Adult

Often times patients on traction are viewed as stable clients with expected outcomes.

When getting pt out of bed have open end of chair facing the foot of the bed.

Buck’s traction = knee immobilityRussell traction = femur or lower legDunlap traction = skeletal or skinBryant’s traction = children <3y, <35 lbs with femur fx.

Nephrotic Syndrome leads to proteinuria

Glomerulonephritis leads to hematuria.

RespiratoryRales = CHFRhonchi = pneumoniaWheezes = AsthmaHemoptysis = Lung cancer or TBPleural Pain =Possible PE

Safe suction range: 100-120 mmHg

"The good lung down"

Tympanic membrane: pearl grey = normal.

6L Nasal Cannula is the most you can give, anything above that really doesn’t improve oxygenation.

1L NC = 24% Fi02

2 L = 28%

3 L = 32%

6L = 44% Fi02

Herpes simplex incubation = 2-12 days.

Neuro/Brain

Temporal lobe - hearingFrontal - personality changesOccipital - visualBrain stem - bladder/bowel

Detached retina = floater or sensation of a curtain or veil over the visual fieldMacular degeneration = middle of vision

Cataracts: loss of red reflex.

Down's syndrome: white flecks in the iris

Intraocular Pressure (IOP) = Higher in the morning; have glaucoma patients schedule appts. early in the morning.

Ménière’s disease = tinnitus, vertigo, N/V, sensorineural hearing loss on the involved side.

Posturing:

Decordicate: Flexion (cord problems)

Decerabate: Extention & rotation (brainstem problems, = Bad)

Decorticate posturing: flexion of the upper extremities and the extension of the lower extremities. Also plantar flexion of the feet.

Decerebrate posturing: extension of the upper extremities with internal rotation of upper arms and wrists. The lower extremities extend with some internal rotation noted at knees and feet.

deceberate (brainstem problem)- hands like an "e",

decorticate (cord problem)- hands pulled in toward the cord

Neuroleptic malignant syndrome (NMS) is like S&M:

You get hot (hyperpyrexia)Stiff (increased muscle tone)Sweaty (diaphoresis)

BP, pulse, and respirations go up &You start to drool

AUTONOMIC DYSREFLEXIA-triggered by sustained stimuli at T6 or below.

Vasodialation above injury,(flushed face, increased bp etc)

Vasoconstriction below injury(pale, cool, no sweating.

- S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension

- Place client in sitting position (elevate HOB) first before any other implementation.

Types of partial seizures

Simple partial: symptoms confined to one hemisphereComplex partial: begins in one focal area; spreads to both hemispheres.

Types of generalized seizures

Abscense (petit mal): loss of responsiveness, but continued ability to maintain posture control and not fall.

Myoclonic: movement disorder (not a seizure) Clobic: opposing muscles contract and relax alternately in rhythmic pattern. Tonic: muscles are maintained in continuous contracted state (rigid posture) Tonic-clonic: (grand mal, major motor); violent total body seizure Atonic: drop and fall attack Akinetic: suddenr brief loss of muscle tone or posture.

Oh Oh Oh To Touch And Feel A Girls Vagina And Heaven

CN I: Olfactory – smell test

CN II: Optic – sight

CN III: Ocularmotor – Six-point gaze, PERRLA

CN IV: Trochlear – Six Point Gaze, PERLLA

CN V: Trigeminal – Mastication

CN VI: Abducens – Six Point Gaze, PERRLA

CN VII: Facial – Smile/Scrunch Test.

CN VIII: Acoustic – Hearing Tests

CN IX: Glossalpharangeal – Swallowing/Gag Sensation

CN X: Vagus – Uvula Rise

CN XI: Spinal Accessory – Neck and shoulder shrug

CN XII: Hypoglossal – Tongue movement (Light Tight Dinamite)

Alzheimers Stages

Stage I: Lasts 1-3 years. Memory loss, poor judgment/problem solving/adaptation

Stage II: Lasts 2-10 years. Loss of memory, communication difficulties, psychosis.

Stage III: Loss of all mental abilities and ability to care for self.

Muscle Biopsy confirms muscular dystrophy.

Tactile fremitus: normal = not palpable below 3-4th intercostal.

Echocardiogram = used to assess heart valves.

Erbs point = 3rd L ICS; pulmonic and aortic murmurs are best heard there

Hemophilia = is x-linked. Mother passes disease to son.

SIADH = concentrated urine, dilute plasma, common cause = lung CA

Cardiac

Right-sided heart failure: edema, ascites, and hepatomegaly.

Ventricular gallop: is the earliest sign of heart failure

"O" is the universal donor (remember "o" in donor)

The Heart secretes ANP (atrial natriuretic peptide) a cardiac hormone causing sodium excretion.1. Actions of ANP oppose those of the renin-angiotensin-aldosterone system.2. ANP decreases blood pressure and reduces intravascular blood volume.3. Atrial stretching increases the amount of ANP released.

Parkland Formula

4cc x Kg x % BSA Burned = Total Volume Necessary

1st 8hrs – ½ total volume

2nd 8hrs – ¼ total volume

3rd 8 hrs – ¼ total volumes

Infective Endocarditis: Osler's nodes and splinter hemorrhages.

S1- Systole- heard best at apex- LUB - tricuspid and mitral valves close

S2- Diastole- heard best at base(think top)- DUB - aortic and pulmonic valves close

Ausculate S3 and S4 extra heart sounds by turning pt on the left side and using the bell of stethoscope to listen at apex.

A mitral murmur can best be heard at the apex (bottom) of the heart

Bruit = use the bell side of the stethoscope

S1 = Closing of mitral/tricuspid (AV) valves heard at the beginning of systole and heard best in the mitral region

S2 = Closing of aortic/pulmonic (semi lunar) valves heard best over aortic region at the end of systole

S3 = Ventricular gallop – start of diastole, ventricles filing

S4 = Atrial gallop – end of diastole

Use DISTRACTION method s with toddlers and manic patients only.

On the ECG or EKG:P wave = atrial depolarizationP-R interval = represents atrial,AV node, & Purkinje depolarizationQ wave = septal depolarizationR wave = apical depolarizationS wave = depolarization of lateral wallsQRS complex = spread of excitation through the muscle of the venticlesT wave = venticular repolarization

Menieres Disease = low sodium diet

GI/GU

Yogurt, buttermilk and beets often reduce the smell of colostomies

Ascites management – Albumin, pulls fluid back. Diuretic = removes fluid

Toxic Amonia levels = asterixis (flapping hands)

Most obstructions = small bowel.

Most large bowel obstructions = cancer

Ulcerative colitis: 3-30 stools per day WITH blood and mucus. Pain in LLQ: relieved by defecation.

Crohns disease: NO obvious blood or mucus in stool. Pain: Right lower quadrant pain that is steady or cramping...or pain could be in periumbilical area, tenderness and mass in the RLQ.

Diverticulitis: no corn or popcorn.

Laennec’s Cirrhosis: Related to alcoholism.

Gastric Lavage: preformed before adiminsitration of activated charcol.

A liver that is tender on palpation is suggestive of viral hepatitis.

Acute glomerulonephritis - follows streptococcal infectionEdema - mild, usually around the eyesBlood Pressure - elevatedUrine - dark, tea colored (hematuria), slight/mod proteinuriaBlood - normal serum protein, + ASO titer

Nephrotic Syndrome - usually idiopathicEdema - severe, generalizedUrine - dark, frothy yellow, massive proteinuriaBlood - decreased serum protein, - ASO titer

Endocrine

Abd Ultrasound = Dx for cholecystitis

Beta cells = produce insulin

Pancreatitis = increased Amylase and lipase and glucose levels, decreased serum Ca levels

Myasthenia Gravis: worsens with exercise and improves with rest.Myasthenia Crisis: a positive reaction to Tensilon--will improve symptomsChronic alcohol use is the most common cause of hypoMg, which may result in cardiac arrest

Cholinergic Crisis: caused by excessive medication-stop med. Giving Tensilon will make it worse

Koch/Kock Pouch: is continent, doesn't nec need a drainage bag, use absorbent dressing on it. Drain with catheter Q 3-4.

Paget's disease is characterized by excessive bone destruction, skeletal deformities, and cortical thickening.

Rheumatoid arthritis: Pain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Joints red, hot swollen, boggy, and decreased ROM.

Osteoarthritis: Pain and stiffness occurs during activity. Joints may appear swollen, cool, and bony hard.

Crohns = small intestine

Ulcerative colitis = large intestine

Blurred Vision is indiciative of HyperglycemiaDouble vision is indicative of Hypoglycemia

Risk factors for Legionnaires disease advanced age, immunosuppression, end stage renal disease, and diabetes

Transmission: Contaminated showers

Rheumatoid arthritis: Swan-neck deformity and ulnar deviation.

Pain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Joints red, hot swollen, boggy, and decreased ROM.

Osteoarthritis: Heberden’s and Bouchnard’s nodes

Pain and stiffness occurs during activity. Joints may appear swollen, cool, and bony hard.

Pheochromocytoma: hypersecretion of epi/norepi

- persistent HTN

- increased HR

- hyperglycemia

- diaphoresis

- tremor

- pounding HA

Nursing Considerations: avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor

Addisons vs Cushings

Addisons = up down, down down downCushings= down up up up up

K+/Ca+| BP | Volume | Na+ | Glucose |

Everything else wouldnt be hard to remmenber: moon face, hirsutism, buffalo hump, obesity

Thyroid storm is HOT (hyperthermia)Myxedema coma is COLD (hypothermia)

Graves disease: Their hyper and run their self in the graveConn's disease- retention of sodium and water and over secretion of aldosterone

PARATHYROID PROBLEMShyperparathyroidism= hypercalcemia=hypophosphatemiahypoparathyroidism=hypocalcemia=hyperphosphatemia

Cancer

Yogurt has live cultures- dont give to immunosuppressed pt

Internal radium implant = low residue diet

TNM classification:T=primary growth.1-4 with increasing size; T1s indicates carcinoma in situN=lymph node involvment.0-4 indicates progressively advancing nodal diseaseM=metastasis.1 indicates presence of metastasisStages 0-IV: all cancers divided into 5 stages incorporating size, nodal involvement, and spread

Breast Cancer Risk Factors:

>50 years of age FIRST child born after 30 years of age Grandmother, Mother, Sister has it Personal history of breast cancer

Diabetic Ketoacidosis = don't give K+ until the patient has been hydrated and urine output is adequate.

Menorrhagia – Hypothyroidism

Zollinger-Ellison syndrome = Report promptly to his/her healthcare provider any finding of peptic ulcer (night time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite)

Weber's hearing testIn the Weber tuning fork test, the nurse places the vibrating tuning fork in the middle of the client's head, at the midline of the forehead, or above the upper lip over the teeth. –

- Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear.

- If the client has a conductive hearing loss in one ear, the sound is heard in that ear.

Community Health

Disaster Plan: A way to remember who to remove first is by using ABCA - AmbulatoryB - Bed RiddenC - Critical Care

5 rights of delegationRight taskRight circumstanceRight communication

Right personRight feedback

BioTerrorism Level I - local emergency Level II - regional aid from surrounding counties Level III - local and regional assets are overwhelmed state or federal assistance is needed

Percutaneous Umbilical Blood sampling: ike amniocentesis but cord punctured. Tests for chromosomal anomalies, feta karyotyping, and blood disorders

SPACINGFirst spacing - normal distribution of fluid in the intracellular fluid.Second spacing - an abnormal accumulation of interstitial fluid (edema).Third spacing - Occurs when fluid accumulates in a portion of the body from which it is not easily exchanged with the rest of the ECF - is any fluid not where it is supposed to be (ascites).

Mental Health

Kohlberg’s Theory of Moral Development:

Stage 0 = Egocentric judgement (birth – 2 years), no judgement of right/wrong

Stage 1 = punishment-obedience (2 - 3 years), view the world in a selfish way.

Stage 2 = instrumental relativist (4 – 7 years), conscience emerges

Stage 3 = good boy-nice girl (7 – 10 years), maintainance of friendships

Stage 4 = law and order (10 – 12 years), following rules.

Stage 5 = Social contracts (adolescents), gives and takes and expects nothing in return.

Stage 6 = Universal ethical principles (adult), control of conduct is internal.

Munchausen Syndrome

is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization. In a variation of the disorder, Munchausen by proxy (MSBP), an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care.

Emphysema: Barrel chest, pink color, clubbed fingernails.

Huntington's Chorea:

50% genetic, autosomal dominant disorderS/S: chorea --> writhing, twisting, movements of face, limbs and body-gait deteriorates to no ambulation-no cure, just palliative care

Gout: Avoid beets, milk, eggs

Brown pigmentation around the ankles of patient indicates venous insufficeny

Starve a gastric ulcer, feed a duo ulcer

Rheumatic Fever Signs and SymptomsRheumatic fever is a complication of untreated strep throat, caused by bacteria called Group A Streptococcus. It is potentially life threatening. Since one of the main symptoms of rheumatic fever is pain in the joints, use the word, JOINTS to remember the signs and symptoms.J- Joints are painfulO- Over a long period it can damage the heart I- Infection may be too mild to be recognizedN- Nervous system can be affected leading to choreaT- Throat that is soreS- Swollen joints

The MM band reflects CPK from skeletal muscle. – Elevated in skeletal muscle disease. The MB band reflects CPK from cardiac muscle. The BB band reflects CPK from the brain.

Salem sum tube- turn patient every 2 hours to promote emptying of stomach contents.

Pacemaker spikes on T wave indicate that the pacemaker is not capturing appropriately and should be adjusted for this patient.

A patient who is having muscle spasm while in traction should be repositioned to see if the spasms decrease.

Multiple mylomas=increased immunloglobins expected.

Celiac Disease: Cant have BROW!

B- BARLEY

R- RYE

O- OAT

W- WHEAT

Miller abbott tube is used for decompressing intestine, which relieves the small intestine by removing fluid and gas from small intestine.

Colonoscopy = Left sims position

Thyroid Storm: Abrupt onset CHF, delirum, altered clotting, febrile. Give dig, hydrocortozone and Tylenol.

Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP

Grave disease-hyperthyroidism

Anxiety Irritability Difficulty sleeping Fatigue A rapid or irregular heartbeat A fine tremor of your hands or fingers An increase in perspiration Sensitivity to heat Weight loss, despite normal food intake Brittle hair Enlargement of your thyroid gland (goiter) Change in menstrual cycles Frequent bowel movements

Toxic Shock: Staph A. High fever (102+), diffuse sunburn-like rash, HoTN, orthostatic syncope, dizziness. Desquamation of palms/soles occurs 1-2 weeks after initial onset.

Meningitis = look for nuchal rigidity, Kernigs sign (can't extend knee when hip is flexed) and Brudinskis sign (flex neck and knee flexes too) petichial rash.

Mini Mental Status Exam = Judgement, Orientation, Memory, Affect, Consciousness, Speech

Keratitis is a bacterial or viral infection of the cornea that can lead to corneal ulceration. Photophobia, pain, and tearing are common symptoms.

Infective endocarditis = murmur

Caffine: can precipitate or worsen fibrocystic breast disease.

Acute appendicitis: expect to see pain first then nausea and vomiting.

Gastroenitis: you will see nausea and vomiting first then pain.

Crutch-walking upstairs: Up with the good, down with the bad. Up = good food first.

Cushing's Triad = HTN (widening pulse pressure, systolic rises), Bradycardia, irregular resp

MISC

FAT Soluable Vitamins: ADEK –

A - visual acuity

D – Bone Calcificaiton/Cacium Absorbtion

E – Antioxidant

K – Blood Clotting

Water Soluible:

B1 - Thiamine – for Alcoholic Patients

B6 – amino acid metabolism – for TB Patients

Folic Acid – RBC formation – for Preggo’s

B12 – nerve function – For Pernicious Anemia, Vegitarians.

Full Liquid: anything liquid at room temperature (include oatmeal)

Greek: Bread served w/every meal.

Low-purine diet: NO spinach, poultry, liver, lobster, oysters, peas, fish or oatmeal

Pork is good source of thiamineRed Meat / Turnips / Hoarseradish may give false + for guaiac.

Vit C: May cause false negative for guaiac.

HyperMg+

Bradycardia, Lethargy, Hyperactive DTR’s, HoTN, N/V, Bradynpnea

HypoMg+

Widened QRS, U waves, Tachycardia, Tetany, Chovstek’s/Trosseau’s, Babinski

HYPO Ca+ = “CATS”

C-convulsionsA-arrythmias

T-tetanyS-spasms and stridor (laryingospasm)

HYPER Ca+ = “SCRAM, U”S – SedationC – ConfusionR – Reflexes AbsentA – Abdominal PainM – Muscle WeaknessU – uncoordinated

HYPERkalemia S/Sx = MURDER

M-muscle weaknessU-urine, oliguria, anuriaR-respiratory distressD-decr cardiac contractilityE-ECG changesR- reflexes, hyperreflexia, or flaccid

HYPOkalemia S/Sx = SUCTIONS – skeletal muscle weakness

U – U wave

C – Constipation

T –Toxicity of Dig

I – irregular pulse

O – orthostatis (dizziness)

N – numbness or paresthesia

Hyperkalemia Causes: ‘MACHINE’

Medicationa (ace inhibitors, NSAIDS)

Acidosis (metabolic & repiratory)

Cellular destruction (burns, traumatic injuy)

Hypoaldosteronism, Hemolysis

Nephrons, renal failure

Excretion (impaired)