NCLEX NOTES

Aortic Aneurysm:
 constipation & straining can cause↑abdominal pressure & risk for rupture
 encourage pt to drink ↑fluid & use dietary fiber to prevent constipation
 DO NOT advise to ↑ lower extremities above level of the heart
 contraindicated, ↑ pressure to the aortic artery

Addison's disease:
 ↓ the production of all adrenal hormones, compromising the body's natural stress
response & ↑ the RISK of INFECTION
 Cause ↑ retention of K+ which may result in cardiac dysrhythmias.
 Results in hypo function of the adrenal glands, which causes ↓ Na+, hypovolemia, & ↑
K+
 ↓ Na+, ↓ BG & ↑ K+
 Glucocorticoids
 Convert protein & fat into glucose
 Essential to life, are ↓ in Addison’s disease
 Pt will need exogenous Glucocorticoids therapy for the rest of pt’s life.
 Addisonian crisis: acute adrenal insufficiency precipitated by physical & psychological
stressors
 manifestations include N/V, extreme weakness, severe hypoglycemia, S/S of
shock,
 highest PRIORITY is to prevent ↓ cardiac output
 It leads to hypovolemia, hypotension, tachycardia, shock
 ↑ FLUID D5 NS
 PROVIDE STEROID replacement
most important information pt needs to know

 Nursing care includes administering hydrocortisone therapy &
vasopressors, rest, monitor V/S.
 Should ↑ fluid & salt intake during hot weather

Adrimycin:

 Chemotherapeutic agent
 Baseline cardiac function studies are required to monitor the IRREVERSIBLE
CARDIOTOXIC effects of doxorubicin HCL
 Causes bone marrow depression
 Report signs of infection such as sore throat & fever
 Urine turns red for 1-2 days
 Stomatitis may occur 5-10 days after use

Air fluidized surface:

 protects the skin from moisture

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  used for pt with pressure ulcers stage 3+

Albumin (serum):
 administered to maintain serum level & normal oncotic pressure (osmotic) pressure
 It does this by pulling fluid from interstitial spaces into intravascular compartment.
 Same thing with K+ 3.5-5.5

Alzheimer’s disease:
 Early symptom includes recent memory loss, & changes in motor activity such as
continuous pacing, wandering & agitation.

Ambulatory Aids:
 crutches:
 Using both crutches on stairs:

the good leg goes up, the bad leg comes down
 the good goes to heaven & the bad goes to hell

 Walk on surface:
 Bad leg with crutches goes first followed by good leg
 Cane:
 Used only if pt can tolerate some weight on affected leg

Cane

Opposite

Affected

Leg
 Walking:

Cane, weaker leg then stronger leg
 up stairs:

unaffected leg 1st

then affected leg & cane
 Down stairs:

Advance cane & weak leg

Then strong leg
 GOOD goes UP & BAD goes DOWN
 When teaching pt how to use cane nurse should

Stand slightly behind pt on pt’s strong side
 Walker:
 Wandering

2
  walker
 Wilma’s
 with
 Always
 affected
 Late
 leg

Amyotrophic Lateral Sclerosis:

 AKA Lou Gehrig’s disease
 progressive, ultimately fatal disorder that damages the motor neurons
 While motor neuron damage does not affect the senses, personality, thought, or memory,
it does weaken & eventually paralyze the body.
 ALS, is a disease of the parts of the nervous
system that control voluntary muscle
movement
o Difficulty swallowing
o does not changes mental state

Anatomical position:
 Palms faces forward

Antabuse (disulfaram):
 AVOID OTC cough/cold meds because they
contain alcohol & any intake of alcohol will
cause a severe reaction including
 Pounding headache
 Flushed skin
 Tachycardia
 SOB
 Chest pain
 Blurred vision
 Hypotension
 Possible confusion

Antacids:
 ↑ intake of Mg+ containing antacids & laxatives can cause ↑Mg+>2.5
 S/S of ↑Mg+ include
 Depress CNS & cardiac impulse transmission
 Muscle weakness
 Drowsiness
 Decrease deep tendon reflexes
 hypotension
 D/C oral Mg+

3
  Support ventilation
 Administer loop diuretics or IV Ca+
 Teach about OTC drugs that contain Mg+
 Should be given at BEDTIME
 Amphojel (AL (OH) 3):
 administer after meal
 max acid secretion occurs 1 to 3 hrs AFTER MEALS
 Tums
 Milk of Mg
 Calcium & sodium carbonate
 You have to give 1 hour apart with antihistamine

Antihistamines
 decrease gastric secretions
 Tagamet
 Zantac
 Pepcid
 given with MEALS

Anti-cholinergic:
 Atropine:
 if allergic to this med maybe allergic to Atrovent
 Treatment of choice for sinus bradycardia 2mg
 Cogentin: used to control extrapyrimidal symptoms

Anticoagulant:
 Heparin:
 Normal APTT is 20-30sec
 Maximum PTT is 112sec
 Therapeutic level is 1.5-2.5 control
 Nurse needs permission to administer
 Protamine Sulfate – antidote of Heparin
 Coumadin
 INR normal 2-3
 Should be instituted 4-5 days before discontinuing heparin therapy
 3-5 days to reach peak level

Anticonvulsants:
 Can cause folate & vitamin D deficiencies
 Dilantin:
o Metabolized & excreted by liver
o Drug of choice in E.R for status epileptics
o Brush & floss teeth daily

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 o May turn urine pink, red or reddish brown
o Therapeutic level 10-20mcg/ml
o CONTRAINDICATED in PREGNANCY
o Toxicity:
 Nystagmus >20
 Ataxia >30
 Slurred speech >30
 Tegretol:
o Inhibits nerve impulses & ↓ the pain of the condition
o Use in treatment of tic douloureux
o Causes immunosuppressant
 Blood dyscrasias such as aplastic anemia, leukopenia, anemia,
thrombocytopenia
 Notify MD if experience SORE THROAT
o Food to room temp
o rinse mouth after eating, avoid brushing
o Therapeutic level 5-12mcg/ml
o Before surgery inform anesthetic because amount of anesthesia may need to be ↓
because pt is on anticonvulsant
o Interferes with action of hormonal contraceptives
o Photosensitivity
 Topiramate(Topomax):
o 2000-3000ml of fluid to prevent kidney stones
o Should not use oral contraceptives

Antidiarrheal
 Loperamide (imodium): used for "travelers diarrhea"
o report fever & blood in stool

Anti-embolism stocking:
 Should be worn the entire time pt is in hospital
 Should be remove for bath
 Should be applied before pt gets out of bed

Antiemetic
 Prochloperazine (compazine):
 used to prevent n/v after surgery
 especially important when activities such as gagging & coughing can put pressure
on the suture line
 incompatible in a syringe with all other meds
 use separate syringe when being administered with another med
 Zofran:
 Given right before chemotherapy
 Promethazine (Phenergan):

5
  H1 receptor blocker
 Reglan:
 Stimulates motility of upper GI tract, contraindicated with possible hemorrhage in
GI tract, used to treat nausea of chemotherapy
 Should not be administered to pt with ulcers

Antihypertensive:
 Ace Inhibitors:
 Capoten (Captopril):
 Use 1 hr before food or 2 hrs after food
 Use salt substitute
 Best drug for preventing or slowing down the destruction of your kidneys
 Calcium Channel Blockers:
 Nifedipine(Procardia):
 Safe during pregnancy
 Verapamil hydrochloride(Calan):
 Used to treat SVT
 Check pt HR prior to admission
 Assess for peripheral edema
 Diltiazem hydrochloride (Cardizem

Anti-infective:
 Vancomycin: used for severe staph infections that is unresponsive to other antibiotics
 Used for dental procedures
 Before administer for UTI do clean catch urine
 Zithromax:
 Gonorrhea
 Cipro:
 Must be given at equal intervals (12hrs) around the clock to maintain blood levels
 take 1hr before or 2 hr after meals
 encourage increase FLUIDS
 If rash develop stop med & notify MD
 Tetracycline
 Should be taken on an EMPTY STOMACH
 Should be avoided in children <8 because it may cause enamel hypoplasia &
permanent yellowish gray to brownish tooth discoloration
 Causes photosensitivity
 Encourage pt to wear sunscreen
 Neomycin:
 Aids in ↓ intestinal flora that act on protein substances, causing production of
ammonia
 Detoxifies by liver
 Gentamicin:

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  Broad spectrum antibiotic
 after instilling drop, put pressure on the lacrimal sac for 1 min to prevent
systemic absorption
 never touch eye tissue with equipment (would contaminate bottle of medication)
 ototoxic to 8th cranial nerve & nephrotoxic
 monitor renal function such as BUN & Creatinine
 ↑ BUN & ↓ Creatinine
 If pt experience allergic reaction can be treated with antihistamines, epinephrine,
bronchodilators
 Can get super-infections which is more common with broad spectrum antibiotics

Antilipemic
 ↓ absorption of fat soluble vitamin ADEK
 Monitor pt for ↑ PT & prolonged bleeding which would alert nurse to vitamin K
deficiency
 Enzyme that helps metabolize cholesterol is activated at night
 Med should be taken with evening meal
 Lovastatin(Mevacor):
 administer with food
 Cholesterol restricted diet
 Simvastatin(zocor):
 used when diet & exercise fails to normalize cholesterol
 causes lens opacity & liver dysfunction
 Questran:
 side effect is constipation so ↑ fiber
 Regular exercise to prevent atherosclerosis
 Take other meds 1 hour before or 4-6 hours after taking questran

Antipsychotic meds:
 Clozapine (Clozaril): has potential to suppress bone marrow & cause agranulocytosis
 Report FEVER & SORE THROAT
 Use for Schizophrenia
 Monitor CBC, drugs will be d/c if WBC falls below 2000
 Contraindicated in pregnancy; excreted in breast milk
 Thorazine: used for treatment of schizophrenia.
 Contraindicated for pt with alcohol withdrawal
 Stelazine: schizophrenia
 breast- feeding is contraindicated
 Haldol: used in treatment of Tourette syndrome
 Fever indicates NMS
 Oculogyric crisis, emergency
 Eyes are locked upward
 Very irritating to subcutaneous tissues

7
  Give deep IM in large muscle mass
 Hypotension, advice pt to rise slowly
 Particularly effective in reducing assaultive behavior associated with anxiety
 Risperidone: s/s include extra pyramidal reactions, headache, insomnia
 like all antipsychotics, Risperidone can potentially cause tardive dyskinesia (TD),
extrapyramidal symptoms (EPS), & neuroleptic malignant syndrome (NMS),
although the risk for trigger diabetes
 Ultraviolet treatment contraindicated for pts who take antipsychotic drugs
(photosensitivity)
 Prolixin: drug of choice for noncompliant pts
 Can be given IM

Antistreptolysin O:
 ↑ Serum titer test indicates glomerulonephritis

Antiviral:
 Zovirax(acyclovir)
 Administer with food, may cause N/V& diarrhea
 Given 5 times/day
 for recurrent genital herpes
 Possible complications include acute glomerulonephritis
 ↑ fluid during treatment to prevent precipitation in renal tubules

Apgar score:
1. Heart rate
2. Respirations
3. Reflex irritability
4. Muscle tone
5. Skin color

Appendicitis:

 Midway between the right anterior iliac crest & the

umbilicus
 It is usually the location of the greatest pain in the child with appendicitis.

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Apraxia:
 Loss of purposeful movement in the absence of motor or sensory impairments
 Pt may not be able to perform ADLs

Arterial insufficiency:
 NEVER elevate legs
 advice pt to sit on side of bed when experiencing pain
 dangle legs to ↑ arterial blood
 pain is not caused by cold therefore to wear warm cotton pants will not relive it
 Pain is caused due to insufficient blood circulation
 hypoxia to the tissue
 venous insufficiency do opposite
 elevate legs

Ascites:
 protruding umbilicus
 caput medusa

o indicates portal vein obstruction

 shifting dullness indicates over the abdomen indicates ascites

Aspirin:
 do not use during pregnancy; can cause infant hemorrhage

Asthma:
 Absence of wheezing during acute respiratory distress in pt with asthma indicates small
airways completely constricted
 It is ominous sign in this pt
 Take meds at the same time on regular bases

Atrial septal defect:

 Hallmark a fixed S2 split, which is continuous, & results from prolonged emptying of the
right ventricle.

Autism:
 Finger flapping

9
Autonomic Dysreflexia:
 Damage to T6 and above; PRIORITY ABCs
 ↑ HOB 90 degrees
 to ↓ BP
 Place extremities in dependent position to ↓ venous return to heart & ↑ venous return to
brain.
 Assess for Bowel & Bladder impaction
 Loose constrictive clothing
 Administer antihypertensive medications.
 Avoid use of fan because cold draft may trigger autonomic dysreflexia
 Management of AD
1) Sitting position to ↓ BP
2) Check Foley catheter
3) Monitor AD q 10-15 min
4) Label the chart for risk AD
5) Instruct the pt how to prevent AD (full bladder, impaction, pressure on skin, cool
draft)
 Signs/Symptoms:
 Severe pounding heading
 slow heart rate
 blurred vision
 profuse sweating
 flushing (RED)
 nasal congestion
 piloerection

Bandage:
 Figure of 8 technique to bandage a joint such as an ankle, elbow or knees
 Circular bandage technique to secure a bandage
 Recurrent technique to bandage a stump, hand or scalp

Bell’s palsy:
 Chew food on unaffected side of mouth
 Use artificial tears
o Causes an inability to close the eye
o Prevents drying of the cornea
 Tape eyes shut at night
o Help retain moisture
 Avoid sleeping with windows open
o Due to trigeminal hyperesthesia, protect face from
cold & draft
 7 cranial nerve
th

10
  Increased lacrimation
 Go away in 3-5 weeks

Benzodiazepines:
 Are useful in treating anxiety, insomnia, agitation, seizures, and muscle spasms, as well
as alcohol withdrawal.
 Benzodiazepines are potent anticonvulsants & have life-saving properties in the acute
management of status epilepticus.
 The most commonly used benzodiazepines for
 Anticonvulsant:
 lorazepam (Ativan) & diazepam (valium)
 Alcohol dependence
 Librium & valium
 Most common
 alprazolam (Xanax)
 bromazepam (Lexotanil)
 clonazepam (Klonopin)
 temazepam (Restoril)
 oxazepam (Serax)
 Hypoxia, headache, sedation

Beta Blocker:
 Atenolol(Tenormin):
 True cardioselective
 Beta 1 blocker
 Can be given to asthmatics without causing issues
 ↓ CO, SBP/DBP
 Inderal (Propranolol):
 May mask symptoms of hypoglycemia
 Contraindicated in HF & Pulmonary edema
 Metropolol tartrate(Lopressor):
 side effects include bradycardia, hypotension, BRONCHOSPAMS which can be
life threatening

Bile Salts:
 Used to aid in digestion of fat & absorption of fat soluble vitamins ADEK

Biophysical profile:
1. Nonstress test
a. Pt sits in a chair or lie on a table with fetal monitoring equipment hooked to the
belly.
b. The monitor will record baby's heart rate in conjunction with any uterine activity.
c. Pt asked to press a button when baby moves so that the heart rate can be seen in

11
 relationship to that movement
2. Fetal tone
3. Fetal breathing
4. Fetal motion
5. Quantity of amniotic fluid

Biopsy:
 Liver:
 Perform Valsalva maneuver during insertion of needle
 This ensures liver does not move as it does with regular respiratory

excursions

Birth Control
 Diaphragm:
o Must remain in vagina at least 6 hours after intercourse
o Before insertion place 1tsp of spermicidal gel around rim & in the dome
o If >4 hours pass between the time the diaphragm was inserted & intercourse
occurs, use additional spermicidal gel
o Should be rechecked for correct size
 Annually
 After child birth
 If pt gained > 15lbs

Blood transfusion:
 Type O universal donor
 would usually be combine with Rh- negative blood & packed RBC
 All equipment should be ready before is ordered from blood bank
 Normal saline is isotonic & can be used with blood transfusion
 Attached packed cells to IV using Y tubing

12
  19 gauge angiocath
 Stop IV Amphotericin (antifungal) because it can cause allergic reaction with blood
transfusion
 pt can donate blood up to 5 weeks before surgery
 can give 2-4 unit blood
 has to be afebrile & has normal Hemoglobin & Hematocrit
 Hemolytic reaction
 Low back pain, headache, hematuria, hypotension
 Allergic reaction
 Urticaria, pruritus, bronchospasm, facial flushing & epiglottal edema
 Afebrile reaction
 Flushing, palpitation & nausea
 Autologous transfusion
 Collect & later transfer pt’s own blood
 Guaranteed compatibility
 Look for symptoms of bacterial reaction because that’s the only thing that can
happen
 Tachycardia, chills & fever
 You won’t see symptoms of allergy because pt can’t be allergic to its own blood

Blood Urea Nitrogen:

 Measures the amount of urea nitrogen, a waste product of protein metabolism, in the
blood
 Urea is formed by the liver & carried by the blood to the kidneys for excretion
 Because urea is cleared from the bloodstream by the kidneys, a test measuring how much
urea nitrogen remains in the blood can be used as a test of renal function
 Factors that can cause BUN alterations, including protein breakdown, hydration status,
& liver failure
 ↑ BUN : known as azotemia
 Impaired renal function
 CHF as a result of poor renal perfusion
 Dehydration
 Shock
 Hemorrhage into the GI tract
 Acute myocardial infarction
 Stress
 Excessive protein intake or protein catabolism
 Diseased or damaged kidneys cause ↑ BUN because the kidneys are less
able to clear urea from the bloodstream.
 In conditions in which renal perfusion is ↓, such as hypovolemic
shock or CHF, BUN levels ↑.
 A patient who is severely dehydrated may also have a ↑ BUN due
to the lack of fluid volume to excrete waste products
 urea end- product of protein metabolism, diet ↑ in protein, such as

13
 ↑-protein tube feeding, may also cause the BUN to ↑
 ↑ bleeding in GI tract will cause ↑ BUN because digested blood is
a source of urea.
 For example, a hemorrhage of one liter of blood into the GI
tract may ↑BUN up to 40mg/ml.
 Lab test result which indicates that pt at ↑t Risk for falling is ↑BUN
 Elevated BUN indicates: salt & water depletion
 ↑BUN can cause confusion, disorientation, convulsion, which easily lead
to fall
 water depletion could also result in falls due to orthostatic hypotension
 ↓ BUN
 Liver failure
 Malnutrition
 Anabolic steroid use
 Over hydration, Which can result from prolonged IV fluids
 Pregnancy (due to increased plasma volume)
 Impaired nutrient absorption
 Syndrome of inappropriate anti-diuretic secretion (SIADH)
 Because urea is synthesized by the liver, severe liver failure causes a ↓ of
urea in the blood
 over hydration causes a ↓ BUN
 Pt with SIADH (ADH) hormone responsible for stimulating the kidney to
conserve water causes excess water to be retained in the bloodstream
rather than being excreted into the urine
 SIADH can cause the BUN level, along with other important
substances, to decrease because the fluid volume of the
bloodstream may significantly increase.

BMI:
 Underweight: <18.5
 Normal weight: 18.5-24.9
 Overweight = 25-29.9
 Obesity: 30 or greater

Bone scan:
 Reveal stress fracture, fracture, & infection in the bone or joints
 After injection (only IV) of` the tracer, pt asked to drink ↑ fluid
o in the time between the tracer injection & the test
 to maintain hydration &↓ radiation dose
o void before the test
 to prevent distended bladder
o Scanning will be performed 2 or more hours afterwards.
o Pt should stay still
o Scan painless
o Actual scan 1-3 hrs

14
Breast self-examination:
 Use pads (palmar surface of the middle three fingers) of your first three fingers
 Press the breast against the breast wall in a circular motion
 Palpation begins in the upper lateral guardant; it moves from periphery to the areola &
moves around the breast counterclockwise.

 Easy way to remember

1. stand in front of the mirror with arm at sides
2. while standing, press hands firmly into hips and bow slightly
3. While standing raise one arm & palpate breast firmly
4. lie down, raise one arm, & palpate breast firmly

Breast milk:
 Produce with the delivery of the placenta, which causes the secretion of prolactin, which
in turn produces breast milk.

Breathing:
 Pursed lip: breath should never be held during pursed lip breathing

 Do not take deep breath.

 Breathe in (inhale) through nose slowly for two counts (1, 2) keeping mouse
close.
 Breath out (exhale) slowly through pursed lips while counting to 4 (1, 2, 3, 4)
 Used for emphysema, COPD.

Bronchodilators
 Singulair: used for long-term control of asthma by decreasing frequency of asthma
attacks
 Not used for acute asthma attacks

15
  Takes several weeks to lessen effects of chronic asthma
 Theophylline (Aminophylline):
 normal level 10-20
 S/E include Tachycardia, N/V, hypotension, confusion, headache, flushing &
seizure
 Can be given IV or PO
 causes rapid pulse & dysrhythmias
 Antispasmodic
 Terbutaline(Brethine):
 Used as a fast acting bronchodilator for short term asthma
 Used as a tocolytic to delay premature labor

Buerger’s disease:
 AKA thromboangiitis obliterans
 Acute inflammation & thrombosis of arteries & veins of the hands & feet
 Associated with smoking
 Characterized by a combination of inflammation & clots in the blood vessels, which
impairs blood flow
 This eventually damages or destroys tissues & may lead to infection & gangrene
 Begins in the hands & feet & may progress to affect larger areas of the limbs.
 Pain & weakness in your legs & feet or your arms & hands
 Swelling in your feet & hands
 Fingers & toes that turn pale when exposed to cold (Raynaud's phenomenon)
 Open sores on your fingers & toes
 Digital sensitivity to cold

Bulimia:
 if physical assessment revealed HOARSE VOICE that is barely audible refer pt stat to
MD because high risk for tracheoesophageal fistula from esophageal tear
 laryngitis is danger sign

Burns:
 Muscle weakness & lethargy are signs of hypokalemia, which can occur on the 3rd day
after a burn
 Hypokalemia is caused by diuresis
 First-degree burns:
 are usually limited to redness (erythema)
 White plaque & minor pain at the site of injury
 These burns usually extend only into the epidermis.
 Deep partial thickness:
 2nd degree burn
 Additionally fill with clear fluid, have superficial blistering of the skin, & can
involve more or less pain depending on the level of nerve involvement.
 involve the superficial (papillary) dermis & may also involve the deep (reticular)

16
 dermis layer
 Blisters, deep red, shiny &wet
 painful , blanching
 Gently clean & then leave the area open
 Leave uncovered
 clean away debris & dirt
 Leave blisters intact (do not break)
 no Vaseline
 Full Thickness:
 3rd degree
 Dangerous
 charred, waxy, white appearance of skin
 destroyed skin & muscles
 eschar tissue

Buspirone (Buspar):
 Take 14-30 hours before therapeutic effect take place.
 Treatment of generalized anxiety disorder
 buspirone is less effective than benzodiazepines
 therefore benzodiazepines 1st to be used

Cancer:
 Gastric cancer:
 develops sign – a yellow skin cast (jaundice), it is sign of metastasis
 gastric cancer metastasized into other organ – liver
 Lung Cancer:
 Common cause of SIADH, which is abnormal secretion of ADH
 results in ↑ water absorption & dilutional hyponatremia
 Diuretics used to promote fluid loss
 Cervical cancer:
 woman with cervical cancer & radioactive cesium implant should avoid sexual
intercourse & tampons for 6 weeks (until next follow-up visit)
 avoid activities that cause abdominal strain for 6-8 weeks
 Colorectal:
 Risk factors include
 >40
 h/o ulcerative colitis

Carpal Tunnel Syndrome:

 condition in which the median nerve is compressed at the wrist, leading to
pain, paresthesias, & muscle weakness in the forearm & hand
 Phalen’s maneuver: put back of hands together & bend both wrists at the same time

17
  Tinel’s sign: lightly tapping the area to elicit a sensation of tingling or “pins & needles”

Cast Care:
 After cast is applied elevate arm on pillow for 24-48 hours
 this protects from pressure & flattening of cast
 Petal edges of cast after cast is DRY
 To do so early would result in crumbling of plaster into cast

Cataracts:
 Opacity of lens that prevents the refraction of light
 Lens become less hydrated & more dense
 Distorted blurred vision
 Pt with cataract sees objects as distorted & blurred
 annoying glare
 pupils changing from black to gray to
 milky white pupil
 Most common cause of visual impairment
 Congenital or acquired
 Symptoms:
 painless
 perception of color may change
 Removal cataract with a lens implant allows correction of refraction of distant vision
 Pt may not require glasses to see distances, but may still need glasses for reading
or close work.
 Do not do jerky movement (vacuuming can ↑ IOP)!
 Ask someone to do the vacuuming for the a few weeks after surgery
 teach pt about post activities & restrictions
 avoid straining during bowel movement after surgery
 do not fly, do not go to high altitudes in 30 days
 Avoid strenuous activity for 3 months
 Implementation:
 Pre op: the following
 withheld anticoagulants for several days to prevent hemorrhage
 Check for hemorrhage
 Instill dilating drops every 10 minutes x 4 hours before surgery
 Check pupil-constricted with lens implanted, dilated without lens
 Take FLU SHOT to avoid cold which would result in sneezing & coughing thus ↑

18
 IOP
 Post op:
 Eye drops, antibiotics, anti-inflammatory, corticosteroids
 Eye patch for 24 hours
 Damp eye cloths to remove secretions
 Pt may complain of scratchy feeling for several days & blurred vision for
several days to weeks,
 eye may appear slightly red
 Night shields
 1-4 weeks
 Sleep on unaffected side
 Surgeries may be separated by several weeks or several months

CAT scan
 Pt have to lie 30 min in a closed space
 can cause anxiety if pt claustrophobic
 CT imaging uses special x-ray for Ds: osteoporosis, bone cancer, organ problems;
contrast material administer via IV if pt not allergic to dye.

Catheter:
 Foley:
 When removing use clean – non-sterile gloves.
 Sterile gloves required for catheter insertion
 Intermittent self-catheterization (man only)
 use Valsalva maneuver ( hold breath & bear down) before doing catheterization
 Straight single:
 Clamp catheter after 300-500ml of urine has drained because rapid decompression
of bladder can result in bladder wall damage.

Celiac disease
 6-24 months
 Gluten intolerance
 Protein found in wheat
 Inflammation causes damage to mucosal tissue of the small intestine, especially the villi
that absorb nutrients, which results in mal-absorption of food.
 Gluten free diet
 wheat, rye, oats
 pasta, cereal & canned foods
 Celiac Crisis:
 Severe diarrhea
 Dehydration
 metabolic disturbances like
 ↓ k+ ↓ Ca+ ↓ Mg+ & ↓ protein

19
Central line:
 If disconnected, 1st nursing intervention:
 place pt on the left side in Trendelenburg position
 This position ↑ the likelihood that the air will pass into the RA & be

dispersed by way of the pulmonary artery

 then O2 treatment & notify physician
 Central venous catheter (CVC) insertion:
 use Valsalva maneuver to prevent air embolism or Trendelenburg position
 if becomes dislodged, apply a catheter clamp
 if unavailable, nurse can place a sterile syringe or catheter plug into the catheter
hub
 Pt should not deep breathe!
 Complications include
 Pneumothorax
 due to possible lung puncture
 obtain equipment for insertion of chest tube if pt c/o restlessness
& dyspnea
 thrombophlebitis
 Respiratory distress
 Dysrhythmias

Central Venous Pressure:

 Normal CVP ranges from 4-10cm water or 3-7mm Hg
 Measures pressure in right ventricle
 Swan-Ganz catheter measures the pulmonary wedge pressure(PWP) which is an indirect
reading of the pressure in the left ventricle

Cerebral Vascular Accident:

 risks factors
1. Race
 African Americans
2. Gender
 male
3. Substance abuse
 Cocaine
4. Smoking

20
  Heavy alcohol use
5. Diabetes, obesity, high cholesterol
 Left side
o Controls speech, math skills, analytical thinking
 Right side
o Impulsive behavior
o Disorientation to person, place & time

Cesium implant:
 Internal radiation implant
 Not radioactive
 Means radiation is sealed either in a body cavity or a tumor which means it is
protected
 You can discard of urine in the hospital bathroom

Cheyne stokes respirations:

 AKA periodic breathing, irregular pattern of rapid breathing which builds from shallow
to very deep respirations & then back to shallow, followed by a period of apnea.
 Often referred to as crescendo-decrescendo pattern
 seen in severe CHF, drug overdose, ↑ ICP, & renal failure

Chest tubes:
 The 1st 24 hrs after chest surgery about 500-1000ml of drainage occur
 with 100-300 being in the first 2hrs & then a progressive decline in amount
 1 chamber collects drainage
st

 Water Seal chamber:

 2nd chamber
 There should be bubbles in water seal chamber when the pt exhale, cough, or
sneeze
 These bubbles indicate that the system is removing air from the pleural
space
 Fluid in water seal chamber should fluctuate with respirations of the patient,
rising with inspiration, & falling with expiration
 Absence of fluctuation indicates either that the lung has re-expanded
 Or that there is an obstruction of the chest draining tube
 Most common causes are pt lying on tube, kinking, dependent
loops, clots or fibrin
 Suction control chamber
 3rd chamber
 there should be continuous gentle, slow but steady bubbling

Chronic Renal failure:

 Dietary management:
 ↑ COH intake to help improve energy & prevent protein catabolism

21
  1-2 liters of fluid
 No salt substitutes because many of them are ↑ in K+, which may not be
adequately excreted by the compromised kidneys
 Body unable to store excess protein, which breaks down into waste & cannot be
excreted by the compromised kidney

Circumcision:
 Do not remove yellowish- white exudates during cleaning of the area.
 Use Vaseline on gauze on circumcision before diapering
 Dressing change after 3 days of procedure

Cirrhosis:
 Liver removes or neutralizes poisons from the blood, produces immune agents to control
infection, & removes germs & bacteria from the blood.
 It makes proteins that regulate blood clotting & produces bile to help absorb fats & fat-
soluble vitamins.
 In cirrhosis of the liver, scar tissue replaces normal, healthy tissue, blocking the flow of
blood through the organ & preventing it from working, as it should.
 Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, &
carbohydrates.
 Causes of Cirrhosis: Hepatitis B, C & D
 S/S:
 Edema & ascites:
 Liver loses its ability to make the protein albumin, water accumulates in
the legs (edema) & abdomen (ascites).
 Bruising &bleeding:
 Liver slows or stops production of the proteins needed for blood clotting
result in pt bruising or bleeding easily. The palms of the hands may be
reddish & blotchy with palmar Erythema
 Jaundice:
 A yellowing of the skin & eyes that occurs when the diseased liver does
not absorb enough bilirubin
 Itching: Bile products deposited in the skin may cause intense itching.
 Gallstones: If cirrhosis prevents bile from reaching the gallbladder, gallstones
may develop.
 Toxins in the blood or brain: A damaged liver cannot remove toxins from the
blood, causing them to accumulate in the blood & eventually the brain. There,
toxins can dull mental functioning & cause personality changes, coma, & even
death. Signs of the buildup of toxins in the brain include neglect of personal
appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in
sleep habits.
 Sensitivity to medication:
 Cirrhosis slows the liver's ability to filter meds from the blood. Because
the liver does not remove drugs from the blood at the usual rate, they act
longer than expected & build up in the body.

22
  This causes a person to be more sensitive to meds & their side
effects.
 Portal hypertension:
 Normally, blood from the intestines & spleen is carried to the liver
through the portal vein
 However, Cirrhosis slows the normal flow of blood through the
portal vein, which increases the pressure inside it resulting in
portal hypertension.
 Varices:
 When blood flow through the portal vein slows, blood from the intestines
& spleen backs up into blood vessels in the stomach & esophagus
 These blood vessels may become enlarged because they are not meant to
carry this much blood. The enlarged blood vessels, called Varices, have
thin walls and carry high pressure, & thus are more likely to burst. If they
do burst, the result is a serious bleeding problem in the upper stomach or
esophagus that requires immediate medical attention.
 Insulin resistance and type 2 diabetes:
 Cirrhosis causes resistance to insulin. This hormone, produced by the
pancreas, enables blood glucose to be used as energy by the cells of the
body
 If you have insulin resistance, your muscle, fat, & liver cells do not use
insulin properly. The pancreas tries to keep up with the demand for insulin
by producing more. Eventually, the pancreas cannot keep up with the
body's need for insulin, and type 2 diabetes develops as excess glucose
builds up in the bloodstream.
 Liver cancer:
 Hepatocellular carcinoma, a type of liver cancer commonly caused by
cirrhosis, starts in the liver tissue itself. It has a high mortality rate.
 Problems in other organs:
 Cirrhosis can cause immune system dysfunction, leading to infection.
 Fluid in the abdomen (ascites) may become infected with bacteria
normally present in the intestines
 Cirrhosis can also lead to impotence, kidney dysfunction & failure, &
osteoporosis.

Colostomy:
 Ascending: feces are fluid
 Transverse: feces are mushy
 Descending: feces are semi-mushy
 Sigmoid: feces are solid
 pt may eventually gain enough control that he would not need a colostomy

23
 
 Controlling odor & gas:
 Place breath mint inside pouch
 Drink cranberry juice & butter milk
 Eat crackers, toast & yogurt
 Use a commercially prepared deodorizer inside the pouch
 Do not skip meals or chew gum

Concerta:
 ADHD
 CNS stimulant
 Administer AM before child goes to school

Confabulation:
 Lying to fill Memory gaps
 Result of vitamin B deficiency
 alcoholism, Korsakoff syndrome has confabulation

Conjunctivitis (viral):
 extremely contagious
 child should be kept home from school or day care until child has received antibiotic
eye drops for 24 hours

Contraction stress test:

 If your baby will be okay with the ↓ oxygen levels that normally occur during
contractions during labor
 If the placenta is healthy & can support the baby
 Oxytocin administered IV to cause labor contractions
 Pt may also massage nipples

24
  This tells the body to release Oxytocin
 If baby's HR ↓ in a certain pattern instead of ↑ after a contraction, baby may have some
problems with the stress of normal labor.

 Usually done if pt have an abnormal biophysical profile

 A biophysical profile uses ultrasound during a non-stress test to measure a series
of physical characteristics of your baby.
 DO NOT eat or drink for 4 to 8 hours before the test
 Empty your bladder before the test
 consent form
 Normal test result NEGATIVE

Cor pulmonale:
 RHF
 Pulmonary hypertension is the common link between lung dysfunction & the heart in cor
pulmonale
 fatigue, ↑RR, exertional dyspnea, & cough

Corticosteroids:
 ends in SONE
 alters BG
 Can take up to 3 weeks before therapeutic effect can be reached
 instruct pt to clear nasal passages before use
 Oral corticosteroids: Cause gastric irritation & should be TAKEN WITH MEALS
 Daily dose of long-term should be administered in A.M. to coincide with body’s normal
secretion of cortisol
 Needs to ↑ Ca+
 Administer with meals to ↓ GI distress
 Causes immunosuppression

25
  Surgery ↑ demand for corticosteroid
 Prednisone:
 Needs to be ↑ during surgery
 Dexamethasone
 ↓ Leukocyte infiltration at the site of ocular inflammation
 This ↓ the exudative reaction of diseased tissue, lessening edema, redness &
scarring
 Prescribed to help ↓ edema caused by brain tumors
 ↑ BG common adverse reaction to the drug

Cost-effective measure:
 Cost-effective measure during a low-census shift
o charge nurse should contact with supervisor
o excessive staff may be floated to another unit that requires additional personnel
o only superviser has this information

CPR:
1. Assess responsiveness
a. Open airway with head tilt or chin lift
2. activate emergency medical system
3. call for defibrillator
4. assess breathing
a. Breathing- look, listen & feel for sign of breathing
b. If child not breathing place mouth over infant’s mouth & nose & ventilate infant
5. provide two slow breaths
6. assess pulse
a. Circulation-check brachial artery for 5-10 seconds for a pulse
b. If not found compress lower sternum with 2-3 fingers

26
27
Creatinine:
 normal value 0.5-1.5

Crede's maneuver:
 Performed by applying manual pressure over lower abdomen
 This procedure promotes complete emptying of the bladder in pt with lower motor
neuron damage that impairs the voiding reflex.
 Useful in T12-L1 injuries which can cause incontinence of the urine bladder & bowel
complications

Cushing’s disease:
 Hypercortisolism
 There is a ↑ in body fat, causing a buffalo hump, truncal obesity & moon face.
 cortisol is released from the adrenal gland in response to ACTH being released from the
pituitary gland


 Thin arms & legs due to muscle wasting

 Edema, purple skin striations, & ↓ resistance to infection

 Excessive sweating
 Thinning of skin which causes easy bruising
 Cushing's disease specifically refers to a tumor in the pituitary gland that stimulates
excessive release of cortisol from the adrenal gland by releasing large amounts of
ACTH.
 In Cushing's syndrome, ACTH levels will normally ↓ due to negative feedback from
the ↑ levels of cortisol.
 Persistent HTN (due to the aldosterone-like effects) & insulin resistance, leading to
hyperglycemia, which can lead to DM
 With Glucocorticoids excess, Aldosterone hypersecretion occurs & Na+ is retained,
therefore K+ is excreted leading to ↓ K+
 Causes Na+ retention which ↑ urinary K+ loss
 Encourage pt to ↑ K+ rich foods such as fresh fruits

Prunes
 Prone to FLUID OVERLOAD & CHF due to sodium & water retention

28
Cutaneous anthrax:
 Infection of the skin caused by the bacterium Bacillus anthracis
 The bacteria causes disease when it comes into contact with non-intact skin
 standard precaution

Cystic fibrosis:
 malabsorption disorder
 Inherited disease of the mucus & sweat glands
 Mucus produced by the exocrine glands particularly
 Those of the bronchioles, small intestine, pancreatic & bile ducts is abnormally
thick, causing obstruction of the small passageways of these organs
 Diagnosed prior to birth by genetic testing or in early childhood by a sweat test
 Risk factor for pneumonia
 CF causes COPD & pancreatic exocrine deficiency.
 Chronic multisystem disorder affecting the exocrine glands
 It affects mostly lungs, pancreas, liver, intestines, sinuses & sex organs.
 CF causes mucus to be thick & sticky
 MOPP
 Poly arteritis nodosa
 The mucus clogs the lungs, causing breathing problems & making it easy for
bacteria to grow.
 This can lead to problems such as repeated lung infections & lung damage
 Pt with CF can develop DM
 thick mucus obstruct pancreatic ducks
 delayed breast development, but normal sex
 Drug of choice Ticar
 For treatment of pseudomonas pneumonia that can develop with CF
 Adverse effect include ↓ platelet adhesion, hypothrombinemia, look for petechiae
signs

29
Deep Vein Thrombosis (DVT):

 blood clots form within the large veins of the body, such as the calves & thighs, or also
sometimes in the pelvis, chest, or arms
 These blood clots impede the circulation of blood & nutrients to the limbs, as well as to

30
 various organs & body systems.
 Such clots may become very dangerous if they break off because they can travel to
another part of the body such as the lungs, brain, or heart & block circulation to that
organ.
 This may result in severe tissue damage & create a life-threatening situation if the clot is
left untreated
 Treatment:
 Compression stockings assist the body in returning blood to the heart.
 These stockings place graduated pressure on the lower leg, with the
greatest pressure around the ankle, to assist upward blood flow back to the
heart.
 ELEVATE LEGS while resting or lying down can help assist blood flow in the
lower limbs.
 Bed rest for 5-7 days

Defibrillator:
 Emergent treatment for V-fib
 Completely depolarizes myocardial cells so SA node can reestablish as pacemaker
 Produces asystole of heart to provide opportunity for natural pacemaker (SA
node) to resume as normal pacer of heart activity
 Synchronize button should be OFF
 Synchronize button on during Cardioversion
 Synchronize shock with R-wave
 Used for A-fib & Atrial flutter
 set joules at 200, then 200-300 j, then 360 j;
 used pads soaked with gel, cream or saline
 it prevents burns
 paddles placed over right sternal border & apex of heart
 check monitor between shocks for rhythm (3 shocks recommended )
1. place gel pads on chest
2. say “clear” before defibrillation

Dehydration:
 Early S/S include
 thirst, irritability, confusion, & dizziness
 Late S/S include
 Coma, seizures, sunken eyeballs, ↑ HR with hypotension

Demerol:
 Can cause respiratory depression in the neonate if given < 4 before birth
 CNS depressant crosses placenta
 Affects fetal HR variability
 Pancreatitis, biliary disease, sickle cell

31
Diabetes:
 Glucose:
 If pt’s Glucose level 32 mg/dl most concern is pt safety
 seizure, altered mental status, at this critically low level
 Pad the side rails of the stretcher.
 Glucose tolerance test: normal <140
 Blood Glucose monitoring is preferred over urine testing in the elderly because
the renal threshold for glucose starts to ↑ leading to false-negative readings
 Results in elevated glucose level
 Glucose Tests:
 Fasting blood sugar
 Measures the amount of sugar in your blood after you fast for at least 8-
hours or overnight
 normal < 100 mg/dl
 To confirm the diagnosis, your doctor may repeat the fasting blood sugar
test on another day.
 If your test results are 126 mg/dl or higher twice in a row after at least
eight hours of fasting, you may have diabetes.
 Random blood sugar
 random blood sugar
 Measures your blood sugar at any point in time, not necessarily a
certain amount of time after a meal, snack or beverage
 Normal < 200 mg/dl
 If your random blood sugar level is > 140 mg/dl but < 200 mg/dl
you may have pre-diabetes
 Oral glucose tolerance test
 measures your body's response to sugar
 First, your fasting blood sugar level is measured.
 Then you drink a sugary solution.
 Your blood sugar level is measured after one hour & again after
two hours
 If your blood sugar level rises more than normal, you may have
diabetes.
 For this test to be accurate, it is important to eat normally and be in good
health.
 Even a cold can affect the results.
 So can inactivity or certain medications. A modified version of the oral
glucose tolerance test, known as a glucose challenge test, is often used to
screen pregnant women for gestational diabetes
 normal <140 mg/dl
 Glycated hemoglobin (A1C) test
 A1C test not used for diagnosing prediabetes or diabetes
 Instead, it gauges how well pt manages diabetes

32
  A1C test reflects your average blood sugar level for the past 2-3 months.
 Test results show what percentage of your hemoglobin — a protein found
in red blood cells — is sugar coated (glycated)
 Normal 4.5-7.6%
 An A1C level > 7% may indicate the need for a change in your diabetes
treatment plan

 Hypoglycemia:
 Liquids containing sugar if conscious
 SKIM MILK is ideal if tolerated
 Dextrose 50% IV if unconscious
 Glucagon 1mg IM, SQ
 Follow with additional carbohydrate in 15 minutes
 Insulin:
 Administer ½ morning before surgery to prevent hypoglycemia
 Pt NPO before surgery, ½ dose usually sufficient
 Pt has BG level 68 & pt is nauseated
 Nurse should administer insulin because during sickness BG levels will ↑.
 Pt needs insulin.
 Insulin dependent woman during pregnancy (DM Type 1)
 requirement will ↑ & after delivery insulin requirement will ↓ & so will
glucose
 Hypoglycemic meds:
 Oral
 Act by stimulating beta cells in the pancreas to release endogenous insulin
 Some facilitate insulin’s action on peripheral receptor sites
 Delay the absorption of glucose in the intestinal tract
 Piggybacking oxytocin permits d/c of the drug if necessary while
permitting the vein to remain open via primary IV.
 Glucotrol:
 ↑ pancreatic production of enzymes
 Glucagon:
 An injectable form of glucagon is vital first aid in cases of severe
hypoglycemia when the victim is unconscious or for other reasons cannot
take glucose orally.
 Used to treat hypoglycemia resulting from insulin overdose
 In an unconscious pt arousal usually achieved within 5-20 minutes of
administration
 Once consciousness have been regained COH should be given orally
 Somogyi effect: rebound hyperglycemia following hypoglycemia episode while
sleeping
 Advice pt to check blood sugar during the night

Digoxin:
 Stimulates parasympathetic division of the ANS to ↑ vagal tone

33
  Vagal effect slows heart rate, ↑ refractory period, & slows conduction through
atrioventricular nodes & junctional tissues thus ↑ the potential for new
arrhythmias’ to develop.
 Excreted in the kidneys
 ↑ cardiac contractility & ↓conduction which leads to ↑ CO
 Med effective if breath sound clear anterior & posterior
 Therapeutic level 0.5-2.0

Diuretic:
 Loop:
o Lasix:
 Maybe become severely hypotension & hypokalemic
 Ex. Muscle weakness which is a sign of ↓K+
 Ototoxic especially when given with other ototoxic drug such as an
NSAID
 Given IV push should be administered slowly over 1-2 minutes
 Osmotic:
o Mannitol(Osmitrol):
 Use only in hospital setting
 Use in cases of head trauma to ↓ICP
 Use for pt with Chemotherapy
 Thiazide
o HCTZ:
 water pill
 Alert for S/S of ↓ vitamin K in pt taken thiazide diuretics

Diverticulitis diet:
 Low fat & high fiber
 Ex: tuna sandwich with whole-wheat toast with carrot sticks will ↑ bulk in stools.
 Do not use tomato & cucumber because contain seeds & may stuck in intestine.

Dobutamine:
 Acts directly on beta receptors
 Activate dopaminergic sites at low doses.

Dressing change:
1. wash hand with soap
2. wear (don) clean gloves
3. remove the soiled dressing
4. wash hand with soap

34
 5. don sterile gloves
6. Perform sterile dressing change.

Dumping syndrome:
 No fluids 1h before or 2h after meals
 Avoid drinking fluids with meals
 Fluids should be given BETWEEN MEALS
 Avoid concentrated sweets
 ↓ intake of COH since they are the first to be digested, rest will dumped in jejunum
causing pain, diarrhea within 30 minutes.
 Lie down after eating
 ↑ fat & proteins

Effleurage:
 Massaging of abdomen using both hands in circular motion during contractions

Electro convulsive treatment (ECT):

 NPO after midnight
 given general anesthesia
 Before starting
1. Explain procedure to pt (will have memory loss & confusion)
2. Ask pt to void, remove dentures & glasses
3. administer atropine 30 min before ECT to reduce secretions
4. Orient pt that he/she after ECT will be confused
5. Expect headache
6. Pt should NOT have backache
 ECT used for depressed & catatonic pts

Electroencephalogram (EEG):
 important pt deprived (should not sleep after 2-3 AM)
 important pt sleeps during the test – to find out abnormities in the brain
 should eat to avoid hypoglycemia
 avoid coffee 24-48 before the test

35
Emphysema:
 lung sound hyperesonance
 pursed lip breathing to strengthen
respiratory muscle
 Low oxygen
 ↑ fluid to 3000 unless contraindicated
to help liquefy secretions & facilitate
their removal
 High fowlers position to improve
ventilation
 Picture is subcutaneous emphysema

Enema:
 DO NOT Insert more than 3-4 inches
 1 in infant, 2 in child
 Place solution 12 inches above the
anus.
 Heat 105 degrees slightly higher than
body temp
 Volume 750-1000
 (children 250-500)
 Place pt in left side position with legs flexed (Sim’s position)

Epidural:
 Begins 1 hr after the fluid bolus administration
 Ex: fluid bolus at 8:30, epidural has to start at 9:30.

Epiglottis:
 Priority maintain patent airway by assisting MD with intubation
 Obtain chest x-ray to confirm diagnosis
 If it is present child taking to ER for tracheal intubation or stat surgical airway
 DO NOT check child’s throat unless immediate intubation can be performed stat

Exercise:
 Weight bearing exercise:
 Primary way to develop high-density bones, decrease bone reabsorption &
stimulate bone formation
 would also help maintain mobility with left sided weakness.

36
Eye patch:
 You will have difficulty judging distance of objects.

Fire:
 Rescue/remove
 Alarm
 Confine/close
 Evacuate

Fosamax:
 Inhibits bone resorption
 Can be highly irritating to the GI tract especially the esophagus, causing irritation &
ulcerations/erosions
 Dysphagia can also result
 Administered 30 minute ac
 Pt should sit for at least 30 minutes to facilitate delivery to the stomach & prevent acid
regurgitation & esophageal reflux.
 Should be taken 1st thing in the morning
 If pt miss dose, should resume regular dosing schedule next day.

Freud’s stages:
 Ego: Test reality & direct behavior by mediating between the pleasure seeking
instinctual drives of the id and the restrictiveness of the superego.
 Id: source of psychic energy
 Superego: conscience

Fruits:
 Fresh are ↓ in phosphate

Garlic
 Can potentiate action of diabetic drugs (Insulin & others) & cause hypoglycemic effect!

Glaucoma:
 Characterized by optic nerve damage
 Leading cause of blindness, male AA & Asian descent, older than 40
 IOP tends to be higher in the morning; doctor’s appointment is likely to be more
accurate in the morning.
 Cannot be corrected by surgery or treatment; life long disease. Pilocarpine is med.
 Assessment:
o blurred vision
o light with halos
o ↑ IOP
o Pain

37
 o Headache
o ↓ in peripheral vision (late symptom)
o Implementation: the following
 Administer miotics lifelong
 surgery last resort
 Acetazolamide (Diamox)
 If pt allergic to sulfa do not give this drug with sulfonamide
antibiotic
 Open angle glaucoma- ↑ IOP(10-21)
o Needs miotics (constrict pupils)
 Diamox & Pilocarpine: s/s: blurry & cloudy vision; rainbows or halos
around light;
 DO NOT administer MYDRIATICS(causes dilation of the pupils) thus ↑ IOP
o EX. Atropine & Epinephrine
 Headache, goal prevent further damage by maintaining IOP WNL
 Low dosage on topical meds to see effectiveness cholinergic, miotics to↑

Glasgow Coma Scale:

 Provides a score in the range 3-15
 Patients with scores of 3-8 are in a coma.
 The total score is the sum of the scores in three categories. For adults the scores are as
follows:

Glasgow Coma Scale - provides a score in the range 3-15; patients with scores of 3-8 are in a
coma. The total score is the sum of the scores in three categories. For adults the scores are
as follows:

38
  Eye+ Motor + Verbal = 3 to 15
 Coma is defined as:
1. not opening eyes
2. not obeying commands
3. Not uttering understandable words

Glomerulonephritis:
 Diagnosis: Elevated Serum antistreptolysin O titer test
 Instruct pt about S/S of venous thrombosis
 sudden onset of hematuria, proteinuria, & red cell casts
 HTN, edema, & impaired renal function
 Puffiness of the eyelids & facial edema
 The urine is dark & scanty.
 Decrease LOC, abdominal & flank pain
 Occurs after skin or throat infection

Gonorrhea:
 Treatment consists of antibiotic therapy with ceftriaxone 125mg IM once plus
doxycycline 100mg PO BID FOR 7 DAYS

Gout:
 overproduction & under excretion of uric acid
 Colchicines:
 Used for acute Gout attack
 Expect foot to appear pale
 avoid high purine foods
 organ meats, meat soup, gravy, anchovies (small saltwater fish), sardine, fish,
seafood, asparagus, spinach, peas, dried legume, wild game
 drink 2000-3000 water
 use high C/H diet
 will increase uric acid excretion
 restrict alcohol
 excessive weight loss (ex 3 lb per wk) can precipitate gouty arthritis
 Benemide
 ↑ effect of amoxicillin
 Combine they are good for STD’s
 Encourage partial weight bearing while ambulating

Granular cast
 In urine indicates renal disease

Greenstick fracture:

39
  bone not completely separated even though fractured
 1 side of the bone is broken while the other side is bent
 Fracture line extends only partially to bone substance & does not disrupt bone continuity
completely

Guillian-Bare syndrome:
 Classic symptoms include respiratory failure, & flaccidity due to paralysis of the muscles
& urinary retention due to loss of sensation

Halo Vest traction:

 Do not raise the leg rests of the wheelchair because weight of the halo vest will cause

wheelchair to tip backward.

 If pain occurs when pt chews – with jaw movement in 24-48 hrs after traction applied,
 may indicate that skull pins have slipped onto the thin temporal plate
 NOTIFY MD

Hanta virus pulmonary syndrome:

 causes S/S of thrombocytopenia

40
Head injuries:
 Closed: prone to ↑ ICP; ↑ HOB 30-45 degrees to promote venous drainage

 Concussion: mild brain injury in which trauma to the head results in

a temporary disruption of normal brain function
o Ex “I fell down & don’t remember”
o s/s: HA, retrograde amnesia, transient LOC.

Hearing test:
 Weber
 assesses bone conduction
 tuning fork place on head or forehead
 normal to hear sound on both ear
 Rhine
 Assesses air conduction
 hold tuning fork 2 inches from ear canal & against mastoid bone, air
conduction>bone conduction
 Weber & Rhine: help to distinguish between nerve deafness & conduction problems due
to middle ear disease.
 Nerve deafness:
 On Weber’s test sound lateralizes to good ear
 Air conduction>bone conduction
 Ex: Aging, drugs, tumors
 Conduction deafness:
 Weber lateralizes to diseased ear
 Bone conduction>air conduction
 Ex: Otitis media, otosclerosis
 Conductive loss:
 Disorder in auditory canal, eardrum, ossicles
 Sensorineural loss:
 Disorder of organ of Corti or auditory nerve

41
Heart assessment:

 The nurse can best auscultate for heart sound by asking the pt to lean forward & exhale
forcefully
 Tricuspid area: (LLSB) 5th ICS @ the lower left of the sternal border
 Auscultate for S1
 Bicuspid area: midclavicular line 5th ICS @ apex of the heart
 Auscultate for S1 which is
 Closure Mitral (bicuspid) & tricuspid valves.
 Lub sound
 Loudest at apex of heart
 Aortic: 2nd ICS Right Sternal Border
 Pulmonic: 2nd ICS Left Sternal Border
 S2- closure Aortic & Pulmonic valves.
 Dub sound
 Loudest at base of heart
 Erb’s point – at the 3rd ICS left of the sternum
 Good for auscultating Aortic & Pulmonic murmurs
 PMI – Apical pulse : Left 5th ICS 7 to 9 cm lateral to the midsternal line

42
Heimlich maneuver
 is used to dislodge food or other foreign bodies in the throat

Hepatitis:
 Hepatitis A: contact precautions
 Chronic hepatitis C
 Infection with this virus causes inflammation of & low-grade damage to the liver
that over several decades can lead to cirrhosis.
 Chronic hepatitis B & D:
 The hepatitis B virus is probably the most common cause of cirrhosis worldwide,
less common in US & Western world. Hep B, like hep C, causes liver
inflammation & injury that over several decades can lead to cirrhosis. Hepatitis D
is another virus that infects the liver, but only in people who already have
hepatitis, B. Hepatitis B transmitted through parental drug abuse & sexual contact.
 Autoimmune hepatitis: This disease appears to be caused by the immune system
attacking the liver and causing inflammation, damage, & eventually scarring & cirrhosis

Hernia (incarcerated)
 cannot be returned to body cavity
 protruding hernia cannot be reduced
 Hiatal:
 Awaken at night with heartburn
 Inguinal:
 Bulge in lower right quadrant
 Pain at umbilicus radiating down to the groin

Herpes Zoster (disseminated):

 airborne & contact precautions
 keep doors closed at all times
 negative air pressure room

Hip Replacement (total):

 Can sit in recliner as long as hip flexion is < 45-60 degrees
 Avoid stooping
 Do not sleep on operative side until directed to do so
 Use soap & water to clean incision
 Continue with exercise

Hip spica cast

 Can cause Cast syndrome
 superior mesenteric syndrome
 s/s include N/V, abdominal pain, bloating
 Call MD!

Hirschsprung’s disease:

43
  Caused when certain nerve cells (called parasympathetic ganglion cells) in the wall of
the large intestine (colon) do not develop before birth
 Without these nerves, the affected segment of the colon lacks the ability to relax
& move bowel contents along
 This causes a constriction & as a result, the bowel above the constricted
area dilates due to stool becoming trapped, producing mega colon

(enlargement of the colon).

Histamine blocker:
 Small frequent meals are not necessary
 Tagamet

Hyperbaric oxygen therapy:

 Benefits a compromised skin graft, because it ↑ oxygen at the wound site promote
healing.

Hyperthyroidism:
 Grave's disease
 Autoimmune disease where an individual's own antibodies attach to thyroid stimulating
hormone receptors within cells of the thyroid gland & then trigger overproduction of
thyroid hormone.
 Propylthiouracil (PTU):
 Blocks synthesis of thyroid hormones by preventing iodination of thyrosine
 PTU inhibits iodine & peroxidase from their normal interactions with
thyroglobulin to form T4 & T3
 This action ↓ thyroid hormone Adverse effect is Agranulocytosis
 Fever
 sore throat

Hypothyroidism:

44
  plan measures to deal with Cardiac dysrhythmias related to ↓ serum Ca+
 Avoid use of narcotics
 Most important tracheotomy set available in the room due to risk for laryngospasm
 Synthroid:
 ↑ metabolic process in the body, including glomerular filtration rate thereby ↑
urinary output
 Accelerates the degradation of vitamin K-dependent clotting factors
 As a result the effects of Coumadin are enhanced
 Therefore, dosage of Coumadin should be ↓ in a pt on thyroid replacement
hormone
 Withheld if pulse >100
 A.M before breakfast to prevent Insomnia

Hypoxia:

Early sign of hypoxia

Immunization:
Age Birth 1 2 4 6 12 15 18 24 4-6 11- 13-
mths mths mths mths mths mths mths mths years 12 18y
y
4 HepB Hep Hepatitis B Series
B #1 Hep B#2 Hep B #3

5 Dtap Dtap Dtap Dtap Dtap Dtap Td Td

4 HIB HIB HIB HIB HIB

4 IPV IPV IPV IPV IPV

2 MMR MMR#1 MMR#2 MMR#2

2 Varicella Varicella Varicella

5 PCV PCV PCV PCV PCV PCV PPV

Influenza Influenza(yearly)

Hep A Hepatitis A series

45
Impetigo:
 HONEY colored crusted lesions
 caused by Staph & Strep
 untreated can cause acute glomerulonephritis
 look for signs of periorbital edema which indicates post-streptococcal glomerulonephritis

Incentive spirometer:
 Advice pt to sit on edge of bed if possible,
or sit up as far as can in bed.
 Hold the incentive spirometer in an
upright position.
 Place mouthpiece in mouth & seal lips
tightly around it.
 Breathe in slowly & as deeply as possible,
raising the yellow piston toward the top of
the column. The yellow coach indicator
should be in the blue outlined area.
 Hold your breath as long as possible (for
at least 5seconds). Allow the piston to fall
to the bottom of the column.
 Rest for a few seconds & repeat Steps
one to five at least 10 times every hour when you are awake.
 Pt should position yellow indicator on the left side of the spirometer to show his best
effort. Use the indicator as a goal to work toward during each repetition.
 After each set of 10 deep breaths, practice coughing to be sure your lungs are clear
 If you have an incision, support your incision when coughing by placing a pillow firmly
against it.
 Once you are able to get out of bed, walk in the hallway & cough well. You may stop
using the incentive spirometer unless otherwise instructed by your health care provider

Inducing vomiting:
 Contraindicated in pt
 <1 (infants)
 Pt ingested petroleum distillate such as charcoal lighter fluid
 Corrosives such as detergents

Infant developmental stage:

 2 month old can lift the head 45 degree when in prone position; 4-6 month rolls over,
plays with own hands and grasps objects with both hands.

46
Inflammatory bowel disease:
 Chronic diarrhea stools occurring 10-12 times per day
 Diarrhea & vomiting with severe abdominal distention

Influenza:
 Most common complication is pneumonia.
 Should be given to adults >50 years, pt with chronic conditions & persons traveling to
foreign countries.
 Contraindicated if allergic to eggs
 If pt has fever & cough delay administration of vaccine
 Vaccine deferred in presence of ARDS
 Droplet precaution:
 facemask
 gown
 gloves

Intracranial pressure:
 ↑ head circumference & HIGH PITCH CRY are the 1st sign of ↑ ICP in children
 Changes in speech, LOC, restlessness, & confusion
 ↓ amount of procedures
 sensitive to touching, jarring, loud noise
o Will cause ↑ ICP
 Do not hyperventilate, it will ↓ CO2 (patent vasodilator) & cause ↑ ICP
 DO NOT administer Demerol, Morphine
o May mask symptom of ICP PATHOPHYSIOLOGY OF ICP

Ipecac syrup:
 Not vomiting is priority; if none occurred, you may repeat dose in 20 minutes.
 Pt to remain NPO until following day

Irritable bowel syndrome

 Involves pattern of alternating diarrhea & constipation

Ischemic myocardial tissue changes:

1. Cause ↑ of the ST segment
2. ↑ or inverted t-wave
3. & a pathological Q-wave

Jaundice:
 Physiological jaundice- immature hepatic function
o Occurs after 24 hrs, peak 72, and last 5-7 days
 Pathological jaundice: occurs within 24hrs after birth
 Infant bilirubin > 15 phototherapy considered at 72 hrs age.

47
Knee amputations:
 Above Knee Amputation
 skin needs to be firm- wash & dry gently twice each day
 do not put cream on it
 use only cotton or wool residual limb socks not nylon socks
 change daily
 DO NOT elevate residual limb after the 1st 24 hrs
 can result in hip flexure
 after 24 hrs encourage pt to lie in a prone position ( 30 min 3 times per day)
 or put sand on residual limb for a short time
 expose residual limb to air daily
 facilitates healing
 perform active range of motion (not passive ROM);
 Post-op:
 important to perform neuromuscular check every hour for 12 hours
 then every 2 to 4 hours because surgery can interrupt blood supply to the
affected extremity & immediate intervention is required
 PRIORITY is to provide cast care to affected extremity
 monitor incision bleeding q 4 hrs
 assess for possible DVT if pt complains of calf pain with movement

Kock pouch:
 internal collection pouch
 Pt does not need to be on special diet
 Empty pouch 2-4 times daily
 Increase fluid to prevent renal calculi

Kussmaul breathing:
 Is the very deep & labored breathing with ↑ frequency
 found among people with severe acidosis
 it is a form of hyperventilation
 The most commonly occurring in diabetics in diabetic ketoacidosis
 Blood gases will show a low pCO2 because of a forced ↑ respiration (blowing off the
carbon dioxide).
 The patient feels an urge to breathe deeply, an "air hunger", & it appears almost

48
 involuntary.
 A metabolic acidosis soon produces hyperventilation.
 Kussmaul breathing is a sign of coma & imminent death in diabetic patients

Lactate Ringers:
 Is given during labor because replaces electrolyte loss.

Lactovegeterian:
 Do no eat eggs

Laryngotracheobronchitis (LTB):
 Characterized by edema & inflammation of upper airways
 Early symptoms include inspiratory stridor & restlessness

Lead Poisoning:
 normal 0 -10
 10-19
o check in three month
 20-40
o Needs immediate test
 >than 70 STAT
 BEST to give MILK
o Because milk provides a large amount of vitamin D & it optimizes deposition of
lead in the long bones
 houses build before 1978 are of concerned
o if such houses are being remodeled, neither children nor pregnant woman
should not be in them until the works is fully done and cleaning has occurred
 Normal ammonia level 80-110

Legionnaire’s disease:
 cause by bacteria (like pneumonia)
 does not spread from person to person
 lives in the environment, usually in water, hot water tanks
 Spread by aerolised route showers, ACs, etc.
 Risk factors include
 Advance age
 Severe immunosuppression
 End-stage renal disease
 Diabetes
 Smoking
 Pulmonary disease
 Standard precautions

Librium:

49
  Antianxiety & sedative/hypnotic
 Used to treat anxiety & alcohol withdrawal
 Causes drowsiness & sedation

Licorice:
 Herb that can ↑ K+ loss

Lidocaine:
 Antiarrythmic drug
 Sometimes used to treat V-tachycardia (mg & K+)
 Signs of toxicity include confusion & restlessness.
 Never given PO its IV or IM
 DO NOT administer during complete heart block
 During heart block, the AV node blocks all impulses from the SA node so the atria &
ventricle move independently
 because Lidocaine suppresses ventricular irritability it may diminish the existing
ventricular response

Lithium:
 Therapeutic level 0.5-1.2
 Lithium replaces Sodium in the cells
 ↓ sodium diet will precipitate lithium toxicity
 Pt has to have regular sodium diet & adequate fluid intake.
 Perform blood studies, EKG, urinary function test before administering lithium
 Avoid Na+ depletion because lithium replaces Na+ in the cells precipitating
lithium toxicity
 1-3 weeks for therapeutic effect
 Side effects:
 Fine hand tremor
 Dizziness
 anesthesia at skin
 weight loss
 Anorexia/nausea
 Depression
 Monitor pt for suicidal behavior
 Toxicity:
 Fine tremors of fingers, wrist & hands, N/V, diarrhea
 Only time you’ll see diarrhea, most of the drugs causes constipation
 Pt looks drunk or flu like, suspect TOXICITY

Lyme disease:
 Predominantly found in mid Atlantic states, coastal states
 Ex. Connecticut
 Not found in tropical areas

50
Lugol’s solution:
 ↓ release of thyroid hormone
 administered 10-14 days prior to surgery
 ↓ Vascularity & size of the thyroid; will ↓ post-op hemorrhage.

Lupus:
 Diagnostic test include
1. Lab test include an above normal anti-DNA test
2. + Antinuclear antibody test
3. + Lupus Erythematous cell test
 Proteinuria & hyperlipidemia are common
 teach pt to avoid all direct exposure to the Sun
 no work in garden (immunosuppresed)
o Lesions will become worse.
 Pt should be in REMISSION for at least 5 months prior to conceiving
 Should wait 2 years after diagnosing before conceiving

Lumbar puncture:
 Place in FLAT SUPINE position, which prevents headache & leaking of CSF at the site.
 Headache, common sign of lumbar puncture
 1st assess for CSF leakage when headache is indicated
 Is performed to obtain specimens, relieve pressure, inject dye
 Lateral fetal position at head of bed
 Insect needle between 3rd or 4th ICS

Magnesium sulfate:
 CNS DEPRESSANT that blocks neuromuscular transmissions
 relaxes smooth muscles, ↓BP, ↓ ACTH
 Use as an adjunct to treat acute nephritis & severe toxemia.
 MgSO4 can give additive effect with narcotic drug
 Be careful when administering with those drugs.
 MgSO4 toxicity: can cause respiratory depression & urinary retention
 Antidote for MgSO4 is calcium gluconate.
 Mg+ agents not usually administered for pt with renal failure

Medication administration
 Rectal administration offers the patient the longest duration of pain relief 6-8 hrs.
 After administering wrong dose of the medication, the nurse should do the following
o Record the dose of med administered & dose of med ordered
o assess &record pt’s actual response
o inform MD

51
 o record any adverse response to med
o submit report as soon as possible (within 24 hr)

Mechanical ventilation:
 After initiating MV, it is most important to check BP because it can be ↓ due to ↓ CO
 no need to check RR because it was adjusted by the machine
 best mode to wean the pt from ventilator
 Synchronized intermittent mandatory ventilation (SIMV)
 allows for spontaneous breaths at his own rate & tidal volume
between ventilator breaths
 assist-control is not good for weaning pt from ventilator because tidal
volume is preset so each breath is delivered at a set volume regardless of
pt’s needs

Meniere’s disease
 N/V, vertigo, tinnitus, nystagmus, progressive loss of hearing on affected side
 Antihistamines, tranquilizers such as valium, antiemetic, vasodilators
 Acute phase bed rest, low sodium diet, avoid alcohol nicotine and caffeine
 Stand in front of pt when speaking to prevent pt from turning head to see nurse thus ↓
vertigo

Meningitis (Bacterial):
 Prophylactic
 Droplet precautions until they have been on antibiotics for 24 hours
 Isolation for the 1st 24 hours & close to the nursing station thereafter for maximal
observation

Migraine:
 Triggers include
 Fatigue
 Long time without eating
 Chocolate, cheese, coffee

Mitral stenosis:
 Causes diastolic, rumbling & low pitch murmur.

Mononucleosis:
 “Kissing diseases” caused by the Epstein Bar virus in children.
 s/s: constant fatigue , fever, sore throat, swollen lymph glands, enlarge spleen
 after 3 weeks the spleen would still be enlarge
 cautious pt to be careful

52
  avoid doge ball & other physical activities that can cause injuries

Morphine:
 Adult dosage 10mg/70kg of body weight when giving parentally
 ↓ blood return to the right side of the heart & ↓ peripheral resistance
 ↓ preload & after load pressures & ↓ cardiac workload
 Cause vasodilation & pooling of fluid in extremities
 Provides relief from anxiety

MRSA:
 Requires contact precautions

Multiple Sclerosis:
 Teach pt to sleep on stomach to minimize spasm of the flexor muscles of the hips &
knees.
 Prone position can minimize spasm of flexor muscles of the hips & knees during
exacerbation.
 Overextension avoided
 Urinary retention
 Hyprereflexia of the extremities
 Numbness or tingling sensation
 ↓ Short-term memory
 Keep suction machine with catheter next to patient to ensure patent airway & prevent
aspiration

Myasthenia Gravis:
 Autoimmune disorder
 ↓ ACTH
 Symptoms more severe in the evening
 The drug Tensilon is slowly given through an intravenous line
 The health care provider may want to fatigue your muscles by having you do
various exercises such as counting until your voice diminishes or holding your arms
above your shoulders until they drop.

 The rest of the Tensilon is then given

 perform some repetitive muscular movements like crossing & uncrossing your legs with
particular attention paid to whether your muscle strength is improved by the Tensilon

53
  In MG muscle will improve immediately following administration of Tensilon

Myocardial infarction:
 After MI cardiac arrhythmias causes roughly 40-50% of deaths.
o VENTRICULAR DYSRHYTHMIAS
 Interior MI can cause heart failure.
 Post MI sublingual nitro, tissue plasminogen activator, & telemetry
 Significant clinical sign include:
1. T wave inversion
2. prolonged PR interval
3. ST-segment elevation

Myelogram:
 Lumbar puncture with injection of contrast medium, allowing x-ray visualization of the
vertebral canal
 contrast medium is injected into spinal subarachnoid space through a spinal puncture
 identifies tumors, cysts, herniated vertebral discs
 OIL BASED
o Visualize spinal column & subarachnoid space
o Must remain flat for 12-24hrs
o Need to replace fluid lost with removal of oil based dye
 WATER BASED
o Monitor for seizure
 NPO for 8hrs prior to test

NSAIDs
 Naprosyn:
 used as an analgesic
 S/S includes headache, dizziness, GI distress, pruritus, & rash, fluid retention
 Headache, drowsiness dizziness, heartburn & nausea, GI bleeding
agrranulocytosis any stomach pain lasting more than 2 days may indicate bleeding
& should be reported
 Cinopril:
 Assess for bleeding

Nasogastric tube:
 Elevate HOB 60-90 degrees
1. This facilitates swallowing & movement of tube trough GI tract
 When pt becomes nauseated & there is a decrease in the flow of gastric secretions
1. Nurse should confirm placement by aspirating gastric content & testing pH of
fluid
 Ph should be between 0-4
2. Then nurse would irrigate tube with NS after checking for position of tube

54
Necrotizing fasciitis:
 Aka, flesh eating bacteria, is a rare infection of the deeper layer of the skin & the
connective tissue.
 Causes severe pressure like pain out of proportion to visible signs

Nephrotic syndrome:
 Many types of kidney inflammation, called glomerulonephritis can cause nephrotic
syndrome.
 Is a collection of symptoms, which occur when the kidneys become leaky & lose a lot of
protein into the urine?
o As a result the level of protein in the blood falls.
 At the same time, the kidneys cannot get rid of salt (sodium).
 Together, this results in fluid overload, which causes swelling of the face, legs (edema).
 common complication venous thrombosis; other- HTN, edema

Nitroglycerin:


Non-rebreathing mask:
 Provides the highest oxygen concentration

Nystagmus:
 Abnormal, involuntary, rapid oscillating eye movement; may be horizontal, vertical,
rotary, or mixed in direction.
 May reflex labyrinth, or vestibular dysfunction, neurologic disease, barbiturate
intoxication, congenital or occupational factors

Osteoporosis:
 Wight bearing exercise which enhances bone formation
 Walking

Otitis media:
 Acute infection of the middle ear, associated with URI
 Factors that increase OM include
 Exposure of illness from other children
 Smoking in the home
 Bottle feeding while child is laying down
 congenital disorders such as down syndrome & cleft palate
 Use of a pacifier past 6 months
 Fever, pain, headache, ear noises, head rolling, crying, ear tugging
 Antihistamines, nasal decongestion, position on side of affected ear post-op

Otosclerosis:
 Causes deafness; s/s include hearing loss & buzzing ear noise.

55
Pacemaker:
 Anytime the pulse rate drops below the preset rate on the pacemaker, the pacemaker is
malfunctioning
 Pulse should be maintained at the minimal rate set on the pacemaker

Pancreatic enzymes:
 DO NOT administer with antacids
 Should be given to child just before meals so enzymes are available for digestion
 Can be sprinkled in food

Pancuronim (Pavulon):
 Facilitates optimal ventilation & prevent pt from fighting the ventilator
 Antidote Neostigmine bromide(Prostigmin) or Atropine which are anticholinergic
drugs that reverse respiratory muscle paralysis

Parkinson disease:
 Degenerative disorder of the CNS that often impairs the sufferer's motor skills & speech
 Encouraged use of raised toilet seats which will ↓ strain on back muscles & make it easier
for pt to rise from seat without injury
 Michael J. Fox
 Muscle rigidity, tremor, a slowing of physical movement (bradykinesia) and, in extreme
cases, a loss of physical movement (akinesia).
 insufficient formation and action of dopamine
 Levadopa:
 Urine may appear darker than usual
 Used in treatment of Parkinson disease

PEEP:
 Delivers positive pressure during expiration to keep airways constantly open

PeptoBismol:
 should be used with caution for pt taking ↑ dose of aspirin because it ↑ potential for
toxicity

Peritoneal dialysis:
 If Young woman Bloody outflow could be because of menstruating
1. Because of hypertonocity of dialysate, blood from uterus is pulled through the
fallopian tubes into the effluent
 no intervention required
 If fluid outflow inadequate
1. Turn pt from side to side
2. Check for kinks in tubing
 Continuous Ambulatory peritoneal dialysis (CAPD): some major complication include

56
  cloudy or opaque dialysate which is the earliest sign of peritonitis
 Normal outflow is yellow & clear.
 Dialysate can cause over weight, talk with dietitian.

Pertussis:
 AKA “Whooping Cough” especially at night
 Highly contagious
 Transmitted by direct contact, droplet, contaminated articles
 Maintain high humidity & restful environment

Ph:
 Blood:
 7.35-7.45
 Urine
 Child: 4.5- 8.0
 Adult: 4.6- 6.0

Phototherapy:
 Common adverse effect in children is watery stool, which result from excretion of
bilirubi
↑↓

PKU:
 normal <2
 Inborn error of metabolism involving an inability to properly metabolize phenylalanine
an essential AA
 Bresast milk or formula 24 hours before test is taken
 Done 2-3 days after birth
 Initial specimen should be collected as close to discharge as possible but not after
7 days
 If specimen is collected before child is 24 hours old a repeat test should be done
in 2 weeks

Placenta
 After delivering the placenta, the fundus is usually firmly contracted & located below the
umbilicus
o Fundus at umbilicus 8-12 hours postpartum
o moves 1 fingerbreadth/day
 Produces estrogen & progesterone
 Detoxifies some drugs & chemicals
 Exchange site for food, gas & waste.
 Placental transport of substance to and from fetus begins in 5th week
 Immunity:

57
 o Fetal immunity is transferred through the placenta
o Maternal immune system is actually suppressed during pregnancy to prevent
maternal rejection of the fetus, which the mothers’ body considers a foreign
protein

Phenobarbital:
 Should be injested into a large muscle mass
 Do not be mix or give with any other drugs since barbiturates are involved in many drug
interactions.
 Used within 30 minutes after open

Physical assessment:
 Normal:
1. Inspect
2. Palpate
3. Percuss
4. Auscultate
 Abdomen:
1. Inspect
2. Auscultate
3. Percuss
4. Palpate
 Newborn
1. Auscultate heart & lungs
2. Record heart & respiratory rate
3. Palpate & percuss the abdomen
4. Elicit reflex throughout assessment
5. Examine eyes, ears, & mouth
 if infant begins crying earlier in the exam, examine mouth 1st

Polyarteritis Nodosa
 Rare autoimmune disease
 Featuring spontaneous inflammation of the arteries (arteritis)
 Because arteries are involved, the disease can affect any organ of the body
 The most common areas of involvement include the muscles, joints, intestines
(bowels), nerves, kidneys, & skin.
 Poor function or pain in any of these organs can be a symptom

58
  Poor blood supply to the
bowels can cause abdominal
pain, local bowel death, &
bleeding
 Fatigue, weight loss, & fever
are common
 Common in middle-age
people
 Unknown cause but it has
been reported after hepatitis B
infection
 Diagnosis ↑ of blood
sedimentation rate and C-
reactive protein
 ↑ WBC & platelet
 RBC ↓
 Biopsy of involved tissue that reveals the inflamed blood vessels (vasculitis)
o Vasculitis of the bowel and kidneys can often be detected with an angiogram (x-
ray testing while contrast "dye" is infused into the blood vessels)

Precautions:
 Airborne:
o Rubeola(measles)
o TB
o Varicella(chicken pox)
o Shingles
o SARS
o Disseminated herpes zoster (contact)
o Private room keep doors close
 Contact:
o Diphtheria
o Rubella
o MRSA & other infections caused by multidrug resistant
o SARS
o Scabies
o Hepatitis
o Smallpox(standard)
o Doors close
 Droplet:
o Diphtheria (contact)
o Rubella(contact)
o Scarlet fever

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 o Influenza(meningitis)
o Mumps
o pertussis
o Pneumonia
o Private room, Doors may remain open
 Hand should be washed before removing mask to prevent transfer of microbes to face

Pregnancy:
 Fundal Height:
 10-12 weeks
 Fundus slightly above symphysis pubis
 16 weeks
 Fundus halfway between symphysis pubis & umbilicus
 20-22 weeks
 Fundus at level of umbilicus
 28 weeks
 3 fingerbreadth above umbilicus
 36 weeks
 Fundus just below ensiform cartilage
 Fundal Height corresponds with weeks of pregnancy
 26 weeks=26cm
 Weight gain: 25-35lbs total
 1st trimester: 2-4lbs
 2nd trimester: 12-14lbs
 1 pound/week until
delivery
 3rd trimester: 8-12 lbs
 Primigravida : normal progress of labor at
1 – 1.2 cm dilation of the cervix per hour
 Labor:
 S/S impending labor: contractions
q 5 min in 1 hr

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  S/S active labor: contraction q 3-4 min, bloody show
 Transition phase: 8-10 cm dilated, complete effacement
 ↑ Pressure in pelvis causes intense desire to urinate.
 Fetal movement ↓ with onset of labor
 Medications:
 Ritodrine (Yutopar):
 Help manage preterm labor.
 ↓ Frequency & intensity of uterine contractions by stimulating B2
receptors in the uterine smooth muscle
 Drug of choice when trying to INHIBIT labor
 Rhogam:
 Rh incompatibility occurs when a woman without the Rh factor (a protein
found on the red blood cells of most people), conceives a child who has
the Rh factor.
 The mother's Rh-negative blood will react against the Rh-positive blood
of her fetus & attack it with antibodies.
 Medication not given if pt has been synthesized by a previous pregnancy
 Terbutaline(Brethine):
 Used as a fast acting bronchodilator for short term asthma
 Used as a tocolytic to delay premature labor

61
  Oxytocin:
 Tetanic contractions are the most serious adverse effect associated with
Oxytocin administration.
 Prolonged Oxytocin infusion may cause water intoxification, leading to
seizures, coma & death.
 Responsible for milk, let down reflex.
 Adverse effects HTN, fluid overload, uterine tetany.
 Oxytocin never can be administered through primary IV
 oxytocin is always given via an INFUSION PUMP
 Stadol
 Should give in active phase to prevent respiratory depression of newborn
 Should not give when birth is expected to occur within 2 hours
 Non-stress test:
 Complications:
 Preeclampsia:
 Triad consist of HTN, Proteinuria, facial swelling
 Placenta previa:
 Abruptio placenta:
 Potential for fluid volume deficit
 Frequency:
 Beginning of one contraction to the beginning of another contraction
 Fetal Positions:
 Occiput posterior: causes intense back pain because of fetal compression of the
sacral nerves.
 Amniocentesis:
 Determines chromosomal & neural tube defects
 fetal sex
 Fetal lung maturity during 3rd trimester

Preload:
 Volume in left ventricle at end of diastole
 ↓ by any condition that ↓ circulating volume such as hemorrhage, sepsis, &
anaphylaxis.
 Hemorrhage ↓-circulating volume by loss of volume from intravascular space.
 Sepsis & anaphylaxis ↓ circulating volume by ↑ capillary permeability

Proton Pump Inhibitor:

 Prevacid
 30 minute before meals, can be sprinkle on food

Pyelogram:

62
  Enemas to clean the bowel of stools is administer
 Should D/C metformin(glucophage) 48 hours prior to procedure because it might cause
life threatening lactic acidosis.
 You will need to urinate immediately prior the procedure to ensure the bladder is empty,
and access to a vein will be placed in an arm

Pyloric Stenosis:
 Pt become lethargic, dehydrated & malnourished
 Pt will be fussy & seems hungry all the time

Pyridium:
 Urinary analgesic
 Used for pain with chronic UTI
 Taken with food to ↓ GI irritation
 Urine is red to orange
 Should only take for 2 days when taken with antibacterial agent

QT interval corrected for heart rate:

 Divide QT interval by square root of R-R interval.

Reflexes:
 Babinski: reflex occurs when the great toe flexes toward the top of the foot & the other
toes fan out after the sole of the foot has been firmly stroked
 Disappears after 2 years
 Moro: child abducts his extremities & fans his fingers when hears a noise
 disappears at 2-3 month
 Tonic: turning neonates head on the side when supine
 Extremity on same side extend & those on opposite side flex
 Absence of red reflex in newborn is Emergency!
 cause blindness optic nerve

Reglan:
 blocks dopamine receptors in brain which can cause extrapyrimidal symptoms
associated with Parkinson’s disease
 associated with HTN
 Stimulates motility of upper GI tract, used to treat nausea of chemotherapy
 Prevents or ↓ side effects of Platinol, a chemotherapy agent.

63
Respiratory assessment:

 Right middle lobe: Right anterior chest between 4th & 6th ICS
 Bronchial sounds are present over the large airways in the anterior chest near the second
and third ICS
 Lung sounds:
 Normal sounds
 Vesicular: soft & low pitch breezy sound heard over most of the
peripheral lung fields
 Bronchovesicular: harsh sounds heard over the mainstem bronchi
 Bronchial: loud, coarse, blowing sound heard over the trachea
 Abnormal sounds
 Rhonchi: musical sound or vibration commonly heard on inspiration.
 Turn, cough & deep breathe
 Done to promote ventilation & prevent respiratory acidosis

Retina (Detached):
 Portion of the eye that perceives light & transmit impulses from nerve cells to the optic
nerve
 Symptoms:
 flashes of light
 loss of vision
 floaters moving in vision
 confuse because of problem with vision
 painless because there are no pain fibers in the retina
 Treatment:

64
  Scleral Buckling compresses the sclera to repair a detached retina
 bed rest
 eye in dependent position, if surgery done in right eye
 position down
 eye patched 1 or both, pt will be prepared for surgery (Laser technique)
 sedatives & tranquilizers
 avoid stooping, straining of stool avoid sneezing, coughing, straining stool can
cause increased IOP
 If gas or oil used to reattach retina, sleep on abdomen with affected eye down
for several days (do not elevate head or shoulder
 Fluorescein angiography (EYE) can be a very useful procedure for assessing
retinal disease (retinal circulation); a dye administered IV
 after exam pt should avoid direct sunlight (wear dark glasses); drink more
fluid after procedure; dye causes temporary staining on the skin

Retinopathy of Prematurity (ROP):

 Seen with respiratory distress, artificial ventilation, apnea, bradycardia, heart disease,
hypoxia, acidosis, sepsis
 Immature RBC of retina constrict & become necrotic
 Happens in infants
 prematurity, low birth weight
 Relationship of oxygen to ROP
 Prevent by using minimal oxygen concentration

Rheumatic fever:
 Develop after group A Strep
 Episode of Pharyngitis (sore throat)
 May cause MITRAL STENOSIS

65
Rheumatoid arthritis:
 Muscle strength will ↑ with isometric & resistive exercises
 Important to maintain consistency of exercise program to maintain joint mobility
 when inflammation is severe, ↓ # of repetitions of the exercise
 do not stop exercising
 active exercises better than passive ones
 applying splints to rest inflamed joints
 using Velcro fasteners on clothes to aid in dressing
 applying moist heat to joints to relax muscles & help relieve pain
 take warm bath as soon as pt get up
 lie flat with 1 pillow under head
 ↑ knee may cause flexion contractures

ROM:
 will ↑ joint mobility & ↓ pain & prevent contractures

Saline compress:
 Warm saline good for phlebitis from an IV

SARS:
 need airborne & contact precaution
 negative pressure

Schizophrenia:
Positive symptoms Negative symptoms
 Hallucinations  Slowed thought
 Have to do with the 5 senses  Idea of Reference
 Delusions  Diminished spontaneity
 False fixed idea  Flat affect
 Bizarre behavior  Loss of drive
 Loose association  Apathy
 Attention/Concentration difficulty
 Few words
 Withdrawal
 Depression
 Not able to experience pleasure

66
Selective Serotonin Reuptake Inhibitor:
 Antidepressant
 serotonin is believed to play an important role in the regulation of anger, aggression,
body temperature, mood, sleep, vomiting, sexuality, & appetite.
 Low levels of serotonin may be associated with several disorders, namely ↑ in aggressive
& angry behaviors, clinical depression, OCD
 SSRIs ↑ the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake
into the presynaptic cell, ↑ the level of serotonin available to bind to the postsynaptic
receptor.
 Celexa(Citalopram)
 Elavil:
 Antidote is Physostigmine(Antilirium).
 Paroxetine (Paxetil):
 2nd generation antidepressant, may cause constipation
 Prozac (fluxetine):
 SSRI for Depression
 Never take omitted dose
 Return to regular dosing
 Cause dry mouth
 Chew gum & good hygiene
 Orthostatic hypotension
 Takes about 4 weeks for full effect beware of suicidal ideation
 Tofranil:
 Side effects include
 sore throat
 Fever
 ↑ fatigue
 Vomiting/diarrhea
 Zoloft(Sertraline)

Sequential compression device (SCD):

1. put the anti-embolism stocking on before wrapping & securing the sleeves
a. the stockings can ↓the itching, sweating & heat that can build up under the plastic
sleeves & thereby can cause discomfort & skin irritation
2. Start by positioning sleeve under the leg so that the opening is at the knee (in front).

Shock:
 elevate legs to prevent aspiration
 do not put on Trendelenburg position
 will cause pressure on thoracic cavity
 do not elevate head
 will impair circulation to the head;
 ANAPHYLAPTIC SHOCK
 epinephrine

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  Hypovolemic shock
 Trendelenburg position - have the victim lie flat with the feet elevated about 12
inches to increase

Sickle cell anemia:

 Fluid most important during crisis
 Place pt in a room with non-infectious pt

Smallpox Vaccine:
 Shouldn’t give to pt with immunologic problem

Snellen chart:
 Normal is 20/20
 Back number indicates distance at which a person with normal vision can read the chart.
 20/200 considered legally blind

Sounds:
 bruit is abnormal vascular sound
 Dull sound during percussion over symphysis pubis is a sign of distended urine bladder
 The presence of a solid mass underneath the surface will produce a dull sound

Specific Gravity:
 Normal value is 1.010-1.030
 Measures concentration of particles in urine
 Urea nitrogen 10-30
 Serum creatinine 0.5- 1.5

Spinal injury:
 Transfer: Never bend knee, swing legs.
 keep straight alignment, logroll,
 Pt. focuses on using arms.
 Administer high intake of fluid to help prevent UTI
 Most concern Autonomic dysreflexia
 If pt complains of severe HA, check BP (will ↑)
 put in a sitting positions
 AD Can happen amongst pt in rehab center
 Cervical result in quadriplegia (all 4 extremities affected).
 C1-C2- loss of ability to breathe
 C1 – C4 level may require a ventilator to breathe
 C5 –T1
 hands affected
 T1-T12 paraplegia

68
  injuries at level T1-T6 cause ↓respiration because abdominal muscles are
affected
 lack of control of abdominal muscles which affects on diaphragm then
affect on pt’s respiration
 should be independent in self care & wheelchair because hands are not affected
 T9- T12
 Allows good trunk control & good abdominal muscle control
 Sitting balance is very good
 Legs paralyzed
 Lumbar & Sacral injuries yield ↓control of the hip flexors & legs

Stab Wound:
 Encourage pt to lie on affected side
 then unaffected lung can expand to its fullest potential
 ↑ HOB to ↓ pressure on diaphragm & allowing diaphragm to ↓ with gravity

Sterile field:
1. Assemble necessary equipment
2. Place sterile drape (dress) on the work surface
3. open wrapper of sterile item with bare hand
a) with naked hand not with sterile gloves
4. Dispose of outer wrapper
5. Set sterile field ABOVE waist level
a) below waist level is considered contaminated
6. Do not open all sterile packs
a) they should be opened PRN
7. do not place the supplies at the edge of the sterile field
a) any item placed on the outer 1 inch of the field must be discarded
8. Do not open supplies with sterile gloves
a) set up field before donning sterile gloves

Stimulants:
 Produces mood swings, tachycardia, anorexia, weight loss

Stomatitis:
 Caused by a thrush infection, which can cause mouth pain
 This is a sign of Super infection

Strabismus:
 Involuntary drifting of one eye out of alignment with the other eye; "lazy eye”

69
  Deviation of eye
 Diplopia
 Tilts head or squints
 Visual axes are not parallel so the brain receives two messages
 Ex. Child closes one eye to see a poster on the wall
 Implementation
 Corrective lenses
 eye patching & exercise to strengthen muscle of eye that deviates
 put eye patch on stronger eye
 this will encourage child to use weaker eye
 surgery done after eye patching
 ambliopia due to untreated strabismus

Streptococcal infections:
 occurring in childhood may result in damage to heart valves
 an autoimmune reaction occurs between antibodies against the bacteria & heart valves
particularly mitral

Stridor:
 Indicates upper airway constriction
 Harsh, high pitched noises on inspiration

Prozac, ssri nausea, vomiting, cramping, diarrhea, gi system disturbance, no cv s/e

Strokes:
 Right-sided stroke include left-sided weakness, impulsiveness, and poor judgment.

Sulcralfate (carafate):
 Used to treat duodenal ulcers & will bind with tetracycline HCL(Sumycin) inhibiting
absorption

Supplements:
 Should be given after meals

Surgery:
 Pre-op pt:

70
  verify that consent form is signed
 obtain & record VS
 ask the pt empty bladder
 instruct the pt to stay in bed
 administer pre-op meds
 Barbiturates
 N/V, tachycardia, coarse tremor, seizure
a) Secobarbital(Seconal)
b) Pentobarbital(Nembutal)
 Anticholinergics
 Indicated for ↓ of salivation & prevention of ↓ HR
a) Atropine
b) Scopolamine
c) Robinul
 Benzodiazepines
 Used to enhance anesthetic induction
a) Midazolam(Versed)
b) Lorazepam(Ativan)
 Opiod analgesics
 ↓ pain perception, produce sedation & ↓ anxiety
a) Demerol(meperidine)
 Sedating Antihistamines
 Cause CNS depression & produce mild sedation
 S/E include drowsiness, headache, ↓BP, urinary retention & dry
mouth
a) Benadryl
b) Atarax
c) Vistaril (hydroxyzine)
 Post-op pt:
 Never put with pt considered “dirty” (COPD, any other infection) in the same
room
 More important bowel sounds
 Do not offer oral fluid until bowel sounds returned.
 Normal 5-30 sounds/minute
 Monitor I&O very important
 Complications
1. Wind: lungs
 Atelectasis
 pneumonia
2. Wound: infection
3. Water: Urinary retention, infection
4. Walk: Thrombophlebitis, DVT
5. Ambulate to prevent DVT’s
6. bed rest for 5-7 days to prevent pulmonary embolism
7. use warm moist soaks

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Syphilis:
 develops in 2-6 wks
 Begins with papule & then becomes ulcer

Synchronized intermittent mandatory ventilation (SIMV):

 Allows for spontaneous breath at his own rate and tidal volume between ventilator
breaths

Systemic Lupus Erythematous:

 important lipid profile & urinalysis YEARLY
 because Proteinuria & hyperlipidemia are common with SLE
 Perform test each year

Tetralogy of fallot:
1. Pulmonic stenosis
2. Interventricular septal defect
3. Dextroposition of the aorta so that it overrides the interventricular septum & receives
venous as well as arterial blood
4. Right Ventricular Hypertrophy.

Thrombolytic agent:
 To salvage myocardium it must be administer within 12 hours.
 Dangerous- contraindicated after brain injury.

Thyroid Replacement hormone:

 ↑ metabolic rate of all tissues,
 S/S include ↑ HR & chest pain

Thyroidectomy:
 Complications include HYPOCALCEMIA, muscle flaccidity, injury to parathyroid
gland causes ↓ in serum Ca, assess for tingling around mouth, toes, & muscular
twitching.
 can cause injury on parathyroid gland
 post-op most important to assess
 numbness in fingers,
 muscular twitching which are signs of ↓Ca+

Tissue necrosis:
 S/S of beginning of TS include
o Irregular, mottled ring with bluish purple central area

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Toddler:
 walking without help at 13 – 15 month
 building a tower of 3-4 blocks 18 month
 using 2-3 word phrases 24 month
 jumping with both feet at 30 month
 If they have difficulty breathing & wheezing on inspiration, may be aspirating large
pieces of food (hot dog, nuts)
 child kicks ball without falling

Tonsils:
 1+ : barely visible outside the tonsillar pilar
 2+ : between tonsillar pilar and uvula
 3+: touches uvula
 4+ : touching each other

TPA:
 “Clot buster”
 Dissolves clot within coronary arteries

TPN:
 Hyperglycemia may occur if it is administered too rapidly
 is inserted by central line
 central line related complication can be air embolism
 s/s air embolism: dyspnea, anxious, restless, chest pain & coughing
 put pt on Trendelenburg position on the left side to displace air
away from the pulmonary artery & into the apex of the heart,
notify physician;
 causes ↓ K+
 flush unused catheter with lumens with a diluted heparin solution BID
 should use sterile technique for dressing
 albumin are the best indicators of long term nutritional status
 when inserting subclavian triple lumen catheter for administration of TPN
 pt should be placed SUPINE with head low & turned away from the insertion site
 this produces dilation of neck & shoulder vessels, making entry easier &
preventing air embolus

Tracheostomy:

73
  Indwelling tube inserted into an opening made into the trachea to bypass an upper airway
obstructions
 to remove trachea-bronchial secretions
 to permit the use of mechanical ventilation
 or to prevent aspiration of oral or gastric secretions in the unconscious pt
 Cuff
 fits snugly within the tracheal wall
 Stenosis should not occur
 Cuff is inflated during continuous mechanical ventilation, during & after eating &
1 hour after a tube feeding when pt is unable to handle oral secretions & when pt
may aspirate
 Cuff should be inflated anytime pt is in danger of aspiration
 Inflated prior to oral hygiene & deflated after oral care
 Inflating cuff when needed doesn’t require MD’s order

1 - Vocal cords
2 - Thyroid cartilage
3 - Cricoid cartilage
4 - Tracheal cartilages
5 - Balloon cuff


Traction:
 Russell: skin traction applied to a lower extremity with extremity suspended over the
bed & a sling place over the knee
 Buck: skin traction applied to a lower extended extremity

74
 o Make sure tape & elastic bandage are secured
o Nurse REMOVES foam booth 3x/day to inspect skin
o Turns pt every 2 hours to the unaffected side
o Turns pt to unaffected side especially with fracture
o Back care q/2hrs to prevent pressure sores
o Dorsiflex the foot
 Use to assess function of peroneal nerve
 Weakness on dorsiflexion may indicate pressure on nerve
o Elevates foot of pt’s bed
 Provide counter traction
o

 Complications:
o A: Atelectasis
o W: wasting of bones
o F: functional loss of muscle
o U: urinary stasis
o L: last but not least, constipation

Transdermal patch:
 Never use alcohol, soap, oil, lotion for cleansing.
 Use warm water

Transsphenoidal hypophysectomy:

75
  Surgical removal of the pituitary gland
 A small oval gland at the base of the brain in vertebrates, producing hormones
that control other glands & influence growth of the bone structure, sexual
maturing, & general metabolism
 Instruct pt to avoid activities that ↑ ICP
 Pt NOT ALLOWED to brush teeth for 1-2 weeks
 Lack of ADH from pituitary will cause diabetes insipidus & diuresis with very low
specific gravity
 Most important for nurse to monitor SG

Transurethral prostatectomy
 Your prostate is a walnut-shaped gland located below the outlet of the bladder.
 surgical procedure in which the doctor removes an overgrowth of tissue from

Your prostate gland through a cystoscope

 a tube like instrument with a light inserted in the urethra
 Another term for this surgery is transurethral resection of the prostate, or TURP.
 Continuous bladder irrigation enables urine to keep flowing

76
Trendelenburg test:
 Use for pt with varicose veins

Trochanter roll:
 Used to position unconscious pt
 Current location for a trochanter rolls from lateral aspect of hip to the mid-thigh
 Hip joints lie between these points.

Tuberculosis:
 Classic sign dry cough with blood –tinged sputum & night sweat.
 Nurse should FIRST: put a mask on pt
 May come back under period of stress
 Will always have positive skin test for TB
 Treatment include
 Isoniazid (INH) which can cause neuropathy
 Give B6 vitamin to prevent neuropathy, dizziness & ataxia
 At risk for developing hepatitis
 Monitor liver function test
 Avoid ingesting alcohol
 Fatigue & dark urine initial indication of hepatic dysfunction
 Vitamin B6 deficiency & neuropathy can be caused by TB meds
 Ethambutol (myambutol):
 optic neuritis & ↓ visual activity
 eliminates certain bacteria that causes Tb
 use in combination with other meds to treat & prevent spread of TB to others
 Rifampin (Rifadin):
 May cause urine, tears or saliva to turn orange
 Treat meningococcal carriers

77
Tumor lysis syndrome:
 results in ↑K+, ↓Ca+, hyperuricemia, & Hyperphosphatemia

Tympanic membrane:
 separates external & middle ear

Ulcer:
 Gastric:
 Pain occurs ½ -1 hour after eating
 Rarely occurs at night
 Not helped by ingestion of food
 May be malnourished because food may cause N/V
 Antacids
 Duodenal (peptic):
 occurs 2-3 hours after a meal
 at night
 prior to ingestion of food

Ulcerative colitis:
 Rectal bleeding, pus & mucus in stool
 Abdominal pain, pre-medication
 Vomiting, diarrhea fecal incontinence weight loss dehydration
 Begins in rectum & moves upward
 Remissions & relapses
 Acute contraindicated for colonoscopy because of risk of perforation
 High protein, calorie, low fat & fiber diet

Valsalva maneuver:
 Hold the breath & bear down
 activates Vagus nerve & will ↓HR
 Vagus nerve can be activated by massaging the carotid artery only one side

Vemox:
 Pinworms
 Increase fat in diet

White Blood Cells:

78
  Basophils: responsible for releasing histamine during an allergic reaction
 Eosinophils: function is phagocytosis of antigen-antibody complexes that are formed in
allergic reactions

Withdrawals:
 Alcohol withdrawal:
 hyper alert, startles easily
 anorexia
 Tremor
 Insomnia
 increase pulse
 Causes mental retardation

 Narcotic:
 WATERY EYES
 cramps
 tremor
 FLU LIKE SYMPTOMS:
 Runny nose
 YAWNING
 fever
 muscle & joint pain
 diarrhea
 Cocaine:
 severe craving
 depression
 Fatigue
 hypersomnia
 Amphetamine: depression, disturbed sleep, Restlessness, disorientation
 Barbiturate: N/V, tachycardia, coarse tremor, seizure

Xanax:
 shouldn't be used if No pregnant

Z-track method:

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  Variation of standard IM techniques for administering meds that is highly irritating to
subcutaneous and skin tissues.
 Prevents meds from leaking into subcutaneous & skin tissues

Metabolic complications from administration of TPN include hyperglycemia, hypoglycemia, hypocalcemia,

hypokalemia, hypomagnesemia, hyponatremia, and hypophosphatemia. Hyperglycemia is the most common
complication of TPN. Hypoglycemia can occur when TPN is suddenly withdrawn. Electrolyte deficiencies can
occur. The addition of electrolytes is individualized based on the client's metabolism and on the underlying
condition.

Myopia or nearsightedness is a predisposing factor in the development of a retinal tear. Hypertension, cranial
tumors, and sinusitis are not causes of retinal tears unless they result in eye trauma.

Stapedectomy

1. General information
1. Removal of diseased portion of stapes and replacement with a prosthesis to conduct vibrations from the
middle ear to inner ear; usually performed under local anesthesia
2. Used to treat otosclerosis
2. Nursing interventions: preoperative
1. Provide general pre-op nursing care, including an explanation of post-op expectations.
2. Explain to the client that hearing may improve during surgery and then decrease due to edema and packing.
3. Nursing interventions: postoperative
1. Position the client according to the surgeon's orders (possibly with operative ear uppermost to prevent
displacement of the graft).
2. Have client deep breathe every 2 hours while in bed, but no coughing.
3. Elevate side rails; assist the client with ambulation and move slowly (may have some vertigo).
4. Administer medications as ordered: analgesics, antibiotics, antiemetics, anti-motion-sickness drugs.
5. Check dressings frequently for excessive drainage or bleeding.
6. Assess facial nerve function, i.e., ask client to wrinkle forehead, close eyelids, puff out cheeks, smile and
show teeth; check for any asymmetry.
7. Question client about pain, headache, vertigo, and unusual sensations in the ear; report existence to
physician.
8. Provide client teaching and discharge planning concerning
1. Warnings against blowing nose or coughing; sneeze with the mouth open
2. Need to keep ear dry in the shower; no shampooing until allowed
3. No flying for 6 months, especially if an upper respiratory tract infection is present
4. Placement of cotton ball in auditory meatus after packing is removed; change twice a day.

Hemodynamic Monitoring (Swan-Ganz Catheter)

1. A multilumen catheter with a balloon tip that is advanced through the superior vena cava into the right atrium,
right ventricle, and pulmonary artery. When it is wedged it is in the distal arterial branch of the pulmonary artery.
2. Purposes
1. Proximal port: measures right atrial pressure
2. Distal port
1. Measures pulmonary artery (PA) pressure (reflects left and right heart pressures) and pulmonary
capillary wedge pressure (PCWP) (reflects left atrial and left ventricular end diastolic pressure).
2. Normal values: PA systolic and diastolic less than 20 mm Hg; PCWP 4-12 mm Hg
3. Balloon port: inflated with 1-2 cc air to obtain PCWP
4. Thermistor lumen: used to measure cardiac output if ordered
3. Nursing care
1. A sterile dry dressing should be applied to site and changed every 24 hours; inspect site daily and report
signs of infection.

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 2. If catheter is inserted via an extremity, immobilize extremity to prevent catheter dislodgment or trauma.
3. Observe catheter site for leakage.
4. Ensure that balloon is deflated with a syringe attached, except when PCWP is read.
5. Continuously monitor PA systolic and diastolic pressures and report significant variations.
6. Irrigate line before each reading of PCWP.
7. Maintain client in same position for each reading.
8. Maintain pressure bag at 300 mm Hg.
9. Record PA systolic and diastolic readings at least every hour and PCWP as ordered, noting position of client.

Central Venous Pressure (CVP)

1. Obtained by inserting a catheter into the external jugular, antecubital, or femoral vein and threading it into the
vena cava. The catheter is attached to an IV infusion and H2O manometer by a three-way stopcock.
2. Purposes
1. Reveals right atrial pressure, reflecting alterations in the right ventricular pressure
2. Provides information concerning blood volume and adequacy of central venous return
3. Provides an IV route for drawing blood samples, administering fluids or medication, and possibly inserting a
pacing catheter
3. Normal range is 4-10 cm H2O; elevation indicates hypervolemia, decreased level indicates hypovolemia.
4. Nursing care
1. Ensure client is relaxed.
2. Maintain zero point of manometer always at level of right atrium (midaxillary line).
3. Determine patency of catheter by opening IV infusion line.
4. Turn stopcock to allow IV solution to run into manometer to a level of 10-20 cm above expected pressure
reading.
5. Turn stopcock to allow IV solution to flow from manometer into catheter; fluid level in manometer
fluctuates with respiration.
6. Stop ventilatory assistance during measurement of CVP.
7. After CVP reading, return stopcock to IV infusion position.
8. Record CVP reading and position of client.

Cardiopulmonary Resuscitation (CPR)

1. General information: process of externally supporting the circulation and respiration of a person who has had a
cardiac arrest
2. Nursing interventions: unwitnessed cardiac arrest
1. Assess LOC.
1. Shake victim's shoulder and shout.
2. If no response, summon help.
2. Position victim supine on a firm surface.
3. Open airway.
1. Use head tilt, chin lift maneuver.
2. Place ear over nose and mouth.
1. look to see if chest is moving.
2. listen for escape of air.
3. feel for movement of air against face.
3. If no respiration, proceed to #4.
4. Ventilate twice, allowing for deflation between breaths.
5. Assess circulation: palpate for carotid pulse; if not present, proceed to #6.
6. Initiate external cardiac compressions
1. Proper placement of hands: lower half of the sternum
2. Depth of compressions: 1 1/2-2 inches for adults
3. One rescuer: 15 compressions (at rate of 80-100 per minute) with 2 ventilations
4. Two rescuers: 5 compressions (at rate of 80-100 per minute) with 1 ventilation

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In thinking of anti anxities medication

Think of smelling the leaves as the way to relax...

L- librium
E- equanil
A-ativan
V-valium
E- equanil
S-serax

To remember how blood flows from the heart! think....

Arteries- Away ,arteries carries oxygenated blood away from the heart to the tissue.
veto-viens, carry blood to the heart.

S/S OF MI(myocardial infarction)- think of DANCE PAD....

D-dyspnea
A- anxiety
N-nausea/vomiting
C-crushing substernal chestpain
E-elevated temp.

P-pallor
A-arrythmias
D-diaporesis

FIRE SAFETY! PRC & RACE

P-protect pt.from injury

R-report the fire
C-contain the fire

R-rescue or remove the pt.

A-activate the fire alarm!
C-contain fire by dosing windows & doors
E- extinguisher flames

To remember to avoid food with Synthroid? "It's A SYN to AVOID food"

Think PLATE to remember key blood components...

P-plasma
L-leukocytes
A- AB antigens
T-thrombocytes
E- erythrocytes

To assess the postpartum pt. think BUBBLE beer bubbles

B-breast
U-uterus

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B-Bowels
B-bonding
L-lochia
E-episiotomy

glaucoma...

C- close angle glaucoma

H- halo vision
O- open angle glaucoma
P- peripheral vision loss/ tunnel vision

H is symptom for Close angle and P is for Open angle

w/UTI think urinary tract is full of infection;

LOOK FOR;

F-frequent urge to void

U-urine that is foul smelling and cloudy
L-low grade fever
L-lethargy

When a child has a cyanotic heart defect,check for the

"4'C's"

C-cyanosis,especially increasing with crying

C-crabbiness or irritability
C-clubbing of digits
C-crouching or squating,which increase systemic venous return,shunt blood from extremeties to the head and
trunk and decrease cyanosis

Muscoskelatal interventions

P= pressure
R=rest
I=ice
C=compression
E=elevation
S=support

CHOLECYCTITIS/CHOLELITHIASIS, remember 4 F's

F - female
F - forty (40 yr olds)
F - Fat (obesity)
F - Fried foods

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