THE NURSING
A Study Bundle for Nursing Students
Anatomy
Med-Surg
Pharmacolo
Pediatrics
Maternity
Fundament
nursebossstore.com
Authors: Fiskvik Antwi, PhDN, RN.
Simon Osei, PhDN, RN
Rachel Antwi, BSN, RN
Copyright © 2021 by NurseBoss Store
All Rights Reserved.
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table of contents
Fundamentals of Nursing............................
IV Fluids..........................................................................
Anatomy and Physiology............................
Medical-Surgical Nursing............................
Med-Surg Flashcards......................................
Shock...............................................................................
Hepatitis.......................................................................
Burns................................................................................
Chest Tube Management............................
Electrolyte Imbalance....................................
EKGs/ECGs..................................................................
Lab Values...................................................................
ABGs..................................................................................
Pharmacology........................................................
Drug Calculation...................................................
Insulin..............................................................................
Maternal and Child Health..........................
Pediatric Disorders............................................
Nursing Health Assessment......................
Cranial Nerves.........................................................
Patient Assessment Template..............
Nurse Report Template.................................
Nursing Process.....................................................
5-41
42-51
52-82
83-233
234-280
281-299
300-302
303-308
309-312
313-318
319-344
345-349
350
351-426
427-431
432-433
434-467
468-500
501-508
509-524
525-529
530
531-600
FUNDAMENTALS OF
NURSING
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TABLE OF CONTENTS
TABLE OF CONTENTS
1. The Healthcare Delivery System
2. The Nursing Process
3. Nursing Ethics
4. Nursing Concepts
5. Cultural Competence
6. Electrolyte Imbalance
7. Head-to-Toe Assessment
8. Patient Positioning
9. IV Therapy
10. Vital Signs
11. Nutrition
12. Wound Care
13. Medication Administration
14. Infections
15. Transmission Precautions
16. SBAR Communication Tool
17. Blood Groups
18. Oxygen Therapy
19. Nursing Theorists
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The Health Care Delivery System
Definition
Components of the HCS
A health care delivery system
involves an organization of
people, institutions and
resources to provide health
care services to meet the
needs of a population.
1. The patient (consumer)
2. Professional care providers:
doctor, nurse, etc.
3. Organization: hospital, clinic
4. Economic environment:
regulatory bodies,
Insurance, etc.
Methods of Healthcare
Delivery
Levels of Healthcare
Managed Care System: a
system organized to
manage cost, utilization and
quality.
Case Management: a
collaborative process of care
to meet the patient's
health care needs. The case
managers are nurses.
Primary Healthcare:
provides universal health
care that is accessible to
individuals, families and the
community.
PRIMARY CARE
1. First level of contact
2. Promotive + Preventive care
3. Clinics, etc.
4. Involves disease prevention,
counseling, education, screening
SECONDARY CARE
1. Curative services
2. Diagnosis and treatment of
patients
3. Hospitals, emergency
department etc.
TERTIARY CARE
1. Higher level of care
2. Specialized care + speciality units
3. ICU, cancer treatment, cardiac
surgery, etc.
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The Health Care Delivery System
Type of
Healthcare Settings
1. Hospitals
2. Ambulatory care centers
3. Home health
4. Primary care centers: offices
5. Schools
Interprofessional Care
Interprofessional/
interdisciplinary care involves
the collaboration among
healthcare professionals to
provide patient-centered care.
6. Daycare centers
7. Mental health centers
8. Rehabilitation centers
9. Hospice
10. Occupational health
11. Assisted-living
Finance and Healthcare
1. Medicare: federal health
insurance. Coverage: >65
years and younger people
with disability.
2. Medicaid: federal and state
program for people with
low income
3. Private Insurance
Current Trends and
Issues in Healthcare
1. Nursing shortage
2. Healthcare cost
3. Globalization
4. Technology
5. Complexity of patient
care
6. Increase of chronic illness
7. Increase of the elderly
population
8. Changing demographics
9. Political influence
10. Increasing diversity
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The Nursing Process
Definition
The nursing process is a
systematic, deliberative and
dynamic method of providing
patient-centered care.
The 5 Sequential Steps
Assessment
Importance
1. It allows the nurse to identify
the patient's needs
2. It allows the nurse and patient
to set mutual goals
3. It provides continuity of care
4. It allows the recognition of
potential risk(s)
5. It provides documentation and
communication among other
health professionals
The 5 Column Care Plan
Assessment
Diagnosis
Subjective and objective data
Nursing Diagnosis
Includes the label, etiology, and
defining characteristics
Planning
Expected Outcomes
Short-term and long-term goals
Interventions
Implementation
List independent and
collaborative interventions
Evaluation
Evaluation
Evaluate the expected
outcome. Present evidence that
supports the outcome.
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The Nursing Process
Assessment
Diagnosis
Systematic method of collecting
data to determine patient's needs.
Types of Data
1. Subjective data: patient's
feelings, emotions, sensations.
E.g. Dizziness
2. Objective data: Observable and
measurable. E.g. Vital signs
Sources of Data
1. Primary: from the patient
2. Secondary: family, medical
records, healthcare
professionals etc.
Method of Data Collection
1. Interview, 2. Physical
examination, 3. Observation, 4.
Lab tests
A clinical judgment of a patient's
response to an actual or health risk,
which gives a foundation for
interventions toward an outcome.
Parts of a nursing diagnosis
1. Label
2. Etiology
3. Defining characteristics
Planning
1. Prioritize care
2. Establish short-term and
long-term goals.
3. Establish nursing
interventions: Independent
and collaborative
interventions
Implementation
1. Care plan implementation
SBAR
S- Situation
B- Background
A- Assessment
R- Recommendation
PRIORITIZING NURSING DIAGNOSIS
Maslows Hierachy of
Needs
Selfactualization
Self-esteem
Love and Belonging
Safety and Security
Physiological Needs
Evaluation
1. Reassessing the patient's
progress as compared to the
expected outcome
2. Document statements of
evaluation.
3. Establishing an alternative plan
when the outcome was not met.
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Nursing Ethics
Definitions
Ethical Dilemmas
Values: individual beliefs that
guide and influence behavior.
Ethical dilemmas: conflict between
the nurse's ethical values or moral
principles.
Ethics: a system of moral
principles that involves
systematizing concepts of right
and wrong conduct
Making ethical desicions
Tip: Use the nursing process to make
ethical decisions.
1. Describe the situation and
gather data (assessment)
2. Identify the ethical problem
(recognize conflict of own values)
3. Plan: Identify options,
consequences, and affected
stakeholders. Make a decision
based on ICN code, competence,
or consult with an expert, etc.
4. Implementation
5. Evaluate outcome.
Ethical Principles
1.Autonomy: respecting the
patient's right to make health
decisions.
Nurses' Role: Mutual goal
setting, patient education,
advocacy
2. Fidelity: Keeping promises
and remaining faithful.
Nurses' Role: Being faithful in
the provision of competent and
quality care.
3. Justice: Fairness
Nurses' Role: Avoid
discrimination, bias.
4.Beneficence: promote
good/benefits.
Nurses' Role: Patient advocate,
promote well-being
5. Nonmaleficence: Do no harm
Nurses' Role: Promote patient
safety, prevent risks.
ICN Code of Ethics
International Council of Nurses: a
federation of national nurses
associations. Ensures quality
nursing, advancement of practice,
and policy development
Code of ethics: guide of principles
designed to consider the values and
obligation of the profession.
4 Principles:
1. Nurse and People
2. Nurse and Practice
3. Nurse and the Profession
4. Nurse and Co-worker
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Nursing Ethics
The Nurse Practice Act
Confidentiality
Every state has their own Nurse
Practice Act.
Purpose: to ensure that patients are
receiving safe and quality care
Patient confidentiality is
protecting and maintaining
patient's privacy.
Nurse Practice Act outlines
standards for:
1. educational programs
(accreditation)
2. scopes of nursing practice
3. licensure
4. disciplinary actions
5. authority
6. reciprocity: apply and being
endorsed in another state
Health Insurance Portability and
Accountability Act (HIPAA):
federal law to ensure that the
patient’s medical data remains
private and secure.
American Nurses
Association
ANA aims to advance the
nursing profession.
1. Advocate health care issues
2. Promote safe working
environment
3. Promote quality nursing
practice
4. Promote health and
wellness of nurses
Informed Consent
A process of seeking patient's
permission before a medical
treatment/intervention.
Components:
1. Describe and educate patient
on proposed intervention
2. Educate patient on their role
in decision making
3. Discuss the risks and benefits
4. Discuss alternative
intervention(s)
5. Assess patient's
understanding
6. Elicit the patient's preference
and decision (through
signature)
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Nursing Concepts
Definitions
ICN definition:
Nursing encompasses
autonomous and collaborative
care of individuals of all ages,
families, groups and
communities, sick or well and in
all settings.
WHO definition of health:
Health is a state of complete
physical, mental and social wellbeing and not merely the
absence of disease or infirmity
Aim of Nursing
1. To promote health
2. To prevent illness
3. To restore health
4. To alleviate suffering
Roles of a Nurse
1. Caregiver
2. Educator
3. Leader
4. Collaborator
5. Communicator
6. Advocate
7. Leader
8. Counselor
Nursing as a Profession
What makes nursing a
profession.
Criteria:
1. Defined body of
knowledge
2. A clear educational
pathway
3. Autonomy
4. Code of ethics
5. Professional
organization that sets
standards
6. Ongoing Research (EBP)
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Nursing Concepts
Professional
Organizations
1. International Council of
Nursing (ICN)-a federation of
national nurses associations.
Ensures quality nursing,
advancement of practice, and
policy development
2. American Nurses Association:
aims to advance the nursing
profession.
3. American Association of
Colleges in Nursing (AACN):
focus on quality education.
Performs accreditation of
nursing institutions
4. The Joint Commission:
accredits and certifies health
care organizations and
programs in the USA
5. National Student Nurses'
Association: professional
development of nursing
students
6. Quality and Safety Education
for Nurses (QSEN): ensures
quality education
7. National League for Nursing
(NLN): professional testing
service in USA for nursing
education
Nursing Practice
What guides nursing
practice?
1. Standards of Nursing
Practice
2. Nurse Practice Act
3. The Nursing Process
Trends in Nursing
1. Evidence-Based Practice
2. Aging population
3. Nursing shortage
4. Diverse population
5. Increase chronic illness
6. Primary healthcare
7. Cultural competent care
8. Advance practice
9. Health promotion
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Cultural Competence
Definitions
Culture: the shared beliefs,
norms and values of a particular
social group.
Race: The distinctive physical
traits/phyisical characteristics
shared by a group of people
(skin pigmentation, hair texture,
etc.)
Cultural Competency
Key components of cultural
competency.
1. Cultural Awareness
2. Cultural Attitude
3. Cultural Knowledge
4. Cultural Skill
Ethnicity: culturally defined
group that shares a common
and distinctive culture, religion,
language, etc.
Culture,
Health & Healthcare
Cultural Competency
Cultural Competence is the
ability for healthcare
professionals to interact and
provide culturally appropriate
care to patients in cross-cultural
communities.
Culture influences:
1. Patient's perception of
health, illness and death
2. Beliefs of the causes of pain
3. Expression of pain
4. Gender roles
5. Treatment preferences
6. Health promotion/ Nutrition
7. Mental health
8. Physiologic variations:
certain groups are prone to
developing specific diseases
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Cultural Competence
Transcultural Nursing
Campinha-Bacote Model
Transcultural Nursing:
Transcultural nursing is focused
on being aware and sensitive to
cultural differences and focusing
on individual patients, their
needs, and their preferences.
Campinha-Bacote's Model views
cultural competency as a process.
Cultural Care Theories
Leininger Sunrise Model:
Leininger's model assist
healthcare professionals to
provide culturally competent care
and avoid stereotyping.
The model utilizes three concepts:
1. Culture care
maintenance/preservation:
the nursing actions and
provisions that support the
patient's cultural practices.
2. Culture care
negotiation/accommodation:
the provision of support
toward cultural activities that
do not pose threat to the
patient's health/wellbeing.
3. Cultural
restructuring/repatterning:
helping patients modify or
change their cultural activities
that causes harm towards
health.
1. Cultural Awareness:
Healthcare professionals
consciously examine their own
cultural background, biases,
beliefs and values.
2. Cultural Knowledge:
Understands the cultural
world views.
3. Cultural Skill: Cultural
assessment
4. Cultural Encounters: Cultural
exposure, cultural practice
5. Cultural Desire: motivation to
engage in the cultural
competency process.
Cultural Assessment
Cultural Assessment Includes
assessing
1. Ethnic Background
2. Religious preferences
3. Food preferences/pattern
4. Health Beliefs/Values
5. Health Practices
6. Family patterns
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ELECTROLYTE IMBALANCE
HYPERVOLEMIA
HYPOVOLEMIA
Causes:
Causes:
1. Heart failure
2. Liver cirrhosis
3. Excess fluid/ sodium
intake
4. Renal failure
Symptoms:
1. Elevated BP
2. Bounding pulse
3. Ascites
4. JVD
5. Edema
6. SOB/crackles
7. S3 heart sound
8. Urine specification
<1.010
HYPERNATREMIA
Causes:
1. Dehydration
2. Diabetes insipidus
3. Fluid loss-GI
4. Cushing Syndrome
5. Increased Na
Intake
Symptoms:
1. Cardiac: Tachycardia,
Increased BP
2. GI: Thirst
3. GU: Oliguria
4. Neuro: Restlessness,
anxiety
5. Skin: Edema
1. Vomiting
2. Diarrhea
3. Continous GI suctioning
4. Hemorrhage
5. DKA
6. Burns
7. Adrenal desease
8. Systemic infection
Symptoms:
1. Decreased Bp
2. Tachycardia/weak pulse
3. Decreased urinary output
4. Poor skin turgor
5. Restlessness/Confusion
6. Dry mucus membranes
7. Thirst
HYPONATREMIA
135-145mEq/L
Causes:
1. Diuretics
2. Diarrhea
3. Vomiting
4. Congestive HF
5. Hyperglycemia
6. Medication
7. Continuous gastric suctioning
Symptoms:
1. Cardiac: Tachycardia,
hypotension, thready pulse
2. GI: Nausea, Vomiting
3. GU: Oliguria
4. Neuro: Restlessness, headache
dizziness, weakness,seizures
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ELECTROLYTE IMBALANCE
HYPERKALEMIA
Causes:
1. Kidney failure
2. Trauma
3. Sepsis
4. Potassium-sparing
diuretics
5. Addison's disease
6. Dehydration
7. Metabolic acidosis
Symptoms:
1. Cardiac: V-fib, T wave
elevation, prolonged PR, Flat
P wave, Wide QRS
2. GI: Abdominal cramps
3. GU: Oliguria
4. Neuro: Numbness, tingling,
hyperreflexia, flaccid
paralysis
5. Risk: Cardiac arrest
HYPERCALCEMIA
HYPOKALEMIA
3.5-5.5mEq/L
Causes:
1. Diarrhea
2. Vomiting
3. Gastric suctioning
4. Low potassium diet
Symptoms:
1. Cardiac: Hypotension,
Arrhythmias, Flattened Twave, ST depression
2. GI: Nausea, Vomiting,
decreased peristalsis
3. GU: Polyuria
4. Neuro: Dizziness, weakness,
decreased reflexes,
Metabolic Alkalosis
HYPOCALCEMIA
8.5-10.5mEq/L
Causes:
1. Bone cancer
2. Hyperparathyroidis
m
3. Hyperthyroidism
4. AKI
5. Rhabdomylysis
6. High Vitamin D
intake
Symptoms:
1. Cardiac: Increased BP, heart
block (may lead to cardiac
arrest)
2. GI: Dehydration, constipation,
polydipsia
3. GU: Polyuria, kidney pain
4. Neuro: Confusion, irritability
5. Musculoskeletal: Bone pain
Causes:
1. Lack of Vitamin D intake
2. Lack of Calcium intake
3. Hypoparathyroidism
4. Hypothyroidism
5. Burns
6. Sepsis
7. Kidney/liver disease
Symptoms:
1. Cardiac: Arrhythmias,
Bradycardia, Hypotension,
weak pulse
2. Neuro: Paresthesia, muscle
spasms, seizures, Trousseau
signs, Chvostek signs
3. Resp: Dyspnea, Lanryngospasm
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ELECTROLYTE IMBALANCE
HYPERMAGNESEMIA
Causes:
1. Laxative use that
contains Mg
2. Use of antacid
(containing Mg)
3. Renal dysfunction
4. Decreased adrenal
function
HYPOMAGNESEMIA
1.3-2.1mEq/L
Causes:
1. Chronic alcoholism
2. Hyperaldosteronism
3. Diabetic ketoacidosis
4. Malabsorption,
Malnutrition
5. Chronic diarrhea
6. Dehydration
Symptoms:
Symptoms:
1. Cardiac: Hypotension,
bradycardia, weak pulse,
cardiac arrest
2. Resp: Dyspnea, low RR
3. Neuro: Confusion, dilated pupils,
lethargy
4. Musculoskeletal: Muscle
weakness, facial paresthesia,
decreased reflexes
1. Cardiac: Arrhythmias,
Tachycardia, High BP
2. Neuro: Seizures, Delusions,
Hallucinations
3. Neuromuscular: Tetany,
Chvostek signs,Positive
Trousseau's
Functions of Electrolytes.
1. Sodium (Na): found in extracellular fluid. Maintains acid-base
balance, ECF osmolarity, sodium-potassium pump, and
neuromuscular functions.
2. Calcium (Ca): Major cation in teeth and bones. Aids
coagulation, cardiac conduction, and hormonal secretion.
3. Potassium (K): found in the intracellular fluid. Participates in
sodium-potassium pump, and neuromuscular function.
4. Magnesium (Mg): ICF cation. Has an effect on myoneural
junction, skeletal muscles, parathyroid hormones and cardiac
contractions.
5. Phosphorus (P): Main ICF anion. Acts as a hydrogen buffer.
Promotes energy storage.
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HEAD-TO-TOE ASSESSMENT
General Survey
1. Assess physical appearance, mood,
affect and grooming.
2. Assess orientation: Oriented to
Person, Place, Time and Situation.
3. Assess level of consciousness.
4. Assess speech.
Vital Signs
Pulse: 60-100 bpm
Blood Pressure Systolic: 120
Diastolic: 80
Respiratory Rate: 12-18 bpm
O2 Saturation: 95-100%
Temperature: 97.8-99.1 degrees F
36.5-37.5 degrees C
Head/Face
1. Assess head size, shape,
symmetry.
2. Inspect and palpate head, scalp
3. Palpate sinuses and TMJ
Face
1. Assess facial symmetry
2. Assess cranial nerve 7
Eyes/ Ears/ Nose
1. Inspect external eye structures,
conjunctiva and sclera.
2. Test cranial nerve III, IV, VI
3. PERRLA- Pupils are Equal, Round,
Reactive to Light and
Accommodation.
4. Pupil size: 3-5mm
Ears: Assess for redness, drainage.
Test cranial nerve-Vestibulocochlear
Nose: Assess shape, symmetry, size,
patency. Test cranial nerve I
Mouth
1. Inspect lip color, sores, gums, tongue,
teeth, soft and hard palate, uvula
2. Test cranial nerve 9, 12 and 10
Neck
1. Palpate lymph node, carotid artery,
presence of goiter.
2. Auscultate for bruits.
3. Test cranial nerve 11
Lungs
1. Inspect symmetrical chest movement
2. Palpate for pain and lumps
3. Percuss using the Z-block method
4. Auscultate lung sounds
Heart
1. Auscultate heart sounds (Aortic,
Pumonic, Erb's Point, Tricuspid and
Mitral) using diaphram then bell
Abdomen
1. Inspect, Auscultate, Percuss, Palpate
2. Inspect skin color, contour and aortic
pulsations.
3. Auscultate bowel sounds from RLQ
clockwise.
Skin and Extremities
1. Assess and inspect skin, nails, muscle
strength, ROM, curvature of spine.
2. Palpate pulses
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PATIENT POSITIONING
POSITION
Supine
Dorsal Recumbent
Fowlers
Tripod
Prone
Lateral
EXPLANATION
Lying flat on back without a pillow.
Lying flat on back. Patient head elevated
on a pillow.
1. Head of bed is elevated 45-90 degrees
2. High fowlers: Head of Bed is at 90
degrees
3. Semi-fowlers: Head of Bed is at 30-45
degrees.
4. Low fowlers: Head of Bed is at 15- 30
degrees
Sitting at the side of bed and leaning on
the side table.
patient lies on the abdomen with head
turned to one side
patient lies on one side of the body with
the top leg in front of the bottom leg and
the hip and knee flexed
Trendelenburg
HOB is low, foot of bed is raised
Reverse
Trendelenburg
HOB is elevated, foot of bed is lowered.
Lithotomy
patient is on their back with hips and knees
flexed and thighs apart.
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IV THERAPY
Importance of IV therapy.
Intravenous fluids maintain/restore fluid balance + electrolyte
balance
Types of IV Fluids.
Isotonic Solutions
Osmotic pressure is the
same inside and outside
the cell.
not
o
d
ith
ellS
c
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e
l
Th
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r
o
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ove
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d
i
flu
ICF
Hypertonic Solutions
ECF
Osmotic pressure draws
water out of the cell
into the ECF (highly
concentrated)
KS
N
I
HR
S
L
CEL
ICF
ECF
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IV THERAPY
Osmotic pressure draws
water into the cell from
the ECF (diluted)
Hypotonic Solutions
LLS
E
SW
L
L
CE
ICF
ECF
ISOTONIC SOLUTION.
0.9% saline (NS)
5% dextrose (D5W)
Ringer's Lactate (LR)
1. Used with the
administration of
blood products.
2. To replace Na + Cl
3. Caution: Cardiac
and renal
patients.
1. Used to treat
hypernatremia
2. Used to treat
hypoglycemia
3. Dehydration/Fluid
loss
4. Do not use for
resuscitation.
1. Burns
2. Electrolyte loss
3. Hypovolemic shock
(bleeding)
4. Dehydration
Nursing Considerations
1. Assess and monitor vital
signs, lung sounds, lab
values (electrolytes)
ICF
ECF
3. Monitor for any changes in
fluid balance, electrolyte
concentrations
2. Assess contraindications.
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IV THERAPY
HYPERTONIC SOLUTION.
5% dextrose in
0.9% saline
10% dextrose in
water (D10W)
5% dextrose in
0.45% saline
1. Fluid and
electrolyte
replenishment
1. Maintenance fluid
1. Caloric supply
Nursing Considerations
1. Assess and monitor vital
signs, lung sounds, lab
values (electrolytes)
3. Monitor signs of hypervolemia
ICF
ECF
HYPOTONIC SOLUTION.
0.45% Saline
1. Fluid replacement
among patients
with hypovolemia
ICF
ECF
Nursing Considerations
1. Assess and monitor vital
signs, lung sounds, lab
values (electrolytes)
2. Avoid in patients with liver
disease, trauma, risk for
increased ICP or burns.
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IV THERAPY
It is important for the nurse to monitor for signs of
IV therapy complications such as pheblitis,
thrombopheblitis, hematoma, air embolism and
hypervolemia.
IV THERAPY
COMPLICATIONS
Pheblitis
Inflammation
of the vein
Thrombopheblitis
Hematoma
collection/ pooling of
blood outside the blood
vessel.
Clots in the veins
Air Embolism
blood vessel blockage
caused by one or more
bubbles of air
Hypervolemia
Fluid volume overload
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VITAL SIGNS
BLOOD PRESSURE
TEMPERATURE
120/80
Blood pressure: the force that
blood exerts against the inner
walls of blood vessels.
120 Systolic pressure
80 Diastolic Pressure
1. Elevated BP: >120-129/<80
2. Stage 1 Hypertension: 130139/80-89
3. Stage 2 Hypertension: >140/>90
97.8-99.1 degrees F
36.5-37.5 degrees C
1.
Oral-mouth
2. Axillary-armpit
3.
Temporalforehead
4. Rectal-rectum
5. Tympanic-ear
PULSE OXIMETRY
95%-100%
Used to measure the level of 02
saturation in the body.
PULSE
60-100 bpm
1. Temporal pulse
2. Carotid pulse
3. Brachial pulse
4. Radial pulse
5. Apical pulse
6. Femoral pulse
7. Popliteal pulse
8. Pedal pulse
Pulse:
Absent= 0
Weak = +1
Normal = +2
Full = +3
Bounding = +4
COPD Patient normal SPO2:
88%-92%
RESPIRATIONS
12-18 breaths/min
Assess:
Respiratory Rate
Respiratory Depth
Respiratory Pattern
Respiratory rate may
increase due to pain, fever,
and other medical
conditions.
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NUTRITION
Nutrition
Portion Size
Carbohydrates:
1. source of energy.
2. Spares the use of
protein for energy
3. Breakdown of fatty
acids
Proteins
1. Growth and
development of
body tissues.
2. Build and repair
tissues.
Fats
1. Stored energy
2. Protect organs
3. Maintain body
temperature
Vitamins
1. Fat-soluble vitamin:
A,D,E & K
2. Water soluble:
Vitamin B & C
Minerals
1. Growth and
development.
2. Enhance cell
function.
Therapeutic Diets
1. Clear liquid diet: fluids
(prevent dehydration)
Monitor pt. hydration.
2. Full fluid diet:
Transition after clear
fluid diet.
3. Soft diet: soft texture.
4. Low fiber diet
5. High fiber diet: Used
for constipation.
6. Low fat diet
7. Low sodium diet
8. Low potassium diet
9. Diabetic diet
10. DASH diet
11. Vegan/vegetarian diet
Body Mass Index (BMI):
WEIGHT(kg)/HEIGHT (m2)
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NUTRITION
DISORDER
DIET
1. Low sodium
RENAL DISEASE: 2. Low potassium
3. Fluid restriction
1. Low sodium
HYPERTENSION: 2. Low fat diet
CONSTIPATION: 1. High fiber diet
BURNS: 1. High protein diet
1. Low carbohydrate
DIABETES: diet
2. Low sugar diet
CELIAC DISEASE: 1. Gluten free diet
1. Low sodium diet
CAD: 2. Low fat diet
PANCREATITIS: 1. Low fat diet
1. Low fat diet
OBESITY: 2. Calorie restriction
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WOUND CARE
Wound Healing
1. Hemostasis Phase: first
phase of wound healing.
Begins at onset of injury.
Goal is to stop bleeding.
Body activates thrombin,
platelets (emergency repair
system).
2. Inflammatory Phase:
Coagulation and WBC
activation
3. Proliferative Phase: fill and
cover the wound with new
connective
tissues(epithelialization)
4. Maturation Phase: collagen
fiber strengthening.
Stages of Pressure
Wounds
Stage 1: Non-blanchable
erythema (redness) of intact
skin
Stage 2: Partial-thickness loss
of skin. Affects the epidermis
and dermis.
Stage 3:Subcutaneous fatty
tissue affected. Muscle,
tendon, ligament, cartilage,
and bone are not exposed.
No tunneling would be
observed.
Stage 4: Muscle, tendon,
ligament, cartilage, and bone
are exposed.
Unstageable: Obscured tissue
damage due to eschar
Wound Assessment
The wound color, type, size,
location, tissue type.
Presence of exudate, tunneling
Symptoms such as pain,
inflammation, odor
Assessment of Wound edges
and the surrounding skin for
excoriation or maceration.
Colour Classification
1. Black necrotic (eschar):
debride wound surgically
2. Yellow (sloughy): to deslough, prevent infection.
3. Green (infected): control
infection and achieve healing.
4. Red (granulating): protect
and support healing.
5. Pink (epithelializing): protect
and support healing
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MEDICATION ADMINISTRATION
Pharmacokinetics
Pharmacokinetics is the study of
drug movement/action in the
body in terms of absorption,
distribution, metabolism and
excretion.
Drug Administration
Routes
Oral
1. Most frequently used
route.
2. Do not administer to:
patients with dysphagia, or
vomiting.
Transdermal/Topical Route
Absorption
Absorption is the drug movement
from the administration site
to blood stream
Distribution
Drug distribution from one location
to another
Metabolism
Metabolism is the chemical
alteration of a drug in the body.
1. Drug delivery through the
skin
2. Ointment, patches, etc
Rectal/Vaginal
1. Rectal: administered
through the anus into the
rectum
2. Suppository, enema,etc
3. Vaginal: intravaginal
administration
4. Antibacterials and
antifungals, etc
Inhalation Route
1. Patient inhales into their
airway (nasal/oral passage)
Excretion
Excretion is the process of
removing a drug & metabolites
from the body.
Buccal and Sublingual
1. Buccal: gums and cheeks
2. Sublingual: Under the
tongue
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MEDICATION ADMINISTRATION
Drug Administration
Routes
Otic Route
1. Warm solution
2. Have patient tilt head
3. Adults: pull auricle upward
and backward
4. >3 years: pull auricular down
and back
Ocular Route
1. given into the eye by drops,
gel, or ointment
Parenteral
Routes
Parenteral drug administration:
non-oral route that allows the
medication to bypass the GI
system.
Types:
1. Intradermal
2. Subcutaneous
3. intramuscular
4. Intravenous
IV route: immediate onset of action
Nasal Route
1. Medication administered
through the nose
Parenteral Route
10-15 Degree Angle
45 Degree Angle
90 Degree Angle
25 Degree Angle
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MEDICATION ADMINISTRATION
Drug Rights
1. Right Drug
2. Right Patient
3. Right Dose
4. Right Route
5. Right Time
6. Right Documentation
7. Right Assessment
8. Right to Refuse
9. Right Drug Interaction
10. Right Education
Types of Drug Orders
1. Routine Order: carried out as
specified until discontinued
2. P.R.N: As needed
3. Single Order: Directive is
carried out only once as
specified by physician
4. Stat Order: A single order
carried out at once
5. Written Order: inscribed by a
physician on a prescription pad
6. Verbal Order: When receiving
verbal orders, write the order
down exactly as heard,
repeat the order back to the
physician, document, have
physician cosign
Medication
Order
Date:
Name of Medication:
Dosage:
Time and Frequency:
Route of Administration:
Name and Signature of Prescriber:
Patient Information:
Times of Medication
Administeration
Before meals: ac
After meals: pc
Twice a day: bid
Three times a day: tid
Four times a day: qid
Every day: daily
Every hour:qh
Every two hours: q2h
Every four hours: q4h
Every six hours: q6h
As needed: prn
As desired: ad lib
At bedtime: hs
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INFECTION
CHAIN OF INFECTION
Causative
Agent
Risk of infection by a
microorganism
Susceptible
Host
Impairment of the
body's natural
defenses
Humans, plants,
animals, food, water
Portal of Entry
GI tract, Respiratory
tract, GU tract, blood
Portal of Exit
GI tract, Respiratory
tract, GU tract, blood
Reservoir
Mode of
Transmission
Direct: Contact
Indirect: Through a vehicle
( surgical instruments,
utensils
Airborne: droplets
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STAGES OF INFECTION
INCUBATION
The time between exposure to pathogen and first symptom.
PRODROMAL
Onset of first symptom to distinct symptoms. The number of
pathogen multiplies and the immune system reacts.
ILLNESS STAGE
Symptoms are pronounced and specific to the infection
CONVALESCENCE
Patient begins to recover gradually. Acute symptoms
disappears.
PERSONAL PROTECTIVE EQUIPMENTS
DONNING PPE
REMOVING PPE
REMOVING PPE
1. Gown
1. Gloves
2. Mask
2. Gown
3. Goggles or face shield
3. Mask
4. Gloves
4. Hand hygiene
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TRANSMISSION PRECAUTIONS:
Airborne Precautions
≤
1. Particles are smaller
( 5µm)
2. Diseases: TB, measles,
varicella
Nursing Actions
1. Negative pressure room
(private room)
2. Masks: N95, respirators
Droplet Precautions
1. Particles are >5 microns (µm)
2. Droplet spread is via the
upper respiratory tract
(nose, nasal passages and
pharynx).
3. Diseases:
a. Pneumonia
b. Influenza
c. Meningitis
d. Pertussis
e. Mumps
f. Rubella
Nursing Actions
1. Place patient in a private
room
2. Wear a surgical mask.
Contact Precautions
1. Contact spread occurs
through direct contact.
2. Involves a direct or indirect
transmission.
3. Diseases:
a. Wounds
b. Herpes
c. Scabies
d. Impetigo
Nursing Actions
1. Place patient in a private
room
2. Wear gloves and a gown.
Protective Precautions
Remember:
Protective precautions are maintained
for immunocompromised patients.
1. Patient is placed in a private room
2. Patient wears a mask when they
leave the room.
3. The private room should have a
positive pressure ventilation and
Hepa filtered air.
Standard Precautions
Infection prevention and control
measures that applies to all patients.
This includes:
1. Hand hygiene
2. The use of mask, gloves, gown, and
goggles when applicable.
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SBAR COMMUNICATION TOOL
Unit:
DOB:
Dx:
Room:
Age:
Name:
ADM. Date:
Code:
Situation:
SITUATION
Past Med History:
Allergies:
Medications:
BACKGROUND
Other:
Vital Signs:
IV fluids:
Neuro:
Tubes/Drains:
Resp:
Labs:
Pain:
Other:
ASSESSMENT
CV:
GI/GU:
Skin:
Treatment Plan:
Discharge Plan:
RECOMMENDATIONS
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SBAR COMMUNICATION TOOL
SITUATION
BACKGROUND
ASSESSMENT
RECOMMENDATIONS
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BLOOD GROUP
Definitions
1. Antigen: a substance
that stimulates the
immune system to
release antibodies.
2. Antibodies: proteins
that bind to the body's
foreign invaders.
Known as the
"recognizers".
Donor: A, AB
Donor: B, AB
Recipient: A, O Recipient: B, O
Antibodies
Antigens
Universal
Recipient
Donor: AB
Universal
Donor
Recipient: 0
NONE
NONE
Rh factor
a type of protein found on the
outside of red blood cells
Rh positive: has the protein
Rh negative: do not have the
protein
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OXYGEN THERAPY
Abnormal Breathing
1. Eupnea: normal breathing rate and pattern
2. Tachypnea: increased respiratory rate
3. Bradypnea: decreased respiratory rate
4. Apnea: absence of breathing
5. Hypernea: deep respirations/breathing
6. Cheyne-stokes: increase and decrease in respirations with
apnea
7. Biot's: rapid gasps with short pauses between sets
8. Kussmaul: tachypnea and hyperpnea
9. Apneustic: prolonged inspiration and shortened expiration
OXYGENATION
02 supplementation is used to increase patient's
oxygen saturation and increase oxygen
delivery/tissue perfusion to the vital organs
Protective Precautions
O2 Masks
Simple face mask:
40% to 60%
Rate: 5 to 8 L/min
Venturi Mask
24% to 50%
Flow rate: 4 to 12 L/min
Nasal Cannula
24% to 44%
Flow rate: 1 to 6 L/min
Partial Rebreather
40% to 70%
Flow rate:
6 to 10 L/min
Non- Rebreather
60%-100%
Flow rate: 10 to 15 L/min
Standard Precautions
Face Tent
Flow rate: 10 L/min
Prolonged oxygen deprivation causes hypoxia
and damage to the brain and vital organs.
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NURSING THEORISTS
Florence
Nightingale Environment
theory
Hildegard Peplau Interpersonal
theory
Virginia Henderson
- Need Theory
Dorothea Orem Self-care theory
1. Think environment
2. Theory focuses on Unsanitary conditions of the
environment that can affect health.
3. Nurses can control the environment to promote
healing and recovery of patient.
4. Components of the environment: ventilation,
light, warmth, effluvia, noise
1. Think nurse-patient relationship
Phases:
1. Orientation: Patient realizes that they need help.
Nurse gathers data about patient issue(s)/problem.
2. Working phase: Nursing interventions, therapeutic
communication, interdisciplinary interventions.
3. Termination phase: Discharge planning. Termination of
nurse-patient relationship.
1. Think 14 basic needs of a patient
2. Definition of nursing: The unique function of the
nurse is to assist the individual, sick or well, in the
performance of those activities contributing to
health or its recovery (or to peaceful death) that he
would perform unaided if he had the necessary
strength, will, or knowledge.
1. Wholly compensatory nursing system-Patient
dependent
2. Partially compensatory- Patient can meet some
needs but needs nursing assistance
3. Supportive educative-Patient can meet self care
requisites, but needs assistance with decision
making or knowledge
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NURSING THEORISTS
SISTER CALISTA
ROY ADAPTATION
MODEL
MADELEINE
LEININGER CULTURE CARE
DIVERSITY AND
UNIVERSALITY
PATRICIA BENNER
- FROM NOVICE
TO EXPERT
LYDIA E. HALL THE CORE, CARE
AND CURE
1. The goal of care is adaptation to change
2. The nursing care facilitates the adaptation
3. The person is an open adaptive system with
input (stimuli), who adapts by processes or
control mechanisms (throughput). The output can
be either adaptive responses or ineffective
responses
Leininger's model assist healthcare professionals to
provide culturally competent care and avoid stereotyping.
The model utilizes three concepts:
1. Culture care maintenance/preservation
2. Culture care negotiation/accommodation
3. Cultural restructuring/repatterning
Described 5 levels of nursing experience and
developed:
1. Novice
2. Advanced beginner
3. Competent
4. Proficient
5. Expert
1. Core: the patient
2. Care: the role of the nurse
3. Cure: the medical treatment given by health
care professionals.
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KNOW YOUR
IV
FLUIDS
Website: nursebossstore.com
Instagram: nursebossessentials
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BODY FLUID
BODY FLUID
Intracellular fluid: fluid in the cell
Extracellular fluid: fluid outside of the cell
r
la
lu
el
ac UID
tr FL
ex
intracellular FLUID
osmosis
Movement of fluid across a membrane due to
differing concentrations
REMEMBER
Function of body fluid
1. Deliver nutrients to cells
2. Removes waste
3. Temperature regulator
4. Lubricant
The movement of fluid is from low concentration to a high concentration.
LOW CONCENTRATION
HIGH CONCENTRATION
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iv fluids
Importance of IV therapy
Intravenous fluids maintain/restore fluid balance + electrolyte
balance
Types of IV Fluids.
Isotonic Solutions
Osmotic pressure is the
same inside and outside
the cell.
Isotonic Solutions
t
o no h
d
l
l
it
ce
The r swell w
ko
ent
n
i
m
r
e
h
v
s
mo
fluid
ICF
ECF
Osmotic pressure draws water
out of the cell into the ECF
(highly concentrated)
Hypertonic Solutions
Hypertonic Solutions
l
Cel s
ink
Shr
ICF
Hypotonic Solutions
ECF
Osmotic pressure draws water into
the cell from the ECF (diluted)
Hypotonic Solutions
ells
w
S
l
Cel
ICF
ECF
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complications
Phlebitis
Inflammation of the vein.
Causes: the prolong use of an IV site, trauma during IV insertion
Signs and Symptoms: redness, tenderness around the IV site, pain,
warmth
Hematoma
Collection/ pooling of blood outside the blood vessel.
Signs and Symptoms: bruising around the IV site.
Infiltration
Infiltration occurs when IV fluid leak into the surrounding
tissue.
Causes: IV catheter dislodge (or improper placement)
Signs and Symptoms: swelling, burning sensation, cool skin
and blanching
Hypervolemia
Fluid volume overload
Causes: IV infusion rate and volume
Signs and Symptoms: elevated BP, edema, SOB, crackles, bounding
pulse
infection
Local or systemic infection
Signs and Symptoms: elevated temperature, redness at IV site
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iv FLUIDS
isotonic solutions
0.9%
NORMAL
SALINE
5%
DEXTROSE
(D5W)
LACTATED
RINGER'S
Isotonic fluid
Isotonic fluid
Isotonic fluid
HYPOTONIC solutions
0.45%
SALINE
Hypotonic Fluid
HYPERTONIC solutions
5% Dextrose
in 0.9%
Saline
Hypertonic Fluid
5% Dextrose
in 0.45%
Saline
10%
Dextrose in
Water
(D10W)
Hypertonic Fluid
Hypertonic Fluid
5% Dextrose
in Lactated
Ringer’s
Hypertonic Fluid
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ISOTONIC FLUIDS
0.9% nORMAL sALINE
0.9%
NS
Isotonic fluid
type of fluid
0.9% Normal saline is an isotonic solution.
used for
1. Used with the administration of blood
products.
2. To replace Na + Cl
remember
1. Caution: Cardiac and renal patients.
2. Monitor for any changes in fluid
balance, electrolyte concentrations
5% DEXTROSE (d5w)
5%
DEXTROSE
(D5W)
Isotonic fluid
type of fluid
5% Dextrose is an isotonic solution
used for
1. Patients with hypernatremia
2. Used to treat hypoglycemia
3. Dehydration/Fluid loss
remember
1. Do not use for resuscitation.
2. Contraindicated among patients with head
injury
3. Monitor for any changes in fluid balance
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ISOTONIC FLUIDS
lactated ringer's
LACTATED
RINGER'S
Isotonic fluid
type of fluid
Ringers lactate is an isotonic solution
used for
1. Burns, Electrolyte loss
2. Hypovolemic shock (due to significant
amount of blood volume lost)
3. Dehydration
rEMEMBER:
Monitor for any changes in fluid balance,
electrolyte concentrations
HYPOTONIC SOLUTIONS
0.45% sALINE
0.45%
SALINE
type of fluid
0.45% saline is a hypotonic solution (1/2 NS)
used for
1. Fluid replacement among patients with
hypovolemia
Hypotonic Fluid
rEMEMBER
1. Avoid in patients with trauma, risk for
increased ICP or burns.
2. Monitor for hypotension
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HYPERTONIC fluids
5% dextrose in 0.9% saline
type of fluid
5% Dextrose
in 0.9%
Saline
5% Dextrose in 0.9% Saline is a hypertonic solution
USED FOR
1. Fluid and electrolyte replenishment
2. Treat hypovolemia
Hypertonic Fluid
rEMEMBER:
1. Monitor signs of hypervolemia
5% dextrose in 0.45% saline
5% Dextrose
in 0.45%
Saline
Hypertonic Fluid
type of fluid
5% Dextrose in 0.45% Saline is a hypertonic solution
used for
1. Maintenance fluid
rEMEMBER
1. Monitor signs of hypervolemia
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HYPERTONIC fluids
10% dextrose in water (D10W)
type of fluid
10%
Dextrose in
Water
(D10W)
Hypertonic Fluid
10% dextrose in water (D10W) is a hypertonic solution
USED FOR
1. Caloric supply
rEMEMBER:
1. Monitor signs of hypervolemia
5% Dextrose in Lactated Ringer’s
5% Dextrose
in Lactated
Ringer’s
type of fluid
5% Dextrose in Lactated Ringer’s is a hypertonic solution
used for
1. Fluid and electrolyte replenishment and
caloric supply
Hypertonic Fluid
rEMEMBER
1. Monitor signs of hypervolemia
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iv catheter gauge
14G ORANGE
Trauma, Rapid
infusion
16G GRAY
Trauma,
Surgery
18G GREEN
20G PINK
22G BLUE
24GYELLOW
26GVIOLET
Blood
transfusions
IV fluids and
medications
Slower infusions, IV
fluids, small veins
Fragile veins,
elderly,
pediatrics
Neonates
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STUDY GUIDE
Anatomy and Physiology Study Guide for
Nursing Students
Website: nursebossstore.com
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Table of Content
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Cardiovascular System
Respiratory System
Gastrointestinal System
Hepatic System
Genitourinary System
Nervous System
Integumentary System
Reproductive System
Muscular System
Skeletal System
Lymphatic System
Endocrine System
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Cardiovascular System
Objectives
1. Functions of the cardiovascular system
2. Types of circuits
3. Types of blood vessels
4. Structure of the heart
5. Heart chambers
6. Heart valves
7. Blood flow
8. Electrical conduction
9. Coronary arteries
10. Blood vessels
11. Key terms
Notes...
Key points from this section...
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Functions of the
Cardiovascular System
1. Transports O2 and CO2
2. Transports nutrients
3. Circulation of hormones
4. Removes waste
products
5. Maintenance of body
temperature
6. Circulates antibodies
1.Two Types of Circuits
Pulmonary Circulation:
Transports blood to and from
the lungs.
Systemic Circulation:
Transports blood to and from
the rest of the body
2. Types of Blood Vessels
Arteries
Arterioles
Capillaries
Venules
Veins
4. Heart Chambers
Upper chamber: Atrium
Lower chamber: Ventricles
1. Right atrium- receives deoxygenated blood from
the superior and inferior vena cava
2. Right ventricle- receives blood from the right
atrium and pumps to the lungs
3. Left atrium- receives oxygenated blood from the
lungs
4. Left ventricle- receives blood from the left atrium
and pumps it to the body through the aorta.
3. Structure of the Heart
The heart is a cone-shaped organ that lies within
the mediastinum between the lungs.
The heart is protected by the pericardial sac. The
parietal pericardium is the outer membrane. The
visceral pericardium is the inner membrane. The
pericardial sac contains 5-20ml of pericardial fluid.
LAYERS OF THE HEART
1. Epicardium: outermost layer of the heart
2. Myocardium: middle layer of the heart
3. Endocardium: innermost layer of the heart
5. Heart Valves
Atrioventricular valves: tricuspid and
bicuspid valve
1. Tricuspid Valvea. Location: between the right
atrium and right ventricle
2. Bicuspid Valve (mitral)
a. Location: between the left
atrium and left ventricle
Semilunar valves: pulmonary and
aortic valve
3. Pulmonary valve
a. Location: between
right ventricle and
pulmonary artery
4. Aortic valve:
a. Location: between left
ventricle and aorta
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Blood Flow
1. Deoxygenated blood from the
superior and inferior vena cava goes
into the right atrium (through the
tricuspid valve) and into the right
ventricle. From the right ventricle,
blood flows through the pulmonary
valve into the pulmonary artery and
to the lungs.
2. Oxygenated blood from the lungs
flows through the pulmonary veins
and into the left atrium and left
ventricle through the mitral valve.
From the left ventricle, blood flows
into the aorta through the aortic
valve and to the body.
1.Electrical Conduction
1. SA (Sinoatrial) Node:
pacemaker of the heart.
Impulse starts at the SA node.
Beats: 60-100BPM.
2. AV (Atrioventricular) Node:
Impulse travels from the SA
node to the AV node. Known
as the gatekeepers. Causes a
delay so that the atrium can
fully empty into the ventricles.
Beats: 40-60BPM
3. Bundle of His: The impulse
travels through the Bundle of
His which branches out into the
right and left branch bundles
4. Purkinje Fibers: The impulse
travels to the Purkinje fibers.
Beats: 20-40BPM
2. Coronary Arteries
1. Right coronary artery
2. Left coronary artery
Coronary arteries supplies blood
to the heart muscles. The heart
needs oxygen-rich blood to
function.
Plaque formation is usually found
in the coronary arteries.
3. Blood Vessels
1. Artery: Carries high-pressure blood from the heart
to the arterioles.
2. Arterioles: Controls blood flow from the arteries to
the capillaries through vasodilation and
vasoconstriction.
3. Capillary: Allows the exchange of nutrients, gases
and wastes between the blood and tissue fluid.
4. Venule: Connects capillaries to the veins.
5. Veins: Carries low-pressure blood from the venules
to the heart.
4. Key Terms
5. Key Terms
1. Cardiac Cycle: a
heartbeat, complete
series of systolic and
diastolic events.
2. Cardiac output: the
amount of blood
pumped by the
ventricles per minute.
Formula: SV*heart rate=
CO
3. Stroke volume: the
volume of blood
discharged from the
ventricle with every
contraction
1. Blood pressure: the
force that blood exerts
against the inner walls
of blood vessels.
2. Systolic pressure:
maximum pressure
during ventricular
contraction
3. Diastolic pressure:
minimum arterial
pressure during
ventricular relaxation.
4. Blood pressure: 120/80
5. Blood volume: 5L
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Respiratory System
Objectives
1. Functions of the respiratory system
2. Upper respiratory tract
3. Lower respiratory tract
4. Organs of the respiratory system
5. Key terms
6. Inspiration
7. Expiration
8. Respiratory volumes
9. Lung capacity
Notes...
Key points from this section...
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Topic: Respiratory System
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Functions of the Respiratory
System
1. Breathing
2. Gaseous exchange
internally and externally
3. Removes carbon dioxide
4. Speech
5. Olfaction
6. Maintain acid-base
balance
7. Maintain body heat
3. Organs of the Respiratory System
1. Nose: filters, moistens, humidifies and warms
air, receptors for sense of smell.
2. Paranasal sinuses: air-filled cavities that
surrounds the nasal passages.
3. Pharynx: passageway for food and air
(Nasopharynx, laryngopharynx and
oropharynx)
4. Larynx: air passageway, voice box, glottis
2. Lower Respiratory Tract
(plays a role in coughing)
1. Trachea
5. Epiglottis: a leaf shape flap that prevents
2. Bronchi
food from entering the lower respiratory
3. Bronchioles
tract.
4. Alveolar duct
6. Trachea: located in front of the esophagus,
5. Alveolar sacs
tube running from the larynx and branches
6. Lungs
into right and left bronchi. Cleans, warms, and
Trachea
moistens incoming air.
Superior lobe
7. Bronchial tree: Consists of right and left main
of left lung
bronchi, which divides within the lungs to form
Left main
lobar and segmental bronchi and bronchioles.
(primary)
Superior lobe
The bronchi are lined with cilia.
bronchus
of right lung
Lobar (secondary) 8. Bronchioles: delivers air to the alveolar sacs
bronchus
9. Alveoli: Site for gaseous exchange
10. Lungs: right lung is divided into 3 lobes. The
Segmental
left lungs is divided into 2 lobes. The right lung
Middle lobe
(tertiary)
of right lung
bronchus
is larger than the left lung. The lungs is
Inferior lobe
located from the clavicle to the diaphragm.
of left lung
Inferior lobe
11. Pleurae: produces lubricating fluid.
of right lung
1.Upper Respiratory Tract
1. Nose
2. Paranasal Sinuses
3. Pharynx
4. Larynx
5. Epiglottis
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Topic: Respiratory System
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Key Terms
1. Breathing: movement of air in and
out of the lungs
2. Gaseous exchange: the diffusion of
oxygen from the lungs to the
bloodstream and the elimination of
carbon dioxide from the blood
stream to the lungs that occurs
between the alveoli and capillaries
within the lungs
3. Perfusion: blood flow to capillaries
4. External respiration: gas exchange
between the capillaries and alveoli.
5. Internal perfusion: gas exchange
between the capillaries and tissues.
1.Inspiration
1. Inspiratory muscles contract (diaphragm
moves downwards; external intercostals
contracts and rib cage moves upwards).
2. Thoracic cavity size increases.
3. Lungs are stretched; intrapulmonary volume
increases.
4. Intrapulmonary pressure decreases to –1
mm Hg.
5. Air flows into lungs until intrapulmonary
pressure is equal to atmospheric pressure.
2.Expiration
1. Inspiratory muscles relax (diaphragm moves
upwards; rib cage moves downwards due
to recoil of costal cartilages).
2. Thoracic cavity size decreases.
3. Elastic lungs recoil passively; intrapulmonary
volume decreases.
4. Intrapulmonary pressure rises (to +1 mm
Hg).
5. Air flows out of lungs until intrapulmonary
pressure is 0
Average lung capacity
Male: 6L of air
Female: 4.8L of air
3. Respiratory Volumes
1. Tidal Volume (TV): volume of air inhaled
and exhaled without effort (resting
condition)
2. Inspiratory Reserve Volume (IRV): the
volume of air that can be forcefully
inhaled beyond tidal volume inhalation.
3. Expiratory Reserve Volume (ERV): the
volume of air that can be forcefully
exhaled beyond tidal volume
exhalation.
4. Residual Volume (RV): the amount of air
that remains in the lungs after full
exhalation.
4. Lung Capacity
1. Total Lung Capacity (TLC): the volume of
air in the lungs after maximum
inspiration.
2. Vital Capacity (VC): the volume of air
that can be expired after a maximum
inspiration.
3. Inspiratory Capacity (IC): maximum
volume of air that can be inspired after
expiration
4. Functional Residual Capacity (FRC):
Volume of air remaining in the lungs
after a normal tidal volume expiration
Hyperventilation: fast breathing
Hypoventilation: slow breathing
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Gastrointestinal System
Objectives
1. Functions of the gastrointestinal system
2. Structures of the gastrointestinal system
3. Digestive processes
4. Mouth
5. Esophagus
6. Stomach
7. Small intestines
8. Large intestines
9. Digestive enzymes
Notes...
Key points from this section...
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Topic: Gastrointestinal System
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Functions
1. Digest foods
2. Absorbs nutrients
3. Excrete waste products
4. Synthesize nutrients
Structures
1. Mouth
2. Esophagus
3. Epiglottis
4. Stomach
5. Esophageal sphincter
6. Pyloric sphincter
7. Small intestine
8. Jejunum
9. Ileum
10. Large intestines
11. Colon
12. Ileocecal valve
13. Liver
14. Gallbladder
15. Pancreas
Key Terms
1. Mastication: chewing
2. Chyme: semi-fluid mass
that is created when food
is partly digested.
3. Segmentation: rhythmic,
localized back and forth
movement of bolus
through contraction and
relaxation of muscles in
the intestines
4. Peristalsis: waves of
contraction and relaxation
of muscles to move food
downwards.
5. Bolus: ball-like mixture of
food and saliva
Digestive Processes
1. Ingestion: process of taking in food through the
mouth.
2. Propulsion: movement of food through the
alimentary canal. Swallowing (voluntary),
peristalsis (involuntary, waves of contraction and
relaxation of muscles to move food
downwards).
3. Mechanical digestion: physical process that does
not change the chemical nature of the food.
(Chewing, tongue movement, segmentation)
4. Chemical digestion: digestive enzymes that
breaks down complex food molecules
5. Absorption: the process of nutrients entering the
bloodstream.
6. Defecation: eliminates indigestible substances
through the anus as feces.
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Topic: Gastrointestinal System
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Mouth
1. Ingest food
2. Mastication
3. Salivary amylase: breakdown
carbohydrates
4. Swallowing
5. Moistens food into a bolus
Esophagus
Esophagus: muscular tube that
carries food from the pharynx to the
stomach
Stomach
1. Mixes food with gastric juices
2. Hydrochloric acid
3. Pepsin: gastric juice that breaks
down protein
4. Carries food into the duodenum
as chyme
5. Secretes intrinsic factor required
for vitamin B12 absorption
Liver: produces bile, emulsify lipids.
Gallbladder: stores and release bile.
Pancreas: secretes insulin,
bicarbonate and digestive enzymes
Small Intestines
1. Absorption of nutrients
2. Chyme propels at a slower rate to facilitate
absorption
3. Segmentation
Large Intestines
1. Absorption of water, electrolytes and vitamins
2. Propels feces to the rectum.
Rectum: stores feces
Anus: defecation
Digestive Enzymes
1. Salivary amylase: breaks down starch
2. Hydrochloric acid: gastric acid
3. Pepsin: breaks down protein
4. Intrinsic factor: absorption of B12
5. Gastrin: regulates gastric acidity
6. Lactase: breaks down lactose
7. Sucrase: breaks down sucrose to fructose and
glucose
8. Enterokinase: breaks down trypsinogen into trypsin
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Hepatic System
Objectives
1. Functions of the hepatic system
2. Lobes
3. Hepatic circulation
4. Hepatic disorders
Notes...
Key points from this section...
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Topic: Hepatic System
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Functions
1. Production of bile
2. Glucose metabolism
3. Bilirubin excretion
4. Drug metabolism
5. Fat and protein metabolism
6. Clotting factors
7. Filters and remove toxins
8. Ammonia conversion
1.Lobes
1. The liver is divided into 4 lobes
2. Right lobe
3. Left lobe
4. Caudate lobe
5. Quadrate lobe
3. Disorders
1. Portal hypertension
2. Jaundice
3. Esophageal Varices
4. Hepatic Encephalophathy
5. Cirrhosis
6. Ascited
2.Hepatic Circulation
The hepatic portal vein is responsible for carrying up to 70% of the blood that
passes through the liver. The hepatic artery is responsible for 30% to 40% of
hepatic oxygenation. The hepatic system is responsible for receiving blood from
the gastrointestinal region and venous drainage from the pancreas and spleen.
One of the functions of the hepatic system is to supply the liver with metabolites
to limit damage that toxins can cause after reaching the systemic circulation.
Blood from the hepatic artery are oxygenated, but nutrient poor . Blood from
the organs of the GI system flows through the portal veins and into the sinusoids
of the liver, allowing for processing of nutrients in the liver. The liver is rich in
specialized immune cells called Kupffer cells to destroy pathogens. Blood collects
in a central vein that drains into the hepatic vein and finally the inferior vena
cava.
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Genitourinary System
Objectives
1. Functions of the genitourinary system
2. Renal parenchyma
3. Nephron
4. Glomerulus
5. Bowman's capsule
6. Acid-base balance
7. Urine formation
8. Tubules
9. Bladder
10. Adrenal gland
11. Renin-angiotensin-aldosterone system
Notes...
Key points from this section...
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Topic: Genitourinary System
Functions
The kidneys are two fist-sized bean
shaped organs situated on either side
of the vertebral column in the
posterior abdomen. The kidneys are
covered by the renal capsule. On top
of each kidney are the adrenal
glands.
Functions includes:
1. Electrolyte balance
2. Acid-base balance
3. Removes waste
4. Removes water
5. Vitamin D activation
6. Blood pressure control
1.Main Structures
The kidney is divided into 2 main structures.
1. Renal cortex
2. Renal medulla
The renal medulla contains renal pyramids and
renal tubules. The renal column are between each
pyramid.
2.Renal Parenchyma
1. Renal cortex: the outer rim of the kidney.
It contains the glomeruli and a portion of
the nephron tubules.
2. Medulla: houses the renal pyramids that
hold the collecting ducts, collecting tubules,
and long loops of Henle. It also contains
blood vessels and nerves.
3. Renal pelvis: drains urine from the collecting
ducts of the nephrons. The renal pelvis is a
collection area.
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Cortex
Renal Pyramid
Medulla
5. Glomerulus
Blood flows into the glomerulus through
the afferent arterioles and out via the
efferent arterioles. Filtration occurs in the
glomerulus. That includes electrolytes,
waste, glucose, amino acids.
Glomerular Filtration Rate (GFR):
filtration pressure. GFR is a diagnositic
method to assess renal function.
5. Bowman's Capsule
Houses the glomerulus and receives
glomerular filtrate.
3. The Nephron
The nephron is the functional unit of the kidney.
Major functions:
1. Regulates and filters water soluble
substances.
2. Reabsorbs water, nutrients and
electrolytes.
3. Exceretes waste
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Topic: Genitourinary System
Acidosis:
1. Increased secretion and
excretion of hydrogen ions
2. Increase reabsorption of
bicarbonate and decreased
excretion.
3. Increased ammonia production
Alkalosis:
1. Decreased secretion and excretion
of hydrogen ions
2. Decreased reabsorption of
bicarbonate and increased
excretion
3. Decreased ammonia production
URINE FORMATION
Acid-Base Balance
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1.Tubules
Proximal convolated tubules:
1. Reabsorbs filtered sodium
2. Maintains acid-base balance. Reabsorbs
bicarbonate and and secretes hydrogen.
3. Obligatory water reabsorption
4. Reabsorption of electrolytes
5. Reabsorption of glucose and amino acids.
Loop of Henle:
1. Dilutes or concentrates urine
2. Ascending limb reabsorbs NaCl (NaCl
active pump).
3. Descending limb reabsorbs water
Distal convolated tubules:
1. ADH causes water reabsorption
2. Aldosterone causes Na reabsorption
Filtered fluid moves into the collecting duct,
renal pelvis into the ureters and then the
bladder.
2.Bladder
A muscular sac that provides a holding area for
urine until it is excreted through the urethra. It
can contract and relax.
3. Adrenal Gland
Located on top of both kidneys. Influences the
regulation of sodium and water.
Filtration
Reabsorption
Secretion
Excretion
4. Renin-Angiotensin-Aldosterone
System
Decreased
renal blood
flow
Renin release
Angiotensino
gen
The renin-angiotensinaldosterone system is a
hormone system that is
essential to regulate
blood pressure and fluid
volume
Angiotensin 1
Angiotensin 2
Vasoconstriction
Aldosterone
Na, water
retention
Increased BP
Increased
Organ Perfusion
1. The kidneys secretes erythropoietin
2. Vitamin D synthesis is dependent on
the kidneys
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Nervous System
Objectives
1. Functions of the nervous system
2. CNS
3. PNS
4. Neuron
5. Parts of a neuron
6. Reflex arc
7. Parts of the brain
8. Lobes of the cerebrum
Notes...
Key points from this section...
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Topic: Nervous System
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Function
1. Sensory function
2. Transmits information to the brain
3. Processes information in the brain
4. Motor function
5. Maintains homeostasis
6. Controls and coordinate body
organs
1.Nervous System
The nervous system is divided into:
1. Central nervous system
2. Peripheral nervous system.
The peripheral nervous system is divided into:
1. Somatic nervous system (voluntary): sends
and relays information to and from the
skeletal muscles and skin
2. Autonomic nervous system (involuntary):
sends and relays information to internal
organs
The autonomic nervous system is divided into
1. Sympathetic nervous system: stress
response
2. Parasympathetic nervous system: controls
body when at rest
3. Parts of the Neuron
1. Dendrite: receives and carries impulse
to the cell body.
2. Cell body: includes the nucleus
3. Axon: carries impulses away from cell
body
4. Schwann Cells: cells produces myelin in
the PNS
5. Myelin sheath: insulates and covers
the axon
6. Node of Ranvier: nodes in the myelin
sheath
Impulse travels from the
dendrite to cell body to axon
2.Neuron
The neuron is the basic functional cell of the
nervous system. The neurons transmits impulse.
Types of neurons:
1. Sensory neuron: transmits impulse to the CNS
2. Motor neuron: transmits impulse from the
CNS
3. Interneurons: between sensory & motor
neurons in the CNS
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Topic: Nervous System
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Key Terms
1. Stimulus: a change in the
environment that causes a
response.
2. Excitability: the neuron response
to a stimulus to convert to an
impulse.
3. Synapse: a gap between one
neuron's axon and the dendrite of
another
4. Neurotransmitters: chemicals that
cross the gap (synapse) and
continue the impulse
1.Reflex Arc
A reflex is an involuntary action in response to
a stimuli. A reflex action goes through a
process called the reflex arc.
1. Receptor: a reaction to a stimulus occurs
2. Afferent pathway: the sensory neurons
transmits impulses to the CNS
3. Interneurons: includes synapses in the CNS
(mostly in the spine)
4. Efferent pathway: motor neurons
transmits impulses from the CNS to the
effector
5. Effector: a muscle or gland that responds
to the stimulus
2.CNS
Central Nervous System: brain and spinal cord
Meninges: covering of the brain and spinal
cord. The three layers are
1. Dura mater: the outer covering
2. Arachnoid mater: the middle layer
3. Pia mater: the innermost layer
Cerebrospinal fluid: clear, colorless
body fluid found in the brain and spinal cord
3. Parts of the Brain
1. Cerebellum: movement and motor
learning
2. Cerebrum: activities that includes
planning, perception, emotion,
thought
3. Thalamus: exchanges of information
4. Medulla: involuntary/autonomic
responses
5. Brainstem: (medulla, pons, and
midbrain) involuntary response
6. Hypothalamus: maintain the
homeostasis of the body
4. Lobes of Cerebrum
1. Frontal: planning, movement and
coordination
2. Parietal: processing, language
3. Temporal: auditory, speech and visual
perception
4. Occipital: visual perception
1. Cranial nerve: 12 nerves
2. Spinal nerves: 31
a. Cervical nerve, b. Thoracic nerve
c. Lumbar nerve d. Sacral nerve
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Integumentary System
Objectives
1. Functions of the integumentary system
2. Layers of the skin
3. Accessory organs
4. Epidermis
5. Dermis
6. Hypodermis
7. Accessory organs
Notes...
Key points from this section...
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Topic: Integumentary System
1.Functions
1. Protection
2. Excretion
3. Body temperature regulation
4. Cutaneous sensation
5. Vitamin D synthesis
2. Layers of the Skin
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5. Dermis
1. Made of fibrous connective tissue that contains
arterioles for supplying nutrients
2. Contains pili arrector muscles
3. Contains nerves and hair follicles
4. Contains sebaceous gland to secrete sebum onto
skin surface, and sudoriferous glands to secrete
sweat
1. Epidermis
2. Dermis
3. Hypodermis
6. Hypodermis
1. Made up of connective tissues and adipose
tissues
2. Contains large blood vessels.
3. Accessory Organs
Hair, hair follicles, pili arrector muscle,
sebaceous gland , sudoriferous gland , nails
, and mammary gland
4. Epidermis
Made of stratified squamous epithelium and no
blood vessels.
Four layer of cells are found in the epidermis of
the body surface:stratum basale , stratum
spinosum , stratum granulosum , and
stratum corneum
Melanocytes: produces melanin
7. Accessory Organs
Hair: Hair roots and hair shaft
Pili arrector muscle: attached to each hair
follicle
Sebaceous gland: oil gland
Sudoriferous gland: sweat gland
Nails: made of keratin
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Reproductive System
Objectives
1. External genitalia of a male
2. Internal genitalia of a male
3. External genitalia of a female
4. Internal genitalia of a female
Notes...
Key points from this section...
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Topic: Reproductive System
Male
1.External Genitalia of a Male
External genitalia
1. Penis: urinary and reproductive
elimination
2. Scrotum: Houses and protects the
testes
2. Internal Genitalia of a Male
Internal organs:
1. Testes: responsible for producing
testosterone and sperms
2. Ductal system: The vas deferens is the
tube that sperms passes through
3. Seminal vesicle: secretes fluid during
ejaculation
4. Prostate: secretes alkaline fluids that
assist in sperm motility, sperm
protection, sperm nourishment.
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Female
1.External Genitalia of a Female
External genitalia:
1. Mons pubis
2. Labia majora and minora
3. Clitoris
4. Vestibule
5. Perineum
Internal organs:
1. Vagina: muscular tube from the vulva to
the uterus
2. Cervix: cylinder-shaped neck of tissue that
connects the vagina and uterus
3. Ovaries: two sex organs on each side of
the uterus
4. Fallopian tubes: three sections (Isthmus,
ampulla and infundibulum)
5. Uterus: the womb, located within the
pelvic cavity. Divided into (cervix, uterine
isthmus, corpus, fundus)
2. Menstrual Cycle
The four main phases of the menstrual cycle
are:
1.Menstruation
2. The follicular phase
3. Ovulation
4. The luteal phase
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Muscular System
Objectives
1. Functions of the muscular system
2. Skeletal muscles
3. Types of muscle tissues
4. Muscle contraction
Notes...
Key points from this section...
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Topic: Muscular System
Functions
1. Movement
2. Posture
3. Produces heat
4. Stabilize joints
Terminologies
1.Neuromuscular junction: the junction
between a nerve cell and muscle fiber.
2. Tendons: fibrous connective tissue
connects bone to muscle
3. Ligaments: fibrous connective
tissue that connects bone to bone
1.Major Parts of Skeletal Muscle
1. Epimysium: surrounds the entire
muscle
2. Perimysium: surrounds a bundle of
muscle fibers
3. Endomysium: surrounds a single
muscle fiber
4. Fascia: on the outside of the
epimysium
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Types of Muscle Tissue
Three basic muscle types
•Skeletal muscle
•Cardiac muscle
•Smooth muscle
Skeletal muscle:
Most are attached by tendons to bones,
Striated and voluntary movement
Cardiac Muscle
Found in the heart.
Has striation
Has a nucleus
Involuntary movement
Smooth Muslce
Has no striation
Involuntary movement
Found in walls of hollow organs
2. Microscopic Anatomy of
Skeletal Muscle
1. Sarcolemma: plasma membrane
2. Sarcoplasmic reticulum: smooth
endoplasmic reticulum. Stores calcium
3. Sarcoplasm: cytoplasm fluid in a cell
The Sliding Filament Theory of Muscle
Contraction
1. A muscle fiber contracts when a
nerve impulse causes the
myosin filaments to pull
actin filaments closer together and
thus shorten sarcomeres within a
fiber. When all the sarcomeres in
a muscle fiber shorten, the fiber
contracts.
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Skeletal System
Objectives
1. Functions of the skeletal system
2. Joints
3. Types of blood tissues
4. Classification of bones
5. Anatomy of a long bone
6. Process of bone formation
7. Healing of a bone fracture
Notes...
Key points from this section...
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Topic: Skeletal System
Functions
1. Support structures
2. Protect organs
3. Formation of blood cells
4. Regulates phosphate and calcium
5. Movement
Parts of the skeletal system
1. Bones, 2. Joints, 3. Ligaments, 4.
Cartilages
Skeleton
1. Axial skeleton
a. Cranium
b. Vertebrae
c. Ribs
2. Appendicular skeleton
a. Limbs
b. Shoulders
c. Hips
1.Types of Bone Tissues
Adult skeleton has a total of 206 bones
Types of bone tissue (osseous):
1. Spongy bone: Has many open spaces
2. Compact bone: Dense
2. Classification of Bones
1. Long bones:femur and humerus
2. Short bones: tarsals, carpals
3. Sesamoid bones: patella
4. Flat bones: sternum, skull, ribs
5. Irregular bones: hips, vertebra
3. Anatomy of a Long Bone
1. Diaphysis: the length of a long bone
2. Epiphysis: spongy bone at the end of
the long bone
3. Periosteum: connective tissue
membrane covering the diaphysis
4. Articular cartilage: covers the
epiphysis
5. Medullary cavity: mostly contains fats
in adults
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Joints
Function:
1. Holds bones together
2. Allows movement
Functional classification of joints
1. Synarthroses – immovable joints
2. Amphiarthroses – slightly moveable
3. Diarthroses – freely moveable joints
Structural classification of joints
1. Fibrous joints: Immovable
2. Cartilaginous joints: Immovable
3. Synovial joints: freely moveable
4. Ball and socket: shoulder joint, hip joint
5. Condyloid: wrist
6. Saddle: carpometacarpal joint
7. Pivot: proximal radioulnar joint
4. Process of Bone Formation
Process of bone formation – ossification done
by bone-forming cells called osteoblasts
Types of Bone Cells:
1. Osteocytes: the mature bone cells
2. Osteoblasts: the bone-forming cells
3. Osteoclasts: Breaks down bone matrix for
remodeling and release of calcium
5. Healing of Bone Fracture
1. Hematoma formation
2. Fibrocartilage callus formation
3. Bony callus formation
4. Bone remodeling (Bone remodeling is a
process by both osteoblasts and osteoclasts)
Tendons: connects muscle to bone
Ligament: connects bone to bone
Cartilage: a soft, gel-like padding
between bones to facilitate movement
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Lymphatic System
Objectives
1. Functions of the lymphatic system
2. Lymphatic structures
3. Lymphatic circulation
4. Lymphatic vessels
5. Lymph ducts
6. Immunity
Notes...
Key points from this section...
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Topic: Lymphatic System
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Function
1. Returns excess fluid from tissue to
blood
2. Body defense and immunity
3. Maintains and distributes
lymphocytes
4. Hemopoiesis
The lypmhatic system functions with
the circulatory and immune system.
The lymphatic system is a network of
vessels that transports and drains
lymph from the tissues into the blood.
1.Lymphatic Structures
4.Lymph Ducts
1. Lymph: a clear watery fluid
2. Lymphatic nodes and vessels: removes fluids,
bacteria etc.
3. Spleen: largest of the lymphatic organs,
screens blood, removes pathogens, erythrocyte
and platelet destruction, RBC formation in fetus
4. Thymus: primary function is in early life,
Secretes thymosin and thymopoietin
5. Tonsils: Destroy bacteria that breach the
mucosal membrane from outside
2. Lymph Circulation
→
→
→
Interstitial fluid Lymph Lymph capillary
Afferent lymph vessel Lymph node Efferent
lymph vessel Lymph trunk Lymph duct
{Right lymphatic duct and Thoracic duct (left
side)} Subclavian vein (right and left) Blood
Interstitial fluid
→
→
→
→
→
→
→
3. Lymphatic Vessels
Lymphatic capillaries
Lymphatic vessels
Lymphatic collecting vessels
Lymphatic trunks and ducts
1. Right lymphatic duct:
a. Drains lymph from the upper
right quadrant of the body
b. The upper right arm and the
right side of the thorax and
head
2. Thoracic duct:
a. Largest lymphatic vessel
b. Drains lymph from the rest of
the body
5.Immunity
Adaptive Immunity is also known as
acquired immune system that includes
the processes to eliminate pathogens.
Two types:
1. Cell-mediated immunity: involves
the formation of cytotoxic T cells.
2. Antibody-mediated immunity: also
known as humoral immunity. Involves
antibodies produced by B cells which
cause the destruction of
microorganisms
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Endocrine System
Objectives
1. Functions of the endocrine system
2. Structures
3. Endocrine gland and hormones
4. Definitions
Notes...
Key points from this section...
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Topic: Endocrine System
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Functions
Structures
The endocrine system is made up of
glands that produces and secretes
chemicals, hormones and
substances.
Functions:
1. Growth and development
2. Control mood
3. Metabolism
4. Reproduction
5. Regulates the way body
organs functions.
1. Hypothalamus: Control center of the brain.
Controls the pituitary gland
2. Pituitary Gland: master gland. Located at
the base of the brain
3. Thyroid gland: located at the front of the
trachea.(metabolism, growth &
development)
4. Parathyroids: regulates calcium levels in the
blood
5. Adrenal gland: located on top of the
kidneys (produces hormones responsible for
metabolism, stress response, blood pressure
regulation, immune system)
6. Pancreas: regulates blood glucose
7. Ovaries: produces eggs, progesterone and
estrogen
8. Testes: produces sperms and testosterone
Endocrine
Gland
Pituitary Gland
Anterior Pituitary
Posterior Pituitary
Hormone
Anterior and posterior pituitary hormone
Growth Hormone (GH)
Thyroid-Stimulating Hormone (TSH)
Luteinizing Hormone (LH)
ACTH
Follicle- Stimulating Hormone (FSH)
Prolactin
ADH, Oxytocin
Adrenal Gland
Aldosterone, cortisol, epinephrine and
norepinephrine
Thyroid Gland
T3, T4.
Pancreas
Insulin, glucagon, somastatin
Ovaries
Estrogen, progesterone
Testes
Testosterone
Definitions
1.Hormones: chemical
messengers that are
secreted directly into
the blood
2. Prostaglandins:
lipids made at site of
injury that do not enter
bloodstream
3. Positive feedback:
an action that causes
more of that action to
occur in a positive
feedback loop
4. Negative feedback:
actions that are against
the stimulus in a
negative feedback loop
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A Review Guide For Nursing Students
PART 1
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Table of Content
1. Cardiovascular Disorders
2. Respiratory Disorders
3. Gastrointestinal Disorders
4. Pancreatic Disorders
5. Hepatic Disorders
6. Genitourinary Disorders
7. Neuro Disorders
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Cardiovascular
TABLE OF CONTENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Coronary Artery Disease
Angina
Myocardial Infarction
Heart Failure
Cardiogenic Shock
Pericarditis
Endocarditis
Myocarditis
Cardiac Tamponade
Aortic Aneurysm
Hypertension
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Disease: Coronary Artery Disease
Risk Factors
1. Age
2. Gender
3. Family history
4. Hypertension
5. High blood cholesterol
level
6. Diabetes
7. Smoking
8. Obesity
Signs and Symptoms
1. Chest pain
2. Dyspnea/SOB
3. Fatigue
4. Dizziness
5. Syncope
6. Cough
7. Normal findings during
Cardiovascular
Pathophysiology
Coronary artery disease is caused by
atherosclerosis (plaque formation) that
results in the narrowing or occlusion of one
or more coronary arteries.
CAD results in decreased myocardial tissue
perfusion and decreased myocardial
oxygenation which leads to angina, MI, HF
or death.
Diagnostic Tests
1. Electrocardiography
2. Cardiac catheterization
-may show atherosclerotic lesions.
3. Blood lipids level would be elevated.
asymptomatic period
Nursing Management
Treatment
Pharmacology
1. Calcium Channel Blocker
2. Nitrates
3. Cholesterol-lowering
medications
Surgical Interventions
1. Coronary Angioplasty
2. Vascular stent
3. Coronary artery bypass
Nursing Assessment
1. Pain assessment, vital signs/ECG
Nursing Interventions
1. Administer oxygen
2. Administer medications
3. Promote bed rest
4. Place client in a Semi-Fowler's position.
Patient Education
1. Lifestyle modifications
2. Low-sodium and low-cholesterol diet.
3. Stress management
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Disease: Angina
Cardiovascular
Risk Factors
Pathophysiology
1. Family history of heart
disease
2. Hypertension
3. High blood cholesterol
4. Diabetes
5. Smoking
6. Obesity
Angina is chest pain due to decreased
myocardial oxygenation. This causes
myocardial ischemia.
Types of angina.
1. Stable angina-occurs due to activity.
Pain relieved by rest.
2. Unstable angina- unexpected chest pain
that increases in severity, duration and
occurrence (may occur at rest).
3. Variant angina- occurs due to coronary
artery spasm. Occurs at rest.
4. Intractable angina- chronic
5. Preinfarction angina- occurs before an
MI
Signs and Symptoms
1. Pain
2. Dyspnea/SOB
3. Tachycardia
4. Palpitations
5. Dizziness
6. Syncope
7. Diaphoresis
(Sweating)
8. Pallor
9. Elevated BP
Treatment
Pharmacology
1. Calcium Channel Blocker
2. Nitrates
3. Cholesterol-lowering
medications
4. Anti-platelet therapy
Surgical Interventions
1. Coronary Angioplasty
2. Vascular stent
3. Coronary artery bypass
Diagnostic Tests
1. Electrocardiography
2. Stress test
3. Cardiac catheterization
Nursing Management
Nursing Assessment
1. Pain assessment, vital signs/ECG
Nursing Interventions
1. Administer oxygen
2. Administer nitroglycerin
3. Cardiac monitoring
4. Pain management
5. Promote bed rest
6. Place client in a Semi-Fowler's position.
7. Establish an IV access.
Patient Education
1. Lifestyle and dietary modifications
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Disease: Myocardial Infarction
Risk Factors
1. CAD
2. Atherosclerosis
3. High cholesterol level
4. Diabetes
5. Hypertension
6. Smoking
7. Stress
Signs and Symptoms
Cardiovascular
Pathophysiology
MI occurs due to myocardial tissue damage
as a result of oxygen deprivation. Ischemia
may lead to necrosis if myocardial tissue
oxygenation is not restored.
Obstruction locations of an MI
1. Left anterior descending artery
2. Right coronary artery
3. Circumflex artery
1. Pain- crushing substernal
pain that radiates to the
left arm, jaw or back.
2. Dyspnea
3. Dysrhythmias
4. Pallor
5. Cyanosis
6. Diaphoresis
7. Anxiety
Diagnostic Tests
1. Troponin- level rises between 4-6 hours
2. CK-MB- peaks after 18 hours.
3. Myoglobin- level rises between 2-3
hours
4. ECG- May show ST-elevation MI (STEMI)
-or non-ST-elevation MI (NSTEMI)
Nursing Management
Treatment
Pharmacology
1. Morphine
2. Nitroglycerin
3. Thrombolytic therapy
4. Beta-blockers
5. Antidysrhythmic medications
Immediate treatment:
Oxygen: Increase oxygen
delivery
Aspirin: reduce blood clotting
Nitroglycerin: vasodilation
Morphine: pain reliever
Nursing Assessment
1. Pain, respiratory status, vital signs, ECG,
peripheral pulse and skin temperature.
Nursing Interventions
1. Administer oxygen
2. Administer aspirin, nitroglycerin and morphine
3. Cardiac monitoring
4. Administer thromobolytic therapy,
antidysrhythmics, beta-blockers.
5. Monitor BP
6. Monitor intake and output
7. Notify HCP if the systolic pressure is lower than
100 mm Hg after medication administration.
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Disease: Heart Failure
Risk Factors
1. CAD
2. MI
3. Myocarditis/Endocarditis
4. Diabetes
5. Hypertension
6. Abnormal heart valves
7. Cardiomyopathy
8. Congenital heart disease
Cardiovascular
Pathophysiology
HF is the inability of the heart muscle to
pump enough blood to meet the metabolic
demands of the body. Therefore, there is
a decrease in cardiac output.
Types:
Right-sided heart failure and left-sided
heart failure.
Signs and Symptoms
Right-sided HF (evident in
systemic circulation)
Edema of the extremities,
abdominal distention, JVD,
splenomegaly, hepatomegaly,
weight gain
Left-sided HF (evident in the
pulmonary system)
Dyspnea, crackles, tachypnea,
pulmonary congestion, dry cough
Diagnostic Tests
1. Blood tests/ Cardiac bio markers
2. Chest X-ray
3. Electrocardiogram (ECG)
4. Echo cardiogram
5. Stress test
6. Cardiac computerized tomography (CT) scan,
Magnetic resonance imaging (MRI). and
Coronary angiogram.
Nursing Management
Treatment
Pharmacology
1. Morphine
2. Digoxin
3. ACE-Inhibitors
4. Beta-blockers
5. Diuretics
Monitor for acute pulmonary edema
1. Place patient in a high Fowler's
position.
2. Oxygen therapy
3. Administer morphine sulfate and
diuretics.
4. Insert Foley's catheter.
5. Intubation and ventilation support if
prescribed.
Other nursing interventions
1. Administer prescribed medication regime.
2. Monitor daily weight
3. Monitor intake and output.
4. Provide balance between rest and
activities.
5. Educate patient on lifestyle and dietary
modifications.
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Disease: Cardiogenic Shock
Risk Factors
1. CAD
2. MI
3. Myocarditis/Endocarditis
4. Diabetes
5. Hypertension
6. Abnormal heart valves
7. Cardiomyopathy
8. Congenital heart disease
Cardiovascular
Pathophysiology
Cardiogenic shock is a condition caused by
failure of the heart to pump adequately.
This results in decreased cardiac output
and decreased tissue perfusion.
Signs and Symptoms
1. Hypotension
2. Tachycardia
3. Chest pain/discomfort
4. Decreased urine output,
less than 30ml/hr.
5. Diminished peripheral
pulse
6. Confusion/disorientation
Diagnostic Tests
1. Blood tests/ Cardiac bio markers
2. Chest X-ray
3. Electrocardiogram (ECG)
4. Echo cardiogram
5. Stress test
6. Coronary angiogram
Nursing Management
Treatment
Assessment
Orientation, respiratory status, pain, vital
signs, peripheral pulse, intake and output
Treatment Goal
To improve the heart's
Interventions
pumping ability and maintain 1. Administer medications (see pharmacologic
interventions).
tissue perfusion.
2. Oxygen therapy
Pharmacology
3. Monitor vital signs
1. Morphine sulfate
4. Monitor BP after diuretic and nitrate
administration.
2. Diuretics
5. Prepare client for procedures to improve
3. Nitrates
coronary tissue perfusion and cardiac output:
4. Vasopressors and positive
PTCA, coronary atery bypass grafting,
insertion of intraaortic balloon pump, etc.
inotropes (Improve organ
6. Monitor urinary output
tissue perfusion)
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Disease: Pericarditis
Cardiovascular
Risk Factors
Pathophysiology
1. MI
2. Autoimmune diseases
3. Injury
4. Heart surgery
5. Bacterial, viral and fungal
infections
Pericarditis is an infection of the
pericardium. The pericardium is comprised
of two thin sac layers that surrounds the
heart.
Chronic pericarditis causes thickening of
the pericardium which results in the
accumulation of fluid (and causes a
decrease in pericardial elasticity).
This may result in further complications such
as heart failure and cardiac tamponade.
Signs and Symptoms
1. Pain
a. Pain that radiates to
the left side of neck,
shoulders and back
b. Pain experienced during
inspiration
c. Pain experienced when
in a supine position
2. Fever
3. Fatigue
4. Pericardial friction rub
(during auscultation)
Diagnostic Tests
1. History and physical examination
2. Chest X-ray
3. Electrocardiogram (ECG)
4. Echo cardiogram
5. Blood culture
Nursing Management
Treatment
Pharmacology
1. Analgesics
2. NSAIDS
3. Corticosteroids
4. Antibiotics (for bacterial
infections)
5. Diuretics
6. Digoxin
Surgical Intervention
1. Pericardiectomy
1. Pain assessment
2. Assess for signs of cardiac tamponade.
3. Auscultate lungs (listen for pericardial
friction rub).
4. Position patient in a high Fowler's
position (leaning forward to reduce pain).
5. Blood culture
6. Administer medications
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Disease: Endocarditis
Risk Factors
1. Congenital heart defects.
2. IV illegal drug use
3. Damaged heart valves
4. Valve replacement
5. Prosthetic heart valve
Signs and Symptoms
Cardiovascular
Pathophysiology
Inflammation and infection of the
endocardium, the inner lining of the
heart chambers and heart valves.
Entry:
1. Oral cavity
2. Infection
3. Invasive procedures
1. Fever
2. Weight loss
3. Heart murmurs
Diagnostic Tests
4. Pallor
1. Blood culture test
5. Clubbing of fingers
6. Petechiae
2. ECG
7. Splenomegaly
3. Chest X-ray
8. Red tender lesions on
4. Echo-cardiogram
hands and feet- Osler's
5. CT scan
nodes
6. MRI
9. Nontender hemorrhagic
nodular lesions- Janeway
lesions
Nursing Management
Treatment
Pharmacology
1. Antibiotics
Assessment
1. Assess skin for petechiae
2. Assess nail beds and clubbing of fingers
3. Assess for Janeway lesios and Osler's nodes
4. Assess blood culture results
Interventions
1. Monitor cardiovascular status
2. Monitor signs of emboli and heart failure.
3. Provide rest and activity balance to prevent
thrombus formation
4. Maintain antiembolism stockings
5. Administer antibiotics
Education
1. Temperature monitoring
2. Oral hygiene
3. Teach client on the signs and symptoms of
complications (emboli and heart failure).
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Disease: Myocarditis
Cardiovascular
Risk Factors
1. Previous pericarditis
2. Bacterial, viral or
fungal infection.
3. Allergic response
Pathophysiology
Myocarditis is the inflammation of the
heart muscles (myocardium).
Myocarditis may affect the heart's
pumping ability and cause
arrhythmias.
Signs and Symptoms
1. Fever
2. Chest pain
3. Pericardial friction rub
4. Tachycardia
5. Murmur
6. Dyspnea
7. Fatigue
Diagnostic Tests
1. Blood test (Cardiac enzymes-CPK
level)
2. ECG
3. Chest X-ray
4. Echo-cardiogram
5. CT scan
6. MRI
Nursing Management
Treatment
Pharmacology
1. Analgesics
2. Salicylates
3. NSAIDs
4. Antidysrhythmic drugs
5. Antibiotics
1. Place client in a comfortable position
(Semi-Fowler's position).
2. Oxygen therapy
3. Administer medications as prescribed (see
pharmacologic therapy)
4. Provide rest periods
5. Avoid activities that causes overexertion
6. Monitor for heart failure,
cardiomyopathy and thrombus as signs of
complications.
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Disease: Cardiac Tamponade
Cardiovascular
Risk Factors
Pathophysiology
1. Cancer
2. Tuberculosis
3. Hypothyroidism
4. Kidney failure
5. Chest trauma
6. Pericarditis
Cardiac tamponade is a syndrome caused
by accumulation of fluid in the pericardial
cavity (pericardial effusion). Cardiac
tamponade decreases ventricular filling
and cardiac output.
Signs and Symptoms
This may cause complications such as
pulmonary edema, shock, or death.
1. Increase central venous
pressure (CVP).
2. Jugular venous distention
3. Muffled heart sound
4. Pulsus paradoxus
5. Decreased cardiac output
Diagnostic Tests
1. Chest X-rays (an enlarged, globeshaped heart may indicate cardiac
tamponade).
2. Thoracic CT scan (fluid accumulation).
3. Magnetic Resonance Angiogram
(determine cardiac blood flow).
4. Echo cardiography
Nursing Management
Treatment
1. Cardiac tamponade is a
medical emergency
2. Client is managed in a critical
care unit for hemodynamic
monitoring
3. IV fluids are prescribed for
decreased cardiac output.
4. Pericardiocentesis is
performed (a procedure to
remove fluids in the
pericardium).
1. Place client on hemodynamic monitoring.
2. Administer IV fluids are prescribed.
3. Prepare client for pericardiocentesis
procedure.
4. Monitor client after the procedure for any
recurrence of tamponade.
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Disease: Aortic Aneurysm
Risk Factors
1. Tobacco use
2. Hypertension
3. Family history
4. Age (65 and older)
5. Gender (male)
6. High blood cholesterol
level
Cardiovascular
Pathophysiology
Aortic aneurysm is an
enlargement/dilation of the aorta.
Aneurysm may occur anywhere along
the abdominal aorta.
Signs and Symptoms
Thoracic aneurysm:
dyspnea, cyanosis, weakness,
hoarseness, syncope, pain.
Abdominal aneurysm:
abdominal pain, abdominal
tenderness, systolic bruit over
aorta, mass above the
umbilicus.
Rupturing aneurysm:
tachycardia, hypotension,
abdominal pain, s/s of shock,
hematoma at the flank
region.
Diagnostic Tests
1. Abdominal ultrasound
2. CT scan
3. Ateriography
Nursing Management
1. Assess abdominal distension
Pharmacology
2. Assess peripheral pulse, temperature,
1. Antihypertensive drugs-to
color and capillary refill.
maintain BP and prevent
pressure on the aneurysm.
3. Monitor vital signs
Surgical Intervention
4. Monitor for signs of aneurysm rupture
1. Abdominal aortic aneurysm
5. Administer medication (see
resection- section is replaced
with a graft.
pharmacologic interventions).
2. Thoracic aneurysm repair- a
thoractomy procedure is used 6. Prepare client for surgical procedure
to enter the thoracic cavity,
expose the aneurysm and a
7. Implement post operative interventions
Treatment
graft is sewn on the aorta.
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Disease: Hypertension
Risk Factors
1. Obesity
2. DM
3. Physical inactivity
4. Tobacco use
5. Alcoholism
6. Family history
7. Secondary hypertension:
caused by underlying
condition
Signs and Symptoms
1. Increased BP
2. Headache
3. Dizziness
4. Chest pain
5. Blurred vision
6. Tinnitus
Remember: it may be
asymptomatic
Cardiovascular
Pathophysiology
Hypertension is the most common lifestyle
disease.
Hypertension is multifactorial that causes
an increase in peripheral vascular
resistance and an increase in blood
pressure (chronic).
Elevated BP: >120-129/<80
Stage 1 Hypertension: 130-139/80-89
Stage 2 Hypertension: >140/>90
Diagnostic Tests
1. History/BP monitoring
2. ECG
3. Echocardiography
4. Blood chemistry
5. Urinalysis
6. Lipid panel
7. CT scan
8. Chest xray
Nursing Management
Treatment
Goal of treatment:
1. Reduction of BP
2. Prevention of organ
damage
Lifestyle changes
1. Diet
2. Exercise
Pharmacology
1. Anti-hypertensive
medications
1. Assess and monitor BP
2. Obtain family history
3. Monitor weights
4. Goal: weight reduction or maintenance
5. Diet: sodium restriction
6. Smoking cessation
7. Educate patient on pharmacological
treatment
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RESPIRATORY
TABLE OF CONTENT
1.
Asthma
2. COPD-Chronic Bronchitis
3.
COPD-Emphysema
4.
Pleural Effusion
5.
Hemothorax
6.
Pneumothorax
7.
Pneumonia
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Disease: ASTHMA
Risk Factors/Causes
1. Allergies
2. Stress
3. Hormonal changes
Signs and Symptoms
1. Chest tightness
2. Wheezing
3. Shortness of breath
4. Cough
5. Restlessness
Treatment
Pharmacology
1. Bronchodilators
2. Corticosteroids
3. Anticholinergics
Respiratory
Pathophysiology
Chronic inflammatory disease of the
airway.
Inflammation and hypersensitivity to
a trigger (stimuli).
Smooth muscle constriction of the
bronchi.
Intermittent airflow obstruction.
Diagnostic Tests
1. ABGs
2. Pulmonary function tests
3. Peak expiratory flow
4. Spirometry
5. Allergy test
6. Pulse oximetry
7. CBC
Nursing Management
1. Assess patient's respiratory rate, depth
and pattern
2. Monitor pulse ox
3. Monitor vital signs
4. Maintain patent airway
5. Administer O2 therapy as prescribed
6. Administer medications as ordered.
Patient Education
1. Medication regimen.
2. Identify and avoid triggers.
3. Long term management.
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Disease: COPD- Chronic Bronchitis
Risk Factors/Causes
1. Smoking
2. Exposure to dust
and chemicals.
3. Air pollution
Respiratory
Pathophysiology
Progressive respiratory disease.
Overproduction of mucus due to
inflammatory response.
Causes airway narrowing and
ventilation-perfusion imbalance.
Signs and Symptoms
1. SOB
2. Cough
3. Sputum production
4. Fatigue
5. Wheezing, crackles
6. Cyanosis
Treatment
Pharmacology
1. Bronchodilators
2. Glucocorticosteroids
3. Anticholinergics
4. Mucolytic agents
Diagnostic Tests
1. ABGs
2. Pulmonary function tests
3. Spirometry
4. Chest X-ray
5. Sputum culture
Nursing Management
1. Assess respiratory rate, depth and
pattern.
2. Auscultate lungs
3. Maintain patent airway
4. Place patient in Fowler's position
5. Provide O2 therapy as ordered.
6. Increase oral fluids and maintain
hydration.
7. Perform chest physiotherapy
Patient Education
1. Deep breathing exercises
2. Nutrition and hydration
3. Smoking cessation
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Disease: COPD- EMPHYSEMA
Risk Factors/Causes
1. Smoking
2. Exposure to dust
and chemicals.
3. Air pollution
Signs and Symptoms
1. SOB
2. Cough
3. Sputum production
4. Fatigue
5. Wheezing, crackles
6. Cyanosis
7. Barrel chest
8. Clubbing of nails
Treatment
Pharmacology
1. Bronchodilators
2. Glucocorticosteroids
3. Anticholinergics
4. Mucolytic agents
Respiratory
Pathophysiology
Progressive respiratory disease
characterized by the enlargement of
the alveolar.
Enlargement causes decrease in
alveolar elasticity, alveolar wall
damage and decrease in alveolar
surface area.
Diagnostic Tests
1. ABGs
2. Pulmonary function tests
3. Chest X-ray
Nursing Management
1. Assess respiratory rate, depth and
pattern.
2. Auscultate lungs
3. Maintain patent airway
4. Place patient in Fowler's position
5. Provide O2 therapy as ordered.
6. Increase oral fluids and maintain
hydration.
7. Perform chest physiotherapy
Patient Education
1. Deep breathing exercises (pursed lip
breathing)
2. Nutrition and hydration
3. Smoking cessation
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Disease: PLEURAL EFFUSION
Risk Factors/Causes
Transudative Effusion
1. Cirrhosis
2. Heart failure
3. Hypoalbuminemia
Exudative Effusion
1. Pneumonia
2. Cancer
3. Pulmonary embolism
4. Tuberculosis
Signs and Symptoms
1. SOB
2. Chest pain
3. Dry, nonproductive
cough
4. Diminished breath
sounds
5. Pain during
inspiration
Treatment
1. Thoracentesis
2. Chest tube insertion
3. Pleurectomy
4. Pleurodesis
5. Treatment of underlying
condition
Pharmacology
(Depends on the underlying
condition)
1. Diuretics- congestive
heart failure.
2. Antibiotics
3. Anticoagulantspulmonary embolism
Respiratory
Pathophysiology
Accumulation of fluid in the pleural
space.
Fluid accumulates between the
visceral and parietal pleura of the
lungs.
Pleural fluid: transudate or exudate
Diagnostic Tests
1. Pleural fluid analysis
2. CT scan
3. Chest radiography
4. Transthoracic ultrasonography
Nursing Management
1. Identify underlying cause
2. Assess respiratory rate, depth
and pattern
3. Monitor vital signs
4. Elevate the head of bed
5. Administer O2 therapy as ordered
6. Administer medications as
ordered
7. Prepare patient for possible
thoracentesis.
8. Chest tube management
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Disease: HEMOTHORAX
Risk Factors/Causes
1. Thoracic/heart surgery
2. Chest trauma
3. Blood clotting defect
4. Anticoagulant therapy
5. Lung cancer
6. Tuberculosis
Signs and Symptoms
1. sOB
2. Tachypnea
3. Chest pain
4. Tachycardia
5. Hypotension
6. Diminished breath
sounds on affected
side
7. Restlessness
8. Cyanosis
9. Anxiety
Treatment
1. Stabilize patient
2. Stoppage of bleeding
3. Thoracentesis
4. Chest tube insertion
Surgical Intervention
1. Thoracotomy
2. VATS-Video assisted
thoracoscopic surgery
Respiratory
Pathophysiology
Accumulation of blood in the pleural
cavity.
Causes respiratory distress.
Diagnostic Tests
1. Thoracentesis
2. ABGs
3. CT scan
Nursing Management
1. Assess diagnostic test results.
2. Assess respiratory rate, depth and
pattern
3. Monitor vital signs
4. Elevate the head of bed
5. Administer O2 therapy as ordered
6. Pharmacologic pain management
7. Non-pharmacologic pain management
8. Chest tube management/care
9. Administer IV fluids as ordered
10. Administer blood transfusion as ordered
11. Prepare patient for surgery, if indicated.
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Disease: PNEUMOTHORAX
Risk Factors/Causes
1. Chest injury
2. Ruptured air blebs
3. Mechanical ventilation
4. Lung disease: cystic fibrosis
5. Chest surgery
6. Smoking
7. Genetics
8. Invasive procedures
Signs and Symptoms
Spontaneous pneumothorax
1. SOB/ Cyanosis
2. Tachycardia
3. Asymmetrical chest
movement
4. Diminished breath sounds on
affected side
5. Chest pain
Tension pneumothorax
1. Tracheal deviation away
from affected side
2. SOB/ Tachypnea/Cyanosis
3. Hypotension/weak pulse
4. Chest pain
5. Decreased CO
Treatment
1. Oxygen therapy
2. Chest tube insertion
Pharmacology
1. Antibiotics
Surgical Management
1. If 1500 ml of blood is
aspirated initially by
thoracentesis then
thoracotomy is
performed.
Respiratory
Pathophysiology
Air leaks into pleural space. Pleural space is
exposed to positive atmospheric pressure
(pressure is normally negative). Causes
impaired lung expansion.
Results in full lung collapse or partial lung
collapse.
Types
1. Spontaneous pneumothorax
2. Tension pneumothorax
3. Traumatic pneumothorax
Diagnostic Tests
1. ABGs
2. Thoracic CT scan
3. CBC
4. Thoracentesis
5. Chest X-ray
Nursing Management
1. Assess respiratory status
2. Maintain patent airway
3. Monitor vital signs
4. Administer O2 therapy as ordered
5. Chest tube management: monitor for
kinks and bubbling
6. Pain management
7. Maintain bed rest
Patient Education
1. Deep breathing exercises
2. Educate patient on the use of Incentive
spirometer
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Disease: PNEUMONIA
Causes
Community acquired pneumonia
1. Streptococcus pneumoniae
Hospital acquired pneumonia
1. Prolonged hospitalization
2. Mechanical ventilation
3. Chronic illness/co morbid
Aspiration Pneumonia
1. Substance entering the
airway due to vomiting or
impaired swallowing
Signs and Symptoms
1. SOB
2. Productive cough
3. Tachypnea
4. Use of accessory
muscles
5. Fever
6. Cyanosis
7. Pleuritic chest pain
Treatment
1. Hydration (IV fluids)
2. Blood culture
3. Respiratory Management
Pharmacology
1. Antibiotics
2. Antiviral angents
3. Antitussives
4. Antipyretics
5. Analgesics
Respiratory
Pathophysiology
Inflammation of the pulmonary tissue
caused by bacteria, fungi and viruses
Types:
1. Community acquired pneumonia: onset
of pneumonia symptoms that occurs in
the community setting or for the first
48 hours after admission
2. Hospital acquired pneumonia: onset of
pneumonia symptoms after 48 hours of
admission
3. Aspiration pneumonia: bacterial
infection from aspiration
Diagnostic Tests
1. ABGs
2. Sputum culture
3. Chest X-ray
4. CBC-WBC
5. Blood culture
6. Pulmonary function studies
7. Bronchoscopy
Nursing Management
1. Assess respiratory status
2. Maintain patent airway
3. Monitor vital signs
4. Assess swallowing if cause is aspiration
5. NPO status maintained if cause is aspiration
6. Administer O2 therapy as ordered
7. Chest physiotherapy
8. Maintain bed rest/Semi-Flower's position
9. Increase fluid intake
10. High-calorie, protein diet
Patient Education
1. Fluid intake
2. Deep breathing/coughing
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3. Medication regimen
Gastrointestinal
TABLE OF CONTENT
1.
Hiatal Hernia
2. Gastroesophageal Reflux Disease
3.
Gastritis
4.
Appendicits
5.
Peptic Ulcer Disease
6.
Ulcerative Colitis
7.
Crohn's Disease
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Disease: Hiatal Hernia
Causes/Risk Factors
1. Injury
2. Aging
3. Obesity
Signs and Symptoms
1. Heart burn
2. Dysphagia
3. Regurgitation
4. Epigastric pain
Treatment
Gastrointestinal
Pathophysiology
The diaphragm has a small opening
(hiatus) through which the esophagus
passes before connecting to the
stomach.
Hiatal hernia occurs when a portion of
the stomach herniates through the
diaphragm and into the thorax.
Diagnostic Tests
1. Upper endoscopy
2. Barium swallow (esophagram)
Nursing Management
1. Assess pain
Pharmacology
2. Elevate head of bed (HOB)
1. Antacid
3. Avoid eating 2 to 3 hours before bedtime
a. Neutralizes
4. Provide small frequent meals
stomach acids
5. Avoid lying down after eating
2. Proton pump inhibitors
6. Administer medications as ordered
a. Blocks acid
production- reduces
Patient Education
stomach acid
Surgical intervention may
be required
1. Avoid alcohol, fatty foods, caffeine,
tobacco, and other irritants
2. Avoid eating 2 to 3 hours before bedtime
3. Avoid lying down after eating
4. Avoid anticholinergics
5. Maintain healthy body weight (exercise)
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Disease: GERD
Causes/Risk Factors
1. Hiatal Hernia
2. Pregnancy
3. Pyloric surgery
4. Smoking
5. Obesity
6. Alcohol
7. Fatty foods
Signs and Symptoms
1. Heart burn
2. Dysphagia
3. Regurgitation
4. Epigastric pain
5. Dyspepsia
(indigestion)
Treatment
Pharmacology
1. Antacid
a. Neutralizes stomach
acids
2. Proton pump inhibitors
a. Blocks acid
production- reduces
stomach acid
3. Histamine H2 antagonist
a. Blocks histamine
(decreases
stimulation of
stomach acid
production).
Gastrointestinal
Pathophysiology
A digestive disorder that occurs due to the
backflow of gastric content.
Impaired or dysfunctional lower
esophageal sphincter (LES) causes
regurgitation of stomach content into the
esophagus.
Complications- esophagitis, Barrett
esophagus, esophageal stricture.
Diagnostic Tests
1. Upper endoscopy
2. Esophageal pH studies
3. Barium swallow (esophagram)
Nursing Management
1. Assess pain
2. Elevate head of bed (HOB)
3. Avoid eating 2 to 3 hours before bedtime
4. Avoid lying down after eating
5. Administer medications as ordered
Patient Education
1. Avoid alcohol, fatty foods, caffeine, tobacco,
and other irritants
2. Avoid eating 2 to 3 hours before bedtime
3. Avoid lying down after eating
4. Avoid NSAIDS and anticholinergics
5. Maintain healthy body weight (exercise)
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Disease: Gastritis
Causes/Risk Factors
1. Bacterial infection
2. Autoimmune disease
3. Prolong use of NSAIDs
4. Excessive alcohol use
5. Smoking
6. Dietary factors
Signs and Symptoms
Acute Gastritis
1. Nausea/vomiting
2. Anorexia
3. Abdominal pain
4. Acid reflux
5. Hiccups
Chronic Gastritis
1. Indigestion
2. Heart burn after meals
3. Vitamin B12 deficiency
4. Anorexia/nausea/vomiting
Treatment
Gastrointestinal
Pathophysiology
Gastritis is the inflammation of the gastric
mucosa.
Acute gastritis- caused by the overuse of
NSAIDs, aspirin or excessive alcohol intake.
Chronic gastritis-consistent inflammation of
the gastric mucosa. May be caused by H.
pylori bacteria, or autoimmune diseases.
Diagnostic Tests
1. Endoscopy
2. H. pylori test
3. Upper GI X-ray
Nursing Management
Pharmacology
1. Assess pain
1. Antacid
2. Monitor signs of hemorrhagic gastritis
a. Neutralizes stomach
3. Maintain NPO status until symptoms
acids
2. Proton pump inhibitors
subsides
a. Blocks acid
4. Administer medications as ordered.
production- reduces
stomach acid
3. Histamine H2 antagonist Patient Education
a. Blocks histamine
1. Educate patient to avoid irritating
(decreases
foods.
stimulation of
2. Educate patient on the importance of
stomach acid
production).
medication regime and adherence.
4. Antibiotics: to treat
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Disease: Appendicitis
Risk Factors
1. Abdominal trauma
2. Inflammatory bowel
disease
3. Infection in the
gastrointestinal tract
4. Foreign body
5. Viral infection
Gastrointestinal
Pathophysiology
Inflammation of the vermiform appendix.
Inflammation causes obstruction of the
appendiceal lumen.
Complications: Prolong inflammation may
cause the appendix to burst/rupture
leading to peritonitis.
Signs and Symptoms
1. Rovsing's sign: pain
experienced at the RLQ
when pressure is applied
and released at the LLQ
2. Periumbilical abdominal
pain
3. RLQ pain
4. Fever
5. Abdominal rigidity
Treatment
1. Appendectomy: surgical
removal of the appendix
2. Pain management
3. IV fluids
Pharmacology
1. Antibiotics
Diagnostic Tests
1. CBC (WBC)
2. CT scan
3. Abdominal ultrasound
Nursing Management
1. Assess pain
2. Abdominal assessment
3. Monitor VS
4. Pre-operative care: NPO + IVF
5. Post-operative care: Monitor surgical site
+ monitor for signs of infection
Patient Education
1. Post-operative education
a. Early ambulation
b. Deep breathing exercises
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Disease: Peptic Ulcer Disease
Risk Factors/Causes
1. H. pylori bacteria
2. NSAIDS
3. Irritants
4. Smoking
Signs and Symptoms
1. Epigastric pain after
meals
2. Dark, tarry stools
3. Weight loss
4. Coffee ground emesis
Treatment
Pharmacology
1. Antibiotics
2. Histamine H2 blockers
a. Blocks histamine
(decreases
stimulation of
stomach acid
production).
3. Proton pump inhibitor
a. blocks acid
production to
promote healing
Gastrointestinal
Pathophysiology
Ulceration that erodes the gastric or
duodenal mucosa.
Mucosal inflammation and ulceration
is caused by H. pylori bacteria.
Complications: GI hemorrhage,
bowel obstruction
Diagnostic Tests
1. Laboratory tests for H. pylori
2. Endoscopy
3. Barium Swallow (Upper
gastrointestinal series)
Nursing Management
1. Abdominal Assessment (abdominal
sounds)
2. Monitor vital signs (BP,P)
3. Monitor stools for blood
Patient Education
1. Dietary modification: avoid
irritants
2. Smoking cessation
3. Avoid NSAIDS
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Disease: Ulcerative Colitis
Risk Factors/Causes
1. Age
2. Family history
Signs and Symptoms
1. Diarrhea with pus or
blood
2. Abdominal pain
3. Abdominal
tenderness
4. Fever
5. Fecal urgency
Treatment
Pharmacology
1. 5-aminosalicylic acid (5ASA)
2. Corticosteroidsmoderate to severe
ulcerative colitis
3. Immunosuppresantsreduces inflammation.
Gastrointestinal
Pathophysiology
Known as an Inflammatory Bowel
Disease.
Characterized by the ulceration and
inflammation of the colon and rectum.
Causes poor nutrient absorption.
Complications: Nutritional deficiencies,
hemorrhage and perforated colon
Diagnostic Tests
1. Colonoscopy
2. Stool specimen analysis
Nursing Management
1. Assess and monitor vital signs
2. Assess pain
3. Monitor fluid balance
4. I/O charting
5. Monitor electrolyte levels (lab studies)
6. Monitor stool frequency and
characteristics
7. Obtain daily weights
8. Pain management
9. Maintain NPO status if indicated (severe
condition)
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Disease: Crohn's Disease
Risk Factors/Causes
1. Autoimmune
2. Heredity
Gastrointestinal
Pathophysiology
Crohn's disease is a type of
inflammatory bowel disease (IBD) that
causes inflammation in the
gastrointestinal tract (leads to
thickening, scarring and narrowing)
Signs and Symptoms
1. Diarrhea with pus
2. Fever
3. Abdominal pain
4. Abdominal distention
5. Weight loss
6. Reduced appetite
7. Iron deficiency
Treatment
Pharmacology
1. 5-aminosalicylic acid (5ASA)
2. Corticosteroids
3. Immunosuppresantsreduces inflammation.
Diagnostic Tests
1. Colonoscopy
2. Stool specimen analysis
3. CT scan
4. MRI
Nursing Management
1. Assess and monitor vital signs
2. Assess pain
3. Monitor fluid balance
4. I/O charting
5. Monitor electrolyte levels (lab studies)
6. Monitor stool frequency and
characteristics
7. Obtain daily weights
8. Pain management
9. Maintain NPO status if indicated (severe
condition)
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Pancreas & Gallbladder
TABLE OF CONTENT
1. Pancreatitis
2. Cholecystitis
3. Cholelithiasis
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Disease: Pancreatitis
Risk Factors/Causes
1. Hyperlipidemia
2. Hypercacemia
3. Gallstones
4. Abdominal surgery
5. Abdominal trauma
6. Obesity
7. Infection
Signs and Symptoms
1. Left upper abdominal
pain that radiates to the
back
2. Abdominal pain that
worsens after meals
3. Abdominal tenderness
4. Fever
5. Tachycardia
6. Hypotension
7. Steatorrhea: chronic
pancreatitis
Treatment
1. NPO status
2. Pancreatic enzyme
supplements
3. Pain management
4. IV fluids
5. Surgical procedure to
remove bile duct
obstruction.
6. Cholecystectomy (if cause
is gallstones)
7. Pancreatic Jejunostomy
Gastrointestinal
Pathophysiology
Inflammation of the pancreas.
Obstruction of pancreatic secretory
flow, activation and release of
pancreatic enzymes. Digestive
enzymes starts digesting the
pancreas.
Diagnostic Tests
1. Electrolyte levels (Calcium)
2. Elevated level of pancreatic enzymes
3. WBC
4. CT scan
5. Abdominal ultrasound
6. Endoscopic ultrasound
7. MRI
8. stool test: for chronic pancreatitis
Nursing Management
1. Assess pain
2. Provide pharmacologic and nonpharmacologic pain management
3. Monitor fluid and electrolytes
4. Maintain NPO status as ordered
5. Manage biliary drainage
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Disease: Cholecystitis
Risk Factors/Causes
1. Gallstones
2. Tumor
3. Infection
Signs and Symptoms
1. Epigastric pain that
radiates to the right
shoulder
2. Fever
3. Nausea/Vomiting
4. Murphy's sign
5. Belching
6. Flatulence
7. Abdominal tenderness
Treatment
1. NPO status
2. Pain management
3. Antiemetics: for nausea
and vomiting
4. Analgesics: pain
Surgical intervention
1. Cholecystectomy:
removal of the
gallbladder.
2. Choledocholithotomy:
removal of gallstones
Gastrointestinal
Pathophysiology
Inflammation of the gallbladder.
Acute inflammation: is often due to
cholelithiasis.
Chronic inflammation: repeated
acute inflammation that causes the
gallbladder to be thick-walled and
scarred.
Diagnostic Tests
1. CBC- WBC
2. Abdominal ultrasound
3. Endoscopic ultrasound
4. CT scan
Nursing Management
1. Assess pain
2. Provide pharmacologic and nonpharmacologic pain management
3. Maintain NPO status
4. Prepare patient for procedures
Post operative interventions
1. Monitor respiratory complications
2. Encourage coughing and deep breathing
3. Encourage early ambulation
4. Tube drainage management (if any).
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Disease: Cholelithiasis
Risk Factors/Causes
1. Obesity
2. High cholesterol
levels
3. Women over 40 years
4. Diabetes
5. Cirrhosis
Signs and Symptoms
1. Sudden pain in the right
upper quadrant
2. Abdominal distention
3. Dark urine
4. Abdominal pain after
eating fatty foods.
Treatment
Pharmacology
1. Analgesics
2. Antibiotics
Surgical intervention
1. Cholecystectomy:
removal of the
gallbladder.
Medications to dissolve
stones
1. Chenodeoxycholic
2. Ursodeoxycholic acid
Gastrointestinal
Pathophysiology
Gallstones are hard, crystalline
structures that abnormally forms
and obstruct the gallbladder / bile
duct.
Most of cholelithiasis is caused by
cholesterol gallstones.
Diagnostic Tests
1. Cholesterol levels/LDLs
2. Cholecystogram
3. Laparoscopy
4. Abdominal ultrasound
5. Endoscopic ultrasound
6. CT scan
7. MRI
Nursing Management
Preoperative Care
1. Prepare patient for surgery
Postoperative Care
1. Monitor vital signs
2. Monitor respiratory status
3. Pain management
4. Monitor drainage/incision site
5. Monitor intake and output
6. Maintain NPO status
7. Deep breathing exercises
8. Early ambulation
Patient Education
1. Ambulation/ 2. Avoid heavy lifting/ 3. Avoid
bathing for 48 hours/ 4. Report fever/ 5. Dietary
modification/ 6. Assess wound site daily.
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Hepatic Disorders
TABLE OF CONTENT
1.
2.
3.
Cirrhosis
Portal Hypertension
Esophageal Varices
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Disease: Cirrhosis
Risk Factors/Causes
1. Chronic alcoholism
2. Hepatitis
3. Biliary obstruction
4. Right-sided HF
Gastrointestinal
Hepatic Disorders
Pathophysiology
Cirrhosis is a chronic progressive
disease of the liver characterized by
fibrosis (scarring).
Signs and Symptoms
1. Jaundice
2. Edema
3. Splenomegaly
4. Liver enlargement
5. Ascities
6. Abdominal pain
7. Steatorrhea
8. Bleeding- decreased Vit K
9. Red palms
10. Itchiness
11. Weight loss/ Loss of
appetite
12. White nails
Treatment
Diagnostic Tests
1. Liver Function Test
2. INR/Prothrombin time
3. MRI
4. CT scan
5. Liver Biopsy
Nursing Management
1. Treatment of underlying
1. Identify underlying/precipitating factors
cause
2. Perform daily weights
a. Alcohol dependency
3. Administer vitamin supplements- KADE
b. Hepatitis treatment
4. Monitor for signs of infection
5. Monitor for signs of bleeding
2. Treatment of Cirrhosis
6. Nutrition- low sodium
complications- ascites,
gastric distress, portal
Patient Education
hypertension, etc.
1. Alcohol cessation
3. Liver Transplant- in severe 2. Low sodium diet
cases of Cirrhosis
3. Low saturated fats
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Disease: Portal Hypertension
Causes
1. Cirrhosis
2. Portal vein
thrombosis
Signs and Symptoms
1. Gastrointestinal bleeding
a. Dark/tarry stools
b. bleeding from varices
2. Ascites
3. Decreased platelets and
WBC
4. Splenomegaly
5. Thrombocytopenia
6. Encephalopathy
Treatment
Gastrointestinal
Hepatic Disorders
Pathophysiology
Portal veins carries blood from the
digestive organs to the liver.
Portal hypertension-increased pressure
in the portal veins due to obstruction of
the portal blood flow.
Complications- Hepatic encephalopathy,
ascites, GI bleed, varices rupture.
Diagnostic Tests
1. CBC- low platelets
2. Hemoccult
3. Endoscopy
4. Ultrasound
Nursing Management
1. Endoscopic therapy
1. Monitor intake and output
2. Dietary/lifestyle
2. Assess level of consciousness
modifications
3. Monitor coagulation studies
3. Transjugular intrahepatic 4. Perform daily weights
portosystemic shunt
5. Administer diuretics as ordered
(TIPS)-radiological
6. Administer Vit K as ordered
procedure
4. Distal splenorenal
Patient Education
shunt (DSRS)-surgical
1. Low sodium diet
procedure
2. Alcohol cessation
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Disease: Esophageal Varices
Causes
1. Cirrhosis
2. Thrombosis in the
portal vein
3. Heart failure
4. Schistosomiasis
Signs and Symptoms
1. Jaundice
2. Dark-colored urine
3. Ascites
4. Nausea/Vomiting
5. Spontaneous
bleeding/easy bruising
6. Spider nevi
7. Hypotension
8. Tachycardia
9. Pallor
10. General malaise
11. Pruritus
Treatment
1. Primary goal is to prevent
bleeding.
2. Beta blockers- to reduce
pressure in the portal
veins
3. Vasopressin
4. Somatostatin/Sandostatin
5. Sclerotherapy
6. Endoscopic band ligation
Gastrointestinal
Hepatic Disorders
Pathophysiology
Esophageal varices occurs when there is a
blockage in the blood flow to the liver due to
scarring or clotting in the liver.
This results in an increased pressure from the
portal vein.
The increased pressure causes blood to flow into
smaller veins in the esophagus. The smaller
fragile veins may become distended and
rupture, causing life--threatening hemorrhage.
Diagnostic Tests
1. CBC
2. Coagulation studies
3. Liver function test
4. Endoscopy
5. CT scan
Nursing Management
1. Monitor vital signs
2. Monitor lung sounds
3. Elevate HOB
4. Administer O2 as ordered
5. Administer IV fluids as ordered
6. Monitor lab values-coagulation studies
7. Administer Vit K as ordered
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Genitourinary
TABLE OF CONTENT
1.
2.
3.
4.
5.
6.
7.
Acute Kidney Injury
Chronic Kidney Disease
Glomerulonephritis
Nephrotic Syndrome
Renal Calculi
Urinary Tract Infection
Pyelonephritis
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Disease: Acute Kidney Injury
Causes
Prerenal-outside the kidney
1. Dehydration, infection outside of
the kidney, decreased cardiac
output
Intrarenal-parenchyma of the kidney
1. Infection within the kidney
parenchyma, obstruction, tubular
necrosis, renal ischemia
Postrenal-between kidney and
urethral meatus
1. Calculi, cystitis, bladder
cancer/obstruction
Signs and Symptoms
Oliguric Phase
1. Urine output: <400mL/d,
pericarditis, excessive
fluid volume, uremia,
metabolic acidosis,
neurological changes.
Diuretic Phase
1. An increase in urine
output 5L/day.
Recovery Phase
1. Recovery may take 6
months to 2 years.
Treatment
1. Treatment of underlying
cause
2. Treatment of
complications
a. Fluids and
electrolytes
imbalances
3. Pharmacology
a. Antibiotics
b. NSAIDs
c. Diuretics
Genitourinary
Pathophysiology
Renal cell damage characterized by a
sudden deterioration in kidney function.
AKI can cause cell death, decompensation
of renal function and hypoperfusion.
The signs and symptoms of AKI are due to
the retention of fluids, the retention of
nitrogenous waste and electrolyte
imbalances.
Diagnostic Tests
1. Urinalysis
2. Urine output measurement
3. BUN/ Creatinine
4. Kidney ultrasound/Imaging
Nursing Management
Oliguric Phase
1. Administer diuretics
2. Fluid restriction-if hypertension is
present
Diuretic Phase
1. Administer IV fluids
2. Monitor Lab values
Recovery Phase
1. Patient education-decrease sodium,
protein, fluid and potassium intake
2. Monitor intake and output.
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Disease: Chronic Kidney Disease
Causes
1. AKI
2. Hypertension
3. Urinary obstruction
4. Diabetes
Signs and Symptoms
1. Hypertension
2. SOB
3. Kussmaul respirations
4. Oliguria/anuria
5. Uremia
6. Edema
7. Irritability
8. Restlessness
9. Pulmonary edema
10. Pulmonary effusion
11. Body weakness
12. Yellow-gray pallor
13. Proteinuria
Treatment
1. Hemodialysis
2. Peritoneal Dialysis
Kidney transplant
Pharmacology
1. Angiotensin-converting
enzyme (ACE) inhibitors
2. Angiotensin II receptor
blockers
3. Diuretics
4. Corticosteroids
5. Erythropoietin
supplements
Genitourinary
Pathophysiology
Slow, progressive and irreversible loss of kidney
function.(GFR <60mL/min).
Results in uremia, electrolyte imbalances,
hypervolemia (inability to excrete sodium and
water) or hypovolemia (inability to conserve
sodium and water).
Stages of CKD
1. At risk: >90mL/min
2. Mild CKD: 60-89mL/min
3. Moderate CKD: 30-59mL/min
4. Severe CKD: 15-29mL/min
5. ESKD: <15mL/min
Diagnostic Tests
1. Kidney function testBUN/Creatinine
2. Glomerular filtration rate
3. CBC
4. Kidney ultrasound
5. Urinalysis
Nursing Management
1. Monitor vital signs
2. Monitor cardiopulmonary system
3. Perform daily weights
4. Monitor lab values
5. Monitor intake and output
6. Low protein/sodium diet
7. Fluid restriction
8. Dialysis treatment
9. Administer medications
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Disease: Glomerulonephritis
Causes
1. Immunological diseases
2. Strep throat
3. Autoimmune diseases
Genitourinary
Pathophysiology
A group of renal diseases caused by
immunologic response that triggers
the inflammation of the glomerular
tissue.
Signs and Symptoms
1. Dark colored urine
2. Hematuria
3. Proteinuria
4. Azotemia
5. Oliguria
6. Edema
7. Elevated BP
8. JVD
9. Dyspnea
Treatment
Pharmacology
1. Antibiotics
2. Antihypertensive drugs
Diagnostic Tests
1. Urinalysis
2. CT Scan
3. MRI
4. Bun-increased
5. Creatinine-increased
6. Decreased GFR
7. Increased Urine Specific Gravity
Nursing Management
1. Monitor vital signs
2. Monitor respiratory status
3. Monitor BP
4. Monitor fluids and electrolytes level
5. Maintain fluid restrictions as ordered
6. Obtain daily weights
Patient Education
1. Medication adherence
2. Fluid restrictions
3. Dietary modifications
4. Increase carbohydrates in diet
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Disease: Nephrotic Syndrome
Causes
1. Diabetes Mellitus
2. Heart failure
3. SLE
4. Amyloidosis
Signs and Symptoms
1. Periorbital and facial
edema
2. Ascites
3. Peripheral edema
4. Proteinuria
5. Hypoproteinemia
6. Hyperlipidemia
7. Electrolyte imbalance
8. Fatigue
9. Lethargy
Treatment
Pharmacology
1. Diuretics
2. ACE-Inhibitors/ ARBS
3. Corticosteroids
4. Immunosuppressant
Genitourinary
Pathophysiology
Nephrotic syndrome is characterized
by excessive excretion of protein in
the urine (proteinuria), leading to
low protein levels in the blood
(hypoproteinemia).
This leads to edema and
hypovolemia.
Diagnostic Tests
1. Urinalysis
2. BUN, Creatinine
3. Elevated Albumin
4. Blood cholesterol and blood
triglycerides-increased
5. Electrolytes
Nursing Management
1. Monitor vital signs
2. Monitor BP
3. Monitor lab values-protein
4. Intake and output charting
5. Obtain daily weights
6. Low salt/sodium diet/Low cholesterol
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Disease: Renal Calculi
Causes/Risk Factors
1. Dehydration
2. Family history
3. UTI
4. Hypercalcemia
5. Obesity
6. High calcium diet
Signs and Symptoms
1. Pain in the costovertebral
region
2. Fever
3. Persistent need to
urinate
4. Elevated RBC,WBC noted
in urine
Treatment
Treatment depends on the
type, size and cause of the
calculi.
Pharmacology-antibiotics
Small Calculi
1. Increase water intake
2. Pain medications
3. Alpha blockers
Large Calculi
1. Extracorporeal shock
wave lithotripsy (ESWL)
2. Surgical intervention
Genitourinary
Pathophysiology
Renal calculi is also known as kidney
stones. Calculi is made up of minerals and
salt deposits that is found in the urinary
tract.
Types
1. Calcium stones
2. Cystine stones
3. Struvite stones
4. Uric acid stones
Diagnostic Tests
1. 24-hours urine collection
2. Urinalysis
3. CBC
4. Ultrasound
5. KUB radiography
Nursing Management
1. Monitor vital signs
2. Monitor temperature
3. Pain management
4. Encourage fluid intake of 3L/day
5. Encourage ambulation
6. Monitor urine output
7. Strain urine
8. Administer medication as ordered.
Patient Education
1. Increase fluid intake
2. Dietary restrictions
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Disease: Urinary Tract Infection
Causes/Risk Factors
1. Vesicoureteral reflux
2. Urinary catheterscontinuous or long term
use
3. Female
4. Renal calculi
5. Sexual activity
Signs and Symptoms
Acute pyelonephritis
1. Flank pain, Fever, chills,
bacteriuria, pyuria
Cystitis
1. Lower abdominal pain,
burning on urination,
hematuria, frequent
urination, incontinence
Urethritis
1. Lower abdominal pain,
burning on urination,
hematuria, frequent
urination, incontinence
Treatment
Pharmacology
1. Antibiotics
2. Analgesics
3. Antipyretics
Genitourinary
Pathophysiology
UTI is the infection/inflammation of
any part of the urinary system.
1. Acute pyelonephritis:
inflammation of the kidneys
2. Cystitis: Inflammation of the
bladder
3. Urethritis: Inflammation of the
urethra
Diagnostic Tests
1. Urine sample
2. Urine culture
3. Kidney ultrasound
4. CT scan
Nursing Management
1. Monitor vital signs
2. Monitor temperature
3. Encourage fluid intake 3L/day
4. Monitor intake and output
5. Obtain daily weights
6. Administer medications as ordered
Patient Education
1. High calorie, low protein diet
2. Non-pharmacologic pain management
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Disease: Pyelonephritis
Causes/Risk Factors
1. Vesicoureteral reflux
2. Urinary catheterscontinuous or long term
use
3. Female
4. Renal calculi
Genitourinary
Pathophysiology
Inflammation of the renal pelvis
caused by bacterial infection.
Signs and Symptoms
1. Fever/chills
2. Flank pain
3. Costovertebral angle
tenderness
4. Hematuria
5. Tachypnea
6. Tachycardia
7. Nausea
8. Cloudy urine
9. Increased urine frequency
and urgency
10. Pyuria
11. Bacteriuria
Treatment
Pharmacology
1. Antibiotics
2. Analgesics
3. Antipyretics
4. Antiemetics
5. Urinary antiseptics
Diagnostic Tests
1. Urine sample
2. Urine culture
3. Blood culture
4. Kidney ultrasound
5. CT scan
Nursing Management
1. Monitor vital signs
2. Monitor temperature
3. Encourage fluid intake 3L/day
4. Monitor intake and output
5. Obtain daily weights
6. Administer medications as ordered
Patient Education
1. High calorie, low protein diet
2. Non-pharmacologic pain management
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Neuro
TABLE OF CONTENT
1.
2.
3.
4.
5.
6.
Traumatic Head Injury
Meningitis
Stroke
Multiple Sclerosis
Seizures
Parkinson's Disease
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Disease: TRAUMATIC BRAIN INJURY
Causes/ Risk Factors
1. Falls
2. Sports injury
3. Vehicular accident
4. Violence
Signs and Symptoms
1. Increased ICP
2. LOC changes
3. Confusion/altered mental
status
4. Papilledema
5. Body weakness
6. Seizures
7. Paralysis
8. Slurred speech
9. CSF drainage from the ears
or nose
Signs and symptoms depends on
the type of injury and severity.
Treatment
Mild Injury
1. Close monitoring
2. Antibiotics
3. Wound care
Moderate to severe injury
1. Treatment focuses on
increasing cerebral
oxygenation, maintaining BP
and preventing further
injury.
2. Craniotomy
NEURO
Pathophysiology
Trauma to the skull that causes brain damage.
Types:
1. Concussion-injury that causes the head to
move back and forth forcefully
2. Contusion-bruising
3. Epidural hematoma- hematoma between
skull and dura
4. Subdural hematoma-blood between
between the dura and arachnoid
5. Intracerebral hemorrhage-bleeding inside
the brain
6. Subarachnoid hemorrhage-bleeding into
the subarachnoid space
7. Skull fractures- break in the cranial bone
Diagnostic Tests
1. GCS
2. Physical Assessment
3. CT scan
Nursing Management
1. Monitor respiratory status
2. Maintain patent airway
3. Initiate seizure precautions
4. Assess neurological changes
5. Assess pupil size
6. Monitor vital signs
7. Monitor for signs of increase
intracranial pressure.
8. Prevent neck flexion
9. Pain management
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Disease: Meningitis
Causes
1. Streptococcus pneumoniae
2. Neisseria meningitidis
3. Haemophilus influenzae
Pathophysiology
Meningitis is the inflammation of the
meninges. The meninges covers the brain
and spinal cord. Meningitis is mostly
caused by bacterial or viral infection.
Signs and Symptoms
1. Fever
2. Headache
3. Skin rash
4. Rigidity of the neck
muscles (nuchal rigidity)
5. Positive Kernig's sign and
Brudzinski's sign
6. Decreased LOC
Treatment
Bacterial meningitis
1. Antibiotics
IV fluids: fluids replacement
Antipyretics
Diagnostic Tests
1. Lumbar puncture: CSF fluid is
collected to test for the
pathogen
2. CT scan
3. MRI
4. Blood culture
Nursing Management
1. Infection control precautions
2. Monitor neurological status
3. Assess LOC
4. Monitor vital signs
5. Initiate seizure precautions
6. Administer antipyretics as ordered
7. Encourage and increase hydration
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Neuro
Disease: Stroke
Risk Factors
1. TIA
2. Hypertension
3. smoking
4. Atherosclerosis
5. Diabetes
6. High cholesterol
Signs and Symptoms
1. Drooping of face
2. One sided weakness
3. Slurred speech
4. Blurred vision
5. Agnosia
6. High BP
7. Unilateral neglect
8. Apraxia
Treatment
1. An IV injection of
recombinant tissue
plasminogen activator
(tPA)-ischemic stroke
2. Hemorrhagic stroke: stop
bleeding. Prevention of
increased ICP
Pathophysiology
Stroke is the loss of neurological functions
due to the lack of blood flow to the brain.
Types
1. Ischemic Stroke (Clots)- an obstruction
in the blood vessel that supplies blood
to the brain.
2. Hemorrhagic Stroke (Bleeding)weakened blood vessel ruptures.
3. Transient Ischemic Attack- temporary
stroke (a warning stroke)
Diagnostic Tests
1. CT scan
2. MRI
3. Electroencephalography
4. Carotid ultrasound
5. Cerebral arteriography
Nursing Management
1. Maintain patent airway
2. Administer 02
3. Administer tPA
4. Monitor VS-maintain BP @ 150/100
5. Monitor LOC
6. Monitor for signs of increase ICP
7. Elevate HOB
8. Administer IV fluids
9. Insert Foley's catheter
10. Prevention of DVT
11. Assist with self care and ADLs
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Disease: Multiple Sclerosis
Risk Factors
1. Autoimmune disorders
2. Viral infection
Neuro
Pathophysiology
Multiple sclerosis is a CNS inflammatory
disease (chronic), characterized by
the demyelination axons. This damage
results in varied neurological dysfunctions.
Signs and Symptoms
1. Weakness
2. Fatigue
3. Blurred vision
4. Nystagmus
5. Sensory loss
6. Dysphagia
7. Bowel and bladder
dysfunction
8. Electric-shock sensations
9. Neuralgias
Treatment
There is no cure. Treatment
goal is focused on managing
symptoms, acute attacks and
slowing the progression of the
disease.
Diagnostic Tests
1. CT scan
2. MRI
3. Lumbar puncture
Nursing Management
1. Assess muscle function and mobility
2. Pain management
3. Assess sensory function
4. Monitor vision changes
5. Cluster nursing activities
6. Patient's safety measures
7. Encourage independence
8. Encourage bladder and bowel training
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Disease: Seizures
Risk Factors/Causes
1. Meningitis
2. Head trauma
3. Stroke
4. Fever
5. Brain tumor
Signs and Symptoms
The signs and symptoms depends
on seizure history and type.
Before seizure
1. Aura
During seizure
1. Loss of consciousness during
seizures
2. Uncontrollable involuntary
muscle movements
3. Loss of bladder and bowel
control
After seizure
1. Headache
2. Confusion
3. Slurred speech
Treatment
Pharmacology
1. Anti-seizure medication
Pathophysiology
Seizures is characterized by a sudden, uncontrolled
electrical disturbance in the brain.
Epilepsy: chronic seizure activity.
Types:
Generalized Seizures-all areas of the brain are
affected
Tonic-Clonic- may begin with an aura.
Tonic phase- muscle rigidity , then loss of
consciousness
Clonic-hyperventilation and jerking
Absence-loss of awareness (stare blankly into
space)
Myoclonic-brief, jerking movement of a
muscle/muscle group
Atonic-sudden loss of muscle strength
Partial Seizures-affects one part of the brain
Simple partial
Complex partial
Diagnostic Tests
1. An electroencephalogram
2. Computerized tomography
3. Magnetic resonance imaging
(MRI)
4. Neurological exam
Nursing Management
1. Assess time and duration of seizure
activity
2. Provide patient safety
3. Turn patient to the side
4. Maintain airway
5. Avoid restraining patient
6. Loosen clothing
7. Administer O2
8. Monitor behavior before and after
seizure activity
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Disease: Parkinson's Disease
Risk Factors
1. Age >65
2. Family history
Neuro
Pathophysiology
A progressive neurological disease
characterized by depletion of dopamine
and acetycholine imbalances.
Signs and Symptoms
1. Bradykinesia
2. Tremors
3. Slow movement
4. Blank facial expression
5. Posture: forward tilt
6. Rigidity of extremities
7. Pill rolling
8. Drooling
Treatment
Pharmacology
1. Carbidopa-levodopa
2. Dopamine agonist
3. Catechol Omethyltransferase (COMT)
inhibitors
Diagnostic Tests
1. Medical history
2. Signs and symptoms
3. Neurological examination
4. Physical examination
Nursing Management
1. Neuro assessment
2. Assess ability to swallow
3. Provide patient's safety
4. Promote independence
5. Promote physical therapy
6. Diet: high calorie & soft diet
Treatment goal
1. Increase/maintain independence
2. Improve mobility
3. Improve nutritional status
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A Review Guide For Nursing Students
PART 2
nursebossstore.com
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Table of Content
1. Thyroid Disorders
2. Pancreatic Disorders
3. Adrenal Cortex Disorders
4. Pituitary Gland Disorders
5. Skeletal Disorders
6. Hematology Disorders
7. Reproductive Disorders (F)
8. Reproductive Disorder (M)
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THYROID DISORDERS
TABLE OF CONTENT
1.
2.
3.
4.
Hypothyroidism
Hyperthyroidism
Hypoparathyroidism
Hyperparathyroidism
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Disease: Hypothyroidism
Risk Factors/Causes
1. Autoimmune diseases
2. Iodine deficiency or
excess
3. Thyroiditis
4. Thyroidectomy
Thyroid Disorders
Pathophysiology
The thyroid gland produce hormones that
are responsible for regulating the body's
metabolic rate (energy).
In hypothyroidism, the thyroid gland is
underactive (Hyposecretion of thyroid
hormones).
Remember: LOW ENERGY
Signs and Symptoms
1. Fatigue/body weakness
2. Weight gain
3. Oligomenorrhea
4. Hair loss
5. Bradycardia
6. Coldness
Diagnostic Tests
1. Physical examination
2. Thyroid Function Test
3. Serum T3/T4
7. Constipation
8. Myxedema
Nursing Management
Treatment
1. Monitor HR
2. Administer levothyroxine as prescribed.
Pharmacology
1. Levothyroxine
Patient Education
1. Educate patient on medication
compliance. Levothyroxine is to be taken
for a life-time.
2. Constipation: High fiber diet and
increase fluids
3. Diet: low-calorie, high fiber diet
4. Weight reduction: exercise plan
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Disease: Hyperthyroidism
Risk Factors/Causes
1. Graves' disease
Signs and Symptoms
1. Exophthalmos: bulging
eyes
2. Palpitations
3. Tachycardia
4. Weight loss
5. Oligomenorrhea
6. Hot flashes
7. Irritability
8. Nervousness
9. Diarrhea
Thyroid Storm
1. Fever
2. Tachycardia
3. Hypertension/Increased RR
Treatment
Pharmacology
1. Propylthiouracil (PTU)
2. Methimazole
3. Radioactive iodine
therapy
Surgical Intervention
1. Thyroidectomy
Thyroid Disorders
Pathophysiology
The thyroid gland produce hormones that
are responsible for regulating the body's
metabolic rate (energy)
In hyperthyroidism, the thyroid gland is
overactive (Hypersecretion of thyroid
hormones (T3 and T4))
Remember: HIGH ENERGY
Thyroid Storm: acute and life-threatening
emergency for uncontrolled hyperthyroidism.
Diagnostic Tests
1. Physical examination
2. Thyroid Function Test
3. Serum T3/T4
4. Thyroid ultrasound
Nursing Management
1. Monitor BP, P
2. Administer medications as prescribed.
3. Obtain daily weights
Patient Education
1. Educate patient on medication compliance
2. Diet: High calorie diet
3. Avoid stimulants
Thyroid Storm
1. Maintain patent airway
2. Medications: Antithyroid medication, Beta
Blockers, Glucocorticoids, Nonsalicylate
antipyretics
3. Cooling blankets
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Disease: Hypoparathyroidism
Risk Factors/Causes
1. Thyroidectomy (and the
removal of the
parathyroid).
Thyroid Disorders
Pathophysiology
The parathyroid gland produces the
parathyroid hormone (PTH) that maintains
the serum calcium level in the body.
Hypoparathyroidism is caused by
hyposecretion of parathyroid hormones.
Signs and Symptoms
1. Positive Trousseau's sign
2. Positive Chvostek's sign
3. Hypocalcemia
4. Hyperphosphatemia
5. Hypotension
6. Tetany
7. Muscle cramps
8. Anxiety
9. Numbness and tingling
Diagnostic Tests
1. Calcium and Phosphate serum levels
2. Positive Chvostek's and Trousseau's sign
3. Patient History
Nursing Management
Treatment
Pharmacology
1. IV Calcium Gluconate
2. Vitamin D supplements
1. Monitor BP, P
2. Monitor calcium/ phosphorus level
3. Administer medications as prescribed
4. Diet: high Calcium, low Phosphorus diet
5. Seizure precautions-(hypocalcemia)
3. Phosphate binders
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Disease: Hyperparathyroidism
Risk Factors/Causes
1. Chronic kidney failure
Thyroid Disorders
Pathophysiology
The parathyroid gland produces the
parathyroid hormone (PTH) that maintains
the serum calcium level in the body.
Hyperparathyroidism is caused by
hypersecretion of parathyroid hormones.
Signs and Symptoms
1. Hypercalcemia
2. Hypophosphatemia
3. Weight loss
4. High BP (Hypertension)
5. Bone and joint pain
6. Bone deformities
7. Fatigue
8. Cardiac dysrhythmias
9. Kidney stones
Diagnostic Tests
1. Calcium and Phosphate serum levels
2. Patient History
3. Bone X-ray
Nursing Management
Treatment
Pharmacology
1. Calcitonin
2. Bisphosphonates (oral/IV)
3. Furosemide
4. Phosphates
Surgical Intervention
1. Parathyroidectomy
1. Monitor BP
2. Monitor calcium/ phosphorus level
3. Increase fluid intake
4. Promote body alignment
5. Promote safety precautions
6. Administer medications as prescribed
7. Diet: High fiber/ moderate calcium
8. Pre and post operative care
(parathyroidectomy)
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PANCREATIC DISORDERS
TABLE OF CONTENT
1.
Type 1 Diabetes
2.
Type 2 Diabetes
3.
Diabetes Ketoacidosis
4. Hyperosmolar Hyperglycaemic State
5.
Hypoglycemia
6.
Hyperglycemia
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Disease: Type 1 Diabetes
Risk Factors/Causes
1. Autoimmune response
2. Genetics
3. Onset: childhood
Signs and Symptoms
1. Polyuria: increased
urination
2. Polydipsia: Increased
thirst
3. Polyphagia: Increased
appetite
4. Weight loss
5. Hyperglycemia
6. Blurred vision
Treatment
Pharmacology
1. Insulin
Monitoring
1. Continuous glucose
monitoring
Pancreas
Pathophysiology
A chronic condition in which the
pancreas (beta cells) is unable to
produce insulin.
Diagnostic Tests
1. Fasting blood sugar (FBS)
2. Glycated hemoglobin
3. Random blood sugar
4. Urinalysis
Nursing Management
1. Monitor glucose levels
2. Insulin administration
Patient Education
1. Glucose monitoring
2. Insulin administration technique
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Disease: Type 2 Diabetes
Risk Factors/Causes
1. Obesity
2. Sedentary lifestyle
3. Hypertension
4. Hyperglycemia
5. Onset: adulthood
Pancreas
Pathophysiology
Type 2 Diabetes is characterized by
insulin resistance and impaired insulin
secretion.
Complication: Hyperosmolar
Hyperglycaemic State
Signs and Symptoms
1. Polyuria: increased
urination
2. Polydipsia: Increased
Diagnostic Tests
thirst
3. Polyphagia: Increased
1. Fasting blood sugar (FBS)
appetite
2. Glycosylated hemoglobin (HbA1C)
4. Weight gain
3. Random blood sugar
5. Poor wound healing
6. Fatigue
4. Urinalysis
7. Blurred vision
8. Recurrent infections
9. Numbness and tingling of
hands and feet
Nursing Management
10. Dry skin
Treatment
Pharmacology
1. Oral hypoglycemic
medications
2. Insulin
Nonpharmacologic therapy
1. Monitor glucose levels
2. Medication administration
Patient Education
1. Diabetic Diet
2. Exercise
3. Medication adherence
1. Glucose monitoring
2. Dietary plan
3. Exercise regime
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Disease: Diabetic Ketoacidosis (DKA)
Risk Factors/Causes
1. Onset: Sudden
2. Infection
3. Complication of Type 1
Diabetes
Signs and Symptoms
1. Fruity breath
2. Kussmaul's respiration
3. Ketosis
4. Acidosis
5. Electrolyte loss
6. Lethargy
7. Coma
Treatment
1. IV fluid replacement
2. IV insulin: treat
hyperglycemia
3. Correct electrolyte
imbalance: Monitor
potassium levels
Pancreas
Pathophysiology
DKA is a sudden, life-threatening
complication of Type 1 Diabetes.
Characteristics:
1. Hyperglycemia
2. Dehydration
3. Ketosis
4. Acidosis
Diagnostic Tests
1. Serum glucose
2. Serum ketones
3. Osmolarity
4. Electrolyte level
5. BUN level
6. Creatinine level
Nursing Management
1. Monitor glucose levels
2. Administer IV insulin as prescribed
3. Administer IV fluids
4. Monitor potassium levels
5. Monitor cardiac status
6. Monitor signs of increased
intracranial pressure
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Disease: Hyperosmolar Hyperglycaemic State (HHS)
Risk Factors/Causes
Pathophysiology
1. Onset: Gradual
2. Infection
3. Complication of Type 2
Diabetes
Signs and Symptoms
1. Dehydration
2. Hyperglycemia
3. Electrolyte loss
4. Dry skin
5. Lethargy
Treatment
1. IV fluid replacement
2. Insulin: If applicable
3. Correct electrolyte
imbalance
Pancreas
Hyperosmolar Hyperglycaemic State
(HHS) is a complication of Type 2
Diabetes.
Characteristics:
1. Extreme hyperglycemia
2. There is no presence of ketosis or
acidosis
Diagnostic Tests
1. Serum glucose: >800mg/dL
2. Serum ketones: negative
3. Osmolarity
4. Electrolyte level
5. BUN level: elevated
6. Creatinine level: elevated
Nursing Management
1. Monitor glucose levels
2. Administer IV fluids
3. Monitor electrolyte levels
4. Administer insulin if applicable
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Disease: Hypoglycemia
Risk Factors/Causes
1. Too much insulin or
diabetic medication
2. Skipping meals
3. Increased physical
activity
Signs and Symptoms
1. Confusion
2. Palpitations
3. Blurred vision
4. Inability to concentrate
5. Fatigue
6. Body weakness
7. Lightheadedness
8. Diaphoresis
9. Cold and clammy skin
Remember: The symptoms
depends on the level of the
blood glucose.
Treatment
1. Simple carbohydrates
2. Glucagon (IV,IM)
3. 50% Dextrose (IV)
Pancreas
Pathophysiology
Hypoglycemia occurs when there is a
sudden decrease of blood glucose level
<60 mg/dL.
Mild: <60mg/dL
Moderate: <40mg/dL
Severe: <20mg/dL
Diagnostic Tests
1. Serum glucose
2. Physical assessment
Nursing Management
1. Assess glucose level
2. Administer 15g of simple carbohydrates
3. Recheck blood glucose level in 15 minutes
4. Administer 15 g of simple carbohydrates if
necessary.
5. If blood glucose level is still <60mg/dL or in
severe cases (altered LOC): Administer 50%
dextrose (IV)
Unconscious patients:(DO NOT ADMINISTER ORAL
FOOD OR FLUID)
1. Assess glucose level
2. Administer Glucagon (IV,IM) or 50% Dextrose
(IV)
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Disease: Hyperglycemia
Risk Factors/Causes
1. Diet
2. Inactivity
3. Not taking
insulin/diabetic
medication
Signs and Symptoms
1. Polyuria
2. Polyphagia
3. Polydipsia
4. Dehydration
5. Blurred vision
6. Fruity breath
7. Dry skin
Treatment
1. Insulin
2. Glucose monitoring
3. Diabetic diet
Pancreas
Pathophysiology
Hyperglycemia occurs when there is an
increase in blood glucose >200mg/dL
Diagnostic Tests
1. Serum glucose
2. Physical assessment
3. Urinalysis
Nursing Management
1. Assess glucose level
2. Insulin administration as prescribed
Education
1. Educate patient on glucose
monitoring
2. Educate patient on diabetic diet
3. Educate patient on exercise.
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ADRENAL CORTEX DISORDERS
TABLE OF CONTENT
1. Addison's Disease
2.
Cushings
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Disease: Addison's Disease
Risk Factors/Causes
1. Autoimmune disease
Adrenal Cortex
Pathophysiology
Addison's disease is the inadequate
production of steroid hormones by the
adrenal cortex.
Addisonian Crisis: life-threatening
condition. Caused by stress, infection or
surgery.
Signs and Symptoms
1. Weight loss
2. Fatigue
3. Lethargy
4. Hypotension
5. Hyperkalemia
6. Hypercalcemia
7. Hyponatremia
8. Hyperpigmentation
Diagnostic Tests
1. ACTH stimulation test
2. Elevated Potassium, Calcium levels
3. CT Scan
4. MRI
Nursing Management
Treatment
Pharmacology
1. Glucocorticoid
2. Mineralocorticoid
1. Monitor BP
2. Monitor daily weights
3. Monitor intake and output
4. Monitor electrolyte level
5. Monitor glucose level
6. Administer medications as prescribed
Addisonian Crisis:
1. Administer glucocorticoids IV
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Disease: Cushings
Risk Factors/Causes
1. Adrenal tumor
Adrenal Cortex
Pathophysiology
Cushing syndrome is the excessive level of
adrenocortical hormones (cortisol).
Remember: Addison's disease is the
hyposecretion of steroids. Cushing
syndrome is the hypersecretion of steroids.
Signs and Symptoms
1. Moon face
2. Buffalo hump
3. Truncal obesity
4. Hypertension
5. Hyperglycemia
6. Hypernatremia
7. Hypocalcemia
8. Hypokalemia
9. Masculine features
(Hirsutism)
Diagnostic Tests
1. Stimulation test
2. Electrolyte levels
3. CT Scan
4. MRI
Nursing Management
Treatment
1. Chemotherapeutic
agents: for adrenal
tumors
2. Glucocorticoid
replacement: lifelong
1. Monitor BP
2. Monitor daily weights
3. Monitor intake and output
4. Monitor electrolyte level
5. Monitor glucose level
6. Administer medications as prescribed
7. Prepare patient for adrenalectomy if
applicable
Surgical intervention:
1. Adrenalectomy
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PITUITARY GLAND DISORDERS
TABLE OF CONTENT
1. Hypopituitarism
2. Hyperpituitarism
3. Diabetes Insipidus
4.
SIADH
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Disease: Hypopituitarism
Risk Factors/Causes
1. Pituitary tumor
2. Head injury
3. Stroke
4. Autoimmune
5. Encephalitis
Signs and Symptoms
Signs and symptoms depend
on the hormone affected.
Growth Hormones:
1. Obesity, Decreased BP
TSH
1. Obesity, Fatigue,
decrease BP
ACTH
1. Sexual dysfunction
Gonadotropins
1. Sexual dysfunction
ADH
1. Low BP, Decreased CO
Treatment
Pharmacology
1. Hormone replacement
Pituitary
Pathophysiology
Pituitary gland is located at the base of
the brain.
Hypopituitarism is the hyposecretion of
pituitary hormones.
Hormones that may be affected:
1. Growth hormone (GH)
2. Luteinizing hormone (LH) and folliclestimulating hormone (FSH)
3. Thyroid-stimulating hormone (TSH)
4. Adrenocorticotropic hormone (ACTH)
5. Anti-diuretic hormone (ADH)
Diagnostic Tests
1. Blood test: Hormonal level
2. ACTH stimulation test
3. CT Scan
4. MRI
Nursing Management
1. Daily weights
2. Hormonal replacement may be
prescribed
3. Provide emotional support
4. Allow patient to verbalize feelings
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Disease: Hyperpituitarism/ Acromegaly
Risk Factors/Causes
Pathophysiology
1. Pituitary Tumors
Pituitary
Pituitary gland is located at the base of
the brain.
Hyperpituitarism is caused by the
hypersecretion of growth hormone.
Signs and Symptoms
1. Enlarged Organs
2. Large hands and feet
3. Hypertension
4. Cardiomegaly
5. Oily skin
6. Diaphoresis
7. Hyperglycemia
8. Husky-sounding voice
9. Sleep apnea
10. Joint pain
Diagnostic Tests
1. Oral Glucose Tolerance Test
2. IGF-1
3. CT Scan
4. MRI
Nursing Management
Treatment
Pharmacology
1. Growth Hormone
Receptor Antagonist
1. Administer medication
2. Prepare patient for hypophysectomy if
applicable
3. Provide emotional support
4. Pain management
Surgical Intervention
1. Hypophysectomy:
removal of pituitary
tumor
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Disease: Diabetes Insipidus
Risk Factors/Causes
1. Stroke
2. Trauma
3. Craniotomy
Pituitary
Pathophysiology
Diabetes Insipidus is characterized by the
hyposecretion of ADH. This results in
abnormal increase in urine output.
Remember: Antidiuretic hormone (ADH)
causes the kidneys to release less water.
If ADH level is low, there is an increase in
water loss.
Signs and Symptoms
1. Polyuria
2. Diluted urine
3. Dry mucous membranes
4. Postural hypotension
5. Tachycardia
6. Low urinary specific
gravity
7. Headache
8. Body weakness
9. Fatigue
Diagnostic Tests
1. Water deprivation test
2. Increased BUN
3. Low urinary specific gravity
Nursing Management
Treatment
Pharmacology
1. Desmopressin
acetate/Vasopressin
1. Monitor fluids and electrolytes
2. Monitor weights
3. Monitor intake and output
4. Monitor skin integrity
5. Administer hypotonic saline (IV)
6. Administer medications as prescribed
IV Therapy
1. IV hypotonic saline
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Disease: SIADH
Risk Factors/Causes
1. Stroke
2. Trauma
3. Lung disease
Signs and Symptoms
1. Fluid overload
2. Weight gain
3. Hypertension
4. Hyponatremia
5. Tachycardia
6. Concentrated urine
7. Low urinary output
8. Nausea/Vomiting
Treatment
Pharmacology
1. Loop diuretics
2. Vasopressin
antagonists
Pituitary
Pathophysiology
Syndrome of Inappropriate Antidiuretics
Hormone Secretion (SIADH) is the secretion
of ADH in excess levels. This results in
water retention.
Remember: Antidiuretic hormone (ADH)
causes the kidneys to release less water.
If ADH is high, there is an increase in water
retention.
Diagnostic Tests
1. Urine osmorality
2. Serum Sodium levels
Nursing Management
1. Monitor BP/P
2. Monitor serum Na levels
3. Initiate seizure precautions
4. Restrict fluid intake
5. Monitor weights
6. Elevate HOB
7. Administer medications as
prescribed
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SKELETAL DISORDERS
TABLE OF CONTENT
1.
Gout
2. Rheumatoid Arthritis
3. Osteoarthritis
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Disease: Gout
Risk Factors/Causes
1. Diet
2. Obesity
3. Kidney disease
Signs and Symptoms
1. Joint pain (Intense)
2. Inflammation
3. Swelling and redness
4. Low grade fever
5. Pruritus
6. Tophi
Skeletal
Pathophysiology
Gout is a systemic disorder characterized
by elevated uric acid and urate crystals
that accumulate deposits in the joints and
other body tissues.
Stages
1. Asymptomatic stage
2. Acute Gouty arthritis
3. Chronic Gout
Complications: Kidney stones
Diagnostic Tests
1. Uric acid level
2. X-ray imaging
3. Joint fluid test
Treatment
Pharmacology
1. Analgesics
2. Anti-inflammatory
Agents
Nursing Management
1. Assess ROM
2. Diet: low-purine
3. Encourage fluid intake
(2000mL/day)
4. Administer medications
5. Provide comfort and
nonpharmacologic interventions
3. Uricosuric Agents
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Disease: Rheumatoid Arthritis
Risk Factors/Causes
Pathophysiology
1. Higher risk in women
2. Age: Onset is most
frequent between the
ages of 40-50
Skeletal
Rheumatoid Arthritis is an autoimmune
disorder.
The immune system attacks the joints,
leading to dislocation and permanent
deformity.
Signs and Symptoms
1. Joint stiffness
2. Joint tenderness
3. Joint deformity
4. Pain (moderate to
severe)
5. Rheumatoid nodules
6. Fatigue
7. Fever
8. Weight loss
Diagnostic Tests
1. Xray
2. Rheumatoid Factor: Blood test
(Negative or <60 units/mL)
Nursing Management
Treatment
Pharmacology
1. NSAIDs
2. Glucocorticoids
3. DMARDs: Diseasemodifying antirheumatic
drugs
Surgical Intervention
A surgical intervention
would be recommended
to restore function.
1. Assess pain
2. Administer medications as prescribed
3. Assess ROM
4. Provide nonpharmacologic pain
management such as positioning, heat
or cold therapy.
5. Assess and assist patient with self care
6. Promote energy conservation
7. Pre and post operative care if applicable
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Disease: Osteoarthritis
Risk Factors/Causes
1. Aging
2. Obesity
3. Genetics
Signs and Symptoms
1. Joint pain
2. Joint stiffness
3. Crepitus
4. Swelling
5. Limited ROM
Temperature affects
symptom severity.
Treatment
Pharmacology
1. NSAIDs
2. Acetaminophen
3. Muscle relaxant
Therapy
1. Physical therapy
Surgical Intervention:
May be required
Skeletal
Pathophysiology
Osteoarthritis is the most common
form of arthritis.
Osteoarthritis causes deterioration of
joint cartilage.
Diagnostic Tests
1. MRI
2. Joint fluid analysis
Nursing Management
1. Assess pain
2. Administer medications as
prescribed
3. Assess ROM
4. Provide non-pharmacologic pain
management
5. Encourage balance between rest
and physical therapy (low impact
exercises).
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HEMATOLOGY DISORDERS
TABLE OF CONTENT
1. Iron Deficiency Anemia
2. Thrombocytopenia
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Disease: Iron Deficiency Anemia
Risk Factors/Causes
Pathophysiology
1. Diet
2. Blood loss (GI bleeds)
3. Pregnancy
4. Mensuration
5. Inability to absorb iron
Hematology
Iron deficiency anemia is characterized by
insufficient iron which leads to depletion of
red blood cells. This results in decreased
hemoglobin and decreased oxygencarrying capacity of the blood.
Signs and Symptoms
1. Fatigue
2. Pallor
3. Brittle nails
Diagnostic Tests
1. CBC
2. Hematocrit
3. Hemoglobin
4. RBC size: smaller
5. Serum iron levels
6. Stool testing
7. Ferritin
Nursing Management
Treatment
1. Iron supplement
2. Treatment of underlying
cause
3. Diet: Iron-rich foods
1. Administer Iron supplements as
prescribed (Oral, IM or IV)
2. Educate patient on the side effects of
iron supplements: Constipation and black
stools
3. Educate patient on iron-rich diet/foods
4. Educate patient to increase vitamin C
consumption in their diet
5. Educate patient to take liquid iron
supplements with a straw to prevent
teeth staining.
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Disease: Thrombocytopenia
Risk Factors/Causes
Pathophysiology
1. Bone marrow disease
2. Autoimmune disease
3. Splenomegaly
4. Alcoholism
5. Anemia
Signs and Symptoms
1. Easy bruising (Purpura)
2. Petechia
3. Prolonged bleeding time
4. Bleeding gums
5. Epistaxis (Nose bleeds)
6. Blood in urine or stools
7. Heavy menstrual flows
Hematology
Platelets (thrombocytes) stops bleeding by
clumping and forming plugs in the blood
vessel injury site.
Thrombocytopenia is a condition
characterized by low blood platelet count.
Causes:
1. Platelet destruction: autoimmune
2. Platelet sequestration: trapped platelet
in the spleen (enlarged spleen)
3. Decreased platelet production: bone
marrow disease.
Diagnostic Tests
1. Platelet count: <150,000
2. Increase INR & PT/PTT
3. Physical examination and patient
history
Nursing Management
Treatment
1. Platelet transfusions
2. Corticosteroid treatment
3. Bone marrow transplant.
1. Monitor lab values
2. Monitor INR, PT/PTT
3. Use electric razors
4. Avoid anticoagulants, aspirin and
thrombolytics
5. Protect patient from falls/injury
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REPRODUCTIVE DISORDERS
TABLE OF CONTENT
1.
PCOS
2.
Endometriosis
3. Pelvic Inflammatory Disease
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Disease: PCOS
Risk Factors/Causes
1. Excess androgen
2. Heredity
Reproductive
Pathophysiology
Polycystic ovary syndrome (PCOS) is a
hormonal disorder characterized by excess
androgen levels.
The ovaries may develop follicles.
Signs and Symptoms
1. Diabetes
2. Infertility
3. Sleep apnea
4. Irregular periods
5. Polycystic ovaries
Treatment
1. Diet
2. Weight loss
3. Metformin
4. Oral contraceptives
5. Anti-androgens
Diagnostic Tests
1. Pelvic examination
2. Ultrasound
Nursing Management
1. Educate patient on the importance
of
a. Weight loss
b. Low fat diet
c. Medication adherence
d. Glucose monitoring
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Disease: Endometriosis
Risk Factors/Causes
1. No known cause
Reproductive
Pathophysiology
Endometriosis occurs when the tissues
lining the uterus grows outside the uterus.
With endometriosis, the tissues outside
the uterus thickens, breaks down and
bleeds with each menstrual cycle.
Signs and Symptoms
1. Dysmenorrhea
2. Painful intercourse
3. Excessive bleeding
4. Infertility
Diagnostic Tests
1. Ultrasound
2. Laparoscopy
Nursing Management
Treatment
1. Hormone therapy
2. Treatment of anemia
1. Educate patient on
a. Pain management
b. Anemia
c. Hormone therapy
Surgical Intervention
1. Hysterectomy
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Disease: Pelvic Inflammatory Disease
Risk Factors/Causes
Pathophysiology
1. Being sexually active
2. Having multiple
partners
3. Unprotected
intercourse
Signs and Symptoms
1. Fever
2. Pelvic pain
3. Increased vaginal
discharge
Treatment
1. Antibiotics
2. Treatment for partner
3. Temporary abstinence
until treatment is
complete
Reproductive
Pelvic inflammatory disease (PID) is an
infection of the female reproductive
organs
Diagnostic Tests
1. WBC/Urinalysis
2. Medical history
3. Ultrasound
4. Laparoscopy
Nursing Management
1. Educate patient on
a. Antibiotic regimen
b. Protected intercourse
c. Treatment of partner
d. Temporary abstinence
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REPRODUCTIVE DISORDER
TABLE OF CONTENT
1. Varicocele
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Disease: Varicocele
Risk Factors/Causes
1. No known risk factors
Signs and Symptoms
1. Dull pain in scrotum
2. Varicocele may be
visible
3. Swelling
Treatment
Treatment depends on
the severity and
complications
Reproductive
Pathophysiology
Varicocele is the enlargement of the veins
that transport oxygen-depleted blood
away from the testicles.
Diagnostic Tests
1. Physical examination
2. Scrotal Ultrasound
Nursing Management
1. Educate patient to
a. Wear athletic supporter to
relieve pressure
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A Review Guide For Nursing Students
PART 3
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Table of Content
1. integumentary Disorders
2. DISORDERS OF THE EYES
3. dISORDERS OF THE EARS
4. cancers
5. IMMUNE DISORDERS
6. skeletal disorders
7. PERIPHERAL VASCULAR DISORDERS
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INTEGUMENTARY
TABLE OF CONTENT
1.
2.
3.
4.
5.
pressure ulcers
psoriasis
acne vulgaris
skin cancer
frostbite
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Disease: PRESSURE ULCERS
SKIN
Causes/Risk Factors
Pathophysiology
1. Malnutrition
2. Friction
3. Pressure
4. Shear
5. Prolonged immobility
6. Lack of sensory perception
7. Incontinence
Pressure ulcers- skin integrity is impaired
due to prolonged pressure.
Signs and Symptoms
Stage I
Skin remains intact, redness
Stage II
Partial-thickness loss of the
epidermis and some of the dermis
Diagnostic Tests
Stage III
Full-thickness loss of the dermis &
1. Skin assessment
subcutaneous tissue.
Stage IV
Full-thickness loss of the skin
(muscle, bone and tendons are
exposed). Slough, eschar,
undermining and tunneling may
be present.
Suspected Deep-Tissue Injury
Localized area of skin is
discolored. Skin feels "boggy".
Skin is intact but there is ischemic
subcutaneous tissue injury below
skin.
Nursing Management
Unstageable
Full-thickness tissue loss covered Prevention
by eschar/necrotic tissue/slough
1. Assess patients at risk for developing pressure
ulcers
Treatment
2. Assess skin integrity
1. Wound care- to promote 3. Initiate measures to prevent the development
of ulcers: adequate nutrition, positioning and
wound healing
turning immobilized patients every 2 hours,
2. Pain management
passive/active ROM exercises, pressure relief
3. Adequate nutrition
devices, keeping patient skin dry, preventing
wrinkled sheets, using lotions to keep skin
lubricated
Nursing Interventions
1. Assess wound (location, size, type/amount of
exudate, undermining, tunneling)
2. Provide appropriate wound care (wound
dressing, debridement, skin grafting)
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Disease: PSORIASIS
SKIN
Causes/Risk Factors
Pathophysiology
1. Stress
2. Infection
3. Weather
4. Skin injury
5. Autoimmune reaction
A chronic, inflammatory skin disorder
that causes rapid buildup of skin cells.
Signs and Symptoms
1. Itchy skin (Pruritus)
2. Red patches of skin
3. Silvery-white scales
4. Joint pain observed with
psoriatic arthritis
Diagnostic Tests
1. Skin assessment
2. Skin biopsy
Nursing Management
Treatment
Pharmacology
1. Topical Corticosteroids
Patient education
1. Educate patient on medication regimen
2. Educate the patient to avoid scratching
3. Provide emotional support
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Disease: ACNE VULGARIS
Causes
1. Excess sebum
production
2. Bacteria
3. Inflammation
Signs and Symptoms
SKIN
Pathophysiology
A chronic skin disorder characterized
by skin lesions (usually begins at
puberty).
Types
1. Comedones
2. Nodules
3. Papules
4. Pustules
1. Whiteheads (closed
comedones)
2. Blackheads (open
Diagnostic Tests
comedones)
1. Skin assessment
3. Painful, red and pusfilled (Cystic acne)
4. Painful lumps deep
under the skin (nodules)
5. Red small bumps
(papules)
6. Red small bumps with Nursing Management
pus (Pustules)
Patient education
Treatment
Treatment goals:
1. Avoid or lessen skin
damage
2. Acne control
1. Educate patient on the use of
oral and topical medications
2. Educate patient to avoid
squeezing the lesions
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Disease: SKIN CANCER
Causes/Risk Factors
1. Excessive sun exposure
2. Exposure to radiation
3. Family history of skin
cancer
SKIN
Pathophysiology
Skin cancer is the abnormal
(malignant) growth of skin cells.
Types:
1. Basal cell carcinoma
2. Squamous cell carcinoma
3. Melanoma.
Signs and Symptoms
Basal cell carcinoma
1. Pearly, waxy nodule
Squamous cell carcinoma
Diagnostic Tests
1. Red nodule
1. Skin assessment
2. Rough, reddish scaly
2. Skin biopsy
patch
3. Oozing/bleeding
Melanoma
1. Irregular border
2. Color: black, brown,
and tan
Nursing Management
3. Circular
Prevention
1. Educate patient on the causes/risk
Treatment
factors
Surgical interventions:
2. Educate patient on preventative
1. Cryosurgery
practices (sunscreen, wearing
2. Curettage
protective clothing, self assessment
3. Electrodesiccation
and reporting skin changes)
4. Excisional surgery
Other nursing interventions:
1. Provide nursing care for surgical/
nonsurgical interventions
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Disease: FROSTBITE
Causes
1. Cold weather
Signs and Symptoms
First-degree
Skin redness + edema
Second-degree
Fluid-filled blisters
Third-degree
Blood-filled blisters +
eschar formation
Fourth-degree
Full-thickness necrosis
Treatment
1. Rewarming of the skin
2. Protecting skin- sterile
dressing applied loosely
SKIN
Pathophysiology
Skin cell and tissue damage caused
by prolonged exposure to extreme
low temperatures.
Areas mostly affected:
1. Fingers
2. Toes
3. Nose
4. Ears
Diagnostic Tests
1. Skin assessment
Nursing Management
1. Rewarming the area affected
2. To prevent tissue damage, avoid
massaging the area
3. Monitor for signs of complications
(compartment syndrome)
4. Administer medications
Pharmacology
1. Analgesics
2. Tetanus prophylaxis
Patient education
3. Antibiotics
Other treatment depending on
1. Educate patient on preventative
severity:
practices
1. Debridement
2. Amputation
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EYES
TABLE OF CONTENT
1.
2.
3.
4.
legal blindness
cataract
glaucoma
retinal detachment
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EYES
Disease: LEGAL BLINDNESS
Causes/Risk Factors
1. Eye trauma
2. Diabetic retinopathy
3. Cataracts
4. Glaucoma
5. Age (macular
degeneration)
Pathophysiology
Vision is 20/200 or less in the better eye
or field of vision is less than 20 degrees.
Signs and Symptoms
1. Inability to see (Vision is
20/200 or less in the
better eye or field of
vision is less than 20
degrees)
Diagnostic Tests
1. Visual acuity test
2. Visual field test
Nursing Management
Treatment
1. Patient education on
adaptive products and
learning new skills
1. Orient the patient to the environment
(using a focal point and allowing the
patient to touch objects)
2. Speak to the patient in a normal tone
3. Ensure that you alert the patient when
approaching (and introduce yourself)
4. Assess patient's level of independence
5. Educate patient on the proper use of a
cane
6. Assist patient during ambulation
7. Provide emotional support
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EYES
Disease: CATARACTS
Causes
1. Congenital cataracts
2. Traumatic cataracts-due to
injury
3. Senile cataracts- due to
age
4. Secondary cataractsarising from another eye
disease
Signs and Symptoms
Early signs
1. Blurred vision
Late signs
1. Double vision
2. White pupils
3. Vision loss-gradual
Pathophysiology
Cataract is the clouding or opacity of
the lens of eye.
Diagnostic Tests
1. Visual acuity test
2. Retinal exam
3. Slit Lamp
Nursing Management
Treatment
1. Cataract surgery
Preoperative Medications
1. Cycloplegics & Mydriatics
(ophthalmic medications
that are used to dilate
the pupil)
Postoperative medications
1. Antibiotic eye drops
2. NSAID eye drops
1. Assess patient's visual acuity
2. Prepare patient for cataract surgery
Medications: Cycloplegics & Mydriatics
3. Postoperative care:
Position: Semi-Fowler's
Assist patient during ambulation
Provide patient safety
Maintain eye patch
4. Patient education
Avoid lifting heavy objects
Avoid eye straining & pressure
Prevent constipation
Medication adherence (eye drops)
The use of sunglasses
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EYES
Disease: GLAUCOMA
Risk Factors
1. >60 years of age
2. Family history
3. increased IOP
4. Diabetes, HTN
Signs and Symptoms
Open-angle glaucoma
1. No pain
2. Tunnel vision
Closed-angle glaucoma
1. Eye pain
2. Blurred vision
3. Eye redness
4. Halos around lights
Other s/s
1. Increased IOP
Treatment
Glaucoma damage cannot be
reversed.
The treatment goal is to
1. prevent complication (vision loss)
and
2. lower intraocular pressure
Pharmacology
a. Miotics: cause the pupil to
constrict
b. Beta-blockers: decrease IOP
c. Carbonic anhydrase
inhibitors: reduce the
production of fluid in the eye
Surgical Management
1. Trabeculectomy
Pathophysiology
Glaucoma (a group of eye diseases) is characterized
by increased intraocular pressure (IOP) and
subsequently, damage to the optic nerve.
In glaucoma, there is fluid buildup which causes
increased eye pressure (due to inadequate
drainage of aqueous humor or overproduction of
aqueous humor)
Normal eye pressure (IOP): 10-21 mm Hg
Complication: blindness
Types:
1. Open-angle glaucoma: most common
2. Closed-angle glaucoma- AN EMERGENCY
Diagnostic Tests
1. Tonometry: to measure IOP
2. Visual acuity test
3. Gonioscopy: observe drainage
angle
4. Pachymetry: measure the
thickness of the eye's cornea.
Nursing Management
1. Educate patient of the importance of
medication adherence (life-long use)
2. Educate patient to avoid
Anticholinergic medication
3. Educate patient to report any vision
changes + other developing symptoms
4. Remember to treat closed-angle
glaucoma as a medical emergency
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Disease: RETINAL DETACHMENT
Causes/Risk Factors
1. Trauma
2. Hemorrhage
3. Aging
4. Family history
5. Myopia
EYES
Pathophysiology
Retinal detachment is the separation of
the retina from the epithelial layer.
Complete retinal detachment results in
blindness.
Signs and Symptoms
1. Blurred vision
2. Photopsia- flashes of
light
3. Floating spots
4. The feeling of curtainlike shadow blocking
portion of the visual
5. Loss of peripheral vision
Diagnostic Tests
1. Retinal examination
Nursing Management
Treatment
Surgical management:
The goal is to repair the
retina detachment.
The surgical interventions
include:
1. Scleral buckling
2. Laser surgery
3. Cryosurgery
4. Diathermy
1. Providing a calm environment
2. Encouraging bed rest
3. Patch both eyes as prescribed
4. Ensure patient safety
5. Patient education: avoid touching the
eyes, medication adherence, avoid
straining activities
Postoperative management
1. Patch both eyes as prescribed
2. Monitor for any complications
3. Encourage bed rest
4. Prevent straining activities that can
increase IOP
5. Educate patient to follow up & at home
eye care
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EARS
TABLE OF CONTENT
1.
2.
3.
Otitis media
External otitis
Meniere's Disease
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EARS
Disease: OTITIS MEDIA
Causes/Risk Factors
1. Age (children)
2. Infant feeding (Bottlefed)
Pathophysiology
Otitis media is an
infection/inflammation of the middle
ear (common among children)
Signs and Symptoms
1. Ear pain
2. Fever
3. Fluid drainage from
ears
4. Loss of balance
Diagnostic Tests
1. Ear examination using an
otoscope
5. Hearing difficulties
2. Pneumatic otoscope
6. Tugging on ear
3. Tympanometry
(children)
7. Irritability (children)
Treatment
1. Pain management
2. Antibiotic therapy
Nursing Management
1. Position child sitting upright
(Fowler's) or on unaffected side
2. Encourage mothers to breastfeed
baby
3. For bottle-fed babies, educate
mother to position baby upright
during feeding
4. Educate mother/adult patient on
antibiotic therapy adherence
5. Monitor for signs of complications
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EARS
Disease: EXTERNAL OTITIS
Causes/Risk Factors
1. Age (common in children)
2. Allergies
3. Skin conditions (eczema
or psoriasis)
4. Injury to ear
5. Irritants: hair spray, etc
Pathophysiology
Infection of the structure of the
external ear canal (common among
children)
Signs and Symptoms
1. Pain
2. Redness
3. Edema
4. Ear Tenderness
Diagnostic Tests
1. Ear inspection
5. Blocked ear
6. Itching
7. Exudate
Nursing Management
Treatment
Pharmacology
1. Antibiotics
2. Corticosteroids
3. Analgesics
1. Administer medications as prescribed
2. Provide a calm environment & promote
rest.
3. Provide non-pharmacologic pain
management (apply heating pad to
affected ear)
4. Educate patient to avoid irritants
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EARS
Disease: MENIERE'S DISEASE
Causes/Risk Factors
1. The cause is unknown
2. Infection
3. Genetics
Pathophysiology
Meniere's disease is a disorder of the
inner ear caused by the
overproduction or decreased
absorption of endolymphatic fluid.
Signs and Symptoms
Major Signs and Symptoms
1. Vertigo-dizziness
2. Uni-lateral
sensorineural hearing
loss
3. Tinnitus-ringing in the
Diagnostic Tests
1. Medical history to assess the
signs and symptoms
2. Audiometric testing
ear
Other Signs and Symptoms
1. Headaches
2. Nausea and vomiting
Treatment
There is no cure. Care provided is
supportive.
Pharmacology:
1. Antihistamines
2. Diuretics
3. Antiemetics
4. Tranquilizers 5. Anticholinergics
Diet:
1. Low salt diet
Surgical Management:
1. Labyrinthectomy
2. Endolymphatic sac, or shunt,
surgery
Nursing Management
1. Provide patient safety
2. Provide a calm environment and bed
rest
3. Administer prescribed medications
(see treatment)
4. Low salt diet and fluid restriction as
prescribed
5. Provide pre and post operative care
Patient Education
1. Low salt diet
2. Avoid alcohol, smoking and caffeine
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CANCER
TABLE OF CONTENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
cancer
pain
breast cancer
endometrial cancer
ovarian cancer
cervical cancer
testicular cancer
prostate cancer
bladder cancer
pancreatic cancer
gastric cancer
lung cancer
leukemia
lymphoma
multiple myeloma
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Disease: CANCER
CANCER
Risk Factors/Causes
Pathophysiology
1. Genetics
2. Prolonged sun exposure
3. Diet
4. Smoking
5. Chemical + radiation
6. Pollutants
7. Or no known cause
Cancer is characterized by abnormal
growth of cells (cells mutate + change in
their morphology), whereby it
proliferates and can metastasize.
Signs and Symptoms
1. C-hanges in bladder or
bowel
2. A-sore that doesn’t heal
Diagnostic Tests
3. U-nusual bleeding or
1. Biopsy
discharges
4. T-hickening or lumps
2. Physical examination
5. I-ndigestion
3. Imaging: CT scan, MRI, Ultrasound
6. O-bvious changes in the
skin
4. Lab test: Urinalysis, CBC
7. N-agging cough or
hoarseness
8. U-nexplained anemia
Nursing Management
9. S-udden weight loss
1. Initiate infection control
2. Treatment of nausea and vomiting
Treatment
3. Patient education on surgical and non
1. Chemotherapy
surgical interventions
2. Radiation therapy
4. Monitor adverse effects of
3. Surgery
chemotherapy and radiation therapy
4. Hormone therapy
5. Pre and post operative care
6. Provide emotional support
7. Pain management
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Disease: PAIN
CANCER
Risk Factors/Causes
Pathophysiology
1. Inflammation
2. Psychological factors
3. Compression of nerves
4. Obstruction of an organ
According to the International
Association for the Study of Pain, pain is
an unpleasant, subjective sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage.
Signs and Symptoms
The best indicator of pain is
through verbalization since it
is a subjective experience
Diagnostic Tests
1. Pain assessment tools
Behavioral & Physiologic
Indicators of Pain
1. Facial grimace
2. Crying/screaming
3. Clench eyes
4. Guarding
5. Vital signs: Increased HR, Nursing Management
1. Assess pain
BP, RR
Treatment
Treat the underlying cause
of pain.
2. Assess the underlying cause of pain
3. Provide pharmacologic pain
management as prescribed
(analgesics, opioids)
4. Non-pharmacologic pain management
a. Physical- positioning
b. Environmental- dimming lights,
providing a calm environment
c. Cognitive technique- Guided
imagery
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Disease: BREAST CANCER
Risk Factors/Causes
1. Age (older women)
2. Gender-women
3. Family history of
breast cancer
CANCER
Pathophysiology
Breast cancer is the most common type
of cancer diagnosed among women.
Breast cancer common sites of
metastasis are the lungs, bone, liver,
and the brain.
Signs and Symptoms
1. Mass-firm irregular mass
that is painless (located
in the upper outer
Diagnostic Tests
quadrant of the breast)
1. Breast examination
2. Asymmetry of the breast
3. Nipple discharge (blood
2. Mammography
or clear)
3. Breast biopsy
4. Lymphedema
5. Skin changes over the
breast- dimpling
6. Scaling & peeling of the
skin around areola
Nursing Management
7. Orange skin over breast
1. Patient education on surgical and non
Treatment
Early detection:
1. Patient education on
Breast-self examination
Other interventions:
1. Chemotherapy
2. Radiation therapy
Surgical Interventions:
1. Lumpectomy
2. Mastectomy
3. Mammoplasty
surgical interventions
2. Monitor adverse effects of chemotherapy
and radiation therapy
3. Provide emotional support
For postoperative interventions
1. Monitor vital signs
2. Encourage deep breathing and coughing
3. Monitor for signs of infection
4. Drainage management if any
5. Patient education: home care and follow
up care
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Disease: ENDOMETRIAL CANCER
Risk Factors/Causes
1. Older age
2. Obesity
3. Family history of
endometrial cancer
4. Hormone therapy
5. Polycystic ovary disease
Signs and Symptoms
1. Postmenopausal
bleeding
2. Pelvic pain-late sign
3. Enlarged uterus
4. Vaginal discharge
CANCER
Pathophysiology
Cancer of the uterus. Endometrial
cancer begins from the endometrium
of the uterus.
Common sites of metastasis: ovaries,
pelvis, lungs, liver and bone.
Diagnostic Tests
1. Endometrial biopsy
2. Hysteroscopy
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
3. Hormone therapy
Surgical Intervention:
1. Total abdominal
hysterectomy (removal of
the uterus) and bilateral
salpingo-oophorectomy
(removal of both of the
fallopian tubes and ovaries)
1. Patient education on surgical and non
surgical interventions
2. Providing emotional support
3. Pre and post operative care
4. Patient education: home care and
follow up plan
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Disease: OVARIAN CANCER
Risk Factors/Causes
1. Older age
2. Family history
3. Endometriosis
4. Obesity
Signs and Symptoms
1. Abdominal swelling
2. Abdominal
discomfort
3. Constipation (and
other GI
disturbances)
4. Weight loss
CANCER
Pathophysiology
Ovarian cancer arises from the ovaries
and has a higher mortality rate.
Ovarian cancer grows rapidly and
spreads quickly.
Diagnostic Tests
1. Elevated CA-125 (tumor marker)
2. Exploratory laparotomy
3. Transvaginal ultrasound
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
Surgical Intervention:
1. Total abdominal
hysterectomy and
bilateral salpingooophorectomy
Palliative care
1. Patient education on surgical and non
surgical interventions
2. Providing emotional support
3. Pre and post operative care
4. Supportive and palliative care
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Disease: CERVICAL CANCER
Risk Factors/Causes
1. HPV-Human
papillomavirus
2. Early sexual activity
3. Smoking
4. Multiple sexual partners
Signs and Symptoms
1. Vaginal discharge
(foul odor)
2. Painful urination
(Dysuria)
3. Blood in urine
(hematuria)
4. Pelvic pain
5. Weight loss
CANCER
Pathophysiology
The cervix connects the vagina and
uterus. Cervical cancer arises from the
cervix.
Common sites of metastasis is confined
in the pelvis or can occur via lymphatic
spread
Diagnostic Tests
Screening:
1. Pap test
Diagnostic tests
1. Colposcopic examination
2. Biopsy
Nursing Management
1. Patient education on surgical and non surgical
interventions
2. Providing emotional support
Treatment
1. Chemotherapy
3. Pre and post operative care
2. Laser therapy
Hysterectomy
3. Radiation
1. Monitor vital signs
4. Cryosurgery
2. Encourage patient to perform deep breathing
Surgical Management
exercises
1. Hysterectomy-removal of the
3. Monitor vaginal bleeding
uterus
2. Conization- removal of the
Pelvis exenteration
cylindrical part of the cervix
1. Educate patient on ileal conduit and
3. Pelvis exenteration-removal of
organs from the urinary,
colostomy
gastrointestinal, and
2. Sexual counseling
reproductive system.
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Disease: TESTICULAR CANCER
Risk Factors/Causes
1. History of cryptorchidism
2. Age (men between 1535)
3. Family history
Signs and Symptoms
1. Swelling of the
testicles
2. The sensation of
heaviness in the
scrotum
Late signs
1. Abdominal mass
2. Respiratory
symptoms
3. Bone pain
Treatment
1. Chemotherapy
2. Radiation therapy
Surgical Management
1. Radical inguinal
orchiectomy- removal of a
testicle
2. Retroperitoneal lymph
node dissection- removal
of lymph nodes
CANCER
Pathophysiology
Testicular cancer arises from the
testicles.
Common sites of metastasis: liver,
lungs, bone and adrenal glands.
Diagnostic Tests
Early detection:
1. Testicular self-examination
Diagnostic tests:
1. Testicular ultrasound
2. Blood test- determine levels of tumor
markers
Nursing Management
1. Patient education on surgical and non surgical
interventions
2. Providing emotional support
3. Pre and post operative care
Post operative care
1. Monitor vital signs
2. Monitor for signs of bleeding
3. Monitor for signs of infection
4. Pain management
Patient education
1. Reproductive health/options
2. Avoid heavy lifting
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Disease: PROSTATE CANCER
Risk Factors/Causes
1. Age (>50)
2. Family history
3. Smoking
4. Hx of STI
Signs and Symptoms
1. Hematuria
2. Nocturia
3. Urinary retention
4. Increased urinary
frequency
5. Urinary hesitancy
CANCER
Pathophysiology
Prostate cancer is cancer that occurs in
the prostate.
Common sites of metastasis:
surrounding tissues + through the
lymphatics and blood vessels (bone,
liver, lungs & kidneys).
Diagnostic Tests
1. Digital rectal exam
2. Prostate-Specific Antigen will be
elevated (but also in BPH. Further
testing needs to be done)
3. Transrectal ultrasound
4. Biopsy of prostate gland
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
3. Hormone therapy
Surgical Management
1. Prostatectomy
2. Orchiectomy- removal of
testicles
1. Monitor urinary output (red to light pink
urine would be seen for 24 hours) + monitor
for excessive bleeding
2. Monitor vital signs
3. Encourage increase fluid intake
2000mL/day to 3000 mL/day
4. Maintain continuous bladder irrigation-as
indicated
5. Medications such as antibiotics & analgesics
should be administered as prescribed.
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Disease: BLADDER CANCER
Risk Factors/Causes
1. Family history
2. Smoking
3. Older age
4. Gender-males
Signs and Symptoms
1. Hematuria
2. Painful urination
(Dysuria)
3. Urinary frequency
4. Urinary hesitancy
CANCER
Pathophysiology
Papillomatous growth in the bladder
urothelium that progress to
malignancy.
Common sites of metastasis: bone,
liver & lungs
Diagnostic Tests
1. Cystoscopy
2. Biopsy
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
Surgical Management
1. Transurethral resection of
bladder tumor (TURBT)
2. Cystectomy
3. Ileal conduit
4. Neobladder reconstruction
5. Kock pouch
6. Indiana pouch
7. Ureterostomy
8. Vesicostomy
1. Provide preoperative care
2. Educate patient on the post surgical
interventions.
Postoperative care
1. Assess: stoma, incision site, bowel
function
2. Monitor: urinary output, vital signs, signs
of complication (shock, hemorrhage,
peritonitis), skin integrity around
drainage
3. Notify physician: necrosis of the stoma,
urine output is less than 30mL/hr
4. Maintain NPO status as prescribed
5. Provide emotional support
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Disease: PANCREATIC CANCER
Risk Factors/Causes
1. Diabetes
2. Smoking
3. Older age
4. Family history
Signs and Symptoms
1. Jaundice
2. Weight loss
3. Abdominal pain
4. Stools- clay colored
5. Urine- dark colored
6. Nausea and vomiting
Poor prognosis
CANCER
Pathophysiology
Pancreas cancer arises from the
pancreatic tissues (pancreatic ductal
adenocarcinoma- the most common
type of pancreatic cancer)
Diagnostic Tests
1. Elevated tumor marker- CA19-9
2. An endoscopic ultrasound
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
Surgical Management
1. Pancreaticoduodenectomy
-Whipple procedure
1. Provide preoperative care
2. Educate patient on the post surgical
interventions.
Postoperative care
1. Monitor blood glucose levels
2. Pain management
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Disease: GASTRIC CANCER
Risk Factors/Causes
1. H. pylori infection
2. Smoking
3. Gastric ulcers/gastritis
4. Alcohol
5. Men
6. Diet
CANCER
Pathophysiology
Gastric cancer is the malignant growth
of cells in the stomach.
Complications
1. Dumping syndrome
2. Hemorrhage
3. Metastasis
Signs and Symptoms
Initial symptoms
1. Dyspepsia
2. Gastric fullness/bloated
Diagnostic Tests
3. Epigastric pain
1. Endoscopy
4. Indigestion
2. Biopsy
Late symptoms
1. Weight loss
2. Nausea/vomiting
3. Body weakness
4. Gastric obstruction
Nursing Management
5. Ascites
1. Monitor: VS, hematocrit and
hemoglobin
Treatment
2. Administer vitamin supplements
1. Chemotherapy
3. Pain management
2. Radiation therapy
Postoperative management
3. Palliative care
1. Position: Fowler's
2. Administer parenteral Nutrition as
Surgical Management
prescribed
1. Gastrectomy
3. Monitor : NG suction, intake and
output
4. Maintain NPO status
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Disease: LUNG CANCER
Risk Factors/Causes
1. Smoking
2. Air pollutant
3. Family history
Signs and Symptoms
1. Cough
2. Dyspnea
3. Wheezing
4. Blood-tinged sputum
5. Weight loss
6. Decreased breath
sounds
7. Fatigue/body weakness
8. Chest pain
9. Hoarseness
Treatment
1. Chemotherapy
2. Radiation therapy
3. Oxygen therapy
Pharmacology- analgesics,
expectorants, bronchodilators,
corticosteroids
Surgical Management
1. Laser therapy
2. Thoracentesis- to remove pleural
fluid
3. Pneumonectomy-removal of an
entire lung
4. Lobectomy-removal of the entire
lobe of one lung
5. Segmental resection
CANCER
Pathophysiology
Lung cancer is also known bronchogenic
cancer. Bronchogenic cancer originate
in the epithelium of the bronchus.
Types:
1. Squamous cell
2. Adenocarcinoma
3. Small cell lung cancer (SCLC)
4. Non-small cell lung cancer (NSCLC)
Diagnostic Tests
1. Chest x-ray
2. CT scan
3. MRI
4. Fiberoptic bronchoscopy
5. Sputum cytology
6. Biopsy
Nursing Management
1. Maintain patent airway
2. Assess respiratory status
3. O2 therapy
4. Positioning: Fowler's
5. Administer medications
6. Diet: high-protein, high-calorie diet.
7. Provide a calm environment
Postoperative management
1. Maintain patent airway
2. Monitor vital signs and respiratory status
3. Chest tube management
4. O2 therapy
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Disease: LEUKEMIA
Risk Factors/Causes
1. No known cause
2. Risk factors: genetics,
exposure to chemicals
Signs and Symptoms
1. Fever & frequent
infections
2. Easy bleeding and
bruising
3. Petechiae
4. Anemia
5. Pallor, body weakness,
fatigue and weight loss
6. Enlarged liver, spleen
and lymph nodes
7. Tachycardia,
hypotension, dyspnea
8. Bone pain
Treatment
1. Chemotherapy
2. Radiation therapy
3. Transfusions of red
blood cells and platelets
4. Bone marrow transplant
Pharmacology
1. Antibiotics, antifungal
and antiviral
CANCER
Pathophysiology
Leukemia is a type of cancer that affects the white
blood cells and the bone marrow due to the abnormal
overproduction of leukocytes.
Because leukemia affects the bone marrow, there is an
underproduction of red blood cells, platelets (and
overproduction of immature leukocytes). This therefore
causes anemia, leukopenia, thrombocytopenia and
increased risk for infections due to low immunity.
Types of leukemia:
1. Lymphocytic
2. Myelocytic/myelogenous
Classification
1) Acute Lymphocytic Leukemia 2) Acute Myelogenous
Leukemia 3) Chronic Myelogenous Leukemia 4) Chronic
Lymphocytic Leukemia
Diagnostic Tests
1. CBC
2. Bone marrow aspiration and biopsy
Nursing Management
Infection
1. Initiate infection precautions
2. Care for patient in a private room (protective
isolation)
3. Hand washing and strict aseptic technique
4. Monitor for signs of infection
5. Avoid invasive procedures
6. Avoid constipation, diarrhea and rectal trauma
7. Administer antimicrobials
Bleeding
1. Monitor for signs of bleeding
2. Monitor lab values
3. Administer blood components
4. Ensure patient's safety
Nutrition
1. High calorie, high carbohydrates and high
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Disease: LYMPHOMA
Risk Factors/Causes
1. Viral infection
2. Family hx
CANCER
Pathophysiology
Two types of lymphomas: Hodgkin's and
non-Hodgkin's
Lymphoma- cancer of the lymph nodes
and lymphocytes
Signs and Symptoms
1. Enlarged lymph nodes,
spleen and liver
2. Fever + chills
3. Night sweats
4. Weight loss
Spreads through the lymphatic system
involving the lymph nodes, spleen and
then through the blood stream.
Diagnostic Tests
1. Lymph node biopsy- shows the
presence of Reed-sternberg giant
cell
2. CT scan
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
1. Initiate infection & bleeding
precautions
2. Monitor side effects due to
chemotherapy and radiation therapy
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Disease: MULTIPLE MYELOMA
Risk Factors/Causes
1. No known cause
2. Risk: Family hx
Signs and Symptoms
1. Bone pain
2. Osteoporosis
3. Thrombocytopenia (low
platelet count)
4. Leukopenia (low white
blood cell count)
5. Anemia
6. Frequent infections
7. Fatigue
CANCER
Pathophysiology
Multiple myeloma is characterized by
cancerous plasma cells that accumulate
within the bone marrow.
The accumulation of plasma cells in the
bone marrow causes decrease
production of immunoglobulin and
antibodies.
The cancerous plasma cells produces
abnormal proteins.
Diagnostic Tests
1. Blood tests
2. Urinalysis: shows Bence Jones
proteinuria
3. Bone marrow aspiration
4. Elevated calcium and uric acid
Nursing Management
Treatment
1. Chemotherapy
2. Radiation therapy
3. Blood transfusion
Pharmacology
1. Antibiotics
2. Analgesics
3. Diuretics: increase the
excretion of Ca
4. Bisphosphonate: slow down
or prevent bone loss
1. Ensure patient's safety: monitor for
skeletal fractures (provide skeletal
support)
2. Initiate infection & bleeding precautions
3. Increase fluid intake
4. Administer medications (see treatment)
Patient education
1. Signs and symptoms of an infection
2. Safety measures at home to prevent
fractures.
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IMMUNE
TABLE OF CONTENT
1.
Allergy
2. Systemic Lupus Erythematosus (SLE)
3.
Goodpasture's Syndrome
4.
hiv/AIDS
5.
Fever
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IMMUNE
Disease: ALLERGY
Causes/Risk Factors
1. Drugs
2. Food
3. Insect
4. Airborne (pollen)
5. Latex
Signs and Symptoms
1. Hives
2. Itching skin
3. Sneezing
4. Wheezing
5. Tearing, red or swollen
eyes
Pathophysiology
Allergy: An immune response to a
foreign substance that triggers a
reaction.
Latex allergy: hypersensitivity to
latex
Anaphylactic shock: occurs due to a
severe allergic reaction (drugs, food,
insect bite, etc)
Diagnostic Tests
1. Skin test
2. Blood test
3. History taking
6. Swelling of the lips,
tongue, face or throat
Nursing Management
Treatment
Pharmacology
1. Antihistamines
2. Corticosteroids
3. Anti-inflammatory
agents
Anaphylaxis:
1. Epinephrine
1. Identify and remove allergen
2. Maintain patent airway
3. Administer medications (see treatment)
Anaphylactic Reaction
1. Remove allergen, maintain patent
airway
2. Monitor vital signs
3. Administer epinephrine promptly
4. Initiate 02 therapy
5. Initiate IV therapy & monitor urine
output
6. Position: supine position with leg
elevated
Patient education
1. Educate patient to avoid allergen
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Disease: Systemic Lupus Erythematosus (SLE)
Causes/Risk Factors
1. No known cause
Risk factors:
1. Genetics
2. Environmental
3. Hormonal
4. Medications
IMMUNE
Pathophysiology
Systemic Lupus Erythematosus (SLE) is
a chronic, inflammatory autoimmune
disease where the body attacks
healthy tissues.
Signs and Symptoms
1. Butterfly rash on the
face
2. Joint pain/swollen joints
Diagnostic Tests
3. Fever
1. Positive antinuclear antibody (ANA)
4. Fatigue
2. Elevated erythrocyte
5. Sensitivity to sunlight
sedimentation rate and C-reactive
6. Weight loss
protein level
7. Hair loss
3. CBC
8. Chest pain when
4. Urinalysis
breathing
9. Edema
Nursing Management
10. Raynaud’s phenomenon
1. Monitor skin integrity, signs of bruising and
bleeding, intake and output, signs of
complications, BUN and creatinine
Treatment
2. Encourage deep breathing exercises.
There is no cure for SLE. The goal is to
control symptoms and provide
3. Pain management (pharmacologic and nonsupportive care when major organs
pharmacologic management).
are affected.
4. Administer medications (see treatment)
Pharmacology
5. Diet: high-iron, high-protein (unless
1. NSAIDs
2. Topical corticosteroids
contraindicated)
3. Systemic Corticosteroids
6. Provide emotional support
4. Immunosuppressants (for serious
Patient Education
cases)
5. For anemia: iron, folic acid
1. Avoid prolong exposure to sunlight
6. Antimalarials
2. Healthy diet
(Hydroxychloroquine)
3. Adequate rest
Pain management
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Disease: Goodpasture's Syndrome
Causes/Risk Factors
1. No known cause
Risk factors:
1. Genetics
2. Environmental factors
IMMUNE
Pathophysiology
Goodpasture's syndrome is a rare,
autoimmune disease that forms
autoantibodies and attack the
basement membranes of the lungs and
kidneys.
Signs and Symptoms
Lung-related symptoms:
1. Shortness of breath
2. Cough
3. Chest pain
4. Hemoptysis (coughing up
blood)
Kidney-related symptoms
1. Edema
2. Weight gain
3. Oliguria
4. Hematuria
5. Increased BP
6. Increased HR
Treatment
Pharmacology
1. Corticosteroids
2. Immunosuppressant drugs
Plasma exchange
(plasmapheresis)
Diagnostic Tests
1. Serum anti-GBM antibody tests
2. Urinalysis
3. CT scan, chest X-ray
4. Bronchoscopy
5. Kidney biopsy
Nursing Management
1. Monitor respiratory status
2. Elevate head of bed
3. Oxygen therapy as prescribed
4. Deep breathing exercises
5. Administer medications as prescribed
6. Monitor weights and I/O, creatinine
and BUN
7. Diet: low protein diet
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IMMUNE
Disease: HIV/AIDS
Causes/Risk Factors
Pathophysiology
High risk groups:
1. Use of IV drugs
2. Multiple sexual
partners + unprotected
sex
3. Receiving blood
products
Acquired immunodeficiency syndrome
(AIDS) is a chronic illness caused by the
human immunodeficiency virus (HIV) which
attacks the T cells.
Signs and Symptoms
Primary infection (Acute HIV)
Two to four weeks (up to 3
months)
1. Flu-like illness
Clinical latent infection (Chronic
HIV)
1. Infected person do not have
any symptoms of HIV
infection (can last for 10
years or longer)
Progression to AIDS
1. Fever, weight loss, fatigue
2. Night sweats, chills, swollen
lymph nodes
3. Diarrhea, nausea & vomiting
4. Opportunistic Infections
Treatment
Mode of transmission:
1. Sexual contact
2. Blood and blood products (& sharing of
needles)
3. Mother to baby- preventive treatment
to reduce the risk of transmission.
Diagnostic Tests
1. ELISA Test & Western Blot
2. Viral load: polymerase chain
reaction (PCR)
3. T lymphocyte and B lymphocyte
subsets; CD4 counts, CD4
percentages
Nursing Management
1. Provide respiratory support (monitor
respiratory status + O2 therapy)
2. Initiate protective isolation
precautions
3. Practice universal/standard precaution
4. Provide emotional support
Pharmacology
1. Anteroviral drugs
a. Reverse
trancriptase
inhibitors
Patient Education
b. Protease inhibitors
1. Proper nutrition
2. Compliance to treatment
3. Skin care
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IMMUNE
Disease: Fever
Causes/Risk Factors
1. Infections
2. Inflammatory diseases
3. Prolong exposure to
hot environment (may
cause hyperthermia)
Signs and Symptoms
1. Temperature: >38.0
(degrees celsius)
2. Skin: warm, flushed
3. Lethargy
4. Chills
5. Sweating
6. Malaise
Pathophysiology
Fever is the elevation in body
temperature.
Temperature:
Normal: 36.4-37.0 (degrees
celsius)
Fever: >38.0 (degrees celsius)
Diagnostic Tests
1. Increased temperature
2. High White Blood Cell Count (due
to an infection)
Nursing Management
Treatment
Treat underlying cause
(infection)
Pharmacology
1. Antipyretics
1. Monitor temperature
2. Assess and treat underlying cause
3. Non-pharmacologic management:
remove excess clothing, cooling
measures, sponge bath.
4. Increase fluid intake
5. Medications: Antipyretics
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MUSCULOSKELETAL DISORDERS
TABLE OF CONTENT
1.
2.
3.
4.
Osteoporosis
STRAINS
SPRAINS
FRACTURES
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MSD
Disease: Osteoporosis
Causes/Risk Factors
1. Gender: among
postmenopausal women
2. Age
3. Family history
4. Low calcium intake
5. Sedentary lifestyle
6. Smoking
Signs and Symptoms
1. Asymptomatic during
early stages
2. Back & hip pain
3. Decline in height
4. Kyphosis of the dorsal
Pathophysiology
Osteoporosis- a metabolic disorder
that is defined as bone
demineralization.
Bone mass decreases- which causes
the bone to become porous & fragile
(risk for fractures).
Diagnostic Tests
1. Bone mineral density (BMD)
2. Bone x-rays
3. Serum calcium level
spine
Nursing Management
Treatment
1. Ensure patient safety
2. Move patient gently when
repositioning
3. Encourage ROM exercises
4. Diet- high in calcium, vitamin D, protein
and iron
5. Administer medications (see treatment)
1. Diet- increased calcium
and vitamin D
Pharmacology
1. Calcium supplements
2. Bone resorption inhibitor
Patient education
3. Analgesics
1. Proper body mechanics
2. The use of assistive devices
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Disease: STRAINS
Causes/Risk Factors
1. Poor body mechanics
2. Higher risk among
athletes
Signs and Symptoms
1. Ecchymoses (bruising)
2. Pain or tenderness
3. Swelling
Pathophysiology
Strains- Injury to the muscle or
tendons due to overstretching.
MSD
Diagnostic Tests
1. Physical examination
2. X-ray
3. MRI
Nursing Management
Treatment
Pharmacology
1. Antiinflammatory
medications
2. Analgesics
3. Muscle relaxants
For severe strains- surgical
repair
1. Heat and cold application
2. Encourage the patient to rest to
promote healing
3. Administer medications as prescribed
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MSD
Disease: SPRAINS
Causes/Risk Factors
1. Direct or indirect injury
2. Higher risk among
athletes
Signs and Symptoms
1. Pain
2. Swelling
3. Limited joint
movement
Pathophysiology
A sprain is a stretching or tearing of
ligaments.
Diagnostic Tests
1. Physical examination
2. Xray
3. MRI
Nursing Management
Treatment
Management:
Rest, ice, compression and
elevation (RICE)
Pharmacology
1. Antiinflammatory
medications
2. Analgesics
3. Muscle relaxants
Moderate Sprain- cast
Severe Sprain- Surgery
1. Encourage the patient to rest to
promote healing
2. Apply ice packs to affected joint
3. Elevate limb
4. Assist in applying with tape, splint or
cast
5. Administer medications as prescribed
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Disease: FRACTURES
Causes/Risk Factors
1. Injury
2. Persons with
osteoporosis
Signs and Symptoms
1. Pain
2. Loss of
function/deformity
3. Crepitus
4. Edema
5. Ecchymosis (skin
Pathophysiology
MSD
A fracture is a broken bone. There is a break in the continuity of
the bone structure.
Types
1. Closed fracture: bone break without open wound in skin.
2. Open fracture (compound): fracture with an open wound.
3. Complete fracture: complete break through the bones that
separates into two.
4. Incomplete fracture: the bone doesn't break completely.
5. Comminuted fracture: break into more than two fragments.
6. Greenstick: one side of the bone is broken, the other side is
bent
7. Transverse fractures: fracture straight across the bone.
8. Oblique: fracture that run at an angle across
9. Spiral: fracture that circles or spirals around the shaft.
10. Impacted: a part of the bone that impact another bone
11. Compression: one bone compresses another bone
Diagnostic Tests
1. X-ray
2. CT
3. MRI
discoloration)
Nursing Management
Treatment
1. Reduction
2. Fixation
3. Traction
4. Cast
Pharmacology
1. Analgesics
1. For open fractures, cover wound with sterile
dressing
2. Assess neurovascular status
3. Provide pharmacologic and non-pharmacologic
pain management
Traction care:
1. Ensure that the traction weight bag is hanging
freely.
2. Monitor for any complication of immobilization.
3. Assess skin integrity
Casts:
1. Monitor for circulatory impairment
2. Assess skin integrity
3. Educate the patient to avoid placing any
object inside the casts.
Prevent and manage potential complications.
1. Compartment syndrome, Skin breakdown,
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PERIPHERAL VASCULAR DISORDERS
TABLE OF CONTENT
1.
2.
PERIPHERAL ARTERIAL DISEASE
PERIPHERAL VENOUS DISEASE
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Disease: PERIPHERAL ARTERIAL DISEASE
Causes/Risk Factors
1. Smoking
2. Diabetes
3. Hypertension
4. High blood cholesterol
level
Signs and Symptoms
PERIPHERAL
VASCULAR DISORDERS
Pathophysiology
Arterial narrowing or occlusion
(arteriosclerosis) which causes O2
and nutrients to the lower
extremities.
Leads to tissue damage (ischemia +
necrosis)
1. Pain (sharp)
2. Absent pulse
3. Skin:
a. cool to touch
Diagnostic Tests
b. pale skin
1. Ankle-brachial index (ABI)
c. absent hair + shiny
2. Doppler ultrasound
skin
d. thin, dry + scaly skin
e. no edema
4. Lesions:
a. Red sores on the
toes/feet
b. punched out
appearance
Nursing Management
5. Gangrene (death of
1. HANG (DANGLE) the patient's legs
tissues)
Treatment
Pharmacology
1. Antiplatelets
2. Cholesterol-lowering
drugs
Surgical Intervention
1. Angioplasty
2. Bypass surgery
3. Endarterectomy
an "a" shape
a= PAD
2.Monitor pain
3.Monitor for any signs of gangrene
4. Provide a warm environment + warm clothing
5. Do NOT apply direct heat to the extremities
(such as heating pads.
6. Administer medications as prescribed
Patient Education
1. Avoid caffeine + smoking (due to vasoconstrictive
effects)
2. Skin assessment
3. Hydration
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Disease: PERIPHERAL VENOUS DISEASE
Causes/Risk Factors
1. Smoking
2. Diabetes
3. Hypertension
4. High blood cholesterol
level
PERIPHERAL
VASCULAR DISORDERS
Pathophysiology
Pooling of blood in the extremities
due to the inability to bring blood
back to the heart (vascular
insufficiency)
Signs and Symptoms
1. Pain (achy + dull)
2. Presence of a strong
pulse
Diagnostic Tests
3. Skin:
1. Ankle-brachial index (ABI)
a. presence of edema
2. Doppler ultrasound
b. Warm legs
c. yellow/brown
ankles
4. Lesions:
a. irregular shaped
sores
5. No presence of
Nursing Management
gangrene
1. ELEVATE the patient's legs
Treatment
Pharmacology
1. Antiplatelets
2. Cholesterol-lowering
drugs
Surgical Intervention
1. Angioplasty
2. Bypass surgery
3. Endarterectomy
v= PvD
v shape
2. Administer medications as prescribed
Patient Education
1. Avoid caffeine + smoking (due to
vasoconstrictive effects)
2. Skin assessment
3. Hydration
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CRITICAL CARE conditions
PART 4
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Table of Content
1. respiratory disorders
2. neuro disorders
3. cardiovascular disorders
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RESPIRATORY
TABLE OF CONTENT
1.
PULMONARY EMBOLISM
2. ACUTE RESPIRATORY DISTRESS SYNDROME
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Disease: PULMONARY EMBOLISM
RESPIRATORY
Causes
Pathophysiology
1. Blood clots
2. Fat, Tumor
3. Air emboli (due to IV
therapy)
Pulmonary embolism is the
obstruction/blockage of a pulmonary
artery mostly caused by blood clots
(travel from the deep vein in the legs to
the lungs)
Risk Factors:
DVT, Surgery, prolonged
immobility, trauma
Signs and Symptoms
1. Sudden SOB
2. Chest pain (sharp)
3. Tachycardia
4. Hypotension
5. Cool and clammy skin
6. Cough (bloody
sputum)
7. Dizziness
8. Fever
Diagnostic Tests
1. Pulmonary angiogram
2. CT pulmonary angiography
3. Ventilation-perfusion scan
4. Chest X-ray
5. MRI
Nursing Management
1. Assess respiratory rate, depth and
pattern
Treatment
2. Administer O2 therapy as ordered
Pharmacology
3. Position: High Fowler's
1. Anticoagulants:
4. Active/passive leg exercises
prevent clot formation
5. Monitor thrombolytic and
2. Thrombolytics: dissolve
anticoagulant therapy (coagulation
clots
studies)
Surgical Interventions:
1. Surgical embolectomy:
removal of clot
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Disease: ACUTE RESPIRATORY DISTRESS SYNDROME
Pathophysiology
Causes
Direct Injury
1. Trauma to the chest
2. Smoke and toxic chemical
inhalation
3. Aspiration, drowning
Indirect Injury
1. Sepsis, 2. Pancreatitis, 3.
Blood transfusion, 4. Drug
overdose
Signs and Symptoms
1. Rapidly progressive
dyspnea
2. Tachypnea
3. Hypoxemia
4. Crackles
5. Tachycardia
6. Altered mental status
7. Cyanosis
RESPIRATORY
ARDS is characterized by the build up of fluid
in the alveoli. This results in decreased gas
exchange and leads to deprivation of
oxygen to the vital organs.
3 PHASES: exudative, proliferative, and
fibrotic
1. Exudative phase: leakage of fluid +
protein to the alveoli lumen (pulmonary
edema)
2. Proliferative phase: repair of damaged
alveolar structure
3. Fibrotic phase: Damage and fibrosis of
the alveoli and lung tissues.
Diagnostic Tests
1. Blood test to measure oxygen
level
2. Chest x-ray
3. Echocardiogram- to rule out heart
failure
Nursing Management
Treatment
1. Mechanical ventilation
using PEEP (PEEP
maintains the patient's
airway pressure)
2. Supplemental oxygen
Pharmacology
1. Diuretics
2. Anticoagulants
3. Corticosteroids
1. Maintain patent airway
2. Monitor respiratory status
3. Administer supplemental oxygen as
prescribed
4. Position: Prone position
5. Administer medications as prescribed
6. Prepare patient for intubation &
mechanical ventilation using PEEP
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NEURO
TABLE OF CONTENT
1.
2.
3.
4.
5.
6.
7.
increased intracranial pressure
spinal cord injury
AUTONOMIC DYSREFLEXIA
cerebral aneurysm
traumatic brain injury
stroke
seizures
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Disease: INCREASED INTRACRANIAL PRESSURE
Causes
1. Brain tumor
2. Hydrocephalus
3. Hemorrhage
4. Meningitis
5. Hematoma
6. Head injury
NEURO
Pathophysiology
Increased ICP is a rise in the pressure
inside the skull.
The normal intracranial pressure is
between 5-15 mmHg.
Signs and Symptoms
1. Altered LOC, Double vision
2. Pupils-dilated, Headache
3. Irregular respiration
4. Vomiting
Late signs:
1. Increased systolic BP,
decreased HR
2. Body weakness + decreased
motor function
3. Positive Babinski reflex
4. Posture:
Decorticate/decerebrate
5. Seizures
(Cushing's triad are signs that
indicates increased ICP. This
includes: increased systolic BP,
decreased HR and decreased RR)
Treatment
Pharmacology
1. Antiseizures
2. Antihypertensive
3. Antipyretics
4. Muscle relaxants
5. Corticosteroids
Diagnostic Tests
1. MRI
2. CT scan
Nursing Management
1. Position: elevate head of bed to 30
degrees (prevent flexion of neck & hips)
2. Monitor respiratory status, neurological
status, vital signs
3. For mechanical ventilation: maintain the
PaCO2 at 30 to 35 mm Hg (this results in
decreased ICP due to vasoconstriction)
4. Monitor ABGs
5. Maintain normal body temperature
Patient Education
1. Avoid Valsalva's maneuver
2. Avoid straining activities
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Disease: SPINAL CORD INJURY
NEURO
Causes
Pathophysiology
1. Motor vehicle accidents
2. Sporting injuries
3. Violence (gun shots,
wounds)
4. Falls
5. Diseases: cancer
6. Fractures/compression of the
spinal cord
SCI- damage that occurs to any part of the
spinal cord/nerves causing permanent changes
(such as loss of motor function, changes in
sensation, reflexes and strength).
Signs and Symptoms
Classification
1. Complete- total loss of sensation & function
2. Incomplete (partial)- some sensory & motor
function remains
1. Loss of motor function and
decreased sensation
2. Loss of bladder/bowel
control
3. If C3-C5 are involved, it
affects breathing
4. Muscle spams
Remember: the signs and
symptoms is dependent on
the level and severity of
injury
Tetraplegia (Quadriplegia)- paralysis of all
extremities
Paraplegia-paralysis of the lower extremities
Diagnostic Tests
1. X-rays
2. MRI
3. CT scan
4. Neurological examination
Nursing Management
Emergency management:
1. Immobilize the spine (on spinal backboard
with head in a neutral position)
2. Maintain patent airway
Treatment
3. Use the logrolling technique to maintain
1. Immobilizing the spine
alignment.
2. Respiratory management Acute phase
1. Monitor respiratory status
2. Monitor for signs of neurologic shock
3. Prevention/management
3. Monitor for signs of Autonomic dysreflexia
of long-term
(damage above T6)
Other nursing care:
complications
1. Turn patient every 2 hours to maintain skin
integrity.
4. Surgical intervention
2. Educate patient on physical rehabilitation
3. Range of motion exercises
4. Prevention and management of long-term
complications of SCI
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Disease: AUTONOMIC DYSREFLEXIA
Causes
Common causes
1. Distended bladder
2. Constipation
NEURO
Pathophysiology
Autonomic dysreflexia is a sudden
uncontrolled sympathetic response
(overreaction) to stimulation.
Autonomic dysreflexia is common among
people with spinal cord injuries (damage
above T6)
Signs and Symptoms
1. Severe high blood
pressure
2. Severe bradycardia
3. Throbbing headache
4. Blurred vision
5. Flushed skin above
injury level
6. Pale skin below injury
level
7. Goosebumps
8. Nasal congestion
9. Sweating
Treatment
Pharmacology
1. Antihypertensive drugs
Treatment depends on the
cause.
This is a medical emergency.
Diagnostic Tests
1. Blood and urine tests
2. CT or MRI scan
3. ECG
Nursing Management
1. Position: High Fowler's
2. Remove the stimulus
3. Loosen clothing
4. Assess for bladder distention,
constipation or other stimulus (check
for any kinks if the client has a urinary
catheter).
5. Medication: antihypertensive drug
6. Monitor VS (BP & P every 5 mins)
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Disease: CEREBRAL ANEURYSM
Causes/ Risk Factors
1. Hypertension
2. Smoking
3. Older age
4. Excessive alcohol use
5. Head trauma
NEURO
Pathophysiology
A bulge or ballooning of a weakened
blood vessel in the brain.
A brain aneurysm can rupture, resulting
in hemorrhagic stroke.
Signs and Symptoms
1. Headache
2. Changes in vision
3. Tinnitus
4. Seizures
5. Nuchal rigidity
Diagnostic Tests
1. CT scan
2. MRI
3. Cerebral angiogram
Nursing Management
Treatment
Pharmacology
1. Antiseizure medication
2. Anti-hypertensive
medication
(hypertensive patients)
Pain management
1. Maintain patent airway
2. Monitor VS
3. Position: semi-Fowler's
4. Administer supplemental oxygen as
prescribed
5. Provide a calm environment
6. Pain management
7. Administer medications as prescribed
Patient Education:
1. Educate patient to avoid straining
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Disease: TRAUMATIC BRAIN INJURY
Causes/ Risk Factors
1. Falls
2. Sports injury
3. Vehicular accident
4. Violence
Signs and Symptoms
1. Increased ICP
2. LOC changes
3. Confusion/altered mental
status
4. Papilledema
5. Body weakness
6. Seizures
7. Paralysis
8. Slurred speech
9. CSF drainage from the ears
or nose
Signs and symptoms depends on
the type of injury and severity.
Treatment
Mild Injury
1. Close monitoring
2. Antibiotics
3. Wound care
Moderate to severe injury
1. Treatment focuses on
increasing cerebral
oxygenation, maintaining BP
and preventing further
injury.
2. Craniotomy
NEURO
Pathophysiology
Trauma to the skull that causes brain damage.
Types:
1. Concussion-injury that causes the head to
move back and forth forcefully
2. Contusion-bruising
3. Epidural hematoma- hematoma between
skull and dura
4. Subdural hematoma-blood between
between the dura and arachnoid
5. Intracerebral hemorrhage-bleeding inside
the brain
6. Subarachnoid hemorrhage-bleeding into
the subarachnoid space
7. Skull fractures- break in the cranial bone
Diagnostic Tests
1. GCS
2. Physical Assessment
3. CT scan
Nursing Management
1. Monitor respiratory status
2. Maintain patent airway
3. Initiate seizure precautions
4. Assess neurological changes
5. Assess pupil size
6. Monitor vital signs
7. Monitor for signs of increase
intracranial pressure.
8. Prevent neck flexion
9. Pain management
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Disease: STROKE
Causes/ Risk Factors
1. TIA
2. Hypertension
3. smoking
4. Atherosclerosis
5. Diabetes
6. High cholesterol
Signs and Symptoms
1. Drooping of face
2. One sided weakness
3. Slurred speech
4. Blurred vision
5. Agnosia
6. High BP
7. Unilateral neglect
8. Apraxia
NEURO
Pathophysiology
Stroke is the loss of neurological functions
due to the lack of blood flow to the brain.
Types
Ischemic Stroke (Clots)- an obstruction
in the blood vessel that supplies blood
to the brain.
Hemorrhagic Stroke (Bleeding)weakened blood vessel ruptures.
Transient Ischemic Attack- temporary
stroke (a warning stroke)
Diagnostic Tests
1. CT scan
2. MRI
3. Electroencephalography
4. Carotid ultrasound
5. Cerebral arteriography
Nursing Management
Treatment
1. An IV injection of
recombinant tissue
plasminogen activator
(tPA)-ischemic stroke
2. Hemorrhagic stroke: stop
bleeding. Prevention of
increased ICP
1. Maintain patent airway
2. Administer 02
3. Administer tPA
4. Monitor VS-maintain BP @ 150/100
5. Monitor LOC
6. Monitor for signs of increase ICP
7. Elevate HOB
8. Administer IV fluids
9. Insert Foley's catheter
10. Prevention of DVT
11. Assist with self care and ADLs
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Disease: SEIZURES
Causes/ Risk Factors
1. Meningitis
2. Head trauma
3. Stroke
4. Fever
5. Brain tumor
Signs and Symptoms
The signs and symptoms
depends on seizure history and
type.
Before seizure
Aura
During seizure
Loss of consciousness during
seizures
Uncontrollable involuntary
muscle movements
Loss of bladder and bowel
control
After seizure
Headache
Confusion
Slurred speech
Treatment
Pharmacology
Anti-seizure medication
NEURO
Pathophysiology
Seizures is characterized by a sudden, uncontrolled
electrical disturbance in the brain.
Epilepsy: chronic seizure activity.
Types:
1. Generalized Seizures-all areas of the brain are
affected
a. Tonic-Clonic- may begin with an aura.
i. Tonic phase- muscle rigidity , then loss of
consciousness
ii. Clonic-hyperventilation and jerking
b. Absence-loss of awareness (stare blankly into
space)
c. Myoclonic-brief, jerking movement of a
muscle/muscle group
d. Atonic-sudden loss of muscle strength
Partial Seizures-affects one part of the brain
Simple partial
Complex partial
Diagnostic Tests
1. An electroencephalogram
2. Computerized tomography
3. Magnetic resonance imaging
(MRI)
4. Neurological exam
Nursing Management
Assess time and duration of seizure
activity
Provide patient safety
Turn patient to the side
Maintain airway
Avoid restraining patient
Loosen clothing
Administer O2
Monitor behavior before and after
seizure activity
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CARDIOVASCULAR
TABLE OF CONTENT
1.
2.
deep vein thrombosis
Disseminated intravascular
coagulation
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Disease: DEEP VEIN THROMBOSIS
Causes
1. Age (older age),
obesity, smoking
2. Prolong immobilization
3. Trauma
4. Increased blood
coagulability
Signs and Symptoms
1. Edema of the
affected extremity
2. Warmth & discolored
skin in the affected
leg
3. Pain
4. Tenderness
CARDIOVASCULAR
Pathophysiology
Deep vein thrombosis (DVT)- thrombus
(blood clot) forms mostly in the deep vein
of the lower extremities.
Complication:
Pulmonary Embolism (PE)- life-threatening
The blood clot in the legs can break and
travel to the lungs causing pulmonary
embolism
Diagnostic Tests
1. D-dimer blood test: a type of
protein produced when there is
blood clots
2. Duplex ultrasound
Nursing Management
Treatment
Prevention
1. Prevent prolonged
immobilization
2. Active, passive ROM
3. Compression stockings
Treatment:
1. Anticoagulants: prevent
further formation of clots
2. Thrombolytics: dissolve
clots
3. Prevention of PE
Prevention
1. Nursing interventions to prevent DVT
(see treatment)
Other nursing interventions:
1. Administer anticoagulants and
thrombolytics
2. Prevention of pulmonary embolism
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DISEASE: DISSEMINATED INTRAVASCULAR COAGULATION
Pathophysiology
Causes
1. Blood transfusion
reaction-major cause
2. Cancer
3. Pancreatitis
4. Sepsis
5. Pregnancy complications
Signs and Symptoms
1. Bleeding (various
parts in the body)
2. Bruising
3. Blood clots
4. Fever
5. Decreased BP
6. SOB
7. Confusion
Treatment
1. Treatment of the
underlying cause
2. Plasma transfusionsreplace blood clotting
factors
Pharmacology
1. Anticoagulants-prevent
further formation of clots
Disseminated intravascular coagulation
(DIC) is characterized by an
overstimulation of the proteins that
control blood clotting which causes
microclots throughout the body.
Diagnostic Tests
1. D-dimer
2. Partial thromboplastin time
(PTT)
3. Prothrombin time (PT)
4. CBC
Nursing Management
1. Assess respiratory status
2. Monitor VS
3. Monitor coagulation studies
4. Monitor patient's level of
consciousness/mental status
5. Administer O2 as prescribed
6. Administer medications
7. Provide supportive care
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Bleeding
Bleeding
Hypotension
Hypotension
Arrhythmias
Arrhythmias
Hypersensitivity
reaction
Hypersensitivity reaction
Thrombolytic drugs dissolve clots by
activating plasminogen that forms
plasmin.
FLASHCARDS
PART 1
A Review Guide For Nursing Students
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table of content
1. Cardiovascular Disorders
2. Respiratory Disorders
3. Gastrointestinal Disorders
4. Pancreatic Disorders
5. Hepatic Disorders
6. Genitourinary Disorders
7. Neurologic Disorders
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CARDIOVASCULAR DISORDERs
1. Coronary Artery Disease
2. Angina
3. Myocardial Infarction
4. Heart Failure
5. Cardiogenic Shock
6. Pericarditis
7. Endocarditis
8. Myocarditis
9. Cardiac Tamponade
10. Aortic Aneurysm
11. Hypertension
CORONARY ARTERY DISEASE
rISK FACTORS/causes
1. Age
2. Gender
3. Family history
4. Hypertension
5. High blood cholesterol
level
6. Diabetes
7. Smoking
8. Obesity
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Coronary artery disease is caused by
atherosclerosis (plaque formation) that
results in the narrowing or occlusion of
one or more coronary arteries. CAD
results in decreased myocardial tissue
perfusion and decreased myocardial
oxygenation which leads to angina, MI,
HF or death.
NURSING MANAGEMENT
1. Pain assessment, vital signs, ECG
2. Administer oxygen, medications
3. Promote bed rest
4. Place client in a Semi-Fowler's position.
5. Patient Educationa. Lifestyle modifications, Low-sodium and
low-cholesterol diet.
1. Chest pain
2. Dyspnea/SOB
3. Fatigue
4. Dizziness
5. Syncope
6. Cough
7. Normal findings during
asymptomatic period
Treatment
Pharmacology
1. Calcium Channel Blocker
2. Nitrates
3. Cholesterol-lowering medications
Surgical Interventions
1. Coronary Angioplasty
2. Vascular stent
3. Coronary artery bypass
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ANGINA
rISK FACTORS/causes
1. Family history of heart
disease
2. Hypertension
3. High blood cholesterol
4. Diabetes
5. Smoking
6. Obesity
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Angina is chest pain due to decreased
myocardial oxygenation. This causes
myocardial ischemia.
Types of angina.
Stable angina-occurs due to activity.
Pain relieved by rest.
Unstable angina- unexpected chest pain
that increases in severity, duration and
occurrence (may occur at rest).
Variant angina- occurs due to coronary
artery spasm. Occurs at rest.
Intractable angina- chronic
NURSING MANAGEMENT
1. Pain assessment, vital signs/ECG
2. Administer 02, nitroglycerin
3. Cardiac monitoring
4. Pain management
5. Promote bed rest (Semi-fowler's position)
6. Establish an IV access.
7. Patient Education- Lifestyle and dietary
modifications
1. Pain
2. Dyspnea/SOB
3. Tachycardia
4. Palpitations
5. Dizziness
6. Syncope
7. Diaphoresis (Sweating)
8. Pallor
9. Elevated BP
treatment
Pharmacology
Calcium Channel Blocker
Nitrates
Cholesterol-lowering medications
Anti-platelet therapy
Surgical Interventions
Coronary Angioplasty
Vascular stent
Coronary artery bypass
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Myocardial Infarction
rISK FACTORS/causes
1. CAD
2. Atherosclerosis
3. High cholesterol level
4. Diabetes
5. Hypertension
6. Smoking
7. Stress
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
MI occurs due to myocardial tissue
damage as a result of oxygen
deprivation. Ischemia may lead to
necrosis if myocardial tissue
oxygenation is not restored.
NURSING MANAGEMENT
Nursing Assessment
1. Pain, respiratory status, vital signs, ECG, peripheral
pulse and skin temperature.
Nursing Interventions
1. Administer oxygen
2. Administer medications
3. Cardiac monitoring
4. Monitor BP, intake and output
5. Notify HCP if the systolic pressure is lower than 100
mm Hg after medication administration.
1. Pain- crushing
substernal pain that
radiates to the left
arm, jaw or back.
2. Dyspnea
3. Dysrhythmias
4. Pallor
5. Cyanosis
6. Diaphoresis
7. Anxiety
Treatment
Pharmacology
Morphine, Nitroglycerin, Thrombolytic
therapy, Beta-blockers, Antidysrhythmic
medications
Immediate treatment:
Oxygen: Increase oxygen delivery
Aspirin: reduce blood clotting
Nitroglycerin: vasodilation
Morphine: pain reliever
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Heart Failure
rISK FACTORS/causes
1. CAD
2. MI
3. Myocarditis/Endocarditis
4. Diabetes
5. Hypertension
6. Abnormal heart valves
7. Cardiomyopathy
8. Congenital heart disease
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Right-sided HF (evident in
systemic circulation)
1. Edema of the extremities,
abdominal distention, JVD,
splenomegaly,
hepatomegaly, weight gain
Left-sided HF (evident in the
pulmonary system)
1. Dyspnea, crackles,
tachypnea, pulmonary
congestion, dry cough
HF is the inability of the heart muscle to
pump enough blood to meet the
metabolic demands of the body.
Therefore, there is a decrease in cardiac
output.
Types:
Right-sided heart failure and left-sided
heart failure.
NURSING MANAGEMENT
1. Monitor for acute pulmonary edema
2. Place patient in a high Fowler's position.
3. Oxygen therapy
4. Administer morphine sulfate and diuretics.
5. Insert Foley's catheter.
Other nursing interventions
1. Administer prescribed medication regime.
2. Monitor daily weight, intake and output.
3. Provide balance between rest and activities.
4. Educate patient on lifestyle and dietary modifications.
Treatment
Pharmacology
Morphine
Digoxin
ACE-Inhibitors
Beta-blockers
Diuretics
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Cardiogenic Shock
rISK FACTORS/causes
1. CAD
2. MI
3. Myocarditis/Endocarditis
4. Diabetes
5. Hypertension
6. Abnormal heart valves
7. Cardiomyopathy
8. Congenital heart disease
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Cardiogenic shock is a condition
caused by failure of the heart to
pump adequately. This results in
decreased cardiac output and
decreased tissue perfusion.
1. Hypotension
2. Tachycardia
3. Chest pain/discomfort
4. Decreased urine output,
less than 30ml/hr.
5. Diminished peripheral
pulse
6. Confusion/disorientation
NURSING MANAGEMENT
Assessment
Orientation, respiratory status, pain, vital signs,
peripheral pulse, intake and output
Interventions
Administer medications
Oxygen therapy, Monitor vital signs
Monitor BP after diuretic and nitrate administration.
Prepare client for procedures
Monitor urinary output
Treatment
Treatment Goal
To improve the heart's pumping ability and
maintain tissue perfusion.
Pharmacology
Morphine sulfate
Diuretics
Nitrates
Vasopressors and positive inotropes
(Improve organ tissue perfusion.)
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Pericarditis
rISK FACTORS/causes
1. MI
2. Autoimmune diseases
3. Injury
4. Heart surgery
5. Bacterial, viral and
fungal infections
PATHOPHYSIOLOGY
Pericarditis is an infection of the
pericardium. The pericardium is
comprised of two thin sac layers that
surrounds the heart.
Chronic pericarditis causes thickening of
the pericardium which results in the
accumulation of fluid (and causes a
decrease in pericardial elasticity).
This may result in further complications
such as heart failure and cardiac
tamponade.
NURSING MANAGEMENT
1. Pain assessment
2. Assess for signs of cardiac tamponade.
3. Auscultate lungs (listen for pericardial friction
rub).
4. Position patient in a high Fowler's position
(leaning forward to reduce pain).
5. Blood culture
6. Administer medications
sIGNS AND SYMPTOMS
1. Pain
a. Pain that radiates to
the left side of neck,
shoulders and back
b. Pain experienced during
inspiration
c. Pain experienced when
in a supine position
2. Fever
3. Fatigue
4. Pericardial friction rub
(during auscultation)
Treatment
Pharmacology
Analgesics
NSAIDS
Corticosteroids
Antibiotics (for bacterial infections)
Diuretics
Digoxin
Surgical Intervention
Pericardiectomy
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Endocarditis
rISK FACTORS/causes
1. Congenital heart
defects.
2. IV illegal drug use
3. Damaged heart valves
4. Valve replacement
5. Prosthetic heart valve
PATHOPHYSIOLOGY
Inflammation and infection of the
endocardium, the inner lining of the
heart chambers and heart valves.
Entry:
Oral cavity
Infection
Invasive procedures
NURSING MANAGEMENT
1. Assess skin for petechiae
2. Assess nail beds and clubbing of fingers
3. Assess for Janeway lesios and Osler's nodes
4. Assess blood culture results
5. Monitor cardiovascular status
6. Monitor signs of emboli and heart failure.
7. Provide rest and activity balance to prevent
thrombus formation
8. Maintain antiembolism stockings
9. Administer antibiotics
sIGNS AND SYMPTOMS
1. Fever
2. Weight loss
3. Heart murmurs
4. Pallor
5. Clubbing of fingers
6. Petechiae
7. Splenomegaly
8. Red tender lesions on hands
and feet- Osler's nodes
9. Nontender hemorrhagic
nodular lesions- Janeway
lesions
Treatment
Pharmacology
Antibiotics
Penicillin, nafcillin and ampicillin, are
the drugs of choice for enterococcal,
streptococcal, and staphylococcal.
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Myocarditis
rISK FACTORS/causes
1. Previous pericarditis
2. Bacterial, viral or
fungal infection.
3. Allergic response
PATHOPHYSIOLOGY
Myocarditis is the inflammation of
the heart muscles (myocardium).
Myocarditis may affect the heart's
pumping ability and cause
arrhythmias.
NURSING MANAGEMENT
1. Place client in a comfortable position (Semi-Fowler's
position).
2. Oxygen therapy
3. Administer medications as prescribed (see
pharmacologic therapy)
4. Provide rest periods
5. Avoid activities that causes overexertion
6. Monitor for heart failure, cardiomyopathy and
thrombus as signs of complications.
sIGNS AND SYMPTOMS
1. Fever
2. Chest pain
3. Pericardial friction rub
4. Tachycardia
5. Murmur
6. Dyspnea
7. Fatigue
Treatment
Pharmacology
Analgesics
Salicylates
NSAIDs
Antidysrhythmic drugs
Antibiotics
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Cardiac Tamponade
rISK FACTORS/causes
1. Cancer
2. Tuberculosis
3. Hypothyroidism
4. Kidney failure
5. Chest trauma
6. Pericarditis
PATHOPHYSIOLOGY
Cardiac tamponade is a syndrome
caused by accumulation of fluid in the
pericardial cavity (pericardial effusion).
Cardiac tamponade decreases
ventricular filling and cardiac output.
This may cause complications such as
pulmonary edema, shock, or death.
NURSING MANAGEMENT
1. Place client on hemodynamic monitoring.
2. Administer IV fluids are prescribed.
3. Prepare client for pericardiocentesis
procedure.
4. Monitor client after the procedure for any
recurrence of tamponade.
sIGNS AND SYMPTOMS
1. Increase central venous
pressure (CVP).
2. Jugular venous
distention
3. Muffled heart sound
4. Pulsus paradoxus
5. Decreased cardiac
output
Treatment
Cardiac tamponade is a medical emergency
Client is managed in a critical care unit for
hemodynamic monitoring
IV fluids are prescribed for decreased
cardiac output.
Pericardiocentesis is performed (a
procedure to remove fluids in the
pericardium).
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Aortic Aneurysm
rISK FACTORS/causes
1. Tobacco use
2. Hypertension
3. Family history
4. Age (65 and older)
5. Gender (male)
6. High blood cholesterol
level
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Aortic aneurysm is an
enlargement/dilation of the aorta.
Aneurysm may occur anywhere along
the abdominal aorta.
NURSING MANAGEMENT
1. Assess abdominal distension
2. Assess peripheral pulse, temperature, color and
capillary refill.
3. Monitor vital signs
4. Monitor for signs of aneurysm rupture
5. Administer medication (see pharmacologic
interventions).
6. Prepare client for surgical procedure
7. Implement post operative interventions
Thoracic aneurysm:
dyspnea, cyanosis, weakness,
hoarseness, syncope, pain.
Abdominal aneurysm:
abdominal pain, abdominal
tenderness, systolic bruit over
aorta, mass above the umbilicus.
Rupturing aneurysm:
tachycardia, hypotension,
abdominal pain, s/s of shock,
hematoma at the flank region.
Treatment
Pharmacology
1. Antihypertensive drugs-to maintain BP
and prevent pressure on the aneurysm.
Surgical Intervention
Abdominal aortic aneurysm resectionsection is replaced with a graft.
Thoracic aneurysm repair- a thoractomy
procedure is used to enter the thoracic
cavity, expose the aneurysm and a graft
is sewn on the aorta.
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Hypertension
rISK FACTORS/causes
1. Obesity
2. DM
3. Physical inactivity
4. Tobacco use
5. Alcoholism
6. Family history
7. Secondary hypertension:
caused by underlying
condition
PATHOPHYSIOLOGY
Hypertension is the most common
lifestyle disease.
Hypertension is multifactorial that
causes an increase in peripheral vascular
resistance and an increase in blood
pressure (chronic).
Elevated BP: >120-129/<80
Stage 1 Hypertension: 130-139/80-89
Stage 2 Hypertension: >140/>90
NURSING MANAGEMENT
1. Assess and monitor BP
2. Obtain family history
3. Monitor weights
4. Goal: weight reduction or maintenance
5. Diet: sodium restriction
6. Smoking cessation
7. Educate patient on pharmacological
treatment
sIGNS AND SYMPTOMS
1. Increased BP
2. Headache
3. Dizziness
4. Chest pain
5. Blurred vision
6. Tinnitus
Remember: it may be
asymptomatic
Treatment
Goal of treatment:
Reduction of BP
Prevention of organ damage
Lifestyle changes
Diet
Exercise
Pharmacology
Anti-hypertensive medications
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Respiratory DISORDERs
1. Asthma
2. COPD-Chronic Bronchitis
3. COPD-Emphysema
4. Pleural Effusion
5. Hemothorax
6. Pneumothorax
7. Pneumonia
ASTHMA
rISK FACTORS/Causes
1. Allergies
2. Stress
3. Hormonal changes
PATHOPHYSIOLOGY
Chronic inflammatory disease of
the airway.
Inflammation and hypersensitivity
to a trigger (stimuli).
Smooth muscle constriction of the
bronchi.
Intermittent airflow obstruction.
NURSING MANAGEMENT
1. Monitor patient's respiratory rate, depth and
pattern, pulse ox, vital signs
2. Maintain patent airway
3. Administer O2 therapy as prescribed
4. Administer medications as ordered.
Patient Education
1. Medication regimen.
2. Identify and avoid triggers.
3. Long term management.
sIGNS AND SYMPTOMS
1. Chest tightness
2. Wheezing
3. Shortness of breath
4. Cough
5. Restlessness
Treatment
Pharmacology
1. Bronchodilators
2. Corticosteroids
3. Anticholinergics
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COPD- Chronic Bronchitis
rISK FACTORS/causes
1. Smoking
2. Exposure to dust and
chemicals.
3. Air pollution
PATHOPHYSIOLOGY
Progressive respiratory disease.
Overproduction of mucus due to
inflammatory response.
Causes airway narrowing and
ventilation-perfusion imbalance.
NURSING MANAGEMENT
Assess respiratory rate, depth and pattern.
Auscultate lungs
Maintain patent airway
Place patient in Fowler's position
Provide O2 therapy as ordered.
Increase oral fluids and maintain hydration.
Perform chest physiotherapy
Patient Education
Deep breathing exercises
Nutrition and hydration
Smoking cessation
sIGNS AND SYMPTOMS
1. SOB
2. Cough
3. Sputum production
4. Fatigue
5. Wheezing, crackles
6. Cyanosis
Treatment
Pharmacology
1. Bronchodilators
2. Glucocorticosteroids
3. Anticholinergics
4. Mucolytic agents
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COPD- EMPHYSEMA
rISK FACTORS/causes
1. Smoking
2. Exposure to dust and
chemicals.
3. Air pollution
PATHOPHYSIOLOGY
Progressive respiratory disease
characterized by the enlargement
of the alveolar.
Enlargement causes decrease in
alveolar elasticity, alveolar wall
damage and decrease in alveolar
surface area.
NURSING MANAGEMENT
Assess respiratory rate, depth and pattern.
Auscultate lungs
Maintain patent airway
Place patient in Fowler's position
Provide O2 therapy as ordered.
Increase oral fluids and maintain hydration.
Perform chest physiotherapy
Patient Education
Deep breathing exercises (pursed lip breathing)
Nutrition and hydration
Smoking cessation
sIGNS AND SYMPTOMS
1. SOB
2. Cough
3. Sputum production
4. Fatigue
5. Wheezing, crackles
6. Cyanosis
7. Barrel chest
8. Clubbing of nails
Treatment
Pharmacology
Bronchodilators
Glucocorticosteroids
Anticholinergics
Mucolytic agents
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PLEURAL EFFUSION
rISK FACTORS/causes
Transudative Effusion
1. Cirrhosis
2. Heart failure
3. Hypoalbuminemia
Exudative Effusion
1. Pneumonia
2. Cancer
3. Pulmonary embolism
4. Tuberculosis
PATHOPHYSIOLOGY
Accumulation of fluid in the
pleural space.
Fluid accumulates between the
visceral and parietal pleura of
the lungs.
Pleural fluid: transudate or
exudate
NURSING MANAGEMENT
1. Identify underlying cause
2. Assess respiratory rate, depth and pattern
3. Monitor vital signs
4. Elevate the head of bed
5. Administer O2 therapy as ordered
6. Administer medications as ordered
7. Prepare patient for possible thoracentesis.
8. Chest tube management
sIGNS AND SYMPTOMS
1. SOB
2. Chest pain
3. Dry, nonproductive
cough
4. Diminished breath
sounds
5. Pain during
inspiration
Treatment
Thoracentesis
Chest tube insertion
Pleurectomy
Pleurodesis
Treatment of underlying condition
Pharmacology
(Depends on the underlying condition)
Diuretics- congestive heart failure.
Antibiotics
Anticoagulants- pulmonary embolism
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HEMOTHORAX
rISK FACTORS/causes
PATHOPHYSIOLOGY
1. Thoracic/heart surgery Acculumation of blood in the
2. Chest trauma
pleural cavity.
3. Blood clotting defect
Causes respiratory distress.
4. Anticoagulant
therapy
5. Lung cancer
6. Tuberculosis
NURSING MANAGEMENT
1. Assess respiratory rate, depth and pattern
2. Monitor vital signs
3. Elevate the head of bed
4. Administer O2 therapy as ordered
5. Pain management
6. Chest tube management/care
7. Administer IV fluids as ordered
8. Administer blood transfusion as ordered
9. Prepare patient for surgery, if indicated.
sIGNS AND SYMPTOMS
1. sOB
2. Tachypnea
3. Chest pain
4. Tachycardia
5. Hypotension
6. Diminished breath
sounds on affected side
7. Restlessness
8. Cyanosis
9. Anxiety
Treatment
Stabilize patient
Stoppage of bleeding
Thoracentesis
Chest tube insertion
Surgical Intervention
Thoracotomy
VATS-Video assisted thoracoscopic surgery
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PNEUMOTHORAX
rISK FACTORS/causes
1. Chest injury
2. Ruptured air blebs
3. Mechanical ventilation
4. Lung disease: cystic
fibrosis
5. Chest surgery
6. Smoking
7. Genetics
8. Invasive procedures
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Spontaneous pneumothorax
SOB/ Cyanosis, Tachycardia
Asymmetrical chest
movement
Diminished breath sounds on
affected side, Chest pain
Tension pneumothorax
Tracheal deviation away
from affected side
SOB/ Tachypnea/Cyanosis
Hypotension/weak pulse
Chest pain, Decreased CO
Air leaks into pleural space. Pleural space
is exposed to positive atmospheric
pressure (pressure is normally negative).
Causes impaired lung expansion.
Results in full lung collapse or partial lung
collapse.
Types
Spontaneous pneumothorax
Tension pneumothorax
Traumatic pneumothorax
NURSING MANAGEMENT
Assess respiratory status
Maintain patent airway
Monitor vital signs
Administer O2 therapy as ordered
Chest tube management: monitor for kinks and
bubbling
Pain management and maintain bed rest
Patient Education
Deep breathing exercises
Educate patient on the use of Incentive spirometer
Treatment
Oxygen therapy
Chest tube insertion
Pharmacology
Antibiotics
Surgical Management
Sometimes surgery may be necessary
to close the air leak.
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PNEUMONIA
rISK FACTORS/causes
Community acquired pneumonia
Streptococcus pneumoniae
Hospital acquired pneumonia
Prolonged hospitalization
Mechanical ventilation
Chronic illness/co morbid
Aspiration Pneumonia
Substance entering the
airway due to vomiting or
impaired swallowing
PATHOPHYSIOLOGY
Inflammation of the pulmonary tissue
caused by bacteria, fungi and viruses
Types:
Community acquired pneumonia: onset
of pneumonia symptoms that occurs in
the community setting or for the first 48
hours after admission
Hospital acquired pneumonia: onset of
pneumonia symptoms after 48 hours of
admission
Aspiration pneumonia: bacterial
infection from aspiration
NURSING MANAGEMENT
Assess respiratory status, monitor vital signs
Maintain patent airway, O2 therapy
Assess swallowing if cause is aspiration
NPO status maintained if cause is aspiration
Chest physiotherapy, Increase fluid intake
Maintain bed rest/Semi-Flower's position
High-calorie, protein diet
Patient Education
Fluid intake
Deep breathing/coughing
Medication regimen
sIGNS AND SYMPTOMS
1. SOB
2. Productive cough
3. Tachypnea
4. Use of accessory muscles
5. Fever
6. Cyanosis
7. Pleuritic chest pain
Treatment
Hydration (IV fluids)
Blood culture
Respiratory Management
Pharmacology
Antibiotics
Antiviral angents
Antitussives
Antipyretics
Analgesics
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Gastrointestinal DISORDERs
1. Hiatal Hernia
2. Gastroesophageal Reflux
Disease
3. Gastritis
4. Appendicits
5. Peptic Ulcer Disease
6. Ulcerative Colitis
7. Crohn's Disease
Hiatal Hernia
rISK FACTORS/Causes
1. Injury
2. Aging
3. Obesity
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
The diaphragm has a small opening
(hiatus) through which the
esophagus passes before connecting
to the stomach.
1. Heart burn
2. Dysphagia
3. Regurgitation
4. Epigastric pain
Hiatal hernia occurs when a portion
of the stomach herniates through
the diaphragm and into the thorax.
NURSING MANAGEMENT
1. Assess pain
2. Elevate head of bed (HOB)
3. Avoid eating 2 to 3 hours before bedtime
4. Provide small frequent meals
5. Avoid lying down after eating
6. Administer medications as ordered
Treatment
Pharmacology
Antacid
Neutralizes stomach acids
Proton pump inhibitors
Blocks acid production- reduces
stomach acid
Surgical intervention may be required
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GERD
rISK FACTORS/causes
1. Hiatal Hernia
2. Pregnancy
3. Pyloric surgery
4. Smoking
5. Obesity
6. Alcohol
7. Fatty foods
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
A digestive disorder that occurs due to
the backflow of gastric content.
Impaired or dysfunctional lower
esophageal sphincter (LES) causes
regurgitation of stomach content into the
esophagus.
Complications- esophagitis, Barrett
esophagus, esophageal stricture.
NURSING MANAGEMENT
1. Assess pain
2. Elevate head of bed (HOB)
3. Avoid eating 2 to 3 hours before bedtime
4. Avoid lying down after eating
Patient Education
1. Avoid alcohol, fatty foods, caffeine, tobacco, and
other irritants
2. Avoid eating 2 to 3 hours before bedtime
3. Avoid lying down after eating
4. Avoid NSAIDS and anticholinergics
5. Maintain healthy body weight (exercise)
1. Heart burn
2. Dysphagia
3. Regurgitation
4. Epigastric pain
5. Dyspepsia (indigestion)
Treatment
Pharmacology
Antacid
Neutralizes stomach acids
Proton pump inhibitors
Blocks acid production- reduces stomach
acid
Histamine H2 antagonist
Blocks histamine (decreases stimulation
of stomach acid production).
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Gastritis
rISK FACTORS/causes
Bacterial infection
Autoimmune disease
Prolong use of NSAIDs
Excessive alcohol use
Smoking
Dietary factors
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Gastritis is the inflammation of the
gastric mucosa.
Acute gastritis- caused by the overuse
of NSAIDs, aspirin or excessive alcohol
intake.
Chronic gastritis-consistent inflammation
of the gastric mucosa. May be caused by
H. pylori bacteria, or autoimmune
diseases.
NURSING MANAGEMENT
1. Assess pain
2. Monitor signs of hemorrhagic gastritis
3. Maintain NPO status until symptoms subsides
4. Administer medications as ordered.
1. Patient Education
2. Educate patient to avoid irritating foods.
3. Educate patient on the importance of medication
regime and adherence.
Acute Gastritis
1. Nausea/vomiting
2. Anorexia
3. Abdominal pain
4. Acid reflux
5. Hiccups
Chronic Gastritis
1. Indigestion
2. Heart burn after meals
3. Vitamin B12 deficiency
4. Anorexia/nausea/vomiting
Treatment
Pharmacology
Antacid
Neutralizes stomach acids
Proton pump inhibitors
Blocks acid production- reduces stomach
acid
Histamine H2 antagonist
Blocks histamine (decreases stimulation of
stomach acid production).
Antibiotics: to treat bacterial infection
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Appendicitis
rISK FACTORS/causes
1. Abdominal trauma
2. Inflammatory bowel
disease
3. Infection in the
gastrointestinal tract
4. Foreign body
5. Viral infection
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Rovsing's sign: pain
experienced at the RLQ
when pressure is applied
and released at the LLQ
2. Periumbilical abdominal
pain
3. RLQ pain
4. Fever
5. Abdominal rigidity
Inflammation of the vermiform
appendix.
Inflammation causes obstruction of the
appendiceal lumen.
Complications: Prolong inflammation
may cause the appendix to
burst/rupture leading to peritonitis.
NURSING MANAGEMENT
1. Assess pain
2. Abdominal assessment
3. Monitor VS
4. Pre-operative care: NPO + IVF
5. Post-operative care: Monitor surgical site + monitor
for signs of infection
Patient Education
1. Post-operative education
a. Early ambulation
b. Deep breathing exercises
Treatment
Appendectomy: surgical removal of
the appendix
Pain management
IV fluids
Pharmacology
Antibiotics
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Peptic Ulcer Disease
rISK FACTORS/causes
1. H. pylori bacteria
2. NSAIDS
3. Irritants
4. Smoking
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Ulceration that erodes the gastric or
duodenal mucosa.
Mucosal inflammation and ulceration
is caused by H. pylori bacteria.
1. Epigastric pain after meals
2. Dark, tarry stools
3. Weight loss
4. Coffee ground emesis
Complications: GI hemorrhage,
bowel obstruction
NURSING MANAGEMENT
1. Abdominal Assessment (abdominal sounds)
2. Monitor vital signs (BP,P)
3. Monitor stools for blood
Patient Education
1. Dietary modification: avoid irritants
2. Smoking cessation
3. Avoid NSAIDS
Treatment
Pharmacology
Antibiotics
Histamine H2 blockers
Blocks histamine (decreases stimulation
of stomach acid production).
Proton pump inhibitor
blocks acid production to promote
healing
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Ulcerative Colitis
rISK FACTORS/causes
1. Age
2. Family history
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Diarrhea with pus or
blood
2. Abdominal pain
3. Abdominal
tenderness
4. Fever
5. Fecal urgency
Known as an Inflammatory Bowel
Disease.
Characterized by the ulceration and
inflammation of the colon and rectum.
Causes poor nutrient absorption.
Complications: Nutritional deficiencies,
hemorrhage and perforated colon
NURSING MANAGEMENT
1. Assess and monitor vital signs
2. Assess pain
3. Monitor fluid balance
4. I/O charting
5. Monitor electrolyte levels (lab studies)
6. Monitor stool frequency and characteristics
7. Obtain daily weights
8. Pain management
9. Maintain NPO status if indicated (severe
condition)
Treatment
Pharmacology
5-aminosalicylic acid (5-ASA)
Corticosteroids-moderate to severe
ulcerative colitis
Immunosuppresants- reduces
inflammation.
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Crohn's Disease
rISK FACTORS/causes
1. Autoimmune
2. Heredity
PATHOPHYSIOLOGY
Crohn's disease is a type of
inflammatory bowel disease (IBD)
that causes inflammation in the
gastrointestinal tract (leads to
thickening, scarring and narrowing)
NURSING MANAGEMENT
1. Assess and monitor vital signs
2. Assess pain
3. Monitor fluid balance
4. I/O charting
5. Monitor electrolyte levels (lab studies)
6. Monitor stool frequency and characteristics
7. Obtain daily weights
8. Pain management
9. Maintain NPO status if indicated (severe condition)
sIGNS AND SYMPTOMS
1. Diarrhea with pus
2. Fever
3. Abdominal pain
4. Abdominal distention
5. Weight loss
6. Reduced appetite
7. Iron deficiency
Treatment
Pharmacology
5-aminosalicylic acid (5-ASA)
Corticosteroids
Immunosuppresantsreduces inflammation.
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Pancreatic DISORDERs
1. Pancreatitis
2. Cholecystitis
3. Cholelithiasis
Pancreatitis
rISK FACTORS/Causes
1. Hyperlipidemia
2. Hypercacemia
3. Gallstones
4. Abdominal surgery
5. Abdominal trauma
6. Obesity
7. Infection
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Inflammation of the pancreas.
Obstruction of pancreatic secretory
flow, activation and release of
pancreatic enzymes. Digestive
enzymes starts digesting the
pancreas.
NURSING MANAGEMENT
1. Assess pain
2. Provide pharmacologic and nonpharmacologic pain management
3. Monitor fluid and electrolytes
4. Maintain NPO status as ordered
5. Manage biliary drainage
1. Left upper abdominal
pain that radiates to
the back
2. Abdominal pain that
worsens after meals
3. Abdominal tenderness
4. Fever
5. Tachycardia
6. Hypotension
7. Steatorrhea: chronic
pancreatitis
Treatment
NPO status
Pancreatic enzyme supplements
Pain management
IV fluids
Surgical procedure to remove bile
duct obstruction.
Cholecystectomy (if cause is
gallstones)
Pancreatic Jejunostomy
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Cholecystitis
rISK FACTORS/causes
1. Gallstones
2. Tumor
3. Infection
PATHOPHYSIOLOGY
Inflammation of the gallbladder.
Acute inflammation: is often due to
cholelithiasis.
Chronic inflammation: repeated
acute inflammation that causes the
gallbladder to be thick-walled and
scarred.
NURSING MANAGEMENT
1. Assess pain
2. Provide pharmacologic and non-pharmacologic
pain management
3. Maintain NPO status
4. Prepare patient for procedures
Post operative interventions
1. Monitor respiratory complications
2. Encourage coughing and deep breathing
3. Encourage early ambulation
4. Tube drainage management (if any).
sIGNS AND SYMPTOMS
1. Epigastric pain that
radiates to the right
shoulder
2. Fever
3. Nausea/Vomiting
4. Murphy's sign
5. Belching
6. Flatulence
7. Abdominal tenderness
Treatment
NPO status
Pain management
Antiemetics: for nausea and vomiting
Analgesics: pain
Surgical intervention
Cholecystectomy: removal of the
gallbladder.
Choledocholithotomy: removal of
gallstones
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Cholelithiasis
rISK FACTORS/causes
1. Obesity
2. High cholesterol levels
3. Women over 40 years
4. Diabetes
5. Cirrhosis
PATHOPHYSIOLOGY
Gallstones are hard, crystalline
structures that abnormally forms and
obstruct the gallbladder / bile duct.
Most of cholelithiasis is caused by
cholesterol gallstones.
NURSING MANAGEMENT
Postoperative Care
1. Monitor vital signs, respiratory status
2. Pain management
3. Monitor drainage/incision site, intake and output
4. Maintain NPO status
5. Deep breathing exercises and early ambulation
Patient Education
1. Ambulation/ 2. Avoid heavy lifting/ 3. Avoid bathing
for 48 hours/ 4. Report fever/ 5. Dietary
modification/ 6. Assess wound site daily.
sIGNS AND SYMPTOMS
1. Sudden pain in the right
upper quadrant
2. Abdominal distention
3. Dark urine
4. Abdominal pain after
eating fatty foods.
Treatment
Pharmacology
Analgesics
Antibiotics
Surgical intervention
Cholecystectomy: removal of the
gallbladder.
Medications to dissolve stones
Chenodeoxycholic
Ursodeoxycholic acid
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hepatic DISORDERs
1. Cirrhosis
2. Portal Hypertension
3. Esophageal Varices
Cirrhosis
rISK FACTORS/Causes
1. Chronic alcoholism
2. Hepatitis
3. Biliary obstruction
4. Right-sided HF
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Cirrhosis is a chronic progressive
disease of the liver characterized by
fibrosis (scarring).
NURSING MANAGEMENT
1. Identify underlying/precipitating factors
2. Perform daily weights
3. Administer vitamin supplements- KADE
4. Monitor for signs of infection
5. Monitor for signs of bleeding
6. Nutrition- low sodium
Patient Education
1. Alcohol cessation
2. Low sodium diet
3. Low saturated fats
1. Jaundice
2. Edema
3. Splenomegaly
4. Liver enlargement
5. Ascities
6. Abdominal pain
7. Steatorrhea
8. Bleeding- decreased Vit K
9. Red palms
10. Itchiness
11. Weight loss/ Loss of
appetite
12. White nails
Treatment
Treatment of underlying cause
Alcohol dependency
Hepatitis treatment
Treatment of Cirrhosis
complications- ascites, gastric
distress, portal hypertension, etc.
Liver Transplant- in severe cases of
Cirrhosis
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Portal Hypertension
rISK FACTORS/causes
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Gastrointestinal bleeding
a. Dark/tarry stools
b. bleeding from varices
2. Ascites
3. Decreased platelets and
WBC
4. Splenomegaly
5. Thrombocytopenia
6. Encephalopathy
Portal veins carries blood from the
digestive organs to the liver.
Portal hypertension-increased
pressure in the portal veins due to
obstruction of the portal blood flow.
1. Cirrhosis
2. Portal vein
thrombosis
Complications- Hepatic
encephalopathy, ascites, GI bleed,
varices rupture.
NURSING MANAGEMENT
1. Monitor intake and output
2. Assess level of consciousness
3. Monitor coagulation studies
4. Perform daily weights
5. Administer diuretics as ordered
6. Administer Vit K as ordered
Treatment
Endoscopic therapy
Dietary/lifestyle modifications
Transjugular intrahepatic portosystemic
shunt (TIPS)-radiological procedure
Distal splenorenal shunt (DSRS)-surgical
procedure
Patient Education
1. Low sodium diet
2. Alcohol cessation
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Esophageal Varices
rISK FACTORS/causes
1. Cirrhosis
2. Thrombosis in the portal
vein
3. Heart failure
4. Schistosomiasis
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Esophageal varices occurs when there is
a blockage in the blood flow to the liver
due to scarring or clotting in the liver.
This results in an increased pressure from
the portal vein.
The increased pressure causes blood to
flow into smaller veins in the esophagus.
The smaller fragile veins may become
distended and rupture, causing life-threatening hemorrhage.
NURSING MANAGEMENT
1. Monitor vital signs
2. Monitor lung sounds
3. Elevate HOB
4. Administer O2 as ordered
5. Administer IV fluids as ordered
6. Monitor lab values-coagulation studies
7. Administer Vit K as ordered
1. Jaundice
2. Dark-colored urine
3. Ascites
4. Nausea/Vomiting
5. Spontaneous bleeding/easy
bruising
6. Spider nevi
7. Hypotension
8. Tachycardia
9. Pallor
10. General malaise
11. Pruritus
Treatment
Primary goal is to prevent bleeding.
Beta blockers- to reduce pressure in the
portal veins
Vasopressin
Somatostatin/Sandostatin
Sclerotherapy
Endoscopic band ligation
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Genitourinary disorders
1. Acute Kidney Injury
2. Chronic Kidney Disease
3. Glomerulonephritis
4. Nephrotic Syndrome
5. Renal Calculi
6. Urinary Tract Infection
7. Pyelonephritis
Acute Kidney Injury
rISK FACTORS/Causes
Prerenal-outside the kidney
1. Dehydration, infection outside
of the kidney, decreased cardiac
output
Intrarenal-parenchyma of the kidney
1. Infection within the kidney
parenchyma, obstruction,
tubular necrosis, renal ischemia
Postrenal-between kidney and
urethral meatus
1. Calculi, cystitis, bladder
cancer/obstruction
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Renal cell damage characterized by a
sudden deterioration in kidney function.
AKI can cause cell death, decompensation
of renal function and hypoperfusion.
The signs and symptoms of AKI are due to
the retention of fluids, the retention of
nitrogenous waste and electrolyte
imbalances.
NURSING MANAGEMENT
Oliguric Phase
1. Administer diuretics
2. Fluid restriction-if hypertension is present
Diuretic Phase
1. Administer IV fluids
2. Monitor Lab values
Recovery Phase
1. Patient education-decrease sodium, protein, fluid and
potassium intake
2. Monitor intake and output.
Oliguric Phase
1. Urine output: <400mL/d,
pericarditis, excessive fluid
volume, uremia, metabolic
acidosis, neurological
changes.
Diuretic Phase
1. An increase in urine output
5L/day.
Recovery Phase
1. Recovery may take 6 months
to 2 years.
Treatment
Treatment of underlying cause
Treatment of complications
Fluids and electrolytes
imbalances
Pharmacology
Antibiotics
NSAIDs
Diuretics
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Chronic Kidney Disease
rISK FACTORS/causes
1. AKI
2. Hypertension
3. Urinary obstruction
4. Diabetes
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Slow, progressive and irreversible loss
of kidney function.(GFR <60mL/min).
Results in uremia, electrolyte
imbalances, hypervolemia or
hypovolemia.
Stages of CKD
At risk: >90mL/min
Mild CKD: 60-89mL/min
Moderate CKD: 30-59mL/min
Severe CKD: 15-29mL/min
ESKD: <15mL/min
NURSING MANAGEMENT
1. Monitor vital signs
2. Monitor cardiopulmonary system
3. Perform daily weights
4. Monitor lab values
5. Monitor intake and output
6. Low protein/sodium diet
7. Fluid restriction
8. Dialysis treatment
9. Administer medications
1. Hypertension, SOB
2. Kussmaul respirations
3. Oliguria/anuria
4. Uremia, Edema
5. Irritability, Restlessness
6. Pulmonary edema
7. Pulmonary effusion
8. Body weakness
9. Yellow-gray pallor
10. Proteinuria
Treatment
Hemodialysis
Peritoneal Dialysis
Kidney transplant
Pharmacology
Angiotensin-converting enzyme (ACE)
inhibitors
Angiotensin II receptor blockers
Diuretics
Corticosteroids
Erythropoietin supplements
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Glomerulonephritis
rISK FACTORS/causes
1. Immunological diseases
2. Strep throat
3. Autoimmune diseases
PATHOPHYSIOLOGY
A group of renal diseases caused
by immunologic response that
triggers the inflammation of the
glomerular tissue.
NURSING MANAGEMENT
1. Monitor vital signs (Bp), respiratory status
2. Monitor fluids and electrolytes level
3. Maintain fluid restrictions as ordered
4. Obtain daily weights
Patient Education
1. Medication adherence
2. Fluid restrictions
3. Dietary modifications
4. Increase carbohydrates in diet
sIGNS AND SYMPTOMS
1. Dark colored urine
2. Hematuria
3. Proteinuria
4. Azotemia
5. Oliguria
6. Edema
7. Elevated BP
8. JVD
9. Dyspnea
Treatment
Pharmacology
Antibiotics
Antihypertensive drugs
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Nephrotic Syndrome
rISK FACTORS/causes
1. Diabetes Mellitus
2. Heart failure
3. SLE
4. Amyloidosis
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Nephrotic syndrome is characterized
by excessive excretion of protein in
the urine (proteinuria), leading to low
protein levels in the blood
(hypoproteinemia).
This leads to edema and hypovolemia.
NURSING MANAGEMENT
1. Monitor vital signs
2. Monitor BP
3. Monitor lab values-protein
4. Intake and output charting
5. Obtain daily weights
6. Low salt/sodium diet/Low cholesterol
1. Periorbital and facial
edema
2. Ascites
3. Peripheral edema
4. Proteinuria
5. Hypoproteinemia
6. Hyperlipidemia
7. Electrolyte imbalance
8. Fatigue
9. Lethargy
Treatment
Pharmacology
Diuretics
ACE-Inhibitors/ ARBS
Corticosteroids
Immunosuppressant
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Renal Calculi
rISK FACTORS/causes
1. Dehydration
2. Family history
3. UTI
4. Hypercalcemia
5. Obesity
6. High calcium diet
PATHOPHYSIOLOGY
Renal calculi is also known as
kidney stones. Calculi is made up
of minerals and salt deposits that
is found in the urinary tract.
Types
Calcium stones
Cystine stones
Struvite stones
Uric acid stones
NURSING MANAGEMENT
1. Monitor vital signs, temperature
2. Pain management
3. Encourage fluid intake of 3L/day
4. Encourage ambulation
5. Monitor urine output
6. Strain urine
7. Administer medication as ordered.
Patient Education
1. Increase fluid intake
2. Dietary restrictions
sIGNS AND SYMPTOMS
1. Pain in the
costovertebral region
2. Fever
3. Persistent need to
urinate
4. Elevated RBC,WBC
noted in urine
Treatment
Treatment depends on the type, size and cause of
the calculi.
Pharmacology-antibiotics
Small Calculi
Increase water intake
Pain medications
Alpha blockers
Large Calculi
Extracorporeal shock wave lithotripsy (ESWL)
Surgical intervention
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Urinary Tract Infection
rISK FACTORS/causes
1. Vesicoureteral reflux
2. Urinary catheterscontinuous or long
term use
3. Female
4. Renal calculi
5. Sexual activity
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Acute pyelonephritis
Flank pain, Fever, chills,
bacteriuria, pyuria
UTI is the infection/inflammation of any
part of the urinary system.
Acute pyelonephritis: inflammation of
the kidneys
Cystitis: Inflammation of the bladder
Urethritis: Inflammation of the
urethra
Cystitis
Lower abdominal pain, burning
on urination, hematuria,
frequent urination, incontinence
Urethritis
Lower abdominal pain, burning
on urination, hematuria,
frequent urination, incontinence
.
NURSING MANAGEMENT
1. Monitor vital signs, temperature
2. Encourage fluid intake 3L/day
3. Monitor intake and output
4. Obtain daily weights
5. Administer medications as ordered
Patient Education
1. High calorie, low protein diet
2. Non-pharmacologic pain management
Treatment
Pharmacology
Antibiotics
Analgesics
Antipyretics
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Pyelonephritis
rISK FACTORS/causes
1. Vesicoureteral reflux
2. Urinary catheterscontinuous or long term
use
3. Female
4. Renal calculi
PATHOPHYSIOLOGY
Inflammation of the renal pelvis
caused by bacterial infection.
NURSING MANAGEMENT
1. Monitor vital signs
2. Monitor temperature
3. Encourage fluid intake 3L/day
4. Monitor intake and output
5. Obtain daily weights
6. Administer medications as ordered
Patient Education
1. High calorie, low protein diet
2. Non-pharmacologic pain management
sIGNS AND SYMPTOMS
1. Fever/chills
2. Flank pain
3. Costovertebral angle
tenderness
4. Hematuria
5. Tachypnea
6. Tachycardia
7. Nausea
8. Cloudy urine
9. Increased urine frequency
and urgency
10. Pyuria
11. Bacteriuria
Treatment
Pharmacology
Antibiotics
Analgesics
Antipyretics
Antiemetics
Urinary antiseptics
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NEUROLOGICAL disorders
1. Traumatic Head Injury
2. Meningitis
3. Stroke
4. Multiple Sclerosis
5. Seizures
6. Parkinson's Disease
Head Injury
rISK FACTORS/Causes
1. Falls
2. Sports injury
3. Vehicular accident
4. Violence
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Increased ICP
2. LOC changes
3. Confusion/altered mental
status
4. Papilledema
5. Body weakness
6. Seizures
7. Paralysis
8. Slurred speech
Trauma to the skull that causes brain
damage.
Types
Contusion
Concussion
Intracerebral hematoma
Subdural hematoma
Basilar skull fracture
Closed head injury
Complications:
Hematoma, Increased ICP,
Cerebral bleed, Seizures, CSF leakage,
infections
NURSING MANAGEMENT
1. Monitor respiratory status
2. Maintain patent airway
3. Assess neurological changes
4. Assess pupil size
5. Monitor vital signs
6. Monitor for signs of ICP
7. Prevent neck flexion
8. Monitor CSF drainage
9. Pain management
Signs and symptoms depends on
the type of injury and severity.
Treatment
Mild Injury
Close monitoring
Antibiotics
Wound care
Moderate to severe injury
Treatment focuses on increasing cerebral
oxygenation, maintaining BP and preventing
further injury.
Pharmacology
Anti-seizure medication
Mannitol, Dexamethasone, Furosemide.
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Meningitis
rISK FACTORS/causes
1. Streptococcus
pneumoniae
2. Neisseria meningitidis
3. Haemophilus
influenzae
PATHOPHYSIOLOGY
Meningitis is the inflammation of the
meninges. The meninges covers the brain
and spinal cord. Meningitis is mostly
caused by bacterial or viral infection.
NURSING MANAGEMENT
1. Infection control precautions
2. Monitor neurological status
3. Assess LOC
4. Monitor vital signs
5. Initiate seizure precautions
6. Administer antipyretics as ordered
7. Encourage and increase hydration
sIGNS AND SYMPTOMS
1. Fever
2. Headache
3. Skin rash
4. Rigidity of the neck
muscles (nuchal rigidity)
5. Decreased LOC
Treatment
Bacterial meningitis
Antibiotics
IV fluids: fluids replacement
Antipyretics
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Stroke
rISK FACTORS/causes
1. TIA
2. Hypertension
3. smoking
4. Atherosclerosis
5. Diabetes
6. High cholesterol
PATHOPHYSIOLOGY
Stroke is the loss of neurological
functions due to the lack of blood flow
to the brain.
Types
Ischemic Stroke (Clots)- an
obstruction in the blood vessel that
supplies blood to the brain.
Hemorrhagic Stroke (Bleeding)weakened blood vessel ruptures.
Transient Ischemic Attacktemporary stroke (a warning
stroke)
NURSING MANAGEMENT
1. Maintain patent airway
2. Administer 02
3. Administer tPA
4. Monitor VS-maintain BP @ 150/100
5. Monitor LOC
6. Monitor for signs of increase ICP
7. Elevate HOB
8. Administer IV fluids
9. Insert Foley's catheter
10. Prevention of DVT
11. Assist with self care and ADLs
sIGNS AND SYMPTOMS
1. Drooping of face
2. One sided weakness
3. Slurred speech
4. Blurred vision
5. Agnosia
6. High BP
7. Unilateral neglect
8. Apraxia
Treatment
An IV injection of recombinant tissue
plasminogen activator (tPA)-ischemic
stroke
Hemorrhagic stroke: stop bleeding.
Prevention of increased ICP
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Multiple Sclerosis
rISK FACTORS/causes
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Autoimmune disorders Multiple sclerosis is a CNS inflammatory
disease (chronic), characterized by
2. Viral infection
the demyelination axons. This
damage results in varied neurological
dysfunctions.
NURSING MANAGEMENT
1. Assess muscle function and mobility
2. Pain management
3. Assess sensory function
4. Monitor vision changes
5. Cluster nursing activities
6. Patient's safety measures
7. Encourage independence
8. Encourage bladder and bowel training
1. Weakness
2. Fatigue
3. Blurred vision
4. Nystagmus
5. Sensory loss
6. Dysphagia
7. Bowel and bladder
dysfunction
8. Electric-shock sensations
9. Neuralgias
Treatment
There is no cure. Treatment goal is
focused on managing symptoms, acute
attacks and slowing the progression of
the disease.
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Seizures
rISK FACTORS/causes
1. Meningitis
2. Head trauma
3. Stroke
4. Fever
5. Brain tumor
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Seizures is characterized by a sudden,
uncontrolled electrical disturbance in the brain.
Epilepsy: chronic seizure activity.
Types:
Generalized Seizures
Tonic-Clonic
Absence
Myoclonic
Atonic
Partial Seizures
Simple partial
Complex partial
NURSING MANAGEMENT
1. Assess time and duration of seizure activity
2. Provide patient safety
3. Turn patient to the side
4. Maintain airway
5. Avoid restraining patient
6. Loosen clothing
7. Administer O2
8. Monitor behavior before and after seizure
activity
The signs and symptoms depends
on seizure history and type.
Before seizure
1. Aura
During seizure
1. Loss of consciousness during
seizures
2. Uncontrollable
involuntary
muscle movements
3. Loss of bladder and bowel
control
After seizure
1. Headache
2. Confusion
3. Slurred speech
Treatment
Pharmacology
Anti-seizure medication
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Parkinson's Disease
rISK FACTORS/causes
1. Age >65
2. Family history
PATHOPHYSIOLOGY
A progressive neurological disease
characterized by depletion of
dopamine and acetycholine
imbalances.
NURSING MANAGEMENT
1. Neuro assessment
2. Assess ability to swallow
3. Provide patient's safety
4. Promote independence
5. Promote physical therapy
6. Diet: high calorie & soft diet
Treatment goal
1. Increase/maintain independence
2. Improve mobility
3. Improve nutritional status
sIGNS AND SYMPTOMS
Bradykinesia
Tremors
Slow movement
Blank facial expression
Posture: forward tilt
Rigidity of extremities
Pill rolling
Drooling
Treatment
Pharmacology
Carbidopa-levodopa
Dopamine agonist
Catechol O-methyltransferase (COMT)
inhibitors
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DISORDER:
rISK FACTORS/causes
PATHOPHYSIOLOGY
NURSING MANAGEMENT
sIGNS AND SYMPTOMS
Treatment
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Bleeding
Bleeding
Hypotension
Hypotension
Arrhythmias
Arrhythmias
Hypersensitivity
reaction
Hypersensitivity reaction
Thrombolytic drugs dissolve clots by
activating plasminogen that forms
plasmin.
FLASHCARDS
PART 2
A Review Guide For Nursing Students
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table of content
1. Thyroid Disorders
2. Pancreatic Disorders
3. Adrenal Cortex Disorders
4. Pituitary Gland Disorders
5. Skeletal Disorders
6. Hematology Disorders
7. Reproductive Disorders
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THYROID DISORDERs
1. Hypothyroidism
2. Hyperthyroidism
3. Hypoparathyroidism
4. Hyperparathyroidism
Hypothyroidism
rISK FACTORS/causes
1. Autoimmune diseases
2. Iodine deficiency or
excess
3. Thyroiditis
4. Thyroidectomy
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
The thyroid gland produce hormones
that are responsible for regulating the
body's metabolic rate (energy).
In hypothyroidism, the thyroid gland is
underactive (Hyposecretion of thyroid
hormones).
Remember: LOW ENERGY
NURSING MANAGEMENT
1. Monitor HR
2. Administer levothyroxine as prescribed.
Patient Education
1. Educate patient on medication compliance.
Levothyroxine is to be taken for a life-time.
2. Constipation: High fiber diet and increase fluids
3. Diet: low-calorie, high fiber diet
4. Weight reduction: exercise plan
1. Fatigue/body weakness
2. Weight gain
3. Oligomenorrhea
4. Hair loss
5. Bradycardia
6. Coldness
7. Constipation
8. Myxedema
Treatment
Pharmacology
Levothyroxine
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Hyperthyroidism
rISK FACTORS/causes
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
The thyroid gland produce hormones that
are responsible for regulating the body's
metabolic rate (energy)
In hyperthyroidism, the thyroid gland is
overactive (Hypersecretion of thyroid
hormones (T3 and T4))
Remember: HIGH ENERGY
1. Graves' disease
Thyroid Storm: acute and life-threatening
emergency for uncontrolled
hyperthyroidism.
NURSING MANAGEMENT
1. Monitor BP, P
2. Administer medications as prescribed.
3. Obtain daily weights
Patient Education
1. Educate patient on medication compliance
2. Diet: High calorie diet
3. Avoid stimulants
Thyroid Storm
1. Maintain patent airway
2. Medications: Antithyroid medication, Beta Blockers,
Glucocorticoids, Nonsalicylate antipyretics
3. Cooling blankets
1. Exophthalmos: bulging eyes
2. Palpitations
3. Tachycardia
4. Weight loss
5. Oligomenorrhea
6. Hot flashes
7. Irritability
8. Nervousness
9. Diarrhea
Thyroid Storm
1. Fever
2. Tachycardia
3. Hypertension/Increased RR
treatment
Pharmacology
Propylthiouracil (PTU)
Methimazole
Radioactive iodine therapy
Surgical Intervention
Thyroidectomy
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Hypoparathyroidism
rISK FACTORS/causes
1. Thyroidectomy (and
the removal of the
parathyroid).
PATHOPHYSIOLOGY
The parathyroid gland produces
the parathyroid hormone (PTH)
that maintains the serum calcium
level in the body.
Hypoparathyroidism is caused by
hyposecretion of parathyroid
hormones.
NURSING MANAGEMENT
1. Monitor BP, P
2. Monitor calcium/ phosphorus level
3. Administer medications as prescribed
4. Diet: high Calcium, low Phosphorus diet
5. Seizure precautions-(hypocalcemia)
sIGNS AND SYMPTOMS
1. Positive Trousseau's
sign
2. Positive Chvostek's sign
3. Hypocalcemia
4. Hyperphosphatemia
5. Hypotension
6. Tetany
7. Muscle cramps
8. Anxiety
9. Numbness and tingling
Treatment
Pharmacology
IV Calcium Gluconate
Vitamin D supplements
Phosphate binders
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Hyperparathyroidism
rISK FACTORS/causes
1. Chronic kidney failure
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
The parathyroid gland produces the
parathyroid hormone (PTH) that
maintains the serum calcium level in the
body.
Hyperparathyroidism is caused by
hypersecretion of parathyroid
hormones.
NURSING MANAGEMENT
1. Monitor BP
2. Monitor calcium/ phosphorus level
3. Increase fluid intake
4. Promote body alignment
5. Promote safety precautions
6. Administer medications as prescribed
7. Diet: High fiber/ moderate calcium
8. Pre and post operative care
(parathyroidectomy)
1. Hypercalcemia
2. Hypophosphatemia
3. Weight loss
4. High BP (Hypertension)
5. Bone and joint pain
6. Bone deformities
7. Fatigue
8. Cardiac dysrhythmias
9. Kidney stones
treatment
Pharmacology
Calcitonin
Bisphosphonates (oral/IV)
Furosemide
Phosphates
Surgical Intervention
Parathyroidectomy
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DISORDER:
rISK FACTORS/causes
PATHOPHYSIOLOGY
NURSING MANAGEMENT
sIGNS AND SYMPTOMS
Treatment
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pancreatic DISORDERs
1. Type 1 Diabetes
2. Type 2 Diabetes
3. Diabetes Ketoacidosis
4. Hyperosmolar
Hyperglycaemic State
5. Hypoglycemia
6. Hyperglycemia
Type 1 Diabetes
rISK FACTORS/causes
1. Autoimmune response
2. Genetics
3. Onset: childhood
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
A chronic condition in which the
pancreas (beta cells) is unable to
produce insulin.
NURSING MANAGEMENT
1. Monitor glucose levels
2. Insulin administration
Patient Education
1. Glucose monitoring
2. Insulin administration technique
1. Polyuria: increased
urination
2. Polydipsia: Increased
thirst
3. Polyphagia: Increased
appetite
4. Weight loss
5. Hyperglycemia
6. Blurred vision
Treatment
Pharmacology
Insulin
Monitoring
Continuous glucose monitoring
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Type 2 Diabetes
rISK FACTORS/causes
1. Obesity
2. Sedentary lifestyle
3. Hypertension
4. Hyperglycemia
5. Onset: adulthood
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Type 2 Diabetes is characterized by
insulin resistance and impaired insulin
secretion.
Complication: Hyperosmolar
Hyperglycaemic State
NURSING MANAGEMENT
1. Monitor glucose levels
2. Medication administration
Patient Education
1. Diabetic Diet
2. Exercise
3. Medication adherence
Polyuria: increased urination
Polydipsia: Increased thirst
Polyphagia: Increased
appetite
Weight gain
Poor wound healing
Fatigue
Blurred vision
Recurrent infections
Numbness and tingling of
hands and feet
Dry skin
treatment
Pharmacology
Oral hypoglycemic medications
Insulin
Nonpharmacologic therapy
Glucose monitoring
Dietary plan
Exercise regime
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Diabetic Ketoacidosis (DKA)
rISK FACTORS/causes
1. Onset: Sudden
2. Infection
3. Complication of Type 1
Diabetes
PATHOPHYSIOLOGY
DKA is a sudden, life-threatening
complication of Type 1 Diabetes.
Characteristics:
Hyperglycemia
Dehydration
Ketosis
Acidosis
NURSING MANAGEMENT
1. Monitor glucose levels
2. Administer IV insulin as prescribed
3. Administer IV fluids
4. Monitor potassium levels
5. Monitor cardiac status
6. Monitor signs of increased intracranial
pressure
sIGNS AND SYMPTOMS
1. Fruity breath
2. Kussmaul's respiration
3. Ketosis
4. Acidosis
5. Electrolyte loss
6. Lethargy
7. Coma
Treatment
IV fluid replacement
IV insulin: treat hyperglycemia
Correct electrolyte imbalance: Monitor
potassium levels
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Hyperosmolar Hyperglycaemic State (HHS)
rISK FACTORS/causes
1. Onset: Gradual
2. Infection
3. Complication of Type
2 Diabetes
PATHOPHYSIOLOGY
Hyperosmolar Hyperglycaemic
State (HHS) is a complication of
Type 2 Diabetes.
Characteristics:
Extreme hyperglycemia
There is no presence of ketosis
or acidosis
NURSING MANAGEMENT
1. Monitor glucose levels
2. Administer IV fluids
3. Monitor electrolyte levels
4. Administer insulin if applicable
sIGNS AND SYMPTOMS
1. Dehydration
2. Hyperglycemia
3. Electrolyte loss
4. Dry skin
5. Lethargy
treatment
IV fluid replacement
Insulin: If applicable
Correct electrolyte
imbalance
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Hypoglycemia
rISK FACTORS/causes
Too much insulin or
diabetic medication
Skipping meals
Increased physical
activity
PATHOPHYSIOLOGY
Hypoglycemia occurs when
there is a sudden decrease of
blood glucose level <60 mg/dL.
Mild: <60mg/dL
Moderate: <40mg/dL
Severe: <20mg/dL
NURSING MANAGEMENT
1. Assess glucose level
2. Administer 15g of simple carbohydrates
3. Recheck blood glucose level in 15 minutes
4. Administer 15 g of simple carbohydrates if necessary.
5. If blood glucose level is still <60mg/dL or in severe
cases (altered LOC): Administer 50% dextrose (IV)
sIGNS AND SYMPTOMS
1. Confusion
2. Palpitations
3. Blurred vision
4. Inability to concentrate
5. Fatigue
6. Body weakness
7. Lightheadedness
8. Diaphoresis
9. Cold and clammy skin
Remember: The symptoms
depends on the level of the
blood glucose.
Treatment
Simple carbohydrates
Glucagon (IV,IM)
50% Dextrose (IV)
Unconscious patients:(DO NOT ADMINISTER ORAL FOOD
OR FLUID)
1. Assess glucose level
2. Administer Glucagon (IV,IM) or 50% Dextrose (IV)
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Hyperglycemia
rISK FACTORS/causes
1. Diet
2. Inactivity
3. Not taking
insulin/diabetic
medication
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Hyperglycemia occurs when there
is an increase in blood glucose
>200mg/dL
NURSING MANAGEMENT
1. Assess glucose level
2. Insulin administration as prescribed
Education
1. Educate patient on glucose monitoring
2. Educate patient on diabetic diet
3. Educate patient on exercise.
1. Polyuria
2. Polyphagia
3. Polydipsia
4. Dehydration
5. Blurred vision
6. Fruity breath
7. Dry skin
treatment
Insulin
Glucose monitoring
Diabetic diet
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disorder:
rISK FACTORS/causes
PATHOPHYSIOLOGY
NURSING MANAGEMENT
sIGNS AND SYMPTOMS
Treatment
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ADRENAL CORTEX DISORDERs
1. Addison's Disease
2. Cushings
Addison's Disease
rISK FACTORS/causes
PATHOPHYSIOLOGY
1. Autoimmune disease Addison's disease is the inadequate
production of steroid hormones by
the adrenal cortex.
Addisonian Crisis: life-threatening
condition. Caused by stress,
infection or surgery.
NURSING MANAGEMENT
1. Monitor BP
2. Monitor daily weights
3. Monitor intake and output
4. Monitor electrolyte level
5. Monitor glucose level
6. Administer medications as prescribed
sIGNS AND SYMPTOMS
1. Weight loss
2. Fatigue
3. Lethargy
4. Hypotension
5. Hyperkalemia
6. Hypercalcemia
7. Hyponatremia
8. Hyperpigmentation
Treatment
Pharmacology
Glucocorticoid
Mineralocorticoid
Addisonian Crisis:
1. Administer glucocorticoids IV
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Cushings
rISK FACTORS/causes
1. Adrenal tumor
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Cushing syndrome is the excessive
level of adrenocortical hormones
(cortisol).
Remember: Addison's disease is
the hyposecretion of steroids.
Cushing syndrome is the
hypersecretion of steroids
NURSING MANAGEMENT
Monitor BP
Monitor daily weights
Monitor intake and output
Monitor electrolyte level
Monitor glucose level
Administer medications as prescribed
Prepare patient for adrenalectomy if
applicable
1. Moon face
2. Buffalo hump
3. Truncal obesity
4. Hypertension
5. Hyperglycemia
6. Hypernatremia
7. Hypocalcemia
8. Hypokalemia
9. Masculine features
(Hirsutism)
treatment
Chemotherapeutic agents:
for adrenal tumors
Glucocorticoid replacement:
lifelong
Surgical intervention:
Adrenalectomy
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DISORDER:
rISK FACTORS/causes
PATHOPHYSIOLOGY
NURSING MANAGEMENT
sIGNS AND SYMPTOMS
Treatment
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pituitary gland DISORDERs
1. Hypopituitarism
2. Hyperpituitarism
3. Diabetes Insipidus
4. SIADH
Hypopituitarism
rISK FACTORS/causes
1. Pituitary tumor
2. Head injury
3. Stroke
4. Autoimmune
5. Encephalitis
PATHOPHYSIOLOGY
Pituitary gland is located at the base
of the brain.
Hypopituitarism is the hyposecretion of
pituitary hormones.
Hormones that may be affected:
Growth hormone (GH)
Luteinizing hormone (LH) and
follicle-stimulating hormone (FSH)
Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone
(ACTH)
Anti-diuretic hormone (ADH)
NURSING MANAGEMENT
1. Daily weights
2. Hormonal replacement may be
prescribed
3. Provide emotional support
4. Allow patient to verbalize feelings
sIGNS AND SYMPTOMS
Signs and symptoms depend
on the hormone affected.
Growth Hormones:
1. Obesity, Decreased BP
TSH
1. Obesity, Fatigue,
decrease BP
ACTH
1. Sexual dysfunction
Gonadotropins
1. Sexual dysfunction
ADH
1. Low BP, Decreased CO
Treatment
Pharmacology
Hormone replacement
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Hyperpituitarism/ Acromegaly
rISK FACTORS/causes
PATHOPHYSIOLOGY
Pituitary gland is located at the
base of the brain.
Hyperpituitarism is caused by the
hypersecretion of growth
hormone.
1. Pituitary Tumors
NURSING MANAGEMENT
1. Administer medication
2. Prepare patient for hypophysectomy
if applicable
3. Provide emotional support
4. Pain management
sIGNS AND SYMPTOMS
1. Enlarged Organs
2. Large hands and feet
3. Hypertension
4. Cardiomegaly
5. Oily skin
6. Diaphoresis
7. Hyperglycemia
8. Husky-sounding voice
9. Sleep apnea
10. Joint pain
treatment
Pharmacology
Growth Hormone Receptor
Antagonist
Surgical Intervention
Hypophysectomy: removal of
pituitary tumor
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Diabetes Insipidus
rISK FACTORS/causes
1. Stroke
2. Trauma
3. Craniotomy
PATHOPHYSIOLOGY
Diabetes Insipidus is characterized by
the hyposecretion of ADH. This results
in abnormal increase in urine output.
Remember: Antidiuretic hormone
(ADH) causes the kidneys to release
less water.
If ADH level is low, there is an
increase in water loss.
NURSING MANAGEMENT
1. Monitor fluids and electrolytes
2. Monitor weights
3. Monitor intake and output
4. Monitor skin integrity
5. Administer hypotonic saline (IV)
6. Administer medications as prescribed
sIGNS AND SYMPTOMS
1. Polyuria
2. Diluted urine
3. Dry mucous membranes
4. Postural hypotension
5. Tachycardia
6. Low urinary specific
gravity
7. Headache
8. Body weakness
9. Fatigue
Treatment
Pharmacology
Desmopressin acetate/Vasopressin
IV Therapy
IV hypotonic saline
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SIADH
rISK FACTORS/causes
1. Stroke
2. Trauma
3. Lung disease
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
Syndrome of Inappropriate
Antidiuretics Hormone Secretion
(SIADH) is the secretion of ADH in
excess levels. This results in water
retention.
Remember: Antidiuretic hormone
(ADH) causes the kidneys to release
less water.
If ADH is high, there is an increase in
water retention.
NURSING MANAGEMENT
1. Monitor BP/P
2. Monitor serum Na levels
3. Initiate seizure precautions
4. Restrict fluid intake
5. Monitor weights
6. Elevate HOB
7. Administer medications as prescribed
1. Fluid overload
2. Weight gain
3. Hypertension
4. Hyponatremia
5. Tachycardia
6. Concentrated urine
7. Low urinary output
8. Nausea/Vomiting
treatment
Pharmacology
Loop diuretics
Vasopressin antagonists
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DISORDER:
rISK FACTORS/causes
PATHOPHYSIOLOGY
NURSING MANAGEMENT
sIGNS AND SYMPTOMS
Treatment
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SKELETAL DISORDERs
1. Gout
2. Rheumatoid Arthritis
3. Osteoarthritis
Gout
rISK FACTORS/causes
1. Diet
2. Obesity
3. Kidney disease
PATHOPHYSIOLOGY
Gout is a systemic disorder
characterized by elevated uric acid
and urate crystals that accumulate
deposits in the joints and other body
tissues.
Stages
Asymptomatic stage
Acute Gouty arthritis
Chronic Gout
sIGNS AND SYMPTOMS
1. Joint pain (Intense)
2. Inflammation
3. Swelling and
redness
4. Low grade fever
5. Pruritus
6. Tophi
Complications: Kidney stones
NURSING MANAGEMENT
1. Assess ROM
2. Diet: low-purine
3. Encourage fluid intake (2000mL/day)
4. Administer medications
5. Provide comfort and
nonpharmacologic interventions
Treatment
Pharmacology
Analgesics
Anti-inflammatory Agents
Uricosuric Agents
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Rheumatoid Arthritis
rISK FACTORS/causes
1. Higher risk in women
2. Age: Onset is most
frequent between
the ages of 40-50
sIGNS AND SYMPTOMS
1. Joint stiffness
2. Joint tenderness
3. Joint deformity
4. Pain (moderate to
severe)
5. Rheumatoid nodules
6. Fatigue
7. Fever
8. Weight loss
PATHOPHYSIOLOGY
Rheumatoid Arthritis is an
autoimmune disorder.
The immune system attacks the
joints, leading to dislocation and
permanent deformity.
NURSING MANAGEMENT
1. Assess pain
2. Administer medications as prescribed
3. Assess ROM
4. Provide nonpharmacologic pain management
such as positioning, heat or cold therapy.
5. Assess and assist patient with self care
6. Promote energy conservation
7. Pre and post operative care if applicable
treatment
Pharmacology
NSAIDs
Glucocorticoids
DMARDs: Disease-modifying
antirheumatic drugs
Surgical Intervention
A surgical intervention would be
recommended to restore function.
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Osteoarthritis
rISK FACTORS/causes
1. Aging
2. Obesity
3. Genetics
PATHOPHYSIOLOGY
Osteoarthritis is the most common
form of arthritis.
Osteoarthritis causes deterioration of
joint cartilage.
NURSING MANAGEMENT
1. Assess pain
2. Administer medications as prescribed
3. Assess ROM
4. Provide non-pharmacologic pain
management
5. Encourage balance between rest and
physical therapy (low impact exercises).
sIGNS AND SYMPTOMS
1. Joint pain
2. Joint stiffness
3. Crepitus
4. Swelling
5. Limited ROM
Temperature affects
symptom severity.
Treatment
Pharmacology
NSAIDs
Acetaminophen
Muscle relaxant
Therapy
Physical therapy
Surgical Intervention:
May be required
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HEMATOLOGY DISORDERs
1. Iron Deficiency Anemia
2. Thrombocytopenia
Iron Deficiency Anemia
rISK FACTORS/causes
1. Diet
2. Blood loss (GI bleeds)
3. Pregnancy
4. Mensuration
5. Inability to absorb
iron
PATHOPHYSIOLOGY
Iron deficiency anemia is characterized
by insufficient iron which leads to
depletion of red blood cells. This
results in decreased hemoglobin and
decreased oxygen-carrying capacity of
the blood.
NURSING MANAGEMENT
1. Administer Iron supplements as prescribed (Oral,
IM or IV)
2. Educate patient on the side effects of iron
supplements: Constipation and black stools
3. Educate patient on iron-rich diet/foods
4. Educate patient to increase vitamin C
consumption in their diet
5. Educate patient to take liquid iron supplements
with a straw to prevent teeth staining.
sIGNS AND SYMPTOMS
1. Fatigue
2. Pallor
3. Brittle nails
Treatment
Iron supplement
Treatment of underlying
cause
Diet: Iron-rich foods
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Thrombocytopenia
rISK FACTORS/causes
1. Bone marrow
disease
2. Autoimmune disease
3. Splenomegaly
4. Alcoholism
5. Anemia
PATHOPHYSIOLOGY
Platelets (thrombocytes) stops bleeding by
clumping and forming plugs in the blood
vessel injury site.
Thrombocytopenia is a condition
characterized by low blood platelet count.
Causes:
Platelet destruction: autoimmune
Platelet sequestration: trapped
platelet in the spleen (enlarged spleen)
Decreased platelet production: bone
marrow disease.
NURSING MANAGEMENT
1. Monitor lab values
2. Monitor INR, PT/PTT
3. Use electric razors
4. Avoid anticoagulants, aspirin and
thrombolytics
5. Protect patient from falls/injury
sIGNS AND SYMPTOMS
1. Easy bruising (Purpura)
2. Petechia
3. Prolonged bleeding
time
4. Bleeding gums
5. Epistaxis (Nose bleeds)
6. Blood in urine or stools
7. Heavy menstrual flows
treatment
Platelet transfusions
Corticosteroid treatment
Bone marrow transplant
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DISORDER
rISK FACTORS/causes
PATHOPHYSIOLOGY
NURSING MANAGEMENT
sIGNS AND SYMPTOMS
Treatment
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rEPRODUCTIVE DISORDERs
1. PCOS
2. Endometriosis
3. Pelvic Inflammatory
Disease
PCOS
rISK FACTORS/causes
1. Excess androgen
2. Heredity
PATHOPHYSIOLOGY
sIGNS AND SYMPTOMS
Polycystic ovary syndrome (PCOS) is a
hormonal disorder characterized by
excess androgen levels.
The ovaries may develop follicles.
NURSING MANAGEMENT
1. Educate patient on the importance of
a. Weight loss
b. Low fat diet
c. Medication adherence
d. Glucose monitoring
1. Diabetes
2. Infertility
3. Sleep apnea
4. Irregular periods
5. Polycystic ovaries
Treatment
Diet
Weight loss
Metformin
Oral contraceptives
Anti-androgens
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Endometriosis
rISK FACTORS/causes
1. No known cause
sIGNS AND SYMPTOMS
PATHOPHYSIOLOGY
1. Dysmenorrhea
2. Painful intercourse
3. Excessive bleeding
4. Infertility
Endometriosis occurs when the
tissues lining the uterus grows
outside the uterus.
With endometriosis, the tissues
outside the uterus thickens,
breaks down and bleeds with
each menstrual cycle.
NURSING MANAGEMENT
1. Educate patient on
a. Pain management
b. Anemia
c. Hormone therapy
treatment
Hormone therapy
Treatment of anemia
Surgical Intervention
Hysterectomy
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Pelvic Inflammatory Disease
rISK FACTORS/causes
1. Being sexually active
2. Having multiple
partners
3. Unprotected
intercourse
PATHOPHYSIOLOGY
Pelvic inflammatory disease (PID) is
an infection of the female
reproductive organs
NURSING MANAGEMENT
1. Educate patient on
a. Antibiotic regimen
b. Protected intercourse
c. Treatment of partner
d. Temporary abstinence
sIGNS AND SYMPTOMS
1. Fever
2. Pelvic pain
3. Increased vaginal
discharge
Treatment
Antibiotics
Treatment for partner
Temporary abstinence until treatment
is complete
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REPRODUCTIVE DISORDERs
1. Varicocele
Varicocele
rISK FACTORS/causes
1. No known risk factors
PATHOPHYSIOLOGY
Varicocele is the enlargement of the
veins that transport oxygendepleted blood away from the
testicles.
NURSING MANAGEMENT
1. Educate patient to
a. Wear athletic supporter to relieve
pressure
sIGNS AND SYMPTOMS
1. Dull pain in scrotum
2. Varicocele may be
visible
3. Swelling
Treatment
Treatment depends on the
severity and complications
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shock
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what is shock?
Shock is an acute, life-threatening condition in which the body is not
getting enough blood flow to maintain the normal supply of oxygen
and nutrients for optimal cell function.
This leads to hypoxia (lack of oxygen at the tissue level).
COMPLICATIONS
1. Multiple organ
dysfunction syndrome
2. Disseminated
intravascular
coagulation
Circulatory failure
Decreased CO
Lack of blood perfusion to vital organs
summary of the types of shock
CARDIOGENIC SHOCK
Occurs due to the heart's inability to pump enough blood
HYPOVOLEMIC SHOCK
Severe bleeding or fluid loss (burns, trauma)
ANAPHYLACTIC SHOCK
Severe allergic reaction (drugs, food, insect bite)
SEPTIC SHOCK
Occurs due to an infection. Severe complication of sepsis
NEUROGENIC SHOCK
Occurs due to damage to the nervous system
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shock
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INITIAL STAGE
INITIAL STAGE
OH NO! The body is not getting enough blood!
The level of oxygen is low! We are experiencing cell hypoxia!
Sorry guys! I need to start performing anaerobic metabolism
REFRACT PROG
COMP
Things are getting worse! Lactic acid is accumulating
COMPENSATORY STAGE
The body is here to SAVE THE DAY! We need to work
together to increase cardiac output and blood volume
PROGRESSIVE STAGE
OH NO! We failed! Now our vital organs are compromised
and the shock cannot be reversed
REFRACTORY STAGE
Brain damage + cell death
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stages of shock
INITIAL STAGE
1. Decreased cardiac output causes the cells to be deprived of
oxygen
2. The cells begin to perform anaerobic metabolism
3. Anaerobic metabolism causes the build up of lactic acid
which leads to metabolic acidosis
4. The liver is unable to remove and breakdown lactic acid
because of the lack of oxygen.
WHAT WILL YOU SEE IN THIS STAGE
1. Decreased cardiac output
2. Decreased mean arterial pressure (MAP)
3. Elevated serum lactate
COMPENSATORY STAGE
1. During this stage, the body is here to SAVE THE DAY!
2. The body tries to compensate and intervene to
stop/overcome the shock.
3. The body tries to increase the CO + blood volume
WHAT WILL YOU SEE IN THIS STAGE
1. Respiratory: Hyperventilation
2. Skin: Cool and clammy or Warm/flushed
3. Cardiac: Increase HR
4. GU: Oliguria may develop
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stages of shock
PROGRESSIVE STAGE
1. The SAVE THE DAY plan did not work and the body's
intervention failed.
2. Vital organs are compromised and the shock cannot be
reversed
3. Anaerobic metabolism continues and metabolic acidosis
increases.
4. Leakage of fluid in the surrounding tissues (capillary
permeability) + blood viscosity increases.
WHAT WILL YOU SEE IN THIS STAGE
1. CNS: Altered mental status
2. RESP: Acute respiratory distress syndrome
3. CARDIAC: Decreased CO+ tissue perfusion,
4. Skin: Cyanosis
5. GU: Oliguria, GI: GI bleeding
REFRACTORY STAGE
1. Vital organs fails and the shock is irreversible
2. Brain damage + cell death
WHAT WILL YOU SEE IN THIS STAGE
1. Unconsciousness
2. Brain damage
3. Cell death
4. Impending death
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cardiogenic shock
cardiogenic shock
Cardiogenic shock occurs due to the heart's
inability to pump enough blood. Pulmonary
edema will occur due to back up of blood.
HEART
FAILURE
MI
MYOCARDITIS
HEART
VALVE
DISEASE
causes
cardiogenic shock
signs and symptoms
treatment
1. Oxygen therapy
1. CARDIAC: Fast, weak pulse,
2. Pain management
decreased systolic blood
3. Hemodynamic monitoring
pressure, chest pain
4. Intra-aortic balloon pump
2. RESP: Orthopnea, rapid, shallow
Pharmacology:
respirations, crackles
1. Vasopressors and inotropes
3. SKIN: Cool/Clammy Skin,
cyanosis
Cyanosis
4. GU: Oliguria, CNS: Confusion
nursing management
1. Monitor patient's vital signs
2. Initiate O2 therapy
3. Administer IV fluids as prescribed and monitor for any signs of fluid overload
4. Place a catheter and monitor urine output
5. Provide supportive care
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hypovolemic shock
hypovolemic shock
Hypovolemic shock occurs when there is a
loss in intravascular blood volume due to
severe bleeding or fluid loss
Internal
bleeding
severe
bleeding,
vomiting,
diarrhea
burns
causes
hypovolemic shock
signs and symptoms
1. CARDIAC: Hypotension,
tachycardia(rapid, weak and thready
pulse)
2. RESP: Rapid, shallow breathing
3. SKIN: Pale, Cool/Clammy Skin
4. GU: Oliguria
5. CNS: Confusion, restlessness, anxiety
treatment
1. Treat the underlying cause
of the severe blood or fluid
loss
2. Fluid resuscitation
nursing management
1. Monitor patient's vital signs, temperature, capillary refill, I/0
2. Monitor patient's level of consciousness
3. Initiate O2 therapy
4. Initiate IV fluid therapy
5. Blood transfusion may be required
6. Patient position: Supine with the legs elevated
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Distributive shock
Distributive shock results from excessive vasodilation
and the impaired distribution of blood flow.
1. ANAPHYLACTIC SHOCK
2. SEPTIC SHOCK
3. NEUROGENIC SHOCK
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ANAPHYLACTIC SHOCK
anaphylactic shock
Anaphylactic shock occurs due to a severe
allergic reaction (drugs, food, insect bite, etc)
1. Reintroduction to the sensitized allergen
2. IgE binds to the antigen
3. Activation of mast cells + basophils
4. The mast cells then release massive amounts
of histamine + other inflammatory mediators
5. Massive vasodilation occurs + decrease tissue
perfusion
6. Bronchospasm & laryngeal edema may occur
anaphylactic shock
signs and symptoms
1. CARDIAC: Tachycardia,
hypotension
2. RESP: Shortness of breath,
bronchoconstriction
3. SKIN: Hives, flushed, itching,
localized edema
4. GU: Oliguria
5. CNS: Decreased LOC
treatment
(This is a medical emergency)
1. O2 therapy
2. IV therapy
Pharmacology:
1. Epinephrine
2. Albuterol
3. Antihistamines
4. Hydrocortisone (corticosteroids)
nursing management
1. Remove allergen, maintain patent airway
2. Monitor vital signs
3. Administer epinephrine promptly
4. Initiate 02 therapy
5. Initiate IV therapy & monitor urine output
6. Position: supine position with leg elevated
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SEPTIC SHOCK
septic shock
Septic shock occurs due to an infection.
(Severe complication of sepsis). This
results in vasodilation and increased
capillary permeability due to the release of
histamines and proteolytic enzymes.
1. invasive procedures
2. Immunocompromised Patients
3. Malnourishment
4. Elderly people
risk factors
septic shock
signs and symptoms
1. CARDIAC: Hypotension, tachycardia
2. RESP: increased respirations
3. SKIN: Initial stage-flushed & warm
4. GU: Oliguria (late stage)
5. Immune: Fever
6. CNS: Anxiety, restlessness,
lethargy
treatment
1. IV fluid therapy
2. Oxygen therapy
3. Mechanical ventilation
(intensive care) may be
required
Pharmacology
1. Antibiotics, Inotropes
nursing management
1. Monitor vital signs
2. Monitor respiratory status
3. Initiate IV fluids and oxygen therapy
4. Administer medication as prescribed
5. Nutritional therapy
6. Fever management
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NEUROGENIC SHOCK
neurogenic shock
Neurogenic shock occurs due to damage to the
nervous system. There is a loss of sympathetic
nerve activity which results in vasodilation.
SPINAL
CORD
INJURY
INJURY OF
THE
BRAIN STEM
Spinal
anesthesia
cause
VASODILATION
neurogenic shock
signs and symptoms
1. CARDIAC: Hypotension,
bradycardia
2. SKIN: Dry, warm skin
3. Depending on the type of
injury, patient may have no
bladder control and
diaphragmatic breathing
treatment
1. IV fluid therapy
2. O2 therapy
Pharmacology:
1. Inotropic agents
2. Atropine: severe bradycardia
nursing management
1. Perform neurologic assessment
2. Maintain patent airway
3. Monitor vital signs
4. Initiate O2 therapy and IV fluids as prescribed
5. Foley catheter for patients who do not have bladder control
6. Maintain proper alignment of spine
7. Administer medication as prescribed
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TEMPLATES
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cardiogenic shock
cardiogenic shock
causes
cardiogenic shock
signs and symptoms
treatment
nursing management
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hypovolemic shock
hypovolemic shock
causes
hypovolemic shock
signs and symptoms
treatment
nursing management
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ANAPHYLACTIC SHOCK
anaphylactic shock
anaphylactic shock
signs and symptoms
treatment
nursing management
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SEPTIC SHOCK
septic shock
risk factors
septic shock
signs and symptoms
treatment
nursing management
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NEUROGENIC SHOCK
neurogenic shock
cause
VASODILATION
neurogenic shock
signs and symptoms
treatment
nursing management
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REVISION notes
summary
cardiogenic shock
summary
hypovolemic shock
summary
ANAPHYLACTIC SHOCK
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REVISION notes
summary
SEPTIC SHOCK
summary
NEUROGENIC SHOCK
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Hepatitis is characterized by the inflammation of the liver tissues.
1. VIRUS
2. BACTERIA
1. ALCOHOL
2. MEDICATIONS
3. TOXINS
FECAL-ORAL (FOOD+WATER)
BLOOD & BODY FLUIDS
BLOOD & BODY FLUIDS
OCCURS WITH HEP B
FECAL-ORAL (FOOD+WATER)
1. Production of bile
2. Glucose metabolism
3. Bilirubin excretion
4. Drug metabolism
5. Fat and protein
metabolism
6. Clotting factors
7. Filters and remove toxins
8. Ammonia conversion
1. Incubation period: virus
multiplies and spreads
(no symptoms)
2. Prodromal (pre-icteric)
phase: 1-5 days. S/S:
anorexia, malaise,
nausea and vomiting,
RUQ pain
3. Icteric phase: dark
urine, jaundice, weight
loss, RUQ pain.
4. Recovery phase: pt
signs and symptoms
improves.
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1. BLOOD TEST:
a. ALT & AST (elevated)
b. Bilirubin
2. STOOL SAMPLE:
a. Hepatitis A
3. URINE SAMPLE:
a. Bilirubin
4. LIVER BIOPSY
5. LIVER ULTRASOUND
1. Prevention: Immunization
(Vaccines for hepatitis A and
hepatitis B)
2. Prevention: hand-hygiene
3. Rest
4. Diet (high carbs, high calories)
(low protein and low fat)
5. Hepatitis B: Antiviral
medications
In patients with findings
suggesting acute viral
hepatitis, the following
studies are done to screen for
hepatitis viruses A, B, and C:
IgM antibody to HAV (IgM
anti-HAV)
Hepatitis B surface
antigen (HBsAg)
IgM antibody to hepatitis
B core (IgM anti-HBc)
Antibody to HCV (antiHCV)
Hepatitis C RNA (HCVRNA) polymerase chain
reaction (PCR)
1. Assess GI status
2. Monitor daily weights
3. Promote high carbs, high calories, low protein and fat diet
4. Pt. Education: hand hygiene, avoid alcohol, avoid sex during
treatment
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BUR
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Three layers of the skin:
1. Epidermis
2. Dermis
3. Hypodermis
Definition:
Burns lead to:
1. Infection
2. Hypothermia
3. Disturbed body image
4. Changes in level of
independence/function
Damage of the layers of the skin caused by heat, chemicals, or radiation
PATHOPHYSIOLOGY of burns:
1. Injured tissue releases vasoactive substances
2. Fluid shift
a. Increased capillary permeability (lasts for 26 hours)
b. Blood vessels dilate and leak fluid into interstitial space
c. Amount of fluid shift depends on extent of injury
d. Body edema
e. Decreased intravascular blood volume
3. Hyper K+ due to cell damage + hypo Na
4. Cardiac: increased HR, decreased CO
5. Respiratory: Airway edema, pulmonary cap. leakage
6. Immune system: diminished response, Increased risk of infection
7. Renal: oliguria
8. GI: Paralytic ileus may occur due to lack of blood flow to the GI system
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1. Thermal burn: external heat
sources that raise the
temperature of the skin and
tissues.
2. Radiation burns: prolonged
exposure to ultraviolet rays of
the sun.
3. Chemical burns: caused by
solvents
4. Electrical burns: burns caused
by electrical currents
5. Friction burns: caused by heat
generation through friction
6. Inhalation: respiratory injury
(inhales combustion during a
fire)
Definition: inhales combustion
during fire.
Remember: priority is airway
management.
Nursing Assessment:
1. Facial burns
2. SOB, wheezing, cough,
nasal flaring, stridor
Carbon Monoxide Poisoning
1. Carbon monoxide is a
poisonous gas that has no
smell or taste.
Nursing Assessment: cherry red
discolouration.
superficial burn:
-Affects the epidermis, mild redness with pain, no blisters
superficial partial-thickness burn:
-Affects the epidermis + dermis, redness, swelling, pain, large blisters
FULL-thickness burn:
-Affects the epidermis + dermis + hypodermis. May appear white, deep
red, yellow, brown or black.
No sensation. Requires skin grafting
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1. The front and back of the head and neck equal 9% of the body's
surface area.
2. The front and back of each arm and hand equal 9% of the body's
surface area.
3. The chest equals 9% and the stomach equals 9% of the body's
surface area.
4. The upper back equals 9% and the lower back equals 9% of the
body's surface area.
5. The front and back of each leg and foot equal 18% of the body's
surface area.
6. The genital area equals 1% of the body's surface area.
The size of a burn
can be quickly
estimated by using
the "rule of nines."
This method divides
the body's surface
area into
percentages.
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remember: Fluid
shift
1. Duration: first 24 hours
2. Maintain patent airway
3. IV fluid therapy
s
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1. Patient will experience
tachycardia, low cardiac
output and low blood
pressure.
1. Hgb/Hct…elevated due to fluid loss
2. Glucose…elevated due to stress response
3. Sodium…decreased
4. Potassium…increased due to tissue destruction
5. Albumin…decreased
6. ABG’s
a. pO2…decreased
b. pCO2…increased due to resp injury
c. pH…decreased metabolic acidosis
d. CO…elevated-smoke inhalation
Maintain patent airway
Administer IV fluids
Monitor lab values
Monitor vital signs
Monitor output (Foley's
catheter)
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remember: capillary
permeability is restored
1. Duration: 48-72 hours after injury
2. Goal of care:
a. prevent infection-antibiotics
b. nutrition
c. pain management
d. wound closure
1. High protein diet
2. High carbohydrate diet
3. High vitamins in diet
4. Calories: >5000(severe
burns)
1. Prevent ulcers
a. Antacids, H2 receptor
antagonist
2. Prevent infection
a. Antibiotics
3. Pain management
a. Opioid analgesics (IV)
remember: Beyond hospitalization
Goal:
1. Focus on patient reaching maximum level of function.
2. Body image
3. Self esteem
4. Activities of daily living
5. Emotional support
6. Promote wound healing
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respiratory disorders
Chest Tubes
Chest tubes are inserted in the pleural space to remove air, fluid or blood
and restore lung expansion.
UWSD-Under Water Sealed Drains
CONDITIONS THAT REQUIRES CHEST TUBE INSERTION
Pleural effusion: Accumulation of fluid in the pleural space.
Fluid accumulates between the visceral and parietal pleura
of the lungs.
Pleural fluid: transudate or exudate
Hemothorax: Accumulation of blood in the pleural cavity.
Pneumothorax: Air leaks into pleural space. Pleural space is exposed
to positive atmospheric pressure (pressure is normally negative).
Causes impaired lung expansion.
Results in full lung collapse or partial lung collapse.
Types
Spontaneous pneumothorax
Tension pneumothorax
Traumatic pneumothorax
Post-surgical intervention: e.g. cardiac surgery. A chest tube is
inserted to prevent complications. It ensures that fluid and air is
drained fluently from the pleural space.
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CHEST TUBE
types
1. Wet suction system
2. Dry suction system
CHAMBERS
Drainage collection chamber
1.Drainage collection chamber:
collects drainage from the
pleural cavity. Located at the
right side of the system where
the chest tube connects to the
system.
Wet suction system: regulate suction
pressure by the height of the column
of water in the suction control
chamber.
Dry suction system: uses a selfcontrolled regulator that controls the
amount of suctioning.
Water seal chamber
2. water seal chamber: the
water in the underwater seal
fluctuate with inspiration and
expiration.
Excessive bubbling: air leak
Suction control chamber
dry suction system
3. Suction control chamber:
In a wet suction systemcontrolled by the level of water
in the suction control chamber.
In a dry suction system: selfregulator controls the amount of
suctioning.
wet suction system
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nursing interventions
nursing interventions
assessment
1. Vital signs-Bp, HR, SPO2, RR
2. Pain assessment
3. Assess respiratory status/auscultate lung sounds
4. Monitor for any signs of infection at the insertion site.
DRAINAGE collection chamber
1. Monitor drainage: Normal (<100mL(cc)/hour). Notify HCP if
drainage is >100mL(cc)/hour)
a. Note the color: unexpected bloody fluids, and cloudiness.
water seal chamber
1. If the water does not fluctuate, there is a kink or the lungs have
reexpanded.
2. Air is removed through the tube, but air is prevented from entering
the lungs.
3. Continuous bubbling: air leakage.
4. Patient with pneumothorax: intermittent bubbling in the water seal
chamber (assess dislodgment and disconnection)
Suction control chamber
1. Wet suction chamber: gentle bubbling is noted.
other nursing considerations
1. Maintain chest tube drainage system below patient's chest
2. Ensure that the connection is secured
3. Keep the tube free from any kinks or obstructions.
4. Do not milk chest tube (unless indicated by physician).
5. Avoid clamping chest tube without prescription.
6. Drainage breaks: insert tubing (1 inch) into a bottle of sterile water.
7. Dislodged chest tube: cover the insertion site (sterile dressing),
tape 3 sides and notify the physician.
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ELECTROLYTE
IMBALANCE
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HYPERVOLEMIA
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Definition:
Increase in extracellular fluid volume. Fluid and sodium
retention. Also known as fluid overload or excess fluid volume
Function:
Extracellular fluid are body fluid located outside of the cell.
The extracellular fluid provides a medium for exchanges of
substances between the ECF and the cells.
Causes:
1. Heart failure
2. Liver cirrhosis
3. Excess fluid/ sodium
intake
4. Renal failure
Nursing Interventions
Symptoms:
1. Elevated BP
2. Bounding pulse
3. Ascites
4. JVD
5. Edema
6. SOB/crackles
7. S3 heart sound
8. Urine specification <1.010
6. Obtain daily weight
1. Monitor Bp and pulse
2. Monitor respiratory status 7. Restrict sodium intake
3. Monitor intake and output 8. Monitor lab values
4. Fluid restriction
5. Diuretics
HYPOVOLEMIA
Definition:
Hypovolemia is the loss of extracellular fluid.
Function:
Extracellular fluid are body fluid located outside of the cell.
The extracellular fluid provides a medium for exchanges of
substances between the ECF and the cells.
Causes:
1. Vomiting
2. Diarrhea
3. Continous GI suctioning
4. Hemorrhage
5. DKA
6. Burns
7. Adrenal desease
8. Systemic infection
Nursing Interventions
1. Monitor Bp and pulse
2. Administer isotonic IV fluids
3. Encourage fluids
4. Monitor intake and output
Symptoms:
1. Decreased Bp
2. Tachycardia/weak pulse
3. Decreased urinary output
4. Poor skin turgor
5. Restlessness/Confusion
6. Dry mucus membranes
7. Thirst
6. Assess skin turgor
7. Assess hydration levels
8. Assess urine specific gravity
9. Monitor lab values
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Na
nursebossstore.bigcartel.com
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HYPERNATREMIA
135-145mEq/L
Definition:
Sodium serum level >145 mEq/L
Function:
Sodium is mostly found in the extracellular fluid.
Sodium helps to maintain concentration of extracellular fluid,
neuromuscular function, sodium-potassium pump and acid-base
balance.
Causes:
Symptoms:
Cardiac: Tachycardia,
Increased BP
GI: Thirst
GU: Oliguria
Neuro: Restlessness,
anxiety
Skin: Edema
1. Dehydration
2. Diabetes insipidus
3. Fluid loss-GI
4. Cushing Syndrome
5. Increased Na Intake
Nursing Interventions
1. Monitor Bp
2. Monitor respiratory status
3. Monitor neurologic status
4. Monitor intake and output
Na
5. Obtain daily weight
6. Monitor serum sodium levels
7. Increase hydration
8. Low sodium diet
HYPONATREMIA 135-145mEq/L
Definition:
Sodium serum level <135 mEq/L
Function:
Sodium is mostly found in the extracellular fluid.
Sodium helps to maintain concentration of extracellular fluid,
neuromuscular function, sodium-potassium pump and acid-base
balance.
Causes:
1. Diuretics
2. Diarrhea
3. Vomiting
4. Congestive HF
5. Hyperglycemia
6. Medication
7. Continuous gastric
suctioning
Nursing Interventions
1. Monitor Bp
2. Monitor respiratory status
3. Monitor neurologic status
4. Monitor intake and output
5. Institute seizure
precautions
Symptoms:
Cardiac: Tachycardia, thready
pulse, hypotension
GI: Nausea, Vomiting
Neuro: Restlessness, headache
dizziness, weakness,seizure
6. Assess skin turgor
7.Obtain daily weight
8. Monitor serum sodium levels
9. Fluid intake restriction
10. High sodium diet
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K
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HYPERKALEMIA
3.5-5.5 mEq/L
Definition:
Potassium serum level >5.5 mEq/L
Function:
Potassium is mostly found in the intracellular fluid. Potassium
participates in potassium-sodium pump and neuromuscular
function.
Causes:
Symptoms:
Cardiac: V-fib, T wave elevation,
prolonged PR, Flat P wave, Wide QRS
GI: Abdominal cramps
GU: Oliguria
Neuro: Numbness, tingling,
hyperreflexia, flaccid paralysis
Risk: Cardiac arrest
1. Kidney failure
2. Trauma
3. Sepsis
4. Potassium-sparing
diuretics
5. Addison's disease
6. Dehydration
7. Metabolic acidosis
Nursing Interventions
K
1. Monitor cardiac status
2. Monitor HR and rhythm
3. Monitor intake and output
4. Low potassium diet
HYPOKALEMIA
3.5-5.5mEq/L
Definition:
Potassium serum level <3.5 mEq/L
Function:
Potassium is mostly found in the intracellular fluid. Potassium
participates in potassium-sodium pump and neuromuscular
function.
Causes:
1. Diarrhea
2. Vomiting
3. Gastric suctioning
4. Low potassium diet
Symptoms:
Cardiac: Hypotension, Arrhythmias,
Flattened T-wave, ST depression
GI: Nausea, Vomiting, decreased
peristalsis
GU: Polyuria
Neuro: Dizziness, weakness,
decreased reflexes, Metabolic
Alkalosis
Nursing Interventions
5. Monitor potassium level
1. Monitor cardiac status
6. Monitor hydration status
2. Monitor HR and rhythm
3. Monitor intake and output
4. High potassium diet
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Ca
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HYPERCALCEMIA
8.5-10.5mEq/L
Definition:
Calcium serum level >10.5 mEq/L
Function:
Calcium is a cation that contributes to bone strength,
necessary for hormonal secretion, cardiac conduction and
participates in the sodium-potassium pump.
Causes:
Symptoms:
1. Bone cancer
2. Hyperparathyroidism
3. Hyperthyroidism
4. AKI
5. Rhabdomylysis
6. High Vitamin D intake
Cardiac: Increased BP, heart block
(may lead to cardiac arrest)
GI: Dehydration, constipation,
polydipsia
GU: Polyuria, kidney pain
Neuro: Confusion, irritability
Musculoskeletal: Bone pain
Nursing Interventions
1. Monitor cardiopulmonary 4. Monitor cardiac rhythms
status
5. Monitor serum calcium levels
2. Monitor neurologic status 6. Low calcium diet
3. Monitor vital signs
Ca
HYPOCALCEMIA
8.5-10.5mEq/L
Definition:
Calcium serum level <8.5 mEq/L
Function:
Calcium is a cation that contributes to bone strength,
necessary for hormonal secretion, cardiac conduction and
participate in the sodium-potassium pump.
Causes:
1. Lack of Vitamin D intake
2. Lack of Calcium intake
3. Hypoparathyroidism
4. Hypothyroidism
5. Burns
6. Sepsis
7. Kidney/liver disease
Symptoms:
Cardiac: Arrhythmias, Bradycardia,
Hypotension, weak pulse
Neuro: Paresthesia, muscle spasms,
seizures, Trousseau signs, Chvostek
signs
Resp: Dyspnea, Lanryngospasm
Nursing Interventions
1. Monitor cardiac status
5. Seizure precautions
2. Monitor HR and rhythm
6. Assess neuromuscular movements
3. Monitor respiratory status 7. Increase Vit D and calcium intake
4. Monitor calcium levels
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Mg
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HYPERMAGNESEMIA 1.3-2.1mEq/L
Definition:
Magnesium serum level >2.1 mEq/L
Function:
Magnesium regulates the intracellular fluid calcium levels.
Magnesium has an effect on the myoneural junction, skeletal
muscles, parathyroid hormone secretion and cardiac contraction.
Causes:
Symptoms:
1. Laxative use that
contains Mg
2. Use of antacid
(containing Mg)
3. Renal dysfunction
4. Decreased adrenal
function
Nursing Interventions
Cardiac: Hypotension, bradycardia,
weak pulse, cardiac arrest
Resp: Dyspnea, low RR
Neuro: Confusion, dilated pupils,
lethargy
Musculoskeletal: Muscle weakness,
facial paresthesia, decreased
reflexes
1. Monitor cardiopulmonary 3. Intake and output
status
4. Monitor neurologic status
2. Monitor respiratory status,5. Decrease Mg dietary intake
Bp and P.
6. Avoid laxatives
Mg
HYPOMAGNESEMIA
1.3-2.1mEq/L
Definition:
Magnesium serum level <1.3 mEq/L
Function:
Magnesium regulates the intracellular fluid calcium levels.
Magnesium has an effect on the myoneural junction, skeletal
muscles, parathyroid hormone secretion and cardiac contraction.
Causes:
1. Chronic alcoholism
2. Hyperaldosteronism
3. Diabetic ketoacidosis
4. Malabsorption,
Malnutrition
5. Chronic diarrhea
6. Dehydration
Symptoms:
Cardiac: Arrhythmias, Tachycardia,
High BP
Neuro: Seizures, Delusions,
Hallucinations
Neuromuscular: Tetany, Chvostek
signs,Positive Trousseau's
Nursing Interventions
1. Assess level of
consciousness
2. Assess VS
3. Monitor Mg levels
4. Monitor Intake and output
5. Monitor cardiopulmonary status
6. Increase Mg dietary intake
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EKG
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table of content
1. Terminologies
2. Electrical Conduction
3. EKG Breakdown
4. EKG Interpretation
5. 5-Lead Placement
6. Electrolyte Imbalance
7. Normal Sinus Rhythm
8. Sinus Bradycardia
9. Sinus Tachycardia
10. Sinus Arrhythmia
11. Premature Atrial Contractions (PAC)
12. Atrial Fibrillation
13. Atrial Flutter
14. Premature Junctional Contraction (PJC)
15. Premature Ventricular Contractions (PVC)
16. Ventricular Tachycardia
17. Ventricular Fibrillation
18. First-Degree Block
19. Second-Degree AV Block (TYPE 1)
20. Second-Degree AV Block (TYPE 2)
21. Third-Degree AV Block
22. Aystole
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the
basics
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terminologies
ekg/ecg: is a test that measures the electrical signals in the heart.
bradycardia: slow heart beat <60bpm
tachycardia: fast heart beat >100bpm
normal sinus rhythm:
Electrical impulse from the sinus node is properly transmitted.
sinus tachycardia:
SA node firing faster than 100 bpm
sinus bradycardia:
SA node firing at less than 60 bpm
sinus ARRYTHMIA:
A cyclic change associated with respiration.
CARDIOVERSION:
Cardioversion is done by sending electric shocks (lower amount of
energy) to the heart through electrodes placed on the chest.
Synchronized shock, not done with CPR
defibrillation
Defibrillation is the treatment for immediately life-threatening
arrhythmias with which the patient does not have a pulse, ie
ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).
This uses a higher amount of energy, with CPR.
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ELECTRICAL CONDUCTION
SA NODE:
Sinoatrial Node
Pacemaker of the heart.
Impulse starts at the SA node.
M
P
B
00
1
0
6
:
S
T
A
BE
AV NODE:
Atrioventricular Node
Impulse travels from the SA node to
the AV node. Known as the
gatekeepers. Causes a delay so that
the atrium can fully empty into the
ventricles.
BUNDLE OF HIS:
The impulse travels through the
Bundle of His which branches
out into the right and left
branch bundles
M
P
B
0
-6
0
4
:
S
T
A
E
B
M
P
B
0
6
40
:
S
T
A
E
B
purkinje fibers:
The impulse travels to the
purkinje fibers.
M
P
B
40
0
2
:
S
T
A
BE
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ELECTRICAL CONDUCTION
p wave
QRS
COMPLEX
P wave: represents atrial
depolarization (contraction)-SA
NODE IS RESPONSIBLE.
qrs complex
R
U wave: U wave may be seen
following the T wave. This is not
common.
ST
SEGMENT
P
PR interval
PR segment: Starts at the atrial
contraction and ends at the beginning
of ventricle depolarization.
ST SEGMENT
ST segment: represents ventricular
repolarization.
T wave: represents ventricle
repolarization
u wave
QRS complex: represents ventricular
depolarization
PR
INTERVAL
T wave
T
Q
S
QT INTERVAL
qt interval
The QT interval represents the time
for both ventricular depolarization
and repolarization to occur.
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ekg interpretation
Steps in EKG Interpretation
1. Determine R-R interval: Regular R-R intervals
2. Calculate the rate: (Atrial & ventricular rates), Bradycardia, Tachycardia
3. Evaluate the P wave: Present, Regular, P wave for each QRS complex.
4. Calculate PR interval: Consistently within the normal range
5. Analyze the QRS complex: <0.12 seconds, QRS complex for every P wave
6. Examine T wave: consistently present and normal
7. Calculate QT interval
8. Look for other characteristics
determining the heart rate
1. Used to determine the HR for
regular and irregular rhythms
2. Count the number of P waves
in six seconds and multiply 10.
3. Ventricular Rate: count the
number of R waves or QRS
complexes in 6 seconds and
multiply by 10.
CHARACTERISTICS
1. Heart Rate: 60-100 bpm
2. PR Interval: 0.12-0.2 sec
3. QRS: 0.06-0.12 sec
4. ST segment: 0.08 sec
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5-lead placement
mnemonic (LEAD PLACEMENT)
1. White on right
2. Smoke (black) over fire (red)
3. Snow (white) on green grass (green)
4. Chocolate close to the heart."
lA
RA
v
rl
Ll
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electrolyte imbalance
Potassium
Hyperkalemia
3.5-5.5 mEq/L
1. T wave elevation
2. Wide QRS complex
3. Prolonged PR interval
4. Flat P wave
Hypokalemia
1. Flat/inverted T wave
2. ST depression
3. U wave
calcium
8.5-10.5mEq/L
HypercalCemia
1. Shortened ST segment
2. Shortened QT interval
HypocalCemia
1. Prolonged ST segment
2. Prolonged QT interval
MAGNESIUM
1.3-2.1mEq/L
HYPERMAGNESEMIA
1. Prolonged PR interval
2. Widened QRS
HYP0MAGNESEMIA
1. Flattened/Inverted T wave
2. Prolonged QT interval
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know
your
rhythms
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NORMAL SINUS RHYTHM
normal sinus rhythm
n
o
i
t
p
i
Descr
1. Atrial and ventricular rhythms are regular.
2. Rate: 60-100 beats/min
3. PR interval and QRS width are within normal
limit
1. Normal sinus rhythm refers to the normal heart
beat originating from the sinoatrial node.
2. Slight variations in rhythm regularity may be
noted with the respiratory cycle
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sinus bradycardia
SINUS BRADYCARDIA
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Atrial and ventricular rhythms
are regular
2. Rate: less than 60 beats/min
3. Normal P wave precedes each
QRS complex
4. PR. interval and QRS width
are within normal limits
1. Medications:
a. Antihypertensive
drugs
2. Normal among
athletes
3. Sleep(at rest)
TREATMENT
1. Patient may be asymptomatic
2. Treatment for symptomatic patients (decreased cardiac
output, altered LOC, SOB)- Administration of atropine.
3. Pacemaker
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sinus TACHYCARDIA
SINUS tACHYCARDIA
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Atrial and ventricular rhythms
are regular
2. Rate: >100 beats/min
3. Normal P wave precedes each
QRS complex
4. PR interval and QRS width are
within normal limits
1. Increased physical activity
2. Fever
3. Stress/anxiety
4. Hemorrhage
5. Caffeine/alcohol
6. Heart failure
7. Electrolyte imbalance
8. Hyperthyroidism
TREATMENT
1. Symptoms: SOB, palpitations, dizziness, syncope.
2. Treatment: treat the underlying cause
3. Medications: Beta blockers, Calcium channel blockers
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sinus Arrhythmia
SINUS ARrhythmia
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Rhythm are irregular
2. Rate: 60-100 beats/min
3. P wave: sinus
4. PR interval: normal
5. QRS width: normal
A cyclical change in the
heart rate associated
with respirations.
TREATMENT
1. No treatment required unless patient is symptomatic.
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premature atrial
contractions (pac)
PAC
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Rhythm are regular (irregular
with PAC)
2. Rate:Is that of underlying
rhythm.
3. P wave: premature, appears
different than normal. P wave
may be buried in the preceding
T wave.
4. QRS complex: P wave may not
be followed by QRS complex
1. Enlarged atria
2. Heart diseases
3. Hyperthyroidism
4. Caffeine
5. Tobacco
6. Nicotine
TREATMENT
1. Increasing number of PAC, (Paroxysmal Atrial
Tachycardia: 3+PAC at 140-250 beats/min
2. Medications: Calcium channel blockers, Beta blockers,
Amiodarone
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atrial fibrillation
ATRIAL FIBRILLATION
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Atrial rhythm is irregular
2. Ventricular rhythm is irregular
3. Atrial: 350-600bpm
4. Ventricular: less than atrial
5. No P wave
6. PR interval is not measurable
7. Fibrillatory waves before QRS
complex
1. Heart disease
2. Heart tissue damage
3. Congenital heart
defects
4. Hypertension
TREATMENT
1. Unstable patients: prepare for cardioversion
2. O2 therapy
3. Anticoagulants: to prevent emboli
4. Administer cardiac medications (beta blockers, calcium channel
blockers, digoxin)
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atrial flutter
ATRIAL FLUTTER
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Atrial rhythm is regular
2. Atrial: 250-400 bpm
3. Ventricular: less than atrial
4. P wave: sawtooth
5. PR interval: not measurable
6. QRS complex: less than or
equal to 0.12s
1. Atrioventricular (AV)
valve disease
2. Pericarditis
3. Heart failure
4. MI
TREATMENT
1. Unstable patients: prepare for cardioversion
2. Administer medication: Anticoagulant
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premature junctional
contraction (PJC)
pjc
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Rhythm: premature beat
2. Rate: is that of underlying
rhythm.
3. P wave: premature, inverted,
within, hidden or after QRS
complex.
4. PR: is short on the PJC
5. QRS complex: normal
1. MI
2. Digoxin toxicity
3. Valvular heart disease
TREATMENT
1. Treat the underlying cause.
2. Medication: Quinidine
3. Discontinue digoxin if applicable
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PREMATURE VENTRICULAR
CONTRACTIONS
pvc
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Rhythm: Irregular
2. Rate: is that of underlying
rhythm.
3. P wave: absent (no P wave with
PVCs
4. PR: not measurable
5. QRS complex: QRS complex in PVC
is premature, wide and abnormal
1. Electrolyte imbalance
2. Hypoxia
3. Stimulants
4. Withdrawal
5. Heart failure
6. MI
7. Drug toxicity
TREATMENT
1. Treat the underlying cause.
2. Medications: Antiarrhythmics (amiodarone)
3. Management of electrolyte imbalance (hypokalemia)
4. Discontinuation of drug causing toxicity
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Ventricular TACHYCARDIA
VENTRICULAR
TACHYCARDIA
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Rhythm: regular
2. Rate: 140-250 beats/min
3. P wave: absent
4. PR: not measurable
5. QRS complex: QRS complex is
wide, bizarre
1. MI
2. CAD
3. Digoxin toxicity
4. Caffeine
TREATMENT
1. Stable patient with a pulse: Oxygen, antidysrhythmic therapy
2. Unstable patient with VT (with pulse and s/s of decreased CO):
Oxygen, antidysrhythmic therapy, synchronized cardioversion, cough
CPR.
3. Unstable patient without a pulse: Defibrillation, CPR
IMPORTANT: VT can lead to Ventricular Fibrillation and then death.
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Ventricular FIBRILLATION
VENTRICULAR
fibrillation
n
o
i
t
p
i
Descr
s
e
s
u
a
c
1. Rhythm: chaotic rapid rhythm
2. Rate: Not measurable
3. P wave: absent
4. PR: not measurable
5. QRS complex: not measurable
Remember:
-VF is fatal. Patient lacks a pulse,
BP, respiration, and is unconscious
1. Untreated VT
2. Drug toxicity
3. Damage to the heart
muscle- Cardiac injury
4. Cardiomyopathy
5. Electrolyte imbalance
TREATMENT
1. Initiate CPR
2. Defibrillation
3. Oxygen therapy
4. Medication: Antidysrhythmic therapy
Epinephrine
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FIRST-degree block
FIRST-degree
block
n
o
i
t
p
i
Descr
1. Rhythm: Atrial and Ventricular rhythms are regular
2. Rate: Varies
3. P wave: sinus
4. PR interval: prolonged
5. QRS complex: normal
TREATMENT
1. No treatment is required.
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SECOND-DEGREE av bLOCK (TYPE 1)
SECOND-DEGREE
block (TYPE 1)
n
o
i
t
p
i
Descr
n
o
i
t
i
defin
1. Rhythm: Atrial (regular),
Ventricular (irregular)
2. Rate: Ventricular rate (less than
atrial rate)
3. P wave: regular
4. PR: lengthens progressively until
QRS drops
5. QRS complex:A QRS complex is
dropped. Normal duration <0.12sec
Second-Degree Block Type 1 is
also known as Wenckebach.
Characterized by progressive
lengthening of the PR
interval until a QRS complex
is dropped.
TREATMENT
1. Patient is usually asymptomatic
2. May not require treatment
3. Decreased cardiac output- administer atropine
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SECOND-DEGREE av bLOCK (TYPE 2)
SECOND-DEGREE
block (TYPE 2)
n
o
i
t
p
i
Descr
n
o
i
t
i
defin
1. Rhythm: Atrial (regular),
Ventricular (irregular)
2. Rate: Ventricular rate (less than
atrial rate)
3. P wave: 2 to 3 P waves before QRS
complex
4. PR: Normal and consistent
5. QRS complex:A QRS complex is
dropped. Normal duration <0.12sec
Second-Degree Block Type 2
is also known as MobitzII
A Mobitz Type II heart block is
characterized by an
intermittent dropped QRS.
The PR is normal and
consistent
TREATMENT
1. Pacemaker is the treatment used for second-degree
block (type 2)
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THIRD-DEGREE av bLOCK
THIRD-DEGREE
BLOCK
n
o
i
t
p
i
Descr
1. Rhythm: Regular
2. Rate: Atrial rate (normal),
Ventricular rate (<60bpm)
3. P wave: no relationship
with QRS complex
4. PR: Varies
5. QRS complex:Normal
&
s
n
g
i
s
ms
o
t
p
sym
1. Confusion
2. Syncope
3. Chest pain
4. Dyspnea
TREATMENT
1. Pacemaker is the treatment used for third-degree
block
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aystole
aystole
n
o
i
t
p
i
Descr
s
e
s
u
a
c
Aystole is characterized by a
flat line. This means that
there is no rhythm, no rate,
no P wave, No PR interval
and no QRS complex.
1. Hypoxia
2. Hypovolemia
3. Hypo/hyperkalemia
4. MI
5. Heart failure
TREATMENT
1. Treatment for aystole
is to perform CPR
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LAB
VALUES
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LAB VALUES
nursebossstore.com
Hematology
Electrolytes
WBC:
RBC:
Hematocrit:
5,000-10,000
4,500-6,000
(M) 42%-52%
(F) 37%-47%
Hemoglobin: (M) 14-18 g/dL
(F) 12-16 g/dL
Platelets:
150,000-400,000 cells/mcL
Platelets:
PT:
PTT:
aPTT:
INR:
Coagulation
150,000-400,000 cells/mcL
10-13 seconds
25-35 seconds
30-40sec-HEPARIN
2-3 seconds
Renal
BUN:
8-25 mg/dL
Creatinine:
0.6-1.2 mg/dL
Creatinine Clearance: (M) 97-137 mL/min
(F) 88-128 mL/min
GFR:
90 mL/mmol
Na+:
K+:
Mg+:
Ca+:
PO4:
Cl-:
pH:
PaCO2:
PaO2:
HCO3:
SaO2:
135-145 mEq/L
3.5-5.0 mEq/L
1.5-2.5 mEq/L
8.5-10.5 mg/dL
3.0-4.5 mg/dL
95-105 mEq/L
ABGs
7.35-7.45
35-45 mmHg
80-100mmHg
22-26 mmHg
95%-100%
Albumin:
Bilirubin Total:
AST:
ALT:
ALP:
Total Protein:
Liver
3.4-5.4 g/dL
0.1-1.2 mg/dL
10-40 U/L
7-56 U/L
20-40 U/L
6.2-8.2 g/dL
Blood Glucose
Glucose: 70-100 mg/dL
HgBA1C: 4%-5.6%
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LAB VALUES
nursebossstore.com
Hematology
Electrolytes
WBC:_____________
RBC:_____________
Hematocrit: (M)__________
(F) __________
Hemoglobin:(M)__________
(F) __________
Platelets:______________
Na+:__________
K+:___________
Mg+:_________
Ca+:__________
PO4:__________
Cl-:___________
Coagulation
ABGs
pH:____________
PaCO2:_________
PaO2:__________
HCO3:_________
SaO2:__________
Platelets:____________
PT:____________
PTT:___________
aPTT:__________
INR:___________
Liver
Renal
Total Protein:__________
Albumin:______________
Bilirubin Total:________________
Bilirubin Direct:_______________
AST:_____________
ALT:_____________
Alkaline Phosphate
Total:____________
BUN:_________________
Creatinine:____________
Creatinine Clearance:
(M)_______________
(F)________________
GFR:_________________
Blood Glucose
Glucose:____________
HgBA1C:____________
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LAB VALUES
Cardiac
Troponin I:
Myoglobin:
CK-MB:
CPK-MB:
0-0.4 ng/mL
5-70 ng/mL
0-3ng/mL
3%-5%
Therapeutic Drug Levels
Digoxin:
Theophylline:
Phenobarbital:
Lithium:
Carbamazepine:
0.5-2 ng/mL
10-20 mcg/mL
15-40 mcg/mL
0.8-1.5 mmol/L
4-10 mg/L
Other Lab Values
Glucose Tolerance Test:
Fasting: 60/100 mg/dL
1 hour: <200 mg/dL
2 hours: <140 mg/dL
Prostate Specific Antigen (PSA):
4.0 ng/mL
Lactic Acid:
0.5-1.0 mmol/L
nursebossstore.com
Lipid
Cholesterol Total:
LDL:
HDL:
Triglycerides:
<200 mg/dL
<100 mg/dL
>60 mg/dL
<150 mg/dL
Other Lab Values
Ammonia:
BNP:
CRP:
D-Dimer:
Folic Acid:
15-45 U/dL
<125 pg/mL
<3.0 mg/L
<0.50
2.7-17.0 ng/mL
Vital Signs
Heart Rate:
Blood Pressure:
O2 Saturation:
Respiration:
Temperature:
60-100 bpm
90/60- 120/80 mmHg
95%-100%
12-18 bpm
97.8-99.1 F
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LAB VALUES
Cardiac
Troponin I:____________
Troponin T:___________
Myoglobin:____________
CPK-MB:______________
Therapeutic Drug Levels
Digoxin:_____________________
Theophylline:________________
Phenobarbital:_______________
Lithium:____________________
Carbamazepine:______________
Other Lab Values
Glucose Tolerance Test:
Fasting:_____________
1 hour:______________
2 hours:_____________
Prostate Specific Antigen (PSA):
____________________
Lactic Acid:
___________________
nursebossstore.com
Lipid
Cholesterol Total:_____________
LDL:______________
HDL:______________
Triglycerides:________________
Other Lab Values
Ammonia:_______________
BNP:____________________
CRP:____________________
D-Dimer:________________
Folic Acid:_______________
Vital Signs
Heart Rate:__________________
Blood Pressure:______________
O2 Saturation:_______________
Respiration:_________________
Temperature:________________
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Arterial Blood Gases
ABGs is the measurement of the acidity, and the level of oxygen and carbon dioxide in the
blood. ABGs is used to evaluate the acid-base status of a patient.
In order to interpret a patient's ABG status, it is important to:
1.Know the lab values
2. Determine whether it is a respiratory or metabolic problem
3. Know whether it uncompensated, partially
compensated or fully compensated (evaluate the pH value)
1
Acidosis
pH
Alkalosis
Normal
Values
<7.35 >7.45 7.357.45
CO2
>45
<35
35-45
HCO3
<22
>26
22-26
2
ROME
Respiratory
pH
CO2
Alkalosis
O pposite
pH
CO2
Acidosis
pH
HCO3
Alkalosis
pH
HCO3
Acidosis
M etabolic
Equal
3
Uncompensated:
When the pH value is out of the normal
range and CO2 or HCO3 is within the
normal range.
Partially Compensated:
The CO2, HCO3 and pH values are out of
range.
Fully Compensated
The pH is within the normal range.
CAUSES:
Metabolic Acidosis: DKA, Addison's
disease, renal failure, diarrhea, liver
damage
Metabolic Alkalosis: Continuous gastric
content suctioning, vomiting, diuretics,
antacid
Respiratory Acidosis: Pneumonia, airflow
obstruction, paralysis, over sedation
Respiratory Alkalosis: Fever, increased
respiratory rate and depth, anemia, CHF
COMPENSATION MECHANISM
The kidneys excretes
excess acid and HCO3 or
retains hydrogen and
HCO3
The lungs compensates
through
hyperventilation and
hypoventilation
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STUDY GUIDE
A Pharmacology Study Guide for Nursing
Students
Website: nursebossstore.com
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Table Of Content
Introduction
Cardiovascular Drugs
Respiratory Drugs
Gastrointestinal Drugs
Genitourinary Drugs
Antibiotics
Neurological Drugs
Anti-Diabetic Drugs
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Introduction
Terminologies
Medication Rights
Drug Suffixes and Prefixes
Therapeutic Drug Level
Drug Antidotes
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Terminologies To Remember
❖ Pharmacology
Pharmacology is the study of drugs
❖ Drug
❖
❖
A substance, when introduced to the body, causes a physiological
effect.
Pharmacodynamics
The effect (physiological and biochemical) that a drug has on the
human body. Another definition is the body’s biological response to
the drug
Pharmacokinetics
Pharmacokinetics is the study of drug movement/action in the body
in terms of absorption, distribution, metabolism and excretion.
❖ Mechanism of Action
❖
❖
❖
❖
❖
❖
Mechanism of action refers to the biochemical processes in which
yields the drug effect.
Indication
Purpose of administering a certain drug
Contraindication
Reason against administering a certain drug
Absorption
Absorption is the drug movement from the administration site
to blood stream
Duration
Duration is the length of time that a drug is effective.
Onset
Onset is the time taken for a drug effect to take place after
administration
Peak
Peak is the highest level of drug concentration in the blood
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Terminologies To Remember
❖ Therapeutic Effect
❖
❖
❖
❖
Therapeutic effect is the response to a drug that is favorable
(good effect).
Adverse Effect
Adverse Effect is the undesirable effect of the drug (bad
effect)
Systemic Effect
Systemic effect is defined as effects that occur in other
tissues that is distant to administration site
Side Effect
Side effect is the secondary effect of a drug. It may be
therapeutic or adverse
Idiosyncratic effect
Idiosyncratic effect is an unknown effect or cause
❖ Agonist
❖
❖
❖
Agonist drugs bind to a receptor and stimulates the function
of the receptor
Antagonist
Antagonist drugs bind to the receptors and prevent the
function of the receptor
Hypersensitivity
An undesirable reaction produced by the immune system in
response to an antigen or drug
Metabolism
Metabolism is the chemical alteration of a drug in the body.
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10 RIGHTS OF MEDICATION
ADMINISTRATION
Right Drug
Right Patient
Right Dose
Right Route
Right Time
Right Documentation
Right Assessment
Right to Refuse
Right Drug Interaction
Right Education
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Classification of Drugs
Therapeutic Classification: the drug’s therapeutic
usefulness
Anticoagulant: influence blood clotting
Antihypertensive: lowers blood pressure
Antianginals: treat angina
Antihyperlipidemics: lowers blood cholesterol
Pharmacological Classification: how the drug acts
Diuretics: lowers plasma volume
Calcium Channel Blockers: blocks heart calcium
channels
Drug Name
Chemical Name: chemical composition
Generic Name: indicates drug group
Trade Name: name registered by the manufacturer
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Medication Summary
Medication Orders
Types of Drug Order
Date:
Name of Medication:
Dosage:
Time and Frequency:
Route of Administration:
Name and Signature of
Prescriber:
Patient Information:
Routine Order:
Carried out as specified until
discontinued
Factors that affect drug
absorption
1. Route
2. Dosage Formulation
3. Surface Area
4. Blood Flow
5. Lipid solubility
6. Food and Fluids
Remember: some drugs need to
be
taken on an empty stomach.
Other drugs should be taken on
a full stomach or
with food to enhance absorption
or minimize gastric irritation.
P.R.N: As needed
Single Order: Directive is carried
out only once as specified by
physician
Stat Order: A single order
carried out at once
Written Order: inscribed by a
physician on a prescription pad
Verbal Order: When receiving
verbal orders, write
the order down exactly as
heard, repeat the order back to
the physician,
document, have physician cosign
Telephone Order: Many
institutions do not accept this
order
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Drug Suffixes and Prefixes
Cardiac Drugs
1. ACE Inhibitors: -pril
2. Beta Blockers: -olol
3. Calcium Channel Blockers:
-ipine
4. Loop Diuretics: -semide
5. ARBs: -sartan
Resp Drugs
1. Xantine: -phylline
2. Bronchodilator (beta
agonist): -terol
3. Antihistamine: - tadine, iramine
4. Corticosteroid: pred-,
cort-, -asone, -olone
GI Drugs
1. PPIs: -eprazole, oprazole
2. H2 Receptor Antagonists:
-tidine
3. Antiemetics: -setron
4. PEG: peg-
Antibiotics
1. Cephalosporin: cef-,
ceph2. Penicillin: -cillin
3. Quinolones: -floxacin
4. Macrolides: -mycin
5. Tetracycline: cycline
6. Antiviral: -vir
Neuro
1. Benzodiazepine: -zepam,
zolam
2. SSRIs: -etine
3.Barbituates: -barbital
4. Tricyclic Antidepressants:
-ipramine
Pain
1. NSAIDs: - fenac, -profen
2. Local anesthetic: -caine
3. General anesthetic: -ane
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Therapeutic Drug Level/Antidote
Therapeutic Drug Levels
Digoxin:
0.5-2 ng/mL
Theophylline:
10-20 mcg/mL
Phenobarbital:
15-40 mcg/mL
Lithium:
0.8-1.5 mmol/L
Carbamazepine:
4-10 mg/L
Phenytoin:
10-20mg/L
Lidocaine:
1.5-5mg/L
Drug: Antidote
Opioids: Nalaxone
Wafarin: Vit K
Heparin: Protamine
Cholinergics: Atropine
Acetaminophen:Acetylcysteine
Benzodiazepines: Flumazenil
Insulin: Glucagon
Digoxin: Digoxin Immune Fab
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Cardiovascular Drugs
Thrombolytic Agents
Antiplatelets
Anticoagulant
Cardiac Glycosides
Thiazide Diuretics
Loop Diuretics
Potassium Sparing Diuretics
ACE-Inhibitors
Angiotensin II Receptor Blocker
Calcium Channel Blocker
Beta Adrenergic Blocker
Adrenergic Agonist
Antianginal
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Drug Class: Thrombolytic Drugs
Medications
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Cardiovascular
TENECTEPLASE
ALTEPLASE
Mechanism of Action:
Adverse/Side Effects:
Thrombolytic drugs dissolve clots
1. Bleeding
by activating plasminogen that
forms plasmin.
2. Hypotension
Three major classes:
1. Tissue Plasminogen Activator
(tPA)
2. Streptokinase (SK)
3. Urokinase (UK)
The three major classes dissolve
blood clots, however, their
mechanism (process) to do so
differs.
Indications:
1. Acute MI
2. Acute ischemic stroke
3. Pulmonary embolism
Thrombolytic drugs dissolve
clots, prevent organ damage,
and improve blood flow.
3. Arrhythmias
Contraindications:
1. Cerebral hemorrhagic
stroke
2. Trauma injury
3. GI bleeding/active internal
bleeding
4. Known allergy
5. Hypertension
6. Recent surgery
Assessment/ Nursing Considerations/Patient Education
1. Assess coagulation studies 1. Educate patient on tooth
2. Monitor VS: monitor for
brushing and shaving.
tachycardia and
2. Educate patient on the
hypotension
3. Monitor for signs of
side/adverse effects.
bleeding: petechiae,
bruises, dark-colored stools.
4. Monitor neurological
status/changes
5. Monitor for adverse effects
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Drug Class: Antiplatelet Drugs
Medications
nursebossstore.com
Cardiovascular
(ASA) acetylsalicylic acid- Aspirin
Clopidogrel (Plavix)
Mechanism of Action:
Antiplatelet drugs prevent
the aggregation or adhesion
of platelets.
Indications:
1. MI
2. Stroke
3. Stents
4. Prevention of
cerebrovascular occlusion
Aspirin can be used with
thrombolytic therapy. It is used
for the long term management
of the conditions stated above.
Adverse/Side Effects:
1. Bleeding
2. Bruising
3. GI bleeding
4. Dark-tarry stools
5. Hematuria
Contraindications:
1. History of
thrombocytopenia
2. Known allergy
3. Head trauma/injury
4. Recent surgery
5. Active internal bleeding
Assessment/ Nursing Considerations/Patient Education
1. Educate patient on tooth
1. Assess contraindications
brushing (soft tooth brush)
2. Monitor VS: BP, P
and shaving.
3. Monitor coagulation studies
2. Educate patient on the
side/adverse effects.
3. Educate patient to take
medication with meals to
avoid GI upset.
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Drug Class: Anticoagulant Drugs
Medications
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Cardiovascular
Heparin Sodium/ Enoxaparin
Wafarin Sodium
Mechanism of Action:
Anticoagulants interfere and
prevent the formation of clots by
inhibiting factors in the clotting
cascade.
Heparin Sodium: prevents
thrombin from converting
fibrinogen to fibrin.
Adverse/Side Effects:
1. Hypotension
2. Bleeding/bleeding gums
3. Thrombocytopenia
4. Hematuria (blood in urine)
5. Epistaxis
Wafarin Sodium: reduces vitamin-K Toxicity S/S: Nausea, hepatic
clotting factors (X, IX, VII, II)
dysfunction, GI upset,
Enoxaparin: is a low molecular
weight heparin
vomiting, diarrhea
Indications:
Contraindications:
1. GI ulcers
2. Active internal bleeding
3. Bleeding disorder
4. Hemorrhagic brain injury
5. Liver disease
6. Kidney disease
Drug Interactions
1. Green-leafy vegetables
2. NSAIDS/Allopurinol/salicylates
3. Phenytoin/Corticosteroids
4. Sulfonamides/Cimetidine
1. MI
2. DVT
3. Pulmonary embolism
4. Angina
5. Afib
Anticoagulants are used
among patients who are at
risk for developing clots.
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindications
1. Educate patient on
2. Monitor coagulation studies
tooth brushing (soft
3. Monitor for signs of bleeding
tooth brush) and
4. Infusion pump should be used
shaving.
for accurate rate of delivery
5. Maintain antidote: Vit K is the 2. Educate patient on
antidote for wafarin,
side/adverse effects.
protamine sulfate is the
antidote for heparin.
6. Maintain patient's safety.
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Drug Class: Cardiac Glycosides
Medications
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Cardiovascular
Digoxin (Lanoxin)
Mechanism of Action:
Cardiac glycosides inhibit Na+/K+
ATPase in the myocardium. This
increases the intracellular calcium
level in the myocardium.
Therefore, cardiac glycosides
increase cardiac contractility/the
force of myocardial contractions
(positive inotropic effect).
However, cardiac glycosides also
decrease heart rate( negative
chronotropic effect).
Indications:
1. Heart failure
2. Atrial tachycardia
3. Atrial fibrillation
4. Atrial flutter
Adverse/Side Effects:
1. Vision changes: blurred or
yellow vision
2. GI upset
3. Bradycardia
4. Dysrhythmias
5. Fatigue
Signs of digoxin toxicity:
vomiting, diarrhea, irregular
heart rhythms, confusion,
visual disturbances, fatigue
Contraindications:
1. Hypokalemia
2. Hypothyroidism
3. Ventricular dysrhythmias
4. Renal disease
5. Heart block
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindications
1. Educate patient of s/s
2. Assess VS (+apical pulse): Count apical
of digoxin toxicity.
pulse for 60secs. Withhold medication
if pulse <60beats/min and notify HCP
2. Educate patient to
3. Monitor serum digoxin level (0.52ng/mL)
consume a high
4. Monitor electrolyte levels + renal
function
potassium diet (if
5. Monitor signs of digoxin toxicity
6. Monitor potassium levels: hypokalemia
applicable)
can increase digoxin toxicity
7. Obtain ECG
8. Maintain antidote: Digoxin immune
Fab
365 / 601
Drug Class: Thiazide Diuretics
Medications
nursebossstore.com
Cardiovascular
Chlorothiazide, Chlorthalidone
Hydrochlorothiazide, Metolazone
Mechanism of Action:
Thiazide diuretics increase
the excretion of Na and
water in the distal
convoluted tubule.
Thiazide is a mild diuresis as
compared to loop diuretics
Indications:
1. Hypertension
Adverse/Side Effects:
1. Hypotension
2. Hyponatremia
3. Hypokalemia
4. Hyperglycemia
5. Hypercalcemia
6. Hyperuricemia
7. Fatigue/weakness
Tip: the side and adverse
effects are mostly electrolyte
imbalances.
Contraindications:
1. Fluid and electrolyte imbalance
2. Renal failure
3. SLE
Interactions:
Patient taking
1. Digoxin: can cause digoxin
toxicity due to changes in
potassium levels
2. Lithium: can cause lithium
toxicity
3. Corticosteroids
4. Antidiabetic medications
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor vital signs: BP,P
3. Monitor electrolytes, glucose
level, BUN & creatinine
4. Monitor urinary output/weight
1. Educate patient on
increasing potassium in
diet
2. Educate patient of
preventing orthostatic
hypotension: slowly
change position
3. Diabetic patients
should monitor blood
glucose regularly.
366 / 601
Drug Class: Loop Diuretics
Medications
nursebossstore.com
Cardiovascular
Furosemide
Torsemide
Mechanism of Action:
Loop diuretics decrease the
reabsorption of sodium and
chloride in the ascending Loop of
Henle.
(Hence the name-loop diuretics
main effect is in the Loop of Henle.)
Loop diuretics may cause changes
in cardiac output and BP due to its
potency as compared to thiazide
diuretics.
Indications:
1. Hypertension
2. Edema due to HF, renal
disease
3. Acute pulmonary edema
Adverse/Side Effects:
1. Hypotension/orthostatic
hypotension
2. Hyponatremia
3. Hypokalemia
4. Hearing loss: due to rapid flow
of injection of IV furosemide
Contraindications:
1. Hypersensitivity
2. Anuria
3. Hepatic coma
4. Severe electrolyte depletion
Interactions:
1. Digoxin
2. Lithium
3. Aminoglycoside
4. Anticoagulants
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor vital signs: BP,P
3. Monitor electrolytes, glucose
level, BUN & creatinine, uric acid
4. Monitor urinary output/weight
1. Educate patient of
preventing orthostatic
hypotension: slowly
change position
2. Increase potassium in
diet.
367 / 601
nursebossstore.com
Drug Class: Potassium-Sparing Diuretics Cardiovascular
Medications
Spironolactone
Amiloride
Mechanism of Action:
Potassium-sparing diuretics
cause sodium and water
excretion in the distal tubule,
whilst promoting potassium
retention (blocks aldosterone
receptors)
Adverse/Side Effects:
1. Hyperkalemia-major
concern
2. Lethargy
3. Arrhythmias
Mostly used for patients with a
higher risk of hypokalemia.
However, the major concern of
potassium-sparing diuretics is
monitoring for hyperkalemia
Indications:
1. Hypertension
2. Edema
3. Fluid retention secondary
to a condition
4. Heart failure
Contraindications:
1. Kidney disease
2. Hepatic Disease
3. Hyperkalemia
Interactions:
1. Lithium
2. ACE Inhibitors
Caution:
1. Patient taking potassium
supplements
2. Diabetic Patient
Assessment/ Nursing Considerations/Patient Education
1. Assess
1. Educate patient on
interactions/contraindications
low potassium diet
2. Monitor vital signs: BP,P
and signs of
3. Monitor electrolyte levels (pay
attention to potassium levels)
hyperkalemia
4. Monitor for symptoms of
hyperkalemia
5. Monitor ECG for peaked T wave (a
sign of hyperkalemia) and
dysrhythmia
6. Monitor urinary output/weight
368 / 601
Drug Class: ACE Inhibitors
Medications
nursebossstore.com
Cardiovascular
SUFFIX- PRIL
Captopril, Lisinopril, Enalapril
Mechanism of Action:
Angiotensin-Converting
Enzyme Inhibitor (ACE
Inhibitors) prevents the
conversion of angiotensin I to
angiotensin II which prevents
vasoconstriction.
Remember: angiotensin II is a
vasoconstrictor and stimulates
aldosterone release.
Adverse/Side Effects:
1. Dry cough
2. Hypotension
3. GI distress
4. Tachycardia
5. Hyperkalemia
6. Angioedema
Hence, ACE Inhibitors are
antihypertensive drugs.
Indications:
1. Hypertension
2. Heart failure
Contraindications:
1. Hypersensitivity to ACE
Inhibitors
2. Renal failure
Interactions:
1. Potassium-sparing diuretics
and supplements due to
the potential of
hyperkalemia
2. NSAIDs
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor vital signs: BP,P
3. Monitor potassium serum level
4. Monitor glucose level of diabetic
patients (hypoglycemia may
occur)
1. Educate patient on
low potassium diet
and signs of
hyperkalemia
2. Educate patient on
dry cough as a
potential side effect
3. Educate patient on BP
monitoring
369 / 601
Drug Class: Angiotensin II Receptor Blockers
Medications
nursebossstore.com
Cardiovascular
SUFFIX- SARTAN
Losartan, Candesartan, Valsartan
Mechanism of Action:
ARBs prevent aldosterone
release and peripheral
vasoconstriction by selectively
blocking angiotensin II
receptors.
ARBs is primarily an
antihypertensive drug
Indications:
1. Hypertension
2. Heart failure
Adverse/Side Effects:
1. Hypotension
2. Diarrhea
3. Nausea/vomiting
4. Hyperkalemia
5. Fatigue/ weakness
6. Angioedema
Contraindications:
1. Renal failure
2. Hepatic impairment
Interactions:
1. Potassium-sparing diuretics
and supplements due to
the potential of
hyperkalemia
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor vital signs: BP,P
3. Monitor potassium serum level
4. Monitor glucose level of diabetic
patients (hypoglycemia may
occur)
1. Educate patient on
low potassium diet
and signs of
hyperkalemia
2. Educate patient on BP
monitoring
370 / 601
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Drug Class: Calcium Channel Blockers
Medications
Cardiovascular
SUFFIX- PINE
Nifedipine, Amlodipine
Mechanism of Action:
Calcium channel blockers
prevent calcium ions movement
across myocardial cell
membrane.
This causes relaxation of
smooth muscle.
Therapeutic effects includes:
decreased cardiac workload,
decreased myocardial oxygen
consumption and decreased
blood pressure.
Indications:
1. Hypertension
2. Angina
Adverse/Side Effects:
1. Hypotension
2. Bradycardia
3. Dysrhythmias
4. Dizziness
5. Fatigue
Contraindications/Caution:
1. AV block
2. HF
3. Bradycardia-use with
caution
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Assess liver enzymes level
3. Monitor vital signs: BP,P
1. Educate patient on
side effects of dizziness
and fainting
2. Educate patient on BP,
P monitoring
371 / 601
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Drug Class: Beta Adrenergic Blockers
Medications
Cardiovascular
SUFFIX- LOL
Atenolol, Carvedilol
Mechanism of Action:
Beta adrenergic blockers block the
effect of epinephrine at the
receptor sites.
Adverse/Side Effects:
1. Hypotension
2. Bradycardia
3. Dizziness, Weakness
4. Fatigue
5. Hyperglycemia
6. Bronchospasm
7. Orthostatic hypotension
Therapeutic effects: decrease
cardiac workload, BP, HR and
myocardial oxygen demands.
Selective BB: affects only the
beta1 adrenergic sites (heart)
Nonselective BB: (lungs and heart)
acts on both beta 1 and beta 2
adrenergic sites
Indications:
Contraindications/Caution:
1. Hypertension
2. Angina
3. Glaucoma
4. Migraine
5. Dysrhythmias
1. Asthma- due to side effect
of bronchospasm
2. Bradycardia
3. Renal failure
4. AV block
5. Diabetes mellitus (use with
caution)
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Assess liver enzymes level
3. Monitor vital signs: BP,Pwithhold medication if BP/P is
not within therapeutic
parameters
4. Monitor respiratory status
1. Educate diabetic
patients on glucose
monitoring-the effect of
beta blockers can mask
hypoglycemia
2. Monitor BP, P
3. Educate patient to
stand up slowly-due to
orthostatic hypotension
372 / 601
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Drug Class: Adrenergic Agonist
Medications
Cardiovascular
Dobutamine, Dopamine, Epinephrine
Mechanism of Action:
Adrenergic agonist stimulates the
adrenergic receptors (both alpha
or beta receptors) of target
organs.
Therapeutic effect:
1. Heart: increase contractility,
HR, increase cardiac output
2. Lungs: bronchodilation
Adverse/Side Effects:
1. Hypertension
2. Tachycardia
3. Dysrhythmias
4. Palpitations
Examples includes:
1. Epinephrine,
2. Dopamine, 3. Dobutamine
Indications:
1. Epinephrine: acute
hypersensitivity, asthma,
cardiac arrest
2. Dobutamine: positive
inotropic effect (heart failure)
3. Dopamine: positive inotropic
effect,increase blood flow to
the kidneys
Contraindications/Caution:
1. Ventricular fibrillation
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications 7. Monitor adverse effect
2. Monitor vital signs: BP,P
8. Monitor medication effect
3. Monitor respiratory status
and patient's response
4. Auscultate lungs for adventitious
sounds
5. Monitor ECG
6. Monitor urine output
Note: Be cautious when preparing,
calculating and administering drug
373 / 601
nursebossstore.com
Drug Class: Antianginal Agents
Medications
Cardiovascular
Nitroglycerin
Mechanism of Action:
Nitrates are antianginal
agents that relax smooth
muscles, resulting in
vasodilation, reduced
preload (dilating veins) and
afterload (dilating arteries)
and decreased myocardial
oxygen demand.
Indications:
1. Angina pectoris
Adverse/Side Effects:
1. Hypotension
2. Reflex tachycardia
3. Pallor
4. Fatigue/body weakness
Contraindications/Caution:
1. Increase ICP
2. Hypotension
3. Hypovolemia
4. Cerebral hemorrhage
5. Anemia
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1. Educate patient to place
2. Monitor vital signs: BP,P
sublingual medication under
3. Monitor respiratory status
tongue
4. Assess neurological status
2. Educate patient on how to
5. Assess ECG
use sublingual medication,
6. Administer type of medication
transdermal patch, topical
correctly (sublingual medication,
ointment and translingual
transdermal patch, topical ointment
medication.
and translingual medication)
374 / 601
Cardiac Drug Study
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
375 / 601
Respiratory Drugs
Anticholinergics
Antihistamine
Expectorants
Mucolytics
Decongestants
Antitussives
Glucocorticoids
Sympathomimetic Bronchodilators
Methylxanthines Bronchodilators
376 / 601
nursebossstore.com
Drug Class: Inhaled Anticholinergics
Medications
Respiratory
Atrovent (Ipratropium)
Mechanism of Action:
Inhaled anticholinergics prevent
the binding of acetylcholine
(neurotransmitter) by blocking
muscarinic receptors.
This results in bronchodilation
(relaxation of smooth muscle in
the bronchi).
Indications:
1. COPD-Chronic obstructive
pulmonary disease
2. Asthma
Adverse/Side Effects:
1. Cough
2. Palpitation
3. Dry mouth
4. Throat irritation
Contraindications:
1. Glaucoma
2. Hypersensitivity- patient
with peanut allergy should
not take ipratropium
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor urinary output
3. Increase patient's hydration
4. Increase fiber in diet
1. Educate patient on
increase hydration
and fiber in diet
377 / 601
nursebossstore.com
Drug Class: Antihistamine
Medications
Respiratory
Brompheniriamine
Chlorpheniramine
Mechanism of Action:
Antihistamine selectively
blocks and prevents the
effects of histamine at the
histamine-1 receptor sites.
Therapeutic effect: decrease
bronchial secretions
Indications:
Adverse/Side Effects:
1. Drowsiness/sedation
2. Fatigue
3. GI disturbance
4. Dry mouth
5. Hypotension
6. Urinary retention
Contraindications:
1. Use with caution among
1. Allergic rhinitis
COPD clients
2. Common cold
3. Nausea and vomiting (due
Interactions:
to motion sickness)
1. Diphenhydramine- may
cause a prolong
anticholinergic effect
Assessment/ Nursing Considerations/Patient Education
1. Assess
1. Educate patient to
interactions/contraindications
avoid alcohol due to
2. Proper medication
sedation and CNS
administration
effect
3. Patient safety due to CNS
2. Educate patient on
effect
side effects such as
4. Monitor urinary output and signs
dry mouth
of urinary retention
378 / 601
thenursebossstore.bigcartel.com
Drug Class: Expectorants
Medications
Respiratory
Guaifenesin
Mechanism of Action:
Expectorants reduce the
surface tension of bronchial
secretion and induce
productive cough to promote
patent airway.
Indications:
1. Dry, nonproductive cough
Adverse/Side Effects:
1. Rhinorrhea
2. Rash
3. GI irritation
4. Throat irritation
Contraindications:
1. Hypersensitivity
Assessment/ Nursing Considerations/Patient Education
1. Assess underlying cause of
coughing
2. Assess contraindication
3. Assess respiratory status
4. Assess skin for rashes
5. Prevent GI irritation by
encouraging patient to have
small frequent meals
1. Educate patient on
deep breathing and
coughing.
2. Encourage patient to
increase fluid intake
379 / 601
Drug Class: Mucolytics
nursebossstore.com
Medications
Respiratory
Acetylcysteine
Mechanism of Action:
Mucolytics liquefy or thins
respiratory secretions (mucus) for
airway clearance (productive
cough).
Adverse/Side Effects:
1. Rhinorrhea
2. Rash
3. GI irritation
4. Throat irritation
Mucolytics breaks apart disulfide
bonds (disulfide bonds holds mucus
secretions together). This action
results in mucus thinning and
productive cough.
Indications:
1. Dry, nonproductive cough
Contraindications:
1. Hypersensitivity
2. COPD- Mucolytic drug with
dextromethorphan
3. Acute bronchospasms
(asthma)
Assessment/ Nursing Considerations/Patient Education
1. Assess underlying cause of
coughing
2. Assess contraindication
3. Assess respiratory status
4. Assess skin for rashes
5. Prevent GI irritation by advising
patient to have small frequent
meals
1. Educate patient on
deep breathing and
coughing.
2. Encourage patient to
increase fluid intake
380 / 601
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Drug Class: Decongestant
Medications
Respiratory
Oxymetazoline, Phenylephrine
Pseudoephedrine
Mechanism of Action:
Decongestants cause
vasoconstriction in the upper
respiratory system. This leads to
shrinking swollen mucous
membrane and reduced fluid
secretion.
Adverse/Side Effects:
1. Palpitations
2. Anxiety
3. Hyperglycemia
4. Restlessness
5. Rebound congestion
Types: 1. Topical decongestants,
Oral decongestants and nasal
steroid decongestants
Indications:
1. Common cold
2. Sinusitis
3. Allergic rhinitis
4. Otitis media
5. Acute coryza
Contraindications:
1. Hypertension
2. DM
3. Hyperthyroidism
Assessment/ Nursing Considerations/Patient Education
1. Educate patient on the
1. Assess contraindications
duration of taking
2. Monitor BP and P
decongestants (no longer
3. Monitor ECG
than 2 to 3 days) due to
4. Monitor glucose level in diabetic
rebound congestion
patients
(prolong use of
decongestants causes
vasodilation due to nasal
mucosa irritation)
381 / 601
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Drug Class: Antitussives
Medications
Respiratory
Benzonatate, Dextromethorphan
Mechanism of Action:
Antitussives suppress the
cough reflex by directly
acting on the cough control
center in the medulla.
Indications:
1. Dry cough (nonproductive
cough)
2. COPD
Adverse/Side Effects:
1. Sedation (antitussives are
centrally acting)
2. Drowsiness (antitussives
are centrally acting)
3. Dry mouth
4. GI upset (nausea and
irritation)
5. Dependency
Contraindications:
1. Head injury
2. Postoperative patients
Interaction
1. Antidepressants
2. Monoamine oxidase
inhibitors
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindication
2. Assess neurological status
3. Encourage increase fluid intake
4. Place patient in a Fowler's
position.
5. Assess for history of addiction
(medication dependency may
occur)
1. Educate patient on
sedative effect of
antitussives to avoid
injury.
2. Avoid alcohol
382 / 601
Drug Class: Glucocorticoids (Corticosteroids)
Medications
nursebossstore.com
Respiratory
Beclomethasone
Mechanism of Action:
Glucocorticoids are antiinflammatory agents that
decrease inflammatory
response in the airway.
Adverse/Side Effects:
1. Headache
2. Irritability
3. Local infection
Therapeutic effect: increase
airflow, reduce edema.
Indications:
1. Asthma
Contraindications:
1. Hypersensitivity
2. Respiratory infection
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindications
2. Monitor respiratory status
3. Assess adventitious sounds
4. Monitor for signs of infectiondue to prolong use
Educate patient on drug
therapeutic use and side
effects
383 / 601
Drug Class: Sympathomimetic Bronchodilators
Medications
thenursebossstore.bigcartel.com
Respiratory
Salmeterol, Isoproterenol
Mechanism of Action:
Sympathomimetic affects the
beta-receptors found in the
bronchi which leads to the
relaxation of smooth muscle in the
bronchi.
Therapeutic effect: airway dilation
Other effects: increase BP, HR,
vasoconstriction (due to
sympathomimetic mimicking the
effects of the sympathetic nervous
system.
Indications:
1. COPD
2. Asthma
Adverse/Side Effects:
1. Tachycardia
2. Dysrhythmias
3. Palpitation
4. Restlessness
5. Dry mouth
Contraindications:
1. Cardiac dysrhythmias
2. PUD-peptic ulcer disease
3. Hyperthyroidism
Caution:
DM, Glaucoma, HTN
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindication
2. Monitor respiratory status
3. Assess adventitious sounds
4. Monitor neurological status
Educate patient on
increasing fluid intake
384 / 601
Drug Class: Methylxanthines Bronchodilators
Medications
thenursebossstore.bigcartel.com
Respiratory
Theophylline
Mechanism of Action:
Xanthines are
bronchodilators that relax
the smooth muscles of the
respiratory system (bronchi)
and blood vessels.
Indications:
1. COPD
2. Asthma
Adverse/Side Effects:
1. Tachycardia
2. Dysrhythmias
3. Palpitation
4. Restlessness
5. Dry mouth
6. Hyperglycemia
Contraindications:
1. Cardiac dysrhythmias
2. PUD-peptic ulcer disease
3. Hyperthyroidism
Caution:
HTN, Glaucoma, DM
Assessment/ Nursing Considerations/Patient Education
1. Assess contraindication
Educate patient on
2. Monitor respiratory status
increasing hydration.
3. Assess adventitious sounds
Educate patient not to
4. Monitor neurological status
5. Monitor glucose level of DM patients crush capsules
6. Monitor theophylline therapeutic
level: 10-20mcg/mL
7. Theophylline cause cause risk for
digoxin toxicity.
385 / 601
Resp Drug Study
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
386 / 601
Gastrointestinal Drugs
Proton Pump Inhibitors
Histamine (H2)Receptor Antagonist
Antacid
Antiemetics
Laxatives
387 / 601
nursebossstore.com
Drug Class: Proton Pump Inhibitor
Medications
Gastrointestinal
SUFFIX- ZOLE
Omeprazole, Esomeprazole
Mechanism of Action:
Proton pump inhibitors
suppress the secretion of HCL
in the stomach by inhibiting
hydrogen-potassium
adenosine triphosphate
enzyme (the enzyme that
generates HCL).
Indications:
1. Peptic ulcer
2. GERD
3. Erosive esophagitis
4. Zollinger Ellison's
syndrome
Adverse/Side Effects:
1. Abdominal pain
2. Headache
3. Nausea
4. Vomiting
5. Diarrhea
Contraindications:
1. Hypersensitivity
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Administer drug before meals
3. Schedule drug to avoid
interactions
4. Provide small frequent meals
Educate patient to not
crush or chew capsule.
388 / 601
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Drug Class: Histamine (H2) Receptor Antagonist
Medications
Gastrointestinal
SUFFIX- DINE
Ranitidine, Cimetidine
Mechanism of Action:
Histamine (H2) receptor
antagonist blocks the action
of histamine, which produces
HCL secretion.
This action promotes ulcer
healing.
Indications:
1. Peptic ulcer
2. Erosive esophageal
3. Zollinger Ellinson's
syndrome
4. Prevents stress ulcers
Adverse/Side Effects:
1. Dizziness
2. Confusion
3. Impotence
4. Rash
5. Pruritus
Contraindications:
1. Hypersensitivity
2. Pregnancy and lactation
3. Hepatic or renal
dysfunction
Assessment/ Nursing Considerations/Patient Education
1. Assess
Educate patient to take
interactions/contraindications
medication with meals or
2. Schedule drugs to avoid
at bedtime.
interactions
3. Monitor IV doses carefully
4. Cimetidine and antacid should be
administered 1 to 2 hours apart
(antacid can decrease the
absorption of cimetidine)
389 / 601
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Drug Class: Antacid
Medications
Gastrointestinal
Aluminum hydroxide, Calcium carbonate
Mechanism of Action:
Antacid are alkaline compounds
that neutralizes acids and
prevents the conversion of
pepsinogen to pepsin in the
stomach.
Types of compounds:
1. Aluminium compounds
2. Magnesium compounds
3. Calcium compound
4. Sodium bicarbonate
Indications:
1. GERD
2. Indigestion
3. Promote ulcer healing
Adverse/Side Effects:
1. Hypokalemia
2. Headache
3. Nausea
4. Vomiting
5. Diarrhea: magnesium
hydroxide retains water which
may cause diarrhea
6. Constipation: aluminium
compound
Adverse/side effect depends on the
specific compound.
Contraindications:
1. Hypersensitivity
2. Pregnancy and lactation
Caution:
1. Electrolyte imbalance
2. Renal dysfunction
Assessment/ Nursing Considerations/Patient Education
1.Educate patient to chew
1. Assess
tablets thoroughly and follow
interactions/contraindications
with a glass of water.
2. Monitor electrolyte level
2. Administer antacid apart
from any other oral
3. Monitor for hypermagnesemia:
medications to ensure
magnesium-containing antacid
adequate absorption of the
should be used with caution due other medications (1 to 2 hours
apart)
to the risk of hypermagnesemia. 3. Shake liquid before pouring
390 / 601
Drug Class: Antiemetics
nursebossstore.com
Medications
Gastrointestinal
Aprepitant, Ondansetron
Mechanism of Action:
Antiemetics suppress nausea and
vomiting by acting on the brain's
control center to stop the nerve
impulse.
The choice of antiemetic depends on
the cause of nausea and vomiting.
TYPES
1. Serotonin antagonist
2. Dopamine Antagonist
3. Antihistamine
4. Glucocorticoids
5. Benzodiazepine
6. Anticholinergics
Indications:
1. Nausea
2. Vomiting
3. Gastroenteritis
4. Chemotherapy
5. Motion sickness
Adverse/Side Effects:
1. Drowsiness
2. Sedation
3. Constipation
The type of antiemetic contributes
to the adverse/side effect
Contraindications:
1. Narrow-angle glaucoma
2. Corticosteroids are
contraindicated with untreated
infections
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1.Educate patient when using
2. Monitor intake and output
oral antiemetics, to take it one
3. Monitor fluid and electrolyte status
4. Position client in a Flower's position to hour before travel to prevent
prevent aspiration
motion sickness.
5. Provide safety precaution if client is
drowsy
6. Administer antiemetics before
treatment/procedure that causes
nausea.
7. Limit oral intake with client nauseated or
vomiting.
391 / 601
Drug Class: Laxatives
nursebossstore.com
Medications
Gastrointestinal
Bulk-forming: Psyllium, Methylcellulose
Stimulant: Senna. Osmotics: Magnesium Hydroxide
Mechanism of Action:
Laxatives promote bowel elimination.
Types:
1. Bulk-forming laxatives: absorbs
water into the intestinal lumen
and feces to increase the size of
the fecal mass and soften stool.
2. Osmotic Laxatives: causes
increased osmotic pressure in the
intestinal lumen (and water
retention). The stool becomes
semifluid.
3. Stimulant laxatives: stimulate
intestinal motility
Indications:
1. Constipation
2. Prevent straining in post op
patients
3. Empty bowel in pre op care
4. Obtain stool specimen
5. Orally ingested toxic
compounds
Adverse/Side Effects:
1. GI disturbance
2. Dehydration
3. Electrolyte Imbalance
Contraindications:
1. Bowel obstruction
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor fluids and electrolyte
levels
3. Encourage increased fluid intake
4. Laxative use should be
temporary
1.Educate patient on
high fiber diet
2. Educate patient on
exercise
3.Educate patient on
increasing fluid intake
392 / 601
Gastro Drug Study
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
393 / 601
Genitourinary Drugs
Fluoroquinolones
Sulfonamides
Thiazide Diuretics
Potassium Sparing Diuretics
Loop Diuretics
394 / 601
Drug Class: Fluoroquinolones
Medications
thenursebossstore.bigcartel.com
Genitourinary Drugs
levofloxacin, moxifloxacin, ciprofloxacin, ofloxacin
Mechanism of Action:
Flouroquinolones interfere with
DNA gryase (an enzyme) needed
by the bacteria for the synthesis
of DNA
Indications:
1. Treatment of respiratory, skin
and urinary infections (caused
by E. coli)
Adverse/Side Effects:
1. Headache
2. Drowsiness
3. Dizziness
4. Nausea
5. Vomiting
6. Photosensitivity
7. Bone marrow depression
8. Superinfections
Contraindications:
1. Hypersensitivity
2. Seizures
3. Renal disorders
4. Pregnancy/children
Interaction
1. Antacid
2. Iron
3. Calcium
4. Magnesium
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Monitor allergic reaction
a. completing medication
3. Do not administer medication with
regimen
antacid, iron, calcium or magnesium b. report if symptoms persist
supplements
c. increase fluid intake
4. Encourage increase fluid intake
d. avoid medication with
5. Monitor I and O
antacid, iron, calcium and
6. Monitor renal lab values
magnesium
395 / 601
Drug Class: Sulfonamides
Medications
thenursebossstore.bigcartel.com
Genitourinary Drugs
sulfadiazine, sulfasalazine
Mechanism of Action:
Sulfonamides Inhibit a metabolic
process essential for the function
and growth of the bacterial cell.
Inhibit folic acid synthesis.
Sulfonamide blocks
paraaminobenzoic acid to prevent
synthesis of folic acid
Indications:
1. UTI
2. Trachoma
Adverse/Side Effects:
1. Nausea
2. Vomiting
3. Diarrhea
4. Bone marrow depression
5. Hepatotoxicity
6. Nephrotoxicity
7. Photosensitivity
8. Renal damage: a result of
crystalluria
9. Hypersensitivity
Contraindications:
1. Hypersensitivity
2. Renal/hepatic disease
3. Pregnancy
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Hx of hypersensitivity
a. completing medication
3. Monitor intake and output
regimen
4. Encourage fluid intake
b. report if symptoms persist
c. the use of sunscreen
d. increase fluid intake
396 / 601
Drug Class: Thiazide Diuretics
Medications
thenursebossstore.bigcartel.com
Genitourinary Drugs
Chlorothiazide, Chlorthalidone
Hydrochlorothiazide, Metolazone
Mechanism of Action:
Adverse/Side Effects:
Thiazide diuretics increase
sodium and water excretion
in the distal tubule.
1. Hypotension
2. Hyponatremia
3. Hypokalemia
4. Hyperglycemia
5. Hypercalcemia
6. Hyperuricemia
7. Fatigue/weakness
Thiazide is a mild diuresis as
compared to loop diuretics
Indications:
1. Hypertension
2. Edema
Contraindications:
1. Fluid and electrolyte imbalance
2. Renal failure
3. SLE
Interactions:
Patient taking
1. Digoxin: can cause digoxin
toxicity due to changes in
potassium levels
2. Lithium: can cause lithium
toxicity
3. Corticosteroids
4. Antidiabetic medications
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor vital signs: BP,P
3. Monitor electrolytes, glucose
level, BUN & creatinine
4. Monitor urinary output/weight
1. Educate patient on
increasing potassium in
diet
2. Educate patient of
preventing orthostatic
hypotension: slowly
change position
3. Diabetic patients
should monitor blood
glucose regularly.
397 / 601
Drug Class: Potassium-Sparing Diuretics
Medications
thenursebossstore.bigcartel.com
Genitourinary Drugs
Spironolactone
Amiloride
Mechanism of Action:
Potassium-sparing diuretics
cause sodium excretion in the
distal tubule, whilst promoting
potassium retention.
Mostly used for patients with a
higher risk of hypokalemia.
Adverse/Side Effects:
1. Hyperkalemia-major
concern
2. Lethargy
3. Arrhythmias
However, the major concern of
potassium-sparing diuretics is
monitoring for hyperkalemia
Indications:
1. Hypertension
2. Edema
3. Fluid retention secondary
to a condition
Contraindications:
1. Kidney disease
2. Hepatic Disease
3. Hyperkalemia
Interactions:
1. Lithium
2. ACE Inhibitos
Caution:
1. Patient taking potassium
supplements
2. Patient with diabetes
Assessment/ Nursing Considerations/Patient Education
1. Assess
1. Educate patient on
interactions/contraindications
low potassium diet
2. Monitor vital signs: BP,P
and signs of
3. Monitor electrolyte levels (pay
attention to potassium levels)
hyperkalemia
4. Monitor for symptoms of
hyperkalemia
5. Monitor ECG for peaked T wave (a
sign of hyperkalemia) and
dysrhythmia
6. Monitor urinary output/weight
398 / 601
Drug Class: Loop Diuretics
Medications
thenursebossstore.bigcartel.com
Genitourinary Drugs
Furosemide
Torsemide
Mechanism of Action:
Loop diuretics decrease
reabsorption of sodium and
chloride in the ascending Loop of
Henle.
(Hence the name-loop diuretics
main effect is in the Loop of Henle.)
Loop diuretics may cause changes
in cardiac output and BP due to its
potency as compared to thiazide
diuretics.
Indications:
1. Hypertension
2. Edema due to HF, renal
disease
3. Acute pulmonary edema
Adverse/Side Effects:
1. Hypotension/orthostatic
hypotension
2. Hyponatremia
3. Hypokalemia
4. Hearing loss: due to rapid flow
of injection of IV furosemide
Contraindications:
1. Hypersensitivity
2. Anuria
3. Hepatic coma
4. Severe electrolyte depletion
Interactions:
1. Digoxin
2. Lithium
3. Aminoglycoside
4. Anticoagulants
Assessment/ Nursing Considerations/Patient Education
1. Assess
interactions/contraindications
2. Monitor vital signs: BP,P
3. Monitor electrolytes, glucose
level, BUN & creatinine, uric acid
4. Monitor urinary output/weight
1. Educate patient of
preventing orthostatic
hypotension: slowly
change position
399 / 601
Genitourinary Drug Study
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
400 / 601
Antibiotics
Penicillin
Cephalosporin
Aminoglycosides
Tetracycline
Sulfonamide
Fluoroquinolones
Antimycobacterials
401 / 601
Drug Class: Penicillin
nursebossstore.com
Medications
Antibiotics
Penicillins, Extended-Spectrum Penicillins
Penicillinase-Resistant Antibiotics
Mechanism of Action:
Penicillins inhibit bacterial cell wall
synthesis. Penicillin prevents
bacteria from using the substance
muramic acid peptide that is
essential for the bacteria's outer
cell wall. Therefore, the bacteria's
cell wall swells, ruptures and dies.
Indications:
1. Treatment of streptococcal
infections
2. Treatment of meningococcal
meningitis
3. Bacterial Infections
Adverse/Side Effects:
1. Allergies
2. Superinfections: when
antibiotics disrupts normal flora
causing new infections (yeast
infection)
3. GI: nausea, vomiting, abdominal
pain, diarrhea, glossitis,
stomatitis, gastritis, furry
tongue, sore mouth
Contraindications:
1. Renal disease
2. Hypersensitivity
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity reports
Educate patient on
2. Assess interactions/contraindications
a. completing medication regimen
3. Hx of drug allergies
b. report if symptoms persist
4. Monitor for hypersensitivity after drug
c. signs of superinfections
administration
5. Discontinue drug when an allergic reaction
is noted (notify physician)
6. For mild allergic reaction: diphenhydramine
7. For severe allergic reaction: epinephrine SC
or IV
402 / 601
Drug Class: Cephalosporin
Medications
nursebossstore.com
Antibiotics
1st Generation Ceph: Cefazolin, 2nd Gen Ceph: Cefoxitin
3rd Gen Ceph: Cefoperazone, 4th Gen Ceph: Cefipime
Mechanism of Action:
Cephalosporins inhibit bacterial cell wall
synthesis.
Classification:
1. First generation cephalosporins:
effective against gram-positive and
gram-negative bacteria.
2. Second generation cephalosporins:
less effective against gram-positive
bacteria.
3. Third generation cephalosporins:
weak against gram-positive bacteria,
potent against gram-negative bacilli
4. Fourth generation cephalosporins:
active against gram-negative and
gram-positive organisms
Indications:
1. UTI caused by E. coli
2. Surgical wound infection
3. Gram-negative bacterial
meningitis
4. Treat multiple resistant gramnegative infection
5. Bacterial Infections
Adverse/Side Effects:
1. Superinfections
2. GI disturbances
3. Nephrotoxicity (especially
among the elderly)
Adverse Effect
1. Allergies
Contraindications:
1. Hypersensitivity
2. Renal/hepatic impairment
Assessment/ Nursing Considerations/Patient Education
1. Monitor
Educate patient on
hypersensitivity/superinfections
a. completing medication
2. Monitor I/O and creatinine levels
regimen
(patients with hx of renal insufficiency) b. report if symptoms persist
3. Monitor IV site for thrombopheblitis c. signs of superinfections
(pain, swelling and redness)
d. Avoid alcohol
403 / 601
Drug Class: Aminoglycosides
Medications
nursebossstore.com
Antibiotics
amikacin, gentamicin
Mechanism of Action:
Aminoglycosides inhibit bacteria
protein synthesis.
They inhibit the translation of
mRNA to protein by irreversibly
binding to bacteria ribosome.
Indications:
1. Serious/life threatening
infections
Adverse/Side Effects:
1. Ototoxicity (may lead to deafness)
2. GI effect: nausea, vomiting,
diarrhea, hepatic toxicity, weight
loss, stomatitis
3. Cardiac: hypertension, palpitations,
hypotension
4. Hypersensitivity
5. Nephrotoxicity: hematuria,
proteinuria, increased BUN levels,
decreased urine output
6. Confusion, disorientation
Contraindications:
1. Hypersensitivity
2. Renal/hepatic disease
3. Myasthenia gravis
4. Parkinson
5. Herpes (active infection)
6. Hearing loss
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Monitor for signs of nephrotoxicity
a. completing medication
3. Provide safety measures due to CNS regimen
effects
b. report if symptoms persists
4. Monitor renal and hepatic function
c. changes in urinary pattern
(toxic effect on kidney)
d. reporting any tinnitus
404 / 601
Drug Class: Tetracycline
Medications
nursebossstore.com
Antibiotics
doxycycline, minocycline
Mechanism of Action:
Tetracycline are broad-spectrum
and inhibits protein synthesis
which causes the inability for
bacterial growth
Indications:
1. Pneumonia
2. Lyme disease
3. Endocervical infections
Adverse/Side Effects:
1. Nausea
2. Vomiting
3. Epigastric burning
4. Stomatitis
5. Glossitis
6. Photosensitivity and rash
Contraindications:
1. Hypersensitivity
2. Renal/hepatic disease
3. Pregnancy
4. Children below 8
Interactions
1. Penicillin
2. Cephalosporin
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Do not administer tetracycline to
a. completing medication
children under 8- (tetracycline may
regimen
cause teeth and bone damage)
b. report if symptoms persist
3. Avoid administering tetracycline
c. the use of sunscreen
with diary products or antacid
405 / 601
Drug Class: Sulfonamides
Medications
nursebossstore.com
Antibiotics
sulfadiazine, sulfasalazine
Mechanism of Action:
Sulfonamides Inhibit the metabolic
process essential for the function
and growth of the bacterial cell.
Inhibit folic acid synthesis.
Sulfonamide blocks
paraaminobenzoic acid to prevent
synthesis of folic acid
Indications:
1. UTI
2. Trachoma
Adverse/Side Effects:
1. Nausea
2. Vomiting
3. Diarrhea
4. Bone marrow depression
5. Hepatotoxicity
6. Nephrotoxicity
7. Photosensitivity
8. Renal damage: a result of
crystalluria
9. Hypersensitivity
Contraindications:
1. Hypersensitivity
2. Renal/hepatic disease
3. Pregnancy
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Hx of hypersensitivity
a. completing medication
3. Monitor intake and output
regimen
4. Encourage fluid intake
b. report if symptoms persist
c. the use of sunscreen
d. increase fluid intake
406 / 601
Drug Class: Fluoroquinolones
Medications
nursebossstore.com
Antibiotics
levofloxacin, moxifloxacin, ciprofloxacin, ofloxacin
Mechanism of Action:
Flouroquinolones interfere with
DNA gryase (an enzyme) needed
by the bacteria for the synthesis
of DNA
Indications:
1. Treatment of respiratory, skin
and urinary infections (caused
by E. coli)
Adverse/Side Effects:
1. Headache
2. Drowsiness
3. Dizziness
4. Nausea
5. Vomiting
6. Photosensitivity
7. Bone marrow depression
8. Superinfections
Contraindications:
1. Hypersensitivity
2. Seizures
3. Renal disorders
4. Pregnancy/children
Interaction
1. Antacid
2. Iron
3. Calcium
4. Magnesium
Assessment/ Nursing Considerations/Patient Education
1. Assess culture and sensitivity results Educate patient on
2. Monitor allergic reaction
a. completing medication
3. Do not administer medication with
regimen
antacid, iron, calcium or magnesium b. report if symptoms persist
supplements
c. increase fluid intake
4. Encourage increase fluid intake
d. avoid medication with
5. Monitor I and O
antacid, iron, calcium and
6. Monitor renal lab values
magnesium
407 / 601
Drug Class: Antimycobacterials
Medications
thenursebossstore.bigcartel.com
Antibiotics
isoniazid (INH), rifampin, ethambutol, pyrazinamide, and streptomycin
Mechanism of Action:
Two main mechanism of action:
a. inhibition of the cell wall
synthesis
b. affects the DNA and/or RNA of
the bacteria
The major drugs used in
tuberculosis are isoniazid (INH),
rifampin, ethambutol,
pyrazinamide, and streptomycin.
Indications:
1. TB
2. Leprosy
Adverse/Side Effects:
1. Peripheral neuropathy
2. Jaundice
3. Discoloration of bodily fluids
4. Rashes
5. Headache
6. Malaise
7. Drowsiness
8. Nausea
9. Vomiting
10. Anorexia,
11. Stomach upset
12. Abdominal pain
Contraindications:
1. Hypersensitivity
2. Renal/hepatic disease
Assessment/ Nursing Considerations/Patient Education
1. Encourage patient to comply with
Educate patient on
medication regimen
a. completing medication
2. Administer vitamin B6 with isoniazid regimen
to prevent peripheral neuropathy
b. treatment of TB takes at
3. Monitor for hepatotoxicity (jaundice, least 6 months
dark urine, enlarged liver)
c. Diet: high in vitamin B6
4. Monitor for signs of liver damage
d. Weight monitoring
(elevated ALT, Elevated AST)
e. Avoid alcohol
5. Monitor patient weight
408 / 601
Antibiotics Drug Study
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
409 / 601
Neuro Drugs
NSAIDs
Salicylates
Acetaminophen
Opioid Analgesics
Morphine Sulphate
Meperidine HCL
Hydromorphone
Anticholinesterases
Benzodiazepines
Hydantoins
Barbiturates
410 / 601
Drug Class: Nonsteroidal anti-inflammatory drugs
Medications
nursebossstore.com
Neurological Drugs
ibuprofen, diclofenac
Mechanism of Action:
NSAIDs have anti-inflammatory,
analgesic and antipyretic properties.
NSAIDs inhibits prostaglandin
synthesis
Types:
1. First-generation NSAIDs: inhibit
COX-1 and COX-2 and are used
to treat inflammatory disorders.
2. Second generation NSAIDs:
inhibits COX-2 only. Inhibits pain
and inflammation
Indications:
1. Rheumatoid arthritis and
osteoarthritis
2. Dysmenorrhea
3. Reduction of fever
Adverse/Side Effects:
1. Dysrhythmias
2. Dizziness
3. GI disturbances/GI bleeding
4. Hypotension
5. Hepatotoxicity
6. Tinnitus
Contraindications:
1. Hypersensitivity
2. Peptic Ulcer
3. Bleeding disorders
4. Renal or hepatic disease
Interactions
1. Anticoagulant
2. Sulfonamides, phenytoin
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1. Educate patient the
2. Monitor for edema
medication regimen, side
3. Provide supporting care
and adverse effects
4. Maintain hydration
5. Monitor for adverse effects
411 / 601
Drug Class: Salicylates
nursebossstore.com
Medications
Neurological Drugs
ASPIRIN (acetylsalicylic acid)
Mechanism of Action:
Salicylates inhibit synthesis of
prostaglandin. Salicylates have
anti-inflammatory, antipyretic and
analgesic properties.
Aspirin suppresses platelet
aggregation by inhibiting
synthesis of thromboxane A2
(causes platelet aggregation)
Indications:
1. Rheumatoid arthritis and
osteoarthritis
2. Dysmenorrhea
3. Reduction of fever
4. Suppression of platelet
coagulation
Adverse/Side Effects:
1. Dizziness
2. Tinnitus
3. Mental confusion/drowsiness
4. GI disturbance
5. Visual changes
6. Bleeding
7. Decreased renal function
Contraindications:
1. Hypersensitivity
2. Bleeding disorders
3. Impaired hepatic/renal function
4. Children/adolescents with flu
symptoms, chicken pox,
influenza (risk for Reye's
syndrome)
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1. Educate patient on the
2. Monitor for edema
medication regimen, side
3. Monitor signs of bleeding
and adverse effects
4. Monitor serum salicylate
5. Administer drug with food to
alleviate GI effects
412 / 601
Drug: Acetaminophen
nursebossstore.com
Medications
Neurological Drugs
Acetaminophen
Mechanism of Action:
Acetaminophen inhibits
prostaglandin synthesis (limited to
CNS and not periphery)
Indications:
1. Pain
2. Fever
3. Preferred use in children
4. Replacement for patients with
aspirin toxicity
Adverse/Side Effects:
1. Nausea
2. Vomiting
3. Hepatotoxicity
4. Oliguria
5. Rash
Contraindications:
1. Hypersensitivity
2. Alcoholism
3. Impaired hepatic/renal function
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1. Educate patient on the
2. Monitor VS
time frame of medication
3. Monitor liver enzymes
use.
4. Antidote of acetaminophen:
acetylcysteine
413 / 601
nursebossstore.com
Drug Class: Opioid Analgesics
Medications
Neurological Drugs
Morphine Sulfate, Pethidine, Fentanyl, Tramadol
Mechanism of Action:
Centrally acting opioid analgesics
act as agonist by stimulating
specific opioid receptors in the CNS
that results in analgesia,
euphoria, and sedation.
Suppresses pain impulses.
Indications:
1. Pain
2. Preoperative medication
Adverse/Side Effects:
1. Respiratory depression
2. Decreased cough: due to
inhibition of cough reflex
3. Light-headedness, dizziness
4. Nausea and Vomiting
5. Urinary retention
6. Constipation
7. Lethargy and sleep
8. Postural hypotension
9. Sweating
Contraindications:
1. Hypersensitivity
2. Respiratory dysfunction
3. Head Injury
4. Increased ICP
5. Severe hepatic and renal
disease
6. Hemorrhage
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1. Encourage deep breathing
2. Assess pain
and coughing
3. Monitor VS (BP, P, RR, SPO2)- Hold
medication and notify HCP if there is
2. Avoid activities that
bradycardia, hypotension, respiratory
requires alertness
depression
4. Auscultate lung sounds
5. Provide non-pharmacologic pain
management with opioids
6. Monitor intake and output.
7. Assess urinary retention
8. Provide safety precautions
9. Have antidote/opioid antagonist on hand.
414 / 601
nursebossstore.com
NEURO DRUGS
Generic Name:
Generic Name:
Generic Name:
Trade Name:
Trade Name:
Trade Name:
Morphine Sulphate
Avinza
Drug Class:
Opioid Analgesics
Mechanism of Action:
Centrally acting opioids
analgesics act as agonist by
stimulating specific opioid
receptors in the CNS that
results in analgesia, euphoria,
and sedation.
Therapeutic Use:
Meperidine HCL
Pethidine
Drug Class:
Opioid Analgesics
Mechanism of Action:
Centrally acting opioids
analgesics act as agonist by
stimulating specific opioid
receptors in the CNS that
results in analgesia, euphoria,
and sedation.
Therapeutic Use:
Pain
Preoperative medication
Pain
Preoperative medication
Side/Adverse Effects:
Side/Adverse Effects:
1. Respiratory depression
2. Orthostatic hypotension
3. Constipation
4. Sedation, Confusion
5. Urinary retention
Contraindications:
Hypersensitivity
Respiratory dysfunction
Head Injury
Increased ICP
Severe hepatic and renal
disease
Hemorrhage
Nursing Considerations:
1. Monitor VS
2. Monitor signs of
respiratory depression
3. Encourage deep
breathing exercises
4. Encourage deep
breathing and coughing
5. Avoid activities that
requires alertness
6. Antidote: nalaxone
1. Hypotension
2. Dizziness
3. Drowsiness
4. Urinary Retention
Contraindications:
Hypersensitivity
Respiratory dysfunction
Head Injury
Increased ICP
Severe hepatic and renal
disease
Hemorrhage
Nursing Considerations:
1. Monitor VS
2. Monitor signs of
respiratory depression
3. Encourage deep
breathing exercises
4. Encourage deep
breathing and coughing
5. Avoid activities that
requires alertness
Hydromorphone
Dilaudid
Drug Class:
Opioid Analgesics
Mechanism of Action:
Centrally acting opioids
analgesics act as agonist by
stimulating specific opioid
receptors in the CNS that
results in analgesia, euphoria,
and sedation.
Therapeutic Use:
Pain
Side/Adverse Effects:
1. Respiratory depression
2. Constipation
Contraindications:
Hypersensitivity
Respiratory dysfunction
Head Injury
Increased ICP
Severe hepatic and renal
disease
Hemorrhage
Nursing Considerations:
1. Monitor VS
2. Monitor signs of
respiratory depression
3. Encourage deep
breathing exercises
4. Encourage deep
breathing and coughing
5. Avoid activities that
requires alertness
415 / 601
nursebossstore.com
Drug Class: Anticholinesterases
Medications
Neurological Drugs
Ambenonium chloride
Edrophonium
Mechanism of Action:
Used to treat muscle weakness in
myasthenia gravis.
Anticholinesterases blocks
acetylcholine breakdown.
Indications:
1. Myasthenia gravis
Adverse/Side Effects:
1. Increased GI motility
2. Pupillary miosis
3. Bronchospasm
4. Increase bronchial secretion
5. Sweating
6. Hypotension
7. Bradycardia
8. Dizziness
Contraindications:
1. Hypersensitivity
2. Peritonitis
3. GI obstruction
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1. Educate patient on drug
2. Monitor signs of cholinergic crisis and
use, side/adverse effect.
myasthenic crisis
2. Educate patient to take
3. Assess neuromuscular status
medication with food to
4. Provide safety measures
prevent nausea, vomiting
and diarrhea
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DrugClass: Dopaminergic Drugs
Medications
Neurological Drugs
Apomorphine, Amantadine
Mechanism of Action:
Dopaminergic drugs stimulate
dopamine receptors and increase
dopamine concentration.
Indications:
1. Parkinson’s disease
Adverse/Side Effects:
1. Muscle twitching
2. Chest pain
3. Nausea and Vomiting
4. Urinary retention
5. Confusion
6. Hallucinations
7. Constipation
8. Orthostatic hypotension
Contraindications:
1. Hypersensitivity
2. Glaucoma
3. Psychiatric disorder
Assessment/ Nursing Considerations/Patient Education
1. Assess interactions/contraindications
1. Encourage patient to
2. Assess VS
change position slowly to
3. Note that carbidopa-levodopa can
minimize orthostatic
cause hypertensive crisis
hypotension
4. Provide safety precautions
2. Avoid alcohol
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Drug: Benzodiazepines
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Medications
Neurological Drugs
SUFFIX: PAM. LAM
Diazepam, Lorazepam
Mechanism of Action:
Benzodiazepines are used to treat
absence seizures.
They enhance the effect of GABA
resulting in sedative, sleepinducing, anti-anxiety,
anticonvulsant, and muscle
relaxant properties
Indications:
1. Preoperative anxiety
2. Seizures
3. Skeletal muscle spams
Adverse/Side Effects:
1. Sedation, drowsiness
2. BP changes
3. Hypotension
4. Blurred vision
5. Hepatoxicity
6. Respiratory depression
Contraindications:
1. Hypersensitivity
2. Myasthenia gravis
3. COPD
4. Bronchitis
5. Sleep apnea
Assessment/ Nursing Considerations/Patient Education
1. Antiseizure precautions
1. Educate patient to:
2. Provide safety precaution
a. Avoid alcohol and OTC
3. Monitor lab values
b. Caution when
4. Monitor renal function test
performing activities that
5. Monitor liver function test
requires alertness
6. Antidote: Flumazenil
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Drug: Hydantoins
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Medications
Neurological Drugs
Phenytoin
Mechanism of Action:
Blocks sodium channels and inhibits
neurons from firing to stabilize
central nervous system membrane
Indications:
1. Seizures
Adverse/Side Effects:
1. Sedation, drowsiness
2. Nausea
3. Vomiting
4. Nystagmus
5. Decrease platelet count
6. Increase serum glucose level
7. Hypotension
8. Blurred vision
Contraindications:
1. Hypersensitivity
2. Psychoses
3. Impaired renal and hepatic
function
4. Pregnancy
Interactions:
Oral contraceptives
Assessment/ Nursing Considerations/Patient Education
1. Antiseizure precautions
1. Educate patient to:
2. Provide safety precaution
a. Avoid alcohol and OTC
3. Monitor lab values
b. Caution when
4. Monitor renal function test
performing activities that
5. Monitor liver function test
requires alertness
6. Phenytoin should be given at a slow
rate to prevent hypotension
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Drug: Barbiturates
Medications
Neurological Drugs
SUFFIX: arbital
Phenobarbital, butabarbital
Mechanism of Action:
Stimulates the inhibitory
neurotransmitter system in the
brain.
Indications:
1. Tonic-clonic seizures
2. Intubation/sedation
Adverse/Side Effects:
1. Sedation, drowsiness
2. Hypotension
3. Respiratory depression
Contraindications:
1. Hypersensitivity
2. Psychoses
3. Impaired renal and hepatic
function
4. Pregnancy
Assessment/ Nursing Considerations/Patient Education
1. Antiseizure precautions
1. Educate patient to:
2. Provide safety precaution
a. Avoid alcohol and OTC
3. Monitor lab values
b. Caution when
4. Monitor renal function test
performing activities that
5. Monitor liver function test
requires alertness
6. Monitor ECG
7. Monitor for signs of infection
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Neuro Drug Study
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
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Anti-Diabetic Drugs
Insulin
Biguanides
Sulphonylureas
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Drug Class: Insulin
Medications
Anti- Diabetic Drug
Lispro, Lantus, Regular, NPH
Mechanism of Action:
Insulin replaces endogenous insulin.
Facilitates the transport of
metabolized food nutrients across
cell membranes.
Adverse/Side Effects:
1. Hypoglycemia
2. Reaction at injection site
Insulin
Indications:
1. Type 1 diabetes
2. Type 2 diabetes
3. Diabetic ketoacidosis
Rapid Acting: Lispro
Onset: 15min
Peak: 1 hour
Duration: 2-4 hours
Short Acting: Regular (R)
Onset: 30min
Peak: 2-5 hourS
Duration: 3-6 hours
Intermediate Acting: NPH Long Acting: Lantus
Onset: 1-2 hours
Onset: 1-2 hours
Peak: 4--12 hours
Peak: no peak time
Duration: 12-18 hours
Duration: 24 hours
Contraindications:
1. Hypoglycemia
Assessment/ Nursing Considerations/Patient Education
1. Assess signs and symptoms of
1. Educate patient on
hypoglycemia
glucose monitoring
2. Administer medication using
2. Educate patient on insulin
subcutaneous site.
self-administration
3. Rotate injection site
4. Store insulin in cool place
5. Do not administer insulin into areas
that are swollen, red or itching
6. Provide good skin care and foot care
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Drug Class: Biguanides: Metformin
Medications
Anti-Diabetic Drugs
Metformin
Mechanism of Action:
Decrease production of glucose by
the liver and also reduces insulin
resistance.
Indications:
1. Type 2 diabetes
2. PCOS
Adverse/Side Effects:
1. Decrease appetite
2. Nausea
3. Diarrhea
4. Vitamin B12 deficiency
Contraindications:
1. Hypersensitivity
2. Type 1 diabetes
Assessment/ Nursing Considerations/Patient Education
1. Assess vital signs and blood glucose
1. Educate patient on signs
level
of hypoglycemia
2. Withhold metformin after radiological 2. Educate patient on low
study (with the use of IV dye)
carb diet
3. Monitor nutritional status
3. Educate patient on
4. Administer Vitamin B12 supplements
glucose monitoring
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Drug Class: Sulphonylureas
Medications
Anti-Diabetic Drugs
Chlorpropamide
Glimepiride
Mechanism of Action:
Stimulates insulin secretion by the
beta cells of the pancreas
Indications:
1. Type 2 diabetes
2. PCOS
Adverse/Side Effects:
1. Decrease appetite
2. Nausea
3. Diarrhea
4. Hypoglycemia
Contraindications:
1. Hypersensitivity
2. Type 1 diabetes
Assessment/ Nursing Considerations/Patient Education
1. Assess vital signs and blood glucose
1. Educate patient on signs
level
of hypoglycemia
2. Monitor for hypoglycemia
2. Educate patient on low
3. Instruct patient not ingest alcohol
carb diet
with sulfonylureas
3. Educate patient on
4. Monitor nutritional status
glucose monitoring
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Anti-Diabetic Drug Study
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
Generic Name:
Brand Name:
Drug Class:
Dosage:
Uses:
Nursing Considerations:
Side/ Adverse Effect
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DRUG
CALCULATION
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The
Basics
Medication
Administration Routes
1. PO: by mouth/orally
2. SubQ: Subcutaneous
3. IM: Intramuscular
4. ID: Intradermal
5. SL: Sublingual
6. PR: per rectum
7. NG: Nasogastric tube
8. IV: Intravenous
9. GT: Gastrostomy tube
10. IVP: IV push
11. IVPB: IV piggyback
Types of Drug
Preparation
1. Tablet: tab(s)
2. Drop: gtt
3. Suspension: susp
4. Suppository: supp
5. Enteric coated: EC
6. Elixir: elix
7. Controlled release: CR
10 Rights of Medication
Administration
1. Right Drug
2. Right Patient
3. Right Dose
4. Right Route
5. Right Time
6. Right Documentation
7. Right Assessment
8. Right to Refuse
9. Right Drug Interaction
10. Right Education
1. Before meals: ac
2. After meals: pc
3. Twice a day: bid
4. Three times a day: tid
5. Four times a day: qid
6. Every day: daily
7. Every hour:qh
8. Every two hours: q2h
9. Every four hours: q4h
10. Every six hours: q6h
Times Of
11. As needed: prn
Medication
12. As desired: ad lib
Administration
13. At bedtime: hs
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Conversion Factors
Remember: Conversions can be based on volume or weight
Conversion
Based on
Volume
VOLUME
1 mg = 1,000mcg
1 g = 1,000mg
1 oz = 30mL
8 oz = 1cup
1 oz = 2tbsp
1 tsp = 5mL
1 tbsp = 15mL
1 tbsp = 3tsp
1 mL = 1cc
1 mL = 5gtts
1L = 1,000mL
WEIGHT
1 kg = 2.2lbs
1 lb = 16 oz
Calculation:
From pounds to kg = divide by
2.2
From kg to pounds = multiply by
2.2
Conversion
Based on
Weight
Safe nursing care mandates accuracy in the
calculation of dosages and solution rates. In
medication calculations, there is no room for
mistakes.
Measurement Systems
There are three measurement systems used in dosage
calculation/pharmacology. That is: a. metric system, apothecary system and
household system.
a. Metric system: gram (g), milligram (mg), microgram (mcg), kilogram (kg),
milliliter (mL) and milliequivalent (mEq)
b. Apothecary (historical system of volume and mass unit): minim (min), pint
(pt), dram, ounces (oz), grain (gr)
c. Household system (what patients use at home): teaspoon (tsp),
tablespoon (tbsp), gallon (gal), pounds (lb), cups
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Basic Volume-Related Formula
The physician order. Example: 4mg
Desired Dose
Have
Volume
The volume that the
medication is available in:
Example: 2mg/1mL
The dosage that the
medication is available in:
Example: 2mg/1mL
Desired Dose
Have
Tablet
Tablet
A physician orders lorazepam 4 mg
IV Push. The nurse has 2 mg/mL vials
on hand. How many mL should be
given?
4mg Desired dose
2mg Have
Volume
1mL = 2mL
Answer
A physician orders DRUG 50 mg/day
po. The nurse has 100mg/ tab on
hand. How many tablets should be
given?
Tablet
50mg Desired dose 1 tab=0.5 tab
100mg Have
Answer
Pediatric Doses
Remember: Pediatric dosage calculations are based on body weight(kgs).
Always convert pounds to Kgs. Formula below is used for safe dose range.
Weight per Kg
Dose per Kg = Amount to Administer
Calculate the dose of a drug in mLs for a child weighing 22
lb. The dose required is 40 mg/kg/day divided BID and the
suspension comes in a concentration of 400 mg/5 mL.
Step 1. Convert pounds to kg: 22 lb × 1 kg/2.2 lb = 10 kg
Step 2. Calculate the dose in mg: 10 kg × 40 mg/kg/day =
400 mg/day
Step 3. Divide the dose by the frequency: 400 mg/day ÷ 2
(BID) = 200 mg/dose BID
Step 4. Convert the mg dose to mL: 200 mg/dose ÷ 400 mg/5
mL = 2.5 mL BID
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IV Flow Rate Calculation
Calculating: mL/hr
mL of amount to be infused
total hours
Calculate 1000ml of normal saline
over 2 hours.
=mL/hr
1000mL 500mL/hr
2 hours
1. If the question provides liters,
convert to mL. 1L= 1000mL
2. 2. If the question provides
minutes, convert to hours.
60min=1 hour
Calculating: gtt/min (drops/min)
mL of amount to be infused
total minutes
A total of 2000mL normal saline is
drop
to infuse at 50mL/hr. Drop factor of
=gtt/min
tubing is 10gtt/mL
factor
50mL 10 gtt/mL= 8 gtt/min
60min
Calculating: Remaining Time of Infusion
Volume Remaining (mL)
Drops per min
Drop
=minutes remaining
factor
Calculation: A patient has IV infusion at 400 mL level. It is
regulated to run for 22 drops per minute using a macrodrip
set with drop factor 20. Calculate the remaining time of
infusion.
400mL
22
20= 363 mins
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insulins
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MATERNAL
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table of content
1. Anatomy and Physiology
2. Signs of Pregnancy
3. Naegele's Rule
4. Gravidity and Parity
5. GTPAL
6. Fundal Height
7. Fetal Development
8. Changes During Pregnancy
9. Discomforts During Pregnancy
10. Nutrition During Pregnancy
11. Conditions During Pregnancy
a. Gestational Diabetes
b. Iron Deficiency Anemia
c. Gestational Hypertension
d. Ectopic Pregnancy
e. Placenta Previa
f. Abruptio Placenta
g. Abortion
h. Torch Infections
12. Labor and Delivery
a. Labor
b. True/False Labor
c. Stages of Labor
d. 5Ps
e. VEAL CHOP
f. Labor Complications
i. Preterm Labor
ii. Cord Prolapse
13. Postpartum-Newborn Care
a. Lochia
b. Postpartum Hemorrhage
c. APGAR SCORE
d. Postpartum Infections
i. UTI
ii. Mastitis
iii. Endometritis
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anatomy and physiology
Female Reproductive System
INTERNAL ORGANS
1. Vagina: muscular tube from the
vulva to the uterus
2. Cervix: cylinder-shaped neck of
tissue that connects the vagina and
uterus
3. Ovaries: two sex organs on each
side of the uterus
4. Fallopian tubes: three sections
(Isthmus, ampulla and infundibulum)
5. Uterus: the womb, located within
the pelvic cavity. Divided into
(cervix, uterine isthmus, corpus,
fundus)
Ovarian hormones:
follicle-stimulating hormone
Luteinizing hormone
Ovarian hormones: are released by the anterior pituitary gland
THE MENSTRUAL CYCLE
The four main phases of the
menstrual cycle are:
1.Menstruation
2. The follicular phase
3. Ovulation
4. The luteal phase
The ovaries secrete two main
hormones—
estrogen and progesterone
1. Menstrual cycle: 28 days
(average length)
2. Ovulation: occurs on the
14th day
3. Fertilization: fusion of
the egg + sperm
4. Implantation: occurs 8-9
days after conception.
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SIGNS OF PREGNANCY
PRESUMPTIVE SIGNS
PROBABLE SIGNS POSITIVE SIGNS
PRESUMPTIVE SIGNS
1. Amenorrhea (missed period).
2. Enlarged breast
3. Quickening: feeling of fetal movement
4. Enlarged breast
5. vomiting
6. Nausea
7. Fatigue
PROBABLE SIGNS
1. Positive pregnancy test
2. Uterine enlargement
3. Goodell's sign: softening of cervix
4. Chadwik's sign: bluish coloration of vulva,
cervix and vagina.
5. Hegar's sign: softening of the lower
uterine segment
POSITIVE SIGNS
1. Fetal heart
2. Fetal movement
3. Ultrasound or radiography
subjective
think "mother"
THE DOCTOR AND NURSE
CAN OBSERVE AND
DOCUMENT
Positive sign is
conclusive (diagnostic)
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NAEGeLE'S RULE
DEFINITION
Used to calculate the estimated date of delivery (based on a
normal 28-day menstrual cycle).
FIRST DAY OF LAST MENSTRUAL PERIOD
January 10th, 2021
Subtract 3 months
October 10th 2020
October
17th 2021
Add 7 days
October 17th 2020
Add 1 Year
estimated date of
delivery
October 17th 2021
Full term: 40 weeks (average)
The calculation is based on a 28-day cycle.
Remember: practice makes perfect. Do as much practice
test questions using the 4 steps presented above.
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gravidity and parity
GRAVIDITY
Gravida: pregnant woman
Gravidity: the number of pregnancies
Nulligravida- never been
pregnant.
Primigravida: pregnant
for the first time.
Multigravida: 2+
pregnancies
NULL- NONE
PRIMI-FIRST
MULTI-MULTIPLE
PARITY
Number of times a woman has
given birth to a fetus with a
gestational age of 24 weeks or
more.
Include all babies (living or still
birth)
Nullipara- no births above
20 weeks of gestation.
Primipara: 1 birth after 20
weeks of gestation
Multipara: multiple
pregnancies that reached
the stage of fetal
viability.
NULL- NONE
PRIMI-FIRST
MULTI-MULTIPLE
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gtpal
GTPAL: DESCRIBES PREGNANCY OUTCOMES
GRAVIDITY
TERM BIRTHS
PRETERM BIRTHS
ABORTIONS
1. Number of pregnancies
(twins and triplets are
counted as one)
2. Present pregnancy included.
1. The number born at term
(longer than 37 weeks of
gestation)
2. Twins and triplets are
counted as one.
20-37 weeks of gestation.
(Count twins and triplets as
one)
Includes alive and still birth
Less that 20 weeks of
gestation.
Count twins and triplets as one
also include miscarriages
LIVING CHILDREN
Current living children.
Count children individually
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FUNDAL HEIGHT
The fundal height is used to determine the gestational age of a
fetus by determining the distance in centimeters from the symphysis
pubis to the top of the uterine fundus.
MEASURING THE FUNDAL HEIGHT
is
t
n
me
e
r
su
a
e
m
m
in c
Position patient to lie back
Start measuring from the symphysis pubis
Run the tape measure along the midline
of the woman’s abdomen to the top of
the uterine fundus
Monitor for
supine
hypotension
Fundal height (cm)= fetal
gestational age.
(20cm=20weeks)
16 weeks= fundus is located
between the symphysis pubis and
umbilicus
20-22 weeks= fundus is located
at the level of the umbilicus
36 weeks= fundus is at the
xiphoid process
Patient with inaccurate fundal height
measurement should have a serial
assessment of fetal size using
ultrasound
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fetal development
preembryonic PERIOD:
first 2 weeks
week 4/5
Embryonic PERIOD:
2-8 weeks
week 8
FETAL period:
9weeks-birth
week 12
1. Heart begins to
beat
1. Blood begins to
circulate
2. Organs are present
1. Sex is visible
2. Face is formed
3. Heart tones can be
heard using a
Doppler
week 16
week 20
week 24
1. Movement is
present
week 28
1. Lungs are
developed
week 40
1. The average fullterm 40- week
Baby is
here!
1. Heartbeat is
detected by fetoscope
2. Lanugo covers body
week 32
1. Bones are
developed.
1. Fetus can hear
week 36
1. Skin becomes less
wrinkled.
2. Skin is pink.
3. Baby position down in
pelvis
TRIMESTERS
First Trimester: 0-12
weeks
Second Trimester: 13-28
weeks
Third Trimester: 29-40
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CHANGES DURING PREGNANCY
cardiovascular
Increased CO
Increased HR
Increased blood volume
Respiratory
Increased O2 consumption
Diaphragm pushes upwards
SOB may be experienced
Gastrointestinal
Nausea, Vomiting
Acid reflux, Constipation
Changes in taste and smell
genitourinary
Increase urination
Bladder sensitivity
Increase bladder capacity
Endocrine
Oxytocin stimulates contractions
Weight gain
Thyroid activity increases
Increased water retention
Prolactin causes the lactation process
SKIN/musculoskeletal
1. Striae
2. Linea nigra
3. Increased hair growth
4. Umbilicus protrudes
5. Abdominal wall stretches
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Discomforts during pregnancy
1.Nausea and Vomiting
2. Fatigue
Intervention: Eating dry crackers Interventions: Frequent naps/rest
before rising up from bed.
Relaxation and exercise
3. Heartburn
Intervention: Have small, frequent meals.
Sit upright after meals for 30mins-1hour
4. Increased urination
Intervention: Adequate fluid intake,
Avoid fluid intake before bedtime.
Kegel exercises
5. EDEMA/varicose veins
Intervention: Elevate legs
Supportive stockings
Avoid standing or sitting for
long periods
6. Constipation
Intervention: Increase fiber in
diet. Increase fluid intake
7. uti
Intervention: Consult with
physician. Follow treatment
regimen
8. Hemorrhoids
Intervention: Soaking in a sitz
bath
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NUTRITION during pregnancy
calories
300-500 additional calories
WEIGHT GAIN
Total weight gain: 25-35lbs
FOLIC ACID
Recommendation: 600
micrograms (mcg) of folic acid
daily.
CALCIUM
Calcium supplements
Diary foods
Dark, leafy green vegetables
Important for fetus: Bone and
teeth formation
PROTEIN
Increase protein in diet.
Vitamin B12 is found in animal
protein.
PROTEIN
=
vit b12
defeciency
iron
Build hemoglobin for fetus
VITAMINS
Vitamin D: for calcium
absorption
Increase fruits and vegetables
fiber
To prevent/reduce constipation
fluid intake
Recommendation: 2-3L/day
No alcohol, Limit caffeine
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CONDITIONS
RELATED TO
PREGNANCY
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CONDITIONS during pregnancy
GESTATIONAL
DIABETES
pathophysiology
Impaired glucose tolerance that occurs during the 2nd or 3rd
trimester of pregnancy.
RISK FACTORS
1. Obesity
2. Multiple pregnancies
3. Family history of DM
DIAGNOSTIC TEST
1. Glucose tolerance test
2. 3-hour oral glucose
tolerance test (OGTT)
signs & SYMPTOMS
1. Polyuria: increased
urination
2. Polydipsia: Increased
thirst
3. Polyphagia: Increased
appetite
4. Blurred vision
5. Glucose in urine
6. Frequent UTIs
7. Excess weight gain
Nursing management
1. Diet, Insulin
2. Glucose monitoring, Low impact exercise
3. Monitor weight
4. Monitor fetal status
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CONDITIONS during pregnancy
Iron Deficiency
Anemia
pathophysiology
Iron deficiency anemia is characterized by insufficient serum
iron. This results in decreased hemoglobin and decreased
oxygen-carrying capacity of the blood.
causes
signs & SYMPTOMS
1. Diet: low consumption
of iron-rich foods.
2. Insufficient serum iron.
1. Fatigue
2. Pallor
3. Hemoglobin: <10mg/dL
DIAGNOSTIC TEST
Pharmacology
1. Hemoglobin/Hematocrit
2. Serum iron level
3. RBC size: smaller
1. Ferrous Sulfate
2. Folic acid
3. Vitamin C: increase iron
absorption
Nursing management
1. Monitor hemoglobin/hematocrit levels
2. Educate patient on medication regime
3. Encourage iron-rich foods
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CONDITIONS during pregnancy
gestational
Hypertension
Gestational hypertension
Blood pressure >140/90 mm Hg after 20 weeks gestation with
no proteinuria (excess protein in the urine).
preeclampsia
Mild preeclampsia: BP >140/90 but <160/110,
Proteinuria: 1+
Severe preeclampsia: BP >160/110, Proteinuria: >3+
Signs of preeclampsia: HYPERTENSION + PROTEINURIA
ECLAMPSIA
Seizures in preeclamptic patient
Intervention
complications
1. DIC/ fetal death
2. Abruptio placentae
3. HELLP syndrome: Hhemolysis, EL- elevated
liver enzymes, LP- low
platelet count.
1.BP monitoring
2. Fetal monitoring
3. Bed Rest (lateral position)
4. Antihypertensive medications
5. Administer Magnesium sulfate: prevent seizures.
Monitor for magnesium toxicity (antidote: calcium gluconate)
6. Initiate seizure precaution: preeclampsia/eclampsia
7. Monitor for HELLP
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CONDITIONS during pregnancy
ectopic
pregnancy
pathophysiology
Ectopic pregnancy occurs when an ovum implants outside of the
uterus (mostly in the fallopian tube). Risk for tubal rupture and
hemorrhage.
RISK FACTORS
signs & SYMPTOMS
1. Previous ectopic
pregnancy
2. Vitro fertilization (IVF)
DIAGNOSTIC TEST
1. Abdominal pain
(stabbing pain)
2. Vaginal spotting
3. Hemorrhagehypotension,
tachycardia
1. Ultrasound
Treatment
Pharmacology
Methotrexate-used to stop cell growth
Laparotomy procedures
1. Salpingostomy: ectopic pregnancy is removed and the
fallopian tube left to heal.
2. Salpingectomy: ectopic pregnancy and fallopian tube are
removed.
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CONDITIONS during pregnancy
placenta
previa
pathophysiology
Placenta previa occurs when the placenta partially or totally
covers the mother's cervical opening.
TYPES
signs & SYMPTOMS
1. Marginal: Placenta is
attached in the lower
region of the uterus but
does not cover cervical
opening.
2. Partial: Placenta covers a
part of the cervical opening
3. Total: The placenta covers
the entire cervical opening.
1. Painless bright red
bleeding
2. Bleeding
3. Soft uterus
Diagnostic test
Ultrasound
Nursing Management
1. Avoid vaginal examination
2. Medication: corticosteroids
3. Continuous monitoring of mother and fetal status
4. Promote rest (left side lying)
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CONDITIONS during pregnancy
abruptio
placenta
pathophysiology
Abruptio placenta is the premature separation of the placenta
from the uterus. RISK FOR: Hemorrhage, shock and fetal
distress.
RISK FACTORS
1. Hypertension
2. Smoking
3. Cocaine
4. Abdominal injury
signs & SYMPTOMS
1. Abdominal pain
2. Bleeding: dark red
3. Hypovolemic shock (s/s)
4. Uterine becomes hard
5. Fetal distress
Nursing Management
1. Monitor mother and fetal status
2. O2 therapy as prescribed
3. Monitor bleeding: remember to count the # of pads
4. Side lying
5. Medication: corticosteroids
6. IV fluids/blood as prescribed
7. Prepare for Caesarian section
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CONDITIONS during pregnancy
abortion
pathophysiology
Abortion is the termination of pregnancy before 20 weeks of
gestation (either spontaneously or electively)
Types
signs & SYMPTOMS
1. Spontaneous: natural cause
2. Complete: all tissues of conception
leaves the body
3. Missed: tissues of conception
remains in the uterus
4. Threatened: Spotting & cramping
5. Inevitable: Bleeding & dilated
cervix
1. Bleeding/Blood clots
2. Cramping
Nursing Management
1. Monitor VS
2. Monitor bleeding (signs of shock)
3. Count pads
4. Administer IV fluids as prescribed
5. Procedure: prepare for Dilation and Curettage (D&C) for
inevitable /incomplete abortion.
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CONDITIONS during pregnancy
torch
infections
Toxoplasmosis: found in raw meat (or undercooked), cat
feces.
Patient education: Mother should NOT clean litter
boxes. Cook meat well.
OTHER:
Syphilis, Hepatitis A & B, Varicella, HIV
Rubella:
S/S: deafness, congenital defects: heart, eyes and
brain
Cytomegalovirus: droplet transmission
S/S: low birth weight, jaundice, hearing loss,
seizures
Herpes simplex virus:
Transmitted during vaginal delivery (delivery is
usually cesarean section)
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LABOR AND
DELIVERY
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LABOR
signs that precede labor
1. Contractions (Braxton Hicks)
2. Lightening
3. Rupture of membrane
4. Weight loss (1-3 pounds)
5. Increased in energy
6. Cervical ripening
7. Increased vaginal discharge
8. GI disturbance
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TRUE VS LABOR
true labor
1. Contractions:
i. Regular
ii. Stronger
iii. Longer
2. Softening of the cervix
i. Cervical dilation
ii. Effacement
3. Fetus engages in the pelvis
i. Presenting part compresses the bladder
FALSE labor
1. Contractions:
a. Irregular
b. Walking decreases contractions
2. No cervical changes or dilation
3. No effacement
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STAGES OF LABOR
FIRST STAGE
second STAGE
From the onset of labor
to complete dilation.
The second stage is
between full dilationbirth
Phases:
1. Latent Phase: 03cm (from mild to
moderate
contractions)
2. Active Phase: 4-7cm
3. Transition phase 810cm dilation
(contractions are
very strong)
Third STAGE
The third stage is
between the delivery of
the baby and the
delivery of the placenta.
FOURTH STAGE
The fourth stage is
between placenta
delivery until mother's
stabilization.
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5pS
ASSSAGEWAY
Remember: birth canal
4 Types of
pelvic shape
Gynecoid (most common),
android, anthropoid
(oval), and platypelloid
(flat)
assenger
Remember: fetus, membranes & placenta
Attitude: The relationship of fetus' body parts to one another.
Normal attitude: general flexion, fetal extension
fetal lie: The relationship between the long axis (spine) of the fetus
with respect to the long axis (spine) of the mother.
Lie: Longitudinal/vertical (cephalic or breech)
Transverse or horizontal- cesarean section is needed
Presentation: Part of the fetus that enters the pelvic inlet first.
Cephalic: head first, Breech: buttocks first, Shoulder:
shoulders first (transeverse)
position: Relationship of presenting part to maternal pelvis
station: Station 0: at ischial spine
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owers
osition
5pS
Contractions causes effacement and
dilation
Effacement: Shortening and thinning
of cervix during first stage of labor.
Dilation: Full dilation 10cm
(enlargement of cervix)
Birthing positions.
This includes:
1. Squatting position
2. Lithotomy position
3. Upright position
4. Sitting position
Emotional Response
sychological Anxiety or fear
Response
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VEAL CHOP
A method used to understand the different fetal heart rate patterns
variable deceleration
cord compression
early deceleration
head compression
acceleration
oxygenated or OK
late
deceleration
placental
insufficiency
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labor Complications
preterm labor
Onset of uterine contractions before 37 weeks of gestation.
signs and symptoms
Signs of true labor (regular contractions, vaginal discharge and
cervical dilation)
Pharmacology
Administer Glucocorticoids (to improve fetal lung maturity)
Administer magnesium sulfate: monitor magnesium sulfate
toxicity.
cord prolapse
Cord prolapse occurs when the cord descends through the
cervix below the presenting part of the fetus.
RISK
Risk for decrease blood flow and oxygenation to the baby.
NURSING INTERVENTIONS
Call for help
Insert 2 fingers in the vagina (lift the fetal head off the cord)
Position: Trendelenburg or knee to chest position
Monitor fetal heart rate
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Postpartum
Newborn care
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lochia
RE
D
lochia rubra
n
BR
IG
HT
Remember: bright red
Lasts for 1-3 days
br
k/
n
pi
Remember: pink/brown
Lasts: day 4 to day 10
ow
lochia SEROSA
ow
ye
ll
Remember: yellow/white
Can last up to 6 weeks
/w
hi
te
lochia alba
ABNORMAL FINDINGS
When pad is soaked within less than 15 minutes.
Increased abdominal pain
Fever
Foul smelling or purulent lochia
Bright red bleeding after 3 days
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POSTPARTUM HEMORRHAGE
POSTPARTUM
HEMORRHAGE
Definition: The mother loses
>500 mL of blood in a normal
delivery and >1000mL of
blood in a cesarean delivery
CAUSES
uterine Atony: The uterus stops contracting
Lacerations
Retained placental fragments
Signs and Symptoms
1. Heavy bleeding
2. Tachycardia
3. Hypotension
4. Tense and rigid uterus
5. Decreased hematocrit
Nursing Interventions
1. Administer O2
2. Assess and monitor vital signs
3. IV replacement + blood products
4. Massage uterine fundus
5. Administer oxytocin, hemabate, & methylergonovine
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APGAR ASSESSMENT
SCORE
0
HEART RATE
1
<100/MIN
2
>100/MIN
RESP RATE
ABSENT
SLOW/
WEAK
MUSCLE TONE
ABSENT
SOME
FLEXION
ACTIVE
REFLEX
IRRITABILITY
NONE
GRIMACE
CRY
COLOR
PALE OR
BLUE
ACROCYANOSIS
PINK
VIGOROUS
CRY
Distressed
0-3 Severely
requires medical attention and resuscitation
Distressed
4-6 Moderately
clearing of the airway and supplementary oxygen
Condition
7-10 Good
Baby is in best possible health
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POSTPARTUM infections
Urinary tract infection
PATHO
Inflammation of any part of the urinary system
causes:
C-section, frequent vaginal examination, catheterization
Interventions:
1. Urine sample, antibiotics, analgesics
mastitis
PATHO
Inflammation/infection of the breast tissue
causes:
Poor feeding technique, block duct
Interventions:
1. Antibiotics 2. Educate patient to breastfeed frequently 3.
Educate patient to empty breast after feeding
endometritis
PATHO
Inflammation/infection of the inner lining of the uterus
causes:
C-section, retained placental fragments, internal fetal monitoring
Interventions:
1. Vaginal+blood culture
2. Antibiotics + analgesics
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PED
I
A
dis
T
ord RI
ers C
A St
udy
Gui
de f
or N
ursi
ng S
tud
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ents
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INTEGUMENTARY DISORDERS
1. ECZEMA
2. SCABIES
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INTEGUMENTARY DISORDERS
ECZEMA
description
Skin inflammation involving the epidermis.
Forms:
1. Infantile: Onset (2-6 months)
2. Childhood: Onset (2-3 years)
3. Preadolescent and Adolescent: Onset (12
years)
Interventions
Signs & Symptoms
1. Avoid skin exposure to irritants
2. Lubricate skin
3. Soothe skin with cold compressions
4. Medications: Antihistamines, topical
corticosteroids
5. Avoid wet diapers
1. Redness
2. Inflammation
3. Itching
4. Papules
5. Oozing or crusting.
6. Scaly patches of skin.
SCABIES
description
1. Highly contagious parasitic skin disorder
caused by the human itch mite (Sarcoptes
scabiei).
2. Transmission: skin-to-skin contact
Interventions
1. Monitor skin around wound
2. Medications: topical scabicide- educate the
parents on application, Anti-itch topical
treatment, antibiotics
3. Change bedding daily
4. Treat the family
Signs & Symptoms
1. Itching
2. Rash
3. Pruritus
4. Burrows in skin: Fine grayish
red lines
5. Thick crusts on the skin (crust
scabies)
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HEMATOLOGY DISORDERS
1. SICKLE CELL ANEMIA
2. IRON DEFICIENCY ANEMIA
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Hematology disorders
Sickle Cell Anemia
description
In sickle cell anemia, hemoglobin A is replaced by
abnormal sickle hemoglobin S.
Other characteristics: Sticky sickle cells, sickle cells
block blood flow
Sickle cell crisis:
Vaso-occlusive crisis, sequestration, aplastic,
hyperhemolytic
Interventions
Normal red
blood cells
SickleD RED
BLOOD CELLS
Signs & Symptoms
1. Pain
2. Anemia
3. Jaundice
4. Heart
failure/dysrhythmias
5. Enlargement of the
bones
1. O2 therapy
2. Blood transfusion
3. Electrolyte replacement
4. Pain management
5. Infection prevention: antibiotics
6. Non-pharmacologic pain management:
positioning
7. Diet: high calorie, high protein diet, folic acid
supplement
iRON DEFICIENCY aNEMIA
description
Iron deficiency anemia is characterized by insufficient
iron which leads to depletion of red blood cells. This
results in decreased hemoglobin and decreased
oxygen-carrying capacity of the blood.
Interventions
Administer Iron supplements
Educate on the side effects of iron supplements:
Constipation and black stools
Educate parents on iron-rich diet/foods
Educate parents to increase vitamin C consumption in
their child's diet
Educate parents to give the child liquid iron
supplements with a straw to prevent teeth staining.
Signs & Symptoms
1. Fatigue
2. Pallor
3. Brittle nails
4. Low hemoglobin and
hematocrit levels
5. Shortness of breath
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ENDOCRINE DISORDERS
1. FEVER
2. DEHYDRATION
3. TYPE 1 DIABETES
4. DIABETES KETOACIDOSIS
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endocrine disorders
fever
description
Fever is the elevation in body
temperature.
Temperature:
1. Normal: 36.4-37.0 (degrees celsius)
2. Fever: >38.0 (degrees celsius)
Interventions
!
!
!
!
!
R
E
V
E
F
Signs & Symptoms
1. Monitor temperature
2. Assess underlying cause
3. Non-pharmacologic management: remove excess
clothing, cooling measures, sponge bath.
4. Medications: Antipyretics
Remember: do not administer Aspirin
due to the risk of reye's syndrome
1. Temperature: >38.0
(degrees celsius)
2. Skin: warm
3. Lethargy
4. Chills
Dehydration
description
Dehydration is a fluid and electrolyte
imbalance that results from decreased fluid
intake, increased fluid output (vomiting,
diarrhea) or fluid shift (burns and sepsis).
Interventions
1. Monitor vital signs
2. Monitor weight
3. Monitor intake and output
4. Treat cause of dehydration
5. Mild dehydration: oral rehydration therapy
6. Severe dehydration: maintain NPO, IV therapy
7. Remember: signs and symptoms depends on the
severity of dehydration
Signs & Symptoms
1. Weight loss
2. Increased pulse
3. Tachypnea
4. Increased thirst
5. Oliguria
6. Sunken anterior fontanel
7. Sunken eyes
8. Irritability
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endocrine disorders
TYPE 1 DIABETES
description
An autoimmune dysfunction in which the beta
cells are being destroyed. The pancreas (beta
cells) is unable to produce insulin.
Insulin is an essential
hormone produced by the
pancreas. Its main role is to
control glucose levels in the
body
Risk factor/causes
Autoimmune response
Genetics
Onset: childhood
Interventions
Signs & Symptoms
1. Polyuria: increased
urination
2. Polydipsia: Increased
thirst
3. Polyphagia: Increased
appetite
4. Weight loss
5. Hyperglycemia
1. Glucose monitoring
2. Insulin: diluted insulin for infants
3. Balanced diet
4. Exercise
n
io
at
lic
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co
DIABETIC KETOACIDOSIS
description
DKA is a sudden, life-threatening
complication of Type 1 Diabetes.
Characteristics:
Hyperglycemia, Dehydration, Ketosis,
Acidosis
Interventions
IV fluid replacement
IV insulin: treat hyperglycemia
Correct electrolyte imbalance:
Monitor potassium levels
O2 therapy
Signs & Symptoms
1. Fruity breath
2. Kussmaul's respiration
3. Ketosis
4. Acidosis
5. Electrolyte loss
6. Lethargy
7. Confusion/Coma
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RESPIRATORY DISORDERS
1. EPIGLOTTITIS
2. BRONCHITIS
3. ASTHMA
4. CYSTIC FIBROSIS
5. PNEUMONIA
6. BRONCHIOLITIS
7. INFLUENZA
8. TONSILLITIS
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Respiratory disorders
epiglottitis
description
Inflammation and swelling of the
epiglottis.
Cause: Haemophilus influenza
treated as an emergency
Interventions
1. Maintain patent airway (priority)
2. O2 therapy as ordered
3. Monitor respiratory status
4. Maintain NPO
5. Do not place the child in a supine position
6. Avoid throat culture
7. Medications: antibiotics, antipyretics
8. Prepare resuscitation equipment
Signs & Symptoms
1. Fever
2. Severe sore throat
3. Difficulty speaking
4. Drooling
5. Tachycardia
6. Difficulty breathing
7. Stridor
bronchitis
description
Inflammation of the lining of the bronchial
tubes.
Causes: viral infection
Bronchitis may be either acute or chronic
Interventions
1. Monitor temperature
2. Monitor respiratory status
3. Increase fluid intake
4. Medications: antipyretics, cough
suppressants
Signs & Symptoms
1. Fever
2. Nonproductive cough
3. Productive cough
(after 2 days)
4. Chest pain
5. Chills
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Respiratory disorders
asthma
description
Chronic inflammatory disease of the airway.
Inflammation and hypersensitivity to a trigger
(stimuli).
Smooth muscle constriction of the bronchi.
Intermittent airflow obstruction.
Interventions
1. Maintain patent airway
2. Assess respiratory status
3. Administer humidified O2
4. Administer medications
(anticholinergics, corticosteroids,
bronchodilators)
5. Chest physiotherapy
Signs & Symptoms
1. Dyspnea, wheezing,
chest tightness, non
productive cough
2. Restlessness
3. Hyperresonance on
percussions
Cystic Fibrosis
Diagnostic tests:
1. Sweat test: More than 60 mmol/L:
diagnosis of cystic fibrosis
2. Stool analysis and Pulmonary function test
description
CF is an exocrine gland dysfunction that results to
chronic respiratory infections, pancreatic enzyme
insufficiency, sweat gland dysfunction (results to
increased Na + Cl sweat concentration). Thick mucus
produced by the exocrine gland obstruct organs.
CF is progressive and incurable.
Interventions
Resp- Monitor resp status, chest physiotherapy,
antibiotics, bronchodilators, O2 therapy, mucolytics,
anticholinergics
GI- Diet (Vitamins, high-protein, high calorie diet),
Monitor weight and stool pattern, administer
pancreatic enzymes.
Others- Monitor vital signs, monitor electrolyte levels,
provide emotional support
Signs & Symptoms
Resp- barrel chest, clubbing of fingers,
dyspnea, wheezing & cough
GI: Meconium ileus, Steatorrhea, Rectal
prolapse, Bile-stained emesis
Skin: High Na + Cl in sweat,
dehydration, electrolyte imbalance
Reproductive system: Sterility
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Respiratory disorders
pneumonia
description
Inflammation of the pulmonary tissue caused
by bacteria, fungi and viruses.
Viral pneumonia: occurs more frequently than
bacterial pneumonia.
Bacterial pneumonia: serious infection
Aspiration pneumonia: Substance enters the
airway due to vomiting or impaired
swallowing
Interventions
Viral pneumonia:
1. 02 therapy, 2. antipyretics, 3. chest
physiotherapy 4.Increase fluid intake, Iv fluids
Bacterial pneumonia:
1. O2 therapy, IV fluids, antibiotics, suction mucus,
promote rest, increase fluid intake
Signs & Symptoms
1. Cough
2. Wheezing
3. Fever
4. Chills
5. Tachypnea
Bronchiolitis
description
Inflammation of the lining of the bronchioles
due to RSV (Respiratory Syncytial Virus).
Interventions
1. Maintain patent airway
2. Humidified oxygen
3. Increase fluid intake
4. Place the child at a semi-fowlers position.
5. Periodic suctioning
Signs & Symptoms
1. Rhinorrhea
2. Cough
3. Fever
4. Wheezing
5. Tachypnea
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Respiratory disorders
Influenza
description
Influenza is a viral infection that attacks
the respiratory system.
Highly contagious airborne disease.
Interventions
Signs & Symptoms
1. Promote bed rest
2. Administer antiviral medication
3. Increase fluid intake
1. Cough
2. Fever
3. Myalgia
4. Fatigue/body
weakness
Tonsillitis
description
Tonsillitis is the inflammation of the tonsils.
The tonsils are two oval-shaped pads of
tissue at the back of the throat.
Interventions
1. Medications: Antipyretics, Antibiotics
2. Surgical intervention: tonsillectomy-the removal of
the tonsils
a. Monitor for postoperative bleeding (a sign of
bleeding is frequent swallowing)
b. Begin with clear fluids then proceed to soft
diet.
c. Remember: do not administer any red liquids
Signs & Symptoms
1. Swollen tonsils
2. Sore throat
3. Snoring
4. Painful swallowing
5. Fever
6. Muffled voice
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NEUROLOGICAL DISORDERS
1. MENINGITIS
2. SEIZURES
3. REYE'S SYNDROME
4. CEREBRAL PALSY
5. HEAD INJURY
6. HYDROCEPHALUS
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NEUROLOGIC disorders
The primary function of the
meninges and of the
cerebrospinal fluid is to protect
the central nervous system
MENINGITIS
description
Meningitis is an inflammation of the protective membranes covering the brain
and spinal cord.
Other causes
Causes
BACTERIA
virus
1. Trauma
2. Cancer
3. Neurosurgery
DIAGNOSTIC TEST
CSF is obtained through lumbar puncture
BACTERIAL Meningitis
Results: Positive gram stain, Appearance (cloudy), WBC (elevated),
Glucose (decreased) Protein (elevated)
VIRAL Meningitis
Results: Negative gram stain, Appearance (clear), WBC (elevated),
Protein (within normal range), Glucose (within normal range)
Interventions
1. Droplet precautions
2. Assess LOC, increased ICP
3. Medications: IV antibiotics (bacterial
meningitis), antipyretics, corticosteroids
4. Monitor for hearing loss
DROPLET PRECAUTIONS
Droplet spread is via the upper respiratory tract (nose,
nasal passages and pharynx).
Nursing Actions
1. Place patient in a private room
2. Wear a surgical mask.
Signs & Symptoms
1. Positive Brudzinski's
sign
2. Positive Kernig's sign
3. Fever, headache
4. Irritability
5. Bulging anterior
fontanels
6. Nuchal rigidity
7. Photophobia
8. Nausea/vomiting
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NEUROLOGIC disorders
SEIZURES
description
Seizures: a sudden, uncontrolled
electrical disturbance in the brain.
Epilepsy: Chronic seizures
seizure types:
Generalized Seizures
1. Tonic-Clonic
2. Absence
3. Myoclonic
4. Atonic
Partial Seizures
1. Simple partial
2. Complex partial
Nursing Interventions:
1. Initiate seizure precautions
2. Assess time and duration of seizure
activity
3. Provide patient safety
4. Turn patient to the side
5. Maintain airway
6. Avoid restraining patient
7. Loosen clothing
8. Administer O2
9. Monitor behavior before and after
seizure activity, vital signs
10. Maintain NPO status after seizure
MEDICATION:
Anti-seizure medication:
e.g.Phenytoin
RISK FACTORS
1. Fever
2. Meningitis
3. Head trauma
4. Stroke
5. Brain tumor
6. Electrolyte imbalances
DIAGNOSTIC TESTS:
1. An electroencephalogram
2. Computerized tomography
3. Magnetic resonance imaging
(MRI)
4. Neurological exam
Signs and symptoms
The signs and symptoms depends on seizure
history and type.
Before seizure
Aura
During seizure
Loss of consciousness during seizures
Uncontrollable involuntary muscle
movements
Loss of bladder and bowel control
febrile seizures
A febrile seizure is a convulsion in
a child that's caused by a fever.
The fever is often from an
infection.
Types:
1. Simple febrile seizures
2. Complex febrile seizures
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neurological disorders
REYE'S SYNDROME
description
Reye's syndrome is characterized by
encephalopathy and fatty changes in
liver
Risk factors: Viral infection, Aspirin
Diagnostic test
1. Liver Biopsy
2. Liver enzymes: ALT, AST
3. Blood ammonia level
Aspirin is not used among children due to
the risk of Reye's syndrome
Interventions
Signs & Symptoms
1. Assessment: Hx of viral illness (4-7 days
prior), liver enzymes and blood
ammonia level (elevated).
2. Monitor s/s of increased ICP, LOC
3. Positioning: HOB @ 30 degrees
4. Monitor intake and output
1. Fever
2. Vomiting
3. Irritability
4. Lethargy
5. Hepatic dysfunction
CEREBRAL PALSY
description
Cerebral Palsy is a disorder that
affects movement, posture and muscle
tone.
Spastic cerebral palsy is the most
common type.
Interventions
1. Assessment: developmental and
growth status
2. Physical therapy, speech therapy
3. Braces
4.Medication: anti-seizure
Signs & Symptoms
1. Developmental
delays
2. Delayed growth
3. Abnormal posture
and motor function
4. Opisthotonos
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NEUROLOGIC disorders
HEAD INJURY
description
Trauma to the skull that causes
brain damage.
EARLY SIGNS OF INCREASED ICP
1. Infants: High-pitched cry, poor feeding,
irritability, bulging fontanel, setting sun
sign, Macewen's sign (percussion: you will
hear a cracked-pot sound)
2. Children: Blurred vision, seizures,
headaches
types:
Late signs of increased icp
Open Head Injury:
Object
penetrates skull
Closed Head Injury:
Blunt trauma
1. Decorticate: flexion
2. Decerebrate: extension
3. Cheyne-Stokes respirations
4. Decreased LOC
5. Abnormal pupil reaction
6. Bradycardia
7. Poor sensory and motor function
Decorticate & decerebrate
Nursing Interventions:
1. Immobilize the neck and spine
2. Elevate head @ 30 degrees (if it is
not a spinal cord injury)
3. Head position: midline position
4. Monitor airway (O2 therapy)
5. Assess vital signs and level of
consciousness
6. Do not suction patient
7. Seizure precautions
8. Educate child to avoid straining
9. Insert urinary catheter
MEDICATION:
1. Antibiotics: laceration
2. Osmotic diuretic (mannitol): decrease
cerebral edema
3. Anticonvulsants: seizures
4. Acetaminophen: headaches
Decorticate:
1. The arms are bent in toward the
body
2. wrists and fingers are bent and
held on the chest
3. Legs extended
Decerebrate:
1. The head and neck being arched
backward
2. Arms and legs are extended
COMPLICATIONS:
1. Epidural hemorrhage
2. Subdural hemorrhage
3. Brainstem involvement
4. Leakage of CSF: drainage from
nose/ears is positive for glucose
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NEUROLOGIC disorders
HYDROCEPHALUS
description
Abnormal CSF accumulation due to
the imbalance of CSF production
and absorption
types:
Communicating: non-obstructive
hydrocephalus
Non-communicating:
Obstructive
hydrocephalus
surgical intervention
The goal of the surgical intervention
is to bypass the blockage and
prevent CSF accumulation.
Shunt
1. Surgical insertion of a drainage
system, called a shunt.
Endoscopic third ventriculostomy
1. Treatment of choice for
obstructive hydrocephalus
MEDICATION:
1. Antibiotics
2. Analgesics
Signs and symptoms: infant
1. Increase head size (circumference)abnormal rate of head growth
2. Bulging fontanelle
3. Setting sun sign
4. Dilated scalp veins
5. Macewen’s sign (“cracked pot sound”)
Signs and symptoms: Children
1. Headache on awakening
2. Nystagmus
3. Irritability
4. Vomiting
5. Apathy and confusion
6. Papilledema
Preoperative care
1. Assess LOC, head circumference
and increase ICP
2. Support head and neck
3. Provide small and frequent
feeding
Postoperative care:
1. Assess for signs of increased ICP
2. Assess head circumference
3. Assess for signs of infection
4. Provide shunt care
5. Position: unoperated side to
avoid pressure on shunt valve.
6. Remember: a high, shrill cry in an
infant is a sign of increased ICP.
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CARDIOVASCULAR DISORDERS
1. Defects that increase pulmonary blood flow
2. Defects that decrease pulmonary blood
flow
3. Obstructive defects
4. Mixed Blood Flow
5. Rheumatic Fever
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CARDIOVASCULAR disorders
defects that increase pulmonary blood flow
Atrial Septal Defect:
Pathophysiology: a hole in the septum between the left and
right atria.
Signs and symptoms: Heart murmur, palpitations, tachycardia,
decreased peripheral pulse (other signs of decreased cardiac
output)
Management: Atrial septal defect may be closed using cardiac
catheterization.
VENTRICULAR SEPTAL Defect:
Pathophysiology: a hole in septum that separates the heart's
lower left and right ventricles
Signs and symptoms: Murmur (harsh and loud heard at the left
lower sternal border), other signs of decreased cardiac
output.
Management: Ventricular septal defect may be closed using
cardiac catheterization.
PATENT DUCTUS ARTERIOSUS:
Pathophysiology: This occurs when the ductus arteriosus
fails to close after birth.
Signs and symptoms: Bounding pulse, wide pulse pressure,
machine-like murmur
Medication: Indomethacin
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CARDIOVASCULAR disorders
defects that DECREASE pulmonary blood flow
TETRALOGY OF FALLOT
PATHOPHYSIOLOGY:
Tetralogy of Fallot includes 4 defects:
1. Ventricular septal defect (VSD): a hole in septum that separates
the heart's lower left and right ventricles
2. Pulmonary stenosis: the pulmonary valve is narrow.
3. Overriding aorta:defect in the aorta. The aorta is shifted to the
right and lies directly above the VSD.
4. Right ventricular hypertrophy: right ventricle thickens
SIGNS AND SYMPTOMS:
1. Cyanosis
2. Hypoxia
3. Clubbing of fingers and toes
4. Poor growth
Diagnostic tests:
1. Echocardiography
2. Chest X-ray
sURGICAL MANAGEMENT:
1. Surgical intervention is an effective treatment option for
Tetralogy of Fallot.
2. Surgical intervention: temporary procedure that uses a shunt
3. Surgical intervention: complete repair
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CARDIOVASCULAR disorders
obstructive defects
Aortic STENOSIS:
Pulmonary Stenosis:
Pathophysiology: the aortic valve is
narrow
Signs and symptoms: Exercise
intolerance, murmur, chest pain,
hypotension.
Management: Aortic Valvotomy,
Balloon valvuloplasty.
Pathophysiology: the pulmonary
valve is narrow.
Complications: Right ventricular
hypertrophy, HF, Arrhythmia
Signs and symptoms: Murmurs
Management: Valvotomy
COARCTATION OF THE AORTA
Pathophysiology: Obstruction of blood flow due to narrowing of the aorta
near the ductus arteriosis.
Signs and symptoms: High BP in the upper extremities as compared to the
lower extremities. Bounding pulse at the upper extremities and cool skin
at the lower extremities.
Management: Aortic Valvotomy, Balloon valvuloplasty.
defects that results in MIXED BLOOD FLOW
Truncus Arteriosus:
Hypoplastic left heart syndrome:
Pathophysiology: A single arterial
trunk due to failed septation
between the left and right
ventricle
Signs and symptoms: HF, lethargy,
heart murmurs, cyanosis, poor
feeding & growth
Management: Surgical intervention
within first few months of life.
Pathophysiology: The left side of
the heart is not fully developed.
Signs and symptoms: Heart failure,
lethargy, cyanosis
Management: The procedures are
done in three stages. Norwood
procedure, Glenn procedure, Fontan
procedure.
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CARDIOVASCULAR disorders
RHEUMATIC FEVER
Inflammatory autoimmune disease.
Occurs after a throat infection from a
bacteria called group A
streptococcus.
it affects the:
1. Heart
2. Blood vessels
3. CNS
4. Joints
5. Skin
nURSING INTERVENTIONS
1. Pain assessment
2. Non-pharmacologic management
3. Bed rest
4. Educate parents on the need for
antibiotic prophylaxis for any
invasive procedures (& dental
work)
5. Educate parents on the medical
and pharmacologic regime
MEDICATION:
1. Antibiotics
2. Anti-inflammatory agents
Signs and symptoms
1. Cardiac: Chest pain , Heart murmur,
carditis
2. Musculoskeletal: Painful and tender joints,
subcutaneous nodules
3. Skin: Erythema marginatum (red lesions of
the trunk and extremities)
4. CNS: Uncontrollable involuntary
movements (chorea), fever (+sore throat)
Lab Tests:
1. Elevated anti-streptolysin-O
titer
2. Elevated C-reactive protein level
3. Throat swab test
4. Elevated erythrocyte
sedimentation rate
major criteria (diagnostic tests)
1. Carditis: inflammation of the heart
2. Chorea: Uncontrollable involuntary
movements
3. Erythema marginatum: red lesions of
the trunk and extremities
4. Subcutaneous nodules
5. Polyarthritis
minor criteria (diagnostic tests)
1. Fever
2. Arthralgia: joint pain
3. Elevated erythrocyte
sedimentation rate
4. Elevated C-reactive protein level
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GENITOURINARY DISORDERS
1. NEPHROTIC SYNDROME
2. GLOMERULONEPHRITIS
3. CRYPTORCHIDISM
4. EPISPADIAS/HYPOSPADIAS
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GENITOURINARY disorders
NEPHROTIC SYNDROME
description
Nephrotic syndrome is characterized by
excessive excretion of protein in the urine
(proteinuria), leading to low protein levels
in the blood (hypoproteinemia).
This leads to edema and hypovolemia.
Interventions
1. Monitor vital signs
2. Monitor BP
3. Monitor lab values-protein
4. Intake and output charting
5. Obtain daily weights
6. Low salt/sodium diet/Low cholesterol
7. Medications: Corticosteroids, Diuretics
Signs & Symptoms
1. Periorbital and facial edema
2. Ascites
3. Peripheral edema
4. Proteinuria
5. Hypoproteinemia
6. Hyperlipidemia
7. Electrolyte imbalance
8. Fatigue
9. Lethargy
glomerulonephritis
description
A group of renal diseases caused by immunologic
response that triggers the inflammation of the
glomerular tissue.
Acute: 2-3 weeks after streptococcal infection
Chronic: after acute phase
Interventions
1. Monitor BP
2. Monitor fluids and electrolytes level
3. Maintain fluid restrictions as ordered
4. Obtain daily weights
5. Sodium restriction in diet
Medications: Antihypertensive drugs, diuretics,
antibiotics
Signs & Symptoms
1. Dark colored urine
2. Hematuria
3. Proteinuria
4. Azotemia
5. Oliguria
6. Edema
7. Elevated BP
8. Dyspnea
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GENITOURINARY disorders
cryptorchidism
description
Testes fail to descend into the
scrotum.
Interventions
Surgical Intervention:
1. Orchiopexy (1-2 years)
Postoperative care
1. Monitor for signs of infection
2. Monitor for bleeding
3. Pain management
Signs & Symptoms
1. Can't see or feel the
testicle in the scrotum.
2. Scrotum is flat and
smaller than normal
epispadias/hypospadias
description
Epispadias and Hypospadias is a birth defect
characterized by an abnormal placement of the
urethra opening.
Epispadias: remember "TOP"
Hypospadias: remember "BOTTOM"
Interventions
Surgical Intervention
1. Urinary stent
2. Between the ages of 6 and 18 months.
Postoperative care:
1. Monitor intake and output
2. Medication: antibiotics
Education
1. Signs and symptoms of an infection
Signs & Symptoms
1. Epispadias: an abnormal
opening at the top of the
urethra
2. Hypospadias: an
abnormal opening at the
bottom of the urethra
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GASTROINTESTINAL DISORDERS
1. HIRSCHSPRUNG DISEASE
2. INTUSSUSCEPTION
3. GERD
4. APPENDICITIS
5. CELIAC DISEASE
6. HYPERTROPHIC PYLORIC STENOSIS
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GASTROINTESTINAL disorders
Hirschsprung disease
description
Hirschsprung disease is characterized by
the lack or absence of ganglion cells in some
areas of the colon.
This results in mechanical obstruction &
decreased motility
Complications: Enterocolitis
Interventions
Diagnostic test: Rectal biopsy
Surgical Intervention
1. Colostomy
2. Removal of areas of bowel.
Diet: low-fiber, high calorie, high protein diet.
Remember: Do not take temperature rectally.
Signs & Symptoms
Newborns
1. No meconium stool
2. Abdominal distention
3. Vomiting (bile)
Children
1. Constipation
2. Ribbon-like stools
3. Growth delay
INTUSSUSCEPTION
description
Intussusception occurs when a segment of the
intestine "telescopes" inside of another.
This results in bowel obstruction.
Interventions
1. IV fluids, Antibiotics and NG tube (used for
decompression)
Treatment
1. A water soluble contrast or air enema.
Signs & Symptoms
1. Abdominal pain (severe)
2. Vomiting
3. Mass in the abdomen
(sausage-shaped).
4. Stool mixed with blood
and mucus-jelly stools
5. Weakness/lethargy
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GASTROINTESTINAL disorders
GERD
description
Gastroesophageal Reflux Disease is a
digestive disorder that occurs due to the
backflow of gastric content.
Diagnostic tests: Upper endoscopy
Esophageal pH studies
Interventions
Signs & Symptoms
Assess pain
Elevate head of bed (HOB)-children >1 year
Medications: Proton pump inhibitors, Histamine H2
antagonist
Teaching
Avoid infant from lying down after eating
Small, frequent meals
Burp infant
Infants:
1. Irritability
2. Spits up
Children:
1. Cough
2. Heartburn
3. Poor weight gain
Appendicitis
description
Inflammation of the vermiform appendix.
Inflammation causes obstruction of the appendiceal
lumen.
Complications: Prolong inflammation may cause the
appendix to burst/rupture leading to peritonitis.
Interventions
1. Appendectomy: surgical removal of the appendix
2. Pain management, IV fluids
Pharmacology
1. Antibiotics
Nursing Intervention
1. Assess pain
2. Abdominal assessment
3. Monitor VS
4. Pre-operative care: NPO + IVF
5. Post-operative care: Monitor surgical site + monitor for signs
of infection
Signs & Symptoms
1. McBurney's point
2. Periumbilical
abdominal pain
3. RLQ pain
4. Fever
5. Abdominal rigidity
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GASTROINTESTINAL disorders
celiac disease
description
Celiac disease is the intolerance of gluten.
Gluten is a protein found in wheat, barley
and rye.
Interventions
Signs & Symptoms
1. Educate family on gluten-free diet.
2. Foods to eat: fruits, corn, rice, glutenfree flour/cereal, eggs, fish, vegetables.
3. Avoid wheat, barley or rye.
1. Steatorrhea
2. Weight loss
3. Abdominal pain
4. Abdominal
distention
5. Anemia
6. Fatigue
hypertrophic pyloric stenosis
description
Thickening (hypertrophy) of the pylorus
muscles which results in an obstruction. Food is
blocked from entering duodenum.
Interventions
Surgical Intervention:
1. Pyloromyotomy
Intervention
1. Obtain daily weights
2. Monitor I/O and episodes of vomiting
3. Postoperative care (pyloromyotomy)
Signs & Symptoms
1. Projectile vomiting
2. Persistent hunger
3. Dehydration
4. Metabolic Alkalosis
5. Olive-shaped mass
(RUQ)
6. Weight loss
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MUSCULOSKELETAL DISORDERS
1. FRACTURES
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musculoskeletal disorders
FRACTURES
description
A fracture is a broken bone.
There is a break in the continuity
of the bone structure.
types:
1. Closed fracture: bone break without
open wound in skin.
2. Open fracture (compound): fracture
with an open wound.
3. Complete fracture: complete break
through the bones that separates into
two.
4. Incomplete fracture: the bone doesn't
break completely.
5. Comminuted fracture: break into more
than two fragments.
Nursing Interventions:
1. Pain assessment
2. Skin integrity assessment
3. Neurovascular status assessment
4. Monitor for immobilization
complications
5. Provide pharmacologic and nonpharmacologic pain management
6. Encourage patient to change
position (as tolerated/as
prescribed)
Compartment Syndrome
5Ps:
1. Pain
2. Paresthesia
3. Pulselessness
4. Paralysis
5. Pallor
Signs and Symptoms
1. Pain
2. Loss of function/deformity
3. Crepitus
4. Edema
5. Ecchymosis (skin discoloration)
TRACTION CARE
1. Ensure that the traction weight bag
is hanging freely.
2. Monitor for any complication of
immobilization.
3. Assess skin and neurovascular status
casts
1. Pain assessment
2. Assess neurovascular status
3. Assess skin integrity
4. Prevent indentation by supporting cast
with the palms of hand (plaster casts,
exposed casts).
5. Educate the family and child to avoid
placing any object (such as toys) inside
the casts.
COMPLICATIONS:
1. Compartment syndrome
2. Skin breakdown
3. Pressure ulcers
4. Constipation (lack of mobility)
5. Neurovascular impairment
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Nursing Health
Assessment
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INTRODUCTION
REMEMBER
INSPECTION
PALPATION
INTRODUCTION
1.
Introduce yourself.
2. Perform hand hygiene.
3. Provide patient privacy.
4. Verify patient ID and DOB.
5.
Explain procedure.
PERCUSSION
AUSCULTATION
ORIENTATION
Use these questions as guidelines to
assess the patient's orientation.
1.
2.
3.
4.
5.
What is your name?
What is your date of birth?
Where are you now?
Who is the current president?
Can you tell me what month
it is?
6. What are you doing here?
VITAL SIGNS
Pulse: 60-100 bpm
Blood Pressure Systolic: 90-129
Diastolic: 60-80
Respiratory Rate: 12-18 bpm
O2 Saturation: 95-100%
Temperature: 97.8-99.1 degrees F
PAIN ASSESSMENT
P
Q
R
S
T
Provoking/ Precipitating Factor: What causes
the pain to worsen?
Palliative Factor: What makes the pain better?
Quality: Describe the pain.
Region: Where is the pain located?
Radiation: What other areas do you feel the
pain?
Severity: Pain scale.
Time/Temporal Factors: Does the pain
intensity changes? Is the pain intensity
constant?
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THE NEURO SYSTEM
MENTAL STATUS
CRANIAL NERVES
1. Olfactory Nerve: Smell
2. Optic Nerve: Vision
3. Oculomotor Nerve: Pupil
restriction and eye movement
4. Trochlear Nerve: Eye movement
5. Trigeminal Nerve: Touch and pain
of face and head, muscles for
BALANCE AND COORDINATION
Gait and Balance
chewing.
1. Observe patient's gait pattern 6. Abducens Nerve: Eye movement
as they walk away from you
7. Facial Nerve: Taste of the
and back.
anterior tongue, facial
2. Have patient stand from a
expression muscles and
sitting position.
somatosensory information from
3. Instruct patient to hop in place
ear
on each foot.
8. Vestibulocochlear Nerve:
Coordination
Hearing/ Balance
1. Have patient touch nose and
9. Glossopharyngeal Nerve: Taste
your index finger continuously.
of the posterior tongue,
swallowing muscles.
STRENGTH, ROM AND REFLEXES
10.Vagus Nerve: Sensory, motor
Assess muscle strength.
and autonomic function of
Assess reflex using the tendon
viscera.
reflex grading scale.
11. Spinal Accessory Nerve: Head
Instruct patient to distinguish
movement
between sharp and dull
12. Hypoglossal Nerve: Control
sensations.
Assess for numbness and tingling
tongue muscle.
Add a little bit of body text
1. Assess mood, appearance,
affect and grooming.
2. Assess speech
3. Assess level of consciousness
4. Assess orientation
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HEAD, EYES, EARS, NOSE, MOUTH
HEAD
INSPECTION
1. Skin color.
2. Head size and shape.
3. Assess facial symmetry. (Cranial nerve 7)
4. Observe abnormal facial movements.
5. Assess whether the eyes and ears are at
the same level.
PALPATION
1. Cranium- Palpate for lesions, masses.
2. Hair- Palpate for any signs of infestation 3.
and bald spots.
4. Sinuses- Palpate the frontal and maxillary
sinuses.
5. TMJ- Palpate for signs of stiffness and
clicking
EARS
INSPECTION
1. Redness, drainage and
abnormalities.
PALPATION
1. Palpate and observe for tenderness,
lesions and masses.
2. Test cranial nerve-Vestibulocochlear.
MOUTH
INSPECTION
1. External: inspect lip color and
sores.
2. Internal: Inspect gum, tongue,
teeth, lesions, soft and hard
palate.
CRANIAL NERVE
Test cranial nerve - Glossopharyngeal
Test cranial nerve- Hypoglossal
Test cranial nerve- Vagus
EYES
INSPECTION
1. inspect the external eye
structures.
2. Inspect the conjunctiva and sclera.
3. Test cranial nerve III, IV and VI (see
assessment of neuro).
4. Examine pupil reactivity to light.
5. Test accommodation.
PERRLA- Pupils are Equal, Round and
Reactive to Light and
Accommodation.
Pupil size- 3-5mm and equal in size
NOSE
INSPECTION
1. External: Inspect for drainage, size
and symmetry, shape. Inspect the
septum.
2. Internal: Inspect for redness and
polyps.
TEST
1. Nare patency
2. Cranial nerve- Olfactory
NECK
INSPECTION
1. Inspect trachea (mid-line), JVD,
lesions and lumps.
PALPATION
1. Palpate lymph nodes.
2. Palpate carotid artery and
auscultate for bruits.
3. Palpate and determine the
presence of a goiter.
CRANIAL NERVE
Test cranial nerve- Accessory.
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THE RESPIRATORY SYSTEM
ASSESSMENT/HISTORY
1. Assess RR, O2
saturation, ABGs
2. Assess for history of:
a. SOB
b. Cough
c. Chest pain
d. Family history
e. Respiratory illness
PALPATION
1. Pain and Lumps
PERCUSSION
Use the Z-block method:
Resonance: heard over normal
lungs.
Dull sound: solid/ fluid filled
area
Hyperresonance: Heard over
hyperinflated lungs
Tympany: pneumothorax
INSPECTION
1. Symmetrical chest
movement
2. Labored breathing
ABGs
pH: 7.35-7.45
PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
O2 Saturation: 95%-100%
HCO3: 21-28 mEq/L
AUSCULTATION
Auscultate posterior,
anterier and lateral chest.
Listen for:
1. Crackles
2. Wheezes
3. Rhonchi
4. Stridor
5. Pleural rub
Use the Z-block pattern
from the apex to the base.
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THE CARDIOVASCULAR SYSTEM
1. Assessment
1. Vital signs
a. BP, HR, RR, O2
saturation
2. Assess for
a. Skin temperature
b. Cyanosis
c. Moisture
d. Capillary refill
e. Peripheral pulse
f. Edema
g. Varicose veins
3. Palpation
1. Locate the apical
pulse (PMI)
2. Assess for thrills
(palpable murmurs).
3. Assess for heaves
2. Inspection
1. Pulsation of the chest
wall
Assessment tools
Capillary Refill: Normal = <3
Delay = >3
Pulse:
Absent= 0
Weak = +1
Normal = +2
Full = +3
Bounding = +4
4. Auscultation
1. Listen to heart sounds
and murmurs.
2. Use the diaphragm of
the stethoscope then
the bell.
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ABDOMINAL/GI/GU
Remember
INSPECTION
1. INSPECTION
1. Skin color, contour
and aortic pulsation
AUSCULTATION
PERCUSSION
PALPATION
2. AUSCULTATION
Auscultate bowel sounds.
Begin with RLQ and
clockwise.
Bowel sounds
1. Absent- No bowel sound
after listening for 5
minutes.
2. Hypoactive- One bowel
sound every 3-5 minutes.
3. Normal bowel soundGurgles 5-30 every
minute.
4. Hyperactive- >30 sounds
per minute
3. PERCUSSION
Tympanic Sound: Gas filled
abdomen (normal)
Dullness: solid viscera, fluid,
stool predominate, posterior
solid structure (e.g. liver)
4. PALPATION
Light palpation followed by deep
palpation.
Palpate and observe for pain,
rigidity, masses and tenderness
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EXTREMITIES
UPPER EXTREMITY
INSPECTION
Inspect the skin for
redness or skin
breakdown and
color. Inspect palms
and nails.
PALPATE
Palpate the radial
and brachial pulses
and capillary refill.
Assess muscle
strength and ROM.
LOWER EXTREMITY
INSPECTION
Inspect the skin for redness
or skin breakdown, hair
growth, swelling, feet and
nails.
PALPATE
Palpate pulses- popliteal
pulse posterior, tibial pulse,
and dorsalis pedis pulse.
Palpate for pitting edema.
Babinski Reflex- create an S
curve under the feet using
a pen and observe curled
toes.
Assess muscle strength
using the Oxford Strength
Grading Scale
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CRA
NIA
LN
ERV
ES
A St
udy
Gui
de f
or N
ursi
ng S
tud
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ents
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Cranial Nerves
Cranial Nerves Summary
cn i:
Olfactory
cn ii:
Optic (occasions)
CN= CRANIAL NERVE, S=SENSORY
M=MOTOR
Function: Smell
(s)
Function:
Vision
(s)
cn iii:
Oculomotor (our)
Function:
cn iv:
Pupil
restriction
and eye
movement
Trochlear (trusty)
Function:
Most eye
movement
cn v:
Trigeminal (truck)
Function:
Face
sensation,
Mastication
Function:
Abducts
the eye
Function:
Facial
expression,
taste
Function:
Hearing/
Balance
Function:
Swallowing
Gag reflex
(both)
Sensory,
motor and
autonomic
function of
viscera.
(both)
Function:
Head
movement,
Shoulder
shrug
(m)
Function:
Control
tongue
muscle.
(m)
cn vi: Abducens
cn vii:
cn
cn
Facial
(on)
(acts)
(funny)
Vesti(very)
viii: bulocochlear
Glossoix: pharyngeal (good)
cn x:
Vagus
(vehicle) Function:
cn xi:
Accessory
cn xii:
Hypoglossal (how)
(any)
(m)
(m)
(both)
(m)
(both)
(s)
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Cranial Nerves
cn i:
Olfactory
(on)
Function: Smell
aSSESSMENT:
(s)
FINDINGS:
1. The client is able to identify the
test odor with each nostril.
2. Strength of smell with each
nostril is the same.
1. Ask the client to occlude one
nostril with eyes closed.
2. Place a test odor under each
nostril and ask the client to
identify the smell.
3. Evaluate the patency of the
nasal passages bilaterally
ABNORMAL FINDINGS:
1. Hyperosmia: heightened sense of smell. Hypoosmia: diminished olfactory acuity.
Anosmia, the inability to recognize odors (unilateral or bilateral)
2. The most common cause is a cold/ nasal allergies or trauma.
cn ii:
Optic (occasions)
aSSESSMENT:
Function:
Visual Acuity
1. Assess visual acuity using a Snellen Chart.
Instruct the client to cover one eye and ask
the client to recite the letters shown and
record acuity.
Visual fields
1. Test visual fields via confrontation.
2. At eye level, instruct the client to cover the
left eye (examiner covers the right eye).
Ask the client to say "now" when the
examiner's fingers enter from out of sight,
into the client's peripheral vision. (Repeat)
Fundoscopy
1. Direct visualization of optic nerve
Vision
(s)
FINDINGS:
Visual Acuity
1. Client is able to read with each
eye and both eyes. (20/20
vision)
Fundoscopy
1. Normal findings of the optic disc,
physiological cup, retinal vessels
and fovea observed
ABNORMAL FINDINGS:
1. Legally blind-20/200
2. Papilledema in fundus: Loss of venous pulsations, loss of the disc margin
flame shaped hemorrhages, loss of the physiologic cup
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Cranial Nerves
cn iii:
Oculomotor (our)
aSSESSMENT:
Light
1. In a dimly lit room, ask the client to
focus on an object in a distance
2. Swing the penlight from the side
towards the pupil.
3. Observe the response of the
illuminated pupil.
4. Note the response of the other pupil.
Accommodation
1. Ask client to alternate gaze from the
near to the far object.
2. Move an object towards the client’s
nose.
Function:
Pupil
restriction
and eye
movement
(m)
FINDINGS:
Reaction to light
1. Both Illuminated and non-illuminated
pupil should constrict.
Accommodation:
1. Pupils- constrict (near object)
2. Pupils-dilate (distant object)
3. Pupils-converge (object moves
towards nose)
PERRLA (pupils equally round and reactive
to light and accommodation)
ABNORMAL FINDINGS:
1. Anisocoria- one pupil is larger than the other. 2. Diplopia ("seeing
double") 3. Ptosis- droopy eyelid. 4.Inability to accommodate
cn iv:
Trochlear (trusty)
aSSESSMENT:
1. Stand 1 ft in front of client
2. Instruct the client to follow the
penlight only with their eyes
without moving their head
upward, downward, to the
side and diagonally
Function:
Most eye
movement
(m)
FINDINGS:
Both eyes are able to follow
penlight smoothly.
ABNORMAL FINDINGS:
1. Gaze palsy: inability to move both eyes together in a single horizontal
or vertical direction.
2. Nystagmus: uncontrolled eye movement.
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Cranial Nerves
cn v:
Trigeminal (truck) Function:
aSSESSMENT:
Corneal reflex:
1. Using a Q-tip, lightly touch the lateral
cornea of eye to elicit blink reflex.
Sensation
1. Ask the client to close their eyes and say
"sharp" or "dull" when they feel an
object touch their face.
Masseter muscle:
1. Palpate the temporalis and masseter
muscle as client bites down hard.
2. Ask the client to open their mouth
against resistance of your hands at the
base of chin
Face
sensation,
Mastication
(both)
FINDINGS:
1. Client was able to elicit corneal
reflex
2. Sensitive to stimuli
3. Masseter muscle: no weakness
observed. Normal motor
function of mastication.
ABNORMAL FINDINGS:
1. Absent corneal reflex
2. Sensory deficit
3. Weakness of the jaw
cn vi:
Abducens
(acts)
aSSESSMENT:
1. Stand 1 ft away from client
with a penlight.
2. Ask the client to follow the
penlight through the six
cardinal fields of gaze.
Function:
Abducts
the eye
(m)
FINDINGS:
1. Both eyes move in
coordination and parallel
alignment observed
ABNORMAL FINDINGS:
1. Gaze palsy: inability to move both eyes together in a single horizontal
or vertical direction.
2. Nystagmus: uncontrolled movements.
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Cranial Nerves
cn vii: Facial
(funny)
Function:
aSSESSMENT:
1. Ask the client to perform different
facial expressions (smile, frown,
puff cheeks, close eyes, raise
eyebrows)
2. Ask client to close their eyes and
extend their tongue.
3. Place various taste (sweet, sour,
salty, bitter) and ask client to
identify the different tastes.
Facial
expression,
taste
(both)
FINDINGS:
1. The client is able to perform the
different facial expressions with
ease
2. The client is able to identify the
different tastes.
ABNORMAL FINDINGS:
1. Weakness of muscles to perform facial expressions
2. Facial asymmetry including drooping, sagging or smoothing of normal facial
creases.
3. Client is unable to distinguish the different tastes
cn viii:
Vestibulocochlear (very)
aSSESSMENT:
Hearing
1. Ask the client to occlude one ear and instruct
the client to close both eyes.
2. Vigorously rub your fingers, or whisper in one
ear and ask the client to repeat what was
heard.(repeat)
3. Weber test is a test for lateralization
4. Rinne test compares air conduction to bone
conduction.
Balance
1. Assess client's gait by instructing them to
walk across the room
Function:
Hearing/
Balance
(s)
FINDINGS:
Hearing
1. Client is able to hear in both ears.
2. Positive Weber test: client is able to
hear it in both ears
3. Positive Rinne test: air conduction is
greater than bone conduction
Balance
1. Upright posture and steady gait.
ABNORMAL FINDINGS:
1. Conductive hearing impairment: bone conduction is equal or greater than air
conduction.
2. Sensineuronal hearing loss: vibration is heard longer in the air than usual.
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Cranial Nerves
cn ix:
Glossopharyngeal (good)
aSSESSMENT:
Function: Swallowing
Gag reflex
(both)
FINDINGS:
1. Ask the client to swallow.
2. Instruct the client to yawn
and observe the soft palate.
3. Ask the client to open their
mouth wide, protrude their
tongue, and say "AHH".
4. Elicit gag response.
1. Client is able to swallow without
difficulty
2. Soft palate observed to rise
symmetrically
3. Uvula is observed to remain
midline
4. Client elicited gag reflex
ABNORMAL FINDINGS:
1. Dysarthria-muscles that produces speech are damaged
2. Dysphagia- inability to swallow
3. Uvula deviation
cn x:
Vagus
(vehicle)
aSSESSMENT:
1. Ask the client to cough
2. Ask the client to swallow and
speak
Function:
Sensory, motor
and autonomic
function of
viscera.
(both)
FINDINGS:
1. Client is able to swallow without
difficulty
2. Client is able to speak audibly
ABNORMAL FINDINGS:
1. Dysarthria-muscles that produces speech are damaged
2. Dysphagia- inability to swallow
3. Hoarseness
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Cranial Nerves
cn xi:
Accessory
(any)
aSSESSMENT:
Function:
Head
movement,
Shoulder
shrug
(m)
FINDINGS:
1. Sternocleidomastoid: Instruct
the client to turn their head
from side to side, and against
resistance (examiner's hands)
2. Trapezius: instruct the client to
shrug their shoulders against
resistance (examiner's hands)
1. Client should be able to turn
head from side to side.
2. Client is able to shrug shoulders
ABNORMAL FINDINGS:
1. Asymmetry
2. Peripheral lesions produce ipsilateral sternocleidomastoid (SCM)
weakness and ipsilateral trapezius weakness.
cn xii:
Hypoglossal (how)
Function:
aSSESSMENT:
1. Ask the client to open their
mouth and inspect the
tongue
2. Ask the client to protrude the
tongue and move from side
to side
Control
tongue
muscle.
(m)
FINDINGS:
1. Client tongue is midline
2. Client is able to move tongue
from side to side
ABNORMAL FINDINGS:
1. Deviations of the tongue from midline
2. Inability to protrude the tongue
3. Tongue atrophy and fasciculations
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CRANIAL NERVE
templates
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Cranial Nerves
Cranial Nerves Summary
cn i:
Function:
cn ii:
Function:
cn iii:
Function:
cn iv:
Function:
cn v:
Function:
cn vi:
Function:
cn vii:
Function:
cn viii:
Function:
cn ix:
Function:
cn x:
Function:
cn xi:
Function:
cn xii:
Function:
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Cranial Nerves
cn i:
(on)
aSSESSMENT:
Function:
(s)
FINDINGS:
ABNORMAL FINDINGS:
cn ii:
(occasions)
aSSESSMENT:
Function:
(s)
FINDINGS:
ABNORMAL FINDINGS:
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Cranial Nerves
cn iii:
(our)
aSSESSMENT:
Function:
(m)
FINDINGS:
ABNORMAL FINDINGS:
cn iv:
(trusty)
aSSESSMENT:
Function:
(m)
FINDINGS:
ABNORMAL FINDINGS:
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Cranial Nerves
cn v:
(truck)
aSSESSMENT:
Function:
(both)
FINDINGS:
ABNORMAL FINDINGS:
cn vi:
(acts)
aSSESSMENT:
Function:
(m)
FINDINGS:
ABNORMAL FINDINGS:
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Cranial Nerves
cn vii:
(funny)
Function:
aSSESSMENT:
(both)
FINDINGS:
ABNORMAL FINDINGS:
cn viii:
(very)
aSSESSMENT:
Function:
(s)
FINDINGS:
ABNORMAL FINDINGS:
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Cranial Nerves
cn ix:
(good)
aSSESSMENT:
Function:
(both)
FINDINGS:
ABNORMAL FINDINGS:
cn x:
(vehicle)
aSSESSMENT:
Function:
(both)
FINDINGS:
ABNORMAL FINDINGS:
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Cranial Nerves
cn xi:
(any)
aSSESSMENT:
Function:
(m)
FINDINGS:
ABNORMAL FINDINGS:
cn xii:
(how)
aSSESSMENT:
Function:
(m)
FINDINGS:
ABNORMAL FINDINGS:
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Room No.
Name:
ADM:
Allergies:
HT:
T:
NEURO
RESP
GI
Patient Assessment
MD:
Age:
Code Status:
Diet:
WT:
P:
RR:
DOB:
BMI:
BP:
SPO2:
CARDIO
HR, Heart rhythm, BP, Pulse, Heart Sounds,
Capillary Refill, Skin
tugor/color/temprature/moisture
Mental status, GCS, LOC, PERRLA,
Muscle Strength (ROM)
GU
Respiratory rate/depth/pattern, Use of
accessory muscle, Nasal flaring, Anterior &
posterior breath sounds, Spo2
Bowel sounds on 4 quadrants, Peristalsis,
Diet, Stool quantity and appearance
Urine output/ color/consistency
Bladder distention, Voiding method
SKIN
Skin turgor/color/temp/moisture/lesions/
breakdown/bruising/dressings
NOTES
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Room No.
Name:
ADM:
Allergies:
HT:
T:
NEURO
RESP
GI
Patient Assessment
MD:
Age:
Code Status:
Diet:
WT:
P:
RR:
DOB:
BMI:
BP:
SPO2:
CARDIO
HR, Heart rhythm, BP, Pulse, Heart Sounds,
Capillary Refill, Skin
tugor/color/temprature/moisture
Mental status, GCS, LOC, PERRLA,
Muscle Strength (ROM)
GU
Respiratory rate/depth/pattern, Use of
accessory muscle, Nasal flaring, Anterior &
posterior breath sounds, Spo2
Bowel sounds on 4 quadrants, Peristalsis,
Diet, Stool quantity and appearance
Urine output/ color/consistency
Bladder distention, Voiding method
SKIN
Skin turgor/color/temp/moisture/lesions/
breakdown/bruising/dressings
NOTES
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Nursing Care Plan
Med Dx: nursebossstore.com
Subjective Data
Objective Data
Nursing Diagnosis
Expected Outcomes
Nursing Interventions
Rationale
Evaluation
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Nursing Care Plan
Med Dx: nursebossstore.com
Subjective Data
Objective Data
Nursing Diagnosis
Expected Outcomes
Nursing Interventions
Rationale
Evaluation
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Nursing Care Plan
Med Dx: nursebossstore.com
Subjective Data
Objective Data
Nursing Diagnosis
Expected Outcomes
Nursing Interventions
Rationale
Evaluation
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Nurse Report Sheet
Room No.
Name:
ADM:
Allergies:
HT:
Isolation:
Medical Diagnosis:
Neuro:
MD:
Age:
Code Status:
Diet:
WT:
Activity:
Patient's Hx:
DOB:
BMI:
NPO:
Chief complaint:
ASSESSMENT
Time
TEMP
Cardiac:
HR
RR
Resp:
BP
SPO2
PAIN
GI/GU:
IV:
IV fluids:
SKIN:
O2 Therapy:
Tube Feeding:
LABS
DATE:
FOLEY:
Last BM:
WBC:
Treatment Plan:
RBC:
HGB:
HCT:
PLT:
PTT:
INR:
BUN:
CR:
Discharge Plan:
NA:
K:
MG:
BNP:
TROP:
OUTPUT:
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ALL YOU NEED TO KNOW…
THE
NURSING
PROCESS
Fiskvik Boahemaa Antwi, RN, MN.
Simon Akwasi Osei, RN, MN. 531 / 601
2
Copyright © 2019 by Fiskvik Boahemaa Antwi
All rights reserved. This book or any portion thereof
may not be reproduced or used in any manner whatsoever
without the express written permission of the publisher
except for the use of brief quotations in a book review.
532 / 601
3
Important Disclosure
Please keep in mind that the case studies and care plans are for examples and
educational purposes only. Due to evidence-based practice, some of these
treatments may change over time. Hence, do not base your patient’s treatment
on this care plan. There are different care plans and concept mapping formats
among various nursing institutions. However, it is important to note that the
principles remain the same. The most important aspect of the care plan is the
content, as it serves as the foundation in providing care.
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5
All You Need to Know…
Grab your pen and paper, because today you are going to learn the necessary
foundation of nursing care…the nursing process. The five steps in the nursing
process include:
Assessment, Diagnosis, Planning, Implementation, and Evaluation.
A nursing care plan is a tool that is utilized in the nursing process as a form
of documentation. Without the nursing care plan, quality and continuity of
care would be lost.
There are many books, journals, and materials that provide a comprehensive
overview of the nursing process. However, this book aims to simplify the
concept of the nursing process as you use other resources as well.
To complete the activities in this book, you would need the NANDA-I, the
NIC, and the NOC list. This book also includes examples, explanations,
images, and areas for you to write your answers.
Happy Care Planning!
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Dear Nursing Students,
Here is a simple case scenario that you would be referred to as you
complete the chapter’s activities.
CASE SCENARIO
Mr. Harry Fernando is a 68-year-old male admitted to the medicalsurgical unit and diagnosed with congestive cardiac failure. The
client states that he has been experiencing shortness of breath for
over three days and has swollen feet. “I am not able to sleep at
night because I cannot breathe.” According to Mr. Fernando’s wife,
he complains of body weakness and the inability to perform daily
tasks.
Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30
years; however, he does not drink alcohol or use recreational drugs.
Mr. Fernando has a family history of cancer, diabetes and
hypertension, and coronary artery disease.
Mr. Fernando loves to eat KFC and burgers. He is currently
concerned about his health status but isn’t sure what to do.
Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp
36.9, RR 24 bpm. Crackles noted in the right lung base upon
auscultation.
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Table of Content
CHAPTER
TOPIC
PAGE
NUMBER
1
INTRODUCTION
10
2
ASSESSMENT
16
3
DIAGNOSIS
25
4
PLANNING
32
5
IMPLEMENTATION
41
6
EVALUATION
44
7
CONCEPT MAPPING
47
8
ANSWER KEY
57
9
CASE SCENARIOS
66
10
REFERENCES
72
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NURSES DISPENSE COMFORT, COMPASSION, AND
CARING WITHOUT A PRESCRIPTION.
--Val Saintsbury
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O
B
J
E
C
THE NURSING PROCESS
OBJECTIVES
In this chapter, you would learn:
1. The definition of the nursing process.
2. The steps in the nursing process.
3. The importance of the nursing process.
4. Nursing care plan.
NOTES
KEY POINTS FROM THIS CHAPTER…
T
I
V
E
S
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10
I
N
T
R
O
D
U
C
THE NURSING PROCESS
Definition:
A systematic, deliberative and dynamic method
of providing patient-centered care.
The 5 Sequential Steps
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
What is the
nursing
process?
ACRONYM:
ADPIE
Importance of the Nursing Process
• It allows nurses to identify the patient’s needs.
• It allows nurses and patients to set and communicate goals.
• It allows the recognition of potential risk(s).
• It provides continuity of care.
• It provides adequate documentation and communication among
other health professionals.
T
Assessment
I
Evaluation
O
N
Implementation
Diagnosis
The
Nursing
Process
Planning
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The Four Column Care Plan
Nursing Diagnosis
Expected
Outcomes
Interventions
Evaluation
In this column, you would write
the nursing diagnosis, which
includes a label, etiology, and
defining characteristics.
In this column, you
state your goal and
expected outcome
that you want your
patient to meet.
In this column, you
would state the
steps that would
help the patient
reach the expected
outcome. This
includes nursing
independent and
collaborative
interventions.
In this column, you
would state
whether the
expected outcome
was met or not.
(If the expected
outcome was met:
provide evidence.)
(A Short Sample)
Activity intolerance related to
an imbalance between oxygen
supply and demand as evidence
by verbalization of generalized
weakness and inability to
perform activities of daily
living.
Patient would
demonstrate the
use of effective
energyconservation
techniques when
performing
activities of daily
living after 8 hours
of nursing
interventions.
1. Assess the
patient’s level of
physical ability.
2. Assess the
factors that cause
activity
intolerance.
3. Monitor the
patient’s vital signs.
4. Encourage the
patient to perform
activities at a
slower rate.
5. Encourage the
patient to take
intermittent rest
between activities.
6. Gradually
increase patient’s
activities.
7. Cluster task to
be performed by
the patient.
8. Assist the
patient with
activities of daily
living.
9. Etc.
(If the expected
outcome was not
met: Present
evidence that
supports this claim.
State the reason
why the outcome
was not met and
make mention of
what you would do
next.)
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The Five Column Care Plan: For Students
Nursing Diagnosis
Expected
Outcomes
Interventions
Rationale
Evaluation
In this column, you
would write the
nursing diagnosis,
which includes a label,
etiology, and defining
characteristics.
In this column, you
state your goal and
expected outcome
that you want your
patient to meet.
In this column, you
would state the
steps that would
help the patient
reach the
expected outcome.
This includes
nursing
independent and
collaborative
interventions.
(A Short Sample)
In this
column, you
would
include a
rationale for
every
nursing
intervention.
This
includes a
citation
from a book
or journal.
In this column, you
would state whether
the expected outcome
was met or not.
(If the expected
outcome was met:
provide evidence.)
Activity intolerance
related to an
imbalance between
oxygen supply and
demand as evidence
by verbalization of
generalized weakness
and inability to
perform activities of
daily living.
Patient would
demonstrate the
use of effective
energyconservation
techniques when
performing
activities of daily
living after 8 hours
of nursing
interventions.
1. Assess the
patient’s level of
physical ability.
2. Assess the
factors that cause
activity
intolerance.
3. Monitor the
patient’s vital
signs.
4. Encourage the
patient to perform
activities at a
slower rate.
5. Encourage the
patient to take
intermittent rest
between activities.
6. Gradually
increase patient’s
activities.
7. Cluster task to
be performed by
the patient.
8. Assist the
patient with
activities of daily
living.
9. Etc.
(If the expected
outcome was not met:
Present evidence that
supports this claim.
State the reason why
the outcome was not
met and make mention
of what you would do
next.)
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The Six Column Care Plan: For Students
Assessment
Nursing
Diagnosis
Expected
Outcomes
Interventions
Rationale
Evaluation
In this column,
write the
subjective and
objective data.
In this column,
you would write
the nursing
diagnosis,
which includes
a label,
etiology, and
defining
characteristics
.
In this column,
you would state
your goal and
expected
outcome that you
want your patient
to meet.
In this column,
state the steps
that would help
the patient reach
the expected
outcome. This
includes nursing
independent and
collaborative
interventions.
(A Short Sample)
In this
column,
include a
rationale for
every nursing
intervention.
This includes
a citation
from a book
or journal.
In this column, you
would state whether
the expected outcome
was met or not.
(If the expected
outcome was met:
provide evidence.)
Activity
intolerance
related to an
imbalance
between
oxygen supply
and demand as
evidence by
verbalization
of generalized
weakness and
inability to
perform
activities of
daily living.
Patient would
demonstrate the
use of effective
energyconservation
techniques when
performing
activities of daily
living after 8
hours of nursing
interventions.
1. Assess the
patient’s level of
physical ability.
2. Assess the
factors that
cause activity
intolerance.
3. Monitor the
patient’s vital
signs.
4. Encourage the
patient to
perform
activities at a
slower rate.
5. Encourage the
patient to take
intermittent rest
between
activities.
6. Gradually
increase patient’s
activities.
7. Cluster task to
be performed by
the patient.
8. Assist the
patient with
activities of daily
living.
9. Etc.
(If the expected
outcome was not met:
Present evidence that
supports this claim.
State the reason why
the outcome was not
met and make mention
of what you would do
next.)
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A
ACTIVITY 1.
1. What factors can affect the implementation of the nursing process?
C
T
I
.
V
2. Using your creativity, draw and label the steps in the nursing process.
I
T
Y
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O
B
J
E
ASSESSMENT
OBJECTIVES
In this chapter, you would learn:
1. Definition of assessment.
2. Components of assessment.
3. Types of assessment.
4. Elements of a complete health assessment.
5. Techniques to gather and organize data.
C
NOTES
KEY POINTS FROM THIS CHAPTER…
T
I
V
E
S
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A
S
S
ASSESSMENT
Assessment is the first phase of the nursing process.
Definition
Assessment is a deliberative and systematic method of collecting
information/data to determine the patient's needs.
Components
o Data collection
E
o Data verification
o Data organization
o Data recording/documentation
S
1. DATA COLLECTION
Types of Data
S
Where do I
collect my
patient’s data?
Subjective Data: (What the patient’s SAY!)
o The client’s perception of health problems.
o What the patient tells you.
M
E
o Feelings, emotions, sensations, etc.
PAIN
ANXIETY
DIZZINESS
Objective Data: (What you OBSERVE!)
N
T
o Observable and measurable.
VITAL SIGNS
LAB VALUES
DIAGNOSTIC
TESTS
SUBJECTIVE DATA VS OBJECTIVE DATA
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A
S
S
E
S
Sources of Data
o Primary Source: From the patient.
o Secondary Source:
o Family
o Health-care professionals
o Medical records
o Research
Method of Data Collection
o Interview
o Physical examination
o Observation
o Laboratory Test
o Review of Medical Record
Interview Technique
S
A structured and organized conversation to obtain information on
current health problems and needs from the patient or patient's
relative.
M
Phases
E
N
T
Orientation Phase
o Introduction and explanation of the purpose of conducting the
interview are done. The nurse sets a comfortable environment and
builds rapport.
Working Phase
o Interview to obtain the health status of the patient. The nurse
uses a variety of communication techniques.
Termination Phase
o The information obtained is summarized. The patient or nurse
asks questions. The interview ends in a friendly manner.
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A
S
S
Elements of an Effective Interview
o
o
o
o
o
o
o
o
Clear goals set
Culturally sensitive
Self-introduction
Choose an effective communication strategy
Congruent verbal and non-verbal communication
Maintain Rapport
Confidentiality
Closure
Types of Interview Question Technique
E
S
S
M
Open-ended questions
o It allows the patient to describe and explain a given situation.
o Example: How do you feel today?
Close-ended questions
o This allows the patient to give a direct answer to the question.
o Example: Are you in pain?
2. DATA VALIDATION
o This is done to ensure that the data is valid
o Double-checking of data/information
o Validation of data involves comparing data with other sources.
3. DATA ORGANIZATION
E
N
o Organizing data allows a nurse to cluster and arrange the data
obtained logically and systematically to aid the formulation of
nursing diagnosis.
4. DATA RECORDING
o Documentation of data
o If it was not written, it was not done.
T
Types of Assessment
o
o
o
o
Comprehensive Assessment
Focused Assessment
Ongoing Assessment
Emergency Assessment
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S
S
E
COMPLETE HEALTH ASSESSMENT
A complete patient’s health assessment includes:
o
o
o
o
patient’s history
physical assessment
diagnostic and laboratory test results
review of any other health information.
Past Medical History
This includes both past medical and surgical procedures.
Questions to ask? (Follow up with When/Why)
1.
2.
3.
4.
5.
S
S
Have you ever had surgery?
Have you ever been hospitalized?
Did you have any childhood illness?
Do you currently have any illness/problem?
What are your current medications?
Family History
This includes:
o Illness in the family.
o Genetic disorders in the family.
M
Family History Genogram
E
N
Grandfather, 80,
HF
Female
Grandfather, 91,
DM, Stroke
Male
T
Grandmother,
93, HF
Father, 63,
well
Mother, age 61,
hypertension
Deceased Female
Grandmother,
78, Cancer
Sister, age 40,
well
Patient, 32, DM,
HTN
Sister, age
37, Cancer
Deceased Male
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A
S
S
E
S
Activities of daily living
Identify the patient's ability to perform activities of daily living.
This includes:
1.
2.
3.
4.
5.
6.
7.
Diet, food allergies, special diets
Sleep habits
Exercise
Urinary and bowel elimination frequency
Use of tobacco, marijuana, alcohol, etc.
Religious practices
Sexual practices.
Socioeconomic Factors
This includes:
S
M
E
N
T
1. Financial resources.
2. Insurance plan.
3. Financial aid
Spiritual and Cultural Factors
This includes:
1. Spiritual needs
2. Religious practices
3. Cultural beliefs
Remember:
Remain nonjudgmental during
the assessment of your
patient’s spiritual beliefs.
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S
S
E
Physical Assessment
Four basic physical examination techniques
o
o
o
o
Inspection: USE YOUR 5 SENSES.
Palpation: FEEL
Percussion: PRODUCE A SOUND
Auscultation: LISTEN
Diagnostic Testing Data
o Understand the process to access patient’s diagnostic
test results.
o Understand the normal and abnormal values.
S
ASSESSING GROWTH AND DEVELOPMENTAL STAGES
S
According to Erikson, there are eight stages in psychosocial
development. Nurses need to assess which stage the patient falls under,
to better understand whether the developmental task has been met or
whether the patient cannot resolve a conflict expected in the particular
stage.
M
E
N
T
Trust vs Mistrust
Stage 1: From birth till age 1
Autonomy vs. Shame and
Doubt
Stage 2: Ages 1-3
Initiative vs Guilt
Industry vs Inferiority
Identity vs. Role confusion
Intimacy vs. Isolation
Generativity vs. Self-absorption
Integrity vs. despair
Stage 3: Ages 3-6
Stage 4: Ages 6-12
Stage 5: Ages 12-18
Stage 6: Ages 18-40
Stage 7: Ages 35-65
Stage 8: 65and above
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ACTIVITY 2.
Scenario
C
T
I
V
I
T
Mr. Harry Fernando is a 68-year-old male admitted to the medicalsurgical unit and diagnosed with congestive cardiac failure. The client
states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;
however, he does not drink alcohol or use recreational drugs. Mr.
Fernando has a family history of cancer, diabetes and hypertension and
coronary artery disease.
Mr. Fernando loves to eat KFC and burgers. He is currently concerned
about his health status but isn’t sure what to do.
Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.
SUBJECTIVE DATA
OBJECTIVE DATA
Y
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A
C
2. Quote a phrase that shows that the data was gathered from a
secondary source.
3. As a nurse, what other information would you obtain from Mr.
Fernando?
T
I
V
_
I
T
4. What developmental stage does Mr. Fernando belong in? What are
some of the developmental tasks expected of him?
Y
.
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O
B
DIAGNOSIS
OBJECTIVES
In this chapter you would learn:
J
E
C
1. Parts of a nursing diagnosis.
2. Types of nursing diagnosis.
3. Nursing diagnosis dos and don’ts.
4. Differentiating medical and nursing diagnosis.
5. Prioritizing of nursing diagnosis.
Notes
Key points from this chapter…
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NURSING DIAGNOSIS
The nursing diagnosis is the second step of the nursing process after the
assessment and clustering of the gathered data.
Definition of Diagnosis
The NANDA (North America Nursing Diagnosis Association) defines
nursing diagnosis as
a clinical judgment of an individual, family, or community response to an
actual or health problem risk, which gives the foundation for definitive
interventions towards the achievement of an outcome.
Steps in formulating nursing diagnosis
1. Gather both subjective and objective data from your
assessment.
N
2. Cluster the data that relates to a problem.
3. Develop a list of problems.
4. Prioritize the list of problems.
O
S
I
S
5. Formulate a nursing diagnosis for each problem.
Parts of nursing diagnosis
Example: Decreased cardiac output related to decreased cardiac
contractility to meet the metabolic demands of the body as evidence by
a pulse of 119, Bp- 98/62, cold and clammy skin, an ejection fraction of
30%.
There are three parts to the nursing diagnosis.
1. The label: Decreased cardiac output
This is written from the NANDA-I terminologies. This is the
patient’s problem.
2. The etiology: decreased cardiac contractility to meet the metabolic
demands of the body
This statement is preceded by the phrase “related to." These are
the related factors that cause and contribute to the patient's problem.
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D
I
3. The defining characteristics: a pulse of 119, Bp- 98/62, cold and
clammy skin, an ejection fraction of 35%.
This is a list of signs and symptoms that supports the diagnosis.
This statement is preceded by the phrase "as evidence by."
Remember:
A
G
A potential risk diagnosis only
has a label and etiology. (It has
Types of Nursing Diagnosis
not yet occurred.)
Actual Diagnosis: Impaired gaseous exchange
N
Potential Risk Diagnosis: Risk for infection
Syndrome Diagnosis: Chronic pain syndrome
Wellness Diagnosis: Readiness to enhance family coping
O
S
I
S
Actual Diagnosis (IT IS ALREADY HAPPENING.)
An actual diagnosis describes an existing problem.
For example, a patient experiencing shortness of breath and medically
diagnosed with asthma may have a nursing diagnosis of an ineffective
breathing pattern.
Potential Risk Diagnosis (MIGHT OCCUR)
This is a problem that the patient is at risk of developing. The goal is to
prevent the problem from occurring with proper planning and
implementation of interventions.
For example, a bedridden patient is at risk of developing pressure ulcers.
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Syndrome Diagnosis
This is a cluster of problems of risk.
Example: Post trauma syndrome, chronic pain syndrome, etc.
I
A
G
Wellness Diagnosis
A patient’s response to a degree of wellness. This is mostly used among
patients who are healthy but want to maintain or improve the wellness
level.
Example: a patient who wants to enhance knowledge about a balanced
diet would have a nursing diagnosis of readiness to enhance knowledge.
Nursing Diagnosis DO’S and DON’TS
DO’s
N
O
S
I
S
o Write nursing diagnosis
that nurses are licensed
to treat.
E.g., Decreased cardiac
output related to
decreased cardiac
contractility to meet the
metabolic demands of the
body as evidence by a
pulse of 119, Bp- 98/62,
cold and clammy skin, an
ejection fraction of 30%.”
o Let the nursing diagnosis o
be evidence-based and
clear.
E.g., Acute pain related to
decreasing oxygenation to
the myocardium as
evidence by patient
verbalization of chest pain
of (0-10)8.
DON’TS
o Don’t write medical diagnosis
as a label.
E.g., Heart failure related to
decreased cardiac
contractility to meet the
metabolic needs of the body
as evidence by a pulse of 119,
Bp- 98/62, cold and clammy
skin, an ejection fraction of
30%.”
Don’t let the nursing
diagnosis be unclear.
E.g. Acute pain related to the
inability for oxygen to
penetrate the myocardium
and cause decrease
oxygenation as evidence by
the patient complaining of
chest pain.
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D
I
A
Include the label, etiology, and
signs and symptoms for all
actual nursing diagnosis.
E.g., Acute pain related to
decreasing oxygenation to the
myocardium as evidence by
patient verbalization of chest
pain of (0-10)8.
G
N
O
S
I
Don’t omit any aspect from an
actual nursing diagnosis.
E.g., Acute pain related to
decreasing oxygenation to the
myocardium.
Other Common Mistakes
o Don’t write a diagnosis for a diagnostic test or treatment plan
E.g., Computed tomography scan of the lungs related to
decreased tissue perfusion.
o Don’t repeat the diagnosis
E.g., Ineffective airway clearance related to the inability to
clear the airway as evidence by coughing.
Nursing Diagnosis VS Medical Diagnosis
Medical Diagnosis: Disease focused.
E.g., Pleural Effusion
Nursing Diagnosis: Patient's response to the disease (patient-focused).
S
E.g., Ineffective breathing pattern related to decreased lung expansion
secondary to fluid accumulation in the pleura space as evidence by
dyspnoea, nasal flaring, chest x-ray, and the use of accessory muscles.
Note that the nursing diagnosis is the patient's response to having
pleural effusion.
Nursing diagnosis also addresses mental, physical, social, and social
aspects of health, patient education, comfort.
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Questions to Ask Yourself.
Ask yourself the following questions:
I
A
G
N
o Does the label, and NANDA-I definition match the patient's
current problem?
o Does the etiology support the label?
o Do the defining characteristics support the label and etiology?
Prioritizing Nursing Diagnosis
Remember that nursing care is continuous. You won’t have time to
address all of the patient’s problem. It is important to address the
highest-priority diagnoses first.
High-priority nursing diagnosis: Involves immediate and emergency
physiological needs.
Intermediate priority diagnosis: Involves nonemergency or potential risk.
Low-priority nursing diagnosis: Involves a long-term plan.
O
S
I
S
SelfActualization
Self-Esteem
Love and Belonging
Safety and Security
Physiological Needs
Prioritization: The use of the Maslow's Hierarchy of
Needs
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T
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ACTIVITY 3
Scenario
Mr. Harry Fernando is a 68-year-old male admitted to the medicalsurgical unit and diagnosed with congestive cardiac failure. The client
states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;
however, he does not drink alcohol or use recreational drugs. Mr.
Fernando has a family history of cancer, diabetes and hypertension, and
coronary artery disease.
Mr. Fernando loves to eat KFC and burgers. He is currently concerned
about his health status but isn’t sure what to do.
Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.
Create 4 nursing diagnosis (Three actual and one potential diagnosis)
1.
2.
Y
3.
4.
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O
PLANNING
B
J
OBJECTIVES
In this chapter, you would learn:
1. Identification of expected outcomes.
2. How to formulate patient outcomes.
E
3. How to utilize NOC.
4. How to develop nursing interventions.
5. How to use NIC.
C
NOTES
Key points from this chapter…
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P
PLANNING
L
Identifying the Expected Outcome
A
N
N
The goal of nursing care to assist patient reach their highest functional
level. If the patient cannot fully recover, the nursing care goal is to
assist the patient in being comfortable and coping with the declining
health status. Therefore, it is critical to establish an expected outcome
for nursing care. It is important to remember that expected outcomes
are geared towards the patient's performance and not the nurse's
interventions or actions.
An Outcome Statement
An outcome statement includes:
o
o
o
o
Specific behaviors that denote the patient has reached the goal.
A criterion to measure the attained behavior.
The condition in which the behavior should occur.
A specific timeframe.
Elements of an Outcome Statement
I
N
G
B
M
Behavior
Measure
A desired
behavior that
is observable.
Measuring of
behavior. (How
much, how
long, etc.)
C
Condition
Condition in
which behavior
should take
place.
T
Time Frame
Specific time
frame in which
the behavior
should occur
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P
Long-Term and Short-Term Goals
Long-term goals: It takes weeks or months to achieve.
Short-term goals: It takes a lesser amount of time.
L
A
Writing Outcome Statements
o Begin with specific action verbs such as ambulate, perform, state,
verbalize, participate, demonstrate, etc.
o Make sure that the statement is specific
o Avoid the use of unnecessary words
o Only use the accepted abbreviation
o Include the patient in the participation of goal setting.
Nursing Outcome Classification (NOC)
N
N
NOC is a standardized patient outcome categorization that helps nurses
formulate effective interventions.
Purpose of NOC
o Ensure consistent measurement of the patient's outcome.
o Validate the effectiveness of nursing care to improve quality.
o Aids in the integration of electronic health database in nursing
care planning.
The NOC has a Likert scale that allows nurses to evaluate patient's
status effectively.
I
N
G
Example of NOC Scales:
1 (Extremely Compromised)
to
5(Not Compromised)
1(Never Demonstrated)
to 5(Consistently Demonstrated)
1(None)
to
5(Extensive)
Example:
Imbalanced nutrition: Less than body requirements related to decreased
oral intake secondary to surgical intervention as evidence by a sudden
decrease of BMI from 22.5-17.5.
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P
NOC:
Nutritional Status: Food and Fluid Intake (1008)
o (100801) Oral food intake at a level of 4 within 5 days.
o (100803) Oral fluid intake at the level of 4 within 5 days.
L
Nursing Intervention
Nursing intervention should be realistic, measurable, and achievable.
A
Types of Intervention
Independent Intervention: An independent intervention is within the
scope of nursing practice. For example:
o Patient teaching.
o Self-care and performing activities of daily living.
N
N
I
Collaborative Intervention
A collaborative intervention includes consultation with another health
care member. For example:
o Administration of medication
o Administration of intravenous fluids
o Diagnostic test
How to Write Nursing Interventions
Nursing interventions should be based on the specific nursing diagnosis
and expected outcome. The purpose of the nursing interventions is to be
comprehensive to achieve the goal.
Nursing interventions should:
o Be Actions (begin with a verb)
N
G
o
o
o
o
o
Monitor the patient’s temperature.
Assess respiratory rate, depth, pattern.
Perform passive range of motion exercises.
Be scientific and evidence-based.
Include rationale from nursing books, journals, and care plans.
Have available resources.
Include the patient's willingness and consent.
Possess competence to perform the intervention.
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P
Nursing Intervention Classification (NIC)
L
Sample Using NIC and NOC
NIC is a standardized evidenced-based nursing intervention. NIC
includes 554 interventions and grouped into 30 classes and 7 domain
groups.
Here is a short sample on how to use the NIC and NOC
Nursing Diagnosis
A
Imbalanced nutrition: Less than body requirements related to decreased
oral intake secondary to surgical intervention as evidence by a sudden
decrease of BMI from 22.5-17.5 in 30 days.
NOC LABEL
N
o 100801 Oral food intakes at a level of 4(substantially adequate)
within 5 days.
o 100803 Oral fluid intakes at the level of 4(substantially adequate)
within 5 days.
NIC LABEL
N
I
N
o Nutrition Management
o Nutritional Counselling
o Nutritional Monitoring
Tips for writing nursing interventions.
Ensure that the nursing interventions are simple to understand.
Clearly, state the action verb.
Prioritize patient’s safety.
Interventions should be collaborative between the nurse and
the patient.
o Follow the institutional policy.
o Ensure all resources are available.
o Focus on independent nursing actions first.
o
o
o
o
G
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A
C
T
I
V
I
ACTIVITY 4
Scenario
Mr. Harry Fernando is a 68-year-old male admitted to the medicalsurgical unit and diagnosed with congestive cardiac failure. The client
states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;
however, he does not drink alcohol or use recreational drugs. Mr.
Fernando has a family history of cancer, diabetes and hypertension, and
coronary artery disease.
Mr. Fernando loves to eat KFC and burgers. He is currently concerned
about his health status but isn’t sure what to do.
Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.
1. Create expected outcomes and nursing interventions.
T
Y
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A
C
T
I
V
I
T
Y
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A
C
T
I
V
I
T
Y
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A
C
T
I
V
I
T
Y
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O
IMPLEMENTATION
B
J
OBJECTIVES
In this chapter, you would learn:
1. Care plan implementation
2. Documentation.
E
C
Notes
Key points from this chapter…
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I
M
P
L
E
M
E
N
T
A
T
I
O
N
IMPLEMENTATION
Implementation is the fourth step in the nursing process. This phase
involves putting the care plan into action to achieve the desired set
outcome(s). It includes:
o
o
o
o
Executing planned intervention.
Using critical thinking to prioritize needs.
Assessing and reassessing the patient.
Communication, documentation and referrals.
Documentation
Documentation depends on the facility’s policy. The facility’s policy
dictates the format of documenting interventions.
Documentation Format
There are different types of nursing documentation formats that can be
utilized in the clinical setting. This includes:
The PIE system: Problem-intervention-evaluation.
E.g.
P- Ineffective Breathing Pattern
I- Patient assessment revealed the use of accessory muscle, RR of
25, SPO2 of 95%. The patient is placed on continuous SPO2 and RR
monitoring every 15 minutes. The patient is placed in a semifowlers position and oxygen therapy 4L/min as prescribed ongoing.
E- After 1 hour of nursing intervention, the patient had an
increase of SP02- 98% and RR of 18.
The SOAP Format: Subjective, Objective, Assessment Planning.
E.g.
S- Patient verbalize chest tightness
O- Use of accessory muscles, RR- 25, SPO2 95%
A- Ineffective Breathing Pattern
P- Assess and monitor respiratory rate, depth, and pattern.
Administer 02 therapy 4L/min. Place pt. in a semi-fowlers position.
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I
M
P
L
E
M
E
N
T
A
T
I
O
N
The SBAR Format: Situation, Background, Assessment, Recommendation
This type of documentation is done between health care providers.
Situation: Briefly explaining the situation.
Background: Provide relevant history that relates to the patient’s
current problem.
Assessment: Assess patient’s problem.
Recommendation: What is requested to be done.
ACTIVITY 5
Question 1.
Create an SOAP documentation format for any of your nursing
diagnosis.
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B
J
EVALUATION
OBJECTIVES
In this chapter, you would learn:
1. The importance of evaluation.
2. The process of evaluation.
E
C
Notes
Key points from this chapter…
T
I
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V
A
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EVALUATION
Evaluation is the fifth stage in the nursing process. However, it is
essential to remember that, despite it being the fifth stage, it is an
ongoing process of the first four stages. In includes:
o Reassessing the patient.
o Patient progress as compared to the expected outcome
established.
o Documenting statements of evaluation.
The purpose of evaluation
o
o
o
o
Determine complication
Assess patient’s response to intervention
Improve the quality of care
Determine whether care conform to evidence-based standards
U
Reassessment
A
Assessment: Vital signs change, a change in the pain rate.
T
Reassessment allows the nurse to identify whether the patient’s
condition is improving or whether interventions are effective. Check for:
Nursing diagnosis: Relevancy of diagnosis, new defining characteristics
Planning: Realistic goals, congruence of nursing interventions, and
expected outcomes.
Evaluation: Change between expected outcome and current condition.
Evaluating the Expected Outcome
I
O
Achieved Outcome
Outcome Not Achieved
Upon evaluation, you may discover
that the patient has met the shortterm goal. Hence, the intervention
was adequate, and the outcome was
met.
Upon evaluation, you may discover
that the patient did not meet the
short-term goal. Hence, the
interventions should be reexamined;
goals should be reassessed.
N
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A
C
T
I
V
I
ACTIVITY 6
Scenario
Mr. Harry Fernando is a 68-year-old male admitted to the medicalsurgical unit and diagnosed with congestive cardiac failure. The client
states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;
however, he does not drink alcohol or use recreational drugs. Mr.
Fernando has a family history of cancer, diabetes and hypertension, and
coronary artery disease.
Mr. Fernando loves to eat KFC and burgers. He is currently concerned
about his health status but isn’t sure what to do.
Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.
1. Evaluate your nursing care. (Assume that your expected
outcomes/goals were met).
T
Y
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O
B
J
CONCEPT MAPPING
OBJECTIVES
In this chapter, you would learn:
1. The definition of concept mapping.
2. The use of concept mapping.
E
C
3. The steps in developing a concept map care plan.
NOTES
Key points from this chapter…
T
I
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C
O
N
C
E
P
T
M
CONCEPT MAPPING
Concept mapping is an innovative approach in planning patient care.
Concept mapping places “concepts” or ideas of patient’s problems into a
diagram. Concept care maps are used to:
o
o
o
o
Systematically organize the patient's data.
Create relationships among the data.
Prioritize
Provide a holistic approach to care.
Steps in Developing Concept Care Mapping
Preparation
Prior to step 1, it is important for you to gather all clinical data
(subjective and objective data). The assessment phase must be complete
and accurate.
Step 1. Develop A Skeleton Diagram
Detail the problems that you assessed and collected. The key problems
are also known as concepts. In the middle, write the medical diagnosis.
Key Problem
Key
Problem
Key
Key Problem
Key Problem
Medical Diagnosis
A
p
Priority Assessment
Key Problem
Key Problem
Key Problem
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C
O
N
C
E
P
T
Step 2. Analyze and Categorize Data
Analyze and categorize the data from both objective and subjective
data. This provides supportive evidence for the medical diagnosis and
nursing diagnosis. Include abnormal assessment findings, medical history,
etc.
Key Problem:
Key Problem:
Key Problem:
Data:
Data:
Data:
Key Problem:
Key Problem:
Data:
Medical Diagnosis
Priority Assessment
Data:
Key Problem:
Key Problem:
Key Problem:
Supporting Data:
Supporting Data:
Supporting
Data:
M
Step 3: Indicate relationships
A
In the example below, in terms of prioritization, ineffective airway
clearance is first, followed by ineffective breathing pattern, activity
intolerance, and anxiety.
P
Secondly, the lines represent the relationship between the problems. For
example, the line between ineffective breathing pattern and anxiety
shows that respiratory distress causes the patient’s anxiety.
Draw lines between problems that relate, then prioritize the problem.
Replace the key problem with the nursing diagnosis.
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C
O
N
Ineffective Breathing Pattern
Supporting Data
4
Dyspnea, RR, SPO2, nasal flaring, use of
accessory muscles, tachypnea, prolong
expiration,
Anxiety
Verbalization
of anxiety
Supporting Data
Priority Assessment:
Dyspnea
3
Activity
Intolerance
ASTHMA
Supporting
Data:
Tachypnea
C
2
Airway patency, breathing,
safety, activity tolerance.
1
Restlessness
Verbalization of
weakness
Tired appearance
Inability to
perform daily
tasks.
Ineffective Airway Clearance
E
P
T
M
A
Supporting Data:
Cough
Dyspnea
Respiratory Rate
SPO2
Step 4: Identify goals and expected outcome and nursing strategies
(interventions)
This includes a general goal and behavioral outcome at the top of the
template. Nursing strategies are the nursing interventions that would be
implemented.
Step 5: Evaluate the patient’s outcome/response.
In this step, evaluate the patient's response to the nursing strategies.
For example, under the diagnosis of ineffective breathing pattern,
assessment of respiratory rate, depth, and pattern would be a nursing
strategy. In the patient's response, you would state the patient's
respiratory rate, depth, and pattern.
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Problem #
Goal:
Expected Outcome (Behavioral Outcome): The patient will…
N
C
E
P
T
Nursing Intervention
Patient Response
1.
2.
3.
4.
5.
6.
M
7.
8.
A
Evaluation:
P
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Remember that concept care mapping is dynamic, depending on the
institution. The core principle is to establish relationships among the
problems. Follow your teacher's instruction and maintain the core
principles when formulating your care plan.
Other Concept Care Mapping Templates.
Nursing Dx:
Assessment:
N
C
Expected Outcome:
Interventions:
Nursing Dx:
E
Assessment:
P
Outcome:
Expected
Goal Evaluation:
Assessment:
MEDICAL
DIAGNOSIS
Assessment:
M
A
P
Expected Outcome:
Interventions:
Goal Evaluation:
Interventions:
T
Nursing Dx:
Goal Evaluation:
Nursing Dx:
Assessment:
Expected Outcome:
Interventions:
Goal Evaluation:
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ACTIVITY 7
Scenario
Mr. Harry Fernando is a 68-year-old male admitted to the medicalsurgical unit and diagnosed with congestive cardiac failure. The client
states that he has been experiencing shortness of breath for over three
days and has swollen feet. “I am not able to sleep at night because I
cannot breathe.” According to Mr. Fernando’s wife, he complains of body
weakness and the inability to perform daily tasks.
Mr. Fernando has a history of hypertension, diabetes, AF,
hypercholesterolemia for over 20 years. He had a coronary artery
bypass surgery 10 years ago. He is a known smoker for over 30 years;
however, he does not drink alcohol or use recreational drugs. Mr.
Fernando has a family history of cancer, diabetes and hypertension and
coronary artery disease.
Mr. Fernando loves to eat KFC and burgers. He is currently concerned
about his health status but isn’t sure what to do.
Vital signs showed: BP 97/52, irregular pulse 80, SaO2 94%, Temp 36.9,
RR 24 bpm. Crackles noted in the right lung base upon auscultation.
CREATE A CONCEPT MAP FOR ONE OF YOUR DIAGNOSIS.
T
Y
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A
Problem #
C
Expected Outcome (Behavioral Outcome): The patient will…
Goal:
T
I
Nursing Intervention
Patient Response
1.
V
I
T
Y
2.
3.
4.
5.
6.
7.
8.
Evaluation:
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ANSWERS
N
S
W
REMEMBER THAT NURSING IS DYNAMIC AND THIS IS JUST A CASE
SCENARIO. THEREFORE, THERE WOULD BE MISSING PIECES. THE
GOAL OF THIS SECTION IS TO GIVE YOU A GUIDE ON HOW TO
ANSWER THE QUESTION. YOU ARE NOT LIMITED TO THESE
ANSWERS ALONE. AGAIN, REMEMBER, NURSING IS DYNAMIC.
E
R
TRY BEFORE YOU TAKE A
PEEK!
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ACTIVITY 1
1. According to Miskir and Emishaw (2018), the factors that may affect
the implementation of the nursing process includes:
o
o
o
o
o
o
o
o
No writing formats
Lack of follow up and monitoring
Lack of time
Lack of knowledge
Increasing workload
Nursing staff shortage
Lack of support
Lack of reference materials.
(You may include other factors that may affect the implementation of
the nursing process.)
2. Draw and label the steps in the nursing process. (You may create your
design.)
E
1
ASSESSMENT
R
2
5
THE NURSING
EVALUATION
DIAGNOSIS
PROCESS
S
4
3
IMPLEMENTATION
PLANNING
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ACTIVITY 2
1.
OBJECTIVE DATA
SUBJECTIVE DATA
o
o
o
o
o
o
o
SOB for 3 days
“I am unable to sleep at night
because I cannot breathe.”
Family history
Past medical and surgical
history
Known smoker for 30 years
Diet: KFC and Burger
Concerned about health
o
o
o
Vital signs showed: BP
97/52, irregular pulse 80,
SaO2 94%, Temp 36.9, RR
24 bpm.
Crackles noted in the right
lung base upon auscultation.
Bilateral pedal edema.
W
2. According to Mr. Fernando’s wife, he complains of body weakness and
E
R
S
the inability to perform daily tasks.
3. Additional subjective data: Weight gain, allergies, medication history,
social history, religion, lifestyle habits.
Additional objective data: Degree of pitting (edema), jugular vein
distention, diagnostic test results, ECG, Lab results, blood chemistry,
peripheral pulse, capillary refill, cyanosis.
4. Mr. Fernando’s stage according to Erik Erikson is Integrity vs Despair.
It includes focusing on one's life and either transitioning to being happy
and satisfied with one's life or experiencing a deep sense of regret.
With his medical condition, the nurse must assess whether the patient is
pleased with the life lived or experiencing depression and grief.
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ACTIVITY 3
(The nursing diagnosis is not limited to the list below.)
1. Ineffective breathing pattern related to decreased lung expansion
secondary to pulmonary congestion as evidence by SaO2 94%, RR 24
bpm, crackles noted in the right lung base upon auscultation, dyspnea,
SOB, and orthopnea.
2. Decreased cardiac output related to decreased myocardial
contractility as evidence by BP 97/52, irregular pulse 80, pedal edema.
3. Excess fluid volume related to increased fluid retention secondary to
decreased myocardial contractility as evidence by bilateral pedal edema,
orthopnea, crackles noted in the right lung base upon auscultation and
dyspnea.
4. Activity intolerance related to an imbalance between oxygen supply
and demand as evidence by verbalization of generalized weakness and
inability to perform activities of daily living.
5. Disturbed sleep pattern related to decreased lung expansion
secondary to pulmonary congestion as evidence by patient verbalization
of difficulty sleeping, dyspnea, SOB, orthopnea SaO2 94%, and RR 24
bpm.
6. Deficient knowledge related to lack of understanding of the disease
process as evidence by verbalization of health concern and lifestyle
behaviors.
7. Risk for impaired gaseous exchange related to pulmonary congestion.
8. Risk for ineffective tissue perfusion related to decreased stroke
volume secondary to inadequate myocardial contractility.
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ACTIVITY 4 and 6
(Only three nursing diagnosis were used as a sample.)
Nursing Diagnosis:
N
S
W
Ineffective breathing pattern related to decreased lung expansion secondary
to pulmonary congestion as evidence by SaO2 94%, RR 24 bpm, crackles noted
in the right lung base upon auscultation, dyspnea, SOB, and orthopnea.
Expected Outcomes
1. The patient will maintain a blood oxygen saturation level between 95% to
100% after 1 hour of nursing intervention.
2. The patient will maintain a respiratory rate within 12-20bpm after 1 hour of
nursing intervention.
2. The patient will demonstrate a diaphragmatic pursed-lip breathing technique
after 1 hour of nursing intervention.
Interventions
1. Assess respiratory rate, depth, and pattern every 2 hours.
2. Auscultate breath sounds every 4 hours.
E
3. Monitor the patient’s vital signs every 2 hours.
4. Place the patient in a semi-fowlers position.
5. Encourage a diaphragmatic pursed-lip breathing technique.
6. Administer oxygen therapy as per physician order. (Specify)
R
7. Administer medication(s) as prescribed by the physician. (State medication
name, time, dose and route).
8. Monitor any medication(s) side effects.
9. Assist patient to perform relaxation techniques.
S
10. Document nursing interventions and the patient’s response.
Outcome:
The outcome was met. After 1 hour of nursing intervention, the patient
maintained a blood oxygen saturation of 96%, maintained an RR of 20bpm, and
demonstrated diaphragmatic pursed-lip breathing technique every thirty
minutes.
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N
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ACTIVITY 4 and 6
Nursing Diagnosis
Decreased cardiac output related to decreased myocardial contractility as
evidence by BP 97/52, irregular pulse 80 and bilateral pedal edema.
Expected Outcome:
1. After 8 hours of nursing intervention, the patient will demonstrate an
increase in cardiac output as evidence by increase in BP within normal systolic
range of 110-129 and diastolic range of 60 and less than 80; a regular 3+ pulse
on a graded scale of (0-4+) with a rate ranging from 60-100bpm and a decrease
in bilateral pedal edema of 0-2+ on a graded scale of (0-4+).
Interventions
1. Assess apical and peripheral pulses every 2 hours.
2. Assess heart and lung sounds every 4 hours.
3. Place the patient on cardiac monitoring as per the physician's order.
E
4. Monitor fluid input and output.
5. Place the patient in a semi-fowlers position.
6. Encourage periodic rest and assist with ADLs.
7. Administer oxygen therapy as per physician order. (Specify)
R
8. Administer medication(s) as prescribed by the physician. (State medication
name, time, dose and route).
9. Monitor any medication side effects.
10. Document nursing interventions and the patient’s response.
S
Outcome:
The outcome was met. After 8 hours of nursing intervention, the patient
demonstrated an increase in cardiac output as evidence by a maintained BP of
115/72, regular 3+ pulse and rate of 88bpm, and a decrease of bilateral pedal
edema of 2+.
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ACTIVITY 4 and 6
Nursing Diagnosis
Excess fluid volume related to increased fluid retention secondary to
decreased myocardial contractility as evidence by bilateral pedal edema,
orthopnea, Crackles noted in the right lung base upon auscultation and dyspnea
and BP 97/52, irregular pulse 80
Expected Outcome:
Patient would regain and maintain fluid balance as evidence by decrease of
bilateral pedal edema on the scale grade of 0-2, increase in BP within normal
systolic range of 110-129 and diastolic range of 60 and less than 80; a regular
pulse of 3+ on a graded scale of (0-4+) and maintain a regular breathing pattern
after 8 hours of nursing interventions.
Interventions.
W
1. Assess BP, pulse and respiratory rate, depth, and pattern every 2 hours.
2. Auscultate breath sounds every 4 hours.
3. Maintain fluid restriction as per physician order.
4. Maintain a low sodium diet.
E
R
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5. Weigh patient daily and compare to previous weights.
6. Elevate the patient's lower limbs.
7. Administer medication(s) as prescribed by the physician. (State medication
name, time, dose and route).
8. Monitor any medication side effects.
9. Document nursing intervention and the patient's response.
Outcome:
The outcome was met. After 8 hours of nursing interventions, the patient
demonstrated a maintained fluid balance as evidence by a BP of 115/72, a
regular 3+ pulse of 88bpm, and a decrease of bilateral pedal edema of 2+ and
RR of 20bpm.
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ACTIVITY 5
A
SOAP format:
N
S
S- The Patient verbalized SOB for over 3 days.
O- SaO2 94%, RR 24 bpm. Crackles noted in the right lung base upon
auscultation, dyspnea, SOB, and orthopnea.
A- Ineffective breathing pattern
P- Assess and monitor respiratory rate, depth, and pattern. Administer
02 therapy. Place pt. in a semi-fowlers position.
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E
R
S
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ACTIVITY 7.
The arrows are used to show the relationships between the diagnosis. For example, an
Ineffective breathing pattern can cause disturbed sleep patterns and activity intolerance.
Decreased cardiac output causes excess fluid volume, activity intolerance, disturbed sleep
pattern, and ineffective breathing pattern. This format is shown below.
Disturbed sleep pattern
5
Supporting Data:
Patient verbalization of
difficulty sleeping, dyspnea,
SOB, orthopnea SaO2 94%
and RR 24 bpm.
1
2
Ineffective breathing
pattern
Decreased cardiac output
Supporting Data:
Supporting Data:
SaO2 94%, RR 24 bpm.
Crackles noted in the
right lung base upon
auscultation, dyspnea,
SOB, and orthopnea.
CONGESTIVE HEART
FAILURE
BP 97/52, irregular pulse
80, bilateral pedal edema.
Assessment:
Respiration, Cardiac Output,
Activity Tolerance, Fluid
retention
E
3
4
Activity intolerance
R
Supporting data:
Verbalization of
generalized weakness
and inability to
perform activities of
daily living.
Excess fluid volume
related
Supporting Data:
Bilateral pedal edema,
orthopnea, crackles noted
in the right lung base upon
auscultation and dyspnea.
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CASE
STUDIES
Here are additional case studies. The aim is for you to apply the basic
concepts that you have learned. Remember that these case scenarios
sometimes omit other relevant information that might be crucial in
creating a comprehensive care plan. The goal is to critically think like
a nurse and fill in the gaps with the question:
WHAT OTHER INFORMATION
SHOULD I OBTAIN?
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CASE STUDY 2
Mrs. Kathrine George is a 30-year-old female who was admitted with a
medical diagnosis of pneumonia. She complains of cold for two weeks,
decrease oral intake, dyspnea, orthopnea, and body weakness. “I have
been coughing up thick pink sputum." The assessment showed dry mucous
membranes, hot and pale skin, decreased breath sounds, and inspiratory
crackles upon auscultation. Mrs. George has a medical history of asthma.
She has no past surgical history. Mrs. George has no known food or drug
allergy and does not smoke or abuse alcohol and drugs.
Create a nursing care plan and concept care map for Mrs. George.
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CASE STUDY 3
A 79-year-old female is admitted with a medical diagnosis of COPD. The
patient states that she has been experiencing shortness of breath for
the past 24 hours. She is using her accessory muscles, and you noticed
nasal flaring. Patient breathing is fast and irregular. Vital signs show
oxygen saturation was 82%, HR 120, BP 160/90, RR 34. Lung sounds are
diminished, and a chest X-ray revealed a hyper-inflated lung and
flattened diaphragm. The patient oxygen setting is 2L/min; however, she
begins to complain that the oxygen level is too low. ABGS show PCO2 59,
pH 7.24, PO2 52, O2 Sat 82%.
Create a nursing care plan and concept care map.
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CASE STUDY 4
A 50-year-old male is admitted with complaints of abdominal pain on a
pain rating of 9(0-10 scale). He described his pain as intermittent and
stabbing. He also complained of frequent dark tarry stool for the past 4
days and described a coffee brown looking emesis. He stated that his
current medications are Aspirin and Lisinopril, however, he is unable to
remember the dosage. He feels dizzy and always tired. The patient has a
dry mucous membrane, is pale and diaphoretic. Vital signs showed BP
98/62, HR 115, O2 Sat 99%.
Create a nursing care plan and concept care map.
NOTES
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