2010 review readiness

8/8/2019 2010 review readiness

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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


-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).


- 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.


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


high fever

(38.5C or above).


- 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


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


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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


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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


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Thought Blocking

Eating Disorder

Anorexia Nervosa Eating Disorders Bulimia

Diet, diet, diet Eating Pattern Eat, eat, vomit


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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


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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


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2010 review readiness

Documents

Transcript of 2010 review readiness