophilia A most common
o Spontaneous easy bruising, joint pain with bleeding, prolonged internal and external bleeding from
mild traumas, gingival bleeding, GI bleeding, hematuria, pallor
o Plan: assess forinternal bleeding, analgesics for joint pain-not aspirin, avoid IM injections, bedrest
during bleeding episodes, avoid contact sports
o TMT: plasma or factor VII cryoprecipitate, bedrest, analgesics (aspirin contraindicated)
Pituitary Disorders: anterior hormones: growth, TSH, ACTH, LH, FSH. Posterior hormones: oxytocin,
vasopressin, ADH
o Dwarfism (Hypopituitarism): height below normal, body proportions normal, sexual maturity
delayed, skin fine
o Hyposecretion of growth hormone, occurs before maturity
o Etiology unclear (predisposition- pituitary tumors, idiopathic hyperplasia)
o TMT: hormone replacement. Complications: diabetes.
o Plan: monitor growth and development, refer for psychological counseling as needed,
hormone replacement theory, testosterone therapy, thyroid hormone replacement, hCG
injection.
o Acromegaly: body size enlarged, coordination poor, flat bones enlarged, sexual abnormalities, deep
voice, skin thick and soft, visual field changes
o Hypersecretion of growth hormone occurs after maturity
o diagnosis growth hormone measured in blood plasma
o TMT: external irradiation of tumor, hypophysectomy (removal of pituitary or portion of it with
hormone replacement
o Plan: administer dopamine agonists; somatostatin analogs; growth hormone receptor
blockers, provide care during radiation, hypophysectomy: elevate head, check neuroligcal
status and nasal drainage, observe for hormonal deficiencies (thyroid, glucocorticoid),
observe for hypoglycemia, avoid coughing, avoid tooth brushing for 2 weeks.

Cancer
o Change in bowel, bladder habits, sore that does not heal, unusual bleeding or discharge, thickening
or a lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wort or
mole, nagging cough, hoarseness
o Risk factors:
o Immunosuppression, advancing age, genetic predisposition
o Physical: radiation, chronic irritation
o Chemical: food additive: nitrites, industry: asbestos, pharmaceutical: stillbesterol, smoking,
alcohol
o Genetic, viral (Epstein- Barr virus, Burkitts lymphoma
 o Stress
o Common cancer types: caucasion: lung, breast, colorectal, prostate. AA: lung, prostate, breast,
colorectal, uterine. Asian: breast, colorectal, prostate, lung, stomach. Hispanic: prostate, breast,
colorectal, lung
o Classifications: carcinoma: epithelial tissue, sarcoma: connective tissue, lymphoma: lymphoid
tissue, Leukemia: blood forming tissue (WBC and platelets)
o Plan:
o Cancer prevention: avoid known carcinogens (dont smoke, wear sunscreen, eliminate
asbestos in building), avoid excessive intake of animal fat, avoid nitrates found in lunch
meats, sausage, and bacon, decrease intake of red meat, limit alcohol intake, increase
intake of bran, broccoli, cauliflower, brussels sprouts, cabbage, foods high in vit A and C
o Chemo:
Teletherapy (radiotherapy):
External radiation (cobalt): leave radiology markings intact on skin, avoid
creams, lotions, deodorants, perfumes, use lukewarm water to cleanse area,
assess skin for redness, cracking, no hot water bottle, tape, wear cotton
clothing.
Brachytherapy (internal radiation): cesium, radium, gold
Sealed source (cesium)-mechanically positioned source of radioactive material
placed in body cavity or tumor. Lead container and long handled forceps in
room in event of dislodgment, save all dressings and bed linens until source is
removed, urine and feces not radioactive, do not stand close or in line with
radioactive source
Unsealed source of radiation, unsealed liquid given orally or instilled in body
cavity. All body fluids contaminated, greatest danger from body fluids during
first 24-96 hours
Nursing for internal radation:
o Assign client private room, wear dosimeter film badge at all times
when interacting with client (offers no protection but measures amount
of exposure), do not assign pregnant nurse, limit close contact to 30
minutes per 8 hour shift, provide shield in room.
Avoid use of soaps, powders, lotions, wear cotton, loose fitting clothing.
Mouth care: Stomatisis: develops 5-14 days after chemo begins. Sx: erythema,
ulcers, bleeding. Rinse with saline or chlorhexidine; avoid hot temp or spicy foods,
topical antifungals and anesthetics
Nutritional changes: anorexia, malabsorption and cahchexia (wasting), conform food
to clients preferences
Pain relief 3 step ladder
Mild: nonnarcotic meds (acetaminophen) along with antiemetics,
antidepressants, glucocorticoids
Moderate pain: weak narcotics (codeine) and nonnarcotic
Severe pain: strong narcotics- morphine
-Leukemia: neoplastic disease that involves the blood forming tissues of the bone marrow, spleen, and
lymph nodes; abnormal, uncontrolled, and destructive proliferation of one type of white cell.
o Ulcerations of mouth and throat, pneumonia, septicemia, altered leukocytes, anemia, fatigue,
lethargy, bone and joint pain, hypoxia, bleeding gums, ecchymosis, petechiae, retinal hemorrhage,
weakness, pallor, weight lost, heptomegaly, splenomegaly, disorientation, convulsions
o Diagnose: bone marrow aspiration. Complications: osteomyelitis, bleeding, puncture of vital organs
o Classification of leukemia:
o Acute: rapid onset and progresses to a fatal termination within days to months; more
common among children and young adults.
o Chronic: gradual onset with a slower more protracted course, more common in age 25-60
o Plan: assess for signs of bleeding, good mouth care, high cal diet, freq feedings of soft easy to eat
food, antiemetics, neutropenia, strict handwashing, prevent skin breakdown, administer blood
transfusions,
-Skin Cancer: major risk factor is overexposure to sun.
o Basal cell carcinoma: most common type of skin cancer rarely metastasize but commonly reoccurs.
Small waxy nodule on sun exposed areas of body. May ulcerate and freckle
o Squamous cell carcinoma: may metastasize to blood or lymph. Rough, thick, scaly tumor seen on
arms or face
 o Malignant melanoma: most lethal of skin cancers; highest risk persons with fair complexions, blue
eyes, red or blonde hair, freckles; metases to bone, liver, spleen, CNS, lung, lymph. Variegated color
(brown, black mixed with gray or white) circular lesion with irregular edges seen on trunk or legs.
o Diagnose by skin lesion biopsy
Intracranial Tumors:
o Seizures- more cortex, papilledema, personality disturbances- frontal lobe
o Diagnose: classified according to location:
o Supraterntorial- incision behind hairline, surgery within the cerebral hemisphere
o Infratentorial: incision made at nape of neck around occipital love; surgery within brain stem
and cerebellum
o Plan: elevate HOB 30-45 degress after supratentorial surgery. Position client flat and lateral on
either side after infratentorial.
o Observe for complications: respiratory difficulties, increased ICP, hyperthermia, meningitis,
wound infection
o Admnister medications: corticosteroids, osmotic diuretics, mild analgesic, anticonvulsants,
antiemetics, no narcotics because changes in LOC)
Carcinoma on Larnynx
o Pain radiating to the ears, hoarsenss, dysphagia, foul breath, dyspnea, enlarged cervical nodes,
hemoptysis
o Causes: industrial chemicals, cigarette smoking, alcohol, chronic laryngitis, straining of vocal cords,
family hx
o Observe for post-op difficulties: fistula, respiratory difficulties, stenosis of trachea, rupture of carotid
o Communicate with esophageal speech, artificial larynx- mechanical device
o Radiation therapy

Mobility
o Lumbar lordosis: exaggerated concavity in the lumbar region
o Kyphosis: exaggerated convexity in the thoracic region
o Scoliosis: lateral curvature of a portion of the vertebral column
Immobility:
o Isometric exercise: alternate contraction and relaxation of muscle without moving joint.
Maintenance of muscle strength when joint immobilized
o Therapeutic positions:
o Supine: avoid hip flexion (which can compress arterial flow)
o Prone: promotes extension of hip joint. Not good for ppl with CVD or respiratory issues
o Head elevated: increases venous return, max lung expansion
o Modified Trendelenburg: increases blood return to het. Relieves pressure on lumbosacral
area
o Elevation of extremity: increases venous
return, decreases blood vol to extremity.
o Crutches: 8-10 in. out to side. Elbows flexed 20-30
degree angle
o GOING UPSTAIRS GOOD LEG FIRST,
CRUTCHES, THEN BAD LEG
o VISE VERSA GOING DOWN.
o UP WITH THE GOOD DOWN WITH THE
BAD
o Cane: hold cane in hand opposite affected extremity.
Advance cane then leg
Joint Disorders

Pagets Disease:
o Pain, bowed legs, decreased
height, shortened trunk with
long arms, enlarged skull, long
bone spine and rib pain, kyphosis, excessive bone resorption. Bone is excessively broken down
Bursitis:
o Pain due to inflammation, decreased mobility
o Inflammation of connective tissue sac between muscles, tendons, and bones.
o Promote ROM, cortisone injection
Osteoporosis:
o Kyphosis, low back pain (hips and spine)
o Reduction in bone mass with no changes in mineral composition. Degenerative disease, loss of
bone density and tensile strength
o Diagnosed by bone mineral density: less of equal to 2.5=osteoporosis
o ROM exercise, physiotherapy, calcitonin, raloxifene, estrogen
Osteomyelitis:
o Pain, swelling, warmth on affected area, elevated ESR, leukocytosis (increase in WBC)
o Infection of the bone
Osteolmalacia:
o Decalcification of bones due to inadequate intake of vitamin D, absence of exposure to sunlight,
CKD
o Give vitamin D rich foods: milk, eggs, vitamin D
enriched cereals, bread
Spina Bifida/Neural tube defects:
o Dimpling at the site- spina bifida occulta
o Bulging sac like lesion filled with spinal fluid and
covered with a thin, bluish, ulcerated skin-
meningocele
o Bulging sac like lesion filled with spinal fluid and
spinal cord-myelomeningocele.
o Hydrocephalus increases risk, paralysis of lower
extremities, musculoskeletal deformities: club feet,
dislocated hips, kyphosis, scoliosis, neurogenic
bladder
o Risk factor is folic acid deficiency
o Plan:
o No tmt for occulta
o Surgical repair for meningocele/myelomeningocele
o Position client on abdomen or semiprone with sandbags
Neuromuscluar Disorders:
 o Cerebral Palsy: athetosis (abnormal muscle contractions), spasticity, rigidity, ataxia, atonicity.
Neonate: cant hold head up, feeble cry, inability to feed. Infant: FTT. Toddler: intellectual delay,
physical delay
o Voluntary muscles poorly controlled due to brain damage.
o TMT: ambulation devices, surgical lengthening of heel cord to promote stability and function
o Medications: muscle relaxant, tranquilizers, anticonvulsants, intrathecal pump, baclofen
o Never tilt head back when feeding because of choking. High cal diet
o Muscular dystrophy: muscle weakness, lordosis/scoliosis, waddling gait, joint contractures,
stumbling falling
o Progressive muscle weakness, atrophy of voluntary muscle, no nerve effect. Genetic
o Diagnostic: CPK, abnormal electromyogram, abnormal muscle biopsy.
o TMT: intense PT, active and passive ROM. Light spinal braces or long leg may help
ambulation
o Prevent contractures
o Parkinsons Disease: tremors (pill rolling motion), akinesia (loss of automation), rigidity, weakness,
motorized propulsive gait, slurred monotone speech, dysphagia, salivation, constipation,
depression, dementia
o Deficiency of dopamine; increased acetylcholine levels
o Encourage finger exercises, ROM, goose stepping walk, walk with wider base, concentrate on
swinging arms while walking
o Educate family: does not lead to paralysis, intellect not impaired, sight and hearing are
intact, disease is progressive but slow
o Medications: dopaminergics- levodopa, amantadine, antivirals
o Myasthenia Gravis: muscular weakness produced by repeated movements soon disappears
following rest, diplopia, ptosis, impaired speech, dysphagia, resp distress, periods of remission and
exacerbations
o Deficiency of acetylcholine at myoneural junction. Etiology unclear, chronic progressive
intellect intact
o Diagnosed by injecting antichonesterase and seeing positive result
o Avoid factors that could precipitate MG crisis: infections, emotional upsets, use of
streptomycin, neomycin- produce muscle weakness.
o MG: crisis: sudden inability to swallow, speak or maintain airway.
o Multiple Sclerosis: early: vision, motor sensation changes. Late: cognitive and bowel changes.
Muscular incoordination ataxia, spasticity, intention tremors, nystagmus, incont, sexual dysfxn
o Demyelination of white matter throughout brain and spinal cord, leads to paraplegia or
complete paralysis
o ROM, warm baths, encourage 2000 ml fluid intake daily, use cane or walker, use weighted
bracelets and cuffs to stabilize upper extremities, bladder and bowel training, no tetracycline
or neomycin because increase muscle weakness with MS
o Lou Gehrigs Disease:
o Tongue, fatigue, atrophy with fasciculation (brief muscle twitching), dysphagia, aspiration,
progressive muscular weakness, muscular wasting, atrophy, spasticity, usually begins in
upper extremities, emotional lability, cognitive dysfunction, no alteration in autonomic,
sensory, or mental function
o Diagnose: progressive, degenerative disease involving lower motor neurons of spinal cord
and cerebral cortex, leads to mix of spastic and atrophic changes in cranial and spinal
musculature.
o Plan: progressive terminal disease

Interventions to Promote Comfort

Pain- the fifth vital sign, psychosocial
o Acute: an episode of pain that lasts from a split second to 6months, decreased healing, VS,
diaphoresis
o Chronic: episode of pain that lasts 6 months or longer, fatigue, depression, weight gain, immobility
Traction:
 Reduce fracture, alleviate pain, prevent deformities,
promote healing.
Types of traction:
o skin (bucks extension, Russels, pelvic
traction)- pulling force applied to skin
o skeletal (halo, crutchfield tongs)- pulling force
applied to bone
Maintain straight alignment of ropes and pulleys,
weights should hang free, maintain continuous pull.
Fractured hip: leg
shortened, adducted,
externally rotated

Thyroid Disorders:
Myxedema
(hypothyroidism):
o Decrease in
BMR, T3, T4,
and an increase in TSH, decreased activity level, sensitive to cold, obese, alopecia, dry skin
and hair, decreased ability to perspire, slowed physical and mental function
o Plan: instruct about causes of myxedema coma: acute illness, surgery, chemo, discontinuing
med), be patient, allow extra time for them, provide blankets and extra clothing, keep room
at 75 degrees.
Graves Disease (Hyperthyroidism):
o Increased BMR, T3, T4, high titer anti-thyroid, hyperactive, sensitive to heat, weight loss,
tachy,
exophthalmos, fine
soft hair,
accelerated
physical and
mental functions
o Plan: limit activities
to quiet ones,
restrict visitors and
control choice of
roommate, avoid
stimulants, use
calm unhurried
manner
Parathyroid Disorders:
Hypoparathyroidism:
o Tetany, muscle spasms, clonic convulsions,
paresthesia, tachy, positive chvostek and Trousseus
sign, anxiety, depression, dysphagia. Decreased calcium, PTH and increased phos.
Hyperparathyroidism:
 o Fatigue, muscle weakness, cardiac dysrhythmias, emotional irritability, renal caniculi,
pancreatitis, peptic ulcer, benign parathyroid tumor, neck trauma, increased in calcium and
parathyroid hormone, decrease in phos.

Transmission Precautions:
Airborne: private room with monitored negative air pressure. Door kept closed, wear a N-95 HEPA
filter. TB, measles, rubella, shingles, chicken pox
Droplet: private room, wear mask if coming into close contact, door may remain opne, pneumonia,
Flu, mumps, pertussis
Contact: herpes, MRSA, C-diff, scabies, RSV, rotavirus, hepatitis A

Tuberculosis:
Progressive
fatigue, anorexia,
weight loss,
irregular menses,
low grade fever,
night sweats,
irritable, coughs
sometimes with
blood, chest tight,
dyspnea, dull
aching chest
Lyme Disease:
Rash
(erythematous
papule that
develops into
lesions), flu like sx,
cardiac conduction
defects,
neurological
disorders
(paralysis).
Multisystem
infection
transmitted to
humans by tick
bite, most common
during summer
months.
Antibiotics:
doxycycline,
ceftriaxone,
azithromycin
STI:
Syphilis: treat with
penicillin,
erythromycin,
ceftriaxone,
tetracyclines. Copper colored rash on palms and soles, low grade fever. Reportable disease
Gonorrhea: thick discharge from vagina or urethra. Usually asymptomatic in females, pain with
intercourse. Yellow green discharge. Ceftriaxone, doxycycline, azithromycin, monitor for
inflammatory disease.
Genital Herpes: painful vesicular genital lesions, difficulty voiding, acyclovir, sitz baths, must notify
sexual contacts, precautions with vaginal delivery.
Chlamydia: dysuria, frequent urination, thick discharge, pelvic pain, painful menses. Treat with
azithromycin, -cycline. Must notify contacts
Cytomegalovirus: fever, malaise, visual impairment, adrenalitis, hepatitis, disseminated infection
Kaposis sarcoma: small purplish brown, no painful, diagnosed by biopsy
Botulism: drooping eyelids, weakened jaw, dysphasia, blurred vision, symmetric descending weakness,
may cause death. Contaminated food: 12-36 hours, aerosol inhalation: 24-72 hours. No person to person
transmission.

Growth and Development:

- 1 month:
o head sags, early crawling
movement
o toy: mobiles 9-10 in from face
- 2 months:
o closing of posterior fontanelle,
moro reflexes, able to turn from
side to back, can follow a moving
object with eyes
o toy: mobiles 9-10 in from face
o toy: rattles, cradle gym
- 3 months:
o can bring objects to mouth at
will, head held erect and steady,
smiles in mothers presence
o toy: rattles, cradle gym
- 4 months:
o absent tonic neck reflex,
drooling, moro reflex absent after 3-4 months
o toy: rattles, cradle gym
- 5 months:
o birth weight doubled, takes objects given to them
o toy: rattles, cradle gym
- 6 months:
o teething may begin, can turn from back to stomach
o toy: bright colored toys small enough to grasp but big enough for safety
- 7 months:
o grasps toy with hand, fear of strangers, abrupt mood shifts.
o toy: bright colored toys small enough to grasp but big enough for safety
- 8 months:
o anxiety with strangers
o toy: bright colored toys small enough to grasp but big enough for safety
- 9 months:
o elevates self to sitting position, responds to parental anger, dada may be heard.
o toy: books with large pictures, large push pull toys, teddy bears
o toy: bright colored toys small enough to grasp but big enough for safety
- 10 months:
o crawls well, pulls self to standing position, brings hands together, vocalizes one or two words
o toy: books with large pictures, large push pull toys, teddy bears
- 11 months:
o erect standing with support
o toy: books with large pictures, large push pull toys, teddy bears
- 12 months:
o needs help while walking, sit to stand without assistance, eats with fingers, mama and dada
o toy: books with large pictures, large push pull toys, teddy bears
- 15 months:
o walks alone, builds 2 block tower
- 18 months:
o anterior fontanelle closed, climbs stairs, 10 words, thumb sucking
- 24 months:
o early efforts at jumping, 300 word vocab, obeys easy commands
- 30 months:
o walk on tip toes, stand on one foot, sphincter control for toilet training
- 12-20 years old:
o body image, peer and social relationships, identity and autonomy important
 - 20-45 years old:
o work and career, establishes intimacy
- 45-65 years old:
o decreased cognitive and physical function, altered family, self-care deficit, altered body image.
- 65 and above years old:
o self-care deficit, isolation, altered relationships, decreased independence, family processes
altered.
Fetal alcohol syndrome:
- thin upper lip, epicanthus folds, maxillary hypoplasia, intellectual deficiencies, motor deficiencies,
microcephaly, hearing disorders, irritability during infancy and hyperactive during childhood, small
for gestational age.
Pregnancy:
- Naegeles rule: count back 3 months from first day of last menstrual period and add seven days and
one year.
- Chadwicks sign: cervix softens, mucus plug in canal, bluish color
Fetal Development abnormalities:
- Turners Syndrome (female with only one X chromosome): stunted growth, fibrous streaks in
ovaries, usually infertile
- Klinefelters syndrome: (male with an extra X): usually infertile, mild intellectual delay
- PKU: disorder due to autosomal recessive gene creating a deficiency in liver enzyme phenylamine.
Toxic to brain cells.
- Tay-Sachs Disease: deficiency of hexosaminida A, apathy and regression in motor and social
development, decreased vision
- Diagnostic Tests:
o AFP test: fetal serum protein to predict neural tube defects, threatened abortion, fetal
distress, suggest possible downs.
o CVS: early antepartal test to diagnose fetal karyotype, sickle cell, PKU, downs, Duchenne
muscular dystrophy.
Labor and Delivery:
- Lightening: subjective sensation as fetus descends.
- Contractions: frequency of less than every 2 minutes should be reported, more than 90 seconds
should be reported because of potential risk of uterine rupture or fetal distress
- Management of fetal distress: turn client onto left side, check for cord prolapse, elevate presenting
part of the cord, place in Trendelenburg or knee to chest position
Postpartum:
- Lochia: day 1-3 rubra (bloody with fleshy odor, may be clots), day 4-9 serosa (pink/brown with
fleshy odor), day 10+ alba (yellow-white), should not have foul odor indicates infection.
- Warm compresses and ice packs between feedings.
- At signs of late decelerations: position mother on left side lying, if no change, move to other side,
Trendelenburg or knee to chest position, ominous repetitive, stop oxytocin, prepare for c section
- FHR best heard at LOA
Ectopic Pregnancy:
- Missed period, unilateral lower quadrant pain after 4-6 weeks of normal pregnancy, rigid tender
abdomen, low hct, low hcg levels in urine and blood, bleeding, pain due to egg outside of uterus
HTN/Preeclampsia/Eclampsia:
- Diagnosed and treated before the 20th week of pregnancy.
- Severe pre-eclampsia: greater than 160/110, no seizures, headache, oliguria (difficulty peeing),
RUQ pain, thrombocytopenia, HELLP. Only cure is delivery of fetus, control BP with hydralazine
- Eclampsia: greater than 160/110, seizures, same as severe pre-eclampsia, severe headache, renal
failure, cerebral hemorrhage, tmt: DIC management, deliver fetus
Placenta Previa:
- First and second trimester spotting, third trimester bleeding that is sudden, bright red, potentially
profuse, painless.
- The placenta is implanted in the lower uterine segment, usually near or over the cervical opening,
placenta may partially or totally cover cervix.
- Plan: bedrest, sidelying or Trendelenburg for at least 72 hours, no vaginal or rectal exam (use
ultrasound). Get patient ready for delivery- c-section cant do vaginal.
Abruptio Placentae
- Painful, dark red vaginal bleeding, may be scant to profuse, abdomen tender and painful, possible
fetal distress, contractions
- Premature separation of the placenta
 - Plan: monitor for maternal shock and fetal distress, prepare for immediate delivery, monitor for PE,
infection, renal failure
Preterm Labor:
- Occurs between 20-37 weeks
- Plan: bedrest, side lying, administer terbutaline (stop contractions used to delay delivery), uterine
monitoring, daily weights.
Induction of Labor:
- Mother cannot have CPD, begin oxytocin administration, piggyback to principal IV line through
infusion pump, usual contraction patterns: q 2-3 minutes, lasting for 90 seconds or less.
Postpartum Hemmorhage:
- Blood loss greater than 500 ml after a vag birth or 1000 ml after a c-section.
Childbirth-neonatal:
- Airway- bulb suctioning- mouth first, then nose.
- APGAR: 0-3 poor, 4-6 fair, 7-10 excellent
- Tonic flex: fencing position, lying on back with head turned to one side will be in extension while on
opposite side will be flexed
- Moro reflex: elicited by sudden disturbance in the infants immediate environment, body will stiffen,
arms in tense extension, fingers in c formation.
- Babinski sign: stroking the sole of the foot from heel upward and toes fan.
RDS
- Labored respiration after several minutes or hours of normal respiration, cyanosis, expiratory
grunting, nasal flaring, unresponsive, apneic episodes
- Causes: surfactant deficiency disease, prematurity
- Position side lying with head supported by small folded blanket or on back with neck slightly
extended. CPAP or PEEP.
Perinatal Asphyxia:
- Meconium staining (nonbreech), signs of intracranial damage, increased pressure, altered
fontanelles, seizures, brady, abnormal respirations with cyanosis and decreased RR
- Prepare for aggressive ventilator assistance, keep airway open
Cleft Lip and Palate:
- Cleft lip: small or large fissure in facial process of upper lip or up to nasal septum.
o Repaired during 1-3 months
- Cleft palate: midline, bilateral, unilateral fissures in hard and soft palate.
o Repaired 12-18 months
Normal Reproduction:
- Menstruating women: 1 week after onset of menstrual period
- No menstruating women: first day of each month.
Reproductive Disorders:
- Toxic Shock Syndrome (TSS): sudden onset fever, vomiting, diarrhea, drop in systolic BP, and
erythematous rash on palms and soles.
Galactosemia: error of carbohydrate metabolism
Errors in BP reading:
- Inaccurately high: cuff too short or too narrow
- High diastolic: If client supports his or her own arm then sustained muscular contraction can raise
BP
- Inaccurately low: cuff too long or too wide
 Responses to avoid when
communicating:
- close ended
questions that can
be answered yes
or no.
- advice giving-
encourages
dependency may
not be right
- responding to
questions that are
related to ones
qualifications or personal life in a embarrassed or concrete way; keep conversation client centered
- why questions
-