Lecture Notes

Le Not My Notes: NCLEX

Delegation RN LPN Specialized Care (Inc. Level of skill, Newly recovered) Routine Care Severe Cases Chronic cases Sterile Procedure Stable clients Newly Diagnosed Unstable clients With Complications (acute, life threatening) Assessment, Teaching, Evaluation

UAP/NC Activities of Daily Living

o Latex Allergy = Kiwi fruit allergy o History of MVA(head trauma)  Polyuria  Diabetes Insipidus o

o o o o o o o o o

Cushing’s triad: 1.) wide pulse pressure 2.) Dec. RR 3.) Dec. PR * Note a dec. in LOC before Cushing’s triad Saw Palmetto = Same as Finasteride  prevents dysuria  given to clients with BPH to dec. the size of prostate. Ma Huang = Same as ephedra  substitute of Sudafed  Shabu or amphetamine like effect Di Huang = Dec. blood sugar for DM Black Cohosh = Inc. Estrogen  for menopause  relieves hot flushes Blue Cohosh = a uterine tonic for starting labor  also after delivery for uterine contraction Chamomile = CI in asthma  causes bronchospasm = CI with gingkobiloba Heart Block = Atropine Sulfate Tachycardia = Lidocaine How many servings of milk, fruit and vegetables a day = 3-4/meal

Chemotherapeutic Agents 1. Cisplastin = causes stomatitis 2. Azathioprine = 3. Methotrexate = Psychotropic precautions Conversion Disturbances Primary Gain Motivation Behind the s/sx

Secondary Gain The attention that they get

Tertiary Gain Extent to w/c the s/sx is manifested in order to please the health care provider

o Goal on Pre-eclampsia = To prevent seizure o Ileostomy  Normal  2-3 days after (-) discharge Fat embolism 1.) Dyspnea 2.) Chest pain 3.) Petechiae on the chest o Priority administer O2  To dec. surface tension of fat globules DIC = Disseminated Intravascular Coagulation

1

o Systemic clotting  bleeding o

Priority = Prevent systemic clotting

o Normal Fibrinogen level = 180-340mg/dl  < 100  bleeding

Narcotic Withdrawal Syndrome • • • • • • •

Hypertonicity Hyperactivity Irritability Poor Sucking Sleepiness Shrill cry High pitched cry

Fetal Alcohol Syndrome Hypotonicity Irritability Poor Sucking Facial Deformity Microcephaly

o Priority = Physiologic Integrity  Vitals signs  Give Valium Macular Degeneration o CMV = Cytomegalovirus infection o Loss of central & peripheral vision  blindness Erb’s Palsy o Attained during delivery  reversible  complete recovery after 3 months Steps of Heimlich Maneuver = stand behind =wrap arms around the client = fist over xiphoid process = upward abdominal thrust Septic Shock o Systemic infection o Centralized vasodilation o Dec. BP o Inc. Temperature Cleft Palate o Post surgery = prone o Post feeding = side lying Cleft Lip & Palate o Post surgery = side lying o Cleft lip is 1st done followed by the repair of the palate o Must first satisfy the rule of 10: 1.) 10 weeks 2.) 10 lbs. 3.) 10 Hgb Situation in which consent of parents are not needed: 1.) STD’s 2.) Delivery 3.) Substance abuse Diabetic Clients o 50-70% CHO

2

o Raisin  best to bring during travel o

1 rice is equal to 2 servings of popcorn

MI Sequence of enzymes that increases during MI: 1.) Myoglobin = 30 min-1hr post MI 2.) Troponin = 3-6hrs upto 3 weeks 3.) CK MB = Inc 4 – 8 hrs post MI, back to normal in 3 – 4 days 4.) AST = 8 – 20 u/L normal, Inc 6 – 10 hrs post MI, back to normal a week later 5.) LDH = Inc 2 – 3 days post MI, back to normal by 10 – 14 days LDH = 45 – 90 u/ml Normal LDH 1 = Heart LDH 2 = RES LDH 3 = Lungs LDH 4 = Kidney & Pancreas LDH 5 = Liver Pilocarpine sweat Test (Induce Sweating)  Cystic Fibrosis (Autosomal recessive) Dysthemia  Less severe form of depression Incentive Spirometer  Inhale Peak Flowmeter  Blow as hard as fast as possible Gentamycin Toxic Effects: 1.) Ototoxic 2.) Nephrotoxic 3.) Neurotoxic Influenzae vaccine Varivax  Do not give Aspirin  may lead to Reye’s Syndrome Kwell  CI to pt with seizure Dx Procedures: 1.) 2.) 3.) 4.) 5.)

ABG Amniocentesis Thoracocentesis Bronchoscopy MRI

Angiogram: 1.) Capillary Refill time 2.) Distal Pulses 3.) Puncture site for bleeding = If the site is on the femoral  Keep leg extended for 24 hrs.

3

Respiratory Alkalosis  breath to a paper bag Respiratory Acidosis  Deep Breathing Commonly asked drugs: 1.) 2.) 3.) 4.) 5.) 6.) 7.)

Lanoxin Heparin Acetaminophen MgSO4 Cytoxan Synthroid Vaccines

Do the CHECK method Theophylloine = 10-20mg/dl – adult = 5-10mg/dl – pedia Acetaminophen SE = Hard stools Commonly asked diseases: 1.) Alzeihmenrs 2.) Sickle Cell Anemia 3.) Pancreatitis 4.) Bipolar Disorders 5.) Liver Cirrhosis 6.) Hemophilia 7.) AIDS 8.) DM 9.) Cystic Fibrosis Droplet  within 3 feet Airborne  Beyond 3 feet Informed consent o For adult or minor with capacity o Require full understanding of procedure o Protects the client, nurse, surgeon and hospital o For emancipated minors: o Married minors o Military service o Living away from home o Had a child Procedures requiring consent: 1. Surgical Procedure 2. Invasive that requires entry to a body cavity 3. Visualization or radiologic procedure with contrast medium 4. General Anaesthesia, local infiltration and regional block Conditions that doesn’t need parents consent: 15 y/o = antibiotics for acne 16 y/o = pelvic exam 17 y/o = request for contraceptives 18 y/o = Dx exam for recurrent H/A 19 y/o = surgery for bone tumor Assesment o Empowering children to the greatest extent feasible ELEMENTS o Explain to the child his condition and the reason why the procedure has to be done in lay man’s term

4

o o o

Clinical assessment of patient’s understanding Solicit child’s willingness Expectation

Ethical Care Concept 1.) Autonomy = Living will, freedom of choice, self determination and privacy.

a. Advance Directive = List of don’t’s (client’s with progressive chronic illness in which death is expected) b. Durable Power of Attorney for health Care= appoints a proxy that will decide for the patient. 2.) Beneficence = duty to promote well being of others Ideal Beneficence = “Nag kusa” 3.) Non-Maleficence = Restrained self from doing something that might harm someone. “Do not harm”. 4.) Justice = Fairness Clinical Issues 1. Unsafe nurse/pt ratio Intervention: o Address verbally and document. o Report to charge nurse  Supervisor  director 2. No response by Physician Promote Safety: o Side rails up o Move pt near nurses station o Use restraints appropriately (last resort) 3. Inappropriate order o Document it o Notify the charge nurse o Notify the physician Legal Issues Malpractice = Negligent conduct in rendering prof. service = did not exercise care Respondeat Superior = Superior is responsible to the actions of subordinates. Referral Agencies for special care during admission Pt advocate = Empower pt to know his/her rights and privileges 1.) 2.) 3.) 4.)

social worker Children’s protective services Adult protective services Organizations

Care of the hospitalized clients Mantoux Test 15mm = gen. population 10mm = DM, Alcoholism

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5mm = HIV Areas where bruises are indicative of child abuse: 1. Lower Back 2. Upper Back 3. Side of the abdomen Special Considerations Infants o o o

Greatest risk for fluid and electrolyte imbalance Hypothermia and infections Approach them in non-threatening manner

Toddler o o o

Increased separation anxiety Briefly prepare them for procedures due to short attention span Describe sensation that they may feel during procedure

Preschooler o o o o

o

Fear of physical harm Believe that illnesses is a form of punishment Explanations must be brief, honest and in natural terms Use demonstrations and play in providing health teaching Can use adult seatbelt if  40lbs or 40 inches tall, also if he could look at the window in sitting position

School Age o o o

Realistic understanding of death = 9 -10 Needs more detailed teachings Allow them to make some choices

Adolescence o o o o o

Developed abstract thinking and ability to problem solve Logic and reasoning Full and honest explanation Primary concern are with the present time Focus on appearance

Elderly o o o o

o o

Nutrition is a primary concern Muscle atrophy Dec body water, BMR Dec renal, CV, GIT function Dec taste, smell, visual acuity (cataract, arcuc senilis = fatty deposits around pupil_) With multiple medications due to chronic diseases  OH, Nephrotoxic

Triage = a system of client evaluation to establish priorities PRINCIPLES

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Emergency Situation = greatest risk receives priority Major Disasters = those requiring minimal care are treated first = Those requiring specialized care may be given minimal care or no care

Tree of Strategy for Prioritizing Ask 

Look 

Where  Disaster Area = Least injured  Emergency Area = Most injured Case

Same Area = all OB = all Psycho = all MS = all Pedia

Various Areas Physiologic vs. Psychological Acute vs. Chronis Unstable vs. Stable

Evaluate and look for = Complications = Immediate need = Adverse effects Prioritizing Signs and symptoms Consider = Symptoms related to ABC = symptoms which are indicative of complications Prioritizing Nursing Diagnosis Consider = Tyoe of N. Dx = Actual (Problem) = Risk (Vulnerable) = Possible (Inadequate data) = Wellness Prioritizing Interventions

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Diagnostic  Verify the Dx  Assessment Therapeutic  Assess pt Teaching  Informing the patient Referral  Involves a member of the health team Independent  Decision Making Level’s of prioritizing Level 1: Emergent S = evere shcock C = ardiac arrest, Cervical Spine Injury A = irway compromise, altered LOC M = ulti system E = clampsia Level 2: Urgent (stable) Fe = ver Mi = nor burn less 10% Mi = nor musculo Skeletal d/o La = creation Di = zziness Level 3: Chronic / Minor Injuries Dental problems Routine Medications Missed Menses Chronic Low Back Pain Prioritize Cardiovascular = Neurological Cases Acute Complications Consider = Age and Dx of the pt Fort MS Cases: Think “ABC” For Psyche: Safety First In case of fire: ARCE (new) : RACE  If caused by O2, turn off O2 first DELEGATION: Transfer of responsibility for the performance of an activity from one individual to another. Direct: Identified by the RN Indirect: Task based on the families list Complex task = never delegated = requires judgment on how to proceed Non-complex task: can be safely performed recording to exact directions : can be delegated Task that cannot be delegated (HOSPITAL) 1. Administration of: = Investigational drugs = Cancer Drugs = IV push drugs = Blood and blood products = TPN = Implanted device

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2. Hemodialysis Functions Task that cannot be delegated (HOME HEALTH) a.) initial set up of pt controlled analgesic pump = changing of flow rates = changing medications reservoir = filling the reservoir b.) NGT feeding KNOW THE RULES 1.) Do not delegate: o Assessment o Teaching o Evaluation o Preparation and administration of meds 2.) Delegate o ADL o Routine o Standard Procedures Know the 5 rights of delegation 1.) Right Task 2.) Right Circumstances 3.) Right Person 4.) Right Person/Communication 5.) Right Supervision Social

Therapeutic Relationship

Goals: Socialization

Goal: Mental Health trust

Phases: 1. Pre-interaction – self awareness of nurses 2. Orientation – contract  do’s and don’ts 3. Working phase – identification & resolution of problems 4. Termination phase – evaluation Therapeutic Communication 1. 2. 3. 4. 5.

Don’t ask why Avoid passing the buck Don’t give false reassurance Avoid nurse centered response Recognize the pt’s feelings

CORE CONCEPTS o o o

o

Therapeutic phrases Open ended questions are Generally Therapeutic Closed ended effective for manic and pt’s in crisis

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o

Direct questions for suicidal pts

Bruit = high pitched Murmur = low pitched 20/20 = Vision  attained at 3-6 years old Decorticate

Decerebrate

Flexed Adducted

Arms

Flexed Abducted

PlantarFlexed Extended

Legs

PlantarFlexed Extended

How to attack the questions? 1. 2. 3. 4.

Consider the pt’s dx Know what is normal Some conditions have inherent and expected changes in the normal values Minimal deviation from normal values are not reportable

Sodium = 135-145 Meq/L Dilutional Hyponatremia = < 120  Inc reisk for seizure = 115  Seizure Precaution Addison – Hyponatremia, Hyperkalemia Cushings – Hypernatremia, Hypokalemia Potassium = 3.5-4.5 Meq/L Normal = < 3.5  Muscle weakness Calcium = 4.5 – 5.5 Meq/L Normal = 9 – 10 mg/dl Hypercalcemia  Inc H2O intake Multiple Myeloma  Inc serum calcium level Hypoparathyroid  Dec Ca Levels in blood Thyrocalcitonin  Deposits Ca to bones Parathyroid Hormone  Bone Ca to blood Glucose = < 50  Hypoglycemia = > 140  Hyperglycemia CREATININE = .5 – 1.5 Meq/L = Best indicator for kidney function = Inc creatinine  Kidney failure BUN = 10 – 20 mg/dl = Also an indicator for kidney function = Inc BUN  Kidney failure RBC = 4.5 – 5.5 = Dec  bleeding, shock, anemia = Inc in polycythemia

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= Phlebotomy  removal of 500ml of blood = Dec RBC  Activity intolerance = Inc RBC  CVA  Risk for injury WBC = 5,000 – 10,000 = Post partum  > 15,000 = Leukemia  > 150,000  Hyperleukocytosis  Risk for injury Platelets = 150,000 – 450,000 = < 150,000  Thrombocytepenic precaution = < 20,000  bleeding precaution = > 500,000  bleeding d/o = Risk for Injury PT = 11 – 12 seconds INR = 24 seconds = > 24  bleeding PTT = 60 – 70 seconds INR = 175 seconds APTT = 30 – 40 seconds INR = 100 seconds Monitored  Heparin = > INR  bleeding

X 20

X 25 X 25

Hbg Female = 12 – 16 Male = 14 – 18 Newborn = 14 – 24 Pregnant = 10 – 12 = < 10  report = Results to Anemia  Activity Intolerance Hematocrit = 35 – 45 Danger of hydration = < 35  Overhydration  Fluid Volume excess = > 45  Underhydration  Fluid Volume deficit

Acid – Base Imbalance Respiratory

Metabolic

Alkalosis

Acidosis

Alkalosis

Acidosis

Def in CO2

Excess CO2

Excess HCO3

Def HCO3

Hyper ventilation Hypermetabolism Hypoxia Hypotension

Lung Disease Airway obstruction Resp Depression Neurological & Muscular dse

Cushings Hypokalemia Excessive loss of acids GI vomiting

Ketone overload Lactic Acid production Kidney Disease GI disease

s/sx

s/sx

s/sx

s/sx

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Restlessness Anxiety Tachycardia Syncope

Restlessness Apprehension Tachycardia Dec LOC Dec DTR

Cyanosis Hypotension Apathy Weakness

Confusion Hyponatremia Anorexia Weakness Dull H/A Kaussmaul’s breathing

Breath thru paper bag Breath thru cupped hand

Deep breathing

Administer Ammonium Cl

Mechanical ventilator

ABG determination

PH  7.35 – 7.45 Hco3  22 – 26 CO2  35 – 45

Alkalosis

Acidosis

Inc Inc Dec

Dec Dec Inc

HCO3  determinant for Metabolic d/o CO2  determinant for respiratory d/o RAMS = Respiratory d/o, Alternate arrow direction = Metabolic d/o, Same arrow direction Compensation Compensation

PH

Uncompensated Partially compensates Fully compensated

Abnormal Abnormal

Compensatory Mechanism No Change Change

Normal

Change

APGAR 1 minte  Assess cardio, pulmonary and neurological status of the baby 5 minutes  adjustment to extrauterine life 10 minutes  when 2nd apgar is below 6 7 – 10  admission 4 – 6  O2 and warm 0 – 3  Resuscitation A-ppearance P-ulse G-rimace A-ctivity R-espiratory effort

0 All blue Absent No rxn Flaccid

1 Acrocyanosis < 100 Weak cry Some flexion and extension

Abnormal

Irregular

2 Pink > 100 Vigorous cry Spontaneous flexion & extension Lusty

Computation: 1.)

D S

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2.)

Vol. in cc X gtt factor # of hrs. X 60

3.) IV fluid replacement in pediatric pt Weight < 10 kg  X 100/kg 11 – 20 kg  1000ml/10kg  In excess X 50 2 kgs  1,500ml/20kg  in excess X 20 Isolation Precaution I. Standard II. Transmission Based a. Doplet b. Airborne c. Contact •

I. II.

A. B. C.

HW √

PR X

Mask, goggles √ (surgical)

Gloves √

Gown √

√ √ √

√ √ √

√ √(PRM) X

X X √

X X √

PRM (particulate Respirator Mask)

Standard  AiDS, HIV, Hepa, Roseola Transmission Based: Droplet  Mumps, Mycoplasmal Pneumonia, Rubella Airborne  Measles (Rubeola), TB, Varicella Contact  Clostridium deficile, Respiratory borne, scabies, Sarcoidosis, RSV • Hepa with bowel incontinence  Contact precaution

Principles: 1. If patient goes out from the room  let the patient wear mask 2. Coherting  Same illness  Share room 3. Standard Precaution  exemption in pedia  diapered, incontinent, < 6 y/o  contact precaution HERBAL REMEDIES Saw Palmetto o Stops progression of BPH like Finasteride o Ease urinary difficulty o Interferes with iron absorption o CI: pregnancy and lactation o SE: stomach ache Blue Cohosh o Uterine tonic o Used in the last 2 – 4 weeks o To ease labor pains o Jump start stalled labor o Deliver retained placenta o Stop bleeding after delivery Black Cohosh o Sppress LH but not FSH o Relieves symptoms of menopause o Not habit forming

13

o

o

Does not cause cancer Limit use to 6 months  alters the normal hormonal balance

Ma-Huang o CNS Stimulant o Causes addiction o Withdrawal symptoms: depression, fatigue, irritability o With ephedra like effect o Used to treat asthma o Can cause weight loss o Not given inpatients with DM  alters the blood sugar level Chamomile o For diarrhea, anti-bacterial, anti-viral o CI: Bronchial asthma, anticoagulant therapy Cranberry o For UTI and asthma o Not for DM o Safe in pregnancy o Use with caution in DM Echinacea o Immune system stimulant o Not used for more than 14 days o Store it away from direct light o Not given in TB and chronic conditions Ginger o Anti-emetic, tx for colic and flatulence o Report bleeding and CNS depression Ginseng o Fatigue, atherosclerosis, depression, Ca o Report ginseng abuse syndrome, Diarrhea, nervousness, edema, insomnia Gingko Biloba o Improves blood circulation o Used in Alzheimer’s Disease o CI  pregnancy, lactation and clotting d/o Gotu Kova o Improves memory o For UTI, snake bites, rheumatism o CI: pregnancy, lactation and use of sedatives KAVA o Anxiety, menstrual problem, leprosy o AE: CNS depression, hepatotoxicity o Not given to pts with antipsychotic  inc sedative effects of drugs VALERIAN o Tranquilizer, sedative o Not given with valium o Uses: insomnia, mm. spasm DRUGS

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Iron Supplements  FeSO4 C= Mineral Supplement  Anemia H= Relief of fatigue / Inc strength E= Best before meals, after meals if with GI irritation C= takes effect after 2-3 weeks, Inc absorption with orange juice K= Elixiform  use straw Injectable  Z track method (laterally stretch the skin, 10 seconds) SE: Constipation and black stools Antidote: Deferoxamine HCL (Desferal) RHOGAM C= Prevents RH sensitization H= ( - ) Hemolytic reaction E= 27-28 weeks AOG, ideally 72 hrs after delivery of baby with Rh (+) and ( - ) Coomb’s C= Pain in injection site K= Check Coombs test only in ( - ) OXYTOCIN Pitocin C=

Methergine

Induce Labor

Contracts uterus after placental delivery Increase force of Uterine contraction

H= firmly contracted uterus E= As prescribed C= Report prolonged duration of contraction K= Avoid: Blue cohosh Check BP o o

Pitocin initially causes Hypotension then rebound hypertension Methergine initially causes Hypertension then rebound Hypotension

TOCOLYTICS C= Relaxes the uterine mm. during preterm labor H= ( - ) contractions / relaxed uterus Ritodrine HCl (Yutopar) E= Onset of preterm labor C= Report maternal tachycardia HR > 130  Arrhythmia K= Prepare antidote  Propanolol Magnesium Sulfate C= Anticonvulsant, NS depressant

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H= ( - ) Seizure E= As prescribed PIH C= Report MgSO4 intoxication  Hypotension, hypocalcemia and H/A K= Check BP, urine output, RR, Patellar reflex  if Dec  antidote  Ca Gluconate Therapeutic level: o Loading dose  4 – 7 Meq/L o Maintenance  1.5 – 3 Meq/L o Depression of DTR if  8 Meq/L o Dec RR if  10 – 12 Meq/L Coagulation Process Vit K dependent clotting Factors Thromboplastin

Fibrinogen  Fibrin (clot)

Prothrombin

Thrombin

Coumadin

Heparin

Coumadin / Heparin Coumadin (Oral) C= H= E= C= K=

Heparin (Injectable)

Anticoagulant ( - ) Clot formation Onset: 2 – 5 days 1 -2 days Report signs of bleeding Avoid green leafy Vegetable (contains Vit K) Avoid hard bristle toothbrush Vit K Protamine Sulfate PT PTT

Antidote: Lab:

CHEMOTHERAPY CELL CYCLE G0

Mitosis Interphase

Resting

G1 RNA production

Alkalating Agents

Anti-metabolites

S DNA synthesis Antibiotic

G2

Cell division

RNA synthesis Plant Alkaloid

Hormones

16

Interferes DNA replication

Interferes DNA & RNA Replication

Inhibit DNA & RNA synthesis

Interferes DNA synthesis

Interferes RNA synthesis

* CYTOXAN * MUSTARGEN

*METHOTREXATE (antidote: Leucoverin)

*ADRIAMYCIN GLENOXANE

*ONCOVIN

*TAMOXIFEN

C=

ANTI-PSYCHOTIC Typical

Atypical Anti-emetic Mania Schizophrenia Bipolar d/o

H=

Haloperidol (Haldol) Dec ( + ) symptoms (wala sa normal being)

Clozapine (Clozaril) Dec ( + ) and ( - ) symptoms

Hallucinations Delusion Looseness of Association

Apathy Alogia Avolition Anhidonia Dec dopamine levels

E= C=

pc = after meals Side effects: 1.)Agranulocytosis Fever, sore throat 2.) NMS Fever, mm rigidity 3.) EPS Mm rigidity

Anticholinergic Tachycardia Dry mouth Blurred Vision Constipation Dec BP

Side Effects: Leukopenia (<3,500 = signs of infxn) (if < 2,00 = protective isolation)

EPS = Cogentin Akineton Artane Malignant Hyperthermia = Parlodel Muscle rigidity = Dantrolene, Dantrium K=

Liver Fxn Test No direct exposure to sunlight = Photosensitivity Anti-Parkinsonian at hand CI = St. John’s wort

C=

ANTI-PARKINSONIAN AGENT Dopaminergic Inc Dopamine

Anticholinergic Dec Ach

L-Dopa Carbidopa

Congentin Benadryl

17

(Sinimet) H= E=

Dec mm rigidity Dec pill rolling (after 2-3 weeks) after meals

C=

H/A, Irritability, Restlessness

K=

No to Vit B6 = dec absorption of drug Check BP and HR No CHON ANTI-ANXIETY

C=

Valium Librium = Acute alcohol withdrawal syndrome = dec tremors H=

Dec center of wakefulness

E=

Before meals

C=

Dizziness Drowsiness Dry Mouth

K=

Avoid Alcohol and Caffeine Administer Valium separately = incompatible with any other drugs Avoid KAVA & VALERIAN = Inc Resp depression

C=

ANTI-DEPRESSANT

H=

SSRI

TCA

MAOI

Stimulant

ZOLOFT

VIVACTIL CETAVIL TOFRANIL

PARNATE NARDIL MARPLAN

RITALIN

Dec re-uptake of Serotonin

Prevents re-absorption of Norepinephrine

Prevents the destruction of serotonin & Norepinephrine

Directly stimulates the CNS

E=

After meals

C=

Inc appetite Adequate sleep Initial effect = 2-3 weeks Full effect = 3-4 weeks Side effects: Dec libido Impotence

K=

Cardiac Arrhythmias

Hypertensive Crisis

Growth suppression

Check the BP Avoid Citrus juices  Dec absorption of anti-depressants Observe dietary modifications Avoid St. John Wort

18

Avoid Tyramine containing foods: Cheddar, Swiss, Cottage and Aged cheese Cola, coffee, soy sauce C=

ANTI-MANIC AGENTS LITHIUM

H= E=

After meals – pc

C= Mild 1.5 Meq/L Thirst Ataxia H/A Irritability Beginning Fine hand tremors

K=

TEGRETOL DEPAKENE (Carbamazipine) (Valproic Acid) Anti-Convulsant Alternative drug for pregnant Women Dec Hyperactivitywithin 2 – 3 weeks Acute Mania = Give Anti-Psychotic with anti-manic

Check signs of toxicity: Moderate 2.5 Meq/L Nausea Anorexia Vomiting Diarrhea Coarse hand tremors Abdominal Cramps Coma  Death

Severe > 2.5 Meq/L

Monitor Lithium Level  early morning (before breakfast) Out patient at least once a month Drug of choice for toxicity  Diamox, Mannitol CI: 1.) Pregnancy 2.) Lactation 3.) Renal Failure Dietary Modification  Inc Na (6 – 10 gm) and Inc Fluid ( 3L or more) Acute Dose: .5 – 1.5 Meq/L Maintenance: .5 – 1.2 Meq/L Elderly : not exceed 1.0 Meq/L  due to poor renal excretion

MUSCULOSKELETAL DRUGS C=

Focus: Gold Therapy Suppresses Arthritis

H=

( - ) Inflammation

E=

IM  weekly Lie supine for 10 mins to prevent OH

19

C=

Check: Signs of Stomatitis Dermatitis Unusual Bleeding Unusual Bruising Fever Sore Throat

K=

Monitor Renal Function Test

C=

ANTI-INFLAMMATORY Ibuprofen (NSAID’s)

Aspirin

Anti-Inflammatory Anti-pyretic Analgesic For RA & OA

Anti-Inflammatory Anti-pyretic Analgesic Anti-Platelet aggregate Anti-rheumatic

H=

( - ) Inflammation, ( - ) pain, ( - ) RA ( - ) fever, ( - ) platelet aggregation

E= C=

K=

pc – after meals Report: Visual disturbances Allergy Sore throat Fever Black Stool

Ringing in the ears Nausea & Vomiting Rapid breathing Hyperpnea  toxicity

Annual eye exam Check bleeding time

C=

ANTI-GOUT AGENTS Probenecid

Excretion of u.a.

Colchicine

Allopurinol

Acute (8-12 hrs) Prevent deposition of u.a. Anti-inflammatory

Chronic (1-3 weeks) Prevent formation of u.a.

H=

Decrease uric acid

E=

Given with food

C= K=

NAVDA Allergy

Bruising

H/A, drowsiness Agranulocytosis

Inc fluid intake 2 – 3 L/day Frequently check serum uric acid level

20

CARDIAC DRUGS NITRATE A. Nitroglycerine Sublingual Trans-mucosal = between gums, cheecks and lips B. Isordil Sustained release, with water and don’t crush Patch Nasal Spray C= Caridac drug (Nitrate) Dilate coronary arteries and arterioles  Dec pre-load H=

( - ) Anginal Pain

E=

Give before onset of pain 3 X at 5 mins interval After 15 mins ( + ) pain  report  May indicate MI 1. Ointment = Cover with plastic and put adhesive tape 2. Patch = Non-Hairy part 3. Oral spray = 3 sprays in 15 mins

C=

S.E. Facial flushing, H/A, Hypotension K=

Rise slowly to prevent OH Tablet on dry, dark container 6 months  Discard Burning Sensation  Indication that the drug is still potent

C=

CARDIAC GLYCOSIDE Digoxin

H=

E=

Digitoxin Strengthen Myocardial Contraction Na-K-pump is converted to Na-Ca-pump Thus increasing force of contraction

Onset 5 – 20 mins

Onste 30 mins – 2 hrs Observe GI irritation

C=

K=

Excreted by kidneys

Excreted by the liver

Normal level 14 – 26

Anti-dote: Digibive Normal level 5 -2 ug/dl

Check HR = Adult 60 Older Children = 70 Infants = 90 – 110

DOPAMINE and DOBUTAMINE

21

DOPAMINE

DOBUTAMINE Inc force of contraction Correct Hemodynamic For Emergency Situation

H= Adequate Urine Output E= Emergency Situation C= Always in diluted form K= Compute the drugs properly

C=

ANTI-ARRYTHMICS Lidocaine (Xylocaine) For PVC’s

H=

Quinidine Atrial Fibrillation ( - ) Arrythmia Slow ventricular rate Slow atrial rate

E= Given as prescribed C=

Rash Convulsion

Blurring of Vision Tinnitus/Ototoxicity

K= Check HR Evaluate ECG C=

H=

THROMBOLYTICS Streptokines TPA Dissolves the clot by preventing the formation of fibrin (fibrinolysis) ( - ) Clot formation Clot Dissolved

E=

Effective within 6 hours After MI  within 24 hrs

C=

Report Bleeding Monitor VS

K=

Contraindicated to clients that are prone to bleeding

C=

ANTI-LIPEMIC AGENTS LOVASTATIN (Tablet)

H=

QUESTRAN (Powder) Dec LDL = 30 – 80

22

(HDL should be > 80 and LDL < 80) E=

Before meals or at night time

C=

Caution: Hepatotoxic

K=

Questran  1 pack of powder + 4 – 6 oz of fluid (water, milk or juice) Check liver function test Rash and bleeding

C=

PERIPHERAL VASODILATOR Paracid Smooth muscle relaxant  Facilitates blood circulation

H= E= C= K=

( - ) Ischemia After Meals Instruct patient that drug may cause H/A and SOB Long term use is individual

C= H=

BETA-BLOCKER (Timolol, Esmolol, Nadolol) Dec BP, for Hyperthyroidism, Dec sympathetic (Autonomic) nervous system stimulation

E=

Before meals

C=

Rise slowly: Lie down for 30 mins after medication. Instruct patient that meds may cause bronchospasm Do not give chamomile and aspirin

K= C=

ANTICHOLINERGIC Atropine Sulfate Vasolytic Agent

H=

Inc heart rate (check complete heart rate)

E=

Before meals

C=

Avoid hot environments

K=

Check for rashes and SOB NEURO-DRUGS Anticonvulsants (Dilantin)

C= H=

Decrease Seizure Threshold

E=

After Meals

C=

Epilepsy  Maintenance Chronis Use  Gingivitis Visit dentist at least once a year Soft bristle toothbrush, massage the gums Urine is pink tinged

K=

SAS ( Saline Flush  Administer drug  Saline Flush

23

To Prevent precipitate C=

CHOLINESTERASE Neostigmine

Tensilon

Cognex

Myasthenia Gravis

Alzeihmers

Long Acting

Short Acting

Maintenance

Treatment

Diagnostic

Treatment

H= E=

Inc muscle strength Before Activity Before meals  Use muscles of mastication

C=

Chewing becomes stronger Medication is lifetime Report S/Sx of hepatotoxicity

K=

Check liver fxn test Keep at bedside  Neostigmine  Antidote: atropine sulfate Do not give echinicea Prepare Tracheostomy

Inc mental functioning At bedtime Dec dizziness

C=

ANTI-TB Rifampicin

INH

Streptomycin

Ethambutol

Peripheral Neuritis (Give B6)

Oto, nephro, neuroTOXIC

Hepatotoxic Psychotic like Sx

H=

( - ) Infection

E=

Before Meals

C=

Red orange urine Don’t use contact lenses

K=

Take the complete treatment as prescribed by the doctor ( 6 – 12 months ) Incomplete TB treatment  Lead to MDRTB

C=

ANTI-ASTHMA Theophylline Adult = 10 – 20 mg/dl Pedia = 5 – 10 mg/dl Dilates bronchioles

H=

Ease breathing

E=

In the morning  because it causes insomnia

C=

Nausea and vomiting Theophylline toxicity

K=

Check the pulse rate Avoid Chamomile  cause bronchospasm Avoid aspirin --? Cause bronchospasm

Cromolyn Na Prevents anti-histamine release

Rashes

24

Inhaler  Acute Steroid  Chronic C=

MUCOLYTICS (Mucomyst)

H=

Antidote for aspirin toxicity Dec viscosity of mucous Loose phlegm

E=

No specific time

C=

Inc OFI S.E.  bronchospasm

K=

Suction Medication has a foul odor that resemble rotten egg

C=

EMETIC Syrup of Ipecac

H=

To induce vomiting  non-corrosive Pedia below 6 months  ( - ) vomiting

E=

Dose depends on age 6 mos – 1 yr = 10ml 1 – 12 yrs = 15ml > 12 yrs = 30ml

C=

Administer with glass of water to enhance effects of ipecac Cardiotoxic = Ensure that child vomits the entire amount

C= Maalox 1-2 hrs

ANTACIDS Peptic Ulcer Disease Ranitidine 4-6 wks

Sucralfate 8 wks

Neutralizes HCl

Dec HCl secretion

Coats GIT

Normal HCL 2 – 5 Maximum 10 H=

( - ) Pain, dec HCl

E=

Usually on an empty stomach 1 hour before meals 2 hours after meals Shake liquid SE: diarrhea Constipation

C=

K=

Short term therapy  Electrolyte imbalance

25

ENDOCRINE DISEASE C=

INSULIN

OHA

Type 1

Diabetes Mellitus

Regular – Humulin Intermediate – NPH Long-acting – ultra lente H=

Orinase Diabinase Metformin

Inc transfer of glucose to cell membrane

Pancreas to secrete insulin

E=

Before breakfast

C=

Report Hypoglycemia: Dizziness Dec LOC Diff. of problem solving

K=

Type 2

Hypo occurs usually occurs at the peak of action of meds: Before lunch In the afternoon or before dinner In midnight or next day Rank: 4 – 8 – 12/16

C=

THYROID DRUGS Synthroid (supplement) For Hypothyroidism

H=

PTU Tapazole ( 10 times greater than PTU) For Hyperthyroidism

Normal BMR

Dec T3 and T4, Adequate appetite and sleep

E= C=

In morning to prevent insomnia Report signs of overdose: Insomnia, palpitation & Nervousness

Round the clock Report: Fever, sore throat, body malaise

K=

Life time

Monitor HR & BP

C=

STEROID Cortisone

Floricef Replacement Therapy Addision’s Disease

H= E= C=

K=

Correct Fluid and electrolyte Imbalance In the morning Given intramuscularly Avoid abrupt withdrawal AE: Bruising  Bone marrow depression Avoid salty foods  edema Maintain a balance diet  obesity

26

Avoid crowded areas  Infection C=

RENAL DRUGS EPOGEN Inc RBC production  for Chronic Renal Failure

H=

Normal Hemoglobin

E=

As prescribed

C=

Report Polycythemia  Inc production of RBC  CVA Check Complete Blood Count

C= Loop Diuretic (Lasix)

DIURETIC Thiazide Diuretic (Hydrochlorothiazide) Duiril

K – Sparring Diuretic (Spirinolactone) Aldactone

Loop of Henle Prevent Na absorption

Distal Tubule Prevents Na absorption

Blocks aldosterone Retains water

H=

Increase urine output and decrease pt’s weight

E= C=

Early morning  prevent nocturia Hypokalemia Dec K Dec na

K=

Hypokalemia Dec K Dec Na Dec Ca Dec mg

Inc K Dec Na

Inc Sodium in diet Check Electrolyte level Check BP IMMUNUREN (Azathioprine)

C= H= E= C=

Immunosuppressant ( - ) rejection of organs As prescribed Report: Nausea, vomiting Thrombocytopenia Bruising Infection

K=

Check CBC Frequent Handwashing

C=

MIOTICS (Pilocarpine) For Glaucoma

MYDRIATICS (ATSO4) CI for Glaucoma For eye exam

H=

Normal IOP

Dilatation of pupils

27

E=

Lifetime in glaucoma

As prescribed

C=

Lower conjunctival sac Press inner canthus 1 – 2 mins to prevent systemic SE

Report: eye pain & blurring of vision Avoid alertness after medication

K=

Check BP and Blood sugar

C=

ANTIBIOTICS Vancomycin MRSA

Penicillin Gonorrhea Syphillis

H=

( - ) Infection

E= C=

Tetracycline Lymes Rocky Mountain Fever

Before meals With GI irritation  After meals Ototoxic, Nephrotoxic, Neurotoxic

Allergy

K=

Hepatotoxic

Check I and O Peak Level = 15 – 30 mins after administration Trough level = 15 – 30 mins before the next dose Antidote: Epinephrine Given with probenecid

Deep IM and check CBC

Guidelines on Gross Cultural Orientation and adjustment Try to get to know as much as you can about: o Social customs o Family Life o Class structure o Religion o Economics o Value System Some Areas of Culture Differences 1. Communication o Message interpretation o Personal Space o Eye contact o Touch 2. View of Time o Present oriented (Hispanics, Africans) o Future oriented (Europeans, Americans) o Past Oriented (Tribal/Traditional) 3. Family Type

28

o o

Nuclear Extended

4. Nutrition = kosher diet, jalal 5. Religion o Catholics o Jehova’s Witnesses o 7th day Adventist o Mormons Culture Bound Syndrome Black  Inc blood Chinese  Koro Hispanics  Pasmo Whites  Anorexia, Bullimia Death and Dying ASIANS Family and friends of same sex will prepare and wash the body MUSLIM 1. Washing of the body - women – cleanse women - men – cleanse men 2. After washing 3 time the body is wrapped in 3 pieces of clean white cloth 3. Special prayers 4. Bury the body with the head facing mecca 5. Burial of fetus = < 130 days  discard like tissue = > 130 days  proper burial rites JEHOVA’S WITNESS o Autopsy is accepted if required by law o The parts to be removed from the body o Cremation is permitted

FRAMEWORK Main Problem: SIADH  Neuroendocrine Most common / initial manifestations = SIADH  Oliguria Laboratory Data = Dec Na, Inc BP Nursing Diagnosis  Dec Na  N. Dx. Fluid and Electrolyte imbalance Priority Intervention = Dec Na  115 meq/L  Implement seizure precaution Leukemia Main Problem: Proliferation of Immature WBC Periods of remission and exacerbation Remission = Absence of s/sx  Lymphycytic  Lymphocytes  Pedia Exacerbation = Active s/sx  Myelogenous  Granulocytes  Adults S/Sx Initial: Anemia Bleeding  severe / unexplained Infection

29

Lab. Data:

WBC  Hyperleukocytosis  WBC 150,000

N. Dx: Priority  Safety Reverse, Isolation precaution  relative wear mask Thrombocytopenic precaution Cytotoxic Precaution Bleeding Precaution Standard Precaution HEMOPHILIA Main Problem  Inherited disorder Type A X-linked Recessive 50% male offspring ( - ) Factor 8 S/Sx:

Type B X-linked recessive 50% male oofspring ( - ) factor 9

Von Willebrands disease Autosomal dominant Male & Female

Hemarthrosis  Hallmark  elbow, wrist, ankles, knees Hematoma Hematuria Hematemesis Hemmorhage

Lab Data: Clotting time N. Dx: Risk for injury, altered growth Priority: Safety Blood Transfusion, Plasma Expanded 1. Rest 2. Immobilize 3. Cold compress 4. Elevate

30

SICKLE CELL ANEMIA IRON DEFICIENCY ANEMIA

PERNICIOUS ANEMIA

FOLIC ACID DEFICIENCY

SICKLE CELL ANEMIA

APLASTIC OR FANCONIS ANEMIA

THALASSEMIAS 1. Minor 2. Intermediate 3. Major

Inc. def. of iron Dec absorption Excessive loss

Lack of Vit. B12 Absence of intrinsic factor In stomach:

Deficiency in Folic Acid

Inherited  31Autosomal Recessive  status of Parents (See Table A.1 below)

Pancytopenia Hemolytic

Due to defect in polypeptide chains of RBC

Baby  chubby but pale Due to over intake of milk Women  menstruation

Aging  atrophy Surgery  removal

RBC C/S shape  thrombus  occlude bv Vasoclusive Crisis  due to DHN Aplastic Crisis (hemolytic anemia)  dec RBC, WBC & platelets Spleenic sequestration crisis  spleen destroys rbc rapidly

Dec RBC, wbc and platelet

RBC destruction Common in blacks, Indians, Greeks, Chinese & Italians

S/Sx: 3 F’s: Fatigue, Fainting, Forgetfulness

S/Sx: 3 F’s + beefy red Tongue (glossitis) Peripheral neuritis

Pregnant Breast feeding Infant Adolescent Alcoholic Poor feeding practice Over cooking of veggie S/Sx: 3 F’s With peripheral neuritis

S/Sx: Fever, joint pain, paralysis & weakness CVA

S/Sx: 3 F’s, Inc infection, Inc bleeding

N. Dx: Activity Intolerance Priority: Bedrest, supplement Iron 2 wks, Inc iron diet  organ meats, Green leafy vegetables, dried fruits Relief of Fatigue *Desferral  Antidote

Lab: schillings test N. Dx. Risk for injury Priority: Rest B12 supplement *Absence of beefy red tongue

Lab: Folic Acid < 4 mg/dl N. Dx: Fatigue Injury Priority: Rest FA supplement Green Leafy veg  Spinach, broccoli  Help RBC production

Lab data: *Sickle dex test – trait *Hgb electrophoresis – Confirms the disease N. Dx: Activity Intolerance, Risk for injury, unilateral neglect Priority: Pain relief & hydration Blood transfusion  refer to geneticists

Lab Data: Dec Hgb, wbc & platelet N. Dx: Risk for injury, Infection, activity intolerance Priority: protect form infection, CBR, BT

S/Sx: Depends in types Mild: Mild anemia Intermediate: Anemia, spleenomegaly, hemosiderosis, accumulation of iron in tissues Major: severe anemia with hepatomegaly Lab Data: Dec Hgb N. Dx: Activity Intolerance Priority: Bedrest, steroids, spleenectomy

31

Table A.1: Autosomal Recessive Normal A. 1 parent with trait 50% B. 2 parents with trait 25% C. 1 parent with trait the 0% The other with disease D. Both parents with disease )%

Trait 50& 50% 50%

Disease 0% 25% 50%

0%

100%

Neoplastic Thrombocytopenia Purpura  Dec Platelet  due to viral infection  autoimmune reaction  drug use S/sx: Petechiae, ecchymosis, hematoma Lab Data: Platelet < 20,000, Dec Hgb N. DX: Risk for injury Priority: Safety, prevent bleeding Supplement with folic acid Blood transfusion CHD ACYANOTIC (Left to right shunting)

CYANOTIC (Right to left shunting)

Inc pulmonary blood flow

Obstructive conditions

Dec pulmonary blood flow

Ventricular septal defect Atrial septal defect Patent ductus arteriousus

Pulmonary stenosis Aortic stenosis Coarctation of the aorta

Tetralogy of Fallot Truncus arteriosus Transposition of great vessels Tricuspid atresia Hypoplastic left heart syndrome

Risk factors: Maternal infection (14 mos) Age (> 40) Medical Condition (DM) Alcoholism Brow seating (feeding)  due to activation of ANS Baby sleeps after 3 minutes of sucking Difficulty in feeding Tachycardia Tachypnea Frequent URTI Heart Failure Retarded Growth Semi Fowlers Priority: provide warmth Initial: L sided heart failure  dyspnea & O2 & surgery Late: R sided heart failure < 2 y/o = O2 2 – 7 y/o = Surgery> 7 = Surgery as soon as possible

Cyanotic (tet spell)  CVA If walking  squat If not walking  knee chest

32

RHEUMATIC FEVER Systemic inflammation of connective tissues (joints, CNS, heart) Risk Factors: (conditions 2-4 weeks before diagnosis) Sore throat Impetigo Scarlet Fever S/Sx: Major: Carditis  tachycardia at rest Arthritis  migratory Sub Q nodules  painless Eryythema Marginatum  rashes Chorea  Abnormal movement

Minor: Fever Murmur Tachycardia

Lab: Inc ESR = Male (1-2 mm/hr, Female 20 mm/hr), Inc ASI titer N.Dx: Altered tissue perfusion, Dec CO, Pain Diet: Inc fluid intake, Inc CHON Meds: ASA, Penicillin to prevent heart valvular damage Complications: Cardiac Valvular Disease  stenosis and regurgitation Stenosis  narrowing, fusion of leaflets Regurgitataion  incomplete closure STENOSIS Mitral Dec pitch Diastolic murmur

REGURGITATION Aortic High pitch Systolic murmur

Mitral High pitch Systolic murmur

Aortic Blowing diastolic murmur

Treatment: Antibiotics Anticoagulants Pregnant Clients Classifications: I

II

III

IV

No Limitation of activities

Symptoms with activities of daily living

Symptoms with less than ordinary ADL’s

Symptoms even at rest

Fibrillation

VENTRICULAR PVC

Fibrillation

Extra QRS

Widened QRS

ARRYTHMIAS = Abnormal cardiac rhythm ATRIAL Flutter

Sawtooth patter  Pwave  P:QRS ratio 2:1-4:1-6:1 Quinidine

Epinephrine

Lidocaine

33

Defibrillation Defibrillation CPR CPR, Quinidine QRS = < .10, 2 squares PR = .12-.20 = 35 small squares

Defibrillation CPR

ABNORMAL CARDIAC RHYTM Heart Block  PR interval Primary  prolonged PR Interval = No intervention Secondary  Progressively prolonged PR Interval = Atropine Sulfate Tertiary  P & R wave are independent of each other = Pacemaker = HR < 5 beats below the limit = Hiccups  Failure = Belching  decreasing heart rate = Signs of shock  weak pulse = Stay away from electromagnetic field CAD o

Narrowing and obstruction of coronary arteries

o Dec O2  Hypoxia  Angina o ( - ) O2  Neurosis o

Risk Factors: CAD Atherosclerosis Smoking Elevated Cholesterol HPN Obesity Physical inactivity Stress

Angina

MI

Stable  Pattern is predictable             Anterior Wall Unstable  Pattern is unpredictable Variant (Printzmetal)  Severe form          Posterior Wall Nocturnal __> @ night Decubitus  when lying down             Lateral Wall Intractable  Unresponsive to treatment Post MI  After MI Pain < 20 min Upper sternum Pressure Relieved by rest Nitroglycerine

Precipitates: Eating Elimination Extreme temp Emotion Effort

Pain > 20 min Lower sternum Crushing, Excruciating Not relieved by rest Morphine (Check RR)  Antidote  Naloxone

Associated S/sx:

34

Agitation Restlessness Cold clammy skin HPN

Lab Data: Inc cholesterol < 200 ECG changes

Inc cardiac enzymes Inc ST segment Inc ESR

N. Dx: Pain Position in Semi Fowlers Administer drugs as ordered Diet: Cholesterol restricted diet Percutaneous Transluminal CardioAngioplasty = Done if 50% of blood supply to heart is impended = Insertion of a balloon tipped catheter  ballooning  cardiac stent Coronary Artery Bypass Graft = Done if 50% of blood supply to heart is impended = Placing a new blood vessel Health Teaching: o Avoid strenuous activities o Can resume sexual activity  if can climb 2 – 3 flights of stairs with no dyspnea o Provide frequent rest periods o Discharge Instructions  Avoid life threatening conditions HEART FAILURE = Inability of the heart to pump adequate amount of blood to meet the metabolic demand of the body. Risk Factors: MI Heart valvular disease RHD HPN Arrhythmia S/Sx: Left sided: Dyspnea, pink sputum, productive cough, pulmonary edema Right sided: Distended neck veins, ascites, ankle edema, hepatomegaly Lab Data: Left cardiac function  Swan Ganz Right Cardiac Function  CVP N. Dx: Altered tissue perfusion and dec CO Priority: To Inc CO

35

Position in semi fowlers Administer drugs as prescribed  Digitalis, Vasodilators, Diuretics *Morphine  dec venous return to the heart  peripheral vasodilating effects Diet  Low Na, Low Cholesterol Assess breath sounds, edema, heart sounds HYPERTENSION = Silent Killer disease Hypertensive disorders of pregnancy = Persistent elevation of BP above 140/90 = 120/80  Pre-hypertensive = 110/70  normal Risk Factors: Family Hx Age Blacks Obesity Stress Smoking Types: 1.) Essential  Unknown 2.) Benign  Unknown / Long duration 3.) Malignant  Acute, short duration 4.) Secondary --? Due to medical condition Complications: Occipital HA Retinal Hemorrhage Pedal Edema

4 common complications: CAD CVA CRF CHF

Lab: Inc in cholesterol, Inc LDL, Inc TAG N. Dx: Altered health maintenance  Tx is prolonged = Vasodilator, Anti-lipemic agents * Common cause of concern  Bronchospasm, Dec libido Diet  Dec Na, Dec cholesterol NON-PHARMACOLOGIC REGIMEN Stress Mx: Exercise  deep breathing, walking, stress free hobbies (like walking by the bay) HPN in pregnancy  Unknown = Generalized vasospasm  due to virus  H. Lualba = 2nd trimester = B4 20 wks AOG  H. Mole / GTD = after 20 wks AOG  PIH = Before and after pregnancy  chronic hypertension HYPERTENSIVE D/O OF PREGNANCY o Inc BP

36

PRE-ECLAMPSIA o Inc BP o Edema o Proteinuria: Mild : BP  140/90 Protein  < 5gm/24hrs Severe: BP  160/110 & above Protein  > 5 gm/24hrs o Mx: Darkened room Inc CHON diet MgSO4: Antidote --> Ca Gluconate ECLAMPSIA o Inc BP o Edema o Proteinuria o Convulsion  bleeding  HELLP Syndrome (hemolysis, elevated liver enzyme, low platelet  manifested with petechiae PVD

Arterial Occlusion Pallor ( - ) or minimal Thick & brittle *Intermittent Claudication (-) Cold Dry

Color Edema Nails Pain Pulse Temperature Ulcer BUERGER’S (Thromboantgitis Obliterans) - Acute -A&V - Male - Lower ex - Smoking - Inflammation of arteries and veins

RAYNAUD’S DISEASE - Intermittent - arteries - Female - Upper ex (97%) toes, ears, LE (3%) - Cold - Vasospasm of arteries

Venous Occlusion Ruddy Severe Normal Homan’s sign Normal Warm Wet ARTERIOSCLEROSIS OBLITERANS - Chronic - arteries - Male - Upper & Lower ex - hardening arteries

Pain Intermittent Claudication – Intermittent color changes (Pallor, Cyanosis, Redness) Lab data: Painless Doppler UTZ N. Dx: Pain & altered tissue perfusion Priority: Anti HPN, Vasodilator, Anticoagulants Instructions: Avoid smoking, swimming in cold water

37

PULMONARY EMBOLISM - A clot lodges in one of the pulmonary arteries Risk Factors:

1.) VA  Trauma 2.) Hypercoagulation 3.) Arrhythmia 4.) Thombosis S/Sx:

Anxiety / Agitation Dyspnea Restlessness Tachycardia Tachypnea Chest Pain *Crackles Lab Data: Perfusion Lung Scan N. Dx: Pain, Ineffective breathing pattern Priority: Positioning Right sidelying Administer Anticoagulant ABDOMINAL AORTIC ANEURYSM - Weakening of the walls of the aorta - Congenital - Angina - Chronic HPN Types: 1.) Fusiform – bulging of both sides of bv 2.) Disecting – Dissected inner wall of bv 3.) Saccular – forms a pouch or sac S/Sx: Assymptomatic Pulsating Abdominal mass Low Back Pain Inc BP of Ue, Dec BP in LE Lab data: Aortography, X-Ray N. Dx: Risk Poor injury  altered tissue perfusion Safety  Most Abdominal Palpation Prepare pt for surgery that will involve grafting After surgery  assess for distal pulses KAWASAKI’S DISEASE - Acute systemic inflammation of the vascular system - Heart & blood Vessels - Common in Japanese, toddler & pre-schooler - Unknown S/Sx: High spiking fever for 5 days of more Strawberru tongue, palmar desquamation

38

Lab Data: 2 D-Echo, ECG N. Dx: Altered tissue perfusion, Dec Cardiac output Priority: Tx is supportive, ASA Diet: Clear Liquid Discharge Infection: Teach Pt. CPR 5:1  Pedia 15:2  Adult 30:2 1. To Assess risk of developing mitral valve stenosis in pt. What should the nurse ask the pt? A: Did you have streptococcal infection 2. How to assess intermittent Claudication: A: Ask the pt to walk and note presence of pain 3. What should the nurse prepare at bedside with PVC A: Xylocaine 4. Priority in pt with complete heart block A: Altered tissue perfusion 5. Goal of Care with atrial fibrillation A: Inc CO 6. Coomon complication of sickle cell anemia? A: CVA 7. Signs of left sided heart failure A: Dyspnea on excretion 8. When planning an exercise program in pt with HPN, Nurse should ask? A: How do you spend your leisure time CYSTIC FIBROSIS - Inherited multi system disease affecting the exocrine gland - Autosomal recessive  each pregnancy  (Disease 25%, trait 50%) - Excessive Mucous production  Made = Sterility, Female = Diff. in concerning S/Sx: Initial: Abdominal distention Malabsorption Syndrome  Steatorrhea  Foul smelling fatty, stool Salty when kissed Lab: Pilocarpine Sweat test Respiratory Therapy: Blowing Exercise  Trumpet  Blowing Bubbles GI Therapy: Pancreatic Enzyme  Pancreas  Viokase  with each meal & snacks Refer pt’s prevents  geneticist Pt. Grows  OB PNEUMONIA - Mycoplasma Pneumonia (pedia), Legionnaires disease (elderly, alcoholic, immunosuppresion) - Inflammation  Allveoli  Exudate, Consolidation - Viral, Bacterial, Rickettsia S/Sx: 5 Cardinal signs & symptoms 1. Fever 2. Sputum 3. Pleuritic Chest Pain 4. Chills 5. Cough

39

PNEUMONIA Viral: -

Low grade fever Thin & watery sputum WBC either normal or slightly increased

Bacterial - High grade fever - Rusty sputum - WBC severely increased Lab data: Chest X-ray, sputum exam, ABG analysis N. Dx: Impaired Gas Exchange Ineffective Airway clearance Ineffective Breathing pattern Priority: Bed Rest, Inc OFI, Administer meds as ordered: antibiotics CROUP ACUTE LARYNGITIS

LTB

BRONCHIOLITIS

Toddler

Infant & toddler Viral & Bacterial

Infant < 6 mos (RSV)

Larynx

Inflammation of the Larynx and trachea

Bronchioles

S/Sx: Cough: Barking, metallic Stridor: Present Wheezing: Absent Fever: Absent

Harsh & Brasky Present Absent Low Grade

Paroxysmal & Hacking Present Present Moderate to high grade

Lab Data: Throat Swab PE X-ray

X-ray Throat swab PE

X-ray ELISA Throat swab PE

N. Dx: Infection, Ineffective breathing pattern Priority: Tx of infection Multi-drug therapy OPD (Obstructive Pulmonary Disease) Narrowing and obstruction of the airway Emphysema

Bronchitis

Asthma

40

-overdistended alveoli

- inflammation of bronchioles

-excessive mucus

Smoking RE,TACY,TACHY DC Barrel Chest

Gelatinous Sputum Inc coughing

Whitish sputum Orthopnea

Bronchodilators

Activity: Soft ball Baseball

Lab Data: X-ray, ABG Analysis N. Dx: Ineffective Breathing Pattern Ineffective Airway Clearance Orthopneic Semi-Fowlers Principles in Nursing Care: Bronchodilator Rest Oxygen low flow Nebulize Chest Physiotherapy High Fowlers IPPB – Intermittent Positive Pressure Breathing Aerosol Liberal Fluid Intake

Aminophylline Steroid Theophylline Histamine Antagonist Mucolytic Antabuse

Complication: Cor Pulmonale Right Ventricular Hypertrophy Pneumothorax Spontaneous

Open

Tension

Ruptured Bullae/alveoli

Chest injury

Trauma

Increase tension and pressure Thoracic cavity Lung collapse ( - ) breath sounds Dyspnea Pain 3 way bottle sys Pointers for Respiratory:

1.) Mist  Priority? A: Change the linen and clothing to keep the pt dry. 2.) Goal of care for child with bronchiolitis? A: Minimize O2 expenditure 3.) Pancrease is given with meal 4.) Patient with TB  What is the purpose of NGT?

41

A: To aspirate swallowed sputum 5.) S/Sx that indicates emphysema? A: Barrel shaped chest 6.) Development of Edema? A: Moist and noisy breathing 7.) Common risk factor for Legionnaire’s disease? A: Immunosuppression 8.) Mycoplasmal Pneumonia is manifested by? A: Fever & productive cough PKU

o Inherited disorder characterized by absence of phenylalanine hydroxylase (PH) which converts phenylalanine o o o

to tyrosine (precursor)  melanin for hair, eyes, skin Normal level = 2mg/dl, 4mg may indicate PKU, 8mg confirms PKU Autosomal recessive Phenylalanin is toxic to the brain and causes MR

S/Sx: Asymptomatic at birth: Diarrhea, Anorexia, Lethargy, Anemia, skin rashes N. Dx: Knowledge deficit Altered nutrition Risk for injury  seizure Health Teachings: Low Phenylalanine  up to adolescence  9-10 y/o Refer to Geneticists and nutritionist Produce list of foods that’s is allowed and not allowed

HASHIMOTO DISEASE o

o o o

o

Congenital deficiency in T3 and T4 S/sx  Asymptomatic  maternal hormonal transfer 2 – 3 mos s/sx appear Behavioral: Apathy, well behaved baby Physical: Large tongue, short structure, retarded growth  MR

Lab data: Dec T3 and T4 N. Dx: Knowledge deficit Risk for activity intolerance Altered growth & development Priority: Administer Synthroid, single morning dose forever Report: Tachycardia (palpitations) Insomnia Nervousness *Provide warm environment * Refer to special education center PANCREAS ALPHA CELLS Glucagon

BETA CELLS Insulin

MODY (Maturity onset Diabetes in young adults)

Absence IDDM (Type I)

Deficiency NIDDM (Type II)

42

Combination of IDDM & NIDDM Pregnancy 2nd trimester Developed placenta secretes HPL (Human placental lactogel  counteracts insulin

Juvenile onset Ketosis prone Thin

Maturity onset after 35 Non Ketosis form Obese

Gestational: (White’s classification) Types: A: Chemical DM: B: onset: >20 y/o C: 10 – 19 y/o D: < 10 y/o D1: < 10 y/o D2: > 20 y/o D3: Beginning retinopathy D4: Hardening arteries D5: HPN E: Pelvic arteries F: Retinopathy H: Cardiopathy R: Retinopathy T: Transplant kidney - Absence or deficiency in insulin affects, CHO, Fats & CHON metabolism - Insulin facilitates entry of glucose into the cell - If there is no insulin  glucose remains outside the cell  hyperglycemia  fluids are attracted to cell & blood - Cells dehydrated (brain)  compensatory mechanism  Polydipsia - Cells dehydrated (brain)  Inc glomerular filtration rate  Poly uria  leads to weight loss  cell stones  brain  polyphagia Lab Data: FBS, Glycosylated Hgb, Hemogluco test N. Dx: Knowledge deficit Altered Nutrition Altered Elimination Risk for Infection Priority: To maintain normal blood sugar Diet: 50 -70 % CHO, 20 – 30% Fats, 10 – 20% CHON Well balanced diet Insulin: Type I, pregnant 2nd trimester  Inc dose Anti-Diabetic Agents  sulfonylreas  CI --> sulfa Drugs Blood sugar  am and pm Ensure Adequate food intake Transplant of pancreatic cells Exercise  Moderate Scrupulous Foot care  Avoid barefoot, avoid synthetic shoes  Indicated: Foot powder, snuggly fitting shoes, cotton socks, visit podiatrist atleast once a year Complications: Hypoglycemia: Blood Sugar  < 150mg/dl RF: too much insulin, missed meal, exercise S/Sx: Diaphoresis Decreased LOC Diff in problem solving

Hyperglycemia: Blood sugar  > 140mg/dl RF: Too little insulin, Inc food intake, pregnancy, Infection, stress, surgery Type I DKA Acetone breath De H2O Warm skin

type II HHNK Inc GI s/sx DeH2O Inc serum Osmolality

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3 P’s 3 P’s Kussmauls breathing TX: Airway, Fluid and Insulin  rapid acting insulin

Tx: Simple sugar

Other Complications: 1.) Microangiography  damage to small retinal blood vessels 2.) Atherosclerosis  hardening of arteries  HPN 3.) Neuropathy  Kidney damage 4.) Retinopathy  Opthalmopathy  damage to nerves 5.) Peripheral / Autonomic  Dec nerve impulse transmission

PITUITARY GLAND ADH Fluid Retention

Risk Factor S/sx: Lab Data:

Deficiency Diabetes Insipidus

Exercise SIADH

Trauma Surgery Polyuria (21L/day) Polydipsia

Trauma Tumor

Fluid deprivation test NPO X 12 hrs Concentrated urine Specific Gravity: < 1.005

Vasopressin Depressin Lepressin

Check specific Gravity

Monitor and output and specific gravity of urine Goal of care: Excretion of fluid  Diuretics and anti-HPN

Fluid retention Dilutional Hyponatremia Check Sodium

Growth Hormone Ant. Pituitary Gland Promotes growth Deficiency Dwarfism  Mahal Achondroplasia  “Nanus Syndrome”  Dagul

Excess *Before closure of growth plate  Gigantism  Taller, slender  Marfans’ Syndrome  Genetic d/o, a. Dominant  spine d/o  Scoliosis  Cardiac problem *After closure of growth plate  Acromegally  enlargement of Extremities * Inc growth hormone and glucose ADRENAL

Outer Cortex

Middle Medulla

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Glucocorticoids Gluconeogenesis Def. Addison’s

Mineralocorticoids Na retention Excess Cushings

Epinephrine Nor-epinephrine

Excess Conn’s Syndrome

fight/flight response Tumor Pheochromocytoma  excess epi and norepinephrine HPN, H/A Inc hyperglycemia Hypermetabolism

Commons syndrome  Aldosteronism Lab Data: Inc VMA  2 – 7 mg/dl in 24 hrs Avoid vanilla containing foods, 14 hrs before the test

ADDISON’S Deficiency Glucocorticoids Mineralocoticoids RF: Autoimmune Surgery S/Sx:

Glucocorticoids

Hypoglycemia Hyponatremia Hyperkalemia Hypotension – shock like Brown skin pigmentation Truncal Obesity Mood swings Facial hirsutism Buffalo hump Moon Facie

CUSHING’S

CONN’S

Excess Mineralocoticoids Tumor

Excess Mineralocoticoids tumor

Hyperglycemia Hypernatremia Hypertension

Hypertesnsion Hypernatremia Hypertension

Truncal Obesity Mood swings Facial hirsutism Buffalo hump Moon Facie

Truncal Obesity Mood swings Facial hirsutism Buffalo hump Moon Facie

Maintain Fluid and electrolyte Balance Steroids steroids inhibitor *Fludrocotisone Florinef Mitotaine Dec s/sx: Normal Na and blood sugar Diet: Inc Na, Dec K Dec Na, Inc K Client Teachings: Meds for life Prone to osteoporosis Avoid crowded areas Excessive poor wound healing

inc Na & dec K, Inc BP Anti-HPN Diuretics Dec Na, Inc K

THYROID T3, T4 BMR

CALCITONIN Deposition of Ca in the bones

Deficiency

Excess

Hypothyroidism - Cretinism - Myxedema

Hyperthyroidism - Grave’s disease - Basedow’s disease - Parry’s disease

RF: Autoimmune, tumor

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S/Sx: Facial edema Intolerance to cold Hypometabolism Lab Data: Dec T3, T4, Inc TSH - Activity intolerance -Uthyroid state  Normal - Give thyroid supplement - Synthroid SE: - Insomnia - Nervousness - Palpitation Diet: - Dec Calories - Warm environment

Exopthalmos Goiter Hypermetabolism Intolerance to cold Inc T3, T4, Dec TSH - Risk for injury - Uthyroid state - Anti thyroid drugs - Propylthiouracil - Agranulocytosis (Fever, Soar throat) - Inc Calories - Cold environment

THYROID SURGERY Preparation

Post operative

- Lugol’s solution (2 wks before surgery) - Dec size & vascularity of thyroid gland - Give in straw and diluted in water or apple juice - S/sx of iodism  Metallic taste

- Monitor complication 1. Hemmorrhage – bruises 2. Laryngospasm – tracheostomy 3. Damage to laryngeal – inability to speak, aphonia 4. Tetany – Dec in Ca > Tingling, chvostek, Trouseau sign 5. Thyroid crisis Complications: Fever, Inc HR, check VS

PARATHYROID - Inc Ca in the blood Hypothyroidism

Hyperthyroidism

Surgery

Tumor

S/Sx; Early: Tingling, chvostek, Trouseau sign

- Pain, bone destruction, fracture / osteoporosis - Von Recklinghausen disease

N. Dx: Risk for injury - Give Ca supplements - Inc Ca in diet

Renal calculi formation Lab Data: Inc Ca in blood N. Dx: Risk for injury Priority: Surgery Mx: Inc OFI

Pointers: 1. Manifestations of Ketoacidosis: A: Rapid and deep breathing 2. Post thyroidectomy  Tetany of hands, feet and muscle twitching, the nurse knows the doctor would order? A: Ca Gluconate 3. W/c of the ff. indicates hypothyroidism? A: Intolerance to cold 4. In PKU, which is not indicated? A: Milk Shake

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5. Which of the ff. manifestation indicates a complication post thyroidectomy? A: Tachycardia 6. Which of the ff. interventions is appropriate for a pt with Addison’s disease? A: Monitor the BP 7. Insulin was given at 8 am, when do you expect hypoglycemia? A: Before lunch 8. In PTU an expected outcome is a? A: Dec in PR 9. Hypothyroidism  best question? A: Do you tire? 10. Which of the ff. data needs to be assured in head injury? A: Dec urine specific Gravity

NEPHROTIC SYNDROME Congenital Autoimmune

ACUTE GLOMERULONEPHRITIS Acquired  sore throat Autoimmune

- Inability of the kidneys to maintain fluid balance *hyponatremia

- Kidney damage

S/Sx: - Normal or dec in BP - Peripheral Edema subsides at the end of the day - Frothy urine color

- Inc BP - Progressive peripheral edema at the end of the day - tea colored urine / cola

Lab Data: - Most significant data  Proteinuria = > 10mg/24hrs - Proteinuria = < 10mg/24hrs - ( - ) Colloid osmotic pressure  edema - Inc ASOT N.Dx: - Fluid Volume excess - Risk for impaired skin integrity Mx: - Goal of care  promote fluid balance - Restricted fluid - Frequently turn client - Steroids - AGN: Anti-HPN - Dec Na, Inc CHON - Dec Na, Dec CHON

WILM’S TUMOR - Congenital tumor of kidneys - unilateral left kidney - palpable on abdomen - common in children < 5y/o - ( + ) HPN, Hematuria - Risk for injury - Promote Safety - Prepare pt for surgery & chemotherapy - Avoid abdominal palpation CYSTITIS - Ascending infection

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- Bladder  Ureters  Kidneys  pyelonephritis  CVA tendency RF: - bubble bath - Silk underwear - Prolonged driving - Catheterization S/Sx: - Burning sensation Lab Data: - Urinalysis - Inc WBC - Inc glucose Tx: - Treat infection - antibiotics - Acid ash diet - Inc OFI - Avoid risk factors RENAL FAILURE ACUTE

CHRONIC

- Sudden cessation of kidney function RF: PreRenal -Dec circulation of Blood volume S/sx; Oliguric Phase -Dec urine output - < 400ml

- Progressive/ irreversible destruction of kidney tissues - Scar formation

IntraRenal -disease of kidney

PostRenal - obstruction -stone

- AGN, NS

Diuretic Phase

Recovery Phase

-polyuria, dec Na & K

- 1-2 yrs

1. Dec renal reserve – polyuria, nocturia, polydipsia 2. Renal insufficiency – Inc BUN & creatinine 3. Renal Failure – HPN, Renal Damage 4. ESRD – Azotemia, uremia Lab Data: - Inc BUN & Crea

N. Dx: - Fluid & electrolyte imbalance Priority: Restore circulating fluids - Monitor intake and output - Response of client on therapy – output, BP Meds: Diuretics, Dec Na diet, Anti-HPN, digoxin

N. Dx: - Fluid & electrolyte imbalance Priority: Fluid restrictions Meds: Epogen to prevent anemia - Amphogel – prevent hyper phosphatemia - Diuretics, Anti-HPN, Digitalis Diet: Dec Chon Mx: Dialysis: 3 X a week or every 48 hours

DIALYSIS Hemodialysis Dialyzing agent - Dialyzing Machine Access Fistula shunt -internal access - external access -anastomisis of a & v - palpate for thrills and auscultate bruit

Peritoneal - Dialyzing agent – Peritoneum Access - Ten khoff catheter - assess rigid abdomen  peritonitis

Complications

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Disequilibrium

Dialysis Encephalopathy

Rapid removal of waste product Fluids and electrolytes GI CNS NAVDA H/A Dizziness Restlessness - Report to MD

-Aluminum toxicity -S/Sx: dementia, dizziness -Report to MD

BPH - Glandular enlargement of the prostate - After age 40, male S/Sx: - Dec size & force of urinary stream - Nocturia - Dysuria - Frequency, urgency, hesitancy Lab Data: DRE  @ age 40 Priority: Promote Urinary elimination  Prepare for surgery TURP  no incision Suprapubic Retropubic -above the bladder -below the bladder

Perineal -causes impotence

Pointers 1. An elderly with oliguria and flank pain may indicate a problems caused by? A: Intake of neomycin 2. Which laboratory data needs to be reported? A: urine specific gravity of 1.004 3. 12 hrs after TURP – the pt complains of spasm A: Check patency of retention catheter. 4. A 2 y/o boy with Nephrotic Syndrome with periorbital edema & frontal edema what will be the essential nursing measure: A: turn pt frequently 5. Which of the ff is a common complication of chronic renal failure? A: Anemia 6. A pt with Nephrotic Syndrome asks “Why am I gaining weight?” the best reponse is? A: you have sodium retention that attracts water 7. During hemolysis, pt with HA and vomiting, restless and confused, he is having? A: Disequilibrium syndrome 8. After peritoneal dialysis the return flow with dialyzate solution is inadequate, What should the nurse do? A: Turn pt from side to side. 9. A Priority N. dx to a pt with renal stones? A: Pain

OTITIS MEDIA - Infection of middle ear - URTI - Faulty feeding

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- swimming in dirty waters - Pain, fever, earache Lab Data: PE, otoscope, bulging tympanic membrane N. Dx: Pain  antibiotic, decongestant, Pseudafed Chronic: myringotomy tube insertion RETINAL DETECHMENT o Separation o Sensory pigment  retina o Aging  40 y/o o Trauma o S/sx: visual floaters  painless Cobwebs, veil like, floating spots o Lab Data: Opthalmoscopy, PE o N. Dx: Risk for injury o Priority: Safety, bedrest, affected side towards the bed o Scleral buckling  using laser to create a scar o Avoid sudden head movement, bending and blowing of nose o Surgery: Trabeculoplasty  trabecular meshwork  laser  out pt Ttrabeculectomy  trabecular meshwork  removal  in pt for 1 -2 days o Avoid bending and sudden eye movement o Report: eye pain and bleeding GLAUCOMA o Inc IOP o Open Angle: Chronic  Inc aqueous humor o Closed Angle: Acute  forward displacement of iris o Aging > 40 y/o o Familial o “tunnel vision” o “Gun barrel vision” o “halos around lights” o “Loss of peripheral vision” o Blindness o Lab Data: Tonometry, (gonioscopy  differentiate open from closed angle glaucoma), perimetry -> visual fields o N. Dx: risk for injury, safety, dec IOP o Meds: Myotics  pilocarpine o CI: Midriatics CATARACT o Opacity of lenses o Poor color perception o Painless o Aging > 40 y/o o Prolonged steroids o Lab Data: Opthalmoscopy  ( - ) red light reflex o N. Dx: Risk for injury o Surgery: Peripheral iridectomy  hole in lens  cataract is suctioned Photoemulsification  needle like structure inserted into the lens -> crush cataract o Avoid bending and sudden eye movement o Report: eye pain and bleeding

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MENIERE’S DISEASE - Imbalance in the endolymphatic fluids - inner ear - RF: -High altitudes (pilots and divers) - s/sx: -Hearing loss -Tinnitus -Vertigo – revolving motion - Lab Data: - Caloric stimulation test - N. Dx: - Risk for injury - Intervention: - Safety - Position  supine or flat - Diet: Low Na - CI: Streptomycin  ototoxic - Meds: DIAMOX

OTOSCLEROSIS - Hardening of the bones in the inner ear - affected  stapes -Aging -diff in communicating -tinnitus -conductive hearing loss - Weber and Rhine’s test - Impaired communication - establish communication - stapedectomy  mobilize stapes - post surgery: avoid blowing of nose - avoid deep diving - avoid flying in small airplanes

Pointers: 1. Post trabeculoplasty  eye pain. A: Call MD 2. Pt with tunnel vision, N. Dx? A: Inc risk for injury 3. Which drug will help dec aqueous humor? A: DIAMOX 4. Post Cataract extraction, what is the position? A: On unaffected side to dec edema 5. Which intervention will help prevent loss of vision in glaucoma? A: Taking the meds correctly as ordered 6. Which describes trabeculoplasty? A: Surgical intervention that aims to create a passageway for the blocked fluid.

DUCHENNE’S MUSCULAR DYSTROPHY

ERB DUCHENNE PARALYSIS

- genetically transmitted - X-linked recessive (mother to son – 50% disease, Mother to daughter – 25% trait) S/sx: - Gower’s sign  arms used to push body to stand up - Waddling gait - Difficulty in running and climbing  1 ½ to 2 ½ - Progressive weakness  respiratory paralysis - Lab Data: EMG, PE N. Dx: Ineffective breathing pattern Impaired physical mobility - Prepare tracheostomy set - Refer parents to geneticists - refer to PT - Treat symptoms

- acquired - Birth trauma (hyperextension of shoulder) - Brachial Plexus – upper plexus - Reversible, recovery after 3 mos - Klumpke’s paralysis – lower plexus

CEREBRAL PALSY

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- non- progressive (fixed) d/o - neuromuscular system - uncoordinated movements - related to brain anoxia and prolonged labor S/sx: - Exaggerated reflexes - Early pattern of hand dominance  10 – 12 months - poor posture - Arching of back - Frequent tongue thrusting - scissor gait Lab Data: - CT Scan - Muscle biopsy N. Dx: - Risk for injury - Improved Physical integrity - Altered nutrition Priority: Promote Safety & mobility Assist ambulation Support: crutches, cane, walker, leg braces - Drugs – muscle relaxants, anti-convulsants - Surgery – release of tendon of Achilles - Foods that sticks on spoon CSF FLOW Lateral Ventricles  Foramen of Monroe  3rd Ventricle  Aqueduct of Sylvius  Foramen of Lushka & Magendie  4th Ventricle  Sub-arachnoid spaces HYDROCEPHALUS - Interruption of CSF flow - Not a disease - Manifestation  d/o - Arnold Chiari Malformation  Elongation of brainstem  Obstructs the flow of CSF - Dandy Walker  atresia  narrowing of foramen of Lushka & Magendie  CSF flow - Excessive production (communicating) or obstruction of CSF (non-communicating) S/Sx: Projectile vomiting, irritability, enlarged head (Normal  33-35 cm), Sunset eyes, separation of sutures, seizure) Bossing sign  pronounced forehead Macewen’s sign  cracked pot percussion of head Lab data: CT Scan, MRI N. Dx: Risk for injury Priority: Safety, Seizure precaution Meds: Anti-convulsants Position: Semi-Fowlers Low-fowlers Surgery: Insertion of ventriculoperitoneal shunt - Check  Inc in ICP - Measure head frequently SPINA BIFIDA - Failure of spinal processes to fuse - neural tube defects - Occulta: Dimpling, tuff of hair, lumbo-sacral area - Cystica: Meningocel  CSF & meniges, Myelomeningocele  CSF, meninges, spinal cord

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Lab Data: PE, MRI Alpha Feto CHON analysis  Increased Normal  15 – 30 N. Dx: Risk for infection, Impaired mobility - Sidelying or prone  best position - Cover with wet sterile gauze - Surgery  within 48hrs  prevent paralysis of LE  After sac is closed  may lead to hydrocephalus - Tape measure  @ bedside to measure head

Increase ICP - ICP more than 15mmHg -Normal 0 – 10 - 11 – 20  mild - 21 – 30  moderate - 31 and above  severe - Maybe due to trauma - Space occupying lesion - A congenital defect S/Sx: Early: Decreasing LOC Late: VS changes, Cushing’s triad, widened PP, Dec PR, Dec RR Lab Data: Subdural / intravascular monitoring N. Dx: Risk for injury Priority: Safety, head of bed elevated, evaluate LOC, promote a patent airway Discharge instutions: meds, mitoring, seizure precaution BACTERIAL MENIGITIS - Infections  inflammation with menigitis - N. Menigitides - Influenze Virus - HIB Vaccine S/Sx: Inc ICP, Brudzinski’s sign, Kernig’s sign Lab Data: CSF, Dec Sugar, Inc WBC, Inc Protein N Dx: Risk for injury, Risk for injection Meds: Antibiotics as prescribed Precaution: Respiratory Droplet Complication: Hearing Impairment Audiologist Screening and testing REYES SYNDROME - Toxic - Encephalopathy & Hepatopathy - Fatty infiltration - CNS and Liver - V. Vax related to Reye’s - Triad Symptoms: Fever, Dec LOC, Bleeding tendencies Stages: 1.) Stage 1 = Confused 2.) Stage 2 = Lehargic 3.) Stage 3 = Decorticate 4.) Stage 4 = Decerebrate 5.) Stage 5 = Comma Diagnostic: Biliary fxn test, bleeding time, clotting time, Neuro assessment GCS N Dx: Risk for injury

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Priority: Safety  Bleeding precaution, clotting time, Neuro-assessment GCS  Vivax ( + ) chickenpox  Reye’s SEIZURE - Abnormal discharge of electrical impulse in the brain RF: Metabolic d/o  Delirium Alcoholism  withdrawal symptoms Intake of drugs & trauma S/Sx: Types 1.) Absence / petitmal  brief periods of non-activity 2.) Jacksonian  Starts on body parts  to whole body 3.) Grandmal  Tonic: gen. contractions, Clonic: alternating contraction & relaxation S/Sx: Dura  feeling of uneasiness before seizure and LOC and convulsion. N. Dx: Ineffective Airway Clearance Risk for injury Smal pillow at the back of head or lap Meds: Anti-convulsants, Dilantin - Refer to Neorologist - Subs. Abuse screening - EEG, MRI, CT Scan Precaution: Avoid extremes Avoid emotional stress Lifetime anti-convulsants CVA - Sudden cessation of brain functions due to dec O2 RF: Thrombosis, embolism, hemorrhage & infarction Progression: 1.) TIA  brief neurologic deficits  30 secs  24 hrs 2.) Stroke in evolution  body weakness / facial weakness 3.) Completed stroke Frontal Lobe  personality, speech changes  Broca’s aphasia  Expressive Aphasia  Inability to say the right words Temporal  Memory, Wernicke’s Aphasia  Inability to comprehend Parietal Lobe  sensation & orientation Occipital  Visual disturbance S/Sx: Indicative of Complication Hemiplegia  Paralysis of right or left side of body Homonymous Hemianopsia Emotional Lability  Mood swings Aphasia  Expressive and receptive Dysphagia  Swallow food at least twice - C4-C5 deccusation of spinal cord - Right lesion  Left eye, right face , Left body affectation  Unilateral Neglect Lab Data: Inc cholesterol  Normal 200 EEG, MRI, CT-scan N.Dx: Ineffective breathing pattern - Head of bed elevated - Refer to PT & OT Diet: Low Na, Low Fat Meds: Anti-convulsants, vasodilator, diuretics

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NEUROMUSCULAR DISEASE

GBS

MG

MS

ALS (Lou-Gehrig)

PNS

NMJ

CNS

Upper & Lower Motor Neuron

- Inflammation & destruction of PNS - Autoimmune  viral infection - No gender related factors

- Autoimmune (early – male 20 – 40 y/o, late – female > 50 y/o) - Deficiency in acetylcholine receptor sites - descending muscle weakness -from face downward

- Whites/females - Demyelination of neurons in CNS - Brain and Spinal Cord

- Autosomal dominant - Male & Female

- Ptosis - Difficulty in chewing - Decrease voice

- Diplopia - Ptosis - Impaired sensation - Impaired sexual function - General muscle paralysis Lab: MRI, localizes areas of plaque formation N.Dx: - Ineffective breathing pattern - Sensory perceptual alteration Priority: - Maintain patent airway Meds: - steroids - Muscle relaxants - Bladder stimulant - Avoid hot or cold shower - Assist diet in ambulation * Bladder retraining program – self catheterization - Handwashing  to prevent ascending infection -Refer to PT & OT

- Dysphagia

S/Sx: - Ascending or descending muscle paralysis - Mixture - Respiratory Depression - Lab. CSF Analysis  Inc CHON N.Dx: - Ineffective breathing pattern Priority: - Promote patent airway

- Prepare tracheotomy set @ bedside - steroids - Refer to Respiratory Therapist

CI: Talking long  respiratory depression Diagnostic: Tensilon  short 30 secs  lasts for 5 mins Drugs: Neostigmine  lifetime  Antidote  ATSO4

Complications: - Crisis - Myesthenic: Dec Meds  Neostigmine - Cholinergic: Inc Meds  ATSO4

Lab: EMG, CT Scan, MRI N.Dx: Ineffective breathing pattern Priority: - Airway - Prepare tracheostomy set

- Supportive and preventive - Advance directive & living will

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