Nursing Bullets

Psalm 23:18
There is surely a future

hope for you, and your
hope will not be cut off..
NURSING FACTS IN BRIEF
Psychotherapeutic, Somatic and

Psychopharmacologic Management
ANTIPSYCHOTIC DRUGS
Neuroleptics or major tranquillizers
Takes effect in 1-4 weeks
Indications:
psychosis,
delusions,
hallucinations, schizophrenia, mania, insomnia
Blocks dopamine in the brain lessens
psychotic thinking and bizarre behaviors
Typical Antipsychotics blocks dopamine
receptors in the brain, produces many EPS
Examples of typical Antipsychotics:Thorazine,
Prolexin, Mellaril, Serentil, Stelazine, Haldol,
Moban
Atypical Antipsychotics: weaker dopamine
receptors, lesser incidences of EPS
Dopamine System Stabilizer: stabilizes
dopamine input. Example: Abilify
Side
effects:
EPS
(
dystonia,
pseudoparkinsonism, akathisia),
Neuroleptic malignant syndrome ( most fatal
reaction) fever, unstable BP, diaphoresis,
pallor delirium, confusion
Tardive
dyskinesia
(irreversible)
lipsmacking, blinking, grimacing, unnecessary
facial expressions
Anticholinergic SE: dry mouth, urinary
retention,
blurred
vision,
constipation,
tachycardia, dry nasal passages
Agranulocytosis: fever, malaise sore throat.
Photosensitivity.
Orthostatic hypotension- drop of BP due
sudden change in position and prolonged
standing
Contraindications: pregnancy, lactation, DM,
liver impairment, CV diseases, glaucoma
Nursing Management: 1. Avoid skin contact. 2.
Mix with juice. 3. Do not mix with antacids. 4.
Avoid direct sunlight. 5. Teach client about
orthostatic hypotension. Slowly withdraw drug
to prevent seizures. 6. Report signs of
agraulocytosis.
ANTI-ANXIETY DRUGS
Anxiolytics/ sedatives/ hypnotics
Reduces involuntary awakenings and increases
sleep time
Indications: anxiety and anxiety D/O, alcohol
withdrawal, borderline personality D/O
Benzodiazepines mediate actions of GABAdecreases anxiety
Benzodiazepines ( more side effectss):
Valium, Ativan, Librium, Xanax, Serax,
Restoril, Dalmane
Non-Benzodiazepines (lesser side effects):

Buspar, Catapres
Antihistamines (prevents EPS, allergy, motion
sickness): Benadryl, Atarax, Vistaril
Side effects: drowsiness and sedation, poor
coordination, dizziness, nausea, headache
Contraindications:
pregnancy,
lactation,
pulmonary disorders
Nursing Management: 1. Give at bedtime. 2.
Avoid alcohol and caffeine-rich foods. 3. Give
before meals. 4. Do not give solutions that are
cloudy. 5. Observe for therapeutic and adverse
side effects. 6. Abrupt cessation causes
agitation, rebound insomnia, nightmares and
sudden death. 7. Teach client to report signs
of agranulocytosis 8. Give drugs separately to
prevent drug to drug interactions. 8. Never
mix with antitacids.
ANTI-MANIC DRUGS
Mood stabilizers.
Takes effect in 1-3 weeks or more
Indicated for manic episode in bipolar
disorders
Normalizes
serotonin,
norepinephrine,
acethycholine and dopamine to prevent
depression and mania
Side effects: mild nausea and vomiting, fine
hand tremors, loss of appetite, polydipsia,
polyuria, metallic taste in the mouth, edema,
acne
Examples:
Lithium
(Eskalith,
Lithium
Carbonate), Carbamazepine, Valproic Acid
Normal serum level: 0.6-1.2 mEq/L
Toxic level: more than 1.5 mEq/L
Nursing Management:1. Monitor serum lithium
level regularly. 2. 3 grams of daily salt. 3. 2-3
liters of fluids per day. 4. Mannitol and dialysis
for lithium toxicity. 5. Do not give morning
dose until serum sample is taken.
ANTI-PARKINSONS
Usually appear after initial dose of antipsychotics. Treats EPS
Attempts to correct imbalance between
dopamine and acetylcholine
Side effects: sedation, atropine psychosis,
photosensitivity, anti-cholinergic side-effects,,
agranulocytosis,
orthostatic
hypotension,
hormonal changes.
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/410-0250
- 1 -
Examples:
Cogentin,
Artane,
Parlodel,
Larodopa, Benadryl
Nursing Management: 1. Give meds with food.
2. Observe for therapeutic side effects and
improvement in gait and posture. 3. Teach
about orthostatic hypotension. 4. Limit
strenuous activities. 5. Avoid taking antidepressants. 6. Weekly CBC monitoring. 7.
Weigh client regularly. 8. Calorie-controlled
diet and light exercise.
ANTI-DEPRESSANTS
Mood elevators; second line agent
Indications: major depressive disorders,
anxiety disorders, bipolar disorders, eating
disorders
Balances serotonin and norepinephrine
Tricyclic Anti-depressants (1-3 weeks):
Sinequan, Pamelor, Elavil, Norpramine,
Tofranil.
Antidote: Physostagmine (Antilirium) only with
life threatening symptoms
MAOI (2-4 weeks): Parnate, Nardil, Marplan;
third line agent
Used for clients who does not respond to TCA
or cannot tolerate SSRI
Contraindications: pregnancy, lactation, CHF,
HPN, liver and kidney problems, alcoholism,
schizophrenia, over 60 and under 16 years of
age, DM
Avoid
tyramine-rich
food---causes
hypertensive crisis
Antidote: Phentolamine ( Regitine) for
increased BP
SSRI (2-3 weeks): first line agent; Zoloft, Paxil,
Prozac
Broad spectrum action, most popular
Indications: depression, anxiety, bulimia,
alcoholism, schizophrenia, OCD
Nursing Management: 1. Should be taken in
morning for 4 weeks for full effects. 2. Avoid
TCA or MAOI= FATAL!!! 3. Monitor BP before
dosage change to detect hypo pr hypertension.
4. Avoid altering dosage. 5. Do not operate
machineries and driving. Report unusual
symptoms like tremors, nausea and vomiting,
anorexia, nervousness and sexual dysfunctions.
6. Notify doctor of depression worsens.
ELECTROCONVULSIVE THERAPY
Introduction of 70-150 volts for 0.2-8.0
seconds producing 30-60 seconds seizures,
confusion and memory loss.
Contraindications:
recent
MI,
asthma,
pulmonary disorders, increase ICP, fractures
and dislocations
Nursing Management: 1. Informed consent.
2. NPO by midnight baseline VS and memory
abilities and premeds like Atropine sulfate
(decreases secretions); Brevital ( short-acting
barbiturate);
succinylcholine
(muscle
relaxant).
Post- treatment: side lying, oxygenate, orient,
quiet environment.
ALTERNATIVE TREATMENT MODALITIES

Behavior therapy modifying observable
behavior
Cognitive therapy replacing appropriate
thoughts
Thought Stopping decreases depression and
anxiety of irrational provoking behaviors
Reframing/Relabelling- relabels dysfunctional
behaviors or thoughts to a more reasonable
one.
Rational-Emotive therapy- individuals values
and beliefs control behavior.
Deep- breathing exercises- mild to moderate
anxiety
Benzons relaxations response- relaxes mild to
moderate anxiety
Assertiveness training- right to choose ones
response at a given situation
Desensitization gradual exposure to the
feared object
Flooding/Implosive therapy- sudden exposure
to the feared object
Gestalt therapy here and now theory
Family therapy- establishes communication
and family interactions
Group therapy 8-10 members; homogenous or
heterogenous
Aversion therapy- introduction of a noxious
stimuli
Milieu therapy- using environment for
therapeutic purposes
Play therapy- ideal for children
Art therapy expression of feelings through
drawings, etc
Recreational therapy involving into activities
Vocational therapy learning new skills
Music therapy soft music relaxes the body
and the mind
Sex therapy- maintain healthy sexual
functioning
Reminisce therapy- used for older people
Notes:
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The vision that you glorify in your mind, the ideal that
you enthrone in your heart - this you will build your life
by, and this you will become.
- 2 -
Jeremiah 17:7
"But blessed is the man who

trusts in the LORD, whose
confidence is in him."
Anxiety, Anxiety Disorders, Psychosomatic

and Mood disorders
ANXIETY AND ANXIETY DISORDERS
ANXIETY
Amxiety is the feelings of uncertainty,
uneasiness and tension to an unknown object.
Fear is bodys physiologic response to a known
danger.
Signal anxiety- anticipated event
Anxiety trait- component of personality
Anxiety state- result of stressful situation
Free-floating anxiety- always present
Phases: normal, acute, chronic and panic
Level 1 (Mild): increase alertness, ability to
learn and challenged
Level 2 (Moderate): narrowing of perception
occurs. Pacing, tremors, increase verbalization
Level 3 (Severe):
perception reduces.
Inappropriate
verbalization,
lack
of
determination
Level 4 (Panic): Disintegration of personality
occurs. Individual loses control
Physiologic
symptoms:
elevated
VS,
diaphoresis, vertigo, sweaty palms, dilated
pupils
Psychologic symptoms: withdrawal, irritability,
anger feelings of worthlessness, helplessness
and apprehension
Behavioral symptoms: pacing, inability to sit
still, nervous habits
Intellectual symptoms: decreased interest and
productivity,
nonresponsive,
forgetful,
rumination
ANXIETY DISORDERS
Panic Disorders: out of the blue, experiences
frightening and uncomfortable symptoms.
Lasts 1 minuite to I hour, onset begins late
teens or early twenties, more seen in women.
Symptoms of panic attack: palpitations
diaphoresis, tremors choking, vertigo, SOB
Phobic disorders: most common form of
anxiety disorder.
Phobia is the irrational fear of an object.
A person unconsciously displaces the source of
anxiety from an unpleasant childhood
experience.
Avoidance of the object allows the person to
be free from anxiety.
Agoraphobia (fear of public places); Social
phobia (avoid situations); Specific phobia 5
subtypes: animal, natural environment, bloodinjection injuries, situational, others such as
sound, space and costumed characters.
Generalized Anxiety disorders: unrealistic or

excessive anxiety or worrying in a 6 month
period.
Associated restlessness, fatigue, irritability,
impaired concentration, muscle tension and
sleep disturbances
Obssessive-Complusive
Disorder:
characterized by obsessions and compulsions
Common obsessive thought involve religion,
violence, symmetry and contamination
Post-traumatic Stress Disorder: exposure to
traumatic experiences such as rape, combat,
crimes, violence, etc.
Symptoms of PTSD: recollections, flashbacks,
nightmares, avoidance, insomnia, exaggerated
response, labile emotion
Acute onset refers to symptoms less than 3
months; chronic if more than 3 months.
Acute Stress Disorder: lasts for 2 days and
either resolve within 4 weeks.
Avoids stimuli that causes recollections of the
trauma.
MOOD DISORDERS
Bipolar I: presence of one manic episode with
or without depression.
Bipolar II: presence of one hypomanic episode
and major depression
Cyclothymic Disorder: numerous episodes of
hypomania and depression for 2 years
Dysthymic Disorder: depressed mood for at
least 2 years for more days than not
MANIA
Manic Episode: abnormal, persistent elevated
mood for 1 week.
Hypomanic episode: elevated mood for 4 days
Affective symptoms: elation, humorous, lack
of shame or guilt
Physiological symptoms: dehydrartion, poor
nutrition, little sleep time, weight loss
Cognitive symptoms: ambitious, deny danger,
illusions, lack judgment
Behavioral symptoms: aggressive, excessive
spending
of
money,
hyperactive,
argumentative
Nursing management: provide safety, reduce
external stimuli, avoid competitive activities,
allow verbalization of feelings, limit setting,
be firm and consistent.
- 1 -
DEPRESSION
Depression:
lowered or saddened mood;
feeling of multiplied unhappiness for at least 1
week
Major depression: symptoms that persist over
a minimum period of 2 weeks.
Symptoms:
apathy,
sadness,
sleep
disturbances, guilt, anger, hopelessness,
helplessness, worthlessness, withdrawal, selfblame, ruminations, destructive thoughts,
suicidal thoughts
Women are more prone than men
Average onset is mid-20s
Occurrence of depression in children and
adolescents can be more devastating than in
adults.
Nursing
management:
Provide
safe
environment, structured activities, listen to
verbalization of feelings, divert attention,
help build self-esteem.
SUICIDE
Suicide is the outcome of a persons inability
to cope with catastrophic stress.
Ideation- persons thought regarding suicide
Gestures- non-lethal acts to get attention
Threats- verbal statements to declare suicide
Attempt- actual implementation of ending
ones life
Causes of suicide: mental disorder, personality
abnormalities,
family history, physical
disorders
Suicide risk factors:anhedonia, hopeless, male,
over 60 years old, adolescents (15-24), living
alone, unemployed, prior suicide attempts,
family history, substance abusers
Nursing Management: recognize level of
depression, observe behavioral cues, listen to
verbalization, provide safe environment,
supportive relationships, increase self-esteem,
emotional and professional support.
SOMATOFORM DISORDERS
Somatization disorder: Briquets syndrome
Various physical complains over several years
usually appear before age 30.
Involves 4 different body functions: 2
gastrointestinal, 1 sexual symptom and 1
neurologic symptoms other than pain.
Conversion disorder: one or more symptoms
or deficits ( numbness or paralysis)
Characterized by La Belle Indifference (little
or no concern about disorder)
Not intentionally produced Malingering
Causes distress or impairment in social,
occupational or other important areas of
functioning
Pain disorder: pain is the major complaint for
several months
Pain is usually caused by stress or unconscious
conflict.
Body Dysmorphic Disorder: excessive concern
of a perceived defect involving body image.
Symptoms: compulsive mirror checking or

inability to look at ones reflection or image.
Excessive grooming behaviors: combing hair,
plucking eyebrows, shaving, etc.
Obssession with plastic surgery. In obscure
cases, patient perform surgeries themselves.
Hypochondriasis: preoccupation of having a
serious disease.
Doctor-shopping or hospital-hopping
Doctors reassurance does not calm the fears.
Might have had a serious illness as a child.
DISSOCIATIVE DISORDERS
Dissociative disorder is a disruption of the
functions of consciousness, identity, momery
or perception of the environment.
Dissociative Amnesia: lossof memory in
regards to important events.
Classified as: Retrograde ( inability to recall
remote past) Anterograde ( inability to recall
immediate past)
Dissociative Fugue: sudden, unexpected
travel away from home and unable to recall
the past.
Client is unaware of the travel to another
location.
Dissociative Identity Disorder: formerly
known as multiple personality disorder
A person is domanted by one or two or more
personalities which controls ones behavior.
Seen in adult women than men.
Depersonalizaton Disorder: strange alteration
in perception or experience of self-esteem
with sense of unreality.
Detachment from oneself, feeling of going
crazy or insane.
Cannot separate reality from fantasy
Feelings of being in a dream-like or movie-like
state, mechanical or bizarre appearance
Nursing management: Present reality, use
grounding techniques, reduce external stimuli,
redirect attention away from self, avoid
sympathizing with the client, increase
socialization activites, provide therapies (
hypnosis, abreaction, cognitive and behavioral
therapy). Administer drugs (anxiolytics and
anti-depressants).
Notes:
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- 2 -
Matthew 6:33
But seek ye first the kingdom of
God, and his righteousness; and
all these things shall be added
unto you.
Applied Pharmcology
I. Drugs affecting the Eyes, Ears, and Nose.
Glaucoma- Acetazolamide (Diamox) inhibits
the aqueous humor production.
- Pilocarpine (Pilocar).
Rhinorrhea- Phenyleprine.
Otitis Media- high dose of oral Amoxicillin.
Allergic rhinitis- Diphenhydramine (Benadryl)
and Chlorphenyramine which are
antihistamine.
- Loratidine (Claritin), cetirizine HCl (Zyrtec).
II. Drugs affecting the Central and Peripheral
Nervous System
Status Epilepticus- IV diazepam (Valium) or
lorazepam (Ativan).
- IV phenytoin (Dilantin) or Phenobarbital.
- Valproic acid.
Febrile seizure - IV or rectal diazepam (Valium).
Cerebral edema - Mannitol by promoting
osmotic diuresis.
Mysathenia gravis - Pyridostigmine (Mestinon)
inhibits acetylcholinesterase activity.
Parkinsons Disease - Levodopa (L-dopa), acts
as dopamine agonist.
III. Drugs affecting the Cardiovascular System
Patent ductus arteriosus- Indomethacin
(Indocin), an NSAID.
Congestive Heart Failure - Digoxin (Lanoxin), a
cardiac glycoside that enhances the afterload.
- Dopamine and Dobutamine, due to its Beta-1
adrenergic effect.
IV. Drugs affecting the Respiratory System

Pulmonary Edema- Furosemide (Lasix).
- Hydrochlorothiazide (Hydrodiuril).
Status Asthmaticus/Anaphylactic shockEpinephrine (Adrenalin).
Bronchial asthma- Isoproterenol (Isuprel), an
adrenergic agent with Beta-2 effect.
- Theophylline (Theodur), inhibits the slowreacting substance of anaphylaxis
- Terbutaline (Bricanyl), Salmeterol (Seretide).
- Ipatropium bromide (Combivent), an
anticholinergic agent.
Bronchospasm with cardiac diseaseMetaproterenol, Terbutaline, Salmeterol,
Formoterol, and Albuterol.
All are pure Beta-2 adrenergic agonist.
Whooping cough- Codeine, a narcotic agent
with antitussive activity.
V. Drugs affecting the Gastrointestinal System
Acute Pancreatitis and CholecystitisPropantheline bromide (Probanthine), an
anticholinergic agent.- Morphine.
Abdominal cramps related to diarrhea
- Atropine sulfate.
Nausea and vomiting- Metoclopromide (Plasil),
Promethazine HCl (Phenergan), and
Ondansetron (Zofran).
All are antiemetic agents.
Myocardial Infarction- Epinephrine (Adrenalin).

- Morphine, a narcotic agent for severe pain.
Heartburn and gastritis- AlOH, MgOH, CaCO3,

Na2CO3, antacids that neutralizes the acidity.
- Omeprazole (Losec), Esomeprazole (Nexium),
are proton-pump inhibitors.
- Ranitidine (Zantac), Famotidine (Pepcid), are
H2- receptor antagonists.
Ventricular fibrillation- Lidocaine.

- Verapamil.
Peptic Ulcer Disease- Sucralfate (Carafate)

coats the ulcer-lining.
Sinus Bradycardia- Atropine sulfate.
PUD related to H. pylori infectionCombination of Bismuth, Amoxicillin, and

Metronidazole.
- Combination of Omeprazole, Amoxicillin, and
Clarithromycin (most effective).
Palpitation related to hyperthyroidismPropranolol (Inderal) by blocking B-1 adrenegic

activity.
Palpitation or hypertension with underlying
COPD- Metoprolol (Neobloc).
- 1 -
Constipation in patients with MI, stroke, postsurgical procedures- Lactulose.

Irritable Bowel Syndrome- Psyllium (Metamucil).
VI. Drugs affecting the Renal System
Congestive Heart Failure- Furosemide (Lasix),
a loop diuretic inhibiting sodium and chloride
reabsorption.
Nephrotic Syndrome- Furosemide (Lasix).
Hyperaldosteronism- Spironolactone
(Aldactone).
VII. Drugs affecting the Endocrine System
Diabetes Mellitus- Oral hypoglycaemic agents
(Sulfonylureas).
- Insulin.
Hyperthyroidism- Methimazole and
Propylthiouracil, antithyroid agents that
prevents formation of T3 and T4.
Hypothyroidism- Levothyroxine (Synthroid).
Addisons Disease- Hydrocortisone (Solucortef).
VIII. Antimicrobial Agents
Bacterial Pneumonia in infants and children <
5 years old- Amoxicillin with clavulanic acid
(Augmentin).
Bacterial Pneumonia in older children and
adolescents- Erythromycin (communityacquired).
- IV cefuroxime (hospital-acquired).
Pulmonary Tuberculosis- Rifampicin
(Rimactane), Isoniazid (INH), Pyrazinamide
(PZA).
Leprosy- Dapsone.
Cholera- Tetracycline.
Amebiasis- Metronidazole (Flagyl).
Shigellosis- Cotrimoxazole (Bactrim).
Inflammatory Bowel Diseases- Sulfasalazine
(Azulfidine).
Cirrhosis with Hepatic Coma- Neomycin.
Osteomyelitis- Nafcillin, Clindamycin (Dalacin-C).
IX. Antiparasitic Agents
Enterobiasis (Pinworms) and Ascariasis
(Roundworms) - Mebendazole.
Malaria- Chloroquine, Primaquine, and
Quinine.
X. Drugs affecting the Hematologic System

Patients with history of MI or Stroke- Aspirin
(Aspilet), an antiplatelet drug.
Patients with Arrhythmia or those prone to
Thromboembolism- Warfarin (Coumadin) and
Heparin sodium.
Pulmonary Embolism, Stroke, MI- Streptokinase
and Urokinase, which dissolves blood clots.
XI. Drugs that affect the Musculoskeletal System
Rheumatoid Arthritis- Aspirin.
Gout- Colchicine.
- Allopurinol.
XII. Drugs for Obstetrical Uses
Uterine Atony- Oxytocin (Syntocinon).
- Methylergonovine (Methergin).
Preterm Labor- Terbutaline (Bricanyl).
Preeclampsia- Hydralazine (Apresoline).
- Methyldopa (Aldomet).
Eclampsia- Magnesium sulfate.
NOTES:
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Excellence can be attained if you care more than others
think is wise,Risk more than others think is safe,
Dream more than others think is practical, and
Expect more than others think is possible.
- 2 -
II Timothy 1:7
Touch
For God hath not given us the
Spatial orientation)
spirit of fear, but of power, and

love, and a sound mind.

Bio Physical Concept in Nursing and
Rehabilitation/laboratory tests
NEUROLOGY
CT SCAN
A structural imaging study using a computer-basedx-ray to provide a cross sectional image of the
brain.
Advantages:
100% sensitivity
When MRI is contraindicated ,CT is the procedure of

choice.
To Dos:
Ask if (+) allergy to Iodine
Tell the patient to expect a sensation of feeling

flushed if contrast is injected through IV catheter
Procedure may last for 10 to 30 min
Maintain immobility on the entire process
Instruct clients to remove metallic items

MRI
Noninvasive structural imaging procedure that uses

powerful magnetic field and radiofrequency waves
to create an image
The imaging procedure of choice for most

neurololgic disorders.
Types:
Closed-tunnel-like
Open MRI-NO close chamber.The patient can

comfortably see all views while the scan is in
progress.
Advantages:
NO radiation / exposure to contrast medium
Sensitivity to blood flow
Ability to distinguish water, iron, fat and blood.

Disadvantages:
NO to patients with pacemakers, aneurysm

clips/implants
To DOs:
Use of bathroom prior to procedure-( may last 40 to

90minutes.)
Instruct patients to remove metal items
Encourage patient to remain still as possible during

the procedure
Inform that the scanner will make a dull , thumping

noise throughout the procedure
PET (Positron Emission Tomography)
A computer based functional imaging that permits

study of the brains metabolism , blood flow and
chemical processes.
Provides information on patterns of glucose and O2

metabolism.
To Dos:
Procedure requires injection or inhalation of a

radioactive substance that emits protons.
Reassure patient that radiation exposure is minimal
Advise patient to void prior to procedure since it

may take several hours
Cerebral Angiography
Following local anesthesia , radiopaque dye is injected
through catheter in brachial or femoral artery and passed
through cervical blood vessels to assess cerebral circulation.
Cerebral Hemisphere
Frontal lobe
Thought
Memories
Emotions
Moral behavior
Parietal lobe
Taste
Temporal lobe
Smell
Hearing
Memory
Emotional expression
Occipital lobe
Language
Visual interpretation
Cranial nerves:
CN
I
II
DYSFUNCTION
INTERVENTIONS
Decreased sense of
smell
Decreased visual
acuity and
visual fields
Is often accompanied by impaired

taste and weight loss
Frequent reorientation to
environment. Position objects around
client in deference to visual
impairment
Intermittent eye patching
Lubricate eyes to protect against
corneal abrasions
III Double vision

IV,VI (diplopia)
V
Decreased facial
sensation
Inability to chew
Decreased corneal
reflexes
VII Facial weakness and

decreased taste(ant.
tongue)
VIII Hearing loss,
imbalance, vertigo,
tinnitus
Caution in shaving and mouth care.

Choose easy to chew foods with high
caloric content. Protect corneas from
abrasion by using lubricant
Oral hygiene. Account for decreased
food intake. Cosmetic approach to
hiding facial weakness.
SAFETY! Move slowly to prevent
nausea and emesis. Assist ambulation
IX
X
Dysarthria, Dysphagia, Maintain airway. Prevent aspiration.

cardiac and respiratory Swallow therapy
instability
XI
Inability to turn
Mobility aids. Physical therapy
shoulders or turn head
from side to side
XII Dysarthria, dysphagia
Maintain airway. Prevent aspiration.

Swallow therapy
Brainstem (Midbrain , Pons , Medulla)
Medulla Oblongata - Apneustic center.

Potent stimulus is hypoxia.
Cerebellum- Coordination of movement
Pituitary Gland - the master gland
Neurons-the functional unit of the Nervous system

wrapped by myelin sheath.
Choroid plexus-Responsible for the production of CSF.

EENT:
Ophthalmoscopic Test
Examination of the eye that combines an
ophthalmoscope and a lens for observing
minute structures in the cornea , iris and
fundus.
Tonometer applied to cornea-measures IOP
Normal: 12 21 mmHg
- 1 -
IOP increased in glaucoma

Snellens Chart
Normal: 20/20
Assesses visual acuity
The higher the denominator, the poorer the vision
GENERAL NURSING CARE FOR EYE SURGERY
PRE-OPERATIVE:
-Explain procedures
-Allow verbalization of feeling and expectations
-Teach post-op care
POST-OPERATIVE NURSING CARE
Lie on unoperated side
Avoid constipation
Avoid sneezing and coughing
Neck Hyperextension
Report any sudden sharp pain
Avoid sensory deprivation
Nutrition
Innervation:
ALL Extraocular muscle-innervated by CN III EXCEPT:
Superior Oblique-Trochlear nerve
Lateral Rectus-Abducens nerve
Larynx-the voice box
9 Phonation (Voice formation)-the most complicated
function of the larynx.
Epiglottis-The structure that overhangs the larynx that
prevents the foods from entering the larynx and the trachea
while swallowing.
9 S.Mutans and S.Viridans-two of the normal flora of
the oral cavity implicated in the causation of
bacterial endocarditis.
Respiratory:
Surfactants
Certain lipoproteins that reduce the surface tension of
pulmonary fluids , allowing change of gases in the alveoli and
contributing to the elasticity of the pulmonary tissue.
Lecithin Spingomyelin ( Normal ratio - 2:1).
Alveoli
Small outpouching of walls of alveolar space through which
gas exchange takes place.
Cardiology
ECG
Measurement of the electrical current spread into the tissues
surrounding the heart.
Depolarization - reversal of the resting potential in
excitable cell membranes when stimulated
Repolarization - the return to resting potential.
P wave- Atrial depolarization
QRS complex- potentials generated when the

ventricles depolarize prior to contraction
T wave- ventricular repolarization.
PR interval the duration between the beginning of

the P wave and the beginning of the QRS complex..
Q-T interval-contraction of the ventricles lasts

almost from the beginning of the Q wave to the end
of the T wave.
Laboratory Tests:
Creatinine Phosphokinase (CPK-MB)
A blood test used to detect damage to the heart
muscle, skeletal muscle and brain.
Chest X ray
A radiograph made by projecting xrays through organs or
structures of the body onto the photographic film.
Lactate Dehydrogenase (LDH)

Measures anaerobic carbohydrate metabolism and
as one of the several serum indicators of MI and
muscular dystrophies.
Sputum Exam
Sputum coughed out first thing in the morning and specimen
sent to the laboratory. Done for three consecutive mornings.
Troponin Test
Measures level of cardiac troponins to differentiate
cardiac from non-cardiac chest pain.
Mantoux Test (Tuberculin Test)

Administration of Intradermal injection of a purified protein
derivative of the tubercle bacilli.
RESULT READ AFTER 48 TO 72 HOURS-a hardened ,raised , red
area of 8 to 10 mm is a positive reaction.
Purposes:
ABG
This test helps to evaluate gas exchange in the lungs by
measuring the gas pressures and pH of an arterial sample
ABG normal values
PaO2
80-100 mmHg
PaCO2
35-45 mmHg
pH
7.35- 7.45
HCO3
22- 26 mEq/L
O2 Sat
95-99%
Vibraessae-group of hair in the nostrils use to filter the
inspired air .
Mucociliary escalator-group of fine cells called cilia
continuously moving bringing the minute dirt and mucus
accessible for expectoration.
TURBINATE BONES ( CONCHAE)

INCREASE THE MUCOUS MEMBRANE SURFACE
OF THE NASAL PASSAGES AND SLIGHTLY
OBSTRUCT THE AIR FLOWING THROUGH THEM.
TRAPS DUST
WARMS INSPIRED AIR
Pneumocytes:
Type I responsible for the lining of the lungs and alveoli
Type II-responsible for the secretion of surfactants
Type III resposible for the natural defense of the lungs.
9
9
9
9
Evaluating patients with unstable angina

Detecting reperfusion after coronary
recanalization
Estimating MI size
Detecting MI perioeperatively
Gastrointestinal System
GUAIAC TESTS (Occult Blood Test)
Common practices are the following; for 3 days
before the test and during the stool collection
period:
High fiber content.
Avoid red meat in the diet.
Avoid food with a high peroxide content:
Turnips
Cauliflower
Broccoli
Horseradish
Melon.
Avoid :
Iron preparations
Iodides
Bromides
Aspirin
NSAIDs
Vitamin C supplements greater than 250
mg/day
Hydrogen Breathe Test
- 2 -
Measures the amount of hydrogen produced in the

colon,absorbed in the blood,and then exhaled in the
breath.
NPO 12 hours before the procedure.
The patient should not smoke after midnight before
the test.
NO Antibiotics and laxative / enemas 1 week before
the test.
9
9
9
9
UPPER GASTROINTESTINAL SERIES AND SMALL BOWEL

SERIES
Upper GI series and small-bowel series are
fluoroscopic x-ray examinations of the esophagus,
stomach, and small intestine after the patient
ingests barium sulfate.
As the barium passes through the GI tract,
fluoroscopy outlines the GI mucus and organs.
Double-contrast studies administer barium first
followed by a radio lucent substance, such as air, to
produce a thin layer of barium to coat the mucusa.
Important:
Explain procedure to patient.
Instruct patient to maintain low-residue diet for 2
to 3 days before test and a clear liquid dinner the
night before the procedure.
Emphasize NPO after midnight before the test.
Patient will be instructed at various times
throughout the procedure to drink the barium (480
to 600 mL).
Instruct the patient that stool will be light in color
for the next 2 to 3 days from the barium.
BARIUM ENEMA
Fluoroscopic x-ray examination visualizing the entire
large intestine.
Can visualize structural changes, such as tumors,
polyps, diverticula, fistulas, obstructions, and
ulcerative colitis.
Air may be introduced to provide a double-contrast
study.
Explain to the patient:
What the x-ray procedure involves.
That proper preparation provides a more
accurate view of the tract and that
preparations may vary.
ULTRASONOGRAPHY
1. A noninvasive test focuses high-frequency sound
waves to obtain an image of the structure.
2. Ultrasound can detect small abdominal masses,
fluid-filled cysts, gallstones, dilated bile ducts,
ascites, and vascular abnormalities.
3. Ultrasound with Doppler for vascular assessment.
NURSING AND PATIENT CARE CONSIDERATIONS
Abdominal ultrasound usually requires the patient to
be NPO for at least 6 hours before the procedure.
Change position of patient, as indicated, for better
visualization of certain organs
ENDOSCOPIC PROCEDURES
Endoscopy is the use of a flexible fiberoptic tube to
visualize the GI tract
Endoscopes contain multipurpose channels that
allow for air insufflation, irrigation, fluid aspiration,
and the passage of special instruments.
Other functions include:
Biopsy or cytology of lesions
Removal of foreign objects or polyps
Control of internal bleeding
Opening of strictures.
Important:
9 An IV sedative will be
administered.
9 A plastic mouthpiece will be used
to help relax the jaw and protect
the endoscope.
The patient may be asked to

swallow once in a while as the
endoscope is being advanced.
Air is inserted during the
procedure to permit better
visualization of the GI tract.
Keep patient NPO until patient is
alert and gag reflex has returned.
May resume regular diet after gag
reflex returns and tolerating fluids.
PROCTOSIGMOIDOSCOPY AND COLONOSCOPY

Visualization of the anal canal, rectum, and sigmoid
colon through a fiberoptic sigmoidoscope.
The patient must be NPO after midnight.
Use of Enemas containing neomycin to decrease the
bowels bacteria count .
Kayexalate enema to decrease the serum
potassium level)
To soften the stool ( oil-retention enemas)
To relieve gas( tidal,milk and molasses,or
fleet enemas)
Endocrine
Growth hormone
2. Prolactin
3. Gonadotrophins- LH and FSH
4. Stimulating hormones and trophic hormones
ACTH
TSH
MSH
Stores and releases
1. OXYTOCIN
2. ADH/Vasopressin
Growth Hormone (Somatotrophic Hormone)
Causes growth of almost all cells and tissues
of the body.
Promotes mitosis and cell size an specific
differentiation of certain types of cells.
Prolactin
Promotes development of the breasts and
secretion of milk
Gonadothrophs
LH
Plays important role in ovulation
Secretion of female sex hormones by the ovaries and
testosterone by the testes.
FSH
Causes growth of follicles in the ovaries prior to
ovulation
Promotes sperm formation in the testes.
Adrenals:CORTEX
Secretes three types of STEROID hormones
1. Glucocorticoids
Cortisol, cortisone and
corticosterone
2. Mineralocorticoids
Aldosterone
3. Sex hormones
Estrogen and testosterone
ADRENAL MEDULLA
Secretes Adrenergic Hormones:
Epinephrine
Nor-epinephrine
Pancreas (Endocrine)
ALPHA - GLUCAGON
BETA
- INSULIN
DELTA - SOMATOSTATIN
F
Pancreatic polpeptide
The Ovaries contains Granulosa and Theca cells
which secrete ESTROGEN and Progesterone
The testes contains Leydig cells that secrete
Testosterone
Radio-Active iodine uptake (RAI)
Measures the absorption of the injected iodine
isotope by the thyroid tissue
Increased uptake may indicate HYPERfunctioning
gland
- 3 -
Decreased uptake my indicate HYPOfunctioning

gland
Thyroid Scan
Performed to identify nodules or growth in the
thyroid gland
Pretest
Check for pregnancy
Thyroid medication may be withheld temporarily
NPO
Post-test
Ensure proper disposal of body wastes
FASTING BLOOD GLUCOSE
Aids in the diagnosis of Diabetes (Screening)
Pre-test: NPO for 8 hours
Normal FBS- 80-109 mg/dL
Glycosylated Hemoglobin A 1-C
Blood glucose bound to RBC hemoglobin
Reflects how well blood glucose is controlled for the
past 3 months
FASTING is NOT required!
N- 4-7%
Good control- 7.5%or less
Fair control- 7.5 % to 8.9%
Poor control- 9% and above
Thyroid
Growth
CNS maturation and development
BMR regulation
Stroke volume increased
Circulation
Fat Metabolism
CHO metabolism
Hypothyroidism
DOC-Levothyroxin( Synthroid) -should be taken on an
empty stomach
LOW calorie, LOW cholesterol and LOW fat diet
Manage constipation appropriately
Provide a WARM environment
Avoid sedatives and narcotics
Instruct patient to report chest pain promptly
Hyperthyroidism
Exophthalmos-The least seen yet he most pathognomonic in
hyperthyroidism
Goiter-the most common manifestation
PTH
Actions:
o Increases bone resorption
o Inhibits renal PO4 reabsoprtion (Phosphaturic
effect).
o Increases renal Ca reabsorption
o Increases intestinal absorption of Ca
Parathyroid hormone regulates serum calcium
levels
HYperparathyroidism
Increased serum Ca level
Decreased serum PO4
Increase bone resorption
Hypoparathyroidism
Numbness and tingling sensation on the face
(+) Trosseaus and Chvosteks signs
Bronchospasms, laryngospasms, dysphagia
Cardiac dysrhythmias
Hypotension
TO DOs:
Place a tracheostomy set. O2 tank and suction at the

bedside
Prepare CALCIUM gluconate
Provide a HIGH-calcium and LOW phosphate diet
VIT D:
Advise client to eat Vitamin D rich foods

Place a tracheostomy set, O2 & suction machine at
bed side
Active form is 1,25-dihydroxycholecalciferol
Calcitonin
Facilitates Ca reabsorption in the kidneys
Increases Ca absorption in the GIT
Synthesized and secreted by parafollicular cells of
the thyroid
Secretion is stimulated by an increase in serum Ca
Inhibits bone resorption
9
Urine testing for glucose

Benedicts test
Ketones
9
ONLY Regular insulin can be used

INTRAVENOUSLY
IMPORTANT:
Insulin is administered at home subcutaneously
Cloudy insulin should be thoroughly mixed by
gently inverting the vial or ROLLING between the
hands
Select syringes that match the insulin
concentration.
U-100 means 100 units per mL
Instruct the client to draw up the REGULAR (clear)
Insulin FIRST before drawing the intermediate
acting (cloudy) insulin
SOMOGYI EFFECT
Nocturnal hypoglycemia followed by rebound
hyperglycemia
Due to the production of counter regulatory
hormones- glucagon. cortisol and epinephrine
Hematology
Delivers nutrients,hormones
O2 to tissues
Collect and dispose wastes from the cellular

metabolism
RBC
Responsible for carrying O2 and CO2

between the lungs and tissues via the
hemoglobin
Biconcave, disc-shaped NO nucleus.

WBC
Colorless, nucleated ,primary function is
for protection against invading
microorganism
Functions:
Phagocytocis
Immunocytes
B and T lymphocytes
Plasma Cells (BM)
Life Span of 1 week.
WBC Differential:
Neuts: infection, inflammation, stress
Eosin: allergies
Baso: polycythemias, allergic reactions
Monos: Lymphoproliferative disorders, some
leukemias
Lympho: infection, immunodeficiencies,
lymphoproliferative disordes, leukemia
Hemoglobin
Heme-the O2 carrying component of Hemoglobin
Globin-bound to Iron
Sites of Blood components formation
Liver
- active fro 5 to 6 weeks to 6
months AOG
Spleen -active 4 to 8 months AOG
BM
-active at 5 moths AOG and
becomes the primary site from 7 month AOG and
thereafter.
- 4 -
Vertebrae, Sternum,Iliac bones, Skull, and long

bones .
ANEMIA
Kinds:
Iron Deficiency Anemia

Folate Deficiency Anemia
Aplastic Anemia
Pernicious Anemia
Duodenum and Upper Jejunum-site of Iron Absorption
Fe Deficiency Anemia(Microcytic, hypochromic anemia)
Most common Anemia
Causes:
Chronic Blood Loss
Bleeding
FOLATE DEFICIENCY ANEMIA
(MEGALOBLASTIC ANEMIA)
Causes
Poor dietary intake
Alcoholism
Anorexia nervosa
Malignancy
Pernicious
Macrocytic, hyperchromic anemia
A progressive megaloblastic macrocytic anemia that
results from the lack of intrinsic factor resulting to
disorder in RBC maturation.
To Do:
May be caused by certain drugs as:

Colchicine
Neomycin
Cimetidine
Hormonal contraceptives
Schillings Test
Most definitive diagnostic test to note absorption
of Vit B12.
Vitamin B12 IM
Iron therapy
Blood transfusion as needed
Physical examination every six months
*At risk for Gastric Cancer
Aplastic anemia
Hypoplasia of the bone marrow resulting to
PANCYTOPENIA
Anemia
Leukopenia
Thrombocytopenia
Causes
Congenital
Acquired
Idiopathic
Infections
Medications
Heavy metals
Cellular Growth and Differentiation
Repair of Tissues
-Needs nutrients as Vitamins ACE Iron and Protein.
Regeneration - Same cell type

Apoptosis.
replacement after injury or
Bone- osteOMA
Muscle- myOMA
Blood vessels- angiOMA
Fibrous tissue- fibrOMA
MALIGNANT
Undifferentiated
Erratic and Uncontrolled Growth
Expansive and Invasive
Secretes abnormal proteins
METASTATIC
Suffix SARCOMA / CARCINOMA
Processes Involved
Point mutation - Change in a gene occurring spontaneously affecting
the expression of the gene.
Deletion - Loss of a piece of a chromosome.
STEPS:
INITIATION
Carcinogens alter the DNA of the cell
Cell will either die or repair

PROMOTION
Repeated exposure to carcinogens
Abnormal gene will express
Latent period
PROGRESSION
Irreversible period
Cells undergo NEOPLASTIC transformation then malignancy

Etiology of Cancer
1. PHYSICAL AGENTS
Radiation
Exposure to irritants
Exposure to sunlight
2. CHEMICAL AGENTS
Smoking
Dietary ingredients
Drugs
Benzene
3. Genetics and Family History
Colon Cancer
Breast cancer
4. Dietary Habits
Low-Fiber
High-fat
Processed foods
Alcohol
5. Viruses and Bacteria
DNA viruses- Hepa B, Herpes, EBV, CMV, Papilloma Virus
RNA Viruses- HIV
Bacterium- H. pylori
6. Hormonal agents
DES
OCP especially estrogen

7. Immune Disease
AIDS
Tumor Characteristics
Fibroplasia - Replacement by connective tissue.

Hypertrophy- Compensatory mechanism as a result of increased
Differentiation extent
Apoptosis - Programmed cell death to balance cell proliferation.

Metaplasia - Metaplasia-the reversible conversion of normal tissue
Pleomorphism-variation in size and function
workload as exemplified by Ventricular hypertrophy in CHF.
cells into another
Anaplasia - Loss of normal cell differentiation .A characteristic of a

tumor cell.
Pleomorphism-variation in size and function

Cancer
BENIGN
Normal mechanism and proliferation of cells are disturbed

which results in distinctive morphologic alterations of the
cell and aberrations in tissue patterns.
Well-differentiated
Slow growth
Encapsulated
Non-invasive
Does NOT metastasize
Suffix- OMA
Adipose tissue- LipOMA
to which the parenchymal cells resemble

comparable normal cells both morphologically and functionally.
Anaplasia-Marked morphologic
and functional changes.
Rate of Growth
Local Invasion
The growth of Cancer cells are accompanied by progressive

infiltration , invasion , and destruction of the surrounding tissue.
`
The Spread of Primary Cancer in Another Organ Made Possible:
Direct seeding into body cavities or surfaces

Lymphatics
Hematogenous
Diagnostic Evaluation
Complete medical history
PE
Biopsy
Estrogen and Progesterone levels
CBC
Platelet count
Blood Chem
- 5 -

Imaging Procedures
Screening
Male and female- Occult Blood, CXR, and DRE
Female- Breast Examination, Mammography and Paps

Smear
Male- DRE for prostate, Testicular self-exam

Nursing Assessment
9 Utilize the ACS 7 Warning Signals
CAUTION
C- Change in bowel/bladder habits
A- A sore that does not heal
U- Unusual bleeding
T- Thickening or lump in the breast
I- Indigestion
O- Obvious change in warts
N- Nagging cough and hoarseness

Nursing Assessment
Weight loss
Frequent infection
Skin problems
Pain
Hair Loss
Fatigue
Disturbance in body image/ depression
Presence of mass
Non-healing wounds
Presence of discharge
The American Joint Committee of Cancer (The TNM Classification)
T-Primary tumor
Tx-Primary tumor unable to assess
TO-NO evidence or Primary tumor
Tis-Carcinoma in Situ
T1,T2,T3,T4- Increasing size and or local extent of primary tumor
N - Presence or absence or regional lymph node involvement
Nx - Regional lymph nodes are unable to assess
NO - No regional lymph node involvement
N1,N2,N3 - Increasing involvement of regional lymph nodes
M - Absence or presence of distant metastases
Mx - Unable to assess
Mo - Absence of distant metastasis
M1 - Presence of distant metastases
Management
Depends on type of
malignancy histologic cell type, stage,

presence of metastasis and condition of the patient.
BIOPSY
Fine Needle Aspiration Biopsy-Tissue is obtained by application
of suction through a needle attached to a syringe.
Core needle biopsy Needle biopsy with a large hollow
needle.Highly accurate and done in OPD
Incisional Biopsy of a selected portion of a lesion.
Excisional Biopsy of tissue removed by surgical cutting.
Treatment and Types of Surgical Procedures
Primary treatment Removal of tumor
with margin
Local excision- for small-sized mass

Wide excision -For bigger sized mass
Adjuvant treatment- In addition to the treatment rendered.
Debulking Therapy may be bone prior to surgery to lessen the

mass size and bleeding tendency.
Salvage treatment -The use of an extensive
surgical approach to
treat a local recurrence after implementing a less extensive
primary approach.
Palliative Treatment - A control NOT a treatment

Reconstructive or Rehabilitative
Preventive or Prophylactic
S (Synthesis)- DNA component doubles in preparation for cell

division
G2 (Gap 2 Phase ) - CHON and RNA synthesis occurs

M (mitosis) phase - Divides in 2 identical daughter cells
GO - Resting, refractory to chemotherapy.
Therapeutic Strategies
Adjuvant therapy
Neoadjuvant therapy - Administration of several courses of
chemotherapy before definitive surgical intervention.
High dose /Intensive therapy Administered in the BM

Preoperative Chemotherapy Done prior to surgery
Adverse
Effects of Chemotherapy
Alopecia
Anorexia
Renal /hepatic d/o
Mucositis
Anemia
Neutropenia
Thrombocytopenia
MAINTAIN TISSUE INTEGRITY
Handle skin gently
Do NOT rub affected area
Lotion may be applied
Wash skin only with SOAP and Water

Nursing Intervention
MANAGEMENT OF ALOPECIA
Alopecia begins within 2 weeks of therapy
Regrowth within 8 weeks of termination

Encourage to acquire wig before hair loss occurs
Encourage use of attractive scarves and hats
Provide information that hair loss is temporary BUT anticipate
change in texture and color
Chemotherapy General Effects:

Assessment :
Integumentary
Pain
Swelling
Rashes
Skin pigmentation
Taste changes
Stomatitis if present
Gastrointestinal
DHN
Nausea and vomiting
Electrolyte Imbalance
Anorexia
Jaundice
Liver enzymes,liver function tests and total bilirubin
Hematopoietic Disorder
Anemia
Color, Turgor, capillary refill

Presence of Dyspnea,fatigue,weakness,vertigo
Provide frequent Rest Periods
Neutropenia
Assess signs of infection

Adventitious breath sounds
Fever
Thrombocytopenia<20thou
Assess skin
Stool,urine,gums
Chemotherapy
Respiratory and Cardiovascular System

Assess:
effect on healthy cells
An induction for advanced disease with no alternative treatment
Lung sounds
Pulmonary fibrosis (Age>60,Has had pulmonary
Adjunct therapy
Cardiac studies before administering Doxorubicin and
Intent is to destroy as many tumor cells as possible with minimal

exists
Cell Cycle
G1 (Gap 1 )-RNA and CHON synthesis
radiation,Bleomycin or with preexisting lung disease)

Cyclophosphamide (Cardiotoxic)
Neuromuscular
Paresthesia
DTR
GUT
- 6 -
Monitor UO
BUN Crea
We make our world significant by the courage of
our questions and by the depth of our answers.
- 7 -
Philippians 4:6 - do not be anxious

about anything, but in everything by
prayer and supplication with
thanksgiving let your requests be made
known to God.

CARDIOVASCULAR CONDITIONS
Cardiovascular
(Angina) {r necrosis (MI)
9
9
9
9
9
9
{irreversible}[pathologic Q
wave/permanent in the ECG]
Eating a heavy meal, strenuous exercise,
sex, exposure to cold Decreased blood
flow (heart) decreased TP (heart)
decreased O2 (heart) anaerobic
respiration production of lactic acid
PAIN management decreased O2
demand by rest and SFF
Angina
o Pain relieved by rest and NTG
o NTG
Vasodilation orthostatic hypotention
move gradually Monitor BP
Store in a dark and amber container
Effective tingling sensation no
need to notify physician
Maximum of 3 tablets with 5 minute
interval
MI
o Pain relieved by Morphine SO4
Narcotic analgesic
Can cause respiratory depression
monitor RR and O2 saturation
Antidote narcan
Cardioversion synchronous
Defibrillation unsynchronous
Buergers disease CS
vasoconstriction stop CS common in
men
Raynauds stress and cold
vasoconstriction common in female
Congestive heart failure
o Left sided pulmonary
Dyspnea
Crackles
Polycythemia due to decrease O2 to
the kidneys
Clubbing of the fingers due to
prolonged hyxia
Orthopnea
o Right sided systemic
Hepatomegaly
Distended neck veins
Edema
Portal hypertension
Ascites weight gain
Varicose veins
o Digoxin
Cardiac glycoside
Positive inotrophic effect increased
strength of myocardial contraction
Negative chronotrophic effect
decreased cardiac rate monitor CR
never give if CR below 60 bpm
Adverse effect
V omitting
A norexia
N ausea
D iarrhea
A bdominal pain
REMEMBER: earliest GI; late
halo vision
Antidote Digibind
Decreased RBC Activity in tolerance,
Fatigue, provide rest, Anemia
Decreased Platelets Prone to bleeding,
avoid parenteral injection, apply
pressure on injection site, high risk for
injury
Decreased WBC prone to infection,
reverse isolation
Increased WBC presence of infection
First Day/Newly diagnosed Knowledge
deficit
9 Decreased TP in heart Ischemia
9
9
9
9
9
9 Heparin anticoagulant prevent

further enlargement of clot not dissolve
them monitor APTT/PTT antidote
protamine SO4
9 Coumadin anticoagulant prevent
further enlargement of clot not dissolve it
monitor PT vitamin K is the antidote
9 Urokinase/Streptoase dissolves the
clot
9 Lidocaine with Epinephrine when
combine has a very low pH and is,
therefore very painful when injected.
However, the pain can be minimized by
buffering the solution with sodium
bicarbonate, and by giving the
injection subdermally at a very slow
rate.
- 1 -
9 Epinephrine is added to local

anesthesia to increase the duration.
However, epinephrine causes
vasoconstriction and decreased
bleeding, which weakens tissue
defenses and increases the incidence of
wound infection.
9 Acute aortic dissection has a physical
signs and symptoms such as BP
differences between arms and or legs,
cardiac tamponade, and aortic
insufficiency murmur
9 Common side effect of beta blockers is
fatigue, which occurs early in the
treatment and depression which occurs
later.
9 Most common cause of death within the
first few hours following an MI is
Cardiac Arrhytmias generally
Ventricular Fibrillaton.
1. What type of abnormal cardiac rhythm
can be slowed through Valsalva
maneuvers and/or carotid massage?
Supraventricular rhythms
2. Name some common Valsalva maneuvers.
Holding the breath, stimulation of the gag
reflex, ipecac, squatting, pressure on the
eyeball, or immersing the face in ice
3. What is the common side effect of bblockers?
Fatigue, which occurs early in treatment:
and depression, which occurs later.
4. What is the most common cause of death
within the first few hours following an
MI?
Cardiac dysrhythmias, generally V-fib
5. What are the ECG findings on a patient
with hypokalemia?
Flattened T-waves, depressed ST segments,
prominent P-waves, prominent U-waves, and
prolonged QT and PR intervals
6. What are the ECG findings on a patient
with hyperkalemia?
Peaked T-waves, prolonged QT and PR
intervals, diminished P-waves, depressed Twaves, QRS widening levels exceeding 10
mEq/L, and a classic sine wave.
7. What is the first ECG finding for a patient

with hyperkalemia?
The development of tall-peaked T-waves at
levels of 5.6-6.0 mEq/L, which are best seen
in the precordial leads
8. During the first hours after a myocardial
infarction, why is it important to monitor
the patients ECG?
Arrhythmias are the leading cause of death
following an infarct
9. Why should you count a patients apical
pulse before administering digitalis?
A symptom of digitalis toxicity is a slow
pulse.
Notes:
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To believe in yourself and to follow your dreams,
to have goals in life and a drive to succeed, and to
surround yourself with the things and the people
that make you happy - this is success!
- 2 -
Matthew 6:33
Phillipians 4:6
Be anxious for nothing, but in everything
by prayer and supplication, with
thanksgiving, let your requests be made
known to God.
Care of the Elderly and Hospice Care/Care in Death and Dying

BULLETS ON CARE OF THE ELDERLY/ GERONTOLOGICAL
NURSING
The young adult extends from 20 to 40 years old,

middle adult from 40 to 60 years old, and late adult
above 60 years old.
The young adult (20-40):

o Majority consider this as their reproductive years
and peak of their functioning.
o
Has the capacity to develop intimate, lasting and
committed relationship with another person, or a
cause, institution or creative effort.
o The young adult is capable of principled reasoning.
Their choice of action is based on principles.
o Develops a sense of responsibility, the maintenance
of appropriate impulse control, the ability to plan
and implement realistic goals, and the development
of a career.
In middle and late adulthood (40-60; 60 above):

o Various physical changes take place like decreased
in skeletal muscle function, thinning of hair,
decreased visual acuity, diminished taste
sensation, wrinkles occur due to poor skin turgor,
decreased moisture and loss of subcutaneous fats
etc.
o Menopause occurs in women between ages 40 and
50, average of 47 years old.
o Climacterium (Andropause) occurs in men due to
decrease of androgen levels between ages 70 and 90
years old.
o This stage is considered the years of stability and
consolidation.
o A person becomes more altruistic, and concepts of
service to others and love and compassion gain
prominence.
o The person may experience midlife crisis between
ages 35 to 45, the deadline decade. This occurs
when the individual recognizes that he has reached
the halfway mark of life.
Gerontology is the science and study of the aging

process.
Gerontologic Nursing is the care and attention to

individuals undergoing the aging process with the
emphasis on the developmental stages of aging.
Geriatrics is the science and study of the physiologic

and pathologic problems of individuals in their later
maturity.
Senility is the aging process characterized by severe

mental deterioration.
Theories of Aging : Biological

o Genetic/ Mutation Theory affirms that changes in
replication of DNA-RNA are the causes of aging.
o Autoimmune/ Immunologic Theory states that aging
is caused by factors that change the immune system.
o Wear and Tear Theory compares the body to a
machine. Parts wear out and the machine breaks
down.
o Rate of Living Theory avers that the body has a
fixed rate of potential for living. The faster one
lives, the sooner one ages and dies.
Waste Theory describes aging as the accumulation

of chemical wastes in the body that produce
deterioration.
o Endocrine Theory states that events occurring in
the hypothalamus and pituitary gland are
responsible for changes in the hormone production
that result in the organisms decline.
Theories of Aging : Psychosocial
o Disengagement Theory arises from the fact that
human beings are mortal and must eventually leave
their place and role in the society.
o Activity Theory assumes that the same norms exist
for all mature individuals. The degree to which the
individual acts like or looks like is the determinant
of the aging process.
o Continuity Theory accounts for the continuous flow
of phases in the life cycle and does not limit itself
to change.
Elderly usually feel cold even in warm climate because
they have a poor temperature regulation.
Loss of calcium from bones especially in vertebral bodies
may increase the elderly to increased propensity to
fracture. They usually decrease in height of about 1
inch due to thinning of intervertebral disks; common
among postmenopausal women.
The elderly are at high risk for fluid electrolyte
imbalance; dehydration and dizziness occur even within
short time of food and fluid deprivation.
Developmental Tasks of the Older Adult:
9 Adjusting to decreasing physical strength and health.
9 Adjusting to retirement and reduced income.
9 Adjusting to the death of ones spouse.
9 Establishing an explicit affiliation with ones age
group.
9 Meeting social and civil obligations.
9 Establishing satisfactory living arrangements.
9 Establishing satisfactory relationships with adult
children.
9 Finding meaning in life.
Communication considerations:
o Demonstrate respect by remembering names and
calling the person by the name.
o Face the person when speaking.
o Speak distinctly and clearly.
o Do not shout, increased frequency of voice pitch
makes hearing difficult.
o Provide written instruction/ repetition of
instruction; memory and attention span have
diminished.
Promoting Independence and Self-Esteem
o Place equipment conveniently and encourage the
use of self-help devices.
o Encourage them to do as much as possible for
themselves, provided that safety is maintained.
o Assist with personal care as necessary.
o Acknowledge the elderly clients ability to think,
reason, and make decisions.
Hygienic Practices and Skin Care
o Daily bath is not necessary (dry skin).
o Use mild, superfatted soap.
o
- 1 -
Use bath oils, lanolin or body lotion (no alcohol).

Use pressure mattresses, flotation pads/ mattresses
alternately.
o Change position frequently.
o Massage bony prominences and weight-bearing
areas every 2 hours.
o Assist in ambulation as much as possible.
o Foot care- soak feet in warm water before cutting nails.
Visual Aids and Dental Care
o
o
o
o
o
o
o
o
o
o
o
o
Keep eyeglasses clean and always available

Keep night lights on to prevent accidents
Clean dentures following each meal
Prevent loss of dentures
Exercise and Body Alignment

o
Regular exercises of feet and legs to prevent peripheral

vascular disorders (PVDs).
Encourage correct posture and deep breathing.
Promote proper body alignment.
Use supportive pillows and firm mattress.
Footboard keeps cover off the toes.
Active ROM, gradual change of position.
Provide leather-soled, well fitting shoes to prevent
accidents/ falls.
Sleep Patterns and Mental Status

o Elderly sleep lightly, intermittently with frequent
waking; provide low bed/ night light and adequate
supervision when getting up.
Nutritional Needs
o Increase in fiber and fluid to prevent constipation.
o Encourage vitamins and mineral supplements.
o Provide foods that are high in CHON.
Urinary Elimination
o
o
o
Frequency of voiding is common (decreased muscle tone

of the bladder with impairment of bladder emptying
capacity; increased residual, urine infection).
Increase fluid intake to dilute urine and decrease its
irritating properties (limit fluids during the night to
prevent nocturia).
Reduced sensation, decreased awareness of the need to
empty bladder.
Relaxation of perineal muscles in elderly women
interferes with complete emptying of the bladder (UTI).
Many elderly men have BPH.

Involutional changes in the lining of the vagina lead
to decreased resistance to organism (infection with
discharge).
Emotional Needs
o Needs someone to talk to (plan time to visit; allow
visits with a clergyman).
o Comforted by touch (conveys feeling of concern,
interest and acceptance).
o Maintain family contact.
o Provide diversional activities (books/ magazines
with large prints, radio, TV).
o Allow to verbalize about feelings on death (do not
avoid the topic).
Physiologic changes associated with aging that
influence medication administration and effectiveness:
o
o
o
o
o
o
o
o
Altered memory and less acute vision.

Decrease in renal function, resulting in slower elimination
of drugs and higher drug concentration in blood-stream for
longer periods.
Less complete and slower absorption from the GI tract.
Increased proportion of fat to lean body mass, which
facilitates retention of fat soluble drugs and increases
potential for toxicity.
Decreased liver function which hinders biotransformation
of drugs.
Decreased organ sensitivity which means that the
response to the same drug concentration in the vicinity of
the target organ is less in older people than in the young.
Altered quality of organ responsiveness resulting in
adverse effects becoming pronounced before the
therapeutic effects are achieved.
Common Problems among the Elderly:

o Confusion/Dementia Nursing Interventions:
Spend time with the patient.
Use touch to convey concern.
Provide frequent reiteration of orienting data

(time and place).
Have clocks or calendars in the environment.
Explain all actions, procedures and routines

to the patient.
Address the patient by his name.
Keep a routine of activities.

o Osteoporosis Nursing Interventions:
Have adequate calcium in the diet- milk,

dairy products, dish, beans, cereals, calcium
supplements.
Get regular exercise, if not contraindicated.
Avoid alcohol, quit smoking. They reduce

bone mass.
Make the home safe to avoid accidents.
Use good body mechanics when lifting

objects (bend the knees instead of the back).
Wear rubber-soled, low-heeled shoes that

grip well.
Put items frequently used within easy reach.
Use handrails when going up and down stairs.

o Postural Hypotension Nursing Interventions:
Get out of bed slowly and in stages.
Sleep with head of bed elevated several

inches.
Have a daily fluid intake of 2-3 liters.
Avoid hot showers or baths, may cause

vasodilation, thereby, venous pooling.
Avoid straining at stool. This may cause fall

of BP.
Avoid bending down and suddenly standing

up again.
Use thigh-length elastic stockings to reduce

venous pooling.
o Hypertension Nursing Interventions:
Encourage stress reduction and relaxation.
Encourage healthy diet (fresh fruit, rice,

vegetable).
Reduce salt intake to 1 to 6 grams per day.
Take prescribed medications at regular basis.

Elderly abuse:
o
o
o
o
o
o
Psychologic abuse is instilling fear, threat or making the

eldery perform demanding tasks.
Physical abuse includes hitting, slapping or burning.
Financial abuse is taking their money or forcing them to
sign over their assets.
Infringement of personal rights such as restraining for long
periods of time against their will or isolating them from
normal social interactions.
The perpetrator of the abuse is usually the spouse or the
child of the victim.
Caregivers who abuse their family members are often
middle-aged or older or have emotional problems such as
alcoholism or substance abuse.
According to Kubler Ross, there are five stages of Death

and Dying (DABDA):1. Denial, 2. Anger, 3. Bargaining,
4. Depression, 5. Acceptance
The FOCUS of Hospice Care is to give support and care
of the dying person and family, with the goal of
facilitating a peaceful and dignified death, more so, to
improve the QUALITY of life, rather than CURE.
According to legend, one day a man was wandering in the desert when he
met Fear and Plague. They said they were on their way to a large city where
they were going to kill 10,000 people. The man asked Plague if he was
going to do all the work. Plague smiled and said, "No, I'll only take care of
a few hundred. I'll let my friend Fear do the rest.
- 2 -
Joshua 1:9 ...Be strong and

courageous. Do not be terrified; do
not be discouraged, for the Lord
your God will be with you wherever
you go

COMMUNICABLE DISEASE 1
PART 1: COMMUNICABLE DISEASE
A. GERMAN MEASLES Rubella
1. Occurrence of rashes Centripetal
2. Nature of rashes Maculo-Papulo
3. Duration of rashes 3 days, without
desquamation
4. Period of Communicability 7 days
before to approximately 5 days after
appearance of rash
5. Teratogenic effect to fetus 1st
trimester
6. Type of Isolation Respiratory
7. Preventive Immunization MMR Vaccine
- given at 12 15 months
- check for an allergy of egg prior
to MMR Vaccine
B. MEASLES Rubeola
1. Occurrence of rashes from hairline
downward to the trunk
2. Nature of rashes Maculo-Papulo
3. Duration of rashes more than 3 days with
desquamation
4. Period of Communicability from catarrhal
stage to 5 days after rashes
5. Type of Isolation Respiratory
6. Pathognomonic Kopliks
7. Most common complication Pneumonia
8. Routine Management Vitamin A.
9. Measles Vaccine very sensitive to heat
storage; freezer
- given at 9-12 months
- 85% protection 9 months
- 95% protection 12 months
C. ROSEOLA INFANTUM
1. Incidence 6 months-2 years
2. Occurrence of rashes Centrifugal
3. Nature of rashes Macule, nose pink; fade
upon pressure
4. Duration of rashes 1-2 days
5. Period of communicability not highly
contagious
6. Prevention NO Immunization
D. CHICKEN POX Varicella
2. Nature of rashes Vesicular
3. Duration of rashes start to dry on the 6th
day onward
4. Period of communicability before rashes
and until the vesicles become dry
5. Type of isolation Respiratory

6. Most common complication secondary
bacterial skin infection
7. Management Pastelike application of
antipruritus
8. Chicken Pox sometimes fatal to those
receiving steroid
9. Preventive Varicella
E. HERPES ZOSTER Shingles
2. Nature of rashes Vesicles with presence
of pain
3. Management Same as in Chicken Pox
- NEVER give ASA to clients
suffering from any viral infection.
It may lead to Reyes syndrome.
F. INFLUENZA
1. Incubation period 24-72 hours
2. Period of communicability Limited to 3
days from clinical onset
3. Prevention Flu vaccine
G. MUMPS Epidemic Parotitis
1. Incidence 5-15 years old
2. Period of communicability Most
communicable immediately before and
after swelling begins
3. Type of isolation Respiratory
4. Management Maintain bed rest
- Analgesic
- Encourage fluids and soft bland
foods
- Apply hot or cold compresses to
neck which ever is more
comforting
- To relieve orchitis - fitted
suspensory
5. Prevention MMR Vac.
H. TUBERCULOSIS
1. Ranks 6th in the leading cause of morbidity
and mortality
2. 6-12 months after infection the most
hazardous period for the development of
clinical disease
3. Degree of communicability depends on;
a. Numbers of bacilli discharged
b. Virulence of bacilli
c. Aerosolization by coughing,
sneezing
4. Case Findings DSSM primary diagnostic
tool
- 1 -
HEMOPTYSIS in the only contraindication to sputum

collection
5. Category Treatment Regimen
A. Category I 6 months treatment
1. New smear positive PTB
2. With extensive parenchymal
lesions
3. extrapulmonary TB
4. Severe concomitant HIV disease
B. Category II 8 months treatment
1. Treatment failure
2. Relapse cases
3. Return after default
C. Category III 4 months treatment
-New Smear negative PTB with minimal
parenchymal lesions on CXR
D. Category IV
- Chronic still smear positive after
supervised re-treatment
-Refer to A. DOTS PL us center
B. Provincial/City NTP coordinator
FDC number of tablet will depend on body weight
BODY WEIGHT
30-37 Kg
38-54 kg
55-70 kg
Above 70 kg
I.
NO. OF TABLETS PER

DAY
2
3
4
5
DIPTHERIA
1. Period of communicability 2 weeks but usually
shorten with the use of antibiotic
2. Pathognomonic Pseudomembrane
3. Immunity
A. Infants born of mothers who had
diphtheria are relatively immune but
disappear before the 6 months.
B. Immunity is often acquired through
unrecognized infection
C. Usually life long immunity
4. Prevention DPT = 1 months x 3 doses = 4
weeks interval
5. Absolute Contraindication
A. DPT2 or DPT3 if child has
convulsions or shock within 3 days
after DPT
B. Vaccines containing the whole cell
pertussis component if child has
neurological disease
J. PERTUSSIS Whooping Cough

1. Period of communicability early Catarrhal
2. Sources of infection discharged from laryngeal
and bronchial mucous membrane of infected
persons.
3. Description of cough paroxysmal cough ending
in a characteristics whoop or prolong crowing
noise
4. Immunity usually life long after infection.
A. Normal suck for the first 2 days of life

B. Onset of illness between 3 to 26 days
C. Inability to suck followed by stiffness of
the body and or convulsion
4. TT Immunization Schedule
VACCINE
TT1
TT2
TT3
TT4
TT5
MINIMUM
INTERVAL
As early as
possible during
pregnancy
At least 4 weeks
later
At least 6 months
later
At least 1 year
later
At least 1 year
later
PROTECTION
---80%
95%
99%
99%
L. POLIOMYELITIS
1. Period of communicability from incubation
period to prodromal stage
2. Mode of entry:
A. GIT more common entry
B. Respiratory
3. Paralysis Asymmetrical
4. Immunity life long
5. Prevention OPV
- Storage Temperature 15degree
Celsius 25 degree Celsius
- 2 gtts do not let the dropper touch
the Childs tongue
- If the child spits it out, GIVE another
dose
M. LEPROSY
1. Methods of Transmission
A. Prolonged skin to skin contact
B. Respiratory
2. Diagnosis currently based on clinical signs and
symptoms
- SSS SLIT SKIN SMEAR is an optional
procedure.
3. R. A. 4073 Advocates home treatment
4. MDT Multiple Drug Therapy
1. PB PAUBACILLARY
- Tuberculoid Type and Indeterminate
- Duration of treatment 6-9 months
2. MB MULTIPAUBACILLARY
-Lepromatous Type and Borderline or
Mixed Type
- Duration of treatment 12months18months
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Success is a state of mind. If you want success,
start thinking of yourself as a success.
K. TETANUS Lockjaw
1. Causative Agent Clostridium Tetany
- Anaerobic bacillus
- Vegetative
- Sporative
2. Incubation Period 3 days to 1 month or more
- The shorter the incubation period
the prognosis is usually poor
3. Tetanus Neonatorum; A newborn with history
of:
- 2 -
Isaiah 41:10
So do not fear, for I am with you;
do not be dismayed, for I am your God.
I will strengthen you and help you;
I will uphold you with my righteous right hand.

Cognitive Disorders, Substance-related disorders,
Eating and Sexual Disorders
COGNITIVE DISORDERS
Characterized by the syndromes of
delirium, dementia and amnesia
Caused by general medical conditions,
substances or a combination of these
factors
Confusion, memory impairment, speech
and language difficulties and impairment
of ability to plan or engage in complex
tasks are clinical manifestations
ALZHEIMER DISEASE
Progressive neurodegenerative illness of
unknown cause
Presence of neurofibrillary tangles and
neuritic plaque in the brain
Characterized by disturbance in judgment,
memory, affect, cognition and orientation
Course of disease is 2 to 20 years with
sundowners syndrome
Stages are: forgetfulness, confusion,
ambulatory dementia and end stage
DELIRIUM
There is clouding of consciousness or
reduced clarity of awareness of the
environment
Marked disturbance of recent memory
Disoriented to time and place
Speech may be rambling, incoherent or
sparse
Trouble finding words or identifying
objects
Perceptual disturbances may include
hallucinations and illusions
Persecutory delusions based on sensory
misperceptions are common
Develops over a course of hours or days
and fluctuates in severity
Often reversible and temporary
DEMENTIA
Deterioration of memory and cognition
Due to general medical conditions or is
substance related
Cognitive deficits are apparent even with
clarity of consciousness
Memory impairment is the hallmark
Develops insidiously as the condition
progresses
Misplacing personal objects
Becoming disoriented in unfamiliar
surroundings
As dementia progresses, learning deficits
become more prominent
Individuals with pprogressive dementia

eventually forget even their own names
May have aphasia (language disturbance);
apraxia (impaired ability to carry out
motor activities despite intact motor
function); agnosia (inability to recognize
familiar objects or persons)
Impaired ability to think abstractly and
plan, initiate, sequence, monitor and stop
complex behavior
Have difficulty conceptualizing or solving
problems
ANOREXIA NERVOSA
Eating disorder characterized by
obsessional weight loss without an
identifiable organic cause
10 to 20 times more common in girls than
in boys
Refusal to maintain weight
Fear of gaining weight or becoming obese
Disturbed body image
Amenorrhea for three cycles
Heightened activity level
Dry, scaly skin
Lowered metabolic rate
Possible low T3 levels
Normal TSH levels
Hypokalemia
Hypochloremia
Anemia
Parotid gland swelling
ECG changes
BULIMIA NERVOSA
Characterized y ravenous overeating
followed by guilt, depression and anger
A sense of lack of control over eating exists
Recurrent episodes of binging and purging
Self-evaluation unduly influenced by body
shape and weight
Binging episodes occur in secret
Wide fluctuations in weight
Persistent overconcern with weight and
body shape
Attempts to lose weight
Binging episodes terminated by sleep,
abdominal pain, social interruption or selfinduced vomiting
Hypokalemia
Parotid gland swelling
Dental erosion and caries
Menstrual irregularities
Anemia
- 1 -
SUBSTANCE ABUSE DISORDES

Substance use disorders are syndromes of
pathologic use of a substance
Substance induced disorders are
disturbances of thinking, emotion or
behavior caused by intoxication with or
withdrawal from a psychoactive substance
Substance dependence is a pathologic
pattern of substance use that results in
impairment or distress
Substance abuse is a maladaptive pattern
of abuse
Substance intoxication is reversible,
substance specific syndrome
Substance withdrawal is substance specific
syndrome that appears when a substance
is withdrawn
Addiction refers to overwhelming
involvement with seeking and using drugs
or alcohol
Alcohol Use Disorders, include alcohol
dependence and alcohol abuse disorder
Alcohol Induced Disorders include alcohol
intoxication, alcohol withdrawal, alcohol
withdrawal delirium
Alcohol-induced persisting dementia
Alcohol-induced persisting amnestic
disorder include korsakoffs psychosis and
wernickes encephalopathy
Alcohol withdrawal delirium is a severe
alcohol withdrawal syndrome
Disulfiram (antabuse) is an aversion
therapy
Heroin, morphine, codeine, opium and
methadone are opiates
Withdrawal from amphetamine causes
psychotic behavior
Cocaine is the most addictive drug known
to man
Hallucinogens cause distorted perceptions
Overdosage of marijuana can cause
psychosis
SEXUAL DISORDERS
Sexual dysfunction disorders involve a
disturbance in the processes that
characterize the sexual response cycle
May include sexual desire disorders, sexual
arousal disorders, orgasmic disorders and
sexual pain disorders
Sexual desire disorder include hypoactive
sexual desire disorder and sexual aversion
disorder
Sexual arousal disorders include female
sexual arousal disorder and male erectile
disorder
Orgasmic disorders include inhibited
female orgasm, inhibited male orgasm and
premature ejaculation
Sexual pain disorder includes dyspareunia
Paraphilia is a disorder characterized by
unusual sexual imagery
Paraphilias involve non-human objects, the
suffering and humiliation of oneself or
another person
Bestiality/Zoophilia; animals
Exhibitionism; exposing of genitals
Fetishism; inanimate articles
Frotteurism; touching and rubbing against
nonconsenting person
Sexual masochism; experiencing emotional
or physical pain
Sexual sadism; infliction of pain
Pedophilia; prepubertal children
Necrophilia; corpses
Telephone scatologia; telephoning
someone and making lewd and obscene
remarks
Transvestic fetishism; cross-dressing
Voyeurism; peeping toms
Plushophilia; stuffed toys
Hybristophilia; commiting crimes
Urophilia; urine
Coprophilia; feces
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No matter how good you get you can always

get better and that's the exciting part.
- 2 -
Psalm 71:5 For You are my

hope, O Lord GOD;
You are my trust from my
youth.

Conditions in Pediatric Nursing
There are 4 cardinal signs of meningitis:
KERNIG, BRUDZINSKI, NUCCHAL RIGIDITY &
PHOTOSENSITIVITY.
There are 2 causes for meningitis: Bacterial
and Viral; but only the Viral is airborne.
One of the major nursing management for
meningitis is to decrease environmental
stimulation.
Seizures are disturbances in normal brain
function resulting from abnormal electrical
discharges in the brain
Many seizures are idiopathic.
There are 3 categories of seizure:
GENERALIZED, PARTIAL(FOCAL),UNCLASSIFIED.
Drug of choices for seizure include
Carbamazepine (Tegretol) and Phenytoin
(Dilantin)
Hydrocephalus is an increase in the
production of CSF more than 200 ml in
children.
There are 4 cardinal signs of hydrocephalus:
MACEWEN, SETTING SUN EYES, BOSSING &
CUSHINGS TRIAD.
Shunt is the main treatment for
hydrocephalus and is placed on the right side,
thus, position the child on his left.
Neural tube defects include ANENCEPHALY,
ENCEPHALOCELE & SPINA BIFIDA
(MYELODYSPLASIA).
One of the major causes of NTD is
deficiency in vitamin B9 (Folic Acid)
Myelomeningocele child has sensory and
motor loss while meningocele child has none.
The cause of Reye syndrome in children
mostly is ASPIRIN TOXICITY.
The priority of the Patent Ductus Arteriosus

is to monitor the LUNG or the Pulmonary
function of the child.
Drug of choice for any hole originating in
the heart of a child is INDOMETHACIN
(Indocin).
There are 4 diseases in Tetralogy of Fallot:
Pulmonary Artery Stenosis, Right Ventricular
Hypertrophy, Ventricular Septal Defect,
Overriding of the Aorta.
The main priority nursing management of a
child suffering from TOF is to provide oxygen.
Surgeries of TOF include: Blalock-Taussig
Shunt, Modified Fontan Procedure, Modified
Rashkind Procedure.
Position of choice for tet spells is Tripod or
Squatting
The cause of Kawasaki disease is unknown.
Prominent signs of Kawasaki disease is
STRAWBERRY TONGUE & PMN RASH.
One of the major causes for Rheumatic
Heart Disease is GABHS.
Drug of choice for a child with RHD is
Penicillin or Erythromycin.
Kawasaki disease is otherwise known as
MUCOCUTANEOUS LYMPH NODE SYNDROME.
Management for Kawasaki disease is
intravenous immunoglobulin.
Croup is a general term referring to the
condition in the respiratory system with a
BARKING, BRASSY OR SEAL-LIKE COUGH.
There are 3 diseases categorized in croup:
EPIGLOTITIS, LARYNGOTRACHEOBRONCHITIS,
BRONCHIOLITIS.
The cause of Epiglotitis is Haemophilus
Influenzae Virus type B.
- 1 -
Among the 3 disease of croup, its

bronchiolitis which is the most contagious.
UTI is a common disease of the females

secondary to shorter urethra.
Nursing management of epiglotitis include

NO THROAT CULTURE.
Drug of choice for UTI is LEVOFLOXACIN

(LEVOX)
The prophylaxis of Bronchiolitis is RSV-IVIg.
Cryptorchidism is a condition wherein the

testis failed to descend into the scrotum.
Asthma is due to 3 pathological conditions:

BRONCHOSPASM, INCREASE MUCUS
PRODUCTION & ALVEOLAR INFLAMMATION.
Cryptorchidism usually can be managed

with human chorionic gonadotropin injections
in early life.
Wheezing in asthma is made upon

expiration while stridor is made upon
inspiration.
Hypospadia will manifest a dripping urine

while hyperspadia will have a fountain urine.
The cause of Sudden Infant Death Syndrome

is Idiopathic.
Circumcision is usually delayed in a boy

with hypospadia / hyperspadia.
SIDS can be diagnosed upon autopsy,

revealing no possible cause of death for the
infant.
There are 4 signs of developmental

dysplasia of the hips: BARLOW, ORTOLANI,
ALLIS, & TRENDELENBURG.
Nursing management for SIDS is to give

health teachings on the parents for the
prevention of its occurrence.
DDH has 2 categories: SUBLUXATION &

DISLOCATIONS.
Cystic fibrosis is a condition wherein there

is a malfunction of the exocrine part of the
pancreas.
A child with CF requires more sodium in the
diet.
Drug of choice for the child with CF is
PULMOZYME, which helps decrease the
viscosity of the mucus.
Clicking sound produced upon external

rotation of the hips is ORTOLANI.
Management of DDH includes: PAVLIK
HARNESS, HIP SPICA CAST, FREJKA CAST.
Scoliosis is a condition wherein there is a
lateral curvature of the spine.
Scoliosis is common in girls secondary to the
use of shoulder bags and/or sleeping
conditions.
AGN commonly occurs in a child who has a

history of rheumatic fever / rheumatic heart
disease.
There are 4 types of scoliosis: THORACIC,

THORACOLUMBAR, LUMBAR & DOUBLE.
The cause of acute glomerulonephritis is

Group A Beta Hemolytic Streptococcus.
Management of scoliosis include: BOSTON,

MILWAUKEE, CHARLESTON BRACES.
Cardinal sign of AGN is TEA-COLORED

URINE.
Talipes is the medical name for clubfoot.
A child suffering from neprhosis usually is

having MUERCKE BANDS in his/her nails.
Management of a child with Nephrotic
syndrome includes increasing protein in the
diet.
Management of a child with Wilms tumor is
to provide a caution that there should be NO
PALPATION OF THE ABDOMEN.
There are 4 types of clubfoot: VARUS,

VALGUS, EQUINUS, CALCANEUS.
Management of clubfoot includes casting
the affected leg.
Pyloric stenosis is condition wherein there is
hypertrophy of the pyloric canal leading to
the obstruction in the gastrointestinal tract.
The vomitus of a child with pyloric stenosis
will always be
ACIDIC.
- 2 -
Management of a child with pyloric stenosis

includes small frequent feeding and feeding in
a semi-fowlers position.
Surgery will only be the treatment for a

child with esophageal atresia or
tracheoesophageal fistula.
The prominent sign of a child with pyloric

stenosis will be an OLIVE-SHAPED MASS
palpated at the RUQ.
Hirschsprungs disease is also known as

aganlionic megacolon
Intussusception is a condition wherein there

is an invaginating or telescoping of the ileum
into the ascending colon.
Prominent sign of this condtion will be
SAUSAGE-SHAPED MASS upon palpation of the
RLQ.
The stool of a child with intussusception is
CURRANT-JELLY or BLOODY-MUCOID.
The child with celiac disease should not be
given with foods rich in GLUTEN.
Gluten-rich foods are found in barley, rye,
oats, wheat.
The child suffering from celiac disease can
only consume RICE & CORN to prevent
diarrhea.
Celiac disease is a genetic problem; there is
no cure for it.
The child with celiac disease cannot digest
the protein GLIADIN, a component of GLUTEN.
The main part affected in hirschsprungs

disease is the SIGMOID COLON.
Ganglion cells are missing in a child with
Hirschsprungs disease
The prominent stool of a child with
Hirschsprungs disease is RIBBON-LIKE STOOL.
PKU is a genetic problem wherein there is a
missing enzyme known as PHENYLALANINE
HYDROXYLASE TRANSAMINASE.
A child with PKU will manifest ALBINISM,
DWARFISM, CRETINISM & IMPOTENCE.
Leukemia is a blood disorder wherein it
targets the blood-forming organs.
Management for Leukemia includes blood
transfusion for life or bone marrow
transplants.
There are 4 types of leukemia: ACUTE
LYMPHOCYTIC LEUKEMIA, ACUTE
MYELOGENOUS LEUKEMIA, CHRONIC
LYMPHOCYTIC LEUKEMIA, CHRONIC
MYELOGENOUS LEUKEMIA.
Cleft lip is medically termed as

cheiloschisis, while cleft palate is
palatoschisis.
Hemophilia is a genetic disease common in

males.
Cleft lip is common in boys while cleft

palate is common in girls.
There are 3 forms of Hemophilia: CLASSIC,

CHRISTMAS, VON WILLEBRAND
Management for cleft lip is cheiloplasty

while for cleft palate is palatoplasty.
IDA is the most common type of anemia in

children.
Feeding for a child before surgery either

with cheiloschisis or palatoschisis or both is
based on the ESSR method.
Fanconi anemia is a type of anemia wherein

there is bone marrow suppression.
Medicine dropper should be used after

surgery only.
A child with cheiloschisis or palatoschisis
will have the problem in his/her sucking
reflex.
Signs of tracheoesophageal fistula include:
COUGHING, CHOKING, CYANOSIS.
Sickle cell anemia is an anemia wherein

there is sickling in the RBC.
SickeDex is the test for sickle cell anemia
where blood is the specimen to be withdrawn.
As simple as it sounds, we all must try

to be the best person we can: by making
the best choices, by making the most of
the talents we've been given.
- 3 -
Ezra 10:4
...Rise up; this matter is in your
hands. We will support you, so

take courage and do it."
Documentation and Records Management

/ Physical Assessment
Documentation- Serves as a permanent
record of client information and care.
Reporting- Takes place when two or more
people share information about client care
either face to face or by telephone.
Chart or Client Record- A clinical record
- Is a formal, legal
document that provides
evidence of a clients
care.
Charting- Recording on a clients medical
record
Ethical and Legal Considerations
o Restricted to health
professionals involved in giving
care to the client.
o Institution or agency is the
rightful owner of the clients
record.
o This does not however exclude
the clients rights to the same
records.
o Maintain privacy and
confidentiality.
Ensuring confidentiality of computer
records
1. Personal password to enter and sign off
2. After logging on, never leave computer
terminal unattended
3. Do not leave client information
displayed on the monitor where others
may see it
4. Shred all unneeded computer
generated worksheets
5. Know policy and procedure for
correcting an entry error
6. Follows agencys procedures for
documenting sensitive material such as
Dx of AIDS
7. It Personnel must install firewall to
protect the server from unauthorized
access
Purposes of Clients Record / Chart

1. Communication
2. Legal Documentation It is admissible
as evidence in a court of law
3. Research
4. Statistics
5. Education Serves as an educational
tool for students in health discipline
6. Audit and Quality Assurance Monitors
the quality of care received by the
client and the competence of health
care givers (JCAHO)
7. Planning Client Care
8. Reimbursement
9. Health Care Analysis
Types of Records
1. SOMR / SOCR / SOR
- Source oriented medical /
clinical record
- Traditional client record
2. POMR / POCR / POR
- Problem oriented medical /
clinical record
- Data are arranged according
to the problems
What style should a nurse use in charting?
1. Narrative- Chronological, sequential
narration
2. SOAP / SOAPIE / SOAPIER / APIE
3. Focus Charting Positive changes or
response of client to the treatment
D- Data
A- Action
R- Response of client
4. Charting by exception (CBE)
5. Computerized documentation
6. Case Management
- 1 -
Characteristics of Good Reporting

1. Brevity Entries are concise
2. Use of ink / permanence
3. Accuracy
4. Appropriateness
5. Completeness and Chronology
6. Use of standard terminology Use only
abbreviations and symbols approved
bye the institution, spell correctly use
proper grammar
7. Signed Sign each entry w/ your full
name and status SN or RN
-- Script not printing is used for
the signature
8. In case of error Correct errors by
drawing a single (Horizontal) line
through the error
9. Confidentiality
10. Legal awareness
11. Legible
12. Do not use the word patient or pt in
the chart. The chart belongs to the pt.
all information in the chart pertains to
the patient
13. A horizontal line is drawn to fill up a
partial line. This is to prevent other
persons from adding information in the
nurses notes.
Kardex Provides a concise method of
organizing and recording data about a
client, making information readily
accessible to all members of the health
team.
Reporting
Types of Reporting:
1. Change of sheet reports or
endorsement
2. Telephone reports
3. Telephone orders
4. Transfer reports
Incident Report
Documenting Everyday events
PHYSICAL HEALTH EXAMINATION

Conducted from the head to the toes
(cephalo-caudal technique) : skin, hair,
nails head, face, ears, eyes, nose sinuses,
mouth, throat, neck, breasts and axillae,
thorax/back, heart and peripheral vessels,
upper extremities, abdomen, anus, and
rectum, genitals, and lower extremities.
Determine the mental status and LOC or
state of awareness at the beginning of
physical examination.
Protect the clients privacy during the
entire procedure. Invasive procedures
cause feelings of embarrassment.
Prepare the needed articles and
equipment before start of procedure. To
conserve time, effort and prevent fatigue
in the client.
1. The sequence of methods for physical
examination of the abdomen is as
follows: inspection, auscultation,
percussion, and palpation. No
abdominal palpation among clients with
tumor of the liver or the kidneys.
2. During physical examination of the
abdomen, it is important to flex the
knees to relax the abdominal muscles,
thereby facilitating the examination of
abdominal organs.
3. The sequence of examining the
abdomen is as follows: right lower
quadrant, right upper quadrant, left
upper quadrant and the lower
quadrant. (RLQ, RUQ, LUQ, LLQ)
4. The best position when examining the
chest is stting/ upright position.
5. The best position when examining the
back is standing position. This enables
the examiner to assess the posture and
the gait of the client.
6. To palpate the neck for
lymphadenopathy or enlargement of
the thyroid gland, the nurse stands
behind the client
7. If ophthalmoscopy is done, darken the
room for better illumination
8. If instrument vaginal examination is
done, pour warm water over the
vaginal speculum before use. To ensure
comfort.
9. If a female client is examined by a
male doctor, a female nurse must be in
attendance. This ensures that the
procedure is done in ethical manner.
The victory of success is half won when one gains the habit of setting
goals and achieving them. Even the most tedious chore will become
endurable as you parade through each day convinced that every task, no
matter how menial or boring, brings you closer to fulfilling your dreams.
- 2 -
Romans 8:28
And we know that God causes everything

to work together for the good of those
who love God and are called according to
his purpose for them.

DOH Programs
DOH is the leader of health in the country. It is
mandated to promote and protect the health of all
Filipinos.
Certain
programs of DOH like IMCI, utilizes an
acceptable decision to which the nurse has to
follow in the management of simple cases.
Health Programs and guidelines emanate from the

DOH LGUs are the implementers of these programs.
Simple uncomplicated cases are managed in the

health center. Inform client on the nature of
illness, treatment, prevention and control.
DOHs specific role as a leader serves as national

policy and regulatory institution. It formulates
monitors and evaluates health policies, plans and
programs.
As enabler and capacity builder, DOH ensures the
highest achievable standards of quality health care,
health promotion and health protection.
FOURmula One for Health is the over-arching
framework of Health Sector Reform (HSRA).
HSRA came about because of continuing existence
of many health burdens. To cite high burden from
CD, rising burden from NCD and chronic diseases,
these are the heaviest on the poor.
The national Objectives for Health (NOH) 20052010 provides a roadmap for stakeholders in health
and health related sectors to identify and
harmonize their effort to attain its time-honored
vision of health for all Filipinos and to continue its
mission to ensure accessibility and quality of health
care of all Filipinos especially the poor.
The concept of Primary Health Care (PHC) is
partnership and empowerment of the people as the
core strategy in the effective provision of
community-based essential health services, that is
accessible, acceptable and sustainable at a cost
which the community and the government can
afford.
Healthy mother will have healthy children, the
future citizens of the country. Healthy citizenry
makes a strong and healthy nation.
Breastfeeding benefits mother, the child and the
community. It will reduce maternal and infant
mortality.
Birth spacing is one pillar of family planning. It
contributes in the reduction of infant, maternal
and under 5 deaths
Knowing the high risk factors among women can
prevent maternal mortality. Advocate Reproductive
Health Program.
Many childrens diseases are preventable through
immunization. There is no contraindication in
immunization.
Micronutrient like Vitamin A is important to

pregnant women. One protocol however is not to
give it to pregnant women before 4 months of
pregnancy.
IMCI has been established as an approach to
strengthen the provision of comprehensive and
essential health package to the children
Children with various health conditions are difficult
to manage. The protocol in IMCI helps in the
appropriate treatment
In the country, the main oral health problem are
dental caries (tooth decay) and periodontal
diseases (gum diseases)
Among 21 WHO countries, Philippines ranked
second worst in dental diseases, mostly in rural
areas.
DOH give high premium to comprehensive maternal
and child care program. One of the Millenium
Develomental Goal (MDG) is to reduce the MMR and
IMR.
Many of the Non-Communicable Diseases (NCD) are
linked to unhealthy lifestyle.
Communicable Diseases (CD) are preventable.
Knowing how the disease is transmitted can
prevent CD.
The Philippines is among the Asian countries with
greatest number of emergencies from natural
cause.
Emergency/Disaster preparedness is everybodys
responsibility. Individuals and families must be
taught how to cope-up with emergencies and
disasters.
To reduce immediate and long term morbidity and
disability is the goal of emergency of Emergency /
Disaster Preparedness.
Some emergencies become disasters when not
properly
managed.
Communities
must
be
adequately prepared for and able to respond
effectively to an emergency.
- 1 -
Disaster strike hardest at the most vulnerable

group the poor, women, children, elderly and
disabled.
Response to emergencies begins with an assessment
of public health problem.
Know what is important. Identify public health
priorities. Provide emergency health service and
rehabilitation fast.
beneficiaries are: marginalized,

critical and hard to reach areas.
undeserved,
Blood are no longer for free voluntary blood

donations are done in hospital Red Cross stations
and some designated places.
Epidemiologys main concern is the study of factors
that influences the occurrence and distribution of
diseases, defects disabilities which happen in
groups or aggregation of individuals.
When sources are scarce and people are displaced,

there is a great risk of ill health. Prevent disease
outbreak.
Epidemiology is considered the backbone of disease

prevention. It prevents occurrence of epidemic.
One of the 4 elements for FOURmula One for

Health is Good Governance. Its goal is to enhance
health system performance at national and local
level.
Statistics of morbidity and mortality indicates how

well a community health services are managed.
Success and a failure of health workers are also an
issue.
Dental care is among the essential health care for

the adolescents. Adolescence is the period
between 1024.
Adolescence is the most critical period of growth

and development in a person.
At the age 19 years old, 12% of adolescents are

already sexually active. They have high percentage
of unmet FP services.
Fertility
awareness,
human
sexuality
and
counseling are basic services will help adolescents
develop sexually responsible.
A major cause of maternal death are complication
from unsafe abortion as a result of unwanted
pregnancy.
Preventing
unwanted
pregnancy
through FP reduces maternal death.
Domestic violence against women and children
(VAWC) is important social and public issue. One
common cause is sexual violence.
Prevention and control of eye disorder like cataract
is awareness of the disorder. About 62% of
blindness is caused by cataract.
Mental health does not only mean psychiatric
disorder. A positive approach to life and a positive
state of well-being, prevent mental disorders.
The 4 public health problem on mental health are
defined burden, undefined burden, hidden burden
and future burden.
Mental health sub-program includes wellness of
daily living, extreme life experience, mental
disorder and substance abuse and other forms of
addiction.
Sentrong Sigla, a quality assurance program of
DOH, aims for active partnership between DOH and
LGUs. The goal is quality health care, services and
facilities.
Guiding principles of SS Certification focuses on
Public Health Program such as MCH, FP, Prevention
and Control of CD and Non-CD and promotion of
healthy lifestyle.
Botika ng Barangay (BnB) will promote equity in
health by ensuring availability and accessibility of
affordable
safe
medicines.
The
priority
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Nothing we achieve in this world is achieved

alone. It is always achieved with others
teaching us along the way.
- 2 -
Hebrews 11:1
Now faith is the assurance of
things hoped for, the evidence of
things not seen.

Problems in Sensation
(EENT and Integumentary System)
CATARACT
The crystalline lens becomes opaque
With age, lens fibers become more densely packed,
making the lens less transparent
One of the leading cause of preventable blindness
Usually starts unilateral but often times both lenses are
affected in time
Possible causes:
y
Aging
y
Anterior uvietis
y
Blunt or penetrating trauma
y
Congenital
y
Diabetes mellitus
y
Hypoparathyroid
y
Long-term steroid treatment
y
Radiation exposure
y
UV light exposure
Assessment findings
y
Glare
y
Distorted images
y
Gradual dimmed or blurred vision
y
Nyctalopia (poor vision at night)
y
ROR (red-orange-reflex lost ) as
cataract matures
y
Yellow, gray, or white pupil.
Diagnostic tools
y
Slit lamp biomicroscopy
y
ophtlalmoscope
y
A scan ophthalmic ultrasound
Nursing Diagnoses
y
Disturbed sensory perception (visual)
y
Impaired physical mobility
y
Risk for injury
Treatment
ECCE w/ PCIOL extra capsular cataract extraction with
post chamber intraocular lens
Phacoemusification
Planning and Goal
y
The client will have a safe post operative course
y
The client will take steps to prevent infection
and reduce intraocular pressure
y
IMPLEMENTATION
y
Provide a safe environment for the client .
orient the client to his surroundings to reduce
the risk of injury.
y
Modify the environment, to help the client meet
self care needs by placing items on the
unaffected side, prevent pressure rise o the
affected side.
y
caution the client not to rub the eyes
y
No bending, straining at stool, coughing ,
sneezing
y
provide sensory stimulation (large prints or
tapes) to help compensate for vision loss.
GLAUCOMA:
y
The client experiences visual field loss
due to the damage to the optic nerve
resulting from increased intraocular
pressure
y
Can lead to blindness if left untreated
y
Two types open angle and closed angle
y
Open angle glaucoma: there is
overproductions of aqueous humor
angles are open.
y
Closed-angle the flow of aqueous
humor is obstructed because of the
narrow angle
CAUSES:
y
y
y
y
y
y
DM
Family history of glaucoma
Long-term steroid treatment
Previous eye trauma or surgery
Race (blacks have a higher
incidence)
Uvietis
Assessment:
Chronic open angle glaucoma:
y
Initially asymptomatic
y
Atrophy and cupping of the optic nerve head
y
Increased intraocular pressure
y
Narrowed field of vision (tunnel)
y
Possible asymmetric involvement
Acute angle-closure glaucoma
y
Acute ocular pain(severe,)
y
Headache (severe, frontal)
y
Blurred vision
y
Dilated pupil
y
Halo vision
y
Increased intraocular pressure
y
Nausea and vomiting
Diagnostic evaluation:
y
y
y
y
Gonioscopy
Ophthalmoscopy
Perimetry
tonometry
Nursing Diagnoses
y
Acute pain
y
Anxiety
y
y
Risk for injury
Treatment
y
Chronic open-angle glaucoma
y
Reduction of intraocular pressure
y
Trabeculoplasty
Acute angle closure glaucoma
y
Lower down IOP (emergency)
y
Laser iridectomy , surgical iridectomy if
pressure doesnt decrease with drug therapy.
Chronic open-angle glaucoma
y
Alpha-adrenergic agonist: (alphagan)
y
Beta-adrenergic antagonist : timolol (timoptic)
Acute-angle closure glaucoma
Cholinergic: pilocarpine
Planning and Goals
y
The clients vision will improve ad pain will
disappear
y
The client will be able to perform postoperative
self-care
y
The client will take steps to prevent infection
and reduce IOP
Implementation:
y
Explain the disease process or surgical
procedure to reduce anxiety
- 1 -
y
y
y
y
y
y
Assess eye pain and administer medications as

prescribed
Provide a safe environment
Modify the environment to meet the clients
self-care needs
In acute episodes limit activities that inc IOP
Report eye pain not relieved by analgesic that is
accompanied by nausea and vomiting and
decrease vision
Encourage the client to express feelings about
changes in his body image to aid acceptance of
visual loss.
RETINAL DETACHMENT:
y
Separation of the retina from the choroids(the
middle vascular layer of the eye between the retina
and the sclera)
y
Occurs when a hole or tear in the retina develops ad
the vitreous seeps between the retina and the
choroids, if left untreated retinal detachment can
lead to vision loss.
POSSIBLE CAUSES:
y
Aging
y
Diabetic neovascularization
y
Familial tendency
y
Hemorrhage
y
Inflammatory process
y
Myopia
y
Trauma
y
Tumor
Assessment finding
y
Blurred vision worsening as the detachment increases
y
Painless change in vision
y
Photopsia ( recurrent flashes of light)
y
With progression of detachment, painless vision loss that
maybe described as veil, curtain, or cobweb that
eliminates part of the visual field.
y
Indirect ophthalmoscopy shows retinal tear or
detachment.
y
Slit lamp examination reveals retinal tear or
detachment
y
Ultrasound shows retinal tear or detachment in
the presence of a cataract.
Nursing Diagnoses:
y
y
Risk for injury
y
Anxiety
Treatment
y
y
y
y
Complete bed rest and restriction of eye

movement to prevent further detachment
Cryoprexy, if theres a hole in the peripheral
retina
Laser therapy, if theres a hole in the posterior
portion of the retina
Scleral buckling to reattach the retina
Planning and goals

y
The client will remain free fro injury
y
The client will understand the treatment options
y
The client will be free from permanent visual
impairment
Implementation:
y
Assess the visual status and functional vision in
the unaffected eye to determine self-care
needs.
y
Prepare the client for surgery by explaining
possible surgical interventions technique to
alleviate some of the clients anxiety.
y
Postoperatively instruct the client to lie o his
back or on his unoperated side to reduce
intraocular pressure on the affected side.
y
y
y
y
Discourage straining during defecation, bending

down, and had coughing, sneezing or vomiting
to avoid activities that increase intraocular
pressure.
Provide assistance with activities of daily living
to minimize frustration and strain.
Assist with ambulation, as needed, to help the
client remain idependent.
Approach the patient from the unaffected side
to avoid startling him
Orient the client to his environment to reduce
the risk of injury.
Menieres disease
y
Is a dysfunction in the labyrinth that produces
vertigo, sensorineural hearing loss, and
tinnitus.
y
It affects adults
y
Men more common than women
y
Age 30-60
Assessment findings
y
Severe vertigo
y
Tinnitus
y
Feeling of fullness or blockage in the ear
y
Severe nausea
y
Vomiting
y
Sweating
y
Giddiness
y
Nystagus
y
Sensorieural hearing loss
y
Audiometric studies indicate a sensorineural
hearing loss and loss of discrimination and
recruitment.
Nursing diagnoses:
y
Disturbed sensory perception (auditory)
y
Powerlessness
y
Risk for injury
Treatment
y
y
Restrict sodium intake to less than 2 gms per

day
Surgery to destroy the affected labyrinth
permanently relieves symptoms but at the
expense of irreversible hearing loss.
Drug therapy options:

y
Anticholinergic: atropine
y
Cardiacstimulant: epinephrine
y
Diuretic
y
Antihistamine: diphendyramine
y
Antihistamine: meclezine
y
sedative
Planning and goal
y
The client will reagain hearing or develop
alternate means of communication
y
The client will use available support systems to
develop coping abilities to deal with thhe
disorder
y
The client will remain free from injury.
Implementation:
y
Advise the client against reading and exposure
to glaring lights to reduce dizziness
y
Keep the side rails of the clients bed up to
prevent falls
y
Instruct the client to avoid sudden position
changes and task that vertigo makes hazardous
because an attack ca begin quite rapidly.
y
If the client is vomiting record fluid intake and
output and characteristics of vomitus to prevent
dehydration.
Examinations are formidable even to the best

prepared, for the greatest fool may ask more than
the wisest man can answer.
- 2 -
Psalms 37:5
Commit thy way unto the Lord; trust also

in him; and he shall bring it to pass.
Emergency, Disaster, Critical Care and Multi System Failure
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
BCLS is a means of providing oxygen to the brain, heart and

other organs until help arrives
The BLS follows the A-B-C principle
A= airway
B= breathing
C= circulation
First STEP in BCLS is : ASSESSMENT - determine Unresponsiveness
Assess for 5-10 seconds
Shake the victims shoulder and ask: are you okay

Assess BREATHING
Place ear over the nose and mouth
Look for chest movement
Perform for 3-5 SECONDS

OPEN the airway
Head tilt-Chin Lift method
Jaw thrust maneuver if neck injury is suspected

If BREATHING: place on side if no neck injury; DO NOT move if
with neck injury. If NOT BREATHING: deliver INITIALLY 2 rescue
breath via mouth to
mouth, Then deliver 10-12
breaths/minute
Assess CIRCULATION
Check for the carotid pulse on the side close to you for
5-10 SECONDS
If with (+) pulse ; continue giving 10-12 breaths/minute
Assess CIRCULATION
Correct hand placement: LOWER HALF of sternum one

hand over the other with fingers interlacing :If withOUT
pulse: START Chest Compressions 80-100
compressions/min
SHOCK is an abnormal physiologic state where an imbalance
exists between the amount of circulating blood volume and the
size of the vascular bed.
Cellular effects of shock: In the absence of oxygen, the cell
will undergo Anaerobic metabolism to produce energy source
and with it comes numerous by-products like lactic acid
Other effects of shock: circulatory function diminishes there is
decreased cardiac output Hypotension and decreased tissue
perfusion will result
There are three stages of shock
a. Compensatory stage
b. Progressive stage
c. Irreversible stage
THE COMPENSATORY STAGE OF SHOCK
a. In this stage, the patients blood pressure is within
normal limits.
b. Patients blood is shunted from the kidney, skin and GIT
to the vital organs- brain, liver and muscles
Manifestations of cold clammy skin, oliguria and hypoactive
bowel sounds can be assessed.
Nursing management of Shock includes monitoring of tissue
perfusion & vital signs, reduction of anxiety, administering
IVF/ordered medications and promotion of safety
THE PROGRESSIVE STAGE OF SHOCK: In this stage, the
mechanisms that regulate blood pressure can no longer
compensate and the mean arterial pressure falls.
The major effects of the progressive stage of shock is:
Blood flow to the brain becomes impaired, the mental
status deteriorates due to decreased cerebral perfusion
and hypoxia.
The overworked heart becomes dysfunctional. Heart rate
becomes very rapid (as high as 150 bpm
Laboratory findings will reveal increased BUN and
Creatinine. Urinary output decreases to below 30 mL/hour.
18. Other effects of the Progressive stage:

The reduced blood flow to the GIT causes stress ulcers
and increased risk for GI bleeding.
Hypotension, sluggish blood flow, metabolic acidosis
(due to accumulation of lactic acid), and generalized
hypoxemia can interfere with normal blood function.
19. THE IRREVERSIBLE STAGE OF SHOCK
This stage represents the end point where there is
severe organ damage that patients do not respond
anymore to treatment. Survival is almost impossible to
maintain
20. Medical management is the use of life supporting drugs like

epinephrine and investigational medications.
21. Assessment of a patient in shock
Early stages: may be normal due to compensatory
mechanisms
Later stages: systolic and diastolic blood pressure drops.
22. Other Assessment findings
Respirations: rapid and shallow, due to tissue anoxia and
excessive amounts of CO (from metabolic Acidosis)
Level of consciousness: restlessness and apprehension,
progressing to coma
Urinary output: decreases due to impaired renal
perfusion
Temperature: decreases in severe shock (except septic
shock).
23. Nursing Interventions:
Basic life support
Fluid replacement
Vasoactive medications
Nutritional support
24. Specific Nursing Interventions:

Maintain patent airway and adequate ventilation.
Promote restoration of blood volume; administer fluid

and blood replacement as ordered
Administer drugs as ordered
Minimize factors contributing to shock.
Maintain continuous assessment of the client.
Provide psychological support: reassure client to relieve
apprehension, and keep family advised
Provide Nutritional support
25. TRIAGE is to sort patients in groups based on the severity of
their health problem and the immediacy with which these
problems must be addressed
26. Triage category Immediate, Priority 1, Color Red, Conditions
- Chest wounds, shock, open fractures, 2nd &-3rd burns
27. Triage category Delayed, Priority 2, Color Yellow, Conditions
- Stable abdominal wound, eye and CNS injuries
28. Triage category Minimal, Priority 3, Color Green, Conditions
- Minor burns, minor fractures, minor bleeding
29. Triage category Expectant, Priority 4, Color Black,
Conditions - Unresponsive, high spinal cord injury
30. In the ER department, pts. needing emergency critical care, the
nurse will attempt to restore spontaneous circulation with the
following interventions:
Defibrillation, drugs,
Endotracheal intubation
Fluids (rhythm appropriate IV medications)
31. Defibrillation Look for ventricular fibrillation. electrode
placement: Right of the upper sternum just below the Right
clavicle; Left of the nipple in the midaxillary line
32. Endotracheal Intubation - isolates the airway and keeps it
patent, reduces the risk of aspiration
33. Intubation as well, permits suctioning of the trachea, and
provides route for administration of certain drugs.
Critical Care Nursing
34. Ability to regenerate- can function even 75% of liver mass is
damage
35. If liver damage is extensive, the liver fails or regeneration can
be irregular with fibrous tissue replacement.
36. Plays a vital role in phagocytosis thru the livers own immune
system in cells called the Kupffer cells
37. In liver failure, there will be the presence of dependent edema,
ascites, pleural effusion. This is due to the damaged livers
inability to maintain colloid osmotic pressure and metabolize
albumin
38. The major complications of Hepatic failure are the
following:Hepatic encephalopathy, Esophageal Varices and
Portal Hypertension
39. The major cause of Portal Hypertension is obstruction
specifically scarred tissues in the hepatic sinusoids
40. The major effect of Esophageal varices is hemorrhage
- 1 -
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
The livers inability break down harmful or toxic substances and

excrete as harmless by-products. Results to the symptoms of
Liver failure.
Death often follows rupture of esophageal varices.
To stop hemorrhage, health practitioners perform emergency
measures: administration of vasopressin, balloon tamponade or
the insertion of a Sengstaken Blakemore tube
The pressure of the balloons against the varices may stop the
bleeding. It is important to release this pressure periodically to
prevent tissue necrosis.
The esophageal balloon is not left inflated for more than 24
hours. Also, it is important to remove secretions and saliva that
accumulate above the balloon to prevent aspiration.
ALERTS:
* Balloon pressures should never exceed 45mmHg.
* Fully deflate both balloons prior to extubation.
* Clamp the tube before extubation to prevent liquid escaping
from distal end and being aspirated into lungs.
First to deflate: Esophagus
Second to deflate: Stomach
Scissors are kept near patient at all times in case balloons
migrate superiorly and cause respiratory obstruction in non
intubated patients.
Accurate records will be kept of amount and nature of drainage
from tube or from mouth.
The patients nose and mouth will be kept clean and free of
pressure areas.
To relieve ascites present in liver failure, abdominal
paracentesis is done
Nursing responsibilities preprocedure :
a. informed consent
b. Assist pt. to void
c. High fowlers position
d. Appropriate draping
e. Assisst in administration of anesthesia
Nursing Responsibilities after the procedure:
a. check dressing for leaks
b. label specimen appropriately
c. monitor vital signs specifically, temperature and blood
pressure
d. Measure, describe and record the fluid collected
e. Assess for hypovolemia, electrolyte loss, changes in
mental status
A fr. 8 catheter is used for the procedure
Because bilirubin is not secreted so easily from the liver cells in
cirrhosed livers, it builds up in the blood, leading to jaundice,
Intense itching is due to bile products being deposited in the
skin.
If the liver is cirrhosed it no longer filters out toxins effectively.
This causes the toxins to build up in the blood, like ammonia,
which can cause mental impairment or a condition as Hepatic
Encephalopathy
The patient with Hepatic Encephalopathy may also have
personality changes and needs constant supervision to maintain
safe patient care.
Ammonia is a product of protein metabolism, and so the pt. with
hepatic cirrhosis
In the later stages will have low protein and high
calorie diet
Monitoring for declining Neurologic Function: The first
parameter is:
Level of Consciousness determined and assessed by
the Glasgow Coma Scale..
A change in the level of consciousness is is the most sensitive
indication of deterioration
Signs of increasing intracranial pressure include the ffg:
Bradycardia
increasing systolic pressure
widening pulse pressure
An ominous development of increasing intracranial pressure:
a. bradycardia
b. hyperthermia
c. tachypnea
Motor Function Assessed thru observing spontaneous movements
Should the pt, unable to show spontaneous response to stimuli,
a response to pain is assessed.
The presence and absence of spontaneous activity of an
extremity is noted, speech and eye signs are also assessed.
Abnormal responses (lack of motor response; extension
responses) are associated with poorer prognosis.
A unilaterally dilated and poorly responding pupil may develop
impending hemorrhage and cerebral ischemia.
Maintaining airway is one of the most important goals of
management in patients with impaired neurologic function.
The brain is extremely sensitive to hypoxia and neurologic
deficits worsen in the presence of hypoxia
Poor oxygenation through obstructed airways causes C02
retention and hypoventilation, producing cerebral vessel dilation
and increased intracranial pressure and cerebral edema
72. Keep the head elevated 30 degrees, a position that

facilitates the drainage of secretions and decrease
intracranial pressures
73. Closely monitor ABG values to assess adequate ventilation
and more adequate cerebral perfusion
74. The presence of hyponatremia which usually follows head
injury and other electrolyte imbalances which may be seen
as lethargy, confusion and seizures
75. Nutrition must be started as soon as possible. Early Initiation
of nutrition have shown good outcomes of pts. with head
injury
76. Maybe in the form of parenteral thru central lines, NGT,
ileostomies, PEG
77. Feeding will be continuous till swallowing reflex returns and
the pt. is able to meet daily requirements
78. Restraints must be avoided or to be used as a last resort.
Any form of restraint is most likely to be countered with
resistance leading to injury or >ICP.
79. The pt. emerging from coma, often is seen with symptoms of
lethargy and stupor, then agitation. The agitation and
restlessness maybe due to discomforts brought about by
contraptions pain, full bladder and hypoxia.
80. Opoids are not to be used since these medications depresses
respirations, blood pressure, constrict pupils and alter
responsiveness
81. Catheterize for urine incontinence, may use condom
catheter for males, lubricate skin in copious amount
82. Elevate temperature of the head injured patient maybe due
to damage to the hypothalamus, cerebral irritation from
hemorrhage, or infection. Prevent chills, this increases ICP.
Antibiotics maybe prescribed.
83. Adequate blood flow remains to be the primary requirement
to provide life and function to any organ inside the body
84. Tissue oxygenation depends on how much oxygen from
arterial blood perfuses a certain tissue
85. The body can selectively increase blood flow to some areas
while others, like the skin and skeletal system can tolerate
low levels of oxygen for hours without dying or being
damaged.
86. Addisons is Hypofunction of the adrenal cortex.
87. All 3 classes of adrenal corticosteroids are reduced
(glucocorticoids, mineralocorticoids & androgens)
88. In secondary Addissons only mineralocorticoids are rarely
impaired
89. A marked increase in the rate of cortisol secretion by the
adrenal cortex aids the body coping effectively with
stressful situations.
90. Cortisol is anti-inflammatory by preventing capillary
permeability. Helps maintain vascular integrity and fluid
volume, has a mineralocorticoid effects.
91. Aldosterone (mineralocorticoid) maintains exracellular blood
volume. It acts on the renal tubule to promote renal
reabsorption of Sodium and excretion of potassium and
hydrogen ions
92. The cause of Addisons disease is autoimmune disease the
adrenals are being destroyed by the bodys immunesystem.
Susceptibility genes are identified
93. other causes are tuberculosis, fungal infections, HIV &
metastatic cancer.
94. pharmacological reasons are: Intake of Nizoral therapy,
chemoplastic drugs, anticoagulants
95. Manifestations occur only after 90% have been destroyed.
The disease is often advanced before it is diagnosed, it
comes insiduosly
96. Cortisol the most abundant and potent glucocorticoid. The
major function is the regulation of glucose concentration
97. Acute Addisons disease is a life threatening emergency
caused by a sudden decline of these hormones. Focus on
prevention of shock during the acute stage aggressive
symptoms are seen:
98. The signs signs and symptoms are thefloowing: postural
hypotension leading to circulatory collapse
99. The mainstay of treatment is replacement
therapy.Hydrocortisones are the most commonly used form
of replacement therapy. Given high doses
100. 2/3 dose in the am and 1/3 dose in the evening
101. Increased doses of cortisol during times of severe stress.
"Use what talent you possess: the woods would be very

silent if no birds sang except those that sang best."
- 2 -
Proverbs 13:4
"The appetite of the lazy craves and
gets nothing, while the appetite of
the diligent is richly supplied."

Endocrine Disorder
ENDOCRINOLOGY
Endocrine system is linked with nervous system &
immune system.
Hypothalamus governs the pituitary gland through
its releasing and inhibitory hormones (GnRH, CRH,
TRH, GHRH, SOMASTOSTATIN[ the sole inhibitory
hormone]).
Pituitary gland (master gland) governs the body
through its hormones.
Hormones are chemical messengers that modulate
the cellular and systemic response of the body.
PITUITARY GLAND
Anterior ( FSH, LH, ACTH, TSH, PROLACTIN, GH)
Posterior (OXYTOCIN, ADH)
9 Hypopituitarism (accompanied by posterior
pituitary dysfunction)
GH: dwarfism ( give GH subcutaneously
in multiple weekly doses)
ADH (vasopressin) : Increases water
reabsorption
Diabetes insipidus (deffeciency of ADH)
Causes: congenital, head injury, tumor,
surgery of the pituitary gland, infection,
renal failure
Cardinal signs: excessive diluted (1.0011.005) urine, polydipsia
Diagnostic exam: fluid deprivation test
o Withhold fluids 8-12
o Obtain weight, serum and urine
osmolality
o Confirmed: serum osmolality < 300
mOsm/kg
o Give vasopressin SQ (determines
the cause of D.I)
Management: Increase fluid
intake
DOC: desmopressin (intranasal, IM)
Syndrome of Inappropriate Antidiuretic Hormone
(SIADH): excessive ADH
Causes: Overmedication of vasopressin,
benign pituitary tumor, head injury,
nonendocrine ( ex. Bronchogenic
carcinoma)
Cardinal sign: fluid retention, dilutional
hyponatremia
Management: fluid restriction with
furosemide
9 Hyperpituitarism
Most common cause: pituitary adenoma
Manifestations: increase activities of hormones in

the pituitary gland (especially growth hormone)
GH: Gigantism (<18), Acromegaly (<18)
Management: transphenoidal hypophysectomy
WOF: Increase ICP, Rinorrhea (check for
glucose), D.I
THYROID GLAND
Thyroid hormones: T3, T4 and calcitonin
T3 is more potent than T4.
Major function: cellular metabolic activity.
HYPOTHYROIDISM
Child: CRETINISM; adult: MYXEDEMA
Most common cause of hypothyroidism in adults:
HASHIMOTOS THYROIDITIS.
Manifestations are due to hypometabolic state.
ALERT: prolongs effect of anesthesia, sedatives and
opiods.
MYXEDEMA COMA: end stage. Precipitated by
COLD EXPOSURE, trauma,infection and
depressants.
Signs: stuporous, hypoventilation, hypoglycemia,
hyponatremia, hypotension, hypothermia.
ALERT: NO REWARMING! ( increase vasodilation =
shock)
DOC: LEVOTHROXINE ( WOF: signs of
hyperthyroidism)
THYROTOXICOSIS
Most common type: hyperthyroidism (GRAVES
DISEASE)
Earliest and most consistent manifestation
(cardio): tachycardia, palpitations, increase CO
Presenting symptom: nervousness
Cardinal signs of Graves disease (autoimmune) :
Toxic goiter, Ophthalmopathy, Dermopathy.
Dalrymples sign- abnormal wideness of palpebral
opening; infrequent blinking.
Von Graefes sign- failure of the upper lid to move
downward promptly and evenly with the eyeball
looking downward; instead it moves tardily and
jerkingly.
Joffroys sign- absence of forehead wrinkling when
patient looks upward.
Diagnostic exam: sensitive TSH assay and free T4
measurement.
DOC: propylthiouracil (PTU); with meals;takes
several weeks before it takes effect.
Toxic effect (rare): agranulocytosis ( WOF: sore
throat). DISCONTINUE!
Radioactive therapy: destroys the overactive
thyroid cells. Treatment of choice for elderly.
Give PTU and propanolol before and after therapy.
- 1 -
Instruct the patient that it is tasteless and

colorless.
NO RADIATION SAFETY PRECAUTIONS NEEDED!
Side effects: radiation thyroiditis and parotiditis
(causes dryness and irritation of mouth). Give sips
of water, ice chips or salt and soda gargles 3-4
times/day (1 tsp. of salt, 1 tsp. of soda in 2 cups of
warm water).
WOF: THYROID STORM (associated w/ Graves/
acute elevation of catecholamine).
Hyperpyrexia : > 38.5C
Extreme tachycardia: > 130 bpm
Altered mental status: extreme irritability,
delirium or coma
Hypotension
Vomiting
Diarrhea
Cause of death: cardiac arrhythmias.
Prohibited in pregnant and lactating women.
Postpone pregnancy for 6 months after therapy.
Surgery of choice: SUBTOTAL THYROIDECTOMY (
limit production of thyroid hormone)
Patient should be euthyroid for 4-6 weeks ( give
PTU, lugols solution [ WOF: iodism] and beta
blocker).
COMPLICATIONS: hemorrhage, airway edema,
laryngeal nerve damage and hypocalcemia.
Hemorrhage and airway edema:
Earliest sign: FREQUENT CLEARING OF THE
THROAT OR SWALLOWING.
Place in Semi-fowlers position
Support head and neck when moving.
Check for fluid at the nape.
Ice collar (if bleeding)
TRACHEOSTOMY SET AT BEDSIDE
Laryngeal nerve damage: WOF voice changes
(hoarseness).
Hypocalcemia: WOF tingling sensation of toes,
fingers and around the mouth; (+) Chvostek and
(+) Trousseaes sign.
DOC: CALCIUM GLUCONATE
PARATHYROID GLAND
Parathormone: increases serum calcium
HYPOPARATHYROIDISM
Causes: thyroidectomy, parathyroidectomy
Diagnostic exam: serum Ca 5-6 mg/dL or lower
Cardinal sign: tetany, Trousseaus sign,
chvosteks
Parenteral parathormone for acute
hypoparathyroidsim with tetany
Tracheostomy and Ca gluconate should be at
bedside!
Seizure precautions
HYPERPARATHROIDISM
Primary: due to parathyroid adenoma.
Secondary: renal failure or chronic
malabsorption of calcium
Diagnostic exam: serum Ca ( >10 mg/dL),
radioimmunoassay of Parathormone
(differentiate primary from secondary)
Management: parathroidectomy
Hydrate, Eat right, Mobilize
Hypercalcemic crisis: serum Ca > 15 mg/dL.

Gice calcitonin and corticosteroids
ADRENAL GLAND
Adrenal cortex hormones: salt ( mineralocorticoids
[aldosterone] ), sugar ( glucocorticoids
[hydrocortisone] ) and sex (androgen).
Aldosterone is the acute life saver hormone.
Aldosterone is mainly regulated by the renninangiotensin system and serum potassium.
Hydrocortisone is the stress fighter hormone.
Hydrocortisone is mainly regulated by the diurnal
pattern and stress.
Adrenal medulla hormones: cathecolamines:
epinephrine and norepinephrine (works with the
CNS)
ADRENAL INSUFFICIENCY
Main cause of (primary) Addisons disease is
idiopathic (autoimmune).
Signs and symptoms appear when 90% of the
adrenal gland is destroyed.
Cardinal sign: asthenia
Hyperpigmentation differentiates primary to
secondary adrenal insufficiency.
Most dangerous sign: arterial hypotension
Diagnostic exam: ACTH stimulation test (primary:
increase, secondary: decrease).
Electrolyte imbalance: hyponatremia,
hyperkalemia.
DOC: cortisone (taken for life)
Give meds in the morning to mimic diurnal
pattern.
Do not stop taking the meds abruptly. TAPER IT!
Increase the dose during stress.
WOF: ADRENAL CRISIS (due to stress or under
medication).
ABDOMINAL PAIN is the initial manifestation.
DOC: dexamethasone
CUSHINGS SYNDROME
Increase secretion of adrenal hormones (especially
glucocorticoid)
Normal diurnal pattern is lost.
Most common cause: iatrogenic prolonged
glucocorticoid therapy.
Cushings disease (if the cause is a pituitary
adenoma).
Electrolyte imbalance: hypernatremia,
hypokalemia
Diagnostic exam: overnight dexamethasone
suppression test
Transphenodal hypophysectomy (if the cause is
pituitary in origin) WOF: clear liquid leaking
through the nose (CSF).
Rinorrhea (may be CSF)
Adrenalectomy (if the cause is adrenal in origin).
Give hydrocortisone 12- 48 hrs. post-op.
DOC: Ketoconazole ( medical adrenalectomy) for
ectopic causes.
PHEOCHROMOCYTOMA
A benign tumor in the adrenal medulla
(chromaffin cells)
- 2 -
Diagnostic exam: vanillylmandelic acid test (a 24

urine collection: measures cathecolamine levels)
Normal: 14mcg/ 100 mL of urine
9 avoid caffeine cocoa, vanilla, cheese, gelatin 2days
before and during the test
Cardinal sign: hypertension (chronic sustained

elevation of BP or paroxysmal HPN)
Triad: headache, diaphoresis and palpitations
Management: during attacks: bedrest w/ HOB

elevated
Definitive treatment: Adrenalectomy

PANCREAS
Islets of Langerhans: beta cells: insulin (induces

hypoglycemia), alpha cells: glucagon (induces
hyperglycemia).
Diabetes mellitus: most common endocrine disorder.
Major classification: primary (no associated disease is

present [type 1 & 2]), secondary ( an identifiable
disorder caused the diabetes syndrome)
Cardinal sign: hyperglycemia.
Classical clinical manifestation: polyuria, polydipsia,

polyphagia
OLD Diagnostic exam: Oral glucose tolerance test (OGTT)

NPO 8
FBS (normal: 80-110 mg/dL)
Give 50- 200 g glucose load ( ave: 75g)
Blood drawn 30 min, 1, 2, 3 after.
(+) DM: 2 value of 200mg/dL
NEW Diagnostic exam: FASTING PLASMA GLUCOSE

(FPG) >126 mg/dL (7.0 mmol/L) and random plasma
glucose (RPG) >200mg/dL (11.1 mmol/L)
Glycohemoglobin ( HbA1c): checks glucose control in 60120 days; glucose bound to hemoglobin. Basis of doctors
for the treatment of choice of DM.
< 7.5%good control
> 7.5- 8.9% fair control
> 9% poor control
Non-DM: 4-6%; DM: 7% or lower.
Type 1: destruction of pancreatic cells: little or absent

insulin.
Type 2: insulin resistance and impaired insulin

secretion.
Primary treatment: Type 1: insulin, Type 2: weight loss

(500-1000 calories subtracted from the daily total: 1-2
lbs weight loss/week)
OVERALL DM MANAGEMENT GOAL: To normalize insulin

activity and blood glucose levels to reduce the
development of vascular and neuropathic complications.
THERAPEUTIC GOAL: Euglycemia without hypoglycemia

while maintaining a high quality of life.
FOUNDATIONS OF DIABETIC MANAGEMENT: Nutrition,

Meal planning and Weight control
5 COMPONENTS OF DIABETIC MANAGEMENT:

Nutritional therapy: OBJECTIVE: control of total caloric
intake to attain or maintain reasonable body weight,
control of blood glucose levels and normalization of
lipids and blood pressure to prevent heart disease.

9 Diet: CARBOHYDRATES: 50-60% , FAT: 20-30%,
PROTEIN: 10-20%
Exercise: lowers blood glucose and reducing

cardiovascular risk factors by increasing insulin
utilization, alteration of blood lipid concentrations,
increasing levels of HDL and decreasing total
cholesterol and triglyceride levels.
9 15g carbohydrate before exercise.

9 DONT GIVE INSULIN PRIOR TO EXERCISE!
9 Should be done at the same of the day
regulary.
Monitoring
9 CORNER STONE OF DIABETES MANAGEMENT:
Self monitoring of blood glucose (SMBG)
[insulin takers: 2-4 times daily a.c and at
bedtime, non-insulin: 2-3/ week with 2 post
prandial]
9 BEST TIME: at the peak time of medication (for
dosage adjustments)
Pharmacologic therapy
Insulin: type 1[ lifelong], type2[temporary if diet
and oral hypoglycemic agents are ineffective]
Goal: to mimic pattern of insulin
secretion in response to food intake
and activity patterns.
Eat food at the onset and peak to avoid
hypoglycemia.
Human insulins are preferred over
from pig and cow sources (they are
not antigenic).
Regular insulin: the only insulin that
can be given via IV.
Storage: spare vials (refrigerator), vials
in use (room temperature). Avoid
extreme temperatures!
If mixed insulins is needed: draw
regular (clear) first then long acting
(cloudy)
Best site (in order): abdomen, arm
(posterior surface), thighs (anterior
surface), and hips
Dont use alcohol to cleanse the area!
Complications:
o Local allergic reaction:
antihistamine 1 before insulin
o Systemic allergic reaction:
desensitization
o Insulin lipodystrophy: systemic
rotation of injection sites (use all
available injection sites in 1 area
before rotating. Distance
between sites: 0.5- 1 inch, max
time: 2-3 weeks )
o Insulin resistance: give more
concentrated dose and
prednisone
o Dawn phenomenon:
hyperglycemia at 3 A.M- change
time of injection: dinner timebedtime
o Somogyi effect: nocturnal
hypoglycemia followed by
rebound hypoglycemia- decrease
evening dose or increase bedtime
snack
o Insulin waning: progressive rise in
blood glucose (bedtime to
morning
- 3 -
Alternative methods
Insulin pens: has insulin prefilled cartridges. Ideal
for 1 type of insulin injection or premixed; for
patients with impaired manual dexterity, vision, or
cognitive function.
Jet injectors: delivers insulin through the skin under
pressure in an extremely fine stream. Insulin is
absorbed faster. Side effect: bruising.
Continuous subcutaneous insulin infusion (insulin
pump): mimic the function of normal pancreas.
o Ideal site: abdomen
o Delivered at a basal rate: 0.5- 2.0 U/hr
o Only rapid-acting insulin is used
o Premeal bolus can be given
o Change needle or catheter at least q 3 days.
o Most common risk: ketoacidosis in type 1
(due to occlusion in the infusion set).
Hypoglycemia in type 2. Do manual injection
of insulin.
Oral Antidiabetic Agents:
o Used as an adjunctive therapy
o For type 2 diabetes if MNT is not effective
o Sulfonylureas: stimulates the pancreas to
secrete insulin ( tolazamide [tolinase],
glipizide [glucatrol])
o Non-Sulfonylurea Insulin Secretagogues:
stimulates insulin release from the
pancreatic beta cells (repaglinide [prandin])
o Biguanides: facilitates action of insulin on
peripheral receptor sites (metformin
[glucophage])
o Alpha-Glucosidase Inhibitors: delay glucose
absorption in the intestinal GIT
(acarbose[precise])
o Thiazolidinediones: enhance insulin action
at the receptor site without insulin
secretion of beta cells (rosiglitazone
[avandia])
Education: FOCUS: patient empowerment
7 tips for managing DM
o Healthy eating
o Being active
o Monitoring
o Taking medicines
o Problem solving
o Reducing risks
o Health coping
2 main type of information and skills: survival skills
and in-depth and continuing education
Alcohol consumption should be moderated. It primarily
causes hypoglycemia. Later on it could lead to excessive
weight gain, hyperlipidimia and hyperglycemia
Women: 1 bottle with low-calorie or less sugar drinks
and food per day.
Men: 2 bottle with low-calorie or less sugar drinks
and food per day.
Complications of DM are all caused by uncontrolled
hyperglycemia.
Acute complications
Hypoglycemia: usually before meals
9 Mild (blood glucose: <60
mg/dL):Tremor, Palpitations,
Nervousness, Hunger: give 15g fastacting simple carbohydrate. If
resolved give a protein and
carbohydrate snack (milk or cheese
and crackers)
9
Inability to concentrate,
Lightheadedness, Diplopia,
Drowsiness, Irrational, Numb (lips
and tongue), Slurred speech:give 1530g fast-acting simple carbohydrate.
Additional food after 15 min.
9 Severe(blood glucose: <20 mg/dL):
Disoriented, Seizure, Loss of
consciousness (or even coma): if
unconscious or cant swallow, give 1 mg
GLUCAGON [SQ or IM], if awakens give
a small meal and notify physician. In
hospitals: 25-50 mL of D50W IV.
Diabetic ketoaidosis (DKA) (type 1): blood
glucose: 300-800 up to 1000 mg/dL
9 Main cause: decreased or missed
dose of insulin, stress, undiagnosed
or untreated DM.
9 Cardinal signs: Hyperglycemia,
Dehydration and Electrolyte loss,
Acidosis (Kussmauls respiration,
acetone breath).
9 Prevention: give insulin even if the
patient vomits, increase dose
during stress
9 ManageRehydment: 3 Rs
(Rehydration, Restoring
electrolytes and Reverse acidosis)
Hyperglycemic Hyperosmolar Nonketotic
Syndrome (HHNS) (type2): blood glucose: 6001200mg/dL [extreme hyperglycemia without
ketosis]
9 Cardinal signs: Hypotension,
Profound dehydration,
Neurological symptoms
9 Same treatment with DKA
9 WOF: renal failure (assess fluid
status and urine output)
Long-Term Complications
9 Macrovascular ( CAD and MI)
9 Microvascular
Painless Retinopathy: for advanced cases: argon
photocoagulation
Nephropathy: ACE inhibitors, prevent UTI, avoid
nephrotoxic drugs, diet: low Na and low protein.
o Insulin can be incorporated in a dialysate
bath for dialysis of patients with renal
failure.
o
Neuropathy
o (Peripheral) Initial symptoms: paresthesia
and burning sensations
o (Autonomic): Cardio(tachycardia,
orthostatic hypotension), GIT(delayed
gastric emptying, constipation/ diarrhea),
GUT (neurogenic bladder)
The universe is full of magical

things, patiently waiting for our
wits to sharpen.
Moderate (blood glucose: <40

mg/dL): Confusion, Headache,
- 4 -
Proverbs 19:21
Many are the plans in a man's

heart, but it is the LORD's
purpose that prevails.

Public Health and Family Health Nursing
^ Primary Health Care is essential health care made
universally accessible to individuals and families in
the community by means acceptable to them at a
cost they can afford
^ Nursing procedures in the community include:

Clinic visit, Home visit, BP measurement, Bag
technique
^ Concept of PHC is characterized by partnership and

empowerment of the people.
^ Bag technique is a tool which will enable the nurse

to perform a nursing procedure with ease and
deftness, to save time and effort with the end view
of rendering effective nursing care to clients.
^ Framework for meeting the goal of primary health

care is organizational strategy.
^ Four Pillars in PHC are: Active community
participation, Multi-sectoral linkages, Use of
appropriate technology, Support mechanism made
available.
^ DOH roles: Leadership in Health, Enabler and
Capacity Builder, Administrator of Specific services
^ Public Health bag is an essential and indispensable

equipment of the nurse which she has to carry
along during home visits.
^ Points to consider in the use of bag (4Cs):
Complete contents, Clean, Contact with patients
articles is avoided, Convenient arrangement
^ DOH vision: Leader, Advocate and Model of

promoting Health for all in the Philippines
^ Principles of bag technique: Minimize or prevent

spread of infection, save time and effort, show
effectiveness of care, can be performed in a
variety of ways.
^ DOH mission: Guarantee Equitable, Sustainable and

Quality Health for all Filipinos
^ Pregnant women should have at least four prenatal

visits.
^ DOH goal: Health Sector Reform Agenda (HSRA)
^ 1st visit: before 4th month of pregnancy, 2nd visit:

6th to 7th month, 3rd visit: 8th month, 4th visit: 9th
month
^ Framework for Implementation of HSRA: FOURmula

ONE for Health
^ Goals of FOURmula One: Better health outcomes,
More Responsive health systems, Equitable health
care financing
^ Elements of FOURmula One: Health Financing,
Health Regulation, Health Service Delivery, Good
governance.
^ Community health nursing process: Assessment,
Planning, Implementation, Evaluation
^ Planning process has the following steps: Goal
setting, Constructing a plan of action, Developing
an operational plan.
^ 3 frameworks for evaluation: structural elements,
process elements, outcome elements.
^ Family Nursing care problem categories: Health
deficit, Health threat, Foreseeable Crisis
^ 2 doses of tetanus toxoid must be received by a

woman one month before delivery to protect baby
from neonatal tetanus.
^ Fully Immunized Mother (FIM): mother with 5 doses
of tetanus toxoid.
^ Micronutrient supplementation for pregnant
women: Vitamin A and Iron.
^ Vitamin A to pregnant women is given starting on
the 4th month of pregnancy, 2x a week at a dose of
10,000iu.
^ Iron with folate (600mg/400g) is given daily for 6
months.
^ Emergency signs for pregnant women: unconscious
or convulsion, vaginal bleeding, severe abdominal
pain, looks very ill, severe headache with visual
disturbances, severe breathing difficulty, fever and
severe abdominal pain.
- 1 -
^ Emergency Obstetric care strategy entails the

establishment of facilities that provide emergency
obstetric care for every 125,000 population which are
strategically located.
^ EmOC: Basic Emergency Obstetric Care (BEmOC) and
Comprehensive Emergency Obstetric Care (CEmOC)
^ Postpartum visits: 1st visit 1st week postpartum,
preferably 3-5days; 2nd visit 6 weeks postpartum.
^ Overall goal of family planning is to provide universal
access to family planning information and services
wherever and whenever they are needed.
^ Absolute contraindications: DPT2 or DPT 3 are not

given to a child who had convulsions or shock within 3
days after DPT1; Live vaccines are not given to
children who are immunosuppressed.
^ Giving doses of a vaccine less than the recommended
4 weeks interval may lessen antibody response.
^ Freeze-dried vaccines need diluents (BCG and Anti
Measles Vaccine).
^ Diluents of freeze-dried vaccines are stored in the
refrigerator compartment.
^ Fertility awareness based (FAB) methods tell a woman

when the fertile period of her menstrual cycle starts
and ends.
^ OPV and Anti-Measles Vaccine are very sensitive to
^ FAB methods include: calendar method, Billings

method, BBT, Symptothermal, Standard days and 2
day method.
^ BCG is sensitive to heat, stored in the refrigerator
^ Standard days method can be used by women with

menstrual cycle between 26 to 32 days; and should
abstain from sexual intercourse from day 8 to 19
(prevent pregnancy).
heat, stored in the freezer at -15 to -25C.
compartment at 2 to 8C.
^ DPT and Hepa B vaccines are sensitive to freezing,
stored in the refrigerator compartment at 2 to 8C.
^ Artificial methods of family planning include chemical

method (hormones) and barriers.
^ Use one syringe one needle per child during

vaccination.
^ IUD considered abortifacient since it may not

prevent fertilization, instead prevents implantation;
best inserted during menstruation since woman is
100% sure that she is not pregnant.
^ Interval between doses of DPT1,2,3 and OPV1,2,3 are

4 weeks.
^ Permanent methods include vasectomy and bilateral

tubal ligation.
^ 3 Es of Breastfeeding: Early breastfeeding ( initiate
within 1hr after birth), Exclusive for the first 6 months
of life (only breastmilk, not even water is allowed),
Extend up to 2 years
^ Complementary foods for infants should be: timely,
adequate, safe and properly fed.
^ Milk code (EO 51) covers products like breastmilk
substitute including infant formula, milk products.
^ Rooming in and Breastfeeding Act (RA 7600) requires
both public and private health institutions to promote
rooming-in and to encourage, protect, and support
the practice of breastfeeding.
^ Food fortification Law RA 8976
^ Target year for eradication of measles and neonatal
tetanus is 2008.
^ It is safe and immunologically effective to administer
all EPI vaccines on same day but at different sites.
^ Vaccination schedule should not be restarted from the
beginning even if interval between doses exceeded
recommended interval.
^ Interval between Hepa B 1 & 2 is 6 weeks, between

Hepa B 2&3 is 8 weeks.
^ Fully Immunized Child is a child who received one
dose of BCG, 3 doses of OPV, DPT and Hepa B and one
dose of anti-measles vaccine before his first birthday.
^ Common nutritional deficiencies in the country are:
Vitamin A, Iron and Iodine.
^ Dosage of Vitamin A for Infants is 100,000iu, for
Children: 200,000iu.
^ High risk children such as those with measles, severe
pneumonia, persistent diarrhea and malnutrition also
receive Vitamin A supplementation.
^ Postpartum mothers receive Vitamin A capsule at a
dose of 200,000iu, once within 4 weeks after delivery.
^ Newborn screening act is RA 9288.
^ Newborn screening is ideally done 48 to 72 hours after
birth, but not in the first 24 hours.
^ Diseases being screened for include: G6PD deficiency,
PKU, Congenital Hypothyroidism, Congenital Adrenal
Hyperplasia,
Galactosemia.
"Ability
may
get you to the top, but
it takes character to keep you there."
^ Moderate fever, mild acute respiratory infection,

diarrhea and vomiting are not contraindications to
vaccination.
^ General contraindication to vaccination is any serious
condition that needs hospitalization.
- 2 -
1 Chronicles 22:13
decrease the metabolism

excess
Then rate
you willcausing
have success
if you aredrug
careful
to observe
the decrees and laws
accumulation which can
lead
to toxicity
that the LORD gave Moses for Israel. Be
strong and courageous. Do not be afraid
or discouraged.
Fundamentals of Pharmcology
Pharmacokinetics is the process of drug movement

to achieve drug action. The 4 process are
absorption, distribution,
metabolism/biotransformation, and
excretion/elimination
Pharmacodynamics is the study of drug

concentration and its effects in the body
Drugs that are lipid soluble and non-ionized are

absorbed faster than water soluble and ionized
drugs
Excipients are fillers and inert substances are used

in drug preparation to allow the drug to take on
particular size and shape and enhance drug
dissolution
Generally, drugs are both disintegrated and

absorbed faster in acidic fluids with a pH of 1 or 2
rather than in alkaline fluids
Most oral drugs are absorbed in the surface area of

small intestine through the action of the extensive
mucosal villi. Absorption is reduced if the villi are
decreased in numbers
Drugs given IM are absorbed faster in muscles that

have more blood vessels, such as the deltoid, than
in those that have fewer blood vessels. SubQ tissue
has fewer vessels, so absorption is slower in such
tissue
Bioavailability of the drug is the percentage of
administered drug dose that reaches the systemic
circulation. The percentage of bioavailability for
the oral route is always less than 100%, but for the
IV route, it is usually 100%
The process in which the drug passes to the liver
first is called first pass effect, or hepatic first
pass. Some drugs do not go directly into the
systemic circulation following oral absorption but
pass from the intestinal lumen to the liver via the
portal vein.
The portion of the drug that is bound is inactive
because it is not available for the receptors and the
portion that remains unbound is free, active drug.
Only free drugs are active and can cause
pharmacologic response
When two highly protein bound drugs are given
concurrently, they compete for protein-binding
sites, thus causing more free drug to be released
into the circulation
The liver is the primary site of metabolism. Liver
diseases such as cirrhosis and hepatitis can
The half life (t) of a drug is the time it takes for

one-half of the drug concentration to be
eliminated. Metabolism and elimination affect the
half-life of the drug
The main route of drug elimination is through the

kidneys (urine)
The kidneys filter free, unbound, water soluble

drugs and drugs that are unchanged. Protein bound
drugs cannot be filtered through the kidneys.
The urine pH influences drug excretion. Acid urine

promotes elimination of weak base drugs, and
alkaline urine promotes elimination of weak acid
drugs, like aspirin.
The most accurate test to determine renal function

is creatinine clearance (CLcr). Creatinine is a
metabolic byproduct of muscle that is excreted by
the kidneys.
A decrease in GFR results in increase creatinine

level and decrease in urine creatinine clearance
Drug response can cause a primary or secondary

physiologic effect or both. Dipenhydramine
(Benadryl) has the primary effect to treat
symptoms of allergy, and the secondary effect is a
CNS depression that causes drowsiness
Onset of action is the time it takes to reach the

minimum effective concentration (MEC) after a
drug is administered
Peak action occurs when the drug reaches its

highest blood or plasma concentration
Duration of action is the length of time the drug

has a pharmacologic effect
Most receptors, protein in structure are found on

cell membranes. Drug binding sites are primarily on
proteins, glycoproteins, proteolipids and enzymes
Drugs that produce a response are called agonists,

and drugs that block a response are called
antagonists
Almost all drugs, agonists and antagonists, lack

specific and selective effects. Drugs that affect
various sites are non specific drugs. Drugs that
affect various receptors are non selective drugs
Categories of drug action includes:

o Stimulation or depression, which increases or
decreases the rate of cell activity or secretion
from a gland
o Replacement drugs, such as insulin replace
essential body compounds
- 1 -
o
o
Drugs that inhibit or kill organisms interfere

with bacterial cell growth
Drugs that act by the mechanism of irritation,
like laxatives irritate the inner wall of the
colon, thus increasing peristalsis and
defecation
The therapeutic index (TI) estimates the margin of

safety of a drug through the use of a ratio that
measures the effective dose (ED) in 50% of persons
or animals and the lethal dose (LD) in 50% of
animals. The closer the ration is to 1, the greater
the danger of toxicity
Drugs with a low therapeutic index have a narrow
margin of safety. Drugs with a high therapeutic
index have a wide margin of safety and less danger
of producing toxic effects
The therapeutic range (therapeutic window) of a
drug concentration in plasma should be between
the minimum effective concentration in the plasma
for obtaining desired drug action and the minimum
toxic concentration, the toxic effect
Peak drug level is the highest plasma
concentration of drug at a specific time. The
trough level is the lowest plasma concentration of
a drug, and it measures the rate at which the drug
is eliminated
Drug tolerance occurs when a client develops a

decreased response and requires higher dose. Drug
tolerance to a frequently repeated administration
of a certain drug is known as tachyphylaxis
Pharmacogenetics is the effect of a drug action

that varies from a predicted drug response because
of genetic factors or hereditary influence
A placebo effect is a physiologic benefit from a

compound that may not have the chemical
structure of a drug effect
The traditional five rights are (1) the right client

(2) the right drug (3) the right drug (4) the right
time and (5) the right route
The five additional rights are (1) the right

assessment (2) the right documentation (3) the
clients right to education (4) the right evaluation
(5) the clients right to refuse
The right client can be ensured by checking the
clients identification bracelet and by having the
client stating his/her name.
A telephone order (TO) or verbal order (VO) for

medication must be cosigned by the prescribing
health care provider within 24 hours
Side effects are physiologic effects not related to

desired drug effects. These are essentially
harmless and can be ignored
To avoid drug error, the drug label should be read

three times: (1) at the time of contact with the
drug bottle or container, (2) before pouring the
drug, and (3) after pouring the drug
Adverse reactions are more severe than side

effects. Adverse reactions are always undesirable
and must always be reported
Check that the medication order is complete and

legible. If the order is not complete or legible,
notify the nurse manager and physician
In the traditional stock drug method, the drugs

are dispensed to all clients from the same
containers. In the unit dose method, drugs are
individually wrapped and labeled for single doses
Calculate the drug dose correctly. When in doubt,

the drug dose should be recalculated and checked
by another nurse
When the drug has a long half-life (T), the drug is

given once a day. Drugs with a short half life are
given several times a day at specified intervals
Administer drugs that are affected by foods, such

as tetracycline, before meals. Administer drugs
that can irritate the stomach, such as potassium
and aspirin, with food to decrease GI discomfort
Assess he clients ability to swallow before

administration of oral medications.
Do not crush or mix medications with foods or

beverages or other substances before consultation
with a pharmacist. Do not mix medications in an
infants formula feeding
The right assessment requires that appropriate

data be collected before administration of the drug
When immediate drug response is desired, a large

initial dose known as the loading dose, of drug is
given to achieve a rapid minimum effective
concentration in the plasma
Toxicity results from over-dosage or build up of

medication in the blood due to imbalanced
metabolism and excretion
When two drugs with similar action are

administered, the drug interaction is called an
additive effect and is the sum of the effects of the
two drugs
When two or more drugs are given together, one
drug can potentate or have synergistic effect on
the other drug
When two drugs are combined that have opposite,

or antagonistic effects, the drugs cancel each
others drug effect
Allergic reactions are not a result of the

pharmacological effects of the drug but rather a
response of the patients immunological system to
the presence of the drug. Prior sensitization to the
drug is generally required
Idiosyncratic reactions are the result of abnormal

reactivity to a drug caused by genetic differences
between the patient and non reacting individual
Photosensitivity is a skin reaction caused by

exposure to sunlight. It is caused by the interaction
of a drug and exposure to UV light, which can cause
cellular damage.
- 2 -
The right documentation requires that the nurse

immediately record the appropriate information
about the drug administered
If the drug is embedded in a matrix patch and

diffuses into the skin, the drug is diffused over the
entire surface of the patch and probably may be
cut
If the drug is pooled in a reservoir patch and is

released via a semi permeable membrane, the
patch must not be cut
The right evaluation requires that the effectiveness

of the medication be determined by the clients
response to the medication
Remember to remove foil-backed patches before

Magnetic Resonance Imaging (MRI) is performed to
prevent burns
The client has the right to refuse the medication.

When a medication is refused, this refusal must be
documented immediately.
A nurse should never apply a topical medication

without first protecting his/her own skin
Do not double dip gloves and applicators that

come in contact with a client should not be
reinserted into the container
To administer eye drops, gently pull down the skin

below the eye to expose the conjunctival sac.
Medication place directly in the cornea can cause
discomfort or damage
To administer eardrops in children, pull down and

back on the auricle. In adults, pull up and back on
auricle. After 3 years of age, same as adults
Vaginal suppositories are inserted into the vagina

with the client in lithotomy position
Preferred areas for intradermal injections are

lightly pigmented, thinly keratinized, and hairless,
such as the ventral midforearm, clavicular area of
the chest, and scapular area
For tuberculin testing, measure only the indurated

area; do not include redness in the measurement
Aspirate subcutaneous injections, except with

heparin
Locations for Subcuteneous injections includes the

abdomen, upper hips, upper back, lateral upper
arms and lateral thighs
Gently massage area of subcutaneous injections

unless contraindicated, as with heparin
Apply gentle pressure to the SubQ injection site if

the client is on anticoagulant therapy to prevent
bleeding or oozing into the tissue and subsequent
bruising and tissue damage
Insulin syringe measured in units for use with

insulin only.
Use the tuberculin syringe for amounts less than

0.5 ml
Intramuscular drugs are used for more rapid effect

of drug than with the SubQ route. Used for
irritating drugs, aqueous suspensions and solutions
in oil
Locations of IM injections in pediatrics includes

ventrogluteal, dorsogluteal, deltoid, and vastus
lateralis
The right to education requires that the client

receive accurate and thorough information about
the medication and how it relates to his/her
particular situation
According to JCAHO, the following abbreviation,

acronyms and symbols must not be used: U (for
unit), IU (for international unit), QD (for everyday),
QOD (for every other day); trailing zero and lack of
leading zero; MS and MSO4
Oral medications are not given to clients who are
vomiting, lack a gag reflex, or who are comatose.
Clients may need a brief rest before proceeding
with further intake of medications
Enteric coated and timed release capsules must be
swallowed whole to be effective. Crushing would
alter the place and time of absorption of the drug
Advise client not to eat fatty food before ingesting
an enteric coated tablet because fatty foods
decrease absorption rate
Drugs given sublingually or buccally should remain

in place until fully absorbed. No foods or fluids
should be taken while the medication is in place
Pour liquid at eye level. The meniscus is at the line

of desired dose
Persons with diabetes should not be given elixirs or

syrups that contain sugar
Discard unused solutions from ampules.

Appropriately store unused stable solutions from
open vials
Administer only drugs that you have prepared. Do

not prepare medications to be administered by
another
Offer ice chips to numb taste buds when giving

bad-tasting drugs. When possible, give bad tasting
medications first, followed by pleasant tasting
liquids.
Administer no more than 2.5 to 3 ml of solution
intramuscularly at one site. Infants receive no more
than 1 ml of solution intramuscularly at one site
When administering drugs to a group of clients,

give drugs last to clients who need extra assistance
Record amount of fluid take with medications on

input and output chart
Oral medications can be administered through a

nasogastric tube but should not be mixed with the
entire tube feeding solution
- 3 -
Clients with low weight should be evaluated for

sites with adequate muscle. The ventrogluteal
muscle is the preferred site for adults and infants
older than 7 months
Do not use the dorsogluteal site for IM injections in

children, for infants younger than 7 months, the
vastus lateralis is preferred
The z-track injection technique prevents

medication from leaking back into the subQ tissue.
It is frequently advised for medications that cause
visible and permanent skin discoloratios (e.g. iron
dextran)
Drugs administered by IV act more rapidly than

those by mouth, subQ, and IM.
Acccessible peripheral veins (e.g. cephalic or

cubital vein of the arm) are preferred. When
possible, ask the client of his/her preference
In newborns, the veins of the feet, lower legs, and

head may be used after the previous sites have
been exhausted
If the IV rate is to infuse at 100 ml/hr or more, the

macrodrip set is usually used. If the infusion rate is
less than 100 ml/hr, or the client is a child, the
microdrip set is preferred
Drugs should be added to the IV bag or bottle

immediately before administering the IV fluid.
Inject the drug into the rubber stopper and rotate
the bag several times to ensure that the drug is
dispersed throughout the solution
Do not add the drug while infusion is running unless

the IV bag is rotated
Inject medications slowly to minimize tissue

damage. Do not administer injections if sites are
inflamed, edematous or lesioned
Rotate injection site to enhance absorption of the

drug (e.g. insulin) Document the injection site
Key aspects of pediatric medication administration:

(1) honesty is a priority; (2) careful attention to
vocabulary; (3) forceful restraint should never be
used; (4) praise and positive reinforcement, (5) the
child should not be threatened or shamed into
taking a medication
Developmental needs of Pediatric clients with

administrations of medications:
o Stranger anxiety (infant): maintain a nonthreatening approach and move slowly
o Hospitalization, illness or injury may be
viewed as a punishment (3-6 year olds): allow
control where appropriate, encourage
positive relationships and expression of
feelings
o Fear of Mutilation (3-6 year olds): explain the
procedures carefully; use less intrusive routes
such as oral route, play
Physiological factors which may affect drug action
in the pediatric patients includes:
o reduced gastric acidity, small muscle mass,
thin stratum corneum, high proportion of
water in body, reduced protein-binding
capability, unpredictable hepatic enzyme
production and immature renal system
reduced gastric acidity, prolonged gastric

emptying time, diminished muscle tone and
motor activity in the lower GI, reduced blood
supply to major organs, diminished
proportion of water in the body, diminished
protein-binding capability, increased
proportion of fat in the body, reduced
hepatic and renal function and impaired
homeostatic responses
The metric system is a decimal system based on

the power of 10. The apothecary system uses
Roman numerals instead of Arabic numbers to
express the quantity. The household system of
measurement is not as accurate because of the lack
of standardization of spoons, cups and glasses.
Drugs have several names. The chemical name of

the drug describes the drugs chemical nature
The generic name is the official or non proprietary

name for the drug. This name is not owned by any
pharmaceutical company and is universally
accepted
The brand (trade) name, also known as proprietary

name is chosen by the drug company and is usually
a registered trademark owned by that specific
manufacturer
Over-the-counter (OTC) drugs are drugs that are

available without prescription, are found in most
households.
Drug abuse generally refers to an overindulgence

of a chemical substance that results in a negative
impact on the psychologic, physical or social
functioning of an individual
Chronic abuse of drug may lead to addiction. Drug

addiction is a complex disease of the CNS
characterized by compulsive, uncontrolled craving
for and dependence on a substance to such a
degree that cessation causes severe emotional,
mental or physiologic reactions
Physical dependence is altered physiologic state

from prolonged substance use; regular use is
necessary to prevent withdrawal syndrome
Psychologic dependence is compulsive need to

experience pleasurable response from the
substance
Craving is subjective need for a substance, usually

experienced after decreased use or abstinence.
Cue-induced craving is stimulated in the presence
of situations previously associated with drug taking
Republic Act No. 9502 Cheaper medicines
act of 2008
Republic Act No. 9165 Comprehensive
Dangerous Drugs Act of 2002
Republic Act No. 8203 - Special Law on
Counterfeit Drugs
Republic Act No. 6675 - Generics Act of
1988
Republic Act No. 6425 - Dangerous Drugs
Act of 1972
Republic Act No. 5921 Pharmacy Law
"The whole world steps aside for the man

who knows where he is going."
Physiological factors which may affect drug action

in geriatric patients includes:
- 4 -
In a client with PUD,James

milk is
1:5contraindicated
because its high calcium
content
If any of you lacks stimulate
wisdom, he s the
secretion of gastric ashould
cid. ask God, who gives
generously to all without finding
The most common cause

of itappendicitis
a
fault, and
will be given tois
him.
fecalith.
Problems in Digestion, Metabolism and

Elimination/Nutrition
Lower GI series is a fluoroscopic procedure that
allows for examination of the Large intestines after
administration of a Barium Enema.
Rovsings is elicited by palpating the Left lower

quadrant and pain is manifested on the right lower
quadrant. It is seen in a patient with appendicitis.
Before a lower GI series nursing interventions

include withholding foods and fluids, and
administering a bowel preparation to thoroughly
cleanthe bowel.
Never administer a laxative or enema to a client

with suspected appendicitis because of the
possibility of rupture.
Important nursing intervention after Upper GI

endoscopy is withholding food and fluids until the
gag and cough reflex returns.
Never administer a pain medication to a patient

suspected with appendicitis until a final diagnosis
has been made, because this may mask the pain
that accompanies a ruptured appendix.
Before a fecal occult blood test, advise the patient

to avoid red meat, iron and high fiber for 1-3 days.
The most common location of crohns disease is the

terminal ileum.
Before any GI examination that involves

administration of contrast agents, note the
patients allergies to iodine, seafood and
radioopaque dyes.
The diet for a client with crohns disease is a low

fat, lactose free diet.
The most common location of Ulcerative colitis is
the sigmoid with Rectal involvement.
Gastric analysis is a procedure that aspirates the

contents of the stomach through a nasogastric tube
to measure the acidity of gastric secretions.
The predominant symptom of ulcerative colitis is

rectal bleeding.
Before a gastric analysis, instruct the patient not to

smoke for 8-12 hours before the test.
The diagnostic test to differentiate between

crohns disease and ulcerative colitis is
Colonoscopy with Biopsy.
Before a liver biopsy assess baseline

coagulation/clotting studies.
The diet recommended to avoid colon cancer is a

low fat, high fiber diet.
During a liver biopsy, position the patient supine

with arms over the head and instruct patient to
Exhale and hold his breath during insertion.
The key signs of colorectal cancer are (1)Change in

bowel pattern and (2)rectal bleeding.
Bile is produced in the liver and stored in the

gallbladder.
The assessment test that should be performed

annually after 40y/o to screen for colon cancer is
Digital Rectal exam.
The most common complication after a liver biopsy

is hemorrhage.
After a liver biopsy, position the patient on his
Right lateral side.
The most common cause of PUD is Helicobacter
Pylori infection.
The major diagnostic test for PUD is
EsophagoGastroDuodenoscopy (EGD).
The purpose of a Vagotomy (cutting the vagus
nerve) in a client with gastric ulcer is to reduce the
stomachs ability to produce acid.
The complication of gastric surgery that the nurse
should always monitor for is Dumping Syndrome.
To prevent dumping syndrome, the consumption of
high carbohydrates and liquids should be avoided.
Complications of PUD include Hemorrhage,
perforation and obstruction.
The purpose of radiation therapy before surgery in

the treatment of colon cancer is to reduce the size
of the tumor.
A common symptom of gastric cancer is a feeling of
fullness
The diagnostic test to determine gastric cancer is a
gastroscopy.
The assessment test used to diagnose hemorrhoids
is digital rectal exam.
The diet recommended for a client with
hemorrhoids is a high fiber diet.
The early signs of peritonitis are pain and a rigid
abdomen.
The client with cholecystitis typically has right
upper quadrant pain that may radiate to the right
scapula or shoulder; nausea; and vomiting
especially after eating a heavy meal.
- 1 -
Murphys sign is when a patient reacts to pain and

holds his breath on inspiration. It is common in
cholecystitis.
During colostomy irrigation, the irrigation bag

should not be suspended not more than 18 above
the stoma.
The most common test to diagnose cholecystitis is

abdominal ultrasound.
During colostomy irrigation, the irrigation catheter

should be inserted not more than 4 into the
stoma.
The major cause of pancreatitis is alcohol abuse.

The enzymes Amylase and Lipase are increased in
pancreatitis.
The laboratory results that signify pancreatitis are:
elevated amylase, lipase and glucose; decreased
calcium.
A patient with pancreatitis should be advised to
avoid alcohol and caffeine.
Cullens sign is bluish discoloration of the
periumbilical area in a patient with pancreatitis. It
is due to hemorrhage.
Turners sign is bluish discoloration of the (left)
flank area in a patient with pancreatitis. It is due
to hemorrhage.
The temperature of water used for colostomy

irrigation should be between 37.8C to 40.6C.
If the color of a stoma is much lighter than when
previously assessed, decreased circulation should
be suspected.
Laennecs (Alcoholic) cirrhosis is the most common
type of cirrhosis.
Hematemesis is a clinical sign of esophageal
varices.
Lactulose is used to prevent and treat hepatic
encephalopathy in portal hypertension.
The most common component of gallstones is
cholesterol.
The diagnostic test used for definitive diagnosis of

cirrhosis is Liver biopsy.
Obese women are more susceptible to gallstones

than any other group.
Before undergoing Paracentesis, the client should

be asked to void to minimize the risk of
puncturing/lacerating the bladder.
NOTES:
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The most serious complication of esophageal

varices is hemorrhage.
A pair of scissors should always be present at the
bedside of a patient with a Sengstaken Blakemore
tube.
In a patient with a sengstaken Blakemore tube, the
esophageal balloon should not be inflated greater
than 20mmHg.
A client with reflux (e.g., hiatal hernia, GERD,
achalasia) should remain upright after eating.
GERD is caused by a high fat diet, alcohol,
caffeine, peppermint, chocolate and theophylline.
Clients with diverticulitis should avoid foods with
seeds because of the possibility of being trapped
in the diverticula.
In a client who has an ileostomy or colostomy, diet
should include spinach and parseley because they
act as intestinal deodorizers.
The preferred site for a permanent colostomy is
the descending colon.
A client with a colostomy must establish a regular
irrigation schedule (once a day, same time each
day) so that regular emptying of the bowel occurs
without stomal discharge in between irrigations.
Pancreatic cancer may cause jaundice, Pain and
weight loss. The most common site is the Head of
the pancreas.
A client with an ileostomy shouldnt eat corn
because it may obstruct the opening of the pouch.
"Don't be afraid to take a big step. You

can't cross a chasm in two small jumps."
- 2 -
Matthew 28:20
I am with you always, to
the close of the age.
Health Teaching
The teaching process consists of four basic

steps: PREPARATION, PRESENTATION,
APPLICATION, REVIEW AND EVALUATION
Gerontics is the branch in care for the elderly

which emphasizes the nursing aspect of taking care
an elder person.
Principles of patient teaching always will start

with the decision of the priority needs of the patient.
Gerogogy/Geragogy
is
the
method
communicating and teaching an elder person.
Narrative discourse is to recount events, usually

in the past.
Gerontology is the branch of study wherein the

focus is more of the process of aging.
Hortatory discourse is to command, suggest or

propose.
Geriatrics is the branch in medicine wherein it

deals with the conditions and treatment of the
diseases common in elderly.
A case study is a type of teaching strategy which

it utilizes a controlled representation of a piece of
reality that learners can manipulate to better
understand the corresponding real situation.
In teaching an elder person, always use a

medium to low tone of voice.
Avoiding monopolies, encouraging quiet

members to talk, and tolerating some silence
should be the focus of the teacher to empower
students.
Role playing is a form of drama in which learners
spontaneously act out roles in an interaction
involving problems or challenges in human
relations.
Vitamin D is the most toxic vitamin.
Wernicke-Korsakoff syndrome is a condition
wherein the patient has vitamin B1 deficiency
secondary to alcohol consumption.
The RYB color code for dressing stands for RED,
YELLOW, BLACK.
The red means its inflamed, the yellow signifies
pus infection while the black tells you of the
necrotic tissues.
The best exercise for an osteoporotic woman is
the ISOKINETIC EXERCISE.
Ideally, health teachings should be given a day
prior to surgery.
Demerol is an opioid analgesic which also
causes vasoconstriction, thus, the nurse should
take first the blood pressure.
Diuretics should not be given before bedtime to
prevent nocturia episodes and frequent urinating
especially early morning.
of
In teaching a senile dementia, communicate in

simple words, short sentences, and a calm tone of
voice.
The nurse should instruct a patient having blood
transfusion to report chills, itching or rashes
immediately.
To prevent malnutrition, the daily recommended
milk consumption of Filipinos is 2-3 servings.
In oral glucose tolerance test, the nurse should
instruct the patient to avoid eating or drinking 8
hours prior to the diagnostic exam.
Osteoarthritis is a form of arthritis wherein it is a
degenerative disease of the joints evidenced by
heberdens and bouchards nodules.
Turnips are contraindicated for patients with
goiter.
the patient should report cold sweats, body
weakness and trembling immediately if taking oral
hypoglycemic drugs.
The primary nursing focus of a patient with
Alzheimers disease is safety.
Traditional signs of death include: cessation of
apical pulse, biots respiration, diminished reflexes.
Brown spots or liver spots are considered to be
normal
in
elder
persons
secondary
to
hyperpigmentation.
Make progress one time and it makes you happy.
Make progress day after day, week after week and it
makes you a champion.
- 1 -
1 Peter 5:7
Casting all your care
upon him; for he careth
for you.
Integrated Community Health Nursing
Public health by C.E. Winslow is defined as science and art of

promoting health, preventing disease and prolonging life
through organized community efforts.
Ecosystem influencing optimum level of functioning include:
political, behaviour, heredity, health care delivery system,
environment, socio-economic.
Core business of public health: disease control, injury
prevention, health protection, healthy public policy, promotion
of health
Public health nursing: special field of nursing that combines
skills of nursing, public health and some phases of social
assistance
CHN by Ruth Freeman: a service rendered by a professional
nurse with communities, groups, families, individuals at home,
in health centers, in clinics, schools, places of work for the
promotion of health, prevention of illness, care of the sick and
rehabilitation.
Lillian Wald coined the term public health nursing to denote a
service available to all people.
Health care delivery system: private and public sector
Roles of the DOH: Leadership in health, Enabler and capacity
builder, Administrator of specific services.
Vision of the DOH: Leader, Advocate and Model of promoting
Health for All in the Philippines.
Mission of the DOH: Guarantee Equitable, Sustainable and
Quality health for all Filipinos
Goal: Health Sector Reform Agenda (HSRA)
Framework for implementation of HSRA: FOURmula One for
Health
Goals of FOURmula One: Better health outcomes, More
responsive health systems, equitable halth care financing
Elements of FOURmula One: Health financing, Health
Regulation, Health Service Delivery, Good Governance
Roadmap for All Stakeholders in Health: National Objectives for
Health 2005 to 2010
Inter Local Health System: system of health care in which
individuals, communities and all other health care providers in a
well-defined geographical area participate together in providing
quality, equitable and accessible health care with Inter Local
Government Unit partnership as the basic framework.
Composition of the Inter Local Health Zone (ILHZ): people,
boundaries, health workers, health facilities.
Primary Health Care (PHC): essential health care made
universally Accessible to individuals and families in the
community by means Acceptable to them at a cost they can
Afford
Primary Health Care was declared during the First International
Conference on Primary Health care in Alma Ata, 1978.
LOI 949 is the legal basis of Primary health care in the
Philippines signed in October 19, 1979 and has an underlying
theme Health in the Hands of the People by 2020.
Concept of PHC is characterized by partnership and
empowerment of the people that shall permeate as the core
strategy in the effective provision of essential health services.
Framework for meeting the goal of primary health care is
organizational strategy, which calls for active and continuing
partnership among the communities.
4 pillars of PHC: Active community participation and
involvement; inter and intra sectoral linkages, use of
appropriate technology and support mechanism made available
Type of health worker in the community vary depending upon:
available manpower resources, local health needs and problems,
political and financial feasibility
2 levels of primary health care workers: Village or Barangay
health workers and Intermedieate level health workers
Categories of health problems: health deficit, health threat,
foreseeable crisis, wellness state.
Health deficit occurs when there is a gap between actual and

achievable health status.
Health threats are conditions that promote disease or injury.
Foreseeable crisis include stressful life events
Wellness state is based on current competencies and
performance, clinical data and explicit expression of desire to
achieve higher level of state
Community health nursing problem categories: health status
problems, health resource, and health related problems
Planning in CHN includes the ff steps: goal setting, constructing
a plan of action, and developing operational plan
Evaluation utilizes three classic frameworks: structural
elements, process elements, outcome elements.
Home visit is a family-nurse contact which allows the health
worker to assess the home and family situation in order to
provide the necessary nursing and health related activities.
Purposes of home visit: give nursing Care, Assess living
conditions, establish a close Relationship with the public,
Educate clients, use the inter-referral system and promote
Service utilization
Principles in planning for a home visit: must have a Purpose,
make use of all Information about the clients, give priority to
Needs of the family and plan should be Flexible
Guidelines to consider regarding the frequency of home visits:
Needs, Acceptance, Policy of the agency, Other agencies and
health personnel involved in clients care, Past services given to
family and Ability of family to recognize their own needs
Bag technique is a tool by which the nurse will be able to
perform a nursing procedure with ease and deftness, to save
time and effort, with the end view of rendering effective
nursing care\
Public health bag is an essential and indispensable equipment of
the public health nurse which she has to carry along during her
home visits.
Principles of bag technique: minimize or prevent spread of
infections; save time and effort, show effectiveness of care, can
be performed in a variety of ways.
Important points to consider in the use of the bag (4 Cs):
Complete contents, Clean, Contact with patients articles is
avoided, Convenient arrangement
Community organizing stages (DOH): Community analysis, Design
and Initiation, Implementation, Program MaintenanceConsolidation, Dissemination and Reassessment
Community analysis components: demographic, socio-economic
profile, health risk profile, health/wellness outcome profile,
survey of current health promotion programs, studies conducted
in certain groups.
Community organizing steps (MAGLAYA): Preparatory phase,
Organizational phase, Education and training, Collaboration,
Phase-Out
Ottawa Charter for Health Promotion defines health promotion
as the process of enabling people to increase control over and to
improve their health.
Action areas for health promotion: Build healthy public policy,
Create supportive environments, Strengthen Community action,
Develop personal skills, Reorient health services
WHO principles of health promotion: involves the population as
a whole, directed towards action, combines diverse but
complimentary methods, aims at effective and concrete public
participation, a societal and political venture.
Epidemiologic triangle: agent, host and environment
Agents of disease: Infectious agents, Chemical Agents, Physical
Agents, Nutritive elements
Host factors influences exposure susceptibility or response to
agents
- 1 -
Intrinsic factors include genetics, age, sex, ethnic group,

physiologic, immunologic experience, pre-existing disease,
human behaviour.
Environmental factors influences existence of the agent,
exposure or susceptibility to agents.
Three components of the environment: physical, biological and
socio-economic environment
Patterns of disease occurrence: sporadic, endemic, epidemic,
pandemic
Sporadic is the intermittent occurrence of a few isolated and
unrelated cases in a given locality
Endemic occurrence is the continuous occurrence throughout a
period of time of the usual number of cases in a given locality
Epidemic occurrence is of unusually large number of cases in a
relatively short period of time
Pandemic is the simultaneous occurrence of epidemic of the
same disease in several countries.
Age is the single most useful variable associated in describing
the occurrence and distribution of disease.
Males have a higher mortality rates than females for a wide
range of diseases. Females have higher morbidity rates.
National Epidemic Sentinel Surveillance System (NESSS) is a
hospital based information system that monitors the occurrence
of infectious diseases with outbreak potential.
Vital Statistics refers to the systematic study of vital events such
as births, illnesses, marriages and deaths.
Statistics of disease (morbidity) and statistics of deaths
(mortality) indicate a state of health of a community and the
success or failure of health work.
Rate shows the relationship between a vital event and those
persons exposed to the occurrence of said event.
Ratio is used to describe the relationship between 2 numerical
quantities or measures of events without taking particular
considerations to time or place.
Field Health Services and Information System has 4 components:
Treatment Record, Target/Client Lists, Reporting Forms and
Output reports
Treatment Record is the fundamental building block or
foundation of FHSIS.
Target/Client list constitute the second building block of the
FHSIS.
4 major noncommunicable diseases: cardiovascular diseases,
cancer, COPD, DM.
3 major risk factors: tobacco smoking, physical inactivity and
unhealthy diet.
Key intervention strategies for NCD prevention and control:
Establishing program direction and infrastructure; Change
environments; Change lifestyle; Reorient health services
Physical activity of moderate intensity at least 30 mins should
be done most days of the week.
Physical activity of vigorous intensity at least 30 mins should be
done 3 or more days of the week.
Vision 2020: Right to Sight; a global initiative to eliminate
avoidable blindness by year 2020.
The 5 preventable/ treatable conditions causing blindness are:
cataract, refractive errors and low vision, trachoma,
onchocerciasis and childhood blindness.
4 facets of mental health as a public health burden: Defined
burden, undefined burden, hidden burden, future burden.
Defined burden refers to the burden affecting persons with
mental disorders.
Undefined burden refers to the portion of the burden relating to
the impact of mental health problems to persons other than the
individual directly affected.
Hidden burden refers to the stigma and violations of human
rights.
Future burden refers to the burden in the future resulting from
the aging of the population, increasing social problems and
unrest inherited from existing burden.
Environmental health is a branch of public health that deals
with the study of preventing illnesses by managing the
environment and changing peoples behaviour to reduce
exposure to biological and non-biological agents of disease and
injury.
3 preventive strategies for the epidemiological triad: Change
peoples behaviour; manipulate the environment; increase
mans resistance or immunity to disease agents.
Level I water supply facilities: (point source) protected

well, developed spring
Level II water supply facilities: Communal faucets or
water stand posts
Level III water supply facilities: Waterworks system or
individual house connections
Level I toilet facilities: pit latrines, reed odourless earth
closet, pour-flush toilet and aqua privies
Level II toilet facilities: water sealed and flush type with
septic vault/tank disposal facilities.
Level III toilet facilities are water carriages connected to
septic tanks and/or to sewerage system to treatment
plants.
Four rights in food safety: Right Source, Right
Preparation, Right Cooking, Right Storage
Rule in food safety: When in Doubt, Throw it out!
Sentrong Sigla Movement is joint project of the DOH and
LGU with the goal of providing quality health care
services and facilities.
Level and scope of Certification include: Basic SS
certification, Specialty Awards, Award for excellence
Basic SS certification: minimum input, process and
output standards for integrated public health services for
4 core programs, facility systems, regulatory functions
and basic curative services
Specialty awards: second level quality standards for
selected 4 core public health programs
Award for Excellence: highest level quality standards for
maintaining Level 2 standards for the 4 core public
health programs and level 2 facility systems for at least 3
consecutive years.
Scope and structure of Sentrong Sigla Quality standards
Level 1: Facility and systems standards; Integrated Public
Healht Function Standards; Basic Curative Function
standards and Regulatory Function Standards
Scope and structure of Sentrong Sigla Quality standards
Level II: Local health systems development and
Integrated public health functions.
Disaster: serious disruption of the functioning of a
society, causing widespread human, material or
environmental losses
Emergency: any occurrence which requires an immediate
response
Hazards: any phenomenon which has the potential to
cause disruption or damage to humans and their
environment
Risk level of loss or damage that can be predicted from
a particular hazard affecting a particular place at a
particular time from the point of view of the community
RA 7719 Blood services act of 1994
Walking blood donors: potential donors who will be on a
list with their blood types and are on call when
needed.
Botika ng Barangay refers to a drug outlet managed by a
legitimate Community Organization, NGO and LGU with a
trained operator and a supervising pharmacist and
specifically licensed by the Bureau of Food and Drugs to
sell, distribute and make available low-priced generic
OTC drugs, and recently, selected medication for chronic
diseases such as DM, HPN and Asthma.
One doesn't recognize the really

important moments in one's life until
it's too late.
- 2 -
1 Chronicles 22:13
Then you will have success if you are
careful to observe the decrees and laws
that the LORD gave Moses for Israel. Be
strong and courageous. Do not be afraid
or discouraged.
Nursing Jurisprudence & Code of Ethics in Nursing

SALIENT ASPECTS OF THE PHILIPPINE NURSES ACT LAW (RA
9173) AND LEGAL RESPONSIBILITIES OF NURSES
COMPOSITION OF BON
(Section 3)
ONE (1) CHAIR/CHAIRPERSON
SIX (6) MEMBERS OF THE BOARD
QUALIFICATIONS OF BON
(Section 4)
Natural born Filipino Citizens and resident of the
Philippines
Be a member of good standing of the accredited
professional organization of Nurses;
Be a registered Nurse and a holder of Masters
degree in Nursing, education or other allied Medical
Profession conferred by a College or University duly
recognized by the government.
QUALIFICATIONS OF BON
Have at least 10 years of continuous practice of the
profession prior to the appointment. That the last 5
years of which shall be in the Philippines.
Not have been convicted of any crime involving
moral turpitude.
QUALIFICATIONS FOR ADMISSION IN THE NLE
(Section 13)
FILIPINO CITIZEN (Natural Born or Naturalized
Filipino Citizen)
BSN GRADUATE (Transcript of record plus RLE
Requirements)
GOOD MORAL CHARACTER
QUALIFICATIONS OF THE CLINICAL INSTRUCTORS
(Section 27)
ONE (1) YEAR CLINICAL EXPERIENCE
RN, MAN or RN, MA.ED or RN with ALLIED MEDICAL
PROFESSION conferred by a College or University
duly recognized by the government.
QUALIFICATIONS OF THE DEAN (Section 27)
FIVE (5) YEARS OF CLINICAL PRACTICE
RN, MAN
QUALIFICATION OF CHIEF NURSE
AT LEAST FIVE (5) YEARS EXPERIENCE IN
NURSING SERVICE ADMINISTRATION

NINE (9) UNITS IN MANAGEMENT AND
ADMINISTRATION COURSES.
Administrative Supervision of the Board, Custodian
of its Records(Section 8)
POWERS OF BON (Section 9)
Conduct the Licensure Examination
Issue, suspend or revoke Certificates of Registration
for the practice of Nursing
Monitor and enforce quality standards of Nursing
Practice in the Philippines.
Ensure quality Nursing Education
Quasi- judicial power
Promulgate the Code of Ethics
Quasi Legislative power
Executive Power
REMOVAL OR SUSPENSION OF BOARD MEMBERS
(Section 11)
Continued neglect of duty
Commission or toleration of irregularities in the
Licensure examination
Unprofessional, immoral or dishonorable conduct.
Qualification before Appointment to BON (Section 5)
RESIGN from ANY EMPLOYMENT.
NO PECUNIARY INTEREST
DUE PROCESS OF THE LAW
It is a law that HEARS first before imposing a
punishment.
TRIAL or HEARING before punishment
TERM OF OFFICE (Sec. 6)
BON SHALL SERVE FOR A PERIOD THREE (3) YEARS.
THREE KINDS OF APPOINTMENT
REGULAR APPOINTMENT
AD INTERIM
HOLD OVER
BILL OF RIGHTS OF PATIENTS
RIGHT TO INFORMATION/CONSENT
RIGHT TO MAKE DECISIONS/AUTONOMY
RIGHT TO PRIVACY AND CONFIDENTIALITY
RIGHT TO QUALITY CARE.
REVOCATION AND SUSPENSION OF LICENSE(Section 23)
SUPERVISORY OR MANAGERIAL POSITION

RN, MAN
QUALIFICATION OF THE CHIEF NURSE IN THE
MILITARY
AT LEAST FIVE (5) YEARS OF SUPERVISORY OR
MANAGERIAL POSITION
RN, MAN and MASTERS DEGREE IN THE MILITARY
STAFF COURSE
SUPERVISOR OR MANAGERIAL POSITION
RN
TWO (2) YEARS OF EXPERIENCE OF GENERAL
For unprofessional or unethical conduct

For gross incompetence and serious ignorance
For the use of fraud, deceit, false statement in
obtaining a Certificate of registration
For violations of the Code of Ethics for Nurses
Malpractice
Negligence
Practice of the Profession
License
permission to practice the profession
-granted when the applicant meets the
requirement established by the STATE Law
and the Administering Agency.
- valid during the life of the holder unless it
is revoked or suspended.
- considered as a PRIVILEGE./JURISDICTIONAL
- 1 -
When can you be allowed to practice outside the territory

of the Phils using your local license?
Under Section 20 by RECIPROCITY and 21 by SPECIAL
PERMIT of the RA 9173.
RECIPROCITY
SPECIAL PERMIT
Well known Specialists or outstanding experts.
(Internationally recognized)
Free Medical Mission
Exchange of Professors
LAWSUITS
- ARE PROCEEDINGS IN COURT.
PURPOSE: to enforce a right to redress a wrong
PARTIES:
a. Criminal action
-Complainant
-Respondent
b. Civil action
-Plaintiff
-Defendant
Important Terms
Subpoena-court summons is served directing a witness to
appear and give testimony on the date and time ordered.
Subpoena duces tecum- served to a witness requiring him
to bring records, papers or charts
Testimony of facts testifying only on what he knows
based on facts.
Testimony of opinion- may only be given by expert
witness
Expert witness- one who is qualified to testify based on
special knowledge, skills and training.
Perjury- false swearing under oath.
Privilege against self incrimination-right not to answer
any question that will incriminate him/her.
Hearsay evidence- repetition of what the witness has
heard others say.
Ante mortem statement- dying declarations, considered
hearsay except when made by a victim of a crime.
MORAL TURPITUDE
LIABILITIES
PRINCIPAL
ACCOMPLICE ACCESSORY
CONTRACT
It is an agreement between two persons which creates an
obligation recognized by the law.
Two kinds of Contract
According to Format
According to Statement
contract
According to format
1. Formal Contract
2. Informal Contract
According to Statement
1. Expressed Contract
2. Implied Contract
WILL
Testator/testatrix- is a person who makes the will.
Probate- to prove the validity of the will in Court is
known as probate.
Escheat when his property is transferred in the name of
the Republic of the Philippines.
TWO KINDS OF A WILL
Holographic will- when the testator entirely writes down
the will. Date and signature of the testator should be
indicated in the will.
Notarial/nuncupative/authenticated will- when the
testator orally makes the will and will ask someone to write it
down or him.
will
Two kinds of Succession
Testate when there is a will executed by the testator.
Intestate- when there is no will executed by the testator.
Circumstances that affect criminal liabilities

Exempting Circumstance
1. imbecile or insane person, unless he acted with
lucid interval.
2. the person is under 9 yrs of age.
3. over 9 yrs but under 15 unless he/she acted with
discernment
4. when it is a mere accident
5. when the person acted under the impulse of an
uncontrollable fear.
6. when the person acted under the compulsion of an
irresistible force.
Mitigating Circumstance
When the offender is under 18 yrs or over 70 yrs of age
When there is voluntary surrender
When there is passion/ obfuscation
When there is sufficient provocation
When the person is deaf, mute and dumb, blind
when there is no intention to commit so grave a wrong as
the one committed
Any kind of mental illness that will diminish will power
Aggravating Circumstance
When on takes advantage of public position
When there is an abused of confidence
When the crime is committed inside the Church
When the crime is committed on the occasion of fire,
shipwreck, earthquake, epidemic or other calamity.
When it is committed because of a price, reward
When it is committed in times of natural calamities
When it is committed with evident premeditation
When it committed with craft, fraud and disguise
Justifying Circumstance
When there is an unlawful aggression
When the person is under imminent danger
When the means employed in order to prevent or to
repel the aggression must be reasonable.
RES IPSA LOQUITUR (THE THING SPEAKS FOR ITSELF)
The nurse failed to make used of appropriate judgment
The instrument used is within the exclusive control of
the nurse
There is lack of voluntary participation on the part of the
patient.
RESPONDEAT SUPERIOR
(Let the master answer for the liability of his employee)
There must be an employer-employee relationship.
The liability of the employee must be worked related.
REAPPLICATION FOR A REVOKED LICENSE
One has the right to reapply for a revoked license after
the expiration of a MAXIMUM PERIOD of FOUR (4) years in the
interest of justice and equity.
Provided that the reasons for the revoked license had
already been cured and corrected.
INACTIVE NURSES
Failure of one to practice the nursing profession for FIVE
CONSECUTIVE YEARS will make one to be inactive.
Requirements to be backed in nursing profession:
a. ONE MONTH DIDACTIC TRAINING
b. THREE (3) MOS. PRACTICUM
IN A HOSPITAL ACCREDITED BY BON.
OATH TAKING
Section 16
All qualified candidates are required to take the oath
before BON or to any GOVERNMENT OFFICIAL AUTHORIZED to
administer the oath.
EPIKIA
Taking or treating some acts as exception to the rule.
E.G. A nurse is confronted with a dangerous patient and a
doctor cannot be contacted, then she might use restraints in
emergency pursuant to the principle of epikia.
Stare decisis
Stand by the decision of the Court
Nobody can predict the future but its worth trying to

influence the direction.
- 2 -
Philippians 4:13
I can do everything
through him who gives
me strength.
NEUROLOGICAL
Charcots triad
The brain is contained within the skull (or

cranium)
o Scanning speech
3 coverings (meninges are for support, protection

& nourishment)
1. dura mater
2. arachnoid mater
3. pia mater
o Nystagmus
2 hemispheres
1. left side controls the right side
a. analysis
b. calculation
c. problem solving
d. verbal communication
e. interpretation
f. language
g. reading
h. writing
2. right side controls the left side
a. perception of physical environment
b. art
c. nonverbal communication
d. music
e. spiritual aspects
o Intention tremors
o Brudzinskis
o Kernigs
o Nuchal rigidity
o Opisthotonus
The most common form of stroke is ischemic

stroke which occurs in 10% of the population
Paralysis
o Ascending: Guillan-Barret syndrome
o Descending: Myasthenia Gravis
o Assymetrical onset of paralysis
Tremors
o Intentional: Multiple sclerosis
o Resting: Parkinsons
Cushings triad
o Hypertension
o Bradycardia
o Bradypnea
Drug of choice:
o Myasthenia gravis: pyridostigmine
(Mestinon)
o Parkinsons disease: leveodopa (L-Dopa) +
carbidopa (Sinemet)
o Alzheimers disease: donepezil (Aricept);
tacrine (Cognex)
o Multiple sclerosis:
if relapsing-remitting
interferon beta (Betaseron,
31 pairs of Spinal Nerves

a. cervical 8
b. thoracic 12
c. lumbar 5
d. sacral 5
e. coccygeal 1
Signs of meningeal irritation
Avonex) [First line]

glatiramer (Copaxone)
[Second line]
for acute exacerbations

prednisone (Delasone)
SCI at the C3-C5 level leads to respiratory

paralysis due damage to the phrenic nerve
SCI at the C6-T1 level leads to quadriplegia
SCI at the T6 and above causes autonomic

dysreflexia
Common symptoms of autonomic dysreflexia:

High blood pressure.
Seeing spots or blurred visions.
Pounding headache.
Nasal congestion.
Flushed face.
Red blotching on the neck and chest.
Sweating above level of injury.
Goose bumps.
Cool, clammy skin.
- 1 -
Nausea
Ipsilateral: on the same side as the spinal cord

lesion(hemiplegia)
Contralateral (on the opposite side)
3 classifications of reflex activity

1. Muscle stretch or DTR
2. Superficial or cutaneous
3. Pathological
Sympathetic
a. Activated by stress
b. Increased epinephrine
c. Fight or flight response
d. Increased HR, BP
e. VC
f. Decreased peristalsis & decreased
secretions of digestive juices &
saliva
g. Dilated pupils
h. Increased sweat
Parasympathetic
a. Restores & maintains vital body
functions
b. Slows HR
c. Increased GI activity
Activates bladder & bowel evacuation
Reflexes:
1. DTR: involuntary contractions of muscles or
muscle groups responding to brisk
stretching near the insertion site
a. Using a reflex hammer
b. Achilles, patellar, biceps, triceps
2. Superficial reflexes: elicited by irritating
the skin on the area being assessed
a. Plantar (Babinskis) is elicited using
the handle of the hammer
i. Indicates
corticospinal
disease
b. Abdominal reflex is assessed using
the end of the cotton applicator
i. Upward and outward
contraction of the upper abs
should occur
ii. Contraction of the lower abs
c. Results
i. Diminished
ii. Absent
SEIZURES DISORDERS
Generalized
1. Tonic-clonic
seizures:
rigid
tonic
contractions of muscles & loss of postural
control followed by a clonic stage of
intermittent contraction & relaxation
o
Incontinence is common
2. Absence seizures: loss of conscious
activity without muscle involvement
3. Myoclonic seizures: very mild, sudden,
involuntary muscle contractions or maybe
rapid, forceful movements
o
Trunk or extremities
o
No LOC
Partial
1. Simple: finger, hand, ability to talk or
smell; no LOC
2. Complex: LOC; with cognitive, affective,
psychosensory, motor symptoms
o Automatisms or mechanical,
repetitive motor behavior
performed unconcsciously
Lip smacking
o Auras are peculiar sensations that
precede the attack
Taste, smell, sight, or sound
o Dizziness or funny feelingx
ECF
o
Major cation: Na [135-145 mEq/L]
Major anion: Cl [96-106 mEq/L]
Major cation: K [3.5-5.5 mEq/L]
Major anion: HP []
ICF
NOTES:
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"This one step -- choosing a goal and

sticking to it -- changes everything."
- 2 -
Psalm 28:7
"The LORD is my strength and
my shield; my heart trusts in
him, and I am helped..
Non-Communicable Disease Prevention and Control;Environment HEalth
I. ENVIRONMENTAL HEALTH
Environmental Health
Branch of public health
Study of diseases/ illnesses
Preventive Strategies
1. Change mans behavior
2. Manage the environment
3. Increase immunity
Environmental Sanitation
Study of all factors in mans physical environment
Has effect of well-being and survival
Environmental and Occupational Health Office
Promotion of healthy environmental conditions
Water Supply (Approved Facility)
Level 1: Point Source
a. Spring and Well with outlet
b. No distribution system
c. 15 to 25 households
d. 250 meters away
e. 40 to 140 liters of water
Level 2: Reservoir and Piped distribution
a. Communal faucet and Stand posts
b. 25 meters away
c. Average of 100 households
d. 40 to 80 liters of water
Level 3: Pipe distributor network and Household
taps
a. Waterworks system
b. Individual house connection
c. Minimum treatment
Excreta and Sewage Disposal
Level 1 Toilet facility
a. Non-water carriage / requiring small amount
of water
b. Pour flush toilet and aqua previes
a. On-site toilet facility
b. Water sealed and flush type
c. With septic vault and /or tank disposal
a. Water carriage types
b. Connected to septic tanks
c. Sewerage system to Treatment plant
Food Sanitation
Four Rights in Food Safety
1. Right Source- identify proper sources
2. Right Preparation- cleaning and preparation
3. Right Cooking- cooking temperature for meat
products is 70C- re-heating 70C
4. Right Storage- room temperature 4-5hours
- warm storage 60C and above
- cold storage 10C and below
Rule in Food Safety: WHEN IN DOUBT. THROW IT

OUT
Food Establishment Classification
1. Class A Excellent
2. Class B Very Satisfactory
3. Class C Satisfactory
Environmental Laws and Policies
R.A 6969 Toxic Substance and Hazardous
and Nuclear Waste Control Act of 1990
R.A 8749 Clean Air Act
R.A 9003 Ecological Solid Waste
Management Act of 2000
R.A 9275 Clean Air Act of 2004
P.D 856 Sanitation Code of the
Philippines
Nursing Responsibilities
1. Health Education
2. Actively Participate in training
component
3. Deworming activities
4. Coordinate Programs
5. Advocate and Facilitator
6. Environmental sanitation
campaign
7. Role model
8. Interpretation and
Implementation of PD 856
9. Assist in disaster
Management.
II. NON-COMMUNICABLE DISEASE PREVENTION AND CONTROL
FOUR MAJOR NON-COMMUNICABLE DISEASE

1. Chronic Obstructive Pulmonary Diseases
2. Diabetes Mellitus
3. Cardiovascualr Diseases
4. Cancer
D.A.L.Y
(Disability Adjusted Life Year)
Number of years of healthy life lost to premature
death
Risk Factors and Prevalence Rate

Risk Factor
Physical Inactivity
Smoking
Hypertension
Hypercholesterolemia
Obesity
Diabetes
Prevalence
Rate
60.50%
34.80%
22.50%
8.50%
4.90%
4.60%
- 1 -
D.O.H Goal
1. Analyze the social, economic, political and
behavioral determinants
2. Reduce exposure of individuals and population
to major determinants
3. Strengthen health care for people
Approaches to NCDs
1. Comprehensive Approach focus on Primary
Prevention
2. Community Based Approach
4. Integrated Approach
Key Intervention Strategies

1. Establishing program direction and
infrastructure
2. Changing Environments
5. Changing Lifestyle
6. Reorienting health services
Role of Public Health Nurses

1. Health Advocate (promote active community
participation)
2. Health Educator (essential tool to achieve
community health)
3. Health Care Provider (care provider to clients
and render different level of care)
4. Community Organizer (community health
development and empowerment)
5. Health Trainer (provides technical assistance)
6. Researcher (provides valuable information and
prevents irrelevant interventions)
4. Cancer Screening
C- change in bladder and bowel
habits
A- a sore that does not heal
U- unusual bleeding or discharge
T- thickening or lumping in the breast
and elsewhere
I- indigestion and difficulty in
Swallowing
O-obvious change in wart or mole
N- nagging cough or hoarseness in
voice
U- unexplained anemia
S- sudden weight loss
5. Chronic Obstructive Pulmonary Diseases
> 50 years old
> smoking for many years
> symptoms of progressive and
increasing shortness of breath on
exertion
>chronic productive cough
Risk factors
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Tobacco Use
Radiation Exposure
Second-hand smoke
Excessive alcohol intake
Chronic irritation
Vitamin A deficiency
Poor Nutrition
Weakened Immune system
Occupational exposure
Obesity
11. Age
Risk Assessment and Screening Procedures

1. Cigarette Smoking
2. Nutrition and Diet
3. Overweight / Obesity
4. Physical Inactivity and Sedentary
5. Lifestyle
6. Excessive Alcohol Drinking
Screening Guidelines and Procedures
1. Hypertension
Classification according to JNC-7
Category
BP reading
Normal
<120 / < 80
Pre-hypertension
120-139 /80 89
Hypertension 1
140-159 / 90-99
Hypertension 2
160 / 100
2. Blood Cholesterol
Level
<200mg/100ml
200-239mg/ 100ml
240mg/100ml and
above
Interpretation
Normal
Elevated
Elevated (at risk)
3. Diabetes Mellitus
Fasting Blood Sugar Values
Result
Interpretation
109 mg%
Normal
110-125 mg%
IGT
126 mg%
Possible DM
Diabetes Mellitus
1. Type I (Insulin Dependent DM)
= Juvenile DM/ Juvenile Onset
DM/ Ketosis Prone
DM/Idiopathic
2. Type II (Non-Insulin Dependent DM)
= Adult onset/ Maturity onset DM/ Ketosis
resistant DM
Risk factors
1. Family history
2. Obesity
3. Lifestyle
4. Previously identified IGT
5. History of gestational DM
Criteria for DM
1. symptoms of DM plus RBS >200mg/dl
2. FBS >126 mg/dl
3. Two-hour blood sugar > 200mg/dl during OGTT
Chronic Obstructive Pulmonary Diseases
= difficult expiration
= use of accessory muscles f expiration
1. Chronic Bronchitis
2. Emphysema
3. Asthma
Primary Cause: Smoking

Contributory
1.
2.
Air pollution
Occupational exposure to noxious dusts and gases
Diagnosis: Spirometry
Since light travels faster than sound, people appear bright
until you hear them speak.
- 2 -
Psalms 118:8-9
"It is better to trust in the Lord than
to put confidence in man. [It is]
better to trust in the Lord than to
put confidence in princes.
Normal Pediatric Nursing
Growth is the increase in size of a structure. Human growth is orderly and

predictable, but not even; it follows a cyclical pattern. Development is
the maturation of physiologic and psychosocial systems to more complex
state.
Phylogeny: development or evolution of a species or group; a pattern of
development for a species. Ontogeny: development of an individual
within a species
G & D occurs in cephalo caudal meaning development occurs throughout
the bodys axis. Example, the child must be able to lift the head before
he is able to lift his chest.
Proximo-distal is devpt that progresses from center of body to the
extremities. Example, a child is able to achieve control from the arm to
the fingertips as proven in the development of prehensile capability.
During the oral stage of development, the infant receives satisfaction,
relieves tension and derives pleasure from sucking and chewing. Non
gratification results to fixations like smoking and excessive gum chewing.
To establish and maintain patency of the airway, suctioning is done 4
5sec but not more that 10 sec in term babies, less than 5 sec in pre term
babies. Suctioning is always mouth before the nose to prevent Gasp
reflex.
A NB should be positioned to the R side to increase pressure to the L side
of the heart. This position favors the closure of Ductus Arteriosus and
Foramen Ovale, and gastric emptying thereby preventing reflux of gastric
contents and aspiration
Supine position is recommended for infants above 3 mos. Prone position
is contraindicated because it may predispose the infant to SIDS.
Temp of the NB at birth is 36.4- 37.2 o C. Their temperature is usually
unstable and takes 6-8 hours to stabilize.
Factors that influence circulatory changes after birth are: Lung expansion
and cutting of the umbilical cord.
The purposes of breastfeeding includes:BONDING - a special mutual
relationship between mother and infant ideally started on the FIRST
PERIOD OF REACTIVITY. It also FACILITATES RELEASE OF COLOSTRUM AND
BREAST MILK, STIMULATES PRODUCTION OF PROLACTIN AND OXYTOCIN
and PREVENT JAUNDICE
APGAR scoring is primarily done to determine the degree of acidosis and
the need for CPR and to evaluate ability of the NB to adjust
extrauterinely
The Silvermann Andersen scoring is done to determine the degree os
respiratory distress. This is commonly done to high risk babies as
necessary.
IDENTIFICATION in NBs is important and done preferably in the presence
of the parents. Several methods of identification include Double
banding, finger and footprints and birthmarks like hemangiomas.
Initial bathing is done using H20 with non-alkaline based soap to prevent
destruction of acid mantle of the skin. Light oil is used primarily only to
allow spread of vernix caseosa. Antimicrobial solution only when there is
active infection.
Cord care principles include sterile clamping using Betadine and 70%
alcohol to prevent OMPHALANGIA. It may be removed after 24- 36 hours
if in the hospital.
Vit k is given intramuscularly with a dose of 1 mg for term NBs and .5
mg in pre terms. Ideal site include the thigh muscles, Vastus lateralis and
Rectus Femoris.
Correct sites for PR taking in NBs are the Apical pulse, Brachial and
Femoral pulse. if weak or absent, a condition is present.
BP of NBs is 80/46 mmHg at birth, at 10 days maybe 100/50 mmHg.
Normally, their BP is higher in the LE and lower in the UE and can be
taken by Doppler or Flush methods.
In Physical assessment, a NBs abdomen is shaped like a dome and
cylindrical. A SCAPHOID shape indicates DIAPHRAGMATIC HERNIA.
The liver of a NB is palpable 2-3 cm BELOW RIGHT COSTAL MARGIN, the
kidneys at about 1-2 cm above umbilicus and the spleen on the left
quadrant
Breastfed babys stool is golden yellow, mushy and soft, has a sweet
odor, and passed every after breastfeeding. Bottle fed baby stool is pale
yellow, hard and formed, has an offensive, foul odor and passed once a
day
Care for infants with cardiac anomalies include: Improving the efficiency
of cardiac function thereby increase the cardiac output, decreasing the
cardiac workload, decreasing edema and Improving tissue perfusion.
In fetal circulation, foramen ovale is the opening b/n two atria, ductus
venosus is the shunt from liver to the inferior vena cava, and your ductus
arteriosus is the shunt from the pulmonary artery to the aorta.
during the feto-placental circulation, the pressure in the heart is much
higher in the right side, but once breathing/crying is established, the
pressure will shift from the R to L side, and will facilitate the closure of
the Foramen Ovale.
In an infant, feeding problems such as fatigue, tachypnea and irritability
may be signs of congenital heart defects. Infants with congenital heart
defects are at higher risks for heart failure.
Blalock-Taussig is just a temporary or palliative surgery which creates a
shunt between the aorta and pulmonary artery so that the blood can
leave the aorta and enter the pulmonary artery and this oxygenating the
lungs and return to the left side of the heart, then to the aorta then to
the body.
Mongolian spots are stale grey or bluish patches of discoloration

commonly seen across the sacrum or buttocks due to accumulation of
melanocytes and they disappear in 1 year. They are not linked to steroid
use or pathologic conditions.
NBs Lose about 5 to 10% of their weight day 2 3 after birth and regain it
within 10 days. Their weight gain is 28g /day in the first 6 months,
14g/day from 6 months to 12 months.
A normal pattern of weight gain in young infants is: 2x in 6 months, 3x in
1 year and 4x in 2 year.
NBS involves several types of testing. Phenestix test is a dxtic which uses
a fresh urine sample (diapers) and mixed with ferric chloride. If (+), there
will be a presence of green spots at the diapers. Guthrie test is another
test for PKU and is the one that mostly used. The specimen used is the
blood and it tests if CHON is converted to amino acid
infants have greater body surface area than adult, increasing their risk to
F&E imbalances. Also infants cant concentrate a urine at an adult level
and their metabolic rate, also called water turnover, is 2 to 3 times
higher than adult. Plus more fluids of the infants are at the ECF spaces
not in the ICF spaces.
1 month old infants can lift their heads, respond to sound, see black and
white patterns. Reflexes are apparent and indicates their neurologic
maturity.
2 month old infants vocalize by cooing and gurgling, hold their head at 45
deg angle, show social smile and appreciate mobile toys. Extrusion reflex
starts, and they may start mini push ups. 3 month old infants shows
minimal head bobbing, and holds head for a longer period of time.
4 month old infants can hold head without lagging, may have eruption of
first tooth, can turn to 1 side. They appreciate teething toys, nibbling
and rattles.
5 month old infants amuse them selves by playing with hands and feet,
may distinguish BOLD colors, recognize their name and starts to turn to
new sound. Mouthing objects and increased salivation due to teething
persists.
6 month old infants roll in both directions, imitate sounds and blow
bubbles and loves sound producing toys. Weight increases 100%, they
start to sit and lunge forward as if attempting to crawl.
7 month old infants reach for things with a sweeping motion, starts to
combine syllables and may wave bye bye. Sitting becomes more
frequent although not independently.
8 month old infants are able to sit and crawl, point to objects and
attempt an upright position without success. Cognitive development
increases as manifested by object permanence, fear of strangers and
separation anxiety.
9 month old infants combines syllables to a wordlike sound and they
understand the word NO. Banging of objects is a common pre
occupation, so is the pat a- cake game, and cruising. Self feeding is also
seen during this time.
10 month old infants crawl very well and start to use fingers by showing
pincer grasp. They indicate most of their wants by using gestures and
Dada mama words are apparent.
11 month old infants attempts standing alone for a few seconds although
cruising is well adapted. They are able to follow simple directions
because they enjoy imitating others activities.
12 month old infants reflects a 200% weight gain from their birth weight
and may have gained 50% of the birth height. They jabber wordlike
sounds usually pertaining to food. Standing is not a problem at this time
though walking is attempted or may already be achieved. Preferred toys
are big trucks with pulleys or cart that can be pushed.
Toddlerhood is considered a slow growth stage. Weight gain is
approximately 11 lb (5 kg) during this time and birth weight is quadrupled
by 2 1/2 years. Toddlers gain a height of 20.3 cm (8 inches) and a head
circumference of 19 - 20 inches (49 - 50 cm) by 2 years. The anterior
fontanel closes by 18 months.
Toddlers vital signs are the following: Pulse 110; respirations 26; blood
pressure 99/64. Primary dentition (20 teeth) is completed by 2 1/2 years
and development of sphincter control starts at 18 24 months which is
necessary for bowel and bladder control.
Cognitive tasks are apparent: REMEMBER: C R E A T I N G T O T S
Centering, Ritualism, Exploration and elimination, Animism, Temper
Tantrums, I- me-myself age, Negativism and are common in toddlers
Toothbrushing during twenty, Offer choices, Talk with calm and
consistency, separation anxiety are common nursing interventions for
toddlers.
PASTA - Parallel play, Autonomy vs. Shame and Doubt, Sensorimotor
pre operational stage, Toddlerhood, Anal stage are the stages in toddler
age according to the Theorists.
Slower growth rate continues in pre schoolers: Weight: increases 4 - 6 lb
(1.8 - 2.7 kg) a year and Height: increases 2 1/2 inches (5-6.25 cm) a
year. Birth length is doubled by 4 years.
Vital signs decrease slightly in preschoolers, Pulse: 90-100, Respirations:
24-25/minute, BP is systolic 85-100 mm Hg and diastolic 60-90 mm Hg.
Changes in the lymphatic tissues increase, particularly the tonsils. IgG
and IgA antibodies also show significant increase. Heart size change in
reference to the thorax as the anteroposterior and transverse diameter of
the chest reach adult proportions which may cause transient murmurs.
Their Gross motor development include walking up the stairs using
alternate feet by 3 yrs, walking down stairs using alternate feet by 4
years, riding the tricycle by 3 years and standing on 1 foot by 3 years.
- 1 -
Other gross motor skills include: Hopping on 1 foot by 4 years, Skipping

and hopping on alternate feet by 5 years, balancing on 1 foot with eyes
closed by 5 years, throwing and catching ball by 5 years, jumping off 1
step by 3 years and jumping rope by 5 years.
Fine motor development are indicated by Hand dominance established by
5 years, Building tower of blocks by 3 years, Tying of shoes by 5 yrs,
copy circles, may add facial features by 3 years and copy a square, and
trace a diamond by 4 years.
Their Caloric requirement is approximately 90 calories/kg/day. They may
demonstrate strong taste preferences and more likely to taste new foods
if they are given the chance to assist in the preparation.
Their kind of play is predominantly associative play though they enjoy
imitative and dramatic play. They Imitate same-sex role functions in
play, they enjoy dressing up, dollhouses, trucks, cars, telephones, doctor
and nurse kits. Nurse should provide toys to help develop gross motor
skills: tricycles, wagons, outdoor gym; sandbox, wading pool
Pre schoolers are in the Phallic stage where self stimulation by fondling,
masturbation, touching and looking at the genitals becomes a sense of
release to the child. A child attaches better to the parent of the opposite
sex thus, the Oedipal, Electra complex, according to Freud.
This stage is marked also by a highly imaginative child which is
manifested by increased fears of abandonement, the dark, mutilation and
separation. Likewise, the child uses imagination to deal with fears by
creating imaginary friends and telling tall tales.
Due to the limitation of emotional expression, behavioral characteristics
also become apparent during this age like regression, bruxism and sibling
rivalry. A very good nursing intervention during this time would be PLAY
therapy to allow non verbal self expression.
The type of play in this age is cooperative play where the child is able to
play with other preschoolers. Associative play because they associate the
roles they enact with their significant others. Imitative play because
they assume the roles exactly how they see their significant other do it.
Toys at this time should be gender specific. Gender identity starts so this
will help the child identify what objects or activities identifies them with
being a girl or a boy.
According to Kohlberg, their idea of right and wrong is based on the
approval or the disapproval of their significant other. At this time, a good
role model is needed.
Children at this age are most prone to different types of child abuse
because of their dependence to their significant others. Presence of a
responsible significant others is most important.
Make believe is most appropriate because it enhances the imitative play
and imagination of the preschooler. C and d are for infants while letter B
is recommended for schoolers because it enhances competitive play.
Accdg to Kohlberg, a preschooler is under pre-conventional where a child
learns about instrumental purpose and exchange, that is they will do
something do for another if that person does something with this child in
return
a 5y/o views death in degrees, so the child most likely will say that he
is just a bit dead. Personification of death like boogieman occurs in
ages 7 to 9 as well as denying death can if they will be good. Denying
death using jokes and attributing life qualities to death occurs during age
3-5.
The school age is considered a slow growth stage where height gain is
only 2 inches (5 cm) per year and weight is doubled over this period
At age 9, both sexes assume the same size. At age 12, girls grow bigger
than boys and the boys appear leaner than girls.
Dentition shows significant change during this age. Lose of first primary
teeth start at about 6 years. They gain 28 teeth between 6-12 yrs old.
The caloric need of school age children diminish in relation to body size:
85 kcal/kg. Junk food may become a problem because they are
exposed to these types of snack in school. Obesity is a risk in this age
group because a lot of parents tend to overfeed their children and the
fact that they are not able to monitor the food intake of their children
while in school.
Bone growth faster than muscle and ligament development so they
become susceptible to bone fractures. This is the best time for these
children to undergo Scoliosis screening.
Vision is completely mature which is indicated by a good hand-eye
coordination. This development encourages smoothness and speed in fine
motor control.
School age children develops their Gross motor skills in a certain pattern
which predominantly involves large muscles. At this time, they are very
energetic, have greater strength, coordination, and stamina. This
capacity helps them sustain athletic and physical games and activities.
6 year old children compete actively in the classroom, play in groups
unless tired and under stress. They perform better when they are given
special and specific attention even for short periods of time only.
Children of this age do not respond well to competition and they react
better to non competitive, group games. When they are exposed to
individual games where they are expected to perform, they resort to
cheating so as to win.
7 year old children are more definitive so promises must be kept because
they view them as definite, firm commitments. They also show intense
attachment to people outside of the family such as the teacher.
8 year old children seek the company of other children and this is
particularly seen in school where they perform better as a group. This is
also said to be the NATURAL HOMOSEXUAL stage where they would rather
be with friends of the same sex.
9 year old children take value of their peer group seriously and this is
called gang age. They particularly follow a common set of behavior
geared towards attempting to assume adult like behaviors. It may be
manifested throu their choice of clothes, food, color and even interests.
10 year old children enjoy staying in groups as well as privacy. A new
cognitive development starts enhancing the sense of ownership/property.
This age is indicated by hoarding of toys, food, personal items and even
common things found in the house.
Sense of humor is apparent during the school age period. Punishments
and reprimands given to schoolers usually result from this new behavioral
characteristic.
11 year old children starts an increasing interest in the opposite sex in

subtle ways. At this age, the development of secondary sex
characteristics also start which makes them particularly insecure.
12 year old children are more comfortable in social situations than before
although they still feel uncomfortable being pushed into boy-girl situation
until they know how to control their bodies better. More secondary sex
characteristics appear which worsens their incapacity to adjust.
According to Erik Erickson, the school age is in the Industry inferiority
stage of psycho social development.
Their cognitive development is indicated by the Period of
industry/concrete operational thoughts at 7 where there is increased
interest in exploration and adventure. They like to indulge in activities
that accomplishment or production, which develops confidence.
Developmental milestones include: DECENTERING projecting self into
other peoples situation, ACCOMODATION adapting thought process to
fit what is perceived, CONSERVATION change in shape does not
necessarily mean change in quantity and CLASS INCLUSION objects
belong to more than 1 classification.
School age children have a more realistic fear than younger children.
These include death, disease or bodily injury, punishment. School phobia
may develop and usually results in psychosomatic illness.
Adolescent stage is described as a SPURT growth stage Girls show a height
increase of approximately 3 inches/year. This rate slows at menarche and
stops at around age 16 to 18.
Adolescent boys show a growth spurt which starts at around age 13. Their
height increase 4 inches/year and only slows down in their late teens.
Boys double their weight between 12 and 18 and this is closely related to
their increasing muscle mass.
As to body shape, boys become leaner with broader chest.Girls have fat
deposited in thighs, hips, and breasts while their pelvis broadens.
Both males and females develop hyper activity of their Apocrine glands
causing increased body odor, hair growth and sweating. This increased
production of sebum and plugging of sebaceous ducts causes a common
problem in preteens - acne
Development of secondary sex characteristics and sexual functioning
under hormonal control in both girls and boys.
In girls, the breast development is first sign of puberty. The first stage is
the bud stage where the areola around the nipple is protuberant.Breast
development is complete around the time of first menses
In boys, enlargement of testes is the first sign of sexual maturation. It
occurs at approximately age 13 or about 1 year before growth spurt. The
scrotum and penis increase in size until age 18.
Boys reach reproductive maturity at about age 17, with a viable sperm.
Nocturnal emission is a physiologic reflex and masturbation increases
Pubic hair continues to grow and spread until mid 20s and facial hair
appears first on upper lip. Voice changes due to growth of laryngeal,
cartilage.
Gynecomastia, the slight hypertrophy of breasts due to estrogen
production occurs in young boys but will pass within months. This is a
common cause of embarrassment at this age.
Early adolescence starts at age 12-14 years. This is the start of puberty
and indicated by physical body changes resulting in an altered selfconcept.
A common behavior during this stage is when adolescents tends to
compare their own body to others. Early and late developers have anxiety
regarding fear of rejection.
They also are prone to mood swing due to hormonal changes. Fantasy
life, daydreams, crushes are all normal, and help in role play of varying
social situations.
Nurses should reiterate to parents that this age may indicate a behavior
of increased independence. Teach them that acceptable limitations and
consistent discipline is important.
Middle adolescence is indicated by separation of the child from their
parents (except financially). They are more able to identify own values
and can define self (self-concept, strengths and weaknesses).
These age group partakes in peer group and conform to values/fads.
They also show increased heterosexual interest thru constant
communication with the opposite sex and formation of love
relationship.
late adolescence stage is manifested by Achieving a greater
independence.At this age, they start to chooses and focus on specific
vocations.
Unlike the earlier stages, a more selfless individual emerges as seen in
participation in society activities, groups and issues. They are able to find
their own identity and mate.
Late adolescence also indicates development of own morality which
indicates complete physical and emotional maturity.
Cogintive abilities of adolescent include development of abstract thinking
abilities, scientific reasoning and formal logic.They enjoy intellectual
abilities and are able to view problems comprehensively.
Body image is a common characteristic of adolescents and threats include
acne, obesity, injury or death and the unknown.
Childrens response to death vary according to the age bracket. toddlers
may insist on seeing a significant other long after that persons death.
Preschoolers see death as temporary; a type of sleep or separation.
School-age see death as a period of immobility and feel death is
punishment. Adolescents have an accurate understanding of death.
The truth is that all of us attain the greatest

success and happiness possible in this life
whenever we use our native capacities to their
greatest extent.
- 2 -
Psalm 55:22
Cast your cares on the LORD and
he
he will sustain you;
he will never let the righteous fall.
Nursing Concepts and Processes
Madeleine Leininger postulated Transcultural

Nursing- helping a client to improve or attain a
health condition through specific cultural
caring processes (cultural values, beliefs, and
practices).
o Sister Callista Roys Adaptation Theory states
that a person must continuously acclimatize
himself to the changes in his environment to
maintain his health.
o Imogene Kings Goal Attainment Theory works
on the premise that nursing, as a helping
profession, assists individuals and groups in the
society to attain, maintain, and restore health.
o Hildegard Peplau introduced the Interpersonal
Model. She defined nursing as an interpersonal
process of therapeutic interactions between a
sick individual and a nurse. It has four phases:
Orientation, Identification, Exploitation, and
Resolution.
o Patricia Benner described the level of Clinical
Competence of nurses as to Novice, Advanced
Beginner, Competent, Proficient, and Expert.
Nursing, as a profession, serves ALL society and
not the specific interest of a group only.
Nursing is considered to be a profession because of
the following characteristics: education, theory,
service, autonomy, code of ethics, and
exclusively, it has CARING.
ROLES OF NURSES:
o The nurse, as an ADVOCATE, promotes whats
best for the client and protects his rights as
well.
o The nurse, as a MANAGER, plans, gives
directions, develops staff, monitors operations,
gives rewards fairly, and represents both staff
and administration as needed.
o The nurse, as a CARE PROVIDER, supports the
client by attitudes and actions that show
concern for client welfare especially meeting
her needs.
o The nurse, as a RESEARCHER, participates in
the scientific investigation and uses research
findings in practice.
o The nurse, as a COLLABORATOR, works in
combined effort with all those involved in care
delivery.
o The nurse, as a COUNSELOR, helps the client
to recognize and cope with stressful
psychologic or social problems.
There are three types of nursing interventions:
independent or nurse-initiated, dependent or
physician-initiated,
and
interdependent
or
collaborative interventions.
There are Five Nursing Care Delivery Models:
o In Total Patient Care Delivery Model, the
nurse is responsible for all aspects of a clients
care.
o In Functional Nursing, it involves division of
tasks of each nurse. (e.g medication, IV, TPR
etc. )
- 1 -
Nursing involves a humanistic blend of scientific

knowledge (SCIENCE), and holistic nursing practice
(ART).
The four major concepts in nursing theories are
the person, environment, health, and nursing.
They are considered the major concepts because
they are applicable in all settings of nursing
practice.
Some Theorists:
o Florence Nightingale was the first nursetheorist who proposed the significant role of
the environment in assisting the patient in his
recovery. She was also notable for her work,
Notes on Nursing: What It Is and What It Is
Not.
o Virginia
Henderson
conceptualized
the
fourteen (14) basic needs and defined the
unique function of a nurse, that is, to assist
the sick or well individuals to gain
independence as the nurse-patient interaction
progresses.
o Martha Rogers coined nursing as a science of
Unitary Human Beings, that human beings
are more than and different from the sum of
their parts.
o Lydia Hall developed the CARE (unique in
nursing), CORE (therapeutic use of self), and
CURE (collaboration, for instance, with the
physician) of nursing.
o Myra Levin illustrated the Four Conservation
Principles: Energy (food, oxygen, and fluids),
Structural Integrity (skin and mucous
membrane), Personal Integrity (personality),
and Social Integrity (family and community).
o Betty Neuman proposed the Health Care
System Model, which states that, nursing is a
unique profession concerned with the factors
(intrapersonal,
interpersonal,
and
extrapersonal) affecting a persons response to
stresses.
o Dorothea Orem is known for her Self-Care
Deficit Theory. It has three classifications of
nurses functions: a.)Wholly Compensatory,
b.) Partially Compensatory, and c.) EducativeSupportive functions.
o Jean Watson explicated the Human Caring
Model. She emphasized that nursing is the
application of the art and human science
through transpersonal caring transactions to
help persons achieve mind-body-soul harmony.
o Dorothy Johnson conceived the development
of Behavioral System Model that is composed
of seven systems: Ingestive, Eliminative,
Affiliative,
Aggressive,
Dependence,
Achievement, and Sexual and Role Identity
Behavior.
In Team Nursing, the RN usually leads the

team composed of RNs and assistive personnel
(nurse assistants, health aides).
In Primary Nursing, the top aim is placing the
RN at the bedside and improves the
professional relationships between staff.
In Case Management, it is a care delivery
approach that coordinates and links health care
services to clients and their families.
Important Facts in Nursing History:

o San Lazaro Hospital was founded in 1578 by
Brother Juan Clemente. It was exclusively built
for patients with leprosy.
o Iloilo Mission Hospital School of Nursing was
established by the Baptist Foreign Mission
Society of America. The first trained nurses in
the Philippines graduated here in 1909.
o St. Pauls Hospital School of Nursing, located
in Intramuros, was established by the
Archbishop of Manila and provided general
hospital services.
o Philippine General Hospital School of Nursing
began in 1901 as a small dispensary mainly for
Civil Officers and Employees in the City of
Manila. It later grew into Civil Hospital.
o St. Lukes Hospital School of Nursing began
also as a small dispensary in 1903. In 1907, the
school opened with three Filipino girls admitted
in combined classes with Philippines General
Hospital School of Nursing and St. Pauls
Hospital School of Nursing.
o The University of Sto Tomas (UST) School of
Nursing is the first college of nursing in the
Philippines, which started on February 11,
1942. It operated as a separate entity from the
Santo Tomas Hospital.
o The University of the Philippines College of
Nursing was established in 1948. Its first dean
was Ms. Julita Sotejo.
o Loreto Tupas was called the Dean of the
Philippine Nursing and Florence Nightingale
of Iloilo.
o Anastacia Giron-Tupas was the first Filipino
nurse to occupy the position of chief nurse
superintendent in the Philippines. She was also
the founder of Philippine Nurses Association.
o Linda Richards was the first graduate nurse in
the US from the New England Hospital for
Women in Boston.
o Philippines Nurses Association is the national
organization of Filipino nurses.
o National League of Nurses is the association of
nurses employed by the government.
Periods of Nursing
o The pre-historic man believed that illness was
caused by the evil spirit, and practiced
hypnosis, charms, dances, incantations, fire,
water, herbs, and trephining to drive the evil
spirits away.
o The Period of Apprentice Nursing extends
from the founding of religious nursing orders in
the crusades. It was also called on the job
training even if nursing care was formed
without any formal education.
o The Period of Educated Nursing began on June
15, 1860 when the Florence Nightingale School
of Nursing opened at St. Thomas Hospital in
London.
o The Period of Contemporary Nursing covers
the period after World War II to the present.
Scientific and technological developments as

well as social changes mark this period.
Concepts on Health:
o Health and Illness are highly individualized
perceptions. Meanings of health and illness vary
among people, in relation to geography and to
culture.
o According to WHO, health is a state of
complete physical, mental, and social wellbeing, and not merely the absence of disease
or infirmity. It is also a fundamental right of
every human being.
o Abraham Maslows Hierarchy of Needs
includes five different aspects: Physiologic,
Safety and Security, Love and Belongingness,
Self-Esteem, and Self-Actualization.
Models of Health:
o Dunns Theory on Health-Illness Continuum
describes the interaction of the environment
with well-being and illness.
o Health Belief Model describes the relationship
between a persons belief and behaviour.
o The Clinical Model views people as physiologic
system with related functions and identifies
health as the absence of signs and symptoms.
o Role Performance Model defines health in
terms of individuals ability to fulfil societal
roles such as performing work.
o Adaptive Model views health as a creative
process and disease as a failure in adaptation.
o Eudemonistic Model conceptualizes that
health is a condition of actualization or
realization of a persons potential.
o Leavell and Clarks Agent-Host-Environment
Model (Ecologic Model) avers that there are
three interactive factors that affect health:
Agent (microorganisms), Host (person), and
Environment (habitat where both agent and
host are present).
Suchmans Stages of Illness:
o Symptom Experience- physical, cognitive, and
emotional.
o Assumption of Sick Role- accepts the illness
and seeks support.
o Medical Care Contact- seeks advice of health
professionals.
o Dependent Patient Role- becomes more
passive and accepting; dependent on HCP.
o Recovery/ Rehabilitation- returns to former
roles and functions.
Classification of diseases can be described as:
Hereditary, Congenital, Metabolic, Deficiency,
Traumatic, Allergic, Neoplastic, Idiopathic,
Degenerative, and Iatrogenic.
Remission is used to refer to lessening in the
severity of symptoms or their temporary
disappearance during the course of an illness.
Exacerbation is used when a disease becomes more
active again with recurrence of pronounced
symptoms.
The patterns of the occurrence of diseases are
classified as: Endemic (present more or less in a
community), Epidemic (increasing number of cases
in a community), Sporadic (occasional cases
occur), and Pandemic (extremely widespread).
Levels of Prevention include: primary (to
encourage optimal health), secondary (diagnosis
and screening), and tertiary (obtaining an optimal
health status after a disease).
- 2 -
Medical asepsis is also known as clean technique,

When assessing non-verbal behaviours, consider
while Surgical asepsis is sterile technique.
cultural influences. Variety of feelings can be
expressed by a single non-verbal expression.
Nosocomial/
Hospital-Acquired/
HealthcareAssociated Infection may occur more than 48
Effective communication is reciprocal interaction
hours after admission.
based on trust and aimed at identifying client
needs and developing mutual goals.
Incubation period extends from the entry of
microorganisms into the body to the onset of signs
Important aspects of health education are
and symptoms.
information
(provision
of
knowledge),
communication (exchange of information), and
The Chain of Infection is sequenced as followed:
education (change in knowledge, attitude and
Etiologic Agent, Reservoir, Portal of Exit, Mode of
skills).
Transmission, Portal of Entry, and Susceptible
Host.
Trust is the foundation of a positive nurse-client
relationship.
Contact transmission of infectious organisms on
the hands of caregivers is the most frequent mode
Therapeutic communication is a fundamental
of transmission in health care facilities.
component in all phases of the nursing process, and
for establishing effective nurse-client relationship.
Handwashing is the single most important infection
control practice.
Documentation serves as permanent record of
client information and care.
Any item introduced into sterile tissues or the
vascular system, such as surgical instruments,
Reporting takes place when two or more people
cardiac and urinary catheters, vaginal speculum,
share information about client care, either face to
implants, IV fluids, and needles, must be sterile.
face or by telephone.
Never touch with bare hands anything that is wet
Charts and Records can be used to monitor the
coming from a body surface.
quality of care received by the client and the
competence of healthcare providers.
Standard or Universal Precautions intend to
prevent transmission of blood borne and moist body
The Kardex consists of a series of cards kept in a

substance pathogens.
portable index file or on computer generated
forms.
NEVER recap needles. Use the needle disposal
container.
Telephone orders should be written and repeated
for accuracy. Write the order onto the doctors
Surgical technique is a team effort. Everyone in
order sheet, and indicate that it is a verbal order
the team must have sterile conscience.
or telephone order.
Put on gloves on the non-dominant hand first,
Incident Report should be completed as soon as
then on the dominant hand.
possible as part of the Quality Improvement.
There are three stages of General Adaptation
Chart objective facts, NOT your interpretations or
Syndrome (GAS): Stage of Alarm (flight-or-fight
opinions.
reaction), Stage of Resistance (adaptation), Stage
of Exhaustion (failure to adapt).
In recording, describe behaviours rather than
feelings to allow other health team members to
A therapeutic relationship focuses on helping the
determine the actual problems of the client.
patient solve problems and achieve certain welldefined, mutually agreed upon, health-related
Correct errors by drawing a single horizontal line
goals.
through the error, write the word ERROR, and then
affix your signature.
A stress is an essential aspect of existence and is
something that each person has to cope.
Bloom identified the three (3) Domains of
Learning: Cognitive, Psychomotor, and Affective;
Coping is a process a person uses to manage events
also known as KSA
that he/she encounters and perceives as stressful.
Failure to cope may lead to crisis.
The ADPIE or nursing process is the cornerstone of
the nursing profession.
Crisis suggests a situation in which usual coping
strategies are ineffective, and the person is
Nursing Diagnosis is a statement of clients
disorganized or unable to solve problems
potential or actual alteration of health status. It
appropriately.
uses the critical-thinking skills of analysis and
synthesis, and usually uses the P-E-S format.
The crisis state tends to be temporary, selflimiting, acute, lasting four to six weeks only.
Something that is NOT written is considered as
NOT done.
Maturational or Developmental Crisis is associated
NOTES:
with expected normal and predictable growth and
________________________________________________
development, requiring role changes in these
________________________________________________
transitional periods.
________________________________________________
Social Crises include natural disasters like floods,
________________________________________________
earthquakes, or hurricanes; terrorist attacks; riots
________________________________________________
and violent crimes. s
________________________________________________
Anxiety is a feeling of uneasiness from
________________________________________________
unrecognized cause, while fear is a feeling of dread
________________________________________________
to a recognized cause.
________________________________________________
Explore feelings of patients who are anxious.
________________________________________________
Focusing on clients feelings prove to be
________________________________________________
therapeutic in most situations.
________________________________________________
Some non-therapeutic techniques in communication
________________________________________________
are: reassuring, giving approval, rejecting,
________________________________________________
disapproving, agreeing, disagreeing, advising,
probing,
challenging,
testing,
defending,
"The roots of true achievement lie in the will to
requesting an explanation, indicating the
existence of an external source, belittling feeling
become the best that you can become."
expressed, making stereotyped comments etc.
- 3 -
Jeremiah 29:11
"For I know the plans I have for

you," declares the LORD, "plans to
prosper you and not to harm you,
plans to give you hope and a future."

NURSING RESEARCH
Research is a systematic, orderly process of studying
concepts or phenomena. It is also an honest
investigation which ensures that data presented are valid
and reliable.
The main purpose of conducting research is to improve
the quality of lives of people. Nursing Research, on the
other hand, has the main purpose of improving the
quality of care provided to clients.
The conduct of a research study observes the presence of
the components of ORDER and SYSTEM,
SYSTEM, CONTROL and
MANIPULATION,
MANIPULATION, EMPIRICISM and GENERALIZATION.
GENERALIZATION. In
the absence of such components, the inquiry will not be
considered as a valid research study.
ORDER & SYSTEM is an important component of research
which requires the inquiry to follow a logical series of
steps from identifying the problem to obtaining and
interpreting data.
CONTROL and MANIPULATION attempts to eliminate any
factor that would destroy the relationship of the
variables in the study. This component aims to increase
research efficiency.
EMPIRICISM refers to gathering data which are based on
objective reality and can be perceived through human
senses.
GENERALIZATION refers to the applicability of research
outcomes to the general population. It can be achieved
if random sampling is used in the study and if extraneous
variables are controlled.
In Random sampling, generalization is possible since all
the members of the population were given equal chances
to participate; thereby, all their characteristics are
presumed to be represented in the sample.
Evidence-based practice refers to clinically competent
care based on best scientific evidence available.
Research plays an important role as the means to show
scientific evidence.
The levels of evidence are ranked with META-ANALYSIS
OF SEVERAL CONTROLLED STUDIES as the highest level
(Level 1), SINGLE EXPERIMENTAL STUDY (Level 2), QUASIEXPERIMENTAL STUDY (Level 3), NON-EXPERIMENTAL
STUDY (Level 4), REVIEW OF LITERATURE, PROGRAM
EVALUATION, BENCHMARKING (Level 5) and OPINIONS
FROM EXPERTS (Level 6) as the lowest level of evidence.
Logical reasoning is widely used in the conduct of
research. DEDUCTIVE REASONING, which uses arguments
to move from general to specific, is used in research
when we form assumptions (generally acceptable facts
about the study) and during analysis and interpretation
of data when the findings of the study is compared to
findings of other related researches.
INDUCTIVE REASONING, which uses arguments to move

from specific to general, is used during generalization of
the outcome of research to the population.
The types of research are classified according to purpose
(Basic, Applied or Action), according to time element
(Past-historical, present-descriptive and futureexperimental), according to statistical significance
(Qualitative or Quantitative) and according to frequency
of data gathering (Longitudinal or cross-sectional).
Basic research is conducted in pursuit of knowledge for
knowledges sake with the purpose of generating and
refining theories and constructs. It has no practical
application to the population.
Applied research seeks to apply a scientific knowledge to
solve problems, to make decisions, and to develop new
programs or methods. Experimental studies are good
examples of applied research.
Action research has the same purpose with that of
applied research; it will only be the adequacy of related
literature which will determine an APPLIED from an
ACTION research.
Applied research will require extensive and adequate
review of related literature for the outcome of the study
to be generalized to the target population. Action
research is conducted when there are limited related
literatures on the topic and generalization is only
applicable to the accessible population.
Qualitative research Involves study of phenomena and
concepts which are not measurable. It uses narrative
documentation in data gathering. Experiences, quality,
attitudes are some of the basic examples of qualitative
data.
Quantitative research is conducted on concepts which
are measurable. It will use statistics to analyze &
interpret data.
REPLICATION is the process of repeating a study using the
same method, different subjects and different
experimenters. It ensures that results are valid &
reliable
The start of research is the identification of the
PROBLEM, also known as the topic or the focus of the
study. It may come from experiences, various
literatures, interest of the researcher, theories and other
concepts from related disciplines.
Communication of research aims is reflected through the
problem statement, statement of purpose, research
questions and hypothesis.
The problem statement has to reflect the nature of the
inquiry, the context and its significance. It will be
operationalized through the research questions, which
are specific queries that researchers want to answer.
Research questions are ACTION-ORIENTED
- 1 -
Not all problems are researchable. Problems that are

controversial and would have differing opinions from
people (like debate topics) are not good researchable
problems.
Researchable problems has to be NOVEL (original),
SIGNIFICANT to the profession, the researcher has
INTEREST and EXPERTISE on the topic, and has
FEASIBILITY in terms of time, material and human
resources, budget and ethical considerations.
Ethical principles that must be observed in research
includes beneficence and non-maleficence, autonomy
and justice.
The principle of beneficence and non-maleficence
dictates that all participants to the study must not be
harmed (physical or psychological) or exploited. The
research should likewise provide benefits to the
population.
Autonomy is observed when participants are their right
to self determination. This is achieved when no threat,
coercion or compensation was used in obtaining samples
in the study.
The REVIEW OF LITERATURE is conducted to help
researchers validate the novelty of the problem, obtain
comparison of results from related studies and establish
the framework of the study. Conceptual and Research
literatures are the classifications of related literatures
that are reviewed.
Conceptual literatures mostly contain theories, opinions
and viewpoints of experts and authorities while Research
literatures contain results from several research studies
like theses and dissertations.

Primary sources of the review of literature describe
studies written by the researchers themselves while
secondary sources are those studies prepared by another
person other than the original researcher.
Related literature must be current (not more than 5
years). Older documents can be used in the study if
justification will be made that there are no recent
literature or studies about the topic and the concepts
presented in the literature is still relevant.
The framework is the conceptual underpinnings of a
study; thereby, it is the studys backbone, background
or support Theoretical and conceptual are the types of
frameworks used in research.
Theory and research have a mutual relationship; a theory
is developed through research, while research needs
theories to form its study framework.
A theory which is not anymore studied in research will
cease to exist.
A Theoretical Framework is based on a theory and has a
more formal approach. A conceptual framework has a
less formal approach and it is developed by the
researcher.
A conceptual framework is created through analysis, the
process of breaking down into parts, and synthesis, the
process of putting together related concepts.
The HYPOTHESIS is a tentative answer to the statement
of the problem and is the predicted relationship between
the variables in research. It is a requirement for
QUANTITATIVE but not for qualitative studies.
The types of hypotheses are Null versus Research,

Directional versus Nondirectional and Simple versus
Complex.
A null or statistical hypothesis (expressing a NO
RELATIONSHIP prediction) is stated if a statistical
formula will be used. It provides a mind set of no
relationship; thereby preventing any biases on the part
of the researcher. An alternative hypothesis (expressing
a SIGNIFICANT RELATIONSHIP) will be accepted if the
NULL is rejected.
Directional hypothesis specifies the exact relationship
between the variables and it is stated when researchers
have a strong justification that it is the correct and exact
relationship between the variables. Nondirectional
simply states that there is a significant relationship but
will not specify the relationship.
Hypothesis dictates the statistical test to be used in the
study. A two-tailed test (possibility of yielding either of 2
results) is used for any NULL hypothesis stated while
one-tailed test is used for a DIRECTIONAL hypothesis.
Variables in research are characteristics of individuals,
things and events which vary (may be present or absent
in some; with varying levels in individuals). Major
variables in research include the Independent Variable,
which is the presumed cause, and the Dependent
Variable, the presumed effect of the phenomena.
Experimental design controls and manipulates the
INDEPENDENT variable to observe its effect on the
DEPENDENT variable, which will be measured in the
study.
In Comparative studies, the INDEPENDENT variable is the
characteristic which varies in the groups being compared
and will not be controlled. The DEPENDENT variable is
the point of comparison and will be measured in the
study.
Extraneous (other terms are Intervening, Confounding)
variables are other factors that can change the result of
the study. They are controlled in research to have valid
and generalizable results.
The RESEARCH DESIGN is the overall plan of the study to
obtain the answers to the research questions.
Procedures and strategies in conducting the study will be
specified by the research design.
Structured designs are specified before data collection,
and this is mostly seen in QUANTITATIVE studies.
Flexible designs evolve (or emerge) during the collection
of data, as seen in most QUALITATIVE studies.
QUALITATIVE studies have the following designs:
Historical, Ethnology, Case studies, Phenomenology and
Grounded-Theory research. They are all conducted in
the NATURAL setting and collects narrative
documentation of informants.
Historical researches are studies of past events. It
collects from primary sources data, like interviews and
examination of historical documents through EXTERNAL
criticism of data (determination of the originality and
genuineness of the document) and INTERNAL criticism of
data (determination of the worth of the content).
Ethnology or ethnographic research studies the
traditions, practices, beliefs of ethnic or cultural groups.
They are conducted to understand the unique culture of
identified groups.
- 2 -
Phenomenology studies the lived experiences shared by

people while Case Studies are researches done on one
person or a group of persons focusing on identifying and
solving problems. Grounded Theory is about the
development of a minor theory into a major or grand
theory.
A design may also be classified according to the
manipulation of variables. If the INDEPENDENT variable
is controlled and manipulated, a control group is present
and randomization is used in obtaining samples, it is a
TRUE EXPERIMENTAL design.
A QUASI-EXPERIMENTAL design is conducted when only
control and manipulation of the INDEPENDENT variable is
seen but there is no randomization and/or control group.
When variables are observed in their natural environment
and are not manipulated, it depicts a NONEXPERIMENTAL
design.
Experiments are conducted for the following reasons:
The immediate effect can be elicited or observed,
variables can be manipulated and manipulation of
variables will not pose ethical problems
If variables can be manipulated but will cause ethical
problems, the study will be conducted using
nonexperimental designs
Experiments are conducted in a controlled setting
(LABORATORY setting) where a TREATMENT (independent
variable) is given to an experimental group while is it
withheld from another group (control group). The
DEPENDENT variable will be measured after the
treatment and the results from the two groups are
compared to elicit the cause-effect relationship of the
variables.
Descriptive studies are usually UNIVARIATE (one

variable), although some descriptive studies have several
variables but their relationships are nor being
established. Survey, which is a self-report data
investigation, is the most basic type of descriptive
research.
This is an example of a descriptive study: The Level of
Anxiety of preoperative elderly patients in tertiary
hospitals. The lone variable in the study is Level of
Anxiety, and the population is preoperative elderly
patients.
CORRELATION evolves from descriptive through an
additional purpose. Correlation has the purpose of
describing the population and explaining relationships of
variables. Correlation studies the relationship of two or
more variables that co-exist (present in individuals).
Correlational studies usually do not identify
INDEPENDENT and DEPENDENT variables since the
variables are considered CORRELATIONAL and are not
perceived to have a cause-effect relationship.
The findings in correlational studies are either a POSITIVE
(the variables go to one direction), NEGATIVE (the
variables go to opposite directions) or NO RELATIONSHIP
exists between the variables.
This is an example of correlation: The relationship of
leisure time (LT) and socio-economic status (SES) to
the anxiety levels (AL) and academic performance
(AP) of school-age children.
Experiments need to have INTERNAL and EXTERNAL

validity. Interval validity is obtained when any change
in the DEPENDENT variable can only be attributed to the
INDEPENDENT variable.
COMPARATIVE researches have the same purpose as

correlation, with an additional purpose of comparing two
or more groups. It is conducted either as a
RETROSPECTIVE (inquiry starts with the dependent
variable and goes back to the past for the cause) or
PROSPECTIVE (inquiry starts with the independent
variable and looks forward in the future for the effect)
study.
Threats to Internal Validity include mortality (dropout of

participants), instrumentation change, maturation,
history (significant event occurred between the time of
treatment and observation) and selection bias.
In Comparative studies, the INDEPENDENT VARIABLE is

the characteristic which varies in the groups while the
DEPENDENT VARIABLE is the point of comparison and will
be measured in the study.
EXTERNAL validity is concerned with the degree to which

the research outcome can be generalizable to the
population. Threats to external validity include the
Hawthorne effect (deliberate change in behavior of
subjects caused by their awareness that they are being
studied), Rosenthal Effect (change in behavior caused by
the effect of the experimenter) and Halo Effect (biased
effect of the researcher determining good and bad
subjects).
This is an example of a comparative study: The

difference in the level self esteem of elderly living in
a nursing home and those living with their children at
home. The independent variable is the type of home of
elderly because this varied from the two groups. The
dependent variable is level of self esteem, which is the
point of comparison and will be measured in the study.
This is an example of an experiment: The effect of the

progressive muscle relaxation (PMR) on the blood
pressure of hypertensive patients. PMR is the
independent variable (cause) because it is the treatment
and it will be controlled and manipulated by the
researcher by giving it to the experimental group and
withholding it to the control group. The dependent
variable is BP because it will be observed and measured
(effect) after the treatment.
NONEXPERIMENTAL studies are conducted is variables are
measurable but cannot be manipulated and relationships
are established through observation of natural
phenomena.
The types of NONEXPERIMENTAL designs are classified
according to purpose. If the purpose of the study is to
simply DESCRIBE the population on phenomena, the
design is DESCRIPTIVE.
The term POPULATION refers to the total aggregate of all

individuals relating to the topic. This is also known as
the TARGET POPULATION when the same total aggregate
are beneficiaries of the outcome of the study.
The ACCESSIBLE population is a group derived from the
target population who are presumed to have the same
characteristics as the target population. This is the
group where the samples (actual study participants) will
be drawn.
Probability Sampling is a procedure which gives equal
chances for all members of the population to participate
in the study. Generalization of result is possible with
this type of sampling procedure.
Simple random requires that all the members of the
population are part of the selection. It uses the simple
procedure of drawlots to get samples.
- 3 -
Stratified random sampling is a more extensive

procedure with an initial step of classifying individuals
according to their common characteristics into different
strata, after which, equal number of samples are taken
from each of the strata. It is done to ensure that all the
characteristics of the population are well represented.
Cluster sampling forms groups according to the
individuals proximity (geographical location). There will
be random selection of clusters, and when a cluster is
drawn, all its members will be the sample in the study.
Systematic sampling uses a sampling interval (the result
of dividing the number of population over the number of
samples needed) in getting its study participants.
The sample Size in Quantitative Studies are computer
using the Slovins Formula, a widely-used formula which
accounts for a margin of error in sampling. In using the
formula, the researcher is recognizing that about 1%-5%
of the samples taken are not fully representing the
population in the study.
Homogeneity of the population refers to consideration in
sampling where there are similarities in the
characteristics of the members of the population.
Effect Size, on the other hand, refers to the
consideration when the independent variable in the study
really affects the dependent variable. These
considerations will allow the researcher to get a smaller
number of samples than what is required.
Attrition is a consideration when the nature of the study
will have a big possibility of having drop outs of samples.
When this is considered, the researcher must get a higher
number of samples than what is ideal.
The plan of the study is presented through a RESEARCH
PROPOSAL. This should include Chapters 1, 2 and 3 of
the research paper, budget proposal and the timetable of
activities. A PILOT STUDY follows the proposal, which is
necessary to validate research instruments and to
Identify and control extraneous variables.
Research instruments undergo reliability (test for
accuracy and consistency) and validity (test for
appropriateness; that instrument measures intended
concept) testing before it can used in data gathering.
Mechanical instruments are mostly tested under
reliability testing while written instruments
(questionnaires, interview guides) are both tested on
reliability and validity.
Face Validity refers to a first glance examination of the
written instruments by experts. The result should reveal
that upon cursory examination, the instrument is
measuring intended concept.
Content Validity requires a correlational coeffiecient
computation of the scores of a pilot group in a long
version (instrument being validated) and a shorter, but
valid version of an instrument measuring the same
concept. The instrument will get content validity when
the CVI (Content Validity Index) is within the range of a
strong positive relationship (+0.7 to +0.9)
Data are gathered in research through three methods:
Self report, observation and biophysiologic
measurements. All these data collection method uses
process recording (actual data gathering)
Self report gathers subjective data through distribution
of questionnaires to respondents or interviews using a
guide.
Observational method gathers objective data from study

participants through the use of human senses with the
aid of simple mechanical instruments.
Biophysiologic measurement uses extensive devices to
monitor the reaction of the body to a certain stimuli
(e.g. stress test)
The Likert Scale is the most common behavioral scale
used in written instruments. It is characterized by series
of declarative sentences and a range of responses usually
from strongly agree to strongly disagree. It uses the
Interval level of measurement in assigning scores to each
responses.
Data are categorized according to different Levels of
Measurement namely nominal, ordinal, interval and
ratio. Nominal level of Measurement, considered the
lowest level, is used for coding. These are categories
with no ranking (e.g. gender male, female)
Ordinal level of Measurement is presented as categories
with hierarchy but no numbers. (e.g. level of anxiety;
educational attainment). Ordinal and Nominal levels of
measurements will be analyzed using nonparametric
statistics.
Interval and Ratio levels of Measurement both deal with
real numbers and will be analyzed using parametric
statistics. Interval will not have a possible zero point
(e.g. body temperature) while Ratio will have a true zero
point (e.g. score in an exam).
Data in Qualitative research is analyze using logical
reasoning and analysis. Data for Quantitative research is
analyzed using statistics.
Descriptive statistics are used to describe the population
on a concept or phenomena. Measures of Central
Tendency are descriptive statistics that are used to
describe population on their commonalities or averages.
Mean, mode, median are examples.
Measures of Variability are used to describe whether
population is homogeneous or heterogeneous. Standard
deviation (summary of average deviation from the mean)
and Range (highest score minus the lowest score) are its
common examples.
Correlational statistics like Pearsons r, Spearman rho,
Correlational Coefficient, Scatter plot, are used to
describe relationship/s of variables and shows whether a
positive, negative or no relationship exists between 2
variables. If more than two (3 or more) variables are
used in the study, Multiple Regression statistics will be
used.
Tests of Difference are used to show the CAUSE-EFFECT
relationship of variables by comparing the results of two
or more groups. For two groups being compared,
statistics used are T-test, paired T-test, Chi square. If
more than 2 groups are being compared, use the ANOVA
(Analysis of Variance).
Notes:
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"Confidence is the hinge on the door to success."
- 4 -
1 John 4:18
"There is no fear in love;
but perfect love casteth out
fear ... "

Nursing Therapeutics 1
DISORDERS AND NURSING CARE/POSITIONING
Nursing care/positioning AFTER the procedure:
Thoracentesis -------------------------------------------------
unaffected side,
Lobectomy ----------------------------------------------------
unaffected side, with chest tube
Segmentectomy ----------------------------------------------
unaffected side, with chest tube
Pneumonectomy ---------------------------------------------
Affected side (slightly affected side
Eye surgery ---------------------------------------------------
Unoperated side down (unaffected side)
Liver biopsy --------------------------------------------------
Right side
Lumbar puncture ---------------------------------------------
Flat on bed
Lower spinal surgery ----------------------------------------
Flat on bed, log rolling (turning technique)
Cervical spinal surgery --------------------------------------
slight elevation of head
Cardiac catheterization --------------------------------------
Bed rest X 24 hours, affected extremity in
No complete lateral turning to prev. mediastinal shift), No chest tube
Extension, sand bag over site,assess peripheral pulses

Hip replacement ----------------------------------------------
Affected limb Abducted
Amputation ---------------------------------------------------
Elevate extremity for 24 hours
Supratentorial surgery ---------------------------------------
Semi-Fowlers pos
Infratentorial surgery ----------------------------------------
Flat position, avoid neck flexion
Nursing care/ positioning During the procedure:

Paracentesis --------------------------------------------------
Sitting position
Thoracentesis ------------------------------------------------
Upright leaning on overbed table, sitting

Straddling a chair
Insertion of TPN catheter -----------------------------------
Trendelenburg position
Enema ---------------------------------------------------------
adult left lateral position

Infant/small children- dorsal recumbent
TURP ----------------------------------------------------------
lithotomy position, cystoclysis
Female Catheterization --------------------------------------
Dorsal recumbent
Important Nursing Care Before the procedure

Paracentesis
Bowel surgery/colonoscopy
Liver Biopsy
CT Scan with dye/IVP
MRI
Ultrasound of KUB-P
Ultrasound of LGBP
ABG determination
Giving Digitalis
Giving Narcotics
Positioning for:
Arterial disorders -------------------------------------------Venous disorders -------------------------------------------Increased ICP -----------------------------------------------COPD ---------------------------------------------------------NURSING ALERTS!
Post Hip Replacement
Pulsating abdominal mass
Glaucoma
DVT.Thrombop[hlebitis
Suspected Appendicits
Post spinal cord injury
Increased ICP/IOP
=Empty bladder, weigh patient

=Cleansing Enema
=Administer Vit K to prevent bleeding
=Assess allergy
=Asses for claustrophobia,Remove metals
=Full Bladder
=NPO FMN, Laxative HS
=Allens Test
=Assess Apical Pulse (5th L ICS MCL)
=Assess RR
Put leg on dependent position
Elevate extremity
Head elevated 15 to 30 degrees
Avoid neck flexion
Upright position
= Avoid Hip Flexion/adduction
= Avoid abdominal palpation
= Avoid Mydriatics (Atropine)
= Avoid massaging legs vigorously
= Avoid aplplying heat, giving laxative,
Enema
= Avoid flexion of the neck
= Avoid coughing, vomiting, Valsalva
- 1 -
CHARACTERISTIC SIGNS/SYMPTOMS AND DISORDERS

Vertigo, tinnitus and hearing loss
Flashes, floaters and veils
Increased IOP, loss of peripheral vision, tunnel vision and
Halos,rainbows around lights
Opacity of the lens, painless loss of vision
Bradykinesia, cogwheel rigidity, shuffling propulsive gait and
Pill rolling tremor
Ascending paralysis
Ptosis, dysphagia, respiratory paralysis
Charcots Triad (scanning speech, intention tremors, nystagmus)
Flaccid paralysis
Crepitus
Pulsating abdominal mass
Tophi
Subcutaneous nodules, morning stiffness
Heberdens nodules, Bouchard nodules
Corarse facial features, wide hands and feet
Physical and mental retardation
Exopthalmos, tachycardia, heat intolerance
Water intoxication, hyponatremia
Polyuria, decresed specific gravity of urine
Polyphagia, polyuria, polydipsia, hyperglycemia
Kussmaull resp., ketonemia,ketonuria, fruity odor in breath
Marked hypertension
Cushings Sign (increased systolic BP. Bradycardia, decreased RR)
Kernigs sign, Brudzinski sign, nuchal rigidity
Chvosteks sign, Trousseaus sign, tetany, cramps
Cullens sign,
+ Homans sign
Murphys sign
Altered LOC, wide pulse pressure
Periorbital edema, increased ASO titer
Kaposis sarcoma, Pneumocystiiis carinii pneumonia infection
Bronze skin pigmentation, hypotension
Progressive memory loss
Beefy red tongue, lack of intrinsic factor
Chest pain relieved by rest and nitroglycerin
Right lower quadrant pain, rebound tenderness, + Blumberg sign
And + Psoas sign
Right upper quadrant pain, nausea and vomiting, fat intolerance
Boardlike abdomen/abdominal rigidity, absent bowel sounds
Abdominal distension, + fluid wave
Persistent hoarseness
Chronic cough, hemoptysis
Anorexia, weight loss , cachexia
Hematochezia
Melena
Pink puffer, barrel shaped chest
Blue bloater
Wheezes, mucoid cough, allergic reaction
Rusty sputum
Night sweat, hemoptysis, + mantoux test
Butterfly rash
Painless cervical lymph node enlargement
Orange peel appearance, dimpling, retraction of nipple
Paralysis of one side of face
Decreased urinary stream, nocturia
Intermittent claudication
Epidermal and dermal involvement with blister/vesicles
Dyspepsia, early satiety
Hypotension, muffled heart sounds
Jugular vein distension, ascites, pitting dependent edema
Crackes/rales, PND, increased PAP, Increased PCWP
Hemiplegia/hemiparesis, aphasia, homonymous hemianopsia
Lateral curvature of spine
Gibbus formation
Paradoxical chest movement, dyspnea
Left lower quadrant pain
Jaundice, icteric sclerae, acholic stool, tea-colored urine output
Altered LOC, Flapping tremor (asterixis )
Heartburn
Reddish-purple hue of skin and mucosa
Cherry red skin
Murmur
Bruit
Pericardial friction rub
Pleural friction rub
Severe shooting pain in one side of the face
Bloody mucoid diarrhea
-----------------------
Menieres Disease
Retinal detachment
-----------------------
Glaucoma
Cataract
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Parkinsons disease
Guillain Barre syndrome
Myasthenia Graves
Multiple Sclerosis
Poliomyelitis
Fracture
abdominal aortic aneurysm
Gouty arthritis
Rheumatoid arthritis
Osteoarthritis
Acromegaly
Cretinism
Graves disease
SIADH
Diabetes insipidus
Diabetes mellitus
DKA
Pheochromocytoma
increased ICP
Meningitis
Hypocalcemia
Pancreatitis
Deep vein thrombosis, thrombophleitis
Cholecystitis
Increased ICP
Glomerulonephritis
AIDS
Addison;s disease
Alzheimers disease
Pernicious anemia
Angina Pectoris
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Appendicitis
Cholecystitis
Paralytic ileus
Ascites
Laryngeal Ca
Bronchogenic Ca
Cancer
Colorectal Ca, lower GI bleeding
Upper GI bleeding
Emphysema
Chronic Bronchitis
Asthma
Peumococcal pneumonia
PTB
SLE
Hodgkins disease
Breast CA
Bells Palsy
BPH
Arterial disorder (ASO, TAO)
2nd degree burn
Gastric Ca
Cardiac tamponade
Right side heart failure
Left side heart failure, pulmonary edema
CVA
Scoliosis
Potts disease
Flail chest
Diverticulitis
Biliary obstruction
Hepatic encephalopathy
Hiatal hernia
Polycythemia Vera
Carbon monoxide poisoning
Valvular heart disease
Peripheral Vascular Occlusion
Pericarditis
Pleuritis
Trigeminal Neuralgia
Ulcerative colitis
It is better to know some of the questions than all of the answers.

- 2 -
Proverbs 12:25
An anxious heart weighs
a man down.
Nursing Therapeutics 2
Hypothalamus controls bodys temperature

Temperature is the balance between heat
production and heat losses
factors that affect temperature are BMR, Age,
thyroxine output, Hormones, time, stress
Alteration in temperature includes pyrexia
(38.1C above), hyperpyrexia (41C) and
hypothermia (35 C below)
Tympanic temperature reading best reflect
core temperature
Pulse is control by the Autonomic Nervous
System
factors that affect pulse rate are age, gender,
position, medication, stress
Apical pulse should be assess on a lying position
Carotid pulse is assessed for cardiac arrest for
adult and brachial pulse for infant and child.
Defribilation kills the heart temporarily
Respiration is controlled by Medulla oblongata
and Pons
Factors that affect respiration are age,
environment, altitude, stress, medication
Blood pressure is determined by blood volume,
elasticity of the blood vessels, hematocrit level
and peripheral resistance
Orthostatic Blood pressure measurement is
used to monitor the drop of blood pressure.
Physical assessment is used to confirm,
validate and refuse a data
Cephalocaudal approach is used when doing
physical assessment
The four modes of physical assessment are
Inspection,
palpation,
percussion
and
auscultation
Consent must be obtained for physical
assessment
Privacy should be observed in conducting
physical assessment
Thermotherapy
increased
superficial
temperature and local metabolic rate,
Heat therapy is contraindicated for acute
muscle injury, impaired circulation, sensory
impairment, bruises and open wound
in most hospital, the water temperature is
controlled at a temperature not to exceed 43.3
C to prevent injury
Petroleum jelly may be used to prevent tissue
damage when hot packs are applied
Monitor Vital sign frequently when systemic
cold is applied
When using hypothermia blanket, use towel to
wrap hands and feet to protect skin from injury
Observe skin for purplish color, and check
client for numb feeling after cold application
are removed
Do not allow the client to lie on a constant
heat source such as heating pad or
aquathermic pad
Do not apply heat to an edematous area until
the reason for edema has been determined
Gel packs provide more aggressive cooling than

ice bags, so deserve grater caution
During cold therapy, erythema will occur
The four stages of cold progression are cold,
stinging, burning, numbness
Discontinue cold therapy upon numbness
Never apply a fully coole cold packs directly to
the skin
Bony areas usually requires half the treatment
time as fatty areas
Do not apply an instant chemical pack to the
face and never use pins to secure pack
Elderly clients are more susceptible to injury
from heat and cold therapy as a result of
physiologic changes or medical conditions
Vital signs and frequent assessment may need
to be carried out during heat and cold therapy
as vasodilation from heat or vasoconstriction
from cold can cause changes in cardiac function
and blood pressure
Pressure sore is caused by three basic factors:
pressure, friction, shearing force
Factors that might be at risk in developing a
pressure sore are: malnutrition, increased
temperature,
decreased protein intake,
decreased
sensation,
decreased
mental
capacity, immobility
Pressure ulcer are graded from stage 1 to 4
The three major phases of wound healing are
inflammation, proliferation and maturation
The RYB (red, yellow, black) classifies open
wounds that are healing by secondary or
delayed primary intention in both acute and
chronic wound
The three types of wound healing are primary,
secondary and tertiary intentions
The goals of wound healing includes: remove
necrotic tissue, prevent infection, absorb
drainage, maintain a moist environment,
protect wound from further injury
Ensure that skin is kept clean and prevent it
from getting too dry
Provide a balanced diet high in protein,
vitamins and mineral for tissue repair
Ensure a fluid intake of 2,000 mL/day for
adequate hydration
Do not elevate head of the bed more than 30
degrees
Reposition a bedridden client atleast every 2
hours and a chair bound client every hour
Common fecal elimination problem includes
constipation,
diarrhea,
incontinence,
flatulence
Lack of exercise, irregular defecation habits,
bland diet and overuse of laxative are all
thought to contribute to constipation
Sufficient fluid and fiber intake are required to
keep feces soft
An adverse effect of constipation is straining
during defecation
- 1 -
AN adverse effect of prolonged diarrhea is

fluid and electrolyte imbalances
When inspecting the client stool, the nurse
must observe its color, consistency, shape,
amount, odor, and the constituents
Digital removal of an impaction should be
carried out gently
Enema is used to relieve constipation, fecal
impaction, flatulence and is also used for
evacuation and in lowering body temperature
Proper positioning must be observed in doing
enema. Left lateral position for adults and
dorsal recumbent position for child and infants
Urinary elimination depends on normal
functioning of the urinary, ardiovascular and
nervous system
Alteration in urine production and elimination
includes polyuria, oliguria, anuria, frequency,
nocturia,
urgency,
enuresis,
hematuria,
incontinence and retention
Incontinence
can
be
physicallya
and
emotionally distressing to client
Clients with urinary retention is at risk for tract
infection
The most common cause of urinary tract
infection is invasive procedure
Goals for client with problems with urinary
elimination problems includes maintaining or
restoring normal elimination patterns and
preventing skin breakdown
Urinary catheterization is frequently required
for clients with urinary retention but is only
performed when all other measures to
facilitate voiding fails
Gradual decompression should be done in
doing straight catheterization
Fr 16 18 is used fro male client and Fr 12 14
is used for female client for catheterization
For retention catheter, inflate the balloon
with 5 ml of sterile NSS
For client with retention catheter, acidifying
urine is a must. Food such as meat. Fish. Eggs
and cereals
Normal ph of urine is 6 or a range of 4.6 8
Clean voided specimen is used for routine
urinalysis
Midstream urine specimen is used for urine
culture
timed urine specimen collection is used to
assess the ability of the kidney to concentrate
and dilute urine; determine level of specific
constituents; determine disorders of glucose
metabolism
if the client or staff forgets and discard the
clients urine during times collection, the
procedure must be restarted from the
beginning
To collect a stool specimen for infant, the
stool is scraped from the diaper
For occult blood examination, the client
should be instructed to avoid dark-colored
food, red meat, iron and hemoglobin rich food
for 48 74 hours
Avoid collecting specimen during menstrual
period
Sputum specimen is best collected early
morning to help the client expectorate all the
secretions that has been accumulated at night
Method of sputum collection includes deep
breathing and coughing exercise, suctioning
and chest physiotherapy
Blood test are the mot commonly used

diagnostic test and can provide valuable
information about the hematologic system and
other body system
Walker promotes more stability compare to
cane and crutches
Crutches observes different gaits such as: 4
point gait, 3 point gait and 2 point gait, plus
swing to and swing through
Cane should always be places on the stronger
side of the body
Client should always be free from restraint
Reason for placing the client on a restraint
includes: disruptive behavior, procedure and
transfer
Never anchor the restraint on the side rail
Free movement should be provided when
placing the client on a restraint
Two types of visualization are direct and
indirect. Direct method make use of gadget or
instrument to visualize a body area/organ.
Indirect method make use of dye, electrical
impulses
KUB X-ray (kidney, ureters, bladders) are
painless
for voiding cystourethrogram films are taken
before, during and after voiding
Retrograde pyelogram (RPG) outlines the
pelvis and ureters. Epinephrine at the bedside
should be prepared
A pink tinged urine is normal after cystoscopy
because of the irritation of the mucus
membrane
Distending bladder for KUB ultrasound is done
for better imging
A 24 hours bed rest after renal biopsy is
encouraged to prevent bleeding
Blood Transfusion is used to improved the
oxyen carrying capacity of the blood and
restore the blood volume
0.9% NaCL is the only fluid solution allowed for
blood transfusion
Label the blood and warm the blood at a room
temperature
Use needle gauge 18 or 19 for BT to allow easy
flow of the blood
Do not mix medication with blood transfusion
Stop the transfusion immediately for any
complication that might occur during blood
transfusion
NOTES:
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"If you can imagine it, You can achieve it.

If you can dream it, You can become it."
- 2 -
Psalm 62:8
Trust in him at all times, O people;

pour out your hearts to him, for
God is our refuge.
Perioperative Nursing
3 Phases of Perioperative Nursing
1. Preoperative phase starts from the time the surgical
decision is made
2. Intraoperative phase admission of the client in the
operating room
3. Postoperative phase admission of the client in the
recovery room
Classification of surgical procedures
I. According to PURPOSE
1. Diagnostic - to confirm or establish the presence of a
disease condition
2. Curative- to treat the disease condition.
a. Ablative - removal of a diseased organ
b. Constructive - repair of congenitally defective organ
c. Reconstructive- repair of damaged organ
3. Palliative- to relieve distressing signs and symptoms
II. According to degree of RISK
1. Major surgery
* High risk
* Extensive
* Prolonged
* Large amount of blood loss
* Vital organs may be handled or removed great
* Great risk of complications
2. Minor surgery
* often perform in a day surgery
* few serious complications
* less risk
III. According to URGENCY
1. Emergency- done immediately to save or limb.
2. Imperative- done within 24 to 48 hours.
3. Planned /required- may be scheduled week or months
4. Elective - not absolutely necessary for survival
5. Optional. Requested by the client.
6. Day (Ambulatory) done on out-patient basis
Surgical Risks
1. Age
* Very young and elder clients are greater surgical risks
2. General health
* any infection or pathophysiology increases surgical risk
3. Concurrent or prior pharmacotherapy
* The regular use of certain medications can increase
surgical risk like anticoagulants, tranquilizers,
corticosteroids and diuretics
4. Nutritional status
* Obesity and malnutrition increase surgical risk
5. Mental status
* Disorders that affect cognitive function may affect the
clients ability to understand and cope with the stresses of
surgery
Effects of Surgery To the Client
1. Stress response is elicited.
2. Defense against infection is lowered.
3. Vascular system is disrupted.
4. Organs functions are disturbed.
5. Body image may be disturbed.
6. Lifestyles may changed.
PREOPERATIVE PHASE
A. Informed consent (Operative Permit/ Surgical consent)
* The surgeon is responsible for obtaining the informed
consent
* The nurse may witness the clients signature on the
agency consent form
* Informed consent is only possible when the client
understands the information- conscious, mentally
competent and not sedated
Purposes
1. To ensure that the client understands nature of the
treatment including the
potential complications and
disfigurement (explained by AMD)
2.
To indicate that the clients decision was made without

pressure.
3. To protect the client against unauthorized procedure.
4. To protect the surgeon and hospital against legal action by a
client who claims that unauthorized procedure was
performed.
Circumstances requiring a permit
1. Any surgical procedure where scalpel, scissors, suture,
hemostats of electrocaogulation may be used
2. Entrance into a body cavity- e.g. paracentesis,
bronchoscopy, cystocopy, colonoscopy,,
proctosigmoidoscopy
3. General anesthesia, local infiltration, regional block.
5. Radiographic procedure (those requiring the use of dye)
Requisites for validity of informed consent
1. Written permission is best and is legally acceptable.
2. Signature is obtained with the clients complete
understanding of what to occur
-Adults sign their own operative permit
-Obtained before sedation
3. Secured without pressure or duress
4. A witness is desirable nurse, physician or other authorized
persons
6. In an emergency, permission via telephone or telefax is
acceptable
7. For minor (below 18 yrs,), unconscious, psyschologically
incapacitated, permission is now required from responsible
family member (parent / legal guardian).
Physical preparations
1. Preoperative assessment
a. Current health status
b. Allergies
c. Medications
d. Previous surgeries
e. Mental status
f. Understanding of the surgical procedures and
anesthesia
g. Smoking
h. Alcohol
i. Coping
j. Social resources
k. Cultural and spiritual considerations.
2. Screening Tests
a. Complete blood count
b. Blood grouping and cross-matching
c. Serum electrolytes
d. Fasting blood glucose
e. BUN and creatinines
f. ALT, AST, LDH and bilirubin
g. Urinalysis
h. Chest x-ray
i. ECG )all clients over 40 years of age and/or clients with
preexisting cardiac conditions)
j. Pregnancy test (all female clients of childbearing age)
3. Preoperative teaching
- reduces clients anxiety and postoperative
complications and increases their
satisfaction
with the surgical experience
- four dimensions
a. Information- what will happen, when and what the
client will experience
b. Psychosocial support and reduce anxiety
c. Roles of the client and support people in
preoperative preparations, the surgical
procedure
and during the postoperative phase
d. Skill training
- turning/moving
- deep breathing
- coughing
- splinting the incisions
- ambulating
- using an incentive spirometer
4. Physical preparation
- 1 -
a.
Nutrition and fluids

* Adequate hydration and nutrition promote healing
*Revised guidelines on preoperative fasting (Crenshaw
and Winslow, 2002)
- Consumption of clear liquids up to 2 hours before
elective surgery requiring general anesthesia, regional
anesthesia or sedation-analgesia
- Light breakfast (ex: tea and toast) 6 hours before the
procedure
- Heavier meal 8 hours before surgery
b. Elimination
* Enemas before surgery are no longers routine
* cleansing enemas for bowel surgery
*enemas help prevent postoperative constipation
and contamination of the surgical area
* Peristalsis may return after 24-48 hours
* IFC to ensure empty bladder prior to surgery
c. Hygiene
* ask the client to take a bath or shower the
evening or morning of surgery or both
* purpose is to reduce the risk of wound infection
* Clients nails should be trimmed and free of
polish
* remove cosmetics, hairpins, clips, personal
clothings
* puts on operating gown before transferring the
client to the OR
d. Medications
* preoperative medication are given to the client
prior to going to the operating room
* must be given at a scheduled time or on call
1) Sedatives and tranquilizers
ex:secobarbital and diazepam
- given to reduce anxiety and ease anesthetic induction
2) Narcotic analgesics
to provide client sedation and reduce the required
amount of anesthetic
ex: morphine and meperidine
3) anticholinergic
to reduce oral and pulmonary secretions and prevent
Laryngospasm
Ex: atropine, scopolamine and glycopyrrolate
4) Histamine-receptor antagonists to reduce gastric fluid
volume and gastric acidity
Ex: cimetidine, ranitidine
5) Neuroleptanalgesic agents
to induce general calmness and sleepiness
Ex: Innovar
e. Rest and sleep
* promote rest and sleep the night before surgery
* a sedative may be given
* Adequate rest helps the client manage the stress of
surgery and helps healing
f. Valuables
* Jewelry and money should be sent home or label them
and place in a locked storage area
* Wedding ban maybe taped in place ( should be
removed if there is anger of the fingers swelling after
surgery)
g. Prostheses
* dentures, contact lenses, contact lenses , artificial
limbs, eyeglasses, wigs and false eyelashes must be
removed before surgery
* Hearing aids are left in place
h. Special orders
* check the surgeons orders for special requirements
(NGT,insulin, antimeboli stocking)
i. Skin preparation
* carried out during the intraoperative phase
* surgical site is cleansed with an antimicrobial soil and
reduce the resident microbial count to subpathogenic
levels
j. Safety protocols
* Universal Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong
Person Surgery (JCAHO, 2003)
1) Preoperative verification
- done at the time surgery is scheduled, during admission,
and whenever the client is transferred to another caregiver
2) Mark the operative site
- may use the clients initials, surgeons initials and the
word Yes
- do not use an X mark
3)
Time-out
- To conduct a final verification of the correct client,

procedure and site
k. Vital signs
* assess and document vital signs for baseline data
l. Antiemboli stockings
* Firm, elastic hose to compress the veins of the legs to
facilitate the venous return; to prevent venous stasis
and venous thrombosis and to reduce
peripheral
edema
* apply stocking in the morning if possible before the
client arises
m. Sequential compression devices
* promote venous return from the legs
* inflate and deflate plastic sleeves wrapped around the
legs to promote venous flow
INTRAOPERATIVE PHASE
Goals of Care: Asepsis, homeostasis, safe administration of
anesthesia, hemostasis
A. Principles of perioperative asepsis
1. General
a. Keep sterile supplies dry and unopened
b. Check package sterilization expiration date to verify
sterility
c. maintain general cleanliness in surgical suite
d. maintain surgical asepsis throughout the procedure
2. Personnel
a. Personnel with signs of illness should not report to
work
b. Surgical scrub
3. Maintaining a sterile field
a. create a sterile field using sterile drapes
b. use the sterile field to place sterile supplies where
they will be available during the procedure
d. Drape the equipment prior to use
e. keep drapes dry and out of contact with nonsterile
objects
f. utilize sterile technique while adding or removing
supplies from sterile fields
4. Sterile supplies and solutions
a. Check expiration dates for sterility
b. Dont use solutions that were opened prior to current
use
c. lip the solution after initial use by pouring a small
amount of liquid out of the bottle into a waste
container to cleanse the bottle lip
Members of the Surgical Team
1. Surgeon heads the surgical team and makes decision about
the surgical procedure
- captain of the ship
2. Assistant surgeon
3. Anesthesiologist or nurse anesthetist alleviates pain and
promotes relaxation with medications
- anesthesia provider
- maintains hemodynamic stability of the client and
alerts the surgeon immediately to any complications
4. Circulating nurse
- coordinates activities and manages client care by
continually assessing client safety, aseptic practice, and
the environment
5. Scrub nurse
- assists surgeon; wears sterile gown, gloves, caps and
eye protection
- drapes the client and handles sterile instruments and
supplies
- accounts of all sponges, needles and instruments
together with the circulating nurse
Position During Surgery
1. Dorsal recumbent hernia repair, mastectomy, bowel
resection
2. Trendelenburg lower abdomen, pelvic surgeries
3. Lithotomy vagnal repairs, D & C, rectal surgery, APR
4. Prone spinal surgeries, laminectomy
5. Lateral kidney, chest, hip surgeries
Principles of Positioning the Client
Explain purpose of position
1. Avoid undue exposure
2. Strap the person to prevent falls
3. Maintain adequate respiratory and circulatory function
4. Maintain good body alignment
5. position should provide:
a. optimal visualization of and access to the
surgical site
b. optimal access to IV lines and monitoring devices
c. protection of the client from harm
- 2 -
6.
client is positioned after anesthesia is induced and

before surgical draping of the client
Types of Anesthesia
1. General
- total loss of consciousness and sensation
- protective reflexes are lost
- produced amnesia
- IV, inhalation, rectal
2. Regional reduce all painful sensation in one region of the
body without inducing unconsciousness
- topical, local infiltration, field block, nerve block, IV
regional, spinal, epidural block
3. Conscious sedation
- minimal depression of the level of consciousness
- client retains the ability to maintain a patent airway
and responds appropriately to commands
Stages of Anesthesia
1. Onset/induction
extends from the administration of anesthesia to the
time of loss of consciousness
2. Excitement/delirium
extends from the time of loss of consciousness to the
time of loss f lid reflex
3. Surgical
extends from the loss of lid reflex to the loss of most
reflexes
surgical procedure is started
4. Medullary/stage of danger
- characterized by respiratory/cardiac depression or arrest
American Society of Anesthesiology Physical Status
Classification System
I. Healthy client with no systemic disease
II. Mild systemic disease
III. Severe systemic disease
IV. Severe systemic disease that presents as a constant threat to
survival
V. Client who is not expected to survive without surgical
procedure
VI. Brain-dead client whose organs are being donated
E. Emergency operation of a client with a poorer physical status
Complications and Discomforts of Spinal Anesthesia
1. Hypotension
2. Nausea and vomiting
3. Headache
4. Respiratory paralysis
5. Neurologic complications
Surgical Incisions
1. Butterfly craniotomy
2. Limbal for eye surgeries
3. Halstead/elliptical for breast surgeries
4. abdominal for abdominal surgeries
5. Mc Burneys for appendectomy
POSTOPERATIVE PHASE
Goals:
1. Maintain adequate body system functions
2. restore homeostasis
3. alleviate pain and discomfort
4. prevent postop complications
5. ensure adequate discharge planning and teaching
Nursing Care of Patient during the Immediate Postop (Immediate
Postanesthesia Recovery RR)
1. Transport of the client from the OR-RR
a. avoid exposure
b. avoid rough handling
c. avoid hurried movement and rapid changes in
position
2. Nursing assessments and interventions
Assessment
a. Appraise air exchange status and note skin color
b. Verify identity, operative procedure, surgeon
c. Assess neurologic status (LOC)
d. Determine VS and skin temperature (CV status)
e. Examine operative site and check dressings
f. Perform safety checks
* Position for good body alignment
* side rails
* restraints or IVs. BT
g. require briefing on problems encountered in OR
Interventions
a. Ensure maintenance of patent airway and adequate
respiratory function
lateral position with the face slightly down (no

pillow)
keep airway in place until fully awake
suction secretions
encourage deep breathing
elevate clients upper arm on a pillow
administer humidified oxygen as ordered
b. assess status of circulatory system
monitor vital sign and report abnormalities
observe signs and symptoms of shock and hemorrhage
promote comfort and maintains safety
continuous, constant surveillance of the client until
he/she is completely out of anesthesia
recognize stress factors that may affect the client in
RR and minimize these factors
Transfer of the Client from RR to the surgical unit
Parameters for Discharge from RR
1. Conscious and oriented
2. able to maintain a clear airway and deep breathe and
cough freely
3. stable vital signs
4. active protective reflexes (ex: gag and swallowing)
5. able to move all extremities
6. adequate urinary output ( at least 30 ml/hr)
7. a febrile or a febrile condition has been attended to
8. dressings are dry and intact
Ongoing Care of the Postoperative Client
Goals
restore homeostasis and prevent complications
maintain adequate cardiovascular and tissue
perfusion
maintain adequate respiratory function
Assessment
* assessments are made every 15 minutes until vital signs
stabilize, every hour for the next 4 hours, then every 4 hours for
the next 2 days
a. Level of consciousness
* assess orientation to time, place and person
b. Vital signs
* take pulse, respiration, blood pressure and O2
saturation every 15 minutes until stable
c. Skin color and temperature
* pale, cyanotic, cool and moist skin may be a sign of
circulatory problems
d. Comfort
* assess pain with the clients vital signs
* pain maybe due to muscle strain, flatus and angina
* ask client to rate pain on a scale of 1 to 10
* objective indicators of pain: pallor, perspiration,
muscle tension, and reluctance to cough, mover or
ambulate
e. Fluid balance
* assess type and amount of intravenous fluids, flow
rate and infusion site
* monitor I and O
f. Dressing and bedclothes
* inspect clients dressing and bedclothes underneath
the client
* excessive bloody drainage on dressings/bedclothes
indicate hemorrhage
g. Drains and tubes
* determine color, consistency and amount of drainage
from all tubes and Drains
Interventions
1. Pain Management
* Pain is greatest 12-36 hours after surgery, decreasing
after the 2nd or 3rd postoperative day
* PCA or continuous analgesic administration
* PRN parenteral or oral analgesics should be
administered on a routine basis (every 2 to 6 hours) for
the 1st 24 to 36 hours
2. Positioning
* Spinal anesthesia flat on bed for 8-12 hours
* Semi-conscious/unconscious placed on one side with
the head slightly Elevated or in a position that promotes
drainage of secretions
* elevate extremities
3. Deep-breathing and coughing exercises
* help remove mucus preventing pneumonia and
atelectasis
* incentive spirometer for deep breathing
* may be done hourly or every 2 hours
* incision must be splinted before coughing
-
- 3 -
4.
Leg exercises
* prevent thrombophlebitis
* to be done every 1 to 2 hours during waking hours
5. Moving and ambulation
* turning promotes maximum lung expansion
* turn to sides at least every 2 hours
* early ambulation prevents respiratory, circulatory,
urinary and gastrointestinal complications; general
muscle weakness
* generally, ambulation begins the evening of the day of
the surgery or the first day after surgery
* ambulation should be gradual begins with sitting and
dangling the feet
6. Hydration
* IV
* oral intake is permitted small sips of ater
7. Diet
* NPO immediately postop
* Oral intake is resumed when peristalsis has returned
* DAT clear liquids initially- full liquid
* Regular diet
8. Urinary elimination
* urinary bladder tone returns within 6 to 8 hours
9. Suction
* maybe continuous or intermittent
10. Wound care
* regularly inspect dressing- clean, dry, and intact
* excessive drainage hemorrhage, infection or an open
wound
* change dressing assesses the wound for appearance,
size, drainage, swelling, pain and the status of a drain
or tubes
11. Surgical dressings
* dressings are changed regularly
12. Wound drains and suction
* Penrose drain to permit the drainage of excessive
serosanguineous fluid and purulent material and to
promote healing of underlying tissues
* Hemovac or Jackson-Pratt a drain connected to
either an electric suction or a portable drainage suction
13. Sutures
* Skin sutures are removed 7-10 days after surgery
* Retention sutures 14-21 days
Potential Postoperative Problems
1. Respiratory
a. Pneumonia
S/S: fever, cough, expectoration of blood-tinged or
purulent sputum, dyspnea, chest pain
Px: deep-breathing exercises and coughing,
moving in bed, early ambulation
b. Atelectasis
S/S:
dyspnea,
tachypnea,
tachycardia,
diaphoresis, anxiety, pleural pain, decreased
O2 sat
Px: same as pneumonia
c. Pulmonary embolism
S/S: sudden chest pain, shortness of breath,
cyanosis, shock
Px: turning, ambulation, antiemboli stockings,
sequential compression devices
2. Circulatory
a. Hypovolemia
S/S: tachycardia, decreased urine output,
decreased BP
Px: early detection of signs and fluid/blood
replacement
b. Hemorrhage
S/S: overt bleeding, increased pain, increased
abdominal girth, swelling or bruising around
incision
Px: early detection of signs
c. Hypovolemic shock
S/S: rapid weak pulse, dyspnea, tachypnea,
restlessness and anxiety; urine output less
than 30 ml/hr; decreased BP, cool, clammy
skin, thirst, pallor
Px: IV; prevent hemorrhage, early detection of
signs
d. Thrombophlebitis
S/S: aching, cramping pain, swelling of the
affected area, red and hot to touch, vein feel
hard, positive Homans sign
Px:
early
ambulation,
leg
exercises,
entiemboli stocking; adequate fluid intake
e. Thrombus
S/S: Venous- same as thrombophlebitis
Arterial pain and pallor of affected extremity; decreased or
absent peripheral pulses
Px: Venous same as thrombophlebitis
Arterial: maintain prescribed position; early detection of signs
f. Embolus
Px: turning, ambulation, leg exercises
3. Urinary
a. Urinary retention
S/S: bladder disterntion
Px: monitor I and O, interventions to facilitate
voiding, urinary catheterization
b. UTI
S/S: burning sensation when voiding, urgency,
cloudy urine, lower abdominal pain
Px: adequate fluid intake, early ambulation,
aseptic straight cath, good perineal hygiene
4. Gastrointestinal
a. Nausea and vomiting
S/S: complaints of feeling sick to the stomach;
retching or gagging
Px: IV fluids until peristalsis returns then clear
fluid, full fluids, and regular diet;
antiemetic drugs; analgesics for pain
b. Constipation
S/S: absence of stool elimination, abdominal
distention and discomfort
Px: adequate fluid intake, high-fiber diet,
early ambulation
c. Tympanites
S/S: abdominal distention and discomfort (gas
pains), absent bowel sounds, Vomiting
Px: early ambulation, avoid using straw,
provide ice chips or water at room temp
d. Postoperative Ileus
S/S:
abdominal
pain
and
distention,
constipation, absent bowel sounds and
vomiting
5. Wound
a. Wound infection
S/S: purulent exudates, redness, tenderness,
fever, wound odor
Px: keep wound clean and dry, surgical aseptic
technique when changing dressings
b. Wound dehiscence
S/S: increased incision drainage, visible
underlying tissue
Px: adequate nutrition, incisional support and
avoidance of strain
c. Wound evisceration
S/S: opening of incision and visible protrusion
of organs
Px: same as wound evisceration
6. Psychologic
a. Postoperative depression
S/S: anorexia, tearfulness, loss of ambition,
withdrawal, rejection of others, feelings of
dejection, sleep disturbances (insomnia or
excessive sleeping)
Px:
adequate
rest,
physical
activity,
opportunity to express anger, and other
negative feelings
NOTES:
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"He who asks a question is a fool for five minutes; he who

does not ask a question remains a fool forever."
- 4 -
1 Chronicles 16:11
Seek the Lord and his strength,
seek his face continually.
Personality, Personality Disorders and Schizophrenia
Mental health: A state of well-being where a person

can realize his own abilities to cope with the normal
stresses of life and to function productively (World
Health Organization)
Mental illness: A clinically-significant behavioural or
psychological syndrome or pattern that occurs in an
individual and that is associated with present distress
or disability (American Psychiatric Association)
Psychiatric nursing: An interpersonal process
whereby a professional nurse practitioner, through
therapeutic use of self, assists an individual, family,
group, or community to promote mental health, to
prevent mental illness and suffering, to participate in
the treatment and rehabilitation of the mentally ill,
and, as necessary, to help them find meaning in their
experiences
The challenge in each stage is to resolve the conflict.

Resolution prepares the individual for the next
developmental stage.
Psychosocial Developmental Aberrations
Trust vs. Mistrust: Gullibility; suspiciousness

Autonomy vs. Shame and Doubt: Impulsivity;
compulsion
Initiative vs. Guilt: Ruthlessness; inhibition
Industry vs. Inferiority: Narrow virtuosity; inertia
Identity vs. Role Confusion: Fanaticism; repudiation
Intimacy vs. Isolation: Promiscuity; exclusivity
Generativity
vs.
Stagnation:
Overextension;
rejectivity
Ego Integrity vs. Despair: Presumption; disdain
Harry Stack Sullivan theorized that the human

personality
involves
more
than
individual
characteristics, and that inadequate or non-satisfying
relationships produce anxiety, which is the basis for
all emotional problems.
Facets of Psychiatric Nursing
Science: The use of nursing theories in practice

Art: The therapeutic use of self
Core: The interpersonal process
The most significant assumption under Freuds

psychoanalytical theory is that all behavior has
meaning and can be understood.
Sullivan developed the concept of the therapeutic

milieu, where the nurse functions as a participantobserver.
The Royal Decree of 1808 is the first Philippine

legislation related to mental health. Issued by the
Spanish government, it established a hospital for the
insane at Hospicio de San Jose, a charitable religious
institution, to care for its first patient, a sailor of the
Spanish Royal Navy.
Public Laws & Resolution No. 2122 of 1912 created

the first government mental health facility at the
Insane Department of the San Lazaro Hospital.
The preconscious is the domain of the human mind

that consists of knowledge that can be made available
to conscious awareness with effort or concentration
Structures of the Human Personality
Id: Present at birth; consists of all instinctual drives

for sex and aggression; operates on the pleasure
principle; uses primary process thinking (imagination)
Superego: Begins to develop at age 3 and matures by
age 12; the result of the moral training of childhood;
comprised of the conscience (prescribes and punishes)
and the ego-ideal (proscribes and rewards)
Ego: Develops during infancy as the child begins to
see self as a separate entity from the primary
caregiver (self-concept); operates on the reality
principle; uses secondary process thinking (reality
testing); responsible for impulse modulation
Psychosexual Developmental Milestones
Oral stage: Self-concept and body image
Anal stage: Power, punishment, and ambivalence
Phallic stage: Oedipus-Electra complex; penis as
organ of interest for both genders (penis envy in girls
and castration anxiety in boys)
Latency stage: Energy used to gain new knowledge
and skills in social relationships; sense of industry and
mastery; chum friendship
Genital stage: Sexual identity; independence from
home; ability to love and to work
Erikson is a Freudian ego-psychologist who developed
the concept of the Eight Ages of Man.
Personality development proceeds according to the
epigenetic principle.
Culture-Bound Syndromes
Amok (Philippines, Malaysia, Laos): A dissociative

episode followed by outburst of violent behavior
directed at people or objects.
Ataque de nervios (Philippines, Latin America):
Characterized by uncontrollable shouting, crying,
trembling, & verbal or physical aggression; occurs
frequently as a direct result of a stressful family event
Falling-out / Blacking-out (Philippines, Southern US,
Caribbean): Sudden collapse without warning; person
claims inability to see and may feel powerless to
move
The Mini-Mental Status Exam (Mini-MSE) is an
abridged evaluation tool that looks into five areas of
higher brain functioning: Orientation, Registration,
Attention, Recall, and Language.
Schizophrenia
Is no longer considered a single illness, but rather a

syndrome or a disease process characterized by
distorted and bizarre thoughts, perceptions,
emotions, movements, and behavior
- 1 -
Usually diagnosed in late adolescence or early

adulthood, with peak ages of onset: 15 to 25 years for
males, and 25 to 35 years for females
Acute dystonia: Torticollis, opisthotonus, oculogyric

crisis, and laryngospasm; treated with IM benztropine
(Cogentin) or IM/IV diphenhydramine (Benadryl)
The neurobiologic theory states that an excess in

dopamine and serotonin is responsible for the clinical
manifestations of the disease.
Pseudo-parkinsonism: Onset within first week of

initiation; rigidity, bradykinesia, and resting tremors;
treated with amantadine (Symmetrel)
Subtypes
Paranoid: Delusions and hallucinations are present
but thought disorder, disorganized behavior, and
affective flattening are absent
Disorganized: Thought disorder and flat affect are
present together
Catatonic: Subject may be almost immobile or exhibit
agitated, purposeless movement. Symptoms can
include catatonic stupor and waxy flexibility.
Undifferentiated: Psychotic symptoms are present
but the criteria for paranoid, disorganized, or
catatonic types have not been met.
Residual: Positive symptoms are present at a low
intensity only.
Akathisia: Inner sense of restlessness; the most

common EPS; also the primary reason for noncompliance; unresponsive to treatment; propranolol
(Inderal) for the palpitations; diazepam (Valium) for
the psychomotor agitation
Tardive dyskinesia: Late and irreversible; lipsmacking, tongue-thrusting, blinking, chewing and
choreiform movements; manifestations disappear with
sleep; warrants discontinuation
Neuroleptic malignant syndrome: Potentially fatal;

high fever, muscle rigidity, serum CPK,
leukocytosis; onset within first week; warrants
immediate discontinuation; dantrolene (Dantrium) for
muscle spasms
MRI: Ventricular enlargement and cortical atrophy

PET Scan: Diminished glucose & O2 uptake by the
temporal and frontal lobes
Positive manifestations: Hallucinations, delusions,
disorganized thinking, ambivalence, agitation, and
aggression
Negative
manifestations:
Anergia,
avolition,
anhedonia, emotional withdrawal, flat/blunted affect
Personality Disorders
Characterized by enduring patterns of feeling,

thinking, and behaving that become rigid, pervasive,
and stable over time
An enduring pattern of inner experience and

behavior that deviates markedly from the
expectations of the culture of the individual who
exhibits it (American Psychiatric Association)
Patterns are inflexible and pervasive across many

situations, due in large part to the fact that such
behavior is ego-syntonic (i.e., the patterns are
consistent with the ego integrity of the individual),
and therefore, perceived to be appropriate by that
individual
Typical/Conventional/Traditional Antipsychotics
Classified as non-selective dopamine antagonists;

reduce only the positive manifestations; high
potential for adverse reactions (e.g., anticholinergic,
extrapyramidal)
Fluphenazine (Prolixin); haloperidol (Haldol)

Perphenazine (Trilafon); loxapine (Loxitane)
Chlorpromazine (Thorazine); thioridazine (Mellaril)
Thioridazine (Mellaril) has a maximum daily dose of

800 mg due to possible pigmentary retinopathy.
Typical/Conventional/Traditional Antipsychotics
Classified as selective dopamine and serotonin

antagonists; reduce both positive & negative
manifestations, with greatly reduced risk for adverse
reactions
Clozapine
(Clozaril);
risperidone
(Risperdal);
olanzapine (Zyprexa); quetiapine (Seroquel)
Clozapine: Agranulocytosis, dose-related seizures

Risperidone:
Rhinitis,
insomnia,
sedation,
galactorrhea
New-Generation Antipsychotic:
Aripiprazole (Abilify)
Classified as dopamine system stabilizer; controls all

manifestations, with virtually no adverse reactions
Tolerance usually sets in by the third week, hence

atypical antipsychotics are given concurrently
Extrapyramidal syndromes (EPS) are due

excessively low dopamine levels caused
antipsychotic therapy.
to
by
Cluster A>> Odd or Eccentric Disorders

Paranoid: Irrational suspicions and mistrust of others
Schizoid: Lack of interest in social relationships,
seeing no point in sharing time with others
Schizotypal: Also avoids social relationships, though
out of a fear of people; odd, magical thinking;
considered mild schizophrenia
Cluster B>> Dramatic, Emotional, or Erratic Disorders
Antisocial: Pervasive disregard for the law and the
rights of others
Borderline: Extreme black-and-white thinking,
instability in relationships, self-image, identity and
behavior
Histrionic: Attention-seeking behavior, including
inappropriate sexual seductiveness and shallow or
exaggerated emotions
Narcissistic: Grandiosity, need for admiration, and a
lack of empathy
Cluster C>> Anxious or Fearful Disorders
Avoidant: Social inhibition, feelings of inadequacy,
extreme sensitivity to negative evaluation and
avoidance of social interaction
Dependent: Psychological dependence on other
people
Obsessive-compulsive: Rigid conformity to rules,
moral codes, and excessive orderliness
Wisdom consists of the anticipation of consequences.

- 2 -
Psalm 28:7
"The LORD is my strength and
my shield; my heart trusts in
him, and I am helped.
RENAL URINARY CONDITIONS
The functional unit of the kidney is the nephron.
The kidneys filter blood, selectively reabsorb

substances that are needed to maintain the
constancy of body fluid and electrolytes and
excrete metabolic wastes.
The most dangerous electrolyte imbalance in a

patient with renal failure is Hyperkalemia.
Protein in the urine is a sign of glomerular injury.
Anuria is daily urine output of less than 50 ml.
In bladder carcinoma, the most common finding is

Painless, gross hematuria.
A client with renal failure should receive a high

calorie diet thats low in protein as well as
potassium and sodium.
Urinary frequency, urgency can occur when the
urinary tract is irritated (e.g. UTI, Catheter
removal)
Polyuria is increased excretion of a large volume of
urine or a urine output of 2500 ml or more within
24 hours.
The most common cause of Acute

glomerulonephritis is Group A beta hemolytic
streptococcal infection.
The most common organism involved in UTIs
is E.Coli.
An acid ash diet is advised in a patient with
UTI. Cranberry juice and ascorbic acid are
common examples.
A KUB provides a radiographic image of the
Kidneys, Ureters and Bladder.
The most common type of UTI is Cystitis
(bladder).
The most common symptoms of renal calculi
include Renal colic, CVA tenderness, and Flank
pain.
Acute renal failure is reversible while chronic
renal failure is irreversible.
The common symptoms in BPH include
decreased force of urinary stream, urinary
hesitancy and urgency and interrupted urine
stream.
If a client cant void, the first nursing intervention

should be bladder palpation to assess for bladder
distention.
Evaluating blood urea nitrogen and serum

creatinine levels assesses kidney function.
UTIs can cause urgency and frequency, dysuria,

abdominal cramps or bladder spasms.
Stress incontinence is involuntary leakage of urine

triggered by sneezing, coughing, or a change in
position.
To ensure the patency of the AV fistula, the

nurse must palpate for thrill and auscultate for
bruit.
Urge incontinence is the inability to suppress an

urge to urinate.
The most common complication of peritoneal

dialysis is peritonitis.
The normal urine output is 30 ml per hour or it

normally ranges from 800 to 2000ml/day and
averages between 1200 and 1500 ml/day.
For a client with suspected renal or urethral

calculi, the nurse should strain the urine to
determine whether calculi have been passed.
First morning urine is the most concentrated and

most likely to show abnormalities. It should be
refrigerated or sent to the lab immediately.
The most common component of kidney stones is

Calcium.
The 3 causes or categories of Acute renal failure

are Pre-renal, Intra-renal and Post-renal.
The surgical management of choice BPH is

TURP.
Never take the BP or draw blood on the arm
with an AV fistula.
In collecting a specimen for urine culture and

sensitivity, the nurse should instruct the client
to collect the specimen from the Mid-stream
of urine.
If a task has once begun,

never leave it till it's done.
Be the labor great or small.
Do it well or not at all
- 1 -

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Psalm 23:18

There is surely a future

NURSING FACTS IN BRIEF

Psychotherapeutic, Somatic and

Non-Benzodiazepines (lesser side effects):

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/410-0250

ALTERNATIVE TREATMENT MODALITIES

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/410-0250

"But blessed is the man who

NURSING FACTS IN BRIEF

Anxiety, Anxiety Disorders, Psychosomatic

Generalized Anxiety disorders: unrealistic or

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/410-0250

Symptoms: compulsive mirror checking or

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/410-0250

NURSING FACTS IN BRIEF

IV. Drugs affecting the Respiratory System

Myocardial Infarction- Epinephrine (Adrenalin).

Heartburn and gastritis- AlOH, MgOH, CaCO3,

Ventricular fibrillation- Lidocaine.

Peptic Ulcer Disease- Sucralfate (Carafate)

Sinus Bradycardia- Atropine sulfate.

PUD related to H. pylori infectionCombination of Bismuth, Amoxicillin, and

Palpitation related to hyperthyroidismPropranolol (Inderal) by blocking B-1 adrenegic

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/410-0250

Constipation in patients with MI, stroke, postsurgical procedures- Lactulose.

X. Drugs affecting the Hematologic System

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/410-0250

spirit of fear, but of power, and

NURSING FACTS IN BRIEF

When MRI is contraindicated ,CT is the procedure of

Ask if (+) allergy to Iodine

Tell the patient to expect a sensation of feeling

Procedure may last for 10 to 30 min

Maintain immobility on the entire process

Instruct clients to remove metallic items

Noninvasive structural imaging procedure that uses

The imaging procedure of choice for most

Open MRI-NO close chamber.The patient can

NO radiation / exposure to contrast medium

Sensitivity to blood flow

Ability to distinguish water, iron, fat and blood.

NO to patients with pacemakers, aneurysm

Use of bathroom prior to procedure-( may last 40 to

Instruct patients to remove metal items

Encourage patient to remain still as possible during

Inform that the scanner will make a dull , thumping

A computer based functional imaging that permits

Provides information on patterns of glucose and O2

Procedure requires injection or inhalation of a

Reassure patient that radiation exposure is minimal

Advise patient to void prior to procedure since it

Is often accompanied by impaired

III Double vision

VII Facial weakness and

Caution in shaving and mouth care.

Dysarthria, Dysphagia, Maintain airway. Prevent aspiration.

XII Dysarthria, dysphagia

Maintain airway. Prevent aspiration.

Brainstem (Midbrain , Pons , Medulla)

Medulla Oblongata - Apneustic center.

Cerebellum- Coordination of movement

Pituitary Gland - the master gland

Neurons-the functional unit of the Nervous system