INDEX

1. CARDIOVASCULAR SYSTEM 02

2. RESPIRATORY SYSTEM 29

3. GASTRO INTESTINAL SYSTEM 47

4. ENDOCRINE SYSTEM 64

5. GENITO URINARY SYSTEM 76

6. NERVOUS SYSTEM 83

7. MUSCULO SKELETAL SYSTEM 97

8. EYE AND EAR 104

9. DERMATOLOGY 109

10.PAEDIATRIC NURSING 115

11.PSYCHIATRIC NURSING 173

12.COMMUNITY HEALTH NURSING 195

13.ADMINISTRATION & 198

MANAGEMENT

14.RESEARCH AND STATISTICS 201

15.OBG 205

1
MEDICAL SURGICAL NURSING
CARDIO VASCULAR SYSTEM

Heart is situated on the right side of the thorasic cavity . if it present in the left side of the body is known as
dextrocardia

3 layers – pericardium ( outer) , mayocardium ( middle ), endo cardium( inner ) . normal pericardial fluid in
pericardium 10 -30 ml

Left ventricle is the largest chamber

Conduction system – SA node( is producing 60-100 impulses/mt. SA node producing impulses is the basic
of our heart beat ), AV node ( if SA node is fail toproduce impulses then the AV node is producing 40-60
impulss/mt ), bundle of his, purkinje fibres ( 20-40 impulses/mt )

AORTA – is supplying oxygenated blood to entire body . the branches are

✔ Ascending aorta – is supplying oxygenated blood to mayocardialcell through coronary artery

✔ Arch of aorta – is supplying oxygenated blood to brain and upper extrimities
✔ Desending aorta – is supplying blood to abdominal organs and lower extrimities
Coronary artery branches

✔ Right coronary artery – is supplying to right atrium & ventricles, inferior portion of left ventricle,
posterior septal wall & SA node and AV node
✔ Left coronary artery
● Left anterior desending - anterior wall of left ventricle, anterior ventricular septum,apex of
the left ventricle
● Circumflex artery - ls supplying blood to left atrium, lateral and posterior surface of the left
ventricle
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HEART SOUNDS

⮚ S1: produced by closure of atrio ventricular valves (ventricular depolarization).

Auscultation at the apex of heart, patient position supine.( because clearly audible and big sound )

⮚ S2: produced by closure of semi lunar valves (ventricular repolarisation)

Auscultation at the Erbs point, patient position supine

⮚ S3 physiological heard in newborn, pregnancy and athletes

GALLOP
⮚ S3 gallop (ventricular gallop) cause systolic heart failure
Auscultation apex, pt position left lateral ( because is not clearly audible in supine position ).
⮚ S4 gallop (atrial gallop) cause diastolic heart failure.
Auscultation apex, patient position left lateral.
HEART MURMURS

⮚ SYSTOLIC MURMER - causes; aortic stenosis, pulmonic stenosis, mitral regurgitation ( in mitral
regurgitation murmer radiating to the left axiala ), tricuspid regurgitation, ASD(systolic ejection
murmur), VSD ( holosystolic murmur)

⮚ DIASTOLIC MURMUR: Causes: aortic and pulmonic regurgitation mitral and tricuspid stenosis

⮚ CONTINUOUS MURMUR : causes PDA (machinery murmur or Gibson murmur ) , coarctation of

aorta

⮚ BRUIT AND THRILL SOUND : Bruit is vascular murmur . Causes : PVD, renal artert stenosis,
carotid artery stenosis, aneurysm, COA, atherosclerosis, AV fistula, thrill is tremor or vibration felt
on palpation AV fistula

CARDIAC OUTPUT

⮚ VOLUME OF BLOOD EJECTED FROM Ventricle per minute.

⮚ Normal is: 5 litre /minute

STROKE VOLUME
⮚ Is the volume of blood pumped from the ventricle per beat.
⮚ Normal: 70 ml per beat
⮚ Stroke volume = EDV - ESV volume of blood pumped by the left or right (ESV = 140ml, EDV =70
ml)

PRELOAD OR EDV & AFTER LOAD

⮚ Preload is the end diastolic volume that stretches the right and left ventricle of the heart to its greatest
dimension under variable physiology dimension.
⮚ After load is the pressure against which the heart must work to eject blood during systole

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EJECTION FRACTION & CARDIAC RESERVE

⮚ Ejection fraction is the percentage of blood ejected from a chamber with each contraction
⮚ Normal: 50% to 65%
⮚ Cardiac reserve: is the difference between the rate at which the heart pumps blood and its maximum
capacity for pumping blood at any given time
⮚ Normal 25 to 30 L per mit

CVP ( CENTRAL VENOUS PRESSURE )

⮚ Cvp is pressure in the superior venae cavae or (right atrial pressure)
⮚ Normal 3-8 mmhg or 4-12 cmh2o
⮚ CVP insertion position – supine or slight trendelenberg position
⮚ CVP monitoring position semifowlers position
⮚ During CVP monitoring normally the fluid level at the phlebostatic accesses
⮚ During CVPmonitoring if air embolism occur place the client left lateral and trendelenberg position
⮚ During CVP monitoring the fluid level should be at phlebostatic access.

PULSE PRESSURE
⮚ Difference between systolic and diastolic blood pressure.
⮚ Normal value 120 – 80 = 40 mm of hg

PULSE DEFICIT
⮚ is the difference between apical pulse and peripheral pulse. ( always epical pulse is higher than
peripheral pulse)

PULSE PARADOXUS
⮚ Is an abnormally large decrease in stroke volume, systolic bp ( minimum less than 10 mmofhg ) and
pulse wave amplitude during inspiration
⮚ Causes- COPD, Asthma, Cardiac taponade, Croup syndrome

CARDIAC TAMPONIDE
⮚ Increased fluid collection in pericardial space. ( C/M is BECKS TRIAD {hypotension,jvd,muffled
heart sound } )

MAP ( mean atrial pressure )

⮚ Is the average blood pressure in an individual during a cardiac cycle.
⮚ Normal 70 -100 mm of hg
⮚ Mean Arterial Pressure
⮚ MAP= (2 X diastolic pressure) + (systolic pressure)/3
⮚ MAP of about 60 is necessary to perfuse coronary arteries, brain, kidneys.

CHEST LEADS
Elements of chest leads
Lead Positive electrode placement View of heart
V1 4th intercostal space to right sternum Septum
V2 4th intercostal space to left sternum Septum
V3 Directly between V2 and V4 Anterior
V4 5th intercostal space at left midclavicular line Anterior
V5 Level with V4 at left anterior axillary line Lateral
V6 Level with V5 at left midaxillary line lateral

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I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral

View of heart Leads

Inferior II, III, aVF
Lateral I,aVL, V5, V6
Anterior V3, V4
Septal V1,V2
AUSCULTATION POINT
⮚ Aortic area – second intercostals space at the right border of sternum
⮚ Pulmonic area – second intercostals space at the left border of the sternum
⮚ Erbs point – left third intercostals space at left sterna border
⮚ Tricuspid valve ( to the right ventricle ) – left fourth,fifth intercostals spaceand lower left
sterna border
⮚ Mitral valve (to left ventricle ) – left 5th intercostals space at the left midclavicular line

BASIC LIFE SUPPORT

⮚ It is a level of medical care which is used for victims of life threatening illness or injuries until they
can be given full medical care at a hospital . it can be given any one
⮚ STEPS
❖ Seen safety
Shout for help
Check the responsiveness of the client by shouting or shaking
No response - call for help
To get an automatic external defibrillator
❖ Monitor pulse ( time 5- 10 second only ) - No pulse start CPR
❖ Site of compression lower 2/3rd of sternum toward nipple line

FEATURES INFANT CHILD ADULT

Pulse site Brachial Carotid or femoral Carotid
Compression rate 100-120 100-120 100-120
Compression ventilation 30:2 30:2 30:2
ratio one rescuer
Two rescuers 15:2 15:2 30:2
Depth of compression 4cm 5cm Must be 5cm
ADVANCED CARDIAC LIFE SUPPORT

⮚ Inside the hospital if client undergone cardiac arrest the professional team is treating the client with
the help of an medicine.
⮚ Common difference in BLS & ACLS -drug adrenaline and aminodarone is using in ACLS
⮚ Common steps- CPR, airway, defibrillation
Waveform Capnography

● Non invasive measurement of graphical display of end tidal C02(ETC02)

● Most reliable method for conforming placement and monitoring dislodgement
● Quality monitoring of CPR
● Post resuscitation goal is 35-40 MM HG

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CHOCKING

⮚ It is the mechanical obstruction at the flow of air from the environment in to the lungs. Chocking
prevents breathing and can be partial or complete.
⮚ Adult chocking
✔ C/M the person tightly hold the neck
✔ Management – first ask the client are you chocking
✔ Followed by Heimlich maneuver ( abdominal thrust )
✔ Abdominal thrust is contra indicated in pregnancy and post partum women,abdominal
surgery – in this perform chest thrust and instruct the client to forcefully cough.
⮚ Infant chocking
✔ Place the infant on prone position on your left arm and give five back blows then chest thrust
HYPERTENSION

Definition of blood pressure: blood pressure is pressure exerted by blood on walls of arteries.
Hypertension: blood pressure more than 140/90 mm of hg.
Blood pressure=CO × TPVR (total pulmonary vascular resistance )
Reason for false high bp – cuff is small & rapid deflation
Reason for false low bp – cuff is large
Causes of hypertension

● Vasoconstriction, old age, obesity, smoking, alcoholism, black colour

● 1- primary hypertension (90- 95%)- essential hypertension
● 2- secondary hypertension (5-10%)- renal disease

Blood pressure Systolic(upper) Diastolic(lower)

Normal Under 120 Under 80
Prehypertension 120-139 80-89
Hypertension (stage 1) 140-159 90-99
Hypertension (stage 2) Above 160 Above 100
Hypertensive crisis Above 180 Above 110

⮚ CLINICAL FEATURES
● Early morning Headache
● Vertigo
● Tinnitus
● Blurring of vision

⮚ DIAGNOSTIC EVALUATION
● ECH – LVH is present
● Monitor the BP at different position

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MANAGEMENT OF HYPERTENSION

● Diet low sodium ( it will help to decrease pre load ), low saturated fat, high potassium ( blood vessel
is dilated & sodium is excreting) , high soluble fiber
● Identify the cause and treat them
● Exercise – aerobic exercise
● For immediate reduction of BP administer- NTG, AMINODEPINE, SODIUM NITRO-PRUSIDE
ACE INHIBITOR (enlapril)

● Use: LVF, hypertension, HTN in dm patient, MI .

● Mechanism of action - reduce blood volume (preload). vasodilatation (afterload)
● Drugs; enalapril, captopril.
● Sid effects; hypotension, cough, hyperkalemia, headache, fatigue, agranulocytosis,
● Contraindication; - pregnancy, renal stenosis
ALPHA BLOCKERS

● Use;- HTN, BPH, Raynaud’s disease , pheochromocytoma, CHF.

● Drugs- (trazodone, alfuzosin, doxazosin)
● Carvedilol labetalol (both alpha and beta blocker)
● Side effect (depression, weakness, fatigue, dry mouth, dizziness, hypotension, tachycardia
BETA BLOCKERS (PROPANOLOL, ATENOLOL)

● Uses; - hypertension , arrhythmia, MI , glaucoma, theophylline overdose, portal hypertension,

hyperthyroidism
● MOA - ; sympathetic blocker (blocks the release of epinephrine and norepinephrine)
● Side effects; nausea diarrhea, bronchospasm, hypotension, bradycardia, heart block, sexual
dysfunction, mask hypoglycemia, hyperkalemia,
● Contraindication; - asthma.
● Glucagon is used to treat overdose.
CALCIUM CHANNEL BLOCKERS

● MoDE OF ACTION -; smooth muscle relaxation dilates artery.

● Reduce force of contraction, reduce SA nodal rate.
● Uses; ht,, angina(nocturnal).
● Side effects; constipation, dizziness, headache, hypotension, tachy or brady cardia
● Avoid with beta blocker ,Amlodipine, Nifedipine
DIURETICS

❖ MODE OF ACTION - Increases urine output >reduces blood volume> reduces preload> reduces
cardiac output >reduces systolic blood pressure.

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LOOP DIURETICS

● Action site ascending loop of Henley.

● Used in edema in CKD, CHF, pulmonary edema.
● Inhibit sodium chloride, calcium, potassium reabsorption.
● Side effects; hypernatremia, hypokalemia hypotension, hyperuricemia, hyperglycemia, alkalosis,
ototoxicity, hypocalcemia.
● Examples; furosemide 40 mg, torsemide 20 mg
POTASSIUM SPARING DIURETIC

● Uses: CHF , hypertension, ascites.

● Drugs: amyloid, spironolactone
● Side effect: hyperkalemia, hypernatremia, hypotension, headache, metabolic acidosis, thirst.
● Action site; collecting duct, DCT
VASODILATOR

● MODE OF ACTION : dilate veins reduces preload, dilates the artery reduce afterload.
● Use; HTN , angina.
● Side effects; chest pain, palpitation, headache, nausea dizziness, flushing, hypotension tachycardia.
● Interaction; sildenafil (Viagra)
VASODILATORS CLASSIFICATION

● VENOUS: nitrates, molsidomine

● Mixed: alpha adrenergic blockers, ACEI, angiotensin II inhibitors, K+ channel activators,
nitroprusside
● ARTERIAL: minoxidil, Hydralazine
COMPLICATION OF HYPERTENSION

IMMEDIATE LONG TERM

Hypertensive crisis Retinopathy
(acute life Nephropathy
threatening Neuropathy
condition. D.BP CAD
more than 110

HYPOTENSION
⮚ BP less than 90/60 mm of hg
⮚ CLINICAL FEATURES
● Dizziness
● Blurred vision
● Fatigue
● Weakness
● Fainting

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MANAGEMENT

● Position: supine with foot end elevated.

● Iv fluids isotonic (NS or RL).
● Drugs: dopamine, dobutamine, epinephrine.
● Crystalloid- vs- colloids

✔ Crystalloids: are solutions of salt and water with variable electrolyte composition and contain
no protein or colloids
✔ Colloids: contain larger insoluble molecules, which act to retain existing fluid and promote
increase in blood volume

TYPES OF IV FLUIDS
1. CRYSTALLOIDS
● Isotonic
o 0.9 % sodium chloride (NS)
o Lactate ringers
o Dextrose 5% in water (D5W)
● Hypotonic
o 0.45% sodium chloride
● Hypertonic
o 5% dextrose in NS
o 5% dextrose in lactated ringers
o 5% dextrose in 0.45% ½ NS
o 10% dextrose in water
2. COLLOIDS (plasma expanders)
● Albumin
● Plasma protein fraction
● Dextran,Hetastarch
CRYSTALLOID VS COLLOIDS

Crystalloids Colloids
Low molecular weight high molecular weight
Iso/hypo/hypertonic hypertonic
Increase hydrostatic pressure increase oncotic pressure
Expands interstitial volume expands plasma volume
Time ½-30 minutes time ½-2 hrs
Replacement ratio- 3:1 replacement ratio 1:1
Allergic reaction- rare allergic reaction common
Cheap expensive

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INFLAMATORY DISOREDERS OF HEART

PERICARDITIS

⮚ Inflammation of the pericardium ( outer layer of the heart ) . inflammatory process thickening of the
pericardium, constrict the heart causing compression
⮚ Cause
✔ Virus – coxsakie virus A & B , HIV
✔ Bacteria – pneumococci, strepto cocci, staphylococci
✔ Fungus – histoplasma
✔ Toxoplasmosis infection – micrositic parasitic infection. Carrier is cat faces
✔ Uremia, neoplasm, trauma
✔ As an auto immune response
✔ Hypersensitivity
o Acute pericarditis – may occur within the initial 48 – 72 hours after am MI
o Post mayo cardial infraction syndrome / dresslers syndrome – it is
characterised by pericarditis with effusion and fever tht develops 4 – 6 weeks
after MI
o LYME disease - for detail refer integumentary disorder
⮚ CLINICAL FEATURES
✔ Left sub sternal crushing ,squeezing pain radiating to the neck , jaw, left shoulder, and back
✔ Pain increases in supine position and relieved by sitting and leaning forward
✔ Pain intensity is increased during respiration, coughing, supine position
✔ Pericardial friction rub ( scratchy high pitched sound ) fever & chills
✔ Increase WBC, ST Segment elevation
✔ Atrial fibrillation is common
⮚ MANAGEMENT
✔ High fowlers or sitting upright position
✔ Drug- analgesics. NSAID, corticosteroid, diuretcs
✔ Check blood culture to identify the organism
✔ S/M pericardiectomy
⮚ COMPLICATION
✔ Cardiac tamponade – excessive accumulation of pericardial fluid in the pericardium
o C/ M – becks traid ( hypotension with narrow pulse pressure, jugular vein
distension, muffled heart sound )
o Management – peri cardiosynthesis
✔ Pericardial effusion – moderate accumulation pericardial fluid in pericardial sac C/M –
hiccups due to phrenic nerve compression
✔ Pulsus paradoxus
✔ Decrease cardiac output

ENDO CARDITIS
⮚ Inflammation of the endocardium ( inner lining of the heart )
⮚ CAUSE
✔ Group A- beta haemolytic streptococci ( always first priority )
✔ Staphylococci
✔ Valvular disorder
✔ Dental procedures (H/O 3-6 month before )
✔ IV drug abusers / lack of aseptic technique during IV therapy
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 ⮚ PATHOPHYSIOLOGY
✔ Vegetation formation ( right side vegetation can cause pulmonary embolism. Left side
vegetation can cause – CAD, stroke , gangrene & cellulites in the extremities, liver & kidney
injury )
⮚ CLINICAL FEATURES ( cross check the picture from net )
✔ Petechiae or echmosis
✔ Splinter haemorrhage
✔ Oslers node – painful, tender, red colour pea shape lesion found on finger tips or toes
✔ Janeways lesion – flat , painless, small red spot may be found on the palms and soles
✔ Roths spot – fundoscopic examination may reveal hemorrhagic retinal lesion
✔ Fever, fatigue, clubbing of finger.
⮚ D/E - increased – WBC,ESR,CRP
Positive blood culture

⮚ MANAGEMENT
✔ Bed Rest to prevent cardiac complication
✔ Anti embolism stocking
✔ Antibiotics
✔ Maintain aseptic technique
✔ Encourage oral hygiene
✔ Take medication at correct time

SHOCK
● Shock is a systemic state of low tissue of perfusion which is inadequate for normal cellular
respiration
⮚ COMMON FEATURES OF SHOCK
● Initially tachycardia followed by bradycardia
● Hypotension
● Poor peripheral pulse
● Extremities clammy and cold
● Oliguria
● Dyspnoea
● Altered LOC
● Pedal oedema
● In septic shock additionally fever present
● In anaphylactic shock – rashes, swelling, wheezing.

TYPES OF SHOCK

⮚ CARDIOGENIC SHOCK ANAPHYLATIC SHOCK

● Limited iv fluid (ns) ● It is a serious allergic reaction
● Inotropic drug dobutamine ● Causes (bees sting, medication,
● O2 administration latex, food)
● Heart transplantation ● Management
● Remove sting
● Epinephrine (IM), Steroids
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 ⮚ HYPOVOLEMIC SHOCK NEUROGENIC SHOCK
● Causes (bleeding, vomiting, ● Causes (spinal cord injury above t6)
diarrhea) ● Loss of sympathetic tone
● Management ● Management
● Position supine with leg elevated ● Dopamine
● Iv fluid (ns) or RL ● Vasopressin
● Vasopressin ● Atropine
● Blood
● Colloid
SEPTIC SHOCK Priority Nursing diagnosis
● Cause (appendicitis, pneumonia,
diverticulitis, meningitis) Ineffective peripheral tissue perfusion
● Management
● Iv fluid
● Broad spectrum antibiotics iv
● Culture specific antibiotics iv
● Source control, Vasopressin

PACEMAKER
⮚ SA node is the pace maker of the heart is producing 60-100 impulses /minute
⮚ Client education after pacemaker insertion
✔ Teach the sign and symptoms of pace maker failure
✔ Hiccups, swelling of ankles, dizziness, weakness, fatigue, chest pain, dyspnoea
✔ Monitor any infection – redness, swelling, discharge
✔ Monitor pulse & BP on the opposite side of the pacemaker
✔ Wear loose cloth & use mobile phone on the opposite side of the pacemaker

✔ THINGS CONTRAINDICATED
● MRI
● Tens
● Electric trimmer
● Radiation
● Metal detector
● Anti-theft device
● Contact sports, electric mixer
COMPLICATION

● Hemothorax, Pneumothorax, Cardiac perforation, Dislodgment

VALVULAR DISORDER
⮚ Three problems occur in to the valve-
⮚ atresia, ( absence of opening )
⮚ stenosis, ( narrowing of the valve )
⮚ Regurgitation ( back flow )

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 Heart right side valves Heart left side valves
⮚ Tricuspid valve ⮚ Mitral valve
⮚ Pulmonic semi lunar valve ⮚ Aortic semi lunar valve

CLINICAL FEATURES

● Right side valvular problems that can cause right side heart failure
● Left side valvular problems that can cause left side heart failure
D/E

● 2D ECHO
MANAGEMENT

✔ Balloon valvulo plasty

✔ Commissurotomy or valvotomy
✔ Valve replacement
⮚ Mechanical prosthetic valve
⮚ Bio prosthetic valve
✔ Homograft ( from human cadever donor )
✔ Xeno graft ( from animals )
● Bovine ( from cow )
● Porcine ( from pig )
✔ Pre operative intervention
⮚ Consent
⮚ With held medicine – heparin , digoxin (12 hour prior), diuretics
⮚ Administer potassium suppliments
✔ Post operative intervention
⮚ Mechanical valve replacement done. Life long the client should take anti coagulant example
– warfarin and the client should avoid vitamin K food.
⮚ If biological valve replacement done take immune suppressants to prevent rejection.
⮚ Initially weakness is common
⮚ Maintain good oral hygiene with soft tooth brush
⮚ Mechanical valve – avoid MRI
⮚ Use mobile phone on the right side of the body
⮚ Avoid driving for several months
⮚ If prosthetic valve was inserted a soft audible, clicking sound may be heard its normal.

CONGESTIVE HEART FAILURE

● Congestive heart failure is a inability or failure of the heart to adequately meet the needs of organs
and tissue for oxygen and nutrients .CHF is not a diseae it is the complication of some another
cardiac disorder.
● TYPES / Clinical manifestation
RIGHT SIDE HEART FAILURE LEFT SIDE HEART FAILURE
● Venous congestion features ● Pulmonary congestion
● It will affect to the systemic circulation ● It will affect to pulmonic circulation

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 ● Jugular vein distension ● Initially dyspnoea
● Kussmaul sign (high JVP during ● Tachycardia, tachypnoea
inspiration), ● dyspnoea, orthopnoea
● hepatojugular reflux, ● PND,
● weight gain, edema ● haemoptysis, dry cough
● Abdominal distension ● pulse alternance
● fatigue, ascites, hepatomegaly, ● clubbing of finger (Hippocratic
anorexia, nocturia. finger)
● Initially hypertension F/BY ● rales (fine crackles), oliguria,
hypotension ● S3 or S4, high PCWP (normal 2-15
MM OF HG)
● Pedal edema
DIAGNOSIS

● BNP (brain natriuretic peptide) more than(100pg/ml). ANP increased ( nomal less than 27
● ECHO (EF less than 40%).
MANAGEMENT

● Position high fowler’s with leg dependent, sleeping semi fowlers.

● Diet (low sodium, low saturated fat)
● Drugs to reduce preload (diuretics, NTG).
● Drugs to reduce afterload (ACE inhibitor, calcium channel blocker).
● Drugs to reduce workload (beta blocker)

CARDIAC GLYCOSIDES
● Use for systolic heart failure, arrhythmia.
● Drug digoxin.
● Moa: positive inotrope, negative chronotropic, negative dromotropic.
● Therapeutic range 0.5-2 ng/ml.

● NURSING INTERVENTION DURING DIGOXIN THERAPHY

● Monitor potassium daily – hypokalemia can cause digoxin toxiciyty
● Administer potassium rich diet along with digoxin example- banana, orange etc.
● Or potassium sparing diuretics( spironolactone ) along with digoxin . but this can cause
hyperkalemia.
● Before each dose monitor apical pulse , if bradycardia withheld the medicine and report to the
doctor
● Monitor toxicity features

ADULT CHILD
● Features Anorexia, nausea vomiting, ● Poor feeding
diarrhoea ● Brady cardia
● fatigue, abdominal pain,
● delirium, ● Child ( less than 70 )
● halo yellow or green, hypotension, ● Infant ( less than 90 )
● bradycardia ( less than 60 ) ● Headache
● heart block, PVC, VT, VF. ● vomiting
● ECG changes ST Depression, T
inversion, PR prolongation.
● CAUSE OF TOXICITY: hypokalemia, hypomagnesaemia, hypocalcemia, renal impairment
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MANAGEMENT OF DIGOXIN TOXICITY.

● Digoxin immune tab or digitab, charcoal.

● Atropine
● Cardiac pacing
● Mgso4 , lidocaine

CORONARY ARTERY DISEASE

⮚ Coronary artery is the branch of ascending aorta is supplying oxygenated blood itself in to the heart

⮚ CAUSE – ATHEROSCLEROSIS ( plague – platelet + fibrinogen )

⮚ RISK FACTORS

MODIFYING RISK FACTORS NON- MODIFYING RISK FACTORS

● Smoking & alcoholism ● Age ( high in old age )
● DM & HTN ● Sex ( high in males )
● Stress ● Hereditary
● Obesity & lack of exercise ● Colour ( high in blacks)
● Hyperlipedemia

1st stage – IHD , 2ND stage - angina pectoris, 3rd - stage – MI

⮚ ISHEMIC HEART DISEASE

● Lack of blood circulation in to the myocardial cell
● C/M – palpitation, syncope, asymptomatic chest pain, dyspnoea
● D/E – ECG – ST segment depression & T- wave depression
● MANAGEMENT
● Identify the risk factor and eliminate them
● Diet – low calorie, low sodium, low cholesterol, low fat, & fibre rich diet for life long
● Drug of choice – NTG ( vasodilator action ) – side effect is hypotension, chest pain,
head ache.
● Administer calcium channel blockers

⮚ ANGINA PECTORIS
● Chest pain or pressure due to myocardial ischemia.
● Word meaning (strangling feeling in the chest).
● Due to high o2 demand and low supply.
● Pain triggering factors (physical mental stress, high altitude, cold exposure).
● Clinical features: chest pain
o Left sub sternal crushing, squeezing pain radiating to the neck ,jaw, left shoulder and
back
o Pain intensity is not increased or decreased during respiration
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 o Time - 15 sec to 15 minute.
o Pain is relieved by rest or NTG
o nausea, dyspnoea, anxiety, sweating, palpitation, dizziness, tachycardia.
o HTN
CLASSIFICATION

● Stable or exertion angina- relieved by rest or NTG

● Unstable or crescendo angina - mild to moderate pain . rhythm change. Pain is not relieved by
NTG
● Cardiac syndrome x or micro vascular angina – obstruction in small coronary artery . especially
occur in females
● Silent angina
● Nocturnal – night time angina
● variant or prince metals / vasospastic angina – it result from coronary artery spasm. Resting time
pain severe. And next day same time pain occur
● refractory angina – not responding to usual treatment. Treat ment option heart transplantation
DIAGNOSTIC TEST

● ECG (ST depression inversion). nocturnal (ST elevation t inversion).

● Monitor cardiac enzyme – all cardiac enzyme is normal
MANAGEMENT

● Assess the characteristics of pain

● Rest in a fowler’s position.
● 3 L oxygen via nasal canulla
● Drug NTG ( vasodilatation ) – total 3 tablet every five minute interval ( if pain is not relieved then
administer morphine )
● Route (sublingual, oral buccal, spray, patches( apply on non hairy area), iv).
● s/e- orthostatic hypotension
● Calcium channel blocker
● Beta blocker
● Anticoagulant.
HEPARIN

● Route (iv & sq)

● Half-life 1.5 hrs
● Lab value to monitor (APTT).
● APTT normal 20-39 sec (1.5 to 2.5)
● Antidote is protamine sulphate
● With held five days before surgery
● Side effects; thrombocytopenia, hyperkalemia, alopecia, osteoporosis, bleeding.
WARFARIN

● Coumadin
● Route; oral
● Antidote; vitamin. k
● Monitor lab value (PT, INR ) normal 9.5 -12 sec (2 -3.5 sec )
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 ● With held 3 days before surgery
● Contraindicated in (pregnancy)
ASPRIN

● Acetylsalicylic acid.
● Routes (oral, rectal, iv, im).
● With held 1 days before surgery
● Antidote (sodium bicarbonate, vitamin k, FFP, charcoal).
● Side effects: ulcer, bleeding, hyperuricemia, Reye’s syndrome, tinnitus, hyperkalemia, rashes,
headache, dizziness
● Contraindication (Reye’s syndrome,3rd trimester pregnancy)
CABG ( coronary artery bypass graft )

● Graft
● Most commonly using Great saphenous vein 80%
● LIMA ( left internal mammary artery )

MYOCARDIAL INFARCTION
⮚ Heart attack (blockage of coronary artery leads to death of heart muscles).
⮚ MI occurs when myocardial tissue is abruptly and severely deprived of oxygen
CLINICAL FEATURES

● Chest pain more than 15 minute nor relieved by rest or NTG.

● Pain is relieved by only morphine
● Pain mainly occur early morning
● Remaining pain character same as angina
● Chest tightness, pressure, squeezing, Levine’s sign ( ischemic chest pain )
● Tachycardia or bradycardia, palpitation, sweating nausea, vomiting, shortness of breath, headache,
hypertension or hypotension.
● Atypical mi in diabetes mellitus , elderly(delirium). Women (back pain, neck pain, shortness of
breath , indigestion).
OBVIOUS CHANGES PRESENT IN THE NECROTIC MAYO CARDIUM

✔ After MI first 6 hour there is no change

✔ After six hour area become swellen and blue ( wound healing first step inflammatory phase )
✔ After 48 hours grey in colour
✔ After 8-10 days – granulation tissue formation ( 2nd stage proliferative phase )
✔ After 2-3 month scar tissue formation ( 3rd stage maturation phase )

17
DIAGNOSIS

AWMI LAD V3 V4
PWMI RPD V7 V8 V9
IWMI RPD II,III,AVF
LWMI Left circumflex AVL, V5, V6
SMI LAD V1 V2
ECG

AWMI (v3 v4)

1) tall T within 1- 2 minute.
2)ST elevation (injury). 2-4 hrs - drug of choice streptokinase ( thrombolytic )
3) T inversion (ischemia) 8-12 hrs
4) q wave 1-2 day (necrosis)
CARDIAC ENZYMES ( all cardiac enzyme is elevated )

● Troponin (I,- most specific ), troponin T – most accurate

● CKMB
● Myoglobin
● LDH 1
● 2nd day WBC count is elevated due to inflammatory [rocess in the necrotic mayocardium
MANAGEMENT

⮚ MONA – 1. Morphine 2. Oxygen 3. NTG 4. Aspirin ( if the client is de-saturated give

priority for oxygen 3-4 L /mt via nasal canula)
⮚ Morphine
⮚ Action- opiod analgesics, it decreases myocardial demand for oxygen
⮚ Side effect of morphine - respiratory depression (mgnt- oxygen, encourage deep breathing and
coughing exercise).
⮚ Signs of overdose- alterd LOC, decrease BP, RR, SPO2, pin point pupils.
⮚ Antidote- Nalaxone
⮚ Clopidogrel (Plavix), Statins ( to decrease cholesterol in the blood and to prevent heart attack and
stroke), Ace inhibitor, Beta blockers
⮚ Stool softeners (Dulcolax)
⮚ Position semi fowler
● PCI – percutaneous coronary intervention
● Thrombolytic therapy - Uses (ST elevation mi, stroke, pulmonary embolism, dvt,)
Examples; streptokinase, alteplase, urokinase)
● Side effects; hypotension, nausea, bleeding, allergic reaction.
● Antidote; aminocarporic acid.
COMPLICATION OF CAD

Post MI complications

● Cardiac Arrhythmias
● pericarditis

18
 ● Congestive heart failure – right or left . but most of the time left ventricular failure is occur. Because
the majority branches of the coronary artery is supplying blood to the left ventricle.
● Pulmonary edema due to left side heart failure
● Cardiogenic shock
SURGICAL MANAGEMENT of CAD

⮚ Cardiac catheterisation
✔ Coronary angiogram ( Nsg intervention – ask sea food allergy, monitor serum
creatinine and nephro toxicity, with held metformin 48 hours prior for to prevent lactic
acidosis,when injecting die metallic taste occur i mouth ,before procedure monitor
peripheral pulse for post procedure comparison)
✔ Percutaneous trans luminal coronary angioplasty
✔ Laser assisted angioplasty
✔ Stent application
✔ Atherectomy
⮚ Coronary artery by pass graft
✔ Most commonly safenous vein is using or internal mammary artery
✔ Normal drain amount – 70-100 ml per hour
✔ Priority nursing diagnosis – impaired gas exchange & acute pain
✔ At the time of discharge teach the sign and symptoms of complication.

DEFIBRILLATION & CARDIOVERSION

● Defibrillation is the treatment for life threatening cardiac dysrhythmias.
● Defibrillation indication – VF , pulse less VT
● Cardio version aim to convert an arrhythmia back to sinus rhythm. ( indication all cardiac
dysrhythmias )

FEATURES CARDIOVERSION DEFIBRALATION

Timing Planned Emergency
Synchronization Synchronized Non synchronized
Joules 50-200j Biphasic - 120 -200 J
monophasic
1.200 J 2. 200-300J 3. 360J
Indication Atrial flutter, atrial fibrillation, SVT, VT without pulse VF
VT with pulse
Atrial fibrillation 200J(Monophasic)
120-200 J(Biphasic)
Atrial flutter 100J (M) 50-100 J (B)
Ventricular tachycardia with pulse 200
J(M), 100J (B)
Nursing intervention

✔ Be confirm that no one is touching to the patient or its surrounding.

✔ Apply paddles at correct place

19
ELECTRO CARDIO GRAM
⮚ ECG paper consist of 1500 small boxes and 300 large boxes
⮚ Horizontal line denoting time & vertical line denoting voltage

ECG COMPOSES OF
P – WAVE Arterial depolarisation 0.11 second
QRS – Ventricular depolarisation 0.12 second
COMPLEX
PR INTERVAL The time need for sinus node stimulation, 0.12 – 0.20
arterial depolarisation, conduction through second
AV node before ventricular depolarisation
T – WAVE Ventricular repolarisation
ST SEGMENT Early ventricular repolarization
QT – Total time need for ventricular contraction
INTERVAL and relaxation
PP – To determine arterial rhythm
INTERVAL
RR – To determine ventricular rhythm
INTERVAL
U – WAVE Repolarisation of purkinje fibers & papillary
muscles

ARRHYTHMIA OR DYSRHYTHMIA

SINUS BRADYCARDIA

● Heart beat is less than 60 beats per minute

● Causes
✔ vagal maneuver (ocular-cardiac reflex, Valsalva maneuver, mammalian diving reflex, carotid
sinus massage)
✔ Sleep, hypothermia, hypothyroidism, digitalis, beta blocker, calcium channel blocker,
adenosine, high ICP.
✔ Rectal temperature monitoring
20
 ● ECG CHANGE

PR interval & QRS

width are within
normal

● Management
● Oxygen administration
● Treat the exact cause
● Drug of choice (atropine) side effect – pupil dilation, all body secretion decreased
● Epinephrine

SINUS TACHYCARDIA

⮚ atrial and ventricular rate are 100- 180 beats per minute ( rhythm regular )
⮚ cause
✔ hyperthyroidism
✔ hyperthermia
✔ stress & tension
✔ pain
✔ exercise
⮚ ECG

PR interval & QRS

width are within
normal limits

⮚ Management
✔ Drug of choice beta blocker – propanalol
✔ Treat the exact cause

ATRIAL FLUTTER

● Atrial flutter occurs in the atrium and creates impulses at a regular rate between 240-340 beats /
minute
● Cause – CAD, HTN, Mitral valve disorder
● ECG

21
 Abnormal P WAVE
Name – saw tooth
ECG

MANAGEMENT

● Beta blocker
● Calcium channel blocker, adenosine 6 mg IV
● Cardio version
● RFA- radio frequency ablation
ATRIAL FIBRILLATION

● Heart is producing irregular 350 – 600 impulses per minute

● Rare condition.
● Complication clot formation.
● ECG

No definitive P wave can be

observed . only fibrillatory
waves before each QRS
complex

● MANAGEMENT
A(ANTICOAGULANT)
B(BETABLOCKR)
C(CALCIUM CHANNEL BLOCKER)
D(DIGOXIN)
E(ELECTRIC Cardio Version).
Aminodarone for to stabilize unstable rhythm to stable rhythm

SUPRA VENTRICULAR TACHYCARDIA

● Starts from atria or av node

● Rate 150-270
● Features; shortness of breath, palpitation,
● chest pain, tachycardia, dizziness, loc
● ECG

22
MANAGEMENT

● Adenosine
● Vagal maneuvers
● Beta blocker
● Cardio version
● RFA
● Amiodarone

PRE MATURE VENTRICULAR CONTRACTION

● Heart beat initiated by purkinje fibers.

● CAUSES – hypoxia, hypokalemia
TYPES

● BIGEMINY
● TRIGEMINY
● QUADRIGEMINY
● COUPLETS
● TRIPLETS
● ECG CHANGES

QRS Complex may be

unifocal or multi focal
P wave not visible
RR not measurable

23
MANAGEMENT

● BETABLOCKER
● CALCIUM CHANNEL BLOCKER
● MAGNESIUM SUPPLEMENT
● RFA – radio frequency ablation
● ICD – implantable cardioverter defibrillator

VENTRICULAR TACHYCARDIA

● Heart beat 140- 250 beats per minute

● CAUSES;
● VT can leads to cardiac arrest
● Types
Stable client Unstable client
✔ With pulse ✔ Without pulse
✔ No sign and symptoms of decrease ✔ There is a sign and symptoms of
cardiac out put decrease cardiac output
Management Management
✔ Aminodarone ✔ synchronised cardioversion or
✔ Lidocaine defibrillation
✔ Cardioversion ✔ ICD

● ECG
WIDE
QRS.complex,
Pwave not
visible ,
PR not
measurable

VENTRICULAR FIBRILLATION

● Impulses from many irritable foci in the ventricles fire in a totally disorganised manner
● VF is fatal if not successfully terminated within 3-5 minutes
● Cause – CAD

24
 ● CLIENT LACKS vitals and heart sound

ECG

MANAGEMENT ( order is important )

● DEFIBRILLATION
● CPR
● adrenaline
● AMIODARONE (CLASS III ANTIARRHYTHMIC DRUG)- DOSE 300 MG

HEART BLOCK
FIRST DEGREE AV BLOCK

⮚ Is a disease of the electrical conduction system in which pr intervals more than 0.20 seconds.
⮚ Cause (delay in conduction through av node)
SECOND DEGREE AV BLOCK

⮚ One or more atrial impulses fail to conduct to the ventricles.

⮚ Types
Type 1(Mobitz 1, Wenckebach).

Type 2(Mobitz 2, hay)

TYPE 1

● Block above AV
● Ecg progressive prolongation of PR and dropped qrs.
TYPE 2

● Problem below av node (his-purkinje system)

● Ecg constant PR missing of QRS
THIRD DEGREE AV BLOCK

● Impulses produced by SA node cannot propagate to ventricles (complete block).

● Ecg no relation between p wave and QRS complex

25
VASCULAR DISORDER

VENOUS DISORDER - VENOUS THROMBOSIS

TYPES

⮚ 1. PHLEBITIS - inflammation of the superficial vein due to IV line insertion

⮚ C/M - redness, swelling, pain , warm or cool area
⮚ MANAGEMENT
● Stop the transfusion
● Remove the canula ( re insert at the proximal area )
● Apply thombogel/ mgso4 dressing

⮚ 2. THROMBOPHLEBITIS – thrombus associated inflammation

⮚ 3. DVT
⮚ 4. PHLEBO THROMBUS – Thrombus without inflammation
✔ CAUSES
● Virchow’s triad ( venous stasis or prolonged immobility, venous disease
example varicose vein , hypercoagulability disorder )
✔ RISK FACTOR
● Smoking, lower limb fracture
● Polycythemia,
● Abdominal & orthopaedic surgery
● Use of oral contraceptive
● Pregnancy, obesity

✔ CLINICAL FEATURES
● Homans sign ( dorsiflexion of the foot indicate pain in calf muscles )
● pain, tenderness, swelling, warmth, redness, edema over the area.

✔ DIAGNOSIS
● D dimmer (fibrin degradation product),
● Venous ultrasound
● History collection
● physical examination

26
MANAGEMENT

PREVENTIVE MANAGEMENT COLLABORATIVE MANAGEMENT

● Early ambulation or exercise ● Bed rest
● Bed rest with elevate the extremity up ● Administer anticoagulants
to heart level ● Elevate the extremity above the level
● Use anti embolism stocking/TED of heart
HOSE / DVT PUMP ● Avoid massage
Note : the principle involved in above said ● Avoid knee gatch & leg crossing
intervention is helping for venous ● Thrombolytic – heparin F/BY warfarin
compression and increase venous return ● TPA within five days
thus will help to prevent clot formation ● Thrombectomy
● Inferior vena cava filter
● Injection . S/C enoxaparin
( LMWH )

✔ COMPLICATION
● Pulmonary embolism
● Chronic venous insufficiency

ANEURYSM
✔ Abnormal dilatation of arterial wall
✔ CAUSES- syphilis, HTN , hyperlipidemia, smoking, pregnancy, monckberg’s sclerosis. Most
common disease atherosclerosis
✔ Classification
● Fusiform – bilateral dilatation
● Secular – one side dilatation
● Aortic dissecting
● Pseudo aneurysm or false aneurysm

✔ FEATURES OF ABDOMINAL AORTIC ANEURYSM

● Pulsating abdominal mass sensation, abdominal pain, low back pain
● Bruits sound ( during auscultation ),
● If ruptured rapture (hypotension tachycardia, loc, gray turner’s sign & features of shock ).
✔ FEATURES OF TAA
● Hoarseness, chest pain, dyspnoea.
✔ DIAGNOSTIC EVALUATION
● USG
● MRI

27
 ✔ MANAGEMENT – ANTI HYPERTENSIVE,
✔ S/M – aortic aneurysm resection surgery

ARTERIAL VS VENOUS ULCER ( cross check the picture from net )

FEATURES ARTERIAL VENOUS
Cause DM, smoking DVT, varicose veins
Site Under foot lateral Medial aspect
Depth Deep Super financial
Borders Punched out or regular Irregular
Pulse Absent Present
Temperature Cold Warm
Hair growth Absent Present
Oedema Less More

Treatment position Leg dependent Leg elevate

Pain If leg is elevated If leg is dependent

Diameter Small Large

Prognosis Bad Good

Dressing Unna boot dressing or hydrocolloid dressing wuth zinc

oxide for wound cleaning only use NS avoid betadine
and hydrogen peroxide dcause granulation tissue I
present

INTERMITTENT CLAUDICATION PAIN MGNT – severe leg pain due to arterial insufficiency.

● CILOSTAZOL
● PENTOXIFILLINE (Trental)
● Leg in dependent position.

THROMBOANGITIS OBLITERANCE OR BUERGER DISEASE

✔ Occlusive disease of the median and small arteries and veins. The distal upper and lower limbs are
affected most commonly
✔ CAUSES; - tobacco, male.
✔ FEATURES – intermittent claudication, ischemic pain, pain more at night, coolness, numbness,
diminished distal pulse, development of ulceration.
● MANAGEMENT – vasodilaotrs, avoid smoking

RAYNAUD PHENOMENON
● Vasospasm of the arterioles and arteries of the upper and lower extremities

28
CAUSES

● Females 15-30 year

● Primary
● Over exposure to cold
● Secondary SLE, scleroderma, prolonged vibration, oral contraceptives, frozen food packing,
Lyme disease.
MANAGEMENT

● Avoid Cold Exposure

● Vasodilators - Calcium Channel Blocker (Amilodipin)

Key points

✔ Mayocarditis – cause coxakie virus, C/M – Gibson murmer

✔ Never wear elastic compression stockings over a wound but wear over the wound dressing
✔ Varicose vein - cause is prolonged standing and this mainly occur in saphenous vein. Clinical
features is trendelenberg test. Management sclerotherapy and vein stripping.
✔ Most common exercise testing is telemetry testing for to detect coronary artery diseases. Before this
procedure avoid take stimulants such as alcohol ,smoking, coffe and with held theophiline products
and anti hypertensives

koilonichia

29
 RESPIRATORY SYSTEM

Functions of respiratory system

Primary functions

● Provide oxygen to the cell for metabolism

● Remove carbon dioxide as the waste product of metabolism
Secondary function

● Humidification and filtration of air

● Voice production
● Maintain acid base balance
● Temperature maintenance

Anatomy of respiratory system

Upper respiratory tract- it include nose, sinus, pharynx ( passage way for food and oxygen ), larynx
(voice production and the part glottis is helping for coughing reflex) and epiglottis

Lower respiratory tract – it include

● Trachea – trachea location according to vertebral column C6 - T5 ( length 10 –12 CM )

● Carina – the point in which trachea divides in to right and left main stem bronchi is carina
● Bronchi – right bronchus is larger than left
● Bronchioles- not helping for gas exchange
30
 ● Alveoli- grape like structure helping for gas exchange . the distal portion of alveoli to bronchioles is
known as pleural acini. type 2 alveolar cell is producing surfactant . without surfactant the lung
would be collapse.
● Lungs – right lung is larger than left because for to accommodate heart in the left side of the thoracic
cavity. Right lung 3 lobes and left lung 2 lobes. The upper lobe of the lung having too much air
circulation and lower lobe containing blood circulation
● Pleural cavity - covering of lungs. Outer layer parietal pleura and inner layer visceral pleura. In
between pleural fluid present
Respiratory nerves

● Phrenic nerve, vagus nerve, thorasic nerve

Respiratory muscles

● Scalene muscle – which elevate the first two rib

● Sternocleido mastoid muscle – which elevate the sternum
● Trapezious and pectoralis muscles – which fix the shoulder during the time of respiration
PHYSICAL EXAMINATION RESPIRATORY SYSTEM

● INSPECTION
● PALPATION
● PERCUSSION
● AUSCULTATION
INSPECTION :

● Monitor any abnormal chest

● Barrel chest – anterior and posterior diameterr of the chest is increased. Example emphysema and
COPD
● Funnel chest /concave chest /pectus exavatum : a condition in which the breast bone sinks in to the
chest. The causes are genetic, noonan syndrome and marfan syndrome.
● pigeon chest/pectus carinatum,/convex chest.- it is a malformation of the chest characterised by a
protrusion of the sternum and ribs. The causes are rickets, poorly controlled asthma, scoliosis. The
clinical features are- clubbing (hippocratic fingers), jugular vein distension, retraction, nasal flaring,
paradoxical movement

pectus exavatum pactus carinatum

31
PALPATION ( NOT MANDATORY )

• crepitation
• tracheal deviation
• tactile fremitus ( increased in pneumonia and decreased in pneumothorax and pleural effusin )
• vocal fremitus ( vibration feeling increased in pneumonia and decreased in COPD )
• tussive fremitus ( is a vibration felt on the chest when the patient cough )

PURCUSSION

• Resonance
• Dull or flat ( if fluid )
• Hyper resonance
• Tympanic ( if gas occur )

AUSCULTATION

NORMAL BREATH SOUND

• Normal rhythm and depth - Eupnoea

• Bronchial- air is passing through the terminal trachea and bronchi.
• Bronco Vesicular – air is passing through the bronchioles
• Vesicular- air is passing through the alveoli. This we have to hear at the distal area of the chest.

ADVENTITIOUS BREATH SOUND ( abnormal breath sound )

• STRIDOR : a harsh vibrating shrill sound produced during respiration when there is completely airway
obstruction. Management – intubation or tracheostomy.

• WHEEZES : a musical sound or whistling sound commonly heard during expiration ,when air is
passing through the partially obstructed airway passage. Example asthma.

Management of wheezing - Bronchodilators ( action it dilate the bronchial wall )

32
• Beta 2 Agonists : Terbutaline, Ritodrine, Salbutamol, Fomoterol.

o Adverse Effects : Tachycardia, Palpitation, Tremor, Sweating, Anxiety, Insomnia Arrhythmia,

Hypokalemia.
● Methylxanthine

Theophylline (therapeutic level )10-20 Mcg/Ml)

Side effect :N/V, Tachycardia, Headache, Insomnia, Dizziness, Hypokalemia.

Antidote; Beta Blocker.

• CRACKLES : sound heard when air is passing through the fluid filled alveoli example- pulmonary
edema. C/M cyanosis. Management – diuretics and mechanical ventilation

• FRICTION RUBS ( heard in pleurisy . C/M knife like chest pain during respiration ) )

• RALES RESPIRATION / POPPING SOUND – here the condition TB

COMMON DIAGNOSTIC TESTS

Chest X – ray

✔ Remove the metal object or jewelleries from the area.

✔ If a female client coming for x- ray ask the client regarding any possibility of pregnancy.
✔ Instruct the client to practice valsalva maneuver. ( take deep breath and hold it )

Sputum collection – ( for identify the organism )

✔ Early morning specimen is best .

✔ Collect Minimum 15 ML sputum in a sterile container.
✔ Specimen should collect before starting antibiotic therapy
✔ Before specimen collection instruct the client to take several deep breath followed by coughing, for
getting adequate amount of sputum.
✔ Before specimen collection instruct the client to avoid clean the mouth with antibiotic lotion or
Colgate but can clean with plane water.

Suctioning

✔ Before suctioning hyperventilate the client.

✔ Duration- 10 second not exceed more than 15 second.
✔ After few second the client develop coughing or cyanosis , stop suctioning and administer oxygen
✔ Tracheotomy suctioning insert 10cm suction catheter. For nasal suctioning up to pharynx.
✔ After suctioning again hyperventilate the client.

Bronchoscophy - visualisation of the larynx, trachea and bronchi with the help of an fiberoptic
bronchoscope

✔ Pre- procedure intervention

✔ Consent ( taken by the doctor )
✔ Monitor coagulation report ( PT, APT, INR )
✔ Midnight onwards NPO
33
 ✔ Keep all life saving equipment at the bed side
✔ Post procedure intervention
✔ Priority for airway and vitals monitoring
✔ Semi fowlers position
✔ Put the client for NPO till gag reflex return
✔ Monitor any complication

LUNG SURGERY – PNEUMONECTOMY

✔ Indication – CA lung, no benign tumour

✔ Post op position – lateral

CHEST PHYSIOTHERAPY – applying percussion or vibration over the thoracic area and loosening the
lung secretion

⮚ Best time early morning

⮚ Perform one hour before or two hour after meal
⮚ During CPT if pain occur immediately stop the procedure
⮚ If the client is having nebulisation give nebulisation 15 min prior procedure.
⮚ Correct order of these procedure are ( 1.bronchodilator - 2. Nebulisation - 3. CPT - 4. Suctioning )
⮚ Contra indication
✔ Increase ICP
✔ Abnormal vitals , chest injury/surgery, rib fracture, H/O pathological fracture

POSTURAL DRAINAGE – use of gravity to drain secretion from segments of the lungs may be combined
with CPT

⮚ Best time early morning

⮚ Common position trendelenberg position
✔ Secretion present upper part of the lung- sitting and leaning forward position
✔ Lower anterior part – lying on unaffected side with trendelenberg position
✔ Lower posterior – prone with trendelenberg position
⮚ Stop postural drainage if sinusitis occur
⮚ After procedure provide mouth care
⮚ Contra indication - increase ICP , unstable vitals

ABG ( arterial blood gas )

⮚ Most commonly sample collecting from radial artery

⮚ Before sample collection explain the procedure to the client.
⮚ Before sample collection perform allens test to determine the collateral circulation of the ulnar
artery. The capillary refilling is occur within 6 second the radial artery is properly function we can
collect the sample from same area. More than 6 second choose another area.
⮚ Character of syringe – heparinised
⮚ Place the specimen inside the ice bag and send to the laboratory
Result ( normal values )

● PH 7.35-7.45 HCO3- 22-26meq/l

● PCO2 35-45mm of Hg
34
 ● PO2 80-100mm of H

PH – it means hydrogen iron concentration.

HCO3 – is the extra cellular buffer is

produced by the liver and kidney

TYPES OF ACID BASE IMBALANCE

1. RESPIRATORY ACIDOSIS
❖ Causes; Hypoventilation, Copd, Pulmonary Oedema, ARDS.
❖ Ph Less Than 7.35
❖ Pco2 More Than 45
❖ P02 Less Than 80
❖ Hco3 More Than 26
❖ Management- treat the exact cause , mechanical ventilation position ( semi fowlers of high
fowlers )
2. RESPIRATORY ALKALOSIS
❖ Cause - Hyperventilation, Excessive Mechanical Ventilation, Anxiety, Pain, Panic,.
❖ Ph More Than 7.45
❖ Pco2 Less Than 35
❖ P02 More Than 80
❖ Hco3 Less Than 22
❖ Management – treat the exact cause and use re breather mask

3. METABOLIC ACIDOSIS
Causes- Lactic Acidosis, Keto acidosis (Dm, Starvation,), Kidney Failure, Diarrhoea, Addison’s Disease ,
Ileostomy, Heat Stroke, Sepsis, INH, Rhabdomyolysis. Dehydration, liver cirrhosis. Over intake of aspirin.

❖ Features - Chest Pain, Headache, Vomiting, Kussmaul Respiration ( deep and laboured
breath for to eliminate carbon dioxide ), Muscle Weakness, Seizures, Abdominal Pain
❖ Ph Less Than 7.35
❖ Hco3 Less Than 22
❖ Pco2 Less Than 35
❖ Management – drug of choice sodium bicarbonate and treat the exact cause

4. METABOLIC ALKALOSIS
❖ Causes- Vomiting, Bulimia Nervosa, Pyloric stenosis, Ng Tube, Laxatives, Loop
Thiazide Hypokalemia.
❖ Ph More Than 7.45
❖ Hco3 More Than 26
❖ Pco2 More Than 45
❖ Management – drug carbonic an-hydrate inhibitor or HCL and treat the actual cause

STEPS FOR TO ANALYSE ABG

⮚ Step 1 – look at the PH . less than 7.35 acidosis and more than 7.45 alkalosis

35
 ⮚ Step 2 – look at the Pco2 . it is elevated or decreased. If the pco2 reflects opposite to ph then its
respiratory imbalance.

⮚ Step 3 – look at the Hco3- it is elevated or decreased . Hco3 reflects corresponding to ph then its
metabolic imbalance

⮚ Step 4 – if the PH is in a normal range of ( 7.35- 7.45 ) compensation should be present. In this
situation consider 7.40 is normal less than 7.40 is acidosis and more than 7.40 is alkalosis
⮚ Step 5 – if the ph is not in normal range patialy compensation or uncombensation is present
✔ In respiratory condition look at HCO3 for the level of compensation . it is in normal range
uncompensatory condition and abnormal partially compensation occur
✔ In metabolic condition look at PACO2 for the level of compensation . it is in normal range
THORACENTESIS AND ICD

Insertion of a needle in to the pleural cavity is known as thoracentesis

⮚ Indications – pneumothorax, pleural effusion, hydrothorax, hydropneumothorax.

⮚ Intervention before procedure
o Consent and monitor the coagulation report.
o Take one chest x- ray for post procedure comparison
o Procedure performing under the guidance of USG
o Needle insertion site 2nd and 3rd intercosstal area for air removing and in between 8th ,9th
for blood and fluid removal
⮚ Intervention – during procedure
o Position- if the patient is able to sit – sitting with leaning forward position the both
hand should be supported to cardiac table ( orthopnic position ) . if unable to sit high
fowlers position the towards the unaffected area.
o During needle insertion avoid coughing deep breathing and movement more over practice
valsalva manoeuvres.
o After procedure apply a pressure dressing over the area

36
NURSING INTERVENTION DURING ICD CARE

▪ PRINCIPLES OF THE CHEST TUBE - Gravity, Under Water Seal, Suction.

▪ Monitor the chest drain is properly functioning. Water oscillate is denoting the tube is
properly functioning. Also known as ( fluctuation of the tube ). The exact meaning is bubbles
present inside tube move inward during inspiration and move outward during expiration. if
water oscillates is absent that means the tube is obstructed or blocked. Immediately reported
to the doctor
▪ The expected drain amount is 70 – 100 ml per hour . normal colour is dull red in colour.
Bright red abnormal
▪ If the chest drain is inserted for removal of air: intermittent bubbling,tidalling, fluctuation
indicate properly functioning but continuous bubbling indicate air leakage and report to the
doctor.
▪ Apply pressure dressing over the incision area.
▪ Instruct the client to practice deep breathing and coughing exercise.
▪ Keep petroleum gauze pad dressing and artery forceps always at the bedside
▪ During care accidentally if the tube is come out the best nursing intervention is immediately
cover the area with petroleum gauze pad dressing and then report to the doctor
▪ If Icd is detatched from water seal chamber, dip the distal end in sterile water.
▪ When ever shifting for x ray place the drainage bag below the body level and during the time of x-
ray unclamp the tube.
▪ During chest tube removal instruct the client to practice valsalva maneuver
▪ Monitor complication

▪ 1. Tension pneumothorax
▪ 2. Subcutaneous emphysema- accumulation of air beneath the skin. C/M crepitus on palpation.
Management needle puncturing.

37
 TUBERCULOSIS
• Cause - Mycobacterium Tuberculosis ( group – acid fast bacilli ) it is a Aerobic bacteria.

• Shape - Rod Shaped

• Epidemic disease

• Airborne or (Droplet Nuclei ) infection.

• Staining (Ziehl –Neelsen)

Location – can occur anywhere in the body example spine ( pots spine ), meanings, kidney, bone , intestine.
Because for the growth of organism only oxygen is needed . in lungs infection most commonly affect upper
lobe where oxygen concentration is high.

Incubation period – 2 – 12 weak

CLINICAL FEATURES

• Fever, Night Sweats, Productive Cough, client shows rales respiration/ popping sound

• Dry Cough ( initially ), Weakness, Anorexia, Chest Pain

• Weight Loss, Haemoptysis, Crackles, Increased Fremitus

DIGNOSIS
• HISTORY & Physical examination

• X-RAY- shows upper lobe

infiltration.

• MANTOUX TEST

⮚ It is a intra-dermal skin sensitivity test ( site – inner surface of upper 1/3 rd of the forearm on the left
hand )
⮚ Using 26 G NEEDLE

⮚ Amount 0.1 ML

⮚ Indurations After 48-72 Hrs

38
⮚ If redness or itching occur that means allergy with PPD not positive mantoux test

⮚ Palpable Raised Area denoting positive

● 5mm 0r More; HIV , Person With Recent Contac With A Tb Pt, Organ Transplanted, X –Ray
Findings.
● 10mm Or More; Drug Abuser, Dm , CKD ,Low Body Weight, Child Less Than 4,Health Care
Workers.
● 15mm Or More; Person With No Risk Factor.
⮚ Reason for false positive test – expected those who are taken BCG. AND after TB attack mantoux
remain positive for life long.

⮚ SPUTUM ACID-FAST BACILLI ( confirmatory test )

PREVENTION

• Isolation - NEGATIVE PRESSURE ROOM ( always close the doors and windows ) & use N95
MASK ( when ever suspecting use the patient and its confirmation situation both patient and
health care provider )

• BCG ( route intra dermal )

TREATMENT

● 99 DOTS (RNTCP 2017)

Initial Phase 4fdc (Fixed Dose Combination) R I E P (Rifampicin, Isoniazid, Ethambutol,

Pyracinamide )

● Continuation Phase 3 FDC (R I E)

● DIET- high calorie, protein, iron and vitamin C rich diet

● NURSING CARE.- reassure the client that after 2-3 weeks of medication therapy it is unlikely that the
client infect anyone

● DAILY DOSE

● FIRST LINE DRUGS

✔ Streptomycin, rifampicin
✔ Ethambutol, pyrazinamide
✔ isoniazid

NAME OF THE DRUG NURSING INTERVENTION

STREPTOMYCIN - It is in the form of injection

- It is amino-glycoside antibiotics
- It is contra indicated in pregnancy
- side effect Nephrotoxic, Ototoxicity,

39
 RIFAMBICIN -Instruct the client to take the tablet in early morning with
empty stomach.
- urine colour become orange on next day onwards
- Hepatic toxic drug so monitor LFT frequently

ISONIAZID -more hepato toxic drug.

- it can cause peripheral neuropathy so instruct the client to
take vitamin B6 food

ETHAMBUTOL Side effect – optic neuritis, colour vision, red- green colour
blindness

PYRAZINAMIDE -hepatotoxic
- instruct the client to take much more water otherwise gout
like symptoms develop

Second line drug - gentamycin ( oto-toxic and nephrotoxic ), amikacin ( nephrotoxic in old age ),
tetracycline ( in less than 12 year can cause nephro toxicity and oral syrup can cause tooth stain. )
tetracycline side effect – visual changes,blurred vision,decrease clour perception

● Nursing diagnosis-
● Impaired gas exchange
● ineffective airway clearance

PNEUMONIA
• Inflammation of the Lung parenchyma cells.

• Risk group - immune suppressed ( old age , under five children , performed organ transplantation
because they are taking immune suppressed tablet for to prevent rejection )

• Common causative agent - staphylo coccus ( droplet infection ), streptococcus, pseudomonas

aerugenosa, enterobacter, MRSA( contact)

TYPES OF PNEUMONIA

1. CHEMICAL PNEUMONIA

• Due To Aspiration Or Inhalation Of Irritants

• Streptococcus & Staphylococcus ( Droplet )

2. HAP ( hospital acquired pneumonia )

• After 48 Hrs Of hospital Admission. It is a nosocomial infection

• Cause – MRSA ( methicillin resistant staphylococcus aureus ). Mode of transmission- Direct Contact

40
• It is two types

⮚ ventilators associated pneumonia (VAP) – PRECAUTIONS ( head end elevation, closed suction,
mouth care, use anti- embolism stockings, H2receptor or PPI , avoid administer humidified oxygen
⮚ iatrogenic pneumonia – health care induced pneumonia due to lack of aseptic technique

• Drug of choice - Vancomycin, Linezolid

• Contact Precaution (Hand Wash, Gown, Gloves, Alcohol Hand Rub)

3. CAP (community acquired pneumonia )

It will develop out side the hospital or first two day inside the hospital

• Risk group - over crowded population . the cause is mycoplasma pneuminae (no cell wall )

• Drug of choice - tetracycline.

4. PNEUMOCYSTIS PNEUMONIA (PCP)

• Fungus infection . the cause is Pneumocystic Jirovecii

• Opportunistic Infection. Mainly occur in AIDS patient.

• Drugs Dapsone, Trimetrexate, Clindamycin.

• Prevention (Prophylaxis With Co-Trimoxazole)

5. HYPOSTATIC PNEUMONIA

Mainly occur in bed ridden patient due to pooling of secretion in the lungs. Management is use spirometry
and change position frequently.

DIGNOSIS CLINICAL FEATURES

• Chest X Ray,
✔ Highgrade fever
• Sputum Culture ✔ Productive cough with rust coloured
sputum ( in PCP dry cough occur because
• CBC & ESR
sputum is too viscous )
✔ Chest tightness
✔ Stridor & crackles
✔ Dyspnoea & decrease breath sound
✔ Use of accessory muscles for breathing
✔ Tachycardia, dry mouth
✔ rhonchi

PREVENTION

• Pneumococcal Vaccine ( administer every five yearly . this vaccine safe in old age )

• Streptococcus Pneumonia

41
 MANAGEMENT

⮚ Priority for airway clearance

✔ Administer humidified oxygen to loosen secretion.
✔ Take much more water (3 L ) it will help to loosening the secretion
✔ Every two hourly change the position of the client
✔ Practice deep breathing and coughing exercise./ use incentive spirometer.
✔ Chest physiotherapy followed by postural drainage / suctioning
⮚ Position – semi fowlers position
⮚ Monitor saturation
⮚ Diet- high calorie and protein with small amount and frequent meal.
⮚ Complete bed rest and increase the activity gradually
⮚ DRUG- antibiotics, bronchodilators, mucolytics, expectorant, analgesics,
⮚ Nursing diagnosis – ineffective airway clearance.

PULMONARY EMBOLISM
❖ Any obstruction or block in to the pulmonary artery ot its branch
❖ CAUSES –
❖ thrombus , emboli,
❖ fat, air, vegetation,
❖ tumour . the main reason for emboli is DVT.
❖ ASSESSMENT-
✔ initial feature is restlessness, apprehension
✔ cough, chest pain
✔ cyanosis, crackles
✔ haemoptysis ( pink colour frothy sputum)
✔ petechia or ecchymosis present at below the axila or over the chest.
❖ Diagnosis- pulmonary angiography.
❖ MANAGEMENT ( order is important )
▪ Inform to the rapid response team or cord blue or doctor.
▪ High fowlers position
▪ Oxygen administration
▪ Monitor lung sound
▪ Monitor ABG – result respiratory acidosis
✔ Administer anti coagulant- heparin followed by warfarin
✔ Surgical management – embolectomy
✔ Nursing diagnosis- impaired gas exchange

Nursing Intervention During Anticoagulant Therapy

❖ Initially administer heparin (High molecular weight) 3 – 4 days followed by warfarin for long term
duration. Because then only will get the effectiveness of warfarin.
❖ Best time of warfarin administration evening 6 pm.
❖ Safest anticoagulant in pregnancy heparin. Because it will not cross to the placental barrier.
❖ Whenever administer
Heparin Monitor APTT (Normal value 20 – 39sec. therapeutic range up to 90sec)
Warfarin Monitor
42
 1) PT (Normal value 9.5 – 12 sec. therapeutic range up to 30sec)
2) INR (Normal value 1.3 – 2.0)
❖ Low molecular heparin. eg:- Enoxaparin (Best time 11am – 2pm)
Route subcutaneous
Site – Thigh and Abdomen
Best site in pregnancy- Abdomen
Whenever administer subcutaneous heparin after needle insertion avoid withdrawal of the piston and after
injection avoid massage.
Whenever administering in to the abdomen leave 2c.m away from the umbilicus and anywhere can
administer.

CHEST TRAUMA OR THORACIC INJURY

Types of trauma – blunt trauma and penetrating trauma

Effect

⮚ 1. Rib fracture
❖ Single rib fracture . it result from blunt trauma
❖ 5-10 ribs most vulnerable. Because least protected by muscles.
❖ Clinical features – pain at the site that increases with inspiration, client splint the site ,
shallow respiration
❖ Management – high fowlers position. Pain medication. Ribs usually unite spontaneously .
perform splint the chest during breathing.
⮚ 2. Flail chest
❖ Multiple Adjacent Rib Are Broken In Multiple Places
❖ Signs & Symptoms - Dyspnoea, Chest Pain, Paradoxical Chest Wall Movement, Poor Air
Movement
❖ MANAGEMENT- Definitive management, Positive –pressure ventilation may be needed
( mechanical ventilation )

Complication of chest trauma

❖ Pulmonary contusion ( alveolar bleeding )

❖ ARDS- priority nursing diagnosis – impaired gas exchange
❖ Pneumothorax

PNEUMOTHORAX
Accumulation of air in pleural space

TYPES

1. OPEN PNEUMOTHORAX ( always associated external chest wound is present )

✔ Features; Sucking Sound on Inspiration, Sob, Decreased Breath Sound, Tachypnea.
✔ Management Close The Wound,
✔ ICD
✔ Dressing (vented dressing – three side closed and one side remain open for to prevent
tension pneumothorax

43
 2. CLOSED PNEUMOTHORAX ( no chest wound )
✔ The causes are- injury to the lung from broken ribs, rupture of blisters, insertion of sub-
clavian catheter, mechanical ventilation
3. TENSION PNEUMOTHORAX ( may or may not associated chest wound

✔ Clinical Feature -- Chest Pain, Shortness of breath, Tachycardia, Hypotension, Trachea

Deviation to the unaffected area, Cyanosis, Loc, jugular vein distension, Absent Of
Breath Sound, Tympanic, decreased chest movement .
✔ Management - Needle Decompression
✔ ICD

DIAGNOSTIC TEST – X- ray

MANAGEMENT – Thoracentesis and

ICD

RESPIRATORY FAILURE
✔ It is condition due to other lung disease or disorder
✔ Occurs when insufficient o2 is transported to the blood or inadequate co2 is removed from the
lungs and the clients compensatory mechanism fail.
✔ pao2 less than 60mm of hg. hypoxemia (normal 95-100) and Paco2 more than 45 hypercapnia
✔ management. – treat the exact cause . intubation and mechanical ventilation

COPD ( CHRONIC OBSTRUCTIVE PULMONARY DISEASE )

✔ it is an irreversible disease condition
✔ CAUSES – smoking, alpha 1 antitrypsin deficiency, air pollution, occupation exposure
✔ It is a combination of disease

• CHRONIC BRONCHITIS (BLUE EMPHYSEMA OR PINK PUFFER

BLOATERES) It is the presence of chronic
productive cough for 3 months in each of 2 • Abnormal Permanent Enlargement Of
consecutive years Alveolus

Clinical features
Clinical features

44
 ❖ Productive Cough ❖ Cough
❖ Dyspnoea ❖ Barrel Chest
❖ Clubbing ❖ Tripod Position
❖ Crackles ❖ JVD
❖ Dull ❖ Clubbing
❖ High Fremitus ❖ Tachycardia
❖ Cyanosis ❖ Wheezing
❖ JVD ❖ Dyspnoea
❖ PFT ❖ Weight Loss
❖ Pursed Lip Breathing
❖ Anxious
❖ Hyper resonant
❖ Hoover’s Sign Inward Movement Of
Lower Rib Cage During Inspiration.

COMPLICATION

✔ Pulmonary insufficiency
✔ Pulmonary hypertension
✔ Cor-pulmonale ( enlargement and weakness of the right side of the heart )
✔ Cardiac dysrhythmias
✔ Respiratory acidosis

MANAGEMENT

✔ Administer 1-2 L oxygen via nasal canula if the Spo2 is less than 90% ( normal SPO2 in COPD
88-92 % and normal person 94-98% ). If more oxygen is administered it will suppress the
hypoxic drive.
✔ Position – in COPD – High fowlers and in emphysema – semi fowlers position
✔ Chest physiotherapy followed by postural drainage or suctioning
✔ Take more water. It will help to loosening the secretion
✔ Administer bronchodilator followed by steroid. When ever the symptoms is subside first stop
steroid then bronchodilator. After oral steroid administration clean the mouth with water
otherwise steroid can precipitate in the mouth that can cause fungal infection . example oral
candidiasis .clinical feature is white patches in the mouth . drug of choice is nystatin
✔ Instruct the client to practice pursed lip breathing./ diaphragmatic or abdominal
✔ Avoid smoking
✔ Avoid allergens and early treatment of respiratory tract infections.
✔ VACCINATION- every five yearly pneumo cocci vaccine and yearly influenza vaccine
✔ DIET - high caloric, high protein and avoid hot cold spicy and gas forming food

✔ Nursing diagnosis- ineffective airway clearance ( chronic bronchitis )

Impaired gas exchange ( emphysema )

45
BRONCHIAL ASTHMA
⮚ It is a intermittent reversible airway disease
⮚ Cause – allergy ( antigen antibody reaction or hypersensitivity. )
⮚ Example of allergen ( antigen ) - exercise, occupational exposure, pollens, dust, drugs. – aspirin
NSAID, Beta adrenergic blockers
⮚ Pathophysiology –
o 1. Allergen is entering the body
o 2. our immune cell especially mast cell is releasing the antibody like histamine for to destroy
the allergen.
o 3. Antigen and antibody reaction occur. Due to this reason the bronchial inflammation and
broncho spasm develop
o 4. So the airway is partially obstructed and breathing difficulty develop
⮚ Clinical features
o Wheezing
o Pulses paradoxes ( a large fall in systolic BP ,and pulse volume when the patient breath in
minimum 10 mmhg or more . )
o IgE level elevated
o Increase eosinophil count
o Child maintain tripod position
o Cough, chest tightness, cyanosis
o Absent or diminished lung sound

CLASSIFICATION

⮚ Mild intermittent – symptom less or equal to 2 times per week. Exacerbations are brief .hours to
days .intensity of exacerbations vary. Nocturnal symptoms occur twice a month.
⮚ Mild persistent – symptoms greater than 2 times per week. But less than one time /day.
exacerbations may affect activity. Night time symptoms more than 2 times per month .
⮚ Moderate persistent – daily symptoms. Exacerbations at least 2 times per week and may last for
days. Night time symptoms more than one time per week. Exacerbations affect activity.
⮚ Severe persistent. – continous symptoms. Limited physical activity. Frequent exacerbations.
Frequent night time symptoms.

MANAGEMENT

⮚ High fowlers or sitting upright position.

⮚ Oxygen administration
⮚ Administer bronchodilators
⮚ After the use of Rotacaps(MDI) instruct the patient to perform oral gargle to prevent oral candidiasis
⮚ Administer steroid
⮚ Stay with the client to reduce anxiety.
⮚ Complication- status asthmatics – is a severe life threatening asthma episode that is refractory to
treatment and may result in pneumothorax, cor- pulmonale or respiratory arrest

NURSING DIAGNOSIS – ineffective airway clearance

GOAL – short term goal- maintain SPo2 more than 96% and maintain the patent airway
46
 Long term goal – development of a home and school management plan

Oxygen Concentration Available with

Common Adjuncts at Sea Level

Device Liters/Minute % IO2

Nasal Cannula 1 24
Nasal Cannula 2 28
Nasal Cannula 3 32
Nasal Cannula 4 36
Nasal Cannula 6 44
Simple Mask 5-6 40
Simple Mask 6-7 50
Simple Mask 7-8 60
Partial Nonrebreather Mask 7 70
Partial Nonrebreather Mask 8 80
Partial Nonrebreather Mask 10 >90

NRBM( non- rebreather mask ) 100%

STEROIDS

⮚ Example - Dexamethasone
⮚ Action - Anti Inflammatory
⮚ Adverse Effects; Acne, Weight Gain, Depression, Hypertension, Cataract, Peptic Ulcer,
Osteoporosis, Hyperglycaemia, Psycosis, Candidiasis, Hypokalemia, Hypocalcaemia,
Hypernatremia, Cushing Syndrome.

Sternum NASAL TRUMPET

47
Key points

✔ Pleural effusion means pleural fluid more than 200ml at pleural cavity
✔ Collection of pus in the pleural cavity is known as emphyma. The pus converted to solid form is
known as fibrothorax. The management is decortications
✔ Inflammation of pleural cavity is known as pleurisy. Management high fowlers and turn towards the
affected side and splint the chest while coughing and breathing.
✔ Legionnaires disease- acute bacterial lung infection caused by legionella pneumophilia. It is a
waterborne disease. Drug of choice erythromycin.
✔ Influenza – two types H5N1 & H1NI. Drug of choice tamiflu or oseltamavir.
✔ Histoplasmosis – fungal lung infection caused by histoplasma capsulatum. Infection same like
pneumonia. Drug of choice amphotericin-B . side effect of the drug is nephrotoxicity.
✔ Mononucleosis 0r kissing disease – acute viral infection caused by ebstain barr virus.infection
affected to lungs and spread through saliva. Main clinical feature night swetting.lumphedema.
complication splenomegaly so take precaution to prevent splenic rupture
✔ ARDS – collection of fluid in the alveoli. Priority nsg diagnosis is impaired gas exchange.

48
 GASTROINTESTINAL SYSTEM

FUNCTIONS

❖ Process food substance

❖ Digestion and absorb the product of digestion in to the blood
❖ Excrete un absorbed material
❖ Absorption of the water from the large intestine
❖ Provide an environment for micro- organism to synthesize nutrients such as vitamin k
ANATOMY

❖ UPPER GI TRACT – mouth to stomach ( it include lip, teeth, tongue, palate, pharynx. Salivary
gland ( saliva contain ptyalin enzyme), Epiglottis )

49
 ❖ Stomach ( shape J shape , capacity 1.5 litre )
⮚ It producing HCL ( amount - 1.5 L , PH - 3.5 )
⮚ Function of HCL breaking food in to paste and kill the organism present in the food . chief co
enzyme present pepsin that convert protein to protease and peptones.
⮚ Parietal cell of stomach is producing the intrinsic factor that helps for the digestion and
absorption of vitamin B12.
⮚ mucous membrane present inside the stomach and duodenum that protect from acidity.
❖ LOWER GI TRACT - (duodenum to rectum )
⮚ It include small intestine. Length 5.25m ( duodenum, jejunum , and ileum ) function
absorption of nutrients. Maximum absorption of fat occur at duodenum
⮚ Large intestine ( function excretion of waste and absorption of water )
⮚ Appendix – location near the ceecum .
❖ LIVER – largest gland in the body . weight 3-4 pound.
⮚ Functions- liver contain kupffers cells ,which remove bacteria in the portal venous blood
(detoxification).
⮚ Stores and filters blood (200 – 400 ml )
⮚ Helping for blood coagulation and protein metabolism
⮚ Produce bile – daily 500-1000 ml . the function is helping for fat metabolism
⮚ Store vitamin A,D,B &iron
Position for liver biopsy- During- supine or left lateral, After- right lateral ( because compression
will help to prevent bleeding )

❖ PANCREAS – partially endocrine and partially exocrine

⮚ Head and body is exocrine. Is producing pancreatic juice ( amylase + lipase + tripsinogen )
⮚ Daily 1.5 litre production helping for CHO ,FAT, protein metabolism. Ph –8
ABDOMINAL EXAMINATION ORDER

1. Inspection
2. Auscultation
3. Percussion
4. Palpation – palpate the right lower quadrant
first and palpate the painful area at last

INSPECTION ( cross check the picture from net )

► STOOL CHARACTER
⮚ Malena – it means black color stool denoting dark bleeding
⮚ Hematochezia-it means fresh blood in stool or bright bleeding
⮚ Fecal Occult Blood (Guaiac Test)- to rule out occult blood.
⮚ Red Currant Jelly Stool- intussuception
⮚ Ribbon Like Stool- hirschpung’s disease
⮚ Steatorrhea- fat in the stool
⮚ Blood And Mucosa
50
 ⮚ Gray Or Clay ( colicystitis and colilithiasis )
⮚ Rice Water stool - cholera
⮚ Pea Soup stool - typhoid
► Asterixis (Flapping Tremor)- liver cirrhosis
► Xanthelasma (is a deposition of yellowish cholesterol rich material that can appear around eye )
► Xanthoma ( is a deposition of yellowish cholesterol rich material that can appear anywhere in the
body )
► Caput Meduca- dilated veins in abdomen
► Spider Angioma(Spider Naevus)
► Gynecomastia
► Palmar Erythema
► Jaundice
► Cullen Sign- ecchymosis in peri umbilical area
► Turner’s Sign- ecchymosis in flank area
► Edema
AUSCULTATION

► Bowel Sound. ( Normal 5-35 Times Per Mt.)

PALPATION

► Blumberg Sign Or Rebound Tenderness

► Pitting Edema
► Organomagaly

PERCUSSION

► Dulness or flat – it means fluid accumulation ( ascitis )

► Tympanic- it mean gas accumulation

RYLES TUBE INSERTION

❖ PURPOSE- To decompress stomach, gastric lavage( wash ), gastric gavage ( feeding ), to decrease
the risk of aspiration and a diagnostic evaluation purpose
❖ Contra indication- obstruction, TEF, nasal bone fracture, CSF- Rhinorrhoes
❖ Tube measurement – tip of the nose to ear lobe then xyphoid process
❖ Position of the client- high fowlers or sitting upright position with head tilt forward the chin flexed
position. This position will assist to close the trachea and open the oesophagus.
❖ During tube insertion if any cough or cyanosis occur immediately remove the tube and administer
oxygen
51
 ❖ During tube insertion if resistance occur – instruct the client to take deep breath and same time the
nurse rotate tube at 180 degree and re insert. If not passing then remove and report to the doctor.
❖ Tube position confirmation – 1. X-ray, 2. Aspirate the content and analyze the PH,
3. auscultate the sound.
❖ Tube feeding position.
● For intermittent feeding- high fowlers position
● Continuous feeding – semi fowlers position
● Before tube feeding aspirate the content , if the amount is more than 50% of the previous feed
or more than 100ml with held the feed more over aspirated content re insert to the client.
● Tube feeding compilation – fast feeding can cause abdominal distension and diarrhoea.
● CLOGGED tube- any kinking or obstruction in to the tube due to feed content inside the
tube. Prevention , before and after feeding apply luke warm water in to the tube.
● For long term feeding practice PEG ( percutaneous endoscopic gastrostomy ).

ENEMA
❖ Administration of solution in to the rectal area,
❖ Purpose – laxative , nutrient, analgesic , antipyretic, sedation.
❖ Position –left lateral position or left sims position (purpose is to drain the enema fluid by its gravity
❖ Self enema position- lithotomy ( supine with hip and knee flexed) or semi prone position.
❖ Oil enema position trendelenberg position.
❖ Enema solution temperature ( adult = 40 – 43degree )and ( infant 37 degree )
❖ Large volume enema (maximum 100-250 ml at atime )
● The rectal tube should insert 6.6 – 8.8 CM or (3 - 4 inch )
● The enema bag should e hang at a height of 18 – 22 inch.
● During enema if pain occur - 1. Reduce the height of enema solution.2. Stop or clamp the
enema tube
● After subsiding pain slowly restart.

BODY MASS INDEX (BMI) = Weight in KG

Height in meter square

Normal 18.5 TO 25
Under weight Less than 18
Over weight 25 TO 30
Obesity More than 30

Example - height 6 feet 8 inch. Weight 120 lbs( pound ) find the BMI

1 feet = 30 cm, 1 inch = 2.5 cm, 1Kg = 2.2 lbs

So height in meter = 6 X 30 = 180 CM. Ie 8 inch in CM 8 X 2.5 = 20 CM

So total height in cm 180+20 = 200CM OR 2 meter

Next step weight in KG = 120/2.2 = 54.54

BMI = 54.54 /2 X 2 = 54.54/4 = 13.63 ( under weight person )

52
 ABDOMINAL
QUADRANTS

SR NAME OF THE ORGANS OCCUPIED

NUMBER QUADRANTS
1 RIGHT Liver, gall bladder, Right .kidney and small intestine
HYPOCHONDRIUM
2 EPIGASTRIUM Stomach, liver, pancreas, duodenum, spleen, adrenal glands
3 LEFT Spleen, colon, left kidney, pancreas
HYPOCHONDRIUN
4 RIGHT LUMBAR Gall bladder, liver, right colon or ascending colon
5 UMBILICAL Jejunum, ileum , duodenum
6 LEFT LUMBAR Descending colon and left kidney
7 RIGHT ILEAC Appendix and cecum
8 HYPOGATRIUM Urinary bladder, sigmoid colon, female reproductive organs
9 LEFT ILEAC Descending colon and sigmoid colon

GASTRO ESOPHAGEAL REFLEX DISEASE

⮚ Stomach content regurgitate in to the oesophagus
⮚ Causes – poor development of cardiac sphincter, stimulant food items, abnormal intestinal
contraction ( motility disorder )

⮚ Clinical features
● Pyrosis ( heart burn )
● Globus ( something in throat feeling )
● Dyspepsia, regurgitation
● Hypersalivation/ water brash
● Odenophagia ( painful swallowing )
● Vomiting
Management

⮚ Small and frequent meal

⮚ Reverse trendelenburg position.
⮚ Low protein and low fat with easily digestible CHO
⮚ Avoid stimulant food
⮚ Take water between meal and maintain up right position after meal
⮚ Avoid anticholinergic which delay stomach emptying
⮚ S/M fundoplication - Nursing diagnosis - fluid volume deficit

53
GASTRITIS
⮚ Inflammation of the mucous membrane of the stomach

Cause Clinical feature

H . pyloric bacteria o Epigastria pain
o Contaminated food , spicy food. o nausea, vomiting,
o Drug induced – NSAID , aspirin, anorexia, dehydration
ibuprofen o Pyrosis/heart burn
o Smoking &alcohol o Belching
o Radiation therapy o Hiccups
o As an auto immune disorder o Hemetemesis
o Zollinger-Ellison Syndrome o malena
(gastrin- secreting tumor of islets
cells in the pancreas causing
overproduction of gastric acid
resulting in peptic ulcer).
o Diet; Coffee, Carbonated Drinks.
o Crohn’s
o Stress
o Gastrinoma- tumor in the
pancreas or duodenum that
secretes excess of gastrin leading
to ulceration of duodenum,
stomach and GI

⮚ DIAGNOSTIC evaluation - endoscopy

o Left lateral position
o Administer atropine ( for to decrease the secreation ) and glucagon ( as a muscle relaxant
)priorly
o After procedure before giving anything to mouth check the gag reflex

⮚ MANAGEMENT
o Put The Client NPO till symptom subside.
o After symptom subside Initially administer clear water
o Avoid administer stimulants to the client.
o Antibiotics- clarythromycin and metrogel
o Administer syrup sucrafen – it work as a mucosal barrier protectant
o H2receptor ( rantac ) or PPI (omiprazole ) both drug will help to decrease the production of
HCL OR administer antacid ( gelucil ) it will neutralise the gastric secretion.
o Bismuth salt or pepto-bismol
o SURGERY – gastrectomy or billroth 1 & 2 procedure

54
ACUTE PEPTIC DISEASE
⮚ CAUSES - same as gastritis
CLASSIFICATION

► GASTRIC
► DUODINAL
► OESOPHAGEAL
► CURLING ULCER ( is an acute gastric erosion resulting as a complication of burn. Due to
decreased plasma volume leads to ischemia and necrosis )
► CUSHING ULCER. ( due to increased ICP )

FEATURES GSATRIC DUODENAL

AGE Above 50 Below 50
COMMON 20% 80%
PAIN After 30 minutes of food intake ( After 2 hour of food intake ( food
food ingestion increase pain ) ingestion decrease pain )
RELEVED BY Vomiting Food intake
WEIGHT Loss Gain
BLEEDING Hematemesis more common than Malena
malena and rigid board like
abdomen .
CA Yes No
LOCATION At the antrum Duodenum.

DIGNOSIS

► ENDOSCOPY, UREA BREATH TEST (UBT), CBC

► BIOPSY
► CEA ( carcinoma embryonic antigen )
MANAGEMENT

Medical and nursing management same as gastritis

► SURGICAL MANAGEMENT ( surgical site from epigastria to umbilicus )

● Total gastrectomy
● Vagotomy- cutting of vagus nerve. Because it stimulating for the production of HCL
● Antrectomy
● Billroth 1 procedure – also known as gastroduedenostomy
● Billroth 2 procedure – gastro jejunostomy

Post operative intervention after abdominal surgeries ( both adult and child )
Most commonly surgery is perform under general anaesthesia.
55
 ⮚ After general anaesthesia the priority assessment order.
1. Airway/SPO2/Respiratory system
2. Cardiovascular system
3. Nervous system
4. Surgical site
⮚ Put the client for NPO till bowel sound return. Usually 1 – 3 days.
⮚ Insert NG tube and keep it open. For gastric decompression.
⮚ Before giving oral feed monitor the bowel sound or ask the client are you passes the flatus (Mainly in
adults)
⮚ Once bowel sounds return Initially administer clear water.
⮚ Exercise Deep breathing or coughing exercise/ use spirometer. Whenever coughing perform splint
the incision. ( exercise after 2 days )
⮚ Monitor complication
Bleeding – Clinical feature is pain and abdominal distention.
⮚ Gas accumulation – Clinical feature abdominal distention and pain. But this occur at 2nd post-
operative day.
Management Instruct the client to ambulate .
⮚ Infection.
⮚ Monitor the complication of surgical wound. ( cross check the picture from net )
1) Wound dehiscence – Rupture of suture due to increased pressure in the surgical site.
2) Wound Evisceration – Protruding of internal organs through ruptured suture site.
Management Apply sterile socked dressing.
Special attention in adult

First 24 hour complete bed rest. After that the client can ambulate.

Use ant embolism stockings.

COMPLICATION OF GASTRIC SURGERIES

► Bleeding( bleeding is the most common complication after any surgeries ) , diarrhoea,
hypoglycemia
► DUMPING SYNDROME
⮚ The rapid emptying of the gastric content in to the small intestine leads vertigo, palpitation
and giddiness
⮚ Clinical features – symptoms occur after 30 minutes meal
o Borborgymi ( loud gurgles in the abdomen indicate hyper peristalsis )
o Abdominal cramping, feeling of abdominal fullness

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 ► PERNICIOUS ANEMIA ( vitamin B12 deficiancy ) ( refer pediatric hematology page no 152 )

BARIATRIC SURGERY – It Is A Cosmetic Surgery Mainly Using For The Treatment Of An Obesity
TYPES – 1. total gastrectomy
2. billroth 1 & 2 surgery
3. vertical banded gastroplasty
4. panniculectomy- removal of pannus( excessive adipose tissue in stomach)
5. circumgastric banding
6. gastric bypass

CHOLECYSTITIS
⮚ Inflammation of the gall bladder
⮚ Cause – cholelithiasis( stone present in the gall bladder )
⮚ Risk factor for cholelithiasis – fatty, female, fertile client, after forty age, ( due to increase estrogens)
Pregnancy, use of oral contraceptives, diabetes mellitus ( because in DM bile production is high )
CLINICAL FEATURES

⮚ Right hypochondral pain radiating to the right scapula 2- 4 hours after fatty meal that persist
up to 6 hours ( BOAS SIGN )
⮚ Positive Murphy sign- when palpating lower liver border, patient shows breathing difficulty
⮚ steatorrhoea ( accumulation of fat in stool )
⮚ indigestion, jaundice with prurities
⮚ grey or clay coloured stool
⮚ hypo active bowel sound
⮚ fever with chills
⮚ nausea, vomiting, anorexia, dehydration

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DIAGNOSIS – ERCP ( endoscopic retrograde cholangio pancreatography ) ,USG ,CT- scan

MANAGEMENT

⮚ Low Fat Diet,

⮚ Meperidine
⮚ ESWL – extra corporeal shock wave lithotripsy
⮚ Cholecystectomy - Recovery Time Open (4-6 W) Laparoscopy (4 -7 Day). ( Surgical Site
Right Upper Quadrant ) .
⮚ after surgery T –tube drain is inserting to clear the ductal pathway become open . expected
drain 500 ML over 24 hour.

APPENDICITIS
⮚ Inflammation of vermiform appendix
⮚ Cause - any kinking or obstruction in to the appendix
⮚ Clinical features
● Mild fever
● Constipation or diarrhea
● nausea, vomiting, anorexia, dehydration.
● Hamberger sign-physician provides favorite food for the patient, if patient consumes the food
it is consider other than appendicitis, a positive sign indicates patient decline the food
● kochers sign – peri-umbilical pain that descent to the right lower quadrant or pain at the MC-
burneys point .
● positive dunphy sign – coughing can causing abdominal pain.
● Rovsing sign – when palpating to the left side of abdomen pain present at the right side
● Psoas sign- forceful extension of thigh leads to severe right lower abdominal pain
● Rebound tenderness – applying pressure on the abdomen ,and after releasing pressure
abdominal pain will be develop .
● Murphys traid – fever, N/V, pain in right lower abdomen.
● Obturator sign
DIAGNOSIS EVALUATION

► History collection &physical examination, C-T scan, USG, CBC

Management

► Maintain right lateral position

► Avoid hot application, enema, bowel wash ( chance of rupture )
► Provide cold application
► Appendectomy ( surgical site – right lower quadrant )
► Antibiotics

58
 ► Monitor complication
● Rupture of appendix that can cause peritonitis ( less than 6 year it is complicated , rupture
mainly due to immaturity of the organ )
● Clinical feature – high grade fever with chills
o Cramp like abdominal pain
o Tachypnoea with tachycardia
o Progressive abdominal distension
o Rebound tenderness
● Management – right lateral with semi fowlers position – it will help to prevent spread of
infection from abdominal cavity to thoracic cavity
● Antibiotics- broad spectrum antibiotics- ampicillin, amoxycilliln except streptomycin.
● Surgery – open laprotomy

PANCREATITIS
● Inflammation Of The Pancreas

CAUSES CLINICAL FEATURES

⮚ Biliary (cholilithiasis induced ) ⮚ Mid epigatric or left hypochondral pain radiating to
⮚ Alcoholism the back after eating fatty food , alchohol, and
⮚ Drugs – steroid,HIV drugs, supine position,pain relieved by forward posture
valporic acid ⮚ Fever with chills, N/V, Anorexia, dehydration.
⮚ Hypertriglyceridemia ⮚ Steatorrhoea
⮚ Idiopathic ⮚ Deficiency of fat soluble vitamin ( A,D E,K )
⮚ Tauma ⮚ Hypocalcemia
⮚ Scorpion sting ⮚ Hyperglycemia
⮚ Viral & bacterial infection ⮚ Cullen sign
⮚ Turners sign
⮚ Absence of pancreatic enzyme in duodenum.
⮚ Increased serum amylase,lipase, alkaline
phosphatase, bilirubin.

MANAGEMENT
⮚ Diagnosis (Serum Lipaseis increased )
⮚ High Protein Diet. Avoid heavy meal
⮚ Administer pancreatic enzyme with each meal
⮚ Do not administerpancreatic enzyme in NPO perio
⮚ H2 receptor / PPI
⮚ P- PAIN : avoid morphine because chances of metabolic acidosis,( dilaudid, tramadol can give
⮚ A- antispasmodic drug
⮚ N – NPO/NGT suction – pancreas to rest and TPN ( total parenteral nutrition )
⮚ C – calcium replacement
⮚ R- replacement of fluid and electrolyte
⮚ E – endocrine (insulin ) exocrine (amylase and lipase with food ) replacement
⮚ A- antibiotics
⮚ S – steroids during acute attack
59
 ⮚ Surgical management – pancreactectomy and wipples procedure ( complication – hyperglycemia
⮚ Complication of pancreatitis is – acute pneumonia

LIVER CIRRHOSIS
Nodule formation and scaring of the liver

Clinical features

60
 COMPLICATIONS
Asterixis,
fetor hepaticas ⮚ Hypertension
spider angioma ⮚ Pleural effusion
oedema ( generalized ) ⮚ Ascitis
⮚ Metabolic acidosis
⮚ Bleeding
⮚ anemia
⮚ Portal hypertension
⮚ Esophageal varices ( C/M – black tarry
stool )
⮚ Hemorrhoids
⮚ Caput meducae
⮚ Hepatic encephalopathy due to peak
ammonium concentration

DIAGNOSTIC EVALUATION

⮚ Hypernatremia
⮚ Heperkalemia
⮚ Hypercalcemia
⮚ Increase bilirubin
⮚ Increase ammonium

MANAGEMENT

⮚ Treat the cause

⮚ Antihypertensive, diuretics
⮚ Avoid hepatotoxic drug- PCM,
acetaminophen, barbutarates
⮚ Diet – high CHO , caloric, low fat
and moderate protein
⮚ Syp. Lactulose/defolac to prevent
hepatic encephalopathy or bowel
wash
⮚ Thorasentesis and parasentesis
⮚ Administer albumin

61
 HEMORROIDS
⮚ Dilated varicose veins of the anal canal
⮚ Cause – portal hypertension, constipation, pregnancy.
⮚ Clinical feature – bright red rectal bleeding with defecation, rectal pain and itching.
⮚ Management
● Encourage high fiber and fluid
● Administer stool softeners
● Avoid prolonged sitting
⮚ Surgery ( hemorrhoidectomy, sclerotherapy, minimally invasive procedure of hemorrhoids )
– during surgery provide lithotomy position
⮚ Post operative intervention
● Position- prone or lateral and avoid supine position
● First 24 hour cold application
● After 24 hour hot sits bath ( temperature 43degre or 110 degree Fahrenheit)
● Instruct the client to limit sitting for a short period

DIVERTICULOSIS AND DIVERTICULITIS

⮚ OUT POUCHING of the intestine is known as diverticulosis. The name of the pouch is diverticulam.
⮚ Inflammation of diverticulam is known as diverticulitis.
⮚ Mostly occur into the sigmoid colon.
⮚ Assessment – left lower quadrant abdominal mass and pain , cramp like pain, abdominal
distension, palpable tender rectal mass, malena
⮚ Diagnostic evaluation – CT scan ( avoid – enema and colonoscopy it will cuse rupture )
⮚ MANAGEMENT – DIVERTICULOSIS OR ACCUTE PHASE MANAGEMENT.
● Take 2.5 to 3.0 litter water per day
● Soft high fibre food to take
● Avoid gas forming food and indigestible roughage. Because these items trapped in to the
diverticuam and create inflammation.
● Avoid seed contain food – cucumber, water melon, nuts, fresh fruits. These substances
become trapped in diverticullam and cause inflammation
● provide high fibre diet.
⮚ MANAGEMENT - DIVERTICULITIS OR CHRONIC PHASE MANAGEMENT
● provide low fibre diet because it will irritate the inflamed mucosa.
● Avoid seed contain food – cucumber, water melon, nuts, fresh fruits. These substances
become trapped in diverticullam and cause inflammation.
● Instruct the client to take bulk foaming laxative example – BRAN or drug . psyllium

INFLAMATORY BOWEL SYNDROME

⮚ An ulcer formation any where in intestine. Occur from distal to proximal.
⮚ Types. 1. Ulcerative colitis ( ulcer present in to the large intestine – starting in rectum
extending up to cecum). 2 chrons disease ( ulcer present in to the small intestine especially
terminal ileum)
⮚ Clinical feature

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 Ulcerative colitis Chrons disease
. bloody /frothy diarrhoeas . semi solid diarrhea which may contain mucous and pus
. severe dehydration . malnutrition or malabsorption syndrome
. abdominal tenderness and . electrolyte imbalance, vitamin deficiency
cramping
. bleeding due to deficiency of . right lower quadrant cramp like and colicky pain after
vitamin k meal
. anaemia, electrolyte imbalance . fever, anorexia, weight loss
. Colon become oedematous . disappearing abdominal mass

FEATURES CROHN’S ULCERATIVE COLITIS

CAUSE INFECTION AUTOIMMUNE
SITE Any site (ileum- cecum) Rectum sigmoid
DEPTH trans mural Mucosa
LESION Skipped lesion Continuous
STOOL Bloody Blood and mucosa
WEIGHT LOSS More Less
FISTULA Common No
PAIN SITE Right lower Left lower
TENESMUS No Yes
RECTUM INVOLVEMENT May 100%
ABDOMINAL MASS Yes No
BARIUM String sign Lead pipe sign
TREATMENT Antibiotics Surgery

⮚ Management
● Drug - anti diarrheal, antibiotics, antispasmodic.
● Maintain NPO
● IVF + Electrolyte,
● complete bed rest
● Total parenteral nutrition ( TPN ) - always on IV controller, and frequently monitor
hyperglycemias. Tubing use single use ( maximum 24 hour) & monitor daily weight .
● Following acute phase diet progress from clear liquids to low fibre. Instruct the client to
avoid gas forming food, milk products, whole wheat, grains, nuts, raw fruits, vegetables ,
pepper and alcohol should be avoid.
● Diet elementary diet – it means diet containing all micronutrients and easily absorbing
● Close monitoring any complication
● Monitor complication- bowel perforation leads to peritonitis ( for detail refer
appendicitis )

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COLOSTOMY AND ILEOSTOMY
❖ An stoma create in to large intestine is known as colostomy. In to the small intestine is known as
ileostomy.
❖ PRE OPERATIVE INTERVENTION.
✔ Administer laxative or enema.
✔ Instruct the client to eat a lower fiber diet for 1 – 2 days before surgery.
✔ Administer intestinal antiseptics and antibiotics ( metrogel )as prescribed to clean the bowel
and to decrease the bacterial content of the colon. ( continuous antibiotic administration can
cause bleeding in post operative period due to damages of the intestinal flora )
❖ POST OPERATIVE INTERVENTION

STOMA ABD. SITE STOLL CHARACTER

Ileostomy Right lower Liquid or fluid
Ascending colon Right upper Semi liquid
Transverse colon epigastrium mushy or mud fecus
Desending colon Left upper semi Solid fecus
Sigmoid colon Left lower Normal or solid stool

✔ Initially performing hydrocolloid dressing or wet dressing ( below wet above dry cotton ) for
moisture.
✔ Place a pouch system in the stoma as soon as possible.
✔ Monitor the stoma daily.
● Normal stoma colour is bright red, pink or shiny.
● White colour indicate fungal infection
● Pale pink , peach colour indicate anaemia.
● Purple, black or blanching colour indicate decrease circulation to the stoma indicate
tissue necrosis. Immediately report to the doctor.
✔ Give priority for ileostomy patients ( extra skin layer protection). And apply skin barrier
protecting agent over the stoma. Example karayagum powder or Zinc Oxide.
✔ Post operatively avoid gas forming food and odour forming food. ( cabbage. Broccoli,
cauliflower, egg yolk). During colostomy care if smell occur first ask the client what type of
food he is taken
✔ Colostomy irrigation
● Character – Luke warm tap water ( temperature 106- 110 )

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 ● Amount- 500 to 1000 ml. colostomy irrigation stimulate bowel emptying.
● Position of the client- ambulatory same position sitting in toilet. Bed redden towards
affected side.
● Irrigation tube insert 2-3 inch inside the stoma. And irrigation perform after 1 hour
meal.
● For getting the better result of colostomy irrigation slightly massage the abdomen.
● Avoid frequent irrigation it leads to fluid and electrolyte imbalance.
● During irrigation if pain occur immediately clamp the tube.
● After colostomy the client can perform all normal activities including swimming.
● Oral feeding can start 4-6 days later colostomy ( this is the minimum time for stoma
setting.)
● Take 6-8 week time for complete maturation of stoma.
● Should not apply antibiotics directly over the stoma.
● Nursing diagnosis- disturbed body image.

HEPATITIS

DIGNOSIS

❖ SGPT OR ALT ( highly specific liver enzyme ) is more than 1000

❖ SGOT OR AST ( less specific liver enzyme ) is more than 1000
❖ Alkaline phosphate is normal or slightly elevated
❖ Total bilirubin increased
❖ Serum ammonia is increased only encephalopathy situation
❖ HEP-B (HBSAG)
❖ HEP-A, C, D, E(ELISA)IGM.
Hepatitis A – feco oral route and commonly occur in children during diaper changing. incubation
period 2-6 week

Hepatitis B- serum hepatitis . most highly occur and most commonly occur through blood .
incubation period 6-24 weeks .complication- cirrohosis, hepatocellular carcinoma, fulminant hepatitis.

Hep D- it is the complication of hep B. and occur co infection along with hepatitis B

Hep E – it is a waterborn disease . water purification is the only prevention

65
INVERTOGRAM is a diagnostic test mainly we are using to detect = imperforate anus

PARACENTESIS
⮚ Draining of fluid from the abdominal cavity . it is the management of ascitis
⮚ Pre procedure intervention. Empty the bladder before procedure
⮚ Bedredden patient provide fowlers position and conscious patient positioned upright on the edge of
the bed with the back supported and feet resting on a stool
⮚ Before and after procedure monitor the weight
⮚ After procedure observe hematuria. It indicate blader puncture
⮚ Large amount of fluid will drain at a time this can cause hypovolemic shock

Key points
● Intetestinal obstruction – the clinical feature is silent abdomen or absent peristaltic movement.
priority management fluid and electrolyte management.
● Anoscophy position – left lateral or knee chest
● Proctoscophy – visualisation of the sigmoid colon. position providing during examination is left
lateral with right leg bend

ENDOCRINE SYSTEM
Functions of endocrine system

⮚ Maintenance and regulation of vital functions .

⮚ Response to stress and injury
⮚ Growth and development
⮚ Energy metabolism
⮚ Reproduction
⮚ Maintain fluid electrolyte and acid base balance

66
Note - three glands is equally responsible for to maintain the hormone become normal .

HYPOTHALAMUS- it is situated at the base of the brain. ( master of master gland ) is producing all
type of releasing and inhibiting hormone

PITUITARY ( master gland )

� ANTERIOR LOBE (ADENOHYPOPHYSIS)

� GH- Enhances body growth.

� TSH-stimulate thyroid gland

� ACTH-stimulate adrenal gland

� FSH- stimulate ovary to produce ovum

� LH- stimulate ovary to release ovum

� PRL- Milk secretion and production

� POSTERIOR LOBE (NEUROHYPOPHYSIS) – posterior lobe is not producing any hormone ,is
storing and secreting hormone those produced by the hypothalamus

� OXYTOCIN- uterine contraction during labor and milk ejection.

� VASOPRESSIN – water re-absorption from kidney tubules

DISORDERS OF ADH
� DIABETES INSIPIDUS � SIADH (syndrome of inappropriate ADH)

� It is a condition due to hypo secretion of ADH � It is a condition due to hyper secretion of

ADH
� CAUSES
� CAUSES
� Head injury, infection, Hypophysectomy.
� Pituitary tumour
� S/S
� S/S
� Polyuria
� Water intoxication
� Polydipsia
� Hyponatremia
� Excessive thirst.
� Delirium
� Dehydration- hypotension,
� Tachycardia.
� Tachycardia.
� Passing of concentrated urine.
� Passing of diluted urine.
� High urine specific gravity

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 � Low urine specific gravity � Low serum osmolarity.

� High serum osmolarity. � D/E

� Hypernatremia � Water loading test.

� D/E � MANAGEMENT
� Restrict the fluid intake.
� Water deprivation test. � Hypophysectomy
� MANAGEMENTT � DEMENCOCYCLINE
� Safety. Nursing diagnosis – fluid volume excess
� Increase the fluid intake.
� Administer ADH/ Vasopressin (to decrease urine
output and to Increase the bp) route – intranasal

� Nursing diagnosis- fluid volume dedecit

GROWTH DISOREDER

Increased growth hormone in adult – acromegaly

Increased growth hormone in child – gigantism

Decreased growth hormone- dwarfism . dwarfism child is hyperactive.

THYROID GLAND (situated at the anterior part of the neck )

� It produces:

� T3 ( tri-iodothyronine) and T4 ( thyroxine ) which helps in regulating BMR. The by product of

metabolism is heat, heat stored in our body inthe form of energy .if the tyroid hormone is nomal
range then the metabolism is normal and all physiological function of the body is normal.

� Thyrocalcitonin- which helps in deposition of calcium in bones ( ie decrease blood calcium level )

THYROID DISORDERS

� HYPOTHYROIDISM � HYPERTHYROIDISM

� Condition due to hypo secretion of thyroid � Condition due to hyper secretion of thyroid
hormones (decrease BMR) hormones (INCREASED BMR)
� TYPES
� Types � Primary- increase –T3,T4 &decrease
� Primary- decrease T3,T4 & INCREASE TSH,TRH
TSH,TRH � Secondary- increase T3,T4,TSH &decrease
TRH
� Secondary- decrease T3,T4,TSH &increase � Tertiary- increase – T3,T4,TSH,TRH
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 TRH � CAUSES
� Manipulation during thyroidectomy
� Tertiary- decrease T3,T4,TSH,TRH � Thyroid tumour
� CAUSES � Iodine deficiency
� S/S
� Autoimmune or hashimotor thyroididtis � Increase T3 &T4
� Decrease TSH
� Use of lithium & aminodarone
� Weight loss, soft skin, silky hair
� S/S � Intolerance to heat
� Decrease T3 &T4 � Hypertension & tachypnoea
� Increase TSH � Tachycardia & palpitation
� Weight gain ,fatigue ,hard skin � Diarrhoea
� Intolerance to cold � Insomnia, goitre
� Hypotension � Tremors, diaphoresis, diplopia
� Bradycardia & bradypnoea � Chemosis (redcolour eye )
� Memory changes � Personality changes
� Menstrual irregularities � Exophthalmos (protrusion of eyeball)
� Chances of abortion in pregnancy
� Cardiac enlargement prone to develop CHF
� Constipation
� Dry coarse hair.
� Myxoedema (puffiness over face and Around
eyes) � MGT
� Thyroidectomy
� MGT
� Safety. � Provide cool environment
� Provide warm environment � Decrease the fibre intake.
� Increase the fibre intake. � Administer iodides, beta blocker, propyl
� Administer levothyroxine sodium lifelong.( thiouracil (PTU)
should take in early morning with empty � S/E of PTU
� Agranulocytosis
stomach. Long term use can cause
osteoporosis ) � Bradycardia
� S/E

� Tachycardia, Palpitation
� Complication
� Complication � Thyroid storm- life threatening due to extreme
� Myxoedema coma- life threatening due to high thyroid hormones
extreme low thyroid hormones � Causes – manipulation of thyroid gland during
� Hypothyroidism is not treating early then surgery,infection and stress
chances of mental retardation � C/M –fever, tachycardia, nausea
� Causes – infection, surgery,sudden stoppage vomiting,irritability
of LTS, use of sedatives& anesthetics
� MGT
� C/M – above said clinical features & features � Administer iodides, beta blocker, propyl
of shock thiouracil (PTU) and glucocorticoids before
thyroidectomy
� MGT

69
 � Priority for airway � Permanent management thyroidectomy.
� Administer warm IV isotonic solution
� Iv - LTS

THYROIDECTOMY- ( during surgery position is roses position ie hyperextension of the neck

� PRE-OP intervention

� Administer PTU, POTASIUM IODIDE, beta blocker and glucocorticoids to prevent thyroid storm
during surgery

� Teach the client how to cough post operatively

� POST OP intervention

� Monitor Respiratory status ( first priority for airway), Keep O2,suction tracheostomy set at the bed side

� Semi fowlers position & avoid supine position ( supine position can cause laryngeal oedema )

� Monitor for complication

� Bleeding- at the back of the neck

� Laryngeal nerve damage ( C/ M- hoarseness of voice, muffled voice , dyspnoea, dysphasia )

� Tetany or hypocalcaemia due to accidental injury to the parathyroid gland. If occur prepare to
administer calcium gluconate.

� If complication occur immediately report to the doctor

PARATHYROID GLAND ( situated in side the thyroid gland )

� It produces parathormone which regulates calcium balance in the blood ( increase blood calcium )

HYPOPARATHYROIDISM HYPERPARATHYROIDISM

� Condition due to hypo secretion of parathormone hormone � Condition due to hypersecretion of

(maintaining calcium balance in blood) parathormone hormone
(maintaining calcium balance in
� CAUSES
blood)
� Thyroidectomy
� CAUSES
� S/S
� Tumour
� Hypocalcaemia
� S/S
� Hypophosphatemia
� Hypercalcemia
� Numbness and tingling of lips � Hypophosphatemia
� Excessive thirst.
� Hypotension, bradycardia
� Bone destruction.

70
 � Bronchospasm, laryngospasm � Renal stones.
� MGT
� Seizure
� Decrease calcium and increase
� Positive Chvostek’s sign- contraction of facial muscles in phosphorus.
response to a light tap over the facial � Increase the fluid intake.
nerve in front of the ear � Administer calcitonin- route intra
� Positive trousseau’s sign- carpopedal spasm induced by nasal
inflating the bp cuff above the systolic bp
for a few minutes.
� MGT
� Increase calcium and decrease phosphorus.
� Increase the fluid intake.

� Administer calcium gluconate

ADRENAL GLAND (Situated top of each kidney )

� ADRENAL CORTEX ( outer shell )- Produces corticosteroids, it includes three hormones

1. Glucocorticoids (cortisol, cortisone,corticosterone)- 1. regulate or decrease carbohydrate, protein

metabolism. ( which means increase blood glucose ) 2. suppresses immune response.

2. Mineralocorticoids(aldosterone)- retention of sodium and water and excretion of potassium

3. Androgens- regulate secondary male sexual characteristics.

ADDISON’S DISEASE CUSHING DISEASE

71
� Condition due to hypo secretion of adrenal � Condition due to hyper secretion of adrenal
cortex hormone. ( gluco & mineralocorticoid) cortex hormone.

� CAUSES � CAUSES
� Removal of pituitary or adrenal gland � Pituitary tumour.
� S/S � Overuse of steroid
� Hypoglycaemia
� Weight loss � S/S
� Fatigue, weakness. � Hyperglycaemia
� Hyponatremia-hypotension.
� Hypovolemia
� Hyperkalaemia
� Hypercalcemia
� Bronze pigmentation of skin � Weight gain, muscle wasting and weakness
� Menstrual irregularities in female &impotence in � Moon face, buffalo hump
men � Truncal obesity or centralised obesity with thin
� MGT extrimities
� Administer steroid lifelong.(side effect – � Pendulous abdomen
hyperglycemia,cataract,osteoporosis ) � Hirsutism( abnormal growth of hair in female
� Diet –high calorie ,protein,CHO faces )
� Protect the client from infection � Plethora ( redness over cheek )
� Avoid sedatives ,anesthetics,barbuterates � Hypernatremia-hypertension.
� Hypervolemia-oedema
COMPLICATION-
� Hypokalaemia
Addisonian crisis ( absolute deficiency due to � Hypocalcaemia- tetany
surgery, infection,sudden stoppage of steroids ) � Fragile skin that easily bruises

Clinical features - above said features & features � MGT

of shock � Hypophysectomy/ adrenalectomy.
� Stop steroids
Management � Antihypertensive, diuretics
Adminster IV fluid NS .( RL contra indicated � Special skin care
because hyperkalemia is present ) � Diet – increase calcium, law calorie and low
sodium
Adminster IV hydrocortisone � Nursing diagnosis- impaired skin integrity
� Disturbed body image

ADRENAL MEDULLA ( inner core of adrenal gland )

It produces catecholamines (epinephrine and norepinephrine), it is the part of sympathetic nervous
system which helping for vaoconstruction and increase HR & BP and which helps in regulating vitals

72
 PHEOCHROMOCYTOMA
� Condition due to hyper secretion of catecholamines by adrenal medulla

� CAUSES

� Adrenal tumour

� S/S
� Paroxysmal sustained hypertension
� Tachycardia.
� Hyperglycaemia.
� Palpitation
� D/E - VMA URINE TEST (VANILLYLMANDELIC ACID) in 24hrs urine ( normal value
14mcg/100 ml more than this value pheochromocytoma )
� Biopsy is contra indicated because chance for rupture
� Can take CT,MRI
� MGT
� Avoid beta blockers ( because this can cause hyperglycemia )
� Administer calcium channel blocker and alfa adrenergic receptor blockers
� Adrenalectomy

DISORDER OF THE PANCREAS

Partially endocrine and partially exocrine
⮚ Endocrine cell of pancreas is islets of langerhans
⮚ Alpha cells - secrete glucagon ( gluco - neogenesis is the function ) . the function of
glucagon is the production of glucose from glycogen, protein or fat OR non CHO sources . (
release during hypo glycemic period )
⮚ 1 gram CHO = 4 kilo calories
⮚ 1 gram protein = 4 kilo calories
⮚ 1 gram fat = 9 kilo calories

⮚ Beta cells – secrete insulin ( function – it decrease blood glucose level by shifting blood
glucose in to cells. Shift potassium in to cells. It helps for glycogenolysis – conversion of
glycogen in to glucose )
⮚ Delta cells – produce somatostatin – which suppresses alfa cell and beta cells

DIABETES MELLITUS
� Metabolic disorder ( decrease level of CHO,FAT,PROTEIN metabolism ) due to decrease or absence of
production of insulin by the pancreas.

73
 TYPES

� TYPE-I (IDDM) or juvenile DM . auto immune disorder. Mainly occur less than 13 years. In this
absolute deficiency of insulin

� TYPE-II (NIDDM) – in this type insulin production is present either adequate ( if adequate the demand
of body is high eg. Obese condition ) or the production of insulin is relatively less. So anyway with the
help of an that insulin FAT & PROTEIN METABOLISM 0ccur but CHO metabolism is interrupted
.mainly occur after 35 years ( middle adulthood ), hereditary

� Gestational DM ( refer OBG )

� R/f of type II DM

� Obesity, Family history, Pregnancy, HTN

� S/S

� Polyuria ( osmotic diuresis due to increased renal threshold energy )

� Polydipsia.

� Polyphagia.

� Delayed wound healing ( because the glucose mediated chamber is promoting bacterial growth ). &
decreased circulation to the feet ( due to increased blood viscosity )

� Blurred vision

� Recurrent infection

� D/E

� FBS & PPBS

FBS RANGE PPBS

80-100MG/DL normal 100-140mg/dl

100- 126 mg/dl Pre-diabetic 140-200mg/dl

More than 126mg/dl diabetic More than 200mg/dl

� HBA1C- to detect at least 3 months of glucose control level.( it is the confirmatory test )

� Normal for DM patient- below 7%

� ABOVE 6.5 DM

� MGT
� Exercise at least 3 times in a week ( applicable only in type 2 )
� Diet ( low CHO, FAT and adequate protein )
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� OHA-eg: orinase, tolbutamide, METFORMIN
� Contraindication of OHA

� Type-I, Chronically ill patient, Post op patients

INSULIN

● Store insulin at 2-8 degree

● If –less than 2 degree or more than 30 degree discard it.
● Once vial is opened can use for 28 days.
Type BRAND ONSET PEAK DURATION
NAME(S) How long works
Rapid-acting Humalog 10 to 30 1 to 3 hours 3 to 5 hours
Novolog minutes
Apidra,aspart
Short-acting Regular(R) 10 to 30 2 to 4 hours Up to 12
minutes hours
Intermediate NPH(N) 1.5 to 4 hours 4 to 12 hours Up to 24
acting hours
Long-acting Lantus 0.8 to 4 hours Minimal peak Up to 24
Levemir hours
NOTE- can load regular insulin and NPH in same syringe but first load regular then NPH.

Drug therapy: Insulin

Problems with Insulin therapy

ꟷ Hypoglycemia
ꟷ Allergic reactions
● Local inflammatory reaction
ꟷ Lipodystrophy
● Hypertrophy or atrophy of SQ tissue r/t frequent use of same injection site.
Management- rotate the site of insulin injection

COMPLICATION OF INSULIN

� DAWNS PHENOMENON- Prebreakfast hyperglycaemia between 2-8am due to nocturnal release of

hormones such as cortisol, epinephrine etc.

� MGT- administerintermediate or NPH at bedtime

� SOMOGYI PHENOMENON- Due to peak action of insulin hypoglycaemia occurs at 2-3am which
causes release of counter regulatory hormones which in turn leads to hyperglycaemia at 7am.

� MGT- Administer extra snacks at bedtime or decrease the dose of bed time insulin .

COMPLICATION OF DM

� HYPOGLYCEMIA

� Condition due to low blood glucose level (below 70mg/dl)

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� CAUSE

� Low food intake.

� Excessive thirst

� Increase dose of insulin drugs

� Some drugs can cause hypoglycemia – aspirin, alcohol, sulphonamide, oral contraceptives,
monoamine oxidize inhibitors, ACE-inhibitors

� S/S
� Excessive hunger.diplopia,altered LOC
� Sweating, headache, palpitation.
� Slurred speech, tremors,
� Headache, confusion, seizure
� MGT
� Check the blood glucose level
� If conscious or shaky or responding administer 10-15gm of fast acting CHO (6-10 hard candies, 1 cup of
a juice, 4 tsp of sugar, 1 tbsp. of honey)
� If the patient is not responding or unshaiky DEXTROSE 50 % 30-50ml
� If unconscious administers s/c or IM glucagon

COMPLICATIONS OF DM

TYPE 2 TYPE 1

● Retinopathy ● DKA
● Nephropathy
● Neuropathy
● CAD
● Cholilithiasis
● HGHNKS

DIABETIC KETO ACIDOSIS

� It is the Complication of TYPE-I DM.

� It is due to lack of insulin production by pancreas leading to hyperglycaemia, dehydration and

ketoacidosis. ketone body is the byproduct of fat metabolism. in DKA ketone bodies present in bold and
urine.

� CAUSES

� Illness, infection
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� Lack of insulin intake.

� S/S

� Hyperglycaemia(300-800mg/dl)

� Ketonuria

� Metabolic acidosis, hyperkalemia, dry skin

� Kussmaul’s respiration(DEEP LABORED BREATHING for to eliminate CO2)

� Fruity breath smell.or paint smell breath

� Cellular Dehydration

� D/E- Rothera test – checking albumin in urine

� IV NS, IV INSULINE – infusion always on iv controller

HHNS ( complication of type 2 DM )

Hyperglycaemic, Hyperosmolar, Non-ketonic Coma (HHNC)

● Can occur when the action of insulin in severely inhibited

● Seen in pts. w/ NIDDM, elderly persons w/ NIDDM

Precipitating factors

Infection, renal failure, MI, CVA, GI hemorrhage, Pancreatitis, CHF, TPN, Surgery, dialysis, steroids

S/SX

� Polyuria Oliguria (renal insufficiency)

� Lethargy
� Increase temp, increase PR, decrease BP, signs of severe fluid deficit
� Confusion, seizure, coma
� Blood glucose level 600-1200.

Interventions for DKA and Hyperosmolar Coma

● Regular insulin IV push IV drip

● 0.9% NaCl IV – 1 L during the 1st hr, 2-8 l over 24 hours.
● Administer sodium bicarbonate IV to correct acidosis
● Monitor electrolyte levels, esp. serum K+ levels
● Administer K+, monitor UO hourly (30ml/hr)

CLIENT EDUCATION
TYPE-I patient education.-1. Teach the patient how to adminster insulin.

2. Monthly cross check glucose value in glucometer reading with lab values
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Type 2- Daily observation of foot, avoid hot water because they are having neuropthy. But can use
look warm water it promote circulation.

● Well fitting shoes, Podiatry- Treatment of diabetic foot

GENITO URINARY SYSTEM

FUNCTIONS
❖ maintain homeostasis of the blood and acid base balance
❖ excrete end product of protein metabolism
❖ control fluid & electrolyte balance
❖ excrete bacterial toxins ,water soluble drugs
❖ secrete rennin and erythropoietin ( rennin is produced from juxta glomerular kidney cell &
erythropoetinin is produced by fibroblast in the kidney )

IMPORTANT POINTS
● nephrons is the functional units of the kidney
● the totalbladder capacity – 1 litre
● normal adult urine output – 1.5 litre/day ( have to maintain 30-50ml /hour )
● the inner lining of urinary bladder is covered by transitional epithelium
● creatinine is the end product of protein & muscle metabolism . increased level in the blood
indicate renal failure ( normal value – 0.5 – 1.5 mg/dl )

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 ● BUN by product of proten metabolism in liver
● Normal urine specific gravity – 1.010 to 1.030
● Normal urine color- amber
● Urine specimen collect early morning. Amount 10 – 20 ml
● For urine culture sensitivity collect midstream urine specimen in a sterile container
● Cystocele – prolapsed urinary bladder, management kegel exercise
● Catheterisation
✔ Position ( male supine. Female – lithotomy )
✔ Over foleys catheter pseudo membrane occur, it’s a fungal infection. Drug of choice
fluconazole,cotrimoxazole
● 24 hour urine sample any one sample is missed again restart the procedure
● Renal biopsy position – prone ( after procedure – supine position, post procedure monitor
bleeding at ythe back of the body )

● SPASTIC BLADDER/ OVER ACTIVE BLADDER

✔ A problem with bladder function that causes the sudden need to urinate
✔ RISK FACTOR – obesity, constipation, poorly controlled DM, catheter related infection,
over activity of detrusor urinary muscle
✔ Management – antimuscarinic & intermittent catheterisation

● Cancer bladder clinical feature – painless hematuria

GLOMERULO NEPHRITIS
● destruction,inflamation, and sclerosis of glomeruli of both kidney occurs
● CAUSE - group a beta hemolytic streptococcus.
● Clinical features
✔ Proteinuria, edema
✔ Hematuria ( dark smoky cola colored red brown urine )
✔ Peri orbital edema
✔ H/O throat infection 2-3 week before
● COMPLICATION – pleural effusion, CHF, pulmonary edema,
● Management
✔ Anti- biotic
✔ Fluid restriction – 500-600 ml
✔ Daily weight and I/O charting
✔ Diet – high calorie, low protein, low sodium, low potassium
✔ Nursing diagnosis – fluid volume excess

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 MANAGEMENT

● Anticolinergic
● Example-
● Atropine or benztropine
● Kegels exercise

MANAGEMENT

● Low Sodium Moderatly High Protein

● Penicillin
● Prednisone
● Lasix
● Weight Check. ( same time, scale,
● Special skin care

RENAL CALCULI
TYPES – nephro-lithiasis ( inside the kidney ) ,uro-lithiasis ( inside the ureter ) , cysto-lithiasis ( inside the
urinary bladder )

Causes – purine food, increase calcium,increase vit,D, increase uric acid, immobilisation

Clinical features

● Renal colic which originates in the lumbar region and radiates around the side and down to the
testicles in men and to the bladder in women
● Ureteric colic which radiates towards the genitaliaband thighs
● Nausea and vomiting
● Diaphoresis and hematuria

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 MANAGEMENT

● Priority for pain management

● Monitor vital especially
temperature increase indicate
infection.
● Increase fluid intake
● Avoid massage over the
flank area
● Strain the urine for to detect
the PH
● Dietary- alkaline stone
provide acidic ash food. If
acidic stone provide alkaline
ash food
● Surgery- lithotrypsy

URINARY TRACT INFECTION

❖ ORGANISM - E. COLI, pseudomonas
❖ More common in girls because urethral opening is short and near to rectum
❖ CLINICAL FEATURES

MANAGEMENT

● ANTIBIOTICS –
SULFONAMIDE
● CITRUS JUICE
● INCREASE FLUID
● CLEAN PERINEUM
FROM FRONT TO
BACK
● USE COTTON
UNDERWEAR

BENIGN PROSTATE HYPERTROPHY/HYPERPLASIA

It is a slow enlargement of the prostate gland with hyperplacia ( increase the number of cells ) and
hypertrophy ( increase the size of the tissue )

❖ CAUSES
● AGE ABOVE 60, HIGH DHT ( dy-hydroxy testosterone ), OBESITY, DM.

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❖ DIGNOSIS - PSA ( prostate specific antigen more than 4 nanogram/dl ) – blood sample
❖ MANAGEMENT
✔ alpha adrenergic receeptor blocker (tamsulosin) or terazocin. It can inhibit the
contraction of smooth muscles.
✔ anti antrogen(finasteridin). It will help to decrease hormonal stimulation
❖ S/M - TURP

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 RENAL FAILURE
It is slow progressive irreversible loss in kidney function with GFR less than or equal to 60ml/mt. For 3
month or longer

TYPES

1. ACUTE RENAL FAILURE

2. CHRONIC RENAL FAILURE

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MANAGEMENT – DIALYSIS

RENAL TRANSPLANTATION

Dietary restriction

DIALYSIS PRINCIPLES
OSMOSIS movement of
solvent from
lower
concentration
to higher
concentration.

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DIFFUSION diffusion
movement of
solute from
higher
concentration
to lower
concentration
ULTRA Pressure
FILTRATION needed for
shifting the
fluid
● Maximun No of dialysis in week – 3 .
● Complication of dialysis - diseqilibrium syndrome, air embolism, dialysis encephalopathy

RENAL TRANSPLANTATION

● Maximum transplantation time 72 hours

● Kidney can take from living donour or cadavour donour( brain death patient )
● Ensure that the recipient is free of any infection
● Administer immune suppressive medication to the recipient as prescribed for 2 days
before the transplantation for to prevent rejection.
● Hemodialysis is performed until adequate kidney function is established
● Urine output begins immediately if the donour was a living donoue. It is delayed for a few
days or more with the cadaver kidney
● Client education

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 ✔ Teach rejection features – fever, pain or tenderness over the grafted area, 2-3 ound
weight gain over 24 hours
✔ Edema, hypertension, malaise
✔ Increase- BUN,CREATININE,WBC
✔ Avoid sports and contact with those who are having infection and avoid prolonged
sitting

Key points
⮚ Cystitis means inflammation of the gall bladder, causes – E-coli, enterobacter
⮚ Urethritis is inflammation of urethra

NERVOUS SYSTEM
CLASSIFICATION
⮚ Central nervous system
● Brain
● Spinal cord
⮚ Peripheral nervous system
● Spinal nerves ( 31 pairs )
● Cranial nerves (12 )
⮚ Autonomic nervous system
● Sympathetic nervous system
● Parasympathetic nervous system

Central nervous system

a. Brain
b. Spinal cord
Brain

a. Cerebrum
b. Brainstem
c. Cerebellum
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Cerebrum:

a. Frontal lobe- higher intellectual function, speech production, ipsilateral ,motorfunction, reasoning,
judgement ,thinking, concentration, Broca’s area- motor speech

b. Temporal lobe- hearing, memory, speech perception, Wernicke’s area- auditory comprehension
c. Parietal lobe- primary somatic sensory area and pain and perception.
d. Occipital lobe- vision, colour perception
Brain stem:

a. Medulla oblongata - regulate sneezing, coughing, vomiting, swallowing, controlling vitals

b. Pons-regulation of respiration
c. Midbrain- reflex centre for papillary reflexes and eye movements
Cerebellum: is responsible for equilibrium and posture, BALANCE

Diencephalon – thalamus (controls emotions) and hypothalamus (critical role in temperature

regulation)

Autonomic nervous system

a. Sympathetic nervous system (fight or flight response)

b. Parasympathetic nervous system (conserves, restores function)
Spinal cord

⮚ It is the pathway of spinal nerves

⮚ Total 31 pairs ( cervical – 8, thoracic – 12, lumbar – 5, sacral – 5, coccyx – 1 ). But total vertebral
colom is 33 (( cervical – 7, thoracic – 12, lumbar – 5, sacral – 5, coccyx – 4)
⮚ Much more synapse junction present is spinal cord ( the junction between two neurons )
Meninges

⮚ Covering of brain and spinal cord

⮚ Three layers ( duramater( outer layer ). Arachnoids space(middle ), pia mater(inner layer ) )
⮚ Arachnoids space contain CSF present
⮚ CSF is produced from choroid plexus and absorbed by sub arachnoids willi
⮚ Normal amount ( 120- 150 ml )
⮚ Normal CSF Pressure 5-15 mm of hg or 36-180 cm/h2o
Blood supply – circle of willis ( normal 750 to 1 liter per minute )

Neuro transmitters

⮚ Acetylcholine
⮚ Dopamine
⮚ Nor-epinephrine
⮚ Polypeptides
⮚ Serotonin
⮚ Amino acids

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NEUROLOGICAL ASSESSMENT
Cranial nerves assessment

SR.NO Cranial nerves Type Functions Clinical

significance
1 Olfactory Sensory smell
2 Optic Sensory vision eye pain

3 Occulomotor Motor eyeball movement inability to open

Upper eyelid elevation eye
pupillary reaction
4 Trochlear Motor Upward and downward
movement of eye
5 Trigeminal Mixed Sensory- Touch perception Toothache ,facial
of face, oral and cornea pain
motor-chewing
&swallowing

6. Abducent Motor Lateral movement of eye

7 Facial Mixed Sensory - Taste perception
of anterior two-third of
tongue (sweet and salt)
motor- facial movements
8 Vestibulo Sensory Hearing hearing loss
cochlear(Acoustic
)
9 Glossopharyngeal Mixed Sensory- - Taste perception
of posterior one-third of
tongue
Gag reflux
chewing and swallowing
10 Vagus- it is Mixed parasympathetic function inability to
parasympathetic decrease heart rate produce sound
nerve decrease BP
phonation.
Gag reflux
production of HCl in
stomach
sensation behind ear
11 Spinal Accessory Motor movement of uvula,
trapezius muscle,
sternocleidomastoid muscle
12 Hypoglossal Motor Tongue movement

88
MONITOR THE LEVEL OF CONSCIOUSNESS

ADULT CHILD SCORE

BEST EYE ⮚ Spontaneous ⮚ 4
RESPONSE ⮚ To voice ⮚ shout ⮚ 3
⮚ To pain ⮚ 2
⮚ none ⮚ 1
BEST ⮚ oriented ⮚ coos & babbles ⮚ 5
VERBAL ⮚ confused ⮚ irritable cries ⮚ 4
RESPONSE ⮚ inappropriate words ⮚ cries to pain ⮚ 3
⮚ incomprehensible sound ⮚ moans to pain ⮚ 2
⮚ none ⮚ none ⮚ 1
BEST ⮚ obey command ⮚ 6
MOTOR ⮚ localised pain ⮚ 5
RESPONSE ⮚ withdrawal ( normal flexion ) ⮚ 4
⮚ decortications (abnormal flexion ) ⮚ 3
⮚ decerebration ( extension ) ⮚ 2
⮚ none ⮚ 1

Score 13-15 normal

Less than 8 – unconsciousness
3 –deep coma or death
ASSESSMENT OF PUPIL

⮚ Normal pupil reaction – PERRLA ( pupils equally round and reacting to light and accommodation
⮚ 3-5 mm pupil dilation considered as normal
⮚ Unilateral dilation of pupil indicate compression of third cranial nerve
⮚ Bilateral dilation of pupil indicate midbrain injury ( ominous sign )
⮚ Pin pointed or constricted pupil indicate Pons damage or poison or drug toxicity.

Assessment of posture

Reason for decorticate posture

1. Non- functioning of
cortex

Reson for decerebrate posture

1. Brain stem lesion

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Assessment Of Meningeal Irritation

CLASSICAL SIGN GENERAL FINDINGS

● Neck rigidity ● Nausea & vomiting
● Positive kernigs sign = ● Photophobia
loss of ability of a supine ● Seizure
client to straighten the ● Irritability
leg when it is fully flexed ● Tachy cardia
at the hip and knee. ● Nystagmus
● Positive brudzinki sign- ● Headache
involuntary flexion of hip ● Muscle pain
and knee when the neck ● Personality and behaviour changes
is passively flexed. ● Short attension apan

Diagnostic tests

a. CT- if contrast is used, must be assessed for allergy to iodine or sea food
Lumbar puncture

⮚ LP- insertion of needle into L3-L4 OR L4-L5

⮚ C shape position (LATERAL RECUMBEND)
⮚ Before procedure empty the bladder
⮚ Take consent
⮚ Normal CSF value
a. Cell - 0.5 cells/ml
b. Protein- 15-45 mg/dl
c. Glucose- 45-100 mg/dl
d. Pressure – 70-180 mmH20
e. Post procedure Position- flat in bed for at least 6 hours after procedure
f. Spinal head ache management hydration

Myelogram

⮚ if gas is injected provide Trendelenburg position after procedure and if it is liquid based dye elevate
head and thorax
⮚ Cerebral arteriogram- assess the bilateral pedal pulses

EMG-

⮚ useful to assess muscular dystrophy and nerve disorders

⮚ before procedure avoid apply lotions and cream over the skin
⮚ with held anti coagulant before procedure

90
EEG (electroencephalography)

● Avoid stimulants and sedatives during the procedure, HEAD SHAMPOOING ( for removal of
oil

INCREASE ICP

⮚ Three components is equally responsible for to maintain the icp normal.

● Adequate blood supply- normally 20% of cardiac out put ( 750 ml to 1 litre )
● Adequate electrolyte
● Normal amount of CSF
⮚ If any variation can occur in these factors that can cause cerebral edema. The cerebral edema is the
cause of increase ICP
⮚ Cerebral oedema is three types – vasogenic, cytotoxic, interstitial
⮚ SITUATION that cause increase ICP : cva, brain tumour, seizure, meningitis, encephalitis, head
injury, hydrocephalus, cerebral palsy , craniotomy
⮚ CLINICAL FEATURES

Adult Children
Early signs Early signs
● Altered sensorium (restlessness, ● excessive vomiting
confusion, disorientation) or ● high shrill cry
altered LOC. ● tense bulged anterior
● Headache fontanels
● Projectile vomiting
● Irritation
● Cheyne stroke respiration

Late signs Late signs

● cushing traid ● seizure
✔ systolic hypertension
✔ bradycardia
✔ increase pulse pressure
● Positive Babinski reflex
● Abnormal posture (decorticate,
decerebrate, opisthotonos
posture)
● Seizure

⮚ MANAGEMENT
✔ PRIORITY FOR AIRWAY
✔ Can administer morphine to the client. but the client should be on mechanical ventilator.
(because morphine is respiratory depressants.)
✔ Maintain the PAC02 normal or below normal. Hyper ventilation helps to this process
✔ Avoid nasal suctioning and hypoxia.
✔ Maintain the body temperature normal .because shivering can worsening icp.
✔ Limit fluid intake 1.2 litre per day
91
 ✔ Decrease environmental stimuli.
✔ Avoid Valsalva maneuver. & avoid coughing,sneezing,straining
✔ Elevate head of the bed 15- 30 degree not much more
✔ Avoid hip flexion and neck flexion
✔ Avoid Trendelenburg position
✔ Drug fibre rich for to prevent constipation

⮚ PHARMACOLOGY
✔ Drug of choice – osmotic diuretics eg. mannitol
✔ Anticonvulsive, corticosteroid for to decrease cerebral oedema.
✔ Muscle relaxant for prevent shivering
✔ Administer hypertonic solution and avoid hypotonic solution
✔ Syp. Defolac or lactulose for to prevent constipation
⮚ SURGICAL MANAGEMENT
✔ V P shunt, spinal tapping, endoscopic third ventriculostomy
⮚ NURSING DIAGNOSIS
✔ INEFFECTIVE CEREBRAL TISSUE PERFUSION

STROKE (CEREBROVASCULAR ACCIDENT /BRAIN ATTACK)

It is the neurological dysfunction due to decreased blood supply to the brain especially to cerebrum

Causes

● ischemia due to atherosclerosis

● cerebral aneurysm
● Heart failure
● valvular disorders
● Head injury

Modifiable factors Non modifiable factors

Hypertension , alcohol, obesity ,

smoking , Age
use of oral contraceptives, Gender (high in male but mortality in female
DM , anticoagulant,
stress Ethinicity

Transient Ischemic Attack (TIA)- it is a mini stroke with no dead brain tissue . it the warning sign of
stroke .and it is a temporary focal loss of neurological function caused by ischemia of one of the vascular
territories of the brain. Symptoms last for 24 hour and minimum for 5 minutes

92
Types of stroke

1. Thrombotic stroke - due to ischemia. it constitute 70%

2.Haemorrhagic stroke - due to bleeding. it constitute 30%.

Signs/Symptoms

ASSESSMENT

F- fascial dropping

A- arm weakness

S- slurred speech

T- don’t waste time

● Dysphagia
● Hemiplegia-one side body paralysis
● Unilateral neglect-avoiding affected side
● Homonymous hemianopsia-blindness on the same side of paralysis (management – instruct the client
to scan the room )
● Agnosia- inability to recognize familiar objects or person
● Apraxia-inability to carry out voluntary and skillful movements
● Proprioception alteration- client maintain abnormal posture so risk for injury.
● Aphasia-impaired communication
✔ Expressive – unable to understand what we said (management – provide one pen and paper)
✔ Receptive – unable to understand what we said (management – often a written word or use
communication board)
✔ mixed
● Dysmetria- inability to judge distance
● Acalculia-unable to perform simple mathematics
● Agraphia- cannot write
● Alexia- unable to read
● Right side brain stroke – left side body paralysis
● Left side brain stroke – right side body paralysis

Diagnosis- CT scan

Management

PREVENTIVE

● ISCHEMIC- ANTI COAGULANT, surgery- trans luminal angioplasty,and stenting

● Hemorrhagic- anti hypertensive medication

COLLABORATIVE

● Thrombotic stroke-administer thrombolytics Tissue Plasminogen Activator within 3hrs.after the

onset of clinical feature

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 ● Hemorrhagic stroke- craniotomy
● Management of increased ICP
● prevention of aspiration- provide lateral position, upright position for feeding, AVOID LIQUID
ORALLY.
● Provide pureed diet with thickened fluid
● refer to speech therapist to learn swallowing technique
● provide passive range of motion exercise.
● change position every 2hrly if bedridden..

Craniotomy

Post operative intervention

● prevention of infection
● monitor ICP and neurological status, HR
● provide midline neutral position of head
● prevent neck and hip flexion
● expect periorbital edema and ecchymosis of one or both eyes. if so apply cold compress.
● monitor the drain (30-50ml/Shift).
● provide range of motion exercises.
● administer coumadin for 3-6months

SEIZURES
⮚ Abnormal electrical discharge of the brain from the cerebral hemisphere
⮚ Type
● Generalized seizures (Tonic Clonic) Adult.- tonic clonic, Absent Seizure(Children),
myoclonic, atonic, febrile
● Partial – simple and complex partial
⮚ Stages
● Pre-ictal( aura) - before develop seizure the client body produce warning symptoms( mainly
in sensory form )
● Tonic spasm phase – stiffness of the body . the C/M are – client fall the ground from sitting
or standing position, opisthotonous posture, frothy discharge from mouth, cayanosis, cease
the breath,
● Clonic spasm phase – jerking of the body C/M are – involuntary passage of urine and stool,
tongue or cheek bite with loss of consciuosness
● Post ictal phase - one sleep like stage , headache present

⮚ MANAGEMENT – during seizure

● Priority for airway clearance
● If the client having a seizure, maintain a patent airway. Do not force the jaws open or place
anything in the client’s mouth, and avoid suctioning.
a) Maintain left LATERAL POSITION
b) SAFETY
● Place a pillow under the head for protection of head
● Loosening the cloth
● The drug of choice is phenytoin.

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 ● An adverse effect of phenytoin (dilation) is gingival hyperplasia , hypotension,
bradycardia, purple glove syndrome
● Therapeutic level of phenytoin in blood – 10-20 mg/dl . more than 32 toxic
● Phenytoin antidote – activated charcoal
● Other drug of choice- lorazepam, diazepam , sodium valporate,carbamazepine
● STATUS EPILEPTICUS (LORAZEPAM)
● Nursing diagnosis- during seizure – 1. ineffective airway clearance 2. Risk for injury

MULTIPLE SCLEROSIS
⮚ Demyelization Of Neurons Or CNS. It is a slow progressive disease
⮚ Causes – auto immune disorder, viral infection, usually occurs 20 – 40 years
⮚ Triggering factor- exposure to hot
⮚ Clinical features
Early Middle Terminal stage

● Tremor &spasticity ● Dysarthria( difficulty ● Ataxia

of lower extremities to articulating word ) ● Respiratory
● Parasthesia ● pins needle sensation difficulty
● Diplopia ● shimmering
● Fatigue & weakness ● + babinski reflex
● Optic neuritis

⮚ MANAGEMENT
● To help relieve muscle spasm in a pt who has multiple sclerosis the nurse should administer
baclofen . side effect is tremor
● Avoid Hot Bath & perform regular exercise
● Exercise - Yoga In Ac Room
● Dignostic evaluation EMG
● Drug during exacerbation steroid eg:Iv Prednisone
● Administer immune modulators Interferon Beta 1 A(Betaferon)
● Client should avoid hot temperature it should exacerbate the condition
● Immune suppressants- avonex, betaserone,copaxone
● Diet- increase fluid, low fat, high fibre, food high in potassium, vit B12 , vit.c

MYASTHENIA GRAVIS

⮚ It is a decrease in receptors sites for acetylcholine characterised by considerable weakness and

abnormal fatigue of the voluntary muscles.
⮚ It is an auto immune disease. (The thymus gland is producing the antibody)
⮚ Cause- deficiency of acetylcholine ( function transfer impulses from nerves to muscle )
⮚ Since smallest concentration of ACTH receptors are in cranial nerves
⮚ CLINICAL FEATURES

95
 EARLY LATE
. ptosis . diminished breath sound
. diplopia . respiratory paralysis & failure
. Dysphasia
. weakness and fatigue of
skeletal muscles

⮚ Diagnostic test
o EMG CONFERMATORY TEST
● Ice test
● Tensilon test (Edrophonium chloride) – when ever administer tensilon if the muscle
strength is improving it means myasthenia gravis. If the client condition is deteriorating
that mean cholinergic crisis
● Tensilon - Atropine sulphate is the antidote for tensilon and is given to treat cholinergic
crisis
● Tensilon test side effect – ventricular fibrillation . so keep defibrillator at the bed side
before test
⮚ MANAGEMENT
⮚ Myasthenia gravis worsens with exercise and improvement with rest
⮚ Intubation & mechanical ventilation
⮚ Plasmapheresis
⮚ Drug of choice- Anti cholinesterase eg:Pyridostigmine, neostigmine, prostigmine
⮚ Antidote of anticholinestrase- Atropine sulphate.
⮚ Steroid
⮚ Immune suppressants
⮚ Exercise – blowing bubble exercise
⮚ Complication – myasthenia crisis , c/m – tachycardia,tachypnoea,cayanosis, boweland bladder
incontinence

PARKINSON’S DISEASE
⮚ Its a degenerative disease caused by depletion of dopamine
⮚ It is a basal ganglia disorder. Parkinson’s disease is usually caused by deficiency of dopamine in the
substantia nigra nerve
⮚ Risk factor – Wilsons disease( accumulation of copper in the cells ), encephalitis, repeated head
injury, encephalitis
⮚ Clinical features
a. Parkinson’s main signs are RAT (rigidity, akinesia, and tremors),
b. Resting Tremor, ( pill rolling )-
c. Mask Like Face,
d. Festinating Gate.
e. Drooling of saliva from mouth
f. Bradykinesia( slow movement )
g. cogwheel rigidity( passive movement of limbs can cause severe joint pain ).
h. Monotonic speech ( speech quality is soft )
i. Camptocormia-bent spine syndrome(kyphosis).
j. Bladder incontinence (mgnt. Bladder retraining exercise )
k. Akinesia ( loss of muscle power )

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 ⮚ MANAGEMENT
● SINEMET ( levo dopa+ carbi dopa ), bromocriptine, amantadine. Levodopa-sideeffect is
on-off phenomenon
● PHYSIOTHERAPY – passive range of motion exercise
● Prone position to facilitate posture
● Those who are taking anti Parkinson medicine should avoid vitamin B6 food
( pyridoxine ).
● Should avoid MAOI – chance for hypertensive crisis
● Increase fluid intake
● Diet – high caloric, protein, fibre rich soft diet
● Chances of depression associated with immobility
● Nursing diagnosis - impaired physical mobility, risk for injury

TRIGEMINAL NEURALGIA
⮚ Pain present in the fifth cranial nerve
⮚ Causes – compression of blood vessels, herpes virus infection, infection of teeth
⮚ Clinical features- dysphasia, severe pain on gums, nose, across the cheeks, situations that stimulate
symptoms like cold, hot, face washing
⮚ Management.
● Avoid hot or cool foods and administer fluids
● DRUG CARBAMAZIPINE
● Priority nursing diagnosis - acute pain.

BELL’S PALSY
⮚ Temporary paralysis of one side of the face due to injury to the seventh cranial nerve(7th)
cranial nerve . facial nerve
⮚ Cause – birth injury, trauma, meningitis
⮚ Clinical features – dysphasia, inability to close the eyes, loss of taste
⮚ management
● The major complication of bell’s palsy is keratitis (corneal inflammation) which results from
incomplete eye closure on the affected side.
● DARK ROOM
● STEROID & fascial exercise

GUILLAIN- BARRE SYNDROME (DEMYELINATION OF PNS)

⮚ It is an acute infectious neuronitis of the cranial and peripheral nerves. It is an auto immune disorder
⮚ The major concern in GB syndrome is difficulty breathing, monitor respiratory status closely
⮚ H/ O respiratory or GI infection2-3 week before
⮚ Ascending to descending paralysis
⮚ Diagnosis nerve conduction velocity
⮚ Management - Iv immune globulin IgG, PLASMAPHERESIS, INTUBATE

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AMYOTROPHIC LATERAL SCLEROSIS

⮚ ALS is a condition in which there is a degeneration of motor neurons in both the upper and lower
motor neuron systems.

ENCEPHALITIS
⮚ Inflammation of brain parenchymal cells
⮚ Cause urbo virus
⮚ Drug of choice- Acyclovir (zovirax) is the drug of choice for herpes encephalitis

MENINGITIS
⮚Inflammation of covering of brain
⮚TYPES
⮚PAYOGENIC – BACTERIAL – streptococcus, neisseria, hemophilus influenza type B
⮚ASEPTIC – VIRUL – entero virus, varicella zoaster,
⮚FUNGAL &PROTOZOAL
⮚Risk factor- craniotomy, skull fracture, those who are living in crowded areas . eg dormitory and
prison
⮚ Mode of transmission: bacteria ( airborn/droplet ) virus ( direct contact )
⮚ Clinical features
Signs of meningeal irritation seen in meningitis include nuchal rigidity,
positive Brudzinki’s sign and
positive Kerning’s sign
seizure, increase ICP
⮚ Lumbar puncture

Content of Bacterial infection Viral infection Normal value

CSF
protein decreased Decreases 15-45 mg/dl
glucose decreases Decreases 45-100 mg/dl
cell increases Increases 0- 5 cells/ml
colour cloudy Clear clear

⮚ The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral
palsy often associated with birth trauma
⮚ management
PRIVET ROOM
Dark room
Viral infection – acyclovir
Meningo coccal meningitis can cause septic shock

HEADACHE ( common clinical feature along with neurological disease )

⮚ MIGRAINE. (high in Female. Increase In Morning, Unilateral, Aura, N/V, Photo & Phono
Phobia, 4-72 Hrs)
● DRUG OF CHOICE SUMATRIPTAN.
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 ⮚ CLUSTER HEADACHE (Male, Evening, Unilateral Orbital Periorbital Temporal Pain, 15 Mit -3
Hrs
● MANAGEMENT - O2, BETABLOCKER, SUMATRIPTAN.

⮚ STATUS MIGRANITUS ( head ache more than 72 hours. Avoid –coffee , wine, pickle, chocolate,
cheese, sausage

● Drug – sumatriptine + serotonin agonist

HEAD INJURIES
⮚ It is trauma to the skull resulting in mild to extensive damage to the brain
⮚ Types
a. Open – scalp lacerations
b. Closed - concussion, contusion ( coup and counter coup injury )
c. Hematoma- EDH,SDH, ICH
d. EDH- it is associated with treating of the middle meningeal artery (most severe )
e. SDH- it is associated with tearing of vein
⮚ Clinical features
✔ Altered level of consciousness
✔ Increase ICP features
✔ Battle sign (post auricular or mastoid echymosis )
✔ Racoon eye (purple discoloration around the eye – management- cold application )
⮚ DIAGNOSIS
✔ CT,MRI
✔ If otorrhoea or rhinorrhoea occur perform – HALO RING/ CONCENTRIC RING TEST
(bloody discharge)
✔ If clear discharge perform beta transferin test
⮚ Management
✔ First aid

P-PROTECT
R- REST
I – ICE
C – COMPRESSION
E – ELEVATION

✔ All management of increase ICP

✔ craniotomy
✔ After supra tentorial surgery, the patients should be in the semi fowlers position
✔ After infratentorial surgery, place the patient in flat position

SPINAL CORD INJURY

⮚ Trauma to the spinal cord causes partial or complete disruption of the nerve tract and neurons
⮚ EFFECTS OF SPINAL CORD INJURY
✔ Spinal shock- flaccid paralysis, loss of activity below level of the injury.
✔ Neurogenic Shock; C/M Hypotension, Bradycardia
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 ✔ Autonomic dysreflexia- sudden increase in ICP in patients with spinal cord injury above the
level of T6 .it is due to full bladder or constipation.
✔ Features: severe thrombing headache,severe hypertension and bradycardia, flushing above the
level of injury, dilated pupil, sweating,.
✔ Management; provide semi to high fowlers position 2. Assess for full bladder.
✔ Quadriplegia
✔ Cervical injuries
● C2-C3 is usually fatal
● C4- respiratory difficulty
✔ Thoracic injuries- paraplegia
✔ Lumbar injuries- paraplegia
✔ Sacral injuries- neurogenic bladder
✔ Below the level of injury no sensation , no reflexes, no movement
✔ S2 injury ejaculation problem. S2-S4 erection and ejaculation problem
Priority nursing action

● Raise the head of the bed

● Loose tight clothing on the client
● Check for bladder distension or other noxious stimulus
● Administer antihypertensive medications
● Document
● Always suspect spinal cord injury when trauma occurs until his injury is ruled out.
● Immobilize the client on a spinal backboard with the head in a neutral position to prevent an
incomplete injury from becoming complete . practice LOG ROLL method
● Airway ( only jaw thrust method)
● Administer oxygen
● Monitor vitals
● Initiate aneurysm precautions
● If cervical injury occur prepare for skull tongs and halo fixation device
● Surgery – laminectomy

MUSCULOSKELETAL DISORDERS

OSTEOPOROSIS
⮚ Demineralization of bone is known as osteoporosis.
⮚ Osteoporosis is characterized by decreased bone mass and increased bone fragility.
⮚ Most commonly occur in to the wrist, hip, and vertebral column.
⮚ The condition same as hypercalcemia.
⮚ TYPES /CAUSES
o PRIMARY- the causes are decreased calcium intake, poor vitamin D , old age ( males due to
deficiency of testosterone and in menopausal women due to deficiency of estrogen).
o SECONDARY – the causes are alcoholism, drug induced ( steroids, LevoThyroxine Sodium,
anticonvulsants, aluminum containing antacids ) , malabsorption syndrome.
⮚ Clinical features
o Back pain occurs after lifting or bending.
o Back pain that increases with palpation
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 o Decline in height from vertebral compression
o Dowagers hump.( kyphosis).
o hypercalcemia
o pathological fracture
o renal stones
⮚ Management
o Drug of choice – calcitonin
o Bisphonates – example alendronate.
Action- it inhibit osteoclast mediated bone resorption there by increasing total bone mass.
Side effect – esophagitis, ocular problems.
Contra indication – esophageal disorder, person who do not sit or stand.
Nursing responsibility- should be administered in empty stomach with one glass of water
and should remain sitting or standing and can take food after 30 minutes.
o Instruct the client to perform weight bearing activities for to reduce weight .eg walking
exercise.
o Diet high calcium , protein and vitamin D .

PLANTAR FASCITIS
Inflammation of plantar skin commonly seen in marathon runners due to prolonged use
of heal of the foot
Management - leg stretching exercises, use cushion shoes

GOUT ( NORMAL URIC ACID 3.5 – 7.5 mg/dl)

⮚ Gout is a systemic disease
⮚ CAUSE
o PRIMAY GOUT – result from incomplete purine metabolism ( acidic + protein food )
o SECONDARY – result from another disease . example psoriasis
⮚ Pathology- increased uric acids in the blood can converted to crystal form and deposited in to the soft
tissue can cause renal calculi and deposited in to the joint can cause gauty arthritis.
⮚ Clinical features
o Pain and inflammation of one or more small joints
o Tophi
o Pruritis from urate crystsls in the skin.
o Joint pain and swelling.
⮚ Diagnostic test- synovial fluid aspiration is confirmation test
⮚ Management
o Drug of choice - allopurinol ( zyloprim ) and colchicines
o NSAID
o Provide low purine diet. Take alkaline ash food.
o Take much more water .it will help to excrete the uric acids through urine and to prevent
stone formation.
o Avoid excessive movement of the joint.

RHEUMATOID ARTHRITIS

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⮚ Inflammatory disease leads to destruction of connective tissue and synovial membrane. Mainly
affecting peripheral joints and knee joint.
⮚ Cause – auto immune disease, genetic factor.
⮚ Clinical features- CROSS CHECK THE PICTURE FROM NET

TYPICAL FEATURES OTHERS

1. Early morning stiffness 1.inflamation,tenderness &stiffness of joint
lasting more than
30mts.
2. B/L symmetrical 2.spongy ,soft feeling in the joint
arthritis
3. Ulnar drift 3.increased ESR
4. Swan neck 4.decresed ROM
5. Hamer toe

⮚ DIAGNOSTIC TEST
o X – ray ( joint deterioration )
o Blood test – RA factor
o Synovial tissue biopsy ( showing pannus tissue or granulation tissue)
⮚ MANAGEMENT
o NSAID, steroid, methotrexate ( methotripsin)
o Monitor medication related blood loss through GUAIAC TEST ( stool for occult blood ).
o Surgery – synovectomy , TKR .

OSTEO ARTHRITIS
⮚ It is progressive degeneration of the joint. Marked by progressive deterioration of the articular
cartilage in peripheral and axial joints.
⮚ CAUSE – trauma. Obesity. Fracture. Infection.
⮚ ASSESSMENT- CROSS CHECHK THE PICTURE FROM NET
o Initially pain during activity and will be relieved by rest.
o Difficulty getting up from prolonged sitting.
o Heberdens node- a hard or bony swelling that can develop in the distal inter phalangeal
joints.
o Bouchards node- are hard bony outgrowth on the proximal interphalangeal joints.
⮚ MANAGEMENT
o Corticosteroid directly in to the joints.( intra articular) . after medication continues hot
application.
o NSAID and muscle relaxants.
o Immobilize the affected joints.
o Maintain weight within normal range with a normal well balanced diet.

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 DEVICES USED IN MUSCULO SKELETAL DISORDERS
CRUTCH

⮚ Indication – amputation
⮚ Hold the crutch on the unaffected side and during ambulation the nurse should stand on the affected
side
⮚ Measurement-
⮚ Walking up the stairs- first move unaffected leg then affected leg and crutch.
⮚ Down the stairs- first crutch, then affected leg and then un affected leg.
CANE
⮚ Indication- weakness in to the lower extremities
⮚ Hold the cane on the unaffected side, so that the cane and weaker leg can work together with each
step.
⮚ During ambulation the nurse should stand on the affected side.

WHEEL CHAIR AND STRETCHER.

⮚ Place this material on the unaffected side.
⮚ The nurse should stand on the affected side.

ROLLER WALKER
⮚ Indication- those who are weakness in to the upper extremities

FRACTURE
⮚ It is a break in to the continuity of the bone.
⮚ TYPES.
● Closed or simple
● Comminuted- the bone crushed with three or more fragments.
● Compression- a fractured bone is compressed by other bone
● Depressed – bone fragments are driven inward.
● Green stick – common in children .one side of the bone is Brocken and the other part is
bent.
● Impacted – a part of the fracture bone is driven in to another bone.
● Incomplete
● Oblique – the fracture line runs at an angle across the axis of the bone.
● Open or compound fracture – the bone is exposed to air. Sterile dressing is needed
● Spiral- the break partially encircles bone
● Transverse
● Pathological fracture

⮚ MANAGEMENT
● Immediate intervention is immobilization ( for to prevent further damage and
immobilization is basic requirement for bone healing)
● SPLINT & SLINGS
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 ● Reduction – it restores the bone to proper alignment. Types open and closed.
● Fixation - it provide immediate bone strength. And immobilization. Types internal and
external.
● CAST- Nursing intervention
✔ Keep the cast extremity elevated.
✔ Monitor the distal area – if having poor peripheral pulse, numbness, tingling
sensation, cyanosis, and swelling occur that means cast compression present .
the best nursing intervention is immediately report to the doctor or cut the cast
✔ Instruct the client to keep the cast clean and dry. And avoid stick any object inside the
cast.
✔ If any foul discharge, smell occur from inside the cast or hot spot over the cast
indicate inside the cast infection is present
✔ EXERCISE- during cast – isometric exercise or passive exercise. After cast
removal – active assistive range of motion exercise.

● TRACTION- traction provides proper bone alignment and reduce muscle spasm.
✔ Nursing intervention- maintain proper body alignment.
✔ Ensure that the weight hang freely and do not touch the floor.
✔ Do not remove or lift the weight without a physician order.
✔ Ensure that pulleys are not obstructed and ropes in the pulleys move freely.
✔ TYPES :
o Skeletal traction – priority pin site care with chlorohexidine
o Skin traction
1. Cervical skin traction - it relieve compression and muscle spasm of neck &
extremity.
2. Bucks extension – use fracture in to the lower limbs or tibial bone.
3. Russels or brayands traction- use fracture in to the femur.
4. Dunlops traction- horizontal traction is applying to clear humorous
fracture.

COMPLICATIONS OF FRACTURE

1. Prolonged bed rest can cause bed sore

2. Osteomayelitis
3. DVT
4. FAT embolism.
✔ A fat embolism originates in the bone marrow and occurs after a fracture when a fat globule
is released in to the blood stream.
✔ Client with long bone fracture are at the risk for the development of a fat embolism.( femur,
pelvis, humorous, vertebra, ribs )
✔ It occurs within the first 48-72 hours following injury
✔ Clinical feature - petechial rash or ecchymosis should be present at the side of the neck
or upper chest. Hypotension ( remaining features and management same as pulmonary
embolism )
✔ MANAGEMENT
● Notify the physician

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 ● High fowlere position
● administer Oxygen.
5. PULMONARY EMBOLISM ( refer adult respiratory)

6. COMPARTMENT SYNDROME
✔ It occurs when pressure increases within one or more compartment leading to tough fascia
surrounds muscle group.
✔ Assessment- 5P( Pain, paleness , pulselessness, parasthesia, paralysis) and edema.
✔ Management – notify, fasciotomy
7. DISUSE SYNDROME- is the generic name for a physical state caused by bed rest , immobility or a
lack of physical activity.
8. AVASCULAR NECROSIS- when a fracture interrupts the blodd supply to a section of bone leading
to bone death.

AMPUTATION
⮚ It is the surgical removal of a lower limb or part of the limp
⮚ Classification – 1, traumatic amputation . 2. Surgical amputation.
⮚ Types – 1. Above knee amputation, 2. Below knee amputation, 3. Syme amputation, 4. Mid foot
amputation, 5. Toe amputation.
⮚ POST OP INTERVENTION
❖ After surgery first 24 hour elevate the extremity to prevent hip contracture.
❖ After 24 hour to provide supine position to prevent hip contracture
❖ After 24 hour every day 20 minutes to provide prone position to prevent hip contracture
❖ The second post operative day onwards massage toward the site to make as cylindrical
shape to prepare for prosthesis. It will help to decrease pain and mobilizing the scar.
but the massaging is performing the 15th day for prosthesis preparation.
❖ Use triangular pillows inside and out side the thigh to prevent internal and external rotation of
the thigh.
❖ After 24 hour avoid hip flexion.
❖ Use anti embolism stockings or TED HOSE.
❖ Monitor complications.
1. Bleeding – if occur first mark the area and report to the doctor.
2. Neuroma
3. Infection
4. Phantom limb sensation pain – it is a neurogenic pain treated with high dose
analgesics ( both pre and post operatively ) or with the help of an mirror box
therapy . mirror box therapy will help to convert the sensory perception to visual
perception.
❖ Prepare for prosthesis

TOTAL KNEE REPLACEMENT

⮚ Post operatively 24-48 hours as prescribed to exercise the knee and provide moderate flexion and
extension.
⮚ Administer analgesics before passive range of motion to decrease pain.
⮚ Post operatively initially perform crutch walking.
⮚ Avoid leg crossing and hip flexion post operatively.
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TOTAL HIP REPLACEMENT
⮚ Always maintain leg abduction swith pillow between the legs
⮚ Avoid adduction and leg crossing.
⮚ Post op exercise- isometric quadriceps exercise.

SPINE DEFORMITIES
1 KYPHOSIS - posterior or convex curvature or outward curvature of the spine . commonly seen in
osteoporosis, and parkinsonism
2 LORDOSIS – forward or upward or inward curvature of spine. Also known as concave model. Can
seen in pregnancy.
3 SCOLIOSIS – lateral curvature of spine
4 Management – physiotherapy, brace application, spinal fusion surgery

SPRAIN MANAGEMENT- PRICE

P- Protection.

R-Rest

I-Ice

C-Compression.

E-Elevation

PAGET DISEASE or osteitis deformans

1 . It is a skeletal disorder characterised by exessive proliferation of osteoclast causing cellular
remodelling and deformity of one or more bones. The affected bones shows signs of deregulated
bones remodelling with execessive bone break down and disorganised new bone formation

2 . commonly affected parts - pelvis, femur, lumbar vertebrae and skullbones.

3 . causes - family history, aging, more common in males, associated with viral infections such as
respiratory synctialvirus

4 . C/M - severe bone pain, joint distraction, fracture, arthritis, spine deformities, loss of hearing in one
/both ears

5 . D/E- X-ray, bone scan,elevated alkilane phosphate, normal calcium&phosphorous level

Management

⮚ No permanent cure
⮚ Administer NSAID, calcitonin, bishopnates

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 ⮚ Promote safety measures
⮚ Monitor hearing loss
⮚ Provide vitamin D suppliments
⮚ Surgery – osteotomy
⮚ Exercise – weight bearing exercise

JUVENILE IDEOPATHIC ARTHRITIS

⮚ Auto immune disease affecting the joints and other tissue such as articular cartilage more common in
girls
⮚ C/M – stiffness, swelling, limited motion of affected joints, joints are warm to touch & tender and
painful , UVULITIS ( is an inflammation of the uvula. This is the small piece of finger
shaped tissue that hangs down in the back of the throat. Which carries blindness
⮚ Management. – only supportive not curative, NSAID, methotrexate, corticosteroid, encourage RPM
exercise

OSTEOGENIC SARCOMA/BONE CANCER

⮚ It is common in children
⮚ It affect the metaphysis of the long bone in the lower extrimitied more common in femur
EXERCISE

EYE DISORDERS

ANISOCORIA
⮚ It is a condition characterized by an unequal size of the pupils.
⮚ Cause- 1. Physiological – it is normal
2. Mechanical -- previous trauma or eye surgery or inflammations
3. Oculo motor nerve palsy
4. Pharmacological agent – anticolinergic example atrophine sulphate.
⮚ Management- administer miotics

⮚
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 ADIES SYNDROME
⮚ It is a neurological disorder characterized by a tonicaly dilated pupil that reacts slowly to light but
shows a more definite response to accommodation
⮚ Cause – damage of post ganglionic fibers of the parasympathetic intervention of the eye.
⮚ Pilocarpine drugs for constrict pupil.

REFRACTIVE ERRORS
⮚ MYOPIA – a condition in which close objects apear clearly. But far ones don’t. management –
concave lens.
⮚ HYPEROPIA – long site present .management use convex lens.
⮚ PRESBYOPIA- vision loss due to aging. Due to decreasing elasticity in the lens. To check refractive
errors with the help of ansnellens chart.

CATARACT
⮚ Opacity of the lens
⮚ TYPES / CAUSES
✔ SENILE CATARACT- due to aging process
✔ INHERITED – congenital
✔ TRAUMATIC – due to ant other eye injury
✔ SECONDARY – due to another eye disease or drugs eg long term use of steroids
⮚ CLINICAL FEATURE
✔ Early features: blurred vision (floaters) and decreased color perception
✔ Diplopia, decreased color perception, presence of white pupil, redness of eye ( only in senile

Management - Administer mydriatrics pre operatively - to dilate the pupil eg:atropine. S/E- dry
mouth, constipation, tachycardia

⮚ Surgical management:
✔ Extra capsular extraction of the lens ( phacoemulsification is the principle )
✔ Intra capsular extraction ( total lens and capsule are removed )
⮚ Post operative intervention
✔ Elevate the head of the bed at 45 degree and turn the client from supine to non operative side.
✔ Avoid getting strain to the eye.
✔ Clean the eyes from inner canthus to the outer canthus.
✔ Monitor complication. Decreased vision and pain
✔ The final best vision will not be present until 4-6 week following cataract removal .because
this is the time should take for wound healing
⮚ Nursing diagnosis : disturbed sensory perception related to ocular lens opacity.

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 GLAUCOMA
⮚ A group of ocular diseases resulting in increased intra ocular pressure. increase IOP result from
inadequate drainage of aqueous humor from the canal of schlemm or over production of aqueous
humor. So increase IOP will compress the optic nerve and the pupil is dilated that result blindness.
⮚ Normal IOP Is 10-21 mmof hg . tonometer is using for measure IOP
⮚ Aseesment
✔ Early features- increase IOP, tunnel vision or decreased accommodation
✔ Headache, halos around light , loss of peripheral vision

⮚ Management
✔ Vision problem is not corrected with lenses.
✔ Administer drugs for to decrees IOP. Eg. Timilol , xalatan.
✔ Administer diamox for to decrease the production of aqueous humor
✔ Atropine is contra indicated in this disease (anti colinergics) or mydriatrics ( drugs
which is using for to dilate pupil
✔ Administer miotics for to constrict pupil eg. pilocarpine S/E- bradycardia, hypotension
✔ S/m - trabeculectomy and iridectomy
✔ Eye surgery position – towards the un affected side

RETINAL DETACHMENT
⮚ Detachment or separation of the retina from the epithelial eye wall.
⮚ It occurs when the layers of the retina separate because of accumulation of fluid between them or
tumors.
⮚ When detachment become complete blindness occurs.
⮚ Assessment : flashes of light, sense of curtain being drawn over the eye, floaters or black spot
⮚ MANAGEMENT
✔ Provide bed rest. Cover both eyes to prevent further damage.
✔ Avid jerky head movement
✔ Cryosurgery : nitrous oxide is injecting into the epithelial eye wall and to freeze the cells
✔ Vitrectomy : after surgery prone position
✔ Drainage of fluid from sub retinal space
✔ Sclera buckling, laser therapy .

EAR DISORDERS
Anatomy and physiology

⮚ Function : hearing and maintenance of body balance or equilibrium.

⮚ Anatomy
✔ Outer ear – pinna, mastoid process, auditory canal and anterior portion of the ear drum .
function collecting the sound waves.
✔ Middle ear - ear drum , maleus, incus, stapes ( smallest bone in human body),( the bony
ossicles which decrease the amplitude of the sound ) and Eustachian tube ( which allows
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 equalization of air pressure on each side of the tympanic membrane so that the membrane
does not rupture)
✔ Inner ear - semicircular canal and cochlea, and the cochlea contain eighth cranial nerve
vestibule cochlear nerve.
✔ which is helping for hearing and maintain equilibrium of the human body.

EAR ASSESSMENT

⮚ Autoschopic examination – less than 3 year pinna down and back more than 3 year up and back for
to visualize the auditory canal . Normal character of tympanic membrane is grey color , opaque .
⮚ TUNING FORK TEST
✔ Webers test _ place the vibrating tuning fork at the middle of the for head or in front of the
nose, if patient get conduction equally in both ears(normal). if the conduction is louder in one
ear it denotes conductive hearing loss to that ear. this is performing to detect conductive
hearing loss.
✔ Rinne test – place the vibrating tuning fork at the mastoid process patient get vibration to an
extent through the bone. after the vibration is stopped place the fork in front of ear to get
vibration through air If air conduction is more than bone conduction it indicates positive test
or normal hearing . air conduction is two times longer than bone conduction
⮚ Vestibular assessment
✔ Caloric test- is a test of the vestibulo-ocular reflex that involves irrigating cold or warm
water or air into the external auditory canal. Ice cold or warm water or air is irrigated into the
external auditory canal, usually using a syringe. If the water is warm (44 °C or above) is
used horizontal nystagmus towards irrigated ear. If the water is cold, relative to body
temperature (30 °C or below) horizontal nystagmus away from irrigated ear.
✔ Romberg test-Romberg's test, Romberg's sign, or the Romberg maneuver is a test used in an
exam of neurological function for balance. Ask the subject to stand erect with feet together
and eyes closed. Watch the movement of the body in relation to a perpendicular object behind
the subject. Romberg'stest is positive if the patient falls while the eyes are closed.
✔ Hallpikes maneuver-The client starts on sitting position, the examiner lowers the client to the
exam table and rather quickly turns the client's head to 45 degree position. If after about 30
seconds there is no nystagmus, the client is returned to a sitting position and the test is
repeated on the other side.
✔ Gaze nystagmus evaluation- client's eyes are examined as the client looks straight ahead, 30
degrees to each side, upward and downward.Any spontaneous nystagmus-an involuntary,
rhythmic, rapid twitching of eyeballs- represent a problem with the vestibular system.

⮚ TERMINOLOGIES
✔ Otalgia – ear pain
✔ Cholesteatoma - tumor of the middle ear and mastoid process that contain cholesterol.
✔ Labyrinthitis – inflammation of the labyrinth membrane
✔ Cerumen – ear vax
✔ Otosclerosis – a condition characterized by abnormal spongy bone formation around the
stapes . this is a middle ear problem can cause conductice hearing loss. Management
stapedectomy.
✔ Presbycusis- progressive hearing loss associated with aging process
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 ✔ Myringitis – inflammation of the tympanic membrane.
✔ Ototoxic drugs- aminoglycoside antibiotics( streptomycin, gentamycin, amikacin,
tobramycin. )
- Anti neoplastic ( cisplatin vincristine)
- Diuretics eg. Lasix
- Others Eg. Quinine, aspirin and salicylate.

⮚ EAR SURGERIES ( cross check the picture from net )

✔ MYRINGOTOMY OR TYMPANOTOMY – incision in to the tympanic membrane.
✔ OSSICULOPLASTY – surgical re construction in to the three bony ossicles in the
middle ear
✔ STAPEDECTOMY – removal of stapes ( stapedotomy means incision in to the stapes)
✔ FENESTRATION – complete removal of stapes and prosthesis insertion
✔ MYRINGOPLASY OR TYMPANOPLASTY – repairing of the tympanic membrane.

MENIERES DISEASEOR ENDOLYMPHATIC HYDROPS

⮚ It is a disorder of the inner ear. That can affect auditory system and vestibular system. it refers to
dilation of the endolymphatic system by over production or poor reabsorption.
⮚ CAUSES: viral or bacterial infection, allergic reaction, long term stress, women more than men,
retention of sodium
⮚ Clinical feature
✔ Typical symptoms – tinnitus , vertigo, sensory neural hearing loss
✔ Photophobia, nausea and vomiting, severe head ache

⮚ MANAGEMENT
✔ Anti-histamine
✔ Diuretics – lasix
✔ Anti emetics and vestibulosupressants ( haloperidol )
✔ Sedative eg. Diazepam
✔ Cryosurgery and endolymphatic drainage
✔ Complete bed rest ,provide assistance for walking.
✔ Initiate sodium and water restriction

OTITIS MEDIA
⮚ Inflammation of the middle ear. Mainly occur in children. It is occurring as a result of a blocked
Eustachian tube. It is a common complication of acute respiratory infection.
⮚ Infants and children are more prone to otitis media because their eustachian tubes are shorter wider
and straighter
⮚ Cause:
● The common cause is streptococcus pneumonia.
● Hemophilus influenza
● Moraxella catarrhalis
● High risk: child not maintain up right position for feeding, bottle feeding baby, acute
respiratory infection.
⮚ CLINICAL FEATURE
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 ● Excessive crying, fever, irritability
● Older children complaint otalgia
● Rolling of head from side to side and pulling on or rubbing the ear
● Otorrhea
⮚ MANAGEMENT
● ENCOURAGE fluid intake and avoid chewing because it increases pain
● Position – affected side down.
● Administer analgesics or antibiotic ear drops for 14 days
● Surgery – myringotomy and insertion of tympanoplasty tubes into the middle ear to equalize
pressure and keep the ear aerated. It is a surgical procedure for facilitating drainage in otitis
media.
● Post-operative intervention
▪ Avoid – Airplane travelling, nose blowing, pinch the nose trills, vigorous coughing
and sneezing, and avoid take water through straw
▪ Keep the ear clean and dry
▪ Use ear plug during shampooing
▪ Instruct the parents that if the tubes fall outs it is not an emergency but the physician
should be notified.
⮚ PREVENTION
● MAINTAIN UPRIGHT POSITION FOR FEEDING
● Promote breast feeding and avoid bottle feeding
● Keep immunization up to date
● Early treat upper respiratory infection

ACOUSTIC NEUROMA
⮚ Benign tumor in the distal portion of the eight cranial nerve ( aquastic nerve)
⮚ Clinical feature - tinnitus, vertigo, and sensory neural hearing loss
⮚ Management- surgery through craniotomy

DERMATOLOGY
BURNS
⮚ Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolyte
⮚ Types – 1. Thermal burn
2. electrical burn
3. chemical burn
4. inhalation
5. radiation

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 ⮚ CLASSIFICATION

ACCORDING TO BURN ACCORDING TO EXTENT OF BODY SURFACE AREA

DEPTH
RULE OF 9 IN ADULT IB BABIES &
YOUNG CHILDREN
FIRST Head & neck– 18%
DEGREE(SUPERFICIAL);
RED, DRY, PAINFUL, Each arm 9X2=18%
HEALING 5-10 DAY.
Back &buttoks – 18%
SECOND DEGREE
PARTIAL THICKNESS Chest &abdomen-
SUPERFICAL; EPIDERMIS =18%
DERMIS, RED WITH BLISTER, Lower extremity –
MOIST, VERY PAINFUL,2-3 13.5 X 2 = 27%
WEEKS.SCALDS Genitalia – 1%
DEEP PARTIAL THICKNESS;
DEEP DERMIS, YELLOW
WHITE, DRY, DISCOMFORT,3- Head – 9%
8 WEEK, SCARRING. Ant. trunk -18%
Post. Trunk – 18%
Upper extremity – 9X2=18%
THIRD DEGREE (FULL
THICKNESS) FULL DERMIS, Lower extremity – 18X2 = 36%
WHITE OR BROWN, Genitalia – 1%
LEATHERY, PAINLESS,
MONTHS.

FOURTH DEGREE; MUSCLE,

BONE, BLACK, ESCHAR, DRY,
PAINLESS, AMPUTATION.

COMPLICATION

⮚ If burn occur in the face, neck ,and chest = pulmonary complication

⮚ Other body area – electrolyte imbalance- HYPERKALEMIA, HYPONATREMIA
⮚ 24-48hrs Hypovolemia
⮚ 48-72hrs Diuresis phase.
⮚ CAUSE OF DEATH : ARDS, hypovolemia, septic shock, arrhythmia, renal failure
⮚ Common burn in children – scald burn ( liquids and gases ). Burn in children can cause growth
restriction
⮚ Most critical burn neck burn

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 ⮚ Management
● First aid

R RESCUE
A ALARM
C CONFINE
E EXTINGUSH
P PULLED UP
A AIM AT BASE
S SQUEEZE
S SWEEP

● Emergency phase management- priority for ABC & calculate the percentage of burn
● Resuscitative phase – administer fluid to prevent hypovolemic shock . mainly using
parkland formula

● Medication only IM
● Reverse isolation/ PPI
● Diet High Protein, Calorie,
Vit-C, D, Zinc.

● Acute phase - wound care

Wound care steps Types of wound covering

⮚ Hydrotherapy ( time 30 min ⮚ Auto graft
⮚ Debridement ⮚ Homograft
● Mechanical ⮚ Xeno graft
● Enzymatic ⮚ Cultured skin
● Surgical ⮚ amnion
⮚ Wound coverings
⮚ Wound closure
● rehabilitative phase – rehabilitative planning should be done at the time of admission onwards

nursing diagnosis
⮚ burn present in face , neck, chest – ineffective airway clearance
⮚ 80% burn all over the body – fluid volume deficit
⮚ 80% burn priority nursing diagnosis at the time of discharge – disturbed body image

PHEMPHIGUS
⮚ It is an auto immune disease commonly affecting oral cavity .
⮚ C/M – it present as oral blisters especially in the buccal and the palate mucosa
- Weight loss, mal nutrition
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 - It also affect conjunctiva, nose, esophagus, vulva, vagina, pelvis, anus
- Blister can leads to ulcerative lesion

D/E – positive NIKOLSKYS SIGN (RUBBING OF SKIN CAUSES EXFOLIATION)

⮚ Management /- cortico steroid & immune suppressants and plasmapheresis

PRESSURE ULCER
⮚ Causes – immobility. Mal
nutrition, sensory deprivation
⮚ STAGES;
⮚ Stage 1; non blanchable redness.
⮚ Stage 2; blister, red, shallow
crater.
⮚ Stage3; deep crater,
subcutanious tissue affected.
⮚ Stage 4; bone tendon muscle.
⮚ Stage 5; unstageable, escar.

COMPONENTS OF BRADEN SCALE.

1. Sensory perception.
2. Activity
3. Mobility
4. Nutrition
5. Moisture
6. Friction/shear
Management

Preventive Collaborative
● Every 2 hourly change the position ● Avoid massage over the red area
of the client ● Antibiotics
● Use air bed or water bed ● Skin grafting
● Be sheet is wrinkle free ● Perform hydrocolloid dressing or wet
● Keep skin clean and dry dressing
● Use cream and lotions to lubricate ● DIET HIGH PROTEIN HIGH CALORIE
the skin VIT-C ( but first priority for protein )
● ROM every 8 hourly

Risk for impaired skin integrity Impaired skin integrity

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ALOPACIA – loss of hair
Types Alopecia acreta
● Alopecia totalis- no hair in the
head
● Alopecia universalis – no hair in
the body
● Alopecia acreta- auto immune
disease. In which bald spot in
the head of any shapes .
management – corticosteroid

Types of Wound drainage

Serous Clear watery plasma

Purulant Thick, yellow, green tan or brown

Sero sanguineous Pale, Pink, watery mixture of clear and red fluid.

Sanguineous Bright red indicate active bleeding.

Stages of Wound Healing

Stage IHemostasis and inflammatory phase
● Bleeding is stop and area become inflamed.
Stage IIProliferative phase
● Formation of new granulation tissue like cell, nerves and blood vessels
Stage IIIMaturation Phase
● Formation of Black Crest or Eschar that helps to healing.

TYPES OF WOUND HEALING.

1. PRIMARY INTENTION- wound is closed by suturing.

2. SECONDARY INTENTION- wound is closed by a graft or a flap.
3. TERTIARY INTENTION- wound is left open for a variable period.

PSORIASIS
⮚ It is a long lasting auto immune disease characterized by silverey patches of the skin.
⮚ Causes – long term stress, hormonal change, medication.
⮚ Clinical features.
❖ Red dry itchy wound

116
 ❖
Skin scaling lesion - silver colored in center red boundary
❖
Yellow discoloration, pitting, and thickening of the nail
❖
Psoriatic arthritis
Koebner phenomenon – is the development of psoriatic lesion at the of injury. such as
❖
scratched or sunburn area
⮚ Management
❖ Topical medication – coal tar, gluco-corticoid, anthralin
❖ Systemic medication – 1. Acitretin – slowing cell production 2. Cyclosporine and
methotrexate

SYSTEMIC LUPUS ERETHEMATUS (SLE)

⮚ Auto immune disease commonly affect heart, kidney, joint and connective tissue
⮚ Chronic progressive, systemic inflammatory disease that can cause major organs and systems to fail.
⮚ Assessment – malar rash or butterfly rashes of the face. Discoid rashes
⮚ Diagnosis – positive ANA test ( anti nuclear anti body )
⮚ Management- immune suppressants. plasmapheresis

SKIN CANCER ( cross check the picture frm net )

⮚ BASAL CELL CARCINOMA – this is the mostcommon types. It affect the basal cell of epidermis
and metastasis to other organs. It appear as waxy border with papule with red centre crater. (
central depression )
⮚ SQUAMOUS CELL CARCINOMA – it affect the keratinocytes and can metastasis via lymph
nodes. It appear as a oozing, bleeding crusted lesion (a black center like )
⮚ MELANOMA – new unusual growth or changes in the existing mole. The most serious type of skin
cancer. It affect the melanocyte and it is a highly fatal condition. Which metastasis can occur to the
brain,lung, bone or liver .
⮚ Assessment.
❖ Melanoma ABCDEFG ( these characters are used by the dermatologist to classify melanoma
❖ A – asymmetry
❖ B – border( irregular with edges )
❖ C – color
❖ D – diameter (more than 6 mm )
❖ E - evolving/ elevated
❖ F- firm to touch
❖ G – growing
⮚ Management – chemotherapy and radiation therapy
⮚ Prevention – avoid sun exposure from 11am to 3 pm. Apply sun screen lotion with ( SPF- sun
protection factor)20 to 30 minute before going out

TINEA SKIN INFECTION

⮚ Fungal infection of the skin. Mainly affect feet between toes and groin.
⮚ Types
❖ TINEA PEDIS – of the foot between the toes . also known athletes foot
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 TINEA UNGUINM – inflammation of toes or finger nails.
❖
TINEA CRURIS – inflammation to the groin.
❖
TINEA CORPORIS – inflammation other part of the body..
❖
❖
TINEA CAPITUS- fungal infection of scalp presented with loss of hair with ulceration of
scalp
⮚ Assessment – redness , itching, a rash that may form blister. More extreme cases oozing is present.
⮚ Management - contact isolation. Anti fungal agent – cotrimoxazole.

BEE STING BITE ( give emergency attention to the patient)

⮚ Bee sting ……..> histamine release……….>bronco construction…………>
dyspnoea/wheezing/rashes
⮚ Rashes usually wheel like reaction ( cross check the picture from net )
⮚ Management
✔ Quicly remove the sting and application of ice packs
✔ Sting is usually removed by scraping or brushing with the edge of he needle
✔ If the victim is allergic to venom of bee, there will be swelling of lips, tongue, and rashes and
pruritis.
✔ To prevent anaphylactic shock administer subcutaneous adrenaline

LYME DISEASE
Causative organism-Borrelia burgodeferi

it is caused from a tick bite commonly seen in wooden or grassy area.

signs/symptoms

1. asymptomatic
2. symptoms appear days to months after bite.
3. a small pimple develops that progress into a ring shape rash (bullseye rash) ( picture from net )
4. flu like symptoms.
5. neurological and cardiac manifestation
Management
● Gently remove the tick with tweezer and flush it in toilet.
● administer antibiotics & avoid wooden and grassy area.

SHINGLES
⮚ it is an acute viral infection of dorsal nerve route of ganglion caused by herpes zoaster virus
⮚ it can be caused by reactivation of varizella zoaster with history of chicken pox or immune
suppressive condition
⮚ MOT – airborn, droplets, direct contact
⮚ C/M – fever, crusted skin vesicles along the peripheral sensory nerves of the trunk,thorax,anf
face, burning sensation, pruritis or itching.
⮚ Management - isolation, maintain standard and contact isolation, antiviral ( acyclovir or zovinax )
and analgesics& corticosteroid
⮚ Vaccination – varicella

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 PAEDIATRIC NURSING

GROWTH AND DEVELOPMENT

Growth Increase the size of the body. It can measure in the form of KG, cm, lbs

Development It is defined as progression towards maturity. Thus the terms are used together to describe
the physical mental, and emotional processes associated with the growing up of children.

New Born Position

Term babies Supine position

Pre term babies Lateral/ Semi prone

ANTHROPOMETRIC MEASUREMENT OF THE NEW BORN

Birth weight – 2.7-3.9kg

Height 45- 55 cm

Chest circumference 31-33cm (it is less than 2 cm of head circumference).

Head circumference 33-35 CM

CHANGES OF ANTROPOMETRICAL MEASUREMENT

● Birth weight doubled at 6 month and tripled at 1 year. (9kg)

● Height increases by ¾ inch per month
● By 1 -2 years of age head circumference and chest circumference are equal after that chest circumference
is increase head circumference comparatively decreasing.

GROWTH PERIODS
New Born Birth – 28 days

Infant – 1 month to 1 year

Toddler – 1 year to 3 year

Pre-school – 4 year to 6year

School age children – 6 year to 12 year

Adolescence – 12 – 18 year

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 GROWTH CHART

Appropriate for Gestational Age (AGA) – between 10th and 90th percentiles

It can be presumed to have grown at a normal rate regardless of the time of birth-preterm, term or post-term

Large for Gestational Age (LGA) – above 90th percentiles

It can be presumed to have grown at an accelerated rate during fetal life;

Small for Gestational Age (LGA) – below 10th percentiles

It can be assumed to have intrauterine growth restriction or delay.

MILE STONES INFANT

2 – 3 month

Social smile begins

Turn head side to side

Hold head in midline

4 – 5month

Grasps object

Turn head side to side

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 6 – 7month Creeps

Sit with support

Exhibit fear of strangers

8 – 9month Sit steadily unsupported

Crawls

May stand while holding on

10 – 11 month

Can change form prone to sitting position

Walks while holding on to furniture

Stand securely

12 – 13 monthWalks with one hand held

Can drink from a cup

14 – 15 month Walk alone

Can crawl upstairs

24 month Pour water into a cup

3 year- rides tricycle, throw a ball overhead. 4 years- hop on one foot.

NEW BORN ASSESSMENT

The new born requires through skilled observation to ensure a satisfactory adjustment to extras uterine life.

ASSESSMENT ORDER IN NEWBORN

● Respiratory system
● Cardiovascular system
● Integumentary system

OR

1. Respiration, 2. heart rate, 3. Temperature, 4. reflexes

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 Step I INITIAL ASSESSMENT - APGAR SCORE

SIGNS SCORE
0 1 2
RESPIRATION Apnea Slow, irregular or weak cry Good cry or lusty cry

HEART RATE Absent Less than 100 Over 100

MUSCLE TONE Flaccid Flexion of extremities Active body

movement
REFLEX No response Grimace Cough or sneeze
IRRITABILITY
COLOR Blue or pale Body pink but extremities Complete pink
blue or acrocynosis

Scoring - 7 – 10 normal

4 -6 mild depression

0 -3 severe depression

Note : - Evaluation of all fine categories are made on 1 – 5 minutes after birth.

Step II

Head to foot examination

1. Skin
● Normally bright red smooth with lanugos and white cheesy substances or vernix caseosa
● Abnormal findings ( cross check the picture from net )
● Milia
● Mongolian spot
● Erythema toxicum
● Harlequin coloration and mottling
2. Head
● Anterior fontanel or Bregma– diamond in shape
close at 18 month.
Posterior fontanel or lamda-triangular in shape
close at 1 ½ - 3 month

Monitor any abnormality

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a) Craniosynostosis / Brachycephaly
→ It is a condition in which one or more of a fibrous sutures in an infant skull permanently fuses their by
changing the growth pattern of the skull.
b) Caput succedaneum
→ It is the edema of the soft tissue over bone
c) Cephalohematoma
→ It is swelling caused by bleeding in to an area between the bone and its periosteum.

3. Neck and facial feature

a) Bell’s PalsyTemporary paralysis of one side of the face due to injury to the seventh cranial nerve that is
facial nerve.
b) Erb’s Palsy Upper brachial plexus injury can cause Erb’s palsy. It is also called waiters tip hand
c) Klumpke Palsy Lower plexus injury can cause Klumpke palsy.
d) Neck - Tonic neck reflex present. Abnormalities in neck – Torticollis or torticose neck syndrome. It may
be due to injury to the sternocleidomastoid muscle

4. Chest

a) Anterior, posterior and lateral diameter are same

b) Abnormalities in chest
● Pigeon chests or pectus carinatum or convex chest
● Funnel chest or pectus exacavatum or concave chest

5. Umbilicus

a) Should have 2 artery and 1 vein

6. Monitor any congenital abnormality in another part of the body.

Eg :- Heart, Abdomen, Extremities, Genitalia.

ASSESSMENT OF REFLEXES IN NEW BORN

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 1. Sucking and Rooting
● Touch the new born lip, cheek or corner of the mouth with a nipple. The new born turn head towards the
nipple, opens the mouth takes hold of the nipple and sucks. Disappear after 3 – 4 month old. But persist
up to 1 year.
● If sucking is absent, to give spoon feeding

2. Tonic Neck or Fencing Reflex

● As the new born faces the left side, the left arm and leg extend outward while the right arm and leg flex
● Disappear 3 – 4 month old

3. Palmar Grasp Reflex

● Light touch of the palm produces reflex flexion of the fingers.

● Disappear 3 – 4 month old.

4. Plantar Grasp Reflex

● Placing object or finger beneath the toes causes curling of toes around the object.
● Disappear 8 – 12 month old

5. Moro’s Reflex / Startle Reflex

● Elicited by pulling the baby halfway to sitting position from supine and suddenly let the head fall back.
● Consist of rapid abduction and extension of arms with the opening of bands, tensing of the back muscles.
Flexion of the leg and crying.It is used to defect hearing in infants.

TEETH ERUPTION
● 6– 8 month lower incisors
● 8 – 12 month Upper incisors
● 13 – 19 month Pre –molars and molars
● 16 – 23 month Canine and cuspid
● At 28 month 20 temporary teeth.
● Oral care started at 1 year
● Toilet training start at 2 – 3 year(bowel training at 2 year bladder training at 3 year)
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 Play Therapy

● Infancy Solitary play

● Toddler Parallel play or therapeutic play (child Never share the toys)
● Pre – School Co-operative play (They share the toys)
● School age Competitive play
● Adolescence Games and Athletic Activity

● Site of IM injection in Children

● Infant or (less than 3 year)Vastus lateralis, Rectus femoralis.
● Children (After 3 year) Deltoid

BREAST FEEDING
● According to the WHO and AAP breast feeding is the normal way of providing young infants with the
nutrients they need for healthy growth and development.
● Breast feeding helps defiance against infections, prevent allergies and protect against a number of
chronic conditions.
● BFHI 1991

Physiology of Lactation

1. MammogenesisEnlargement of breast and protruding the nipple

→ Estrogen and progesterone is helping in this stage
2. Lactogenesis Synthesis and secreting of milk in the breast alveolar cells. Prolactin is helping for
this stage.
3. Galactokinases Ejection of milk. Oxytocin is helping to stimulate the breast alveolar cells to eject
the milk.
4. Galactopoesis Maintenance of lactation. hormone responsible for this stage is prolactin and
adequate sucking.

Types of Breast milk

1. Colostrums’ First four days
2. Transitional milk 4th day to 15 day
3. Mature milk 15th day onwards

Benefits of Breast feeding – maternal

● Economical easily available

● Sucking is stimulating oxytocin production thus to prevent PPH.
● Promote Rooming In.
● It is natural method of contraception.
● Reduce risk of diabetes mellitus and ovarian cancer.

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 Nursing Intervention

● Maintain upright position for feeding

● First sucking is helping to stimulate the breast alveolar cells
● Practice good LATCH –ON to prevent drooling of milk
● Empty one breast, and start another. Because then only the child will get both fore milk and Hind milk
● A healthy mother will produce about 500 – 800ml of milk/day. she require about 700 Kcal/
Aditional/day
● Practice demand feeding policy

Drugs to Improve milk production

● Metoclopramide -10mg TDS

● Sulpulride
● Intranasal oxytocin – side effect nasalvasoconstruction

CONTRA INDICATION

Maternal

→ Acute breast complication eg. breast abscess

→ Herpus simplex lesion of the breast
→ Puperial psychosis
→ Receiving drugs
Eg : Antiepileptic, Ant cancerous, Antipsychotic
→ HIV

Neonatal
→ Birth Asphyxia, Increase lCP, lactose intolarance, Galactosemia

GENETIC DISORDERS
Types

1. Autosomal Dominant trait disorder

● Males and females are equally affected.

● Any one parent or both parentsare affected.
● In dominant trait disorder disease features externally visible in the body.
● If One parent is affected(getting 50% chance of inheritance)or Both parent should affected–
(getting100% chance of inheritance ).
Eg:- Achondroplacia or congenital dwarfism, Adult PKD

126
 2. Autosomal Recessive Trait disorder

● Males and females are equally affected.

● Parents are only the carriers(sign and symptoms of the disease is externally absent. it is hidden in the
body)
● If only one parent is the carrier getting 25% Chances for the disease affecting to the child, 25% Chance
for unaffected the disease. But 50% chance for again the child is in carrier stage
Eg :- Cystic fibrosis, beta thalassemia, PKU, Infantile PKD, sickle cell anemia.
3. X – linked Recessive trait disorders
● Males are affected. But females are the carrier
Eg :- Hemophilia
● Female child is getting carrier stage from diseased father and the boy become infected from carrier
mother.

Example 1:- Father has no hemophilia. But mother is the carrier. The result is

If Boy child 50% the disease is affecting

If female child 0% chance for the carrier stage

Example 2:-Father hemophilic positive. But mother not in carrier stage the result become

If Boy child – 0% chance for hemophilia.

If female child – 100% chance for carrier stage

NOTE- but rarely the disease is affecting to the female. (if father is hemophilic and mother is the
carrier situation)

RESPIRATORY DISORDER

CROUP SYNDROME
● It is Laryngeotracheobronchitis
● Risk group 3 month – 5 years
● Cause allergy/ Para influenza virus.mycoplasma, respiratory synctyl virus ( droplet infection )

Clinical Features

● Mild fever
● Barking cough due to laryngeal edema
● Wheezing
● Diaphoresis
● Stridor
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 Types

● Typical Symptoms more at night

● Atypical Symptoms more at day

Management

● Maintain patent airway

● Administer humidified oxygen (O2)
● Monitor stridor
● Have resuscitation equipment available at the bed side

Drugs

● Administer nebulization with adrenaline. It will help to decrease edema

● Administer corticosteroid to decrease inflammation
● Avoid cough syrup and cold medicine.

Nursing Diagnosis

● Ineffective airway clearance related to laryngeal edema

EPIGLOTITIS
● Inflammation of the epiglottis
● Risk group 2 years – 5 years

● Cause
→ Homophiles influenza type B
→ Streptococcus pneumonia

Clinical Feature
● High fever
● Absence of spontaneous cough
● Dysphonic
● Drooling of saliva from mouth
● Child maintain tripod position

Prevention

● Administer H1b. vaccine –Benefit prevention of meningitis and epiglottitis

Management

● Priority for airway clearance

● Maintain lateral position and avoid supine position
● Provide cool mist oxygen therapy
● Provide NPO till gag reflex return.
● Avoid oral temperature monitoring, and throat swab culture because this can cause spasm and stridor.

128
● When monitor oral temperature place the thermometer bulb at the lateral side of the frenulum of the
tongue.

Nursing Diagnosis

● Ineffective airway clearance.

CYSTIC FIBROSIS
● It is an autosomal recessive trait genetic disorder
● It is a multisystem, genetic fatal disorder
● The disease is affecting to the exocrine glands.
Eg :- Pancreas, liver, salivary gland, mammary gland sweat gland etc
Pathology

Due to abnormal gene transmission ( CFTR) the mucous produced by the exocrine gland is abnormally
thick, tenuous and copious causing obstruction of the small passage ways of the affected organs
particularly in the respiratory, GI, reproductive system

Note :-It is an incurable disorder and respiratory failure is a common cause of death.

Clinical features

1. Respiratory system

● Stagnation of mucous in the airway

● Dry non productive cough
● Wheezing
● Dyspnea, cyanosis, clubbing of the finger

Complication

● Pneumonia
● Emphysema
● Atelectasis

2.G.I System

● Initial sign - Meconium ileus

● Steatorrhea
● Vitamin deficiency
● Bleeding
Complication
● Intestinal obstruction
● Malnutrition
● FTT

3. Integumentary System

● Dehydration
● Electrolyte imbalance
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 4. Reproductive System

● Delay puberty
● Infertility

Diagnostic Test

1. Quantitative sweat chloride test (confirmatory test)

● Minimum 50 – 75 gm sweat is needed

● Apply sweat stimulating hormone in the client body (eg:- Pilocarpine iontophoresis)

Result

● Less than 40 meq/dl is normal

● 40 – 60 meq/dl doubtful
● More than 60meq/dl positive.

2. Stool Examination’

3. Chest X-ray

Management

No definitive management only symptomatic treatment.

Respiratory Management

To give Not to give

1. more water. 1. Steam inhalation
2. Chest physiotherapy 2. Cough suppressant
3. Nebulization with tobramycin
4. Bronchodilator
5. Flutter mucous clearance device
6. Vaccine- pneumococci and influenza

G.I Management

● Administer Amylase + lipase (Pancreatic enzyme) along with each meal

● Balanced diet – high calorie, high protein and multivitamin
● Ensure adequate salt and water
● Administer dornasealfa medicine it will help to loosening the secretion.

TRANSIENT TACHYPNOEA OF THE NEW BORN (TTNB)

1. Temporary increased respiratory rate in new born.
2. It results from incomplete re-absorption of fetal lung fluid in full –term new born.
3. Usually disappears within 24 – 48 hours.
4. Risk factor LSCS, preterm

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5. Clinical feature
● Respiration more than 60 times/mt
● Expiratory grunting, crackles, cyanosis
● Chest x-ray shows interstitial edema and pleural effusion( normal after 48 hours)

Management

● O2 administration
● Supportive care.

RESPIRATORY DISTRESS SYNDROME ( Hayaline membrane disease )

1. Severe breathing difficulty especially in pre-term new born
2. Cause deficiency of surfactant

3. Clinical feature
● Nasal flaring
● Tachypnea
● Expiratory grunting.
● Decreased breath sound
● Sea saw respiration
● Cyanosis
● Breathing difficulty

Diagnostic Evaluation

131
 Result – Both score are widely used for the categorization of respiratory distress in neonates.

Score of 4 or more for at least 2 hours during the first 8 hours of life denotes clinical RD and
require assessment of the infant by a physician. An RD score of 6 or more is an indication for
ventilator support.

3. ABG Respiratory acidosis

Management

● Priority for airway clearance

● Administer O2
● Administer oxygen at the lowest possible concentration especially in preterm babies for to prevent retinal
damage.
● Mechanical ventilation
● Drug of choice – Administer surfactant directly inside the lungs through E.T tube.

Prevention

Administer Betamethasone to the pregnant ladies those who are expecting preterm labor for early
maturity of fetal lung .

Nursing Diagnosis

Impaired gas exchange R/To deficiency of surfactant.

TONSILITIS
1. Inflammation of tonsils
2. Cause
● Group A. Beta hemolytic streptococci
● Pneumococcal, H. influenza
3. Clinical Feature
● Redness, pain, swallowing difficulty
● Enlargement of lymph nodes
● Mouth breathing and unpleasant mouth odor.

4. Management

● Antibiotics (eg:- Azithromycin or erythromycin)

● Liquid diet
● Gargling only pre-operatively
● Surgery
● Tonsillectomy (During surgery provide Rose position)

Post – operative intervention

● Position
→ Prone or lateral position
→ Avoid supine position
→ If breathing difficulty occur to give semi fowlers position
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● Child having frequent swallowing it means bleeding from the surgical site.
● Can be seen old dried blood clot in vomits is normal.
● Post operatively give clear cold water or ice chips. It will help to decrease pain and bleeding.
● Post operatively avoid
→ Milk or milk product
→ Ice-cream
→ Red color food
→ Citrus fruit and carbonated beverages
→ Gargling
● Discourage coughing
● Monitor complication
→ Eustachian tube obstruction
→ Ear pain

CARDIOVASCULAR DISORDER- CONGENITAL HEART DISEASE

Types

1. Acynotic CHD

2. Cyanotic CHD

Acynotic Heart Disease – It means mixing of oxygenated and deoxygenated blood and the mixed blood is
going in to the deoxygenated area.

Eg:- ASD, VSD, PDA, coarctation of aorta

Cyanotic Heart Disease – It means mixing of oxygenated and deoxygenated blood and mixed blood is
going in to the oxygenated area. That can cause cyanosis.

Eg:- TOF, TGA, TAPVD, Tricuspid atresia

HEART MURMERS

Disease Character of Cardiac murmur

VSD Loud holosystolic harsh murmur
TOF Loud holosystolic harsh murmur
PDA A continuous washing machine like murmur
ASD SYSTOLIC EJECTION MURMER

Disease Shape of the heart in chest x-ray

Coarctation of aorta The figure of 3 appearance and erosion of lower margin of rib
TOF Boot shaped heart due to right ventricular hypertrophy
TGA Egg on a string sign or egg on side appearance
TAPVC Figure of 8 or snow man appearance
TETROLOGY OF FALLOT
It include 4 defect
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1. VSD
2. Pulmonary stenosis
3. Right ventricular hypertrophy
4. Over riding of aorta

Clinical features

● Hyper cyanotic spell or blue bell (Cyanosis) , tet spell (dyspnea)

● Koilonychias or spoon shaped nails
● Tachycardia
● Poor growth
● Murmur – Harsh systolic ejection murmur at the upper left sternal border in third space
● Chest x-ray – Boot shaped heart
● Poor feeding, older children maintain squatting position.

Management

1. Priority for to treat hyper cyanotic spell

● Position Knee chest or squatting (INCREASES AFTER LOAD)
● 100% oxygen by face mask
● Administer morphine sulfate it will help to decrease the infundibular spasm
● Administer IVF
2. Administer propranolol for to treat tachycardia.
3. REST.

Surgical Management

● Do the corrective surgery in the first year of life.

● Surgery comes under palliative surgery
● Name Blalock Thomas taussing shunt surgery.

RHEUMATIC FEVER
● It means inflammation at the all layers of heart. (Pericarditis + Myocarditis + Endocarditis)
● RHD is the first complication of Rheumatic fever. ie, inflammation is affecting to the valves of the
heart. eg:- Mitral valve

Cause

→ Group A. Beta hemolytic streptococci

→ Auto immune response Within 2 – 3 weeks after a streptococcal throat infection body produces
antibody which mistakenly attack healthy tissues in the body.

Risk factor

● Living in slum area, crowded area

● Age 5 – 15
● Malnourished

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 Pathological Change

Pericardium – Pericardial effusion

Myocardium Formation of Asch off’s bodies

Endocardium Vegetation formation (pus+ fibrin + micro-organism)

Fusion of valves and chordae tendinae

Clinical Features
1. jhone’s criteria

Major

● Carditis
● Poly arthritis
● Chorea (Involuntary movement of face and extremity during mental stress)
● Erythema marginatum – It is a pink color macules seen mainly trunk and extremities.
● Subcutaneous nodules –Non tender movable nodules on the bony prominence especially joint area

Minor

● Fever
● Polyarthralgia
● Increase WBC, ESR
● +ve CRP
● ECG Prolonged PR interval

Disease Identification through Jones criteria

→ 2 majors + H/O throat infection 2 – 3 weeks before

→ 1 major + 2 minor + H/O throat infection 2 – 3 weeks before

Confirmatory Test

ASO Titer

Management

● Monitor vital sign.

● Complete bed-rest for to prevent cardiac complication.
● Hot or cold application
● Initiate seizure precaution
eg :- Sodium valproate or carbamazepine

● Rheumatic fever – drug of choice BENZATHINE PENICILLIN(G)

Penicillin If allergic

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 Azithromycin or erythromycin If allergic ( azithromycin side effect- diarrhoea, chest pain,
nausea, itching, loss of appetite, dark urine, clay colored stool )

Then administer vancomycin

Nursing intervention when administer Penicillin

� It should be administer after skin sensitivity test.

� If penicillin is allergic, Cephalosporin, Ampicillin and Amoxycillin become allergic.
� Penicillin action cell wall destruction
� Penicillin is administering to prevent the re-occurrence of the disease.
� Penicillin create allergy then administer the antidote – Adrenaline or epinephrine
� Penicillin allergy clinical features
● Coughing, wheezing, dyspnea
● Hives
● Itchy watery eye
● Swelling around skin and face

Surgical Management - Mitral valve replacement.

KAWASAKI DISEASE
● It is also known as mucocutaneous lymph node syndrome
● It is an autoimmune disease in which the medium sized blood vessels throughout the body become
inflamed
● The disease mainly affecting the endothelium of coronary artery
● Mostly occur in under 5 year children
● Mainly it including blood vessels, skin, mucous membrane and lymph nodes

Clinical Features

● Remittent fever
● Red throat
● Swollen hands
● Bilateral conjunctivitis
● Enlargement of cervical lymph nodes
● Desquamation of skin or peeling of skin.
● Strawberry tongue.
● Thrombocytosis.

Management

▪ IV immune globulin.
▪ Salicylate or aspirin may be prescribed
▪ Do not administer aspirin or aspirin containing product if the child has exposed to viral infection along
with Kawasaki disease for the prevention of Reye’s syndrome.
▪ Symptoms may last 2 months
▪ Monitor the sign and symptoms of aspirin toxicity
Eg:- Headache, tinnitus, Bruising

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▪ Avoid administer live attenuated vaccine for 11 month after IV immune globulin therapy
Eg:- MMR, Varicella, etc
HOME CARE INSTRUCTION FOR DIGOXIN ADMINISTRATION

� Administer 1hr before meal or 2hr after meal

� Do not mix with any fluid or food.
� If the dose is missed and more than 4hr has elapsed, withhold the dose and give the next dose in
scheduled time.
� If less than 4hr has elapsed administer the missed dose.
� If more than 2 consecutive doses have been missed, notify the physician.
� Do not double or increase the dose for missed doses.
� If the child vomits do not double or increase the dose.
� If the child has teeth give water after digoxin if possible brush the teeth to prevent tooth staining.
� Give potassium rich diet such as baked potatoes, banana etc to prevent digoxin toxicity
� Monitor for digoxin toxicity such as poor feeding vomiting, bradycardia, green vision halo vision
etc.
� Therapeutic level of digoxin in blood 0.5-2ng/dl.

NERVOUS SYSTEM

HYDROCEPHALUS
It is a medical condition in which there is an abnormal collection of CSF. This may cause increase ICP
and progressive enlargement of head.

Types

● Communicating – Impaired absorption within the subarachnoid space

● Non communicating – Obstruction of CSF flow in the ventricular system does occur

Assessment

1. Infant

● Macewen’s sign
● Increased head circumference
● Anterior fontanels tense, Bulging and non pulsating
● Frontal bossing or prominent forehead

2. Child

● Irritating and lethargy

● Headache
● Vomiting
● High shrill cry , seizure

Note :-Early manifestation of increased ICP in children is excessive vomiting

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 Medical Management

● Mannitol.
● Anticonvulsant
● Tab. Diamox – It will help to decrease CSF production

Surgical Management

1. Endoscopic third ventriculostomy

2. Shunting procedure
ꟷ Ventriculo Atrial shunt
ꟷ Ventriculo pleural shunt
ꟷ Ventriculo ureter shunt
ꟷ Ventriculo peritoneal shunt – This is most commonly performing because in peritoneal cavity much
more capillaries is present. These capillaries is easily absorbing the fluid

Post Operative Intervention

● If ICP is normal keep the child flat as prescribed to avoid rapid reduction of intracranial fluid.
● Observe for increase ICP, If increase ICP occurs elevate the head of the bed 15 – 30 degree to enhance
gravity.
● Turn the patient from supine to non-operative side to prevent pressure on shunt.
● Daily monitoring of head circumference.
● Strict intake and output charting.
● During VP shunt if ICP increases( high pitched shrill cry), provide ventricular tapping.
● Monitor the complication
ꟷ Frequent manipulation of shunting procedure can cause infection.
ꟷ Latex allergy (When collecting history ask about nut’s allergy).

BOTULISM
� It is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium Botulinum.
� Mode of Transmission
● Organism are found in the soil.
● Spread through food, air or wound.
● incubation period 12 hour – 72 hour

Pathology

The toxin destroys the Neurotransmitter Acetylcholine that leads to muscle weakness or paralysis.

Assessment

● Abdominal cramps, diarrhea vomiting

● Ptosis, Blurred vision, Diplopia
● Difficulty swallowing/speech

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 Management

● Administer the Anti – toxin

● Botulism immunoglobulin
● Injection penicillin
● Induction of vomiting/enema

Special character of the disease

● It cannot spread person to person.

● Disease not affect the level of consciousness.
● Disease not associated with fever.

Prevention

● Vaccine available but not widely using.

● Food heat at 100degree C for 5 minute.
● Take food hygiene
● Proper wound care

CEREBRAL PALSY
● It is a general term for a group of permanent movement problem due to injury to the extra pyramidal or
pyramidal motor system.
● They cause physical disability mainly in the areas of body movement there may also be problems with
sensation perception and communication ability.
● In this condition according to chronological age physical development present. But there is no mental
and cognitive development.

Causes

1. Prenatal Rubella infection

Trauma, Genetic factor

2. Intranatal Precipitating delivery

Fetal distress

3. Post natal cause Head trauma or infection

Clinical Features

● Altered muscle tone ( Stiff and rigid arms or legs)

● Irritability and crying
● Feeding difficulties
● Delayed developmental mile stones
● Persistence of primitive infantile reflexes (eg:- Moros, tonick neck)
● Client maintain opisthotonos posture
● Seizure

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 Management

● Antispasmodic – eg:- Baclofen, Side effect – Tremor

● Symptomatic treatment
● Physiotherapy – for to relieve muscle spasm
● Provide nursing care according to the mental development rather than the chronological
development
● Provide a safe environment
● Position the child upright after meal

SPINA BIFIDA
● It is a neural tube defect. ie, failure to close the neural tube during embryonic period.
● Cause – Folic acid deficiency in pregnancy
ꟷ Daily intake -200 mcg
ꟷ In pregnancy – 400 mcg ( a lady delivered her first baby with spina bifida for to prevent spina
bifida in her second baby she should take 4000 mcg folic acid daily )
Types

1. Spina Bifida Occulta

● Posterior vertebral arch fail to close in the lumbosacral area.

● Neurological deficit are not usually present

2. Spina Bifida Cystica

⮚ Meningocele - Lumbosacral area one protrusion is present. It involves meanings, CSF, not involved
the neural tube, the protrusion is covered with a sac
ꟷ Neurological deficit are absent

⮚ myelomeningocele
ꟷ Lumbosacral area one protrusion. The protrusion is covered by as thin membrane prone to leakage or
rupture. The protrusion involves meninges, CSF, and spinal cord.
ꟷ Neurological deficit are present

Clinical Manifestation

● Below the level of protrusion no sensation, no movement, no reflexes.

● Flaccid paralysis of the legs.
● Altered bladder and bowel function bladder distension

Note: -Perform credes maneuver ( apply firm pressure over the bladdef ) for to eliminate urine

● Hydrocephalus

Management

⮚ Prone or lateral position.

⮚ Avoid supine position.
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⮚ Surgical closure should be performed within 24 – 72 hours.
⮚ Perform hydrocolloid dressing or wet dressing over the defect.
⮚ Avoid adhesive dressing.
⮚ Avoid getting the sac is rupture.
⮚ Protect the client from infection and hypothermia.
⮚ Provide ROM
⮚ Increase fluid and fiber rich diet for older children

Surgical Management

❖ Laminectomy.

DOWN SYNDROME or TRISOMY -21

It is a chromosomal abnormality

Cause

Addition of one extra chromosome in the 21st pair.

Total 47 chromosomes in down syndrome patient.

Risk Factor

▪ Women age more than 34.

▪ Hypothyroidism during pregnancy.

Clinial Features

▪ Grey spot on iris (BRUSHFIELD SPOT)

▪ Over curved helix
▪ Protruding or large tongue
▪ Single transverse palmer creases(SIMIAN LINE)
▪ Low set ears
▪ Brachycephaly
▪ Speech delay
▪ Separated eyebrows
▪ Poor eye contact during feeding
▪ High risk for leukemia due to immune dysfunction
▪ Leg sandle sign (Separated wide gap between big toe and 2nd)

Diagnostic Evaluation

▪ Triple test during pregnancy ( it include three test )

ꟷ Estrogen
ꟷ HCG(HIGH)
ꟷ AFP

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 Management

▪ Positive re-enforcement
▪ Supportive management and safety and Correcting structural deformities

GENITO URINARY ABNORMALITY

CRYPTORCHIDISM
It is also known as undescended testis- failure to descend the testis in to the scrotal cavity.

Cause

● Absence of testis
● Prematurity

Management

● Palpate the inguinal area followed by the abdominal area.

● Monitor during the first 12 month of life to determine whether spontaneous descend occur.

Surgical Management

● Orchiopexy – Should be perform in between 1 year – 2 year. If the testis do not descend spontaneously.
● At the time of discharge counseling the parents regarding future fertility of the child.

WILMS TUMOR
● It is also known as nephroblastoma or kidney tumor of childhood.
● Peak incidence 3 years of age.
● Boys and left kidney are more affected
● Wilms tumor associated syndrome

W – Wilms tumor
A – Aniridia (Absence of iris)
G – Genito urinary defect
R – Mental retardation
STAGES
Stage I- tumor is within the kidney and can be completely resected.

stageII- tumor extend beyond the kidney and can be completely resected.

Stage III- tumor extend through the lymph nodes and cannot be resected.

StageIV- tumor extend to other organs through blood sream.

StageV- Bilateral involvement.

Clinical Features

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1. Initially painless, non pulsating abdominal mass. (But later pain present)
2. Increase abdominal girth
3. Anemia due to
● Rupture and hemorrhage
● Decreased erythropoietin
4. Hypertension due to Renin Angiotensin reaction
5. Urinary retention /hematuria
6. Symptoms like dyspnoea, chest pain occur it means metastasis occur in lungs

Diagnosis

1. CT
2. MRI
3. Biopsy is contraindicated because chance for rupture and metastasis

Management

Pre-operative intervention

● Monitor vitals
● Avoid abdominal palpation. because palpation can cause rupture of the tumor
● Measure abdominal girth daily
● Administer antihypertensive medication

Surgical Management

● Nephrectomy

Post – operative intervention

● First 24 hour complete bed rest

● Turn the client from supine to non-operative side
● Monitor bleeding at the back of the body
● Monitor bowel sound. because increase chance of intestinal obstruction
● Monitor color of urine and any infection.

EPISPADIASIS AND HYPOSPADIASIS

❖ It means abnormal urethral opening.
❖ Epispadias means urethral orifice is located on the dorsal (Upper) surface of the penis.
❖ Hypospadias is means urethral orifice is located below the glans penis along the ventral surface.

Management

❖ Surgery is done before the age of toilet training preferably between 16 – 18 month of age.
❖ Circumcision is not perform on a newborn with epispadiasis and hypospadiasis because the fore skin
may be used in surgical reconstruction of the defect.

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 Post – operative Intervention (Meatotomy)

❖ Encourage fluid intake to maintain adequate output.

❖ Monitor urine output and notify the physician if there is no urinary output for one hour.
❖ Administer antibiotic and pain medication.

GASTRO INTESTINAL SYSTEM

GERD
❖ It is back flow of gastric contents in to the esophagus as a result of relaxation or incompetence of cardiac
sphincter.
❖ In infants it is considered as normal. and require only medical therapy.

Clinical Features

❖ Non projectile vomiting (large vomiting)

❖ Passive regurgitation
❖ Poor weight gain
❖ Irritability
❖ Older children complaint heart burn
❖ Anemia
❖ Note - Vomiting leads to aspiration and recurrent respiratory infection, while collecting history
should ask frequency of respiratory infection

Management

❖ After feeding proper burping.

❖ Monitor lung sound / coughing before, during and after feeding
❖ After feeding maintain lateral position
❖ For feeding practice thicken formula ( cereals paste should added in milk )
❖ Avoid vigorous activities and play after feeding
❖ Avoid stimulant food items. eg:- Chocolate, tomato, fatty food, etc
❖ Drug
● H2 receptor /PPI
● Acetaminophen – To relieve reflex pain

Surgical Management

❖ Nissen fundoplication procedure

Complication

❖ Easophagitis
❖ Aspiration pneumonia
❖ Sudden infant death syndrome

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 Nursing Diagnosis

❖ Fluid volume deficit related to vomiting

PYLORIC STENOSIS ( hypertrophic pyloric stenosis )

● Narrowing of the pyloric canal between stomach and duodenum.

Clinical Features

● Projectile vomiting
● Dehydration
● Electrolyte imbalance
● Metabolic alkalosis
● Olive shaped mass is in the epigastrium just right of the umbilicus
● Visible waves of peristalsis
● Bulging in the lower part of the rib (at right side)

Complication

● Malnutrition
● Failure to thrive

Management

● Provide high fowlers position

● After feeding maintain right lateral position
● Monitor vitals, I/O charting, S/S of dehydration
● Iv fluid
● Drug – Atropine
ꟷ It decrease peristaltic movement
ꟷ It decrease acid production

Surgery

● Ramstead procedure or pyloromyotomy

Nursing Diagnosis

● Fluid electrolyte imbalance related to vomiting

TRACHEO EASOPHAGEAL FISTULA AND ESOPHAGEAL ATRESIA

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 TEF Esophageal Atresia
● Abnormal connection between trachea and easophagus ● It means the esophagus terminate before it
● This disease result of failed separation of the esophagus and reaches in the stomach
trachea by a septum that forms by the fourth week of gestation ● In maternal history of polyhydramnios
Clinical Features present
● Coughing Clinical Features
● Chocking ● Drooling of saliva from mouth
● Cyanosis ● Whenever inserting a Ryles tube it should
● Abdominal distention not reach in to the stomach
● Increased respiratory distress during and after feeding

Management

● Priority for airway – Intubation or mechanical ventilation

● Maintain NPO
● Administer IVF
● Till surgical closure perform gastrostomy feeding

Surgical Management

● Thoracotomy
● Wait up to one year for surgical closure
● Post operatively – maintain mechanical ventilation
● Neck neutral position
● Avoid head and neck movement
● Inspect the surgical site have any infection
● Provide proper chest drain care
● Before giving oral feeding perform Barium swallow examination to detect any obstruction in the upper
GI tract
● When ever provide first feed monitor any feed content in the chest drain. If present it denotes
anastomotic leaks

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 CLEFT LIP AND CLEFT PALATE
Cleft LipIt result from failure of the maxillary and median nasal process to fuse.

Cleft Palate It is a midline fissure of the palate that result from failure of the two sides to fuse.

Cause

● Genetic / Hereditary
● Rarely due to folic acid deficiency
● Anti-convulsant during pregnancy
● Maternal smoking
● Teratogenic factor

Management (surgery)

Cleft Lip Cheiloplasty – timing 3 – 6 month ( post operatively provide LATERAL position and
use elbow restraints )

or Rule of 10

-- 10 Ibs weight

ꟷ 10 gm Hb
ꟷ 10 week old

Cleft Palate Palatoplasty timing 6 -18 month (PRONE position post operatively )

ꟷ But close as early as possible to facilitate speech development

Post operative intervention

● Maintain supine or lateral position and avoid prone position

● Use restraints. eg:- Elbow, mitten, jacket
● Distraction is very effective in children (Mind diversion) compare with restraints
● Provide lip protector or a metal appliance
● Apply antibiotics
● After palatoplasty avoid hard food items orally

Complication

● Otitis media
● Nasal speech
● Difficult feeding

Nursing Diagnosis (In parents)

● Disturbed body image

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 INTUSSUCEPTION
Telescoping of one portion of the bowel into another portion. The condition results in obstruction to the
passage of intestinal contents.

Clinical Feature

▪ Colicky abdominal pain.

▪ Bilious vomiting (Color greenish yellow)
▪ If in a new born case delay in passing meconium.
▪ Tender distended abdomen, possibly with a sausage – shaped abdominal mass.
▪ Current jelly like stool containing blood and mucous.
▪ The proximal position of the intestine telescopes in to the distal portion.

Diagnostic Evaluation

▪ usg

Management

▪ Antibiotics
▪ Insert NG tube – It should be open
▪ Administer hydrostatic reduction enema with barium or NS.
▪ Monitor for the passage of normal brown stool which indicate that the intussusceptions has reduced
itself.

ABDOMINAL WALL DEFECT

It includes

● OmphaloceleHerniation of the abdominal contents through the umbilical ring. The

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 protrusion is covered by a translucent sac that may contain bowel or other abdominal organ.
● Gastroschisis Occurs when the herniation of the intestine is lateral to the umbilical ring. No
membrane covers the exposed bowel.
● Bladder exstrophy or Ectopia vesicleIt is characterized by extrusion of the urinary bladder
to the outside of the body through a defect in the lower abdominal wall.
Management
▪ The affected area is covered with a saline gauze piece or perform hydrocolloid dressing or wet dressing.
A layer of plastic wrap is placed over the gauze to provide additional protection against moisture loss.
▪ Avoid getting the sac is rupture.
▪ Protect the client from infection and hypothermia.
▪ Surgical management skin grafting.

Care over a grafted area

▪ The affected side should be elevate.
▪ Avoid excessive movement or pressure over the grafted area because wound adhesion should not be
present.
▪ If any discharge occur form the grafted area apply firm pressure over the graft.
▪ Sign and symptoms of graft rejection.
⮚ Pain
⮚ Redness
⮚ Itching
⮚ Fever
⮚ Purulent discharge

HIRSCHPRUNGS DISEASE
● It is also known as congenital a ganglionic
mega colon.
● It occurs due to congenital absence of the
parasympathetic ganglionic nerve cell that
regulate to the activities of the colon.
● The affected segment of the colon cannot relax
and pass stool through the colon, creating an
obstruction.
● Defect mainly affecting recto sigmoid colon.

Clinical Features

● Failure to pass meconium in newborn.

● Bilious vomiting.
● Abdominal distention.
● Ribbon like and foul smelling stool.

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 Diagnostic Evaluation

● Rectal biopsy ( denoting abscence of ganglionic cells )

Management

● New born period perform temporary colostomy.

● Stool softness and rectal irrigation with NS.
● After completion of 9kg weight perform the surgery.
ꟷ Duhamel procedure or pull through procedure.

DIARRHOEA
Loose or watery stool.

Cause

● Acute diarrhea
ꟷ Rota virus
ꟷ Antibiotic therapy
ꟷ Parasite infection
● Chronic diarrhea
ꟷ Malabsorption syndrome
ꟷ IBS
ꟷ Immune deficiency. eg:- AIDS

Clinical Features

1. Abdominal pain or cramping.

2. Electrolyte imbalance. eg:- Hyponatremia
3. Metabolic acidosis.
4. Character of the stool depending upon the type of infection
● Vibrio cholera – Rice water stool
● Typhoid fever – Pea soup stool
● E-coli infection – Loose stool and low grade fever
● Desentry – Bloody stool

Management

● Contact isolation
● Monitor skin integrity
● IVF and electrolyte
● Antibiotics

Prevention

Administer rotavirus vaccine.

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DEHYDRATION
● It is a common fluid and electrolyte imbalance in infants and children.
● In infants the organs that conserve water are immature, placing then at risk for fluid volume deficit.

Cause

● Decrease fluid intake

● Burn
● DKA
● Diarrhea
● Diaphoresis
● Diuretic therapy

Clinical Feature

● Weight loss more than 10% – Daily 1kg weight loss indicate 1 litre water loss present in the body.
● Poor skin turgor (In children check – Abdomen, Adult – Forehead, fore arm)
● Depressed anterior fontanels (Only in less than 18 month babies)
● Absent or decreased tears during crying
● Kussmaul respiration (Deep and rapid)
● Behavior – lethargic
● Sunken eye
● Capillary refilling more than 4 seconds
● Oliguria

Sign and symptoms of dehydrated child become on a Rehydration stage

1. Vitals stable
2. Urine is clear
3. Good skin integrity

Management

1. Treat the exact cause

2. IVF
3. Administer ORS

CELIAC DISEASE
● It is an auto immune disorder.
● Intolerance to gluten, the protein component of wheat, Barley, RYE
● Gluten is a endosperm protein. It contains amino acid.
● It results in the accumulation of the amino acid glutamine which is toxic to intestinal mucosal cell.
● Intestinal Villi atrophy occurs, which affect absorption of ingested nutrients.
● Willi atrophy can see through endoscopic examination.
● Symptoms occurs most often between 1 – 5 years.
● There is usually an internal of 3 – 6 month between the introduction of gluten in the diet and the onset of
symptoms.

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 Clinical Features

● Malnutrition
● Vitamin deficiency
● Acidic diarrhea
● Rapid dehydration
● Abdominal pain and distention

Management
Lifelong elimination of gluten sources

B – Barley

R – RYE

O – Oats – (CAN BE GIVEN)

W – Wheat

PHENYLKETONURIA
● PKU is an inborn error of metabolism involving impaired metabolism of phenylalanine one of the
Amino acid.
● PKU is a autosomal recessive trait genetic disorder that result in central nervous system damage from
toxic level of phenylalanine in the blood.
● Phenylalanine more than 2mg/dl is considered as PKU.
● Phenylalanine present in protein rich food.

Cause
Deficiency of hepatic enzyme phenylalanine hydroxylase, which convert phenylalanine in to Tyrosine
which is again metabolized in to dopamine and melanin.

Clinical Features
1. Digestive problem and vomiting
2. Seizure
3. If not treating early mental retardation
4. Eczema
5. Hypertonic
6. Liver cirrhosis
7. Fare skin
8. Blue eye
9. Hypo pigmentation of hair (Red color) due to absence of melanin.

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 Diagnostic Evaluation
⮚ Metabolic Screening or Guthrie test or heal prick test
● The infant should have begun formula or breast milk feeding before specimen collection.
● First sample should send 48 – 72 hours
● Repeat sample on the 7th day
● Most accurate sample on the 3rd day

Management
Restrict phenylalanine intake or protein rich food. But not completely avoid because it is an essential
amino acid

HEMATOLOGICAL DISORDER

ANEMIA
It means – Decrease Hemoglobin – less than 12gm

Types

● Sickle cell anemia

● Iron deficiency anemia
● Aplastic anemia
● Pernicious anemia

SICKLE CELL ANEMIA

● It is a genetic abnormality.(ART)
● If constitutes a group of disease termed hemoglobinopathies. In which hemoglobin ‘A’ is partially or
completely replaced by abnormal sickle hemoglobin S.
● Hemoglobin ‘S’ is sensitive to changes in the oxygen content of the RBC
● Insufficient oxygen causes the cells to assume a sickle shape and the cell become rigid and clumped
together obstructing capillary blood flow leads to tissue hypoxia and pain
● Sickle cell crisis are acute exacerbation of the disease is caused by dehydration

Clinical Features

● Generalized body pain

● Abdominal pain
● Swelling of the hands, feet and joints
● Hypersplenism

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 Management

⮚ Priority for to treat pain

● Maintain adequate hydration and blood volume with normal saline or oral fluid. (Without
adequate hydration pain will not be controlled)
● Oxygen administration and blood transfusion
● Administer analgesics
⮚ Antibiotics
⮚ Semi fowlers leg extended position during crisis
⮚ Genetic Counseling
⮚ BLOOD TRANSFUSION

IRON DEFICIENCY ANEMIA or MICROCITIC HYPOCHROMIC

⮚ Iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in
RBC.
Causes
● Blood loss
● Malabsorption
● Decrease iron intake

Clinical Features

● Weakness and fatigue

● Paleness
● Koilonychias/ Spoon shaped nail

Diagnostic Evaluation

● CBC
● Sr. Ferritin monitoring
● Peripheral smear Hypo chromic and microcytic cell

Management

1. Severe deficiency ( less than 6 gm )

● Blood transfusion
● IV or IM iron injection
● For IM injection practice ‘Z’ track method ( for to prevent regurgitation of medicine from muscle to
subcutaneous )
2. Mild deficiency ( 8 – 10gm )
● Instruct the client to take iron rich food
eg :- Green leafy vegetable, dry fruits, liver, etc
3. Moderate deficiency ( 6 – 8 gm )
● Administer iron supplements.
● Give iron supplements between meals or one hour before meal for maximum absorption. Acidic
medium is promoting iron absorption

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● Instruct the client should take the tablet along with citrus fruits juice for maximum absorption.
eg:- Lemon or orange
● Avoid take along with milk and antacid. ( can cause poor absorption )
● Iron tablet side effect
ꟷ GI upset eg:- Foul alter taste, Constipation, Black color stool
● Oral syrup can cause tooth stain - for prevention instruct the client should take the medicine through
straw or after medication clean the mouth with water .

APLASTIC ANEMIA
● Decrease RBC, WBC, Platelet

Types / Causes

⮚ Congenital – Due to chromosomal alteration

ꟷ As an autoimmune disorder

⮚ Acquired – Due to bone marrow suppression.

Eg:-
1. Drug
→ Chemotherapy
→ Chloramphenicol (drug of choice in typhoid)
→ Antimetabolites
→ Anti - seizure
2. Radiation
3. Infection
→ Hepatitis
→ Biliary TB
4. Chemical agent
eg:- Arsenic, Benzene, gold
Clinical Features
● Pancytopenia ( decrease RBC,WBC,PLATELET )
● Petechiae
● Purpura
● Weakness
● Risk for infection
Diagnostic Evaluation
● Bone marrow biopsy
Site – AdultSternum, vertebra, ileac crest
Child Sternum, Tibia

● CBC

Management

● Whole blood transfusion

● Bone marrow transplantation
● Corticosteroid
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 ● Colony stimulating factors may be prescribed to enhance bone marrow production.

NOTE – dyscrasis means decrease platelet & increase WBC . can seen in leukemia and
haemophilia

PERNICIOUS ANEMIA
It is also known as vitamin B12 deficiency or vegetarian anemia

Causes

1) Deficiency of intrinsic factor

2) Decrease vitamin B12 intake

Clinical features
1) Smooth red beefy tongue
2) Paleness
3) Gait problems
4) Slight jaundice

Diagnostic evaluation
1) Peripheral smear – normochromic, macrocytic cell
2) Confirmatory test- shrilling test

Management
● Administer vitamin B12 injection cyanocobalamin lifelong if the cause is deficiency of intrinsic factor
● Those who are taking vitamin B12 injection frequently monitor CBC or reticulocyte count
● Instruct the client to take vitamin B12 rich food. Eg: brewer’s yeast, green leafy vegetables,organ meat,
citrus fruit
● Complication – gastric ulcer and gastric cancer

THALASSEMIA
● It is an autosomal recessive trait genetic disorder
● It is characterized by the reduced production of one of the globins chain in the synthesis of hemoglobin
● Increased level of iron in the blood is deposited in to the organs(hemosiderosis or hemochromatosis) that
can cause organ damage
Clinical features

1) Frontal bossing
2) Maxillary prominence
3) Hepato splenomegaly
4) Severe Anemia
Diagnostic evaluation

1) Prenatal – amniocentesis
Chronic villus sampling

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2) CBC
ꟷ Peripheral smear- microcytic hypochromic cell
ꟷ Hb electrophoresis is the confirmatory test

Management

● No specific treatment
● Monthly blood transfusion
● Administer the antidote of iron deferoxamine (working as chelating therapy. And monitor
nephrotoxicity)
● s/m – splenectomy to relieve abdominal pressure
●
HEMOPHILIA (royal disease)

● It is an X- linked recessive trait genetic disorder

● It refers to a group of bleeding disorder result from a deficiency of clotting factor
Types

● Hemophilia A or classical hemophilia

o It result from deficiency of clotting factor VIII
● Hemophilia B or Christmas disease
o It result from deficiency of clotting factor IX
Clinical features

1) Abnormal bleeding in response to trauma or surgery – especially after circumcision

2) Epistaxis
3) Hemarthrosis- bleeding into the joint
4) Joint pain, swelling, tenderness, and limited range motion
5) Risk of intra cranial hemorrhage
6) PT NORMAL PTT HIGH
Management

1) Monitor for bleeding and maintain bleeding precautions

2) Administer desmopressin acetate
3) Administer- cryoprecipitate
4) Teach the parent regarding the sign and symptoms of internal bleeding
5) If bleeding occur apply manual pressure 15 min
Nursing Diagnosis

Risk for bleeding

VON WILLEBRAND DISEASE

● It is a bleeding disorder.
● Due to deficiency of Von Willebrand factor.
● Affecting both males and females.
● Von Will brand caused by low level of clotting protein in blood.

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 Clinical Features

● Excessive menstrual bleeding.

● Gum bleeding.

Management

❖ Same as hemophilia

BLOOD TRANSFUSION
Types of blood component Indication Timing
1. Packed RBC Anemia 3-4 hours
2. Platelet Thrombocytopenia 15-30 mnt
3. Fresh frozen plasma or Clotting factor replacement Over 2 hour
cryoprecipitate
4. Whole blood Aplastic anemia 3-4 hour
Hemorrhage
Hypovolemic shock
5. Albumin Hypoalbuminemia 2-3 hour

Nursing Intervention
1. consent
2. RN – nurse is permitted to give blood transfusion
3. The blood bag should collect 30 minute before transfusion from the blood bank
4. Large volume of refrigerate blood infused rapidly cause cardiac dysrhythmia
5. Medication never added to blood component
6. The first 15 minute administer too slowly under close supervision
7. Infusion should not exceed more than 4 hour. Because hemolysis can occur that leads to hyperkalemia
8. Monitor any reaction , if reaction is occur
● Stop the transfusion
● Keep the IV line open with NS
● Be along with the pt bedside and instruct another nurse to contact the physician
● Return the bag and tubing’s to the blood bank

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 Complication

1. S/S of immediate transfusion febrile reactions

● chills with diaphoresis
● fever
● anxiety,head ache
● tachycardia,tachypnoea
2. S/S of allergic reaction
● mild – fascial flushing, hives, rash,pain (muscle, chest, back), itching, swelling
● severe - increase anxiety, wheezing, dyspnoea, decrease BP, nausea, vomiting
3. Hemolytic reaction- hemoglobinopathies ,fever with chills, chest pain, low back pain, decrease BP,HR
& increase respiration
4. Circulatory overload
5. Disease transmission – Hep. C, B, AIDS
6. Frequent blood transfusion Hypocalcaemia because citrate present in bllod for to prevent clotting. This
citrate bind the calcium and extrete through urine
Note – universal donour O-, universal recipient AB+

TYPES OF IV FLUID
1. ISOTONIC SOLUTION
● Same osmolality as body fluid
● Increase ECF volume volume
Eg:- i) 0.9 %. NS - indication ischemic shock, contra indication CHF
ii) RL - content potassium.

● Indication- post operative bleeding and burn

● Contra indication- renal failure, hyperkalemia
iii) Dextrose 5% in distilled water

2. HYPOTONIC SOLUTION
● More dilute solution and have as lower osmolality than body fluid
● Cause the movement of water enter in to the cell
● Administer slowly to prevent cellular edema. Eg: 0.45% NS, 0.33%NS,

3. HYPERTONIC SOLUTION
● More concentrated solution and have a higher osmolality than body fluid
● Cause movement of water from cells into extra cellular fluid
● Administer slowly for to prevent, organ shrinkage
● Example 3%NS , D10%, mannitol, DNS

4. COLLOID- PLASMA EXPANDER

● Pull fluid from the interstitial compartment into the vascular compartment. Eg: dextran, albumin

CALCULATION
MEDICATION DOSE FORMULA

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Dose prescribed/ dose in hand X total ml= dose in ml

Eg: a physician has prescribed an antibiotic Inj.Taxim 625 mg IV 8 hourly. The medication available at
pharmacy 10 ml= 1000 mg. Then how many ml administer to the child.

Answer:

Dose prescribed/ dose in hand X total volume

625/1000 X 10= 6.25 ml

CLARKS FORMULA- CALCULATING A CHILDS DOSAGE FROM THE ADULT

DOSAGE

Bodysurface area of child in m2/1.73 X adult dose= child dose

Eg: a physician has prescribed an antibiotic for a child. The average adult dose is 250 mg. the child has a
body surface area of 0.41 m2. What is the dose of child?

Answer:

BSA of child m2/1.73 X adult dose

0.41/1.73 X 250= 0.236 X 250= 59.24 mg

FLUID DROP CALCULATION FORMULA

IV drip set is two types

Micro drip set- 1 ML= 60 drops

Macro drip set – 1 ML = 15- 20drops

Formula

Total amount of fluid in ml X drop factor/ total hour X 60

Eg: a physician has prescribed an IV fluid NS 800ml over 6 hour through micro drip set. Then how many
drops per minutes you should administer to the client

Answer:

800 X 60/6 X 60= 48000/360= 133 drops/ mt

Note: if it is in macro drip set (put 15 or 20)

800 X 15/6 X 60= 12000/360= 33 drops /mt.

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Exercise - : a physician has prescribed an IV fluid NS 1.5 l over 24 hour through micro drip set. Then how
many drops per minutes you should administer to the client

INFUSION PRESCRIBED BY UNIT DOSAGE PER HOUR

Calculation of these problems can be done by a two step process

Step I:

calculate the amount of medication per ML

Known amount of medication in solution/total volume of diluents = amount of medication per ml

Step II:

calculate milli litres per hour

Dose per hour desired/ concentration per ml = infusion rate or ml/hr

Eg: 500ml D5 % with 20000 unit of heparin sodium. Physician ordered administer 1000 unit/hour. Then
how many ml/hours you should administer to the client.

Step I: 20000/500 = 40 unit/ml

Step II: 1000/40 = 25 ml/ hour answer: 25 ml /hour

Exercise

1. A physician prescribed administer RL 800 ml over 4 hour. Then how many ml/hour you should
administer to the client?
a. 800/4 = 200 ml/hour

2. A physician has prescribed an antibiotic for a child is 50 mg/ kg/ day divided into 2 doses. The child has
a body weight of 66 lbs (pound). The medication available at pharmacy 1gm= 10ml. then how many ml
you should administer at one dose?
a. Step I: convert the child weight from pound (lbs) to kg
1.2 lbs = 1 kg
= 66/2.2= 30 kg
b. Step II : calculating one day dose
50mg/ kg/day
Ie, 50 X 30= 1500 mg/day
1500/2 = 750 mg each dose
c. Step III: volume (ml) should administer at one dose
Dose prescribed/ dose in hand X total ml
Ie, 750(mg)/ 1 (gm) X 10
= 750 mg/1000 mg X 10 = 7.5 ml/dose

TYPES OF DRUG REACTION

1. side effect : it is the predicted secondary effect that the drug cause. It is harmless and common for all
eg: side effect of bronchodilator is tachycardia

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 2. Adverse/toxic effect: It is the unexpected toxic effect caused by drug which is not discovered during
drug testing. it is not common for all. eg: patient taking amikacin complain of respiratory distress.
3. Anaphylactic reaction: it is due to hypersensitivity reaction or allergic effect due to release of
histamine. it may occur due to drug, blood transfusion or bee sting bite. administer antihistamine for
toxicity.
4. Idiosyncratic effect - it is unknown reaction of drug where the client may overreact or under react or
reaction opposite to normal.
5. Drug tolerance - it is reduced effect /decreasing therapeutic effect of drug due to long-term use. eg:
long term use of cetrizine may cause drug tolerance

ELECTROLYTE IMBALANCE
SODIUM (NA+)= CNS symptoms

it is rich in intravascular fluid

c) normal value 135-145 MEq/lt

d) function- to maintain the oncotic pressure of the blood

Hyponatremia Hypernatremia
⮚ decrease 135 meq/lt ⮚ increase 145 meq/lt
cause Cause
1. diarrhea 1. Sodium intake
2. diuretics administration 2. Renal failure
3. water toxicity 3. Corticosteroid
eg: drowning, bladder irrigation 4. Fasting(Increased H2O intake)
5. Diabetes insipidus
4. oxytocin overdose 6. Cushing
5. Addisons disease Clinical manifestation
clinical manifestation ● Altered cerebral function
● Headache personality change ● Agitation, confusion
● Confusion ● Extreme thirst
● Seizure ● Oliguria
● Abdominal cramp ● Dry skin
● Hypotension ● Increased urine specific gravity
● Polyuria ● Hyper tension
● Decreased urine specific gravity Management
Management ● Monitor vitals
● Monitor vitals ● Administer diuretics
● Administer hypertonic saline. eg :- 3%.Ns ● Restrict sodium
● Increase sodium intake ● If the cause is fluid loss prepare to
Eg:- Butter, Canned food, Cheese, Milk, administer IV infusion
mustard

POTASSIUM (K+)- cardiac rhythm

● It is rich in intracellular fluid.

● Function – It is helping for muscle contraction along with calcium.
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● Normal value 3.5 – 5.00 meq/lt
● Potassium deficit is potentially life threatening. Because this can cause cardiac dysrhythmia. So
immediately report to the doctor.

Hypokalemia Hyperkalemia
⮚ Less than 3.5 ⮚ More than 5
Cause Cause
● Diuretics – Lasix ● DKA
● Alkalosis / Hyperinsulinism ● Renal failure
● Cushing Syndrome ● Spironolactone
● Vomiting/ Diarrhea ● Acidosis
● NG suction ● Tumor lysis syndrome
● Water intoxication ● Addison's disease
● Digoxin toxicity
Clinical Features
Clinical Features
● Slow weak irregular HR
● Thread, Weak irregular pulse ● Hypotension
● Orthostatic hypotension ● Muscle cramps
● Shallow respiration ● Hyperactive bowel sound
● Paresthesia ● Diarrhea
● Absent bowel sound
● Paralytic Ileus
ECG Changes
ECG Changes
● Flat P – wave
● ST- depression ● Wide QRS complex
● Shallow flat or inverted T –wave ● Tall peaked T – Wave
● Prominent u-wave
Management
Management
● Monitor vitals and ECG
● Monitor vitals and ECG ● Treat the exact cause
● Administer injection potassium over ● IV regular insulin + Dextrose
dilution administer slowly under cardiac ● Administer Albuterol
monitoring. ● Dialysis
● Maximum recommended infusion rate is 5
10 mEg/ hour. Not exceed more than 20
● Increase potassium intake.
Eg:- Banana, Orange, Carrot, Spinach and
fresh fruits.

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 CALCIUM AND PHOSPHORUS
● Calcium normal value 8.6 -10mg/dl
● Phosphorous normal value 2.7 – 4.5 mg/dl
● Function
● Calcium and phosphorus is equally responsible for the formation of bone and teeth.
● Calcium is helping for muscle contraction.

Hypocalcemia/Tetany Hypercalcemia
⮚ Calcium less than 8.6mg/dl ⮚ Calcium more than 10mg/dl
Cause Cause
● Decrease intake of calcium ● Kidney disease
● Lactose intolerance ● Use of thiazide diuretics
● Malabsorption ● Hyperparathyroidism
● Inadequate intake of vitamin D ● Use of gluco-corticoid
● End stage kidney disease ● Dehydration
● Acute pancreatitis ● Use of Lithium
● Immobility
● Removal of parathyroid gland Clinical Features
● Increased heart rate
● Hypertension
Clinical Features ● Bone destruction
● Increased heart rate ● Profound muscle weakness
● Hypotension ● Disorientation
● Bronchospasm ● Formation of Renal Calculi
● Positive – Trousseau’s sign ● Abdominal distention
● Positive Chvostek’s sign ● Constipation
● Hyperactive bowel sound ● Decreased bowel sound
● Leg cramps
Management
Management ● Monitor vital/
● Monitor vitals/ ● ECG
● ECG ● Short ST segment
● Prolonged ST interval ● Wide T –wave
● Prolonged QT interval ● Administer Calcitonin
● Administer calcium orally or IV ● Route intranasal
● Prewarm the medication ● Increase water intake
● Vitamin D supplements ● Movement with caution because chance for
● Initiate seizure precaution pathological fracture
● Increase calcium food
Eg:- Milk or its products, egg yolk, yogurt

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 Note :- HypophosphatemiaSame as hypercalcemia

Hyperphosphatemia Same as hypocalcemia

MAGNESIUM- Reflex activity and vital sign

Normal value 1.6 – 2.6 mg/dl

Function

● It helps to maintain normal nerve and muscle function.

● Keep the heart beat steady
● Helps bone remain strong

Hypomagnesemia Hypermagnesemia
⮚ Less than 1.6 mg/dl ⮚ More than 2.6 mg/dl
Cause Cause
● Malnutrition ● Mg containing antacid and
● Vomiting / Diarrhea laxatives
● Celiac disease ● MgSO4 administration
● Crohn’s disease ● Renal failure
● Drug – Diuretics
● Chronic alcohol
● Hyperglycemia
● Insulin administration

Clinical Features Clinical Features

Vitals and reflexes increased Vitals and reflexes decreased
ECG ECG
● Prolonged PR interval
● Tachycardia ● Wide QRS complex
● Hypertension ● Bradycardia
● Shallow respiration ● Hypotension
● Trousseaus sign ● Reflexes decreased and vitals
● Chvosteks sign decreased
● Irritability / Confusion Eg:- Absent deep tendon reflex
Management Poor knee jerk reflex
● Monitor vitals/ECG ● Skeletal muscle weakness
● Prolonged ST interval ● Drowsy/ Lethargy
● Prolonged QT interval Management
● Administer Mgso4 IV ● Monitor vital/ ECG
● Increase magnesium food ● Diuretics for excretion
Eg:- avocado,cauliflower,greenleafy veg. ● Administer antidote-Calcium
Milk,peas,pork,beef,potato gluconate

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 COMMUNICABLE DISEASE

MEASELS OR RUBEOLA
● Agent – Paramyxovirus / Morbillivirus
● Incubation period 10 – 20days
● Mode of transmission
ꟷ Airborne/Droplet/contact/Tran placental
Clinical Feature
● Fever
● Coryza
● Cough
● Conjunctivitis
● Kolpik’s spot- small red spot with a bluish white center and a red base located on the buccal
mucosa .( cross check the picture from net )

Management

● Isolation
● Dark room/humidified room

RUBELLA
● Agent Rubella virus.
● Incubation period 14 -21 days
● Mode of transmission
ꟷ Airborne/Droplet/Contact/Tran placental
● Communicable period 7 days before to about 5 days after the rash appear.

Clinical Feature

Pinkish red maculopapular rash that begins on the face and spread of the entire body within 1 – 3
days.

Sources of Infection

Nasal secretion, Blood, Stool, Urine

Management

● Isolation
● Special attention in pregnancy – Infection in pregnancy can cause CHD, cataract, growth retardation,
pneumonia, congenital defect in ear and brain.
Prevention
● Vaccine is available
● It is a live attenuated vaccine
● Vaccine contra indicated in pregnancy
● Women should conceive at least 3 month after Rubella vaccination

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 MUMPS OR RUBULA
● Agent Paramyxovirus
● Incubation period 14 – 21days
● Mode of transmission – Droplet/ Direct contact

Clinical Feature

● Parotid gland swelling

● Jaw or Ear pain
● Orchitis

Management

● Droplet precaution
● Hot or Cold application
● Liquid diet.

PERTUSIS OR WHOOPING COUGH

● Agent Bordetella Pertussis
● Incubation period 5 – 21 days
● Mode of transmission Droplet

Clinical Feature

● Respiratory infection
● Cough
● Cyanosis
● Toung protrusion

Management

● Isolation
● Antimicrobial therapy
● Pertussis Immune globulin.

DIPHTERIA
● Agent Corny bacterium diphtheria
● Incubation period 2 – 5days
● Mode of transmission
ꟷ More droplet

Clinical Feature

● Low grade fever

● Sore throat
● Foul smelling mucopurulant nasal discharge
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 ● Neck edema or bull neck
● Grey or white patch in throat

Diagnostic Test

● Throat swab culture

● Shick test

Management

● Isolation
● Administer diphtheria antitoxin
● Tracheostomy with mechanical ventilation.

CHICKEN POX
Agent Varicella zoster

Incubation period 13 – 17 days

Mode of transmission Airborne/ Droplet/Contact

Clinical Feature

Macular rash that first appear trunk and scalp and moves to the face and extremities.

Management

⮚ Isolation – Negative pressure ventilation room

⮚ Injection Acyclovir
⮚ Supportive management

TETANUS
⮚ Agent Clostridium tetani
⮚ Mode of transmission – Direct contact
⮚ Incubation period 7 – 10 days

Clinical Features

⮚ Spasm and stiffness of jaw

⮚ Seizure
⮚ Patient maintain Opisthotonos posture

Management

⮚ Isolation
⮚ Antitoxin
⮚ Symptomatic treatment

168
 Prevention

⮚ T.T vaccine
⮚ Booster dose of TT every 10 yearly

RABIES
⮚ Causative agent – Lyza virus
⮚ Infected from – Dog, Monkey, Fox, Bat, Raccoon
⮚ NEGRI BODIES

SCARLET FEVER
⮚ Agent Group A Beta hemolytic streptococcus
⮚ Incubation period 1 -7 days
⮚ Mode of transmission Direct contact/Droplet

Clinical Feature

⮚ High fever
⮚ Vomiting
⮚ Headache
⮚ Enlarged lymph nodes in the neck
⮚ Red fine sand paper like rash develop in the Axilla, groin and neck that spread to cover the entire
body except face
⮚ White strawberry tongue followed by red strawberry tongue

Management

⮚ Antibiotic
⮚ Isolation

AIDS ( acquired immune deficiency syndrome )

● Agent HIV virus
● Mode of transmission Blood, Body fluid, Sexual contact, Breast feeding, Not transmitted through
saliva
● Incubation period – Month to year

Clinical Feature

● Opportunistic infection
● Chronic cough leads to pneumonia
● TB
● Pneumocystis pneumonia
● Diarrhea & Oral candidacies

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 Diagnostic Evaluation

● ELISA
● Confirmatory test is Western Blot test – In this CD4+ cell is less than 200(Normal 500 – 1200)

Complication

Kaposi’s Sarcoma – Skin cancer

Management

IF POSITIVE WE CAN START DRUG.

● Administer ART. eg:- Zidovudine

Benefit -->Decrease viral load

-->Increase CD4+ cell count

-->Prevent opportunistic infection

HIV patient Needle Stick injury occur Nursing Responsibility

● Wash the area with running water

● Avoid squeezing
● Do not panic
● Do ELISA –test
● Taken ART within 72 hour
● Do ELISA after 6 MT

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 Difference Between Killed Vaccine and live attenuated vaccine
❖ An inactivated vaccine (Killed) works when the immune system responds to a piece of a bacteria or virus
or to a toxin produced by the germ.
eg:- DPT, IPV
❖ Live attenuated vaccine contains a living although significantly weakened version of a virus or bacteria.
eg:- MMR, Varicella, OPV

NUTRITIONAL DEFICIENCY DISORDER

CLASSIFICATION OF VITAMIN

❖ WATER SOLUBLE VITAMIN

1. Vitamin C – Ascorbic acid

FunctionPromote Immunity
 Helps in wound healing
 Increase absorption of Iron
Deficiency Scurvy
Sources Citrus fruits, tomato, Broccoli, Cabbage.

2. VITAMIN B –COMPLEX

● B1 – Thiamine
DeficiencyBeriberi
Sources Bran, Spinach, Rice, legumes

● B2 – Riboflavin
Function It is required by the body for cellular respiration
Deficiency Dermatitis, glossitis, Cheliosis
SourcesLegumes, cereals, egg, milk, green leafy vegetables

● B3 – Niacin
DeficiencyPellagra
Sources Chicken, peanut, mushroom, liver, beef, Avocado, seafood

● B6 – Pyridoxine
Function It is needed to maintain the health of nerves, skin, and RBC
Deficiency Peripheral neuropathy and neuritis
Sources Yeast, corn, meat, poultry, fish

● B9 – Folic acid
Function Help in DNA synthesis and formation of blood tissue and cell division.
Deficiency In pregnancy – Neural tube defect
Non pregnancy – Megaloblastic anemia
Sources Green leafy vegetables, liver, grape fruit, Orange
Daily intake In pregnancy – 400mg , Non pregnancy 200 mcg

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Vitamin B12 – Cyanocobalamin

Deficiency Pernicious Anemia

Sources Brewer’s yeast, citrus fruit, green leafy vegetables, Dry fruits, Nuts
Function Normal functioning of the Brain and Nervous system.
Involved in the formation of RBC helps to regulate DNA.

❖ FAT SOLUBLE VITAMINS

● Vitamin A (Retinol)
ꟷ Helps for vision
ꟷ Deficiency Night blindness/ Keratomalacia, or Xerophthalmia
ꟷ C/M Bitot spots
ꟷ Sources Liver, egg yolk, whole milk, green leafy vegetables, Orange

● Vitamin D (Calcitrol)
ꟷ Helps for absorb calcium
ꟷ Deficiency Rickets
ꟷ Sources Fortified milk, fish oil, sunlight
ꟷ
● Vitamin E (Tocoferol)
ꟷ It is beauty vitamin
ꟷ Helps for fertility
Sources Almonds, Spinach, sweet potato, Avocado

● Vitamin K (Menadiol)
ꟷ Helps for blood clotting
ꟷ Deficiency bleeding
ꟷ Sources Green leafy vegetables, Broccoli, Spinach, Cauliflower, Cabbage

LACTODEX POWDER
Indications
1. Vitamin A deficiency
2. Eye problems
3. Skin disease
4. Scurvy
5. Cell damage
6. Wound healing
7. RBC production
8. Vitamin D deficiency
9. Growth & Development

HYPERBILIRUBENEMIA
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→ Jaundice is the yellow color of the skin and sclera caused by deposit of Bilirubin.
→ Normal Bilirubin in newborn- less than 5 mg/dl in pre term and less than 12mg/dl in term babies
Types

Physiological Jaundice Pathological Jaundice

●Appear after 24 hour of birth. ● Appear within 24 hours of birth.
●Total bilirubin rises by less than 5 mg/dl per day. ● Increase of bilirubin more than
●Serum level less than 15 mg/dl. 5mg/dl/day.
●Maximum limit 14 days. ● Serum bilirubin more than 15 mg/dl.
Cause ● It will be beyond 14 days.
● Preterm Causes
● Liver immaturity and Hemolysis. ● RH incompatibility.
● Breast feeding. ● ABO incompatibility.
Prevention ● G6PD deficiency.
● Administer barbiturates to the pregnant mother to ● Hematoma.& Inborn error metabolism.
prevent Jaundice in newborn.
Assessment

● Note that Jaundice starts at the head first spread to the chest, abdomen and then the arms and legs
followed by the hands and feet.
● Poor sucking reflex.
● Poor muscle tone.
● Enlarged liver.

Clinical Assessment of Jaundice

Area of Body Bilirubin level d/mg

Face 6
Upper trunk 9
Lower trunk thigh 12
Arms & lower legs 15
Palms & soles >15

Management

1. Aim of treatment to prevent kernicterus.

2. Promote hydration/ Breast feeding. It will help to excrete Bilirubin through urine.
3. Prepare for phototherapy.
● The light waves covert the toxic bilirubin in to water soluble non toxic form which is easily excreted
through urine and stool
● It also enhances hepatic excretion of unconjugated bilirubin in to the intestinal lumen.
● Nursing Intervention during Phototherapy
● Cover both eye’s and gonads.
● Monitor skin temperature closely.
● Increase fluid intake.
● Expect loose green stool and green urine.
● Reposition new born every 2 hourly.

● Complication of Phototherapy
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 ● Eye damage
● Dehydration
● Impotency
● Sensory deprivation

4. Intravenous Immunoglobulin

5. Exchange transfusion

6. Drug phenobarbitone

MUSKULOSKELETAL DISORDER

CONGENITAL HIP DYSPLASIA

It is the abnormal development of the hip that may develop during fetal life, infancy or childhood. In
these disorders the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis.

Assessment

● Allis sign or Galeazzi sign (shortening of the affected limb) - this also can seen in femur fracture
● Positive Ortolani test
● Positive Barlow test
● Positive Trendelenburg sign

Management

● Birth to 6 month of age splinting of the hips with a Pavlik harness.

● Bryant traction.
● Older children Operation reduction and reconstruction.

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 CONGENITAL CLUB FOOT
❖ It is also known as talipes equinovarus

❖ Types
● Talipus Varus An inversion or bending inward.
● Talipus valgus An eversion or bending outward.
● Talipus Equinus Toes are lower than heal.
● Talipus Calcaneus Toes are higher than heal.

Risk Factors

● Spina Bifida
● Oligohydramnios
● Smoking during pregnancy

Management

● Casting and splinting

● Ponseti method (Stretching and casting)
● Wheaton Brace
● Dennis Brown Bar
● Surgery done in between 9 – 12 month

CLAVICLE FRACTURE IN NEW BORN

⮚ Causes – shoulder dystocia

⮚ C/M – crying with movement of affected arm, fussiness, the affected shoulder may appear slightly
lower than uninjured shoulder, the infant themselves may not move the affected arm as much as the
un injured arm
⮚ Management
● Can heal very quickly without any problems
● Usually no treatment is required
● The parent my be instructed to pin the child sleeve of the affected arm to the front of their
clothing to avoid moving the arms while it heal

Complication of IV Therapy
1. Air embolism.
2. Circulatory overload.
3. Electrolyte overload.
4. Hematoma
● Collection of blood in to the tissue
● Clinical Feature: - Ecchymosis, immediate swelling, leakage of blood at the site painful lump at the
site.
5. Infection.
6. Phlebitis.
7. Infiltration.
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● It is seepage of the IV fluid out of the vein and in to the surrounding interstitial spaces.
● Clinical Feature: -Edema, Pain, coolness of the site may or may not have blood return.
8. Tissue damage
● Damage the skin, vein, S/C tissue
● Clinical Feature :-Skin color change, Discomfort at the site

Complication of Tracheostomy
1. Tracheomalacia Constant pressure exerted by the cuff causes tracheal dilation and erosion
of cartilage.
2. Tracheal stenosis Due to scar formation from irritation of tracheal mucosa by the cuff.
3. Tube obstruction
4. Tube dislodgement
5. TEF Cuff pressure causes erosion of the posterior wall of the trachea.

Transfer of heat from new born Body

1. Conduction – the transfer of body heat to a cooler solid object in contact with the baby eg. tepid
sponge ( covering surface with a warmed blanket or towel helps minimize conduction heat loss).

2. Convection- the flow of heat from the body surface to cooler surrounding air.(eliminating drafts such
as windows or air con, reduces convection).
3. Evaporation –loss of heat through conversion of a liquid to vapor.

4. Radiation – the transfer of heat to a cooler object not in contact with the baby.

Conversion
● 1 litter = 1000 ml
● 1 gm = 1000 mg
● 1 mg = 1000 mcg
● 1 gm = 15 grain (gr)
● 1/150 gr = 0.4 mg
● 1 ounce = 30 ml
● OD = Right eye
● OE = Left eye
● OU = Both eye
● 1 kg = 2.2 lbs
● 1 teaspoon = 5 ml
● 1 table spoon = 15 ml
● PC = After meal
● AC = Before meal
● 1 inch = 2.5 cm
● 1 feet = 30 cm
● 1 lbs = 453g

PSYCHIATRIC NURSING
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ANXIETY DISORDER

Anxiety is natural response to stress. It is a subjective experience that includes feeling of

apprehension, uneasiness and uncertainty

Types of anxiety level

1. Mild: mild occurs due to tension of everyday life. This type of anxiety may be motivating and
enhances growth. HIGH PERCEPTION
2. Moderate: It focus on immediate concern, it narrows the perception
3. Severe: pt is feeling that something bad is about to happen. They need direction to focus
4. Panic attack: sudden onset of feeling with intense apprehension, tremors and dis organized
personality. They have inability to focus
Signs and symptoms of anxiety: -

1. Restlessness
2. Inability to focus
3. Sleep problems
4. Physical discomfort
Panic attack

- Chocking
- Chest pain
- Laboured breathing
- Dizziness
- Blurred vision
- Feeling of anxiety
Mgt of anxiety

- Provide calm and quite environment and remain with client

- Encourage the client to verbalize the feeling
- Encourage problem solving
- Attend to pt physical symptoms
- Assure the pt that getting anxiety is a normal process
- Administer anti-anxiety drugs
Anti-anxiety drugs

Action: - it depresses CNS and produces relaxation and depress anxiety

Benzodiazepines

1. Diazepam (Valium)
2. Midazolam
3. Lorazepam
s/e of anti-anxiety drugs : - daytime sedation

- Dizziness
- Headache

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 - Blurred vision
- Hypotension
- Amnesia
- Antidote flumazenil
Contraindication- angle closure glaucoma

POST-TRAUMATIC STRESS DISORDER (PTST)

After experiencing a psychologically traumatic event- the individual is prone to re- experience the event and
has recurrent and intuitive dreams or flashback

Causes:

- Natural disaster
- Murder
- Accident
- Rape
- Terrorist attack
- Violence
- Physical, emotional or sexual abuse
Symptoms

- Detachment (separation from the environment)

- Depression
- Anxiety
- Sleep disturbance
- Nightmares (a frightening or unpleasant dream )
- Poor concentration
- Hyper vigilance
- Avoidance of activity
Mgt

- Be non-judgemental and supportive

- Assure the client, that their feelings and behaviour are normal
- Encourage the client to express the feeling
- Assess the client in adopting coping or defence measurements
- Encourage systemic desensitisation

DEFENCE MECHANISM
It is an unconscious process that defense a person against anxiety. It is a coping mechanism that
enable a person to reduce stress or anxiety

1. DENIAL: when we refuse to accept or believe the existence of something that is very unpleasant to
us. Disowning consciously intolerable thoughts and impulses.
2. RATIONALIZATION: it is a defence mechanism in which the individual justify the failure and
socially acceptable behaviour, by giving socially approved reasons
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 It operates by 2 mechanisms
a) Sour grape: (unskilled worker blames always the tool)
b) Sweet lemon: (a poor man says, he doesn’t want to earn money because, money is the root cause
of many evil event)
3. CONVERSION: expression of emotional conflict through physical symptoms
4. PROJECTION: transferring one’s internal feelings, thoughts, unacceptable ideas to another person
5. DISPLACEMENT: feeling towards one person are direct to another person who is less powerful or
less threatening
6. SUPPRESSION: conscious deliberate for getting of painful thoughts, ideas and feeling. They will
be ….
7. REPRESSION: unconscious process in which client black undesirable and unacceptable thoughts
8. COMPENSATION: putting forth extra effort to achieve in areas where one has a real or imagined
deficiency.
9. FANTACT : gratification by imaginary achievements and wishful thinking
10. REGRESSION : returning to an earlier developmental stage to express an impulse to deal with
anxiety

PHOBIA
Phobia is irrational fear of an object, for a situation that persist. Defense mechanism commonly used in
phobia is repression and displacement

Types

1. Acrophobia – fear of height

2. Agoraphobia - fear of open space
3. Aerophobia - fear of flying
4. Astraphobia - fear of electrical storms
5. Algophobia - fear of pain
6. Agra phobia – fear of sexual abuse
7. Ailurophobia - fear of cat
8. Hematophobia - fear of blood
9. Claustrophobia –fear of closed space
10. Arachnophobia - fear of spider
11. Hydrophobia - fear of water
12. Mysophobia - fear of germs
13. Monophobia - fear of being alone
14. Nyctophobia - fear of darkness
15. Pyro phobia - fear of fire
16. Gloss phobia - fear of public speaking
17. Xenophobia - fear of strangers
18. Zoophobia - fear of birds
Management

FLOODING – some times referred to as in vivo exposure therapy, is a form of behavior therapy and
desensitization or exposure therapy. based on the principles of respondent conditioning. As a
psychotherapeutic technique, it is used to treat phobia and anxiety disorders including post traumatic stress
disorder

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 - Identify the basis of anxiety
- Allows the client to verbalized the feeling
- Teach relaxation techniques such as breathing exercises muscle relaxing exercises and visualization
of pleasant situation.
- Promote desensitisation by gradually introducing the client to the feared object or situation, in small
doses
- Always stay with the client, for safety and security, never force the client to concentrate on phobic
objects
- Encourage psychotherapy

OCD- OBSESSIVE COMPULSIVE DISORDER

Obsession: - pre-occupation with persistently initiative thoughts and ideas.

Compulsion: - performance of repetitive behaviors or rituals to divert the unacceptable thoughts. DONE TO
REDUCE ANXIETY

Causes

● Decreased serotonin level

Mgt of OCD

- Identify the situation that precipitate OCD

- Never stop the pt from OCD behaviour
- Divert or distract the pt from the behaviour by giving games, puzzles, or simple task
- Allow the client to perform the behaviour, best set time limits
- Administer anti-depressant
- Recreational therapy
- CBT
Nsg diagnosis - Disturbed through process or disorder

SCHIZOPHRENIA (SPLIT MIND (EUGEN BLEULER)

It is a group of mental disorder characterized by psychiatric features (hallucination, delusion)
disordered thought process, disrupted interpersonal relationship. It can cause disorders in effect mood,
behavior, personality thought process.

Causes

Increase dopamine level high level of serotonin

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Symptoms

(Physical characteristics)

- Unkept- appearance (poor hygiene)

- Body image disturbance
- Preoccupied with somatic complain
- Neglect hygiene, eating, sleeping, elimination
Abnormal motor behaviour

- Echolalia (Repeated words of others)

- Echopraxia (repeated movement of others)
- Waxy flexibility (having one’s arm or leg placed in a certain position and holding the same position
for hours)
- Dyskinesia (Difficulty in movement)
- Stupor (sitting on one area and fixed vision for a long period of time)
Emotional characteristics

- Mistrust
- Hostility (viewing the centric world as enemy)
- Helplessness
- Hopelessness
- Anxiety
- Anger
- Guilt
- Depression
- Ambivalence (status of having mixed fooling or ideas about something or someone (-ve feeling)

Abnormal thought process

- Confabulation: filling the memory gap with fantasy

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 - Flight of ideas: Jumping from one to another without completion
- Neologism: creation of new words + meaning is known only to the pt
- Word salad: mixture of words + phrases that has no meaning
- Loosing of association: no connection with the sentences
- Thought blocking: sudden cessation in the middle of sentences
- Circumstantialities: before getting into actual answer for the questions ask the client gets caught with
countless explanation

SCHIZOPHRENIA CARDINAL FEATURES

Delusions (Disturbed thought process)

False fixed unshakable beliefs

Types of delusions

⮚ Grandeour delusions: false beliefs that one’s is a powerful and important person
⮚ Jealousy: false beliefs that one’s partner going out with another person
⮚ Persecution: false belief that somebody is going harm them
Mgt of Delusion

⮚ Present reality to the pt

⮚ Ask the client to describe the delusion
⮚ Do not be aggressive
⮚ Do not argue with the client hot delusions are false
⮚ Validate if delusion are real
⮚ Encourage the client to express the feelings
Abnormal perception

ILLUSION: misinterpretation of stimulus

HALLUCINATION: it is a false perception without a stimulus

Types

1. Auditory
2. Visual
3. Tactile
4. Olfactory
5. Gustatory
Management.

⮚ Encourage the pt verbalize about hallucination

⮚ Present reality to the pt
⮚ Avoid touching the client
⮚ Decreased stimulus in the environment and shift the pt to another area
Types of Schizophrenia

1. Paranoid: -in which a person loses touch with reality. C/M including suspiciousness, hostility,
delusion, auditory hallucination, anxiety, anger/ violence

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 2. Catatonic: - problem with movement or psychomotor disturbances. Most dangerous. very less
movement and does not respond to instructions
i. Stupor
ii. Immobility
iii. Waxy flexibility
iv. Purposeless unwanted movement
v. Echolalia
3. Residual – have previous history of schizophrenia pt shows intermittent signs of schizophrenia
negative symptoms.
4. Disorganized- Extreme social withdrawal, disorganized speech behaviour
Selfishness- stereotyped behaviour, inability to perform activity of daily living
5. simple [ no positive symptoms)
Management

- Assess the client physical needs

- Maintain safe environment
- Remove all sharp instrument
- Participate in one to one interaction with client
- Spend time with client if the client is unable to respond
- Avoid touching the client
- Sit with the client silently
- Tell the client when you are leaving
- Present reality to the client
- Do not make promises to the client that cannot be met
- Provide simple creative activity such as puzzle, or game
- Use canned or packed food
- Stay with the client if he or she is frightened
- Monitor for suicidal tendencies
- Provide radio for ask if insomnia
Antipsychotics

Typical: chlorpromazine, Haloperidol, Trifluoperazine, loxapine,

Atypical: Risperidone, Olanzapine, clozapine, palperidone,

Action: Improve the thought process and behavior of the client with psychotic symptoms. It affect dopamine
receptors in the brain

Side effect: - anti-cholinergic effect. Eg. atropine drug- dry mouth, Tachycardia, Urinary Retention,
constipation, hypertension

● Who can take anti-cholinergic?

- Pt with incontinence of urine
- contraindication anti-cholinergic cannot take GERD
SIDE EFFECT

- Extrapyramidal symptoms (EPS) (Parkinsonism)

- Rigidity
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 - Bradykinesia
- Tremors at rest
- Mask like face
- Drooling/ dysphagia
- Dystonia (muscle tone movement disorder) characterized by prolonged involuntary movement

- Neuroleptic malignant syndrome: - (may cause death)

It is a potential fatal condition that occurs any time during antipsychotic medication

Symptoms

- Dyspnoea
- Tachypnoea
- Tachycardia
- Fever
- Altered LOC
- Difficulty swallowing
- Sever EPS
- Seizure
- Oculogyric crisis
- Treatment benztropine
GRIEF

Natural response to loss

STAGES of grief: -DABDA ( according to kubler ross theory )

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D - Denial – not believing what has occurred

A – Anger- Anger towards the last one

B – Bargaining – (no, not, me, yes I am) bargaining to some one

D – Depression – after bargaining leads to depression and especially to good tasty acceptance

A – Acceptance – lastly will accept

BIPOLAR MOOD DISORDER

It is characterized by mania and depression with normal mood in between

MANIA DEPRESSION
Cause – increased nor-epinephrine Cause – decreased nor-epinephrine and
serotonin
: extroverted – highly energetic It affects feeling, thoughts and behaviors
Symptoms Symptoms
- Become angry quickly - Hopelessness
- Extraverted personality - Powerlessness
- Grandeur delusion - Helplessness
- Persecutory delusion - Low safe esteem
- Flight of ideas - Introverted
- Unlimited energy - Sleep disturbance
- Loss of appetite - Lack of interest in physical appearance
- Distracted by stimulus - Decreased speech
- Buffoon like appearance - Increased or decreased appetite
- Restlessness - Somatic complaint
- Low mood
- Low mood with high energy high
chance for suicide

MANAGEMENT - MANIA

Drug of choice: lithium carbonate ( it is a mood stabilizing agent )

Therapeutic level: 0.6 – 1.2 mEq/L

Symptoms ( toxicity features )

- Confusion, headache, abdominal bloating,

- Polyuria
- Polydipsia
- Weight gain
- Dry mouth, diarrhoea, muscle weakness
- Hand tremors
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 - Fatigue
- Alopecia
- Hypothyroidism
Lithium antidote- diamox or acetazolamide

Other drugs- sodium valporate and carbamazepine

NURSING MANAGEMENT

- Provide less hazardous environment

- Avoid argue with the client
- High calorie finger like food
- Provide private room if possible
- Avoid competitive games
- Administer lithium
MANAGEMENT OF DEPRESSION

ANTIDEPRESSANTS (First line drug SSRI SNRI (insomnia) )

1. Reuptake inhibitor
Action: It inhibit serotonin uptake + elicit a anti-depressants action

Class -

A. SSRI – selective serotonin reuptake inhibitors

Eg: sertraline (Zoloft), Fluvoxamine, Fluoxetine (Prozac) , citalopram,

B. SNERI – selective, non-epinephrine reuptake inhibitor

Eg: Duloxetine, venlafaxine,

C. A typical anti-depressant
Eg: Bupropion (Zyban), mirtazapine, nefazodone, trazodone
S/E: - dry mouth

- Headache, weight loss, sleepy, drowsy,

- Dizziness, tremor, decreased libido
- Diaphoresis
- Blood pressure changes
- Photosensitivity
- Seizure
- Insomnia and sexual dysfunction ( most common side effect of anti- depresants )

2. Tricyclic antidepressants (TCA)

Action: block the release of non- epinephrine and serotonin from pre- synaptic junction

Example . Amitriptyline, Imipramine, Amoxapine

S/E: Anticholinergic effect

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 o Dry mouth
o Urinary retention
o Constipation
o Blurred vision
o Tachycardia
o Dilated pupils
Nsg responsibility

- Inform the client that anti-depression it may take several weeks for desired effect (2 to 4 weeks)
- Take with food on milk
- Instruct the client to avoid alcohol and driving, avoid alcohol consumption

3. Monoamine oxidase inhibitor (MAOI)

Inhibit the enzyme MAO which is present in brain, platelet, liver, spleen, and kidney. MAO
metabolize amines, nor-epinephrine

Example – phenelzine, tranylcypromine, isocarboxacid, selegiline

Contraindications: should not be used with levodopa, OHA, dopamine, epinephrine, nor-epinephrine,
tyramine containing food, nasal decongestion. Because it cause hypertensive crisis. Eg: phenelzine,
isocarboxazid

S/E: - insomnia

- Dizziness
- Anti-cholinergic effect
THYRAMIN…. Containing food

- Avocado , Banana, Caffeine containing products

- Chicken, liver, beef, Papaya
- Cheese, Red wine, Beer, Raisins
Nursing management

- Remove all sharp equipment or instrument

- Monitor for one to one supervision
- Ask the pt directly have you thought of hurting himself
- Decreased environmental stimulus
- Do not leave the pt alone
- Meet the physical need of the pt
- Avoid arguement to the patient

ECT- electro convulsive therapy

An elective treatment for depression (not a curative care) It consist of inducing tonic clonic seizure by
passing an electric current.

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Contra indications of ECT

- Recent myocardial infraction

- Stroke
- Intracranial mass lesions
Indications of ECT

- Major depression
- Mania pt resistant to lithium
- Schizophrenia
s/e:

- Confusion
- Disorientation
- Short term memory loss
Note – the usual course is 6-12 treatment, 2-3 times per week

Nursing intervention – before procedure

1. Consent
2. Explain the procedure to the client and teach the client and family what to expect.
3. Maintain NPO status midnight or at least 4 hour.
4. Monitor vitals
5. Empty bladder, and bowel before procedure
6. Remove dentures, lenses, hairpins, etc.
7. Administer atropine sulphate before procedure ( it will help to decrease secretion and bradycardia
during procedure )
Nursing intervention – during procedure

1. Monitor BP through out procedure

2. Administer oxygen and insert a IV line
3. Place ECG & EEG leads
4. An airway is placed to prevent biting the toung
5. Administer succinylcholine (muscle relaxant ) and thiopental sodium ( short anaesthetics)
6. Amount of current using – ( 70-120 V )
7. Timing ( 0.7 sec – 1.5 sec )
Nursing intervention – after procedure

1. Priority for airway and keep emergency tray always at the bedside
2. Monitor vitals
3. Once the client is awake talk to the client and take the vitals
4. Reorient the client frequently
5. Before giving anything to mouth check the gag reflex.

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EATING DISORDERS-
ANOREXIA NERVOSA: BULIMIA NERVOSA

It is associated with stressful life event. Client Client indulges in eating plenty, followed by parking
initially fear obesity and body image to distorted. behavior. Client will remain in the normal weight of
It can be life threatening because death can occur range, but things that the life are noted by eating
due to starvation, suicide, electrolyte imbalance. related conflict

Symptoms Symptoms
- Refuse to eat - Attempt to loss the weight through diet,
- Appetite loss vomiting, compulsive exercise
- Feeling of lack of control - Consumption high caloric food
- Self-induce vomiting - Poor inter personal relationship
- Self-administered enema - Low self esteem
- Compulsive exercise - Mood swing
Physical - Metabolic alkalosis
- Weight loss (BMI less than 18) - Loss of tooth enamel and dental decay
- Decrease temperature, pulse, BP - BMI 18.5 -24.9
- Constipation - RUSSELL SIGN ( calluses on the knuckles
- Metabolic acidosis or back of the hand due to repeated self
- Hyperkalemia induced vomiting over long period of time )
- Dry scaly skin
- Sleep disturbance
- Bone dehydration

Management.

- Assess the client nutritional status

- Encourage the client to express feeling about eating disorder
- Set a time limit for each meal
- Pleasant, relaxed environment for eating
- Daily check the wt at the same time using same scale, same dress after client voiding
- Decrease anxiety
- Administer antidepressants
- Provide devotionals therapy
- Provide psychotherapy
Nursing diagnosis- body image disturbance

DEMENTIA
It is an organic disorder with progressive deterioration functioning. It may result in self-care deficit

1) Alzheimer’s disease:
It is irreversible form of senile dementia memory. It affects the cerebral cortex
Incidence: - More common in female gender with genetic history

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Stages: recent memory impaired remote intact

Stage

1. Stage 1 -Mild: forgetfulness

2. Stage 2- moderate- confusion
3. Stage 3- several- Ambulatory dementia
4. Stage 4- late stage- complete memory loss
Symptoms

- Wandering- management is REORIENT

- Self-care deficit
- Confusion
- Altered sleep pattern
- Agnosia – inability to recognize familiar person or objects
- Apraxia – inability to comfort voluntary on skilful movement
- Aphasia – language disturbance in understanding and experiencing spoken words
- Amnesia – complete memory loss
- Sundowning syndrome – symptoms become prolonged on and increased in evening
Management

- Priority is providing safe environment

- Primary goal is to improve physical and functional ability
- Orient client to environmental ……… of the pt
- Help the client to maintain independent
- Give simple game or activity
- Provide ample time to complete the task
- Provide sedation to limit wandering
- Use simple sentences for communication
- Use from low pitched voice
- Provide hand over hand assisted exercise to improve the co-ordination such as wooden boards with
multiple
Drug to treat Alzheimer’s – Acetyl cholinesterase inhibitors

Eg: Donepezil: DOC too Alzheimer’s, Memantine, galantamine, rivastigmine

S/E:

- Dizziness
- Headache
- Nausea
- Diarrhoea
- Confusion
Nursing diagnosis - risk for injury , impaired physical mobility

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DELIRIUM
Altered level of consciousness. Sudden onset of confusion

Causes

- Alcohol withdrawal
- Head injury
- Stroke
- Toxic levels of medicines or chemicals
Signs

- Confusion
- Disorientation
- Language deficit
- Hallucination
- Illusion

SUBSTANCE ABUSE
It is a mal adoptive pattern of a substance, use that impaired the cell in board senses

ALCOHOL ABUSE

- Alcohol is CNS depressant

- Affect all body tissues
Symptoms

- Slurred speech
- Unsteady gait
- Restlessness
- Confusion
- Binge drinking
- Arguments
Antidote - fomepizole

Psychological symptoms

- Depression
- Hostility (viewing the world has enemy)
- Rationalization
- Suspiciousness
- Irritability
- Isolation
Complication of alcohol abuse- vitamin B1 deficiency. Wernicke’s exophalopathy and Korsakoff
psychosis

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Withdrawal symptoms

- Anxiety, Delirium, Agitation, Fever, Insomnia, Tachycardia

- Tremor, HTN, Hallucination, Delusion
Interventions

Benzodiazepines, B1, magnesium

- It is a medical emergency because death can occur, MI, aspiration, fat embolism on electrolyte
changes
- Assess vital signs, neurological symptoms every 5 minutes, seizure precautions
- Administer multivitamins
- Prepare for therapy
● Marijuana, cocaine, heroin, codeine, are C1 classification of drug abus

ERICKSON THEORY OF PSYCHOSOCIAL DEVELOPMENT:

Erickson describe the human life cycle into ego development. From birth to death

Stages for birth to death

1. Birth- 1 ½ year trust Vs mistrust

2. Toddler- 3 years- autonomy vs shame or doubt
3. Late child hood- 3-6 year – intiativeness vs guilt
4. School age- 6-12 years – industry vs inferiority
5. Adolescence – 12-20 years – identify vs role confusion
6. Early adult hood- 20-35 years- intimacy vs isolation
7. Middle adult hood- 35- 65 years- generosity vs stagnation
8. Late adult hood- 65 years to death- integrity vs despair

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SIGMUND FRAUD PSYCHOSOCIAL DEVELOPMENT THERAPY
ORAL. Stage:- (birth to 1 year) pleasure is obtained through stimulation of mouth .

ANAL stage: - (1 to 3 years) Toilet training begins in the period child from elimination or focus and form
their no tension

PHALLIC stage: - (3 to 6 years) child experience pleasure and conflict feeling ….. with genital organs

- Development of Oedipus complex

- edipus complex
LATENT stage: - (6-12 years) it is tapering of conscious biological sexual ….

GENITAL stage: - (12 years to beyond) development of puberty. Individual develop satisfaction from
sexual emotional relationship to opposite sex

PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

1. birth to 2 years: - sensory motor stage
2. 2 to 7 years: - pre-occupational/stage/ eccocentric
3. 7 to 11 years: - concrete operational
4. 11 to beyond: -formal operational

Milieu’s therapy: - milieu refers to physical and social environment in which client receive treatment. It
uses the safe environment to meet the client needs

THERAPEUTIC COMMUNICATIONS
1. Silence – client able to think about their problems doesn’t feel pressure or obligation to speak
2. Offering calls- offer to provide comfort to the client by presence eg: nursing staff tells that I will sit
with you and I will walk with you
3. Accepting- (listening) indicate non-judgemental acceptance of clients and this perception by
nodding and following what client says or demands
4. Give recognition: - indicate to the client you are aware of him and his behaviour. Eg: nurse says
good morning John; you have combed your hair this morning
5. Making observation- verbalize what you perceive. Eg: nurse: I notice that you can’t seeing to sick
skill
6. Encouraging description- ask the client to verbalize the perception. Eg: what is happening to you
now
7. Used broad openings- encourage the client to introduce topic of conversation eg: what are you
thinking about?
8. Offering general needs- to encourage the client to continue discussing the topic eg: tell me more
about that
9. Re-statting – repeat what client was said. Eg: client: I don’t want to take this medicine. Nurse: you
don’t want to take this medicine
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 10. Reflecting – direct client questions all statements back to encourage expressions of ideas and
feelings eg: client: do you think I should call my father. Nurse: what do you want to do?
11. Focussing- encourage client to stay on a topic or a point and eg: nurse- you were talking about
identify the based on
12. Exploiting – encourage the client to express feeling or idea. Eg: tell me more about
13. Clarification- encourage the client to make ideas or feelings more expressed or understandable eg:
nurse: I don’t understand and that’s what you mean? Would you explain to me?
14. Presenting reality- report events or situation as they really are. Eg: client: I don t get to talk to my
doctor. Nurse: I saw your doctor talking to you today morning
15. Translating into feelings- encourage the client verbalize feelings, expressed in another way. Client:
I will never be got better. Nurse: you sound rather helpless and hopeless
16. Suggesting collaboration- offer to work with client towards the goal. Client: I fail at everything I
try.
Nurse: we can collaborate or work together to achieve the goals

TOURRETTE SYNDROME (TIC DISORDER)

It is a neuropsychiatric disorder of childhood onset(2-15yr) characterized by multiple motor tics and at
least one vocal tics. Tics are sudden repetitive non-rhythmic movements

Features:

● Eye blinking
● Throat clearing
● Facial movements
● Shrinking of shoulders
● Chorea
● Dystonia

Management

Behavioral modification

Administer adrenergic blockers (clonidine) to relieve anxiety .

AUTISM/ RETTS SYNDROME/ASPERGERS SYNDROME

It is a disorder characterized by abnormal social interaction and impaired communication. Parents can
identify autism only by the age of 3yr.

Features

● Upto 3yr-only facial expressions

● By 6yr- tell words
● By 9yr- form sentences
● Child uses repeatative words
● Attached to inanimate objects

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Management

Use communication board

Decrease mental stress

Encourage interactions with others.

ADHD ( ATTENTION DEFICIT HYPERACTIVE DISORDER )

● It is a behavioural disorder characterised by inappropriate degree of attention with hyperactivity
● Sign and symptoms
✔ Talks excessively
✔ Poor attention
✔ Easily distracted with stimulus
✔ Fidget with hand and feet
● Management
✔ Drug- methyl phenodite ( Ritalin ) side effect – insomnia, tachycardia, hypertension
✔ Provide classrooms and home with less stimulus
✔ Provide behavioural therapy and take all preventive measures and safety precaution

CHILD ABUSE
It is a non accidental physical injury or act of avoiding care by a parent or person responsible for the
child

TYPES

1. Neglect
2. Physical.
3. Emotional
4. Sexual.
Shaken Baby syndrome: it is a form of physical abuse characterized by violent shaking of infant
younger than 1yr, which results in intracranial haemorrhage casuing cerebral edema and death.

s/s: subdural haemorrhage, retinal bledding, cerebral edema.

Management;

1. Meet the physical and emotional need of the child

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MASLOWS HIERARCIAL THEORY

NURSING PROCESS
It is a systematic process of providing nursing care

Steps

● Assessment
● Nursing diagnosis
● Planning
● Implementation
● Evaluation

I. Assessment

it is collecting ,organizing and verifying data.

Types of assessment.

1Initial assessment - it is performed when a person enters health care facility for the first time.

2. Emergency Assessment-assessment done during emergency situation.

3.Time lapsed Assessment-is scheduled to compare a patient's current status to baseline data obtained
earlier.

4.Focus Assessment- assessment in which more detailed information are collected on. an already identified
problem.

Techniques of Assessment

A.History collection- uses open ended questions

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Types of Data

● Subjective data-what the patient says or it is the symptoms eg: patient complaints of stomach pain
● Objective data-what the nurse find from examination or it is the signs eg: urine is cloudy

Data verification- comparison of subjective and objective data.

B.Physical Examination

Steps

1. Inspection
2. palpation
3. percussion
4. Auscultation.

Order of Abdominal examination

Inspection,Auscultation,percussion and palpation.

Palpate right lower quadrant and at last left lower quadrant.

Percussion- if gas- tympanic sound and if fluid- dull or flat sound.

II. Nursing Diagnosis

Identification of actual and potential health problems.

Types of nursing Diagnosis

1.Actual nursing Diagnosis- it indicates current problem. Eg: Acute pain related to surgical incision.

2.potential nursing diagnosis-it indicates problems originating in future

Eg: Risk for infection related to improper aseptic technique

Prioritizing nursing diagnosis

Priority is based on Maslow physiological need (air,comfort,water,food,sleep, excretion and

homeostasis).

Goals to be achieved

Short term goals- it is achieved within short period of time or within hospital stay.it focus on immediate
need of the patient.

Long term goals- it is to improve the functional ability and decrease disability.it is achieved at home or in
health care centre.

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Common nursing Diagnosis

1. Asthma,Copd,Pulmonary embolism

Impaired gas exchange

2.pneumonia, pulmonary edema

Ineffective airway clearance.

3. Hypervolemia

Impaired gas exchange

Fluid volume excess.

4. Hypovolemia,dehydration

Fluid volume deficit

5. Burns, bedsore,

Impaired skin integrity

6. Stroke, Parkinson,

Impaired swallowing

Self care deficit

7.HIV/AIDS

Risk for infection

III. Planning

It includes listing therapeutic interventions. Eg: providing steam inhalation

IV. Implementation

Actualization of nursing care plan through nursing interventions. Eg:administrating medications, giving
nebulization

V. Evaluation

Checking the effectiveness and efficacy of intervention or checking whether the goals are achieved or
not.

● If goal is fully met- discontinue or revise the care plan.

● If partially met- add new intervention
● If not met- reassess and formulate new care plan

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Stages of sleep
Stages duration
stage1(NREM) = very light 5-15mts
sleep, sense of falling common
stage2(NREM) = Light sleep, 5-15mts
body temperature drops, heart
rate slows
Stage 3&4(NREM)=slow 5-15mts each
brain waves delta develops
stage 4 slightly deeper, body
repairs itself
stage5 (REM) = dreaming 10mts in first cycle (Up to 1hr in subsequent
occurs, brain activity similar to cycle)
waking levels
sleep cycle restart after REM

Difference between night terrors and nightmare

Night terrors Nightmares

Happens earlier in sleep occur in the last third of the night

during REM

cannot remember dream occurs during REM sleep

vividly

Does not recall the event the may vividly remember the dream
next morning

Always wakes you up may or may not wake us from sleep

COMMUNITY HEALTH NURSING

HEALTH

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or
infirmity.

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EPIDEMIOLOGICAL TRIAD

The levels of Prevention

PRIMARY SECONDARY TERTIARY

Prevention prevention Prevention
Definition An intervention implemented An intervention An intervention
before there is evidence of a implemented after a implemented after a
disease injury disease has begun, but disease or injury is
before it is established
symptomatic
Intent Reduce or eliminate causative Early identification Prevent sequelae (stop
risk factors (risk reduction) (through screening) bad things from getting
and treatment worse)
Example Encourage exercise and Check body mass index Help obese individuals
healthy eating to prevent (BMI) at every well lose weight to prevent
individuals from becoming check-up to identify progression to more
overweight,IMMUNIZATION. individuals who are severe consequences
overweight or obese

Roles of community Health Nursing

Seven major roles are?

● Clinician
● Educator
● Advocate
● Managerial
● Collaborator
● Leader
● Research

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Disease occurrence in populations

● Sporadic : occasional cases occurring at irregular intervals;eg: polio

● Endemic: continuous occurrence at an expected frequency over a certain period of time and in a
certain geographical location;eg:common cold,fever
● Epidemic or outbreak: occurrence in a community or region of cases of an illness with a
frequency clearly in excess of normal expectancy;Tuberculosis
● Pandemic: epidemic involves several countries or continents, affecting a large population.
Eg:influenza, CORONA OR COVID 19 (mode of transmisio droplet & airborn )
SPECIFIC DEATH RATE

Disease-specific death rate

Total number of deaths due to a disease (eg: cancer) in a defined area during a specified period / mid-year
population X1000

CRUDE DEATH RATE

Types of mortality rates

Crude death rate: number of deaths in an area in a year per 1000 population counted at midyear

Total no. of Deaths from all causes in 1 year/ no. of persons in the population at mid-yearX1000

EXAMPLE

Calculate specific death rate and crude death rate from the following table

July 1 population- 364283

CVD - 4200

Cancer- 3500

TB - 2500

Total = 10200

Solution:

SDR due TB = 2500/364283X1000 = 0.0068/1000 population

CDR = 10200/364283 X1000 = 0.028/1000 population

INCIDENCE AND PREVALANCE

Prevalence: refers to the total number of individuals in a population who have disease or health condition at
a specific period of time, usually expressed as a percentage of the population.

Incidence: refers to the number of individuals who develop a specific disease or experience a specific
health-related event during a particular time period (such as month or year)

MNEMONIC:

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Incidence looks at new cases

Prevalence looks at all current cases.

Total number of new cases of a specific

Disease during a given time period

Incidence rate = *100

Total population at risk during the

Same time period

All new and pre-existing cases of a specific

Disease during a given time period

Prevalence rate = *100

Total population during the same time period

EPIDEMIC POINT SOURCE (CONTAMINATED WATER)

EPIDEMIC SOURCE(STAGNATED WATER).

NURSING ADMINISTRATION
Roles of professional nurse

● Care provider
● Researcher
● Educator
● Leader
● Advocate
● Collaborator
● Manager
DELEGATION

Transferring the responsibility of performing a nursing activity to another person, while retaining
accountability for the outcome. Sources: American Nurses Association (ANA)/ National Council of state
Boards of Nursing (NCSBN) 2006

National Association of State School Nurse Consultants (NASSNC) 2010.

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JOB DESCRIPTION OF NURSES

Scope of practice
RN LPN/LVN UAP
● Clinical assessment ● Monitoring RN findings ● Activities of daily living
● Initial client education ● Reinforcing education ● Hygiene
● Discharge education ● Routine procedures ● Linen change
● Clinical judgement (catheterization) ● Routine, stable vitals
● Initiating blood ● Most medication ● Documenting input/output
transfusion administrations ● Positioning
● Psychological support ● Ostomy care
● Tube patency & enteral
feeding
● Specific assessments

BENNER’S MODEL

NOVICE: has no professional experience

ADVANCED BEGINNER: can note recurrent meaningful situational components, but not prioritize
between them

COMPETENT: begins to understand actions in terms of long-range goals

PROFICIENT: perceives situations as wholes, rather than in terms of aspects

EXPERT: has intuitive grasp of the situation and zeros in on the accurate region of the problem

Ethical principles and Concepts

● Autonomy-self-determination, freedom
● Justice-Fairness to all people. Equal treatment
● Fidelity-faithful to commitments made to self and others
● Beneficence-Doing good
● Non maleficence- do not harm
● Veracity- Truthfulness
TORT

● Tort = a civil wrong; damage to property or a personal injury cause by another person
● Unintentional Torts = injuries that are the result of an accident or an action that was not intended to
cause harm
● Negligence = careless conduct that causes foreseeable harm to another person
o This is the most common unintentional tort
o Eg: pushing a friend into a pool- they hit their head and have a concussion and cannot work
for 2 days
o Your actions were negligent – you should have foreseen that your actions might cause an
injury
Intentional Torts

● Any intentional acts that are reasonably foreseeable to cause harm to an individual, and that do so.
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 ⮚ ASSAULT- verbal harassment by showing objrcts or by fearful contact.
⮚ BATTERY – intentional touching of others without their consent.
⮚ INVASION OF PRIVACY- intruding into private matters
⮚ FALSE IMPRISONMENT – restraining the patient without clinical evidence. And detaining
the pt.
⮚ DEFAMMATION OF CHARACTER- gossiping about others
▪ Slander- speaking bad about others
▪ Libel-writing bad about others

LEADERSHIP STYLES

⮚ AUTOCRATIC (AUTHORITARIAN) – this type of style is leader focussed. Leader dominates the
group and give commands rather than seeking suggestions.
⮚ DEMOCRATIC (PARTICIPATIVE) – In this style leader and each member of the group is
important. Leader seek suggestions from the group. It is not suitable during emergency situation.
⮚ LAISSEZ- FAIRE (FREE- REIGN) in the style leader assume a passive role and all decisions are
taken by members
Confidentiality

● Confidentiality means protecting all confidential information concerning patients

● Knowing patient’s secrets obtained in the course of professional practice, does not entitle the nurse to
hint at them in some way that exposes those secrets
● Disclosure could only be made with consent
Accountability

Accountability is a legal obligation in health care which is also an ethical and moral responsibility. It is
important to assume responsibility for one’s own nursing practice. The American Nursing Association
(ANA) has a code that states, the nurse will assume accountability for nursing judgement and actions.

REPORTS

Incident Reports

● Used to documents any unusual occurrence or accident in the delivery of client care
● The incident report is not part of the medical record, but it may be used later in litigation.
ADVANCE DIRECTIVES

⮚ Written instructions about future medical care

⮚ Only used: if you are seriously ill or injured, and unable to speak for yourself
⮚ Should include: living will, durable power of attorney
NURSING DELIVERING SYSTEM

Modalities of patient care

1. Primary nursing: total care of an individual Is the responsibility of one nurse

2. Team nursing: a group of nurses work together to fulfil the full functions of professional nurse, to be
led by one nurse

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 3. Case method/ total patient care: provides one-to-one RN- to-client ratio and constant care for a
specific period of time
4. Functional method/task nursing: the oldest nursing practice modality, task-oriented method: I nurse
for giving medicines, no one id responsible for total care of any patient, it accomplished the most
work in the shortest amount of time
5. Modular nursing: RN provides direct nursing care with assistance of aids.
Triage systems and Tags

The most common classification uses the internationally accepted four colour system.

Red: indicates high priority treatment or transfer. Eg: massive Haemorrhage, Tension Pneumothorax.

Yellow: signals medium priority, eg, isolated simple femur fracture

Green: is used for ambulatory patient’s eg, isolated abrasions, contusions, sprains.

Black: for dead or those minimal chance of survival, eg, massive head injuries, 95% coverage with third
degree burns.

BIOMEDICAL WASTE MANAGEMENT

COLOUR WASTE DESCRIPTION

Yellow Human tissues, organs, body parts, items contaminated by blood/body fluids, soiled cotton and
dressing, soiled plaster casts etc.
RED Catheters, tubes, cannula, syringes, plastic IV bottles and sets, used gloves, infected plastics,
specimen containers, lab waste, microbiology cultures, used or discarded bags of blood/blood
products, vaccines etc.
BLUE Glass items, needles, syringes, scalpes, blades, used and unused sharps etc
BLACK Discarded medicines, discarded cytotoxic drugs etc
GREEN General waste, non-infected plastic materials, papers, disposables, carboards, metal containers,
office waste, food waste etc.

NURSING RESEARCH & STATISTICS

RESEARCH DEFINITION: - Systematic & scientific process of finding a solution to a problem or
relationship between facts

COHORT STUDY

� Form of observational study usually undertaken to find existence of association between suspected cause
and the disease. It is also called as incidental study.

� In this study cohorts are identified prior to the occurrence of the disease

� It proceeds from cause to effect (present-Future), hence it is prospective.

� For a medical entry, initial health examination was conducted and recorded from 1995-2016.some of
them are having BMI more than 25 so the Researcher planned to conduct a study to find out the
relationship of development of CAD in people with BMI more than 25. which among the following is
the most suitable study?

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 CASE CONTROL

� Case are people already with suspected disease are compared with control, are people who are exposed
to suspected cause

� It proceeds from effect to cause (present-past), hence it is retrospective

� In a community 100 males who are residing near to a power station were diagnosed with hypertension.
The researcher found that people living in this area are more prone for hypertension, so planned to
compare these patients with 100 males from the same area without hypertension. Based on this situation
which design the researcher will conduct to find out the association?

ODD’ S RATIO

Calculating Odds Ratio (OR)

Disease No Disease
(Case) (Control)
Exposed A B
Unexposed C D

OR = Odds that a case was exposed(A/C)

Odds that a control was exposed(B/D)

= AD

BC

ODDS RATIO CALCULATION

yes no
Yes 56(a) 274(b)
no 18(c) 390(d)
Endometrial

Carcinoma

Estrogen

Odds ratio = ad/bc

= 56X390/18X274

= 21840/4932

= 4.42

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 Correlational Research Design

◻ Understand linkages and relationships among two or more variables without introducing any intervention.
◻ Generate hypothesis that can be tested in experimental research.(Polit & Beck, 2004)
◻ Using correlational analysis, researcher determines:
◻ Strength type (Positive or Negative)

CROSS SECTIONAL

� In this study design researcher collects date from the samples only one-time i.e one period of data
collection.

� Eg: researcher collects awareness about swine flu among people in a population

STATISTICS
MEASURES OF CENTRAL TENDENCY

Mean = Sum of all data values

Number of data values

Symbolically,

=∑

Where (read as ‘X bar’) is the mean of the set of x values,

eg: - Mean = Sum of all data values

Number of data values

= 15+13+18+16+14+17+12

= 105/7 = 15

MEDIAN
1, 3, 3, 6, 7, 8, 9
Arrange the values in an ascending order.
Median = 6
5,8,10,11,13,15,17,18,22
1, 2, 3, 4, 5, 6, 8, 9
There are 9 values here
Median = (4+5)
Median = Size of (9+1) th item
2 = 4.5 207
 2

= 10/2 = 5th item

The 5th item in the series is 13

Median =13

MODE

● The mode
● This is the value that occurs most frequently in a data set
● Example:
● Find the mode
● 6, 7, 2, 3, 4, 6, 2, 6 mode is 6
● 6,7, 2, 3, 4, 5, 9, 8 no mode

RANGE

Definition :

The range of a set of data values is the difference between the maximum data value and the minimum data
value.

Range = (maximum value) – (minimum value)

It is very sensitive to extreme values; therefore not as useful as other measures of variation.

3 4 6 7 9
4 6 4 7

Range
PROBABILITY DISTRIBUTION
9 – 3 =6
EXAMPLE:

Total amount collected from 10 persons are 90 rupees with standard deviation ( =4). Express this in form
of probability distribution

Solution

SD = 4

Mean = Total amount collected

Total persons

= 90/10 = 9

Probability Distribution = Mean+-SD

So 9 +-4
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Z-SCORE

Formula :

Z = X -µ

Z Standard (Normal) or Z score

X member element of group

µ mean of expectation

Ꝺ standard deviation

EXAMPLE:

A study was conducted among 100 people for Hypertension. Out of it 75% of people have high BP and
expressed as 175 +-10. Find the % of BP ranging between 165 – 185mmHg

Solution:

Here 175 +- 10 means

mean +- standard deviation µ =175, Ꝺ =10

Find Z-score for 165mmHg

Z = 165 -175

10

= -10/10 = -1

Z score for 185 mmHg

X =185 µ = 175 Ꝺ = 10

Z = 185 -175

10

= 10/10 = 1

Z lies between zone of

-1 to +1 µ +- 1 Ꝺ = 68%

So % of getting BP between 165 – 185 mmHg is 68%

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Exercise 1. X = 8,3,4,3,8,9,4,6,2,8 . find the mean median mode and range

Exercise 2. Inorder to find the the probability distribution 81 apple is collected from 9 trees . and the
standard deviation is 2.

OBG
ANATOMY – UTERUS

Parts –fundus (upper portion

-body (middle portion)

- cervix 9 (lower aspect)

Weight-50-60. Gram

SHAPE- pear shape

Weight in pregnancy -1 kg

FERTILIZATION

It means fusion of sperm ad ovum occurs at ampulla of the fallopian tube.

IMPLANTATION

The zygote is propelled towards the uterus. Fertilization to implantation timing is 7-10 days

PLACENTA

● Shape discoid shape.

● Weight 500GM or 1/6 of the fetus
● Placental layer – amnion (fetal surface) chorion (maternal surface) .in between placental barrier is
present.
● Substances will cross to the placental barrier-protein, drugs, amino acids, alcohol, virus, fatty
acids glucose, electrolyte, IgG hormones, and antibodies.
● Substances do not cross to the placental barrier- fat, insulin, bacteria, parathyroid hormone,
calcitonin, IgM.
● Complete development of the placenta occurs at 12 weeks.

UMBILICAL CORD

● It contains two artery and one vein. artery carry deoxygenated blood and vein carries oxygenated
blood.

PELVIS

● Gynecoid pelvis-normal female pelvis. most favorable for successful labor and birth.
● Anthropoid pelvis-oval shape, adequate outlet with a narrow pubic arch.
● Android pelvis- heart shaped resembles male pelvis.
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 ● Platypelloid- flat with an oval inlet. wide transfers diameter but short anterior posterior diameter
making labor and birth difficulty.

AMNIOTIC FLUID

● Normal color- early pregnancy colorless. At term pale straw color

● Normal amount at term- 800-1200ml (average 1000ml)- more than 2 litter poly hydramnios less than
200 ml oligohydramnios.
● Abnormal color
-green meconium stain.
-golden –RH incompatibility
-Greenish yellow or saffron-post maturity.
-dark color-accidental hemorrhage.
-Dark brown or tobacco juice color-IUD.
FETAL DEVELOPMENT

⮚ 2-3 week. Blood circulation begins and heart is tubular and begins to beat.
⮚ 3-5 weeks. Double heart chambers are visible.
⮚ 8weeks.every organ system is present.
⮚ 12 weeks. Kidney begins to form urine. And sex is visually recognizing
⮚ 16 weeks. fetus is 100 grams. lanugo begins to develop. fetal ossification occurs.
⮚ 24 weeks. Fetus has ability to hear.
⮚ 28 weeks. Fetus is 1.1Kg. brain is developing rapidly and if born neonate can breathe at this time.
⮚ 32 weeks. bones fully developed
⮚ 6 weeks. Skin is pink and less wrinkled.
⮚ 40 weeks. weight.3.2KG length 40 CM .skin pink and smooth. testis is in the scrotum, and labia
majora are well developed.

NAGELES RULE-

- This rule is using for estimating EDD.

- Use of nageles rule requires that the women have a regular 28 th day menstrual cycle.
- First day of last menstruation + 7 days – 3month + 1 year = EDD

GTPAL SCORE

✔ G-GRAVIDITY – it means number of pregnancies.

✔ T – number of term delivery (delivery occur after 37 weeks completion considered as term
delivery.ie delivery occur at 38,39,40 weeks)
✔ P- number of preterm deliveries. (deliver occur at after 20 weeks completion and 37 or before 37
weeks considered as preterm delivery).
✔ A- ABORTION (deliver occur before 20 weeks)
✔ L - number of current living children.

Example - a lady is pregnant for the sixth time .she had one cutaneous abortion in the first trimester. She
deliverd twin daughter at 37 week gestation and twin boy at 35 week gestation. Also delivered twin boy at
38 week gestation and girl after completion of 37 weeks .before one year one daughter was expired due to
pneumonia apply GTPAL score – G6T2P2A1L6

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PREGNANCY SIGN AND SYMPTOMS.

PRESUMPTIVE SIGN:

⮚ Amenorrhea
⮚ Nausea and vomiting due to increased HCG hormone (placenta is producing HCG hormone)
⮚ Increase size and increased feeling of fullness in breast. (due to increased estrogen and progesterone)
⮚ Pronounced nipples.
⮚ Urinary frequency. (because the enlarged uterus is compressing the urinary bladder)
⮚ Quickening. - the first fetal perception feels by the mother itself. it occur 20 weeks in primigravida
and 16 week in multi Para
⮚ Fatigue

PROBABLE SIGN:

⮚ Uterine enlargement
⮚ Chadwick sign- violet discoloration of the vagina, vulva and cervix occur at about week 4.
⮚ Goodle sign- softening of the cervix that occur at beginning of the second month.
⮚ Hegar sign. Compressibility and softening of the lower uterine segment occur at about week 6
⮚ Ballottement-rebounding of the fetus against the examiners figure on palpation.
⮚ Braxton hick’s contraction- irregular painless contraction that may occur intermittently throughout
pregnancy.
⮚ Positive UPT

POSITIVE SIGN:

⮚ FHR is detected by electronic device at 10-12 week. and through fetoscope by 20 weeks.
⮚ Active fetal movement.
⮚ Outline of the fetus via USG.

FUNDAL HEIGHT CALCULATION:

⮚ It is measured to evaluate the gestational age of the fetus.

⮚ At 16 week the fundus can be found approximately half way between the symphysis pubis and the
umbilicus.
⮚ During the second and third trimester (18-30 weeks) fundal height in CM approximately equals fetal
age in weeks + 2 CM. EXAMPL. gestational week 24 , fundal height is 22-26 CM.
⮚ At 20-22 weeks fundus is approximately at the location of he umbilicus.
⮚ At 36 weeks up to the level of xyphoid process. After that descend occur.

BEST POSITION IN PREGNANCY – left lateral (especially in second and third trimester) for to
prevent vena cava syndrome

FHR

⮚ Early pregnancy 160-170 beats per minute.

⮚ At term 120-160 beats per minute.

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MINOR DISCOMFORT IN PREGNANCY

DISCOMFORT CAUSES
Nausea and vomiting Increase HCG Hormone
Syncope Increase blood volume
Anemia
Sudden position changes
Breast tenderness Increase estrogen and progesterone
Increased vaginal discharge Hypertrophy and thickening of the vaginal
mucosa
Nasal stiffness Increase estrogen
Heart burn Increase progesterone
Head ache Changes in blood volume
hemorrhoids Increase venous pressure and constipation
constipation Increase progesterone
Decrease intestinal motility
Displacement of the intestine due to pressure
of the uterus
Back pain Due to abnormal posture
Leg cramps Altered calcium and pressure on the uterus on
the nerves

ANTE NATAL DIAGNOSTIC TESTS

ULTRA SONO GRAPHY.

⮚ At 12 weeks performing to confirm pregnancy and to identify the location of placenta.

⮚ At 22 weeks for anomaly scan.
⮚ If the gestational week is less than 20 fill the balder and after 20 weeks empty the bladder.

TRIPLE TEST DURING PREGNANCY:

⮚ It includes three tests.

⮚ 1 – hcg
⮚ 2- estriol or estrogen
⮚ 3- alfa feto protein sampling-maternal blood is withdrawing to detect neural tube defect or
abdominal wall defect present in the fetus. alfa feto protein is produced from the fetal liver and it
will cross to the placental barrier and enter the mothers blood . increased level indicate congenital
anomaly. In non pregnancy increased alfa feto protein indicate she is having some type of liver
disease.

CHORIONIC VILLUS SAMPING:

⮚ Sample collection from placenta. perform at 10-13 weeks .

⮚ Types trans cervical and trans abdominal.
⮚ Is performing to detect genetic abnormality in fetus.

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AMNIOCENTESIS:

⮚ Performing at 15- 20 weeks.

⮚ Amount should be collected 10-20 ml
⮚ Is performing to detect genetic abnormality, metabolic defect and fetal lung maturity.

ANOTHER TEST

● Fern test
● Non stress test
● Contraction stress test
● Hemoglobin and HCT
● GTT

NORMAL LABOUR
EUTOCIA – NORMAL LABOUR

DYSTOCIA – DIFFICULT LABOUR

TRUE LABOUR PAIN CHARACTER:

✔ Intensity and duration of pain is increased.

✔ Uterine contraction associated with cervical dilation is present.
✔ True labor pain associated with show.
✔ Hardening of uterus.
✔ Formation of bag of for-waters.
✔ Pain is not relieved by enema or sedatives.

STAGES OF LABOUR

✔ FIRST STAGE - It starts from the onset of true labour pain and ends with full dilatation of
cervix. average duration in primi 8-12 hours and in multi 4-6 hours

✔ SECOND STAGE - it starts from the full dilatation of cervix and ends with expulsion of the fetus
from the birth canal. Timing 2 hours in primi and 30 minutes in multi.

✔ THIRD STAGE - It begins after expulsion of the fetus and ends with expulsion of he placenta. and
membranes. is about 15 minutes in both primi and multi. sign and symptoms of third stage of
labor. -gush of vaginal bleeding, uterus feels hard to touch, lengthening of abdominal cord.

✔ FOURTH STAGE – it is the stage of observation for at least one hour after expulsion of the
placenta.

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PHASES IN FIRST STAGE OF LABOR

STAGE CERVICAL INTERVAL DURATION FHR

DIALATION

Latent phase 1-4 cm 15-30 minutes. 15-30 seconds Every 60-90

minutes
Active phase 4-7 cm 3-5 minutes 30-60 seconds Every 30 minutes

Transitional 8-10 cm 2-3 minutes 45-90 seconds Every 5 – 15

phase minutes

NOTE: early deceleration of FHR, it is due to head compression late deceleration of FHR indicate
fetal distress. management give left lateral position and administer oxygen.

MECHANISM OF LABOR

▪ ENGAGEMENT/LIGHTENING/DROPPING
▪ DESCENT
▪ FLEXION
▪ INTERNAL ROTATION OF HEAD
▪ CROWNING
▪ EXTENTION
▪ RESTITUTION
▪ EXTERNAL ROTATION OF THE SHOULDER AND INTERNAL RATATION OF THE
BODY
▪ EXPULSION

POST NATAL PERIOD OR PUPERIAL PERIOD

⮚ It means first 6 weeks after delivery.

⮚ Changes in post natal period
● Involution of uterus- daily 1 CM fundal height is decreasing.
⮚ LOCHIA- it is the vaginal discharge for the first 2 weeks. Initially alkaline in nature later it is acidic in
nature. (normally female vaginal PH is acidic because presence of doderlian bacillus bacteria is
producing lactic acid.)
⮚ TYPES OF LOCHIA
● LOCHIA RUBRA- red in color. duration 1-4 days. It consist of blood , fetal membrane, deciduas,
vernix caseosa, lanugo and meconium.
● LOCHIA SEROSA- color yellow ,pink, or pale brown. Duration 5-9 days. It consist less RBC, more
leukocytes, wound exudates, mucous from cervix and micro organism.
● LOCHIA ALBA- pale white in color. Duration 10-15 days. It contains plenty of deciduas cells
leukocytes, mucous, fatty and granular epithelial cells.
● After LCS Also lochia present. average amount 250 ml
● If the amount is scandy or increase it means infection

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POST PARTUM PSYCHOLOGICAL ADAPTATION

1. Taking in – dependant phase

● First 24 hour range 1-2 days, focus on self and meeting basic needs,reliance on others to
meet needs of comfort,rest,closeness,nourishment,relivesbirth,excited and
talkative.mom wants to talk about her experience of labor & birth ,pre occupied with
her own needs
2. Taking hold – dependent/independent phase
● Starts end of 3rd day post partum,last for 10 days to several weeks,focuseson care of
baby,desire to take charge,still need nurturing and acceptanceby others,eagerness to
learn,and in this phase possible experience to post partum blues.more ready to resume
control of her body ,baby &taking on mothering role.needs reassurance if
inexperienced.
3. Letting go – independent phase
● Focuses on forward movementof family as unit with interacting members reassertion of
relationship with partner,resumptionof sexual intimacy,resolution of individual
roles.this phase by 5th week

ANTE PARTUM HEMORRAHAGE.

1. PLACENTA PREVIA
⮚ Placenta is situated in to the lower uterine segment.
⮚ Cause is unknown
⮚ Clinical feature
● Sudden onset of painless, bright red vaginal bleeding occurs in the last half of
pregnancy.
● Uterus is soft, relaxed and non-tender.
● Fundal height is more than the period of amenorrhea.
⮚ Most complicated type of placenta previa is type II posterior
⮚ MANAGEMENT.
● Monitor maternal vitals and FHR
● Avoid vaginal examinations
● Provide Trendelenburg position to the mother
● Monitor the amount of bleeding and fetal distress. administer IV fluid and blood
products.
● If bleeding is heavy prepare for longitudinal C.S/ Vertical C.S

2. ABRUPTIO PLACENTA
⮚ Premature separation of the placenta from the uterine wall after the 20 week of
gestation and before the fetus is delivered
⮚ Causes
● Trauma
● Short cord (normal length 45-50 CM)
● Sick placenta
● Cocaine abuse
● Previous history of longitudinal C.S
⮚ Clinical features
● Dark red painful vaginal bleeding.
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 ● Severe abdominal pain
● Uterine rigidity
● Sign of fetal distress
● sign of maternal shock if bleeding is excess.
● DIC
⮚ MANAGEMENT
⮚ Monitor maternal vitals and FHR.
⮚ Administer oxygen, IVF, and blood products.
⮚ Place the client in a extremely Trendelenburg position.
⮚ Prepare for delivery of fetus as quickly as possible with vaginal delivery, preferably if the
fetus is healthy and stable and the presenting part is in the pelvis.
⮚ Emergency C.S is performed if the fetus is alive but shows sign of distress.

PELVIC INFLAMATORY DISEASE

SR.NO INFECTION CAUSATIVE ASSESSMENT DRUG OF
AGENT CHOICE
1 Syphilis Treponema pallidum Stage 1- painless vesicles penicillin
at genital area.
Stage 2- painless vesicles
all over the body and
generalized
lymphadenopathy.
Stage 3- CNS involvement
and hearing loss
2 Gonorrhoea Neisseria gonorrhea Presence of green creamy Prefer LSCS
vaginal discharge Single dose IM
inj.
Cephalosporine
/ceftriaxone
followed by
azithromycin
orally.
3 trichomoniasis Trichomonas Yellow frothy Metronidazole
vaginalis mucopurulant foul
smelling vaginal discharge

4 Vaginal Candida albicans White cheesy vaginal Fluconazole

candidiasis discharge
5 Cytomegalo MOT-close personal Mother may be Anti viral
virus contact, trans asymptomatic. Prefer LSCS
placental, breast milk, Effects to the fetus-LBW,
exposure to vaginal jaundice, hearing loss,
secretion blindness, seizure , death.
6 Herpes simplex STD Painful vesicles in the No PV
New born commonly genital area. examination
infected during Effect to the fetus- Acyclovir
delivery by direct neurological impairment LSCS
contact with lesion in and death
genital tract

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PREGNANCY INDUCED HYPERTENSION
⮚ It is a multi system disorder of unknown etiology characterized by development of hypertension to the
extend of 140/90 mmofhg or more with protenuria after 20th week in a previously normotensive and
non-proteinuria women.
⮚ Risk factor
● Primigravida
● Family history
● Placental abnormality
● Incompatibility
● Age less than 19 and more than 40
⮚ Clinical features
● Alarming features- early morning head ache. Disturbed sleep. Oliguria. Epigastric pain. Diminished
vision
● Late features- hypertension. Edema (pitting edema over ankles persist at early morning) and
proteinuria

⮚ Complication
● Maternal- eclampsia
HELLP syndrome
H – hemolysis
EL – elevated liver enzyme
LP- law platelet count
Accidental hemorrhage
Preterm labor and PPH and sepsis
● Fetal- fetal distress, IUD, IUGR, Prematurity. And asphyxia
⮚ Management
⮚ Drugs- methyl dopamine, labetalol, nifedipine, hydralazine
⮚ Diuretics.
⮚ Complete bed rest to prevent cardiac complication
⮚ Diet- high caloric high protein adequate sodium and adequate water. or balanced diet.
⮚ Legumes can give (rich sources of protein daily 100gram )
⮚ Administer MgSo4 to prevent eclampsia and preterm labor.
⮚ Frequently monitor neurological status and magnesium toxicity.(MGSO4 TOXIC(BURP)- decrease
BP, decrease u/o, decrease respiration, decrease platellar reflex.)

BREAST CANCER
⮚ RISK FACTOR
✔ Age after 40 years
✔ Nulliparity
✔ First delivery after 35 years
✔ Previous history of uterus, ovary and fallopian tube

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 ⮚ Clinical feature
✔ Initially painless lump over the nipple, over breast or below the axilla. But later pain present.
✔ Asymmetry of the breast. Ie affected breast being higher.
✔ Clear to mucoid purulent nipple discharge
✔ Orange peal skin
⮚ Diagnostic evaluation
✔ Early detection
● 1. Mammogram- should perform after 40 years every early
● 2. Breast self examination
If the lady has every 28th day cycle should perform 7-10 days after menstruation.
Menopausal women or after hysterectomy should perform every month in a day
✔ Confirmatory test
● Biopsy
● CT, MRI, PET scan
● (CA15-3, CA27-29)
⮚ Management
✔ Chemotherapy- vincristine, cisplatin
● Side effect- reversible alopecia
● Nausea and vomiting – so give anti emetic prior to chemotherapy
● Anemia-so frequently monitor CBC
● Leucopenia and fever
● Tumor lysis syndrome- it include hyperkalemia, hyperphosphatemia, hypocalcemia, and
increase BUN and azotemia.
● Gastritis
✔ Radiation therapy
✔ Modified radical mastectomy
✔ Post operative intervention
● Semi fowlers position to work the drain effectively
● Affected hand should be elevate to prevent lymphedema.
● No IV line, no injection, no BP measurement on the affected hand.
● Exercise- morning mastectomy done the evening exercise is just movement of the wrist and figures
● First exercise- ball squeezing or wall climbing exercise.
● Flowed by combing of hair and put up the hair
● Avoid over usage of the affected arm for several month
● Avoid wear tight jewelers or cloth on the affected hand
● Avoid get sunlight on the affected area
● For hormonal manipulation instruct the client to take tamoxifen tablet(nolvadex)
✔ Nursing diagnosis
● At the time of discharge – disturbed body image.

OVARIAN CANCER
It grows rapidly ,spread fast and is often bilateral.metastasis can occur due to organs in the pelvis or through
other organs,including lining of abdomen, lymph nodes,lung and liver

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R/F – nulliparity , hormone therapy after menopause, use of fertility medication,obesity,women B/W 55-65
years

S/S – asymptomatic in early stage, abdominal discomfort & bloating, dysfunctional vaginal bleeding,
abdominalor pelvic or back pain, frequent urination, elevated tumour marker ( ca 125 )

Management – TAH with BSO – total abdominal hysterectomy with bilateral

salphinjonoopherectomy

ABORTION

✔ A pregnancy that end before 20 weeks of gestation spontaneously or electively.

✔ Types.
● Spontaneous
● Induced
● Threatened- spotting and cramping without cervical change occur.
● Inevitable- spotting and cramping occur and cervix begins to dilate and efface
● Incomplete
● Complete
● Missed-product of conception are retained in utero after fetal death.
● Habitual-spontaneous abortion occur in three or more successive pregnancies
✔ Clinical feature
● Spontaneous vaginal bleeding.
● Uterine cramping or contractions
● Hemorrhage and shock can result if bleeding is excessive.
✔ Management
✔ Maintain bed rest and monitor vitals
✔ Count perineal pads to evaluate blood loss
✔ Prepare the client for dilation and curettage as prescribed for incomplete abortion
✔ Rh (D) immune globulin (RhoGAM) is prescribed for an Rh-negative woman (within 72 hour)

GESTATIONAL DIABETES MELLITUS

⮚ Gestational diabetes occurs in pregnancy during in second or third trimester in client not previously
diagnosed as diabetic and occurs when the pancreas cannot respond to the demand for more insulin.
⮚ It should be screened for gestational diabetes between 24 to 28weeks of pregnancy.
⮚ Cause – placenta producing hormone HPL (human placenta lactogen-it working as a growth
hormone). HPL hormone resist the power of maternal insulin. So, hyperglycemia will develop.
⮚ Risk factors- age after 35 years, obesity, family history
⮚ Clinical features- polydipsia, weight loss, polyuria, glycosuria, polyhydramnios, recurrent UTI
⮚ Effect to the fetus-baby is macro baby (because glucose molecules shift to the fetus)
● Hypoglycemia for few days
● Lethargic/dull nature
● Poor cry, sucking reflex
⮚ Diagnostic test –GTT
⮚ MANAGEMENT

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 ⮚ Antenatal management
● DIETARY MODIFICATION- low carbohydrate diet
● Exercise
● Inj. Insulin
● Asses for sign of maternal complication such as pre-eclampsia.
⮚ Intervention during labor
● Monitor fetus status closely for sign of distress and, it noted prepare the client for immediate C.S
● Carefully regulate insulin and provide glucose IV as prescribed because labor depletes glycogen that
cause hypoglycemia
⮚ Intervention during post-partum period
● Observe the mother closely for a hypoglycemic reaction because a precipitous decline in insulin
requirement normally occurs (the mother may not require insulin for the first 24 hours.)
● Regulate insulin needs as prescribed after the first day, according to blood glucose testing.

POST PARTUM HEMORRHAGE.

⮚ Bleeding of more than 500ml after delivery
⮚ Cause
● Most common cause atonic uterus
● Laceration of vagina
● Retained placental fragments
● Grand multipara
● Operative delivery
⮚ Management
● Massage the fundus for uterine atony
● Monitor vitals and fundus every 5-15 minutes
● The nurse along with the patient side .and instruct another nurse to contact the physician.
● Assess and estimate blood loss by pad count (1gram= 1 ml of blood)
● To start NS OR RL with oxytocin (1litre with 20 units) at 60 drops per minute
● Arrange for blood transfusion
● Oxytocin 10 units IM OR Methergine 0.2Mg IV.
● GIVE ANTIBIOTICS-ampicillin and metronidazole & Prepare for dilatation and curettage

SURGERY
CESSARIAN SECTION

⮚ TYPES – 1. vertical/longitudinal 2. transverse

⮚ INDICATION

Elective Emergency
1. Placenta previa 1. Abruption placenta
2. Previous cesarean 2.Occult/cord prolapse
3. CPD and previous uterine surgeries 3.Fetal distress

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CLEIDOTOMY

⮚ One or both clavicles may cut with scissors to reduce the shoulder girth.
⮚ Indication- shoulder dystocia.
⮚ Surgery do not do in living fetus

DRUGS

NAME OF THE ROU INDICATION CONTRA COMPLICATION TOXICIT

DRUG TE INDICATIO Y
N MANAG
EMENT
Oxytocin IM . Abortion 1.Hypertension 1.Uterine hyperstimulation .
IV . After abortion 2. Placenta 2.uterine rupture administer
Intra for to prevent previa 3.waterintoxication/hyponatr oxygen
nasal bleeding 3.Fetal distress emia . stop
. for contraction 4.Mal-position 4.hypotension oxytocin
stress test 5.nasal vaso construction . monitor
. induce labor 6.fetaldistress maternal
. augmentation of 7.fetalhypoxia/fetal death vital/fhr
labor .do not
. minimize blood leave the
loss and to client
control PPH. alone
. INTRANASL .
oxytocin administer
stimulate the anti-
lactation dote
mgso4
Methergine/ergo IM Active . Hypertension . nausea and vomiting Monitor
metrine IV management of . Cardiac . hypertension vitals
( directly third stage of disease . bradycardia Close
stimulate uterine labor . Peripheral . uterine cramping monitorin
muscle and helps To stop atonic vascular . gangrene of toes g of BP
in arresting uterine bleeding disease
bleeding)

Ovulation drugs - clomiphene

Rectal thermometer insertion length 0.5 to 1 inch

PPE inserting order – gown, mask, goggles gloves
PPE removing order – gloves, gown, goggles, mask

IMPORTANT ANTIDOTE

⮚ Heparin : protamine sulphate

⮚ Warfarin : VITAMIN k
⮚ Potassium : regular insulin+ glucose / albuterol
⮚ Organon phosphate : atropine sulphate
⮚ Insulin : dextrose 50%
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⮚ Dopamine : phentolamine
⮚ Digoxin : Digi bind/Digifab
⮚ Cyclophosphamide : mesna
⮚ Cyanide : sodium thio sulphate
⮚ Lithium : Diamox
⮚ Beta blocker : glucagon
⮚ Midazolam/diazepam : flumazenil
⮚ Anti-cholinergic : physostigmine
⮚ PCM/acetaminophen : mucomilt/N -acetyl cystine
⮚ Morphine : naloxone hydrochloride
⮚ Iron : deferoxamine
⮚ Led : succimer/dimercaprol
⮚ Penicillin : adrenaline
⮚ Thrombolytic : amino carporicacid
⮚ Magnesiumsulphate : calsiumgluconate
⮚ Universal antidote : activated charcoal
⮚ OPOIDS : NALAXONE

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