Values to know
Blood pressure 120/80
Heart Rate 60-100bpm
SPO2 95-100% or 88-92% for COPD
Temperature 36.5-37.5
Respiratory Rate 12-20 rpm
Andie
Morris
Andie.morris12@hotmail.co.nz
ADULT HEALTH
3
CARDIOVASCULAR
RESPIRATORY
NEUROLOGICAL
NERVOUS SYSTEM
GASTROINTESTINAL
MUSCULOSKELETAL
ACID/BASE BALANCE
DIABETES
RENAL
DIGESTIVE SYSTEM – LIVER, GALLBLADDER AND PANCREASES
INTEGUMENTARY
IMMUNE SYSTEM
OTHER INFECTIONS
TRANSMISSION PRECAUTIONS
SEXUALLY TRANSMITTED DISEASES
CANCER
POST-OPERATIVE CARE
VITAMINS
3
8
10
16
16
18
20
20
22
24
25
30
31
33
33
34
36
36
MATERNITY NURSING
36
FEMALE REPRODUCTIVE SYSTEM
CHANGES TO THE BODY IN PREGNANCY
ANTENATAL TESTING
PREGNANCY COMPLICATIONS
POSTPARTUM MOOD DISORDERS
CERVICAL SCREENING
36
37
38
38
40
41
CHILDREN’S HEALTH
41
WEIGHT AND NEWBORNS
THE APGAR SCORE
INFANT REFLEXES
JAUNDICE IN NEWBORNS
CONGENITAL DEFECTS
RESPIRATORY
TONSILLITIS
OTITIS MEDIA
REYES SYNDROME
ECZEMA IN CHILDREN
MEASLES
CONJUNCTIVITIS
FAMILY VIOLENCE AND CHILD ABUSE
WELL CHILD CHECKS
CHILD DEVELOPMENT
41
41
41
42
42
43
45
45
45
45
46
46
47
47
48
MEDICATIONS
50
ANTIBIOTICS
50
1
Andie Morris
OPIOIDS
NON-OPIOID ANALGESIA
CLEXANE – ENOXAPARIN
ANTACIDS
PROTON-PUMP INHIBITORS
INHALERS
CORTICOSTEROIDS
DIURETICS
ACE INHIBITORS -PRILS
NITRO-GLYCERINE SPRAY OR SUBLINGUAL
DIGOXIN – SLOW AND HARD
BETABLOCKERS - LOL
OXYGEN THERAPY
DIABETES
HISTAMINES
ANTIHISTAMINES
FLUID THERAPY
HORMONAL CONTRACEPTION
PHARMACODYNAMICS
MEDICATION CALCULATIONS
KO AWATEA INFORMATION
MEDICATION MANAGEMENT POLICY WAIKATO DHB 2020
51
51
52
52
52
52
52
52
53
53
54
54
54
55
55
55
56
56
57
57
58
58
MENTAL HEALTH
60
MENTAL HEALTH STATUS EXAM
RISK ASSESSMENT
SUICIDE PREVENTION
CO MORBIDITIES IN MENTAL HEALTH
ALCOHOL WITHDRAWAL ASSESSMENT
ANOREXIA NERVOSA
BIPOLAR AFFECTIVE DISORDER
SCHIZOPHRENIA
PSYCHOSIS
ANXIETY
DEPRESSION
COGNITIVE BEHAVIOURAL THERAPY (CBT)
RECOVERY MODEL “ACHIEVING THE LIFE WE WANT IN THE PRESENCE OR ABSENCE OF MENTAL DISTRESS ”
METHAMPHETAMINE ADDICTION
THE SUBSTANCE ADDICTION (COMPULSORY ASSESSMENT AND TREATMENT ACT) 2017
CRIMINAL PROCEDURE (MENTALLY IMPAIRED PERSONS) ACT 2003
PROTECTION OF PERSONAL AND PROPERTY RIGHTS ACT 1988
CHILD/ADOLESCENT MENTAL HEALTH
61
62
62
63
64
64
64
65
65
65
66
66
66
67
67
67
67
68
MENTAL HEALTH MEDICATIONS
68
ANXIOLYTICS
ANTIDEPRESSANTS
MOOD STABILISERS
CHOLINESTERASE INHIBITORS
ANTIPSYCHOTICS
DIETARY SUPPLEMENTS
68
69
69
70
70
70
MISCELLANEOUS
71
2
Andie Morris
SMOKING CESSATION
ENDURING POWER OF ATTORNEY
PUBLIC HEALTH AND DISABILITY ACT 2000
RESTRAINTS
NURSING COUNCIL OF NEW ZEALAND “A REGULATOR BODY TO EMPOWER”
THE HEALTH OF MAORI ADULTS AND CHILDREN
CODE OF RIGHTS
CORONERS
CLINICAL ASSESSMENT/ SHIFT DOCUMENTATION
READINGS
71
71
73
73
75
75
76
77
77
78
ADULT HEALTH
Cardiovascular
Blood pressure regulation
Blood volume, Overall compliance, Cardiac output, peripheral resistance,
Parasympathetic and sympathetic nervous system
Parasympathetic – releases acetylcholine > slows heart
Sympathetic – releases catecholamines, epinephrine (adrenaline) and
norepinephrine (noradrenaline) to increase heart rate.
RAAS system increases blood pressure
1) Blood pressure drops
2) Sympathetic nervous system stimulates
3) Kidneys cells release RENIN
4) Activate angiotensinogen (liver)
5) Creates angiotensin 1
6) ACE (angiotensin-converterting-enzyme (found on the surface of the lung
and kidneys, converts angiotensin 1 to angiotensin 2
7) Angiotensin 2 constricts vessels and increases blood volume.
How is cardiac output (the amount of blood ejected by each ventricle in 1 min)
regulated- heart rate (beats per min, sympathetic stimulation ^, drugs ^,
parasympathetic, Ace) and stroke volume (preload venous return, blood volume,
atrial contraction/ afterload, hypertension, vasoconstriction/ contractibility)
Normal values of Blood pressure
Optimal <120/<80
Normal <130/<90
High Normal 120-139/85-90
Hypertension >140/>90
Electrical impulses of the Heart
PQRST –
P- Atrial depolarisation then impulse delayed at AV node
QRS – ventricle depolarisation
T- Ventricle repolarisation
Imbalance of oxygen supply and demand in the Heart
Factors that decrease oxygen supply- atherosclerosis, anaemia, low coronary blood flow (hypotension, aortic valve
incompetence)
Factors that increase Oxygen demand- stress, physical work, tachycardia, increased force of constriction,
hypertension, thyrotoxicosis. When it is imbalanced = ischemia. When there is pain in the heart it is angina. This can be
stable meaning pain only on exertion or unstable meaning it happens at any time. The cause of this can be a spasm or
blockage.
Signs and symptoms will be chest pains because of the ischemia and inflammatory process. The sympathetic nervous
system will be activated which will mean an increase B.P due to vasoconstriction.
Congestive Heart Failure
Information: When there is not enough cardiac output to maintain metabolic need. Think of it as if the hart is a water
bottle. If you cannot squeeze the bottle with enough force water will not come out the top (systolic failure) and if the
water is not full enough when the bottle is squeezed not all the water will come out (Diastolic failure)
Systolic failure – Contraction issue
3
Andie Morris
Diastolic Failure – Filling issue
Risk Factors: Fatty heart valves, arrhythmias, infraction, Family history, Uncontrolled hypertension, recreational drug
use, viruses
Presenting symptoms:
Left sided Heart Failure
Causes fluid to back up into the LUNGS- Symptoms
causing DROWNING
Dyspnoea, rales, orthopnoea, weakness, nocturia,
increased HR, Nagging cough, Weight Gain
Right Sided Heart Failure
Causes fluid to back up into the BODY – Symptoms
causing SWELLING
Enlarged liver, swelling in hands and legs, weight
gain, oedema, large neck vein, lethargic, irregular
HR, Nocturia,
Diagnostic tests: B type Natriuretic peptide – bio markers released by ventricles when there is excessive pressure
X-ray – Ventricles would be hypertrophied, duller lung colour, stretched spidery veins
Echo, Nuclear stress test, heart catherization
Treatment: Response to meds, Labs – Potassium, tropins, Creatine, high fowlers position, smoking cessation support,
alcohol cessation support, prevent readmission with education (Low salt diet, fluid restrictions, flu vac, early signs),
watch for weight gain (this indicated fluid collection in the lungs or body)
Medications –
Ace inhibitors, Betablockers, Diuretics Anticoagulants, Vasodilators, DIGOXIN
Complications:
Can result in heart attack or stroke
Myocardial Infarction.
Information: AKA a heart attack, occurs
when blood flow decreases or stops in one
or more of the coronary arteries, to a part of
the heart, this causes damage to the heart
muscles. The blockage can be due to a buildup of plaque (cholesterol) and cellular
waste products.
Risk Factors: high blood pressure, high
cholesterol levels, high triglyceride levels,
diabetes and high blood glucose levels,
obesity, smoking, age, family history (stress,
lack of exercise, certain illegal drugs,
preclampsia)
Presenting symptoms: pressure or tightness
in the chest, shortness of breath, sweating, nausea, vomiting, anxiety, coughing, a fast heart rate, jaw pain, upper back
pain
Diagnostic tests: ECG – In the first hours and days after the onset of a myocardial infarction, several changes can be
observed on the ECG. First, large peaked T waves (or hyperacute T waves), then ST elevation, then negative T waves
and finally pathologic Q waves develop.
Blood test – looking for an enzyme called TROPONIN T (this is only in your blood if you’ve had a heart attack as it is
released from the heart muscles after injury)
Angiogram – looks for areas of blockage in the arteries
Echocardiogram – identifies areas of the heart that aren’t working properly
Stress Test – shows how the heart responses to situations
Treatment: CABG – Coronary artery bypass graft – reroute of veins and arteries around the blockage
Angioplasty – unblocks arteries using a catheter and places a stent
4
Andie Morris
Medications – aspirin (to break up the blood clot),
thrombolytics (dissolve clots), antiplatelets (prevent new clots),
nitro-glycerine (widen blood vessels), betablockers (lower
blood pressure and relax heart muscle), Ace inhibitors (also to
lower blood pressure and decrease stress on the heart),
Analgesia
Complications: arrhythmias, heart failure, heart rupture, valve
problems, death
Angina (ischemic chest pain)
Information: chest pain caused by heart disease, can be
triggered by exertion, stress, cold, heavy meals. Tachycardia in response to angina is detrimental because it increases
oxygen demand and impairs perfusion of the coronary arteries.
Two Types of angina:
Stables angina – involves occasional pain lasting 5-15 minutes, usually caused by exercise or activity and is relieved by
rest or Glyceryl trinitrate
Unstable angina – might have no trigger and can occur when resting, may last longer than 10 minutes and may not fully
be relieved by glyceryl trinitrate – more likely to cause a heart attack
Presenting symptoms: a squeezing pain/tightness/heavy sensation in the chest usually lasting up to 15 minutes, pain
or discomfort in arms/jaw/back/neck, shortness of breath, nausea, weakness, dizziness
Diagnostic tests: exercise tolerance test, coronary angiography,
Treatment: smoking cessation, controlling hypertension (ace inhibitor, betablocker), improving diet, losing weight,
lowering blood cholesterol with medications (if necessary), exercise program, Glyceryl trinitrate (nitro-glycerine),
angioplasty, CABG,
Complications: heart attack
Aortic Dissection
Information: When there is a tear in the aortic Type B going down Type A closer to the heart. This tear causes blood to
build up in it which will clot. This causes a risk for DVT, Stroke amongst others.
Risk Factors: uncontrolled hypertension, atherosclerosis (hardening of the arteries), pre-existing aortic aneurysm
Presenting symptoms: sudden severe chest or upper back pin, severe abdominal pain, loss of consciousness,
breathlessness, fainting, trouble talking, loss of vision
Treatment: Lower the blood pressure and heart rate – Anti hypertensives (labetalol/ beta blockers), a stent can be put
in
Complications: death due to severe internal bleeding, organ damage (kidney failure), stroke
Deep Vein Thrombosis.
Information: a formation of a clot within a deep vein.
Risk Factors: stasis of venous circulation (blood cannot just pool and
not move in a vessel as it will just start to clump together conditions
that lead to this can be immobilisation, varicose veins, surgery,
traveling for long hours, obstructions, heart failure and afib),
Hypercoagulability (patients high risk for clots can include, cancer,
sepsis, dehydration, birth control, postpartum period) Endothelial
damage to the vein (iv drug usage, indwelling devices, medications
that damage the vein, trauma or injury to the vessel (surgery)
Symptoms: redness, swelling, vary warm, pain
Treatment: prevention with teds and SCD’s, don’t massage area as it
can dislodge, elevate the extremity, bed rest, anticoagulants, heparin,
warfarin, thrombolytics, filter, compress, observe signs and symptoms
Shock
Information: A state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory
system.
Four types of chock depending on what effected the flow of blood all are like threatening
5
Andie Morris
Obstructive Shock: when blood can’t get to where it needs to go. A pulmonary embolism is one condition that may do
this. Conditions that can cause a build-up of air or fluid in the chest cavity can lead to this. Including collapsed lung,
hemothorax, cardiac tamponade
Cardiogenic Shock: damage to the heart can decrease the blood flow to the body leading to this. Common causes include
damage to heart muscle, irregular heart rhythm, very slow heart rhythm.
Distributive Shock: conditions that cause the blood vessels to lose their tone can cause this. When they lose their tone,
they can become open and floppy that not enough blood pressure is supplied to organs. Symptoms include flushing,
hypotension, loss of consciousness. There are many types of this shock such as Anaphylaxis shock, septic shock,
neurogenic shock
Hypovolemic Shock: happens when there isn’t enough blood in the blood vessels (intravascular space) to carry oxygen
to the organs. Can be caused by severe blood loss >15% of their blood volume. This will cause a decrease in cardiac
preload because there is a major depletion of volume =, there will be a decrease in the amount of venous return to the
heart. (if the patient has lost less than 10% of blood volume symptoms will be normal blood pressure, capillary refill
less than 2 seconds and urine output greater than 30ml/hr. This shows that the patient is asymptomatic until 15% or
more blood is lost. Then the signs will be rapid/weak/absent pulse, Irregular heartbeat, anxiety/restlessness,
decreased urine output, blood pressure 70/56, pale cool skin), The best position for a patient with hypovolemic shock
is the modified Trendelenburg.
Presenting symptoms: rapid/weak/absent pulse, Irregular heartbeat, rapid shallow breathing, light headedness,
cool/clammy skin, dilated pupils, lacklustre eyes, chest pain, nausea, confusion, anxiety, decreased urine output, thirst
and dry mouth, low BGL, loss of consciousness,
Diagnostic tests: may be evaluation of external symptoms, hypotension, weak pulse, rapid heartbeat. X rays, blood tests
Treatment: get blood circulating ASAP. This can be done by giving fluids, drugs, blood products and supportive care.
Once stable a cause can be determined. Adrenaline for anaphylactic shock (you know this is successful when the
patients breathing becomes easier), blood transfusion to replace blood loss for hypovolemic, medications and heart
surgery for cardiogenic shock, antibiotics for septic shock
Complications: Death
Hypovolemic Shock
Information: When there is low fluid volume in the intravascular system. This decrease of volume then decreases
cardiac output which leads to decreased tissue perfusion which limits the cells access to oxygen. A person must lose
15% or more of their volume to show signs and symptoms.
Two Types of ways to lose body from the intravascular system:
Relative Hypovolemic Shock
Absolute Hypovolemic Shock
An INSIDE shift from the
An OUTSIDE fluid shift from the
intravascular system to the
intravascular system to the
interstitial spaces.
outside body.
Tends to be more concealed
Massive bleeding from injury or
Fluids or blood collecting or
surgery
leaking inside the body from
Excessive fluid loss from oral
internal bleeding, third spacing
(vomiting), GI (diarrhoea),
of fluid (severe burns due to
integumentary (sweating)
increased capillary
permeability), fracture of long
bones, damage to organs
Massive vasodilation from septic
shock
Major depletion of volume> decreases the amount of venous return> decreases preload> decreases stroke volume>
Decreases cardiac output > if cardiac output drops too low the amount of blood that should be going to the organs per
minute will fall> lowered oxygen received by cells > hypoxic cell injury > body will attempt compensation by activating
the sympathetic nervous system
Signs and Symptoms: Depends on the amount of volume lost but typically Tachycardia, hypotension, cool/clammy skin,
weak peripheral pulses, anxiety, decreased urinary output, central venous pressure low
Treatment: Monitor oxygenation (may need intubation) urinary output, if bleeding hold firm, place in modified
Trendelenburg position, Obtain IV access (at least two needed for rapid fluid delivery), collect labs, Crystalloids (saline
will add more volume but watch for fluid overload), Colloids (albumin or hetastarch, will stay in the intravascular space
for longer due to larger molecules, monitor for fluid overload) give warmed fluids to avoid hypothermia, Blood
products frozen fresh plasma to help with clotting , platelets for uncontrolled bleeding to help with thrombocytopenia
6
Andie Morris
Anaphylactic Shock
A form of Distributive shock. Occurs due to an allergen in the
body this leads mast cells or basophile to release histamine
and other chemicals system wide which then decrease tissue
perfusion causing shock to occur.
Anaphylactic reaction – first starts with sensitisation for a
reaction to occur. This means that during the first exposure
the allergen there is the creation of IgE antibodies, these
antibodies attach to the mast cell or basophil and wait for the
second exposure. When this second exposure to the allergen
occurs it causes the release of histamine and leads to
anaphylactic reaction. This is a Type I hypersensitivity
reaction. Meaning the allergen attaches to IgE antibodies on
mast cells and basophils. This leads to a system wide release
of histamines.
Anaphylactoid Reaction – Non IgE related. The patient doesn’t have to be sensitised for the reaction to happen but can
happen with the first time exposure. Causes came reaction as anaphylactic but it’s not through the Ige antibodies on the
mast cells or basophils. Allergens for this type include contrast dyes, chemotherapy agents, NSAIDS. These agents
directly cause the mast cells and basophils to breakdown and release histamine.
Histamines effect on the body – Causes dilation of vessels (lowering blood pressure and tissue perfusion),
Bronchoconstriction (narrowed airways and respiratory failure), increased heart rate, increases the permeability of
vessels (lead to swelling and depletes intravascular space of fluid that shifts to the interstitial space), itching, increases
contraction of GI stomach muscles and increases gastric secretions (leads to nausea, vomiting, diarrhoea and GI pain)
Signs and symptoms: are due to histamine so what histamine causes is also the signs and symptoms (dyspnoea,
wheezing, swelling of upper airways, can’t speak, coughing, stuffy nose, watery eyes, tachycardia, hypotension (due to
compensation), loss of consciousness, vomiting, nausea, red, swollen, itchy, hives.
Treatment: Prevention! KNOW patients allergies, airways, high flow oxygen and continuous vital sign monitoring,
Trendelenburg position, adrenaline IM (patients breathing will then become easier), patient education around
avoiding allergen, medi alert bracelet, epi-pen education
Sepsis
Information: first septicaemia is when bacteria enters the bloodstream and causes blood poisoning which triggers
sepsis. Sepsis is an overwhelming and life threatening response to infection. It is when the body’s immune system
response abnormally to an infection. The immune system goes into overdrive and starts to attack the body organs.
Risk Factors: Suppressed immune system, extreme age (very old/very young), organ transplant recipients, after any
surgical procedure, indwelling devices, and sickness (chronic, diabetes, renal/liver failure), Common infections that
lead to sepsis include pneumonia, urine infections, intraabdominal infections, infections of the skin such as cellulitis, or
joints such as septic arthritis, infections of the blood.
Presenting symptoms:
Sepsis is a spectrum ranging from mild to severe.
Mild Symptoms (Warm Phase)
Systemic inflammatory Response
Early signs include compensation
Temperature above 38 or below 36
Heart rate above 90
Respiratory rate above 20 or PaCo2 below 32
White blood cell count above 12,000 or below 4,000
Restless/anxious
Low Blood pressure
Warm/flushed skin due to vasodilation
Hyperthermia
High cardiac output - tachycardia
Lethargic/anxious
Severe symptoms (Cold Phase)
Sepsis confirmed infection + Systemic inflammatory
response syndrome
Septic Shock
Late signs = no compensation
Cold/clammy pale skin
Severe hypotension that fluids are not fixing
Increased Heart Rate and Respiration rate
Oliguria (less than 400mL out urine in 24 hours)
Coma
Hypothermia
Severe lactate over 2-4mmol/L (because organs will
release lactic acid when using anaerobic)
MODS – Multiple organ dysfunction
Diagnostic Tests: Cultures, blood test
Treatment: Take cultures,
Start Antibiotics ASAP (after cultures) To fight the organism
Crystalloids/colloid To increase perfusion
Enteral Nutrition To ensure nutrition to fight infection
7
Andie Morris
Protein Activated C Anti-inflammatory and anti-thrombotic (watch for bleeding)
Titrate Vasocompressors – Norepinephrine For Vasoconstriction when fluid doesn’t work
Inotropic For heart Strength
Steroids- corticosteroids low dose Only for some patients reduces amplified inflammation if Vasocompressors don’t
work
Haemodynamic – central venous line
Oxygenate to increase oxygen possibly intubation
Glucose – keep under control as serum lactate below 2-4mmol/L not normal
Complications: complete organ failure, organs not receiving sufficient oxygen or blood to function properly, stroke,
amputation of limb due to clots,
Septic Shock – occurs due to sepsis and leads to a major decrease in tissue perfusion to organs and tissues also a
decrease in systemic vascular resistance due to vasodilation. Shock (where cells are deprived of oxygen due to the lack
of perfusion) occurs due to an invasion by a microorganism (septic).
Iron Deficiency Anemia
Information: Low iron causing low supply of haemoglobin
Presenting symptoms: pale, weakness, low Hgb and Hct, Microcytic and hypochromic RBC.
Diagnostic test: Blood test
Treatment: oral iron intake (red meat, shellfish, spinach, legumes, turkey), iron supplement (between meals and with
fruit juice for maximum absorption, avoid giving with milk or antacids as it decreases absorption), teach about
expecting dark coloured stool and constipation.
Respiratory
Asthma
Information: Allergens get into the system and IgE
antibodies pick it up and take it to mast cells which hold
histamines. Histamine is then released into the blood
stream.
Three stages
(1) bronchoconstriction. This is when the smooth muscle
reacts to an irritant and constricts.
(2) inflammation this is when the mucosa layer thickens
due to a reaction to the inflammation and there is no longer
a round opening.
(3) is the swelling of the mucus and increased mucus
production.
Types of asthma include extrinsic (allergic) Intrinsic (nonallergy) mixed or exercise included. Triggers can be
inflammatory like allergens or infections, irritants like temp
change and stress or other which could be tobacco.
Risk factors: having a parent with asthma, having a severe
respiratory infection as a child, being exposed to certain
chemical irritants or industrial dusts.
Presenting symptoms: Coughing, difficulty breathing, shortness of breath, wheezing
Diagnostic tests: include – ABG – determines O2 and acid base balance, spirometry test – shows functional residual
capacity, chest X-ray- looking for overinflated lungs, depressed diaphragm, horizontal ribs, sputum analysis- rule out
infection.
Treatment: short term Beta 2 agonists- salbutamol- bronchodilator
Corticosteroids- anti-inflammatory, reduce the release of anti-inflammatory mediators. Or glucocortsteriods – reduces
inflammation
Complications: pneumonia, collapse of lung, respiratory failure where oxygen levels become dangerously low or levels
of carbon dioxide are too high
Emphysema COPD
Information: After the lungs are repeatably exposed to irritants the airways lose their elasticity and become thickened
and swollen. The swelling means the passageway for air becomes narrower. Causing partial blockage of the passages
carrying inhaled and exhaled air and a reduced capacity for the lungs to extract the oxygen from inhaled air.
8
Andie Morris
Risk Factors: Smoking, long term exposure to certain industrial pollutants or dust. Small percentage caused by familial
or genetic disorder alpha 1 antitrypsin deficiency.
Presenting symptoms: Breathlessness with exertion and eventually breathlessness most of the time in advanced
disease, susceptibility to chest infection, cough with phlegm production, fatigue, barrel shaped chest (from expansion of
the ribcage in order to accommodate enlarged lungs), cyanosis, pursed lip breathing
Diagnostic tests: Lung function test (spirometry), chest x ray, CT scan.
Treatment: smoking cessation, avoiding irritants, respiratory rehabilitation programs (education on emphysema,
introduce appropriate exercise, improve lung function through specific breathing techniques, advice on adapting life,
emotional support), oxygen treatment (16hrs/day) , medications – anti-inflammatory, bronchodilators, antibiotics,
stress management techniques, gentle regular exercise, Flu vaccine yearly
Complications: Pneumonia, collapsed lung (air pockets that may burst causing lung deflation), heart problems
(damaged alveoli reduced number capillaries and lower oxygen levels in the blood stream may mean that the heart has
to pump harder to move blood through the lungs. Over time this can cause serious strain).
Pneumonia
Information: An infection in one or both lungs. Caused by
bacteria, viruses, and fungi. Causes an inflammation in the
alveoli they can fill with fluid or pus making it difficult to
breath. It is transmitted through inhalation of airborne droplets
from sneezing and coughing. Includes influenza, respiratory
syncytial virus, rhinovirus (common cold)
Can be Hospital acquired, community acquired, ventilator
associated, aspiration pneumonia,
Risk Factors: infants’ birth to 2, 65+, weakened immune systems,
chronic conditions (asthma, cystic fibrosis, diabetes, heart
failure), respiratory infection, hospitalised or ventilated patients,
stroke victims that have trouble swallowing, people exposed to
lung irritants such as pollution, fumes and certain chemicals
Presenting symptoms: coughing, fever, sweating or
chills, shortness of breath, chest pain, fatigue, loss of
appetite, nausea, headaches
Diagnostic tests: Chest X-ray, blood culture, sputum
culture, pulse oximetry, CT scan, fluid sample,
bronchoscopy
Treatment: Oral antibiotics, antiviral, antifungal,
respiratory therapy (maximising oxygenation through
medications directly into the lungs or education of
breathing exercises, oxygen therapy)
Complications: Worsened chronic conditions,
bacteraemia, lung abscesses, impaired breathing, acute
respiratory distress syndrome, pleural effusion, death
Bronchitis
Information: inflammation of the lining of the bronchial
tubes. Can be either acute or chronic. Often develops
after a cold or other respiratory infection. Chronic is
more serious involving constant irritation or
inflammation of the lining often due to smoking.
Risk Factors: a cold or flu previous
Presenting symptoms: Acute: Chest discomfort, cough
that produces mucus, fatigue, fever, shortness of breath,
wheezing, even after it has cleared there may still be a
nagging cough that lingers for 4 weeks.
Diagnostic tests: physical exam, ask about medical history, symptoms, blood test to look for infection or a chest x ray to
look at the bronchial tubes and rule out pneumonia.
Treatment: most do not need antibiotics however if you have a bacterial infection in your airways with bronchitis virus
it may be prescribed. Bronchitis should go away in a week. Drink fluids use inhaler if needed, rest, aspirin or
paracetamol, use humidifier or breathe steam in the bathroom, do not smoke and avoid second-hand smoke.
Complications: COPD - Chronic Bronchitis – mucus build up
9
Andie Morris
Pulmonary Embolism
Thrombus lodges into branch of pulmonary artery (can also be due to fat embolism from a fracture of a long bone)
Signs and symptoms: blood tinged sputum, chest pain, cough, cyanosis, jugular vein distention, shortness of breath,
feeling of impending doom, hypotension, tachypnoea, tachycardia
Treatment: head of the bed elevation, oxygen therapy, arterial blood gases, anticoagulants
Influenza
Information: viral respiratory infection, spread through contact and droplet
Risk Factors: diabetes, heart disease, pregnant, over 65
Presenting symptoms: acute fever, chills, headache, fatigue, sore throat, cough, achy muscles, cough, stomach upsets
Diagnostic tests: physical exam,
Treatment: monitor lung sounds, rest, fluid intake, administer antivirals, antipyretics
Complications: can worsen other long-term medical conditions (congestive heart failure, asthma, diabetes),
pneumonia, death, ear infections, inflammation of the heart/brain/muscle tissue, and multi organ failure, trigger an
extreme inflammatory response leading to sepsis
Haemothorax – blood in the pleural cavity
Pneumothorax – air in the pleural space = lung collapses and can push the heart and great vessels towards another
lung
Signs and symptoms: no breath sounds on affected sides, cyanosis, shortness of breath, hypotension, chest pain,
subcutaneous emphysema, sucking sound, tachycardia, increased respiratory rate, decreased movement
Treatment: Cover the chest opening with a three-sided semi-occlusive dressing (1st priority) , oxygen therapy, fowlers
position, prep for chest tube insertion
Pleural effusion – collection of fluid in the pleural space preventing lung from fully expanding
Signs and symptoms: pleuritic pain, shortness of breath, dry cough, tachycardia, fever, decreased breath sounds over
area
Treatment: prep pt for thoracentesis, fowler position, monitor breath sounds
Flail Chest: Life threating medical condition the occurs when a segment of the rib cage breaks due to trauma and
becomes detached from the rest of the chest wall
Signs and symptoms: Extreme pain in chest, tenderness in the area of break, significant difficulty in breathing,
bruising/inflammation, uneven rising or falling of your chest when breathing, tachycardia, hypotension, cyanosis
Treatment: fowlers position, provide O2, cough and deep breathing, analgesia, bed rest, prep for incubation
Neurological
Strokes
Information: A stroke is when oxygen rich blood cannot
reach brain cells, therefore the cells begin to die.
Types of strokes:
Ischemic stroke: a blockage of the blood vessels causing a
lack of blood flow to the area. It can happen due to stenosis
(narrowing of the artery) or a blockage (embolism – clot
from another part of the body (heart), travels to the brain, or
thrombosis – clot formed within the artery wall)
Haemorrhagic stroke: rupture of the blood vessels causing
bleeding which leads to no blood being able to perfuse the
brain cells and excessive swelling. Can be caused by an
aneurysm burst, hypertension or age.
T.I.A: A warning sign! When the blockage only lasts a small
amount of time, will show signs and symptoms but they will resolve.
Risk Factors: smoking, blood thinners, rhythms, oral contraceptives, family history, excessive weight, old age,
hypertension, atherosclerosis, inactivity, previous T.I.A, elevated glucose, aneurysm
Presenting symptoms: will depend on the side of the brain injured. Watch for Face drooping, Asymmetry in the face,
slurred speech
10
Andie Morris
Diagnostic tests: CT to identify type of stroke and rule out bleeding as TPA cannot be administered to a haemorrhagic
stroke, angiography, MRI
Treatment: TPA- tissue plasminogen
activator which dissolves the clot by
activating protein that causes fibrinolysis,
must be given within 3 hours of stroke and
only to ischemic strokes, Criteria (CT scan
negative, labs normal, BP controlled and
under 185/110, hasn’t recently received
heparin). Interventions from TPA (Check
bleeding as it is a thinner, neuro checks all
the time, BP meds, vitals, labs, glucose, bed
rest to prevent falls and bleeds, no needles
or IMI injections, ICU, airway, cranial nerves
(gagging, pupils), bladder/bowel function,
skin pressure areas, nutrition/diet soft foods
and thickened fluids.
Complications: permanent damage
Limbic System:
A group of structures linked to emotion.
Such as amygdala, hippocampus, Para
hippocampal Gyrus (structure surrounding the hippocampus), Cingulate cortex, septal nuclei, mammillary body, fornix,
hypothalamus (hormone release and homeostats),
Nursing during Loss of consciousness
The role of a nurse in this situation is to prevent potential complications e.g. respiratory distress, pneumonia,
aspiration, pressure ulcers. This is achieved by
Maintaining patent airways: elevating the head end of the bed (prevents aspiration), positing the patient lateral or semi
prone, suctioning, chest physiotherapy, auscultate every 8hrs, endotracheal tube or tracheostomy
Protecting the patient: padded side rails, restraints, take care to avoid injury, talk with the client in between
procedures, speak positively to enhance self-esteem and confidence of the patient
Maintain fluid balance and managing nutritional needs: assess the hydration status, start iv-line, liquid diet, NG tube
Maintain Skin integrity: regular changing of position, passive exercises, back massages, use splints or foam boats to
prevent foot drop, special beds to prevent pressure on bony areas
Prevent Urinary retention: Palpate for full bladder, insert catheter, condom catheter for male and absorbent pads for
females in case of incontinence, inducing stimulation to urinate.
Provide sensory stimulation: provided at an appropriate times to avoid sensory deprivation, effort made to maintain
the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep, maintain the same
schedule each day, orient the client to day/date/time, touch and talk, proper communication, address the client by
name and explain each procedure
Family needs: family support, education, care
Maintaining the regular doses of treatment and follow
consultants’ instructions
Cerebral Palsy
Information: is an umbrella term that refers to a group of
symptoms and disabilities. Each person with CP will have
different experiences.
Risk Factors: more common in boys than girls, Caused by
brain damage but no exact cause in known but could be –
poor brain development in the womb, maternal infections,
disruption of blood flow to developing brain, genetic
conditions, ingestion of toxins/drugs, damage to the head of
skull during delivery, complications related to premature
delivery, deprivation of oxygen during birth, excessively
forceful forceps or vacuum extractor,
Presenting symptoms: Potential issues may include:
Movement and walking difficulties, speech difficulties,
learning disabilities, cognitive impairments, hearing and
vision loss, epilepsy (common co- occurring), emotional and
behavioural challenges, spinal deformities, joint problems
11
Andie Morris
Four types: Spastic CP: increased muscle tone and causes delayed developmental milestones, abnormal movements,
movement inhibition, stiff and spastic movements, difficulties controlling muscle movement, difficulties moving from
one position to another
Spastic quadriplegia: impacts a Childs upper and lower limbs and body. Severely restricting mobility
Spastic Diplegia: Only affects the lower half of the body, many can still walk with some impairments and may need
assistive devices
Spastic hemiplegia: Affects one side of the body only, usually the arm more than the leg. Most can walk.
DYSKINETIC CP
Second most common – Dystonia (repetitive and twisting motions), athetosis (writhing movements), chorea
(unpredictable movements), poor posture, painful movements, difficulty swallowing or talking.
ATAXIC CP
Least common, poor balance, limited coordination, tremors, shaky movements that are difficult to control
MIXED CP
Causes symptoms characteristic of two or three types.
Diagnostic tests: no single test,
Treatment: no cure, but medications to control symptoms, Baclofen or muscle relaxants, diazepam, anticonvulsants,
anticholinergics, antacids, stool softeners/laxatives, sleep aids. Surgery to improve mobility or manage pain (tendon or
muscle release, repair of hip dislocations and scoliosis surgery), therapy (Physical, occupational, feeding, aqua, horse
and animal, music, play, behavioural speech, bowel program)
Complications: co existing complications include hearing deficits, vision impairments, seizures, cognitive disability,
ADHD, Behavioural and emotional issues, feeding issues, gastric reflux, constipation, scoliosis, joint problems, sleep
disorders.
Seizures / Epilepsy
Information: epileptic seizures happen because a sudden burst of uncontrolled electrical or chemical activity in the
brain. Can range from brief pauses to stiffening and or jerking of the whole body.
what to do if someone has a seizure around you: stay with them, prevent
injury (move nearby objects), do NOT hold them down, do NOT put
anything in their mouth, do NOT give them water, pills or food until they
are fully alert, if it is longer than 5 minutes call
111, be sensitive/supportive/and calm
Risk Factors: most is genetic, damage to the brain cells after head injury
or illness (stroke, meningitis).
Presenting symptoms: Seizures: some people may “go blank” for a few
seconds or minutes, other remain full conscious during a seizure and can
describe the experience, other consciousness is affected, and they are
confused when it ends. Seizures may involve the whole brain
(generalised seizure) or part of the brain (focal seizure).
Types of seizures:
Generalised seizures – abnormal activity on both sides of the brain,
momentary stares, loss of consciousness, falls, repetitive muscle jerks, 6
types of generalised seizures (absence seizures, myoclonic seizures,
generalised clonic seizures, generalised atonic seizures – drop attack-,
generalised tonic seizures. Generalised tonic-clonic seizures – grand
mal).
Focal seizures (partial seizures) – starts in one part of the brain. The
sensations you feel when having a seizure depends on the part of the
brain it effects. Can be classified in many ways depending on the focal
awareness and impaired awareness. May spread to affect both parts of the brain and result in bilateral body and limb
stiffening and jerking. This is called a focal to bilateral tonic clonic seizure possible triggers for a seizure: forgetting
medication, stress, anxiety, lack of sleep, irregular meals. Blood glucose, heavy alcohol/drug use, flickering lights,
periods, illnesses that causes fevers, some medications.
12
Andie Morris
Diagnostic tests: recurrent seizures, history, triggers, EEG (measures activity of the brain), Brain scans CT or MRI
Treatment: Anti-epileptic drugs, surgery, ketogenic diet, complementary therapies such as aromatherapy to help with
relaxation
Advice:
Triggers, medications, regular reviews, Balanced diets, exercise, limited alcohol, safe environments,
Complications: Sudden unexpected death in epilepsy (SUDEP) – when a person dies with epilepsy and there is no other
cause of death
Meningitis
Information: A inflammation of the meninges covering the brain and spinal cord.
Many causes being viral or bacterial infection. Can develop very rapidly over a few
hours
Risk Factors: Babies and young children under 5, teenager, young adults, older
adults, weakened immune system, shared accommodations,
Presenting symptoms:
Babies/toddlers – Fever, crying/unsettled/irritable, refusing drinks or feeds,
vomiting, sleepy/floppy/harder to wake, stiff neck, dislike of bright lights, reluctant
to wake, rash
Teenager/adults - Fever, headache, vomiting,
sleepy/confused/delirious/unconscious, joint pains, stiff neck, discomfort to light,
rash
Diagnostic tests: difficult to diagnose, history or symptoms, clinical exam, blood
test, lumbar puncture
Treatment:
Bacterial meningitis: IV Antibiotics (recover and reduces risk of complications such as brain swelling and seizures)
Viral Meningitis: Usually mild and clears on its own. Resting, keeping warm, comfortable, drinking fluids
Non-infective meningitis: corticosteroids. In some cases, no treatment is required.
Complications:
Death, septic shock, cerebral oedema, seizures, arteritis/venous thrombosis, subdural effusions, hydrocephalus,
deafness
Intracranial Pressure
Information: the pressure exerted by fluids such as cerebrospinal fluid inside the skull and on the brain tissue.
Risk Factors: brain tumour, acute liver failure, heart failure, idiopathic intracranial hypertension, infections, seizures,
meningitis,
Presenting symptoms: headache, visual symptoms/blurred vision, pain with eye movement, reduced visual acuity and
vision field loss are late signs, nausea/vomiting, tinnitus, learning/cognitive difficulties, irritability, recent rapid weight
gain, coma, increased blood pressure, seizures
Diagnostic tests: MRI, lumbar puncture
13
Andie Morris
Treatment: Ventilation, medications antihypertensives, surgery, craniotomies (holes drilled in the skull to remove
pressure.
Complications:
Delayed treatment can lead to brain damage, long term coma or death
Glasgow Coma Scale
Guillain-Barre Syndrome
Information: an autoimmune neuro condition where the immune system attacks the nerves in the peripheral nervous
system. The immune system starts out by attacking the illness the patient had. It then starts to confuse the cranial and
PNS nerves for the illness. And therefore, the immune systems begin to attack the myelin sheath on the nerve cells. It
can then start to affect the parasympathetic and sympathetic nervous system therefore the nerves that regulate blood
pressure, heart rate/Rhythm, temperature, vision, GI, and renal
Risk Factors: a previous infection, can happen to anyone at any age.
Presenting symptoms: GRADUAL BLOCKING OF SENSATION, acute inflammatory demyelinating polyneuropathy is
the most common type and starts with paralysis/weakness/tingling sensation in the lower extremities and migrates
upward over time. It can be so severe the person will experience paralysis, inability to regulate temperature, blood
pressure issues, cardiac dysthymias
Diagnostic tests: nerve conduction studies, lumbar puncture
14
Andie Morris
Treatment: There is currently no cure, but treatment can help to decrease signs and symptoms if started within 2
weeks of symptoms. It may take the patient 1-2 years to return to baseline
Nurses role: monitor for progression, change in reflexes, spread, respiratory status, airway management at bedside,
evaluate their swallowing, communication, pain, pressure injuries, prevent blood clots, eye care, nutrition. Range of
motion activities.
Complications:
Delayed treatment can lead to brain damage, long term coma or death
Multiple Sclerosis
Information: an autoimmune disease in which the body
attacks itself without any known cause or reason. Affects
the nerves of the brain and spinal cord. It effects each
person in a different way. In people with MS, something
triggers the destruction of myelin – a fatty substance that
coats and protects nerve fibres in your brain and spinal
cord. The damaged myelin forms scar tissue (sclerosis).
Often the nerve fibre is also damaged. When any part of
the myelin sheath or nerve fibre is damaged or destroyed,
nerve impulses travelling to and from your brain and
spinal cord are distorted or interrupted. This causes
weakening and deteriorating of a wide range of bodily
functions
Risk Factors: people in cooler climates, young adults,
women, Caucasians, close relative of people with it,
smokers, exposure to the Epstein-Barr virus (the virus
that causes glandular fever also known as mono), thyroid
diseases, diabetes type 1, inflammatory bowel disease.
Presenting symptoms: vision problems such as blurred or
double vision, muscle spasms, muscle or nerve pain,
weakness or lack of co-ordination of the limbs, extreme
tiredness that can affect balance and concentration,
bladder or bowel problems (urinary
retention/constipations), problems with sexual
performance, speech and swallowing difficulties, mood
swings and depression, thinking/concentration/memory
problems.
Different Types of MS
Relapsing-remitting MS: recurrent episodes with
symptoms suddenly increasing or new symptoms
developing. This is followed by periods in which symptoms improves or disappear
Secondary progressive MS: within 15 years of diagnosis. Gradual, progressive worsening of neurological function
regardless of whether you have acute relapses.
Primary Progressive MS: neurological symptoms develop progressively from the outset, usually with slowly increasing
lower limb weakness
Clinically Isolated Syndrome: If you only have one episode or symptoms it is hard to predict which category
Progressive Relapsing MS: least common type, when the condition shows clear progression but also acute attacks with
or without full recovery.
Diagnostic tests: Symptoms can come and go so can be difficult to diagnose, blood tests to rule out other causes of
symptoms, MRI or brain and spinal cord, lumbar puncture, evoked potential test (recording of the nervous systems
electrical responses to the stimulation of specific sensory pathways such as vision.
Treatment: Treat relapses with steroid medications, prevent relapses with disease modifying therapy ease symptoms
minimise disability by rehabilitation.
Complications: Depression, epilepsy, paralysis typically in legs, muscle stiffness, mental changes (forgetfulness/mood
swings), problems with bladder/bowels/sexual
15
Andie Morris
Neurogenic Shock
Information: this type of shock leads to the inability of the sympathetic nervous system to stimulate nerve impulses.
This causes haemodynamic problems. This leads to a decrease in tissue perfusion where cells that make up our organs
and tissue don’t receive enough oxygen hence signs and symptoms of shock occur. This is a type of distributive shock
(anaphylactic and septic shock are other types). This means that the vessels that deliver blood flow to the cells have an
issue with distributing that blood flow.
Risk Factors: car accidents that cause central nervous system damage or spinal cord injury, sport injuries causing
trauma to the spine, gunshot wound to spine, medications that effect the autonomic nervous system, improper
administration of anaesthesia to the spinal cord.
Presenting symptoms: hypotension, bradycardia (because the PNS system), hypothermia, warm/dry extremities but
cold body
Diagnostic Tests: physical exam, CT scan, MRI, Urinary catheter
Treatment: manage the patients ABCS (airway, breathing, circulation and spine), protect the spine by keeping it
immobile as you don’t want to cause more damage and decrease perfusion to the spine.
May need intubation and mechanical ventilation,
Maintain tissue perfusion with IV fluids Crystalloids as it fills the dilated vessels, increases venous return to the heart
which will increase cardiac preload and cardiac output.
Vasopressors – causes vasoconstriction which will increase SVR and increase blood pressure
Rewarming devices for hypothermia
Catheter
Prevent DVT by applying TED’s Range of motion exercises and anticoagulants as ordered. Avoid crossing patient legs or
placing pillows under knees because these further compromises circulation
Atropine – quickly increase the heart rate and block effects of the parasympathetic system on the body.
Nervous system
Controls the function we cannot consciously control like our heart rate, digestion, rate of breathing, pupil response. It
is divided into two systems. It is important for these systems to always balance each other out to keep or things
regulate in our body. For example. The SNS will have to kick in to save your like however eventually it will have to slow
down with the PNS.
Sympathetic Nervous System
Is the “keep you alive fight or flight” system. It increases the heart rate, blood pressure, dilates the pupils for better
vision. Therefore a huge role it plays is that in controls vasomotor tone. This means that the SNS regulates the diameter
of our vessels. It will cause vessels to constrict or dilate as needed depending on the signals it receives from the body.
Parasympathetic Nervous System
Is known as the “rest and digest” system. It helps us relax by decreasing our heart rate and allows us to digest food
among other functions
Gastrointestinal
Stool Type:
Small, dry, hard→ constipation
Light grey/clay colour→ biliary obstruction
Mucus in stool→ ulcerative colitis
Greasy, fatty, foamy→ pancreatitis
Black, tarry→ upper GI bleed
Bright red (melena)→lower GI bleed
Blood on surface of stool→ haemorrhoids
Gastro-oesophageal reflux (GORD) .
Information: Abnormal amounts of gastric content in the
oesophagus caused by reflux
Risk Factors:
Presenting symptoms: pain and burning (heart burn) may
result in anaemia from blood loss due to ulceration.
Treatment: antacids, acid reducers e.g. proton pump inhibitors,
lifestyle changes diet (no alcohol, caffeine, chocolate or
peppermint), eat sitting up, stop smoking.
Complications: oesophageal ulcers, cancer,
16
Andie Morris
Appendicitis
Information: Inflammation of the appendix
Presenting symptoms: Fever, nausea, vomiting, diarrhoea, stomach pain as the inflammation gets worst the pain
becomes more severe, very painful if you push two fingers into the abdomen.
Diagnostic tests: Physical exam, based on symptoms, blood tests for signs of infection, urine test to rule of UTI,
ultrasound
Treatment: appendectomy, care for incision sites, activity limitations, pain control
Complications: if the appendix bursts the pain can spread to the whole abdomen, stomach will feel hard and tight, the
pain is then caused by the entire lining of the abdomen becoming infected and inflamed (peritonitis)
Diarrhoea
Information: Not enough absorption of nutrients and water due to impaired digestion or absorption of food.
Risk Factors: increased GI motility due to increased faecal bulk due to increased fibre and stretch. Faster movement of
food through intestines therefore insufficient time for absorption. Another cause low digestive enzyme therefor
incomplete digestion. Decreased bile salts therefore incomplete fat digestion. Decreased absorption area therefore
decreased absorption. Could also be increased GI motility due to direct stimulation of peristalsis by infective agents.
Large volume = osmotic or secretory small volume = inflammatory or increased motility.
Presenting symptoms: runny stools, frequent
Diagnostic tests: stool and blood, signs of dehydration or malnutrition, x-ray, endoscopy. Pathophysiology- Loss of
intestinal content, loss of fluid, weight loss, loss of electrolyte, spasms.
Treatment: Astringent (green or black tea), rehydrate, antispasmodics or decrease peristalsis, bulk-forming foods or
drugs, anti-microbials, absorbents, anti-inflammatory.
Complications: fluid loss, electrolyte loss, vascular collapse
Constipation
Information: Difficulty or infrequent stool motions. Excess water absorption from gut when movement of faeces in the
colon is slow. Pathophysiology- adnominal distension, increased toxin reabsorption, haemorrhoids, Valsalva
manoeuvre.
Risk Factors: not enough fibre, low mobility, low fluid, drug side effect, GI obstructive lesions, weak abdominal
musculature, pain on passing stool, pregnancy.
Presenting symptoms: fewer than three stools a week, lumpy or hard stools, feeling a blockage, feeling as though you
can’t properly empty
Diagnostic tests: physical exam and assessment of symptoms
Treatment: fluids, bulk laxatives, lubricant, stimulants, osmotic (lactulose), enema, exercise.
Complications: haemorrhoids, anal fissure, faecal impaction, rectal prolapse
Vomiting
Information: Loss of stomach content via mouth., loss of acids, electrolytes, fluids and bile or blood possibly.
Risk Factors: Causes can be local or CNS.
Presenting symptoms: vertigo, rapid pulse, excessive sweating, dry mouth, abdominal pain, fever
Diagnostic tests: assessment of physical signs
Treatment: Antiemetics, and finding the underlying cause
Complications: dehydration, electrolyte imbalance, pH imbalance, aspiration, psychological stress, trauma in the GIT.
Peptic ulcers
Information: Destruction of the mucosa or mucosa and muscle and even perforation (all layers). Can be gastric or
duodenal, acute or chronic, superficial or deep.
Risk Factors: - decreased or altered protective mucus, helicobacter pylori (Bacteria), NSAIDS, increased gastric juice
secretion due to increased vagal stimulation, less inhibition of gastric secretions, inappropriate increase gastrin
secretion.
Presenting symptoms: dull pain in stomach, weight loss, not wanting to eat due to pain, nausea/vomiting, bloating,
feeling easily full, burping or acid reflux
Diagnostic tests: Faecal antigen, urea breath test, endoscopy, barium meal, biopsy, blood – anaemia or electrolytes.
Treatment: Hpylori eradication (antibiotics), Mucosal protection, Reduction in gastric acid secretion, antacids.
Adequate rest, diet change stress management.
Complications: bleeding, perforation, penetration and gastric outlet obstruction
Inflammatory Bowel Disease
Information: Gastritis, Ulcerative Colitis- shallow inflammatory of the large intestinal mucosa mainly in the rectum,
Crohn’s- deep ulcers and fissures develop along whole intestine but mostly in the distal ileum, Gastro-enteritis, Irritable
bowel syndrome- altered bowel habit, but no specific inflammation.
Andie Morris
17
Risk Factors: Age, family history, smoking,
Presenting symptoms: abdominal pain, diarrhoea, blood in stool, weight loss, nausea, fever.
Diagnostic tests: biopsy,
Treatment: corticosteroid to reduce inflammation, followed by amino-salicylate anti-inflammatory drug and or
biologic therapies that inhibit inflammatory chemicals from inflamed cells
Complications: malnutrition with weight loss, colon cancer, bowel obstruction, intestinal rupture
Paralytic Ileus
Information: ileus is the medical term for lack of movement somewhere in the intestines that leads to a build-up and
potential blockage of food material.
Risk Factors: post-surgical due to being prescribed medications that can slow intestinal movement such as morphine or
oxycodone, intestinal cancer, crohns disease, diverticulitis, Parkinson’s disease, electrolyte imbalance, sepsis,
Presenting Symptoms: abdominal cramping, appetite loss, feeling of fullness, constipation, inability to pass gas, stomach
swelling. Nausea, vomiting stool like contents
Diagnostic Tests: Physical exam (no bowel sounds or excessive bowel sounds), x-ray, CT, ultrasound
Treatment: a low fibre diet can reduce the bulky stool making is easier to pass, a metal stent to make the intestine more
open, abdominal surgery to remove the blockage, identify the underlying cause
Complications: Can lead to an intestinal obstruction meaning no food, material, gas or liquids can get through, can tear
the intestine which can cause bowel contents which have high levels of bacteria to leak into the areas of your body
cavity – deadly, necrosis, peritonitis,
Nasogastric and Nasojejunal Tubes
Nasogastric Tubes
A small tube passed through the nose into the stomach.
Reasons – decompression of a gastrointestinal tract, drainage of stomach contents, lavage of gastric contents,
assessment and treatment of upper gastrointestinal bleeding, delivery of medication, providing hydration and enteral
nutritional support
Nasojejunal Tubes
A small tube passed through the nose and into the small bowel to feed children when gastric feeding is poorly tolerated
or contraindicated.
When should you not put a tube in?
In a young person/infant with a basal skull fracture, maxilla facial abnormalities, nasopharyngeal abnormalities- in
these cases oral insertion is indicated.
Only suitable for liquid formula feeds, blended diets are not to be administered in these types of tubes.
Possible complications
Pulmonary intubation, pneumothorax, tube displacement, aspiration, nausea/vomiting, nasopharyngeal discomfort,
rhinitis, sinusitis, otitis media, nasal erosion/ulceration, knotting of the tube, gastro-oesophageal reflux, fistula
formation
Flushing
Should be flushed before and after feeds and all medications this will reduce the likelihood of blockages
In hospital water for injection is used
At home boiled and cooled water for babies less than 6 months (2-3 mL0 and tap water for older (5-10mL).
If child is on a fluid restriction the least amount of fluid must be used. Measured by calculating how much the tube
holds X 1.5.
Musculoskeletal
3 types of muscle found in the human body
Skeletal Muscle Tissue
Primarily attach to bones through tendons and they help you move the body. The contract
voluntarily through the somatic nervous system allowing movement in the body at will.
Made up of: connective tissue layers, muscle fibres, blood vessels and nerves
Functions: support posture, protect organs, produce heat.
18
Andie Morris
Compartment syndrome
Information: caused by bleeding or swelling within an enclosed bundle of muscles known as a muscle compartment.
Occurs when the pressure within a compartment increase restricting the blood flow to the area and potentially
damaging the muscles and nearby nerves.
Two Types:
Acute – happens suddenly after fracture or severe injury, medical emergency,
can lead to permanent muscle damage if not treated.
Chronic – happens gradually usually during and immediately after repetitive
exercise (such as running or cycling), usually passes within minutes of
stopping activity, no a medical emergency no permanent damage.
Risk Factors: a broken bone or crushing injury, plaster cast or tight bandage
before it has stopped swelling, burns, surgery to repair damaged or blocked
blood vessels
Presenting symptoms: Aching, tenderness, burning or cramping pain (intense
pain) in a specific area of the affected limb, tightness in the affected limb,
numbness and weakness (usually signs of permanent damage), foot drop in
severe cases, occasionally swelling or bulging
Diagnostic tests: physical exam – checks for tightness, tenderness in the
muscle at rest, compartment pressure measurement teats – doctor inserts a
needle into the muscle
Treatment: emergency fasciotomy (an incision to cut open your skin and fascia
surrounding the muscles to immediately relieve the pressure inside the muscle compartment). The wound is closed a
few days later and occasionally a skin graft may be required to cover the wound.
Complications: After 4-6 hours of this syndrome neurovascular damage is irreversible
Joint replacements – Hip
Information: Also known as a hip arthroplasty. It is done to decrease or eliminate pain and improve functional status.
Patients who have a THJR should have VTE prophylaxis (TED stockings, SEDS),
Risk Factors: osteoarthritis, rheumatoid arthritis, avascular necrosis, traumatic arthritis, hip fractures, benign or
malignant bone tumours
Treatment Post operatively: verify the practitioners orders, confirm patient identity, explain all post procedure care to
patient and family if appropriate, monitor vitals, assess pain, neurovascular observations (colour, temperature, toe
movement, sensation, oedema, capillary filling, pedal pulse), encourage deep breathing and coughing exercises to
prevent post procedure pneumonia, monitor lab results (INR if on Warfarin, CBC, prothrombin time, partial
thromboplastin time), monitor for phlebitis, observe the closed wound drain for proper function and monitor for
discharge colour (proper drainage prevents a hematoma, purulent discharge and fever may indicate infection), fluid
intake and output, catheter removal, prophylactic antibiotics, laying position with no pressure on wound/affected side,
pillows between the legs and educate not to cross their legs
Complications: immobility (can cause shock, pulmonary embolism, pneumonia, phlebitis, paralytic ileus, urinary
retention, bowel impaction, infection, fat embolism,
Rheumatoid Arthritis
Chronic systemic inflammation leading to destruction of connective tissue + synovial membrane in joints. Ultimately
leads to dislocation and permanent deformity of joint
Signs and symptoms: inflammation of joints, pain + stiffness in the morning, muscle atrophy, spongy joints, weight loss
Diagnosis: Rheumatoid factor blood test confirms diagnosis
Treatment: ROM exercises, Balance between rest + activity, prevent flexion contractures, avoid weight bearing on
inflamed joints, PT and OT, use chairs with high backs, use a small pillow when laying down
Osteoarthritis
Deterioration of articular cartilage in peripheral and axial joints; mostly on weight-bearing joints (hips, knees, hands)
Signs and symptoms: pain that increases with activity and decreases with rest, pain increases with temp change,
Heberden’s or Bouchard’s nodes, joint swelling may be minimal, crepitus
Treatment: Pain + corticosteroid meds, avoid flexion of knees + hips, avoid large pillows when laying, apply cold pack
when joint is inflamed, Rest, Balance activity + rest, Limit activity when in pain
19
Andie Morris
Acid/Base Balance
pH- 7.35-7.45.
PaO2 – 75-100mmHg.
HCO3- 22-26 mmol/L
Sodium – 135-145 mmol/L
PaCO2- 35-45mmHg.
Potassium- 3.5-5 mmol/L
Chloride 95-105mmol/L
Ph Less than
7.35
ACIDOSIS
HCO3 Less
than
22mmol/L
Ph Over 7.45
Alkalosis
PaCO2
Greater than
45mmHg
Respiratory
Metabolic
Possible Causes
- Diarrhoea
- Pancreatic
- Ketoacidosis
- Urinary Diversion
Treatment: Volume
replacement with saline,
correct cause, correct
electrolytes and monitor
Possible Causes
- upper/lower airway obstuction
- foreign body
- bronchospasm
- respiratory depression
- GA
_ Narcotic overdose
- Haemothorax
- Flail Chest
- Decreased Cardiac output
Treatment: maintain airway, O2
therapy, deep breathing, reverse
narcotic
PCO3
Greater than
26mmol/L
PaCO2 Less
than 45
Respiratory
Metabolic
Possible Causes
- Gastric fluid losses
- massive transfusion
- post diuretic therapy
Treatment: Minimise Ph
rise, treat cause,
discontinue lactate and
gastric suctioning, hold
antacids, replace
electrolytes, observe
muscles spasm
Possible causes
- decreased O2 delivery
- CNS stimulation
- anxiety/ hyperventilation
- pain
- fever
- trauma
- infection
- pulmonary disease, pneumonia,
asthma
- oedema
Treatment: Treat cause
Diabetes
Diabetes Type One
Information: an auto immune response which is when the t cells attack the b cells, so the isles of the Langerhans in the
pancreas doesn’t produce insulin. Major signs of untreated diabetes include increased thirst, increased urinary output
and increased appetite. Unmanaged diabetes can lead to weight loss due to depletion of his body stores of fats and
protein. Physical and emotional stress on diabetes may cause the secretion of stress hormones that cause an elevation
in blood glucose levels. Diabetic ketoacidosis. Cellular starvation.
Risk Factors: Family history
Presenting Symptoms: To create more energy fat (adipose tissue) breaks down into fatty acids which the body uses for
energy. And the liver continues to release stored glucose because the cells think they’re starving because the insulin.
Lethargy and fatigue – because it thinks, the body is starving the body only supplies vital organs and brain with the
little glucose it has), kidneys – too much glucose goes into the urine (glucosuria) this draws water with it (polyuria)
this means dehydration. Acidosis, hyperglycaemia, electrolyte loss, fruity breath or nail polish breath
Diagnostic Tests: CT scan of the pancreas, vision test to look for cataracts, neuropathy, renal functions. Other tests –
random BGL level over 11mmol/L, fasting plasma glucose over 7mmol/L, glycated haemoglobin (HbA1c) greater than
55mmol/L, oral glucose tolerance test.
Andie Morris
20
Treatment: maintain BGL, regular testing, stabilise it to prevent
ketosis, insulin therapy, diet and exercise, fluid and electrolytes
because they are losing fluids.
insulin are used they must be compatible, dose is based on age,
weight, diet and lifestyle
Insulin management – measured in units, two or more injections
per day, stored in the fridge, it is denatured if frozen, if 2 types of ins
Complications: more likely to develop another autoimmune disease.
Microvascular complications – Nephropathy- Diabetes can cause
high blood pressure which can damage the kidneys after a long
time. Pressure in the delicate filtering system of the kidneys.
Neuropathy- nerve damage, retinopathy – damage to the blood
vessels behind the eye.
Macrovascular complications – Cardiovascular disease, stroke,
atherosclerosis.
Patho- sugar is absorbed and BGL rises, beta cells release insulin
(GLUT 2) which opens GLUT 4 to absorb glucose this lowers BGL
alpha cells sense it’s too low and secrete glycogen this makes the
liver release stored glucose. And BGL rises.
Diabetic Ketoacidosis
Information: This happens when insulin in the body is low. This
then prevents glucose from getting into the cells to be used as fuel.
The liver then produces more glucose and fat is broken down too
rapidly for the body to process. Fat is broken down into a fuel called
ketones. Ketones are normally produced when the body breaks down fat after a long time between meals. However,
when ketones are produced too quickly and build up in the blood and urine, they can be toxic by making the blood too
acidic (metabolic acidosis).
Risk Factors: Type one diabetes, under the age of 19, Trauma emotional or physical, stress, fever, heart attack or stroke,
drug or alcohol addiction. More commonly seen in type one but can happen in type two in prolonged uncontrolled
blood glucose, missing doses of medication or severe illness/infection
Presenting symptoms: Polyurea, polydipsia, high BGL, high ketones in urine, nausea, confusion, fruity breath, fatigue,
rapid breathing, dry mouth and skin > can lead to coma or death
Diagnostic tests: Bloodwork including potassium, sodium (assess metabolic function), arterial blood gas, BP, Chest-X
(look for signs of infection)
Treatment: Fluids Via IV (dehydration< could be 0.9% normal saline), Insulin therapy (until BGL’s safe), Electrolyte
replacement (osmotic diuresis causes excretions of electrolytes in kidneys).
Diabetes Type Two
information: A result of the body not creating enough insulin to keep blood glucose levels normal or your body is
resisting the effects of insulin. If glucose is too high in the body, it causes damage
Risk Factors: overweight, fat distribution primarily around the abdomen, inactivity, family history, ethnicity, age,
prediabetes, polycystic ovarian syndrome
Presenting symptoms: polyuria, excessive thirst, excessive eating/hunger, weight loss, blurred vision,
tingling/numbness/pins and needles feeling in lower limbs, vaginal thrush
Diagnostic tests:
- Random blood glucose test: A blood sample is taken at a random time
- Fasting blood glucose test: A blood sample is taken after an overnight fast
- Glycosylated haemoglobin (Hb1Ac) test: This blood test is a measure of a person’s average blood glucose level for
the past 2–3 months.
21
Andie Morris
-
Lipid profile assessment:
Treatment: Nursing role incudes educating, monitoring and administering. Diet, exercise and medications advice
Diets: individualised
Exercise: Aerobic the best as it helps the body use insulin e.g. Cardio running/walking/swimming
Educate signs of hypoglycaemia
“I’m sweaty, cold and clammy…give me some candy”
Sweating, clammy, confusion, light headedness, double vision, tremors , coma
Signs of hyperglycaemia
“I’m hot and dry… I must be on a sugar high”
Polyphagia, polydipsia and polyuria
Complications:
Coronary heart disease, neuropathy, nephropathy, cataracts, retinopathy, diabetic foot, impotence, cellulitis, diabetic
foot.
Hyperglycaemic Hyperosmolar Nonketotic Syndrome
High BGL which causes the blood to become very concentrated “hyperosmolar” but without the breakdown of ketones.
No ketones or acidosis. Osmotic Diuresis causes extraction of electrolytes.
Symptoms: high glucose, polyurea, polydipsia, dehydration, fever, mental status changes (confusion/seizures), Coma
Treatment: IV fluids (0.9% Saline, progress to 0.45%NS to hydrate cells), Regular Insulin (Titrate insulin based on BGL
checks, cannot rapidly give pt Insulin as the brain cannot cope), Watch Potassium levels (insulin causes K* to move
back into the cell)
Renal
Renal tests.
Tests- blood
Serum Creatinine - creatinine level of ^1.2 for women and ^ 1.4 for men, early sign of decreased kidney productivity.
Higher the kidney failure higher the creatinine level in the blood.
Glomerular Filtration Rate(GFR)- test that measures how well the kidneys are removing wastes and excess fluid from
the blood normal value for GFR is 90 or above. A GFR below 60 is a sign that the kidneys are not working properly.
Once the GFR decreases below 15, one is at high risk for needing treatment for kidney failure, such as dialysis
Blood Urea Nitrogen (BUN)- Urea nitrogen comes from the breakdown of protein in the foods you eat. A normal BUN
level is between 7 and 20. As kidney function decreases, the BUN level rises.
Tests- urine
Urinalysis- The strip changes colour in the presence of abnormalities such as excess amounts of protein, blood, pus,
bacteria and sugar. A urinalysis can help to detect a variety of kidney and urinary tract disorders, including chronic
kidney disease, diabetes, bladder infections and kidney stones.
Urine Protein- This may be done as part of a urinalysis or by a separate dipstick test. An excess amount of protein in the
urine is called proteinuria. A positive dipstick test (1+<) should be confirmed using a more specific dipstick test such as
an albumin specific dipstick or a quantitative measurement such as an albumin-to-creatinine ratio.
Microalbuminuria- detect a tiny amount of protein called albumin in the urine. People who have an increased risk of
developing kidney disease, such as those with diabetes or high blood pressure, should have this test or an albumin-tocreatinine ratio if their standard dipstick test for proteinuria is negative.
Creatinine Clearance- Creatinine is a waste product that comes from the normal wear and tear on muscles of the
body. Creatinine clearance test compares the creatinine in a 24-hour sample of urine to the creatinine level in your
blood to show how much waste products the kidneys are filtering out each minute.
Kidney stones
Information: When crystals build up in the tubule of the nephron and can obstruct the collecting duct. Normally gets
stuck in one of three places.
22
Andie Morris
Four different types of crystals
1. Calcium oxalate
2. Uric acid
3. Struvite
4. Cystine
Risk Factors: Family/personal history, dehydration, diets, obesity, digestive diseases
Presenting symptoms: Fever, tachycardia, hematuria, nausea, acute flank pain in groin and stabbing pain from
inflammation and blockage.
Diagnostic tests: FBC, CRP, MCP, Urinalysis, 24hr urine collection, x ray (highlights calcium), Ct scan.
Treatment: analgesia, antiemetic, IV fluids. Small stone pass by themselves. Big stone – Lithotripsy (shock waves that
break the stone into smaller), Endoscopy ureteroscopy.
Complications: hydronephrosis (fluid backs up in kidneys) – renal failure.
UTI Cystitis.
information: Inflammation of the bladder wall caused by bacteria going up the urethra. Bacterial growth is promoted by
the pH, warmth, nutrients and moisture.
Risk Factors: Sexually active – bacteria pushed into the urethra, pregnancy, some birth controls like diaphragms,
menopause
Presenting symptoms: strong urge to urinate, burning sensation when urinating, passing small amounts of urine
frequently, hematuria, cloudy or strong-smelling urine, pelvic discomfort, low grade fever.
Diagnostic tests: Urinalysis, cystoscopy – looks at the bladder.
Treatment: antibiotics, address cause, ensure hydration, analgesia, prevent complications
Complications: pyelonephritis
Pyelonephritis.
Information: A cystitis infection that has travelled up from the bladder to the kidneys.
Risk Factors: Diabetes, stress urinary incontinence, structurally or functionally abnormal genitourinary tract
Presenting symptoms: dysuria, fever, rigor (sudden chill), malaise, costovertebral tenderness, flank pain, nausea,
delirium.
Diagnostic tests: urinalysis, bloods looking for creatinine as kidneys should dispose of this, CT, IVP (can see the
dilation).
Treatment: – antibiotics (stronger than cystitis, analgesia and fluids.
Complications: renal failure
Acute renal failure.
Information: Sudden deterioration or cessation of renal function. Caused by decreased renal blood flow.
Pre-Renal- (focus on blood) Low BP, Hypovolemic shock, dehydration, cardiogenic shock, septic shock.
Intrarenal – Direct damage to kidneys, inflammation, infection, drug, autoimmune. Acute glomerulonephritis, Acute
tubular necrosis.
Post-renal- obstruction of urine, prostatic hypertrophy, kidney stones, tumour.
Three phasesOliguric phase – reduced blood flow and GFR, reduced urine output and holds onto electrolytes, waste product
accumulation, increased plasmatic urea and creatinine. hypovolemia, low BP and perfusion. Symptoms- because of
toxin build up, nausea, fatigued, delirium, metabolic acidosis, electrolyte imbalance. Treatment- fluids but not too fast.
Diuretic Phase- Increased BP therefore increase in GFR, Diuresis, let’s go of most of electrolytes, the increased BP will
stunt the kidneys cells and they may start becoming necrotic. Complication: electrolyte imbalance will result in death if
untreated.
Recovery Phase – Normal BUN and C, urine output 1-2L/Day
Risk Factors: Pyelonephritis
Presenting symptoms: decreased urine output, fluid retention, shortness of breath, fatigue, confusion, nausea,
weakness, irregular heartbeat
Diagnostic tests: blood test, urine test, ultrasound, biopsies
Treatment: prevention, identify underlying cause (pre, intra or post), fluid therapy (Electrolytes), ACE inhibitors,
Controlled diet (restrict protein, potassium), EPO (injection), Get rid of waste (dialysis), transplant, Antibiotics.
23
Andie Morris
Complications: fluid build-up, chest pain, permanent kidney damage, death.
Digestive system – Liver, Gallbladder and pancreases
Liver Diseases
Cirrhosis
Information: hepatocytes are damaged as a result of exposure to drugs, most
commonly alcohol or sever chronic hepatitis. Extensive fat and scar tissue
deposition prevents normal lobule formation and obstructing portal blood flow
Risk Factors: chronic alcohol abuse, chronic viral hepatitis, fat accumulating in the
liver, iron build-up in the body, cystic fibrosis, poorly formed bile ducts, destruction
of the bile ducts, infections (syphilis or brucellosis)
Presenting symptoms: include fatigue, enlarged liver, jaundice, ascites and anorexia.
Diagnostic tests: lab tests, blood tests for bilirubin/creatine/screening for hepatitis/INR, imaging tests MRI/CT, biopsy
Treatment: treatment for alcohol dependency, weight loss, medications for hepatitis, medications to control other
causes, liver transplant
Complications: high blood pressure in veins that supply the liver, oedema in legs and abdomen, enlargement of spleen,
bleeding, infections, jaundice, build-up of toxins on the brain, bone disease, increased risk of liver failure, acute-onchronic cirrhosis, malnutrition
Hepatitis
Information: Chronic or acute condition caused by drugs, chemicals or viruses, Hepatitis A-F.
A
B
C
D
Faecal-Oral
Blood/body fluids
Blood/body fluids
Blood/body fluids
Food and Water
Sex and IV drug use
IV drugs, sex
Can only occur with
Acute only
Acute & Chronic
Acute & Chronic
hepatitis type B
Signs and symptoms Risk infants and
Most cases turn
Not common
Hepat.
young children
chronic
Acute and Chronic
(asymptomatic or
(complications)
Signs and symptoms
Signs and
typical symptoms
Signs and symptoms
typical
symptoms typical
such as GI (nausea,
typical as type A
Diagnostic:
vomiting, stomach
Diagnostic:
Diagnostic:
- HDAg, Antipain), jaundice,
- HBsAg
- Anti-HCV
HDV
clay- coloured stool,
(infectious)
(chronic0
fatigue, joint pain,
Treatment:
Treatment:
- Anti-HBs
dark urine)
Antivirals
Antivirals
(immune/
recovered)
Contagious
Preventative: no
Prevention: Hep B
2 weeks before and
vaccine, no post
vaccine, hand
Treatment:
1-3 weeks after
exposure immune
hygiene
Acute: support
Diagnostic:
globulin, hand
Anti-HAV
hygiene, blood and
Chronic: antiviral
- Img (Active
donation screening
interferon
infection) & IgG
(recovered
Prevention: vaccine,
from a past
immune globulin (24
infection, or
hours), testing
they’ve had a
(pregnancy), hand
vaccine)
hygiene
Treatment:
Rest and
supportive therapy.
Prevent: Hand
washing, vaccine,
post exposure
immune globulin
within 2 weeks of
exposure (temp
passive immunity)
E
Faecal-oral
Food, water
(undercooked
pork/wild game)
Acute only
Acute Only
Signs and
symptoms mild
Diagnostic:
- Antibodies
Treatment:
Supportive and rest
Prevention: hand
hygiene
Transmission: Infected blood or other body fluids getting into cuts and scratches, Sexual contact, Sharing personal
items such as toothbrushes and razors , Sharing of needles by intravenous drug users, Tattooing, acupuncture and body
24
Andie Morris
piercing if equipment is not sterilised, From a mother to her unborn baby (the highest risk of transmission is during
birth
Risk Factors: sharing needles, birth, lack of safe water, poor sanitisation, living with infected person, sex with infected,
travelling to areas of high endemicity without being immunised.
Presenting symptoms: fatigue, enlarged liver, jaundice, anorexia, pain, pale fatty faeces, tea coloured urine.
Diagnostic tests: Blood test
Treatment: No treatment, body will clear it on its own and the liver will heal itself in 6 months with no lasting damage.
Complications: Scarring of the liver, liver cancer
Gall Bladder diseases Cholelithiasis
Information: Gall stones form from precipitated bile salts, cholesterol.
Risk Factors: female, over 40, overweight or obese, pregnancy, high fat diet.
Presenting symptoms: sudden and rapid intensifying pain in upper right portion of the abdomen, back pain between
shoulder blades, pain in right shoulder, nausea or vomiting
Diagnostic tests: ultrasound
Treatment: Need to be removed by a chemical dissolution, lithotripsy or surgery, or the whole gall bladder may be
removed.
Complications: inflammation of gall bladder, blockage or common bile duct or pancreatic duct, gallbladder cancer
Cholecystitis
Information: Gall bladder is swollen and inflamed leading to severe pain in right upper quadrant of abdomen.
Risk Factors: metabolic, infection, necrosis.
Presenting symptoms: itchy skin, pain, nausea, jaundice, murphy’s sign, Five F’s.
Diagnostic tests: per and post op care, Assess, monitor and document pain, vitals, wounds, NG tube, medications, low fat
diet, dietician referral, education
Treatment: anticholinergic drugs – decrease bile and pancreatic secretions, Surgery- cholecystectomy, fluids nil per
mouth, analgesia, antiemetics,
antibiotics.
Pancreaticoduodenectomy
(Whipple Procedure)
Information: Operation used to
remove the head of the pancreas.
After preforming it the surgeon
reconnects the remaining organs
to allow food digestion.
Used for: Pancreatic cancers, cysts,
tumours, pancreatitis, ampullary
cancer, bile duct cancer,
neuroendocrine tumours, trauma
to pancreas or small intestine
Risks: Bleeding at surgical site,
infection, delayed emptying of the
stomach, leakage from pancreases
or bile duct connection, diabetes
(temporary or permanent)
Treatment: Nutrition, pain
management.
Integumentary
Pain
Damaged cells release
prostaglandins, histamines,
bradykinins are released due to
inflammation. Binds to Nociceptor
and respond and carry signal or
impulse through the back of the
25
Andie Morris
spinal cord (dorsal horn). Transduction changes the chemical path to an electrical one and the impulse travels from
neuron 1 to neuron 2 which is when substance P is released and where the nerve crosses the midline. The third neuron
goes to the sensory cortex of the brain.
Classifications
Nociceptive – response to injury of tissues, skin and muscles (somatic – musculoskeletal well localised or Visceral –
hollow organs, smooth muscle)
Neuropathic – primary lesion or disease in somatosensory nervous system, spinal cord injury, phantom limb pain
Inflammatory – activation and sensitisation of nociceptive pain pathway.
Acute – sudden / Chronic – nerve damage, dull, poorly localised.
Pain assessment- Onset, Location, Duration, Characteristics, relief, Treatment
Causes of pain- chemical (acid), thermal (temperature), mechanical (physical damage)
The gate control theory of pain asserts that non-painful input closes the nerve "gates" to painful input, which prevents
pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to
suppress pain
Wound Healing
Types of wounds: Pressure ulcer, surgical incision, Burns, Blunt force trauma, missiles or puncture, tears or lacerations,
open/closed, Abrasions.
Principles of Wound Management
Protect the wound and keep it clean, good alignment, no infection, correct suture material, check for haematoma, good
hydration and nutrition (the building blocks of healing), Pain management.
Arthrodesis – joint immobilisation / fusion
Phases of Wound healing:
26
Wound Exudate:
Andie Morris
Factors that Delay Wound healing:
Oxygenation (healing tissues require an increased energy demand. This additional energy is generated from oxidative
metabolism which in tur increases the oxygen demand of the healing tissue. ATP that is generated from this process
helps supple the power for tissue repair)
Infection
Age (reduced skin elasticity, due to the degradation of the elastic tissue and collagen fibres in the outer dermal layer,
thinner skin, decreased inflammatory response)
Sex hormones (modulating inflammation)
Stress (cortisol, a hormone that is very responsive to stress, stress induced elevations in cortisol interfere with
activities important for wound healing including the production of pro-inflammatory cytokines at the wound site)
Diabetes (overtime affects the nerves and leads to poor blood circulation making it hard for blood to reach the areas
for wound repair)
Obesity (poor perfusion and oxygenation of subcutaneous adipose tissue can predispose patients to infection because
when there isn’t enough oxygen, leukocytes are able to ingest bacteria but are unable to kill them leading to infection,
medications
Alcoholism (diminishes the bodies resistance to bacteria and other harmful elements causing them to be at a high risk
for infection)
Smoking (nicotine is a vasoconstrictor that reduces the nutritional blood flow to the skin resulting in tissue ischemia
and impaired healing)
Nutrition (vit C is essential for collagen synthesis, Vit A enhances epithelization and Zinc is necessary for cell mitosis
and cell proliferation)
Cast care
Keep cast elevated, allow 24-72 hrs for cast to dry, handle a wet cast with palms of hands, turn the extremity q1-2hrs to
allow air circulation, use hair dryer on cool setting to help with drying process (do NOT use heat), do not insert any
objects into cast to relieve itching, monitor for S/S of infection, keep cast clean + dry
Burns
Information:
Types of Burns:
Superficial or Epidermal: Epidermis only
involved, burn appears red, no blistering, is
painful, healing quickly with no scaring
Partial thickness:
Superficial partial thickness or superficial dermal
– Superficial part of dermis as well as epidermis
involved, burn has blisters, base of blister pink
normal capillary refill, is painful, should heal
spontaneously by epithelialisation within 14
days, colour match defect only
Mid dermal – Extends midway into the dermis
and entire epidermis, burn has blisters, base of
blister dark red, capillary refill is sluggish,
painful, should heal spontaneously but often
prolonged with estimated healing between 14-21
days
Deep partial thickness or deep dermal –
Destruction of the dermal vascular plexus, may
have some blistering, base of blisters are blotchy
red, loss of capillary refill, loss of sensation, do not heal spontaneously
Full Thickness – Destruction of epidermis and dermis, white/waxy/charred appearance, no capillary refill, no
sensation, do not heal spontaneously.
Must think about inhalation injury as well, was the burn close to the mouth/nose/face
Was the burn going around the circumference of the body – if it was risk about blood flow and around lungs this would
prevent chest expansion during inhalation
Causes:
27
Andie Morris
Burns and scalds (thermal burn): mortality from burns and scalds are low but pain and scarring high, rates of injury
highest in 12-24 months
Electrical: Usually low voltage in children usually involving extension cords, may be more serious than they appear on
the surface, may cause rhabdomyolysis which increased myoglobin release. This can cause renal failure. If urine is dark
start therapy immediately – fluid administration increases, mannitol given if pigment does not clear, metabolic acidosis
should be corrected by maintaining adequate perfusion and adding sodium bicarbonate.
Chemical: Ingested dishwasher powder. Can result from exposure to acids, alkalis or petroleum products. Alkali burns
tend to be deeper and more serious than acid. Immediately flush away chemical with large amounts of water for at least
20-30 minutes, alkali burns may require continuous irrigation for 8 hours, consider possibility of systemic effects of the
chemical. If ingested endoscopy recommended
House Fire: Admission rate following house fire is low, mortality is high
Treatment:
Airways – hoarse voice, stridor, cough, carbonaceous sputum, secure airway early,
C-Spine,
Breathing – consider carbon monoxide poisoning – CO has a greater affinity than oxygen for haemoglobin so displaces
oxygen, assume Carbon monoxide exposure in patients burned in exposed areas, higher CO levels may result in
headaches, nausea, confusion, coma and death
Circulation – in shock is present look for alternative cause – acute burns rarely cause shock
Disability
Environment – temperature (beware of hypothermia, remove clothing and jewellery
Consider Co-existing injuries especially if associated motor vehicle accident, blast or explosion, electrocution, jump or
fall while escaping fire
Acute Treatment of Burn
Apply tap water at room temperature onto burned area for at least 20 minutes within 3 hours of burn unless completed
pre-hospital NEVER use ice or iced water, keep the non-burned area dry and warm, stop cooling if core body temp is
below 35
Analgesia – opioids often required initially consider IV morphine or IN Fentanyl, cover burn with occlusive dressing
(cling film) will reduce pain
Fluid Resuscitation – insert IV like if burn is more than 10% BSA, Take blood for Hb, U and Es, Cr, BSL. Albumin if
greater than 10% BSA, if shocked give bolus of saline 20ml/kg and look for cause.
Tetanus prophylaxis.
Clean burn with NaCl, remove loose nonviable skin, tense large blisters should be popped with a sterile needle, small
blisters can be left alone, blisters of fingers left, maintains moist environment for optimal healing with Aquacel Ag.
Complications: Scarring, infection. Circumferential burns have the greatest risk of obstruction of blood flow and
consequent ischemia.
Pressure Injuries
It is the breakdown of skin integrity due to unrelieved pressure of some type. Unrelieved pressure can be from a bony
area on the body that comes into contact with a hard surface or medical device that causes unrelieved pressure. In
addition, this can happen due to friction and shearing of the skin. This is where the skin and bone are pulled in opposite
directions causing injury to the capillary bed that perfuses the skin.
Risk Factors: poor nutrition, immobile, neuro issues, diabetics, incontinence of urine or stool, activities that causes
friction or shear (patient sliding down bed or not properly moved in bed)
Sites of concern: Occipital, ears, shoulders, elbows, sacral area, hips, inside knees, heels, ankles
Stages:
Stage 1: skin is completely intact the area will be red but it does not blanch (hence turn white when pressed on)
Stage 2: skin is visibly damaged and not intact with partial loss of the dermis, no subq (fatty tissue) will be visible.
Wound may be opened with superficial red/pink opened ulcer or may have the formation of an opened or closed blister
Stage 3: skin visibly damaged with full loss of the skin tissue. May see fatty tissue, wound edges may be rolled away,
bone tendon and muscle NOT visible.
Stage 4: Skin visibly damaged, full loss of skin, exposed bone, muscle, tendon and ligaments
Unstageable: Slough (yellowish or tan) or brownish lack is covering a full thickness ulcer, cant assess the actual depth
of the wound because of the slough covering the ulcer
Deep Tissue Injury: presents as purplish/blackish area over intact skin. Fatty tissue below also injured. May feel heavy
or spongy
Treatment: PREVENTION, head to toe assessments, Braden scale every shift, keep skin dry, turns 2 hourly, watch
friction, air mattress when appropriate, skin assessments, nutritional assessments, wound care.
28
Andie Morris
Impetigo – School Sores
Information: Most commonly caused by staphylococcus aureus and streptococcus pyogenes. It is contagious until the
site is completely healed if not on treatment. If on treatment it is not contagious after 48 hours of topical ointment and
24 hours of oral antibiotics. The children will need to stay home from school until the sores have dried up.
Risk Factors: typically, effects children aged between 2-6. Infections are most common in the summertime due to
children becoming more active and running around bumping ad scraping their skin which decreases its integrity and
allows for bacteria to enter the skin. In addition, children play in close proximity to each other and this leads to the
spread of infection. can spread to people by contact with sores. Most infectious when weeping or crusting, should be
clean and covered. Also spread when contact with infected clothing, toys and towels.
Signs and symptoms: itchy, painful red blister or bump which can rupture, if it is not a blister it can spread, the lesion
will start to leak fluid that is honey coloured, clear or pus, it will leave behind red patched that crust over with
yellowish brown crust. Most commonly found on mouth and nose
Treatment: removing the crust to apply antibiotic ointment, oral antibiotics
Education: full antibiotic treatment, separate linens, toys, towels, hand hygiene
Shingles
Information: also known as herpes Zoster, due to reactivation of Varicella-Zoster in a pt with a history of chicken pox,
eruption of rash occurs in the unliteral segmental distribution on the skin along the infected nerve, pt should be on
contact precautions.
Risk Factors: Previous Chicken Pox
Presenting symptoms: unilateral clustered skin vesicles, fever, burning/pain, pruritis
Treatment: avoid scratching the area, antivirals and nerve pain treatment.
Hypothermia
Information: Occurs when the body can no longer produce enough heat
to counter the heat it is losing. The part of the brain that controls
temperature called hypothalamus. As the body loses heat quickly the
body will shunt blood away from the skin to reduce the amount of heat
that escapes. Instead the body will send the blood to vital organs of the
body (heart, lungs, kidneys, brain) electrical impulses in the brain and
heart will slow down when cold.
Stage
Body
temperature
Signs and symptoms
High blood pressure, shivering,
rapid breathing and heart rate,
constricted blood vessels, apathy
and fatigue, impaired judgment, and
lack of coordination.
Presenting symptoms: challenging to think,
move and take preventative action. If the
person stops shivering this is a bad sign.
Typically, people will remove their clothes
and lay down, fall asleep and die in severe
Irregular heartbeat, a slower heart
cases.
rate and breathing, lower level of
Treatment: a warm dry place, removing wet
28°C to
Moderate
consciousness, dilated pupils,
clothing, covering the whole body in blankets
32.2°C
low blood pressure, and a decrease
(only the face left clear), providing skin to
in reflexes.
skin if possible to transfer heat, providing
warm drinks if person is conscious (no
Laboured breathing, nonreactive
alcohol or caffeine), CPR if needed, do not rub
Less than
Severe
pupils, heart failure, pulmonary
or massage the person as it can causes
28°C
oedema, and cardiac arrest.
cardiac arrest, warming devices, warmed IV
fluids to irrigate body cavities, getting the patient to inhale warm purified air,
Mild
32.2°C to
35°C
Hyperthermia
Information:
high body temperatures. Considered separate from other conditions where internal bosy sources such as infection, heat
regulating problems and adverse reaction cause a raise in body temperature. Heat exhaustion is a more serious stage of
hyperthermia
29
Andie Morris
Presenting symptoms: excessive sweating, exhaustion, flushed or red skin, muscle cramps/spasm, headaches, nausea
Heat exhaustion: cold/pale/wet skin, extreme or heavy sweating, nausea/vomiting/diarrhea, headaches, muscle
cramps, exhaustion, weakness, intense thirst, dizziness, less urination, difficulty paying attention mild oedema of lower
extremities and hands, temporarily fainting.
Heat stroke: fast/strong pulse/weak pulse, fast deep breathing, hot/red/wet/dry skin, nausea, headache, confusion,
dizziness, disorientation, blurred vision, irritability/mood swings, lack of concentration, fainting, seizure, organ failure,
coma, death
Treatment: sipping cool water or electrolyte drink, loosening or removing clothing, lying down and relaxing, cool bath
or shower, cool wet cloth of forehead, running cool water over wrists, ice packs, fan, IV fluids containing electrolytes,
monitoring,
Immune system
Immune reaction – 1st skin, 2nd internal defensives (Phagocytes, inflammation), and 3rd (B and T cells, acquired) line of defence. B cells
produce antibodies which are specific to the antigen they came from. Vaccination- administering antigens for the body
to make own antibodies = active memory cells.
Allo-ImmunityAllergic reaction- over
reaction of immune system
to harmless antigens.
Anything can be an
allergen. Very common,
local (itchy eyes) or
systemic (anaphylaxis)
reaction. Pollen into nose
produces IgE cells which
produces histamine
therefore allergy.
Immune Deficiency
disordersAuto-Immune diseases- an
abnormal immune response
where the antibodies in the
body attack its own healthy
cells or tissue.
Tests for immune disorders- WCC, CRP, ESR, Lymphocyte marker assay, Cell mediated (Skin test), Humoral immunity,
Immunofluorescence.
Treatment- Corticosteroids, Non-steroidal anti-inflammatories, Immunoglobulins, Plasmapheresis,
Antibodies, bone marrow transplant, symptomatic no cure.
Immunisations
stored between 2-8 degrees C – Z track intramuscular,
Why? No treatment to some diseases, treatment may only stop symptoms, to prevent
cancer, to prevent disease complications, prevent spread of disease
If someone asks/needs information/education: do not offer pamphlets or resources as
a registered nurse as it is well within the scope of practice of an RN to provide
education to patients
30
Andie Morris
Boostrix – Tetanus/Diphtheria/Pertussis
Influvac – influenza
Rotarix – Rotavirus
Infanrix-Hexa – Diphtheria/tetanus/pertussis/polio/hepatitis B/haemophilus Influenzae type B
Synflorix – Pneumococcal
Priorix – Measles/ Mumps/ Rubella
Hiberix – haemophilus influenzae type B
Varivax – Varicella (chicken pox)
Infranrix IPV – Diphtheria/ tetanus/ poli/ pertussis).
Boostrix - Tetanus/ diphtheria / Pertussis
Gardasil – HPV 2 injections given 6 months apart for 14 and under if over 15, 3 injections over 6 months apart
Normal reaction to vaccines: tenderness, redness, swelling, low grade fever, drowsiness, decreased appetite.
Hold off vaccine: if previous anaphylaxis or temp over 38.
How to give- hold baby in comfort hold, administer in order of increasing pain, do not feed while giving injection it may
make the child associate feeding with pain.
Passive immunity – acquired through transfer of antibodies or activated t cells from immune host – provides immediate
protection but the body does not develop memory
Active immunity – Is induced in the host itself by antigen and lasts longer (immunisation)
Other Infections
MRSA
Information: Methicillin-resistant staphylococcus aureus, causes infection in different parts of the body, is tough to
treat and is resistant to commonly used antibiotics.
Risk Factors: spread by contact so touching another person who has it on their skin can give it to you, insulin
dependent diabetes, haemodialysis or continuous ambulatory peritoneal dialysis, injecting drug users, HIV
Presenting symptoms: Depends where you are infected most often causes mild infection on the skin (sore/boils or
abscesses), can causes serious skin infections or infect surgical wounds, the bloodstream, the lungs or the urinary tract.
Diagnostic tests: Swabbing (nasal swab, perineum/groin swab, swab from possible sites of infection, urine if indwelling
catheter.
31
Andie Morris
Meningococcal Disease
Information: Can develop very quickly. Spread by droplets coughing/sneezing, kissing and sharing drinks and food. A
bacterial infection most cases caused by Group B meningococcal bacteria. More common in winter. Spread by droplet.
Risk Factors: babies and young children, teenager and young adults, weakened immune systems (chemotherapy
patients/HIV), close contact to someone infected, respiratory infections, shared accommodation such as halls/boarding
school, overcrowding, exposure to tobacco smoke.
Presenting symptoms: Develop suddenly: High fever, headache, sleepiness, joint and muscle pain, stiff neck, dislike of
bright lights, vomiting, crying, refusal to feed in infants, a rash consisting of reddish-purple pin prick spots.
Diagnostic tests: blood test, cerebrospinal fluid
Treatment: early treatment of antibiotics
Complications: Can cause meningitis (infection of the membranes that cover the brain) and Septicaemia (blood
poisoning), death or permanent disability such as deafness. purpura fulminans where blood clots develop in the
bloodstream. These block small blood vessels and cause tissue to die. This is why patients
with meningococcal septicaemia lose fingers, toes and entire limbs. Clotting can also damage vital organs
Tuberculosis
Information: A notifiable disease. A chronic
bacterial infection caused by mycobacterium
tuberculosis. Mainly in the upper lungs (apex)
(because it loves oxygen and that’s where most
oxygen is), however once it’s in the body it can
travel to the brain, joints, liver, spine and kidneys.
AIRBORNE spread by active cases with signs and
symptoms (because it is very small it can suspend
itself in the air). Must wear an N95 mask, with a
negative pressure room with the door closed.
Can remain inactive for years without causing
symptoms or spreading to others. When the
immune system in weakened with Dormant TB it
can then become active and cause infections in the
lungs and other organs.
Spread through Droplet, coughing, sneezing,
spitting bacteria is carried in the air and people
nearby can breathe them in
Types of TB
New case: Active TB in a person who has never been treated before or has an active disease form a new genotype
Relapse or reactivation: active TB in a person whose TB has been non-infectious or quiescent following full, partial or
no treatment
Latent Infection: a person with a positive Mantoux test and no evidence of active disease
Old disease on preventative treatment: no active disease or latent infection
Resistant TB: Takes over, treatment no longer will work, can go to the brain.
Risk Factors: close contact to someone with tb (jail, long term hospital care), alcohol and IV drug abuse, certain disease
(diabetes, cancer and HIV, immune system issues immunosuppressant peoples), Occupations (Health Care Workers),
below the poverty line (homeless), refugees,
Presenting symptoms: can be asymptomatic or symptomatic: anorexia, fatigue, weight loss, chills, night sweats,
coughing that lasts 3 weeks, haemoptysis and chest pain, appetite loss, night sweats, unintentional weight loss
In young children: fever, lassitude, and cough.
Diagnostic tests: first test for TB- The Mantoux tuberculin skin test, chest X-ray, sputum analysis,
Treatment: - isoniazid (INH), rifampin (RIF), ethambutol (EMB), pyrazinamide (PZA), side effects of Rifampicinheartburn, wind cramp, drowsiness, poor coordination, oral thrush, conjunctivitis, itchy res skin, blisters, swelling of
the face. Lips shortness of breath
Prevention: BCG vaccine for high risk (if they’ve had this vaccine and do a skin test for tb it will give a false positive
because they have been exposed through the vaccine)
Complications: meningitis, pleurisy, pericarditis, bone or joint infection, renal infection, gastro tract infection,
peritonitis or lymphadenitis or disseminating via the bloodstream and affecting multiple organs,
32
Andie Morris
Transmission Precautions
Standard Precautions
EVERY Patient ALL the time
Contact Precautions
MRSA, Lice, Skin infections,
conjunctivitis, wound
infections
Hand hygiene (soap and water when hands are visibly soiled, before eating/touching
food, after the bathroom, diarrhoea illnesses C.diff, Norovirus, Rotavirus), the use of
PPE, proper handling of contaminated sharps, supplies and equipment, environmental
cleaning, handling of laundry, patient room placement
Wear disposable apron/gown when there is a chance that clothing may come into
contact with infectious material, wear gloves when in contact with patient, wear
surgical mask/eye protection when there is a chance of body fluid splash back, Hand
hygiene
Droplet Precautions
Whooping Cough,
Streptococcal pharyngitis,
pneumonia, influenza,
German measles (rubella),
Mumps, Rhinovirus,
meningococcal
Airborne Precautions
Chicken Pox, Herpes Zoster
(shingles), Measles,
Tuberculosis
Wear surgical mask when within 1m of patient, place patient in a single room, place a
surgical mask on patient during transportation
Protective Precautions
For severely immunocompromised patients, place patient in a single bedded room,
positive pressure room, HEPA filtration, avoid use of absorbent fabric on furniture,
everyone entering must clean their hands, gloves, facemasks and gowns not necessary
unless per standard precautions
Wear an approved N-95 mask or FFP2 respirator mask, place surgical mask on patent
in transportation, patient in a single room (preferably negative pressure, if this is not
available then have a window open to minimise number of infected particles in the air,
keep the door closed, even after the patient has left the air must be completely
changed.
Donning PPE
Hand hygiene, Gown, Mask/Respirator, Goggle/face shield, Gloves
Doffing
There are clean and dirty areas when doffing. Clean areas you may touch while removing and dirty areas you cannot
touch. Clean areas include the inside and back of the gown, gown ties, inside the gloves, earpieces/straps. Contaminated
areas are the outside and front of gloves, front of gown, outside the mask, face shield, goggles and respirator.
Gloves, gown, face shield/goggles, mask or respirator
Sexually Transmitted Diseases
Chlamydia
signs & symptoms: for most there are none, but can include vaginal
discharge, bleeding between periods, lower abdominal pain, pain
when peeing, pain during sex, discharge from penis,
Transmission: passed during unprotected sex, sexual contact
including vaginal, oral and anal, pregnant woman can spread
bacteria to baby during birth,
Treatment: antibiotics pills for 7-10 days or just one day,
Complications: can spread from cervix to uterus and fallopian tubes
and can causes pelvic inflammatory disease which can damage and
block tubes, may not be able to get pregnant if both tubes are
blocked- in men it can spread from penis to balls and cause painful
swelling and can cause infertility
33
Andie Morris
Gonorrhoea
Signs and symptoms: gonorrhoea discharge -may be thin,
watery, green or yellow in colour, can be pain or burning when
peeing, inflammation of the foreskin, vaginal bleeding between
periods, pelvic pain
Transmission: spread through skin contact during sex, can get it
in the throat and anus from oral and anal sex
Treatment: antibiotics and wait 7 days after antibiotics to have
sex again
Complications: In females may lead to pelvic inflammatory
disease – an infection in the fallopian tubes, uterus and cervix.
This them can lead to permanent damage to the reproductive
tract causing infertility.
HIV
Signs and symptoms: Flu like symptoms a few weeks after being infected, 5 – 10 years after getting an infection people
who have HIV who aren’t on treatments often get illness such as pneumonia and cancer because their immune system
is weakened.
Transmission: Anal and vaginal sex and through contact with infected blood
Treatment: No cure however, antiretroviral agents are funded which stops the virus from damaging your immune
system.
Complications: AIDS – this is when someone with HIV develops one or more of a list of 25 AIDS- defining illnesses
(pneumonia, herpes, cervical cancer). There is no laboratory testing for aids it is a clinical diagnosis. This is a notifiable
infection.
Prevention: condoms, don’t share needles, get tested, be monogamous, limit sexual partners, vaccination, don’t douche,
don’t abuse alcohol or drugs
Syphilis
Signs and symptoms: sore or ulcer at the site of infection – genitals, anus or mouth, can appear 3 weeks after
transmission and may last 3-6 weeks. Without treatment the person remains infectious. If it remains untreated the
disease will progress to secondary syphilis symptoms then may be rashes with red or brownish spots, swollen lymph
glands, fever, hair loss, muscle and joint aches, headaches, tiredness, warty growths in skin folds. Without treatment it
will then progress further to late syphilis
Transmission: Sexual contact and from mother to baby in pregnancy (this baby may die in the womb, shortly after birth
or may be born early – possibly with congenital abnormalities like blindness, deafness or meningitis) Untreated babies
may become developmentally delayed, have seizures or die.
Treatment: Antibiotic injections. The length of treatment will depend on the stage.
Complications: Without treatment it will then progress further to late syphilis this can cause damage to the heart, brain,
nerves, eye, blood vessels, liver, bones, joints.
Herpes
Signs and symptoms: most people don’t have symptoms and are unaware. You may get symptoms 2 days or 2 months
after infection. Can be itching/burning/tingling pain, painful spots/sores that change to clear fluid filled blisters,
redness or rash in genital area, pain while peeing, flu like symptoms, vaginal discharge.
Treatment: Antiviral drug – this drug helps to reduce the number of outbreaks and speeds up the healing process but
does not cure you.
Genital Warts (HPV)
Signs and symptoms: There are many types of HPV. Some high-risk types of HPV (types 16 and 18) may cause abnormal
cell changes of the cervix (which can lead to cervical cancer years later), the anus, vulva, or throat in women. In men,
these types can cause these changes in the penis, anus, or throat. Low-risk types of HPV infect the genital area and can
cause warts (HPV type 6 and 11).
Treatment: is optional as most warts will clear by themselves. Treatment can be freezing them, applying cream or
liquids, laser treatment and surgery. Treatment will remove the warts but not get rid of the virus.
Cancer
Information: uncontrolled cell growth leading to potentially serious health problems.
34
Andie Morris
Grade
1.
Cells differ slightly from normal cells +
are well differentiated
Stage
Carcinoma in situ
2.
Cells more abnormal and moderately
differentiated
Tumour limited to tissue of origin
3.
Cells very abnormal and poorly
differentiated
limited local spread
4.
Cells are immature, undifferentiated, and
cell of origin is difficult to determine
Local and regional spread
5.
Distant metastasis
Presenting symptoms: sores/wounds that don’t heal, indigestion, hoarseness, obvious changes in wart/mole, lump in
breast, unusual bleeding
Diagnostic tests: mammogram, pap smear, rectal exam, colonoscopy, Skin inspection, Biopsy (definitive means of
diagnosing cancer (surgical incision made in tissue and examined under a microscope)
Treatment: chemotherapy (kills or inhibits reproduction or neoplastic cells and also kills normal cells (skin, hair, GI
lining most affected)
Radiation: destroys cancer cells with minimal exposure to normal cells, effective only for tissue in direct path of
radiation beam. Wash irradiated area with soap and water daily to (do NOT – remove radiation marking, use powders,
lotions, creams on skin at radiation site, avoid clothing or binding that will rub the skin too much at site and avoid
exposure to the sun.
Complications: infection is a main cause of death, metastasis
Chemotherapy
Chemotherapy is a drug treatment that uses powerful chemicals to kill fast-growing cells in your body it can be used for
cancer, bone marrow diseases and immune system disorders. It can be used by its self or alongside other treatments. It
can be used after surgery to kill any cancers left behind, to shirk a tumour so that other treatments such as radiation
are possible, to ease signs and symptoms.
Risks: side effects can be significant; each drug is different and has different side effects. Common ones include nausea,
vomiting, diarrhoea, loss of appetite, hair loss, fatigue, fever, mouth sores (because these tissues normally divide rapdly
and are damaged by chemotherapy agents), pain, constipation, easy bruising, bleeding
Long last side effects: Damage to lung tissue, heart problems, infertility, kidney problems, nerve damage, risk of second
cancer.
How to prepare: Have a catheter, port or pump installed into the vein for long term use, blood tests to check kidney,
liver functions and heart tests to check for heart health to see if the body is ready for chemotherapy, check for dental
infections for reduce the risk of complications during chemotherapy, plan ahead for side effects (such as infertility, egg
freezing)
Forms: Infusions, pills, shots, creams, directly at the tumour during surgery.
When working with chemotherapy agents it is important to remember that they can be harmful to you and therefore it
is essential to stay protected when working with them. It can cause reproductive problems. Always wear the
appropriate PPE this includes gowns, gloves, goggles and face shields. For 48 hours post treatment the patient will
secrete hazardous drug metabolite within their sputum, tears, semen, vaginal secretions, urine and stool.
Breast cancer
Risk factors: female, over 50, 1st degree relative with history, BRCA1 and BRCA2 mutations, menopause after 50,
smoker, alcohol consumption, high fat diet, sedentary life, hormone therapy post menopause.
when is best time to do breast examination? – self breast exams monthly 3-5 days after period and the same time each
month
Post-operative: The patient should be encouraged to regularly exercise her arm and shoulder through a rage of
movements to maintain a full range of motion in their shoulder and arm. If lymphoedema occurs the patient should be
educated on compression bandaging, exercises and minimising arm trauma
35
Andie Morris
Post-Operative Care
Post Anaesthetic Care unit
Immediate assessment: ABC (airway, breathing, circulation), Levels of consciousness, wounds, drain, IV, pain
Aim: Maintain Air way, measurement of Vital signs in immediate post-operative period, continuous cardio-respiratory
monitoring and pulse oximetry monitoring, links the patient for escalation of care in response to abnormal
physiological observations, pain relief, monitor haemodynamic.
Process: Administer oxygen as ordered, continuously monitor ECG, pulse and Blood pressure, assess surgical site, check
patency of catheters, drains and tubes, provide warm blankets and prevent hypothermia, check lab results.
Discharge requirements: conscious and orientates, easy noiseless breathing, protective reflexes are active, vital signs
have been stable, intake and urinary output is adequate.
Post-operative Ward
Aim: Restore homeostasis and prevent complications, maintain adequate respiratory and cardiovascular function,
maintain adequate fluid and electrolyte balance, nutrition and elimination, promote comfort – pain management,
promote wound healing – activity and mobility, provide psychological support, hygiene needs.
Post-operative exercises: Deep breathing and coughing to prevent pneumonia, leg exercises to prevent DVT, calf
pumping to prevent DVT, foot circles, leg lifts, repositioning/turning to prevent pressure sores, preventing wound
dehiscence, promote fibre-rich diet to prevent constipation
Vitamins
Vitamin D
Vit D is important for good bones
Young children that don’t get enough vit D can develop rickets which causes bowed legs and knock knees
Adults that don’t get enough can develop bone weakness and increase the risk of fracture.
How do we get Vitamin D? most people get it through their skin whenever we get the sun on our skin. However,
because of the risk of skin cancer you must be careful. Vitamin D in foods (oily fish, milk, eggs, liver, plant-based
substitutes, liquid meal replacements)
Vitamin K
A single vitamin K injection at birth is the most effective way of preventing a serious bleeding disorder called vitamin k
deficiency bleeding or VKDB.
Vitamin K helps blood to clot and prevents serious bleeding, all babies need vitamin K to produce clotting factors. This
is because all babies have low levels of vitamin K at birth and without vitamin K babies are at risk of getting VKDB or
HDN (haemorrhagic disease of the new-born), VKDB can cause brain damage or death. In Adults Vitamin K is naturally
present in the body and is made in the intestine from food.
MATERNITY NURSING
Female Reproductive System
The Process: Hormones cause primary oocytes to develop into secondary oocytes, in its protective sac called a follicle,
once the follicle is bigger than the rest it becomes a vesicular follicle, with a secondary oocyte it is then ejected from the
ovary during ovulation it will only become fully mature if fertilised. The site of ovulation heals and forms the corpus
luteum which then becomes a tiny scar called corpus albicans (degenerated corpus luteum).
Diagnosing pregnancy
Presumptive signs of pregnancy: absent period, fatigue, enlarged breasts, sore breasts, increased urination, movement
of fetus in uterus, nausea
Probable signs: positive pregnancy test, bouncing back of the fetus, outline of the fetus can be palpitated, Braxton Hicks,
softening of the cervix (Goodells Sign), bluish colour to the vulva, cervix and vagina due to increased blood flow
(Chadwick’s sign), enlarged uterus
36
Andie Morris
Positive signs of pregnancy: Fetal movements felt by doctor/nurse, electronic device detects fetal heart sounds,
delivery of baby, ultrasound detects baby, visible movement of baby.
Testing for hCG – human chorionic gonadotropin, in the urine as it is only released when a fertilised egg implants in the
uterus.
Changes to the body in pregnancy
Skin
o
o
o
o
o
Linea nigra
Striae Gravidarum – the tearing of collagen
Chloasma – increased blood flow
Increased sweat glands
Increased hair on scalp
Circulation
o
o
Heart is enlarged
o
Heart rate increases by 15-25%
o
Stroke volume increases by 35%
o
Cardiac output increases by 50% due to the increased
activity of the RAAS and oestrogen increased absorption of water
by the kidneys
o
Blood pressure should stay the same
o
Increased blood volume to uterus to provide nutrients and
growth
o
Increased blood flow to skin, mucus membranes, by 70%
o
Blood flow to lower extremities slowed due to iliac vein and
inferior vena cava being compressed when standing this leads to distention of veins and oedema in the legs,
vulva, rectum and pelvis
When in the supine position the aorta and inferior vena cava are compressed causing the heart to strain
leading to hypotension and dizziness.
Respiratory
o Increased O2 and CO2 causing polyuria.
o Increased O2 needed for metabolism, increased red blood cells to carry waste products
o Increased breathing depth
o Shortness of breath
o Nasal congestion
o Pressure on diaphragm and lungs due to growing baby
o Respiratory infection risk
Urinary
o
o
o
o
o
o
o
37
Relaxation of bladder due to progesterone and dilation of uterus
Increased reabsorption of sodium and H2O due to RAAS
Urine may contain more glucose due to greater volume of filtrate
Increased urination
Fluid does not have the pressure to move back into vessels causing oedema in the lower limbs
Creatinine decreased and Urea decreased
Increased risk of UTI
Andie Morris
Gastrointestinal
Food needs
o Iron 1000mg daily (50% more)
o Lots of fibre to avoid constipation
Foods to avoid
o Caffeine (200mg allowed)
o Alcohol
o Oily fish (only 2/week)
o Raw, undercooked or cured meats
o Soft cheeses
Supplements During Pregnancy
Folic acid – for the first 12 Weeks – helps to prevent birth defects of
the babies brain, and spine, such as spina bifida.
Iodine – during pregnancy and breast feeding – helps the baby to grow and develop especially in the brain. Pregnant
and breast feeding mother need more iodine than usual. Also eat foods high in iodine such as well-cooked seafood, milk,
eggs, some cereal and bread.
Vitamin D – needed for strong bones and joints and health muscles and nerve activity. If your baby is born with low
vitamin D levels it may affect its development. To increase vitamin D try to get outside, eat foods high in vitamin D like
oily fish, eggs, margarine, milks, yogurts. People more likely to be low are, liver or kidney disease, certain medications
(anticonvulsants), darker skin, if you spend most of your time inside
Antenatal Testing
Screening is up to the mother to decide. The midwife or specialist will give information and support their decision
whether to be screened or not.
If screening shows that the mother or baby may have a condition they will be offered further tests that will let the
mother know for certain.
• Complete blood count
• Polycose or glucose tolerance test
• serum antibodies
• Urine cultures
35-37 Weeks Pregnant
• One blood sample
• Blood group and Rhesus factor
• Haemoglobin (iron)
• Harmful antibodies
• immunity to rubella
• hepatitis B carrier
• Syphilis
• HIV
• Diabetes and risk
• Ultrasound from week 10 and
rountinely at 18-20 weeks
• Early scans and blood tests for down
syndrome
26-28 Weeks Pregnant
First Midwife Appointment
First trimester
First Pregnancy blood tests
At the first midwife appointment
• Group B Streptococcal infection (if
indicated)
• Vagial swab
• Urine Cultures
Pregnancy complications
Morning Sickness
Treatment and prevention – drink lots of water before and after meals, take naps, ventilate your home to eliminate
scents that make you nauseous, avoid spicy foods, eat small meals, avoid fatty foods, take vitamins at night.
Alcohol and Smoking Effects on the Fetus
38
Andie Morris
Alcohol – baby more likely to be small, premature and have development or physical problems (fetal alcohol
spectrum disorder. Can also reduce a woman’s milk supply, it can be passed from the milk to the infant and damage
the developing brain.
Smoking- low birth weight that could be harmful, increased risk of pneumonia, asthma or glue ear. Increases the
risk of SIDS, risk losing your baby (miscarriage or stillbirth).
Heartburn during pregnancy
Management - watch what you eat, no spicy foods, avoid citrus, tomatoes, onions, garlic, caffeine, chocolate, soda, eat
small frequent meals instead of large ones, sit up straight to eat, don’t eat within three hours of going to bed, don’t
smoke, elevate your head when sleeping, drink after meals not with them, wear loose fitting clothing, no alcohol,
medications - Gaviscon no antacids
Pre-Eclampsia
Information: hypertension in pregnancy after 20 weeks with evidence that other organs are involved. At the halfway
point. Different from gestational hypertension (this just has high BP; pre-eclampsia has protein in the urine as well)
This happens during pregnancy with the spiral arteries. These arteries play a role in providing blood flow to the
placenta and baby. In a normal pregnancy these arteries widen in the uterus to help increase blood flow which is vital
to provide nutrients and oxygen. In pre-eclampsia these arteries stay narrow which causes an ischemia placenta
(placenta is deprived of oxygen-rich blood flow it needs to flourish and grow) this causes the placenta to become
stressed and releases substances into the circulation in hopes of increasing blood flow however these are very toxic to
the moms endothelial cells (the lining inside blood vessels throughout body and organs), these substances can cause
damage to the vessels and they won’t work properly. It can cause vasospasm (lose their tone so they contract) and
increase in permeability (vessels leak)
Risk Factors: chronic hypertension, pre-existing diabetes, renal disease, autoimmune diseases, family history, oocyte
donation, overweight, multiples, first pregnancy, being young (under 18) or old (over 35)
Presenting symptoms: High blood pressure (damaged endothelial cells lose tone and vasospasm starts to occur leading
to an increase in pressure) and significant amounts of protein in the urine (due to kidney injury as the kidneys are
being deprived of proper blood flow and endothelial cells that line the glomerulus are damaged and start to leak
protein from the blood into the urine) . Ongoing persistent headache, changes in vision, pain in upper belly, sudden and
new swelling in face, hands and eyes.
Diagnostic tests: Blood pressure measurement and urinalysis. The criteria include having a new onset of hypertension
with 2 readings 4-6 hours apart, proteinuria, and organ injury (liver, brain, kidneys).
Treatment: woman at high risk should start taking low dose aspirin and calcium before 16 weeks to reduce their risk of
developing. If it develops treat with antihypertensives. Should be treated as inpatients. Rest and gentle activity,
delivery of baby will end pre-eclampsia, lay on the left side, magnesium sulphate administered to prevent seizures
during and after labour (antidote is calcium gluconate), protein rich diet
Complications: should be regularly assessed for cardiovascular and renal risk in the long term. Damage to
kidneys/liver, greater chance of stroke, increased risk of blood clots, placental abruption, eclampsia (seizures), risks to
baby – poor growth, increased risk of premature birth, increased chance of still birth.
Gestational Diabetes
Information: A Carbohydrate intolerance of variable severity first recognised in pregnancy that goes away after
birth
Risk Factors: Previous GDM, PCOS, Multiple pregnancies, older woman, ethnicity, BMI >35, family history of diabetes
>50mmol/mol referent to diabetes in pregnancy team
41-49 mmol/mol for oral glucose tolerance test not polycose
<40 mmol/mol continue regular screening process.
Diagnostic tests: HbA1c is lower in pregnancy. Decreased in weeks 12-16 and in the third trimester.
Treatment: self-monitoring. Aim for a tight control BGL’s should remain in normal limits and testing should occur 6
times daily every day. Before meals it should be 4-5mmol/l and 2 hours after meals it should be 4-6.7 mmol/l
Complications: causes a high risk of still birth and miscarriage, hypertension, polycythaemia and jaundice, metabolic
complications (hypoglycaemia, hypocalcaemia and hypomagnesaemia), sepsis
Effects on fetus – fetal pancreas increases insulin production leading to increases in growth and fat stores, fetal
insulin also inhibits the accumulation of the protein surfactant, which is necessary for lung development,
macrosomia which may lead to birth trauma, shoulder dystocia, nerve palsies and fractures. Respiratory diseases
e.g. RDS, TTN, congenital anomalies
39
Andie Morris
Anemia
Information: During pregnancy, your body produces more blood
to support the growth of your baby. If you're not
getting enough iron or certain other nutrients, your body might not be able to produce the amount of red blood
cells it needs to make this additional blood. It's normal to have mild anemia when you are pregnant
Risk Factors: Have two pregnancies close together, multiplies in pregnancy, vomiting frequently due to morning
sickness, do not consume enough iron, have a heavy pre-pregnancy menstrual flow, vegetarians/vegans, celiac or
crohns disease,
Presenting symptoms: fatigue, progressive paleness of skin, rapid HR, shortness of breath, trouble concentrating
Diagnostic tests: during antenatal blood tests by checking haemoglobin (part of the blood that carries oxygen) and
haematocrit (amount of red blood cells in a certain amount of blood)
Treatment: Iron supplements
Complications: baby may not grow to a heathy weight, premature birth, low birth weight, keeps the mother from
recovering quicker post birth
Breast Feeding
Provides proteins, carbohydrates and fats that are needed for growth
and cell function. Prolactin is the hormone that tells the body to make
breast milk, this takes place in the pituitary gland. The pituitary gland
also releases oxytocin from the brain when breastfeeding and allows
the baby to get breast milk. Oxytocin can make the mother feel sleepy
and relaxed. It can raise the body temperature so the mother may feel
hot while breast feeding, or the mother could feel thirsty or give them
a headache.
Benefits – improves physiological, nutritional, health, psychological,
social, economic, environmental, protects infants from sudden infant
death, reduces asthma, reduces eczema, enhances cell meditated
responses to antigens, provides immunological protection from
insulin dependent diabetes, crones, ulcerative colitis, allergies,
improves vision, reduces obesity, passive immunity
Decreases infant mortality and morbidity by decreasing –
gastrointestinal illnesses, diarrhoeal illnesses, necrotising
enterocolitis, otitis media, UTI’s, respiratory infections
Aim – 8- 12 feeds a day, 12-20 1st breast 10-15 2nd breast with 3 bowel movements
Troubling shooting: some issues may be
o Breast engorgement (nurse frequently and use a warm compress before feeding and a cold compress after)
o Poor breastfeeding latch (practice different positions, compress the areola between your fingers, tickle the
babies check, the babies chin and nose should touch your breast with their lips flaying outward)
o Mouth problems (cleft palette may require surgery)
o Poor milk supply (be sure mother is well fed, rested and hydrated, check latching,)
o Flat or inverted nipples (compress areola while feeding)
o Sore or burning nipples (check baby position, after feeding expose nipple to the air for a few minutes, use
cream)
o Nipple confusion
o Plugged milk ducts.
Postpartum Mood Disorders
“Blues”
Begins 2-4 days postpartum
Usually lasts 48 hours but can last up to 10 days
Considered to be normal emotional changes
Does not require medications
Increases the risk of postpartum depression
Depression
Onset within 4 weeks postpartum
Typically lasts 2-6 months
40
Andie Morris
Must ask about suicidal risk
Risk Factors: Previous mood disorder, stressful life events, unemployment, marital conflict, lack of support from
friends/family
Treatment: May be reluctant to medications if breastfeeding, short term safety of SSRI’s long-term effects unknown, if
severe consider ECT
Impact on Child: Association with cognitive delays especially in males, insecure attachments at 18 months, increased
behavioural disturbances at 5 years, impaired mother child communication
Postpartum Psychosis
Most often has an affective basis usually manic but can be depressive, onset 2-3 weeks postpartum lasting 2 days to 8
weeks, may have suicide/infanticidal idealations,
Risk Factors: previous history or family history of psychosis,
Treatment: with antidepressants, mood stabilisers and/or antipsychotics consider ECT
Cervical Screening
Information: One of the easiest ways to prevent cancer
Why: almost all cervical cancers are caused by HPV, this virus is spread through sexual activity. With regular cervical
screening any changes on the cervix can be detected and treated before they become cancers.
Who: woman aged between 25 and 69, have ever been sexually active, this includes woman immunised against HPV,
single woman, lesbians, have a disability, been through menopause, no longer having sex, If they have had a
hysterectomy they should check with their doctor.
Who can Screen? Doctors, practice nurses, family planning, community health services such as Maori health services,
Pacific health services, woman’s health services or screening support services.
When? Every Three years, people who have had abnormal tests may need to have them more often.
CHILDREN’S HEALTH
Weight and newborns
it is normal for babies to lose weight for the first 3 days after birth. A loss of
7-10% in the first week is normal. This should be regained by 2 weeks. Birth
weight is doubled by 4 months and tripled by 13 months in boys and 15
months in girls.
The Apgar Score
Apgar (appearance, pulse, grimace, activity and respiration) score Is a test
given to newborns soon after birth. The test checks heart rate, muscle tone,
and other signs to see if extra medical care or emergency care is needed.
Usually given twice at one minute old and 5 minutes old. Each section is
given a score of 0-2 2 being the best.
Infant reflexes
Moro Reflex – present at birth, peaks in first month , disappeared by month
two, initiated by pulling the infants up from the floor and then releasing it, it
will spread its arms pull arms in
Walking/Stepping Reflex – when soles touch surface they will attempt to
walk, disappears at 6 weeks.
Rooting Reflex – assistance in breasting feeding, baby will turn its head towards anything that
strokes its cheek or mouth
Sucking Reflex – Causes infant to suck at anything that touches the roof of
their mouth
Tonic Reflex – One to Four months when a child turns their head to one side
the arm will straighten, and opposite arm will bend
41
Andie Morris
Plantar Reflex – plantar flexion of the foot. Toes move away from shin is
normal. Abnormal reaction is Babinski, dorsiflexion of the foot, foot angels
towards the shin big to curls up
Babinski can indicate upper motor neuron lesion constituting damage to
the corticospinal tract. Occasionally this reflex is the first and only sign of
serious disease process. An abnormal reaction typically prompts neurological
investigations such as CT scan of the brain, MRI of the spine as well as a lumbar
puncture for the study of cerebrospinal fluid.
Jaundice in Newborns
Information: Yellowing of the skin and eyes caused by too much bilirubin in the baby’s blood. A baby’s liver does not
remove bilirubin as well as an adult one causing a rapid build-up.
Risk Factors: Build-up of bilirubin, premature, isn’t getting enough breast milk, breastfed, different blood type than the
mother, genetic problem, is born with high red blood cell numbers or a large bruise on the head.
Presenting symptoms: Yellow skin on the face, chest and stomach then legs, babies may be sleepy, fussy, floppy or have
trouble breathing.
Diagnostic tests: Appearance
Treatment: depends on case. Mild usually goes way on its own, breast feed more often, fluids, phototherapy, exchange
blood transfusion, IVig (IV Immunoglobulin)
Congenital Defects
Cleft Lip/Palate
Information: congenital anomalies due to failure of soft tissue or bone to fuse, Cleft lip will close earlier than a cleft
palate
Risk Factors: medications take while pregnant, diabetes, obese during pregnancy, family history
Treatment: Cleft lip repair 3-6 months, cleft palate repair 2-24 months. Before repair possible assess ability to
suck/swallow/breath, monitor fluid intake and daily weights, hold infant upright and direct milk to the side/back of
mouth, provide feeds in small amounts, suction and bub syringe at bedside,
Complications: otitis media, speech impairments
Coarctation of the Aorta
Information: This is a congenital heart defect. This is when there is a narrowing present in a section of the aorta. The
aorta is the largest artery in the body that carries rich oxygenated blood to a collection of other arteries to supply the
brain, organs and tissue. In this condition the areas of the aorta that are found before the narrowing will experience a
HIGH blood pressure and areas found after the narrowing will experience a low blood pressure. This narrowing tends
to occur after the left subclavian artery. There are two types of CoA:
Preductal: narrowing between the subclavian artery and before the ductus arteriosus
Post ductal: narrowing occurs after the ductus arteriosus most common in adults.
Signs and symptoms: will vary depending on the degree of the narrowing if severe many babies will start to develop
signs and symptoms suddenly (heart failure), high pressure to the structures in the upper body will causes Nose bleeds,
headaches, stroke, strong pulses in upper body, absent pulses in lower extremities, notching of the ribs due to collateral
circulation (body creates extra circulation to bypass the narrowing, which will be seen on the ribs and cause them to
have notched out appearance on a chest x-ray)
Diagnostic Tests: during a prenatal visit with a fetal ultrasound or after birth with an echocardiogram.
Treatment: monitor for signs and symptoms, report blood pressures, medications prior to surgery that help the hearts
function is digoxin, and diuretics, surgery includes removing the area that is narrow and reconnecting the ends usually
done by 2 years old. May need a balloon angioplasty later on to reopen the artery if narrowing occurs again.
Complications: heart failure (due to the high blood pressure before the narrowing which can lead to decreased cardiac
output if not treated this is because the left ventricle will have to work harder to pump against the high pressure)
Transposition of the great Arteries
Information: when the pulmonary artery and the aorta are in switched positions. No communication between the right
and left side of the heart. Each side of the heart has its own circulation and it’s the opposite of how circulation should
occur. This leads to NO OXYGENATED BLOOD going to the body and tissues. Some babies may have slight
42
Andie Morris
communication between each side if another congenital defect is
present (many times this is the case). This can provide short term
benefits until surgery can be performed to correct it.
The pulmonary artery should carry unoxygenated blood RIGHT to
the lungs to get oxygenated, while the aorta should carry
oxygenated blood that has LEFT the lungs to go to the body. In
transposition of the great arteries, the opposite is occurring
Key concept of anatomy for TGA: The pulmonary artery is carrying
oxygenated blood that is just re-circulating over and over to the lungs
and NEVER going to the body. The aorta is carrying unoxygenated
blood and pumping it all over the body. The is very futile because it
won’t meet the body’s oxygen demands.
Signs and symptoms: cyanosis, BLUE BABIES, increased respiratory
rate, increased heart rate, cool extremities, poor feeding and growth
rate, heart failure,
Diagnostic tests: typically discovered during a prenatal visit during a
fetal ultrasound and echocardiogram can be used to diagnose it.
Treatment: keeping the patent ductus arteriosus open with prostaglandin E and enlarging the foramen ovaleor an ASD
to allow blood to keep mixing until open heart surgery is performed within the first month of life, ballon atrial
septostomy (temporary until surgery) during a heart Cath to enlarge a hole in atrial septum catheter is inserted into the
heart through a vessels to enlarge the formen ovale or an atrial septal defect already present this allows unoxygenated
and oxygenated blood to mix and enter the systemic circulation.
Complications: Deadly if not treated.
Respiratory
Pertussis- Whooping Cough
Information: highly infectious disease that is spread by droplets (coughing and sneezing), caused by bacteria which
damages the breathing tubes.
Risk Factors: contact with infected person, epidemic exposure, pregnancy
Presenting symptoms: severe bouts of coughing which may be accompanied by vomiting and whooping sound, a runny
nose, sneezing, slight fever and a mild irritating cough which lasts 1 to 2 weeks. This is the most infectious period.
Babies in this phase can get apnoea, The later stage symptoms include spasms of coughing followed by a big breath in
or high-pitched ‘whoop’ sound in children. Infants and adults generally do not have the characteristic 'whoop'. Infants
and young children often appear very unwell, and may turn blue and vomit with coughing bouts.
Diagnostic tests: nasopharynx swab (area where the nose and throat meet), blood tests
Treatment: no treatment , antibiotics can be
prescribed in the early stage to stop the spread and
may reduce symptoms if given early enough – to ease
the cough – drink warm fluids, humidifier in the
bedroom, saline nose drops to remove thick mucus,
avoid coughing triggers – smoke, perfume and
pollutants
Complications: Pneumonia, hypoxic encephalopathy,
Otitis media, TB, Epistaxis, Reinduction of
paroxysmal coughing with upper respiratory
infections, seizures.
Strep Throat (GAS)
Group A streptococcal bacteria that causes a sore
throat. Must be checked!
Treatment: One off penicillin injection or 10 days of
oral antibiotics.
Rheumatic Fever
Information: Group A streptococcal bacteria. Starts
as strep throat- if strep throat isn’t treated with
antibiotics it can cause rheumatic fever. It is an
autoimmune disease.
43
Andie Morris
Risk Factors: repeated untreated strep throat infections
Presenting symptoms: sore and swollen joints, ongoing fever that lasts days, rash over the elbows, wrists, knees, ankles
and spine, small lumps under the skin, unusual jerky movements. High temp (past 38), Stomach pains, weight loss,
extreme tiredness.
Diagnostic tests: no test, just a look into the illness, a throat swab, medical history
Treatment: Penicillin injection for 10 Years or until 21 Years old.
Complications: symptoms of rheumatic fever may go away on their own however the inflammation from one rheumatic
fever attack could develop into rheumatic heart disease – scarring of the heart valves.
Prevention program: keep your home warn and dry, create space to spread out (no crowding), increase awareness,
improved access to timely and effective treatment for strep throat infections in priority communities.
Croup
Information: Most at risk are babies aged 6 months to 3 years of age. A
viral infection spread through the air with people cough or sneeze
droplet, that causes the larynx to become swollen and the trachea to
become blocked, can also affect the bronchi in the lungs.
Risk Factors: aged between 6 months and 3 years, family history of
disease, living in densely populated region, traveling to or from
developing countries, no influenza vaccine
Presenting symptoms: Viral Croup symptoms: Begins with a cold and
develops into a barky cough, child’s airway will swell making it hard
for them to breath and will causes them to breathe loudly. A
temperature as high as 40
Spasmodic croup symptoms: Spasms that occur during the night and
early morning, child will wake up gasping for breath, during spasms will
hear hoarseness and barky cough, stridor sounds when child breathes.
Diagnostic tests: Physical Exam of listening to cough or breathing and
asking for symptoms
Treatment: A mild case may be managed with paracetamol at home, encourage fluids and comfort your child. A single
dose of oral corticosteroid medications such as dexamethasone or prednisolone – reduces swelling may be prescribed.
If the child is in hospital, they may need oxygen therapy or may need adrenaline through a nebuliser.
Complications: Airway obstruction, secondary infections
Cystic Fibrosis
Information: a genetically inherited condition caused by a
faulty gene that must be passed from the mother and father.
Mainly affects the lungs and digestive systems, happens
when the exocrine glands are working incorrectly these
effects secretions such as mucous, tears, sweat, digestive
enzymes). CF the mucus becomes thick and sticky and
blocks the tiny tubes of many organs. This mucus can be
hard to cough up and virus/bacteria/fungus can become
trapped under it. Which can cause inflammation and
infection making it harder and harder to breath and often
causing a chronic cough and repeated chest infections. In the
digestive system thick secretions also block the flow of
digestive enzymes from the pancreas to the duodenum
where it is needed to breakdown food, without the enzymes
the fats and vitamins can’t be absorbed causing malnutrition and poor weight gain
Risk Factors: both parents carrying the gene
Presenting symptoms: most babies are screened at birth and are diagnosed before symptoms occur. But they can be
salty tasting skin, slow weight gain or failure to thrive even with a good appetite, wheezing and coughing and
pneumonia, abnormal bowel movements.
Diagnostic tests: Guthrie heel prick at birth, x ray and sputum analysis
Treatment: physiotherapy for airway clearance, antibiotics, bronchodilators and vitamin supplements are used. Some
medications are preventative measures while some treat specific problems. Pancreatic enzymes capsules with most
foods to help absorb nutrients
Complications:
In males the van deferens are blocked or have never developed this can cause fertility problems but does not cause
sexual impotence. Woman may have irregular periods related to nutritional issues but produce healthy eggs . chronic
cough, shortness of breath, repeated infections, bronchiectasis, nasal polyps, liver disease, CF related Diabetes,
progressive respiratory failure
44
Andie Morris
Tonsillitis
Information: inflammation of the tonsils caused by bacteria or viral infection
Risk Factors: having the common cold, glandular fever, measles strep throat
Presenting symptoms: sore throat, swollen tonsils, difficulty swallowing, fever, swollen glands in the neck
Diagnostic tests: throat exam, throat swab
Treatment: Antibiotics or tonsillectomy
Rationale for removal of tonsils – obstructed breathing ( swollen tonsils that block the airways causing snoring,
difficulty breathing or short pauses in breath), frequent and severe bouts of tonsillitis (7 in 1 year and effects
work/school, 5 infections each year for 2 years, 3-4 infections each year for 3 years) , long lasting not responding to
treatment, abscess behind tonsils, diabetes, suspected tumour
Management of postop bleed at home- suck on ice and cold water to drink, rest their head high on a pillow, if a large
amount of blood hospital
Otitis Media
Information: Inflammatory (infection) disease of the middle ear
what does the tympanic membrane look like in acute otitis media – inside the ear will be red, swelling, blood, pus, air
bubbles, fluid in the middle ear, perforation of the ear drum,
Why are children more prone- In young children, the eustachian tube is shorter and more horizontal than it is in older
children and adults. This makes it more likely to become infected
Risk Factors: premature baby, low birth weight, early onset, family history, Altered immunity
Presenting symptoms: intense crying and fits of fussiness, clutching ear, complaining of ear pain, sleeplessness, neck
pain, fluid drainage of the ear, vomiting, diarrhoea. Lack of balance.
Diagnostic tests: Physical exam
Treatment: analgesia, antibiotic therapy
Complications: causes hearing loss- mastoiditis-infection in the bone in the skull, meningitis
Reyes Syndrome
Information: Rare disorder that causes brain and liver
damage. Occurs in children who have recently had a viral
infection such as chicken pox or the flu. Taking aspirin
while having such infection can increase the risk of
developing Reyes
Risk Factors: using aspirin to treat viral infections such as
flu
Presenting symptoms: vomiting, followed by irritability or
aggressiveness, then child may become confused and
lethargic. Seizures or coma.
Diagnostic tests: unexplained brain dysfunction
Treatment: No cure, but symptoms can be managed,
steroids help to reduce swelling in the brain,
In hospital - fluid management, electrolyte therapy,
evaluation of cardiorespiratory status. Monitor of liver
function. Control of seizures. Corticosteroids and diuretics to rid of excess fluid and insulin to increase glucose
metabolism
Complications: rarely fatal. Can cause varying degrees of permanent brain damage.
Eczema in children
Information: Inflammatory skin disease that affects 20% of children. It can become infected and see a doctor if the skin
starts to swell and become more painful, pus develops, infected area bigger than a 10-cent coin, small red spots appear
around eczema
Risk Factors: Triggers can include irritants like soaps and detergents, skin infections, contact allergens, food and
inhalant triggers, stress
Presenting symptoms: Dry patches of itchy red skin. Commonly behind the knees, on arms, hands, neck and Face
Diagnostic tests: History and clinical/physical examinations.
Must be present- pruritus, eczema, chronic or relapsing history, typical morphology and age specific patterns
Treatment: Advice regarding avoiding triggers
45
Andie Morris
Advice regarding bathing and soap substitutes (once or twice daily, warm water no more than 10-15 mins, emollient
products, bath oils help, regular antiseptic baths)
Moisturisers (several times a day, smoothed not rubbed in the direction of hair growth)
Topical corticosteroids (there are benefits and harms, three potencies should not be used for long, applied in a thin
layer to affected area 2x daily, before or after emollients, long term use has rarely shown side effects)
Antibiotics (7-14 days different types) and antihistamines
(not recommended, does not help with itch, can be used to
aid sleep)
Advice regarding recognition of infection,
A clear plan for review by health professional
Wet Wraps (a damp layer bandaged with layers of dry
bandages over. Increase penetration of topical agents
through skin, should be short term (less than 7 days) with
corticosteroids should only be done with medical advice)
Complications: Psychosocial impact, frequency of skin
infections, frequency of days off school and activities, sleep
Measles
Information: Highly contagious, call before visiting a GP,
transmitted through droplets from the nose or throat of an
infected person. A viral illness.
Risk Factors: Unvaccinated people, being too young for the
MMR vaccine, people travelling in countries/regions where
there is a current outbreak, people born overseas where
vaccination is less likely, people with a chronic illness or
weakened immune system
Presenting symptoms: symptoms start 7-18 days after being
exposed.
First symptoms: Fever, cough, runny nose, sore and watery pink eyes, sometimes small white spots of the back inner
cheek of the mouth.
Days 3-7 of illness A blotchy rash which starts of the face, behind the ears then moving over the head and down the
body this rash can last up to a week.
Diagnostic tests: Based on characteristic of symptoms, can be confirmed with blood test and rash and/or throat/nose
swab
Treatment: pain relief (paracetamol) to reduce pain and discomfort, fluids, treating sore eyes by wiping the crustiness
from eyelids and lashes and avoiding bright light.
Complications:
Ear infections, diarrhoea, pneumonia (main causes of death from measles), seizures, swelling of the brain, 1 in 10
people will need hospital treatment, measles during pregnancy increases the risk of miscarriage, premature labour and
low-birth weight babies, deafness and brain damage.
Protecting Children who can’t be immunised: the biggest group of those with low immunity are those receiving cancer
treatment. This is because chemotherapy attacks bone marrow and reduces the effectiveness of the immune system
making these children more susceptible to infection, the immune system continues to decline over the course of
treatment and for 6 months after treatment . Because the vaccine contains a live virus these children cannot be
immunised. This means that everyone around them must be immunised so that they cannot spread it. When
children finish chemotherapy they are re-immunised.
If there is measles in their school they must stay away until the risk of getting it has passed, during an outbreak the
child should stay away from crowds such as shopping malls, movie theatres and big events or they should go at off-peak
times, not taking a school bus, uses hand sanitiser regularly, has the same food restrictions as a pregnant lady, iv
antibiotics monthly to guard against pneumocystis pneumonia.
Conjunctivitis
Information: bacterial and viral conjunctivitis is very contagious, spread through contact to eye to hand or objects
contaminated
Presenting symptoms: redness, oedema, discharge, burning
Treatment: hand hygiene, antibiotics or antiviral eye drops, no sharing towels, no school/day-care until 24 hours post
antibiotics treatment, avoid rubbing eye and wearing eye make-up.
46
Andie Morris
Family Violence and child Abuse
Child Abuse and Neglect
Forms : Physical, sexual, emotional,
Parental Characteristic: Mental health factors (depression/anxiety), stress, decreased mental capabilities, poor selfesteem, substance abuse.
Risk Factors: Poor family functioning, poor physical environment, poor physical health, family relationships
(chaos/conflict/stress/crisis), Poverty.
How to identify:
Regression in behaviour
Recognition at school (anxious and withdrawn)
Doesn’t cruise/ Can’t Bruise (if the child can’t walk they can’t get bruises)
High suspicion of abuse in burns, head injury, rib fractures
History of accident seems out of proportion
Role reversal (children comforting parents in the ER / Not always the case but is seen in abused children)
Parents down playing the seriousness of injury
Health Consequences: Poor health status, poor quality of life, high use of health services (chronic pain,
fainting/seizures, eating disorders, cardiac issues.
Screening (Nurses Role): Know who to ask, ask the same basic questions
Give lots of opportunists to answer but don’t push
Respect the answer
Come back to the same questions
Give a safe and helpful response
Build trust (victims may view help as suspicious)
Ask in order “do the conditions or circumstances indicate that a child’s needs are unmet?” and “what harm or threat of
harm may have resulted?”
HEEADSSS assessment
Screening should occur as part of health history, during visits for a new problem, during any new patient consultation,
new intimate relationships, preventive care consultation, well child assessments, times of high risk (alcohol/drug
abuse, sexual health consultations, mental health consultations, chronic pain), every emergency department visit,
The process: Report concerns to statutory agency, the police, or Oranga Tamariki
Section 195A of the crimes Amendment Act states failure to protect a child or vulnerable adult is liable for the offence
of failing to take reasonable steps to protect them
Sex abuse
Symptoms - Acting out inappropriate sexual way toys
Nightmares/sleeping problems
Becoming withdrawn or clingy
Unusually secretive
Sudden unexplained personality changes/mood swings/seeming insecure
Regressing to younger behaviours like bed wetting, unaccountable fear of places or people
Outburst on anger
Changes in eating habits
New adult words for body parts with no obvious source
Talking of a new friend
Unexplained gifts/money
Self-harm
Physical signs like unexplained soreness/bruises around mouth or genitals
STI, Pregnancy
Running away
Not wanting to be alone with particular person.
Well Child checks
-
Birth
24-48 Hours
1st Week
2-6 weeks
Before School Check: Checks for things that might impact learning in school, done at age 4.
- Sights/hearing
47
Andie Morris
-
Nutrition/Dental
Attention/Behaviour
Language (communication)
Growth
Immunisation status
Referrals
Child Development
48
Andie Morris
Infant (birth-1 year)
Biological:
Toddlerhood (1-3)
Biological:
Pre-schooler (3-5)
Biological:
School age (6-12)
Biological:
Adolescent (13-18)
Biological:
Weight: doubles @ 6
mos, triples @ 1 year
Growth slows
Growth slows + stabilizes
Weight gain is slower:
2-3 kg/yr
Weight: birth weight
quadrupled @ 2.5 yrs
Weight: 2-3kg/yr
Predictable sexual
maturation + physical
growth but highly
variable
Length: 2.5cm/month
until 6 mos, @ 1 year
length  by 50%
Height: 7.5cm/yr
Fontanelles: posterior
close @ 6-8 wks.,
anterior @ 12-18 mos
Vision: 20/40 is
acceptable
Vision: can focus @ 4
wks.
Fine motor: improved
manual dexterity @ 1215 mos, throw ball @
18 mos
Height: 5cm/yr
Height:  by 6-9cm
Slender and erect
posture
Gross motor: skip + hop
on 1 foot @ 4, skip on
alternative feet, jump
rope, swim, and skate @
5
Loss of temporary
teeth! *dental health
is important bc
permanent teeth are
now growing
Growth spurt; begins
earlier in girls
Psychosocial:
Psychosocial:
Industry v
Inferiority: pts want
to gain new skills and
knowledge to feel
confident; 
competition
Identity v Confusion:
developing sense of self
and personal identity
*Tanner stages
Fine motor: grasp
Gross motor: head
control, sitting,
crawling
Gross motor: walk @ 12
mos, run @ 18 mos,
walk upstairs @ 2 yrs,
jump @ 2.5 yrs
Health care
assessments done
chest and thorax first
Psychosocial:
Psychosocial:
Trust v Mistrust:
having needs met
(when hungry get fed,
when dirty get
changed)
Autonomy v
Shame/Doubt: giving
autonomy leads to no
shame
As nurse: offer comfort
after needles
Ritualization provides
comfort
Differentiate self from
others, withstand
delayed gratification,
control bodily fx, 
communication, and
negativism (say no to
everything)
Gross to fine motor
refinement: tricycle →
bicycle, jumping →
skipping, catching ball
more consistently,
refined drawing
Start doing head to toe
assessments and should
be screened for
strabismus (eye
condition where they do
not align with each
other)
Psychosocial:
Initiative v Guilt: pt
wants to be independent
and be praised for this
Development of
conscience
Appreciate right v wrong
d/t parent’s reaction
(rewards or
punishment), not d/t
moral thinking
Cognitive:
Cognitive:
Concrete operational
(7-11 yrs):
Formal operational:
Cognitive:
Sensorimotor (birth2yrs)
Pre-operational (2-7
years); pre conceptual
phase (2-4 years)
Pre-operational (2-7
years): intuitive thought
phase (4-7 years)
49
Symbolic thought, can’t
perform mental
operations (no
Sexual identity
Magical thinking*
Cognitive:
Uses reflexes and
moves voluntarily using
senses to interact with
env
Peer support is very
important
Peer approval is
strong motivator
As nurse: ensure pt
knows they didn’t cause
sickness on themselves
or sibling
Cognitive:
As nurse: give choices
and be assertive
Growing sense of
independence (take
on new
responsibilities)
Developing autonomy
(emotional, cognitive,
behavioural)
More reasoning, but not
quite logical
Conservation +
decentration
(understand multiple
Abstract thinking (can
think of past
experiences + future
consequences)
Andie Morris
Reflexive behaviour→
simple repetitive acts→
imitate activity
conservation skill),
egocentric, intuitive
*object permanence =
acquiring memory* @
6-8mos
Nutrition:
Milk for first 6 months
Solids @ 6 months
(iron fortified cereals –
rice, barley, oatmeal,
multigrain)
Veggies and fruits
introduced 1 at a time
Honey delayed until 1
yr (d/t botulism)
Centration (focus on 1
aspect of situation), time
is abstract, magical
thinking (ghosts), social
awareness
No conservation
understanding
Vision 15/30
Know right v wrong
d/t understanding
standards of
acceptable behaviour
symbolism, and formal
logic
 decision making skills
egocentric (look deeper
into themselves and see
what they desire + how
to achieve it)
Language:
Nutrition:
Use numerical pain
scale @ 7
Social Development:
1 yr = 4 words
90 kcal/kg, fluid 100
ml/kg, begin proper diet
Peer pressure (can be
+ or -)
Family and parental
relationship
Play is more social = 
chance of abduction
Stress w
extracurricular
activities
Peer groups
Romantic relationships
2 yrs = 300 words
3 yrs = simple
sentences
Toilet training:
sphincter control @ 1824 mos. Ensure motor
readiness (undoing
button/zipper)
400 IU of Vit D
(prevents rickets
Awareness of racial
identity
Stutter is normal for < 6
months
Speech delay is not
normal
Injuries:
Injuries:
Injuries:
Choking, MVA d/t car
seat, drowning
(bathtub and pool),
mechanical suffocation
Falls*, choking, playing
with electrical outlets
Drowning, MVA* (d/t
running on street, and
reversing)
Nursing Interventions:
Nursing Interventions:
Nursing Interventions:
Encourage parent
Encourage parents to
hold + remain with pt
Maintain toilet training
procedure
involvement in care of pt
Provide opportunities
for non-nutritive
sucking
Encourage independent
behaviour
Give clear explanations
to relieve fears
Short explanations
(use toys to make
explanations clear)
Provide pt with toys
(comfort + stimulation)
perspective and parts
of problem)
Provide rewards for
good behaviour
Social media
Cyberbullying
Efficient language
skills = nurse can use
detailed explanations
Social Development:
Social env (school,
work, community)
*MH: eating disorders,
ADHD, anger, suicide
Injuries:
Sporting injuries*
(concussion), head
injuries d/t not
wearing helmet; big
risk taking group
Nursing Interventions:
Provide privacy
Explain treatments
clearly
Encourage
continuation of school
work
Nursing Interventions:
Privacy +
confidentiality
Quiet + nonthreatening
env
HEADSSS (health risk
Qs)
Encourage
participation in making
treatment decisions
Medications
Antibiotics
Information: Can be bactericidal (to kill) or bacteriostatic (to stop)
-Static ones slow the growth of bacteria by interfering with the process it goes through to multiply including DNA
replication, metabolism and protein production
-Cidial antibiotics kill the bacteria by preventing it from making a cell wall.
Both of these can be either narrow or broad spectrum.
Narrow means it can only kill some bacteria.
Broad means it kills all bacteria both good and bad in the body.
50
Andie Morris
Used for: Infections
Examples: Penicillin, Trimoxazole
Side Effects: Nausea, vomiting, diarrhea, bloating, loss of appetite, stomach cramping
Bacteria that can be resistant: TB – difficult to treat and can take months
Gonorrhoea – have become resistant to some antibiotics
Staph – is everywhere (skin, noses) usually not harmful but when it is can be hard to treat when around MRSA,
How does a resistance start? Overuse and misuse of antibiotics (not completing antibiotic course or using it in farming
to make animals bigger) every time you use an antibiotic there is a chance one might survive due to changes in their
DNA, how to help – use fewer antibiotics, hand washing, immunise, take full courses of antibiotics and don’t miss days.
Opioids
Used for mild to severe pain.
Agonist, partial agonist, antagonist. This means they bind to and activate certain receptors in the body (including the
brain, brain stem, and spinal cord) this can make a patient feel calmness, pain relief, euphoria, calmed breathing (watch
for it being too slow)
Rapid onset and long duration, good tolerance, minimal side effects.
Monitoring required- RR, O2, BP, consciousness, urine output, BGL, Pain level, prescription, administration rate.
Action of opioids- Mu receptors, Pain transmission in CNS, Smooth muscle, stimulates chemoreceptor trigger zone,
inhibits substance P, decreases hypothalamic effect on ANS, Suppresses oxytocin release.
Pharmacokinetics- Not well absorbed orally, variable bioavalibity, variable elimination, pethidine has active
metabolites, not highly protein bound, crosses placenta and blood brain barrier, tolerance and addiction.
Pharmacodynamics- are agonists to endogenous opioid receptors in CNS, opioid receptors include Mu and kappa,
opioids bind to receptors to hyperpolarise and thus reduced neuro excitability, effect- reduced transmission, altered
perception and interpretation. Mainly on Mu receptors.
When not to use them – biliary surgery, hypersensitivity, diarrhoea, ulcerative colitis, respiratory disease, renal disease
(can use methadone or fentanyl, oxycodone).
Signs of opioid withdrawal: the process of the drug leaving the body – not life threatening, can feel like a bad case of the
flu, agitated, anxious, worried, sleep disruptions, goose bumps, aches all over, vomiting, stomach upsets,
Naloxone- competitive antagonist to natural opioid receptors. Displaces opioids at receptor. It also attaches to the
receptors without activating them and stops the opioids from attaching to them.
Onset of 1-5 minutes and lasts 30-90 minutes, can require multiple doses. No tolerance or addiction but may produce
withdrawal symptoms from opioids.
Route- nasal spray while patient lays on their back or IM injection into the thigh
Non-opioid analgesia
Used for mild to moderate pain, properties analgesic, anti-inflammatory, antipyretic. Anti-prostaglandin or
antihistamines, peripheral and central acting.
NSAID- COX1 and COX 2 inhibitors, onset 30-60 minutes, duration 4-12 hours, side effects- gastric irritation, bleeding,
allergy, liver and renal toxicity.
Paracetamol- weak inhibitor of COX thus no anti-inflammatory properties, action mainly in CNS- COX3, many
formulations (oral, liquid), Quick absorption in GIT, onset 20 minutes, peak blood level 30-60 min, metabolised in liver
excreted in urine, minimal side effects.
AspirinInformation: Inhibits COX1- anti-inflammatory, analgesic, and antipyretic and antiplatelet. Irreversible COX inhibition.
Rapid absorption in Stomach, peak level 20-40 min
Side effects: triggers asthma, gastric ulceration, bleeding
51
Andie Morris
Clexane – Enoxaparin
Information: it is a low molecular weight heparin that works by reducing the blood clotting activity.
Used for: prophylaxis of venous thromboembolic disease, in particular those associated with orthopaedic, general,
major colorectal or cancer surgery. Prophylaxis of VTE in general medical patients bedridden due to acute illness,
treatment of VTE, treatment of unstable angina and non-Q-wave myocardial infarction (administered with aspirin)
Side effects: pain, bruising or irritation at injection site, hard inflamed nodules at the site, itchy red rash at injection site,
itchy skin, bleeding.
Antacids
Information: Neutralises stomach contents to treat heartburn symptoms. May cause rebound effect. Overuse can lead to
gastric acid production problems.
Examples: Gaviscon, Calcium Carbonate
Side effects: Diarrhoea or constipations, flatulence, stomach cramps or nausea.
Proton-pump inhibitors
Information: Prevents movement of hydrogen ions from the parietal cell into the stomach. PPI bind irreversibility to H+
K+ and ATP enzyme. All gastric acid secretions are blocked. H2 blockers and antihistamines do not stop the action of
this pump.
Used For: prevention and treatment of conditions affecting your stomach and gut, including peptic ulcers and gastrooesophageal reflux disease (GORD). PPIs may be given together with antibiotics to get rid of Helicobacter pylori, a
bacteria found in the stomach that can cause ulcers.
Examples: Omeprazole, lansoprazole, Pantoprazole, rabeprazole
Side Effects: Headache, diarrhoea, constipation, abdominal pain, flatulence, fever, nausea, avoid long term use.
Inhalers
Will first administer the bronchodilator and then the corticosteroid. With a 5-minute break in-between
Preventers – used over a long term to prevent asthma symptoms from coming on.
- Must be taken daily even with no symptoms
- Take days/weeks to work compared to relievers which take minutes.
- Examples (Corticosteroid) Beclomethasone, budesonide, fluticasone
- It is important to not skip doses
- Bronchodilators (salmeterol, formoterol) widens the airway by relaxing the muscle that surrounds the airways.
Relievers – used to relieve symptoms for quick relief when experiencing trouble breathing. Fast acting
- A first aid treatment
A spacer
- A long plastic tube the inhaler fits into.
- Hold the medication until you can breathe it in. makes it easier to use and helps get the medication into the lungs.
Prevents thrush as the medication won’t be sitting in the mouth
Corticosteroids
Information: Mimics the actions of naturally occurring corticosteroids, lowers inflammation in the body, reduce
immune system activity, ease swelling, itching, redness, and allergic reactions
Important Notes: not to be used if hypersensitivity to any ingredient, systemic infections unless specific anti-infective
therapy is given, live virus immunisation, caution if hypertensive, liver failure, congestive heart failure, diabetes,
epilepsy
Used in inflammatory bowel disease, asthma, bronchitis, colitis
Side Effects: Osteoporosis, hypertension, diabetes, weight gain, increase vulnerability to infection, cataracts, thinning of
the skin, bruising easily
Example: prednisolone, dexamethasone
Side Effects osteoporosis, hypertension, diabetes, weight gain, increased vulnerability to infection, thinning of the skin.
When used in asthma: taken 5 minutes after a bronchodilator, not to be used in acute attacks, only a long-term
preventer.
Diuretics
Helps the body get rid of sodium and therefore water follows, increases the amount of urine produced. By getting rid of
the extra water it reduces the strain on the heart and blood vessels by lowering the blood pressure.
52
Andie Morris
Important notes: Daily weighs if taking for Heart Failure, limit alcohol, regular urine and blood tests for potassium and
BGL’s
Used to treat: Hypertension, oedema caused by heart failure, kidney failure or liver disease.
Examples:
Loop Diuretics – Frusemide and bumetanide – these diuretics
work on the Ascending loop of Henle in the nephron and is the
most powerful diuretic. It works by inhibiting Na-K-Cl
cotransporter protein. It prevents these ions from being
reabsorbed into the body. As a result, it increases the sodium
concentration in the filtrate and will decrease how the nephron
is able to reabsorb water. Because water follows Na therefore
more water leaves as urine. This is used in heart failure, liver
impairment, pulmonary oedema, hypertension (Not as effective
as thiazides), high calcium levels. As a nurse you must watch for
dehydration, monitor patients intake and output, daily weights,
monitor labs, provide easy access to bathroom to prevent falls,
Thiazide Diuretics – Bendroflumethiazide – inhibits the thiazide sensitive sodium-chloride cotransporter in the early
part of the distal convoluted tubule. Decreasing the amount of sodium reabsorbed and therefore water follows sodium
out of the body. Can lead to electrolyte imbalances such as hypercalcemia, hypokalaemia. Used in hypertension, heart
failure and renal calculi (formed from calcium). As a nurse you must watch for dehydration, daily weights, monitor
input and output, labs, signs of gout, glucose levels in diabetics, provide bathroom access, effectiveness.
Potassium-sparing Diuretics – Amiloride – they work on the distal parts of the nephron specially the distal tubule
and collecting duct. This leads to less sodium being reabsorbed which leads to a diuretic effect. Used for hypertension,
oedema, due to heart failure liver impairment or nephrotic syndrome, hyperaldosteronism. As a nurse you must
monitor vitals and labs, intake and output, hyperkalaemia, avoid high potassium foods (potatoes, pork, oranges,
tomatoes, avocadoes, strawberries, spinach, fish, mushrooms) , administer with a meal or right after
Side Effects: Dizziness, feeling faint when you stand up, signs of dehydration (muscle cramps, weakness, dry mouth,
thirst)
ACE inhibitors -prils
Information: Inhibits ACE (released by the lungs) this then prevents the conversion of angio 1 to angio 2 which lowers
blood pressure
Important notes monitor potassium levels and renal function (BUN, Creatinine), monitor for angioedema (signs deep
swelling of the face and mouth). NOT TO BE USED IN asthmatic patients, kidney disease, allergy or pregnancy or
Used for: Hypertension
Examples lisinopril, quinapril, captopril
Side effects dry cough, nausea, rash and headache
Nitro-glycerine Spray or sublingual
Information: prevent heart attacks and relieves angina by increasing blood flow to the heart by dilating the coronary
arteries and reducing the hearts workload by decreasing myocardial oxygen consumption. To take place tablet
under the tongue. Do not swallow, do not eat or drink for 10-15 minutes
Important notes take when you begin to feel pain, if pain is still present in 5 minutes take again (up to two more times
within 15 minutes), each dose must be five minutes apart, if you still have chest pain call 111. Not to be taken in patient
with intracranial pressure, if they’ve take phosphodiesterase inhibitors. When administering this, then administer
oxygen, obtain an ECG, and cardiac enzymes.
Used for Angina
Side effects headaches, dizziness, light headedness, nausea, flushing. Expected findings can e facial flushing, burning
under the tongue, headaches, dizzy, hypotension
53
Andie Morris
Digoxin – slow and hard
Information: positive inotropic causing the heart to beat stronger and also a negative chronotropic causing the heart
to beat slower.
Important notes for 8-month-old baby 100bpm needed. Digoxin toxicity – vision changes, nausea, vomiting, irregular
heartbeat, toxic level anything over 2.4ng/mL. Digibind is the anti-digoxin. Must have a heart beat greater than 60bpm
to have.
Used for Heart Failure
Side effects changes in mood/mental alertness, anxiety,
Betablockers - lol
Information: Block the sympathetic function of the heart by blocking Beta 1 Receptor in the pacemaker of the heart.
This decreases the heart rate and therefore decreases the blood pressure
Important notes: Contradicted in obstructive lung diseases and PVD. Nurses Role – bradycardia, taper off cannot be
stopped suddenly, no asthma or COPD (because it blocks Beta2 receptors in the lungs and can cause constriction of the
bronchi), watch blood glucose closely, circulation impaired, orthostatic hypotension. Iff the patient is showing signs of
uncompensated heart failure (swelling, dyspnoea and crackles in lung fields) do not give betablockers. This is because
betablockers slow down the heart rate and decrease the strength of contractions (negative inotropic effect) this can
lead to heart failure in some patients and nurses must monitor for this. Betablockers can however be used if the patient
has stable heart failure sometimes. This medication cannot be suddenly stopped. Should be tapered off over a 2-week
period.
Used for: Angina, hypertension, cardiac dysrhythmias, glaucoma, migraines, tremors/anxiety
Examples: Labetalol,
Side effects masks symptoms of hypoglycaemia such as tachycardia because the medication causes bradycardia, and
therefore is causes hypoglycaemia, bradycardia, fatigue, hypotension, bronchoconstriction
Oxygen Therapy
Information: helps to relieve hypoxemia and maintain adequate oxygenation of the tissues and vital organs, increases
blood oxygen content so that the heart doesn’t have to pump as much blood per minute to meet tissue demands
Types:
Nasal Cannula – simple and safe, comfortable, effective for low oxygen concentrations, not possible in patients with
nasal obstruction
High-flow Nasal cannula – easier to tolerate than a mask, not to be used in pts with facial trauma, possible to deliver
50-92% with relative humidity of 95-100% flow rate 15-60L/Minute
Simple Mask – possible to deliver concentrations of 35-50%, impractical for long therapies
Nonrebreather Mask – delivers the highest possible oxygen concentration 60-80% with required intubation and
mechanical ventilation, effective for short term therapy, uncomfortable due to tightness,
CPAP mask – enables spontaneous breathing with or without artificial airway, tight fit can be uncomfortable,
increased risk of pneumothorax,
Transtracheal Oxygen Administration – receiving oxygen through a catheter inserted into the tracheal cartilage
through a small permeant opening, no drying mucous membranes, easy to conceal, not for pts risk of bleeding,
uncompensated respiratory acidosis (don’t use),
Venturi Mask – contains a device that mixes a specific volume of air and oxygen. Possible to add humidity or aerosol
therapy, deliveries highly accurate oxygen concentration despite the pts respiratory pattern.
Important notes Elevate pts head to 30-45 degrees unless contraindicated to prevent health care associated
pneumonia. Frequently assess for signs of hypoxia (restlessness/ decreased level of consciousness, increased heart
rate, arrhythmias, perspiration, dyspnoea, use of accessory muscles, yawning, flared nostrils, cyanosis, cool clammy
skin, obtain vitals as needed.
Used for: COPD, Asthma, Cystic Fibrosis, Heart failure, pulmonary hypertension, acute care situations suggest
hypoxemia, severe trauma, acute MI, short term therapy or surgical intervention
Side effects watch for oxygen toxicity (if they’re receiving a concentration above 60% for more than 24 hours)
prolonged high concentrations can cause lung injury, measure ABG’s to repeatably to determine whether high
concentration remains necessary. Humidification systems can become contaminated increasing risk of infection,
hypothermia and increased oxygen consumptions can result from administering cool oxygen. Pressure areas can form
around the patient’s head/face/nose if prolonged.
54
Andie Morris
Diabetes
Metformin – reduces the amount of sugar the liver releases into the blood, also makes the body respond better to
insulin.
Watch for renal function, diarrhea
Insulin function – facilitate glucose uptake and usage by cells, increase glycogen synthesis, and decreasing
gluconeogenesis, increasing accumulation of fatty acids, decreases ketogenesis, moves potassium, magnesium, and
phosphates into cells. Works by binding to GLUT4 and lets glucose into the cells.
Key things to remember: Rotate the sites to prevent lipodystrophy (pitting of the subq fat) sites include abdomen, arms
and thighs. Don’t massage the site after administration >increases the risk of Hypoglycaemia. Insulin is not oral because
it is a protein hormone and therefore will be broken down by digestive chemicals in the stomach and intestines before
it can get into the blood steam and perform its function.
Ultra-short acting (Humalog, novorapid)-binds to insulin receptor “15 minutes feels like an hour during 3 rapid
responses”
Onset: 15 Minutes
Peak:1 Hour
Duration: 3 Hours
Short acting (actrapid, humilin)- SHORT staffed
nurses went from 30 patients 2 8 patients
Onset: 30 Minutes
Peak: 2 hours
Duration: 8 Hours
Intermediate acting (Humulin NPH, Protophane)
– “Nurses Play Hero 2, 8, 16-year old’s”
Onset: 2 Hours
Peak: 8 hours
Duration: 16 hours
Long acting (ultralente, ultratard)- “The 2 long
nursing shifts never peaked but lasted 24 hours”
Onset: 2 Hours
Peak: NONE
Duration: 24 Hours
Histamines –
Are found in high levels in lungs, skin and Gastro tract. Released by mast and basophils cells.
Histamines are hypersensitivity reactions to such things like drugs (morphine), Venoms, and Traumas
Histamine H1 activation, in the body causes increased capillary dilation and leads to decreased BP, increased capillary
permeability leads to increased oedema, increased bronchiolar smooth muscle contraction, increased activation of
peripheral nociceptive receptors causing pain and pruritis, decreased AV Nodal conduction.
Histamine H2 activation in the body causes increased gastric acid leading to gastrointestinal ulcers, and increased SA
nodal rate, positive inotropism and automaticity
suppressed acid secretion in the stomach, selective antagonist to H2 receptors in parietal cells.
Therapeutic uses – gastric or stress ulcers, upper GIT bleeding, Gastro-oesophageal reflux Disease, duodenal ulcer with
or without H. Pylori.
Antihistamines – can be oral, nasal or eye drops
used to treat: acid reflux, allergic reactions, motion sickness, nausea and vomiting with pregnancy, preoperative
sedation, sleep and cold medicines, Parkinson disease, acute Extrapyramidal symptoms (
Examples: 2nd generation drugs Cetirizine. Loratidine very unlikely to enter CNS and reduces the sedation effects. 1 st
generation drugs have many side effects such as sedation. Sedation can be useful at night time.
55
Andie Morris
Fluid Therapy
Crystalloid VS Colloid Solutions
Crystalloid – Aqueous solution of mineral salts or other water-soluble molecules, have a low osmotic pressure in blood
due to haemodilution
Colloids – mixture of larger insoluble molecules (Blood is a colloid), colloids preserve a high colloid-osmotic pressure in
the blood.
Very important to warm the fluids before giving them because the patient may develop hypothermia if not
Crystalloid solutions
Saline – most common, isotonic > does not cause dangerous fluid shifts, generally used for extracellular fluid
replacement, if only saline is given O2 carrying capacity is decreased (Dilution Anaemia), not suitable for patients with
heart failure/oedema
Dextrose – used if patient is hypoglycaemic or hypernatremia, becomes hypotonic when glucose is metabolised so can
cause fluid overload.
Hartmann’s Solution – a solution of multiple electrolytes (sodium, chloride, lactate, potassium, calcium), used in
patients with haemorrhage, trauma, surgery, burns, also used to buffer acidosis.
Colloid Solutions
Albumin – 40g/100ml – used in liver diseases, severe sepsis or extensive surgeries
Albumin 200g/100ml – used in haemorrhage/plasma loss due to burns/crush injury/peritonitis/pancreatitis or
hypoproteinaemia or haemodialysis
Polygeline (Haemocoel) – gelatine cross linked urea, used in dehydration due to GI upsets (Vomit/diarrhoea)
Blood Products
Whole Blood – RBC, WBC, plasma, clotting factors, electrolytes, used to replace blood volume and maintain
haemoglobin level and increases O2 carrying capacity
Nursing responsibilities when transfusing blood – transfer one unit at a time, ensure the consent form is signed or get a
medical officer to complete the consent. No other medications or fluids may be transferred in the same line. Only saline
can be given at the same time as other fluids can cause clumping, two RN’s must verify the orders, the identification,
blood bank information, expiration date everything must match before the product is given.
Type O -universal donor Type AB universal recipient, 18 gauge or larger, if other medications are infusing at the same
time, they will need a different IV access, base line vitals,
Start the transfusion slowly 2mL/min for the first 15 minutes and remain at the patient’s bedside for this time. If the
blood is tolerated the rate may be increased.
Reaction symptoms: sweating, chills, chest pain, shortness of breath, headache, back pain, nausea, vomiting, itching,
rash
If this occurs – stop the transfusion, notify doctor, monitor vitals every 5 minutes, based on reactions medications
(corticosteroids, fluids, antihistamines, antipyretics, vasopressors, diuretics), Labs, document
Hormonal Contraception
How Pregnancy Happens
Man
1. Production of sperm Vasectomy
2. Sperm moves through the ducts
3. Deposited into the Vagina Barrier methods
(condom)
4. Sperm moves through the uterus and oviduct
5.
56
Woman
1.
Production of primary oocyte Combined pill, Depo
Provera
2. Ovulation
3. Enters oviduct Tubal ligation
4. Oocyte moves along oviduct
Sperm and Oocyte meet in oviduct IUD, ECP, Prolonged progesterone (Rods)
6. Fertilisation Emergency Contraceptive
Andie Morris
7.
Implantation of blastocyte in the endometrium
Types of contraceptive:
Oral: Mini pill – progesterone only, or
Combined pill – progesterone and oestrogen,
Contraindication: Risk of venous thromboembolism increased, migraines with aura and over 35, heavy smokers, some
anti-epileptics and antibiotics can reduce the concentration of contraceptives and decrease the efficacy
Depo Provera: 3 monthly injections of progesterone – prevents implantation by altering endometrium
Jadelle: Two Rods in the arm, subcutaneous progesterone implant, 3-5 years of contraception
Mirena: Progesterone implant in the cervix, 5-10 years of contraception
Emergency Contraceptive Pill: taken after unprotected sex, can take up to 72 hours after but most effective within 24
hours after, contains 1.5mg (very high level) of progesterone
Synthetic Oestrogen
- Inhibits FSH, this stops follicle development
- Inhibits LH, this stops ovulations
Synthetic Progesterone
- Inhibits ovulation
- Thickens the mucus in the cervix preventing sperm
from getting through.
Most effective to lest effective: Vasectomy, combined pill, continuous progesterone (Jadelle), Mirena, condom,
withdrawal, prolonged breast feeding
Pharmacodynamics
Is the pharmacology mode of action or effect of the drug. The action of the drug on living tissue. Can also be defined as
the biological effects produced by the interaction of a drug and the target site (cells, fluid, receptors).
Agonist – a drug that initiates a physiological response when combined with a receptor
Antagonist – a substance which interferes with or inhibits the physiological action of another.
Drugs do NOT create functions but modify existing functions in cells, tissues and organs. They achieve this by
stimulating activities e.g. sympathomimetic, depressing or inhibiting activities e.g. angiotensin converting enzyme
inhibitor, irritation e.g. cayenne, replacing or supplementing chemicals e.g. vitamin C, destroying cells or interfering
with cell reproduction e.g. chemotherapy.
Drugs can be non-receptor mediated or receptor mediated.
Non-receptor mediated actions include
Physical – osmosis – used in glaucoma because it attracts water from cells or demulcent the soothing effect of cough
lozenges
Chemical – drugs that have chemical reactions include antacids because of the neutralisation the occurs when it’s taken
Antibody – BCG vaccine triggers the production of antibodies and thus gives an active immunity.
Placebo – not really drugs as they have no effect, but they are used in contraceptives and as part of clinical trials.
Receptor mediated actions are more specific and can be receptors on the cell membrane or
receptors inside the cell
Enzymes – e.g. ACE inhibitor plays a role in blood pressure by binding to the receptors can inhibiting the conversion.
What are drugs used for? Prevention/prophylaxis, treatment/cure, replacement/supplement, diagnosis, mitigation
(reduction of severity/painfulness/seriousness) or palliation
Drugs have primary effects and secondary effects as well. These can be at the same or different site. For example
paracetamol as an analgesia has a beneficial secondary effect as an antipyretic effect. It also has an unwanted secondary
effect as a constipation.
Medication Calculations
Want/Got X Stock Volume =
Dose prescribed/Dose available X Quantity =
Flow Rate
[Total volume X Drop Factor] / time in minutes = Drops per minute
57
Andie Morris
mL per hour
Total Volume in mL / Number of Hours = mL per hour
Infusion Time
Total Volume to Infuse / mL per Hour being Infused = Infusion Time
Ko Awatea Information
Medication safety: allergies should be checked with patients when the medication is initially selected and checked
against the medication chart and at the patient’s bedside before the medication is administered.
- Registered Midwives, registered nurses, and doctors can write in the Allergy and adverse reaction box.
Double checking: When using a IVAC/Baxter pump
Direction and Delegation
Enrolled nurses: Contribute to nursing assessment, care planning, implementation and evaluation of care for health
consumers and their families. Assist health consumers with activities of daily living, observe changes in health
conditions and report these changes to a registered nurse. Administer medications and other nursing care
responsibilities to their assessed competency. May be a second checker for generic medications (level 1), IV medicines
and electronic devices with generic certification. They are accountable for their own nursing actions and practice in
accordance with legislation, level of knowledge and experience.
The responsibilities of an RN in regard to an EN administering the medications – the RN must complete a full
assessment of the patient and if there has been no change to their condition over the last 24 hours the RN then may
delegate full care to the EN
Errors: when there is an error you should stop the process by alerting the colleague or seek the intervention of a
senior colleague to stop the process and also complete a datix report online. As WDHB employees we have the
responsibility to intervene to prevent an error occurring.
5 Rights
Right time
Right dose
Right drug
Right route
Right patient
Plus, three – right to refuse, right indication and right documentation
Medication Management Policy Waikato DHB 2020
-
-
58
All errors must be recorded on datix
Nurses and midwives must ensure nutrition and food services are altered to any allergies the patient has
Medications should not be dispensed unless documentation of allergies is completed
It is the job of the prescriber/nurse/pharmacist to complete the WHDB “adverse reactions to medicines or
vaccine” form and send it to pharmacy services
When transferring a patient who is prescribed and receiving medical treatment where there are potential supply
issues e.g. unusual or restricted medications not routinely held in stock, nursing staff should ensure arrangements
are made, prior to transfer, for a supply of medication to go with the patient. This allows the receiving hospital to
continue treatment until such time that the medicine(s) can be obtained
All prescribers, administrators and/or others using the medication chart must document their name, sample
signature or initials, designation and registration number on the relevant section of the medication chart. This
information should be legible.
Verbal orders (including telephone prescriptions), will only be accepted when the prescriber is unable to write a
prescription/medication chart in person.
New Zealand legislation does not allow for verbal orders for controlled drugs. The following are deemed as
acceptable ways of prescribing controlled drugs within the legislation:
o Anticipatory prescribing, where a range of PRN doses of controlled drugs are prescribed using the
medication chart.
o Using a standing order in accordance with section 10 of this policy
When a verbal order is given in person, it must be accepted by one person legally authorised to administer. Where
the verbal order is given over the phone, it must be accepted by two such legally authorised persons.
The following must occur for all verbal orders:
Andie Morris
The prescriber must communicate the prescription clearly including stating the name of pt, verifying
their allergies/adverse reactions status, state the name of the medicine, dose, route, and frequency or
time of the dose
o The prescription must be read back to the prescriber for confirmation.
o The prescription must be recorded and identified as a verbal order by the acceptor(s) on the inpatient
medication chart, under the verbal orders section or if this is full, under the once only section.
o The entry on the inpatient medication chart must be dated, timed and signed by the acceptor(s), with
the full name of the prescriber giving the verbal order documented.
o The person administering the medicine must record the instruction in the patient’s clinical record.
o The prescription must be countersigned and dated by the prescriber within 24 hours of giving the
verbal order.
A verbal order becomes invalid after 24 hours if it has not been countersigned by the prescriber. Medicines must
not be administered from a verbal order if it is invalid.
Pharmacists may write clarifying notes on the prescriptions
The health care team must ensure that a patient on leave:
- Can either self-medicate, or there is a responsible person to administer the medicine to the patient.
- Is prescribed adequate medicines for the period of leave. These medicines must be labelled according to
legislative requirements
A maximum of one week’s supply will be dispensed from the hospital pharmacy for patients going on leave, unless
previously arranged with the pharmacy.
The “five rights + three” should be checked:
o
-
-
o
o
o
-
-
All medications removed from the original containers and placed into an additional container (e.g. burette, syringe
or intravenous fluids) and not for immediate use must be labelled with a completed Waikato DHB approved
‘medication added’ label.
The details of each individual medicine administered, or deliberately withheld, or refused, must be documented on
the patient’s administration record, ensuring that any written entries and the signature are unambiguous and
legible. Documentation of medicine administration must be completed at the bedside immediately after the
medicine has been administered. Use the approved codes as outlined on the national medication chart and
approved abbreviations in Appendix A.
Medicines should not be administered in a covert or disguised manner if the patient has the capacity to give
consent or refuse treatment with medication. Covert administration of medicines must be of benefit to and in the
best interests of the patient.
To allow cover administration of medicines the following must all be met:
•
•
•
-
-
59
The right medicine in the right dose must be administered to the right person at the right time by the right
route.
The administrator is certain the patient has the right indications for the medicine and completes the right
documentation.
The administrator knows when a person has the right to refuse medication or not
The patient must lack the capacity to make an informed decision about their treatment, and evidence of this
assessment must be recorded in the patient’s clinical notes.
It must be likely that the prescribed medicine will bring about a significant improvement in the patient’s health
and/or safety, or that the medicine(s) will significantly reduce the threat that the patient poses to others.
The forced administration of the medicine(s) by any route will cause high levels of distress to the patient
The decision to administer medicines covertly must be multi-disciplinary and, as a minimum, include the patient’s
specialist, the charge nurse manager or delegate and family members or carers or those who have legal
responsibility for decisions regarding a patient’s care (e.g. enduring power of attorney). In an urgent situation the
prescriber and a senior nurse may make the decision to covertly administer medicines but a formal multidisciplinary review of the decision to covertly administer medicines should be undertaken at the earliest
opportunity.
Note that the Mental Health Act does not include covert administration of medication and does not explicitly
mention a patient’s capacity when considering treatment. The Mental Health Act only allows for compulsory
treatment of a patient’s mental disorder and does not allow compulsory treatment of physical disorders
Patients are not to self-administer class B controlled drugs
Methadone is a strong opioid which can be used for both the treatment of severe pain and for the treatment of
opioid addiction.
Andie Morris
-
When prescribed for pain relief it is managed like other strong opioids e.g. morphine. Refer to sections 0 and 7 of
this policy.
When prescribed for opioid addiction there are some additional requirement
Prescribing methadone for opioid addiction is restricted to doctors working for the Community Alcohol and Drug
Service (CADS) or doctors with delegated authority to prescribe from that service.
-
MENTAL HEALTH
S8- application for assessment.
(applicant must be 18yrs old and
have seen the person within 3 days.
S8B- Medical certificate supporting
S8A (medical practitioner must have
seen them within 3 days)
S9- arrangement to attend
preliminary assessment examination
(presented by DOA in presence of
family, career or justice of the peace)
S10- Psychiatrist examines patient.
Certificate of preliminary
assessment.
S11- First period of treatment and
assessment (within 5 days)
S11(3)- change of status from
outpatient to inpatient (within the 5
days)
S11(4)- Change of status from
inpatient to outpatient (within the 5
days)
S11(5)- Leave of
absence
S12- Certificate of further
assessment
S13(3)- change of status from
outpatient to inpatient (within 14
days)
S13(4)- Change of status from
inpatient to outpatient (within 14
days)
S13(5) - Leave of absence
S14- Certificate of final assessment
S14(4)- Application to attend court
(compulsory treatment order)
S15- Status of patient pending
determination of application. For up
to fourteen days from application.
Patient remains liable for treatment
and assessment. Judge can extend
this time not exceeding 1 month.
S16- Review of patient’s condition
by judge after requested by a patient
who feels like they don’t need to be
under the act
S18- Judge to examine patient where
compulsory treatment sought.
S29- Community compulsory
treatment order
S29(3A)- Notice to patient subject to
a community CTO directing status to
inpatient for up to 14 days. (can only
occur twice within 6 months)
S29(3B) – notice to patient subject
to a community CTO directing status
to inpatient in
accordance with S13
and S14
S30 – Inpatient compulsory
treatment order
S30(2) Change of status from
inpatient to community CTO (S29).
S31- Leave of absence for patient
subject to S30 (up to 3 months can
be extended a further 3 months).
S31(4)- cancelation of leave
S34(2)- RC application to court to
extend CTO
S34(4)- Indefinite extension of CTO
– inpatient or community
S59- Consent to treatment when
subject to CTO. Patient must consent
in writing to treatment after the first
month of CTO otherwise a second
opinion is required.
S76(3)- Clinical review of patient
subject to CTO (within first 3 months
and then 6monthly
S111- power of the RN to detain a
person for up to 6 hours for urgent
assessment.
60
Andie Morris
The Mental Health Act defines “mental disorder” as:
•
•
an abnormal state of mind (whether of a continuous or intermittent nature), shown by delusions or disorders of
mood, perception, volition or cognition, where
this abnormal state of mind means that either:
• there is a serious danger to the person's health and safety or to the health and safety of another person,
or
• the person's ability to care for themselves is seriously reduced.
Responsible Clinician – usually psychiatrist is responsible for the patient’s treatment while under the Act
Principal Caregiver – a friend/family who is most concerned with the patients care.
Director of Area Mental Health Services (DAMHS) – appointed by district health boards and are responsible for the ACT
in their area, if someone believes another is unwell, they can apply to this person to have them assessed.
Duly authorised officer (DAOs) – senior health professionals with special responsibilities under the act. Help with the
applications under the act and arrange assessments
District inspectors – lawyers with responsibilities for hoarding the patient’s rights under the act.
World health Organisation defines mental disorders “Comprise a broad range of problems, with different symptoms.
However they are generally characterised by some combination of abnormal thoughts, emotions, behaviour and
relationships with others.
In a hospital unit: If a patient is attempting self-harm the nurse should care for the injury and explore the patient’s
activities and feelings immediately before the episode, as well as a watch and document
Mental Health Status Exam
Behaviour- eye contact, body language, personal space, motor activity (tremors, tics, lip smacking), goal directed
(purposeful, bizarre, repetitive, compulsive tidying), gait, gestures, grooming/dress
61
Andie Morris
Affect/mood – affect: the observable behaviour the represents the expression of an emotion to others
(constricted/blunt/flat/inappropriate/incongruent - inappropriate emotional expression to the content being
discussed. Inauthentic or superficial /labile)
Mood: a subjective feeling of emotion that colours the perception of the
world(depressed/anger/anxiety/dysphoric/elevated/euthymic/expansive/irritable)
Thought- speech, tone/flow, volume, clarity, defects (stammering/stuttering), attention (distractible, preoccupied,
rumination – preoccupied with single idea or theme associated with anxiety, OCD), hypervigilant
Form of thoughts
Logical (coherent)
↓
Circumstantial
↓
Tangential
Central idea’s, not communicable, irrelevant speech
↓
Loose association
Can be symptom of schizophrenia, little and / or vague connection
↓
Flight of ideas
Multiple thoughts, manic, without obvious connection
Orientation – orientated to time and place
Memory – immediate, short term, long term
Motivation – positive, negative, passive, decision making abilities,
future plans
Intellectual functioning
Insight – self-awareness, understanding of current symptoms
Risk assessment
an estimation of the likelihood of an adverse event occurring under
particular circumstances within a particular time frame.
Aim of assessment- to determine the clients immediate, ongoing,
and preventative needs and risks to ensure client safety.
Treatment planning- psychosocial assessment assists planning in
partnership with client and family
Concepts of risk
Risk formulation- the background and current situation of the client
provides an information base
Risk management – aims to minimise the likelihood within context.
Risk factors- particular features of illness, behaviour or circumstances.
Suicide prevention
Government initiatives –
- Promote Mental health and prevent problems
- Improve care of those with mental health problems
- Improve care of those who have made suicide attempts
- Reduce access to means of suicide
- Promote safe reporting and portrayal of suicide in media
- Support families
- Expand evidence about rates, causes, and effective interventions
Mauri Ora (health individuals) Whānau Ora (healthy families) Whai ora (healthy community)
62
Andie Morris
Assess patients’ risk
Risk factors (male, previous attempt, change in
treatment, history of substance use, chronic physical
illness, loss of something, most likely to commit suicide
after starting medications as they gain more energy to
complete already made plans, spring time may also be a
common time for a patient to commit as the weather
warms but life doesn’t improve for them) there is also
protective issues such as reason for living, concerns for
others or a sense of belonging.
Risk management
Done with or by a senior nurse, involves risk
formulations and then a plan which may be
hospitalisation
If a patient state they feel like killing themselves or a nurse
suspects it, the nurse should be upfront and ask, “do you feel like
killing yourself?” “Do you have a plan?”
Legal and ethical issues
Mental health act 1992 for the mentally disordered or at risk of
suicide. Privacy act and privacy code has limitations and patients
need to be aware. This means that if they tell us that they have a
plan we must protect them and notify their health team.
Co morbidities in mental health
Blood tests – because of the medications (liver screening, lipid
levels, glucose, prolactin, urea and electrolytes, thyroid function,
CBC, B12 and folate, serum levels)
Screening- cervical cytology, testicular exam, teeth-reduced saliva
due to meds, eyes-meds cause cornea damage, breast hyperprolactactinaeima, urine- polyurea
(diabetes) – dehydration, bowels- constipation due to food
choice/meds/low exercise.
Lifestyle – insomnia, smoking, low exercise, alcohol and drug use,
poor diet can lead to diabetes, caffeine stimulant causing
anxiety/stomach complications/ arrythmias, sexuality risk of HIV
meds can affect function.
Often causes diabetes
Care planning: involves hope, education, support, self-advocacy,
personal meaning.
63
Andie Morris
Alcohol withdrawal assessment
Alcohol withdrawal is the most dangerous substance to withdrawal from. This is because of the risks it causes to the
body such as cardiac arrest this is why it is important to detox in a medical environment. Depending on how dependent
the patient was to alcohol will show how severe the symptoms will be.
Symptoms
Anxiety, sleep disturbances, seizures, sweating, low blood pressure, confusion, appetite, nausea, hallucinations
Highest risk 6hrs after stopping,
Treatment: Diazepam
Wernicke’s Korsakoff
Sudden onset related to thiamine deficiency. Symptoms include jerky eye movement, poor balance, confusion and
drowsiness. This can lead to Korsakoff if untreated with high doses of thiamine.
Anorexia Nervosa
Information: Occurs when a person severely reduces the amount of food they eat. This makes them lose more weight
than is healthy for their age and height. Those with anorexia have an obsessive fear or gaining weight. They may diet or
exercise too much so they can lose weight or stay slim. This typically begins during adolescence. Defined as being 15%
or more below your ideal weight for your height.
Causes: family patterns (depression, eating disorders, alcoholism), social factors (society’s emphasis on thinness,
society’s intolerance of fatness, pressure to achieve), personal factors (low self-esteem, overly sensitive to other
opinions, perfectionist, poor problem-solving skills, anxious, self-critical, very self-conscious)
Signs: refusing to eat around people, having rituals around eating such as counting mouthfuls, a particular plate or tiny
mouthfuls, lying about eating, constant preoccupation with food, moody or angry when asked about dieting, usually
thin appearance, increasing weight concern, wearing only baggy or concealing clothing, exercising too much, repeatedly
weighting themselves, difficulty concentrating, restlessness and hyperactivity, changes in personality
Complications: due to weight drops changes in the body happen such as body functions slow down so as to not use up
too much energy (a sign is lowered body temperature so the person feels cold), menstrual periods stop, blood flow to
arms and legs is reduced causing them to feel cold and blue, fine hair may grow on the back, arms and face, further
weightless causes vital organs such as the brain and heart are affected, starvation of the brain causes loss of
concentration, difficulty thinking clearly, depression and irritability, starvation of the heart muscle leads to heart failure
or disturbances in heart rhythm which can lead to sudden death
Treatment: Addressed medical, nutritional, psychological and behavioural aspects. Psychosocial treatment (therapy),
psychoeducation, medications (antipsychotic and antidepressants SSRI’s), complementary therapies (mindfulness,
hypnotherapy, yoga) hospitalisation (cognitive behaviour therapy, DBT)
When an inpatient the aims are: achieve physiological stability, commence appropriate refeeding, initiate nutritional
recovery, undertake psychiatric assessment, engage young person and family with outpatient treatment.
Bipolar Affective Disorder
Information:
Can be bipolar 1 or bipolar 2. Bipolar 1 involves periods of severe mood episodes from mania to depression. Bipolar 2
disorder is a milder form of mood elevation involving milder episodes of hypomania that alternate with periods of
severe depression.
Manic VS hypomanic
Hypomanic is a form of elevated mood but less severe than manic. – no significant impairment, still functioning but may
be sleepless, more activity, very talkative, still able to have a normal life
Manic episode the person may have extreme physical and mental over activity and poor judgement. This can cause
exhaustion as the person may not be resting and eating during this time.
Distractible, irritable, grandiose, flight of ideas, activity increased, sleep decreased, talkative for at least one week,
causes significant impairment, not attributable to substances or medical conditions.
Presenting symptoms: impulsivity, increased energy, recklessness, lack of judgement, lack of sleep, lots of talking,
psychosis, sexual disinhibition, self-inflated ideas (thinking they have skills that they do not.)
64
Andie Morris
Diagnostic tests: must have had on manic or hypomanic episode AND one depressive episode.
Treatment: Educate them on sleep (watch sleep patterns), small snacks for them to snack on to encourage eating,
empowerment to find their early warning signs. Medications
Exhaustion = lower the mood encourage slowing down, remind them to eat and drink, cut caffeine, decrease physical
activity
Impulsiveness= set limits
Vulnerability = remind person of appropriate conversation, calm and clear conversation.
Inadvertent harm = remind them to eat and drink
Intentional harm= medications.
Schizophrenia
Information:
Stages –
Premorbid (no symptoms of MH)
Prodrome (early symptoms often vague)
Acute (psychotic symptoms)
Recovery from symptoms, relapse.
Risk Factors: Childhood trauma
Diagnosis: must have 1,2 or 3 plus 1 more of the following – for at
least one-month, total disease length over 6 months
1. delusions
2. hallucinations
3. Disorganised speech
Disorganised/catatonic behaviour, negative symptoms
Positive (things that you can see psychosis), delusions, hallucinations,
illusions, disorganisation
Negative (things that are gone), lack of concentration, decreased
problem solving, flat affect, anhedonia, flat speech, cognitive deficit
Effects of Schizophrenia: schizophrenia causes the person to be more
vulnerable to situations such as financially vulnerable, sexually
vulnerable. Schizophrenics are more likely to be victims than they
are to be violent or perpetrators. Therefore, it is essential for them to
feel accepted and have a strong support system this can help to
improve the outcomes of treatment for psychotic disorders.
Treatment: Engage the person, work with the persons goals, meet the person where they are, monitor Mental status
and risk status, be aware of depressive and suicidal thoughts, monitor for effects of medications
Reassure the client they are safe, be aware of your own behaviours, discuss use of PRN meds sensory modulation.
Clozapine weekly blood tests weekly for 18 weeks then monthly. Signs of fever or sore throats then discontinue.
Psychosis
Illusion – wrong or misinterpreted perception of a sensory experience
e.g. the mailbox is a man
Delusion – a fixed false belief that is outside the normal cultural beliefs of a person (associated with
schizophrenia)
e.g. the mailbox is your boyfriend
Hallucination – a sensory perception that is not experienced by others (associated with schizophrenia, bipolar,
depression, delirium and substance abuse) can be auditory, visual, olfactory, gustatory, tactile, typically
frightening
e.g. the mailbox is shouting at you
Anxiety
Information: excessive worrying and anxiety for over 6 months, disrupted functional connectivity of the amygdala and
its processing of fears and anxiety, includes phobias.
65
Andie Morris
Presenting symptoms: restlessness, tired easily, problem concentrating, irritability, muscle tension, problem with sleep,
panic attacks (palpitations, sweating, shaking, Shortness of breath, numbness, feeling that something bad is going to
happen, occurrence of at least 1 attack, constant worry about reoccurrence, must rule out other diagnosis)
Diagnostic tests: at least 3 symptoms that are interfering with daily functioning
Treatment: CBT/DBT will work if there is a mental trust between patient and leader, SSRI, SNRI, Short term benzos,
WRAP Plan,
Depression
Information:
is an illness that can affect how you feel for months. Depression can start at any age from childhood to old age. People
with depression often have other problems such as anxiety, substance abuse disorders, personality disorder and may
engage in deliberate self-harm.
Causes: stressful events (breakups or financial troubles), a family history, physical illness (stroke or heart attack),
traumatic events in childhood can lead to depression later in life, certain medications, social isolation
Presenting symptoms: anhedonia, low mood for a long time, motor retardation, weight changes (gain or loss due to
appetite changes), sleep reduced or increased due to changing in sleeping pattern, decreased activities of daily living,
suicidal idealations, depression with psychotic symptoms – delusions linked to negative side of life, thoughts of
hopelessness or death
Treatment: anti-depressants (may increase suicide ideation as it increases energy levels first before thoughts, so they
get the energy to complete), ECT (very few side effects and works well), physical health.
Cognitive behavioural therapy (CBT)
One of the most evidence-based
psychotherapy for:
-
Anxiety disorder
Mood disorder
Eating disorder
Personality disorder
Substance abuse
Chronic pain
Psychotic disorder
•
•
•
Short / quick time frame
Cost effective
A valid first line treatment for many
disorders
Behaviour
reinforces
thought
Thoughts
create
feelings
Thoughts
“I am worthless” - This thought
begins to repeat in the brain
automatically
↓
Creates Feelings of depression
↓
Behaviour- Staying in bed all
day
Feelings
creates
behaviour
Recovery Model “achieving the life we want in the presence or absence of mental distress”
The recovery model is the ability to live well in the presence or absence of one’s mental illness.
The patient must define for themselves what ‘living well’ means to them. The definition is broad because recovery is
different for everyone. The aim is to work with individuals to support them in ways to minimise the level of distress
and impact on their day-to-day lives as much as possible. This approach requires mental health services to develop and
draw on their own resources and requires that they develop and draw on the resources of people with mental illness
and their community. Recovery is when the patients take an active role in improving their lives.
The right conditions for recovery are strength and interrelationships of our self-determination, personal resources,
supports, therapies and our social and economic opportunities. Must ensure all of these factors are maximised for both
people with mental illness and those with loss of well-being.
Ways to do this
- Finding hope and developing self-esteem and resilience (the capacity to recovery quickly from difficulties,
knowing how to cope with setbacks)
- Having a sense of purpose and meaning in your life
- Building healthy relationships
66
Andie Morris
-
Gaining independence
In Waikato there is the integrated recovery services. This place offers people the chance to build new skills (music,
painting), gain access to computer skills, CV making, work experiences. This assists them in gaining new skills,
independence, builds relationships with new people in similar situations in life,
A WRAP (wellness recovery action plan) is a patient made prevention and wellness process that people can use to get
well, stay well and make their life the way they want it to be. Develops lists of things the patient wants to do every day
to stay well, identify triggers and early warning signs, late warning signs, wellness tools, action plans for responding to
crisis, crisis plan and post crisis plan.
Methamphetamine addiction
Information: meth is a powerful l=, highly addictive stimulant that affects the central nervous system. It causes a rapid
release of dopamine, serotonin and noradrenaline this produces enhanced feeling of energy, mood and libido. The
feelings of increased confidence, alertness, and wellbeing or euphoria lasts
around 6 hours.
Risks: can be due to the drug or the things done while using. Physical
dependence, sleep problems, decreased appetite, weight loss, malnutrition,
tooth decay, loss of teeth, skin sores, anxiety, mood changes, depression,
suicidal thoughts, aggression and violent behaviour, psychosis,
cardiovascular problems e.g hypertension, stroke, heart attack, risky sexual
behaviour causing STI or pregnancy, overdose, risk of injecting hepatitis,
HIV, Skin infections, social effects job loss, home, relationships, criminal
convictions.
Signs of addiction: compulsion, loss of control, cravings, continued use
despite consequences.
Treatment: counselling, motivational interviewing, CBT, medication, group
therapy, family therapy, detox programs, residential treatment programs
such as higher ground, rehab in hospital or home.
The Substance Addiction (Compulsory Assessment and Treatment Act) 2017
The compulsory assessment and treatment of people who are considered to have a severe substance addiction
This applies to:
o Severe addiction problem which places them in danger of serious harm and servery impacts their
ability to care for themselves
o The person must be unable to understand, remember to make decisions about treatment options
o All other options have been exhausted and compulsory treatment is necessary
o Suitable treatment is available
Criminal Procedure (Mentally impaired persons) Act 2003
Provides the courts with appropriate options for the detention, assessment and care of defendants and offenders with
an intellectual disability
Whether a defendant may or may not be found unfit to stand trial for an offence as assessed by the criteria in the crimes
act (1961)
Detained in a forensic facility; requiring treatment for mental disorder = person remanded for a court report, pending
trial or court sentencing.
Protection of Personal and Property Rights Act 1988
Provide appointment of guardian to oversee care of a person’s personal needs/property
To help people who have lost the capacity to make or understand decisions about their own personal offers or
property, or who are no longer able to tell other people what they have decided
Applies to:
o Mentally ill
o Have an intellectual disability
o Have a severe head injury
o Are elderly and have become mentally incapacitated
67
Andie Morris
Child/Adolescent Mental health
o Co-Morbidity very common
o Ones who commit suicide haven’t accessed Mental health services.
Risks: Poor quality of family life, school/community environments, poor physical health, Attachment problems
(extreme neglect can cause, abuse), 50% more likely to develop if parent mentally unwell (due to becoming socially
isolated if they are taking care of their parent, elevated risk of internalising problems like depression/anxiety,
externalising problems such as aggressive and antisocial behaviour
HEADSS Assessment: Home, education, eating, Activities and peer relationship, Drugs/Alcohol, sexuality, suicide,
safety and spirituality.
Emotional Disorder: anxiety, PTSD, Adjustment disorders (common in separated parents), depressive disorders
(present angry)
Disruptive Disorder: Disrupts the processing of information, difficult to learn, hyperactivity, inattention, impulsive,
restless, more likely to use drugs, can lead to conduct disorders
Conduct Disorders: aggression to people/animals, destruction of property (break into houses/start fires),
deceitfulness, serious violations of rules. Treatment: good rules, consequences, routine.
Eating Disorder: Avoidant/restrictive food, picky eaters, can lead to dependence on supplements or even feeding
tubes, cardiac problem, anorexia characterised by distorted body image excessive dieting that leads to severe
weight loss with a pathological fear of becoming fat. Bulimia characterised by frequent episodes of binge eating
followed by inappropriate behaviours such as self-induced vomiting to avoid weight gain. Outpatient care as first
line of treatment but failure to response to outpatient can result in Inpatient, can cause (hypothermia, hypotension,
electrolyte abnormalities and cardiac arrythmias)
Addiction: binge drinking, substance dependence, high prevalence between co-morbidity.
Autism: usually significant problems with language, social interactions and behaviour
Tourette’s syndrome: neurological disorder repetitive, stereotyped, involuntary movements.
Mental Health Medications
Anxiolytics
Benzodiazepines
are GABA receptor agonists. GABA (gamma-aminobutyric acid), is the major inhibitory neurotransmitter in the CNS.
Stimulation of the GABA receptors therefore causes widespread neural inhibition. This results in reduced anxiety, sleep,
psychoactivity (changes in perception, mood, consciousness, cognition or behaviour), as well as anticonvulsant and
muscle relaxing actions
Important notes: only for 2-4 weeks after you can become dependent, withdrawal effects if stopped suddenly, body
becomes used to its effects, can causes sleepiness and effect concentration, limit alcohol. Cannot take during pregnancy
as it passes through the placenta or in breast milk causing dependency, withdrawal and possibly death in fetus.
Stopping benzos abruptly can cause withdrawal effects such as agitation, insomnia, seizures, muscles cramps and
vomiting.
Used to treat: alcohol withdrawal, severe anxiety, agitation, panic attacks, muscle spasms, severe insomnia, relaxation
during certain medical procedures, seizures if quick effect is needed
Examples: Alprazolam, diazepam, lorazepam, nitrazepam, midazolam
Side Effects: Drowsiness, confusion, dizziness, trembling, impaired co-ordination, vision problems, grogginess.
Barbiturates
Most well-known anxiolytics and also have . They reduce anxiety by stimulating the inhibitory GABA receptors. In
addition, they inhibit receptors for the stimulating neurotransmitter glutamate.
Important Notes: highly addictive qualities so are only prescribed for short duration of no more than 3-4 weeks to
prevent dependence and tolerance. Overdose can cause deep sedation, coma or death.
Examples: amobarbital (Amytal), pentobarbital (Nembutal), and secobarbital (Seconal)
Side Effects: Drowsiness, headache, hypotension, nausea, sedation, skin rash, slow breathing, coma, fainting,
hallucinations, temporary breathing cessation.
68
Andie Morris
Antidepressants
Selective Serotonin Re-Uptake Inhibitors (SSRIs)
Serotonin in a neurotransmitter that has influence on mood, emotion. SSRIs increase serotonin in synaptic clefts by
blocking (or "inhibiting") reuptake into the presynaptic neuron, meaning more serotonin is available to pass further
messages between neurons
Important Notes: On the lowest possible dose, usually lasts for at least 6 months but can be longer in people with
recurrent problems. May take 3-4 weeks to become effective. Monitor for serotonin syndrome
Examples: Fluoxetine (Prozac), Citalopram, sertraline,
Side Effects: feeling agitated, anxious, nausea, dizziness, blurred vision, loss of libido, erectile dysfunction, mania and
agitation, suicidal ideation.
Serotonin-Noradrenaline Re-Uptake Inhibitors (SNRI)
Important Notes: May take 3-4 weeks to become effective. Monitor for serotonin syndrome.
Examples: Mirtazapine, Venlafaxine
Side Effects: Similar to SSRI’s
Nursing interventions: correct dose, report side effects, monitor effectiveness – decrease in symptoms, education, drugs
and herbal interactions, monitor serotonin syndrome.
Serotonin Syndrome
Information: develops when there is too much serotonin in the brain.
Symptoms: Muscle spasms the patient can’t control this usually occurs within hours to days of the person taking
medication or changing doses. Agitation/restlessness, confusion, anxiety, hypertension, tachycardia, hyperthermia,
tachypnoea, dilation of the eye, diaphoresis (sweating), shivering, vomiting, diarrhoea, arrhythmias, tremors,
hyperreflexia, muscle rigidity.
Treatment: Benzodiazepine to decrease agitation seizures and muscle stiffness, cyproheptadine a drug that blocks
serotonin production, IV fluids, withhold SSRI’s and inform doctor
Tricyclic antidepressants
Generally block the effects of both serotonin and noradrenaline (norepinephrine), like SNRIs
Can also treat: migraine, panic disorder, obsessive-compulsive disorder, recurrent headaches, and some forms of pain
Important Notes: Can make the effects of alcohol stronger, cannot be taken with SSRI’s or SNRI’s, not suitable for
suicidal clients. Tricyclic medications are also toxic so can be lethal in overdose. Tricyclic toxicity is a medical
emergency. Toxicity usually starts mildly with anticholinergic effects but can develop into serious toxicity with
seizures, coma, hypotension and QRS prolongation with ventricular dysrhythmias. If suspected the patient is normally
treated with sodium bicarbonate and charcoal to remove the medication and close monitoring of the patient heart rate
and rhythm and level of consciousness is required.
Examples: Amitriptyline, clomipramine, dothiepin
Side Effects: Anticholinergic side effects such as constipation, dry mouth, dizziness, plus side effects from SSRI’s and
SNRI’s, sexual dysfunction
Monoamine-Oxidase Inhibitor (MAOI)
Their mode of action is by blocking the enzyme monoamine oxidase, which breaks down the
neurotransmitters dopamine, serotonin and noradrenaline.
Important Notes: Not usually prescribed as they cause hypertension if taken with foods high in tyramine (cheese, liver,
yogurt, marmite)
Examples: Moclobemide, phenelzine, isocarboxazide
Side Effects: Postural hypotension, drowsiness, insomnia, headache, Weakness, dry mouth, constipations
Mood stabilisers
The mode of action can vary depending on the drug given, generally all involve the altering of sodium channels in the
central and peripheral nervous systems. It is not clear how lithium carbonate works but it is believed to provide a
69
Andie Morris
source of lithium ions that may act by competing with sodium ions at various sites. This is believed to alter the ability of
neurons to release, activate or respond to neurotransmitters. The mode of action for sodium valproate has not been
fully established. Its anti-convulsant effect is attributed to the blockage of Na+ channels and increased brain levels of
GABA. It is the increase of GABA which is believed to contribute to the anti-manic properties.
Important Notes: Mood stabilisers can cross the placenta and can act as a teratogen and can also interfere with
menstrual cycles, so caution is advised in women of childbearing age and pregnancy. advising patient around regular
blood monitoring which is required on lithium, conducting blood tests for lithium levels (therapeutic range is 0.6-1.2
mmol/L, toxic is greater the 1.5mmol/L), advise patient can cause sedation, and monitor for seizures as well as check
the effectiveness and monitoring for side effects.
Used to treat: balanced mood for people with intense shifting moods such as bipolar. There are a number that can also
be used as anticonvulsants for people with seizures
Examples: lithium carbonate, sodium valproate, carbamazepine and lamotrigine
Side Effects: sleepiness, dizziness, a metallic taste in the mouth, increase appetite, weight gain, nausea, skin rash,
irregular periods, changes in RBC and lithium carbonate can cause lithium toxicity
Lithium Carbonate – the gold standard, it slows things down. Watch for dehydration, drink lots of water to avoid
toxicity, Blood tests for lithium levels to make sure it’s in a therapeutic level. Every three months. Leaves the body
through the kidneys so need to monitor kidney function so lithium is known for causing kidney failure and it can’t
secrete it properly.
Cholinesterase Inhibitors
These drugs stop or inhibit the enzyme acetylcholinesterase from breaking down into acetylcholine in synapses in the
brain. This results in more acetylcholine accumulating in the neuron synaptic clefts. Acetylcholine is an important
neurotransmitter in memory. People with Alzheimer’s disease have low levels of acetylcholine in their brain
Important notes: They do not treat it but slow the progression of dementia symptoms
Used to treat: Dementia
Examples: Donepezil, galantamine and rivastigmine.
Side Effects: Diarrhoea, muscle cramps, fatigue, nausea, insomnia, headache, fainting, dizziness, heart palpitations
Antipsychotics
Nursing interventions that must occur prior to a patient starting antipsychotics include: vital signs, allergies, blood
tests, ECG, height and weight.
Typical First Generation – for positive symptoms
Typical antipsychotic medication is the blockage of dopamine D2 receptors in the central nervous system.
Examples: includes haloperidol, chlorpromazine, zuclopenthixol and flupentixol decanoate
Side Effects: Movement and muscle disorders, akathisia, dystonia, tardive dyskinesia and parkinsonism
Extrapyramidal side effects are treated with benztropine
Atypical Generation – for negative symptoms
Atypical antipsychotics also blocks dopamine D2 receptors but additionally block serotonin receptors
Important Notes: If the patient is to be started on Clozapine, weekly blood tests are to be completed to monitor for
agranulocytosis (unable to fight infection with this) until the patient has been on the medication for 18 weeks and
then blood tests are done monthly. Clozapine cannot be suddenly started or stopped without regular blood tests and
careful monitoring is required if the person develops an infection.
Examples: Clozapine, risperidone, olanzapine, quetiapine and aripiprazole
Side Effects: Increased appetite, weight gain, insulin dysregulation, increased prolactin, metabolic syndrome, sexual
dysfunction, increased salivation and agranulocytosis
Dietary supplements
Supplements with proven efficacy;
•
•
70
St John’s wort – mild depression, interacts with a lot of drugs
Omega 3 – depression / Bipolar
Andie Morris
•
Melatonin - sleep
Emotional support of animals
•
Evidence based unclear, low risk
Social integration – better outcome, Exercise, Yoga, Acupuncture
Miscellaneous
Smoking Cessation
ABC’s
A- Ask/document
B- Brief Advice
C- Cessation Support
Barriers
Health care worker who smoke, time, knowledge, skills, healthcare
workers who see ABC’s as beyond their job description, fear of
consequences – being eft out, illness, weight gain, boredom, viewing
smoking as a stress reliever
Treatment options
-
-
Patch 21mg, 14mg, 7mg – clean and dry skin, remove old then
new, redness is normal, can remove at night
Gum 4mg, 2mg – regular use, bite then put between cheek and
gum, chew for 30 minutes
Lozenge 2mg, 1mg –
regular use, suck don’t
chew, put between cheek
and gum
Inhaler 15mg – 1 smoke =
10 puffs
Oral mouth spray 1mg –
regular or craving use,
don’t swallow
immediately
Enduring Power of Attorney
What is it?
Your EPA authorises the person you name as your attorney to make decisions on your behalf about your personal care
and welfare if you become mentally incapable.
Your attorney can make decisions only on the personal care and welfare matters you specify in the EPA. In making
decisions, your attorney has to follow any conditions and restrictions set out in your EPA and the Act
When acting under the EPA, the overriding consideration of your attorney is to promote and protect your welfare and
best interests.
Your attorney must encourage you to develop your own competence to act on your own behalf as much as you possibly
can, and to be part of the community. They must consider the financial effects of any decision about your personal care
and welfare.
Your attorney must follow any court orders under the Act that relate to your EPA and any personal order or property
order under the Act, even if there is a conflict between the order and your EPA.
Andie Morris
71
Your attorney may follow any advance directive you have given. They must do so in good faith and with reasonable
care. Before doing so, they must first consult you and anyone you have specified in your EPA that you want to be
consulted. Your attorney cannot follow an advance directive that asks them to do something that they are prohibited
from doing
When does it start?
Unlike an ordinary power of attorney, an EPA comes into force only if you lose mental capacity. Your attorney’s
decisions apply as if you had made them and had full capacity to make them.
Only if a relevant health practitioner has issued a medical certificate stating that you are mentally incapable or if the
court has decided that you are mentally incapable
What can’t they do?
There are some things that the law says can only be done personally (for example, making an oath or a declaration).
Your attorney cannot:
- make a decision entering you into a marriage or civil union, or dissolving your marriage or civil union
- make a decision about the adoption of any of your children
- refuse consent to you having medical treatment that might save your life or prevent serious damage to your
health
- consent to you having electro-convulsive treatment, or any surgery or treatment on your brain that’s meant to
change your behaviour
- consent to you being part of a medical experiment, unless it is to save your life or prevent serious damage to
your health.
- Your attorney also cannot act for their own benefit or for the benefit of anyone else other than you.
Who else is involved?
When acting under the EPA your attorney must, as far as is practicable, seek advice from you and from anyone you have
named in your EPA to be consulted (either on all matters, or on the specific matters you have stated in your EPA).
What if no one agrees with the attorney?
Some people have the automatic right to apply to the court to review any decision your attorney makes while acting
under your EPA.
These people include:
- The patient
- any relative of yours
- medical practitioners
- the manager of any hospital, rest home, or residential care facility you are receiving care in
- a person from a government-funded abuse and neglect prevention service
- a social worker.
Any other person can apply to the court to review your attorney’s decisions, but they need the permission (leave) of the
court to do so.
An application for review of your attorney’s decisions can be made at any time, including after the EPA has ceased to
have effect. If an application for review is made, you will need a lawyer to represent you. The court will appoint a
lawyer to act for you if you do not already have one.
The court can make any order it thinks fit.
A written or oral directive:
Advance
directive
•
•
by which a person makes a choice about a possible future health care procedure; and
that is intended to be effective only when he or she is not competent.
See the Code of Health and Disability Services Consumers’ Rights set out in the Health and
Disability Commissioner (Code of Health and Disability Services Consumers’ Rights)
Regulations 1996.
72
Andie Morris
Public Health and Disability Act 2000
The Minister of Health has overall responsibility for the health and disability support system. The Minister works
through the Ministry of Health to enter into accountability arrangements with DHBs, determines the health strategy,
and agrees with government colleagues how much public money will be spent on the public delivery of services. The
Minister with responsibility for disability issues determines the disability strategy.
•
The Ministry of Health has as number of key functions. The Ministry:
o
o
o
o
o
o
o
o
provides policy advice on improving health outcomes, reducing inequalities and increasing participation
acts as the Minister’s agent
monitors the performance of District Health Boards, and other health sector Crown entities
implements, administers and enforces relevant legislation and regulations
provides health information, and processes payments
facilitates collaboration and co-ordination within and across sectors
provides nationwide planning and maintenance of service frameworks
plans and funds public health, disability support services and other services that are retained centrally
•
The Office of the Health and Disability Commissioner: Te Toihau Hauora, Haua ̄tanga, is responsible for
promoting and protecting the rights of consumers of health and disability support services as specified in the
Code of Health and Disability Services Consumers’ Rights.
Health and disability consumer advocacy services: Nga ̄ Kaitautoko, operates health and disability consumer
advocacy services for people who believe there has been a breach of their rights under the Code of Health and
Disability Services Consumers’ Rights.
The Office of the Ombudsmen can investigate any decision or recommendation by a central or local
government organisation that affects any person or body of people in their personal capacity.
Individuals who believe there has been a breach of their rights under the Privacy Act 1993 can take their
complaint to the Office of the Privacy Commissioner. The Privacy Act 1993 promotes 12 information privacy
principles relating to the collection, holding, use and disclosure of personal information.
Consumers of health and disability support services can also complain to the Human Rights Commission if they
believe they have suffered unlawful discrimination. Such complaints are pursued under the auspices of the
Human Rights Act 1993.
•
•
•
•
Restraints
Used to keep people safe: the person being restrained and those around the person (staff, family, visitors).
Should only be used when all other interventions have been unsuccessful and there is a risk of harm to people if they
aren’t used.
Types of restraints:
- Environments (including seclusion, fences, locked doors, furniture, bedrails)
You would use this when: there is a risk of falling out of bed, likely wandering or roaming, at risk of injury to
self or others.
-
Physical (including straps and lap belt restraints, vest restraints, mitt restraints, elbow/arm split, wrist ankle)
You would use this when: confused or agitated and at risk of injuring themselves or others (trying to pull out
an IV), likely to get up and wander, unable to cooperate when medical treatment is needed.
-
Personal (including personal restraint)
You would use this when: medical treatment is required and the person is likely to be too agitated or
aggressive, may be planned in advance, preventing removal of feeding tube or drain, keeping peoples airway
open if they are unconscious, preventing a person from moving into dangerous situations such as stepping
onto a road
Seclusion can only legally be implemented for patients under the mental health act 1992 or the intellectual
disability compulsory care and rehabilitation act 2003
When:
- Managing agitation (anxiety and aggression)
- Preventing a person wandering
- Providing physical support
73
Andie Morris
-
Assisting with treatment
Rule around restraints:
- Incorrect use of restraints can cause distress and possible injury to people so they must be used with care and
supervision
Risk assessment:
A risk assessment must be done before restraints are used and then a decision may be made
A restraint should only be used if:
•
•
•
People are a risk to themselves and/or others.
All other alternatives have been tried and have been found to be unsuccessful.
The benefits and risks of using the restraint have been considered and the benefits outweigh the risks.
Consent:
Except in emergency situations, consent must be obtained before using a restraint. It is expected that the following will
be explained to the person:
-
All alternative to the use of restraint
Associated risks and benefits
What restraint will be used
The expected duration of its use.
If the person’s ability to give consent is impaired, consent can be obtained from the family or guardians.
Someone who has been given enduring power of attorney (EPA) for a person has authority to act for that person.
An EPA for personal care and welfare comes into effect when the person becomes mentally incapable.
Risks of Restraints: Emotional risks (increased confusion, anxiety, increased anger, frustration, decreased
communication), blood clots, skin breakdown, muscle weakness, pneumonia,
constipation, nerve damage, asphyxiation, death
Alternatives to restraints:
- Increased monitoring (providing a watch, a room closest to the nurse’s
station)
- Using alarm devices that notify staff of movement
- Lowering the bed to reduce falls
- Assistive equipment is the correct size and is comfortable
- Leisure activities to distract the pt from a situation
- Careful observation of the person watching for signs of pain, hunger, thirst,
bathroom needs
- Removing excess stimulation
- Verbal interaction/direction (telling pt the behaviour is unacceptable)
- Covering invasive tubing, IVs, with a bandage
Monitoring: Physical restraints may need to be checked every 15 minutes; an environment restraint may need to be
checked every 2 hours.
Colour, circulation, skin breakdown, breathing, posture, degree of restriction, comfort levels, personal needs
74
Andie Morris
Nursing Council of New Zealand “A regulator body to empower”
Roles:
Issue practicing certificates
Set competencies
Protect the public
Governing body of nurses
Audit nurses
Credit and monitor education provider
Set state exam
Set scopes of practice for RN, EN, RNP
Disciplining nurses > complaints to registrar of nursing
council professional conduct committee
Creations:
Code of conduct
Competencies
Professional boundaries
Guidelines to social media and electronic communication (2012)
Guidelines to cultural safety
Guidelines: responsibilities for direction and delegation of care to enrolled nurses
Laws they are bound by:
HPCAA (2003) Health practitioners competence assurance act ( brought 11 laws together including Treaty of Waitangi,
medicines act 1981 and medicines amendment act, privacy act 1993, health information privacy code 1994, health and
safety reform bill 2014, misuse of drugs amendment regulation 2014, NZ bill of rights, cartwright inquiry 1988, health
and disability commissioners act 1994, code of health and disability services consumers rights 1996)
Health and disability services consumers right 1996
The Health of Maori Adults and Children
Treaty of Waitangi
Signed on 6th February 1840
Tools of colonisation – Language, laws, lands, education, health, written history, Christianity.
Effects of Colonisation
- Eco base lost
- Mana lost
- Poverty and disease. Pakeha
- Conflict between people
- Cultural practices suppressed
- ALLOSTATIC LOAD – stress that is based down for generations. Throws the body off balance (neuro, endocrine,
immune, cardiovascular) can increase the risk of metabolic syndrome, obesity, diabetes, hypertension, heart
and artery disease, depression, auto-immune, memory, failure to ovulate, erectile dysfunction.
- Alcohol introduced
Health
- Illnesses were treated by Maori with karakia and rituals as well as medicinal plants, physical massage and
water for sprinkling or immersion. The emphasis was on finding the cause and getting rid of the spirit or
dealing with the transgression responsible for it rather than on patient care.
- Maori had no immunity against many of the virulent diseases that pakeha brought to New Zealand. Venereal
infections, measles, influenza, typhoid fever, dysentery and tuberculosis were brought. As well as gonorrhoea
and syphilis which has an effect on birth rates and still births
Maori Councils Act 1900
Maori councils and local marae committees were elected in almost every Maori district. Health improvement was one of
their most important functions. Influential Maori were appointed to government positions as native sanitary inspectors
to assist the health work of councils. However, they started to struggle largely due to inadequate financial resources.
This then led to Native health Nurses where concentrated on community health work in Maori settlements many
remote and without easy access to doctors.
Tohunga Suppression Act 1907
Complaints were often made by health officials and others that tohunga (Priests/traditional healers), were endangering
rather than enhancing Maori health. It reinforced the idea that this was an undesirable activity. Not many prosecutions
were made under the act however and tohunga continued to practise.
75
Andie Morris
– Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and
Practice – NCNZ
The FOUR principles include
- The THREE P’s
Participation,
Protection, Partnership
- Tonga
The Council’s definition of
cultural safety is:
“ The effective nursing practice of
a person or family from another
culture, and is determined by that
person or family. Culture includes,
but is not restricted to, age or
generation; gender; sexual
orientation; occupation and
socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability.
The nurse delivering the nursing service will have undertaken a process of reflection on his or her own cultural identity and
will recognise the impact that his or her personal culture has on his or her professional practice. Unsafe cultural practice
comprises any action which diminishes, demeans or disempowers the cultural identity and well-being of an individual.”
Health
Maori have persisting health inequities in New Zealand. This includes high rates of obesity and diabetes as a range of
other health conditions than non-Maori. They also have higher rates of smoking. A key challenge is to improve access to
health services for Maori adults and children. E.G. Maori are more likely to report an unmet for primary health care for
a range of reasons including transport and cost.
What can be done (Health behaviours and risk factors)?
- Improving trends for the age at which Maori babies are fed solid foods
- Improving levels of physical activity and vegetable intake
- Obesity rates
- Smoking rates
Health Conditions
- Higher burden from longer term health conditions (stroke, Ischaemic heart disease, diabetes, high blood
pressure, chronic pain, arthritis)
- Contrasting mental health results (higher mental health issues but less likely to seek health)
Maori Health Strategy
He Korowai Oranga
The Māori Health Action Plan aims to improve health outcomes for Māori by:
o Setting out priority areas for action, key progress measures, and milestones to meet Treaty of Waitangi
obligations for improving Māori health and to achieve equitable health outcomes for Māori
o Strengthening Māori-Crown relationships, ensuring a shared commitment to act, and enable Māori whānau,
hapū and iwi to exercise control over their pathway to health and wellbeing
o Supporting the role of Mātauranga Māori in the development and delivery of health services to Māori, including
the provision of Rongoā Māori
o Promoting collective action by Government agencies, social sectors (including health), and communities in
working towards pae ora
o Enabling changes across the broader social, economic and behavioural determinants of health as key levers
improving Māori health
Code of Rights
1.
The right to be treated with respect.
76
Andie Morris
2.
The right to be treated fairly.
3.
The right to dignity and independence.
4.
The right to have good care and support that fits your needs.
5.
The right to be told things in a way that you understand.
6.
The right to be told everything you need to know about your care and support.
7.
The right to make choices about your care and support.
8.
The right to have support.
9.
The right to decide if you want to be part of training, teaching or research.
10. The right to make a complaint.
Coroners investigate cases of death where:
•
•
•
•
•
the cause is unknown;
in the case of suicide or unnatural or violent death;
for which no doctor’s certificate is given;
if the death occurs as a result of a medical, surgical or dental procedure, or while under anaesthetic or while a woman
was giving birth; and
for people who are under compulsory care or custody, no matter what they die of
Clinical Assessment/ Shift Documentation
Cardiovascular;
o Patient’s rate and rhythm (if they are receiving internal or external pacing this is documented here as the mode and
rate of pacing, as well as the pacemaker settings for sensitivity and stimulation)
o The current BP as well as the target MAP and whether this is being achieved with inotropes or unsupported
o Perfusion, skin colour and temperature, capillary refill
o The current regime of thrombophylaxis including thrombo-embolic devices (TED), sequential compression devices
(SCD), enoxaparin, etc o Additional cardiovascular notes can be made including areas of oedema, additional
anticoagulation i.e. heparin, issues such as bleeding and anything else of note
Respiratory;
o Following chest auscultation the patient’s air entry, breath sounds and any added sounds i.e. wheeze can be noted
o Ventilation settings i.e. mode of ventilation, PS, PEEP and oxygen (O 2) requirements, endotracheal tube (ETT) size
and position at the lip/gum or tracheostomy size and position at the skin if an adjustable flange is used
o Document the patient’s work of breathing noting areas such as respiratory rate (RR), use of accessory muscles, and
any respiratory distress, secretions, coughs
o Additional respiratory notes can be made i.e. underwater seal drain (UWSD) insitu (document any
swinging/bubbling, that the suction is connected and the bellows are out, ensure fluid volume (water) in UWSD is up to
level required)
Neurological;
o Document the patient’s Glasgow Coma Scale (GCS), sedation/agitation score, and responsiveness
o Pain score and analgesia charted i.e. IV opioids, PCA/NCA, etc During this assessment it is important to prioritise the
patient's needs and be conscious of the patient's condition and comfort level. This is especially important in the CCD
setting where the patient's rapidly changing condition can be challenging; you'll need to continually reassess the
patient and reprioritise care needs. - Additional neurological notes can be made here regarding pupil size and
responsiveness to light, current ICP and target ICP, log-roll, use of restraints
Renal;
o Document urine output, colour and concentration
o If the patient is undergoing dialysis – CVVHDF: Fresenius 5008/Prismaflex
o IV fluids charted and fluid balance
o Whether they have a catheter insitu
Gastrointestinal;
o Document feeds charted/dietary requirements if eating and drinking
77
Andie Morris
o Whether there is a nasogastric/orogastric tube (NGT/OGT)
o Date of last bowel motion (BM) and any action required as per the bowel protocol
o IV insulin protocol running
o Bowel sounds (BS) present/quiet/active
o Whether the patient has a stoma
Integumentary
o Document any pressure areas or wounds
o Note any excessive sweating or any skin conditions, areas of redness, etc
Wounds/Dressings
o Are the dressings intact or requiring redressing?
o Describe any drainage (exudate) from the wound i.e. serous (thin, watery, clear);
purulent (opaque tan to yellow serous), etc; also describe the amount of exudate i.e. none, scant (wound tissues moist,
no measurable drainage), etc
Social
o Document any family meetings, visiting restrictions, family dynamics of note, family visits
Readings
https://www.mcnz.org.nz/assets/MediaReleases/f74334fa3c/2019-Review_Appendix-1_Draft-informed-consentstatement.pdf?fbclid=IwAR2xINSY2koiswLkwvwRnbXyfqu-gKvoiBwKyQyvNkLnuTFQioeDP1xu5F4
https://www.health.ny.gov/professionals/ems/pdf/assmttools.pdf
Ministry of Health
Treaty of Waitangi
1840
Medicines Act 1981
Privacy Act
1993
NZ Bill of Rights Act
1990
Health Information Privacy Code
1994
Medicines amendment
act 2013 + Health and
safety reform bill 2014 +
Misuse of Drugs
amendment act 2014
Cartwright Inquiry
1988
Health and disability commissioner –
complaints, investigations, advocacy
Health and disabilities Commissioner Act
1994
Code of health and disability services consumers rights
1996
Health practitioners
disciplinary Tribunal –
complaints
Registrar of the nursing council professional
conduct committee (complaints)
Health Practitioners Competence Assurance Act
2003
Nursing Council of New
Zealand
Register of Nurses
Code of ethics 2010 (NZNO)
Autonomy, beneficence, nonmaleficence,
justice, confidentiality, veracity, fidelity,
guardianship of the environment, being
professional
Competencies
Domain 1: Professional responsibility
Domain 2: Management of nursing Care
Domain 3: interpersonal relationships
Domain 4: interprofessional health care and
quality improvement
1.
2.
3.
4.
5.
6.
7.
8.
Code of Conduct 2012
8 principles
Respect the dignity and individuality of the
patient
Respect the cultural needs and values of patients
Work in partnership with patients to promote
and protect their wellbeing
Maintain patient trust by providing safe and
competent care
Maintain patient’s privacy and confidentiality
Work respectfully with colleagues to best meet
patient needs
Act with integrity to justify patient trust
Maintain public trust and confidence in the
nursing profession
4 Values
Respect
Trust
Partnership
Integrity
78
Andie Morris