•
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•
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@NurselnTheM:aking
@nurseinthemakingkristine
[!]~
.
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TABLE OF CONTENTS
l~,
Head-To-Toe Assessment .......................................................................... 5
•
Dosa9e Calculation ................................................................................. 9
•
Lab Value Cheat Sheet with Memory Tricks ••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 21
Electrolyte Imbalances .......................................................................... 25
(0
0
Fundamentals ...................................................................................... 31
Mental Health .................................................................................... 49
~ Mother Baby ...................................................................................... 59
Pediatrics ........................................................................................... 77
~ Med-Sur9
•
Renal I Urinary System ............................................................... 100
•
Cardiac System ..........................................................................108
@ Endocrine System ....................................................................... 128
Respiratory Disorders .................................................................. 136
• ) Hematolo9y Disorders ................................................................. 140
Gastrointestinal Disorders ............................................................ 144
t_=) Neurolo9ical Disorders ................................................................. 148
t, Critical Care (Bun rs & Shock) ......................................................... 153
•
e
e
ABGs ....................................................................................... 159
Musculoskeletal ......................................................................... 163
Pharmacolo9y .................................................................................... 167
Templates & Planners .......................................................................... 199
Note from Kristine ............................................................................ 209
NOTES
Every
"ccot1l>liSl-ft1e NT
st~rts with the
decision to TRY.
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5
HEAD-TO-TOE ASSESSMENT
Introduction
Orientation
O INSPECT
0
0
0
PALPATE
Knock
What is your iname?
PERCUSS
Introduce yourself
Do you know where you are?
Wash hands
Do you know what month it is?
Provide privacy
Who is the current U.S. president?
0 2 SATURATION: 95 -100%
Verify cl ient ID and DOB
What are you doing here?
TEMPERATURE: 97.8- 99.1 °F
Explain what you are doing
(using non-medical language)
A&O X 4 = Oriented to Person,
Place, Time, and Situation
RESPIRATIONS: 12-20 breaths per min
AUSCULTATE
PULSE: 60-100 bpm
BLOOD PRESSURE: 120/ 80 mmHg
1
J
PULSE SCALE
Head & Face
HEAD
VII: FACIAL
f: Inspect head/ scalp/ hair
f: Palpate head/ scalp/ hair
FACE
f: Inspect
•
•
•
•
•
•
Raise eyebrows
Smile
Frown
Show teeth
Puff out cheeks
Tightly close eyes
f: Check for symmetry
f: To assess CRANIAL NERVE 7, check....
_)
a
PULSE IS ABSENT
1+
2+
3+
4+
DIMINISHED
IORMAL
FULL
BOUNDING, STRONG
-
Neck, Chest (lun9s) & Heart
NECK
f: Inspect and palpate
EYES
f: Palpate carotid pulse
f: Inspects external eye structures
f: Check skin turgor (under clavicle
!{
f: Inspect color of conjunctiva and sclera
POSTERIOR CHEST
f: PERRLA
• Pupils Equal, Round, Reactive to Light,
& Accommodation
f: Inspect
f
fl
1
f: Auscultate lung sounds in posterior and lateral chest
• Note any crackles or diminished breath sounds
ASSESS THE DEPTH ~
ANTERIOR CHEST
OF THE RESPIRATIONS
f: Inspect:
note if it's LABORED or UNLABORED
EFFORT
RHYTHM
note if it's REGULAR or IRREGULAR
• Use of accessory muscl es
• AP to transverse diameter
• Sternum configuration
f: Palpate: symmetric expansion
5 Areas for Listeninq to the Heart
f: Auscultate lung
ALL fEOPLE .ENJO) I IME MAGAZINE
sounds ➔ anterior and lateral
• Note any crackles or diminished breath sounds
Aortic
Pulmonic
,: 's ,int
-
Tricuspid
Mitnl
HEART
.......__,. f: Auscultate heart sounds (A, P, E, T, M)
with diaphragm and bell
• Note any murmurs, whooshing, bruits, or
muffled heart sounds
6
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HEAD-TO- TOE ASSESSMENT
.
Periphera~s
UPPER EXTREMITIES
.
* Have the client stand up (if able)
* Inspect the skin on the back
* Inspect: spinal curvature
(cervical/ thoracidlumbar)
* Palpate spine
* Note any lesions, lumps,
SHOULDER
* Inspect and palpate
* Note any texture, lesions, temperature,
moisture, tenderness, & swelling
* Palpate radial pulses bilaterally
• Inspect, palpate, and assess
ELBOWS
J
• Inspect, palpate, and assess
HANDS AND FINGERS
0
PULSE IS ABSENT
1+
2+
3+
4+
DIMINISHED
N01ll'4AL
Spine
or abnormalities
• Inspect hands/fingers/nails
•
_J
Palpate hands and finger joints
• Check muscle strength of
hands bilaterally
FULL
• Does each hand grip evenly?
BOUNDING, STRONG
Lower Extremities (hips, knees, ankles)
.
If we were to percuss + p.il p.ite before
listening (auscult.iting), we would ;alter
the bowel sounds. This would lead to
in.iccurate results.
~
Abdomen
.
• Inspect:
• Skin color
• Contour
• Scars
• Aortic pulsations
LOWER EXTREMITIES
* Inspect:
•
•
•
•
•
Overall skin coloration
Lesions
Hair d istri bution
Varicosities
Edema
* Inspect and palpate
KNEES
Time t.iken for capill.iry bed to
regain its color .ifter pressure
has been .ipplied
0
PALPATE
HYPOACTIVE: One bowel sound every 3-5 minutes
NORMOACTIVE: Gurgles 5-30 times per m inute
HYPERACTIVE: Can sometimes be heard without a
stethoscope. Constant bowel sounds
(> 30 sounds per minute)
* Inspect and palpate
r-.
O PERCUSS
ABSENT: Must listen for at least S minutes to chart
absent b owel sounds
( NORMAL <2-3 SECONDS )
ANKLES
AUSCULTATE
• Ught palpatloocall 4 qo,dcaots )
~
CAPILLARY REFILL TIME (CRT)
* Inspect and palpate
8
• Auscultate bowel sounds:
all 4 quadrants (start in RLQ and go clockwise)
* Palpate: Check for edema (pitting or non-pitting)
* Check capillary refill b ilaterally ,
HIPS
Assess in different order:
O INSPECT
Posterior pulse
l__! Dorsal pedis pulse bilaterally
• Check strength bilaterally
• Dorsiflexion flexion against resistance
0
PULSE IS ABSENT
1+
2"
3+
4+
DIMINISHED
N01ll'4AL
1OVERALL
~ Positions and drap es client appropriately
I
during exam (gave client privacy)
~ Gave client feedback/instructions
I
~ Exhibits professional manner during exam,
I
treated client with respect and dignity
FULL
BOUNDING, STRONG
~ Organized: exam fo llowed a logical sequence
(order of exam "made sense")
7
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NOTES
It's a beautiful thin9
when a CAREER
and a PASSION
cot1e JogfTlffR.
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9
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ABBlEVIATIONS
~-TIMES OF MEDICATION:
ac
before mea ls
pc
after meals
daily
every day
bid
two t imes a day
tid
three times a day
qid
four times a day
qh
•~;;;;~~;;~;;;~~;;
;;~~~'~;~~
I
1
~~;;~
i
·•.
Rem ember: tid = 3X a day
ANSWER: If t hey are receiving 1 mg for 3X a day,
t hat's 1 mg x 3 = 3 mg per day
by mouth
IM
intram uscu larly
every hour
PR
per rectum
ad lib
as desired
SubO
subcutaneously
stat
immediately
SL
subl ingual
q2h
every 2 hours
ID
intradermal
q4h
every 4 hours
GT
gastrostomy tube
IV
intravenous
q6h
every 6 hours
IVP
int ravenous push
prn
as needed
IVPB
intravenous piggyback
hs
at bedtime
NG
nasogastric tube
.---- DRUG PREPARATION ----.
tablet
cap, caps
capsule
gtt
drop
I
I
~ - ROUTES OF ADMINISTRATION-~
PO
tab, tabs
\
How many mg wil l they receive in one day?
APOTHECARY
&HOUSEHOLD
METRIC
g (gm, Gm)
gram
mg
milligram
microgram
gtt
drop
min, m, mx
minim
tsp
teaspoon
pt
pint
EC
enteric coated
mcg
CR
controlled release
kg (Kg)
kilogram
gal
gallon
susp
suspension
L
liter
dr
dram
el, el ix
elixir
ml
milliliter
oz
ounce
sup, supp
suppository
T, tbs, tbsp
tablespoon
mEq
milliequivalent
qt
quart
SR
sustained release
10
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CONVERSIONS
BASE
1 mg = 1,000 mcg
THE METRIC SYSTEM
LARGE unit to SMALL unit ➔ move decimal to the RIGHT
SMALL unit to LARGE unit ➔ move decimal to the LEFT
1 g = 1,000 mg
1 oz= 30 ml
8 oz= 1 cup
MOVING TO A LARGER UNIT?
Move the decimal place to the Left
(Ex : mcg ➔ mg)
1 tsp = 5 ml
/
0
1 dram = 5 ml
1 tbsp = 15 ml
1 tbsp = 3 tsp
1 l = 1,000 ml
1 ml = 5 gtts (drops)
I
I
::s~o
1
1 lb = 16 oz
! 120 lbs ; 2.2
·•.
:•1 ~;~O mg (1.5 mg)
~
···- ·············································································································
120 lbs = __ kg
•
I
A mg is larger than a mcg
Therefore yo u move d ecimal
lb ➔ kg
DIVIDE by 2.2
1 kg= 2.2 lbs
..
;~~~:~~~ =:~
150~~
•.
l arqer unit
think l eft
= 54.545 kg
.. •···········
kg ➔
lb
.............
MULTIPLY by 2.2
45.6 kg = _ _ lbs
45.6 kg x 2.2 = 100.32 lbs
I
················································--·--···················
11
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DOSAGE CALC RU LES
•
Show ALL your work.
Medication error kills,
prevention is crucial!
Leading zeros must be placed before any decimal point.
The decimal po int may be missed without the zero
•
.2 mg shou Id be 0.2 mg
WHY? .2 cou ld appear to be 2
(0.2 mg of morphine is VERY different than 2 mg of morphine!)
8
No trailing zeros .
•
8
0.7 ml NO, 0.70 ml
1 mg NO, 1.0 mg
WHY? 1.0 could appear to be 10!
Do not round until you have the final anwser!
HOW TO ROUND YOUR FINAL ANSWER
If the number
in the thousands p lace
is 5 OR GREATER
➔
The # in the hundredth place is rounded up
~ 1.995 mg is rounded to 2 mg
~ 1.985 mg is rounded to 1.99 mg
DECIMAL
REFERENCE GUIDE
34.732
If the number
in the thousands p lace
is 4 OR LESS
➔
•
8
· H]IL..
,~h,
The # is dropped
hundredths
tenths
0.99l mg is rounded to 0.99 mg
Most nursing schools, if not all, do not give partial credit.
This means every step must be done correctly!
12
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FORMULA METHOD
For Volume-Related Dosa9e Orders
...................................................
D
X
H
V -- A
....................................................
D=
Desired
EXAMPLE: " The physician orders 120 mg ... "
H=
•
Some m ed ications like hep ari n and
insul in are prescri b ed in units/ hour
Dosage of medication available
EXAMPLE: "The medication is supplied as 100 mg/ 5 m l "
VA-
Volume the medication is available in
EXAMPLE: " The medication is suppl ied as 100 mg/ 5 ml"
Amount of Medication required for administration
YOUR ANSWER
•
You should assume that al l questions
are asked " per dose" unless th e question
g ives a t imeframe (example: "how many
tablets will you give in 24 hours?")
.····· · · ·. . · .................. EXAMPLE 1 ····························· · · . . / . · · · ··························· EXAMPLE 2 ··············· · ····· · · · · ..\
/ . Ordered: Drug C 150 mg
Available: Drug C 300 mg/tab
How many tablets shou ld be given?
\
D
xV = A
H
D
- XV = A
H
What's our desired? Drug C 150mg PO
What do we have? Drug C 300mg/tab
What's our quantity/volume? tablets
150 ~
-:- 300 fRQ x 1 tab = 0. 5 tabs
150 -:- 300 = 0.5 x 1
\..... . . . . . . . .•;,:uf;):@,1Jil
Ordered: Drug C 10,000 units SubQ
Available: Drug C 5,000 units/ml
How many ml should be given?
=
10,000 't::lRit_s -:- 5,000 0A-it_s x 1 ml = 2 ml
10,000-:- 5,000 = 2 x 1 = 2 ml
0.5 tabs
0.5 tabs I
What's our desired? Drug C 10,000 SubQ
What do we have? Drug C 5,000 units
What's our quantity/volume? 1 ml
························/
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\.. . . . . . . . . . . . . . . •;,:(;jf;):U:NJil
2 ml
I
······················/
13
IV FLOW RATES
ml of solution
What if the question
is given in MINUTES?
-
total hours
Since there are 60 minutes
in one hour, use this formula:
ml/hr
ml of solution
X
.
min
If the question is asking for flow rate and you're g iven
units of ml , you need to write t he answers in ml/hr!
•
ORDERED: 1000 ml DSW to infuse over
3 hours. What wil l the flow rate be?
1000 ml
3 hr
\.....
(rounded to the nearest whole numbe r)
(
..
.
tota I minutes
30 ~
...··/
-
X 60 miQ :
100 ml/hr
ANSWER:
j
drop
factor
X
ml/hr
ml/ hr is always rounded to the nearest WHOLE num ber!
50ml
ANSWER: 333 ml/hr
ml of solution
=
ORDERED: Infuse 3 grams of Penicill in in
50 ml no rmal sa line over 30 minutes.
= 333.333 ml/hr
..
.
60
(minutes)
··......... ,.,,, .................................................................. , .. ,, ...........................·
What if t he question
is given in HOURS?
9tt/min
Since there are 60 minutes
in one hour, use this formula:
Convert hours to minutes!
•
If a drop factor is included, the question
is asking for flow rate in gtt/min.
EXAMPLES:
1 ho ur = 60 minutes
2.5 hours = 150 m inutes
REMEMBER OUR
ABBREVIATIONS:
gtt means "drop"!
You need to write t he answers in gtt/ minute!
ORDERED: 1000 ml of Lactated Ringer's to
infuse at 50 ml/hr. Drop fa ctor for tubing is
a 5 gtt/ml. (Conve rt: 1 hour = 60 min)
50
ml-
60 min
X 5 gtt/m.l-
50 + 60
=
0.833
= 4 gtt/min
X
5
=
4.166
Round to the nearest whole n umber ➔ 4
·...UW,if:i:OWa;l 4 gtt/min 1. 0
~~~~t~~~~~~i~IEt:e\ nd!
over 45 minutes. The t ubing you are using
has a d rop factor of 10 gtt/ml.
100 ml.:
- - - - X 10 gtt/mt. = 22 gtt/min
45 min
100 + 45
=
2.222 X 10 = 22.222
Round to the nearest whole number ➔
. . ..,,11n,1MHWa;!
2 2 gttlmin
22
1. 0 ~~~~t~~~~~~i~~t:e\nd!
14
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PRACTICE QUESTIONS
Do all 10 quest ions w ithout looking at the correct answers on the following pages. Don't forget to show
all your work. After you are done, wa lk through each question ... even the q uest ions you got correct!
•
ORDERED: Rosuvastat in 3000 mcg PO ac
AVAILABLE: Rosuvastatin 2 mg tablet (scored)
How many tabs will you administer in 24 hours?
•
ORDERED: Tylenol supp 2 g PR q6h
AVAILABLE: Tylenol supp 700 mg
How many supp will you administer?
Round to nearest tenth.
•
250 ml normal saline over 5 hours.
Tubing drop factor of 10 gtt/ ml.
•
Humulin R 200 units in 100 ml of normal
saline to infuse at 4 units/ hr.
. . Dopamine 600 mg in 200 ml of normal saline to
infuse at 10mcg/ kg/ min. Pt weight• 190 lbs.
•
ORDERED: Potassium cholride 0.525 mEq/lb PO
d issolved in 6 oz of ju ice at 0930
AVAILABLE: Potassium cholride 12 mEq/mL
How many ml of potassium chloride
will you add to the juice for a 66.75 kg
patient? Round to nearest tenth.
.W
•
•
2.5 l normal saline to infuse over 48 hours.
1000 ml O5W to infuse over 4 hours.
~ ORDERED: Morph ine 100 mg IM q12h prn pain
" ' AVAILABLE: Morphine 150 mg/2.6 ml
How many ml will you administer?
Round to nearest hundredth .
•
150 ml Cipro 250 mcg
to infuse over 45 minutes.
15
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COMPREHENSIVE REVIEW
•
ORDERED: Rosuvastat;n 3000 mcg PO ac
AVAILABLE: Rosuvastatin 2 mg tablet (scored)
How many tabs will you
administer in 24 hours?
mcq
➔
3,2,9,g mcg
-~
mq
=3
~
•
ORDERED: Tylenol supp 2 g PR q6h
AVAILABLE: Tylenol supp 700 mg
How many supp will you administer?
Round to nearest tenth.
q ➔ mq
mg
2$.vv.
SMALL TO BIG:
move the decimal point 3 to the left
unit i, 9ettin9 lar9er think Left
= 2000
-~
~
mg
BIG TO SMALL:
move the d ecimal point 3 to the rig ht
..........STEP ·2: READY·TO USE DATA ..............................
ORDERED: 3 mg
AVAILABLE: 2 mg
VOLUME: 1 tab
ADMINISTERED AC: before each meal
QUESTION IS ASKING: dosage in 24 ho urs
D
XV = A
H
D
XV = A
H
SHOW YOUR WORK- - - - - - - ,
3 mg_
= 1.5
DON'T FORGET TO CHECK
TIMES OF MEDICATION!
2mg_
0
1.5 x 1 tab
= 1.5
= 4.5 tabs per day
~
1.5 x 3
ROUND:
ORDERED: 2000 mg
AVAILABLE: 700 mg
VOLUME: 1 supp
No rounding necessary
4.5 tabs
The m edication is o rdered
to be g iven AC, which
means before each meal.
Since there are 3 meals
in a day (24 hours),
the answe r m ust be
mult ip lied by 3.
SHOW YOUR WORK- - - - - - ,
2000 ~
700 M8
= 2.857
2.857 x 1 supp
~
0
REMEMBER RULE #4
Don't round till the end!
= 2.857 supp
ROUND: Nearest tenth
2.857 s upp
➔
2. 9 supp
2.9 supp
16
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COMPREHENSIVE REVIEW
•
•
ORDERED: Potass;um chlodd e 0.525 mEq/ lb PO
d isso lved in 6 oz of juice at 0930
AVAILABLE: Potassium chlorid e 12 m Eq/ ml
How many ml of potassium chloride will
you add to the juice for a 66.75 kg patient?
Round to nearest tenth.
r······ STEP
1000 ml DSW to infuse over 4 hours.
1: CONVERT· DATA ·················································,
66 .75 ~
mE9/lb
x 2 . 2 (l b~
➔
= 146.85 lb
0
mE9
In this case, o rdered amount
depends on patient weight
( 0.525 mEq~x 146.85'fu._= 77.096 mEq )
. ········STEP·2: READY·TO USE DATA ······························
ORDERED: 77.096 m Eq
AVAILABLE: 12 mEq
VOLUME: 1 ml
1000 ml
4 hr
r······· STEP 3: IRRELEVANT DATA ··············O ················i
)
i
Disso lved in 12 oz of juice at 0930
Questio n asked for
l
"per dose" because no
j
!
1................................................................................................ t im efrem e w as g iven .....
D
XV = A
H
ml of solution
SHOW YOUR WORK
77.096 rnf.;_q
- - - - - = 6,424
6,424 X 1 ml = 6.424 ml
6.424
SHOW YOUR WORK
..---....,,_
12 ~
ROUND:
= ml/hr
total hours
°"'
0
REMEMBER RULE #4
Don't round til l the end !
1000 ml
4 hr
~
= 250 mUhr
0
ml/hr is alw ay s
rounded t o the nea rest
WHOLE number !
Nearest tenth
ml ➔
ROUND:
6,4 ml
No rounding necessary
6.4 mL
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17
COMPREHENSIVE REVIEW
•
•
15C ml Cipro 250 mcg to infuse
over 45 minutes.
25C ml normal saline over 5 hours.
Tubing drop factor of 10 gtt/ml.
If the question is asking for flow rate
("to infuse") and you're g iven ml
of solution, you need to write the
answer in ml/hours!
0
········ STEP 1: CONVERT· DATA ················································
hr ➔
NIA
min
1 hour = 60 minutes
60 ~~n
5'1..·x
,...._ --,n....,
1
········· STEP ·2: READY· TO USE DATA ································1,,
= 300min
ML OF SOLUTION: 150 ml
TOTAL HOURS: 45 min
f········--STEP 2: READY·TO USE DATA······························i
~
1
.....................................................................................................................................
i
!
1
C ip ro 250 mcg
IMPORTANT: don't let this inform ation lead you to use
the wrong form ula. In this exam ple, we're asked for a
flow rate which requires m l of solution and total t ime.
ml of solution
tot~I minutes
x
60= ml/hr
SHOW·YOUR WORK- - - - - - - ,
~
0
REMEMBER RULE # 4
Don't ro und till the end!
ROUND:
No rounding necessary
~
0
ml/hr is always
rounded to the nea rest
WHOLE number!
i
!
l
-
!
ml of IV solution
time in minutes
x drop factor = qtt/min
SHOW·YOUR WORK- - - - - - - ,
250ml
300min
150ml
- - - - = 3.333 x 60 = 200 mUhr
45 min
I
ML OF SOLUTION: 250 ml
TOTAL MINUTES: 300 min
DROP FACTOR: 10 gtt/ ml
= 0. 8333 mUmin
0
REMEMBER RULE #4
Don't round till the end!
~
0.8333 mljmin x 10 gtt/ml.. = 8.3333 gtt/ min
ROUND: g tt/m l is always rounded to the nearest whole number!
8.3333 gtt/min ➔ 8 gtt/ min
0
The question may not
specify to round the final
answer to a whole number;
you are expected to know
this with gtt/min units.
8 gtt/min
16
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COMPREHENSIVE REVIEW
•
Humulin R 200 units in 100 ml of normal salin•
to infuse at 4 units/ hr.
.
Dopamin• 600 mg in 200 ml of normal
saline to infuse at 10 mcg/ kg/ min.
Pt weight= 190 lbs.
If the q uestio n is asking for flow rate
("to infuse") and you're given ml
o f solutio n. you need to write the
answ er in ml/hours!
0
·········· STEP 1: CONVERT DATA ··············································
mcq
NIA
mq
➔
~
10 mcg = 0.010 mg
lb ➔
SMALL TO BIG:
move the d ecimal point 3 to the left
kq
unit ii 9ettin9 L.r9er t hink Left
190 lb / 2.2 = 86.363 kg
,········· STEP 2: READY·TO USE DATA ································,
l
! DESIRED: 4 unit s/hr
!
! AVAILABLE: 200 units
!
m9/ k9
l
--
min
m9
➔
0
min
In this case, ordered amount
d ep end s on patient w eig ht
0.010 mg/kg/min x 86.363~ = 0.863 mg/min
1........... VOLUME:·
1·00 .mL···················································································I
STEP
.,·········
.
i
N~
3: IRRELEVANT·DATA ·······································,.
,···········STEP ·2: READY ·TO USE DATA ·····························
DESIRED: 0.863 mg/min
AVAILABLE: 600 mg
VOLUME: 200 ml
..
i
r········· STEP
I
D
XV = A
H
D
H
SHOW·YOUR WORK- - - - - - - ,
4 u~ /hr
200 u~ s
. N/A
..
3: IRRELEVANT DATA ·····································i
..
xv
0.02 /h r x 100 ml = 2 mUhr
ROUND: No rounding necessary
600 mg_
0
ml/hr is always
ro unded t o t he nearest
WHOLE number!
I
.
A
SHOW·YOUR WORK- - - - - - - ,
0.863 rng_/min
= 0.02 /hr
..
= 0.001 43 /min
0.00143 /minx 200 ml = 0.2878 mUmin
0.2878 mUrr'tiQ_ x 60 miQ. = 17 .2727 ml/hr
JIil+.
--Wu .
Th . .
1s 1s inm min
u~·ii ;;f
~~t,
ROUND: mUhr is always rounded to nearest whole number!
17.2727 mUhr ➔ 17 mUhr
2 ml/hr
19
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COMPREHENSIVE REVIEW
•
2.5 :.. normal saline to infuse over 48 hours.
0
If the question is asking for flow rate
("to infuse") and you're given ml
of solution, you need to write the
answer in mVhours !
•
ORDERED: Morph ine 100 mg IM q12h prn pain
AVAILABLE: Morph ine 150 mg/2.6 ml
How many ml will you administer?
Round to nearest hundredth.
N/A
!....................................................................................................................................~
,···········STEP·2: READY·TO USE DATA······························,
99
ML OF SOLUTION: 2500 ml
TOTAL HOURS: 48 hr
I
~~~~~i~:~~
r·······-- STEP
3: IRRELEVANT DATA····--······O ·················:
\
I
I
Questio n asked for
IM q12h prn pain
(
j
"per dose" beceuse no
I
timefrem e w as g iven
(
=...................................................................................................................... .............. :
r··········STEP 4: FORMULA USED ············································,
ml of solution
= ml/hr
tot.11 hours
D
XV = A
H
.......... ,,,,,,,,- -···································································································
SHOW·YOUR WORK- - - - - - - ,
SHOW·YOUR WORK- - - - - - .
100 ~
2500
ml
48 hours
= 52.0833 mUhr
ROUND: mUhr is always rounded to nearest whole number!
52.0833 mUhr ➔ 52 mUhr
= 0.6666
150 mg_
0.6666 x 2.6 ml = 1.7333 ml
ROUND: nearest hundredth
1.7333
ml ➔
1.73 ml
20
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21
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LAB VALUE CHEAT SHEET
BLOOD PRESSURE
SYSTOLIC
120 mmH9
DIASTOLIC
80 mmH9
_
a
Q
MAGNESIUM
1.5 - 2.5 mq/dl
HEART RATE
60 - 100 bpm
PHOSPHORUS
2.5 - 4.5 mq/dl
RESPIRATIONS
12 - 20 breaths/min
SPECIFIC GRAVITY
TEMPERATURE
97.8 - 99°F (36.5 - 37.2°C)
GFR
1.010 - 1.030
90 -120 ml/min/1 .73 m2
OXYGEN
95-1000/o
BUN
7- 20 mq/dl
OXYGEN IN COPD PT.
as low as 880/o
CREATININE
0.6 -1.2 mq/dl
~
COPD pts are expected to have low 01 levels
AMYLASE
COMPLETE BLOOD COUNT (CBC)
WBCs
4,500 -11,000 /f!L
RBCs
4.5 - 5.5 X10 6 / f!L
PLTs
150,000 - 450,000 lf! L
HEMOGLOBIN (HGB)
FEMALE: 12 -16 q/dl
MALE: 13 -18 q/dl
HEMATOCRIT (HCT)
FEMALE: 36% - 48%
MALE: 39% - 54%
LIVER FUNCTION TEST (LFT)
HBA1C
NON-DIABETIC
4 - 5.6%
ALT
7 - 56 U/L
PRE-DIABETIC
5.7 - 6.4%
AST
DIABETIC
> 6.5%
ALP
Goal for diabetic:
< 6.5%
BILIRUBIN
5 - 40 U/L
40 -120 U/L
0.1 -1.2 mq/dl
UNDERWEIGHT
PH
HEALTHY WEIGHT
PaCO2
35 - 45 mmHq
PaO2
80 -100 mmHq
HCO3
22 - 26 mEq/L
OVERWEIGHT
OBESITY
25.0 - 29.9
> 30.0
0 -150 U/L
LIPASE
SODIUM
135 -145 mEq/ L
POTASSIUM
CHLORIDE
3.5 - 5.0 mEq/L
95 -105 mEq/ L
CALCIUM
9 -11 mq/dl
BUN
7 - 20 mq/dl
CREATININE
0.6 -1.2 mq/dl
ALBUMIN
3.4 - 5.4 q/dl
TOTAL PROTEIN
6.2 - 8.2 q/d L
PT
10 - 13 sec
PTT
25 - 35 sec
aPTT
NOT ON HEPARIN: 30-40 secs
ON HEPARIN: 47-70 secs
INR
NOT ON WARFARIN: < 1 sec
ON WARFARIN: 2 - 3 sec
LIPID PANEL
OTHER
TOTAL CHOLESTEROL
<200 mq/dl
MAP (mean arterial pressu re) 70 -100 mmHq
TRIGLYCERIDE
<150 mq/dl
ICP Cintracranial pressu re)
5 -15 mmHq
LDL
<100 mq/dl
GLASCOW COMA SCALE
BEST
HDL
>60 mq/dl
' '' ', LDL bad cholesterol
17
W - we want LOW levels
' ' ' '' HDL Happy cholesterol
- we want HIGH levels
MILD: 13-15
=15
MODERATE: 9-12 SEVERE: 3-8
Lab values, instruments, and institutions d iffer bassd on the facility. Local oolicy should supersed e. Author & publisher int end this rsfarsnce to bs
free of errors but no g uarantee can be mad e & assume no responsibility for any o utcomes rssulfng from its use.
11
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SODIUM: 135 - 145
*Commit to memory!
POTASSIUM: 3.5 - 5
PHOSPHORUS: 2.5 - 4.5
BANANAS:
PHOR: 4
There are about 3-5 in every
bunch & you want them half
US: 2 (me + you = 2)
ripe
'2-.
~
ff
So, think 3.5 - 5.0 ~
CALCIUM: 9 - 11
CALL 911
MAGNESIUM: 1.5 - 2.5
MAGnifying g lass
you see 1.5 - 2.5
bigger than normal
·········
CHLORIDE: 95 -105
~
Think of a chlorinated pool that ~ 0 0
you want to go in when it's
~a~
SUPER HOT: 95 - 105 °F
'=:,
~
Q
.?qn11~
acJ
• Hemog lobin (Hgb)
Female: 12 - 16 g/d l
Male: 13 - 18 g/dl
• Hematocrit (HCT)
Female: 36% - 48%
Male: 39% - 54%
To remember HCT,
multiply Hgb by 3
~
,,,,,,,-- "
= 36
16 X 3 = 48
12 X 3
= 39
18 X 3 = 54
13 X 3
BUN: 7 - 20 m9/dl
CREATINE: 0.6 -1.2 m9/dl
Think hamburger BUNs ...
Hamburgers can cost anywhere
from $7 - $20 dol lars
LITHIUM's t herapeutic range (0.6 - 1.2 mmol/L)
(Female)
(Male)
This is the same value as
Lithium is excreted almost solely by the kidneys ...
And creatine is a value that tests how well your kidneys filte r
ft
........................................................................................................................................................................................................................................................................................
23
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NOTES
It doesn't 9et
EASIER,
you just 9et
STRONGER!
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15
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SODIUM IMBALANCE
$01) I lAM is a major ELECTROLYTE found in ECF. Essential for acid-base, fluid balance,
active & passive transport mechanism, irritability & CONDUCTION of nerve-musde tissue
~
~
HYPERNATREMIA
lushed skin
~ estless, anxious, confused, irritable
ncreased BP & fluid retent ion
E
dema (pitting)
D ecreased urine output
S
kin flushed & dry
A
gitation
L
ow-grade fever
T
hirst (dry mucous membranes)
HYPONATREMIA
> 145 mEq/L
• BIG & BLOATED
F
135 - l&+S mEq/L
< 135 mEq/L
HYPQVOLEMIC HYPONATREMIA:
HYPERVOLEMIC HYPONATREMIA:
+of fluid & sodium
t body water that is greater than Na+
s tupor/coma
L
imp muscles (muscle weakness)
A
norexia (nausea/vomiting)
0
rt hostatic hypotension
L
ethargy (weakness/fa tigue)
T
achycardia (t hready pulse)
s eizures/headache
s tomach cramping
(hyperactive bowels)
• Increased sodium excretion
• Diaphoresis (ex: high fever)
• Diarrh ea & vomiting
• Dra ins (N GT suction)
• Diuretics
(Thiazide & loop d iuretics)
• SIADH
• Increased sodium intake
• Excess oral sodium ingestion
• Excess adm inistration
of IV fluid s w/ sodium
• Hypertonic IV fluids
• LOSS OF FLUIDS!
• Fever
• Watery d iarrhea
• Diabetes insipidus
• Excessive diaphoresis
• Infection
• Adrenal insufficiency (adrenal crisis)
• Inadequate sodium intake
• Fasting, N PO, Low-salt diet
• Kidney disease
• Heart failure
A D D
HEHOCONCENTRATION
=
INCREASED SODIUM!
A
Kidney problems
ADMINISTER IV sodium chloride infusions
(Only if due to hypovolemia)
• Decreased sodium excretion
•
A
D
DIURETICS (If due to hypervolemia)
Hyponatremia ➔ high fluids & low salt = hemodilution
D
DAILY WEIGHTS
Where sodium goes, water FLOWS
S SAFETY (orthostatic hypotension AKA risk for fa lls)
• If due to fluid loss:
• Administer IV infusions
A
• If t he cause is inadequate
renal excretion of sodium:
• Give d iuretics that promote sodium loss
L
• Restrict sodium & fluid intake as prescribed
T
AIRWAY PROTECTION (NPO)
Don't give food to a lethargic, confused client
(INCREASED RISK FOR ASPIRATION)
LIMIT WATER INTAKE
Hypervolemic hyponatremia (high fluid & low salt)
TEACH about foods high in sodium
(Canned food, packaged/processed meats, etc.)
26
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POTASSIUM IMBALANCE
PO,A$ $ I UM
imbalance plays a vital role in cell METABOLISM, and TRANSITION of
nerve impulses, the functioning of cardiac, lung, muscle tissues, & acid-base balance.
~
> 5 mEq/L
TIGHT & CONTRACTED
M uscle cramps & weakness
rine abnormalities
R eflex es (t
DTR}
< 3.5 mEq/L
Thready, w eak, irregular pu lse
O rthostatic hypotension
Shal low respirations
Paresthesias
D ecreased cardiac cont ractility (+HR, + BP}
~
HYPO KALE MIA
A nxiety, lethargy, confusion, coma
R espiratory distress
E CG changes
mEq/L
~
HYPERKALEMIA
U
3.5-5
•
•
•
•
Tall peaked T waves
Flat P waves
Widened ORS complexes
Prolonged PR intervals
• Medication
• Potassium-sparing diuret ics (Spironolactone}
• Ace inh ib ito rs
• NSAI Ds
• Excessive potassium intake
(Example: rapid infusion of potassium-cont aining IV solutions)
• Kidney disease or t hose on Dialysis
• Decreased potassium excret ion
• Adrenal insufficiency (Addison's d isease}
• Tissue damage
• Acidosis
Hyporeflexia
Hypoactive bow el sounds (constipation)
Nausea, vomit ing, abdominal distention
ECG chang e s ~
• ST depression
• Shallow or inverted T wave
• Prominent U wave
• Actual t otal body potassium loss
* Inadequate potassium intake
• Fasting, NPO
* Movement of potassium from t he
extracellular fluid t o t he intracellular fluid
• A lkalosis
• Hyperinsu linism
• Dilut io n of serum potassium
• Water intoxicat ion
• IV therapy with potassium-deficient sol utions
• Hyperuricemia
• Hypercatabolism
• Monitor EKG
* O ral pot assium supplements
• Discont inue IV & PO potassium
• Liquid potassium chloride
• Potassium-excreting diuretics
* Potassium-retaining diuretic
* Potassium is NEVER administered
• Prepare the client for dialysis
by IV push, IM, or subcut routes.
• Prepare for administration:
• IV potassium is always diluted &
adm inistered using an infusion device!
• Initiate a potassium-restricted diet
•
IV ca lci um g luconate & IV sodium bica rb
• Avoid t he use of salt substitutes or
other potassium-containing substances
POTASSIUM & SODIUM = OPPOSITES
EXAMPLE: 1" NA= ,I. K+
27
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CALCIUM IMBALANCE
CA LC I UM is found in the body's cells, bones, and teeth. Needed for
'I - 11 mq/d L
proper functioning of the CARDIOVASCULAR, NEUROMUSCULAR,
ENDOCRINE systems, blood dotting & teeth formation
~
~
HYPERCALCEMIA
HYPOCALCEMIA
>11mg/dl
< 9 mg/dl
( onvulsions
8
A rrhythmias (diminished pulses)
one pain
A rrhythmias
(
ardiac arrest (bounding pulses)
uscle weakness
etany
S
pasms & stridor
GO NU M8 ness in the fingers, face, & limbs
K id ney stones
M
T
+(DTR)
E xcessive urinatio n
J
POSITIVE
CHVOSTEK'S
Carpal sp asm caused
by inflating a
blood pressure cuff
Cont ract ion of facial
m uscles w/ light tap
over t he fa ci al nerve.
..
Think "C"
for Cheesy smi le
• Increased calcium absorption
• Decreased calcium excretion
• Kidney disease
• Thiazide diuretics
• Increased bone resorpt io n of calcium
• Hyperparathyro id ism / Hyperthyroid ism
• Ma lignancy
(bone dest ruct ion from metastatic t umors)
* Inhibit ion of calcium absorption from t he GI t ract
• Increased calcium excretion
• Kidney disease, d iuretic phase
• Diarrhea & steat orrhea
• Wound drainage
* Condit ions t hat decrease
the ionized fraction of calcium
• Hemoconcentration
• DIC IV or PO calcium
• DIC Thiazide diuretics
• Administer phosphorus, calcit onin,
bisphosphonates, & prost aglandin
synt hesis inhibitors (NSAIDs)
• Avoid foods high in calcium
CALCIUM & PHOSPHATE = INVERSE
• Adm . calcium PO or IV
• Fo r IV, warm before & ad m. slow ly
• Adm . aluminum hyd roxide & Vit D
• Initiate seizu re precaut io ns
• 10% calcium (acute calcium defi cit)
• Consume foods high in calcium
EXAMPLE: 1" CA+ = -i, P04
16
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MAGNESIUM IMBALANCE
Most of the MA GNE $ I UM found in the body is found in the bones.
Regulates BP, blood sugar, muscle contraction & nerve function.
~
HYPERMAGNESEMIA
1.5 - 2.5 m9/d L
J,
> 2.5 mg/dl
HYPOMAGNESEMIA
< 1.5 mg/dl
MAGNESIUM I$ A $ET>A1"IVEf
• LOW EVERYTHING AKA SEDATED
• HIGH EVERYTHING AKA NOT SEDATED
Low energy (drowsiness/ coma)
High HR (tachycardia)
Low HR (bradycardia)
High BP (hypertension)
Low BP (hypotension)
Increased deep tendon reflex (hyperreflexia)
Low RR (bradypnea)
Shallow respirations
+Respirations (shallow)
R~.
Twitches, paresthesias
,I, Bowel sounds
Tetany & seizures
,I, DTR's (deep tendon reflex)
Irritability & confusion
Also see .
(
h
nm
YPoca/cern.
Ca& M . ,a.
•
9 rise
andfa/1
together!
Carpal spasm caused by inflating a blood pressure cuff
Cont raction of facia l muscles w/ light tap over the facia l nerve
• Increased magnesium intake
• Magnesium-containing antacids (TUMS)
& laxatives
• Excessive adm. of magnesium IV
• Renal insufficiency
• ,I, renal excretion of Mg = t Mg in the blood
• OKA (Diabetic Ketoacidosis)
• Insufficient magnesium intake
• Malnutrition/vomiting/diarrhea
• Malabsorption syndrome
• Celiac & Crohn's d isease
• Increased magnesium excretion
• Diuretics or chronic alcoholism
• Intracellular movement of magnesium
• Hyperglycemia & Insu lin adm.
• Sepsis
• Diuretics
• IV adm. calcium chloride or calcium gluconate
• Magnesium sulfate IV or PO
• Restrict dietary intake of Mg containing foo ds
• Seizure precautions
• Avoid the use of laxatives & antacids
containing magnesium
• Instruct t he client to increase
magnesium-containing foods
• Hemodialysis
MAGNESIUM & CALCIUM
= SAME
19
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NOTES
You are
ctoSeR Tlf"N
you were
YESTERDAY.
© ZOZl HunelnlheMakin9 UC. Sharin9 and dirtrihtin9 d,is copyri9ht,d mat,rial without permission is ill,9al.
31
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BLOOD TYPES
➔
W.iter
Ions
Proteins
Nutrients
W.iste
Pl;asm:a
550/o of tot.. , u,uu
CENTRIFUGE
G.ises
➔ White Blood Cells & Pl:atelets
➔
>10/o of total blood
6-0
£').
Erythrocytes
V
450/o of total blood
-
ANTIGEN:
A
ANTIGEN:
B
ANTIGEN:
ANTIBODIES:
B
ANTIBODIES:
A
ANTIBODIES:
A, 0
RECIPIENT:
DONOR:
A-
0..
A+
BB+
ABAB+
31
A&B
0
RECIPIENT:
ALL
DONOR:
Ident ifies the cell
0
<
\U
ANTIBODIES:
O pposite of t he type of antigen that is foun d on t he RISC
O+
\-
AB
NONE
Proteins that el icit immu ne response
►
~
m
DONOR:
ALL
ANTIGEN:
Protects body frorn "invade rs" (t hink ANTI)
o-
...
B,AB
DONOR:
RECIPIENT:
NONE
CIJG CIJG IIJG [i]lil
ANTIGENS- - - - - - - .
LU
0
0
A,AB
B,O
RECIPIENT:
A&B
I' 37 14Dlli j s UJIE I
PLASMA·ANTIBODIES
o-
"'
A.
Adevice that uses force to separate
co mponents of flu ids. It separates
flu ids of different densities .
Th is is how labs separate blood .
DONOR BLOOD TYPES
O+
A-
A+
B-
B+
AB-
AB+
•• •
•• • •• •
•• • •• •
•• • •• • •• • •• •
Rh FACTOR ----,
0
0
HAS
DOES NOT HAVE
R.h on surface
R.h on surface
CAN RECEIVE
CAN RECEIVE
I \
0 0
i
0
Always check with your hospital's protocol about blood product administration
© ZOZl HunelnlheMakin9 UC. Sharin9 and dirtrihtin9 d,is copyri9ht,d mat,rial without permission is ill,9al.
ABBREVIATIONS
AAA Abdominal AorticAneurysm
AbdAbdomen
Ac Before Meals
ACLS Advanced Cardiac life Support
AD Admitting Diagnosis
A&D Admissionand Discharge
Ad lib As Desired
AU Acute lymphocytic leukemia
AOL Activities of Daily living
Adm. Admission
AmbAmbulation
AKAAbove-the-Knee Amputation
AVAtrioventricular
AP orA.P. Appendectomy
Bid Twice a Day
BLS Basic life Support
BM Bowel Movement
BP Blood Pressure
BICA Below-the-Knee Amputation
BUN Blood Urea Nitrogen
BPH Benig n Prostatic Hyperplasia
BX Biopsy
CABG Coronary Artery Bypass Graft
C/0 Complaining Of
CAD Coronary Artery Disease
CBC Complete Blood Count
CCU CardiacCare Unit / Coronary Care Unit
C&S Culture & Sensitivity
CF Cystic Fibrosis
CHF Congestive Heart Failure
CKD Chronic Kidney Disease
CPR Cardiopulmonary Resuscitation
COPDChronicObstructive Pulmonary Disease
CVA CerebrovascularAccident (stroke)
eve CentralVenous Catheter
DIC Discontinue or Discharge
D&C Dilatationand Curettage
DI Diabetes lnsipidus
DIC Disseminated lntravascular Coagulation
DKA Diabetic Ketoacidosis
DM Diabetes Mellitus
DVT Deep Vein Thrombosis
DX Diagnosis
ECG or EKG Electrocardiog ram
ED Emergency Department
EENT Eye, Ears, Nose and Throat
NPO Nothing by Mouth
NKA No Known Allergies
02 Oxygen
OB Obstetrics
OOB Out of Bed
OR Operating Room
0A Osteoarthritis
Ortho Orthopedics
OT Occupational Therapist
Pc After Meals
Pm or p.r.n. As Needed
Pie op Before Surgery
PFT Pulmonary Function Test
PLT Platelets
m Endotracheal Tube
FBS Fasting Blood Sugar
Fx Fracture
GttorG.T.T. GlucoseTolerance Test
HOB Head of Bed
HS Bedtime
Hx History
ICU Intensive One Unit
LMP last Menslrual Period
LOC level of Consciousness
LES lower Esophageal Sphincter
SOB Shortness of Breath
S8AR Situation, Bacl:ground,
Assessment, Recommendation
SSE orS.S.E. Soap Suds Enema
PTCA PercutaneousTransluminal
Coronary Angioplasty
PRBC Pacl:ed Red Blood Cells
PVC Premature Ventricular Contraction
Rom/R.O.M. Range of Motion
RBC Red Blood Cell
RT Respiratory Therapist
RA Rheumatoid Arthritis
LP lumbar Puncture
l&O Intake and Output
MAP Mean Arterial Pressure
MRI Magnetic Resonance Imaging
MVA Motor Vehicle Accident
NGT NasogastricTube
Stat At Once, Immediately
SI.E Systemic lupus Erythematosus
STD Sexually Transmitted Disease
SIADH Syndrome of Inappropriate Antidiuretic
Hormone Secretion
Tid ThreeTimes a Day
T&S Type and Screen
TPN Total Parenteral Nutrition
TIATransient lschemic Attack
TB Tuberculosis
TIJRPTransurethral Resectionof the Prostate
UA Urinalysis
un Urinary Tract Infection
US Ultrasound
VS Vital Signs
WBCWhite Blood Count
WNL Within Normal limits
DO NOT USE
POTENTIAL PROBLEM
u
Mistaken for "O" (zero) or " cc"
unit
IU
Mistaken for IV (intravenous)
or the number 10 (ten)
"international unit"
Mistaken for each other
"daily" or "every other day"
Decimal point is missed
"X mg " "0.X mg "
MS, MSO4, MgSO4
Can mean morphine sulfate
or magnesium sulfate
"morphine sulfate " "magnesium sulfate "
@
Mistaken for the number "2" (two)
cc
Mistaken for U (units) when poorly written
O.D., OD, q.d., qd,
O.O.D.,OOD, q.o.d, qod
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
THE NURSING PROCESS
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
Data t he nurse obtains
t hrough t heir assessment
& ob servat ion
SET SMART GOALS
SPECIFIC
"ml" or " milliliters"
■
•••••••••••••••••••
■
••••••••••••••••••••••••••••••••••••••
Gather information
Verify t he information
collected is clear & accurate
SUBJECTIVE DATA
OBJECTIVE DATA
at"
( __A_SS_
Ess_ )
"A DELICIOUS PIE"
What t he client tells t he
nurse
11
(_DI_AG_NO
_ S_E __)
( ___
E~_AL_U_AT_E __)
Determ ine the outcom e of goals
Interpret the information collected
Evaluate client's compliance
Identify & prio rit ize t he problem
through a nursing d iagnosis
(be sure it's NA NDA approved)
Document cl ient's respo nse t o p ain
M odify & assess fo r need ed changes
.,.
( IMPLEMENT
)
( __P_
LA_N__)
MEASURABLE
ACHIEVABLE
RELEVANT
TIME FRAME
Reach ing those g oals t hro ugh
performing t he nursing actions
Set goals to solve the problem.
Prioritize the outcomes o f care
" Implementing " t he goals set above
in the p lanning stage
33
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PRIORITY QUESTIONS
D AIRWAY
ABCs
0
0
#1
YOU KNOW YOU ARE BEING ASKED
A PRIORITY QUESTION WHEN THE
QUESTION ASKS:
most important?
• W hat is the initial response?
• W hat is the
BREATHING
• W hich action shou ld t he nu rse t ake
CIRCULATION
first?
When you see these questions,
you should imm ediately think of
PATENT AIRWAY
MASLOW'S HIERARCHY OF NEEDS
as well as ABCs!
• Patent means "open"; the airway is clear!
• ASK YOURSELF: Can they successfully breathe oxyge n in and breathe CO2 out?
#2 BREATHING
• Gas exchange taking place inside the lungs
• ASK YOURSELF: Can gas exchange successfully happen in their lungs?
#3 CIRCULATION
• Can they circulate blood through their body and are their organs being perfused?
• ASK YOURSELF: /s there a re ason that the blood isn't pumping/ circulating in the body?
(Example: The heart is working to pump t he b lood to t he vita l o rgans)
MASLOW'S HIERARCHY OF BASIC NEEDS
This shows the 5 levels
of hu man needs
PHYSIOLOGICAL NEEDS
Ho pe
Sp iritu al w ell-being
Enhance d growth
Utrn:0~~
NEEDS
Pain is considered
"psychological" meaning
it does not take priority.
* Pain ra rely kill s people
I
,j.
J__./'
I
being th e most important
(Oxygen, flu ids, nutrit ion, shelter)
ABCs fall into Maslow's
PHYSIOLOGICAL need 1
Cont rol
Competen ce
Po sit iv e reg ard
Accep tan ce/worth iness
➔
➔
• Mainta in support system s
Protect from isolation
➔
•
• Pro tectio n fro m inj ury
• Promo t e feeling o f security
• Trust in nurse-cl ient relationsh ip
➔
• A irway
• Respiratory effort
• Heart rate, rhyth m, and strength o f contraction
• N ut r itio n
• Elim inatio n
34
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NURSING ETHICS & LAW
PATIENT RIGHTS
ETHICAL PRINCIPLES
THE RIGHT TO ...
UTO OHV ]
Respect for an individual's right
to make their own decisions
NO
➔ Privacy
➔ Considerate
& respectful care
➔ Be informed
Obligation to do & cause no harm to others
BE EFICENCE
l
➔ Know the names
& roles of the
persons who are involved in care
➔ Consent or refuse treatment
Duty to do good to others
➔ Have an advance directive
JUSTIC~
Distribution of benefits & services fairly
➔ Obtain their own medical records
& results
VERACITj
CONSENT
Obligation to tell the truth
TYPES OF CONSENT:
FIDE 1Tij
•
•
•
•
•
•
Following through with a promise
HIPAA
THE HEALTH INSURANCE
PORTABILITY & ACCOUNTABILITY ACT
➔ Clients records are private
➔ Treatment can not be done without
a client's consent
& they
have the right to ensure the medical
information is not shared without
perm1ss1on
➔ All health care professionals must
inform the client how their health
information is used
➔ The client has the right to obtain a
copy of their personal health
information
Adm ission agreement
Immun ization consent
Blood transfu sion consent
Surgical consent
Research consent
Special consents
➔ In the case of an emergency when a
client cannot give consent, then consent
is implied through emergency laws
➔
Minors (under 18), consent must be
obtained from a parent or legal guardian
Befo re sig ning t he consent, th e client must be informed
of the foll ow ing risks & b enefits of surgery, treatments,
procedures, & plan of care in layman's terms so the
client understands clearly w hat is b eing done.
35
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INFECTION CONTllOL
~ ➔ PERSONAL PROTECTIVE EQUIPMENT
DONNING
DOFFING
PUTTING ON PPE
REMOVING PPE
• Remove PPE at the client's doorway or
outside the room
• Put on PPE before entering the client 's room
• Do not touch your face while wearing PPE
• If hands become soiled while removing PPE,
stop & perform hand hygiene
• Minimize contact with items in the client 's room
• After hand hygiene, continue with PPE removal
0
HAND
HYGIENE
.GOWN
MASK/
RESPIRATOR
•
A
V
GOGGLES/
FACE SHIELD
~~ 0
~
et £
~~~
.GLOVES
REMOVE
GLOVES
ftREMOVE
~~~~
V
PROTECTIVE
EYEWEAR
4t
REMOVE
GOWN
•
0
0
REMOVE&
DISCARD
RESPIRATOR
~~
PERFORM
HAND
HYGIENE
~
00 ~
HOSPITAL-ASSOCIATED INFECTIONS (HAis)
CAUTI ........ Catheter-associated urinary tract infection
SSI ............. Surgica l site infection
CLABSI ...... Centra l line-associated b lood infection
Meticulous hand hy9iene practices
and use of chlorhexidine washes
helps in preventin9 HAis
VAP ........... Venti lator-associated pneumon ia
36
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INFECTION CONTllOL
STAGES OF INFECTION
• Bacter ia
• Virus
INCUBATION
• Fungus
• Prion
• Human
• Parasite
• A nimal
• Surfac es
Leaves the host
more susceptible
to infections
Interval between t he pathogen
entering t he body & t he presentation
of the first symptom
• Food
• Soil
CHAIN
OF
INFECTION
• Insects
PRODROMAL STAGE
Onset of general symptoms to more d istant
symptoms; t he pathogen is multiplying
• How it g ets to the host
ILLNESS STAGE
• Same as porta l of exit
Symptoms specific to t he infection appear
• Contact
• Dro plet
• Airborne
CONVALESCENCE
• Vecto r borne
Acute symptoms d isappear and
total recovery could take days to months
TRANSMISSION BASED PRECAUTIONS
. . . . . .. . . . . . . . ,Jl;J:IWJ:ij . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . f!f>tD~!=it··. . . . . . . . . . . . . . . . . . . . . . .. . . . ~:ii,St . . . . . . . . . . .
• Single ro om under neg at ive pressure
• Door remains closed
• Hea lth care workers wear a
respiratory mask (N95 or hig her level)
Measles
C
T uberculosis
V aricella (Chickenpox)
rnssem;nated hecpes-zoster (Sh;ng le
*Airborn e precaution is
no longer need ed when all
lesions have crusted over.
• Private room o r a client whose body
cultures contain the same organism
• Wear a surgical mask
• Place a mask o n the client whenever
t hey leave t he room
• Adenovirus
• Diphtheria {pharyngeal)
• Epiglottitis
• Influenza {flu)
• Meningitis
• Mumps
• Parvovirus B19
• Pertussis
• Pneumonia
• Rubella
• Scarlet fever
• Private room or cohort cl ient
• Use gloves & a gown whenever
entering t he cl ient's room
• Colonization or
infection with a
multidrug-resistant
organism
When in contact with
C. Diff, patient's hands
must be washed
• Enter~c .infe~i~n.s ___,,1f withsoap &water
(Clostnd1um d1ff1c1 le)
• Respiratory infections
when performing
hand hygiene
(RSV, Influenza)
• Wound & skin infections
(cutaneous d iphtheria, herpes sim p lex,
impet igo, p ed iculosis, scab ies,
staphylococci, & varicella-zost er)
• Eye infections (conjunctiv it is)
• Sepsis
• Streptococcal pharyngitis
37
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IV THERAPY: TYPES OF IV SOLUTIONS
.. .
MEMORY TRICK: " EN,ER ii-IE VESSEL FROM ,I-IE CELLS"
-...... . ..
··•··•~··
. .. . ·•· ~
-~
.•...
. . .. ~...
~
·
EXAMPLES:
USED FOR:
5% saline
Cerebral edema
3% saline
Hyponatremia
(low levels of sodium)
5% dextrose in 0.9% saline (DSNS)
0
1 IV administration
2 effects of the solution
3 homeostasis after
5% dextrose in 0.45% saline (D5 ½ NS)
Metabolic alkalosis
Maintenance fluid
5% dextrose in LR (DSLR)
Hypovolemia
10% dextrose in water (D10W)
MONITOR FOR:
MORE SALT in the solution,
LESS WATER in the solution. The vessel
becomes MORE concentrated than the cell.
Water then LEAVES the cell.
Therefore, the cells will SHRINK.
Fluid Volume Overload
UYPERtonic think
U/GU numbers
5% DEXTROSE IN WATER (05W)
• The- only exception to thi, memory trick i, ➔ rurti as ISOTONIC and t hen
SCl/o DEXTROSE IN WATER (DSW)
chn9es to HYPOTONIC
when the dextrose i, met abolized.
.
___...,.
MEMORY TRICK: "S,AYS WHERE I PU, Ii" .__
.....,. .... ... ..... ..... ... .
............
... . . . ..: . .
-~···.~;t?:
..
.. : . .
.
•.
.. .
.
u···. . _· ~:_:. .
.
:-
..
EXAMPLES:
USED FOR:
0.9% sodium chloride (NS) (normal saline) Blood loss
(hemorrhage, burns, surgery)
5% dextrose in water (DSW)*
.•
Dehydration
Lactated Ringers (LR)
(vomiti ng & diarrhea)
~
.
Fluid maintenance
Same osmolality as body fluids
(Equal water & particle ratio)
NORMAL SALINE
is the only solution compatible to
use with blood or blood products
MEMORY TRICK: "GO
1
2
3
IV administration
effects of the solution
homeostasis after
our
OF iUE VESSEL" + /NiO iUE CELL -
EXAMPLES:
USED FOR:
0.45% saline (1 / 2 NS)
Diabetic ketoacidosis (DKA) ' -
0.33% saline (1/3 NS)
Helps kidneys excrete
excess fluids
0.225 saline (1/ 4 NS)
5% dextrose in water (DSW)*
LESS SALT in the solution, MORE WATER in the solution.
The vessel becomes LESS concentrated than the cell.
Water then ENTERS the cell. Therefore, the cells will SWELL.
Hypernatremia
(high levels of sodium)
DO NOT GIVE WITH:
\
In DKA, there is
so much 9lucose in
the cells, the1 need
W.iter!
t ICP
Burns
Trauma
36
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IV THERAPY: BASICS
®
Fluid in our body is found in 2 places:
•
• IV
INTRACELLULA & EXTRACELLULAR
(ICF)
f 1uid
••
(ECF)
·~s•oE the ce 11
fluid OUTSIDE the cell
•
~
(Millions of these cells in our body)
ISF
- INTERSTITIAL FLUID (ISF) - - INTRAVASCULAR (IV) flu id that surrounds the cel l
AKA fluid in the tissues
plasma/ fluid in
the b lood vessels
•
The cells love to have everything equal (homeostasis) .
But when fluids/solutes shift, DIFFUSION/OSMOSIS
occurs to get back to homeostasis again.
0
DIFFUSION
OSMOSIS
the movement of a
SOLUTE from a
t he movement of WATER
through a semipermeable
membrane from a
II I GUER
Sodium
is a solute!
LOWER
concentration
to a
solute concentration
to a
LOWER
concentration
11/GUER
solute concentration
ICF
SF
•
Sodium is the cool kid,
so water wants to be his friend.
from a
UIGUER
water concentration
toe
LOWER
water concentration
(until t here is
equal concentratK>n)
(until t here is equal concentration)
Large molecules
GOES WA1"ER FLOWS!
s.iid
nother w.iy...
(until there is equal concentration)
COLLOIDS
I
WHERE SOt>/UM
.'
;i
nl
EXAMPLE: If sodium shifts into
the cell (intracellular space)
water will follow and leave the
extracellular space (the vessel)
CRYSTALLOIDS
Small molecules
Colloids have LARGE molecules making it more
efficient at increasing flu id volume in the blood.
Crystalloids have SMALL molecules.
They are less expensive t han colloids and
provide immediate fluid resuscitation.
EXAMPLES:
USED FOR:
EXAMPLES:
Albumin
Shock
Hypertonic solution
Fresh frozen plasma (FFP)
Pancreatitis
Isotonic solution
Burns
Hypotonic solution
Excessive bleeding
39
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IV THERAPY: COMPLICATIONS
mmmm,
• Tachycardia
• Chest pain
• Hypotension
• + LOC
• Cyanosis
WOOmJ
• At the site ...
• Pain
• Swelling
• Coolness
• Numbness
• No blood return
~
•
•
•
•
•
•
Tachycardia
Redness
Swelling
Chills & Fever
Malaise
Nausea & vomiting
AIR EMBOLISM
Air enters the vein
throuqh the IV tubin9
• Clamp the tubing
• Turn client on the left side & place
in Trendelenburg position
• Notify the HCP
INFILTRATION
IV fluid leaks into
surroundin9 tissue
•
•
•
•
Remove the IV
Elevate the extremity
Apply a warm or cool compress
Do not rub the area
INFECTION
Entry of microor9:anism
into the body via IV
• Remove the IV
• Obtain cultures
• Possible antibiotics administration
CIRCULATORY
OVERLOAD
•
•
•
•
t blood pressure
Distended neck veins
Dyspnea
Wet cough & crackles
Administration of
fluids too rapidly
(fluid Volume Overload)
wa0m
PHLEBITIS
• At the site
• Heat
• Redness
• Tenderness
• +Flow of IV
Inflammation of the vein
Can lead to a clot
(th rombophlebitis)
•
•
•
•
+ flow rate (keep-vein-open rate)
Elevate the head of the bed
Keep the client warm
Notify the HCP
• Remove the IV
• Notify the HCP
• Restart the IV on the opposite side
HEMATOMA
• Ecchymosis
• At the site
• Blood
• Hard & painful lump
Collection of blood
in the tissues
• ELEVATE the extremity
• Apply Pressure & Ice
'tO
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BLOOD TRANSFUSIONS
FACTS ABOUT
BLOOD TRANSFUSION
ADMINISTRATION
OF BLOOD TRANSFUSION
• Ad ministered by the RN
1111) Insert an IV line using a 16g*, 18g, or 20g IV needle
• Only Normal Saline (NS) can be used
in conjunction with b lood
•commonly used for trauma patients ""\
111111) Run it with normal sal ine
(keep-vein-open-rate)
1111)
Begin the transfusion slowly
0
0
8
J
If you use too small of a needle,
like a 24 gauge needle wh en
administering blood products,
it will cause the blood to LYSIS.
The first 15 min is the *HOST CRITICAL*
The RN must stay at bedsid e
• Type & screen and a cross match
are good for 72 HOURS
All b lood mu st be
Blood must be
hung (started) within
transfused w ithin
30 MINUTES
4 HOURS
from the time th e b lood is
p icked up from the blood bank
of the time th e b lood
was hung (started)
Vital signs are monitored every 30 minutes - 1 hour
After 15 minutes the flow can be increased
(un less a transfusion reaction has occurred)
Document the patient's tolerance to the
administration of the blood product
TRANSFUSION REACTION
fRANSFUSION
REACTION
tachycardia, itching,
skin rash, wheezing,
dyspnea, anxiety,
flushing, fever,
back pain -
STOP the transfusion
if you suspect a
- TRANSFUSION REACTION - - -
Atransfusion reaction is an adverse reaction that
happens as a result of receivin9 blood transfusions
IMMEDIATE TRANSFUSION REACTION
Chills, diaphoresis, aches, chest pain, rash, hives, itching,
swelling, dyspnea, cough, wheezing, o r rapid, thready pulse
- - - SIGNS OF - - - TRANSFUSION REACTIONS
• Fast heart rate
• Itching/urticaria/skin rash
• Wheezing/dyspnea/tachypnea
CIRCULATORY OVERLOAD
• Anxiety
Infusion of blood too rapid for the client to tolerate
• Flushing/ fever
Cough, dyspnea, chest pa in, headache, hypertension,
tachycardia, bounding pu lse, distended neck vein, wheezing
• Back pa in
SEPTICEMIA
Blood that is contaminated with microorganisms
Rapid onset of chills, high fever, vomiting, diarrhea,
hypotension & shock
NURSING ACTIONS TO A
TRANSFUSION REACTION
STOP the transfusion
Change the IV tubing down to the IV site
IRON OVERLOAD
Keep the IV open w/ normal saline
Complication that occurs in client's who
receive multiple blood transfusions
Notify the HCP & blood bank
Vomiting, diarrhea, hypotension, altered hematologica l va lues
Do not leave the client alone (monitor the
cli ent's vital signs & continue to assess the client)
"Always check with your hospital~ protocol about IV and blood product administration
41
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PHARMACOKI NETICS
'
I r /
/
~•
PHARMACOKINETICS:
"ADME"
A t!mJruGRJ__
Medication g oing
from the location of
administration
t o the b loodstream
D cm iru l!h.® tt
Tra nsportation by bodi ly
fluids of the medication
t o where it needs t o go
M Gl=itrrmma_ _
How is t he medication
going t o be b roken down?
HOST
COMMON
SITE:
ORAL
SUBCUT &IM
IV
fakes the
Iongest
to absorb
Depe nds on the site
of blood perfusion .
Qu ickest
absorption
ti me
➔
Circu lation
➔
Permeability of the ce ll membrane
➔
Plasma protein bind ing
INFLUENCING FACTORS: - - - - - - - - - - - - - ,
➔
HO.ST
COMMONLY
DONE BY:
Age
(Infa nts & elderly have a limited med-metabolizing capa city)
➔
Medication type
➔ First-pass effect
A drug given orally gets metabolized
and it s effects are greatly reduced
before it reaches t he systemic
circulation. It 's generally related to
➔
How is the medication going t o
be eliminated from the body?
M ore b lood perfusion
= rapid absorption
INFLUENCING FACTORS: - - - - - - - - - - - - - ,
LIVER
E 1mJ=it@tt
The study of how drugs are
moved throughout the body
some medications
the liver or gut. It may need to be
administered via parenteral route
(subQ , IM, or IV) because t his route
byp asses t he liver and gut .
Nutritional status
INFLUENCING FACTORS: - - - -- - - - - - - - - ,
➔ Kidney dysfunction
Leads t o an increase in the
d urat ion and int ensity of a
med icat ion response
If the kid neys aren't
working/excreting waste,
t he medication will stay
in t he body which leads
t o t oxic levels
KIDNEYS
42
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MEDICATION ADMINISTRATION
@ RIGHTS OF MED ADMIN
RIGHT CLIENT
f•
~ROUTINE
~ SINGLE
"ONE-TIME"
K Wrong medication
Used for a single case.
Not a routine medication.
RIGHT DOSE1
K Incorrect dose
K Wrong ...
._ Client
._ Route
._ Time
~STAT
--
RIGHT MED••••
Only for administration once
and given immediately.
RIGHT ROUTE/
RIGHT DOCUMENTATION
Medication error kills,
prevention is crucial!
Given on a regu lar schedule with
or without a termination date.
@
RIGHT TIME
& - COMMON -&
MEDICATION ERRORS
~ TYPES OF ORDERS
K Administer a medication the
client is allergic to
~PRN
0
"As needed " must have an
indication for use such as pain,
nausea & vomiting.
K Incorrect
DIC of Medication
K Inaccurate prescribing
SCOPE OF PRACTICE
~
RN
UAP
LPN/LYN
• Post-op assessment
Stable client
Routine, sta ble vital signs
• Initial client teaching
Monitor RN's findings
& gather data
Documenti ng input and output
Specific assessments
Can get b lood from t he
blood bank
• Starting b lood products
• Steri le procedures
• IVs & IV medications
• Discharge education
• Clinical assessment
Reinforce teaching
Routine procedures
(catheterization, ostomy ca re,
wound ca re)
Monitors IVFs & b lood products
Adm inister injections & narcotics
(not IVs meds & 1st IV b ag)
Tube potency & enteral feedings
When a regi stered nurse
delegates tasks to others,
responsibility is transferred
but accountability for patient
care is not transferred.
T he RN is still responsible!
~ = Registered Nurse
Sterile procedures
~
I
~
(not with aspiration risk)
I~
Positioning
I
~ Ambulation
I
IE
I
®
Lung sounds, bowel sounds,
& neurovascular checks
....
Feeding
Cleaning
Linen change
I
~ Hygiene care
LPN = Licensed Practical Nurse LYN = Licensed Vocational Nurse UAP = Unlicensed Assistive Per sonn~
43
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PARENTERAL ADMINISTRATION
Any route of administration that does not involve druq absorption throuqh the GI tract
INTRADERMAL (ID)
USES:
• TB testing
• Allergy seruitivities
Normal to
overweight
clients
Thin
clients
NEEDLE
SIZE:
USUAL
SITE:
25 • 27 gauge
Inner forearm
SUBCUTANEOUS(SUBQ)
non-irritating, water-soluble
NEEDLE
SIZE:
USUAL
SITE:
medication (insulin & heparin)
23 • 25 gauge
• Abdomen
USES:
• Posterior
upper arm
• Thigh
Giving a malnourished/ t hi n client a medication at a
90° angle could lead t o accident al intramuscular injury!
INTRAMUSCULAR (IM)
Do not inject more than
3 ml (2 ml for the deltoid)
D ivid e larger v o lum es int o t w o
sy rin ges
& use two d ifferent sit es
USES:
Irritating,
solutions in oils,
NEEDLE
SIZE:
USUAL
SITE:
22 • 25 gauge
• Deltoid
and aqueous
• Vastus lateralis
suspensions
• Ventrogluteal
INTRAVENOUS (IV)
USES:
NEEDLE
SIZE:
USUAL
SITE:
Administering
medic:ations, fluids,
16 gauge:
• Hand
clients who have trauma
& blood products
• Wrist
18 gauge:
• Cubital foua
• Foot
surge ry & blood administration
22 • 24 gauge:
25° angle used when starting an IV
• Sc:alp
children, older adults,
& clients who have medical
issues or are stable post-op
GAUGES & IV USES- - - - - - - - - - - --
•
Trauma, surgery, rapid
fluid administration (bolus)
0
Administering blood,
rapid infusions (bolus),
CT scans with IV dye
Medi • >n'S rcutioe
ther pies, IV fluids
rv fluids, medications
Some hospir.afs a.'fo w b!ood
to be admin isre r<:d w;d, 20 G
Ped"tatric patients
olrt.:.r
n.
•
n+c
s
Afvtays check with yrur hospita l's protocol
about JV and b.tood p roduct odrriir,i strati'o n
© ZOZl HunelnlheMakin9 UC. Sharin9 ••d dirtrihtin9 d,is copyri9ht,d mat,rial without permission is ill•9•I.
NON PARENTERAL ADMINISTRATION
Absorbed into the system throuqh the diqestive tr~ct
CONTRAINDICATIONS: vom it ing,
aspiration precautions/ absence of a gag
reflex, decreased LOC, difficulty swal lowing
Lateral or sims' posit ion
..J
.!
➔ Use lubrication
V
~ ➔ Insert beyond the interna l sph incter
Have cl ient sit at 90 ang le to help w it h
swallowing
L➔
NEVER crush enteric-coated or time-release
med ications
~
Break or cut scored tablets on ly!
Leave it in for 5 mi n utes
I➔ Supi ne w ith knees bent & feet flat
e
~
on the bed, close to hi ps
:; ➔ Insert the suppos itory along t he posterior
~
L➔
wa ll of t he vag ina (3 - 4 inches deep)
Stay supine for at least 5 minutes
➔ Place the patch on a dry and
clean area of skin (free of hair)
➔ Rotate the sites of the patch to prevent
skin irritation
➔
If there is d ried section use a moisten sterile
gauze and wipe from inner to outer canthus to
prevent bacterial from entering the eye
➔
Have the client t ilt t heir head back sl ightly
➔ A lways take off the o ld patch before
placing a new one o n
~ ➔
lu
➔ Ri nse mouth after the use of steroids
➔
Hold t he dropper 1 -2 cm above the
conjunctiva sac & drop medication
directly into the sac
➔
Close eye lid & apply gentle pressure on
t he nasolacrimal duct for 30 - 60 seconds
➔
Have client tilt their head
➔ 20 - 30 seconds between puffs
➔ 2 - 5 m inutes between d ifferent medications
➔ Use a spacer if possib le to prevent thrush
-
SUBLINGUAL: Under the tongue
BUCCAL: Between the cheek & the gum
➔
*
"'~
.____.
Do not swallow!
Keep the medication under the tongue
(subl ingual) or in between the cheek
and gum (bucca l) unt il it has completely
absorbed
➔ Warm the solut ion before adm.
to prevent vertigo & dizziness
~ "" ➔ ADULTS: pul l ear UPward & outward
. ,.. ,,
➔
ADfu]
p LT
lEJ
CHIL
Pull lower eye lid down gently to
expose the conjunctiva! sac
~
N
< 3 YEARS OF AGE: pul l ear DOWN & back
--==-------==--=--=--=--=--=--=-=--=--=--=--=--=----:~ :==:::::::===
r•
1
au ➔ Have client lie supine
i
"'
➔ Do not blow nose for 5 min
after drop instillation
45
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Normal
DESCRIPTION
INDICATION
LOCATIONS
Loss of color
L.ick of blood flow,
anemia, shock
Face, conjunctiva, n.iil beds,
palm, lips, mucous membranes
can be blanchabfe
or non-b lanchable
Inflammation, localized vasodi lation,
sun exposure, rash, hyperthermia
(areas of trau ma or p ressure)
Yellow to or.1n9e
liver-dysfunction
PALLOR
ltedness
ERYTHEMA
JAUNDICE
JAU DICE
is to p ress gent ly on
the forehead or nose.
If the skin looks
yellow where you
applied pressu re, it
indicates jaundice.
Skin
Skin, scler.i,
mucous membr.ines
~
PERIPHERAL CYANOSIS;;
Cpnosis of the peripherals
Cfin9ertips, palms, toes)
CYANOSIS
Hypoxia (not enou9h oxy9en)
or impaired venous return
Bluish
Lips, mucous membranes, __)
nail beds skin
---.,,_
Cpnosis around the mouth,
ton9ue or mucous membranes
~ Medical emergency!
EDEMA is accumulation of
exms fluid in the body's tissues tho\t
causes swellin9 of the skin
➔ Non-pittin9
TYPES OF
fnm tho skin
+2
+3
+4
TRACE
MILD
MODERATE
SEVERE
=
=
=
•
fflNl!l~
PITTING is when you
press the edematous area
for a few seconds and it
dimples or pits
+1
-
Rarely a lif e-t hreatening medical emergency
~ CENTRAL CYANOSIS
'
pittin9 odoma can loak
fluid out dir«tly
Ja,aiict
The best way to
assess for
SEROUS
Clear, watery plasma .•
SANGUINEOUS
Bright red blood.
'
,
,
Pale, pink, watery.
SEROSANGUINEOUS
Mixture of clear and red fluid.
PURULENT
=
Thick, yellowish-green. . .
Foul odor.
,..
PRIMARY LESION
SECONDARY LESION
Develops as a result of a disease process
ltesult from a primary lesion or due to a client's actions (scratching, picking)
MACULE
PAPULE
NODULE
FISSURE
Flat discolor.ition
of the skin <l cm
Example: freckles
Solid, sli9htly
elevated lesion <lcm
Example: moles
Solid & elevated
lesion > 1cm
Example: lipomas
linear crack/tear with abrupt edge
Example: anal fissures,
athletes foot
Normal tissue is lost & replaced
with connective tissue causing a scar
Example: healed area
after surgery/injury
~
PUSTULE
WHEAL
VESICLE
EROSION
SCALE
Enclosed
pus-filled cavity
Example: acne
Superficial,
raised lesion
Example:
allergic reactions
Elevated cavity
containing clear fluid
Example:
chickenpox, shingles
Scooped-out, shallow depression
Example:
severe pressure injuries
Compact, flaky skin
(silvery or white)
Example: psoriasis
46
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PRESSURE INJURIES (ULCERS)
"DECUBITUS ULCER" "BED SORES"
BRADEN SCALE
WHAT IS A PRESSURE INJURY?
Asses your client's skin
EVERY shift for pressure injuries
using the Braden Scale!
The b reak down of skin integrity d ue t o unrelieved p ressure
•
•
•
•
......
...
Skin is intact (unbroken)
Nonblanchable redness
Swol len t issue
Darker skin ➔ may appear blue / purp le
SENSORY PERCEPTION
MOISTURE
·;:
0
0'
+-'
"..,
'°
+-'
"
~
- ACTIVITY
MOBILITY
NUTRITION
0
•
•
•
•
0
__,
- FRICTION & SHEAR
Skin is NOT intact
Partial thickness loss
No fatty tissue is visible
Superficial ulcer
C
0
- LOW RISK: 22 - 23
"......
➔
.:;
+-'
......
~
+-'
C
• Skin is NOT intact
• Full thickness SKIN loss
➔ Damage to o r necrosis of subQ tissue
➔ No bone, muscle, or tendon exposed
• Ulcer extend down to t he underlying fascia,
but not through it
• Deep crater with or w ithout t unneling
LESS RI
• 19 - 21
- HIGH RISK: <18
PREVENTION
[JI[IID(;CTffl!]J]
➔ Apply pressure relieving devices
(overlays, specia lty beds, air cushions,
foam-padded seat cushions, etc.)
• Skin is NOT intact
• Full thickness TISSUE loss
➔ Destruction of tissue
➔ Bone, muscle, or tendon exposed
• Deep p ockets of infection & tunneling
➔ Do not use donut-type devices
or synthetic sheepskins!
f;®IDW!Ulfilj((ffi)
➔t
p rotein intake--------... •
.
➔ Adequate hydration
· ,
• Skin is intact (unbroken)
• Tissue beneath the surface is damaged
• Appears purple or dark red
➔
Possib le enteral nutrition
, '
'
~n
~ tm~ I3
➔ C lean skin with m il d soap
➔ C lean incontinent clients
➔ Do not scrub or rub bony prominences
Stage cannot be determined due to eschar
or slough covering the visibility of the wound
RISK FACTORS
•
"AVOIDS PRESS"
A GING SKIN
P ooR NUTRITION
V ASCULAR DISORDERS
R EDUCED RBC1 (ANEMIA)
O sESITY
E DEHA
IHHOBIUTY & INCONTINENCE
D IABETES
➔ Barrier for incontinence
➔ Moisturizer for hydration
~
➔ Turn/reposit ion your cl ient every
2 hours while in the bed
➔ Lift, do not PULL
S ENSORY DEFICITS
s
EDATION
S KIN FRICTION
• Pul ling cou ld cause shearing
& friction from force
47
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HYPOVOLEMIA VS. HYPEllVOLEMIA
HYPOVOLEMIA
.J,
HYPERVOLEMIA
-t
~
.J,
"Low• "VOLUME" "IN THE BLOOD"
11
HIGH
' , Dehydr.ition • Fluid volume deficit CFVD) • Hypovolemic shock!
.J,
11
"VOLUME"
11
~
IN THE BLOOD"
' , Over- hydr.ition • Fluid volume excess
CAUSES .
• He.irt fai lure
• loss of fluid from ANYWHEH
•
•
•
•
•
•
Thoracentesis
Paracentesis
Hemorrhage
NG t ube
Trauma
GI loses
- Vomiting
- Diarrhea
• Kidney dysfunction
• Can 't filter the b lood = back up of fluids
• Cirrhosis
Third spacing shifts
the fl uids from the
INTRAVASCULAR SPACE (the vein)
into the
INTERSTITIAL SPACE (third space).
• Third spacing
• Burns
,I
• Ascites _ _ /
This causes a drop
in the circulating /,\
blood volume
c_l.::,
• Polyuria (peeing .i lot)
• Diabetes
• Diuretics
• Diabetes insip idus
• t HR (bounding)
• Edem.i
• +Weight
• +Skin turgor
• + Urine output
• t HR Cwe.ik & thready)
• t Respir.itions
• t Urine specific gr.ivity
709f
Mo~_!!!!:Y RE
• Wet lung sounds
• Crackles / dyspnea
• Due to back flow of fluid from the heart
• Dry mucous membr.ines
~
• Polyuria
00
• Kidneys are trying to get rid of the excess fluid
• Thirst
"- LESS VOLUME
Liss ::
• Distended neck vein (JVD)
• t CVP
• Fl.it neck veins
• +(VP
SIGNS &SYMPTOMS
• tBP ~
• t Weight
SIGNS &SYMPTOMS
• •BP --. .
• t Sodium intake
I
~RE
• t Urine specific gr.ivity
• t Serum sodium
• t Hem.itocrit (%)
• t BUN
8
NURSING CONSIDERATIONS / TREATMENT
• fluid rep l.icement
~•
•
•
+Serum sodium
+ BUN
..
e
NURSING CONSIDERATIONS / TREATMENT
,,,,,
• low sodium diet
· ,
• Fluids (PO or IV)
· ·
'
' .
·
• Safety preoutions
• Risk for fall due to orthostatic hypotension
• Daily 1&0 + weights
• +Urine specific gr.ivity
• +Hematocrit (%)
• Daily 1&0 + weights
~
WHERE ~ODIUM GOES
WAHR FLOWS!
• Diuretics
• High-Fowler's or Semi-fowler's position
• Easier to breathe
46
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THERAPEUTIC COMMUNICATION TECHNIQUES
Client-centered type of communication to build and help
relationships with clients, families, and all relationships.
DON'T
DO
•
•
•
•
• Ask "why"
Allow client to control the discussion
Give recognition/validation
Active listening!
Use open-ended questions
• Ask too many questions
• Give advice
• Give fa lse reassurance
Don't be a LOSER, be an active listener!
• Change the conversation topic
L
0
S
E
Lean forward towa rd the client
Open posture
Sit squarely facing the client
Establish eye contact
R Relax & listen
• Give approval or disapproval
• Use close-ended questions/ statements
"Don't worry!"
"Tell me more about that"
" I think you shou ld _ _ "
"So you are saying you
haven't been sleeping well?"
"Don't be silly"
"That's great!"
"Tel l me more about
- --
!....................................................................................................................!
THERAPEUTIC COMMUNICATION CAN BE BOTH ...
&
Words a person speaks
You may say all the "right" t hings
but deliver it poorly.
Facial expressions
Movement
Eye contact
Appearance
Posture
Body language
Vocal cues
(yawning, tone of voice, pitch of voice)
50
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PERSONALITY DISORDERS
PARANOID
SCHIZOID
SCHIZOTYPAL
• Indifferent
ODD
or
ECCENTRIC
• Suspicious of others
• Seclusive
• Thinks everyone
wants t o harm them
• Detached
♦
♦
Odd t hinking
(magical thinking)
St range appearance
• Doesn't care for
close relationships
ANTISOCIAL
BORDERLINE
HISTRIONIC
NARCISSTIC
• No care for others
DRAMATIC
or
EMOTIONAL
♦
Unstable
♦
Manipulative to
self & others
• Aggressive
• Manipulative
♦
• Doesn't fo llow
t he rules
Fear o f neglect
AVOIDANT
ANXIOUS
or
INSECURE
♦
Seeks attention
♦
Center of attention
by being seductive
& flirtatious
AKA narcissus
• Anxious in social settings
◄
Extreme dependency
on someone
• Avoids social interactions
bu t desires close relat ionships
◄
Searches urgently to
find a new relationship
when the ot her fails
···············································
~ sf
· ·
.,..
a ety ·1s a pnonty
~
Clients with .i person.ility
disorder .ire .it .i t risk
fo r violence & self- hum
* Develop a therapeutic relationship
* Respect t he cl ient's needs while st ill setting
• Perfectionist
• Control issue
♦
.~•
a
I
Medications such as:
Antidepressants
• Anxiolytics
• Antipsychotics
• Mood stabilizers
Therapies such as:
•
•
•
•
* Give the cl ient cho ices to improve their
feeling of cont rol
........................................................ ,., ........... ,,, .......................................... :
Rig id
TREATMENT
limits and consistency
: .... , .. ,
• Needs consistent
applause
OBSESSIVE
COMPULSIVE
DEPENDENT
• Fear of abandonment
* Egocentric
.........
Psycho
Group
Cognit ive
Behavioral
.................................
................... ...
,, ...... ,
,., ... ,.,,
•For more information about psychiatric medications, see the Pharmacology Bundle
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EATING DISORDERS
•
*
,I, Weight(BM I <18.5)
• Binge eating fol lowed by purging
•
,I, Blood pressure
*
,I, Heart rate
• Normal weight to overweight
(BM I 18.5 -30)
•
,I, Sexual development
•
,I, Subcutaneous tissue = Hypothermia
•
,I, Period regularity
~ &fromelectrolyte
dehydra_tion
imbalance
• Teeth erosion
• Bad breath
• May use laxatives and/or diuretics
• Amenorrhea (period may stop)
• Binge eating not followed
by purging
• Tend to be overweight
• Binging causes:
• Depression
• Hatred
• Shame
TREATMENT
• Refuses to eat
Monitor cl ient during and
after meals for acts of purging
• Lanugo (thin hair to keep the body warm)
• Typically does not purge
• Restricts self from eating
• Fear of gaining weight
• Constipation (from dehydration)
....................................................
TREATMENT
~
I
t WEIGHT SLOWLY
(2 -3 lbs a week)
~ MONITOR EXCERISE
; J
......................................................... .
& REFEEDING SYNDROME
Potential compl ications when fluids, electrolytes,
and carbohydrates are introduced too qu ickly to a
malnourished client. Treatment should b e done
slowly to avoid t his syndrome.
.,
.
;
.
TREATMENT FOR ALL EATING DISORDERS
Teach
coping skills
Maintain
trust
Have the client be a part
of the decision making
& the plan of care!
Therapy
group, individual or family
'- - - - - - - - - - - - - - - - - - - - - -··········································································································································
51
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BIPOLAR DISORDER
MOOD SWINGS:
Depression to mania with periods of normalcy
DEPRESSIVE PHASE
Periods of HIGH mood
Irritabl e & hyper
May require hospitalization
Periods of LOW mood
SIGNS & SYMPTOMS
Sad
<YMPTOMS
~.,,. <
Restless
+Sleep
Low energy levels
Flight of ideas
Conversation is all over
the place with rapid speech
Delusions
Sleep disturbances:
too much or too littlesleep
Hallucinations
·........................................................................................·
lmpulsivity
Examples.· maxing out credit cards,
engaging in risky behavior
Grandiosity
Hyper mood
Leads to exhaustion
Poor judgement
Elevated activity
Leads to malnutrition & dehydra tion
For cl ie nts wit h mania, the nurse should
offer ene rg y & p rotein-d ense foods that
are ea si ly cons ume d on the g o (finger foods!)
Manipulative behavior
HAMBURGERS • SAN DWICHES
FRUIT JUICES • GRANOLA BARS• SHAKES
TREATMENT
ro
NURSING CONSIDERATIONS
FOR THE ACUTE PHASE
• Provide a safe environment
Remove harmful objects from the room
• Set limits on manipulative behavior
• Provide finger foods & fluids
• Re-channel energy for physical activity
• ,I, Stimuli
- Turn off or turn down the TV & music
- Keep away from other clients if they are bothersome
• Lithium carbonate
• Anticonvulsants
PHARMACOLOGY
• Antidepressants
• Antipsychotics
• Antianxiety
See pharmacology section for more details
53
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SCH IZOPH REN IA SPECTRUM DISORDER OVERVIEW
1 PHASES
1
PRE-MORBID
~
POSSIBLE CAUSES
(not ful ly known)
Normal functioning.
Symptoms have not become apparent yet.
t in the neu rotransmitter
DOPAMINE
2
PRODROHAL
3
More tempered form of the disorder.
Can be months to years for the disorder to
become obvious.
ILLICIT SUBSTANCE
(LSD & Marijuana)
ENVIRONMENTAL
(malnutrition, toxins,
viruses during pregnancy)
SCHIZOPHRENIA Posit ive sympto ms are noticeable and apparent .
4
RESIDUAL
Periods of remission. Negat ive symptoms
may remain, but S&S of the acute stage
(positive symptoms) are gone.
GENETICS
(family history)
--SIGNS & SYMPTOMS-~
POSITIVE
NEGATIVE
Delusions
Flattened/ bland effect
-
Lack of energy
Anxiety/ agitation
Reduced speech
Hallucinations
Jumbled speech
Disorganized behavior
• Medication
- Antipsychotic medications
- Antidepressants
- Mood stab ilizers (lithium)
- Benzodiazep ines
Avolition
•For more information about
Lack of motivation
Auditory *most common
TREATMENT~
psychiatric medications, see the
Anhedonia
Pharmacology Bundle
Not capable of feeling joy or pleasure
Lack of social interaction
• Therapy
• Exercise
I NURSING CONSIDERATIONS
~ Try to establish trust wit h the client
~ Encourage compliance with the medications
~ Promot e self-care
~ Encourage group activities
~ Offer therapeutic communication
I
···· HOW TO ADDRESS HALLUCINATIONS? ...1. .............................. .
• Don't address the hallucinations - - - - . . .
• Be com passionate
• Bring the conversation back to reality
• Do not argue with the client
EXAMPLE:
"/ don't see spiders
on the wall but
I see you are scared"
• Provide safety for t he client & the staffl
·······································································································1································
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TYPES OF DEPRESSION
ACUTE: 6 - 12 weeks
Hospitalization & medications may be perscribed
GOALS:
Has at least 5 of these symptoms
every d ay for at least 2 weeks:
Depressed mood
Too much or too little sleep
Indecisiveness
Thoughts of death (su icide)
+abilityto think/concentrate
+Depressive symptoms
Not able to feel pleasure
t or -1, motor activity
Weight flu ctuations
t Functiona lity
CONTINUATION: 4 - 9 mo nths
(5%change within a month)
Medication is continued
Treatment
for the client
w,f/ reflect ,L
Wnat
Phase they
are in!
GOALS:
Prevent relapse
MODimpairs the client's normal fun ctioning
MODis not the same depression seen in bipolar disord er
MODis not a mood swing, it's constant
MAINTENANCE: 1+ year
Medication may be continued or be phased out
GOALS:
Prevent relapse & further depressive episodes
L ;! ,:, ;:a; ;\'l-1+ •ffi; 1t•1;!
~
-V -
•
1
;
a.,a,,;!.,;;CJ;:,., •t t
Emot ional
t Eat ing
Depression that occurs during the luteal phase of the menstrual cycle.
+ Energy
-1,
Concentration
ISORDER
Depression that happens after
a woman goes through childbirth. _
The woman may feel disconnected
from the world. She may have a
fear of harm ing her newborn.
Depression associated with withdrawal or the use of alcohol and drugs.
D STHYMIA)
Amore mild form of depression compared to MOD,
although it can turn into MOD later in life.
NURSING CONSIDERATIONS
• Safety is a priority. Those strugg ling with
depression have a higher su icide risk.
F.F.EClil~E DISORDER (SAO)
INITIATE SUICIDE PRECAUTIONS:
Depression that occurs seasonally.
Often occurs during the winter months when there is less sunshine.
1.
TREATMENT
• Remove sharp things
• Keep medicationsout of reach
• Removeobjects that may be used
for strangulation (wires)
Lig ht thera py
......................................................................................................................
ANTIDEPRESSANTS
• SSRls
• TCAs
• SNRls
• MAOls
NON-PHARMACOLOGICAL
THERAPIES
• Light t herapy
• St. John's wort
ELECTROCONVULSIVE THERAPY (ECT)
Used for clients who are unresponsive to other treatments. i
Transmits a brief electrical stimulation to the patient's brain. \
w
• The client is asleep under anesthesia
~ • The client will not remember
tJ and is unaware of the procedure
o • Muscle relaxants may be given to
8: +seizure activity & +risk for inj ury
@'t'
i
~
~ • Client may have memory loss, confusion,
'V )
~
,
j
\
. . .~~~~.~~~~.'.~'.~~~-~:'.~~-~~~~:. ~~ti~:~~~~~~~;. ~::~;~e;;:;:.:;;;;;;;~;~~~~.~~
.~ ~.:~~'.~~:. ~~~~'.:.. .I
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• Help the client identify coping methods
& teach alternatives if needed
• Provide local resou rces such as chu rches,
local prog rams, commun ity resou rces, etc.
• ENCOURAGE:
• Physical activity
• Self-care
• Supportive relationships
Individual therapy, support groups,
& peersupport
55
DIFFERENT TYPES OF ANXIETY DISORDERS
NORMAL
WORST
HILD
N
1/h
MODERATE
I~
orrna f ea t_hy
amount o anxiety.
A llows one to have sharp
focus & p roblem solve.
I
Nail-biting
Tapping
Foot jitters
Th;nk;ng ab;!;ty ;,
impaired. Sha rp focus
&
bl
.
1
~loh em-so_ ving can
s 1 apperl, JUSlt at a
1ower eve.
f
G I upset
Headache
Voice is shaky
SEVERE
PANIC
Focus & problem solving
are not possible.
Feelings of doom
may be felt.
Most extreme anxiety.
Unstable & not in touch
with rea lity.
Dizziness
Headache
Nausea
Sleeplessness
Hyperventilat ion
Pacing
Yelling
Running
Hallucinations
Experiences extreme fear of anx iety when separated from
someon e they are emotionally connected to. T his is a
normal part of infancy, but not a normal part of adulthood.
Separation
Anxiety Disorder
SOME EXAMPLES:
Specific Phobia
Irrational f ear of a pa rti cular object or situation.
Social Anxiety Disorder
(Social Phobia)
• Monophobia - Fear of being alone
• Zoophobia - Fear of animals
• Acrophobia - Fear of heights
Fear of social situat ions or p resenting in front of groups. T hey fear emba rrassment.
T hey may have symptoms (real or fake) to escape the situation.
Panic Disorder
Reoccurring panic attacks that last 15 - 30 minutes with physical manifestat ions.
Extreme fear of certain places where the client feels unsafe or def enseless.
May even be too fearfu l o f places to maintain employment.
Generalized Anxiety
Disorder (GAD)
~
s._
~
3
Uncontrolled extreme worry for at least 6 months
that causes impairment of functionality.
Obsessive Compulsive
Disorder <0(0)
'!!
~
"open sp~ce"
I
~
~
AGORA
MEANS
OBSESSION:
COMPULSION:
Recurrent thoug hts
Recurrent acts or behaviors
T his obsessiveness is usually because it decreases stress & helps deal with anxiety.
-
I
Hoardin9 Disorder
Compulsive desire to save it ems even if they have no value to the person.
It may even lead to unsafe living environment s.
Body Dysmorphic
Disorder
Preoccu pied with perceived f laws or impe rfections in physical appearance
that the client thinks they have.
~
~
...~
';'
-
56
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SOMATIC SYMPTOM & RELATED DISORDERS CSomatoform Disorders)
: ...... ..1
.
....
.
tt,,: ,,, ;tin: iJ,.,:, ,,ii,, .J .,4 .t1.......
• Consumed by physical manifestat ions
to the point it disrupts daily life
Somatization is psychological stress that presents
through physica l symptoms that can not be exp lained by any patho logy or diagnosis.
• Seeks medical help from multiple places
• Rem ission & exacerbations
NURSING CONSIDERATIONS
• SAFETY is a priority
• Overmed icates with analgesic and
ant ianxiety medicat ions
Asses for symptoms or thoughts
of self-harm or suicide
• Understand the somatic symptoms are real
to the client even though they are not real
....
..
MANIFESTATIONS ................................. =
• Help the cl ient verbalize their feelings while
limiting the amount of time talking about
their somatic symptoms
• t Stress = t somatic symptoms
~ PHQ-15:
PATIENT HEALTH QUESTIONNAIRE 15
An assessment tool used to ident ify 15
of the most common somat ic symptoms
• Assess coping mechanism & educate
on alternat ive ways of coping
MANIFESTATIONS .................................
Sudden onset of neurologica l manifestat ions &
physical symptoms without a known neurological
diagnosis. It can be related to a psycholog ical conflict/need beyond their conscious control.
NURSING CONSIDERATIONS
• Ensure SAFETY
I
MOTOR
I
.
Paralysis pseudoseizures
Pseudocyesis:
Signs & symptoms of pregnancy without the
presence of a fetus AKA false pregnancy.
This may be present in a client who desires
to become pregnant
SENSORY
• Gain trust & rapport with the client
Bl indness
Deafness
Sensations (burning/tingling)
Inabil ity to smell/speak
• Assess coping mechanism
& educate on alternative ways of coping
• Assess stress management methods
~ MEDICATIONS
• Encourage therapy such as:
- Individual therapies
- Group therapies
- Support groups
The cl ient may be prescribed
antidepressants or anxiolytics
POSTTRAUMATIC STRESS DISORDER (PTSD)
~AN IFESTATIONS
Lasting longer than 1 month:
Mental health condition where exposure to a t raumat ic event has occured .
• Anxiety
• Detachment
NURSING CONSIDERATIONS
• Night mares of the event
• Teach relaxation techn iques
• Teach ways to
,1,
• Support groups
~ t"fEDICATIONS
anxiety
~
Antidepressants may be prescribed
•For more information about antidepressants, see the psychiatric section in the Pharmacology Bundle
57
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NEUROCOGNITIVE DISORDERS
DELIRIUM
ALZHEIMER'S
SHORT TERM / SUDDEN CHANGE
CONTINUOUS
Impairment (hours - days)
Decline of function (months - years)
• Genetics
Family history (immediate family)
There is always an underlying cause...
something is causing the delirium!
•
•
•
•
Hospitalization
ICU delirium
Polypharmacy
Old age
• Head Injury
Traumatic brain injuries (TBI)
& head trauma
• Stroke
• Surgery
• Restraints
Don't get Dementia
& Alzheimer's confused!
Dementia is a general term
that refers to a group of symptoms,
not a specific disease_
Dementia may advance to a
major neurocognitive d isorder
such as Alzheimer's d isease_
• Advanced Age
>65 have the highest risk
• Cardiovascular Disease & Lifestyle Factors
Inactivity, unhealthy diet, high cholesterol,
obesity, & diabetes
• Secondary to a medical condition
(infection, electrolyte imbalance,
substance abuse ___ etc)
STAGES OF ALZHEIMER'S DISEASE
Delirium is a medical emergency and
requires prompt diagnosis & treatment
• Disorganization
- Most common to time & place
- Happens mostly at night
• .l,
Memory
• A nx iety & ag itation
• Del usiona l thinking
• Ranges from lethargic to hypervig ilance!
0
.....
i:
EARLY STAGE
not noticeable
to others
ILi
~
ILi
MIDDLE STAGE
noticeable to o thers
Q
0
%
w
w
>
w
"'
LATE STAGE
Requires
full assistance
~
• M emory lapse
• M isplacing things
• Short t erm memory
• Difficulty focusing
• Can still accomp lish
own ADL's
• Forgets own history
• Get s lost & w and ers often
• Difficulty completing t asks • Get s angry & frustrat ed
• Personality changes
• Unable to d o some ADL's & self-care
(may be incontinent)
•
•
•
•
Need s assist ant with all ADL's
Losing the cap ability to have discussions
Losing physical skills (walking, sitti ng, sw allowing)
May result in d eath or co ma
Caring for a client with Alzheimer's is very complex!
• Safety: prevent physical harm
• Avoid restrains when p ossib le
• Remember physical needs
(Hygiene, food, water, sleep, etc)
• Maybe prescribed
anti-anxiety/antipsychotic med ications
• Help fam ilies in p lanning for
extend ed care
• Monit o r nutrition, w eight,
& fluid s status
• Maintain a q uiet enviro nment
to ,I. stim uli
• Cholinesterase inhibitor may be
(
prescri b ed t o improve q uality of life
\
b ut does NO T cure the disease_
Communication - - - ~
• Speak sl owly
• Give one direction at a ti me
• Don't ask comp lex o r open-ended
questi ons
• Ask simple, direct q uest ions
• Fa ce the client directly wh en speaking
:······· ·••iJUi--------·························································· ·
Used in early & m oderate st ag es o f
dem ent ia & A lzheim er's disease. M ay
donepezil
Aricept
galantami ne
Razadyne
'·········al so .be..used. for. Parkinson 's.dem ent ia ........ . rivastigmine
Reversible if prompt
treatment is initiated
Exelon
Irreversible
56
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59
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ABBREVIATIONS
NST .... ..... ...... Non-stress test
CST ...... .... ...... Contraction stress test
IUP/I UFO ...... Intrauteri ne pregnancy / intrauteri ne fet al demise
SAB ............... Spontaneous abortion
TAB ........ ........ Therapeu tic abortion
LMP ...... .... ..... Last menstrual period
ROM .............. Rupture of membranes
SROM ............ Spontaneous rupture o f membranes
AROM ........... Artificial rupture of membranes
PROM ............ Prolonged rupt ure of membranes (>24 hours)
PPROM ......... Preterm premature rupture of membranes
SV O ............... Spontaneous vaginal delivery
BPP ........ .. ...... Biophysical profile
V BAC.... .. ....... Vaginal birth after cesarean
FHR ...... .. ....... Fetal heart rate
EFM ...... .... ..... Electronic feta l monitori ng
US .......... ... ..... Ultrasound transducer (detects FH R)
FSE ........ ... ..... Fetal scalp electrode (precise read ing of FHR)
IUPC ...... ... ..... Intrauteri ne pressure catheter (strength o f contractions)
LTV ........ ........ Long term variability
SVE...... .. ........ Steri le vaginal exam
MLE ...... .. ....... M idline episiotomy
AFI .......... ....... Amniotic fluid index
BUFA ............. Baby up for adoption
NPNC ............ No prenatal care
PTL ................ Preterm labor
BOA...... ... ...... Born on arrival
BTL ................ Bilateral tubal ligation
O&C / O&E ... Dilation & curettage I dilation & evacuation
LPNC ............. Late prenatal care
TIUP .............. Term intrauterine pregnancy
V MI / V FI ...... Viable male infant/ viable female infant
EOB ............... Estimated date of birth
EOC .... .. ... ...... Estimated date of confinement
EOO .... .. ... ...... Estimated date of delivery
PREGNANCY DURATION
38 WEEKS
40 WEEKS
GESTATIONAL AGE
TRIMESTERS
FETAL AGE
This refers to t he age of the
developing baby, counting
from t he estimated d ate of
conception. The fetal age
is usually 2 weeks less tha n
the gestational age.
The number of completed
weeks counting from the
1st day of the last normal
menstrual cycle (LMP).
►
[ o - 13WEE~
SECOND TRIMESTER
----+-
I
THIRD TRIMESTER
----+-
I 27 - 40 W EEKS
14 - 26 W EEKS
PRENATAL TERMS
Gravida / Gravid ity
A woman w ho is pregnant/ the number of pregnancies
NULLIGRAVIDA
PRIMIGRAVIDA
MULTIGRAVIDA
Never been pregnant
Pregnant for
t he fi rst t ime
A woma n who has
had 2+ pregnancies
Parity
The number of pregnancies that have reach viability (20
weeks of gestation} w hether the fetus was born alive or not
NULLIPARA
0
Zero pregnancies
beyond viability
(20 weeks)
PRIMIPARA
MULTIPARA
1
2+
Two or more
pregnancies that
have reached
viab ility (20 weeks)
One pregnancy
t hat has reached
viab ility
(20 weeks)
Preg~~ncies t hat have reached 20 we: : - - 7
but e nded before 37 weeks
~
Pregnancies t hat
have lasted between
week 37 and week 42
EARLY TERM: 37 - 38 6/7
FULL TERM:
39 - 40 6/7
LATE TERM:
41 - 41 6/7
A pregnancy that goes beyond 42 weeks
60
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GTPAL
An acronym used to assess preq nancy outcomes
0
0
G
GRAVIDITY
TERM BIRTHS
•
The nu mber of pregnancies
•
The number born at term
• Incl udes t he present pregnancy
• Incl udes miscarriages / abortio ns
• Twins / trip lets count as o ne
• > 37th week of gestation
• Incl udes alive or st illborn
• Twins / trip lets count as o ne
PRE-TERM
BIRTHS
•
The number of pregnancies delivered
beginning with the 20th -36 6hth weeks
of gestation
• Incl udes alive or st illborn
• Twins / trip lets count as o ne
0
ABORTIONS/
MISCARRIAGES
The number of pregnancies delivered
before 20 weeks gestation
• Counts with gravid ity
• Twins / trip lets count as o ne
LIVING
CHILDREN
The number of current living children
• Twin / triplets count individually
:······~NSWER ICEY ~ .....
i P-0-1-l· P (J l •! i no
\.....z-1-0-N <ol_'!.~no....
PRACTICE QUESTION
PRACTICE QUESTION
You are adm itting a client to the mother-baby
un it. Two hours ago she delivered a boy on
her due date. She g ives her obstetric history
as follows: she has a three-year-old daughter
who was del ivered a week past her due date
and last year she had a miscarriage at 8 w eeks
gestation. How would yo u note this history
using the GTPA L system?
A prenatal client's o bstetric history ind icates that
she has been pregnant 3 ti mes previo usly and
that all her children fro m previous pregnancies are
living. O ne was born at 39 weeks gestat ion, twins
were born at 34 w eeks g estation, & anot her child
was born at 38 weeks gestation . She is currently 38
weeks pregnant. W hat is her gravid ity & parity using
the GTPA L system?
A. 2-2-1-0-2
B. 3-2-1-0-1
C. 3-2-1-0-2
D. 3-2-0-1-2
A. 4-1-3-0-4
B. 4-1-2-0-3
C. 4-2-1-0-4
D. 4-2-2-0-4
61
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PREGNANCY SIGNS & SYMPTOMS
PRESUMPTIVE
( SUBJECTIVE )
NOT a d efinite d iag nosis for preg nancy!
P Period Absent (Amenorrhea)
R Really tired
E Enlarged breasts
S Sore breasts
Why is quickenin9 not a positive si9n?
U Urination increased (urinary frequency)
Q uicken ing can b e d ifficult to
d istinguish from perista lsis or g as
so it can not be a positive sig n.
Movement perceived (quickening)
E Emesis & nausea
PROBABLE
( OBJECTIVE )
"Think n Pre9nancy si9ns that the nurse or doctor can observe
"Oortor
p Positive(+) pregnancy test (high levels of the hormone: h(G) -------,.._
Why is a positive
R Returning of the fetus when uterus is pushed w/ fingers (ballottement) pre9nancy test not a positive si9n?
0
High levels of hCG can be associated
w ith other cond itions such as certain
med ications or hydatid iform mole
(mo lar preg nancy).
Objective
B Braxton hicks contractions
A A softened cervix (Goode II's sign)
B Bluish color of the vulva, vagina, or cervix (Chadwi,ck's sign)
L Lower uterine segment soft (Hegar's sign)
E Enlarged uterus
POSITIVE
( OBJECTIVE )
F Fetal movement palpated by a doctor or nurse
E Electronic device detects heart tones •
T The delivery of the baby
u
62
s
1hink
b"
"by
CID
CD
ca:,-
=·-
Can only be attributed to a fetus
I-
. . . . . -..
- .
Ultrasound detects baby
Seeing visible movements
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PlEGNANCY PHYSIOLOGY
HOllt~O ES
Probctin: A llows for breast milk p roduct ion
Estro9,n: Growth of fetal organs & maternal t issues
Pro9,stt'ron, & R.,laxin: Relaxes smooth muscles
h(G:
MUSCU LOSKELETAL
• Lordosis: center of gravity sh ifts forward
lead ing to inward curve of sp ine
• Low back pain
• Carpa l tunnel syndro me
• Calf cramps
Produced by p lacenta, p revents menstruatio n
Oxytocin: St imulates cont ractions at the start of labor
RESPIRATORY
• t Basal metabolic rate (BMR)
• t 02 needs
PITUITARY
• Respiratory al kalosis (MI LD)
• ,I,
FSH/LH due to t Prog esterone
• t Prolactin
• t Oxytocin
CARDIOVASCU LAil
• t Cardiac output
(t Hea rt rate + t stro ke volume)
• Blood pressure stays t he same ,
or a slight decrease
.f
• t in p lasma vol ume
• •Enlarges
(May develop
....
• t Thyroxine
• May have moderate enlargement
of the t hyroid g land (goiter)
• t Metabolism & t appet ite
systolic murm urs)
GAST ROI NTESTI NAL
• t GFR from t p lasma vol ume
• Smooth muscle relaxation
of the uterus = t risk of UTl's!
• t Urgency, frequency & nocturia
• EDEMA! !
• Pyrosis
t Progesterone = LOS to relax = t heartburn
• Constipation & hemorrhoids
t Progesterone = ,I, gut motility
• Pica
Non-food cravings such as ice, clay,
and laundry starch
SKIN
• Striae
Stretch marks (abdomen, breasts, hi ps, etc)
• Chloasma
Mask of p regnancy
Brown ish hyperpigmentat ion of t he skin
• Linea Nigra
" Pregnancy line" da rk line that develops
across your belly during pregnancy
• Montgomery glands / Tubercles
Small rough/ nodular/ pimple-like appearance
of the areola (nipple)
HEMATOLOGICAL
Fl BRI NOGEN -
Non-pregnant levels: 200-400 mg/dL
Pregnant levels: up to 600 mg/dL
Pregnant women are
HYPERCOAGULABLE
(increased ri sk for DVTs)
• t Wh ite b lood cells
• ,I, Platelets
RBCVOLUME
ANEMIA
Plasma vol ume is greater t han t he amount of
red b lood cel l (RBC) = hemodilution = physiological anemia
63
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1
NAEGELE S RU LE
Used for estimating the expected date of delivery (EDD) based on LMP (last menstrual period)
DATE OF LAST MENSTRUAL PERIOD -
LLI
-J
~
REMEMBER:
How many days are
in each month?
2:
~
LLI
3 CALENDAR MONTHS
+ 7 DAYS + 1 YEAR
1 st day of last period:
Minus 3 calendar months:
Plus 7 days:
Plus 1 year:
September 2, 2015
June 2, 2015
June 9, 2015
June 9, 2016
~(EDD)
FACTS ABOUT NAEGELE'S RULE
11
30 days hath September,
April, June & November.
Al I the rest have 31, except
February alone (26 days) 11
• Bases ca lculation on a woman who has a
28-day cycle (most women vary)
• The typica l gestation p eriod is 280 days (40 weeks)
• First -t ime mothers usually have a slightly longer
gest ation period
WHAT TO AVOID DURING PREGNANCY
,,L:·TERATOGENIC DRUGS ·--~
---·········
r···· TORCH INFECTIONS ················
\/---- - - - - - - - - - - ,
G .'' ts TERA-TOWAS
I
TORCH infections are a group of
infe ctions t hat cause fetal abnormalities.
Pregnant women sho uld avo id these
infe ctions!
T Thalidomide
E Epileptic medications (valproic acid, phenytoin)
R Retinoid (vit A)
_______
', :r /,,.
,;;
G ·,,
ts TORCH
f
((
A Ace inhibitors, A RBS
T Th ird element (lithium)
0 O ral contraceptives
T Toxoplasmos is
Pa~v O Virus-B19 (fifth d isease)
W Warfarin (coumad in)
R Rubella
A Alcohol
C Cytomega lovi rus
S Sulfonamides & su lfones
H Herpes simplex virus
64
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STAGES OF LABOl
CERVIX
8
FROM 0-10 CM
l,to,tCm lyl
tJ>
• Promote co mfort
- Warm show er, massage, or ep idural
6 • Offer fluids & ice chips
• Cervix dilates: 1- 3 cm
• Intensity: M ild
• Contractions: 15 - 30 mins
z~ • Provide a quiet environment
w
Ei'.
w
~
• Encourage void ing every 1 - 2 hours
• Encourage participat ion in care & keep informed
Active
• Instruct pa rtner in effleurage (light stroking of t he abdomen)
• Cervix dilates: 4 - 7 cm
• Encourage effective breathing patterns & rest between contractions
• Intensity: Moderate
• Contractions: 3 -5 min (30-60 sec in duration)
•
Transition
• Cervix dilates: 8 - 10 cm
• Intensity: Strong
• Contractions: Every 2-3 min (60-90 sec in duration}
THE
Labo r
Active ly
Tra nsition in9
>30 min =
!let.lined
pl.1cent.i
THE PLACENTA IS DELIVERED
ISDELIVERED
➔
Starts when cervix is fully dilated & effaced
The PLACENTA is expel led (5 - 30 min after b irth)
➔
Ends after the baby is d elivered
SIGNS O F A PLACENTA DELIVERY
• Lengthening umbilical cord
• Provide ice chips & oint ment for dry lips
• Provide praise & encouragement to t he mother
tJ)
[o'EuvERY MECHANl"cs"]
• Gush of b lood
"Shiny Schultz "
Side of baby delivered 1st
• Uterus changes from oval
to g lobu lar shape
"Dirty Duncan "
Sid e of mother delivered 1st
z
• Monitor uterine contractions & mot hers vital signs
~
~
Cl:'.
w
• Maintain privacy & encourage rest between
contractions
tJ)
• Assessing mothers vita l signs
0
• Uterine status (fun dal rubs every 15 minutes)
• Encourage effective breathing patterns & rest
between contract ions
zw
>
Cl:'.
• Provide warmth to t he mother
Q
~
z
• Monitor for signs of b irth
(perinea I bulging o r visualization of fetal head)
z
~
w
~
z
RECOVERY!
\\
• Promote p arental-neonatal attachment
• Examine p lacenta & verify it's intact
- Sho uld have 2 arteries & 1 vein
···.
✓ •FIRM
• Midline
RECOVERY: fi rst 1-4 hours after d elivery of th e p lacenta
• Assessing the fundus
• Continue to mon itor vital signs & temperature for infection
X
• Soft
• Boggy
• Displaced
• Adm inister IV fluids
~
V
looks like a
smiley face!
• Monitor lochia d ischarge (lochia may be moderate in amo unt & red).
• Monitor for respiratory depression, vo miting, & aspiration if general anesthesia was used
• Great time to watch for comp lications such as bleeding (p ostp artum hemorrhage)
2 "A" for ARTERIES
1 "V" for VEIN
65
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TRUE VS. FALSE LABOR
O ccu r regularly
• Stronger
• Longer
• Closer t ogether
Irregu lar
St op s wit h walking / posit ion change
Felt in the back or the abdomen
above the umbilicus
M ore int ense with walking
Felt in lower back ➔ rad iati ng t o the lower
portion of t he abdomen
Often st ops with comfort measures
Cont inue d espite the use of comfort measures
May be soft
Prog ressive change
NO sign ificant change in ....
• Effacement
• Dilat ion
• Softening
• Effacement
No bloody show
• Dilat ion signaled by the
appea ra nce of bloody show
In post erior position
(ba by 's head facing mom' s front of b elly)
• Moves to an increasi ngly anterior posit ion
(baby' s head facing mom's back)
Presenting parts become engag ed in the p elvis
Presenting part is usu al ly
not engaged in the pelvis
Increased ease of breathing
(more roo m to breathe)
Presenting part presses d ownward &
compresses the b ladder = uri nary freq uency
SIGNS OF LABOR
LABOR
Moving the fetus, p lacenta,
& the membranes out of the
uterus thro ugh the birth canal
~·ans of Precedin9 Labor
Lighten ing
Increased vagina l discharge (b loody show)
R.eturn of urinary freque ncy
Cervica l ripening
R.upture of membra nes "water breaking"
Persiste nt backache
Stronge r Braxton Hicks contractions
Days preced ing labor
• Surge of energy
• Weig ht loss (1 - 3.5 pounds) from a fl uid shift
66
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FETAL HEAllT TON ES
M"1rrorII ,• ma9e of mom I s con t ract·ions
(They don't technically come early)
II
•
NORMAL
FETAL HEART RATE:
120 - 160 BPM
CAUSE:
From head compression
2
~
-e
~
"'
(I)
-
.
..c
-.;
::i
C
:I:
«
0
•I
:§
z
_t.r,
INTERVENTION:
Continue to mon itor
No intervention needed
.2
T
Eu
I
0 ~
Ee
0
0
-
•
X
\!)
z
i:i2
::)
INTERVENTION:
DIC oxytocin
Posit ion change
Oxygen (nonrebreather)
Hydration (IV fl uids)
Elevate legs to correct
the hypotensio n
(I)
..c
-.;
:§
vi,
~
I
z
0
z
_t-rJ.g
T
Eu
0 ~
Ee
8
X
\!)
z
i:i2
::)
2
..,~
:;;
(I)
..c
-.;
:§
vi,
vi,
C
LLI
ail:
I
z
0
z
-'··i
T
E
0 "'
~
Ee
0
0
Literally comes late after mom's contraction
CAUSE:
Uteroplacental in sufficiency
2
..,~
:;;
LLI
ail:
---
I
•
•
@ *Variable: Looks "V" shaped
I
I
•I-
CAUSE:
Cord compressio n
INTERVENTION:
DIC Oxytocin
Amn ioinfusion
Position change
Breathin g techniques
Oxygen (nonrebreather)
Side-lying or knee
ch est wil l relieve
p ressure on cord
I
-
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67
PRE EC LAM PSIA OVERVIEW
Overview of Hypertensive dlisorders during pregnancy
1sr TRIMESTER
~
2ND
TRIMESTER
3RD
TRIMESTER
w
w
SYSTOLIC > 140
s
OR.
0
<"I
CHRONIC HTN:
Before pregnancy
or before 20 weeks!
PREECLAMPSIA: HTN after 20 weeks gestation wit h systemic features
11
11
PR.E eclampsia
p Proteinuria ]
~
iii.
P.
Risi ng BP
~
tO
E Edema
Hypertension may be
abbreviated
"HTN"
GESTATIONAL HTN: HTN after 20 weeks without systemic features
SIGNS & SYMPTOMS
PATHOLOGY
RISK FACTORS
Pathology isn't
completely known
• HX of preeclampsia in previous
PLACENTA
is the root cause
• Fami ly histo ry of preeclampsia
pregnancies
• 1st pregnancy
a
• Severe headache
• RUQ or epigastric pain
DIASTOLIC > 90
AMA
(advanced maternal age)
~
• Obesity
• Defective spiral
artery remodeling
• Very young (< 18) or very old (>35)
• Medical condit ions
• Systemic vasoconstriction
& endothelial dysfunct ion
(Chronic HTN, rena l d isease,
• Visual disturbances
diabetes, autoimmune d isease)
• + Urine output
• Hyperreflexia
• Rapid weight gain
HELLP SYNDROME
Variant of p reeclampsia
Life-th reatening complication
[
EC.LAMPSIA
J
(seizures activity or a coma)
IMMEDIATE CARE:
• Side-lying
• Padded side rails with p illows/blankets
H Hemolysis
• 02
EL Elevated liver enzymes
• Suction if needed
• Do not restrain
LP Low platelet count
• Do not leave
MAGNESIUM SULFATE
frox1c1rvil
RX given to prevent seizures during & after labor.
*Remember: magnesium acts like a depressant
~
HERAPEUTIC RANGE : 4 - 7 m9/dl
• RR < 12
• ,1, DTR's
*Mag is excreted in urine
/ " +UOP ➔ t Mag levels
• UOP <30 m L/hr
• EKG Changes
ANTIDOTE: CALCIUM GLUCONATE
*because magnesium sulfate can cause respiratory depression
66
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VEAL CHOP
Atool to help interpret fetal strips
Variable
Decelerations➔
Early
➔
Decelerations
Cord
Compression
m
Head
Compression
Accelerations ➔
OK
Late
➔
Decelerations
Placental
Insuff ici ency
(normal fet:al oxyqen:ation)
ASSESSMENT OF UTERINE CONTRACTIONS
DURATION
FREQUENCY
INTENSITY
RESTING
TONE
BEGINNING of the
contraction to the END
of that same contraction
Number of contractions
from the BEGINNING of
one contraction to the
BEGINNING of the next
Strength of a
contraction
at its PEAK
• Lasts 45 - 80 seconds
• Should not exceed 90 seconds
Only measured through external monitoring
• 2 - 5 contractions every 20 minutes
• Shoul d not be more FREQU ENT
then every 2 minutes
Only measured through external monitoring
• 25 - 50 mm Hg
• Shoul d not exceed 80 mm HG
Can be palpated
• Average: 10 mm HG
TENSION in the uterine
muscle between contractions • Shoul d not exceed 20 mm HG
(relaxation of t he uterus =
Can be palpated
fetal oxygenation between
contractions)
MILD - nose
MODERATE - chin
.STRONG - forehead
.SOFT= good
FIRM = not resting
enough
69
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LABOR & Bl RTH PROCESSES
S factors that affect the process of labor & birth ...........
: FETUS & PUCENTA
PASSAGEWAY
POSITION
POWERS
PSYCHOLOGY
THE BIRTH CANAL
POSITION OF THE MOTHER
CONTRACTIONS
EMOTIONAL RESPONSE
FETUS & P L A C E N T A - - - - - - - - - - - - - - - - - - .
SIZE OF THE FETAL HEAD
FETAL PRESENTATION
FONTANELS
• Space between the bones of
the skul l allows for mold ing
• Anterior (larger)
- D iamond-shaped
- Ossifies in 12-18 months
• Posterior
- Triangle shaped
- C loses 8 - 12 weeks
ANTER IOR
Refers to the part of the fet us that ent ers
the pelvic inlet first through the birth canal
during labor
0
CEPHALI~
•
• Head first
• Presenting part: Occip it al
(back of head/skull)
__
~.
f ~ KJ>
~
E)BREECH
HOLDING
• Buttocks, feet, or both first
• Presenting part: Sacrum
• Change in the shape of the
feta l skul l to "mold " & fit
through the birth canal
POSTERIOR
ft SHOULDER
V • Shoulders first
• Presenting part: Scapula
FETAL LIE
Relation of the long axis (spine) of the fetus t o the long axis (spine) of t he mother
LONGITUDINAL OR VERTICAL
• The long axis of the fet us is para llel with the long ax is of the mother
• Long itudinal: cephal ic or breech
TRANSVERSE, HORIZONTAL, OR OBLIQUE
• Long axis of the fet us is at a right ang le t o the long axis of the mother
• Transverse : vaginal birth CANNOT occu r in this posit ion
• Oblique: usually converts t o a long it udinal o r transverse lie during labor
-------------------------CONTINUED ➔
70
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LABOR & Bl RTH PROCESSES
CONTINUED
FETAL ATTITUDE
FETAL POSITION
GENERAL FLEXION
• Back of the fetus is rounded so that
the ch in is flexed on the chest, thig hs
are flexed on the abdomen, legs are
flexed at the knees
BIPARIETAL DIAMETER
• 9.25 cm at term, the largest transverse
diameter and a n important indicator of
fetal head size
.,,...--+
Hnd, foot, butt (do1ert to exit of utem}
FETAL STATION
(
• Where t he b aby's PRESENTING PART is located in the pelvis
• Measured in cent imeters (cm)
,.. ,_
• Find t he ischial spine • ZERO
I'm (+) th.it I'm
• Above the ischial spine is (-)
9ettin9 th is b.iby out
• Below the ischial spine is ( +) _ _ /
+4 / +5 = Birth is .ibout to h.ippen
A
V
ENGAGEMENT
• Feta I station ZERO = baby is "engaged "
• Present ing parts have entered down into
t he p elvis inlet & is at the ischial spine line (0)
When does this happen?
SUBOCCIPITOBREGMATIC DIAMETER
• Most critical & sma llest of the
anteroposterior diameters
• FIRST-TIME MOMS: 38 weeks
• ALREADY HAD BABIES:
can happen when labor starts
~
----~
----~-----
~
---g----•
~
----a>---~----~ ------
~----1.SChicil
SPine
PASSAGEWAY
THE BIRTH CANAL: Riqid bony pelvis, soft tissue of cervix, pelvic floor, vaqina & introitus
TYPES OF PELVIS
•
•
GYNECOID
• Classic fema le type
• Most common
ANDROID
• Resembling the male pelvis
LOWER UTERINE SEGMENT
• Stretchy
CERVIX
• Effaces (thins) & d ilates (opens)
• After fetus descends into the vag ina, the cervix is drawn
upward and over the first portion
ANTHROPOID
• Oval-shaped
• Wider anteroposterior d iameter
PLATYPELLOID
-
SOFT TISSUE
• The flat pelvis
• Least common
PELVIC FLOOR MUSCLES
• Helps the fetus rotate anteriorly
VAGINA
INTROITUS
• Externa l opening of the vagina
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71
LABOR & Bl RTH PROCESSES
POSITION OF THE MOTHER DURING BIRTH
UPRIGHT POSITION
LITHOTOMY POSITION •
Sitting on a birthing stool o r cushio n
Supine posit ion with buttocks o n the table
•ALL FOURS" POSITION
LATERAL POSITION
On all fours: p utting your weight
on you r hands & feet
Lay ing on a sid e
Frequent changes in
position helps with:
Relieving fatigue
Increasing comfort
Improving circulat ion
CONTRACTIONS: PRIMARY & SECONDARY - - - - - - - - - -
PRIMARY POWERS
SECONDARY POWERS
INVOLUNTARY uterine contractions
Signals t he beginning of labor
VOLUNTARY bearing-down efforts by the
women once the cervix has dilated
• Does not affect cervical d ilation b ut helps w ith
expu lsion of infant o nce t he cervix is fu lly d ilated
[Li_:D
:..:.:IL::__
AT_IO_N_]............................................................................
• Dilation of the cervix is the gradual
en larg ement or wid ening of the cervical
o pening & canal once labor has begun
• Labo ring women start to feel an involuntary
urge to push & she uses secondary p owers to
aid in the expulsion of t he fetus
• Pressure from amn iotic fluid can also
apply force to d ilate
0
····························································
closed
[F
•E~~~~~:.,:~:~::L,r:;::::::~:::::
10 cm
full dilation
it t rigg ers the maternal urg e to bear down
[ EFFACEMENT ] ............................................................................:
..
..
• Shorten ing & th inning of the cervix d uring
the first stag e of labor
• Cervix no rmally:
2 -3 CM lon9
• W hen t he p resent ing part reaches t he p elvic
fl oor, the contractions change in character
& become expulsive.
EMOTIONAL
RESPONSE
Anxiet y can in crease pain p erceptio n
& the need for more med ications
(analgesia & anesthesia)
1 CM thick
• The cervix is " pulled back / thinned out"
by a shortening of the uterine muscles
THINGS TO CONSIDER:
72
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NEWBORN ASSESSMENT
APGAR
ACTIVITY
Flexed arms
& legs
Acrive
0
< 100
> 100
Floppy
Minimal response
to stimulation
Prompt
response to
stimulation
Blue / pale
all over
Pink body
Blue extremit ies
(acrocyanosis)
Pink
No
breathing
Slow
& irregular
Vigorous
cry
PULSE
GRIMACE
(Reflex irritability)
APPEARANCE
(Skin color)
RESPIRATION
(Effort)
I
BLOOD PRESSURE (BP)
SYSTOLIC
(Not done routinely)
HEART RATE (HR)
'
<P'Pft
'
Dry with a b lanket or place in warmer
r
Blood flow from umbilical vessels & placenta stop at birth
Acrocyanosis: Blueness of hands & feet ~
(normal during the first 24 hours of life)
Closure of:
• Ductus arteriosus
• Foramen ovale
• Ductus venosus
Transient murmurs are normal
D
CAPUT SUCCEDANEUM:
a
e ID
60 -80 mmH9
40 - 50 mmH9
110 - 160 bpm
can be 180 if cryin9
can be 100 if sleepin9
RESPIRATORY RATE (RR)
Suction with bulb syringe / deep suction
" N ewborns are obligatory nose breathers
WARMTH
Absent
(Muscle tone)
AIRWAY
@:,mu,
l·O·MUI
SCORE
0
0
7 - 10 supportive care
4 - 6 moderate depression
< 4 aggressive resuscitation
·
Equal to the# of weeks 9estation or hi9her
GENERAL
RISTICS
Like a
baseball CAP
CEPHALOHEMATOMA:
• Birth trauma (collection of blood)
• Does not cross the suture lines
8mthin9 pattern is IRREGULAR.
Newborns are ABDOMINAL breathers.
(f)
To count breaths, place your
hand on their .ibdomen
("j'\ Countfor.i
full minute!
fonbnPl/es
m~ be BULGING • hon
th, •-.6on, <rie,,
"'mib, or is lyin9 d.,.,..
This is norm;;i/.
8ul9in9 = increase ICP or hydrocephalus
Sunken = dehydration
,.
D
Should have
2 ARTERIES & 1 VEIN
V
Len9th & Wei9ht
HOLDING:
Abnormal head shape
that results from
pressure (normaO
TEMPERATURE (T) (Auxi liary) 97.7 - 99.5°F (36.5 - 37.5°C)
SIGNS OF RESPIRATORY DISTRESS
• Retr.ictions • N;ual flarin9 • Gruntin9
M
V
,
·
30 - 60 breaths/min
MAP
• Edema (collection of fluid)
• Crosses the suture lines
Should be d ry, no o d or & no drainage
EXPECTED
LENGTH
44 • 55 cm
17 - 22 in
EXPECTED
WEIGHT
2,500 - 4,000 9
5 lb, 8 oz - 8 lb, 14 oz
•
looks like a smi ley face!
Head & Chest Circumference
HEAD
32 - 39 cm
CIRCUMFERENCE 14 - 15 in
• measure above eyebrows
CHEST
30 - 36 cm
CIRCUMFERENCE 12 - 14 in
EVAPORATION:
CONVECTION:
CONDUCTION:
RADIATION:
Moisture from
skin & lungs
Body heat to
cooler air
Body heat to a
cooler surface
in direct contact
Body heat to a
cooler object nearby
• measure above nipple line
............................,......,
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l:tMhUI
BREASTS
Infection & inflammation of breast tissue
• May be sore aft er breastfeeding
• Breastfeed every 2 - 3 hours
(15 - 20 m inut es each breast)
• Posit ion newborn "tummy t o mummy"
• Lat ch should be completely around the areola
• Continue breastfeed ing
• Warm compress
• Hydration
• Rest
• Analgesics
• Wash handsl
(!) UTERUS
UTERINE ATONY
SYMPTOMS
RISK FACTORS
• Enlarged
• Soft
• Boggy
• Poorly contracted ut erus
• Not mid line
• Ret ained placenta
• Chorioamnion itis (infect ion)
INTERVENTIONS
• Uterine fatigue
• Fu ll bladder
• Fundal massage
• Assist to void or use in-and-out catheter
BOWELS
HEMORRHOIDS
Constipation is common after b irth .
Increasing FLUIDS & FIBER may help!
INTERVENTIONS
• May see b lood in the st ool
• Should begin to shrink
fol lowing birth
BLADDER
• Postpartum urinary retention is common
- In -and-out catheterizat ion may be needed
- Bladder dist ention can cause a d isplaced & boggy uterus!
LOCHIA
11
Rea 11 y Sore After"
■ ;uj:jJj ~~i~h~;~d
Tucks / witch hazel
Icepack
Squeeze bottle
Sitz Bath
SIGNS OF INFECTION
~
-----------
•
•
•
•
•
•
•
•
. .&. . .
Foul smel ling or purulent lochia
Fever (> 100.4 F )
Abdominal tenderness
Tachycardia
....................................................................................
f}jn}tj ~i~~~~~~own
whitish-yellow
10 - 14 days
*Can last up to 6 weeks
4} ~p~,?.~~~=,~~o~~~~s~~mmon
0
for women following ch ildbirth _ _.,..,. • Crying
• As the nurse ask about feel ings of.. .
depression • hopelessness • self-harm • harm to the newborn
• Irritable
• Sleep disturbances
• Anxiety
SECTION Cc-section incisions)/ Episiotomy
. Feel ings of guilt
• Promote proper wound hea ling
• Report to the health care provider: pain • inflammation • surrounding skin is warm to touch
74
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POSTPARTUM HEMORRHAGE
............................................................................................................................................................................
VAGINAL BIRTH: loss of >500 ml of blood
POSTPARTUM
HEMORRHAGE
is defined as:
CESAREAN BIRTH: loss of> 1,000 ml of b lood
A CHANGE IN HEMATOCRIT BY 1O0/o
..............................................................................................................................................................................
PATHOLOGY
The uterus is like a
BASKET WEAVE
OF MUSCLE FIBERS
. The uterus
1s ofte
n called th
LIVING LIGATUR/
I SIGNS & SYMPTOMS I
that crimps off vessels
protecting mom
from hemorrhage.
I
RISK FACTORS
• Hypoton ia of the uterus
• Multiple gestations
• Atony / boggy uterus
• Polyhydramn ios
• Deviated to the right
• Macrosomic fetus(> 8 lbs)
• Uncontrolled bleeding
• Multifet al gestation
#1 c.iuse of
uterine .itony is
If the uterus is not doing this
crimping off, it causes bleeding!
A FULL
BLAOOER
i
~-----------d
DRUGS
This is .i w.iy to remember
11
OH _MY HEMORRHAG E"
OXYT0CIN
11
Pitocin
11
ACTION
Stimulates contract ion
of the uterine
smooth muscle
METHERGINE
11
Methylergonovine
the order in which
the dru9s .ire used
HE ABATE
M'S0PR0ST0L
ACTION
Hemabate is a
prostagland in!
Hemabate helps control
blood pressure and
muscle contractions
(ut erine contractions).
given rectally
11
ACTION
Vasoconstrict ion
CONTRAINDICATIONS
Contraindicated in
people with hypertension
* Remember vasoconstriction
causes blood pressure to rise
ACTION
Stimulates contraction
of the uterine
smooth muscle
CONTRAINDICATIONS
Contraindicated in
people with asthma
·...................................................................................................................................................................................................................................................................·
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75
NOTES
Today I will
NoT STReSS oveR
what I can't
CONTROL.
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77
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PEDIATRIC MI LESTON ES
GROSS MOTOR
FINE MOTOR
• Head lag
• Rou nd ed back whi le s itt ing
• Lifts and turns head t o t he sid e in prone position
LANGUAGE
• Fists most ly clenched
• Involuntary hand
move ments
• Raises head & chest
• Head control improving
• Makes ve rbal noise (coos)
• Raises head 4 5 d eg rees in prone
• Tiny head lag in pul l-t o-sit
• Lifts head & looks around
• Ro lls fro m prone t o sup ine
• Head leads body w hen pulle d to sit
• Holds hand in front o f
face with hands ope n
•
.
.
~ Iii on the floor
rhyme, with foor!
• Bats at o bjects
• Babbl ing (copies no ises)
• Grasps ratt le
• Ro lls fro m supi ne t o prone & b ack aga in
• Sits with back upright whe n supporte d
You 9ra>p ,omethin9
with 5 fin9er>
• Trip od sit
• Releases objects in hand
to take anothe r
• Sits al o ne w it h some use o f hands for support
• Transfers objects fro m
o ne hand t o the o the r
• Sits uns upported
• Gross pincer grasp (rakes)
• Crawls w it h abdome n o ff t he floor
• Bangs o bjects t o gethe r
• Pul l t o stand
• Able to cru ise on object s (furn iture )
• Fine p ince r grasp
• Puts objects into
containers & takes t hem o ut
• Babbles (nonsp ecific)
• Offers objects to o thers
& releases t he m
• Walks independently
• Sits d own from standing p osit ion w it hout assistance
RECEPTIVE LANGUAGE
• Understan ds common words independent of
context
• Follows a one-step gestured com mand
76
• Feeds self fi nger-foods
• Draws simple marks o n
pap e r
• Turns pages in a book
EXPRESSIVE LANGUAGE
• First word (example: "mama")
• Uses a finger to point to things
• Imitate s: gestures & vocal
&
• RECEPTIVE LAN6UA6E
• E PP.ESSIVE UN6UA6E
• SIGNS OF DELAY
)
SIGNS OF DELAY
&
• After independent walking for several months
- Pe rsistent tiptoe walking
- Fai lure to develop a mature walking pattern
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PEDIATRIC MI LESTON ES
,,,,,,
"'
e
• Walks independently
0
z:
A
"'
0
"'
"'
\l)
• Feeds self finger foods
"'
...0
• Uses index finger to
point
z:
z
• Full pincer grasp
developed
• Climbs stairs
• Kicks a ba ll
• Pulls toys
• Able to stand
on tiptoes
.
Think Terrible Two',!
• Climbs on
& off furn iture
• Uses their hands a lot for:
reaching, grabbing,
releasing, stacking blocks
•
.
• Builds tower of 6-7 cubes
• Right/ left-handed
• Turns book pages
• Scribbles, paints,
& imitates strokes
• Removes shoes and socks
• Turns doorknobs
• Stacks four cubes
• Puts round pegs into holes
• Understands
100-150 words
• Understands "no"
• Points to named body
parts/ pictures in books
~
• Follows commands
without gestures
• Says: "what's this?"
:;
V
• Looks at adults when
0
...
;.::
"'
~
\l)
~
j::
~
• Understands 200 words
• Says: "my" & "mine"
communicating
... • Repeats words
I • Babbles sentences
\D
z
~
• Vocab: 15-20 words
• Vocab: 40-50 words
• Uses names of fam iliar
objects
• Sentences of 2-3 words
(ex. "want cookie" )
-sa
<E:] • Persistent tiptoe walking
...
0
0
"'
3
;;;
• Vocab:150-300 words
• Use descriptive words:
hungry, hot, cold
~
~
• Listens to simple stories
• Follows a series of
2 independent
commands
• Does not develop a
mature walking pattern
• Not walking
• Not speaking 15 words
• Does not understand the
function of common
household items
• Does not: use two-word
sentences, imitate
actions, or follow basic
instructions
• Cannot push a toy with
wheels
79
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PEDIATRIC MI LESTON ES
e"'
0
:::t:
"'
0
"'
"'
• Climbs we ll and runs easily
• Ped als t ricycle
• Wal ks up & down stairs with
alt ernat ing feet
• Bends ove r without fa ll ing
•
•
•
•
•
Throws ball overhead
Kicks b al l forward
Can bounce a b all b ack
Hops on one fo ot
Alternating feet going up & d own step s
•
•
•
•
•
•
• Uses scissors
• Co p ies capital letter
• Draws c ircles, squ ares, & traces
a c ro ss or diam ond
• Draws a person w ith 2-4 body parts
• La ces shoes
•
•
•
•
• Underst ands most sentences
• Speaks in com plete sentences
• Underst ands p hys ical re lat ion
(in, on, unde r)
• Tel ls a story
• Most of t he child's speech can be
unde rsto od
• Follows a 3-p art command
• 75% o f speech unde rstood by
outs ide observe rs
• Participates in long & detailed
conve rsat ions
• St ays on topic in conversation
• Tal ks about past, future, and
im aginary eve nts
I.!>
e"'
0
:::t:
w
z
ii:
Undresses self
Copies circles
Towe r of 9-10
Hold s a pencil
Screws a nd unscrews lid s
Turns b ook pag es one at a t ime
• Half o f the conve rsation
unde rsto od by outsid e fam ily
• Says: "why?"
• May b e able t o:
• Skip
• Sw im
• Skate
• Clim b
• Sw ing
Can draw a person and some letters
May dress/undress t he mselves
Can use a fork, spoon, & knife
Mostly cares for own toileting needs
• Explains how an item is used
• Knows the nam e of fam iliar an ima ls
• Answers questions t hat use "why"
and "whe n"
Z
0
• 3 or 4-word sentences
5 • Talks about past
• Knows at least one color
~
• Vo cab: 1,000 words
• Can cou nt to 10
i
• Says the ir name , age, & gender
• Uses language t o engage in
make -b e lieve
~
• Uses p ronouns and p lura ls
• Can count a few nu mbers
• Recalls p art o f a story
• Vocab : 1,500 words
• Speech should be co mp le t ely
intel ligible , eve n if the child has
art iculation d ifficult ies
V
• Says name & address
• Speech is generally gram mat ica l correct
• Vo cab: 2,000 words
\
;w
...
C
0
z
"'
I.!>
;;;
•
•
•
•
•
•
•
•
•
•
Difficu lty with stairs
Falls a lo t whi le wa lking
Can't b uild a 4 + b lo ck t owe r
Ext reme d ifficulty sep arating
from pare nts
No make -b e lieve play
Can't copy a c ircle
No short paragraphs
Doesn't understand simp le
instruct ions
Unclear speech & drooli ng
Litt le int e rest in o the r kid s
•
•
•
•
Can't jum p in plac e or rid e a tricycle
Can't stack 4 blocks
Can't throw a b al l overhead
Does not grasp crayon with thu mb
and fingers
• Difficulty with scrib b ling
• Can't copy a ci rcle
• Doesn't say 3 + word sentences
• Can't use the words "me " & "you"
• Ignores o ther childre n or doesn't
show int e rest in inte ractive g ames
• St ill clings or cries if pare nts leave
•
•
•
•
f
I
I
Sad o ften
Little interest in p laying w ith othe r kids
Unable to sep arate fro m their p are nts
Is extreme ly aggressive, fearful ,
p assive, or t imid .
• Easy d istracted (can't concentrate fo r
5 m inutes)
• Can not d o AOL's by t hemselves
(b rush teeth, undress, wash & dry
hands, etc)
• Rare ly e ngages in fantasy play
60
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PEDIATRIC MI LESTON ES
...
l&I
C
z:
• Pubic hair spread
latera lly, begins to
curl, pigmentation
increases
• Pubic hair becomes
more coarse in texture
& takes on adult
distribution
• Growth &
enlargement of testes
& lengthening of the
pen is
• Testes, scrotum, &
penis continue to grow
• Lengthy look due to
extremities growing
faster than the trunk
• Glands penis develops
• The skin around the
scrotum darkens
• Mature pubic hair
distribution & coarseness
• Breast enlargement
disappears
• Adult size & shape
of testes, scrotum,
and penis
• Scrotum skin darken ing
• May experience
breast enlargement
• Voice changes
w
I
l&I
~
• First menstrua l
period (average age
is 12 years)
• Pubic hair becomes
coarse in texture
• Breasts bud and
areola continue to
enlarge (no separation
of the breasts)
• Areola & papilla
separate from the
contour of the breasts to
form a secondary mound
• Amount of hair increases
• Mature pubic ha ir
distribution and
coarseness
• Pubic hair begins to curl
& spread over the mons
pubis
61
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PEDIATRIC CPR (<ll MONTHS)
C:ardi:ac :arrest in inf:ants usu:ally
stems from RESPIRATORY ETIOLOGY
ORDER OF EVENTS
O
PULSE
Check pulse no longer
than 10 seconds
PEDIATRIC VITAL SIGNS
Ell RESPIRATIONS
e
SYSTOLIC BP
NEWBORN
30- 50
120 -160
60-80
6 MO -1 YR
30- 40
120 -140
70-80
2-4 YR
20- 30
100 -110
80- 95
5-8 YR
14- 20
90 -100
90 -100
8-12 YR
12- 20
80 -100
100 -110
60-90
100 -120
. s.
>12 YR
INFANT: Check BRACHIAL p ulse
"' ,
PULSE
Check CAROTID pulse
12-20
.
..
:................
.
'
~
.. .
................
. ..................
CALL FOR HELP
Active the emergency response system / shout for nearby HELP
Delegate someone else to call 911 / get the A ED
0
CHEST COMPRESSIONS
: ···SINGLE RESCUER·································
2 minutes of CPR before retrieving the A ED
j 30:2 compression-to-breath
Rat e of 100 - 120 compression/ min
ratio
Using either 2 f ingers or 2 t humbs on t he st ernum
: ···TWO RESCUERS···································
Dept h: INFANT: Equal to one-th ird of chest's
anterior-posterior d iameter
j 15:2 compression-to-breath
ratio
CHILD: 2 inches
Allow for recoil between compress ions
.•.•.....•••.•........•••........•
2-FINGER
'
0
COMPRESSION
TECHNIQUE
.....••.......••.•••.........•...
.
2-THUMB
ENCIRCLING HAND
TECHNIQUE
CONTINUE UNTIL SIGNS OF HELP ARRIVE OR AED BECOMES AVAILABLE
61
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· ~ Sayin9 Pia9et's Co9nitive Sta9es is Fun
0 - 2 YEARS
♦ Deve lopment t hrough our 5 senses ~ ()(\ @('fl\
♦ Deve lopment t hrough mot or response
♦ OBJECT PERMANENCE is developed \
♦ Egocent ric
• Can only see t he world
from one's own point of view
\.{1..J--~ ---~
.
~ {d
®
Realizing that objects that
are out of si9 ht stil I exist
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -:
PREOPERATIONAL STAGE
0
♦ Symbolic thinking
♦ Imagin ation -
:
2 - 7 YEARS
~
♦ Abstract th inking is still difficult
• M ag1caI th in king
:,
• ANIMISM - thinks objects are alive
• Plays pretend
♦ Asks a lot of questi ons (int uition)
:,
:
'
7 -11 YEARS
,-------------------------------------------------------- -----------------------------------------------~
I
♦ Deve lop concrete cogn itive operations
•
Sorting b locks in a certa in order
i1J
'
liji ~ '
fi
I
I
Q'
♦ CONSERVATION is developed - - - - - - - - - - - ~ CONSERVATION
♦ Conductive reasoning (Mathematical advancements)
understanding t hat
____ _____ ____________________________________________________________ someth ing stays t he same _j
in volume even though
its shape changes.
FORMAL OPERATIONAL STAGE
®
> 11 YEARS
;i:~~1:-1:~;~~I: -~~~~~;~~~:-~~~~-I:-~~~-~~~~i-:i~~~-;~;~~i~~---------------
r-.-----------:-: ::~-:~
r
'
♦ HYPOTHETICAL THINKING - Can t hink outsi de t he present
♦ Abstract concepts
• Love, hate, fai lures, successes
♦ De ductive reason ing
63
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VARIATIONS IN PEDIATRIC ANATOMY & PHYSIOLOGY
NORMAL
RESPIRATORY
• Narrow airways
• Newborns have+ alveoli than an adult
•
•
•
•
~o
~~T
1.~
• Thousands of alveoli grow each day 00
~□
for the first few months of life!
~
Floppy airways from less cartilage
Obligatory nose breathers
t metabol ic rate
t 02 requ irements
EDEMA
0
©
0
HEAD SIZE
• Head is the fastest growing part of
an infant (large in proportion to the body!)
• Head & neck muscles are not well
developed
BRAIN & SPINAL CORD
• Cranial bones not completely fused
• The brain is high ly vascular
= t risk for hemorrhage
• Sutures & fontanels makes the skul l
flexible and al lows for growth
of the brain
• The spine is very mobile
= t risk for cervical spin injury
EARS
t RISK FOR EAR INFECTION
• Eustach ian t ubes are
short, wide, & flat
= making dra inage difficult
= harbors m icroorgan isms
IMMUNE SYSTEM
t RISK FOR INFECTION
• Immature immune systems
• + inflammatory response
• Limited exposure to d isease
(losing immun ity from maternal
ant ibodies)
CARDIOVASCULAR
• The transit ion from fetal
circulation ➔ normal circulation
at birth
• Infants hearts are th inner
and less compliant
NERVOUS SYSTEM
• Myelinization is incomplete
at birth
• Myelinization happens in
CEPHALOCAUDAL DIRECTION )
(head to tail)
• Epidermis is thinner
• Blood vessels are closer to the
surface - loses heat very easily!
/.,
CEPHALOCAUDAL
DIRECTION
(HEAD TO TAIL)
HEAD CONTROL
BEFORE WALKING!
PROXIMODISTAL
KIDNEYS
• Kidneys are larger in relat ion to abdomen = less protection
(INWARD OUTWARD)
• G FR is slower
• + abilit y to concentrate urine & reabsorb = t risk for dehydrat ion
64
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Sudden death of a previously healthy infant youn9er than 1 year of aqe
RISK FACTO S
AGE: 1 - 6 months (t risk)
Socioeconomic status
THERE ARE
Preterm
Lack of prenatal care
Sleep posit ion
Genetic
NO
Sibling death
Bedding (can be smothe red)
Nicot ine exposure
Room temp (cooler is better)
SIGNS OR SYMPTOMS!
Sudden death
Leading ca use of
death in infants
EDUCATION / PREVENTION
Sleep in SUPINE POSITION
Bedding
Firm mattress
No toys, b lankets, pillows, or stuffed animals
Avoid over b undling or overdressing the infant
Avoid smoking
0
No co-bedding
(Infant should sleep separate from the parents)
0
Normal room temp
Encourage pacifier use
'I
I I
,,
•Q
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ABCs OF
SAFE SLEEPING
Alone
Q
On their Back
0
In a Crib
65
NEURAL TUBE DEFECTS
. . - - - SPINA BIFIDA - - - . .
NORMAL SPINE
is a general term for a birth defect
typically diagnosed during pregnancy
where the spinal column fails to close.
The neural tube closes:
3rd - 4th week of gestation
Spina bifida means "SPLIT SPINE"
CAUSES
NOT KNOWN ...
BUT MANY FACTORS HINDER NORMAL CNS DEVELOPMENT
• Drugs
• Malnutrition
• Chemicals
• Genetics
e
SPINA BIFIDA OCCULTA
Defect of the vertebral
body WITHOUT
protrusion of the
spinal cord or meninges.
• Folic acid deficiency (Vitam in 89)
• Dia betes
• Obesity
Typically asymptomatic
Does not need immediate
medica l care if asymptomatic.
May have d impling,
abnorma l patches of
hair, or discoloration near
the spine.
If symptoms are present,
the client may get an MRI.
MENINGOCELE
Meninges herniate
through a defect
in the vertebrae.
Sac protruding
from the spinal area.
Most are covered
w ith skin.
Usually minor or
no neurolog ical deficits.
MYELOMENINGOCELE
Protrusion of
the meninges,
cerebrospinal fluid,
and spine.
Skin may be
exposed as well.
Surg ical correction
of the lesion
e
The spinal cord often
ends at the point
of the defect.
-
Absent motor
& sensory function
beyond t hat point.
•
•
•
•
•
•
•
•
Multiple surg ical procedures
Paralysis
Bladder/ bowel incontinence
Neurogenic bladder
Meningit is (infection)
Hypoxia
Hemorrhage
Freq. catheterization causes ...
• Latex allergy
• UTls / pyelonephritis
• Renal damage
66
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BRONCHIOLITIS (RSV>
small airways in the lungs
4 BRONCHIOLITIS ;)
inflammation
INITIAL
Upper respiratory symptoms
• Nasal congest ion
• Runny nose
• Cough
• Sneezi ng
Fever
V ira l illness usually caused by
Respiratory syncytial virus (RSV)
Very cont agious
Sta rts as an upper respirato ry infection
& moves into t he ch est
CONTINUED
GENT
Lower respiratory t ract symptoms
• Tachypnea
• Cough
• Wh eezing
Grunting
Nasal fl aring
Cyanosis
Hypoxia
Respiratory failure
A pneic episodes
.
.
...
.....
Self-limited illness & supportive care
.. ..
.
• Oxygen
..
.
.
• Suctioning
..
Saline nose drops & then suction the nares with a bulb syringe ...
..
to remove the secretions b e fore feeding or at bed time
.
.
.
.
.
• Position the child at a 30 - 40 degree angle
.
.
.
.
.
..
Hyd ration
.
.
.
.
Increase flu id intake (oral or IV) (risk for dehydrat ion)
.. ...
Airway maintenance
Hospitalization
Only necessary if th e ch ild has severe symptoms
~-·
--------
HOST
CHILDREN
CAN BE
MANAGED
ATHOHE
Use contact & standard precautions during care
67
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RARE DISEASE AFFECTING YOUNG CHILDREN
RECOVERING FROM A VIRAL ILLNESS
(FLU OR CHICKEN POX)
EXACT CAUSE UNKNOWN
Triggered due to the intake of sa licyl ates
or sa licyl ate-conta ining p roducts
such as aspirin to treat a viral illness
(Flu / Chickenpox)
- - - • • ENCEPHALOPATHY/ CEREBRAL EDEMA
' \ I I..,
.((
t
,,
CI) Confusion (changes in mental status)
® Hyperreflexia
1'
1'
1'
(D Irritability
(D Lethargy
@ Diarrhea & vomiting
(D Seizures
/ER. ENZYMES
T
T
Early recognition & treatment
Educate on products
that contain SALICYLATES:
Education on prevention!
Monitor fluid status
ASPIRIN
Swelling of the brain occurs
• Ma inta ini ng cerebra l perfusion
• Manag ing & prevent ing increased ICP
• Seizure precaut ions
ALKA-SELTZER
PEPTO-BISMOL
KAOPECTATE
66
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INTUSSUSCEPTION
ILEUM TELESCOPES INTO THE CECUM
"'w
OBSTRUCTION
~
0
= PAIN
u
"'w
..J
...
w
COMPRESSION OF BLOOD VESSELS
BLOOD FLOW DECREASES
BOWEL ISCHEMIA
RECTAL BLEEDING (CURRANT JELLY STOOLS!)
Intermittent pain / cramping ~
t
Child draws up their legs toward
the abdomen in severe pain
.
.
THIS IS
w hI 1e crying
BECAusE
Vomiting & diarrhea
~!~~~:;_z::s
Currant-jelly stools (bloody)
Lethargy
Sausage-shaped mass
in the upper mid-abdomen
May spontaneously be reduced
(Passage of normal , brown stoo ls)
IV fluids
Antibiotics
Decompression via NG tube
Provide comfort & emotional
support to the parents
♦
NOT COMPLETELY KNOWN
May be due to a virus that
causes swelling
Condition child is born with
• Diverticul um
• Po lyps
DIAGNOSTIC / TREATMENT
AIR. or BAR.IUM ENEMA
works to d iagnose
& also hel ps reduce
th e intussusceptio n
Monitor for signs of perforation & shock
May need air or barium enema
•
Provide education to child & fam ily about pre-op & post-op
69
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HYPERTROPHIC PYLORIC STENOSIS
A HYPERTROPHIED PYLORIC MUSCLE
CAUSES NARROWING OF THE PYLORIC CANAL
THICKNESS CREATES
A NARROW STOMACH OUTLET
HYPERTROPHIC
PYLORIC
+
+
!NCR.EASE IN SIZE
PYLOR.US
HYPERTROPHIED
PYLORUS MUSCLE
NORMAL
STENOSIS
+
NAR.R.OWING
Opening from the stomach
into the small intestines
STOHACH
CONTAINS ACID
WHICH 8ECOHES
DEPLETED WHEN
VOHITING WHICH
Projectile vomiting
Non-bilious emesis
&
Olive-shape mass palpable in the right upper quadrant
Infants will be hungry constantly despite regular feedings
METABOLIC
ALKALOSIS
Weight loss
DEHYDRATION!
~
t H emato cr it from hemoco nce nt ration
t BUN
Monitor ...
•
•
•
l&O's
Vomiting episodes & stools
Signs of dehydration & electrolyte imbalances
Obtain daily weights
Provide comfort & emotional support
to the parents
PYLOROMYOTOMY
Cut t he muscle of
t he pylorus
...
Re lieving t he gastric
o utlet o bstructio n
Educate about surgery
90
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EPIGLOTTITIS
I
WHAT IS THE EPIGLOTTIS?
inflammation
of the
EPIGLOTTIS
leading to an
UPPER AIRWAY
OBSTRUCTION
~
Piece of cartilag e
at the back of the tong u e
FUNCTION:
Closes the entry to the trachea
during swallowing ....
AKA prevents aspiration
Most common cause: HAEMOPHILUS INFLUENZA TYPE B
PEos incid
~ailing due~~
H,b vaccinat·•on
Streptococcus pneumonia
Tachycardia
Drooling / dysphagia
Sore throat
Tripod position
High fever
Anxious / apprehensive / agitation
Sitting forward with the neck
extended to breath - mouth open
Difficulty speaking
Retractions (chest)
Nasal flaring
Nasal flaring
Strider
(Frog-like croa k on inspiration)
Absent cough!
Never leave the client
Asses oxygen status
IV access
Do not visualize the throat with a tongue blade.
Take oral temperature or take throat culture ...
WHY? It can cause REFLEX LARYNGOSPASMS
(cutting off the airway)
May need emergency intubation
Calm environment
• Stay with parents
• Don't restrain the chi ld
• Help to avoid crying
• Most comfo rtable position
(usually tripod position)
Do not place them in supine position.
It becomes harder to breathe.
NPO
Medications
• Antibiotics
• Antipyretics
• Corticosteroids
(decrease inflamma tion)
• IV Fluids
91
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LARYNGOTRACHEOBRONCHITIS "CROUP"
Inflammation of the
LARYNX, TRACHEA, & BRONCHI
LARYNGO TRACHEO BRONCHI
occur as a result of viral infection
+
LAR.YNX
Most commonly caused by
the PARAINFLUENZA VIRUS
Inflammation & edema obstructs the airway
~
.:;__ C)
a
•
CROUP
+
BRONCHI
G,
0 NS ET Sudden (at night)
\_\\ I
"""'
+
TRACHEA
Symptoms occur at night
Stridor
Subglottic swelling
(causes hoa rseness in the voice)
Seal-bark cough ~\\/
...
ITIS
+
INFLAMMATION
EPIGLOTTITIS
Rapid (within hours)
FEVER.
Fluctuating
High
COUGH
Yes
No
DYSP11AGIA
No
Yes
Viral
Bacterial
Not typically
Yes
CAUSE
EMER.GENCY
HOME CARE
SEEK HELP
Self-limiting
(Usually resolves on its own)
When the child is indicating
respiratory distress
• Corticosteroids (-1, inflammation)
• Child is confused/restless
• Racemic epinephrine
• Blue lips/nails
• Humidified air
(steamy bathroom or mist humidifier)
• t respiration rate
• Encourage rest & fluid intake
• Retractions
• Calm environment for the child
• Nasal flaring
(b reathing faster, but less air is going in)
• Drooling/can't swallow
92
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FEVER MANAGEMENT
NORMAL TEMP
FEVER
97.5°F to 98.6°F
36.4°C to 37.0°C
> 100.4°F C3a.o 0 c>
SIGNS & SYMPTOMS
Flushed skin
l
Diaphoresis (sweating)
Chills
Restlessness
Administer antipyretics (ibuprofen)
Do not adm inister aspirin
(risk for Reye's Syndrome)
Monitor for S&S of dehydration
& electrolyte imbalances
Provide adequat e fluids!
Sponge bath
Tepid wat er for 20-30 min.
Squeeze over back & body
Remove excess clothing
& coverings to ,1, the temp
Lethargy
Cool compress on the forehead
FEBRILE SEIZURE
t.JJ',:i@i,):ij~-----~
Rapid t in core temperature
Seizures associated with a FEVER
Not related to:
• int racranial infection
• metabolic imbalance
• viral il lness
RISK FACTORS
Usually
DOES Nor
have long t erm
complicat·tons
such as e p,·1epsy
or i~tellectua/
disability
Child may be drowsy during postictal
period
• 6 months - 5 years
NOT anticonvulsants therapy
• Rapidly developed fever
Rectal Diazepam
• HIGH fever
Educate the parents to seek help if...
• Family history of febrile seizures
•Last> 5 min
• Certain vaccines
•
Repeated seizures
• DTP & MMR
93
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CYSTIC FIBROSIS (Cf)
CF IS AN
Multisystem disorder of the EXOCRINE GLANDS
w ith increased production of th ick mucu s
~~
GENETIC DISORDER
Gene mutation (CFTR): prevents exocrine g lands
from properly function ing
EXOCRINE GLANDS: Produce & transfer secretions
(mucus, tears, sweat, & enzymes) via ducts
t viscosity of mucus
=t
resistance to ciliary action
= slowing the flow rate of mucus, lead ing to
mucus plugging
Dad is a
carrier of
CF gene
ft
¼
Mom isa
carrier of
CF gene
2 mutated CF genes = CYSTIC FIBROSIS
♦
Ambry test
♦ Positive sweat sod ium ch loride test
-
♦
Genetic screen
Treatment of the mucus
• Chest physiotherapy (PT)
• Postural drainage
• Huff coughing
• Nebulizers
Bronchodi lators, mucolytics,
anti -inflammatories
Treat & prevent infection
Drains airways of thick mucus to be coughed up
• Stimulates cough
• Hel ps loosen mucus
• Results in deep breathing
• Builds up strength and endurance
of respiratory muscles
~
• Improves card iovascu lar fi tness - . . . , . Done multiple times a day between
1-2 hour increments
• NOT done right before or after mea ls!
Ca uses vibrations & percussions to break apart
the mucus (vests, manual vibration}
Prevent GI blockage
• Fluids & stool softeners
t protein, t fat, t ca lorie
• Fat soluble vitamin supplementation A, K, E, D
All Kids Eat Donuts
Possible supplemental oral feedi ng or entera l feeding
Pancreatic enzymes:
• Pancrelipase or Pa ncreati n
• Can swa llow a capsules or spri nkle enzymes
on foods that are acidic such as apple sauce!
94
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MANIFESTATIONS OF CF
NOSE & SINUSES
RESPIRATORY
• INFECTION: Thick mucus creates
a great environment for bacteria l growth
• Pseudomonas
• Staph. aureus
• Pneumonia
• Bronch itis
• Thick mucus = blocked airways
• Obstructive pulmonary d isease
(Emphysema)
• Clubbing
• Barrel-shape chest
• Pneumothorax
• Strain on lungs = pulmonary hypertension
• Sinusitis
• Nasal polyps (snoring, stuffiness)
PANCREAS
PANCREAS SECRETES THICK MUCUS
• Deficient in pancreatic enzymes:
(Protease, Amylase, Lipase)
• Weight loss
• Inadequate protein absorption
• Deficiency of protein
• Failure to thrive
• Insul in deficiency
• Hyperglycem ia
• CF-related diabetes
CARDIOVASCULAR
LIVER
• Pulmonary hypertension
puts strain on the heart
• Right-sided heart failure
• Bile duct blocked from
THICK mucus
• Gallstones
• Bil iary cirrhosis
.., I!
C
• Sweat g lands produce
t chloride = salty skin
• Salty sweat & salty tears
wh ich leads to
• Dehydration
• Electrolyte imbalance
REPRODUCTIVE
BOYS
• Th ick mucus blocks the
vas deferens = Infertil ity
Gl~LS
• Th ick cervical mucus b locks sperm
from penetrating = Infertility
STOMACH & INTESTINES
• Fecal impaction
• Rectal prolapse
• Bowel obstruction
• lntussusception
• Back up of stool in intestine
• Constipation
• Vomit ing
• Abdomina l d istention
• Cramping
• Anorexia
• RLQ pain
• Meconium ileus in infants
• Steatorrhea
• Frothy (bulky}, fatty,
foul-smell ing stools
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FETAL CIRCULATION IN UTERO
FORAMEN OVALE
Blood is SHUNTED from the right atrium
to the left atrium by the FORAMEN OVALE
~
How can blood be shunted from
the right atrium to the left atrium?
PRESSURE
DIFFERENCE!
Blood bypasses the lungs ... why?
Blood flows from
to
It's already oxygenated blood from the placenta (mom)
SUPERIOR
VENA CAVA
RIGHT ATRIUM
low resistance.
Lungs: High resistance from all
the flu id. So the blood does not
wa nt to go in the lungs!
DUCTUS
AORTA
ARTERIOSUS
FORAHEN
OVALE
Blood goes from the
interior vena cava to t he
right atrium as well as some
deoxygenated b lood comi ng from
the SUPERIOR VENA CAVA.
DUCTUS ARTERIOSUS
Blood is SHUNTED from
the pu lmonary artery
into the aorta by
the ductus arteriosus
So t he blood is now MIXED
(oxygen-rich & oxygen-poor b lood)
liver not fully
functionin9 yet
DUCTUS VENOSUS
AORTA
LIVER
Umbilical vei n is carrying
oxygenated blood from the
p lacenta. It passes t he LIVER
(Some blood wi ll go to the liver)
VENOSUS
but most wil l be SHUNTED
to the INFERIOR VENA CAVA by
the DUCTUS VENOSUS
FROM PLACENTA ➔ .,..-......-
ou,i
THE PLACENTA IS THE ''LIFELINE"
BETWEEN MOTHER & BABY
The Placenta is like
"TEMPORARY LUNGS"
for the fetus whi le in utero
Mixed blood is now in the
aorta and being pushed out
to oxygenate the fetus
DESCENDING
AORTA
~
HBILICAL
ARTERIES
TO PLACENTA .._
•
high resistance
,.. ,_
~@ Athink AWAY
BLOOD GOES
BACK TO THE
PLACENTA TO GET
OXYGENATED
AGAIN!
!.~~:~
2 UMBILICAL \
,deoxygenated b lood + waste
ARTERIES
AWAY from the baby back to the placenta
1 UMBILICAL
Gives oxygen rich blood TO the baby
VEIN
I
♦
SHUNTS TO KNOW
I
DUCTUS VENOSUS
♦ FORAMEN OVALE
♦ DUCTUS ARTERIOSUS
96
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DEVELOPMENT DYSPLASIA OF THE HIPS CDDH>
Abnormal development of the hip joint
A baby's bones are not ossified yet
so they have the ability to dislocate
& relocate easily
...-----...__
DISLOCATION No contact between
femoral head & acetabu lum
SUBLUXATION Partia l d islocation
(acetabulum is not completely
in contact with the hip joint)
DYSPLASIA Hip joint doesn 't have the proper
' - - - - -~( "
shape to fit together correctly
~
Ultrasound for in utero
X-ray for th ose older than 6 months
Barlow test & Ortolani
~
Listen for any noises during the exam .
There sh ould be no "cl unks" hea rd or felt .
.______...,,_\
If "clun ks " are felt or hea rd
= a positive sign for DOH
BARLOW
TEST
Avascular necrosis of the femoral head
,1,
ROM
Leg-length discrepan cy
Early osteoarthrit is
• FEMALE ➔ more lax ligaments
from maternal hormones
• Breech positioning
• O ligohydramnios
• Femoral nerve palsy
Early detection & treatment are crucial. The bones are not ossified
in ea rly infa ncy, so you want to man ipulate them to grow p ro perly. If
DDH is not treated early the bones will ossify and develop inco rrectly.
> 6 MONTHS
Pavlik harness:
INSTRUCTIONS
FOR
PAVLIK HARNESS
Sta b ilizes the hip by p rev enting h ip extension
4 MONTHS - 2 YEARS
Closed reduction :
• Requi res g enera l anesthesia w here the h i p s w ill b e
placed b ack int o the acetab u lum by th e su rgeon
• Spica cast is w o rn after surgery to m ai nta in reduction
• After spica cast th e chi ld w ill w ea r a b race u nti l
aceta bu lum is fu lly norma l
Must wear the ha rness at all times!
Do not adjust the straps or remove
harness until instructed by the HCP
Change the diaper while the baby
is in the harness
Check for redness, irritation or
breakdown 2-3 ti mes per day
> 2 YEARS OR NO IMPROVEMENTS
Place baby on their back to sleep
WITH SURGERY OR HARNESS
Place long knee socks and undershirt
to prevent rubbing of the harness
O pen surgical reduction fol low ed by castin g
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SCARLET FEVER
. . . - - - - - - - - - - - - - - - - - - - - - - S C A R L E T FEVER----.
Complication of group A streptococcal infection AKA Strep throat
NK
STREP!
Not all children who have strep will develop scarlet fever
TRANSMISSION: Droplets & resp iratory t ract secretions.
Transmission happens in close contact such as schools & daycares.
~
Onset ABRUPT!
Strawberry tongue
RED RASH!
• Sandpaper-like rash
Tender cervical nodes
Pharyngitis
Exudate may be present
Fever, body aches,
chills
'\
Tonsils are red
Beg ins on
t he NECK & CHEST
and spreads outwards
'\II,,
t o THE EXTREMITIES!
S's of SCARLET FEVER
Rash is usual ly not
seen o n t he p alm s
& so les of t he feet
♦ Strawberry ton9ue
♦ Sandpaper rash
······ ... • •· ·
Rheumatic fever
Early dia9nosis
~ treatment are very
important to prevent
complications!
Glomeru lonephritis
Abscesses of the throat
Pneumonia
Most children can be cared for at home
Antibiotics (Penicillin V)
• Erythromycin for those allergic to Penicillin
Take antibiotics as directed ....
Finish the medication even if the
child appears to be better!
Fluids & soft foods ~
Provide comfort
Cool mist humidifier
•'l
I .
n:.
· '"
SOUPS, TEAS, POPSICLES, SLUSHIES
_,
'
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99
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FUNCTIONS
0
0
ANATOMY OF THE KIDNEY
CID-BASE BALANCE
ATER BALANCE
MINOR CALYX
( ) LECTROLYTE BALANCE
0
0
,,
ii!,:
OXIN REMOVAL
RENAL VEIN
RENAL
HILUM
LOOD PRESSURE CONTROL
I
0
RENAL PELVIS
_;
ENAL ARTERY
RENAL MEDULLA
METABOLISM
~:I
/I
RENAL NERVE _,,../
[
( ) RYTHROPOIETIN
VITAMIN
MAJOR CALYX
URETER ,
(
~
.,
·
PYRAMID
PAPILLA
, _ _- : : , - - - RENAL COLUMN
I
~
RENAL CORTEX
CAPSULE
TERMS TO KNOW
DYSURIA ................................ Pain while urinating
NOCTURIA ............................. Excessive urinat ion at night
HEMATURIA ........................... Bloody urine
FREQUENCY ......................... .Voiding more t han every 3 hours
URGENCY .............................. St rong desire t o void
INCONTINENCE ..... .......... ...... lnvoluntary void ing
ENURESIS .............. .......... ...... lnvoluntary void ing during sleep
PROTEINURIA .... .............. .... .. Abnormal amounts of protein in the urine
OUGURIA .......... .............. ...... Urine output: <400 mUday
ANURIA .............. ............. ...... Urine output: <50 mUday
MICTURITION .... .............. ..... .Voiding
URINE FORMATION
1) _
_____,.
~
~
~
~
~
Blood flows into the kidneys:
120 ml/min
Filters water, electrolytes, & small
molecules into the glomerulus
(Large molecules stay
in the b loodstream)
Fluid moves from renal
tubules into the capillaries.
They reabsorb fluid into the
venous circulation.
!)
!)
~
~
~
ffiJlID
Fluid moves from
the capillaries into
the renal tubules to get
eliminated/excreted.
LAB VALUES RELATED TO THE KIDNEYS
Adul ts should void
1-2 Uday
No less than 30mUhr
You will see INCREASED BUtl
& Creatinine le•els durin9 kidney injury/failure
~
GFR
Glomerular Filtration Rate: rate of blood flow through the kidneys.
BUN
Blood Urea Nitrogen: Normal waste product resulting from the breakdown
of proteins. t Levels can indicate a kidney problem & be toxic in the body.
CREATININE
End product of muscle metabolism solely f iltered from the b lood via g lomerulus
0.6 - 1.2 HG/DL
URINE SPECIFIC GRAVITY
Measures the kidney's ability to excrete or conserve water
1.010 - 1.030
CREATININE CLEARANCE
The amount of blood the kidneys makes per minute that is FREE of creatinine
90 -
7-20 HG/DL
85 - 125 ML/HIN
95 - 140 ML/HIN
FEHALES:
HALES:
100
120 ML/MIN
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PATHOLOGY
0 Untreated strep
6 Immune system response by
creating antigen-antibody complexes
(1 4 days after infection)
0
0
0
These antibodies get " lodged " in the glomeruli
Inflammation & scarring
J. GFR
It's not the strep that causes the inflammation of the kidneys.
It's the antigen-antibody complexes that form due to the
st rep that causes the inflammation & damage to the glomeruli
~•GNS & SYMPTOMS
♦l,.e
urine
-·te in the blood
_, urine (col~ color)
· 1es
f
MAIN CAUSE:
-lysin) Titer
· - r:ause! (strep)
..tions
,...:tion
triction
of carbohydrates
~
RECENT GROUP A BETA-HEMOLYTIC
STREPTOCOCCAL INFECTION
Monitor
• Daily intake & output
• Daily weight ~
~ Bed rest
~ Monitor blood pressure
• Antihypertensives
• Diuretics
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MED-SURG
RENAL/
URINARY
WHAT IS IT?
Sudden renal damage! Causes a build-up of waste, fluid, and electrolyte imbalance.
It can be reversib le. Formerly called Acute Renal Failure.
~~'-£NAL FAIL.(J~ ~
~
Dam.19e BEFORE
/ , ~,_.."ENAL FAJL.iJ.
~
Dama9e IN
~~
~
the kidneys
,&.
the kidneys
VOLUME/PERFUSION TO THE KIDNEYS
PROLONGED ISCHEMIA
~ Cardiac damage
~ Myoglobinuria
~ Hemoglobinuria
• + or impaired cardiac output
• Examples: Ml
~ Rhabdomyolysis
~ Nephrotoxic drugs
~ Vasodilation
• Examples: NSAIDs, antibiotics
(aminoglycosides), chemo drugs,
cont rast dyes
~ Infections
• Examples: Glomerulonephritis
~
Hemorrhage (hypovolemia)
~ Burns
~ GI losses (vomiting/diarrhea)
~t,'\"ENAL FAJL.IJ.
,o
~~
Dama9e AFTER
the kidneys
OBSTRUCTION/BLOCKAGE IN THE URINARY TRACT
~
Renal calculi (stones) ~ Blood dots
~ Benign prostatic hyperplasia (BPH) ~ Tumors ~ Neuro damage (stroke)
I
OH
ONSET / INITIATION
OH
OLIGURIC
DARN
DIURETIC
RENAL
RECOVERY
➔
➔
➔
Triggering event
(Prerenal, lntrarenal
or Postrenal Failure)
+ Urine output< 400 ml/24 hrs
Glomerulus decreases the
ability to filter blood(+ GFR)
INTERVENTIONS7
~ Correct & identify the underlying cause
to prevent long term damage to nephrons!
~ Low protein diet ~ Limit fluid intake
~ Strict 1&0 + daily weights
~
Monitor EKG & labs • Watch for HYPERkalemia > 5.0
• t BUN & Creatinine
~ Dialysis may be needed until kidney function returns
Cause of AKI is corrected
Gradual t in urinary output
~
t in kidney function
May take up to 6 - 12 months
~
Large amount of dilute urine with electrolytes
& hypokalemia
~ Monitor the patient for dehydration
Some patients may never recover and
may develop chronic kidney disease (CKD)
102
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MED-SURG
RENAL/
URINARY
PATHOLOGY INFLAMMATORY RESPONSE IN THE GLOMERULUS
+
DAMAGE TO MEMBRANE
+
LOSS OF PROTEIN (ALBUMIN)
Albumin regulates oncotic pressure
+
HYPOALBUMINEMIA
J
~
CAUSES
SYNTHESIS OF
CHOLESTEROL
& TRJGLYCERJDES
+
~
CAN LOSE
PROTEIN THAT
HELPS FIGHT
INFECTIONS
ALBUMINISA
PROTEIN WHICH
PREVENll CLOT
FORMATION
FLUID
SHIFT
~
HYPERUPIDEMIA
LOW ALBUMIN LEVELi \,
+
GENERALIZED EDEMA
CAUSES-----.
+
POSSIBLE BLOOD CLOTS
(THROMBOSIS)
Clmmuno9lobulins)
~
+
RJSIC FOR INFECTION
SIGNS & SYMPTOMS
Bacteria or viral infection
Hypoalbumenia
• Edema
• Fatigue & loss of appetite
• Hyperlipidemia
Cancer
Genetic predisposit ions
Systemic d isease (lupus or d iabetes)
Proteinuria (> 3 g/day)
• Large amounts of protein in the urine
NSAIDs
INTERVENTIONS
~
~ Monitor fluid status
• Daily weights & !&O's
• Swelling & abdom inal girth
~ Diet mod ifications
Medications
• Diuretics
• Statins (lipid-lowering drugs)
• Prednisone to .i inflammation
• Antineoplastic agent
• lmmunosuppressant
• .i Cholesterol & saturated fats
~ Monitor signs of...
• .i Na+ intake
• Moderate protein intake
• Infection
• Blood clots
103
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MED-SURG
RENAL/
URINARY
PATHO
.-----SIGNS & SYMPTOMS-----,
• Progressive & irreversible loss
of kidney function .
In the end stages of CKD,
ALMOST EVERY BODY SYSTEM is negativity affected
• Occurs over a long period of t ime.
• + Urinary output (UOP)
• O liguria = <400 ml/day
• Anu ria = <100 ml/day
.-----CAUSES----.
• Proteinuria & hemat uria
• Untreated acute kidney injury (AKI)
• Diabetes mell itus
• Lethargy
• Hypertension
• Altered LOC/confusion
• Family history
• Seizures
• Recurrent infections
• Hypertension
• Autoimmune disorders
• Fluid volume excess (Hypervolem ia)
• Heart fail ure
STAGS
• Anorexia
Stages are based on the GFR rate
• Nausea/vomiting
AS CICD WORSENS ... GFR DECREASES -l,
u
u
u
8
if
• Uremic fetor (ammonia breath)
• Metallic taste
GFR
> 90
• Impaired immune
& inflammatory response
60-89
• Anem ia(+ erythropoietin [EPO])
• t Risk for b leeding
45-59
30- 44
• Prolonged bleeding t ime
• Amenorrhea
• Erectile dysfunct ion
• + Libido
15- 29
<15
(END STAGE RENAL DISEASE)
--TREATMENT-~
• Dialysis
• Kidney transplant
• Uremic frost
• Pruritus
&
e
LABS
• t BUN
• t Creat in ine
• t K+
• t Magnesium
• -1,
Calcium
• t Phosphate
104
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MED-SURG
RENAL/
URINARY
HEMODIALYSIS
PERITONEAL DIALYSIS
MOST COMMON METHOD
INSIDE THE BODY
3X a week (3 - 5 hours per treatment)
)t
ARTIFICIAL
KIDNEY
1'
DIAlYSATE
SOLUTION
~
LOOD
BlOOD
TO
DIALYSER
~
\
I
I
r
~ DRAIN :
I
I
I
I
FISTULA
THE DIALYZER
kidney)
Warm the solution!
(Artificial
...
...
Filters out toxins/waste products
...
Brings b lood to the d ialyzer
Brings clean b lood back to the body
VASCULAR ACCESS
"-
~
GllAFT
FISTULA
Joining an artery to a vein
Inserting synthetic graft
material between
an artery and vein
Needs time to
heal and mature
...
Dialysate is infused into the
peritonea l cavity by gravity
...
Close the clamp on the infusion line
...
Dialysate dwells for a set
amount of time (dwell time)
...
...
Flu id drains from the peritoneal cavity by gravity
...
The dra inage tube is undamped
A new conta iner of dia lysate is infused
as soon as drainage is complete
...
REPEAT!
EVALUATION OF PATENCY
ti/ Feel the thrill. ..
ti/ Hear the bruit ...
COMPLICATIONS
AVOID ...
• Hypotension
X Compression
• Disequ il ibrium syndrome
X Blood draws
• Hemorrhage
X Blood pressure readings
• A ir em bolus
X Tight cloth ing
• Electrolyte imbalances
X Carrying bags
Performed at the bedside
or in the operating room
COMPLICATIONS
• Periton itis (infection)
• Cloudy or bloody dra inage
• Fever
• Abdominal pa in
• Ma laise
X Sleeping on that arm
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MED-SURG
RENAL/
URINARY
PATHO
Infection within the urinary system
caused by either a BACTERIA,
VIRAL, or FUNGUS.
IS MOSTCOHHON
SPEOFICAUY
E.cou
CAUSES - - - - .
UTl's typically start
in the lower tract
& move upwards
making it to
the upper tract
i
I
>a.:
~
C
z
PYELONEPHRITIS
infection of the kidneys
ii2
:::,
\
• Most common in women
(shorter urethra & urethra is close
to the rectum)
....,-- URETERITIS
~
infection of the ureter
• Overuse of antibiotics
j
• Indwelling catheters
• Hormone changes
(pregnancy changes)
CYSTITIS
tC
infection of the bbdder
z
• Diabetes
ii2
:::,
• Lifestyle
URETHRITIS
• Baths, scented tampons, perfumes etc.
EDUCATION
infection of the urethr.i
.-----SIGNS & SYMPTOMS----.
• Take entire antibiotics course
• Smelly urine
• Wipe from front to back
• Chills & fever
• Void after intercourse
• Costovertebral angle (CVA) tenderness
• Avoid caffeine & ETOH
• Nausea & vomiting
• Void frequently
• Headache/malaise
Avoid bubble baths, perfumes,
or sprays!
• Painful urination (dysuria)
Wear non-tight cotton underwear
• Frequency & urgency
• Burning on urination
\
- - --___J
----
• Nocturia
NURSING CONSIDERATIONS7
• Maintain fluid status --► "flushing" out
• 2 - 3 L per day
the urinary tract
• Remove the catheter ASAP
(per HCP order)
• Incontinence
• Hematuria
• Fever
• WBC's in the urine
Take urine culture
• Medications
_____.,
BEFORE giving
• Antibiotics -----fi rst dose of ant ibiotics
• Analg esia (cont rol pain)
• Phenazopyridine (Pyridium)
~
Analgesic to +pain
May turn urine orange
ELDERLY CLIENTS
➔
HAY SHOW
DIFFERENT SYMPTOMS
• Confusion
• Lethargy
• New incontinence
106
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PATHO
TREATMENT
Stones (calcul i) found in
the urinary tract & kidney!
• MEDICATION.S to control the * PAIN *
• NSAIDs ~
• Opioids analgesics
.i. Pain & inflammation
(makes the stone easier to pass)
NEPHROLITHIA.SI.S:
stones in the kidneys
I
URETEROLITHIA.sl.S:
stones in the ureter
V
STONES
• .STRAIN THE URINE
• keep any stones & send them
to the lab to eva luate the type of stone
• GET THEM MOVING OR FREQUENTLY TURNING THEM!
• Stones can be very large
or very small
• 1' FLUID.S!
'--.._
~
Push stone forward & out!
Decreases risk of infection
• DIET
• Limit protein, NA + foods, & calcium
• They can be found inside the
ICIDNEY.S, URETERS, o r the BLADDER
• PROCEDURE.S:
SIGNS &
SYMPTOMS
DIAGNOSIS
• PAIN!
• KUB: X-ray of kidneys,
ureters, bladder
• Discomfort
• IVP: intravenous pyelogram
• Hematuria .. (RBCs)
• Pyuria -
Extmorporeal Shock Wave Lithotripsy (ESWL)
Sends shock waves to break up the sto ne!
•W1041J• Percutaneous Nephrolithotomy
Stone removed by an incision made o n
the back where the kidneys are located.
• Ult rasound or CT scan
(W BCs)
• Nausea & vomiting
.
NONINVASIVE
• Urine test
Uric acid is a w aste p rod ucts
of t he b reakdown of purines
CALCIUM
URIC ACID
Forms d ue to t amount s
of calciu m & oxalate
in t he urine
Too much uric acid
in t he urine
(acidic urine)
)
STRUVITE
Persistent alkaline
environment t hat is
amm o nia-rich urine
Due to a bacteria
Rare, genetic,
inherit ed diso rder
t hat affect s renal
absorption of cyst ine
Hypercalcemia
Hypercalciuria
Gout
Hyp e rparat hyroidism
t Int ake of Na+
Foods high in purine
or animal prot eins
Dehydrat io n
Dehydration
G I disorders
Met abolic issues
(Diab etes)
t Int ake of ca lcium
sup p lements with vit D
C hron ic urinary t ract
infect ions (UTI 's)
Foreig n b o d ies
N eurogenic b ladder
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CARDIAC OUTPUT (CO)
.J, CO = .J, perfusion to the body
• ,1, LOC
• Lungs sound wet due to back flow
• Shortness of breath
• Skin will be cold & clammy
• ,1, UOP
• Weak peripheral pulses
Total volume pumped per minute
Normal 4 - 8 L/min
Less volume = ,1, CO
More volume = t CO
CO
(?D
= HR x Stroke Volume C)
Cardiac
Heart
Output
Rate
STROKE VOLUME
CONTRACTILITY
Amou nt of blood pumped
out of th e ventricle with
each beat or contraction
Force / strength
of contraction of
the heart muscle
% of blood expelled from the left
ventricle with every contraction
Normal EF: 50 - 70%
~
~
'
EXAMPLE :
If the EF is 55%, the heart is pumping out
55% o f what's inside of the left ventricle
PRELOAD
AFTERLOAD
Amount of b lood returned to
th e right si de of th e heart at
th e end of diastol e
Pressure that th e left vent ri cl e has to pump ag ainst
(the resistance it must overcome t o circul ate b lood)
Cardiac output
(CO)
Cardiac Index
(Cl)
Central Venous Pressure
(CVP)
Mean Arterial Pressure
(MAP)
Systemic Vascular resistance
(SVR)
Clinically measured by systolic blood pressure!
Tot al volume pumped per minute
Normal 4 - 8 Umin
Cardiac outpu t per body surface area
Cl=
CO
2.5 - 4.0 Umin/ m2
surface area
Pressure in the superior vena cava.
Shows how much p ressure from t he
blood is returned t o the right atrium
from t he superior vena cava.
Average p ressure in the syst emic circulation
(your body) t hrough the card iac cycle
The resistance it t akes to push
blood t hrough the circulatory
system to create blood flow
2-8 mmHg
70-100 mmHg
At least 60 mm Hg is require d to
adequately perfuse the vital organs
800-1200 dynes/sedcm
106
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r-· · RIGHT-
r-···lEFT···································:
!
;
(4\
Deoxy9en.ted Blood
(D Pulmon.iry Vein •
Superior Ven.a C.iva
\_.!} / Inferior Ven.a C.iva
@ Left Atrium
@ 8icuspid/Mitr.il V.ilve
@ lti9ht Atrium (R.A)
@ Tricuspid V.ilve (TV)
®
@ Left Ventricle
R.i9ht Ventricle (R.V)
@ Aortic V.ilve
T.
@ Pulmonary V.ilve (PV)
®
Pulmonary Artery•
rt.
carries
blood to the
ti SSUES/BODY
OVERVIEW OF BLOOD VESSELS
•'",
•
m,;.,
O'XYGENA1TD
DEO'XYGENA1ED
blood to the LUNGS
ARTERIES
Carry oxygenated
blood to tissues
Oxy9enated Blood
!... .......................................................... .........
VEINS
Carry deoxygenated
blood b.ack to the he.art
AV Node
Arteries think Aw.iy from the heart
Bundle
of His
~ - - - - - -• EXCEPTIONS - - - - - - ~
The only exception t o th is is t he
PULMONARY ARTERY a nd PULMONARY VEIN
,I,
•
carries oxygenated b lood
from t he lungs t o the hea rt
brings deoxygenated blood
from t he heart to the lungs
SA Node
ELECTRICAL CONDUCTION _J
OF ,HE HEAR,
Right bundle
branch
-
~
Pu rkinje
fibers
STEPS IN THE HEART'S CONDUCTION SYSTEM ----.
Primary pacem aker of th e heart.
SA node (SinoAt rial node) ~ Creates electrical impulses of
Generates & t ransmits
ELEORICAl
IMPULSES
which stimulates
contractions of
the atria and then
the ventricles.
60 • 100 bpm ________.
A
AV node <At rioVentricular)
~
.
BIG
Bundl e of Hrs
BOUNDING
Bundl e branch es (ri9ht & left )
PULSE
Purkinje fib ers - - - --
NOTE:
Th;,;,. • .,,..,
h,,,t ,.t,
Secondary pacemaker of t he heart
"backup pacemaker." If th e SA node
malfu nctions, t he AV node takes over
at a rate of 40 • 60 bpm
:_J
If th e SA & th e AV nodes fa il,
the Purkinje fi bers can fi re at
a rate of 30 • 40 bpm
109
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MED-SURG
CARDIAC
AUSCULTATING HEART SOUNDS
s AREAS
FOR LISTENING- ~ 'l-1.-< All People ~njoy Time Ma9azine
TO THE HEARTC)
Aortic Right 2nd intercosta l space
c:::::::::::::~__
c::?"--
~ Pulmonic Left 2nd intercosta l Space
~~
=~
ERB', Point (S1, S2) Left 3rd
g ~ Tricuspid
O
Hitr~I
intercosta l space
Lower left sternal border 4t h intercosta l
Left 5th intercosta l, medial to midclavicular line
'-----------------te i: ~
i:t:~;:;:~;;~ ~
~ ~ ~~~::~:i~ ~.:
........................................................................................................
S1
LUB
•
+
S2
Tricuspid & mitral valve closure
CLOSING OF THE VALVES
+
Valve open ing does not
normally produce a sound
Aortic & pulmonic valve closure
DUB
S3
S4
EARLY DIASTOLE in rapid ventricle filling
+
ABNORMAL VENTRICULAR FILLING
Extra • sounds
LATE DIASTOLE & high atrial pressure
(forcing blood into a stiff ventricle)
SYSTOLE:
DIASTOLE:
Ventricle
pump I ejection
Ventricle
relax I filling
=
=
LUB (5 1)
DUB (52)
' I ' ,,
-
.
~
"COZY RED"
c:a
CO (contract) ZY (systole)
RE (relax) D (dia stole)
~ '(}
~
110
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QRS COMPLEX
P WAVE ..... .. ..... . Atrial contraction (DEpolarization)
r:
PR
INTERVAL
PR
SEGMENTJ
TP
INTERVAL
1-, o n
Q
- "'
ST
f SEGMENT
PR SEGMENT .... . Movement of electrical activity
from atria to ventricles
o
QRS COMPLEX.. . Ventricle contraction (DEpolari zation)
ST SEGMENT .... . Time between ventricular
depolarization
& repolarization
T WAVE ..... .. ..... . Ventricle relaxing (RE polarization)
TP INTERVAL .... . Ventricle are relaxing & filling
~
0
QT INTERVAL
HEART RHYTHM .
MEASUREMENTS :
I
PR INTERVAL
0 .1 2 - 0.2
·--------- BASIC RHYTHMS ---------·
I
I
:I
NORMAL SINUS
: SINUS TACHYCARDIA
: SINUS BRADYCARDIA
I
60 - 100 bpm :
> 100 bpm
:
< 60 bpm
'
QRS COMPLEX
0 .06 - 0.12
•
,, ',,
I
QT INTERVAL
< 0 .40 seconds
PR INTERVAL
•
ST SEGMENT
Movement of electrical
Time between ventricular deactivity from atria to ventri cles polarization and repolari zation
(ventricular contraction)
DE polariution think ...
DEcompressinq
RE pol~rintion think ...
RE iaxing
RE polarizing
REfillinq with blood
QT INTERVAL
Time take from ventri cles
to depolarize, contract,
and repolarize
5-LEAD PLACEMENT
WHITE ON RIGHT
SMOKE OVER...
CHOCOLATE
IN MY HEART
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111
P-WAVE
NORMAL SINUS 60 - 100 bpm
SINUS TACHYCARDIA > 100 bpm
SINUS BRADYCARDIA < 60 bpm
Identify & examine the P-waves
• Should be present & upright
• Comes before ORS complex
• One P-wave for every ORS complex
PR INTERVAL
Normal PR interval:
Measure PR interval
0.12 - 0.2 seconds
QRS COMPLEX
Normal ORS complex:
0.06 - 0.12
Is every P-wave
followed by a
QRS complex?
• Should not be widened or shortened( W"d .
- th is may indicat e problems!
' e~ ,soften
seen rn PVC
Electrolyte imb ,5'
......\& d
a ances
rug toxicity!/
- - 0.20:oc. - - - +
1 large box = 0.20 seconds
R-R
5 large boxes = 1 second
1 sma ll box = 0.04 seconds
Are the R-R intervals consistent?
• Regu lar or irregu lar?
DETERMINE THE HEART RATE
--------~
I.
6 SECOND METHOD
I.
Be sure and h
the strip is/ eek that
C
seconds'
oun t'ie b
.
Count the number of R's in between
~
the 6 second strips & mult iply by 10 _./
6 R's X 10 = 60 beats per minutes
oxes
BIG BOX METHOD
300 divid ed by the number
of big boxes between 2 R's
300 I 5 = 60 8PM
· • IDENTIFY THE EKG FINDING!
112
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RATE
RHYTHM
P-WAVE
PR INTERVAL
QRS COMPLEX
60 - 100 b pm
RATE
RHYTHM
P-WAVE
PR INTERVAL
QRS COMPLE
< 60 bpm
Regular
Upright & un iform before each ORS
Normal
Normal
-
R
SINUS BRADY
A. The sinus node creates an impu lse
'W at a slower-than-no rmal rat e
• Lower metabolic needs
• Sleep, athletic t raining, hypothyroidism
• Vagal stimulat ion
• Medicat ions
• Calcium channel blockers, beta blockers, Amiodarone
Regular
Upright & un iform before each ORS
Normal
Normal
• Correct the underlying cause!
• t
t he heart rate t o normal
SINUS TACHY
A The sinus node crea tes an impu lse
'W at a faster-than-normal rate
• Physiologic or psychological stress
• Blood loss, fever, exercise, dehydration
• Certain medicat ions
RATE
RHYTHM
P WAVE
PR INTERVAL
QRS COMPLE
> 100 b pm
Regular
Upright & un iform before each ORS
Normal
Normal
• Ident ify t he underlying cause!
• +t he heart rate t o normal
• Stimulants - caffeine, nicotine
• Illicit d rugs - cocaine, amphetam ines
• Stimulate sympathetic response - epinephrine
• Heart fai lure
• Cardiac tamponade
• Hypert hyroidism
113
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VENTRICULAR TACHYCARDIA (VT)
RATE
RHYTHM
P-WAVE
PR INTERVAL
QRS COMPLE,
A
w
look, Iike tomb1tone1
100 - 250 bpm
Regular
Not visible
None
W ide (like tom bstones) > 0.12 seconds
Irregular, coarse waveforms of d ifferent
shapes. The ventricles are quivering
and there is no contractions or cardiac
output which may be fatal!
MANIFESTATIONS
~~~~~
• Myocardial ischemia / infarction
• Patient is usually awake (unlike V-fib)
• Electrolyte imbalances
• Chest pain
• Digoxin toxicity
• Lethargy
• Stimulants: caffeine & methamphetamine
• Anxiety
• Palpitations
LOWoxYGEN
UNSTABLE CLIENTS
WITHOUT A PULSE
• Oxygen
Also called PULSELES.S V·TACH
• Antidysrhythmics (ex. Amiodarone ... stabilizes
t he rhythm)
•CPR
• Synchronized administration of shock
(delivery in sync with the ORS wave).
-
• Syncope
STABLE CLIENT - - - - - - ~
WITH A PULSE
• Synchronized Cardioversion
10
No Cardiac Out
Put
• Follow ACLS protocol for defibrillation ~
• Possible intubation
• Drug therapy
~~-;•r,•r"l4"D~
• Epinephrine, vasopressin, amiodarone
• Cardioversion is NOT defibrillation!
(defibrillation is only given with deadly
rhythms!)
UNTREATED VT can lead to ➔ VENTRICULAR FIBRILUTION ➔ DEATH ~
114
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VENTRICULAR FIBRILLATION (V-FIB)
RATE
RHYTHM
P-WAVE
PR INTERVAL
QRS COMPLE
Unknown
Chaotic & irregular
Not visible
Not visible
Not visible
Rapid, d isorganized pattern of electrical activity
in t he ventricle in wh ich electrica l impulses
arise from many d ifferent foci!
~
CAUSES ~ MANIFESTATIONS
~
• Cardiac injury
• Loss of consciousness
• Medication toxicity
• May not have a pulse or blood pressure
• Electrolyte imbalances
• Respirations have stopped
• Untreated vent ricular tachycardia
• Cardiac arrest & death!
•
C
• CPR
NO CARDIAC
OUTPUT
==
TioTHOE~YGEN
BOoy
• Drug Therapy
• Oxygen
• Vasoconstriction : Ep inephrine
Defib (follow ACLS protocol for
defibrillation)
• Antiarrhythmic: Amiodarone, lidocaine
J
• Possibly magnesium
• Possible intubat ion
' \ I I_,
•
"Defib the Vfib"
CARDIOVERSION VS. DEFIBRILLATION
CARDIOVERSION - - - - - - .
DEFIBRILLATION - - - - - - - ,
• Synchronized shock
• Asynchronous
• Lower amount of energy
• Higher amount of energy
• Not done with CPR
• Resume CPR after shock
• Stable clients
• Unstable clients
• Ex.A-fib
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• Example: pulseless VT or VF
115
ATRIAL FIBRILLATION (A-FIB)
IRREGULAR R-R INTERVALS
++ + + +
~~~
RATE
RHYTHM
P·WAVE
PR INTERVAL
Usually over 100 8 PM
Irregular
None. They are irregular (fibrillary waves)
Visible
....__QR_Sc_o_MP_LE_X_N_o rm
_ a_
l
Uncoord inated electrical act ivity in t he atria
t hat causes rapid & d isorg anized "fibbing"
of the muscles in t he atrium.
_T
_H
_E_ATRIA-IS
QUIVERING!
MANIFESTATIONS
~
• Open heart surgery
• Most commonly asymptomatic
• Heart failure
• Fatigue
• COPD
• Malaise
• Hypertension
• Dizziness
• lschemic heart disease
• Shortness of breath
• Tachycardia
ALL DUE
TO
LOWo2
• Anxiety
• Palpitations
~
TREATMENT ~~~~~~~~~~~~~~~
STABLE PT.- - - - - - - - - ,
UNSTABLE PT.- - - - - - - ---,
• Oxygen
• Oxygen
• Drug therapy!
• Card ioversion
• Beta b lockers
• Calcium channel blockers
• Digoxin
• Synchron ized ad min istration of shock
(d elivery in sync with the ORS wave).
• Cardioversion is NOT defibrillation!
• Amiodarone
• Anticoagulant therapy
to prevent clots
116
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PREMATURE VENTRICULAR CONTRACTIONS (PVCS)
RATE Depends on the underlying rhythm
RHYTHM Regular but interrupted due to early P-waves
P·WAVE Visible but depends on timing of PVC
(may be hidden)
PR INTERVAL Slower t han normal but still 0.12 - 0.20 seconds
QRS COMPLEX Sharp, b izarre, and abnorma l during the PVC
Early "premat ure" conduction of a ORS complex
BIGEMINY: every other beat
TRIGEMINY: every 3rd b eat
QUADRAGEMINY: every 4th beat
• Heart failure
• Myocardial ischemia / infarction
EXERCISE
FEVER
HYPERVOLEHIA
HEART FAILURE
TACHYCARDIA
• Drug toxicity
• Caffeine, tobacco, alcohol
• Stress or Pain
• Increased workload on the heart
R-ON-T PHENOMENON: PVC arises
spont aneously from t he repolarization
gradient (T-wave) may precipitate V-fib
_.,,1f
• May be asymptomatic
*TX based on underlying cause*
• Feels like your heart ...
• May not be harmful if the client has a healthy heart
• "Skipped a beat"
• Oxygen
• " Heart is pounding"
• Decrease caffeine intake
• Chest pain
• Correct the electrolyte imbalances
• DIC or adjust the drug causing toxicity
• Decrease stress or pain
ASYSTOLE
FLATLINE
~
CAUSES
~
• Myocardial ischemia/ infarct ion
• Heart failure
• Electrolyte imbalances
(common : hypo/hyperkalemia)
• Severe acidosis
• Cardiac tamponade
TREATMENT
• High quality CPR
•
•
•
•
•
•
Heel of hand on the center of the chest
Arms straights
Shoulders aligned over hands
Compress at 2 - 2.4 inches at a rate of 100 - 120 min
30 compressions to 2 rescue breaths
Minimal interruptions
• Cocaine overdose
117
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ATRIAL FLUTTER
SAWTOOTH
RATE 75-150 BPM
RHYTHM Usually regular
P·WAVE "Sawtooth" P-wave configuration
shaped flutter waves
Similar to A-fib, but t he heart's electrica l
signals spread through the atria. The heart's
upper chambers (at ria) beat too qu ickly
but at a regular rhythm .
~
PR INTERVAL Unable to measure
QRS COMPLEX Usually norma l & upright
CAUSES ~~~~~~~ MANIFESTATIONS
• Coronary artery disease (CAD)
• May be asymptomatic
• Hypertension
• Fatigue / syncope
• Heart failure
• Chest pain
• Valvular disease
• Shortness of breath
• Hyperthyroidism
• Low blood p ressure
~
• Chronic lung disease
• Pulmonary embolism
• Cardiomyopathy
STABLE PT. - - - - - - - ~
UNSTABLE PT.- - - - - - - - ~
• Drug therapy!
• Cardioversion
• Ca lcium channel blockers
• Antiarrhythmics
• Synchronized administration of shock
(delivery in sync with the ORS wave).
• Anticoagulants
• Cardiovers ion is NOT defibrillation!
116
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SIGNS & SYMPTOMS
RIGHT SIDED HF
•
l eft Side think l unqs
Fluid is backinq up into
the VENOUS SYSTEM
Fluid is backinq up
into the LUNGS
= pulmonary symptoms
welling of t he legs & hands
0THER.s&s
• ales (crackles)
eight gain
t UQp
Hypotension
S3 Gaflop
dema (pitting)
arge neck veins (JVD)
eakness / fatigue
octurnal paroxysma l dyspnea
ethargy / fatigue
~-
rregular heart rate
ncreased HR
agging coug h (frothy, blood tinged sputum)
aining weig ht (2 -3 lbs a day)
Hepatomega/
Spfenomega/:
Anorexia
octuria
irth (Ascites)
· · · · · · · · · · · · · · · · · · · · · · · SYSTOLIC HF VS. DIASTOLIC HF · · · · · · · · · · · · · · · · · · · · · ·
DIASTOLIC HF
Stiff & non-compliant
heart muscle
Weakened
heart muscle
EJECTION FRACTION (EF)
Amount of blood PUMPED OUT
0/oEF
The vent ricle does not
EJECT properly
EF REDUCED
The ventricle does not
FILL properly
--~•
Amount of blood IN THE CHAMBER
NORMALEF - - ~ • NORMAL EJECTION FRACTION
500/o-700/o
____
......................................................................................................................................................................................................................
119
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MED-SURG
CARDIAC
HEART FAILURE:
DIAGNOSIS & INTERVENTIONS
DIAGNOSIS
.----BNP-----------------e-----.
BNP 100 • 300 p9/ml. .... HF is suspected
B-TYPE NATRIURETIC PEPTIDE
BNP > 300 p9/ml ............. Mild HF
Secreted when there is
t pressure in the ventricle
BNP > 600 p9/ml.. ........... Moderate HF
BNP > 900 p9/ml ............Severe HF
.----- CHEST X-RAY---. .----- ECHOCARDIOGRAM ------.
LOOKS AT:
Enlar9ed heart &
pulmonary infiltrates
~
ejection fraction,
back flow,
& valve problems
Ejection Fraction (EF) EF is + in
most types of HF
NORMAL RANGE:
55%-750/o
....
INTERVENTIONS
MONITOR:--__,
REPORT-S&S·OF- - - ~
FLUID RETENTION
• Strict 1&0s
.
. h
~
• Daily we1g ts - - - ·
Report
weig ht gain
• Edema
(2-3 lbs)
• Weight gain
• Edema
DIET-MODIFICATIONS:- : 7
• Fluid restrictions
•+Sodium
~
spread
{\uids
• + Fat
• + Cholesterol
out during
the day
{~
Suck on
hard candy
to ~ thirst
ELEVATE-HOB- - - - ~
(Sem i-Fowler's posit ion)
BALANCE PERIODS
OF ACTIVITY & REST
120
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MED-SURG
CORONARY ARTERY DISORDERS (CAD)
-v--PATHO-----
- - RISK FACTORS--------
Fatty plaques develop
NON-MODIFIABLE
MODIFIABLE
.i
Age
Diabetes
Obesity
Gender
Hypertension
Smoking
Physica l inactivity
High cholesterol
Race
Called ATHEROSCLEROSIS
.i
Restriction of blood flow
to th e heart
Metabolic Syndrome
Family history
SIGNS & SYMPTOMS---------Inadequate blood supply to
the heart = ,I, 0 2 to th e heart.
,1,
02
INFARCTION: Death
Chest pain t hat is caused
by myocardial ischemia )
X
---.,'' • ~hest pa~n w/ acti~ity
: • Shortness of breath
:
I
: • Fatigued
I
',
-----------~
I
I
I
DIAGNOSIS - - - - - - BLOOD
PREVENTION - - - • Management
of hypertension
➔
ISCHEMIA
ISCHEMIA:
CARDIAC
• Management
of diabetes
• Smoking cessation
• Diet
• Exercise
TREATMENT- - - -- - - • Lipid -l owering medications " Statins"
TEST ➔ Lipoprotein profile
• Heart-hea lthy d iet
• Physica l activity ~
• LDL
• HDL
.
.
• Smoking cessation
• Total cho lesterol
• Stress management
• Trig lycerides
WEEKLY
EXERCISE GOAL,s
Moderate: 75 min
Vigorous: 150 .
m,n
• Hypertension management
ECG
• Assess for changes in ST segments
or T-waves!
• Diabetes management
• Corona ry stent / angioplasty
• Corona ry Arte ry Bypass Graft (CABG)
CHOLESTEROL-------
LDL
Low Density
Lipoprotein
~
Want LOW Levels
(< 100 mg/dL)
BAD Cholesterol
HDL
Hi9h Density
Lipoprotein
Want HIGH Levels
(> 60 mg/dL)
HAPPY Cholesterol
121
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PERIPHERAL
VENOUS DISEASE
(PVD)
· PERIPHERAL ARTERIAL DISEASE
(PAD)
r-----
Narrow artery (atherosclerosis) where
oxygenated blood ca n't get to t he
distal extremities (hands & feet).
Deoxyg enated blood
ca n't get back to t he heart.
Pooling of oxygenated blood
in the ext remit ies.
0
0
/schemia & necrosis
of the extremities
Sharp pain:
Get, wor,e at ni9ht
" rest pJi n"
Dull, constant, achy pain!
Interm ittent cbudication
May not be palpable
due to edema
Very poor or even absent
0 __
B_lo_od- is_ P_o_oL_IN_G_in_t_he_ l_e9---
(
)
Warm le9s
(Blood is warm)
Cool
TEMP?
Stasis dermatitis
(Brown/yell ow)
Pale, hairless, dry, scaly, t hin skin
due to lack of nutrients ( ,I, 0 )
COi.OR?
Venous STASIS ulcers,
lrre9ubr shaped wounds, shallow
POSITIONflG?
Re9u lar in shape, red sores
round appearance "punched out"
We have too much blood ! Gan9rene i1
caused by insufficient amount s of blood .
GANGRENE?
Elevate
Veins
No blood = cool le9
(blood is warm)
Po1ition1 t hat m,ke it wone: d, n9lin9,
1ittin9/1t ,nd in9 for long period, of t ime
GANGRENE?
POSITIONING?
r.";\
~
....__
Tai-slack
su_e_d_
ea-blood
t h_c_au-supply
se_d -by_
.
of
_,
( _ _ _ _o_a_n9_1e_a_rt_er_ie_s _ _ _)
CAUSES OF BOTH
Smoking • Diabetes • High cholesterol • Hypertension
DX: Doppler Ultrasound or Ankle Brachia! Index (ABI)
TllEATM ENT -
KEEP VEIN OPEN!
• Elevate V eins
• Medications
V
TREATMENT -
GET BLOOD HOVING!
• o A ngle Arteries
(Dependent posit ion)
A
• Perform daily skin care with moisturizer
- Aspi rin or Clopidogrel
• Stop smoking
- Cholest erol low ering drugs " statin"
• Avoid tight clothing (vasoconstrict ion)
• Surgery
- Angioplasty
• No heating pads!
• Medications
- Bypass (CABG)
- Vasodilators
- Endarterectomy
- Ant iplatelets
122
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.------ PERIPHERAL -----.
VENOUS DISEASE
(PVD)
...----~-PE RI PH ERAL
ARTERIAL DISEASE
(PAD)
--------c
Na rrow artery (athe rosclerosis) where
oxygenated blood ca n't get to the
distal extremities (hands & feet).
Deoxyg e nated blood
ca n't get back to the heart.
Pooling of oxygenated blood
in the extremities.
PAIN?
PULSE?
/schemia & necrosis
of the extremities
oc__)
ococ___
) )
EDEMA?
TEMP?
COLOR?
(
(
EDEMA?
)
)
TEMP?
COLOR?
WOUNDS?
GANGRENE?
POSITIONING ?
0(___)
(
)
GANGRENE?
POSITIONING ?
0(_ _)
(
)
CAUSES OF BOTH
-------- · - - - - · - - - - - - - · - - - - - - - - - DX: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
TREAMENT
v
• P_o_s_
i ti_o_n _ _ _ _ _ _
• Medications
TREAMENT
• Position
A
• Perform _ _ _ _ _ _ _ __
• Stop _ _ _ _ _ _ _ _ _ __
• Surgery
• Avoid
• No
--------------------
• Medications
123
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Angina is chest pain associated with ischemia.
It's due to narrowing of at least one major coronary artery.
TYPES OF A N G I N A - - - - - - - - - -STABLE
UNSTABLE
" Pred ictable"
" Prei nfarction"
Occurs with EXERTION
Occurs at REST
& MORE FREQUENTLY
PRINZMETAL'S / VARIANT
" ( oronary arte ry
vasospasm"
Pain at REST with
reversible ST-ELEVATION
Exercise o r
strenuous activity
SIGNS & SYMPTOMS
INTERVENTIONS
• Chest pain (heavy sensation)
may rad iate to neck, jaw,
or shou lders
GOAL:
+oxyqen demand
tl;J444i!i1Ut•1:1Al•t34•1•1;J¥9
f
• Unusual fatigue
• Weakness
PCI
• Shortness of breath
• Pallor
'
CABG
Percutaneous
Coronary Interventions
Coronary Artery
Bypass Graft
• Diaphoresis
DRUG THERAPY
,1,
NITRATES
CALCIUM CHANNEL
BLOCKERS
Vasod ilators
Relaxes b lood vessels
ischemia = ,I, pain
Usually admin istered
sublingual
t oxygen supply
z!:
-u
Ill ::C
ti
C
A. Ill
I-
,I,
myocard ia l oxygen
consumption
to the heart
Prevents platelet
aggregat ion &
thrombosis
,I. workload of heart
SUBLINGUAL NTG OR SPRAY
I-"
BETA BLOCKERS
ANTIPLATELET /
ANTICOAGULANT
• 1 t ab/spray sublingual every 5 m inutes,
up to 3 doses.
Keep in original container
(dark, glass bottle)
in a d ry, cool place.
Do not swallow or
chew th ese tablets
• If angina is not relieved or is worse
5 min after the first dose, call 911 !
124
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MED-SURG
MYOCARDIAL INFARCTION CM I)
PATHO
Com plete bloc kage in one or mo re art eries of t he heart
Coronary arteri es
become na rrow
d ue to p laq ue
bu ild-up
MYOCARDIAL
INFARCTION (Ml)
ANGINA
ATHEROSCLEROSIS
➔
➔
Due to
ischemia
(l ow 0 2)
SIGNS & SYMPTOMS
Shortness of breath
Nausea & vom iting
Sweating
Pale & dusty ski n
Plaque ruptu re
become a blood clot
that blocks arteries of
the heart
DIAGNOSIS
Sudden , crush ing , radiating chest pa in that continues despite rest & medications
•
•
•
•
CARDIAC
• ECG
WOMEN PRESENT WITH
DIFFERENT SYMPTOMS
• ST-Elevation (no 0 2)
• ST-Depression (low 0)
• T-wave inversion
• Fatigue
• Shoulder blade d iscomfort
• TROPONIN
• Shortness of b reath
• STRESS TESTS
PAIN FELT IN THE... Left arm • Mid back/shoulder • Heartburn
• Chem ical & exercise
I TREATMENT
IMMEDIATE
MORPHINE
--•• CATH LAB OR
CLOT BUSTER
i workload of the heart
& i pain
~ OXYGEN
\ : , t O to the heart
2
A
NITROGLYCERIN
~
opens up the vessels
ASPIRIN
Prevents platelets from
sticking together
PREVENTION -~••
&REST
MEDICATIONS ~
Throm bo lytics
(clot busters)
Example: Streptokinase
SURGERY
PCI " Percutaneous
Coronary Intervention"
CABG
Endarterectomy
- Cut out the blockage
PREVENT / STABILIZE CLOT
Heparin IV
REST THE HEART WITH ...
Nit ro
Beta-Blockers
Calcium channel blockers
125
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MED-SURG
CARDIAC
CARDIAC BIOMARKERS
TROPONIN
Prot ein released in the blood st ream
0 - 0.03 n9/m L
when the heart muscle is damaged.
There are 3 isomers of tropon in
• Troponin C: binds ca lcium to activate
muscle contraction
• Troponin I & T: specific for cardiac muscle
CAN REMAIN ELEVATED
FOR AS LONG AS 2 WEEKS
BEST indicator of an acute Ml
CK-MB
CREATINE KINASE - MB
0-S n9/m l
An enzyme released in the bloodstream
when the heart, muscles or brains are damaged!
24 HOURS
Cardiac-specific isoenzyme
BUT less reliable than Troponin
MYOGLOBIN
Myoglobin is found in cardiac & skel etal muscle
NOT a specific indicator of an acute Ml,
but a(-) sign is good for ruling out an acute Ml
9
S - 70 n9/m l
12 HOURS
Myo9lobin think Muscle
BNP
BRAIN NATRIURETIC PEPTIDE
A peptide released when th e ventricle is filled
w ith too much fluid and STRETCHES!
Normal: <100 p9 /m L
Mi ld HF : 100 - 300
Moderate HF : 300 - 700
Severe HF: >700
Indicates heart failure (HF)
126
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HYPERtension = HIGH BP
MOST ACCURATE DIAGNOSIS FOR HTN
CATEGORIES
SYSTOLIC
(SQUEEZE)
NORMAL
< 120
'
DIASTOLIC
(DECOMPRESS)
CONGESTIVE HEART FAILURE (CHF)
Overworking of the heart muscle
(ventricle enlarges)
""'
z
C
< 80
~
PRE-HTN
120 - 139
STAGE 1 HTN
140 - 159
STAGE 2 HTN
> 160
LL HTN CRISIS
> 180
~-----------------------------------------~
80 - 89
90 - 99
> 100
I
,I
STROKE
@
al!:
0
C
I-
l&I
Weak & narrow vessels
could lead to rupture of vessels
RENAL FAILURE
~~
u
l&I
I&.
I&.
C
Too much blood flowing to the
kidneys at a fast rate & high pressure
VISUAL CHANGES
®
> 120
Damages blood vessels in the retina
(blurred vision, can't focus on objects)
RISK FACTORS
•
A lso called
ESSENTIAL o r IDIOPATHIC HTN
• Cause is unknown
• Not curable, on ly control lable
0
0
0
0
~
SECONDARY HTN
PRIMARY HTN
Race (Afri can Americans)
Intake of Na/ ETO H
Smoking
Low K+ & vitamin D levels
0
0 A dvanced age
G t Cho lesterol
0 Too much caffeine
0 O besity
0 Rest ricted activity
0 Sleep apnea
SIGNS & SYMPTOMS ~ ~ ~ ~
C
Usually asymptomatic!
Commonl7 calll!d thr
"SILENT KILLER"
Symptoms: • Bl urred vision
(if seen) • Headache
• Chest pain
• Nose bleeds
• Limit alcoho l intake
• Smoking cessation
•
•
•
•
•
•
Chronic kidney disease
Diabetes
Hypo/Hyperthyroid ism
Cushing syndrome
Pregnancy
Certain d rugs (oral contraceptives)
CHECKING
BLOOD PRESSURE
➔
Place stet hoscope over
b rachia! artery
➔ Patie nts should not s moke, exercise, etc.
within 30 minutes of having their BP checked
(could lead to inflated BP)
➔ Instruct t he clie nt to:
• Sit in a chair with legs uncrossed
• A rm at • level
• Correct size cuff ~
EDUCATION
• Limit sod ium intake
• Has a d irect cause I preexisting condition
Family HX
➔ No BPs should be
auscultated in arms with:
• Teach how to measure BP
& keep a record
Too small =
fa lse high BP
• Mastect omy
Too large =
- HX of AV shunt
fa
lse low BP
- Blood clots
- PICC lines/ cent ral lines
• Exercise p rograms for
weig ht loss if needed
SUFFIXES
II
ABCDD II
A
B
C
D
D
ACE inhibitors
-PRIL
BETA Blockers
-OLOL
Calcium Channel Blockers -PINE -AMIL
Digoxin
Diuretics
127
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HEl>-SUR6
ENDOCRINE
ENDOCRINE SYSTEM OVERVIEW
HYPOTHALAMUS
Regulates hunger, t hirst ,
sleep, body t emp.
PITUITARY GLAND
PINEAL GLAND
Regulates energy,
met abolism, and g rowth
Releases melatonin, w hich
regulates daily sleep-wake cycle
f
PARATHYROID GLAND
Helps regulat e calcium
& phosphorus in t he b lood
THYROID GLAND
Regulates energy,
metabo lism, and growt h.
• \i:lt••l/lrn.
Produces 3 hormones:
n,l
-----
Cont rols g rowth, sugar metab olism , kid ney fun ct ion,
& stress (released ep inephrine & norepinephrine,
t he fi g ht or fli g ht hormones )
PANCREAS
A ids in the d igest ion of p rotein, fats, and carbohydrates.
Pro duces insulin to cont rol blood sugar.
-.__
OVARIES
Produces the fem.ile hormones:
••
ESTES
Produces the m.ile hormone: •
126
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NO food
Consume food
"'
"'
"'
"'
"'
"'
"'
Pancreas "back up plan "
Blood sugar increases
Glucagon hormone is released
This causes th e pancreas to release insulin
Breaks d own stored g lucose (glucagon) in the liver
Insulin puts sugar & potassium into t he cells!
Releases g lucose into t he b lood stream
TYPE 1
DIABETES
,_ \
•
►
\:)
0
_,
0
:c
ti
Q.
TYPE 2
DIABETES
DOES NOT PRODUCE ENOUGH INSULIN
OR PRODUCES "BAD" INSULIN THAT DOES NOT WORK PROPERLY
.,,,NO INSULIN PRODUCTION
Type ONE we have nONf
• Caused by an autoimmune response
• The cells are sta rved of glucose since t here
is no insulin to b ring it into t he cells
• The cells b reak d own p rotein and fat into energy
causing keton es t o build up = ACIDOSIS!
• Usually d iag nosed in
chi1dh J
~
-
, errible , wos are BAD
I
Insulin resist ance
::c
Insulin receptors are w orn o ut & not w orking p roperly!
~
Usual ly diagnosed in
.1dulthood
(due to a poor diet, sedentary lifestyl e, and obesity)
I
,,,,_
"'-._ A.A
•
►
\!l
0
0
,j
Easy :o ~emember bec.1use childho.,J comes _,/
ST in l,fe and ;;adulthood comes 2 ND
.------- ONSET: ABR.U PT - - - - SIG S & SfMPTO S - - - ONSET: GR.AOUAL-___,
C
.----T ET E T
Hyperglycemia
only has 1 t reatm ent:
2+ t reatm ents:
Glucose >115 & HbA1C 6 .5 +
jh»
INSULIN
Oral hypoqlycem ic aqents
will not work for th is pt.
DIET & EXERCISE
Polyuria: Excessive peeing
Polydipsia: Excessive t hirst
Polyphagia: Excessive hunger
•
ORAL HYPOGLYCEMIC AGENTS
Example: Metformin
POSSIBLY INSULIN
Insulin dependent for life!
z
"'
0
ii
V
_,
Insulin is not administered routinely in a type l
diabetes patient. Only in t imes of stress, surqery,
or sickness will insulin need to be admin istered,
DIABETIC KETOACIDOSIS (DKA)
ONSET: ABRUPT
Not eno ug h insulin
• Ketosis & acid osis
"'
• Dehydration
:l
Q.
N O acid osis p rese nt !
• Ku ssmaul respirat ions
(trying to bl ow off CO2)
:E:
0
Simply hig h amounts of
g lucose in th e blood
• Hyperglycem ia
0
V
Cells b reak d"'own protein
fat into energy
,&.
s build up = Acidosis!
ONSET: GUDUAL
ii
V
Q. Bl ood sugar b ecomes VERY hig h
L::
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS)
Sl6NS - SYt"'PTOt S
PATI OLOGY
• Acid b reath "fruity b reath "
TlEAT1 E''IT
t
Hyperglycemia
>600 +
V
_ __.
Fluid replacement
IV INSULIN • Fluid replacement
Correction of electrolyte imbalances
Correction of electrolyte imbalances
Possib le Insulin adm inistration
LO G TERM COMPLICATIO S
KIDNEY
NEPHR.OPATHY
Renal Failure
~
NERVES
NEUR.OPATHY
@
EYE
HEART
R.ETINOPATHY
HTN & ATHER.OSCLER.OSIS
Loss of sensation
129
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HEl>-SUR6
ENDOCRINE
HYPERGLYCEMIA VS. HYPOGLYCEMIA
HYPERGLYCEMIA
~
BLOOD SUGAR
>200 m9/dl
Gradual (hours to days)
~ .· ·.
V
HYPOGLYCEMIA
1.0 - 110 m9/d ~
<70 m9 /dl
Happens suddenly
I I.___ _ _S_IG_N_S&_S_Y_M_PT_O_MS_ _ ___,
• Polyur~:GNS & SYMPTOMS
•
• Cool & clammy skin
• Headache
• Sweating (Diaphoresis)
• Shakiness
• Polyphag ia
• Deep, rapid breaths
(air hunger)
• Palpitations
• Hot & dry skin
• Numbness & t ingling
• Fatigue & weakness
• Dry mouth
(dehydration)
• Slow wound healing
• Ina bil ity to aro use
from sleep
• Can lead to coma ~
• Confusion
Fruity breath
G • Polydipsia
L
• Vision changes
J L
CAUSES
•
+ BLOOD SUGAR
BLOOD
GLUCOSE GOAL:
• Sepsis (infectio n)
• Exercise
• Swimmi ng, cycling, college athlete etc.
G • Stress
• Steroids
• Alcohol
• Skipping insulin or oral diabetic medication
• Peak times of insulin
~
• Not eating a diabetic diet
DIABETIC DIET
L
Complex carbohydrates
Fiber-rich foods
Saturated fats
Heart-healthy fish
Cholesterol
" Good fats "
Sodium
tg est risk
for H
YPog/ycern;a
J
TREATMENT
/ i'
15 X 15 X 15
•~d
[_
PIO INSUL1
h as the h· h
CONSCIOUS PATIENTS
Trans fats
Sugar-free flui ds
fJ
J
CAUSES
Oral intake of
15 GRAMS
of carbohydrates
Juices, soda,
Recheck
blood glucose
in 15 MIN
Give another
15 GRAMS
of carbohydrates
if needed
low fat milk.
NOT peanut butter
or high fat milk
TREATMENT
• Adm inister insulin as needed ~
• Test urine for ketones
GENERIC
NAMES
BRANO
NAMES
,
UNCONSCIOUS PATIENTS
RAPID
SHORT
llffERHEDIIIE
LONG
Llspro
Aspa rt
Glulisine
re gular
npb
G larg·ne
Detemir
Humalog
Novolog
Apidra
Humu in R
Novo in R
Humu·nN
Novo ·n N
Do not put anything in an unconscious
cli ent's mouth, they can ASPIRATE!
Administer IV 50% dextrose (D50)
OR 6luc:.09on (IM, IV, SubQ)
/r\
.r
m
EMERGENCY
c.. /1" '-pid response
Lantus
Levemir
130
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~ The thyroid gland produces 3 hormone (T3, T4, & Calciton in)
• You need IODINE to make these hormones
~ Thyroid g ives you
ENERGY!
0
0
HYPERTHYROIDISM
HYPOTHYROIDISM
.____ _ _ _
Pi_rH_O_L_OG_Y_ _ _ ____,I
'--I_ _ _ _P_~_rH_O_LO_G_Y_ _ _ ___,
Excessive p roduction of thyroid hormone
Low production of thyroid hormone
NOT ENOUGH ENERG, !
TOO MUCH ENER
• Graves d isease
• Too much Iodi ne (helps makes T3
.
' ~
d, , ,
A . h
'd
d' .
• H ash 1moto s 1sease
• nt1-t yro1 me ,cations
+ T4)
• Toxic Nodular Goiter
• Not eno ugh Iodine
• Pitu itary hormone
• Thyroid replacement medication (Toxicity)
• Thyroidectomy
• Affects women more
often then men
LAB VALUES
1' T3& T4
LAB VALUES
+ TSH
+ T3&T4
SIGNS & SYMPTOMS
1' TSH
SIGNS & SYMPTOMS
• Goiter (enlarged thyro id)
• No energy
• Sl urred speech
• Fatigue
• Dry skin
• Irritable
• Hot
• No expressions
• Coarse hair
• .&. Attention span
• EXOPHTHALMOS
• Weight gain
• Decreased
• HR
• GI function (constipation)
• Blood sugar (Hypoglycemia)
• Hyper-excitable
• Nervous/tremors
• Increased appetite
• Weight loss
• Hair loss
• Increased:
• Blood pressure
• Pulse
• G I function
Bulging eyes
due to fluid
accumulation
behind the eyes
.....
& LIFE-THREATENING COMPLICATIONS
THYROID STORM!
, V ACUTE / LIFE THREATENING EMERGENCY!
TREATMENT
• A nti-Thyroid Medications
• Methimazole or PTU
• Beta Blockers(+ HR & BP)
• Iodine Compounds
__
• Cold
• Amenorrhea
.,.,
& LIFE-THREATENING COMPLICATIONS
MYXEDEMA COMA!
TREATMENT
• Hormone replacement (replacing levothyroxine)
• Synthetic levothyroxine
• Synthroid or Levothroid
• Will be on this medication forever
• Radioactive Iodine Therapy
• Thyroidectomy
'For more information about thyroid medications, see the Pharmacology Bundle
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The parathyroid gland produces and secretes PTH (parathyroid
hormone) which controls the levels of CALCIUM in the blood
0PTH
HYPERPARATHYROIDISM
1' CALCIUM
0PTH
HYPOPARATHYROIDISM
+ CALCIUM
+ PHOSPHORUS
._____ _ _ _C_AU
_S_ES_ _ _ ____,I
1' PHOSPHORUS
.__I_____C_AU_S_ES_ _ _ ____,
PRIMARY CAUSE:
Tumor or hyperplasia of the parathyroid
• Can occur due to accidenta l removal
of the parathyroid
• Thyroidectomy, parathyroidectomy,
or radical neck dissection
SECONDARY CAUSE:
Chron ic kidney fai lure
• Genetic predisposition
• Exposure to rad iation
SIGNS & SYMPTOMS
• Magnesium depletion
• STONES: Kidney stones (t calcium}
SIGNS & SYMPTOMS
• BONES:
• Skeletal pain
• Pathological fractures from bone deformities
• Numbness & tingling
• A bdominal MOANS
• Muscle cramps
• Nausea, vomiting, and abdominal pain
• Tetany
• Weight loss / anorexia
• Constipation
• Hypotension
• Psychic GROANS
• Mental irritability
• Confusion
• Anxiety, irritabi lity, & depression
•
TREATMENT
• Parathyroidectomy
•
•
- - POSITIVE TROUSSEAU'S:
Carp al spasm caused by
inflating a blood pressure cuff
CHVOSTEK'S SIGNS:
Contraction of facial muscles
with light tap over the fa cial nerve
• Removal of more than one gland
• Administer
• Phosphates, calcitonin, & IV
or oral b isphosphonates
• DIET: t fiber & moderate ca lcium
TREATMENT
• IV Calcium
• Phosphoru s binding drugs
• DIET: t Calcium
+ Phosphorus
132
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~
RETAINS: NA+ & H20
LOSES: K+
ADRENAL CORTEX HORMONES:
~
Glucocorticoids • Mineralocorticoids • Sex hormones
0
•
0
CUSHING'S
ADDISON'S
Disorder of the adrenal cortex
Disorder of the adrenal cortex
TOO MANY STEROIDS
NOT ENOUGH STEROIDS
•
They "have a CUSHION "
•
.
'
'
We need to "ADD"some
__.I I._______C_AU_S_ES_ _ _ ___.
...__ _ _ _C_AU
_S_ES_ _ _ _
• Females
• Surg ical removal of both adrena l g lands
• Overuse of cortisol medicat ions
• Infection of t he adrenal glands
• Tumor in t he adrenal g land that secretes cortisol
• TB, cytomega lovirus, & bacterial infections
.____ _ _
SI_G_
NS_&
_S
_Y_M_PT_O_M_S_ _ ___,I
I.___ _ _ _SI_G_NS_&_ S
_Y_M_PT_O_M_S_ _ ___,
• M uscle wast ing
• Weight gai n
• Fatigue
• + Blood sugar
• Moon face
• Hi rsutism
• Na usea / vomiting
/ diarrhea
• +Na & Hp
(masculine chara cteristics)
• Buffalo hump
• t G lucose
t NA+
• Truncal obesity
w/ thin extremit ies
• +K+ +CA+
• Supraclavicular fat pads
• Hyp ertension
TREATMENT
• Anorexia
• Hyperpigmentation
of the skin
• Hypotension &
Hypovolemia!
• Vitiligo: white areas
of depigmentation
• Confusion
9
• Requ ires lifelong g lucocorticoid replacement
• Avoid infection
• Adm. chemotherapeutic agents
if adrenal tumor is present
ADDISONIAN CRISIS
•
•
SIGNS&
SYMPTOMS •
'-./ •
•
•
.....---..
• Adrenalectomy
t K+
Profound fatigue
Dehydration ..... shock!
Renal fa ilure
Vascular collapse
TREATMENT
Hyponatremia
Fluid resuscitation
Hyperkalemia
& high-dose
hydrocortisone
TREATMENT
• Adm. gl ucocorticoid and/or mineralocorticoid
• Diet: high in p rotein & carbs
133
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ANTIDIURETIC HORMONE (ADH):
ADH regulates & balances
the amount of water in your blood
0
SYNDROME OF INAPPROPRIATE
ANTIDIURETIC HORMONE (SIADH)
• Medications
• Vincristine
•
• Phenothiazines
Severe pneumonia
•
Head injury
•
Brain surgery
L
• Head t rauma, brain t umor
• Manipulation of the
p ituitary
•
• Weight gain without
edema
Surgical ablation,
craniotomy, sinus surgery,
hypophysectomy
• Antidiabetic drugs
L
• Infections of the central
nervous system (CNS)
•
M ening itis, encephalit is,
orTB
• Failure of the renal
tubules to respond to
ADH
SIGNS & SYMPTOMS
• Excretes large am ounts
of d iluted urine
• Muscle pain & w eakness
• Hypertension
• Polydipsia
• Postural hypotension
• Tachycardia
• Polyuria
SIGNS & SYMPTOMS
• Fluid volume overload
J
CAUSES
• Anticonvulsants
• Nicotine
• Low urinary output
of concentrat ed urine
~WATER
• Thiazide diuretics
• Tumor
L
NOT ENOUGH ADH
• Antidepressants
• Disorders of t he CNS
t>I think t> ry Inside
can lead to an
ADH problem
CAUSES
• TB
•
INCREASED
rn1iJim WATER
• Pulmonary d isease
DIABETES INSIPIDUS (DI)
~CP
SIADH is often of non-endocrine origin
TOO MUCH ADH
0
(increased thirst)
• Tachycardia
(increased urine output)
• Nausea & vomiting
• Dehydration
• Hyponatremia
• Headache
• Low urinary specific
gravity
\
• Decreased skin turgor
• Dry mucous membranes
~_ _ _ _
TREATM_EN_T_ _ _~I
• Implement seizure precautions
L
Norm~) specific 9r~vity:
1.005 - 1.030
TREATMENT
• Adequate fl uids
• IV hypotonic saline
• Elevat e HOB to prom ote venous return
• Restrict fluid intake
• Adm. loop diuretics
• ADH replacement (replace the missing hormone!)
• Vasopressin or desmopressin
• Monitor
•
• Adm. vasopressin antagon ists
Intake & output
• Weight
134
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MED-SURG
ENDOCRINE
ADRENAL MEDULLA DISORDER
.---- ADRENAL MEDULLA HORMONES: ----,
Epi neph rine • Norepi neph rine
0
PHEOCHROMOCYTOMA
RARE tumor on the ;1dren;1I gl;1nd th;1t secretes excessive
;1mounts of epinephrine & norepinephrine
L
J
CAUSES
• Fam ily history that makes them prone to developing the tumor
Adrenal qland
Too much
adrenaline
is re leased from
adrena l 9land
1
0
SIGNS & SYMPTOMS
TREATMENT
• Hypertension (severe)
• Ad renalectomy (if a t umor is p resent)
• Head ache
• Tel l the client not to smoke, d rink caffeine
o r change positio n suddenly
@
• Heat (excessive sweating)
• Hype rmetabolism
• Hype rg lycem ia
/
(
•Ad m. ant i-hype rtensives
_,,,,,--A 'd·------_ • Promote rest & ca lm environment
VO I
Stimuli!
I
\
\ • Diet: hig h in ca lories, vita mins, & minera ls
I
~
It may cause a
:
I
\
hypertensive
/
'-,,,
crisis! _,,,/
..... ___ __ .....
\
--
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135
MED-SUR6
RESPIRATORY
AUSCULTATING LUNG SOUNDS
TIP~ FnR Ll~Tl=NIN l " " " l l f - - - - - - - - - - - - - - - - - - Listen for a - - - - - - - - - - ,
..,._.,__~~.,.-...-...-...i111111i-...,
FULL INHALATION TO EXPIRATION
Listen d irectly o n the skin with the d iaphragm
on each spot
ANTERIOR
Listen ing inside the INtercostal spaces
(IN between
the ribs)
POSTERIOR
Will hear
lobes well
Will hear
lobes well
UPPER
Listen to t he anteri or & posterior chest
LOWER
Have the client sit upright (high fowler's),
arms resting across t he lap.
Instruct client to take deep breaths
Listen from top to bottom (com pari ng sides)
NORMAL SOUNDS
1;);m: (3: tt-00 i;fl3: #JD
(4Ji(3!l!J3
1
DESC jPTIO
DESCRIPTIO
High, loud & hollow tubular
DUP
Inspiration
DESCRIPTIO
Soft, low pitched,
b reezy / rushing sound
LOCATIO HEARD
A nteriorly only
(heard over trachea & larynx)
f );0:®m!J f00!tm
LO~TIO HE
Medium pitched, hollow
LOCATIO HE PD
D
Heard anterior & p osteriorly
Heard anterior & p osteriorly
:no
< expiration
DUR
:no
DURATIO
= expirat ion
Inspirat ion > expiration
Inspirat ion
ABNORMAL (ADVENTITIOUS) SOUNDS
c:, 3:G): iii: (!0!tlm!J: i❖)
DISCRETE CRACKLING SOUNDS
DESCRIPTION'
, High p itched, crackling sounds
(Sound like fi re crackling, or velcro coming part)
DESCRIPTION,
DUE TO:
EXAMPLE:
DESCRIPTION:
DUE TO:
EXAMPLE:
DESCRIPTION:
DUE TO:
13 6
EXAMPLE:
High-pitched m usical instrument with
• m ore than o ne type of sound q uality
(polyph onic)
Previously defl ated airways that are popping back open
DUE TO:
EXAMPLE:
Pulm onary edem a, asthma, obstructive d iseases
A ir moving through a narrow airway
Asthm a, bronchitis, chronic em physem a
Low pitched, wet bubbling sound
Inhaled air collides with secretion in the trachea or large bronch i
Pulmonary edem a, pneum onia, depressed cough reflex
DESCRIPTION'
High p itched wh istlin~ or gasping
• with harsh sound quality
Low pitched, harsh/ grating sounds
Pleura is inflam ed and loses it's lubricant fluid.
It' s literally th e surfaces ru bbing together d uring respirations
DUE TO:
EXAMPLE:
Disturbed airflow in larynx or trachea
Croup, epiglottis, any airway obstruction
CJ~EQUI~ES MEDICAL AITEN1WN
Pleuritis
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RFACTS
• CO PD is a prog ressive d isord er wh ich means the
d isease gets worse over time; it' s irreversib le!
Pulmonary disease
t hat causes
chronic airflow
obstructio n
• A lveo li sac lose their elasticity (inab ility to fu lly exhale)
.___ _ _ _ EMPHYSEMA or CHRONIC BRONCHITIS
fi
Smoking
w:l•Oi❖W:M•
• Breathing in harmf ul irrita nts
• Arterial b lood gases (ABG 's)
Occupation exposu re
• Chest x-ray
Infect io n
.
• Pulmonary fu nct io n test: Sp irometry
Air pollution
=
FVC
FORCED EXPIRATORY
VOLUME
FORCED VITAL
CAPACITY
(Protects the lining
..
of the lungs)
Genetrc a norma 11t1es ~
Obstructive lung disease
FEV1 / FVC ratio of less than 70%
FEV1
Deficiency of
Alpha1 - antitrypsin
.
.
-----
b
Asthma
Severe resp iratory infection in childhood
=
EMPHYSEMA VS CHRONIC BRONCHITIS
EMPHYSEMA---------.
Abnorm.il
distention
of .iirsp.i"s
Enl.ir9ement & destruction
of .iirsp.ice dist.ii to the
termin.il bronchiole
LIMITED
AIRFLOW
.J,
Hyperventil.ition (bre.ithin9 fast>
Tryin9 to blow off CO 2
t'-,.~'l t,.
CHRONIC·BRONCHITIS------.
02
&
t CO2
Mucus
secretion
Airway obstruction
Ci nflam mation)
Chronic productive couqh
& sputum production
for >3 months (within 2 consecutive years)
sit-\P'TOMS
<,\\i1
"PINK PUFFERS"
• Hyperi nflation of t he lungs
(barrel chest)
• Thin - weig ht loss
• Burn ing a lot of calories
from breathing a lot!
• Sho rtness of breath
• Severe dyspnea
• O verweight
• Cyanotic (blue) - Hypoxem ia
• .i 0 2 & t CO2
• Peripheral edema
• Rhonchi & wheezi ng
• Chron ic coug h
137
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MED-SUR6
RESPIRATORY
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
NURSING MANAGEMENT & EDUCATION
MONITOR RESPIRATORY SYSTEM
OXYGEN THERAPY
• Lung sou nds
• Sputum production ________
• COPD clients are st imulated to breathe due
to ,I, 0 2 (if you give too much 0 2... they lose their
"drive to breathe ")
• Oxygen status
• Healthy cl ients are st imulated to breath due to t CO2
Adm. 0 2 during exacerbations
or showing signs of respiratory d istress
LIFESTYLE MODIFICATIONS
• Smoki ng cessation
• Determine read iness
• Develop a plan
• Discuss nicotine replacement
Adm. oxygen with caution to clients with
CHRONIC HYPERCAPNIA (elevated PaC0 2 levels)
1 - 2 liters max
DIET MODIFICATIONS
•
•
•
•
Clients wit h COPD (especially emphysema)
are using a lot of their energy to breathe,
therefore burn ing a lot of calories
Promote nutrition
Increase calories
Small frequent meals
Stay hydrated
• Thins mucous secretions
TEACH PROPER BREATHING TECHNIQUES
iO~
small, frequent
mea Is t hat are
rich in PROTEIN
----
PROMOTES CARBON DIOXIDE ELIMINATION
• Pursed lips
• Diaphragmatic breathing
A llows better expiration by t airway pressure
that keeps air passages open during exhalation!
SURGERY
• Bul lectomy
• LVRS: lung vol ume reduction surgery
• Lung transplant
We want to use the DIAPHRAGM
rather t han the accessory muscles to breathe!
STAY UP TO DATE ON VACCINES
• Th is strengthens the d iaph ragm
and slows down breathing rate
• Influenza & pneumococcal vaccine
.J, the incidence of pneumonia
MEDICATION
BRONCHODILATORS
• Relaxes smooth muscle of lung airways = better airflow
• Symbicort (steroid+ long-acting bronchodilator)
CORTICOSTEROIDS
• .J, inflammation (oral, IV, inhaled)
• -•
• Example: Prednisone, Solumedrol, Budesonid
BUPROPION (ANTI-DEPRESSANT)
*For more information about respiratory medications, see the Pharmacology Bundle
" - ,uone"
"- inide"
"- olone"
- - ORDER OF EVENTS - Bronchodilator
Dilated airways
Corticosteroids
Airways are open now in
o rder for the steroids to
do its job!
136
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PATHOLOGY
Lower respiratory tract infection
that causes inflammation of ALVEOLI SACS!
gas exchange
takes place in
the alveoli. ..
so pneumonia
ca uses impaired
HEALTHY
PNEUMONIA
,;!],
~
gas exchange.
SYMPTOMS
RISK FACTORS
Can be COMMUNITY-ACQUIRED or HOSPITAL-ACQUIRED!
• t Temperature: mild - high fever
• t HR
• Prior infection
• t RR
• lmmunocompromised
♦ HIV, young/old,
♦ Attempting t o b low off CO 2
•
,I,
ALVEOLI IS INFLAMED
& FULL Of FLUID!
HEALTHY ALVEOLI
ARE WIDE & OPEN!
Lung diseases
auto imm une infections
0 2 saturation
Immobility
Aspiration risk
• Postoperative
• Chills
♦ COPD
• Chest pain
• Difficulty breathing
DIAGNOSTIC
• Productive cough
• Unusual breath sounds: coarse crackles & wheezes
Chest X-ray
t White blood cells
Sputum culture
• Respiratory acidosis
• t CO2
,1,
0
,;!],
2
shows pulmonary
infiltrates
or pleural effusions
INTERVENTIONS
can be
BACTElllAL, VIR.AL, or
FUNGAL
• Monitor...
♦
♦
♦
EDUCATE
Respirat ory status
Vital signs: HR, temp, & pulse oximetry
Color, consistency & amount of sputum
• Diet
♦
t Calorie
• t Protein
♦
t Flu id s (oral or IV)
♦
Small frequent meals
ihins se
.
& comp cretrons
d
ensates
ehydration
from fever
• Medications
♦ Antipyretics
• Antibiotics (only for bacteria)
♦ Antivirals
• Semi Fowler's position
♦
Bronchodilators
Cough suppressants
♦ Mucolytic agents
♦
Helps Jung
expansion
• Use of Incentive Spirometer ~
♦ Helps to pop open the alveoli
sacs & get the air moving
• Up to date vaccines
♦ Annua l flu shot
♦ Pneumococcal vaccine
• Smoking cessation
• Hand washing & avoiding sick people!
139
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PATHOLOGY
WALL IS
INFLAMED
& THICKEN
Chronic lung disease that causes an inflamed,
narrow, & swollen airway (bronchi & bronchioles)
• Exercise-induced asthma
• Certain drugs
• NSAIDS, aspirin
CLASSIFICATIONS
.
.
.
TIGHTENED
SMOOTH
MUSCLE
A
CAUSES
• Genetic
• Environmental
• Smoke, pollen, perfumes, dust mites,
pet dander, cold or dry air, etc. • ·• •
• GERO
·.
&
.
• ••
••
ASTHMATIC
AIRWAY
DURING ATTACK
ASTHMATIC
AIRWAY
NORMAL
BASED ON SYMPTOMS - - - - - - - - - - - - - - - - - ,
HILD INTERMITTENT
HILD PERSISTENT
< 2 a week
> 2 a week
Not daily
◄; t·1·)i;';i 13; !M@i iii f
SEVERE PERSISTENT
Daily symptoms & exacerbations
that happen 2x a week
Continually showing symptoms
with frequent exacerbations
SIGNS & SYMPTOMS
NURSING CARE - - - - - =--- - - - i
CHARACTERIZED BY FLARE-UPS
(meaning: it comes & goes)
• Assess client's airway
• Dyspnea (shortness of breat h)
• Provide frequent rest periods
• Tachypnea (fast respiratory rate)
• Adm. oxygen therapy
• Goal: keep the 0 2 at 95 - 100%
• Chest tightness
• Anxiety
0
STATUS
ASTHMATICUS
• High Fowler's position
• Maintain a calm environment to
Life-threatening asthma episode
Medical emergency!
OXYGEN
+stress
,&.
• Asses PEAK FLOW METER reading
• Wheezing
HYDR.ATION
...
• Asses for cyanosis & ret raction s
• Coughing
NEBU LIZATION
• Mucus production
• Use of accessory muscles
• AIR TRAPPING
~
,&.
Air trapping causes the client to retain CO2
which is
=IJEUlJEJ7~
MEDICATIONS
• BronchoDI_LATORS
/
RAPID RELIEF
Short-acti ng (Albu terol) _ ___,... PREVENTS
Long-acting (Salmeterol)
•ASTHMA ATTACKS
Methylxanthines (Theophylline)
SYSTEMIC CORTICOSTEROID
PEAK FLOW METER
"'
I
• Corticosteroids
_....,. ANTI-INFLAMMATORY
Suffix -ASONE & -IDE
AGENTS
Ex: Beclomethasone
• Leukot riene Modifiers
• Shows how controlled the asthma is & if it's getting worse
• Establ ish a baseline by performing a "personal best" read ing
• Client will exhale as hard as they can & get a reading
GREEN= GOOD
YELLOW = NOT TOO GOOD
RED= BAD
• Anticholinergics
' For more information about respiratory medications, see the Pharmacology Bundle
140
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MED-SURG
HEMATOLOGY
IRON DEFICIENCY ANEMIA
~ PATHOLOGY
........................................................................ • •
RED BLOOD CELLS ROLE
~ TYPE OF ANEMIA CAUSED BY .I, IRON LEVELS
~
L
Iron is ESSENTIAL to hemoglobin in red b lood cel ls.
I
~ The body uses IRON to make hemoglobin .
r
Hemoglobin carries oxygen to the cells!
CAUSES-----.
HEMOGLOBIN (HGB)
:;
Found in the RBC's
It 's a prot ein that contains IRON
__
,!:.
SYMPTOMS--------.i11
, ~-.,.
W
• Blood loss / hemorrhage
• Pallo r
• Malabsorpt ion
• Weakness & fatigue
• Inadequate dietary
intake of iron
•
Transports 0 2 & removes CO 2 from the
j
body w it h the help of hemoglobin (Hg b) 1
• Microcyt ic (sma ll) red blood cells
• ,I,
hemog lobin &
-1,
hematocrit
NOlf"iAL VALUES
Hemoglobin (Hgb)
Female: 12 - 16 g/d l
Male: 13 - 18 g/d l
Hematoerit (HCT)
Female: 36% - 48%
Male: 39% - 54%
IRON-RICH FOODS
r
E gg Yolks
Legumes
I ron-fortified cereals
A pricots
O ysters
Red meats
T ofu
Tuna
Po
ultry
N uts
Seeds
INTERVENTIONS--• Diet changes
Administerin9 Iron Supplements
• t Iron
• t Protein
+ ABSORPTION
1" ABSORPTION
Calcium:
Vitamin C:
Milk & antacids
Fruit ju ice & mu ltivitam in
• t Vitamins
• Ad min ister iron
• O ral, IM, o r IV
• D/ C any d amag ing d rugs
• If act ive bleed is suspected,
identify cause & control b leeding !
Liquid iron stains the teeth!
1. Take w it h a st raw
Side Effects of
Iron Supplements
2. Brush t eeth after
Black stool
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I
Constipat ion
)
Fou l aftertaste
141
PATHOLOGY
+ PLATELETS
~ Platelets help clot the b lood
~
Platelet aggregation
•
The clumping together of p latelets that form
/ ..············· Normal Platelet Count ··········•...
latelet d isorders
\. 150,000 - 450,000 per microl iter
··...............................................................................
............ Thrombocytopenia ··················.
a p lug at the site of the injury
~
+platelets = think BLEEDING
nlarged spleen
SYMPTOMS
• Weakness, dizziness,
tachycard ia, hypotension
• Purpura (bruising)
thanol (alcohol -induced)
• Bleeding from the gums & nose
oxins (drug-induced)
• Heavy menstrual cycles
• Prolonged bleeding t ime
• Petech iae (pinpoint bleeding)
• Blood in stool or urine
• t IN R & t PT/PTT
DIAGNOSIS
• Bleeding time
• Platelet transfusion
• aPTT - Activated partial thromboplastin time
• Bone marrow transplant
• Platelets are made in the bone marrow
• PT - Prothrombin time
• INR - International normalized ratio
• Splenectomy
• For t hose unresponsive to medica l therapy
• + Hgb & Hct
• Use electric razors
• Use small need le gauges
• NO aspirin
• Decrease needle sticks
• Protect from injury
IMMUNE THROMBOCYTOPENIC PURPURA CITP)
Formerly called "idiopathic thrombocytopenia purpura 11
PATHOLOGY
Autoimmune d isease where the body produces
antibod ies against its own th rombocytes (Pl atelets)
·· ITP ·····•....
< 20,000
·························
"Purpura" is in the name because it causes easy
bruising & petechiae in the trunk & extremities!
j
CAUSES
• Ch ildren after viral illness
• Females (ages 20 - 40)
• Pregnancy
142
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MED-SURG
HEMATOLOGY
HEMATOLOGY LAB VALUES
EXPECTED
RANGE
RED BLOOD CELLS
(RBCs)
WHITE BLOOD
CELLS (WBCs)
DESCRIPTION
F
4.2 - 5.2 X 10 6 /u l
M
4.7 - 6.1 X 106 / ul
4,SQQ
- 11,QQQ / UL ~
~ Fluid volu m e o verload ~
Red b lo od ce ll s
transport oxygen to
t he b ody's cells.
~
more volume
dilutes the R8Cs
Anemia
~ Renal d isease
(leek of erythropoiet in p roduction)
The white bl ood eel Is are a
p art of t he imm une system
and he lp to fight
G infe~ions and
~ Dehydratio n
/fluid vol um e d eficit
~ Hyp er activity of t he bone marrow
WBCs < 4,500 /u L
Q
~ ~B.>1 FQ
·
Less volume
concentrates
ihe RBCs
~ Hemorrhage
~ lmmunosuppress·on
WBCs > 11,000 /ul
~ Current or recent INFECTIONO
& inflammatio n
d iseases.
~ J?J.....::
PLATELETS
(PLT)
HEMOGLOBIN
(HGB)
HEMATOCRIT
(HCT)
ACTIVATED
PARTIAL
THROMBOPLASTIN
TIME (aPTT)
150,000
- 450,000 /ul
M
13-18 9/dl
It also retu rns CO 2 from t he
tissues back to the lun s.
F
36%-480/o
The percent of b lood
that is mad e up of
red b lood cell s
(expressed as a %).
M
390/o - 540/o
NORMAL
aPTT measures how
long it takes for a
b lood clot to form .
(net en 21nticea9,l:ants)
30 - 40 seconds
PLTs <150,000 /ul
,I, Platelets t hi nk
1.5 - 2.0
~
x t he norm.ii v.i lue ( -' :}
10 - 12 seconds
ON HEPARIN THERAPY
1.5 - 2.0
x t he normal v.i lue
NORMAL
(net en 21nticea9,l:ants)
<1
ON HEPARIN THERAPY
IN R.2.0 - 3.0
INR. 2.5 - 3.5
BLEEDING • :
~
~ Dehydratio n (hemoconcentratio n)
Anemia
~ Hemorrhage
~ Fluid ret ent ion (hem odilut ion)
~ Dehydratio n (hemoconcentratio n)
~
Anemia
~ Low oxyg en availability
(smo king , p ulmonary diseases
~ Hemorrhage
(COPD), high altitudes)
,,,,,
< o.s
mc9/ml
~ Heparin therapy
, ,,,,
Numbers ue LOW
Clots will GROW
---1-----
Prothrombin t ime
measures the amount of
tim e needed to form a clot.
It's also used to m on itor
~
RIN the effectiveness of t he
l=2._anticoagul ant: WARFARIN.
•
.
'
Numbers ue too UI GU
= Patient will 'DIE
(from increased bleeding)
~
Deficiency in vitamin K
~
Deficiency in d otting factor
~ Liver d'seese
-+----------+------------1
~ Werferin therapy
IN R is ca lcu lated from
t he prothrombin t im e an d
is used to m on itor o ral
anticoagul ants such as
WARFARIN.
Numbers ue LOW
Clots will GROW
,, ,,,
,M
~
Numbers ue t oo UI GU
= Pat ient will 'DIE
(from increased bleeding)
(l.nrt nl_. ,c,pl~tt.,nt)
D-DIMER
~ Certain cancers
~ Fluid ret ent ion (hem odilut ion)
~ Hype rcoagulable
the effectiveness of t he
anticoagul ant: HEPARIN.
PLTs > 450,000 /ul
~ Infectio n
ON HEPARIN THERAPY B ~ lt's also used to m onitor
NOR MAL
INTERNATIONAL
NORMALIZED
RATIO (INR)
Hemoglobin is an iron
containing protein found in
red b lood cells. It transports
oxygen from the lungs
to the t issues.
F
12 - 16 9/dl
(net en 21nticea9,l:ants)
PROTHROMBIN
TIME (PT)
Pl atelets help clot t he b lood.
Platelet agg regatio n is
t he clump ing togethe r of
p latelets that form a p lug
at the site of the injury.
D-d imers are fragments
of fibrin that are in the
b lood when a clot d issolves
or is b roken dow n.
0.4;.,., holps t. ~,,..;.. jf •
clot;, p,...nt -i..rw in tt..1""7
Additional tests are need ed
to confirm and determine a
specific d iagnos·s
~ Blood clot is ruled out
~ Blood clot may b e p resent
in t he body
)
MED-.SUR6
GASliRO
ACUTE & CHRONIC PANCREATITIS
e
PATHO
The islets of Langerhans
secrete INSULIN & GLUCAGON
Sudden inflammatio n that is
REVERSIBLE if p rompt recog nit ion
and treatment is done
INTO THE BLOOD STREAM
Pancreatic t issue:
secrete digest ive
enzymes that break
down CARBOHYDRATES,
• Gallstones
• Damages the ce lls of the pancreas
• Infection
• M ed ications
• Tumor
• Trauma
pancreas by its own
digest ive enzymes
released too ea rly
in the pan creas
• Recu rre nt damag e to the cells
of the pancreas
• Cystic Fib rosis
In CHRONIC, you w ill see different S&S
due to t he p rolonged damage & loss of function
In ACUTE, t here will still b e working
functions of t he pancreas.
1
AUTO-DIGESTION of th e
dden sever PAIN!
• Mid-epigastric pain LUO
• Chronic epigastric pain or no pain
• Pain t after drinking ETOH
or after a fatty meal
• Nausea & vomiting
• Fever
• t HR &
LABS
t
t
t
t
t
• Excessive & prolonged consumption of
alcohol (ETOH)
• Alcohol (ETOH)
PANCREATITIS is an
Chronic inflammation
that is IRREVERSIBLE
• Repeat ed episodes of acute pancreatitis
• Blocks the bile d uct
PROTEINS & FATS
@IliillI@
• Steatorrhea "fatty stools"
• Oily/greasy frot hy stool
+ BP
• Weight loss
• Can't d igest food p roperly
• t Glucose
Amylase
Li pase
• Mental confusion & agitation
WBCs
• Rigid/ board-like abdomen
• Jaundice
• Yellow ish color of the skin from
build up of b ile
Bili rubin
• Grey-Turner's Sign
• Bluish d iscoloration at t he fl anks!
• Diabetes Mellitus
• Damage to the islet of Langerhans
• Cullen 's Sign
• Bluish d iscoloration o f the umbil icus
•.Cullens = .Circle belly button
• Dark urine
• Fro m excess b ile in t he b ody
• Abdominal guarding
Glucose
,I, Pl ate lets
,I, Ca & M9
__J
MEDICATIONS
DIGESTIVE ENZYMES (EXOCRINE)
• Opioid analgesics
• Pancreat ic enzymes
• A ntibiotics
• Insulin
• Proton Pump Inhibitors (PPl's}, H2 antagonists, antacids
INTERVENTIONS
AMYLASE: Breaks d own carbs to glucose
PROTEASE: Breaks down proteins
LIPASE: Breaks down fats
• Rest t he pancreas!
• NPO (we don't want stimulat ion of t he enzymes}
• IV fluids
DIET
• Pain manag ement
• t protein
(no g reasy, fatty foods}
• Positioning
• Side lying ➔ fetal position, NOT sup ine!
• Li mit sugars
• Complex carbo hydrate
(fruits, veg etables, g rains}
• Insert NG tube
• Remove stomach contents
■ +fa t
• NO ETO H!
•
Glu cose
Blood pressure
lnt.ike & output
L.iboratory values
Stools
144
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MED-
Mi
Gl"S RO
IN FLAM MATO RY BOWEL DISEASE Cl 8D)
TRANSVERSE
•J,U:f·1
Inflammation that
occurs anywhere
in the GI tract
(mouth - anus)
Inflammation & ulceration
of only the large intestine
& rectum
ENDING
SIGNS & SYMPTOMS
• Cobble-stone appearance
• Fever
RECTUM
• Cramping after meals
A
W
colectomy
with ileostomy
• Ulcers cause
• Rectal bleeding
• Bloody diarrhea
• Abdominal cramping
• t HR & .i BP
• Hypovolemic shock
• Mucus like diarrhea (semisolid)
• Malnutrition
• Abdomina l distention
• Malaise
• Nausea & vom iting
• Dehydration
• Vitamin K deficiency
INTERVENTIONS
for the Acute Ph ase
Adm. fl uids, electrolytes . - - - - . _ _ _
or p arenteral nutrition
~
\)~iY1
Whole-wheat 9niins
Fruits & ~eqet.ibles
ftuts
Corticosteroids
lmmunosuppressants
Antid iarrheals
Sa licylate compounds
MONITOR
NPO
• Bowel sounds
• Bowel perfor:ation
DIET
• Peritonitis
• Clear liquids to +fiber
Caffeine
• t Protein
• Hemorrh:aqe
'-..
• Vitamins & iron supplements
• Stool
---------_ • Avoid gas-forming foods
AVOID SMOKING
• Color
• Consistency
• Presence of blood
' - - - - MEDICATIONS
145
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MED-.SUR6
GASliRO
TYPES OF HEPATITIS
HEPATITIS
"
• VIRAL (A, B, C, D, E)~
~
• EXCESSIVE USE OF ALCOHOL
LIVER INFLAMMATION
11
1NFLAMMATION OF THE LIVER
TRANSMISSION
HAV
• HEPATOTOXIC MEDICATIONS
11
SIGNS & SYMPTOMS
TREATMENT
lgM =
Active infection
Fecal & oral
• Food & water
lgG =
Recovered Ut 's ~one)
GI sy mptoms
8 IS BOTH
ACUTE &CHRONIC
DIAGNOSTIC
Anti-HAV
ACUTE ONLY
H8V
-4th_
CAUSED BY:
t hink
ody fluids
(Semen, saliva)
• Birth & blood
• Childbirth, sex,
& IV drugs
Supportive
therapy...
REST!
(N&V, stomach pain, anorexia)
ACUTE
HBsAG =
Active infection
Dark-colored urine
(lay-colored stool
Supportive
therapy & rest
Anti-HBs =
Immune/ recovery
CHRONIC
Antivirals
Vomiting
HCv
Body fluids
• Most common:
IV drug users
Flu-like symptoms
ACUTE &CHRONIC
HDV
ACUTE &CHRONIC
HEV
ACUTE ONLY
Anti-HCV
Antivirals
No post exposure
immunoglobulin
Interferon
HDAg
Antivirals
Anti-HOV
Interferon
Anti-HEV
Supportive
therapy...
REST!
J41undice
D ep ends o n
&D •
t
uDs
Hep D occurs
with Hep B
Fecal & oral
of the skin from the
bu ildup of bilirubin
• Food & water
uncooked meats,
3rd wo rld countries
EDUCATION FOR ALL TYPES OF HEPATITIS!
LABS:
• Rest
• + Protein & fat
• Diet
• Proper hand hygiene
• Educate o n toxic
substances to avoid
• Small frequent meals
• Do not share personal
hygiene products
• A lcoho l, acetaminophen,
aspirin, sedatives
• t Carbohydrates
• t Calories
• Avoid sex unt il hepatit is
ant ibodies are negative
Liver enzymes
ALT: 7 - 56 U/ L
AST: 5 - 40 U/ L
Bilirubin: <1 mg /dl
Ammonia: 15 - 45 mcg/ dL
ALL WILL BE ELEVATED IN HEPATITIS
146
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.. FUNCTIONS OF A HEALTHY LIVER ··
HEALTHY
LIVER
DETOX THE BODY
✓~
FATTY
HELPS TO CLOT THE BLOOD
CIRRHOSIS
LIVERn r ; ,. , - ~
v----
HELPS TO METABOLIZE
(BREAKDOWN) DRUGS
inc ruse liver
SYNTHESIS (MAKES) ALBUMIN
:,
dest ruct ion
~
due t o fat deposit s
the form~t ion of
sc~ r t issue of t he liver
=.....
Liver cells are DESTROYED and
replaced w ith fibrotic (scar) t issue.
Loss of no rmal function of t he liver.
... •
.. •
...
...
...
.
..................
CAUSES
.
ETO H consu mption
SIGNS & SYMPTOMS
• Chronic dyspepsia (GI upset)
• Jaundice
• Yellow discolorat ion
in t he eyes & skin
• t Bilirubin & ammonia
GI b leeding (esophageal varices)
• + Plat elets
Splenomegaly
• Edema
• It chy skin
• Risk for bleeding
• +WBC's
• Risk for infect ion
• A bdominal pain
• Electric razor
• Soft-bristled tooth brush
• Pressure on all venipuncture
• No mo re alcohol
A nemia
Hepat ic encephalopathy/ coma
• Due to t ammonia levels (ammonia is a sedative}
Hepat orenal Synd rome
• Acute kidney injury in clients with liver failure
MEDICATIONS ·
/
• Preven~ b leeding .
_ / • Paracent esis
• Bleeding precautions
• Removal of flu id from the
• Measure abdominal girth
peritoneal cavity (ascites}
• Daily weight s & l&O's
Portal HTN
• Porta l veins b ecome na rrow due t o scar t issue
Gynecomast ia
• Breast develo pment in men
···· TREATMENT ········
• Rest
...
.
...
COMPLICATIONS
• Ast erixis
• Liver flap
• Ascites
.....
..
Nonalcoho lic fat ty liver disease (NAFLD)
• Viral hepat itis B & C
• Toxins & parasites
• Au toimmune
• Fat col lection in t he liver
• Hepatotoxic drugs
(obesity, diabetes, t cholesterol}
• Liver t ransplant
• A ntacids
• Vitamins
THE LIVER CAN'T
METABOLIZE DRUGS
WELL WHEN IT'S SICK
• Diuretics
• Lactulose
• +serum ammonia through the stool
&
DO NOT GIVE ACETAMINOPHEN TO PEOPLE WITH LIVER ISSUES!
• Avoid narcotics
147
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HED-SURG
NEURO
NEUROLOGICAL ASSESSMENTS
MEN1Al! STAliUS
LEVEL OF CONSCIOUSNESS (LOC)
Level of CONSCIOUSNESS (LOC)
is always #1 with neuro log ica l assessment
A cha nge in LOC may be the
on ly sign that there is a PRO BLE M !
~
~
ARE THEY AWARE OF THEIR SURROUNDINGS?
~
ARE THEY ORIENTED TO PERSON, PLACE, TIME, & SITUATION?
~
DO THEY HAVE THEIR SHORT TERM & LONG TERM MEMORY?
~
,,.,,,, ...
----- ......... ,
/
PUPILLARY CHANGES
PERRLA
Pupils, Equal, Round, React ive to Lig ht & Accommod at io n
®
NORMAL PUPIL SIZE: 2 - 6
mm
TOOL FOR ASSESSING A CLIENT'S RESPONSE TO STIMULI
= No response •
= Present, but sluggish o r diminished
~ = More b risk t han excited; Hyperactive
No response
Oriented
5
~ intermittent, or transient clonus
Confused
4
Inappropriate words
None
3
2
1
Obeys command
6
Localizes p.iin
5
Withdraws
4
Flexion
3
2
1
To p.iin
None
3-15
t;
8
CD
3
2
1
Extension
a:
A.
a:
• What are you doing here?
To speech
MOTOR
RESPONSE
3
<8
(1\lJ 15
• Who is t he current U.S. president?
4
Unclear sounds
LU
• Do yo u know what mont h it is?
Spont;rneous
EYE
OPENING
RESPONSE
le
I-
............ ___ .,..,,
~
• Do yo u know where you are?
)
GWGOW COMA SCALE
VERBAL
RESPONSE
• What is your name?
~sk these
\
I
•
\
: types of ciuest1ons ~
I
I
,
to ;;issess
,
\
I
\ mental status: ,'
''
,
'
,,
Severe imp.iirment of neurolo9iul function, com.i, or br.iin de.1th
Unconscious patient
~ = Active or expected response •
/'fl\ = Bri sk, Hyperactive, w it h
ELICITED BY STROKING THE
LATERAL SIDE OF THE FOOT
rrThe lateral so le of the foot is st roked
and t he t oes contract & draw toget her.
•D
cr11
J
C
Toes fan out w hen st ro ked .
Remember this is only normal in new borns &
infa nts up t o 2 years of age, b ut abnorma l in ad ults!
Normal in Babies & th e Big t oe fans out
Fully .ilert & oriented
146 ~~~~-~~~~~~~
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WHAT IS A
SEIZUR'?
Abnorma l & sudden
elect rical activity of the brain
WHAT IS
EPILEPSY?
Chronic seizure activity
due to a chronic condition
~
• t fever
• Hypoxia
(Febrile seizure in child)
When symptoms start
before t he actual seizure
Warning sign right before
the seizure happens:
(can be d ays before
t he seizure happens)
• Weird smell or taste
• Brain tumor
• CNS infect ion
• Hypoglycemia
• Drug o r alcohol withdrawal
• Head injury
• A BG imbalance
• Hypertension
• Altered vision
• Dizzy
GENERALIZED
SEIZURES
SEIZURE!
Recovery after t he seizure
Status Epilepticus:
a seizure that lasts
>S minutes w ithout
any consciousness
during the seizure
• Headache
• Possible injury
• Confusion
• Very tired
SEIZURE PRECAUTIONS
" Used to be called grand-mal"
May begin w ith an aura.
Stiffening (tonic) and/ or
rigidity (clonic) of t he muscl es.
maintain a
patent airway
have oxygen &
Sudden jerking or stiffening
of t he extremit ies (arms or legs).
Remember if the seizure lasts
> 5 minutes is status epileptics.
This needs IMMEDIATE attention
suction avai lable
Usually looks like a blank
stare t hat lasts seconds.
Often goes unnoticed
Sudden loss of muscle tone.
May lead to sudden falls
or dropping t hings.
pillow
under
head
Sensory symptoms wit h motor
symptoms and stays aware.
They may report an aura.
Altered behavior/awareness
and loses consciousness
for a few seconds.
bed in
lowest position
client in
side-lying posit ion
(immediately post -seizure)
DON'T----------~
• Restrain t he client
• Place anything in t heir mouths
• Force t he jaw open
• Leave t he cli ent
149
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"Thromb ot ic or embolic"
RUPTURED ARTERY
THROMBOSIS: b lood clot that formed on the artery wall
ANEURYSM (weakening of the vessel)
EMBOLISM: A clot has left part of the body
UNCONTROLLED HYPERTENSION
Blood flow is cut off w hich leads to ISCHEMIA.
The collection of b lood i n t he b rain
leads to ischemia & increased ICP
TRANSIENT ISCHEHIC ATTACKS: •T1A s•
1
"Mini strokes"
The sam e p athology as a stroke
but no cerebral infa rction o ccurs
:. . . . . . . . . . . . . . . . . . . . . . . . i
•
TREATMENT
•
•
~
STOP THE BLEEDING
PREVENTINCREASEDICP
FIBRINOLYTIC THERAPY
(TPA) TISSUE PLASHINOGEN ACTIVATOR
DISSOLVES DOWN ,UE BLOOD CLO,,
Poor prognosis
Avoid IM injections
Needs caref ul monitoring in an intensive care unit
Avoid unnecessary IV punctures
Prevent injury (bed rest )
the b rain
Blood may need to be removed to ,I, p ressure on
Check fo r b leeding
.. -----..
RISK FACTORS
TYPES OF APHASIA
• Arm numbness;
can 't lift arm
RECEPTIVE
S peech d ifficu lty
• Slurred speech
Unable to comprehend
speech
(WERNIC l<E'S AREA)
T ime t o call 911
~
EXPRESSIVE
Can comprehend
speech
(but can't respond
back with speech)
• Hypertension
• Atherosclerosis
• Anticoagulation
therapy
• Diabetes Mellitus
• Obesity
• Stress
• Ora l contraceptives
• Fami ly history
of strokes
• O lder age
• Ma le gender
• Black
• Hispanic
(BROCA'S AREA)
.:· NURSING MANAGEMENT ...................................................................:.
: ♦ Assist w ith saf e feeding
• Do not feed until gag reflex
has come back
• +chances of aspiration
• Keep suction at the bedside
• Crush medications
LIQU ID
•
•
•
•
Thi·n
Nectar-like
Honey-like
Spoon-thick
♦ Positio ni ng of the client ♦ Assist with communication skills
• Elevate head of
the bed to + ICP
• Place a pillow under
the affected arm in a
neut ral posit ion
FOOD
• Pureed
• Mechanically altered
• Mechanically softened
• Regular
: PREVENTATIVE DVT
: MEASURES
Compression stockings
• Frequent position
♦ Preventative DVT measures
:
change
♦ Assist with Activities of Daily Living (ADL's) : • Mobilization
/ 7••
♦ Encourage passive range of motion
every 2 hours
♦ Communication
• Be patient
• Make c Iear statements
• Ask simple questions
• Don't rush!
~
• Frequent rest periods
• Dress
the affected
side first
• Support affected side
150
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xn:
HYPOGLOSSAL
FUNCTION:
H
O oh,
O oh,
O oh
To
Touch
A nd
Feel
Very
G ood
Ve lvet.
Such
Heaven!
GLOSSO MEANS TONGUE!
Tonque movement (sw~ l lowinq & speech)
TEST:
Insp ect tongue & ask to stick tongue out
XI: SPINAL ACCESSORY H
FUNCTION:
O lfactory
O ptic
O cu lomotor
T roch lear
T rigem ina l
A b d ucen s
Facial
Vestibulocochlear / A coustic
G lossopha ryngeal
Vagus
Sp inal Accessory
H ypog lossa l
Some
Say
M arry
M oney
But
My
Broth er
Says
Big
Brains
M atter
M ore
1: OLFACTORY
Sensory
Sensory
M otor
M otor
Both
M otor
Both
Sensory
Both
Both
M otor
M otor
FUNCTION:
Sense of smell
TEST:
Smell substance with eyes closed
(test each nostril sep arately)
@
Controls strenqth of neck & shou lder musc les
11: OPTIC
FUNCTION:
TEST:
Vision
Ask the client to rotate their head & shrug
their shoulders
TEST:
r
-~
E
F p
TOZ
LP ED
P E CF O
• Snellen chart
• Ophthalmoscopic exam
• Confrontation to check
peripheral vision
~
X: VAGUS
SE
FUNCTION:
MOTOR. - Sw~llowinq, spe~kinq, & couqh
SENSOR.Y - hci~ I senution
TEST:
Sensation coming from skin around the ear
Oc ul u (eye) moto r (movement)
Controls most eye movements,
pupil constriction, & upper-eyelid rise
'"~ •tlM·Ul·P:f:i;ti:tai:11
rn c
Osso
FUNCTION:
MEANS TONGUE!
TEST:
GL
• Lookup, down, & inward
• Ask the client to fo llow your fi nger
as you move it towards their face
MOTOR. - Tonque movement & sw~ ll owinq
SENSOR.Y - faste (sour & bitte r)
TEST:
XII
Test tongue by giving client sour, bitter, & salty substance.
vm:
VESTIBULOCOCHLEAR / ACOUSTIC SE
FUNCTION:
FUNCTION:
Cont rols downwud & inwud eye movement
hl~nce & heu inq
TEST:
TEST:
• Stand with eyes closed
• Otoscopic exam
./
• Rinne & Weber Tests - - - - -
VII: FACIAL
8
R.INNE TEST
@
• Look up, down, & inward
• Ask the client to follow your finger
as you move it towards their face
WEBER. TEST
VI: ABDUCENS
~
FUNCTION:
FUNCTION:
FUNCTION:
MOTOR. - hci~I exp ression
SENSOR.Y - faste (sweet & u lty)
Controls pu~l lel eye movement
Abduction - movin g laterally
AKA away from m id line
MOTOR. - M~stic~tion (bitinq & chewinq)
SENSOR.Y - F~ci~I senution
TEST:
• Ask client to do different facial expression
(Frown, smile, raise eyebrows, close eyes, b low etc)
• Test tongue by giving client sour,
sweet, bitter, and salty substances.
TEST:
• Look up, down, & inward
• Ask the client to fol low your finger
as you move it towards their face
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TEST:
• Pressure on the forehead cheek & jaw
with a cotton swab to check sensation
• Ask client to open mouth
& then bite down
151
.__- - - - - - ~.....................................................................................................
WHAT ARE
Ne rves that oriqinate from the brain stem .
CRANIAL NERVES? They send info rmation to & from va rious pa rts of the body.
_. .....................................................................................................
_______
~
<
xn:
FUNCTION:
TEST:
O~x_,=________._<
FUNCTION:
MNEMONICS
Ooh,
Ooh,
Ooh
To
Touch
A nd
Feel
Very
Good
V elvet.
Such
Heaven!
O__
O__
O__
T__
T__
A__
F__
Some
Say
M arry
M on ey
But
My
Brother
v_ _ _ / A . _ _ Says
G
Big
V
Brains
S
M atter
H
M ore
~
l~:
S_ _
S_ _
M__
M__
B._ _
M__
B_ _
S_ _
B._ _
B._ _
M__
M__
SE
SENSORY
M
MOTOR
8
BOTH
<
1:
FUNCTION:
TEST:
~
E
FUNCTION:
TEST:
<
11:
F p
TOZ
LP ED
P
= CF
0
<
FUNCTION:
TEST:
©,.. ._!_1x:_ _ _ _ __
~<
FUNCTION:
TEST:
XII
('p) vm:
<
FUNCTION:
Ci.
IV:
FUNCTION:
<
TEST:
TEST:
~
ce)
vn:
TEST
<~
VI:
TEST
< ~ v:
FUNCTION:
FUNCTION:
FUNCTION:
TEST:
TEST:
TEST:
<
WANT MORE WORKSHEETS?
152
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MED-SURG
CRITICAL CARE
,~f.~,
WHAT IS ABURN?
~ ·,
l>;ima9r to skin inte9rity
r··············
BURNS INJURY DEPTH
SUPERFICIAL - - - - - - - - - - - - = - - - . .
TYPES OF BURNS ···········
BLANCHING:
present
• Epidermis
• Pink & painful (stil l has nerves)
HEALS:
a few days
• No scarring
Superficial he at
Examples: liquid, steam, fire
SUPERFICIAL PARTIAL THICKNESS - -
CHEMICAL
BLANCHING:
present
• Epidermis & d ermis
Bu rn cause d by a toxic substa nce
Can be Alkali or Acidic
Examples: bleach, gasoline, paint thinner
• Blist ers, shiny, & moist
HEALS:
2 - 6 weeks
• Pai nfu l
RADIATION
Sunburns (UV radiation)
& cancer treat m ent (radiation therapy)
FULL THICKNESS - - - - - -.. . . . .
INHAL.ATION
• Epidermis, dermis, & hypoderm is
Caused by inhaling smoke which can cause
fla me injury or ca rbon monoxide poisoni ng
• May look black, yellow, red & wet
• No pain/ li m ited pai n (nerve fibers are d estroyed)
FRICTION
• Skin will not heal (need skin grafting)
Bu rn cause d when an object rubs off the skin
Examples: road rash, scrapes, carpet burn
• Eschar: dead tissue, leat hery; must b e removed !
Skin has been overexposed to cold
Example: frostbite
LAYERS
of the skin
J,
El ctncal current t hat passes
o ugh the body causing damage within
POTEN11Al COHPUCATIONS
'=I==. . ·-·
. -··- -
I
EPIDERMIS
DERMIS
HYPODERMIS ~I_ _.,______...___,,.----,_.-,,-
~-~~~
Dysrhythmias, Fracture of bones
Release of myoglobin & hemoglobin
into the blood which can clog the kidneys.
Slbcut/htty tissue
r ······................
'
BURN LOCATION
················
RESPIRATORY
DISABILITY
TROUBLE HEALING
•
•
•
•
•
•
•
•
• Poor blood supply
• Diabetes
• Infection
Face
Neck
Che st
Torso
Hands
Feet
Joints
Eyes
INFECTION
COMPARTMENT SYNDROME
Any open area where
bacteria can easily enter
• In the extremities
Tight skin such as eschar acting
• Perineum
• Ears
• Eyes
like a band around the skin
cutting off blood circulation
····································································································
INHALATION INJURY
Damage t o the respirat ory system!
Happens mostly in a c:losed area
~--'-- SIGNS OF - ~
INHALATION INJURY
Hair singed
around the face,
neck or torso
Trou ble talking
Soot in t he nose or mouth
Confusion or anxiety
CARBON MONOXIDE (CO)
POISONING
Carbon monoxide travels
faster than oxygen, making
it bind t o hgb first.
Now oxygen cannot b ind
to hgb = HYPOXIC
Classic symptom: cherry red skin
Treatment: 100% 02
----NOTE:---Oxyge n saturation may appear normal
153
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EHERGENT PHASE
©
Onset of Inju ry to th e restorat ion of cap ii lary permeability
24 - 48 HOURS
after burn
PATHO--------~
VITAL SIGNS--~ . . . NURSING CONSIDERATIONS
t Capillary permeability (leaky vessels) causing:
t Pulse
• Plasma leaves the intravascular spacj
• A lbumin & sodium follows
+ Blood pressure
+ Cardiac output
Lr~ds to
Edrm~
Fluids shih to the interstit ial t issue
]
TIIINI:
HYPOVOLEMIC
SHOa?
• Fluids (Lactat ed Ringer's, crystalloids)
• Fo ley catheter to monitor urinary
output (UOP)
GOAL: > 30 ml/hr of UOP
(fro m ,I. p e rfusion to the
kidneys)
t Potassiu m (K+)
t Hemat ocrit (HCT)
,1.
W hite Blood Ce lls (W BCs)
• Decrease edema
- Elevat e extremities
above heart level
t BUN / Creatine
~ ~~~~~-~~~!;,.Q -
©
t o wound closu re
- PATHO----------~
Capillary permeab ility is restored w hich leads to t he
body d iuresing (increased urine production). All the
excess fluid t hat shifted from t he int erstit ial t issue
shifts back int o the intravascular space.
- GOALS - - - - - - - - - • PREVENT INFECTION
- Systemic ant ibiotic t herapy
• ENSURE PROPER NUTRITION
- Needs t calories
- Prot ein & Vit C t o promote healing
• ALLEVIATE PAIN
• WOUND CARE
- Always prem edicate before wound care!
- Debridement or grafting
i
• Establish IV access (preferably 2)
• Parkland form ula
+ Urine output
Leads to f luids volume deficit <FVD)
in the intravascular space
1
I
•
48 - 72 HOURS
after burn & until wounds have healed
NURSING CONSIDERATIONS - - - - - - ~
• RENAL
• Diuresis is happening
• Foley cath et er t o m onitor UOP
• RESPIRATORY
• Possib le intubat ion if respirat ory complicat ions occurred
• GASTROINTESTINAL
• Since t he client is in FVD, t here is
+ perfusion t o t he st o m ach
• Paralytic ileus
• C urli ngs ulcer
• Med icat ion t o d ecrease chance o f ulcers
• H2 hist ami ne blocking agent (+HCI)
• Monit or bowel sounds
• May need NG t ube for suctioning
R EHABILITATIVE PHASE
Bu rn healed and the patient is funct ioning mentally & physically
GOALS - - - - - - - - - - - - -- 9-\1• Psychosocial
• Activities of daily living (ADLs)
• O ccupational t heory (O T)
• Cosm etic correct ions
• Physical t herapy (PT)
154
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RULE OF NINES
Used to calcu late the tota l volume of
fl uids (m l ) th at a p atient needs 24 hours
after exp eriencing a burn
Apply only in 2nd & 3rd de gree burns.
................
Quick est imate of th e % of the
total body surface area (TBSA)
has been effected by a p artial &
full-th ickness burn in an adult client.
4 ML X TBSA (0/o) X BODY WEIGHT (KG)
= TOTAL ML OF FLUID NEEDED
"-:======~ .::::::::::=====~
Give th e fi rst½ of the solution
in the FIRST 8 HOURS
- - -~- - Over the NEXT 16 HOURS,
give the second ½ of the solution
·· ······················································································································· ·····
I
I
PRACTICE QUESTION
A 25 yea r o ld ma le p at ie nt who we ig hs 79 kg has
susta ined bu rns to the back o f t he right a rm, p oste rio r trunk, front of t he left leg, and t he ir ante rior he ad
and neck. Using th e Rule of Nines, ca lcu lat e t he tota l
body surface a rea pe rcentag e t hat is burned .
Back of right arm - 4.5%
]
Posteri or t ru nk - 18%
Front of left leg - 9%
Anteri or head & neck- 4 .5%
ANSWER:
360/o
The for m ula uses TBSA (%). Howe ver, you m ust
calculate using 3 6. Not 0 .36 (a lso written as 36%).
Use th e Parkland fo rmu la to ca lculate
the tota l a mount of Lactated Ringe r's
so lution that wi ll be g ive n over t he
next 24 hou rs.
4 ml X 36% X 79 kg • 11,376 ml
,--------*--------,
11,376 / 2 • 5,688 ml
FIRST
ANSWER:
11,376 ML
8 HOURS
,--------•--------,
11,376 / 2 • 5,688 ml
NEXT 16 HOURS
Keep in m ind: the question could a sk you for mL g ive n in th e first
24 hours, the first 8 hours, e tc., so read the q uestion care fully.
155
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WHAT IS SHOCK?
~
A life-threaten ing cond it ion resulting from INADEQUATE TISSUE PERFUSION.
This leads to p ossible cel l dysfunction, cel l death, and even organ fa ilure.
ETIOLOGY - - - - SIGNS & SYMPTOMS ---TREATMEN
➔ Large gauge IVs (at /east 2)
, S ,~YPOVOLEMIC
•Low•
HR
BP
➔ Fluids
~
,L
,J.
co
Pulse
"VOLUME·
"IN THE BLOOD"
Weak,
thready
pulse
Decreased intravascula r volume
CAUSES
NON-HEMORRHAGIC
{not from bl,,din )
(example: normal saline
or Lactated Ringers)
Not a lot of Tachycardia
blood b eing Compensating
pumped by
to increase
the heart
blood flow
CVP
Skin
• FLUID SHIFT c~d~m~ or .ucitu)
• Colloids (albumin)
Hypotension
• Blood products
(p lasma, PRBCs, & PlTsJ
SVR
Other Signs & Symptoms
r:
Cyanosis
• SEVERE DEHYDRATION
(Bluish t int of
the lips, tongue,
(w,mitin9, diurhn, burns)
t HCT hemoconcentration
,1.
and fingertips)
HEMORRHAGIC
{from blt!t!din )
Cool, pale skin
. .
HCT actually hemorrhaging
the RBCs
+ blood being
perfused to the • Oliguria (urine output of <30 mUhr)
Vasoconstnct1on body = low
capillary refill
(>3 seconds)
,I.
• TRAUMA
• GI BLEED
• POSTPARTUM
& blood replacement
• Crystalloids
02
• Confused, agitated
~
due to decreas:_~- •~
C :od flow to the brain . /
SIGNS & SYMPTOMS ---TREATMENT---
ETIOLOGY
The heart can't pump
enouq h blood to meet the
perfusion needs of the body
Pulse
co
J,
NOTE:
There is enough blood,
Weak
peripheral
pulses
00
I
t he heart just can 't
pump it to the body
which causes fluid
accumulation in
t he lungs!
HR
BP
~
J,
Tachycardia
Not a lot of
blood being Compensating
pumped by
to increase
the heart
blood flow
Hypotension
➔
For an Ml: Angioplasty
Thrombolytics
➔ Oxygen
➔
~ Vasopressors
Vasopressors
.
.
(example: epmephrrne,
dobutamine, dopamine)
➔
Diuretics
• ,I.
• ,I.
cause vasoconstriction
which t blood flow
and increases
perfusion to
the organs
t he workload of the heart
extra blood volume
➔ (helps
Intra-aortic balloon pump ,
to improve coronary
artery blood flow & t CO)
,•
!!
~
;:
Diastole Systole
Skin
CAUSES
• Damage from an acute M l
• Severe hypoxemia
Cool,
clammy
skin
• Acidosis
• Hypoglycemia
capillary
refill
(>3 seconds)
,I.
• Cardiomyopathy
• Cardiac tamponade
• Dysrhythmias
BP
= llood pre11ure
CVP
SVR
Other Signs & Symptoms
• Jugular vein distention (JVD)
~
• Chest pain
• Oliguria (urine output of <30 mUhr)
• Confused, agitat ion
Vasoconstriction
blood being
perfused to the
body = low02
,1,
(
~
~
d ue to decreased ~ ;!::;'.)
od flow to the brain
From fluid
• Dyspnea
accumulation
in the lungs: • Pulmonary edema
HR= Heart rate CO= Cardiac output SVR = Systemic vascular resistance CVP = Central venous pre11ure
156
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MED-SURG
DISTRIBUTIVE SHOC~
CRITICAL CARE
(Se tic, Neuro enic, An~ h l~ctic)
Lea ky blood vessels
DISTRIBUTIVE:
•
'
'
ln t ravascular vo lume
poo ls in t he p eriph eral
blood vessels
-+
Excessive vasodilation
(w id ening o f vessels)
ETIOLOGY
TREATMENT
Caused by widespread infection or sepsis .
CORRECT THE UNDERLYING CAUSE
➔ Fluid replacem ent
➔ Broad-spectrum antibiotics ~
CAUSES
•
•
•
•
-+
Since t he blood is in t he
p e rip he ral s, it is NOT p e rfu sing
t he vi ta l o rg ans w hich causes
relative hypovole mia
➔ Vasopressors (norepinephrine & dop amine)
Pneumonia
• Wound infection
Urosepsis
• Invasive procedures
Bacteria
• lndwellin9 medical devices
Intra-abdominal infections (catheters)
➔ N euromuscular b lockade agents & sedat ion
• +metabolic demands & provides comfort
➔ M ed ications to prevent stress ulcers
• H2 b locking agents
• Proton pump inhibitors (PPls)
SIGNS & SYMPTOMS
Pulse
co
HR.
Bounding
pulses
~
~
BP
CVP
Init ially warm & flushed,
but as the BP drops,
the skin becomes cool,
pale & mottled
Other Si9ns & Symptoms
➔ Hyperth ermia & fever
➔ Increased respiratory rat e
Tachy cardia
Skin
Hypot ension
➔ GI upset: Nausea, vomiting, d iarrhea,
decrease gast ri c motility
SVR.
➔
J,
Broad spectrum
antibiotics are used when
the o rganism is not yet
known/ d etermined.
O nce th e organism is
known, th e client can
b e put o n more specific
antib iotics.
J,
t Inflammatory markers
t WBCs
t C-reactive protein (CRP)
Vasodilation
Remember
parasympathet ic
FTIOLOGY- - - - -SIGNS & SY PTO~S
1
Vasodilation due to a loss of balance between
co
~~
In neu rogen ic shock, t he
client mainly experiences
parasymp athetic
st imulation w hich causes PARASYMPATHETIC
STIMULATION
VASODILATION for
an extended period
,,,,.. RELATIVE HYPOVOLEMIA:
SYMPATHETIC
STIMULATION
......
_,,,,,,
There is enough b lood
Hypotension volume. However, the vascular
space is dilated, so b lood
volume is d isp laced causing
t he sympathetic NS is not working
hypovolemia.
t o compensate & t t he HR
(
-
, " ',
Skin
PARASYMPATHETIC
➔ Cau ses dilation (relaxing)
STIMULATION
of the smooth muscles
(~st & di9..,t)
•
P think
Peaceful
)
(veno us blood pooling)
Hypother mia:
warm/ d ry extremities,
cold body
TEAT E
Vasodilation
DEPENDS ON THE CAUSE OF THE SHOCK
➔ Spinal cord injury
• Spinal cord injury
(;,bove T6, cenic;,ll
• Spinal anesthesia
• Nervous system dama9e
➔ Assess & manage airway
M ay ne ed intubation o r mech anical ventilation
PROTECT THE SPINE:
Keep spine imm obilized
➔ IV fl uid s
& Watch for fluid ,olume overload
➔ Increased risk for clots due t o pooling of blood
• Watch for sign s of a clot ~
• Compression devices
• An tit hrombotic agents (heparin)
NEUR09enic = Issue with NERvous system
y
(cervical collar, b ackboards,
lo g-ro lling)
➔ Elevate t he head of the bed
," ', • Insulin reaction
•
SVR.
CVP
Dry, warm extremities
SYMPATHETIC
➔ Cau ses constriction (t ight ening)
STIMULATION
of the smooth muscles
<Fi9ht or fli9ht>
CAUSF.S
means
RELAXED EVERYTHING
HR.
S&S OF BLOOD CLOTS:
, Pain in th e extremities
• Redness
• Tend erness
• Warmth
I 1
·
_
➔ Vasopressors (example: epinephrine, dobutamine, dopamine)
BP= l lood pressure HR = Heart rat e CO= Cardiac output SVR= Syst emic uscular resistance CVP = Central ,enous pressure
157
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DISTRIBUTIVE:
Leaky blood vessels
Excessive vasodilation
(widening of vessels)
➔
lnt ravascula r volum e
pools in t he p e ripheral
blood vessels
➔
- - - - - SIGNS & SYMPTOMS - - - -
ETIOLOGY SEVERE ALLERGIC REACTION
Pulse
co
HR
BP
Rapid, weak pulse
J,
~
J,
Tachycardia
Hypotension
Forei9n subst.ince fanti9en)
+
+
+
+
}
Systemic .inti9en-.intibody reaction (l9E)
CAPILLARY PERMEABILITY:
Fluid is leaving the intravascular space
Mast cells rele.ise potent v.iso.ictive subst.ince •
(hist.imine/br.idykinin)
~
Activates infl.imm.itory cytokines
Since the blood is in the
peripherals, it is NOT perfusing
t he vital organs wh ich causes
re lative hypovolemia
.~ .
Skin
Generalized flushing
Causes VASODILATION & capillary permeability
CAUSES/TRIGGERS
Often unknown (idiopathic)
• Foods (example: pe.inuts) ,
~
• Medications
• Insects (example: bee stin9)
SVR
CVP
%
• Latex
• Exercise-induced .inaphylaxis (EIA)
Vasodilation
Other Signs & Symptoms
* CARDIAC
* RESPIRATORY
• Cardiac dysrhythmias
or cardiac arrest
• Bronchoconstriction
• Difficulty breathing
• Wheezing
• Coughing
• Unable to sp eak
* GI
• Nausea/vomiting
• Acute abdominal pain
* SKIN
* FEELING OF
~
• Itching, generalized flushing, redness,
hives, or a rash may be present
IMPENDING DOOM
Signs & symptoms usually occur
with in 2 - 30 minutes of exposure to antigen
➔
HOW-TO USE AN EPINEPHRINE
AUTO-INJECTOR (EAi)
H;gh-flow
o:~.~ATHENT • . ' .
➔ First-line drug: EPINEPHRINE *
➔ Store in dark room
• Causes vasoconstrict ion & bronchodilation
➔ Other possible medicat ions
• Ant ihistamines
• Diphenhydramine (Benadryl)
• Albuterol (Provent il)
• Corticosteroids
➔ Fluids
➔ Stay with the client & monitor
EDUCATION POINTS:
t
BIPHASIC ANAPHYLAXIS:
A recurrence of anaphylaxis
after appropriate treatment
➔ Administer EAi immediately
after the first sign of an
allergic reaction
EXPECTED SYMPTOMS
AFTER ADMINISTRATION:
➔ Tachycardia
➔ Palpitat ions
➔ Dizziness
~
§
'-----------t!
;:p .replmte ,n,e~t,e11, V5P
~IUCTOa
i
;
BP= l lood pre11ure HR= Heart rate CO= Cardiac output SVR = Sy,temic u,cular re>itbnce CVP = Central venou, pre11ure
156
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It
[!}
DID©
ARTERIAL
~
+
BLOOD
GAS
ABGs MEASURE HOW
C@l•lts@~
THE BLOOD IS IN THE
ARTERIAL CIRCULATION.
"also a measure of 9ases
such as 02 & Co2
II
II
II
Measurement of how
acidic or alka lotic you r blood is
re9u lated by both
lun9s & kidneys
Measurement of
carbon dioxide in the blood
CO2 think aCid
R.e9ulated
by the lun9s
Measurement of
bicarbonate in the blood
Bicarbonate think Base
R.e9ulated
by the kidneys
•
-
Measurement of
oxy9en in the blood
\
I
I
7,35-7A5
B
B
R.e9ulated
by the lun9s
80-100
tt
Value not needed to interpret alkalosis or acidosis.
It just tells you if the patient is hypoxic or not.
J J
-
---omt11mmmm--~
KNOW YOUR LAB VALUES!
CIDOSIS
ALICALOSIS
PH
<7,35 (±) 7.35 - 7.45
CO 2
>45
HC03 < 22
~
ROME METHOD-~
- _- _- -~
NORMAL
0
35- 45
©
22 - 26
RESPIRATORY OR A METABOLIC PROBLEM? •
>7.IJ5
(!)
< 35
©
>26
,.......____ ~ ~ :==~
TIC-TAC-TOE METHOD
ACID
NORMAL
BASE
...,............._ ____. ~ ~ ~----.0~
0
PH
ual- 1 PH
t ~
-1-
3
t
Alka
I HC0 +IAddo
3
UNCOMPENSATED, PARTIALLY COMPENSATED, OR FULLY COMPENSATED?
If the PH is out of ranqe &
CO2 or HCO3 is in ranqe
=
UNCOMPENSATED
If CO2, HCO, & PH
ALL out of ranqe
=
If PH is in ranqe
(7.35 - 7.'l-5)
=
are
PARTIALLY
COMPENSATED
FULLY
COMPENSATED
7.35
7.45
7.40
Acidosis
Alblosis
Absolute
Norma l
( . PH IN RANGE? Just btc••" th, PH is "nonn• I", it un st ill foll on• ><idotic ,id• or •lk>lotic , id•
. - - - - - - - - - -KIDNEYS- - - - - - - - - - LUNGS- - - - - - - - - ,
How do the
or9ans
Com pen sate?
Excreting excess
~
-
BICARB
HYDROGEN
-
HYPERventilation
ACID & BICARB (HC0 3)
OR
• CO2 = ALKALOSIS
Retaining
HYPOventi lation
-
HYDROGEN & BICARB (HC0 3)
- - ---1:: C: . •
159
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MED-SURG
ABGs
ABG PRACTICE QUESTION EXAMPLE
QUESTION
Aclient with a bowel obstruction has been treated with 9astric suctionin9 for 4 days. The nurse notices
an increase in naso9astric draina9e. Which Acid-b.ise imb.ilance does that nurse correctly identify?
The p.itient 1.ibs .ire the followi n9
).!
What does the problem 9ive you?
7.50
Q ACIDIC
<ft ALKALOTIC
Q
NORMAL
CO 2
50
@ ACIDIC
Q
ALKALOTIC
Q
NORMAL
HCO 3
32
Q ACIDIC
<ft ALKALOTIC
Q
NORMAL
O YES
® NO
Is the CO2 in m9e?
O YES
® NO
~ NO
Is the HC03 in r.in9e? O YES
i
UNCOMPENSATED /
.
@ PARTIALLY COMPENSATED
0
PH
7.50
Q ACIDIC
<ft ALKALOTIC
Q
NORMAL
CO 2
50
@ ACIDIC
Q
Q
NORMAL
HCO 3
32
Q ACIDIC
0
CO2
NORMAL
Is the CO2 in m9e?
O YES
Is the HC03 in r.in9e? O YES
® NO
® NO
~ NO
0
UNCOMPENSATED /
.
@ PARTIALLY COMPENSATED
0
FULLY COMPENSATED
RESPIRATORY ALICALOSIS
METABOLIC ACIDOSIS
.---- FINAL-ANSWER: -
Which of the four scen;;;irios from
the R.OME method m;;;itches the
inform;;;ition given in your problem?
Respir.itory
PH t
CO2+
Alk;;;ilosis
Opposite
PH+
CO2 t
Acidosis
( Met.ibolic
PH t
HC0 3 t
Alk;;;ilosis )
PH+
HC0 3 +
Acidosis
Q
Q
Q
UNCOMPENSATED, PARTIALLY COMPENSATED,
or FULLY COMPENSATED?
O YES
RESPIRATORY ACIDOSIS
rft METABOLIC ALKALOSIS
Equal
Is the pH in r.in9e?
BASE
PARTIALLY COMPENSATED
What does the problem 9ive you?
<ft ALKALOTIC
NORMAL
METAeouc ALKALOSIS,
FULLY COMPENSATED
ALKALOTIC
Value not
needed to
interpret a lkalos is
or acidosis. It just
tells you if the
patient is
hypoxic or not.
32 mEq/L
Q
Q
Q
UNCOMPENSATED, PARTIALLY COMPENSATED,
or FULLY COMPENSATED?
Is the pH in r.rn9e?
HC03
ACID
PH
0
➔
Ph 7.50
PaC02 50 mm Hq
Pa02 90 mm Hq
RESPIRATORY ACIDOSIS
RESPIRATORY ALICALOSIS
METABOLIC ACIDOSIS
<s6 METABOLIC ALICALOSIS
.---- FINAL-ANSWER: METAeouc ALKALOSIS,
PARTIALLY COMPENSATED
160
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MED-SURG
RESPIRATORY ACIDOSIS VS. RESPIRATORY ALKALOSIS
ABGs
~~
>-
>-
U>
0
U>
....
0
->"'
:J:
Q.
0
:J:
!c
LUNG PROBLEM
KIDNEYS COMPENSATE
The lungs are
RETAINING
too much col
The kidneys excrete excess
HYDROGEN & retain
BICARB (HCO)
Q.
"'
:::,
"'
C
Q.
0
:J:
!c
LUNG PROBLEM
KIDNEYS COMPENSATE
The lungs are
LOSING
too much col
The kidneys excrete excess
BICARB (HCOJ & retain
HYDROGEN
Q.
PH
CO2
PH
CO2
< 7.35
>45
>7.45
< 35
RETAINING CO2 : "Depress" breathinq
l&.I
V
0
....
0
->"'
:J:
@ rugs
(opio ids & sedatives)
@ dema
"'
:::,
"'
C
LOSING CO2 : "Tachypnea
l&.I
11
t Temperature
V
(fl uid in t he lungs)
Aspirin toxicity
Q neumonia (excess m u cus in the lungs)
Hyperventilation
4) espiratory center of the brain is damaged
@ mboli (p ulmonary emboli)
0
pas ms of the bronchial
0
ac elasticity damage
(asthma)
• t Heart rate
(COPD & emphysema)
• Confused & tired
:z::
"'
• Tetany
0
t-
•
t Blood p ressure
• Confusion
• EKG changes
:z::
•
t Resp iration rate
• Headache
• (+) Chvostek's sign_ _ /
•
t Heart rate
• Sleepy / coma
•
Restlessness
A.
►
"'
.a
z
"'
"'
U)
z
"'
0
1-
• Adm inister 0
• Turn, cough, & deep-breathe (TCDB)
>
a:
•
• Provide emotional support
1-
• Fix the b reath ing p roblem!
l&.I
>
a:
• Encourage good breathing patterns
Pneumonia : t fl uid s to thin secretions
& adm inister antibiotics
1-
l&.I
• Rebreathing into a paper bag
z
•
If CO2 >50, they may need an endotracheal tube
• Give anti-anxiety medications or sedatives
to +b reath ing rate
•
Monitor potassium levels
• Monitor K+ & Ca- levels
1-
z
z
"'
0
-z
2
• Semi-Fowler's posit ion
l&.I
POCALCEH/A
,--
z
l&.I
Twitch·in9 of th
facial
e
muscles wh
tap •
en
pin9 the facial
nerve in
Hy
response t 0
NORMAL IC+
3.5 - 5,0 mmol/L
NORMAL CA9 -11 m /dl
161
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MED-SURG
ABGs
METABOLIC ACIDOSIS VS. METABOLIC ALKALOSIS
~~
~CiYDl©m-
>-
>-
U>
0
U>
....
0
-
~
:J:
a.
~
KIDNEY PROBLEM
LUNGS COMPENSATE
Too m uch HYDROGEN
Too littl e BICARB (HCO)
The lungs will
blow off CO2
0
....
0
->"'
:J:
Q.
0
:J:
!c
II.I
"'
C
::,
V
LUNGS COMPENSATE
Too much BICARB (HCO)
Too little HYDROGEN
The lungs w ill retain
CO2
!c
Q.
"'
KIDNEY PROBLEM
Q.
•
PH
HCO3
PH
HCO3
<7.35
< 22
>7.45
> 26
Diabetic ketoacid o s ~
• Acute/chronic kid ney injury
"'
::,
"'
C
II.I
_N~t enough insulin
_ - fat met;.ibolism
- excess ketones facid)
V
• Too many antacids
---..
•
T
100
much
sod,um b· b
ICar onate <BASE)
•
Diuretics
•
Excess vom iting
•
Hyperaldosteronism
•
,1, Respiratory ra t e ~
•
,I,
! reakin9 down of fats
•
Malnutrition ~ - excess ketones (acid)
•
Severe d iarrh ea
______.. ~emembe s·
comes out fr ICa rb
0 your B.ise
• t Respiratory rate---..,.
•
I
~
~
Hyperkalemia
• Muscle twitching
• Weakness
• Arrhythmias
%:
"'
0
....
ICUSSMAUL'S BREATHING
Deep rapid breathing
> 20 breaths per minute
~
%:
►
"'
ea
z
"'
"'
Blood p ressure
•
,I,
•
Confu sion
(
•
Monitor int ake & output
NORMAL IC+
3.5 - 5,0 mmol/L
\
,--~
•
>
•
Init iate seizure precaution
>
II.I
•
Monitor K+ levels
"'1-
Potassium (K+)
• Dysrhythm ias
• Tetany
• Muscle cramps/weakness
• Tremors
• Vom iting
• EKG changes
M et abolic ACIDOSIS = t serum pot assium
Metabolic ALKALOSIS = ,I, serum potassium
0
II.I
HYPOVENTILATl~N
<12 breaths per minute
\!)
• Administer IV solution of sod ium bicarb
to t bases & + acids
~
Excess loss of
hydrochloric acid (H(O
from the stom.ich
__--.
.:= •
~
:=;
1-
z
z
• Give insulin (this sto ps the
breakd own of fats which stops
keto nes from being produced)
• Monitor for hypovolemia
due to polyu ria
• Dialysis to
remove toxins
Monitor K+ and Ca- levels
NORMAL CA9 -11 m /dl
Administer IV fluids to help
t he kidneys get rid of bicarbonate
•
•
Replace K+
Giv e antiemetics for vomiting
(Zofran o r Phenergan)
• Watch for signs of respiratory d istress
• Diet
• t Calories
• ,I. Protein
162
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WHAT IS A FRACTURE? A fracture is a complete or incomplete disturbance in t he p rogression of bone structure
-TYPES OF FRACTURES
~
[:=Jg
COMMINUTED
TRANSVERSE
The bone is crushed
causing lots of little
fragments
The bone is fractured
straight across
STAGES OF BONE HEALING
C
STAGE Q
H EMATOMA FORMATION
.
• First 1-2 days of fracture
• Bleeding into the injured site occurs
"HE
FELL
BECAUSE
HE WAS
RUNNING"
C sTAGE
[::7~
11 )
f IBROCARTILAGINOUS CALLUS FORMATION
OBLIQUE
GREENSTICK
The fracture runs at an
angle across t he bone
One side of the bone is
bent, the other is broken
• Formation of granulation tissue
• Reconstruction of bone begins
• Still not strong enough to bear weight
(
STAGE Ill )
BONY CALLUS FORMATION (OSSIFICATION)
• 3rd - 4th week of fracture healing
• Mature bone is replaci ng the callus
IMPACTED
SPIRAL
The fractured bone is
driven into another bone
The break partial ly
encircles the bone
(srAGE ~
REMODELING
• This may take months to years!
• Compact bone rep laces spongy bone
• X-rays are used to monitor the progress of bone heal ing
OPEN/COMPOUND
A fracture where the bone
breaks through the skin
COMPARTMENT SYNDROME
Increased pressure and bu ild -up, causes tissue impairment leading to cell death!
Pressure
t
4,
Blood flow cut off
4,
Tissue d.im.19e due to HYPOXIA
(1.ick of oxygen)
SIGNS & SYMPTOMS - • Deep, throbbing, unrelenting pain
• Pain unrelieved by medications
• Disproportional to the injury
rf
REATMENT
• Place extrem ity at the heart level
(not ab ove heart level)
• Intensifies with passive ROM
• Open the cast or spl int
7
FASCIOTOHY
Fascia is cut
to relieve tension
& pressure
_J
163
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I PATHOLOGY
~ Gout is a form of arthritis
WHAT IS
HYPERURICEMIA
characterized by
~
increased uric acid levels. •hi9h" "uric :acid"
.£
+
"in the blood"
URIC ACID?
Uric acid is created from purine
breakdown during d igestion. It 's
produced by the liver and is mostly
excreted by the kidneys.
This causes deposits of
uric acid crystals in the joints.
EXPECTED RANGE:
F: 2.5 - 8 m9/dl
Accumulation of sod ium urate
crystals in joints such as the big
toe and hands, o r other areas
such as the ears.
, ,,,,
H: 1.9 - 7.5 m9/dl
CAUSES- - - - - - - - .
• Diet high in purines
• Certain medications
SIGNS & SYMPTOMS
Can be ACUTE or CHRONIC
• Acute gouty arthritis
• Bone deformity
• Pain (severe)
• Joint damage
• Swelling
• Tophi
• Warmth at the site
• Renal ca lculi
EDUCATION- - l>'
• Educate on avoid ing:
•
•
•
•
Foods high in purines J
Med ications (aspirin)
A lcohol
Dehydration
.._.....
• Diuretics (causes dehydration)
• Aspirin
• Cyclosporine
• Disorder of purine metabolism
• Ki dney problems
• Inadequate excretion of
uric acid by the kidneys
°",qh inp,.
.,./.
.
"~-
,
A
W
• Stay hydrated:
2-3 liters per day
• Uric acid deposits can cause kid ney stones, ,
fluids help prevent t his!
f
• Weight loss program if overweight
)
MEDICATIONS- - - - - - - - - - - - - - - - - - - - - - - .
allopurinol
~
A loprim, Zyloprim,
Lopurin
~ AlloPurinol ➔ Prevents 9out
Miti gare, Colcrys
Colchicine ➔ for- C ute 9out-tt-cks
•For more information about gout medications, see the musculoskeletal section in the Pharmacology Bundle
164
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r DIAGNOSTIC~
PATHOLOGY- - - - - - - -
•
OSTEOPOROSIS
"relatin9 to bone"
~ Bone density test:
Osteoporosis
essentially means:
HAVING POROUS
BONES
~
"porous"
~ The rate of BONE RESORPTION (osteoCLASTS) is g reater
than the rate of BONE FORMATION (osteoBLASTS)
= !. DECREASED TOTAL BONE MASS
This process takes X-ray
images
measuring calcium
and other minerals
in the bones
tformal bone marrow has small holes in it,
but osteoporosis causes much lar9er holes
RISK FACTORS ~ - - - - - - - - - ,
G
0
e
Maybe asymptomatic until a
fracture occurs
~ FRACTURES (hips, spine, wrist) ~
Age: women after menopause
(t he decrease in estrogen at menopause
causes increase b one resorp tion)
I
~ Low back, neck, or hip pain
Lifestyle (smoking, excessive alcohol intake,
G
0
SIGNS & SYMPTOMS ~-__,
~
Calcium & vitamin intake is LOW
I
Dual-energy x-ray
absorptiometry (DEXA)
~
sedentary lifestyle, imm obility)
Caucasian or Asian women
The back wil l be rounded
(hunch back) causing height loss
Clients often think they
fell and broke somethin9,
BUT bones may break
fi rst uusin9 them to
hll.
Inherited (fa mily history)
Underweight /malabsorption disorder
(Celiac disease, ba riatric surgery, eating disorde~
Med ications: long-term use of corticosteroids,
anticonvulsants, levothyroxine, long-term use of
p roton pump inhibitors, etc.
PREDNISONE
D
NURSING INTERVENTIONS
ASSESSING FOR
RISK FACTORS
EDUCATE ON WAYS
TO PREVENT
( OSTEOPOROSIS
TEACHING ABOUT ~
PREVENTING INJURY
~ Calcium supplements
w ith Vitamin D
~ Bisphosphonates
I
(ends in "DRONATE ")
• N on-slip socks
• Communicate fal ls risk
Educate on stoppinq
smokinq & limit inq alcohol
I MEDICATIONS
I
• Use call light
• Clutter-free environment'
I
~
• Weight-bearing exercises
(weights, hiking, etc).
• Consume foods rich in
calcium & vitamin D
• No area rugs
(risk for falling)
• Watch out for pets
• Keep glasses near by
ALEN DRONATE
D
•For more information about bisph osphonates,
see the Pharmacology Bundle
165
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MED-SURG
MUSCULOSKELETAL
RISK FACTORS
PATHOLOGY
'"'
a
~ OA is a noninflammatory degenerative disord er of the joints.
The articular cartilage breaks down, which lea d s to d amage to
the bone.
~
"'
-1-
-::c
~
~
a
LI.I
t;
0
H.E
..£
..,E
~
::c
~
C
C
0
!c
2:
::,
• Functional
impairment
PROXIMAL
~ Weight loss
t
~ Occupational therapy (On
& physica l therapy (PT) ~
H
~
~
MOVEMENT/ EXERCISE ➔ Agg ravated / symptoms worsen
REST ➔
Symptoms are relieved
8
AC.ETAHIHOPHEH
KS~IOS
Exact mechanism is unknown
swollen,
_ _ __
V inflamed
It's classified as an autoimmune disease.
synovial
membrane
• Symm etric joint pain
• Symptoms are typica lly
BILATERAL & symm etric
• St iffness in the morning
(lasting > 1 hour)
• Sw elling, warmth,
and redness
STAGES OF
RHEUMATOID ARTHRITIS
O SYNOVITIS
• Inflammation of the synovium
• Synovial membrane thickens
SIGNS & SYMPTOMS- - - -
6
• Deform ity of the fi~
PANNUS FORMATION
• Pa nnus is a layer of vascular
fibrous tissue
• Can effect all joints
(fingers, wrists, neck,
shoul d ers, etc).
{) FIBROUS ANKYLOSIS
• Systemic effects: heart,
lungs, skin, etc.
6
• Joint invaded by fibrous
connective tissue
This causes loss of ...
• Articular surfaces
• Joint motion
• Ligament elasticity
BONY ANKYLOSIS
• When the bones are fused together
_)
DIAGNOSIS - - - - - - - - - - - - - - .
• Hard to diagnose because symptoms are very sim ilar
to other diseases
~
(+)Rheumatoid factor
~ Increase erythrocyte sedimentation
~ C-reactive protein (indicates inflammation in the body)
~ X-ray show s joint d eterioration
LI.I
::c
Occu rring
mostly at the
weight-bearing
joints
(hips, knees)
• Bony enlargem ents
Proximal
interphalangeal
(PIP) called
BOV01,:;D'S t'OOES
~ RA is a ch ronic, inflammatory type of arthritis,
1-
• Genetics
• Stiffness
(morning stiffness)
~ Exercise
I PATHOLOGY
--"'
• Certain occupations (heavy labor)
• Pain
Distal
interphalangeal
(DIP) called
~ Walking aids (canes)
I
• Old er age
~ -SIGNS & SYMPTOMS
(splints, braces, knee braces)
'--...,..
• OBESITY
• Female gender
Bone ends
rub together
~ Orthotic devices
\
~
Eroded
cartilage
1----· J
TREATMENT- - -
~ Analgesics
'"'
C
~
t
It's caused by the breakdown of cartilage between the joints.
GOAL: Decrease joint pain & swelli
Decrease changes of joint
deformity & minimize d isability.
• Medications
~
irnc.ost£a<>IOS
(I) ~
0
lfAllof
• Surgery
• SYNOVECTOHY: removal of synovium
• JOINT REPLACEMENT
• ARTHRODESIS: "joint fusion "
• Joint support
• Splints & assistive devices
RISK FACTORS
May cause an
•
inflammatory
•
response &
destructive [
•
synovial fluid
•
• Range of motion (ROM) exercise
Environmental factors (smoking, pollution)
• Low impact exercise (walking, water aerobics, etc).
Bacterial or viral illness
• Occupational therapy (OT) & physical therapy (PT)
Cigarette smoking
• Heat or cold? HEAT ➔ For stiffness
COLD ➔ For pain/inflammation
Family history
166
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167
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SUFFIXES
&
PREFIXES
=======i
Bro.id spectrum .intibiotics .................................... -OXACIN
Tetr.icyclines .................................................... -CYCLINE
Sulfon.imides .................................................... SULFCeph.ilosporins .................................................. -CEF CEPHPenicillins ........................................................ -CILLIN
Aminoglycosides & m.icrolides ................................. -MYCIN
Fluoroquinolones ................................................ -FLOXACIN
Antivir.il (disrupts vir.il m.ituration) ........................ -VIRIMAT
Antivir.il (undefined group) .................................. VIR- -VIR- -VIR
Antivir.il (neuraminid.ise inhibitors) ........................ -AMIVIR
Antivir.il (.icyclovir) ............................................ -CYCLOVIR
HIV protease inhibitors ........................................ -NAVIR
HIV/ AIDS ....................................................... -VUDINE
Antifungal
... . .. .. .. .. . ... . ... . .. .. .. .. . .. ... . .. .. .. .. . ... .
-AZOLE
Local anesthetics ............................................... -CAINE
Barbiturates (CNS depressant) ............................... -BARBITAL
Benzodiazepines (for anxiety/sedation) ..................... -ZOLAM
Benzodiazepines (for anxiety/sedation) ..................... -ZEPAM
Oral hypoglycemics ............................................. -IDE -TIDE -LINIDE
Inhibitor of the DPP-4 enzyme ............................... -GLIPTIN
Thiazolidinedione ............................................... -GLITAZONE
166
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SUFFIXES
&
PREFIXES
ANTI HYPERTENSIVES
ACE inhibitors
-PRIL
Beta-blockers
-OLOL
Angiotensin II receptor antagonists
-SARTAN
Calcium channel blockers
-PINE -AMIL
Vasopressin receptor antagonists
Alpha-1 blockers
.................... .
........................... .
-VAPTAN
-OSIN
Loop diuretics
-IDE -SEMIDE
Thiazide diuretics
-THIAZIDE
Potassium sparing diuretics
-ACTONE
ANTIHYPERLIPIDEMICS
HMG-CoA reductase inhibitor ........... ................
-STATIN
OTHER
Anticoagulant (Factor Xa inhibitor)
-XABAN
Anticoagulants <Dicumarol type)
-AROL
Anticoagulants (Hirudin type)
-IRUDIN
Low-molecular-weight heparin (LMWH)
-PARIN
Thrombolytics (clot-buster)
-TEPLASE -ASE
Antiarrhyth mics
-ARONE
Opioids
-DONE
Opioids
-ONE
NSAI D's (anti-inflammatory)
-OLAC -PROFEN
Salicylates
ASPRIN (ASA)
Nonsal icylates
ACETAMINOPHEN
Histamine Hl antagonists (HZ-blockers)
Proton pump inhibitor (PPls)
Laxatives
........ ....... -TIDINE -DINE
...... .... ............ ....... -PRAZOLE
..................................................... -LAX
© 2021 Hm,lnlh,Hakin9 ll( \harin9 • d distn"bot.n9 tlus coppi9ht,d m•t•r•I wi"thout p•rminion ; i
-9•
169
SUFFIXES
&
PREFIXES
Selective serotonin
reuptake inhibitors (SSRls)
-OXETINE
-TALOPRAM
-ZODONE
Serotonin-norepinephrine
reuptake inhibitors CSNRI/DNRD
-FAXINE -ZODONE
-NACIPRAM
Tricyclic antidepressants CTCAs)
-TRIPTYLINE
-PRAMINE
Corticosteroids
-ASONE -OLONE -INIDE
Triptans (anti-migraine)
-TRIPTAN
Ergotamines (anti-migraine)
-ERGOT-
Antiseptics
-CHLORO
Antituberculars (T8)
RIFA-
Bisphosphonates
-DRONATE
Neuromuscular blockers
-NUIM
Retinoids (anti-acne)
TRETIN-
Phosphodiesterase 5 inhibitors
-AFIL
Carbonic anhydrase inhibitors
-LAMIDE
Progestin (female hormone)
-TREL
Atypical antipsychotics
-RIDONE
UPPER RESPIRATORY
Second-gen antihistamines (Hl antagonist) ............... -ADINE
Second-gen antihistamines (Hl antagonist) ............... -TIRIZINE
Second-gen antihistamines (Hl antagonist) ............... -TICINE
Nasal decongestants. .......................................... -EPHRINE -ZOLINE
LOWER RESPIRATORY
Betal-agonists (Bronchodilator) ............................. -TEROL
Xanthine derivatives ........................................... -PHYLLINE
Cholinergic blockers ............................................ -TROPIUM
Cholinergic blockers ............................................ ·CLINDIDIUN
lmmunomodulators & leukotriene modifiers ............... -ZUMAB -LUKAST
170
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ANTIDOTES &
THERAPEUTIC
LEVELS
' \.,
Opioids / Narcotics ........ NALOXONE (NARCAN)
NO more Opioids
NAR.CAN ➔ OPIOIDS
,_ \',.,.
Durin9 WAR, Vit.imin IC Kills WARfarin
Warfarin (Coumadin) ............ VITAMIN K
' \ I 1,.
Heparin ............................ PROTAMINE SULFATE
You will need HELP from .i PRO to stop bleeding out
Di9oxin ............................. DIGIBIND OR DIGIFAB
Anticholiner9ic toxicity .......... PHYSOSTIGMINE
' \ I ,,
Benzodiazepines ................... FLUMAZENIL (ROMAZ1CpN) :
I FLU fast in my mercedes BENZ
1
Choliner ic toxicity ............... ATROPINE (ATROPEN) 'ii , We don't h.ive time to CHAT, we hne .i toxic situ.ition
9
CHOLINGER.I( ➔ AYR.OPINE
Acetaminophen <Tylenol> ........ ACETYLCYSTEINE (MUCOMYST), ii ,, ACETAMINOPHEN ➔ ACETYLCYSTEINE
\ I
' \ I I ,,,
Ma9nesium sulfate ............... CALCIUM GLUCONATE
ii
MAG9ie CAI.Ls for help!
MAGNESIUM ➔ CALCIUM
.._\I J .,.
Iron toxicity ....................... DEFEROXAMINE
ii
DEFEROXAMINE ➔ FERrous mem "cont.iinin9 iron"
Lead toxi.city ...................... SUCCIMER OR. CALCIUM DISODIUM EDETATE ~ .
Alcohol withdrawal ............... CHLORDIAZEPOXIDE (LIBRIUM)
,
Beta blockers . . . . . . . . . . . . . . . . . . . . . GLUCAGON ' ' ' '~Bet.i blockers be GONe with Glm GON
Calcium channel blockers ........ GLUCAGON, INSULIN, OR CALCIUM
Aspirin ............................. SODIUM BIC~~,BONATE
Insulin reaction ................... GLUCAGON
'
''' ',
You t.ike ASPIRIN when you h.ive .i he.id.iche. You m.iy
.ilso w.int .i SM.TY sn-ck when you h.ive .i he.id.iche.
,
If you w.int your insulin GONe, you 9ive Gluc;iGON
Pyridoxine ......................... DEFEROXAMINE
Tricyclic antidepressants ........ SODIUM BICARBONATE
Cyanide poisonin9 ................ HYDROXOCOBALAMIN
Look at these memory tricks to help
with rememberin9 these antidotes!
Di9oxin ........................................ 0.5 - 2.0 n9/ml (> 2 = TOXIC)
Lithium ....................................... 0.6 - 1.2 mEq/L
Theophylline .................................. 10 - 20 mc9/dl
Dilantin (Phenytoin) ........................ 10 - 20 m9/L
Ma9nesium sulfate .......................... 4 - 7 m9/dl
Acetaminophen <Tylenol) ................... 10 - 20 mc9/ml
Gentamicin .................................... 5 - 10 mc9/ml
Salicylate ..................................... 100 - 300 mc9/ml
Vancomycin .................................. Peak: 20 - 40 mc9/ml
Trou9h: 5 -15 mc9/ml
Valporic acid ................................. 50 - 100 mc9
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171
~ Analqesic
~ Ana lqesic
& antipyretic
~ Anti-infla mmatory
~ Anticoaqulant
& antipyretic
Action is not completely known.
Does NOT have any anti-inflammatory
or anti platelet effects.
• Anal9esic
• Inh ib its prostaglandins. Prostaglandins make pain
receptors more sensitive to feel pain.
• Mild to moderate pain
• Aspirin substitute for those with:
• Antipy retic
body temp by d ilating the blood vessel
& spreading the blood throughout t he body.
• ,I,
• Allergy to aspirin
• b leeding tendencies
• Children with fever / flu -like symptoms
• Aspi rin
• Prolongs bleeding times.
• Inh ib its the clumping of p latelets.
USES- - - - - - - - - - - " " " "
•
•
•
•
•
• Mild to moderate pain
• ,I, body temp
• Inflammatory cond itions
(RA, OA, & rheumatic fever}
• Aspirin is used to ,I, the risk of an Ml & CVA
SIDE EFFECTS- -• GI upset
• Heartburn
-----~
Hives
Hemolytic anem ia
Pancytopenia
Hypoglycemia
Liver damage
• Hepatotoxicity
• Hepatic fa ilure
These side effects
rarely occur when the
medication is taken as directed.
They occur due to
CHRONIC USE
or
HIGHER DOSAGE
THAN RECOMMENDED
• Jaundice
• Anorexia
• Nausea / vomiting • G I b leed ing
CONTRAINDICATIONS • Known sensitivity to Salicylates or NSAI DS
• Any BLEEDING TENDENCIES
• GI b leeding (peptic ulcers}
.- ·,
D.
• Blood dyscrasia
• Bleed ing d isorders
• On anticoagu lants
• Vit K deficiency
• Ch ildren w ith recent viral infection
• Risk for REYE'S SYNDROME!
NURSING CONSIDERATIONS ~~~
• Stop taking salicylates 1-w eek prior to major surgery
(remember t ri sk for bleed ing}
• Monitor for GI bleed ing
• Known sensitivity to acetaminophen
• Those w ith liver dysfunction
• Chronic alcohol use
1
1
N
~!!
r
~
a
~
m
C
o
~
~e
!
~
n
~
!!~!~!~veral
l
[
•
health & alcohol use
(i)
Ma lnourished clients & those with chronic
alcohol use (>3 drinks /day} are at increased risk
for liver damage
• Limit dosage to 1000-2000 mg/day!
This protects the liver cells
& destroys acetaminophen metabolism
1) Gastric lavage (within 4 hours of ingestion)
1) Gastric lavage
2) Activated charcoal (within 2 hours of ingestion)
2) Give ant idote via nebulizer
within 24 hours of ingestion
172
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Gets their name because they produce an
anti-inflammatory effect but th ey are not steroids!
r ACTION
~
~
~
Anti-infl am matory
Analgesic
Anti pyretic
Inhibit p rostag land in synt hesis
by b locking
cyclooxygenase (COX)
~
®}3f)
Enzyme that
mainta ins stomach li ning
Enzym e th at
t riggers pain
Ibuprofen
Advil
fenoprofen
Nalfon
cox2
in hibitin9 cox1
fl urbiprofen
Inhibit,
1 - - - - - - - - - - - l f - - - - - - - without
diclofenac
celecoxib
Celebrex
ketorolac
Sprix (nasal spray)
naproxen
Aleve
indomethacin
lndocin
+J../
SUFFIXES: -PROFEN, -OLAC
This means they in hib it pa in, but also in hib it the
enzyme t hat maintains the lin ing of the stomach !
uses~~~~..,.._,,...,._,._,,._,,
SIDE EFFECTS~~~~..........,
• M ild to mod erate pain
• Menst rua l cramps
• +fever
• Muscu loskeletal d isorders
• OA & RA
C
~~:~~:p~,?.!~~!IONSa
to NSAIDs o r aspirin
• Clients with clot history
• Ml, CVA, PE, DVT
• Clients with liver, kid ney,
or b leeding disorders
• N ausea / d iarrhea / vomiting
• Anorexia
• Abdomin al pa in / discomfort
• Heart
• HTN & heart fa ilu re
• Kid ney clogg ing
• NSAIDs are nephrotoxic!
• Blood clots
• Stroke
Certain medications are known to cause
bronchospasms in clients with asthma.
We want to "BAN" these medications
from asthma patients.
NURSING CONSIDERATIONS~~~
• NSAIDs cause G I upset such as acid reflex
0 ETA BLOCKERS
• Adm in ister p roton pump in hib ito rs (PPls)
•
O mprazole
•
Pantoprazole
• Educate : take with food to decrease sto mach upset
Q
sPtRIN
C} sAIDS
• Don't take on an empty stomach
173
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PAIN
MANAGEMENT
MEDS
OPIOID ANALGESICS
GENERIC
hyd romorphone
ACTION ~
.bJ
CNS Depressant
· ~
• +anxiety & sedate post-op
• +anxiety in those w ith dyspnea
Binds to o pioid receptors in the brain which
causes an analg esic sedative, & euphoric effect.
codeine
oxycod one
fentanyl
•
Relieve pain (myocard ial infarction}
•
M anage o pioid dependence
•
Treat d iarrhea & intestinal cramping
• Most commonly used opioid for chronic pain.
..._..,,....,..,-;,,• • Can be g iven in many form s:
Opioids do NOT produce an
anti-inflammatory effect or an
antipyretic effect. So they are not
used to reduce fevers or for
9out / rheumatoid arthritis.
(PO, nasally, subcut, IM, IV, & suppository)
SIDE·EFFECTS ~ ~ ~ ~
• • GI Function
• Constipation
J
LONGTERM
SIDE EFFECTS
Client will NOT
build tolerance
• +Vital signs
• Sedation, insomnia,
weakness, d izziness
• Pruritus (itching}
The body adapts to the dru9
(9ets used to it)
Cl ient WILL
build tolerance
• IV adm in
-+ Reversal agent for o pioid overdose
-+ Opioids last longer t han the effect of naloxone (Narcan}
-+ Repeat doses may b e needed
• Burning sensation
•
•
The body 9oes throu9h
"withdrawals" & experiences
ne9ative effects when
the medication is STOPPED!
SHORT TERM
SIDE EFFECTS
• Nausea
•
e w.mimnm ~
Hi9her doses of medication are needed
to achieve the same effect!
· •HR
• • BP (hypotension}
· •RR
• +CNS function
'IE ti J;l m! ~
This reverses the opioid's effects
and the cl ient 's pain will come back!
Preventative measures for CONSTIPATION
• Adm. stool softeners or laxatives
• Daily exercise
• Fluids, Fiber, & Fruits ➔ Fill up the toilet!
• Encourage client to defecate when they feel the urge (do not wait)
0 Remove old patch before p lacing
a new one
Client respirations beg in to drop
0 Date & initial the patch
0 Dispose old patch in t he sharps container
• Coaching the client to breath may increase the respiratory rate
0 Do not app ly over hair
• Administer naloxone (Narcan)
0 Rotate sites
0 Avoid the sun or heat
(it increases absorption}
Preventative measures for falls
• Opioids causes orthostatic hypotension
• Educate to rise slowly, assist the client with ambulatory activities
• Keep the room well lit
;--t:J: I3rn.IDfil!OOmC I3•l@j ml nt---·
I
I
~
• Take PO opioids with food to decrease GI upset
•
i
Do not drink ETOH !
Respiratory depression
• RR< 12
I
~ If t he client is unarousable
~~~~~~~~~~~~~~~~~~~~~~~~~~~
,
174
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SULFONAMIDES & FLUOROQUINOLONES
ANTIBIOTICS
* Antibiotics and antibacterials are used interchangeably
* Antibiotics are only used for bacterial infection (not viral)
* Finish the entire prescription of antibiotics (even if you are feeli ng better)
* NO alcohol (antibiotics are hard on the liver)
* A culture & sensitivity test
• CULTURE is a test to determine th e type of bacteria
• SENSITIVITY TEST is to determine what kind of medication will work best
• Always obtain cultures b efore administering an antibioti c
l
sulfadiazine
~ PN◄nrn
sulfasa lazine
-
sulfamet hoxazole
a.eJII :r.i ◄ rn [l]lB=OJiil~ Hi~
-
Azulfidine
Bact rim
I
Bacteriostatic (slow-9rowin9)
a.mmInhibit folic acid m etabolism .
,:m.n1~ ©«!l~ rn .rn;, im~ 0~
Increase FLUIDS intake because
sulfas dry out th e body
"':::.
It slows the g rowth o f t he b act eria
Since sulfas cause photosensit ivity,
we want to use sunb lock and avoid
t he sun!
enough for t he b o dy to take over wit h
its own defense m echanic (WBCs)
Patient may bruise easily
• Monitor skin & hand le wit h care
Acut e otit is med ia
Ulcerat ive colit is
Crystal luria
• Crystals in the urine
c~noi!:m1•n~:um:o
HEMATOLOGIC CHANGES
.t.. •
• Leukopenia ( ,I. W BCs)
W •
• Thrombocytopenia (+ platelets)
• Aplastic anemia ( ,I. RBCs)
ciprofloxacin
Hypersensitive t o sulfa d rugs
~
~
Factive
ofloxacin
Floxin
moxifloxacin
Avalox
-
Interferes with t he synt hesis
of bacterial DNA
"'
(Causes d eat h of _ , _ .
the b acterial cell)
•• ••
• GI UPSET!
• Nausea, diarrhea, abdominal p ain
• Lo wer resp iratory infections
• Dizziness
• Bone & j oint in fections
____,
mm
• UTls
Your Tendon is
near the FLOOR
& can rupture due to
FLOORoauinolones
r
'
//1\'
I~
®J~iii!:ml•II~Mim~0 ,;!\
~™
•
,.,
I ....____ _
Allergy t o sulfony lureas
like Glyburide (oral antibiotics)
____.
gemifloxacin
& TENDON RUPTURE
(Especially the elderly
taking corticosteroids)
.......' \ I / /,.,
Topical: used for burn wounds
Photosensitivity
• Increased risk for sunburn!
t RISK FOR TENDONITIS
Take folic acid daily
UTls (commonly caused by E.coli)
Chills / fever
• Photosensitivity
_J
mm
GI UPSET!
• Nausea, vomiting, anorexia,
d iarrhea, abdominal pain, stomatit is
.:
•
• STls
• Infections of t h e skin
• Ophthalmic sol utions for eye infections
• Clients wit h a history of
hypersensit ivity to t he
flu oroquinolones
~
• Ch ildren < 18 years old
• G ive wit h caut ion to:
• D iab etics, those with renal
impairment , history of seizures,
& t he elderly.
• Fluoroquinolones cause
photosensitivity. We want to use
sunblock and avoid th e sun!
i iJ:i!
• Take on an EM PTY stomach
w/ full glass of wate,
rr!Ji
175
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O'ifilill
penicillin V
amoxicillin
----t
ampicillin
~
piperacillin
Penicillin;;ue-resisbnt
~ Aminopenicillins
~
Broad Spectrum Antibiotic
Inhibits the integrity of~
the bacterial cell wall
f![
I-
Renal disease, asthma,
bleeding disorders, GI disease
. . .... l
Extended-spectrum
(UTls)
-mm:mm
GI UPSET!
• Stomatit is & dry mouth
• Gastrit is, nausea, vomiting, d iarrhea,
& ab dominal pain
ORALLY - Inflammation of the tongue (Glossitis)
History of allergies to
CEPHALOSPORINS or PENICILLIN
Septicemia
Pregnancy & breast-feeding safe
M eningitis
Penicillin makes oral contraceptive
ineffective
• use additional contraceptive
Intra-abdominal infections
STls (syphil is)
Respiratory infections (pneumonia)
Educate: take with FOOD to
i GI upset
Penicillin allergy is very common!
IH INJECTION - Pain at the site
IV INJECTION - Irritation & inflammation (Phlebit is)
~ ------------------& --@;!fflj 4llii~J,a--& -----------------{.i,
,
'
Ask about allergy to PENICILLIN or CEPHALOSPORINS before administering the first dose!
A client who is allergic to penicillin also may be allergic to cephalosporins.
''--------------------------------------------------------------------------~''
cefadroxil
Bactericida l - kills bacteria
cefazolin
Ancef
(Causes death of
the bacterial cell)
cephalexin
Keflex
GENERATION MEDICATIONS
,
,'
•
sr GENERATION MEDICATIONS
No
JJ
:
• History of allergies to
CEPHALOSPORINS or PENICILLIN
• Adm inister with caution:
cl ients with renal disease,
hepatic impairment,
b leeding disorder
• Otitis media
• Respiratory infections
cefaclor
cefoxit in
• Bone infections
Mefoxin
• Use prophylactically pre-opt, int ra-opt,
and post-opt to prevent infection
during surgery.
cefoteta n
Ro
• UTls
GENERATION MEDICATIONS
cefdinir
ceftriaxone
Rocephin
cefotaxime
Claforan
PREFIXES & SUFFIXES:
-CEF- & -CEPH-
• Cephalosporins make oral
contraceptive ineffective
• use additional contraceptive
• Do NOT drink alcohol while
on this medication.
• GI UPSET!
• Nausea, vomiting, diarrhea
• Aplastic anemia ( i RBCs)
• Dizziness
• Stevens-Johnson syndrome (SJS)
• Malaise
• Heartburn
• Fever
• Nephrotoxicity
i
• Toxic epidermal necrolysis
• IV INJECTION - Irritation & inflation (Phlebit is)
• IH INJECTION - Pain at the site
176
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ANTIBIOTICS
TETRACYCLINES & AMINOGLYCOSIDES
~
tetracycline
doxycycline
Atridox
m ino cycline
Arestin
demeclocycline
• SKIN
• Skin & soft t issue infection
• Fluocoqu inolones cause
photosensitivity. We want to use
sunblock and avoid the sun!
• Severe acne
• Rocky mountain spotted fever
SUFFIX: -CYCLINE
Bacteriostatic (slow- 9rowin9)
• Tetracyclines make oral contraceptives
ineffective
• Use additiona l contraception
• Helicobacter Pylori (H. pylori)
CJ
\J\l.
• Take on an EMPTY stomach
with a fu ll glass of watec
•
~ Causes tooth d iscolo ration
----------
• Do not give to chi ldren younger
than 9
Inhibits bacterial protein synthesis
. t:tttm,- - - - - - - ,
• GI DISTRESS!
• N ausea / vomiting / diarrhea
• Known allergy to tetracyclines
• Skin rashes
• Photosensitivity reaction
gentamicin
kanamycin
neomycin
streptomycin
• Sit up for 30 min after taking med ication
• Do not lay down
• Pill induced esophagus
(HEARTBURN & scaring of the esophagus!)
• Contraindicated in lactation
~
• Stomatitis
•
Tet~cyclines think Toxic
to the developin9 fetus
• Avoid ca lcium/ dairy products
• These prevent the absorption
of the drug
'I:\
~
ra.mmBactericidal - kills bacteria
Blocks the ribosome from
reading the mRNA. Then the
bacteri al can't multiply.
Monitor:
• Renal status
• Neuro status
• Respiratory status
Evaluate clients comments
re lated to any hearing issues
mm
0ED™3
GI DISTRESS!
• N ausea / vomiting / anorexia
Rash & hives
A
09lycosides are A 1ean antibiotic
because they have very harmful side effects.J
~
,
Known al lergy to aminoglycosides
Hea ring loss
Musculoskeletal d isorders
(Myasthenia gravis & Parkinson's disease)
Contradicted for location
BOWEL PREPARATION: Decrease
normal flora in the GI for those
having abdominal surgery
Management of hepatic coma
• Decreasing the ammonia in
the intestines
ffiiU:lit•U•>!1'3ite Hurts the kidneys: Proteinu ri a hematuria, & increase BUN & Creatinine.
Hurts the ears: Tinnitus, vertigo, hearing loss, which may be permanent.
Hurts the br ain: Numbness, tumors, convu lsions, m uscu lar pa ralysis.
177
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GENERIC
LOOP DIURETIC
TRADE NAME
furosemide
bumetanide
Bumex
torsemide
Demadex
SUFFIX: -NIDE, - HIDE
NURSING
- ACTION- - - PURPOSE - - - SIDE EFFECTS- - CONSIDERATIONS - • Inhibit reabsorption
of NA+ & ClActs on 3 sites
=
t reabsorption
• Hypertension
• .i Hypokalemia Lt,
• Obtain baseline vital signs
• Heart failure
• + Hypotension
• Renal disease
• t Hyperglycem ia
• Adm. furosemide SLOWLY
(rapid ~~m. can cause (if;)
• Edema
• Photosensitivity
• Pulmonary edema
• .i Hyponatremia
t!7
ototox1c1ty)
• Replace K+ if< 3.5 mEq/ L
• Dehydration
•
NORMAL POTASSIUM
~
POTASSIUM WASTING!
3.5 - 5.0
THIAZIDE DIURETIC
GENERIC
TRADE NAME
hyd roch lorothiazide
Microzide
chlorothiazide
Diuril
methyclothiazide
SUFFIX: -THIAZIDE
NURSING
- ACTION- - - PURPOSE - - - SIDE EFFECTS- - CONSIDERATIONS - • Inhibit reabsorption
of NA+ & Cl-
• Hypertension
• .i Hypokalemia
• Obtain baseline vital signs
• Heart failure
• Monitor intake & output
• Excretion of
Na+, Cl-, & H20
• Renal disease
• + Hypotension
• + Hyponatremia
• Cirrhosis
• .i Libido
• Edema
• t Hyperglycem ia
• Replace K+ if< 3.5 mEq/ L
• NEVER g ive K+ IV push
• Corticosteroids
• Photosensitivity
• Estrogen therapy
• Dehydration
t UOP
=
.i blood volume
• Azotemia
POTASSIUM WASTING!
• Give w/ meals to .i GI upset
• Avoid giving to pt.'s
with gout
• Monitor renal fu nction
• Daily weights
• Same time, same scale!
• Clients with a sulfa allergy
should avoid thiazide
diuretics Lt,
176
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DIU~ESIS ,UE BODY
Diuretics
=Diuresis =Dry inside
• WHERE SODIUM GOES •• • WA1ER FLOWS!
• Instruct the client to make slow posit ion
• Sodium makes us retain water
• Low sod ium d iet (SODllAM SWELLS!)
changes (diuretics cause orthostatic hypotension)
• Monitor...
• Give diuretics in the morning, not at night
• You don 't want your client peeing
.
.
al l night long (Noctu na)
• Daily weights (report 2-3 lbs weight gain)
• Intake_& output
• Vital signs
.,. Potassium levels
OSMOTIC DIURETIC
NURSING
- ACTION - - - PURPOSE - - - SIDE EFFECTS- - CONSIDERATIONS • t the thickness of
the filtrate so
water can 't be
reabsorbed
• Treatment of cerebral
edema
intraocular pressu re
(IOP)
• ,I,
• Excretion of
Na+ & Cl-
• Edema
• Only adm inistered IV
• Blurred vision
• May crystallize
(check solution before adm.)
• Nausea, vomiting,
& diarrhea
• Urinary retent ion
• Perform neuro assessment
& LOC (if using for
cerebra l edema)
K+ SPARING DIURETIC
ACTION
PURPOSE
• Blocks aldosterone
• Hypertension
(" salt water" hormone) • Edema
• Lets fluid out of
• Hypokalemia
the body, into
• Hyperaldoste ronism
the potty!
~
• Cross-sex hormonal
• Excretion of
therapy )
Na+ & H20
I)
',I
NOTK+
(spares potassium)
NURSING
SIDE EFFECTS - ~ CONSIDERATIONS - • Hyperkalemia (> 5.0)
• Diarrhea
• Gastritis
• Avoid eating foods high
in potassium (green leafy
veggies, melons, bananas,
avocado, etc.)
• Drowsiness
• Erectile dysfunction
• Gynecomastia
(enlargment of the)
SPIRONOLACTONE
INHIBITS
TESTOSTERONE
breasts in men)
EDUCATE:
GYNECOMASTIA IS USUALLY
REVERSIBLE AFTER THERAPY
HAS STOPPED
• Avoid salt substitutes
& potassium supplements
• Monitor K+ levels
L'.'.t, Watch out for HYPERKALEMIA
( K+
> 5.0 m Eq/L)
179
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OVERVIEW
LDL-
~
Ei_,
is when lipids stick to the b lood vessel
w alls which can obstruct b lood fl ow
HDL-
0
0
+ The
goa l of all antihyperlipidemic drugs is to lower
lipid levels in the b lood
IAD CHOLESTEROL
Low Density
Lipop rotein
LU
+ Atherosclerosis
Want LOW Levels (<1 00 mg/ d L)
-
Want HIGH Levels (>60 mg/dl)
High Density
Lipop rotein
HAPPY CHOLESTEROL
HMG-COA REDUCTASE INHIBITORS 11STATINS11
fH;Q
~E~;E~S0)
"'LU
::::>
"'
.. d .
Hyperl1p 1 em1a
PRIMARY PREVENTION : ~
L
Preventab le treatment for patients at risk for
coronary artery d isease (CAD)
SECONDARY PREV ENTION:
Stabilizes fatty plaques in clients with current
coronary artery d isease (CAD)
"'z
0
i=
u
cc
lovastatin
Al toprev
Statins are not a cure!
pitavastatin
Livalo
simvastati~
Zoco r
rosuvastatin
Crest or
~
u
LU
LL
~
LU
LU
i:::,
Ill
z
0
"'z
0
~
Monitor liver enzymes
• A LT/ AST
5
~
Monitor therapeutic response
• Statins sho uld lower LDL, & increase HDL
Avoid grapefruit consumption
• Increases risk for toxicity of statins
LU
0
~
z
0
u
Stati ns are pregnancy category X & should
not be taken w hile breastfeed ing
~
z
~
z
ii
• Headache
• Nausea
• Dizziness
• Constipat ion
• C ramping
• A b d ominal p ain
• Hyperglyce m ia
+ Rare condition where t he muscles are damaged
+ Myog lobin leaks into the b lood which can cause kidney damage
+ Signs & symptoms:
• Muscle pa in, tenderness, or weakness
• Accompanied by malaise or fever
• t creatine kinase levels
• Dark urine color (tea or cocoa li ke urine)
Monitor for signs of rhabdomyolysis because
statins have been associated w ith this
~
::::>
Lescol
Inhibits the enzyme
HMG-CoA Reductase
BILE ACID RESINS
Colestid
"'LU
::::>
"'
rm
♦ Hyperlip idemia
♦
♦
Gal lstone dissol ution
Pruritus associated wit h
partial biliary o bstruction
LU
LL
LL
LU
LU
0
~
Bile is made & secreted by the liver
cc
Then, it's stored the gallbladder
,J,
i=
u
,J,
O nce emu lsifi ed, the fa ts & li pids
are absorbed in the intestines
GI
• Constipation
Bile Acid Resins binds to the bile
acid to form an insol ub le substance
(can not be absorbed by the intestine)
,J,
• Increase risk for bleeding
R/T Vit K m alabso rpt ion
• V itamin A & D
d efi ciencies
So it's excreted with t he feces
,J,
b ile acids = liver uses cho lesterol
to make more b ile = --1, cholesterol
-1-
"'z
0
5
~
LU
0
~
,J,
~
u
colesevelam
"'z
0
z
0
u
~
z
~
~
::::>
z
W elchol
+ Bile acid resins may interfere
w ith t he d igestion of fats,
preventing the absorpti on of
fat-soluble vitamins
All Kids E.it Donuts
• Vitamin A & D may
be g iven in a water-solub le
for long term therapy
+ Bile acid resins may cause
constipation, so educate to ...
• Increase fluids, fibers
• Exercise regu larly
• Use stool softener
160
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ACE INHIBITORS
BETA BLOCKERS
;ln9iotensin-convertin9 enzyme inhibitors
GENERIC
GENERIC
ca t o ril
enalapril
Vasotec
fosinopril
--+--
lisi no pril
Prinivil
z
0
y_
IA.I
"'
::::,
"'
+ Hypertension
+ Heart Failure
+ Inhibits RAAS Ren in-Angiotensin-A ldosteron-System
C
0
8
0
= ANGIOEDEMA
= COUGH (DRY)
= ELEVATED K+
H
propra nolol
lnd e ral
nadolol
Systolic
~ + Blocks norepinephrine & epinephrine
(fight or flight hormones)
,1. Resistance
,1.
Workload
c
,I.
Cardiac Output
IC
YPotension
Dizzi
;;;
+ Blocks the negative effects of the
sympathetic nervous system
•
+ Inhibiting ACE will inhibit this vasoconstricting effect,
decreasing b lood pressure!
~
Corgard
b
+ ACE converts angiotensin I ➔ angiotensin II
(a powerful vasoconstrictor)
V
metoprolol
+ Hypertension
+ Stable angina
+ Chron ic / compensated heart fai lure
(not acute heart failure)
+ Dysrhythmias
Dilates blood vessels, which lowers blood pressure.
They do not directly affect the heart rate.
+ RAAS is t he main hormonal mechanism involved in
regulating the blood pressure
IA.I
LL.
LL.
IA.I
IA.I
Sect ral
SUFFIX: -OLOL
SUFFIX: -PRIL
IA.I
"'
::::,
"'
acebutolol
Beta blockers can b e
selective or non-selective
• Mean ing they can
block d ifferent beta sites
(beta 1 and/or beta 2)
~ + Bradycardia & heart Blocks
V
( THE B'S OF
BETA BLOCKER~
IA.I
LL.
LL.
IA.I
+ Breathing p roblems
• Bronch i spasms
1&.1
+ Bad for heart fa ilure patients (in an acute setting)
C
~
;;; + Blood sugar masking
z
"'
0
5
"'C
IA.I
;;;
z
0
V
+ Monitor K+ levels
• Normal 3.5 - 5.0
• Educate to avoid foods high in potassium
& avoid salt substitutes
"'::::,z
+ Assess for ang ioedema
• Swel ling of the area beneath the skin o r mucosa
(deep edema)
• DANGEROUS: swell ing of the face & mouth
+ Educate to not sudden ly stop t he medication it can
cause rebound hypertension (needs to be tapered off)
+ Ace inh ib itors are contraind icated in pregnancy
due to the teratogenic effects on the fetus
Masks S&S of hypoglycemia (low b lood sugar)
+ Blood p ressure lowered - Hypotension
+ Monitor for hypotension
• Educate on changing positions slowly
\!)
z
;;;
•
+ Assess BP & pu lse routinely
"'
+ Monitor for hypotension
ti
+ Educate on changing p ositions slowly
Z
0
"'C
IA.I
;;;
z
8
\!)
z
+ Do not give non-selective beta b lockers to asthma
p atients or COPD patients (remember: non-selective
works on Beta 1 & Beta2 = Lung constriction)
+ Educate to not sudden ly stop the medication. It can
cause rebou nd hypertension (needs to be tapered off)
;;; + Monitor for S&S of heart fai lure
"'::::,z
• These med ications p roduce inotropic effects
(t contraction strength of t he • )
• S&S of • failure:
Wet lung sounds, weight gain, edema, etc
161
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CALCIUM CHANNEL BLOCKERS
V ERY
NICE
DRUGS
Verapamil
Cala n
Nifedipine
Procardia
0 ilt iazem
Cardizem
-I
-I
Norvasc
amlodipine
-----l
Cardine
nicardipine
SIDE EFFECTS - - - - - - - .
usES
1
~ LOWER
HR & BP
• Orthostatic hypotension
• Dizziness
• Hypertension
• Flushing
• Angina
•
• Headache
• Dysrhythmias
• Peripheral edema
• Constipation
ACTION
Blocks movement of calcium
calcium = .i ava il able for
transm ission of nerve impulses)
( ,J,
• Relaxes b lood vesse ls
• .i b lood pressure
• t supply of oxygen to the heart
• .i • ·s workload
a~
NURSING CONSIDERATIONS- - - - - - - -~- - - - - - - .
• Antihypertensives cause
orthostatic hypotension
• Change positions slowly
• Sit on the side of the bed fo r
a few minutes before standing
• Educate to not sudden ly stop
the medication. It can cause
REBOUND HYPERTENSION
(needs to be tapered off).
• Do not drink grapefruit juice
• Leg elevat ion & compression
to reduce edema
•
.,
.
• To help with CONSTIPATION:
()
O(J
•
Fluids, Fiber, & Fruits
~
Fill up the toilet!
·
,
t
''
~
162
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Prevents new clots or prevents cu rrent clots from 9ettin9 bi99er! Anticoa9ulants do not dissolve clots & do not thin the blood .
Anticoa9ulants are use fo r clients who are at an inc reased risk for CLOT FORMATION!
WARFARIN
warfa ri n
HEPARIN
the same time?
YES!
Commonly used
together. Gives time
for Warfarin
Coumad in
ACTION - - - - - - - - - - - - - - - -.. . .
ACTION - - - - - - - - - - - .
Heparin inhibits the formation of fibrin clots.
Inhibits the conversion of fibrinog en to fibrin
to kick in!
(inactivates fa ctors need ed for t he cl otting)
• Interferes w ith the production of VITAMIN K
._ USED IN THE LIVER TO MAKE CLOTTING FACTORS
USES - - - - - - - - - - -;nr:::rmJ
• .SHORT-TERM THERAPY
of clotting fa ctors II (prot hrombin}, VII, IX, and X.
(Prot hrombin is required for the clotting}
• ,I,
• Wo rks qu ickly
ROUTES - - - - - - - - - - - - - - • NOT g iven orally ~
USES - - - - - - - - - - --iar:::rrd
• LONG-TERM THERAPY
• Given by inject ion (IV or subq}
• Works slowly (a few days to take effect}
• IV drip
ROUTES
-
•
• O ral ly ..____..,
SAFE DURING PREGNANCY?
'
• IV
G'.j
YES!
PROTAMINE SULFATE
SAFE DURING PREGNANCY?
[Rj
LOW MOLECULAR WEIGHT
HEPARIN (LMW)
NO!
VITAMIN IC
LMW HEPARIN IS ADMINISTERED:
NURSING CONSIDERATIONS
• Subq in the belly
•
•
•
•
• Educate client to be consistent wit h t heir vitamin K
fo od intake (green leafy veg etables, liver, etc.}
• Ant ib iotics increase the risk for BLEEDING
(they increase INR}
e noxaparin
Loveno x
dalteparin
Fragmin
2 inches from t he umb ilicus
90 degree ang le!
After subq injection, it 's common t o have b rusing, irritation, & pain!
Do not massage injection site after
For LMW heparins, we don't look .at blood co.a9s.
We w.ant to mon itor PLATELET COUNT! "')
• W ill have freq . blood test to check
t herapeutic range
Hep.irin Induced Thrombocytopeni.i (HIT) V
Should check pl atelets whil e on LM W.
• Educate to take t he p ill at t he same time every day
Norm;al PLT count: 150,000 - 450,0 00
.-------------COAGULATION~---- - - - - ,
NOT ON ANY ANTICOAGULANT:
PT: 10 - 12 seconds
INR.: < 1
.iPTT: 30 - 40 seconds
WARAFIN
. h· 1N•
Ne;uured wit
.
..
ABBBREVIATIONS:
INTERPRETATION:
PTT: Proth rombin Time
;aPTT: Activated Partial Thromboplastin Time
INR: International Normalized Rat io
Numbers are TOO high = Patient will die
(increased bleed ing)
Numbers ;a re LOW = Clots will GROW
THERAPUTIC RANGE:
1.5 - 2 times the no rm.ii v.ilue
INR: _
(_,;If
2 3
INR: 2.5-3.5
(Heart valve rep lacement)
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I
HEPARIN
Me.isured with: •PTT
~
THERAPUTIC RANGE:
1.5 - 2 times the norm.ii v.ilue
• PTT: 47 - 70 SECONDS
163
CARDIAC GLYCOSIDES
USES- - - - - - - - - .
ACTION - - - - - - - - - - - ,
• Heart fa ilure
• Cardiogenic shock
• Antiarrhythmic
• Atrial fibrillation
• {+) INOTROPIC ACTIVITY
• Increases the force of the contraction
= increased card iac output
• {-) CHRONOTROPIC: beats slower
•
• {-) DROMOTROPIC: slows impulses sent
through AV node, able
to squeeze more blood
THERAPEUTIC RANGE:
0.8 - 2.0 NG/ML
>2 = Think Toxic
SIGNS OF TOXICITY
Report these to the HCP
een vision,
·ect
D
• Potassium wasting diuretics (Loop)
I
Headache, drowsiness,
confusion, disorientation
Decreased potassium
CHYPOkalemia) <3.5 mEq/L
G
o·19oxin
·
Injured kidneys
a/
GFR. decreased (the elderly)
excreted by
the kid
y
is
most so/e/
ney5
ANTIDOTE: DIGIBIND
~ - NURSING CONSIDERATIONS - • HOLD THE MEDICATION IF
• Adults: <60 bpm
• Children: <70 bpm
• Infants: <90-1 10 bpm
• KEEP ALL APPOINTMENTS:
drug levels & electrolytes
wi ll be mon itored
The APICAL PULSE is located
at the fifth intercostal
midclavicular space.
• The apex of the heart
• Po int of maxi mal
impu lse (PM I)
• Mitral valve
164
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~~..;.,i,,.i.lL,l,.;.,l,LI ~1,,,,,1,,M~
ANTIANGINALS
USES- - - - - - - • Angina (chest pain)
• Prevent angina attacks
• Acute coronary syndrome
A H= Headache
W
H = Hypotension (orthostatic)
H = Hot fl ush ing of t he face
ACTION - - - - - -
• VASODILATOR
Dilators do the following:
(!) Decrease b lood pressure
(!) Dilates vessels
(!) +Vascular resistance
VASODILATION
NORMAL BLOOD VESSEL
D = decrease cardiac workload
D = decrease oxygen consumption
• Rash
• Subl ingual
• Tingling/ burning sensation
• Known hypersensitivity to nitrog lycerin
• Transderma l
• Contact dermat itis
• Clients taking phosphodiesterase (PDE) inh ibitors
ALARMING SIGNS
9
• Allergy to adhesive (transdermal)
• Head trauma, cerbral hemorrhage
• Severe anemia
• Lack of coordination
QUICK
• Lightheadedness
SLOW ONSET
QUICK
• Pallor
• IV
• Sublingual tabs
• Transligual spray
• Irritable
SLOW
• Nitro patch
• Nitro ointment
• Sustained-release tablets
NURSING CONSIDERATIONS - - - - - - - - - - - - - - - - - - - - - -....-DO NOT TAKE with phosphodiesterase (PDE) inhibitors
• Stop the med ication if systolic BP drops below
100 or the baseline drops below 30 mm Hg
(erectile dysfunction (ED) dru9s)
/2\
• Monitor blood pressure
Ends in "-afil " Like sildenafil (viagra)
~ Causes dangerously low blood pressure resulting in d eath
• Increased risk for fal ls due to orthostatic hypotension
• Educate: rise slowly when getting up
PATIENT EDUCATION - - - - - - - - - - - - - - - - - - - -----1
TOPICAL & TRAN.SDERMAL PATCH ~ ..;;::,,..
•
•
•
•
•
Remove prior dose
Rotate sites
Place over a clean/hairless area
Wear gloves
Do not rub nitro ointment into the skin,
it can cause rap id absorption!
• Patches can be worn in the shower
.SUBLINGUAL NTG OR .SPRAY
.SUBLINGUAL OR BUCCAL
1 tab/spray subl ingual
every 5 minutes, up to 3 doses.
• Place BUCCAL tablet between
t he cheek and gum
• Place SUBLINGUAL under t he tongue
• Rinse with water before
p lacing the tablets in your cheek
If angina is not relieved or is
worse 5 m in after
the first dose, ca ll 911 !
165
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IACTION
pred nisone
D eltasone
hyd rocort isone
Hyd rocort
dexam et hasone
O zurdex
flut icasone
Flovent HFA
b eclomet hasone
flunisolide
Aerospan
ciclesonide
Zetonna
~
ANTI-INFLAMMATORY EFFECTS!
• They reduce the number of mast cel ls in the airway
-THERAPUTIC USES
• COPD
• Rheu matoid arthritis
• Lupus
Can also be adm inistered :
IV, IM, PO, rectally, ocu larly
--..........-
TOPICAL
CORTICOSTEROIDS
S's of Steroids
-
~
Su9ar: Hyperglycemia
~
Soft Bones: Causes osteoporosis
I
~ Sick: Decreased immunity/ sepsis
I Sad: Depression
I
~ Salt: Water & salt retention (hyp ertension)
I
~ Sex: Decreased lib ido
I
~ Swollen: Water gain = w eight gain
~
~ Si9ht: Risk for cataracts
Chronic asthma
,-
Nasal polyps
& rhinitis
..._
-
-
Steroids cause ...
INHALED
CORTICOSTEROIDS (IC.S.S)
Dermatitis
Rashes
Eczema
Insect bites
SIDE EFFECTS - - - - - ~
-
IPATIENT EDUCATION
I (Lo n,:rter m corticosteroid rep lace ment)
~ Report si9ns of an INFECTION
Corticosteroids are immunosuppressing
an d can cause an infect ion
Since t hey are ant i-inflammatory, it may
hide the fact th at t he client has an infection
~ lncrnse CALCIUM in the diet
Corticosteroids can cause ost eoporosis & muscl e weakness
I
~ Yeuly optometrist appointment
Corticosteroids may cause CATARACTS
I
I
~
STRESS OR .SURGERY causes a decrease in cortisol
You may need to increase your dose in t im es of stress
~ Ne-,er stop steroids suddenly
Slowly tap er off t he med icat ion!
IMPORTANT TEACHING!
After administration, rinse the
mouth to decrease the risk of
contractin9 a possible fun9al
infection from candidiasis
THRUSH: a type of yeast infection
1 Bronchod ilator f irst (to he lp open up the airways)
, .. ,,,,
2 Wa it 5 minutes
3
Adm inister the Corticosteroid
B comes befo re C
in the alphabet
000
166
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RESPIRATORY
MEDS
BRONCHODI LATO RS (SABA & LABA)
SHORT-ACTING BETA2 AGONISTS
(SABAs)
albuterol
Proventil
ep inephrine
A d renalin
levalbuterol
Xop enex
IACTION
~
Think
~ Albutero l
is for
Acute
Asthma Attacks
BRONCHO-DILATORS
Dilates (opens up) the bronchi
When an agon ist b inds to the beta-2 receptors the
sympathetic nervous system "Fight o r fl ight "takes
effect. THE AIRWAYS RELAX AND DILATE WHICH INCREASES
OXYGEN FLOW which makes it easie r to b reathe.
terbutali ne
LONG-ACTING BETA2 AGONISTS
(LABAs)
salmeterol
formoterol
Fo radil
indacaterol
Arcapt a
arformoterol
Brovana
To remember th;it
bet;i-2 receptors ;ire in the lungs:
you hm TWO LUNGS
Think
Salmeterol
~ isforSlow
and Steady
workin9
a LONG time
To remember beh-1 receptors
found on the hurt:
you only h;ive ONE HEART.
BETA1
IIETA2
(one heart)
(two lobes)
@)
(®)
IUSES
~
SHORT-ACTING BETA2 AGONISTS (SABAs)
Acute symptom relief
• Bronchospasms
• Ast hma
SIDE EFFECTS • Tachycardia
• Palpitations
• Cardiac arrhythmias
• Hypertension
~
LONG-ACTING BETA2 AGONISTS (LABAs)
Lon9-term management
• COPD
• Ch ron ic Bronch itis
• Prevent ion of bronchospasms
• Nervousness & anxiety
• Insomnia
PATIENT EDUCATION - - - - - - - - - - - .
, _ -IMPORTANT TEACHING!
After administration, rinse the
mouth to decrease the risk of
contracting a possible fungal
infection from candidiasis
THRU.SH: a type of yeast infection
1
Bronchodilator first (to help open up the airways)
, \',,
2
Wait 5 minutes
3
Administer the Corticosteroid
•
8 co mes before C
· ,.
in the .ilph.ibet
000
167
(X;anthine derivatives)
(Meth lx~nthines)
BRONCHODI LATOR
RESPIRATORY
MEDS
ACTION
~
aminophylline
dyphy lline
er
oxt riphylline
Choledyl SA
t heophy lline
Theochron
~
Dil ates (opens up) the bronch i
Lufylli n
+
BRONCHO-DILATORS
Stimulate the central nervous system (CNS) to
p romote bronchodilation.
Relaxat ion of the smooth muscles of the bronchi.
USES- - - - - - - - - - - - - - - .
THEOPHYLLINE- -
• Rel ief & p revent ion of b ronch ial asthma
Th era peutic levels
10 - 20 mc9/d L
• Tx of b ronchospasms seen in COPD
Toxic >20 mc9/d L
SIDE EFFECTS - - - - • Tachycard ia
SIGNS OF TOXICITY
• Tonic clonic seizures
• Tachycardia & dysrythmias
• Pa lp itations
• Nervousn ess
& anxiety
• ECG changes
• Irritable
(HOLi NERGI( BLQ(KI NG
ALSO CALLED:
~
I
~
I
~
ANTICHOLINERGIC DRUGS
CAnticholinerqic}
ACTION
1
~ Cholinerg ic blocking drugs BLOCK THE
PARASYMPATHETIC NERVE t hat causes the
airway to constrict .
CHOLINERGIC BLOCKERS
PARASYMPATHOLYTIC DRUGS
I
By blocking th is, it allows the airways to rema in o pen.
SIDE EFFECTS
umeclidinium
lncruse
ipratropium
Atrovent
BLOCKS
RESPIRATORY USES
SECRETIONS ➔
Dry Inside
~ Can't See - Blurred vision
~ Can't Pee - Dysuria
~ Can't Spit - Dry mo uth
~ Can't Poop - Constipation
Prevention of
bronchospasms
associated
with COPD
1
PATIENT EDUCATION - - - ~
~
• Prevent constipation
••
Fluids,
• Increase fl uids & fi ber
6 Fiber, & Fruits
• To help w ith the dry mouth, increase
Fill up the toilet!
fluids & suck on hard can d ies. _ ____,__ _ _ _ _
I,J
'g
Antichol inerq ic d ruqs are used fo r many
other pu rposes as well , such as:
PARKINSONISM, PEPTIC ULCER,
VAGAL NERVE-INDUCED BRADYCARDIA &
PREOPERATIVE REDUCTION OF ORAL SECRETIONS.
166
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MOOD STABILIZER:
Known for its side effects and narrow therapeutic range
THERAPEUTIC RANGE:
0.6 - 1.2 mE9/ L
ADVERSE REACTIONS
• Nausea/drowsiness/fatigue
• Thirst
• Dry mout h
TOXICITY!
• Weight gain
.· · TOXICITY · .
:ttc Confusion
.......
:ttc Blurred vision
:ttc Diarrhea
:ttc Tinnit us
Ringing in ears
:ttc Slurred speech
LEVELS
·····..._
Mild: 1.5 - 2 mEq/ L
:
-..._, HOW DOES TOXICITY HAPPEN? - - ~
:
\ Moderate: 2 - 3 mEq/ L ) ~ Dehydration _ _ _ _ _ _ .
\
/
causes t lithium levels in blood
\ ......... Severe: > 3 m Eq/ L _.//
~ Hyponatremia
:ttc Coma
...· •'
:ttc Convulsions
·················r···
✓--'------....,
• Excessive swe~tin9
such~ high fever
• Di~rrhe~
'- • Diuretic ther~py
.1
...··
~ Old age
& kidney failure
+ GFR = lithium builds up in the blood
;.....-- - - - - - - - - - - - - - - - - - ~
:ttc Excessive urinat ion
:ttc Exces
:ttc Trem
...................................................,,,,,, .....................................
0
0
· ' ,'
j
....
CONTRAINDICATION
EDUCATION
• Carry ID that shows you are taking lithium
• Educat e on signs & symptoms of toxicity
• Contraindicted in pregnancy
& breastfeeding
• Educat e and stress importance of taking
medicat ion regu larly
• Renal/cardiovascular disease
• Dehydrated patients
Excessive diarrhea or vomiting
• Do not operate heavy machinery or drive
• Receiving diuretics
• Sodium depletion
• Hypersensitivity to tartrazine
• Avoid NSAIDs
+renal blood flow = t
:
• Serum lithium levels should be checked
every 1-2 months
risk for toxicity
• Educat e on drinking p lenty of water to
avoid dehydration (therefore avoiding
toxicity}
• Avoid starting a low salt diet
Sudden + in salt = t in lithium
.................................................... ,,,,,, ....................................:
169
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PSYCHIATRIC
MEDS
ANTIDEPRESSANT DRUGS
SNRls / DNRls
SSRls
Serotonin I Norepinephrine
Selective se rotoni n
reuptake inhibito r
Inhib its uptake
of seroton in = t seroton in
• Depressio n
• A nx iet y
&
Dopamine I Norepinephrine reuptake inhibitor
Think
Affects seroton in,
norepinephrine & dopamine
$ miley
$ erotonin
• OCD
• Eating d isorders
• Depressive episodes
• Anxiety d isorders
e~~
\:~-~
·f ; Headache
~
0
• Nausea
• Dry mouth / thirst
• Constipation
• Tremors
• Difficulty sleeping
3 S's OF SSRls
• Serotonin syndrome
• Sexual dysfu nction
• Stomach issues
.I
•
•
•
•
•
SEROTONIN SYNDROME
• Too much serotonin • Tightness in muscles
in the brain
• Difficulty walking
• Mental changes
• t BP & temp
• Tachycardia
• May take 4-6 weeks to take effect .,..---..
• Take med ication in the morn ing
of com li;i ,
nee
• First line drug for d ep ression/anxiety
& SUICIDE WARNING &
A client w ho had suicidal plans may now have the
energy due to the med ication to carry out the plans!
•
•
•
•
Dry mouth/thirst
Dehydration
Constipation
Nausea/diarrhea
Edvc:ate
im;;ri~~J
(
Dizziness
Vertigo
Photosensitivity
Agitation/tremors
Insomnia
• Fibromyalgia
• Diabetic neuropat hy pai n
~
• May take 4-6 weeks to take effect
• Do not mix with TCAs o r MAO ls
• Zyban is used for smokin g cessation.
Do not use it wh ile taking bupropion
for d epressio n - it could cau se overdose.
GENERIC
TRADE NAME
GENERIC
TRADE NAME
sertraline
Zo loft
b uprop io n
Zyban & Wellb ut rin
citalopram
Celexa
d uloxetine
Cymbalt a
escitalopram
Lexapro
venlafax ine
Effexor X R
fluox etine
Prozac
m ilnacipran
Savel la
vilazodone
V iibryd
nefazodone
-
SUFFIXES: -TALOPRAM, -OXETINE, -ZODONE
SUFFIXES: -FAXINE, -ZODONE, -NACIPRAN
190
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PSYCHIATRIC
MEDS
ANTIDEPRESSANT DRUGS
TCAs
MAOls
Tricyclic antidepressants
Monoamine oxidase inhibitor
Blocks reuptake of seroton in
& norepineph rine in the brai n
Blocks monoam ine oxidase which causes t in
epinephrine, norepineph rine, dopamine, &
seroton in, w hich causes stimulation of t he CNS!
• Depressive episodes
• Bipolar d isord er
• OCD
• Neu ropath y
• Enu resis
Depressio n
~>-,-_.::..i.
• Constipation
Y/r • Orth ostatic hypotension
• Dry mouth
• Drowsiness
• Blurred vision
• Dizziness
• Blurred vision
~
• Constipation
• Dry mouth
• Nausea/ vomiting
( Educ;ite ~
• May take 2- 3 weeks to take effect ,....--.
.
of comp/· ,
• WAIT 14 days after being off MAOls
i;;in,e
to start taking TCAs
im;;~~~)
• Amoxapine is not an anti psychotic drug
but simil ar to th ese drugs, it may cause
TD & NMS (D/C the d rug im mediately
if these symptoms occur)
HYPERTENSIVE CRISIS
t
•
•
•
•
l
Headache
Stiff neck
Nausea / vomitting ........
Fever
_.....···· £ ···... •·..
. I d ·1 ..
eek
·.
• Dia ate pup1s/ tnedicafhelp \
. b
to J
- - - - - -,_ food
i:
\
Pressure /
··..
.•·
····· .... ·····
n take up to 4 weeks to reach
therapeutic levels
• Educate on the signs
& symptoms of HTN crisis
• Avoid foods with Tyram ine
• Aged cheese
~
• Fermented meats
• Chocolate
• Caffeinated beverages
• Sour cream & yogurt
GENERIC
TRADE NAME
amitriptyline
-
GENERIC
TRADE NAME
amoxap ine
-
p henelzi ne
Nardil
clo m i pramine
A nafranil
tra nylcyprom ine
Parnat e
protriptyline
Vivact il
isoca rboxazid
Marp lan
nortriptyline
Pamelo r
SUFFIXES: -TRIPTYLINE, -PRAMINE
191
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PSYCHIATRIC
MEDS
ANTIANXIETY DRUGS CANXIOLYTICS)
BENZODIAZEPINES
•
■
~
USES
ACTION
Bi pola r disorder
Benzos are m ainly
prescribed for:
Binds to cel l receptors
enhancing the effects of
GENERIC
TRADE NAME
alprazolam
Xanax
GABA
lorazepam
Ativan
d iazepam
Valium
clonazepam
Klonopin
ch lord iazepoxid e
Librium
• acute anx iety
GABA
• sed atio n/muscle re laxant
(inhibitory neurot ransm itter)
• seizures
slows/ ca lms t he activity of
the nerves in the brain
SUFFIXES: -ZOUH, -ZEPAM
ANTIDOTE: FLUHAZENIL
• alcohol wit hdraw al
Not a first-line drug for treating
long-te rm psychiatric a nxie ty conditions
•
I FLU fast :~y Mercedes BE
rz
~,J~.ADVERSE DRUG REACTIONS (ADRs)
r-····················· NURSING CONSIDERATIONS······ ................... .
\
TO HELP WITH ADRs
• Mild drowsiness, sedation
• Lightheadedness, d izziness, ataxia
• Visual d isturba nces
Take at night if it makes you d izzy/drowsy
Rise slowly from sitting o r lying
Do not drive or o perate heavy machinery
• Anger, restlessness
• Nausea, constipation, diarrhea
• Lethargy, apathy, fatigue
• Dry mouth
......................................................................................................................
SYMPTOMS OF WITHDRAWAL
W ithdrawals typ ica lly happen when t he
med ication is stopped abruptly o r taken
for >3 months
• t Anxiety
• Agit at ion
• t HR
• Seizures/tremors
• t BP
• Insomnia
• t Temp/sweating
• Vomiting
•+ M emory
• M uscle aches
Fluids, fiber, & exercise!
Give wit h food to + GI upset
Sips of water, suck on hard candy,
chewing sugar-free gum
·.................................................................................................................. ·
NURSING CONSIDERATIONS
• Not meant for long term therapy
because t risk for physical &
psychological DEPENDENCE
• Use of long term therapy leads to
TOLERANCE
Larger doses of the drug are required
to achieve the desired outcome
• M ust be TAPERED
+ the dosage g radually.
NEVER stop the medication abruptly!
...................................................................................................................
LL
CONTRAINDICATIONS & PRECAUTIONS
• Pregnant, labo ring & lactating women
• Elderly (t chance of dementia)
• Impaired liver or kidney function
• Debilitation
Depends on the drug
buspirone (Buspar)
acts on serotonin receptors
hydroxyzine (Vistaril)
acts on the hypothalamus &
brainstem reticular formation
me ro bamate
192
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Most commonly used for psychosis (schizophrenia)
REVIEW: WHY ARE SGAs BETTER THAN FGAS?
SGAs work on both positive & negative symptoms, and have a lowe r risk of developing tardive dyskinesia (TD)
.------FIRST.GENERATION_ ------. ,____ _ SECOND GENERATION -----.
ANTIPSYCHOTICS (FGAs)
ANTIPSYCHOTICS (SGAs)
Also called ATYPICAL
Also called TYPICAL/CONVENTIONAL
GENERIC
TRADE NAME
chlorpromazine
haloperidol
Haldol
loxapine
Adasuve
GENERIC
TRADE NAME
ris eridone
Ris erdal
clozapine
Clozaril
quetiapine
Seroquel
ziprasidone
Geodon
aripiprazole
Abilify
ACTIONS
ACTIONS
• Acts o n both serotonin & dopamine in the brain
• Blocks/ inhibits dopamine from being
released in the b rain
• Helps d iminish positive symptoms of schizophrenia
• Helps diminish positive sym ptoms of schizoph renia
& helps negative symptoms as well!
SIDE EFFECTS
SIDE EFFECTS
Anticho linergic effects
• Higher risk of TD, EPS, & NHS
EXTRAPYRAMIDAL SYNDROME (EPS)
NEUROLEPTIC MALIGNANT SYNDROME (NMS)
• t Weight
Photopho bia
• Orthostatic hypotension
TARDIVE DYSKINESIA (TD)
• Lower risk of TD, EPS & NMS
• t Cholesterol
Photosensitivity
• t Triglyceride
Sedation/lethargy
• t Blood sugar
• Involuntary movements of the face, tongue, or limbs that may be irreversible.
• Parkinson's like symptoms • Akathesia (restlessness) • Dystonia (muscle twitching)
• Combination of symptoms: EPS, high fever, & autonomic disturbance
• One can recover 7-10 days after DC of medication, but it can be fatal
if not treated in time
NURSING CONSIDERATIONS
• Hypersensitivity
• Parkinson's disease
• Comatose cl ient
• Liver problems
• Depressed
• Coronary artery
d isease
• Bone marrow
depressio n
• Blood dyscrasias
• Hyper or
hypotension
~ Educate that it may take
• Teach S&S of TD, EPDS, & NMS!
• Advise the client to get up slowly
6 - 10 weeks to take effect
~
Tell cl ient about adverse
reactions and emphasize
that adherence is very
important
◄
• Check labs
(blood sugar, LDL, triglycerides)
• To decrease the risk of gaining weight,
advise the client about exercise,
low-calorie diet, & monitor their
wei ht.
193
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ACTION
~ The exact mechanisms are not ful ly
known
8
Levothyroxine increases the metabolic rate of t issues
think 7"11Yroid
~
1.
thetic ,UYroid
SIDE EFFECTS - - - - - - ~ Anxiet y
~ GI upset
~ Sweating
MEDICATION CLASS
~ Weight loss
~ Synthetic Hormone
~ Heat intolerance
THERAPEUTIC USES
THERAPEUTIC RESPONSE
• Treats hyp othyro idism
NO LONGER SHOWING SIGNS
OF HYPOTHYROIDISM
• Thyro id -stimu lating hormone
suppression
• Thyro id d iagnostic testing
• Hormone supplement after
thyroidectomy
~
Norma l heart rate (60 -100 8PM)
~
Improved ener9y levels (not fati9ued)
~
Norma l skin (not coo l or pa le)
Should not be used as a
weight loss regimen
PATIENT EDUCATION - - - - - - - • It m ay take 8 w eeks to see t he fu ll effect ~
y Educate
imp:~ the
it
• Report signs of HYPERTHYROIDISM
• Tachycard ia, heart palp itat ions,
we ight loss, insomnia, anxiet y
'~
e~f
Do not stop the med ication if
symptoms resolve. Thyroid hormone
is needed for feta l bra in development!
• Mon itor T4 & T3 levels
• Take o nce a day (in the morn ing befo re breakfa st)
• Take at t he sam e ti m e everyd ay
• Take o n an empt y sto m ach
Levothyroxine is a Life Long therapy
194
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Ci =ii:u:tlB91
MEDICATION CLASS
1
~ First-l ine antithyroid drugs
1
II:?"-
L
First-line antithyroid drugs
L
....----- ACTION - - - - - .
~ Inhibits the manufacture of
I
MEDICATION CLASS- ,
thyroid hormones
~ Does not affect existing thyro id
P revents
thyroid
from bein9
Up
. - - - - - - USES - - - - - ,
~ Treats hyperthyroid ism
I
~ Treats
thyrotoxicosis
~ Treats Graves' disease
hormones circulating in the blood
o r stored in the thyroid gland
(autoimmune disease that
causes hyperthyroidism}
~ Used before thyro idectomy surgery
(shrinking it before the surgery}
.........-'--- SIDE EFFECTS '----~
~
I
~
I
~
Hay fever
Skin rash
Headache
I
~ Nausea & vom iting
I
~ Paresthesias
I
PATIENT EDUCATION
.,,.;:s;::, It
~
;4:tfi,~e
may take 1-2 weeks to
~
~ c
I nee of
see the full effect
__,. •~~<•
~ Report signs of HYPOTHYROIDISM
I
(Bradycardia, weight gain, lethargy,
cold intolerance, depression}
~ Report signs & symptoms of an
infection to the health ca re provider
I
I
(Fever, sore t hroat, etc.}
~ Do not abruptly stop t he medication
{cou ld cause THYROID STOR,....M_~__
} _ __.
. - - - - - - - - -PREGNANCY CONSIDERATIONS
~ Use with extreme caut ion during pregnancy
because they can cause hypothyroidism in t he fetus ~
I
I (d
REMEMBER:
The fetus needs thyroid
~ If it's necessary, PROPYLTHIOURACIL is the p referred drug
oes not cross t he p Iacenta)
.
hor~one for proper
br~in development
:<I
~
~
}---'
195
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RAPID-
GENERIC
~
Lispro
Humalog
ONSET:
Aspart
Novolog
PEAK:
5 - 30 min
30 - 90 min
Glulisi ne
Apidra
DURATION:
3 - 5 hrs
BRAND NAME- . - - - - - - - - - - - - - - - - - - - - ,
HIGHEST RISK
FOR HYPOGLYCEMIA
-SHORT-------r-----------------,
n
Humulian R
Regular
ONSET:
30 - 60 min
PEAK:
2 - 4 hrs
DURATION:
5 - 7 hrs
Novoli n R
C.LE~R
ONLY INSULIN
GIVEN IV
,.. ,,
~ 0 e9ular 9oes " i9ht
~ into the vein
\- - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - -
INTERMEDIATE
n
- u ---._____. . . .____________
Humulin N
NPH
Novolin N
C.LOUO'f
ONSET:
1 - 2 hrs
PEAK:
4 - 12 hrs
DURATION:
18 - 24 hrs
NEVER GIVE IV
LONG------------------,, ,,..
•
Lon9 think
Lonely
Glarg ine
Lantus
Detemir
Levemir
f GUL~R INSULIN & NP1t
.J.':\~f:J 9;
~,..
1 - 2 hrs
PEAK:
None _ /
DURATION:
24 h rs+
LOWEST RISK FOR
HYPOGLYCEMIA
ADMINISTRATION
1Ns1.1/
• Must be g iven subcut or IV
• Insulin is destroyed by the GI tract
so it can not b e g iven PO
~~
C.LE~R C.LOUD'f
lleqular
ONSET:
• Remove all air bubbles
N~\\
• Rotate site 1 inch from previous site
• Common sites: back of arm s, t highs & abdomen
(at least 2 inches away from the bel ly b utton)
C.LOUO'f C.LE~R
N~\\
' \ ' I,
Reqular
COMPLICATIONS
WITHDRAW WITHDRAW
INSULIN
INSULIN
• Hypog lycem ia (especially w ith rapid insulin)
• Weight ga in
• Insulin is a growt h hormone
how to remember this order?
"You are Not Reti red, you are an
RN
11
• Lipoatrophy (loss of subcut fat)
196
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•
A loprim, Zy lopri m,
Lopu rin
all opurino l
nr
ON CLASS
GENERIC
TRADE NAME
co lch icine
Miti gare, Co lcrys
- - - MEDICATION CLASS - - -
-I
~ Uric acid inh ib itors
~ A ntigout agent
l
D~ IT('
~ PREVENTS gout attacks
rr;:s;::,
~
USES
I
0
~ RELIEVES acute gout attacks
Does not hel p with acute attacks
' " ,,
AlloPurinol
➔
.,.,,,..----......
( fake NSAJD}
f~~aocute attac~s,
T aspir;,!
Prevents gout ~
• Does not help w it h pain relie( ,....,,,.. T~
only helps decrease inflamation
,/ :ike N5AJDs\
~r acute attacks
, , , ,,
SIDE EFFECTS
~ GI UPSET:
same 61 sid(> eff.
Nausea, vomit ing, abdom inal pain, d iarrhe ~
(
e
0
(!)
(!)
0
~
r
~
I
.,,
-
NOT asp·
~
.I '
/0
Colchicine ➔ for aCute
gout attacks
SIDE EFFECTS- - - -
GI UPSET:
Nausea, vom iting, abdominal pa in, d iarrhea
~ ADVERSE REACTION:
R.isk for BONE MARROW SUPPRESSION ~
Stop th e med icatio n if a RASH occurs
• This may indicate a
HYPERSENSITIVITY REACTION ~
(Stevens-Joh nson syndrome)
EDUCATION
0
Gulp a lot of fluid durin9 the day
(2-3 Uday)
& take the medication with a 9lass of water
Gulp a lot of fluid durin9 the day
(2- 3 Uday>
& take the medication with a 9lass of water
No Or9an meats
Urine output up to 2 L/day
0
~ A lso PREVENTS gout attacks as well
-
~ SICINRASH
THERAPEUTIC USES ~
~
Takes several months to take effect
• Uric acid deposits can cause
kidney stones
.____,1f
(!)
(!)
0
No Or9an meats
Urine output up to 2 L/day
Takes several months to take effect
• Uric acid deposits can cause
kidney stones
.____,1f
• Fl uids help prevent t his
• Fluids help p revent t his
• Allopurinol + aspirin = t uric acid level s ~
• Take acetaminophen instead
~
197
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alendronate
Binosto
etidronate
Didronel
ibandronate
Bon iva
amidronate
Ared ia
risedronate
Actonel
GENERIC
TRADE NAME
calcitonin (sa lmon)
Miacalcin
. - - - - - MEDICATION CLASS - - - - - ,
~ Hormone
1
~
Bone resorptio n inh ib itors
Hypocalcemic ag ent
'\ ' ,..
MODE OF ACTION
AA CalcitONin helps 1'0Ne down
~
~ calcium levels in the blood!
Bisphosphonates inhibit normal & abnormal
BONE RESORPTION which leads to increased
b one mineral density!
. - - - - - MODE OF ACTION - - - - - ,
THERAPEUTIC USES
~
I
Inhibits OSTEOCLASTS
(Cells that cause bone breakd own)
BUILDS BONE DENSITY & PREVENTS BONE
FRACTURES
,I,
~ Treats & prevents osteoporosis
I
t he rate of bone breakd own
(postmenopausal & long term use o f steroids)
~ Treats paget's disease
. - - - - -THERAPEUTIC USES - - - - - ,
'
~ Treats hypercalcemia
r
~ Treats & prevents postmenopausa l
SIDE EFFECTS
~ Treats hypercalcemia
~ GI UPSET:
l
Nausea, diarrh ea, dyspepsia, acid reflux,
abdominal p ain
• Too much calcium in t he b loodstrea m
(we want it in th e bones, not in t he bloodstream)
- - EDUCATION ~ - • Take with a full g lass of water on an
empty stomach
• Stay upright for 30 minutes ----""
OSTEOPOROSIS
I
O
•
.
• Separate iro n, antacids, & mu ltiple
vitamins at least 30 minutes apart fro m
taking b isphosphonates
,lr- ~,. ~]
,
'
Th.,.
dtcre;;ue
ab,orption
~
~ GI UPSET
I
~
SIDE EFFECTS¾
INTRANASAL ROUTE
N asal irritation & nasal dryness
• Encourage increased intake of
calcium & vitamin D
• Encourage weight-bearing exercises
to preserve bone mass
11
r
If you don't use it , you lose it!
EDUCATION
11
• Encourage increased inta ke of
calcium & vitamin D
NURSING CONSIDERATIONS
~ Monitor serum calcium levels before, during,
& after t h erapy
( NORMAL CALCIUM: \
l
_
_
CAlCITONIN
9 - 11 mg/dl
I
• Encourage weight-bea rin g exercises
to preserve bone mass
11
If you don't use it, you lose it !11
~
196
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TEMPLATES
& PLANNERS
Tear these pa9es out and make copies,
as many as you need!
199
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f
~ URSING DIAGNOSIS {
r
~ UPPORTING DATA {
l_i;OALS
NURSING DIAGNOSIS
J
SUPPORTING DATA
j
GOALS
PATIENT INFO
1
NURSING DIAGNOSIS (
SUPPORTING DATA (
GOALS
(
1
MEDICAL HISTORY
)
)
NURSING DIAGNOSIS
I
SUPPORTING DATA
I
)
GOALS
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COURSE:
I
SUBMITTED
ASSIGN MENT/PROJ HT
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
© 2021 Hunelnlhel1akin9 LL(. Sharin9 and distribotin9 this coppi9hted material without permission is ill"'Jal.
I
DUE DATE
I
SCORE
I
-
-
Test I ~ 1rt:ICNU'
COURSE:
I
TEST DATE
CHAPTERS/TOPICS COVERED
I
GRADE
I
PASSED?
YES
I
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
YES
no
0 0
© 1011 HunelnlheHakin9 UC. Sharin9 and dirtributin9 this copyri9hted material without permis,ion is ille9•I.
HOURLY
□
MONTH: _ _ _ _ _ _ _ _ _ __
□
□ MONDAY
SUNDAY
PRIORITIES
□
TUESDAY
PRIORITIES
PRIORITIES
WEDNESDAY □ THURSDAY
PRIORITIES
PRIORITIES
11
□
□ FRIDAY
SATURDAY
PRIORITIES
PRIORITIES
6AM
6AM
6AM
6AM
6AM
6AM
6AM
7AM
7AM
7AM
7AM
7AM
7AM
7AM
8AM
8AM
8AM
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8AM
8AM
8AM
9AM
9AM
9AM
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10AM
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10AM
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11AM
12PM
12 PM
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12PM
,i
1 PM
1PM
1PM
1 PM
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2PM
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2 PM
2 PM
3 PM
3PM
3PM
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3 PM
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4PM
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5 PM
6PM
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6PM
6PM
6PM
6PM
6PM
7PM
7PM
7PM
7PM
7PM
7PM
7PM
$
·"
:i
l
g
~
1
1
~
E
-[
....
8
i§
"P"'
1
~
....
~
:!"'
8 PM
8PM
8PM
8 PM
8 PM
8 PM
8 PM
l
9PM
9PM
9PM
9PM
9PM
9PM
9PM
~
PRODUCTIVITY HETER
PRODUCTIVITY METER
I T' I -I f-- 1--1 f- l "T' I -I t--- 1 --1 1-"-I T' I -If- 1--1
IAO
GOOD
GHAT!
PRODUCTIVITY METER
t" I -If- I T' I -It- 1--1 t---l "T' I i t--- 1 --1 1-"-I f-- 1
8AO
GOOD
GREAT!
PRODUCTIVITY HETER
-I 1-"-I f-- 1 -If- 1--1 1 -I t--- 1 -I t--- 1 -t 1--'-'I f-- 1 -It
8AO
GOOD
GREAT!
PRODUCTIVITY HETER
I t" I -I t-" I T' l--'--'I f-- 1--1 f- l "T' l-"---1 t" I -If- 1 -f
IAO
6000
GREAT!
PRODUCTIVITY HETER
~
:!"'
~
~
PRODUCTIVITY METER
1 --1 1-"-I T' I -If- 1--1 t----1 t- 1 -t t--- 1 -t 1-"-I f-- 1 -I
1 -1 t-" l --11-"-I f-- 1 If- 1--1 t---l t- 1 -1 t--- 1 -t 1- -1
t----1 t- l -t t--- 1 --11-"-I f-- 1 -1 f- 1--1 f- -1 1- 1 -1 t--- 1
IAO
!AO
!AO
GOOD
GWT!
GOOD
'mt!
GOOD
mm
NURSEINTHEMAKING LLC
1J.:
N
0
9
MONTHLY
MONTH: _ _ _ _ _ _ _ __
YEAR: _ __
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NUR.SEINTHEMAKING LLC
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: :...M.O.N.DAY: .................................................................................
TO DO LIST
□ ------------□------------­
□------------­
............................................................................................................
: : TUESDAY:
□ -----------­
□ -----------­
□ -----------□------------□-------------
··········································································································•···...
: :..WE_D N.E.S_D AV:.........................................................................
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···········································································································
: :· THURSDAY:
□ -----------­
NOTES
: ·•.............................................................................................................
FRI DAY:
·
CsAiiiioiv'::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.
TESTS I EXAMS
: : SUNDAY:
CIELHARE•
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PR.OJECTS / ASSI GNMENTS
....------ PATHOLOGY- - - - - ,
..------SIGNS·& SYMPTOMS----,
.------RISK-FACTORS-----.
. - - - - - - - - - - -COMPLICATIONS- - - - - - - - ~
. . - - - - DIAGNOSIS- - - - ,
..-------TREATMENT- - - - - .
© 2021 HunelnTh,Haki"9 UC. Shari"9 and distn1>1tin9 this mpyn,htH 11atffial without P"r11ission is ill-,al.
PHARMACOLOGY TEMPLATE
DRUG CLASS:
GENERIC NAME
~ - - - - ACTION - - - - - - .
TRADE NAME
~ - -THERAPEUTIC USES - - - - .
. - - - - - - SIDE EFFECTS------.
.----- CONTRAINDICATIONS -----.
.----- NURSING CONSIDERATIONS-__,
© 2021 Hunelnlh0Hakin9 LLC. Sharin9 and distrib1tin9 this copyri9htod material without porminion is ill09at.
.----- PATIENT EDUCATION - - - - .
l'
Month: _ _ _ _ _ _ __
~
SUNDAY
Subject:
MONDAY
Subjtct:
TUESDAY
Subject:
WEDNESDAY
I
Subjtct:
NCLEX Date: _ _ _ _ _ __
l
i
':;"
·c
THURSDAY
11
-~-~Ii
Subject:
FRIDAY
I
SATURDAY
Subject:
Subjtct:
·[
8
Body Systfm:
Body System:
Body System:
Body System:
11 Body System:
Body System:
Body System:
# of Prutice Questions:
# of Prictice Questions:
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# of Prictice Questions:
11 # of Prutice Questions:
# of Prictice Questions:
# of Prictice Questions:
Self Cue:
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Self (ire:
Self Cue:
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i
1
~
:!"
i........"'
~
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l
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1z:
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# of Prutice Questions:
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# of Prutice Questions:
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# of Prutice Questions:
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.
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(9
Yov ma~ be, <;fye,<;<;w, ~ov Ma~ fe-e,( -fiye,c(
and ~ov ma~ wan+ to jve- vp. NvY<;i~ <;c--rwo( i<;
hav-d, fhe-v-e-'<; no dovbt abovt it. 6-ve-v-~one, e,,v-ie-<;,
e-ve-v-~one- ha<; me-(fdown<;, ancl the-v-e, wi ff bemome-nt<; ~ov don't fe-e-f cc,afipw fov- the- fa<;k- at
hand. Bvt fakt;- he-a~ the- e-haffe,~ on(~ makt;-<;
~ov <;fv-o~v-. Pvt in the- wov-k., <;how vp on -lime-,
and pnd an amaz..i~ c;tvd~ 8'ovp. Yov g+ thic;!
- Kvi<;-fine- Tiittfe-, BSN, RN
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