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TUESDAY, FEBRUARY 17, 2009
Psychiatric Nursing
PSYCHIATRIC NURSING
Beliefs—Feelings—Behavior
Id___________________Superego
EGO
ANAL- 18 mos-3yrs
Toilet training
Mom is superego.
Superego is being formed
Child is caught in ambivalence – pulled in 2 opposing factors
Too much toilet training with punishment will result to a child who is:
Dr. Karen Horney- detractor of Freud, didn’t believe in penis envy. Freud said
that it is maybe in her unconscious mind.
Or repressed.
PHARMA MOMENTS
Anti-anxiety Drugs (used also for alcohol withdrawal)
Valium Librium Ativan Serax Tranxene
Miltown Equanil Vistaril Atarax Inderal Buspar
ERIK ERIKSON
mARplan
nARdil
pARnate
DEFENSE MECHANISMS: coping mechanism from stress:
5. Self-actualization
4. Self-esteem
3. Love and belonging
2. Safety and security
1. Air, food, water, shelter, clothing, sex –Basic physiologic needs
LEVELS OF PREVENTION
PRIMARY SECONDARY TERTIARY
Healthy ill Relapse avoidance
Community teaching Crisis intervention Rehab centers
Community demographics Treatment and diagnosis Al anon
STAGES OF INTERACTION
ORIENTATION WORKING TERMINATION
Assessment Problem solving Evaluation
Establishment of trust Discussion Summarize
Tell patient about termination Patient is most cooperative Say goodbye
Set contract Grief-ANGER-focus of RN
Patient is resistant Pt might become violent/suicidal
C- Cogentin
A- Artane
P- Parlodel
A- Akineton
B- Benadryl
L- Larodopa
E- Eldepryl
S- Symmetrel
ABG ANALYSIS
Ph & PCO2-Respiratory-opposite signs
Ph & HC02-Metabolic – same signs
ANXIETY
-vague sense of impending doom. Sympathetic activation.
-provide safety
-Alkalosis-brown bag
-stay with patient
-be directive
1. Survivor
2. Flashback > 1 month
3. Memory – nightmares
MALINGERING------------------------------------- no organic basis (no tissue change)
-pretending to be sick, conscious
-decrease anxiety – for primary gain
-increase attention from RN– secondary gain
Individual Therapy
1. Hypnosis – --------------relaxed state
2. Free association –------ ideas shared to psychoanalyst
3. Catharsis – --------------free to express feeling
4. Transterence- -----------patient feels something for psychoanalyst
5. Countertransterence –--RN feels something for patient
Green light-Go – Epi & Norepinephrine
Red light – Stop – G-gamma
A-amino
B-butyric
A- acid
Anxiety
Effect of GABA:
Drowsy, drink, don’t drive, orthostatic hypotension
Anti-anxiety drug
STELAZINE CLOZARIL
SERENTIL MELLARIL
THORAZINE HALDOL
TRILAFON PROLIXIN
Content of thought---------------Hallucinations/Illusions------------
ADL----------------------------Harm
P/I: Reality/Orient/Safety
Eval: Improved thought process
S & Sx of Schizophrenia:
(-)neg sx (+) positive sx
hypoactive hyperactive flight of ideas
withdrawn restless hallucinations
quiet, flat affect talkative delusions many ideas
poverty of words queen of the world illusions
Types of schizophrenia:
Acknowledge: “I know the voices are real to you. Present reality. “But I can’t hear
them.”
=Assess what voices are saying to know if patient will harm himself.
Nsg Dx: Impaired social interaction – cant form IPR (Interpersonal relationship)
Impaired verbal communication
Self mutilation – cant express anger. Express it inward.
Risk for injury
Assessment:
A- appearance: dirty
B- behavior: clumsy, impatient, easily distracted
C- talkative
Safety
Structure- provide place to study, eat, play,bath,etc.
Schedule – time for everything
Set limits
L- 0.5-1.5 mEq/L (If level is near 2.5-3 mEq/L –will cause ataxia and mental
confusion)
I- increase urination
T- tremors
H- H20- 3L/d
I- increase
T- uu
M- mouth dry
N- Na- 135-145 mEq/L – to hold water
Give task, no group games, any competition will increase anxiety, water the
plants, activities using gross motor skills, escorted walk, punching bag-
displacement.
PERSONALITY DISORDER
1. Schizoid – --------doesn’t care about people, believes that he can stand on his
own, never had a best friend
avoid groups & activities – no enjoyment
cares more about computers, pets
2. Avoidant ----------avoid group – fear criticism, have talent but no confidence.
3. Anti-social– ------as child steal, lie, always get reprimanded
Adult – grand robbery, illegal activities against the law.
drug addiction, drives fast, unsafe sex, thrill seeker.
Good talker, charmer, witty, manipulator. Motto – “I will break the law”
DISULFIRAM
voids alcohol beer
version therapy
ntabuse (DISULFIRAM)
lcoholics anonymous n/v
hypotension
interval of alcohol & antabuse:
12h interval after alcohol intake
B1 – Thiamine
Complications wernickes
Encephalopathy
Korsakoff psychosis
ASENDIN TCA
NORPRAMIN TCA
TOFRANIL TCA
SINEQUAN TCA
ANAPRANIL TCA - OC
AVENTYL TCA
VIVACTIL TCA
ELAVIL TCA
PROZAC SSRI
PAXIL SSRI
ZOLOFF SSRI
LUVOX SSRI
Serotonin ---------makes us happy
Decrease serotonin – pt becomes sad – depression
Increase serotonin – antidepressant
SSRI:
Selective S
Serotonin S – (decrease S/E)
Reuptake R –
Inhibitors I – (1 – 4 weeks)
MAOI
mARplan
NARdil
PARnate
Maslows:
5–
4 – decrease Self-esteem – give TASK
3 – Pt is withdrawn
2 – Risk for self directed violence suicide
1 – eat (wt gain) or not eat(wt loss), sleep or not sleep, hypoactive, decrease sex
SUICIDE CUES:
“I wont be a problem any longer”
“Remember me when I’m gone”
“This is my last day”
“This is my wedding ring. Give it to my son”
- Sudden change in mood.
Suicide Triad:
- Loss of spouse
- Loss of job
- Aloneness
SUBSTANCE ABUSE
Type of Addict:
1. Nervous -----tremors
Give downers
Sx of overdose
1. Identify if drug is upper or downer
2. Check effect
3. Sx of withdrawal
If patient takes a downer, all vital signs are down! If he stops taking it (during
withdrawal), patient will experience the opposite effect of a downer. All his vital
signs will shoot up! Same with uppers.
Ex: Pt had cocaine intoxication. Pt will manifest hyperactivity, tachypnea, seizure.
During withdrawal, pt will manifest bradypnea or coma.
Substance Abuse Moments
(downer)
A – alcohol
B – barbiturates
O – opiates Antidote
N – narcotics - Narcan (narcotic antagonist)
M – marijuana
Morph
CODE
HERO
(uppers)
C – cocaine
H – Hallucinogens
A – amphetamines
Uppers Downers
Seizure decrease RR, decrease HR
Tachypnea Para constricted pupil
Moist mouth
Dilated Blood Vessels
Coma
Asleep
Decreased GI constriction
Decrease GU retention
Decrease BP
State of euphoria
Uppers
Codeine increased heart increase - BP increase, awake
Hallucinogen sympathetic HR increase seizure
Amphetamine pupils- dilate GI - diarrhea
Mouth – dry
Decrease appetite - thin
Stop uppers
Tremors crash syndrome Depressed Suicide
Fatigue
IQ 20 35 50 70 90 110
ALZHEIMER
Anomia- don’t know name of object
Agnosia – problem with senses (smell, taste, hear, touch)
Aphasia – can’t say it
Apraxia – can’t do it
Dissociative Fugue- takes a new personality from a tar away place. New place
new identity.
Dissociative Identity Disorder – multiple personality
Dissociative Amnesia – don’t know who/where I am.
Pre-ECT
N-npo 6 hours
A-atropine sulfate – dry mouth
B-barbiturate
S- succinylcholine chloride – to relax muscles
Post-ECT
Side-lying- lateral
S/E headache, dizziness, temporary memory loss (distinct sx)=RN-orient pt.
EXAMS:
Nsg intervention:
Look for words like:
S=safety, support, stay, set limits, assist
Provide safety. Mobilize support system. I will stay with you. Assist in activity.
Set limit- don’t allow patient to misbehave.
Reactions:
Pediatric Nursing
Average IQ – 90-100
Gifted child- > 130 IQ
Principles of G & D
1. G&D is a continuous process
-begins form conception- ends in death
- womb to tomb principles
2. not all parts of the body grow at the same time or at same rate.
- asynchronism
Patterns of G&D
1. )renal
digestive grows rapidly during childhood
circulatory
musculoskeletal
3. )Lymphatic system- lymph nodes, spleen grows rapidly- infancy and childhood
to provide protection -infection
- tonsil adult proportion by 5 years
Rates of G&D
1. fetal and infancy – most rapid G&D
2. adolescent- rapid G&D
3. toddler- slow G period
4. Toddler and preschool- alternating rapid and slow
5. school age- slower growth
B. Environment
Q – quality of nutrition
S – socio eco. status
H – health
O – ordinal pos in family
P – parent child relationship
Theories of G&D
Developmental tasks- different form chronological age
-skill or growth responsibility arising at a particular time in the individuals life.
The successful achievement of which will ------- a foundation for the
accomplishments of future tasks.
Theorists
1. Sigmund Freud 1856-1939 Austrian neurologists. Founder of psychoanalysis
- offered personality development
Psychosexual theory
stages of psychosocial
a.) trust vs mistrust – 0-18 months.
-foundations of all psychosocial task
-to give and receive is the psychosocial theme
-know to develop trust baby
1. satisfy needs on time
- breastfeed
2. care must be consistent and adequate
-both parents- 1st 1 year of life
3.) give an experience that will add to security- touch, eye to eye contact, soft
music.
b.) Autonomy vs shame and doubt 18-3 years --- independence /self gov’t
develop autonomy on toddler
1. give an opportunity of decision making like offer choices.
2. encourage to make decision rather then judge.
3. set limits
f. Intimacy vs isolation 20-40 yrs -looking for a lifetime partner and career focus
11 months- cruisse
- stands with assistance
Milestones
4years old- furious 4 , noisy, aggressive, stormy
-can button buttons
-copy a square
-jumps and skips
-laces shoes
-vocabulary 1,500
-knows four basic colors
Death-sleep only
School Age
Play- competitive play
Ex. Tug of war, track and field, basket ball
Significant Development
a. boys- prone to bone fracture
b. mature vision 20/20
BOYS:
A-appearance axillary, pubic hair ( 1st sign sexual mat)
D-deepening voice
D- development of muscles
I--inc in testes and penis size
P- prod of viable sperm ( last sign sexual maturity)
Adolescent
Fear
1. obesity
2. acne
3. homosexuality
4. death
5. replacement from friends
6. significant person- opp sex.
Significant dev’t
1. experiences conflict bet his needs for sexual satisfaction and societies
expectation
2. change of body image and acceptance of opp/sex
3. nocturnal emission – wet dreams
4. distinctive odor- due to stimulation apocrine glands
5. sperm is viable by 17 yrs
6. testes & scrotum increase until age 17
7. breast and female genitalia increase until age 18
Problems:
1. vehicular accident
2. smoking
3. alcoholism
4. drug addiction
5. pre marital sex
B. Catheter Suctioning
1.) place head to side to facilitate drainage
2,) suction mouth 1st before nose
-neonates are nasal breathers
3.) period of time
-5-10 sec suctioning, gentle and quick
prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia
due to stimulation vagal nerve
Nsg alert:
1. No smoking
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina leading to blindness
( retro lentalfibrolasia or retinopathy of prematurity)
4. When mecomium stained (greenish) never administer oxygen with pressure
( O2 pressure will push mecomium inside)
SHUNTS-shortcuts
Ductus venosus- -shunts from liver to IVF
Foramen ovale- shunts bet 2 atrias
Ductus arteriosus- from pulmonary artery to aorta
Temp Regulation
- goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)
- maintenance of temp is crucial on preterm and SGA (small for gestational age) -
babies prone to hypothermia or cold stress
-
A. factors leading to dev’t of HYPOTHERMIA
1. preterms are born poi kilo thermic- cold blooded
- babies easily adapt to temp of environment due to immaturity of thermo
regulating system of body. Hypothalamus
2. inadequate SQ tissue
3. baby is not capable of shivering
4. babies are born wet
To Prevent Hypothermia
1. dry and wrap baby
2. mechanical pressure – radiant warmer
pre-heated first isolette (or square acrylic sided incubator)
3. prevent an necessary exposure – cover baby
4. cover baby with tin foil or plastic
5. embrace the baby- kangaroo care
Advantages of Breastfeeding
1. Economical
2. Always available
3. Breastfed babies have higher IQ than bottle fed babies.
4. It facilitates rapid involution
5. Decrease incidence of breast cancer.
6. Has antibodies- IgA
7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT
8. Has macrophages
Store milk- plastic storage container
Store milk – good for 6 months from freezer- put rm temp. don’t heat
Disadvantages:
1. Possibility of transfer HEP B, HIV, cytomegalo virus.
2. No iron
3. Father can’t feed & bond as well
Stages of Breastmilk:
1. Colostrum- 2-4 days present
content: decrease fats, increase IgA, dec CHO, dec CHON, inc minerals,
inc fat soluble minerals
2. Transitional milk- 4 – 14 days
content: inc lactose, inc water soluble vit., inc minerals
3. Mature milk- 14 & up
content: inc fats (linoleic acid) – resp for devt of brain & integrity of skin
inc CHO- lactose – easily digested, baby not constipated.
- resp of sour milk smelling odor of stool.
Health Teachings:
1. Proper hygiene- proper hand washing
Care of breast - cotton balls with lukewarm water
Caked colostrum- dry milk on breast
2. Best position in breastfeeding – upright sitting -avoid tension!
3. Stimulate & evaluate feeding reflexes
a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to
stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be gone
- Purpose rooting- to look for food.
b.) Sucking – when you touch middle of lips then baby will suck
- Disappears by 6 months
- When not stimulated sucking will stop.
2. Transitional stool -
- green loose & shiny, like diarrhea to the untrained eye
3. Breastfed stool - golden yellow, soft, mushy with sour milk smell, frequently
passed
- recur every feeding
4. Bottlefed stool –
- pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day
- with food added -brown & odorous
A- appearance- color – slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate – apical pulse – left lower nipple
G- grimace – reflex irritability- tangential foot slap, catheter insertion
A – activity – degree of flexion or muscle tone
R – respiration
012
HR -absent <100 >100
Resp effort -absent - slow, irreg, weak -good strong cry
Muscle tone - flaccid extremities - some flexion - well flexed
Reflex irritability
Catheter - no response - grimace - cough, sneeze
Tangential Footslap - NR - grimace - cry
Color - blue/pale - acrocyanosis
(body- pink
extremities-blue) - pinkish
APGAR result
0 – 3 = severely depressed, need CPR, admission NICU
4 – 6 = moderately depressed, needs add’l suctioning & O2
7 - 10 =good/ healthy
Circulation
Check for pulslessness :carotid- adult
Brachial – infants
CPR – breathless/pulseless
Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb
Neonates in Nursery
Nsg responsibility upon receiving baby- proper identification
- foot printing, affixing mother thumb print
- take anthropometic measurement
normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm
head circumference 33- 35 cm or 13 – 14 “
Hydrocephalus - >14”
Chest 31 – 33 cm or 12 – 13”
Abd 31 – 33 cm or 12 – 13”
Bathing
- oil bath – initial
- to cleanse baby & spread vernix caseosa
Fx of vernix caseosa
1. insulator
2. bacterio- static
Babies of HIV + mom – immediately give full bath to lessen transmission of HIV
- 13 – 39% possibly of transmission of HIV
3 cleans in community
1. clean hand
2. clean cord
3. clean surface
silver nitrate (used before) – 2 drops lower conjunctiva (not used now)
V/S:
Temp: rectal- newborn – to rule out imperforate anus
- take it once only, 1 inch insertion
Imperforate anus
1. atretic – no anal opening
2. agenetic – no anal opening
3. stenos – has opening
4. membranous – has opening
Earliest sign:
1. no mecomium
2. abd destention
3. foul odor breath
4. vomitous of fecal matter
5. can aspirate – resp problem
Mgt:
Surgery with temporary colostomy
Causes:
1. familial
2. exposure to rubella – 1st month
3. failure of strucute to progress
acyanotic L to R
cyanotic R – L
S&Sx
1. systolic murmurs at lower border of sternum and no other significant sign
2. cardiac catheterization reveals increased o2 saturation @ R side of heart
3. ECG reveals hypertrophy of R side of heart
Nsg Care:
Cardiac catheterization: site – Rt femoral vein
1. NPO 6 hrs before procedure
2. protect site of catheterization. Avoid flexion of joints proximal to site.
3. assess for complication – infection, thrombus formation – check pedal pulses
( dorsalis pedis)
Mgt.
1.) long term antibiotic – to prevent subacute bacterial endocarditis
2.) open heart surgery-
Outstanding Sx:
1. cyanosis after 1st cry (due no exygenation)
2. polycythemia – increased RBC =compensatory due to O2 supply=viscous
blood
=thrombus = embolus = stroke
3. ECG – cardiomegaly
Cardiac cath – decreased O2 saturation
Palliative repair – rashkind procedure
Complete repair – mustard repair
2.) Total Anomalous Pulmonary
venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC
Increased pressure on Rt so blood goes to Lft
3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or
common trunk with VSD
S & Sx 1. cyanosis
2. polycythemia – thrombus = embolus = stroke
Mgt: Heart transplant
Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and
occludes mitral valve.
Jones Criteria
Major Minor
1. polyarthritis – multi joint pain 1. arthralgia – joint pain
2. chorea – sydenhamms chores or
st. vetaus dance-purposeless involuntary hand and shoulder with grimace 2. low
grade fever
3. carditis – tachycardia
erythema marginatum - macular rashes
SQ nodules 3. all lab results
increase antibody
“ C reactive protein
“ erythrocyte sedimentation rate
“ anti streptolysin
o titer (ASO)
Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will
confirm the dx.
Nsg Care:
1. CBR
2. throat swab – culture and sensitivity
3. antibiotic mgt – to prevent recurrence
4. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin.
S/E of aspirin:
- Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and
brain
Respiration
Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of
apnea without cyanosis.
< 15 secs – normal apnea –newborn
Resp Check
Newborn – 40 – 90
1 yr - 20 – 40
2-3yr 20 – 30
5 yrs 20 – 25
10 yrs 17 – 22
15 & above 12- 20
3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration
longer than inspiration. Normal
4.) RHONCHI – snoring sound made by air moving through mucus in bronchi.
Normal
5.) RALES-or crackles – like cellophane – made by air moving through fluid in
alveoli.
Abnormal- asthma, foreign body obstruction.
6.) WHEEZING- whistling on expiration made by air being pushed through
narrowed bronchi .Abnormal – asthma, foreign body obstruction
7.) STRIDOR- crowing or ropster life sound – air being pulled through a
constricted larynx. Abnormal – resp obstruction
Asthma- pathognomonic sign – expiratory wheezing
Pet – fish. Sport – swimming
Drugs – amynophylline – monitor bp, may lead to hypotension
Fibrine hyaline
Sx – definite with in 1st of life
Increase RR with retraction
Inspiratory grunting – pathognomonic
7 – 10 severe RDS (silvermenn Anderson index)
cyanosis due to atelectasis
Mgt:
1. surfactant replacement and rescue
2. pos- head elevated
3. proper suctioning
4. o2 with increase humidity- to prevent drying of mucosa
5. monitor V/S skin color , ABG
LARYNGOTRACHEOBRONCHITIS
LTB – most common Creup -viral infection of larynx, trachea & bronchi
outstanding sx - croupy cough or barking
pathognomonic - stridor
- labored resp
- resp acidosis
- end stage – death
Lab:
1. ABG
2. neck and throat culture
3. dx- neck x-ray to rule out epiglotitis
Nsg Mgt:
1. bronchodilators
2.increase o2 with humidity
3. prepair tracheostomy set
SKIN:
Acrocyanosis
BIRTHMARKS:
1. Mongolian spots – stale gray or bluish discoloration patches commonly seen
across the sacrum or buttocks due to accumulation of melanocytes. Disappear
by 1 yr old
2. MIlla – plugged or unopened sebaceous gland . white pin point patches on
nose, chin or cheek.
3. Lanugo – fine, downy hair – common preterm
4. Desquamation – peeling of newborn, extreme dryness that begin sole and
palm.
5. Stork bites (Talengeictasi nevi) – pink patches nape of neck
hair will grow as child♣ grows old
6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically
& unpredictably as to time & place.
7. Harlequin sign – dependent part is pink, independent part is blue
(side lying – bottom part is dependent pink)
8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold.
9. Hemangiomas – vascular tumors of the skin
3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen
on face or thigh. NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the
entire dermal or subdermal area. Enlarges, disappears at 10 yo.
c.) Cavernous hemangiomas – communication network of venules in SQ tissue
that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage
Skin color blue – cyanosis or hypoxia
White – edema
Grey – inf
Yellow – jaundice , carotene
Vernix Caseosa – white cheese like for lubrication, insulator
INFANT 5-9 yo
ANTERIOR POSTERIOR Ant Post
Head 9.5 9.5 6.5 6.5
Neck 1 1 1 1
Upper arm 2 2 2 2
Lower arm 1.5 1.5 1.5 1.5
Hand 13 1.25 1.25 1.25
Trunk 13 13
Back 13 13
Genital 1 1
@ buttocks 2.5@ 2.5 @
Thigh 2.75 2.75 4 4
Leg 2.5 2.5 3 3
foot 1.75 1.75 1.75 1.75
DEPTH
1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN
-sunburn, heals by regeneration from 1 – 10 days
2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful
scalds¬
3rd degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle &
bone
lethargy,¬ white or black, not painful – nerve endings destroyed
ex. lava¬ burns
Mgt:
1.) 1st aid a.) put out flames by rolling child on blanket
b.) immerse burned part on cold H2o
c.) remove burned clothing of with sterile material
d.) cover burn with sterile dressing
2.) a/w
a.) suction PRN, o2 with increased humidity
b.) endotracheal intubation
c.) tracheostomy
3.) Preventiuon of shock & F&E imbalance
a. colloids to expand bld volume
b. isotonic saline to replace electrolytes
c. dextrose & H2o to provide calories
4.) Tetanus toxoid booster
5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree –
very painful
6.) 1st defense of body – intact skin
prevention of wound infection
a.) cleaning & debriding of wound
b.) open or close method of wound care
c.) whirlpool therapy – drum with solution
7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals –
xenograft
frozen cadaver – hallow graft
8,) diet – increase CHON, increase calories.
ANEMIA-pallor
Causes:
1.)early cutting of cord – preterm – cut umb cord ASAP
fullterm – cut umb cord when pulsation stops
2.) Bleeding disorders – blood dyscrasias
Assessment:
- umphalagia – earliest sign
- newborn receive maternal clotting factor
- newborn growing – sudden bruising on bump area- marks earliest sign
- continuous bleeding – hematrosis – damage or bleeding synovial membrane
Dx test :
PTT. Partial thromboplastin time – reveals deficiency in clotting factor
Long Term Goal- prevention of injury
Nsg Dx- increase risk of injury
HT: avoid contact sport, swimming only, don’t stop immunization – just change
gauge of needle
Falls – immobilized , elevate affected part, apply pressure-not more then 10 min
cold compress
-determine case before doing invasive procedure
Classification :
1. Lympho – affects lymphatic system
2. Myelo – affects bone marrow
3. acute / blastic- affects immature cells
4. chronic/ cystic- affects mature cells
Therapeutic Mgt:
TRIAD:
1. surgery
2. irradiation
3. chemotheraphy
Focus Nsg Care: prevent infection
4 LEVELS OF CHEMOTHERAPHY
1. induction – goal of tx; to achieve remission
meds: IV vincristine
L- agpariginase
Oral predinisone
2. Sanctuary- treat leukemic cells that invaded testes & CNS
give: methotrixate- adm intrathecally via CNS or spine
cytocine, Arabinoside, steroids with irradiation
ABO incompatibility –
Most common incompatibility – ( mom) O – ( fetus) A
Most severe incompatibility (Mom) O– (Fetus) B
Can affect 1st pregnancy
Mgt:
1. initiate breastfeeding to get colostrum
2. Temp suspension of breastfeeding
- content breast milk pregnanedioles – that delays action of glucoronil transferees
Assessment of Jaudice :
1. Blanching neonates forehead, nose or sternum
- yellow skin & sclera
- color of stool – light stool
- color of urine – dark urine
Nsg Resp:
1. cover eyes – prevent retinal damage
2. cover genitals – prevent priapism – painful continuous erection
3. change position regularly – even exposed to light
4. increase fld intake – due prone to dehydration
5. monitor I&O – weigh baby
6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy
= bronze baby syndrome-transient S/E of phototherapy
weigh diaper 1gm = 1cc
Nsg Care:
1.) post VP shunt – side lying on non operated site - to prevent increase ICP
-monitor for good drainage - sign – sunken fontanel
-bulging fontanel – blocked shunt
-change fontanel as child is growing
SENSES
EYES: Assessment
1. check for symmetry
2. sclera – normal color – light blue then become dirty white
pupil – round- adult size
coloboma- part of iris is missing
sign: key hole pupil
-whiteness & opacity of lens congenital cataract
cornea – round & adult size
large – congenital glaucoma
NOSE:
1. flaring alenase – case of RDS
2. cyanosis at rest – choanal atresia - post nares obstructed with bone or
membrane
Sx:
1. resistance during catheter insertion
2. emer. Surgery within 24 h
normal color nasal membrane – pinkish
rhinitis – presence of creases & pale
check sense of smell – blindfold – smell
Epistaxis – nosebleed
- sit upright, head slightly forward to facilitate drainage
- cold compress , apply gentle pressure, epinephrine
EARS:
1. Properly aligned with outer cantus of eyes
low set ear – kidney malformation
ex. Renal aginesis – absence of kidney
sign in uterus : oligohydramnios
sign in newborn: 2 vessel cord
failure to void within 24 h
Otitis Media – inflammation of middle ear. Common children due to wider &
shorter Eustachian tube
Causes
1.) bottle propping
2.) Cleft lip/ cleft palate –
Sx: Otitis
1. bulging tympanic membrane, color – pearly gray
2. absence light reflex
3. observe for passage of milky, purulent foul smelling odor discharge
4. observe for URTI
Nsg Care:
1. position side lying on affected aside – to facilitate drainage
2. supportive care- bedrest, increase fld intake
Med Mgt:
1. Massive dosage antibiotic
Complication – bacterial meningitis
2. Apply ear ointment
Outstanding Sx – Coughing
Choking
Continuous drooling
Cyanosis
Mgt:: Emergency surgery
Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia
Hypervitaminosis
Natal tooth – tooth at birth. Move with gauze
Neonatal tooth – tooth within 28days of life
LIPS- symmetrical
Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of
pregnancy
- common to boys
- unilateral
Sx:
1. evident at birth
2. milk escapes to nostril during feeding
3. frequent colic & otitis media or URTI
Mgt:
1. Surgery
cleft lip repair – Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6
months )
Cleft Palate- uranoplasty = done 4-6 months to save speech
Pre op care
1. emotional support especially to mom
2. proper nutrition
3. prevent colic
feed – upright seating or prone pos
burp frequently 2x at middle and after feeding-lower to upper tap
4. orient parents to type of feeding
rubber tipped syringe – cheiloplasty
paper cup/ soup spoon/ plastic cup – urano plasty
5. apply restraints – elbow restraints
so baby can adjust post op
NECK-
1.) check symmetry
Congenital torticolis- “ wryneck”-burn injury of sternocleidomsstoid muscle during
delivery – due to excessive traction at cephalic delivery
CHEST
1. symmetry
2. breast - transparent fluid coming out from newborn related to hormonal
changes-
3. chest has retroactive – RDS
4. sternum sunken – pectus excavation
ABDOMEN (in order)
1. inspection I
2. Auscultation A
3. percussion P
4. Palpation P = Will change bowel sounds, so do last
Fx of GIT
1. assists in maintaining F&E & acid base balance
2. Processes & absorbs nutrients to maintain metabolism & support G & D
3. excrete waste products from digestive process
Complication = dehydration
Mild dehydration 5% wt loss
Moderate dehydration 10% wt loss
Severe dehydration 15 % wt loss
Earliest sx of dehydration
tachycardia increase temp weight loss
tachypnea sunken fontanel & eyeballs scanty urine
hypotension absence of tears
Severe dehydration:
Oliguria , Prolonged capillary refill time
Mgt:
Acute – NPO ( rest the bowel )
- with fluid replacement – IV
- prone to Hypokalemia – give K chloride
before adm of K chloride – check if baby can void, if cant void – hypokalemia
Drug: Na HCO3 – adm slowly to prevent cardiac overload
Earliest sign
1. failure to pass mecomium after 24h
2. abd distension
3. vomitus of fecal material
early childhood – ribbon like stool
foul smelling stool
constipations
diarrhea
Dx:
1. Barium enema – reveals narrowed portion of bowel
2. Rectal Biopsy – reveals absence of ganglionic cells
3. abd x-ray – reveals dilated loops on intestine
4. rectal manometry – revels failure of intestine sphincter to relax
Esophageal cancer
Assessment :
1. chronic vomiting
2. faiture to thrive syndrome
3. organic – organ affected
4. melena or hematemesis – esophageal bleeding
Dx procedure
1. barium esophogram – reveals reflux
2. esophageal manometry – reveals lower esophageal sphincter pressure
3. intra esophageal pH content – reveals pH of distal esophagus.
Meds of GERD
Anti-cholinergic
a.) Betanicol ( urecholine) – increase esophageal tone & peristaltic activity
b.) Metachloporomide (Reglam) – decrease esophageal pressure by relaxing
pyloric & duodenal segments
- increase peristalsis without stimulating secretions
c.) H2 Histamine Receptor Antagonist – decrease gastric acidity & pepsin
secretion
- Zimetidine, Ranitidine (Zantac) – take 30 min before meals
d.) antacid – neutralizes gastric acid between feedings - Maalox
OBSTRUCTIVE DISORDERS
A. PYLORIC STENOSIS – hypertrophy of muscles of pylorus causing narrowing
&
obstruction.
1.) outstanding Sx- projectile vomiting
- vomiting is an initial sx of upper GI obstruction
- vomitus of upper GI can be blood tinged not bile streaked. (with blood)
- vomitus of lower GI is bilous ( with pupu)
- projectile vomiting – increase ICP or GI obstruction
- abd distension – major sx of lower GIT obst
2.) met alk
3.) failure to gain wt
4.) olive shaped mass – on palpation
5.)serum electrolyte – increase Na & K, decrease chloride
6.) ultrasound
7.) x ray of upper abd with barium swallow reveal “string sign”
Mgt:
1. Pyleromyotomy
2. Fredet Ramstedt procedure
INSTUSSUSCEPTION- invagination or telescoping of position of bowel to
another
Common site – ilio-secal junction
Prone pt: person who eats fat
Complication – peritonitis – emergency
Sx:
1.) persistent paroxysmal abd pain
2.) vomiting
3.) currant jelly stool- dye bleeding & inflammation
- palpate sausage shaped mass
Mgt:
1.) Hydrostatic reduction with barium enema
2.) Anastomosis & pull thru procedura
9 amino acids:
valine isolensine tryptophase
lysine phenylalanine
Dx:
Beutler test – get blood -done after 1st feeding
presence of glucose in blood – sign of galactosemia
galactose free diet lifetime
neutramigen – milk formula
Early Sx:
1. diarrhea – failure to gain wt ff diarrheal episodes
2. constipation
3. vomiting
Late Sx:
1. abd pain – protruberant abd even if with muscle wasting
2. steatorrhea
Mgt:
1. vitamin supplements
2. mineral supplements
3. steroids
Lead poisoning
Lead = Destroy RBC functioning = Hypochornic Microcytic Anemia = Destroy
kidney functioning
Accumulation of anemia = Encepalopathy
Sx:
1. beginning sx of lethargy
2. impulsiveness, learning difficulties
3. as lead increases, severe encepalopathy with seizure and permanent mental
retardation
Dx:
1. Blood smear
2. abd x ray
3. long bones
Mgt:
1. remove child from source
2. if > 20 ug/dL – need chelation therapy = binds with led & excreted by kidney
=nephrotoxic
Amogenital
Female:
Pseudomenstration slight bleeding on vagina related to hormonal changes
Tearing of fourchette with blood – rape/ child abuse
Rape- Report within 48 h
Shape pubic hair in inverted triangle ( female)
Male:
Undescended testes – cyrptorchidism -common to preterm
surgery – orchidopexy
assess scrotum- warm room & hands
Mgt:
Surgery
Mgt:
Circumsicion
Tst of Dx:
Transillumination with use of flashlight - glowing sign
SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac
Types:
1. Meningocele – protrusion of CSF & Meninges
2. Myelomeningocele – protrusion of CSF & Meninges & spinal cord ( most
dangerous)
3. Encephalocele ( CNS complication – hydrocephalus) – cranial meningocele or
myelomeningocele
Most common problem
- rupture of sac
- prone pos
- sterile wet dressing
Most common complication - infection
Myelomeningocele – genitourinary complication- urinary & fecal incontinence
Nsg care: always check diaper
Orthopedic complication – paralysis of lower extremities
Surgery to prevent infection
Post op – prone position
Dx:
1. uneven hemline
2. bend forward- 1 hip higher
1 shoulder blade more prominent
Nsg care:
1. conservative – avoid obesity, exercise
2. preventive – Milwaukee brace - worn 23 h a day
3. corrective surgery – insert Harrington rod
post op- how to move
log rolling- move client as 1 unit
EXTREMITIES:
check # of digits = 20
1. syndactyly – webbing of digits
2. polydactyly – extra digits
3. olidactyly – lack of digits
4. Amelia – total absence of digits
5. pocoamelia- absence of distal part of extremities
TALIPES – “clubfoot”
a.) Equinos – plantar flexion – horsefoot
b.) Calcaneous – dorsiflexion – heal lower that foot anterior posterior of foot
flexed towards anterior leg
c.) Varus- foot turns in
d.) Valgus- foot turns out
Equino varus- most common
Assessment:
1. Straighten legs & flexing them at midline pos
Mgt:
1. Corrective shoe- Dennis brown shoe, spica cast
Fx: of cast –
- to immobilize
- bone alignment
- prevent muscle spasm
lead pencil – mark area to be amputated
cold H20 – hasten setting process
hot H20- slow setting process
CRUTCHES
Fx: To maintain balance
- To support weakened leg
Principles in crutches
- wt of body on palm!
- Brachial pulsing – if wt of body in axila
Renal Disorder Cause Sx Tx NSG CARE
NEPHROTIC
SYNDROME infectious 1. Anasarca- gen edema
2. massive protenuria
3. microscopic or no hematuria
4. serum CHON decreased
5. serum lipid increased
6. fatigue
7. normal or decreased BP Prednisone
Diuretic Focus of care: monitor edema
-weigh daily
Diet:
Increase CHON
Increase K- OJ, beef broth, banana
Decrease Na
AGN ( acute Glomerulo Nephritis)
3A’s;
AGN,
autoimmune,
Grp A Autoimmune
Grp A beta hemolytic streptococcus 1. (PPP) primary peripheral periobital edema
2. moderate protenuria
3. gross hematuria ( smokey urine)
4. serum K increased
5. fatigue
6. increase BP
Complication :
1. hypersensive encephalopathy
2. anemia 1. anti HPN drug
- hydralazine or apresoline
2. iron 1. weigh daily
2. monitor BP & neurologiuc status
3. Diet: decrease K, decrease Na
- Do palm exercise- squeeze ball
Different crutch Gaits:
1. Swing Through
2. Swing to
- no weight bearing are allowed into lower ext
Reactions:
Obstetrical Nursing
MATERNAL/OB NOTES
Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes emotions
and preferences that are related to sexual self and eroticism.
2. Sex – basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human
sexuality.
B. Definitions related to sexuality:
Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life
long dynamic change.
- developed at the moment of conception.