NCLEX REVIEW

PEDIATRICS - Physiological Integrity

Congenital Heart Defects Cyanotic-right to left shuntAcyanotic-left to right shunt

Ventricular Septal Defects-heart failure & murmur

Ss: scalp sweating & sudden weight gainSurgical Repair: purse-string approach or

patch sewn over the openingVSD – closes before 1 year of age

Coarctation of the Aorta- Narrowing of the aortaSs: bounding pulses

Atrial Septal Defect- an opening bet the right & left atria Left atrium over powers the right atrium

Ss: fatigue & dyspnea upon exertion- surgery before age 5

Patent Ductus Arteriosus- like a traffic jam of bloodSs: heart failure, machinery like murmur Asymptomatic

Pulmonic and Aortic StenosisPulmonic - pulmonic valve located in

the right ventricle- asymptomatic,heart failure- murmur & enlarge heart

Aortic- decrease CO2,murmur & heart failure- opening in the left ventricle

Transposition of Great Vessels- pulmonary artery leaves the left ventricle

& the aorta exits from the right ventricle.

Tetralogy of Fallot- four defects that constitute

pulmonary stenosis,overriding aortaright ventricular hypertrophy, vsd PORV

Ss: skin bluish in color, heart murmur

Rheumatic Fever- cause by beta hemolytic strep infectionss: tachycardia,rash,fever,chest pain migratory large joint pain,chorea & skin nodules.*administer penicillin until age 21

Kawasaki Disease- vasculitis infection of the small vesselsss: dry red cracked lips,rashes arms & legs conjunctivitis,strawberry tongue, peeling skin on the palms & soles of feet high fever, unresponsive to antibiotic,

impaired swallowing,coronaryaneurysmGamma Globulin IV 400mg/kg/day x weight in kgLive attenuated vaccine must delayed-polio,MMR

AsthmaSs: chest tightness & dyspnea,distant breath

sounds,wheezing episodes,fatigue & wetlungs

*theophyllinetoxicitydiarrhea,vomiting,headache

Cystic Fibrosis- is hereditary disorder, lung congestion & Infection

Ss: positive sweat test, bulky greasy stools, meconium ileus,early chronic dry cough deficient in vits. A,D &K fat soluble vits.

Down SyndromeSs: almond shape eyes,short broad neck protruding tongue,low set ears,broad hands w/ simian crease

GERDSs: frequent or persistent cough,heart burn abdominal pain,recurrent aspiration,anemiaMain concern: airway obstruction,fluid and Electrolyte imbalance & apnea

Pyloric StenosisSs: mild vomiting turned into vomiting that shot across the room,palpable mass RUQ, hungry,crying

Hirschprung’s Disease- part of bowel there is no nerve cells,

no peristalsis in the section of the bowelss: constipation,foul smelling ribbon like stool abdominal distention

- diagnosis established until infant is 6-12 months old- 10x more common in girls than boys

Epilepsy- chronic seizure disorder asso. w/

recurrent unprovoked seizures.

Spina Bifida- a congenital malformation of spinal column- many areas of the central nervous system may not develop or function adequately.

Ss: club feet,hip dysplexia,latex allergy or sensitivity

Scoliosis- affects female 10-13 yrs. Old- brace must be worn 16-23 hrs a day,7 days a week from 6 mos to 2 yrs to correct- after surgery flat position, log rolling

ss: assymetrical hemline,unequal leg lengths, morethan 5 degree deviation on scoliometer

Cerebral Palsy- abnormal muscle tone & coordination,spastic movement in one or more extremity, and disturbances in gait & abnormal posture.

*ORTALENIS- click hip dysplasia,head of femur displaced fromacetabulum,unequal leg lenght

ss: fluid volume deficit, altered nutrition,ineffective airway

Reye’s Syndrome

- mild viral infection, ICP Encepalopathy Varicella chicken pox risk to develop Reye’s

Ss: viral URTI,severe vomiting,liver dysfunction, fever, cerebral edema & increased ICP,irritability,

agitation* Avoid aspirin administration w/ viral infection

Bronchiolitis- bronchioles become inflammed- cause by a Respiratory Syncytial Virus RSV- RSV- high affinity for respiratory tract mucosa- prevalence in winter & spring

*Ribavirin – antiviral used to treat bronchiolitis Caused by RSV

VIR meds means antiviral

Ss: wheezing in auscultation

Intussusception- nephrosis of bowel tissue- commonly occurs in male 3 & 5 yrs. old

Ss: vomiting,lethargy,sudden acute abdominal pain, sausage shape abdominal mass,bloody stool or jelly stool

Celiac Disease- poor food absorption esp. gliadin- patient unable to digest gliadin a by product of gluten*Serum anti-gliadin antibody- diagnostic test for

Celiac disease*Gluten Sensitive Eneteropathy- other name

Ss: vomiting,diarrhea pale & watery,abdominal distention,foul smelling stool

Diet: No B.R.O.W, iron supplements,vits ADEKin water soluble

Cleft Lip and Palate

- cleft lip repair at 2 months- cleft palate repair at 2 years

Sickle Cell Disease- cell halfmoon shape, blood O2 decrease- common to African-Americans- cause of anemia- an imbalance bet. Red cell destruction & production- 12 to 20 days RBC life span- avoid overheating during physical activities

Ss: hypoxia, organ dysfunction due to ischemia and infarction,painful episodes

Esophageal Atresia & Tracheoesophageal Fistula- infants do not have meconium because saliva cannot enter the stomach

ss: 3 C’s – coughing, choking & cyanosis

Tonsillitis- inflammation of tonsils, hinders swallowing and breathing

ss: sorethroat,bad breath,mouth breathers snores acute – fever chronic – apneic

Epiglottiditis

Ss: sit upright position lean forward,chin thrust out tongue protruding*Haemophilus Influenza-B Hib- prevention for epiglo- ttiditis

ORTHOPEDICS

FractureSs: swelling,intense pain shortening of extremities and limited mobility

Cast Care

TractionSkeletal traction- buck’s traction,russel

Steinman pin,crutchfield Halo vest,Gardner-wells tongs

Skin traction

Total Joint Replacement

Osteoarthritis

Ss: presents w/ Heberden nodes or Bouchard’s nodes

experiences loss of ROM,occurs in weightbearing joints- ESR,CBC,C-reactive protein det. Accurate

diagnosis- Corticosteroids is not prescribed

Rheumatoid Arthritis

- auto immune disease,membrane aroundjoints inflamed,smaller joints

- cause by virus/bacterial infection- ESR & CBC,C-reactive protein and

Rheumatoid factor,ANA & Antibody test- DMARDS-Disease Modifying Anti Rheu-

Matic Drugs-infliximab (Remicade)Etanercept (Enbrel),methotrexate(rheumatrex)

Ss: weight loss, morning stiffness,blateral swollen &tender joints

Systemic Lupus Erythematosus

- auto immune disease that attack diff. organs of the body

- lab. to det. high levels of antinuclear antibody & Coomb’s test,high level of C-reactive protein

- stress,sunlight exposure,infection can contribute to lupus- NSAIDS,corticosteroids,reduce stress

get plenty of rest & exercise are thetreatments

ss: exacerbation & remissions,mild to extreme fatiguesudden unexplained weight loss, pericarditis,nervous system/mental health problems,hairlossRaynaud’s phenomenon

kinds of Lupus - Discoid Lupus- butterfly rash skinChemically /drug- induced lupus-hydralazine

ProcainamideNeonatal lupus- newborn

Gout- acid crystal build in joints- “TOPI” accumulation of crystals big toe- Over production of uric acid,reduce ability

of kidney to get rid of uric acid- Diabetes, obesity & sickle cell anemia

increase the risk- May cause join deformity & limited

motion- Synovial fluis analysis,joint x-rays, uric

Acid elevated Men-6mg/dl women 5mg/dl- diet low in purines,NSAIDS, cortico-

steroids, clochicine, indomethacinallupurinol,naproxen

Ss: pain is throbbing, crushing, excruciating,warmth, tenderness & redness of joints

Amputations

- elevate on pillow for first 24 hours- prevent hip/knee contractures- limb sock must be worn under the pros-

thesisCrutch Walking

- bear your weight to hands not in armpit- position crutches 4 inches to side &

4 inches to front- Swing-through-gait, three-point-gait, Swing-to-gait are the 3 types of technique- Tripod gait is used when client unable to

walk

Common drugs for Orthopedics

Anti-resorptive agents – ex: CalcitoninBiophosphonates - ex: FosamaxBone forming agents - ex: Flouritab, androgensNSAIDS - ex: Celebrex, MobicAntineoplastic agents - ex: Methotrexate

MATERNAL & CHILD

Physiological AdaptationPsychosocial AdaptationSigns of PregnancyFamily Planning

Antepartum

hCG – biological marker of pregnancyAlpha Fetoprotein- present when the baby amnio-

centesis neural tubal defect

Maternal Hypertension – most common cause of

fetal growth retardationEctopic Pregnancy

- zygote implants outside the cavity- Intra abdominal bleeding is common

cause of ectopic pregnancy.

Ss: sharp localized pain when the cervix is touched during vaginal exam, sudden acute abdominal pain , Keh’r sign – pts. lie down there is a pain

in the tip of shoulderdue to accumulation of fluid in the peritonealcavity,due to rupture of zygote

Methotrexate (Trexall) – treatment a folic acid anta-gonist, inhibits cell growth, allowing the tube to be saved

Laparoscopy – small incision into the tube & removal of embryo

Hyperemesis Gravidarum

- increased BUN & decrease urinary output- ketoacidosis-breakdown of fat stored to

make metabolic needs.- high level of hCG & estrogen

Hydatidiform Mole

- absence of FHTs, grape-like clustersof vesicles, vaginal discharge that maycontain vesicles,uterus enlarge to fast.

- Asian women at risk 45 yrs and above.- hcg should be measured weekly until

normal then rechecked every 2-4 weeksthen every 1 to 2 months for 6 monthsto 1 year

Interventions: surgical removal of neoplasm,monitorring for pre-eclampsia & choriocar-cinoma , hysterectomy

Incompetent Cervix

- cervix dilates prematurely usually occur during 4 mothns of pregnancy

- repeated spontaneous & painless second trimester pregnancy.

Preeclampsia

Ss: suddenweight gain,swollen hands and feet, Headache, and blurred vision, hypertension

Proteinuria,anasarca,Severe if diastolic more than 110, Mild 140/90Weight 2 kilos/weekMagnesium sulfate is the drug of choice and

should be monitored for toxicity doneevery 1-2 hrs.- diminishes neuromuscular transmission,

promotes maternal vasodilation and hasanticonvulsant effect.Diminished deep tendon reflexes sign ofMagnesium sulfate toxicity.

Placenta Previa

- painless vaginal bleeding, low implantation of placenta

Placenta Abruptio

- sharp sudden abdominal pain- premature placental separation\- causes, cocaine use, PIH, manual vacuu

aspiration, abortion procedure,rapiddecompression of the uterus multiparadomestic violence

Premature Labor

- can sometimes be stopped by hydratingthe mother and by treating vaginal & UTI

- Bethamethasone,celestone IM injection to help maturation of the lungs

Labor & DeliveryProlapsed Umbilical Cord

- knee-chest position- c-section immediately- cover umbilical cord with saline bandage

Post Partum

- hydrop’s fetalis a serious hemolyticreaction baby experience severe anemiacardiac decompensation,edema

- Rhogam can give to mother w/ Rh+ baby,After spontaneous or induced abortion,Amniocentesis or chronic villi sampling,Bet 28 & 32 weeks of gestation,RH- withBleeding episodes.

- Serum bilirubin normal values .2 to .6- Golden-colored amniotic fluid is severe

Fetal disease asso. w/ Rh factor- Direct Coomb’s test is done w/ the

motherto measure the number of antibodies inher bloodIndirect Coomb’s test is done on baby it tells if there are any antibodies stuck tothe red blood cells.

Newborn Care

- Ballard scale, a newborn assessmentmaturating scale

- Respiratory Rate 30 to 60 breaths/min with 10 seconds apnea

- Red reflex test serious visual defects isperformed in small dark room looking at the retina there’s a red reflex equally red to roll-out any defects of cornea.

CARDIAC Physiological Integrity

Cardiac RhythmsConduction SystemECG ComplexECG Grid

Lead Placement

Snow over grass- right sideSmoke over fire - left side

Interpreting Rhythm StripsNormal ECGConceptsNormal Sinus RhythmSinus BradycardiaSinus TachycardiaSupraventricular Tachycardia SVTAtrial FibrillationAtrial FlutterPremature Ventricular Contractions PVC’sVenticular TachycardiaVentricular FibrillationAsystoleFirst Degree BlockType 1 Second Degree AV Block

Mobitz 1, WenckebachType 2 Second Degree AV Block

Mobitz 2Third Degree AV Block

Complete hear block

Congestive Heart Failure

Left sided Heart Failure

Ss: blood tinged frothy sputum dyspnea, cough, crackles pulmonary congestion, irritability, anxiety

Right sided Heart Failure

Ss: peripheral edema ascites, nocturia, hepatomegally

Monitoring/testing: BNP & hemodynamic monitoring- Cardiac marker for CHFEchocardiogram & Chest X-rayAllen’s test

Myocardial Infarction

Ss: shortness of breath, crushing pain that radiates to his neck and left arm decrease CO2, increase WBC, increase temp. ST segment depression, T wave inversion,Q

waves

Laboratories/testing:CPK MB, LDH, Troponin q8 hrsCoronary arteriogram & 12 lead EKGMUGA Scan-used to measure heart function bydetermining the ejection fraction, this is thepercentage of blood ejected from the heart w/

each beat

Management:MONA- Morphine-Oxygen-Nitroglycerine-ASAFibrinolytics- are used to dissolved clots &

reduced the size of infarction- must administered 6 hrs post MI- before administered insert 2-3 large bore

peripheral IV’s - monitor for bleeding, neuro vital signs

watch rhythmPTCA- procedures performed on a double

vessel disease.

Anti-embolism stocking- to prevent venous stasisand thrombophlebitis.

Repolarization- ventricles are resting & then fill up with blood

Dressleis Syndrome- combination of pericarditispericardial effusion & constrictive peri-carditis. Immune symptoms reaction

Angina Pectoris

Ss: dull chest pain

Treatment: Beta-blockers & calcium channelBlockers ends with pine

Ex: Procardia (Nifidipine) Norvasc (Amlodipine)

Cardiac Tamponade

Ss: tachycardia & distended neck veinsPallor, cardiac rhythm changes

Treatment: elevate head of bed 60 degrees

Vessel Insufficiency

Chronic arterial InsufficiencyChronic venous insufficiency

Deep Vein Thrombosis DVT

SS: tenderness and warm to touch, increasepain with ambulation,no pulse to the affectedextremity, dull ache in calf, one side swelling,heavy sensationCauses of DVT: CHF,MI,obesity,fractures,sepsisHematological disorder,pregnancy,malignancies,Immobilization

Treatment: Doppler of the lower extremities,Venography- due to any clog artery

Hypertension

Buerger’s Disease

SS: numbness & tingling sensation of the toespale finger tips, weak peripheral pulses,ischemiculcerations, intermittent claudication

Tx & Mngmt: smoking cessation, promotion ofIsometric exercises.

Raynaud’s Phenomenon

SS: hand & fingers turning whiteCauses: smoking & stressPrecautions: over the counter cold remedies such

As Sudafed,clonidine,migraine, meds Contain ergot alkaloids

Endocarditis

Ss: fever, clubbing of fingers, malaise, cardiacmurmurs, anorexia

Tx: prophylaxis,antibiotics,oxygen,anticoagulants,

antipyreticsTypes of Shock

1. Hypovolemic- volume reduction ex: bleeding, burns2. Cardiogenic – unable to circulate ex: dysrythmias,

MI, CHF3. Neurogenic – loss of vasomotor tone ex: spinal cord

Injury, spinal anesthesia4. Septic –dilation of blood vessels ex:gram negative

infection5. Anaphylactic- antigen-antibody reaction ex: transfusion

Reaction,allergies, insect bites.

RESPIRATORY Physiological Adaptation

Thoracentesis- removal of fluid from pleural space 50cc

H2OProcedure: take chest x-ray & vital signs

position the client sitting up over bedside table or lying on unaffected side with HOB at 45 degree tell client not to cough,breathe deeply or move during the procedure

Chest Tubes- reestablish a negative pressure- done when there is a fluid build-up in lung- lung cllapse- spontaneous collapse- Fluctuation will occur when the suction is

working properly- bubbling becomes continous,vigorous or

excessive it means there is an air leak inthe system

- inserted at 2nd ICS at the midclavicularline

Tension Hemothorax- complete collapse of the lung- an be fatal as the accumulating pressure compresses vessels decrease venous return and

decrease cardiac output

Hemothorax – is a collection of blood in the pleural cavityPneumothorax – is a collection of air/gas in the pleural

cavity

Fracture of Sternum/Ribs

Flail Chest – tachycardia,assymetrical, multiple fracture

End expiration – the vent exerts a pressure into the lungs to

to keep alveoli open

Ventilator – improves gas exchange and decreases work of breathing

PEEP Positive in Expiratory Pressure – expands the thorax and realign the ribs, denotes amount of

pressure in the end of expiratory pressure.

BIPAP Bi level Positive airway Pressure - is used often with pulmonary edema but may be done prior to Intubation.

CIPAP Continuous Positive Airway Pressure

Lung sounds - nursing assessment for PEEP,CIPAP,ventilator

Pulmonary Embolism

Ss: shortness of breath, cough & increase heartrate, Hypoxemia, chest pain,hemoptysis, angina

- it can occur when a clients become dehydrated

- clients who have venous stasis

- women who take birth control pills

Laboratories/Test:

D-dimer – a lab. work detects presence of high fibrinclot, thrombus

VQ Scan – ventilation perfusion scan, inject isotopeto measure

ABG

TX: oxygen, heparin or Coumadin warfarin, thrombolytics

Surgically placed filter in vena cava.

Chronic Obstructive Airway Disease

Ss: cough & sputum production

Lab/Test: chest x-ray, chest CT, pulmonary functionTests, ABG

Blue- patients suffering from chronic bronchitisPink – patients suffering from emphysema

Tx: bronchodilators,theophylline,inhaled/intravenous/oral steroids, & antibiotic.

Emphysema

- it destroys alveoli- it narrows & collapses small airways- it causes the lungs to lose elasticity

Tx: high in carbohydrates, increase fluid intake

As alveolar wall dies, there is less surface for gasexchange

Asthma

Types of asthma:1. Emotional – cause by person

2. Extrinsic – caused by dust,mold,pets3. Intrinsic – common cold, allergens4. Mediated

PneumoniaTuberculosis

Endotracheal Tube

Goal: to position the end of ETT 2 cm above the bifurca-

-tion of the lungs or the carina

Special Double Lumen ETT – have been developed for lung -and other intrathoracic surgery -this tubes allow one lung ventilation while the -other lung can be collapsed to make surgery -easier. -ETT with a suction port are proven to decrease - the amount of bacteria which could possibly -grow in the secretions

Acute Respiratory Distress Syndrome

-alveolar spaces are filled with fluid-prone position, it makes more alveoli accessible

-ABG indicators if ARDS is improving.

NEUROLOGY – Physiological Integrity

Neurological Assessment

Frontal Lobe- damage, changes in behavior

Neurological assessment:Mental Status- most important indicatorPupillary changes- 2-6mm normal pupilMotor strength & coordinationCorneal assessmentVital Signs- widening pulse pressure when there is

Increase ICPMovement- is the lowest move, speech is the highest

level of brain neuro function

Noxious Stimuli Reaction- the client will pull away from pain

Stimuli used:sternal rub,supraorbital pressure,nailbedpressure, trapezius squeeze

Oculocephalic Reflex test (doll’s eye reflex) & Oculovestibular Reflex test (Ice waterCaloric test)– performed assessing Brain Stem Function

Babinski Reflex – stroked on the lateral part of foot of an infant

under 1 year old + is ok, - is bad over 1 year old + is bad, - is ok

Negative- curled downPositive – curled up

Reflex table – 0 = absent1+ = present,diminished2+ = normal3+ = increase but not necessarily

pathologic4+ = hyperactive

Computed Tomography CT Scan- identify certain lesions- takes pictures in slices- he will need to take his head still- consent due to the dye

Magnetic Resonance Imaging MRI

- identifies abnormalities in soft tissue- using a magnet last to 1hour- client must void prior to exam- clients w/ claustrophobia cannot receive

this exam- clients can talk & hear during the scan- client will hear a thumping sound

Cerebral Angiography

- catheter inserted w/ a dye to the brain- consent due to the dye- metallic taste in mouth- warm sensation during the procedure- clients well hydrated during the

procedure.Complications:

- risk of embolus- check for pulse, hematoma & change in

LOC- 12-24 hours of bed rest

Myelogram- is an x-ray of spinal & sub arachnoid

space- air & water base- NPO 8-12 hours- Does not require a heavy sedative- Dye is injected to sub arachnoid space- Trendelenburg position for Air - 30 to 50 degrees for water- Must be flat in 6-8 hrs.

After procedure observe for the Signs:

Stiff neck & chillsBrudzinski’s sign- when neck is flexed your knee & hips is

also flexed.Kernig’s sign- flex the knee the opposite leg cannot extendPhotophobia & headache

Electroencephalogram EEG

- diagnose seizure disorder- records the electrical activity of the brain- helps in screening for a coma- 3 flat EEG reading indicate brain death

Nursing care:

- put patient in dim light & quiet room- no caffeine alter the results- no sedatives 2-3days prior alter the result

hold sedatives

Pre-procedures:- medicated w/ a mild sedative- may have not caffeine- eat a light breakfast- we may flashlights in the face

Lumbar Puncture

- performed when patient is on unexplained fever and elevated WBC

- invasive procedure- punctured site is 3rd & 4th lumbar sub-

arachnoid space- knee chest position, fetal position lie on

right side- 4-8 hours flat on bed to prevent spinal

Headache, post procedure- Fluid &blood patch- pull out blood use it &

inject at pain area- Normal CSF- clear, no RBC- Abnormal CSF- cloudy, increase protein,

& WBCPerformed when: check for blood, measure pressures,admi-

-nister drugs intrathecally.

Brain Herniation

- cause a sudden decrease of ICP- the brain tissue is pulled down through

theforamen magnum

Epidural Hematoma

- arterial bleed- gain & lost of consciousness for minutes- pts. See stars

Tx: burr holes,remove the clot and control ICP

Subdural Hematoma- venous bleed

Acute & fast – s/s bet. 24 to 72 hours after slow bleed, non- acute bleed

Tx: remove clot to control ICPSub-acute - s/s bet 72 to 2 weeks w/ rapidChronic

Scalp Laceration- infections is the problem

Skull Injury

- may or may not damage the brain

ss: Battle sign-bleeding over the mastoidRacoon eyes-peiorbital bruisingCerebrospinal rhinorrhea

Basal skull fracture- bleeding from eyes, ears, nose, throatfracture at the base of the skull

Open fracture – dura is tornDepressed fracture – is usually require surgery

Concussion

Ss: headache, dizziness, seeing spotsdiff. waking up or speaking, confusion, severe

headache & vomittingContusion

- the brain is bruised w/ a possible surface hemorrhage

Alzheimers- progressive disease, irreversible, loss of cerebral function due to cornical atrophy- begins 40 to 65 y.o. , 8 to 10 years onset to death

Early stage- memory loss, subtles personality,diff of abstract

thinkingMiddle stage- language is impaired, difficulty w/ motor

activity Final Stage- complete loss of languageRohin’s stage- loss of bowel & bladder control

Ss: progressive decline in recent & remote, aphasia,agnosia cannot recognized memory, cannot learn new things, recall, recognized information

Nsg. Management: promote clients independencePromote contact with realityEstablish a routine

J- impaired judgement, inappropriateO- orientation confusedC- confabulation, inventing stories, defense mechanismA- affectM- mentally impaired

Parkinson’s Disease

- decreased production of dopamine

ss: mask-like facial expression, fatigue, stiffness, rigidity & diff. rising from sitting position TRAP- tremors,rigidity,akinesia,poor balance

Lab/test: EEG,MRI,CT Scan

Tx: levodopa, anticholinergics (akineton), antihistamines

-lessened rigidity & tremor

Laminectomy

- excision of vertebral arc, herniated disc- nurse must assess for circulation &

motor sensory checks, dressing, bowel& bladder function

Cervical Laminectomy- level of consciousnessLumbar laminectomy- circulation, motor, 5 p’s, pulse,pallor

Amyoptrophic Lateral Sclerosis LOU GEHRIG’SDisease

- the brain is fine but the body deteriorates- is a degeneration of upper & lower

neurons

ss: mildly clumsy, weakness of upper & lower extremitiesatrophy of the muscle & extremities, trunk

Tx: muscle relaxants for spasticity, speech theraphyMultiple Sclerosis

- 3rd leading causes of death in the US- Destruction of myelin sheath of the brain- Demyelination of white matter

throughoutthe brain and spinal cord

Motor- weakness, paralysis,spasticity, gait disturbancesCranial nerve – blurred vision,dysphagia, diplopia, facial

NumbnessCerebellar – dysarthria, tremor, incoordination, ataxia,

vertigoSensory – paresthesias,decrease proprioceptionCognitive – decrease ST memory, difficulty w/ new

information word finding difficulty, short attention span

Tx: lumbar puncture, MRI, evoked potentials or response

ACTH Adrenocorticotrophic hormone, physical theraphy , occupational theraphy, encourage exerci-se

Glasgow Coma Scale- measures level of consciousness- involves 3 responses, eye opening, verbal

response, best motor response

Coma – is defined as, not opening eyes, not obeying commands, not uttering understandable words

Coma clients is 90% less than or equal 8

8 is the critical score8 at 6 hours, 50% die> 9 not in coma9-11 moderate severity> 12 is a minor injury

Cerebrovascular Accident Stroke

Risk Factor: uncontrolled hypertensionSmoking & obesityIncreased blood cholesterolChronic atrial fibrillationAfrican-american males over 65 y.o.

Transient ischemic attack- double vision, left side of the body paralyzed

2 types of stroke:

Hemorrhagic stroke – blood vessel rupture with bleeding into the brain, hypertensive & older patients

Ischemic stroke – slower onset, caused by cerebral embolism,atherosclesrosis

Subarachnoid hemorrhage- cause by a rupture of intra-

Cranial aneurysmEpidural bleed- artery is involvedSubdural bleed – vein I sinvolved

Guillain Barre Syndrome- last for 6 months- need mechanical ventilation- require intubation- recovery period for few weeks or few

years

Ss: rubbery legs, weakness progressive upward over a period of two days, arms & facial muscles have been affected

Myasthenia Gravis

- problem in neurotransmitter, myelin sheath is intact, but decrease acetylcholine production

ss: drooping of eyelid, speech and swallowing disorder, blurred vision, sensation remained intact

Head InjuryIntracranial Pressure ICPSpinal Cord Injury

PSYCHIATRY – Psychosocial Integrity

DepressionAnxietyManiaPost Traumatic Stress DisorderSchizopreniaSuicideParanoiaPanic DisorderPhobiaHallucinationsPersonality DisorderObssesive-Compulsive DisorderDissociative DisordersAlcoholismAnorexiaBulimiaElectro-Convulsive Therapy ECTAntidepressantsAntipsychoticsAnticonvulsants

ENDOCRINE

Hyperthyroid Graves DiseaseHypothyroid MyxedemaParathyroid ProblemsCushing’s DiseaseDiabetes

ONCOLOGY

Lung CancerLaryngeal CancerBladder CancerStomach CancerCervical CancerUterine CancerBreast cancerColorectal cancerProstate cancerBranchytherapy Internal RadiationTeletheraphy & Beam Radiation External RadiatiChemotherapy

GASTROINTESTINAL – Physiological Adaptation

PancreatitisSs: severe abdominal pain RUQ, rigid

abdomen,bruising around umbilical or flank area, ascitis, abdominaldistention

-worsen after eating & lying flat-decrease hemoglobin & hematocrit-alcohol consumption is the number one cause-no morphine can cause spasm of odi spinchter-give calcium supplements

Fecal occult blood- blue litmus paper signs of bleeding

Medicines: Zantac – decrease acid productions,H2 anta-

gonist Antacids – counteracts stomach acidity Protonix – decrease gastric acids,privacid

nexium Carafate- barriers of acid

Cirrhosis-liver cells necrotic, destroyed & replaced by scar

tissue-increase ammonia level, fiteb breath, bleeding

tenden- cies,-risk for esophageal varices & portal hypertension-increase bilirubin in urine & increase SGOT & SGPT-decrease serum albumin & cholesterol-impaired aldosterone metabolism results to edema-providing thiamine & B12-bleeding precautions, avoid Im injections & aspirin-measure abdominal girth-do not give narcotics-diet must be low in protein & sodium

LV Shunt- remove fluids in peritoneal cavity

Ss: abdominal pain, jaundice, anemia, ascitis, clay colored stool, splenomegally, chronic dyspepsia,firm & nodular liver

Diverticulitis-small inflamed protruding sacs in the colon that have ruptured-causes impacted stools, history of constipation, Low fiber & high carbohydrates

ss: left lower quadrant pain,chills,fever,nausea andvomiting

Hepatic Coma-is diagnosed by examining the serum ammonia level-prescribed lactulose (Cephulac) & Neomycin SO4-decrease protein in the diet,monitor serum ammonia

level-recommend cleansing enema

Ss: confusion & delusion,motor changes,difficult toAwake,asterixis flapping tremor,fetor hepaticus

Musty odor, increase ammonia level

Bleeding Esophageal Varices-liver is damage and that collateral circulation has

formed into 2 of 3 places are rectum,stomach& esophagus

-portal hypertension, increase blood in the liver-coughing & straining can cause rupture of the

Varices-Sandostatin-works to lower the BP in the liver-Sengstaken Blakemore tube in the bed side-administer oxygen

Ss: black tarry stools,paleness,lightheadedness

Ulcerative Colitis-inflammation of ascending colon & rectum-condition affecting the large intestine-low fiber diet to limit motility-avoid meals that are cold-steroids to decrease the inflammation

Ss: rectal bleeding,diarrhea,bloody or mucosy stoolfever & loss of appetite,constipation,weight lossanemia,rebound tenderness

test: colonoscopy,barium enema,sigmoidoscopyCBC

Schilling Test- to test Vit. B 12 in urine

Koch’s pouch- ileostomy, there is internal reservoir(stoma & bag)

Colostomy- permanent stoma is red/pink - irrigate sametime everyday after meal

Ileostomy - temporary don’t irrigate as much- no raw vegestables,nuts,grains & peas

Chron’s Disease-iflammation or ulceration of digestive tract,chronic & relapsing

ss: blood in stool,rebound tenderness,cramping & dehydration,anemia,diarrhea w/ steatorrhea,cramping after meals,abdominal pain,vomiting& fever

Partial Bowel Resection – to allow the intestine to rest and heal

Transvers- semi-soft stoolDescending – formed stoolAscending – liquid stool

Appendicitis

-associated w/ diet low in fiber-elevate head of bed after any abdominal surgery

Ss: increased WBC,sharp pain on right side,nausea &Vomiting,rebound tenderness

Ulcers-pain that is worsenes w/ food-pain & burning worsend at night & lying down-mainly found in males-can be found in the stomach,esophagus,duodenum-avoid spicy foods & caffeine,stop smoking-avoid extreme temp hot or cold

Gastric ulcer-pain 30 mis. to 1 hour after eating mealwhen vomit the pain subsides.

Duodenal ulcers- pain 2 to 3 hrs. after eatingas long there is food in stomachtheres no pain

Gastrectomy- give vit B12 for lifeBillroth I – portion of stomach connect to duodenumBillroth II – large potion of stomach connect to

duodenum

Peritonitis-board like abdomen,low urine output,,nausea & vomiting

Dumping Syndrome-increase circulation of stomach-give complex carbohydrate,avoid simple carbohydrates, high fiber-is more common in Billroth II-recumbent position, drink bet meals-lie left side after meals,eat high fat & protein-decrease stress

Ss: cramping,diarrhea,weakness

Hiatal Hernia-the hole in the diaphragm is too large,the stomach

moves up into the thoracic cavity-small protrusion close to the navel-causes, congenital abnormality,trauma,surgery-small frequent meals,elevate head of bed,take small

bites,avoid spicy foods

Ss: abdominal mass soft can be palpate w/ out pain,fullness after eating & regurgitation

Hyperalimentation TPN

-need to change the tubing with each bag every 24 hours

-can be hung for 24 hours-taper off TPN when discontinuing-needs to be check by 2 nurses before each bag is

hung-put in pump-other medications cannot be infused, only insulin,

Lipids, K+-can be mixed daily-IV bag should never be covered-infection can be frequent complication

Laboratory values to be monitored:

Blood glucose,ketones,BMP,magnesium

Dobhoff Tube-a small bore NG feeding tube not attached to suction-more comfortable & less complications-can remain place for weeks

Central Line

-have client in trendelenburg-rolled towel to middle of back-air from getting in the line,clamp it off-cap the end of tubing,cover the end w/ syringe-position the patient on the left side in case air

will get into the line-post insertion chest xray performed to ensure

proper placement-10ml syringe use in central line

Diagnostic Tests

Barium Enema-drink clear liquids-take laxatives or enemas until clear-ensure post procedure bowel movement

Liver Biopsy-PT/INR,PTT prior to procedure-position pt supine w/ hand behind head-have client lie on affected side for 8 hours

post procedure

Paracentecis-have pt. sit in high fowlers position-have pt. empty his bladder prior to procedure-the fluid removed will be yellow-monitored for signs of shock

GENITOURINARY – Physiological Adaptation

Benign Prostatic Hyperplasia-frequent waking at night to urinate-urination

-serum PSA & urinalysis-PSA secreted by pituitary gland

Medicines:Prazosin (minipress) – helps the urination urgencyDoxazosin (Cardura) – helps the symptoms of BPH

Prostatectomy- normal to pass urine in blood tinged &blood clots & tissue debris

Percutaneous Renal Biopsy-instruct the pt to restrict food & fluids for 8 hrs

before the test-administer mild sedatives 30 to 1 hour before

procedure-check vital & inform pt. to void before procedure-place pt in prone position-observe for bleeding & hypotension

Nephrotic Syndrome-leaking of the protein into the urine-perform U/A,glucose tolerance,serum protein,

Serum albumin,renal biopsy-edema,swelling around eyes,extremities & abdomen-circulating blood volume decrease causing kidney toactivate its Renin Angiotensin cascade,aldosteroneis produce to retain sodium & H2O-Corticosteroids,prednisone & Diuretics drug of choice

Acute Glomerulonephritis-sorethroat,headache & lower back pain-protein in the urine,increase BUN & creatinine,

hematuria & hypertension-strep infection is the main cause-common bet age 6 to 7 yrs. old-antibiotics,bedrest & increase carbohydrates in diet-decrease protein & sodium in the diet and dialysis-reddish brown urine

Renal Failure-sudden loss of kidney function resulting in electrolyte

imbalance 7 retention of nitrogenous substance-during oliguric phase the patient is in a fluid volume

excess-diet should be in high carbohydrates-low protein,sodium,potassium & phosphorous

Urinary Tract Infection-fluids morethan 3,000 ml, acid ash diet-avoid coffee & tea-Medicines: Ofloxacin (Floxin)

Nitrofurantoin (Macrodantin), Pyridium Cotrimoxazole (Bactrim)

Hemodialysis-access route are: External AV shunt,fistula,femoral/

Subclavian cannulation-fistula access 3 months to mature-must be done 3-4 times a week-during treatment period monitor for: depression,

suicidal tendencies,electrolytes & BP-bruit & thrill must be assessed before accessing

hemodialysis access ports-cathflo must be used if pt allergic to heparin-decrease protein, sodium & potassium in the diet-pt. w/ unstable cardiovascular system cant tolerate hemodialysis

Peritoneal Dialysis-ambulatory-dialysate is warm to increase blood flow-patients who get peritoneal dialysis cannot tolerate hemodialysis-possible complications are: peritonitis,respi. Diff.

protein loss-cloudy drainage,there is an infection, it should be

pinktinged color

-if the fluid does not come out, turn the pt side to side

Intravenous Pyelogram-NPO 8 hrs before the test

-sitting straight up during procedure-after procedure, increase fluids,apply warm soaks if

hematoma develops

Cystoscopy-involves a lighted scope which is used to visualize the

bladder-consent, anesthesia, a sedative and enema can be

used-used to diagnosed & evaluate urinary tract disorder,

enlarged prostate,recurrent bladder infection-notify doctor if there is still blood in the urine after

3 days -expect burning on urination

Ultrafiltration-only pulls off water-has the same principles applied as hemodialysis-may be utilized w/ peritoneal dialysis or hemodialysis

Kidney Stones Renal Calculi-KUB & IVP-increase fluid intake and modify his diet,avoid high

contain of calcium & oxalate-strain his urine

Calcium Oxalate: beer,rhubarb and wheat germ, spinach

chocolateCalcium Phosphate: milk & milk products, foods high

incalcium, meats, grains &

cranberryUric Acid: avoid Vit C supplements, corn & lentils

EXtracorporeal shock wave lithotripsy (ESWL)

Pelvic Inflammatory Disease-history of menses,sexual habits, contraceptives

Used

-look for signs of hypovolemia,hypotension & fever

-Medicines: Quinolones,cephalosporins & tetra--cyclines, penicillins

Continous Ambulatory Peritoneal Dialysis CAPD-increase protein & fiber in the diet-ambulatory walking around w/ peritoneal dialysis

going on-complications: hernia, peritonitis, low back pain,

nausea

Continous Renal Replacement Therapy CRRT-little bit longer than hemodialysis-is less aggressive-has only 80ml of blood in the machine at any

giventime

Hemoglobin: male 13-18

Hematocrit: 42-52%

Urine Specific gravity: 1.005-1.029