QUICK NOTES

History of MVA(head trauma) Polyuria Diabetes Insipidus Cushings triad: 1.) wide pulse pressure 2.) Dec. RR 3.) Dec. PR Note a dec. in LOC before Cushings triad

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. Methotrexate = Psychotropic precautions Goal on Pre-eclampsia = To prevent seizure Ileostomy Normal Stools 2-3 days Fat embolism S/S 1.) Dyspnea 2.) Chest pain 3.) Petechiae on the chest Priority administer O2 To dec. surface tension of fat globules DIC = Disseminated Intravascular Coagulation Systemic clotting bleeding Priority = Prevent systemic clotting Normal Fibrinogen level = 180-340mg/dl < 100 bleeding Narcotic Withdrawal Syndrome Syndrome Hypertonicity Hyperactivity Irritability Poor Sucking Sleepiness Shrill cry High pitched cry Fetal Alcohol Hypotonicity Irritability Poor Sucking Facial Deformity Microcephaly

Priority = Physiologic Integrity Vitals signs Give Valium Macular Degeneration CMV = Cytomegalovirus infection Loss of central & peripheral vision blindness Erbs Palsy 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 Systemic infection Centralized vasodilation Dec. BP Inc. Temperature Cleft Palate Post surgery = prone Post feeding = side lying Cleft Lip & Palate Post surgery = side lying Cleft lip is 1st done followed by the repair of the palate 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.) STDs 2.) Delivery 3.) Substance abuse Diabetic Clients 50-70% CHO Raisin best to bring during travel 1 rice is equal to 2 servings of popcorn MI

Sequence of enzymes that increases during MI: 1.) 2.) 3.) 4.) 5.) Myoglobin = 30 min-1hr post MI Troponin = 3-6hrs upto 3 weeks CK MB = Inc 4 8 hrs post MI, back to normal in 3 4 days AST = 8 20 u/L normal, Inc 6 10 hrs post MI, back to normal a week later 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 = RESP. 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 Reyes 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. 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

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 For adult or minor with capacity Require full understanding of procedure Protects the client, nurse, surgeon and hospital For emancipated minors: Married minors Military service Living away from home 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 doesnt 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 Empowering children to the greatest extent feasible ELEMENTS Explain to the child his condition and the reason why the procedure has to be done in lay mans term Clinical assessment of patients understanding Solicit childs willingness Expectation Ethical Care Concept 1.) Autonomy = Living will, freedom of choice, self determination and privacy. Advance Directive = List of donts (clients with progressive chronic illness in which death is expected) 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: Address verbally and document. Report to charge nurse Supervisor director 2. No response by Physician Promote Safety: Side rails up Move pt near nurses station

 Use restraints appropriately (last resort) 3. Inappropriate order Document it Notify the charge nurse 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 Childrens protective services Adult protective services Organizations

Care of the hospitalized clients Mantoux Test 15mm = gen. population 10mm = DM, Alcoholism 5mm = HIV Areas where bruises are indicative of child abuse: 1. Lower Back 2. Upper Back 3. Side of the abdomen Special Considerations Infants Greatest risk for fluid and electrolyte imbalance Hypothermia and infections Approach them in non-threatening manner

Toddler Increased separation anxiety Briefly prepare them for procedures due to short attention span Describe sensation that they may feel during procedure Preschooler 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 Realistic understanding of death = 9 -10 Needs more detailed teachings Allow them to make some choices Adolescence Elderly 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 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 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

Tree of Strategy for Prioritizing Ask Where Disaster Area = Least injured Emergency Area = Most injured Look Same Area = all OB = all Psycho = all MS = all Pedia 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 Diagnostic Verify the Dx Assessment Therapeutic Assess pt Teaching Informing the patient Referral Involves a member of the health team Independent Decision Making Case Various Areas Physiologic vs. Psychological Acute vs. Chronis Unstable vs. Stable

Levels 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 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 Relationship Goals: Socialization trust Phases: 1. Pre-interaction self awareness of nurses 2. Orientation contract dos and donts 3. Working phase identification & resolution of problems Goal: Mental Health Therapeutic

4. Termination phase evaluation

Therapeutic Communication 1. 2. 3. 4. 5. Dont ask why Avoid passing the buck Dont give false reassurance Avoid nurse centered response Recognize the pts feelings

CORE CONCEPTS o o o o o Therapeutic phrases Open ended questions are Generally Therapeutic Closed ended effective for manic and pts in crisis Direct questions for suicidal pts

Bruit = high pitched Murmur = low pitched 20/20 = Vision attained at 3-6 years old Decorticate Flexed Adducted PlantarFlexed Extended Arms Legs Decerebrate Flexed Abducted PlantarFlexed Extended

How to attack the questions? 1. 2. 3. 4. Consider the pts 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 risk 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 = 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 X 20

X 25

APTT = 30 40 seconds INR = 100 seconds Monitored Heparin = > INR bleeding

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

APGAR
1 minute 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 Computation: 1.) D S 2.) Vol. in cc X gtt factor # of hrs. X 60 0 All blue Absent No rxn Flaccid Abnormal 1 Acrocyanosis < 100 Weak cry Some flexion and extension Irregular 2 Pink > 100 Vigorous cry Spontaneous flexion & extension Lusty

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 HW I. Standard II. Transmission Based a. Doplet b. Airborne c. Contact PR X Mask, goggles (surgical) Gloves Gown

(PRM) X

X X

X X

PRM (particulate Respirator Mask)

I. Standard AiDS, HIV, Hepa, Roseola II. Transmission Based: A. Droplet Mumps, Mycoplasmal Pneumonia, Rubella B. Airborne Measles (Rubeola), TB, Varicella C. 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 Cranberry o For UTI and asthma o Not for DM o Safe in pregnancy o Use with caution in DM 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 Alzheimers Disease o CI pregnancy, lactation and clotting d/o VALERIAN o Tranquilizer, sedative o Not given with valium o Uses: insomnia, mm. spasm DRUGS Iron Supplements FeSO4 Mineral Supplement Anemia Relief of fatigue / Inc strength Best before meals, after meals if with GI irritation takes effect after 2-3 weeks, Inc absorption with orange juice Elixiform use straw Injectable Z track method (laterally stretch the skin, 10 seconds) Constipation and black stools Antidote: Deferoxamine HCL (Desferal)

RHOGAM Prevents RH sensitization ( - ) Hemolytic reaction 27-28 weeks AOG, ideally 72 hrs after delivery of baby with Rh (+) and ( - ) Coombs Pain in injection site Check Coombs test only in ( - ) OXYTOCIN Pitocin Methergine Induce Labor Contracts uterus after placental delivery Increase force of Uterine contraction firmly contracted uterus Report prolonged duration of contraction Check BP

 Pitocin initially causes Hypotension then rebound hypertension Methergine initially causes Hypertension then rebound Hypotension TOCOLYTICS Relaxes the uterine mm. during preterm labor ( - ) contractions / relaxed uterus Ritodrine HCl (Yutopar) Onset of preterm labor Report maternal tachycardia HR > 130 Arrhythmia Prepare antidote Propanolol

Magnesium Sulfate Anticonvulsant, NS depressant ( - ) Seizure As prescribed PIH Report MgSO4 intoxication Hypotension, hypocalcemia and H/A Check BP, urine output, RR, Patellar reflex if Dec antidote Ca Gluconate Therapeutic level: Loading dose 4 7 Meq/L Maintenance 1.5 3 Meq/L Depression of DTR if 8 Meq/L Dec RR if 10 12 Meq/L

Coumadin Heparin (Oral) (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 Antidote: Vit K (Coumadin) Protamine Sulfate= Heparin Test Coumadin =PT Heaparni = PTT

ANTI-MANIC AGENTS LITHIUM

 Dec Hyperactivity within 2 3 weeks Acute Mania = Give Anti-Psychotic with anti-manic After meals pc Check signs of toxicity: Mild 1.5 Meq/L Thirst Ataxia H/A Irritability Beginning Fine hand tremors Abdominal Cramps Coma Death Moderate 2.5 Meq/L Nausea Anorexia Vomiting Diarrhea Coarse hand tremors 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 Focus: Gold Therapy Suppresses Arthritis ( - ) Inflammation IM weekly Lie supine for 10 mins to prevent OH Check: Signs of Stomatitis Dermatitis Unusual Bleeding Unusual Bruising Fever Sore Throat Monitor Renal Function Test

ANTI-INFLAMMATORY Ibuprofen (NSAIDs) Aspirin

Anti-Inflammatory Anti-pyretic Analgesic For RA & OA Anti-rheumatic ( - ) Inflammation, ( - ) pain, ( - ) RA ( - ) fever, ( - ) platelet aggregation pc after meals Report: Visual disturbances Ringing in the ears Allergy Sore throat Fever Black Stool Annual eye exam Check bleeding time

Anti-Inflammatory Anti-pyretic Analgesic Anti-Platelet aggregate

Nausea & Vomiting Rapid breathing Hyperpnea toxicity

ANTI-GOUT AGENTS Probenecid Acute (8-12 hrs) Excretion of u.a. Anti-inflammatory Decrease uric acid Given with food Colchicine Chronic (1-3 weeks) Prevent deposition of u.a. Allopurinol

Prevent formation of u.a.

NAVDA drowsiness Allergy Inc fluid intake 2 3 L/day Frequently check serum uric acid level CARDIAC DRUGS NITRATE

Bruising Agranulocytosis

H/A,

A. Nitroglycerine Sublingual Trans-mucosal = between gums, cheecks and lips

B. Isordil Sustained release, with water and dont crush Patch Nasal Spray Caridac drug (Nitrate) Dilate coronary arteries and arterioles Dec pre-load ( - ) Anginal Pain 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 S.E. Facial flushing, H/A, Hypotension Rise slowly to prevent OH Tablet on dry, dark container 6 months Discard Burning Sensation Indication that the drug is still potent CARDIAC GLYCOSIDE Digoxin Strengthen Myocardial Contraction Na-K-pump is converted to Na-Ca-pump Thus increasing force of contraction

Digitoxin

Onset 5 20 mins Observe GI irritation Excreted by kidneys Normal level 14 26 Normal level 5 -2 ug/dl Check HR = Adult 60 Older Children = 70 Infants = 90 110

Onste 30 mins 2 hrs

Excreted by the liver Anti-dote: Digibive

DOPAMINE and DOBUTAMINE DOPAMINE Inc force of contraction Correct Hemodynamic For Emergency Situation Adequate Urine Output Emergency Situation Always in diluted form Compute the drugs properly ANTI-ARRYTHMICS Lidocaine (Xylocaine) For PVCs ( - ) Arrythmia Slow ventricular rate Slow atrial rate Convulsion Check HR Evaluate ECG THROMBOLYTICS Streptokines TPA DOBUTAMINE

Quinidine Atrial Fibrillation

Tinnitus/Ototoxicity

Dissolves the clot by preventing the formation of fibrin (fibrinolysis) ( - ) Clot formation Clot Dissolved Effective within 6 hours After MI within 24 hrs Report Bleeding Monitor VS Contraindicated to clients that are prone to bleeding

ANTI-LIPEMIC AGENTS LOVASTATIN (Tablet) Dec LDL = 30 80 (HDL should be > 80 and LDL < 80) Before meals or at night time Caution: Hepatotoxic Questran 1 pack of powder + 4 6 oz of fluid (water, milk or juice) Check liver function test Rash and bleeding PERIPHERAL VASODILATOR Paracid Smooth muscle relaxant Facilitates blood circulation ( - ) Ischemia After Meals Instruct patient that drug may cause H/A and SOB Long term use is individual BETA-BLOCKER (Timolol, Esmolol, Nadolol) Dec BP, for Hyperthyroidism, Dec sympathetic (Autonomic) nervous system stimulation Before meals Rise slowly: Lie down for 30 mins after medication. Instruct patient that meds may cause bronchospasm QUESTRAN (Powder)

Do not give chamomile and aspirin

ANTICHOLINERGIC Atropine Sulfate Vasolytic Agent Inc heart rate (check complete heart rate) Before meals Avoid hot environments Check for rashes and SOB

NEURO-DRUGS Anticonvulsants (Dilantin) Decrease Seizure Threshold After Meals Epilepsy Maintenance Chronis Use Gingivitis Visit dentist at least once a year Soft bristle toothbrush, massage the gums Urine is pink tinged SAS ( Saline Flush Administer drug Saline Flush To Prevent precipitate

CHOLINESTERASE Neostigmine Myasthenia Gravis Long Acting Treatment Tensilon Alzeihmers Short Acting Diagnostic Maintenance Treatment Cognex

Inc muscle strength Inc mental functioning Before Activity At bedtime Before meals Use muscles of mastication Chewing becomes stronger Medication is lifetime Report S/Sx of hepatotoxicity Check liver fxn test Keep at bedside Neostigmine Antidote: atropine sulfate Do not give echinicea Prepare Tracheostomy Dec dizziness

ANTI-TB Rifampicin Ethambutol ( - ) Infection Before Meals Red orange urine Dont use contact lenses like Sx Peripheral Neuritis (Give B6) Oto, nephro, neuroTOXIC Hepatotoxic Psychotic INH Streptomycin

Take the complete treatment as prescribed by the doctor ( 6 12 months ) Incomplete TB treatment Lead to MDRTB ANTI-ASTHMA Theophylline Adult = 10 20 mg/dl release Pedia = 5 10 mg/dl Dilates bronchioles Ease breathing In the morning because it causes insomnia Nausea and vomiting Theophylline toxicity Check the pulse rate Avoid Chamomile cause bronchospasm Avoid aspirin --? Cause bronchospasm Inhaler Acute Rashes

Cromolyn Na Prevents anti-histamine

Steroid Chronic MUCOLYTICS (Mucomyst) Antidote for aspirin toxicity Dec viscosity of mucous Loose phlegm No specific time Inc OFI S.E. bronchospasm Suction Medication has a foul odor that resemble rotten egg EMETIC Syrup of Ipecac To induce vomiting non-corrosive Pedia below 6 months ( - ) vomiting Dose depends on age 6 mos 1 yr = 10ml 1 12 yrs = 15ml > 12 yrs = 30ml Administer with glass of water to enhance effects of ipecac Cardiotoxic = Ensure that child vomits the entire amount ANTACIDS Peptic Ulcer Disease Maalox 1-2 hrs Neutralizes HCl Normal HCL 2 5 Maximum 10 ( - ) Pain, dec HCl Usually on an empty stomach 1 hour before meals 2 hours after meals Shake liquid SE: diarrhea

Ranitidine 4-6 wks Dec HCl secretion

Sucralfate 8 wks Coats GIT

Constipation Short term therapy Electrolyte imbalance

ENDOCRINE DISEASE INSULIN Type 1 Diabetes Mellitus Regular Humulin Intermediate NPH Long-acting ultra lente Metformin Inc transfer of glucose to cell membrane secrete insulin Before breakfast Report Hypoglycemia: Dizziness Dec LOC Diff. of problem solving 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 THYROID DRUGS Synthroid (supplement) PTU) For Hypothyroidism Normal BMR and sleep In morning to prevent insomnia Report signs of overdose: Nervousness Fever, sore throat, body malaise Life time OHA Type 2 Orinase Diabinase

Pancreas to

PTU Tapazole ( 10 times greater than For Hyperthyroidism Dec T3 and T4, Adequate appetite Round the clock Report: Insomnia, palpitation & Monitor HR & BP

STEROID Cortisone Replacement Therapy Addisions Disease 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 Avoid crowded areas Infection RENAL DRUGS EPOGEN Inc RBC production for Chronic Renal Failure Normal Hemoglobin As prescribed Report Polycythemia Inc production of RBC CVA Check Complete Blood Count DIURETIC Loop Diuretic Sparring Diuretic (Lasix) (Spirinolactone) Duiril Loop of Henle aldosterone Prevent Na absorption water Floricef

Thiazide Diuretic (Hydrochlorothiazide) Aldactone Distal Tubule Prevents Na absorption Blocks

Retains

Increase urine output and decrease pts weight Early morning prevent nocturia Hypokalemia Hypokalemia

Dec K Dec na Na Dec Ca Dec mg Inc Sodium in diet Check Electrolyte level Check BP IMMUNUREN (Azathioprine) Immunosuppressant ( - ) rejection of organs Report: Nausea, vomiting Thrombocytopenia Bruising Infection Check CBC Frequent Handwashing MIOTICS (Pilocarpine) For Glaucoma For eye exam Normal IOP Lifetime in glaucoma

Dec K Dec Na

Inc K Dec

MYDRIATICS (ATSO4) CI for Glaucoma Dilatation of pupils As prescribed Report: eye pain & blurring of Avoid alertness after medication

Lower conjunctival sac vision Press inner canthus 1 2 mins to prevent systemic SE Check BP and Blood sugar ANTIBIOTICS Vancomycin MRSA Syphillis

Penicillin Gonorrhea Rocky Mountain Fever

Tetracycline Lymes

( - ) Infection Before meals With GI irritation After meals Ototoxic, Nephrotoxic, Neurotoxic Check I and O Allergy Hepatotoxic

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 o Nuclear o Extended 4. Nutrition = kosher diet, jalal 5. Religion o Catholics o Jehovas Witnesses

o o

7th day Adventist 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 JEHOVAS 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

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 Type B X-linked recessive 50% male oofspring ( - ) factor 9 Von Willebrands disease Autosomal dominant Male & Female

S/Sx: 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 Table A.1: Autosomal Recessive Norma l 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 )% Neoplastic Thrombocytopenia Purpura Dec Platelet due to viral infection autoimmune reaction drug use

Trait Disease 50& 0% 50% 25% 50% 50% 0% 100%

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) Inc pulmonary blood flow Obstructive conditions

CYANOTIC (Right to left shunting) Dec pulmonary blood flow Tetralogy of Fallot Truncus arteriosus Transposition of great

Ventricular septal defect Pulmonary stenosis Atrial septal defect Aortic stenosis Patent ductus arteriousus Coarctation of the aorta 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 Cyanotic (tet spell) Semi Fowlers Priority: provide warmth CVA Initial: L sided heart failure dyspnea & O2 & surgery If walking squat Late: R sided heart failure If not walking knee chest < 2 y/o = O2 2 7 y/o = Surgery> 7 = Surgery as soon as possible

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 Aortic Dec pitch Blowing diastolic Diastolic murmur Treatment: Antibiotics Anticoagulants Pregnant Clients Classifications: I II III IV Aortic High pitch Systolic murmur REGURGITATION Mitral High pitch Systolic murmur

No Limitation of activities Symptoms with activities Symptoms with les Symptoms even at of daily living than ordinary ADLs rest

ARRYTHMIAS

Abnormal cardiac rhythm ATRIAL Flutter VENTRICULAR PVC Fibrillation Extra QRS Lidocaine Defibrillation CPR

Fibrillation

Sawtooth patter Pwave P:QRS ratio 2:1-4:1-6:1 Widened QRS Quinidine Epinephrine Defibrillation Defibrillation CPR CPR, Quinidine QRS = < .10, 2 squares PR = .12-.20 = 35 small squares 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 o o o Narrowing and obstruction of coronary arteries Dec O2 Hypoxia Angina ( - ) O2 Neurosis 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 Antidote Naloxone Effort Associated S/sx: Agitation Restlessness Cold clammy skin HPN Lab Data: Inc cholesterol < 200 ECG changes 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 Precipitates: Eating Elimination Extreme temp Emotion Pain > 20 min Lower sternum Crushing, Excruciating Not relieved by rest Morphine (Check RR)

Inc cardiac enzymes Inc ST segment

= 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 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 CHF 4 common complications: CAD CVA CRF

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 PRE-ECLAMPSIA o Inc BP o Edema

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 o

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 Venous Occlusion Ruddy Severe Normal Homans sign Normal Warm Wet

Color Edema Nails Pain Pulse Temperature Ulcer

BUERGERS (Thromboantgitis Obliterans) - Acute -A&V - Male - Lower ex Upper & Lower ex - Smoking - Inflammation of arteries and veins hardening arteries

RAYNAUDS ARTERIOSCLEROSIS DISEASE OBLITERANS - Intermittent - Chronic - arteries - arteries - Female - Male - Upper ex (97%) toes, ears, LE (3%) - Cold - Vasospasm of 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 PULMONARY EMBOLISM - A clot lodges in one of the pulmonary arteries Risk Factors: 1.) 2.) 3.) 4.) VA Trauma Hypercoagulation Arrhythmia 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 KAWASAKIS 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 StrawberrY tongue, palmar desquamation 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 30:2 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 pts 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 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 Toddler Viral & Bacterial Larynx Bronchioles S/Sx: LTB Infant & toddler (RSV) BRONCHIOLITIS Infant < 6 mos

Inflammation of the Larynx and trachea

Cough: Barking, metallic Hacking Stridor: Present Wheezing: Absent Fever: Absent grade Lab Data: Throat Swab PE X-ray PE

Harsh & Brasky Present Absent Low Grade

Paroxysmal & Present Present Moderate to high

X-ray Throat swab PE

X-ray ELISA Throat swab

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

Emphysema Asthma -overdistended alveoli excessive mucus Smoking RE,TACY,TACHY DC Barrel Chest sputum Inc coughing Lab Data: X-ray, ABG Analysis N. Dx: Ineffective Breathing Pattern Ineffective Airway Clearance Orthopneic Activity: Soft ball Semi-Fowlers Baseball Principles in Nursing Care: Bronchodilator Rest

Bronchitis - inflammation of bronchioles -

Gelatinous Sputum Orthopnea

Whitish

Bronchodilators

Aminophylline Steroid

Oxygen low flow Theophylline Nebulize Histamine Antagonist Chest Physiotherapy Mucolytic High Fowlers Antabuse IPPB Intermittent Positive Pressure Breathing Aerosol Liberal Fluid Intake Complication: Cor Pulmonale Right Ventricular Hypertrophy Pneumothorax Spontaneous Tension Ruptured Bullae/alveoli 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? 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 Legionnaires disease? A: Immunosuppression 8.) Mycoplasmal Pneumonia is manifested by? A: Fever & productive cough Open Chest injury Trauma

PKU o o o o

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

Absence

(Maturity onset Diabetes in young adults) NIDDM (Type II) Combination of IDDM & NIDDM Maturity onset after 35 Pregnancy 2nd trimester Non Ketosis form Developed placenta secretes HPL Obese (Human placental lactogel counteracts insulin Gestational: (Whites 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

IDDM (Type I) Juvenile onset Ketosis prone Thin

- 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 Hyperglycemia: Blood sugar > 140mg/dl RF: too much insulin, missed meal, exercise RF: Too little insulin, Inc food intake, pregnancy, Infection, stress, surgery S/Sx: Diaphoresis Type I type II Decreased LOC DKA HHNK Diff in problem solving Acetone breath Inc GI s/sx De H2O DeH2O Warm skin Inc serum Osmolality 3 Ps 3 Ps Kussmauls breathing Tx: Simple sugar TX: Airway, Fluid and Insulin rapid acting insulin 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 Deficiency Diabetes Insipidus Risk Factor Trauma Surgery S/sx: Polyuria (21L/day) Polydipsia Lab Data: Fluid deprivation test Exercise SIADH Trauma Tumor

NPO X 12 hrs Concentrated urine Specific Gravity: < 1.005 Vasopressin Gravity Depressin Lepressin Monitor and output and specific gravity of urine Goal of care: Excretion of fluid Diuretics and anti-HPN Dilutional Hyponatremia Check Sodium Growth Hormone Ant. Pituitary Gland Promotes growth Deficiency Excess Dwarfism Mahal *Before closure of growth plate Gigantism Taller, slender Achondroplasia Nanus Syndrome Dagul 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 Check specific

Fluid retention

ADRENAL Outer Cortex Glucocorticoids Gluconeogenesis Def. Addisons Mineralocorticoids Na retention Excess Cushings Excess Conns Syndrome Middle Medulla Epinephrine Norepinephrine fight/flight response Tumor

Pheochromocytoma excess epi and

Commons syndrome norepinephrine Aldosteronism Inc hyperglycemia HPN, H/A

Hypermetabolism Lab Data: Inc VMA 2 7 mg/dl in 24 hrs Avoid vanilla containing foods, 14 hrs before the test

THYROID T3, T4 BMR bones Deficiency Hypothyroidism - Cretinism - Myxedema - Parrys disease RF: Autoimmune, tumor S/Sx: Facial edema Intolerance to cold Hypometabolism Intolerance to cold 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 THYROID SURGERY Preparation Post operative Excess Hyperthyroidism - Graves disease - Basedows disease CALCITONIN Deposition of Ca in the

Exopthalmos Goiter Hypermetabolism

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

- Lugols solution (2 wks before surgery) - Monitor complication - Dec size & vascularity of thyroid gland 1. Hemmorrhage bruises - Give in straw and diluted in water or apple juice 2. Laryngospasm tracheostomy - S/sx of iodism Metallic taste 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 Surgery S/Sx; Early: Tingling, chvostek, Trouseau sign fracture / osteoporosis - Von Recklinghausen disease Hyperthyroidism Tumor - Pain, bone destruction,

N. Dx: Risk for injury Renal calculi formation - Give Ca supplements Lab Data: Inc Ca in blood - Inc Ca in diet 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 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 Addisons 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 GLOMERULONEPHRITIS Congenital Autoimmune - Inability of the kidneys to maintain fluid balance *hyponatremia S/Sx: - Normal or dec in BP - Peripheral Edema subsides at the end of the day edema at the end of the day - Frothy urine color

ACUTE Acquired sore throat Autoimmune - Kidney damage

- Inc BP - Progressive peripheral - 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 WILMS 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 - 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 - Sudden cessation of kidney function irreversible destruction of kidney tissues - Scar formation RF: PreIntraRenal Renal -Dec circulation of -disease of kidney Blood volume S/sx; Oliguric Diuretic CHRONIC - Progressive/

PostRenal - obstruction -stone Recovery

- AGN, NS

1. Dec renal reserve polyuria, nocturia, polydipsia 2. Renal insufficiency Inc BUN & creatinine 3. Renal Failure HPN, Renal Damage -Dec urine output -polyuria, dec Na & K - 1-2 yrs 4. ESRD Azotemia, uremia - < 400ml Lab Data: - Inc BUN & Crea N. Dx: - Fluid & electrolyte imbalance Priority: Restore circulating fluids - Fluid & electrolyte imbalance - Monitor intake and output Priority: Fluid restrictions - Response of client on therapy output, BP - Meds: Epogen to prevent anemia Meds: Diuretics, Dec Na diet, Anti-HPN, digoxin

- Amphogel prevent hyper phosphatemia - Diuretics, Anti-HPN, Digitalis Diet: Dec Chon Mx: Dialysis: 3 X a week or every 48 hours DIALYSIS Hemodialysis Peritoneal Dialyzing agent - Dialyzing Machine - Dialyzing agent Peritoneum Access Access Fistula shunt - Ten khoff catheter -internal access - external access - assess rigid abdomen peritonitis -anastomisis of a & v - palpate for thrills and auscultate bruit Complications Disequilibrium Dialysis Encephalopathy Rapid removal of waste product -Aluminum toxicity Fluids and electrolytes -S/Sx: dementia, dizziness GI CNS -Report to MD NAVDA Dizziness Restlessness - Report to MD

H/A

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

Perineal

-above the bladder impotence

-below the bladder

-causes

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 - 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 o

Avoid bending and sudden eye movement 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 MENIERES DISEASE - Imbalance in the endolymphatic fluids - inner ear - RF: -High altitudes (pilots and divers) - s/sx: -Hearing loss -Tinnitus -Vertigo revolving motion - Lab Data: OTOSCLEROSIS - Hardening of the bones in the inner ear - affected stapes -Aging -diff in communicating -tinnitus -conductive hearing loss

- Caloric stimulation test - N. Dx: - Risk for injury - Intervention: - Safety - Position supine or flat stapes - Diet: Low Na nose - CI: Streptomycin ototoxic - Meds: DIAMOX Pointers:

- Weber and Rhinestest - Impaired communication - establish communication \- stapedectomy mobilize - post surgery: avoid blowing of - avoid deep diving - avoid flying in small airplanes

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.

DUCHENNES MUSCULAR DYSTROPHY PARALYSIS - genetically transmitted - X-linked recessive (mother to son 50% disease, (hyperextension of shoulder) Mother to daughter 25% trait) upper plexus S/sx: recovery after 3 mos - Gowers sign arms used to push body to stand up paralysis lower plexus - Waddling gait - Difficulty in running and climbing 1 to 2 - 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

ERB DUCHENNE - acquired - Birth trauma - Brachial Plexus - Reversible, - Klumpkes

- Treat symptoms CEREBRAL PALSY - 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 Macewens 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 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, Cushings 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, Brudzinskis sign, Kernigs 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 Reyes - 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 Priority: Safety Bleeding precaution, clotting time, Neuro-assessment GCS Vivax ( + ) chickenpox Reyes 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 Brocas aphasia Expressive Aphasia Inability to say the right words Temporal Memory, Wernickes 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