Fundamentals of Nursing

A blood pressure cuff thats too narrow can cause a falsely elevated blood pressure reading. When preparing a single injection for a patient who takes regular and neutral protein Hagedorn insulin, the nurse should draw the regular insulin into the syringe first so that it does not contaminate the regular insulin. Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration. Gavage is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth). According to Maslows hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. The safest and surest way to verify a patients identity is to check the identification band on his wrist. In the therapeutic environment, the patients safety is the primary concern. Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly. The nurse should place a patient who has a Sengstaken-Blakemore tube in semiFowler position. The nurse can elicit Trousseaus sign by occluding the brachial or radial artery. Hand and finger spasms that occur during occlusion indicate Trousseaus sign and suggest hypocalcemia. For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Intractable pain is pain that incapacitates a patient and cant be relieved by drugs. In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic means. Decibel is the unit of measurement of sound.

Informed consent is required for any invasive procedure.

A patient who cant write his name to give consent for treatment must make an X in

the presence of two witnesses, such as a nurse, priest, or physician. The Z-track I.M. injection technique seals the drug deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle thats 1" (2.5 cm) or longer. In the event of fire, the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attempt to contain the fire by closing the door. (E) Extinguish the fire if it can be done safely. A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration. If a patient cant void, the first nursing action should be bladder palpation to assess for bladder distention. The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2" (5 cm) to that measurement. Assessment begins with the nurses first encounter with the patient and continues throughout the patients stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. The appropriate needle size for insulin injection is 25G and 5/8" long. Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml. The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment is the stage of the nursing process in which the nurse continuously collects data to identify a patients actual and potential health needs. >>Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Planning is the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan.

Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Evaluation is the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan. Before administering any as needed pain medication, the nurse should ask the patient to indicate the location of the pain. Jehovahs Witnesses believe that they shouldnt receive blood components donated by other people. To test visual acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate. When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side. During assessment of distance vision, the patient should stand 20 (6.1 m) from the chart. For a geriatric patient or one who is extremely ill, the ideal room temperature is 66 to 76 F (18.8 to 24.4 C). Normal room humidity is 30% to 60%. Hand washing is the single best method of limiting the spread of microorganisms. Once gloves are removed after routine contact with a patient, hands should be washed for 10 to 15 seconds. To perform catheterization, the nurse should place a woman in the dorsal recumbent position. A positive Homans sign may indicate thrombophlebitis. Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent is the number of milligrams per 100 milliliters of a solution. Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). The basal metabolic rate is the amount of energy needed to maintain essential body

functions. Its measured when the patient is awake and resting, hasnt eaten for 14 to 18 hours, and is in a comfortable, warm environment. The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight. Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits. Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Purpura is a purple discoloration of the skin thats caused by blood extravasation. According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldnt recap needles after use. Most needle sticks result from missed needle recapping. The nurse administers a drug by I.V. push by using a needle and syringe to deliver the dose directly into a vein, I.V. tubing, or a catheter. When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. A nurse should have assistance when changing the ties on a tracheostomy tube. A filter is always used for blood transfusions. A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. A good way to begin a patient interview is to ask, What made you seek medical help? When caring for any patient, the nurse should follow standard precautions for handling blood and body fluids. Potassium (K+) is the most abundant cation in intracellular fluid. In the four-point, or alternating, gait, the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg.

In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch simultaneously. The vitamin B complex, the water-soluble vitamins that are essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). When being weighed, an adult patient should be lightly dressed and shoeless. Before taking an adults temperature orally, the nurse should ensure that the patient hasnt smoked or consumed hot or cold substances in the previous 15 minutes. The nurse shouldnt take an adults temperature rectally if the patient has a cardiac disorder, anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal response and lead to vasodilation and decreased cardiac output. When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not detectable). The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit. On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasnt taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed. Comfort measures, such as positioning the patient, rubbing the patients back, and

providing a restful environment, may decrease the patients need for analgesics or may enhance their effectiveness. A drug has three names: generic name, which is used in official publications; trade, or brand, name (such as Tylenol), which is selected by the drug company; and chemical name, which describes the drugs chemical composition. To avoid staining the teeth, the patient should take a liquid iron preparation through a straw. The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. To turn a patient by logrolling, the nurse folds the patients arms across the chest; extends the patients legs and inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds. A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal. The nurse should place the blood pressure cuff 1" (2.5 cm) above the antecubital fossa. When instilling ophthalmic ointments, the nurse should waste the first bead of ointment and then apply the ointment from the inner canthus to the outer canthus. The nurse should use a leg cuff to measure blood pressure in an obese patient. If a blood pressure cuff is applied too loosely, the reading will be falsely elevated. (check for this..it should be decreased bp) Ptosis is drooping of the eyelid. A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension,

or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessels lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. To move a patient to the edge of the bed for transfer, the nurse should follow these steps: Move the patients head and shoulders toward the edge of the bed. Move the patients feet and legs to the edge of the bed (crescent position). Place both arms well under the patients hips, and straighten the back while moving the patient toward the edge of the bed. (research for this) When being measured for crutches, a patient should wear shoes. The nurse should attach a restraint to the part of the bed frame that moves with the head, not to the mattress or side rails. The mist in a mist tent should never become so dense that it obscures clear visualization of the patients respiratory pattern. To administer heparin subcutaneously, the nurse should follow these steps: Clean, but dont rub, the site with alcohol. Stretch the skin taut or pick up a welldefined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger, but dont aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad. For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims position, depending on the physicians preference. Maslows hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization. When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube.

In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage (for example, 10 mm of brown mucoid drainage noted on dressing). To elicit Babinskis reflex, the nurse strokes the sole of the patients foot with a moderately sharp object, such as a thumbnail. A positive Babinskis reflex is shown by dorsiflexion of the great toe and fanning out of the other toes. When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation. In adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space. Two to three hours before beginning a tube feeding, the nurse should aspirate the patients stomach contents to verify that gastric emptying is adequate. People with type O blood are considered universal donors. People with type AB blood are considered universal recipients. Hertz (Hz) is the unit of measurement of sound frequency. Hearing protection is required when the sound intensity exceeds 84 dB. Double hearing protection is required if it exceeds 104 dB. Prothrombin, a clotting factor, is produced in the liver. If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory request. During lumbar puncture, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid. If a patient cant cough to provide a sputum sample for culture, a heated aerosol treatment can be used to help to obtain a sample. If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first.

When leaving an isolation room, the nurse should remove her gloves before her mask because fewer pathogens are on the mask. Skeletal traction, which is applied to a bone with wire pins or tongs, is the most effective means of traction. The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Drugs arent routinely injected intramuscularly into edematous tissue because they may not be absorbed. When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Dentures should be cleaned in a sink thats lined with a washcloth. A patient should void within 8 hours after surgery. An EEG identifies normal and abnormal brain waves. Samples of feces for ova and parasite tests should be delivered to the laboratory without delay and without refrigeration. The autonomic nervous system regulates the cardiovascular and respiratory systems. When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. A low-residue diet includes such foods as roasted chicken, rice, and pasta. A rectal tube shouldnt be inserted for longer than 20 minutes because it can irritate the rectal mucosa and cause loss of sphincter control. A patients bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles. Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal.

While an occupied bed is being changed, the patient should be covered with a bath blanket to promote warmth and prevent exposure. Anticipatory grief is mourning that occurs for an extended time when the patient realizes that death is inevitable. The following foods can alter the color of the feces: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). When preparing for a skull X-ray, the patient should remove all jewelry and dentures. The fight-or-flight response is a sympathetic nervous system response. Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Wheezing is an abnormal, high-pitched breath sound thats accentuated on expiration. Wax or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution. If a patient complains that his hearing aid is not working, the nurse should check the switch first to see if its turned on and then check the batteries. The nurse should grade hyperactive biceps and triceps reflexes as +4. If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. In a postoperative patient, forcing fluids helps prevent constipation. A nurse must provide care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1 C. As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. The body metabolizes alcohol at a fixed rate, regardless of serum concentration. In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. A living will is a witnessed document that states a patients desire for certain types

of care and treatment. These decisions are based on the patients wishes and views on quality of life. The nurse should flush a peripheral heparin lock every 8 hours (if it wasnt used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Quality assurance is a method of determining whether nursing actions and practices meet established standards. The five rights of medication administration are the right patient, right drug, right dose, right route of administration, and right time. The evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals. Outside of the hospital setting, only the sublingual and translingual forms of nitroglycerin should be used to relieve acute anginal attacks. 150.The implementation phase of the nursing process involves recording the patients response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patients activities. The Patients Bill of Rights offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. To minimize omission and distortion of facts, the nurse should record information as soon as its gathered. When assessing a patients health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. A nurse shouldnt give false assurance to a patient. After receiving preoperative medication, a patient isnt competent to sign an informed consent form. When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. A nurse may clarify a physicians explanation about an operation or a procedure to

a patient, but must refer questions about informed consent to the physician. When obtaining a health history from an acutely ill or agitated patient, the nurse should limit questions to those that provide necessary information. If a chest drainage system line is broken or interrupted, the nurse should clamp the tube immediately. The nurse shouldnt use her thumb to take a patients pulse rate because the thumb has a pulse that may be confused with the patients pulse. An inspiration and an expiration count as one respiration. Eupnea is normal respiration. During blood pressure measurement, the patient should rest the arm against a surface. Using muscle strength to hold up the arm may raise the blood pressure. Major, unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Inspection is the most frequently used assessment technique. Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the persons room to provide a comfortable atmosphere. Pulsus alternans is a regular pulse rhythm with alternating weak and strong beats. It occurs in ventricular enlargement because the stroke volume varies with each heartbeat. The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration. When patients use axillary crutches, their palms should bear the brunt of the weight. Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Normal gait has two phases: the stance phase, in which the patients foot rests on

the ground, and the swing phase, in which the patients foot moves forward. The phases of mitosis are prophase, metaphase, anaphase, and telophase. The nurse should follow standard precautions in the routine care of all patients. The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. The nurse can assess a patients general knowledge by asking questions such as Who is the president of the United States? Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). The autonomic nervous system controls the smooth muscles. A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. Its developed in collaboration with the patient. Percussion causes five basic notes: tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek), hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness (medium intensity, as heard over the liver or other solid organ), and flatness (soft, as heard over the thigh). The optic disk is yellowish pink and circular, with a distinct border. A primary disability is caused by a pathologic process. A secondary disability is caused by inactivity. Nurses are commonly held liable for failing to keep an accurate count of sponges and other devices during surgery. The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, and whole grains, commonly have a low water content.

Collaboration is joint communication and decision making between nurses and physicians. Its designed to meet patients needs by integrating the care regimens of both professions into one comprehensive approach. Bradycardia is a heart rate of fewer than 60 beats/minute. A nursing diagnosis is a statement of a patients actual or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions. During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. The patients health history consists primarily of subjective data, information thats supplied by the patient. The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign each entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. The most accessible and commonly used artery for measuring a patients pulse rate is the radial artery. To take the pulse rate, the artery is compressed against the radius. In a resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Laboratory test results are an objective form of assessment data. The measurement systems most commonly used in clinical practice are the metric system, apothecaries system, and household system. Before signing an informed consent form, the patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks

involved; and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, he should have an opportunity to ask questions. A patient must sign a separate informed consent form for each procedure. During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds. This procedure is done to determine the size, shape, position, and density of underlying organs and tissues; elicit tenderness; or assess reflexes. Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. A foot cradle keeps bed linen off the patients feet to prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy. Gastric lavage is flushing of the stomach and removal of ingested substances through a nasogastric tube. Its used to treat poisoning or drug overdose. During the evaluation step of the nursing process, the nurse assesses the patients response to therapy. Bruits commonly indicate life- or limb-threatening vascular disease. O.U. means each eye. O.D. is the right eye, and O.S. is the left eye. To remove a patients artificial eye, the nurse depresses the lower lid. The nurse should use a warm saline solution to clean an artificial eye. A thready pulse is very fine and scarcely perceptible. Axillary temperature is usually 1 F lower than oral temperature. After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. On a drug prescription, the abbreviation p.c. means that the drug should be administered after meals. After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment.

Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Gauge is the inside diameter of a needle: the smaller the gauge, the larger the diameter. An adult normally has 32 permanent teeth. After turning a patient, the nurse should document the position used, the time that the patient was turned, and the findings of skin assessment. PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. When percussing a patients chest for postural drainage, the nurses hands should be cupped. When measuring a patients pulse, the nurse should assess its rate, rhythm, quality, and strength. Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchairs footrests to the sides and lock its wheels. When assessing respirations, the nurse should document their rate, rhythm, depth, and quality. For a subcutaneous injection, the nurse should use a 5/8" 25G needle. The notation AA & O 3 indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or feces, and perspiration. After administering an intradermal injection, the nurse shouldnt massage the area because massage can irritate the site and interfere with results. When administering an intradermal injection, the nurse should hold the syringe almost flat against the patients skin (at about a 15-degree angle), with the bevel up.

To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. The nurse should count an irregular pulse for 1 full minute. A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Prophylaxis is disease prevention. Body alignment is achieved when body parts are in proper relation to their natural position. Trust is the foundation of a nurse-patient relationship. Blood pressure is the force exerted by the circulating volume of blood on the arterial walls. Malpractice is a professionals wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another. As a general rule, nurses cant refuse a patient care assignment; however, in most states, they may refuse to participate in abortions. A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldnt perform. States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from the assistance. These laws dont apply to care provided in a health care facility. A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours. A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal. Although a patients health record, or chart, is the health care facilitys physical property, its contents belong to the patient. Before a patients health record can be released to a third party, the patient or the

patients legal guardian must give written consent. Under the Controlled Substances Act, every dose of a controlled drug thats dispensed by the pharmacy must be accounted for, whether the dose was administered to a patient or discarded accidentally. A nurse cant perform duties that violate a rule or regulation established by a state licensing board, even if they are authorized by a health care facility or physician. To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that can be closed. In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns. The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms. In assessing a patients heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex. The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves. To maintain package sterility, the nurse should open a wrappers top flap away from the body, open each side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. The nurse shouldnt dry a patients ear canal or remove wax with a cotton-tipped applicator because it may force cerumen against the tympanic membrane. A patients identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential. Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States.

Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence. Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Activities of daily living are actions that the patient must perform every day to provide self-care and to interact with society. Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly raised from the chest. The most important goal to include in a care plan is the patients goal. Fruits are high in fiber and low in protein, and should be omitted from a low-residue diet. The nurse should use an objective scale to assess and quantify pain. Postoperative pain varies greatly among individuals. Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. The nurse should provide honest answers to the patients questions. Milk shouldnt be included in a clear liquid diet. When caring for an infant, a child, or a confused patient, consistency in nursing personnel is paramount. The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. The three membranes that enclose the brain and spinal cord are the dura mater,

pia mater, and arachnoid. A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Psychologists, physical therapists, and chiropractors arent authorized to write prescriptions for drugs. The area around a stoma is cleaned with mild soap and water. Vegetables have a high fiber content. The nurse should use a tuberculin syringe to administer a subcutaneous injection of less than 1 ml. For adults, subcutaneous injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G " needle. Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient to state his name. To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a circular motion. The nurse should inject heparin deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. The nurse shouldnt cut the patients hair without written consent from the patient or an appropriate relative. If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma. When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patients condition. Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries.

The hearing aid thats marked with a blue dot is for the left ear; the one with a red dot is for the right ear. A hearing aid shouldnt be exposed to heat or humidity and shouldnt be immersed in water. The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid. The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Heat is applied to promote vasodilation, which reduces pain caused by inflammation. A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Keloid formation is an abnormality in healing thats characterized by overgrowth of scar tissue at the wound site. The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldnt massage the injection site. An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter. A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Platelets are the smallest and most fragile formed element of the blood and are

essential for coagulation. To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Families with loved ones in intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patients prognosis, and to feel that there is hope of recovery. Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. A nonjudgmental attitude displayed by a nurse shows that she neither approves nor disapproves of the patient. Target symptoms are those that the patient finds most distressing. A patient should be advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola. For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal. Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Administering an I.M. injection against the patients will and without legal authority is battery. An example of a third-party payer is an insurance company. The formula for calculating the drops per minute for an I.V. infusion is as follows: (volume to be infused drip factor) time in minutes = drops/minute

On-call medication should be given within 5 minutes of the call. Usually, the best method to determine a patients cultural or spiritual needs is to ask him. An incident report or unusual occurrence report isnt part of a patients record, but is an in-house document thats used for the purpose of correcting the problem. Critical pathways are a multidisciplinary guideline for patient care. When prioritizing nursing diagnoses, the following hierarchy should be used: Problems associated with the airway, those concerning breathing, and those related to circulation. The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. A subjective sign that a sitz bath has been effective is the patients expression of decreased pain or discomfort. For the nursing diagnosis Deficient diversional activity to be valid, the patient must state that hes bored, that he has nothing to do, or words to that effect. The most appropriate nursing diagnosis for an individual who doesnt speak English is Impaired verbal communication related to inability to speak dominant language (English). The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube. To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac. After administering eye ointment, the nurse should twist the medication tube to detach the ointment. When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain pathogens. Crutches should be placed 6" (15.2 cm) in front of the patient and 6" to the side to form a tripod arrangement.

Listening is the most effective communication technique. Before teaching any procedure to a patient, the nurse must assess the patients current knowledge and willingness to learn. Process recording is a method of evaluating ones communication effectiveness. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance. When feeding an elderly patient, essential foods should be given first. Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass. Isometric exercises are performed on an extremity thats in a cast. A back rub is an example of the gate-control theory of pain. Anything thats located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1" (2.5 cm) around a sterile field is considered unsterile. A shift to the left is evident when the number of immature cells (bands) in the blood increases to fight an infection. A shift to the right is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia. Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patients record. A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant. A nurse shouldnt be assigned to care for more than one patient who has a radiation implant. Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant. Usually, patients who have the same infection and are in strict isolation can share a room. Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.

For the patient who abides by Jewish custom, milk and meat shouldnt be served at the same meal. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning). According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60). When communicating with a hearing impaired patient, the nurse should face him. An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system. Hyperpyrexia is extreme elevation in temperature above 106 F (41.1 C). Milk is high in sodium and low in iron. When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patients level of knowledge. The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point. When a patient is ill, its essential for the members of his family to maintain communication about his health needs. Ethnocentrism is the universal belief that ones way of life is superior to others. When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter. In accordance with the hot-cold system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as cold. Prejudice is a hostile attitude toward individuals of a particular group. Discrimination is preferential treatment of individuals of a particular group. Its

usually discussed in a negative sense. Increased gastric motility interferes with the absorption of oral drugs. The three phases of the therapeutic relationship are orientation, working, and termination. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship. Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion. When measuring blood pressure in a neonate, the nurse should select a cuff thats no less than one-half and no more than two-thirds the length of the extremity thats used. When administering a drug by Z-track, the nurse shouldnt use the same needle that was used to draw the drug into the syringe because doing so could stain the skin. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula. When evaluating whether an answer on an examination is correct, the nurse should consider whether the action thats described promotes autonomy (independence), safety, self-esteem, and a sense of belonging. When answering a question on the NCLEX examination, the student should consider the cue (the stimulus for a thought) and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an answer that indicates the need for further information to eliminate ambiguity. For example, the patient complains of chest pain (the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasnt confirmed whether the pain is cardiac. It would be more appropriate to make further assessments. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient. Beneficence is the duty to do no harm and the duty to do good. Theres an obligation in patient care to do no harm and an equal obligation to assist the

patient. Nonmaleficence is the duty to do no harm. Fryes ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns. A = Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction. B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoffs, Biots, or Cheyne-Stokes respiration. C = Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output. D = Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern. E = Everything else. This category includes such issues as writing an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority. When answering a question on an NCLEX examination, the basic rule is assess before action. The student should evaluate each possible answer carefully. Usually, several answers reflect the implementation phase of nursing and one or two reflect the assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated. Rule utilitarianism is known as the greatest good for the greatest number of people theory. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society. Active euthanasia is actively helping a person to die.

Brain death is irreversible cessation of all brain function. Passive euthanasia is stopping the therapy thats sustaining life. A third-party payer is an insurance company. Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective. A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values. Voluntary euthanasia is actively helping a patient to die at the patients request. Bananas, citrus fruits, and potatoes are good sources of potassium. Good sources of magnesium include fish, nuts, and grains. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron. Intrathecal injection is administering a drug through the spine. When a patient asks a question or makes a statement thats emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to whats being said or asked. The steps of the trajectory-nursing model are as follows: Step 1: Identifying the trajectory phase Step 2: Identifying the problems and establishing goals Step 3: Establishing a plan to meet the goals Step 4: Identifying factors that facilitate or hinder attainment of the goals Step 5: Implementing interventions Step 6: Evaluating the effectiveness of the interventions

A Hindu patient is likely to request a vegetarian diet. Pain threshold, or pain sensation, is the initial point at which a patient feels pain.

The difference between acute pain and chronic pain is its duration. Referred pain is pain thats felt at a site other than its origin. Alleviating pain by performing a back massage is consistent with the gate control theory. Rombergs test is a test for balance or gait. Pain seems more intense at night because the patient isnt distracted by daily activities. Older patients commonly dont report pain because of fear of treatment, lifestyle changes, or dependency. No pork or pork products are allowed in a Muslim diet. Two goals of Healthy People 2010 are: Help individuals of all ages to increase the quality of life and the number of years of optimal health Eliminate health disparities among different segments of the population. A community nurse is serving as a patients advocate if she tells a malnourished patient to go to a meal program at a local park. If a patient isnt following his treatment plan, the nurse should first ask why. Falls are the leading cause of injury in elderly people. Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation. Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray. Tertiary prevention is treatment to prevent long-term complications. A patient indicates that hes coming to terms with having a chronic disease when he says, Im never going to get any better. On noticing religious artifacts and literature on a patients night stand, a culturally aware nurse would ask the patient the meaning of the items. A Mexican patient may request the intervention of a curandero, or faith healer, who

involves the family in healing the patient. In an infant, the normal hemoglobin value is 12 g/dl. The nitrogen balance estimates the difference between the intake and use of protein. Most of the absorption of water occurs in the large intestine. Most nutrients are absorbed in the small intestine. When assessing a patients eating habits, the nurse should ask, What have you eaten in the last 24 hours? A vegan diet should include an abundant supply of fiber. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis.

First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values. To induce sleep, the first step is to minimize environmental stimuli. Before moving a patient, the nurse should assess the patients physical abilities and ability to understand instructions as well as the amount of strength required to move the patient. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily). To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet. To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow. Vitamin C is needed for collagen production. Only the patient can describe his pain accurately. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli. Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer.

An Asian American or European American typically places distance between himself and others when communicating. The patient who believes in a scientific, or biomedical, approach to health is likely to expect a drug, treatment, or surgery to cure illness. Chronic illnesses occur in very young as well as middle-aged and very old people. The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions. Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization. School health programs provide cost-effective health care for low-income families and those who have no health insurance. Collegiality is the promotion of collaboration, development, and interdependence among members of a profession. A change agent is an individual who recognizes a need for change or is selected to make a change within an established entity, such as a hospital. The patients bill of rights was introduced by the American Hospital Association. Abandonment is premature termination of treatment without the patients permission and without appropriate relief of symptoms. Values clarification is a process that individuals use to prioritize their personal values. Distributive justice is a principle that promotes equal treatment for all. Milk and milk products, poultry, grains, and fish are good sources of phosphate. The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails. By the end of the orientation phase, the patient should begin to trust the nurse. Falls in the elderly are likely to be caused by poor vision. Barriers to communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis. The three elements that are necessary for a fire are heat, oxygen, and combustible material. Sebaceous glands lubricate the skin.

To check for petechiae in a dark-skinned patient, the nurse should assess the oral mucosa. To put on a sterile glove, the nurse should pick up the first glove at the folded border and adjust the fingers when both gloves are on. To increase patient comfort, the nurse should let the alcohol dry before giving an intramuscular injection. Treatment for a stage 1 ulcer on the heels includes heel protectors. Seventh-Day Adventists are usually vegetarians. Endorphins are morphinelike substances that produce a feeling of well-being. Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure.
MATERNAL NURSING BULLETS

Unlike false labor, true labor produces regular rhythmic contractions, abdominal discomfort, progressive descent of the fetus, bloody show, and progressive effacement and dilation of the cervix. To help a mother break the suction of her breast-feeding infant, the nurse should teach her to insert a finger at the corner of the infants mouth. Administering high levels of oxygen to a premature neonate can cause blindness as a result of retrolental fibroplasia. Amniotomy is artificial rupture of the amniotic membranes. During pregnancy, weight gain averages 25 to 30 lb (11 to 13.5 kg). Rubella has a teratogenic effect on the fetus during the first trimester. It produces abnormalities in up to 40% of cases without interrupting the pregnancy. Immunity to rubella can be measured by a hemagglutination inhibition test (rubella titer). This test identifies exposure to rubella infection and determines susceptibility in pregnant women. In a woman, a titer greater than 1:8 indicates immunity. When used to describe the degree of fetal descent during labor, floating means the presenting part isnt engaged in the pelvic inlet, but is freely movable (ballotable) above the pelvic inlet. When used to describe the degree of fetal descent, engagement means when the

largest diameter of the presenting part has passed through the pelvic inlet. Fetal station indicates the location of the presenting part in relation to the ischial spine. Its described as 1, 2, 3, 4, or 5 to indicate the number of centimeters above the level of the ischial spine; station 5 is at the pelvic inlet. Fetal station also is described as +1, +2, +3, +4, or +5 to indicate the number of centimeters it is below the level of the ischial spine; station 0 is at the level of the ischial spine. During the first stage of labor, the side-lying position usually provides the greatest degree of comfort, although the patient may assume any comfortable position. During delivery, if the umbilical cord cant be loosened and slipped from around the neonates neck, it should be clamped with two clamps and cut between the clamps. An Apgar score of 7 to 10 indicates no immediate distress, 4 to 6 indicates moderate distress, and 0 to 3 indicates severe distress. To elicit Moros reflex, the nurse holds the neonate in both hands and suddenly, but gently, drops the neonates head backward. Normally, the neonate abducts and extends all extremities bilaterally and symmetrically, forms a C shape with the thumb and forefinger, and first adducts and then flexes the extremities. Pregnancy-induced hypertension (preeclampsia) is an increase in blood pressure of 30/15 mm Hg over baseline or blood pressure of 140/95 mm Hg on two occasions at least 6 hours apart accompanied by edema and albuminuria after 20 weeks gestation. Positive signs of pregnancy include ultrasound evidence, fetal heart tones, and fetal movement felt by the examiner (not usually present until 4 months gestation Goodells sign is softening of the cervix. Quickening, a presumptive sign of pregnancy, occurs between 16 and 19 weeks gestation.

Ovulation ceases during pregnancy. Any vaginal bleeding during pregnancy should be considered a complication until proven otherwise. To estimate the date of delivery using Ngeles rule, the nurse counts backward 3 months from the first day of the last menstrual period and then adds 7 days to this date. At 12 weeks gestation, the fundus should be at the top of the symphysis pubis. Cows milk shouldnt be given to infants younger than age 1 because it has a low linoleic acid content and its protein is difficult for infants to digest. If jaundice is suspected in a neonate, the nurse should examine the infant under natural window light. If natural light is unavailable, the nurse should examine the infant under a white light. The three phases of a uterine contraction are increment, acme, and decrement. The intensity of a labor contraction can be assessed by the indentability of the uterine wall at the contractions peak. Intensity is graded as mild (uterine muscle is somewhat tense), moderate (uterine muscle is moderately tense), or strong (uterine muscle is boardlike). Chloasma, the mask of pregnancy, is pigmentation of a circumscribed area of skin (usually over the bridge of the nose and cheeks) that occurs in some pregnant women. The gynecoid pelvis is most ideal for delivery. Other types include platypelloid (flat), anthropoid (apelike), and android (malelike). Pregnant women should be advised that there is no safe level of alcohol intake. The frequency of uterine contractions, which is measured in minutes, is the time from the beginning of one contraction to the beginning of the next. Vitamin K is administered to neonates to prevent hemorrhagic disorders because a neonates intestine cant synthesize vitamin K. Before internal fetal monitoring can be performed, a pregnant patients cervix must be dilated at least 2 cm, the amniotic membranes must be ruptured, and the fetuss presenting part (scalp or buttocks) must be at station 1 or lower, so that a small electrode can be attached. Fetal alcohol syndrome presents in the first 24 hours after birth and produces

lethargy, seizures, poor sucking reflex, abdominal distention, and respiratory difficulty. Variability is any change in the fetal heart rate (FHR) from its normal rate of 120 to 160 beats/minute. Acceleration is increased FHR; deceleration is decreased FHR. In a neonate, the symptoms of heroin withdrawal may begin several hours to 4 days after birth. In a neonate, the symptoms of methadone withdrawal may begin 7 days to several weeks after birth. In a neonate, the cardinal signs of narcotic withdrawal include coarse, flapping tremors; sleepiness; restlessness; prolonged, persistent, high-pitched cry; and irritability. The nurse should count a neonates respirations for 1 full minute. Chlorpromazine (Thorazine) is used to treat neonates who are addicted to narcotics. The nurse should provide a dark, quiet environment for a neonate who is experiencing narcotic withdrawal. In a premature neonate, signs of respiratory distress include nostril flaring, substernal retractions, and inspiratory grunting. Respiratory distress syndrome (hyaline membrane disease) develops in premature infants because their pulmonary alveoli lack surfactant. Whenever an infant is being put down to sleep, the parent or caregiver should position the infant on the back. (Remember back to sleep.) The male sperm contributes an X or a Y chromosome; the female ovum contributes an X chromosome.

Fertilization produces a total of 46 chromosomes, including an XY combination (male) or an XX combination (female). The percentage of water in a neonates body is about 78% to 80%. To perform nasotracheal suctioning in an infant, the nurse positions the infant with his neck slightly hyperextended in a sniffing position, with his chin up and

his head tilted back slightly. Organogenesis occurs during the first trimester of pregnancy, specifically, days 14 to 56 of gestation. After birth, the neonates umbilical cord is tied 1" (2.5 cm) from the abdominal wall with a cotton cord, plastic clamp, or rubber band. Gravida is the number of pregnancies a woman has had, regardless of outcome. Para is the number of pregnancies that reached viability, regardless of whether the fetus was delivered alive or stillborn. A fetus is considered viable at 20 weeks gestation. An ectopic pregnancy is one that implants abnormally, outside the uterus. The first stage of labor begins with the onset of labor and ends with full cervical dilation at 10 cm. The second stage of labor begins with full cervical dilation and ends with the neonates birth. The third stage of labor begins after the neonates birth and ends with expulsion of the placenta. In a full-term neonate, skin creases appear over two-thirds of the neonates feet. Preterm neonates have heel creases that cover less than two-thirds of the feet. The fourth stage of labor (postpartum stabilization) lasts up to 4 hours after the placenta is delivered. This time is needed to stabilize the mothers physical and emotional state after the stress of childbirth. At 20 weeks gestation, the fundus is at the level of the umbilicus. At 36 weeks gestation, the fundus is at the lower border of the rib cage. A premature neonate is one born before the end of the 37th week of gestation. Pregnancy-induced hypertension is a leading cause of maternal death in the United States. A habitual aborter is a woman who has had three or more consecutive spontaneous abortions. Threatened abortion occurs when bleeding is present without cervical dilation. A complete abortion occurs when all products of conception are expelled. Hydramnios (polyhydramnios) is excessive amniotic fluid (more than 2,000 ml in

the third trimester). Stress, dehydration, and fatigue may reduce a breast-feeding mothers milk supply. During the transition phase of the first stage of labor, the cervix is dilated 8 to 10 cm and contractions usually occur 2 to 3 minutes apart and last for 60 seconds. A nonstress test is considered nonreactive (positive) if fewer than two fetal heart rate accelerations of at least 15 beats/minute occur in 20 minutes. A nonstress test is considered reactive (negative) if two or more fetal heart rate accelerations of 15 beats/minute above baseline occur in 20 minutes. A nonstress test is usually performed to assess fetal well-being in a pregnant patient with a prolonged pregnancy (42 weeks or more), diabetes, a history of poor pregnancy outcomes, or pregnancy-induced hypertension. A pregnant woman should drink at least eight 8-oz glasses (about 2,000 ml) of water daily. When both breasts are used for breast-feeding, the infant usually doesnt empty the second breast. Therefore, the second breast should be used first at the next feeding. A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or less at birth. A very-low-birth-weight neonate weighs 1,500 g (3 lb 5 oz) or less at birth. When teaching parents to provide umbilical cord care, the nurse should teach them to clean the umbilical area with a cotton ball saturated with alcohol after every diaper change to prevent infection and promote drying. Teenage mothers are more likely to have low-birth-weight neonates because they seek prenatal care late in pregnancy (as a result of denial) and are more likely than older mothers to have nutritional deficiencies. Linea nigra, a dark line that extends from the umbilicus to the mons pubis, commonly appears during pregnancy and disappears after pregnancy. Implantation in the uterus occurs 6 to 10 days after ovum fertilization. Placenta previa is abnormally low implantation of the placenta so that it encroaches on or covers the cervical os. In complete (total) placenta previa, the placenta completely covers the cervical os.

In partial (incomplete or marginal) placenta previa, the placenta covers only a portion of the cervical os. Abruptio placentae is premature separation of a normally implanted placenta. It may be partial or complete, and usually causes abdominal pain, vaginal bleeding, and a boardlike abdomen. Cutis marmorata is mottling or purple discoloration of the skin. Its a transient vasomotor response that occurs primarily in the arms and legs of infants who are exposed to cold. The classic triad of symptoms of preeclampsia are hypertension, edema, and proteinuria. Additional symptoms of severe preeclampsia include hyperreflexia, cerebral and vision disturbances, and epigastric pain. Ortolanis sign (an audible click or palpable jerk that occurs with thigh abduction) confirms congenital hip dislocation in a neonate. The first immunization for a neonate is the hepatitis B vaccine, which is administered in the nursery shortly after birth. If a patient misses a menstrual period while taking an oral contraceptive exactly as prescribed, she should continue taking the contraceptive. If a patient misses two consecutive menstrual periods while taking an oral contraceptive, she should discontinue the contraceptive and take a pregnancy test. If a patient who is taking an oral contraceptive misses a dose, she should take the pill as soon as she remembers or take two at the next scheduled interval and continue with the normal schedule. If a patient who is taking an oral contraceptive misses two consecutive doses, she should double the dose for 2 days and then resume her normal schedule. She also should use an additional birth control method for 1 week. Eclampsia is the occurrence of seizures that arent caused by a cerebral disorder in a patient who has pregnancy-induced hypertension. In placenta previa, bleeding is painless and seldom fatal on the first occasion, but it becomes heavier with each subsequent episode. Treatment for abruptio placentae is usually immediate cesarean delivery. Drugs used to treat withdrawal symptoms in neonates include phenobarbital

(Luminal), camphorated opium tincture (paregoric), and diazepam (Valium). Infants with Down syndrome typically have marked hypotonia, floppiness, slanted eyes, excess skin on the back of the neck, flattened bridge of the nose, flat facial features, spadelike hands, short and broad feet, small male genitalia, absence of Moros reflex, and a simian crease on the hands. The failure rate of a contraceptive is determined by the experience of 100 women for 1 year. Its expressed as pregnancies per 100 woman-years. The narrowest diameter of the pelvic inlet is the anteroposterior (diagonal conjugate). The chorion is the outermost extraembryonic membrane that gives rise to the placenta. The corpus luteum secretes large quantities of progesterone. From the 8th week of gestation through delivery, the developing cells are known as a fetus. In an incomplete abortion, the fetus is expelled, but parts of the placenta and membrane remain in the uterus. The circumference of a neonates head is normally 2 to 3 cm greater than the circumference of the chest. After administering magnesium sulfate to a pregnant patient for hypertension or preterm labor, the nurse should monitor the respiratory rate and deep tendon reflexes. During the first hour after birth (the period of reactivity), the neonate is alert and awake. When a pregnant patient has undiagnosed vaginal bleeding, vaginal examination should be avoided until ultrasonography rules out placenta previa. After delivery, the first nursing action is to establish the neonates airway. Nursing interventions for a patient with placenta previa include positioning the patient on her left side for maximum fetal perfusion, monitoring fetal heart tones, and administering I.V. fluids and oxygen, as ordered. The specific gravity of a neonates urine is 1.003 to 1.030. A lower specific gravity suggests overhydration; a higher one suggests dehydration. The neonatal period extends from birth to day 28. Its also called the first 4 weeks

or first month of life. A woman who is breast-feeding should rub a mild emollient cream or a few drops of breast milk (or colostrum) on the nipples after each feeding. She should let the breasts air-dry to prevent them from cracking. Breast-feeding mothers should increase their fluid intake to 2 to 3 qt (2,500 to 3,000 ml) daily. After feeding an infant with a cleft lip or palate, the nurse should rinse the infants mouth with sterile water. The nurse instills erythromycin in a neonates eyes primarily to prevent blindness caused by gonorrhea or chlamydia. Human immunodeficiency virus (HIV) has been cultured in breast milk and can be transmitted by an HIV-positive mother who breast-feeds her infant. A fever in the first 24 hours postpartum is most likely caused by dehydration rather than infection. Preterm neonates or neonates who cant maintain a skin temperature of at least 97.6 F (36.4 C) should receive care in an incubator (Isolette) or a radiant warmer. In a radiant warmer, a heat-sensitive probe taped to the neonates skin activates the heater unit automatically to maintain the desired temperature. During labor, the resting phase between contractions is at least 30 seconds. Lochia rubra is the vaginal discharge of almost pure blood that occurs during the first few days after childbirth. Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after childbirth. Lochia alba is the vaginal discharge of decreased blood and increased leukocytes thats the final stage of lochia. It occurs 7 to 10 days after childbirth. Colostrum, the precursor of milk, is the first secretion from the breasts after delivery. The length of the uterus increases from 2" (6.3 cm) before pregnancy to 12" (32 cm) at term. To estimate the true conjugate (the smallest inlet measurement of the pelvis), deduct 1.5 cm from the diagonal conjugate (usually 12 cm). A true conjugate

of 10.5 cm enables the fetal head (usually 10 cm) to pass. The smallest outlet measurement of the pelvis is the intertuberous diameter, which is the transverse diameter between the ischial tuberosities. Electronic fetal monitoring is used to assess fetal well-being during labor. If compromised fetal status is suspected, fetal blood pH may be evaluated by obtaining a scalp sample. In an emergency delivery, enough pressure should be applied to the emerging fetuss head to guide the descent and prevent a rapid change in pressure within the molded fetal skull. After delivery, a multiparous woman is more susceptible to bleeding than a primiparous woman because her uterine muscles may be overstretched and may not contract efficiently. Neonates who are delivered by cesarean birth have a higher incidence of respiratory distress syndrome. The nurse should suggest ambulation to a postpartum patient who has gas pain and flatulence. Massaging the uterus helps to stimulate contractions after the placenta is delivered. When providing phototherapy to a neonate, the nurse should cover the neonates eyes and genital area. The narcotic antagonist naloxone (Narcan) may be given to a neonate to correct respiratory depression caused by narcotic administration to the mother during labor. In a neonate, symptoms of respiratory distress syndrome include expiratory grunting or whining, sandpaper breath sounds, and seesaw retractions. Cerebral palsy presents as asymmetrical movement, irritability, and excessive, feeble crying in a long, thin infant. The nurse should assess a breech-birth neonate for hydrocephalus, hematomas, fractures, and other anomalies caused by birth trauma. When a patient is admitted to the unit in active labor, the nurses first action is to listen for fetal heart tones. In a neonate, long, brittle fingernails are a sign of postmaturity.

Desquamation (skin peeling) is common in postmature neonates. A mother should allow her infant to breast-feed until the infant is satisfied. The time may vary from 5 to 20 minutes. Nitrazine paper is used to test the pH of vaginal discharge to determine the presence of amniotic fluid. A pregnant patient normally gains 2 to 5 lb (1 to 2.5 kg) during the first trimester and slightly less than 1 lb (0.5 kg) per week during the last two trimesters. Neonatal jaundice in the first 24 hours after birth is known as pathological jaundice and is a sign of erythroblastosis fetalis. A classic difference between abruptio placentae and placenta previa is the degree of pain. Abruptio placentae causes pain, whereas placenta previa causes painless bleeding. Because a major role of the placenta is to function as a fetal lung, any condition that interrupts normal blood flow to or from the placenta increases fetal partial pressure of arterial carbon dioxide and decreases fetal pH. Precipitate labor lasts for approximately 3 hours and ends with delivery of the neonate. Methylergonovine (Methergine) is an oxytocic agent used to prevent and treat postpartum hemorrhage caused by uterine atony or subinvolution. As emergency treatment for excessive uterine bleeding, 0.2 mg of methylergonovine (Methergine) is injected I.V. over 1 minute while the patients blood pressure and uterine contractions are monitored. Braxton Hicks contractions are usually felt in the abdomen and dont cause cervical change. True labor contractions are felt in the front of the abdomen and back and lead to progressive cervical dilation and effacement. The average birth weight of neonates born to mothers who smoke is 6 oz (170 g) less than that of neonates born to nonsmoking mothers. Culdoscopy is visualization of the pelvic organs through the posterior vaginal fornix. The nurse should teach a pregnant vegetarian to obtain protein from alternative sources, such as nuts, soybeans, and legumes. The nurse should instruct a pregnant patient to take only prescribed prenatal

vitamins because over-the-counter high-potency vitamins may harm the fetus. High-sodium foods can cause fluid retention, especially in pregnant patients. A pregnant patient can avoid constipation and hemorrhoids by adding fiber to her diet. If a fetus has late decelerations (a sign of fetal hypoxia), the nurse should instruct the mother to lie on her left side and then administer 8 to 10 L of oxygen per minute by mask or cannula. The nurse should notify the physician. The sidelying position removes pressure on the inferior vena cava. Oxytocin (Pitocin) promotes lactation and uterine contractions. Lanugo covers the fetuss body until about 20 weeks gestation. Then it begins to disappear from the face, trunk, arms, and legs, in that order. In a neonate, hypoglycemia causes temperature instability, hypotonia, jitteriness, and seizures. Premature, postmature, small-for-gestational-age, and largefor-gestational-age neonates are susceptible to this disorder. Neonates typically need to consume 50 to 55 cal per pound of body weight daily. Because oxytocin (Pitocin) stimulates powerful uterine contractions during labor, it must be administered under close observation to help prevent maternal and fetal distress. During fetal heart rate monitoring, variable decelerations indicate compression or prolapse of the umbilical cord. Cytomegalovirus is the leading cause of congenital viral infection. Tocolytic therapy is indicated in premature labor, but contraindicated in fetal death, fetal distress, or severe hemorrhage. Through ultrasonography, the biophysical profile assesses fetal well-being by measuring fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate (nonstress test), and qualitative amniotic fluid volume. A neonate whose mother has diabetes should be assessed for hyperinsulinism. In a patient with preeclampsia, epigastric pain is a late symptom and requires immediate medical intervention. After a stillbirth, the mother should be allowed to hold the neonate to help her

come to terms with the death. Molding is the process by which the fetal head changes shape to facilitate movement through the birth canal. If a woman receives a spinal block before delivery, the nurse should monitor the patients blood pressure closely. If a woman suddenly becomes hypotensive during labor, the nurse should increase the infusion rate of I.V. fluids as prescribed. The best technique for assessing jaundice in a neonate is to blanch the tip of the nose or the area just above the umbilicus. During fetal heart monitoring, early deceleration is caused by compression of the head during labor. After the placenta is delivered, the nurse may add oxytocin (Pitocin) to the patients I.V. solution, as prescribed, to promote postpartum involution of the uterus and stimulate lactation. Pica is a craving to eat nonfood items, such as dirt, crayons, chalk, glue, starch, or hair. It may occur during pregnancy and can endanger the fetus. A pregnant patient should take folic acid because this nutrient is required for rapid cell division. A woman who is taking clomiphene (Clomid) to induce ovulation should be informed of the possibility of multiple births with this drug. If needed, cervical suturing is usually done between 14 and 18 weeks gestation to reinforce an incompetent cervix and maintain pregnancy. The suturing is typically removed by 35 weeks gestation. During the first trimester, a pregnant woman should avoid all drugs unless doing so would adversely affect her health. Most drugs that a breast-feeding mother takes appear in breast milk. The Food and Drug Administration has established the following five categories of drugs based on their potential for causing birth defects: A, no evidence of risk; B, no risk found in animals, but no studies have been done in women; C, animal studies have shown an adverse effect, but the drug may be beneficial to women despite the potential risk; D, evidence of risk, but its benefits may outweigh its risks; and X, fetal anomalies noted, and the risks

clearly outweigh the potential benefits. A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations; tachycardia; and shock. A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations; tachycardia; and shock. The mechanics of delivery are engagement, descent and flexion, internal rotation, extension, external rotation, restitution, and expulsion. A probable sign of pregnancy, McDonalds sign is characterized by an ease in flexing the body of the uterus against the cervix. Amenorrhea is a probable sign of pregnancy. A pregnant womans partner should avoid introducing air into the vagina during oral sex because of the possibility of air embolism. The presence of human chorionic gonadotropin in the blood or urine is a probable sign of pregnancy. Radiography isnt usually used in a pregnant woman because it may harm the developing fetus. If radiography is essential, it should be performed only after 36 weeks gestation. A pregnant patient who has had rupture of the membranes or who is experiencing vaginal bleeding shouldnt engage in sexual intercourse. Milia may occur as pinpoint spots over a neonates nose. The duration of a contraction is timed from the moment that the uterine muscle begins to tense to the moment that it reaches full relaxation. Its measured in seconds. The union of a male and a female gamete produces a zygote, which divides into the fertilized ovum. The first menstrual flow is called menarche and may be anovulatory (infertile). Spermatozoa (or their fragments) remain in the vagina for 72 hours after sexual intercourse. Prolactin stimulates and sustains milk production. Strabismus is a normal finding in a neonate.

A postpartum patient may resume sexual intercourse after the perineal or uterine wounds heal (usually within 4 weeks after delivery). A pregnant staff member shouldnt be assigned to work with a patient who has cytomegalovirus infection because the virus can be transmitted to the fetus. Fetal demise is death of the fetus after viability. Respiratory distress syndrome develops in premature neonates because their alveoli lack surfactant. The most common method of inducing labor after artificial rupture of the membranes is oxytocin (Pitocin) infusion. After the amniotic membranes rupture, the initial nursing action is to assess the fetal heart rate. The most common reasons for cesarean birth are malpresentation, fetal distress, cephalopelvic disproportion, pregnancy-induced hypertension, previous cesarean birth, and inadequate progress in labor. Amniocentesis increases the risk of spontaneous abortion, trauma to the fetus or placenta, premature labor, infection, and Rh sensitization of the fetus. After amniocentesis, abdominal cramping or spontaneous vaginal bleeding may indicate complications. To prevent her from developing Rh antibodies, an Rh-negative primigravida should receive Rho(D) immune globulin (RhoGAM) after delivering an Rh-positive neonate. If a pregnant patients test results are negative for glucose but positive for acetone, the nurse should assess the patients diet for inadequate caloric intake. If a pregnant patients test results are negative for glucose but positive for acetone, the nurse should assess the patients diet for inadequate caloric intake. Rubella infection in a pregnant patient, especially during the first trimester, can lead to spontaneous abortion or stillbirth as well as fetal cardiac and other birth defects. A pregnant patient should take an iron supplement to help prevent anemia. Direct antiglobulin (direct Coombs) test is used to detect maternal antibodies attached to red blood cells in the neonate. Nausea and vomiting during the first trimester of pregnancy are caused by rising

levels of the hormone human chorionic gonadotropin. Before discharging a patient who has had an abortion, the nurse should instruct her to report bright red clots, bleeding that lasts longer than 7 days, or signs of infection, such as a temperature of greater than 100 F (37.8 C), foulsmelling vaginal discharge, severe uterine cramping, nausea, or vomiting. When informed that a patients amniotic membrane has broken, the nurse should check fetal heart tones and then maternal vital signs. The duration of pregnancy averages 280 days, 40 weeks, 9 calendar months, or 10 lunar months. The initial weight loss for a healthy neonate is 5% to 10% of birth weight. The normal hemoglobin value in neonates is 17 to 20 g/dl. Crowning is the appearance of the fetuss head when its largest diameter is encircled by the vulvovaginal ring. A multipara is a woman who has had two or more pregnancies that progressed to viability, regardless of whether the offspring were alive at birth. In a pregnant patient, preeclampsia may progress to eclampsia, which is characterized by seizures and may lead to coma. The Apgar score is used to assess the neonates vital functions. Its obtained at 1 minute and 5 minutes after delivery. The score is based on respiratory effort, heart rate, muscle tone, reflex irritability, and color. Because of the anti-insulin effects of placental hormones, insulin requirements increase during the third trimester. Gestational age can be estimated by ultrasound measurement of maternal abdominal circumference, fetal femur length, and fetal head size. These measurements are most accurate between 12 and 18 weeks gestation. Skeletal system abnormalities and ventricular septal defects are the most common disorders of infants who are born to diabetic women. The incidence of congenital malformation is three times higher in these infants than in those born to nondiabetic women. Skeletal system abnormalities and ventricular septal defects are the most common disorders of infants who are born to diabetic women. The incidence of congenital malformation is three times higher in these infants than in those

born to nondiabetic women. The patient with preeclampsia usually has puffiness around the eyes or edema in the hands (for example, I cant put my wedding ring on.). Kegel exercises require contraction and relaxation of the perineal muscles. These exercises help strengthen pelvic muscles and improve urine control in postpartum patients. Symptoms of postpartum depression range from mild postpartum blues to intense, suicidal, depressive psychosis. The preterm neonate may require gavage feedings because of a weak sucking reflex, uncoordinated sucking, or respiratory distress. Acrocyanosis (blueness and coolness of the arms and legs) is normal in neonates because of their immature peripheral circulatory system. To prevent ophthalmia neonatorum (a severe eye infection caused by maternal gonorrhea), the nurse may administer one of three drugs, as prescribed, in the neonates eyes: tetracycline, silver nitrate, or erythromycin. Neonatal testing for phenylketonuria is mandatory in most states. The nurse should place the neonate in a 30-degree Trendelenburg position to facilitate mucus drainage. The nurse may suction the neonates nose and mouth as needed with a bulb syringe or suction trap. To prevent heat loss, the nurse should place the neonate under a radiant warmer during suctioning and initial delivery-room care, and then wrap the neonate in a warmed blanket for transport to the nursery. The umbilical cord normally has two arteries and one vein. When providing care, the nurse should expose only one part of an infants body at a time. Lightening is settling of the fetal head into the brim of the pelvis. If the neonate is stable, the mother should be allowed to breast-feed within the neonates first hour of life. The nurse should check the neonates temperature every 1 to 2 hours until its maintained within normal limits. At birth, a neonate normally weighs 5 to 9 lb (2 to 4 kg), measures 18" to 22"

(45.5 to 56 cm) in length, has a head circumference of 13" to 14" (34 to 35.5 cm), and has a chest circumference thats 1" (2.5 cm) less than the head circumference. In the neonate, temperature normally ranges from 98 to 99 F (36.7 to 37.2 C), apical pulse rate averages 120 to 160 beats/minute, and respirations are 40 to 60 breaths/minute. The diamond-shaped anterior fontanel usually closes between ages 12 and 18 months. The triangular posterior fontanel usually closes by age 2 months. In the neonate, a straight spine is normal. A tuft of hair over the spine is an abnormal finding. Prostaglandin gel may be applied to the vagina or cervix to ripen an unfavorable cervix before labor induction with oxytocin (Pitocin). Supernumerary nipples are occasionally seen on neonates. They usually appear along a line that runs from each axilla, through the normal nipple area, and to the groin. Meconium is a material that collects in the fetuss intestines and forms the neonates first feces, which are black and tarry. The presence of meconium in the amniotic fluid during labor indicates possible fetal distress and the need to evaluate the neonate for meconium aspiration. To assess a neonates rooting reflex, the nurse touches a finger to the cheek or the corner of the mouth. Normally, the neonate turns his head toward the stimulus, opens his mouth, and searches for the stimulus. Harlequin sign is present when a neonate who is lying on his side appears red on the dependent side and pale on the upper side. Mongolian spots can range from brown to blue. Their color depends on how close melanocytes are to the surface of the skin. They most commonly appear as patches across the sacrum, buttocks, and legs. Mongolian spots are common in non-white infants and usually disappear by age 2 to 3 years. Vernix caseosa is a cheeselike substance that covers and protects the fetuss skin in utero. It may be rubbed into the neonates skin or washed away in one or two baths.

Caput succedaneum is edema that develops in and under the fetal scalp during labor and delivery. It resolves spontaneously and presents no danger to the neonate. The edema doesnt cross the suture line. Nevus flammeus, or port-wine stain, is a diffuse pink to dark bluish red lesion on a neonates face or neck. The Guthrie test (a screening test for phenylketonuria) is most reliable if its done between the second and sixth days after birth and is performed after the neonate has ingested protein. To assess coordination of sucking and swallowing, the nurse should observe the neonates first breast-feeding or sterile water bottle-feeding. To establish a milk supply pattern, the mother should breast-feed her infant at least every 4 hours. During the first month, she should breast-feed 8 to 12 times daily (demand feeding). To avoid contact with blood and other body fluids, the nurse should wear gloves when handling the neonate until after the first bath is given. If a breast-fed infant is content, has good skin turgor, an adequate number of wet diapers, and normal weight gain, the mothers milk supply is assumed to be adequate. In the supine position, a pregnant patients enlarged uterus impairs venous return from the lower half of the body to the heart, resulting in supine hypotensive syndrome, or inferior vena cava syndrome. Tocolytic agents used to treat preterm labor include terbutaline (Brethine), ritodrine (Yutopar), and magnesium sulfate. A pregnant woman who has hyperemesis gravidarum may require hospitalization to treat dehydration and starvation. Diaphragmatic hernia is one of the most urgent neonatal surgical emergencies. By compressing and displacing the lungs and heart, this disorder can cause respiratory distress shortly after birth. Common complications of early pregnancy (up to 20 weeks gestation) include fetal loss and serious threats to maternal health. Fetal embodiment is a maternal developmental task that occurs in the second trimester. During this stage, the mother may complain that she never gets to

sleep because the fetus always gives her a thump when she tries. Visualization in pregnancy is a process in which the mother imagines what the child shes carrying is like and becomes acquainted with it. Hemodilution of pregnancy is the increase in blood volume that occurs during pregnancy. The increased volume consists of plasma and causes an imbalance between the ratio of red blood cells to plasma and a resultant decrease in hematocrit. Mean arterial pressure of greater than 100 mm Hg after 20 weeks of pregnancy is considered hypertension. The treatment for supine hypotension syndrome (a condition that sometimes occurs in pregnancy) is to have the patient lie on her left side. A contributing factor in dependent edema in the pregnant patient is the increase of femoral venous pressure from 10 mm Hg (normal) to 18 mm Hg (high). Hyperpigmentation of the pregnant patients face, formerly called chloasma and now referred to as melasma, fades after delivery. The hormone relaxin, which is secreted first by the corpus luteum and later by the placenta, relaxes the connective tissue and cartilage of the symphysis pubis and the sacroiliac joint to facilitate passage of the fetus during delivery. Progesterone maintains the integrity of the pregnancy by inhibiting uterine motility. Ladins sign, an early indication of pregnancy, causes softening of a spot on the anterior portion of the uterus, just above the uterocervical juncture. During pregnancy, the abdominal line from the symphysis pubis to the umbilicus changes from linea alba to linea nigra. In neonates, cold stress affects the circulatory, regulatory, and respiratory systems. Obstetric data can be described by using the F/TPAL system: F/T: Full-term delivery at 38 weeks or longer P: Preterm delivery between 20 and 37 weeks A: Abortion or loss of fetus before 20 weeks L: Number of children living (if a child has died, further explanation is needed to clarify the discrepancy in numbers).

Parity doesnt refer to the number of infants delivered, only the number of deliveries. Women who are carrying more than one fetus should be encouraged to gain 35 to 45 lb (15.5 to 20.5 kg) during pregnancy. The recommended amount of iron supplement for the pregnant patient is 30 to 60 mg daily. Drinking six alcoholic beverages a day or a single episode of binge drinking in the first trimester can cause fetal alcohol syndrome. Chorionic villus sampling is performed at 8 to 12 weeks of pregnancy for early identification of genetic defects. In percutaneous umbilical blood sampling, a blood sample is obtained from the umbilical cord to detect anemia, genetic defects, and blood incompatibility as well as to assess the need for blood transfusions. The period between contractions is referred to as the interval, or resting phase. During this phase, the uterus and placenta fill with blood and allow for the exchange of oxygen, carbon dioxide, and nutrients. In a patient who has hypertonic contractions, the uterus doesnt have an opportunity to relax and there is no interval between contractions. As a result, the fetus may experience hypoxia or rapid delivery may occur. Two qualities of the myometrium are elasticity, which allows it to stretch yet maintain its tone, and contractility, which allows it to shorten and lengthen in a synchronized pattern. During crowning, the presenting part of the fetus remains visible during the interval between contractions. Uterine atony is failure of the uterus to remain firmly contracted. The major cause of uterine atony is a full bladder. If the mother wishes to breast-feed, the neonate should be nursed as soon as possible after delivery. A smacking sound, milk dripping from the side of the mouth, and sucking noises all indicate improper placement of the infants mouth over the nipple. Before feeding is initiated, an infant should be burped to expel air from the stomach.

Most authorities strongly encourage the continuation of breast-feeding on both the affected and the unaffected breast of patients with mastitis. Neonates are nearsighted and focus on items that are held 10" to 12" (25 to 30.5 cm) away. In a neonate, low-set ears are associated with chromosomal abnormalities such as Down syndrome. Meconium is usually passed in the first 24 hours; however, passage may take up to 72 hours. Boys who are born with hypospadias shouldnt be circumcised at birth because the foreskin may be needed for constructive surgery. In the neonate, the normal blood glucose level is 45 to 90 mg/dl. Hepatitis B vaccine is usually given within 48 hours of birth. Hepatitis B immune globulin is usually given within 12 hours of birth. HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is an unusual variation of pregnancy-induced hypertension. Maternal serum alpha-fetoprotein is detectable at 7 weeks of gestation and peaks in the third trimester. High levels detected between the 16th and 18th weeks are associated with neural tube defects. Low levels are associated with Down syndrome. An arrest of descent occurs when the fetus doesnt descend through the pelvic cavity during labor. Its commonly associated with cephalopelvic disproportion, and cesarean delivery may be required. A late sign of preeclampsia is epigastric pain as a result of severe liver edema. In the patient with preeclampsia, blood pressure returns to normal during the puerperal period. To obtain an estriol level, urine is collected for 24 hours. An estriol level is used to assess fetal well-being and maternal renal functioning as well as to monitor a pregnancy thats complicated by diabetes. A pregnant patient with vaginal bleeding shouldnt have a pelvic examination. In the early stages of pregnancy, the finding of glucose in the urine may be related to the increased shunting of glucose to the developing placenta, without a corresponding increase in the reabsorption capability of the kidneys.

A patient who has premature rupture of the membranes is at significant risk for infection if labor doesnt begin within 24 hours. Infants of diabetic mothers are susceptible to macrosomia as a result of increased insulin production in the fetus. To prevent heat loss in the neonate, the nurse should bathe one part of his body at a time and keep the rest of the body covered. A patient who has a cesarean delivery is at greater risk for infection than the patient who gives birth vaginally. The occurrence of thrush in the neonate is probably caused by contact with the organism during delivery through the birth canal. The nurse should keep the sac of meningomyelocele moist with normal saline solution. If fundal height is at least 2 cm less than expected, the cause may be growth retardation, missed abortion, transverse lie, or false pregnancy. Fundal height that exceeds expectations by more than 2 cm may be caused by multiple gestation, polyhydramnios, uterine myomata, or a large baby. A major developmental task for a woman during the first trimester of pregnancy is accepting the pregnancy. Unlike formula, breast milk offers the benefit of maternal antibodies. Spontaneous rupture of the membranes increases the risk of a prolapsed umbilical cord. A clinical manifestation of a prolapsed umbilical cord is variable decelerations. During labor, to relieve supine hypotension manifested by nausea and vomiting and paleness, turn the patient on her left side. If the ovum is fertilized by a spermatozoon carrying a Y chromosome, a male zygote is formed. Implantation occurs when the cellular walls of the blastocyte implants itself in the endometrium, usually 7 to 9 days after fertilization. Implantation occurs when the cellular walls of the blastocyte implants itself in the endometrium, usually 7 to 9 days after fertilization. Heart development in the embryo begins at 2 to 4 weeks and is complete by the end of the embryonic stage.

Methergine stimulates uterine contractions. The administration of folic acid during the early stages of gestation may prevent neural tube defects. With advanced maternal age, a common genetic problem is Down syndrome. With early maternal age, cephalopelvic disproportion commonly occurs. In the early postpartum period, the fundus should be midline at the umbilicus. A rubella vaccine shouldnt be given to a pregnant woman. The vaccine can be administered after delivery, but the patient should be instructed to avoid becoming pregnant for 3 months. A 16-year-old girl who is pregnant is at risk for having a low-birth-weight neonate. The mothers Rh factor should be determined before an amniocentesis is performed. Maternal hypotension is a complication of spinal block. After delivery, if the fundus is boggy and deviated to the right side, the patient should empty her bladder. Before providing a specimen for a sperm count, the patient should avoid ejaculation for 48 to 72 hours. The hormone human chorionic gonadotropin is a marker for pregnancy. Painless vaginal bleeding during the last trimester of pregnancy may indicate placenta previa. During the transition phase of labor, the woman usually is irritable and restless. Because women with diabetes have a higher incidence of birth anomalies than women without diabetes, an alpha-fetoprotein level may be ordered at 15 to 17 weeks gestation. To avoid puncturing the placenta, a vaginal examination shouldnt be performed on a pregnant patient who is bleeding. A patient who has postpartum hemorrhage caused by uterine atony should be given oxytocin as prescribed. Laceration of the vagina, cervix, or perineum produces bright red bleeding that often comes in spurts. The bleeding is continuous, even when the fundus is firm. Hot compresses can help to relieve breast tenderness after breast-feeding.

The fundus of a postpartum patient is massaged to stimulate contraction of the uterus and prevent hemorrhage. A mother who has a positive human immunodeficiency virus test result shouldnt breast-feed her infant. Dinoprostone (Cervidil) is used to ripen the cervix. Breast-feeding of a premature neonate born at 32 weeks gestation can be accomplished if the mother expresses milk and feeds the neonate by gavage. If a pregnant patients rubella titer is less than 1:8, she should be immunized after delivery. The administration of oxytocin (Pitocin) is stopped if the contractions are 90 seconds or longer. For an extramural delivery (one that takes place outside of a normal delivery center), the priorities for care of the neonate include maintaining a patent airway, supporting efforts to breathe, monitoring vital signs, and maintaining adequate body temperature. Subinvolution may occur if the bladder is distended after delivery. The nurse must place identification bands on both the mother and the neonate before they leave the delivery room. Erythromycin is given at birth to prevent ophthalmia neonatorum. Pelvic-tilt exercises can help to prevent or relieve backache during pregnancy. Before performing a Leopold maneuver, the nurse should ask the patient to empty her bladder. PSYCHIATRIC NURSING BULLETS According to Kbler-Ross, the five stages of death and dying anger, bargaining, depression, and acceptance. Flight of ideas is an alteration in thought processes thats characterized by skipping from one topic to another, unrelated topic. La belle indiffrence is the lack of concern for a profound disability, such as blindness or paralysis that may occur in a patient who has a conversion are denial,

disorder. Moderate anxiety decreases a persons ability to perceive and concentrate. The person is selectively inattentive (focuses on immediate concerns), and the perceptual field narrows. A patient who has a phobic disorder uses self-protective avoidance as an ego defense mechanism. In a patient who has anorexia nervosa, the highest treatment priority is correction of nutritional and electrolyte imbalances. A patient who is taking lithium must undergo regular (usually once a month) monitoring of the blood lithium level because the margin between therapeutic and toxic levels is narrow. A normal laboratory value is 0.5 to 1.5 mEq/L. Early signs and symptoms of alcohol withdrawal include anxiety, anorexia, tremors, and insomnia. They may begin up to 8 hours after the last alcohol intake. Al-Anon is a support group for families of alcoholics. The nurse shouldnt administer chlorpromazine (Thorazine) to a patient who has ingested alcohol because it may cause oversedation and respiratory depression. Lithium toxicity can occur when sodium and fluid intake are insufficient, causing lithium retention. An alcoholic who achieves sobriety is called a recovering alcoholic because no cure for alcoholism exists.

According to Erikson, the school-age child (ages 6 to 12) is in the industry-versusinferiority stage of psychosocial development. When caring for a depressed patient, the nurses first priority is safety because of the increased risk of suicide. Echolalia is parrotlike repetition of another persons words or phrases.

According to psychoanalytic theory, the ego is the part of the psyche that controls internal demands and interacts with the outside world at the conscious, preconscious, and unconscious levels. According to psychoanalytic theory, the superego is the part of the psyche thats composed of morals, values, and ethics. It continually evaluates thoughts and actions, rewarding the good and punishing the bad. (Think of the superego as the supercop of the unconscious.) According to psychoanalytic theory, the id is the part of the psyche that contains instinctual drives. (Remember i for instinctual and d for drive.) Denial is the defense mechanism used by a patient who denies the reality of an event. In a psychiatric setting, seclusion is used to reduce overwhelming environmental stimulation, protect the patient from self-injury or injury to others, and prevent damage to hospital property. Its used for patients who dont respond to less restrictive interventions. Seclusion controls external behavior until the patient can assume self-control and helps the patient to regain selfcontrol. Tyramine-rich food, such as aged cheese, chicken liver, avocados, bananas, meat tenderizer, salami, bologna, Chianti wine, and beer may cause severe hypertension in a patient who takes a monoamine oxidase inhibitor. A patient who takes a monoamine oxidase inhibitor should be weighed biweekly and monitored for suicidal tendencies. If the patient who takes a monoamine oxidase inhibitor has palpitations, headaches, or severe orthostatic hypotension, the nurse should withhold the drug and notify the physician. Common causes of child abuse are poor impulse control by the parents and the lack of knowledge of growth and development. The diagnosis of Alzheimers disease is based on clinical findings of two or more

cognitive deficits, progressive worsening of memory, and the results of a neuropsychological test. Memory disturbance is a classic sign of Alzheimers disease. Thought blocking is loss of the train of thought because of a defect in mental processing. A compulsion is an irresistible urge to perform an irrational act, such as walking in a clockwise circle before leaving a room or washing the hands repeatedly. A patient who has a chosen method and a plan to commit suicide in the next 48 to 72 hours is at high risk for suicide. The therapeutic serum level for lithium is 0.5 to 1.5 mEq/L. Phobic disorders are treated with desensitization therapy, which gradually exposes a patient to an anxiety-producing stimulus. Dysfunctional grieving is absent or prolonged grief. During phase I of the nurse-patient relationship (beginning, or orientation, phase), the nurse obtains an initial history and the nurse and the patient agree to a contract. During phase II of the nurse-patient relationship (middle, or working, phase), the patient discusses his problems, behavioral changes occur, and self-defeating behavior is resolved or reduced. During phase III of the nurse-patient relationship (termination, or resolution, phase), the nurse terminates the therapeutic relationship and gives the patient positive feedback on his accomplishments. According to Freud, a person between ages 12 and 20 is in the genital stage, during which he learns independence, has an increased interest in members of the opposite sex, and establishes an identity. According to Erikson, the identity-versus-role confusion stage occurs between ages 12 and 20.

Tolerance is the need for increasing amounts of a substance to achieve an effect that formerly was achieved with lesser amounts. Suicide is the third leading cause of death among white teenagers. Most teenagers who kill themselves made a previous suicide attempt and left telltale signs of their plans. In Eriksons stage of generativity versus despair, generativity (investment of the self in the interest of the larger community) is expressed through procreation, work, community service, and creative endeavors. Alcoholics Anonymous recommends a 12-step program to achieve sobriety. Signs and symptoms of anorexia nervosa include amenorrhea, excessive weight loss, lanugo (fine body hair), abdominal distention, and electrolyte disturbances. A serum lithium level that exceeds 2.0 mEq/L is considered toxic. Public Law 94-247 (Child Abuse and Neglect Act of 1973) requires reporting of suspected cases of child abuse to child protection services. The nurse should suspect sexual abuse in a young child who has blood in the feces or urine, penile or vaginal discharge, genital trauma that isnt readily explained, or a sexually transmitted disease. An alcoholic uses alcohol to cope with the stresses of life. The human personality operates on three levels: conscious, preconscious, and unconscious. Asking a patient an open-ended question is one of the best ways to elicit or clarify information. The diagnosis of autism is often made when a child is between ages 2 and 3. Defense mechanisms protect the personality by reducing stress and anxiety. Suppression is voluntary exclusion of stress-producing thoughts from the

consciousness. In psychodrama, life situations are approximated in a structured environment, allowing the participant to recreate and enact scenes to gain insight and to practice new skills. Psychodrama is a therapeutic technique thats used with groups to help participants gain new perception and self-awareness by acting out their own or assigned problems. A patient who is taking disulfiram (Antabuse) must avoid ingesting products that contain alcohol, such as cough syrup, fruitcake, and sauces and soups made with cooking wine. A patient who is admitted to a psychiatric hospital involuntarily loses the right to sign out against medical advice. People who live in glass houses shouldnt throw stones and A rolling stone gathers no moss are examples of proverbs used during a psychiatric interview to determine a patients ability to think abstractly. (Schizophrenic patients think in concrete terms and might interpret the glass house proverb as If you throw a stone in a glass house, the house will break.) Signs of lithium toxicity include diarrhea, tremors, nausea, muscle weakness, ataxia, and confusion. A labile affect is characterized by rapid shifts of emotions and mood. Amnesia is loss of memory from an organic or inorganic cause. A person who has borderline personality disorder is demanding and judgmental in interpersonal relationships and will attempt to split staff by pointing to discrepancies in the treatment plan. Disulfiram (Antabuse) shouldnt be taken concurrently with metronidazole (Flagyl) because they may interact and cause a psychotic reaction. In rare cases, electroconvulsive therapy causes arrhythmias and death.

A patient who is scheduled for electroconvulsive therapy should receive nothing by mouth after midnight to prevent aspiration while under anesthesia. Electroconvulsive therapy is normally used for patients who have severe depression that doesnt respond to drug therapy. For electroconvulsive therapy to be effective, the patient usually receives 6 to 12 treatments at a rate of 2 to 3 per week. During the manic phase of bipolar affective disorder, nursing care is directed at slowing the patient down because the patient may die as a result of selfinduced exhaustion or injury. For a patient with Alzheimers disease, the nursing care plan should focus on safety measures. After sexual assault, the patients needs are the primary concern, followed by medicolegal considerations. Patients who are in a maintenance program for narcotic abstinence syndrome receive 10 to 40 mg of methadone (Dolophine) in a single daily dose and are monitored to ensure that the drug is ingested. Stress management is a short-range goal of psychotherapy. The mood most often experienced by a patient with organic brain syndrome is irritability. Creative intuition is controlled by the right side of the brain. Methohexital (Brevital) is the general anesthetic thats administered to patients who are scheduled for electroconvulsive therapy. The decision to use restraints should be based on the patients safety needs. Diphenhydramine (Benadryl) relieves the extrapyramidal adverse effects of psychotropic drugs. In a patient who is stabilized on lithium (Eskalith) therapy, blood lithium levels should be checked 8 to 12 hours after the first dose, then two or three times

weekly during the first month. Levels should be checked weekly to monthly during maintenance therapy. The primary purpose of psychotropic drugs is to decrease the patients symptoms, which improves function and increases compliance with therapy. Manipulation is a maladaptive method of meeting ones needs because it disregards the needs and feelings of others. If a patient has symptoms of lithium toxicity, the nurse should withhold one dose and call the physician. A patient who is taking lithium (Eskalith) for bipolar affective disorder must maintain a balanced diet with adequate salt intake. A patient who constantly seeks approval or assistance from staff members and other patients is demonstrating dependent behavior. Alcoholics Anonymous advocates total abstinence from alcohol. Methylphenidate (Ritalin) is the drug of choice for treating attention deficit hyperactivity disorder in children. Setting limits is the most effective way to control manipulative behavior. Violent outbursts are common in a patient who has borderline personality disorder. When working with a depressed patient, the nurse should explore meaningful losses. An illusion is a misinterpretation of an actual environmental stimulus. Anxiety is nonspecific; fear is specific. Extrapyramidal adverse effects are common in patients who take antipsychotic drugs. The nurse should encourage an angry patient to follow a physical exercise program as one of the ways to ventilate feelings. Depression is clinically significant if its characterized by exaggerated feelings of

sadness, melancholy, dejection, worthlessness, and hopelessness that are inappropriate or out of proportion to reality. Free-floating anxiety is anxiousness with generalized apprehension and pessimism for unknown reasons. In a patient who is experiencing intense anxiety, the fight-or-flight reaction (alarm reflex) may take over. Confabulation is the use of imaginary experiences or made-up information to fill missing gaps of memory. When starting a therapeutic relationship with a patient, the nurse should explain that the purpose of the therapy is to produce a positive change. A basic assumption of psychoanalytic theory is that all behavior has meaning. Catharsis is the expression of deep feelings and emotions. According to the pleasure principle, the psyche seeks pleasure and avoids unpleasant experiences, regardless of the consequences. A patient who has a conversion disorder resolves a psychological conflict through the loss of a specific physical function (for example, paralysis, blindness, or inability to swallow). This loss of function is involuntary, but diagnostic tests show no organic cause. Chlordiazepoxide (Librium) is the drug of choice for treating alcohol withdrawal symptoms. For a patient who is at risk for alcohol withdrawal, the nurse should assess the pulse rate and blood pressure every 2 hours for the first 12 hours, every 4 hours for the next 24 hours, and every 6 hours thereafter (unless the patients condition becomes unstable). Alcohol detoxification is most successful when carried out in a structured environment by a supportive, nonjudgmental staff. The nurse should follow these guidelines when caring for a patient who is

experiencing alcohol withdrawal: Maintain a calm environment, keep intrusions to a minimum, speak slowly and calmly, adjust lighting to prevent shadows and glare, call the patient by name, and have a friend or family member stay with the patient, if possible. The therapeutic regimen for an alcoholic patient includes folic acid, thiamine, and multivitamin supplements as well as adequate food and fluids. A patient who is addicted to opiates (drugs derived from poppy seeds, such as heroin and morphine) typically experiences withdrawal symptoms within 12 hours after the last dose. The most severe symptoms occur within 48 hours and decrease over the next 2 weeks. Reactive depression is a response to a specific life event. Projection is the unconscious assigning of a thought, feeling, or action to someone or something else. Sublimation is the channeling of unacceptable impulses into socially acceptable behavior. Repression is an unconscious defense mechanism whereby unacceptable or painful thoughts, impulses, memories, or feelings are pushed from the consciousness or forgotten. Hypochondriasis is morbid anxiety about ones health associated with various symptoms that arent caused by organic disease. Denial is a refusal to acknowledge feelings, thoughts, desires, impulses, or external facts that are consciously intolerable. Reaction formation is the avoidance of anxiety through behavior and attitudes that are the opposite of repressed impulses and drives. Displacement is the transfer of unacceptable feelings to a more acceptable object. Regression is a retreat to an earlier developmental stage. According to Erikson, an older adult (age 65 or older) is in the developmental stage

of integrity versus despair. Family therapy focuses on the family as a whole rather than the individual. Its major objective is to reestablish rational communication between family members. When caring for a patient who is hostile or angry, the nurse should attempt to remain calm, listen impartially, use short sentences, and speak in a firm, quiet voice. Ritualism and negativism are typical toddler behaviors. They occur during the developmental stage identified by Erikson as autonomy versus shame and doubt. Circumstantiality is a disturbance in associated thought and speech patterns in which a patient gives unnecessary, minute details and digresses into inappropriate thoughts that delay communication of central ideas and goal achievement. Idea of reference is an incorrect belief that the statements or actions of others are related to oneself. Group therapy provides an opportunity for each group member to examine interactions, learn and practice successful interpersonal communication skills, and explore emotional conflicts. Korsakoffs syndrome is believed to be a chronic form of Wernickes encephalopathy. Its marked by hallucinations, confabulation, amnesia, and disturbances of orientation. A patient with antisocial personality disorder often engages in confrontations with authority figures, such as police, parents, and school officials.

A patient with paranoid personality disorder exhibits suspicion, hypervigilance, and hostility toward others.

Depression is the most common psychiatric disorder. Adverse reactions to tricyclic antidepressant drugs include tachycardia, orthostatic hypotension, hypomania, lowered seizure threshold, tremors, weight gain, problems with erections or orgasms, and anxiety. The Minnesota Multiphasic Personality Inventory consists of 550 statements for the subject to interpret. It assesses personality and detects disorders, such as depression and schizophrenia, in adolescents and adults. Organic brain syndrome is the most common form of mental illness in elderly patients. A person who has an IQ of less than 20 is profoundly retarded and is considered a total-care patient. Reframing is a therapeutic technique thats used to help depressed patients to view a situation in alternative ways. Fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are serotonin reuptake inhibitors used to treat depression. The early stage of Alzheimers disease lasts 2 to 4 years. Patients have inappropriate affect, transient paranoia, disorientation to time, memory loss, careless dressing, and impaired judgment. The middle stage of Alzheimers disease lasts 4 to 7 years and is marked by profound personality changes, loss of independence, disorientation, confusion, inability to recognize family members, and nocturnal restlessness. The last stage of Alzheimers disease occurs during the final year of life and is characterized by a blank facial expression, seizures, loss of appetite, emaciation, irritability, and total dependence. Threatening a patient with an injection for failing to take an oral drug is an example of assault. Reexamination of life goals is a major developmental task during middle adulthood.

Acute alcohol withdrawal causes anorexia, insomnia, headache, and restlessness and escalates to a syndrome thats characterized by agitation, disorientation, vivid hallucinations, and tremors of the hands, feet, legs, and tongue. In a hospitalized alcoholic, alcohol withdrawal delirium most commonly occurs 3 to 4 days after admission. Confrontation is a communication technique in which the nurse points out discrepancies between the patients words and his nonverbal behaviors. For a patient with substance-induced delirium, the time of drug ingestion can help to determine whether the drug can be evacuated from the body. Treatment for alcohol withdrawal may include administration of I.V. glucose for hypoglycemia, I.V. fluid containing thiamine and other B vitamins, and antianxiety, antidiarrheal, anticonvulsant, and antiemetic drugs. The alcoholic patient receives thiamine to help prevent peripheral neuropathy and Korsakoffs syndrome. Alcohol withdrawal may precipitate seizure activity because alcohol lowers the seizure threshold in some people. Paraphrasing is an active listening technique in which the nurse restates what the patient has just said. A patient with Korsakoffs syndrome may use confabulation (made up information) to cover memory lapses or periods of amnesia. People with obsessive-compulsive disorder realize that their behavior is unreasonable, but are powerless to control it. When witnessing psychiatric patients who are engaged in a threatening confrontation, the nurse should first separate the two individuals. Patients with anorexia nervosa or bulimia must be observed during meals and for some time afterward to ensure that they dont purge what they have eaten. Transsexuals believe that they were born the wrong gender and may seek

hormonal or surgical treatment to change their gender. Fugue is a dissociative state in which a person leaves his familiar surroundings, assumes a new identity, and has amnesia about his previous identity. (Its also described as flight from himself.) In a psychiatric setting, the patient should be able to predict the nurses behavior and expect consistent positive attitudes and approaches. When establishing a schedule for a one-to-one interaction with a patient, the nurse should state how long the conversation will last and then adhere to the time limit. Thought broadcasting is a type of delusion in which the person believes that his thoughts are being broadcast for the world to hear. Lithium should be taken with food. A patient who is taking lithium shouldnt restrict his sodium intake. A patient who is taking lithium should stop taking the drug and call his physician if he experiences vomiting, drowsiness, or muscle weakness. The patient who is taking a monoamine oxidase inhibitor for depression can include cottage cheese, cream cheese, yogurt, and sour cream in his diet. Sensory overload is a state in which sensory stimulation exceeds the individuals capacity to tolerate or process it. Symptoms of sensory overload include a feeling of distress and hyperarousal with impaired thinking and concentration. In sensory deprivation, overall sensory input is decreased. A sign of sensory deprivation is a decrease in stimulation from the environment or from within oneself, such as daydreaming, inactivity, sleeping excessively, and reminiscing. The three stages of general adaptation syndrome are alarm, resistance, and exhaustion.

A maladaptive response to stress is drinking alcohol or smoking excessively. Hyperalertness and the startle reflex are characteristics of posttraumatic stress disorder. A treatment for a phobia is desensitization, a process in which the patient is slowly exposed to the feared stimuli. Symptoms of major depressive disorder include depressed mood, inability to experience pleasure, sleep disturbance, appetite changes, decreased libido, and feelings of worthlessness. Clinical signs of lithium toxicity are nausea, vomiting, and lethargy. Asking too many why questions yields scant information and may overwhelm a psychiatric patient and lead to stress and withdrawal. Remote memory may be impaired in the late stages of dementia. According to the DSM-IV, bipolar II disorder is characterized by at least one manic episode thats accompanied by hypomania. The nurse can use silence and active listening to promote interactions with a depressed patient. A psychiatric patient with a substance abuse problem and a major psychiatric disorder has a dual diagnosis. When a patient is readmitted to a mental health unit, the nurse should assess compliance with medication orders. Alcohol potentiates the effects of tricyclic antidepressants. Flight of ideas is movement from one topic to another without any discernible connection. Conduct disorder is manifested by extreme behavior, such as hurting people and animals. During the tension-building phase of an abusive relationship, the abused

individual feels helpless. In the emergency treatment of an alcohol-intoxicated patient, determining the blood-alcohol level is paramount in determining the amount of medication that the patient needs. Side effects of the antidepressant fluoxetine (Prozac) include diarrhea, decreased libido, weight loss, and dry mouth. Before electroconvulsive therapy, the patient is given the skeletal muscle relaxant succinylcholine (Anectine) by I.V. administration. When a psychotic patient is admitted to an inpatient facility, the primary concern is safety, followed by the establishment of trust. An effective way to decrease the risk of suicide is to make a suicide contract with the patient for a specified period of time. A depressed patient should be given sufficient portions of his favorite foods, but shouldnt be overwhelmed with too much food. The nurse should assess the depressed patient for suicidal ideation. Delusional thought patterns commonly occur during the manic phase of bipolar disorder. Apathy is typically observed in patients who have schizophrenia. Manipulative behavior is characteristic of a patient who has passive aggressive personality disorder. When a patient who has schizophrenia begins to hallucinate, the nurse should redirect the patient to activities that are focused on the here and now. When a patient who is receiving an antipsychotic drug exhibits muscle rigidity and tremors, the nurse should administer an antiparkinsonian drug (for example, Cogentin or Artane) as ordered. A patient who is receiving lithium (Eskalith) therapy should report diarrhea, vomiting, drowsiness, muscular weakness, or lack of coordination to the

physician immediately. The therapeutic serum level of lithium (Eskalith) for maintenance is 0.6 to 1.2 mEq/L. Obsessive-compulsive disorder is an anxiety-related disorder. Al-Anon is a self-help group for families of alcoholics. Desensitization is a treatment for phobia, or irrational fear. After electroconvulsive therapy, the patient is placed in the lateral position, with the head turned to one side. A delusion is a fixed false belief. Giving away personal possessions is a sign of suicidal ideation. Other signs include writing a suicide note or talking about suicide. Agoraphobia is fear of open spaces. A person who has paranoid personality disorder projects hostilities onto others. To assess a patients judgment, the nurse should ask the patient what he would do if he found a stamped, addressed envelope. An appropriate response is that he would mail the envelope. After electroconvulsive therapy, the patient should be monitored for post-shock amnesia. A mother who continues to perform cardiopulmonary resuscitation after a physician pronounces a child dead is showing denial. Transvestism is a desire to wear clothes usually worn by members of the opposite sex. Tardive dyskinesia causes excessive blinking and unusual movement of the tongue, and involuntary sucking and chewing. Trihexyphenidyl (Artane) and benztropine (Cogentin) are administered to counteract extrapyramidal adverse effects.

To prevent hypertensive crisis, a patient who is taking a monoamine oxidase inhibitor should avoid consuming aged cheese, caffeine, beer, yeast, chocolate, liver, processed foods, and monosodium glutamate. Extrapyramidal symptoms include parkinsonism, dystonia, akathisia (ants in the pants), and tardive dyskinesia. One theory that supports the use of electroconvulsive therapy suggests that it resets the brain circuits to allow normal function.

A patient who has obsessive-compulsive disorder usually recognizes the senselessness of his behavior but is powerless to stop it (ego-dystonia). In helping a patient who has been abused, physical safety is the nurses first priority. Pemoline (Cylert) is used to treat attention deficit hyperactivity disorder (ADHD). Clozapine (Clozaril) is contraindicated in pregnant women and in patients who have severe granulocytopenia or severe central nervous system depression. Repression, an unconscious process, is the inability to recall painful or unpleasant thoughts or feelings. Projection is shifting of unwanted characteristics or shortcomings to others (scapegoat). Hypnosis is used to treat psychogenic amnesia. Disulfiram (Antabuse) is administered orally as an aversion therapy to treat alcoholism. Ingestion of alcohol by a patient who is taking disulfiram (Antabuse) can cause severe reactions, including nausea and vomiting, and may endanger the patients life. Improved concentration is a sign that lithium is taking effect.

Behavior modification, including time-outs, token economy, or a reward system, is a treatment for attention deficit hyperactivity disorder. For a patient who has anorexia nervosa, the nurse should provide support at mealtime and record the amount the patient eats. A significant toxic risk associated with clozapine (Clozaril) administration is blood dyscrasia. Adverse effects of haloperidol (Haldol) administration include drowsiness; insomnia; weakness; headache; and extrapyramidal symptoms, such as akathisia, tardive dyskinesia, and dystonia. Hypervigilance and dj vu are signs of posttraumatic stress disorder (PTSD). A child who shows dissociation has probably been abused. Confabulation is the use of fantasy to fill in gaps of memory. Eyes has external parts and intrinsic coats.External parts of the eyes are orbital cavity,Extrinsic Ocular muscles(EOM),eyelashes/eyebrows and eyelids,conjunctiva,and lacrimal apparatus. Intrinsic coats of the eyes include sclerotic coats and uveal tract.Sclerotic coat is the outermost while uveal tract is for nutritive care and consists of iris. Orbital cavity is made up of connective tissue protects eye from trauma. Extrinsic Ocular Muscles are involuntary muscles of the eye needed for gazing movement. Eyelashes/eyebrows are for esthetic purposes. Eyelids or palpebral fissure are opening upper and lower lids which protects the eye from direct sunlight. Meibomean gland secretes a lubricating fluid inside eyelid. Lacrimal apparatus are responsible for tears. Stye or Hordeolum is an inflamed meibomean gland.

The processes of grieving according to Kubbler Ross are DABDA:denial,anger,bargaining,depression,and acceptance. Sclera is part of sclerotic coat which is white.It occupies 3/4 post of eye and refracts light rays. Canal of Schlera is site of acqueous humor drainage. Cornea is the transparent structure of the eye. Uveitis is the inflammation of the uveal tract. Iris is the colored muscular ring of the eye. Circular smooth muscle fiber is a muscle part of the iris which constricts pupil. Radial smooth muscle fiber is a muscle part of the iris with dilates the pupil. 2 chambers of the eye include anterior and retina(innermost layer) Anterior chamber of the eye contains vitreous humor which maintains the spherical shape of the eye,and aqueous humor which maintains the intrinsic occular pressure. Normal Intraocular pressure is 12-21mmHg. Optic discs or blind spot that has nerve fibers only and no auto receptors.Cones are for daylight/colored vision,and rods are for night twilight vision. Scotopic vision is due to vitamin A deficiency and insufficient rods. Macula lutea is the yellow spot center of retina. Fovea Centralis is the area with highest visual acuity or acute vision. There are 4 physiological processes for vision to occur:(a)Refraction of Light(b)Accommodation of lens(c)constriction &dilation of pupils(d)convergence of eyes. Diopters is the unit of measurement of refraction. Emmetropia is the normal eye refraction.

Errors of Refraction are:myopia,hyperopia,,astigmatism,presbyopia. Myopia or nearsightedness can be treated by biconcave lens. Hyperopia or farsightedness can be treated by biconvex lens. Astigmatism is a distorted vision which can be treated by cylindrical. Presbyopia or called old slight or inelasticity of lens due to aging and can be treated by bifocal lens or double vista. Accommodation of lenses are based on thelmholtz theory of accommodation. In near vision the ciliary muscles contract and lens bulges.In far vision,ciliary muscles dilate or relaxes and lens is flat. Exotropia is error on convergence of the eye which 1 eye is normal. Errors on convergence of the eye can be corrected by corrective eye surgery. Esophoria is one of the errors on convergence of the eye. Strabismus is squinting of the eye. Amblyopia is prolong squinting of the eye. Glaucoma is an increase intraocular pressure which if left untreated the optic nerve disc will atrophy resulting to blindness. Predisposing factors of glaucoma are:high risk group(ages 40&above),HPN,DM,Hereditary,obesity,recent eye trauma,inflammation or surgery of the eyes. Chronic or open angle glaucoma is a common type of glaucoma characterized by obstruction in the flow of acqueous humor at trabecular meshwork of canal of schlem. Acute or close angle glaucoma is the most dangerous type characterized by forward displacement of iris to cornea leading to blindness. Chronic closed angle glaucoma is precipitated by acute attack.

Signs and symptoms of glaucoma are:loss of peripheral vision/tunnel vision,halos around lights,headache,nausea and vomiting,eye discomfort,steamy cornea,gradual loss of central vision leading to blindness. Diagnostic procedures for glaucoma are tonometry(result:Increased IOP >1221mmHg),Perimetry(decreased peripheral vision),gonioscopy(abstruction in anterior chamber). Nursing management for glaucoma includes:Enforce CBR,Maintain siderails,administer medications. Meiotic are lifetime medications for glaucoma function is to contract ciliary muscles&constricts pupil.Ex.is pilocarpine Na(Carbachol). Epinephrine eyedrops for glaucoma decreases secretion of aqueous humor. To promote an increase outflow of aqueous humor for glaucoma,Carbonic anhydrase inhibitors are given.Ex. is acetapolamide(diamox). Temoptics(timolol maleate) increases outflow of aqueous humor in glaucoma. Surgery for glaucoma includes trabeculectomy and peripheral iridectomy. Trabeculectomy is eyetrephining or removal of trabecular meshwork of canal of schlem to drain aqueous humor. In Peripheral Iridectomy,portion of iris is excised to drain aqueous humor. Non-invasive trabeculectomy is done by eye laser surgery. Preoperative nursing management for all types of eye surgery:apply eye patch on unaffected eye to force weaker eye to become stronger. Postoperative nursing management for all types of eye surgery includes:Position unaffected/unoperative side to prevent tension on suture line,avoid valsalva maneuver,put eye patch on both eyes,monitor symptoms of IOP which are headache,nausea,vomiting,eye discomfort,tachycardia. Cataract is a partial or complete opacity of the lens.

Predisposing factors of cataracts are aging(degenerative/senile cataract),congenital,prolonged exposure to UV rays,and DM. Loss of central vision(hazy/blurring of vision),painless,milky white appearance at center of pupil and decrease perception of colors are some of the signs and symptoms of cataract. Diagnostic procedure for cataract is opthalmoscopic exam:result:(+)opacity of the lens. Nsg.mgt.for cataracts are:reorient the patient to environment due to opacity,siderails on,give medications,or surgery. Medications for cataracts are mydriatics(mydriacyl) to dilate pupil not to be taken lifetime,cyslopegics(cyclogye) which paralyzes ciliary muscle . ECCLE(Extra Capsular Cataract Lens Extraction) is partial removal of lens. ICCLE(Intra Capsular Cataract Lens Extraction) is total removal of lens and surrounding capsules. Nursing management for post-op cataract surgery are:position unaffected/unoperated side to prevent tension on suture line,avoid valsalva maneuver,monitor symptoms of IOP,and eye patch on both eyes. Retinal detachment is separation of 2 layers of retina.Predisposing factors are:severe myopia,diabetic retinopathy,trauma,following lens extraction,and HPN. Signs and symptoms of retinal detachment are curtain-veil like vision,flashes of lights,floaters,gradual decrease in central vision,headache. Diagnostic procedure for retinal detachment is opthalmoscopic exam. Maintaining siderails is important on all visual diseases. Cryosurgery and scleral buckling are the operative surgeries for retinal detachment. Functions of ear includes hearing and balance(kinesthesia or position sense).

Outer parts of the ear pinna(protects the ear from direct trauma),external auditory meatus(has ceruminous gland-cerumen),typhanic membrane which transmits sound waves to middle ear.

Disorders of outer ear can be entry of objects(put flashlight to give route of exit),foreign objects(beans-bring to MD),and water which has to drain. Middle parts of the ear are ear ossicle(hammer-malleus,anvil-incus,stirrups-stapes) which functions for bone conduction.Conductive hearing loss is the disorder. Eustachian is middle part of ear that opens to allow equalization of pressure on both ears like in yawning,chewing,and swallowing. Child ear characteristics are straight,wide,and short while in adult,it is long,narrow and slanted. Stapedius,tensor tympani are the muscles of middle ear. Inner parts of ear are bony labyrinth(balance/vestibule) and membranous labyrinth that contains cochlea(hearing fxn,has organ of corti),endolymph and perilymph(for static equilibrium),mastoid air cells(air filled spaces in temporal bone in skull). Meningitis is one of the complications of mastoditis. Conductive hearing loss is called transmission hearing loss.Affected part is middle ear(ear ossicles). Causes of conductive hearing loss are impacted cerumen,immobility of stapes,middle ear disease characterized by formation of spongy bone in the inner ear causing fixation or immobility of stapes,and stapes can't transmit sound waves. Otosclerosis is caused by immobility of stapes. Tinnitus and conductive hearing loss is due to impacted cerumen,nurse should assist in ear irrigation. Stapedectomy is removal of stapes,spongy bone and implantation of graft/ear

prosthesis. Predisposing factors of hearing loss are familial tendency and ear trauma and surgery. Audiometry(various sound stimulates(+)conductive hearing loss) is a diagnostic procedure for hearing loss. Weber's test is a test for hearing loss.+ Result is BC>AC.Normal is AC>BC. Post-op mgt.for stapedectomy are:position pt.on unaffected side,DBE(no coughing &blowing of nose coz it might lead to removal of graft),give meds. (analgesic,antiemetic,antimotion sickness agent-meclesinge Hcl(Bonamine),Assess motor function(facial nerve-smile,frown,raise eyebrow),avoid shampoiing hair for 1-2weeks use shower cap also. Sensory Neural Hearing Loss or Nerve Deafness is caused by tumor on cochleal,loud noises(gun shot),presbyuscis,meniere's dse. Presbyuscis is a bilateral progressive hearing loss especially at high frequencies.In elderly patients,face them to promote lip reading. Meniere's disease(endolymphatic hydrops) is an inner ear dse.characterized by dilation of endo-lymphatic system leading to increase volume of endolin. Predisposing factors of meniere's disease are smoking,hyperlipidemia,30years old,obesity(+ chosesteatoma),allergy,and ear trauma and infection. Signs and symptoms of meniere's dse.are tinnitus,vertigo sensory neural hearing loss(triad symptoms),nystagmus,nausea and vomiting,mild apprehension,anxiety,tachycardia,diaphoresis and palpitations. Diagnostic procedures for meniere's dse. is audiometry:result:+sensory hearing loss. Nursing mgt.for meniere's dse.are:provide a comfy and darkened environment,maintain siderails,provide emetic basin,restrict sodium,limit fluid intake,avoid smoking,give medications(diuretics-to remove endolymph,vasodilator,antihistamine,antiemetic,antimotion sickness

agent,sedatives/tranquilizers). Burns are direct tissue injury caused by thermal,electric,chemical and smoke inhaled(TECS). Infection is the highest priority in all kinds of burns. In head burn,the highest priority is airway. The second priority for 1st and 2nd burn is pain. The second priority for 3rd burn is fluid and electrolytes. Thermal burn is direct contact which can be caused by flames,hot grease,and sunburn. Electric burns caused by livewires. Chemical burns has direct contact and caused by corrosive materials like acids. Smoke burn is caused by gas/fume inhalation. Emergent phase is a stage of burn which starts from removal of patient from cause of burn.Source,location,or burn should be determined. Shock phase is characterized by shifting of fluids from intravascular to interstitial space that can lead to hypovolemia. BP and UO dec.,HR and Hct increases,dec.serum Na,inc.serum K and metabolic acidosis indicate hypovolemia. Diuretic/fluid remobilization phase takes 3-5days.This characterized by return of fluid from interstitial to intravascular space. Recovery/convalescent phase is a complete diuresis.Wound healing starts immediately after tissue injury. Burns are categorized by partial burn and full thickness burn. Partial burn includes 1st and 2nd degree burns.1st degree are superficial burns that affects epidermis which caused by thermal burns.This is painful and cause redness(erythema) and blanching upon pressure with no fluid filled vesicles.

Full thickness burns include third and 4th degrees burn that caused by electrical.It affects all layers of skin,muscles,bones.This is less painful,and eschar can be formed. Eschar is a devitalized or necrotic tissue characterized by dry,thick,leathery wound surface. Rules of nines are:head and neck-9%,anterior chest-18%,posterior chest18%,@arm 9+9-18%,@leg 18+18-18%,genitalia/perineum-1% comprising of 100%. Administering isotonic fluid soln,&protein replacements,strict aseptic technique,assisting in hydrotherapy,and preventing complications are some of the nursing mgt.for burned patients. Burn complications include infection,shock,paralytic ileus(due to hypovolemia/hypokalemia),Curling's ulcer(H2 receptor antagonist),septicemia(blood poisoning) and conditions may lead to surgery(skin grafting). Administer analgesic 15-30 minutes before wound debridement in burned patients. If + to burns on head,neck,face,priority is assisting in intubation. Increased CHO,Increase CHON,Increase vit.C,and increase in K(orange) is the diet for burned patients. Medicines for burned patients include:tetanus toxoid(for claustridium tetany),morphine SO4,systemic antibiotics(ampicillin,cephalosporin,tetracyclin),and topical antibiotics(silver sulfadiazine-silvadene,sulfamylon,silver nitrate,povidone iodine-betadine). Claustridium Tetany comes in two ways:tetanolysin which means hemolysis and tetanuspasmin(muscle spasm). GUT or genito-urinary tract unique fxns are:it promotes excretion of nitrogenous waste products and maintains F & E acid base balance. Kidneys are a pair of bean-shaped organ that located retroperitonially(back of

peritoneum) on either side of vertebral column,encased in Bowman's capsule.It functions for urine formation and regulation of BP. Parts of the kidney are:renal pelvis,cortex and medulla. Nephrones are the basic living unit of kidneys. Glomerulus filters the blood going to the kidneys. Kidneys receive 25% of total Cardiac output. Normal Glumerular Filtration Rate/minute is 125ml of blood. In process of tubular reabsorption,124ml of ultra infiltrates(H2O & electrolytes is for reabsorption. In process of tubular excretion,1ml is excreted in urine. In Caesarean Section Hypovolemia,there is a decrease of BP going to the kidneys.RAAS activated,release of Renin(hydrolytic enzyme) at juxtaglomerular apparatus,activating angiotensin 1 mild vasoconstrictor,activating angiotensin II vasoconstrictor,stimulating adrenal cortex,releasing of aldosterone to increase Na & H2O reabsorption,leading to hypervolemia,thus increasing CO,Increase in PR and therefore increased in BP. Ureters size is 25-35 cm long passageway of urine to bladder. Bladder is located behind symphisis pubis characterized by muscular & elastic tissue that is distensible.It functions as reservoir of urine. Normal adult can hold 1200-1800ml of urine. 200-500ml is the amt.needed to initiate micturition reflex. Normal features of urine are:color-amber,odor-aromatic,consistency-clear or slightly turbid,pH-4.5-8,specific gravity-1.015-1.030,(-)WBC/RBC,(-)albumin, (-)E coli,few mucus threads,(-) amorphous urate. Urethra extends to external surface of the body.It is a passage of urine,seminal and

vaginal fluids.Normal size for female is 3-5cm or 1-1 1/2".For males,20cm or 8" long. Cystitis is the inflammation of the bladder.It can be caused by microbial invasion(e coli),common in women,obstruction,urinary retention,increased estrogen levels,and sexual intercourse. Pain in flank area,urinary frequency and urgency,burning upon urination,dysuria or hematuria,fever,chills,anorexia and general body malaise are the most common signs and symptoms of cystitis. +E-Coli is the result of culture and sensitivity in a patient with cystitis. The ff.are the nursing mgt.for cystitis:Force fluid up to 2000ml/day,warm sitz bath to promote comfort,monitor and assess for gross hematuria,provide acid ash diet,give medications,provide health teachings. Acid ash diet consists of cranberry,vit.C,Orange juice to acidify uringe and prevent bacterial multiplication. Systemic antibiotics are given to patient with cystitis,such as ampicillin,cephalosporin,sulfonamides(cotrimoxazole-Bactrim),urinary antiseptics(mitropurantoin-macrodantin),and urinary analgesics(pyridium). Female with cystitis should wash perineum from front to back ,avoid use of bubble bath,tissue paper,powder and perfume. Voiding after sex is advised with patients with cystitis. Hydration is important with cystitis. Pyelonephritis is common complication of cystitis. Pyelonephritis is an acute or chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction,interstitial abscess formation that can lead to renal failure. Predisposing factors for pyelonephritis are urinary retention/obstruction,pregnancy,DM,exposure to renal toxins,microbial

invasion such as E-coli and streptococcus. Costovertebral angle pain(tenderness),fever,anorexia,gen.body malaise,urinary frequency,urgency,nocturia,dysuria,hematuria,burning on urination are the signs and symptomsof acute pyelonephritis. Chronic pyelonephritis symptoms are fatigue,weight loss,polyuria,polydypsia,and HPN. Pyelonephritis has a (+)E.coli and streptococcus in urine culture and sensitivity. Pyeloephritis has an increase WBC,CHON and pus cells in urinalysis. There is a mark urinary obstruction in cystoscopic exam in pyelonephritis. In acute phase on pyelonephritis,CBR is important nursing management. Medications for pyelonephritis are urinary antiseptic and urinary analgesic(pyridium). Nitropurantoin(Macrodantin)is a urinary antiseptic that causes peripheral neuropathy,GI irritation,hemolytic anemia,and staining of teeth. Forcing fluids and providing acid ash diet are necessary in pyelonephritis. Renal failure is a common complication of pyelonephritis. Nephrolithiasis/Urolithiasis are formation of stones at urinary tract. Milk stones are from calcium,oxalate are formed from cabbage,cranberries,nuts,tea,and chocolates while uric acid can be developed from anchovies,organ meats,nuts and sardines. Some of the predisposing factors of nephrolithiasis are:diet(increased in Calcium and oxalate),hereditary like in gout,obesity,sedentary lifestyle,hyperparathyroidism. Signs and symptoms of nephrolithiasis are renal colic,cool moist skin(shock),burning upon urination,hematuria,anorexia,nausea and vomiting. Intravenous pyelography reveals location of the the stone in nephrolithiasis.

Kidney,Ureter,Bladder ultrasound reveals the location of the stone in nephrolithiasis. Cystoscopic exam reveals urinary obstruction in nephrolithiasis. In stone analysis,it can be seen the composition and type of stone in nephrolithiasis.. In urinalysis,there is a mark increase in WBC and CHON. Nursing management in nephrolithiasis are:force fluid,strain urine using gauze pad,warm sitz bath for comfort,alternate warm compress at flank area and medications such as narcotic analgesic -morphine SO4 and allopurinol(zyeoprim),maintain patent IV line,proper diet, and assist in surgery. If + in Ca stones,provide acid ash diet,if + in oxalate stone,provide alkaline diet ex.milk or milk products,if + in uric acid stones,decrease organ meats/anchovies and sardines. Nephrectomy is the removal of the affected kidney. Litholapoxy is a surgery for nephrolithiasis which is the removal of 1/3stones which is not advisable for big stones. Stones will recur. Extracorporeal shock wave lithrotripsy is a non-invasive,which dissolves stones by shock wave in nephrolithiasis treatment. Complication of nephrolithiasis is renal failure. Benign prostatic hypertrophy is an enlarged prostate gland leading to hydro ureter(dilation of ureters),hydronephrosis(dilation of renal pelvis),kidney stones,and renal failure. BPH is common to 50y/o,60-70y/o are high-risk,and this is an influence of male hormones. Decrease force of urinary stream,dysuria,hematuria,burning upon urination,terminal bubbling,backache,and sciatica are the signs and symptoms of BPH.

In diagnosing BPH,digital rectal exam reveals an enlarged prostate gland.KUB reveals a urinary obstruction,cystoscopic exam reveals obstruction,urinalysis shows a marked increased in WBC and CHON. Prostatic massage promotes evacuation of prostatic fluid. Nursing management for BPH are,limit fluid intake,provide catheterization,provide medications(terazozine-hytrin to relax the bladder sphincter,Fenasterideproscare to atrophy the prostate gland). In prostatectomy, the surgery is TURP(transurethral resection of prostate),there is no incision.Assis in cystoclysis or continuous bladder irrigation. Infection should be monitored in patient who had TURP.Monitor symptoms of gross/flank bleeding,bleeding in 24hrs is normal. In TURP,maintain irrigatiion or tube patent to flush out clots to prevent spasm and distention. Acute Renal Failure is a sudden immobility of kidneys to excrete nitrogenous waste products and maintain fluid and electrolytes balances due to increade in GFR. Normal GFR is 125ml/min. Pre-renal cause of ARF is a decrease in blood flow due to septic shock,hypovolemia,hypotension,CHF,hemorrhage,dehydration(decrease blood flow to kidneys). Intra-renal cause of ARF involves renal pathology or a kidney problem such as acute tubular necrosis,pyelonephritis,HPN,and Acute GN. Post-renal cause of ARF involves mechanical obstruction due to stricture,urolithiasis,and BPH. Chronic Renal Failure is an irreversible loss of kidney function.Predisposing factors are DM,HPN,recurrent UTI/nephritis,exposure to renal toxins. Diminished Reserved Volume is the first stage of CRF which is asymptomatic.It has normal BUN,Creatinine,GFR in less than 10-30%.2nd stage is renal

insufficiency and 3rd stage is End stage renal disease. Urinary symptoms of CRF are:polyuria,nocturia,hematuria,dysuria,and oliguria. CRF has metabolic disturbances such as:azotemia(Increased BUN and Creatinine),hyperglycemia,and hyperinulinemia. CRF has GIT disturbances such as nausea,vomitin,stomatitis,uremic breath,diarrhea and constipation. CRF has hematological disturbances such as normocytic anemia,has bleeding tendencies. CRF has Integumentary problems such as itchiness/pruritus,and uremic frost. CRF has F&E disturbances,such as hyperkalemia,hypernatremia,hypermagnesemia,hyperphosphatemia,hypocalc emia and metabolic acidosis. CRF has effect on respiratory system.There is a kussmauls respiration and decrease in cough reflex. CNS effects of CRF are headache,lethargy,disorientation,restlessness,memory impairment. Nursing mgt.in CRF are:enforce CBR,monitor VS,I&O,provide medications,assist in hemodialysis. In CRF,there is a uremic frost,provide meticulous skin care and assist in bathing the patient. Na HCO3 is given in CRF,due to hyperkalemia. Phosphate Binder(amphogel-Al OH gel) is given to CRF ,side effect is constipation. Calcium gluconate is given to CRF coz there is a decrease in Ca. Anti HPn(hydralazine) and vitamin and minerals are given to CRF. Before hemodialysis,secure consent first,explain the procedure,obtain baseline data and monitor VS,I and O,weight check,blood exam,strict aseptic technique,

monitor for signs of complications. Complications of hemodialysis are:bleeding,embolism,disequilibrium syndrome,septicemia,shock(decrease in tissue perfusion). Disequilibrium syndrome is caused by rapid removal of urea ande nitrogenous waste product leading to nausea,vomiting,leg cramps,HPN,disorientation,paresthesia. In hemodialysis patient,avoid taking BP,blood extraction,IV,at side of shunt or fistula coz it might lead to compression of fistula. Maintain patency of shunt/fistula by palpating for shrill and auscultate for bruits.If +,shunt is patent. Bulldog clip should be always at bedside in case of accidental removal of fistula to prevent embolism. Infersole(diastole) is a common dialisate used in hemodialysis. Complications of dialysis are peritonitis and shock. Renal transplantation is the surgery for CRF,complication is rejection.After surgery,patient should be in reverse isolation. Chronic Obstructive pulmonary disease includes chronic bronchitis,bronchial asthma,bronchiectasis,and pulmonary emphysema(a terminal stage). Chronic bronchitis called blue bloaters.It is an inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing cells leading to narrowing of smaller airways. Smoking is the common predisposing factors of all COPD types.Others are caused by air pollution. COPD signs and symptoms are productive cough,dyspnea on exertion,prolonged expiratory grunt,scattered rales/rhonchi,cyanosis,and pulmo.HPN.and gen.body malaise. Pulmonary hypertension leads to peripheral edema,and cor pulmonary.

Cor pulmonary is respiratory in origin. COPD ABG result:PO2 decreased,PCO2 increased which signifies respiratory acidosis,which leads to hypoxemia causing cyanosis. Nursing mgt.for chronic bronchitis are:CBR,meds(bronchodilators,costicosteroids,antimicrobial agents,mucolytics/expectorants,O2(low inflow),force fluids,high fowlers,nebulization and suctioning,institute PEEP(posture end expiratory pressure),provide hlt.teachings,avoid smoking,prevent complications. Chronic Bronchitis complications includes cor pulmonary(right ventricular hypertrophy),CO2 narcosis(leads to coma),atelectasis,pneumothorax(air in pleural space). PEEP is applied to prevent collapse of alveoli. Bronchial asthma is a reversible inflammation of lung condition due to hypersensitivity leading to narrowing of smaller airway. Extrinsic asthma is a type of bronchial asthma called atropic/allergic asthma caused by pallor,dust,gases,smoke,dander,and lints. Intrinsic asthma is a type of bronchial asthma that is hereditary and caused by drugs(aspirin,penicillin,B blockers),food additives(nitrites),foods(seafoods,chicken,eggs,chocolates,milk),physical/em otional stress,sudden change of temp.,humidity and air pressure. Mixed type of bronchial asthma are combination of both extrinsic and intrinsic asthma which is 90% cause of asthma. Prod.or non-prod.cough,dyspnea,wheezing on expiration,cyanosis,mild apprehension &restlessness,tachycardia &palpitation,diaphoresis are the signs and symptoms of bronchial asthma. There is a decrease lung capacity as a result of pulmonary function test in Bronchial asthma. ABG analysis for bronchial asthma is decreased in PO2(respiratory acidosis).

CBR is advised in all COPD types. Bronchodilator or through inhalation or metered dose inhaled/pump is given to pt.with bronchial asthma,it should be given before corticosteroids. Corticosteroids is given to bronchial asthma pt.due to inflammation,give 10mins.after bronchodilator. Other meds.for bronchial asthma are mucolytic/expectorant,antihistamine,and mucomist(at bedside all the time put suction machine). In bronchial asthma,it is advise to increase fluid intake,O2 in a low inflow to prevent resp.distress,nebulization and suction. All COPD types are in a semifowler position except emphysema due to late stage. Complications of bronchial asthma are status asthmaticus and emphysema. Bronchiectasis is an abnormal permanent dilation of bronchus resulting to destruction of muscular and elastic tissues of alveoli.It can be caused by recurrent upper and lower respi.infection,congenital anomalies,tumors and trauma.Signs and symptoms are productive cough,dyspnea,anorexia,gen.body malaise,cyanosis and hemoptisis. Arterial blood gas analysis in bronchiectasis is PO2 decreased. Bronchoscopy is a direct visualization of bronchus using fiberscope in bronchiectasis.Before broncoscopy,secure consent,MD should explain the procedure to the patient,and RN should explain the laboratory,keep the patient NPO,and monitor VS. After bronchoscopy,feeding should be after return of gag reflex,client should avoid talking,smoking,or coughing,monitor signs of frank or gross bleeding,monitor of laryngeal spasm. In case of laryngeal spasm in bronchoscopy,prepare tracheostomy set due to difficulty of breathing. Nsg.management for bronchiectasis is same as emphysema except surgery.

Pneumonoctomy is a removal of affected lung. In segmental lobectomy ,position the patient on unaffected side. Pulmonary emphysema is an irreversible terminal stage of COPD characterized by inelasticity of alveolar wall leading to air trapping,leading to maldistribution of gases.Body is compensating over distention of thoracic cavity resulting to barrel chest.It can be caused by smoking,allergy,air pollution,high risk are elderly,and due to hereditary. Signs of pulmonary emphysema are productive cough,dyspnea at rest due to terminal stage,anorexia and gen.body malaise,rales/ronchi,bronchial wheezing,decrease tactile fremitus(should have vibration),resonance to hyperresonance during percussion,decreased or diminished breath sounds,flaring of alai nares,purse lip breathing due to eliminated PCO2. Pathognomonic sign of emphysema is barrel chest or increase pos/anterior diameter of chest. In emphysema,there is a decrease vital lung capacity during pulmonary function test. ABG analysis for panlobular/centrolobular emphysema is respiratory acidosis,there is decreased in PO2,increased PCO2,resulting to respiratory acidosis,that is why its called blue bloaters. Panacinar/centracinar ABG analysis has decreased PCO2,increased PO2,resulting to respiratory alkalosis,thats why its called pink puffers. Meds.for emphysema includes bronchodilators,corticosteroids,antimicrobial agents,mucolytic/expectorants. Enforce CBR,O2 should be low inflow,force fluids,put patient in high fowlers,nebulization and suction,institute PEEP,HT,are some of the nursing mgt.for emphysema. Pneumothorax is a restrictive lung disorder which is partial/or complete collapse of lungs due to entry or air in pleural space.It is caused by by chest

trauma,inflammatory lung conditions,and tumor. Spontaneous pneumothorax is caused by entry of air in pleural space without obvious cause. Rupture of bleb(alveoli filled sacs) in pt.with inflammed lung conditions is an example of pneumothorax. Open pneumothorax is a type of spontaneous pneumothorax that air enters pleural space through an opening in chest wall ex.is stab/gun shot wound. Tension pneumothorax where air enters pleural space with @inspiration and cant escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side,ex. is flail chest(paradoxical breathing). Signs of pneumothorax is sudden sharp chest pain,dyspnea,cyanosis,diminished breath sounds of affected lung,cool moist skin,mild restlessness/apprehension,and resonance to hyperresonance. ABG analysis for pneumothorax is decreased in PO2,chest x-ray confirms pneumothorax. Nursing mgt.for pneumothorax are:endotracheal intubation,thoracentesis,meds such as morphine SO4 and antimicrobial agents.Assisting in test tube thoracotomy is necessary. If patient is on CPT attached to H2Odrainage,always maintain strict aseptic technique,exercise DBE,prepare petroleum gauze pad,clamp and extra bottle at bedside,give meds such as morphine SO4,and antimicrobial. Petroleum is maintained at bedside during CPT attached to H2O drainage,if dislodged Hemostan is administered.And if in case of air leakage,a clamp is used. In CPT,monitor and assess for oscillation fluctuations or bubbling,if + to intermittent bubbling means normal or intact,H2O rises upon inspiration,H2O goes down upon expiration.If + to continuous,remittent bubbling,check for

air leakage,clamp towards chest tube,notify MD.If - for loop,clots and kink,milk toward H2O seal,indicates re-expansion of lungs. Criteria when MD needs to remove the CPT are if:(-)fluctuations,(+)breath sounds,CXR shows full expansion of lungs. On removal of CPT,Exercise DBE,instruct to perform valsalva maneuver for easy removal,to prevent entry of air in the pleural space,apply vaselinated air occlusive dressing,and dressing should be dry and intact. GastroIntestinal Tract includes alimentary canal,middle alimentary canal,lower alimentary canal,accessory organs,salivary glands. Upper alimentary canal functions for digestion composed of mouth,pharynx(throat),esophagus,stomach and 1st half of duodenum. Middle alimentary canal functions for absorption,composed of 2nd half of duodenum,jejunum,ileum,and 1st half of ascending colon.Complete absorption happens in large intestine. Lower alimentary canal functions for elimination and composed of 2nd half of ascending colon,transverse,descending colon,sigmoid,and rectum. Accessory organs in GIT are salivary gland,verniform appendix,liver,pancreas(autodigestion),gallbladder(for bile storage). Salivary glands include the parotid(located below and front of ear),sublingual and submaxillary.This produces saliva which functions for mechanical digestion,normal saliva is 1200-1500ml/day. Parotitis/mumps is the inflammation of parotid gland caused by paramyxo virus.Signs are fever,chills,anorexia,gen.body malaise,swelling of the parotid glands,dysphagia,ear ache or otalgia. Parotitis can be transmitted through droplet nuclei or direct transmission.Incubation period is 14-21days,period of communicability is 1wk before swelling and immediately when swelling begins. CBR,strict isolation,medications,alternate warm and cold compress at affected

part,gen.liquid to soft diet are the nursing mgt.for parotitis. Medications for parotitis are analgesic,antipyretic,antibiotics to prevent secondary complications such as cervicitis,vaginitis,oophoritis(women),orchitis might lead to sterility for men if occur during/after puberty period,and meningitis /encephalitis for both sexes thats why antibiotic is given. Verniform appendix is located in right iliac or right inguinal area.It functions as lymphatic organ which produces WBC during fetal life and ceases to function upon birth of baby. Appendicitis is the inflammation of verniform appendix can be caused by microbial infection,feacalith(undigested food particles-tomato seeds,guava seeds)or intestinal obstruction.Rebound tenderness is the pathognomonic sign.Other signs include low grade fever,anorexia,nausea,vomiting,diarrhea&constipation,pain @right iliac region,late sign due pain is tachycardia. Clinical manifestations of appendicitis are:CBC result has mild leukocytosis(increase WBC),upon PE,(+)rebound tenderness(flex right leg,palpate right iliac area,there is rebound). Appendectomy is the surgical treatment within24-45hours.Secure consent,do routinary nursing measures such as skin prep,NPO,avoid enema and heat application(might lead to rupture of appendix),give antipyretic,no painkiller(may mask the pain),presence of pain means appendix has not been ruptured. Post-appendectomy,if (+)to pendrose drain,it indicates rupture of appendix,position the affected to drain. Post-appendectomy nsg.mgt.includes also ,monitoring of VS,I&O,bowel sounds,maintain patent IV line,give analgesics for post-op pain,antipyretics(PRN),and prevent complications of peritonitis and septicemia. Liver is the largest gland which occupies most of right hypochondriac region,its

color is scarlet fever,covered by a fibrous capsule called Glisson's capsule,lobules are its functional units. Liver functions are:produces bile,detoxifies drugs,promotes synthesis of Vit.A,D,E,K(fat soluble vitamins),destroys excess estrogen hormone,and necessary in metabolism. Bile emulsifies fats,it is composed of H2O and bile salts,gives color to urine(urobilin) and stool(stircobilin). Hypervitaminosis is excessive intake of Vit.D and K. Vitamin A(retinol) deficiency can cause night blindness.Vitamin D(cholecalciferon) helps calcium,if there is deficiency results to osteoarthritis and rickets. Metabolism of CHO by bile undergoes the process of glycogenesis(synthesis of glycogens),glycogenolysis(breakdown of glycogen),gluconeogenesis(formation of glucose from CHO sources. Bile promotes synthesis of albumin and globulin(CHON).In liver cirrhosis,there is a decreased in albumin. Albumin maintains osmotic pressure,prevents edema,promotes synthesis of prothrombin and fibrinogen,promotes conversion of ammonia to urea. Bile promotes synthesis of cholesterol to neutral fats called triglycerides. Ammonia like breath is called fetor hepaticus. Liver cirrhosis is the lost of architectural design of liver leading to fat necrosis and scarring.Early sign is hepatic encephalopathy characterized by asterixis(flapping hand tremors).Late signs include headache,restlessness,disorientation,decrease LOC(hepatic coma). Nursing priority in liver cirrhosis is assisting in mechanical ventilation. Predisposing factors of liver cirrhosis are chronic alcoholism,malnutrition(dec.vit.B,thiamin),virus,toxicity(carbon tetrachloride),and use of hepatotoxic agents.

Early signs of liver cirrhosis are weakness,fatigue,anorexia,nausea and vomiting,urine becomes tea color,stool has clay odor,amenorrhea,dec.sexual urge,loss of pubic/axilla hair,hepatomegaly,jaundice,pruritus or urticaria. In liver cirrhosis,all blood cells decrease,leukopenia,thrombocytopenia,anemia. Liver cirrhosis ungergoes endocrine changes as well like spider angiomas,gynecomastia,caput medusate,and palmar errythema. Because of liver cirrhosis,ascitis can be developed(bleeding esophageal varices)due to portal hypertension. Hepatic encephalopathy is one of the neurological changes in liver cirrhosis.This is due to ammonia(cerebral toxin) that leads to hepatic coma.Early signs are arterexis(flapping hand tremors),late signs are headache,fetor hepaticus,confusion,restlessness,decrease LOC. Laboratory changes in liver cirrhosis are:liver enzymes such as SGPT(ALT),SGOT(AST) increased,serum cholesterol and ammonia increase,indirect bilirubin increased,CBC(pancytopenia),PTT(prolonged),hepatic ultrasonogra(fat necrosis of liver lobules). Nsg.mgt.for liver cirrhosis are CBR,restrict sodium,monitor VS and I&O,assess for pitting edema,monitor abdominal girth daily(notify MD),well-balanced diet,provide meticulous skin care,prevent complications such as ascites,bleeding esophageal varices,hepatic encephalopathy. Diet for liver cirrhosis is increased CHO,vit.and minerals,moderate fats,and decrease CHON. Ascites is a complication of liver cirrhosis characterized by fluid in peritoneal cavity.Nursing mgt.includes medications(loop diuretics-10-15mins effect),assist in abdominal paracentesis. Abdominal paracentesis is aspiration of fluid in peritoneal cavity.Pre-procedure are:let the patient void before paracentesis to prevent accidental puncture of

bladder as trochar is inserted. Esophageal varices is a complication of liver cirrhosis which is dilation of esophageal veins.Nsg.mgt for esophageal varices are:pitrisin or vasopressin(IM),NGT decompression(lavage),assist in mechanical decompression. In NGT decompression(lavage) for esophageal varices,give first ice or cold saline solution,and then monitor for NGT output. Sengstaken-blakemore tube is provided for esophageal varices.It is a 3lumentyped-catheter.Scissors are at bedside to deflate balloon in emergency cases. Nsg.mgt.for hepatic encephalopathy includes,assisting in mechanical ventilation(due coma),monitor VS or neuro check,put siderails(due to restlessness),and give medications such as laxatives to excrete ammonia. Hepatitis is characterized by jaundice(icteric sclera due to increase bilirubin or kernicterus(hyperbilirubinia),leading to irreversible brain damage. Pancreas is a mixed gland(exocrine and endocrine gland). Pancreatitis is an acute or chronic inflammation of pancreas leading to pancreatic edema,hemorrhage,&necrosis due to auto-digestion. + Cullen's sign at umbilicus is an indication of bleeding pancreas. Predisposing factors of pancreatitis are chronic alcoholism,hepatobiliary disease,obesity,hyperlipidemia,hyperparathyroidism,drugs(thiazide diuretics,pills,pentamidine HCL(Pentam),diet(increased saturated fats). Signs and symptoms of pancreatitis are severe left epigastric pain(radiates from flank area and back) which is aggravated by eating with DOB,nausea and vomiting,tachycardia,palpitations due to pain,dyspepsia(indigestion),decrease bowel sounds,and hypocalcemia. (+)Cullens sign or ecchymoses of umbilical area and grey turner's spots or ecchymoses of flank area are signs of hemorrhage in pancreatitis. Medications for pancreatitis are narcotic analgesic(meperidine HCL-

Demerol),smooth muscle relaxant/anti-cholinergic(papavarine HCL and prophantheline bromide-profanthene),vasodilator(NTG),and Calcium gluconate. Antacid(maalox),H2receptor antagonist(ranitidine-zantac) are given to decrease pancreatic stimulation. In pancreatitis,withhold foods and fluids when pain attacks coz it aggravates the condition. Total Parenteral Nutrition(TPN) or hyperalimentation is prescribed to a pancreatitis patient.A nurse should prevent complications such as infection,embolism,hyperglycemia. Stress management technique for a pancreatitis are DBE and biofeedback,provide comfortable position(knee chest or fetal like position). If patient can tolerate foods,give/increase CHO,decrease fats,and increase CHON. Chronic hemorrhagic pancreatitis is a complication of a pancreatitis. Gallbladder functions as storage of bile which made up of cholesterol. Cholecystitis/cholelithiasis is an inflammation of the gallbladder with gallstone formation.Predisposing factors are women-40yrs.old,post menopausal women undergoing estrogen therapy,obesity,sedentary lifestyle,hyperlipidemia,and neoplasm. Signs and symptoms of cholecystitis are severe right abdominal pain(after eating fatty foods) occurring esp.at night,fatty intolerance,anorexia,nausea and vomiting,jaundice,pruritus,easy bruising,tea colored urine,and steatorrhea. Diagnostic procedure for pancreatitis are serum amylase and lipase are increased,urine lipase increased,serum calcium decreased. Oral cholecystogram(or gallbladder series) confirms presence of stones. Medications for cholecystitis are narcotic analgesic(meperidine HCLdemerol),anticholinergic(atropine SO4),anti-emetic(phenergan-phenothiazide

with anti emetic properties. A patient with cholecystitis should increase intake of CHO,moderate CHON,decrease fats and meticulous skin care is necessary. Cholecystectomy is the removal of gallbladder.After surgery,maintain patency of Ttube intact and prevent infection. Stomach is the widest section of alimentary canal.It has J-shaped structures which contains anthrum,pylorus,and fundus. Stomach has two valves:cardiac sphincter and pyloric sphincter. Stomach contains cells:Chief/zymogenic,parietal/argentaffin/oxyntic cells,and endocrine cells. Chief/zymogenic cells secretes gastric amylase(digest CHO),gastric lipase(digest fats),pepsin(CHON),rennin(digests milk products). Parietal/argentaffin/oxyntic cells function as:to produce intrinsic factor which promotes reabsorption of vit.B12 cyanocobalamin then promotes maturation of RBC. Parietal cells secrete hcl acid that aids in digestion. Parietal cells secrete also endocrine cells that secrete gastrin and aids in increase hcl acid secretion. Stomach functions for mechanical and chemical digestion,storage of food(CHO.CHON that store 1-2 hrs in stomach and fats stay for 2-3hrs in stomach. Peptic Ulcer Disease(PUD) is the excoriation/erosion of submucosa and mucosal lining due to hypersecretion of acid(pepsin),and decrease resistance to mucosal barrier. Peptic Ulcer Disease is common to men,40-55years old,and aggressive persons. Causes of Peptic Ulcer Disease are hereditary,emotional,smoking,alcoholism,caffeine,irregular diet,rapid

eating,ulcerogenic drugs,gastrin producing tumor or gastrinoma(Zollinger Ellisons sign),and microbial invasion(helicobacter pylori). Alcoholism stimulates release of histamine,which stimulates parietal cells to release Hcl acid that cause ulceration. Smoking can cause vasoconstriction leading to GIT ischemia and causes ulceration. Ulcerogenic drugs includes NSAIDS,aspirin,indomethacin,ibuprofen. Indomethacin side effect is corneal cloudiness so annual eye exam is necessary. Metronidazole(Flagyl) is given to patients with ulcer due to invasion of microbe helicobacter pylori. Types of ulcers are according to location(stress ulcer,gastric ulcer,duodenal ulcermost common),ascending to severity(acute or chronic) and stress ulcers. Acute ulcers affect submucosal liing while chronic affects underlying tissue which heals and forms a scar. Duodenal ulcer is the most common type of ulcers. Two types of stress ulcers are curing's ulcer,and cushing's ulcer. Curing's ulcer are due to trauma and births.It caused by hypovolemia,then GIT schemia,results to decrease resistance of mucosal barriers to Hcl acid and leads to ulcerations. Cushing's ulcer is caused by stroke/CVA/head injury that increase vagal stimulation,hyperacidity to ulcerations. Gastric ulcer affected site is intrum or lesser curvature while duodenal ulcer's affected part is duodenal bulb. Pain in gastric ulcer lasts from 30mins-1hr after eating felt in epigastrium which is gaseous and burning and not usually relieved by food and antacid while duodenal ulcers is felt 2-3hrs after eating and pain is in mid epigastrium(12mn-3am usually) which is burning and cramping usually relieved by food and antacid.

In gastric ulcer,there is a normal gastric acid secretion while in duodenal ulcer there is an increased gastric acid secretion. Vomiting is common in gastric ulcer and not in duodenal ulcer. Gastric ulcer has hematemesis while duodenal ulcer has melena. Gastric ulcer has weight gain while duodenal ulcer has weight loss. Gastric ulcer's complication is stomach hemorrhage and duodenal ulcer can cause perforation. Gastric ulcer is common to 60years old and duodenal ulcer is common to 20years old. Diagnostic exams for ulcers are:endoscopic exam,stool from occult blood,GI series,and gastric analysis which is normal in gastric ulcer,and increased in duodenal. Provide bland,non-irritating,non spicy diet to ulcer patients. Nsg.mgt.for ulcer patients include administration of meds such as antacids,h2 receptor antagonist,cytoprotective agents,sedatives/tranquilizers(eg.valium,lithium),anticholinergics(atropine SO4,prophantheline bromide-profanthene). In PUD,avoid caffeine/milk/milk products because it can cause increase in gastric acid secretion. PUD is given Aluminum containing antacids(eg.aluminum OH gel-ampho-gel) can cause constipation and magnesium containing antacids(eg.milk of magnesia) which can cause diarrhea.A comb.of both is Maalox which fever is common side effect. Ranitidine(zantac),cimetidine(tagamet),tamotidine(pepcid) are h2 receptor antagonist given to ulcer patient.Smoking should be avoided due to it can decrease effectiveness of drug. In PUD patients,administer antacid and h2 receptor antagonist 1hr

apart.Cemetidine decrease antacid absorption and vise versa. In PUD patients,cytoprotective agents are given (eg.sucralfate-carafate) and cytotec.Sucralfate provides a paste like substance that coats mucosal lining of stomach. Patient who has history of hpn crisis with peptic ulcer disease,RN should not administer alka seltzer coz it contains large amount of Na. Subtotal gastrectomy or partial removal of stomach is the surgery for PUD. Billroth I(gastroduodenostomy) is the removal of 1/2 of stomach and anastomoses of gastric stump to the duodenum. Billroth II(gastrojejunostomy) is teh removal of 1/2-3/4 of stomach and duodenal bulb and anastomosed of gastric stump to jejunum. Vagotomy(severing of vagus nerve) and pyloroplasty(drainage) are done before surgery for BI or BII. After BI or BII,monitor NGT output.Immediately post op should be bright red,within 36-42h,output is yellow green,and dark red output after 42hrs. Post op meds for BI or BII are analgesic,antibiotic,antiemetics. Post-op nsg.mgt for BI or BII are:maintain patency of IV line,monitor VS and I&O and prevent complications such as hemorrhage,peritonitis,paralytic ileus(most feared),hypokalemia,thrombophlebitis,and pernicious anemia. Hemorrhage is complication of BI or BII surgery that leads to hypovolemic shock which the late sign is anuria. Dumping syndrome is a common complication of BI or BII surgery which is known as rapid gastric emptying of hypertonic food solutions -CHYME leading to hypovolemia.Signs and symptoms or hypovolemia are dizziness,diaphoresis,diarrhea,and palpitations. Avoid fluids i chilled solutions,small frequent feedings(6equally divided feedings),decrease CHO,moderate fats and CHON,put patient flat om bed 15-

30mins after every feeding are the nursing managements for dumping syndrome. Central nervous system comprising the brain and spinal cord. Symphathetic Nervous system involved in fight or aggression response which releases norepinephrine(adrenaline-cathecolamine),stimulates medulla oblongata,and increases all body activities except GIT which happens to decrease coz GIT is not important. Effects of SNS are anti-cholinergic/adrenergic eg.dilation of pupils to aware of surroundings,dry mouth,increased BP &HR due to dilation of bronchioles to take more oxygen,RR increased,constipation and urinary retention. Medriasis is dilation of pupils. Adrenergic agents such as epinephrine(adrenaline) has SNS effects. Beta-adrenergic blocking agents block release of norepinephrine,decrease body activities except GIT(diarrhea),side effects are bronchospasm(bronchoconstrictiion),decrease myocardial contraction,treats HPN,and AVconduction slows down.These agents are given to angina and MI to rest heart. Example of beta-blockers are propanolol,metopanolol,(those ending in -lol). Enalapril and captopril are examples of ace-inhibitors. Calcibloc(nefedipine) is an example of calcium antagonist. Peripheral nervous system(cholinergic/vagal or sympatholitic response involved in fly or withdrawal response,releases acetylcholine(ACTH),it decreases all body activities except GIT( diarrhea) Cholinergic/PNS effects are meiosis,increase salivation, decreases BP and HR,bronchoconstriction that decreases RR,diarrhea due to increased in GI motility and urinary frequency. Meiosis is a contraction of pupils.

Mestinon is an example of cholinergic agents. Atropine SO4 is an example of anticholinergic agents,effect is SNS. Cord and spinal cord is composed of 80%brain mass,10% CSF,10% blood. Monroe Kelly hypothesis is:the skull is a closed vault.Any increase in one component will increase ICP. Normal ICP is 0-15mmHg. Cerebrum functions as sensory,motor and integrative.It is the largest and divided into left and right cerebral hemisphere connected by a bridge called corpus collusum. The lobes of the brain are frontal,temporal,parietal,occipital,insula/island of reil/central lobe and rhinencephalon/limbec. Frontal controls motor activity,controls personality development,this is where primitive reflexes are inhibited,brocca's area or speech center. Frontal lobe is the damaged part in expressive aphasia. Temporal lobe controls hearing,short term memory,wernicke's area or general interpretative area which is the damaged part in receptive aphasia. Parietal lobe is a part of appreciation and discrimination of sensory impulses like pain,touch,pressure,heat and cold. Occipital controls vision. Insula/island of reil/Central lobe controls visceral function or it controls the activities of internal organs. Rhinencephalon or the limbec system controls smell,libido,longterm memory. Anosmia is the absence of smell. Basal Ganglia is the area of gray matter located deep within the cerebral hemisphere.It controls extrapyramidal tract,releases dopamine,controls gross voluntary unit.

Parkinson's disease or pin rolling of extremeties and huntington's disease is a result from decreased dopamine. Myasthenia Gravis and Alzheimer's disease is a result form decreased acetylcholine. Any increase in neurotransmitter resulting to psychiatric disorder. Schizophrenia is an increased in dopamine.While bipolar is an increased in acetylcholine. Mid-brain is the relay station for sight and hearing,controls size of pupil which 23mm is normal size,controls hearing acuity,it controls cranial nerves 3 and 4. Isocoria is equal or normal size of pupil while anisocoria is uneven size that means damaged to midbrain. PERRLA is the abbreviation for normal eye reaction stands for pupil is equally reactive to light and rays. Diencephalon is between brain where thalamus and hypothalamus located. Thalamus acts as a relay station for sensation while hypothalamus is thermoregulating center of temperature,sleep,wakefulness,thirst,appetite/satiety center,emotional responses,controls pituitary function and blood pressure. Brain stem or the pons is called the pneumotaxic center that controls respiration.It controls cranial nerves 5-8. Medullla oblongata controls heart rate,respiratory rate,swallowing,vomiting,hiccups/singultus.This is also known as vasomotor center,spinal deculssation termination.It controls cranial nerves 9-12.This is the lowest part of the brain and most life threatening if damaged. Cerebellum or the lesser rain,smallest part of the brain,which controls posture,gait,balance and equilibrium. Romberg's test is one of the cerebellar tests which needs to RN's to assist.First,the

patient should be in anatomical position for 5-10mins.If (+)to romberg's test,the patient has an ataxia or unsteady gait or drunken like movement with loss of balance. Finger-to-nose test is a cerebellar test which has sign of dymetria or inability to stop a movement at a desired point. Alternate pronation and supination (palm up and down) is a cerebellar test.Positive to this test is inability to alternate palm up and down(dymentrium). Based on Monroe Kellie Hypothesis,skull is a closed container.Any alternation in 1 of 3 intracranial components increases ICP. Normal ICP is 0-15mmHg. Foramen Magnum is serve as fetal circulation while on mother's womb. C1 is also known as atlas while C2 is axis. Cerebro-spinal fluid cushions the brain,and serve as shock absorber.Any obstruction in the flow of CSF,increases ICP. Projectile vomiting increases ICP,24-48hrs.observation is a must. Hydrocephalus is a result of early closure of posterior fontanels thus obstructing the flow of CSF leading to enlargement of skull. CVA or cerebro-vascular accident is a partial or total obstruction of blood supply. Cerebro-spinal fluid or CSF is a clear,color less,odor-less,and contains glucose,protein,and WBC. Increased Intracranial pressure or ICP is due to increase in 1 or the intracranial components. Causes of increased ICP are head injury,tumor,localized abscess,hemorrhae(stroke),cerebral edema,hydrocephalus,inflammatory conditions like meningitis,and encephalitis. Stroke is a partial or complete disruption of air in the blood supply.

Earliest sign of increased ICP us a change or decreased LOC(irritability and agitation,restlessness to confusion,disorientation to lethargy,stupor to coma). Late signs of Increased ICP are change in VS:BP increased(systolic increase,diastole-same),RR is decreased(cheyne-stokes resp.),temperature increased,widening pulse pressure. Cheyne-stokes respiration is between period of apnea or hyperapnea with periods of apnea. Normal adult BP is 120/80.Normal pulse pressure is 40 which is derived from 120 minus 80 of BP. Increased ICP is equal to a BP of 140/80,which is wide pulse pressure of 60. Narrow pulse pressure can be seen in cardiac disorder and shock. Changes in VS in shock are:decreased BP,Decreased temp,increased HR and RR. Signs and symptoms of Increased ICP are change in LOC,change in VS,headache,unical herniation,possible seizure. Optic disk is located in outer surface of retina which is being inflamed or edematous when there an increased in ICP. Decorticate or abnormal flexion is a damaged to cortico spinal tract.While derebrate or abnormal extension is a damaged to upper brain stem(pons). Unical herniation is a unilateral dilation of pupil while tentorial herniation is a bilateral dilation of pupil. During seizure,it is important to maintain patent airway and adequate ventilation,assist in mechanical ventilation,andhyperventilate before and after suction. Hypoxia is a result of cerebral edema,thus increasing ICP and leading to inadequate tissue oxygenation which characterized by early symptoms of restlessness ,agitation,and tachycardia.Bradycardia,extreme restlessness,dyspnea,cyanosis are always late symptoms.

Hypercarbia is an increased in CO2 retention,which stimulates the medulla oblongata and stimulating the lungs to hyperventilate to decrease CO2 and increase O2.CO2 is the most powerful stimulant of respiration. Respiratory distress syndrome is a decreased in oxygen. Suctioning is done 10-15seconds right away after removal of suction cap. Proper way of using ambu bag is ,pump upon inspiration. In mechanical ventilation,important things are maintaining patent airway,monitor VS and IO,prevention of complications of immobility,limit fluid intake(12001500ml/day). Force fluids means increase fluid intake daily,2000 to 3000ml/day but not for increased ICP. Prevention of ICP includes,maintain quiet and comfy environment,avoid use of restraints coz it leads to fractures,side-rails up and avoid clustering of nursing activities, and avoid valsalva maneuver. To avoid valsalva maneuver,give laxatives/stool softener(dulcolax/duphalac),antitussive(dextrometorphan) for cough,anti emetic(plasil-phils.,phenergan-US) for excessive vomiting,avoid lifting of heavy objects,avoid bending and stooping. Increased ICP medications includes:osmotic diuretic(mannitol/osmitrol),loop diuretic(lasix-furosemide),corticosteroids(dexamethasone),mild analgesic(codeine SO4),anticonvulsant(dilantin-phenytoin). While on mechanical ventilation,a patient's head should be elevated 30-45degrees angle neck in neutral position unless contraindicated to promote venous return. Mannitol/osmitrol is an example of osmotic diuretic which promotes cerebral diuresis by decompressing brain tissue.Nursing consideration in Mannitol are;monitor BP coz side effect is hypotension,monitor I&O every hour and <30cc should be reported,administer mannitol via side drip,regulate fast drip

to prevent formation of crystals or precipitate,inform client that he will feel flushing sensation as the drug is introduced. Lasix(furosemide) is a loop diuretic which is given via IV push(expect urine after 10-15mins).It should be given in the morning,immediate effect of lasix is withing 15mins,maximum effect is 6hrs.due.Other nursing management are same as mannitol. Corticosteroids (dexamethasone-decadron) is given to increased ICP to decrease cerebral edema. Mild analgesic(codeine SO4) is given to increased ICP for headache. Hypokalemia,hypocalcemia,hyponatremia,hyperglycemia,hyperurecemia are some of the side effects of lasix or furosemide. Hypokalemia is a decreased in Potassium.Normal value is 3.5-5.5meq/L.Signs and symptoms are weakness,fatigue,constipation,(+)U wave in ECG tracing. Hyperkalemia is an increased in potassium characterized by agitation,irritability,diarrhea,peak T wave which leads to arrythmia,and abdominal cramps. Nsg.mgt. for hypokalemia includes administration of K supplements(eg.Kalium durule,K chloride),provision of potassium rich foods such as asparagus,broccoli,carrots,apple,banana(green),cantalope/melon,and orange. Orange is the highest source of K from fruits and broccoli as vegetable source.Orange is given for digitalis toxicity also. Vit.A rich foods are squash,carrots,yellow vegetables and fruits ,spinach and chesa. Raisins are rich in iron. Foods appropriate for toddler is sphagetti not milk because it increases bronchial secretions,and don't give grapes coz they may choke. Hypocalcemia/tetany is one of the side effects of lasix which is a decreased in

calcium.Normal value of calcium is 8.5-11mg/100ml.Signs and symptoms includes weakness,paresthesia,(+)trousseau sign,(+)chevosteks sign,arrythmia,and laryngospasm. Trousseau sign or carpopedal spasm is the pathognomonic sign of Hypocalcemia or tetany.To test for this sign,put bp cuff on arm,it will elicit hand spasm. Chevostek's sign is sign of hypocalcemia also known as facial spasm. In case of laryngospasm in hypocalcemia,administer calcium gluconate through IV,slowly to prevent cardiac arrest. Arrythmia and seizures are the complications of hypocalcemia. Seizure is sign Calcium gluconate toxicity,administer Mg.SO4. Signs and symptoms of mg.SO4 toxicity are:BP decreased,urine output decreased,RR decreased,Patellar reflexes absent.To counteract Mg.SO4 toxicity,administer Calcium Gluconate. Early sign of mg.SO4 toxicity is that patellar reflexes are absent. Hyponatremia is one of the side effects of lasix characterized by hypotension,some signs of dehydration such as dry skin,poor skin turgor,gen.body malaise,thirst and agitation,and tachycardia. Normal value of sodium is 135-145meq/L. Early sign of dehydration in adult is thirst and agitation while tachycardia in a child. Administration of isotonic fluid solution and force fluids are the management for hyponatremia. Hyperglycemia is an increase in blood sugar level characterized by polyuria,polyphagia,and polydipsia.Monitoring of FBS is necessary which normal value is 80-120mg/dl. Hyperurecemia is an increased in serum uric acid that can result to gouty arthritis and kidney stones.

Tophi are urate crystals in joint. Gouty arthritis symptoms are joint pain,swelling usually at great toe. Kidney stones symptoms are renal colic(pain) and cool moist skin. Gouty arthritis management includes provision of foods such as cheese(not sardines,anchovies,organ meats,legumes and nuts.),force fluids,administration of medications such as allopurinol/zyloprim,and colchicene. Allopurinol/zyloprim inhibits synthesis of uric acid which is the drug of choice for gout while colchicene excretes uric acid which is acute gout drug of choice. Kidney stones management includes forcing of fluids,administration of narcotic analgesics(morphine SO4). Morphine SO4 is a narcotic analgesic for kidney stones.Symptom of toxicity is respiratory depression,checking of RR is priority. Antidote for Morphine SO4 toxicity is narcan(naloxone).Narcan(naloxone) toxicity is characterized by tremors. Digoxin is a cardiac glycosides indicated for Chronic heart failure,normal range is . 5-1.5meq/L and toxicity level is 2. Lithium is antimanic indicated for bipolar,normal range is .6-1.2meq/L,and toxicity level is 2. Aminophylline is a bronchodilator indicated for COPD,normal range is 1019mg/100ml,and toxicity level is 20. Dilantin is a anticonvulsant indicated for seizures,normal range is 1019mg/100ml,and toxicity level is 20. Acetaminophen is a narcotic analgesic indicated for osteoarthritis,normal range is 10-30mg/100ml,and toxicity level is 200. Digitalis is an increased in cardiac contraction and carbon dioxide.Digoxin is given,but check PR,HR first.If HR is below 60bpm,hold digoxin.

Digivine is given to digitalis toxicity,which symptoms are anorexia,nausea,vomiting,diarrhea,confusion,photophobia,changes in color perception. Xantopsia is a change in color perception,having yellow spots. Digoxin can be given to patients with renal failure because it is metabolized in the liver not in kidney. Lithium(lithane) decreases levels of norepinephrine,serotonin,acetylcholine.It's toxicity symptoms include:anorexia,nausea,vomiting,dehydration,hypothyroidism. Lithium excretes Na from the body,so maintain Na intake of 4-10g daily and force fluid to fight dehydration. Cretinism is the only endocrine disorder that can lead to mental retardation. Aminophylline (theophylline) toxicity is characterized by tachycardia,hyperactivity,restlessness,agitation,tremors,irritability.It is important to take BP first,before giving aminophylline and CNS stimulants foods should not be given such as tea,coffee and hot chocolates. Aminophylline is given via sandwich method,mix with PNSS to prevent development of crystal or precipitate. MAOI is antidepressant which can lead to CVA or hypertensive crisis.Ex.are marplan,nardil,and parnate.It takes 3-4weeks before will take effect. Anti parkinsonian agents ex.Levodopa,should not be given along Vit.B6 or pyridoxine coz it reverses its effect. Seizure is 1st convulsive attack while epilepsy is 2nd convulsive attack or successive attack. Febrile seizure is normal below 5years old,but abnormal if above 5years old. Dilantin(phenytoin) is anticonvulsant.It is administer via sandwich method,should be mixed with plain NSS or .9NaChloride to prevent formation of crystals or

precipitate.Give NSS then dilantin then NSS. Dilantin toxicity is characterized by gingival hyperplasia,hairy tongue,ataxia,nystagmus(abnormal movement of eyeballs),and febrile. Gingival hyperplasia is a symptom of dilantin toxicity.Oral hygiene is important,use soft toothbrush and then massage gums. Acetaminophen/tylenol is a non-opoid analgesic and antipyretic given to febrile patients.Hepatotoxicity,increased liver enzymes are the symptoms that can lead to hypoglycemia are some of the symptoms of toxicity. SGPT(serum glutamic piruvate tyranase) and SGOT(serum glutamic oxalo transemic tyranase),BUN,Creatinine should be monitored in administration of acetamenophen. Normal BUN is 10-20 while Creatinine is .8-1. Hypoglycemia symptoms are tremors,tachycardia,irritability,restlessness,extreme fatigue,depression(nightmares),diaphoresis. Acetylcesteine is an antidote for acetaminophen toxicity which causes outpouring of secretions.Suctioning is important. Extreme thirst is a hyperglycemia symptoms. Parkinsons disease(parkinsonism) is a chronic,progressive disease of CNS characterized by degeneration of dopamine producing cells in substancia nigra at midbrain and basal ganglia.Palliative and supportive care is important in this case. Dopamine controls gross voluntary motors. Predisposing factors of parkinsonism is lead and carbon monoxide poisoning,hypoxia,arteriosclerosis,encephalitis,and high doses of drugs such as (reserpine-serpasil,methyldopa-aldomet,haloperidolhladol,phenothiazide). Antidote for lead poisoning is calcium EDTA.

Reserpine(serpasil) is a hypertensive agetn which side effects are depression that can lead to suicidal(promote safety) and breast cancer. Example of antipsychotic agents are haloperidol(haldol) and phenothiazide. Over medications of antipsychotic drugs can lead to neuroleptic malignant syndrome characterized by severe tremors. Side effects of antipsychotic drugs are extra-pyramidal symptoms(EPS). Signs and symptoms of parkinsonism are pill rolling of extremities(early sign),bradykinesia(slow movement),overfatigue,rigidity(cogwheel typestooped posture,shuffling,propulsive gait),mask like facial expressions with decrease blinking of eyes,monotone speech,difficulty arising form sitting position,mood lability,increase salivation,autonomic signs(increase sweating,lacrimation,seborrhea,constipation,and decrease sexual activity). Mood lability is a sign of parkinsonism.They are always depressed which can lead to suicidal tendency.Safety promotion is necessary. Seborrhea is an increased in sebaceous gland. Antiparkinsonian agents include Levodopa(L-dopa),Carbidopa(sinemet),Amantadine Hcl(symmetrel-long acting) that increases levels of dopamine,relieving tremors and bradykinesia. Side effects of antiparkinsonian agents are anorexia,nausea,vomiting,confusion,orthostatic hypotension,hallucination,and arrythmia. Antiparkinsonian agents are contraindicated to narrow angled closure glaucoma and patients taking MAOI(parnate,marplan,nardil). Antiparkinsonian agents should be taken with meals to decrease GIT irritation. Antiparkinsonian agents can cause dark urine and stools. Vit.B6 or pyridoxine should not be given along antiparkinsonian agents,give INH(isoniazide-isonicotene acid hydrazide) instead.

INH can cause peripheral neuritis. Artane and cogentin are anticholinergic agents that inhibits acetylcholine and relieve tremors.It's side effects are SNS. Antihistamine(diphenhydramine Hcl-benadryl) is given to parkinsonism but can cause drowsiness so should be taken at bedtime,and avoid driving and operating heavy equipment. Dopamine agonist(bromotriptine Hcl-parlodel) is given to parkinsonism to relieve tremors,rigidity,and bradykinesia but can cause respiratory depression so closed monitoring of RR is important. Nsg.mgt.for parkinsonism are:maintain siderails,prevent complications of immobility by turning patient every 2hrs,and every 1hr on elderly,assist in passive ROM exercises to prevent contractures,increase fluid intake,high fiber diet to prevent constipation. A good nutrition to maintain for parkinsonism should be,decrease CHON in the morning,increase CHON in the evening to induce sleep due to tryptopan(amino acid),bran and psyllum should be added on diet. Sterotaxic thalamotomy is the surgery for parkinson's disease which complications are subarachnoid hemorrhage,aneurism,and encephalitis.. Multiple sclerosis is a chronic,intermittent disorder of CNS characterized by white patches of demyelenation in the brain and spinal cord.Symptoms undergone remission and exacerbation and common to women 15-35years old. Factors causing multiple sclerosis are slow growing virus and it is autoimmune so it needs palliative and supportive care only. IgG is a normal resident antibody which can pass placenta,a short-acting passive immunity. IgA is a normal resident antibody which responsible for body secretions like saliva,tears,colostrums and sweat. IgM is normal resident antibody which responsible for acute inflammation,the

largest antibody. IgE is a normal resident antibody for allergic reactions. IgD is a normal resident antibody for chronic inflammation. Patients having multiple sclerosis are having visual disturbances like blurring of vision,diplopia/double vision,and scotomas(blind spots) which is the initial symptom. Multiple sclerosis patients have impaired sensation to touch,pain,pressure,heat and cold.They feel numbness,tingling and paresthesias. Multiple sclerosis patients have mood swings like euphoria(sense of elation). Multiple sclerosis patients have impaired motor function including weakness,spasticity(tigas),and paralysis which is the major problem. Multiple sclerosis patients have impaired cerebellar function.Triad symptoms of it are:intentional tremors,nystagmus(abnormal rotation of eyeballs),ataxia and scanning speech.. Multiple sclerosis patients suffer from urinary retention or incontinence,constipation,and decrease sexual ability. Cerebro spinal fluid analysis thru lumbar puncture reveals an increase CHON and IgG in a patient with multiple sclerosis. MRI reveals site and extent of demyelenation in multiple sclerosis. Lhermitte's response is done thru introduction of electricity at the back.If there is spasm and paralysis at spinal cord,it is positive to multiple sclerosis. Supportive management are important for multiple sclerosis such as administration of medications,maintain siderails,assist in passive ROM exercises to promote proper body alignment,prevent complications of immobility,encourage fluid intake and intake of high fiber diet to prevent constipation,providing catheterization due to urinary retention,giving diuretics,giving stress reducing activity sucha as DBE,biofeedback and yoga techniques.

Acid ash diet like grapes,cranberry,orange juice,Vit.C is provided to multiple sclerosis to acidify urine and to prevent bacteria multiplication. Medications for multiple sclerosis in acute exacerbation are ACTH(adrenocorticotropic) and steroids to reduce edema at the site of demyelenation to prevent paralysis. In spinal cord injury,the drugs to be given to prevent paralysis due to edema are ACTH(steroids),immunosupressants,interferone to alter immune response,baclofen(lioresal) or dantrolene Na(Dantrene) to decrease muscle spasticity. Myasthenia Gravis(MG) is the disturbance in transmission of impulses from nerve to muscle cell at neuro muscular junction,also known as descending muscle weakness. Myasthenia Gravis is common to women,20-40years old,unknown cause of idiopathic,an autoimmune disease due to release of cholenesterase. Myasthenia gravis is an auto immune disorder.An enzyme is being released and this destroys ACH(acetylcholine) that is why there is a decrease in acetylcholine in myasthenia gravis. Nursing priorities in Myasthenia gravis are airway,aspiration,and immobility. Ptosis or drooping of upper lid is the initial sign of myasthenia gravis.To confirm the diagnosis,opening of upper and lower lids to check the palpebral fissure. Other signs and symptoms of myasthenia gravis include diplopia,mask like facial expression,dysphagia which is risk for aspiration,weakening of laryngeal muscles(hoarseness of voice),respiratory muscle weakness(tracheotomy set should be at bedside),extreme muscle weakness during activity esp.in the morning. Tensilon test(edrophonium Hcl) is given to myasthenia gravis to temporarily strengthens the muscles for 3-5mins.It is short-term,cholinergic or PNS effect.

Pulmonary function test is done to myasthenia gravis and GBS due to decrease lung capacity. Corticosteroids(decadron-betamethasone)is given to Myasthenia gravis to suppress immune response. Cholinergic or anticholenesterase agents like mestinon(pyridostigmine),neostigmine(prostigmin), are given to myasthenia gravis to increase acetylcholine,side effects are PNS. Patency of airway should be maintained in myasthenia gravis and GBS,also monitoring of VS,I and O,muscle strength or motor grading scale,put siderails all the time,preventing complications of immobility,and providing NGT feeding. Two types of crisis to monitor in myasthenia gravis are myasthenic crisis,and cholinergic crisis. Cholinergic crisis in myasthenia gravis is caused by over medications which characterized by PNS effects.This can be treated by giving atropine SO4(anticholinergic). Myasthenic crisis in myasthenia gravis is caused by under medication,stress and infection which presented by symptoms of unable to see,dysphagia,and unable to breath and can be managed by giving anticholinergic agents. Thymectomy is the surgical procedure for myasthenia gravis and GBS,which is the removal of the thymus gland because thymus gland secretes auto immune antibody. Plasmaparesis is done to myasthenia gravis and GBS to filter the blood. Respiratory arrest is the primary complication of myasthenia gravis,tracheostomy set should be always at bedside. GBS or Guillain Barre Syndrome or ascending paralysis is a disorder of the CNS,bilateral symmetrical polyneuritis.Cause is unknown or idiopathic,an autoimmune,r/t antecedent viral infection and caused also by immunizations.

Diagnostic procedure for GBS is CSF analysis thru lumbar puncture which reveals an increase in IgG and CHON(same with MS). Alternate hypertension to hypotension is a sign of GBS that can lead to arrythmia which is the primary complication. Autonomic changes can be seen in GBS such as increase sweating,increase salivation,constipation and increase lacrimation. Other signs and symptoms of GBS are clumsiness,ascending muscle weakness,dysphagia,decreased or diminished DTR(deep tendon reflexes). Medications for GBS are anticholinergic agents(atropine SO4),corticosteroids to suppress immune response,anti arrythmic agents such as Lidocaine/xylocaine,bretyllium,quinine/quinidine. Lidocaine is given to GBS to treat VTachycardia(arrythmia). Quinines/quinidines is anti malarial agent given to GBS,it should be taken with meals.Side effects include anorexia,nausea,vomiting,headache,vertigo and visual disturbances and toxic effect is cinchonism. Meninges is a 3-fold membrane which covers the brain and spinal cord.It functions as protection and support,nourishment and blood supply. Meninges has 3 layers.Duramater and arachnoid mater in subdural space,pia mater which is in sub arachnoid space where CSF flows L3 and L4 which is site for lumbar puncture. Meningitis is the inflammation of meningitis and spinal cord,caused by meningococcus(most dangerous),pneumococcus,hemophaelus influenza(child),streptococcus(adult meningitis) and this can be transmitted via droplet nuclei. Initial sign of meningitis is stiff neck or nuchal rigidity. Sign of meningeal irritation is opisthotonus or rigid arching of back. Pathognomonic sign of meningitis is (+)Kernig's or leg pain and (+)Brudzinski sign

or neckpain. Signs and symptoms of meningitis are headache,projectile vomiting(due to increase ICP),photophobia,fever chills,anorexia,gen.body malaise,weight loss,decorticate/decerebration and possible seizure. Lumbar puncture or lumbar/spinal tap is done by using of hallow spinal needle inserted to sub arachnoid space bet.L3 and L4 or L4 and L5,then CSF is aspirated for diagnosing meningitis. Lumbar puncture is an invasive procedure so consent should be secured by a nurse and procedure is explained well by the doctor.Diagnostic procedure(laboratory) can be done by a nurse. Before lumbar puncture,patient should empty the bladder/bowel to promote comfort and arch back to clearly visualize L3,L4. Nursing management post lumbar puncture are:flat on bed for 12-24hrs to prevent spinal headache and leak of CSF,force fluid,check punctured site for drainage,discoloration and leakage to tissue,assess for movement and sensation of extremeties. In CSF analysis,it confirms meningitis there is an increase in CHON and WBC,decreased glucose,increased CSF opening pressure,(+)culture microorganism. Normal CSF opening pressure is 50-160mmHg. Complete blood count reveals increase WBC. Meningitis is given broad-spectrum antibiotic(penicillin),antipyretics,and mild analgesic for headache. Broad-spectrum antibiotic(penicillin) is given to meningitis which should be taken with food coz it can give GI irritation,can cause hepatotoxicity and nephrotoxicity,allergic reaction. Diarrhea is the sign of super infection caused by penicillin.

Streptococcus is the normal flora in throat while the normal flora in intestine is ecoli. Strict respiratory isolation 24h in meningitis after start of antibiotic therapy. Due to photophobia and seizure,provide comfortable and dark room in meningitis patients. In meningitis,rehabilitation for neurological deficit is necessary coz it can lead to mental retardation or a delay in psychomotor development. A 2 year old patient post meningitis should be brought to urologist due to damage to sacral area(spina bifida) that controls urination and audiologist due to damage to hearing (post repair myelomeningocele). In providing discharge plan and health teachings to meningitis patients,include teaching of proper nutrition like to increase calories,CHO,CHON for tissue repair and should be small frequent feeding. Meningitis feared complications are hydrocephalus,hearing loss or nerve deafness.

TT1-as early as possible during pregnancy-80% protected. TT2-shld.be given at least 4 wks after tt1,it gives 3yrs.of protection for the mother and 80% child will be protected from neonatal tetanus. TT3-shld.be given at least 6mos. after tt2,it gives 5yrs.of protection for the mother and 90% child will be protected from neonatal tetanus. TT4-shld.be given at least 1yr.later after tt3,it gives 10yrs.of protection for the mother and 99% child will be protected from neonatal tetanus. TT5-shld.be given at least 1yr.later after tt4,it gives lifetime protection for the

mother and 99% all infants born to that mother will be protected from neonatal tetanus. . Bacillus of Calmette and Guerin-given 1 dose @birth or anytime after birth0.05cc @right deltoid,Intradermal route which gives protection to the child against infection from the family. Nsg.considerations:*Pus formation is normal *Increase body temp.-advise tsb,paracetamol q4h. DPT(Diphtheria,Pertussis, and Tetanus) -should be given @6wks or 1 1/2mos -@3 doses with interval of 4wks or 1month,0.5cc@vastus lateralis,IM -An early start could reduce the chance of having pertussis -it is not given beyond 6yrs.of age due to occurence of Neuro-Paralytic reaction -Nsg.considerations: -increased body temp.is normal-advise tsb and paracetamol q4h. Oral Polio Vaccine -given @6wks or 1 1/2mos old,@ 3doses via oral route with interval of 4wks or 1mo. -It gives protection earlier against polio -NPO 3omins.after given HEPA B-should be given @6wks or 1 1/2mos -@3 doses with interval of 4wks or 1month,0.5cc@vastus lateralis,IM -An early start could reduce the chance of having hepa B and becoming a carrier. -Nsg.considerations: -increased body temp.is normal-advise tsb and paracetamol q4h. 6.Measles-given @ 9mos,@1 dose,0.5cc via sc,@right or left deltoid. -give protection @ least 80% against measles -Nsg.considerations:

-increased body temp.is normal-advise tsb and paracetamol q4h. 7.Frontal or coronal planes runs longhitudinally @ right angle to a sagittal plane dividing the body in anterior and posterior regions. -A Sagittal plane runs longhitudinally dividing the body into right and left regions,if exactly midline,it is called a midsagittal plane. -A transverse plane runs horizontally @ a right angle to the vertical axis dividing the structure to suferior and inferior regions. 8.shock and dismay-early signs of a.)denial-1st stage of grief b.)later stage of grief 9.Moving the patient from bed to chair: -Place patient in high fowler's position -Move patient to side of the bed. -Help patient sit on edge of the bed and dangle the legs. -the nurse then faces the patient and places the chair facing the head of the bed. 10. Aging-related physiological changes acct.for the increased frequency of adverse drug reactions in geriatric patients -Renal and hepatic changes cause drugs to clear more slowly in geriatric patients. -with increased age,neurons are lost and blood blow to GI tract decreases. 11.Nurse as an Educator-teaching meds.before discharged Manager-handling and scheduling patient care assignments Changing role-when providing direct care(bathing/taking meds) Pt.advocate-making patient wished known to the doctor. 12.Anxiety-feeling of helplessness,isolation or insecurity. nsg.interventions:-encourage expression of feelings -should be supportive and develop goals together with the patient to give the patient some control over anxiety-inducing reaction

13.Scrub nurse-provides surgical instruments/supplies to the surgeon -maintaining strict surgical asepsis. -assist with gowning and gloving

circulating nurse-acctng. for all gauze,sponges,and needles and instruments. -assist the nurse and surgeon -position the patient,applies appropriate equipment and surgical drapes -provides surgeons/scrub nurse with supplies. 14. Physician orders heparin,7500units,to be administered subcutaneously every 6hrs.The vial reads 10,000units/ml -10,000units/7500units -1ml/X -10,000X=7500 X=7500/10,000 or 3/4ml 15.102'F='C(centigrade temp.) sol:C'=(F'-32)x5/9 +70x5/9 =38.9'C 16.Fecal occult blood test(a.k.a. gFOBT,occult blood test,hemooccult test,guiac test)-to detect GI bleeding which is early sign of colorectal cancer Normal blood in stool-2-2.5ml normal hemoglobin in sample smear=0.05pg/ml of test Preparation: -before the test,eat high fiber diet -refrain from eating red meats,turnips,horseradish -as necessary,stop the medications or tell to laboratory technicians what drugs are u taking in(ex of drugs that may interfere:colchicines,bromides,iron) hematocrit test-+ if filter paper turned to blue after 30-60secs.

hemoglobin test-greater than 0.05pg/ml of fecal sample Electrocardiography-test for evaluating cardiac status,graphically records electrical current generated by the heart.this current radiates to the skin and measured by electrodes connected to an amplifier and strip chart recorder. -standard resting ECG uses 5 electrodes to measure electrical potentials from 12 diff.leads:standard limb leads(I,II,III),the augmented limb leads(aVf,aVL,and aVr.),and the precordial or chest leads(V1 thru V6) ECG tracings-consists of identifiable wave forms:P wave-depicts atrial depolarization,QRS complex-ventricular depolarization,T wave-ventricular repolarization computerized ECG- use small electrode tabs that peel off a sheet and adhere to patient's skin.Entire tracing display in the machine. Purposes of ECG: -to help identify primary conduction abnormalities;cardiac arrythmias,cardiac hypertrophy,pericarditis,electrolyte imbalances,myocardial ischemia,site and extent of myocardial infarction. -to monitor recovery from MI -to evaluate the effectiveness of cardiac medication -to assess pacemaker infarction -to assess effectiveness of thrombolytic therapy and the resolution of ST segment depression or elevation and T-wave changes. Procedure: -explain pt.the need to let still,relax and breaths normally during the procedure. -note if there are cardiac medications -test is painless and takes 5-10mins. -Implementation:supine/semifowler's position,expose the chest,ankles,wrists,place electrodes in proper places. Normal results:

-p wave doesnt exceed 2.5mm(0.25mv) in height or last longer than 0.12sec. -PR interval-0.12 to 0.2 sec for heart rates above 60bpm. A nurse should check the patients blood glucose by fingerstick method if she is experiencing tremors/weakness(Type I diabetes) -Hypoglycemic-no glucose in the urine -low glucose-should be given long acting carbo ex.skimmed milk,it doesnt require insulin.
- Ectropion is an abnormal eversion (outward turning) of the lid margin away from the globe.without normal lid globe position,corneal exposure,tearing,keratinization of the palpebral conjunctiva,and visual lost may result -usually involves lower lids and often has a component of horizontal lid laxity. Medical care: 1.lubricating ointment-if conjunctiva keratinized(contra to herpes simplex infections/corneal ephithetical defects 2.lubrication/moisture shields surgi-care: 1.Horizontal lid laxity-lateral tarsal strip procedure 2.Reinsertion of lower lid retractors(tarsal ectropion) 3.augmentation of anterior lamellae along with excision of any cicatrix(cicatricial ectropion) 4.medial conjunctival spindle procedure-mild to moderate cases of medial ectropion -BLEPHAROPTOSIS-known as ptosis-an abnormal low-lying upper eyelid margin with the eye in primary gaze-Normal adult upper eyelid:lies 1.5mm below the superior corneal limbus and is highest just nasal to the pupil.Etiology is

acquired or congenital.

51.The pathophysiology of chronic open-glaucoma includes:overproduction of acqueous humor with or without adequate drainage of acqueous fluid from the eye. 52.The functional parts of hearing aid include a microphone that converts sounds to electrical signals,which are transmitted to a receiver. 53.Fifth cranial nerve is the one affected in trigeminal neuralgia 54.Pericarditis is characterized by chest pain that's relieved by sitting forward 55.A patient who develops pericardial effusion may have dyspnea,hypotension,and neck vein distention.The diagnostic test to be performed to confirm this diagnosis is an echocardiogram. 56.A patient in pulmonary edema exhibits the most distinctive signs of pink,frothy sputum 57.A patient who's suspected of having active tuberculosis is placed in respiratory isolation until a definitive diagnosis is confirmed by sputum culture for acid fast bacilli. 58.A postoperative vascular surgery patient has acute shortness of breath and anxiety.The nurse suspects the patient may have a pulmonary embolism.The test to be given is a ventilation perfusion scan. 59.A patient with pneumonia should have sputum culture and sensitivity to determine an appropriate antibiotic. 60.Cervical swab is to be performed to determine if the patient has std who is sexually active with vaginal discharge and fever. 61.A patient has a history of chronic renal failure and being treated with continuous ambulatory peritoneal dialysis(CAPD).The patient has peritonitis is the dialysate effluent is cloudy. 62.To determine wether the therapeutic range is maintained to a patient on IV heparin,partial thromboplastin time(PTT) is closely monitored.(60-70sec) 63.Patient on warfarin(coumadin) should monitor closely its prothrombin time(PT) 64.Hemoglobin A1c is closely monitored to a diabetic patient to determine the effectiveness of a therapy. 65.Hyperkalemia can be treated with the administration of 50%dextrose and insulin.The 50%dextrose counteracts the effects of insulin.

66.Schilling test is to be be performed to determine whether it is a folic acid deficiency in a patient with anemia. 67.Potassium is to be monitored in a patient receiving diuretics. 68.A patient receiving betablockers may have alterations in glucose levels. 69.A patient with gout have an elevation in uric acid. 70.Amylase and lipase are typically assessed in a patient suspected with pancreatitis. 71.Urine specific gravity should be tested if a patient is receiving IV fluids and is diuresing large amount of urine. 72.Heme-positive stools can be seen in patient with a lower GI hemorrhage. 73.A patient with a history of alcohol abuse is hospitalized and started on IV with additives of thiamine and folate 74.The patient with liver failure may have alterations in clotting factors. 75.A patient with hepatic encephalopathy will have an alteration in ammonia. 76.Endoscopic retrograde cholangiopancreatography(ERCP) is to be performed in a patient suspected of having a cholelithiasis. 77.The patient with a warfarin(coumadin) overdose should receive Vitamin K to reverse warfarin's effects. 78.A patient with a history of seizures who is taking prescribed medications for the ocndition appears to be having another seizure.The nurse anticipates that the doctor will most likely want to give an additional dose of seizure medication. 79.A patient who has parkinsons disease is expected to have dopamine replacement. situation:Louis whitmanis a 44year old male who's admitted to the emergency department with complaints of severe left flank pain,fever,nausea,and vomiting.The nurse suspects that Mr.Whitman has a renal calculus. 80.To confirm diagnosis in a patient with renal calculus,excretory urography is to be performed. situation:Edith kinney is a 63year old woman who has been diagnosed with heart failure.She has been admitted to the intensive care unit and is exhibiting shortness of breath.

81.Pulse oximetry reading is to be obtained to determine if patient is receiving enough oxygen. 82.A patient who has a pulmonary catheter(PA) has an increased central venous pressure and increased PA pressures. Ben Draper is admitted to the emergency department with acute shortness of breath after eating peanuts.Its determined that he's an ashmatic and is having an asthma attack. 83.Mr.Ben Draper should be given a beta agonist in this condition. 84.Electrocardiogram (ECG) and CK is to be performed in a patient with myocardial infarction(MI). 85.The best test to determine the extent of coronary artery occlusion is a coronary arteriogram. situation:Steven Folger is a postoperative patient who has developed acute renal failure from hypotension. 86.To confirm acute renal failure in a patient,creatinine should be tested. 87.ph-7.28,PaCo2-50,PaO2-24,SaO2-96=analysis is respiratory acidosis. 88.pH-7.52,paCo2-45,Pao2-80,HCO3-30,Sao2-94%=metabolic alcolosis 89.Treatment in metabolic alkalosis is hemodialysis. 90.Cholecystography is an xray study of the gallbladder. 91.Presbyopia means loss of ability of the eye to accommodate secondary to loss of the elasticity of the lens. 92.Communion is an example of spiritual need. 93.An abduction pillow is ordered to a patient in orthopedic unit following a hip replacement surgery,which this prevents internal hip rotation. 94.A patient has a very fast heart rate.To slow the rate down,the patient is asked to hold his breath and bear down which is known as valsalva's maneuver. 95.Z-track injection is a method of IM injection that prevents leakage of the meds into the subcutaneous tissue. 96.A T tube drain is used in a patient following a cholecystectomy is a : a.biliary drainage tube b.drain after breast surgery

c.peritoneal dialysis drain

d.small rubber tubing drain

97.A thrill of an arteriovenous fistula is a palpable sensation. 98.The purpose of a stryker frame is to: a.allow horizontal sound heard with the bell of a stethoscope b.allow vertical turning of the patient to increase calcium absorption c.help prevent contractures d.increase respiratory function and decrease hypotension situation:Eddie joyce has been diagnosed with Grave's disease 99.With grave's dse,the nurse would expect an abnormal laboratory value of increased T4(thyroxine) situation:Leslie Harper has been diagnosed with Cushing's syndrome. 100.With cushing's syndrome,the nurse would expect an abnormal laboratory value of increased cortisol. Reference:mrlrc OBSTETRIC NURSING 1.A female client,17,who is preparing for competition in a national gymnastic tournament is most likely to have a secondary amenorrhea. 2.In an abnormal autosomal recessive disorder,each pregnancy has a 1 in 4 (25%) chance of resulting in another affected child. 3.A woman who has phenylketonuria(PKU) who wants to become pregnant,should follow her lowphenylalanine diet before conception and throughout pregnancy. 4.A fetal hemoglobin of 13gm and a hematocrit of 39% is that fetal blood is more likely to clot as it circulates through the placenta. 5.A fetus who is probably in mother's pelvis,and putting more pressure on mother's bladder,can cause so much urination on her. 6.A pregnant woman is prone to urinary tract infection primarily because nutrients that enhance bacterial growth are excreted by her kidneys. 7.A pregnant woman complaining pain at her thumb ,neither inflamed or discolored,is explained that increased tissue fluid is causing compression of nerve. 8.Sexual intercourse during pregnancy is safe if she is not bleeding and the membranes are intact.

9.The woman tries to care for infants while an experienced mother watches is an example of maternal behavior that best describes role playing during pregnancy. 10.A pregnant woman who had been taught and understood what has been taught if she restates the info she had learned. 11.Poor weight gain during early pregnancy is associated with small-for-gestational age infants. 12.A food that is high in vit.C may enhance absorption of iron. 13.Provide as many choices possible from nutritious foods during pregnancy. 14.The main risk to a woman who practices pica during pregnancy is inadequate intake of essential nutrients. 15.The correct nursing approach regarding caffeine use during pregnancy is to discuss sources of caffeine in addition to coffee and tea. 16.To reduce the incidence of neural tube defects such as spina bifida.women of childbearing age are recommended to consume 0.4mg folic acid per day in foods and supplement. 17.The fetal heartbeat should be visible on ultrasound by the 8thwk following the last menstrual period. ultrasound-before 3mos. doppler-3mos,fetoscope-4mos,stethoscope-5mos. 18.Fewer fetal movements than expected suggest possible reduced placental perfusion with fetal hypoxia. sign of fetal distress:dec. fetal heart rate,meconium stain-amniotic fluid,fetal thrushing. 19.Abnormal MSAFP(maternal serum alpha-fetoprotein) levels are usually associated with chromosome abnormalities. 20.After amniocentesis,report persistent contractions,vaginal bleeding,or fluid leaking. 21.A woman who is assessing fetal movements each day should notify her health care provider if fewer than 12 fetal movements occur during the day. 22.Firm pressure on the palms may reduce labor pain because it stimulates large-diameter nerve fibers,interfering with transmission of pain impulses. 23.The primary benefit of perinatal education is to help parents become active in health maintenance during pregnancy and birth.

24.During active labor,a woman complains of "tingly",still fingers.The nurse should focus primarily on helping her to slow her respiratory rate. 25.A man's active role on her wife during labor to perform simple techniques to help his wife during labor. 26.When assessing a laboring woman's blood pressure,the nurse should check the blood pressure between two contractions. 27.A woman is admitted in active labor.Her leukocyte count is 14,500.Based on this information,the nurse should record the expected results in the woman's chart. 28.The most appropriate time for the nurse to encourage a laboring woman to push is during second stage labor. 29.True labor has begun when there is a change in the amt.cervical thinning. 30.The nurse should note how long the interval between contractions lasts because most exchange of fetal oxygen and waste products occurs then. 31.The primary benefit of the stress of labor to the newborn is ,it stimulates breathing and elimination of lung fluid. 32.LOA is a presentation and position that is most favorable for vaginal birth. 33.Bloody show differs from active vaginal bleeding in that bloody show is dark red and mixed with mucus. 34.A laboring woman abruptly stops her previous breathing techniques during a contraction and makes low-pitched grunting sounds.The priority nursing action is to look at her perineum(nearly baby -delivered) 35.A woman's membrane rupture during a contraction.The priority nursing action is to assess the fetal heart rate. 36.When palpating labor contractions,the nurse should place the fingertips over the fundus of the uterus. 37.When doing Leopold's maneuvers,the nurse palpates a hard round object in the uterine fundus.A smooth,rounded surface is on the mother's right side,and irregular moveable parts are felt on her left side.An irregularly shaped fetal par is felt in the suprapubic area and is easily moved upward.This findings means that the fetal presentation is breech,position is RSA,and the presenting part is not engaged. 38.A woman having her third baby planned epidural analgesia for labor and birth.However,her labor was so rapid that she did not have the epidural.The best nursing action is to use open-ended questions to clarify her true feelings about the experience.

39.Firm contractions that occur every 3minutes and last 100secs(1min.,40secs.),may reduce fetal oxygen supply because they limit time for oxygen exchange in the placenta. 40.The expected response of the fetal heart rate to active fetal movement is acceleration of at least 15bpm for 15secs. 41.The nurse notes a pattern of variable decelerations to 75bpm on the fetal monitor.The initial nursing action is to reposition the woman. 42.The woman who uses cocaine is more likely to have pattern on the electronic fetal heart rate monitor which is late decelerations.(poor blood flow) 43.The tocotransducer should be placed in the fundal area. 44.The nurse should respond to incomplete uterine relaxation between contractions by contacting the physician for a tocolytic order. 45.A woman is admitted in possible labor at 34wks gestation.She is monitored with the external fetal monitor.The nurse should periodically assess the contractions by palpation primarily because her uterus does not contract outward toward the transducer. 46.The nurse notes a pattern of decelerations on the fetal monitor that begins shortly after the contraction and returns to baseline just before the contraction is over.The correct nursing response is to continue to observe and record the normal pattern. 47.Firm sacral pressure is likely to be most helpful in fetal occiput posterior position. 48.A woman receives meperidine(demerol) during labor.Because this analgesic is being used,the nurse should have on hand naloxone(narcan) which antidote for respiratory distress. 49.When stocking a cart for epidural analgesia,the most important nursing action is to verify that no epidural drugs have preservatives. 50.The physician orders meperidine(demerol) 35mg and hydroxyzine(vistaril)25mg slow IV push for a laboring woman.The appropriate nursing action is to remind the physician that hydroxyzine is not given IV,should be IM route. 51.The appropriate nursing action for a woman who has a post-spinal headache is to encourage intake of fluids that she enjoys. 52.A woman having her first baby is trying to use breathing techniques during labor,but has difficulty concentrating.She is 3cm dilated,80%effaced,and the station is 0.The nursing action is to help her find a

specific point in the room to focus on. 53.A woman must have general anesthesia for planned cesarean birth because of previous back surgery.The nurse should therefore expect to administer a ranitidine(zantac). 54.After the physician performs an amniotomy,the fluid is dark green with a mild odor and the FHR is 130140.The most nursing action is to monitor the fetus more closely for non-reassuring signs. 55.The correct setup for oxytocin induction of labor is oxytocin is given as a secondary infusion and is controlled by an infusion pump. 56.A method to prepare the cervix for induction of labor the following day is prostaglandin preparations. 57.Fetal heart rate at hypertonic uterine contractions is 80-100bpm. 58.A woman has externa version to change her fetus position from breech to cephalic.She is not advised to go home if the nurse observed that vaginal discharge is a pale and watery fluid post procedure. 59.A urinary catheter should be readily available when a woman has a forceps-assisted birth because a full bladder reduces available room in the pelvis. 60.During the recovery period after the low forceps birth with a median episiotomy,the nurse should apply cold packs to the perineal area promptly. 61.The woman will be asked to take deep breaths and cough regularly after birth as a preoperative teaching of a planned cesarean birth. 62.The best method to prevent hemorrhage after cesarean birth is to assess the uterine fundus regularly for firmness. 63.When checking a woman's fundus 24hrs.after cesarean birth of her third baby,the nurse finds her fundus at the level of her umbilicus,firm and in the midline.The appropriate nursing action related to this assessment is to document the normal assessment. 64.A woman who is 18hrs.postpartum will have hot flashes and sweats coz her body is getting rid of unneeded fluid. 65.Assess the height of the fundus of a woman who is 3hrs.postpartum and had difficulty of urinating,then urinates 100ml. 66.When teaching the postpartum woman about peripads,the nurse should tell her that the pads should be applied and removed in a front-to-back direction.

67.A mother should get adequate rest after discharge by planning to sleep or rest any time the infant sleeps. 68.To aid episiotomy healing in a woman who is 24hrs.postpartum,she should have warm sitz baths taken 4times per day. 69.To prevent breast engorgement,the nurse should teach the non-lactating postpartum woman to wear a well fitting bra or breast binder constantly. 70.A woman who is 4 hrs.postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra.The nurse's first action should be to determine if the bleeding slows to normal or remains large. 71.To help postpartum woman avoid constipation,the nurse should teach her to drink at least 2500ml of non-caffeinated fluids daily. 72.A new mother should report reappearance of red lochia after it changes to serous which means bleeding or retained placental fragments. 73.Non asking about her baby of a new mother is an example of taking-in phase of maternal behavior. 74.The safe weight loss in a new mother takes 6months. 75.A newborn is rooming in with his teenaged mother,who is watching tv.The nurse notes that the baby is awake and quiet.The best nursing action is to pick the baby up and point out his alert behaviors to the mother. 76.The infant of a diabetic mother is prone to hypoglycemia because high insulin production rapidly metabolizes glucose. 77.The primary difference bet.physiologic and pathologic jaundice is the time of onset and rate of rise in bilirubin levels. -physiologic-3-7days(2-4days) jaundice assessment parameters -pathologic-within 24* 78.The nurse can help prevent many cases of jaundice in the breast fed infant by teaching the mother how to encourage regular and adequate nursing. 79.If nurse notes a 2vessel umbilical cord,the most impt.nursing observation is urine output. 80.An infant's gestational age assessment reveals that her weight is SGA.This means that her weight is lower than expected for her gestation. 81.When weighing an infant,the nurse places a covering on the scale tray to ensure that conductive heat

loss from the infant is minimal. 82.The nurse notes slight resistance when first inserting a rectal thermometer to take a newborn's first temperature.The first nursing action is to notify the infant's pediatrician. 83.A new mother anxiously summons the nurse to her baby's room because she sneezed twice.A bried assessment shows nothing unusual.The appropriate teaching is that lint from the clothes or blankets probably ticked the baby's nose. 84.In cord care,fold the diaper below the cord to speed drying.(7-10days) 85.In nursing infants,limiting time can cause frequent infant hunger because the baby does not receive richer milk. 86.The correct site of injection of hepatitis B immunization for a newborn is the vastus lateralis muscle. 87.A new mother wants to breastfeed but also to feed her infant formula occassionally.The nurse should teach her to avoid using any bottles the first month to establish her milk supply. 88.A woman has had a baby at 29wks of gestatio.She tells the nurse that she can't breastfeed since the baby is so small and early.The nurse should tell her that she can use a breast pump to maintain lactation until nursing is possible. 89.A breastfeeding mother is reluctant to take a prescribed analgesic bec.she doesnt want to pass it to the baby.The nurse should teach her that less medicatio will reach the baby if she takes it 15-30mins before a feeding. 90.A new mother is worried bec.her 1day old baby is taking only 3/4ounce of formula at most feedings.The nurse should teach her that the amount the baby is taking at each feeding is normal at this time. 91.The best way to cure miliaria(rash) is to take measures to cool the infant. 92.If a baby nurses before about 30mins at each feeding and then became 15-20mins,it is normal coz the baby has learned to nurse more effectively and gets more milk in less time. 93.The best way for the nurse to evaluate the quality of a pregnant adolescent's diet is to ask her to describe what she ate the previous day. 94.Correct advise for women who ask about using alcohol during pregnancy is that it is important to avoid it entirely throughout pregnancy. 95.When first presenting an infant with an anomaly to parents,the nurse should emphasize the most

normal aspects of the infant before showing them the anomaly. 96.A woman who had a stillborn infant at 37weeks of gestation angrily asks the nurse why her physician didnt take the baby early.The nurse should understand that the mother's behavior should be expected as part of the normal grieving process. 97.The primary distinction bet.threatened and inevitable abortion is the rupture of membranes. 98.A woman is admitted to the emergency dept.with a possible ectopic pregnancy..A pulse increase from 78-100bpm should be reported immediately to the physician. 99.When caring for a the woman who had a hyatidiform mole evacuated,the clinic nurse should primarily reinforce the need to delay a new pregnancy for 1yr. 100.The woman who is receiving methotrexate for an ectopic pregnancy should be cautioned to eating foods with folic acid. 101.Nursing teaching for the woman who has hyperemesis gravidarum should include eating simple foods such as breads and fruits. 102.A woman who is 34weeks pregnant is admitted with contractions every 2mins.lasting 60secs,and a high uterine resting tone.She says she had some vaginal bleeding at home.and there is a small amount of blood on her perineal pad.The priority action of the nurse is to evaluate the maternal and fetal circulation and oxygenation. 103.The nurse makes the ff.assessments on a woman who is receiving intravenous magnesium sulfate:FHR 148-158,P 88,R10,BP 158/96.The priority nursing action is to stop the magnesium sulfate. 104.When providing intrapartal care for the woman with severe pre eclampsia,priority nursing care is to promote placental blood flow and prevent maternal injury. 105.Clonus indicates that the central nervous system is very irritable. 106.The feature that distinguishes pre-eclampsia from eclampsia is the onset of convulsions. 107.An Rh-negative mother;Rh-positive infant;negative direct coomb's test,a mother should receive RH. (D) immune globulin after birth. 108.The test used to screen for gestational diabetes is the glucose challenge test. 109.The best evaluation for the client goal of accurate insulin administration is that she will accurately withdraw,mix,and inject insulin.

110.The primary fetal risk when the mother has any type of anemia is reduced O2 delivery. 111.Reduction in congenital rubella is best accomplished by immunizing susceptible women at least 3mos.before they become pregnant. 112.Teach the mother who has an active herpes and gave birth thru cesarean to thoroughly wash hands before handling the infant. 113.Correct injection technique for infants of mothers who are known carriers of hepatitis B virus is delay all injections until the infant has been bathed. 114.An infant weighing 8lbs,10ounces is born vaginally.Shoulder dystocia occured at birth.Bec.of this problem,the nurse should assess the infant for creaking sensation when the clavicles are elevated. 115.To promote fetal descent,remind the woman to empty her bladder every 1-2hrs. 116.While in bed,a good position for the woman laboring with a twin pregnancy is side lying.-it enhances circulation. 117.A woman has shoulder dystocia when giving birth.The nurse should expect application of suprapubic pressure. 118.A woman is having a hypotonic labor and is very frustrated bec.this is her third trip to the birth center.Nursing measure is to offer her a warm shower or bath. 119.A woman is receiving magnesium sulfate to stop preterm labor.The essential nursing assessment related to this drug is hourly vital signs,heart sounds,and lung sounds. 128.The nurse notes that a woman has excess lochia 2hrs.after vaginal birth of an 8lb baby.The priority nursing action is to assess the firmness of her uterus. 129.A woman has an 8lb,9oz baby after an 8hr labor(prolonged labor) that required a low-forceps delivery.Her membranes were ruptured for 15hrs.Based on these facts,client teaching should emphasize reporting foul-smelling lochia. 130.The best position for a woman who has a postpartum endometritis is fowler's. left lateral-fetal distress trendelenburg-cord prolapse,bleeding supine-relax 131.A breastfeeding woman develops mastitis.Emptying the breast is impt.to prevent an abscess. 132.To promote drainage of lung secretions in the preterm infant,the nurse should frequently change the

infant's position. 133.The infant who is postmature during the first 8-12hrs after birth,should have blood glucose determinations. placement under phototherapy-preterm blood transfusions-ABO Rh incompatible 134.A preterm infant has been receiving 20ml of breast milk by gavage every 3hrs.The nurse checks the residual before giving the next feeding,and it is 6.5ml.The nurse should hold the feeding and notify the physician. 135.If meconium is present in the amniotic fluid,the infant's mouth and pharynx should be suctioned after the head is born,but before the rest of the body.The primary reason for this action is to avoid drawing meconium into the lower airways with the first birth. 136.Infants receiving phototherapy should be fed every 2-3hrs to promote excretion of bilirubin from the bowel. 137.The nurse notes that a 24-hr old infant is lethargic and his temperature is below normal,a change from an earlier assessment that was normal.Her mother states that she did not breastfeed well and that she spit up the small amount she had ingested.The nurse's next action is to assess for signs of sepsis and report assessment to the physician. 138.A mother who has diabetes is concerned bec.her 36hr.old baby is so yellow.She tells the nurse that she thought her baby's problems were over when his blood glucose stabilized even he was smaller than expected.The best nursing response is that her baby lived in a lower-than-normal oxygen environment during pregnancy and must eliminate more red blood cells. life span of RBC-120days,newborn-90days 139.The nurse notes that a 12hr old infant is jittery,but his blood glucose level is normal.The infant seems hungry,but only takes 1/4ounce of formula with difficulty.The nurse's next action should be to apply a bag to collect the next sample of urine.-to determine if the baby is adequately fed. 140.A woman is considering having a tubal ligation after she gives birth to her second child.The nurse should counsel her that the procedure should be considered permanent and irreversible. 141. Post procedure teaching for a man who has had a vasectomy should include discussion that another form of contraception should be used until the semen is free of sperm. 142.A 30year old woman who thinks she has completed her family is a good candidate for hormone implant.

143.A woman decides to change from the diaphragm to Depo-Provera.Her last menstrual period ended 1wk ago.She should be taught that she should continue to use the diaphragm for the rest of her cycle. 144.A woman should take an oral contraceptive at about the same time each day. 145.A barrier method should be also used while in oral contraceptives to protect from infection. 146.The intrauterine device is an appropriate contraceptive for the woman who is in a mutually monogamous relationship. 147.When teaching the woman to take alendonate(fosamax),the nurse should tell her to remain upright for at least 30minutes after taking the drug each morning. 148.To reduce the risk for toxic shock syndrome,women should be taught to wash hands thoroughly before inserting a tampon or diaphragm into the vagina. 149.Cervical mucus at ovulation should be thin,slippery,and should stretch to at least 6cm. 150.At ovulation,the basal body temperature usually falls slightly at ovulation and is higher during the last half of the cycle. Reference:Evoke learning center-bootcamp 1.A 45y/o male pt.with peptic ulcer has been taking propantheline bromide(probanthine) at home.The nurse should prepare a teaching plan for the patient that indicates the medication acts primarily to suppress gastric secretions. Probanthine-not antacid,all secretions will be decreased,anticholinergic. antacids-neutralize acid in stomach 2.Probanthine bromide is ordered for the client with cholecystitis.This drug is used to decrease biliary contraction.(more on muscle relaxant.) Meperidine(demerol)-to decrease pain 3.A nurse should evaluate a 35y/o client with common bile duct obstruction for signs of hemorrhage.(fat soluble vits.cant be absorbed by bile) 4.Dan 36y/o patient will undergo cholecystectomy,preoperatively,Nurse Dolly instructs him the correct use of an incentive spirometer.This treatment is essential after surgery in the upper abdominal area because the operative incision is near the diaphragm cholecystectomy-right upper quadrant is incised splitting-before deep cough and breathing spirometer-10x every hour,with flow indicator ,maintain 600-900

5.Nurse Aron administers preoperative IM medication at the ventrogluteal site of a patient who will undergo cholecystectomy.He will inject the medication into gluteus minimus. 6.Nurse Arman will provide NGT and drainage care for a clietn who underwent subtotal gastrectomy.Include in the interventions the assessment to the pt. the presence of nausea,vomiting,and abdominal distention.Irrigation of the tube with 30-60ml of sterile water if needed. NGT-aside from drainae,for decompression after surgery 7.After Billroth II procedure,the patient will have NGT in place for several days postoperatively to prevent pressure on suture lines. suctionpressure-25mmHG injection of air-5-10cc of air 8.Life threatening shock is extremely difficult to manage in pancreatitis primarily because of the vasodilating effects of kinin peptides. 9.A 29y/o patient with inserted NGT begins to complain of abdominal distention.Nurse Kimlei will implement first the checking of the function of the suction equipment. -every 4hrs,check for residual,if there is check every 1hr. Formula/prepared solution for NGT-can be given only 4hrs. or if refrigerated it. 10.A low fat,bland diet distributed over 4-6meals daily is the appropriate diet for a patient with chronic pancreatitis. chronic pancreatitis-Increased lipase,amylase is normal,low calcium 11.The physician prescribes metoclopramide HCl(Reglan)-(parasymphatetic/GI stimulant/antiemetic) for a 46y/o patient with hiatal hernia.This drug is to increase the resting tone of the cardiac sphincter. Diaphragmatic hernia-other name-sliding -paraesophageal(rolling) sliding-there is an increase in the fundic of the stomach. 12.A patient with hiatal hernia should eliminate smoking and alcohol use. smoking-can loosen the sphincter. 13.A 65y/o patient with colon cancer is scheduled for an abdominoperineal resection with permanent colostomy.Preoperatively,administer kanamycin the night before surgery. kanamycin-decrease bacteria in the colon(no infection) colostomy-irrigate to 300-600 eyery 3-6days. 14.The appropriate expected outcome for the patient who has had an abdominoperineal colostomy will

be verbalize that he feels free to discuss concerns about sexual functioning. 1.empty pouch to 1/2-1/3 after meals 2.change the size of one pouch 3.positioning-sidelying 15.The client with with liver cirrhosis appears to be having difficulty of breathing 1hr after the insertion of Balloon tamponade.The nurse initial action is to determine whether the tue is obstructing the airway. tamponade-25-45mmHG -can be stayed in 24-48hrs(1-2days) -removing air always go in esophageal -intermittent pressure only 16.Nurse Susan is changing the subclavian dressing of a patient on TPN.In the dressing change,assess for any tube kinks and leakage. 17.A 45y/o patient with hyperhydrosis will undergo Botox therapy.Botulinum toxin type A will be administered by injection into the muscle by a healthcare professional -Botulinum toxin type A produced by the bacteria that causes botulism. -Botulinum toxin typer A affects the nerves-can cause paralysis. -it relaxes the muscle. 18.Botox therapy is indicated to:cervical dystonia(spasms of the neck muscles) -strabismus(a condition in which the eyes do not point in the same direction) -severe underarm sweating -cant give to myasthenia gravis(muscle weakness)-coz BT typer A causes muscle relaxant 19.Botulinum therapy-it is in the FDA pregnancy category C-anything that affects fetus -symptoms of an overdose of botulinum toxin type A include weakness or paralysis,including difficulty breathing or swallowing. 20.Side effects of Botulinum Therapy-an allergic reaction(difficulty breathing,closing of the throat,swelling of the lips,tongue,or face,or nives) -difficulty breathing,breathing,talking or swallowing -unusual,or excessive muscle weakness -chest pain,or irregular heartbeats -eye infection,ulceration,double vision,or other eye problems 21.A priority goal in the first 24hrs.after the client with cushing's disease undergoes bilateral adreanlectomy is to prevent addisonian crisis. steroids-sex hormones(aldosterone)

doses:2/3(am),1/3(pm) ex.dexa 22.After surgery for bilateral adrenalectomy the client is kept on bed rest for several days to stabilize the body's need for steroids postoperatively.Alternatively,flexing and relaxing the quadriceps ,femoris muscle are the helpful exercises to prepare him for ambulation. 23.Nurse Frenzy teaches the client with pituitary adenoma to monitor for signs and symptoms of complications after hypophysectomy which includes hypopituitarism. hyperthyroidism-hypersecretion gigantism-hypersecretion cushings dse-hypersecretion 24.Initial treatment for CSF leak after a transphenoidal hypophysectomy for pituitary tumor would most likely involve placing the patient in semi-fowler's position. -bedrest for 3days,if after 3days,return the client to surgery. 25.Captopril may be prescribed for the patient to reduce vascular changes associated with diabetes mellitus and possibly prevent or delay development of renal failure. captopril-antihypertensive kidney-affected in dehydration 26.St.John's wort-sedative agent,antidepressive,anti anxiety,anti-inflammatory, improve memory. 27.Clinical side effects of saw palmetto-reduces absorption of iron -contraindicated in pregnancy and lactation -nausea and abdominal pain saw palmetto(ginger)-for BPH,for UTI.diuretic, improving memory:ginseng/ginkgo bilova-improve physical stamina 28.Benefits of licorice: -prevent stomach ulcers -treat cough and chills -expectorant garlic: -skin diseases/antibacterial -antifungal/antiviral -fibrinolytic

29.To prevent paralytic ileus in the client after surgery: -continue IV fluid therapy with 1000ml of 5% dextrose in water every 8hrs. 30.The client with Acute Renal Failure asks the nurse if her kidneys will function normally again,nurse response is,it will continue to improve over a period of weeks ARF-oliguric phase-it lasts for 2wks -diuretic-2-3wks -recovery-3mos-1yr. causes of ARF:prerenal and post renal chronic renal failure: -result in ESRD -result in the need for peritoneal dialysis -renal function will be restored thru kidney transplant 2 meds.prior to transplant: a.cycloponine-(sandimmune) a.1-GEAK-grapefruit-increase toxicity of cyclosponine a.2.BGK-[potassium),glucose-decrease BP b.tacrolimus(prograf) 31.Nurse Leah teaches the client with UTI methods to relieve her discomfort until the antibiotics take effect.TEach to take hot tub baths. 32.PHenazopyridine hydrochloride(pyridium)-for UTI -it is used as analgesic on bladder mucosa -check for liver function/reanl function-hepatotoxity/nephrotoxicity -urine will be red or orange while on pyridium 33.Bleeding during peritoneal dialysis is caused by abdominal vessel damage. Hemodialysis-cerebral damage 34.Breast self examination-proper positioning -flat on the back with a rolled towel under the shoulder on the side being examined. Mastectomy-avoid heavy lifting greater than 10lbs-5lbs can be exercises:muscle cant be-nodes only 35.Patient undergone MRM-will undergo radiation therapy,care the site of interstitial radiation therapy,by washing the area with water. 36.TURP postoperatively-watch out for early signs of :respiratory paralysis,hypotension,headache late signs:cardiac arrest,renal failure

37.Patient post TURP has CBI:major goal:maintain catheter patency 38.Syphillis-caused by spirochette -triponema/pallidium,ticks 38. Reference:Edgeworth 1.A client receiving a blood transfusion begins to complain of chills and headache within the first 15mins of the transfusion.Nurse's first response is to discontinue the transfusion. 2.Isosorbide(isordil)-antianginal medication.SE:dizziness-change the position slowly. 3.Abdominal hysterectomy:expected outcome 24*-the client will perform leg exercises hourly. 4.A client has been prescribed furosemide(lasix)80mg twice daily.The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigamy lasting 2mins.During the assessment,the nurse determines that the client is asymptomatic and has stable vital signs.The nurse will do next is to administer potassium. 5.breathing effectively:the client takes a deep abdominal breath and then "huff" coughs three or four times. 6.High fowler's position:a pt.with suspected heart failure. 7.Activity intolerance related to pump failure:priority nursing diagnosis to a patient with heart failure and pulmonary edema. 8.Increase cardiac output:major goal of therapy for a client with heart failure and pulmonary edema. 9.Digoxin:prescribed to a pt.with heart failure:acts to increase myocardial contractility. 10.Captopril:an angiotensin-converting enzyme inhibitor,maybe administered to a patient with heart failure bec.it acts as vasodilator. 11.The nurse teaches a patient with heart failure to take oral furosemide in the morning.The primary reason for this is to help sleep disturbances during the night. 12.Patients with heart failure are prone to atrial fibrillation.During physical assessment,the nurse would suspect atrial fibrillation when palpitation of the radial pulse reveals an irregular pulse rhythm.

13.When teaching the patient about complications of atrial fibrillation,the nurse understands that the complications can be caused by stasis of blood in the atria. 14.tomato juice:should be avoided by patients with heart failure in accordance with 2g sodium diet. 15.Nurse Loraine is admitting a 65y/o old man to the clinical unit.The patient has a history of left ventricular enlargement.During assessment,that she notes +3pitting edema of the ankles bilaterally.The patient does not have chest pain.Nurse Loraine observes that the patient have dyspnea at rest.She infers that the patient may have heart failure. 16.The nurse discharge teaching plan for the patient with heart failure would stress the significance of obtaining daily weights at the same time of each day. 17.A 65y/o,Joshua Angeles is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation.Although the diagnosis was made during childhood,he did not have symptoms until 4years ago.Recently,he would most likely learn that Joshua's childhood health history included rheumatic fever. 18.A patient with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted.The physician orders pulmonary artery pressure monitoring including pulmonary capillary wedge pressures.The purpose of this is to help assess the pressure from fluid within the left ventricle. 19.mitral regurgitation:signs and symptoms-exertional dyspnea 20.The nurse expects that the patient with mitral stenosis with demonstrate symptoms associated with congestion in the pulmonary circulation. 21.A patient who has undergone a mitral valve replacement experiences persistent bleeding from the surgical incision during the early postoperative period.Nurse expects to administer protamine sulfate. 22.The most effective measure the nurse can use to prevent wound infection when changing a patient's dressing after artery bypass surgery is to observe careful handwashing procedures. 23.For a patient who excretes excessive amounts of calcium during the postoperative period after open heart surgery ,the nurse may institute to help prevent complications associated with excessive calcium excretion is provide an alkaline-ash diet. 24.Good dental care is an important measure in reducing the risk of endocarditis.A teaching plan to promote care in a patient with mitral stenosis should include demonstration of the proper use of a manual toothbrush. 25.Before a patient's discharge after mitral valve replacement surgery,the nurse should evaluate the patient's understanding of post surgery activity restrictions.This includes no lifting anything heavier than

10lbs in 1month period post surgery. 26.A company nurse at a large printing plant finds a male employee's BP to be elevated on two occasions 1month apart and refers him to his private physician.The employee is about 25lbs overweight and has smoked a pack of cigarettes for more than 20years.The physician prescribes atenolol for the hypertension.The nurse should instruct the patient to avoid sudden discontinuation of the drug. 27.A patient's job involves working in warm,dry room,frequently bending and crouching to check the underside of a high speed press,and wearing eye guards.The nurse assesses the patient for postural hypotension. 28.The patient realizes the importance of quitting smoking,and the nurse develops a plan to help the patient achieve this goal.The nurse's initial step to this plan is establish the patient's daily smoking pattern. 29.Ineffective health maintenance:priority nursing diagnosis for a patient with hypertension. The ff.pertain to management and case of patients with angina. During the previous few months,Angelo,a 36year old man felt brief twinges of chest pain while working in the garden and has had frequent episodes of indigestion.He comes to the hospital after experiencing severe anterior chest pain while raking leaves.HIs evaluation confirms a diagnosis of stable angina pectoris.After stabilization and treatment,he was discharged at the hospital.At his follow up appointment,he is discouraged bec he is experiencing pain with increasing frequency.He states that he visits an invalid friend twice a week an now cannot walk up the second flight of steps to the friend's apartment without pain. 30.Based on above,an nurse could suggest to help the patient is to take a nitroglycerin tablet before climbing the stairs. 31.BAsed on above,the diet must be followed is low-cholesterol diet.ex-spaghetti with tomato sauce,salad and coffee. 32.The physician refers the patient with unstable angina for a cardiac catheterization.The nurse explains to the patient that this procedure is being used in this specific case to assess the extent of the arterial blockage. 33.ECG-gives info.about electrical conduction of the myocardium. 34.Initial step of physician in treating angina:nitroglycerin 0.3mg given sublingual-vasodilation of peripheral vasculature. 35.SE of nitroglycerin-headache.meds should be at room temp,avoid heat coz may destroy potency.

The ff.pertains to patients requiring CPR: 36.A rescuer is called to a neighbor's home after a 55yr olf man collapses.After quickly assessing the victim,the rescuer determines that the victim is unresponsive.To determine unresponsiveness,the rescuer can call the victim's name and gently shake the victim. 37.Proper hand placement for chest compressions during CPR is essential to reduce the risk of complications which is myocardial infarction. 38.A patient who has been given CPR is transported by ambulance to the hospital's ER department,where the admitting nurse quickly assesses the patient's condition.To determine if CPR is effective,pulse rate is normal. 39.The patient receives epinephrine during the resuscitation in the emergency department.This drug is administered primarily bec.of its ability to enhance myocardial contractility. 40.During CPR,the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions.Liver is the most likely at risk for laceration by forceful compression over the xiphoid process. 41.If the victim's chest wall fails to rise with each inflation when rescue breathing is administered during CPR,the most likely reason is that the airway is not clear. The ff.pertains to management and care of patients with variety of vascular diseases: 42.Peripheral blood flow is dependent on pressure differences of the heart and resistance of the vessels. 43.A common abnormality associated with the development of peripheral vascular disease is high serum lipids. 44.To assess a patient's pedal pulse,the nurse would palpate the top of the foot and inner side of each foot. 45.The patient admitted with PVD asks the nurse why her legs hurt when she walks.The nurse bases her response on the knowledge that the main characteristic of PVD is decreased blood flow. 46.When assessing extremities of PVD,the nurse notes bilateral ankle edema.The edema is related to increased venous pressure. 47.Atherosclerosis results in stenosis of the arteries.Formation of aneurysm is also a result of atherosclerosis. 48.A patient with PVD has chronic,severe pretibial and ankle edema bilaterally.Because the patient is on

complete bed rest and circulation is compromised,one goal is to maintain tissue integrity.This can be helped by turning the pt.every 1to 2hrs. 49.A patient who has been diagnosed withPVD has been discharged.Use of iodine on injured site is contraindicated. 50.The nurse has been assigned to a patient with buerger's disease.Hands and fingers are the most affected sites. 51.The primary goal for the pt.with buerger's dse is to prevent embolus formation. 52.Because smoking cessation is a critical strategy for the patient diagnosed with buerger's dse,the nurse anticipates that the patient will go home with a prescription of nitroglycerin-peripheral vasodilator. 53.The patient with buerger's dse.experiences pain,pallor,and pulselessness which are the signs and symptoms of the dse. 54.Nurse jen is assigned to a pt.with raynaud's dse.The nurse realizes that the underlying etiology of raynaud's dse.is unknown but is characterized by episodic vasospastic disorder of the small arteries. 55.The patient with raynaud's dse complains of cold and numbness on his fingers.The nurse assesses the patient for vasoconstriction.Early sign of vasoconstriction is pallor. 56.The nurse should instruct the patient with raynaud's dse.to wear gloves when handling ice or frozen foods. 57.A patient is discharged after being hospitalized for thrombophlebitis.She will be driving home with her daughter,who lives 2hrs away.During the2hr ride the patient should perform active ankle and foot ROM exercises. 58.Jennifer Quindara is admitted at the clinic with an acute onset of shortness of breath.A diagnosis of pulmonary embolism is made.One common cause of pulmonary embolism is deep vein thrombosis. 59.Bed rest is related to an increased incidence of thrombophlebitis.The plan of care for a patient on bed rest would include turning the pt.every 2hrs,use of thrombolytic dse support hose and passive and active ROM exercises. 60.A patient comes to the hospital complaining of severe abdominal pain.A radiograph reveals a large abdominal aortic aneurysm.The primary goal at this time is to prepare the patient for emergency measures. 61.Before surgery for a known aortic aneurysm,the patient's pulse begins to widen,suggesting increased valvular insufficiency.If the branches of the aortic arch are involved,the patient will have loss of

consciousness. 62.Yalamber Subba complains of sudden,severe pain in his back and chest,accompanied by shortness of breath.The individual describes the pain as a"tearing" sensation.The physician suspects the man is experiencing a dissecting aortic aneurysm.Emergency equipment is brought into the room because one complication of a dissecting aneurysm is cardiac tamponade. 63.An older woman has a history of a left radical mastectomy and now presents with a swollen left arm.The nurse understands that it is appropriate to encourage a dependent position of the affected arm. 64.The pain associated with migraine headaches is believed to be caused by dilation of the cranial arteries. The following pertains to management and care of patients with hematologic health problems. 65.The nurse would instruct the patient to eat meat and dairy products which is best supply of vitamin B12. 66.The nurse understands that the patient with pernicious anemia has a lab.finding of absent intrinsic factor. 67.A patient comes to the clinic 3yrs after undergoing a resection of the terminal ileum complaining of weakness,shortness of breath,and a sore tongue.The nurse should teach the patient if the patient verbalizes to take vit.b12tab every day. 68.A patient is admitted with irondeficiency anemia and blood streaked emesis.The nurse should ask what activities she was able to do in the past 6mos.to determine the extent of the patient's activity intolerance. 69.Lying on the abdomen with toes pointed inward is the best position to relieve discomfort to a patient who had injection of vit.b12 at the ventrogluteal site. 70.The primary purpose of schilling test is to measure the patient's ability to absorbs vit.b12. 71.The nurse should start a 24-48hr urine specimen collection in starting a schilling test. schilling test-taking vit.12 orally with dye,if seen in urine ,means did not absorb 72.The nurse administers packed RBC to a patient.The nurse should discontinue the transfusion if reaction occurs. 73.A patient stated she is afraid of receiving vit b.12 injection bec.of potential toxic reactions.The nurse should explain that vit.b12 is generally free of toxicity bec.it is a water soluble.

74.A patient with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad.Nurse best response is check for diminished sensations. 75.When a patient is diagnosed with aplastic anemia,the nurse monitorsfor changes (?)a.bleeding tendencies b.I and O c.peripheral sensation d.bowel fxn 76.When a patient with thrombocytopenia complains of a severe headache,the nurse interprets that this may indicate cerebral bleeding. 77.The nurse is preparing a teaching plan about increased exercise for a female patient who is receiving long term corticosteroid therapy.Walking is the most appropriate . 78.A patient with a history of acquired thrombocytopenia has been instructed on how to prevent and control hemorrhage.TEach the patient if she said that she can count the number of tissues saturated to detect blood loss during a nosebleed. INTERNATIONAL QUALITY MANPOWER SERVICES,INC. NURSING BULLETS(FUNDAMENTALS OF NURSING)

>>Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.
1.A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure. 2.A blood pressure cuff that is too wide can cause a falsely decreased bp. reading. 3.When preparing a single injection for a pt. who takes regular and NPH insulin,the nurse should draw the regular insulin into the syringe first bec.it is clear and can be measured more accurately than the NPH insulin,which is turbid. 4.Rhonchi refers to the rumbling sounds heard on lung auscultation,they are more pronounced during expiration than during inspiration. 5.Gavage refers to forced feeding,usually thru a gastric tube(a tube passed into the stomach by way of the mouth). 6.According to the maslow's hierarchy of needs,physiologic needs(air,water,food,shelter,sex,activity,and comfort) have the highest priority. 7.Checking the identification band on a patient's wrist is the safest and surest way to verify an patient's identity.

8.A patient's safety is the priority concern in developing a therapeutic environment. 9.Fluid oscillation in the tubing of a chest drainage system indicated that the system is working properly. 10.The nurse should place a patient with a Sengstaken-Blakemore tube in semi-fowler's position. 11.The nurse can elicit Trousseau's sign by occluding the brachial or radial artery:hand and finger spasms during occlusion indicate Trousseau's sign suggest hypocalcemia. 12.For blood transfusion in an adult,the appropriate needle size is 16 to 20g. 13.Pain that incapacitates a patient and can't be relieved by drug is called intractable pain. 14. In an emergency,consent for treatment can be obtained by fax,telephone,or other telegraphic transmission. 15. Decibel is the unit of measurement of sound. 16. In the event of fire,the nurse should 1.remove the patient 2.call the fire department,3.attempt to contain the fire by closing the door, 4,extinguish the fire ,if it can be done safely. 17. A registered nurse,should assign a licensed vocational nurse or licensed practical nurse to perform bedside care,such as suctioning and medication administration. 18.Informed consent is required for any invasive procedure. 19.A patient who can't write his or her name to give consent for treatment must have his or her X witnessed by two persons,such as a nurse,priest or a doctor. 20.The Z-track IM injection techniques seals medication deep into the muscle,thereby minimizing skin irritation and staining.It requires a needle that is 1''(2.5cm) or longer. 21.The therapeutic purpose of a mist tent is to increase hydration of secretions. 22.If a patient can't void,the first nursing action should be bladder palpation to assess for bladder distention. 23.The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. 24.To fit a supine patient for crutches,the nurse should measure from the axilla to the sole and add 2"(5cm) to that measurement.

25. Assessment begins with the nurse's first encounter with the patient and continues thoughout the patient's stay,The nurse obtains assessment data thru the health history,physical examination,and review of diagnostic studies. 26.The appropriate needle size for an insulin injection is 25g and 5/8"(1.5cm)long. 27. Residual urine refers to urine that remains in the bladder after voiding.The amount of residual urine normally ranges from 50 to 100ml. 28. The five stages of nursing process,are assessment,nursing diagnosis,planning,implementation and evaluation. 29. Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnosis,defines short term and long-term goals and expected outcomes,and establishes the nursing care plan. 30.Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action,delegates specific nursing interventions to members of the nursing team,and charts patient responses to nursing interventions. 31. Evaluation refers to the stage of nursing process in which the nurse compares objective and subjective data with the outcome criteria and if needed,modifies the nursing care plan ,making the nursing process circular. 32. Before administering any as needed pain medication,the nurse should ask the patient to indicate the pain's location. 33.Jehova's witnesses believe that they shouldn't receive blood components donated by other people. 34. To test visual acuity,the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without,as appropriate.(20ft.-6.1m) 35. When providing oral care for an unconscious pt.,the should position the pt.on the side to minimize risk of aspiration. 36. During assessment of distance vision,the patient should stand 20"(6.1m) from the chart. 37. The ideal room temp.for a geriatric pt. or one who is extremely ill ranges from 66* to 76*F(18.8*24.4*C) 38. Normal room humidity ranges from 30% to 60%. 39. Handwashing is the single best method of limiting the spread of microorganisms.Hands should be

washed for 10secs.after routine contact with a patient and after the gloves are removed. 40. To catheterize a female patient,the nurse should place her in the dorsal recumbent position. 41. A positive homan's sign may indicate thrombophlebitis. 42. Electrolytes in a solution are measured in milliequivalents per liter(mEq/L).A milliequivalent equals the number of milligrams pr 100 milliliters of a solution. 43. Metabolism takes place in two phases:anabolism(the constructive phase) and catabolism(the destructive phase). 44. The basal metabolic rate represents the amount of energy needed to maintain essential body functions.It is measured when the patient is awake and resting,hasn't eaten for 14 to 18 hours,and is in a comfortable,warm environment. 45. The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight. 46. Dietary fiber(roughage),which is derived from cellulose,supplies bulk,maintains adequate intestinal motility,and helps establish regular bowel habits. 47. Alcohol is metabolized primarily in the liver.Smaller amounts are metabolized by the kidneys and lungs. 48. Petechiae refers to tiny,round,purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. 49. Purpura refers to a purple skin discoloration caused by blood extravasation. 50. According to the standard precautions recommended by the Centers for Dse.Control and Prevention,the nurse shouldn't recap needles after use bec.most o needle sticks from missed needle recapping. 51. The nurse administers a drug by IV push by delivering the dose directly into a vein,IV tubing or catheter with a needle and syringe. 52. When changing the ties on a tracheostomy tube,the nurse should leave the old ties in place until the new ones are applied. 53. A nurse should have assistance when changing the ties on a tracheostomy tube. 54. A filter is always used for blood transfusion.

55. A four-point(quad) cane is indicated when a patient needs more stability than a regular cane can provide. 56. The patient should carry a cane on the unaffected side to promote reciprocal gait pattern and distribute weight away from the affected leg. 57. A good way to begin a patient interview is to ask"What made you seek medical help?". 58. The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. 59. Potassium(K) is the most abundant cation in intracellular fluid. 60. In the four-point gait(alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. 61. In the 3-pt.gait,the patient moves the right leg and left crutch simultaneously and then moves the left leg and the right crutch. 62. In the 2pt.gait,the patient moves the the right leg and the left crutch simultaneously and then moves the unaffected leg. 63.Vitamin B complex,the water soluble vitamins essential for metabolism,include thiamine B1,riboflavin B2,niacin B3,pyridoxine B6,cyanocobalamineB12. 64. When being weighed, and adult patient should be lightly dressed and shoeless. 65. Before taking an adult's oral temp,the nurse shld ensure that the patient hasn't smoked or consumed hot or cold substances in the past 15minutes. 66. The nurse shouldn't take a rectal temp on an adult pt.if the pt. has a cardiac disorder,anal lesions,or bleeding hemmorhoids or has recently undergone rectal surgery. 67. In a pt, with cardiac problems,rectal temp. may stimulate a vagal response,leading to vasodilation and decreased cardiac output. 68. When recording pulse amplitude and rhythm,the nurse shld use these descriptive measures:+3 indicated a bounding pulse(readily palpable and forceful);+2 a normal pulse (easily palpable);+1 a thready or weak pulse(difficult to detect);and 0,an absent pulse(not detectable). 69. The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit.

On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasnt taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed.
70. A drug has 3names:its generic name,which is used in official publications,its trade name or brand name(such as tylenol) which is selected by the drug company,and its chemical name which describes the drug's chemical composition. 71. The patient should take a liquid iron preparation thru a straw to avoid staining of the teeth. 72. The nurse should use the Z-track method to administer and IM injection of iron dextran(Imferon). 73. An organism may enter the body thru the nose,mouth,rectum,urinary or repro.tract or skin. 74. In descending order,the levels of consciousness are alertness,lethargy,stupor,light coma and deep coma. 75. To turn a patient by logrolling,the nurse folds the patient's arms across the chest;extends the patient's legs and inserts a pillow bet.them,if indicated;places a draw sheet under the pt.;and turns the patient by slowly and gently pulling on the draw sheet. 76.The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. 77. A slight blood pressure difference (5to10mm Hg) bet.right and left arm is normal. 78. The nurse should place the bp cuff 1"(2.5cm) above the antecubital fossa. 79. When instilling ophtalmic ointment,waste the first bead of ointment and then apply from the inner canthus to the outer canthus;twist the medication tube to detach the ointment. 80. The nurse should use a leg cuff to measure bp in an obese patient. 81. If the bp cuff is applied too loosely,the reading will be falsely decreased. 82. Ptosis refers to drooping of eyelid. 83. A tilt table is useful for a patient with a spinal cord injury,orthostatic hypotension,or a brain damage

bec. it can move the patient gradually from a horizontal to a vertical(upright) position. 84. To perform venipuncture with the least injury to the vessel,the nurse should turn the bevel upward when the vessel's lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. 85. To move the patient to the edge of the bed for transfer,follow these steps:1.Move the patient's head and shoulders toward the edge of the bed.2.Move the patient's feet and legs to the edge of the bed(crescent position)3.Place both arms well under the patient's hips and straighten the back while moving the patient toward the edge of the bed. 86. When being measured for crutches,a patient should wear his or her shoes. 87. The nurse should attach a restraint to the part of the bed frame that moves with the head,not to the mattress or side rails. 88. The mist in a mist tent should never become so dense that it obscures clear visualization of the patient's respiratory pattern. 89. To administer heparin subcutaneously,the nurse should follow these steps:1.Clean,but dont rub the site with alcohol. 2.Stretch the skin taut or pick up a wll-defined skin fold. 3.Hold the shaft of the needle in a dart position. 4.Insert the needle into the skin at a right (90degree angle) 5.firmly stretch the plunger,but dont aspirate 6.leave the needle in place for 10 secs. 7. withdraw the needle gently at the same angle it was inserted 8.Apply pressure to the injection site with an alcohol pad. 90. For a sigmoidoscopy the nurse should place the patient in a knee-chest or Sim's positon,depending on the doctor's preference. 91. Maslow's hierarchy of needs must be met in the ff.order:physiologic(o2,food,water,sex,rest,and comfort),safety and security,love and belonging,self-esteem and recognition,and self-actualization. 92. When caring for a patient with a nasogastric tube,the nurse should apply a water soluble lubricant to the nostril to prevent soreness. 93. During gastric lavage,a nasogastric tube is inserted,the stomach is flushed,and ingested substances are removed thru the tube. 94. In documenting drainage on a surgical dressing,the nurse should include the size,color,consistency of the drainage-for example,"10mm of brown mucoid drainage noted on dressing." 95. To elicit Babinski's reflex,the nurse strokes the sole of the patient's foot with a moderately sharp object,such as thumbnail.

96. In a positive Babinski's reflex,the great toe dorsiflexes and the other toes fan out. 97. When assessing a patient for bladder distention,the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. 98.The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2hrs. 99. Antiembolism stockings decompress the superficial blood vessels,thereby reducing the risk of thrombus formation. 100. The most convenient veins for venipuncture in an adult are the basilic and median cubital veins in the antecubital space. 101. From 2to 3hrs.before beginning a tube feeding,the nurse should aspirate the patients stomach contents to verify the adequate gastric emptying. 102. People with type O blood are considered to be universal donors. 103. People with type AB blood are considered to be universal recipients. 104. Hertz(Hz) refers to the unit of measurement of sound frequency. 105. Hearing protection is required when the sound intensity exceeds 84dB;double hearing protection is required if it exceeds 104dB. 106. Prothrombin a clotting factor is produced in the liver. 107. If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. 108. During lumbar puncture,the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. 109. A patient who cant cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of sample. 110. If eye ointment and eyedrops must be instilled in the same eye,the eyedrops should be instilled first. 111. When leaving an isolation room,the nurse should remove the gloves before the mask because fewer pathogens are on the mask. 112. Skeletal traction is applied to a bone using wire pins or tongs.It is the most effective means of traction.

113. The total parenteral nutrition solution should be stored in a refrigerator and removed 30-60minutes before use because delivery of chilled solution can cause pain,hypothermia,venous spasm,and venous constriction. 114. Medication is not routinely injected IM into edematous tissue because it many not be absorbed. 115. When caring for a comatose patient,the nurse should explain each action to the patient in a normal voice. 116. When cleaning dentures,the sink should be lined with a washcloth. 117. A patient should void within 8hrs after surgery. 118. An EEG identifies normal and abnormal brainwaves. 119. Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. 120. The autonomic nervous system regulates the cardiovascular and respiratory systems. 121. When providing tracheostomy care,the nurse should insert the catheter gently into the tracheostomy tube.When withdrawing the catheter,the nurse should apply intermittent suction for no more than 15secs and use a slight twisting motion. 122. A low residue diet includes such foods as roasted chicken,rice,and pasta. 123.A rectal tube should not be inserted for longer than 20 mins. it can irritate the mucosa of the rectum and cause a loss of sphincter control. 124. A patient's bed bath should proceed in this order: (face,neck,arms,hands,chest,abdomen,back,legs,perineum) 125. When lifting and moving a patient,the nurse should use the upper leg muscles most to prevent injury. 126. Patient preparation for cholecystography includes ingestion of a contrast medium and low-fat evening meal. 127. During occupied bed changes,the patient should be covered with a bath blanket to promote warmth and prevent exposure. 128. Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is

inevitable. 129. The ff.foods can alter stool color:beets(red),cocoa(dark red or brown),licorice(black), spinach(green), meat protein(dark brown)> 130. When preparing a patient for a skull x-ray, have the patient remove all jewelry and dentures. 131. The fight-or-flight response is a sympathetic nervous system response. 132. Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggests pneumonia. 133. Wheezing refers to an abnormal,high pitched breath sounds that is accentuated on expiration. 134. Wax or foreign body in the ear should be gently flushed out by irrigation with warm saline solution. 135. If patient complains that his hearing aid is not working,the nurse should check the switch first to see if its turned on and then check the batteries. 136. The nurse should grade hyperactive biceps and triceps reflexes at +4. 137. If two eye medications are prescribed for twice daily instillation,they should be administered 5mins apart. 138. In a postoperative patient,forcing fluids helps prevent constipation. 139. The nurse must administer care in accordance with standards of care established by the American Nurses Association,state regulation and facility policy. 140. The kilocalorie(kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1*C. 141. As nutrients move thru the body,they undergo ingestion,digestion,absorption,transport,cell metabolism,and excretion. 142. The body metabolizes alcohol at a fixed rate regardless of serum concentration. 143. In an alcoholic beverage,its proof reflects its percentage of alcohol multiplied by 2.for example,a 100proof beverage contains 50%alcohol. 144. A living will is a witnessed document that states a patient's desire for certain types of care and treatment,which depends on that patient's wishes and views on quality of life. 145. The nurse should flush a peripheral heparin lock every 8hrs(if it wasn't used during the previous

8hrs) and as needed with normal saline solution to maintain patency. 146. Quality assurance is a method of determining wether nursing actions and practices meet established standards. 147. The five rights of medication administration are the right patient,right medication,right dose,right route of administration,and right time. 148. The purpose of evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet desired goals. 149. Outside of the hospital setting,only the sublingual and translingual forms of nitroglycerin should be used to relieve acute anginal attacks. 1.>macular degeneration-dec.color vision >photopsia/bright flashes of light-retinal detachment >diplopia/double vision of everything-cataract/MS/TIA >Inc.IOP-tunnel vision/have to turn to Left/bump into objects *I have a drusen small rays,yellow spots in my eyes 2.>great thief disease-due to build up of Pressure IOP -glaucoma -inc.aqueous -dec.visual field -dec.peripheral vision -turn to L side,bump into objects -dec.visual acuity -halos around lights -with an eye pain -Inc.cup disc ration -pale optic disc >INc.tonometry reading >Risk for injury >DOC-Timolol Maleate -SE:hyperglycemia,palpitation >pilocarpine HCL-Pupillary constriction -dec.conjunctiva >OR-TRabeculoplasty-new pathway of fluid

>Teaching plans:-have an annual check up of IOP -instillation of drug Zalaten,travaten.lumigan -call dr.if With acute pain after OR(1*bleeding/hemorrhage) -no tight shirt collar -1*sugery-prevent build up of P* CI :ATSO4-dilates pupil antihistamine:cycloplegic drugs I:Diamox Beta adrenergic blocker -avoid sex after OR _keep head in dependent position -no sneezing,coughing,blowing of nose -no straining,vomiting Dulcolax/Colase-to soften stool -prevent valsalva -increase fluid intake,increase fiber 3.cataract-opacity of lens of the eye 2* aging process -dec.visual acuity,blurred vision -diplopia dec.color perception -diff.night driving -(-) red reflex N.D.>risk for injury OD-RE OS-LE >doc:ATSO4-midriatic drugs-paralyze ciliary -cyclopegic agent OR-Intracapsular extracting lens -extracapsular -dec.IOP Med-refrigerated >expect stinging-systemic SE >stand shower facing head away from H2O >can do light housekeeping >avoid bending,sex,straining,ball games(bending) 14.13y.old exemplify concept of death infancy-5yrs>doesnt understand,death reversible.temp.departure,sleep 5-9>death is final,can be avoided >assoc.death with aggression/violence >unrelated action causes death 9-12>death is inevitable,end of life

>mortality is understood,fear of death 12-18>fear alingering death,he is still dead .views death philosophy/religion >dangerous behavior 18-25>world religion,cultural belief 25-65>accepts death,waits for own death >death of anxiety 65-above>fear of death,prolonged illness,multiple meaning 5.Inc.Self esteem>assist pt.identify strength >past success >help pt.to be aware of (+)attitude/straight >no to competitive action >praise(+) reinforcement but if given frequently loses bearing 6.Care of DM pt>footcare instructions >no moisturizer in bet.toes >do not go bare foot-risk to injury and infection >alcohol >dries the skin >do not soak feet/cross legs >no tight stockings >no sandals with open toes,no straps bet fingers >do not treat callouses >no to hot/cold H2O >check T* of the tub bath 29.4*-35*C(95F) >no smoke,self-treatment of wound >no adhesive tapes >thin nails across with nail dipper emery board. >wear socks,buy shoes late in the day >check shoes for foreign objects >do not wear the same shoes everyday >leather shoes only >moisturizers ok but not in bet toes >lukewarm water foot wash >feet daily by mirror 7.Crisis intervention goal:assist to return to precrisis level of functioning.Assess pt.capacity to resolve problem a.Check pt's. strengths-reinforced in prob.solving b.'' " weakness to support it c.pt.support system-if available,accessible,adequate 8.Manic Bipolar-action shld.be physical,require release of pt.s energy

Action:raking leaves 9.Divine will-mexican +american culture food-beans and tortillas concept-hot and cold theory labor and delivery-40 days post decision making-shld be by entire family father-machismo religion-RC Baptism of infant-mandatory anointing of the sick amputated limb-burried death-extensive relative shld attend *dying in the hospital NO cant find its way home NO ORGAN DONATION NO EMBALMING mal ono mano milagroso-on the child's neck 10.Prozac,zoloft(SSRI) 2-3wks.take effect -educate pt. med is taking effect-inc.appetite 11."...didnt like the room and food of cousins" sharing perception-it seems that u're concerned ..... to allow more verbalization 12.History of assaultive behavior-to prevent this.. -have a contract for the pt.to adhere(alternative behavior) -make pt.assume a controlled behavior. Behavioral contract-requires detailed info acceptable behavior alternative acceptable behavior consequence of breaking the contract Nurse contribution to care 13.Question the Dr.if given to depressed pt. Ativan-anxiolytic benzodiazepine -ok dor dep.bec they have a little anxiety Paxil-antidep-given in the AM

Elavil-antidep.TCA -its bec causes drowsiness,never with MAOI or SSRI *Navane-antipsychotic (Fulexine) I to Schizophrenic with LOA -no to depressed 14.Cervical Ca-Pt is anger on the grieving process Denial-non acceptance Anger-blames others for the loss-(dr.meds) Bargaining-"if" with guilt,fear of punishment depression-grieves over what happened talkes fairly about past losses Acceptance-letting go "If the tx have started earlier..." 15.Judgement-ability to form right decision@one situation "what would you do.." Abstract-"what do u mean by this sentence?" Insight"What might be wrong in..." 16.ECT-produces grand mal seizure -given anticonvulsion succinyl choline-dec.seizure to petit mal -mim mouth twitching -dec.M pain after ECT >(+) informed consent >NPO 6-8hrs >Check VS baseline parameter >without restraint >raise bed side rails >pt.is asleep during the tx >with anesthesia-to induce sleep >turned to side to facilitate drainage to prevent aspiration *-with M twitching 17.Alzheimers>if without family history of dementia >no exact cause,no exact tx >progressive degenerative dse >"it seems that you are shocked bec.of her condition" *stages of:alarm,resistance,exhaustion

18.ADD-Risk for injury 2* to constant restlessness-hyperactivity-prone to accident >no mood swings-bipolar >not in dep. >distractibility-unable to follow instruction >low impulse control-dangerous to others not to self 19.Schizophrenia Catatonic type with flat affect,apathy waxy flexibility,mutism,mucle rigidity manipulationconfabulation-alcoholic patients self induced vomiting-bulimia(russel sign,dental erosion) 20.Great thief disease-(glaucoma)-have to turn to one side -buid up pressure with in the eye -major direction -from post chamber-pupil-ant.chamber faulty outflow-aqueous humor is blocked increase retinal muscle fibers sx:tunnel vision,Inc.IOP 11-21(normal) 21.ED(erectile dysfunction) doc:viagra-shld not be taken with nitroglycerin and alcohol SE:flushes of the face,h/a,nasal stuffiness 22.Degenerative It dse: assess risk fx:angina,obesity,trauma hx osteoarthritis-destruction of cartilages of the It.wt.bearing Etiology:ageing,obese,trauma/injury,overuse of certain jt,limited movt/stiffness,carpet installer for 30yrs,construction worker,farmer-increase mec.stress "have u ever had injury of.." 23,PCP(pneumocystic carinii pneumonia) s/sx:cough,fever,altered PCO2, ND:ineffective airway doc:pentamidine-prevent 2* infection not cure Bactrim-Inc.fluid "have you taken any source of antibiotic tx" If PCO2 55mmHG alarming Normal35-45 If Inc.inadequate ventilation 24.AIDS-low risk factor-officemate with AIDS

high risk factor-drug addict for 54yearss -BT -Multiple sex partner 25.Hodgkin's dse-cancer of-younger male female red steinburg cell lymphnode >large painless lymphnode(neck) >pruritus >nocturnal sweating >body malaise,fever *biopsy of lymphnodes *CT SCAN of chest and abdomen *CBC *BM Biopsy (bilateral) 26.Schizophrenic/alcoholic pt doesnt want to attend group thx. >"group thx may not seem helpful to u but u can help them" self help group>members who help one another to solve problems >shares common experience >use strength to gain control of their lives *>supportive and educational rather than therapeutic >based on shared experiences 27.16y/o pt.eating and sleeping poorly since brk-up "my life is ruined,better off dead" >has an attempt to suicide >check if has plan >check if has means to control it out >suicide precaution 28.Hepatitis Hepa A-fecal oral route-15-50days B-sclera is yellow >do u experience pruritus lately >pre icteric-loss of appetite icteric-jaundice post-icteric resolution but with fatiqueability ND:activity intolerance >abdominal pain,myalgia,As if urine-bile stained stool >steatorrhea 29.ulceratie colitis(bowel inflam.dse)

>rectal bleeding recently >bloody stool 15-20x in 24hr pd >abdominal cramping 30BPH-dribbling of urine 2* hyperplasia of the prostate gland >nocturia >urinary hesitancy >diminished force of stream >overflow incontinence >distention >renal insufficiency >uniform elastic non-tender PG on DRE PSAT-prostate CA OR-TURP-resectoscope prone to bleeding *PROSCAR-shrinks PG (finasteride)-Increase urinary flow -Decrease DHT-cause of PG growth SOPALMETTO extract licopene-botanical herb found in tomato TURP-high frequency cutting tool beam perineal prostatectomy-with laceration,prostate abscess -lithotomy positioning Supra pubic-with ab.incision Retro pubic-retrograde ejaculation-reflux of semen into the bladder -with milky urine *monitor for bleeding-arterial(to Or for cautery)-urinary drainage bright red,ketsup like with clots veinous-burgundy output-traction on cystoclysis-effective if drainage is red-pink may remove IFC -increase fluid -check pain with 2-3hrs PRN pain med.morphine-check RR first with N/V if given to elderly *help pt get out of bed as soon as permitted to prevent DVT(+)homan signs

*encourage pt to cough,to turn,deep breathing,incentive spirometer *no sex post prostatectomy *temp.A of mental status in elderly,immediate post-op 2* to anesthesia,unfamiliar enst. >reorient pt.frequently >keep iv lines and cath tube secure >adjust irrigation rate Goal:clear and free of clots output >check drainage tubing for external obstruction >bladder spasm,ditrophan oxybutine HCl antispasmodic-5hrs before meal to prevent bladder spasm if with obstruction>irrigate bladder manually 30-50ml NSS by large piston syringe. >notify physician if can't relieve obstruction. >" "if drainage returns to ketsup Shock-dextran-plasma expander dopamine 31.GA-inborn error of purine metabolism -pundagna dse -dusky red great toe,fever,swelling of great toe -ND:pain -bedrest with bed cradle -check UA -colchicine-anti inf -increase fluid intake -avoid organ meat,liver,anchovies -strain urine for calculi allopurinol-decrease UA synthesis -no alcohol-increase purine -avoid emotional stress 32.AGN-biproduct of strep.infxn,cellulitis,impetigo,scarlet fever,SLE if unty-renal failure >smoky cola urine >inc.BP >wt.gain >ND:fluid volume excess check crackles -base lung >uremic frost/sx -slurred speech -ataxia -tremors-unable to keep fix posture,arms extended with hyperflappy tremor of fingers >specific gravity-1.010 "Have u had superficial infxn around your face?""impetigo"

33.Dse.of many looses and chronic autoimmune that affects neurofibers of SC(myelin sheath)(lack of covering of SC) Multiple sclerosis-characterized by "come and go" sx. major types:-relapsing remitting type(develops 1-2wks)resolve over 4-8mos.thennormal -bowel disfunction-double vision-bladder disfunction -altered sex function-intention tremors-paresthesia -cognitive dse-unable to direct limit movt(dymetria) -memory loss-vitmen's sign-muscle weakness-ataxia-slurred speech-impaired judgment-dec.ability to sove-dysarthria-diff.calculation-involuntary eye movt,-dec.visual/hearing acuity CT scan,MRI,EMG-grossly ABNormal ND:activity intolerance Impaired altered urinary elimination self-care deficit related to neuro muscle impairment doc-biological response modifier avonex,bitaseron,lopaxeron(ABC) *alternative Drug REBIF-SC 3x a week immunosuppresive-novautrone-antineoplastic agent methotrexate plus novantron antispasmodic-valium-decrease muscle spasm.dantrium pain medication-zanaflex @bedside-amigo chair-wheelchair with support pt.can lean d body *CREDE MANEUVER apply manual pressure to lower abdomen over the bladder -to express urine Diplopia-eye patch alternately on to the eye. to reduce diplopia *when diplopia ends? -connective lenses may be used *complementary alternative measure -moist -mod.heat -ES of affected area -aroma therapy -guided imagery -massage connection of posture-accupuncture -exercise-increase muscle strenght

Feb

-NORMAL ADULT WHITE BLOOD CELL DIFFERENTIAL

-Neutrophils
-Bands -Eosinophils -Basophils -Lymphocytes -Monocytes 56% or 18000 7800/uL 3% or 0 700/uL 2.7% or 0 450/uL 0.3% or 0 200/uL 34% or 1000 4800/uL 4% or 0 800/uL

THERAPEUTIC SERUM MEDICATION LEVELS

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Acetaminopen (Tylenol) 10 20 ug/mLAmikacin (Amikin) 25 30 ug/mLAmitryptyline (Elavil) 120 -150 ng/mL Carbamazepine (Tegretol) 5 -12 ug/mLChloramphenicol (Chloromycetin) 10 20 ug/mLDesipramine (Norpramin) 150 -300 ng/mLDigotoxin ( Crystodigin) 15- 25 ng/mLDigoxin ( Lanoxin) 0.5 2.0 ng/mLDisopyramide (Norpase) 2 -5 ug/mLEthosuximide ( Zarontin) 40 100 ug/mLGentamycin (Garamycin) 5 10 ug/mLImipramide (Tofranil) 150 300 ug/mLLidocaine (Xylocaine) 1.5 5.0 ug/mLLithium (Lithobid) 0.5 -1.5 ug/mLMagnesium sulphate 4 -7 mg/dL Nortriptyline (Aventyl) 50 150 ng/mLPhenobarbital (Luminal) 10 30 ug/mLPhenytoin (Dilantin) 10 -20 ug/mL Primidone (Myoline) 5 20 ug/mLProcainamide (Pronestryl) 4 10 ug/mLPropranolol (Inderal) 50 100 ng/mL Quinidine (Quinalaglute, Cardioquin) 2 5ug/mLSalisylate 100 -250 ug/mLTheophylline (Aminiphylline, Theo-Dur) 10 -20 ug/mLTobramycin (Nebcin ) 5 -10 ug/mLValproic acid (depakene) 50 -100 ug/mL

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Oct

LAB VALUES

07

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ABG

Ph 7.35 - 7.45 PCO2 35 45 mm Hg HCO3 22 27 mEq/ml PO2 80 100 mm Hg SaO2 93 100% RBC Male 4.5 - 6.2 million/ cubic mm Female 4.0 - 5.5 million/cubic mm WBC 4,300 - 10,800/ cubic mm Platelets 150,000 - 350,000/ cubic mm Hgb Male 14 - 16.5 g/dL Female 12 - 15 g/ dL Hct Male 42 - 52% Female 35 - 47% PT (Warfarin/ Coumadin) Male 9.6-11.8 secs Female 9.5-11.3 secs Should be 1.5 to 2 times the Normal PTT/ APTT (Heparin) 20-36 secs / 30-45 secs Should be 1.5 to 2.5 times the Normal INR 2 3 Standard Warfarin therapy 3 4.5 High dose Warfarin therapy 2-3 Atrial fibrillation, DVT and Pulmonary embolism 2.5-3.5 Prosthetic heart valves Bleeding Time 3 - 7 mins. 8 - 15mins (Saunders)

Electrolytes K 3.5 - 5.1 mEq/ L Mg 1.6 - 2.6 mEq/ L Ph 2.7 - 4.5 mEq/ L Na 135 - 145 mEq/ L Cl 98-107 mEq/ L Ca 8.6 - 10 mg/dL Potassium Chloride IT IS NEVER GIVEN BY IV PUSH, IM OR SUB Q With a dilution of not more than 1mEq/10ml Maximum infusion rate of 5-10 mEq/ hr NEVER to exceed 20 mEq/ hr at any circumstance Blood Sugar 70 110 mg/dL Glycosylated Hgb (glycohemoglobin) less than 7.5% Good 7.6 - 8.9% Fair greater than 9% Poor Vanillylmandelic Acid (VMA) 0.7 - 6.8 mg/24 hrs GFR 125 ml/min Creatinine 0.8 - 1 mg/dL 0.6-1.3 mg/dL (Saunders) BUN 10 20 mg/dL 8-25 mg/dL (Saunders) UO Adult: 30 cc/hr and 720 cc/24 hours Pedia: 2cc/ kg/ hr AST/ ALT

5-40 IU/L Ammonia 9-33 mol/L 35-65 mcg/ dl Albumin 3 - 5 g/dL Amylase 25-151 units/ L Lipase 10-140 units/ L Bilirubin (Total) less than 1.5 mg/ dL Pulmonary capillary mean wedge pressure 4-12 mmHg Central Venous Pressure 2-6 mmHg Plasma Osmolality 280-300 mOsm/kg Serum Alcohol LEGAL .08 - .10 TOXIC! grater than 0.15 (50mg/100cc of blood) greater than 8%

Oct

22

IMMUNITY
Labels: - IMMUNE SYSTEM |

immunity.jpg

IMMUNITY bodys reaction to any foreign body that might enter our tissues
2 types: NON SPECIFIC/ CELLULAR / Innate immunity present in our body since we were born SPECIFIC Mediators (non specific) 1. MECHANICAL BARRIERS Skin (keratinized) Body secretions ( sweat, oil) Cilia (transports) Mucus (traps organism entering the Respiratory tract) 2. CHEMICAL BARRIERS Enzymes (lysozymes) Acids ( kills bacteria by denaturation) Fatty acids skin Gastric acids stomach Complement system becomes activated in cascade fashion 1,2,3.. Activated Complements System presents antigen to the bacteria; once activated, has to be removed from the body 3. INFLAMMATORY RESPONSE Presents the 5 Cardinal signs which is chemically mediated that can come from: Damaged tissues Inflammatory cells E Even from the bacteria itself 5 Cardinal signs & symptoms of inflammation:1. redness (rubor)2. swelling (tumor)3. pain (dolor)4. heat (calor)5. loss of function (functiolaesa) FXN: forms a barrier to confine infection tries to eliminate infectious agent initiates repair of damaged tissues 4 4. CELLS WBCs

a) GRANULOCYTES granulocytic leukocytes; WBCs with granules inside the cytoplasm

1. Neutrophiles plenty; 1st line of defense; 1st to respond during an infectionHALLMARK OF ACUTE INFECTION (10days)Once they leave, they cannot go back (through DIAPEDESIS)CBC - increased Neutrophiles = acute infectionDisease is current; can be bacterial HOW DO NEUTROPHILES KILL BACTERIA? Phagocytic active engulfing Degranulation release granules in the cytoplasm which contains cytotoxins that kill the bacteria 2. Eosinophiles mediate for Allergies; Hypersensitivity reaction; Anaphylactic reaction; Contains vasoactive dilators: Serotonin Histamine Bradykinin Limited phagocytic activitiesPicky eaters eat only * complement system, * Ag aggregated with Ab 3. Basophiles HEPARIN anti coagulant; lesser blood clotsb)

AGRANULOCYTES

1. Monocytes found in the blood which rids bacteria, virus, and other debrisscavengers (10 days in circulation) ACTIVE phagocytesDIAPEDESIS mode of escape w/o damageMACROPHAGES once they are out, monocytes take this form; derivativeNeutrophiles, Monocytes, Macrophages = 3 active phagocytic cells 2. Lymphocytes non phagocytic cellsHALLMARK OF CHRONIC INFECTION

a) T CELLS/ T-LYMPHOCYTES = (Cellular Immunity)T- cells mature in the Thymus glands(Lymphoid organs)Once there is an infection, they become ACTIVE EFFECTOR CELLS Natural killer cells non phagocytic cells which kills by secreting LYMPHOKINES kills ON CONTACT; has intimate contact with bacteria (sila ang Police na pumapatay sa kahit sinong magnanakaw virus,bacteria) Helper cells calls for other WBCs which circulate around the body by secreting OPSONINS (chemically attract WBC). WBC aids in the attack; (nagtatawag para may katulong ang Police sa laban) Suppressor cells the absence of these mediators will cause destruction of normal tissues (taga awat kung bugbog na ang kalaban, kung walang aawat sila-sila din ang magpapatayan kahit kakampi nila"Autoimmune disease") b) B CELLS/ B LYMPHOCYTES - mediator of specific immunity must 1st recognize specific Ag (nag draw-drawing ng cartographic sketch ng magnanakaw the 1st time na pumasok sya sa bahay) acquires Abs once exposed to microorganism (ipapakita niya yung drawing niya sa police para next time na papasok ang magnanakaw kilala na ng police at bubugbugin na niya ang magnanakaw) improves with exposure (mas madalas niya makita at mas madalas sya manakawan, mas lalo na niya nakikilala ang magnanakaw para lalong maituro at mahuli ng police ) Humoral immunity ACTIVE EFFECTOR B CELLS: MEMORY CELLS (Ang "WITNESS" na nag draw-drawing ng cartographic sketch ng magnanakaw the 1st time na pumasok sya sa bahay) PLASMA CELLS makes Abs specific to description of the memory cells; (bumubuo ng "TASK FORCE POLICE" para lumaban sa muling pagbalik, dun lang sa magnanakaw na nai-drawing ng witness - "Antigen-Antibody Response")

IMMUNIZATION is the process by which we reinforce our immune system by introducing antigens that stimulate antibody responses ACTIVE our own body participates in the production of Abs slow acting so it is introduced during our childhood; last longer than passive VACCINES made up of dead, inactivated organisms; parts of Ags; or attenuated (weakened virus or bacteria) PASSIVE giving antibodies (Abs) especially during epidemic Gives immediate protection but temporary (3-6months) Ex. Equine vaccine from horses A) NATURAL from mother to baby B) PASSIVE Abs from other sources

Jul

INBORN ERRORS OF METABOLISM

Labels: + PEDIATRIC NURSING |

03

G6PD Deficiency-Glucose 6 Phospate Dehydrogenase Sex linked recessive (X-linked kaya there is more boys than girls)(bakit boys? Remember that female contains XX genes while male contains X gene. So ibig sabihin if a female had a faulty X gene the other X gene can balance or minimize the effect. So with this principle females are always carriers and males are always affected or they are the ones that manifest the symptoms. Then if the affected male had a female daughter she will be a carrier. To see the complete list of X-linked diseases click on the link: http://philippinenurse.blogspot.com/2008/04/genetics.html) Lacks enzyme G6PD results in premature destruction of RBC if cells are exposed to oxidants, ASA, legumes and flava beans2 forms:1. Congenital Nonspherocytic Hemolytic anemia- group of congenital hemolytic anemias in which there is no abnormal hemoglobin or spherocytosis and in which there is a defect of glycolysis in the erythrocyteCharacterized by:Hemolysis, jaundice, splenomegaly and aplastic anemia2. Drug inducedPrecipitating factors:1. Illness: bacterial and viral infections2. Anti-pyretic drugs (Aspirin and phenacitin)3. sulfonamides4. Anti-malarial drugs (Quinine)5. Various medications such us Vit. K and Methylene blue6. Flava beans and Napthalene (eto ung moth balls or naptalina na nilalagay sa cabinet)Dx Procedure Rapid enzymes screening test or electropoetic RBC Peripheral blood smear- reveals presence of Heinz bodies (hindi eto ung ketchup, this are RBCs that appears to have bite off the cytoplasm, thats why they are sometimes called bite cells)Nursing Management Instruct to avoid foods such us flava beans, red wine, legumes, blueberries, soya foods, tonic water and other drugs that triggers the attack.HOMOCYSTINURIA elevated excretion of amino acid homocystiene It can lead to mental retardation (delays in reaching developmental milestones e.g., crawling, walking, sitting)REVIEW!!!Ireview natin ang mga level of Mental retardationProfound Mental retardation -- IQ 0 to 20 = thinks like an Infant. Cant be trainedSevere Mental retardation --IQ 20-35 Moderate -- IQ 35-50 = can be trained. Mental age is 2-7y/o. Pre-operational stageMild -- IQ 50-70 = Metal age is 712. Educable and can go to schoolBorderline -- IQ 70-90Normal -- IQ 90-110(Balik ulit tayo sa Homocystinuria) Inability to convert amino acid Methionine Autosomal recessive (this means the gene defect is unknowingly passed down from generation to generation. This faulty gene only emerges when two carriers have children together and pass it to their offspring. For each pregnancy of two such carriers, there is a 25% chance that the child will be born with the disease and a 50% chance the child will be a carrier for the gene defect.)Signs/Symptoms Mental retardation Downward subluxation of lens (ectopia lentis) Slender built Pectus excavatum (meron din nito ang may Down syndrome, the sternum appears sunken and the chest concaves.) Abnormal thinning and weakness of the bone (osteoporosis and kyphoscoliosis) Degeneration of the aortaLabtest:Bacterial inhibition assay for methionine Normal is 1mgCongenital Adrenal Hyperplasia- A condition where the adrenal does not produce enough cosrtisol and aldosterone but there is an excessive production of androgens.- This is also autosomal recessiveREVIEW!!!Hormones of the Adrenal CortexAng ating code; SSSSalt- Mineralocorticoids (mainly aldosterone- responsible for Na reabsorption and K excretion)Sugar-Glucocorticoids (mainly cortisol, responsible for glycolisis and gluconeogenesis) Sex- Sex hormonesOversecretion- Cushings syndromeUndersecretion- Addisons diseaseAssessment:In female Large clitoris, closed labial folds Early appearance of pubic hair Deep masculine voice No breast development and menstruation Excessive hair in face (in short nagiging lalaki ung babae)In male:at birth- normal6 months signs of sexual precocity3-4 have pubic hair and enlarged penis, scrotum and prostate but testes is not descendedsterility Labtest:High 17-hydroxyprogesteroneLow serum NaHigh serum K Treatment:CorticosteroidDiet: High sodium, low potassiumPHENYLKETONURIA(PKU) deficiency of liver enzymes (PHT)Phenylalaninehydroxylase Transferase liver enzyme that converts CHON to amino acid9 amino acids:valine isolensine tryptophaselysine phenylalanine Thyronine decrease malanine production1.) fair complexion2.) blond hair3.) blue eyesThyroxine decrease basal metabolism- accumulation of Phenyl Pyruvic acid4.) Atopic dermatitis5.) musty / mousy odor urine6.) seizure mental retardationLabTestGUTHRIE TEST specimen blood- preparation increase CHON intake- test if CHON will convert to amino acidspecimen and urinemixed with pheric chloride, presence of green spots at diaper a sign of PKU DIET:Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanutsGive Lofenalacmilk with synthetic proteinGALACTOSEMIA deficiency of liver enzyme- GUPT Galactose Urovil Phosphatetranferase- Converts galactose to phosphate tranferace glucoseGalactose will destroy brain cells if untreated death within 3 daysDx:Beutler test get blood -done after 1st feedingpresence of glucose in blood sign of galactosemiagalactose free diet lifetime (4life!)neutramigen milk formulaCELIAC DISEASE aka gluten

e enteropathyCommon

gluten

food:Intolerance to food with browB- barleyR- ryeO- oatW- wheat

Pathophysiology:Gluten glutamine ( normal absorption) - Gliadin ( toxic to epithelial cells of villi of intestines, effects is malabsorption syndrome)Malabsorption- Fats = steatorrhea- malnutrition = edema and- decrease in vitamin D = decrease in calcium = osteomalicia- decrease in vitamin K = inadequate blood coagulation = bleedingdecrease in iron folic acid = anemiaEarly Sx:1. diarrhea failure to gain wt ff diarrheal episodes2. constipation3. vomitingLate Sx:abd pain protruberant abd even if with muscle wastingsteatorrhea Celiac Crisis- exaggerated vomiting with bowel inflammationDx:lab studies stool analysisserum antiglyadin confirmatory of diseaseMgt: M gluten free diet lifetimeall BROW not allowedrice & corn - OK!vitamin supplementsmineral supplementssteroids

Jul

INBORN ERRORS OF METABOLISM

Labels: + PEDIATRIC NURSING |
G6PD Deficiency-Glucose 6 Phospate Dehydrogenase Sex linked recessive (X-linked kaya there is more boys than girls)(bakit boys? Remember that female contains XX genes while male contains X gene. So ibig sabihin if a female had a faulty X gene the other X gene can balance or minimize the effect. So with this principle females are always carriers and males are always affected or they are the ones that manifest the symptoms. Then if the affected male had a female daughter she will be a carrier. To see the complete list of X-linked diseases click on the link: http://philippinenurse.blogspot.com/2008/04/genetics.html) Lacks enzyme G6PD results in premature destruction of RBC if cells are exposed to oxidants, ASA, legumes and flava beans2 forms:1. Congenital Nonspherocytic Hemolytic anemia- group of congenital hemolytic anemias in which there is no abnormal hemoglobin or spherocytosis and in which there is a defect of glycolysis in the erythrocyteCharacterized by:Hemolysis, jaundice, splenomegaly and aplastic anemia2. Drug inducedPrecipitating factors:1. Illness: bacterial and viral infections2. Anti-pyretic drugs (Aspirin and phenacitin)3. sulfonamides4. Anti-malarial drugs (Quinine)5. Various medications such us Vit. K and Methylene blue6. Flava beans and Napthalene (eto ung moth balls or naptalina na nilalagay sa cabinet)Dx Procedure Rapid enzymes screening test or electropoetic RBC Peripheral blood smear- reveals presence of Heinz bodies (hindi eto ung ketchup, this are RBCs that appears to have bite off the cytoplasm, thats why they are sometimes called bite cells)Nursing Management Instruct to avoid foods such us flava beans, red wine, legumes, blueberries, soya foods, tonic water and other drugs that triggers the attack.HOMOCYSTINURIA elevated excretion of amino acid homocystiene It can lead to mental retardation (delays in reaching developmental milestones e.g., crawling, walking, sitting)REVIEW!!!Ireview natin ang mga level of Mental retardationProfound Mental retardation -- IQ 0 to 20 = thinks like an Infant. Cant be trainedSevere Mental retardation --IQ 20-35 Moderate -- IQ 35-50 = can be trained. Mental age is 2-7y/o. Pre-operational stageMild -- IQ 50-70 = Metal age is 712. Educable and can go to schoolBorderline -- IQ 70-90Normal -- IQ 90-110(Balik ulit tayo sa Homocystinuria) Inability to convert amino acid Methionine Autosomal recessive (this means the gene defect is unknowingly passed down from generation to generation. This faulty gene only emerges when two carriers have children together and pass it to their offspring. For each pregnancy of two such carriers, there is a 25% chance that the child will be born with the disease and a 50% chance the child will be a carrier for the gene defect.)Signs/Symptoms Mental retardation Downward subluxation of lens (ectopia lentis) Slender built Pectus excavatum (meron din nito ang may Down syndrome, the sternum appears sunken and the chest concaves.) Abnormal thinning and weakness of the bone (osteoporosis and kyphoscoliosis) Degeneration of the aortaLabtest:Bacterial inhibition assay for methionine Normal is 1mgCongenital Adrenal Hyperplasia- A condition where the adrenal does not produce enough cosrtisol and aldosterone but there is an excessive production of androgens.- This is also autosomal recessiveREVIEW!!!Hormones of the Adrenal CortexAng ating code; SSSSalt- Mineralocorticoids (mainly aldosterone- responsible for Na reabsorption and K excretion)Sugar-Glucocorticoids (mainly cortisol, responsible for glycolisis and gluconeogenesis)

03

Sex- Sex hormonesOversecretion- Cushings syndromeUndersecretion- Addisons diseaseAssessment:In female Large clitoris, closed labial folds Early appearance of pubic hair Deep masculine voice No breast development and menstruation Excessive hair in face (in short nagiging lalaki ung babae)In male:at birth- normal6 months signs of sexual precocity3-4 have pubic hair and enlarged penis, scrotum and prostate but testes is not descendedsterility Labtest:High 17-hydroxyprogesteroneLow serum NaHigh serum K Treatment:CorticosteroidDiet: High sodium, low potassiumPHENYLKETONURIA(PKU) deficiency of liver enzymes (PHT)Phenylalaninehydroxylase Transferase liver enzyme that converts CHON to amino acid9 amino acids:valine isolensine tryptophaselysine phenylalanine Thyronine decrease malanine production1.) fair complexion2.) blond hair3.) blue eyesThyroxine decrease basal metabolism- accumulation of Phenyl Pyruvic acid4.) Atopic dermatitis5.) musty / mousy odor urine6.) seizure mental retardationLabTestGUTHRIE TEST specimen blood- preparation increase CHON intake- test if CHON will convert to amino acidspecimen and urinemixed with pheric chloride, presence of green spots at diaper a sign of PKU DIET:Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanutsGive Lofenalacmilk with synthetic proteinGALACTOSEMIA deficiency of liver enzyme- GUPT Galactose Urovil Phosphatetranferase- Converts galactose to phosphate tranferace glucoseGalactose will destroy brain cells if untreated death within 3 daysDx:Beutler test get blood -done after 1st feedingpresence of glucose in blood sign of galactosemiagalactose free diet lifetime (4life!)neutramigen milk formulaCELIAC DISEASE aka gluten e enteropathyCommon gluten food:Intolerance to food with browB- barleyR- ryeO- oatW- wheat Pathophysiology:Gluten glutamine ( normal absorption) - Gliadin ( toxic to epithelial cells of villi of intestines, effects is malabsorption syndrome)Malabsorption- Fats = steatorrhea- malnutrition = edema and- decrease in vitamin D = decrease in calcium = osteomalicia- decrease in vitamin K = inadequate blood coagulation = bleedingdecrease in iron folic acid = anemiaEarly Sx:1. diarrhea failure to gain wt ff diarrheal episodes2. constipation3. vomitingLate Sx:abd pain protruberant abd even if with muscle wastingsteatorrhea Celiac Crisis- exaggerated vomiting with bowel inflammationDx:lab studies stool analysisserum antiglyadin confirmatory of diseaseMgt: M gluten free diet lifetimeall BROW not allowedrice & corn - OK!vitamin supplementsmineral supplementssteroids

NEMONICS FOR NURSES PART 07

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HYPERNATREMIA FRIED SALT F - Fever (low), flushed skin R - Restless (irritable) I - Increased fluid retention & increased BP E - Edema (peripheral and pitting) D - Decreased urinary output, dry mouth SALT S - Skin flushed A - Agitation L - Low-grade fever T - Thirst HYPERKALEMIA - Signs & Symptoms MURDER M - Muscle weakness U - Urine, oliguria, anuria R - Respiratory distress

D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid) HYPERKALEMIA - Causes MACHINE M - Medications - ACE inhibitors, NSAIDS A - Acidosis - Metabolic and respiratory C - Cellular destruction - Burns, traumatic injury H - Hypoaldosteronism/ hemolysis I - Intake - Excessive N - Nephrons, renal failure E - Excretion - Impaired HYPOCALCEMIA CATS C - Convulsions A - Arrhythmias T - Tetany S - Spasms and stridor BLEEDING - S/Sx BEEP B - Bleeding gums E - Ecchymoses (bruises) E - Epistaxis (nosebleed) P - Petechiae (tiny purplish spots) RESPIRATORY DEPRESSION - inducing drugs STOP breathing S - Sedatives and hypnotics T - Trimethoprim O - Opiates P - Polymyxins PNEUMOTHORAX - S/Sx P-THORAX P - Pleuretic pain T - Trachea deviation H - Hyperresonance O - Onset sudden R - Reduced breath sounds (& dypsnea) A - Absent fremitus X - X-ray shows collapse PNEUMONIA - risk factors INSPIRATION I - Immunosuppression N - Neoplasia

S - Secretion retention P - Pulmonary oedema I - Impaired alveolar macrophages R - RTI (prior) A - Antibiotics & cytotoxics T - Tracheal instrumentation I - IV dug abuse O - Other (general debility, immobility) N - Neurologic impairment of cough reflex, (eg NMJ disorders) CROUP - S/Sx SSS S - Stridor S - Subglottic swelling S - Seal-bark cough SHORTNESS OF BREATH - Causes AAAA PPPP A - Airway obstruction A - Angina A - Anxiety A - Asthma P - Pneumonia P - Pneumothorax P - Pulmonary Edema P - Pulmonary Embolus

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16

MNEMONICS FOR NURSES PART 06

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CARDIAC VALVES "TRI before you BI": Tricuspid valve is located in left heart and Bicuspid valve is located in right heart. Blood flows through the tricuspid before bicuspid.

FEMORAL HERNIA FEMoral hernias are more common in FEMales.

"TRY PULLING MY AORTA": Tricuspid Pulmonary Mitral Aorta

PLACENTA-CROSSING SUBSTANCES "Want My Hot Dog": Wastes Antibodies Nutrients Teratogens Microorganisms Hormones/ HIV Drugs

EMERGENCY MEDICINE

ACTIVATED CHARCOAL: CONTRAINDICATIONS CHEMICAL CamP: Cyanide

Hydrocarbons Ethanol Metals Iron Caustics Airway unprotected Lithium CAMphor Potassium

IPECAC: CONTRAINDICATIONS 4 C's: Comatose Convulsing Corrosive hydroCarbon

ATRIAL FIBRILLATION: CAUSES OF NEW ONSET THE ATRIAL FIBS: Thyroid Hypothermia Embolism (P.E.) Alcohol Trauma (cardiac contusion) Recent surgery (post CABG)

Ischemia Atrial enlargement Lone or idiopathic Fever, anemia, high-output states Infarct Bad valves (mitral stenosis) Stimulants (cocaine, theo, amphet, caffeine)

ENDOTRACHEAL TUBE DELIVERABLE DRUGS O NAVEL: Oxygen Naloxone Atropine Ventolin (albuterol) Epinephrine Lidocaine

MALARIA: COMPLICATIONS OF FALCIPARUM MALARIA CHAPLIN: Cerebral malaria/ Coma Hypoglycemia Anaemia Pulmonary edema Lactic acidosis

Infections Necrois of renal tubules (ATN)

MI: IMMEDIATE TREATMENT DOGASH: Diamorphine Oxygen GTN spray Asprin 300mg Streptokinase Heparin

PAIN HISTORY CHECKLIST OLDER SAAB: Onset Location Description (what does it feel like) Exacerbating factors Radiation Severity Associated symptoms Alleviating factors Before (ever experience this before)

SHOCK: SIGNS AND SYMPTOMS

TV SPARC CUBE: Thirst Vomiting Sweating Pulse weak Anxious Respirations shallow/rapid Cool Cyanotic Unconscious BP low Eyes blank

SUBARACHNOID HEMORRHAGE (SAH) CAUSES BATS: Berry aneurysm Arteriovenous malformation/ Adult polycystic kidney disease Trauma (eg being struck with baseball bat) Stroke

VENTRICULAR FIBRILLATION: TREATMENT "Shock, Shock, Shock, Everybody Shock, Little Shock, Big Shock, Momma Shock, Poppa Shock": Shock= Defibrillate Everybody= Epinephine

Little= Lidocaine Big= Bretylium Momma= MgSO4 Poppa= Pocainamide

VFIB/VTACH DRUGS USED ACCORDING TO ACLS "Every Little Boy Must Pray": Epinephrine Lidocaine Bretylium Magsulfate Procainamide

DIABETIC KETOACIDOSIS MANAGEMENT KING UFC: K+ (potassium) Insulin (5u/hour. Note: sliding scale no longer recommended in the UK) Nasogastic tube (if patient comatose) Glucose (once serum levels drop to 12) Urea (check it) Fluids (crytalloids) Creatinine (check it)/ Catheterize

NEUROLOGICAL FOCAL DEFICITS 10 S's:

Sugar (hypo, hyper) Stroke Seizure (Todd's paralysis) Subdural hematoma Subarachnoid hemorrhage Space occupying lesion (tumor, avm, aneurysm, abscess) Spinal cord syndromes Somatoform (conversion reaction) Sclerosis (MS) Some migraines

COMA: CONDITIONS TO EXCLUDE AS CAUSE MIDAS: Meningitis Intoxication Diabetes Air (respiratory failure) Subdural/ Subarachnoid hemorrhage

MALIGNANT HYPERTHERMIA TREATMENT "Some Hot Dude Better Give Iced Fluids Fast!" (Hot dude = hypothermia): Stop triggering agents Hyperventilate/ Hundred percent oxygen Dantrolene (2.5mg/kg)

Bicarbonate Glucose and insulin IV Fluids and cooling blanket Fluid output monitoring/ Furosemide/ Fast heart [tachycardia]

RESUSCITATION: BASIC STEPS ABCDE: Airway Breathing Circulation Drugs Environment

RLQ PAIN: DIFFERENTIAL APPENDICITIS: Appendicitis/ Abscess PID/ Period Pancreatitis Ectopic/ Endometriosis Neoplasia Diverticulitis Intussusception Crohns Disease/ Cyst (ovarian) IBD Torsion (ovary)

Irritable Bowel Syndrome Stones

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15

MNEMONICS FOR NURSES PART 05

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Acid-base"ROME" (Respiratory Opposite, Metabolic Equal) Acidosis Respiratory (opposite): pH Pco2 Metabolic(equal): pH HCO3

Alkalosis Respiratory (opposite): pH Pco2 Metabolic(equal): pH HCO3

Alcohol withdrawal: clinical features"HITS" Hallucinations (visual, tactile) Increased vital signs and insomnia Tremens delirium tremens (potentially lethal) Shakes/ Sweats/ Seizures/ Stomach pains (nausea, vomiting)

Angina: precipitating factors"4E's" Eating Emotion Exertion (Exercise) Extreme Temperatures (Hot or Cold weather)

Anorexia nervosa: clinical features"ANOREXIC" Adolescent women/ Amenorrhea NGT alimentation (most severe cases) Obsession with losing weight/ becoming fat though underweight Refusal to eat (5% die) Electrolyte abnormalities (e.g., K+, cardiac arrhythmia) X - ercise Intelligence often above average/ Induced vomiting Cathartic use (and diuretic abuse)

Appendicitis: assessment"PAINS" Pain (RLQ) Anorexia Increased temperature, WBC (15,00020,000) Nausea Signs (McBurney's, Psoas)

Neurovascular Occlusion: symptoms "6 P's"

Pain Pale Pulseless Paresthesia Poikilothermic Paralysis

Blood glucose (rhyme) Symptom Implication Cold and clammy . . . give hard candy Hot and dry . . . glucose is high

Blood vessels in umbilical cord"AVA" (2 arteries and 1 vein) Artery Vein Artery

Cholecystitis: risk factors"5F's" Female Fat Forty Fertile Fair

Cleft lip: nursing care plan (postoperative)"CLEFT LIP" Crying, minimize Logan bow Elbow restraints Feed with Brecht feeder Teach feeding techniques; two months of age (average age at repair) Liquid (sterile water), rinse after feeding Impaired feeding (no sucking) Positionnever on abdomen

Cognitive disorders: assessment of difficulties"JOCAM" Judgment Orientation Confabulation Affect Memory

Coma: causes"A-E-I-O-U TIPS" Alcohol, acidosis (hyperglycemic coma) Epilepsy (also electrolyte abnormality, endocrine problem) Insulin (hypoglycemic shock) Overdose (or poisoning) Uremia and other renal problems Trauma; temperature abnormalities (hypothermia, heat stroke) Infection (e.g., meningitis)

Psychogenic ("hysterical coma") Stroke or space-occupying lesions in the cranium

Complication of severe preeclampsia"HELLP" syndrome Hemolysis Elevated Liver enzymes Low Platelet count

Cushing's syndrome: symptoms"3S's" Sugar (hyperglycemia) Salt (hypernatremia) Sex (excess androgens)

Diabetes: signs and symptoms"3P's," Polydipsia (very thirsty) Polyphagia (very hungry) Polyuria (urinary frequency)

Diet: low cholesterolavoid the "3C's" Cake Cookies Cream (dairy, e.g., milk, ice cream)

Dystocia: etiology"3P's"

Power Passageway Passenger

Dystocia: general aspects (maternal)"3P's" Psych Placenta Position

Episiotomy assessment"REEDA" Redness Edema Ecchymosis Discharge Approximation of skin

Eye medications Mydriatic = dilated pupils Miotic = tiny (constricted) pupils

Hypertension: complications"4 C's" CAD (coronary artery disease) CHF (congestive heart failure) CRF (chronic renal failure) CVA (cardiovascular accident; now called brain attack or stroke)

Hypertension: nursing care plan "I-TIRED" Intake and output (urine) Take blood pressure Ischemia attack, transient (watch for TIAs) Respiration, pulse Electrolytes Daily weight

Hypoglycemia: signs and symptoms"DIRE" Diaphoresis Increased pulse Restless Extra hungry

Infections during pregnancy"TORCH" Toxoplasmosis Other (hepatitis B, syphilis, group B beta strep) Rubella Cytomegalovirus Herpes simplex virus

IUD: potential problems with use"PAINS" Period (menstrual: late, spotting, bleeding)

Abdominal pain, dyspareunia Infection (abnormal vaginal discharge) Not feeling well, fever or chills String missing

Manipulation: nursing planpromote the "3C's" Cooperation Compromise Collaboration

Medication administration"six rights" RIGHT medication RIGHT dosage RIGHT route RIGHT time RIGHT client RIGHT technique

Melanoma characteristics"ABCD" Asymmetry Border Color Diameter

Mental retardation: nursing care plan"3R's"

Regularity (provide routine and structure) Reward (positive reinforcement) Redundancy (repeat)

Myocardial infarction: treatment"MONA" Monitor/ Morphine Oxygen Nitroglycerin Aspirin

Newborn assessment components"APGAR" Appearance Pulse Grimace Activity Respiratory effort

Obstetric (maternity) history"GTPAL" Gravida Term Preterm Abortions (SAB, TAB) Living children

Oral contraceptives: signs of potential problems"ACHES"

Abdominal pain (possible liver or gallbladder problem) Chest pain or shortness of breath (possible pulmonary embolus) Headache (possible hypertension, brain attack) Eye problems (possible hypertension or vascular accident) Severe leg pain (possible thromboembolic process)

Pain: assessment"PQRST" What Provokes the pain? What is the Quality of the pain? Does the pain Radiate? What is the Severity of the pain? What is the Timing of the pain?

Pain: management"ABCs" Ask about the pain Believe when clients say they have pain Choiceslet clients know their choices Deliver what you can, when you said you would Empower/Enable clients' control over pain

Postoperative complications: order"4W's" Wind (pulmonary) Wound Water (urinary tract infection)

Walk (thrombophlebitis)

Preterm infant: anticipated problems"TRIES" Temperature regulation (poor) Resistance to infections (poor) Immature liver Elimination problems (necrotizing enterocolitis [NEC]) Sensory-perceptual functions (retinopathy of prematurity [ROP])

Psychotropic medications: common antidepressives (tricyclics)"VENT" Vivactil Elavil Norpramin Tofranil

Schizophrenia: primary symptoms"4A's" Affect Ambivalence Associative looseness Autism

Sprain: nursing care plan"RICE" Rest Ice Compression

Elevation

Stool assessment"ACCT" Amount Color Consistency Timing

Tracheoesophageal fistula: assessment"3Cs" Coughing Choking Cyanosis

Traction: nursing care plan"TRACTION" Trapeze bar overhead to raise and lower upper body Requires free-hanging weights; body alignment Analgesia for pain, prn Circulation (check color and pulse) Temperature (check extremity) Infection prevention Output (monitor) Nutrition (alteration related to immobility)

Transient ischemic attacks: assessment"3Ts"

Temporary unilateral visual impairment Transient paralysis (one-sided) Tinnitus = vertigo

Trauma care: complications"TRAUMA" Thromboembolism; Tissue perfusion, altered Respiration, altered Anxiety related to pain and prognosis Urinary elimination, altered Mobility impaired Alterations in sensory-perceptual functions and skin integrity (infections)

Wernicke-Korsakoff syndrome (alcohol-associated neurological disorder)"COAT RACK"

Wernicke's encephalopathy (acute phase) clinical features: Confusion Ophthalmoplegia Ataxia Thiamine is an important aspect of Tx

Korsakoff's psychosis (chronic phase) characteristic findings: Retrograde amnesia (recall of some old memories) Anterograde amnesia (ability to form new memories)

Confabulation Korsakoff's psychosis

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14

MNEMONICS FOR NURSES PART 04

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SIGNS OF CANCER
Change in bowel /bladder habits A sore that doesnt heal Unusual bleeding/ Discharge Thickening of lump breast or elsewhere Indigestion/ Dysphagia Obvious change in wart/ mole Nagging cough/ hoarseness

Unexplained anemia Sudden weight loss

FOCUS OF PATIENT CARE IN CLIENTS WITH CANCER

Chemotherapy Assess body image disturbance (related to alopecia) Nutritional needs when N/V present Comfort from pain Effective response to Tx? (Evaluate) Rest (for patient and family)

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13

MNEMONICS FOR NURSES PART 03

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Basic MI management - "BOOMAR" Bed rest Oxygen Opiate Monitoring Anticoagulation Reduce clot size

To Remember Immunoglobulins - "GAMED" IgG

IgA IgM IgE IgD

Location of the heart valve from right to left - "A Permanently Temperamental Man" Aortic Pulmonary Tricuspid Mitral

"Cut C4, breathe no more" The 3rd, 4th and 5th cervical spinal nerves innervate the diaphragm.

Types of Joint movements - "FEEDPIPE CARDSHARP" Flexion Extension Eversion Dorsiflexion Pronation Inversion Plantarflexion Elevation Circumduction

Abduction Rotation Depression Supination Hyperextension Adduction Retraction Protraction

Cranial Nerves - "Oh Ohh Ohhh To Try And Fit A Gold Velvet So Heavenly" Olfactory CN I Optic CN II Occulomotor CN III Trochlear CN IV Trigeminal CN V Abducens CN VI Facial CN VII Auditory CN VIII Glasopharyngeal CN IX Vagus CN X Spinal/Accessory CN XI Hypoglossal CN XII

"Point and Shoot!" For remembering that Parasympathetics are involved with erection and Sympathetics with ejaculation.

Layers of the scalp - "SCALP" Skin Connective tissue Aponeurosis Loose areolar tissue Pericranium

Carpal bones of the hand (lateral to medial) - "She Looks Too Proud, Try To Chase Her" Proximal row: Scaphoid Lunate Triquetrum Pisiform Distal row: Trapezium Trapezoid Capitate Hamate

Viruses causing diarrhea - "ACNE CAR" Adeno virus

Corana virus Norwak virus Entero virus Calci virus Astro virus Rota virus

The Krebs cycle - "Can I Actually See Some Filipina Mothers" Citrate Isocitrate alpha Ketoglutarate Succinyl CoA Succinate Fumarate Malate Oxaloacetate

Stages of mitosis/meiosis including interphase as a phase - "In Philippines, Men Are Talented" Interphase Prophase Metaphase Anaphase Telophase

Order of prevalence of White Blood Cells, most prevalent to least - "Never Let Monkeys Eat Bananas" Neutrophils Lymphocytes Monocytes Eosinophils Basophils

10 essential amino acids - "PVT. TIM HALL" Phenylalanine Valine Tryptophan Threonine Isoleucine Metheonine Histidine(semi-essential) Arginine(semi-essential) Leucine Lysine

Uses of Chloroquine (other than malaria) - "RED LIP" Rheumatoid arthritis Extra intestinal amoebiasis

Discoid lupus erythematosus Lepra reaction Infectious mononucleosis Photogenic reactions

Bronchodilators - "TO A SIS" Terbutaline Orciprenaline Adrenaline Salbutamol Isoprenaline Salmeterol

Signs of cor pulmonale - "Please Read His Text" Peripheral edema Raised JVP Hepatomegaly Tricuspid incompetence

Portal hypertension features - "ABCDE" Ascites Bleeding (hematemesis, piles) Caput medusae

Diminished liver Enlarged spleen

Key questions needed in an emergency history taking situation - "AMPLE" Allergies Medication Past medical history Last meal Events and environment related to injury

Malignancies that metastisize to bone - "Laging Panalo Kung Taga Bulacan" Lung Prostat Kidney Thyroid Breast

Six "S" in Scarlet Fever Streptococci causal organism Sorethroat Swollen tonsils Strawberry tongue Sandpaper rash

miliarySudamina vesicles over hands, feet, abdomen

Signs of anti-cholinergic crisis - "SLUD" Salivation Lacrimation Urination Defecation

Causes of huge spleen - "3M's" Myelofibrosis Malaria Myelogenous leukemia

Cardinal Symptoms of Parkinson's Disease - "TRAP" Tremor Rigidity Akinesia and bradykinesia Postural Instability

Days of appearance of rashesVaricella(chickenpox) - "Very Sick Patients Must Take Double Exercise" 1st dayScarlet fever 2nd dayPox(smallpox) 3rd dayMumps

4th dayTyphus 5th dayDengue 6th dayEnteric fever(typhoid)

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12

MNEMONICS FOR NURSES PART 02

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SHOCK HYPOTACHYTACHYHYPOTENSIONTACHYPNEATACHYCARDIA I INCREASE ICP HYPERBRADYBRADY CUSHINGS TRIAD:HYPERTENSION (WIDE PULSE PRESSURE)BRADYCARDIABRADYPNEAHYPOGLYCEMIA TREMORS, H TACHYCARDIAIRRITABILITYRESTLESSNESSEXTREMEDIAPHORESISEARLY SIGNS OF HYPOXIARESTLESSNESS AGITATIONTACHYCARDIALATE SIGNS OF HYPOXIABRADYCARDIAEXTREME RESTLESSNESSDYSPNEACYANOSIS C CONGESTIVE HEART FAILURE DIGOXINMORPHINEAMINOPHYLLINEDOPAMINEDIURETICSO2GASSES MONITOR (ABG)MG SO4 TOXICITYBP DECREASEURINE OUTPUT DECREASERESPIRATORY RATE DECREASEPATELLAR REFLEX M ABSENTSICKLE T TO CELL DISEASEHYDRATIONOXYGENATIONPAININFECTIONAVOID HIGH PLACES PREGNANCY INDUCED HYPERTENSIONHEMOLYSISELEVATED LIVER ENZYMESLOWPLATELETS SYMPTOMS AND TOXICITY GI DIGOXINVOMITTINGANOREXIANAUSEADIARRHEAABDOMINAL PAIN FRACTUREPRESSURERESTICE COMPRESSIONELEVATIONTETRALOGY OF FALLOTDISPLACED AORTARIGHT VENTRICULAR HYPERTROPHYOPENING INTO THE SEPTUM (VSD)PULMONARY STENOSISHYPOKALEMIA SKELETAL MUSCLE WEAKNESSU-WAVE ON ECG H CONSTIPATIONTOXICITY TO DIGOXINIRREGULAR WEAK PULSEOTOSTASISNUMBNESS PARESTHESIAPAIN CHECKPAIN A ASSESSMENT PROVOCATIONQUALITYRADIATION, RELIEFSEVERITYTIME HYPERCOAGUABILITYABDOMINAL AORTIC ANEURISM NEUROVASCULAR

PULSELESSNESSPARESTHESIAPARALYSISPALLORVIRCHOWS TRIAD IN DVTVENUS STASISDAMAGE TO VESSELS V (4A)ASSYMPTOMATICABDOMINAL MASSABDOMINAL PULSEACHES LOW BACKANTI TB DRUGS AND SIDE EFFECTS RIFAMPICIN RED-ORANGE URINEISONIAZID A PERIPHERAL NEURITISPYRAZINAMIDE INCREASE URIC ACIDETHAMBUTOL EYE PROBLEMSSTREPTOMYCIN OTOTOXIC

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MNEMONICS FOR NURSES PART 01

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11

glass_with_straw.gif

USE STRAW BECAUSE THESE DRUGS STAIN THE TEETH

LI-

LUGOL'S SOLUTION

IRON

N - NITROFURANTOIN TTETRACYCLINE

LR6 - LATERAL RECTUS : CN6

SO4 - SUPERIOR OBLIQUE : CN4

ALL3 - ALL THE REST : CN3

RADIATION TX VIA:

MUSTARD

ESTROGEN

NITROGEN

STEROIDS

ANTIBIOTICS

DILUTE DECREASE OSMOLALITY

PEDIATRIC NURSING
I . A. GROWTH AND DEVELOPMENT

Definition of Terms: Growth increase in physical size of a structure or whole quantitative structure

2 Parameters of Growth 1. Weight - Most sensitive especially in low birth weight - Weight doubles by 6 months - Triples by 1 year - Quadruples by 2 year 2. Height - Increase by 1 inch per month during first 6 months - And inch per month from 7 12 months

Development increase in the skills or capacity to function qualitative change

How to Measure Development? 1. by simply observing a child doing specific task 2. by noting parents description of the childs progress 3. by DDST (Denver Developmental Screening Test), MMDST (Metro Manila Developmental Screening Test) 4 Main Rated Categories 1. Language for communication 2. Personal Social 3. Fine Motor Adaptive pre tensile ability (ability to use hand movement) 4. Gross Motor Skills ability to use large body movement

Maturation synonymous with development (readiness)

Cognitive Development is the ability to learn and understand from experience, to acquire and retain knowledge to respond to a new situation and to solve problems

I . B. BASIC DIVISION OF LIFE 1. Pre-Natal begins at conception and ends at birth 2. Period of Infancy - Neonatal (first 28 days or first 4 weeks) - Formal Infancy (from 29th day to 1 year) 3. Early Childhood - Toddler (1 3 years) - Pre-School (4 6 years) 4. Middle Childhood school age 7 12 years 5. Period of Adolescent - Pre-Adolescent/Late childhood (11 13 years) - Adolescent (12 21 years)

I . C. PRINCIPLE OF GROWTH AND DEVELOPMENT

1. Growth and Development is a continuous process that begins from conception and ends with death. Principle: womb to tomb 2. Not all parts of the body grow at the same time or at the same rate. Patterns of Growth and Development 1. Renal, digestive, circulatory, Musculo-skeletal (childhood) 2. Neurologic Tissue - Grows rapidly during 1 2 years of life

- Brain (achieve to its adult proportion by 5 years) - Central Nervous System - SC 3. Lymphatic System - Lymph nodes, Spleen, Thymus - Grows rapidly during infancy and childhood (to provide protection against infxn) - Tonsils is achieved in 5 years 4. Reproductive Organ grows rapidly during puberty

3. Each child is unique

2 Primary factors affecting Growth and Development A. Heredity Race Intelligence Sex Nationality B. Environment Quality of nutrition Socio-Economic status Health Ordinal position in family Parent-Child relationship

4. Growth and Development occurs in a regular direction reflecting a definite and predictable patterns or trends A. Directional Trends occurs in a regular direction reflecting the development of neuromuscular functions: these apply to physical, mental, social and emotional developments and includes: a. Cephalo - caudal (head to tail)

- It occurs along bodies long axis in which control over head, mouth and eye movements and precedes control over upper body torso and legs. b. Proximo distal (centro distal) - Progressing from the center of the body to the extremeties c. Symmetrical - Each side of the body develop on the same direction at the same time at the same rate d. Mass specific (differentiation) - In which the child learns from simple operations before complex function or move from a broad general pattern of behavior to a more refined pattern. B. Sequential involves a predictable sequence of growth and development to which the child normally passes. a. Locomotion b. Language and Social skills

C. Secular refers to the worldwide trend of maturing earlier and growing larger as compared to succeeding generations. 5. Behavior is a most comprehensive indicator of developmental status 6. Play is the universal language of a child 7. A great deal of skill and behavior is leaned by practice 8. There is an optimum time for initiation of experience or learning 9. Neonatal reflexes must be lost first before development can proceed Persistent Primitive Infantile Reflex (suspect Cerebral Palsy)

I . D. THEORIES OF DEVELOPMENT

Development Tasks is a skill or growth responsibility arising at a particular time in the individuals life. The successful achievement of which will provide a foundation for the accomplishments of the future tasks. THEORISTS 1. Sigmund Freud (1856-1939) an Austrian neurologist, Founder of psychoanalysis

PHASE OF PSYCHOSEXUAL THEORY a. Oral Phase (0 18 months) - Mouth is the site of gratification - Biting, crying or sucking for enjoyment and to release tension - Provide oral stimulation even the baby is NPO, offer pacifier - Never discourage thumb sucking

b. Anal Phase (18 months 3 years) - Anus - May show toilet training - Elimination, defecation - Principle of - Holding on (child wins, hard headed, anti social and stubborn) - Letting Go - Mother wins (kind, perfectionist, obedient, obsessive compulsive)

c. Phallic Phase (4 6 years) - Genitals - May show exhibitionism - Accept the child fondling his own genital area as the normal area of exploration - Answer the childs question early

d. Latent Phase (7 12 years) - Period of suppression - Because there is no obvious development - Childs energy or libido is diverted to more concrete type of thinking - Help child achieve positive experiences

e. Genital Phase (12 18 years) - Achieved sexual maturity - Learn to establish satisfactory relationship with opposite sex - Give an opportunity to relate with opposite sex

2. Eric Erickson - Trained in psychoanalysis theory - Transits the importance of culture and society to their development of ones society STAGES OF PSYCHOSOCIAL THEORY Trust vs. Mistrust (0 18 months) - Trust is the foundation of all psychosocial task - To give and to receive is the psychosocial theme - How trust is developed: - Satisfy needs on time - Care must be consistent and adequate - Give and experience that will add to security (touch, hugs and kisses, eye to eye contact, soft music Autonomy vs. Shame and Doubt (18 months 3 years) - Autonomy is independence or self governance - How autonomy is developed - Give an opportunity for decision making such as offering choices - Encourage the child to make decisions rather than judge Initiative vs. Guilt (4 6 years) - Learns to do basic things - Activity recommended are modeling clay, finger painting - Develop creativity and imagination to facilitate fine motor development - How initiative is developed: - Give an opportunity of exploring new places and events

Industry vs. Inferiority (7 12 years) - Learn how to do things well - How industry is developed: - Give an opportunity no short assignment and projects Identity vs. Role Confusion (12 20 years) - Learn how he/she is or what kind of person he/she will become by adjusting to new body image - Seeking emancipation or freedom from parents Intimacy vs. Isolation (20 40 years) - Focus on career or looking for lifetime partners

Generativity vs. Stagnation (40 60 years)

Ego Integrity vs. Despair (65 and above) 3. Jean Piaget a Swiss psychologist

STAGES OF COGNITIVE DEVELOPMENT A. Sensorimotor (0 2 years) - Practical intelligence because words and symbols are not applicable - Babies are communicating through sense and reflex

SCHEMA Neonatal Reflex Primary Circular Reaction Secondary Circular Reaction

AGE 1 month 1 4 months 4 8 months

Coordination of Secondary Tertiary Circular Reaction

8 12 months 12 18 months (1 1 year)

BEHAVIOR - All reflexes - Activities related to bodies repetition of behavior (thumb sucking) - Activity not related to body - Discover object or persons code and code memory arises - Anticipate familiar events - Exhibit goal directed behavior - Increase sense of separateness - Use trial and error to discover change of places and events - Code and Code invention of new means - Capable of space and time perception - Transitional phase to operational period BEHAVIOR - Egocentric (unable to view another point of view)

Invention of combination

new

means

thru

mental

18 24 months

B. Preoperation al Thought SCHEMA Pre-conceptual

2 7 years old AGE 2- 4 years

- Their thinking is basically concrete and static - Their concept of time is only now and their concept of distance is only as far as they can see - Not yet aware of the concept of reversibility - Concept of animism (inanimate object is alive)

Intuitive

4 7 years

C. Concrete Operational (7 12 years) - Can find solutions to everyday problems with systemic reasoning - They have concept of reversibility - Activity recommended is collecting and classifying

D. Formal Operational (12 and above) - Period when cognition has achieved its final form - They are capable - Can find scientific reasoning (can deal with the past, present and future) - Capable of abstract and mature thought - Do abstraction by talk time that will sort

4. Kohl berg (1984) recognized the theory of moral development as considered closely to approximate cognitive stages of development STAGES OF MORAL DEVELOPMENT INFANCY

Age (Year) Preconventional 2-3

4-7

Stage (Level I) 1

Description

Punishment/obedience orientation (heteronomous morality). Child does right because a parent tells him/her to and to avoid punishment.

Individualism. Instrumental purpose and exchange. Carries out action to satisfy own needs rather than society. Will do something for another if that person do something for the child

Con vention al 7-10

10-2

(Level II) 3

Orientation to interpersonal relations of mutuality. Child follows rules because of a need to be a good person in own eyes and the eyes of others. Maintenance of social order, fixed rules and authority. Childs finds following rules satisfying. Follows rules of Authority figures as well as parents in an effort to keep the system working

Postcon vention al Older than 12

(Level III) 5

Social contract, utilitarian law-making perspectives. Follows standards of society for the good of all people

Universal ethical Principle orientation. Follows internalized standards of conduct.

I . E. DEVELOPMENTAL MILESTONE PERIOD OF INFANCY a. Play - Solitary play - Non interactive - Priority is safety - Age who appreciate teddy bears - Attitude: proper hygiene b. Fear - Stranger anxiety - Begin at 6 7 months - Peak at 8 months - Diminish by 9 months c. Milestones E.I Neonate - Largely reflex - Complete head lag - Hands fisted - Cry without tears (due to immature larcrimal duct) - Visual fixation of human face

1 MONTH - Dance reflex disappears - Looks at mobile objects

2 MONTHS - Holds head up when in prone - Social smile

- Baby coos - Cry with tears - Closure of posterior fontanel by 2 3 months - Head lag when pulled to a sitting position

3 MONTHS - Holds head and chest when in prone - Follow object past midline - Grasp and tonic neck reflex are fading - Hand regards (3 months)

4 MONTHS - Turns from front to back - Head control complete - Bubbling sounds - Needs space to turn - Laugh aloud

5 MONTHS - Roll over - Turn both ways - Teething rings - Handles rattle well - Moro reflex disappear by 4 5 months

6 MONTHS - Reaches outs in anticipation of being picked up - Handle bottle well

- Sits with support - Uses palmar grasp by 6 months - Eruption of first temporary teeth (2 lower incisors) - Says vowel sounds Ah, ah

7 MONTHS - Transfer objects hand to hand - Beginning fear of stranger - Likes objects that are good sized

8 MONTHS - Sits with support - Peak of stranger anxiety - Plantar reflex disappear

9 MONTHS - Creeps/crawl - Needs space for creeping - Pincer grasp reflex - Combine two syllables Papa, Mama - Priority: safety

10 MONTHS - Pull self to stand - Understand word No - Respond to own name - Peak a boo - Pat a cake since they can clap

11 MONTHS - Cruises - Stand with assistance 12 MONTHS - Stand alone - Take first step - Walk with assistance - Drink from a cup - Cooperate in dressing - Says the 2 words Mama, Papa - Toys: pots and pans, pull toy and learn nursery rhymes

E.2. TODDLER a. Play - Parallel (2 toddlers playing separately) - Provide two similar toys (squawky squeeze toy) - Waddling duck to pull, pull truck, building block and pounding peg b. Fear - Separation anxiety - Do not prolong goodbye, say goodbye firmly - 3 Phases of separation anxiety a. Protest b. Despair c. Denial

c. Milestones 15 months - Plateau stage

- Walks alone (delay in walking maybe a sign of mental retardation) - Puts small pellets into small bottle - Scribbles voluntarily with pencil - Holds a spoon well - Seat self on chair - Creep upstairs - Speaks 4 6 words

18 months - Hide of possessiveness - Bowel control achieved - No longer rotates a spoon - Run and jump in place - Walk up and down stairs holding on (typically places both feet on one step before advancing) - Able to name body part - Speaks 7 20 words 24 months - Can open doors by turning doorknobs - Unscrew lids - Walk upstairs alone by still using both feet on the same step at same time - Daytime bladder control - Speak 50 200 words

30 months - 3 year old do tooth brushing with little supervision - 2 3 year old is the right time to bring to the dentist - Temporary teeth complete and last temporary teeth to appear is the posterior molars - 20 deciduous teeth by age 2 years

- Can make simple lines or stroke for crosses with a pencil - Can jump down from the stairs - Knows full name - Copy a circle - Holds up fingers

36 months - Trusting three - Able to unbutton - Draw a cross - Learns how to share - Full name and sex - speak fluently - Right time for bladder control (night time control) - Able to ride a tricycle - Speak 300 400 words - Clues for toilet training a. Can stand, squat and walk alone b. Can communicate toilet needs c. Can maintain himself dry with interval of 2 hours

d. Character Traits - Negativistic likes to say no (it is their way to search independence) - Limit questions and offer options - Temper tantrums (stomping feet and screaming) - Ignore the behavior - Rigid ritualistic: stereotype - Cause: mastering

- Protruded abdomen - Cause: - Under development of abdomen - Unsteady gait - Physiologic anorexia (give foods that last for a short period of time)

E.3. PRE-SCHOOL a. Play - Associative play, Cooperative play - Play house - Role playing

b. Fear - Body mutilation or castration fear - Dark places and witches - Thunder and lighting

c. Milestone 4 years - Furious four (noisy and aggressive) - Able to button - Copy a square - Lace shoes - Know the 4 basic colors - Vocabulary of 1500 words

5 years - Frustrating five

- Copy a triangle - Draw a 6 part - Imaginary playmates - 2100 words

d. Character Traits - Curious - Creative - Imaginative - Imitative - Why and How

e. Behavior Problems - Telling tall tales (over imagination) - Imaginary friends (purpose: release their anxiety and tension) - Sibling rivalry (jealousy to a newly delivered baby) - Bed wetting - Baby talk - Fetal position - Masturbation is a sign of boredom and should divert their attention

E.4. SCHOOL AGE (7 YEARS) a. Play - Competitive play - Tug o war

b. Fear - School phobia

- To prevent phobia orient child to new environment - Displacement from school - Significant person is the teacher and peer of the same sex - Loss of privacy - Fear of death

c. Significant Development - Prone to bone fracture (green stick fracture) - Mature vision d. Milestones 6 years - Temporary teeth begins to fall - Permanent teeth begins to appear (first molar) - Year of constant motion - Clumsy movement - Recognizes all shapes - Teacher becomes authority figure that may result to nail biting - Beginning interest with God

7 years - Age of assimilation - Copy a diamond - Enjoys teasing and play alone - Quieting down period

8 years - Expansive age - Smoother movement

- Normal homosexual - Love to collect objects - Count backwards

9 years - Coordination improves - Tells time correctly - Hero worship - Stealing and lying are common - Takes care of body needs completely - Teacher find this group difficult to handle

10 years - Age of special talents - Writes legibly - Ready for competitive sports - More considerate and cooperative - Joins organization - Well mannered with adults - Critical of adults

11-12 years - Pre adolescent - Full of energy and constantly active - Secret language are common - Share with friends about their secrets - Sense of humor present - Social and cooperative

e. Character Traits - Industrious - Love to collect objects - Cant bear to loose they will cheat - They are modest
SIGNS OF SEXUAL MATURITY Girl s Increase size of breast and genetalia Widening of hips Appearance of axillary and pubic hair Menarch (last sign) - telarch is the 1st sign of sexual maturity Boys Appearance of axillary and pubic hair Deepening of voice Development of muscles Increase in size of testes and scrotum (1st sign) Production of viable sperm (last sign)

E.5. ADOLESCENT PERIOD - They have distinctive odor because of the stimulation of apocrine gland - They have nocturnal emission (wet dreams) the hallmark for adolescent - Testes and scrotum increase in size until age 17 - Sperm also viable - Breast and female genetalia increase until age 18

a. Fear - Acne - Obesity - Homosexuality - Death - Replacement from friends

b. Significant Person - Peer of opposite sex

c. Significant Development - Experiences conflict between his needs for sexual satisfaction and societies expectations - Core concern is change of body image and acceptance from the opposite sex

d. Personality Trait - Idealistic (parent-child conflict begins) - Rebellious - Very conscious with body image - Reformer - Adventuresome

e. Problems - Vehicular accident - Smoking - Alcoholism - Drug addiction - Pre marital sex

IMMEDIATE CARE OF THE NEWBORN

A. THE 8 PRIORITIES OF THE NEWBORN IN THE FIRST DAY OF LIFE 1. Initiation and Maintenance of respiration 2. Establishment of extra uterine circulation 3. Control of body temperature 4. Intake of adequate nourishment 5. Establishment of waste elimination

6. Prevention of infection 7. Establishment of an infant-parent relationship 8. Development care that balances rest and stimulation for mental development 1. Initiation and Maintenance of respiration Alerts - Second stage of labor initiate airway - Initiation of airway is a crucial adjustment among newborn - Most neonatal deaths with in the first 24 48 hours is primarily the inability to initiate airway - Lung function begins only after birth

How A. Removal of secretions by proper suctioning

B. Proper Suctioning of catheter - Place babys head to side to facilitate drainage - Suction nose first because neonates are nasal obligates - Suction for 5 10 seconds and should be gentle and quick because prolong deep suctioning may result to hypoxia, bradycardia (caused by vagal nerve stimulation) and laryngospasm

C. If not effective, requires effective laryngoscopy to open the airway. After deep suctioning, an endotracheal tube can be inserted and oxygen can be administered by a positive pressure bag and mask with 100% oxygen at 40 60 b/min.

Nursing Alerts: - No smoking sign to prevent combustion - Always humidify to prevent drying of mucosa - Mask should cover nose and mouth - Overdosage of oxygen may lead to scaring of retina which may lead to blindness called RETROLENTAL FIBROPLASIAS (retinopathy of prematurity)

- When meconium stained never administer oxygen because pressure will force meconium to the alveolar sac and cause atelectasis

2. Establishing extrauterine circulation Alerts: circulation is initiated by pulmonary ventilation and is completed by cutting of cord

THE FETO-PLACENTAL CIRCULATION Placenta (via simple diffusion) oxygenated blood is carried by the vein liver Ductus venosus Inferior vena cava right atrium 70% shunted to Foramen ovale - left atrium mitral valve left ventricle aorta lower extremities.

The remaining 30% - tricuspid valve right ventricle pulmonary artery lungs (for nutrition) vasoconstriction of the lungs pushes the blood to the Ductus arteriosus to aorta to supply the extremities. The two arteries carry the unoxygenated blood back to the placenta for reoxygenation.

Alerts: Increase pressure on the left side of heart causes closure of foramen ovale

SHUNTS 1. Ductus Venosus shunt from umbilical vein to inferior vena cava 2. Foramen Ovale shunt between 2 atria (begin to close within 24 hours) 3. Ductus Arteriosus shunt from pulmonary artery to aorta (begin to close within 24 hours)

A. 2 Way to facilitate Closure-of Foramen-ovale 1. Tangential foot slap - So baby will cry to expand lungs - Never stimulate baby to cry when not yet properly suctioned - Check characteristics of cry (strong vigorous and lusty cry) - Cri du chat (meow cry)

2. Proper Positioning - Right side lying

STRUCTURE

APPROPRIATE TIME OF OBLITERATION

STRUCTURE REMAINING

FAILURE TO CLOSE

Foramen Ovale

24 hours complete by 1 year 24 hours complete by 1 month

Fossa Ovalis

Atrial Septal Defect

Ductus Arteriosus

2 months 2 3 months

Ligamentum Arteriosum

Patent Ductus Arteriosus

Ductus Venosus Umbilical Arteries 2 3 months

Ligamentum Venosum Lateral Umbilical Ligament Inferior Iliac Artery Lateral Umbilical Ligament

Umbilical Vein

Inferior Iliac Artery Ligamentum Teres (round ligament of liver)

B. Best position immediately after birth: NSD trendelendberg CS supine or crib level position

Signs of increase ICP 1. Abnormally large head 2. Bulging and tense fontanel 3. Projectile vomiting (surest sign of cerebral irritation) 4. Increase blood pressure but widening pulse pressure 5. Decrease respiratory rate 6. Decrease pulse rate 7. High pitch shrill cry (late sign) 8. Diplopia (sign of ICP from 6 months 1 year)

3. Temperature Regulation Alerts: - The goal in temperature regulation is to maintain it not less than 97.7 oF 36.5 oC - Maintenance of temperature is important for preterm and SGA because it may lead to hypothermia or cold stress A. Factors Leading to the development of Hypothermia 1. Preterm are born poikilothermic (cold blooded) they easily adapt to temperature of environment due to immaturity of thermo regulating system of body 2. Inadequate subcutaneous tissue 3. Newborns are not yet capable of shivering (increase basal metabolism) 4. Babies are born wet B. Process of Heat Loss 1. Evaporation body to air 2. Conduction body to cold solid object 3. Convection body to cooler surrounding air

4. Radiation body to cold object not in contact with body

C. Effects of Hypothermia (Cold Stress) 1. Hypoglycemia due to utilization of glucose (40 45 gm/dl is the normal blood sugar of a newborn) 2. Metabolic Acidosis due to catabolism of brown fats (best insulator of a newborn) 3. High risk for KERNICTERUS (bilirubin in brain) 4. Additional fatigue to already stressful heart

D. Prevention of Cold Stress 1. Dry and wrapped newborns 2. Mechanical measures - Radiant warmer - Isolette (square acrylic sided incubator, must be pre heated first) 3. Prevent unnecessary exposure cover areas not being examined 4. Use tin foil in absence of electricity 5. Embrace baby (called kangaroo care)

4. Establish Adequate Nutritional Intake Alerts: Breastfeed immediately for NSD and after 4 hours for CS (Colostrum is present on the 3rd trimester)

A. Physiology of Breast milk Production - Decrease in level of estrogen and progestin, stimulates the anterior pituitary gland, that stimulates the prolactin of the acinar cells (alveoli) to produce the foremilk stored in lactiferous tubules

B. Advantage of Breastfeeding - Very economical - Always available - Promotes bonding

- Helps in rapid involution - Decrease incidence of breast cancer - Breast fed babies has higher IQ - It contains anti body (IgA) lactobacillus bifidus that interfere attack of pathogenic bacteria in GIT - Contains macrophages (store in plastic container, good for 6 months when stored in freezer) - Disadvantages of breast milk and cows milk - Both has no iron - Possibility of transfer of HIV, Hepatitis B - Father cannot feed or bond as well

C. Stages of Breastmilk 1. Colostrum available 2 4 days after delivery Contents: - Low fats - Low carbohydrates - High protein - High immunoglobulin - High minerals - High fat-soluble vitamins

2. Transitional covering 4 14 days Contents: - High lactose - High minerals - High water soluble vitamins

3. Mature milk 14 days and above Contents: - High fats (linoleic acid responsible for integrity of skin and development of skin) - High carbohydrates (lactose, easily digested, responsible for sour milk smelling odor of stool) - Low protein (lactalbumin)

D. Cows milk Contents: - High fats - Low carbohydrates (add sugar) - High protein (casein) has a curd that is hard to digest - High minerals, has traumatic effect on kidneys of baby - High phosphorus that may cause inverse proportion with calcium

E. Health Teachings 1. Proper Hygiene - Importance of hand washing - Removal of caked colostrum 2. Position - Upright sitting avoid tension to properly empty breast milk 3. Stimulate and evaluate feeding reflexes a. Rooting - touch side of lips or cheek and baby will turn to the stimulus - purpose: to look for food - disappear at 6 weeks because baby can already focus b. Sucking - by touching the middle of lips then baby will suck - purpose: take in food - disappear at 6 months - easily disappear when not stimulated c. Swallowing - food touches posterior portion of tongue automatically swallowed - never disappear cough, gag, sneeze

d. Extrusion/Protrusion reflex - food touches anterior portion of tongue and tongue automatically extruded/protruded - purpose: prevent from poisoning - disappear by 4 months because baby can already spit out 4. The criteria of effective sucking a. babys mouth is hike well up to areola b. mother experiences after pain c. other nipple is flowing with milk

5. To prevent from crack nipples and initiate proper production of oxytocin - begin 2 3 minutes per breast - increase 1 minute per day each breast until you reach 10 minutes each breast or 20 minutes per feeding 6. For proper emptying and continuous milk production per feeding - feed baby on the last breast that you fed him

PROBLEMS EXPERIENCED IN BREASTFEEDING a. Engorgement - soft and non tender (1 day) - feeling of tension and fullness of breast - while feeding warm compress - bottle feeding cold compress and wear supportive bra b. Sore nipple - cracked, wet and painful nipple - exposure to air is the management or 20 watt bulb - avoid wearing plastic liner bra, instead wear cotton bra c. Mastitis - inflammation of breast - causative factor: staphylococcus aureus

- improper breast emptying - unhealthy sexual practices - breast feed on unaffected breast - express your breast on affected side - take antibiotic - increase 500 calories when breastfeeding - involution of breast is 4 weeks

CONTRAINDICATIONS IN BREASTFEEDING Maternal Conditions - HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake

Newborn Conditions - erythroblastosis fetalis - hydrops fetalis - phenylketonuria (PKU) - galactosemia - tay-sachs disease

5. Establishment of waste-elimination

A. Different stools 1. Meconium - Physiologic stool - Blackish green - Sticky - Tar like - Odorless (because of sterile intestines)

- No bacteria - Passed with in 24 36 hours - Failure to pass meconium suspect GIT obstruction a. hirschsprung b. imperforate anus c. meconium ileu (cystic fibrosis)

2. Transitional - Become green, loose and slimy that may appear to be a slight diarrhea to the untrained eye

3. Breastfed stool - Golden yellow, soft, mushy with sour milk smelling odor frequently passed occurring almost nearly every feeding

4. Bottle-fed stool - Light yellow, formed, hard with a typical offensive odor seldom passed 2 3 times a day

5. With supplementary foods added - Brown and odorous

B. Indication of Stool Changes - Light stool: jaundice baby - Bright green: phototherapy - Mucous mixed with stool: allergy - Clay colored: obstruction to bile duct - Chalk clay/whitish clay: barium enema - Black stool: GIT hemorrhage - Blood flecked: anal fissure - Curant jelly: intususeption

- Ribbon like: hirschsprung - Steatorrhea: fatty, bulky, foul smelling suspect malabsorption a case of cystic fibrosis or celiac disease

ASSESSMENT FOR WELL- BEING

A. APGAR SCORING Special Considerations - Taken on first 1 minute, shows the general condition of baby - 15 minutes is optional - Taken again after 5 minutes, to determine babys capability to adapt/ adjust extrauterinely Components Appearance - Color: slightly cyanotic, after first cry baby becomes pinkish Pulse rate - Apical pulse (left lower nipple) Grimace - Reflex irritability (foot slap, catheter insertion) Activity - Degree of flexion (muscle tone) Respiration

APGAR SCORING CHART Score Criteria Heart rate Respiratory effort Muscle tone Reflex irritabil ity Catheter Tangential Footslap Color No response No response Blue/Pale Grimace Grimace Acrocyanosis (body and extremities blue) Cough or sneeze Cry Pink 0 Absent Absent Flaccid extremities 1 Less than 100 Slow irregular weak cry Some flexion 2 More than 100 Good strong cry Well flexed

Interpretation of APGAR Result 0-3: severely depressed, need CPR, admission to NICU 4-6: moderately depressed, additional suction and oxygen administration 7-10: good/healthy

CARDIO PULMONARY-RESUSCITATION Airway (Clear Airway) 1. Shake, no response call for help 2. Place flat on bed 3. Head tilt chin lift maneuver - Contraindicated to spinal cord injury - Over extension may occlude airway Breathing (Ventilating the lungs) 4. Check for breathlessness 5. Administer 2 rescue breaths Circulation (by cardiac compression) 6. Check for pulselessness 7. Do CPR (when breathless and pulse less)

B. RESPIRATION EVALUATION SILVERMAN ANDERSON INDEX CHART

Score Criteria Chest movement Intercostal retraction Xiphoid retraction Nares dilation 0 Synchronized No retractions None None 1 Lag on respiration Just visible Just visible Minimal 2 See saw Marked Marked Marked

Expiratory grunt

None

Stethoscope

Naked ear

Interpretation of Result 0 3: Normal no respiratory distress syndrome 4 6: Moderate RDS 7 10: Severe RDS

C. ASSESSMENT OF GESTATIONAL AGE BALLARD AND DOBOWITZ CLINICAL CRITERIA

Gestational Age (Week s) Findin gs Sole creases Breast nodule (dm.) Scalp hair Ear Lobe Testes Scrotum 2 mm Fine and fuzzy Pliable Testes and scrotum in lower canal, scrotum is small with few rugae 4mm or 3 5 mm Fine and fuzzy Some Intermediate 7 mm 7.5 mm Coarse and silky Thick Testes pendulous, scrotum full with extensive rugae Less THAN 36 Anterior transverse crease only 37-38 Occasional creases in 2/3 39 and up Sole covered with creases

PRE TERM BABIES - 28 32 weeks - Frog leg or lax position - Hypotonic muscle tone - Scarf sign (elbow passes the midline) - Square window wrist (90o angle) - Heel to ear sign - Abundant lanugo - Prominent labia minora and clitoris POST TERM BABIES - More than 42 weeks - Old mans face (classic sign) - Desquamation (peeling of neonate skin characterized by extreme dryness than begin from sole and palm within 24 hours

D. Neonate in the Nursery *Special and Immediate Interventions 1. Upon receiving - Proper identification (foot print with mothers thumb print) - Take antropometric measurement

2. Then take anthropometric measurements a. Length = 19.5 21 inches/47.5 53.75 cm average of 50 cm b. Head Circumference = 33 35 cm average of 34 cm/13 14 inches c. Chest Circumference = 31 33 cm average of 32 cm/12 13 inches d. Abdominal Circumference = 31 33 cm average of 32 cm/12 13 inches

3. Bathing Baby - Normal oil bath - Cleanse and spread vernix - Babies of HIV positive mothers are given full bath to lessen transmission of infection - Insulator - Bacteriostatic - Full bath is safely given when cord falls

4. Dressing the umbilical cord - Follow strict asepsis to prevent infection/tetanus - Use Povidone iodine - Check for 3 vessels (2 arteries and 1 vein) - AVA (2 vessel cord suspect kidney malformation) - Leave about 1 inch of cord - 8 inches if anticipating IV or BT - Check for the cord q 15 minutes for the first 6 hours

- For bleeding: - 30 cc is bleeding to newborn - Hemophilia is excessive bleeding - Ompalagia is bleeding of the cord - Cord turns black on the third day - Falls by 7th 10th day - Failure to fall is umbilical granulation (silver nitrate) - Use saline to clean

5. Credes Prophylaxis - Purpose: prevent opthalmia neonatorum (use erythromycine ophthalmic ointment)

6. Administration of Vitamin K - Action: prevent hemorrhage - Related to physiologic hypoprothrombinemia - Give Aquamephyton, phytomenadione, konakoib (.5 1.5 mg, IM)

7. Weight-taking Normal Weight: 3000 3400 grams/3 3.4 kg/6.5 7.5 lbs Arbitrary Lower Limit: 2500 grams Low Birth Weight: below 2500 grams Small for Gestational Age: less 10 percentile rank Large for Gestational Age: more than 90 percentile rank Appropriate for Gestational Age: within the 2 standard deviation of the mean Physiological Weight Loss: 5 10 percent occurs a few days after birth

E. PHYSICAL EXAMINATION AND DEVIATIONS FROM THE NORMAL A. Important Considerations

a. If the client is new born, cover areas that is not being examined b. If the client is infant, the first vital sign to take is RR (due to fear of stranger) - Begin at east intrusive to the most intrusive c. If the client is toddler and preschool, let them handle an instrument play syringe, stethoscope, d. If the client is school age and adolescent explain procedure COMPONENTS: 1. Vital signs - Temperature is taken rectally to rule out imperforate anus and thermometer is inserted 1 inch - Dont force insertion because it may lead to pruritus - Types of imperforate anus a. Atretic no anal opening, causing failure to pass meconium b. Agenetic - no anal opening, causing failure to pass meconium - abdominal distention - foul smelling stool - vomitus of fecal materials - respiratory problems - Management: surgery with temporary colostomy c. Membranous

CARDIAC RATE 120-160/min - Irregular - Radial pulse is absent, if present suspect PDA

CONGENITAL HEART DISEASES

*Common in girls: PDA, ASD *Common in boys: TOGA (transposition of great arteries), Truncus Arteriosus *Causes: TOF 1. Familial 2. Exposure to rubella (1st month for mother) 3. Failure of heart structure to progress TWO MAJOR TYPES A. ACYANOTIC HEART DEFECTS Left to right shunting

WITH INCREASED PULMONARY BLOOD FLOW 1. Ventricular Septal Defect - Opening between 2 ventricles Signs and Symptoms 1. Systolic murmur at lower border of sternum and no other significant signs 2. Cardiac catheter reveals oxygen saturation at right side of heart 3. ECG reveals hypertrophy of right side of heart Management 1. Long term antibiotic therapy to prevent development of sub acute bacterial endocarditis 2. Open heart surgery

2. Atrial Septal Defect - Failure of foramen ovale to close Signs and Symptoms 1. Systolic murmur at upper border of sternum and no other significant signs 2. Cardiac catheter reveals increase oxygen saturation at right side of heart 3. ECG reveals hypertrophy of right side of heart

3. Endocardial Cushion Defects - AV canal affecting both tricuspid and mitral valve Signs and Symptoms 1. Only confirmed by cardiac catheter Management - Open heart surgery

4. Patent Ductus Arterious - Failure of ductus arteriosus to close Signs and Symptoms

1. Continuous machine like murmur 2. Prominent radial pulse 3. Hypertrophy of left ventricle upon ECG Management 1. INDOMETHACIN (prostaglandin inhibitor that facilitate closure of PDA) 2. Ligation of PDA by 3 4 years old WITH DECREASED PULMONARY BLOOD FLOW 1. Pulmonary Stenosis - Narrowing of valve of pulmonary artery Signs and Symptoms 1. Typical systolic ejection murmur 2. ECG reveals hypertrophy of right ventricle 3. S2 sound is widely split

2. Aortic Stenosis - Narrowing of valve of aorta Signs and Symptoms 1. Left ventricular hypertrophy 2. Typical murmur Management 1. Balloon stenotomy 2. Surgery (last resort)

3. Duplication of aortic arch - Doubling of arch of aorta causing compression to trachea and esophagus Signs and Symptoms 1. Dysphagia 2. Dyspnea

Management 1. Close heart surgery

4. Coarctation of the Aorta - Narrowing of arch of aorta Signs and Symptoms 1. Blood pressure in upper extremities is increased 2. Blood pressure in lower extremities is decreased 3. Outstanding sign is absent femoral pulse Management 1. Take blood pressure in 4 extremities 2. Close heart surgery

B. CYANOTIC HEART DEFECTS Right to left shunting WITH INCREASE PULMONARY BLOOD FLOW 1. Transposition of Great Arteries - Situation where aorta is arising from the right ventricle and pulmonary artery of the left ventricle Signs and Symptoms 1. Cyanosis after 1st cry (outstanding sign) 2. Polycythemia (compensatory mechanism to decrease oxygen supply 3. Prone to thrombus leading to embolism resulting to stroke (complications) Management 1. Palliative repair kashkind procedure 2. Complete repair mustard procedure 2. Total Anomalous Pulmonary Venous Return - Pulmonary vein enters the right atrium or superior vena cava Signs and Symptoms

1. Mixed blood supplying the body (oxygenated and unoxygenated) 2. Open foramen ovale 3. Aspleenia (absent spleen) 4. Mild to moderate cyanosis Management 1. Restructuring of the heart

3. Truncus Arteriosus - Pulmonary artery and aorta is arising from one common trunk or single vessel with VSD Management 1. Positive cyanosis and polycythemia 2. Restructuring of the heart

4. Hypoplastic Left Heart Syndrome - Non functioning left ventricle Signs and Symptoms 1. Cyanosis 2. Polycythemia Management 1. Heart transplant

WITH DECREASE PULMONARY BLOOD FLOW 1. Tricuspid atresia - Failure of tricuspid valve to open Signs and Symptoms 1. Open foramen ovale 2. Cyanosis Management

1. Fontan procedure

2. Tetralogy Fallot - 4 Anomalies Present Pulmonary stenosis VSDOverriding aortaRight ventricular hypertrophy i Signs and Symptoms 1. High degree of cyanosis 2. Polycythemia - Increase red blood - Thrombus, embolus, stroke - Mental retardation - Clubbing of fingernails (chronic tissue hypoxia) late sign - X-ray reveals boot shape heart

3. Severe dyspnea - Relieved by squatting position 4. Growth retardation 5. Tet Spells - Blue spells, short episode of hypoxia

Management 1. Morphine for hypoxic episode 2. Propranolol (Inderal) decrease heart spasm 3. Palliative Repair BLALOCK TAUSSIG PROCEDURE 4. Complete Repair BROCK PROCEDURE

ACQUIRED HEART DISEASE

Rheumatic heart Disease - Inflammatory disease following an infection caused by Group-A beta hemolytic streptococcus (thrives in aerobic environment) Affected Body Parts

- Musculoskeletal cardiac muscles and valves - Integumentary - CNS - Aschoff bodies - Rounded nodules containing of multi nucleated cells and fibroblasts that stays in mineral valve Signs and Symptoms

MAJOR Polyarthritis (multi joint pain) Chorea (sydenh anns chorea ) St. Vitus dance , purposeless/involuntary hand and shoulder movement accompanied by grimace Carditis Errythema marginatum (macular rash) - Subcutaneous nodules

MINOR Arthralgia (joint pain) Low grade fever Increase diagnostic tests a. Antibody b. C-reactive protein c. Erythrocyte Sedimentation Rate d. Anti-streptolysin O titer (ASO)

Management - CBR (avoid contact sports) - Culture and sensitivity (throat swab) - Antibiotic management (to prevent recurrence) - Aspirin (anti inflammatory) - Side Effects: Reyes Syndrome - Non recurring encephalopathy accompanied by fatty infiltration of organs such as liver and brain

RESPIRATION - Abnormal/diaphragmatic - Short period of apnea without cyanosis - Normal apnea of newborn is less than 15 seconds Respiration Check

Newborn 40- 90 1 year 2-3 years 20- 30 5 years 20- 25 10 years 17- 22 15 and above

20- 40

12-20

Breath Sounds Heard on Auscultation

Sound VESICULAR BRONCHOVESICULAR BRONCHIAL RHONCHI RALES

Characteristics Soft, low pitched, heard over periphery of lungs, inspiration longer than expiration, normal. Soft, medium-pitched, heard over major bronchi, inspiration equals expiration, normal . Loud, high-pitched, heard over trachea, expiration longer than inspiration, normal. Snoring sound made by air moving through mucus in bronchi, normal. Crackles (like cellophane) made by air moving through fluid in alveoli. Abnormal ; denotes pneumonia or pulmonary edema which is fluid in alveoli. Whistling on expiration made by air being pushed through narrowed bronchi. Abnormal; seen on children with asthma or foreign-body obstruction. Crowing or rooster like sound made by air being pulled through a constricted larynx, Abnormal , seen in infants with respiratory obstruction. Loud, low tone, percussion sound over normal lung tissue. Louder, lower sound than resonance, a percussion sound over hyperinflated lung issue.

WHEEZING STRIDOR RESONANCE HYPERRESONANCE

RESPIRATORY DISTRESS SYNDROME - Hyaline membrane disease - Cause: lack of surfactant - Common in preterm infants - Hypoxic - Formation of hyaline - Causing atelectasis Signs and Symptoms - Definite within 4 hours of life 1. Increase RR with retractions (early sign) 2. Expiratory grunting (major sign) 3. Flaring alae nassi 4. Xiphoid retractions 5. Intercoastal retractions 6. Respiratory acidosis

Management 1. Keep head elevated 2. Proper suctioning - Oxygen administration - Place on continuous positive airway pressure - Positive end expiratory pressure (maintain alveoli partially open and prevent collapse) 3. Monitor skin color, vital signs, ABG 4. Surfactant replacement and rescue

LARYNGOTRACHEOBRONCHITIS - Infection of larynx, trachea and bronchi

Assessment - Barking cough/croupy cough - Respiratory acidosis Laboratory Studies a. ABG b. Throat culture c. CBC Diagnostic Studies a. Chest and neck x-ray (to rule out epiglotitis) Management a. Bronchodilators b. Oxygen with increase humidity c. Prepare tracheostomy set when necessary

Broncholitis - Inflammation of bronchioles characterized by production of thick tenacious mucous Signs and Symptoms - Cold like/flu like symptoms - Causative agent: respiratory syncitial virus - Drug: Ribavirin (anti viral drug) - End stage epiglotitis (emergency condition or URTI), sudden onset Management

- Tripod position (leaning forward with tongue protrusion) - Never use tongue depressor - Prepare tracheostomy set - Encircle age - Mist tent croup tent, croupette - Nursing management a. Check edges if properly tucked b. Washable plastic material c. Avoid toys that cause friction and hairy and furry materials

BLOOD PRESSURE - 80/46 mmHg after 10 days 100/50 - Normal blood pressure taking begins by 3 years old

Alerts - BP cuff must cover 50 75% (2/3) of upper arm - To large cuff results to false low BP - To small cuff results to false high BP

SKIN - Acrocyanosis (body pink extremities blue) - Generalized mottling due to the immaturity of the circulatory system BIRTHMARKS 1. Mongolian Spots slate-gray-or-bluish discoloration/patches commonly seen across he sacrum or buttocks

- Due to increase melanocytes - Common in asian newborn - Disappear by 1 year, preschool, 5 years old 2. Milia plugged unopened sebaceous gland usually seen as white pinpoint patches on nose, chin and cheek, disappears by 2 4 weeks 3. Lanugo fine downy hair 4. Desquamation peeling of the newborn skin within 24 hours, common among post term 5. Stork bites (telengiectasis nevi) pink patches at the nape of the neck - Never disappear but is covered by hair 6. Erythema Toxicum (flea bite rash) first self limiting rash to appear sporadically and unpredictably as to time and place. 7. Harlequin sign dependent part is pink, independent part is blue (RBC settles down) 8. Cutis marmorata transitory motling of neonates skin when exposed to cold 9. Hemangiomas vascular tumors of the skin 3 TYPES a. Nevus Flammeus macular purple or dark red lesions usually seen on the face or thigh - Portwine stain: never disappear but can be removed surgically b. Strawberry hemangiomas (nevus vasculosus) dilated capillaries in the entire dermal or subdermal area continuing to enlarge but disappear after 10 years old. c. Cavernous hemangiomas Consist of communicating network of venules in the subcutaneous tissue that never disappear with age. - Dangerous type may lead to internal hemorrhage

10. Vernix Caseosa white cheese like substance for lubrication; Color of vernix is same as amniotic fluid SKIN COLOR AND THEIR SIGNIFICANCE Blue cyanosis/ hypoxia White edema Gray infection Yellowish jaundice/ carotinemia (increase carotin) Pale anemia

SKIN DISORDERS
BURN TRAUMA - Is injury to body tissue cause by excessive heat Assessment Depth

1 st (partial thickness) Ex. Sunburn Involves only the superficial epidermis characterized by erythema, dryness and pain Heals 1 -10 days 2 nd (partial thickness) Ex. Scalds Involves the entire epidermis, and portion of dermis characterized by erythema, blistered and moist from exudates which is extremely painful.

3 rd (full thickness) Involves both skin layers, epidermis and dermis/may involve adipose tissue, fascia, muscle and bone. It appears leathery, white or black and not sensitive to pain since nerve ending had been destroyed.

Management 1. First Aid a. Put out flames by rolling the child on a blanket b. Immerse the burned part on cold water c. Remove burned clothing d. Cover burn with sterile dressing 2. Maintenance of a patent airway a. Suction as needed b. Oxygen administration c. ET tube d. Tracheostomy 3. Prevention of Shock and Fluid and Electrolyte Balance a. Colloids to expand blood volume b. Isotonic saline to replace electrolytes c. Dextrose and water provide calories 4. A booster dose of tetanus toxoid 5. Relief of pain such as IV analgesic (morphine sulfate) 6. Prevention of wound infection a. Cleaning and debriding of wound b. Open/close method of wound care c. Whirlpool therapy 7. Skin grafting a. Big skin xenograft b. Taken from cadaver 8. Diet a. High protein b. high calorie

ATOPIC DERMATITIS - Infantile eczema - Skin disease characterized by maculo vesicular errythematous lesion with weeping and crusting - Cause: allergens (main), milk, eggs, citrus juices, tomatoes and wheat - Characterized by extreme pruritus - Sign: linear excoriation, lichenified scaling

Management - Treat main cause - Prosorbbee or Isomil (milk) - Hydrate skin with burrows solution - Prevent infection - Cut short the nails

IMPETIGO - Cause: group A beta hemolytic streptococcus - Characterized by populo vesicular surrounded by localized errythema becoming purulent and ooze forming a honey colored crust - Pediculosis capitis (kuto) - Give oral penicillin - AGN complication ACNE - Self limiting inflammatory disease affects sebaceous glands common in adolescence - Signs: Comedones (sebum causing white heads) - Sebum is composed of lipids Management - Proper hygiene

- Wash face with soap and water - Use sulfur soap or mild soap - Retin A

HEMATOLOGIC DISORDERS
PALLOR-ANEMIA Possible cause of Anemia 1. Early cutting of cord 2. Bleeding Disorder/blood dyscracia HEMOPHILIA - Deficient clotting factor - X link recessive inheritance - Sex link - Excessive bleeding upon cutting of cord or circumcision - Carrier mother passed to son, when son becomes a father he will pass it to his daughter

Hemophilia A (classic) deficiency of the coagulation component (Factor VIII) Hemophilia B (Christmas disease) deficiency in clotting factor IX Hemophilia C deficiency in clotting factor XI

Assessment - Newly delivered baby receive maternal clotting factor - Sudden bruising of bumped area - Continuous bleeding to hemarthrosis - Bleeding or damage of synovial membrane Diagnostic Test - High risk for injury (prevent injury) - Partial thromboplastin time Management

- Avoid contact sports - Significance: determine case before doing any invasive procedure - No aspirin - Immobilize and elevate upon injury - Apply gentle pressure - Cold compress - Blood transfusion: cryoprecipitate, fresh frozen plasma

LEUKEMIA - Group of malignant disease characterized by rapid proliferation of immature WBC - WBC (soldiers of body) - Ratio: 500 RBC:1WBC

Classification (depends on affected part) Lympho lymphatic system Myelo bone marrow Acute/Blastic immature cells Chronic/cystic mature cells Acute lymphocytic common among children

Signs and Symptoms 1. From the invasion of bone marrow - Anemia (pallor, fatigue, constipation) - Bleeding (bruising, petechiae, epistaxis, bleeding in urine, emesis) - Infection - Fever - Poor wound healing - Bone weakens and causes fracture

2. From the invasion of organs - Hepatosplenomegaly - CNS affectation (headache and signs of increase ICP)

Diagnostic Tests and Studies 1. PBS (peripheral blood smear) determine immature WBC 2. CBC anemia, neutropenia, thrombocytopenia 3. Lumbar Puncture place in fetal position without flexion of neck, C position or shrimp position 4. Bone Marrow Aspiration - Site for aspiration is the iliac crest - Put pressure after aspiration - Place on affected side 5. Bone Scan determine bone involvement 6. CT scan determine organ involvement Surgery

Irradiation

Chemotherapy

Therapeutic Management 1. Medications 4 Levels of Chemotherapy

For Induction achieve remission (main goal) IV Vincristine Laspariginase Oral prednisone For Sanctuary treat leukemic cells that has invaded testes and CNS Methothrexate (intrathecally via CNS/spine) Cytocin Arabinoside Extra irradiation For Maintenance continue remission a. Oral Methothrexate b. Oral 6 mercaptopurine c. Cytarrabine For Reinduction treat leukemic cells after relapse occurs IV Vincristine Laspariginase Oral prednisone Antigout Agents treat/prevent hyperuricemic nephropathy Allopurinol (Zyloprim) Increase fluid intake

Nursing Management - Assess for common side effects - Nausea and vomiting - Administration of anti emetics 30 minutes before chemo and continue until 1 day after - Check for stomatitis, ulcerations and abscess of oral mucosa - Oral care (alcohol free mouthwash) no toothbrush - Diet (soft and bland) according to childs preference

- Alopecia (temporary side effects) - Hirsutism - To parents (always repeat instruction)

HEMOLYTIC DISORDER
a. Rh Incompatibility - Mother negative, fetus positive - 4th baby affected - Mother negative, no antigen (no protein factor) - Erythroblastosis fetalis: hemolysis leading to decrease oxygen carrying capacity with pathologic jaundice within 24 hours - Test: Combs Test - Vaccine: Rhogam - Given to RH negative mother within first 72 hours to destroy fetal RBC therefore preventing antibody formation b. ABO Incompatibility - Mother is type O, fetus is type A, B, AB - Most common is O, and A - Severe O and B - First pregnancy can be affected

Assessment - Common is Hydrops fetalis, edematous on lethal state with pathologic jaundice within 24 hours Management 1. Initiation of feeding, temporary suspension of breast feeding to prevent kernikterus 2. Pregnandiole delays action of glucoronyl transferace (liver enzyme that converts indirect bilirubin to direct bilirubin) 3. Use of Phototherapy 4. Exchange Transfusion of Rh or ABO affectations that tend to cause continuous decrease in hemoglobin during the first 6 months because bone marrow fails to produce erythrocytes in response to continuing hemolysis.

Yellow Jaundice Hyperbilirubinemia - Normal: indirect bilirubin 0 3 mg/dl - More than 12 mg/dl of indirect bilirubin in fullterm Kernicterus - Bilirubin encephalopathy more than 20 mg/dl indirect bilirubin in fullterm - Less than 12 mg/dl in preterm because of immature liver Physiological Jaundice - Icterus neonatorum - 48 72 hours - Expose to sunlight Pathological Jaundice - Icterus gravis neonatorum - Clinical jaundice within 24 hours Breastfeeding Jaundice - Pregnandiole - 6 to 7 days

Assessment - Blanching the neonates forehead , nose or sternum - Yellow skin and sclera - Light stool - Dark urine Management Phototherapy - Photo oxidation - Height of 18 20 inches away from baby Nursing Responsibilities

1. Cover the eyes prevent retinal damage 2. Cover genitals prevent priapism (painful continuous erection) 3. Change position for even exposure to light 4. Increase fluid intake to prevent dehydration 5. Monitor I & O weigh baby 1 gram:1 cc 6. Monitor Vital Signs - Avoid use of lotion or oil because it may result to bronze baby syndrome

HEAD Structures Sutures: 3 Fontanels: 12 18 months close Anterior fontanel - Craniostenosis/ craniosinostosis (premature closure of anterior fontanel) Posterior fontanel - 1 x 1 cm - Closes by 2 3 months Microcephaly - Small/slow growing brain - Fetal alcohol and HIV positive Anencephaly - Absence of cerebral hemisphere

Noticeable Structure of the head 1. Craniotabes - Localized softening of cranial bones to 1st born child due to early lightening - Ricketts in older children

2. Caput Succedaneum - Edema of scalp due to prolonged pressure at birth - Characteristics - Present at birth - Crosses the suture line - Disappear after 2 3 days

3. Cephalhematoma - Collection of blood due to rupture of periostial capillaries - Characteristics - Present after 24 hours - Never cross the suture line - Disappear after 4 6 weeks

4. Seborrheic Dermatitis - Cradle cap - Scaling, greasy appearing salmon colored patches usually seen on scalp, behind ears and umbilicus - Primary cause: improper hygiene - Management: proper hygiene, apply oil the night before shampooing (use baby oil or coconut oil)

5. Hydrocephalus - Collection of CSF 2 types a. Communicating extra ventricular hydrocephalus b. Non communicating intra ventricular hydrocephalus also called obstructive Signs and Symptoms - Sign of increase ICP

- Sign of frontal bossing (prominent forehead) - Prominent scalp vein - Sunset eyes Therapeutic Management - Place client in low semi fowlers position (30o) - Osmotic diuretic - Diamox (Acetazolamide) to decrease CSF production - Seizure precaution - Surgery (AV shunt, VP shunt) - Shave just before surgery - Place in side lying position on non operated side - Monitor for good drainage - Sunken fontanel is a good sign - Mental retardation depend on extent of hydrocephalus

SENSES a. Sense of Sight (Eyes) Sclera light blue becomes dirty white Pupils round and adult size a. Coloboma part of iris is missing b. Congenital cataract whiteness and opacity (caused by german measles) Cornea round and adult size, larger in congenital glaucoma
Test of blindness AGE 1. Newborn COMMON TEST General appearance See 10 12 inches Doll s eye test done on 10th day Glabell ars test blink reflex

2. Infant and children 3. 3yr school age

- General appearance - Ability to follow object past midline - Pre school - E chart test for stereosis or depth of perception

- Allen cards for visual acuity - Ishiharas plates for color blindness - Cover testing for strabismus, eye deviation 4. School Age Adult - Snellens test

RETINOBLASTOMA - Malignant tumor of retina - Red painful eye often accompanied by glaucoma (pathognomonic sign: cats eye reflex) - Management: enucleation

b. Senses of Smell (Nose) - Flaring or alae nasi (RDS) - Pale with creases nasal membrane, chronic rhinitis - Inflamed: infection - Cocaine abuse: - No hair - Ulceration with abscess at the nasal mucosa - Perforation of nasal septum - Epistaxis: - Nose bleed - Sit upright with head tilted forward - Cold compress - Apply pressure - Give epinephrine

c. Sense of Hearing (Ears) - First to develop and last sense to disappear - Properly aligned to outer canthus of eye

1. Kidney Malformation - Low set ears

- Renal agenesis - Unilateral/bilateral - Oligohydramnios (sign of renal agenesis in utero) - Failure to fade 24 hours - Kidney transplant

2. Chromosomal Aberrations - More than 35 years A. Nondisjunction 1. Trisomy 21 - Down syndrome - Extra chromosome 21 - 47 XX + 21 or 47 XY + 21 - Cause: advance paternal age - Mongolian slant in eyes - Low set ears - Broad flat nose - Protruding tongue - Puppys neck - Hypotonic (respiratory problem unable to cough out) - Simian crease (single transverse line of palm) - Educable

2. Trisomy 18 3. Trisomy 13 4. Turners 5. Klinefilters Syndrome B. Deletion Abnormalities

1. Cri-du-chat Syndrome 2. Fragile X Syndrome

C. Translocation Abnormalities 1. Balance Translocation Carrier 2. Unbalanced Translocation Syndrome

D. Others 1. Mosaicism a situation wherein the nondisjunction of chromosomes occurs during the mitotic cell division after fertilization resulting to different cells contains different numbers of chromosomes. 2. Isochromosomes a situation wherein the chromosomes instead of dividing vertically it divides horizontally resulting to chromosomal mismatch.

OTITIS MEDIA - Inflammation of middle ear, common in children due to wider and shorter eustachian tube - Common with cleft lip and palate - Bottle propping, may also result to dental caries - Otoscopic: bulging tympanic membrane and absence of light reflex - Observe for passage of milky, purulent and foul smelling odor discharge - Observe for URTI Management - Side lying on affected side to facilitate drainage - Supportive care (TSB, antipyretic) - Massive dosage of antibiotic (may lead to bacterial meningitis) - Apply ear ointment a. below 3 years down and back b. above 3 years up and back - Mucolytics to shrink mucous

- Myringotomy: surgical procedure done by making a slight incision of the tympanic membrane - Place client on the operated side - To prevent permanent hearing loss

MOUTH AND TONGUE a. Bels Palsy - Facial nerve paralysis - VII cranial nerve injury - Related to forcep delivery Signs and Symptoms - Continuous drooling of saliva - Inability to open 1 eye and close other eye Management - Artificial tears - Refer to PT (self limiting)

b. TEF/TEA - Tracheo Esophageal Fistula. Tracheo Esophageal Atresia - No connection between esophagus and stomach - 4 Cs: coughing, choking, cyanosis, continuous drooling - Emergency surgery

c. Epstein Pearls - White glistening cyst usually seen on palate or gums related to hypercalcemia

d. Natal Tooth

- Tooth at moment of birth related to hypervitaminosis (rootless)

e. Neonatal Tooth - Tooth within 28 days

f. Oral Thrush - Oral moniliasis, white cheese/curd like patches that coats mouth and tongue - Treat with anti fungal (Nistatin/Mycostatin)

g. Anodontia - No eruption of temporary teeth

KAWASAKI DISEASE - Common in Japan - Mucocutaneous lymph node syndrome - Drug of choice: Aspirin, Salicylates

Criteria for diagnosis of Kawasaki Disease 1. Fever lasting more than 5 days 2. Bilateral Conjunctivitis 3. Change of lips and oral cavity a. Dry, red, fissure lips b. Strawberry tongue c. Diffuse erythema of mucous membrane 4. Changes of peripheral extremities a. Erythema of the palms and sole b. Indurative edema of the hands and feet c. Membranous desquamation from fingertips

5. Polymorphous rash (primarily on trunk) 6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter

CLEFT LIP - Failure of the median maxillary nasal processes to fuse by 5 8 weeks of pregnancy - Common in boys - Can be unilateral or bilateral CLEFT PALATE - Failure of the palate to fuse by 9 12 weeks of pregnancy - Common in girls Signs and Symptoms a. Evident at birth b. Ultrasound/3 dimensional UTZ c. Milk escape to the nostril d. Common URTI (otitis, cholic)

Therapeutic Management - Surgery - Cleft lip: cheiloplasty done as early as 1 3 months to save sucking reflex - Cleft palate: uranoplasty done 4 6 months to save speech

Nursing Responsibility (Pre Op) - Emotional support - Proper nutrition - Use Rubber tipped medicine dropper - Prevention of cholic a. Feed upright position

b. Burp twice c. Prone position/on abdomen - Orient parents to feeding technique Cleft Lip - Use rubber tipped syringe Cleft Palate - Use paper cup, plastic cup, soup spoon - Use elbow restraints (pre op) - So baby can easily adjust post op (Post Op) - Maintenance of airway - Side lying (cheiloplasty) - Prone (uranoplasty) - Facilitate drainage - Monitor for developing RDS - Proper nutrition - NPO 4 hours post op - Check for colds or nasopharyngitis - May cause septicemia - Begin with clear liquid - Observe for signs of hemorrhage (frequent swallowing) - Usually happens 6 7 days post op - Protect site of operation - Maintain integrity of logan bar a. Half strength hydrogen peroxide and saline b. Prevent baby from crying c. Prevent cholic d. Check for wet diaper

NECK - Check for symmetry

a. Congenital Torticolis - Wry neck - Birth injury of sternocleidomastoid muscle due to excessive traction during cephalic delivery - Management: - Passive stretching exercises daily - Surgery (last) - Complication is scoliosis

b. Congenital Cretinism (congenital hypothyroidism) absence or non-functioning thyroid glands Signs and Symptoms 1. Change in sucking (early sign) 2. Change in crying 3. Sleep excessively due to decrease metabolism 4. Constipation 5. Moon face baby 6. Mental retardation (late sign) Diagnostic Exam - Radio active iodine uptake - Protein bound iodine - radio immuno assay test Reasons for delayed diagnosis - Thyroid glands are covered by sternocleidomastoid - Baby receive maternal thyroxine

- Sleep 16 20 hours a day Management - Synthroid (synthetic thyroid) - Sodium Levothyroxine (given lifetime)

CHEST - Check for symmetry - Breast produces witch milk a transparent fluid related to hormone changes ABDOMEN - Inspection, Auscultation, Palpation, Percussion

A. Diaphragmatic hernia - Protrusion of stomach contents through a defect in the diaphragm due to failure of pleuroperitoneal canal to close Signs and Symptoms 1. Sunken abdomen 2. Signs of RDS 3. Related to shunting Management - CPAP (continuous positive airway pressure) - Diaphragmatic repair within 24 hours B. Ompalocele - Protrusion of stomach contents between junction of abdominal wall and umbilicus - Small: surgery - Large: - Suspension of surgery - Wrap with sterile wet dressing - Apply silver sulfadiazine ointment to prevent infection

GASTROINTESTINAL SYSTEM 1. FUNCTIONS a. Assists in maintaining fluid and electrolyte and acid/base balance b. Processes and absorbs nutrients to maintain metabolism and support growth and development c. Excrete waste products from the digestive system 2. RECOMMENDED DAILY ALLOWANCE a. Calories: 120 calories per kilo body weight per day (360 380 calories) b. Fluids: 16 20 cc per kilo body weight c. Protein: 2.2 grams per kilo body weight

3. SUPPLEMENTARY FEEDING 4 6 months Principles a. Solid food is offered to the following sequence - Cereals: rich in iron (because at 6 months iron is completely catabolized) - Fruits - Vegetables - Meat b. Begin with small quantities c. Finger food is deferred by 6 months d. Soft table food/modified family menu by 1 year e. Dilute fruit juices (6 months) - Ratio: 1 oz. fruit to 4 oz. water - Never give half cooked egg, may cause gastroenteritis/salmoneliosis diarrhea - Avoid giving honey cause infant botulism - Offer new food 1 at a time with interval of 4 7 days to determine food allergies

4. MAJOR CONCEPTS OF FLUID AND ELECTROLYTE BALANCE Distribution of body fluid

- Total body fluids comprises of 65 85% body weight among infants and children - Fluids are greater ECF compartment among infants and children (prone to dehydration)

5. ACID-BASE BALANCE Dependent on the following a. Chemical buffers b. Renal and respiratory system involvement c. Dilution of strong acids and bases on blood

Imbalance of acid a. Respiratory acidosis - Carbonic acid excess - Hypoventilation - Asthma - Pneumonia - Emphysema - Laryngo tracheo bronchitis - RDS

b. Respiratory alkalosis - Carbonic acid deficit - Hyperventilation - Fever - Encephalitis

c. Metabolic acidosis

- Carbonate deficit - Diarrhea - Severe malnutrition - Dehydration - Celiac crisis

d. Metabolic alkalosis - Carbonate excess - Uncontrolled vomiting - Gastric lavage - NGT aspiration - Pyloric stenosis

6. CONDITIONS THAT PRODUCE FLUIDS AND ELECTROLYTES IMBALANCE A. Vomiting - Forceful expulsion of stomach contents Signs and Symptoms a. Nausea b. Dizziness c. Abdominal cramping d. Flushing of face e. Teary eyes Assessment - Amount - Frequency - Force (projectile:IC, pyloric stenosis) Management Banana

Rice, cereal Apple sauce Toast B. Diarrhea - Exaggerated excretion of intestinal content

1. Acute diarrhea are associated with the following a. Gastroenteritis, caused by salmoneliosis (half cooked egg) b. Antibiotic use c. Dietary indescretions 2. CNSD (Chronic Non Specific Diarrhea) a. Food intolerance b. Carbohydrates and Protein malabsorption c. Excessive fluid intake Assessment - Frequency - Consistency - Appearance of green color stool Complications

Dehydration 1. Mild 5% weight loss 2. Moderate 10% weight loss 3. Severe 15% weight loss Signs of dehydration 1. Tachycardia 2. Tachypnea 3. Hypotension 4. Increase temperature 5. Sunken fontanel and eyeballs 6. Poor skin turgor/dry skin and mucous membrane 7. Absence of tears 8. Scanty urine (mark oliguria sign of severe dehydration)

9. Weight loss 10. Prolonged capillary refill time Management 1. Acute NPO to rest bowel, IV infusion 2. Potassium Chloride check if baby can void because it can lead to hyperkalemia leading to cardiac arrest 3. Sodium Bicarbonate metabolic acidosis, administered slowly to prevent cardiac arrest

7. GASTRIC MOTILITY DISORDER HIRSCHPRUNGS DISEASE - Congenital gagnlionic mega colon - Absence of gagliion cells for peristalsis Assessment 1. Neonatal Period - Failure to pass meconium after 24 hours 2. Early Childhood a. Ribbon like stool b. Constipation c. Diarrhea d. Foul smelling stool Signs and Symptoms - Foul odor breath with stool - Vomitus of fecal materials Management - NGT feeding - Surgery a. Temporary colostomy (at 2 -3 months) b. Anastomosis and pull through procedure - Diet: high calorie and low residue (spaghetti and chicken) Diagnostic Procedures 1. Barium Enema reveals the narrowed portion of the bowel

2. Rectal Biopsy 3. Abdominal x-ray reveals dilated loops on intestine 4. Rectal manometry reveals failure of intestinal sphincter to relax Therapeutic Management and Nursing Care

GASTROESOHAGEAL REFLUX (GER) - Chalasia presence of stomach contents in esophagus Assessment Findings a. Chronic vomiting b. Failure to thrive syndrome (organic) c. Esophageal bleeding manifested by Effects and complication - Esophagitis - Aspiration - Carcinoma Diagnostic procedures 1. Barium Esophogram 2. Esophageal Manometry reveals lower esophageal sphincter pressure 3. Intraesophageal pH content reveals pH of distal esophagus Medications 1. Cholinergics a. Betanicole (Urecholine) - to increase esophageal tone and peristaltic activity b. Metochlopromide (Reglan) to decrease esophageal pressure by relaxing pyloric and duodenal segments increasing peristalsis without stimulating secretion c. Histamine receptor antagonist (Ranitidine/Zantac) to decrease gastric acidity and pepsin secretion d. Antacid (Maalox) to neutralize gastric acid between feedings Management 1. Administration of thickened feeding with cereal to prevent vomiting

2. Feed slowly 3. Burp often every 1 oz. 4. Position: below 9 months place in prone with head of mattress slightly elevated on a 30O angle 5. Surgery: fundoplication

8. OBSTRUCTIVE DISORDERS PYLORIC STENOSIS - Hypertrophy of pylorus muscle causing narrowing and obstruction Assessment 1. Projectile vomiting Nursing Alerts: - Vomiting is an initial symptom of upper GI obstruction - Vomitus of upper GI can be blood tinged not bile streaked - Vomitus of lower GI is bilous - Projectile vomiting is either a sign of ICP or GI obstruction - Abdominal distention is the major symptom of lower GIT obstruction 2. Failure to gain weight

3. Palpate olive shape mass

4. Peristaltic wave visible from left to right across epigastrium

Diagnostic Procedures 1. ABG metabolic alkalosis 2. Serum electrolyte: increase Na and K, decrease chloride 3. Ultrasound

4. X-ray of upper abdomen with barium swallow reveals string sign

Therapeutic Management - Surgery: pyloromyotomy

INTUSSUSCEPTION - Telescoping of one portion of the bowel to another - Complication of peritonitis Signs and Symptoms - Acute paroxysmal abdominal pain - Vomiting - Curant jelly stool - Sausage shape mass Diagnostic test - X-ray with barium enema reveal staircase sign Management - Hypostatic reduction with barium enema

9. INBORN ERRORS OF METABOLISM

- Deficient liver enzyme PHENYLKETONURIA - Deficiency of liver PHT (Phenylalanine Hydroylase Transferase) - No tyrosine, melanin, tyroxine basal metabolism Signs and Symptoms - Fair skin - Blonde hair - Blue eyes - Accumulation of phenyl pyrobic acid in the blood - Musty or mousy odor urine - Atopic dermatitis - Seizure - Mental retardation Diagnostic Tests a. Guthrie test Management - Low phenylalanine indefinitely - No food rich in protein (chicken, eggs, meat, legumes, peanut) - Lofenalac

CELIAC DISEASE - Gluten Enteropathy - Intolerance to foods containing barley, rye, oats, wheat (normally converted to gluten) - With celiac disease gluten is converted to gliadin (toxic to the epithelial cells of villi leading to malabsorption of: - Fats (steatorrhea), Protein and Carbohydrates (malnutrition), Calcium (osteomalacia), Vitamin K (bleeding), Vitamin B12 (anemia) Assessment 1. Early signs a. Diarrhea; failure to regain weight ff diarrheal episodes

b. Constipation c. Vomiting d. Abdominal Pain e. Steatorrhea 2. Late signs a. Behavioral changes: irritability and apathy b. Muscle wasting and loss of subconscious fats (protuberant abdomen) 3. Celiac Crisis a. Exaggerated form of vomiting (emergency condition) Diagnostic Procedures 1. Laboratory Studies: Stool Analysis 2. Serum antigliadin and antireticulin antibodies presence indicates disorder 3. Sweat test to rule out cystic fibrosis Therapeutic Management 1. Vitamin supplements 2. Mineral supplements 3. Steroids 11. POISONING - Common among toddlers Principles 1. Determine the substance taken, assess LOC 2. Unless the poison was corrosive, caustic (strong alkali such as LYE) or a hydrocarbon, vomiting is the most effective way to remove the poison from the body 3. Syrup of ipecac oral emetic to cause vomiting after drug over dose or poisoning a. 15 ml to adolescent, school age and pre school b. 10 ml to infant 4. Universal antidote charcoal, milk of magnesia, and burned toast 5. Never administer the charcoal before ipecac

6. Antidote for Acetaminophen poisoning. Acetylsysteine (Mucomyst) 7. For caustic poison a. Prepare tracheostomy set b. Kerosine (use mineral oil to coat the intestine to prevent absorption) c. Give vinegar to neutralize acid (for muriatic acid ingestion)

LEAD POISONING - Destroy RBC functioning - Resulting to hypochromic mycrocytic anemia - Leading to kidney destruction - That leads to accumulation of amonia - Then encephalitis Assessment a. Beginning symptoms of lethargy b. Impulsive and c. As lead increases, severe encephalophaty with seizures and permanent mental retardation Diagnostic Procedure a. Blood Smear b. Abdominal X-ray c. Long bones Management - Remove from source - If higher than 20 mg/dl last management is chelating agent (balance dimmer parol, CAEDTA) less side effects - Binds with lead and excreted slowly via kidney - Side Effects: nephrotoxicity

ANOGENITAL Alerts

Female - Pseudo menstruation - Slight bleeding related to hormonal changes - Rape - Tearing of forchet - Concerned with childs care - Wound follow different stages of healing - Identical wound - Report to authorities within 48 hours (barangay captain, bantay bata) - Shape of pubic hair is inverted triangle

Male - Check testes (undescended) - Cryptorchidism common in preterms and management is orchidopexy - Warm room and hand - Check for arch of urine - Hydrocele: fluid filled scrotum (translumination reveal a glowing sign) - Phimosis: tight foreskin (balanitis infection of glans penis) - Varicocele: veins in scrotum is increased

EPISPADIAS meatus is located dorsal (above glans penis) HYPOSPADIAS meatus is located ventral (below glans penis) CHORDEE fibrous band causing penis to curve downward

Renal Disorder 1. Nephrotic Syndrome

Causes - Infectious

Assessment Findings - Anasarca (general body edema) - Massive proteinuria - No hematuria - Serum lipid increase - Fatigue - Normal or low BP

Treatment - Steroid (Prednisone) - Diuretics (Lasix)

Nursing Care - Monitor hydration status (weight everyday with same clothing) - Decrease sodium, normal protein - Increase potassium intake (beef broth) Monitor weight Monitor BP Neurologic status Increase iron Decrease potassium Decrease sodium

2. AGN - Autoimmune Grp. A beta hemolytic streptococcus - Primary peripheral periorbital edema - Moderate proteinuria - Gross hematuria (smoky urine) - Serum potassium increased - Fatigue - Increase BP

- Anti hypertensive hydralasine (appresoline) - Hypertensive encephalopathy (complication anemia) - Iron infusion

BACK - Check for symmetry and flatness Spina bifida Occulta - Failure of posterior laminae of vertebrae to fuse - Signs and Symptoms: dimpling at lower back - Abnormal tuffs of hair Spina bifida Cystica - With sac Types 1. Meningocele protrusion of CSF and meninges 2. Myelomeningocele protrusion of CSF, meninges and spinal cord 3. Encephalocele cranial meningocele or myelomeningocele

Common Complication - Common problem is rupture of sac (place wet sterile dressing and place in prone position) - Infection - Urinary and fecal incontinence - Paralysis of lower extremities - Hydrocephalus (CNS complication) - Always check for a wet diaper Treatment - Surgery to prevent infection

SCOLIOSIS - Lateral curvature of spine common in school age and adolescent - Uneven hemline - S shape back - When bending 1 hip is higher and 1 shoulder prominent Management 1. Conservative a. Exercise

b. Avoid obesity 2. Preventive a. Milwaukee brace worn 23 hours a day 3. Corrective a. Surgery insertion of Harrington rod (post op do log rolling or move as 1 unit)

EXTREMITIES I . Digits a. Syndactyly webbing of digits (ginger like foot) congenital b. Polydactyly extra digit c. Olidactyly lacking digit Amelia total absence of extremities Pocomelia absence of distal part of extremities Both are caused by THALIDOMIDE

II. Erb-duchennes paralysis/Brachial Plexus injury/Brachial palsy - Birth injury due to lateral and excessive traction during a breech delivery Signs and Symptoms - Inability to abduct arm from shoulder, rotate arm externally and supinate forearm - Absence/asymmetrical moro reflex Management - Abduct from shoulder with elbow flexed

III. Congenital Hip Dislocation - The head of femur is outside acetabulum Types 1. Subluxated most common type 2. Dislocated

Signs and Symptoms 1. Shortening of the affected leg 2. Asymmetrical gluteal fold 3. Limited movement (early sign) 4. (+) Ortolanis sign clicking sound during abduction 5. When able to walk the child limps (late sign) Management 1. Triple the diaper 2. Carry a stride 3. Frejka Splint 4. Pavlik Harness 5. Hip Spica Cast IV. Talipes - Club foot

Types a. Equinos plantar flexion (horse foot) b. Calcaneous or Dorsiflexion the heel is held lower than the foot/the anterior portion of foot is flexed towards the anterior leg c. Varus foot turns in d. Valgus foot turns out Common combination is TALIPES EQUINO VARUS and TALIPES CALCANEO VALGUS

Assessment - Make a habit of straightening legs and flexing to improve to midline position Management - Corrective shoes (Dennis brown SPLINT) - Spica cast CAST Purpose: - Maintain bone alignment - Prevent muscle spasm - Immobilization - Use open palm

- Support with soft pillow and dry naturally Nursing Care to Patient with Cast - Circulation, motion, sensation (neurovascular check) Signs of Circulatory Impairment Blueness or coldness Lack of peripheral pulse Edema not corrected with elevation Pain on the casted extremity Tingling sensation (notify doctor because it is a sign of neurological impairment) Petaling: making the rough surface of cast smooth Mark cast with ballpen if there is bleeding CRUTCHES - To maintain balance, support weakened leg - Place body on palm - Do palm exercises (squeeze ball) Different Crutch Gaits 1. Swing Through Procedure: 1. Advance both crutches 2. Lift both feet/swing forward/land feet in front of crutches 3. Advance both crutches 4. Lift both feet/swing forward/land feet in front of crutches

2. Swing To Procedure: 1. Advance both crutches

2. Lift both feet/ swing forward/land feet next to crutches 3. Advance both crutches 4. Lift both feet/ swing forward/land feet next to crutches - 1 and 2 is indicated if weight bearing is not allowed in both lower extremities

3. Three Point Gait - Indicated if weight bearing is not allowed on lower extremities Procedure: 1. Advance left foot and both crutches 2. Advance right foot 3. Advance left foot and both crutches 4. Advance right foot

4. Four Point Gail Procedure 1. Advance right crutch 2. Advance left foot 3. Advance left crutch 4. Advance right foot

5. Two Point Gail Procedure 1. Advance left foot and right crutch 2. Advance right foot and left crutch 3. Advance left foot and right crutch 4. Advance right foot and left crutch - 4 and 5 is indicated if weight bearing is not allowed on both lower extremities

Other Crutch-Maneuvering Techniques To Sit Down 1. Grasp the crutches at the hand pieces for control 2. Bend forward slightly while assuming a sitting position 3. Place the affected leg forward to prevent weight-bearing and flexion To Stand Up 1. Move forward to the edge of the chair with the strong leg slightly under the sit 2. Place both crutches in the hand on the side of the affected extremity 3. Push down on the hand piece while raising the body to a standing position To Go Down Stairs 1. Walk forward as far as possible on the step 2. Advance the crutches to the lower step. The weaker leg is advanced first and then the stronger one. In this way the stronger extremity shares the work of raising and lowering the body weight with the patients arms. To Go Up Stairs 1. Advance the stronger leg first up to the next step 2. Then advance the crutches and the weaker extremity (Strong leg goes up first and comes down last.) A memory device for the patients is up with the good, down with the bad.

WALKER - A walker provides more support than a cane or crutches The patient is taught to ambulate with the walker as follows: 1. Patient must hold the walker on the hand grips for stability 2. Lift the walker, placing it in front of you while leaning your body slightly forward 3. Walk into the walker, support your body weight on your hands when advancing your weaker leg permitting partial weight-bearing or non-weight-bearing leg as prescribed 4. Balance yourself on your feet 5. Lift the walker and place it in front of you again. Continue this pattern of walking

CANE - A cane is used to help the patient walk with greater balance and support and to relieve pressure on weight-bearing joints by redistributing the weight. Quad canes (four-footed canes.) The cane is held in the hand opposite to the affected extremity

Methods of transferring the patient from the bed to a wheelchair a. Weight-bearing transfer from bed to chair. The patient stands up, pivots his back is opposite to the new seat, and sits down

b. (Left) Non-weight-bearing transfer from bed to chair. (Right) With legs braced c. (Left) Non-weight-bearing transfer, combined method. (Right) Non-weight-bearing transfer, pull-up method

Therapeutic Exercises
Exercise Passive Description An exercise carried out by the therapist or the nurse without assistance from the patient Purpose To retain as much joint range of motion as possible to maintain circulation Action Stabilize the proximal joint and support the distal part. Move the joint smoothly, slowly, and gently through its full range of motion. Avoid producing pain. Support the distal part, and encourage the patient to take the joint actively through its range of motion. Give no more assistance than is necessary to accomplish the action. Short periods of activity should be followed by adequate rest periods. When possible, active exercise should be performed against gravity. The joint is moved through full range of motion without assistance. (Make sure that the patient does not substitute another joint movement for the one intended.) The patient moves the joint through its range of motion while the therapist resists slightly at first and then with progressively increasing resistance. Sandbags and weights can be used and are applied at the distal point of the involved joint the movement should be performed smoothly. Contract or tighten the muscle as much as possible without moving the joint, hold for several seconds, then let go and relax. Breathe deeply. To maintain strength when a joint is immobilized

Active assistance

An exercise carried out by the patient with the assistance of the therapist or the nurse

To encourage normal muscle function

Active

An exercise accomplished by the patient without assistance, activities include turning from side to side and from back to abdomen and moving up and down in bed.

To increase muscle strength.

Resistive

An active exercise carried out by the patient working against resistance produced by either manual or mechanical means.

To provide resistance increase muscle power.

to

Alternately contracting and relaxing a muscle while keeping the part in a fixed position; this exercise is performed by the patient Isometric or muscl e setting

TRACTION - Use to reduce dislocation and immobilize fractures

Principles of Traction

1. The client should be in dorsal or supine position 2. For every traction there is always a counter traction 3. Line of pull should be in line with deformity 4. For traction to be effective it must continuous Types Straight Traction - Weight of body serves as counter pull

Skin Traction - Applied directly to skin a. Bryants traction - Use to immobilize ages below 3 years old - 90O angle with buttoks off bed b. Bucks extension - Immobilize fracture ages more than 3 years old c. Skeletal - Applied directly to bone d. Halo traction - Immobilize spine

Skeletal Traction Nursing responsibility 1. Assess for circulatory and neurologic impairment 2. It can lead to hypertension 3. Be careful in carrying out nursing functions by not moving the weights

AUTOIMMUNE SYSTEM Types of immunity

a. Passive Natural maternal antibodies through placenta or breast milk b. Active Natural contract disease and produce memory cells c. Passive Artificial receive anti serum with anti bodies from another host (Hepa B) d. Active Artificial receive vaccination and produce memory cell

Immunity from mother (last for 9 12 months) - Diptheria - Polio - Pertusis - Tetanus - Measles

NEUROMUSCULAR SYSTEM: Reflexes a. Blink reflex rapid eyelid closure when strong light is shown

b. Palmar grasp reflex solid object is placed on palm and baby grasp object - Purpose: cling to mother for safety (disappear by 6 weeks 2 months)

c. Step in/Walk-in Place Reflex neonate placed on a vertical position with their face touching a hard surface will take few quick, alternating steps. - Placing Reflex: almost the same with step in place reflex only that you are touching anterior surface of a newborns leg. d. Plantar grasp reflex when an object touches the sole of a newborns foot at the base of toes, the toes grasp in the same manner as fingers do (disappear by 8 9 months in preparation for walking)

e. Tonic-neck-reflex when newborns lie on their backs, their heads usually turn to one side or the other. The arm and the leg on the side to which the head turns extend, and the opposite arm and leg contract.

f. Moro reflex test for neurological integrity (jarring crib, loud voice) assume a letter C position (disappear by 4 5 months)

g. Magnet reflex when there is pressure at the sole of the foot he pushes back against the pressure.

h. Crossed extension reflex when the sole of foot is stimulated by a sharp object, it causes the foot to rise and the other foot extend (test for spinal cord integrity)

i. Truck Incurvation reflex while in prone position and the paravertical area is stimulated, it causes flexion of the trunk and swing his pelvis toward the touch.

j. Landau reflex while prone position and the trunk is being supported, the baby exhibit some muscle tone (test for muscle tone and present by 6 9 months)

k. Parachute reaction while on ventral suspension with the sudden change of equilibrium, it causes extension of the hands and legs (present by 6 9 months)

l. Babinski reflex when the sole of foot is stimulated by an inverted J, it causes fanning of toes (disappear by 2 months but may persist up to 2 years)

TRIAD

MATERNAL/OB NOTES
Human Sexuality Concepts A persons sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to sexual self and eroticism. Sex basic and dynamic aspect of life During reproductive years, the nurse performs as resource person on human sexuality. Definitions related to sexuality: Gender identity sense of femininity or masculinity 2-4 yrs/3 yrs gender identity develops. Role identity attitudes, behaviors and attributes that differentiate roles

Sex biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse. Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change. - developed at the moment of conception. II. Sexual Anatomy and Physiology A. Female Reproductive System 1. External value or pretender a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis. Stages of Pubic Hair Development Tannerscale tool - used to determine sexual maturity rating. Stage 1 Pre-adolescence. No pubic hair. Fine body hair only Stage 2 Occurs between ages 11 and 12 sparse, long, slightly pigmented & curly hair at pubis symphysis Stage 3 occurs between ages 12 and 13 darker & curlier at labia Stage 4 occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh . b. Labia Majora - large lips longitudinal fold, extends symphisis pubis to perineum c. Labia Minora 2 sensitive structures clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual arousal (Greek-key) fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery. Site episiotomy. glands. d. Vestibule an almond shaped area that contains the hymen, vaginal orifice and bartholenes

Urinary Meatus small opening of urethra, serves for urination Skenes glands/or paraurethral gland mucus secreting subs for lubrication hymen covers vaginal orifice, membranous tissue vaginal orifice external opening of vagina bartholenes glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs secrets alkaline subs. Alkaline neutralizes acidity of vagina Ph of vagina - acidic Doderleins bacillus responsible for acidity of vagina Carumculae mystiformes-healing of torn hymen e. Perineum muscular structure loc lower vagina & anus Internal: A. vagina female organ of copulation, passageway of mens & fetus, 3 4inches or 8 10 cm long, dilated canal Rugae permits stretching without tearing B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights. Size- 1x2x3 Shape: nonpregnant pear shaped / pregnant - ovoid Weight - nonpregnant 50 -60 kg- pregnant 1,000g Pregnant/ Involution of uterus: 4th stage of labor - 1000g 2 weeks after delivery - 500g 3 weeks after delivery - 300 g 5-6 weeks after delivery - returns to original, state 50 60 Three parts of the uterus - upper cylindrical layer - upper triangular layer - lower cylindrical layer * Isthmus lower uterine segment during pregnancy Cornua-junction between fundus & interstitial Muscular compositions: there are three main muscle layers which make expansion possible in every direction. Endometrium- inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs during menstruation. Decidua- thick layer. Endometriosis-proliferation of endometrial lining outside uterus. Common site: ovary. fundus corpus/body cervix

S/sx: dysmennorhea, low back pain. Dx: biopsy, laparoscopy Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation 2. Lupreulide (Lupron) inhibit FSH/LH production Myometrium largest part of the uterus, muscle layer for delivery process Its smooth muscles are considered to be the living ligature of the body. - Power of labor, resp- contraction of the uterus Perimetrium protects entire uterus C. ovaries 2 female sex glands, almond shaped. Ext- vestibule int ovaries Function: 1. ovulation 2. Production of hormones d. Fallopian tubes 2-3 inches long that serves as a passageway of the sperm from the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus. 4 significant segments 1. Infundibulum distal part of FT, trumpet or funnel shaped, swollen at ovulation 2. Ampulla outer 3rd or 2nd half, site of fertilization 3. Isthmus site of sterilization bilateral tubal ligation 4. Interstitial site of ectopic pregnancy most dangerous B. Male Reproductive System 1. External penis the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female the glands penis. 3 Cylindrical Layers 2 corpora cavernosa 1 corpus spongiosum Scrotum a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes. cooling mechanism of testes < 2 degrees C than body temp. Leydig cell release testosterone

2. Internal The Process of Spermatogenesis maturation of sperm SHAPE \* MERGEFORMAT

Male and Female homologues Male Penile glans Penile shaft Testes Prostate Cowpers Glands Scrotum Female Clitoral glans Clitorial shaft ovaries Skenes gands Bartholin's glands Labia Majora

III. Basic Knowledge on Genetics and Obstetrics DNA carries genetic code Chromosomes threadlike strands composed of hereditary material DNA Normal amount of ejaculated sperm 3 5 cc., 1 tsp Ovum is capable of being fertilized with in 24 36 hrs after ovulation

Sperm is viable within 48 72 hrs, 2-3 days Reproductive cells divides by the process of meiosis (haploid) Spermatogenesis maturation of sperm Oogenesis process - maturation of ovum Gematogenesis formation of 2 haploid into diploid 23 + 23 = 46 or diploid Age of Reproductivity 15 44yo MenstruationMenstrual Cycle beginning of mens to beginning of next mens Average Menstrual Cycle 28 days Average Menstrual Period - 3 5 days Normal Blood loss 50cc or cup Related terminologies: Menarche 1st mens Dysmenorrhea painful mens Metrorrhagia bleeding between mens Menorhagia excessive during mens Amenorrhea absence of mens Menopause cessation of mens/ average : 51 years old Functions of Estrogen and Progestin * Estrogen Hormone of the Woman Primary function: development secondary sexual characteristic female. Others: inhibit production of FSH ( maturation of ovum) hypertrophy of myometrium Spinnbarkeit & Ferning ( billings method/ cervical) development ductile structure of breast increase osteoblast activities of long bones increase in height in female causes early closure of epiphysis of long bones causes sodium retention increase sexual desire *Progestin Hormone of the Mother Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous (twisted) Secondary Function: uterine contractility (favors pregnancy) Others: 1.inhibit prod of LH (hormone for ovulation) 2.inhibit motility of GIT 3. mammary gland development 4. increase permeability of kidney to lactose & dextrose causing (+) sugar 5. causes mood swings in moms 6. increase BBT 10. Menstrual Cycle 4 phases of Menstrual Cycle 1. Phases of Menstrual Cycle: 1. Proliferative 2. Secretory 3. Ischemic 4. Menses Parts of body responsible for mens: hypothalamus anterior pituitary gland master clock of body ovaries uterus Initial phase 3rd day decreased estrogen 13th day peak estrogen, decrease progesterone 14th day Increase estrogen, increase progesterone 15th day Decrease estrogen, increase progesterone I. On the initial 3rd phase of menstruation , the estrogen level is decreased, this level stimulates the hypothalamus to release GnRH or FSHRF GnRH/FSHRF stimulates the anterior pituitary gland to release FSH Functions of FSH: Stimulate ovaries to release estrogen Facilitate growth primary follicle to become graffian follicle (secrets large amt estrogen & contains mature ovum.) Proliferative Phase proliferation of tissue or follicular phase, post mens phase. Pre-ovularoty. -phase of increase estrogen.

Follicular Phase causing irregularities of mens Postmenstrual Phase Preovulatory Phase phase increase estrogen 13th day of menstruation, estrogen level is peak while the progesterone level is down, these stimulates the hypothalamus to release GnRF on LHRF Mittelschmerz slight abdominal pain on L or RQ of abdomen, marks ovulation day. Change in BBT, mood swing GnRF/LHRF stimulates the ant pit gland to release LH. Functions of LH: (13th day-decreased progesterone) LH stimulates ovaries to release progesterone hormone for ovulation VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation. VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum (secrets large amount of progesterone) VIII. Secretory phaseLutheal Phase Postovulatory Phase Increased progesterone Premenstrual Phase

IX. 24th day if no fertilization, corpus luteum degenerate ( whitish corpus albicans) X. 28th day if no sperm in ovum endometrium begins to slough off to begin mens

Fornix- where sperm is deposited Sperm- small head, long tail, pearly white Phonones-vibration of head of sperm to determine location of ovum Sperm should penetrate corona radiata and zona pellocida. Capacitation- ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida. 11. Stages of Sexual Responses (EPOR) Initial responses: Vasocongestion congestion of blood vessels Myotonia increase muscle tension Excitement Phase (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) erotic stimuli cause increase sexual tension, lasts minutes to hours. Plateau Phase (accelerated V/S) increasing & sustained tension nearing orgasm. Lasts 30 seconds 3 minutes. Orgasm (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 10 sec- most affected are is pelvic area. Resolution (v/s return to normal, genitals return to pre-excitement phase) Refractory Period the only period present in males, wherein he cannot be restimulated for about 10-15 minutes Fertilization Stages of Fetal Growth and Development 3-4 days travel of zygote mitotic cell division begins *Pre-embryonic Stage a. Zygote- fertilized ovum. Lifespan of zygote from fertilization to 2 months b. Morula mulberry-like ball with 16 50 cells, 4 days free floating & multiplication c. Blastocyst enlarging cells that forms a cavity that later becomes the embryo. Blastocyst covering of blastocys that later becomes placenta & trophoblast d. Implantation/ Nidation- occurs after fertilization 7 10 days. Fetus- 2 months to birth. placenta previa implantation at low side of uterus Signs of implantation: 1. slight pain 2. slight vaginal spotting - if with fertilization corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed. 3 processes of Implantation 1. Apposition

2. Adhesion 3. Invasion C. Decidua thickened endometrium ( Latin falling off) * Basalis (base) part of endometrium located under fetus where placenta is delivered * Capsularies encapsulate the fetus * Vera remaining portion of endometrium. Chorionic Villi- 10 11th day, finger life projections 3 vessels= A unoxygenated blood V O2 blood A unoxygenated blood Whartons jelly protects cord Chorionic villi sampling (CVS) removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes. E. Cytotrophoblast inner layer or langhans layer protects fetus against syphilis 24 wks/6 months life span of langhans layer increase. Before 24 weeks critical, might get infected syphilis F. Synsitiotrophoblast synsitial layer responsible production of hormone 1. Amnion inner most layer a. Umbilical Cord- FUNIS, whitish grey, 15 55cm, 20 21. Short cord: abruptio placenta or inverted uterus. Long cord:cord coil or cord prolapse b. Amniotic Fluid bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo-skeletal development 3. maintains temp 4. prevent cord compression 5. help in delivery process

normal amt of amniotic fluid 500 to 1000cc polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid oligohydramnios- decrease amt of fluid kidney disease Diagnostic Tests for Amniotic Fluid A. Amniocentesis empty bladder before performing the procedure. Purpose obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for: Genetic screening- maternal serum alpha feto-protein test (MSAFP) 1st trimester Determination of fetal maturity primarily by evaluating factors indicative of lung maturity 3rd trimester Testing time 36 weeks decreased MSAFP= down syndrome increase MSAFP = spina bifida or open neural tube defect Common complication of amniocenthesis infection Dangerous complications spontaneous abortion 3rd trimester- pre term labor Important factor to consider for amniocentesis- needle insertion site Aspiration of yellowish amniotic fluid jaundice baby Greenish meconium Amnioscopy direct visualization or exam to an intact fetal membrane. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid) Nitrazine Paper Test diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid. Chorion where placenta is developed

Lecithin Sphingomyelin L/S Ratio- 2:1 signifies fetal lung maturity not capable for RDS Shake test amniotic + saline & shake Foam test Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity Placenta (Secundines) Greek pancake, combination of chorionic villi + deciduas basalis. Size: 500g or kg -1 inch thick & 8 diameter Functions of Placenta: Respiratory System beginning of lung function after birth of baby. Simple diffusion GIT transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic Excretory System- artery - carries waste products. Liver of mom detoxifies fetus. Circulating system achieved by selective osmosis Endocrine System produces hormones Human Chorionic Gonadrophin maintains corpus luteum alive. Human placental Lactogen or sommamommamotropin Hormone for mammary gland development. Has a diabetogenic effect serves as insulin antagonist Relaxin Hormone- causes softening joints & bones estrogen progestin It serves as a protective barrier against some microorganisms HIV,HBV Fetal Stage Fetal Growth and Development Entire pregnancy days 266 280 days 37 42 weeks Differentiation of Primary Germ layers * Endoderm 1st week endoderm primary germ layer Thyroid for basal metabolism Parathyroid - for calcium Thymus development of immunity Liver lining of upper RT & GIT * Mesoderm development of heart, musculoskeletal system, kidneys and repro organ * Ectoderm development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth First trimester: 1st month Brain & heart development GIT& resp Tract remains as single tube 1. Fetal heart tone begins heart is the oldest part of the body 2. CNS develops dizziness of mom due to hypoglycemic effect Food of brain glucose complex CHO pregnant womans food (potato) Second Month All vital organs formed, placenta developed Corpus luteum source of estrogen & progesterone of infant life span end of 2nd month Sex organ formed Meconium is formed Third Month Kidneys functional Buds of milk teeth appear Fetal heart tone heard Doppler 10 12 weeks Sex is distinguishable Second Trimester: FOCUS length of fetus Fourth Month

lanugo begins to appear fetal heart tone heard fetoscope, 18 20 weeks buds of permanent teeth appear Fifth Month lanugo covers body actively swallows amniotic fluid 19 25 cm fetus, Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks multi fetal heart tone heard with or without instrument Sixth Month eyelids open wrinkled skin vernix caseosa present Third trimester: Period of most rapid growth. FOCUS: weight of fetus Seventh Month development of surfactant lecithin Eighth Month lanugo begin to disappear sub Q fats deposit Nails extend to fingers Ninth Month lanugo & vernix caseosa completely disappear Amniotic fluid decreases Tenth Month bone ossification of fetal skull Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus Drugs: Streptomycin anti TB & or Quinine (anti malaria) damage to 8th cranial nerve poor hearing & deafness Tetracycline staining tooth enamel, inhibit growth of long bone Vitamin K hemolysis (destr of RBC), hyperbilirubenia or jaundice Iodides enlargement of thyroid or goiter Thalidomides Amelia or pocomelia, absence of extremities

Steroids cleft lip or palate Lithium congenital malformation Alcohol lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephaly Smoking low birth rate Caffeine low birth rate Cocaine low birth rate, abruption placenta TORCH (Teratogenic) Infections viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus. T toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat O others. Hepa A or infectious heap oral/ fecal (hand washing) Hepa B, HIV blood & body fluids Syphilis R rubella German measles congenital heart disease (1st month) normal rubella titer 1:10 <1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Dont get pregnant for 3 months. Vaccine is teratogenic C cytomegalo virus H herpes simplex virus Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes 1. Cardiovascular System increase blood volume of mom (plasma blood) 30 50% = 1500 cc of blood - easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to hyperemia of nasal membrane palpitation, Physiologic Anemia pseudo anemia of pregnant women Normal Values Hct 32 42% Hgb 10.5 14g/dL Criteria 1st and 3rd trimester.- pathologic anemia if lower HCT should not be 33%, Hgb should not be < 11g/dL 2nd trimester Hct should not <32% Hgb Shdn't < 10.5% pathologic anemia if lower Pathogenic Anemia Iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women. Assessment reveals: Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia Nursing Care: Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly administered, hematoma. Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation Monitor for hemorrhage Alert: Iron from red meats is better absorbed iron form other sources Iron is better absorbed when taken with foods high in Vit C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip level. Varicosities pressure of uterus use support stockings, avoid wearing knee high socks use elastic bandage lower to upper Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under hips or modified knee chest position Thrombophlebitis presence of thrombus at inflamed blood vessel pregnant mom hyperfibrinogenemia increase fibrinogen increase clotting factor thrombus formation candidate Outstanding sign (+) Homan's sign pain on cuff during dorsiflexion Milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Mgt: Bed rest Never massage Assess + Homan sign once only might dislodge thrombus Give anticoagulant to prevent additional clotting (thrombolytics will dilute) Monitor APTT antidote for Heparin toxicity, protamine sulfate Avoid aspirin! Might aggravate bleeding. Respiratory system common problem SOB due to enlarged uterus & increase O2 demand Position- lateral expansion of lungs or side lying position. Gastrointestinal 1st trimester change

Morning Sickness nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg emesisgravida. Metabolic alkalosis, F&E imbalance primary med mgt replace fluids. Monitor I&O constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet - fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha. Except guava has pectin thats constipating veg petchy, malungay. - exercise -mineral oil excretion of fat soluble vitamins * Flatulence avoid gas forming food cabbage * Heartburn or pyrosis reflux of stomach content to esophagus - small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical increase salivation ptyalsim mgt mouthwash *Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort Urinary System frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos mgt for nocturia Acetyace test albumin in urine Benedicts test sugar in urine Musculoskeletal Lordosis pride of pregnancy Waddling Gait awkward walking due to relaxation causes softening of joints & bones Prone to accidental falls wear low heeled shoes Leg Cramps causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab. Vit D for increased Ca absorption dorsiflexion B. Local Changes Local change: Vagina: V Chadwicks sign blue violet discoloration of vagina C Goodel's sign change of consistency of cervix I Hegar's change of consistency of isthmus (lower uterine segment) LEUKORRHEA whitish gray, mousy odor discharge ESTROGEN hormone, resp for leucorrhea OPERCULUM mucus plug to seal out bacteria. PROGESTERONE hormone responsible for operculum PREGNANT acidic to alkaline change to protect bacterial growth (vaginitis) Problems Related to the Change of Vaginal Environment: Vaginitits trichomonas vaginalis due to alkaline environment of vagina of pregnant mom Flagellated protozoa wants alkaline S&Sx: Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so dont give at 1st trimester treat dad also to prevent reinfection no alcohol has antibuse effect VAGINAL DOUCHE IQ H2O : 1 tbsp white vinegar

Moniliasis or candidiasis due to candida albecans, fungal infection. Color white cheese like patches adheres to walls of vagina. Signs & Symptoms: Management antifungal Nistatin, genshan violet, cotrimaxole, canesten Gonorrhea -Thick purulent discharge Vaginal warts- condifoma acuminata due to papilloma virus Mgt: cauterization 2. Abdominal Changes striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue avoid scratching, use coconut oil, umbilicus is protruding Skin Changes brown pigmentation nose chin, cheeks chloasma melasma due to increased melanocytes. Brown pinkish line- linea nigra- symphisis pubis to umbilicus 4. Breast Changes increase hormones, color of areola & nipple pre colostrums present by 6 weeks, colostrums at 3rd trimester Breast self exam- 7 days after mens supine with pillow at back quadrant B upper outer common site of cancer Test to determine breast cancer: 1. mammography 35 to 49 yrs once every 1 to 2 yrs 50 yrs and above 1 x a yr Ovaries rested during pregnancy Signs & symptoms of Pregnancy Presumptive s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . Subjective Probable signs observed by the members of health team. Objective Positive Signs undeniable signs confirmed by the use of instrument. Ballotment sign of myoma * + HCG sign of H mole - trans vaginal ultrasound. Empty bladder - ultrasound full bladder placental grading rating/grade o immature 1 slightly mature 2 moderately mature 3 placental maturity What is deposited in placenta which Presumptive Breast changes Urinary freq Fatigue Amenorrhea Morning sickness Enlarged uterus Cloasma Linea negra Increased skin pigmentation Striae gravidarium Quickening

signify maturity - there is calcium Probable Goodel's- change of consistency of cervix Chadwicks- blue violet discoloration of vagina Hegar's- change of consistency of isthmus Elevated BBT due to increased progesterone Positive HCG or (+)preg test Ballottement bouncing of fetus when lower uterine is tapped sharply Enlarged abdomen Braxton Hicks contractions painless irregular contractions

Positive Ultrasound evidence (sonogram) full bladder Fetal Fetal Fetal Fetal heart tone movement outline parts palpable

Psychological Adaptation to Pregnancy (Emotional response of mom Reva Rubin theory) First Trimester: No tanginal signs & sx, surprise, ambivalence, denial sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy

Focus: bodily changes of preg, nutrition Second Trimester tangible S&Sx. mom identifies fetus as a separate entity due to presence of quickening, fantasy. Developmental task accept growing fetus as baby to be nurtured. Health teaching: growth & development of fetus. Third Trimester: - mom has personal identification on appearance of baby Development task: prepare of birth & parenting of child. HT: responsible parenthood babys Layette best time to do shopping. Most common fear let mom listen to FHT to allay fear Lamaze classes VII. Pre-Natal Visit: Frequency of Visit:

1st 7 months 1x a month 8 9 months 2 x a month 10 once a week post term 2 x a week Personal data name, age (high risk < 18 & >35 yrs old) record to determine high risk HBMR. Home base moms record. Sex ( pseudocyesis or false pregnancy on men & women) Couvade syndrome dad experiences what mom goes through lihi) Address, civil status, religion, culture & beliefs with respect, non judgmental Occupation financial condition or occupational hazards, education background level knowledge Diagnosis of Pregnancy urine exam to detect HCG at 40 100th day. 60 70 day peak HCG. 6 weeks after LMP- best to get urine exam. Elisa test test for preg detects beta subunit of HCG as early as 7 10days Home preg kit do it yourself Baseline Data: V/S esp. BP, monitor wt. (increase wt 1st sign preeclampsia) Weight Monitoring First Trimester: Normal Weight gain Second trimester:normal weight gain Third trimester: normal weight gain Minimum wt gain 20 25 lbs Optimal wt gain 25 35 lbs 1.5 3 lbs 10 12 lbs 10 12 lbs (.5 1lb/month) (4 lbs/month) (1 lb/wk) (4 lbs/ month) ( 1lb/wk)

Obstetrical Data: nullipara no pregnancy Gravida- # of pregnancy Para - # of viable pregnancy Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age. age of viability - 20 24 wks Term 37 42 wks, Preterm -20 37 weeks abortion <20 weeks Sample Cases: 1 abortion GTPAL 1 2nd mo 2 0 01 0 G2 P0 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 40th AOG 36th AOG misc twins35 AOG 4th month G6 P3 GT P A L 612 2 4

39th week miscarriage stillbirth 33 AOG (considered as para) preg 3rd wk

GP GTPAL 4 2 4 11 1 1

33 P 41st L abort A still 39 triplet 32 4th mon

GP 64

GTPAL 6 2 2 15

Important Estimates: Nageles Rule use to determine expected date of delivery Get LMP -3+ 7 +1 Apr-Dec LMP Jan Feb Mar M D Y +9 +7 no year LMP Jan 25, 04 +9 +7 10 / 32 / 04 - 1 add 1 month to month 11/31/04 EDD McDonalds Rule to determine age of gestation IN WEEKS FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8 Fr sypmhisis pubis to fundus 24 X 7 =21 wks 8 Bartholomews Rule to determine age of gestation by proper location of fundus at abdominal cavity. 3 months above sym pub 5 months level of umbilicus 9 months below zyphoid 10 months level of 8 months due to lightening Haases rule to determine length of the fetus in cm. Formula: 1st of preg , square @ month 2nd of preg, x @ month by 5 3mos x 3 = 9cm 4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st of preg 5 x 5 = 25 cm 6 7 8 9 x x x x 5 5 5 5 = = = = 30 35 40 45 cm cm cm cm 2nd of preg

tetanus immunizations prevents tetanus neonatum -mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3 TT1 TT2 TT3 TT4 TT5 any time during pregnancy 4 wks after TT1 3 yrs protection 6 months after TT2 5 yrs protection 1 yr after TT3 10 yrs protection yr after TT4 lifetime protection

Physical Examination: A. Examine teeth: sign of infection Danger signs of Pregnancy C - chills/ fever - infection Cerebral disturbances ( headache preeclampsia) A abdominal pain ( epigastric pain aura of impending convulsions B boardlike abdomen abruption placenta Increase BP HPN Blurred vision preeclampsia Bleeding 1st trimester, abortion, ectopic pre/2nd H mole, incompetent cervix 3rd placental anomalies S sudden gush of fluid PROM (premature rupture of membrane) prone to inf. E edema to upper ext. (preeclampsia) Pelvic Examination internal exam empty bladder universal precaution

EXT OS of cervix site for getting specimen Site for cervical cancer Pap Smear cervical cancer - composed of squamous columnar tissue Result: Class I - normal Class IIA acytology but no evidence of malignancy B suggestive of infl. Class III cytology suggestive of malignancy Class IV cytology strongly suggestive of malignancy Class V cytology conclusive of malignancy Stages of Cervical Cancer Stage 0 carcinoma insitu 1 cancer confined to cervix 2 - cancer extends to vagina 3 pelvis metastasis 4 affection to bladder & rectum 7. Leopolds Maneuver Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone - use palm! Warm palm. Prep mom: Empty bladder Position of mom-supine with knee flex (dorsal recumbent to relax abdominal muscles) Procedure: 1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation 2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff fundic souffl (FHR) & uterine souffl. Uterine souffl maternal H rate 3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers. To determine degree of engagement. Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be movable). 4th Maneuver: the Examiner changes the position by facing the patients feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude relationship of fetus to 1 another. When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head will be flexed and vertex presenting. Attitude relationship of fetus to a part or degree of flexion Full flexion when the chin touches the chest 8.Assessment of Fetal Well-BeingDaily Fetal Movement Counting (DFMC) begin 27 weeks Mom- begin after meal - breakfast a. Cardiff count to 10 method one method currently available (1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) (2) Expected findings 10 movements in 1 hour or less 3) Warning signs a.) more then 1 hour to reach 10 movements b.) less then 10 movements in 12 hours(non-reactive- fetal distress) c.) longer time to reach 10 FMs than on previous days d.) movement are becoming weaker, less vigorous Movement alarm signals - < 3 FMs in 12 hours 4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples:

nonstress test (NST), biographical profile (BPP) Nonstress test to determine the response of the fetal heart rate to activity Indication pregnancies at risk for placental insufficiency Postmaturity pregnancy induced hypertension (PIH), diabetes warning signs noted during DFMC maternal history of smoking, inadequate nutrition Procedure: Done within 30 minutes wherein the mother is in semi-fowlers position (w/ fetal monitor); external monitor is applied to document fetal activity; mother activates the mark button on the electronic monitor when she feels fetal movement. Attach external noninvasive fetal monitors tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected monitor until at least 2 FMs are detected in 20 minutes if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen if no FM after 1 hour further testing may be indicated, such as a CST Result: Noncreative Nonstress Not Good

Reactive Responsive is Real Good

Interpretation of results reactive result Baseline FHR between 120 and 160 beats per minute At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a 10 to 20 minute period as a result of FM Good variability normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip. result indicates a healthy fetus with an intact nervous system ii. Nonreactive result Stated criteria for a reactive result are not met Could be indicative of a compromised fetus. Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST) 9. Health teachings a. Nutrition do nutritional assessment daily food intake High risk moms: Pregnant teenagers low compliance to heath regimen. Extremes in wt underweight, over wt candidate for HPN, DM Low socio economic status Vegetarian mom decrease CHON needs Vit B12 cyanocobalamin formation of folic acid needed for cell DNA & RBC formation. (Decrease folic acid spina bifida/open neural tube defect) How many Kcal CHO x4,CHON x4, fats x 9 Recommended Nutrient Requirement that increases During Pregnancy Nutrients Requirements Food Source Calories 300 calories/day above the Caloric increase should reflect Essential to supply energy for prepregnancy daily requirement Foods of high nutrient value increased metabolic rate to maintain ideal body weight such as protein, complex utilization of nutrients and meet energy requirement to carbohydrates (whole protein sparing so it can be activity level grains, vegetables, fruits) used for Begin increase in second Variety of foods representing Growth of fetus trimester foods sources for the Development of structures Use weight gain pattern as nutrients requiring during required for pregnancy an indication of adequacy of pregnancy including placenta, amniotic calorie intake. No more than 30% fat fluid, and tissue growth. Failure to meet caloric requirements can lead to

ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage. Protein Essential for: Fetal tissue growth Maternal tissue growth including uterus and breasts Development of essential pregnancy structures Formation of red blood cells and plasma proteins * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH) Calcium-Phosphorous Essential for Growth and development of fetal skeleton and tooth buds Maintenance of mineralization of maternal bones and teeth Current research is : Demonstrating an association between adequate calcium intake and the prevention of pregnancy induce hypertension Iron Essential for Expansion of blood volume and red blood cells formation Establishment of fetal iron stores for first few months of life 60 mg/day or an increase of 10% above daily requirements for age group Adolescents have a higher protein requirement than mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement Calcium increases of 1200 mg/day representing an increase of 50% above prepregnancy daily requirement. 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous 30 mg/day representing a doubling of the pregnant daily requirement Begin supplementation at 30mg/day in second trimester, since diet alone is unable to meet pregnancy requirement 60 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia. 70 mg/day of vitamin C which enhances iron absorption inadequate iron intake results in maternal effects anemia depletion of iron stores, decreased energy and appetite, cardiac stress especially labor and birth fetal effects decreased availability of oxygen thereby affecting fetal growth * iron deficiency anemia is the most common nutritional disorder of pregnancy. 15mcg/day representing an increase of 3 mg/day over prepreganant daily requirements. Protein increase should reflect Lean meat, poultry, fish Eggs, cheese, milk Dried beans, lentils, nuts Whole grains * vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids

Calcium increases should reflect: dairy products : milk, yogurt, ice cream, cheese, egg yolk whole grains, tofu green leafy vegetables canned salmon & sardines w/ bones Ca fortified foods such as orange juice Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood Iron increases should reflect liver, red meat, fish, poultry, eggs enriched, whole grain cereals and breads dark green leafy vegetables, legumes nuts, dried fruits vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage, potatoes iron from food sources is more readily absorbed when served with foods high in vit C

Zinc Essential for * the formation of enzymes * maybe important in the prevention of congenital malformation of the fetus.

Zinc increases should reflect liver, meats shell fish eggs, milk, cheese whole grains, legumes, nuts

Folic Acid, Folacin, Folate Essential for formation of red blood cells and prevention of anemia DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects (spina bifida), abortion, abruption placenta Additional Requirements Minerals iodine Magnesium Selenium Vitamins E Thiamine Riborlavin Pyridoxine ( B6) B12 Niacin

400 mcg/day representing an increase of more then 2 times the daily prepregnant requirement. 300mcg/day supplement for women with low folate levels or dietary deficiency 4 servings of grains/day

Increases should reflect liver, kidney, lean beef, veal dark green leafy vegetables, broccoli, legumes. Whole grains, peanuts

175 mcg/day 320 mg/day 65 mcg/day

10 mg/day 1.5 mg/day 1.6 mg/day 2.2 mg/day 2.2 mg day 17 mg/day

Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy. Vit stored in body. Taking it not needed fat soluble vitamins. Hard to excrete.

2.Sexual Activity should be done in moderation should be done in private place mom placed in comfy pos, sidelying or mom on top avoided 6 weeks prior to EDD avoid blowing or air during cunnilingus changes in sexual desire of mom during preg- air embolism Changes in sexual desire: 1st tri decrease desire due to bodily changes 2nd trimester increased desire due to increase estrogen that enhances lubrication 3rd trimester decreased desire Contraindication in sex: 1. vaginal spotting 1st trimester threatened abortion 2nd trimester placenta previa 2. incompetent cervix 3. preterm labor 4. premature rupture of membrane Exercise to strengthen muscles used during delivery process principles of exercise Done in moderation. 2.) Must be individualized Walking best exercise Squatting strengthen muscles of perineum. Increase circulation to perineum. Squat feet flat on floor Tailor Sitting 1 leg in front of other leg ( Indian seat) Raise buttocks 1st before head to prevent postural hypotension dizziness when changing position shoulder circling exercise- strengthen chest muscles pelvic rocking/pelvic tilt- exercise relieves low back pain & maintain good posture * arch back standing or kneeling. Four extremities on floor Kegel Exercise strengthen pulococcygeal muscles - as if hold urine, release 10x or muscle contraction Abdominal Exercise strengthens muscles of abdominal done as if blowing candle 4. Childbirth Preparation: Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.

a. Psychophysical 1. Bradley Method Dr. Robert Bradley advocated active participation of husband at delivery process. Based on imitation of nature. Features: 1.) 2.) 3.) 4.) darkened rm quiet environment relaxation tech closed eye & appearance of sleep

2. Grantly Dick Read Method fear leads to tension while tension leads to pain b. Psychosexual 1. Kitzinger method preg, labor & birth & care of newborn is an impt turning pt in womans life cycle - flow with contraction than struggle with contraction c. Psychoprophylaxis prevention of pain 1. Lamaze: Dr. Ferdinand Lamaze req. disciple, conditioning & concentration. Husband is coach Features: Conscious relaxation Cleansing breathe inhale nose, exhale mouth Effleurage gentle circular massage over abdominal to relieve pain imaging sensate focus Different Methods of delivery: birthing chair bed convertible to chair semifowlers birthing bed dorsal recumbent pos squatting relives low back pain during labor pain leboyers warm, quiet, dark, comfy room. After delivery, baby gets warm bath. Birth under H20 bathtub labor & delivery warm water, soft music. IX. Intrapartal Notes inside ER A. Admitting the laboring Mother: Personal Data: name, age, address, etc Baseline Data: v/s esppecially BP, weight Obstetrical Data: gravida # preg, para- viable preg, 22 24 wks Physical Exams,Pelvic Exams B. Basic knowledge in Intrapartum. b. 1 Theories of the Onset of Labor 1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) contraction action 2.) oxytocin theory post pit gland releases oxytocin. Hypothalamus produces oxytocin 3.) prostaglandin theory stimulation of arachidonic acid prostaglandin- contraction 4.) progesterone theory before labor, decrease progesterone will stimulate contractions & labor 5.) theory of aging placenta life span of placenta 42 wks. At 36 wks degenerates (leading to contraction onset labor). b.2. The 4 Ps of labor 1. Passenger a. Fetal head is the largest presenting part common presenting part of its length. Bones 6 bones S sphenoid F frontal - sinciput E ethmoid O occuputal - occiput T temporal P parietal 2 x Measurement fetal head: transverse diameter 9.25cm biparietal largest transverse bitemporal 8 cm bimastoid 7cm smallest transverse Sutures intermembranous spaces that allow molding. sagittal suture connects 2 parietal bones ( sagitna) coronal suture connect parietal & frontal bone (crown) lambdoidal suture connects occipital & parietal bone

Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis Fontanels: Anterior fontanel bregma, diamond shape, 3 x 4 cm,( > 5 cm hydrocephalus), 12 18 months after birth- close Posterior fontanel or lambda triangular shape, 1 x 1 cm. Closes 2 3 months. 4.) Anteroposterior diameter suboccipitobregmatic 9.5 cm, complete flexion, smallest AP occipitofrontal 12cm partial flexion occipitomental 13.5 cm hyper extension submentobragmatic-face presentation 2. Passageway Mom 1.) < 49 tall 2.) < 18 years old 3.) Underwent pelvic dislocation Pelvis 4 main pelvic types 1. Gynecoid round, wide, deeper most suitable (normal female pelvis) for pregnancy 2. Android heart shape male pelvis- anterior part pointed, posterior part shallow 3. Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse narrow 4. Platypelloid flat AP diameter narrow, transverse wider b. Pelvis 2 hip bones 2 innominate bones 3 Parts of 2 Innominate Bones Ileum lateral side of hips - iliac crest flaring superior border forming prominence of hips Ischium inferior portion - ischial tuberosity where we sit landmark to get external measurement of pelvis Pubes ant portion symphisis pubis junction between 2 pubis 1 sacrum post portion sacral prominence landmark to get internal measurement of pelvis 1 coccyx 5 small bones compresses during vaginal delivery Important Measurements 1. Diagonal Conjugate measure between sacral promontory and inferior margin of the symphysis pubis. Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC 11.5 cm=true conjugate) 2. True conjugate/conjugate vera measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm 3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or more. Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial tuberosity approximated with use of fist 8 cm & above. 3. Power the force acting to expel the fetus and placenta myometrium powers of labor a. Involuntary Contractions b. Voluntary bearing down efforts c. Characteristics: wave like d. Timing: frequency, duration, intensity 4. Psyche/Person psychological stress when the mother is fighting the labor experience a. Cultural Interpretation b. Preparation c. Past Experience d. Support System Pre-eminent Signs of Labor S&Sx: - shooting pain radiating to the legs - urinary freq. 1. Lightening setting of presenting part into pelvic brim - 2 weeks prior to EDD * Engagement- setting of presenting part into pelvic inlet 2. Braxton Hicks Contractions painless irregular contractions 3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine 4. Ripening of the Cervix butter soft 5. decreased body wt 1.5 3 lbs 6. Bloody Show pinkish vaginal discharge blood & leukorrhea

7. Rupture of Membranes rupture of water. Check FHT Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse Contraction drop in intensity even though very painful Contraction drop in frequently Uterus tense and/or contracting between contractions Abdominal palpations Nursing Care; Administer Analgesics (Morphine) Attempt manual rotation for ROP or LOP most common malposition Bear down with contractions Adequate hydration prepare for CS Sedation as ordered Cesarean delivery may be required, especially if fetal distress is noted Cord Prolapse a complication when the umbilical cord falls or is washed through the cervix into the vagina. Danger signs: PROM Presenting part has not yet engaged Fetal distress Protruding cord form vagina

Nursing care: Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy. Slip cord away from presenting part Count pulsation of cord for FHT Prep mom for CS Positioning trendelenberg or knee chest position Emotional support Prepare for Cesarean Section Difference Between True Labor and False Labor False Labor True Labor Irregular contractions Contractions are regular No increase in intensity Increased intensity Pain confined to abdomen Pain begins lower back radiates to abdomen Pain relived by walking Pain intensified by walking No cervical changes Cervical effacement & dilatation * major sx of true labor. Duration of Labor Primipara 14 hrs & not more than 20 hrs Multipara 8 hrs & not > 14 hrs Effacement softening & thinning of cervix. Use % in unit of measurement Dilation widening of cervix. Unit used is cm. Nursing Interventions in Each Stage of Labor 2 segments of the uterus 1. upper uterine - fundus 2. lower uterine isthmus 1. First Stage: onset of true contractions to full dilation and effacement of cervix. Latent Phase: Assessment: Dilations: 0 3 cm mom excited, apprehensive, can communicate Frequency: every 5 10 min Intensity mild Nursing Care: Encourage walking - shorten 1st stage of labor Encourage to void q 2 3 hrs full bladder inhibit contractions Breathing chest breathing Active Phase:

Assessment:

Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self Frequency q 3-5 min lasting for 30 60 seconds

Nursing Care: M edications have meds ready A ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc. D dry lips oral care (ointment) dry linens B abdominal breathing Transitional Phase: Assessment: Dilations 8 10 cm Frequency q 2-3 min contractions Durations 45 90 seconds intensity: strong Mom mood changes with hyperesthesia

Hyperesthesia increase sensitivity to touch, pain all over Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain keep informed of progress controlled chest breathing Nursing Care: T ires I nform of progress R estless support her breathing technique E ncourage and praise D iscomfort Pelvic Exams Effacement Dilation a. Station landmark used: ischial spine - 1 station = presenting part 1cm above ischial spine if (-) floating - 2 station = presenting part 2 cm above ischial spine if (-) floating 0 station = level at ischial spine engagement + 1 station = below 1 cm ischial spine +3 to +5 = crowning occurs at 2nd stage of labor b. Presentation/lie the relationship of the long axis (spine) of the fetus to the long axis of the mother -spine of mom and spine of fetus Two types: b.1. Longitudinal Lie ( Parallel) cephalic Vertex complete flexion Face Brow Poor Flexion Chin Breech Complete Breech thigh breast on abdomen, breast lie on thigh Incomplete Breech thigh rest on abdominal Frank legs extend to head Footling single, double Kneeling b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation. c. Position relationship of the fatal presenting part to specific quadrant of the mothers pelvis. Variety: Occipito LOA left occipito ant (most common and favorable position) side of maternal pelvis LOP left occipito posterior LOP most common mal position, most painful ROP squatting pos on mom ROT ROA Breech- use sacrum - put stet above umbilicus Shoulder/acromniodorso LADA, LADT, LADP, RADA Chin / Mento LSA left sacro anterior LST, LSP, RSA, RST, RSP

LMA, LMT, LMP, RMP, RMA, RMT, RMP Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus to monitor contractions Parts of contractions: Increment or crescendo beginning of contractions until it increases Acme or apex height of contraction Decrement or decrescendo from height of contractions until it decreases Duration beginning of contractions to end of same contraction Interval end of 1 contraction to beginning of next contraction Frequency beginning of 1 contraction to beginning of next contraction Intensity - strength of contraction Contraction vasoconstriction Increase BP, decrease FHT Best time to get BP & FHT just after a contraction or midway of contractions Placental reserve 60 sec o2 for fetus during contractions Duration of contractions shouldnt >60 sec Notify MD Mom has headache check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia Health teachings 1.) Ok to shower 2.)NPO GIT stops function during labor if with food- will cause aspiration 3.)Enema administer during labor a.)To cleanse bowel b.)Prevent infection c.)Sims position/side lying 12 18 inch ht enema tubing Check FHT after adm enema Normal FHT= 120-160 Signs of fetal distress1.) <120 & >160 2.) mecomium stain amnion fluid 3.) fetal thrushing hyperactive fetus due to lack O2 2. Second Stage: fetal stage, complete dilation and effacement to birth. 7 8 multi bring to delivery room 10cm primi bring to delivery room Lithotomy pos put legs same time up Bulging of perineum sure to come out Breathing panting ( teach mom) Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2nd stage of labor. Episiotomy median less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula) Mediolateral more bleeding & pain, hard to repair, slow to heal -use local or pudendal anesthesia. Ironing the perineum to prevent laceration Modified Ritgens maneuver place towel at perineum 1.)To prevent laceration 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby. Mechanisms of labor Engagement Descent Flexion Internal Rotation Extension External rotation Expulsion Three parts of Pelvis 1. Inlet AP diameter narrow, transverse diameter wider

2. Cavity Two Major Divisions of Pelvis True pelvis below the pelvic inlet False pelvis above the pelvic inlet; supports uterus during pregnancy Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis. Nursing Care: To prevent puerperal sepsis - < 48 hours only vaginal pack Bolus of Ptocin can lead to hypotension. Third Stage: birth to expulsion of Placenta -placental stage Placenta delivered from 3-10 minutes Signs of placental separation Fundus rises becomes firm & globular Calkins sign Lengthening of the cord Sudden gush of blood placenta has 15 28 cotyledons

Types of placental delivery Shultz shiny begins to separate from center to edges presenting the fetal side shiny Dunkan dirty begin to separate form edges to center presenting natural side beefy red or dirty Slowly pull cord and wind to clamp BRANDT ANDREWS MANEUVER Hurrying of placental delivery will lead to inversion of uterus. Nsg care for placenta: Check completeness of placenta. Check fundus (if relaxed, massage uterus) Check bp Administer methergine IM (Methylergonovine Maleate) Ergotrate derivatives Monitor hpn (or give oxytocin IV) Check perineum for lacerations Assist MD for episiorapy Flat on bed Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy. Fourth Stage: the first 1-2 hours after delivery of placenta recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes. Check placement of fundus at level of umbilicus. If fundus above umbilicus, deviation of fundus Empty bladder to prevent uterine atony Check lochia Maternal Observations body system stabilizes Placement of the Fundus Lochia Perineum R - edness E- demaE - cchymosisD ischarges A approximation of blood loss. Count pad & saturation Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc Bonding interaction between mother and newborn rooming in types Straight rooming in baby: 24hrs with mom. Partial rooming in: baby in morning , at night nursery Complications of Labor Dystocia difficult labor related to: Mechanical factor due to uterine inertia sluggishness of contraction hypertonic or primary uterine inertia intense excessive contractions resulting to ineffective pushing MD administer sedative valium,/diazepam muscle relaxant hypotonic secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin. Prolonged labor normal length of labor in primi 14 20 hrs Multi 10 -14 hrs

> 14 hrs in multi & > 20 hrs in primi maternal effect exhaustion. Fetal effect fetal distress, caput succedaneum or cephal hematoma nsg care: monitor contractions and FHR Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding. Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing dx: fluid volume deficit Post of mom modified trendelenberg IV fast drip due fluid volume def Signs of Hypovolemic Shock: Hypotension Tachycardia Tachypnea Cold clammy skin Inversion of the uterus situation uterus is inside out. MD will push uterus back inside or not hysterectomy. Factors leading to inversion of uterus short cord hurrying of placental delivery ineffective fundal pressure Uterine Rupture Causes: 1.) 1.)Previous classical CS 2.)Large baby 3.) Improper use of oxytocin (IV drip) Sx: sudden pain profuse bleeding hypovolemic shock TAHBSO Physiologic retraction ring Boundary bet upper/lower uterine segment BANDLS pathologic ring suprapubic depression a.) sign of impending uterine rupture Amniotic Fluid Embolism or placental embolism amniotic fluid or fragments of placenta enters natural circulation resulting to embolism Sx: dyspnea, chest pain & frothy sputum prepare: suctioning end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body eyes, nose, etc. Trial Labor measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor Multi: 8 14, primi 14 20 Preterm Labor labor after 20 37 weeks) ( abortion <20 weeks) Sx: 1. premature contractions q 10 min 2. effacement of 60 80% 3. dilation 2-3 cm Home Mgt: 1. complete bed rest 2. avoid sex 3. empty bladder 4. drink 3 -4 glasses of water full bladder inhibits contractions 5. consult MD if symptoms persist Hosp: 1. If cervix is closed 2 3 cm, dilation saved by administer Tocolytic agents- halts preterm contractions.YUTOPAR- Yutopar Hcl) 150mg incorporated 500cc Dextrose piggyback. Monitor: FHT > 180 bpm Maternal BP - <90/60 Crackles notify MD pulmo edema administer oral yutopar 30 minutes before d/c IV Tocolytic (Phil)

Terbuthaline (Bricanyl or Brethine) sustained tachycardia Antidote propranolol or inderal - beta-blocker If cervix is open MD steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia. X. Postpartal Period 5th stage of labor after 24hrs :Normal increase WBC up to 30,000 cumm Puerperium covers 1st 6 wks post partum Involution return of repro organ to its non pregnant state. Hyperfibrinogenia - prone to thrombus formation - early ambulation Principles underlying puerperium 1. To return to Normal and Facilitate healing A. Physiologic Changes a.1. Systemic Changes 1. Cardiovascular System - the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers. 2. Genital tract a. Cervix cervical opening b. Vaginal and Pelvic Floor c. Uterus return to normal 6 8 wks. Fundus goes down 1 finger breath/day until 10th day no longer palpable due behind symphisis pubis 3 days after post partum: sub involuted uterus delayed healing uterus with big clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C after, birth pain: 1. position prone 2. cold compress to prevent bleeding 3. mefenamic acid d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia. 1. Ruba red 1st 3 days present, musty/mousy, moderate amt 2. Serosa pink to brown 4 9th day, limited amt 3. Alba crme white 10 21 days very decreased amt dysuria - urine collection - alternate warm & cold compress - stimulate bladder 3. Urinary tract: Bladder freq in urination after delivery- urinary retention with overflow 4. Colon:Constipation due NPO, fear of bearing down 5. Perineal area painful episiotomy site sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compress sex- when perineum has healed II. Provide Emotional Support Reva Rubia Psychological Responses: Taking in phase dependent phase (1st three days) mom passive, cant make decisions, activity is to tell child birth experiences. Nursing Care: - proper hygiene Taking hold phase dependent to independent phase (4 to 7 days). Mom is active, can make decisions HT: Care of newborn Insert family planting method common post partum blues/ baby blues present 4 5 days 50-80% moms overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. let mom cry therapeutic. Letting go interdependent phase 7 days & above. Mom - redefines new roles may extend until child grows.

III. Prevent complications Hemorrhage bleeding of > 500cc CS 600 800 cc normal NSD 500 cc Early postpartum hemorrhage bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding uterine atony. Complications: hypovolemic shock. Mgt: massage uterus until contracted cold compress modified trendelenberg IV fast drip/ oxytocin IV drip 1st degree laceration affects vaginal skin & mucus membrane. 2nd degree 1st degree + muscles of vagina 3rd degree 2nd degree + external sphincter of rectum 4th degree 3rd degree + mucus membrane of rectum

Breast feeding post pit gland will release oxytocin so uterus will contract. Well contracted uterus + bleeding = laceration assess perineum for laceration degree of laceration mgt episiorapy DIC Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate. bleeding to any part of body hysterectomy if with abruption placenta mgt: BT- cryoprecipitate or fresh frozen plasma Late Postpartum hemorrhage bleeding after 24 hrs retained placental fragments Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta, percreta, Acreta attached placenta to myometrium. Increta deeper attachment of placenta to myometrium Percreta invasion of placenta to perimetrium hysterectomy

Hematoma bluish or purple discoloration of SQ tissue of vagina or perineum. too much manipulation large baby pudendal anesthesia Mgt: cold compress every 30 minutes with rest period of 30 minutes for 24 hrs shave incision on site, scraping & suturing Infection- sources of infection 1.)endogenous from within body 2.) exogenous from outside anaerobic streptococci most common - from members health team unhealthy sexual practices General signs of inflammation: Inflammation calor (heat), rubor (red), dolor (pain) tumor(swellinghypertension associated with increase incidence of CVA and subarachnoid hemorrhage. Signs of hypertension Immediate Discontinuation A abdominal painC chest painH - headacheE eye problems S severe leg cramps If mom HPN stop pills STAT! Adverse effect: breakthrough bleeding Contraindicated: chain smoker extreme obesity HPN

DM Thrombophlebitis or problems in clotting factors if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again. DMPA depoproveda has progesterone inhibits LH inhibits ovulation Depomedroxy progesterone acetate IM q 3 months - never massage injected site, it will shorten duration Norplant has 6 match sticks like capsules implanted subdermally containing progesterone. 5 yrs disadvantage if keloid skin as soon as removed can become pregnant Mechanism and Chemical Barriers Intrauterine Device (IUD) Action: prevents implantation affects motility of sperm & ovum right time to insert is after delivery or during menstruation primary indication for use of IUD parity or # of children, if 1 kid only dont use IUD HT: Check for string daily Monthly checkup Regular pap smear Alerts; prevents implantation most common complications: excessive menstrual flow and expulsion of the device (common problem) others: P eriod late (pregnancy suspected) Abnormal spotting or bleeding A bdominal pain or pain with intercourse I nfection (abnormal vaginal discharge) N ot feeling well, fever, chills S trings lost, shorter or longer Uterine inflammation, uterine perforation, ectopic pregnancy Condom latex inserted to erected penis or lubricated vagina Adv; gives highest protection against STD female condom Alerts: Disadvantage: it lessen sexual satisfaction it gives higher protection in the prevention of STDs Diaphragm rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSABLE Ht: proper hygiene check for holes before use must stay in place 6 8 hrs after sex must be refitted especially if without wt change 15 lbs spermicide chem. Barrier ex. Foam (most effective), jellies, creams S/effect: Toxic shock syndrome Alerts: Should be kept in place for about 6 8 hours Cervical Cap most durable than diaphragm no need to apply spermicide C/I: abnormal pap smear Foams, Jellies, Creams Surgical Method BTL , Bilateral Tubal Ligation can be reversed 20% chance. HT: avoid lifting heavy objects Vasectomy cut vas deferense. HT: >30 ejaculations before safe sex O zero sperm count, safe

XI. High Risk Pregnancy Hemorrhagic Disorders General Management CBR Avoid sex Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc) Ultrasound to determine integrity of sac Signs of Hypovolemic shock Save discharges for histopathology to determine if product of conception has been expelled or not First Trimester Bleeding abortion or eptopic A. Abortions termination of pregnancy before age of viability (before 20 weeks) Spontaneous Abortion- miscarriage Cause: 1.) chromosomal alterations 2.) blighted ovum 3.) plasma germ defect Classifications: Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed Inevitable moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation) Types: Complete all products of conception are expelled. No mgt just emotional support! Incomplete Placental and membranes retained. Mgt: D&C Incompetent cervix abortion McDonalds procedure temporary circlage on cervix S/E; infection. During delivery, circlage is removed. NSD Sheridan permanent surgery cervix. CS c. Habitual 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2nd trimester d. Missed fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding Mgt: induced labor with oxytocin or vacuum extraction 5.) Induced Abortion therapeutic abortion to save life of mom. Double effect choose between lesser evil.

Ectopic Pregnancy occurs when gestation is located outside the uterine cavity. common site: tubal or ampular Dangerous site - interstitial Unruptured Tubal rupture missed period sudden , sharp, severe pain. Unilateral radiating to abdominal pain within 3 -5 weeks of missed period shoulder. (maybe generalized or one sided) shoulder pain (indicative of intraperitoneal scant, dark brown, vaginal bleeding bleeding that extends to diaphragm and phrenic nerve) Nursing care: + Cullens Sign bluish tinged umbilicus signifies Vital signs intra peritoneal bleeding Administer IV fluids syncope (fainting) Monitor for vaginal bleeding Mgt: Monitor I & O Surgery depending on side Ovary: oophrectomy Uterus : hysterectomy

Second trimester bleeding C. Hydatidiform Mole bunch or grapes or gestational trophoblastic disease. with fertilization. Progressive degeneration of chorionic villi. Recurs. - gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly. Use: methotrexate to prevent choriocarcinoma Assessment:

Early signs

Early in pregnancy High levels of HCG Preeclampsia at about 12 weeks Late signs hypertension before 20th week Vesicles look like a snowstorm on sonogram Anemia Abdominal cramping Serious complications hyperthyroidism Pulmonary embolus Nursing care: Prepare D&C Do not give oxytoxic drugs Teachings: Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma Avoid pregnancy for at least one year Third Trimester Bleeding Placenta Anomalies Placenta Previa it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta. candidate for CS Sx: frank Bright red Painless bleeding Dx: Ultrasound Avoid: sex, IE, enema may lead to sudden fetal blood loss Double set up: delivery room may be converted to OR Engagement (usually has not occurred) Fetal distress Presentation ( usually abnormal) Surgeon in charge of sign consent, RN as witness MD explain to patient complication: sudden fetal blood loss Nursing Care NPO Bed rest Prepare to induce labor if cervix is ripe Administer IV Abruptio Placenta it is the premature separation of the placenta form the implantation site. It usually occurs after the twentieth week of pregnancy. Outstanding Sx: dark red, painful bleeding, board like or rigid uterus. Assessment: Concealed bleeding (retroplacental) Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage. Severe abdominal pain Dropping coagulation factor (a potential for DIC) Complications: Sudden fetal blood loss -placenta previa & vasa previa Nursing Care: Infuse IV, prepare to administer blood Type and crossmatch Monitor FHR Insert Foley Measure blood loss; count pads Report s/sx of DIC Monitor v/s for shock Assessment:

vesicles passed thru the vagina Hyperemesis gravidarium increase HCG Fundal height Vaginal bleeding( scant or profuse)

Strict I&O Placenta succenturiata 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental fragments if vessel is cut. Placenta Circumvalata fetal side of placenta covered by chorion Placenta Marginata fold side of chorion reaches just to the edge of placenta Battledore Placenta cord inserted marginally rather then centrally Placenta Bipartita placenta divides into 2 lobes Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta Vasa Previa velamentous insertion of cord has implanted in cervical OS Hypertensive Disorders I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum. Gestational hypertension - HPN without edema & protenuria H without EP Pre-eclampsia HPN with edema & protenuria or albuminuria HE P/A HELLP syndrome hemolysis with elevated liver enzymes & low platelet count II. Transissional Hypertension HPN between 20 24 weeks III. Chronic or pre-existing Hypertension HPN before 20 weeks not solved 6 weeks post partum. Three types of pre-eclampsia 1.) Mild preeclampsia earliest sign of preeclampsia a.) increase wt due to edema b.) BP 140/90 c.) protenuria +1 - +2 2.) Severe preeclampsia Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110 , protenuria +3 - +4 3.) Eclampsia with seizure! Increase BUN glomerular damage. Provide safety. Cause of preeclampsia idiopathic or unknown common in primi due to 1st exposure to chorionic villi common in multiple pre (twins) increase exposure to chorionic villi common to mom with low socioeconomic status due to decrease intake of CHON Nursing care: P romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate. P- prevent convulsions by nursing measures or seizure precaution 1.) dimly lit room . quiet calm environment 2.) minimal handling planning procedure 3.) avoid jarring bed P- prepare the following at bedside - tongue depressor - turning to side done AFTER seizure! Observe only! for safely. E ensure high protein intake ( 1g/kg/day) - Na in moderation A anti-hypertensive drug Hydralazine ( Apresoline) C convulsion, prevent Mg So4 CNS depressant E valuate physical parameters for Magnesium sulfate Magnesium SO4 Toxicity: BP decrease Urine output decrease Resp < 12 Patella reflex absent 1st sigh Mg SO4 toxicity. antidote Ca gluconate 3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas) Function: of insulin facilitates transport of glucose to cell Dx: 1 hr 50gr glucose tolerance test GTT Normal glucose 80 120 mg/dl < 80 hypoclycemic ( euglycemia) > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL maternal effect DM Hypo or hyperglycemia 1st trimester hypo, 2nd 3rd trim hyperglycemic Frequent infection- moniliasis Polyhydramnios Dystocia-difficult birth due to abnormalities in fetus or mom. Insulin requirement, decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd 3rd trimester. Post partum decrease 25% due placenta out. Fetal effect hyper & hypoglycemia macrosomia large gestational age baby delivered > 400g or 4kg preterm birth to prevent stillbirth Newborn Effect : DM hyperinsulinism hypoglycemia normal glucose in newborn 45 55 mg/dL hypoglycemic < 40 mg/dL Heel stick test get blood at heel Sx: Hypoglycemia high pitch shrill cry tremors, administer dextrose hypocalcemia - < 7mg% Sx: Calcemia tetany Trousseau sign Give calcium gluconate if decrease calcium Recommendation Therapeutic abortion If push through with pregnancy antibiotic therapy- to prevent sub acute bacterial endocarditis anticoagulant heparin doesnt cross placenta

Class I & II- good progress for vaginal delivery Class III & IV- poor prognosis, for vaginal delivery, not CS! NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver Regional anesthesia! Low forcep delivery due to inability to push. It will shorten 2nd stage of labor. Heart disease Moms with RHD at childhood Class I no limit to physical activity Class II slight limitation of activity. Ordinary activity causes fatigue & discomfort. Recommendation of class I & II sleep 10 hrs a day rest 30 minutes & after meal Class III - moderate limitation of physical activity. Ordinary activity causes discomfort Recommendation: 1.) early hospitalization by 7 months Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort. Recommendation: Therapeutic abortion XII. Intrapartal complications Cesarean Delivery Indications: Multiple gestation Diabetes Active herpes II Severe toxemia Placenta previa Abruptio placenta Prolapse of the cord

CPD primary indication Breech presentation Transverse lie Procedure: classical vertical insertion. Once classical always classical Low segment bikini line type aesthetic use VBAC vaginal birth after CS INFERTILITY - inability to achieve pregnancy. Within a year of attempting it Manageable STERILITY - irreversible Impotency inability to have an erection 2 types of infertility 1.) primary no pregnancy at all 2.) Secondary 1st pregnancy, no more next preg test male 1st more practical & less complicated need: sperm only sterile bottle container ( not plastic has chem.) Sims Huhner test or post coital test. Procedure: sex 2 hours before test mom remains supine 15 min after ejaculation

Normal: cervical mucus must be stretchable 8 10 cm with 15 20 sperm. If >15 low sperm count Best criteria- sperm motility for impotency Factors: low sperm count occupation- truck driver chain smoker administer: clomid ( chomephine citrate) to induce spermatogenesis Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count Implant sperm in ampula 1.) Mom: anovulation no ovulation. Due to increase prolactin hyperprolactinemia Administer; parlodel ( Bromocryptice Mesylate) Action; antihyper prolactineuria Give mom clomid: action: to induce oogenesis or ovulation S/E: multiple pregnancy 2.) Tubal Occlusion tubal blockage Hx of PID that has scarred tubes use of IUD appendicitis (burst) & scarring = dx: hysterosalphingography used to determine tubal patency with use of radiopaque material Mgt: IVF invitrofertilization (test tube baby) England 1st test tube baby To shorten 2nd stage of labor! fundal pressure episiotomy forcep delivery

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Epididymis 6 meters coiled tubules site for maturation of sperm

Vas Deferens conduit for spermatozoa or pathway of sperm Seminal vesicle secretes: 1.) Fructose glucose has nutritional value. 2.) Prostaglandin causes reverse contraction of uterus

Blank! Cant erase! Hypothalamus GnRH Ant Pit Gland FSH LF Fx: Sperm Maturation
Fx: Hormones for Testosterone Production Testes 900 coiled ( meter long at age 13 onwards) (Seminiferous tubules) Ejaculatory duct conduit of semen Prostate gland- secrets alkaline substance Cowpers gland secrets alkaline substance Urethra