Professional Documents
Culture Documents
Atrial Septal Defect- an opening bet the right & left atria
Left atrium over powers the right atrium
Ss: fatigue & dyspnea upon exertion
- surgery before age 5
Tetralogy of Fallot
- four defects that constitute
pulmonary stenosis,overriding aorta
right ventricular hypertrophy, vsd
PORV
Ss: skin bluish in color, heart murmur
Rheumatic Fever
- cause by beta hemolytic strep infection
ss: tachycardia,rash,fever,chest pain
migratory large joint pain,chorea &
skin nodules.
*administer penicillin until age 21
Kawasaki Disease
- vasculitis infection of the small vessels
ss: dry red cracked lips,rashes arms & legs
conjunctivitis,strawberry tongue,
peeling skin on the palms & soles of feet
high fever, unresponsive to antibiotic,
impaired swallowing,coronaryaneurysm
Gamma Globulin IV 400mg/kg/day x weight in kg
Live attenuated vaccine must delayed-polio,MMR
Asthma
Ss: chest tightness & dyspnea,distant breath
sounds,wheezing episodes,fatigue & wet
lungs
*theophyllinetoxicitydiarrhea,vomiting,headache
Cystic Fibrosis
-
is hereditary disorder, lung congestion &
Infection
Ss: positive sweat test, bulky greasy stools,
meconium ileus,early chronic dry cough
deficient in vits. A,D &K fat soluble vits.
Down Syndrome
Ss: almond shape eyes,short broad neck
protruding tongue,low set ears,broad hands
w/ simian crease
GERD
Ss: frequent or persistent cough,heart burn
abdominal pain,recurrent aspiration,anemia
Main concern: airway obstruction,fluid and
Electrolyte imbalance & apnea
Pyloric Stenosis
Ss: mild vomiting turned into vomiting that
shot across the room,palpable mass RUQ,
hungry,crying
Hirschprung’s Disease
-part of bowel there is no nerve cells,
no peristalsis in the section of the bowel
ss: constipation,foul smelling ribbon like stool
abdominal distention
- diagnosis established until infant is 6-12
months old
- 10x more common in girls than boys
Epilepsy
- chronic seizure disorder asso. w/
recurrent unprovoked seizures.
Spina Bifida
- a congenital malformation of spinal column
- many areas of the central nervous system may
not develop or function adequately.
Ss: club feet,hip dysplexia,latex allergy or sensitivity
Scoliosis
- affects female 10-13 yrs. Old
- brace must be worn 16-23 hrs a day,7 days a
week from 6 mos to 2 yrs to correct
- after surgery flat position, log rolling
Cerebral Palsy
- abnormal muscle tone & coordination,spastic
movement in one or more extremity, and
disturbances in gait & abnormal posture.
Reye’s Syndrome
- mild viral infection, ICP Encepalopathy
Varicella chicken pox risk to develop Reye’s
Intussusception
- nephrosis of bowel tissue
- commonly occurs in male 3 & 5 yrs. old
Ss: vomiting,lethargy,sudden acute abdominal pain,
sausage shape abdominal mass,bloody stool
or jelly stool
Celiac Disease
- poor food absorption esp. gliadin
- patient unable to digest gliadin a by product of
gluten
*Serum anti-gliadin antibody- diagnostic test for
Celiac disease
*Gluten Sensitive Eneteropathy- other name
Tonsillitis
- inflammation of tonsils, hinders swallowing
and breathing
Epiglottiditis
ORTHOPEDICS
Fracture
Ss: swelling,intense pain shortening of extremities
and limited mobility
Cast Care
Traction
Skeletal traction- buck’s traction,russel
Steinman pin,crutchfield
Halo vest,Gardner-wells tongs
Skin traction
Osteoarthritis
Rheumatoid Arthritis
- auto immune disease,membrane around
joints inflamed,smaller joints
- cause by virus/bacterial infection
- ESR & CBC,C-reactive protein and
Rheumatoid factor,ANA & Antibody test
- DMARDS-Disease Modifying Anti Rheu-
Matic Drugs-infliximab (Remicade)
Etanercept (Enbrel),methotrexate
(rheumatrex)
Gout
- acid crystal build in joints
- “TOPI” accumulation of crystals big toe
- Over production of uric acid,reduce ability
of kidney to get rid of uric acid
- Diabetes, obesity & sickle cell anemia
increase the risk
- May cause join deformity & limited
motion
- Synovial fluis analysis,joint x-rays, uric
Acid elevated Men-6mg/dl women 5mg/dl
- diet low in purines,NSAIDS, cortico-
steroids, clochicine, indomethacin
allupurinol,naproxen
Physiological Adaptation
Psychosocial Adaptation
Signs of Pregnancy
Family Planning
Antepartum
Hyperemesis Gravidarum
- increased BUN & decrease urinary output
- ketoacidosis-breakdown of fat stored to
make metabolic needs.
- high level of hCG & estrogen
Hydatidiform Mole
- absence of FHTs, grape-like clusters
of vesicles, vaginal discharge that may
contain vesicles,uterus enlarge to fast.
- Asian women at risk 45 yrs and above.
- hcg should be measured weekly until
normal then rechecked every 2-4 weeks
then every 1 to 2 months for 6 months
to 1 year
Interventions: surgical removal of neoplasm,monitor
ring for pre-eclampsia & choriocar-
cinoma , hysterectomy
Incompetent Cervix
- cervix dilates prematurely usually occur
during 4 mothns of pregnancy
- repeated spontaneous & painless second
trimester pregnancy.
Preeclampsia
Ss: suddenweight gain,swollen hands and feet,
Headache, and blurred vision, hypertension
Proteinuria,anasarca,
Severe if diastolic more than 110, Mild 140/90
Weight 2 kilos/week
Magnesium sulfate is the drug of choice and
should be monitored for toxicity done
every 1-2 hrs.
- diminishes neuromuscular transmission,
promotes maternal vasodilation and has
anticonvulsant effect.
Diminished deep tendon reflexes sign of
Magnesium sulfate toxicity.
Placenta Previa
Placenta Abruptio
- sharp sudden abdominal pain
- premature placental separation\
- causes, cocaine use, PIH, manual vacuu
aspiration, abortion procedure,rapid
decompression of the uterus multipara
domestic violence
Premature Labor
- can sometimes be stopped by hydrating
the mother and by treating vaginal & UTI
- Bethamethasone,celestone IM injection
to help maturation of the lungs
Labor & Delivery
Prolapsed Umbilical Cord
- knee-chest position
- c-section immediately
- cover umbilical cord with saline bandage
Post Partum
Newborn Care
- Ballard scale, a newborn assessment
maturating scale
- Respiratory Rate 30 to 60 breaths/min
with 10 seconds apnea
- Red reflex test serious visual defects is
performed in small dark room looking at
the retina there’s a red reflex equally red
to roll-out any defects of cornea.
Cardiac Rhythms
Conduction System
ECG Complex
ECG Grid
Lead Placement
Snow over grass- right side
Smoke over fire - left side
Myocardial Infarction
Ss: shortness of breath, crushing pain that radiates
to his neck and left arm
decrease CO2, increase WBC, increase temp.
ST segment depression, T wave inversion,Q
waves
Laboratories/testing:
CPK MB, LDH, Troponin q8 hrs
Coronary arteriogram & 12 lead EKG
MUGA Scan-used to measure heart function by
determining the ejection fraction, this is the
percentage of blood ejected from the heart w/
each beat
Management:
MONA- Morphine-Oxygen-Nitroglycerine-ASA
Fibrinolytics- are used to dissolved clots &
reduced the size of infarction
- must administered 6 hrs post MI
- before administered insert 2-3 large bore
peripheral IV’s
- monitor for bleeding, neuro vital signs
watch rhythm
PTCA- procedures performed on a double
vessel disease.
Angina Pectoris
Ss: dull chest pain
Vessel Insufficiency
Buerger’s Disease
SS: numbness & tingling sensation of the toes
pale finger tips, weak peripheral pulses,ischemic
ulcerations, intermittent claudication
Raynaud’s Phenomenon
SS: hand & fingers turning white
Causes: smoking & stress
Precautions: over the counter cold remedies such
As Sudafed,clonidine,migraine, meds
Contain ergot alkaloids
Endocarditis
Ss: fever, clubbing of fingers, malaise, cardiac
murmurs, anorexia
Tx:
prophylaxis,antibiotics,oxygen,anticoagulants,
antipyretics
Types of Shock
1. Hypovolemic- volume reduction ex: bleeding, burns
2. Cardiogenic – unable to circulate ex: dysrythmias,
MI, CHF
3. Neurogenic – loss of vasomotor tone ex: spinal cord
Injury, spinal anesthesia
4. Septic –dilation of blood vessels ex:gram negative
infection
5. Anaphylactic- antigen-antibody reaction ex: transfusion
Reaction,allergies, insect bites.
Thoracentesis
- removal of fluid from pleural space 50cc
H2O
Procedure: take chest x-ray & vital signs
position the client sitting up over bedside
table or lying on unaffected side with
HOB at 45 degree
tell client not to cough,breathe deeply or
move during the procedure
Chest Tubes
- reestablish a negative pressure
- done when there is a fluid build-up in lung
- lung cllapse
- spontaneous collapse
- Fluctuation will occur when the suction is
working properly
- bubbling becomes continous,vigorous or
excessive it means there is an air leak in
the system
- inserted at 2nd ICS at the midclavicular
line
Fracture of Sternum/Ribs
Flail Chest – tachycardia,assymetrical, multiple fracture
Pulmonary Embolism
Ss: shortness of breath, cough & increase heartrate,
Hypoxemia, chest pain,hemoptysis, angina
Tx: bronchodilators,theophylline,inhaled/intravenous/
oral steroids, & antibiotic.
Emphysema
- it destroys alveoli
- it narrows & collapses small airways
- it causes the lungs to lose elasticity
Asthma
Types of asthma:
1. Emotional – cause by person
2. Extrinsic – caused by dust,mold,pets
3. Intrinsic – common cold, allergens
4. Mediated
Pneumonia
Tuberculosis
Endotracheal Tube
Goal: to position the end of ETT 2 cm above the
bifurca-
-tion of the lungs or the carina
Neurological Assessment
Frontal Lobe- damage, changes in behavior
Neurological assessment:
Mental Status- most important indicator
Pupillary changes- 2-6mm normal pupil
Motor strength & coordination
Corneal assessment
Vital Signs- widening pulse pressure when there is
Increase ICP
Movement- is the lowest move, speech is the highest
level of brain neuro function
Cerebral Angiography
- catheter inserted w/ a dye to the brain
- consent due to the dye
- metallic taste in mouth
- warm sensation during the procedure
- clients well hydrated during the
procedure.
Complications:
- risk of embolus
- check for pulse, hematoma & change in
LOC
- 12-24 hours of bed rest
Myelogram
- is an x-ray of spinal & sub arachnoid
space
- air & water base
- NPO 8-12 hours
- Does not require a heavy sedative
- Dye is injected to sub arachnoid space
- Trendelenburg position for Air
- 30 to 50 degrees for water
- Must be flat in 6-8 hrs.
Electroencephalogram EEG
- diagnose seizure disorder
- records the electrical activity of the brain
- helps in screening for a coma
- 3 flat EEG reading indicate brain death
Nursing care:
Pre-procedures:
- medicated w/ a mild sedative
- may have not caffeine
- eat a light breakfast
- we may flashlights in the face
Lumbar Puncture
- performed when patient is on
unexplained fever and elevated WBC
- invasive procedure
- punctured site is 3rd & 4th lumbar sub-
arachnoid space
- knee chest position, fetal position lie on
right side
- 4-8 hours flat on bed to prevent spinal
Headache, post procedure
- Fluid &blood patch- pull out blood use it &
inject at pain area
- Normal CSF- clear, no RBC
- Abnormal CSF- cloudy, increase protein,
& WBC
Performed when: check for blood, measure pressures,admi-
-nister drugs intrathecally.
Brain Herniation
- cause a sudden decrease of ICP
- the brain tissue is pulled down through
the
foramen magnum
Epidural Hematoma
- arterial bleed
- gain & lost of consciousness for minutes
- pts. See stars
Tx: burr holes,remove the clot and control ICP
Subdural Hematoma
- venous bleed
Acute & fast – s/s bet. 24 to 72 hours after slow bleed, non-
acute bleed
Tx: remove clot to control ICP
Sub-acute - s/s bet 72 to 2 weeks w/ rapid
Chronic
Scalp Laceration- infections is the problem
Skull Injury
- may or may not damage the brain
Concussion
Ss: headache, dizziness, seeing spots
diff. waking up or speaking, confusion, severe
headache & vomitting
Contusion
- the brain is bruised w/ a possible surface
hemorrhage
Alzheimers
- progressive disease, irreversible, loss of cerebral
function due to cornical atrophy
- begins 40 to 65 y.o. , 8 to 10 years onset to death
Parkinson’s Disease
- decreased production of dopamine
Laminectomy
- excision of vertebral arc, herniated disc
- nurse must assess for circulation &
motor sensory checks, dressing, bowel
& bladder function
Cervical Laminectomy- level of consciousness
Lumbar laminectomy- circulation, motor, 5 p’s, pulse,pallor
2 types of stroke:
Hemorrhagic stroke – blood vessel rupture with bleeding
into the brain, hypertensive & older patients
Myasthenia Gravis
- problem in neurotransmitter, myelin
sheath is intact, but decrease
acetylcholine production
Head Injury
Intracranial Pressure ICP
Spinal Cord Injury
PSYCHIATRY – Psychosocial Integrity
Depression
Anxiety
Mania
Post Traumatic Stress Disorder
Schizoprenia
Suicide
Paranoia
Panic Disorder
Phobia
Hallucinations
Personality Disorder
Obssesive-Compulsive Disorder
Dissociative Disorders
Alcoholism
Anorexia
Bulimia
Electro-Convulsive Therapy ECT
Antidepressants
Antipsychotics
Anticonvulsants
ENDOCRINE
Lung Cancer
Laryngeal Cancer
Bladder Cancer
Stomach Cancer
Cervical Cancer
Uterine Cancer
Breast cancer
Colorectal cancer
Prostate cancer
Branchytherapy Internal Radiation
Teletheraphy & Beam Radiation External Radiati
Chemotherapy
Pancreatitis
Ss: severe abdominal pain RUQ, rigid
abdomen,bruising
around umbilical or flank area, ascitis, abdominal
distention
-worsen after eating & lying flat
-decrease hemoglobin & hematocrit
-alcohol consumption is the number one cause
-no morphine can cause spasm of odi spinchter
-give calcium supplements
Diverticulitis
-small inflamed protruding sacs in the colon that have
ruptured
-causes impacted stools, history of constipation,
Low fiber & high carbohydrates
Hepatic Coma
-is diagnosed by examining the serum ammonia level
-prescribed lactulose (Cephulac) & Neomycin SO4
-decrease protein in the diet,monitor serum ammonia
level
-recommend cleansing enema
Ulcerative Colitis
-inflammation of ascending colon & rectum
-condition affecting the large intestine
-low fiber diet to limit motility
-avoid meals that are cold
-steroids to decrease the inflammation
Chron’s Disease
-iflammation or ulceration of digestive tract,chronic &
relapsing
ss: blood in stool,rebound tenderness,cramping &
dehydration,anemia,diarrhea w/ steatorrhea,
cramping after meals,abdominal pain,vomiting
& fever
Appendicitis
-associated w/ diet low in fiber
-elevate head of bed after any abdominal surgery
Peritonitis
-board like abdomen,low urine output,,nausea &
vomiting
Dumping Syndrome
-increase circulation of stomach
-give complex carbohydrate,avoid simple
carbohydrates, high fiber
-is more common in Billroth II
-recumbent position, drink bet meals
-lie left side after meals,eat high fat & protein
-decrease stress
Ss: cramping,diarrhea,weakness
Hiatal Hernia
-the hole in the diaphragm is too large,the stomach
moves up into the thoracic cavity
-small protrusion close to the navel
-causes, congenital abnormality,trauma,surgery
-small frequent meals,elevate head of bed,take small
bites,avoid spicy foods
Hyperalimentation TPN
-need to change the tubing with each bag every 24
hours
-can be hung for 24 hours
-taper off TPN when discontinuing
-needs to be check by 2 nurses before each bag is
hung
-put in pump
-other medications cannot be infused, only insulin,
Lipids, K+
-can be mixed daily
-IV bag should never be covered
-infection can be frequent complication
Blood glucose,ketones,BMP,magnesium
Dobhoff Tube
-a small bore NG feeding tube not attached to suction
-more comfortable & less complications
-can remain place for weeks
Central Line
-have client in trendelenburg
-rolled towel to middle of back
-air from getting in the line,clamp it off
-cap the end of tubing,cover the end w/ syringe
-position the patient on the left side in case air
will get into the line
-post insertion chest xray performed to ensure
proper placement
-10ml syringe use in central line
Diagnostic Tests
Barium Enema
-drink clear liquids
-take laxatives or enemas until clear
-ensure post procedure bowel movement
Liver Biopsy
-PT/INR,PTT prior to procedure
-position pt supine w/ hand behind head
-have client lie on affected side for 8 hours
post procedure
Paracentecis
-have pt. sit in high fowlers position
-have pt. empty his bladder prior to procedure
-the fluid removed will be yellow
-monitored for signs of shock
Nephrotic Syndrome
-leaking of the protein into the urine
-perform U/A,glucose tolerance,serum protein,
Serum albumin,renal biopsy
-edema,swelling around eyes,extremities &
abdomen
-circulating blood volume decrease causing kidney to
activate its Renin Angiotensin cascade,aldosterone
is produce to retain sodium & H2O
-Corticosteroids,prednisone & Diuretics drug of choice
Acute Glomerulonephritis
-sorethroat,headache & lower back pain
-protein in the urine,increase BUN & creatinine,
hematuria & hypertension
-strep infection is the main cause
-common bet age 6 to 7 yrs. old
-antibiotics,bedrest & increase carbohydrates in diet
-decrease protein & sodium in the diet and dialysis
-reddish brown urine
Renal Failure
-sudden loss of kidney function resulting in electrolyte
imbalance 7 retention of nitrogenous substance
-during oliguric phase the patient is in a fluid volume
excess
-diet should be in high carbohydrates
-low protein,sodium,potassium & phosphorous
Hemodialysis
-access route are: External AV shunt,fistula,femoral/
Subclavian cannulation
-fistula access 3 months to mature
-must be done 3-4 times a week
-during treatment period monitor for: depression,
suicidal tendencies,electrolytes & BP
-bruit & thrill must be assessed before accessing
hemodialysis access ports
-cathflo must be used if pt allergic to heparin
-decrease protein, sodium & potassium in the diet
-pt. w/ unstable cardiovascular system cant tolerate
hemodialysis
Peritoneal Dialysis
-ambulatory
-dialysate is warm to increase blood flow
-patients who get peritoneal dialysis cannot tolerate
hemodialysis
-possible complications are: peritonitis,respi. Diff.
protein loss
-cloudy drainage,there is an infection, it should be
pink
tinged color
-if the fluid does not come out, turn the pt side to side
Intravenous Pyelogram
-NPO 8 hrs before the test
-sitting straight up during procedure
-after procedure, increase fluids,apply warm soaks if
hematoma develops
Cystoscopy
-involves a lighted scope which is used to visualize the
bladder
-consent, anesthesia, a sedative and enema can be
used
-used to diagnosed & evaluate urinary tract disorder,
enlarged prostate,recurrent bladder infection
-notify doctor if there is still blood in the urine after
3 days
-expect burning on urination
Ultrafiltration
-only pulls off water
-has the same principles applied as hemodialysis
-may be utilized w/ peritoneal dialysis or hemodialysis
Hematocrit: 42-52%