0

Pg 1. Index
Pg 3. Lab values
Pg 7. Medications
Pg. 7 Anticholinergics
Pg. 7 GI meds
Pg. 8 Tuberculosis meds
Pg. 8 Antiviral meds
Pg. 8 Antipsychotics
Pg. 9 Antidepressants
Pg. 9 Stimulants (for ADHD)
Pg. 10 Bedwetting/nocturnal enuresis meds
Pg. 10 Lithium
Pg. 10 Anticonvulsants
Pg. 11 Respiratory Meds
Pg. 11 Bisphosphonates
Pg. 11 Alpha Adrenergic Blockers
Pg. 12 Antifungals
Pg. 12 Antibiotics
Pg. 13 Smoking Cessation meds
Pg. 13 Alcohol Cessation meds
Pg. 14 Magnesium sulfate
Pg. 14 Antihypertensives
Pg. 15 Muscle Relaxants
Pg. 15 Diabetic meds
Pg. 16 Antithyroid
Pg. 16 Antianxiety
Pg. 17 Opioids
Pg. 17 NSAID’s
Pg. 18 Neuropathic pain relievers
Pg. 18 Corticosteroids
Pg. 18 Antineoplastic/Anticancer
Pg. 19 Immunosuppressive meds
Pg. 19 Diuretics
Pg. 20 Electrolyte and CBC meds
Pg. 20 H1 Receptor Blocker/Antihistamines
Pg. 21 Anesthetics
Pg. 21 Tocolytics
Pg. 21 Uterotonic meds
Pg. 21 Phosphodiesterase Inhibitors
Pg. 21 Anticoagulants
Pg. 22 Thrombolytics
Pg. 22 Statins
Pg. 23 Fibrates
Pg. 23 Vitamins
Pg. 23 Anti-Parkinson meds
Pg. 23 Oral Poisoning meds
Pg. 23-25 All other meds
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Pg 26. Viruses/STD/Skin Conditions/Vaccinations

Pg. 33 Med-surg Pg. 88 Maternity
Pg. 33 Fluid & Electrolyte Disorders Pg. 88. Physiological Changes I Pregnancy
Pg. 34 Burns Pg. 89 Tests
Pg. 35 Cardiac/Heart Pg. 89 Weeks
Pg. 38 Respiratory Pg. 90 Pregnancy Complications
Pg. 41 Gastrointestinal (GI) Pg. 91 Fetal Movement
Pg. 45 Thyroid Pg. 92 Phases/Stages of Labor
Pg. 46 Gallbladder Pg. 92 Labor Info
Pg. 47 Renal/Kidney and Adrenal Glands Pg. 93 Labor Medications
Pg. 49 Bladder/Urinary/Pelvic Pg. 93 Labor Complications
Pg. 51 Musculoskeletal Pg. 94 Other Complications
Pg. 56 Blood and Circulation Pg. 95 Postpartum Assessment
Pg. 59 Sugar/Diabetes Pg. 96 Postpartum Complications
Pg. 60 Alcohol and drugs Pg. 96 Newborn Assessment
Pg. 61 Liver and spleen Pg. 98 Newborn Defects
Pg. 63 Wound Care Pg. 99 Infant (till 1 years old)
Pg. 64 Neuro Pg 101 Pediatrics
Pg. 68 Tubes and ventilators
Pg. 101 Growth and Development
Pg. 70 Cancer
Pg. 101 Congenital Heart Diseases
Pg. 72 Catheters
Pg. 102 Congenital Anomaly
Pg. 73 Shock
Pg. 104 Acute Conditions- Gastrointestinal
Pg. 74 Allergy
Pg. 104 Acute Conditions- Urinary
Pg. 74 Anemia
Pg. 105 Acute Conditions- Respiratory
Pg. 75 Contraceptive
Pg. 105 Acute Conditions-Neurosensory
Pg. 76 Eyes and ears
Pg. 106 Acute Conditions-Neoplastic
Pg. 77 Other Diseases
Pg. 106 Infectious Disorders
Pg. 80 Psych Pg. 107 Communicable Diseases
Pg. 80. Phobias Pg. 108 Chronic Disorders- Gastrointestinal
Pg. 80. Stress disorders Pg. 108 Chronic Disorders- Respiratory
Pg. 80. Schizophrenia Pg. 108 Chronic Disorders- Hematological
Pg. 82. Depressive disorders Disorders
Pg. 82. Bipolar Disorders Pg. 109 Chronic Disorders- Musculoskeletal
Pg. 83 Delirium/Dementia/Alzheimer’s Disorders
Pg. 84 Childhood disorders Pg. 109 Other
Pg. 84 Personality Disorders Pg 112 Non medical
Pg. 85 Eating Disorders
Pg. 86 Restraints
Pg. 86 Other
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LAB VALUES NOTES

VITALS
Blood Pressure (120-140)/ (80-90)
Pulse/Heart Rate 60-100
Temperature 97.7-99 F (36.6-37.2 C)
Pulse Oximetry 95-100%
Capillary Refill < 3 seconds

ABG (Arterial Blood Gas)

Ph 7.35-7.45
Po2 80-100 MM Hg
pCO2 35-45 mm Hg
HCO3 22-26

CBC
White Blood Count (WBC) 4,000-11,000
Platelets 150,000-400,000
Absolute Neutrophil Count (ANC) 2200-7700
• Neutropenia is when it drops below 1000. If it is below 500 it is severe neutropenia and is a
critical emergency.
Eosinophil 1-2%
Leukocyte 4000-11000
• Leukopenia is < 4000

LABS
Albumin 3.5-5 g/dL
BUN 6-20
Creatinine 0.6-1.3
Hgh male 13.2-17.3 female 11.7-15.5
Alanine Aminotransferase (ALT) 10-40 U/L (0.17-0.68)
Urine Specific Gravity 1.003-1.030
Erythrocyte Sedimentation Rate (ESR) <30mm/hr
Cerebral Spinal Fluid (CSF) pressure 60-150mm H2O
C-Reactive Protein (CRP)-means something is inflamed

OTHER
BMI 18.5-24.9 is normal
Normal urine output is 0.5-1mL/kg/hr or > 30mL/hr
CD4 count 500-1200
Glasgow coma scale –normal is 15
4

Deep Tendon Reflexes (DTR)- normal is 2+

TSH (Thyroid Stimulating Hormone- 0.4-4.2
• T3 70-204
• T4 0.8-2.7

HEART
Fasting total cholesterol <200
LDL (low Density Lipoproteins)<150mg
HDL (High Density Lipoprotein) >40mg
Mean Arterial Pressure (MAP) 70-105
• MAP= (SBP +(2 X DBP))/3
• SBP= systolic blood pressure and DBP=diastolic blood pressure
Troponin- indicator of myocardial infarction
CK-MB- indicator of myocardial infarction
D-Dimer- indicated pulmonary embolism
BNP >100-if more than 100-it indicates heart failure
Cardiac Output 4-8
Central Venous Pressure (CVP) 2-8mm hg
Pulmonary Venous Wedge Pressure (PAWP) 6-12 mm hg
Pulsus Paradoxus –exaggerated fall in systemic blood pressure of >10, during inspiration

BLEEDING AND CLOTTING

aPTT-Activated Partial Thromboplastin Time
• Done while on Heparin
• Therapeutic level on Heparin 46-70 seconds (1.5-2 times the baseline value)
• If it is high-spontaneous bleeding could occur
• It is the newer version of PTT

PT-Prothrombin Time
• Done while on Warfarin
• Therapeutic Range is 11-16 seconds

INR-International Normalized Ratio

• Done while on Warfarin
• Tells you how fast the blood is clotting
• If it is high, it means that it takes a long time to clot so the patient can bleed out
• If it is low, it means that it its slow so clots can form
• Affected by: Antibiotics
• Therapeutic level of Warfarin is 2-3

GLUCOSE/DIABETIC
• Fasting Glucose 70-100mg/dL
5

• The target blood pressure for a patient with diabetes is < 140/90mm Hg
• The goal HbA1c (Hemoglobin A1C) for a diabetic patient is < 7% and 4-6% for a non-diabetic. The
HbA1c tells you the glycemic control over the past 3 months.
• For a critically ill patient or someone receiving nutrition support like TPN-you want the glucose to
be 140-160 and hypoglycemia occurs when the glucose drops to less than 70

ELECTROLYTES
Sodium 135-145
Calcium 9-10.5
Phosphorus 2.5-4.5
Potassium 3.5-5
Magnesium 1.5-2.5

INFANT (0-1yr)
Wet diapers 6-10/day, or 1 every 4hrs
Infants urinary output - 2 mL/kg/hr
Newborn head circumference 12.5-14.5 in (32-37 cm)
Pulse/Heart rate 100-160
Respiratory Rate- 30-60/min
Hemoglobin 12.5-20.5 g/dL
Temperature Range 97.7-99.7F (36.5-37.6 C)
Blood Glucose 40-60 mg/dL within the first 24 hours after delivery

6 RIGHTS OF DRUG ADMINISTRATION

Right Patient
Right Drug
Right Dose
Right TIME
Right Documentation

CRANIAL NERVES
1. I Olfactory (Smell)
2. II Optic (Sight)
3. III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)
4. IV Trochlear (Moves eyeballs)
5. V Trigeminal (Facial muscles incl. chewing; Facial sensations)
6. VI Abducens (Moves eyeballs)
7. VII Facial (Taste, tears, saliva, facial expressions)
8. VIII Vestibulocochlear (Auditory)
9. IX Glossopharyngeal (Swallowing, saliva, taste)
10. X Vagus (Control of PNS e.g. smooth muscles of GI tract)
6

11. XI Accessory (Moving head & shoulders, swallowing)

12. XII Hypoglossal (Tongue muscles - speech & swallowing)
HINT to remember the Cranial Nerves:
7

MEDICATION NOTES
Orange- drug class. Bold-the medication/category under that class

Anticholinergic- blocks the neurotransmitter acetylcholine. Acetylcholine has various functions in the body and
causes various side effects. Therefore, this class of medications can be used to treat various conditions.

Side Effects: blurred vision, urinary retention, dry mouth, constipation, and sedation.

• Hint: can’t see (blurred vision), can’t pee (urinary retention), can’t spit (dry mouth), can’t shit
(constipation).
• For the side effect of sedation, educate the patient not to drive alone or operate heavy machinery.

Contraindications: closed angle glaucoma (increases intraocular pressure), bowel ileus, urinary retention, & BPH.

Examples of anticholinergics:

• Many antihistamines, and tricyclic antidepressants fall under anticholinergics.

• Oxybutynin (Ditropan), Tolterodine (Detrol), Solifenacin (Vesicare) –They are also antimuscarinic used to
treat overactive bladder (as we said above anticholinergic medications cause urinary retention).
• Dicyclomine (Bentyl)-Is also an antispasmodic used to treat IBS (irritable bowel syndrome)
• Atropine-It increases the heart rate for patients with symptomatic bradycardia. It can also be given to dry
patient’s secretions with the death rattle. Before giving it do ECG.
• Scopolamine-It is an antiemetic used for motion sickness, and it also controls secretions. It is usually given
in a patch form. Instructions: put it on a hairless, clean, dry area behind the ear. Apply before traveling.
Replace every 72 hours- remove old one and dispose it, and then out on new one. Wash hands.
• Benztropine (Cogentin)-It is used to treat EPS (extrapyramidal symptoms) that occurs with antipsychotic
medications.

PPI (Proton Pump Inhibitors)-reduces acid production in the stomach

• Examples: Pantoprazole (Protonix), Lansoprazole (Prevacid), Omeprazole, Esomeprazole

• If taken long term, it can decrease calcium absorption and promotes osteoporosis (think risk for fracture)
• It can cause diarrhea, pneumonia, and c. diff infection (because it suppresses acid and ruins normal flora)
• Take 30 minutes before meals.
• It can also be given for an upper GI bleed to reduce GI secretions

Metoclopramide (Reglan)-it increases GI motility and promotes stomach emptying. Therefore, it is used for
delayed gastric emptying, GERD, and as an antiemetic.

• Side effects (usually occur with long term use): sedation/fatigue, restlessness, headache, sleeplessness,
dry mouth, constipation, & diarrhea.
• Side effects that are dangerous and need to be reported to doctor immediately: EPS-extra pyramidal
symptoms like tardive dyskinesia (Note: to reverse EPS symptoms-give Benztropine (Cogentin)).
8

Antacids-neutralize acid in the stomach. Used for stomach ulcers.

• Sucralfate (Carafate, Sulcrate)- Give before meals with water. Give at least 2 hours before and after other
medications.

Fiber-to relieve constipation

• Psyllium, bran

Antidiarrhea

• Loperamide (Imodium)- do not use for more 2 days or if have a fever. Assess fluid and electrolyte levels.

Tuberculosis-

• All are hepatoxic except Ethambutol. So, you will have signs/symptoms like dark colored urine, jaundice,
fatigue, and anorexia. To avoid damage to the liver-do baseline liver function test before giving. Also,
avoid giving with alcohol and other hepatotoxic drugs (like Tylenol).
• Rifampin (Rifadin)- Inform the patient that red/orange body fluids (like tears, sweat..) are a normal side
effect. Tell the patient to wear eyeglasses-not contacts, and to use non hormonal birth control because it
can decrease the effectiveness of oral contraceptives. Take with meals.
• Isoniazid--used to treat latent TB (if active TB, use it with other drugs). Side effects: peripheral neuropathy
(numbness, tingling of extremities). Take vitamin B6 (pyridoxine) to prevent peripheral neuropathy.
• Ethambutol, or Pyrazinamide- to treat active TB. Side effect: optic neuritis (so have frequent eye exam,
report signs of decreased visual acuity and loss of color (red/green)).

Antiemetic- to help with nausea and vomiting

• Ondansetron (Zofran)

Antivirals- used to treat herpes

• Acyclovir (Zovirax), Famciclovir, Valacyclovir

Antipsychotics-used to treat schizophrenia

• Typical: Haloperidol, Fluphenazine

• Atypical: Clozapine, Risperidone, Olanzapine
• Haloperidol- first generation- contraindication for dementia patients
• Clozapine (Clozaril)- Adverse effects include: agranulocytosis (decrease neutrophils), cardiac disease, and
seizures. These are very severe so only used in patients not responding to other drugs. Before starting
clozapine-need WBC to be above 36500 and absolute neutrophil to be above 2000. Therefore, need
baseline CBC and ANC before and during therapy (once week). Tell doctor immediately if fever, sore
throat, or other flu like symptoms. Side effects that are normal: weight gain, hypersalivation/drooling.
• Risperidone
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• Ziprasidone (Geodon)- has a risk for QT prolongation (leads to torsade de points). So do baseline EKG and
potassium check before giving. Place patient on cardiac monitor. Monitor for hypotension, seizures. Do
not take it with alcohol.
• Side effects for both typical and atypical: neuromalignant syndrome and extrapyramidal symptoms (EPS)
but much more common with the typical than the atypical. Give Benztropine to counteract EPS
symptoms.

Antidepressants:

• Monitor for worsening depression, sudden change in behavior, and suicidal thoughts. Do not use SSRI w
other antidepressants
• MAOI- Phenelzine (Nardil), Selegilline (Emsam), Tranylcypromine (Parnate), Isocarboxazid (Marplan)-
o Do not eat foods high in tyramine because it can cause hypertensive crisis
o Need 2 week wash out period between MAOI and any other antidepressant to prevent
hypertensive crisis (severe headache-first sign, blurred vision, dizzy, severe headache, shortness
of breath)
o Can increase blood pressure- so do nasal decongestion.
• Atypical- Bupropion (Wellbutrin)- comes in sr/xl/immediate release. Do not chew sl/xl (extended
release)-swallow it whole. If dose is too high-it can cause seizures. Limit alcohol. Take medication the
same time every day. Take several weeks till the full effect is seen. Side effect: weight loss
• TCA (tricyclic antidepressant)-Imipramine, Amitriptyline (Elavil), Nortriptyline Desipramine-
o Amitriptyline- can cause cardiac toxicity and neuro disturbances like AV block, hypotension,
cardiac arrest, or seizures. Do not take with alcohol.
o Causes anticholinergic symptoms like constipation, urinary retention
• SSRI (Selective serotonin reuptake inhibitor)-
o Citalopram (Celexa), Escitalopram (Lexapro), Sertraline (Zoloft), Paroxetine, Fluoxetine (Prozac),
o Takes 1-4 weeks to see the full effect
o They help with long term anxiety without abuse potential (unlike Benzodiazepines)
o Can be increased by herbs like St. John’s wort
o Side effects: loss appetite, weight gain or loss, GI (nausea, vomiting, diarrhea), headache,
dizziness, insomnia, and sexual dysfunction. These side effects gradual diminish over 3 months.
o When the body has too much serotonin (usually from combination of medications), serotonin
syndrome can occur. Very dangerous. Symptoms of serotonin syndrome: mental status changes
(anxiety, disorientation, agitation), and autonomic dysregulation (hyperthermia, diaphoresis,
tachycardia, hyperreflexia), and neuromuscular hyperactivity (tremor, muscle rigidity, clonus,
hyperreflexia)
• Trazadone-especially used for insomnia with depression. Side effects: orthostatic hypotension, priapism
(if erection few hours go to ER). Take at bedtime. Not with other sedatives, antihistamines, or alcohol.
• Duloxetine (Cymbalta)- antidepressant that also relives pain. Used for chronic pain and antidepressant

Stimulants-used for ADHD

• Methylphenidate (Ritalin, Concerta), Dextroamphetamine, Lisdexamfetamine (Vyvanse)

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• Side effects: insomnia (give after 6pm), decrease appetite, weight loss (give before meals), headache,
irritability, restlessness, and tachycardia
• There is a risk for interruption of growth and development. So, compare weight/height each checkup.
• Given 2-3 times daily.

For bedwetting/nocturnal enuresis

• Desmopressin-antidiuretic. So can also treat DI (diabetes insipidus).

o Monitor for symptoms of water intoxication/hyponatremia.
o Rhinitis, respiratory infections can decrease its effectiveness
o It is a nasal spray
o Side effects: congestion, pain
• TCA (tricyclic antidepressant)- Amitriptyline- can also be used for bedwetting

Lithium- used for bipolar and mania.

• Common side effects: dry mouth, constipation

• It is excreted through the kidneys. So, hold the dose if: condition kidney tries to conserve sodium
(hyponatremia, dehydration) or if decreased glomerular filtration rate.
• Have 2-3L fluids and sodium
• Therapeutic level: 0.6-1.2
• Risk factors for toxicity: DDDD: dehydration, diet low in sodium, decrease renal function, drug to drug
interaction (with NSAID’s, thiazide)
• Toxicity symptoms: GI (nausea, vomiting, diarrhea), Neuro (tremor, confusion, ataxia, sluggishness). If
severe-seizures, encephalopathy.

Anticonvulsants-used to treat seizures

• Discontinue before electroconvulsive therapy (ECT).

• They can depress CNS, cause suicide ideation, and can trigger SJS (Steven Johnson syndrome). Do not
drink/operate heavy machinery while taking it.
• Carbamazepine (Tegretol)-can also be used for neuropathic pain like trigeminal neuralgia. Side Effects:
agranulocytosis(leucopenia). Report symptoms of fever or sore throat.
• Phenytoin (Dilantin)-
o Can cause liver damage-so monitor liver function test.
o Want range between 10-20, so measure blood levels.
o Phenytoin toxicity- gait disturbances (ataxia), gingival hyperplasia, slurred speech, nystagmus,
dysarthria, ataxia, encephalopathy. If given IV-bradyarrhythmia’s and hypotension can occur
o It decreases the effectiveness of some medications like oral contraceptive or warfarin. So, use
nonhormonal birth control (condoms, copper IUD). It can also cause Steven Johnson syndrome.
o Do not use in pregnancy
o Other side effects: increase body hair, rash, folic acid depletion, decrease bone density
(osteoporosis). So have a diet high in folic acid, and calcium.
• Gabapentin (Neurontin)-also used for neuropathic pain
11

• Valproic Acid (Depakote)-also used for bipolar

• Levetiracetam (Keppra)

Antitussive used to suppress cough

• Dextromethorphan
• Codeine. Side effects: constipation, nausea, vomiting, orthostatic hypotension, dizziness. Take with food.
Not for patients with respiratory diseases

Expectorants: thins mucus in airway. Mucolytic-thins mucus in lungs

• Guaifenesin (Robitussin)
• Acetylcysteine (Mucomyst)- given by nebulizer. For cystic fibrosis patients, and respiratory conditions.
But it can cause bronchospasm, so not for asthma patients.

Asthma medications-

• For asthma patient: No beta blockers or NSAID, and you want the oxygen saturation to be more than 92%.
• For short acting/exacerbations/asthma attacks: Bronchodilators (like Albuterol or Levalbuterol)
o During acute asthma exacerbation- no more than 2-4 puffs every 20 minutes up to three times. If
it is not effective, use with inhaled corticosteroids (like Solumedrol) to decrease the inflammation
or with an anticholinergic (like Ipratropium)
o Side effects: tremors, tachycardia, palpitations, restlessness, hypokalemia
o For prevention/to prevent asthma attack- Montelukast (Singulair)
o Corticosteroid inhalers can cause oral thrush. So, rinse mouth after use and can use nystatin oral
suspension.
• Long-acting bronchodilators (Salmeterol). Given with steroid for long term asthma control.
o After inhalation-rinse mouth with water –do not swallow. No smoking. Get pneumococcal and
influenza vaccines.
• Tiotropium (Spiriva)-side effect: xerostomia (dry mouth)-give sugar free candy/gum
• Theophylline-bronchodilator. Therapeutic index 10-20. More than 20-is toxic. Draw serum levels after
giving. Symptoms of toxicity: CNS stimulation (headache, insomnia, GI (nausea/vomiting), arrhythmias,
restlessness). Do not take with caffeine. Complications: seizures or life-threatening arrhythmias.

Bisphosphonates-prevent loss of bone density.

• Alendronate (Fosamax), Risedronate (Actonel), Ibandronate (Boniva), Zoledronic (Reclast)- jaw necrosis
• Take in the morning on an empty stomach, 30 minutes before other medications. Drink extra water and
sit upright 30 minutes after taking (to prevent epiglottis or esophageal irritation).
• Take calcium and vitamin D with it for strong bones.

Alpha Adrenergic Blockers-to treat BPH (benign prostate hyperplasia).

• Doxazosin, terazosin, and tamsulosin

• It relaxes smooth muscle in bladder but also relaxes smooth muscles in vascular.
12

• Side effects: orthostatic hypotension, syncope, falls, ejaculatory dysfunction. So, tell patients to take at
bedtime, and avoid taking with other medications that increase muscle relaxation (like Sildenafil).

Antifungal-to treat fungal infections

• Fluconazole (Diflucan)-broad spectrum antifungal.

• Nystatin-for oral candidiasis/thrush. Remove dentures and soak in nystatin, assess area frequently. Swish
suspension in mouth for several minutes and then swallow the medication. Shake well before using.
Continue for 48 hours after symptoms disappear.
• Terbinafine (Lamsil)- to treat tinea corporis/ringworm. It is a cream. Apply to the affected areas 2 times a
day. Takes 1-4 weeks to complete treatment.

Antibiotics-to treat bacterial infections

• All antibiotics ruin gut health

• With antibiotics- frequent liquid stool can indicate C. diff infection (a common side effect)
• Do not use alcohol for 3 days after starting antibiotics
• WBC can tell you how effective the antibiotics treatment is
• Give prophylaxis antibiotics prior to dental procedures for patients with prosthetic valve replacement,
repaired valves, or a history of infectious endocarditis.

Macrolides-antibiotics

• Azithromycin, Erythromycin, Clarithromycin

• Can cause prolonged QT interval (think torsade’s de pointes). Monitor EKG.
• Hepatotoxicity (think elevated liver enzymes)

Aminoglycosides: antibiotics

• Monitor peak and trough levels.

• Tobramycin- in aerosol form for cystic fibrosis exacerbation
• Streptomycin- side effect: difficulty hearing (tinnitus, subjective hearing loss). Can be a second line drug
to treat TB.
• Gentamicin-side effect: muscle cramping
• Serious adverse reaction: ototoxicity (tinnitus, vertigo), nephrotoxicity. So, assess hearing. Balance.
Urinary output, creatine, kidney function

Cephalosporin-antibiotics

• Ceftriaxone (Rocephin), Cephazolin- side effects: can cause C. diff

Quinolone -antibiotics

• Ciprofloxacin-(photosensitivity), Levofloxacin, Moxifloxacin

• At risk for tendinitis and tendon rupture-black box warning. So, at the first sign of tendon
pain/swelling-stop taking and do not move area, call doctor.
13

• Normal side effect is for urine to be brown while on it

• It is used to treat urinary tract infections
• Levofloxacin (Levaquin)- 2 hours should pass between this drug and consuming aluminum /magnesium
antacids, iron, multivitamins with zinc, or sucralfate.

Tetracycline- antibiotics

• Doxycycline-avoid in pregnancy
• Tetracycline, minocycline
• Take on an empty stomach (1 hour before or 2 hours after meals,) but with a full glass of water
• Avoid antacids, dairy, or iron supplement
• Side effects: Photosensitivity and it decreases the effectiveness of oral contraceptives

Penicillin-antibiotics

• Amoxicillin, Ampicillin
• Cross sensitivity to cephalosporin (so ask what happens/what type of reaction they get)

Other antibiotics:

• Metronidazole (Flagyl)-to treat C. diff, trichomoniasis, or IBD (irritable bowel disease). Side effects:
Metallic taste, GI upset, or dark colored urine. Do not take alcohol for 48 hours after taking it.
• Vancomycin- for severe C. diff or MRSA.
o It is excreted by kidney so monitor BUN/Creatinine 2-3 times a week. If giving through an
IV-monitor trough level before giving.
o Therapeutic level 10-20.
o Vancomycin toxicity: nephrotoxicity (elevated Creatinine) and ototoxicity (hearing loss, vertigo,
tinnitus).
o Infuse over 60 minutes to prevent red man syndrome (facial /upper body flushing) and monitor
for anaphylaxis. Observe IV site every 30 minutes.
• Linezolid (Zyvox)- for MRSA, pneumonia, skin infections. Side effect: headache, diarrhea. Do not eat
tyramine foods.
• Bactrim (it is a combination of two antibiotics)- contraindication: sensitivity to sulfa drugs, pregnant, or
breastfeeding. Side effects: crystalluria. It has a cross sensitivity to glyburide (because they are both sulfa
drugs)

Smoking Cessation Drugs

• Nicotine replacement therapy (patches, gum, inhalers, lozenges)

• Verenicline (Chantix), Bupropion (Wellbutrin, Zyban). Side effects: neuro-psychotic (depression, suicide
thoughts)

Alcohol Cessation Drugs

14

• Disulfiram (Antabuse) – it is an aversion therapy. So, it gives unpleasant side effects when you take
alcohol, making you not want to drink it again. But it is not a cure. Too much is fatal, so you need
informed consent before giving. Tell patients about the danger of drinking alcohol while on it and hidden
sources of alcohol (liquid cold/cough meds, aftershave lotions, colognes, mouthwash, sauce, vinegar, or
flavor extracts). Wear a bracelet alerting others of allergy.

Magnesium Sulfate-for seizures and prophylactically for patient with preeclampsia. It is also used to treat
hypomagnesemia and to treat torsade’s de pointe.

• Give loading dose of 4-6g then maintenance dose 1-2g. Want therapeutic level of 4-7.
• Toxicity-when magnesium level more 7. Symptoms: CNS depressant and blocks neuromuscular
transmission, absent/decreased deep tendon reflexes (DTR), or urinary output less 30/ml/hr.

To Lower Blood Pressure- used to treat hypertension

• To treat preeclampsia Hydralazine (apresoline), methyldopa (aldomet), labetalol (trandate)

CCB (Calcium Channel Blockers)

• Peripherally acting- Nifedipine, Amlodipine (Norvasc), Felodipine, Nicardipine. Side Effects: peripheral
edema (elevate legs, wear stockings), constipation, orthostatic hypotension, dizzy/flushing, or headache.
• Do not give if systolic blood pressure falls below 90
• Do not take with grapefruit juice

ACE Inhibitors (Angiotensin Converting Enzyme Inhibitors)-

• Lisinopril, Captopril, Enalapril

• Side Effects: orthostatic hypotension, hyperkalemia, cough, angioedema (emergency because it can
obstruct the airway, African American’s are at an increased risk), or increase creatine.
• Do not take in pregnancy
• Cough will not be relieved by cough suppressants
• Excreted by kidney- so evaluate kidney function

BB (Beta Blockers)-

• Metoprolol, Atenolol, Bisoprolol-selective

• Carvedilol (Coreg)
• Toprol-xl=long acting-it drops the patient’s blood pressure over a 24-hour period
• Propranolol, Nadolol-nonselective so also works on Beta 2 (the lungs). So, do not give if patient has
asthma/respiratory problems.
• Side effects: bradycardia, bronchospasm, depression, or decreased libido (erectile dysfunction)
• Timolol maleate-ophthalmic medication-to treat high pressure in eye like from glaucoma.

A2RB- Angiotensin 2 receptor blocker

• Side effect: hyperkalemia.

15

• Not in pregnancy.

Nitrates- are vasodilators used to treat angina (chest pain)

• Nitroprusside (Nitropress, Nipride)-used for hypertensive emergencies. Can cause cyanide toxicity with
renal disease.
• Isosorbide dinitrate-long-acting nitrate to prevent angina
• Side effects: hypotension, headache, or flushing
• Hold if systolic blood pressure is below 90
• Do not take with erectile dysfunction medication or alpha blockers (as they all can cause hypotension)
• Infusion: Titration is based on pain and blood pressure every 2-4 minutes until the blood pressure is stable
and pain relieved. If systolic below 90 or 30 below baseline-stop/decrease the infusion.
• Directions for orally: Take nitro. If pain is not relieved, call 911. Then take another nitro. You can take up
to 3 doses, each 5 minutes apart. It is heat/light sensitive so store away from light/heat sources including
body heat and keep tablets in original container. Replace every 6 months. Its normal to have a tingling
sensation under tongue when taking nitro, which is a good sign-it means its potent.
• The patch form-put on once a day (so not as needed). Worn for 12 hours, and then removed. Do not wear
more than 1 patch at a time. Apply on upper body/upper arms, on clean/dry/hairless skin that is not
cracked. Rotate sites. You can wear it in the shower.

Muscle Relaxants-

• Are metabolized by liver-so just clarify with the doctor if patient has liver disease.
• Baclofen-antispasmodic drug. Used for multiple sclerosis to relieve uncomfortable spasm/muscle pain.
Side effect: orthostatic hypotension.
• Cyclobenzaprine (Flexeril)-centrally acting skeletal muscle relaxants. Used for fibromyalgia, or for muscle
spasm/rigidity/pain/injury.
• Succinylcholine- used to paralysis/relax muscle a lot-discontinue if malignant hyperthermia occurs. IV
Dantrolene- used to reverse malignant hyperthermia
• Carisoprodol (Soma), Methocarbamol (Robaxin)

Diabetics Medications

• Metformin (Glucophage)-1st line medication for type 2 diabetes. Side effect: lactic acidosis in patients
with kidney disease. Discontinue if taking IV contrast and restart it 48 hours after (to prevent renal injury).
There is hardly any risk for hypoglycemia. Side effect: GI upset (metallic taste, nausea, diarrhea)
• Thiazolidinediones, Rosiglitazone (Avandia), Pioglitazone (Actos)-increase the risk for bladder cancer,
worsen heart failure. Contraindications: heart failure, volume overload
• Sulfonyurea’s
o Glipizide (Glucotrol)
o Glyburide
o Glimepiride
o Side effect: hypoglycemia, weight gain
o Use sunscreen/protective clothes
16

Glucagon- it converts glycogen to glucose. Given for hypoglycemia if the patient cannot ingest simple
carbohydrates. Watch for rebound hypoglycemia. Given IM. Can be given if glucose not available.

Insulin- to lower blood glucose levels, so it is a treatment for hyperglycemia.

• Regular Insulin-short acting. It reaches its peak effect within 2-5 hours. Given SubQ. Patient is at risk for
hypoglycemia at 2-5 hours after given.
• Lispro (Humalog), Aspart (NovoLog)- rapid acting. It reaches its peak effect 30 minutes-3 hours. There is a
risk for hypoglycemia 30m-3hrs after given. So only given if patient will eat within 15 minutes
• NPH- Intermediate acting- It reaches its peak effect 5-6 hours after taking so risk for hypoglycemia then.
• Insulin Detemir- Long acting. Taken once/twice daily. Another long acting one is -Basal Insulin glargine
(Lantus)-used for glucose control. No peak (so does not matter when you eat food). Long-acting insulin is
used to prevent hyperglycemia for 24hrs.
• Remember even when labs are good-give insulin so it will continue to remain good
• To mix insulin’s:
o Never mix a long acting (glargine, detemir).
o Steps to mix Intermediate (NPH) with short acting (regular)/rapid acting (aspart/lispro):
▪ Clean vials with alcohol swabs. Inject air into NPH, withdrawn needle and insert the air
into regular. Turn regular upside down and withdraw the regular insulin into syringe. Take
out and insert that into NPH. And withdrawn the solution (hint: R before N-RN)
• Insulin can cause hypokalemia. So may need potassium supplement
• A sliding scale (correction)-used to prescribe rapid acting lispro (Humalog) to control postprandial
hyperglycemia

Antithyroid

If someone has hyperthyroidism:

• Propylthiouracil
• Methimazole (tapazole)-can cause neutropenia
• Radioactive iodine (for thyroid storm)

If someone has hypothyroidism or had thyroid taken out

• Levothyroxine (Synthroid)-take consistent in the morning, at the same time. Take 30 minutes before
meal. The dosage is based on TSH level. Report signs of excess thyroid hormone (heart palpitations,
tachycardia, weight loss, insomnia). Safe in pregnancy. Takes up to 8 weeks to see full effect. Antacids,
calcium, iron can interfere. So, take on empty stomach. Usual taken lifelong

Anti-Anxiety

• Buspirone. No CNS effect and low potential for abuse. So, no withdrawal/dependent symptoms. Takes
one week to see some symptom relief and 2-4 weeks to see the full effect. Side effect: dry mouth

Benzodiazepine-aka Benzo’s- they depress/sedate the CNS. Used as an antianxiety and sedative
17

• Are CNS depressants so sedative effect

• Alprazolam (Xanax), Midazolam, Lorazepam (Ativan)
• Midazolam (Versed)- used to induce conscious sedation if undergoing endoscopic procedures. Dose 1mg,
titrate slowly up till speech slurred. No more than 3.5mg. It is usually given with an opioid. Side effect:
airway occlusion, apnea, hypotension, or oxygen desaturation
• Can depress respiratory center so do not use for COPD patients
• For an overdose on a Benzodiazepine- give Flumazenil (Romazicon)

OPIODS- pain relievers

• Side effects: vasodilatation, hypotension, urinary retention, pruritus (give antihistamines like
diphenhydramine), flushing, nausea, vomiting, or constipation
• Do not give to patient with head injury
• Naloxone (Narcan) is an opioids reversal agent for opioid overdose, but it has a short half-life (1-2 hours-
which is shorter than opioids life- so repeat if needed)
• Can depress respiratory center so do not use with COPD patient
• Hydrocodone, Tramadol
• Codeine-also an antitussive
• Methadone (Dolophine)-long half-life. It is used to treat pain and narcotic drug addiction. Early signs of
toxicity: nausea, vomiting, lethargy, respiratory depression.
• Hydromorphone (Dilaudid)-max dose 2mg
• Butorphanol tartrate and Nalbuphine HCL-used in labor in active phase of stage 1 when contractions are
established, and cervix more than 4 cm dilated
• Fentanyl-it can be given via IV for acute pain or through a transdermal patch (called Duragesic) for
chronic pain. Replace the patch every 72 hours. Remove old one then put on new one. The old patch
should be folded and discarded immediately. Do not place heat over patch. Do not cut it. Place on area of
flat, intact skin, clean site, with little hair. It does not have to be on the site with pain.
• Opioid medication must be stored and disposed securely flush down toilet and discarded in sharps
container
• Sign of opioids overdose-constricted pupils
• Morphine
• To dispose of leftover PCA pump meds: have second nurse witness. And document
date/time/amount/reason for waste
• Meperidine (Demerol)-opioids used in early labor. Onset 5 minute through IV. Duration 2-3 hours. Do not
give it within 1-4 hours of birth because can cause neonatal respiratory depression

NSAID- Nonsteroidal Anti-inflammatory- they decrease pain, inflammation, and fever.

• There is an increased risk for thrombolytic activity with them.

• Avoid in patients at risk for falls or low platelet
• Monitor signs of bleeding
• All NSAID can cause: GI toxicity (GI bleed symptoms-black tarry stool), GI upset (dyspepsia, pain), and
peptic ulcers with long term use- so take them with food.
18

• Are nephrotoxic and should be avoided in clients with kidney disease

• Avoid in 3rd trimester because it is a pregnancy category d and category c for 1st/2nd trimester.
• Do not use with asthma patients because can exacerbate asthma symptoms
• Naproxen, Ibuprofen (Motrin, Advil), Acetylsalicylic acid/ASA/Aspirin, Ketorolac (Toradol),
Indomethacin
• Celecoxib-has a black box warning that it increases the risk of heart complications (so think of signs of
myocardial infarction-upper back/shoulder pain)
• Ketorolac-do not use for more than 5 days because side effects include: GI upset, kidney injury, and
bleeding.
• Indomethacin- can also treat patent ductus arteriosus through IM route
• Aspirin toxicity-hyperthermia and tinnitus
• Aspirin and IV gamma globulin are given for Kawasaki. Monitor for heart failure (signs fluid overload)

Neuropathic Pain Relievers

• Pregabalin, Gabapentin

Corticosteroids-does a lot of stuff to the body-mainly suppresses inflammation and suppresses the immune
system.

• Hydrocortisone, Dexamethasone, Prednisone, Dexamethasone, Prednisone

• Methylprednisolone (Solu-Medrol)-for decreasing inflammation of lungs from acute exacerbation of
COPD
• Do not discontinue abruptly and Increase dose in stress time. Can cause hyperglycemia (so report signs).
Can lead to osteoporosis/muscle weakness (so have high calcium diet and protein and low fat/low carbs).
• Side effect: cataracts (so have yearly eye appointments), GI irritation (do not take on empty stomach),
mood swings, irritability (normal)
• You want to recognize the symptoms of Cushing syndrome (too much cortisol)
• Can also mask signs of infection (like a low-grade fever...)
• Other side effects: buffalo hump, moon shape face, hypokalemia, increase weight/blood pressure/glucose

Antineoplastic/Anticancer-

• WBC at lowest at what is called Nadir (which is 7-10 days after chemo started)
• Cisplatin –causes renal toxicity
• Tamoxifen-is used to treat breast cancer and prevent breast cancer from reoccurrence. It blocks estrogen
receptors. Taken for several years after treatment. Side effects: (same as menopause)- hot flashes, vaginal
dryness, menstrual irregularities, or decreased libido (because you are decreasing estrogen). Serious side
effects: thrombolytics event (DVT, PE, stroke), or endometrial hyperplasia
• Cyclophosphamide. Side effects: hemorrhagic cystitis. Drink a lot of water or IV hydration or mesna
therapy
• Methotrexate-drug class of DMARD-can be used for rheumatoid arthritis, and psoriasis. Take meds
regardless of symptoms. It interferes with the folic acid/cell replication cycle.
19

o Side effects: bone marrow suppression (so think anemia, leucopenia, thrombocytopenia
(petechiae, purpura...), hepatotoxic (so no alcohol), and GI effects
o Teratogenic-do not become pregnant on it or at least till 3 months after stopping it
o Only get inactive vaccines (like the influenza, or pneumococcal)

Hydroxychloroquine (Plaquenil)-antimalaria

• Side effect: retinal damage (get eye exam every 6 months), renal toxicity, visual disturbances
• Can take several months till see effect

Tumor Necrosis Factor/TNF Inhibitors-suppresses body’s response to TNF (which is a part of inflammatory
response)- used to treat inflammatory conditions

• Etanercept, Infliximab, Adalimumab- reduces the manifestation of rheumatoid arthritis and slows the
progression of joint damage by stopping the inflammatory response. It is also used for Chron’s disease.
Basically, it suppresses the inflammatory response.
• To see if its effective look at C-reactive protein
• If elevated WBC-report. Do not take if have infection
• Can activate latent TB (because its immunosuppressive), So need TST skin test before and yearly after.

Immunosuppressive Drugs: they suppress the immune system, so suppresses bone marrow etc.

• When on a immunosuppressive drug, at risk for infection

• Azathioprine- used for autoimmune conditions like IBD (Crohn’s), and to prevent organ rejection. Side
effects: nausea, fatigue, leucopenia (WBC under 4000)-tell doctors before giving
• Cyclosporine-side effects: gingival hyperplasia
• Immunosuppressive drugs can convert latent TB to active TB

Diuretics

• Loop-Furosemide (Lasix), Bumetanide -used a lot for congestive heart failure, edema. Produce the largest
amount of fluid lost from the diuretics. Can cause ototoxicity.
• Potassium Sparing-Spironolactone-used when someone has low potassium
• Thiazide-Hydrochlorothiazide-used a lot for hypertension
• Osmotic-Mannitol- used for cerebral edema (ICP) and glaucoma. Side effect: pulmonary edema (crackles)-
auscultate the lungs after given, check i/o, electrolytes, and kidney function. Side effect: decrease urine
output
• Diuretics basically make one pee out fluid. In turn this lowers the blood pressure (because getting fluid
out of body), so patient at risk for hypotension. Therefore, do not give diuretic if low BP. Also, patient is a
fall risk.
• With all diuretics- patient is at risk for fluid and electrolyte imbalances
• The big side effect to diuretics is hypokalemia. So, the potassium sparing diuretics keep the potassium in
the body for patients who have low potassium level.
• If someone if allergic to a loop diuretic- do not give thiazide diuretic
20

• Other side effects: nocturia-so give in the morning

• Never give it IV push-give it slowly
• Monitor I/O, electrolytes, and kidney function
• Osmotic diuretic- Mannitol (Osmitrol)- used for cerebral edema (ICP) and glaucoma. Side effect:
pulmonary edema (crackles)- auscultate the lungs after given, check i/o, electrolytes, and kidney function.
Side effect: decrease urine output

Electrolyte and CBC

Potassium Chloride (KCL)- used to prevent or treat hypokalemia.

• No more than 10meq/hr through peripheral line or 40meq through central line. If given too rapidly can
cause irritation of vein/phlebitis. So, assess site for swelling before giving and every 30 minutes during
infusion. Do it via electric IV pump
• IV potassium should never be given by gravity
• Potassium pill can cause esophagitis. So, take with lots of water and sit upright for 30 minutes after
taking.
• Take during/immediate after meals to prevent gastric upset
• Check potassium level before giving

Sodium Polystyrene sulfonate (Kayexalate)- given to patients with high potassium level/hyperkalemia.

• Hint: K-exit (Kayexalate)- and K is potassium, so potassium leaving your body

• Watch for hypokalemia signs (palpitations, lethargy, cramps)
• Side effects: frequent, loose stools- (which is normal). Watch for fluid overload (JVD, edema, crackles)
• Before giving patient must have normal bowel function because a complication is intestinal necrosis (so
assess for signs of constipation, fecal impaction, recent bowel patterns...)

Calcium Acetate (PhosLo) or calcium carbonate- It is used to treat hyperphosphatemia. The calcium binds to
phosphorus to excrete phosphorus. Given to end stage kidney disease patient. Vitamin D increases calcium
absorption.

Filgrastim (Neupogen)- increases WBC

Epoetin (Procrit)- stimulates production of erythropoietin/RBC. It is used to treat anemia. Side effects:
hypertension (so uncontrolled hypertension is contraindicated for this medication). Given IV/SubQ (not IM). Need
iron, Vitamin b12, folic acid for it to work.

Iron- iron sucrose (Venofer), Ferric Gluconate (Ferrleicit)-can be given with Epoetin

H1 Receptor Blockers- they inhibit the effects of histamine, so used as antihistamine

• Fexofenadine, cetirizine, levocetirizine, loratadine (Claritin), Diphenhydramine (Benadryl).

Promethazine (Phenergan)
• They decrease the inflammatory response by blocking histamine receptors
21

• Used for allergic reactions

Anesthetics- used to produce anesthetic and sedation

• Epidural- local anesthetic. It is contraindicated: uncontrolled hypertension, coagulopathies (extremely low

platelets, clotting disorder), infection at epidural site
• Methohexital, Propofol
• Lidocaine is sodium channel blocker so also used for dysrhythmias

Tocolytics-used to suppress premature labor

• Terbutaline, Magnesium sulfate (therapeutic level 4-7), Indomethacin, Nifedipine. They are used
to suppress uterine contractions in preterm labor-it prolongs pregnancy 2-7 days, giving you enough time
to give steroids to make the lungs mature

Uterotonic Drugs-given to increase labor contractions

• Oxytocin- to increase contractions. Used to induce labor or if attempts to control postpartum bleeding
(like fundal massage, bathroom) do not work. Postpartum dosage: 125-200. Side effect: uterine
tachysystole (more 5 contraction in 10 minutes over half hour)
• Carboprost
• Misoprostol-can also prevent ulcers caused by NSAID because they reduce stomach acid. Pregnancy
category x. Do not take with magnesium.
• Methylergonovine (Methergine)- to treat severe bleeding postpartum. Contraindication: patient with
high blood pressure.

Phosphodiesterase Inhibitors- PDE5 Inhibitors-promote vasodilation and certain relax smooth muscles like
bladder.

• Tadalafil, Sildenafil, Vardenafil- used for erectile dysfunction

• Side effect: hypotension. Do not take with nitrates.
• Can cause prolonged erection

Anticoagulants- used to PREVENT blood clots from forming.

• Used to thin the blood to reduce risk of stroke, heart attack etc
• Warfarin (Coumadin)- monitor with prothrombin time (PT) and International normalized ration (INR).
Don’t eat high Vitamin K foods or grapefruit while on Warfarin. With eating Vitamin K foods- eat
consistent vitamin K –do not decrease or increase your regular consumption while on Warfarin. Antidote
for Warfarin is Vitamin K/Phytonadione
• Warfarin takes 48-72 hours to take effect and then few days for maximum effect. So, overlap it for 5 days
with heparin till INR at therapeutic level
• Heparin (Lovenox)- monitor with partial thromboplastin time (PTT). Antidote for Heparin is Protamine
Sulfate. Complications: Heparin induced thrombocytopenia (HIT)-need to monitor platelet count while on
Heparin and watch for signs of HIT like petechia or purpura. High alert medication.
22

• Normal values for people not on blood thinners: PT (10-12 seconds), PTT (30-45 seconds), INR (1-2). The
point of blood thinners is to make the blood clot, therefore if someone is on a blood
thinner/anticoagulant they are going to have longer clotting times (higher values).
o On Warfarin-want PT to be 1.5-2.5 times that and want INR to be 2-3 (except if artificial heart
valve then you want the INR to be 2.5-3.5.
o On Heparin- want PTT to be 1.5-2.5 times that
•
• Administration steps: Pinch skin and insert needle 90 degrees. Remove at 90 degree. Common to have
pain, bruising, irritation, redness. Do not rub site with hand. Use ice cubes on site if hurts.
• With anticoagulants: Bleeding precautions (soft bristle brush, shave with electric razor.). Report bleeding.
Do baseline CBC (hemoglobin, platelets). Watch for internal bleeding signs: hypotension, tachycardia,
heart rhythm changes, blood in urine. Abdominal/back pain, mental status changes, black tarry stools.
Also watch epistaxis, bleeding gums, hematuria.
• Contraindications: if active bleeding, peptic ulcer, intracranial hemorrhage, or any bleeding disorder
• Do not take with herbs (ginkgo biloba, vitamin E, ginger, garlic) or with NSAID’s like aspirin because it
increases risk for bleeding.
• Other anticoagulants- dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban.
• Fondaparinux (Arixtra)- used to treat DVT after orthopedic surgery. Not given till after 6 hours post op.
Side effect: epidural hematoma (severe back pain, paralysis)
• Clopidogrel (Plavix)- to prevent clots. Side effect: thrombocytopenia and risk for bleeding,
thrombocytopenic purpura. Tell doctor if low platelets
• Factor Xa Inhibitors- are anticoagulants: Rivaroxaban (Xarelto), Edoxaban, Apixaban-they have a lower
risk of bleeding and less monitoring required but there is a risk for ICP bleeding, epidural hematoma.
Immediately tell doctor if neuro symptoms (extreme weakness, altered sensation, numbness). No routine
monitoring of clotting times required.

Thrombolytics-used to treat ACTIVE blood clot

• Alteplase (TPA), Tenecteplase, Reteplase

• Contraindication: active bleeding, recent trauma, aneurysm, av malformation, history of hemorrhagic
stroke, uncontrolled hypertension (over 180/110)
• There is a risk for intracranial hemorrhage. So only used for life threatening conditions.

Statins: used to lower cholesterol levels

• Rosuvastatin (Crestor)
• Side effects: rhabdomyolysis, kidney injury, myopathy
• Tell patient to report symptoms of muscle aches/weakness and take CK levels (it will be elevated if
myopathy)
• Assess liver function test-because it is metabolized through liver
• Contraindication: patients with severe liver/muscle injury
• Take at night/evening because cholesterol is broken down in a fasting state
23

Cholestyramine (Questram) – helps excrete bile from feces so decreases itching and lowers cholesterol. Comes in
package form. Mix with food or juice and give 1 hour after other medications.

Fibrates- used to lower cholesterol levels

• Gemfibrozil, Fenofibrate
• Side effects: muscle aches/cramping

Vitamins

Niacin-B3- lipid lowering properties

Vitamin D- helps maintain bone density.

Vitamin E- prevents leg cramps

Anti-Parkinson’s- used to treat Parkinson’s disorder

• Carbidopa-Levodopa- it does not stop the disease from getting worse, it just helps to control the
symptoms by increasing dopamine levels in the brain. Side effects: orthostatic hypotension (so put them
on fall precautions), harmless discoloration of secretions, dizzy, involuntary movements, risk for falls.
Takes several weeks to see maximum effect. Avoid high protein meals. If take too much can cause
dyskinesia (face/eye twitching, facial grimace)- tell doctor. This medication does not eliminate tremors
just decreases it.
• Benztropine, Trihexyphenidyl –anticholinergic medications used to treat tremors.

Oral Posioning

• oral activated charcoal. It is also given for aspirin toxicity-even if asymptomatic. After giving, give IV
sodium bicarb

Other Medications (that do not fall into one specific category)

Riluzole- is used to treat ALS (Lou Gehrig). It is a glutamate antagonist-which slows neuron degeneration. Can
slow the progression by 3-6 months

Solifenacin (VESIcare)-cholinergic antagonist used to treat overactive bladder. Side effects: dry mouth,
constipation, dizzy, blurred vision

Phenazopyridine (Pyridium)-analgesic to relive pain with urinary tract infection. The urine will turn red/orange
and body fluids discolored with this medication-which is normal. Use sanitary napkins, wear eyeglasses. It is used
to relieve symptoms, does not treat the disease.

Sumatriptan-used to treat migraines. Contraindication: coronary artery disease, uncontrolled hypertension

Cyanocobalamin-for vitamin B12 deficiency. Given every 4 weeks.

24

Donepezil (Aricept), Memantine (Namenda), Rivastigmine- cognitive enhancing medication-used to slow the
progression of Alzheimer disease.

Octreotide- is used to help control upper GI bleed

Digoxin-is a cardiac glycoside.

• It increases cardiac contractility/output and decrease heart rate-so used in heart failure (to increase
cardiac output) and in A-fib (to decrease heart rate).
• The therapeutic range is 0.5-2. Toxicity occurs at level over 2
• Signs of toxicity: bradycardia, heart block, (dizzy/lightheadedness). Other toxicity signs to report: visual
(scotomas, blindness, color alterations). GI (anorexia, vomiting, nausea, abdominal pain-earliest signs).
Neuro (lethargy, fatigue, weakness, confusion), and cardiac arrhythmias
• Check pulse before giving for 1 minute, if it is below 60 –hold the medication.
• Monitor potassium if receiving digoxin because hypokalemia can potentiate digoxin toxicity.
• It is excreted by kidney so monitor bun/creatinine and evaluate kidney function.

Zolpidem (Ambien)- is a hypnotic meds, used for sleep disturbance like for mania

Melatonin-supplement- used for jet lag. Side effect with high dose: vivid dreams, nightmares. Only take once you
get to your destination.

Lactulose-is an osmotic laxative- It promotes excretion of ammonia through feces (like in cirrhosis, hepatic
encephalopathy). It can also be used for constipation. With lactulose you want to see 2-3 stools/day with no
confusion/lethargy. Lactulose can be given orally with a drink or enema. Monitor electrolytes.

Sulfasalazine (Azulfidine)- GI anti-inflammatory medication used to treat IBD (irritable bowel disease). Side effect:
dehydration. Also, can crystallize in kidney so report signs of dehydration or elevated specific gravity. Other side
effects: yellow/orange skin/urine.

Permethrin 5%- is a cream that is used to treat scabies. Massage it all over skin from head to toe for
infants/children.

Isotretinoin (Accutane) used to treat severe acne. Do not use in pregnancy (it is a category X). If childbearing
years- need 2 forms of contraception for 1-month begore starting and 1 month after, and ipledge form. Need two
negative pregnancy tests before giving. Do not give blood while on it. Side effect: dry eyes/mouth/skin. Take with
8oz water. Side effects: photosensitivity, Steven Johnson syndrome. It is made from vitamin A so do not take with
vitamin A supplement, and not with TCA antidepressant.

Norepinephrine (Levophed)-vasoconstrictor and vesicant. It improves heart contractility/output, but the effects
end quick. It can cause skin breakdown if absorbed into skin (if extravasation give antidote-phentolamine
(regitine)- (which is a vasodilator).

Epinephrine- for cardiac arrest, anaphylactic reactions, or severe asthma attacks

25

Allopurinol, Colchicine-anti-inflammatory for gout attacks. Side effects: diarrhea-take with water because GI side
effects.

Sulfasalazine (Azulfidine)- decreases inflammation- for rheumatoid arthritis and IBD. Side effects: crystalluria
(think kidney injury, drink 2 glasses of water). Photosensitivity, folic acid defect (take 1mg/day), agranulocytosis,
Stevens Johnson syndrome, photosensitivity, urine turn orange/yellow

Promethazine- suppository to relief nausea and vomiting and minimize further fluid loss

Pyridostigmine (Mestinon)- for myasthenia gravis. It increases muscle strength. Give it before meals

Clomiphene (Clomid, Serophene)- used to treat infertility. It stimulates ovulation. Take orally for 5 days and
ovulation should occur 5-9 days after completing. Have frequent sex for 5 days after completing (every other day
for 1 week). Side effects: twins, mood swings, hot flashes, nausea, or headache.

Capsaicin cream (Zostrix)-is an OTC analgesic which relives minor pain (like from osteoarthritis, neuralgia). It is
made of hot pepper. Wait 30 minutes after massaging cream before washing hands. Do not use with heat. Side
effect: local irritation (burning/stinging, Erythema).

Finasteride (Proscar)- inhibits further growth of prostate. It is used for BPH. Takes several doses of therapy to
notice differences.

Dopamine-sympathomimetic inotrope. It is used to treat symptomatic hypotension. It improves blood flow if

shock/heart failure and enhances cardiac output and renal output. Side effect: tachycardia, dysrhythmias, or
myocardial infarction

Milrinone (Primacor)-given through IV- to increase contractility and promote vasodilation. It is an inotropic agent
used for heart failure that is unresponsive to other drugs. It is infused over 48-72 hours. Need central venous
catheter. Use infusion pump.
26

VIRUSES/SKIN CONDITIONS/VACCINATIONS NOTES

Scabies-highly contagious.

• Transmitted: contact.
• Symptoms: Causes intense itching especially at night.
• Treatment: ½ applications of permethrin cream. For children/infants’ massage it all skin surfaces from
head to toe (except the eyes). Even after treatment is done the itching continues. Anyone in close contact
with the patient during 30-60 incubation period should be treated.

Ebola (viral hemorrhagic fever)-very contagious with a high mortality rate.

• Transmitted: Need standard/contact/droplet/airborne precautions (need impermeable gown/coveralls,

N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use
apron, single room with doors closed). Visitors are prohibited except parents of kids. A log is maintained
to see who enters or exits room.
• Treatment: no meds or vaccines yet. PPE removal with Ebola occurs in this order: outer gloves first
cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent
piece of PPE and removed last.

E. coli- is abnormal bacteria that lives in human. Most strains are harmless, but few can cause severe abdominal
cramps, bloody diarrhea, and vomiting.

• Transmitted: Can get through contaminated food/water.

• Complication: hemolytic uremic syndrome-life threatening=red cell hemolysis (anemia), low platelets
(petechiae or purpura), and acute kidney injury.
• Treatment: prevent dehydration. Usually improves in a week. Have regular foods.

Middle east respiratory syndrome (MERS)- is a viral respiratory illness.

• Transmitted: Spreads through respiratory secretions. The CDC says: standard, contact, and airborne
precautions with eye protection.
• Symptoms: fever, cough, shortness of breath that worsens and can cause death. Incubation 5-6 days but
can be 2-14 days.

Tapeworm –

• Transmitted: Ingested when person eats food that is contaminated with feces or undercooked meat from
infected animals
• Symptoms: The only sign of tapeworm infection may be segments of the worms, possibly moving, in a
bowel movement.

West Nile virus-mosquito borne disease (encephalitis) that occurs during summer months, especially in humid
weather. Prevention: insect repellent, long sleeves, long pants, light colors, avoid outdoor activities at dawn/dusk
27

Ringworm/tinea corporis- superficial fungal skin infection on skin/hair/nails. Highly contagious.

• Transmitted: via contact (so clean surfaces, and do not share personal items). Spread by sharing
hairbrushes /hats/towels/linen/equipment etc.
• Symptoms: red, scaly, blistered rings on skin/scalp that grow outward as infection spreads
• Treatment: hygiene, limited contact personal items (brush...), prescribed shampoos and topical/oral
meds. Limit contact with infected pets.

Gastroenteritis- aka stomach flu- inflammation of stomach and intestines

• Symptoms: nausea, vomiting, diarrhea. So patient is at risk for dehydration, and sodium loss.
• Treatment: isotonic crystalloid fluids (0.9 sodium chloride, lactated ringer). Tell patient to increase fluid
intake.
• Complications: dehydration and electrolyte imbalances

Multidrug resistant organisms

• Includes: (VRE) vancomycin resistant enterococci, (MRSA) methicillin resistant staphylococcus aureus).
• Transmitted: Need contact precaution (so private room or semi-private with same infection, keep
dedicated equipment for the patient and disinfect everything)
• Treatment: They take treatment for 6-9 months. Hand hygiene (soap/water/alcohol rub for VRE and
MRSA. Only soap/water for C. diff. Place door notice for visitors (they are allowed in but with proper PPE
but write what to wear). Patient only leaves room for essential clinical reasons (like tests).

Clostridioides difficile (C. diff)- is a bacteria that causes severe diarrhea

• Causes: when normal GI flora is destroyed (like with antibiotic use).

• Symptoms: watery diarrhea, nausea, fever, abdominal pain, leukocytosis.
• Complications: Can cause hypovolemia which can lead to low sodium/potassium and a high BUN.
• Transmitted: contact precaution. Wear gown/gloves. Hand wash with water and soap only. Disinfect
contaminated equipment and surfaces with diluted bleach solution. Place patient in single room. Wear
single use disposable gown and clean gloves during patient care. Discard equipment before leaving room.
Hand hygiene before and after with soap and water. Use dedicated medical equipment that is not shared
with other patients and always remains in room.
• Treatment: metronidazole (Flagyl) and oral vancomycin
• Prevent from re-occurrence: clothing/linen washed and dried on hottest setting. Non washable stuff goes
in plastic bag for 3 or more days.

Poison ivy-first wash area before rash. If rash-cool, wet, cream. It does not spread person to person (so not
contagious)
Tinea corporis (ringworm)-fungal infection of the skin
• Transmitted by person or animal.
• Symptoms: scaly itchy circular patches. Highly contagious even through grooming stuff.
• Treatment: topical antifungal
28

Eczema aka Atopic Dermatitis - autoimmune disorder causing skin rash. It is chronic and not contagious.
• Symptoms: pruritus (itching), erythema and dry skin. In infants-red, crusted, scaly lesions is seen. It is
usually diagnosed before 1years old.
• Treatment: alleviate pruritus (so they do not keep scratching or get secondary infection). Keep nails short,
place gloves/cotton stockings over hands, do not wear rough fabrics or wooden clothing, moisturize, and
keep skin hydrated. Give tepid baths with gentle soap. Gently pat dry after bath and then put emollient
(Eucerin/Cetaphil). Wear soft clothing (like cotton), and long sleeve at night. Avoid triggers like heat/low
humidity.
Psoriasis- chronic autoimmune disease that causes rapid turnover of epidermal cells.
• Symptoms: Dry, scaly, red rashes on skin, and silver plaques.
• Treatment: No cures but avoid triggers (stress, trauma, infection). Also give topical therapy (steroids,
moisturizes), phototherapy (UV light) and systemic medications.
Bed bugs-

• Symptom: Cause itchy red rash.

• Intervention: launder clothes in hot water, highest temp on dryer. Store in a tightly sealed plastic bag. Get
a professional pest control company to evaluate a classroom. Treat the entire house for bed bugs. They
can inhabit any (even clean) environment.

Tick-

• Symptom: bulls eye rash.

• Give prophylactic antibiotics.

Lyme disease-develops after deer tick.

• Symptom: Initially get flu like symptoms (headache, fever, and fatigue), then get bulls eye rash-which you
want to report immediately.
• Treatment: antibiotics.
• Complication: can cause carditis, or meningitis.
• To prevent tick bite: insect repellent (DEET), avoid tall grass/thick underbrush. Wear long sleeve shirts
with long pants.
• Treatment: Remove tick with tweezers

Oral candidiasis/thrust- fungal infection

• Causes: from antibiotics, not rinsing mouth after steroid inhaler, or from immature immune system.
• Risk Factors: immunosuppressed, patient taking steroids/antibiotics, AIDS, poor oral care, infants.
• Transmitted: It can go to a mom’s breast milk or go from toys in a baby’s mouth to another’s kids’ mouth.
• Symptoms: pearly milk curd white lesions/patches on oral mucosa, tongue, or palate. They are
non-removable and bleed when touched.
• Treatment: antifungal (nystatin) and proper oral hygiene
Candida – fungus infection

• Symptom: white, curd/cheese like vaginal discharge.

29

• Treatment: antifungal (fluconazole)

Impetigo- Is a highly contagious bacterial skin infection. It usually occurs in kids, in hot humid weather.

• Symptoms: itchy, burning, red pustules that rupture into honey-colored crusts.
• Treatment: antibiotic ointment. 24-48 hours after taking, they are not contagious. The lesions heal within
a week. With no antibiotics it takes 2-3 weeks, and they are contagious until the lesion heals.
• Interventions: wash hand before and after touching. Isolate patients’ clothes and linen and wash them in
hot water. Keep patients’ fingernails short and clean. Do not be with others for 24-48 hours after
antibiotics. Keep area covered with gauze when in contact with other. Soak lesion in warm water, saline,
or burrows solution and clean with mild antibacterial soap before applying the antibiotics. Avoid alcohol
because its irritating

Human papillomavirus (HPV)- is an STI (sexually transmitted infection).

• It causes genital warts and cervical cancer. There are different strains- type 16/18 causes nearly all the
cervical cancer cases. It is usually asymptomatic and genital warts are painless.
• Transmitted: It can spread through vaginal, anal, or oral sex. Even without symptoms, it can spread
through sexual contact, or skin to skin contact (even with a condom).
• Prevention: vaccine against HPV before being sexually active. The recommended age for vaccine is 11-12
for boys and girls. It can be given at age 9 and up to age 26. Patients with HPV need to have annual pap
test because the virus increases risk of cervical cancer.

HIV-is a viral infection. The virus attacks CD4 cells (which help the body fight infection). This makes the person
infected with HIV at risk for infection. When the CD4 cell count goes below 200-then the person is said to have
AIDS, and they are at high risk for opportunistic infections.

• Interventions: Standard precaution. The patient should be up to date with immunizations. Do not eat
undercooked foods or have contact with cat litter. Do not drink water from poorly sanitized areas. Always
use latex or synthetic condoms, and dental dams for sex (natural barriers like lambskin do not work).
Sharing personal hygiene devices that may have been exposed to blood (like toothbrushes, razors)
increases HIV transmission risk and should be avoided.
• Treatment: antiretroviral therapy (ART). It decreases the viral load and increases CD4 cell count. The
treatment is lifelong and needs strict adherent. If they are sexually active, they need regular testing.

Influenza aka The Flu

• Transmitted: through inhaling droplets through sneezing, coughing, or speaking. If you need to be in
contact with someone with the flu-wear mask.
• Symptoms: fever, chills, muscle ache, headache, cough, sore throat, nasal congestion, and malaise.
• Treatment: rest, hydration, humidified air, antipyretics. Antivirals like oseltamivir (Tamiflu) can be given.
• Prevention: Everyone over 6 months should have the vaccine unless they have life threatening allergy to
vaccine.
30

Bacterial vaginosis-is an overgrowth of vaginal bacterial flora. Is causes a fish like vaginal odor. This condition is
not usually serious and is treated with oral or vaginal antibiotics (like metronidazole).

Genital herpes- is an STI (sexually transmitted infection)

• Causes: herpes simplex virus. Highly contagious. Remains in body even after lesions healed.
• Treatment: there is no cure, you just treat the symptoms and prevent it from not spreading. Do not
touch/scratch them because they can spread-so use gloves when putting on antiviral or analgesic meds.
Clean lesion with warm water and soap. Keep clean and dry. During active lesion-abstinence. After
outbreak resolved-used condom. Keep area clean/dry. No perfumed soaps/bubble bath. Proper hand
hygiene. Use sitz bath and oatmeal bath. Dry lesions w hair dryer on cool setting. Use warm water and
mild soap.

Shingles aka Herpes Zoster-

• Causes: varicella zoster virus (which also causes chickenpox).

• Transmitted: Shingles lesions that are open may transmit the infection by both air and contact. The
client with disseminated shingles that are not crusted over will require contact precautions, airborne
precautions, and a negative airflow room to prevent transmission of the infection to others in the
hospital. Localized shingles require only standard precautions for clients with intact immune systems and
contained/covered lesions.
• Risks: immunocompromise patient.
• Symptoms: unilateral, linear pattern of fluid filled blisters. Patients have pain and itching.
• Interventions: Cover the rash. Ask the patient if they had the chicken pox (because it is from same virus so
someone older, or a weaker immune system can have it reactivated)

Trichomoniasis- is an STI (sexually transmitted infection).

• Symptoms: profuse, frothy, yellow/green, mal-odorous vaginal discharge. Can also have pruritis, dysuria,
dyspareunia (pain during sex).
• Treatment: oral metronidazole (Flagyl). Patient education: abstain from sex till infection clears (1 week
after treatment). No drinking alcohol while taking medication until 3 days after. Have partner treated
simultaneously. Use condom. Know side effects of metronidazole (dark colored urine, metallic taste).
• Complication: vaginitis (vaginal inflammation and discharge)

Gonorrhea- is an STI (sexually transmitted infection)

• You need to treat the partner also. Do not have sex till the treatment is completed and no longer
symptoms.
• Complication: pelvic inflammatory disease (PID) and infertility
• Symptom: asymptomatic.
• The CDC says annual gonorrhea screening for all sexually active females less than 25 years (or older than
25 years if they have risk factors). Use latex condoms to reduce risk of getting it.

Chlamydia-most common STI (sexually transmitted infection)

31

• Risk factors: multiple sex partners, new partner.

• Prevention: All sexually active women under 25 years (or above 25yr if high risk) are screened annually
for Chlamydia and gonorrhea
• Symptoms: Many patients are asymptomatic or have minor symptoms (spotting after sex, dysuria, and
abnormal vaginal discharge)- but they can still transmit the infection.
• Treatment: antibiotics. The sex partners are also given treatment
• Complication: pelvic inflammatory disease (PID) and infertility

Rabies- is a severe infection affecting nervous system. Risk factor: exposure to bats.

Purpura- is red/purple blotches that do not blanch with pressure. It symbolizes that there is bleeding underneath
the skin

Acanthosis nigricans –is a symmetric, hyperpigmentation velvety plaque in axilla and neck area. Skin tags are
common. It indicates insulin resistance. You should refer them to doctor for undiagnosed diabetes mellitus or
metabolic syndrome.

Tuberculosis

• Transmitted: airborne
• Symptoms: low grade fever, night sweats, anorexia/weight loss, fatigue, hemoptysis. They also get
symptoms depending on location. 85% of time it is pulmonary, and those symptoms include: cough,
purulent/blood tinged sputum, shortness of breath
• Diagnosed:
o TST (Mantoux) aka Tuberculosis Skin Test. The solution is called tuberculin (PPD). The test involves
two steps. Injection in forearm. evaluation of injection site after 48-72 hours. If there is a red area
(induration) of more 15mm then positive response. However, this does not mean the person has
active TB, it only means the person was exposed to TB in the past. So, to see if the patient has
active disease, do chest x-ray, positive sputum culture, presents of symptoms. AFB (acid fast
bacilli) sputum culture and smear test (collect in morning sputum on 3 consecutive days), and the
presents of symptoms
o Administering TB: 1ml TB syringe with 27 gauge 1/4inch needle. Clean gloves. Position the left
forearm to face upwards and clean skin (hands width above the wrist). Place non dominant hand
1inch below insertion site and pull skin down so it is taut. Insert needle 10-degree angle with the
bevel up (not more than 15 degrees cause then it is subQ). Advance tip of needle through
epidermis to dermis, the outline of bevel should be visible under the skin. Inject the medication
slowly while raising a small wheal (bleb) on skin. Remove needle, do not rub. Circle area with a
pen
o An alternative is the QFT – Quantiferon-TB blood test. - it measures how the immune system
reacts to TB. Positive means the patient is infected with TB. It is more expensive, but you go once
to the doctor and the results are available 24 hours later
• Other: Noncompliance is a major issue with TB medications because it takes 6 months to treat and there
are unpleasant side effects so DOT-directly observed therapy-basically watching them take it.
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Vaccines/Immunizations

• Severely immunocompromised patients (patients on corticosteroid therapy, chemotherapy, AIDS)

generally should not receive live vaccines (like varicella-zoster vaccine, measles-mumps-rubella, rotavirus,
yellow fever).
• You can give a patient vaccine even if they have a penicillin allergy, mild illness, recurrent infection
exposure, or current antibiotics use.
• Normal vaccination reactions: mild fever, soreness, redness at injection site. Put warm compress to
injection site and can take Tylenol /ibuprofen if needed after.
• Give HIB vaccine at 2 and 4 months – to protect against epiglottis.
• Give MMR vaccine-to kids between 12-15 months. But it is safe to give to under 12 months especially if
given within 72 hours of initial measles exposure. But if they do get the MMR vaccine before 1 years old,
they need to get it again between 12-15 months and again at 4-6 years.
• A patient with a history of seizures should get a separate MMR and varicella vaccine and not a
combination of the MMRV vaccine.
• Varicella vaccine is given to prevent varicella zoster (aka chickenpox).
• Pneumococcal vaccination- is given to all adults over 65 years old. They should get 2. Teach them to stop
smoking, proper cough method, and to practice respiratory/hand hygiene. Avoid crowds/individually with
respiratory illness
33

MED SURG NOTES

Fluid and Electrolytes Disorders:

Diabetes insipidus (DI)-is when there is low antidiuretic hormone (ADH). ADH promotes water reabsorption in the
kidneys- so a loss of ADH means massive diuresis of diluted urine-basically they keep peeing. Symptoms:
increased urine output (polyuria), increased thirst (polydipsia), decrease urine specific gravity (less 1.003), dilute
urine, elevated serum osmolality (more 295). Hypernatremia (more 145), hypovolemia, hypotension, severe
dehydration. Treatment: Desmopressin (medication). Hint-DI like die- I would die if I keep needing to pee while on
a date.

SIADH- syndrome of inappropriate antidiuretic hormone secretion- is the opposite of Diabetes Insipidus, it
means there is an increase of ADH, causing retention of water. It can cause dilutional hyponatremia (seizure
precautions) and hypervolemia (from fluid retention) and can lead to severe neuro dysfunction. Symptoms: low
serum osmolality, low serum sodium, decreased urine output, high specific gravity. Causes: lung cancer, CNS
disorders (stroke), meds (desmopressin, carbamazepine). Treatment: fluid restriction, oral salt tablets, and
hypertonic iv solution (3% NACL) in small quantities.

Dehydration- the cardinal signs of dehydration are poor skin turgor, dry mucous membranes, tachycardia,
orthostatic hypotension, weakness, skin tenting, and lethargy. Treatment: oral rehydration, maintain fluid and
electrolyte balance

Diarrhea-usually self-limiting and lasts less than 48 hours. If it lasts for more than 48 hours and fever or bloody
stools-go to doctor. Causes: microbes, dietary intolerances, malabsorption, medication, laxative overuse.
Treatment: eat bulk forming foods. Rest. Fluids, acetaminophen (if fever). Loperamide.

Water intoxication- too much water in the body. It can lead to hyponatremia. Causes: dilute formula for infant.
Symptoms: (are the signs of hyponatremia): irritability, lethargy, hypothermia, and seizures (facial edema),
headache, mental status changes, weakness, and if severe seizures, neuro changes, or death.

Third spacing-when the fluid goes from the blood to a place it cannot be used. So, it leads to less fluid circulating
around the body. Symptoms: hypotension, decrease output, tachycardia. Causes: after abdominal surgery

Hyponatremia-low sodium concentration in blood. Symptoms: irritability, lethargy, hypothermia, headache,

mental status changes, weakness, and seizure. Place patient on seizure precautions.

Hypernatremia: high sodium concentration in blood. Causes: dehydration, vomiting, diarrhea. Symptoms: neuro
symptoms: restlessness, seizures, increased thirst with dry mucous membranes. Place patient on seizure
precautions.

Hypoglycemia-low blood sugar. Symptoms: irritability, seizures

34

Hyperglycemia-high blood sugar. Symptoms: excessive thirst, increase urination, abdominal pain, headache,
fatigue, blurred vision.

Hypercalcemia high calcium level- constipation, polyuria

Hypocalcemia- low calcium level. Causes: thyroidectomy/parathyroidectomy. Symptoms: positive trousseau’s

(carpal spasm) and Chvostek’s (facial twitching), tetany (tingling in hands/feet/mouth), seizures, laryngeal stridor,
cardiac dysfunction. Treatment: calcium gluconate.

• To test for trousseau sign (place the blood pressure cup on the arm, inflate to pressure more than systolic
blood pressure. Hold in place for 3 minutes. If hypocalcemia- it will induce a spasm of hand/forearm
muscle.
• To test for Chvostek’s sign- tap the face at the angle of the jaw and watch for contraction on same side of
face

Hypomagnesemia-low magnesium level. Causes: alcohol abuse, inadequate nutritional intake, increased loss via
GI/renal. Symptoms: (similar to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs,
hyperactive reflexes, and seizures. It can also cause a prolonged QT interval that increases susceptibility to
ventricular tachycardia (Like torsade’s de pointes). Treatment: IV magnesium sulfate.

Hypophosphatemia- low phosphate level. Symptoms: muscle weakness and respiratory distress

Hypokalemia- low potassium level. Causes: diuretics, diarrhea. Symptoms: muscle cramps, muscle weakness,
paresthesia, flattened T waves, Paralytic ileus (abdominal; distension, decreased bowel sounds), cardiac
arrhythmias. Treatment: IV KCL (potassium chloride)- do not give more that 10meq/hr-so give it via infusion pump
and always dilute it. If it is given too fast, it can cause a cardiac arrest (so do not give it via gravity).

Hyperkalemia—high potassium levels. Symptoms: paralysis/weakness, unstable dysrhythmias, cardiac arrest. It

can also lead to metabolic acidosis, and cardiac dysthymias. Treatment: IV dextrose with insulin. If there is EKG
changes (like peaked T waves) give calcium gluconate.

Burns-

• Burn management- ABC (airway, breathing, circulation). For circulation give LR (lactated ringer). After
ABC-Pain meds, they are at risk of infection, removing eschar
• Leads to a large fluid shift which causes a decrease perfusion to GI tract (so do not give oral medications)
and damages the subcutaneous layer (so do not give subQ or IM injection)- so give medications IV route.
• The biggest complication of burns is hypovolemic shock (electrolyte imbalance).
• The best indicator that fluid resuscitation has been corrected is urine output (@ least 30ml/k/hr).
• With chemical or radioactive agent, the priority is to decontaminate the hazardous substance. Usually
have decontamination area (with showering, cleansing station)- go into first with running water. Remove
any clothing and discard (because as long as chemical on skin further injury may occur).
• Burn home care: soak in cool water, remove clothing, cover with clean, dry cloth, do not put anything else
on.
35

Cardiac/Heart
DASH Diet-is a diet for a patient with hypertension. It includes reduce foods high in sodium, sugar, cholesterol,
trans/saturated fat. They should increase consumption of fresh fruits, whole grains, fat free dairy, and low
cholesterol meats and legumes

Rheumatic fever- is an acute inflammation of heart. It occurs 2-3 weeks after a step infection. It is caused by a
delay onset of an autoimmune reaction. It affects the heart, skin, joints, and CNS.

Holter monitor- continuously records the patient’s EKG for 24-48 hours. Place the electrodes on the patient and
attach to recording units. The patient should keep a diary of activities and symptoms, no bathing during test
period, and do normal activity. After that the patient will go to doctor and review the data.

Femoral popliteal bypass surgery-involves circumventing a blockage in the femoral artery with a synthetic or
autogenous (artery or vein) graft to restore blood flow. Interventions: neurovascular assessment of the affected
extremity and compare with the preop baseline.

Heart Failure- The heart is a muscle that pumps out blood. Blood increases the volume (think more fluids). So, if
the pump fails, there will be a fluid backup somewhere and a decrease of fluid pumped out. There are two types
of heart failure: right or left. Right sided heart failure-is when the right sided heart fails-so the blood backs up to
the body, causing systemic symptoms. Left sided heart failure-is when the left sided heart fails-so the blood backs
up to the lungs, causing pulmonary symptoms.
Right side heart failure symptoms include: edema, jugular vein distension, increased abdominal girth/ascites,
hepatomegaly, weight gain.
Left side heart failure symptoms include: orthopnea (shortness of breath when lying flat), paroxysmal nocturnal,
dyspnea, crackles, s3 sounds.
Heart Failure interventions: diuretics (to decrease the fluid volume overload). Do not take NSAID’s because they
can cause sodium retention (which would cause more fluid retention). Do not eat high sodium foods like frozen
meals. Weigh the patients daily, assess the breaths, check respiratory status, and give oxygen accordingly.
Treatment: loop diuretics (Furosemide)- to reduce the fluid retention. For chronic heart failure-beta blockers or
ACE receptor blockers.
Note: heart failure can cause dilutional hyponatremia and is expected. If borderline low level, it does not require
immediate attention.

Hypertensive crisis-is a systolic blood pressure more than 180 and a diastolic of more than 120 with evidence
organ damage (kidney damage, retinopathy, heart failure, hemorrhagic stroke.). Early symptom: headache.
Treatment: IV vasodilators like nitroprusside sodium. You want to decrease the blood pressure slowly (not from
200 to 120) like over 24hours. Once the blood pressure is stabilized, then give oral antihypertensive medications
(like labetalol, nicardipine).

Pharmacologic nuclear stress test- uses vasodilators drugs produce vasodilation of the coronary arteries in
patients with suspected coronary heart disease. A radioactive dye is injected so a special camera can produce
images of heart. Preop: do not eat/smoke/drink on day of test. No caffeine or decaffeinated products 24 hours
36

before. Do not take theophylline 1-2 days before. Do not take insulin (because with no food it can cause
hypoglycemia). Do not take cardiac medications.

Aortic dissection-is a tear in the inner lining of the aorta. So, blood comes out and weakens the aorta wall causing
less perfusion to the vital organs. Causes: hypertension. Symptoms: acute onset of excruciating sharp/ripping
chest pain that radiates to the back. Treatment: emergency surgery. Before surgery give IV beta blockers to lower
the heart rate /blood pressure.

Aortic stenosis: is the narrowing of the aortic valve (so it stops the blood flow from the left ventricles to the
aorta). Causes: hardening of the valves, congenital heart disorders, or inflammation. If its left untreated, it can
lead to heart failure and pulmonary hypertension. Symptoms: it is usually asymptomatic but can have a loud
systolic ejection murmur heard over the aortic area, chest pain, syncope worsened by exertion.

Mitral valve prolapse- is a condition in which blood leaks backward through the mitral valve in the heart. This
backflow of blood may result in a heart murmur, palpitations, dizzy, lightheadedness, or chest pain. Treatment:
beta blockers. Tell the patient no caffeine (because of palpitations), Check ingredients of OTC/diet pills for
stimulants, reduce stress, no alcohol, and exercise. They are at risk for: infective endocarditis.

Pacemaker- is a small device that is placed in the chest or abdomen to help control abnormal heart rhythms.
Interventions: You want to report fever/signs of redness/swelling/drainage at site. Carry pacemaker ID card with
med alert bracelet. Take pulse daily and tell doctor if below rate. No cell phone in pocket or directly over
pacemaker. No MRI. Hold phone on the opposite side of ear. Tell airport of pacemaker. Do not stand near an
antitheft detector in store entry ways. Do not lift arms over shoulder on side of pacemaker till doctor says.
Microwave ovens are safe. Assess for electrical and mechanical capture of heart rate.

Implantable cardioverter defibrillator (ICD)-s device that senses and defibs life threatening dysthymias. It also
includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for
bradycardias that may occur after defibrillation. The ICD consists of a lead system placed into the endocardium
via the subclavian vein. The pulse generator is implanted subcutaneously over the pectoral
muscle. Postoperative care and interventions are the same as pacemaker implantation.

Defibrillation- is used for V-Fib and pulseless V-Tach. You want to turn on the Defibrillator. Place the pads on the
patient’s chest. Charge it. It will say all clear and deliver a shock. Immediately resume chest compressions. You
should be doing CPR the whole time till it says all clear.

Synchronized Cardioversion- it delivers shock on the R wave (in the QRS complex). It is used for supraventricular
tachycardia, V-tach with a pulse, and A-fib with a rapid vent response. You must make sure the defibrillator is
synched.

Coronary artery bypass grafting- CABG- is a surgery done to restore blood flow to the heart due to a blockage in
the coronary artery. It is done by taking blood vessels from an area in the body to bypass the damaged artery.
Discharge teaching: do not smoke, lose weight, health, exercise. Daily shower. Wash off surgical incisions gently
mild soap and water and pat dry but not soaked in water. They can do light housework in 2 weeks postop, but
37

nothing weighing more 5lbs (till 6 weeks postop). Tell doctor if chest pain/shortness of
breath/fever/redness/drainage/swelling of incision site.

Coronary angiography- is an invasive diagnostic study of the heart. It uses contrast dye, usually containing iodine,
and x-ray pictures to detect blockages in the coronary arteries that are caused by plaque buildup. The patient is
sedative with medication, and they go through femoral/radial artery. The patient feels warm/ flushed when dye is
injected, and compression to the puncture site. After the patient lies flat for several hours.

Myocardial ischemia- Causes: anything that increases oxygen demand to the cardiac muscles like physical, intense
emotion, temperature extremes, smoke, stimulants etc.

• When a patient has chest pain and you think Myocardial infarction: Interventions: ABC (airway,
breathing, circulation), sit them upright, give oxygen if hypoxic. Baseline vitals. Auscultate. 12 lead EKG.
2-3 large bore IV catheters. Assess pain. Medicate for pain (nitro). Continuous EKG monitoring. Baseline
blood work (cardiac markers, serum electrolytes). Portable chest x-ray. Aspirin
• Female, elderly, and diabetic patients tend to present with atypical symptoms of myocardial infarction
like nausea or fatigue. They may not always experience chest pain and many people report chest pain as
indigestion. Also even when people do experience pain, it may be atypical or may radiate to unusual
locations (like the jaw, back).

Angina-is chest pain because of myocardial infarction. If there is stable chronic angina-give nitro to relieve the
pain. If nitro does not work, give morphine.

Acute coronary syndrome-broad term that includes a range of cardiac stuff like unstable angina and MI.
Treatment: IV nitro until treatment plan (percutaneous coronary intervention, thrombolytic, bypass)

Pericarditis-is inflammation of the pericardium (membrane sac surrounding heart). This can lead to increase fluid
in pericardium (pericardial effusion). And when increase fluid on heart, it cannot contract and eject blood which
can lead to life threatening cardiac tamponade. So, when you assess a patient with pericarditis look for symptoms
of cardiac tamponade. With pericarditis the inflamed pericardium rub against each other (so you will have
pericardial friction rub-high pitched, leathery, grating sound), and it can cause pain that’s worse when deep
breathing, coughing, or supine. So, place the patient in fowler position (45-60 degrees) with support to lean on
(sitting up and leaning forward to relieve the pain). Other treatment: give NSAID/Aspirin with Colchicine

Ineffective endocarditis-is an infection of the endothelial lining of the heart. So there is vegetation over the valves
that can break off and immobilize to different organs causing stroke, ischemia (which can manifest as the
following symptoms: paralysis on the side, pain/pallor of extremities, abdominal pain, splinter hemorrhages,
arthralgia (multiple joint pain), weakness, fatigue, or fever. Treatment: antibiotics IV for 4-6 weeks. Tell the
patient to check their temperature at home regularly. Report fever because that means that the antibiotics are
not effective. To prevent endocarditis- this patient should get prophylactic antibiotics before dental procedures.
(The following patients should also get prophylactic antibiotics before dental procedures: prosthetic heart valve,
history of ineffective endocarditis, congenital heart disease, cardiac transplantation.)
38

Cardiac catherization- is done to assess and diagnose coronary artery disease. They put a catheter with iodine
through a vein or artery (usually femoral) which goes to the heart. Use vein if doing right sided catheterization
and an artery if doing left sided heart catheterization. Postop: a pressure dressing is applied, and the patient is
placed supine with the affected extremity flat for 2-6 hours. Assess hemodynamics (blood pressure, heart rate,
strength of distal pulses, color, temperature of extremities). And assess for bleeding at the incision. Any report of
back/flank pain, tachycardia, hypotension. -report because it can be retroperitoneal bleeding. If there is
bleeding-apply direct manual pressure to vessel puncture site. Complications: allergic reaction to IV contrast,
contrast nephropathy (because the iodine contrast can cause kidney injury), or lactic acidosis (so discontinue
metformin 24-48 hours before and restart it 48 hours after).

Respiratory

Respiratory distress-Interventions: Place in high fowlers. Oropharyngeal suction. Give 100% oxygen by
nonrebreather mask. assess lung sounds. Notify doctor.

Stridor- high pitched, vibration, harsh sound heard during inspiration. It indicates a partial airway obstruction.
Stridor and other signs respiratory distress after thyroidectomy is life threatening because of airway swelling. You
want to have suction, oxygen, and a trach tray nearby

Incentive spirometer- is a device used for postop patients to prevent atelectasis like with rib fractures. Give pain
medication before incentive spirometry. Do 5-10 breaths per session every hour while awake. Instructions: sit up
or in high fowlers. Hold device at even level, seal lips tightly on mouthpiece. Inhale deeply for 2-3 seconds (up to
6). exhale slowly. Breathe normally and then repeat. Cough at end of session.

Chronic Obstructive Pulmonary Disease (COPD): refers to 2 conditions-emphysema and chronic bronchitis. It is a
slowly progressive, persistent airflow obstruction associated with chronic inflammation of the airway. Risk factors:
tobacco smoke (cigarette, pipe, cigar), and working as car mechanic (because of the fumes). Treatment: steroids
for exacerbation, nebulizer. Also do not increase oxygen levels, because COPD patients only breathe because they
sense a lack of oxygen, not because of carbon dioxide- so if you give them too much oxygen, the drive to breathe
will decrease.

COPD patients can have chronic colored sputum, wheezing. Anxiety, difficulty breathing, shortness of breath. An
oximetry reading of ≥88% is generally acceptable in an asymptomatic client with COPD. With severe COPD, they
have chronically low oxygen levels-so to compensate the body produces more red blood cells, so they have
polycythemia (so do not give them iron supplements). COPD patients are also at risk for respiratory infections.
Give them flu/pneumococcal vaccinations. Tell them to seek medical help for increased sputum, worsening
shortness of breath, or a lack relief from prescribed emergency meds (like albuterol, ipratropium). They should
eat small, frequent, high calorie meals because tiring otherwise.

Oxygen-if a fire has occurred, oxygen can feed it. Vaseline should be avoided-because flammable (so use water
soluble lubricant instead). keep oxygen canisters at least 5-10 feet away from gas stoves. Precaution with cooking
oils and grease by fireplace, wood stoves, candles (any open flames). Nail polish remover and nail polish has
39

acetone-which is flammable. Avoid synthetic and wool fabrics because they can cause static electricity (use cotton
blanket and wear cotton fabrics).

Chronic bronchitis- is one type of COPD. The inflamed bronchial tubes cause excessive mucus production, chronic
cough. They usually have a viral infection before. Interventions: increase fluids 2-3L/day. Cool mist humidifier.
Guaifenesin (expectorant). Abdominal breathing with huff (force expiratory technique), chest physiotherapy,
airway clearance handle devices.

Aspiration pneumonia- is when aspirated material (foods, emesis, gastric reflux) causes an inflammatory
response and allows bacteria to grow. Risk Factors: cognitive changes (dementia, head injury, stroke, sedation),
difficulty swallowing, compromised gag reflex, tube feeding. Preventions: thicken liquids. Fully awake (no sedating
medications before). Elevated head of bed to 90 degrees for 30 minutes post op and never lower less than 30
degrees. Facilitate swallowing by flexing neck (chin to chest). Give antiemetics. Monitor
coughing/gagging/pocketing food. If have tracheostomy-partially/fully deflate cuff.

Crackles- may be heard with fluid overload, aspiration, or pneumonia.

Acute respiratory failure- is when there is damage to alveoli/capillary membrane causing alveoli to collapse and
fluids to leak. life threatening. The lungs cannot oxygenate blood and excrete carbon dioxide. Symptoms:
refractory hypoxemia. mental status changes (restlessness, confusion, lethargy, drowsiness), and alterations in
acid base balance. Also, paresthesia’s, dyspnea, tachypnea and hypoxemia. Priority: is the impaired gas exchange

Lung contusion-is a bruised lung. It is caused by a blunt chest force trauma (like when chest hit a car steering
wheel). It is life threatening because bleeding into the lungs can lead to ARDS. Interventions: Monitor for 24-48
hours as symptoms (like dyspnea, tachypnea, tachycardia) usually develops as the bruise gets worse. Other
symptom include: inspiratory chest pain. Treatment: oxygen, medications, and ventilator support.

Pleural effusion-is when there is an unusual amount of fluid around the lungs. Diagnosed: chest x-ray/CT scan.
Treatment: thoracentesis. Symptoms: dyspnea with nonproductive cough, chest pain with respirations.
Diminished breath sounds/absent breath sounds in lung base, dullness to percussion, decreased tactile fremitus

Thoracentesis- is a procedure in which a needle is inserted into the pleural space to remove excess fluid from the
pleural space so patient can breathe easier. It can be done for diagnostic or as a treatment. Complications:
pneumothorax, bleeding, Altered mental status changes. Before the procedure-place the patient upright in a
sitting position on the side of the bed, leaning forward over the table with the arms on supported pillows.

Pneumothorax- is when air gets in the lungs and collapses. Symptoms: respiratory distress, air hunger,
tachycardia, hypotension, sudden worsening dyspnea, tachypnea, hyper-resonant when percussing, drop in
oxygen saturation. If air cannot escape the pleural space, it can cause a tension pneumothorax. Priority
intervention: apply sterile occlusive dressing (petroleum gauze) taped on 3 sides, after covering then place a chest
tube to get out the air.

Tension pneumothorax- is when air enters pleural space but cannot escape. Symptoms: tachypnea, hypotension,
tachycardia, hypoxia, JVD, and tracheal deviation (late sign). It is a medical emergency. Treatment: occlusive
40

dressing with 4 sides, then emergency large bore 20 gauge inserted at mid axillary line for needle decompression,
then chest tube placement.

Pulmonary edema-is when there is too much fluid in the alveoli that leads to the lungs swelling. It is acute, and
life threatening. Symptoms: shortness of breath, frothy blood /pink tinged sputum, tachypnea, edema, if
auscultate-rails and crackles, and hypoxemia. Treatment: oxygen, diuretics

Pneumonia-is an acute inflammation of lungs caused by bacteria. Symptoms: fever, chills, productive cough,
dyspnea, pleuritic chest pain, fatigue, crackles (fine and coarse), sputum production, increased vocal/tactile
fremitus. Bronchial breaths in peripheral fields, unequal chest expansion. It can lead to pleurisy. Postop
pneumonia- pain control (so they can move, deep breath etc.). Ambulate within 8 hours of surgery. Cough with
splinting every hour. Deep breathing/incentive spirometer every hour. Fowlers position (45-60 degrees).
Turn/reposition every 2 hours. Swab mouth with chlorhexidine every 12 hours. Use hand hygiene.

Pleurisy- Is an inflammation of the tissues that lines the lungs and chest cavity. Symptoms: stabbing chest pain
that increases with inspiration/cough. Pleural friction rub.

Fremitus-is a palpable vibration on the chest wall.

Rhonchi-low pitched wheezing-heard over large airways during expiration.

Asthma
• Asthma exacerbation/attack- Causes: due to triggers (allergens, respiratory infection, exercise, cold air
etc.). Symptoms: high pitched expiratory wheezing (If the wheezing/breath sound stops=silent
chest-which means that there is a lack of airflow, and it is an emergency). Other symptoms: chest
tightness, dyspnea, cough (the earliest sign), and retractions. Interventions: The nurse should assess the
severity by assessing the peak expiratory flow using a peak flow meter. Then assess respiratory rate and
lung sounds. Treatment: nebulizer with short acting beta agonist medication (like albuterol) and oral/IV
corticosteroids. The best indicator of effectiveness is the oxygen saturation
• Acute severe asthma exacerbations aka Status Asthmaticus-is when severe airway obstruction and air
trapping continues despite aggressive treatment with bronchodilators and corticosteroids. The patient is
at risk for respiratory failure.
• Peak flow meter –it measures the airflow out of lungs (peak expiratory flow rate). It is the best indicator
of moving air in an asthmatic patient. The results are categorized as green (≥80% of personal best and
good control), yellow (50%-79% of personal best and caution-need a change in treatment), and red (<50%
of personal best - a medical alert-need immediate treatment). Steps: Move indicator to 0 before using,
then exhale as quickly and forcibly as possible through mouthpiece. The personal best is the highest peak
flow reading a patient can get over a 2-week period.

Bronchoscopy-is a procedure done to see the bronchi with a camera that is passed through nose/mouth. It is
done to diagnose, get tissue, remove secretions or objects.
Interventions: mild sedation (midazolam), and topical anesthetic (lidocaine) to nares and throat to suppress
gag/cough reflex. Complications: hemorrhage, hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia,
41

pneumothorax (rare), and adverse effects from medications used before and during the procedure.

Gastrointestinal (GI)

Hiatal Hernia-is when a part of the stomach pushes through the diaphragm. Causes: conditions that increase
intrabdominal pressure (like pregnancy, obesity, ascites, tumors, heavy lifting), and weaken muscles of the
diaphragm. Symptoms: Can be asymptomatic or have symptoms of GERD (like heartburn, dysphagia, pain increase
when supine or when abdominal pressure). Interventions: change diet (avoid fat foods and those that lower
esophagus sphincter pressure (like chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals,
decrease fluids during meals. Do not eat meals close to bedtime. Do not smoke. Lose weight. Do not lift/strain.
Elevate head of bed 30 degrees. No tight clothing.

Inguinal hernia- is the protrusion of the abdominal contents through the inguinal canal-looks like bulge in lateral
groin. Causes: increased intraabdominal pressure (like from heavy lifting). Common in men. Symptoms of inguinal
hernia: dull pain exacerbated by exercise/straining and a palpable bulge on assessment. Treatment: minimally
invasive surgery. If strangulation of intestines, then emergency treatment. (Strangulation/bowel obstruction
symptoms: abdominal distention, severe pain, nausea, vomiting). To prevent reoccurrence: avoid activities that
increase intrabdominal pressure (like coughing, heavy lifting) for 6-8 weeks post op. Splint the incision and keep
the mouth opened while sneezing if you need to sneeze/cough.

Small bowel follow through-examines anatomy and function of the small intestines using x-ray images. Barium is
ingested and x-ray images are taken every 15-60 minutes to visualize barium as it passes through the small
intestines. It can tell if you have decreased motility, increased motility, fistulas, or obstruction. Tell the patient:
fast before and drink lots of fluids after the exam. Chalky stools may be present 24-72 hours after exam. If brown
stool does not return after 72 hours or abdominal pain/fullness tell doctor.

Barium enema- is an x-ray exam done to visualize the colon to detect polyps, ulcers, tumors, or diverticula. It is
done by injecting contrast into rectum to produce clear images. Contraindicated: in patient with acute
diverticulitis. Tell the patient: take a cathartic (magnesium citrate, polyethylene glycol) to empty stool. Do a clear
liquid diet the day before. They might experience abdominal urge to defecate. Postop: chalky, white stool is
normal. Take laxative (magnesium hydroxide). Drink fluids.

Bowel obstruction- is a blockage in the small or the large intestine. Symptoms: nausea, vomiting, abdominal
distention, green vomit, decreased stool. It can lead to dehydration and electrolyte disturbances, bowel
perforation, infection (peritonitis), tissue necrosis, or sepsis and is an emergency.

Small bowel obstruction-Symptoms: rapid onset of nausea, vomiting, colicky intermittent abdominal pain,
abdominal distention. It can lead to perforation, bowel ischemia. Treatment: NPO status, insert an NG tube, give
IV fluids, pain control

Large bowel obstruction-there is a gradual onset of symptoms like cramping abdominal pain, abdominal
distension, absolute constipation, lack of flatus
42

Valsalva maneuver-is holding your breath while bearing down. When bearing down the vagus nerve is stimulated
so it temporarily slows the heart and decreases the cardiac output. It also increased intraabdominal/thoracic
pressure so do not do the Valsalva maneuver if patient diagnosed with: ICP, stroke, head injury, glaucoma, eye
surgery, or heart disease

Bowel sounds -are normally intermittent (every 5-15 minutes). They should be high pitched and gurgling that you
can auscultate with the diaphragm in each quadrant. Cardiovascular bruits (like swishing, humming, buzzing)
usually indicate arterial narrowing or dilation, and is heard with the bell. If a patient underwent surgery that
required bowel manipulation-there will be absent bowel sounds for the first 24-48 hours. Peristalsis should return
within 24 hours in the small intestines and 3-4 days in long intestines. Other things that can cause absent bowel
sounds: general anesthesia, peritonitis, late stages of mechanical obstruction.

Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes that
can cause borborygmi include: gastroenteritis, diarrhea, and the early phases of mechanical obstruction.

Ileostomy-is a surgical procedure done to create an opening/stoma in the abdominal wall through which the small
intestines is brought out of the body. Immediately postop: low residue diet (so low fiber). After the ileostomy
heals, the patient reintroduces fiber foods one at a time and thoroughly chew it to monitor for stool output. The
patient should avoid: high fiber foods (like popcorn, coconut, brown rice, multigrain bread). Avoid stringy
vegetables (like celery, broccoli, asparagus). Avoid seeds/pits (like strawberries, raspberries, olives). Avoid edible
peels (like apple slices, cucumber, dried fruit).

Colostomy-is a surgical procedure done to create an opening/stoma in the abdominal wall through which the
large intestines is brought out of the body so the stool can pass and bypass the obstructed portion of the colon.
Depending on the location of the colostomy, the stool will have different characteristics. Drink fluids, eliminate
gas and odor foods (like broccoli, cauliflower, dried beans, Brussels sprouts). Empty the pouch when it becomes
1/3 full to prevent leaks.

• The stool produced in the ascending and transverse colon is semiliquid and does not need irrigation. But
you should irrigate the descending or sigmoid colon to promote bowel regimen.
• The stoma should between pink to brick red (indicating vascularity and viability). Minor bleeding /oozing,
or mild/moderate swelling is normal for 2-3 weeks after the surgery. Immediately postop-there will be no
stool. If there is not enough blood supply, it can change the stoma color to pale/dusky/cyanotic color-so
report that

Colonoscopy- is a procedure in which a doctor uses a colonoscope or scope, to look inside the rectum and colon.
The patient should have a clear diet the day before and be NPO for 8-12 hours before. The day before the exam
use bowel cleansing agent like cathartic, enema, or polyethylene glycol. Complications: perforation, rectal
bleeding. During the colonoscopy-air is inflated into the colon so post op they may need to pass gas.

Bronchoscopy-uses an endoscope to visualize larynx, trachea, bronchi. The patient is sedated. Postop: immediate
assessment of the respiratory status and keep them NPO until the gag reflex returns.

Percutaneous endoscopic gastrostomy (PEG)-invasive procedure under conscious sedation to place a tube for
feeding.
43

Peritonitis – is inflammation of the membrane lining the abdominal cavity. Causes: rupture of the appendix
(appendicitis) or perforated bowel. It is an emergency. Symptoms: fever, abdominal rigidity, guarding, rebound
tenderness., and abdominal distension. Treatment: according to cause-usually antibiotics, or surgery.

Gastric lavage- is done through a tube to remove ingested toxins and irritate stomach (like by overdose). It is
rarely done nowadays because of the risk for aspiration, perforation, and dysthymias. It is only done if the
overdose is lethal and if can be done within 1 hour of the overdose. Position the patients head of the bed elevated
and have emergency respiratory equipment. First decompress than lavage.

Enema- introduces liquid into the rectum. It is done to treat constipation or to give medications. There are
different types of enemas. If an enema is given too fast, it can cause spasm (cramps, pain)-if this occurs then stop
for 30 seconds and continue with a slower rate. Directions: Place the patient in sims position. Lubricate the enema
tip and gently insert 3-4 inches into the rectum. Direct tubing tip toward umbilicus (anteriorly) during insertion to
prevent intestinal perforation. The enema should be at room temperature or warmed.

Lactose intolerance- means that the patient gets GI symptoms after eating milk products (like flatulence,
diarrhea, bloating, cramping). Cause: missing enzyme lactose. Treatment: restricting lactose containing foods,
Enzyme replacement (lactai) to decrease symptoms, and supplemental calcium and vitamin D. Some dairy
products like aged cheeses and live cultured yogurt have little to no lactose and can be eaten.

Gastroesophageal reflux disease (GERD)- AKA Acid Reflux- when stomach acid frequently flows back into the
esophagus. Interventions/treatment: lose weight, Small frequent meals, chew gum. They should avoid: caffeine,
alcohol, nicotine, high fat foods, chocolate, spicy foods, peppermint, carbonated beverages. Elevate the head of
the bed when sleeping. Do not eat at bedtime, and do not lie down immediately after eating.

Abdominoplasty-is a tummy tuck

Gastroduodenostomy (Bill Roth 1)- is a surgical procedure in which they remove the distal 2/3 of the stomach
and create an anastomosis (connection) between the stomach and duodenum. It is usually done cases of stomach
cancers. Interventions: NPO till bowel sounds return. DVT prophylaxis (like cough, splint etc.). Small frequent
meals to prevent dumping syndrome. Also eat meals high in fat/protein/fiber (because they take a long time to
digest). No fluids with meals.

Dumping syndrome-is when the gastric content empties too quickly into the small intestines. Dumping syndrome
is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage area in the
stomach. Symptoms: hypotension, abdominal pain, nausea, vomiting, dizziness, sweating, tachycardia (within 30
minutes of eating). Interventions: no fluid with meals (have them 30 minutes apart). Lie (do not sit) down after
meals to slow gastric emptying. low carb diet.

Bariatric surgery for weight loss- surgery on the stomach/small intestines to restrict the patient’s intake. Postop:
manage pain, nausea. Monitor for complications like: infection, fluid and electrolyte imbalance, dumping
syndrome, or an anastomotic leak. Do not use NG tube because can cause hemorrhage and anastomotic leak.
44

Give IV antiemetics. Low fowlers after eating. PCA pump or morphine for pain.
• After bariatric surgery (like a gastric band, or sleeve gastrectomy), they will have a reduced stomach
capacity. So postop- So first give them only small meals of clear liquids, then 24-48 hours post-full liquids,
then solids… Also, they should be having small frequent meals. Not anything high in sugar
Refeeding syndrome- is a lethal complication of nutrition replenishment malnourished patients. Like after a
period of starvation (like giving food to anorexic patient, Chronic alcoholic). Basically, what happens is –after the
patient gets food, insulin is secreted and leads to potassium/phosphorus/magnesium shift and can lead to
respiratory failure, and cardiac dysthymias. Symptoms: rapid declines in phosphorus, potassium, or magnesium.
Also, fluid overload, sodium retention, hyperglycemia, thiamine deficiency. To prevent obtain baseline
electrolytes

Abdominal aortic aneurysm dissection- An aortic aneurysm is a bulging, weakened area in the portion of the
aorta that runs through the abdomen. Causes: increased pressure. Symptoms: hemorrhage shock, pulsatile mass
in periumbilical area slight to the left. Bruit over site. Back or abdominal pain. Hypotension. Treatment:
emergency repair because prolonged hypotension can lead to graft thrombosis/graft leakage. Interventions:
Check pulses- it can be absent 4-12 hours postop. But pedal pulse decreased from baseline and absent pulse with
painful/cool/mottled extremity can be an arterial/graft occlusion. Monitor renal perfusion status. Urine output
should be at least 30ml/hour.

Endovascular abdominal aortic aneurysm repair-treatment for abdominal aortic aneurysm. Monitor puncture
site for bleeding/hematoma. Palpate peripheral pulses. Monitor for graft leakage or separation (which is priority).
Symptoms of graft leakage: ecchymosis of groin area, increase abdominal girth, tachycardia, weak/abscent
peripheral pulses, increased pain in pelvis/back/groin.

Paralytic ileus- is an obstruction of the intestine due to paralysis of the intestinal muscles. Symptoms: abdominal
discomfort and distension, nausea, vomiting. Interventions: NPO (no opioids especially because it causes
constipation), NG tube with fluids, and antiemetics.

Inflammatory bowel disease (IBD)- is an umbrella term for conditions of inflammation of the bowel. It includes:
Ulcerative Colitis and Chron’s disease. Symptoms: chronic inflammation, bloody stools, anemia, elevated
ESR/CRP/WBC blood labs. Dehydration is quite common because IBD patients can have a lot of diarrheal stools in
a day. Treatment: sulfasalazine-anti-inflammatory

Irritable bowel syndrome (IBS)-chronic bowel condition/discomfort caused by altered intestinal motility (there is
no inflammation like by IBD). Symptoms: diarrhea, constipation, or both. Treatment: reducing the
diarrhea/constipation, pain meds. Manage with diet, exercise, and stress management. Patient should restrict gas
producing foods (like bananas, broccoli, beans, cabbage, onions, bagels), and avoid other GI irritants (like spices,
hot/cold food or drink, dairy-except yogurt, fatty foods. Increase fiber intake, and bland foods are generally
tolerated well.

Ulcerative colitis-is chronic inflammation and ulcers of long intestines. Symptoms: abdominal pain, frequent
bouts of bloody diarrhea, anorexia, and anemia. Interventions: diet high in protein, low residue diet (to rest the
45

bowel), and easy digestible foods. Keep a diet journal to identify triggers. Have 2-3ml/day of fluids (to prevent
dehydration). Small frequent meals. Manage pain, promote nutrition, Address psychosocial needs. Evaluate
treatment adherence. Complication: toxic megacolon- (severe inflammation of colon distension). It is life
threatening.

Diverticulitis- is a sac like protrusion that occurs in the long intestines. When they become inflamed/infected-the
diverticular becomes diverticulosis. Symptoms: fever, lower left quadrant pain, diarrhea. Causes: chronic
constipation. Treatment: To treat acute diverticulitis have a low residue diet with no fiber foods. But after the
symptoms resolved then have a diet high in fiber, water, exercise. Antibiotics. Can take fiber supplement like
psyllium or bran. Anything that increase ab pressure (lifting, coughing) or increases peristalsis (laxative, enema)
can lead to perforation or rupture of diverticula so do not do. Complications: abscess formation, bleeding into
stool, and intestinal perforation resulting in diffuse peritonitis.

Peptic ulcer- are open sores that develop in the inside lining of your stomach and the upper portion of your small
intestine. The acid in the stomach can then lead to GI bleeding and perforation. Risk factor: h. pylori infection,
genetic, chronic NSAID use, stress, diet, lifestyle choices. Interventions: Tell the patient that NSAID’s damage the
GI mucosa, do not smoke, no alcohol. Do not eat a lot throughout the day. Treatment: h. pylori treatment incudes
antibiotics and proton pump inhibitors.

Abdominal examination- place patient in a supine position: inspect, auscultate (place diaphragm on right lower
quadrant because high pitched sounds heard there), percuss, and then palpate

Thyroid

Hypothyroidism- is a condition in which the thyroid gland is not able to produce enough thyroid hormone so they
will have low T3/t4 and high TSH levels. Symptoms: (of low metabolism): bradycardia, hypotension, fatigue, cold
intolerance, hypothermia, constipation, fragile, dry skin and hair loss, forgetfulness, weight gain, irregular periods.
Treatment: Synthroid. Check labs every 6-8 weeks. Do not stop taking in pregnancy. Take in the morning on an
empty stomach. If severe hypothyroidism, it can lead to myxedema coma

Myxedema coma-is a severe state of hypothyroidism which causes decreased level of consciousness and can lead
to coma. Symptoms: hypothermia, bradycardia, hypotension, hypoventilation. Treatment: Give respiratory
support (ventilation with a bag valve mask) and assist in intubation. The patient needs thyroid hormone
replacement with IV levothyroxine (after respiratory status is secured). It can take a week for improvement.

Hyperthyroidism- is an overactive thyroid- when your thyroid gland produces too much of the hormone
thyroxine. Symptoms: fever, tachycardia, sweating. Weight loss, moist skin, increased appetite, difficulty sleeping.
heat intolerance. Interventions: high calorie diet (4000-5000). Have 6 full meals. No stimulants (like caffeine).
Treatment: Radioactive iodine -gives large doses destroying all thyroid gland (usually used for thyroid cancer). It
has a delayed response so need up to 3 months for maximal effect.
• Before treatment: tell doctor is had CT scan or something involving iodine recently. Hold antithyroid
46

medications 5-7days before. Take pregnancy test before. Remove dentures, and jewelry around the neck.
• After treatment, the patient emits radiation and excreted bodily fluids are radioactive. Teach home
precautions: limit contact with pregnant women/children. Use separate toilet and flush 2/3 times after
each use. Use disposable utensils, and do not share food that could transfer saliva. Isolate personal
laundry (clothing/linen) and wash separately. Sleep in separate beds from other. Do not sit near others for
prolonged time (like on a train, or flight). Stop breastfeeding 6 weeks before the treatment- do not
resume breastfeeding that baby but can breastfeed with future pregnancies.

Thyrotoxicosis-thyroid storm- complication of hyperthyroidism when excessive amount of thyroid hormone is

released into circulation like with a stressful incident. Symptoms: rapid onset of fever, tachycardia, elevated blood
pressure, cardiac arrhythmias, anxious, restlessness, tremulous, altered mental status. Treatment: iodine, beta
blockers, reduce fever, maintain hydration- monitor them and supportive care for symptoms.

Graves’ disease- is an autoimmune disorder that causes hyperthyroidism, or overactive thyroid. The immune
system attacks the thyroid and causes it to make more thyroid hormone than the body needs. New or worsening
tachycardia with graves’ disease can indicate thyroid storm/thyrotoxicosis. Symptoms: exophthalmos (can be
irreversible)- so raise head of bed, artificial tears, tape patients’ eyes shut when sleeping. Regular eye visits.
antithyroid drugs. Stop smoking. Restrict salt. Use dark glasses. Perform intraocular muscle exercises.

Thyroidectomy- is a surgical procedure to remove all or a part of the thyroid gland. It is used to treat
hyperthyroidism or thyroid cancer. The patient is at risk for airway compromise due to potential neck swelling,
hypocalcemia, and nerve damage. Interventions: the nurse should report symptoms of hypocalcemia. Assess for
stridor or new/worsening changes in voice strength/quality (hoarse, whisper). Keep emergency airway equipment
at bedside. Place the patient in semi fowlers position. Maintain neutral head/neck alignment.

Gallbladder

Cholecystitis- is inflammation of the gallbladder. Causes: cholelithiasis (gallstones). Symptoms: pain in right upper
quadrant, referred pain to right shoulder and scapula. They usually ate fatty foods 1-3 hours before this
happened. Other symptoms: low grade fever, chills. Nausea, vomiting, anorexia. Murphy’s sign. Leukocytosis.
Indigestion, restlessness, diaphoresis Treatment: NPO first, then medications

Cholecystectomy- is a surgical procedure to remove the gallbladder. Postop interventions: Early ambulation and
deep breathing. Clear diet till bowel sounds return. low fat diet (can do regular diet after few weeks). Resume
normal activity slowly. Remove dressing the day after surgery and they can shower but not bathe. Symptoms of
infection: redness, edema, pus, severe pain, fever, chills- you should report if occurs. Postop complications:
Pneumonia, surgical site infections, UTI, peritonitis.
47

Renal/Kidney and Adrenal Glands

Dialysis- is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can
no longer perform these functions naturally. The amount of fluid removed is called ultrafiltration. Interventions:
assess vitals, fluid status, vascular access. Calculate the last post dialysis weight and patient’s current pre dialysis
weight. Once connected to dialysis machine give IV heparin into blood. The medications will be removed from
blood during hemodialysis, so most meds are held till after dialysis to prevent their removal. Phosphorus is not
filtered with dialysis so the patient will need to take phosphate binders before dialysis (like calcium carbonate).
The patient is prone to hypotension with dialysis, and elevated creatine levels is expected.

Av fistula – is surgical connection of an artery to a vein to get vascular access for hemodialysis. This causes the
vein to become engorges and thick (called mature) over several weeks/months and then it can sustain frequent
access by 2 large bore needles. Interventions/patient education: Tell the patient to squeeze rubber ball (to get it
mature). Palpable for thrill/vibration over fistula or an auscultated bruit (swoosh) means its patent. If no thrill, it
can indicate clot formation. No drawing blood, sleeping on, or carrying heavy stuff on the extremity that the AV
fistula is on. They should not wear restrictive clothes/jewelry. Monitor for symptoms of infection/bleeding after
dialysis-and report. Keep site clean. Complications: infection, stenosis, thrombosis, hemorrhage.

Peritoneal dialysis-dialysate is infused into abdominal cavity by catheter and then clamp tubing to allow fluid to
dwell for a specific time. After dwell time catheter is unclamped and fluid drains out via gravity. During dwell time
and instillation- monitor the patient for respiratory distress. Complications: peritonitis (from contamination of the
infusion). Symptoms: cloudy peritoneal effluent, tachycardia. Later symptoms: low grade fever, abdominal pain,
rebound tenderness. Treatment: antibiotics. Other interventions: Collect the effluent from drainage bag for
culture and sensitivity. Report signs of peritonitis and use sterile technique. Put catheter drainage bag below
abdomen and the patient in fowlers/semi fowlers.

Dialysis disequilibrium syndrome (DDS)-is a rare but life-threatening complication that can occur in the initial
stages of hemodialysis. Prevention: slow rate of dialysis. During hemodialysis, the solutes are removed quicker
from blood than brain/CSF so more fluid in brain and can increased ICP. Symptoms: nausea, vomiting, headache,
restlessness, change in mentation, or seizure. Interventions: If you think the patient has DDS-call the doctor,
because it can lead to a coma. If identified during treatment-stop/slow rate of dialysis. And do interventions to
decrease cerebral edema and manage symptoms.

Nephrolithiasis-aka renal calculi- is a kidney stone. Symptoms: sudden severe abdominal or right flank pain
radiating to groin. Nausea, vomiting. Causes: lifestyle, diet, immobilization, dehydration. Treatment: ESWL,
Analgesics at regular intervals, rehydration, ambulation. Strain all urine

Nephrolithotripsy-inserting a needle through the skin into pelvis of kidney. It is done to break through and
remove kidney stones too large to remove other methods. Postop: a temporary percutaneous nephrostomy tube
may be placed to prevent obstruction. So, maintain tube patency is crucial. Left flank pain and no drainage from
nephrostomy tube can indicate obstruction which can lead to kidney injury. So gently irrigate the nephrostomy
tube. Postop the patient is placed prone. Post op it is normal to have burning on urination or hematuria.
48

Extracorporeal shock wave lithotripsy (ESWL)-it uses high shock waves to break up kidney stones into small
fragments that can be excreted into the urine. It is an outpatient procedure with general anesthesia. During the
procedure temporary ureteral stents are placed to facilitate the passage of stone fragments and prevent occlusion
of ureter. Stents are removed 1-2w. postop: increase fluids, bruising and pain in back/flank is normal-analgesics.
Postop: Blood in urine- is normal for the first 24 hours. Report any symptoms of infection (like fever, chills).

Kidney biopsy - is a procedure that involves taking a small piece of kidney tissue for examination with a
microscope. Contraindication: uncontrolled hypertension. Complication: bleeding. Preop: get informed consent,
discontinue all anticoagulants, and antiplatelets for at least 1 week. Type/crossmatch them for blood. Make sure
the blood pressure is well controlled. Post op: monitor vitals every 15 minutes for first hour. Tachycardia,
tachypnea, or hypotension can indicate blood loss. Assess puncture site for bleeding. Have the BUN and creatinine
measured every 24 hours. Position them on the affected/left side for 30-60 minutes.

Pyelonephritis aka Kidney inflammation -is a severe bacterial infection in that kidney that causes it to swell.
Symptoms: chills, fever, vomiting, flank pain, costovertebral angle (CVA) tenderness (which is felt by placing your
hands over the patients lower back and placing the other hand on top and masking a fist to gently “thump” or tap
the area). Treatment: vigorous IV fluids and IV antibiotics. Before giving antibiotics, make sure to do blood and
urine cultures. Complications: It can lead to scarring and be life threatening.

Nephritic syndrome-Symptoms: massive proteinuria and hypoalbuminemia. It causes severe edema (on the
abdominal, face, perineum). Interventions: Daily dipstick urinalysis. To Collect a nonsterile urine specimen from an
untrained child-put several cotton balls in dry diaper and squeeze urine into dipstick. Check diaper frequently and
collect and test it within 30 minutes of urination. Also, they are usually on corticosteroid therapy-which have an
immunosuppressive effect-so they are at risk for infection).

Chronic kidney disease or failure -is the progressive loss of kidney function that usually occurs over many
years. Symptoms: hyperkalemia and hyperphosphatemia, fluid overload, anemia, and proteinuria (up to 150/day
is normal for them). Interventions: The patient should avoid salt substitutes (which have potassium in them).
Sodium restriction (so no cured meat, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, salad
dressing. Potassium restriction (so no raw carrots, tomatoes, orange juice). Monitor fluid intake (it is often
restricted). Low protein diet (eat .6-.8g/kg/day)-but if they are already on hemodialysis-they should have an
increase protein. Low phosphorus diet (so low amount of chicken, turkey, dairy). To treat hyperkalemia give them
sodium polystyrene sulfonate (kayexalate). Complications: uncontrolled hypertension, hypertensive
encephalopathy (because the kidneys regulate fluid volume and blood pressure, so if the kidneys are damaged-it
causes high blood pressure.

Hypertensive encephalopathy- is a sudden elevated in blood pressure (a hypertensive crisis) which causes
cerebral edema and increased ICP. It is an emergency. Causes: chronic kidney disease. Triggers: exacerbation of
hypertension, medications (like MAOI), head injury, pheochromocytoma. Symptoms: the main ones are a severe
headache, nausea, vomiting, and visual impairment. Other symptoms include: anxiety, confusion, epistaxis,
seizures, coma. Treatment: medication to lower the blood pressure- and should be given within 1 hour to prevent
damage to heart, kidney, and brain.
49

Pheochromocytoma-is a tumor on the adrenal medulla that causes excess release of catecholamines like
epinephrine/norepinephrine leading to paroxysmal hypertension crisis. Interventions: nitroprusside (to lower
blood pressure). Avoid abdominal palpation. Avoid activities that precipitate hypertensive crisis (bending, lifting,
Valsalva maneuver).

Cushing syndrome- excess corticosteroid production. Symptoms: androgen excess (acne, hirsutism, menstrual
irregularities). Metabolic (truncal obesity, hypertension, hyperglycemia, moon face, buffalo hump (fat on
face/back of neck)). Skin changes (bruising, purple striae, skin atrophy). Also, muscle weakness and bone loss
Interventions: Do a 24-hour urine test- to test for no cortisol. If more 80-120 then Cushing syndrome. Instructions
for 24-hour urine: dark jug, exactly 24 hours. discard 1st urine. Time wise only record the start and end time not
each one in between. Refrigerator.

Addison’s disease- aka adrenocortical insufficiency- the adrenal glands is responsible for secretion of
glucocorticoid, mineralocorticoid, androgens. So, with Addison’s there is too little production. (opposite of
Cushing). Symptoms: bronze hyperpigmentation of the skin, low cortisol. vitiligo. patchy/blotchy skin. Treatment:
corticosteroid (like hydrocortisone, dexamethasone, prednisone)

• Addisonian crisis—is a life-threatening completion of Addison disease. Can lead to shock. Tell doctor.
Causes: shock/stress (infection). Symptoms: hypotension, tachycardia, dehydration, hyperkalemia,
hyponatremia, hypoglycemia, fever, weakness/confusion. Treatment: first shock management so fluid
resuscitation with NS and 5% dextrose, and high dose hydrocortisone replacement IV push

Bladder/Urinary/Pelvic

Pelvic fracture- Causes: MVA, falls. Interventions: Assess for internal hemorrhage (abdominal distension, vital
signs, hct, hgh), paralytic ileus (assess bowel sounds), neurovascular deficits (assess extremity circulation,
sensation, movement) and abdominal/GI organ injures (assess hematuria, urine output of less .5/kg/hr).

Pelvic inflammatory disease- is when bacteria from the genital tract spreads upwards through cervix and causes
infection in female reproductive organs. It is not contagious. Causes: untreated STI (sexual transmitted infection).
Risk Factors: history of PID, multiple sex partners, previous STI, unprotected sex, IUD placement within the past 3
months, recent abortion, pelvic surgery. Symptoms: pelvic/lower abdominal pain, menstrual
irregularities/increased menstrual cramps, painful intercourse, fever, abnormal vaginal discharge. Complication:
can lead to ectopic pregnancy and infertility.

Cystoscopy-You place a flexible scope is placed through the urethra to the bladder to examine the lining of your
bladder and urethra. Interventions: place the patient in lithotomy position. Tell them to drink a lot of fluids, and
not to drink alcohol or caffeine (because they irritate the bladder). Tell doctor if bright red blood when urinating,
blood clots, if not able to urinate, fever, chills, abdominal pain not relieved with medications. It is normal for the
50

patient to experience the following after: pink tinged urine, dysuria. Complications: urinary retention,
hemorrhage, infection.

Priapism-is a prolonged painful erection (more than 2 hours). Other symptoms: bluish discoloration of penis
(which can indicate ischemia), intense pain, rigid penis, difficulty voiding, anxiety, and embarrassment.
Causes/Risk Factors: medications (like sildenafil, trazadone), preexisting diseases (like sickle cell), cocaine, alcohol.

Paraphimosis- is when you cannot return the foreskin (of an uncircumcised male) to its original position.
Symptoms: pain, swelling, impaired lymph/blood flow. Causes: foreskin left in retracted position for long time
(under condom catheter sheath).

Testicular torsion- the spermatic cord twists, cutting off the blood supply to the testicles. It is an emergency.
Symptoms: severe testicle pain. Treatment: should be done immediately because only have a short time to treat
before needs to be surgical removed (like 4-6 hours).

Urine specimen- should not be from the collecting bag. You should only take it from a port by catheter. So, clean
the port with alcohol. Aspirate urine with sterile syringe. Use aseptic technique to transfer to a sterile specimen
cup.

Timed urine collection tests- you should get the container from the lab. The container must be kept cool (on ice,
refrigerated) so no bacteria. If you did not save all the urine-discard the urine and container and restart again. You
want to start collection in the morning after the patients first morning void and end the same hour the next
morning.

Urge incontinence / overactive bladder- is when the bladder randomly contracts and causes a strong urge to go
with some urine leaking. Causes: spinal cord injury, impaired bladder, neuro diseases (like Parkinson, stroke).
Interventions: lose weight (to reduce pressure on the pelvic floor). Anticholinergic medications (like oxybutynin).
Avoid bladder irritants (like artificial sweeteners, caffeine, citrus juice, alcohol, carbonated drinks, nicotine). Do
pelvic floor exercises and bladder training (like void every 2 hours and gradually lengthen the time between
voids).

Pessary- is a vaginal device that supports the bladder- can be used as a treatment for incontinence. Patient
education: They can have sex with it. They need to be fitted for it by doctor, but they can insert it themselves. The
patient can remove it themselves when want to, but removal by the doctor at 2/3 months at a time is
recommended. Side effect: increased vaginal discharge (only report if odor). If ineffective then reconstructive
surgery may be indicated.

Urinary retention- is common post op and with BPH (benign prostate hyperplasia). Acute urinary retention is
treated with rapid complete bladder decompression. When doing bladder decompression assess for hypotension,
and bradycardia

Stress incontinence- happens when physical activity (like coughing, sneezing, running or heavy lifting) puts
pressure/stress on your bladder. Interventions: The goal is to prevent skin breakdown through bladder training.
So, tell the patient: empty bladder every 2 hours when awake and every 4 hours at night. Do pelvic floor exercises.
51

(it can take 6 weeks to see changes). Do not use natural bladder irritants (like smoking, caffeine, alcohol). Or you
can use a pessary.

Urinary tract infection (UTI)- is an infection in any part of your urinary system (can be the kidneys, ureters,
bladder, or urethra. Interventions/Patient education: wipe front to back, do not get constipated or strain. Drink
plenty of fluids. Avoid bubble baths/products. Avoid antibacterial soap. Wear cotton underwear.
• UTI in a young female can have following symptoms: fever, suprapubic pain, dysuria
• UTI in an elderly patient can have following symptoms: mental status changes, confusion

Vasectomy-is a surgery done for permeant male sterilization. They cut the vas deference. Postop: use alternative
birth control till doctor confirms that semen samples are free of sperm.

Transurethral resection of the prostate- TURP- put a scope in to remove obstructing prostate tissue. Postop: first
24 hours the urine goes from red to pink. Small clots are normal for 36 hours. Do continuous bladder irrigation
with a 3-way Foley catheter for 24-36 hours to flush out small clots and prevent obstruction. Painful bladder
spasm is expected after TURP. The bowel/gas will not return for at least 24 hours postop. Give pain medication.

Benign prostatic hyperplasia (BPH)-is prostate enlargement that is quite common with men over age 50 years. It
compresses the urethra and causes voiding problems. Causes: hormonal changes related to aging. Symptoms:
urinary urgency/frequency/hesitancy, dribbling after urinating, nocturia, and urinary retention. Treatment:
lifestyle changes, medications (Finasteride) and symptom management. They may need surgery for prostate
resection. With BPH there is an increased risk for UTI.

(Symptoms of BPH are like those of a UTI but specific to UTI is burning sensation with urination and cloudy/foul
smelling urine).

Prostatitis-is inflammation of the prostate. Causes: bacterial infection. Symptoms: rectogenital pain, burning,
urinary hesitancy, urinary urgency. Treatment: antibiotics, anti-inflammatory medications (like ibuprofen), alpha
adrenergic blockers (like tamsulosin). Drink water (no coffee, tea, caffeinate beverages because they have a
diuretic effect). They should complete the antibiotics even if the symptoms are better. Can have
sex/masturbate-helps relieve discomfort (with a condom). Take stool softeners so they do not strain. Take sitz
baths.

Prostatectomy- is a surgical procedure for the partial or complete removal of the prostate. Postop: small blood
clots may occur-up to 36 hours after surgery. If it continues after-tell the doctor. Do not do Valsalva maneuver up
to 8 weeks post op. Do not do any rectal interventions (so no suppositories or enemas). Do not strain with bowel
movement. It’s important to prevent constipation. Signs of complication that you should call a doctor: reduced
urine stream, persistent bleeding/blood clots, urinary retention, fever, and dysuria.

Musculoskeletal

Myasthenia gravis-is an autoimmune disorder in which acetylcholine receptors are blocked causing fluctuating
muscle skeletal weakness. The first muscles that are affected are the ocular/facial and those responsible for
52

chewing/swallowing. Symptoms: ptosis (upper eye lid drooping), diplopia (double vision), bulbar signs (difficulty
speaking/swallowing). , muscles weakness as the day goes on. Treatment: medication- Pyridostigmine (which is an
anticholinesterase)-give it before meals. They should get the flu and pneumonia vaccine. Complications:
Myasthenia crisis-is when the muscles that are affected are the respiratory muscles and it causes respiratory
failure. Causes: stress, infection, undermedication.

Quadriplegia (Tetraplegia)- is when the lower limbs are completely paralyzed and complete/partial paralysis of
upper limbs. Causes: cervical spinal cord injury. Depending on the injury the airway could have been affected. So,
nurse should frequently assess breathing, muscle use, vital capacity, tidal volume, and ABG’s.

Guillain barre syndrome (GBS)- is an acute, immune polyneuropathy. It causes ascending muscle paralysis and no
deep tendon reflexes (it can occur over hours). It can affect the whole body. Most patient have a history of a
respiratory tract/GI infection. Complications: Neuromuscular respiratory failure. Interventions: Watch for
respiratory failure signs (not being able to cough, shallow respirations, dyspnea/hypoxia, not being able to lift
head/eyebrow. Assess pulmonary functions with serial spirometry. Measuring forced vital capacity (FVC) is gold
standard for assessing ventilation (a decline in FVC indicates respiratory arrest impending and will need
endotracheal intubation.

Ankylosing spondylitis-is an inflammatory disease of the spine. There is no known cause, and no cure. Symptoms:
lower back pain and stiffness-which is worse in the morning and improves as the day goes on. Interventions:
proper posture, daily stretching, spine stretching exercises (like swimming, racket sports). Stop smoking and
practice breathing exercises. Rest during flare ups. Sleep on back and on firm mattress. Take NSAID/Ibuprofen
with meal/snack to avoid gastric upset. Anti-inflammatory’s.

External fixation-is putting metal pins/screws through the skin to the bone and attaching them to a metal rod
outside body. Purpose: to stabilize the bone and allow for early ambulation. Interventions: assess for symptoms of
infection (like a low-grade fever, drainage, pain, redness, swelling. Pin looseness). Treatment: immediate
antibiotics (because it can lead to osteomyelitis – an infection of the bone). Interventions: do sterile pin care w ½
strength hydrogen peroxide and NS or chlorhexidine solution. Neurovascular assessment. Notify doctor is the pins
are loose and do not turn them to tighten them.

Halo external fixation device-it stabilizes a cervical or high thoracic fracture when there is barely any damage to
the ligament or spinal cord. Interventions: Assess pin for looseness. Monitor sensory/motor function. Clean pin
site with sterile solution (water, chlorhexidine). Keep vest liner clean and dry (change weekly or when soiled and
use cool air dryer to dry). Place foam inserts under pressure point. Place small pillow under head when supine to
reduce pressure device. Keep correct sized wrench available in case of emergencies. Only doctor can adjust the
pins. Do not grab the device when positioning /moving the patient.

Osteomalacia-is a reversible bone disorder caused by a Vitamin D deficiency. Symptoms: weak, soft, painful bones
that easily fracture. With a Vitamin D deficiency, calcium and phosphorus cannot be absorbed in the GI tract. They
are also at an increased risk for falls. Interventions: safety measures like canes/walkers, light to moderate activity.
Increase calcium, phosphorus, and vitamin D intake.
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Osteomyelitis-is a serious bone infection that requires long term treatment with antibiotics

Osteogenesis imperfecta (OI) aka Brittle bone disease- is a rare, genetic disease that causes impaired synthesis of
collagen by osteoblasts. Collagen allows bone to be flexible and strong. So impaired collagen bones frail and easily
fracture (Basically in OI, the bones are brittle and fracture easily). It is autosomal dominantly inherited.
Interventions: the priority is to minimize additional fractures. You should also check the blood pressure manually.
Lift an infant by putting your hands under the broadest areas of their body (like back, butt). Reposition frequently
using supportive devices.

Osteopenia- is a more than normal bone loss for that age/sex. Interventions: they need calcium and vitamin D.
Milk produces are the best sources for calcium. But if they are lactose intolerant-fish, tofu, green vegetables, or
almonds are good choices

Osteoarthritis (OA)-is a degenerative disorder of the synovial joints that causes progressive erosion of cartilage.
causing bone spurs, calcifications, and ulceration within the joint space., and no cushion between the bones.
Symptoms: pain that gets worse with weight bearing exercises, crepitus (especially over the knee joint), morning
stiffness (goes away within 30 minutes of awakening), decreased joint mobility and ROM. Atrophy of muscles.

Osteoporosis- is a disease in which the density and quality of bone are reduced. Interventions: calcium, vitamin D
supplement, stop smoking and alcohol, do weight bearing exercises (like walking, dance, and lifting weight) for 3
times a week for 30 minutes. Medications like bisphosphonate. Prevent falls (place the bed low and in a locked
position, place the call light and personal belonging in reach, orient patient and use nonskid footwear, eyeglasses,
hearing aids, assist devices. Keep the room well lite and free of clutter.

Parkinson disease-is a progressive neuro disorder that causes bradykinesia (loss of autonomic movement),
rigidity, shuffling gait, and resting tremors. It is caused by an imbalance of dopamine (which is low) and
acetylcholine. Treatment: anticholinergic medications (like benztropine, trihexyphenidyl) or Levodopa/Carbidopa

Amyotrophic lateral sclerosis (ALS) aka Lou Gehrig disease- is a progressive loss of motor neurons. It can go from
spasms to atrophy to swallowing difficulty to respiratory failure. There is no cure, and they usually die within 5
years. Symptoms: fatigue, constipation, and muscle weakness (twitching, muscle spasm, difficulty swallowing,
difficulty speaking, respiratory failure, paralysis). Interventions: respiratory support with BiPAP or mechanical
ventilation (via a tracheostomy). Medications like Riluzole (which is a glutamate antagonist)- slow the progression
by 3-5 months. Mobility assistive devices, and communication assistive devices.

Multiple sclerosis- is a progressive demyelination of the CNS that stops nerve impulses. Symptoms: muscle
weakness, spasticity, incoordination, loss balance, dysarthria, and fatigue. Dehydration and extreme temperatures
can cause an exacerbation. Interventions: the patient should walk with their feet apart for support. Assistive
devices are usually required. Exercise and gait training, if not good- wheel chair. Bladder training schedule. Need
maximal assistance with ADL’s

Casts- is applied to immobilized fractured extremities during healing. Instructions: Avoid getting cast wet. Elevate
affected extremity above heart for the first 48 hours to reduce edema. Perform exercises to prevent muscle
54

atrophy. Report numbness and tingling, pallor, coolness, pain unrelieved by RICE and a loss pedal pulse. Swelling
in cast can indicate compartment syndrome. Never insert anything inside the cast because it can cause tissue
injury. To reduce itching underneath the cast-use cool setting of hair dryer. Do not place anything in or around it.
Symptoms of infection: sores, purulent drainage, foul odors, and persistent itching.
• Large body casts- if it is too tight- the patient is at risk for bowel obstruction, which can lead to bowel
ischemia.
Slings- instructions: keep the elbow flexed 90 degrees, hand above level of elbow, bottom of sling ends in middle
of palm with fingers visible.

Rhabdomyolysis- is the breakdown of muscle tissue that spills into the blood. Causes: injury from overexertion,
dehydration, severe vasoconstriction (like with cocaine use), heat stroke, and trauma. It can lead to acute kidney
injury. Symptoms: urine very dark-cola brown/amber color (can be bloody too), oliguria, fatigue. Elevated creatine
kinase (more 15000). Treatment: to prevent kidney damage- give a rapid IV bolus

Fibromyalgia-is a chronic nonspecific pain disorder. It causes bilateral musculoskeletal axial pain (above and
below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Symptoms: fatigue, sleep
disturbance, emotional distress (anxiety, depression), mild cognitive impairments (forgetfulness, difficulty
concentrating). Treatment: treat the symptoms, muscle relaxants, narcotics, NSAID’s, and antidepressants

Sprain- Interventions: RICE- Rest for 48 hours, Ice (10 minutes every hour for the first 48 hours), Compression,
Elevation (above the heart for the first 48 hours), analgesics (every 6 hours), exercise rehab as soon as pain
subsides

Carpal tunnel-is pain and paresthesia of the hand caused by median nerve compression at the wrist. Symptoms:
weakness, pain, numbness, impaired sensation in medical nerve distribution. Symptoms are worse during sleep
(because of prolonged wrist flexion). Treatment: wrist immobilization splint

Joint dislocation- it can be an emergency because it can compress surrounding vasculature causing limb
threatening ischemia. Symptoms of joint dislocation: pain, deformity, decreased ROM, and extremity paresthesia.

Cauda equine syndrome- motor and sensory deficits caused by an injury to L4-L5. It is a medical emergency.
Symptoms: The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (like motor
weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (which is a late
sign). Treatment: urgent reduction of pressure on the spinal nerves to prevent permanent damage.

Rheumatoid arthritis (RA)- is a chronic autoimmune condition causing painful inflammation of the synovial joints.
Contractures of the ligaments can also occur, causing weakness and deformity and reduced ADL. Symptoms:
symmetrical pain and swelling that affects the small joint of hands/feet. Morning joint stiffness that last from 60
minutes-hours. Elevated ESR and rheumatoid factor levels. Heart valve injury is common with RA also.
Treatment/Interventions: medications- DMARD’s (like Methotrexate)- take even if no symptoms
To help morning stiffness of affected joints take warm shower/bath after waking up or apply heat (because heat
decreases stiffness and relaxes muscles). Pain control is top priority to be able to perform ADL’s. No cure just
prevention. Prevention: joint protection- use body aligners/immobilizers when resting to keep extremities
55

straight. Do not elevate, keep straight. Gentle ROM. Frequent rest periods.

Juvenile idiopathic arthritis- is the most common type of arthritis in children with no known origin. Instructions:
low impact exercises, weight bearing and non-weight bearing exercises that involve ROM and stretching. They can
do swimming, stationary bike, throwing/kicking ball, low impact dancing, walking, yoga, but no high impact like
dodgeball.

Septic arthritis-is an infection in a joint (like the hip). It is an emergency because the joint can become necrotic.
Symptoms: localized (like pain, limited range of motion) and systemic (like fever) infection symptoms. Causes:
recent surgery, injections, trauma, or spread from adjacent infection (like from cellulitis). Treatment: culture the
blood/fluid, antibiotics.

Fat embolism- a type of embolism in which the embolus consists of fatty material. It develops 24-72 hours post
orthopedic injuries (especially long bone/pelvic fractures) and is life threatening. Symptoms: respiratory problems
(dyspnea, tachypnea, hypoxemia). Neuro (AMS, confusion, restlessness). Petechia rash (pin size purple spots that
do not blanch with pressure)-on neck/chest/axilla (this is the main difference between a fat embolism and
pulmonary embolism). Treatment: No specific treatment. Early stabilization of injury and surgery as soon possible
to repair long bone fracture. Minimize movement of injured extremity

Compartment syndrome- is swelling and increased pressure within a confined space (a compartment) that can
lead to tissue ischemia. Symptoms: 6 P’s: Pain (unrelieved by repositioning or analgesics), Pallor, Pulselessness,
Paresthesia’s (tingling/numbness/burning), Poikilothermic (coolness), Pressure, and Paralysis.
Treatment/Interventions: If not treated within 4-6 hours, it can lead to ischemia. So, the first priority is to tell the
doctor. Place extremities at heart level and loosen tight bandage/casting material. If this does not work a
fasciotomy may be needed. Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway,
assessing mental status, and providing frequent reorientation during periods of postictal confusion.

Mandibular fracture- is a fracture of the jaw. The priority is if teeth wired together-is a patent airway. So, if the
patient is chocking on secretions-suction. If that does always not work-cut wires (tape to head of patient’s bed).

Rotator cuff tear- occurs gradually from aging, repetitive use, injury to shoulder (like from swimming, tennis).
Symptoms: shoulder pain/weakness. Severe pain when arm is abducted between 60-120 degrees (painful arc).
Diagnosed: imaging.

Buck traction- is a skin traction to immobilize hip fractures and reduce pain/spasm until the patient can undergo
surgery to repair fracture. Interventions: Put traction boot to leg below fracture site. Weight should pull on
leg/hip to maintain alignment of limb. Limb in neutral position. Skin traction puts pressure on
nerves/tissue/blood- so assess neurovascular status (pulse, capillary refill, color, temperature, sensation,
movement) and skin integrity in limb. Watch pain level because increase pain can indicate neurovascular
compromise. Do not reposition patient. Loosen Velcro straps if the boots are too tight and tighten the straps if the
boot is too loose – and reassess neurovascular status 30 minutes later. Provide a fracture pan, (which is smaller
than a bedpan), for elimination needs. Weights should always be free hanging and should never be placed onto
56

the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed
to prevent excessive pull on the extremity

Hip replacement- Complications: bleeding, prosthetic dislocation, DVT, infection. Interventions: the nurse should
the check drainage device and dressing frequently to monitor blood loss. Patient should have an abduction pillow
between the legs or 2/3 pillows between the knees when turning from side to side. Do not cross legs at ankles or
knees. Head of bed should be less than 60. Do not go on operative side-if you need to turn the hip kept in
abduction. Look for signs of hip dislocation (like shortening and internal rotation). Use chair with armrest and high
firm seat. Perform 2-3 times daily leg exercises (like isometric quadriceps, gluteal setting, leg raises, abduction
exercise). Do not flex the hip more 90 degrees so give patient elevated toilet seat and not recliner chairs. Do not
twist at waist, reach across, or bend forward. Use assistive devices when getting dressed like
reacher/grabber/sock puller, long handled shoehorn.

Total knee replacement- Postop: they are at risk for infection so put them in a room with a patient with no
infection or at the lowest risk. Complication: contracture (shortening /hardening of muscles that can lead to
deformity/rigidity of joint). To prevent: maintain operative knee in extended position with knee immobilizer or a
pillow placed under lower leg/heel. Do not place the pillow under knee. Can put cold packs intermittently over
knee to reduce pain/swelling. Can use continual passive motion device. Can apply leg immobilizer during
ambulation
Contraindication to surgery: recent/current infection. So, report to doctor if they experience burning on urination
because it can be a UTI. Tell the patient to stop taking NSAID’s (including celecoxib) 7 days before surgery (to
decrease the risk of bleeding)

Colles fracture-is a type of wrist fracture (a distal radius fracture). Causes: patient tries to break a fall with an
outstretched arm/hand and lands on heel of hand. Most common with women over 50 year from osteoporosis.
Interventions: priority is a neurovascular assessment (pulse, temperature, color, capillary refill, sensation,
movement) Then analgesics, ice, elevate over heart, tell patient to move fingers

Blood and Circulation

Hypovolemia- is a decrease in volume of blood plasma. Symptoms: hypotension, tachycardia, decreased urinary
output, and a narrowing pulse pressure

Polycythemia vera-is a chronic bone marrow disorder in which too many RBC.WBC/Platelets are produced. They
are at risk for: blood clots and strokes. Symptoms: hypoxia, face/hands/feet become red ruddy color, headache,
and blurred vision. Instructions/Interventions: elevate legs when sitting, support stockings. Fluid during exercise
and hot weather. Monitor for signs of thrombosis (like swelling/tenderness in legs). Monitor for symptoms of
stroke. It can cause itching so reduce water, starch bath, and pat the skin dry. Treatment: Periodic phlebotomy to
remove excess blood (no iron supplements and stuff).

Disseminated intravascular coagulation (DIC)-Is when the platelets and clotting factors are consumed in clotting
and become unavailable for body use, leading to bleeding complications. Symptoms: frank external bleeding
57

(venipuncture site bleeding), signs of internal bleeding (like petechiae, ecchymosis, hematuria, hematemesis, and
bloody stools), and respiratory distress (because of bleeding/clotting into lungs). Treatment: Rapid replacement of
clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death.

Sepsis- is an exaggerated response to infection in the bloodstream. It is life threatening. Causes: it can be from a
local infection like a pressure injury. Risk factors: elderly (because aging decreases the immune response).
Symptoms: of infection (like fever, leukocytosis). However, the elderly will not have the typical signs- and can
have these signs: AMS, hypothermia, leucopenia. Treatment: antibiotics (need to do culture before giving). If it is
not treated early, the sepsis can lead to septic shock (persistent hypotension) or multiorgan dysfunction. With
sepsis the patient is at risk for DIC.

Peripheral artery disease (PAD)- is when the arteries of extremities become atherosclerotic (thick/hard). It
reduces tissue perfusion and causes ischemic pain (from the decreased blood flow) and can lead to gangrene. Risk
factors: hypertension, diabetes, hyperlipidemia, and smoking. Symptoms: Intermittent claudication (cramping
pain in muscles of legs during exercise). Pain can also be at rest and described as burning pain that is worse when
elevating legs and improves when legs are dependent. thick brittle nails. Skin-cool/dry/scaly/hairless (because no
oxygen). Ulcers/gangrene at most distal body parts. Burning, aching, numbness of the skin. Interventions: lower
the extremity below the heart (because you are trying to get blood to flow to the feet). Skin care (lotions), warmth
(blankets, socks)-but no heating pad. Never apply direct heat because of the risk for burn. Stop smoking, avoid
tight clothes/stress, regular moderate exercise, be at an ideal body weight. Low sodium diet. Glucose control in
diabetic, blood pressure control/statins/antiplatelets. Take medications (vasodilator, antiplatelets). Proper
limb/foot care. Complication: gangrene of foot

Venous insufficiency-inability of leg veins to efficiently pump blood back to the heart. So, there is not enough
venous blood return to heart. It can lead to venous stasis, and leg ulcers. Risk factors: standing (because with
venous blood is not going from feet back to central circulation. Symptoms: varicose veins, skin on the lower legs
that is warm and thick and has a brown discoloration. Large irregular superficial ulcer with drainage. Edema.

Deep vein thrombosis (DVT)- is a blood clot that forms in a vein deep in the body. Risk factors: varicose veins,
decreased mobility, surgery, age over 60. Prevention: anti-embolism stockings, frequent neurovascular
assessment of the extremities. Diagnostic testing: venous ultrasound. (They used to use the human sign-pain in
the calf with dorsiflexion. Now they do not use that). Symptoms: unilateral leg edema, calf pain, warmth to the
touch, erythema, tenderness on palpation, low grade fever. Treatment: anticoagulant (heparin, enoxaparin).
Interventions/Patient Education: Do not massage or use sequential compression on affected extremity (because it
can dislodge and become a pulmonary embolism). They can ambulate. Drink fluids. Limit alcohol/caffeine elevate
legs when sitting and dorsiflex feet (upwards). Exercise program change positions frequently. No restrictive
clothes (tights. Jeans). Diet if overweight.
• Anti-embolism stockings-do not roll them down, fold down, cut or alternate in anyway. Should smooth
wrinkles before putting on. Toe opening should be located planta side of foot/under toes. Put on before
ambulating while in bed.

Pulmonary embolism (PE) - is a complication of DVT. It is when the blood clot breaks off and travels to the lungs.
58

Risk factors: the greatest risk factor is postop (so if scenario where patient had surgery or had c-section and is
tachycardic etc. think of a PE…). Other risk factors: venous stasis, hypercoagulability of blood, endothelial damage.
Obesity, smoking, genetic disposition. Symptoms: anxiety/restlessness, pleuritic chest pain/tightness, shortness
of breath, tachycardia, tachypnea, hypoxemia, cough, and hemoptysis. Interventions: The nurse's priority is
rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen, and notifying the
health care provider. Elevate head of bed.

Von Willebrand disease-is a genetic bleeding disorder caused by deficiency of von Willebrand factor. Symptoms:
bleeding. Interventions/treatment: To stop bleeding –give intranasal desmopressin, thrombin. If major bleeding-
then give a replacement of von Willebrand factor. They should wear a med ID bracelet. Tell doctor of signs of
bleeding (like severe joint pain/swelling, headache, blood in urine/stool, uncontrollable nosebleed). Use
humidifier/nasal spray to keep mucosa moist. No aspirin or NSAID’s. No activities that are a risk for injury.
Maintain gum integrity. Report heavy menstrual bleeding (like soaking a pad less 3hrs).

Immune thrombocytopenia purpura (ITP)-is autoimmune disorder where the antibodies destroy the platelets.
Symptoms: petechiae, platelet count less 150, 000. They are at risk for bleeding. Interventions/Patient education:
use a soft bristle toothbrush, gentle flossing, non-alcoholic mouthwash. No high intensity sport, only low impact
(like walking). Wear nonskid footwear. Take stool softeners/laxatives as needed. Use electric razors not
safety/straight razors. Do not take NSAID’s (like aspirin, ibuprofen, ketorolac). Use opiates and Tylenol

Blood transfusion-

• Before starting blood transfusion: tell the patient to void/empty urinary catheter and discard urine
(Because if a transfusion reaction occurs- you need to collect a fresh urine specimen to check for
hemolyzed RBC). Make sure to get the blood type and compatible.
• Steps: First get blood from blood bank than verify blood with type and crossmatch results. You need to
use 2 patient identifies with another nurse there. Use a Y tubing. First prime with NS, then clamp the NS
side. Spike the blood and leave blood side of the Y tubing open while the saline side is closed. The saline is
only used to prime the tubing and flush after, it is not to be infused at same time as the blood. Set the
infusion pump for 2-4 hours- not rapid.
• After: Remain with the patient for the first 15 minutes and watch for signs of reaction (like fever, chills,
nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea). If there is a
reaction-stop transfusion. Take another vital 15 minutes after the infusion. Take vitals after the infusion is
complete. When the blood is complete- open the saline side of the Y tube and flush all blood. Return the
blood bag set to the lab. Use a new IV Y tubing for the second unit of blood
• Other: Blood is given through an 18 gauge or larger catheter. If another fluid has been infused though the
IV catheter then first discontinue it and then flush it with NS, and then give the blood. Monitor vitals
during transfusion per facility-specific protocol (like before transfusion, 15 minutes after transfusion
begins, periodically). Transfuse blood products within 4 hours. The nurse remains with the patient for the
first 15 minutes and gets vital signs directly to see adverse reaction (like fever, chest pain). Can delegate
vitals if patient is stable after 15 minutes
• Complications: acute hemolytic transfusion reaction (which is life threatening). It is when a patient’s
antibodies destroy the transfused RBC. Causes: incompatibility. Early signs of hemolytic reaction- red
59

urine, fever, anxiety, tachycardia, hypotension. Late signs- DIC, hypovolemic shock. If this occurs- stop the
transfusion immediately. Give NS through a different port, notify doctor and assess the patient.

Blood loss-is a medical emergency. Interventions: First-lower bed and place patient supine (so blood gets to the
brain, and vital organs), and then ensure IV access and continuing fluids

Allen test- is done before collecting blood at radial artery. It assesses the arterial blood supply of the hand. It is
done by blocking blood supple and seeing if normal color comes back to your hand within 5-15 seconds. If it does,
it means that one artery is healthy enough to supply blood to your hand all by itself and ABG’s can be drawn. If it
is negative and the palm does not return to a pink color-use a different site.

Phlebotomy- is the process of taking blood. Steps: clean the site. Fix/hold vein taut (stretched). Insert needle
bevel up to 15-degree angles. Do not attempt to insert it more than 2 times on each person. Do not do it on same
side as mastectomy. Do on the arm without the IV in it. If you have to use that arm, then use the vein below/distal
to point of IV infusion with tourniquet placed in between.

Phlebitis-is inflammation of a vein. Causes: irritating drugs (like vancomycin), catheter movement in vein (like it’s
not stable), bacteria (poor aseptic technique). Symptoms: pain, swelling, warmth at site, redness extending along
the vein. If any of these signs occur-remove the IV line immediately because it can lead to thrombophlebitis and
emboli, or a bloodstream infection.

Infiltration- is a complication that occurs when solution infuses into the surrounding tissues of an infusion site.
Interventions: discontinue the IV line immediately and start a new one (in the opposite extremity). Elevate the
affected extremity (to decrease swelling) and place a cold/warm moist compress on it.

Extravasation-is the infiltration of a drug into the tissue around vein (like norepinephrine). Symptoms: pain,
blanching, swelling, redness. Interventions: stop the infusion and disconnect the IV tubing. Aspirate the drug from
the IV catheter with a syringe and remove the IV catheter. Elevate the extremity above heart level. Tell doctor and
get antidote prescription (like Phentolamine). Do not flush or give more medication. Obtain new access through
central line/unaffected extremity.

Sugar/Diabetes

metabolic syndrome- is a cluster of conditions that occur together, increasing your risk of heart disease, stroke,
and type 2 diabetes. You need 3 or more of the following to be diagnosed with metabolic syndrome: Waist
circumference, Blood pressure, Triglyceride, HDL, Glucose (Mnemonic- is "We Better Think High Glucose”).

Hypoglycemia- is a glucose level below 70, from too much insulin. It is life threatening and much more dangerous
than hyperglycemia (because no glucose to the brain so it can lead to neuro impairment. Symptoms: (when
hypoglycemic the brain releases epinephrine so the symptoms are like that). Symptoms: trembling, palpitations,
anxiety, restlessness, diaphoresis, pallor. When hypoglycemia happens for a long time it causes these symptoms:
Neuro (confusion, seizures, coma), sweating, irritable, tremors, AMS (diff speaking, confusion), tachycardia,
hunger. For infant, the symptoms of hypoglycemia include: jitters, cyanosis, tremors, pallor, poor feeding,
60

retractions, lethargy, low oxygen saturation, and seizures. Interventions: assess, check capillary blood glucose,
give 15grams of simple carbohydrate rapid digested (orange juice, soft drink, candy, low fat milk). Check blood
10/15 minutes after that. If the patient cannot orally ingest or has AMS or has dysphagia than give
dextrose/glucose 50 IV push and glucagon

Diabetic ketoacidosis (DKA)- is hyperglycemia (of more than 250) in a diabetic patient from a deficit of insulin (so
the glucose cannot be stored. It is life threatening. Causes: not enough insulin, not good self-management, stress
with illness/infection. Symptoms: nausea, vomiting, abdominal pain, polyuria, kussmaul respirations,
fruity/acetone smell, dehydration, urine ketones, hyperglycemia, and lethargy. It leads to ketosis (metabolic
acidosis). Basically, body can’t use the huge amount of glucose in blood, so it goes into a starving state and breaks
its own fat into ketones causing a metabolic acidosis (low pH a low hco3). To compensate for this, the body does
kussmaul respirations (which has a fruity/acetone smell) to reduce the carbon dioxide levels. Interventions:
Priority: fluids IV bolus of NS/0.9 sodium chloride (because it helps excrete glucose and restores balance. Then
give IV regular insulin, fluids, potassium. Other interventions: vasoactive medications (like norepinephrine, or
dopamine), and hourly blood glucose monitoring. DKA patients are at risk for hypovolemic shock, and severe
dehydration

Stress induced hyperglycemia- Causes: surgery, trauma, acute illness, infection- they cause the glucose to go up.
(About 80% of ICU patient become hyperglycemic with no history of diabetes). Complications: infection, increased
length of stay, acute kidney injury. Prevention/to minimize complications- for critically ill patient you want glucose
level between 140-180. For non-critically ill patients you want the glucose below 140 fasting and below 180
random.

Diabetes sick day management: Patient education: on sick days: take more blood glucose level checks (every 1-4
hours). Increases/decreases blood glucose levels. Get enough hydration. Test for urinary ketones frequently.

Peripheral neuropathy- is nerve damage caused by chronically high blood sugar and diabetes. It leads to
numbness, loss of sensation, and sometimes pain in your feet, legs, or hands. It is the most common complication
of diabetes. Interventions/patient education: Wash feet daily with warm water and mild soap. Test water with a
thermometer before. Gently pat dry feet and in between toes. Use lanolin to prevent dry skin but do not put it
between toes. Inspect for cuts. Use cotton/lamb’s wool to separate overlapping toes. Cut toenail across and nail
file curves. Do not go bare foot. Wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear
clean, absorbent socks with seams aligned. Do not use OTC products on cuts. Do not sit with legs crossed or wear
tight fitted clothes. Daily exercise. No high heels/open heels/opened toed. Wear clean absorbent (cotton) socks.
No barefoot/hot pad/hot water/restrictive shoes/clothing/crossing legs for long time. Do not self-treat
corns/calluses/ingrown toenails.

Alcohol and drugs

Alcohol- is a CNS depressant, which causes hypoglycemia and vitamin B1/Thiamine deficiency
61

Alcohol use disorder aka alcoholism- is when they get dependent on alcohol and it becomes the sole focus which
negatively impacts their social life etc. Treatment goal: total abstinence from alcohol. You want the patient to:
express accountability, use insight to face reality, coping skills (support group, relaxation), set goals (like fitness
etc.), maintain abstinence

Alcohol intoxication- Symptoms: confusion, coordination impairment, drowsiness, slurred speech, mood swings,
and uninhibited actions.

Alcohol Withdrawal- It starts 8 hours after the last drink and peaks 24-48 hours. When withdrawing from alcohol
they might experience the following: gross tremors, agitated, hyperreflexia, delirium tremens (like hallucination,
confusion, shaking). Treatment: benzodiazepines (lorazepam, diazepam).

Wernicke’s encephalopathy- is a neurological disorder induced by thiamine, vitamin B1, deficiency (which
happens to alcoholics). Symptoms: altered mental status, oculomotor dysfunction, ataxia.

Opioid Withdrawal- Symptoms: (same symptoms as Sympathetic nervous system)- increase pulse/blood pressure,
sweating, insomnia, diarrhea. Treatment: opioid-methadone or buprenorphine. Non opioid- clonidine

Liver and spleen

Hepatitis- inflammation of liver. Causes: infection, toxins, trauma, drug use, alcohol, poisoning. Symptoms:
impaired live function symptoms. Diagnosed: elevated ALT/AST. Interventions: rest and activity, avoid
hepatotoxins (like alcohol, Tylenol). Caution with medications that are metabolized in the liver (like appetite
stimulants, antipruritic, analgesics, sedatives). Eat low fat, small, frequently with larger breakfast. Oral care. Avoid
extremes in food temperatures. drink water (2500-3500ml/day). Use condom during sex. Do not share
razors/toothbrush. Eat protein and carbs

• Hepatitis A- is transmitted fecal/oral through poor hand hygiene and improper food handling by infected
person. After a person acquires the infection, it reproduces in liver and secreted in bile. A vaccine against
hep A is given at 1 years old and if you at risk for getting it (health care workers, men having sex with
other men, drug user, traveling to areas with high prevalence, patient with clotting disorders, patients
with liver disease)
• Hepatitis B- is transmitted through contact with blood, semen, saliva, or vaginal secretions (mnemonic: B
is for body fluids). Symptoms: The patient can be asymptomatic. Early symptoms: nonspecific (like
malaise, nausea, vomiting, abdominal pain). Later symptoms: jaundice, weight loss, clay colored stool,
thrombocytopenia. To prevent- hep B vaccine
• Hepatitis C- leads to a chronic infection. Use standard precaution with these patients.

Cirrhosis – is a progressive, degenerative disease caused by destruction of liver parenchyma. Its end stage to
many live diseases. Causes: structural changes altering blood flow from liver, and decreased liver function,
alcohol.
62

Symptoms: pruritis (because of the buildup of bile under skin). Skin breakdown, edema, delayed wound healing,
loss muscle/fat tissue from pressure points (like butt, heel). They will also have elevated bilirubin, elevated
PT/INR, elevated ammonia. Hypoalbuminemia and hyponatremia, low platelet level.
Interventions: Semi fowlers (30-45 degrees), or fowlers (45-60 degrees)- to reduce pressure on the diaphragm, or
side lying with head elevated. Skin care - special mattress, turn every 2 hours. Distract with music/TV. Tell the
patient to cut nails short, wear cotton gloves, wear long sleeve shirts so not to scratch. Also baking soda, calamine
lotion, cool wet cloths. Medications like Cholestyramine- to increase excretion of bile salts, periodic paracentesis
(to relieve distension), diuretics. Complications: ascites, varices, hepatic encephalopathy, hemorrhage.

Hepatic encephalopathy-a complication of liver cirrhosis/end stage liver disease from a buildup of ammonia
which causes neurotoxic effects (like mental confusion etc.). Precipitating factors: hypokalemia, high protein
intake, constipation, GI hemorrhage, hypovolemia, infection, hypertensive crisis. Symptoms: can range from sleep
disturbances to coma and include: Altered AMS, nausea, vomiting, seizures, confusion, headache, Asterixis (is
flapping hand tremors during arm extension), Fetor hepaticus (a musty, sweet odor of the breath), Lethargy,
confusion, and slurred speech. Intervention: meds to lower ammonia level. Lactulose is commonly used to treat
asterixis as it promotes ammonia excretion.

Ascites- an accumulation of fluids in the peritoneal space. It usually occurs in a patient with liver cirrhosis.
Symptoms: It increases abdominal pressure causing weight gain and abdominal distension/discomfort, and short
of breath. Treatment: paracentesis

Paracentesis- is a procedure done to remove excess fluid from the abdominal cavity or to collect a specimen of
ascetic fluid to diagnose. It does not permanently treat ascites (it is only done if they are experiencing breathing
or pain due to ascites). Before the procedure: get informed consent. Tell them to void. Assess weight, vitals, and
abdominal girth. Place the patient in high fowlers/upright position. Assess closely for hypotension.

MRI Cholangiopancreatography (MRCP)- is a noninvasive diagnostic test used to visualize the biliary, hepatic, and
pancreatic ducts via MRI (like to diagnose cholecystitis, cholelithiasis, or biliary obstruction). MRCP uses oral or
IV gadolinium (a noniodine contrast material). Contraindications: metal/electrical implants or gadolinium allergy,
or pregnancy.

Endoscopic retrograde cholangiopancreatography (ERCP)- putting endoscope through mouth to pancreatic and
biliary duct. Contrast solution used can be as a barium and it makes the patients stool white for up to 3 days.
Encourage fluids. Complication: perforation, pancreatitis-which is life threatening.

Pancreatitis- is an acute inflammation of the pancreas that causes autodigestion. Causes: cholelithiasis and
alcoholism. Symptoms: severe left upper quadrant/epigastric pain radiating to back (it improves if lean forward
and get worse if lie flat). Pancreatic enzymes elevated (amylase/lipase), nausea, vomiting, tachycardia,
hyperglycemia, steatorrhea, sinus tachycardia. Treatment: supportive/symptom relief. NPO (because any food can
63

exacerbate the symptoms.) Ng tube to suction secretions. Pain medication IV. Iv fluid. Position semi fowlers or
side lying. Complications: Respiratory problems after like ARDS, hypocalcemia, hypovolemia, pancreatic abscess.

Jaundice- s a condition that causes skin and the whites of the eyes to turn yellow. Causes: elevated bilirubin/
liver disease. Symptoms: yellowing of skin and sclera (icterus). Intense itching that can get worse with hot water
and strong soap.

Liver biopsy- the liver makes coagulation factors and is highly vascular so before the biopsy check PT/PTT/INR,
and check blood type and crossmatch it. Insert the needle between the 6-9th rib while the patient is supine with
the right arm overhead and holding breath. Postop: frequent vitals. lie on right side for minimum 2-4 hours to
splint incision and stay on bed rest for 12-14 hours. Watch for rising pulse and respirations with hypotension
(which is an early sign of hemorrhage).

Spleen-is a part of the immune system. It purifies blood and removes microorganism’s that cause infection. So, if
a patient had a splenectomy- they can have overwhelming bacterial infection or rapid onset of sepsis. Basically,
minor infection can become major. So, any indicator of infection (like low grade fever, chills, headache) needs
immediate interventions.

Wound Care

Wound culture- is done to identify microorganism to prescribe antibiotics. Steps: wash hands. Put on gloves.
Remove old dressing and discard gloves. Wash hands. Put on sterile gloves. Clean wound with NS. Wash. New
gloves. Swab with a sterile swab from center out (do not contact skin). Put swab in sterile container. Apply topical
meds. Remove gloves. Label and document.

Dry dressing change- use clean gloves (do not need sterile gloves). Preform Hand hygiene. Clean wound with
sterile saline from center outwards. With sterile gauze, dry the wound. Monitor for infection. Put dry, occlusive,
sterile gauze over wound bed (do not use saline or anything wet).

Negative pressure wound therapy- puts negative pressure on the wound to take away bacteria/exudates. It
promotes healing by stimulating cell growth. Interventions: Give pain medication30 minutes before doing. After
cleaning the wound, put skin protectant around the wound to prevent breakdown and promote an airtight seal.
Cut a sterile foam dressing to fit the wound shape and then place in wound bed. Put occlusive dressing large
enough to coverer 1.2/2 inches beyond the wound edges (to create a seal). Then connect a vacuum assisted
closure to create the negative pressure. The foam dressing should compress when the device is turned on
(meaning proper seal and function). The foam dressing uses a sterile technique.

Wound irrigation- is done before closing an open wound. Interventions: give analgesic 30 minutes before
irrigation. Put gown and mask. Fill 30-60ml sterile irrigation syringe. Attach a 18/19-gauge needle to the syringe
and hold 1inch above area. Use continuous pressure to flush wound. Repeat till drainage clear. Dry surrounding
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wound. If patient did not have tetanus vaccination within 5-10 years ago-give. Clean from least to most
contaminated.

Emptying Jackson Pratt reservoir- Jackson Pratt is a closed wound surgical drain that is placed after
abdominal/breast reconstruction surgery. Purpose: to prevent fluid buildup in closed space. Steps to empty: hand
hygiene (sterile). Pull plug over bulb to open device and pour drainage into calibrated container. Empty every 4-12
hours unless ½-2/3 full before then. Compress the empty bulb by squeezing it from side to side with ½ hands till
totally collapses. Clean spout on bulb with alcohol and replace plug when totally collapsed.

Pressure ulcers- are areas of damaged skin caused by staying in one position for too long. Interventions: assess
patient for their risk of getting a pressure ulcer by using a Brandon scale upon admission and at least once daily.
To prevent use emollient/barrier cream. Use foam padding on chairs. Provide prompt incontinence care and use
additional barrier cream to keep skin clean and dry. Reposition patient with a turn sheet every 2 hours using
devices (pillows, foam wedges). Avoid pulling/dragging patient up in bed as shearing can occur. Do not massage
bony prominence.

Dehiscence- when a surgical would reopens/separates. Causes: impaired circulation/oxygen/wound healing,

mechanical stress on wound, vomiting/coughing. Risk factors: diabetic, older age, obesity, malnutrition,
infection, steroids). Prevention: stool softeners (like docusate), antiemetics (like ondansetron), abdominal binder,
monitor tight glycemic control to decrease infection risk and promote wound healing. Splint abdomen against
wound when coughing/moving.

Wound evisceration- is protrusion of internal organs through the wall of incision. It occurs 6-8 days after surgery
(especially if abdominal surgery or if patient is obese). Risk factors: diabetic, obesity (because poor wound
healing). Interventions: The nurse stays with the patient calls for help. Cover the wound with sterile NS dressing.
Position in low fowlers with knees bent. Patient remains NPO. Treatment: emergency surgery

Neuro

Basilar skull fracture –is a break of the bone at the base of the skull. Symptoms: ecchymosis around eye
(periorbital/raccoon eye) or postauricular (battle sign). With basilar skull fracture-there is a potential of cerebral
spinal fluid (CSF) leakage-so test the drainage for dextrose to see if its CSF. If the drainage is clear, do dextrose
testing to confirm if CSF. But blood can make it unreliable (because blood has glucose). So put halo/ring test (add
few drops blood to gauze and assess characteristic patterns of coagulated blood surrounded by CSF. If there is
CSF- no NG/oral gastric tube inserted blindly (without machine guiding). Other interventions: evaluate LOC
changes and temperature, assess head/neck for subQ bleeding.

Blunt force trauma-to the head. Severe complications: brain damage, herniation, retinal detachment, seizures,
increase ICP. Symptoms of retinal detachment: perception of lightning flashes, floaters, curtain like or
gnats/hairnet/cobweb effect through visual field. Retinal detachment is an ocular emergency can cause
permanent blindness
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After head injury like a concussion- the patient can experience loss of memory of the event (retrograde amnesia),
headache or bleeding tongue. Interventions: No opioids/CNS depressants. Have someone with the patient. No
driving/heavy machinery/contact sports /hot baths for 1-2 days. Tell doctor if drowsiness, nausea, vomiting,
worsening headache, seizures, vision change, behavioral change, weakness/numbness, or difficulty with balance.

Aphasia:

1. Broce=expressive-they understand but cannot speak or its extremely hard to. They are aware.
2. Wernicke=receptive (fluent) they cannot comprehend spoken/written. They are not aware.
3. Global- they cannot read, write, or understand speech-most severe form of aphasia

Causes: neuro (like stroke, TBI), dysphasia, aphasia. Interventions: the nurse should not complete tasks for the
patient. Encourage independence. Ask short/simple yes or no questions. Use gestures or pictures to show
activities. Remain with the patient and stay calm. Do not raise voice. Visual aids and hand gestures may be more
effective means of communication.

Trigeminal neuralgia is characterized by intermittent severe, unilateral facial pain precipitated by light touch, hot
or cold foods, chewing, and swallowing. Pain is severe, intense, burning, or electric shock like in gums/lips and
severe pain along cheekbones. Interventions—the priority is pain control with medication. Give carbamazepine.
Oral care- Soft toothbrush with warm mouth wash, lukewarm water. Do not eat food/drinks too hot /cold. Room
at even/moderate temperature. Avoid rubbing/facial massage. Use cotton pads to wash face. Soft diet with high
calories. Chew on unaffected side.

Bell palsy-is an inflammation of cranial nerve 11 (facial nerve) causing facial muscle weakness and inability to
close the eye on one side. Symptoms: unilateral facial paralysis with absent of stroke. Not able to close eye on
affected side. Alteration in tear production (less/dry tears, or more tears). Flattening of nasolabial fold. Not able
to smile/frown symmetrically. Can lose taste on anterior 2/3 of tongue. Treatment: corticosteroids to reduce the
inflammation. Teach oral/eye care. Eye care: use glasses during day, wear patch (or tape eyelids) at night. Use
artificial tears during day. Oral care: chew on unaffected side, soft diet, good oral hygiene.

Lumbar puncture aka spinal tap- is an invasive procedure used to remove a sample of cerebrospinal fluid (CSF)
from the subarachnoid space in the spine. It is a sterile procedure. Contraindication: elevated ICP. Steps: nurse
should get consent, gather supplies, explain procedure, empty bladder, place side lying with knee up or bent
forward, provide distraction. Insert needle in vertebrae between L3-L5 and draw CSF. Label specimen containers,
apply bandage, bring specimen to lab. Postop: lie patient flat, with no pillows for 4 hours. Increase fluid intake for
24 hours. A headache is normal after, and so is pain radiating down leg-its temporary.

Cerebral Spinal Fluid (CSF) normally it should be: clear, colorless, little protein, little glucose, minimal WBC. No
microorganism. Normal CSF pressure is 60–150 mm H2O.

Intracranial pressure (ICP)- is the pressure inside the skull. The skull is a closed system and any increase pressure
can have detrimental effects. Symptoms of increased ICP: Early symptoms: bulging fontanels and increased head
66

circumference and sunset eye. Late symptoms: Cushing triad (Indicates brain stem compression)- systolic
hypertension with widened pulse pressure, bradycardia, respiratory depression. Other signs: projectile vomiting
with no nausea, headache, changes in LOC, ataxia, pupil dilation, seizures. Interventions: get vitals, call doctor,
Raise head of bed 30 degrees with neck in neutral position. stool softeners. Pain medication. Manage fever (with
cool sponges, antipyretics, ice). Maintain calm environment. Minimal noise, oxygen. Hyperventilate and
preoxygenate patient before suctioning (reduces carbon dioxide and ICP). Suction max of 10 seconds and only as
needed. Encourage patient not to cough, strain, increase abdominal/thoracic pressure.

Subarachnoid intracerebral bleed-is a rupture of a vessel in the brain. It is an emergency. Symptoms: “worse
headache of life”. Onset is abrupt.

VP shunt- takes fluid out of your brain and moving it into your abdomen where it is absorbed by the body. This is
done to lower the pressure and swelling in the brain-like to treat hydrocephalus. It is placed at 3 to 4 months. It is
tunneled under the scalp and can be palpated. Complications: blockage, infection. Blockage causes signs of ICP.

Stroke aka cerebrovascular accident (CVA)- is a brain attack. It occurs when the blood supply to the brain is
blocked. There are two types: Ischemic and Hemorrhagic. Ischemic is when circulation to brain is blocked.
Hemorrhagic is when a blood vessel in the brain ruptures. They both can lead to tissue death. Risk factors:
diabetes, high cholesterol, hypertension, smoking, obesity. Older age, genetic susceptibility. The single most
modifiable factor is hypertension. Symptoms: Numbness or weakness in the face/arm/leg, especially on one side,
Confusion or trouble understanding other people, Difficulty speaking, Trouble seeing with one or both eyes. Use
mnemonics FAST to assess for stroke: F-facial dropping. A-arm weakness, S-speech difficulties, T-time(note).
Interventions: immediately do a CT scan (Have to do CT scan before giving thrombolytics because its only given for
ischemic not hemorrhagic strokes). Start 2 large bore IV lines for rapid infusion. Know exactly when the symptoms
started. Prevent activity that can increase ICP or blood pressure so: reduce stimuli, stool softener to reduce
straining. Reduce exertion. Bed rest. Assist with ADL. Head midline position. Neuro assessment.
Treatment: thrombolytic therapy (like alteplase, TPA)-must be within 4.5 hours from onset of stroke.
1. Tissue plasminogen activator (TPA)-dissolves clots and restores perfusion in ischemic stroke. It must be
given within 3-4.5 hours from onset of symptoms. Contraindications: history of intracranial hemorrhage,
active bleeding, surgery within 2 weeks ago, head trauma/stroke in past 3 months, current anticoagulant
use (or 2-5 days ago).
Homonymous hemianopsia-loss of half the visual filed on same side (like Loss of left side of visual field on both
eyes). Causes: stroke. The patient is at risk for neglecting self-care, safety, and injury. Interventions: teach
them to turn head. Keep food/fluids within field of vision.

Seizure- is a sudden, uncontrolled electrical disturbance in the brain. With seizures, there are 4 phases: 1.
Prodromal- warning signs before seizure. 2. Aural- before a seizure, the patient experiences visual/sensory
changes (not all patients will recognize phase 1 or 2). 3. Ictal- active seizure activity. 4. Postictal phase- patient is
confused while recovering. Ha.
Seizures may include: tonic (body stiffening), clonic (muscle jerking), atonic (loss of muscle tone or "drop attack"),
myoclonic (brief muscle jerk), or tonic-clonic (alternating stiffening and jerking) body motions. Interventions: note
duration and symptoms, call for help, pad side rails, turn on side (to open airway), loosen clothes, have suction
equipment ready for after seizure. Never restrain them.
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2. Absent seizures-usually in children age 4-12 years and disappears at puberty. Symptoms: brief LOC and
appear inattentive or daydreaming with no loss of postural body tone except slight like dropping a pencil.
Last less 10 seconds, and often unrecognized. They have no recollection it occurred. Can happen multiple
times a day. They are unresponsiveness during seizures. Treatment: anticonvulsant medications

Status epilepticus-is a serious, life threatening emergency in which a patient has been seizing for 5 minutes or
longer. Risk Factors: hydrocephalus, VP shunt. Symptoms: grunting, dazed appearance. Interventions: the priority
is to stop the seizure so give IV Benzodiazepam’s (like lorazepam).

Epilepsy-is chronic seizure activity. Treatment: lifelong anticonvulsant medication. Tell the patient about avoiding
seizure triggers like alcohol, sleep deprivation, or stress. Practice relaxing methods (like biofeedback). Wear
epilepsy med identification bracelet in case of emergency.

Electroconvulsive therapy (ECT)- it induces a seizure for 15-20 seconds. It is done to treat mood disorders like
major depression, bipolar, and schizophrenia. Interventions: tell the patient: NPO 8 hours before. They will get
anesthesia with muscle relaxant, so the patient is unconscious and does not feel pain. Do not drive. It is normal
for have temporary memory loss and confusion right after.

Coup-contrecoup injury- when the body in motion stop suddenly (like the head hits car windshield)- causes
contusion (bruising) of brain tissue. First the soft tissue strikes the hard skull in same direction as momentum
(coup). Then body bounces back and so does brain (contrecoup). When falling forward (coup), the frontal lobe is
affected first. So executive function, memory, speech (broca area), voluntary movement are affected first. The
countercoup injury most likely affects occipital lobe (vision).

Electroencephalogram (EEG) diagnostic procedure to see if abnormal electrical discharges in brain which is
causing a seizure. Interventions: Wash hair to remove oil. Avoid caffeine, stimulants, and CNS depressants. The
test is not painful.

If you suspect cervical spine injury-the priority is to ensure patent airway and immobilize spine. Interventions:
place rigid hard collar (neck), place patient on firm surface (backboard), move patient as unit (logroll method).
Tape down patient’s head and use straps to immobilize the arms. After immobilization-get vitals to see if
neurogenic shock (which is a complication of spinal cord injury). Abdominal breathing or increase work breathing
can indicate impending loss of airway and needs immediate intubation.

Carotid endarterectomy-is a surgery to remove plaque from carotid artery. Interventions: Keep checking for new
signs of altered neuro status. These patients are at risk for stroke, so use mnemonics FAST to assess for stroke:
F-facial dropping. A-arm weakness, S-speech difficulties, T-time(note). Monitor the blood pressure for 24 hours
postop because hypertension can strain site and cause hematoma leading to hemorrhage/airway obstruction (you
want the systolic to be between 100-150).
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Tubes and ventilators

Airway: if respiratory problem, and patient needs air

• Mechanical Ventilation-gives spontaneous respirations.

1. Noninvasive- face/nasal mask (attached to ventilator). The patient needs to be alert/stable
a. CPAP (through face/nasal mask)-gives continuous pressure to keep alveoli and tongue
(so sleep apnea) open
b. BiPAP (through face/mask)-gives different levels of pressure during
inspiration/expiration
c. If these options do not work or need more-go to invasive:
2. Invasive- intubation (attached to ventilator)
a. look at intubation part- (includes ET tube and trach)
• Intubation
1. Endotracheal tube intubation- (ET tube/ETT) is a tube placed through mouth into trachea/lungs.
o Steps: have equipment nearby. First-pre-oxygenate, medication to block muscle, may need to
suction if cannot see where placing ET tube. Check right position (by inflating lungs with
balloon and listening to breath sounds or do an x-ray to confirm-best way). Secure tube.
o After intubation-it is normal up to 6 hours not to have gag reflex
o ET tube can be attached to a mechanical ventilator, if they need more oxygen than ET tube
alone can give.
o Can leave be left in for 14days after that-need a tracheostomy/tract tube
2. Trach intubation- done through a tracheostomy. It is used more for long term. 1 finger should fit over
tie, change every 24 hours or if wet/soiled. You should inflate the cuff (so the balloon opens inside)

Mechanical Ventilation:

Modes: Assisted Control (full support-patient gets breaths regardless, but patient can breathe).
Synchronized Intermittent Mandatory (patient gets breaths but must inhale TV). Pressure Support (patient is
being extubated soon, so they get very little breaths)

Settings: Tidal volume/TV (tells you the amount of air going to lungs, 400-800). FiO2 (the percentage of
oxygen going to lungs needed to maintain adequate blood oxygen levels). PEEP (amount of pressure left in circuit
at end of exhalation, 5-10),

Alarms- (to tell you if something is wrong): Always first look at patient. There are 2 types: high pressure
(which means that there is resistance somewhere-like obstruction, coughing, water in tube.). Low pressure (like
leak/dc) in the system. If the patient gets worse- assess lung sounds, discontinue ventilator, and manually
ventilate patient with bag device.

They are at risk for: ventilator associated pneumonia, aspiration. Interventions: use minimal sedation.
Oral care with chlorohexidine every 2 hours. Give morphine

Suctioning: Done: if adventitious sounds, ARDS, high pressure alarm, rhonchi to removes secretions. Sterile
technique. Steps: Semi fowlers, pre oxygenate with 100% for 30 seconds, deep breaths, cough as catheter enters
69

trachea, advanced till resistance the retract 1 cm, then apply suction while rotating when withdrawing (so suction
only when withdrawing). Suction for less than 10 seconds

To give feeding eternally:

• First-check gastric residue (should be no more than 250ml) and gastric pH measurement (for tube
placement, less 5), air auscultation, x-ray (the definite way).
• Check gastric residue every 4 hours (if continuous feeding), hold if more 500.
• Signs of intolerance-abdominal distension, nausea, vomiting.
• If tube clogged-large barrel syringe, aspirate water. Or digestive enzymes

Feeding Tubes:

• Ng tubes:
o Small bore-for feeding and medication only
o Large bore aka Salem sump-for feeding/medication and suctioning
o Inserting- if the patient coughs-withdraw slightly, wait, and then continue. If obstruction-rotate it.
If still obstructed-withdraw completely and insert into another nare.
o Flush before and after. Confirm with x-ray for placement.
• PEG Tube (percutaneous endoscopic gastro)- is placed in stomach with balloon. There are two ports to
give feeding and medication. Used for long term
• Button tube-same as PEG-just for confused patients or patients pulling on tube.

Chest Tube-used to remove air or fluid to re-expand lungs/heart.

• Tube goes from patient (lungs/heart) out to drainage system-called the collecting chamber. It continues
to the middle chamber called the water sealed chamber. (as the patient breathes in and out- it should go
up and down, except if patient is on positive pressure mechanical ventilation-then it goes down when
they breathe in). then goes to suction controlled chamber
• There is a section in the water sealed chamber called air leak monitor and if continuous bubbling=it
indicates an air leak (but if the patient has a pneumothorax –its normal to have intermittent bubbling). If
no bubbling at all=indicates the lung re-expanded or there is a kink.
• There are 2 types of chest tubes
1. Wet suction- comes with water that you put in it. You should see bubbling in it.
2. Dry suction –no water. No bubbling, get more suction from.
• You should keep the whole drainage system below the patient’s chest. Do not milk/strip/clamp the
tubing. When removing it-tell the patient to do the Valsalva maneuver, and place them in semi fowler
position
• Problems:
o If chest tube becomes dislodges-you should cover with sterile dressing and tape on 3 sides
o If chest tube system breaks-you should insert tubing into 1inch sterile water and get new one
70

Cancer

Cancer warning signs: Mnemonics: CAUTION: Change in bowel /bladder habits, A sore that x heals, Unusual
bleeding or discharge, Thickening or a lump, Indigestion or diff swallowing that x goes away. Obvious change in
wart/mole. Nagging cough/hoarse

Radiation- affects tissues with rapidly proliferating cells (like oral mucosa, GI, bone marrow), and then slowly
affects proliferating cells (like cartilage, bone, kidney). So early symptoms a patient may experience: oral mucosal
ulcers, vomiting, diarrhea, low blood count. Mucositis (inflammation in mouth) and xerostomia (dry mouth).
Interventions/Patient education: Avoid irritants like acid or spicy foods. Have nutrition drinks like Ensure. Artificial
saliva. Sip water throughout day. clean mouth with NS after meal and at bedtime. Use soft bristle toothbrush. Put
lidocaine to alleviate oral pain. Use water soluble lubricating agents to moisten mouth because dry. No
hot/spicy/acidic foods. No aseptic mouthwash with alcohol.

Chemotherapy-side effect: bone marrow suppression. So, a fever in present of neutropenia can rapidly develop
into life threatening sepsis. Interventions/Patient education: no garden/fresh flowers/plants. Do not have
standing water. Strict handwashing. Private room, and visitors wear mask. No raw or unwashed vegetables. Eat
protein. No raw/uncooked meat. Bathe daily/ moisturize.

Tumor lysis syndrome-is a complication of chemotherapy. It means a rapid release of intracellular components
into the bloodstream (so potassium and phosphorus go from cell to blood). Which produces uric acid so
hyperuricemia, and they get deposited into the kidney causing renal injury. Treatment: allopurinol (zyloprim) and
IV hydration

Multiple myeloma is a cancer of the bone marrow that causes bone degeneration and skeletal pain. Symptoms:
spinal/pelvic /rib pain with physical activity.

Testicular cancer- is common in men ages 15-35 years old. Risk factors: undescended testes-perform TSE
(testicular self-exam) monthly on same day, in a warm shower, using thumb and 1st two fingers, and with both
hands each separately.

Brachytherapy/internal radiation- putting radioactive implant on cancerous site/tumor for 24-72 hours. It is used
to treat endometrial and cervical cancer. Interventions: Staff time should only be in room for max of 30 minutes
per shift-so cluster care. Cannot go in if pregnant or under 18. All staff must wear dosimeter film badge. If the
implant dislodges-first use long handles forceps and a lead lined container (should be kept in room) to contain
radiation exposure, then tell doctor.

Teletherapy/external beam radiation- Interventions/ Patient education: do not rub/scratch/scrub skin. Wear
loses clothes. Use soft, cotton bed sheet/towel. Pad dry after bathing. No bandages or tape on treatment area.
Clean skin daily in lukewarm shower with mild soap with no fragrance/deodorant. Do not wash off any radiation
71

ink markings. Use creams/lotions approved by doctor. No OTC creams, oils, ointment. No tanning/sunbathing.
Outside wear long pants, sleeves, hats, and use SPF sunscreen 30 or more. Avoid temperature extremes (like
ice/heating pads). Maintain cool/humid environment.

Endometrial cancer-Symptoms: postmenopausal bleeding or abnormal premenopausal bleeding

Cervical cancer- Causes: HPV virus, and early sex activity (like before age 18), multiple sex partners, impaired
immune system (like HIV, on immunosuppressive drugs like steroids), oral contraceptive, tobacco. Symptoms:
irregular, painless vaginal bleeding. Its asymptomatic at first. Prevention: pap test screening. And HPV vaccine.

Ovarian cancer-symptoms: (are subtle)-abdominal bloating, pelvic pain/pressure, abdominal girth increase, early
satiety, abdominal/back/leg pain, urinary urgency/frequency, GI disturbances. It is usually not diagnosed until into
late stage.

Oral cancer-is cancer of the lips/tongue/mouth/pharynx/larynx. Risk factors: chronic alcoholic/tobacco, poor oral
hygiene, chronic irritation to mucosa (chip teeth, improper fit of dental appliances), excessive UV light (sun
bathing), unprotected oral sex (HPV). The most common type is squamous cell carcinoma which initially looks like
a nonhealing lesion/ulcer. Other symptoms: mucosal thickening, difficulty swallowing, mouth bleeding, sore spots,
leukoplakia (white patches), change in salivation.

Skin cancer- The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and
melanoma. Melanoma is the deadliest. Risk factors: history, certain traits (light skin, blonde hair, light eyes, many
freckles). Lot of moles. Immunosuppressed. UV light exposure. To prevent: do monthly skin checks. ABCDE
assessment (Asymmetry (one half of the mole doesn’t match the other), Border irregularity, Color that is not
uniform, Diameter greater than 6 mm (about the size of a pencil eraser), and Evolving size, shape or color)

• Melanoma-interventions: avoid sun between 10am-4pm (even in winter). Wear protective clothing.
Sunscreen (broad spectrum. SPF more 15 daily and more 30 for outdoor). Apply it 15-30 minutes before
going out. Reapply every 2 hours. Reapply after water/sweat even if it says resistant. Do not use tanning
beds.

Bladder cancer- Causes: smoking/tobacco, carcinogen exposure at work (like printing, iron, aluminum, paint,
metal, machine). Symptoms: painless hematuria- (blood in urine with no pain).

Breast cancer-. Risk factors: female, age over 50, first degree relative (mother or sister), BRCA1/2 genetic
mutation, history of endometrial/ovarian cancer. Menarche before 12 years or menopause after 55 years. Other
risk factors: hormone therapy (so like estrogen or combined oral contraceptives), postmenopausal weight gain
(fat stores estrogen). Smoking, alcohol consumption, fat intake, sedentary lifestyle. Diagnosed: mammography
Symptoms: when palpated breast there is a lump that is hard, irregular shaped, non-mobile, and nontender. Later
signs of breast cancer include a newly retracted nipple or an orange-peel appearance of the breast tissue (peau
d'orange) caused by the plugging of dermal lymph drainage

• Mastectomy- is the surgical removal of one or both breasts, partially or completely. Postop: semi fowlers
position with the affected side arm elevated on several pillows to promote drainage and prevent pooling.
72

Bend fingers then go to arm gradually over post op days. Full ROM comes within 4-6 weeks of
mastectomy.

Catheters

Central venous catheter- are used to give fluids, medications, nutrition, and for hemodynamic monitoring.
Interventions: proper hand hygiene and nonsterile gloves. The hubs should be disinfected with antiseptic (70%
alcohol pads, or .5% chlorhexidine with alcohol, 10% povidone iodine.) Allow antiseptic to dry before using
hub/port. After putting in check results on chest x ray to see if tip in place. Give anticoagulants in form of heparin
flush-standard 2-3ml w 10u/ml -100units. If venous thromboembolism give doses 1000-10000. Do single dose vial
or prefilled syringe to reduce infection risk. TPN is given through CVC. Change occlusive dressing every 7 days. The
distal port or triple lumen CVC is the largest lumen and should be used for CVP (right atrium pressure) monitoring.
Flushing of a central venous catheter with NS is recommended before medication infusion to see patency.
Preferably use 10ml syringe. Use the push-pause method. Do not inject against resistance.

• Peripheral inserted central venous catheters (PICC)-is inserted via basilic or cephalic veins into SVC. Uses:
long term antibiotic therapy, chemo treatment, TPN. Interventions: The nurse should measure/document
external length of PICC during dressing changes. If the length of external portion changes-can be from
migration of the tip of catheter from original position. So, hold IV fluids/medications, secure PICC, notify
doctor for x-ray. Inspect insertion site for signs of infection (redness, drainage) and dressing integrity.
Change sterile dressing every 48 hours with a gauze dressing or every 7 days with a transparent
semipermeable dressing (bio patch) and change immediately if dressing lose/torn, soiled, damp. Flush line
before and after medications. No venipuncture/blood pressure on same arm as line. If loose corner-then
temporarily reinforced them with tape. Also scrub the hub with alcohol/chlorhexidine for 10-15
seconds-before flushing, drawing blood, or giving medications. Complications: occlusive of catheter,
phlebitis, air embolism, infection. So before changing central line dressing- hand hygiene. Sterile
technique with nurse wearing mask. Tell patient to turn head away from PICC site so they do not
contaminate it. And when your injecting cap or changing tube-tell the patient to hold breath in (Valsalva
maneuver) to prevent air from getting in line (can lead to air embolism).
• Catheter occlusion-is the most common complication of central venous access devices. So first assess for
mechanical problems by repositioning the patient and assessing for tube clamps/kinks/precipitate. Then
after that-flush device again. If still occluded contact doctor.
• Leakage of more 500ml of air from central venous catheter-is fatal because can cause an air embolism. It
obstructs blood circulations. Interventions: immediately clamp the catheter. Then place the patient in a
Trendelenburg position on left side, give oxygen, tell doctor, and stay with the patient

Air embolism- is a life-threatening complication of central venous catheter (CVC) placement in which air enters
the bloodstream. It can occur after CVC removal. Prevention: when removing a CVC: supine, bear down or exhale,
air occlusive dressing. Never pull hard. Symptoms: dyspnea, hypoxemia, sense of impending doom. Treatment: If
someone has an air embolism: put occlusive dressing to insertion site. 100% oxygen via nonrebreather mask. Left
lateral Trendelenburg. Monitor vitals. Notify doctor. Complication: respiratory distress
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Indwelling urinary catheter-

Uses: urinary retention/obstruction. Need critically ill strict I/O. Perioperative. Prolonged immobilizations. To
improve end of life care. To facilitate healing of open wound. Complications: UTI. To prevent UTI: wash hands,
perineal hygiene with soap/water (not alcohol) each shift and after bowel movement. Keep the drainage system
off the floor/contaminated surfaces. Keep catheter bag below level of bladder. Each patient should have separate,
clean container to empty collection bag and measure urine. Sterile technique. Encourage oral fluid.

• Inserting indwelling urinary (Foley) catheter- use sterile technique (surgical asepsis) to prevent UTI.
Dominant hand should be sterile till completion of the procedure. Place nondominant hand on the
patient’s genitals (to spread the labia or to grasp the penis) to clean and keep in place till catheter
inserted. You can keep the kit on the patient’s legs or on a clean bedside table. Swabs should be disposed
of in the trashcan or in a biohazard bin in accordance with hospital policy
• Removal of indwelling Catheter- wash hands. Privacy. Clean gloves and place a waterproof pad
underneath. Remove adhesive tape. Deflate balloon by allowing water to flow back to syringe-remove all
10ml. Remove catheter. Empty and measure the urine. Remove gloves. Wash hands

Shock

Shock- is the state of not enough blood flow to the tissues of the body because of problems with the circulatory
system. Types:

• Hypovolemic shock (hemorrhagic)- Causes: from anything that reduces intravascular volume (like after
abdominal trauma or surgery, after blood loss. Symptoms: (of inadequate tissue perfusion): change in
mental status, tachycardia with thready pulse, agitation, Cool clammy skin. Oliguria. tachypnea.,
hypotension, tachycardia, low central venous pressure. Treatment: isotonic fluids (NS, LR) IV bolus
• Anaphylactic shock- Causes: allergic reaction. It has an acute onset (20-30 minutes). Interventions: stop
infusion/call help. Ensure airway. oxygen. Epinephrine in muscle. NS. Bronchodilators, antihistamine
(Benadryl), corticosteroids
• Neurogenic shock- it is a vasodilatory shock so massive vasodilation. Causes: damage to the nervous system
(like spinal cord injuries of T6 or higher). Symptoms: hypotension, bradycardia, poikilothermic (cannot
regulate body temperature), warm pink, dry skin.
• Cardiogenic shock-Causes: heart problem. Symptoms: reduced cardiac output (hypotension, narrow pulse
pressure). Treatment: oxygen, EKG, cardiac enzyme testing, reduce cardiac workload. Do not give a bolus
of fluid because the heart must work faster/harder.
• Septic shock- Causes: infection. It is when overwhelming response to infection causing impaired organ
function. Symptoms: fever, hypothermia, hypotension, prolonged capillary refill (more 3 or 4 seconds),
tachycardia, WBC more than 12000 or immature neutrophils more 10%, decrease urine output (less
0.5ml/kg/hr).
74

Allergy

Anaphylactic reaction- is a serious, life-threatening allergic reaction. Symptoms: swelling of lips/mouth/upper

airway, wheezing, difficulty breathing, cardiac symptoms (lightheaded /hypotension, LOC, heart collapse), itching,
flushing. Hives, bronchospasm. Interventions: First call for help. High flow 0xygen via nonrebreather mask. IM
epinephrine. (repeat every 5-15 minutes if no response). Elevate legs. Volume resuscitation with IV fluids.
Bronchodilators (albuterol). Antihistamine (diphenhydramine). Corticosteroids (methylprednisolone)

• Epinephrine/EpiPen: for emergencies. Inject at 90 degree into mid/outer thigh at first sign of allergic
reaction. It can be given through clothing. Hold it in place for 10 seconds. Massage for 10 seconds.
Should seek medical care right after (because it can come back 10-20 minutes again). Side effects: (which
are normal to occur): tachycardia, palpitations, dizziness. Store at room temperature in dark place

Latex allergy-is a natural rubber found in most medical devices (gloves, catheters, tape). It can develop from
repeat exposure. Risks (when likely to have latex): gloves, procedures with balloon tip catheters, blowing up toy
balloons, bottle nipples, pacifiers, condoms/diaphragms. Symptoms: anaphylaxis, lip swelling, allergic contact
dermatitis 3-4 days post exposure. Ask the patient about reaction to common latex objects like balloons etc. They
usually have cross allergy to foods like bananas, kiwis, avocados, tomatoes, peaches, grapes. If severe allergy wear
med alert bracelet and carry EpiPen. Numerous products may contain trace amounts of latex; this crucial
information that may be omitted on the labels.

Allergy skin testing-is the process of introducing the allergen to skin and observe for reaction (wheal, erythema).
Patient education: The patient should avoid antihistamines (like diphenhydramine [Benadryl], loratadine [Claritin],
promethazine [Phenergan], and corticosteroids up to 2 weeks before the test.

Allergy immunotherapy injections- giving the patient an injection of the allergy to trigger the response so the
next time they have reduced symptoms. A little bit can still be fatal and lead to an anaphylactic reaction. So, after
injection remain in facility for 30 minutes after.

Dust mite allergy- dust mite is usually found on beds. Interventions: wash linen every 1-2 weeks with hot water to
prevent. No warm/cold water. Also, can use special allergy proof mattress and pillow cover and vacuum mattress
on regular basis. Not recommended for someone with allergies/asthma to have carpet. If have carpet-vacuum
daily.

Anemia

Anemia-is a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin. There
are many causes and types of anemia.
75

• Megaloblastic anemia- is a vitamin B12 or folic acid deficiency. Vitamin B12 is only found in animal foods
(like meats, fish, poultry, eggs, milk, breads/cereals, or yeast). Risk factors: Vegans. Symptoms of chronic
deficiency: peripheral neuropathy (tingling, numbness). Neuromuscular impairment (gait problems, poor
balance). Memory loss/dementia (if severe/prolonged). Treatment: vegans should take vitamin B12
supplements and vitamin B12 foods (cereals, grain products, soy/ milks, meat substitutes)
• Iron deficiency anemia- from not enough iron. Risk factors/Causes : eating a lot of dairy (because milk
decreases iron absorption), premature birth, delayed introduction of solids, eating cow’s milk before 1
years, GI malabsorption problems, increase iron need time (like in pregnancy, or if child is growing), blood
loss, vegetarians, or a low protein diet.
• Interventions: iron supplements. Iron stores received from the mother are typically depleted by age 5-6
months (2-3 months for preterm infants)- so after this point, iron must be acquired through dietary
sources. Foods with iron include: meats (chicken, pork, beef, lamb, ham, liver). Shellfish (oyster clams,
shrimp). Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, oatmeal. Tell the
patient to eat vitamin C foods with it because it increases its absorption (like citrus fruits, potatoes,
tomatoes, orange juice green vegetables). Also, iron is better absorbed on an empty stomach.

Contraceptive

emergency contraception-prevents pregnancy after intercourse. These pills (like levonorgestrel [Plan B]) should
be taken within 5 days of intercourse; however, efficacy is reduced after 3 days (72 hours). Can also use copper
IUD for 5 days after intercourse.

Contraception aka birth control-used to prevent pregnancy.

Instructions: after starting an oral contraceptive, you need backup for 7 days, unless you started taking it on the
first day of menses.

Complication: hypercoagulable- (if taking estrogen containing contraceptives), so DVT, blood clots

Types:

• Diaphragms are flexible latex/silicone devices inserted before intercourse to cover the cervix to prevent
pregnancy. It does not protect against STI. Women in stable, one partner relationship are a good
candidate for the IUD placement. Complications: pelvic inflammatory disease
• Progestin only pills-POP-they thicken the cervical mucus and thin the endometrium to prevent ovulation
and have no estrogen in it. It is normally taken by breastfeeding moms. It only last 2 hours so at the same
time every day. If pills taken more than 3 hours late- use a barrier method (condom) till pill taken
correctly for 2 days. If you took the pill and vomited or diarrhea within 3 hours, then take another one.
Side effect (normal)- breakthrough bleeding.
• Intrauterine devices (IUD)- is a long-term contraception method. Complications: (use mnemonics PAINS)-
(period abnormalities, ab pain, infection, not feeling well, strings longer). Nurse should assess string
position for first 4 weeks and then after each menses. A longer, shorter, missing string indicates the IUD is
not placed in the uterus-tell doctor and do not have intercourse or use condom till placement verified.
76

Eyes and ears

Strabismus- is crossed eyes- where one eye may appear inward or outward. The brain perceives 2 images
(diplopia) and suppresses the weaker image, if untreated by 4-6yrs, permanent reduction or loss of visual acuity in
the affected eye can occur. Treatment: wear a patch over stronger eye or special corrective lenses. If those do not
success, then surgery.

Retinoblastoma-is an intraocular tumor of the retina. Symptoms: white pupils (instead of red reflex), asymmetric
or differing color in affected eye, fixed strabismus. Treatment: radiation therapy, enucleation (removing eye),
fitting for prosthesis. Siblings should undergo regular ocular screening.,

Open angle Glaucoma- is increase intraocular pressure (so it compresses the optic nerve-which can lead to
permanent blindness). It needs immediate medical intervention. Symptoms: develops slowly and includes
painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased
sensitivity to glare, and halos observed around bright lights, fixed dilated pupils. Ocular redness, blurred vision,
reduced central vision, sudden onset of eye pain. Complication: blindness

Retinal detachment- Symptoms: sudden onset light flashes, floaters, cloudy vision, curtain appearing in vision,
gnat/hairnet appearance in vision field. It is painless but is an emergency because it can lead to blindness in eye.

Age related macular degeneration-is a degenerative eye disease that causes gradual loss of central vision (so they
cannot see straight ahead), leaving peripheral vision intact.

Cataract -cloudiness (opacity/opaque) of the lens that may occur at birth or more commonly in older
adults. Symptoms: painless, gradual loss of visual acuity with blurry vision, scattered light on the lens producing
glare and halos, which are worse at night; and decreased color perception. Treatment: surgery. Postop: do not do
activities that increase intraocular pressure (like bending, vacuuming floors, golf, lifting more 5 pounds, sneezing,
coughing, rubbing eyes, straining during bowel movement). So, they should increase fluids and fiber and take OTC
stool softener/laxatives. it is normal for them to feel itching/sand in eye, photophobia, mild pain. But they should
report to doctor if purulent drainage, increased redness, or severe pain.

Meniere disease - is an inner ear disease from excess fluid in inner ear. Prevention: low sodium diet. Avoid
aggravating substances (nicotine, caffeine, alcohol) and stimuli (TV, flickering lights). Adhere to therapy for relief
(like antiemetics, antihistamines, sedative, diuretics). X change suddenly the head of bed (bending over). Go to
vestibular rehab therapy. Safety during attacks (assistance in walking, bed rest). Symptoms: vertigo, tinnitus,
hearing loss, aural fullness. They say they feel being pulled to ground-drop attacks. Interventions: do fall
precaution, bed low position with 2/3 side rails lifted (not all) and tell patient to call for help to get up. Reduce
stimulation. Restrict salt to prevent fluid buildup in ear. Emesis bin at bed. Can lead to permanent hearing loss.
During an attack- treat with a vestibular suppressant like a sedatives (benzodiazepine), antihistamine,
anticholinergic, antiemetic.
77

Other Diseases:

Autonomic dysreflexia-is a massive uncompensated cardiovascular reaction by the SNS (sympathetic nervous
system) in a spinal cord injury at T6 or higher. It is life threatening and is seen weeks/years after injury. Causes:
bladder irritation due to distension, distended bladder. Symptoms: (exaggerated SNS response) severe
hypertension (like 300), throbbing headache, diaphoresis, bradycardia (like 35), flushing, piloerection. Treatment:
to correct the cause (like bladder distension from catheter obstruction, fecal impaction, tight clothes).
Interventions: Patient should be catheterized asap or check kink if already have catheter. If from bowel impaction-
do digital rectal exam. Remove constrictive clothing. Raise head of bed to 45 degrees or high fowlers.

Sinusitis- Causes: viral, bacterial. Symptoms: severe facial pain, nasal congestion with purulent nasal drainage,
fever. Treatment: antibiotics, supportive

Strep –Is a contagious bacterial throat infection. Interventions: soft diet and cool liquids. Complete all antibiotics.
Replace toothbrush 24 hours after starting antibiotics. Young sibling under 3 should be tested. Can return to
school 24 hours after antibiotics. Do not give throat lozenges to younger kids. Give Tylenol liquid for pain.
Complications: renal/cardiac complications.

Cellulitis-is an inflammation of subQ tissue. Causes: bacteria staph or strep from cut/insect bite/open wound.
Symptoms: edema, pain, fever. Interventions: elevate extremities, warm compress, daily marking, and date of
reddened areas. Standard precaution. Treatment: IV antibiotics.

Gout-inflammation cause by ineffective metabolism of purines- so uric acid accumulates in blood especially in
joints (of big toe). Risk factors: obesity, hypertension, high lipid levels, insulin resistance, poor diet, alcohol,
sedentary lifestyle. Intervention: lose weight. Take 2L water a day. Low purine diet (avoid organ meat-liver,
kidney, brain) and certain seafood (sardines, shellfish). Limit alcohol. Eat a health, low fat diet. Complications:
kidney stones.

Acromegaly- is an overproduction of the growth hormone. Causes: pituitary adenoma. Symptoms: overgrowth of
soft tissues of face/hands/feet/organs, joint pain, skin changes, hyperglycemia. Complications: heart failure.

Huntington disease- is an incurable autosomal dominant disease (requires only one copy of affected gene) that
causes progressive nerve degeneration (so impaired movement, swallowing, speech, cognitive). The classic sign is
chorea (involuntary tic movement). Onset is 30-50 years old. They can die from neuromuscular and respiratory
complications within 20 years of diagnosis. It is confirmed by genetic testing

Transsphenoidal hypophysectomy-is the surgical removal of pituitary gland (which stores/excretes hormones like
ah, ach, growth hormone). Complications: neurogenic diabetes insipidus

Toxoplasmosis- parasites from cat feces/undercooked meal/soil contaminated fruits/vegetables. It can cross the
placenta.
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Systemic lupus erythematosus (SLE)- is an autoimmune disorder that causes chronic inflammation of different
parts of the body. It has exacerbations (flare ups) and then remissions. It can affect heart, CNS, skin, muscles, with
the most targeted organ affected being the skin. Symptoms: red rash butterfly shape on nose/cheeks. Often
related to sun exposure and more pronounced during a disease flare. Also, common recurrent oral ulcers and
painful/swollen joints, extreme fatigue, skin rashes, kidney problems. Treatment: there is no cure but give
immunosuppressants (corticosteroids) or immunomodulators (hydroxychloroquine). Get flu and pneumonia
vaccines. Report fever. Do not go near sick people. Stress can exacerbate it so follow health lifestyle (exercise,
sleep. No smoking). Avoid sunlight (10am-4pm), clean rash with mild soap. Complication: lupus nephritis

Systemic inflammatory response syndrome (SIRS)-is a pathophysiologic response by lot of inflammatory cells.
This overwhelming response causes vasodilation and capillary leakage leading to hypotension and end organ
perfusion. Causes: trauma, tissue ischemia, infection, and shock. Symptoms: fever/hypothermia, tachycardia,
leukocytosis/leucopenia, tachypnea. Treatment: aggressive fluid resuscitation, and treat the cause

Hypothermia- is when the core temperature (rectal) is less than 95F (35C). Risk factors: homeless. Symptoms:
mental status change, shivering, impaired coordination. Interventions: do workup for sepsis and shock and
address the hypothermia. Place patient on cardiac monitor (may need to defibrillator because v-fib can occur).
Complications: cardiac /respiratory failure and coma.

Obstructive sleep apnea (OSA)-is an airway obstruction that can lead to hypoxemia and hypercapnia. Symptoms:
loud snoring, apnea, coughing/gasping, shallow breaths (hypopnea) causing hypoxemia and hypercapnia. During
the day-morning headache, irritability, excessive daytime sleepiness. They are not hard to wake up. Interventions:
Begin on CPAP (it involves using a nasal or full-face mask that delivers positive pressure to the upper airway to
keep it open during sleep.) at night. Limit alcohol. Weight loss. No sedating medications (like benzodiazepines,
antidepressants, antihistamines, or opioids). Do not nap during day.

Lymphedema- is an accumulation of lymph tissue in soft tissue. Causes: lymph node removal, radiation
treatment. Symptoms: arm (if in axillary) feel heavy/painful, motor function impaired. Interventions:
decongestive- so massage to mobilize fluids, compression sleeves, intermittent pneumatic compression sleeve,
clothing less constrictive, isometric exercises, avoid venipuncture /blood pressure/injections on affected limb

Malignant hyperthermia- is inherited. It is a muscle abnormality triggered by certain anesthesia medications or

from succinylcholine (paralytic agent). So, these anesthetics cause excessive calcium to be released that leads to
sustained muscle contractions and rigidity. Early signs: tachypnea, tachycardia, rigid jaw. Then later high fever.
Other symptoms: hypercapnia, muscle rigidity, hyperthermia, hyperkalemia, cardiac dysthymias, myoglobinuria.
Treatment: IV dantrolene

Raynaud phenomenon-is a vasoconstriction from cold or stress usually that affect women 15-40 years old.
Symptoms: color changes in appendages from white to bluish purple. Numbness and coldness. When blood is
restored it becomes reddened and throbbing aching pain, swelling, tingling. Treatment: immersing hands in warm
water. Prevention: wear gloves, dress warm, avoid extremes and abrupt temperature changes, no caffeine
79

excessive, refrain from tobacco product. Stress management like yoga. If all these do not work-calcium channel
blockers.

Frostbite- Interventions: remove clothes/jewelry so it does not constrict. Do not massage. Put in warm not hot
water. No heavy blanket. Give analgesics. Elevate area. Keep open till dry then put loose non adherent sterile
dressings. Look for compartment syndrome.

Marfan syndrome-connective tissue disorder that causes visual/cardiac defects (like aortic problem) and a distinct
long, slender body with disproportional long arms/legs (like Abraham Lincoln). It is inherited autosomal dominant
so 50% chance of getting it. If it is with aortic vessel involvement, there is a risk for aortic rupture. So, during
pregnancy the workload would go up so risk for maternal mortality. So, tell patient to use reliable birth control,
and not to participate in any contact sports because cardiac. Treatment: can include beta blocker.

Buergers disease aka thromboangiitis obliterans- it is like atherosclerosis just only in arteries/veins in arms and
legs-in which a thrombus forms, causing distal extremity ischemia. Most common in young men with a history of
tobacco/marijuana use and chronic dental infection but with no heart risk factor. Symptoms: intermittent
claudication of feet/hands. Over time ulcers can form/Raynaud phenomenon. Treatment: stopping smoking. Do
not use nicotine replacement products (like the patch) only bupropion or varenicline. Avoid cold to affected limbs.
Walk. Give antibiotics if infected. Analgesic. Avoid trauma to extremities.

Sjogren Syndrome- is an autoimmune inflammation of the exocrine glands. It affects the salivary and lacrimal
glands. Symptoms: dry eyes (xerophthalmia), dry mouth (xerostomia). Can lead to corneal ulceration, dental
carriers, oral thrush. Can also affect skin (dry skin/rash). Throat/rhonchi (chronic dry cough). Vagina (dryness and
painful intercourse). Treatment: no cure, so alleviate symptoms. artificial tears. OTC drops to relieve itching,
burning, dryness, gritty sensation in eye. Wear goggles to protect from dry. If dry mouth-sugarless gum and
candy/artificial saliva. Regular dental checkups. Lubricants for vaginal dryness. Do not go in low humid
environments (like centrally heated houses, airplanes). Use humidifiers. Avoid decongestants, irritants (like coffee,
alcohol, nicotine), and acidic drinks (carbonated drinks, juices). Sip water frequently

Scleroderma-is an overproduction of collagen that causes tightening /hardening of skin and connective tissue. It is
a progressive disease, with no cure. Treatment: manage complications. Complication: renal crisis (symptoms:
malignant hypertension, abrupt headache), Raynaud phenomenon, pulmonary fibrosis (scarring of lung tissue),
heartburn, and dysphagia
80

PSYCH NOTES
PHOBIAS

School phobia- an extreme separation anxiety usually in the elementary grades, characterized by a persistent
irrational fear of going to school or being in a school-like atmosphere. Tr8: have child go back to school
immediately.

Agoraphobia- is a fear of being outdoors or otherwise being in a situation from which one either cannot escape or
from which escaping would be difficult or embarrassing. Priority: avoid panic. In severe cases, they can b
homebound because too scared to go anywhere.

Zoophobia- fear of animals

Social anxiety disorder- person fears being scrutinized, observes, embarrassed in social settings

STRESS DISORDERS

Acute stress disorder- happens after traumatic /extremely stressful event. SS: intrusive memories of event,
dissociative symptoms, arousal/reactivity (sleep disturbances, diff concentrating). Interventions: assess for
self-harm. Assess for ineffective coping (alcohol/drugs). Assess impact on job, relationship/sleep etc. Explain that
these feelings are normal. Explore coping strategies. Encourage patient to discuss the traumatic event. If it
happens for more 1month=PTSD.

Post-Traumatic Stress Disorder/PTSD: 3 categories: 1. Experiencing the event (flashbacks, recurring nightmares,
feeling distress/loss of control physical ill-pounding heart, GI, sweating…) 2. Avoiding reminders of the trauma
(avoid places, thought, activities, detached to life, loss interest in life, amnesia to important details of event. 3.
Increase anxiety/emotions (anger, fear, cannot concentrate, insomnia, irritability, hypervigilance, jumpy, restless)

Nurses priority: discuss traumatic event (w no anxiety). Nurse should assess their readiness to talk and encourage
them to discuss at own pace.

PTSD patients with anxiety level of 8/19 and pacing behavior are distressed and need immediate attention as they
might harm themselves/others.

Schizophrenia –
Schizophrenia risk factors: 50% of it is genetic, other risk factors include: altered neurotransmitters, reduce
brain size, prenatal factors, birth trauma, epilepsy, maternal influenza
SS:
a. Positive symptoms- the presence of something not normally there like hallucinations and
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delusions
b. Negative symptoms –an absence of something that should be present like flat affect and impaired
social/interpersonal skills
Schizophrenia patients often become anxious when around others and seek to b alone to relieve anxiety.
Interventions: make brief frequent contact. Accept the patient unconditionally by minimizing
expectations/demands. Assess patient readiness for longer contact. Being with/close by the patient
during group activities. Offer positive reinforcement when patient does interact. If patient just gets yup
and leaves-remain silent and allow patient to leave.
For a patient with schizophrenia and violent behavior-give them antipsychotics (olanzapine, ziprasidone,
haloperidol).
First thing u want to do is assess for Command hallucinations. Ask patient what he is seeing/what being said
to him
Schizophrenia w catatonia is if you have schizophrenia with 2 of the following: immobility (patient remains in
position for long time), remains mute, bizarre postures (holds rigidly in one position). Extreme negativism
(resists instruction or attempt to be moved). Waxy flexibility (limbs stay in same position or attempts to
move by another person. Staring. Stereotyped movement, Prominent mannerism, Grimacing. Pt w
catatonia cannot meet their basic needs for adequate fluid and food intake and are at a high risk for
malnutrition and dehydration. Priority: make sure patient well hydrated and has enough nourishment.
Delusions- false fixed beliefs that cannot be corrected with reasoning.
Different types of delusions examples:
c. Delusion of reference-belief that songs, newspaper, events are personal and significant to them
(the song is a secret message to them)
d. Grandeur- (need to get to Washington for my meeting with the president)
e. Control- do not drink tap water, that how the government controls us
f. Nihilistic-it does not matter if I take my meds. I am already dead (life has no meaning)
g. Somatic-the doctor says I am fine, but I really have lung cancer
h. Persecutory (paranoid)- belief that they are being threatened or treated unfairly in some way
(they r trying to poison me w tap water_
Nurse should: Do not argue/challenge them. Reinforce reality by talking about and encouraging patient to
participate in real events. Do not delve into or have long conversations about delusional belief system
Hallucinations- sensations that appear real but are created by the mind
Tactile- patient feels sensation of being touched (they feel bugs crawling over their skin)
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Auditory or Command- hear sounds/voices that others do not. The antipsychotic medications take a long time
to start and may not eliminate the voices. So, tell patient to develop alternative methods for coping with
the hallucinations. Like to increase external auditory in environment like to watch tv, listen to music
through headphones. Another approach is voice dismissal (telling voices to go away) and CBT (help them
in learning new ways to think about and deal with symptoms)

Depressive Disorders

Suicide-any patient who does not say definitely that he is not suicidal is considered that he is-so do not place
them alone, place them with one to one supervision. Risk factors for committing suicide (mnemonic: sad
persons). Sex (white men do more, women attempt more). Age (teen or more than 45). Depression. Prior
history of suicide attempts (like overdose). Ethanol of drug abuse. Rational thinking loss (hearing voices to
harm self). Support system loss (living alone). Organized plan (having a method). No significant other.
Sickness. Unemployed/unskilled. (pregnancy is a protective factor that protects against suicide).
Depression ss in adolescence: hyper or insomnia, napping by activity. Low self-esteem, withdrawal from
enjoyable activity, anger outburst, aggressive behavior. Inappropriate sex behavior. Weight gain/loss increased or
decrease food intake.

Patients w major depressive disorder can have Psychomotor retardation- a generalized slowing of motor activity
related to a state of severe depression. Person may not have energy to perform ADL’S or interact with others. Or
patients with major depressive disorder can have psychomotor agitation (increased body movement, pacing, hand
wringing, muscle tension, erratic eye movement).

Insomnia- is quite common with depression. You should reduce stimuli in bedroom (no reading/tv in bed), no
naps later in day. Keep bedroom slightly cool, quiet, and dark. No caffeine, nicotine, or alcohol within 6 hours of
sleep. Do not exercise/strenuous activity within 6 hours of going to bed. Do not go to bed hungry. Practice
relaxing techniques. Get at least 20 minutes a day of sunlight. Drink a cup warm milk or eat small amount of
carbohydrates before bed. Do not eat a heavy meal before bed.

Bipolar Disorder

Bipolar- formerly called manic depression. It is a mental health condition that causes extreme mood swings that
include emotional highs (mania or hypomania) and lows (depression). Bipolar patient neglects their personal
needs like hydration, nutrition, and sleep. So, offer them energy /protein dense foods that can be easily carried
and eaten.
Acute mania SS: running around, poor impulse, nonstop talking, distractible, hallucinations, insomnia, wear
inappropriate clothes, neglect hygiene/nutrition. Intervention: quiet, calm environment. Limit amount people in
contact with the patient. 1 to 1 interaction, not group activities. Low lighting. Schedule of activity. Set limits on
behavior. You choose their cloths. Private room.
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Delirium/Dementia/Alzheimer’s

Dementia or Alzheimer

Causes: Genetics, lifestyle, environment.

Diagnosed usually after 65. Early onset is before 60. Children of parent with early onset have 50% chance of
getting it. For late onset risk factor-advancing age, first degree relative, trauma to brain. Dementia
patients have decreased motility and drink less so more prone to constipation. W dementia Remote
memory is spared initially and there is no impairment of consciousness until the late stages of the disease.
To prevent wandering: Place locks (at or above eye level) leading outside. Alarm goes off when exit. Stop sign
on exit. Place a curtain on the door. Keyed deadbolts (with key removed) and close supervision.
Other interventions: Cold/hot labels. Medical identification. Remove household hazards (gas applicants, rugs,
toxic chemicals). All medication out of reach (so no weekly pill taker). Childproof covers. Black mat/strip
by exit. Arrange furniture. Place frequent used things within reach. Label bathroom door and common
rooms. Night light in sleeping area. Use distraction and redirection (going for a walk) for manage agitation.
Speak slowly and use simple words. Use yes/no questions (not open ended). Do not rationalize with them.
Interact w patient as an adult. Respect patient’s dignity by avoiding pet names (honey, darling, sweetie).
Break down hard activities into steps w simple instructions. Decrease anxiety by limiting number of
choices. Allow a lot of time to complete a task.
A lot of times the patient will express their pain through restless behavior or agitation and will exhibit
behavior problems. To manage that: acknowledges patients’ emotions. Reassure them that they will be
kept safe from harm. Distract. Redirect to simple tasks. If all else fails, then antipsychotic medications.
Patients with Alzheimer’s forget if they ate or not so give them food when they say they are hungry. You can
give smaller meals throughout day along with low calorie snacks. Do not reality orient them because it
causes anxiety. Do validation therapy.
Sundowning- This can occur with dementia patients. This means they have increased confusion at night when
there are inadequate lights. Interventions: For moderate dementia-do reality reorientation. Severe
dementia-validation therapy (recognizing the patient’s feelings and concerns)

Delirium- is an acute confusion state in hospitalized pts. it is reversible. SS: hypoactive, hyperactive, or mixed.
Acute mental status changes that fluctuate and inattention w disorganized thinking, altered loc, hallucinations.
Difficult to assess so use standardized tool (confusion assessment method or the ICU delirium screening) Risk
factors: age, neurodegenerative disease (stroke, dementia), polypharmacy, coexisting medical condition
(infection), ABG imbalance, metabolic an electrolyte imbalance, impaired mobility, surgery, untreated pain.
Causes: infection, meds, hypoxia, it is a medical emergency.
84

With delirium, the priority is safety/prevent injury. Place the patient near the nurse’s station with 1 to 1 one
supervision and do frequent reorientation to time, place, and situation. Do not place side bed rails up (because
they will climb over them). No dark room only light room so they stay oriented to the environment.

Childhood Disorders

ADHD=. Attention-deficit hyperactivity disorder. It is a mental disorder with impulsive behavior, difficulty focusing,
or excessive activity. Interventions: offer them 2 choices. Team approach highly effective (so involve the parents,
teachers etc.). You should advocate for individualized services and make direct eye contact and focus with them.
They will not outgrow it. Dietary modifications does not improve the symptoms (ex. So not eating sugar won’t
cure the ADHD). ADHD patients have a hard time with social skills, reaction, and critical judgment by peers. They
have low self-esteem, academic failure, and are at risk for substance abuse and depression.
The way to settle an out of control child is with deep breathing (like blowing a balloon). Take slow deep breaths,
and then when the child is calm you can discuss the disruptive behavior. Other interventions when a child is out of
control is to stay calm and remove child from source of anger and then discuss what caused it, why it is wrong,
and acceptable ways of handling it next time
Isolation the child is not good- so you do not want to tell the child to go out of the room. Instead you should
remove the person from source of anger.
Autism/ Autism spectrum disorder -refers to a group of complex neurodevelopment disorders characterized by
repetitive and characteristic patterns of behavior and difficulties with social communication and interaction. They
are also hypersensitive to sounds, touch, and other senses. Autism has a strong genetic component.
Interventions: calm environment, with no stimuli. Private room away from nursing station. They need structure
and consistency during hospitalization. Do not give them too many choices because its overwhelming.

Personality Disorders:

Cluster A

a. Paranoid- distrust and suspicion of other. Difficult to get along with. Strong need to be self-sufficient and
need high degree of control over environment. Do not be too nice or too friendly.
b. Schizoid- socially detached, does not express emotions, wants to be aloof and alone. Do not try to increase
socialization.
c. Schizotypal-extreme anxiety in social situations. Respect the patients need for social isolation.
Superstition and magical thinking are common.
Cluster B
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a. Antisocial- disregard for others rights and for rules. Manipulative. Irresponsible and blame others.
Interventions: set rules/firm limits, they should take responsibility for their actions. They have a problem
with authority figures.
b. Borderline- unstable intense relationships, distorted self-image, extreme emotions, and impulsiveness
Provide clear boundaries. Clear communication. Assess for self-mutilation behavior.
c. Narcissistic- grandiosity, sense of entitlement, need for admiration, no empathy (they are superior). They
do this to cover up their emptiness inside them. They have a damaged fragile ego from childhood and
have poor self-esteem, so they develop narcissistic to regulate self-esteem and protect the ego.
d. Histrionic-needs attention, shallow, seductive, emotional intensity. They get their self-esteem from others
opinion of them. Inappropriate, provocative, into physical appearance. Gets bored on routine. Has a
difficult time maintaining relationships.
Cluster C

a. Dependent-excessive clinging and needs to be taken care of. They live in fear of rejection/abandonment. To
avoid this, they often manipulate/control (flattery, distancing) to prevent a person from leaving. Can also
engage in harm/suicide to gain attention and prevent another person from leaving. For this patient assign
different staff members so patient does not depend on one.
b. Obsessive-compulsive- It is only considered OCD if, by you interrupting them from what they are doing,
they will experience anxiety. Pt’s with OCD do not realize how much time spent on same activity. So, give
them reflective feedback in nonjudgmental matter. Help the patient get involved in other activities and
problem solving. Help the patient identify circumstances that increase anxiety. Give positive feedback.
Cognitive behavioral therapy -helps them use techniques of thought stopping. Once patient is equipped w
new coping mechanisms, gradually limit time allotted to ritual behavior only.
c. Avoidant-social inhibition and feelings of inadequacy. You should maintain a friendly approach but do
not push the patient into social situation

Eating Disorders

Anorexia- extreme fear of gaining weight, altered perception of own weight. SS: body weight below 75% of ideal.
Enlarge salivary glands and erosion of tooth enamel (if vomited), lanugo. They need to be hospitalized if suicidal
behavior or if they have a medical condition from starving. Interventions: Priority: restore calories, weight gain,
and treat the medical conditions. Other interventions: Need to remain with the patient during eating and for an
hour after. Weigh them each morning (after voiding and before intake w same clothing). You want a weight gain
goal of 2-3lbs/week. Do not focus on food initially but encourage participation in meal planning as the client nears
target weight. Nurse should present reality without challenging the client's illogical thinking. Acknowledge patient
86

feelings. Encourage expression. If a patient is severely ill or not responding to oral intake, they should be given
nutritional support (enteral tube feeding/TPN).

Bulimia nervosa-binge eating and then preventing weight gain (vomiting, exercise, laxatives). Monitor them 1-2
hours post meals. Other signs related to self-induced vomiting are scars/calluses on hand, enlarged parotid
glands, erosion of tooth enamel, dental caries.

RESTRAINTS

If patient is violent- use clear, thorough communication, encourage active participation in care, low stimulation
environment. Give undivided attention to patient like facing them, in an unhurried body language (calm tone).
Last resort if a patient is violent- chemical (lorazepam) and physical restraints. But u cannot use restraints to
prevent escalation to violence. Do not place patient near nurses’ station or security guard because it increases
anxiety.

1. Chemical restraints-is to medicate them (benzodiazepines, psychotropics) to restrict their freedom of

movement or to control social interruptive behavior. So, if you have a patient with a fall risk you first want
to first bed alarms, one to one, assistive devices. If that does not work, then haloperidol(meds)
2. Physical restraint- another way to immobilize/limit body movement of the patient. It includes the belt
restraint and the soft limb restraint.
a. If it is used temporarily during routine procedures or exams than not considered restraints. The
use of full padded side rails in the raised position for clients during a seizure protects them from
immediate injury is not either considered a restraint. An orthopedic leg immobilizer used to
restrict movement and maintain a client's extremity in proper alignment is prescribed for
therapeutic purposes and is not considered a restraint

The least restrictive device or method to keep a client from interfering with medical treatment should always be
tried first, before applying a physical restraint. So, try concealing iv site and tubing by wrapping the forearm in
gauze and elastic stockings for confused patient pulling on iv site. B4 applying hand mitten/soft wrist restraints or
arm board.

Restraints- every 2 hours the nurse should: provide skin care and ROM, ensure basic needs are met (fluids,
nutrition, elimination). Assess skin integrity and neurovascular. Pad bony prominence under restraints.
Determined the need for continued restraints by releasing briefly and assessing patient’s reaction. Attach the
restraints to the area that moves with bed frame. Areas that do not move (base) or move independently (side
rails) should not be used. Place the patient side lying/semi fowlers. Tie with quick release knot. Never square knot.
Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint.
Need prescription for restraint

OTHER
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Somatic symptom disorder-psychological disorder in response to stress that causes physical symptoms (chest
pain, syncope). They spend lot of time and energy on the symptoms. You want the patient to have a stress outlet,
verbalize factors causing it, and have a support system. Identify perceived benefits from the physical symptoms
(like social affirmation, sick role) and minimize indirect benefits from being “sick”. Redirect complaints to
unrelated, neutral topic. Limit time spend talking about symptoms.

Dissociative identity disorder- a condition where 2 or more identities alternately control the patient behavior.
Causes: abuse, trauma. The patient unconsciously does this to protect themselves from stressful memories. Pt is
not aware of the different identities and can be confused by the lost time/gaps in memory. They switch identities
as reaction from stress/triggers. Treatment: integrate the 2 personalities to one while maintaining safety. The
patient should journal about feeling and triggers and use grounding techniques (like deep breathing, rubbing
stone, counting coins) to help counteract the episodes. Monitor for self-harm. Attempt to form trusting
relationship with each identity.

Panic attack- priority is safety so stay with the client.

Codependent behavior- when someone enables the other to continue their bad behavior. They keep the
addiction person secret, suffering physical/psychologically from the addict, and not allowing the addict to suffer
the consequences of their behavior. They make excuses for the addict’s behavior. They focus all their attention on
others at the expense of their own self (blame themselves for addict behavior).
88

MATERNITY NOTES
Physiological Changes I Pregnancy

S1 systolic murmur-normal

Edema-in 3rd trimester-normal (rest and elevate)

Shortness of breath-normal in 3rd trimester

Folic acid- take 400-800mcg of folic acid

Morning sickness- it occurs from rising hormones. You should eat several times a day, drink fluids, high
protein snacks, ginger food, and crackers.

Blood volume-increased because of increase oxygen demand.

Foods you cannot have in pregnancy- unpasteurized milk products, unwashed fruits or vegetables, deli
meat/hot dogs (unless heated till steaming hot), raw fish/meat/liver, fish high in mercury (like shark,
swordfish, king mackerel, tilefish).

Vaccines- no live only inactive vaccines. No MMR, or varicella. The Tdap (tetanus,
diphtheria, pertussis) is recommended for pregnant women at 27-36 week of gestation.
During influenza season (October-March) you can get the inactive flu vaccine, but do not get influenza
nasal spray.

Urinary frequency-is quite common in the first trimester because of hormonal changes.

Leg cramps-common in the 3rd trimester, especially at night. Tell patient to stretch their legs, massage
claves, and increase fluid intake.

Pica-is an abnormal craving to eat stuff that are not normally eaten (like ice, cornstarch, chalk, clay,
dirt, paper). It usually goes with iron deficiency anemia.

Caffeine consumption in pregnancy should be limited to 200-300 mg/day.

Constipation- occurs because of an increase of progesterone (which causes gastric motility),

and because of the iron supplement. Interventions: high fiber diet, high fluids, regular exercise
(moderate to intense), bulk forming fiber supplements (not laxatives because they are dehydrating).
Blood pressure-decreases in pregnancy. It is the lowest at 24-32 weeks. By the 3rd trimester, it gradually
returns to baseline. If it increases more than 30 systolic or more than 15 diastolic from the
pre-pregnancy, it is a problem.
89

Braxton-Hicks contractions –are painless, occasional physiological contractions that are felt
mid-pregnancy and onward. They are normal. The contractions are a concern if they become regular and
persist.

Tests
Leopold maneuver-is when you palpate the pregnant abdomen to identify the fetal presentation.

Fundal height- After 20 weeks the fundal height in cm should correlate with the number of weeks of
pregnant (so 24cm=24weeks). You want to make sure they empty their bladder before.

Nitrazine pH test –you insert the strip into the vagina, and it can differentiate between amniotic fluid
(which is alkaline), and vaginal fluid (which is acidic).  If it is blue-it indicates a positive result and
probable rupture of membranes.  If it is yellow, it indicates a negative result and suggests that
membranes are intact. But semen (sex) or blood can cause a false positive

Bishop score- is used to assess and rate cervical readiness for induction. The higher the score the better
chance of successful vaginal induction (for a nulliparous you want a score over 8).

Reactive nonstress test -indicates that the fetus is well oxygenated and establishes fetal well-being.

Group B Streptococcus (GBS)- Tested at 35-37 weeks. If it is positive the mom is given antibiotics during
labor. If the status of GBS is unknown, then you give antibiotics when ruptured membrane for more
than 18 hours or has a temperature of over 100.4 or more 37 than weeks

Indirect Coombs test- if there is a trauma to the mom (like a car accident), it can cause hemorrhage and
cause the baby’s and mom’s blood to be mixed. If this happens the mom get antibodies against the baby
and can attack. So, after a trauma, you want to do an indirect coombs test. If the mom is Rh negative,
then give immune globulin (which is Rhogam) at 27 weeks and at 72 hours postpartum.

Naegele’s rule- is used to estimate the date of birth (EDB). (The most accurate dating of pregnancy is the
ultrasound at 16-18th week).
• EBD is calculated by taking the date of their last menstrual period, minus 3months and the plus+
7 days.
• –If they conceived in January, February, or March, then they will conceive in the same year. If
they conceived after March, then add a year.
• By last menstrual period, it means when the period started, and is based on 28 date cycle (so can
be a little off)

Weeks
Fetal heart rate- at 7-12 weeks
Quickening- at 18-20 weeks (primigravida), or 14-16 weeks (multigravida)
Feel the baby move-at 16-20 weeks
90

Determine sex by ultrasound-at the end of 12 weeks

All major organs are in place- at the end of 8 weeks

Pregnancy Complications
Gestational hypertension- is a new onset of high blood pressure (over 140/90) that happened after 20
weeks. It occurs with no proteinuria. If there is proteinuria, then it is called preeclampsia.

Preeclampsia- is more severe form of gestational hypertension and can lead to eclampsia(seizures).
• Symptoms: high blood pressure, proteinuria, edema, visual disturbances
• Prevention: give magnesium sulfate and assess the deep tendon reflexes hourly.
o If there is hyperreflexia when giving magnesium, it means seizure)
o Monitor for magnesium sulfate toxicity (decrease deep tension reflexes) and if
magnesium toxicity- give calcium gluconate
o If the mom gets magnesium therapy-the newborn is at risk for respiratory depression at
birth
• Cure: delivery
• Complication: placental abruption, hellp syndrome, liver and renal dysfunction,
thrombocytopenia, seizures
• Do: seizure precaution (suction and oxygen at the bedside, turn patient to left…

Hellp syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count)- is a severe form

of preclampsia. Symptoms: right upper quadrant pain, nausea, vomiting, and malaise. This is extremely
dangerous and can lead to death, but is commonly misdiagnosed because of the regular symptoms

Hyperemesis gravidarum- is a severe persistent nausea and vomiting during pregnancy, that can lead to
dehydration. The symptoms are going to be that of dehydration (like dry mucus membrane, poor skin
turgor, decreased urine output). It can lead to electrolyte imbalance (hypokalemia/hyponatremia),
met alkalosis, nutrition deficiency, ketonuria, and weight loss

Ectopic pregnancy- is when a fertilized egg implants outside the uterus (usually in the fallopian tube).
• Risk Factors: recurrent sexual transmitted infection, tube damage/scarring, IUD, previous tubal
surgeries.
• Symptoms: lower quadrant abdominal pain on one side, moderate vaginal bleeding. Delayed
menses (amenorrhea) with vaginal spotting/bleeding, palpable mass on
pelvic exam, hypovolemic shock (dizzy, hypotension, tachycardia), referred shoulder pain.
• Complications: it can rupture and cause hemorrhage.

Molar pregnancy aka hydatidiform mole- it is a tumor in the uterus and the mom has symptoms of
pregnancy and has intermittent dark brown vaginal discharge.

Supine hypotension syndrome-occurs usually in the 3rd trimester. It is when you lie down, and the
weight of abdominal cavity compresses the vena cava causing hypotension and tachycardia. As the nurse
you should immediately reposition to the left lateral side and place a wedge under hip while supine.
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Fetal Movement

Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. It is a baseline of more
than 160beats/minute for more than 10 minutes.

Fetal movement- is a sign of fetal health and should be felt.

• Factors that affect it: mom’s substance abuse, medications, fasting, and if the fetus is sleeping).
• Fetal movement should not decrease as the baby increases in size.
• Decreased fetal movement-can indicate fetal compromise (not enough oxygen), and the nurse
should do a nonstress test.
o In general, you want 4 movement/hour or 10 distinct fetal movement within 2 hours-that
a reassuring finding
o You and moderate variability
o The heart rate decelerations followed by fetal bradycardia are indicative of uterine
rupture
Accelerations- an abrupt increase in fetal heart rate above the established Deceleration-a decrease in
fetal heart rate below the established fetal heart rate.
o
Early decal –fetal heart rate drops with moms’ contractions is a normal finding-that should return to
normal after contraction.

Late decal-is a decrease in fetal heart rate that begins after the contraction ends.
• What it means: uteroplacental insufficiency and impaired fetal oxygen.
• Causes: maternal hypotension after epidural placement, uterine tachysystole, or chronic
uteroplacental insufficiency (intrauterine growth restriction, preeclampsia, diabetes mellitus).
• Interventions: stop oxytocin immediately. Then reposition to left or right side, give oxygen
(8-10L) facemask, and IV bolus of lactated ringer or normal saline. Notify the doctor. If all these
interventions do not work then subQ Terbutaline, and then notify doctor. If the pattern
continues-prepare for delivery.

VEAL CHOP-way to interpret fetal heart rate

• V-Variable = C-Cord Compression

• E-Early = H-Head Compression

• A-Accelerations = O-Okay

• L-Late = P-Placental Insufficiency

Interventions- accelerations and early decelerations- nothing. Variable and Late decelerations-turn

patient left lateral and give o2.

Basically:
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Early decelerations=FHR mirrors the contraction.

Late deceleration=FHR drops after the contraction.

Variable=looks irregular jagged dips-looks like V

Phases/Stages of Labor

1(0-10cm)
• Early/Latent (0-5cm)-the pain is managed. The patient follows directions- so it is the best time
for patient education
• Active (6-7cm)- the patient is apprehensive, serious, and the pain is increasing. It is hard to
follow instructions.
• Transition(8-10cm)- perineal/rectal pressure. Patient feels the urge to have a bowel movement.
Patient in pain, fear, irritability, anxious, and self-doubt
2-delievery of baby
3-delievery of placenta
4-first few hours after placenta

Labor Info

True Labor-is contractions that cause progressive cervical changes. (mucus plug is not a sign on true
labor).

Position-The optimal position for birth is ROA (right occiput anterior).

• Occiput posterior is intense back pain. Treatment: apply pressure to sacrum by
contractions. Position woman on hands and knees.
• Breech- is when the fetal feet/butt presents first. Complications: ineffective dilation, increased
risk for umbilical cord prolapsed
•
Forceps or vacuum- may be indicated for prolonged second stage labor or fetal distress.

Polyhydramnios-is excessive amniotic fluid. It is a risk factor for postpartum hemorrhage because the
uterus is over distended.

Vaginal discharge increases at the end of pregnancy and may become blood-tinged (pink/brownish) in
the days preceding labor.  This assessment finding may be a sign of approaching labor a client at term
gestation.

Preterm labor- is birth before 37 weeks.

• Risks factors: infection (periodontal disease, urinary tract infection), history of spontaneous
preterm births (biggest factor), tobacco/illicit drugs, non-Hispanic black women.
• Prevention: cerclage (placing sutures to keep the internal cervical os closed).
o It is placed at 12/14 weeks for a patient with a history of cervical insufficiency
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o It is kept in place until 36/37 weeks

o Discharge instructions: activity restriction, recognize preterm labors symptoms
• Symptoms: low back aches, contractions, pelvic pressure, rupture of membranes

Precipitous birth – is a quick labor, that happens less than 3 hours from the onset of contractions to
birth.
• Symptoms: involuntary pushing/bearing down with contractions, grunting, report sensation of
having bowel movement.
• Interventions: If the patient arrives in the 2nd stage of labor (pushing)- you want to assess if the
birth is imminent by putting on gloves and observing the perineum for bulging or crowning of the
presenting fetal part.

Labor Medications
Oxytocin-
• Does: it stimulates contractions of the smooth muscle.
• Used for: It is given to augment labor or to prevent postpartum hemorrhage.
• Other: It is given via electrical infusion pump. It is given through secondary iv line connected to
main IV (isotonic) via the port closest to patient (proximal port) and given at lowest dose possible
and titration until the contractions come 2-3m apart and last for 80-90 seconds. It
needs continuous fetal monitoring every 15 minutes during the first stage labor and every 5
minutes during second. This is because it is a high alert medication. You want to watch the intake
and output because it has a diuretic effect and can cause water intoxication
• Complication: uterine tachysystole, water intoxication, and abnormal fetal heart rate/fetal
distress).

Narcotics
• Can cause fetal sedation/respiratory depression. So, give it at the peak of contractions so less
narcotic gets to baby.

Pudendal nerve block

• Is the choice of pain medication if the birth is imminent with the least maternal and
newborn side effects. It does not relieve the contractions, but it relieves perineal pressure.
Epidural- given 1st or early second state but not in late second when birth imminent (because it takes
20-30 minutes to take adequate effect).

Labor Complications

Shoulder dystocia- When the head comes out and goes back in (which is called turtle sign). It is an
emergency. Risk Factor: macrosomia. Treatment: Do McRoberts maneuver (mom’s legs are held back in
a flexed position and pulled to her chest) apply suprapubic pressure.
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Vaginal hematoma-when there is a trauma to the tissue of the perineum during delivery. It is usually
from forceps, vacuum assisted births, or episiotomy. Symptoms include: persistent/severe vaginal pain
or a feeling of fullness.

Meconium aspiration syndrome- is a type of aspiration pneumonia. Symptoms: Green amniotic fluid
(means that the fetus passed its first stool in utero). If this occurs need resuscitation team present at
birth for immediate evaluation /stabilization. It is also seen with cystic fibrosis patients

VBAC- Vaginal Birth After C-section-it increases the risk for uterine rupture (because of previous
scarring on the uterus). Do not induce this patient.

Uterine rupture. symptoms: abnormal fetal heart rate, constant abdominal pain, loss fetal station,
stopping of contractions

Other Complications

Umbilical cord prolapse- the umbilical cord comes out before baby/presenting part which leads to
cord compression and fetal bradycardia.
• The priority with fetal bradycardia after suspected rupture of membranes is to assess for a
prolapsed cord. 
• The nurse should then manually elevate the presenting fetal part off the cord, leave her hand in
place, and call for help. Place the patient in knee-chest or Trendelenburg position to relieve
pressure on compressed cord. You can also give oxygen/iv fluids.

Placenta abruption-is when the placenta separates prematurely from the uterine wall, causing bleeding
under the placenta.
• Abruptions can be partial, complete, marginal, or overt (can see vaginal bleeding) or concealed
(bleeding behind placenta).
• Risks Factors: abdominal trauma, hypertension, cocaine, history of abruptions, preterm
premature rupture of membranes.
• Symptoms: abdominal/back pain, uterine contractions, uterine rigidity, dark red vaginal
bleeding, tachysystole.
• Interventions: continuous monitoring of the fetus, draw a type/crossmatch for blood. If it is
severe, then an emergency c-section. You want to watch the mom for signs of shock (like
tachycardia, and hypotension). You may need a rapid volume replacement with IV fluids and
blood products.

Premature rupture of membranes (PROM)-is the rupture of membranes before the onset of labor at
term gestation (more 37w). It does not harm the fetus but if labor does not begin after PROM, then you
need to induce labor to decrease the risk for infection (called chorioamnionitis)

Placenta accrete-is an abnormal placental adherence in which placenta implants directly

in myometrium instead of the endometrium.
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• Risk factors: previous c-section

• Diagnosed: ultrasound. So do c-section.
• Complication: life threatening hemorrhage. So, you need at least 2 large bore IV (18 gauge) and a
blood type and crossmatch in case need a blood transfusion is needed.

Placenta previa- the placenta is over the cervical opening. So, when cervical dilation/effacement, the
placenta does not get enough blood and it increases the risk of hemorrhage.
• Diagnosed: ultrasound.
• Symptoms: painless vaginal bleeding after 20 weeks.
• If found early- it resolves by the 2nd trimester. If it continues- may need c-section.
• Treatment: planned c-section after 36 weeks or prior to onset of labor. If there is no
active bleeding the mom can be discharged. Monitor them closely. An additional ultrasound at
26 weeks. Place them on pelvic rest. Do not do vaginal exams and they should not have
intercourse.

Postpartum Assessment

Postpartum stages:
1. Taking in: occurs 24-48 hours postpartum. The mom is physically recovering, and
dependent on the health care team to help take care of the baby.
2. Taking hold: occurs 2-20 days postpartum. The mom is learning the technical skills of mothering
but may feel inadequate.
3. Letting go: after 10 days postpartum. Mom is comfortable with new role.

The patient is at risk for falls

Strong- or foul-smelling vaginal discharge may represent an infection (endometritis)

Lochia-should be assessed frequently for postpartum hemorrhage

• Soaking a pad under an hour=excessive bleeding

Uterus- after placenta is delivered the uterus begins process of involution.

• The uterus should be contracted, midline, and at/slight below the uterus.
• If its boggy/displaced =atony
o Interventions (for atony): fundal massage, void, in and out catheterization

Adoption-you want to encourage the mom to create memories with the newborn to facilitate the
grieving process (like holding the newborn, taking pictures, and naming newborn). Offer the patient a
chance to say goodbye to the newborn. Tell the staff that adoption so no one says anything harmful. It is
a decision, not neglect. Acknowledge the plan early.
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Postpartum Complications
Postpartum hemorrhage- is a blood loss of more than 500mL after vaginal birth, or a blood loss of more
than 1000mL after a c-section.
• Risk factors: history of postpartum hemorrhage, uterine distension (from twins,
polyhydramnios, macrosomia infant (more 8lbs), uterine fatigue (more 24hours of labor), high
parity, medications (like magnesium, oxytocin, or anesthesia)
• Causes: uterine atony (boggy fundus, distended bladder, fundus elevated above umbilicus and
deviated right
• Two types: early and delayed
o Early post-partum hemorrhage- occurs less than 24 hours after birth. Causes:
uterine atony (boggy uterus)
o Delayed post-partum hemorrhage- occurs more than 24 hours after birth. Causes:
retained placental fragments with long third stage of labor, uterine infection
o Interventions: assist patient to void. Then do fundal massage. if those fail-oxytocin

Postpartum Endometritis- is an infection of the uterus.

• Symptoms: fever, chills, tachycardia, uterine tenderness, foul smelling lochia, cramping.
• Causes: bacteria in uterus
• Treatment: antibiotics. So, you need to get blood culture first.

Breast engorgement-is when the breasts are painfully overfull with milk. If the mom is not
breastfeeding, then the focus treatment is to reduce milk. Put ice on both breasts 15-20 minutes every
3-4 hours or put chilled fresh cabbage leaves on breast. Can also take anti-inflammatory analgesic (like
ibuprofen)

Postpartum psychosis- is a rare, but serious psychosis. It is an emergency.

• Causes: genetic and hormonal fluctuation.
• Risk factors: history of bipolar, discontinuing of mood stabilizing medication
• Symptoms :( They come within 2 weeks post-partum). Include: hallucinations, delusions,
paranoia, severe mood changes, delirium, and feeling someone will harm the baby.
• Treatment: hospitalization, medication, long term supportive care.
• Women who have postpartum psychosis are at risk for suicide and infanticide.
•
Mastitis-antibiotic infection of breast tissue that clog’s the milk ducts
• Symptoms: fever, breast pain, local inflammation.
• Treatment: antistaphylococcal antibiotics (dicloxacillin or cephalexin).
• Other interventions: analgesics, frequent milk drainage by breastfeeding every 2-3 hours.
No underwire bras, (soft cup bras are good). Rests, oral fluids, teach proper latch techniques, and
frequent breast feeding.

Newborn Assessment
Caput succedaneum- is edema of soft tissue of the scalp. It is due to prolonged pressure of the
presenting part against the cervix during labor. It resolves in a few days
(mnemonic - caput succedaneum = crosses suture).
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Mongolian spots- Congenital Dermal Melanocytosis- is flat, bluish discolored areas on lower back
/butt. It is benign, and fades over 1-2 years of life. You want to measure them and document them,
so people don’t think it’s from being bruised.

Vernix caseosa- is a protective substance covering the fetus that is a white, cheesy/waxy substance and
is seen mostly in the axillary and genital areas of term newborns.
Milia-are white papules that are usual found on the nose/chin. They go away without treatment within
several weeks.

Normal newborn respiratory rate is 30-60 breaths per minute. The breathing may be slightly irregular,
diaphragmatic, and shallow.
Physiologic heart murmur is expected in the first 48 hours of life during transition from fetal to neonatal
circulation. 

During the first 3-4 months– its normal for an infant to cry 1-3 hours a day when hungry.

Preemies-
• Have lanugo- which is fine hair on the backs/shoulders of preterm newborns. It disappears
around 36 weeks gestation.
• They also have at 28 weeks-smooth, pink skin with visible veins (skin is thin and transparent with
a lack of subQ fat). There areolae are barely visible, with no raised breast buds. Their feet are
smooth with only faint red marks or single transverse crease. Their testes have not descended
yet and are palpable in upper inguinal canal.

Full term- their palpable raised breast bud, and have creases over entire sole, and peeling skin.

Acrocyanosis-is peripheral cyanosis of the hands/feet of a newborn. It is benign/normal during the

first 24 hours or first week if newborn is cold.
• Symptoms: bluish discoloration of hands/feet (can be around the mouth too).
• Cause: poor perfusion to periphery (the body is trying to reduce heat loss.
• Treatment: place the newborn skin to skin with the mom or place the newborn under a
radiant warmer and assess the axillary temperature

Newborn stool- first the newborn makes meconium then they should have thin yellow/brown/green
stools. If they are breastfed-seedy yellow paste. If they are bottle fed=firmer, light brown stools.

Cryptorchidism-is when the testicles are undescended at birth. It is normal, and they will come down by
themselves at 6 months

Crackles (rales)-means that fluid in lungs. This is normal immediately after birth. But
wheezes/stridor/crackles after first few hours of birth is abnormal.
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Mammary gland enlargement, non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal
bleeding (pseudo-menstruation) are benign transient findings commonly seen in newborns; these are
physiologic responses to transplacental maternal estrogen exposure

Hypoglycemia-if a mom has gestational diabetes, when the baby is born, they are at risk
for hypoglycemia
• Treatment: breastfeed/bottle feed. If they cannot tolerate feedings and they are symptomatic
(like lethargy and jittery), then give them IV glucose.
• The normal blood glucose for a newborn baby is 40-60.

Erythema toxicum neonatorum-is a firm, white/yellow papules or pustules surrounded by erythema. It

looks like a flea bite. It appears in the first few days after birth and resolves within 5-7 days, so they
do not need treatment.

Epstein pearls- are small white cysts on the gums and hard palate of a newborn. It is normal and
disappears a few weeks after birth

Newborn Defects
Down syndrome- a single transverse crease across palm of hand. Other signs: small/low set ears, flat
bridge nose, protruding tongue, hypotonia.

Cigarette smoking –leads to perinatal loss, sudden infant death syndrome, low birth weight, and
prematurity. 

Zika- is from mosquitoes, and is transmitted via sex, bodily fluids.

• Symptoms include: viral symptoms.
• Causes: microcephaly, developmental dysfunction and encephalitis.

Fetal alcohol syndrome (FAS) is a condition that results from alcohol exposure during the mother’s
pregnancy. It is a leading cause of intellectual disability and developmental delay. It is diagnosed: history
of prenatal exposure to any amount of alcohol, growth deficiency, neurological symptoms
(like microcephaly), or specific facial characteristics (indistinct philtrum, thin upper lip, epicanthal folds,
flat midface, and short palpebral fissures).

Anencephaly-is a severe neural tube defect that causes little to no brain tissue or skull formation
in utero. Many are still born and if they are born, they are not compatible with life. Interventions
include: Comfort care for newborn and emotional support for family. So dry/bundle/place newborn skin
to skin and give oxygen. Allow the family to hold the newborn to help the grieving process.

Neonatal abstinence syndrome- is when the baby in the womb got used to drugs (opioids, CNS
depressants) from the mom, so by delivery when leaving “place with drugs,” the baby
has withdrawal symptoms.
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• Symptoms: Autonomic nervous system symptoms: stuffy nose, sweating, yawning, sneezing,
tachycardia, and tachypnea. And Central Nervous System symptoms:
irritability, restlessness, jittery, sneezing, diarrhea, vomiting, poor feeding, high pitched cry,
abnormal sleep pattern, and hyperactive reflexes.
• Treatment- swaddling and keeping nasal passages clear, minimize stimulation and treat the
symptoms

Newborn- these are abnormal findings:

• Jaundice (in the first 24 hours is pathological. After 24 hours is physiologic and resolves
itself-though report and monitor.).
• If the newborn did not voiding/ or pass meconium in the first 24 hours.
• If there is signs of respiratory distress like nasal flaring, chest wall retractions, or grunting with
respirations.
• Other abnormal findings: sacral dimple, single artery, or hypotonia.
• Normal head circumference 12.5-14.5. Report less than 12.5 or more than 14.5.

Nursing interventions for newborn immediately after delivery: standard precaution with gloves
(because the newborn is covered in fluids). Clear the newborns airway by suctioning the pharynx and
then the nasal. Thermoregulation should be 97.5-99. Place the baby in a radiant warmer. Prewarm
the linen, place infant socks and cap on, and a thermal skin sensor for monitoring. Give vitamin K IM in
the vastus lateralis within 6 hours of birth (to prevent bleeding), and ophthalmic solution in the eye
within 1 hour.

Infant (till 1 years old)

Iron- Premature infants need iron supplement by age 2-3 months. If an infant is exclusively breastfed-
their iron levels drops by 6 months and they need supplements by 6 months. If they are fed by formula,
it has iron in it, and they do not need a supplement.

Weight/Length/Head
• Weight- the baby’s birth weight doubles by 6 months and triples by 12 months.
• Length- length by first year increases by 50%.
• Head-At birth head circumference is slightly more than chest circumference but equalizes at
12m.

Baby’s fontanels/soft spots-

• Should be flat, slight pulsations in anterior
• It is normal to bulge with crying/coughing/lying down.
• The posterior fontanel closes at 2 months and anterior closes at 18 months

Supplemental formula feedings and artificial nipples -should be avoided because it interferes with the

mother's ability to exclusively breastfeed. Supplemental formula feeds are only provided for medical
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indications (like newborn hypoglycemia, dehydration, excessive weight loss) and if alternate
breastfeeding techniques are unsuccessful.

Infant formula-wash the top of the formula cans with hot water and soap before opening.
Refrigerate any unused/prepared formula but use it within 48 hours. Warm bottles in pan of hot water
under tap warm water. Test formula temperature on inner wrist before serving.
Never overdilute formula or over concentrate it. Never microwave. Any leftover formula in the bottle
should be discarded

Baby’s first 3-4 days- a weight loss of 5-6% is normal. It should return to normal weight by 7-14 days. A
weight loss of more 7% needs evaluation

Care of umbilical cord- The cord beings to dry 24 hours after birth and shrivel, and it turns black in 2-3
days. It separates from the umbilicus 1-2 weeks after birth. You should fold the diaper below the cord.
Keep the cord stump clean and dry, and open to air when possible. Do not put antiseptics like alcohol
on. Report symptoms of infection (like red, drainage, swelling).

Newborn safety- To prevent SIDS (sudden infant death syndrome): Dress the baby in no more than one
layer of clothing that an adult requires. A wearable blanket (sleep sack) can keep the newborn warm and
prevent the head from being covered. Place the newborn supine to sleep. No loose bedding/objects
in the crib (like blanket/stuffed toys/pillows). Make sure the crib slats are no more than 2.5 inches
apart.
 
Car seat- should be rear facing in the back seat of the car. It should be at a 45-degree angle to prevent
airway obstruction. You can place rolled blanket/car seat inserts on both sides to prevent slouching.
Secure a safety seat harness to fit snuggly under the newborns body. No bulky jackets or blankets.
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PEDIATRIC NOTES
Growth and Development:

Separation anxiety- at 6-30 months. They go through 3 stages: First goes protest -child refuses attention from
others, and screams for parents to return, cries inconsolably. Then goes despair- child withdrawn, quiet,
uninterested in activities and displays younger behavior (pacifier, wetting bed). The last stage is detachment
–child is happy and interested. Nurse interventions: build trust and encourage connection with family. If child is
in the hospital, encourage the parents to leave favorite toys, books, and pictures from home. Establish a daily
schedule that is like the child's home routine. Maintain a close, calming presence when the child is visibly upset.
Facilitate phone or video calls when parents are available. Provide opportunities for the child to play and
participate in activities.

Moro reflex-is the startle reflex. Should be present at 3-6 months. Absence of this reflex may indicate brain
damage or spinal cord damage.

Baby’s first food- should be given by 4-6 months. Start out giving Iron fortified cereal first. Wait 5-7 days in
between introducing each new food. At 6-8 months puree foods and vegetables. After introducing puree foods
then introduce finger foods. Cow’s milk is given at 1 years old.

First dental visit- within 6 months of the first tooth or by 1st birthday

Bladder/bowel sphincter control- at age 24 months (so can toilet train)

Toddler-after 2 yrs. The chest circumference exceeds abdominal circumference causing a taller and more slender
appearance. Head circumference increases by 1 in (2.5 cm) during the second year and then slows to a growth
rate of 0.5 in (1.25 cm) per year until age 5. Toddler weight gain should be 4-6 pounds/year. By 30 months, the
toddler should weigh 4 times the birth weight. Physiologic anorexia is a decreased appetite that commonly occurs
with toddlers. For this, you want to provide multiple food options, set schedule for meals, no TV while eating, do
not force them to eat.
Sleep – At 5 years old, they need 11 hours of sleep. Age 12 years old they need 9 hours.

Congenital Heart Diseases

Tetralogy of Fallot- is a complex heart defect that results in decreased pulmonary blood flow, mixing of
oxygenated and unoxygenated blood, and inadequate blood flow into the left side of the heart. Hypercyanotic
episodes called Tet spells (can happen when child cries, becomes upset, or feeding-first thing knee to chest
position). They can also have clubbing of fingers, irritability. O2 sat norm at 65-85 till surgery. Occur in stressful
or painful procedures, on waking, w hunger, crying, feeding. Interventions: calm environment, sooth infant,
pacifier, swaddle/hold if stressed, frequent small feedings. During an acute Tet spell, place the infant in knee chest
position (if x works-morphine) and squatting for older children, and 0xygen.

Atrial septal defect- an abnormal opening between the right and left atria. So, more pressure in left flows back to
right atria and goes back and forth to equalize. This back and forth causes vibration that is a murmur on
auscultation. Symptoms: systolic murmur and fixed split-second heart sound. Acyanotic.
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Ventricular septal defect-there is an opening in the septum between the ventricles, which causes a left to right
shunt (so lot blood flow to lungs-causing pulmonary congestion. So, the patient is at risk for heart failure and
pulmonary hypertension. Symptoms: harsh systolic murmur auscultated near sterna border at 3rd/4th ICS. And
classic heart failure symptoms (like diaphoresis, tachypnea, dyspnea).

Coarctation of the aorta-narrowing of aorta so less cardiac output. Symptoms: weak lower and strong upper
extremity pulse

Patent ductus arteriosus-the ductus arteriosus does not shut as should when baby is born so blood shunts from
aorta back to pulmonary arteries. Symptoms: systolic murmur w machine sound and poor feeding. Interventions:
It usually resolves within 48 hours and does not need interventions. But if it doesn’t, interventions include:
surgical ligation or IV indomethacin.

Pulmonic stenosis- the ventricles try to push blood through a narrowed pulmonary area to the lung, so it causes
increased pressure in the right side. Treatment: balloon angioplasty. NPO 4 hours before. Report a diaper rash to
health care provider because it can delay the procedure (because its inserted femorally and yeast/bacteria can be
on the diaper rash and enter blood stream). Ss: loud systolic ejection murmur, cyanosis.

Mitral stenosis- Symptoms: diastolic murmur

Congenital Anomaly-

Trisomy 21 aka Down syndrome- Risk factor: older age. Symptoms: single palmar crease, short neck with excess
skin (nuchal fold). Cardiac defect is quite common with down syndrome.

Trisomy 18 aka Edwards syndrome- is a life-threatening chromosome abnormality that affects multiple organ
systems. Many fetuses die in utero or within a year of life. Nurses should request a collaborative meeting with a
health care provider. There is no cure.

Cleft palate- is an opening (cleft) in mouth going into nasal cavity so the patient has difficulty sucking/feeding. The
infant cannot create suction and pull milk from bottle/nipple, so they are at risk for aspiration and inadequate
nutrition due to eating difficulties. Treatment: surgery between 6-24 months. Until its repaired: hold infant in an
upright position, tilt the bottle so the nipple is always filled with formula, and point it down and away from cleft.
Use special bottle and nipples including crosscut and preemie nipple, squeezable bottles. Burp the infant often.
Feed every 3-4 hours over 20-30 minutes because feeding too much is too tiring for infant. Postop the surgery:
pain management (sooth the infant because uncontrolled crying leads to hemorrhage). Place the child upright
position to prevent airway obstruction. Use elbow restraints and monitor skin and neurovascular status. Do not
place hard object in mouth like pacifiers, straws, tongue depressor, utensils

Developmental dysplasia of the hip (DDH) –is a hip abnormality that can be present at birth or during the first
few years of life. It is checked for as a standard assessment screening for newborns and infants. Risks: breech,
macrosomia, family history. To reduce risk: proper swaddling=swaddle with hips bent up (flexion) and out
(abduction), car seat with wide base (basically not knees together or narrow stuff (like infant swings, bouncers
because it causes the legs to be together straight). Treatment: non-pharmacological- usually 1st 6 months- harness
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(such as Pavlik harness) or cast. If it does not work, then surgery. Ss of development dysplasia in infant under 3
months=extra inguinal or thigh folds, laxity of hip joint of affected side. Diagnosed: through Barlow and Ortolani
maneuvers (only done by doctor). If it is not treated these signs disappear after 3 months because of muscle
contractures. So once infant is more than 3 months the signs and symptoms include: limited hip abduction,
affected leg can be shorter, notable limp, walking on toes, positive Trendelenburg sign (pelvic tilts). If the
developmental dysplasia of the hip is bilateral then the symptoms also include waggling gait and sever lordosis.
Pavlik harness-is used to treat developmental hip dysplasia-It keeps the hips in a slightly flexed and abducted
position. It is worn for 3-5 months. Interventions: Regularly assess skin, Dress the patient in shirt and knee sock
under the harness. No lotions/powders, and lightly massage the skin under the straps. Put diaper underneath the
straps, and only put one diaper at a time. It is worn all the time (can be removed once a day to bath but kept on
otherwise, like to diaper change).
Pyloric stenosis- the valve between the stomach and small intestine get thick and narrow. Symptoms: (comes 2-8
weeks after birth): projectile vomiting then hungry. Olive shape mass that you can palpate in the epigastric area
right above the umbilicus. Emesis is non-bile. Dehydration (sunken fontanels, decreased skin turgor, delayed
capillary refill. The infant will be constantly hungry.

Hirschsprung disease-aka Megacolon- when some sections of distal part of the large intestines are missing nerve
cells so no peristalsis and stools are not passed: Symptoms: distended abdomen, no passing meconium within
24-48hrs. Difficulty feeding, vomiting green bile, ribbon like stool. Complications: enterocolitis (inflame of colon
can lead to death). Interventions: Some patients will require a temporary colostomy. The stoma from surgery
should be beefy red immediately postop. Any paleness/gray indicates a decreased blood supply. Blood tinge
mucus first few days post op is normal. Day 6-stool coming out-normal.

Intussusceptions- one part of the intestines prolapses and telescopes into another part (which blocks the passage
of intestines contents and interrupts blood supply and causes intestinal tears). It is an emergency because it can
lead to peritonitis. Symptoms: Pain is severe, progressive, with inconsolable crying. It can cause ischemia. Other
ss: bloody currant jelly stools (mix of blood and mucus), sausage shaped right sided mass with palpation (causes
bilious, non-projectile vomiting), intermittent pain (causing the patient to draw knees up). Diagnosed: contrast
enema (air enema)-which can also be a treatment. When giving the saline or air enema monitor for normal brown
stool which means reduction of intussusceptions.

Spina bifida occulta-is a neural tube defect. When the spinal vertebrae does not close during fetal development
–it can allow spinal cord to protrude through the opening. The mildest form=spina bifida occulta. Newborns can
have no impairments or neuro disturbances. Ss: (of spina bifida occulta)- tuft of hair, hemangioma, nevus, dimple
along the base of the spine.

Open spina bifida-aka Myelomeningocele –the spinal cord protruded out. The patient is at a high risk for
infection. Priority: cover the area with a sterile moist dressing. Then place the patient prone with the face to one
side.
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Cerebral palsy- many times they have a baclofen pump to help control muscle spasm (if there is an increase in
muscle spasms with the baclofen pump, it means there is a problem with the pump). Do not stop baclofen
abruptly. Symptoms: clonus/spasticity (Clonus is a series of involuntary, rhythmic, muscular contractions and
relaxations.

Acute Conditions

Gastrointestinal Disorders

Rotavirus-Spread: fecal oral (food, toys, diapers, hands). Symptoms: watery diarrhea (5-7days), fever, vomiting,
foul smelling. Preventions: hand washing, vaccination (before 8 months). Complications: it can lead to
dehydration (lack of tears when crying, extremely fussy or sleepy, decreased urination, dry mucous membranes).

Hyperbilirubinemia –too much bilirubin- treatment: Phototherapy= using fluorescent lights to treat
hyperbilirubinemia/jaundice in newborns. (the light converts bilirubin to a water-soluble form so it can be
excreted in stool/urine. Place the newborn under the light with only the diaper on. No lotions/ointments. Only
remove newborn from the light for feeding. They will need hydration. Monitor the temperature, it should be low
heat.

Appendicitis- (the appendix is located at junction of small intestines and beginning of long intestines). When it
gets obstructed like from fecal matter its causes it to become inflamed. Symptoms: right lower quadrant
continuous pain, tenderness at McBurney point when apply pressure, and Rebound tenderness when release
pressure, Nausea, vomiting, high WBC, abdominal guarding. The inflammation causes swelling and ischemia. If
untreated, the appendix can rupture and release bacteria into the abdominal cavity causing peritonitis and
sepsis-which is an emergency (If this happens, they temporarily will not have pain anymore). Treatment: Surgery
within 24 hours. Fluid resuscitation with IV crystalloids (NS/LR). NPO. Pain medications. Avoid increasing blood
circulation stuff like heating pad or warm blanket on the abdominal cavity.

Necrotizing enterocolitis- usually in preterm infants because their GI is immature. So, when you feed them
bacteria can enter bowel and proliferate, leading to inflammation and ischemic necrosis of intestines. Symptoms:
fever, lethargy, explosive, foul smelling diarrhea, rapidly worsening abdominal distension. Interventions: measure
abdominal girth daily to see worsening gas swelling. NPO. Ng suction to decompress stomach. Parenteral
hydration/nutrition and IV antibiotics. Place supine and un-diapered.

Urinary Disorders

Nephrotic syndrome-there is a change to the glomerulus that leads to massive amount of proteins leaking into
the urine. 4 classic ss: massive proteinuria, hypoalbuminemia, edema, hyperlipidemia. Interventions: monitor fluid
status and swelling, I/O, monitor urine for protein, limit sodium. They are at risk for infection.

Glomerulonephritis in children-inflammation of the glomerulus that leads to red blood cells and mild protein
leaking into the urine. Causes: strep infection. Ss: periorbital and facial/generalized edema, hypertension, oliguria,
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hematuria. Tea /smoky/rusty/cloudy urine. Treatment: they usually recover spontaneously so monitor blood
pressure and fluid status, avoid high sodium foods (no added salts). Complication: severe hypertension.

Urinary tract infection (UTI) aka cystitis- causes: bacterial (E. coli). UTI’s are classified according to the location on
the urinary tract. So, if the bacteria travels to the urethra then urethritis, if it travels to the bladder then cystitis,
and if it ascends all the way to the kidney then pyelonephritis. Symptoms: Cystitis: because it is a lower UTI, it
causes burning with urination (dysuria), urinary frequency/urgency, hematuria, and suprapubic pain.
Pyelonephritis (to kidney) -urinary frequency/urgency, nausea, vomiting, fever with chills, flank pain, CVA
tenderness. It can lead to sepsis. To prevent UTI’s: take all antibiotics, increase fluids, void every 2-4 hours. wipe
from front to back. No synthetic fiber material underwear (nylon/spandex-only cotton). Void after sex. No jelly,
douching, or perineal products. Showers instead of baths.

Respiratory Disorders

Post op tonsillectomy or adenoidectomy- the patient is at risk for bleeding up to 14 days after the surgery.
Bleeding can be life threatening because the airway is compromised. Do not return to strenuous activity for at
least 2 weeks postop. Symptoms of hemorrhage: (restlessness, frequent swallowing, clearing of throat,
restlessness, vomiting blood, pallor). If hemorrhage occurs-the patient should be seen immediately and may need
surgery to cauterize the bleeding vessels. Tell the patient to limit coughing, gargling, clearing of throat, and
blowing nose. Limit physical activity. No milk products (because it causes you to clear your throat). Do not drink
through straw or suction. Do not gargle/Oral mouth rinses/vigorous tooth brushing. It is normal postop to see
slight ear pain, low grade fever, mouth odor.

Peritonsillar abscess-serious complication from tonsillitis or pharyngitis. Symptoms: hot potato (muffled) voice,
trismus (cannot open mouth), pooling of saliva (drooling), uvula deviation to one side. It can cause airway
obstruction-which is life threatening.

Bronchiolitis-inflammation/obstruction of the lower respiratory tract. It starts as an upper respiratory infection

(like rhinorrhea, congestions) and then goes to a lower respiratory infection (like tachypnea, cough, wheezing). So
basically, some patient have mild cold symptoms and some have respiratory distress symptoms. With infants they
will have difficulty feeding, dehydration, irritability (hypoxia). Treatment: supportive, suctioning, oxygen, fluids,
and remove secretions with bulb.

Neurosensory Disorders-

Meningitis- inflammation of the meninges of the brain and spinal cord. It can be caused by bacteria or a viral
infection. If it is caused by bacteria-it can be life threatening. Symptoms: fever, headache, nuchal (neck) rigidity,
photophobia, nausea, vomiting, and changes in mental status. Symptoms for a patient under 2 years old: fever,
restlessness, high pitched cry, seizures, poor feeding, vomiting, budging fontanels, headache, neck stiffness
(nuchal rigidity), photophobia, and altered mental status. Complication: hydrocephalus and increased ICP (which
can lead to brain damage). Diagnosed: lumbar puncture. Before the lumbar puncture do head CT scan (because
increased ICP may contraindicate a lumbar puncture because of the risk of brain herniation). When doing a
lumbar puncture- have the infant’s head and knees tucked in and back rounded out. The nurse should assess for
Keurig sign (pain with the legs up to 90 degrees) and Brudzinski signs (pain when neck up in crunch position).
Treatment: initial-isolate the patient-put them on droplet precautions (includes: surgical mask-just for nurse,
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private room, client masked during transport) until you know if its viral or bacterial. Then immediately start
antibiotics. Discontinue the droplet precaution 24 hours after starting antibiotics. Other interventions: low
stimulation environment (quiet, dim light, cool temp). Seizure precautions. Bed rest with head of the bed 10-30
degrees. Also monitor for increasing ICP signs (like sunset eyes, prominent scalp veins, wide bulging fontanels,
increased head circumference).

Reye syndrome- is a rare but serious disease that causes swelling in the liver and brain of someone who has
recently had a viral infection (like chicken pox or flu). Symptoms: fever, lethargy, acute encephalopathy, altered
hepatic function, elevated serum ammonia. Do not give aspirin or products containing salicylates to children with
a viral infection-they have been shown to increase the risk of getting Reye’s syndrome.

Febrile seizure- is a seizure in a child caused by a spike in body temperature, often from an infection.
Interventions: Never leave the child alone. Prevent them from self-injury (so place them in a side lying position,
removal harmful environments). Nurse should use Tylenol/ibuprofen (if more 6 months) to control the fever and
implement cooling methods (cool damp compress to forehead, increasing air circulate room, wear minimal/loose
clothes). If it occurs for more than 5 minutes –call 911.

Neoplastic Disorders (Tumors- cancer is rare in children)

Hodgkin lymphoma is a malignant cancer of the lymphatic system. Expected early manifestations include
painless enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats

Wilms tumor-aka nephroblastoma-is a kidney tumor. It usually occurs when the child is under 5 years old and
occurs to only one kidney. Once diagnosed- do not palpate the abdomen (to prevent the abdominal from spilling)
and post a sign that says “do not palpate the abdomen” at the patient’s bedside and handle the child carefully
during bathing.

Infectious Disorders

Acute otitis media- inflammation/infection of middle ear. Usually occurs in children under 2 years old. It can
follow a respiratory infection because children’s Eustachian tubes are shorter, straighter, and horizontal.
Symptoms: high fever (like 104), ear pain, loss of appetite, pulling on the ear, tympanic membrane bulging and
very red. Risk Factors: predisposed to smoke, uses pacifiers, drinks from a bottle while lying down. To prevent:
eliminate smoking, routine immunizations, after 6 months eliminate pacifiers. Complications: hearing loss and
spread of infection. Interventions: To prevent more damage give antibiotics (like amoxicillin). If it does not
improve within 48-72 hours of antibiotics see doctor. Take entire medication even if the symptoms go away.

Otitis externa-infection of outer ear. Symptoms: Severe pain when direct pressure is put on the tragus or with
pulling on the pinna.
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Pinworm- are small parasites worms that can live in the colon and rectum. Ss: anal itching, troubled sleeping.
When a person scratches the eggs, they are transferred from fingers to other surfaces. Tr8: antiparasitic meds

Pediculosis capitis- head lice. It is very contagious. Treatment: pediculicide=permethrin 1%. And remove the nits.
Use a nit comb 2-3 days for 2 weeks. Vacuum the carpet frequently. Wash the bedding in hot water and dry on
hot setting. If it is not washable- seal in plastic bag for 2 weeks. Soak all the brushes in boiling water for 10
minutes. You need to treat the siblings, but not the animals.

Communicable Diseases-

Varicella (chicken pox)- It is transmitted airborne, spread of secretions. So, you need airborne precaution (N95
respirator, negative pressure room). If the lesions are open then contact precaution also (gown, gloves, disposable
equipment). They are contagious 1-2 days before the rash appears until all lesions are crusted over (can take like
2-3 weeks).

Fifth disease aka Parvovirus B19-(looks like a slapped face)- Causes: parvovirus b19-school age kids. Transmitted:
contact person to person, especially with respiratory secretions. It takes a week to recover. It is only infectious
before symptoms develop. Symptoms: slapped face look, fever, flu like symptoms. It can be dangerous if the
person is pregnant (so a pregnant nurse should not take care of this patient).

Infectious mononucleosis- Causes: Epstein Barr virus. Transmitted: sharing drinks, kissing, and direct saliva
exposure. Symptoms: fatigue, fever, sore throat, splenomegaly, hepatomegaly, swollen lymph nodes. Treatment:
manage symptoms (because it is a virus)-hydration, pain meds, reduce fever. If they have a sore throat-saline
gargles, anesthetic troches. Avoid contact sports, and rest. Complications: airway obstruction (stridor, difficulty
breathing) from swollen lymph and severe abdominal pain, which you want to tell the doctor about.

Pertussis (whooping cough)- It is very contagious. Transmitted: by cough/sneeze/close contact, so place the
patient on droplet precaution. Symptoms: starts out with cold with a fever, but then violent spasmodic cough
(forced to inhale afterwards so whooping sound made). Coughing can continue till thick mucus plug comes out
and then vomit. Treatment: antibiotics and supportive. Humidified oxygen and fluids. Suction as needed. Monitor
respirations. Position on left lateral side (prevents aspiration). Vaccination. Do not use cough suppressants

Rubella- do not get pregnant for 4 weeks after getting the rubella vaccine.

Measles-aka Rubeola- Transmitted: through air (sneezing, cough) and can remain in the air for up to 2 hours. (So,
place the patient on airborne precaution in a negative pressure room. N95 mask for the nurse). A postexposure
vaccination within 72 hours of exposure is recommended for persons who cannot show immunity, to decrease the
severity and duration of clinical symptoms (to unvaccinated, susceptible family members. The measles starts with
fever, runny nose, cough, red eyes, and sore throat. It is followed by a rash that spreads over the body. The
incubation period is 7-21 days, so you do not see the signs and symptoms until 2 days after exposure.

Scarlet fever- Ss: sandpaper-like skin rash, fever. Treatment: antibiotics

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Chronic Disorders

Gastrointestinal Disorders

Celiac disease-is an immune disease in which the patient cannot eat gluten because it will damage their small
intestine. Interventions: gluten free diet which includes NO BROW- Barley, Rye, Oats, Wheat. They can eat: rice,
potatoes, corn etc. They will be on a gluten free diet for the rest of their life. Replace deficient vitamins (fat
soluble vitamins, iron, and folic acid). Educate them that processed foods like chocolate candy, hot dogs, soy
sauce, malt, and food starch can have hidden sources of gluten.

Respiratory Disorders

Cystic fibrosis-. There is a mutation in the transportation of sodium and chloride gene causing thickened/sticky
secretions. So thickened respiratory secretions accumulate and causes a chronic cough and the patient can not
clear their airways. They eventually get chronic lung disease. It is inherited in an autosomal recessive manner
Interventions: first give bronchodilators than chest physiotherapy. Exercise is good. Give them pancreatic
enzymes with all meals and snacks (do not mix with other substances, the capsule can be sprinkled on applesauce,
yogurt, acidic foods with pH under 4.5 –so not with milk. And do not swallow the capsule whole. Do not crush or
chew them (because its enteric coated)) and do not take too much. They need supplemental vitamins, and a
diet high in calories, fat, and protein. If anorexia, weight loss or a decrease activity-it can indicate infection. Cystic
fibrosis can also cause infertility. They usually only live into their 30’s.

Hematological Disorders

Sickle cell disease-The red blood cells become sickle shape when deoxygenated and clump together and obstruct
the blood vessels. This especially occurs if dehydration, stress, or infection), which can cause a sickle cell crisis.
With a sickle cell crisis, the patient will be in severe acute pain from tissue ischemia. Other ss: elevated bilirubin,
jaundice, elevated reticulocytes, anemia (low hemoglobin), brownish color to urine. You need to help them
immediately because it leads to tissue damage and death. Treatment: IV fluids and pain medications. After doing
that then give them folic acid, blood transfusion, oxygen. When sickle cell crisis they are on bed rest so let them
watch TV (because video games are too stimulating). They are also at risk for infection because they are
immunosuppressed.

Hemophilia- bleeding disorder from not enough coagulation. There are different types- Hemophilia A lacks factor
viii. Hemophilia B lacks factors ix. With Hemophilia the patient is at risk for uncontrollable bleeding. Symptoms:
bleeding externally and internally (joints), prolonged bleeding, severe bruising. Treatment: replace missing
clotting factors (IV push). REST (rest, ice, compression, elevation). Do not place warm only cold on site (because
warm vasodilates and prolongs bleeding. Do frequent neuro assessments. Do not take stuff that increase bleeding
risk (like NSAID’s- aspirin/ibuprofen). Teach about injury prevention. Avoid IM injections. Avoid taking rectal
temperature (or anything that can cause bleeding). Use the smallest gauge needles and put firm constant
pressure to site for 5 minutes. Avoid contact sports. Make sure to do dental hygiene and soft tooth brushing. They
should wear a medic alert bracelet. Monitor for bleeding (intracranial bleeds, bleeding into joints).
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Musculoskeletal Disorders-

Scoliosis-lateral curvature of spine and spinal rotation. Screening age 10-14.

Boston brace/Wilmington brace/TLSO brace/Milwaukee brace- used to stop progression of scoliosis. They do not
cure but prevent from further worsening. The patient wears a cotton t-shirt under the brace. Many teens do not
wear it because of body image, so you want to discuss it with them. No lotion/powder under the brace. Remove
the brace for exercises with the spine. Most braces are worn for 18-23 hours per day and removed for exercise
and bathing.

Duchenne muscular dystrophy-

Is an X linked recessive disorder (so its carried by females and affects men). It occurs due to lack of protein
dystrophin needed for muscle stabilization and causes progressive replacement of muscular tissue with
connective tissue. Symptoms: starts out with calf muscle hypertrophy and later goes to fat/connective tissue.
Grower signs (hips on thighs to push up), enlarged calves, walking on tiptoes, and frequent falling. The disease
onset is usually 2-5 years Treatment: no effective cure. Most children are wheelchair bound and die by age 20-30
years old from respiratory failure. They should avoid floor clutter and prevent falls/injury.

Other

Kawasaki disease- inflammation of arterial walls in childhood, especially the coronary arteries. It can lead to a
coronary artery aneurysm. Causes: unknown. Not contagious. 3 phases: (1.) Acute- sudden high fever that does
not respond to medication, irritable, swollen feet/hands/lips/tongue. (2.) Subacute-skin peels from hands and
feet, Irritable (can last 2months). (3.) Convalescent-the symptoms disappear slowly. Treatment: IV gamma
globulin (IVIG), and aspirin. When discharging the patient, tell them to monitor for fever every 6 hours for 48
hours, take their temperature daily, and if they get a fever tell their doctor because it can be recurrence of
Kawasaki disease (which can lead to coronary artery occlusion).

Esophageal atresia and tracheoesophageal fistula- the esophagus and trachea do not properly separate or
develop. Symptoms: excessive frothy mucus/saliva, choking/coughing/drooling, and apnea and cyanosis during
feeding (so the patient is at risk for aspiration). Treatment: surgery. Interventions: keep the patient supine with
the head of the bed elevated 30 degrees. Insert a NG tube and connect to suction till surgery. The patient is at risk
for aspirations so keep them NPO. Keep suction equipment near to clear secretions.

Epiglottitis- inflammation of epiglottis causing life threatening airway obstruction. It is an emergency. Causes:
bacteria (specifically- hib). So, if someone did not get the hib vaccine think of epiglottis. Symptoms begins with a
high-grade abrupt fever and sever sore throat, followed by 4 D’’s: drooling, dysphonia (voice problem), dysphagia,
distressed airway (inspiratory stridor). Child looks toxic appearing and may be in tripod position (sitting up and
leaning forward) with inspiratory stridor. Interventions: Do not do anything that increases anxiety and do not put
anything in their mouth (so do not poke them with an IV or a throat inspection). Have emergency intubation
available. Complications: serious/sudden airway obstruction

Phenylketonuria (PKU)-is a genetic disorder in which the person lacks the enzyme phenylalanine which converts
the amino acid phenylalanine to tyrosine. Treatment: a low phenylalanine diet for life (not complete elimination,
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just low amounts). Monitor phenylalanine serum levels. Include proteins, special formula. No high phenylalanine
foods (meats, eggs, milk)

Hydrocele- is a type of swelling in the scrotum in which fluid fills around the testes. It usually resolves on its own
before 1 years old. Not an emergency.

Circumcision-you want to restrain the newborn in wrapped blanket or place on special board to prevent injury.
Give nonnutritive sucking of sucrose for pain. Parents should clean the area with warm water, and no soap. No
alcohol-based wipes until its healed (which usually takes 5-7 days). Immediately post op=the penis will be dark red
and after 24 hours, it will be covered in yellow exudates that will continue for 2-3 days. Do not wipe it. Redness,
swelling, odor, discharge indicate infection. Diaper should be changed when soiled at least every 4 hours to keep
the area clean and assess for infection/bleeding. Apply petroleum gel or ointment at every diaper change to
prevent sticking. Diaper should be loose. Bleeding that exceeds size of quarter is concern. Complications:
hemorrhage, infection.

Hypospadias-congenital defect that the urethral opening is underside of the penis. It is corrected by 6-12 month
by surgery redirecting the urethra penis tip. Circumcision is delayed. Postop: catheter or stent, and urine output is
especially important. If there is no urine output for an hour, it can indicate an obstruction.

Lead poisoning- from painted homes before 1978. You should screen children between 1-2 years old until 6 years
old. Lead effects the brain and more than 5 is dangerous. Treatment: chelation therapy. Intervention: prevent
continued exposure like house, hand washing before eating. Wet dust or mop weekly the hard surfaces. Use cold
water. Flush tap water for several minutes

SIDS- prevention: sleep on back, do not sleep with anyone, nothing in the bed, no bumper pads, don’t overheat
them, stop smoking, breastfeed, be up to date on vaccination, use a pacifier.

Nocturnal enuresis- is bedwetting (after an age that the child should be able to control their bladder).
Interventions: restrict to small sips after evening meals, void before bed. Positive reinforcement and motivation
(like a calendar) and do not punish them for wetting. Do not use diapers or training pants. The child should assist
in wet linen changes. Enuresis alarm. If the child is over 5, and all the above interventions fail, or there is no
response to behavioral therapy, or when short term improvement is needed to go to overnight camp-use
medications (like Desmopressin, TCA’s)

Fecal incontinence aka encopresis -is the soiling of underwear with stool by children who are past the age of
toilet training (older than 4 years old). Causes: functional constipation, psychosocial triggers. Treatment:
dis-impaction then prolonged laxative therapy, dietary changes, and behavior modification. So: regularly schedule
toilet sitting times 5-10 minutes after meal for 10-15 minutes. Quiet activity on toilet like reading

Toddler (age 1-3) give them nutrients dense foods. Do not give them foods that have potential for food borne
illness (like raw, or unpasteurized/uncooked foods). Do not give small, hard, or slippery foods that can be chocked
on (like hot dogs, grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, or raisins). Nursing care for
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toddler should be like home routines (preferred snack, anticipating nap time). Give them choices. They are too
little to post schedule or worry about body changes.

Toddlers want autonomy and ritualism. You should limit the opportunities for the toddler to say no (so do not ask-
do you want this…). If they tantrum-ignore behavior, remain in child presence, or put them in time out. Before
eating have a 15-30-minute calm down period so the child will sit and eat dinner. Get the parents involved and
assess them least to most invasive.

Children-school age-when giving injection use age appropriate language (like medication under the skin) and
improve their control- let them do coping skills like counting out loud, or deep breathing. Parent should hold the
child during injection. Tell them the truth about the pain- like the skin will hurt for a minute. Keeping objects like
needle out of view is appropriate for the toddler but not a school age child.
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NON-MEDICAL NOTES
HIPPA- you cannot give those without permission or without the need to know a patient personal health
information.

Case manager- assessing, planning, facilitating, advocating for patient’s health services to accomplish cost
effective quality patient outcomes. They assess patient’s needs, decrease fragmentation of care, coordinate care
and communication between health care providers, make referrals, ensure quality standards are met, arrange for
home health or placement after discharge. They do not do direct patient care. They make daily rounds to review
documentation in patients’ chart but do not see patients personally.

Medication error-1st assess the patient. then tell nursing authority, then complete an incident report within 24
hours

Incident reports- used to document events that pose unanticipated risks to health /safety of
patient/visitor/employee. It is a quality improvement method. Example of times you report:
assault/injury/physical/verbal/sex in healthcare, patient falls (even if no injury), staff/visitor falls, or from a
treatment/intervention (like failure to obtain/intervene on results of diagnostic procedure, inadequate/delayed
diagnosis and monitoring. Delay/omission/incorrect performance/administration of medication, hospital
equipment failure.)

Lateral violence/horizontal- violence from coworker to coworker. Not tolerate. Should: document and keep files
of incident. Report incidents to immediate supervisor. Let bully know that behaviors will not be tolerated. Seek
support from facility/external source

Needle stick injury- remove gloves, wash hands, report to supervisor, go to ER, they will draw blood and give
prophylaxis antibiotics (within 2 hours)

Impaired nurse- tell charge nurse. Document incident. Do not give over handoff to an impaired nurse.

Interpreter- nurse should maintain eye contact with the patient. Translate each word literally. Use basic English
not medical terms, slow speaking, pause after 1-2 sentences to allow for translation. Give simple instructions in
the order it will occur. Get feedback to make sure patient understood (not just nodding)-have patient repeat back.
Use app bilingual or an employee if not then fee based agency or language line. Address patient directly; in first
person. Ask one question at time, avoid complex issue/jokes. Hold preconference with medical interpreter to
review goals on interview. Avoid interpreters from conflicting cultures. Be mindful of cultural/gender/age
preferences

Advanced care planning:

A living will is an advanced directive describing the type of life-sustaining treatments (like cardiopulmonary
resuscitation, intubation, mechanical ventilation, feeding tube) that the client wants initiated if unable to make
decisions.
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A health care proxy (durable power of attorney for health care or medical power of attorney) is a person
appointed by the client to make decisions on behalf of the client. The proxy document only goes into effect
when the health care team determines that the client lacks the capacity to make decisions. This should be
deactivated if the client regains decision-making capacity.
Advanced directive- are prepared by a client prior to the need to indicate the client's wishes. The advance
directive should be put in medical records. The nurse is the advocate to make sure the patient’s wishes are
documented. There is no informed consent involved. Remember advanced directive is a document used to say
patient’s wishes. It is not medical order, so it does not prevent you from doing CPR (To prevent CPR, you need a
DNR). Give copy to everyone listed as healthcare proxy. Two witnesses are needed for completion of advanced
directive form, but witness cannot be the individuals named as proxy.

• If the client does not have a health care proxy, the family members would make decisions for the
client. Occasionally, there is no family and no proxy. If this happens, a proxy may be appointed, an
ethics board may make the decision, or the doctor may be responsible for making the decision.
• A client who is alert and oriented can directly address a health care decision. Clients in a coma (GCS
score ≤7) or with expressive aphasia would need an advance directive to make treatment decisions
because they cannot directly express their wishes. A client who is oriented can make and communicate
decisions for himself although unable to verbalize. The client could nod or write out wishes.

Informed consent-includes 3 things: surgeon explains everything. Patient understands information. Patient is
competent and gives voluntary consent. The nurse witnesses the patient signing. If the patient is unconscious or
under the influence of a mind-altering drug (like opioid), they cannot give consent. Only in life saving stuff you do
not need consent.

To leave against medical advice: Not allowing a competent patient to leave against medical advice is false
imprisonment. People who disqualify: altered consciousness, mental illness (a danger to self or to others), under
chemical influence.

Alternative medicine –Include: garlic on skin. Cupping (causes circular bruised blemished). Coining (round surface
looks like coin/spoon stroked on lubricated skin of back and produces wet like linear lesions. All appropriate and
should not be mistaken for abuse

Dental avulsion- when the tooth separates from mouth of permanent tooth-is a dental emergency. Interventions:
rinse and reinsert tooth into socket within 15 minutes to reestablish blood supply. If it cannot be reinserted-kept
moist by submerging into commercially prepared solution (like Hanks Balanced Salt Solution, cold milk, sterile
saline, or as a last resort saliva- holding it under the tongue).

Dental carries-aka cavities. Causes: bacteria digest carbohydrates in mouth making acids. Interventions: oral
hygiene, do not eat cariogenic foods like (refined, simple sugars, sweet, sticky foods, dried fruit, sugary
beverages). Brush teeth after meals, floss 2 times a week. Rinse mouth with water after meals/snack. Drink tap
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water. Finish meals with high protein foods.

Hearing impairment-you should approach the patient from front and visibly gain their attention before speaking.
Stand directly facing patient and use facial expression and use gestures. If using sign language-use professional
language interpreter. Post a hearing impairment sign at head of bed or on door. Keep room lights on so can read
lips. Direct speech to less affected ear and at a normal volume. Make sure hearing aids are functional and in place
• Hearing aids- you should turn volume off before inserting. Initially wear them for short time (20 minutes)
and gradually increase length of time. Do not wear hearing aids when using hair dryers or heat lamps.
Check that the battery compartment is clean before inserting them. Remove battery at night or when
hearing aid is not in use. Clean hearing aids with a soft cloth. Store in safe, dry place.

Crutches:
• Climbing stairs with crutches- Using a modified three-point gait to ascend the stairs, the client should place
body weight on the crutches and step up with the unaffected leg. Body weight should then be
transferred from the crutches to the unaffected leg. The client should raise the body to align with the
unaffected leg, followed by the affected leg and crutches together.
• Crutches fitting- Make sure 1.2inch space (which is 3-4 finger width apart) between the axilla and the axilla
crutch pad. Support body weight on hands and arms not axilla. There should be 20/30 degree of flexion at
elbow. Then assess patient for proper gait
• Safety with crutches: no clutter, no scatter rugs, look forward, use small backpack to hold personal items
(so hands free when walking), rubber or nonskid soled slippers or shoes with no laces. Rest crutches
upside down. Keep crutch rubber tips dry.

Ear drops-if they are older than 3 years old-pull the ear up and back. If they are under 3 years old- pull ear down
and back. Place patient in prone/supine with head to side. Side effects: dizzy, vomit

Latin America (Mexicans)- mal de ojo- is their belief in the evil eye that comes when someone compliments the
child. To break that touch the child.
Basic life support (BLS)-if a patient is unconscious, pulseless: First verify unresponsiveness (say are you alright…).
Call help/911 to come with an AED. Then assess pulse and respirations while checking carotid pulse and check
patients breathing for no more 10 seconds. If you do not feel a pulse-do CPR (at a rate of100-120. Depth
2-2.5inches).
Total parenteral nutrition (TPN)- is a method of feeding that bypasses the gastrointestinal tract. Interventions:
monitor blood glucose every 6 hours-it should be 140-180. It is given via electronic infusion pump. Use filters to
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remove particulate and microorganisms. TPN is given via central line. Complication: hyperglycemia (so if have
symptoms of excessive thirst, increase urination, abdominal pain, headache, fatigue, blurred vision.)- so first
check blood glucose then slow the infusion rate, give subQ insulin.

Beers criteria- is a list that classifies potential harmful drug for elderly. Example: Sulfonylureas (glyburide)-try
different medications. Aspirin- no more 325mg/day. Antipsychotics-do not give, instead try helping the symptoms.

Postoperative cognitive dysfunction (POCD)- after surgery, some patient may experience POCD. This includes
memory impairment and impaired concentration/language/social/. They may also cry easily, tear up. Risk factors:
pre-existing cognitive deficits, longer time in operating room, operative complication. Can occur days/weeks after
surgery. After healing occurred symptoms resolve. Can be permanent.

Float nurses- they should be assigned to patients they are most familiar with (so if they from ICU, put them with
ICU like patient). Nurse should clarify duties to be performed/say what you are able to and not to do. Then nurse
should be given orientation and clarify what they are comfortable with.

ICU- in ICU important to maintain normal sleep wake cycle so: dim lights at night, quiet uninterrupted periods of
sleep when possible. Do interventions and activities during the day. Frequent reorient patient, as necessary. Open
shades in morning. Excessive stimuli and lack of sleep can cause delirium. To prevent disorientation and delirium
in the ICU, it is important to develop a plan of care that includes maintaining the client's normal circadian rhythm.

In A Disaster Scenario- do the most good for the most people with the available resources. So, the patients that
are most salvageable go first

Menopause- occurs at age 50-52ish. It causes decrease in estrogen leading to osteoblast and cardioprotective
effect. So postmenopausal women at risk: osteoporosis, and coronary artery disease. Other post menopause
changes: weight gain, sleep disturbances, fat redistribution, vaginal atrophy. Interventions: consume dietary
calcium (green, leafy vegetables, dairy). Do weight bearing exercises. Monitor cholesterol closely. Seek dietitian
assistance and maintain low calorie diet rich in fruits and vegetables (because of weight gain). Seek support to
cope with emotional symptoms

Sentinel event-are unanticipated event in health care that causes death/serious physical injury.

Jehovah’s witness-they do not accept blood transfusions in any form (so they will not take red blood cells, white
blood cell, platelets or plasma). To prevent shock when blood loss give non blood volume expanders like NS, LR,
dextran, hetastarch. Recombinant human erythropoietin (epoetin alfa) and IV iron is accepted by most Jehovah
witness and they stimulate RBC production

Pulse ox-is a noninvasive way to measure oxygen saturation. It can be attached to finger, toe, earlobe, nose, and
forehead. Normal level is 95-100. It can be falsely low: dark fingernail polish or artificial nails, hypotension/low
cardiac output (heart failure), vasoconstriction (hypothermia, vasopressor medications), peripheral artery disease,
carbon monoxide, smoke inhalation, and excessive movement.

Carbon monoxide- has a stronger bind to oxygen than hemoglobin does so it displaces hemoglobin and causes
hypoxia that is not reflected by pulse ox. It is produced by burning fuel in a poorly ventilated setting, or from
smoke inhalation from fire or water heater, coal or wood stoves, fireplaces, engine exhaust. Symptoms:
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nonspecific. Ask patient if similar symptoms to others at home, or if there is fuel burning heating/cooking
appliances. The risk increases when closed room so like in the winter. Diagnosed: carboxyhemoglobin test. Priority
action: give 100% oxygen by nonrebreather at 15L/min

Cyanide poisoning- main symptom: bitter almond smell from patient breath

Epistaxis/nosebleed- Causes: dry mucous membrane, local injury (pick nose), insertion foreign body, rhinitis.
Interventions: direct continuous pressure for 10 minutes, cold broth/ice pack on bridge of nose. Quiet/calm,
position upright with head tilted forward. If it does not go away-cauterization, nasal packing (gauze, nasal
tampon, balloon catheter).

Palliative and hospice

• The main difference between palliative care and hospice is that clients receiving palliative care can
receive concurrent curative treatment. Hospice care is only started once the client decides to forego
curative treatment.

Dying- nurses caring for dying patients should do coping skills to avoid compassion fatigue. They should attend
memorial service, take off time from work, support systems, rest, exercise, nutrition. Nurses should provide
psychosocial support to family. Give them factual, open, honest communication with empathy-tell them what is
anticipated to happen and offer self (like say the time is near, I can stay with you). Sit with the family if they want.
Do not taper doses or look at respiratory status.

• Postmortem care- give parents time to talk, cuddle, dress child. Do not do postmortem care: if religious
reasons, family wants to, state law-like with non-natural/traumatic/criminal deaths (ex. suicide). Do not
have to have the family present to do
• Postmortem care- wash and straighten the body, change linen, place pad under perineum to absorb
stool/urine. Place pillow under head to prevent blood from pooling. Place dentures in mouth and close
mouth. Gently close eyes. Remove tubes, lines, dressings (unless autopsy). After family leaves, take
patient to morgue or notify funeral home to arrange transportation (all can be done by UAP).
• For every patient’s death (like brain death) - the organ procurement services are notified. Cardiac support
(dopamine, epinephrine) and respiratory support (ventilator) continue as organ discussion is discussed.
Life support is withdrawn if patient is not a candidate or if the family does not want.

Orthostatic hypotension-the patient is at risk for falls. You want to measure blood pressure and heart rate sitting,
supine, and standing. Maintain each position for 2 minutes then take vitals. If any position change to a decrease in
systolic pressure more than 20 or diastolic more than 10, and/or increased pulse ≥20/min from supine values, the
nurse should discontinue assessment, place the client in a recumbent position, and notify the health care
provider

Falls- Patients at risk: uses assistive devices, orthostatic, taking sedatives or antiparkinsonian medications, age 65
and up, osteoporosis, IV therapy, wet floors, room with furniture, improper toilet seat/bed height, orthostatic
hypotension. Prevention: exercise regularly. Well lit, clutter free home, nightlights, remove or secure rugs to the
floor with double sided tape. Grab bars for bathroom and nonskid mats. Wear shoes or slippers with nonskid
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shoes. Review medications and side effects with doctor. Get regular vision exams. Wear electronic fall alert
devices.

Heat exhaustion-from prolonged exposure to excessive heat. Symptoms: elevated body temperature
(hyperthermia), electrolyte imbalance, dizziness, weakness, fatigue, sweating, flushing, tachycardia, muscle
cramping. Interventions: move patient to a cooler temperature and give cool sports drink or electrolyte drinks like
Gatorade or water. Priority: lower body temperature to prevent heat stroke (mental status changes, organ
damage). If that does not work-place ice on axilla and groin and get further medical help.

Infertility- is the failure to conceive after 12 months (for a woman below 35 years) and 6 months (for a woman
above 35 years old). Causes: above 35 years, hormone dysfunction (PCIS), STI (Chlamydia), recurrent infection
(PID), endometriosis

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