4.7.

) ANGINA PECTORIS

ASSESSMENT
Chest pain, lasting 3-5 minutes
Radiates to neck or left arm
Alleviated by nitroglycerin

ANALYSIS
Adequate pain relief?

IMPLEMENTATION
Monitor vital signs, ECG
Monitor for signs of shock
Administer oxygen, nitroglycerin as ordered

CLIENT EDUCATION
Promote diet and lifestyle changes
NITROGLYCERIN SUBLINGUAL:
Protect from light, moisture and heat
Seek immediate help if 3 doses 5 minutes apart do
not lessen pain

Unstable angina: - lasts longer than 15 minutes

- increases in intensity
- occurs at rest

Teach client importance of reducing risk factors:

1. Stop smoking
2. Control blood pressure
3. Lower lipids aggressively
4. Control blood glucose in diabetic patients
 5.5.) PNEUMOTHORAX
Accumulation of air in pleural space collapse of lung

ASSESSMENT
Sudden sharp pain
Shortness of breath
Hypotension, shock
Neck vein distension
Absent breathing sounds over collapsed lung

IMPLEMENTATION
Bed rest
Monitor vital signs
Oxygen as needed
THORACOSTOMY / CHEST TUBES:
Encourage coughing after chest tube is placed
(this facilitates lung expansion)
Watch for air leak (bubbling)
Do not reposition tube
If tube dislodges, cover with gaze and call for help

client

1 = collection bottle
2 = water seal bottle
3 = suction control bottle

COMMON CHEST TUBE PROBLEMS:

air leak continuous bubbling in water seal bottle

kinks in tubing no fluctuations in water seal with inspiration
insufficient suction no bubbling in suction control bottle
 6.1.) ALTERATION IN NUTRITION

Body mass index = weight / height2 (normal is 20~25 kg/m2)

1. convert pound to kg: 1 lb. = 0.453 kg
2. convert feet to meter: 1 ft. = 0.305 m
3. convert inches to meter: 1 in. = 0.025 m

EXAMPLE: Client is 510 tall and weighs 180 lbs.

1. weight (180 lbs.) = 81.5 kg
2. height (5 ft. +10 in.) = 1.525 + 0.25 m = 1.78 m
3. BMI = 81.5 / (1.78 1.78) = 81.5/3.17 = 25.7
client is slightly overweight

MARASMUS (=SEVERE MALNUTRITION)

Watch for electrolyte imbalance
Do not refeed too rapidly !

OBESITY
Yo-yo dieting may be a/w increased risk for coronary artery disease
Surgery (gastroplasty, gastric bypass) only for severe obesity (BMI > 40)

ANOREXIA NERVOSA
Psychotherapy often required
Restore normal eating pattern / caloric intake
Force-feed in life-threatening situations

I look too fat

 10.4.) ANEMIAS

acute blood loss - hematocrit remains normal in acute phase!

chronic blood loss - may lead to iron deficiency

iron deficiency - search for occult bleeding, especially in elderly

Vit. B12 or folic acid - required for RBC maturation in bone marrow
deficiency
Alcoholics:
B12 and folate deficiency common
Pregnancy:
Folate deficiency common: give supplements!

pernicious anemia - chronic gastritis type A (autoimmune disease)

- antibodies against intrinsic factor from stomach
reduced vit. B12 absorption in small bowels

sickle cell anemia - abnormal hemoglobin (electrophoresis)

- sickle cells seen on blood smear
- painful crises, leg ulcers

thalassemias - abnormal hemoglobin (electrophoresis)

- target cells on blood smear

hemolysis - antibodies against RBCs

- fragile RBCs

Blood hemolysis increased serum bilirubin !

 ASSESSMENT
Fatigue
Pale skin and mucosa
ALL ANEMIAS:
Check CBC, blood smear, hematocrit, hemoglobin and iron
APLASTIC ANEMIA:
Low reticulocyte count indicates decreased production of RBCs
THALASSEMIA, SICKLE CELL ANEMIA:
Hemoglobin electrophoresis shows abnormal hemoglobins
PERNICIOUS ANEMIA:
Schilling test: to evaluate vitamin B12 absorption

ANALYSIS
Skin integrity?
Delayed wound healing?
Effective gas exchange?

IMPLEMENTATION
Provide rest periods to avoid fatigue
Assist with blood transfusions
Monitor for transfusion reactions: pruritus, chills, fever, shock

Vitamin B12

parietal cells
IF
(produce intrinsic factor IF)

B12-IF complex is absorbed in the ileum

 12.10.) CARPAL TUNNEL SYNDROME
Compression of median nerve at wrist joint

ASSESSMENT
Pain in wrist or palm of hand
Paresthesias in radial palmar aspect of hand
Weakness of thumb

IMPLEMENTATION
Relief pressure on median nerve:
(hand elevation, splinting of hand and forearm)
Cortisone injections into carpal tunnel

CLIENT EDUCATION
Avoid prolonged flexion of wrist
Teach proper hand position when using computer keyboard

From Ttreault &Ouellette: Orthopedics Made Ridiculously Simple, MedMaster, 2009

Tinel Sign: Tapping on the wrist of the patient (A) triggers tingling and numbness in
the median nerve territory (B, palmar view).
 13.1.) SIGNS & SYMPTOMS

decorticate posture legs extended, arms flexed

- damage above mid brain

decerebrate posture legs and arms extended, wrist pronation

- damage to mid brain

asterixis flapping tremor (wrist joint and fingers)

- liver failure

ataxia reeling, wide gait

- cerebellar disease
- alcoholism

athetosis slow involuntary snakelike movements

(especially face, neck and upper extremities)
- damage to basal ganglia

chorea bursts of rapid, jerky movements

- Huntingtons disease
(chorea plus intellectual decline)
- rheumatic fever

cogwheel rigidity jerking of arm muscles when passively stretched

- cardinal sign of Parkinsons disease
- side-effect of antipsychotic drugs

Gowers sign proximal muscle weakness

- characteristic way to rise from the floor
(Duchennes muscle atrophy)
 13.2.) GLASGOW COMA SCALE
(coma = 7 points or less)

eye opening response 1 point: no response

2 points: to pain
3 points: to speech
4 points: spontaneously

motor response 1 point: no response to pain

2 points: abnormal extension (decerebrate)
3 points: abnormal flexion (decorticate)
4 points: withdraws from pain
5 points: localizes pain
6 points: obeys verbal commands

verbal response 1 point: no response

2 points: incomprehensible sounds
3 points: inappropriate words
4 points: confused
5 points: oriented to time, place and person

THE COMATOSE CLIENT:

ANALYSIS
Effective breathing pattern?
Effective gas exchange?
Effective cardiac output?

IMPLEMENTATION
Maintain open airways
Monitor vital signs frequently
Monitor neurological status frequently
Skin care: turn client frequently
 16.12.) BURNS
EXTENT:

Rule of 9: The body is divided into 11 areas, each representing 9% of surface.

9%

trunk=4*9%

9% 9%

leg = 2*9% 2*9%

DEGREE:

First degree - pink to red

- mild edema

- no scarring

Second degree - pink to red, blanches on pressure

- blister formation
- hair does not pull out easily

- scarring possible

Third degree - reddened areas dont blanch to pressure

- formation of devitalized, leathery tissue
- hair pulls out easily

- scarring expected
 ASSESSMENT
Determine degree
Determine extent
SIGNS OF CO TOXICITY:
Headache, irritability, confusion
Muscular fatigue
Nausea, vomiting
Convulsions, coma, death

EMERGENCY CARE
First aid ABC
Prevent shock
IV fluids to maintain urine output > 0.5 mL/kg/h
Crystalloids: Salt solutions (for example Ringers lactate)
Colloids: Contains large organic molecules (for example albumin)
Treat respiratory distress

ACUTE CARE
NPO for first 24h, assess bowel sounds (paralytic ileus is common)
Monitor ECG (risk of arrhythmia due to electrolyte imbalance)
Watch for signs of infection and sepsis
High-protein, high-calorie diet
WOUND CARE:
Cleanse wounds and change dressing twice daily
Non-viable tissue (eschar) should be removed
Topical antimicrobial creams or ointments
Maintain asepsis!

REHABILITATION
Prevent contractures
Provide counseling

Half of all fire deaths are due to inhalation of smoke and CO.
 17.5.) PRIMARY AMENORRHEA
= Client never menstruated before

Absence of menses by age 16 if secondary sexual characteristics are present.

Absence of menses by age 14 if secondary sexual characteristics are absent.

Turner syndrome XO
(missing X chromosome)

testicular feminization XY, testosterone receptor defect

(genetically male, but fully developed female)

dysgenesis - absence of tubes, uterus, cervix, upper vagina

Stein-Leventhal - infertility
(polycystic ovaries) - hirsutism
- endometrial hyperplasia

imperforate hymen - monthly abdominal pain but no menses

TURNER SYNDROME:

From Zaher: Pathology Made Ridiculously Simple, MedMaster, 2007

Turner syndrome is the most common cause of primary amenorrhea.

 22.1.) THE DIFFICULT CLIENT

CLIENT YOUR BEST RESPONSE

withdrawn - allow client to set pace

- encourage social activities or games

depressed - assess suicide potential

- let client talk about personal problems
- do not leave client alone

suicidal crisis intervention to asses suicide potential:

- ask for intent Are you tired of living?
- previous attempts?
- specific plan?
- social support system?

- make a No-Suicide Contract !

anxious - convey interest and care

- dont force client
- help client identify sources of anxiety
- suggest relaxation techniques

violent - remain calm and in control of the situation

- give client space, avoid sudden movements
- encourage verbal expression of anger
- restrain or seclude if necessary