2010 review readiness
TRANSCRIPT
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Compilation of Review from:
1. R.A. Gapuz Review Center
2. Royal Pentagon Review Center
3. Merge Review Center
4. KAPLAN
5. Edgeworth
6. Scribd
7. Nursing crib
Prayer for Students
God of Light and Truth, thank you for giving me a mind that can know and a heart that can
love. Help me to keep learning every day of my life, for all knowledge leads to you. Let me be
aware of your presence in all things and at all times. Encourage me when work is difficult and
when I am tempted to give up; encourage me when my brain seems slow and the way forward
is difficult. Grant me the grace to put my mind to use exploring the world you have
created, confident that in you there a wisdom that is real. Amen.
Charles Henderson
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Prayer to St. Joseph of Cupertino for success in Examinations.
This powerful prayer is very effective in examinations. It has to be said before appearing in the
examination. There are two variants to this prayer. Both the prayers are equally effective. You
can choose any one of these:-
First Prayer
O Great St. Joseph of Cupertino who while on earth did obtain from God the grace to be asked
at your examination only the questions you knew, obtain for me a like favor in the examinations
for which I am now preparing. In return I promise to make you known and cause you to be
invoked.
Through Christ our Lord.
St. Joseph of Cupertino, Pray for us.
Amen.
Second Prayer
O St. Joseph of Cupertino who by your prayer obtained from God to be asked at your
examination, the only preposition you knew. Grant that I may like you succeed in the (here
mention the name of Examination eg. History paper I ) examination.
In return I promise to make you known and cause you to be invoked.
O St. Joseph of Cupertino pray for me
O Holy Ghost enlighten me
Our Lady of Good Studies pray for me
Sacred Head of Jesus, Seat of divine wisdom, enlighten me.
Remember, when you succeed in the exams then you should thank St. Joseph of Cupertino in
the Newspaper.
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1. Fundamental of Nursing
2. Leadership and Nursing Management
3. Nursing Research
4. Professional Adjustment
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Types of Leadership:
AUTHORITARIAN OR AUTHOCRATIC leaders makes own decision..More concerned task
accomplishment than w/ concern for people. It promotes hostility and aggression or apathy to
decrease initiative.
DEMOCRATIC PARTICIPATIVE- leaders involved their follower in decision making process.
People oriented focusing on human relations en team work. lead to increased productivity and
job satisfaction.
LAISSEZ-FAIRE OR PERMISSIVE- leaders are loose and permissive and abstain from leading their
staff. They foster freedom for everyone en wants everyone to feed good. Leadership results in
low productivity en employees
Frustrations
Pattern of Nursing Care:
Case Method/Total Patient Care
In case method, the nurse cares for one patient whom the nurse cares for exclusively. The
Case Method evolved into what we now call private duty nursing. It was the first type of nursing
care delivery system.
In Total Patient Care, the nurse is responsible for the total care of the patient during the nurses
working shift. The RN is responsible for several patients.
Functional Nursing
It is a task-oriented method wherein a particular nursing function is assigned to each staff
member. The medication nurse, treatment nurse and bedside nurse are all products of thissystem. For efficiency, nursing was essentially divided into tasks, a model that proved very
beneficial when staffing was poor. The key idea was for nurses to be assigned to tasks, not to
patients.
Team Nursing
The goal of team nursing is for a team to work democratically.
Primary Nursing
The hallmark of this modality is that one nurse cares for one group of patients with 24-hour
accountability for planning their care.
Modular Nursing (District Nursing)
This is a modification of team and primary nursing. It is a geographical assignment of patient
that encourages continuity of care by organizing a group of staff to work with a group of
patients in the same locale.
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Expanded Nursing Role:
1. Nurse Practitioner
A nurse who has an advanced education and is a graduate of a nurse practitioner program.
These nurses are in areas as adult nurse practitioner, family nurse practitioner, school nurse
practitioner, pediatric nurse practitioner, or gerontology nurse practitioner.
2. Clinical Nurse Specialist
A nurse who has an advanced degree or expertise and is considered to be an expert in a
specialized area of practice (e.g., gerontology, oncology).
3. Nurse Anesthetist A nurse who has completed advanced education in an accredited program
in anesthesiology.
The nurse anesthetist carries out pre-operative visits and assessments, and Administers general
anesthetics for surgery under the supervision of a physician prepared in anesthesiology. The
nurse anesthetist also assesses the postoperative of clients
4. Nurse Midwife
A RN who has completed a program in midwifery.
5. Nurse Educator
Nurse educator is employed in nursing programs, at educational institutions, and in hospital
staff education.
6. Nurse Entrepreneur
A nurse who usually has an advanced degree and manages a health-related business. The nurse
may be involved in education, consultation, or research.
Level of Prevention by Leavell and Clark:
Primary Prevention
Providing specific protection against disease to prevent its occurrence is the most desirable
form of prevention. Examples:
a. Mandatory immunization of children belonging to the age range of 0 59
months old to control acute infection diseases.
b. Minimizing contamination of the work or general environment by asbestosdust, silicone dust, smoke, chemical pollutants and excessive noise.
Secondary Prevention
Early diagnosis of a health problem can decrease the catastrophic effects that might otherwise
result for the individual and the family from advanced illness and its many complications.
Examples:
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a. Public education to promote breast self-examination, use of home kits for
detection of occult blood in stool specimens and familiarity with the seven
cancer danger signals.
b. Screening programs for hypertension, diabetes. Uterine cancer(pap smear),
breast cancer (examination and mammography), glaucoma and sexually
transmitted disease.Tertiary Prevention
Continuing health supervision during rehabilitation to restore an individual to an optimal level
of functioning.
Three way bottle:
1st
drainage system
shows a simple drainage system that can be connected to suction or to a
Heimlich valve. The fluid-collection bottle would have measurement
markings on it to help clinicians track the amount of fluid collected. This
system could allow for reduction of a pneumothorax
2nd
water seal and drainage bottle
shows the addition of a water-sealed bottle to the simple drainage system.
This helps to stop the problem of air moving back into the chest, and it also
provides greater capacity for the collection of blood or body fluids without
any clogging of the suction outlet/connection.
3rd
drainage, water seal, and suction
The system has a fluid-collection bottle and a water-sealed bottle, alongwith a pressure-regulating bottle. This bottle helps the system maintain a
measured, constant negative pressure and negative flow.
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Bubbling:
*Bubbles in suction: Continues
*Bubbles in water seal: Intermittent
*What if there is continues bubbling in water seal due to air leak? We need to clamp
immediately the tube near the client*What if there is no bubble? No bubbles means normal or there is an obstruction
*How to remove obstruction? By press release maneuvers
*The tube disconnects? Disconnect in the site ( cover the hole w/ vassoclussive dressing)
Disconnect in the whole bottle (reconnect the tube)
*If broken bottle? Immerse in new bottle
*If the tube disconnect?
-Clamp
-Notify Physician
-Immerse in new bottle
-Reconnect the tube
*Clamp is only for leakage
Care for Tracheostomy and function of Cuff, obturator, and Tie
1. Explain procedure to patient.
2. If tracheostomy tube has been suctioned, remove soiled dressing from around tube and
discard with gloves on removal.
3. Perform hand hygiene and open necessary supplies.
Cleaning A Nondisposable Inner Cannula
1. Prepare supplies before cleaning inner cannula.
a. Open tracheostomy care kit and separate basins, touching only the edges. If kit is not
available, open two sterile basins.
b. Fill one basin fraction -inch (1.25 cm) deep with hydrogen peroxide.
c. Fill other basin fraction -inch (1.25 cm) deep with saline.
d. Open sterile brush or pipe cleaners if they are not already in cleaning kit. Open additional
sterile gauze pad.
1. Don disposable gloves.
2. Remove oxygen source if one is present. Rotate lock on inner cannula in a counterclockwise
motion to release it.
3. Gently remove inner cannula and carefully drop it in basin with hydrogen peroxide. Remove
gloves and discard.
4. Clean inner cannula.
1.
a. Don sterile gloves.
b. Remove inner cannula from soaking solution. Moisten brush or pipe cleaners in saline
and insert into tube, using back-and-forth motion.
c. Agitate cannula in saline solution. Remove and tap against inner surface of basin.
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d. Place on sterile gauze pad.
1. Suction outer cannula using sterile technique.
2. Replace inner cannula into outer cannula. Turn lock clockwise and make sure that inner
cannula is secure. Reapply oxygen source if needed.
Replacing Disposable Inner Cannula
1. Release lock. Gently remove inner cannula and place in disposable bag. Discard gloves anddon sterile ones to insert new cannula. Replace with appropriately sized new cannula.
Engage lock on inner cannula.
Applying Clean Dressing and Tape
1. Dip cotton-tipped applicator in saline and clean stoma under faceplate. Use each applicator
only once, moving from stoma site outward.
2. Apply hydrogen peroxide to area around stoma, faceplate, and outer cannula if secretions
prove difficult to remove. Rinse area with saline.
3. Pat skin gently with dry 4 x 4 gauze.
4. Slide commercially prepared tracheostomy dressing or prefolded non-cotton-filled 4 x
4dressing under faceplate.
Tie
a. Leave soiled tape in place until new one is applied.
b. Cut piece of tape that is twice the neck circumference plus 4 inches (10 cm). Trim ends on
the diagonal.
c. Insert one end of tape through faceplate opening alongside old tape. Pull through until
both ends are even.
d. Slide both tapes under patients neck and insert one end through remaining opening on
other side of faceplate. Pull snugly and tie ends in double square knot. Check that patient
can flex neck comfortably.
e. Carefully remove old tape. Reapply oxygen source if necessary.1. Remove gloves and discard. Perform hand hygiene. Assess patients respirations. Document
assessments and completion of procedure.
Obturator
The obturator is used only to guide the outer tube during insertion and is removed immediately
after the outer tube is in place.
Cuff
A tracheostomy cuff is a balloon around the outside of the trach tube. When the balloon is filled
with air it fits the shape of your windpipe. The balloon seals off the space between the wall of
your windpipe and the trach tube. This seal is needed when you are on a breathing machine
(ventilator) or if you have problems with choking. If the cuff is not inflated, air can pass around
the trach tube.
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Postural Drainage
*POPEVICO [arrangement] that is positioning, percussing, vibrating and coughing
*Do this before meals, the positioning depending on the location of secretion
Different position:
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Suction
To assist in the removal of bronchial secretions that cannot be expectorated by the patient
spontaneously.
* INDICATIONS:
1. Visible presence of secretions in tube orifice
2. Coarse tubular breath sounds on auscultation in patient unable to cough or withoutartificial airway in place.
3. Patient with an artificial airway.
*Once catheter has been placed in trachea, slowly withdraw while applying intermittent suction
and rotating catheter. Remember: Suction should not be applied for more than 10-15 seconds.
*Precautions/Complications,
1. Hypoxia
2. Vagal stimulation: Cardiac arrhythmia
3. Tracheitis
Independent and dependent variable
Independent variable
-use this to stimulate a target population/cause
Dependent variable/Effectual variable
-results of the effects of the study
ExamplesA comparative Study in the Income of Filipino Nurses
Employed in P.G.H. and N.Y.G.H.
Independent variable: PGH and NYGH (place of work)
Target population: Filipino nurses
Dependent variable: income
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Nursing Intervention:
- Change the site of needle
- Apply warm compress. This will absorb edema fluids and reduce swelling.
2. Circulatory Overload - Results from administration of excessive volume of IV fluids.
Assessment:
- Headache
- Flushed skin
- Rapid pulse
- Increase BP
- Weight gain
- Syncope and faintness
- Pulmonary edema
- Increase volume pressure
- SOB
- Coughing
- Tachypnea
- Shock
Nursing Interventions:
- Slow infusion to KVO
- Place patient in high fowlers position. To enhance breathing
- Administer diuretic, bronchodilator as ordered
3. Superficial Thrombophlebitis it is due to overuse of a vein, irritating solution or drugs, clotformation, large bore catheters.
Assessment:
-Pain along the course of vein
-Vein may feel hard and cordlike
-Edema and redness at needle insertion site.
-Arm feels warmer than the other arm
Nursing Intervention:
-Change IV site every 72 hours-Use large veins for irritating fluids.
- Stabilize venipuncture at area of flexion.
-Apply cold compress immediately to relieve pain and inflammation; later with warm compress
to stimulate circulation and promotion absorption.
-Do not irrigate the IV because this could push clot into the systemic circulation
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4. Air Embolism Air manages to get into the circulatory system; 5 ml of air or more causes air
embolism.
Assessment:
-Chest, shoulder, or backpain
-Hypotension-Dyspnea
- Cyanosis
-Tachycardia
-Increase venous pressure
-Loss of consciousness
Nursing Intervention
- Do not allow IV bottle to run dry
-Prime IV tubing before starting infusion.
-Turn patient to left side in the trendelenburg position. To allow air to rise in the right side of
the heart. This prevent pulmonary embolism.
BLOOD TRANSFUSION THERAPY
Objectives:
1. To increase circulating blood volume after surgery, trauma, or hemorrhage
2. To increase the number of RBCs and to maintain hemoglobin levels in clients
with severe anemia
3. To provide selected cellular components as replacements therapy (e.g
clotting factors, platelets, albumin)
Nursing Interventions:
a. Verify doctors order. Inform the client and explain the purpose of the procedure.
b. Check for cross matching and typing. To ensure compatibility
c. Obtain and record baseline vital signs
d. Practice strict Asepsis
e. At least 2 licensed nurse check the label of the blood transfusion
Check the following:
-Serial number
-Blood component
-Blood type
-Rh factor
-Expiration date
-Screening test (VDRL, HBsAg, malarial smear)
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- this is to ensure that the blood is free from blood-carried diseases and therefore, safe from
transfusion.
f. Warm blood at room temperature before transfusion to prevent chills.
g. Identify client properly. Two Nurses check the clients identification.
h. Use needle gauge 18 to 19. This allows easy flow of blood.
j.Use BT set with special micron mesh filter. To prevent administration of blood
clots and particles.
k. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse
reaction usually occurs during the first 15 to 20 minutes.
l. Monitor vital signs. Altered vital signs indicate adverse reaction.
Do not mixed medications with blood transfusion. To prevent adverse effects
- Do not incorporate medication into the blood transfusion
- Do not use blood transfusion line for IV push of medication.
m. Administer 0.9% NaCl before, during or after BT. Never administer IV fluids with dextrose.
Dextrose causes hemolysis.
n. Administer BT for 4 hours (whole blood, packed rbc). For plasma, platelets, cryoprecipitate,
transfuse quickly (20 minutes) clotting factor can easily be destroyed.
Complications ofBlood Transfusion
1. Allergic Reaction it is caused by sensitivity to plasma protein of donor
antibody, which reacts with recipient antigen.
Assessments
-Flushing
-Rush, hives
-Pruritus
-Laryngeal edema, difficulty of breathing
2. Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells,
platelets or plasma proteins. This is the most symptomatic complication of blood
transfusion
Assessments:
-Sudden chills and fever
-Flushing
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-Headache
-Anxiety
3. Septic Reaction it is caused by the transfusion of blood or components
contaminated with bacteria.
Assessment:-Rapid onset of chills
-Vomiting
-Marked Hypotension
-High fever
4. Circulatory Overload it is caused by administration of blood volume at a
rate greater than the circulatory system can accommodate.
Assessment
-Rise in venous pressure
-Dyspnea
-Crackles or rales
-Distended neck vein
-Cough
-Elevated BP
5. Hemolytic reaction. It is caused by infusion of incompatible blood products.
Assessment
-Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible
blood.
-Chills
-Feeling of fullness-Tachycardia
-Flushing
-Tachypnea
-Hypotension
-Bleeding
-Vascular collapse
-Acute renal failure
Nursing Interventions when complications occurs in Blood transfusion
1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.2. Start IV line (0.9% Na Cl)
3. Place the client in fowlers position if with SOB and administer O2 therapy.
4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs
as often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor,
fluids, and steroids as per physicians order or protocol.
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Stages of Labor
Stage 1 (From true labor to complete cervical Dilation)
Significance Latent Active Transitional
Physiologic changes 0-3cm cervicaldilation
4-7cm cervicaldilation
8-10cm cervicaldilation
Maternal attitude Excited and Happy Difficulty of following
instruction
Irritable and
restlessness; Circu-
oral pale
Nursing Intervention Inform the labor
progress
Encourage and praise
client
Stage 2 (Complete dilation to birth of baby)
*Complete Cervical Dilation
*Mother needs Increase Involvement in labor
*Nursing Intervention: Initiates and maintain airway of neonates
Stage 3 (from birth to placental delivery)
*Uterine shape change
*Mother Attitude is cooperative
*Nursing Intervention: Ensure complete placental delivery
Stage 4 (From complete Placental delivery to two four hours after delivery)
*Fundus is firm
*Mother attitude is Excited and fatigue
* Nursing Intervention: Monitor for sign of infection
Menstrual Cycle
1 5 days menses6 14 proliferative= Increase estrogen15 22 secretory= Increase Progesterone
23 28 ischemic = 24th
day Corpus Albicans (whitish) corpus luteum degenerates and
becomes white. 28th
day if no sperm united the ovum, the uterine begins to slough off to have
the next menstruation.
Causes ofBleeding during PregnancyFirst Trimester Bleeding
Abortion termination of labor before age of viability
SPONTANEOUS
o AKA miscarriage
o Causes
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1. Chromosomal aberrations due to advanced maternal age
2. Blighted ovum
3. germ plasm defect
o Natures way of expelling defective babies
o Classifications :
1. Threatenedy Pregnancy is jeopardized by bleeding and cramping but the cervix
is closed and can be saved.
2. Inevitable
y Moderate bleeding, cramping, tissue protrudes from the cervixand the cervix is open.
o Types :
1. Complete
y All products of conception are expelled.y Mgt : emotional support
2. Incompletey placenta and membranes retained.y Mgt : D&C
HABITUAL
o 3 or more consecutive pregnancies result in abortion usually related to
incompetent cervix.
o Management (suture of cervix)
1. McDonald procedure
y Temporary circlagey Side effect infectiony May have NSD
2. Shirodkar
y CS delivery MISSED
o fetus dies; product of conception remain inuterus 4 weeks or longer
o signs of pregnancy cease
1. (-) pregnancy test
2. Dark brown
3. Scanty bleeding
o Mgt : induction of labor/ vacuum extraction
INDUCED
o Therapeutic abortion principle of 2 fold effect
1. Done when mother has class 4 heart disease
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o administer IV
o No IE, No Sex, No enema complication : Sudden fetal blood loss
o prepare Mother for double set up DR is converted to OR
Abruptio Placenta
y it is the premature separation of the placenta from the implantation site.y It usually occurs after the twentieth week of pregnancyy Cause:
o Cocaine user
o Severe PIH
o Accident
y Assessment:o Outstanding sign : dark red & painful bleeding
o concealed hemorrhage (retroplacental)
o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
o rigid boardlike abdomen
o severe abdominal pain
o dropping coagulation factor (a potential for DIC)
o sx : bleeding to any part of the body. Mgt : for hysterectomy
y General Nursing care :o infuse IV, prepare to administer blood
y type and crossmatcho monitor FHR
o insert Foley catheter
o measure blood loss; count padso report s/s of DIC
o monitor v/s for shock
o strict I&O
Placental Succenturiata 1 or 2 lobes connected to the placenta by a blood vessel
Placenta Bipartita placenta divided into 2 lobes
Endometriosis and Endometritis:
Endometriosis is a benign condition in which endometrial glands and stroma are present
outside the uterine cavity and walls. The typical patient with endometriosis is in her 30s,nulliparous, and infertile.
Symptoms:
The characteristic triad of symptoms associated with endometriosis is dysmenorrheal,
dyspareunia, and Dyschezia.
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Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
SOME
DEHYDRATION
- Give fluid and food for some dehydration
(Plan B).
- If child also has a severe classification:
- Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding.
- Advise mother when to return immediately.
- Follow-up in 5 days if not improving.
Not enough signs to classify as some
or severe dehydration.
NO
DEHYDRATION
-Give fluid and food to treat diarrhoea at
home (Plan A).
- Advise mother when to return immediately.
- Follow-up in 5 days if not improving
Dehydration present. SEVERE
PERSISTENT
DIARRHOEA
- Treat dehydration before referral unless the
child has another severe classification.
-Refer to hospital.
Blood in the stool. DYSENTERY -Treat for 5 days with an oral antibiotic
recommended for Shigella in your area.
-Follow-up in 2 days.
No dehydration. PERSISTENT
DIARRHOEA
-Advise the mother on feeding a child who
has
PERSISTENT DIARRHOEA.
-Follow-up in 5 days.
Dengue
Any general danger sign or
Stiff neck.
VERY SEVERE
FEBRILE
DISEASE
-Give quinine for severe malaria (first dose)
unless no malaria risk.
-Give first dose of an appropriate antibiotic.
-Treat the child to prevent low blood sugar.
-Give one dose of paracetamol in clinic for
high fever
(38.5C or above).
-Refer URGENTLY to hospital
NO runny nose and
NO measles and
NO other cause of fever.
Dengue - If NO cough with fast breathing, treat with
oral antimalarial.
OR
If cough with fast breathing, treat with
cotrimoxazole for 5 days.
-Give one dose of paracetamol in clinic for
high fever
(38.5C or above).
-Advise mother when to return immediately.
-Follow-up in 2 days if fever persists.
-If fever is present every day for more than 7
days, refer for assessment.
Runny nose PRESENT or
Measles PRESENT or
Other cause of fever
PRESENT.
FEVER -
DENGUE
UNLIKELY
-Give one dose of paracetamol in clinic for
high fever
(38.5C or above).
- Advise mother when to return immediately.
- Follow-up in 2 days if fever persists.
- If fever is present every day for more than 7
days, refer for assessment.
Community Health Nursing Process
Assessment
-Initiate Contact*Demonstrate
-Caring attitude*Mutual trust and confidence
-Collect data from all possible sources
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-Identify Health problem*Assess coping
-Ability Analyze and interpret data
Planning Nursing Action
-Prioritize needs
-Establish goal based on needs and capabilities of staff-Construction and operation plan
-Develop Evaluation parameters
-Revised plan as needed
Implementation of planned care
-Put nursing plan into action
-Coordinates care and services
-Utilizes community resources
-Delegate
-Supervise/monitor Health Service provided
-Provide health education and training
-Document responses to nursing action
Evaluation of care and services rendered
-Nursing audit
-Care outcomes
-Performances appraisal
-Estimate cost benefit ratio
-assessment problems
-Identify needed alteration
-Revise plan as necessary
Type ofBudgets
Personnel
-Compensation for salaries of workers
Operational
-everyday use of equipment and facilities (gloves, water, electricity)
Capital
-long term use equipment (MRI, CT Scan, hospital beds, hospital buildings)
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3. Bone- Fracture will occur
Assessment
Neurologic status
A. Seizure
B. IrritabilityC. Decrease level of consciousness
Drignulocytosis
Diagnostic:
-Blood lead level
10mg/dl (+)
50mg/dl (acute)
70mg/dl (severe)
-X-ray lead line
Therapeutic management
Chelating agent
1. CaNa EDTA
2. Demerol (BAL)- Assist allergy to iodine and peanut
3. Succimer (Chenet)
-Rotating injection site
-Nephrotoxicity
-BUN/Creatinine
-Increase fluid intake
Leukemia, Anemia, and sickle cell anemia, chemotherapy for pediatric
Leukemia
LEUKEMIA the most frequent type of childhood cancer
Brain tumors 2nd
Etiology:
1. Environmental
Viruses
Familial/genetic
Host factors
STAGES OF TREATMENT
INDUCTION
Goal: to remove bulk of tumor
Methods: surgery, radiotherapy, chemotherapy, BM transplant
Effects: often the most intensive phase
Side effects are potentially life threatening
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Assessment:
Anemia, weakness, pallor, dyspnea
Bleeding, petecchiae, spontaneous bleeding, ecchymoses
Infection, fever, malaise
Enlarged lymph node
Enlarged spleen and liverBone pain
Management:
diagnosis: blood studies, BMA
Treatment stages
Induction
CNS prophylaxis
Maintenance
Nursing Intervention:
Provide care for the child receiving chemo and radiotherapy
Provide support for the family/child
Support child during painful procedures
Use distraction, guided imagery
Allow the child to retain as much control as possible
Administer sedation prior to procedure as ordered
Sickle cell anemia
hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin (HgbS)
HgbS sensitive to changes in the oxygen content of the red blood cell
Risk factors: African American
Insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid
and clumped together, obstructing capillary blood flow
The sickling response reversible under adequate oxygenation
Sickle cell crises vaso-occlusive crisis, splenic sequestration, aplastic crisis
Assessment:
1. Vaso-occlusive crisis
Most common type of crisis
Caused by stasis of blood with clumping of the cells in microcirculation, ischemia and
infraction Fever, pain and tissue engorgement
2. Splenic sequestration
Pooling of blood in the spleen
Profound anemia, hypovolemia, shock
3. Aplastic crisis
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Caused by the diminished production and increased destruction of RBCs, triggered by
viral infection or the depletion of folic acid
Profound anemia and pallor
Implementation:
Administer oxygen and blood transfusions administer analgesics
maintain adequate hydration and blood flow with IV normal saline as prescribed and
with oral fluids
Assist the child to assume a comfortable position so that the child keeps the
extremities extended to bed no more than 30 degrees
avoid putting strain on painful joints
encourage consumption of a high calorie, high protein diet with folic acid
supplementation
administer antibiotics as prescribed
Monitor for signs of increasing anemia and shock (pallor, vital sign changes)
New born Screening test
Newborn screening (NBS) is a simple procedure to find out if your baby has a congenital
metabolic disorder that may lead to mental retardation and even death if left untreated.
Newborn screening is ideally done on the 48th hour or at least 24 hours from birth. Some
disorders are not detected if the test is done earlier than 24 hours. The baby must be screened
again after 2 weeks for more accurate results.
Newborn screening is a simple procedure. Using the heel prick method, a few drops of blood
are taken from the baby's heel and blotted on a special absorbent filter card. The blood is dried
for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab).
Newborn screening results are available within seven working days to three weeks after the
NBS Lab receives and tests the samples sent by the institutions. Results are released by NBS Lab
to the institutions and are released to your attending birth attendants or physicians. Parents
may seek the results from the institutions where samples are collected. A negative screen mean
that the result of the test is normal and the baby is not suffering from any of the disorders
being screened. In case of a positive screen, the NBS nurse coordinator will immediately inform
the coordinator of the institution where the sample was collected for recall of patients forconfirmatory testing.
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Disorder Screened Effects SCREENEDEffect if SCREENED
and treated
CH (Congenital
Hypothyroidism
Severe Mental
RetardationNormal
CAH (Congenital Adrenal
Hyperplasia) Death Alive and NormalGAL (Galactosemia) Death of Cataracts Alive and Normal
PKU (Phenylketonuria)Severe Mental
RetardationNormal
G6PDSevere Anemia,
KernicterusNormal
http://www.doh.gov.ph/faq/show/457.html
Amniocentesis, Ultrasonography, Leopolds Manuevers, and paracenthesis
AmniocentesisPurpose: obtain sample of amniotic fluid by inserting a needle through the abdomen into the
amniotic sac
Fluid is tested for:
y Genetic screeningy Determination of fetal maturity primarily by evaluating factors indicative of
lung maturityDone with empty bladderComplication:
> Most common side effect : INFECTION>
Late : pre term labor> Early : spontaneous abortion
o - down syndromeq - neural tube defect, spina befidaGreenish Meconium Stains (Fetal Distress)Yellowish jaundice, hyperbilirubinemiaCloudy Infection
Ultrasonography
An ultrasound is something like an x-ray. But it uses sound waves rather than radiation to make
black-and white pictures from inside the body.
An ultrasound is used in women who are pregnant, or who might be pregnant. An ultrasound
might be done more than once during a pregnancy, depending on the health of the baby or
mother.
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Anesthesia
Risk for infection
Ineffective breathing pattern
Post Operative Care Unit Monitoring
Assessment:1. Mental status
2. VS= every 15 min for 30mins and every 30mins for 1 hour every one hour for 2 hours
and every 2hours/4hrs
3. Respiratory status
4. Level of pain
5. Surgical site and surgical appliance
6. Level of consciousness
7. Fluid status and reviewing intake and output
8. Neurovascular status of extremities of the client
Goals:
1. Airway will be patent
2. VS will be stable
3. Will be alert and oriented when stimulated
4. Respiratory status will be adequate
5. Surgical site will be intact with dry dressing
6. IV will be intact and patent
7. Pain control will be adequate
8. Output within normal level
9. Temperature is in normal
10.Motor and Sensory function will be in adequate level11.Prevent complication
12.Promote independence with self care
13.Ensure adequate discharge planning and teaching
Pancreatitis
Is the inflammation of the pancreas.
POSSIBLE CAUSES:
1. Alcoholism - chronic
2. Bacterial or viral infection3. Biliary tract disease - acute
4. Blunt trauma to the pancreas or abdomen
5. Drugs: steroids, thiazide diuretics, oral contraceptives
6. Duodenal ulcer
7. Hyperlipidemia
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ASSESSMENT FINDINGS:
a. Abrupt onset of pain in the epigastric / LUQ area that radiates to the shoulder,
substernal area, back, and flank
b. Abdominal tenderness and distention
c. Aching, burning, stabbing, pressing pain
d. Knee-chest position, fetal position, or leaning forward for comfort d/t abdominal paine. Mental confusion, hypocalcemia irritability
f. Nausea and vomiting
g. Tachycardia, shock, hypotension
h. Dyspnea
i. Low grade fever
j. Elevated serum amylase / lipase / glucose
k. Grey Turners, Cullenss sign
l. Chronic steatorrhea
m. Jaundice
n.
Hyperglycemia
TREATMENT: PANCREATITIS
1. NPO, TPN, Bland, low-fat, high-protein diet of small, frequent meals with restricted
intake of caffeine, alcohol, and gas-forming foods
2. Bed rest
3. I.V. fluids (vigorous replacement of fluids and electrolytes) BT: packed RBC, FWB
4. Surgical intervention to treat the underlying cause, if appropriate
5. Maintain position, patency, and low suction of NG tube to prevent nausea and vomiting.
6. Monitor I/O, wt OD, abd girth, electrolytes.
7. Monitor blood glucose levels.
8. Meds: meperidine, H2 blockers, anticholinergics, antacids, Ca gluconate, pancreaticenzyme replacements (Viokase, Pancreatin, Pancrease)
9. Keep the client in semi-Fowlers position (if his blood pressure allows) to promote
comfort and lung expansion.
10.Keep the client in bed and turn him every 2hrs, or utilize a specialty rotation bed to
prevent pressure ulcers.
11.Provide a quiet, restful environment to conserve energy and decrease metabolic
demands.
Cholecystitis
Inflammation of the gallbladder; usually caused by the presence of stones (cholelithiasis), whichare composed of cholesterol, bile pigments, and calcium.
Therapeutic management:
Medical management
- Nasogastric suctioning to reduce nausea and eliminate vomiting
- Narcotics to decrease pain
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- Antispasmodics and anticholinergics to reduce spasms and contractions of the
gallbladder
- Antibiotic therapy if infection is suspected
NURSING CARE:
- Teach dietary modification to achieve a low-fat intake because reduced bile flow willreduce fat absorption; supplementation with water-miscible forms of vitamins A and E
may be prescribed.
- Relieve pain both preoperatively and postoperatively
Observe for signs of bleeding (vitamin K is fat soluble and is not absorbed in the absence
of bile); administer vitamin K preparations as ordered
Provide care following a cholecystectomy: surgical / laparoscopic laser
a. Monitor nasogastric tube attached to suction to prevent distention
1. Maintain patency of the tube
2. Assess and measure drainage
b. Provide fluids and electrolytes via intravenous route
c. Keep the client in a low-Fowlers position
d. Have the client cough and deep breathe; splint the incision (incision is high and midline,
making coughing extremely uncomfortable)
e. Provide care for the client with a T-tube (if the common bile duct has been explored, a T-tube
is inserted to maintain patency)
TREATMENT OF STONES:
CHOLESTEROL DISSOLVENT:
Moctanin is administered through a nasal biliary catheter to dissolve stones left in the
bile duct after cholecystectomy. Dissolution may take 1 to 3 weeks. Observe the client
for anorexia, nausea, vomiting, and abdominal pain.
ORAL BILE ACIDS:
Chenodiol ( chenix ) and ursodiol ( actigall ) are administered to dissolve small stones.
Side effects include diarrhea ( especially with chenodiol ), elevation of hepatic
enzymes,gastritis, and gastric ulcers. Dissolution takes between 6 months and 2 years,
and the success rate is only about 30 %
Hepatitis
Irreversible fibrosis and degeneration of the liver
Therapeutic Intervention:
1. Rest
2. Restriction of alcohol, hepatotoxic drugs.
3. Vitamin therapy: especially the fat soluble vitamins A, D, E and K and vitamin B
(thiamine chloride and nicotinic acid); zinc and calcium supplements
4. Diuretics to control ascites and edema
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e. Bed rest for 24 hrs post.
Diabetes mellitusA group of metabolic diseases characterized by elevated levels of glucose in the blood resulting from
defects in insulin secretion, insulin action, insulin receptors or any combination of conditions.
RISK FACTORS for Diabetes Mellitus
1. Family History of diabetes
2. Obesity
3. Race/Ethnicity
4. Age of more than 45
5. Previously unidentified IFG/IGT
6. Hypertension
7. Hyperlipidemia
8. History of Gestational Diabetes Mellitus
CLASSIFICATION OF DM
y Type 1 DM (Insulin dependent Diabetes Mellitus)y Type 2 DM (Non-insulin dependent Diabetes Mellitus)y Gestational DMy Diabetes Mellitus diagnosed during pregnancyy DM associated with other conditions or syndromes
TYPE 1 DM
CLASSIC Ps
y Polyuriay Polydipsia
y Polyphagia
TYPE2 DM
Decreased sensitivity of insulin receptor to insulin less uptake of glucose HYPERGLYCEMIA
Decreased insulin production diminished insulin action hyperglycemia signs and symptoms
NOTE:NEVER administer ORAL HYPOGLYCEMIC AGENTS to PREGNANT MOTHERS!NURSING MANAGEMENT OF DM
y Nutritional modificationy Regular Exercise
y Regular Glucose Monitoringy Drug therapyy Client Education
NUTRITIONAL MANAGEMENTy 1.Review the patients diet history to identify eating habits and lifestyley 2. Coordinate with the dietician in meal planning for weight loss
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y Daily assessment of the footy Use of mirror to inspect the bottomy Inspect the surface of shoes for any rough spots or foreign objectsy Properly dry the feety Instruct to wear closed-toe shoes that fit well
y Instruct patient NEVER to walk barefoot, never to use heating pads, open-toed shoesand soaking feet
y Trim toenails STRAIGHT ACROSS and file sharp cornersy Instruct to avoid smoking and over-the counter medications for foot problems
Pharmacologic and non pharmacologic pain relief
Non-pharmacologic pain relief
Acupuncture (AH-q-punk-sher)
is based on the belief that life forces or energy move through the body in specific paths. Thesepaths are called meridians (mer-IH-d-uns). With acupuncture, a needle is put into the meridian
that runs to the area where you have pain. This needle blocks the meridian which stops or
decreases the pain.
Aromatherapy (uh-ro-muh-THAIR-uh-p)
is a way of using good smells to help you relax and decrease pain
Biofeedback
teaches your body to respond in a different way to the stress of being in pain. Teaching your
body to relax helps make the pain less. Caregivers may use a biofeedback machine so that you
know right away when your body is relaxed. But, often you may not need any machines. Learn
to take your pulse. Then take it while making your mind think about "slowing down" your pulse.
This can work with breathing, temperature, and blood pressure too.
Breathing exercises
are another physical way to help your body relax.Teaching your body to relax helps make the
pain less. Breathing in and out very slowly is all you do.
Distraction (dih-STRAK-shun)
teaches you to focus your attention on something other than pain. Try playing cards or games,
watching TV, or taking a walk.
Environment (your surroundings)
Being in a quiet place may make it easier for you to deal with the pain.
Guided imagery (IH-mij-ree)
teaches you to put pictures in your mind that will make the pain less intense.
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Heat and cold
can help decrease pain. Some types of pain improve best using heat while other types of pain
improve most with cold.
Laughter
It has been said that "10 minutes of belly laughter gives 2 hours of pain-free sleep!" Laughterhelps you breathe deeper and your stomach digest (break down) food.
Massage
is often used to help a person become more relaxed. Have someone gently massage your back,
shoulders, and neck
Music
It does not matter whether you listen to it, sing, and hum or play an instrument. Music
increases blood flow to the brain and helps you take in more air.
Physical therapy
can be helpful with pain that was caused by not moving one part of your body.
Radiation
can be used to decrease the size of a cancer tumor that is pressing on nerves and causing pain.
Self-hypnosis
is a way to change your level of awareness. This means that by focusing your attention you can
move away from your pain.
Spinal cord stimulationis a nerve stimulation technique that is similar to TENS. The difference is that in SCS an
electrode (a metal wire) is put near the spinal cord during surgery. SCS also uses mild, safe
electrical signals to help control pain.
TENS
is short for transcutaneous (trans-q-TAIN-e-us) electrical nerve stimulation (stih-mew-LA-shun).
A TENS unit is a portable, pocket-sized, battery-powered device which attaches to the skin. The
TENS unit uses mild, safe electrical signals to help control pain.
Touch energy therapiescome from very old beliefs that life forces or energy move through the body in specific paths.
Touch therapies believe disease may cause these paths to become blocked. The therapies use
touch to help unblock these paths, and allow the energy to flow normally. Unblocking the paths
may help you relax and decrease pain.
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3. Promote decision making abilities
4. Provide routine pre-op care:
Consent, NPO, Meds, Teaching about breathing exercise
NURSING INTERVENTION : Post-OP
1. Position patient: Supine
Affected extremity elevated to reduce edema
2. Relieve pain and discomfort
Moderate elevation of extremity
IM/IV injection of pain meds
Warm shower on 2nd
day post-op
3. Maintain skin integrity
Immediate post-op: snug dressing with drainage
Maintain patency of drain (JP)
Monitor for hematoma w/in 12H and apply bandage and ice, refer to surgeon
Drainage is removed when the discharge is less than 30 ml in 24 H
Lotions, Creams are applied ONLY when the incision is healed in 4-6 weeks
4. Promote activity
Support operative site when moving
Hand, shoulder exercise done on 2ndday
Post-op mastectomy exercise 20 mins TID
NO BP or IV procedure on operative site
Heavy lifting is avoided
Elevate the arm at the level of the heart
On a pillow for 45 minutes TID to relieve transient edema
5. MANAGE COMPLICATIONSLymphedema
10-20% of patients
Elevate arms, elbow above shoulder and hand above elbow
Hand exercise while elevated
Refer to surgeon and physical therapist
Hematoma
Notify the surgeon
Apply bandage wrap (Ace wrap) and ICE pack
Infection
M
onitor temperature, redness, swelling and foul-odor IV antibiotics
No procedure on affected extremity
6. TEACH FOLLOW-UPcare
Regular check-up
MonthlyBSE on the other breast
Annual mammography
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Cervical Cancer
Risk Factor:
-HPV infection: HPV is a group of viruses that can infect the cervix.
- Lack of regular Pap tests
- Smoking
- Weakened immune system- many sexual partners
- Using birth control pills for a long time
- Having many children
- DES (diethylstilbestrol)
Sign and Symptoms
- Abnormal vaginal bleeding
-Bleeding that occurs between regular menstrual periods
-Bleeding after sexual intercourse,douching, or a pelvic exam
-Menstrual periods that last longer and are heavier than before
-Bleeding after going through menopause
-Increased vaginal discharge
-Pelvic pain
-Pain during sex
Stage I: The tumor has invaded the cervix beneath the top layer of cells. Cancer cells are found
only in the cervix.
Stage II: The tumor extends to the upper part of the vagina. It may extend beyond the cervix
into nearby tissues toward the pelvic wall (the lining of the part of the body between the hips).
The tumor does not invade the lower third of the vagina or the pelvic wall.
Stage III: The tumor extends to the lower part of the vagina. It may also have invaded the pelvic
wall. If the tumor blocks the flow of urine, one or both kidneys may not be working well.
Stage IV: The tumor invades the bladder or rectum. Or the cancer has spread to other parts of
the body.
Treatment
Women with cervical cancer have many treatment options. The options are surgery,radiation
therapy, chemotherapy, or a combination of methods.
SurgeryRadical trachelectomy: The surgeon removes the cervix, part of the vagina, and the lymph nodesin the pelvis. This option is for a small number of women with small tumors who want to try to
get pregnant later on.
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1. Colostomy Care
2. Insulin Administration and rotation
3. Intervention during hypo and hyperglycemia4. Care for hypo and hyperthyroidism and monitor hypocalcemia
5. Tuberculosis and leprosy late and early Sign
6. Acute and chronic renal failure and hemodialysis
7. Study radiation and chemotherapy and there usual side effect
8. Mammography, BSE, TSE, DRE, and colon cancer, changes that occur during elderly,
bladder, colon, and cervical diagnostic examination
9. AGN, Osteoatritis and rheumatoid arthritis, Bells palsy and trigeminal neuralgia
10.Laryngeal cancer and traceostomy care
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ostomy Care
y Referral to enterostomal therapist.y Encourage verbalization of fears/concerns.y Teach character of drainage: ileostomy liquid 4-6x/day, transverse colostomy mushy
OD, descending/sigmoid soft formed q 2-3 days
y Skin care nystatin, karaya powder, soap/H2O pat dryy Odor control deodorant drops, bismuth tabs, mouthwash solutions, spinach, parsley
added to ostomy bag.
y Odor avoid gas-formers (cabbage, beans, broccoli, cauliflower, corn, onions, eggs,fish, condiments.
y Diet ileostomy (clear liquids, strained fruits/veggies progress to regular diet, Na/K richfood, avoid fried, seasoned food, nuts, raisins, raw fruits)
y colostomy clear liquid, solid low-residue 1st 6 weeksy Ileostomy drainage q 4-6 hrs emptied, pouch 5-7 days max
Ostomy Irrigation
y Only colostomies are irrigated; ileostomy no needy Purposes stimulate emptying of colon to avoid use of appliancey Started 5-7 days post-op in the bathroom preferablyy Equipment: irrigating solution, catheter with stoma tip, irrigating sleevey Tepid water used 18-24 in above stoma (shoulder height)y 500-1000ml irrigated slowlyy Done same time everyday / as preferredy Return flow expected within 15-45 mins
Insulin Administration
Types Onset Peak DurationRegular (humulin R) 30mins- 1hr 2-4hrs 6-8hrs
Intermediate actingInsulin (NPH,
Humulin N)
2-4hrs 6-8hrs 12-16hrs
Long Acting Insulin
(Ultralente, HumulinU)
4-8hrs 12-16hrs 24-32 hrs
Combination (70/30) 30mins 2-12hrs 24 hrs
Teaching points
y Use the same type and brand of syringe; use the same type and brand of insulin toavoid dosage errors.
y Do not change the order of mixing insulins. Rotate injection sites regularly (keepa chart) to prevent breakdown at injection sites.
y Dosage may vary with activities, stress, diet. Monitor blood or urine glucoselevels, and consult physician if problems arise.
y Store drug in the refrigerator or in a cool place out of direct sunlight; do not freeze
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insulin.
y If refrigeration isn't possible, drug is stable at controlled room temperature lessthan 30 C (86 F) and out of direct sunlight for up to 28 days; do not freeze
insulin.
y Monitor your urine or blood for glucose and ketones as prescribed.
y Wear a medical alert tag stating that you are a diabetic taking insulin so thatemergency medical personnel will take proper care of you.
y Avoid alcohol; serious reactions can occur.y Report fever, sore throat, vomiting, hypoglycemic or hyperglycemic reactions,
rash
Care of Client with hypothyroidism and HyperthyroidismHypothyroidism (Myxedema)
y Monitor HR including rhythmy Diet: Low Calorie, saturated and fat diety Thyroid replacement therapyy Assess constipation and provide roughagey Provide warm environment and monitor overdose of meds
Hyperthyroidism
y Provide cool and quite environmenty Obtain wt daily and high calorie and saturated fat diety Administer anti thyroid meds
Medical Management
1. Prophythiouracil(PTU) block thriod synthesis2. Methimazole (Tapazole) Inhibit synthesis of thyroid hormone3. Lugol Solution Decrease size and vascularity of thyroid gland; Platable if diluted with
water,Milk or juice; give with straw to prevent staining; take 2-4 weeks before the resultare evident.
After Thyroidectomy
y Monitor respiratory distress; have tracheostomy set, oxygen, and suction machine at bedside
y Maintain semi fowlers position to reduce edemay Immobilized head with fellow or sand bag to prevent flexion and hyperextension of the
heady Limit client talking and assess for client hoarsenessy Assess for laryngeal nerve damage= high pitch voice, stridors, dysphagia, dysponia, and
restlessness
y Monitor for sign of hypocalcemia and tetany have Ca gluconate at bed side
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Tuberculosis and leprosy late and early sign
Disease Early Sign Late Sign
Leprosy -Change in skin color eitherreddish or white
-Loss of sensation in the skinlesion
-Loss of sweating and hairgrowth
-Thickened and painful nerves-Muscle weakness or paralysis
in the extremities-Pain and redness on the eye
-Nasal obstruction-Ulcer that do not heal
-Madarosis (loss of eyebrow)-Lagopthalmus (inability to
close the eye)-Clawing of fingers and toes
-Contractures-Chronic ulcer
-Sinking of the nose bridge-Gynecomastia (enlargement
of breast
Tuberculosis -Asymptomatic
-Unexplained wt loss-Night sweat-low grade fever and chills
-weakness or fatigue and lossof appetite
-Cough that last for three
weeks and more-Pain in the chest-Hemoptysis
Acute and Chronic renal failure and Hemodialysis
Pre renal Failure cause Acute Renal Failure cause Chronic Renal Failure cause
-Cardiogenic shock-Hypotension
-Acute vasoconstriction-Burns
-Hemorrhage-Septicemia
-CHF
-Acute tubular Necrosis-DM
-Malignant Hypertension-Acute Glomerulonephritis
-Tumors-Blood transfusion reaction
-Nephrotoxicity
-Calculi-Tumor
-Blood clot-BPH
-Strictures-Trauma
-Anatomic malformation
Acute Renal Failure
Oliguric Phase Diuretic Phase Convalescent Phase
(all electrolyte Increase
because it is retain except Ca)-Hypernatremia
-Hyperkalemia-Hyperphostathemia
-Hypermagnesimia-Hypocalcemia
(All electrolytes is decrease
because its secrete)-Hyponatremia
-Hypokalemia-Hypovolemia
(Normal values)
-Normal urine volume-Increase level of
consciousness-BUN is stable and normal
-May develop CRF
Nursing Care:
1. Monitor Fluid and electrolyte balance2. Monitor alteration in blood volume
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c. Sign of renal infectiond. Importance of long term follow up
Rheumatoid arthritis
Auto immune connective disorder
-Morning stiffness-Range of motion exercises
-Encourage self care: provide privacy and pain relief
-Apply local heat or cold
MEDICATIONS
-Analgesics
-Anti inflammatory drugs
CLIENT EDUCATION
Serious risk gastric ulceration from anti inflammatory drugs
Bells palsy
Bell's palsy is a form of temporary facial paralysis resulting from damage or trauma to one of
the facial nerves.
Bell's palsy is most often connected with a viral infection such as herpes (the virus that causes
cold sores), Epstein-Barr (the virus that causes mono), or influenza (the flu).
-some people may have a headache or feel pain behind or in front of their ears
-person may notice one side of his or her face droops or feels stiff
-Some people may only notice a slight weakness, whereas others may not be able to move that
side of their face at all.
- difficulty closing one eye all the way- dryness in one eye
- trouble tasting at the front of the tongue on the affected side
- changes in the amount of saliva or drooling
- hearing sounds that seem louder than usual in one ear
- It's important to eat well and get lots of sleep when you have Bell's palsy. Good nutrition and
rest will help your body as it heals itself.
- One of the hardest things about having Bell's palsy can be dealing with the emotions that go
with it.
Trigeminal neuralgia
Trigeminal neuralgia causes facial pain.Trigeminal neuralgiadevelops in mid to late life. The
condition is the most frequently occurring of all the nerve pain disorders. The pain, which
comes and goes, feels like bursts of sharp, stabbing, electric-shocks. This pain can last from a
few seconds to a few minutes.
Colon Cancer
Sigmoid colon is the most common site
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Nursing Intervention (Pre-op care)
1. Provide HIGH protein, HIGH calorie and LOW residue diet
2. Provide information about post-op care and stoma care
3. Administer antibiotics 1 day prior
4. Enema or colonic irrigation the evening and the morning of surgery
5. NGT is inserted to prevent distention6. Monitor UO, F and E, Abdomen PE
Nursing Intervention (Post- op care)
1. Monitor for complications
Leakage from the site, prolapsed of stoma, skin irritation and pulmonary complication2. Assess the abdomen for return of peristalsis
3. Assess wound dressing for bleeding
4. Assist patient in ambulation after 24H
5. Provide nutritional teaching
Limit foods that cause gas-formation and odor
Cabbage, beans, eggs, fish, peanuts
Low-fiber diet in the early stage of recovery
6. Instruct to splint the incision and administer pain meds before exercise
7. The stoma is PINKISH to cherry red, slightly edematous with minimal pinkish drainage
8. Manage post-operative complication
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1. Psychiatric Nursing
2. Musculoskeletal
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Level of anxiety and anxiolyticAnxiety- Vague sense of impending doom
Mild Anxiety
+1
-Widened perceptual field-Restlessness-Enhance learning capacity
-You seem Restless
Moderate Anxiety+2
acing
RN meds
Severe Anxiety+3
ont know what to say or to do
irective
Panic Anxiety+4
aftey
uicide
Dont touch the client respiratory alkalosis bown bag
ANTIANXIETY
VLAST ME VAIB
Valium ate V Miltown - Meal Vistaril - largavista
Libreum - L Equanil Aqua Kneel Attarax Mga bato (rocks)
Ativan - Ate Guy Inderal hindi ralph
Seraks Sera Ulo Busfar sasakay ng bus
Tranxene - Transit
SchizophreniaEgo disintegration
Impaired reality perceptionGenetic vulnerability
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Stress Diathesis ModelToo much stress in the reality will lead client to escape it and go to the fantasy world
Biological TheoryDopamine level is High
The exact cause is unknown
ffect appropriate, inappropriate, flat, blunt (incomplete emotion)
mbivalence torn between 2 opposing forcesutism
ssociative Looseness
Symptoms
Negative Positive
Hypoactive Hyperactive
Withdrawn Sociable
Apathy Flight of IdeasTalkative
Assess : Content of ThoughtNx Dx : Disturbed thought process
Planning/ Implementation:Present reality
Provide safetyEvaluation: Improve thought process
Assess : Hallucination/ IllusionsNx Dx : Disturbed sensory perception
Planning/ Implementation:Present reality
Provide safetyEvaluation: Improve sensory perception
Assess : SuspiciousNx Dx : Risk for other directive behavior
Planning/ Implementation:P
resent realityProvide safetyEvaluation: Eliminate/ minimize risk for other-directed violence
Assess : SuicidalNx Dx : Risk for self directive behavior
Planning/ Implementation:
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Present realityProvide safety
Evaluation: Eliminate/ minimize risk for self-directed violence
Catatonic
yAmbivalenceyWaxy FlexibilityoIniwan na posture, ganun forever
yNo favorite wordyNegativism
Paranoid
SuspiciousTendency to be violent
MistrustpScaredpWithdrawnNrsg. Int:Develop trust
1 to 1short interaction
frequent visitfoods in sealed container
meds wrappedfor violent pt.
Doors openNear the door
Dont touch the pt.Eye contact
1 arms length awaycall reinforcement
Depression and anti depressant
ANTIDEPRESSANTSANTSAAVE PPZ
Asendin ascendingNorpramin sabaw ng knorr
Tofranil Tofu
Sinequan nood ng Sine Quan ang titleAnafranil kina Ana PraningAventyl kina Aven Til Midnight tayo
Vivactil Bye Back till next weekElavil Eh love mo ba ako
Prozac Pero saka naPaxil - Taksil
Zoloft mag Solo ka
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Aftey
Elective
ide effect is low
erotonin
euptake
to 4 weeks
nhibitor
PPZ
wo to four weeks
riyclic
nti depressantHigher incidence of side effect Serotonin and epinephrine is affected
ANTSAVE
MAOI- Mono Amine Oxidase Inhibitor
All neurotransmitter affected
Highest Side effects
Avoid tyramine rich food
qmay lead toHYPERTENSIVE CRISES
-
8/8/2019 2010 review readiness
69/75
Thiamine rich food
vocado
ge cheese
eer
hocolate
ermented cheese
ickles
reserved foods
oy sauce
The Grief Process
y Denial no! this cant be truey Anger why me, why me, why now
yB
argaining
if something happens, then Ill give something backy Depression Im down 2 weeks or more s/sx major depressiony Acceptance client acts according to situation
-
8/8/2019 2010 review readiness
70/75
Personality Disorder
SCHIZOID
I dont want peopleBelieves he can stand on his own
Never had a best friend
Avoid groups and social activities
no enjoymentCares more about computers and pets
AVOIDANTI avoid people, I fear criticism
Have talent but no confidence
ANTISOCIALI break the law as motto
As a child,: steal, lie, always get reprimandedAdult grand robbery, illegal activitist against the law, drug addiction, drives fast, unsafe sex,
thrill seekerGood talker, charmer, witty manipulator
BORDERLINE my life is an empty glass
Dependent
I cant live without you
q Self esteemPoor decision making skills
HistrionicExcited, dramatic but manipulativeCenter of attention
Narcissistic
I love myself
Insensitive, arrogant
I am the best
-
8/8/2019 2010 review readiness
71/75
-
8/8/2019 2010 review readiness
72/75
Thought Blocking
Eating Disorder
Anorexia Nervosa Eating Disorders Bulimia
Diet, diet, diet Eating Pattern Eat, eat, vomit
-
8/8/2019 2010 review readiness
73/75
Glaucoma and Cataract
Glaucoma
Increase of intraocular pressure as a result of inadequate drainage of aqueous humor
Types:
Acute close angle Glaucoma-result from obstruction to outflow to aqueous humor
Chronic close angle Glaucoma- follow if untreated attack of acute close GlaucomaChronic Open angle Glaucoma- result from over production or obstruction to outflow of
aqueous humor
Acute Glaucoma-result from rapid onset of intraocular pressure >50-70mmhg
Chronic Glaucoma- a slow gradual onset on IOP>30-50mmhg
Normal IOP= 10-21mmhgHalo Vision
Prepare the client forTRABECULOPLASTY as prescribed
- to facilitate aqueous humor drainage
Prepare client for TRABECULECTOMY as prescribed
- allows drainage of aqueous humor into the conjuctival spaces by the creation of an
opening
Cataract
Opacity of the lensCloudy white pupil or opaque
- Surgical removal of the lens, one eye at a time
- A lens implantation may be performed at the time of surgical procedure
EXTRACAPSULAR EXTRACTION
- The lens is lifted out without removing the lens capsule
- may be performed with Phacoemulsion
PHACOEMULSION- The lens is broken up by ultrasonic vibrations & extracted
INTRACAPSULAR EXTRACTION
- The lens is removed within its capsule through a small incision
PARTIAL IRIDECTOMY
- may be performed with lens extraction to prevent acute secondary glaucoma
Crutches, Cane, and Walkers
Crutches GaitTwo point Gait- Move the right foot with the left crutches at the same time then move the left
foot with right crutches at the same time
Three point Gait (non bearing weight) - move both crutches forward followed by affected legand then unaffected leg.
Four point Gait (Polio and cerebral palsy) move the right crutches forward followed by left
foot and then move the left crutches followed by right foot
-
8/8/2019 2010 review readiness
74/75
Swing to Gait (Paralygic with leg braces) Move both crutches forward and then swing bothlegs into crutches at the same time
Swing through Gait Move both crutches forward and then swing both leg through crutches
Note: Good go to heaven and bad go to hell
Cane
y Hold cane in unaffected hand (good) sidey Move cane and leg at the same timey The cane handle should be held with the elbow flex at 30 degree it should be at the level
of femur
Walkers
y The top of the walker should be at the level same of cane with elbow is flex in 30 degreey Advance 6 inches and move to it
Crutches
y Axillary bars are positioned 1 to 2 inches below the axilla; measure 2 to 3 fingersbelow the axilla folds
y Hand bars are positioned so the elbow are flex in 30 degreesy When lying down measure from anterior axilla to the foot and add two inches to the
measurement
y When standing measure two inches below the anterior axillary folds to the toes; and thentape measure outwards 6 inches away the toes.
Cranial Nerves
-
8/8/2019 2010 review readiness
75/75