Neuro/muscul

Meningitis
Hyperactive deep tendon reflexes, tachy, red macular
rash
CSF- cloudy bacterial, clear viral Protein, WBC, CSF
pressure glucose (bacterial)
DROPLET
Kernig Sign: + w/ meningitis = resistance and pain w/
extension of the clients leg from a flex position
Brudzinski Sign: + w/ meningitis = flexion of
extremities occurring with deliberate flexion of the
clients neck
Seizures
Tonic-Clonic Seizures
-usually lasts 1 to 2 min. but no more than 5 min.
Tonic Phase: episode of stiffening of muscle, loss of
consciousness, cessation of breathing, dilated pupils,
and development of cyanosis
Clonic Phase: episode of rhythmic jerking of the
extermitis, irregular resp, bitting of the cheek or tongue
and bladder and bowel loss.
Postictal Phase: may last for several hours.
Unconsciousness may last for 30 min. client wakes up
confused doesnt know what happened. s/s
headache, fatigue, muscle aches
Simple Partial Seizures:
consciousness maintained
dj vu, changes in HR, abnormal flushing, offensive
smells
Parkinsons
Parkinsons Stages:
Stage 1: unilateral shaking or termor of one limb
Stage 2: bilateral limb involvement occurs, making
walking and balance difficult
Stage 3: physical movements slow down significantly,
affecting walking more
Stage 4: tremors may decrease, but akinesia and
rigidity make day-to-day task difficult
Stage 5: client unable to stand or walk, is dependent
for all care, and may exhibit dementia.
Bradykinesia: slow movements
Stroke
LEFT: responsible for language, mathematic skills, and
analytic thinking.
-expressive and receptive aphasia (abilty to speech
and understand language)
-agnosia (unable to recognize familiar objects)
-alexia (reading difficult)
-Agraphia (writing difficulty)
-right extremity hemiplegia (paralysis) or hemiparesis
(weakness)
-slow, cautious behavior
-depression, anger, and quick to become frustrated
-visual changes
RIGHT: visual and spatial awareness and
proprioception
-alter perception of deficits
-one-sided neglect syndrome
-loss of depth perception
-poor impulse control and judgement
-left hemiplegia or hemiparesis
-visual changes, such as hemianopsia

Myasthenia Gravis
autoimmune disorder w/ severe muscle weakness
Tensilon Testing: measurement of the cranial muscle
strength. Medication Edrophonium (Tensilon) adm
(antidote is Atropine) + when muscle strength
improves.
Myasthenic Crisis (undermedicated): resp muscle
weakness mechanical ventilation, weakness,
incontinence, fatigue, hypertension
Cholinergic Crisis (overmedicated): muscle
twitching to the point of resp weakness,
hypersecretions (nausea, dirreaha, resp sections.),
hypotension, ATROPINE
Head injury
s/s: deteriorating LOC, restlessness, irritability, dilated,
pinpoint or asymmetrical puplis slow to react or
nonreactive, abnormal posturing (decerebrate,
decorticate or flaccidity), cushing reflex severe
hypertension w/ widening pulse pressure and
bradycardia. CSF halo sign from nose or ears.
1 hr golden window for best tx. Brain function
diminishes after 3 min w/o O2
HOB 30 degrees.
ICP pressure has not exceeded 25 mmHG for 30 min,
30 mmHG for 15 min, or 40 mmHG for 1 min.
Disorders of the Eye
cataracts: in vision and sensitivity to light
open-angle glaucoma: loss of peripheral vision
Macular Degeneration: loss of central vision
Angle-closure glaucoma: nausea and severe pain
*never turn on op side
Ear
Menieres Disease: vestibular disease characterized
by a triad of manifestations: tinnuitus, unilateral
sensorineural hearing loss, and vertigo
-FLUID restrictions
-limit freq position changes
-dark room
-administer antiemetic
Multiple Sclerosis:
-hyperactive deep-tendon reflexes
-risk for motor dysfunction, intention tremors, poor
coordination, and loss of balance
-double vision
Guillain-Barre Syndrome
-Ascending paralysis
Myasthenia Gravis
-Increased lacrimation (tearing of the eyes)
-Tensilon test (determines myasthenic crisis or
cholinergic crisis)
-double vision
Carbidopa-levodopa
-orthostatic hypotension
-high protein reduces the absorption
-saliva, urine and sweat can be darker color
-takes weeks to months to work
Rheumatoid Arthritis
-Ulnar deviation

-increased sedimentation
-spongy joint tissue
-celecoxib (Celebrex)
Osteoarthritis
-unilateral joint involvement
-compression fractures of the spine
-crepitus
-decrease range of motion
-affects larger joints
-joint pain resolves with rest
Increased Intracranial pressure
-maintain PaCO2 at approx. 35 mmHg
Post-op Craniotomy
-no suction ; only when necessary
-report wound drainage greater than 50ml/8hr
-elevated HOB 30 degrees
-neuros q15-30 min for 4-6 hr after 24 hr post op q2-4
hr
Right-sided homonymous hemianopia
Recombinant tissue plasminogen activator
thrombolytic dissolves blood clots
Recombinant factor VIII
manages symptoms of hemophilia
Amyotrophic Lateral Sclerosis
-rest periods
-adm pain meds
-MONITOR O2 SAT progressive paralysis of resp
muscles
Viral Meningitis
-neuros q4hrs
-standard precautions
-cap refill q4 hrs
-photophobia or light sensitivity
Continuous Passive Motion
-8 12 hr per day
-wear elastic stockings thromboemboli can occur 6
mo post
Subluxation: incomplete or partial dislocation of a
bone in a joint. Limb appears shorter
Atrophy: casted extremity is smaller due to the
wasting of the muscles that occur secondary to the
lack of use
Dislocated hip
-shortening of the leg
Decerebrate Posture
-rigidly extend all four extermities
Decorticate Posture
-internally flex the arms and extend the legs
-internally rotate arms and legs
Arteriovenous Malformation

RANDOM MED SURG B

-A gastric residual of 100 ml from gastrostomy tube or

200 ml from NG tube can indicate overfeeding which
can increase risk of aspiration
-Normal gastric ph 0 to 4
- 30 degrees during feedings
-DO NOT USE PEPPER cancer pts
-hydrogen peroxide use for denture care in cancer pts
ileal conduit
-empty urine bag q2hr
-clean stoma with soap and water
-place tampon over stoma when changing bag
-trim the bag seal 1 to 2 mm wider than the stoma
TPN
-change tubing every 24 hrs
-check blood glucose levels high dextrose content in
TPN
Hypoglycemia
-2 TB raisins
-8 oz milk
- 5 to 7 pieces of candy
-cheese and crackers after acute episode
MS
-intolerant to extreme temps
-avoid exposure to URI
-drinking in moderation
-cardiovascular exercise cannot tolerate

CARDIO
Bradydysrhythmia: s/s confusion, hypotension,
diaphoresis
Pericarditis: friction rub
Cardiac tamponade: pulses paradoxus, - systolic BP
is 10 mmHg higher on expiration or inspiration
endocarditis: valvular disease common complication
total cholesterol is less than 200 mg/dl
HDL above 40 mg/dl
LDL less than 100 mg/dl
25% of fat intake is okay
2 bottles of beer / day is okay moderate
-Claudication occurs with arterial ulcers
CABG mediastinal drainage 150ml/hr okay
-report elevated blood pressure
Dilated cardiomyopathy activity intolerance left
ventricular failure
Iron Deficiency anemia: ferrous sulfate
supplementation
Megaloblastic Anemia: increase folic acid
Pernicious Anemia: Vitamin B12 injections
CHF: sudden onset of SOB, air hungry, coughing
frothy, pink sputum crackles in lungs, pitting edema

Arteriosclerosis obliterans: thin, shiny skin w/

minimal body hair.
venous circulation: reddish brown pigmentation with
impaired.

Low pressure alarm on ventilator: check for loose

connections, artificial airway cuff leak.
high pressure alarm on ventilator: suction airways
(excess secretions), kinks in the tubing, biting on the
endotracheal tube

Kawasakis disease: sunburned appearance with

desquamation

hypoxia: restlessness, apprehension and anxiety.

Fresh frozen plasma: clotting factors check

prothrombin time

pneumonectomy: removal of the lung no chest

tubes

Anti-oxidants: beta-carotene, vit A, C, E and

selenium.

-if a tracheostomy tube becomes dislodged put it

back in
Flail chest: paradoxical movement of the chest wall of
a client who has fractured two or more ribs a portion
of the chest pulls inward on inspiration; on expiration
the same portion expands outward.

Primary or essential hypertension: no identifiable

cause.
Secondary hypertension: r/t an underlying
pathology
erythrocytes: carries oxygen to the tissues
leukocyte: white blood cells
thrombocyte: prevents blood loss.
reticulocyte: immature red blood cell.
Monitoring warfarin: Prothrombin time (PT) or INR
Monitoring heparin: activated partial thromboplastin
time (aPTT)

Respiratory Masks:
rebreather mask:
L/min)
Simple face mask:
L/min)
Venturi Mask:
Nonrebreather Mask:

40% to 70% (6 to 10
40% to 60% (5 to 8
24% to 60% (4 to 12 L/min)
60% to 100% (10 to 15 L/min)

Mechanical ventilation: ABGs

Percutaneous transluminal coronary angioplasty
(PTCA): dilate an obstructed coronary artery
Right CHF: peripheral edema
Left CHF: orthopnea (unable to breathe while lying
down), dyspnea
abdominal aortic aneurysm extending: c/o back
and abdominal pain, BP decreased

pH 7.50 PCO 25 HCO 22 = rep alkalosis

ph 7.50 PCO 35 HCO 30 = meta alkalosis
pH 7.30 PCO 35 HCO 20 = meta acidosis
pH 7.30 PCO 55 HCO 22 = resp acidosis (PCO is greater
than 45)
tension pneumothorax: tracheal deviation to the
unaffected side

MI: sternal chest pain

Pericarditis: dyspnea,

RESP
-pH 7.47 Po2 94 PCo2 30 HCo3 25 = respiratory
alkalosis hyperventilation; have client breathe slowly
into paper bag. -metabolic alkalosis = vomiting and diarrhea
-resp acidosis = decreased exhalation of carbon
dioxide as in COPD
absence of breath sounds: pneumothorax
expiratory wheezing: asthma
inspiratory stridor: narrowed upper airway
rhonchi: partial obstruction of large airways
Chest tubes:
-below level of chest
-suction control chamber should bubble continuously
-water seal chamber should not bubble
-change the whole drainage system when emptying.
-drainage greater than 100 ml in 1 hr needs
interventions
-small, dark-red clots are expected

GI
Paracentesis: increased HR (hypovolemia) potential
complication
-weight should decrease after procedure
-decreased SOB post procedure
Ileostomy:
-pts often experience intolerance to high-fiber foods.
-loose liquid output
-NHP of dark purple stoma = bowel ischemia
-sensation of burning during bowel elimination is
normal.
Ulcerative Colitis exacerbations teaching to
reduce risk
-use progressive relaxation techniques
-arrange activities to allow for daily rest periods
-restrict intake of carbonated beverages
AVOID fiber (causes diarrhea and cramping), milk
(poorly tolerated)
Acute pancreatitis:
-elevated serum glucose
-increased serum amylase
-elevated WBC
-increased bilirubin

-antibiotics should be adm due to increased risk for

infection
-identify the clients level of pain severe abd pain.
-NPO
-at risk for paralytic ileus might need NG tube
-Lipase levels in pancreatitis increase after a rise in
erum amylase and stay elevated for up to 14 days
longer than amylase
-Amylase begins to increase about 3 to 6 hours
following onset of acute pancreatitis. Levels peak in 20
to 30 hr and return to normal in 2 to 3 days.
-hypotension
-tachycardia
-increased leukocyte
Acute Hepatitis B: except joint pain
Complete Bowel Obstruction: obstipation (failure to
pass stool)
Small Bowel Obstruction: abdominal distention
Intraperitoneal Bleeding: periumbilical discoloration
(cyanosis)
Colonoscopy teaching: drink clear liquids for 24 hr
prior to the procedure, and then take nothing by mouth
for 6 hr before the procedure.
Dumping Syndrome: increase protein, avoid simple
sugars
Hepatic encephalopathy:
-reduction of sodium and fluid intake to limit the
development of ascites.
-temporary reduction in animal protein intake due to
the increased production of ammonia.
Cirrhosis
-lactulose: expect bloating, two to three soft stools per
day, high carb diet, drink 1,500 to 2,000 ml per day
-Normal findings: spider angiomas, peripheral edema,
jaundice
-abnormal findings: bloody stools
Colostomy
eggs, fish and broccoli increase stool odor
yogurt can prevent flatus and stool odor.
Post-op gastrectomy
Acute gastric dilation s/s: hiccups ensure patency of
the NG tube, hypotension, tachycardia, epigastric pain
Colorectal cancer
-normal findings: positive fetal occult blood test,
elevated carcinoembryonic antigen (CEA) level,
decrease hemoglobin (9.1) bloody diarrhea,
-CEA level determines the efficacy of chemo levels
will decrease
Appendicitis
Expected findings: low-grade temp, WBC count of
10,ooo to 18,ooo, N/V, right lower quadrant pain

Metoclopramide: monitor for hypertensive crisis, and

ataxia (extrapyramidal symptoms)
Famotidine: take with filtered h20, pain relief after
several days,
*does not have affects on glucose
Hep C
-Increase calories
-treatment for 6 mo
-avoid acetaminophen
Crohns Disease
-fatty, diarrheal stools (steatorrhea)
-hypokalemia
-weight loss
-abdominal pain in the right lower quadrant
Duodenal Ulcer
-pain midline between the umbilicus and xiphoid
process
-left of midline
-pain occurs 1/5 to 3 hr after meals and druing the
night.
Diverticulitis
-left lower quad pain
-should refrain from activity that increase intraabdominal pressure
-lower fiber diet
-avoid laxatives
Splenectomy
HIGHEST PRIORITY: promoting lung aeration = slow
deep and relaxed breaths will facilitate greater lung
expansion and O2 use
TPN
Monitor for shakiness and diaphoresis, weakness,
anxiety, confusion, and hunger: hypoglycemia
Hepatitis A
-can NEVER donate blood again
Esophagogastroduodenoscopy EGD: direct
visualization of mucus in the upper gastrointestinal
tract
Sigmoidoscopy or colonoscopy: visualize the lower
GI tract colon polyps

ENDO
Diabetes insipidus
-limit fluid intake: no more than 3 L per day
-daily weights
-report weight gain or loss of 1 lb per week
-occurrence of nocturia indicates dosage adjustment.
-tachycardia
-increased hematocrit (r/t dehydration)
-increased urine output leads to dilute urine and low
specific gravity
-increased BUN (r/t dehydration)
-polyuria increased urination
-polydipsia increased thirst
hyperglycemic-hyperosmolar state (HHS)

-blood glucose of 846 mg/dl and serum pH 7.40

(serum pH is within expected reference range, but the
blood glucose is greater than 600 mg/dl)
Vanillylmandelic acid test
-screens pt for pheochromocytoma
-no fasting
-24 hour urine (discard the first morning urine)
Diabetic Ketoacidosis DKA
-ph low, carbon dioxide is within excepted range and
bicarbonate
-increased urine output
-weight loss
-deep kussmaul respirations
-blood glucose levels above 300 mg/dl
-causes dehydration nausea and vomiting
-postive urine acetone
-bicarbonate level less than 15 indicates metabolic
acidosis
Adrenal insufficiency
-weight loss, Calcium above expected range, sodium
below expected range
Syndrome of inappropriate antidiuretic hormone
SIADH
-hyponatremia
-retains water
-hypertension
Acute Adrenal insufficiency
-adm hydrocortisone sodium succinate to replace the
cortisol deficiency
- rapid fluid replacement is indicated due to
hypovolemia
Adverse effects of long-term corticosteroid
therapy
-osteoporosis, moon-shaped face, increase risk for
infection
-blurred vision, weight gain
Primary Cushings Disease
-lymphocyte count is below the expected range
-Potassium is below the expected range
-calcium is below the expected range
-blood glucose is elevated
Adrenocorticotropic Hormone stimulation test
(ACTH)
-tests for Addisons Disease = response is absent or
very decreased in clients who have primary adrenal
insufficiency
test Urine and serum cortisol: Cushings syndrome
Type 1 Diabetes:
-During illness teaching: take usual dose of insulin, test
urine for ketones if glucose is greater than 240 mg/dl.
Call doctor if glucose exceed 250 mg/dl. Check levels
every 4 hours.
-alcohol consumption teaching: ingest alcohol with
meals to reduce alcohol-induced hypoglycemia; might
need decrease insulin dosage

Thyroid storm:
-Propranolol = reduction of the effects of thyroid
hormone on the heart. = decreases the rapid heart
rate caused by excessive thyroid stimulation.
Hypoglycemic: cool, clammy skin, diaphoresis,
blurred vision, tremor
Hyperglycemia: rapid, deep respirations, abdominal
cramping, urinary frequency, anorexia, dry mouth,
thirst
Early manifestations of hypoglycemia: drowsiness,
fatigue, headache, shakiness, and nausea
hyperthyroidism (Graves disease): heat
intolerance, restless, and irritable, tremors,
diaphoresis, and insomnia, exophthalmos (wide-eyed
startled appearance)
Hypothyroidism: cold intolerance, lethargy, sunken
eyes, weight gain, constipation, bradycardia,
hypotension
Thyroid replacement drugs: take medication on an
empty stomach do not eat or drink anything for 30 to
60 after taking it
Cushings Disease
-elevated blood pressure
-weight gain
-hirsutism
-Thinning of the skin
Propylthiouracil (PTU): treatment goals are to
increase weight with medication
Hypocalcemia: weak, thready pulse, increased bowel
sounds, tingling and numbness of the hands and feet,
hyperactive deep-tendon reflexes
Preop pheochromocytoma:
-avoid palpating the abdomen (causes hypertensive
crisis)
-will get a adrenalectomy loss of cortisol will need
glucocorticoid post op hormones must be replaced
-monitor client for extreme hypertension b/c
phenchromocytoma is a tumor of the adrenal glands
that causes excessive release of catecholamines
epinephrine and norepinephrine regulates HR and BP.
-Tumor usually benign
Glycosylated hemoglobin levels: or hemoglobin
A1C RBC lifespan approx. 4 mo hemoglobin
attached to glucose
Addisons Disease
-hormone deficiency caused by damage to the outer
layer of the adrenal gland (adrenal cortex)
-do not produce enough cortisol and aldosterone
-diet high in salt, carbohydrates, and protein
-low in potassium
Prolactin: hormone of pituitary gland and is
responsible for lactation

Aldosterone: mineralocorticoid produced by the

adrenal cortex, acts on the kidney promoting the
reabsorption of sodium ion into the blood.
Androgen: promote the development and
maintenance of male sex characteristics
Somatotropin: acromegaly excessive production
somatotropin (growth hormone) after closing of the
epiphyses by the pituitary gland. Enlargement of the
face, jaw, hands, feet and skull

IMMUNE
Breast exam:
normal findings: asymmetrical breast size, presence
of Montgomerys tubercles on the areola, moveable
mass in the left-lower breast quadrant.
Abnormal Findings: breast tissue with an orangepeel appearance
Clindamycin:
PID report watery diarrhea to provider immediately.
Risk for pseudomembranous colitis.
Erythema at the IV insertion site
-extravasation and infection.
Uterine Cancer: transvaginal US, endometrial biopsy
screening
Cervical Cancer: Pap test
Ovarian Cyst: screening; pelvic exam, along with
transvaginal US
Fibroids: vaginal exam, transvaginal US
Leukemia
-WBC
-Hgb levels
-Hct
-platelet
Systemic lupus erythematosus SLE
- urine output
-butterfly rash
-joint inflammation
-wear SPF of at least 30
-should wear gloves when its cold outside painful
vasoconstriction in fingers
-apply moisturizer after bathing skin lesions with warm
water
Lupus Nephritis
-renal calculi
Rheumatoid Arthritis
-subcutaneous nodules
Multiple Myeloma: overgrowth of B-lymphocyte
plasma cells
Hodgkins Lymphoma: Reed-Sternberg cells found in
lymph
Burkitts Lymphoma: Epstein-Barr Virus
leukemia: overproduction of blast phase cells
HIV
-low or decreasing CD4/CD8 indicates disease
progression
- viral load = + response to the therapy

Malignant Melanoma: asymmetrical papule that is

pigmented report to HCP
Psoriasis: patch of slivery-white scales with a red
epidermal base
Seborrheic Keratosis: irregular dry papules that are
black
Human Chorionic Gonadotropin: diagnose testicular
cancer
Kidney hyperacute rejection
-occurs during the first few weeks after transplant
-becomes enlarged
-organ will need to removed
HIV that has progressed to AIDS findings:
Kaposis Sarcoma small purple-colored skin lesions
CD4-T cell count be below 200 cells/mm
-persistent fever, swollen glands, diarrhea, weight loss,
and fatigue
Methotrexate
-avoid crowds
-takes 4 to 6 weeks to work
- folic acid to AE
-diarrhea
Scleroderma
-skin changes; thickening ( too much collagen),
hardening or tightening of skin, blood vessels, and
internal organs,
- Salivation risk of dental caries and gum disease
- Finger contractures arthritis
-Raynauds Disease, muscle weakness
-follow regimen of range-of-motion and musclestrengthening exercises
-renal failure due to constriction of vessels = ankle and
pedal edema
Impetigo: confluent, honey-colored crusted lesions
Varicella or Chickenpox: papules, vesicles, pustules,
and crusts
Herpes Zoster (shingles): unilateral, localized,
nodular skin lesions
Genital Herpes: fluid-filled vesicular rash in the
genital region
Raynauds Disease
-protect against cold with layers of clothing cold can
lead to tissue damage
-rest periods during exercise
-Niacin and pyridoxine have a vasoconstrictive effect
(causes exacerbations)
Pneumocystis Carinii Pneumonia PCP
HIV pts
-Bronchoscopy with biopsy of lung tissue confirms
Erythrocyte Sedimentation Rate (ESR)
-65 mm/hr (elevated) indicates an acute inflammatory
process. Use heat or cold therapy = controls
inflammation

Renal and Urinary

Chronic renal Failure: limit fluid intake, potassium,

protein
Ruptured Bladder: hematuria blood in the urine,
pelvic pain, and oliguria (low urine output)

Arteriovenous Shunt
-auscultate for bruits every 4 hours
-elevated the shunted arm on pillows postop
-DO NOT take BP in that arm
-palpate distal pulses of the shunted arm

Pyuria: pus in the urine- as with UTI

- NO NSAIDS AFTER RENAL TRANSPLANT
Transurethral Resection of the Prostate (TURP):
-pink tinged urine normal finding 24 to 36 hr post op.
once urine returns to yellow color; it could become
pink-tinged, esp w/ activity for up to 6 wks.
-REPORT TO HCP: painful urination could indicate
infection
-Stress incontinence is an expected finding
-retrograde ejaculation normal finding may result in
infertility
Cystoscopy: a direct look inside the clients bladder
through a small camera that is inserted through the
urethra.
Post op: pink-tinged urine and burning on urination
Upper UTI involving the kidneys is present
-casts are protein structures that are precipitated in the
renal tubules presence of indicate a pathologic
condition of the kidney
Kidney Rejection:
Hypertensive
Chronic renal failure
-limit phosphorous, potassium, and sodium
-supplement with calcium because the kidneys are
unable to activate calcium through the GI tract
Prostate Specific Antigen PSA
-PSA testing at age 50
-should not be performed for 48 hours following digital
rectal exam
Renal biopsy: prone with a pillow elevating the
abdomen
Peritoneal Dialysis potential complications:
-hypernatremia
-metabolic alkalosis (dialysate contains 45 mEq/L of
sodium acetate or lactate, and both are metabolized to
bicarbonate)
-at risk for infection
Hemodialysis: Anticoagulants are required for clients
receiving hemodialysis to prevent clot formation.
-risk for seizures if a rapid decrease in fluids

Acute Glomerulonephritis
-weight the client daily
-daily fluid allowance by adding 500 to 600 ml to the
clients previous 24-hr urine output
-client should rest
-periobital edema
-dry, itchy skin
-anuria or oliguria
-hypertension

Nephrectomy: adrenal gland can be removed or

damaged during a nephrectomy so monitor for
hypotension, decrease urine output, and decrease LOC
Continent Internal ileal reservoir: must insert a
catheter through stoma to drain urine
Acute kidney injury: BUN elevated, oliguria, and
hematocrit level decreased.
Pyelonephritis: diabetes pts are at an increase risk
due to reduced bladder tone
-drink 2,000 ml /day
-avoid NSAIDs for pain further damage the kidney
FLUID
Sodium
elevated: dehydration
Hematocrit
Decreased: 2+ pitting edema indicated fluid overload,
which can cause hemodilution
BUN
elevated: dehydration
Protein
elevated: dehydration
hyperkalemia: decreased muscle strength, increased
gastric motility, bradycardia, hypotension, prolonged
PR interval, a wide QRS, flat or absent P waves, and
tall, peaked T waves
hypokalemia: orthostatic hypotension, weak thready
pulse.
Venous Insufficiency: keep feet elevated 20
min/day
do not cross legs
Calcium:
low: cardiac rhythm (1st priority), bradycardia,
tachycardia, hypermobility (bowels), peripheral
sensations to check for paresthesia, check for
hyperreflexia- seizure precaution
hypomagnesemia: hyperactive deep-tendon
reflexes, muscle cramps, numbness, and tingling,
decreased bowel sounds, insomnia, increased blood
pressure
hypophosphatemia: slow peripheral pulsations,
kidney failure, weakness of skeletal muscles, and
eventually rhabdomyolysis (acute muscle breakdown),
decrease in CO

respiratory acidosis: hypotension, peripheral edema,

hyporeflexia
metabolic acidosis: facial flushing

Troponin I
Myoglobin
Cholesterol
HDL
LDL
Triglycerides
RBC
WBC
MCV
MCH
TIBC
Iron
Platelets
Hgb
Hct
PT
aPTT

INR
D-dimer
Fibrinogen
Sodium
potassium
Chloride
Calcium
Magnesium
Phosphorus
AST
ALT
ALP
Amylase
Lipase
Bilirubin
Albumin

Ammonia
BUN
Creatinine
Creatinine Clearance
Urine specific Gravity

pH
PaO2
PaCO2
HCO3
SaO2
CK-MB
Troponin T

7.35 7.45
80 100
35 45
21 28
95 100 %
0% (30 170 units/L)
< 0.2 ng/L

< 0.03 ng/L

< 90 mcg/L
< 200 mg/dL
F: 35 80 mg/dL
M: 35 65 mg/dL
< 130 mg/dL
M: 40 160
F: 35 135 mg/dL
F: 4.2 5.4 million
M: 4.7 6.1 million
5,000 10,000
80 95
27 31
250 460
F: 60 160
M: 80 180
150,000 400,000
F: 12 16
M: 14 18
F: 37 47%
M: 42 52 %
11 12.5 seconds
85 100%
1.5 2 x normal range of
30 40 seconds
monitor for heparin/
increased times can
indicated hemophilia DIC or
liver disease
0.7 1.8 (warfarin)
0.43 2.33
170 340
136 145
3.5 5.0
98 106
9.0 10.5
1.3 2.1
3.5 4.5
5 40
8 20
3 35
30 120
30 85
56 90
0 110
0.1 1.0
3.5 5.0
15 110
10 20
0.5 1.1
80 139

1.010 10.25

Prealbumin 12 mg/dl
below expected reference range protein status is
inadequate = delayed wound healing
-snack as part of bedtime routine can help clients relax
and prepare for sleep
old adult skin changes:
-thick and scaly
-round and reddish-purple (psoriasis)
-small, brown, and located randomly over the body
(moles)
Melanoma: variegated color and irregular borders
metoclopramide: half hour before meals for
gastroesophageal reflux
amputation of the left lower extremity
-elevated no more than 24 hr to prevent contractures
-rewrap the compression dressing three times daily to
promote proper fit of prostehesis and reduce edema
-anchor the residual limb dressing at the nearest joint
proximal to the amputation
pneumococcal: every 3 to 5 years
head injury: low fowlers head in midline position
MS: plan to exercise daily, avoid excessive heat
hyperactive bowel sounds: 30 gurgles and clicks
per minute
normal bowel sounds: 5 to 30 gurgles and clicks per
min
Caloric Test: client lie supine while irrigating with cold
and then warm solution in each ear. An expected
response for a client who has Meniere Disease is
vertigo, nausea, and vomiting.
TB: negative air flow room
Calcium channel blockers: headaches are common
,dumping syndrome: low fiber diet
Dehydration manifestations: tenting of the skin,
increased respiratory rate, urine output 20 ml/hr,
tachycardia, decreased BP

Help prevent falls:

-call light within reach
-slippers with nonskid soles
-bedside commode

continuous enteral feedings:

-irrigate the tube using least 30 ml of water q4hr
-elevated head of the 30 degrees
-auscultate for bowel sound
-change the tubing and feeding every 24 hr