Top Diseases and Procedures

TOP DISEASES, SURGERIES and NURSING PROCEDURES 1. ABDOMINAL ASSESSMENT • Procedure: I-A-Pe-Pa Regular assessment: I-Pa-Pe-A

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Sequence: RLQ  RUQ  LUQ LLQ Position: dorsal recumbent AVOID:  A – ppendicitis  P – heochromocytoma  A – bdominal Aortic Aneurysm  W – ilm’s tumor

2.

ABSENT MECONIUM PASSAGE • Cystic fibrosis • Hirschprung’s disease • Imperforate anus ARTERIAL BLOOD GAS (ABG) • Serum pH 7.35 – 7.45 CO2 35 – 45 HCO3 22 – 26 PaO2 85 – 95 mmHg Increased: Polycythemia Decrease: Anemia •   BEFORE: Allen Test to assess patency of the RADIAL artery*** Avoid suctioning at least 20-30 minutes BEFORE procedure AFTER: Apply pressure on puncture site for 5 minutes

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ABDOMINAL PARACENTESIS • Purpose:  Obtain fluid specimen  To relieve pressure on the abdominal organs d/t the excess fluid •  • BEFORE: Ask client to void DURING: Position: Sitting position Common site: midway between the umbilicus and symphysis pubis Strict sterile technique Measure abdominal girth at the umbilical level Maximum amount drained is 1500 mL Instruction:

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ACROMEGALY • Increase growth hormone AFTER puberty • Increase glucose level • S/Sx:  Broad and bulbous nose  Enlarged hands and feet  Continuous grow of soft tissues (ear, nose) • Complications  Enlarged heart  Diabetes mellitus  Heart failure • Reason of seeking for medical care: change in appearance

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Management:

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6.

Octreotide (Sandostatin)  give SQ if given 3x a week

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) • “shock lung” • Pathophysiology: o Decreased surfactants o Decreased surface tension o Damage to alveolar-capillary membrane o Leakage of fluid into the ITS o Resulting to pulmonary edema • S/Sx: o Dyspnea, retractions

ADDISON’s and CUSHINGS DISEASE ADDISON’s “All STEROIDS (S.S.S.) are DOWN except for Potassium” MAIN DOWN: SUGAR (HYPOGLYCEMIA) PROBLEM AND its DOWN: SALT (HYPONATREMIA) symptoms  HYPOVOLEMIA  DHN, weight loss  HYPOTENSION 7. DOWN: SEX HORMONES  Decrease sexual urge or libido

CUSHING’s “All STEROIDS (S.S.S.) are UP except for Potassium” UP: SUGAR (HYPERGLYCEMIA) UP: SALT (HYPERNATREMIA)

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HYPERVOLEMIA  Edema (Moonface, Weight gain) HYPERTENSION

UP: SEX HORMONES  Decrease sexual urge or libido

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UP: Potassium  HYPERKALEMIA  Weakness, fatigue  Tachycardia, Arrhythmia  Diarrhea  Metabolic acidosis  Tall/ Tented T wave  

Virilization (mascularity in female)  Amenorrhea, Hirsutism, Enlargement of clitoris Osteoporosis Gynecomastia (males)

MNGT:

YES steroids (pro-Na, anti-K) Monitor VS, I&O, weight DIET: high calorie, high CHO (glucose), high NA, low K

DOWN: Potassium  HYPOKALEMIA  Weakness, fatigue  Bradycardia  Constipation  Metabolic alkalosis  Flat T wave NO steroids Monitor VS, I&O, weight DIET: low calorie, low CHO, low Na, high K, high CHON Reverse isolation* BILATERAL ADRENOLECTOMY GIVE Calcium (for osteoporosis)

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S.S.S (Sugar, Salt, Sex hormone)  steroids Cushing’s disease  prone to infection

ANEMIA – Decrease oxygen carrying capacity of RBC • Common Nursing diagnosis: Activity intolerance • TYPES  Pernicious anemia – immature RBC due to lack of vitamin B12

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Aplastic Anemia – decrease RBC, platelet, WBC Sickle cell anemia – sickled RBC  Management: • H - ydration • O - oxygeantion • P – ain management

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ANGINA • 2 GOALS IN ANGINAL MANAGEMENT: o Goal # 1: Increase oxygen supply to the myocardium (vasodilation) o Goal # 2: Decrease oxygen demand

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Nitrates – Goal # 1 Example: Nitroglycerin, Isosorbide mononitrate (Imdur), Isosorbide dinitrate (Isordil)  Side effects: flushing, throbbing headache, hypotension, dizziness  Keep drug only for 6 months, cool, dry and dark environment  Carry all times  DO NOT administer with Sildenafil (Viagra)

 B. C.

AVOID: hot baths (vasodilation)

Beta Blockers – Goal # 2 Example: Propranolol (inderal), Metropolol (Lopressor) Calcium Channel Blockers – Goal # 1 and 2 Examples: Amlodipine (Norvasc), Verapamil, Nifedipine, Diltiazem (Cardizem),

10.

ANEURYSM – is ballooning of the blood vessel • TYPES o Saccular o Fusiform

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Dissecting - a TEAR in the intima of the blood vessel***  Type A – affects the ascending aorta  Type B – affects the descending aorta

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Complication: rupture/ internal hemorrhage/ shock

11. APPENDICITIS • Inflammation of the appendix • LOCATION: RLQ/ right iliac/ Mc Burney’s point • CAUSE:  due to obstruction from fecalith  low fiber diet

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COMPLICATION: Peritonitis

12. APPENDICITIS, manifestations • increase WBC, fever • PECULIAR SIGNS:

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Rovsing’s sign Mc Burney’s sign Psoas sign Obturator sign Blumberg sign (+) cough sign

pressure on the LLQ causes pain in the RLQ pain at RLQ upon palpation pain on passive extension of right hip (lateral position with right hip flexion) pain with passive flexion and internal rotation of the right hip rebound tenderness (peritonitis) RLQ pain on coughing

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With pain – inflammation Without pain – rupture • Tachycardia – late sign • Abdominal distention and paralytic ileus/ decreased or absent bowels sounds 13. APPENDICITIS, management • NPO • POSITION:  (acute phase) most comfortable position; Semi fowler’s to relieve pain and discomfort  (rupture) upright • Sx: Appendectomy  Position: flat on bed • ALLOW: cold application • AVOID:  warm compress  analgesics – will mask the pain*  Laxatives, enema, palpation (increase peristalsis) 14. ARNOLD-CHAIRI MALFORMATION • Related to neural tube defect • S/Sx: o Swallowing difficulty

o o
15. ARTHRITIS

Weakening of the extremities Stridor

RHEUMATOID ARTHRITIS Autoimmune/ Systemic BODY PART AFFECTED S/Sx Small joints (wrist, elbow) Bilateral • Ulnar drift • Boutenniere deformity • Swan neck deformity • Sjogren’s syndrome – excessive dryness of eyes, mouth and vagina • Felty’s syndrome – leukopenia, spleenomegaly Gold therapy Aspirin regularly -w/o for tinnitus-toxicity Steroids Hot and cold compress

OSTEOARTHRITIS Degenerative disease (“wear and tear”) Common aggravating factor: obesity Weight bearing joints (hips, spine, knee, ankle) Unilateral/ progressive • Heberdend’s – distal • Bouchard’s – proximal

GOUTY ARTHRITIS Metabolic Altered purine metabolism Big toe

• Tophi/ podagra – uric acid crystallization • Elevated uric acid

MANAGEMENT

W-weight control (decrease calorie) H-hot compress or ice packs A- aspirin use T- trunk assistive devices- cane

• AVOID: organ meats, alcohol legumes, sardines • Increase fluid intake

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P-probenecid - excretion of uric acid A-allopurinol - decrease production of uric acid C-colchicine - analgesic, antiinflammatory

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16. ASEPSIS Purpose Indication Technique MEDICAL ASEPSIS To reduce microorganism Routine nursing care Disinfection (clean)

S-sulfinpyrazone- reduces uric acid in the blood

SURGICAL ASEPSIS To destroy microorganism including spores Procedure involving sterile areas Sterilization (sterile)

17. AVPU SCALE A – Alert and Awake V – Verbal response to stimuli P – Pain response to stimuli U – Unresponsive

18. BARIUM SWALLOW AND BARIUM ENEMA BARRIUM SWALLOW USE Examination of UGT BEFORE NPO 6 – 8 hours AFTER

BARIUM ENEMA Examination of LGT NPO at midnight (6 – 8 hrs) DIET: Low residue diet, Clear liquid diet (1 – 3 days) Laxatives, Cleansing enema Constipation: Increase fluids, Laxative Stool color: chalky white 1 – 3 days

19. BLEEDING PRECAUTION (OPEN WOUND) P – ressure over the injury E – levate above the heart C – old compress A – rterial pressure T – orniquet 20. BLOOD TRANSFUSION • BEFORE  Check order – 2 RN’s o Client name and identification number o Unit number o Blood type matching o Expiration date  Informed consent  Blood matching  Obtain baseline VS  warm blood at room temperature NOT more than 30 minutes • DURING

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STAY with the patient and Check every 15 minutes – 1st hour Check every hour – succeeding hours

OTHERS:  Gauge: 18 or 19***  Y set filter IV transfusion set***  IV fluid: NSS only (other solution causes hemolysis)  Time o 4 hours: WBC, PRBC o Rapid: Plasma, Platelets, Cryoprecipitate

21. BLOOD TRANSFUSION, Blood Components Blood Component Whole blood PRBC Cryoprecipitate Platelets Fresh frozen plasma Infusion rate 2 to 4 hours 2 to 4 hours 30 minutes Rapid Rapid of bleeding; 1 to 2 hours Volume 500 ml 250 ml 10 ml 35 to 50 ml 250 ml

22. BLOOD TRANSFUSION, Reaction  C – irculatory overload too rapid dyspnea, HPN, increased PR  H – emolytic incompatibility jaundice, shock HA  A – llergic antigen/ antibody transfusion urticaria, wheezing  P – yrogenic bacterial fever, chills 23. BLOOD TRANSFUSION RECTION, management • (in sequence)  B – T stop  L – et the tubings be changed  O –pen NSS

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A – lways check the VS D – octor, where are you! S – cold the bank

24. BONE MARROW BIOPSY/ ASPIRATION

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Bones commonly used: sternum, iliac crest, iliac spines, or proximal tibia (children) DURING  Position: site is sternum  Supine About 1 to 2 mL of bone marrow is obtained.

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site is iliac crest  Prone

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AFTER: PREVENT BLEEDING  Bed rest for 30 minutes  Ice bag on punctured site  Pressure on the puncture site  Position: Lie on operative/biopsied side for 10 to 15 minutes

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BOWEL DIVERSIONS, Types of Ostomy • Ileostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) • Cecostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) • Ascending colostomy watery (prone to Fluid Volume Deficit and Impaired skin integrity) • Transverse colostomy mushy/ semi-formed • Descending colostomy formed • Sigmoid colostomy formed

26. BOWEL DIVERSIONS, Stoma • Color brick red  May turn to pink after several months and years • Sensation normally no sensation • Protrusion ½ to ¾ inches • Drain 1/3 to ½ full • Appliance size (pouch opening) 1/16 to 1/8 inches 27. BOWEL DIVERSIONS, Types of Ostomy

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COLOSTOMY IRRIGATIONS – needed by Descending and sigmoid colostomy

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1st – stimulate 2nd – evacuate Position: sitting

28. BOWEL DIVERSIONS, Foods Causes odor Beans Asparagus Garlic Eggs Spices Celery Cabbage Corn Camote Cauliflower Champagne Cucumbers Carbonated drinks Tapioca Rice Yogurt Apple and apple sauce Banana Cheese

Causes gas:

Thicken stool:

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Permanent colostomy – Descending and sigmoid colostomy Colon cancer – sigmoid colostomy

BREASTFEEDING, Assessment of proper latching • C – hin to breast O – pen mouth widely L – ips turned outward A – reola is visible above only • • Nipple – touches the posterior tongue 9to promote swallowing reflex) Nipple (bottle) – always filled with milk 9to prevent colic) Color of stools:

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Breast fed: golden yellow Formula fed: pale yellow

30. BRONCHIAL ASTHMA

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Most common triggering factor: dust TRIAD symptoms;

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B – ronchoconstriction  caused by leukotrienes I – nflammation  caused by IgE M – ucus production  caused by GOBLET CELLS Give BRONCHODILATOR first, followed by STEROIDS

31. BRONCHOSCOPY • BEFORE: NPO for 6-12 hours prior to procedure; no dentures; maintain good oral hygiene • DURING:  uses local anesthetic spray to minimize gagging while inserting the bronchoscope  supine with head hyperextended • AFTER:  POSITION: semi fowler's

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NPO till gag returns then start with ice chips then followed by sips of water soft diet  regular diet ice bags to throat minimize talking, coughing, laughing; warm saline gargles; assess for respiratory distress

BURNS, causes/ types

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CAUSES/ TYPES:  Thermal burns Scald burns – hot fluids b. Flame – ignition/ fire c. Flash – explosion d. contact with hot objects Chemical burns – acids, alkali Electrical burns – electrical wires Radiation

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33. BURNS, 2 Parameters to meaasure 1) Extent – percentage

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Rule of 9 – quick way Palm method – use for scattered burn

2) Severity – 1st to 4th degree (Depth)

34. BURNS, classification Fist degree Superficial burn PARTIA L Second degree Third degree Superficial Partial thickness burn Deep Partial thickness burn Full thickness burn

Epidermis Epidermis and dermis Skin to SQ

pain, reddened (erythematosus), no edema Very painful, very red, blistered, edema, blanches with pressure Painless Red to Gray/ waxy white color Wet surface (broken blisters) Edema painless, dry, pale, white or charred

sunburn Scalds (contact with hot liquids) Fire • Electricity or lightning • Prolonged exposure to hot liquids/ objects

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Fourth degree

Epidermis, Dermis, SQ tissue, bone and muscles

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HEALING PROCESS 1st degree – 3 to 7 days 2nd degree – average of 21 days 3rd degree – skin grafting  compartment syndrome 4th degree – amputation; skin grafting

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35. BURNS, stages of burn injury 1st stage Fluid Accumulation IV to IT Hypovolemia/ shock Oliguria Decrease Blood volume Decrease BP Increase HR, Increase RR Increase HCT Increase potassium

2nd stage Fluid remobilization IT to IV (Hypervolemia) Diuresis Increase Blood volume Increased BP Fluid overload  CHF

3rd stage Recovery/ Convalescnce Healing process Decreased calcium (calcium is used in wound healing)

Decrease sodium and water Myoglobinuria

Decrease HCT Decrease potassium Decrease sodium and water

36. BURNS, phases of burn management EMERGENT; usually 24 to 48 hours following injury BEGINS Begins at the time of injury ENDS ends with the retoration of capillary permeability (fluid resuscitation) GOAL/ FOCUS • Fluid resuscitation • Fluid replacement are calculated from the TIME of INJURY and not from the TIME OF ARRIVAL at the hospital and • • • •

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ACUTE; Begins 48 to 72 hours after the time of injury

REHABILITATIVE

Begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun begins with wound closure

until the burn is healed

Amount of fluid: based on the client’s weight extent of injury infection control wound care, wound closure, nutritional support, pain management, and physical therapy

until the patient has reached the highest level of functioning

Designed so that the client can gain independence and achieve maximal function

37. BURNS, “must-to-know”

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Burns to the chest, back, neck, and face, PRIORITY nursing diagnosis:

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Ineffective airway clearance***

IV fluid used in FLUID RESUSCIATION: Lactated Ringers (LR) Patient is burning: o “DROP and ROLL”*** o AVOID:  Standing – to prevent inhalation  Running – to prevent fanning of fire Electric burn, first to be done:*** o Turn OFF the electric soource Components of FIRE:*** o Oxygen (open window, oxygen tank) o Friction (drapes, electric spark, friction producing equipment) o Combustible material (kerosene, LPG) Patient with burns with diarrhea, suspected organism: o Clostridium Deficile Chemical burn to the eyes, first thing to do is: o flush the eyes with water continuously for 20 minutes SKIN GRAFT o Heterograft (xenograft) – is a graft of skin obtained from another species, such as a pig. o Autograft – is a graft of skin obtained from the patient itself o Homograft – is a graft of skin obtained from same species like a cadaver 6 to 24 hours after dead

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FIRE management, sequence*** o 1- Protect patient o 2- Activate alarm o 3- Confine the fire o 4- Extinguish the fire FIRE EXTINGUISHER, types*** o Type A – for Trash fire  paper, woods, leaves (contain water under pressure)

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Type B – for Fuel fire  oil, gasoline, kerosene (contains carbon dioxide) Type C – for Electric Fire  appliances, wire (contains dry chemicals) Type D – any kind (contains graphite)

CANCER, RSIK FACTORS

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Breast Cancer o Early menarche o Late menopause o Nulliparity

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1st pregnancy at 35 years old

Bladder Cancer

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Smoking Hair dye

Gastric Cancer o Smoked foods o Peptic Ulcer Disease: gastric ulcer o Raw foods

39. CANCER SCREENING PROCEDURE Breast Self Exam (BSE) Testicular Self Exam (TSE) Mammogram Paps smear Digital rectal Exam (DRE)

SCHEDULE Monthly, 3 to 5 days after the onset of menstruation Monthly, after a warm bath 35 to 40 years – 1x (baseline) 41 to 50 years – every 2 years 51 and above – yearly Onset – 40 – every 3 years 41 and above – yearly 50 and above – yearly 40 and above – yearly (if high risk)

40. CHEMOTHERAPY SIDE EFFECTS Side effects Nausea and vomiting Anorexia Interventions o Provide antiemetics 30 – 60 minutes before chemotherapy o AVOID: unpleasant odors, spicy foods, hot o SFF o Diet: soft bland o Ensure adequate fluid hydration o Frequent oral hygiene o Rinse mouth with ½ strength peroxide and NSS o Brush teeth with soft toothbrush and baking soda o USE: unwaxed dental floss, cotton-tip applicator for viscous xylocaine over lesions Neutropenic precaution o Handwashing o Neutropenic diet/ low-bacteria diet: cooked foods o AVOID: fresh flowers, fruits, vegetables, raw foods, vaccinations o Reverse isolation/ private room o Assess vital signs every 4hours Thrombocytopenic precaution o AVOID: aspirin, IM, invasive procedures, punctures, contact sports o Use soft bristled toothbrush, electric razor, stool softener Blood transfusion Bed rest o Discuss potential TEMPORARY hair loss o Use of wigs o If hair grows back – color and texture changes o AVOID: excessive shampooing o Increase fluids o Temporary

GATRO-INTESTINAL Oral thrush

Neutropenia (WBC)

HEMATOPOEITIC (Bone marrow suppression)

Thrombocytopenia (Platelets)

Anemia (RBC) Alopecia INTEGUMENTARY Cystitis Sterility/ infertility

GENITO-URINARY

41. CHEST TUBE a. DRAINAGE BOTTLE NURSING CONSIDERATIONS: • Keep at least 2 to 3 feet below the chest (to allow drainage by gravity) NEVER raise the bottle above the level of the heart (to prevent reflux of air or fluid) • NOTE:  COLOR: bloody drainage during the first 24 hours •

 OUPUT: 500 – 1000 ml during the first 24 hours*** FLUID DRAINAGE: the tube is inserted at 8th or 9th ICS AIR DRAINAGE: the tube is inserted 2nd or 3rd ICS

COMMON OBSERVATIONS • NO DRAINAGE  Resolution  Obstruction b. WATER SEAL BOTTLE NURSING CONSIDERATIONS: • Immerse tip of the tube in 2- 3 cm of sterile NSS to create water seal COMMON OBSERVATION: • INTERMITTENT BUBBLING/ FLUCTUATIONS/ OSCILLATION/ TIDALLING (rise on inspiration, fall during expiration) • NO FLUCTUATIONS  Obstruction – check and milk the tubing with CAUTION  Low suction

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 Re expand lungs – do chest X- ray for confirmation CONTINUOUS BUBBLING  Air leakage (except during suctioning)

SUCTION CHAMBER NURSING CONSIDERATIONS: • Immerse the tube of the suction control bottle in 10 to 20 cm of sterile NSS (to stabilize the normal negative pressure in the lungs and protects the pleura from trauma if the suction pressure is inadvertently increased) COMMON OBSERVATIONS • CONTINUOUS GENTLE BUBBLING (indicates adequate suction control)  NORMAL

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CHEST TUBE REMOVAL • Give analgesics 30 minutes before removal • Clamp on bedside • DURING removal: let the patient EXHALE and hold breath while doing VALSALVA MANEUVER • Maintain dry, sterile, occlusive dressing EMERGENCY SITUATION • DISLODGE (chest tube removal FROM THE CLIENT)  AT BEDSIDE: vaselinized gauze  Palm pressure (for splinting) • DISCONNECTION (disconnection FROM THE BOTTLE/ bottle breakage) • ATBEDSIDE: Extra bottle immersed in sterile water Clamp (Hemostat) ALERT! Never clamp the test tubes over an expanded period of time. Clamping the chest tubes IF a client with an air in the pleural space will cause increased pressure buildup and possible TENSION PHEUMOTHORAX

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42. CEREBROSPINAL • • •     

FLUID (CSF) ANALYSIS Protects from mechanical trauma Function of CSF: Carries nutrients to brain Characteristics Normal pressure: 5 to 15 mmHg/ 70 to 180 mmH2O Normal volume: 100 to 200 ml WBC: 0 - 5 cells/mm Glucose: 40 to 80 mg/dl (40 to 80 mg/100ml) Protein: 15 to 45 mg/dl (15 to 45 mg/100 ml) Diagnostic test for meningitis, result Increase protein content Decrease glucose content Increase WBC content Cloudy (bacterial meningitis) Clear (viral meningitis)

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43. CHOLECYSTITIS CHOLELITHIASIS: stones in the gall bladder (occurs due to hypercholesterolemia) CHOLECYSTITIS: inflammation of the gall bladder  Stone: cholesterol*, bile pigments, calcium: may cause obstruction, infection  stones may spread to: o common bile duct (choledocholithiasis) o pancreatic duct (pancreatitis) 6F’s: o Female (contraceptives) o Fat (obesity) o Forty (low estrogen levels) o Flatulence o Fair o Fertile (decrease estrogen, high progesterone)

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MANIFESTATIONS:  TRIAD symptoms: o RUQ pain – that radiates to midsternum, scapular area or right shoulder*** o Fever o Jaundice/ pruritus  Increased bilirubin*** Increased alkaline phosphatase if with obstruction***  (+) Murphy’s sign – pain during inhalation when the physician’s hand is placed on the patient’s RUQ abdomen  Decrease ADEK – bleeding (low Vitamin K)  Acholic stools (pale/ gray stools/ clay-colored)  Steatorrhea (no bile to emulsify the fats) DIAG AND LAB  ERCP (endoscopic retrograde cholangiopancreatography)  Oral cholecystography – PROCEDURE OF CHOICE!***  UTZ

INTERVENTION  Pain control o Narcotics o antipasmodics and anticholinergics (to reduce spasms and contractions of the GB)  NGT insertion – for gastric decompression  DIET: high CHO, moderate CHON, low fat  give Vitamin K as ordered SURGICAL INTERVENTIONS:  Cholecystostomy: incision into the GB for the purpose of drainage  Abdominal cholecystectomy: removal of the GB for the purpose of drainage  Laparoscopic cholecystectomy: removal of GB thru an endoscope inserted thru the abdominal wall  Choledochotomy: incision into the CBD for removal of stones 44. CORONARY ARTERY BYPASS GRAFT  Used for multiple vessel affection  Sources of Grafts: o Saphaneous vein o Internal mammary artery o Radial artery 45. CT SCAN • • • • • X-ray Contrast medium – warm sensation AVOID: pregnant women Before: NPO After: increase fluid

46. CVP MONITORING • Measure the pressure of the right atrium • Place the zero level of the manometer at the level if the right atrium (4th ICS) • AVOID: coughing and straining • NORMAL: 2 -12 mmHg

47. CYSTOSCOPY • Direct visualization of the LOWER urinary tract (bladder and urethra) • PURPOSE:  specimen collection  treatment of the interior of the bladder and urethra  Prostate surgery • Local anesthesia – commonly used • POSITION: dorsal recumbent • CONTRAINDICATIONS: acute cystitis, bleeding disorders • AFTER:  Assess  VS  urine characteristic (NORMAL: pink tinged or tea-colored urine)  I&O  Encourage fluids  Sitz bath  Observe for fever, dysuria, pain in suprapubic region 48. DIABETES INSIPIDUS and SIADH DIABETES INSIPIDUS MAIN PROBLEM Decrease ADH secretion NURSING Fluid Volume Deficit DIAGNOSIS Decrease urine specific gravity – DILUTED Dehydration, Constipation Polyuria, Polydipsia Weight loss S/SX Hypotension Hypovolemia Hypernatremia (CONCENTRATIONAL) Hemoconcentration (increase HCT) COMPLICATION Shock Hydration - Force fluids (2 – 3 L/ day) DIET AVOID foods that exert diuretic effect (coffee, tea) Vasopressin DRUGS

SIADH Increase ADH secretion Fluid Volume Excess Increase urine specific gravity CONCENTRATED Edema Oliguria Weight gain Hypertension Hypervolemia Hyponatremia (DILUTIONAL) Hemodilution (decrease HCT) Water intoxication Restrict fluid ALLOW foods that exert diuretic effect (coffee, tea) Diuretics (Loop and Osmotic) Demeclocycline (Declomycin)

49. DUMPING SYNDROME • S/sx:

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 Diarrhea

Shock-like symptoms: diaphoresis, cold and clammy

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50. EAR •

Position after feeding:

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LEFT SIDE LYING (to delay drainage to stomach)

Common complication of gastrectomy

Ear bones (Ossicles)  M – alleus  A – nvil  S – tapes Stirrups

Hammer Incus

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Position during drug administration:  Below 3 years old – down and back  Above 3 years old – up and back

51. ECG • NORMAL

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PR  0.12 – 0.20 seconds QT  0.32 – 0.40 seconds QRS  0.04 – 0.10 seconds

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HYPERKALEMIA Tall T wave HYPOKALEMIA Flat T wave HYPERCALCEMIA Short ST segment and QT interval HYPOCALCEMIA Lengthened ST segment and QT interval Atrial flutter o With P wave (saw tooth) o Regular rhythm o Normal QRS Atrial fibrillation*** o No P wave o Irregular rhythm o Normal QRS Atrial tachycardia o With P wave (different shape) o Regular rhythm o Normal QRS Ventricular fibrillation o No P wave o Chaotic rhythm o No QRS Ventricular tachycardia o No P wave o Regular rhythm o Wide and bizarre QRS

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52. ENEMA • TYPES:

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Cleansing enema Carminative enema Return flow/ Harris flush/ Colonel irrigation Retention

cleansing (3x) flatus flatus (5 – 6x) soften; lubricate (1 – 3 hours)

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SOLUTIONS:  Hypertonic

sodium biphosphate tap water NSS soapsuds, Bisacodyl/ Fleet oil

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Hypotonic Isotonic Irritants Lubricants

Position: left-sidelying/ dorsal recumbent Enema tube – lubricate first; insert in rotating motion

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Infant Child Adult

1 – 1.5 inches 2 – 3 inches 3 – 4 inches

Cramping:  Lower the solution

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Clamp and wait for 30 seconds*** Restart

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Temperature: 100oF (37.7oC)

53. EPIGLOTTITIS • Tripod position*** • Always an emergency situation • Essential equipment for epiglottitis: tracheostomy 54. E.S.S.R.  feeding method of patients with cleft lip and cleft palate • E – nlarge the nipple hole • S – timulate the sucking • S – wallow • R – est EXERCISES, types CHARACTERISTICS OTHER NAME JOINT MOVEMENT CONTRACTION BENEFITS on MUSCLES ISOTONIC Dynamic    Increase strength ISOMETRIC Static/Setting x   Increase strength ISOKINETIC Resistive    Increase strength  Increase size  Increase blood pressure and blood flow to muscles  May be isometric or isotonic with resistance  Weight-lifting

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 Increase tone
       Increase mass Joint flexibility Use of trapeze Walking Swimming Cycling Running

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Increase endurance  Increase heart rate and  cardiac output  Quadricep setting  Squeezing on stress ball  Kegel’s

EXAMPLES

56.

EYES: OTITIS MEDIA (ear problem) • Causes:  Propping the bottle  Passive smoking ***  Frequent tonsillitis •   S/Sx: Otalgia – ear pain Otorrhrea

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Management: Myringotomy with tympanostomy tube First line of drug: Ampicillin Second line of drug: Cotrimoxazole

57.

EYES: CATARACT • S/sx:

   •
58.

Absent red eye reflex Blurring of vision Clouding of lens – from inner to outer

Management: SURGERY ONLY***

EYES: BLIND PATIENT  20/ 200

 
59.

POSITION of the Nurse: Nurse walk one step ahead of the patient Never rearrange things (familiarization of environment)***

EYES: GLAUCOMA • S/sx: Tunnel vision/ PERMANENT peripheral vision loss (“I can’t see the person besides me.”)***  Eye pain  Halo lights*** Eye meds for life NO need for water restriction AVOID: Midriatics (dilation)



• • •

60. EYES: POST-SURGERY

• • •

• • •

Patch AFFECTED eye Night shield at NIGHT AVOID: o Coughing o sneezing, o lifting more than 5 5lbs o bending (from waist), o prolonged watching or reading after surgery ALLOW: o bending (from knees) o sneezing (mouth open) NORMAL: mild to moderate eye pain ABNORMAL: Severe eye pain – infection/ hemorrhage

61. FECAL C-olor -----------brown/yellow – stercobilin O-dor------------aromatic C-onsistensy-----------solid-semi-formed moist A-mount ----------------100-400g/day S-hape------------------cylindrical 62. FOODS rich in IRON • Liver • Green leafy vegetables • Dried fruits • Scallops, shrimps • Oyster, clams • molasses 63. Geriatric client, hearing impairment • Speak infront • Talk slowly • AVOID mounting (lip exaggeration) • AVOID: high pitched voice (shouting) 64. Geriatric client, poor vision • Blind patient: 20/ 200 • Stimulating color: red, orange and yellow • Nurse walk one step ahead of the patient

65. GTPALM

•
•

G – Gravida P – Para

refers to the number of pregnancies regardless of outcome refers to the number of deliveries that reached viability (20 weeks gestation) born dead or alive; multiple births count as 1 delivery regardless of the number of newborns delivered

• • • • •

T – Term deliveries number of TERM births (infants born after 37 weeks and above) P – Preterm deliveries number of PRETERM births (infants born between 20 to 37 weeks) A – Abortions number of pregnancies that end in spontaneous or therapeutic abortion prior to age of viability (20 weeks) L – Live number of children currently alive M – Multiple gestations and births (not the number of neonates delivered)

66. GUILLIAN BARRE SYNDROME • acquired inflammatory disease (12 cranial and 31peripheral nerves)

•
•

Bilateral, Symmetrical, Polyneuritis MANIFESTATIONS: o Clumsiness - 1st sign o ASCENDING PARALYSIS: progressive, bilateral

o
o • •

Dysphagia, Dysarthria, Dyspnea Sensory findings: paresthesia, burning pain, numbness

COMPLICATION: respiratory failure MANAGEMENT: o Symptomatic o Steroid o SAFETY: Side rails o Self-limiting

67. HEARING LOSS • Severity of hearing loss LOSS IN DECIBELS 0–15 >15–25 >25–40

INTERPRETATION Normal hearing Slight hearing loss Mild hearing loss

>40–55 >55–70 >70–90 >90 68. HEPATIC ENCEPHALOPATHY • S/Sx:

Moderate hearing loss Moderate to severe hearing loss Severe hearing loss Profound hearing loss




Altered LOC changes: memory loss, confusion to coma ASTERIXIS – flapping tremor

•
•

DRUGS:  lactulose (NH3 binding effect)  neomycin sulfate (Mycifradin) – inhibits action of intestinal bacteria (that produces ammonia) Diet: decrease protein (to reduce ammonia)

69. HEPATITIS • Hepatitis A and E – fecal-oral (contaminated food and drink) • Hepatitis B, C and D – blood (needle stick, sex)

70. HOSPITAL EMERGENCY COLOR CODING • Code blue – cardiac arrest, medical emergency • Code pink – infant abduction • Code red – hospital fire • Code yellow – bomb threat • Code silver – person with weapon (combative) 71. HOSPITAL TANKS COLOR CODING

• •
• •

Nitrous oxide (laughing gas) Oxygen Cyclospropane Nitrogen Carbon dioxide Helium Medical air

Blue Green Orange Black Grey Brown Yellow

• • •
72.

HYPERKALEMIA, management • G – lucose (D50) • I – nsulin • C – calcium replacement (to force potassium back in the IC compartment) • K – ayexalate (retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea.) • S – odium bicarbonate + • DIALYSIS • DIURETICS HYPOTHYROIDISM AND HYPERTHYROIDISM HYPOTHYROIDISM (myxedema, Hashimoto, cretinism: children) HYPERTHYROIDISM (Grave’s disease, Parry’s disease, Basedow’s disorder, Toxic diffuse goiter, Thyrotoxicosois) Increase T3 – increase BMR, increase VS Increase T4 – increased body heat production Increase Thyrocalcitonin – decreased serum calcium Increase GI motility (diarrhea) Increase Appetite Increase VS (Heat intolerance, tachycardia) Increase Energy (Restlessness, nervousness, tremors insomnia) Increase MEtabolic rate Increase SKIN moist (diaphoresis) Decrease weight (tissue wasting) Decrease menstruation (amenorrhea) Exopthalmus DIET: • High calorie, Low fiber • Increase fluids • High CHON, High CHO, High FATS • Skin care Cool environment

73.

MAIN PROBLEM

S/SX

Decrease T3 – decrease BMR, wt. Gain Decrease T4 – decrease body heat production, catabolism Decrease Thyrocalcitonin – increased serum calcium Decrease GI motility (constipation) Decrease Appetite  increased lypolysis  atherosclerosis  MI Decrease VS (Cold intolerance, bradycardia, hypothermia  most fatal) Decrease Energy (fatigue, lethargy, hypoactive) Decrease MEtabolic rate Decrease SKIN moist (dry, brittle/ coarse hair/ skin) Increase weight (fluid retention, edema) Increase menstruation (menorrhagia) DIET: • Low calorie, High fiber • Increase fluid intake/ IVF (constipation) or decrease fluids (edema) • High CHON, Low CHO, Low FATS Skin care Warm environment

MNGT

Sx: SUBTOTAL THYROIDECTOMY DRUGS  Lifetime thyroid hormone (Levothyroxine (Synthroid)) SE: insomnia  Atrophine SO4, isopreterenol (bradycardia)  Diuretics (edema)  Stool softeners/ laxatives (constipation) NOTE: never give SEDATIVES, narcotics, other CNS depressants

 Radioactive iodine ( I) therapy  Anti-thyroid agents (Thionamides):
131

Propylthiouracil (PTU), Methimazole (Tapazole) SE: agranulocytosis

 Beta blockers: Propranolol (Inderal)  IODIDES:
KISS: Potassium Iodide Saturated solution (lugols solution)

 Steroids: Dexamethasone
COMPLICATI ON MYXEDEMA COMA




Hypothermia Altered LOC leading to coma Bradycardia



THYROTOXIC CRISIS (THYROID STORM)  Fever  Agitation  Tachycardia

74. HYPOPARATHYROIDISM AND HYPERPARATHYROIDISM HYPOPARATHYROIDIS M Decrease Calcium Increased Phosphate Tetany (Chvostek and Trousseau) Laryngospasm Paresthesia High calcium diet Low phosphate diet Calcium gluconate AlOH (Amphogel) Seizure HYPERPARATHYROI DISM Increase Calcium Decreased Phosphate Bone pain/ fracture Renal colic Anorexia, nausea and vomiting Low calcium diet High phosphate diet Calcitonin Furosemide Vitamin D Renal stones

MAIN PROBLEM S/SX DIET DRUGS COMPLICATI ON FOODS high in CALCIUM: • Orange • Spinach • Milk • Yogurt

Aluminum hydroxide (Amphogel), given in HYPOparathyroidism  Antacid but the side effect is phosphate binder Furosemide (Lasix), given in HYPERparathyroidism  Diuretic that eliminates calcium as well as sodium and potassium in urine

75. INCREASED INTRACRANIAL PRESSURE • Cushing’s symptoms:  Increased BP and MAP  Decreased RR and PR  Wide pulse pressure • Position: high-fowlers position • DRUGS: mannitol, steroids • AVOID:  Straining/ constipation  Lifting heavy objects 76. INFORMED CONSENT, purpose • To ensure the client’s understanding of the nature of the surgery • To indicate the client’s decision • To protect the client against unauthorized procedure • To protect the surgeon and hospital against legal action INFORMED CONSENT, circumstances requiring an informed consent • R – adiation or cobalt therapy • A – nesthesia use • B – lood administration • I – nvasive procedure  E – ntrance into a body cavity  S - urgical procedure using scalpel, scissors, suture (Invasive procedures)

77.

78. INFORMED CONSENT

•

Requisites for validity of informed consent  Legal age  Mentally capacitated  Secured within 24 hours before the surgery  Secured before pre-op medication administration

  

Written permission Signature Witness – nurse, physician

•
• •

For minors (under 18), unconscious, psychologically incapacitated  permission from responsible family member For emancipated minors (married, college student living away from home, in military service, any pregnant female or any who has given birth) 4 Criteria are needed to be met if consent is not needed anymore:  There is an immediate threat to life  Experts agree that it is an emergency  Client is unable to consent  A legally authorized person cannot be reached Surgery without consent-- BATTERY!

•

79. ISOLATION PRECAUTION • Tier 1: Standard Precaution  to all blood and body fluids except for sweat  to all clients regardless of diagnosis  hand washing and PPE (clean) • Tier 2: Transmission-based precaution Airborne > 3 feet Droplet nuclei < 5 microns Droplet < 3 feet Droplet nuclei > 5 microns N95 Mask Measles TB Varicella (chickenpox) Meningitis, mumos Pertussis, pneumonia German measles, GABHS (Scarlet fever, pharyngitis) Diptheria MRSA (Staph) Impetigo Scabies Herpes Simplex Hepatitis A Diarrhea

Contact

Skin

Gloves gown

• • 80.

Immunocompromised – first Infectious - last

IV THERAPY, types Characteristics Fluid movement Effect to the cell Indications Examples HYPOTONIC Solute < solvent from Intravascular TO cells Swell Dehydrated patients Distilled water 0.45% NSS 0.33% NSS 2.5% dextrose ISOTONIC Solute = solvent O pressure of solution No movement expand the intravascular compartment Hypovolemia Burns (resuscitative stage) D5W LR NSS D5 0.225% NSS HYPERTONIC Solute > solvent From Intracellular TO Intravascular shrink/ crenation Edema D10W D50W D5NSS 5% dextrose in 0.45% D5LR TPN Dialysate

contraindicated for clients with increased intracranial pressure, clients at risk of 3rd space fluid shift

• Avoid D5W if the client is at risk of increased intracranial pressure (ICP) • Use LR for BURNS

•

EXAMPLES:  D5W/ D10W/ D50W – red  NSS – green  D5NSS – yellow  D5LR – pink  Plain LR – blue  0.45 NSS – sky blue  D5NM – orange

81. IV THERAPY, complications Circulatory overload Air embolism Phlebitis Dyspnea, increased BP SOB, crackles Dyspnea, decreased BP Swelling + Heat slow down Discontinue Left sidelying and trendelenburg Discontinue

Pyrogenic reaction Infiltration

Fever, chills Swelling + Cool

Cold Elevate Restart Discontinue Retain IV equipment for C&S Discontinue Warm/ Moist heat (due to edema) Elevate Restart (another site)

82.

L.A.S.E.R. a. L – ight A – mplification by S – timulated E – mission of R – adiation b. TYPES • • • Carbon dioxide – gas (clear goggles) ND:YAG – Neodymium: Yttrium Alluminum garnet) – bright lamp (green goggles) Argon – gas (orange goggles)

c.

HAZARDS Eyes  goggles Skin  gown and gloves Lungs  mask

83. LATEX ALLERGY • FOODS: o Avocado o Potatoes o Bananas o Passion fruits o Chestnuts o Tropical fruits (mango) o Kiwi fruits o Strawberry o Grapes o Soy beans o Pineapple • Catheters, rubbers, condom, balloons • Contraindicated with spina bifida patients • Assess for signs and symptoms: o STRIDOR (best option) – harsh, high pitch sound caused by air passing through constricted air passages o Urticaria o Wheezing o Watery eyes

• Non latex gloves  vinyl gloves • Non latex balloon  mylar
84. LEVEL OF CONSCIOUSNESS a. GLASGOW COMA SCALE EYE OPENING 4 – Spontaneous 3 – To verbal command 2 – To pain 1 – No response GLASGOW COMA SCALE VERBAL RESPONSE 5 – Oriented, converses 4 – Disoriented, converses 3 – Uses inappropriate words 2 – Makes incomprehensible sounds 1 – No response MOTOR RESPONSE 6 – To verbal command 5 – To localized pain 4 – Withdraws 3 – Flexes abnormally (Decorticate) 2 – Extends abnormally (Decerebrate) 1 – No response

  

7 and below - in a comatose state 3 – lowest score 15 – highest score

b.

A.V.P.U. (for Pediatric client) A – Alert and Awake V – Verbal response to stimuli P – Pain response in stimuli U – Unresponsive Level I (conscious) – 3 C’s: conscious, cognitive, coherent Level II (lethargic) – drowsy, sleepy, obtunded, confused Level III (stuporous) – responds to strong stimuli only Level IV (coma) – unresponsive; absent protective reflexes

c.

85. LEUKEMIA • Increased immature WBC

• •

Decrease matured WBC  risk for infection Decrease RBC  activity intolerance

•

Decreases platelets  risk for bleeding

86. LIVER BIOPSY • BEFORE: Note blood clotting defects, prothrombin time, and platelet count • DURING: exhale and hold breath • AFTER: Right side-lying position

87. LIVER CIRRHOSIS

•

Most common type: Laennec (due to alcohol)

PORTAL HYPERTENSION Portal HPN, Increase collateral circulation  Caput medusa (dilated veins over the abdomen)  Hepatomegaly, Spleenomegaly  Hemorrhoids  Ascites and edema (unable to metabolize protein)  Spider angioma/ telangiectasia (dilated vein/capillaries over the face and trunk)  Esophageal varices, GI bleeding  Leg varicositites 88. LUMBAR PUNCTURE (LUMBAR TAP)

•

PURPOSE: To withdraw CSF to determine abnormalities  Measures CSF pressure (normal opening pressure 60-150 mm H2O)  Obtain specimens for lab analysis (protein [normally not present], sugar [normally present], cytology, C&S)  Check color of CSF (normally clear) and check for blood  Inject air, dye, or drugs (anesthesia) into the spinal canal AREA: Insert needle between L3 – L4 or L4 – L5 (spinal cord ends in L2) BEFORE PROCEDURE:  Obtain consent  Empty bladder DURING PROCEDURE:  Position of the patient: C-position (flex the shoulders, not the head)  Position of the nurse: infront of the patient  Position of the doctor: at the back of the patient AFTER PROCEDURE: prevent spinal headache  Position: flat for 6-12 hours (to prevent spinal headache)  Force fluids (to maintain pressure and prevent spinal headache)  Blood patching  label specimen

•
•

•

•

89. MAGNETIC RESONANCE IMAGING (MRI)/ NUCLEAR MAGNETIC RESONANCE (NMR) • Uses radio waves • BEFORE:  remove metals: jewelry, hairpins, glasses, wigs (with metal clips), and other metallic objects. • AVOID:  patients with orthopedic hardware  intrauterine devices  pacemaker  internal surgical clips  or other fixed metallic objects in the body (braces, retainers) • BEFORE:  Have client void before test. • DURING  remain still while completely enclosed in scanner throughout the procedure, which lasts 45-60 minutes.


 •

Teach relaxation techniques to assist client to remain still and to help prevent claustrophobia] NORMAL: audible humming and thumping noises from the scanner during test. Sedate client if ordered.

90. MANTOUX TEST/ Tuberculin Sensitivity Test or Purified Protein Derivative (PPD) Test

• • •

Route: Read: Result:

ID, 0.1 mL of PPD is injected INTRADERMALLY, creating a wheal or bleb 48 to 72 hours (+) to exposure 10 mm and above  not immunocompromised 5 mm and above  immunocompromised (HIV, pedia, with history of TB, geriatric clients) 0 - 4 mm= NOT SIGNIFICANT Erythema without induration is NOT considered significant

 
 

91. MEDICATION a. Drug interaction • Additive effect • • • b. Synergism/ potentiation Antagonist Interference

1+1=2 eg. diazepam + alcohol = increase sedation 1+1=3 eg. codeine + aspirin = intense pain relief OHA + NSAIDs = hypoglycemia*** 1+1=0 eg. Coumadin + Vitamin K increase or decrease metabolism/ excretion eg. Probenecid decrease excretion of Penicillin immediate/ once eg. Magnesium sulfate (preeclampsia) once eg. Anxiolytic (pre-surgery) carried out indefinitely eg. antibiotics no specific time of administration/ as needed eg. Pain relievers within 24 hours Signed Indicate as Telephone Order Put decimal number

Medication order • STAT (“statim”) • • • • Single order/ one time Standing / routine PRN (“Pro Re Nata”) Telephone order

c.

Drug effects • Therapeutic – desired

•
• •

Side effects – 2nd effect, expected Adverse effects – severe side effect, unexpected Allergic reaction – immunologic response

92.

MEDICATION ORDER, components • Clients name • Date and time of order • Name of drugs • Dose and route • Time of frequency • Signature

93. MRSA (methicillin-resistant Staphylococcus aureus) • 2 types of infection:  Hospital-associated MRSA – happens to people in healthcare settings. Community-associated MRSA – happens to people who have close skin-to-skin contact with others, such as athletes involved in football and wrestling. Practice good hygiene Keep cuts and scrapes clean and covered with a bandage until healed Avoid: o contact with other people’s wounds or bandages o sharing personal items, such as towels, washcloths, razors, or clothes Wash soiled sheets, towels and clothes in hot water with bleach and dry in a hot dryer



• •

•
•

94. MYELOSUPPRESSION

• • •
95.

THROMBOCYTOPENIA  Petechiae ANEMIA  Fatigue NEUTROPENIA  Fever and sore throat

MYOCARDIAL INFARCTION • Cardiac enzymes o after 1 hour o after 2 hour o after 4 hour o after 24 hour • ECG changes o Pathologic Q wave o ST elevation o T wave inversion

Myoglobin Troponin CPK-MB LDH

96. NAEGELE’s RULE • If LMP is from APRIL TO DECEMBER, use the formula: o - 03 + 07 + 01 (MM, DD, YY) • If LMP is from JANUARY TO MARCH, use the formula: o + 09 + 07 (MM, DD)

97. NASOGASTRIC TUBE (NGT) • TYPES


 •

Levin - single lumen Salem sump – double lumen

INSERTION  Measurement: adult (N.E.X.), pedia (N.E.M.U.X.)  Position: high-fowlers and neck hyperextended  Instruction: ask to swallow  Placement: 1- X-ray 2- Aspirate and pH test  normal gastric pH = 1 to 4 (acidic) 3- Listen/ auscultate – after introduction of 10 – 30 ml of air (20 ml) REMOVAL  Instil 50 ml of air

•


 •

Take deep breath and hold  pinch catheter  withdraw Mouth care and blow nose

FEEDING  Check placement  Position: sitting/ upright/ fowlers


  

Check for RESIDUAL CONTENT  dont discard; above 100ml – STOP Hang: 12 inches from point of insertion Flush : 50 to 100 ml of water Remain upright – 30 minutes

98. NEPHRITIS and NEPHROSIS (NEPHROTIC SYNDROME) NEPHROSIS (NEPHROTIC SYNDROME) Increase glomerular membrane permeability Autoimmune 1. Hypoalbuminemia 2. Proteinemia 3. Hyperlipidemia 4. Edema (anasarca) DIET: high protein, low sodium, decrease OFI Ambulate Normal BUN = 10 – 20 Normal creatinine 0.4 – 1.2

NEPHRITIS (NEPHRITIC SYNDROME) Inflammation of the kidneys GABHS Hematuria (gross) Edema (periorbital) HPN Proteinuria Oliguria/ Anuria Increase BUN/ creatinine DIET: low sodium, decrease OFI Bed rest

99. NON-STRESS TEST (NST) and CONTRACTION STRESS TEST(CST) Variables Results NST FM andFHR NORMAL (Reactive/ Positive) Increase FM  Increase FHR (acceleration) Decrease FM  Decrease FHR (deceleration) ABNORMAL (Nonreactive/ Negative) Increase FM  Decrease FHR (deceleration) Decrease FM  Increase FHR (acceleration) 2 FHR acceleration/ 10 minutes Each acceleration increase to 15 bpm/ 15 sec. CST (OCT) UC and FHR NORMAL (Non-reactive/ Negative) Increase UC  Decrease FHR (deceleration) Decrease UC  Increase FHR (acceleration) ABNORMAL (Reactive/ Positive) Increase UC  Increase FHR (acceleration) Decrease UC  Decrease FHR (deceleration) 3 contraction/ 10 minutes Each contraction = 40 to 60 seconds

EARLY LATE

VARIABLE

FETAL HEART RATE DECELERATIONS CAUSE MANAGEMENT Head compression Observation Uteroplacental insufficiency Side-lying position Oxygenation Increased IV fluids Stop Oxytocin (Pitocin) Call the MD Caesarean if not corrected Cord compression Trendelenburg/ Knee-chest/ Side-lying position Oxygenation Increased IV fluids Stop Oxytocin (Pitocin) Call the MD Caesarean section if not corrected

100. OBSTRUCTIVE SLEEP APNEA (OSA) • OSA – is the most common type of sleep apnea syndrome • Cause: o Obesity

o o • •

Old men Smoking

•

Pathophysiology: decrease diameter of the upper airway S/Sx: o Insomnia o Snoring o Morning headaches o Hypertension o Enuresis • Complications: o CAD, HPN o CVA o Premature death o MI, dysrhythmias Management: o AVOID: sleeping in supine, alcohol o Lose weight

101. OR TEAM MEMBERS SCRUB Surgeon Surgical assistant Scrub nurse SCRUB NURSE Performs complete scrub Prepares and hands out instruments Hands instruments while maintaining sterile technique Ensures everybody in the scrub team practices sterile technique Partner in OS and instrument counting Anticipates the needs of the team Patient advocate (act in behalf of the patient); GUARDIAN OF THE PATIENT; doing something that patient can’t do NON SCRUB Anesthesiologist Biomed Circulating nurse CIRCULATING NURSE Greets the client upon arrival – 1st primary responsibility of circulating nurse Checks client identification Sponge counting together with scrub nurse Monitors the urine output and blood loss together with anesthesiologist Ensures the consent form is signed Documents the entire procedure

o o o o o o o

o o o o o o

102. PACEMAKER: CONTRAINDICATIONS o Strong magnetic fields – MRI

o o

Electrical fields – high powered instruments (microwave oven, TV, radio, vacuum cleaners) Cellular phones – do not place near chest; place in the ear farthest in the pacemaker implant

103. PANCREATITIS • Acute pancreatitis can become chronic • AVOID:  Morphine sulfate is not used to treat pain since it can cause the sphincter of Oddi to spasm  Stimulation of the pancreas: DO NOT USE enteral feedings • MANAGEMENT:




Position: Side-lying  to lessen the pain Meperidine (Demerol) Pancreatic enzymes and bile salts with meals*** IV fluids (to prevent shock) insulin for hyperglycemia calcium replacement decrease stimulation of pancreas o NPO-TPN (nothing by mouth; total parenteral nutrition)

 
  

o o o

NG tube anticholinergics H2-receptor antagonists

104. PARKINSON’s DISEASE • Tremors (resting and pillrolling) • Rigidity (cogwheel) • Akinesia/ Bradykinesia • Mask like face

105. PEPTIC ULCER DISEASE • Risk factors: o H. pylori o NSAIDS o Iron o Steroids

o o

Smoking and alcohol Stress

106. PERICARDITIS***

•

Pain is aggravated by: Deep inspiration (so the patient do shallow inspiration)*** o Swallowing o Lying down, turning Characteristic of breathing pattern: o shallow Position to relieve pain: o sitting and leaning forward (orthopnic)

o o

Cough***

• •

107. PHEOCHROMOCYTOMA • Tumor of adrenal MEDULLA

•
•

Main problem: increased production of catecholamines (epinephrine and norepinephrine) S/Sx: o HPN o Hyperhydrosis o High PR

108. POLYCYTHEMIA VERA

•

S/Sx:***

o o
o o o o o

Ruddy complexion  capillary congestion in the skin and mucous membranes Splenomegaly Erythromelalgia Generalized pruritus (due to basophils)*** HPN Increased hematocrit Increased bilirubin Increased liver enzymes Increased RBC Increased WBC Increased platelets (immature)

•

Complication: o Thrombus formation (MI, CVA) o Heart failure o Bleeding due to congestion and overdistention of capillaries and venules o Peptic ulcer due to increased gastric secretions

o
•

Gout due to increased uric acid released by nucleoprotein

Management o Increase fluids

o
o

Phlebotomy  removal of excess blood then DISCARD*** Drugs:

  o

Radioactive phosphorus (32P)  reduces RBC production Nitrogen mustard, busulfan, chlorambucil, cyclophosphamide  to effect myelosuppression

AVOID: iron rich foods  will enhance the production of RBC***

109. PREGNANCY: DISCOMFORTS OF PREGNANCY ASSESSMENT NURSING MANAGEMENT Nausea and vomiting Eat small frequent meals; (morning sickness) eat dry crackers on arising; may occur any time of day Breast soreness Well-fitting bra, decrease caffeinated and carbonated drinks Nasal stuffiness Use cool air vaporizer, increase fluid intake, place moist towel on the sinuses Ptyalism Use mouthwash as needed, chew gum or suck on hard candy Urinary frequency Kegel’s exercise, decrease fluids before bed, report signs of infection, avoid caffeine Constipation Increase fiber and fluids have a regular bowel movement Leg Cramps Increase calcium intake avoid pointing your toes, dorsiflex feet, local heat application Backache Emphasize posture, careful lifting, good shoes (low heeled), stoop to pick up objects

Heartburn Dizziness Ankle edema Fatigue Hemorrhoids Varicose veins

Small, frequent meals avoid overeating, spicy and fatty foods Slow, deliberate movements, support stockings, lie on left side when at rest Rest with your feet elevated, avoid restrictive garments on the lower half of the body Schedule a rest period daily, use extra pillow for comfort Avoid constipation and straining with bowel movement, take a sitz bath, apply witch hazel compress Walk regularly rest with feet elevated avoid long periods of standing and sitting do not cross your legs

110. PREGNANCY: Presumptive signs and symptoms • Fatigue – response to increased hormonal levels • Urinary frequency – caused by pressure of expanding uterus in the bladder • Nausea and vomiting (morning sickness) • Quickening - sensations of fetal movement in the abdomen) - occurs between the 16th and 20th week after the onset of the last menses. • Pigmentation of the skin o Melasma gravidarum (Chloasma) – mask of pregnancy o Abdominal striae (striae gravidarum) – due to stretching, rupture and atrophy of deep connective tissues of the skin o Linea nigra • Amenorrhea – cessation of menses • Breast changes – enlarge and become tender 111. PREGNANCY: Probable signs and symptoms

• • •

Positive Pregnancy test/ HCG in urine or serum Ballottement - sinking and rebounding of the fetus

Braxton Hicks contractions - painless, palpable contractions occurring at irregular intervals, more frequently felt after 28 weeks. They usually disappear with walking or exercise • Leukorrhea - increase in vaginal discharge • Uterine changes – from pear shape to spherical around 8 weeks gestation and becomes ovoid from 16 weeks until term • Enlargement of abdomen - at about 12 weeks' gestation, the uterus can be felt through the abdominal wall, just above the symphysis pubis

• •
•

Hegar's sign - lower uterine segment softens 6 to 8 weeks after the onset of the last menstrual period Chadwick's sign - bluish or purplish discoloration of cervix and vaginal wall Goodell's sign - softening of the cervix; may occur as early as 4 weeks

112. PREGNANCY: Positive signs and symptoms – definite signs of pregnancy • Fetal heart tones (FHTs) - usually heard between 16th and 20th week of gestation with a fetoscope or the 10th and 12th week of gestation with a Doppler stethoscope • Fetal movement felt by the examiner (after about 20 weeks gestation)

•

Fetal body outline through the maternal abdomen in the second half of pregnancy • Fetal sonographical evidence (after 4 weeks' gestation) using vaginal ultrasound. Fetal cardiac motion can be detected by 6 weeks' gestation 113. PREGNANCY: Effects of smoking • Congenital heart defects • SGA • Respiratory distress • Premature death • SIDS 114. STAGES OF PRESSURE ULCERS Stage 1 – non-blanchable, erythema 2 – epidermis and dermis involvement, shallow water blister 3 – subcutaneous involvement, deeper crater 4 – muscles and bone involvement, tissue necrosis

115. PULSE OXIMETRY/ O2 SATURATION/ CONCENTRATION • Measures the oxygen concentration and pulse • Site: finger, toes, nose, earlobe or forehead • Normal: 95 to 100% 70% life threatening • AVOID:  Movement  Nail polish  Light 116. PRURITUS • Bathe in tepid water and apply emollient lotion

• •

AVOID o o ALLOW

soaps and detergents petroleum, mineral oil Calamine Antihistamine oatmeal bath Cocoa-butter Menthol/ camphor Cornstarch Cool environment

o o o
o o o o

• •

Provide cool, light, nonrestrictive clothing Keep nails short Apply cool and moist compress

•

117. Quality Assurance (QA) – focus upon “doing it right” • A systematic process of organization-wide participation and partnership in planning and implementing improvement methods to understand and meet customer needs and expectations • emphasis is on maintaining minimum standards of care

•
•

tended to be REACTIVE rather than proactive involves such methods as: o chart audits o reviewing incident reports o determining whether performance conforms to standards.

• • •

Structure Evaluation – evaluating the “physical setting” Process Evaluation – evaluating “how the nursing care is rendered” Outcome Evaluation – evaluating the demonstrable changes brought by the nursing process

118. TOTAL QUALITY MANAGEMENT (TQM) – focuses on “doing the right thing” • aka Quality Improvement (QI)/ Process Improvement (PI) • QI’s emphasis is upon identifying real and potential problems • participation and partnership in planning and implementing improvement methods to understand and meet customer needs and expectations.

•
•

tends to be PROACTIVE instead of reactive. General Principles of TQM: o quality is achieved through the participation of everyone in the organization

• •

decisions to change or improve a system or process are made based on data (not majority rule) uses such methods as o building quality performance into the work process o meeting the needs of the customer proactively. principle benefits o viewing every problem as a possible opportunity for improvement o involving staff in how the work is designed and delivered (improves staff satisfaction) o empowering staff to identify and implement improvement resulting in increased patient outcomes o increasing the customer’s perception that you care by designing health care processes to meet customer needs, as opposed to the health care provider’s needs.

o o o

improvement opportunities are developed by focusing upon the work process the improvement of the quality of services is an ongoing (continuous) process

119. RADIATION THERAPY TELETHERAPY External Not radioactive Cobalt therapy, Linear Accelerated Radiation

SOURCE PATIENT EXAMPLE S

BRACHYTHERAPY internal Radioactive

1. 2.

Unsealed – oral, IV  radioactive iodine 131, Vitamin B12 Sealed – implant (seeds)  cesium, iridium S – hield: lead + Dosimeter badge T – ime: 5 min/visit; 30 min/ shift; 1 pt/ day D – istance: 3 feet away At bedside: forceps and lead container AVOID: pregnant and children Aratula: “Caution”

ALLOW • Leave markings • Vitamin A and D • Soap and water and pat dry

• • • • •

AVOID Sunlight Alcohol Lotion, powder, cosmetics Adhesive tape Tight clothing

120. SEIZURES • • •

Priority DURING: safety Priority AFTER: airway Seizure Precaution

         

P – osition: side-lying L – oose the clothings A – VOID: resrictions N – ote: duration and characteristics of the seizure O – xygenate: jaw-thrust D – rugs: diazepam,phenytoin, carbamazepine R – emove harmful objects at the bedside A – t the bedside: suction machine P – ad and raise the side rails E – liminate environmental stimuli (bright lights, noise)

121. SCHILLING’s TEST PART 1 (CONFIRMATORY) Vitamin B12 (+) vitamin B12 in urine  normal (-) vitamin B12 in urine  (+) Pernicious Anemia

PART 2 (IDENTIFICATION OF CAUSE) Vitamin B12 and Intrinsic factor (+) vitamin B12 in urine  Pernicious Anemia is stomach in origin (-) vitamin B12 in urine  Pernicious Anemia is small intestine in origin

122. SHOCK - Reduction of arterial pressure leading to decrease blood flow • Types:

(1) (2)

Cardiogenic – loss of cardiac pumping action (MI, CHF)

Hypovolemic – decrease blood volume (burns, bleeding/ hemorrhagic shock, dehydration)  most common (3) Distributive/ Circulatory

 

Neurogenic (SCI, drug depressants) Vasogenic – massive vasodilation

• •
• Stages: COMPENSATORY Normal BP Increased RR and PR cold clammy skin oliguria hypoactive bowel sounds

Anaphylactic – massive reaction to food, drugs and chemical Septic Septic – massive infection

PROGRESSIVE Decreased BP Increased RR and PR Altered LOC Oliguria increased BUN and Creatinine stress ulcers and increased risk for GI bleeding. metabolic acidosis (due to accumulation of lactic acid)

IRREVERSIBLE severe organ damage

•
  

Common Symptom:*** Decrease BP, MAP (Mean Arterial Pressure) Increase RR, PR Narrow Pulse Pressure Position: modified trendelenburg***

•

• • •

In neurogenic shock, the patient is also at an increased risk for  deep vein thrombosis. Major cause of septic shock  gram-negative bacteria First drug to be given for SHOCK  Epinephrine

123. Specimen collection: STOOL  Defecate in a clean bed pan or bedside commode.  Void before the specimen collection (to prevent urine contamination)  QUANTITY: LIQUID STOOL: 15 to 30 mL Refrigerate and label FECAL OCCULT BLOOD TESTING (Guaiac Test) • Occult = hidden

 

SOLID STOOL: About a pea-size or 1 inch (2.5cm)



a.

•
•

Uses a chemical reagent which detects the presence of the enzyme peroxidase in the hemoglobin molecule. RESULTS:


 • •

Changes in color like blue indicates a guaiac positive result No change or any other color than blue indicates a negative result. Avoid contaminating the specimen with urine or toilet tissue. Label Avoid specified foods and vitamin C 3 days prior to collection and specified medication 7 days prior to FALSE NEGATIVE VITAMIN C

•

collection. FALSE POSITIVE • RED MEAT (Beef, liver, and processed meats) • RAW VEGETABLES or FRUITS (Particularly radishes, turnips, horseradish, and melon)

•

MEDICATIONS (NSAIDs, IRON preparations, and ANTICOAGULANTS)

124. Specimen collection: SPUTUM  Sputum – arises from the tissue of the respiratory tract Saliva – excreted by the salivary and mucus glands  BEST TIME: early morning  BEFORE: Mouth care  DURING: o Deep breaths then cough up 15 to 30 mL (1 to 2 tablespoons).

o o
o

Wear gloves when collection. Ask the client to expectorate, not spit Should be cough directly into the specimen container

125. Specimen collection: URINE SPECIMEN PURPOSE CLEAN VOIDED  For routine examination

   

CONSIDERATIONS WHEN COLLECTING Usually collected by the client with minimal assistance Preferably done on the first voided specimen in the morning but it can be collected anytime if needed At least 10 to 30 mL Clean container is used BEST TIME: early morning – concentrated urine Sterile specimen container Place specimen during midstream flow. QUANTITY: 30 to 50 ml – routine urinalysis 5 to 10 ml – C&S Nurse aspirates from the lumen of a latex catheter or from a self-sealing port Collection of all urine produced in 24 hours The first voided urine is discarded; last urine voided included Either refrigerated or preservative is added

CLEAN-CATCH or MIDSTREAM URINE

 

For urine cultures Done when a woman has menstrual period


  

CATHETER 24-HOUR



  

Collection of sterile specimen usually done when client’s are catheterized for other reasons To determine the ability of the kidneys to concentrate urine To determine disorders of glucose metabolism To determine levels of specific constituents





 

126. SPONGE COUNTING • 1- before opening 2- before closure of a body cavity (depends on the surgery done) 3- before skin closure • The SCRUB and the CIRCULATING nurses should count audibly and concurrently

127. STILLBORN CHILD • Management:  Parents need to see, touch, wash, and dress baby  Get footprints, pictures, lock of hair, ID band, name the child and use the name often.  If they don’t see their baby; the parents often never face reality and stuck in the grieving process.  Again, encourage to hold, rock, and cuddle their baby.  Allow and encourage them to take photos of their angel. 128. SUCTIONING • Endotracheal • Position: semi-fowlers • Time: 5 to 10 seconds/ 5 minutes • Interval: 20 to 30 seconds • DURING  Lubricate the catheter with water-soluble lubricant (2 to 3 inches)  Insert during INHALATION in circular motion  DO NOT insert during swallowing (it may enter the esophagus) o But in NGT  let the patient swallow to promote entrance in stomach  Apply suction: during withdrawal • Hyperoxygenate BEFORE and AFTER suctioning  Conscious: DBE  Unconscious: ambubag, 3 to 5 times (12 – 15 LPM)

129. SUDDEN INFANT DEATH SYNDROME (SIDS) • Causes:  smoking, drinking, or drug use during pregnancy  poor prenatal care  prematurity or low birth-weight  mothers younger than 20

  

tobacco smoke exposure following birth overheating from excessive sleepwear and bedding stomach sleeping

130. SUTURES (catgut) – a thread, wire, or other material used in the operation of stitching parts of the body together TYPES OF SUTURES: • Absorbable – digested by body enzyme/ use in internal organs***  plain gut (yellow)  chromic gut (brown) • Non-absorbable – become encapsulated by tissue and remains unless removed (removed 7 days after)  silk (light blue)  nylon (green)  cotton (pink)  Prolene (royal blue)  Mersilenne (Turquoise)  Vicryl (purple)  Dacron (orange)

131. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) • Autoimmune • S/SX:  Fatigue  Arthritis  Sensitivity to sunlight  Butterfly rash • Management:  NO CURE  GOAL: controlling symptoms  steroids 132. TELEPHONE ORDER • Only RN’s may receive telephone orders • The order should be countersigned by the physician within 24 hours 133. TENSILON TEST • edrophonium chloride (Tensilon) IV • evaluation of muscle strength • USE: To diagnose myasthenia gravis • At bedside:  resuscitation equipment  atropine sulfate on bedside for possible CHOLINERGIC CRISIS  neostigmine for possible MYASTHENIC CRISIS • Results:  (+) diagnosis = improvement on muscle function after administration of drug  (-) diagnosis = muscle fasciculations occur as a result of the drug 134. TETRALOGY OF FALLOT • 4 Defects: o Pulmonic Stenosis o Right Ventricular Hypertrophy o Ventricular Septal Defect o Overridding of the Aorta • Tet spells – severe acute cyanosis • Position: Knee-chest/ Squatting*** • Sign o Machine-like murmurs o Clubbing of fingers o Cyanosis • Management: o Surgery: Blalock Taussig procedure  shunting of the subclavian artery and pulmonary artery 135. THORACENTESIS • Purpose: To remove excess fluid or air to ease breathing • POSITION: sitting while leaning forward over a pillow • Chest X-ray identifies best insertion site

•
•

Within the first 30 minutes, not more than 1000 mL should be removed AVOID: coughing , deep breathing AFTER: Unaffected side with head elevation of 30o for at least 30 minutes

• • •

136. THYROIDECTOMY: Complications Bleeding – Feeling of fullness at incision site o Check soiled dressing at nape area, sandbag Accidental removal of parathyroid – Hypocalcemia – classic sign tetany

o

Calcium gluconate, slowly administer- to prevent arrhythmia

• • •

Laryngospasm – DOB, SOB o tracheostomy at bedside, suction Accidental damage of the laryngeal nerve – Hoarseness of voice o Encourage patient to talk post op asap to determine laryngeal nerve damage Thyroid storm – Fever, Irritability, Agitation, restlessness, Tachycardia o beta blockers

137. TOTAL PARENTERAL NUTRITION (TPN)/ PN/ IV HYPERALIMENTATION

• •
• •

Dextrose content  10 to 50% Change the solution after  24 hours Site: central veins (SVC)  subclavian vein (an x-ray is done to confirm its placement) Position during insertion: trendelenburg Complication:  Thrombophlebitis due to hypertonicity of the solution  Hyperglycemia rapid infusion

change access site regulate


   

Hypoglycemia Infection Fluid overload Air embolism Allergy D10W  pedia

abrupt discontinuation hyperinsulinismdon’t stop abruptly unsterile procedure sterile technique rapid infusion regulate

•
•

If TPN is emptied and no doctors follow up order give  hypertonic solution

•

D50W  adult BEFORE:  check label of solution and rate of infusion with medical order  inspect TPN bottle for precipitates or turbidity  administer via an infusion pump DURING: Initially administered at 50 ml/hr***  for the FIRST hour  Monitor glucose  Monitor vital signs every 4 hours AFTER: Monitor WBC • PRIORITY NURSING DIAGNOSIS: High risk for infection • Do not overcorrect flow rate if too slow or fast • STERILE technique*** • Transparent air-occlusive dressing***

 



•

138. T-TUBE • PURPOSE:  To maintain patency***  To drain  To prevent bile leakage to the peritoneum • DRAINAGE Amount: 1st 24 hours – 500 to 1000 ml Normal color of stool after removal – “brown” Draining – does not need doctors order

 

Color: 1st 24 hours – reddish brown

• •

139. TRACTIONS • TYPES  Skin traction – impaired skin integrity  Skeletal traction – risk for infection • Counter traction – weight of the patient • Bucks – not more than 8 to 10 lbs of weight should be applied • Crutchfield tongs (skull tongs) – used to immobilize the cervical spine (indicated for unstable fractures or dislocation of the cervical spine) • Crutchfield tongs/ Gardner-Wells skull tongs • POSITION: supine

140. TRIAGE • “trier”- to sort • To sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be addressed 3 CATEGORIES IN TRIAGE in E.R. URGENT Red Yellow Life, limb, eye threatening Needs treatment in 20 minutes EMERGENT NON-URGENT Green Can wait hours or days

Color Urgency

Examples

Needs immediate attention Chest pain, cardiac arrest, severe respiratory distress, chemicals in the eye, limb amputation, penetrating trauma, severe hemorrhage

to 2 hours Fever >40oC, simple fracture, abdominal pain, asthma with no respiratory distress

sprain, minor laceration, rash, simple headache. Toothache, sore throat

IMMEDIATE Number Color Examples 1 Red Chest wounds, shock, open fractures, 2-3 burns

4 CATEGORIES IN TRIAGE in DISASTER DELAYED MINIMAL 2 3 Yellow Green Stable abdominal wound, eye Minor burns, minor fractures, and CNS injuries minor bleeding

EXPECTANT 4 Black Unresponsive, high spinal cord injury

141. TUNNING FORK TEST

a.

WEBER’S TEST – To test for bone conduction by examining lateralization of sound.  Hold and place the base of the tunning fork on top of the client’s head; ask the client where he/she hears the noise. Results:

  b.

Weber negative – if sound is heard on both sides or localized at the center of the ear. Weber positive – sound heard better on the impaired ear – bone-conductive hearing loss; – sound heard on the normal ear – sensorineural disturbance

RINNE TEST –To compare air conduction from bone conduction.  Ask client to block one ear intermittently (move a fingertip in and out of the ear)  Hold the handle of the activated tuning fork against the mastoid process (until vibrations can no longer be felt/heard by the client).  Immediately hold the vibrating fork with the prongs in front of the client’s ear canal. Results:

 
loss.

Positive Rinne – Air conduction (AC) is greater than bone conducted (BC). Negative Rinne – BC is equal to or longer than air conduction – indicating a conductive hearing



Infants: ring a bell or have the parent call the child’s name (to assess gross hearing); newborns may become silent or open their eyes wide; by 3 or 4 months, child will turn his/her head toward the sound. 142. VENOUS DISORDERS • Management: o Elevate legs o Exercise legs o Early ambulation o Elastic stockings VITAL SIGNS 143. BLOOD PRESSURE a. Systolic – contraction – depolarization Diastolic – relaxation – repolarization b. DETERMINANTS OF BLOOD PRESSURE

• • • •
c.

Pumping action of the heart (strong pumping – BP increases; weak pumping – BP decreases) Peripheral vascular resistance (increased vasoconstriction – BP increases) Blood volume (BV decreases – BP decreases; BV increases – BP increases) Blood viscosity (blood highly viscous – BP increases)

ASSESSING BLOOD PRESSURE

     
 

The cuff should wrap (A) 40% of the arm length and (B) 80% should encircle the adult’s arm (arm circumference)/ 100% of the child’s arm The lower border of the cuff should be 2.5 cm above the antecubital space. Use the bell of the stethoscope  low pitched sounds Pump about 30 mmHg more from the point the pulse has disappeared. Deflate the cuff at a rate of 2 to 3 mmHg per second. Rest the arms for 1 to 2 minutes before taking the blood pressure again, in cases reading is not certain. Calibrate the sphygmomanometer every 6 months Allow 30 minutes for resting if the client has exercise, smoking or ingested caffeine Read lower meniscus of the mercury to prevent error of parallax o error of parallax – if the eye level is higher than the level of lower meniscus



A 40% B 80%

d.

BP in THIGH*** • 1- Position the patient (prone/ supine with knees flexed) • 2- Expose the thigh • 3- palpate the pulse • 4- wrap the BP cuff

e.

Common mistakes FALSE-LOW Bladder of cuff too wide Arm above heart level

FALSE-HIGH Bladder of cuff narrow Arm below heart level Deflating cuff too slowly Inflating too slowly Smoking, caffeine and exercise for the last 30 minutes

144. KOROTKOFF PHASES

•
• • •

Phase 1 – a sharp thump  determines the systole Phase 2 – a blowing or whooshing sound (increasing sound) Phase 3 – a crisp, intense tapping (loud tapping) Phase 4 – a softer blowing sound that fades (muffled sound) Phase 5 – Silence  determines the diastole BP – 104/100/90 (Phases I/ IV/ V)

•
eg

145. TEMPERATURE a. ORAL – accessible and convenient S – Smoking* N – Newborn O – Oral surgery U – Ulceration/injury to the mouth T – Tremors/convulsions H – Hot/cold foods & fluids just ingested  wait for 15 to 30 minutes before taking temperature b. AXILLARY – Safe and non-invasive A – Axillary injury X – eXercise/activity I – Inadequate circulation L – Laging basa (moist pits) A – After bathing RECTAL – Reliable measurement (Inconvenient and more unpleasant) R – Rectal disease/diarrhea I – Immunosuppressed C – Clotting disorders T – Turning to the side is difficult H – Hemorrhoids U – Undergone rectal surgery M – Myocardial infarction TYMPANIC – Readily accessible, reflects the core temperature, very fast 9 Risk of injuring the membrane) E – Evident cerumen A – An ear infection is present R – Reading may vary between left and right measurement

c.

d.

146. PULSE – the wave of blood created by the contraction of the left ventricle.

• • • •
•

Wait for 10 to 15 minutes if he client has been physically active. Use 2 or 3 middle fingertips lightly over the pulse site.

Doppler ultrasound stethoscope (DUS): transducer probe (gel may be applied) and stethoscope headset; when using a DUS, hold the probe lightly over the pulse site. Apical pulse

below 7 years old – located at the 4th ICS LMCL PULSE SITES  Infants, palpable: brachial and femoral

 

7 years old and above – located at the 5th ICS LMCL

  

Allens test: CPR, infants: CPR, adults:

radial brachial carotid

147. RESPIRATIONS – The act of breathing. • 2 Types of breathing  Costal – thoracic  Diaphragmatic – Abdominal • • First to take BEFORE invasive procedures Physiologic apnea

C D

a.

RATE – Eupnea (breathing that is normal in rate and depth), bradypnea (abnormally slow), tachypnea (abnormally fast), and apnea (absence of breathing).

APNEA BRADYPNEA b.

EUPNEA TACHYPNEA

F E I H

DEPTH – Hyperventilation (rapid and deep breaths), hypoventilation (very shallow respirations), and Kussmaul’s breathing (hyperventilation associated with metabolic acidosis).

c.

HYPERVENTILAT ION HYPOVENTILATI ON CHEYNE-STOKES BIOT’S

RHYTHM – Cheyne-Stokes breathing (regular rhythm from very deep to very shallow respirations then temporary apnea) and Biot’s respiration (shallow breaths interrupted by apnea).

148. URINARY CATHETERIZATION: TYPES TYPES Straight Catheter NO. OF SINGLE: only for drainage LUMENS

PURPOSE SPECIAL CONISDERATIONS

Inserted only as much times as it takes to drain the bladder or obtain a urine specimen Coude catheter is a variation of straight catheter which has a curved and tapered tip, usually used for male patients with prostatic hypertrophy 

Indwelling Catheter (Foley or Retention catheter) DOUBLE: • urine drainage • for inflation of balloon (serves as an anchor) OR TRIPLE: • urine drainage • for inflation of balloon (serves as an anchor) • for continuous irrigation Inserted and stays connected to the bladder for a long time Secure catheter tubing: male - upper thigh or abdomen Female - inner thigh NO TUB BATHS, shower is preferable

Collection bag should always be below bladder Position during procedure: FEMALE – Dorsal Recumbent MALE – Supine  Lubricate catheter  Catheter accidentally slips into vagina: leave the catheter in vagina, get new catheter and insert to urethra then remove the catheter from vagina  Increases susceptibility to infection 149. URINE ELIMINATION • Color – amber/straw, transplant • Order – aromatic • pH – 4.5 to 8 • Amount – 1200-1500 ml/day (30-60 ml/hr) • Sp.gr – 1.010-10.25 150. PREVENTING UTI W – ash before and after sex O – n time voiding M – ake us of cotton undergarment A – lways wipe from anterior to posterior N – o sprays, harsh soaps, powder.