MADULID, 2020
UWORLD & LA CHARITY NOTES
WARFARIN
- LIVER is RICH IN VIT K & A!
- INCREASED EFFECT: GET A SOCk!
· Gingko biloba/Ginger
· E Vitamin
· Thyroid hormone
· Amiodarone, ATB, Antifungal, Acetaminophen
• ATB kills intestinal bacteria, which produces
vitamin K. Thus if there is no vitamin K, there
will be more available warfarin causing
increased effect of warfarin
· SSRI
· Omeprazole;
· Cranberry
- DECREASED EFFECT: ROCKS
· Rifampin
· OCPs
· Carbamazepine(tegretol)
· K Vitamin
· St John’s Wort
- SOCK
· SSRI : St. John’s Wort
· Omeprazole : OCPs
· Cranberry : Carbamazepine
· K Vitamin : E Vitamin
- Vit K rich foods should be CONSISTENTLY TAKEN UP
WITH THE SAME AMOUNT EVERYDAY; Amount is not
increased nor decreased
DIGOXIN
- There is no reason a client taking digoxin will experience
lightheadedness because the effect of it is INCREASED
CARDIAC OUTPUT which instead should help the client
with the SSXX;
- Lightheadedness/dizziness may be caused by HEART
BLOCKS (sign of toxicity) s/t BRADYCARDIA
- Hold if <90bpm for infants and young children
- Hold if <70bpm to an older child
- Hold if <60 for an adult
PATCHES
- TRANSDERMAL PATCHES such as NTG and/or Fentanyl
peak is at 1hr thus is NOT USED FOR ACUTE
ANGINA/PAIN; Transdermal patch is more on
maintenance
- If an NTG patch is pulled off after inserting and client
reports chest pain, administer NTG PRN then apply the
patch
- Morphine is given only if NTG does not relieve the pain
- Scopolamine patch (for motion sickness) is applied 4
hours before starting to travel; Replace patch every 3
days
PARESTHESIA & EPIDURAL ANALGESICS
- PARESTHESIA is NOT COMMON OR A COMPLICATION to
a client post hip surgeries or any surgeries below the hip,
which indicates compromised circulation; However, it is
NORMAL to a client POST EPIDURAL ANALGESIA as this
is a SIDE EFFECT
- PARESTHESIA may also be present d/t presence of comorbidities such as DM, GBS or alcohol use
- PARESTHESIA BILATERALLY may be normal but
UNILATERAL is ABNORMAL
- #1 COMPLICATION OF HIP/KNEE SURGERIES is
HEMORRHAGE which precede abduction pillow
· Low Hgb is normal but is only up to 8 hgb: <7 is not
normal after a hip or knee surgery
- EPIDURAL ANALGESICS ARE NOT given together with
ANTICOAGULANTS because of epidural hematoma
incidence which causes cord compression with sssx of
back pain and/or paralysis
FUROSEMIDE/BUMETANIDE; LOOP DIURETICS
- NEPHROTOXIC- On HIGH doses
- OTOTOXIC- On FAST administration
More on KNEE ARTHROPLASTY
- Hospital stay: 3-5 days; Full weight bearing should be
achieved by discharge
- KNEE IMMOBILIZER is used to maintain extension during
ambulation and rest; Remember: Flexion and internal
rotation is avoided to post arthroplasties to prevent
dislocation. GOAL: Extension and abduction
- Client is encouraged to do ROM with extension as much
as possible thus knee immobilizer is used and not to
restrict movement
ANALGESIA
- On PCA PUMP
· Bolus dose is “extra” dose if pain mgt is not
adequate
· Only pt. is allowed to push, nurse only programs the
machine
· Only report for additional dose if pumps made on
pca are twice the number of usual doses being
delivered and no adequate pain mgt is achieved.
· Delivers medication each time patient press the
button
· Continuous IV solution is REQUIRED to KVO for the
medication to be FLUSHED through the line
· Saline/Hep lock is not used as medication is not
flushed to the line
· LOC is a parameter to all patient controlled pumps
such as insulin and PCA pump because they
determine when to infuse the medication to
themselves; Thus a client with sepsis who is more
likely to be disoriented should be assessed for LOC
- HYDROMORPHONE action is 3-4 hrs. Naloxone’s duration
is only up to 90mins. Thus, repeat doses may be
necessary and assessment should be made approx. 60
mins after administering naloxone
MADULID, 2020
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-
Hydromorphone’s peak is 30 minutes, thus client with
hydromorphone should be checked after 30 mins of
administration; Administered over 2-3 minutes
Patient may be agitated 60 minutes after naloxone
administration, signifying weaning off of naloxone; This
differs from a LUCID INTERVAL experienced by patients
with epidural hematoma which is a transition from ALOC
to alert to COMA
OXYCODONE is morphine-like analgesic
FENTANYL is a synthetic opioid
HYDROMORPHONE is 2-3x stronger than morphine
ANALGESICS DURING LABOR
- Pudendal nerve block- used if birth is imminent (0 station
with 100% effacement and 10cm dilation); best pain
relief with least SE with quick administration
- Epidural: 1st or early 2nd stage but not in late 2nd stage
where birth is imminent because the medication peaks
at 30 minutes
- IV Narcotic (Demerol); early labor; has a duration of 2-3
hours, thus is avoided 1-4 hours of birth d/t respi
depression
-
EXTRA CAUTION to older clients d/t risk for fall, worsening
of constipation, and increased risk for respiratory
depression
AT RISK FOR RESPIRATORY DEPRESSION: Old, Respi cases,
Opioid-naïve (new users), and to clients with OSA
Drug abusers are safe to be given narcotics and
withholding narcotics does not resolve addiction;
furthermore, medical use of opioids is not addictive
LARGER doses are given at night to increase interval
between doses and helps the client to rest and sleep
Placed FARTHEST of the station to provide quiet calm
environment, especially those receiving continuous IV
ANALGESIA to contribute to pain management
SIDE EFFECTS (NORMAL): Constipation, N/V (give with
meals), Hypotension, pruritus, urinary retention (normal),
together with tricyclics and anti cholinergics.
AE: Respiratory depression
THUS the risk for respiratory depression and sedation is
NONE to clients on long term opioids as these symptoms
develop tolerance
R. DEPRESSION is common to opioid naïve patients
CONSTIPATION does not develop tolerance, thus is
common to long term opioid use
CODEINE
- Is an opioid; Thus already has opioid SE (N/V, hypotension,
dizziness, constipation) so it should be taken with food
because GI irritation is common
- Photosensitivity is not a feature
MORE ON OPIOIDS:
- WITHDRAWAL
· EARLY 6-12h: Diaphoresis
· LATE 2-3d: Abdominal cramps, nausea, fever
- A client on opioid must ALWAYS be EASY to be aroused.
DIFFICULTY to be aroused means OVERDOSE of
medication or TOXICITY which warrants INTERVENTION
IMMEDIATELY
-
NO OPIOID to clients with head injury or those at risk for
INCREASED ICP because hypoventilation increases ICP
more and assessment will be compromised as decreased
LOC will be mistaken as worsening of condition
NYSTATIN
- Swish and swallow but do not follow with drinking a glass
of water for medication to stay in tissues as long as
possible
- While this is swallowed, corticosteroids/anticholinergics
used for asthma is only swished to reduce
oral/esophageal candidiasis
PAIN ASSESSMENT
- UNCONSCIOUS: For patients who cannot adequately
describe the pain, baseline behavioral indicators must be
obtained to the family members then nonverbal indicators
should be assessed second
- CONSCIOUS: Behavioral assessment tool is not effective
when the client is engaging in activities as the client may
mask different expressions while on activity. THE BEST
assessment tool is to use the SAME scale every day for THE
SAME CLIENT
ISSUES on LIGHTHEADEDNESS/DIZZINESS
- Digoxin; heart block
- NTG; over-dosage/profound hypotension;
- Calcium channel blockers; orthostatic hypotension
ISSUES on HEADACHE
- NORMAL in: NTG, Ca channel blockers, statins, CHF
(dilutional hyponatremia)
- ABNORMAL: Desmopressin
MADULID, 2020
ISSUES on HYPERTENSION/HEART PROBLEMS
- NOT given to Heart failure (causes water retention): ANT
· ADH/Desmopressin
· NSAIDs
· THIZOLIDINEDIONES (-GLITAZONE)
- CI to uncontrolled hypertension (>180)
· SSRIs/MAOIs; these causes constriction
· Kidney transplant
· Thrombolytics
· EPO (SE is hypertension)
-
NSD with previous CS is at risk for uterine rupture
1st sign: abnormal FHR
OTHER signs: constant abdominal pain, loss of fetal
station, sudden cessation of uterine contraction,
tachycardia d/t hypovolemic shock
ISSUES on GRAPEFRUIT: Contraindicated to:
- CaChannel Blocker/Sildenafil; severe hypotension
- Statins: myopathy
NITROGLYCERIN
- PROFOUND HYPOTENSION as evidenced by
DIZZINESS/LIGHTHEADEDNESS is NOT normal and may
indicates overdose, also with CaChannel
- HA, Flushing, Nervousness are normal due to
vasodilation together with CaChannelBl
- EMS is called if no relief of symptoms after taking 1 PILL
- 6 mos. Only:
- INSULIN 3 mos if on ref; 1 mon in room temp
**HYPOTENSION may also be a complication of rapid bladder
decompression and paracentesis (treated with IV albumin)
- Infection is more on if the bladder is not decompressed
DESMOPRESSIN
- Di naghe-headache and De-spray
- Concept: Effects are that of SIADH: Water is restricted
d/t water intox with sssx of low Na-Dilutional
hyponatremia (altered mental status, weakness,
headache) which may cause seizure
ISONIAZID
- Peripheral neuropathy is already an ADVERSE EFFECT
REFLUX ESOPHAGITIS; Taken in the morning, without
meals/antacids/milk and with full glass of water to prevent
reflux esophagitis: No foodà nothing regurgitates
-
TETRACYCLINE
BIPHOSPHONATES/Calcium
· Also w/o food; For bone pain associated with bone
Ca
EXCEPTION: KCL
· With food d/t SE s/c as N/V
MISOPROSTOL/CYTOTEC
- No to CS d/t uterine rupture s/t tearing at the incision
site
- Oxytocin is only given after 4hrs misoprostol is
administered
- Available in oral, vaginal, rectal (only for PPH)
CLOMIPHENE (Clomid, Serophene)
- First line TX for infertility
- Estrogen modulator, inducing ovulation
- Taken day 3-5 of menses and ovulation occurs 5-9 days
after completion of medication.
- Frequent sex is encouraged 5 days after completing the
medication not on the day of taking the medication for
successful contraception
- Increased risk for twin
- Postmenopausal signs, N/V, weight gain d/t fluid
retention are common SE
METOCLOPROMIDE (Reglan)
- An antiemetic and to increase gastric emptying time to
clients with GERD thus may cause diarrhea
- Can cause EPS and TD, just as antipsychotics
- CONCEPT: Antipsychotics can act also as antiemetic in
such a way that antipsychotics decreases the
transmission of Norepi, Epi, Dopamine which is high in
psychotic patients; While antiemetics such as Reglan
decreases nerve impulses so that the vomiting center in
the brain will be blocked. So they both decreases the
nerve impulses or brain reactivity in the brain
- Common SE: Sedation, fatigue, HA, sleeplessness, dry
mouth, constipation, diarrhea (these are all
anticholinergic properties of the medication)
MADULID, 2020
RASHES FROM MEDICATIONS
- ALWAYS consider abnormal even if mild unless otherwise
not normal
- Allopurinol and Dilantin rashes are normal; Rashes with
flu-like symptoms are not normal, which indicates SJS to
Dilantin
SJS; Flulike symptoms with painful purple or red rash that
resembles a 3rd degree burn;
PHENYTOIN
- SE: body hair, rash, folic acid depletion and osteoporosis
- TOXICITY: DEANS
· Dysarthria
· Encephalopathy
· Ataxia
· Nystagmus
· SJS
- Food and calcium decreases its absorption leading to
decreased serum levels resulting to seizures
- Decreases effect of OCP and WARFARIN; OCP is not
recommended as birth control
- PPIs decreases calcium absorption resulting to decreased
calcium levels; Causes c. difficele
- Only MagSulfate is the acceptable anticonvulsant in
pregnancy; NO VALPROATE/PHENYTOIN/CARBAMAZEP
SOME NOTES:
- METHOTREXATE is CI in pregnancy; Only heard in
ECTOPIC / H. MOLE in maternity nursing
§ A DMARD;
§ AE: Bone marrow suppression, GI irritation,
hepatotoxic
§ Petechiae/purpura is a red flag as it signifies
thrombocytopenia
§ N/V are common side effects;
§ Caffeine and folic acid decreases its effectiveness as
methotrexate is a folic acid antagonist
- PHENTOLAMINE REGITINE is the DOC for HTN CRISIS in a
client with PHEOCHROMOCYTOMA; Thus this drug is also
an antidote for norepinephrine extravasation
- ANTIDOTE for ALCOHOL is benzodiazepine
- ANTIDOTE for BENZO/CNS DEPRESSANTS is FLUMAZENIL
ROMAZICON, NALOXONE NARCAN NALTREXONE
PAIN
- From lower back to abdomen; true labor
- Abdomen to lower back: Acute pancreatitis or ruptured
AAA
EPOGEN: only given to Hgb of <10 and if anemia is
symptomatic
- HTN is a major adverse effect; Do not give if hypertensive
or check BP first
SNS; ANTICHOLI; Urinary retention to treat incontinence
(overactive bladder); MAJOR CI is BPH and GLAUCOMA
- AIM is to treat incontinence and not to retain urine;
- Urinary elimination that is normal is the aim of therapy
- Urinary retention is already an adverse effect
- Decreased sweat to treat hyperhidrosis thus can cause
hyperthermia d/t no heat loss mechanism; INC OFI!
- Sedating effect; no mentally alert activities
PNS; CHOLI; Urinary elimination to treat retention (BPH)
OTHER ANTICHOLINERGICS
- Tolterodine; Overactive bladder
- Glycopyrolate; Perioperative, Hyperhidrosis
- Dicyclomine (BentyL); IBS to decrease ulceration by
decreasing GI Acid
- Scopolamine; Motion sickness and Perioperative
- Oxybutynin; Overactive bladder (incontinence) and
Hyperhydrosis
- Atropine, Ipatropium, Tiotropium
- Solifenacin (Vesicare)
CHOLINERGICS
- ZOSINs to treat urinary retention caused by BPH
NO vasodilators should be administered simultaneously; NTG,
Zosins, Sildenafil Viagra
LIVE vaccines are only administered at the age of >2y/o;
MMR, VARICELLA, ROTAVIRUS
HERBAL SUPPLEMENTS
- Saw Palmetto for Prostate: BPH
· GI discomfort
· Increased bleeding/antiacoag effect
- St DepreJOHN’s wort
· HTN Crisis
· Decreased anticoag effect
MADULID, 2020
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Licorice for stomach ulcer and bronchitis
· Hypokalemia
· HTN
Black Cohosh; Menstruation (black); For postmenopausal hot flashes
· Hepatotoxic
Kava for anxiety
· Hepatotoxic
Echinacea & Ephedrafor cold & flu
-
-
-
HYPERKALEMIA
- PQRST, PR, ST
- P wave loss
- QRS wide
- T Tall, peaked
- PR PRolonged
- ST elevation
BUSPIRONE (Buspar)
- An anxiolytic good for maintenance d/t less serious side
effects such as less substance abuse potential, NO
depressant effects, NO withdrawal, NO dependency on
the drug
- NOT an emergency drug because it takes 2-4 weeks to be
effective
- No psychomotor impairment thus driving is permitted
LITHIUM
- ACUTE TOXICITY:
· GI (Vomit, Diarrhea)
- CHRONIC:
· Neuro (ataxia, confusion, agitation, tremors)
· DI SSSX (polyuria, polydipsia (increased thirst)
- THIRST and DRY MOUTH is NOT dehydration thus is
normal
- EXCESSIVE THIRST AND URINATION; NOTE: EXCESSIVE is
NOT NORMAL
- Take with no stimulants/diuretic effect to prevent
dehydration (alcohol, coffee, cola)
- NORMAL Na intake is recommended and NEVER LIMITED
Na INTAKE because it can cause toxicity
- DECREASED RENAL FUNCTION d/t age, co-morbidities or
d/t MEDS SUCH AS NSAID increases the risk for lithium
toxicity
COMMON ANTIPSYCHOTIC NAMES
- ANTIPSYCHOTICS: ZINE PINE DONE DOL except
phenelZINE (MAOIs), carbamazePINE (anticonvulsant)
· HARTS
· Haloperidol
· Abilify
· Risperdal
· Thorazine
· Seroquel
TRIcyclic Antidepressants: TRYPtilline PRAmine
· TRI for 3 girls love TOFU: Tofranil, Anafranil, Elavil
· Bupropion
· TRIcyclics for TRIptylline and 3 girls
SSRIs: line w/o tryp; pram w/o mine; tine; TRIPTANS
MAOIs: PAMANA:
· PROmine (from PRAmine),
· SELEGEline (from TryptiLINE),
· phenelZINE (from ZINE antipsychotics)
BenzodiaZEPines: ZEP and ZOLpidem, and Buspirone
ANXIOLYTICS
· ATI VAngie went to LIBRea to REST
· ATIvan
· Valium
· LIBRium
· RESToril
PSYCH MEDS
- SIDE EFFECTS; ALL NORMAL
· Orthostatic hypotension: ALL psych meds
· Photosensitivity; ALL except ANXIOLYTICS
· Sedation: Benzodiazepines
· Weight gain, sexual dysfunction, GI SSSX (not
constipation), HA, Dizziness (not sedation), insomnia
(not sedation); SSRIs
· Hyperglycemia, dyslipidemia, weight gain- Clozapine
· Weight loss, constipation; Antidepressants
· Dry mouth and thirst: MAOIs
- W/O for:
· Inc. risk for suicide: Antidepressants
· Serotonin syndrome/HTN Crisis: 2 week interval
from one antidepressant to another; SSRIs, Tricyclic
antidepressants, MAOIs
§ Other drugs that may cause SS:
Dextromethorphan, ondasentron, tramadol
· Hypertensive crisis:
§ MAOIs: tyramine rich foods to be avoided 2
weeks before and after MAOI initiation
§ SSRIs: Constricts blood vessels; Prescribed also
for migraine TX
· Torsades de pointes (prolonged QT), hypotension,
seizures; Ziprasidone hcl (Geodon) or antipsychotics
in general including clozapine; No taking of the drug
with alcohol
MADULID, 2020
-
Taken irregardless of food
Any anticoags should not be crushed as MOA will be
increased, thus increasing risk for bleeding
Fondaparinux (Arixtra), an unfractionated heparin;
Enoxaparin is a low molecular heparin
- NO anticoags + epidural d/t epidural hematoma
formation which causes spinal cord compression
- BACK PAIN in Ca patients is also a RED FLAG d/t SC
Compression
OTHER USES:
NEUROPATHIC PAIN/FIBROMYALGIA
- Antidepressant and Anticonvulsants (Gabapentin &
Carbamazepine). Also used to treat tic doloreux
- Antidepressant/Antipsychotics to older adult with
neuropathic pain is not recommended d/t its risks such
as confusion and orthostatic hypotension which places
the client at risk for injury
- Morphine is not used d/t poor pain relief response
MIGRAINE; SSRI d/t constricting effect
DIURETIC AE:
- MUSCLE CRAMPS must be reported to clients receiving
diuretics as it indicates hypokalemia
- FUROSEMIDE: ON (Ototoxic, Nephro); Should not be
administered along with other nephrotoxic agents (
SonNACiF); NEPHROTOXIC agents should be used
cautiously to patients receiving drugs which has narrow
therapeutic levels such as digoxin, lithium to prevent
toxicity
- SPINOROLACTONE: Hyperkalemia
- THIAZIDE (Chlorthalidone): Hyperuricemia,
hypercalcemia and hyperglycemia, photosensitivity and
agranulocytosis
Factor Xa Inhibitors (-Xabans, Dabigatran)
- An anticoag, used for maintenance
- Any anticoags should not be administered with NSAIDs
- Should be kept in original container and not put in
capsule containers to prevent moisture contamination
- Do not immediately stop even if GI upset occurs d/t risk
for stroke
COMMON MEDICATIONS
• Ipatropium for Immediate acting; for emergency
• Tiotropium for laTe; for maintenance
• Albuterol (salbutamol) for immediate; Salmeterol for
long acting and for maintenance
• Methylprednosolone/Solumedrol as a systemic
corticosteroid used for asthma attack
• Acetaminophen is hepatotoxic; NSAIDS are ON
• MetHotrexate is Hepato: MetronidaSole is SJS
• SonNACiFV (ototoxic, nephrotoxic): Streptomycin,
NSAIDs, Aminoglycoside, Cisplatin, Furosemide,
Vancomycin
• 2 Cs not given with Theophylline: Cimetidine,
Ciprofloxacin which increases its levels
· THEOPHYLLINE
§ CNS Toxicity: HA, Insomnia, seizure
§ GI Toxicity: N/V
§ Cardiac toxicity: Arrythmias
• AgranuloCyToSis: Carbamazepine (tegretol),
Clozapine,Thiazide,PTU,Sulfo
• PhoToSensiTivity: Tetracycline, Sulfo, Thiazide
· Yellow SKIN&SUN; Sulfonamide
· Yellow TEETH&SUN; Tetracycline; Taken w/o food,
milk, antacids, iron, and WITH full glass of water for
reflux esophagitis
§ Causes permanent teeth discoloration of the
baby if given to pregnant women
· KID in the SUN: Floroquinolones “Floxacins”;
Crystalluria and photosensitivity
§ Give antacids, iron, zinc, sucralfate 2 hours in
between
• Eye for EtHambutolS, Hydroxychloroquine, Steroid
• SJS: DISC-M; Metronidazole, Isotretinoin,
Dilantin/Phenytoin, Sulfonamide, Carbamazepine
· ISOTRETINOIN
§ For severe/cystic acne derived from vitamin A
§ Teratogenic
§ Since derived from Vitamin A, do not take
vitamin A supplements anymore d/t risk for
toxicity which increases ICP, GI upset, liver
damage and changes in skin and nails
§ No blood donation 1 month after taking d/t risk
for transfusing it to pregnant woman
§ Not taken with tetracycline d/t risk for
intracranial hypertension
• CAPS-F: Sulfonamide: Crystalluria, Agranulocytosis,
Photosensitivity, SJS, Folic acid deficiency
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•
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•
•
•
•
•
No to pregnant and breastfeeding
Same contents with sulfonylureas (Glyburide) and
thiazides
Myopathy (muscle cramps/aches); Statins and fibrates
(gemfibrozil, fenofibrate)
· DX: CK-MB; Myopathy increases CKMB to 10x more
· CI to liver diseases and muscle injury
· BEFORE: check liver enzymes
· WHILE: monitor for muscle aches
Gingival hyperplasia: Dilantin & Cyclosporine
DISCOLORATION:
· Yellow secretions: Pyridium, sulfonamide, rifampicin
· Yellow skin: sulfonamide
· Yellowish brownish urine: Metronidazole
· Yellow teeth: Tetracycline use on <8y/o
· Any color (red brown black) secretions: Dopamine
agonist (levo/carbidopa); Takes several weeks to
effect; avoid high protein meals and orthostatic
hypotension
VANCOMYCIN
· 10-20 mg/L
· Normal: Red man/neck syndrome d/t rapid infusion
§ Hypotension, spasms, dyspnea, muscle pain
§ Histamine is being released too fast causing
symptoms.
§ Infuse over at least 1hr;
· Hydropmorphone must be infused in 3-5
minutes;
· Morphine t/b infused over 4-5 minutes and
diluted with normal saline to prevent
burning during administration
· Adenosine must be infused FAST over 1-2
seconds and is not diluted
§ Observe site every 30 minutes for extravasation
§ Peripheral IV for short term
§ CVC for long term; Like norepi, it can be used
peripherally in emergency then shifted to CVC
§ No need to assess for DTRs (for MagSulfate)
· Not normal: Anaphylaxis
§ Rash, pruritus, wheezing
OxaZOLIDinone: LineZOLID (Zyvox)
· For MRSA, VRSA
· Has MAOI property, should not be taken with other
antidepressants d/t serotonin syndrome
· Antidep can be resumed 24 hrs after delivery
· HA as SE and treated with Acetaminophen
· Diarrhea and fever may indicate C. Difficile or
serotonin syndrome and should be reported
immediately
C. difficile is treated with metronidazole or vancomycin
ORAL and never IV since the bacteria accumulates at the
GI tract. Most dreaded complication is electrolyte
imbalances.
Diarrhea after amoxicillin can be a normal SE of penicillin
and does not warrant discontinuation. However, diarrhea
with epigastric pain may indicate C. difficile
•
•
C. difficile may be caused by prazole (PPIs) since
suppression of acids makes bacteria alive
HYPOMAGNESEMIA, MACROLIDES (-thromycin),
ANTIPSYCHOTICS causes TORSADES DE POINTES ssx by
PROLONGED QT INTERVAL
ANTI-HYPERTENSIVES
- ALL causes orthostatic hypotension and should be
reported immediately ; Other meds that causes
orthostatic hypotension: Diuretics, narcotics, psych
meds, vasodilators, antihistamines
· ALL of these are potential for injury for elderly
patients
- ALL are contraindicated if with HYPOTENSION
- BRADYCARDIA is for BLOCKERS only (Ca&B blockers);
60bpm after administration is considered normal and a
desired result; Just don’t give if <60bpm
- TACHYCARDIA for ACE (reflex tachycardia)
- ACE & ARBS
· Causes hyperkalemia d/t blockage of aldosterone
(Low Na) thus diet is low K
· Nephrotoxic
· CI in pregnancy and hyperkalemia
- ACE
· ANGIOEDEMA as the most dreaded complication
and EMERGENCY (thickening or lip numbness) as it
may cause AIRWAY compromise
· Cough is NORMAL
· May cause tachycardia
- BBlockers
· Erectile dysfunction / decreased libido / depression /
impotence
· Mainstay in HF but not in decompensated HF
because since it is decompensated, no SNS activity
occurs thereby increasing edema, congestion and
hypotension
- CaChannel
· Dizziness, leg edema, constipation and HA are
normal SE
- VENTRICULAR (including PVCs): Lidocaine, Amiodarone
- ATRIAL (including PACs & SVTach): ABCDQ; Adenosine,
B&C blocker, Digoxin, Quinidine: GOAL: DECREASE HR
thereby increasing CO and not to decrease BP nor
prevent stroke
MADULID, 2020
EPINEPHRINE: AUTO INJECTOR “EPIPEN”
- Administered 90 degree angle to mid-outer thigh
- Hold for 10 seconds for proper distribution and massage
for additional 10 seconds
- Expect tachycardia, palpitations, dizziness
- Store in a dark place
- Skin prep (alcohol) is not an issue as it delays treatment
NSAIDs
- CI to nasal polyps, asthma, heart problems & cirrhosis
(causes fluid retention)
- AE: ON & GI bleeding
- Interaction with diuretics d/t fluid retention
- TOXICITY: Shock like VS + Tinnitus
- ADVANTAGE: Reduce risk for colon and prostate Ca
DRUG TO DRUG INTERACTION
- No nephrotoxic agents to clients receiving drugs with
narrow therapeutic levels as these drugs are mainly
excreted via kidneys; Some of these drugs are lithium,
digoxin, phenytoin
- Caution with nephrotoxic drugs that are given
simultaneously
- Drugs that causes the opposite effects should not be
given simultaneously; Such as drugs that causes fluid
retention (NSAID, ADH, Thiazildione) + fluid excretion
such as that of a diuretic; Anticoagulant + Coagulants or
their antidotes;
- Antacids or milk, in general, should not be given together
with other medications as it decreases other
medications’ absorption/effectiveness
- Vasodilators should not be given simultaneously (NTG,
Calcium channel blockers, sildenafil)
- Drugs that causes sedation or orthostatic hypotension
should be cautiously given to older adults
- Cimetidine with Theophylline
TOXICITY:
- SALICYLATE: Give activated charcoal as emergency
management and sodium bicarbonate as its treatment
- NSAID: TOXICITY: Shock like VS + Tinnitus
- THEOPHYLLINE; CNS Toxicity: HA, Insomnia, seizure; GI
Toxicity: N/V; Cardiac toxicity: Arrythmias
- LITHIUM; ACUTE TOXICITY: GI (Vomit, Diarrhea);
CHRONIC: Neuro (ataxia, confusion, agitation, tremors)
DI SSSX (polyuria, polydipsia (increased thirst)
-
PHENYTOIN: DEANS; Dysarthria, Encephalopathy, Ataxia,
Nystagmus, SJS
TUMOR NECROSIS FACTOR
GI DRUGS
- SUCRALFATE; 1 hr before meals, at bedtime, and on
empty stomach with full glass of water; Coats ulcer
better at low pH or in acidic environment, thus antacids
or medications that decreases the production of acid
must be after 30 mins of sucralfate
- IN GENERAL: SUCRALFATE must not be taken together
with other medications
- IN GENERAL: MEDICATIONS must not be taken with
meals, especially with antacids, because it decreases the
medications’ absorption; Except those gastric irritants
such as those with opioid properties
- LIST of some medications taken with NO MEAL/FOOD
· Floroquinolones
· Tetracycline
· Thyroid prep
· Sucralfate
· Those that causes reflux esophagitis except KCl
· Phenytoin
- Taken irregardless of food: Anticoagulants
ANTIDIABETIC AGENTS
THIZOLIDINEDIONES (-GLITAZONE)
- MOA: Increased sensitivity to insulin receptors but do
not cause insulin release
- Worsens HF and causes BC
- HF d/t fluid retention
BIGUANIDES; Glucophage (Metformin)
- Increased sensitivity to insulin receptors
- Reduce glucose production by liver
SULFONYLUREAS; (-gl); Glyburide, Glipizide, Glimepiride
- Only one that causes hypoglycemia & weight gain d/t
insulin release by pancreas
- NEVER given to geriatrics d/t delayed elimination
resulting to prolonged hypogly
MADULID, 2020
THYROID PREP
- Takes 1 month to effect, and 2 months to take
therapeutic effect
- Iron and food decreases its effectiveness thus taken in
the morning without food
ANTITHYROID PREP
- RAI: Primary tx since it DESTROYS thyroid
- IODINE; Blocks t3 and t4 in high doses (negative
feedback); Also decreases gland vascularity
- PTU/Methimazole: Inhibits thyroid synthesis
- Bblocker: For hyperthyroid sssx (HTN, Tachycardia)
ENDOMETRIAL CANCER
- CAUSE: ESTROGEN without progesterone because
ESTROGEN thickens it and progesterone thins it.
Thickening without thinning causes excessive
endometrial proliferation / hyperplasia causing
abnormal cells to grow
- PROGESTERONE: Thickens cervical mucus
- ESTROGEN: Thins cervical mucus
- OCP is not a cause because it has progesterone which is a
protective factor
OVARIAN CANCER
- Abdominal bloating, pelvic pain/pressure, increased
abdominal girth, early satiety are the sssx d/t enlarging
mass at ovarian site.
BREAST CANCER
- Hard, immobile, NONTENDER
- History of endometrial or ovarian cancer
- Menarche before 12 and menopause after 55
- Hormone therapy (estrogen OR progesterone)
PROGESTERONE PILLS; 3333333
- If missed 3h, use barrier
- Vomits/Diarrhea in 3h, take additional dose
- There is no inactive pill, hence heavier mens occurs
ORLISTAT
- Taken if client will eat a fatty meal;
Mgtatae; Diarrhea
AlCa; Constipation
CHOLESTYRAMINE (QUESTRANS)
- Enhances bile salt excretion, decreasing pruritus
- Powdered form to be mixed with apple (juice or sauce)
- Given 1hr after all meds because bile metabolizes
medication; No bileà Toxicity
SELENIUM (for tinea capitis)
- Taken with high fat food
RILUTEK
- For ALS
-
Glutamate antagonist, slowing neuron degeneration
Prolongs survival for 3-6 mos
ALS has 3-5 years life expectancy
Constipation, not diarrhea, is seen in ALS
RAI
- Delayed peak (3mos.)
- ALL BODY FLUIDS are RADIOACTIVE for 1WK: ISOLATE
THE CLIENT!
· Separate toilet; flush 2-3x
· Separate utensils (saliva)
· Limit contact to pregnant and children
· Separate laundry
· Separate bed
· Do not sit with others for a prolonged time
· No BF to current child, resume on the next child
CYANIDE poisoning: bitter almond breath
SALICYLATE TOXICITY: Give activated charcoal as emergency
management and sodium bicarbonate as its treatment
TAMOXIFEN
- Estrogen antagonist in breast; with sssx of no estrogen
(vaginal dryness, hot flashes, decreased libido)
- Estrogen agonist in uterus: (endometrial proliferation
resulting to cancer) and can result to blood viscosity
resulting to DVT/PE
- Does not cause immunosuppression
ANTIRETROVIRAL
- Decreases other drugs’ metabolism thus must be
cautiously given with any other drug as other drugs given
simultaneously may cause toxicity
UNCOMMON DRUG NAMES
- MAOIs
· PROmine (from PRAmine),
· SELEGEline (from TryptiLINE),
· phenelZINE (from ZINE antipsychotics)
- Xaban, Dabigatran
- Fenofoxadine as an antihistamine
- Fondaparinux (Arixtra), an unfractionated heparin
- Bupropion; antidepressant
- Buspirone; benzodiazepine
- Bumetanide: Loop diuretic as in Furosemide
- Zolpidem: benzodiazepine
- Oxazolidinone: Linezolid (Zyvox); MRSA/VRSA drug
- Chlorthalidone; Thiazide diuretic
- Prasugrel, Ticagrelor; Abciximab, eptifibatide, tirofiban;
Antiplatelet
MADULID, 2020
DIALYSIS
- Phosphate binders are not filtered by dialysis. Thus the
only way to remove phosphate accumulation in the
kidney is by administering phosphate binders even
though the client is on dialysis
- Lispro is also given with breakfast prior to dialysis
- Fat soluble vitamins are not affected with dialysis
- Insufficient outflow may be caused by constipation d/t
distended intestines thus stool softeners are prescribed
AVF: 2-4 months before maturation
- REPORT: numbness/paresthesia; no more than 5lb when
carrying objects
- ARTERIAL STEAL SYNDROME: When vein steals too much
blood from the artery causing distal extremity ischemia
(pallor, pain, paresthesia, pulseless-ness) which may
result to limb necrosis
-
CELIAC DISEASE
· ALLOWED: Rice, corn, potato, fish, meat
· NOT ALLOWED: BROW, Pasta, soy sauce, bread,
flour, dinner roll
-
CKD DIET
· No High Ph & K: Milk
· ALLOWED: Those with P: Pineapple, Pear, GraPes,
APPle, Plums + Berries
· NOT ALLOWED: ABOCadoW: Avocado, Banana,
Orange, Coconut, Watermelon
· LOW Na, K, Ph, CHON
ILEOSTOMY
· LOW RESIDUE immediate post ileostomy; Regular
diet once it starts to heal
· ALLOWED
§ Peeled and cooked foods; peach, banana,
potato
§ Low fiber: pasta, rice, refined grains
· NOT ALLOWED
§ High fiber: popcorn, coconut, brown rice,
multigrain bread
§ GREENS: celery, broccoli, asparagus
§ SEEDS: strawberries, raspberries, olives
§ Edible peels (outside); apple. Cucumber, dried
fruit
· NO NEED to irrigate!
· BOWEL OBSTRUCTION may be present post
Ileostomy signaling that the ileostomy is obstructed;
SSSX includes N/V, Abd distention, Dec stool
· This obstruction may go into perforation or tissue
necrosis
· This takes over tingling sensation in AKA “phantom
limp pain” or an active infection; N/V, Distended
abdomen is an emergency immediate post op as this
may cause bowel obstruction
· Clients with -ostomy are at risk for dehydration,
thus increase OFI.
-
NUTRITION
MADULID, 2020
Preparation includes emptying colon with
cathartics, laxatives and enemas thus even after
the procedure, stool is watery and copious, thus
is risk for dehydration
IRON RICH FOOD
· Meat
· Shellfish (oyster, clams, shrimp)
· Eggs, green leafy vegetables, dried fruits, brown rice,
oatmeal
· NO IRON: Bread, pudding, milk, yogurt, apple,
carrots, gelatin, never TEA (inhibits iron absorption)
LACTO-OVO VEGETARIAN; only meat is prohibited; yes
milk and its products and eggs
LACTO-VEGETARIAN; NO OVO (egg) and meat; yes to
milk and its derivatives
MACROBIOTIC; whole grains, vegges and fruits are
emphasized
FULL VEGETARIAN DIET; ISSUES ON ANEMIA
· No lacto (milk and its derivatives)
· No ovo (eggs)
· No meat
· Give cereals / bread to supplement iron & vit b12
and also Ca and Vit D supplementation
PKU
· Lacks enzyme needed for phenylalanine to be
CONVERTED to TYROSINE which results to
irreversible neurological damage s/t phenylalanine
accumulation thus LOW PHENYLALANINE is the diet
· HIGH in phenylalanine: MILK EGGS MEAT
· DIET RECOMMENDED: Fruits and vegetables
· Diet is like a vegan diet: No meat, lacto, and ovo
ORTHODOX JUDAISM
· No combination of dairy + meat: There must be a 3hr interval
· No pork, shellfish and fish w/o scales
DIARRHEA
· REGULAR diet, not BRAT
· No sugar solution d/t low electrolyte content
TOXOPLASMOSIS
· UNWASHED VEGETABLES, RAW FISH/MEAT, COLD
CUTS, HOTDOGS (unless steamed hot) in
immunocompromised and pregnancy is a RED FLAG
d/t TOXOPLASMOSIS
· Another to be avoided is COLD DELI MEATS d/t risk
for LISTERIOSIS during PREGNANCY
· No LIVER in pregnancy d/t risk for
HYPERVITAMINOSIS (A) which is teratogenic
MILK and ICE CREAM are rich in lactose; AGED CHEESE
AND YOGURTS have no lactose; Lactase deficiency is not
an allergy
BARIATRIC SURGERY
· Same as DUMPING diet
· High in FAT: Milk, cream soup, cooked cereals
· Low in CHO: Sugar free drinks
· High in CHON: Sugar free protein shake
· High in Fiber
·
§
-
-
-
-
-
-
-
-
DEMENTIA NUTRITION
-
EARLY: Eats but forgets that she ate
§ May ask for another round of food because of
forgetting that he/she already ate: SFF with low
calorie snacks
· MIDDLE: Did not eat because no hunger sensation
· LATE: Does not know how to eat
DIET is NOT RESTRICTED to IBS!!!! To prevent
malnutrition brought about by frequent diarrhea
ULCERATIVE COLITIS
· Concept: Diarrhea: rest the bowel by eating a low
residue (low fiber) diet and high calorie and CHON
for healing
· Easily digested foods: rice, pasta, cooked veggies,
canned fruits, tender meats
· Avoided: Raw fruits, vegetables, whole grains, highly
seasoned foods, fried and alcohol
WHERE FEVER IS A PRIORITY
1.
-
2.
3.
4.
SEPTIC ARTHRITIS is a PRIORITY as it is prone to develop
necrosis d/t infection which can also result to death and
joint destruction.
SSSX is FEVER with limited ROM and pain; has higher
priority than bronchitis who presents with audible
congestion and mucus producing cough as these are
expected with them.
This is different from fever post spinal fusion surgery
which indicates osteomyelitis which is not a priority over
airway cases.
NEONATE (not infant)
SEPSIS NEONATORUM
INABILITY TO FEED, GRUNTING, LETHARGY in INFANTS
ARE ALWAYS A MEDICAL EMERGENCY
FEVER with refusal to feed, increased sleepiness,
irritability may indicate sepsis neonatorum
This is a priority than URTI, bubble soap ingestion, or a
hydrocele which resolves on the 1st year of the infant
Before a surgery
SIRS:
Fever
or
hypothermia,
tachycardia,
leukocytosis/leukopenia, tachypnea leading to LOW CO2;
FEVER with SHOCK signs could indicate septic shock or
SIRS
MADULID, 2020
1.
-
ABDOMINAL PAIN RADIATING TO THE BACK ; Acute
pancreatitis or Abdominal aortic aneurysm. Higher priority
than Back pain and fever post spinal fusion which indicates
Osteomyelitis
Bruit indicates blood flow in the aneurysm; auscultated
over epigastric or periumbilical area slightly on the left of
the midline
TOF occurs during stress, painful procedures, upon waking up,
hunger, crying, feeding; anything that demands oxygen
MGT
- Pacifier use for calming
- Swaddling
- Knee chest
- UNINTERRUPTED sleep; frequent turning while sleeping is
not recommended
ISSUES ON TOF
- One of the most dreaded complication is stroke
development r/t polycythemia s/t chronic hypoxia
- EXPECTED: Systolic ejection murmur, poor weight gain,
fatigue during feeding d/t frustration of DOB during
feeding
MURMURS:
- PDA: Machine like murmur; dias and sys
- VSD: Harsh systolic
- Semilunar valves stenosis: Systolic ejection murmur
- AV Valves stenosis + Semilunar regurgitation: Diastolic
murmur
SILENCE after wheezing in a client with asthma is ALWAYS an
emergency
- CHF who has headache and fatigue is normal d/t dilutional
hyponatremia. What is emergency is if Na goes to <120
d/t risk for seizures
OSTEOGENESIS IMPERFECTA
- D/t impaired synthesis of collagen causing frail bones and
no bone flexibility
- Check BP manually for more control on pressure
- LIFT via back or buttocks and NEVER in legs, ribcage,
ankles or under arm
- Reposition frequently and pad child to decrease the
pressure over bony prominences by reducing contact
time; TOF sleep is uninterrupted and repositioning is
avoided
EMERGENCIES
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
DOB/Crackles on acute pancreatitis; signifies ARDS
development
REBOUND TENDERNESS / ABDOMINAL RIGIDITY
SUDDEN CRUSHING TEARING BACK PAIN from UPPER TO
LOWER BACK; Descending aortic dissection; PRIORITYControl BP
THROBBING HEADACHE RATED 10/10
LEFT SHOULDER/JAW PAIN RADIATING TO ARM; MI
AIRWAY (Life threatening) is a HIGHER PRIORITY than a
client with COMPARTMENT SYNDROME (Loss of a limb)
SUDDEN increase of pain in a client with sickle crisis, but a
client with life threatening issue or loss of a limb would be
prioritized first
FEVER >38 to a NEONATE which may indicate bacteremia
CONSTIPATION / ATELECTASIS / PNM may be expected
after surgery and is not immediate life threatening unlike
N/V post op which could result to ASPIRATION d/t ALOC
or even EVISCERATION with clients who has large incisions
PETECHIAE
INCREASED ICP
CARDIAC TAMPONADE
PNEUMOTHORAX as evidenced by TRACHEAL DEVIATION
ALOC with N/V- Aspiration to airway compromise
BRIGHT RED DRAINAGE or BLOOD CLOTS or FEVER WITH
CHILLS are NEVER normal to any condition.
Normal is a BLOOD-TINGED or PINKISH color; Bright red would
be an indication of excessive bleeding
- Post amputation
· Wash daily with soap and warm water
· Avoid sitting in a chair for >1hr to prevent hip flexion
contractures
· No irritants (alcohol, lotion, powder) to residual limb
unless prescribed
- Cystoscopy
MADULID, 2020
-
CTT
Prostatectomy
CYSTOSCOPY
- In addition to pink tinged, other expected findings include
frequency and dysuria in 2 days (d/t urethral irritation)
- ABNORMAL: In addition to bright red urine, fever, chills,
oliguria and BLOOD CLOTS
- If with blood clots, CBI will be done
PROSTATECTOMY/TURP with CBI
- Post TURP: Indwelling catheter with expected PAINFUL
bladder spasm tx with antispasmodics (oxybutynin); NO
URINATION around the catheter
- Post TURP that is on CBI: PAIN should not be present as
the CBI already prevents obstruction in the urine outflow
by removing blood clots
- SMALL BLOOD CLOTS are NORMAL up to 3 days
- Dysuria is infection sign together with fever;
- TURP has CBI, Prostatectomy has not
- Foley output should be more than input d/t addition of
renal output urine in CBI
- INDICATION of therapy (CBI) effectiveness: light pink
color output and NOT absence bladder spasm
- NO any rectal insertion to prevent stress on suture lines
and no straining
- BLADDER PAIN on CBI: Obstruction in the foley catheter
by blood and mucus caused by insufficient rate. If
obstructed, manual irrigation with saline is done until
there are no clots or urine is pinkish
JACKSON PRATT DRAIN
- 100 mL/hr during the 1st 24 hours
- Drainage in JP Drain is not affected by position, as what it
affects is negative pressure and not gravity
NSAIDs & Acetaminophen can be given to children. ASPIRIN is
the one’s that is contraindicated d/t Reye’s syndrome which
primarily attacks the liver which may cause hepatic
encephalopathy.
- Cool, damp compress and NOT TEPID WATER nor ICE
BAGS is used for fever d/t increased risk for shivering
SHARPS container should not be overfilled and must be
replaced on a regular basis. This is a priority over urine 24h
discarded and a clergy to administer last ritual rites
ESWL/LASER LITHOTRIPSY
- Post: Expected dysuria and hematuria (bright red) d/t
elimination of stone upon urination ; should be changed
to pink tinged for several hours
- Fever and chills not normal
- OPD under GA
- Ureteral stents are placed during procedure to 2 weeks
after procedure to facilitate passage of stone.
POSTOP NAUSEA IS NORMAL but VOMITING IS A PRIORITY
since these clients are at risk for ASPIRATION d/t vomiting +
ALOC.
OBSTRUCTIVE SLEEP APNEA
- Is an airway emergency as it is a partial or complete airway
obstruction
MADULID, 2020
-
May be caused by sedatives d/t relaxation of muscle tone
which increases airway closure further
- THUS a client with OSA who receives NARCOTICS for pain
killers such as in the case of fractured tibia MUST BE
ASSESSED FIRST after ANALGESIC administration
- This client must be assess first than a client with sickle cell
anemia, PNM with pleuritic chest pain, and a 1d p-op
bowel resection reporting pain at incision site
DETERIORATING GCS is a priority as the need for intubation
increases as the GCS deteriorates; When you are 8, intub8!
- Higher priority than an ALS experiencing dysarthria as this
is normal, postictal seizure whose drowsy and confused as
the nurse can instruct the family members to keep the
client safe, or to a client with migraine 10/10 pain and
nausea as this is an expected finding
-
BASILLAR FRACTURE
- CSF confirms skull fracture which makes the client at risk
for infection
- Clear drainage à test for glucose; however glucose
testing is unreliable if it is blood tinged as blood also
contains glucose, thus halo test should be performed by
placing the blood tinged fluid in a piece of gauze
- Once CSF leak is confirmed: NO: NGT/OGT (must be
guided by visualization), Nose packing
SITUATIONS based on priorities
1. The Client with GI bleed receiving PRBC
· NOTE: A client who is already 1hr receiving BT is NOT
A PRIORITY over those who needs intervention
because the critical period in monitoring BT is the
first 15 minutes
· However, if time is not stated, then a client receiving
blood transfusion is a priority
2. Client with CKD scheduled for dialysis in 30 minutes
- Baseline assessment before dialysis is initiated.
- The nurse should then prepare the client by making
sure the client eats breakfast, administering
prescribed morning medications that are not dialyzed
out, and holding those that are dialyzed out.
- Elevated creatinine level (eg, normal 0.6-1.3 mg/dL
[53-115 µmol/L]) is an expected finding
3. Client with ulcerative colitis (UC) with elevated
temperature and abdominal pain
- UC is an inflammatory bowel disease; fever and
lower-quadrant abdominal cramping are expected
findings.
- After assessing the client, the nurse will administer an
analgesic and an antipyretic as prescribed.
4. Client with history of atrial fibrillation, prescribed warfarin
(Coumadin) – the client is on telemetry; in most facilities,
if dysrhythmias occur, the monitor technician/nurse will
notify the primary care nurse immediately. The goal INR
HYPERTENSIVE ENCEPHALOPATHY
- A medical emergency caused by hypertension which
creates cerebral edema and increased ICP
- Common to people with chronic HTN such as those with
CKD,
- SSSX: HTN + Severe HA, Visual impairment, epistaxis, N/V,
This may precipitate life threatening complications such as
MI, Stroke, AKI
LEFT TO RIGHT SHUNTING
- Causes increased BF to lungs causing pulmonary
congestion with compensatory mechanisms such as
sympathetic stimulation
- SNS: Tachy, diaphoresis during exertion or feeding but
NOT inability to feed nor DOB while eating, poor weight
gain
COMMON CONCEPTS IN PRIORITIZATION
1. An expected finding is not a priority
2. Loss of a LIFE is more important than a loss of a LIMB
An AIRWAY case is not a PRIORITY if it is not life threatening
or if it is expected
MADULID, 2020
is 2.0 to 3.0 for atrial fibrillation. An INR of 3.2 is expected
when adjusting the warfarin dose.
PRINCIPLES OF ASSIGNMENT
- Same CA is to same CA: Same MOT doesn’t mean there
would be no co-infection
- POSTOP can never be assigned to a semi private room
with a potential to infect that postop patient d/t risk for
infection;
- POSTOP patients are NOT INFECTIOUS but AT RISK FOR
INFECTION thus must be paired for clients who are not at
risk for communicating infection; They can be roomed in
on patients at risk for BLEEDING and it is not an issue as
long as the client is not infectious
- SICKLE CELL ANEMIA is at risk for infection d/t SPLEEN
affectation
- HEART SURGERIES post op should have NO CHEST PAIN
AT ALL while at rest; Chest pain indicates ischemia
ON DRUG ADMINISTRATION
- FILTER needle is inserted first to filter the ampule glass
and NOT the injection needle
- When a mentally competent questions the drug (“this is
the first time I saw this drug”), it is better to check for
prescription first
- Notifying an HCP is done when a child vomits after med
administration. Double dosing is not done as the child may
already have been absorbed the medication taken
- PREFILLED syringes often have bubbles inside that needs
NOT to be ejected as this ensures delivery of the entire
dose.
- SQ is done and NOT IM to patients at risk for bleeding.
- <3y/o (toddler); VASTUS LATERALIS, SUPINE WITH KNEES
AND FEET RAISED with FIFTH FINGER FOR SUPPOSITORY
- >3y/o (preschool): Ventrogluteal, Sim’s with Index finger
CONCEPT: A client who is at risk for infection cannot be
roomed in with a client who has low immune system because
a client who is immunosuppressed might be having an
infection already which may possess a threat to a client who is
at risk for infection.
NO rooming in to immunocompromised and infectious clients
as these clients may harm or cause infection to another client
- Erythema on pin sites (might be an infection)
- Cellulitis/Osteomyelitis
- Post fasciotomy (kept open post op)
- POST RUPTURED appendix or 1d POST LAPCHOLE
awaiting for discharge
- Gastroenteritis (salmonella, rotavirus)
- HIV (especially if low CD4 count because patient may be
already infectious but asymptomatic d/t opportunistic
pathogens)
- On hemodialysis (Puncture site carries infection risk)
- DM with CKD d/t immunosuppression which also may
have been infected already
- Cystic fibrosis (RF PNM d/t secretions in lungs)
- Rheumatic fever
- Immunosuppression caused by lifetime steroids (on
transplant) can place a client on developing CANCER
EXAMPLES of CAN BE ROOMED IN
- On a cast/traction with no evidences of infection
- POST appendectomy
- With bleeding risk but with no infection risk
- Minimal change nephrotic syndrome
- Dementia with external urinary condom catheter
A client post OPEN gastric bypass who has LARGE INCISION is
at greatest risk for DEHISCENCE AND EVISCERATION especially
if the client is vomiting or coughing post operatively as these
increases intraabdominal pressure thus is PRIORITY over a
client threatening to DAMA, 15minutes after morphine is
administered (morphine/hydromorphone should be
reassessed 30 minutes after giving)
HEIMLICH MANEUVER
- Toddlers are treated same way with adults
- Upward thrusts with a fist to upper abdomen just
beneath the rib cage; MOA is that the diaphragm
forcefully expels air carrying the object with it
- Client is asked to cough the object first
- Warning signs include stridor, inability to speak, weak
cough, cyanosis
MADULID, 2020
AED
- <8; Front and back of the chest
- >8; Usual placement
WITHDRAW air from the vial first before injecting a DILUENT;
Amount to be withdrawn is the same amount as the diluent;
After diluting, roll into hands, NOT SHAKE, then get the
medication using a STERILE SYRINGE
- A prescription of DISCONTINUE INFUSION OF A DRUG
SUCH AS NSS means that it can be changed to saline/hep
lock but NEVER TO A KVO. KVO needs a prescription.
- Head is TILTED to the AFFECTED ear while on EAR
IRRIGATION with the tip directed toward the top of the
ear canal; Avoid occluding the canal to prevent increased
pressure which might lead to tympanic membrane rupture
EYE IRRIGATION
STEAMING foods is a way of cooking or removing pathogens
thus is OK as a neutropenic diet
Postoperative cognitive dysfunction (POCD).
- Memory impairment and problems with concentration,
language comprehension, and social integration.
- Some clients may cry easily or become teary.
- Increases with advanced age and in clients with
preexisting cognitive deficits, longer operative times,
intraoperative
complications,
and
postsurgical
infections.
- POCD can occur days to weeks following surgery.
POSITION
- 15-30; LF
MADULID, 2020
-
30-45; SF
45-60; F
90: HF
POSITION requiring 90 degrees (High Fowler’s)
- NGT Insertion
- Most respiratory cases except air embolism (Left
trendelenburg), ARDS (prone), COPD, epiglottitis, asthma
(Tripod position) POSITION requiring 60 degrees max
(Fowler’s)
- Prevent dislocation
- Hip arthroplasty
POSITION requiring 30-45 degrees (Semi Fowler’s)
- JVD measurement
- NGT Feeding
POSITION requiring 30 degrees max (Low Fowler’s)
- For better circulation by increasing venous return
- Inc. ICP
- Cardiac catheterization or any procedures requiring
puncture in the femoral site (take note of any back pain
post op as this may indicate hemorrhage from puncture
site)
- Traction
POSITION; 20 degrees (decreased abdominal pressure)
- Evisceration
ABDOMINAL BINDER causes increased intraabdominal
pressure thus is CI to GERD, increased ICP. However, it is
required to post op patients to reduce risk for DEHISCENCE by
providing hemostasis, incision support and to reduce stress
when coughing
-
DEHISCENCE/EVISCERATION occurs when there is lax of
abdominal support/muscles causing lack of adherence of
organs to each other and to the abdominal walls causing
organ protrusion. BINDER is used to strengthen its
adherence to each other
ORTHODOX JUDAISM
- KOSHER Diet
- NO Pork, fish w/o scales, shellfish
- SEPARATE Meat/poultry from dairy for at least 3 hours
such as low fat cheese or yogurt with roast beef
- APPROPRIATE: Hard boiled eggs and blueberries
CPR
- Chest compressions are stopped for 10 sec pulse check
ever 2 mins: 4 rounds of 30:2
- Compressions
· Below the nipple line (infants)
· Below the sternum (for adults)
· Above the sternum (for pregnant); Heart is displaced
on the LEFT
· 2 in. depth (adult)
· 1.5 in. (infants) or 1/3 of the chest
- Normal HR: 100bpm: CPR compressions: 100-120 CC/min
- Normal RR: 12: Breaths delivered: 10-12bpm or every 5-6
seconds; done only if the client has pulse but not
breathing
- Has no pulse, no breath à 30:2
NEWBORN RESUSCITATION
- PPV is done on <100 HR
- CPR + Intubation is done on <60 HR despite PPV
- Epi is done on <60 HR despite CPR
- 30:2 for 1 rescuer; 15:2 if 2 rescuer
MADULID, 2020
-
May adversely affect heart be increasing workload TOO
MUCH and is signed by tachycardia, dysrhythmias and
MI
GASTRIC LAVAGE
- Not done d/t many serious complications (aspiration,
gastric perforation)
- DECOMPRESSION is removal of gastric contents
- LAVAGE is introduction of fluids to rinse stomach
contents which are removed
- DONE if overdose is LETHAL and if GL can be initiated
within 1 HOUR of overdose
- Intubation and suctioning eq. should be ALWAYS
available at the bedside
- LARGE bore tube is used for the introduction of large
amounts of volume
PEDIATRIC CARDIAC ARREST
- Rescue breaths for 2 mins for child with pulse but
without breath. However, if signs and symptoms persist
such as evidences of inadequate skin perfusion (pallor)
and HR is below 60, then immediately initiate chest
compressions because the client is not perfusing the
organs adequately
CARDIAC ARREST
- Neurologic injury as one of the effects.
- THERAPEUTIC HYPOTHERMIA improves clients post
cardiac arrest WITHIN 6hrs of arrest
- Cooling blankets, ice in groin axillae and neck, cold IV
fluids
NEAR DROWNING
- PRIORITY: AIRWAY d/t aspiration of water; Managed by
MECH VENT ET
- 2ND PRIORITY: CARDIO: Irritable heart d/t VERY COLD
heart causing VFIB; Managed by STOPPING STIMULI
SUCH AS NO TURNING, and/or handling the client very
carefully
- BT is not really needed
URINARY RETENTION POST OP
- Common d/t analgesics/anesthesia given
- Walk the patient or let him stand, most especially a male
because the usual urinating position is standing
- Bladder scan use to determine residual urine
- Intermittent and NOT indwelling catheter is used after
knowing residual urine (>300-400 mL) through the
bladder scan
- HOWEVER: Urinary retention present in a client already
catheterized, IRRIGATION of catheter is done and NOT
bladder scan
- LEAKAGE OF URINE from INSERTION SITE of catheter;
may be due to obstruction. Kinks, bladder spasms;
DOPAMINE used in critical care setting
ACTIVATED CHARCOAL
- Standard TX for overdose
- Does not work in: ALIng: Alcohol, Iron, Lithium
RAPID RESPONSE TEAM
- VS:
· BP: <90
· HR: >130 or <40
· RR: >28 or <8
· O2: <90 despite O2
· UO <50mL/4h
· ALOC
- PAIN even 10/10 DOES NOT WARRANT RRT
- A low result but is STABLE overtime does not need an
RRT such as consistent GCS 9 and Low VS throughout the
shift; GCS that is GCS 10 to 9 in 1 hr warrants RRT
FROSTBITE
- CONCEPT: VASOCONSTRICTION to GANGRENE
- Appears mottled, blue, or waxy yellow skin. Deeper
frostbite may cause skin to appear white and hard and
unable to sense touch
- Immerse, preferably in a whirlpool. NOT in higher
temperatures d/t intensify pain even more
- Avoid heavy blankets or clothing to prevent tissue
sloughing; Remove clothing (yes, even cold, to prevent
constriction)
- Elevate after rewarming to reduce edema d/t
VASODILATION of rewarming
- Keep wounds open, allow them to dry before
applying loose, non-adherent, sterile dressings;
- CONCEPT: NO CONSTRICTING CLOTHING / JEWELRIES
- Monitor for signs of compartment syndrome.
- CAUSE: VASOCONSTRICTION; TX: VASODILATION
BLOODY DISCHARGE of PREGNANCY
- Normal at times of intercourse d/t sensitive cervix
- Normal at near delivery or at 39th week
MADULID, 2020
HERPES
- Painful, multiple small vesicular lesions
- NO SEX during active lesions even WITH CONDOMS and
during dormant lesions, SEX WITH CONDOM is preferred
- Itchy: oatmeal baths, diphenhydramine cream; Also used
for Chickenpox but NOT in measles
- Lesions are COMMUNICABLE
HERPES ON PREGNANCY
- Painful genital lesions
- Transmitted to infant in utero
(congenital HSV), perinatally, or postnatally as a result of
direct contact with virus particles shed from the infected
vulva, vagina, cervix, or perineum.
- Neonatal HSV infection has serious morbidity (eg,
permanent neurologic sequelae) and mortality.
- Immediate antiviral therapy (eg, acyclovir) should be
initiated to treat the active infection.
- Vaginal birth is not recommended in the presence
of active lesions; cesarean birth helps reduce the risk of
transmission to the newborn
HERPES ZOSTER
- Itchy, painful, unilateral, linear fluid filled blisters. VZV
reactivates in immunocompromised states, aging since it
stays in sensory nerves dormant after CP infestation
NITRAZINE PAPER TEST
- BLUE if alkaline and signals amniotic fluid which signals
(+) ROM
- May be false POSITIVE d/t alkalinity of BLOOD / SEMEN
thus intercourse must be validated
ZIKA VIRUS
- NO TRAVELLING AT ALL to zika infected places because
mosquito bite is not the only MOT
- IF LIVING IN ZIKA INFECTED AREA, Barrier prec, mosquito
prec, routine Zika testing
GDM- occurs at 24-28 weeks AOG
- Screening test: 1-hour GCT
· Performed any time of day and does not require
fasting
· Draw blood 1hr after 50g glucose ingestion
· <140 mg/dL (7.8 mmol/L; negative for GDM
· ≥140 mg/dL (7.8 mmol/L); Challenge it by 2- or 3hour GTT
- HOWEVER, in GTTTTT , fasting and hourly blood samples
are required
UTZ is performed at 5 mos
GDM screening is done at 6-7mos.
HYPOTENSION brought about by epidural
anesthesia/analgesics must be treated immediately by IV
Fluid bolus. Lightheadedness after epidural anesthesia must
be first assessed to confirm hypotension
LOCHIA
TEENAGE PREGNANCY
- ISSUES to be discussed by the NURSE: Family/social
support, sexual abuse
- NOT to be addressed: Adoption planning and Education
planning or planning for the future
- REPORTABLE CASES: STIs even if client does not want, a
suspicion of abuse by the RN even if HCP disagrees or the
client denies it
-
INCREASES after BF & 7-10d PP d/t sloughing off of
placental site and standing after lying down
- EARLY PP Hemorrhage: <24h
- LATE PP hemorrhage: >24h to 6 wks PP
- BRIGHT RED BLEEDING during defecation is NORMAL d/t
hemorrhoids during birth/pregnancy
CARPAL TUNNEL IN PREGNANCY
- Compression d/t fluid retention, normal.
- Exacerbated during sleep d/t prolonged/unintentional
wrist flexion. MGT: IMMOBILIZE!
MADULID, 2020
UTERINE ATONY
BISHOP SCORING; LABOR INDUCTION
- Different from BIOPHYSICAL SCORING; BISHOP SCORING
determines cervix characteristics (station, effacement,
dilation etc.) while Biophysical scoring determines fetus’
adaptation INTRAUTERINELY and APGAR determines
fetal’s adaptation EXTRAUTERINELY
- Determines success of labor induction and cervical
favorability during delivery
- >6-8cm is good favorability
- NONSTRESS test indicates fetal oxygenation or fetal
adaptation to labor but does not determine labor
progress
NARCOTICS DURING PREGNANCY
- Administered at PEAK of contraction during which the
blood vessels constrict thereby reducing blood flow going
to the fetus, thus amount of narcotics to fetus also
decreases causing: reduced fetal sedation, compromise
and respiratory depression and more drug is absorbed
and remains in maternal blood vessels
- Can be given to prolonged latent phase to provide pain
relief and promote rest during prolonged labor
-
UTERUS IN MIDLINE BUT BOGGY- UTERINE ATONY:
FUNDAL MASSAGE
UTERUS DISPLACED UPWARD TO THE RIGHT OR LEFT
AND BOGGY: Palpate bladder then let the client void
METHYLERGONOVINE (Methergine)
- Produces sustained contractions thus is CI to clients with
high blood pressure
MISOPROSTOL
- Contracts uterine muscle rather than by vasoconstriction
thus is safe for high BP
OXYTOCIN
- High alert medication mostly used for labor
augmentation
- Must be administered with infusion pump, decreasing
hypotension s/t rapid oxy bolus
- Has ADH effect thus water retention is possible, I&O is
monitored
- The basis of amount to be given is not cervical dilation as
it cannot be assessed continuously and varies among
clients
- Initiated at the lowest dose and titrated until the
therapeutic contractions are met (2-3 mins apart and
last for 90 seconds MAX);
OB UTERINE CONTRACTIONS
- MAXIMUM OF:
· 90 seconds duration
· 5 contractions in 10 minutes or every 2 minutes;
NOT every less than 2 minutes because it means
more frequent contractions
· 20 mmHg resting tone
· 80 mmHg intensity
· INTERVAL is the only one that DECREASES in true
labor; Intensity, frequency and duration INCREASES
BREASTFEEDING
- “Tummy to tummy” with mouth in front of nipple and
head aligned in body with mom’s supporting the head
- Feed 15-20 mins. per breast
MADULID, 2020
BREAST ENGORGEMENT/MASTITIS
FOR BREASTFEEDING CLIENTS:
- GOAL: EMPTY BREAST because inflammation occurred
d/t stagnant milk inside the breast;
- Continue BF, Warm compress and massage to empty
- Lose bra, not tight
- Manually express milk and massage
FOR NON-BREASTFEEDING CLIENT
- GOAL: Reduce milk production
- ICE and not heat application; promote constriction
- Chilled fresh cabbage
- Anti-inflamms
- Support bra / breast binder until milk flow is diminished
***MILK for >1yr should be whole and not low fat milk
PRETERM LABOR
- Steroids
- ATB
- Tocolytics and not uterotonics
- C&S for GAHBS infection
- IV Mag sulfate for fetal brain protection
- NO AROM since goal is to prolong labor for steroids to
take effect. AROM is required only to TERM clients
ADOPTION
- Encourage mother to care for the baby
- Tell other staff about adoption to prevent relinquish
remarks
PACIFIER USE
- GOOD to prevent SIDS and for calming effect for TOF
- BAD because it can cause OM
- Done best only ONCE BREASTFEEDING is well established
at age 1 month
- SIDS PREVENTION: Supine until at the age of 4 months
where they can already roll over.
PHYSIOLOGIC WEIGHT LOSS
- No more than 7% at 3-4d; By 1st to 2nd week, return to
birth weight is expected.
WEIGHT GAIN
- 5-7 oz/wk. for the first 6 months of an infant
- 3-5 oz./wk from age 6-12 mos.
PHYSIOLOGIC CHARACTERISTICS OF NEWBORN
- WHITE pearls on gums (Epstein pearls) and margins
- WHITE spots on the nose (milia)
-
Peeling of skin at 3d of life; Cracked skin at birth may
indicate post maturity
CASE MANAGERS
- Focus on health services and advocates for the client and
does not provide direct client care.
- Coordinates between HCPs
- Makes referral and arranges client discharge
- NOT IN FOCUS: Client care, medication reconciliation,
and does not visit client but visit the nursing department
BREASTFEEDING ABSOLUTE CONTRAINDICATIONS
- Take a bath BEFORE IM; Mother’s blood is in the baby’s
skin, making a portal of entry by giving IM makes blood
from the mother go into the baby’s circulation
- Hep B can breastfeed
MADULID, 2020
-
-
Clients who are at greatest risk for safety are placed
NEAR the nurse’s station
· Wandering (dementia) and diarrhea for fluid and
electrolyte imbalances; BRIGHT room d/t confusion
· Depressed clients at risk for suicide
· BRIGHT room is also recommended for those
experiencing hallucinations such as alcohol
withdrawal to minimize shadows causing illusion
§ A new-onset hallucination to a mentally-stable
client (no psych illness) is a priority since it may
indicate alcohol or narcotic/opioid withdrawal,
thus making the client at risk for injury. This
client is a priority over a client experiencing
nausea post ex-lap, a client with DM with foot
ulcer experiencing paresthesia (normal d/t
peripheral neuropathy), and a resting tremor
with a parkinson’s client; NOTE: A client with
DM who does not have foot ulcer and
experiencing paresthesia may be prioritized
since it may indicate a developing foot ulcer.
Clients who requires calm environment for minimized
stimulation is placed FARTHEST of the station with DARK
or MINIMAL LIGHTING
· Manic clients
· Autism/ADHD
· On drug withdrawal
ALCOHOL INTOXICATION
- Causes decrease in BG (hypoglycemia) especially with
DM pts.
- Confusion during alcohol intoxication may be due to
hypoglycemia or acute intoxication thus BG must be
monitored FIRST rather than assessing for withdrawal
signs which occurs 8hrs after intoxication
- CODEPENDENT persons are NOT THE CLIENT but the
ones that let the codependent (alcoholics) behaviors
happen
SUICIDE
- Any clients who say that they do not know or sure if they
are suicidal is a red flag and should be considered
suicidal
DELUSIONAL ANXIETY
- A delusional client showing signs and symptoms of
anxiety such as finding a headband will NEVER STOP or
the anxiety will NOT BE CONTROLLED until the nurse
addresses the problem such as saying “going back to the
room and looking for the headband again”; This
decreases the anxiety and thus the nurse can refocus the
client to reality based activity again. NOTE: This is for the
reason that they stand up for what they believe is right
even in reality, it is not. Thus if they are anxious, nurse
must not challenge or say that there is really no
headband as the anxiety will intensify as they believe
that a headband really is missing. Go back to the room
where there is much more security to the client.
- Telling that there is no headband or diversing the
conversation to other topics will more likely INCREASE
THE CLIENT’S ANXIETY
- EXPLORE CONTENT of delusion but NOT THE MEANING
BEHIND THE DELUSION
· “What do you see at the door” in a client who stares
at the door with grimace;
· “What trouble are you thinking?” rather than
signaling assistance from other staff to a client who
released restraint without help and told the nurse
that there can be trouble now.
FLATTERY: pitting staff members against each other; a way of
manipulation
MADULID, 2020
RESTRAINTS
- Side lying or semi fowler’s for aspiration precaution
- Never in square knot
- Release every 2hrs for skin assessment and ROM
exercises
- Offer fluids and nutrition, toilet every 2 hours
- Do hourly neurovascular checks
- Assess hourly for the newwd for restraints
- There is no such thing as trial discontinuation
-
Grave disability (ie, is unable to adequately care for basic
needs [food, clothing, shelter, medical care, personal
safety]) as a result of a mental illness
NOT REQUIRING INVOLUNTARY ADMISSION
- Sleeping on the floor may be outside the client's normal
behavior but does not meet the criteria for involuntary
admission
- Possession of marijuana
- The diagnosis of a mental illness alone does not justify
the need for involuntary commitment
- Diagnosis of a life threatening condition such as MI
PANIC ATTACKS
- PRIORITY is SAFETY and not the hyperventilation; Thus
remaining in the room with the client is a priority rather
than encouraging DBE
- Exploring reasons for anxiety is appropriate only AFTER
the attack
CATATONIA
- MUTE and RIGID but may show BRIEF hyperactivity
- NUTRITION/FLUID is more important than skin integrity
as MONITORING VS to a client receiving amphetamines
rather than attention span assessment.
PTSD
- RE-EXPERIENCING of events such as nightmares are NOT
HALLUCINATIONS, PARANOIA, LETHARGY, DELUSIONS,
OR BEING BIPOLAR
- PRIORITY: It is highly encouraged for the client to talk
about the trauma because they want to vent it out to
someone
- 3 CATEGORIES
1. FLASHBACKS: nightmares, physical sssx (GI Distress,
tachycardia, diaphoresis)
2. SADNESS: d/t avoidance of triggers that the client
now feels detached, emotionally numb, loss of
interest in life, no goals, amnesia about the event;
NOT LETHARGIC/APATHETIC
3. ANXIETY: insomnia, irritability, anger/fear,
hypervigilance, exaggerated startle response
INVOLUNTARY ADMISSION/DAMA NOT ALLOWED
-
MDA:
Minor with grave disease
Danger to self/others
ALOC
Abuse
Alcohol
AGORAPHOBIA
- Open space phobia; has a trouble escaping or getting
help when panic attacks.
- GOAL: Avoid panic
- Outside the home alone
- In a crowd or standing in a line
- Traveling via any transport means
- On a bridge
- Open/ Enclosed spaces (theaters)
TRANSGENDER
- May identify as male, female, neither or both
- PRIORITY is to ask what is the preferred gender and not
what the client wants for him to be addresses
(he/she/both/neither, name preference)
ACUTE STRESS DISORDER
- Following a traumatic event
- Assess for ineffective coping such as use of alcohol and
drugs
- Verbalization of the experience is encouraged.
AGITATION ON DELIRIUM
- PRIORITY is SAFETY; Another way to state safety
precaution is ONE ON ONE SUPERVISION. Even in a
situation that states a client that it admitted with UTI and
experienced delirium, the cause is UTI thus delirium
cause will not be reversed by taking increasing OFI,
rather SAFETY is still a priority
- OTHER INTERVENTIONS:
· CONFUSION is present in delirium, thus a dark room
will cause more confusion; INTERVENTION: WELL LIT
· LIGHTS are turned off to patients who needs
reduced stimulation such as those WITHDRAWING
from alcohol or drugs
· BED is LOWERED with side rails NOT UP because a
client with safety precautions will climb the side rails
causing more injury
- New onset delirium is a PRIORITY since it is an indication
of worsening condition (infection, electrolyte imbalance,
MADULID, 2020
drug interaction); It takes over GBS absent DTRs at knees
and drooling of a client with PD
- Delirium is also a priority since it is a threat to safety
Autonomic dysreflexia is not given analgesics because cause
of pain is DYS (Distended bladder, Ympacted stool, Skin
pressure)
-
ALZHEIMER’S DISEASE; DEMENTIA
- Affected: communication skills, cognition, ADLs
- Redirection/distraction (going for a walk) is used to
manage agitation
- Simple words (yes/no) or close ended questions are used
- No rationalization with the client
- Use visual cues when giving directions
- Step by step by manner to make complex things easier
- Limit number of choices
- Reality orientation causes more anxiety
- Validation therapy is preferred (“you are safe…”)
- ALL MEDS MUST BE OUT OF CLIENT’S REACH d/t
confusion of time
AUTISM
- 2 PROBLEMS:
· SOCIAL INTERACTION & COMMUNICATION
· RESTRICTED AND REPETITIVE ACTIVITIES
- PRIORITY assessments to possible ASD is social &
communication skills (how many words are produced)
- Hypersensitive to external stimuli (touch, smell, light) thus
a CALMING environment is a priority, one of which is that
away from the nurses’ station/playroom
- Eye contact, move slowly, minimal light
- It is not advisable to co-room with an ASD
- Written schedule of ADLs helps as it fosters consistency
- Bring favorite toys and do not offer variety of toys
- LIMIT VISITORS as the social interaction is impaired with
these types of clients and this is to avoid overstimulation
and facilitates trusting relationship with caregiver
ADHD
- INATTENTIVE TYPE: No attention on tasks or play, no
organization of tasks and are easily distracted
- Being INATTENTIVE, client will NOT LISTEN to verbal
instructions as they dislike mental focusing/attention
thus a written list of schedule is more preferred as it
helps client what will happen at any given time.
- HYPERACTIVITY: some become aggressive and has
difficulty controlling anger especially when frustrated
· Do DBE or blowing up a balloon
· Remove from the source of anger
-
· Rewards
· Acknowledgement of controlling anger is hard
STRUCTURED ENVIRONMENT is the PRIORITY next to
SAFETY as this provides CONSISTENT routine, resulting
into POSITIVE SELF ESTEEM AND SENSE OF SELF.
VISITORS are NOT PROHIBITED but LIMITED since these
clients need interaction with minimal stimulation thus
placed far in the nurse’s station
OTHER PROBLEMS
· IMPAIRED social interaction resulting to POOR SELF
ESTEEM, REJECTION BY PEER which also results to
DEPRESSION/ANXIETY/ACADEMIC WORK FAILURE,
SUBSTANCE ABUSE
· LEARNING DISABILITY but NOT CONFUSION/ALOC
· EMOTIONALLY IMMATURE but NOT delayed
physical growth
RITALIN is NOT used as PRN basis
DO NOT isolate the child or do time out because it is
punitive and not therapeutic, rather remove the client
from the source of anger
ACTIVE FRIENDLINESS
- To withdrawn clients
- CONCEPT: BRIEF, FREQUENT VISITS, NON-DEMANDING
- Stay with the client even if the client says for you to go
out; Just say that you will stay with him/her for a while
- If the client GOES OUT when you sit, allow the client to
do so as its anxiety will shoot up if you follow
SITUATION: The nurse makes a home visit to a client with
Alzheimer disease. While reviewing the client's home care
needs, the client's spouse states, "It's hard to see my spouse
worsen each day. I'm not sure I can keep doing this alone
anymore." Which response by the nurse is best?
- “Tell me about the care you provide in a typical day and
its challenges” RATHER THAN “Perhaps finding a
caregiver to care for your spouse at night might be
helpful”
- This is for the nurse to know and understand the client
more by verbalization
SITUATION: A client with Alzheimer disease is admitted to the
hospital for a urinary tract infection. The daughter says to the
nurse, "I really want to take my mother home and continue
care there. However, lately, my mother has become agitated
and restless at night. I'm awake most of the night, feel
exhausted, and do not know what to do." What is
the best response by the nurse?
- “Our social worker can discuss long term care options
with you” RATHER than “We can ask HCP for meds that
will help your mother sleep” NOR “Your mother can be
cared for in a nursing home”
- Antipsychotics are given cautiously in elderly with
dementia
- Caregiver is already experiencing burnout and a social
worker can provide resources and services for assistance
and support
MADULID, 2020
ACUTE MANIC
- PRIORITY: SAFETY then NUTRITION
- REDUCE STIMULI; Quiet, calm environment, far to
station, low lighting
- One on one rather than group
- Physical activities
1.3 is still a normal Creatinine
- Report an INR of 2.5 because it means that the client is on
warfarin and is contraindicated to patients undergoing
surgery
- Calorie restricted diet is not a CI to oral surgery
- INR with no warfarin use is only 0.75 to 1.3
·
If stoma is immature, obturator cannot be inserted
thus bag valve mask over nose/mouth or covering
stoma with occlusive dressing may be used
PICC
- It is important to measure length of PICC. Change in
length may indicate migration of catheter tip from
original position
PICC
- For long term use
- “Scrub the hub” for 10-15 seconds
SOME FUNDA CONCEPTS
- DRESSING
· REMOVAL is UNSTERILE
· APPLICATION is STERILE
- 1 tourniquet is to 1 patient
- IV bottle is only up to 24 hours max
- IV line is up to 72 hours max
- CVC dressing is changed every 7 DAYS
· Removed immediately once infection is confirmed
- SUPINE during CVC dressing change; Valsalva, head
turned away, sterile technique
- INCISIONS are cleaned by mild soaps + water except
those who underwent circumcision
· CIRCUMCISION
§ Done near discharge to ensure newborn is
stable
§ Apply petroleum jelly to glans penis at diaper
changes
§ Site heals within 7-10days
§ Yellow exudate is normal and is not removed
forcefully and disappears in 3rd day
§ No alcohol-based wipes and soap
-
-
CVC pulled out:
1. CLAMP CATHETER TUBING
2. LEFT TRENDELENBURG
3. Administering oxygen because O2 is only PRN
CTT pulled out: IMMERSE in 250 mL of sterile
water/saline
Tracheostomy tube pulled out: Obturator insertion by
opening airway via curved hemostat; NOT O2 since O2
will just escape without the tub
CATHETERIZATION
- IRRIGATION and PERICARE- ANTISEPTIC /
ANTIMICROBIALS are NOT RECOMMENDED/USED;
- Soap and water only is used in pericare
- Labia is cleaned first, urethra is last (from outer to inner)
MADULID, 2020
-
NO VENTRAL ASPECT as it is near nerves and so is more
painful; There is also at risk for arterial puncture at
ventral aspect of wrist
Do not vigorously shake the blood to anticoagulant in the
chest tube; Gently invert it 5-10 times
Never recap a stylet
ANTIBACTERIAL SOAPS
- Dries the skin causing loss of moisture and increases pH
of skin resulting to worsening of acne
- Also reduces the presence of normal flora and causes
irritation of urethra thus worsening UTIs, so as with
scented/commercially prepared soaps
FEMININE PERINEAL PRODUCTS; Deodorants, powder, sprays
- Avoided as it alters vaginal pH, increasing infection risk
SPERMICIDAL CONTRACEPTIVE JELLY
- Suppress vaginal flora production
- Diaphragm use is discontinued when taking antibiotics
for UTI as it increases pressure on urethra and bladder,
causing incomplete bladder emptying
INFECTIOUS/SAFETY
- PAPER/PLASTIC bag is used to place the contaminated
material before going into trash can BUT NOT PAPER
TOWELS
TUBERCULLIN SKIN TEST
- .1 mL ID
- 1mL syringe with g. 27 ¼ in. needle;
- Left forearm d/t little hair and SQ and readily accessible
for inspection
- Pull skin taut
- 10 degree angle bevel up; 15 degree can cause SQ
injection
- Advance through epidermis with bevel visible under the
skin
VENIPUNCTURE
- Tourniquet is applied 3-5 in. above site for no longer than
1 minute while looking for a vein
- If longer time is needed, release for 3 minutes then
reapply.
- Do not puncture while alcohol used to clean is still wet as
blood may hemolyze or dilute blood sample
TRANSFER
- 1-PERSON ASSIST if COOPERATIVE
- 2-PERSON ASSIST if UNCOOPERATIVE with use of FULL
BODY SLING
- FULL weight bearing: STANDBY only
- PARTIAL weight bearing: Use of gait belt to cooperative
- NONE weight bearing: Use of motorized assist device if
cooperative
- PIVOT on the foot DISTAL to the chair
- Keep feet APART
- Do not bend at the waist
- Transfer client toward stronger side (if client is weak on
left, pivot on right)
VISITORS
- MERSCoV/EBOLA are NOT ALLOWED to have visitors
unless medically necessary
- MRSA/VRE are ALLOWED to have visitors
RISK FOR FALLS; KEYWORDS
- Taking carbidopa means Parkinson’s
- Using a cane means there’s a gait abnormality
- Osteoarthritis
- Age >65 and NOT AGE 50, also not ovarian Ca
- MGT
· Close to station
· Call light within reach
· Low bed position
· LOW side rails: they may climb it up causing all
· Color coded socks
· Limit contraptions (IV, Catheter)
MRSA
- Old adult: 80 y/o
- Suppressed immunity; COPD (Taking steroids)
- Invasive tubes or lines; In an ICE/On mech vent
- History of antibiotic use
MADULID, 2020
-
#1 FACTOR: OLD AGE with SUPPRESSED IMMUNITY
72 y/o with pacemaker receives prophylactic ATB
-
NOREPI
- Causes extravasation
- In a large peripheral vein until 12 hours then should be
shifted to a CVAD
- ONCE EXTRAVASATION, PHLEBITIS, INFILTRATION
happens, IMMEDIATELY REMOVE and NEVER ATTEMPT
to FLUSH the site or administer ANY MEDICATIONS in
the SAME SITE!
-
PHLEBITIS as emergency as it can result to thrombophlebitis
leading to embolus
ENTERAL NUTRITION
- Verify if there is a liquid form available of the medication
- Make sure there is no sustained or extended release
tablets
- Give one medication at a time
- Do not give meds with food because it will form a thick
consistency what may clog the tube
- Tube must be flushed before and after the medication
NASOENTERIC TUBES
- Small bore tubes that uses stylet (guide wire) which is a
metal wire that runs through the tube- facilitates
advancement through GI tract; Removed once xray
verified placement
- STYLET is not inserted when NET is placed. If stylet is
already removed and tube is displaced, it is necessary to
remove the tube again and use guide wire in inserting
- COUGHING, together in suctioning, is normal and
procedure must not be stopped
SUCTIONING
- COUGHING during suction is NORMAL and catheter
should not be withdrawn rather further advanced until
resistance is felt then retracted 1cm before applying
suction to prevent damage in mucosa
- DO NOT suction in the “resistance”, mucosa will be
suctioned causing trauma
-
1 minute interval is applied in between suction and
suction is made for no longer than 10 seconds
100 mmHg is the maximum pressure applied
ROUTINE; O2 first then suction; Prevents hypoxia
EMERGENCY (VOMITING); Suction first then o2; Prevents
aspiration
CONTINUOUS SUCTION is done on GI DECOMPRESSION
· Done on post op
· Residual volumes check are not done and
manipulation post op is restricted d/t potential
damage to sutures
· Residual volumes check are only done in NGT feed
ENDOTRACHEAL INTUBATION
- ET Suctioning injures trachea and bronchi which results
to bleeding and hypoxia thus is used PRN and NOT
ROUTINELY; However, oral care is done ROUTINELY
together WITH **ORAAAAL** SUCTIONING
- Auscultation of NECK is done to monitor ET cuff LEAK
- Cuff is deflated quickly in ET removal
TRACHEOSTOMY
- 1 finger tight under ties
- Deflated once conscious
- Inflate once unconscious
- GOAL: PREVENT DISLODGMENT; Re-insertion if
dislodged in 1st week is very difficult d/t immature tract;
Thus suction and dressing change is only done PRN and
after 24 hrs of insertion
- Coughing and suctioning is done FIRST before deflation
to remove secretions
- In ET: Suction mouth before tube
- In Trach: Suction tube before mouth
PROCEDURE
1. SF
2. Don PPE (mask, goggles, clean gloves)
3. Remove soiled by clean gloves
4. Don sterile then remove old disposable cannula and
replace with new one
5. Stabilize back plate with non-dominant hand then
unlock old cannula by dominant hand then pick up new
cannula touching only outer locking portion then lock in
place
6. Clean the stoma with sterile water or saline, dry and
replace the sterile gauze pad
MADULID, 2020
EXTUBATION
- High fowler’s, humidified O2, oral care, incentive
spirometry
- NPO (no ice chips/oral meds)
NEGATIVE PRESSURE WOUND THERAPY
- Exudate removal
- Stimulates cell growth and vessel perfusion
- Analgesics before the therapy
- Apply skin protectant(skin barrier creams) after wound
cleansing to prevent skin breakdown and to make an air
tight seal
- Sterile foam dressing with size of 1-2 in. beyond wound
edges is applied; Cut not directly over it because material
can fall into the wound directly and may cause trauma
- Sterile technique
different from the pathogen responsible for infection
which is present in the viable tissue
WOUND CARE
- Clean wound bed with sterile saline from center out
- Dry the wound and surrounding skin using sterile gauze
- Apply dry, sterile gauze and NOT saturated with normal
saline over the wound bed; Wet sterile gauze is used for
wet-to-dry dressing
- Cover gauze with occlusive sterile dressing to keep gauze
in place
PEAK FLOW METER
- GREEN (80% up): No SSSX
- YELLOW (50-80%) or from YELLOW TO GREEN: Take
medications and change in TX is NEEDED
- RED (<50%): Emergency medication and immediate
medical TX
- Used after taking a bronchodilator and not after a
corticosteroid
WOUND IRRIGATION
- Done before closing a wound
- Analgesics is given 30 minutes before
- Gown and mask donning
- 30-60 mL sterile irrigation syringe with 18 to 19 gauge
needle
- Use continuous pressure to flush wound
NONREBREATHER MASK
- Inside the deflation bag is OXYGEN
- Thus full deflation in inspiration means there is no
sufficient OXYGEN in the reservoir bag, thus INCREASE
O2 to 15LPM;
- Securement of ports and proper tightness of masks helps
deliver right amount of O2 to be delivered by
minimizing leaks and is not dependent on reservoir bag
deflation
RESPIRATORY FAILURE
- TYPE 1: Hypoxemia d/t O2 circulation; ARDS, PEdema,
shock; Problem in alveoli causing impaired gas exchange
and in circulation (shock)
- TYPE 2: Hypercapnea d/t ventilation failure causing CO2
retention; COPD, MG, Flail chest: In short, patients who
cannot breath normally
SUPRA-GLOTTIC SWALLOW
- Inhale à Hold breathà Swallow à Cough à Swallow à
Breathe
WOUND CULTURE
- CLEANSED with NSS before getting the specimen; Done
by flushing normal saline to the wound to surrounding
skin with 1 inch apart to remove drainage and debris;
The removed pooled drainage contains skin flora
PROCEDURES
- PARACENTESIS: Only local anesthesia: NPO is not needed
- Cardiac diagnostic: regional anesthesia, discharged
within the day
- Cardiac intervention; general anesthesia, discharged 35d
MADULID, 2020
-
-
-
-
-
-
ATB is administered before abdominal surgeries to
sterilize colon, thus preventing complications; not
administered to diagnostic procedures such as
colonoscopy/endoscopy
RAIU
· NPO 2-4hrs
· May eat 1-3 hours after swallowing the iodine;
normal diet when test ends
· Remove dentures, jewelries to allow clear
visualization
· Hold thyroid preps 5-7 days before the procedure
· Safe even allergic to iodine d/t very small amount of
iodine given but still CI to pregnant but still notify
the HCP about the allergy
· No breastfeeding right after the procedure
· No sedation happens: Patient will be conscious
during procedure
PHARMACOLOGIC NUCLEAR STRESS TEST; use
vasodilators (pharmacologic) to stimulate exercise
(stress) for patients suspected of CAD
· Involves “graphy” or heart visualization thus a dye is
injected to see if coronary arteries are well perfused
· NPO with no smoking for 4 hours;
· No caffeine, theophylline for 24 hrs before
· No anti-DM agents to prevent hypoglycemia since
the patient will be NPO for 4 hours + exercise
· No vasodilators (Bblockers, nitrates)
HEART TRANSPLANT
· Physiologic tachycardia is present (90-100bpm) since
the new heart is cut off from the autonomic nervous
system, causing alteration in heart rate during rest
and exercise
UGIB
· NGT is done to decompress. However, in the
presence of esophageal varices, NGT is CI without
visualization d/t trauma causing rupture and
hemorrhage.
· Pantoprazole, octreotide (reduce portal venous
pressure in presence of Esophageal varices
· NPO in preparation for procedures
LUMBAR PUNCTURE
· NORMAL: CHO, CHON, WBC
· ABNORMAL: RBC, Bacteria
· Pain is expected to shoot down the leg but is
temporary
· POST: FOB for 4 hrs
-
BRONCHOSCOPY
· Mild sedation and topical anesthetics are used
· Common: blood-tinged sputum d/t airway
inflammation
· Abnormal: Bright red sputum
· No gag reflex for 2 hours
· Low RR and spO2 are normal d/t sedation effects
-
Positive GUIAC: BLUE
Positive amniotic fluid test: BLUE (alkaline), yellow means
acidic (vaginal secretion)
HEEL STICK
- mEDIAL OR LATERAL SIDE OF OUTER ASPECT OF HEEL
- wARM HEEL FIRST USING WARM COMPRESS
- Venipuncture is LESS PAINFUL and requires FEWER
attempts to obtain a sample, especially if larger volume
is needed
LOW GRADE FEVER is an indicator of systemic infection thus
present in RA and not OA
INCENTIVE SPIROMETRY
- Like doing DBE: Exhale, inhale DEEPLY, hold breath then
exhale SLOWLY
- ANALGESIA is usually given BEFORE DBE/SPIROMETRY for
it to be effective by reducing pain on the incision site.
TELETHERAPY
- No extremes in temp: no heating pads and ice packs
Maintain cool, humid environment for comfort
MADULID, 2020
HEPATITIS
- Anorexia is lowest in the morning, thus encourage larger
breakfast; BUT in general: low fat, small frequent meals,
inc. OFI, adequate CHO CHON & Calories must be
consumed
DM FOOT CARE
- D/t peripheral neuropathy, damaging nerves in
extremities causing impaired sensory function resulting
to injuries/ulcers or diminished blood supply
- Wash feet with warm water and mild soap
- Pat feet dry in between toes
- Use lanolin to prevent dry skin but not in between toes
- Use sturdy leather shoes
- Improve circulation (no crossed legs, fitting garments and
perform daily exercise
- PARESTHESIA in DM is normal d/t presence of peripheral
neuropathy
NORMAL VALUES
-
CD4 Count
-
-
· Infants: >750
· 1-5 years: >500
· >5 y/o: >200
Ejection fraction; 55-70%
24h urine cortisol: <80
Absolute neutrophil count (ANC):
· WBC + Neutrophil %
· <1000: Neutropenia(chemotherapy)
· <500: EMERGENCY
CTT: 100mL/hr MAX even immediate post op
· Sanguineous (bright red) for 1st several hours to
serosanguineous to serous (yellow) over a period of
few days
· Sanguineous never normal after the 1st few hours
· AIR BUBBLES; normal in suction chamber, abnormal
if seen continuous in base of water seal (leaks), but
normal if intermittent.
§ To determine air leak, monitor for continuous
bubbling at base of water seal (letter C)
§ B is part of the water seal but air leak will not be
evident in that upper portion; What to see in
here is the tidalling of fluid that indicates tube
patency
MADULID, 2020
-
-
WARFARIN/HEPARIN
· TV: On clients taking anticoagulant
· CV: On clients not taking
· 1.5-2.0 times CV (3 max)
· aPTT/PTT
• CV: 25-35
· aPTT:
• TV: 45-70
· PTT
• TV: <100
· PT: 11-16 sec
· INR
• CV: 0.75 to 1.3
• TV: 2-3
· HIT and Platelet administration is on platelet, not
aPTT
· Warfarin is given 5d before heparin is stopped
· NEVER given per IM!
CSF: 60-150 mm h20
KCl: max 10mEq over 1 hr in peripheral line; max 40
mEq/hr in CVAD
Troponin I: < 0.5 ng/mL; Onset: 4-5h; Peak: 10-24h;
Duration: 2 weeks
· Most sensitive and specific cardiac marker
Troponin T: < 0.1
Digoxin: 0.5 to 2 ng/mL
Calcium: 8.6 to 10
Crea Clearance: 105-140 mL/min for men; 90-105 for
women; High result is normal
COINING
- Also a way to remove illness from the body
OXYGEN DELIVERY SYSTEM
VENTURI MASK; 24-50%
- MOST accurate oxygen delivery system
- Most appropriate for COPD patients
- For tachypnea, shallow breathing with decreased TV,
hypercarbia, hypoxemia
NONREBREATHER MASK; 60-95%
- HIGHEST O2 concentration
- Usually short term
- With low O2 sat such as PNM, asthma, trauma, sepsis
-
CHOLESTEROL
· TOTAL: <200mg/dL
· Triglycerides: <150
· LDL: <100
· HDL: >50
SMOKING is not CI in MRI, COLONOSCOPY
N&V is normal to a client on MORPHINE!
Galodinium is used in MRI, not iodine
HERBAL MEDICATION
- PRIMARY consideration is checking for herbal for drug
interaction to know for synergetic/antagonistic effects
CUPPING
- A way of culturally removing illness from body
IUD
- Also used as an emergency contraception thus works
immediately and does not require backup contraception
(pertaining to copper and not levonorgestrel IUD); may
be inserted up to 5 days after intercourse
- Heavy mens is expected but not spotting
- Not affected by weight changes unlike diaphragm
MADULID, 2020
-
COPPER promotes ovulation and menses since it does
not contain hormones, its action is to kill the sperm.
Copper (10 years)
Levonorgestrel (3-5 years)
· The pills form is a form of emergency contraception
and taken within 5 days of intercourse, efficacy is
reduced after 3 days
**Menstrual volume should not increase in a client receiving
anticoagulants
VAGINAL RING
- Contains etonogestrel and ethinyl estradiol vaginal ring
(NuvaRing); a combined contraceptive
- The ring is not a barrier and requires time for hormone
absorption
- No sex or backup contraception is needed during 1st 7
days to allow hormones’ full effect
- If displaced during intercourse/defecating: rinse and
place back within 3 hours; otherwise use backup
contraception for 1 week
- Ring is placed for 3 weeks; Once removed, withdrawal
bleeding occurs and a ring is placed after 7 hormone-free
days
OCPs; SPOTTING in between menses is normal, unlike in IUD
In adolescents, showing people with the same condition or
hair loss Is better than finding wigs
ANEMIA
- FORMULA milk and TERM infants have MORE IRON than
breastmilk and PRETERM;
- Iron deficiency anemia in BREASTFED infants do not take
place at the age of 6 mos and below
- PRETERM infants become AT RISK for anemia at the age
of 3 MOS.
ANEMIA: INTERVENTIONS should NOT be given without
knowing the cause as it may be because of nutrition, blood
loss, iron deficiency, sickle cell, thalasemmia etc.
HEMOPHILIA
- NO DIET, just regular diet
- DEHYDRATION is NOT an issueà more on sickle cell
- Intact INTELLECTUAL ability
- JOINT DESTRUCTION as the most dreaded complication,
not heart valve injury (RHDs)
IDA
- Breastfed infant >6 mos. w/o adequate supplementation
- Preterm infants at age 3 mos.
- Not an issue to oldies, they are more prone to have
hemosiderosis and not iron deficiency
SICKLE CELL ANEMIA
- PRECIPITATING FACTORS: Infection, Fatigue,
Dehydration; TX; Avoid infection, fatigue (Bed rest), and
dehydration (IV Fluids)
- PRIORITY: HYDRATION over bed rest and administering
oxygen if a client reports pain d/t vaso-occlusion
· Blood will not flow or the occlusion will not resolve if
there is no adequate hydration even with the
presence of oxygen. Thus infusion of IV NSS is a
priority, second is O2 administration
- Sickled cells die within 20d; Normal cell : 120d
- Severe anemia is EXPECTED and is NOT AN EMERGENCY
- AFFECTED areas:
· MOST DREADED COMPLICATION: Splenic
sequestration crisis; splenomegaly d/t trapped
sickled cells in the spleen; causes severe
hypovolemic shock and is an emergency
· Stroke/CVA
· 1st SIGN IN BABIES: Dactylitis; Swelling of hands and
feet d/t sickled cell blocking blood flow
· PAIN 10/10 d/t BV occlusion; TX: RTC opioids, IV
fluids and bed rest
- Patients with long term pain adapts to the pain and more
often looks comfortable but they really are not: e.g.
watching TV comfortably but really is in pain.
- PAIN in sickle cell is EXPECTED and is not a priority over
low back pain (Ruptured AAA) or left sided pain radiating
to jaw and shoulders (MI)
- PRIORITIZE if spleen is affected/stroke; only prioritize
pain if there is an abrupt change from no pain to 10/10
pain d/t irreversible damage which can occur from tissue
ischemia
- FATIGUE prevention:
MADULID, 2020
·
·
·
·
Watching TV, Listening to music, reading, relaxation,
guided imagery, warm soaks, positioning, gentle
massage for pain
NO finger painting; messy and not appropriate for
bed rest
NO play in the activity room: BEDREST!
NO stimulating activities such as video games
COLON Ca
- Occult GI bleed causing ANEMIA which now results to
FATIGUE and WT LOSS;
- New onset anemia should be assessed to 50 y/o and
above and routine colonoscopy annually should be
started.
- New onset incontinence/retention should also be
assessed to 50 y/o and above to rule out BPH
1.
-
VIRCHOW’S TRIAD
Injury of BV (Surgery)
Hypercoaguability (Postpartum)
Stasis (Inactive, immobile, postop, age)
HIGHEST RISK: POST OP + POSTPARTUM client, higher than a
client with Afib; 1st priority: Abdominal surgeries; 2nd priority:
Hip surgeries
LOW RISK: 35 woman who smokes and uses OCP
2.
-
-
3.
-
NO DVT
CHOLECYSTECTOMY PROCEDURES
· OPEN CHOLE; PNM/ATELECTASIS
· LAPCHOLE: CO2 retention: AMBULATION AND DBE
to remove CO2 and not because of DVT risk
MASTECTOMY; LYMPHEDEMA
· Parethehsia and itching are common post op at the
incision site
Heart surgeries d/t anticoags administration pre and post
op; Mostly on lifetime anticoags after surgeries especially
those involving heart valve repairs
FAT EMBOLI contains fat globules and NOT BLOOD thus
anticoags, compression devices and early ambulation
(should be IMMOBILIZED) is not helpful and are for
clients with DVT
IMMOBILIZE to prevent fat globules dislodgement!;
MOBILIZE for DV
Respi probs: dyspnea, tachypnea, hypoxemia
Neuro changes: ALOC, confusion, restlessness
Petichial rash
Fever
NOT: Severe pain unrelieved by opioids (compartment
syndrome)
4.
DVT has higher priority than AFib because DVT has clot
already while AFib is only at risk for developing clot. DVT
is also higher that a client with atelectasis post CABG
since it is a common complication after heart surgery
PRIORITIZATION:
1.
2.
3.
MYXEDEMA COMA: INTUBATION before IV
Levothyroxine; Levothyroxine takes effect in days to
weeks
DKA: NSS before IV Insulin
CABG incision: Sternum “Sternotomy”, thus atelectasis is
common
· Minimally invasive CABG: In between ribs;
“Thoracotomy incision”; Shorter recovery time but
more painful; Bypass grafts are IMA, radial artery or
saphenous veins
MULTIPLE SCLEROSIS;
- FEET APART + Cane or any other assistive devices: For
incoordination and gait steadiness
- ROM + Stretching exercises: For spasticity & contracture
- Rest & do not increase exercise: For fatigue
- Hydrate + cool temperatures: For exacerbation
COMPARTMENT SYNDROME
- HEAT application is not done
- Placed at level of heart and not above d/t already
compromised blood flow
MADULID, 2020
VOLKMAN’S CONTRACTURE
- A complication of compartment syndrome s/t fracture of
humerus
- A wrist fracture with inability to extend fingers
-
-
COLLES’ FRACTURE
- D/t fall when wrist receives the impact
- “Dinner fork deformity”
- PRIORITY to ANY fracture or musculoskeletal disorders,
even if the scenario indicates that the client reports
severe pain 10/10, is to assess for neurovascular status
to determine development of compartment syndrome
(d/t swelling) or arterial/nerve damage (d/t bone
fragments)
- Other interventions: Analgesia, Ice, Elevate, Fingers ROM
-
RAPID insulin is given within 5 minutes after a meal is
taken
NPH should be given with meals (complex CHO) at night
to prevent morning hypoglycemia; NPH has a peak of 412 hours thus at around 6-7am, patient will be
hypoglycemic
NSS is administered before IV insulin because:
· NSS treats dehydration in life threatening
hyperglycemia thereby suppressing elevated levels
of stress hormones resulting to decreasing BG
because in life threatening hyperglycemia (DKA,
HHNS), most dreaded complication is DEHYDRATION
· IV insulin shifts water, K, glucose INSIDE the cell
thereby worsening dehydration even more if NSS is
not initiated
HYPERGLY: DEHYDRATION
HYPOGLYCEMIA; CNS SSSX
PSORIASIS
HYPERGLYCEMIA
- NORMAL VALUES
· Critically ill & on TPN: 140-180; Hypoglycemia (<70)
is a life threatening condition to these clients
· Normal client: <140 fasting/2hrs PP, <180 random
- 2 RAPID INSULIN PURPOSES
· SCHEDULED PRANDIAL: prevent hyperglycemia;
with food; held if <70mg/dL
· CORRECTIONAL: correct hyperglycemia; no food
taken; held if <150mg/dL
- ISSUE ON HYPOKALEMIA
· DM patients have hyperkalemia d/t insulin
deficiency
· K is already given PO/IV upon insulin initiation (not
NSS initiation) even K levels are still normal
- IV Insulin (Regular) is only given in emergency situations
such as a BG of >200 and is stopped once BG is below
this or if ketosis or acidosis is resolved to prevent
hypoglycemia
- If BG of DKA/HHNK client falls from 500-600 to 250 and
below, administer D10% while continuing the insulin to
prevent life threatening hypoglycemia
RHONCHI and CRACKLES (RALES) are the exact opposite
- Expiration : Inspiration
- Larger : Smaller airway
- Continuous : Discontinuous
- Bronchitis : PNM/P. Effusion/P.Edema; Fluid in alveolià
indicates worsening of COPD (not part of COPD sssx)
Coarse crackles; congestion
Fine crackles; atelectasis
MADULID, 2020
·
·
Shock (Anaphylactic, Cardiogenic)
Anaphylactic shock presents with flushing, pruritus,
rashes d/t vasodilation and not pallor which is
usually seen in shock.
***NEUROGENIC / SPINAL SHOCK; ALL VS are down with
pink, warm, dry skin d/t vasodilation
***Hypothermia (near drowning) also has weak thread to no
pulse at all but the patient is alive. Not dead not until patient
is warm again and with no pulse
SNS SYMPTOMS
- SEROTONIN SYNDROME except GI GU which results to
urinary frequency and diarrhea
Chronic heart failure (CHF)
- Dilutional hyponatremia
· Heplock for medication admin; NOT NSS d/t
congestion
· Furosemide; Corrects dilutional hyponatremia;
Excess water causes it, thus excretion of the fluid
corrects the hyponatremia
· KCl- hypokalemia r/t furosemide.
· Fluid restriction
· Low-salt diet; prevents water retention;
Hyponatremia is d/t excess water and not a dietary
cause
· ACE Inhibitors
· Also applies to SIADH (dilutional hyponatremia) with
hypertonic administration and oral salt tablets,
conviptan (ADH antagonist)
- W/O for S3 HS after an MI which indicates congestion s/t
HF; This is more serious than occasional PVCs after MI
SHOCK LIKE SIGNS
SHOCK: Up PR, Down BP, Narrow pulse pressure, Cold,
clammy, pale skin
- Hypotension with tachycardia and narrow PP,
- Dyspnea (no enough oxygen d/t no blood),
- Syncope
- Weak, thready pulse; Bounding pulse is a sign of
congestion (aortic regurgitation, COA)
- Indicates decreased cardiac output à decreased
ejection fraction
- ALL PRESENTS WITH SSSX OF SHOCK:
· PNEUMOTHORAX
· CARDIAC TAMPONADE except distended jugular
veins
· NSAID TOXICITY
· HEAT STROKE except for Dry Hot skin d/t
hyperthermia and not with cold clammy skin usually
seen in shock
· Aortic stenosis
PULSUS PARADOXUS
1. SF
2. Inflate 20mmHg more than previous BP
3. Determine 1st korotkoff on expiration
4. Determine heart sounds throughout inspiration and
expiration
MADULID, 2020
5. Subtract number 3 and 4= PARADOX
6. >10 mmHg difference is (+) pulsus paradoxus
PULMONARY EMBOLISM
- Hypoxemia and CHF d/t congested blood flow in
pulmonary arteries
- Anxiety, cough, tachycardia (compensates d/t decreased
blood flow s/t obstruction of the embolus)
- With signs of DVT
INFERIOR VENA CAVA FILTER
- Filters blood clots from LE, preventing migration to lungs
- No MRI (Considered metallic foreign object)
- Prevent DVT (no crossing of legs)
ANAPHYLAXIS
- CALL for help
- Epi IM (Open the airway first before O2 administration)
- O2 via non rebreather
- Elevate legs; shock
- Fluid resuscitation; shock
- Bronchodilator
- Antihistamine
- Corticosteroids
AORTIC STENOSIS
- Loud aortic murmur at aortic area d/t ejected blood s/t
stenosed valve
- ABSENT S2
- Feeling of angina or faintness or syncope before a
surgery is normal as it presents with aortic stenosis due
to reduced circulating volume to body and brain, thus
there is no reason to delay the surgery. However, client
must be on bed rest and avoid exertion until the surgery
- TX: RESTRICT ACTIVITY to reduce O2 demand
BLOOD TRANSFUSION
- EARLY: red urine, fever, hypotension
- LATE: DIC, hypovolemic shock
1. STOP IMMEDIATELY and disconnect tubing at
catheter hub
2. IV NSS using NEW tubing: DO NOT FLUSH previous
tubing as more blood will enter the circulation
3. Notify hcp and then after it are the VS checked
STEPS
1. Verify with another nurse at bedside
2. Infuse one unit at a time
3. Obtain VS
4. Use Y tubing and prime with NS and clamp at NS
side; Saline is used only to prime tubing and flush
after insertion; Do not infuse simultaneously
5. Infuse 2-4 hours (PRBC, Whole blood, Plasma);
Cryoprecipitate and platelet concentrate are infused
over 30 minutes to prevent hemolysis
Fever with raised skin pustules are characteristic of smallpox
and is transmitted via droplet;
PAIN OCCURRENCES
- ANKYLOSING SPONDYLITIS; early morning low back
stiffness which resolves with activity
· No cause/cure
· Stiffness of spine, resulting to restricted spinal
mobility
· Stop smoking and do breathing exercises to increase
chest expansion
· Moist heat and NSAIDs for pain
· Immunosuppressants and anti infalmms to reduce
inflammation
· Rest during flare-ups
MADULID, 2020
-
-
-
-
FIBROMYALGIA: MULTIPLE tender points
SCLERODERMA; thickened skin
SJOGREN’S; autoimmune; Dry eyes mouth vagina
· Excorine glands inflammation (lacrimal, salivary)
· Xerophthalmia (dry eyes)
· Xerostomia (dry mouth)
· Use room humidifier and not sitting in front of fans
and air vents as it increases dryness
ROTATOR CUFF INJURY: 4 muscles working together for
shoulder/arm rotation; Caused by overhead arm motion
(swimming, tennis, baseball, weight lifting); SSSX includes
severe pain on abduction
FROZEN SHOULDER: Active and passive ROM restriction
Carpal Tunnel: Pain and paresthesia over first 3 and a
half finger
- Tennis elbow: Tenderness over lateral epicondyle
STROKE
- Clothe first the weak or affected side, to decrease
movement of affected and increase movement of strong
side
Receptive aphasia: visual aids and hand gestures are
more appropriate than written instructions: Receptive
“Receive”; They cannot “receive” instructions
Homo: Same side; Lost of one side of both eyes
COLOSTOMY IRRIGATION
- Helps regain control on the stool passage
- Irrigation container is filled 500 mL to 1000 mL of
lukewarm water, flushed, then re-clamped
- Hanged 18-24 in. above stoma
- Place irrigation sleeve over stoma and extend to toilet
MADULID, 2020
-
Lubricate cone tipped irrigator, insert and hold
Cone is removed and feces drains through sleeve to toilet
Cone tip applicator is used to instill solution and not an
enema set (too big)
Done when colostomy is in the descending colon to anus;
descending colon has normal BM
PESSARY
- Can sex
- Fitted out patient, not surgical
- Clients can insert and remove it
- Must be removed weekly at night to clean it
- If client cannot clean, hcp removes it 2-3 months interval
- SE is increased vaginal bleeding together with IUD and
OCPs
BPH
- Age 50
- Strains to empty the bladder
- Cannot empty bladder fully d/t obstruction
- Hesitancy, urgency, frequency, nocturia
- ABNORMAL (UTI); dysuria and cloudy urine
PROSTATITIS
- Dysuria, hesitancy, urgency
- Treated with NSAIDS/ATB/Alpha adrenergic blockers (Zosins)
- MGT:
· Hydration
· SEX/Masturbate to reduce retained prostatic fluid
· Use condom to prevent transmission of infection
· Stool softeners; tension of pubic muscles presses
against the prostate
· Sitz bath
SMALL BOWEL OBSTRUCTION
- N/V, abdominal pain and abdominal distention
- Can also occur to patients with body cast causing
decreased peristalsis to paralytic ileus to bowel ischemia;
SSSX of bowel obstruction should be reported
LARGE BOWEL
- Abdominal pain and distention, lack of flatus and
constipation
RECTAL HEMORRHOIDS
- Pain during defecation
COLORECTAL CANCER
- Colorectal cancer, in general, includes all colon
(ascending, transverse, descending, rectosigmoid); Thus
if asked in general the symptoms, refer to the photo.
- Occult blood test: every year
- Colonoscopy: every 10 years
COLOSTOMY APPLIANCE
- Appliance is changed every 5-10 days to prevent
peristomal skin irritation
- Irrigation is done daily or PRN
- Bag is emptied when 1/3 full
MADULID, 2020
-
Measure abdominal girth
NPO is done with NGT decompression, parenteral
hydration and IV ATB
No rectal thermometer
Supine and undiapered for assessments
CERCLAGE
- Prevent preterm delivery
- Placement at 3 month AOG if w/ hx of cervical
insufficiency or at 6 mos. AOG if sign of cervical
insufficiency (short cervix) is noted
- Patient should not signs of preterm labor (low back pain
radiating to umbilicus or pelvic pressure)
- Mild cramping post cerclage is common, but not regular
contractions
- It remains in place up to 9mos AOG, unless early removal
is indicated such as ROM/Preterm labor
AMNIOTOMY
- Artificial ROM to induce labor
- To any ROM, risk for cord prolapse is present which can
cause bradycardia, thus in AROM, FHR is monitored
before and after procedure
- Chorioamnionitis may also be a complication;
Temperature monitoring is crucial q2h for the mother
- Procedure is PAINLESS, with some pressure.
NECROTIZING ENTEROCOLITIS
- Common to preterms s/t GI immaturity in such a way
that enteral feeding causes bacteria to bowel where they
can proliferate since the client is preterm (immature
immune system)
ECLAMPSIA
- A client with pre-eclampsia which presents with 3+ DTRs
and clonus has higher priority than a hypotensive (90/60)
client with hyperemesis gravidarum
- 1-2+ DTRs: Pre eclampsia
- 3-4+ DTRs: Severe pre-eclampsia which can lead to
seizures
MADULID, 2020
RISK FOR HYPOGLYCEMIA
- LGA and SGA, Newborn with DM mother, and those born
late preterm age
- Hypoglycemia is <35 to age 1day below, and <25mg/dL if
age 4 hours below; Treated with feeding
- Ideal CBG is >40mg/dL
PRECIPITOUS BIRTH
- Labor lasts only <3 hours
- Signs of imminent birth: involuntary pushing, grunting,
bowel movement sensation
TRANSITION PHASE: 8-10cm
- Most emotionally challenging phase
- Marked anxiety; teach DBE
- Bloody show may be present
- Pushing must be avoided until complete dilation (10cm)
WEIGHT GAIN DURING PREGNANCY
- UNDERWT; 28-40 lb.
- NORMAL WT: 25-35 lb.
- OVERWT; 15-25 lb.
- OBESE (>30 BMI); 11-20 lb.
- Applies to ALL: Wt gain in 1st trimester is normal from 1.1
to 4.4 lb.
ShouldeR
MADULID, 2020
Caput Succ: Crosses Suture line
-
ALL has bleeding except vaginal hematoma
Cervical laceration has no pain because cervix has no
nerve endings
LOCHIA
- LOCHIA that soaks in 2hrs is okay as long as it does not
soak <1hr
MADULID, 2020
PEAK coincides with ONSET
Moderate variability; Normal “reassuring”
MADULID, 2020
-
-
PRESCHOOLERS always are at the greater risk for having
conscience such as blaming self for adoption or blaming
self why a person died because they have imaginary
thinking and most often they wish for another person to
die.
ADOPTION: SCHOOLERS may feel that they want to be in
their biological parents as self-esteem arises
ADOPTION: TODDLERS does not know yet what is a
biological parent from what is not
INFANTS to adhere in routine, bring fav toy, provide
parent’s shirt all of these while in the hospital
ERYTHEMA TOXICUM NEONATORUM
- Firm, white/yellow pustules surrounded by erythema.
- Resolves within 5-7 days
ORAL CANDIDIASIS
- Non-removal patches that bleeds when touched
- Client may have difficulty sucking or feeding d/t pain
- Candidiasis or oral thrush is NOT AN STI, rather is d/t
immunocompromised.
DEVELOPMENTAL MILESTONES
- Stranger anxiety extends up to toddler years; STARTS AT 6
MONTHS AND PEAKS AT 10-18 MONTHS
- Bears full weight while standing with support with sitting
while support at 7mos.
- Prone to sitting or standing position at 10mos. Together
with standing with support and after fully controlling the
sitting position which occurs at 8mos.
GROSS MOTOR
1- Crawls stairs; Walks alone
2- 1 step at a time; Runs w/o fall
3- 2 Alternate steps upward; 3cycle; Jumps 4ward
4- 2 alternate steps downward; balances on 1 foot
5- Skips, walks backward, uses jump rope
FINE MOTORS
1- 2-finger pincer for 2 pages at a time; 2 blocks
2- 6 blocks of tower; 1 pg. at a time; draws LINE; opens door
3- Crayon with finger not fist; Feeds independently; draws
CIRCLE
4- Draws SQUARE; Ties a knot, use spoon and fork; Cuts with
scissors
5- Draws TRIANGLE; Ties shoelace; Prints letters numbers;
independently dresses and bathes
LANGUAGE
1- 3 words, waves goodbye
2- 300 words; States own NAME
3- 3-4 word containing sentence; WHY questions; States own
AGE
4- States >2 COLORS; tells stories
5- States 1 to 10 NUMBERS; speaks full sentence
MADULID, 2020
-
Ht and Wt are taken first before VS; VS is invasive for
pediatrics; CONCEPT: Least invasive to most invasive.
Stacking blocks are appropriate for toddlers
Competitive/cooperative play (puzzles) for school aged
with working towards 1 specific goal
Crayons are appropriate for preschoolers as they can use
it to draw noses on facemask to feel more comfortable in
the hospital
DEATH
- Toddler- SepAnx; Anxious by change in daily routine
· Talk about the death in simple, accurate terms;
Avoiding to talk about the death may increase the
child’s anxiety/confusion
· Consistently assign the same nurse to the child
· Remain with the child as much as possible
· Let the client play
- Preschool- Death as reversible; Guilt/conscience d/t wish
die
- Schooler
· 6-9- Irreversible; Cannot think own death but is
CURIOUS about death and its process
· 10-12- Irreversible; Thinks own death; Death affects
everyone; Perceives death as EVIL
· Adolescent- spiritual aspect of death; adult level
thinking
DDH; Hip dislocation
- MC TX is a Pavlick harness worn for 3-5mos.
· Put shirt and knee socks or clothing under the harness
to prevent skin breakdown
· No lotions powders, also applies in braces and
residual limb amputation
· One diaper at a time UNDERNEATH the straps
·
·
-
CONCEPT: STRAPS must NOT directly touch the skin
Worn ALL THE TIME except for bathing once a day,
otherwise worn even in diaper changes
· Massage skin under straps to promote circulation
PROBLEM: SADDER; affected is SHORTER
GOAL: Abduction and Flexion
MADULID, 2020
CLEFT PALATE
- No ability to create suction
- Upright position when feeding
- Point away from cleft
- Use cross-cut nipple with squeezable bottle to allow entry
of milk to go simultaneous with infant’s own
sucking/swallowing
- Feed slowly over 20-30minutes to reduce risk of aspiration
- Feed q 3-4hours;
GENU VARUM (bow legged) from 6 to 18mos
Straight legs for 18 mos.
GENU VALGUS for Preschooler;
S3 is normal for children
- Mitral and apical area
- S2 in pulmonic area
-
Measuring HC post VP shunt is MONITORING
Suctioning 3mo. old w/bronchiolitis who is irritable and
scheduled for feeding is NOT MONITORING, rather an
intervention and is already experiencing HYPOXIA/RESP
DISTRESS
Tonsillectomy
Expected postoperative findings
- Ear pain when swallowing
- Low-grade fever. Analgesics PRN.
- Superficial infection at the surgical site is common and
causes white, fluid-filled exudate in the throat
with halitosis (ie, bad breath)
Unexpected
- Hemorrhage which can lead to airway compromise with
sssx of restlessness, bloody vomitus, pallor, frequent
swallowing
KAWASAKI DISEASE
MADULID, 2020
-
-
-
≥5 days of fever, non-exudative conjunctivitis,
lymphadenopathy, mucositis, hand and foot swelling, and
a rash
This is not a viral nor bacterial illness
PHASES
· ACUTE; fever unresponsive to medications;
irritability, swollen feet, hands, lips and strawberry
tongue
• Soft foods for painful swollen lips
• Cool compress, unscented lotion, loose fitting
clothes
· SUBACUTE; skin peeling (new skin that grows is
painful); irritability remains
• Quiet environment for irritability to promote rest
• Irritability may last up to 2 months
· CONVALESCENT; disappearance of symptoms; temp
returns to normal
• FEVER must be immediately reported upon
discharge as it signals that the client is developing
Kawasaki, acute phase
No DX, not contagious
IVIG stays in body until 11 mos after introduction thus
interferes with antibody production
· IVIG in high doses retains fluid thus may cause
pulmonary edema thus signs of fluid overload must
be monitored (tachycardia, dec UO, DOB, extra heart
sounds)
Systemic vasculitis (arterial wall inflammation)
First-line treatment consists of IV immunoglobulin and
aspirin to prevent coronary artery aneurysms.
Temporary joint pain and other manifestations of arthritis
(eg, stiffness, decreased range of motion) may occur and
persist for several weeks.
AOM
-
Ear pain, bulging, red tympanic membrane and not
retracted (occurs in chronic infection)
Fever with ear rubbing and being fussy
Pulls on the affected ear, irritability, loss of appetite
RUPTURED TYMPANIC MEMBRANE: Pain relief,
decreasing fever, pus coming out
NOT PAIN WHEN direct pressure on tragus NOR pulling
pinna as these are ss of AOE; AOM pain is inside the ear
and not outside
Symptoms must improve 3d after ATB therapy. Follow up
if it does not because the client may be resistant to the
ATB.
AOM pain is NOT AFFECTED by manipulating outer ear
SMOKING is a RF because it predisposes the child to
respiratory infection
-
Eliminating pacifier use after age 6 is a preventive
measure
BREASTFEEDING is a protective factor
CYSTIC FIBROSIS ISSUES: on PANCREATIC ENZYME
GI: PANCREAS: PANCREATIC OBSTRUCTION d/t thick
secretion obstructing enzyme flow causing malabsorption
including CHO CHON FATS (including fat soluble vit) thus
steatorrhea, diarrhea, flatulence and abdominal cramping
occurs; Diet is high in cho chon fat since the client is deficient
in it
AFFECTED: Pulmonary, pancreas, reproductive
-
-
-
-
Since it is in pancreas, pancreatic enzyme are prescribed,
and absorption must be taken place at the pancreas thus
ENTERIC COATED TABS are used to prevent absorption in
stomach/SI, thus NO CRUSHING/CHEWING
Pancreas is alkaline ,thus tablets will NOT BE ABSORBED
in ACIDIC environment thus taken with acidic foods such
as applesauce, yogurt soft room temp foods which is a
good environment for the drug to be absorbed in pancreas
or for it not to be prematurely absorbed in the GI tract;
NOT TAKEN WITH ALKALINE foods such as MILK which
causes it to CURDLE
Sweat glands are also affected as Na and Cl are not
reabsorbed resulting to INCREASED Na loss thus INC SALT
INTAKE plus water is recommended during hot weather or
in times of perspiration
OTHER FEATURES: Barrel chest and clubbing of fingers,
absent vas deferens, thick reproductive secretions
MADULID, 2020
LEAD POISONING (>5 mg/dL)
- SOURCE: paints in walls, toys, or water from lead pipes or
even in dust/soil , a house built older than 1980 d/t
renovations containing paints
- Attacks blood, brain and kidneys, NOT LIVER
- SSSX: Neuro SSSX: Hyperactivity, impulsive, reading
difficulty, visual motor issues and can lead to permanent
cognitive impairment, seizure, blindness, death
- CHELATION THERAPY is done
- MGT:
· No living in house while renovating (paints)
· Handwash to wash lead residues on toys
· NO VACUUM as it suspends dust in the air. However,
VACUUMING carpets is recommended for allergic
rhinitis or asthmatic clients, dust mite allergy
· NO VACCUM, instead wet dust or mopped weekly
· NO HOT WATER because it dissolves lead from pipes,
DO COLD.
CELLULITIS
- Inflammation of SQ d/t bacterial infection s/t insect bite,
cut, abrasion or open wound
- Elevate affected extremity to decrease edema/promote
lymphatic drainage
- Change soiled linens as the wound may weep causing
infection
- Warm compress
- Mark the site daily for monitoring of improvement
- Standard precautions are applied
IMPETIGO
- HIGHLY contagious bacterial infection common to
children during summer
- Itchy, burning red pustules to honey colored crust
- WITH ATB: not contagious after 1-2 days of therapy and
heals within a week
- W/O ATB: contagious for 2-3 weeks
- MGT:
· Handwashing
· Isolation of clothing and personal items and laundry
by hot water
· Keep fingernails short
· No contact with others when ATB not started until 2
days
· Keep infected area covered with gauze to prevent
re-infection
· NO ALCOHOL: Only mild antibacterial soap
TINEA CAPITIS
- Fungal/ringworm infection of scalp transmitted via direct
contact with person, pets, or even objects (hats, towels,
beddings)
- Fungus needs keratin, thus it is treated with selenium
sulfide shampoo which absorbs keratin producing cells. It
should be taken as prescribed for several weeks to
months and is not discontinued to ensure shedding of
infected keratin completely
- Selenium is best absorbed when taken with high fat foods
(ice cream) with photosensitivity as its SE; This is applied
few times each week
PEDICULOSIS CAPITIS
- Hot water to laundry then placed in hot dryer for 20
minutes
- Not spread by oral contact with utensils; Spread via direct
contact or by nits that hatch in the environment and
remains on clothing/combs/pillows
- No spraying of insecticides
- If items cannot be washed, place in a sealed plastic for 2
weeks
- Vacuum carpets, toys, rugs, mattresses
MADULID, 2020
LYME DISEASE- DEER TICK BITE
- BULL’S EYE rash
- ATB s the TX for carditis/meningitis prevention
- Insect repellants, avoid grassy areas (hike only in trails),
long sleeved shirt and long pants
- NO application of petroleum jelly
- TICKS are removed via tweezers but not crushing it
during removal
BED BUG BITES
- NOT D/T DIRTY ENVIRONMENT thus DIRTY BED SHEETS
ARE NOT THE CAUSE; CAUSE may be anything! Not life
threatening but causes SERIOUS RASH
- TX is PEST CONTROL and NOT WASHING BED SHEETS
DUST MITE ALLERGY
- D/T dirty linens, pillow, mattress covers
- Washed q 1-2wks with HOT WATER and vacuuming
mattress regularly
- NO CARPET or if with carpet, vacuum daily
WEST NILE VIRUS
- Mosquito-caused encephalitis during summer, humid
weather
- Insect repellants, long sleeves and pants, light colors,
avoid outdoors at dawn and dusk
- No need to limit contact with infected pets(ringworm)
and washing of bedding in hot water (scabies/mites)
SCABIES
- Highly contagious
- Intense itching with burrows on the skin w/c are the eggs
that female mite left that continues even after TX
- Permethrin is the TX which should be applied to ALL THE
BODY SURFACES from head to toe with exception of eye
- POC: from infestation to onset of sx (1-2mos.); All in
contact must be seen for TX
- Lives only in the SKIN thus living room areas need NOT
to be fumigated
- All washable that came in contact with skin should be
washed by hottest water, while non-washable (toys,
bears) must be sealed in a plastic for 2-3d as they die
after 3d of non-contact to skin
POISON IVY DERMATITIS
- Oil resin found in leaves, stems, roots.
- Linear in appearance where plant came in contact
- Wash area to remove resin and to prevent spread; an
immediate intervention before the rash appears because
rashes develops 1-2d after exposure
- AFTER rash appears: cool, wet compress, topical
cortisone, discourage scratcing
TOXIC EPIDERMAL NECROLYSIS
- Blisters, epidermal shedding, skin erosion
- A severe form of SJS
- GOAL of therapy: prevent sepsis
- MGT:
· Sterile, moist dressings
· Reverse isolation and strict sterile technique
· Prevent hypothermia; use rewarming techniques
· Sterile, cool compress or eye lubricants
· NO MASSAGE as it increases skin shedding; also
applies to kidney stones d/t further instigation of colic
ATOPIC DERMATITIS; “Eczema”
- GOAL: Alleviate pruritus and keep skin hydrated to
prevent new lesions and infection
EXERCISE INDUCED ASTHMA
- Exercise is not avoided; Bronchodilator is taken 20
minutes before exercise as with sunblock before sun
exposure
- N-acetylceisteine is not used to treat bronchospasm; It
loosens secretions which may worsens bronchospasm
MADULID, 2020
TARGET ORGANS
LIVER- Reye/Acetaminophen
GI- Iron/Aspirin Tocixity; However, Aspirin may cause Reye
KIDNEY- Lead/NSAIDs
SPLEEN- Sickle cell
HEART- Marfan’s, Kawasaki
PANCREAS- Cystic fibrosis
ISSUE ON NEPHROTIC SYNDROME: RISK FOR INFECTION d/t
protein loss (immunoglobulins) + use of steroids since it is an
autoimmune problem.
On DIARRHEA
- Decrease in number of diapers is a sign of dehydration
since it is a reflection of URINARY OUTPUT. BRAT diet is
not recommended for a client with diarrhea
- PETECHIAE during DIARRHEA IS AN EMERGENCY as it is an
indication of HEMOLYTIC UREMIC SYNDROME caused by
E. coli that results in hemolysis, low platelet and AKI.
- Blood in stool is normal for E. coli infected diarrhea d/t
intestinal irritation
- Fruit sugar is A NO NO d/t low electrolyte content.
- REGULAR DIET is recommended
FAILURE TO THRIVE
- d/t inadequate dietary intake primarily because of
disturbance in feeding behavior and psychosocial factors
- Should be assessed by observing the child feeding to
identify the cause of insufficient intake such as type,
quantity of food, how the child is being fed, amount of
time allotted for feeding, and the interaction between the
child and parent
- Measuring ht wt etc. would not determine the factors
relating to inappropriate or insufficient intake
- Child is already DIAGNOSED with FTT, thus measuring ht
wt would not contribute as it does not contain information
WHY the child has FTT. Measuring ht wt would contribute
if the child is not diagnosed yet and if the aim of the tx is
finding what the dx is
1.
2.
3.
4.
5.
RISKS FOR FTT:
DOMESTIC VIOLENCE;
Psych prob with food (anorexia)
POVERTY
Unhealthy eating behaviors
SOCIAL STATUS is a risk factor thus also is
UNEMPLOYMENT but NOT a parent WORKING OUTSIDE
HOME
1.
2.
3.
NOT RISKS
Birth order, whether eldest or youngest
Parents who work outside home
STATUS such as single or married is NOT A RISK FACTOR
as long as the parent is WORKING
INFANT COLIC
- Crying of a 3-4 month old infant 1-3hours a day d/t hunger,
thirst, tired, in pain bored or lonely
-
Nurse must first assess the infant’s pattern and frequency
of crying to know if it is normal or not; Asking the parent
what is done in response to the cry is the second priority
PHYSICAL EXAMINATION
- IAPePa is done in GI, GU (renal artery) and INFANTS
- Continuous suction is stopped temporarily when doing
auscultation for this to be not mistaken as bowel sounds.
PHARYNGITIS by GAHBS
- Contagious
- Soft diet and cool liquid
- NOT CONTAGIOUS 24h AFTER ATB TX; Replace
toothbrush 24h after ATB initiation to prevent
reinfection; Can go to school after 24h of TX
- Throat lozenges, but NOT to TODDLERS d/t aspiration
RISK
PERIOD OF COMMUNICABILITY
- PHARYNGITIS/MENINGITIS/IMPETIGO: Not
communicable 1d after ATB therapy; In meningitis,
technically only H. influenzae requires droplet prec:
Other bacterial and viral orgins do not
- SCABIES & 5TH DISEASE; Not communicable once sssx
appears
SUBMERSION INJURY
- 6hrs as critical period; Respiratory problems occur at this
time with SSX of marked decrease in RR or use of
accessory muscles; These SSSX is more important than
SSSX of hypoxia such as irritability.
RESPIRATORY PEDIA
- LTB is not life threatening even if it presents with stridor
and barking cough as long as O2 sat is adequate;
- EPIGLOTTITIS is ALWAYS A MEDICAL EMERGENCY which
presents as DROOLING with STRIDOR; HiB Vaccine
-
CRACKLES are normal immediately after birth
STRIDOR, WHEEZES are not normal
STRIDOR (high pitched, harsh sound)- partial airway obs.
MADULID, 2020
-
Communicable before symptoms occur; NOT
COMMUNICABLE once symptoms appear such as rashes,
arthralgia or body malaise
Primarily spread via respiratory secretions
Slapped cheek rash that spreads from proximal to distal
surfaces of the body
Course of disease is only 7-10d
TOILET TRAINING
- Bowel: 1.5yrs: 18mos.
- Bladder: 2.5 yrs: 30mos.
- Provide a quiet enjoyable activity (reading) during toilet
sitting to make experience more enjoyable
- Give REWARD for SITTING and NOT BECAUSE OF
DEFECATING
- SSX of training readiness:
· Sit on toilet
· Pull clothes up and down (not necessarily dress self)
· Express need to defecate
· Understands simple commands
· Remain dry in naps
HEARING IMPAIRMENT
- Shy and withdrawn
- Speech is MONOTONE, LOUD, INTELLIGIBLE and use of
gestures and facial expressions may be exaggerated
- Do not speak anything at 1 y/o
- Speaks but intelligible at 2 y/o
PLANNING
- In planning, the very important thing to consider is the
client or the client’s family’s readiness for change;
Implementing change with the family that is not ready
yet may cause frustration on the part of the client and
shock and disbelief.
MMR-V
- RF Seizure to clients with history of seizure
- If with (+) history, give separate MMR and V
- Monitor temp as high temp can go to seizure
- ONCE fever is reported by mom, ask HOW HIGH to
determine risk for seizure
- ONCE exposure to measles is reported, ask to GO TO
HOSP for measles prophylaxis ASAP because rashes will
not immediately be seen d/t incubation period of 7-21d
MEASLES
- MMR Vaccine to exposed 3d w/in exposure
- CALAMINE, DIPHENHYDRAMINE, COOL OATMEAL BATHS
are not used since rashes are not ITCHY unlike the one in
VARICELLA
5th DISEASE
- School aged children
TODDLER
- No concept of time; Affixing daily schedule while
hospitalization is not effective (more appropriate to
clients with autism)
- Pointing out body changes that may occur are more
appropriate to ADOLESCENTS
- Introducing a patient to others with same condition or
PEER SUPPORT is for ADOLESCENTS
MADULID, 2020
MARFAN’s SYNDROME
- Eye, Musculo, Cardio
- Cardio; aneurysm, valve defects such as in KAWASAKI
DISEASE
- PRIORITY: NO CONTACT SPORTS d/t cardiac defects
unlike in CYSTIC FIBROSIS where activity should NOT be
restricted for secretions not to accumulate
- Prophylactic ATB to prevent endocarditis
DUCHENNE MUSCULAR DYSTROPHY
- X-linked recessive
- No dystrophin which is for muscle stabilization
- Proximal LE and pelvis are affected first thus the calf gets
all the work causing hypertrophys
- No cure; wheelchair bound in adolescent and dies at 2030 from respiratory failure
- Throw away rigs
HYPOSPADIAS
- Circumcision is delayed so that foreskin can be used to
reconstruct the urethra
- POSTOP: Catheter or stent will be placed to maintain
patency while new matus heals; UO is an important to
monitor and reflects urethral patency; ABSENCE of UO
for >1hr indicates obstruction and requires immediate
follow up
PYLORIC STENOSIS
- Symptom onset is at 3-5 weeks old
- Common in first born boys
- Non-bilous projectile vomiting ff. by hunger vomit
INTUSSUSCEPTION
- Red, currant jelly is a misxture of blood and mucus d/t
blood leakage s/t bowel ischemia from the telescoping of
the parts of the intestine
MADULID, 2020
-
Although located in ileum, steatorrhea is not seen, it is
more on cystic fibrosis, celiac disease or pancreatic
insufficiency
HIRSCHPRUNG’S DISEASE
- No relaxation of internal anal sphincter causing no
peristalsis resulting to no passage of
meconium/intestinal obstruction
- COMPLICATION: Enterocolitis- colon inflammation which
can lead to death and sepsis with the ff presentation:
fever, foul smelling diarrhea, rapid worsening
abdominal distention, excessive vomiting
- Excessive crying with greenish vomiting is normal
RETINOBLASTOMA- White pupil (leukocoria or cat’s eye
reflex)
- A retinal malignancy
- The white color is the light reflecting the tumor.
INGUINAL HERNIA
- Bowel tissue protrudes d/t weak abdominal wall.
- Dull pain exacerbated by exercise
- Pain, abdominal distension, N/V (sssx of mechanical
bowel obstruction) are d/t bowel segments incarcerated
by hernia.
- Bowel ischemia/strangulation can lead to infection to
death
MADULID, 2020
INFANT OF A DIABETIC MOTHER
- HYPERINSULINISM occurs after birth because the
glucose demand for excessive insulin secretion is low
resulting to hypoglycemia, but hyperglycemia
immediately after birth
- Fetus increases metabolic activity and O2 consumption
thus EPO production also increases causing
polycythemia-induced infant of a diabetic mother with
sssx of HIGH HCT
DELAYED MECONIUM PASSAGE
- Could be a sign of cystic fibrosis (d/t thick secretions
which block intestines) or hirschprung’s
DRUG ADDICTED NEONATE
- Yawning, sneezing and high pitched cry (also a feature of
newborn with inc ICP such as that of an infant with
hydrocephalus)
- CNS STIMULATION (SSSX OF OPIOID WITHDRAWAL):
Irritable, restless, HIGH pitched cry, increased muscle
tone, hyperactive reflexes, sneezing, nasal congestion,
sweating, yawning
- GI SSSX; Poor feed, vomit, diarrhea
CONT…
- Manifests within 24-48 hours
- Risk for skin excoriation from excessive movement
caused by hyperactivity and restlessness;
- Swaddle newborn with arms and legs flexed to prevent
skin damage from excessive movement and minimize
stimulation; gentle, rhythmic rocking may soothe the
newborn
FETAL ALCOHOL SYNDROME
EDWARDS SYNDROME (TRISOMY 18)
- Most cases die in utero or half dies in first week to 1st
birthday
- A chromosomal abnormality: No cure
PRESSURE ULCERS/INJURIES
1. Stage 1: Intact skin with nonblanchable redness
2. Stage 2: PARTIAL skin loss: abrasion, blister, or shallow
crater; up to dermis, red or pink, shiny or dry
3. Stage 3: FULL skin loss: SQ,
4. Stage 4: FULL skin loss: muscle to bone; slogh or escar
may be present
5. Unstageable: If the base is covered by necrosed tissues
or eschar
MADULID, 2020
MADULID, 2020
PULSE OX
-
MI & POST PACEMAKER INSERTION: ATTACH to a cardiac
monitor
HEART FAILURE: Auscultate for breath sounds
MYOCARDIAL INFARCTION
- MOST COMMON dysrthymia Post MI is VFIB
- VTACH/PVCs can occur which can result to vfib thus is
treated quickly
MADULID, 2020
SVT
PACs
PVCs
COMPLETE HEART BLOCK
- Temporary pacing followed by permanent pacemaker
MADULID, 2020
MADULID, 2020
ACROMEGALY
MADULID, 2020
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SHOULDER SLING
- Fingers must be visible to assess for circulation, sensation
and movement
- Sling supports the wrist joint with thumb facing upward
or inward
CANE
- Greater trochanter to the floor
- 6-10 in. in front and to side
- CRUTCH: 2-3 in to side, 6 in front
CARE FOR A CLIENT WITH TRACTION
- For hip immobilization thus reducing pain and spasm
- Traction boot below the fracture site
- Limb must remain in a neutral position (straight)
- Assess neurovascular status and skin integrity
- NO side to side repositioning (wedge pillow use)
because it will compromise the neutral position causing
adduction/abduction of the affected part causing
increasing pain and spasm
- Nurse can adjust velcro straps and hold or support
weight while repositioning the client
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Clean pin sites with sterile chlorhexidine or water
Keep vest dry by cool blow dry and changing weekly or
PRN
Place foam under pressure points
Use small pillow under head
ETHICO-LEGAL CONCEPTS
-
It is appropriate to include “will continue to monitor”
but mention what to monitor such as “will continue
monitor for signs indicating hypoglycemia”
Purpose is to report to risk management so that similar
things will not occur anymore
REPORT FILING is NOT DOCUMENTED in the patient’s
chart such as “File was reported”.
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N. LATERAL/HORIZONTAL VIOLENCE
- Document and report the incident
O. ADVANCE DIRECTIVES
- Advance directive, in general, pertains to living will
- Medical power attorney pertains to healthcare proxy
- In palliative care, medications to reduce discomfort such
as narcotics can be given. HOWEVER, when opioids
toxicity or withdrawal occurs (bradypnea, lethargic), in
which a reversal agent, naloxone, is needed, it SHOULD
NOT be administered because pain will occur and it
oposes the standards of care that will violate a DNR order
P. MEDICATION ERROR
- In a medication error, HCP is first notified so that
necessary treatments be initiated immediately;
Reporting it to the nurse manager will only delay
treatment; After reporting to the HCP in which only then
the nurse can report it to nurse manager and file an
incident report
-
DELEGATION CONCEPTS
- LPN can MONITOR but UAP can only REPORT
- UAP
· Can document: VS (O2 sat but NOT PAIN), U/O
· U/O Documentation can be done BUT NOT U/O
MONITORING such as assessing urine characteristics
· Can report the amount and type the patient ate but
not the urine characteristics
CANNOT do RN SKILLS such as suctioning (except
ORAL suction), tracheostomy care, catheterization,
etc. EXCEPT for VS TAKING and its DOCUMENTATION
· COLOSTOMY: UAP only can empty the drainage and
record it; UAP CANNOT assist a patient with
reapplying a colostomy bag nor position adhesive
wafers
· CAN insert compression stockings but CANNOT
MEASURE it
§ ABOUT COMPRESSION STOCKINGS
§ Open wounds should be covered with occlusive
dressings vefore compression stocking (TED
Hose) application
§ Should be worn continuously and be removed 13x/day only for vascular assessment
§ Wear ted hose with legs on dependent position
while sitting or standing usually during the day
§ Should be worn not larger nor smaller fit
· Assists RN on ambulating a client 1d post op
· Return unused blood to blood bank
· Take family member to waiting room
· Can take VS even in critical situations such as post op
1st hour, to be VS q15 minutes or even a client’s
baseline VS / Weight
· Can also take and record CBGs, but not a newly hired
one; CBGs can also be done by LPNs
· Can connect a client’s ecg leads to cardiac monitor
(only those with training, not a newly hired)
· Weight measurement can be taken but NOT daily
weights as UAP does not know WHEN to take. Oral
hygiene is more appropriate than taking Daily
weights
· ON PAIN:
§ Can report grimacing, can remind patients to
report pain as necessary, can ask patients directly
“Are you having pain”?; These do not necessitate
assessment on the part of the UAP
§ Cannot: ask about PQRST of pain, observing for
relief or “evaluation” of therapy and cannot
determine position changes that relieves pain
which is also an “evaluation”
ONLY RN CAN DO:
· INITIAL (ADMISSION) and LAST teachings
(DISCHARGE)
· ADPE:
· ASSESSMENT except: SOUNDS (Lung and Bowel)
and NEUROVASCULAR CHECKS
§ NOTE: Lung sounds monitoring is a scope of
LPN but evaluation of therapy by using lung
sounds as a parameter is not appropriate:
E.g: Lung sound assessment in response to
bronchodilation effectiveness is an example
of EVALUATION
§ “Observation” is “Monitoring” which is
within the scope of LPN and also means
assessment or monitoring of certain
situations for possible complications such as:
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-
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“Observing mucous membranes, lips
and tongue” to a client with
dehydration; This is different from
observing for actions that indicates
fatigue because it is already an
assessment of sssx or interpretation of
sssx which is more on the RN’s
responsibility
· “Inspecting skin for reddened areas”;
· “Assessing a catheter insertion site for
bleeding/hematoma”
· “Checking area for bleeding every 15
minutes”
· What is prohibited is “assessing skin
turgor”
· NOT DELEGATED to a UAP
§ “Reminding/Encouraging/Ensuring”
patients to do some self-interventions;
These words indicates that the nurse already
taught the client and the purpose of which is
only a reinforcement: such as “drinking
adequate OFI” or “Ensuring oxygen flow of
5L/min via nasal cannula is within scope of
LPN/UAP;
This
differs
from
TEACHING/INSTRUCTING which is an RN’s
job
· DIAGNOSIS, PLANNING
· EVALUATION (except medication effectiveness
evaluation)
· In MEDICATION ADMINISTRATION, LPNs can
generally do anything about it, such as explaining
application of a nicotine patch (scope of
medication administration) and evaluation of
medication
effectiveness
(response
to
medications)
· EAT: Evaluation, Assessment, Teachings (NOTE: LPNs
can reinforce teachings already made by an RN but
never to give first and last teachings
§ Teachings such as “reminding” or “encouraging”
a client to rinse mouth with normal saline is
within LPN’s scope
· BLOOD TRANSFUSION
· IV Medications; All other nursing procedures may be
given by an LPN (Enema, suction, trach care)
Client with kidney stone who needs frequent PRN
medication can be delegated to a newly graduate nurse as
the skill is predictable rather than: Client on 2nd post op
day who needs pain med before dressing change; Client
reporting pain on IV site; Client with leg cast who needs
neuro-circ checks and PRN meds
NO DELEGATION to newly admitted and discharged
NO DELEGATION to a patient which requires IN-DEPTH
ASSESSMENT such as AIDS with pleuritic chest pain or an
anxious client with chronic pain who frequently uses the
call button
NO DELEGATION to patients who has issues such as
patients who are mad, does not want to take medications
and such, as these issues require assessment by an RN
-
Post hip replacement and log rolling technique with a
cervical collar requires an RN for positioning!; It requires
nursing assessment and judgment
NEW graduate nurse must first consult her charge nurse
before consulting the HCP for any clarifications
A hand held nebulizer is more for respiratory therapists
PHYSICAL THERAPIST: “Below the waist”
- Mobility, ambulation and transfer
OCCUPATIONAL THERAPIST: “Above the waist”
- ADLs
- Dressing, bathing
NEUROPATHIC PAIN/FIBROMYALGIA
- Antidepressant and Anticonvulsants (Gabapentin &
Carbamazepine). Also used to treat tic doloreux
- Antidepressant to older adult with neuropathic pain is
not recommended d/t its risks such as confusion and
orthostatic hypotension which places the client at risk for
injury
MIGRAINE; SSRI d/t constricting effect
NOCTURNAL ENURESIS; Tricyclic antidepressants (improve
functional bladder capacity) and Desmopressin (reduces urine
production during sleep)
CANCER
- First step in managing pain in cancer is to ask the patient
about PQRST of pain
- Cancer patients on chemotherapy is at risk for infection,
and if infection already develops, it is a priority or is
important since they also have decreased ability to fight
it; Infection on cancer patients can also be a cause of
death; Even a slight increase in temp in these clients may
already indicate sepsis
BREAKTHROUGH PAIN
- acute onset, abrupt pain caused by poor pain
management
BLEEDING RISK
- No alcohol based mouthwash- dries mucous membrane
- Use PAPER TAPE on skin
- Suppositories are not recommended.
DIAGNOSTICS
- WBC count is the VERY IMPORTANT laboratory test to be
monitored in cancer clients and not Prothombin time
NOR BUN
- WBC is also the very best indicator of ATB effectiveness
- Nitrates effectiveness: Do activities with no chest pain
- Paracentesis: No DOB/Dec abdominal circ
- IV Albumin after paracentesis: No hypotension
- Mannitol: Inc UO
- Lactulose on Hep Enceph: Improved LOC
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Absorbed only in the large intestines which it
produce an acidic environment which converts the
alkaline ammonia to ammonium thus is excreted
rapidly. Given on empty stomach for better results
MagSulfate on Eclampsia: No seizures
BREAST CANCER SCREENING
- Average-risk women for Breast Ca should be screened for
mammography and not CBE
- Any woman at any age with life expectancy over 10
years, annual mammography is recommended
COPD
- ABG results to be sent to lab is more important than a
routine order of an albuterol
- RR of 30-40 is present on exacerbations + wheezes
- If a COPD pt is experiencing DOB and O2 sat shows 99%
with 6L/min of O2, immediately discontinue the oxygen
- If a patient with COPD is having DOB, and O2 sat shows
that the patient is severely hypoxemic, immediately give
high flow oxygen while continuing to monitor for
patient’s O2 sat. Oxygen concentration will be adjusted
down based on client’s O2 saturation improvement
- Normal O2 sat for hypoxemic drive: 89-94%
ANGINA
- APPROACH:
· 1. BP & HR for baseline: Remember: NTG causes
hypotension
· 2. NTG
· 3. Morphine if IV NTG does not relieve the pain
- If chest pain improves after the 1st NTG, give another
dose of NTG until the chest pain is completely gone
ACUTE PANCREATITIS
- NORMAL features but must be reported: hypocalcemia,
& pain unrelieved by medication
- Sinus tachycardia is normal d/t very painful condition
KIDNEY STONES
- PAIN MGT focuses on fluid balance (avoiding over or
under hydration) and not cool packs nor massaging the
area
- Painless hematuria and dull pain in groin area is
common; absence of pain with scanty UO indicate stone
dislodgement and obstruction in urine flow
FRACTURE
- Pain mgt includes elevation of affected part to reduce
swelling thereby reducing nerve compression
- PCA pumps must be pumped 10 minutes before a painful
procedure and should not be based via pain scale
because pain interpretation is different from each other
- COMPARTMENT SYNDROME is more described as pain
on passive motion and not a sudden increase of pain
(arterial obstruction);
HIP FRACTURE
- Groin and hip pain in weight bearing
- AB or Adduction of affected extremity
- External rotation
- SADDER: Shortening/Spasm, Adduction, External rotation
IV Furosemide is the primary TX for normal clients with
hyperkalemia over Kayexalate; However, diuretics in CKD do
not work very well, thus Kayexalate is more preferred than IV
Furosemide to patients with CKD who has hyperkalemia
TREATMENTS for kidney transplant rejection
- REMOVAL for hyperacute rejection
- Increased dose of immunosuppressant for acute
- Conservative management for chronic
- IV ATB for infection
Rapid weight gain, round face, fluid retention or any swelling,
as it may be normal for clients taking steroids, it should be
reported to the HCP
Skin turgor is assessed better on the chest are under the
clavicle than the abdominal area
LAXATIVES in general includes stimulant cathartics, bulk
forming and stool softeners; All of these are contraindicated
to patients with bowel obstruction/ulcerative colitis d/t risk
for bowel/intestinal perforation
ISCHEMIC STROKE
- Ischemia d/t blocked blood flow s/t clots etc.
- High BP is normal with ischemic stroke as the body
compensates to perfuse organs with blood, called
permissive hypertension which occurs 1-2d ater stroke.
This is NORMAL as long as systolic is < 220 mmHg
RETINAL DETACHMENT
- May be d/t trauma
- “Hairnet” like vision; 3Fs: Flashers, Floaters, Falling
curtains
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Consent may or may not be applied depending on the
client’s competence; A medical power of attorney or a
consent from relative is not needed.
PEDIATRIC CAR SEATS
- Wear only light clothing; bulky clothing, sleep sacks
reduces a car’s effectiveness
- Car seat placed in the center
- Rear facing until 2 years old
- Place at 45 degree angle; for the neck and head not move
forward thus not obstruct the airway
- All children <13 at back seat
CEREBELLAR FUNCTION; COORDINATION
- Finger tapping
- Rapid alternating movement (pronation/supination)
- Finger to nose test
- Heel to shin
SENSORY FUNCTION
- Graphesthesia- identify what is being drawn in hand
- Stereognosis- object identification
- Two-point discrimination
AV MALFORMATION
- Tangle of veins and arteries formed during embryonic
development
- Most crucial is blood pressure control d/t risk for
intracranial bleed d/t vein’s weakness
- Report: severe HA, N/V
ECT
- NPO 6-8 hrs
- Bite block is used
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PART 2; ADDITIONAL NOTES
GONORRHEA, CHLAMYDIA, HERPES, PAP SMEAR
OVARIAN CANCER
- Abdominal bloating, pelvic pain/pressure, increased
abdominal girth, early satiety are the sssx d/t enlarging
mass at ovarian site.
BREAST CANCER
- Hard, immobile, NONTENDER
- History of endometrial or ovarian cancer
- Menarche before 12 and menopause after 55
- Hormone therapy (estrogen OR progesterone)
PROGESTERONE PILLS; 3333333
- If missed 3h, use barrier
- Vomits/Diarrhea in 3h, take additional dose
- There is no inactive pill, hence heavier mens occurs
MUCOSITIS
ENDOMETRIAL CANCER
- CAUSE: ESTROGEN without progesterone because
ESTROGEN thickens it and progesterone thins it.
Thickening without thinning causes excessive
endometrial proliferation / hyperplasia causing
abnormal cells to grow
- PROGESTERONE: Thickens cervical mucus
- ESTROGEN: Thins cervical mucus
- OCP is not a cause because it has progesterone which is a
protective factor
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DOCUMENTATION
LAP CHOLE
EBOLA
MASKS
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RITALIN/METHYLPENIDATE; STIMULANTS
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