1

AppleRN Classes

Success is a few simple disciplines,

practiced every day
-Jim Rohn

APPLERN CLASSES
www.AppleRN.com

This book is a supplement to AppleRN Online, Onsite or Live Virtual Course.

It is designed as a workbook style, to be fully effective use the book in
combination with the course.
To enroll in courses please visit our website www.AppleRN.com
 2
AppleRN Classes

INDEX

Topic Page Topic Page Number

Legal and Ethics 3 Neurology 201
Infection Control 12 Neuro Pediatrics 227
Diagnostic Procedures 16 Immunology 232
Growth and Development 27 Renal System 237
Health Assessment 32 Reproductive System 247
overview Disorder
Safety and Position 36 Endocrine 252
Tubes 38 Infectious Disease 280
Pre and Post op Care 41 Eyes 288
MATERNITY 49 Ear 294
Newborn care 83 Hematology 299
High risk newborn 87 Oncology 312
Respiratory system 97 Musculoskeletal 343
Cardiovascular system 117 Integumentary System 362
ECG 128 Burns 370
Ventricular Assistive 143 Mental Health 377
Device
Pediatric CV 153 End of Life Care 404
Cardiovascular 160 Grief and Loss 409
Medications
Gastrointestinal System 168 Test taking strategies, EBP 425
Pediatric GI 192 Medication Calculation 427
GI medication 196 Lab Value 433
 3
AppleRN Classes

Legal and Ethics

Advance directive
To communicate a client’s wishes regarding end-of-life care should the client
become unable to do so.
All clients admitted to a health care facility must be asked if they have advance
directives.
Two components- Living will (client’s wishes) and durable medical power of
attorney (a person designated to make decisions for the client, also called Health
care proxy). Medical/Financial POA
Nursing responsibility: Providing written information
Informing all members of the health care team of the client’s advance directives
Conflict?-Client’s choice takes priority, Document AD status, Ensure - AD is
current
Advocacy
Nurses’ role in supporting clients by ensuring that they are properly informed,
their rights are respected, they are receiving the proper level of care. Nurses
must act as advocates even when they disagree with clients’ decisions.
Nurses are accountable for their actions even if they are carrying out a provider’s
prescription.
It is the nurse’s responsibility to question a provider’s prescription if it could harm
a client
Nurses must ensure that clients are informed of their rights. Do not direct or
control client’s decisions.
Nurses may need to mediate on the client’s behalf when changes need to be
made in the plan of care.
Situations in which nurses may need to advocate for clients or assist them to
advocate for themselves include: End-of-life decisions, Access to health care,
Protection of client privacy, Informed consent, Substandard practice
 4
AppleRN Classes

Ethical principles : Confidentiality - HIPAA

Justice : Treating every client equally regardless of gender, sexual orientation,
religion, ethnicity, disease, or social standing
Autonomy is freedom for a competent client to make decisions for oneself.
Accountability is accepting responsibility for one's actions
Nonmaleficence means doing no harm.
It also relates to protecting clients who are unable to protect themselves due to
their physical or mental condition (infants/children, dementia , sedated)
Fidelity – faithful devotion to duty – the duty to keep one’s promises or word:
Keeping an appointment with a client is an example of fidelity.
Veracity : Truthfulness
HIPAA : Health Insurance Portability and Accountability Act of 1996 is United
States legislation that provides data privacy and security provisions for
safeguarding medical information.
Privacy Tips
Use only minimum required information to take care of the patient.
Do not look at previously assigned client’s information to know about prognosis
Do not tell unit clerk or a transporter about the actual diagnosis or prognosis of
client. OK to tell them about safety precautions.
What to report?
The nurse is required to report an impaired coworker, a suspicious death, and
abuse to appropriate authorities.
The nurse is legally prohibited from sharing health information with client’s
employers or family members without the client's permission.

AMA : Against Medical Advice

 5
AppleRN Classes

A competent client can refuse medical treatment and leave against medical
advice (AMA).
The primary nurse can notify the charge nurse so arrangement can be done. The
nurse should inform the health care provider (HCP).
Explain the consequences (including death) to the client. If the client decides to
leave the facility, even after explanation - the client should be given the AMA
form (informed refusal) and allowed to go.
if the client refuses to sign, the client is still allowed to leave. Document
completely.
AMA : It’s OK to give discharge instructions, results, and prescriptions despite the
client leaving AMA.
It is most important that the client's IV catheter be removed to prevent
complications (eg, infections) and misuse (eg, access for illicit drug injections).
The nurse should document the fluid infused, the site's appearance, and the
integrity of the IV catheter.
Incident reports - records made of unexpected or unusual incidents that affected
a client, employee, volunteer, or visitor in a health care facility.
Completed by the person who identifies incident (within 24 hr of the incident).
Include witnesses’ names., Confidential and are not shared with the client.
Not placed in the client’s health care record nor mentioned in the client’s health
care record. However, a description of the incident itself should be documented
factually in the client’s record (including treatment) . Forwarded to the risk
management department or officer
Incident report - Examples
Medication errors, Procedure/treatment errors, Equipment-related
injuries/errors, Needle stick injuries
Client falls/injuries, Visitor/volunteer injuries, Threat made to client or staff
Loss of property (dentures, jewelry, personal wheelchair)
Sentinel event
 6
AppleRN Classes

Any unanticipated event in a health care setting that results in death or serious
physical or psychological injury. All sentinel events should be reported.
Nursing hand off
Use accurate information. No vague statements. Focus on exact and pertinent
information.
Routine care - is not necessary to report (bath, oral care). Give report at bedside
(ideal)
After shift, any information on paper, which is not part of medical record file
should be shredded. Do not share information on social media sites
Collaboration
Collaboration involves discussion of client care issues in making health care
decisions, especially for clients who have multiple problems.
Collaboration occurs among different levels of nurses and nurses with different
areas of expertise.
Collaboration should also occur between the inter professional team, the client,
and the client’s family/significant others when an inter professional plan of care is
being developed.
Case management is the coordination of care provided by an inter professional
team from the time a client starts receiving care until he or she is no longer
receiving services.
The goal of case management is to avoid fragmentation of care and control cost.
Identify and utilize the resources available to patient.
Nursing role in Case Management
Coordinating care, particularly for clients who have complex health care needs.
Facilitating continuity of care, Improving efficiency of care and utilization of
resources.
Enhancing quality of care provided, Limiting unnecessary costs and lengthy stays.
Advocating for the client and family
Client rights
 7
AppleRN Classes

Client rights are the legal guarantees that clients have with regard to their health
care.
Nurses must ensure that clients understand their rights, and nurses also must
protect clients’ rights during nursing care.
Each client has right to : Refusal of Treatment, Be informed about all aspects of
care and take an active role in the decision-making process. Accept, refuse, or
request modification to the plan of care. Receive care that is delivered by
competent individuals who treat the client with respect.
Liability
Tort- doing something harmful to others. Intentional tort – harming intentionally
Unintentional Tort - Negligence: The unintentional harm a client experiences
because the nurse failed to act in a reasonable and prudent manner.
A nurse fails /forgets to implement safety measures for a client
Malpractice (professional negligence)
Not reasonable at all (can be with negligence) : A nurse administers a large dose
of medication due to a calculation error. The client has a cardiac arrest and dies.
Common Negligent Acts
Failure to assess and/or monitor, including making a nursing diagnosis, Failure to
monitor in timely fashion, Failure to use proper equipment to monitor the
patient, Failure to document the monitoring Failure to notify the health care
provider of problems, Failure to follow orders, Failure to follow the six rights of
medication administration, Failure to convey discharge instructions, Failure to
ensure patient safety, especially for patients who have a history of falling, are
heavily sedated, have disequilibrium problems, are frail, are mentally impaired,
get up in the night, and are uncooperative, Failure to follow policies and
procedures, Failure to properly delegate and supervise
Assault : The conduct of one person makes another person fearful and
apprehensive
Battery : Intentional and wrongful physical contact with a person that involves an
injury or offensive contact
 8
AppleRN Classes

(performing a procedure which client refuses - restraining a client and

administering an injection against his wishes, giving medicines - placebo ).
False imprisonment : A person is confined or restrained against his will
(confinement)
Delegation and Informed Consent
Informed consent consists of 3 principles:
1. The surgeon clearly explains the current diagnosis, planned procedure along
with risks and benefits, expected outcome, alternate treatment options, and
prognosis if the procedure is not performed.
2. The client has indicated understanding of the information.
3. The client is giving voluntary, legal consent for the procedure.
Interpreter should only provide literal translation of the words spoken by the HCP,
not adding any personal advice/information.
Adolescent can give consent (US)
Emancipated adolescent : at least 16 years old and (one of the following)
Married , or serving U.S. army, living apart from parents and managing own
money.
Adolescent with court decision granted as emancipated.
Mature adolescent (in some cases) : 14- 18 yrs old can refuse/receive treatment
for STI, family planning, alcohol and drugs abuse, blood donation and mental
health care.
Who is a mentally or emotionally incompetent client? An individual who :-
has been declared incompetent, is unconscious,
is under the influence of chemical agents such as alcohol or drugs,
has chronic dementia or another mental deficiency that impairs thought
processes and the ability to make decisions.
 9
AppleRN Classes

ASSIGNING, DELEGATING AND SUPERVISING

Delegation FACTS
Nurses can only delegate tasks appropriate for the skill and education level of the
health care provider who is receiving the assignment.
Things RNs cannot delegate:- Nursing process (assessment, planning, diagnosis),
client education, tasks that require clinical judgment to LPNs or AP.
RNs must delegate tasks so that they can complete higher level tasks that only
RNs can perform.
The nurse delegating a task remains legally responsible for the client's total care
during the shift, and may be held liable for delegating inappropriately.
The registered nurse makes assignments according to staff members' experience,
knowledge, and skill level. The more experienced – unstable patients . New
graduates/new nurse – stable patients
The LPN should be assigned stable clients with expected outcomes.
 10
AppleRN Classes

Critical value: A nurse or practitioner must personally take a laboratory critical

value result and then initiate the appropriate steps for the needed interventions
(no unit clerk or UAP)
Five rights of delegation
RIGHT TASK : What tasks should be delegated RIGHT CIRCUMSTANCE : Under
what circumstances
RIGHT PERSON : To whom RIGHT DIRECTION/COMMUNICATION : What
information should be communicated RIGHT SUPERVISION/EVALUATION: How to
supervise/evaluate
The nurse delegating a task remains legally responsible for the client's total care
during the shift, and may be held liable for delegating inappropriately.
Tips- conflicts
When there is inter-staff disagreement, it is important to not have a public
"show.“
Conflict with a physician ? - Immediately leave and go to a private area.
In managing the team, first find out (assess) the reason for a refusal to do a task.
(if CNA refuses to do a task, ask for the reason first).
Emphasize the common goal of working toward safe, quality client care.
Documentation Error
Draw a straight line through the error ,The nurse has to initial and date it.
Errors in charting on a paper chart should never be obliterated, recopied, or
covered with correction fluid. The nurse should not leave blank lines on a chart or
chart for anyone else.
When entering nursing information on the client's chart, nurses should close the
chart completely and sign off before leaving the client's room
Laws and Organizations in NCLEX
ANA: American Nurses Association : The Code of Ethics for Nurses was developed
by ANA www.ana.org
 11
AppleRN Classes

Nurse Practice Act (NPA)

All states and territories have enacted a nurse practice act . The Nurse Practice
Act provides protection of the client from invasion of privacy and breaches in
confidentiality.
All NPAs include:
Authority, power and composition of a board of nursing , Education program
standards
Standards and scope of nursing practice , Types of titles and licenses
Requirements for licensure , Grounds for disciplinary action, other violations and
possible remedies
Joint Commission : An independent, not-for-profit organization,
The Joint Commission accredits and certifies health care organizations and
programs in the United States. It reflects an organization’s commitment to
meeting certain performance standards.
JC focus on patient safety and quality of care.
National Patient Safety Goals Effective January 2018 : Use at least two patient
identifiers
Label containers used for blood and other specimens in the presence of the
patient.

INFECTION CONTROL
Asepsis
Medical asepsis – The use of precise practices to reduce the number, growth, and
spread of micro-organisms (“clean technique”).
 12
AppleRN Classes

It applies to administering oral medication, managing nasogastric tubes, providing

personal hygiene, and performing many other common nursing tasks.
Surgical asepsis – The use of precise practices to eliminate all micro-organisms
from an object or area and prevent contamination (“sterile technique”).
It applies to parenteral medication administration, insertion of urinary catheters,
surgical procedures, sterile dressing changes, and many other common nursing
procedures.
Always check for latex allergies (for pt and HC)
Always use hand hygiene before and after every client contact, after removing
gloves,
after contact with body fluids, after contact with anything in clients’ rooms
after touching any contaminated items (whether or not gloves were worn)
before putting gloves on and after taking them off. before eating, and after using
the restroom.
When hands are visibly soiled, wash them with soap and water.
Hand washing – Reminders
Wash hands with soap and warm water. Rub hands together vigorously, and rinse
under running water.
Wash for at least 15-20 seconds to remove transient flora and up to 2 min when
hands are more soiled.
Keep hands lower than the forearms so that water flows toward the fingertips.
After washing, dry hands with a clean paper towel before turning off the faucet.
The hands are dried, moving from the fingers to the forearms.
Use a clean, dry paper towel to turn off the faucet.
Health Care-Associated Infections (HAIs)
client acquires while receiving care in a health care setting – UTI, Wound infection
Client and care giver education – Hand washing
 13
AppleRN Classes

adequate amount of fluids- prevents urinary stasis and skin break down.
Ensure that pulmonary hygiene (turning, coughing, deep breathing, incentive
spirometry) Cover cough
Standard Precautions
Applies to all body fluids (except sweat), non intact skin, and mucous membranes.
A nurse should implement for all clients. Hand hygiene, Gloves for all
Masks, eye protection, and face shields are required when care may cause
splashing or spraying of body fluids. Gown- to protect HC skin and cloths
PPE : GMEG : HW- Gown-Mask-Eye Protector-Gloves
Removing PPE : GEGM: Gloves-Eye Protector-Gown-Mask – Handwash (CDC
update - please update your notes)
Airborne precautions
MVTS : Measles, varicella, Tuberculosis, SARS(Severe Acute Respiratory
Syndrome), SMALL POX
A private room. Masks and respiratory protection devices for caregivers and
visitors.
Use an N95 if the client is known or suspected to have tuberculosis. Pt wear
surgical mask if going out of room. FIT testing
Negative pressure airflow exchange. Door should be closed. Use Ante room.
If splashing or spraying is a possibility, wear full face (eyes, nose, mouth)
protection.
Droplet precautions
A private room or a room with other clients with the same infectious disease,
ensuring that each client have their own equipment.
Masks for providers and visitors. Mask for pt when outside.
Required in: PPPP SS MM FRED
 14
AppleRN Classes

Streptococcal pharyngitis, Pneumonia (mycoplasma pneumonia, meningococcal

pneumonia), plague, pertussis.
Scarlet fever (a streptococcus infection), Sepsis
Meningitis, Mumps, Flu- Haemophilus influenzae type B, Rubella, Epiglotitis,
Diphtheria
Contact precautions
Protect visitors and caregivers when they are within 3 ft of the client against
direct client and environmental contact infections
A private room or a room with other clients with the same infection. Gloves and
gowns worn by the caregivers and visitors.
Disposal of infectious dressing material into single, nonporous bag without
touching outside of the bag.
C-Diff : Wash hands with soap and water. Disinfect bed and equipments with
chlorine/bleach
All surfaces within 3 feet of the bed are considered contaminated
Contact precautions Requires in : SHIVERS
Staphylococus (MRSA), Herpes simplex, Infected wounds, VRE, Enteric pathogens,
RSV, Scabies
Enteric pathogens- GRACE SS . Gardiasis, Rotavirus, A&E Hep, C-Diff, Echoli,
Shigella, Salmonella
MULTY DRUG RESISTANT???? – CONTACT PRECAUTION
HIV- Standard precautions will be enough.
Sterile technique
Prolonged exposure to airborne micro-organisms can make sterile items
nonsterile.
No coughing, sneezing, and talking directly over a sterile field. No sudden
movements.
 15
AppleRN Classes

Only sterile items may be in a sterile field.

The outer wrappings and 1-inch edges of packaging that contains sterile items are
not sterile.
Discard any object that comes into contact with the 1-inch border.
Touch sterile materials only with sterile gloves.
Consider any object held below the waist or above the chest contaminated.
Do not reach across or above a sterile field. Do not turn your back on a sterile
field.
Hold items to add to a sterile field at a minimum of 6 inches above the field. Keep
all surfaces dry.
Discard any sterile packages that are torn, punctured, or wet
Sepsis = SIRS + Infection : Early fluid resuscitation and IV antibiotic therapy
 16
AppleRN Classes

Diagnostic Procedures
Client Safety in Diagnostic Testing
Knowledge of procedure, risk and benefits, pre and post care.
Informed consent
“Time out” : Right procedure, Right client, Right site.
Perform necessary lab studies pre procedure
NPO ? Hold Med? Pregnant?
Iodine based contrast – Hold Metformin 48 hrs (risk for acidosis)
Check for allergies
Contrast Dye
Assess for allergies – Shellfish, Iodine, contrast media
Hypoallergic contrast available – premedicate with prednisone and benedryl
Intake output – give fluids post procedure (contraindication – HF, Renal disease)
Ensure IV access (20 G)
Warm flushed feeling, or salty, fishy or metallic taste in mouth, possible nausea
for 1-2 mts after injection is expected.
Biopsy: Kidney
Review coag profile (pre). Apply pressure 20 mts
Place client in supine position, bed rest for 8 hours
Increase fluid intake. Report any decrease in urine output or burning on urination
Urine positive for leukoesterase and nitrites, sediment, and RBCs - INFECTION
No aspirin, NSAID, anticoagulants * 2 weeks
Liver : Review coag profile (pre)
Instruct client to exhale breath and hold for at least 10 seconds while the needle
is inserted.
 17
AppleRN Classes

Position – Lay on right side . Rest and Avoid heavy lifting minimum 24 hrs
No aspirin, NSAID, anticoagulants * 2 weeks
Cerebral Angiogram
To assess the blood flow to and within the brain, to identify aneurysms
To define the vascularity of tumors (useful for surgical planning).
It may also be used therapeutically to inject medications that treat blood clots or
to administer chemotherapy.
If the client is pregnant, a determination of the risks to the fetus versus the
benefits.
NPO for 4 to 6 hr prior to the procedure.
Assess for allergy to shellfish or iodine, which would require the use of a different
contrast media.
Assess BUN and serum creatinine to determine kidney’s ability to excrete the dye.
Ensure that the client is not wearing any jewelry.
A mild sedative for relaxation is occasionally administered prior to and during the
procedure
Vital signs are continuously monitored during the procedure.
Client Education : Do not move during the procedure and keep the head
immobilized.
Instruct the client to void immediately before the test.
Instruct the client about a metallic taste in the mouth, a warm sensation over the
face, jaw, tongue, lips, and behind the eyes from the dye injected during
procedure.
Post procedure: The area of entry is closely monitored to ensure that clotting
occurs.
Movements are restricted to seal the artery to prevent re-bleeding at the
catheter site.
 18
AppleRN Classes

Complications: Bleeding
There is a risk for bleeding or hematoma formation at the entry site.
Nursing Actions: Check the insertion site frequently.
Check the affected extremity distal to the puncture site for adequate circulation
(e.g., color, temperature, pulses, and capillary refill).
If bleeding does occur, apply pressure over the artery and notify the provider.
Magnetic Resonance Imaging (MRI) Scan
Absolute contraindications:
Cardiac pacemaker, Implantable cardioverter defibrillator (ICD), Cochlear implant,
Retained metallic foreign body, especially in organs such as the eye
Other concerns: aneurysm and surgical clips, metal rods, screws– Let Doc know
Insulin pump? – Let Doc know – might need insulin other ways
Hearing aids? – remove. Contact lenses – colored lenses are not OK
Remove jewelry, Claustrophobia? – Sedative. Loud noise – ear plugs. Weight
limits
PET Scan
Positron Emission Tomography (to detect blood flow to brain and heart). PET scan
is a nuclear medicine procedure that produce three-dimensional images.
Radiation is short lived- increase fluid to clear it through kidneys
A glucose-based tracer is injected into the blood stream prior to the PET scan. This
initiates regional metabolic activity, which is then documented by the PET
scanner.
Assess for a history of diabetes mellitus.
Alterations in the client’s medications may be necessary to avoid hyperglycemia
or hypoglycemia before and after this procedure
 19
AppleRN Classes

Cerebral Computed Tomography

(CT) Scan with contrast: NPO for at least 4 hr prior to the procedure.
Assess for allergy to shellfish or iodine: Assess renal function
Place pillows in client’s back to prevent back pain: No jewelry
EEG
to identify and determine seizure activity, but they are also useful for detecting
sleep disorders and behavioral changes.
Instruct the client to wash his hair prior to the procedure and eliminate all oils,
gels, and sprays
Instruct the client to be sleep-deprived because this provides cranial stress,
increasing the possibility of abnormal electrical activity.
Increased electrical activity may be stimulated with exposure to bright flashing
lights, or hyperventilate for 3 to 4 minutes.
Lumbar Puncture
Cannon ball position, Empty bladder before procedure
CSF leakage – spinal headache, Encourage the client to lie flat in bed.
Provide fluids for hydration, Administer pain medication.
Prepare the client for an epidural blood patch to seal off the hole in the dura if
the headache persists.
Specimen – immediately send to lab. No need to refrigerate, protect from light
CSF is normally clear. Cloudy - Infection
The adult with a normal CSF has no red blood cells in the CSF.
Protein (15 to 45 mg/dL) and glucose (45 to 74 mg/dL) are normally present in
CSF.
The client may have small levels of white blood cells (0 to 8 cells/mm3).
Halo sign – when CSF mixed with blood
 20
AppleRN Classes

Handling the CSF sample : Immediately send to lab - Hematologic analysis within
one hour
Room temperature is preferred. No need to refrigerate – flu and meningitis virus
will die in freezing temp.
If the CSF is to be scanned for xanthochromia : Protect sample from light
Place specimen bag inside a brown envelope: Do not use the pneumatic tube
delivery system.
CVS
Holter monitoring: Instruct client to resume normal activities, maintain diary of
activities, no shower or swim with electrods.
Echocardiography: To evaluate structural, functional changes in heart
TEE (Trans esophageal)- Consent, NPO, IV line, Exercise testing (stress test)
Instruct client to wear nonconstrictive comfortable clothing, supportive shoes
NPO, no caffeine, alcohol, smoking
EKG: Cardiac dysrhythmias
Central venous pressure (CVP)
Pressure of right heart filling (no left heart): Catheter tip at SVC at juncture with
RA
Measure CVP with client supine, HOB at 45 degrees
Zero point of transducer should be at level of right atrium (Lt mid axillary line, 4
ICS)
Normal CVP value = 2 to 8 mm Hg or (2-8 cm H2O)
High CVP- Hypervolemia, CHF (crackles, JVD, edema, Hepatomegaly, Taut skin
turgor)
Low CVP – Hypovolemia (poor skin turgor, dry mucous membrane)
 21
AppleRN Classes

Percutaneous transluminal coronary angioplasty (PTCA) (balloon catheter)

Preprocedure, maintain NPO status after midnight
Postprocedure, assess distal pulses in both extremities; maintain bed rest with
limb straight for 6 to 8 hours; assess for bleeding, changes in vital signs
Coronary artery stents : Acute thrombosis major concern post-procedure; client
placed on antiplatelet therapy for several months following procedure
Angiogram/Cardiac Cath
NPO, Shave the site, Patent IV Access. Discontinue anticoagulants (pre)
Post – apply pressure (30 mts), Bedrest. Check site for bleeding, hematoma,
swelling, peripheral neurovascular signs (pulse, color, temp, motion, sensitivity)
Vital signs- 15 mts *4, 30 mts * 4, 1 hr* 4
GI
Ultrasound: Restrict food and fluids 4-8 hrs prior to test, Eat fat free meal on
evening prior to ultrasound. For pelvic and renal US- full bladder
EGD – Esophagogastroduodenoscopy
NPO, Consent, hold anticoagulants, Post op- gas pains/burping of air
Contrast – Barium / Meglumine (Gastrografin)
Aspiration risk ? – Barium is better. Perforation suspected? – Gastografin is
better
Upper GI tract study (barium swallow)
NPO after midnight before day of test
Administer laxative post procedure as prescribed; instruct client to increase oral
intake post procedure.
Lower GI tract study (barium enema)
Low-residue diet 1 to 2 days prior to procedure; NPO after midnight before day of
test
Instruct client to increase oral intake post procedure.
 22
AppleRN Classes

Administer laxative post procedure as prescribed

Colonoscopy
anticoagulants?? – Hold. Bowel prep – Golytely
Lateral position/ sims position
Moderate sedation – safety precautions
ERCP (biliary and pancreatic duct) , EGD
NPO 6 to 8 hours preprocedure, Allergy for ERCP dye, Use of anesthetic
Postprocedure, keep NPO until gag reflex returns (1 to 2 hours)
Warm saline gargles or lozenges to sooth sore throat by inserting endoscope
MRCP: Magnetic Resonance Cholangiopancreatography
Uses MRI – pacemaker/pregnancy - contraindicated
Guaiac fecal occult blood test
Ask if red meat or vitamin C supplements taken over last three days
Medication - aspirin, anticoagulants, iron, ibuprofen, and corticosteroids.
Collect the fecal samples from 2 different areas of the specimen
If the test paper turns blue : It’s a positive guaiac result – blood present.
Paracentesis
Preprocedure, have client void, measure abdominal girth, weight, baseline vital
signs
position client upright on edge of bed with back supported, feet resting on stool
(Fowler’s for bedridden client)
measure abdominal girth, and weight; monitor for hypovolemia, electrolyte loss,
mental status changes, encephalopathy
monitor for hematuria, educate client to report urine that is pink, red, bloody
If there is colon polyp : With Individual and family history
 23
AppleRN Classes

Regular screening for polyps and cancer

Flexible sigmoidoscopy every 5 years, Colonoscopy every 10 years
Double-contrast barium enema study every 5 years
CT colonography every 5 years, Colonoscopy : “Gold standard”
Entire colon is examined, Biopsy samples can be obtained
Polyps can be immediately removed and sent to the laboratory for examination
Arthrocentesis
Instruct client to rest joint 8 to 24 hours postprocedure
Instruct client to notify physician if fever or swelling of joint develops.
Arthrography (X ray with dye)
Assess client for allergies to iodine, shellfish
Instruct client that joint may be edematous, tender for 1 to 2 days post procedure
Treat with ice packs, analgesics
Myelography (spinal puncture, inject dye)
Pre procedure : Assess for allergies to iodine, shellfish
NPO 4-6 hrs: Table tilt – to allow dye to reach different levels
Post procedure
If water-based contrast agent used, elevate head of bed 30to 60 degrees for 8
hours to prevent irritation from residual dye.
Oil-based contrast – head of bed flat / 15 degree
If air contrast used, keep head lower than trunk. Increase fluid intake to flush out
dye
Renal
Urine culture and sensitivity : Collect midstream sample in sterile container
urine is positive for leukoesterase and nitrites – need further test
 24
AppleRN Classes

Voiding Cystourethrogram: X ray taken when client is voiding : Embarrassment –

Provide privacy
Intravenous pyelography
Assess client for allergies to iodine, seafood, radiopaque dye
Instruct client to drink at least 1 L fluid post-procedure unless contraindicated
Laxative on evening before test, enema in the morning of test
BUN – if >40, test may be cancelled. (normal- 8-22)
24 hr urine collection
Client to void at the beginning of the collection period and discards this urine
sample because this urine has been stored in the bladder for an undetermined
length of time.
All urine thereafter is saved in an iced or refrigerated container.
The client is asked to void at the finish time, and this sample is the last specimen
added to the collection.
Straining the urine is contraindicated for timed urine collections.
The container is labeled, placed on fresh ice, and sent to the laboratory
immediately after the 24-hour urine collection has ended.
Renal angiography
Assess client for allergies to iodine, seafood, radiopaque dye
Possible feeling of burning, heat along vessel when dye injected, Instruct client to
void immediately before procedure
Assess, mark peripheral pulses
Post procedure : Maintain bed rest
Apply sandbag or other device to apply pressure; prevent bleeding as prescribed
Assess color, temperature, sensation, movement of toes of involved extremity
 25
AppleRN Classes

Inspect catheter insertion site for bleeding, swelling. Encourage fluids unless
contraindicated
Cystoscopy
It uses a flexible fiber-optic scope inserted through the urethra into the urinary
bladder. The client is in the lithotomy position.
Complications associated with cystoscopy include urinary retention, hemorrhage,
and infection
Post procedure: Increase fluid intake as prescribed. Encourage deep-breathing
exercises.
leg cramps- commonly occur
OK to apply heat to lower abdomen to relieve pain and muscle spasm
Inform client that burning on urination, pink-tinged, tea-colored urine, urinary
frequency is common
Monitor for bright red urine, clots; notify physician if present. Report gross
hematuria
Avoid alcohol for 2 days after test – bladder irritant
Respiratory System
Sputum specimen: Obtain early morning sterile specimen from suctioning,
expectoration after respiratory treatment
Always collect specimen prior to antibiotic therapy
If culture prescribed, transport to laboratory immediately
Bronchoscopy
Direct visual examination of larynx, trachea, bronchi with fiberoptic bronchoscope
Assess allergies to drugs, food, latex. Remove dentures, jewelry, contact lenses.
Void before procedure.
HOB – semi fowlers. Coughing with minimal blood – expected. But report if more.
Maintain NPO status until gag reflex returns
 26
AppleRN Classes

Monitor for bronchospasm, b. perforation, dysrhythmias, fever, hypoxemia

Notify physician if fever, difficulty breathing, blood. Lozenges for sore throat
PFT: Lung capacity assessment: Pt to avoid eating heavy meal or smoking prior to
test. Hold medications which might sedate
VQ Scan
Nuclear lung scan after inhaling a mixture of air, oxygen and radioactive gas.
Deep breath and hold – images taken. Report chest pain and SOB (PE)
Thoracentesis
Removal of fluid or air from pleural space via trans thoracic aspiration
If client cannot sit up for procedure, place lying in bed toward unaffected side
with head of bed elevated
Instruct not to cough, breathe deeply, or move during procedure
Postprocedure: Monitor respiratory status
Monitor for signs of pneumothorax, air embolism, pulmonary edema
Arterial blood gases (ABGs)
Pre procedure, perform Allen’s test
Post procedure, apply pressure to puncture site for 5 to 10 minutes or longer if
client taking anticoagulant therapy or has bleeding disorder
Mantoux test
False positives- Need chest x-ray to see active TB infection.
The nurse finds an area that is not heavily pigmented and is clear of hairy areas or
lesions that could interfere with reading the results.
Reinforce to the client the importance of returning for a reading of the injection
site by a health care personnel within 48 to 72 hr.
Advise client not to scratch site, avoid washing site.
 27
AppleRN Classes

Growth and Development

Infants
Expected Growth and Development
The infant’s posterior fontanel closes by 2 to 3 months of age.
The infant’s anterior fontanel closes by 12 to 18 months of age.
Solid food is appropriate around 4 to 6 months
Erikson : trust vs. mistrust
Separation anxiety develops between 4 and 8 months of age.
Parents should remove gyms and mobiles by 4 months because injury can occur
from choking or strangulation.
Car Seats:
Infants in a car seat should face the rear of the vehicle until age 2 or until they
reach the maximum height and weight for the seat.
Infants should have car seats with five-point harness systems.
Toddlers (1 to 3 Years)
Independence: toddlers attempt to do everything for themselves.
Separation anxiety continues
Egocentric: only from their point of view
Temper tantrums : Provide consistent, age-appropriate expectations
Toddlers develop gender identity by age 3. Appropriate activities include:
Filling and emptying containers, Playing with blocks, Looking at books
Playing with push and pull toys, Tossing a ball
 28
AppleRN Classes

Preschoolers (3 to 6 Years)
3 yr old : Ride a tricycle, Jump off bottom step, Stand on one foot for a few
seconds
4 yr old: Skip and hop on one foot, Throw ball overhead
5 yr old: Jump rope, Walk backward with heel to toe, Move up and down stairs
easily
 29
AppleRN Classes

Initiative vs. Guilt

Preschoolers feel good about themselves for mastering skills, such as dressing and
feeding that allow independence.
Favorite toys and play help ease fears, Pretend play is healthy.
Age-Appropriate Activities: Playing ball, Putting puzzles together, Riding
tricycles.
Pretend and dress-up activities, Cooking and housekeeping toys.
Musical toys, Painting, drawing, and coloring. Looking at illustrated books.
School-Age Children (6 to 12 Years)
industry vs. inferiority.
Peers and teachers have great influence. Changes related to puberty begin to
appear.
They place more emphasis on privacy. Prefer the company of same-gender
companions.
Competitive and cooperative play predominates. Play board, video, and number
games.
Play hopscotch, Jump rope, Ride bicycles, team sports. Build models, crafts,
hobbies, read books
Adolescents (12 to 20 Years)
identity vs. role confusion
Physical development and changes. Adolescents often feel invincible to bad
outcomes of risky behaviors
Peer relationships develop as a support system.
Screening for scoliosis- a lateral curvature of the spine- is essential, especially for
girls.
Eating disorders
Age-Appropriate Activities
 30
AppleRN Classes

Nonviolent video games, music, movies. Sports, social events. Caring for a pet
Career-training programs. Reading
Young Adults (20 to 35 Years)
intimacy vs. isolation
risk for alterations in health from: Substance use disorders, Periodontal disease
due to poor oral hygiene, Unplanned pregnancies – a source of high stress
Sexually transmitted infections (STIs), Infertility. Work-related injuries or
exposures. Violent death and injury
Middle Adults (35 to 65 years)
generativity vs. stagnation
At risk for : Obesity, type 2 diabetes mellitus, Cardiovascular disease, Cancer
Substance use disorders (alcoholism), Psychosocial stressors
Older Adults (65 Years and Older)
integrity vs. despair.
Chronic disorders, CV disorders, mobility disorders, Mental health issues.
Safety precautions: Fall Precautions
 31
AppleRN Classes
 32
AppleRN Classes

Nursing Interventions : Examine risk factors, Identify support systems.

Refer clients to educational/community/support resources, Use behavior-change
strategies (clients’ readiness, goals, acceptable intervention). Promote healthy
lifestyle behaviors
Healthy lifestyle behaviors : Use stress management strategies.
Get adequate sleep and rest. Eat a nutritious diet. Avoid saturated fats.
Participate in regular physical activity most days. While outdoors, wear protective
clothing, use sunscreen, and avoid sun exposure between 10 a.m. and 4 p.m.
Wear safety gear (bike helmets, knee and elbow pads). Avoid tobacco products,
alcohol, and illegal drugs. Safer Sex- contraception. Seek medical care when
necessary, get routine screenings, and perform recommended. self-
examinations (breast, testicular).
Health Assessment
Ensure adequate lighting. Maintain a quiet and comfortable environment.
Provide privacy. Look and observe before touching.
Use standard precautions
Inspect, palpate, percuss, and auscultate (except abdominal)
Health History: Determine client’s general state of health
Determine client’s chief complaint and history of present illness
Obtain a family history, Obtain a social history
Gather information about the client’s lifestyle focusing on factors that may impact
health
Screen for domestic violence when conducting a one-on-one interview
Mental Status Exam
Subjective data assessed during the health history interview to include
appearance, posture, body language, dress, hygiene, level of consciousness (LOC),
facial expressions
 33
AppleRN Classes

Determine client’s cognitive level of functioning:

Orientation, Attention span, Recent memory, Remote memory, New learning,
Judgment
Thought processes and perceptions
Stethoscope
Ensure that stethoscope is not cold to touch
Use the diaphragm of the stethoscope to listen to high-pitched sounds (heart
sounds, bowel sounds, lung sounds).
Place the diaphragm firmly on the body part.
Use the bell of the stethoscope to listen to low-pitched sounds (unexpected heart
sounds, bruits).
Place the bell lightly on the body part.
PERRLA : Pupils Equal Round Reactive to Light and Accomodating
Rinne Test Weber test

LOC- Glasgow coma scale – 8 or less- comatose.

 34
AppleRN Classes

Romberg test

Points to remember
Bruises in various stages - ?child abuse
Ant fontanel – close by 12-18 mths
Post. Fontanel – close by 2 months
Skin lesion – ABCDE : Melanoma
A- Asymmetry B-Border irregular C- Color variation D- Diameter > 6mm E
- Evolving
Cancer Screening
C – Change in bowel or bladder A – a sore that doesnot heal
 35
AppleRN Classes

U – Unusual bleeding or discharge T – Thickening or lump

I – Indigestion or difficulty swallowing O – obvious change in a wart or mole
N – nagging cough or hoarsness
 36
AppleRN Classes

CONCEPT: Safety

Fire safety Physiological changes in older Poisons

Turn off oxygen and appliances in client—increase risk of accidents Accidental poisoning
vicinity of fire Prevent Falls common in toddlers,
preschoolers, young school-
If fire occurs and client is on life Assess client’s risk for falling age children, so they must
support, maintain respiratory
If client is at risk, move to room be protected
status manually with Ambu bag
until client is moved. closer to nurses’ station Older adults with
Alert all personnel of fall risk diminished eyesight,
Electrical safety
impaired memory may be
Use three-pronged electrical cords Orient client to surroundings at risk for accidental
ingestion of poison
Any electrical equipment brought Instruct client to ask for assistance
in by client or family must be when getting up Keep Poison Control Center
inspected prior to use phone number on phone or
Explain call bell system and use
in view of phone
Check all electrical cords and bed and chair alarms as necessary
outlets for exposed, frayed, If poisoning occurs,
Keep bed in lowest position
damaged wires
Keep side rails up if required -remove excess
If client receives electrical shock, immediately,
turn off electricity before touching Keep personal belongings within
client reach -identify type and amount if
possible,
Radiation safety Provide adequate lighting
-call Poison Control, induce
Reduce exposure by limiting time Restraints vomiting only if instructed
spent near source, increase by Poison Control,
Must have physician’s
distance as much as possible, use
prescription with specifics about -go to emergency room if
shielding device
type of restraint, time frame for instructed by Poison
Never touch dislodged radiation use; must be renewed following Control
implants agency policy

Disposal of infectious wastes Should not interfere with any

treatments or affect client’s
Handle all infectious materials as
health care
hazard
Assess skin integrity and
Dispose of all sharps immediately
neurovascular status every 30
after use in closed, puncture-
minutes; remove restraints at
resistant, approved disposal
least every 2 hours
container
 37
AppleRN Classes

• Cataract surgery
– Postoperatively, semi-Fowler’s to Fowler’s position on back and
nonoperative side
• Autonomic dysreflexia :involuntary nervous system overreacts- Spinal cord
injury above T6
– Elevate HOB to high Fowler’s position/sitting : to cause the blood to
flow to feet
• Cerebral aneurysm
– Bed rest, with HOB semi-Fowler’s to Fowler’s position
 38
AppleRN Classes

• Brain attack (stroke)

– Hemorrhagic strokes, low Fowler’s position; ischemic strokes, HOB
flat
• Craniotomy
• Place on nonoperative side, semi-Fowler’s to Fowler’s position, head
midline
• Increased intracranial pressure
• Semi-Fowler’s to Fowler’s position, head midline
• Spinal cord injury
• Immobilize, logroll
• Air embolism
• - Trendelenburg’s position on the left side
• Total hip replacement
• Avoid extreme internal and external rotation and adduction
• Maintain abduction when supine or on nonoperative side
Urinary and Renal Tubes, wound drainage
Urinary and Renal Tubes
Types of urinary catheters : Urinary catheter, ureteral tubes, nephrostomy tubes
Routine urinary catheter care
– Maintain collection bag below level of bladder
– Ureteral and nephrostomy tubes
– Never clamp tube; maintain patency
– Monitor strict intake and output
– Irrigate only with physician’s prescriptions, using strict aseptic technique (5
ml max)
Wound Drainage
Measure and record every shift
JP drain and Hemovac- maintain pressure after emptying the bulb
 39
AppleRN Classes

Penrose drain – dressing changes

T-Tube – bile drainage : Keep T-tube below level of surgical wound
Up to 500 ml expected first 24 hrs
About 200 ml in 2-3 days : D/C home ? - Clamping schedule- before and after meal

Nasogastric Tubes Gastrointestinal Tube Feedings Prevent Complications

Decrease risk of aspiration Nasogastric: Nose to stomach Diarrhea
Decompress stomach after Nasoduodenal, nasojejunal: Nose
abdominal surgery to duodenum or jejunum
Aspiration
Provide enteral feedings Gastrostomy: Stomach
Intubation procedures Jejunostomy: Jejunum
Place client in high Fowler’s Assess placement and bowel
position Clogged Tube
sounds; if absent, hold feeding,
Measure tube from tip of nose to notify physician
earlobe to xiphoid process to Assess residual amount; hold
determine length of insertion feeding if residual more than 100
Lubricate tube with water-soluble mL or amount specified by
jelly agency Vomiting

Instruct client to bend head Precautions

forward
Nasoenteric Tube
Insert tube into nostril, advance
Tube inserted nasally to
backward
stomach – then passed to
Have client take sips of water, intestine via persiatlsis
advancing tube while he or she
swallows

When in place, tape appropriately

Irrigation
 40
AppleRN Classes

CONCEPT: ------------------TUBES----------------------------------

Tracheostomy Monitor arterial blood gas (ABG) Suction control chamber

Single Lumen (no inner canula) levels and pulse oximetry
Water should be gently
Double Lumen (with inner canula) Encourage deep breathing and bubbling continuously
coughing
Ambu bag and spare Trach kit - If vigorous bubbling occurs,
Always at bedside Maintain semi-Fowler’s to high notify physician
Fowler’s position
Cuff pressure – 20 mm hg. Cuff Dry suction system
deflated before removing trach Suction PRN, hyperoxygenating
Absence of bubbling in
first
Ensure humidified oxygen flow suction chamber should be
Chest Tube noted
water bottle attached to O2 flow
meter should be filled prn Used to remove abnormal Suction applied via wall
accumulations of air and fluids suction source
Trach care q 8 hrs, Trach ties from pleural space
changed daily. Interventions
Collection chamber
Two people - one hold the trach in Monitor drainage in
place. Drainage should not be more than collection chamber
100 mL/hr; should be reported
If no assistant, place new ties Monitor for fluctuation of
before cutting and removing old Bright red drainage, drainage fluid level in water-seal
ones. amounts that increase suddenly chamber, with respirations
should also be reported
Suction – hyper oxygenate before If bubbling and no
and after. Water-seal chamber movement, and not working
properly, further
No more than 10 sec at a time Water should oscillate with assessment required
client’s respirations
Suction when coming out- rotating Monitor for gentle bubbling
movement If continuous bubbling in in suction chamber
chamber, physician should be
Assess respirations, bilateral notified
breath sounds
Fluctuations that stop may
Placement is confirmed by chest indicate leak; connections should
x-ray (1 to 2 cm above carina) be checked, corrected
Assess placement by auscultating
both sides of chest while manually
ventilating client with Ambu bag
 41
AppleRN Classes

CONCEPT: Pre and Post op Care

Preop Care Preop Care Risk Preop Care Risk

Assessment of risk factors Respiratory disease (COPD, Coagulation defect
is one of the major aspects pneumonia, asthma) (increased risk of
of preoperative care. bleeding)
Cardiovascular disease
Infection (risk of sepsis) (cerebrovascular accident, Malnutrition (delayed
healing)
Anemia (malnutrition, heart failure, myocardial
oxygenation, healing infarction, hypertension, Obesity (pulmonary
impact) dysrhythmias) complications due to
hypoventilation,
Hypovolemia from Diabetes mellitus impact on anesthesia,
dehydration or blood loss (decreased intestinal elimination, and
(circulatory compromise) motility, altered blood wound healing)
glucose levels, delayed
Electrolyte imbalance Certain medications
healing)
through inadequate diet or (antihypertensives,
disease process Liver disease (altered anticoagulants,
(dysrhythmias) medication metabolism and NSAIDs, tricyclic
increased risk for bleeding) antidepressants,
Age (older adults are at herbal medications,
greater risk because of Kidney disease (altered over-the-counter
decreased liver and kidney elimination and medication medications)
function due to age, and excretion)
Substance use
the use of multiple Endocrine disorders (tobacco, alcohol)
prescribed medications) (hypo/hyperthyroidism,
Family history
Pregnancy (fetal risk with Addison’s disease, (malignant
anesthesia) Cushing’s syndrome) hyperthermia)
Immune system disorders Allergies (latex,
(allergies, anesthetic agents)
immunocompromised)
 42
AppleRN Classes

CONCEPT: Pre and Post op Care

Perioperative Care Pre op check Diagnostic Procedures

Obtaining informed Give Preoperative Urinalysis – ruling out of
consent medications : Sedative? infection
Nutrition : NPO as Fall risk- Pt in bed with
Blood type and cross
prescribed side rails up
match – transfusion
Avoid cigarette smoking Prophylactic antibiotics readiness
for 24 hr preop are administered 1 hr
CBC – infection/immune
prior to surgical incision.
Stop herbal meds – risk of status. Hgb and Hct –
bleeding Pt already on Beta- fluid status, anemia
blocker? Give a dose prior
Elimination : Void Pregnancy test – fetal risk
to surgery to prevent a
immediately before of anesthesia
cardiac event and
surgery Clotting studies (PT, INR,
mortality.
Bowel prep if needed aPTT, platelet count)
Cover the client with
(laxative, emema) Electrolyte levels –
lightweight cotton blanket
Surgical site heated in a warmer to electrolyte imbalances
prevent hypothermia. Serum creatinine and
Hair should be shaved or
clipped with electric Hypothermia increases BUN – renal status
clippers or chemical the chance for ABGs – oxygenation
depilatory to prevent status. Chest x-ray –
-surgical wound
traumatizing the skin and heart and lung status
infections,
increasing the risk for
infection. -alters metabolism of 12-lead ECG – baseline
medication, heart rhythm,
Preoperative checklist dysrhythmias, history of
-causes coagulation
cardiac disease,
problems and cardiac
performed on all clients
dysrhythmias.
older than 40 years
 43
AppleRN Classes

CONCEPT: Pre and Post op Care

Pre operative Care Perioperative Care : Absent breath sounds on

Preoperative client Explanation the left may indicate the
teaching endotracheal tube has
Toddler : Immediately
migrated down the right
Inform client that prior to surgery, give a
mainstem bronchus or
requesting opioid brief and simple
there is a pneumothorax.
medications (narcotics) explanation
postoperatively will not Snoring or stridor (a high
Preschoolers: give a brief
make him or her a drug pitch crowing type
and simple explanation,
addict sound) may indicate poor
play therapy
oxygen exchange.
Postoperative pain control School age : Age
techniques (medications, Assess, monitor for
appropriate but complete
immobilization, patient- bleeding
explanation, use pictures,
controlled analgesia, dolls and videos. Orient to environment
pumps, splinting)
Adolescents: Privacy is Apply warm blankets and
Demonstration and extremely important. prescribed oxygen if
importance of range-of- Clear explanation. shivering
motion exercises and early
ambulation for prevention Adults : complete Assess and monitor
of thrombi and respiratory information surgical site, drains,
wound
Purpose of antiembolism Postoperative Care
stockings and pneumatic Assess, monitor for signs
Immediate postoperative
compression devices to of hypocalcemia,
stage
prevent deepvein hyperglycemia, metabolic
thrombosis Assess, monitor airway – or respiratory acidosis or
adequate ventilation? alkalosis
Invasive devices (drains, secretions ?respirations
catheters, IV lines) Assess, monitor for
?signs of respiratory
return of bowel sounds
Postoperative diet distress?

Demonstration and Assess for symmetry of

importance of splinting, breath sounds and chest
coughing, and deep wall movement.
breathing
Use of the incentive
spirometer
Early ambulation
 44
AppleRN Classes

CONCEPT: Pre and Post op Care

Risk Factors for post op Older Adults If comatose or

Respiratory disease semicomatose, position on
Age-related physiologic side with oral airway in place
(respiratory compromise)
changes (decreased liver and
Immune disorder (risk for kidney function) can affect
infection, delayed healing) response to and elimination of Turn client to side-lying
Diabetes mellitus postoperative medications. position if vomiting occurs
(gastroparesis, delayed wound Monitor the client for
healing) appropriate response and
Coagulation defect (increased possible adverse effects. Do not put pillows under
risk of bleeding) knees or elevate the knee
Older adults perspire less, gatch on the bed (decreases
Malnutrition (delayed healing) which leads to dry, itchy skin venous return).
that becomes fragile and easily
Obesity (wound healing,
dehiscence,evisceration) abraded.
The use of paper tape for Expect client to void in 6 to 8
Older adult hours postoperatively
wound dressings may be
Aged- Need special attention to appropriate, as well as lifting
the postoperative recovery. precautions.
Assess pain, type of
Older adult clients are more Older adults may be at risk for
susceptible to cold anesthetic used, and
delayed wound healing preoperative medication, and
temperatures
because of possible whether client received pain
additional warm blankets in compromised nutrition. medication in postanesthesia
the PACU may be required. period
Immediate postoperative
Responses to medications and stage
anesthetics may delay return of
orientation postoperatively. Unless contraindicated, place If opioid has been prescribed,
client in low Fowler’s position. assess client every 30
Avoid supine positioning until minutes for pain relief and
pharyngeal reflexes have respiratory rate and effort
returned

Reinforce wound with sterile

dressing PRN; notify physician
if bleeding occurs from site
 45
AppleRN Classes

CONCEPT: Pre and Post op Care

Malignant hyperthermia Terminate surgery Interventions

Genetic disorder ›› Dantrolene (Dantrium) Encourage client to
Combination of anesthetic is a muscle relaxant to breathe deeply, cough,
agents triggers treat the condition use incentive spirometer
uncontrolled skeletal ›› 100% oxygen, arterial Prevention
muscle contractions blood gases
Cough and deep breath,
Hyper metabolic condition ›› Infuse iced IV 0.9% IS,
causing an alteration in sodium chloride
calcium activity in muscle Reposition every 2 hr
cells (muscle rigidity, ›› Apply a cooling blanket,
ambulate early and
hyperthermia, and damage ice to axillae, groin, neck
regularly.
to the central nervous and head, iced lavage
system). Hypoxia
Pneumonia and
Always check for family Atelectasis Description
history. Description Inadequate
Tachycardia is a first concentration of oxygen
Pneumonia: Inflammation
manifestation. in arterial blood
of alveoli occurring 3 to 5
Other signs: Dysrhythmias, days postoperatively Assessment
muscle rigidity, Atelectasis: Collapse of Restlessness, dyspnea,
hypotension, tachypnea, alveoli, most common hypertension,
skin mottling, cyanosis and postoperative tachycardia, diaphoresis,
protein in urine. complication, 1 to 3 days cyanosis
can quickly lead to a postoperatively Interventions
potentially fatal Assessment
hyperthermia. Encourage client to
Dyspnea, tachypnea, breathe deeply, cough,
Elevated temperature is a crackles over affected use incentive spirometer
late manifestation – rising lung area, fever,
1° to 2° C (2° to 4° F) every productive cough, chest
5 min. pain
 46
AppleRN Classes

CONCEPT: Pre and Post op Care

Pulmonary Embolism Hemorrhage Shock

Description Description Description
Embolus blocking Loss of large amount of Loss of circulatory fluid
pulmonary artery, blood externally or volume; often secondary
disrupting blood flow to internally in short time to hemorrhage
one or more lung lobes
Assessment Assessment
Assessment
Restlessness, weak rapid Restlessness, weak and
Dyspnea, sudden sharp pulse, hypotension, cool rapid pulse, hypotension,
chest or upper abdominal clammy skin, oliguria cool clammy skin, oliguria
pain, cyanosis,
tachycardia, hypotension Interventions Interventions
(shock) Apply pressure to site of If shock develops, elevate
Interventions bleeding legs

Notify physician STAT Notify physician STAT Monitor, assess vital

signs, level of
Monitor vital signs Monitor vital signs
consciousness, intake
Administer oxygen and Administer oxygen as and output, skin
medications as prescribed prescribed
Administer oxygen as
Prevention Administer IV fluids, blood prescribed
as prescribed
Turning and early Administer IV fluids,
Ambulation blood, colloid solutions
as prescribed
TEDS and SCD
 47
AppleRN Classes

CONCEPT: Pre and Post op Care

Thrombophlebitis Urinary Retention Constipation

Inflammation of vein, Involuntary accumulation Abnormal infrequent
accompanied by clot of urine in bladder passage of stool
formation
Assessment Assessment
Assessment
Inability to void, lower Abdominal distention,
Positive Homans’ sign abdominal pain, distended absence of bowel
Aching or cramping pain, bladder, hypertension, movements, anorexia,
tender to touch, Fever tympany sound on headache, nausea
percussion of bladder
Interventions Interventions
Interventions
Assess leg(s) for swelling, Encourage fluid intake up
inflammation, pain, Strict intake and output to 3000 mL/day unless
tenderness, cyanosis contraindicated
Assess for distended
Elevate extremity 30 bladder Encourage early
degrees without pressure ambulation
Encourage ambulation
in popliteal space. SCD, Encourage consumption
TEDS, Ambulte Provide privacy for voiding
of high-fiber foods unless
Passive range of motion Pour warm water over contraindicated
every 2 hours perineum, run water for
Administer stool
client to hear to promote
Do not allow client to softeners and laxatives as
voiding
dangle legs prescribed
Catheterize as prescribed
Instruct client not to sit in
one position for lengthy
period
Administer heparin sodium
or warfarin (Coumadin)
 48
AppleRN Classes

CONCEPT: Pre and Post op Care

Paralytic Ileus Wound Infection Interventions

Description Infection caused by poor Place in low Fowler’s
Failure of appropriate forward aseptic technique or position, with knees bent, if
movement of bowel contents contaminated wound before abdominal incision
surgical exploration; occurs 3
Assessment Cover wound with sterile
to 6 days postoperatively
normal saline dressing, Notify
Nausea, vomiting immediately Assessment physician
postoperatively, abdominal
distention, absence of bowel Fever, chills, warm, tender, Administer antiemetics if
movements, bowel sounds or painful, inflamed incision site, abdominal incision to prevent
flatus elevated white blood cell vomiting, strain on incision
count
Interventions Instruct client to splint
Interventions abdominal incision when
Maintain NPO status until coughing
bowel sounds return Monitor temperature, vital
signs Ambulatory Surgery
Strict intake and output
Monitor incision site for signs General criteria for client
Maintain patency of of infection. Maintain patency discharge
nasogastric tube if in place of drains, assessing drainage
Alert and oriented, Has
Encourage ambulation Change dressings as voided, Has no respiratory
Administer IV fluids, parenteral prescribed. Administer distress
nutrition, medications as antibiotics as prescribed
Ambulates, swallows, coughs,
prescribed Wound Dehiscence Experiencing minimal pain,
bleeding
Separation of wound edges
from suture line Has no vomiting, Has
someone to take home;
Assessment : Increased
physician has signed release
drainage, open wound edges,
appearance of underlying Discharge teaching
tissue through wound
 49
AppleRN Classes

MATERNITY AND PEDIATRICS

Ante Natal care
Physiological Maternal Changes
Cardiovascular system : Pulse may increase 10 beats/min
Blood pressure may decrease in second trimester
Respiratory system: Oxygen consumption increases by 15% to 20%
GI : Nausea, Vomiting, Constipation, Hemorrhoids
Renal system: Frequency of urination increases in first and third trimesters
Endocrine system: BMR rises, Body weight increases
Reproductive system: Uterus enlarges, Cervix changes
Leukorrhea is normal – white /milky discharge PV – due to hormonal changes (if
foul smelling/itching/burning – need to report)
Skeletal system: Center of gravity changes - Lordosis
Integumentary Changes : Linea nigra and Striae, Chloasma, Vascular spider nevi
Pica
Pica is the abnormal, compulsive craving for and consumption of substances
normally not considered nutritionally valuable or edible.
Common substances include ice, cornstarch, chalk, clay, dirt, and paper.
Associated with iron deficiency anemia. So monitor the Hb and HCT
Laboratory Tests : Blood type and Rh factor
Mother is Rh-negative and has negative antibody screen
Will need to repeat antibody screens
Should be given Rho(D) immune globulin (RhoGAM) within 72 hours of birth of
first baby when detected
With every other pregnancy, should be given RhoGAM at twenty-eighth week of
gestation and within 72 hours of birth of baby
 50
AppleRN Classes

Tuberculin skin test: Positive test indicates need for chest x-ray to rule out active
disease
In pregnant client, x-ray cannot be performed until after 20th week of gestation
Urine : Glucose – Diabetes, Protein – Pre Eclampsia, Nitrates and WBC –
Infection
pH may be decreased and specific gravity may be increased (vomiting)
Blood : HCG levels (human chorionic gonadotropin )
Diagnostic Tests: Ultrasonography
Outlines, identifies fetal and maternal structures
Assists in confirming gestational age and estimated date of confinement
Chorionic villus sampling (High Risk)
Assessment of a portion of the developing placenta (chorionic villi), which is
aspirated through a thin sterile catheter or syringe. (10-12 wks)
Detects genetic abnormalities by sampling chorionic villus tissue at eighth to
twelfth week of gestation.
Kick counts (fetal movement counting) – update:10 times in two hours is good
Amniocentesis
Aspiration of amniotic fluid may be done from thirteenth to fourteenth week of
gestation
Used to determine genetic disorders, metabolic defects, fetal lung maturity
Risks : maternal hemorrhage, infection, abruptio placentae, premature rupture of
membranes
Alpha-fetoprotein (AFP) can be measured from the amniotic fluid
High levels of AFP are associated with neural tube defects, such as anencephaly
(incomplete development of fetal skull and brain), spina bifida (open spine), or
omphalocele (abdominal wall defect).
High AFP levels also may be present with normal multifetal pregnancies.
 51
AppleRN Classes

Low levels of AFP are associated with chromosomal disorders (Down syndrome)
or gestational trophoblastic disease (hydatidiform mole).
Fetal lung tests
Lecithin/sphingomyelin (L/S) ratio – a 2:1 ratio indicating fetal lung maturity (2.5:1
or 3:1 for a client who has diabetes mellitus).
Presence of phosphatidylglycerol (PG) – absence of PG is associated with
respiratory distress
After Amniocentesis : Administer RhO(D) immune globulin (RhOGAM) to the
client if she is Rh-negative
Advise the client to report to her provider if she experiences fever, chills, leakage
of fluid, or bleeding from the insertion site, decreased fetal movement, vaginal
bleeding, or uterine contractions after the procedure.
Encourage the client to drink plenty of liquids and rest for the 24 hr post
procedure.
Fern test : Microscopic slide test to determine presence of amniotic fluid leakage
Nitrazine test: Determines presence of amniotic fluid in vaginal secretions;
shades of blue indicate that membranes probably ruptured
Quad marker screening – a blood test that ascertains information about the
likelihood of fetal birth defects. It does not diagnose the actual defect. Checks
Hcg, AFP, Estriol, Inhibin – all proteins from fetus and placenta
Sustained fetal tachycardia (>160/min for >10 minutes) is a concerning finding
that requires further follow-up
Nonstress test (Positive –reactive - is normal)
Performed to assess placental function and oxygenation
Assesses fetal well-being – FHR vs Fetal movement
Normal- Increased FHR with FM. Outpatient clinic, external monitor
Contraction stress test (positive is abnormal)
Performed to assess placental function, oxygenation and baby tolerate labor?
 52
AppleRN Classes

FHR vs Contractions – gives oxytocin

Normal - No late deceleration, no variable deceleration
Early deceleration is ok- due to head compression
Assesses fetal ability to tolerate labor, fetal well-being
Late Decelerations and Variable Decelerations : NOT OK
Fetal Monitoring
External fetal monitoring : Noninvasive; performed using transducer or Doppler
Transducer, fastened with belt, should be placed on side of mother where fetal
back is located (find using Leopold’s maneuvers)
Internal fetal monitoring : Invasive; requires rupturing of membranes;
Attachment of electrode to presenting part of fetus; mother must be dilated 2 to
3 cm to perform this procedure
Contra indication- Closed cervix, Placenta previa, STD, Breach, AIDS, Hep B
Assessment
Nägele’s rule : To estimate date of confinement, delivery date:
subtract 3 months from the first day of the last menstrual period, add 7 days, and
adjust the year
McDonald’s Method – Fundal height – correlate with GA until third trimester.
Consistency ( same person, same measurement) is important
GTPAL acronym : Gravidity – number of pregnancies.
Nulligravida – a woman who has never been pregnant. Primigravida – a woman
in her first pregnancy
Multigravida – a woman who has had two or more pregnancies
Fundal Height
 53
AppleRN Classes

TORCH : Malformations, fetal death

Toxoplasmosis : uncooked meals, cat liter – Avoid backyard garden/soil food
Other infection (usually Hepatitis): poor hand washing, blood and body fluids
contamination
Rubella: Droplet spread – rubella virus
Cytomegalovirus: droplet, body fluids (including tears, saliva, breast milk). Hand
washing.
 54
AppleRN Classes

Herpes Simplex : STI

Presumptive signs
(subjective) : changes that the woman experiences that make her think that she
may be pregnant.
Amenorrhea, Fatigue, Nausea and vomiting, Urinary frequency
Breast changes – darkened areolae, Montgomery’s glands around breast
Quickening – slight fluttering movements of the fetus felt by a woman, usually
between 16 to 20 weeks of gestation
Uterine enlargement, Probable signs
Probable signs (objective)
changes that make the examiner suspect a woman is pregnant (primarily related
to physical changes of the uterus).
Abdominal enlargement related to changes in uterine size, shape, and position
Braxton Hicks contractions – false contractions; painless, irregular, and usually
relieved by walking
Positive pregnancy test, Fetal outline felt by examiner
Hegar’s sign: Softening and thinning of lower uterine segment at about sixth week
of gestation
Goodell’s sign: Softening of cervix, beginning at second month of gestation
Chadwick’s sign: Bluish coloration of mucous membranes of cervix, vagina, vulva
at about sixth week of gestation
Ballottement: Rebounding of fetus against examiner’s fingers on palpation

Positive Sign
Fetal heart rate : 120 to 160 per mt., Active fetal movement
Outline of fetus on x-ray or ultrasonogram
 55
AppleRN Classes

Common Discomforts of Pregnancy

Urinary Frequency, Avoid UTI
Encourage the client to wipe the perineal area from front to back after voiding;
Avoid bubble baths
Wear cotton underpants; avoid tight-fitting pants; Consume plenty of water (8
glasses per day). Avoid urinary stasis
Nausea and vomiting
Eat crackers or dry toast 30 min to 1 hr before rising in the morning to relieve
discomfort.
Small frequent meals, High Protein Snacks
Instruct the client to avoid having an empty stomach and ingesting spicy, greasy,
or gas-forming foods.
Encourage the client to drink fluids between meals. Consume foods high
in vitamin B6 (eg, nuts, seeds, legumes)
Fatigue may occur during the first and third trimesters – frequent rest periods
Heartburn
Eat small frequent meals, Not allow the stomach to get too empty or too full,
sit up for 30 min after meals, , check with her provider prior to using any over-
the-counter antacids.
Backaches
Eexercise regularly, perform pelvic tilt exercises (alternately arching and
straightening the back)
Use proper body mechanics by using the legs to lift rather than the back, and use
the side-lying position.
Constipation
The client is encouraged to drink plenty of fluids, eat a diet high in fiber, and
exercise regularly.
 56
AppleRN Classes

Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin

Hemorrhoids
A warm sitz bath and application of topical ointments will help relieve discomfort.
MEDS : NSAIDs must be avoided during pregnancy
Especially during the third trimester due to the risk of causing premature closure
of the ductus arteriosus in the fetus.
Tylenol is a safe alternative for mild fever and pain. ACE/ARB Should be avoided-
Fetal cardiac and renal problems. No Live vaccines.
Warning Signs of pregnancy
Gush of fluid from the vagina (rupture of amniotic fluid) prior to 37 weeks of
gestation
Vaginal bleeding (placental problems such as abruption or previa)
Abdominal pain (premature labor, abruptio placentae, or ectopic pregnancy)
Changes in fetal activity (decreased fetal movement may indicate fetal distress)
Persistent vomiting (hyperemesis gravidarum)
Severe headaches, edema, epigastric pain - (gestational hypertension)
Elevated temperature (infection). Dysuria (urinary tract infection)
Adolescent pregnancy
Major concerns : Poor nutritional status : Normal weight gain during pregnancy –
25-35 lb
Emotional and behavioral difficulties , Lack of social support systems
Increased risk of stillbirth , Low–birth-weight infants , Fetal mortality
 57
AppleRN Classes

High Risk Antenatal

Diagnostic and Therapeutic Procedures
Ultrasound – to determine the presence of a viable or dead fetus, or partial or
complete products of conception within the uterine cavity.
Dilation and curettage (D&C) – to dilate and scrape the uterine walls to remove
uterine contents for inevitable and incomplete abortions.
Dilation and evacuation (D&E) – to dilate and evacuate uterine contents after 16
weeks of gestation.
Prostaglandins and oxytocin (Pitocin) – to augment or induce uterine contractions
and expulse the products of conception
Ectopic Pregnancy
Abnormal implantation of a fertilized ovum outside of the uterine cavity.
Usually in the fallopian tube, which can result in a tubal rupture causing a fatal
hemorrhage.
Unilateral stabbing pain and tenderness in the lower-abdominal quadrant.
Referred shoulder pain due to blood in the peritoneal cavity irritating the
diaphragm or phrenic nerve after tubal rupture.
Nursing Actions: Replace fluids, and maintain electrolyte balance. (to avoid
shock). Provide client education and psychological support.
HYPEREMESIS GRAVIDARUM
Excessive nausea and vomiting past 12 weeks and results in a 5% weight loss,
electrolyte imbalance, and ketosis
Nursing Care : Monitor the client’s I&O. (urine sp.gravity – increases if
dehydration)
Give the client IV fluids. Assess the client’s skin turgor and mucous membranes.
Monitor the client’s vital signs (hypotension, tachycardia). Monitor the client’s
weight.
 58
AppleRN Classes

Have the client remain NPO for 24 to 48 hr.

Gestational Diabetes
Screen all pregnant women between 24 th- 28th week of gestation
Can be treated by diet alone; some may need insulin
During second and third trimesters, maternal insulin needs increase (hormones –
insulin resistance)
Fetus produces own insulin and pulls glucose from mother, predisposing mother
to hypoglycemia
Risk for polyhydramnions, eclampsia, dystocia, infections (yeast)
Newborn infant of diabetic mother at risk for
hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia,
congenital anomalies
Assessment
Signs similar to those of diabetes mellitus in nonpregnant women (polyuria,
polydipsia, polyphagia)
Monitor the client’s blood glucose. Monitor the fetus. Administer insulin
Client education: Instruct the client to perform daily kick counts.
Educate the client about diet and exercise.
Instruct the client about self-administration of insulin
Signs : Hypoglycemia (nervousness, headache, weakness, irritability, hunger,
blurred vision, tingling of mouth or extremities)
Hyperglycemia (thirst, nausea, abdominal pain, frequent urination, flushed dry
skin, fruity breath)
Gestational Trophoblastic Disease
Hydatidiform Mole - Molar Pregnancy
swollen, fluid-filled, and takes on the appearance of grape-like clusters.
 59
AppleRN Classes

Excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels may be

present
Rapid uterine growth more than expected for the duration of the pregnancy due
to the over proliferation of cells
An ultrasound reveals a dense growth with characteristic vesicles, but no fetus in
utero.
Nursing Actions: Measure fundal height. Symptoms of preeclampsia may be
present
Assess vaginal bleeding and discharge. RhO(D) immune globulin (RhoGAM) to the
client who is Rh-negative
Preterm Labor
Occurs after 20 th week, but before 37th week of gestation.
Risk Factors – H/O preterm delivery or cervical surgery (cone biopsy), mother age
(<17 or >35), current infection (dental/UTI), substance abuse, malnutrition
Contractions occur more frequently than every 10 minutes, last 30 seconds or
longer, persist
Assessment : Rupture of amniotic membranes
Interventions : Maintain left lateral position, Monitor fetal status.
Betamethasone to hasten surfactant production. Administer tocolytics (to stop
contractions)
Ritodrine, Turbutaline, Mag sulphate, Nefidipine, Indomethacin
Client Education
Immediate Actions for pt experiencing suspected premature labor (at home)
1. Empty Bladder
2. Left Lying Position
3. Drink 3-4 cups of water
4.Palpate abdomen to assess contraction, 10 mts apart or closer- contact doc
 60
AppleRN Classes

5. rest for 30 mts and slowly resume activity if symptoms disappear. If symptoms
persist upto 1 hr, contact doc
Tocolytics : Contraindications for tocolytics
Active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis,
greater than 34 weeks of gestation, and acute fetal distress.
Betamethasone : pulmonary edema & hyperglycemia
Indomethacin : PP hemorrhage, blood-tinged sputum
Magnesium sulfate toxicity: -BLURP
Premature Rupture of Membranes
Rupture of the amniotic sac before onset of true labor, regardless of length of
gestation
Assessment : Nitrazine test and Fern test positive, Presence of pool of fluid near
cervix
Interventions: May remain in hospital or at home on bed rest /activity limitations
NO PV (unless absolute necessary, sterile technique) , check temp Q 2hrs,
hydration
If home : Educate to avoid sexual intercourse, insertion of anything into vagina
Avoid breast stimulation if gestation is preterm , Monitor temperature; report
temperature of 100° F immediately, Administer antibiotics to mother as
prescribed
Placenta Previa
Improperly implanted placenta in the lower uterine segment, near or over the
internal cervical os
May be total, partial, marginal, or low-lying, depending on how much of os is
covered
Assessment : Sudden onset of painless, bright red vaginal bleeding
 61
AppleRN Classes

Meds : Corticosteroids, such as betamethasone (Celestone), promote fetal lung

maturation if delivery is anticipated (cesarean birth).
Have oxygen equipment available in case of fetal distress.
Interventions : Monitor maternal and fetal status, Assess for bleeding, leakage,
or contractions
Maintain mother in side-lying position as prescribed
Monitor amounts of bleeding; assess for development of shock
Refrain from performing vaginal exams (may exacerbate bleeding).
Administer IV fluids, blood products, and medications as prescribed
Mother – OK to be home if no bleeding and baby’s status is good
Pelvic rest – No PV/No sexual activity – injury to placenta
Plan for C-section. Additional ultrasounds will be needed to assess progress
Abruptio Placentae
Premature separation of the placenta from the uterine wall after twentieth week
of gestation, before fetus is delivered
A complication associated with gestational hypertension
Assessment : Dark red, painful vaginal bleeding , Uterine rigidity
Interventions : Monitor maternal and fetal status, Maintain bed rest; administer
oxygen
Prepare for delivery of fetus as quickly as possible; vaginal delivery preferred but,
because of emergency, cesarean section may be done
Monitor maternal and fetal status, Maintain bed rest; administer oxygen
Palpate the uterus for tenderness and tone. Assess FHR pattern. Administer IV
fluids, blood products, and medications : Corticosteroids to promote fetal lung
maturity
Administer oxygen 8 to 10 L/min via face mask.
 62
AppleRN Classes

Assess urinary output and monitor fluid balance.

Prepare for delivery of fetus as quickly as possible; vaginal delivery preferred but,
because of emergency, cesarean section may be done.
Placenta accrete
The placenta implantation in the myometrium (normal implantation is in the
endometrium).
During labor and delivery, placenta accrete can results in life-threatening
hemorrhage and retained placental fragments
These clients should have a type and crossmatch on the chart in case an
immediate blood transfusion is needed. They also require two large bore IV site
Supine Hypotensive Syndrome (Vena Cava Syndrome)
Occurs when venous return to heart is impaired by weight of uterus; results in
partial occlusion of vena cava and descending aorta and in reduced cardiac
return, cardiac output, blood pressure
Assessment : Faintness, lightheadedness, vertigo, hypotension, fetal distress
Interventions
Position client in lateral recumbent position to shift weight of fetus off inferior
vena cava
Monitor maternal and fetal vital signs, Toxoplasmosis (add to your notes)
Toxoplasmosis is a disease due to Toxoplasma gondii, a parasite that infects
humans via cat feces or ingestion of undercooked meat.
The parasite can be passed from mother to baby in utero : cause significant
damage to the growing fetus - stillbirth or serious fetal malformations.
Pregnant clients should be advised to stay away from a litter box or cat feces to
reduce toxoplasmosis risk.
HIV/AIDS
Routine laboratory testing in the early prenatal period.
 63
AppleRN Classes

Procedures, such as amniocentesis and an episiotomy, should be avoided due to

the risk of maternal blood exposure.
Avoid internal fetal monitors, vacuum extraction, and forceps during labor.
Administration of injections and blood testing should not take place until the first
bath is given to the newborn.
Instruct the client not to breastfeed
Postpartum period: If mother immuno compromised, place in protective isolation
Antiviral prophylaxis (retrovir -Zidovudine) may be given to mother
Administer retrovir at 14 weeks of gestation, throughout the pregnancy, and
before the onset of labor or cesarean birth.
Administer retrovir to the infant at delivery and for 6 weeks following birth.
Group B, Streptococcus ß-Hemolytic
GBS is a bacterial infection that can be passed to a fetus during labor and delivery.
Positive GBS may have maternal and fetal effects, including premature rupture of
membranes, preterm labor and delivery, chorioamnionitis, infections of the
urinary tract, and maternal sepsis.
Vaginal and rectal cultures are performed at 36 to 37 weeks of gestation.
Administer intrapartum antibiotic prophylaxis (IAP). (Penicillin)
Client who delivered previous infant with GBS infection
Client who has GBS bacteriuria during current pregnancy
Client who has a GBS-positive screening during current pregnancy
Client who has unknown GBS status who is delivering at less than 37 weeks of
gestation
Client who has maternal fever of 38° C (100.4° F)
Client who has rupture of membranes for 18 hr or longer
 64
AppleRN Classes

Bleeding During Pregnancy

Vaginal bleeding during pregnancy is always abnormal.
Spontaneous Abortion: when a pregnancy is terminated before 20 weeks of
gestation (the point of fetal viability) or a fetal weight less than 500 g.
Abortion : Pregnancy that ends before twentieth week of gestation,
spontaneously or electively
Spontaneous: Pregnancy ends because of natural causes
Induced: Therapeutic or elective reasons for terminating pregnancy
Threatened: Developing spontaneous abortion
Inevitable: Threatened loss that cannot be prevented
Incomplete: Loss of some products of conception and retention of others
 65
AppleRN Classes

Oligohydramnios
Low amniotic fluid volume.
Decreased fundal height
Major complications
Pulmonary hypoplasia - due to the lack of normal alveolar distension by amniotic
fluid- baby might need resuscitation.
Umbilical cord compression -Monitor for variable decelerations
Anemia
Predisposes client to postpartum infection
Assessment: Fatigue, headache, pallor, tachycardia, hemoglobin level lower than
10 mg/dL, hematocrit level lower than 30 g/dL
Interventions: Monitor hemoglobin and hematocrit levels every 2 weeks
Instruct client to take iron and folic acid supplements
 66
AppleRN Classes

Medications - Anemia
Ferrous sulfate (325 mg) iron supplements twice daily
Instruct the client to take the supplement on an empty stomach.
Encourage a diet rich in vitamin C-containing foods to increase absorption.
Suggest that the client increase roughage and fluid intake in diet to assist with
discomforts of constipation.
Iron dextran (Imferon) : Used in the treatment of iron-deficiency anemia when
oral iron supplements cannot be tolerated by the client who is pregnant.
Ferrous sulfate (iron) supplementation may also cause constipation.
High-fiber diet, fluids, exercise and Bulk-forming fiber supplements will help
Gestational Hypertension (GH)
Acute hypertensive state that develops after twentieth week of gestation
Hypertensive disorders of pregnancy whereby the woman has an elevated blood
pressure at 140/90 mm Hg or greater recorded at least twice, 4 to 6 hr apart, and
within a 1-week period, after the 20th week of pregnancy
Condition can be mild or severe; can progress to eclampsia, characterized by
presence of seizures
associated with placental abruption, kidney failure, hepatic rupture, preterm
birth, and fetal and maternal death.
Predisposing conditions: Chronic conditions, such as renal disease, hypertension,
diabetes mellitus
Primigravida, especially women younger than 19 years or older than 40 years of
age
Assessment
Mild: Elevated blood pressure, usually 15 to 30 mm Hg above baseline;
weight gain of 1 lb/week or more in last trimester; mild, generalized edema;
proteinuria of 1+ to 2+
 67
AppleRN Classes

Severe: Severe hypertension, systolic blood pressure at least 160 mm Hg or

diastolic at least 110 mm Hg; massive, generalized edema; weight gain;
proteinuria 3+ to 4+; oliguria; visual disturbances; headache; HELLP syndrome of
laboratory findings—hemolysis, elevated liver enzymes, low platelets
Eclampsia: Characterized by generalized seizures
HELLP syndrome
Severe preeclampsia involving hepatic dysfunction.
HELLP syndrome is diagnosed by laboratory tests.
H – hemolysis resulting in anemia and jaundice
EL – elevated liver enzymes resulting in elevated alanine aminotransferase (ALT)
or aspartate transaminase (AST), epigastric pain, and nausea and vomiting
LP – low platelets (less than 100,000/mm3), resulting in thrombocytopenia,
abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly
disseminated intravascular coagulopathy (DIC)
Magnesium sulfate.
Medication of choice for prophylaxis or treatment to lower blood pressure and
depress the CNS.
Nursing Considerations : Use an infusion control device to maintain a regular flow
rate.
Inform the client that she may initially feel flushed, hot, and sedated with the
magnesium sulfate bolus.
Monitor the client’s blood pressure, pulse, respiratory rate, deep-tendon reflexes.
Monitor level of consciousness, urinary output (indwelling urinary catheter for
accuracy),
Monitor for presence of headache, visual disturbances, epigastric pain
Monitor uterine contractions, and FHR and activity.
Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary
output of 30 mL/hr or greater.
 68
AppleRN Classes

Therapeutic magnesium level : 4-7 mEq/L

Monitor the client for signs of magnesium sulfate toxicity.
BLURP: decreased blood pressure; decreased level of consciousness decreased
urinary output; respiratory depression; depressed or absent patellar reflex
Contraindications for Magnesium : Acute fetal distress , Vaginal bleeding and
Cervical dilation greater than 6 cm
If magnesium toxicity is suspected: Immediately discontinue infusion.
Administer antidote calcium gluconate. Prepare for actions to prevent
respiratory or cardiac arrest.
Complications of GH
Hematological conditions, such as disseminated intravascular coagulation,
thrombocytopenia
Placental conditions, such as abruptio placentae, placental insufficiency
Intrauterine growth restriction, intrauterine fetal death
Interventions for mild hypertension: Close monitoring of blood pressure,
Frequent rest periods, Administer antihypertensives as prescribed, Monitor renal
function, especially for proteinuria, intake and output
Interventions for mild preeclampsia
Implement interventions as noted for mild hypertension
Monitor neurological status, especially for signs of impending seizure
Monitor for deep tendon reflexes, presence of clonus
Monitor for HELLP: Laboratory diagnosis for severe preeclampsia characterized by
hemolysis, elevated liver enzyme levels, low platelet count
No added salt diet, with increase in dietary protein and carbohydrates
Interventions for severe preeclampsia
Implement interventions for mild hypertension and mild preeclampsia
Administer magnesium sulfate as prescribed
 69
AppleRN Classes

Monitor for signs of magnesium toxicity, including BLURP

Keep calcium gluconate antidote at bedside at all times
Eclampsia: Diagnosed when seizures occur
Provide care as with any seizure; monitor fetal heart rate and contractions
Administer magnesium sulfate as prescribed
Prepare for delivery of fetus
Discharge instructions
Maintain the client on bed rest, and encourage side-lying position.
Promote diversional activities.
Have the client avoid foods that are high in sodium (may not completely restrict
sodium – possibility of Hypovolemia and fetal distress)
Have high protein diet. Have the client avoid alcohol and limit caffeine.
Instruct the client to be adequately hydrated.
Maintain a dark quiet environment to avoid stimuli that may precipitate a seizure.
Maintain a patent airway in the event of a seizure. Administer antihypertensive
medications as prescribed.
 70
AppleRN Classes

Labor and Delivery

Lightening: Fetus descends into pelvis about 2 weeks before delivery
Leopold maneuvers – abdominal palpation of fetus
Braxton-Hicks contractions increase
True labor: Contractions increase in duration and intensity, Cervical dilation,
effacement are progressive
False labor Labor does not produce dilation, effacement, or descent
Contractions are irregular, without progression. Walking has no effect on
contractions; often relieves false labor

• Bishop score : Bishop score is a system for the assessment and rating
of cervical favorability and readiness for induction of labor. A higher
Bishop score- better chances of vaginal birth
• For nulliparous women, a score ≥8 usually indicates that induction will be
successful
 71
AppleRN Classes

•
• Assessment during Labor (initial)
– BP, PR, RR - q 1 hr, Temp – Q 2 hr
– Contractions q 30 mts (q15 mts – high risk)
• Ice chips and clear liquids – prevent dehydration
• Position comfortably: Relaxation Techniques
• Asessment during Labor (later)
– BP, PR, RR, FHR - q 5 -15mts.
– Contraction - continuous
 72
AppleRN Classes

– Uterine fundus tone

• Episiotomy : document degree (1,2,3,4)
Fetal Heart Rate Monitoring
Normal FHR 120 to 160 beats/min
If change occurs, turn mother to left side, administer oxygen as prescribed
Accelerations may occur with fetal movement or contractions
Early decelerations occur during contractions when fetal head is pressed against
woman’s pelvis; require no intervention
Late decelerations usually associated with impaired placental exchange or
uteroplacental insufficiency; require interventions to improve placental blood
flow and fetal oxygenation, including immediate delivery of fetus
Variable decelerations usually caused by umbilical cord compression; require
change in maternal positioning
Pain Management
• Nonpharmacological : Position changes, Hydrotherapy
– Breathing techniques & Relaxation
• Pharmacological :- Should be minimal risk.
– Lumbar Epidural block : monitor urinary output (retention may
occur). Monitor BP( maternal hypotension)
• Pudendal nerve block – local anesthesia (Lidocane) to pudendal nerve areas
(perineal area)
• help to relieve perineal pressure (no effect on contraction)
• works quickly, better in later stages of delivery
• All systemic drugs cross placental barrier
 73
AppleRN Classes

Systemic analgesia in L&D

Given at peak of contraction- blood flow to baby is minimum at this time –
so medicine effect reach baby slower
• Two major drugs used
– Butorphanol tartrate (Stadol) Nalbuphine hydrochloride (Nubain).
– Maximum 3 doses only – have ceiling effect – wont be effective after
3 doses
– Do not use for mothers with opioid abuse history
• Parameters for safer administration
– Stable maternal vital signs
– Fetus with heart rate of 110-160 beats/min
– Well-established labor contractions
– Cervix dilated to at least 4-5 cm in primipara and 4 cm in multipara
Dystocia
Difficult labor that is prolonged or more painful
May occur because of problems caused by uterine contractions, fetus, or bone
and tissues of maternal pelvis
Assessment : Fetal distress, Lack of progress in labor
Interventions
Assess fetal heart rate (FHR); monitor for distress, Monitor uterine contractions
Assess for prolapse of cord after rupture of membranes
 74
AppleRN Classes

Fetal Positions

• ROA and LOA are most optimal for delivery

• ROP and LOP : mother have more back pain (back labor)
• Most common malposition. Apply counterpressure to the client's sacrum
during contractions - alleviate back pain
• Firm, continuous pressure is applied with a nurse’s closed fist, heel of the
hand, or other firm object like a back massager.
• ROT or LOT – Dystocia – might need manual rotation of baby during labor
Breech Position

⮚ Fetal feet or buttocks presenting first in the maternal pelvis

⮚ No back pain

⮚ Complications: Ineffective dilation of the cervix – dystocia. Increased risk of

umbilical cord prolapses.
Prolapsed Cord
Umbilical cord displaced between presenting part and amnion or protrudes
through cervix, causing compression, compromising fetal circulation
 75
AppleRN Classes

Assessment : Visible umbilical cord, Irregular and slow FHR

Interventions: Relieve cord pressure immediately, call for help.
Turn mother side to side or elevate her hips to shift fetal presenting part toward
her diaphragm
Elevate fetal presenting part lying on cord by applying finger pressure with sterile
gloved hand
Do not attempt to push cord into uterus
Monitor FHR and for signs of hypoxia, Administer oxygen to mother as prescribed
Prepare for emergency cesarean birth as prescribed
Amniotomy
Amniotomy refers to the artificial rupture of membranes (AROM)
After procedure – mother in upright position to facilitate drainage of fluid
Note amniotic fluid color, amount, and odor. Yellowish-green fluid :
meconium in utero
Strong, foul odor : infection
Complications : Prolapsed cord , Fetal bradycardia due to cord
compression. Infection – monitor temp every 2 hrs
Rupture of Uterus
Complete or incomplete separation of uterine tissue as result of tear in wall of
uterus from stress of labor
Assessment : Fetus palpated outside uterus (complete rupture)
Interventions
Monitor for and treat signs of shock; administer oxygen, intravenous fluids, blood
products as prescribed
Prepare mother for cesarean section or hysterotomy with hysterectomy as
prescribed
 76
AppleRN Classes

Provide emotional support for client, partner, family

Vaginal birth after cesarean (VBAC) :
A client with a history of previous cesarean delivery attempting a vaginal delivery
Risk- uterine rupture – Monitor for Nonreassuring fetal heart pattern (ie, variable
or late decelerations, bradycardia).
Maternal manifestations :a change in uterine shape, severe abdominal pain,
and cessation of uterine contractions.
Signs of hemorrhage and hypovolemic shock
Amniotic Fluid Embolism
Escape of amniotic fluid into maternal circulation; debris containing amniotic fluid
deposits in pulmonary arterioles, usually fatal to mother
Assessment
Abrupt onset of respiratory distress, chest pain; cyanosis; seizures; heart failure,
pulmonary edema; fetal bradycardia, distress
Interventions: Institute emergency measures to maintain life
Administer oxygen 8 to 10 L/min; prepare for intubation, mechanical ventilation
Fetal Distress
FHR lower than 120 or more than 160 beats/min
Meconium-stained amniotic fluid, Fetal hyperactivity
Progressive decrease in baseline variability, Severe variable decelerations, late
decelerations
Interventions: Place mother in lateral position; elevate legs
Administer oxygen at 8 to 10 L/min via face mask as prescribed
Discontinue oxytocin (Pitocin) if infusing as prescribed, Monitor maternal and
fetal vital signs
Prepare for emergency cesarean section as prescribed
 77
AppleRN Classes

Special condition
Maternal hypotension after an epidural anesthesia: Treatment
STOP
1. Stop pitocin if infusing.
2. Turn the client on the left side.
3. Oxygen - Administer oxygen.
4. Push IV fluids - If hypovolemia is present
Intrauterine fetal demise
Also called still birth
Perinatal bereavement process. Help bathe and dress the infant
Provide privacy. Encourage to view and hold the body before discharge to the
funeral home
Encourage family members to name the infant, Obtain handprints and
footprints of baby
Cut a lock of the infant's hair for keepsake. Photograph the infant - if parents
prefer
Notify organ procurement organization as per policy
 78
AppleRN Classes

Post Partum Care

Starts immediately after delivery; usually completed around sixth week following
delivery.
Involution: Rapid decrease in size of uterus as it returns to pre pregnant state;
fundal height decreases one fingerbreadth (1 cm) per day.
Boggy uterus (soft and relaxed) – risk for hemorrhage
Afterpains are normal
First 48 hrs pp is greater risk for CV patients
PP diuresis – 2 to 3 L more output first day- normal
Full bladder – increase risk for bleeding
Lochia
Discharge from uterus; consists of blood from vessels of placental site and debris
Rubra (red) occurs from delivery to day 3
Serosa (brownish-pink) occurs from days 4 to 10
Alba (white) occurs from days 10 to 14
Amt can increase by exertion or breast feeding.
Comfort: Ice to perineum – 20 mts on 10 mts off for first 24 hrs. Sitz bath prn
Abnormal Lochia
Excessive - Saturation of a perineal pad in 15 min or less or pooling of blood under
the client’s buttocks. Possibly indicating a cervical or vaginal tear.
Numerous large clots and excessive blood loss (saturation of one pad in 15 min or
less), which may indicate hemorrhage.
Foul odor, which is suggestive of infection.
Persistent lochia rubra in the early postpartum period beyond day 3 - Retained
placental fragments.
 79
AppleRN Classes

Continued flow of lochia serosa or alba beyond the normal length of time may
indicate endometritis, especially if it is accompanied by fever, pain, or abdominal
tenderness.
Hyperthermia common in first 24 hours
Bradycardia common in first week
RHO(D) immune globulin (RhoGAM) : administered within 72 hr to women who
are Rh-negative and gave birth to infants who are Rh-positive to prevent
sensitization in future pregnancies.
Facilitate bonding with newborn
Perineal discomfort: Occurs as result of delivery
Apply ice packs to perineum during first 24 hours
After first 24 hours, apply warmth via sitz bath
Episiotomy: Educate client to perform perineal care after voiding
Encourage use of analgesic spray, analgesics PO as prescribed
Focused postpartum assessment
B – Breasts
U – Uterus (fundal ht, placement, consistency)
B – Bowel and GI function
B – Bladder function
L – Lochia (color, odor, consistency, and amount [COCA])
E – Episiotomy/ Emotional Status
H – Homan’s sign : Vital signs, to include pain assessment , Teaching needs
Warning signs to report
Bleeding – bright red/large clots , Temp > 100.4 F, Chills, Excessive Pain,
Red/Warm breast
 80
AppleRN Classes

Red episiotomy , Foul smelling lochia, Urinary retention, Calf pain or

tenderness or swelling
Breast-feeding
Assess LATCH : Latch achieved by infant, Audible swallowing, Type of nipple
(Flat/inverted)
Comfort of mother, Help given to mother during nursing
Cracked nipples: Expose nipples to air 10 to 20 minutes after feeding; rotate
position of newborn for each feeding
Breast Engorgement
May occur on the third or fifth postpartum day,
Apply cold compresses 15 min on and 45 min off.
Breast-feed frequently; apply warm packs before feeding; apply ice packs
between feeding to increase milk flow and promote the letdown reflex.
Fresh, cold cabbage leaves can be placed inside the supporting bra.
Mild analgesics may be taken for pain and discomfort of breast engorgement.
Cystitis
Infection of bladder
Assessment: Dysuria; lower abdominal pain; increased frequency of urination;
CVA tenderness; fever; proteinuria, hematuria, bacteriuria, white blood cells
(WBCs) in urine
Interventions: Palpate bladder for distention. Obtain urine for culture and
sensitivity as prescribed
Institute measures to assist client to void, such as running water over perineum
Force fluids to 3000 mL/day, if not contraindicated
Administer antibiotics as prescribed, Instruct client in methods of prevention of
cystitis
 81
AppleRN Classes

Hematoma
Localized collection of blood into tissues of reproductive tract after delivery
Assessment : Sensitive, bulging mass in perineal area, discolored skin
Potential for development of shock: Monitor vital signs, presence of abnormal
pain, intake and output, signs of infection
Place ice packs at hematoma site as prescribed , Administer analgesics as
prescribed
Administer blood products as prescribed. Prepare client for incision and
evacuation of hematoma if necessary
Hemorrhage
Bleeding of 500 mL or more following delivery.
Can be caused by uterine atony- inability of the uterine muscle to contract
adequately after birth
Assessment: First 24 hours, early hemorrhage; after first 24 hours, late
hemorrhage
Interventions for signs of hemorrhage or shock
Massage fundus, but no over massage, Monitor vital signs every 5 to 15 minutes
Assess, estimate blood loss by pad count, Monitor hemoglobin and hematocrit
levels
Prepare for administration of oxytocin (Pitocin) and/or blood transfusions if
prescribed
Infection
Any infectious process of reproductive organs that occurs within 28 days of
delivery or abortion
Assessment: Chills , Anorexia , Pelvic discomfort or pain , Vaginal discharge ,
Elevated WBC count, Fever
Risk Factors
 82
AppleRN Classes

a history of previous infections, excessive number of vaginal examinations,

cesarean births,
prolonged rupture of the membranes, prolonged labor, trauma, and retained
placental fragments.
Interventions- Infection: Monitor vital signs every 2 to 4 hours
Provide comfort measures, including position changes, providing warmth
Isolate newborn from mother only if mother can infect baby
Provide high-calorie, high-protein diet; encourage fluid intake of 3000 to 4000
mL/day
Encourage frequent voiding; monitor intake and output
Administer antibiotics as prescribed, following obtaining cultures
Mastitis
Inflammation of breast as result of infection, usually occurring in breast-feeding
mothers, 2 to 3 weeks after delivery
Assessment : Localized heat and edema , Pain , Fever, Complaints of flu-like
symptoms
Interventions: Instruct mother in good hand washing and breast hygiene
techniques, Promote comfort. Maintain lactation in breast-feeding mothers
Encourage manual expression of milk or use of breast pump every 4 hours
Encourage use of supportive bra, to be worn at all times, Administer analgesics,
antibiotics, as prescribed
Others
Thrombophlebitis and Pulmonary Embolism: The care is same as any medical
patient with PE and DVT(both are discussed in detail under hematology)
 83
AppleRN Classes

Newborn care
Initial Care of the Newborn
Monitor for nasal flaring, grunting, retractions, abdominal respirations
Monitor vital signs, signs of hypothermia or hyperthermia
Interventions : Suction mouth and nares , Dry newborn , Stimulate crying
Maintain temperature stability , Keep newborn with mother to facilitate bonding
Position newborn on side or abdomen or in modified Trendelenburg’s position
Ensure newborn’s proper identification
Footprint newborn and fingerprint mother as per agency policy
Place matching bracelets on mother and newborn
prophylactic eye ointment - Erythomycin
The greatest risk to the newborn is cold stress- cover the baby.
High risk for hemorrhagic disorders : Administer intramuscular vitamin K
(AquaMEPHYTON) to neonate
APGAR
Apgar scoring system
Apgar score at 1 minute and 5 minutes, scoring from 0 (very poor) to 2 (excellent)
in following areas as heart rate, respiratory rate, muscle tone, reflex irritability,
skin color
Apgar scoring interventions
 84
AppleRN Classes

Epstein’s pearls – small white specks on gum

Skin : Presence of vernix caseosa and lanugo , Presence of milia, dry peeling skin,
acrocyanosis
Potential presence of ecchymoses, petechiae, Harlequin sign, birthmarks
Abdomen : Umbilical cord with three vessels: two arteries, one vein
Cardiovascular system : 1-minute apical pulse, especially assessing for murmurs
Normal heart rate, 120 to 160 beats/min
Respiratory system: Normal respiration rate, 30 to 60 breaths/min
Signs of respiratory distress, including nasal flaring, grunting, cyanosis,
bradycardia, apnea
Gestational age assessment
Performed within 2 to 12 hr of birth.
Expected reference ranges of physical measurements
Weight – 2,500 to 4,000 g Length – 45 to 55 cm (18 to 22 in)
Head circumference – 32 to 36.8 cm (12.6 to 14.5 in)
Chest circumference – 30 to 33 cm (12 to 13 in)
 85
AppleRN Classes

New Ballard Scale – A newborn maturity rating scale that assesses neuromuscular
and physical maturity.

Physiological versus pathological jaundice

Physiological (also known as normal or milk jaundice) jaundice
occurs after first 24 hours in full-term neonates, first 48 hours in premature
neonates
Benign resulting from normal newborn physiology of increased bilirubin
production due to the shortened lifespan and breakdown of fetal RBCs and liver
immaturity).
Not associated with any other abnormality
Pathological jaundice : Occurs in first 24 hours; may be caused by early
hemolysis of red blood cells.
Associated with other diseases, or with anemia and hepatosplenomegaly
Cord Care
Before discharge, the cord clamp is removed.
Prevent cord infection by keeping the cord dry, and keep the top of the diaper
folded underneath it.
 86
AppleRN Classes

Sponge baths are given until the cord falls off, which occurs around 10 to 14 days
after birth. Tub bathing and submersion can follow.
Cord infection (complication of improper cord care) can result if the cord is not
kept clean and dry.
Monitor for symptoms of a cord that is moist and red, has a foul odor, or has
purulent drainage.
Notify the provider immediately if findings of cord infection are present.
Teaching : Infant abduction : Nurse’s role is protection of newborn from
abduction
Maintain security measures (e.g., locked units) as per agency policy
Check visitors for identification as per agency policy
If locked door alarm goes off, respond quickly as per agency policy
Cord care:
Circumcision: Teach mother to clean penis after each voiding by squeezing warm
water over penis
Uncircumcised newborn: Instruct mother not to pull back on foreskin

• Expected weight loss of baby – less than 6% in first few days - Loss of fluids
More than 7% weight loss- malnutrition/ disease/ need evaluation
• Stool – Breast fed baby – yellow/seedy . Bottle fed baby – brownish color
• Breast feeding – need to be done frequently – 2- 3hrs, 15-20 mts each side
 87
AppleRN Classes

High Risk Newborn

Preterm Infant : Thin skin with visible blood vessels , minimal subcutaneous fat;
jaundiced, weak reflexes, lanugo, Undescended testes in boys, narrow labia in
girls
Interventions : Vital signs : Prevent Cold Stress , Give oxygen
Monitor I/O, electrolytes, daily weight
Handle newborn carefully, changing position Q 1 to 2 hr. Avoid exposure to
infections
Preterm Infant – hypothermia . Increased risk for hypothermia
No Brown Adipose Tissue to make heat (Special fat cells -BAT-developed during
third trimester to help neonate produce heat)
Neonates are unable to generate heat by shivering due to their lack of muscle
tissue and immature nervous systems – So BAT helps – But not in preterm babies
Maintain neutral thermal environment
Cold stress
More metabolism to increase heat – more oxygen demand – more chance of
hypoxia
Clinical manifestations : Neurological : irritability or lethargy
Cardiovascular - bradycardia
Respiratory - tachypnea early, followed by apnea and hypoxia
Gastrointestinal - high gastric residuals, emesis, hypoglycemia
Musculoskeletal - hypotonia, weak suck and cry
Post-term Newborn
Born after 42 week of gestation
Hypoglycemia; parchment-like skin without lanugo; long fingernails, more scalp
hair; long, thin body due to loss of fat and muscle in extremities; meconium
staining.
 88
AppleRN Classes

Interventions : Provide normal newborn care,

Monitor for meconium aspiration, hypoglycemia
The Addicted Newborn
Newborn who has become passively addicted to drugs that have passed through
placenta
Addicting drugs : Heroin, Methadone , Cocaine
Withdrawal symptoms : within 24-48 hours after birth.
Clinical manifestations of withdrawal in infants include irritability, jitteriness, high-
pitched cry, sneezing, diarrhea, vomiting, and poor feeding
Addicted Newborn Care : Monitor vital signs – Respiratory & Cardiac
Hold newborn firm and close to body during feeding and when giving care .
Swaddle infant. Provide small, frequent feedings as prescribed.
Monitor intake and output, give IV.
Reduce environmental stimulation , Provide emotional support for mother
Fetal Alcohol Syndrome
Due by maternal alcohol use during pregnancy
Both physical and mental retardation
Assessment
Short, palpebral fissures; hypoplastic philtrum; short, upturned nose; flat midface;
thin upper lip; low nasal bridge; abnormal palmar creases; respiratory distress;
congenital heart defects; irritability; tremors; poor feeding; seizures
 89
AppleRN Classes

Monitor for respiratory distress , Position newborn on side to facilitate secretion

drainage
Suction PRN , Assess suck and swallow reflexes , Administer small feedings as
prescribed
Monitor intake and output , Monitor weight and head circumference , Decrease
environmental stimuli
Meconium Aspiration Syndrome
Aspiration can occur in utero or with first breath
Assessment: Signs of respiratory distress, Yellow-stained nails, skin, umbilical
cord
Interventions : Suctioning immediately after head is delivered
Exstrophy of the bladder
Congenital disorder – need surgical repair . Bladder exposed externally
Pre op- Place a protective film of plastic (Saran wrap) over the exposed bladder
It keep the tissue moist and prevent infection.
Hyperbilirubinemia
At any serum bilirubin level, appearance of jaundice during first day of life
indicates pathological process
 90
AppleRN Classes

Assessment
Jaundice; elevated serum bilirubin levels; hepatomegaly; poor muscle tone;
lethargy; poor suck reflex
Interventions : Monitor for presence of jaundice
Maintain well-hydrated status . Administer early, frequent feedings as
prescribed
Report any signs of jaundice in first 24 hours to physician
Physiological (also known as normal or milk jaundice) jaundice
Occurs after first 24 hours in full-term neonates, first 48 hours in premature
neonates
Benign resulting from normal newborn physiology of increased bilirubin
production due to the shortened lifespan and breakdown of fetal RBCs and liver
immaturity).
Not associated with any other abnormality
Pathological jaundice
Occurs in first 24 hours; may be caused by early hemolysis of red blood cells.
Associated with other diseases, or with anemia and hepatosplenomegaly
Phototherapy
Expose as much of newborn’s skin as possible, except for shielding eyes and
genital area
Remove shields, patches at least once per shift and assess eyes for infection or
irritation
Monitor skin temperature frequently. Assess for dehydration. Increase fluid
intake as prescribed
Educate parents that stools and urine may be green
Remove Q 4hrs, Reposition newborn Q2 hours . Provide stimulation to newborn
Turn off the phototherapy lights before drawing blood for testing.
 91
AppleRN Classes

Avoid applying lotions or ointments to the skin because they absorb heat and can
cause burns
TORCH Syndrome
Infections on the fetus or newborn caused by one of the following: toxoplasmosis;
other viruses; rubella; cytomegalovirus; herpes
Assessment findings : General symptoms for infections : temperature instability;
tachypnea;
Apnea; tachycardia; poor feeding; decreased muscle tone; lethargy; irritability
Down Syndrome
Trisomy 21. Flat facial profile. Upward slant to the eyes. Small ears, and a
protruding tongue, Hypotonia
Trisomy 18 (Edwards syndrome)
Trisomy 18 is a genetic disorder with a short life expectancy
Characterized by severe cardiac defects and multiple musculoskeletal deformities
Discuss end-of-life choices
There is no cure or treatment
Trisomy 13 (Patau syndrome) also results in early death.
Newborn of mother with AIDS
Consistent monitoring of fetus throughout pregnancy and in neonatal period if
mother is antibody-positive.
No immediate invasive procedures : No circumcision
Newborn can room with mother.
Administer zidovudine (AZT) as prescribed for first 6 weeks of life
Monitor for early signs of immune deficiency
Instruct mother on follow-up care for newborn
Vaccine : No Live Vaccine till HIV status confirmed, Give all other.
 92
AppleRN Classes

Newborn of Diabetic Mother

Neonate born to insulin-dependent mother or gestational diabetic mother
May lead to development of congenital anomalies, hypoglycemia,
hyperbilirubinemia, respiratory distress syndrome
Assessment
LGA : Large for gestational age newborn, Edema in face and cheeks
Signs of hypoglycemia, including twitching, jitteriness, lethargy, seizures;
hyperbilirubinemia
Signs of respiratory distress, including tachypnea, grunting, retractions, cyanosis,
and nasal flaring
Interventions
Monitor for signs of respiratory distress, hypoglycemia, hyper bilirubinemia
The normal range for serum glucose in a newborn at day 1 is 40-60 mg/dL
Obtain daily weight
Feed infant soon after birth with glucose in water, breast milk, or formula as
prescribed
Administer glucose IV as prescribed
Cleft palate
Baby unable to create suction and pull milk or formula from the nipple.
At risk for aspiration and inadequate nutrition
Feeding cleft lip baby: Hold upright position : aspiration risk
Tilt the bottle to fill nipple. Point it down and away from the cleft.
Use special bottles and nipples : Free flow of formula. Use a squeezable bottle -
Press to get more feed to baby. Burp more often
Feed slowly : over 20–30 minutes . Feed frequently : every 3–4 hours
 93
AppleRN Classes

Respiratory Distress Syndrome (RDS)

Serious lung disorder caused by immaturity and inability to produce surfactant,
resulting in hypoxia and acidosis
Assessment : Tachypnea , Flaring nares , Expiratory grunting , Retractions ,
Decreased breath sounds
Apnea , Pallor and cyanosis , Hypothermia , Poor muscle tone
Interventions on RDS
Monitor color, respiratory rate, degree of effort in breathing, arterial blood gases,
oxygen saturation
Support respirations; suction every 2 hours and PRN
Position newborn on side or back, with neck slightly extended
Administer surfactant replacement therapy into endotracheal tube. Surfactant
stabilizes the alveoli and helps increase oxygen saturation.
Administer respiratory therapy as prescribed
Provide nutrition as prescribed. NPO if R > 60
Encourage mother to pump breasts for future nutrition
Encourage bonding of parents and newborn
Sudden infant death syndrome (SIDS)
Leading cause of death among infants aged 1 month to 1 year.
Evidence from research
Maintain smoke-free environment (increased rate of SIDS with smokers in house)
Breastfeeding and keeping the infant's immunizations up to date reduced SIDS
Placing infants to sleep with a pacifier may reduce the risk of SIDS.
Child care practices that reduce the risk of SIDS
Place infants age less than 1 year on their backs to sleep on a firm surface.
The prone or side sleep position should never be used.
 94
AppleRN Classes

Infants should not share a bed with parents/caregivers.

Avoiding soft objects in infant's bed.
Tuck the cover (thin blanket) into the sides and bottom of the mattress
Avoiding bumper crib pads
Use sleep sack to lower the risk of suffocation and keep the infant warm while
preventing the head from being covered.
SIDS : No pillow, No soft toys, No bumper pads

Uterine Oxytocics
Stimulants-
Name Action Side Effect Nursing Role
oxytocin (Pitocin) Uterine Uterine rupture Preassess risk factors, such as
stimulants multiple deliveries. ››Monitor
increase the the length, strength, and
strength, duration of contractions. ›› Have
frequency, and magnesium sulfate on standby if
length of needed for relaxation of
uterine myometrium.Continuously
contractions monitor blood pressure and
pulse rate, uterine
hyperstimulation. Use infusion
pump, report fetal distress. •If
uterine hyperstimulation or non-
reassuring FHR occurs, stop
medication immediately, turn
client to side, infuse IV normal
saline, administer oxygen via
face mask ; notify physician
 95
AppleRN Classes

dinoprostone To promote Diarrhea; nausea, •Should not be given to clients

(Cervidil), cervical vomiting; fever; with significant cardiovascular
ripening and to chills; flushing; disease or history of asthma,
stimulate dysrhythmias; pulmonary disease, Before
uterine bronchoconstriction; administration, have woman
contractions. peripheral void, then maintain supine or
vasoconstriction side-lying position for 30 to 40
minutes after administration.
methylergonovine serious Hypertensive crisis Monitor for manifestations of
(Methergine) postpartum hypertensive crisis (headache,
hemorrhage nausea, vomiting, increased
blood pressure). Methergine is
for use only after, and not
during labor. Do not administer
before delivery of placenta
Tocolytic
Medications
terbutaline sulfate, uterine smooth Tachycardia, Given subcutaneous. Monitor
nifedipine, muscle palpitations, chest FHR, uterine contractions, pulse,
indomethacin relaxation. pain, Tremors, blood pressure, respiratory rate,
anxiety, headache lung sounds, and
daily weights. Limit fluid intake
to 1,500 to 2,400 mL/24 hr.
Med contraindicated for greater
than 34 weeks gestation, Fetal
distress, eclampsia, vaginal
bleeding
Opioid
Analgesics
meperidine decrease the Dry mouth, Nausea Provide ice chips, Administer
hydrochloride perception of and vomiting, antiemetic, Have nalaxone
(Demerol), pain without Tachycardia, available at delivary (for
butorphanol the loss of hypotension, neonatal depression), Monitor
(Stadol), nalbuphine consciousness. decreased fetal heart vital signs and fetal heart rate,
(Nubain) rate (FHR) variability, safety (sedation)
Neonatal depression
 96
AppleRN Classes

Magnesium •Central •Respiratory •Calcium gluconate is antidote.

Sulphate nervous system depression, Monitor for signs of magnesium
depressant and depressed deep toxicity
anticonvulsant; tendon reflexes, Monitor vital signs, especially
also causes hypotension, respirations, every 30 to 60
smooth muscle decreased urinary minutes
relaxation, thus output—symptoms Administer IV infusion via
decreasing of magnesium infusion pump or monitoring
blood pressure, toxicity device
Helps stop Monitor deep tendon reflexes
preterm labor, hourly
prevents and Do not administer if client’s
controls patellar reflex absent or
seizures in respiratory rate below 16
preeclamptic breaths/min, as prescribed
and eclamptic Monitor hourly intake and
clients output; and report hourly
output less than 30 mL
Betamethasone Corticosteroid; •Immunosuppressive •Monitor maternal vital signs;
increases to mother monitor mother for signs of
production of infection; monitor maternal
surfactant white blood cell count
Erythromycin (0.5% •Bacteriostatic •Cleanse neonate’s eyes before
Ilotycin) and and bactericidal instilling drops or ointment;
tetracycline (1%) ointments instill within 1 hour after
and/or eye delivery
drops . Prevent
infection by
Neisseria
gonorrhoeae
and Chlamydia
trachomatis
•Vitamin K necessary to help production of active prothrombin; newborns are
deficient in vitamin K for first 5 to 8 days of life because of lack of intestinal flora
necessary to absorb vitamin K Hyperbilirubinemia in newborn •Administer in
vastus lateralis muscle early in neonatal period. •Monitor for bruising, signs of
bleeding
 97
AppleRN Classes

Respiratory system
ABG: An arterial blood gas (ABG) is a blood test that measures the acidity (pH)
and the levels of oxygen and carbon dioxide in the blood
What are the main elements which help in interpreting ABG?
PH , HCO3 (Bicarbonate) and PCo2 (Partial pressure of carbon dioxide)
CO2 is considered as the “acid” part as it is the gas form of carbonic acid .
(Respiratory)
Bicarb is considered as “base”/Alkaline (Metabolic)
What are the normal values?
PH value = 7.35 to 7.45
HCO3 = 22-28
PaCo2 = 35-45
HCO3 Less than 22 = Acidosis HCO3 more than 28 = Alkalosis
PH Less than 7.35 = Acidosis PH more than 7.45 = Alkalosis
PaCO2 more than 45 = Acidosis. PaCO2 less than 35 = Alkalosis

Common Conditions
NG tube to continuous suction - metabolic alkalosis resulting from loss of acid.
 98
AppleRN Classes

Client who has late-stage salicylate poisoning – Metabolic Acidosis (acetylsalicylic

acid).
DKA – Metabolic Acidosis
Peptic ulcer disease (PUD) with excessive amounts of oral antacids – Metabolic
Alkalosis (anti acid – reduce acid – alkalosis)
Diarrhea or ileostomy – Metabolic Acidosis ( intestinal secretions, pancreatic
secretions are high in bicarbonate – alkali. So loss of alkali- leading to acidosis
Panic attack – Respiratory alkalosis (blow out Co2)
Drug addicts/sedated/pneumothorax/hemothorax – Respiratory Acidosis
(shallow breathing, holding on to Co2)
“compensation”
Compensation is the renal and respiratory adjustment to changes in PH. If PH is
normal, we can say that the body is compensated.
Respiratory system compensate by adjusting CO2 level by changing ventilation
(RR)
The renal system compensate by adjusting bicarbonate, producing more acidic or
alkaline urine.
If pH is normal and PaCO2 and HCO3- are both abnormal, then the patient is
compensated.
If all three values (pH, PaCO2 and HCO3- )are abnormal, then the patient is
partially compensated.
If pH is abnormal, and either PaCO2 or HCO3- are normal, then the patient is
uncompensated.
Adventitious Lung sounds and problems
Crackles (Rales) – On Inspiration – not continuous : Fluid filled in alveoli –
Pulmonary edema
Rhonchi - on expiration – continuous- indicate the presence of secretions in the
larger airway : Changes after cough or suctioning
 99
AppleRN Classes

Stridor – Upper airway obstruction – can hear without stethoscope

Wheezing – musical – asthma
Friction rub – pleural inflammation
Structures and Functions of Respiratory System
Blood Supply : Pulmonary – for gas exchange
Bronchial – for the structures- from bronchial artery ( branch of thoracic aorta) –
return through SVC
Pleura - The chest cavity lined with - parietal pleura . Lungs are lined with visceral
pleura. Space between : intrapleural space. Normally this space contains 20 to 25
mL of fluid -lubrication
Percussion sounds
Normal – Resonance
Pneumonia – Dullness due to consolidation
Pleural effusion – Dullness
Pneumothorax – Hyper-resonant
Emphysema – Hyper-resonant
Tactile fremitus is increased in pneumonia due to consolidation
Labs : ABG. Sputum –Do Rinse mouth first- avoid contamination
AFB –TB?– 3days, early morning- negative pressure room. Skin test – PPD.
Positive Indicate exposure to TB (not active disease) : Read result in 48 to 72 hrs.
Pulse oximetry : SpO2- 95 % or above in room air, COPD- 88% ok. Remove nail
polish, artificial nails to be removed.
PFT – Pulmonary Function Test
 100
AppleRN Classes

Oxygen administration

Hypoxia

Acute respiratory disorders

Rhinitis, Sinusitis, Influenza, and Pneumonia.
Rhinitis : Inflammation of the nasal mucosa
Caused by infection (viral or bacterial) or allergens.
The common cold (coryza)
Allergic rhinitis is commonly known as hay fever.
Excessive nasal drainage, runny nose (rhinorrhea) and nasal congestion
 101
AppleRN Classes

Diagnostic testing may include allergy tests to identify possible allergens.

Nursing Care
Encourage rest (8 to 10 hr/day) and increased fluid intake (at least 2,000 mL/day).
Encourage the use of a home humidifier or breathing steamy air after running hot
shower water.
Promote proper disposal of tissues. Cough etiquette (sneeze or cough into tissue,
elbow or shoulder and not the hands)
Medications – antihistamins, de-congesteants, glucocorticoid sprays
SINUSITIS
Sinusitis is an inflammation of the mucous membranes of one or more of the
sinuses, usually the maxillary or frontal sinus.
S/S: Facial pressure or pain (worse when head is tilted forward)
Nasal congestion, Headache, Cough, Bloody or purulent nasal drainage
Tenderness to palpation of forehead, orbital and facial areas, Low-grade fever
Diagnostic Procedures: CT scan or sinus x-rays
Nursing Care : Encourage the use of steam humidification, sinus irrigation, saline
nasal sprays, and hot and wet packs to relieve sinus congestion and pain.
Teach the client to increase fluid intake and rest. Discourage air travel, swimming,
and diving. Encourage cessation of tobacco use in any form.
Instruct the client on correct technique for sinus irrigation and self-administration
of nasal sprays.
INFLUENZA
Highly contagious acute viral infection. Example: H1N1 (“swine flu”) and H5N1
(“avian flu”).. Preventable by vaccine
S/S: Severe headache and muscle aches, Fatigue, weakness, Hypoxia, Severe
diarrhea and cough (avian flu)
 102
AppleRN Classes

Nursing Care: Maintain airborne and contact precautions for hospitalized clients
with pandemic influenza.
Provide saline gargles. Monitor hydration status, intake and output.
Administer fluid therapy as prescribed by the provider.
Monitor respiratory status.

Pneumonia
Pneumonia :- inflammatory process : produces excess fluid.
Triggered by infectious organisms or by the aspiration of an irritant, such as fluid
or a foreign object.
Immobility is a contributing factor in the development of pneumonia.
There are two types of pneumonia.
Community-acquired pneumonia (CAP) is the most common type and often
occurs as a complication of influenza.
Health care-associated pneumonia (HAP) has a higher mortality rate and is more
likely to be resistant to antibiotics. – VAP – Ventilator associated Pneumonia -
VAP Clinical manifestations : Purulent sputum, Positive sputum culture
Leukocytosis (12,000 mm3), Fever (>100.4 F), Chest x-ray changes - infiltrates
Laboratory Tests: Sputum culture and sensitivity
Obtain specimen before starting antibiotic therapy. Obtain specimen by
suctioning if the client is unable to cough.
The responsible organism is identified about 50% of the time.
CBC – Elevated WBC count (may not be present in older adult clients)
ABGs – Hypoxemia (decreased PaO2 less than 80 mm Hg)
Blood culture – To rule out organisms in the blood
Serum electrolytes – To identify causes of dehydration
 103
AppleRN Classes

Assessment : Crackles, Fever, chills, productive cough, dyspnea, and pleuritic

chest pain
Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is
increased when transmitted through consolidated versus normal lung tissue.
Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds
conducted through consolidated lung tissue.
Bacterial or viral (X ray – infiltrates/consolidation)
Fever, chills, chest pain, SOB, cough, crackle, wheezes
Meds -Antibiotics, analgesics, Steroids, bronchodilators.
oxygen, nutrition, fluids
Prevention in hospitalized patients – measures
Infection control, avoid crowded areas, Aspiration precautions
Early ambulation after procedures, Turn, Cough and deep breath, IS
Nutrition, Fluids, Immunization
Complications of pneumonia: Atelectasis, Risk of hypoxemia. (SOB)
The client has diminished or absent breath sounds over the affected area.
A chest x-ray shows an area of density. Bacteremia (sepsis)
This occurs if pathogens enter the bloodstream from the infection in the lungs.
Acute Respiratory Distress Syndrome (ARDS). Hypoxemia persists despite oxygen
therapy.
The client’s dyspnea worsens as bilateral pulmonary edema develops that is non
cardiac related. A chest x-ray shows an area of density with a “ground glass”
appearance.
ABG findings: High Co2 levels.
Assessment terms: Crackles (rales) -Fine/coarse. Pleuritic chest pain
Tactile fremitus - Transmission of palpable vibrations (fremitus) :
 104
AppleRN Classes

Increased when transmitted through consolidated lung tissue – pneumonia

Decreased in - pneumothorax or pleural effusion
Pneumonia - Bronchial breath sounds might be heard in peripheral lung fields -
High-pitched, harsh sounds conducted through consolidated lung tissue.
Epiglottitis and (Croup - Laryngo-tracheo-bronchitis)
Inflammation and swelling of epiglottis
Flu- fever, sore throat, dysphagia, dysphonia
Tripod position (sit upright leaning on arms, chin thrust out and mouth open).
Droplet precautions (mask). Don’t exam the throat – spasm !!!
ET & tracheostomy set at bedside. NPO, IVF, Antipyretics, antibiotics
Hib Vaccine to reduce the incidence. Tripod position
COPD
Health Promotion and Disease Prevention
Promote smoking cessation. Avoid exposure to secondhand smoke.
Use protective equipment, such as a mask, and ensure proper ventilation while
working in environments that contain carcinogens or particles in the air.
Influenza and pneumonia vaccinations are important for all clients who have
COPD, but especially for the older adult client.
COPD - ASTHMA
Chronic inflammation of airway leading to intermittent obstruction
Spasm of bronchial smooth muscle with airway edema.
Mucosal edema, Bronchoconstriction, Excessive mucus production.
Pulmonary function tests (PFTs) are the most accurate tests for diagnosing
asthma and its severity.
Watch for triggers
Triggers
 105
AppleRN Classes

Environmental factors, such as changes in temperature (especially warm to cold)

and humidity. Air pollutants, Strong odors (perfume)
Seasonal allergens (grass, tree, and weed pollens) . Perennial allergens (mold,
feathers, dust, roaches, animal dander)
Foods treated with sulfites: Example: Baked goods, Jams, Canned vegetables,
Pickled foods, Potato chips. (patient might have wheezing, chest tightness and
cough). Stress and emotional distress
Nursing Care
High- Fowlers, Oxygen, IV, Rest, meds, vaccine, Teaching
ABG, Tele (dysrhythmias) , PFT monitoring
Medications : Steroids, Bronchodialtors, Anticholinergics, aphthous lesions
(canker sores)
Asthma Patient- Metered Dose Inhaler Explanation
Tiotropium (Spiriva)
A long-acting, 24-hour, anticholinergic, inhaled medication used to control
chronic obstructive pulmonary disease (COPD).
It is administered most commonly using a capsule-inhaler system called the
HandiHaler
The capsule should not be swallowed and that the button on the inhaler must be
pushed to allow for medication dispersion
Status asthmaticus
This is a life-threatening episode of airway obstruction that is often unresponsive
to common treatment.
It involves extreme wheezing, labored breathing, use of accessory muscles,
distended neck veins, and creates a risk for cardiac and/or respiratory arrest.
Nursing Actions: Prepare for emergency intubation.
As prescribed, administer oxygen, bronchodilators, epinephrine, and initiate
systemic steroid therapy.
 106
AppleRN Classes

COPD - Emphysema
Progressive destruction of alveoli due to chronic inflammation – decreased
surface area for gas exchange- lose of elasticity of lung tissue- airway collapse
Primary cause – smoking
CXR – Hyperinflated lung, Heart small or normal
“Pink puffer” – barrel chest + pursed lip + accessory muscle breathing+
underweight.
Persistent tachycardia- inadequate oxygen
Wheezing, diminished breath sounds, Hyper resonance on percussion due to
“trapped air”
Difficulty with exhalation due to obstructed airway and mucos
Pursed lip breathing : Instruct the client to: Form the mouth as if preparing to
whistle.
Take a breath in through the nose and out through the lips/mouth.
Do not puff the cheeks. Take breaths deep and slow.
The low-pressure "huff" cough
Better option for COPD patients to remove secretions.
Clients with COPD have weakened muscles and narrowed airways that are prone
to collapse when under increased pressure (like in strong cough)
Position upright – maximizes lung expansion and gas exchange
Deeply inhale and, while leaning forward, force the breath out gently using the
abdominal muscles while making a "ha" sound (huff cough);
Repeat 2 more times (eg, "ha, ha, ha") – keeps airways open while moving
secretions up and out of the lungs.

COPD- Bronchitis
 107
AppleRN Classes

Chronic airway inflammation with chronic productive cough lasting at least 3

months in 2 year
“Blue bloater” :- Bluish-red skin (cyanosis + Polycythemia), Obesity
CXR – Congested lung, Heart enlarged. Chronic productive cough- thick mucus-
foul smelling. Celia disappear – Ineffective airway clearance
Frequent pulmonary infection, Dyspnea, Increased AP diameter
Ideal weight- nutritious food. Meds, Oxygen, Avoid irritants, IZ.
Mucolytic Agents : These agents help thin secretions making it easier for the client
to expel. Ex: Acetylcysteine (Mucomyst), guaifenesin (Mucinex)
Nursing Care
Position the client to maximize ventilation (high-Fowler’s is 90º).
Encourage effective coughing, or suction to remove secretions.
Encourage deep breathing and use of an incentive spirometer.
Administer breathing treatments and medications as prescribed.
Administer oxygen as prescribed.
Monitor for skin breakdown around the nose and mouth from the oxygen device.
Promote adequate nutrition.
Cor Pulmonale (complication of COPD)
Air trapping, airway collapse, and stiff alveoli lead to Increased pulmonary
pressures. Right side heart failure- Increased workload for heart
Blood flow through lung tissue is difficult. Enlargement and thickening of RA, RV
Low oxygenation levels, Cyanotic lips. Enlarged and tender liver
Distended neck veins and Dependent edema
Nursing care: Monitor respiratory status and administer oxygen
Monitor heart rate and rhythm. Meds, IV fluids.
 108
AppleRN Classes

Oxygen is combustible.
Nursing Actions: Post “No Smoking” or “Oxygen in Use” signs to alert others of a
fire hazard. Know where the closest fire extinguisher is located.
Educate the client and others about the fire hazard of smoking during oxygen use.
Have the client wear a cotton gown because synthetic or wool fabrics can
generate static electricity.
Ensure that all electric devices (razors, hearing aids, radios) are working well.
Ensure electric machinery (monitors, suction machines) are well-grounded.
Do not use volatile, flammable materials (alcohol or acetone) near clients who are
receiving oxygen.
COPD- Care after Discharge
Referrals to assistance programs, such as food delivery services, home care
services such as portable oxygen.
Client Education: High-calorie foods to promote energy.
Encourage rest periods as needed. Promote hand hygiene to prevent infection.
Reinforce the importance of taking medications (inhalers, oral medications) as
prescribed. Promote smoking cessation if the client is a smoker.
Encourage immunizations, such as influenza and pneumonia, to decrease the risk
of infection.
Clients should use oxygen as prescribed. Inform other caregivers not to smoke
around the oxygen due to flammability. Provide support to the client and family
Legionnaire’s Disease
Form of pneumonia caused by Legionella pneumophila which grows and
multiplies in a building water system.
Assessment : 1 to 2 days of prodromal symptoms followed by high fever, dyspnea,
vomiting, diarrhea, confusion, elevated WBC count
Interventions: Administer antibiotics as prescribed
 109
AppleRN Classes

Supportive care, including respiratory support, nutritional support, fluid and

electrolyte management
Pneumothorax, Hemothorax
A pneumothorax is the presence of air or gas in the pleural space that causes lung
collapse
A hemothorax is an accumulation of blood in the pleural space
A tension pneumothorax occurs when air enters the pleural space during
inspiration and is not able to exit upon expiration. The trapped air causes
pressure on the heart and the lung leading to a decrease in cardiac output.
A flail chest occurs when several ribs, usually on one side of the chest, sustain
multiple fractures
Signs : Dyspnea (first sign) , crepitus, Tracheal deviation towards unaffected side
Diminished breath sound in affected side- late sign
Unequal chest expansion (reduced on affected side)
Care : Vitals, oxygen, chest tube care, nutrition, Prevent infection, respiratory
failure. Meds- analgesics, antibiotics
Pleural Effusion
Collection of fluid in pleural space. Sharp pleuritic pain; increases with inspiration
Dry, nonproductive cough. Decreased breath sounds over affected area
Chest x-ray shows pleural effusion, mediastinal shift
Interventions: Identify, treat underlying cause, Place client in high Fowler’s
position. Encourage coughing, deep breathing, Surgical intervention
Cystic Fibrosis : Multisystem- thick mucus, Stetorrhea, Sweat test – more NaCl
Newborn- meconium ileus –first sign
Affects – bronchioles – infection
Small intestine – unable to absorb fats and protein
 110
AppleRN Classes

Retarded growth and puberty

Pancreatic and bile duct – clogged- prevent digestive enzymes from reaching
duodenum –digestion and absorption issues
Management – respiratory hygiene, avoid infection, supportive care
Tuberculosis (TB)
Highly communicable disease caused by Mycobacterium tuberculosis
Improper, noncompliant use of treatment programs
Risk factors
Alcoholism; drinking unpasteurized milk from infected cow; younger and older
clients; clients who are homeless and from lower socioeconomic group; crowded
living conditions; intravenous drug user; malnutrition
Transmission: Airborne route by droplet infection
After infected individual has received TB medication for 2 to 3 weeks, risk of
transmission reduced greatly
Mantoux test
No risk factors - 15
An induration of 5 mm is considered a positive test for immuno-compromised
clients.
Ex: HIV Patients, oncology pts, long term corticosteroid ( > than six weeks), Organ
transplant recipients
A positive Mantoux test indicates that the client has developed an immune
response to TB – NOT a confirmation of active disease
An induration (palpable, raised, hardened area) of 10 mm or greater in diameter
indicates a positive skin test.
Ten mm or more is positive in: Recent arrivals (less than five years) from high-
prevalence countries, Injectable drug users, Residents and employees of high-risk
congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters,
etc.), Mycobacteriology lab personnel, Persons with clinical conditions that place
 111
AppleRN Classes

them at high risk (e.g., diabetes, leukemia, end-stage renal disease, chronic
malabsorption syndromes, low body weight, etc.), Children less than four years of
age, or children and adolescents exposed to adults in high-risk categories, Infants,
children, and adolescents exposed to adults in high-risk categories.
False positives- Need chest x-ray to see active TB infection.
The nurse finds an area that is not heavily pigmented and is clear of hairy areas or
lesions that could interfere with reading the results.
Reinforce to the client the importance of returning for a reading of the injection
site by a health care personnel within 48 to 72 hr. Advise client not to scratch site,
avoid washing site
Medications
Combination therapy – 6 to 12 months
Hepatotoxic : Advise the client to report yellowing of the skin, pain or swelling of
joints, loss of appetite, or malaise immediately. Antibiotic property
Isoniazid (Nydrazid) : (INH) : This medication should be taken on an empty
stomach. Monitor for hepatotoxicity and neurotoxicity, such as tingling of the
hands and feet. Vitamin B6 (pyridoxine) is used to prevent neurotoxicity from
isoniazid.
Rifampin (Rifadin): Inform the client that urine and other secretions will be
orange. Inform the client this medication may interfere with the efficacy of oral
contraceptives.
Pyrazinamide: Take with a glass of water
Ethambutol : suppress RNA synthesis. Optic neuritis: Can affect vision- need eye
check up
Streptomycin : Nephrotoxic and ototoxic, Report oliguria, KFT, tinnitus, Drink lots
of fluids
Pulmonary Embolism
Risk Factors: Immobility, DVT, Oral contraceptive use and estrogen therapy
 112
AppleRN Classes

Pregnancy, Platelet problems, Tobacco use, Heart failure or chronic atrial

fibrillation, Autoimmune hemolytic anemia (sickle cell), Long bone fractures,
surgery
A pulmonary embolism (PE) occurs when a substance (solid, gaseous, or liquid)
enters venous circulation and forms a blockage in the pulmonary vasculature.
Health Promotion and Disease Prevention
Promote smoking cessation.
Encourage maintenance of appropriate weight for height and body frame.
Encourage a healthy diet and physical activity.
Prevent deep-vein thrombosis (DVT) by encouraging clients to do leg exercises,
wear compression stockings, and avoid sitting for long periods of time.
Signs and symptoms : Anxiety, Feelings of impending doom, Pressure in chest,
Pain upon inspiration and chest wall tenderness, Dyspnea and air hunger
Adventitious breath sounds (crackles) and cough, Pleurisy, Pleural friction
rub,Pleural effusion (fluid in the lungs), Tachycardia, Tachypnea, Hypotension,
Heart murmur in S3 and S4, Diaphoresis, Decreased oxygen saturation levels,
Low-grade fever, low SaO2, cyanosis
Diagnostics: CT scan, Ventilation-perfusion (V/Q) scan,
D- Dimer : (0.43 to 2.33 mcg/mL).
Nursing care : Oxygen therapy , Semi-Fowler’s , IV access, Vitals
Provide emotional support and comfort, Monitor changes in LOC and mental
status
Medications – watch for bleeding
Anticoagulants – prevent clots from getting bigger
Thrombolytic – dissolve clots
Assess contraindication - active bleeding, peptic ulcer disease, history of stroke,
recent trauma
 113
AppleRN Classes

Discharge education
Provide education to the client for the treatment and prevention of a PE.
Promote smoking cessation if the client smokes. Encourage the client to avoid
long periods of immobility.
Encourage physical activity such as walking. Encourage the client to wear
compression stockings to promote circulation.
Encourage the client to avoid crossing his legs. Remind the client of the increased
risk for bruising and bleeding.
Instruct the client to avoid taking aspirin products, unless specified by the
provider. Encourage the client to check his mouth and skin daily for bleeding and
bruising.
Encourage the client to use electric shavers and soft-bristled toothbrushes.
Instruct the client to avoid blowing his nose hard, and to gently apply pressure if
nose bleeds occur.
Encourage client who is traveling about measures to prevent PE.
Instruct client to arise from sitting position for 5 min out of every hour. Advise
client to wear support stockings.
Inform client to remain hydrated by drinking plenty of water. Instruct client to
perform active ROM exercises when sitting.
Advise the client to monitor intake of foods high in vitamin K (green, leafy
vegetables) if taking warfarin.
Vitamin K can reduce the anticoagulant effects of warfarin.Advise the client to
adhere to a schedule for monitoring PT and INR, follow instructions regarding
medication dosage adjustments (for clients on warfarin), and adhere to weekly
blood draws.

Mechanical Ventilation
There are three types of ventilator alarms: volume, pressure, and apnea alarms.
 114
AppleRN Classes

Volume (low pressure) alarms indicate a low exhaled volume due to a

disconnection, cuff leak, and/or tube displacement.
Pressure (high pressure) alarms indicate excess secretions, client biting the
tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm,
and/or pneumothorax.
Apnea alarms indicate that the ventilator does not detect spontaneous
respiration in a preset time period.
Respiratory Medications
Bronchodilators (inhalers) : Albuterol (Proventil, Ventolin):
Provide rapid relief of acute symptoms and prevent exercise-induced asthma.
Watch the client for tremors and tachycardia. Short acting
Prevention of asthma episode (exercise-induced)
Inhaled, short-acting one is used for prevention of asthma episode
Asthma Medications
Anticholinergic medications, such as ipratropium (Atrovent)
It decreases pulmonary secretions.
Advise clients to rinse the mouth after inhalation to decrease unpleasant taste.
Observe the client for dry mouth. Hard candies, more fluids can be given to
patients.
Salmeterol primarily used for asthma attack prevention in long term.
Not used to abort an asthma attack and not at the onset of an attack.
It is Long acting

Steroid Medications
 115
AppleRN Classes

Steroids- To relieve inflammation. Example : fluticasone (Flovent) and prednisone

(Deltasone)
Client Education
Encourage the client to drink plenty of fluids to promote hydration.
Encourage the client to take prednisone with food.
Decreased immune function, weight gain, fluid retention, risk of bleeding,
hyperglycemia, reduced ht(grwoth) in children
Encourage client to avoid persons with respiratory infections.
Use good mouth care. Rinse mouth after use (prevent infection). Monitor the
client’s throat and mouth for aphthous lesions (canker sores).
Do not stop the use of this type of medication suddenly.
Bone loss : Take vit D
When a client is prescribed an inhaled albuterol and an inhaled glucocorticoid,
advise the client to inhale the albuterol before inhaling the glucocorticoid.
Albuterol promotes bronchodilation and enhances absorption of the
glucocorticoid.
If two inhaled medications are prescribed, instruct clients to wait at least 5 min
between medications
Xanthine : Theophylline (Theo-24)
Narrow therapeutic range. (5 to 15 mcg/mL).
Mild toxicity: GI distress and restlessness. Severe toxicity : Tachycardia,
dysrhythmias and seizures.
If manifestations occur, stop the medication. Activated charcoal is used to
decrease absorption. Llidocaine is used to treat dysrhythmias. Diazepam is used
to control seizures. Caffeine can increase theophylline levels. Avoid Cola, coffee,
and chocolate which contain xanthine . Phenobarbital and phenytoin decrease
theophylline levels.
ANTITUSSIVES
 116
AppleRN Classes

Suppresses cough : Opioids : Codeine: suppresses cough through its action on

the central nervous system. For chronic nonproductive cough.
Safety precautions: GI distress- take with food
Non-opioid: dextromethorphan (found in many different products for cough, such
as Robitussin), benzonatate (Tessalon), diphenhydramine (Benadryl); Mild nausea,
dizziness, and sedation may occur.
Expectorants : Guaifenesin (Mucinex) : allow clients to decrease chest congestion
by coughing out secretions. GI upset : Take with food if GI upset occurs.
Drowsiness, dizziness : Do not take prior to driving or activities if these reactions
occur. Allergic reaction (rash) : Stop taking guaifenesin and obtain medical care if
rash or other symptoms of allergy occur. Increase intake of fluids : thin secretions
Mucolytics. Acetylcysteine (Mucomyst, Acetadote)
Mucolytics enhance the flow of secretions in the respiratory passages.
S/E; Aspiration and bronchospasm when administered orally
Advise clients that acetylcysteine has an odor that smells like rotten eggs.
Mucolytics are used in clients who have cystic fibrosis.
Acetylcysteine is the antidote for acetaminophen poisoning.
Should not be used in clients at risk for GI hemorrhage.
Decongestants
Ex: phenylephrine. To treat allergic or non allergic rhinitis by relieving nasal
stuffiness.
S/E : Vasoconstriction : Avoid in CAD
Rebound congestion secondary to prolonged use of topical agents
Advise clients to use for short-term therapy, no more than 3 to 5 days.
Taper use and discontinue medication using one nostril at a time.

Cardiovascular system
 117
AppleRN Classes

Heart Sounds

S1- Lub- Closure of the mitral and tricuspid valves: the beginning of ventricular
systole (contraction)
S2- Dub- Closure of the aortic and pulmonic valves : the beginning of ventricular
diastole (relaxation)
S3 sound (ventricular gallop) : Due to rapid ventricular filling : can be an expected
finding in children and young adults. Use the bell of the stethoscope.
S4 sound : reflects a strong atrial contraction : can be an expected finding in older
and athletic adults and children. Use the bell of the stethoscope.
Assess the peripheral vascular system for bruits
Carotid arteries – over the carotid pulses
Abdominal aorta – just below the xiphoid process
Renal arteries – midclavicular lines above the umbilicus on the abdomen
Iliac arteries – midclavicular lines below the umbilicus on the abdomen
Femoral arteries – over the femoral pulses
Pulse Pressure: Narrow = hypovolemia shock
Orthostatic Hypotension
 118
AppleRN Classes

Symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports

of seeing spots
Measuring Orthostatic Blood Pressure (add to your notes)
1. Have the patient lie down for 5 minutes.
2. Measure blood pressure and pulse rate.
3. Have the patient stand.
4. Repeat blood pressure and pulse rate measurements after standing 1 and 3
minutes.
A drop in BP of ≥20 mm Hg, or in diastolic BP of ≥10 mm Hg, or experiencing
lightheadedness or dizziness is considered abnormal.

Angina
Chest pain resulting from myocardial ischemia
Patterns of angina
Stable: Exertional angina; occurs with activities that involve exertion, exercise,
emotional stress
Unstable: Occurs with unpredictable degree of exertion or emotion; increases in
occurrence, duration, severity over time
Prinzmetal (variant) Angina – Arterial Spasm (cold
weather/stress/smoking/substance abuse) often awaking client from sleep.
 119
AppleRN Classes

Assessment
Mild or moderate pain, may radiate to shoulders, arms, jaw, neck, back, usually
lasts less than 5 minutes, relieved by rest and/or nitroglycerin; dyspnea; pallor;
diaphoresis
Diagnostic studies: ECG shows inverted T wave, ST depression, or may be normal
Stress test causes chest pain or changes in ECG .
Cardiac enzyme levels can be normal. Cardiac catheterization provides definitive
diagnosis of patency of coronary arteries
Interventions : Assess pain , Bed rest, Assess ECG strip
Administer oxygen, nitroglycerin as prescribed – S/E : headache
Instruct client about diet, weight management, exercise, lifestyle changes
following acute episode
Surgical procedures : Same as for coronary artery disease
Chest Pain Initial Care
Assess airway, breathing, and circulation (ABCs), Position upright
Apply oxygen, if hypoxic
Obtain baseline vital signs, heart and lung sounds
Obtain a 12-lead electrocardiogram (ECG)
Insert 2-3 large-bore IV catheters
Assess pain – OLDCART, Medicate for pain : morphine/ nitroglycerin (Sildenafil +
Nitro –severe hypotension)
Initiate continuous electrocardiogram (ECG) monitoring
Obtain blood work (eg, cardiac markers, serum electrolytes)
Obtain portable chest x-ray
Assess for contraindications to antiplatelet and anticoagulant therapy
Administer aspirin unless contraindicated
 120
AppleRN Classes

Medications
Nitrates: Dilate coronary arteries; decrease preload and afterload, such as
nitroglycerin
Calcium channel blockers: Dilate coronary arteries and reduce vasospasm, such as
nifedipine (Procardia)
Cholesterol-lowering medications: Reduce development of atherosclerotic
plaques, such as lovastatin
β blockers: Reduce blood pressure in individuals who are hypertensive, such as
sotalol (Betapace)
Anti platelets – to reduce risk of MI
Myocardial Infarction
Occurs when myocardial tissue abruptly, severely deprived of oxygen, leading to
necrosis and infarction; develops over several hours
Location of MI
LAD: Left anterior descending artery: Anterior or septal MI
Circumflex artery: Posterior or lateral wall MI
Right coronary artery: Inferior wall MI
Risk factors- Modifiable vs Non modifiable
Atherosclerosis; coronary artery disease; elevated cholesterol levels; smoking;
hypertension; obesity; inactivity; impaired glucose tolerance; stress
Diagnostic studies : ECG: ST chanes, inverted T; abnormal Q wave
Assessment: Pain; nausea and vomiting; Diaphoresis; dyspnea; dysrhythmias;
Cyanosis; coolness of extremities
Risk Factors – Modifiable Vs Non modifiable
Cardiac Enzymes
 121
AppleRN Classes

MI Interventions, acute stage: Same as Chest Pain Initial Care

Interventions following acute episode
Bed rest; range-of-motion exercises as prescribed, activity progression as
tolerated
Complications of MI
Dysrhythmias; heart failure; pulmonary edema; cardiogenic shock;
thrombophlebitis; pericarditis, pulmonary edema
Papillary Muscle Rupture – new murmur
Cardiac rehabilitation: Arrange for client to begin prior to discharge
Teaching: Bleeding precautions – soft tooth brush, electric razor, avoid trauma or
injury, Medic alert identification.

Heart Failure
Inability of heart to maintain adequate circulation to meet metabolic needs of
body
Classification: Acute, chronic
Right ventricular : RV reduced capacity to pump into pulmonary circulation – back
up in rest of body
left ventricular : LV reduced capacity to pump into systemic circulation- back up in
lungs
 122
AppleRN Classes

Compensatory mechanisms Restore cardiac output to near-normal levels

Include increased heart rate, improved stroke volume, arterial vasoconstriction,
sodium and water retention, myocardial hypertrophy
Right-sided failure presents as primarily systemic symptoms, including JVD,
dependent edema, ascites, nausea, hepatosplenomegaly
Left-sided failure presents as primarily respiratory symptoms, including
orthopnea, cough, adventitious breath sounds, tachycardia, dyspnea on exertion,
S3
Pulmonary edema presents as – acute restlessness, anxiety, crackles, pallor,
dyspnea, orthopnea, pink frothy sputom, diaphoresis
BNP : B-type natriuretic peptides :
Made and released by ventricles in response to stretching
Causes natriuresis (excretion of sodium in the urine)
Stretching of the ventricles - increased blood volume (fluid overload) - heart
failure.
Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes
of dyspnea.
Place client in high Fowler’s position , Rest period between activities
Calm environment, Administer oxygen as prescribed (N/C)
Better gas exchange, decrease workload, Suction client PRN as prescribed
Monitor vital signs frequently (watch for hypotension, orthostatic hypo)
Strict intake and output, daily weight, Fluid restriction, Daily weight
Heart Failure (Meds): Administer diuretics as prescribed , Electrolytes (K levels)
Vasodilators, Nitro: reduce preload
ACE inhibitors/ARB : Reduce afterload
Beta blocker: Reduce workload, improve contractions
 123
AppleRN Classes

Administer morphine sulfate as prescribed : Sedation, resp.depression

Administer digitalis as prescribed: Improve contractility (hold HR<60)
HF Teaching
Instruct client about modifiable risk factors, proper administration of medication
regimen . Instruct client to avoid over-the-counter medications
Diet - eat a low-sodium, low-fat, low-cholesterol diet. Instruct client to balance
activity level. Daily weight – report 3 lb a day or 5 lb a week increase
Coronary Artery Disease
Narrowing or obstruction of one or more coronary arteries as result of
atherosclerosis
May be asymptomatic – atypical chest pain – especially in women
Chest pain , Palpitations , Dyspnea , Syncope , Cough Excessive fatigue
Diagnostic studies : ECG shows ST depression or inverted T wave;
cardiac catheterization provides definitive diagnosis; blood lipid levels may be
elevated
Interventions
Educate client about diagnostic tests , Educate client about modifiable risk factors
Diet : Instruct client to eat low-calorie, low-sodium, low-cholesterol, low-fat diet,
with increase in dietary fiber
Instruct client about importance of regular exercise
Surgical procedures
PTCA - Percutaneous transluminal coronary angioplasty - Ballooning
Laser angioplasty , Atherectomy , Vascular stent
Coronary Artery Bypass Grafts
Performed to bypass an obstruction in one or more of the coronary arteries.
 124
AppleRN Classes

Minimally invasive direct coronary artery bypass (MIDCAB) – incision between

ribs- painful
Preprocedure: Verify that client has signed the informed consent form.
Confirm that recent chest x-ray, ECG, and laboratory reports are available if
needed.
Administer preoperative medications as prescribed.
Anxiolytics, such as lorazepam (Ativan) and diazepam (Valium)
Prophylactic antibiotics
Anticholinergics, such as scopolamine, to reduce secretions
Provide safe transport of the client to the OR.
Monitor heart rate and rhythm, oxygenation, and other vital indicators.
Educate pt and family – post op tubes, IS, cough and deep breath, splint incision,
pacemaker
Medications frequently discontinued for CABG : Diuretics 2 to 3 days before
surgery, Aspirin and other anticoagulants 1 week before surgery
Medications often continued for CABG: Potassium supplements, Scheduled
antidysrhythmics, such as amiodarone (Cordarone) Scheduled antihypertensives,
such as metoprolol (Lopressor), a beta-blocker, and diltiazem (Cardizem), a
calcium-channel blocker, Insulin (clients who have diabetes mellitus and are
insulin-dependent usually receive half the regular insulin dose)
Post op Care: Maintain patent airway and adequate ventilation.
Monitor RR, breath sounds, ventilator settings, Chest tube, Suction as needed.
Splint the incision while deep breathing and coughing.
Dangle and turn the client from side to side as tolerated within 2 hr following
extubation.
Assist the client to a chair within 24 hr. Ambulate the client 25 to 100 ft by POD #1
 125
AppleRN Classes

Continually monitor client’s heart rate and rhythm. Treat dysrhythmias per
protocol.
Multidisciplinary team
Maintain an adequate circulating blood volume. Hypotension - graft collapse.
Hypertension - bleeding from grafts and sutures.
Monitor the client’s level of consciousness. Assess neurological status every 30 to
60 min until the client awakens from anesthesia, then Q2 0r q4
Prevent and monitor for infection. hand hygiene. surgical aseptic - dressing
changes and suctioning. Administer antibiotics. Monitor WBC counts, incisional
redness and drainage, and fever. Monitor the client’s temperature, and provide
warming measures if indicated.
Client Education
Monitor and report manifestations of infection such as fever, incisional drainage,
and redness.
Instruct the client to treat angina. S/L Nitro. Diabetes Client - monitor blood
glucose levels. Heart-healthy diet (low fat, low cholesterol, high fiber, low salt).
Smoking cessation. Encourage physical activity - cardiac rehabilitation . Discuss
home environment and social supports.
Pulmonary complications
Atelectasis, pneumonia and pulmonary edema.
Nursing Actions: While the client is intubated, suction every 1 to 2 hr and as
needed.
Turn the client every 2 hr, and advance him out of bed as soon as possible.
Monitor breath sounds, SaO2, ABGs, pulmonary artery pressures, cardiac output,
and urine output, and obtain a chest x-ray as indicated.
Encourage coughing, deep breathing, and use of an incentive spirometer.
Ambulate
Other complications : Fluid and Electrolyte Imbalances, Cardiac Dysrhythmias
 126
AppleRN Classes

Decreased cardiac output : can result from dysrhythmias, cardiac tamponade,

hypovolemia, left ventricular failure, or MI.
Hypothermia : can cause vasoconstriction, metabolic acidosis, and hypertension.
Monitor temperature, and provide warming measures, such as warm blankets
and heat lamps.
Monitor blood pressure. Administer vasodilators if prescribed.
Assure the client that shivering is common following surgery.
Inflammatory Diseases of the Heart
Pericarditis : Inflammation of the pericardium
›› Commonly follows a respiratory infection
›› Can be due to a myocardial infarction
Grating pain, aggravated by breathing. Pain worsens when in supine position,
relieved by leaning forward
Position client in high Fowler’s position, upright, leaning forward
Monitor for signs of cardiac tamponade
Nursing Care - Pericaditis
Auscultate heart sounds (listen for murmur). Assess breath sounds in all lung
fields (friction rub).
Review ABGs, SaO2, ECG and chest x-ray results.
Administer oxygen as prescribed. Monitor vital signs (watch for fever).
Monitor for cardiac tamponade and heart failure.
Obtain throat cultures to identify bacteria - antibiotic therapy. Administer
antibiotics and antipyretics as prescribed.
Pain assessment – Pain med. Encourage bed rest.
Provide emotional support to the client and family, and encourage the
verbalization of feelings regarding the illness.
 127
AppleRN Classes

Myocarditis
Inflammation of the myocardium
Can be due to a viral, fungal, or bacterial infection. Can be a result of pericarditis
Assessment: Fever; pericardial friction rub; murmur
Interventions: Administer analgesics, salicylates, nonsteroidal anti-inflammatory
drugs, antibiotics, digoxin (Lanoxin) as prescribed
Endocarditis
Inflammation of inner lining of heart and valves by bacteria (staph aureuas- acute,
or strep viridans- chronic)
Assessment: Fever; positive blood culture, New heart murmur, Petechiae ,
Splinter hemorrhages in nail beds.
Osler’s nodes – painful nodes on fingers and toes
Janeway’s lesions (irregular, erythematous, flat, painless macules on the palms,
soles)
Roth’s spots – retinal lesion surrounded by bleeding
Endocarditis : Interventions: Prevent venous stasis- periods of rest and activity.
Maintain anti embolic stockings as prescribed
IV therapy – antibiotics ( 6 weeks) . Monitor cardiovascular status
Monitor for signs of emboli throughout body as the bacterial vegetations over the
valves can break off and embolize to various organs- lead to stroke, MI, PE,
ischemia to extremity etc
Client Education
Encourage the client to take rest periods as needed. wash hands to prevent
infection. Avoid crowded areas to reduce the risk of infection. Participate in
smoking cessation (if the client is a smoker).
Educate the client about the importance of taking medications as prescribed.
 128
AppleRN Classes

Ask the client to demonstrate the administration of intravenous antibiotics and

management before discharge.
Educate the client and family about the illness, and encourage them to express
their feelings.
Home infusion therapy: Can have repeated episodes of endocarditis
Report – fever, anorexia, malaise, Gentle, thorough oral care (vigorous brushing
can lead bacteria to enter blood through gum). Need prophylactic antibiotics
before invasive procedures

COMMON ECG
1. NSR

2.Bradycardia

3. Tachycardia

4. Atrial Fibrillation
 129
AppleRN Classes

5 Atrial Flutter

6.SVT

7. PVC

8. Ventricular Tachycardia
 130
AppleRN Classes

9 V Fibrillation

10.

Cardiac dysrhythmias
EKG Strips : Paper divided into small squares:
Width = 1 millimeter (mm) . Time interval = 0.04 seconds . 1 small square = 0.04
seconds
Cardiac Conduction Pathway

EKG basics
 131
AppleRN Classes

P wave - Atrial depolarization (sqeeze/contract)

QRS – ventricular Depolarization . T – ventricular Repolarization (relax)
PQ – Time taken to reach from SA node to AV node
Heart Rate: SA node = 60 to 100 beats/min AV node = 40 to 60 beats/min
Ventricles (Purkinje fibers) = 15 to 40 beats/min
Normal Numbers
PR interval = 0.12 -0.20 seconds (3 -5 small blocks)
QT interval = 0.36 – 0.44 seconds (9-11 small blocks)
First and most important ▪ ASSESS YOUR PATIENT!!
Finding Heart Rate
(Regular) : Count the blocks (big blocks) between R and R. HR = 300/ number of
blocks
(Irregular rhythm ) : Count the number of R waves in a 6 second strip and
multiply by 10. 30 large squares = 6 seconds
Cardiac dysrhythmias can occur in conjunction with other disorders
Normal sinus rhythm
Originates from SA node with atrial and ventricular rates of 60 to 100 beats/min
Sinus bradycardia
Atrial and ventricular rates less than 60 beats/min
Attempt to determine cause; If medication is suspected cause, hold, notify
physician. Administer atropine sulfate as prescribed
Symptomatic bradycardia
A symptomatic bradycardia exists clinically when 3 criteria are present
1. The heart rate is slow 2. The patient has symptoms
3. The symptoms are due to the slow heart rate.
 132
AppleRN Classes

Sinus tachycardia
Atrial and ventricular rates more than 100 beats/min
Assess patient – Are they symptomatic? Are they stable?
Give oxygen and monitor oxygen saturation , Monitor blood pressure and heart
rate , Start IV if not already established , Notify MD , Look for the cause of the
tachycardia and treat it
Fever – give acetaminophen or ibuprofen
Stimulants – stop use (caffeine, OTC meds, herbs, illicit drugs)
Anxiety – give reassurance or ant-anxiety medication
Sepsis, Anemia, Hypotension, MI, Heart Failure, Hypoxia
Atrial fibrillation
No definitive P wave can be observed▪
Hypoxia, HTN, CAD, CHF
Administer oxygen and anticoagulants, prepare for cardioversion as prescribed
Always Irregular
Atrial Flutter
(rate varies; usually regular; saw-toothed)
Seen in Valve disorder (mitral) ▪ Thickening of the heart muscle, Ischemia ▪
Cardiomyopathy ▪ COPD
Cardioversion – treatment of choice
Antiarrythmics such as procainamide to convert the flutter
Slow the ventricular rate by using diltiazem, verapamil, digitalis, or beta blocker
Heparin to reduce incidence of thrombus formation
 133
AppleRN Classes

Supraventricular Tachycardia (>150 bpm)

Causes: Stimulants • Hypoxia • Stress or over-exertion • Hypokalemia •
Atherosclerotic heart disease
Some types of SVT may run in families, such as Wolff-Parkinson-White syndrome
– additional electrical pathway between Atrium and Ventricles (in addition to AV
node)
Treatment : Vagal maneuvers, Gagging, Coughing.
Holding breath and bearing down (Valsalva maneuver). Immersing face in ice-
cold water (diving reflex).
Drug – Adenosine – Give rapidly (1-2 sec)+ rapid saline flush (short half life – 10
sec)
Cardioversion
PVC
A PVC is not a rhythm, but an ectopic beat that arises from an irritable site in the
ventricles.
PVCs appear in many different patterns and shapes, but are always wide and
bizarre compared to a “normal” beat
PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin),
heart diseases, electrolyte imbalances, hypoxia, and emotional stress.
Ventricular tachycardia
Repetitive firing of irritable ventricular ectopic focus at rate of 140 to 250
beats/min
Client may be stable or unstable. No pulse? Begin CPR, Defib.
If pulse present and pt stable – Cardiovert, start meds
Meds: Amiodarone and lidocaine (Xylocaine), antiarrhythmics (procainamide,
sotalol)
Ventricular fibrillation
 134
AppleRN Classes

Chaotic rapid rhythm; ventricles quiver

Defibrillate immediately as prescribed; initiate CPR

Atrioventricular Blocks
Always assess for decreased cardiac output and treat cause
Four types: First-degree block, Second-degree block, Mobitz type I Wenckebach
Second-degree block, Mobitz type II, Third-degree block (complete)
Heart Block : First degree
a delay of impulse from SA node to reach AV node. PR interval >.20 sec (3 to 5
small blocks) But same PR interval for each beat. Can be due to meds such as
digoxin.

No specific treatment- watch for worsening to second or third degree

Second Degree
Can be due to MI/Meds (digoxin, beta blocker)/cardiac surgery
Second Degree AV Block – Type I (Wenckebach) (Mobitz I )
 135
AppleRN Classes

Progressive prolongation of the PR interval, then one dropped QRS

Watch for progression into complete heart block
S/S – bradycardia symptoms – give atropine to increase HR
May need temporary pacemaker if med not working
Second Degree AV Block – Type II
The PR interval does not lengthen before a dropped beat.

Due to BBB. Seen in – MI, CAD, RHD, Drug toxicity. Might need pacemakers

Third Degree/complete

complete absence of conduction between atria and ventricles

Nursing priority: assess the patient for possible causes
monitor blood pressure, pulse, and other vital signs.
Assess for syncope, palpitations, or shortness of breath.
Hypotension may occur due to a low ventricular rate.
For patient safety, lie your patient down to prevent syncope and potential falls.
 136
AppleRN Classes

Cardioversion and Defibrillation

Clients who have atrial fibrillation of unknown duration must receive adequate
anticoagulation for 4 to 6 weeks prior to cardioversion therapy to prevent
dislodgement of thrombi into the bloodstream.
Do TEE to identify the clot. Digoxin is held for 48 hr prior to elective cardioversion
Nursing Actions: Explain the procedure to the client, and obtain consent.
Administer oxygen. Document pre procedure and post procedure rhythm.
Have emergency equipment available.
Complications
Embolism
Cardioversion can dislodge blood clots, potentially causing PE, MI, CVA
Provide therapeutic anticoagulation for clients who have dysrhythmias
Decreased cardiac output and heart failure
Cardioversion may damage heart tissue and impair heart function.
Monitor the client for signs of decreased cardiac output (hypotension, syncope,
tachycardia, LOC changes, activity intolerance) and heart failure
Provide medications to increase output (inotropic agents) and to decrease cardiac
workload (Digoxin, Dopamine, Dobutamine, milrinone)
 137
AppleRN Classes

Implantable Cardioverter-Defibrillator (ICD)

Consists of a lead system placed via subclavian vein to the endocardium
Battery-powered pulse generator is implanted subcutaneously
Sensing system monitors HR and rhythm –identifies VT or VF: delivering 25 joules
or less to heart when detects lethal dysrhythmia
If the first shock is unsuccessful, the device recycles and can continue to deliver
shocks. Instruct client on basic functions of ICD, complications to report
immediately
Instruct client how to take pulse , and to avoid strenuous activity or contact sports
and report any signs of infection or feelings of faintness, nausea and vomiting
Cardiogenic Shock
Failure of heart to pump adequately, thus reducing cardiac output, compromising
tissue perfusion
 138
AppleRN Classes

Assessment : Hypotension, Oliguria, Poor peripheral pulses, Tachypnea,

Tachycardia, Disorientation, confusion
Interventions: Administer morphine sulfate, diuretics, nitrates to decrease heart
workload – help heart to work more effectively
Inotrops - stimulate and increase the force of contraction of the heart muscle
Administer oxygen; prepare for intubation and mechanical ventilation as
prescribed
Monitor vital signs, arterial blood gases, strict intake and output, arterial
pressures as prescribed
Cardiac Tamponade
Pericardial effusion; occurs when space between parietal and visceral layers of
pericardium fill with fluid
Assessment
Pulsus paradoxus (variance of 10 mm Hg or more in systolic blood pressure
between expiration and inspiration).
Beck’s Triad (Low arterial blood pressure, distended neck veins, and distant,
muffled heart sounds)
Interventions: Place client in critical care unit as prescribed
Administer IV fluids as prescribed, Prepare client for pericardiocentesis as
prescribed (position)
supine with the head of the bed raised to an angle of 45 to 60 degrees. This places
the heart in proximity to the chest wall for easier insertion of the needle into the
pericardial sac.
Monitor for recurrence of tamponade following pericardiocentesis
 139
AppleRN Classes

Valvular Heart Disease

Occurs when heart valves are stenosed (cannot fully open) or insufficient or
regurgitant (cannot close completely)
Asymptomatic until late in the progression – Echocarddiogram
Repair procedures : Balloon valvuloplasty; mitral angioplasty; commissurotomy
(relieve stenosis on leaflets), valvotomy
Valve replacement procedures
• Prosthetic valves can be mechanical or tissue.
• Mechanical valves last longer but require anticoagulation.
• Tissue valves last 10 to 15 years.
The aortic valve must be replaced by a mechanical (prosthetic) valve because of
the velocity of the blood flow through the valve. A tissue or biologic valve would
not withstand the force.
Risk Factors: Hypertension, Rheumatic fever (mitral stenosis and insufficiency)
Infective endocarditis, Congenital malformations
 140
AppleRN Classes

Marfan syndrome (connective tissue disorder that affects the heart and other
areas of the body - genetic). In older adult clients causes are degenerative
calcification, papillary muscle dysfunction, infective endocarditis
Mitral stenosis: Common in young woman (pregnant?)
Associated with Afib (may need anitcoagulants). Meds: Diuretics and digoxin
Mitral valve prolapse: Beta blockers, antibiotics before procedures
Mitral insufficiency: Diuretics, nitrates and ACE inhibitors, Low salt diet
Aortic stenosis: Restrict activity to decrease oxygen consumption
Antibiotics with invasive procedures, surgery
Aortic insufficiency: surgery : Signs and Symptoms : Refer to table
• Common – usually asymptomatic until late. Murmurs are usually present
• Left-sided valve – more like LHF
• Right side valve – more like RHF
 141
AppleRN Classes

General interventions:
Administer prescribed treatment for heart failure as prescribed, Administer
oxygen, IV fluids, diuretics, digoxin (Lanoxin), antibiotics as prescribed
Provide low-sodium diet as prescribed
Pacemakers
Temporary or permanent device , Provides electrical stimulation
Maintains heart rate when client’s intrinsic pacemaker fails to provide perfusing
rhythm
Settings
Synchronous or demand : paces only if client’s intrinsic rate falls below set
pacemaker rate
Asynchronous or fixed rate : paces at preset rate, regardless of client’s intrinsic
rate.
Spikes: When pacing stimulus delivered to heart, straight vertical line on ECG strip
or monitor
Temporary pacemakers : Noninvasive temporary pacing; transvenous invasive
temporary pacing
Permanent pacemakers: Pulse generator internal, surgically implanted in
subcutaneous pocket under clavicle or abdominal wall
 142
AppleRN Classes

Function can be checked by pacemaker interrogator or programmer in office or

from home using telephone transmitter device

Post procedure nursing care : Pacemakers

Monitor EKG, Pacemaker site – bleeding, infection
Infection of a pacemaker incision site can travel down the lead wires to the heart,
causing myocarditis and/or endocarditis.
Infection may disrupt pacemaker function, resulting in failure to sense or pace
Signs and symptoms of pacemaker malfunction (eg,dizziness) should be assessed
immediately.
Arm and shoulder restriction , Sling. Dressing clean and dry. No MRI (unless
compatible pacemaker)
Identification card all the time
 143
AppleRN Classes

Do not place a cell phone in a pocket located directly over the pacemaker. Also,
when talking on the cell phone, hold it to the ear on the opposite side of the
pacemaker's implantation site
Avoid standing near antitheft detectors in store entryways
Failure to capture
Failure to capture means that the ventricules fail to response to the pacemaker
impulse. On an EKG tracing, the pacemaker spike will appear but it will not be
cardiomyopathy
Manifestations: Fatigue, weakness, orthostatic hypotension (fall risk)
Heart failure (LHF -dilated type, RHF- restrictive type
Dysrhythmias (heart block), Angina (hypertrophic type). S3 gallop
Cardiomegaly (enlarged heart), severe with dilated type
BNP – elevated (100-400 pg/mL)
Treatment – Heart failure
Treatment symptomatic, similar to care of heart failure (dilated and restrictive
cardiomyopathy), similar to care of MI (hypertrophic cardiomyopathy)
Ventricular Assistive Device
• This is an alternative to heart transplantation for patients with advanced
heart failure.
• It is a form of mechanical circulatory support device (MCSD)
• An LVAD is the most common type of MCSD.
• LVAD is a battery operated mechanical pump that's surgically implanted
into the patient's chest to support heart function and blood flow.
• Today, over 15,000 U.S. patients have an MCSD
Types: Right ventricular assist device (RVAD)
RVAD helps pump blood from the right ventricle to the pulmonary artery
 144
AppleRN Classes

Used for short term purposes. Patients must stay in the hospital
Biventricular assist device (BIVAD): Used if both ventricles need support
Left Ventricular Assistive Device (LVAD): The LVAD is the most common type of
VAD
It works by unloading the left ventricle and pumping blood to the aorta.
• Parts: An inflow Canula : draws blood from the left ventricle into the pump.
• An outflow cannula : carries blood from the pump to the ascending aorta
• Pump : located at the apex of left ventricle : two types: Pulsatile (durability
issues) or continuous (Mostly used)
• Driveline : To send signals from controller : It is the connecting wire.
• System controller : Regulates power, monitors LVAD performance, and
collects data on system operation (alarms)
• Power source : Batteries or AC current

Continuous flow pump : These are designed to unload the heart throughout the
cardiac cycle using a central rotor (motor)
The rotor continuously propels blood, providing continuous blood flow into
systemic circulation.
 145
AppleRN Classes

This may result in a weak, irregular, or nonpalpable pulse due to the continuous
forward flow from the VAD
The pump speed
• This is a fixed number, set by the VAD team, which directly measures how
fast the rotor of the pump spins.
• The speed is determined by hemodynamic and echocardiographic
measurements and is set in revolutions per minute (RPMs).
• The only parameter on the LVAD that can be adjusted is the RPMs, which
are determined and adjusted by a member of the VAD team
• The pump flow is an approximation of the blood flow through the LVAD,
estimated based on pump speed and power.
• The pump flow is patient's cardiac output in liters per minute (L/min)
• The pump power is a measure of voltage and current power consumption
of the pump.
• A gradual increase in power may be a sign of thrombus inside the LVAD
• Pulsatility index (PI): In systole the blood flow in pump increases. Diastole it
decreases.
• PI helps to make an average of blood flow for every 15 seconds.
• The PI is inversely related to the amount of assistance provided by the
LVAD.
• A high PI indicates more native ventricular filling and less pump support.
• A lower PI value indicates less ventricular filling due to less circulating blood
volume or an obstruction in the LVAD, meaning the patient requires more
pump support
• Suction events : Low PIs can lead to "suction events," which means the left
ventricle is underfilled and is being "sucked" into the LVAD.
• Management : Give IV fluids (but a VAD team should be contacted)
• The VAD team may decrease the RPMs, to reduce the speed of the device.
 146
AppleRN Classes

• LVADs depend on adequate preload. So avoid dehydration, overdiuresis,

bleeding etc leading to hypovolemia
Alarms: Pump failure alarm : Due to driveline disconnection, electrical failure, or
connector malfunction.
Assess the connection from the driveline, controller, and power source
Low battery alarm: Connect the LVAD to either battery or AC power
Controller failure alarm: Change controller
Patients should have a spare controller with them that's already programmed
Major complications : Hypotension
• Due to infection, gastrointestinal bleeding, and dehydration.
• Nursing consideration : Pulse many not be palpated in Continuous flow
LVADs.
• Might need doppler / arterial line to obtain BP measurements
• MAPs should be maintained between 70 and 80 mm Hg and shouldn't
exceed 90 mm Hg to ensure appropriate perfusion and to prevent
retrograde flow.
• Infection : Can be related to devise issues, endocarditis, bacteremia, or non
device-related infections such as urinary tract infections, respiratory tract
infections, cholecystitis, and Clostridium difficile infection.
Nursing Consideration : Monitor for infection – sepsis
Secure driveline by an anchoring device
Sterile technique should always be used when performing LVAD site care
Initial dressing changes are usually done daily, then decrease in frequency to
every other day or weekly
If a driveline infection is suspected, the dressing changes are increased to daily.
Patient education : Report erythema, purulent drainage, fever
 147
AppleRN Classes

GI bleed: Neurologic events. Patients with an LVAD are at increased risk for
ischemic and hemorrhagic strokes : So will need anticoagulants : watch for GI
bleed
VAD also affects the intestinal perfusion - changes in GI system – leading to
bleeding
Treatment : Fluids and blood products, fresh frozen plasma, Vit K
Risk : thrombosis and other thrombotic events
Dysrhythmia : Management of atrial dysrhythmias in patients with an LVAD is
similar to patients without an LVAD
Most patients with an LVAD have an implantable cardioverter-defibrillator (ICD).
CPR for patient with LVAD : Follow ACLS protocol – watch for bleeding. Call the
VAD coordinators.
Vascular disorders
Venous thrombosis: Associated with inflammatory process
Phlebitis: Vein inflammation associated with invasive procedures, such as IV lines
Deep vein thrombophlebitis: More serious than superficial thrombophlebitis
because of risk for pulmonary embolism
Elevate affected extremity above level of heart, Avoid using knee gatch or pillow
under knees. Do not massage extremity
DVT prevention Education
Drink plenty of fluids and limit caffeine and alcohol (dehydration)
Elevate legs , dorsiflex the feet (venous return), Exercise
Change position frequently (prevent venous stasis), Stop
smoking (vasoconstriction). Avoid restrictive clothing (eg, Spanx, tight jeans)
Venous insufficiency: Results from prolonged venous hypertension
Intervention: Elevate legs several times a day for at least 15 to 30 min.
Elevate feet approximately 6 inches at night.
 148
AppleRN Classes

Instruct client to avoid crossing legs and wearing constrictive clothing or

stockings.
Instruct client to wear elastic compression stockings and apply them after the
legs have been elevated and when swelling is at a minimum.
Varicose veins
Distended, protruding veins evident; appear darkened and tortuous .
sclerotherapy : (chemical agent is used)
Instruct the client to wear elastic stockings for prescribed time.
Rest for prescribed time. Mild analgesics such as acetaminophen (Tylenol) can be
taken for discomfort.
Vein stripping : removal of large varicose veins that cannot be treated with less-
invasive procedures.
Nursing Care : 3 E’s ; Elevation, Exercise and Elastic compression hose
Arterial Disorders
Assess pain , Monitor extremities for color, motion, sensation, pulses
Assess for signs of ulcer formation
Assist client in developing individualized exercise program
Instruct client to avoid extreme cold temperatures, constrictive clothing on
extremities, crossing legs
Instruct client never to apply direct heat to extremities
Instruct client to avoid smoking, caffeine
Raynaud’s disease
Vasospasm of arterioles, arteries of upper and lower extremities
Assess for blanching of extremity, followed by cyanosis; reddened tissue when
vasospasm is relieved; numbness, tingling, cold temperature of affected extremity
part
 149
AppleRN Classes

Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the

fingertips, and stress.
Interventions : Monitor pulses (diminished or absent peripheral pulses)
Administer vasodilators as prescribed . Instruct client to avoid precipitating
factors such as cold and stress. No smoking
Instruct client to avoid injuries to hands, fingers. Advice pt to keep hands warm
Wear gloves when outdoors, or handling cold food
Buerger’s disease (thromboangitis obliterans)
Occlusive disease of median and small arteries and veins
Assess for ischemic pain in digits while at rest; aching pain that is more severe at
night; cool, numb, or tingling sensation; cool and reddened extremities in
dependent position
Interventions: Instruct client to stop smoking , Monitor pulses
Instruct client to avoid injury to upper and lower extremities, Administer
vasodilators as prescribed

Cellulitis
Cellulitis is characterized by an edematous rash from subcutaneous tissue
inflammation. Elevate the extremity to promote lymphatic drainage of edema
 150
AppleRN Classes

Aortic Aneurysm
Abnormal dilation of arterial wall caused by localized weakness, stretching in
medial layer or wall of artery
Assessment
Pain extending to neck, shoulders, lower back, abdomen; syncope; dyspnea;
tachycardia; cyanosis
Aortic Dissection : (blood leakage into a vessel tear) Sudden onset of “tearing,”
“ripping,” and “stabbing” abdominal or back pain
X-rays reveal the classic “eggshell” appearance of an aneurysm
Pharmacological interventions
Administer antihypertensives as prescribed to maintain BP within normal limits,
prevent strain on aneurysms
A thoracic aortic aneurysm can put pressure on the esophagus and
cause dysphagia. Report any difficulty swallowing – increasing size of aneurysm
Abdominal aortic aneurysm (AAA) – most common, related to atherosclerosis
Constant gnawing feeling in abdomen; flank or back pain
Pulsating abdominal mass (do not palpate; may cause rupture – fatal
hypotension). Bruit
Elevated blood pressure (unless in cardiac tamponade or rupture of aneurysm)
Abdominal aneurysm resection
Surgical resection or excision of aneurysm
Repair can be done via femoral percutaneous placement of a stent graft
(endovascular aneurysm repair)
Or an open surgical incision of the aneurysm with synthetic graft placement.
Following repair of an abdominal aortic aneurysm, hemodynamic stability is a
priority. Prolonged hypotension can lead to graft thrombosis.
A falling blood pressure and rising pulse rate can also signify graft leakage.
 151
AppleRN Classes

Postoperative interventions
Monitor vital signs and peripheral pulses distal to graft site
Limit elevation of HOB to 45 degrees. Strict intake and output
Assess incisional site for bleeding, signs of infection
Instruct client not to lift objects heavier than 15 to 20 lb for 6 to 12 weeks
Instruct client to avoid strenuous activities
Hypertension
Increased blood pressure generally described on more than one reading of over
140/90 mm Hg
Primary or essential hypertension: No known cause for increased BP
Secondary hypertension: Occurs as result of other disorders or conditions
Assessment
May be asymptomatic; headache; dizziness; chest pain; flushed face; visual
disturbances; epistaxis
Chronic hypertension can result in ventricular hypertrophy
Pre hypertension – systolic 120 to 139 mm Hg; diastolic 80 to 89 mm Hg
Stage I hypertension – systolic 140 to 159 mm Hg; diastolic 90 to 99 mm Hg
Stage II hypertension – systolic greater than or equal to 160 mm Hg; diastolic
greater than or equal to 100 mm Hg
Mean arterial pressure (MAP)= average pressure within the arterial system –
normal= >60
MAP = (SBP + 2 DP)/3
Interventions
Obtain BP readings in both arms, sitting and standing
Determine family history of hypertension. Obtain weight. Assess renal function as
prescribed
 152
AppleRN Classes

Nonpharmacological interventions
Instruct client in weight reduction, exercise, relaxation techniques
Instruct client to avoid smoking
Instruct client to eat diet low in sodium as prescribed
Stepped-care approach: Administer medications and reevaluate
Client education : Instruct client about diet management- DASH diet
medications and side effects to report to physician, reading labels on foods to
assess for sodium, how to monitor and take blood pressure
Hypertensive Crisis
Any clinical condition requiring immediate reduction in BP
Acute and life-threatening condition
Assessment : Diastolic pressure higher than 120 mm Hg; headache; confusion;
changes in neurological status; Blurred vision, dizziness, and disorientation,
Tachycardia; tachypnea; dyspnea; cyanosis; Seizures, Epistaxis
Interventions: Maintain patent airway
Administer antihypertensives as prescribed (IV): nitroprusside (Nitropress),
nicardipine (Cardene IV), labetalol hydrochloride
Monitor vital signs, BP every 5 minutes
Assess neurological status such as pupils, LOC, muscle strength, to monitor for
cerebro vascular change.
Maintain emergency medications . Have resuscitation equipment readily available
Bed rest with HOB at 45 degrees. Strict intake and output
Nitroglycerin
Nitroglycerin (NTG) dilates veins and decreases venous return (preload), which
decreases cardiac oxygen demand.
Headache – give tylenol, may reduce dose of NTG
 153
AppleRN Classes

Orthostatic hypotension – safety – supine

Reflex tachycardia – may need beta blocker
Nitro S/L : Prophylactic
Place under the tongue and allow it to dissolve.
Store in original bottles, and in a cool, dark place.
One tab * 3 times, 5 mts apart. If pain not relieved by first tablet, call 911, then
take a second tablet.
Nitro patch
To ensure appropriate dose, patches should not be cut.
Place the patch on a hairless area of skin (chest, back, or abdomen) and rotate
sites to prevent skin irritation.
Remove old patch, wash skin with soap and water, and dry thoroughly before
applying new patch.
Remove the patch at night to reduce the risk of developing tolerance to
nitroglycerin.
Be medication-free between 10 and 12 hr/day.
Ointment: Avoid touching ointment with the hands.
Do not crush or chew oral nitroglycerin or isosorbide tablets.

Pediatric CV
Congestive Heart Failure (CHF) (Pediatrics)
Instruct parents regarding description of diagnosis, administration of medications
Administer 1 to 2 hours after feedings
Use calendar to mark off dose administered
Do not mix medication with foods, fluid. Give water following administration of
digoxin elixir to prevent tooth decay if the child has teeth
 154
AppleRN Classes

If dose is missed and more than 4 hours has elapsed, withhold dose and give next
dose at prescribed time; if less than 4 hours, then administer dose
If child vomits, do not administer replacement dose
If more than two consecutive doses missed, notify physician
Withhold Digoxin
If pulse is less than 90/min in an infant
If pulse is less than 70/min in children

Atrioventricular canal defect

Infant usually has mild to moderate CHF; cyanosis increases with crying
Patent ductus arteriosus
Normal fetal circulation conduit between the pulmonary artery and the aorta fails
to close. Widened pulse pressure, bounding pulses present, “machine hum”
murmur
Meds: Indomethacin or Ibuprofen
 155
AppleRN Classes

But Indoethacin affects blood flow to organs and so may lead to complications
such as renal failure.
Obstructive Defects
Blood exiting the heart meets area of anatomic narrowing (stenosis), causing
obstruction of blood flow
• Infants, children exhibit signs of CHF
Aortic stenosis - a narrowing of the aortic valve
Infants : Faint pulse, Hypotension, Tachycardia, Poor feeding tolerance
Children : Intolerance to exercise, Dizziness, Chest pain, Possible ejection murmur,
signs of exercise intolerance, chest pain, dizziness when standing for long periods
Pulmonic stenosis
Narrowing of the pulmonary valve or pulmonary artery that results in obstruction
of blood flow from the ventricles, Systolic ejection murmur, Cardiomegaly, HF.
Newborns with severe narrowing are cyanotic
Coarctation of aorta
Narrowing of the lumen of the aorta, that results in obstruction of blood flow
from the ventricle
Blood pressure higher, bounding pulses in upper extremities versus lower and
weak or absent pulses in lower extremities versus upper extremities, as well as
cool lower extremities
Signs of CHF may occur in infants
Other signs :- ›› Elevated blood pressure in the arms
›› Bounding pulses in the upper extremities
›› Decreased blood pressure in the lower extremities (difference of 20 mm
between upper and lower extremities)
›› Cool skin of lower extremities
››Weak or absent femoral pulses
 156
AppleRN Classes

›› Heart failure in infants

›› Dizziness, headaches, fainting, or nosebleeds in older children
Decreased Pulmonary Blood Flow
Obstructed pulmonary blood flow and anatomic defect between right and left
sides of heart
Pressure on right side of heart increases, exceeding pressure on left side of heart;
allows unoxygenated blood to enter systemic circulation
Tricuspid atresia
A complete closure of the tricuspid valve that results in mixed blood flow. An
atrial septal opening needs to be present to allow blood to enter the left atrium.
›› Infants – cyanosis, dyspnea, tachycardia
››Older children – hypoxemia, clubbing of fingers
Tetralogy of Fallot
four defects that result in mixed blood flow
≫»Pulmonary stenosis
≫»Ventricular septal defect
≫»Overriding aorta
≫»Right ventricular hypertrophy
Infants have acute episodes of cyanosis (hypercyanotic spells, blue spells,
tetralogy [TET] spells) during periods of crying, feeding, defecating. Knee chest
position is recommended.
Children present with squatting, clubbing of fingers, poor growth.
Infants with TOF will normally maintain oxygen saturations of 65%-85% until the
defect is surgically corrected.
Children can develop polycythemia (RBC)as a compensatory mechanism due to
prolonged tissue hypoxia. Polycythemia will increase blood viscosity, placing an
infant at risk for stroke or thromboembolism
 157
AppleRN Classes

Mixed Defects
Fully saturated systemic blood flow mixes with desaturated blood flow, causing
desaturation of systemic blood flow. Signs of CHF present
Hypoplastic left heart syndrome
Left side of the heart is underdeveloped. An ASD or patent foramen ovale allows
for oxygenation of the blood.
Mild cyanosis, signs of CHF occur until ductus arteriosus closes
Transposition of great arteries, great vessels
Aorta is connected to the right ventricle and the pulmonary artery is connected to
the left ventricle. A septal defect or a PDA must exist in order to oxygenate the
blood
Infants with minimal communication severely cyanotic at birth
Presence of large septal defects or patent ductus arteriosus may be less severely
cyanotic, but with symptoms of CHF
Truncus arteriosus
Failure of septum formation, resulting in a single vessel that comes off of the
ventricles. Characteristic murmur present
Infant exhibits moderate to severe CHF, variable cyanosis, poor growth, activity
intolerance
Interventions: Cardiovascular Defects
Monitor For signs of defect, Vital signs closely
Respiratory status for symptoms of respiratory distress
– Auscultate lungs for presence of crackles, rhonchi, wheezes
– Position in Reverse Trendelenburg’s if respiratory effort increases
Administer humidified oxygen, Provide endotracheal tube, ventilator care as
prescribed
Monitor for hypercyanotic spells, Assess for signs of CHF, Assess peripheral pulses
 158
AppleRN Classes

Maintain strict fluid restriction, Monitor intake, output, daily weight

– Provide high-calorie diet, Administer medications as prescribed
– Keep child as stress-free as possible, Child should have maximal rest
– Prepare child, parents for cardiac catheterization, if appropriate
Cardiac Surgery
Postoperative interventions
Monitor vital signs, Maintain aseptic technique
Monitor for signs of sepsis, including diaphoresis, lethargy, fever, altered level of
consciousness
Monitor all lines, tubes, catheters as appropriate
Assess for discomfort, pain; medicate as prescribed. Encourage periods of rest
If bleeding occurs at a catheterization site in the groin, the nurse should apply
direct pressure approximately 2.5 cm (1") above the insertion site.
Omit outside play for 2 to 3 weeks. Avoid strenuous activities and activities where
child could fall for 2 to 4 weeks. No organized physical education for 2 months
Avoid crowds for 2 weeks , maintain normal childhood routines and discipline
No-added-salt (NAS) diet as prescribed
Maintain clean, dry incision
Avoid immunizations, invasive procedures, dental care for 2 months
Stress importance of dental care, after waiting period, every 6 months
If signs of infection, respiratory difficulty, changes in normal behavior occur,
notify physician
Rheumatic Fever
Inflammatory, autoimmune disease that affects connective tissues of heart,
joints, subcutaneous tissues, blood vessels of central nervous system.
 159
AppleRN Classes

Presents 2 to 6 weeks after untreated or partially treated group A beta-hemolytic

streptococcal infection of upper respiratory tract
Assessment : Fever, inflamed joints/ nodules present, erythema marginatum,
carditis
Laboratory Tests : Throat culture for GABHS
Serum antistreptolysin-O (ASO) titer – elevated or rising titer, most reliable
diagnostic test
C-reactive protein (CRP) – elevated in response to an inflammatory reaction
Erythrocyte sedimentation rate – elevated in response to an inflammatory
reaction
Interventions: Administer massage, heat and cold therapies as prescribed for
joint pain
Bed rest during febrile phase. Limit physical exercise in child with carditis
Administer salicylates, anti-inflammatory agents as prescribed
Instruct parents about follow-up care, need for prophylactic antibiotic therapy
prior to dental care and invasive procedures
Kawasaki Disease: Interventions
Assess vital signs, heart sounds and rhythm
Assess extremities for edema, redness, desquamation
Assess mucous membranes for inflammation
Daily weights, Administer soft foods , Provide passive range of motion
Coronary artery aneurysms are the most serious potential sequelae in untreated
clients, leading to complications such as myocardial infarction and death.
Echocardiography is used to monitor these cardiovascular complications.
Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary
aneurysms and subsequent occlusion.
 160
AppleRN Classes

Cardiovascular Medications
Anticoagulants
Prevent extension and formation of clots by inhibiting factors in clotting cascade
and decreasing blood coagulability
Side effects : Bleeding: Implement bleeding precautions
Heparin sodium
Normal activated partial thromboplastin time (aPTT) 20 to 30 seconds –
Therapeutic : 1.5 to 2.5 times the control value
Antidote is protamine sulfate
Warfarin sodium (Coumadin)
Normal PT is 11 to 12.5 seconds
Therapeutic level of INR with warfarin = 2-3
Avoid green leafy vegetables??? – don’t change routines
 161
AppleRN Classes

Antidote is vitamin K (phytonadione [AquaMEPHYTON])

Thrombolytic, Antiplatelet
Thrombolytic : Dissolve clots
Antidote : Aminocaproic acid (Amicar) is antidote for streptokinase
Antiplatelet - Inhibit aggregation of platelets and prolong bleeding time – Aspirin
Side effects : Bleeding
Interventions: Monitor for bleeding
Implement bleeding precautions

Antihypertensive Medications
Diuretics : Blocks the reabsorption of sodium, chloride and water
Loop : furosemide (Lasix), Bumetanide (Bumex), Torsemide (Demadex)
Thiazide Diuretics : work in the early distal convoluted tubule
Hydrochlorothiazide (Hydrodiuril), Indapamide (Lozide, Lozol) Chlorthalidone
(Hygroton), Metolazone (Zaroxolyn)
Lasix – Ototoxicity, Dig toxicity with Hypokalemia
Electrolyte imbalance: hypokalemia, hyponatremia, hypocalcemia, hyperglycemia,
hypomagnesemia
 162
AppleRN Classes

Electrolyte imbalance: hypokalemia, hyponatremia, hypocalcemia, hyperglycemia,

hypomagnesemia
Monitor vital signs (orthostatic hypotension), appropriate laboratory values, I&O,
Daily Weight
High-potassium foods (BP DC NS) bananas, potatoes, dried fruits, citrus fruit, nuts
and spinach).
Avoid night time administrations- nocturia
Diabetic clients- monitor glucose
Potassium-Sparing Diuretics -spironolactone (Aldactone), triamterene (Dyrenium),
amiloride (Midamor)
Block the action of aldosterone (sodium and water retention), which results in
potassium retention and the secretion of sodium and water.
S/E ; Hyperkalemia, Endocrine effects (impotence in male clients; irregularities of
menstrual cycle in female clients)
Low K foods

Teach clients to avoid salt substitutes that contain potassium.

Triamterene (Dyrenium) : Blue urine
 163
AppleRN Classes

Osmotic diuretics – Manitol

Reduce ICP - drawing off fluid from the brain into the bloodstream.
Use a filter needle when drawing from the vial and a filter in the IV tubing (To
prevent administering microscopic crystals)
Monitor daily weight, I&O, and serum electrolytes.
Alpha -Adrenergic Blockers
Causes vasodilation and decrease the blood pressure. Ends with “zosin”
Example : prazosin, doxazosin mesylate (Cardura), terazosin
Side effects : Hypotension, Tachycardia, Sodium and water retention
GI disturbances: Take the initial dose at bedtime to decrease “first-dose”
hypotensive effect
Interventions: Monitor blood pressure and apical heart rate
Monitor for fluid retention and edema
Alpha2 Agonists
Clonidine, Methyldopa : Act on CNS and decrease the cardiac output
S/E : Drowsiness and sedation – Safety precautions
Dry mouth : Encourage clients to chew gum or suck on hard candy, and to take
small amounts of water or ice chips
Rebound hypertension : if abruptly discontinued
Transdermal patches are applied every seven days.
Advise clients to apply patch on hairless, intact skin on torso or upper arm
Renin Angiotensin Mechanism
Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotension II Receptor
Blockers (ARB)
Prevent peripheral vasoconstriction
 164
AppleRN Classes

ACE - Ends in “prill” : captopril, Enalapril Fosinopril , Lisinopril , Ramipril,

,Moexipril
ARB – Ends in “sartan” : losartan, Valsartan, Irbesartan, Candesartan, Olmesartan
Hyperkalemia and hypotension are contraindications for giving ACE inhibitors

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotension II Receptor

Blockers (ARB)
Side effects
ACE : Persistent dry cough, Angioedema (swelling -tongue and oral pharynx-
airway obstruction)
First-dose orthostatic hypotension (start low dose, monitor other meds
?diuretics?BP?)
Hypotension, Tachycardia, Hyperkalemia, Hypoglycemia in diabetic client
Captorpil – neutropenia, Rash and dysgeusia (altered taste)
Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotension II Receptor
Blockers (ARB)
 165
AppleRN Classes

Interventions: Avoid use with potassium supplements and potassium-sparing

diuretics
NSAIDs may decrease the antihypertensive effect of ACE inhibitors. Avoid
concurrent use.
captopril and moexipril should be taken at least 1 hr before meals. Other ACE
inhibitors can be taken with or without food.
Monitor vital signs and for signs of hyperkalemia, Instruct diabetic client about
the risk for hypoglycemia
Instruct client to report persistent dry cough, ACE inhibitors can increase levels of
lithium
Renin Inhibitors -aliskiren (Tekturna)
S/E – Diarrhea, Angioedema, Hyperkalemia
High-fat meals interfere with absorption
Nitroprusside - a centrally-acting vasodilator
Avoid prolonged use, use separate IV line. Light brown color is normal.
Plasma level at less than 10 mg/dL.
Monitor for Cyanide poisoning (headache and drowsiness, and may lead to
cardiac arrest – D/C med.
Calcium Channel Blockers
Many ends with “dipine”. Eg- Nifedipine, Amlodipine
Other meds: Verapamil & Diltiazem
Consuming grapefruit juice can lead to toxicity
Nifedipine : Reflex tachycardia, Peripheral edema
Verapamil : constipation, dig toxicity
Verapamil and Diltiazem : Orthostatic hypotension, peripheral edema,
bradycardia, heart failure, heart block
 166
AppleRN Classes

Beta Adrenergic Blockers

Ends with “lol”
Propranolol and nadolol affects both heart and lungs. Bronchoconstriction can
occur. Avoid in asthma pts.
S/E – Bradycardia, AV block, orthostatic hypotension (avoid sudden changes in
position), sexual dysfunction
Nesiritide
Dilates arteries and veins and is used to treat decompensated heart failure
Side effects: Hypotension, Dysrhythmias
Interventions: Monitor apical heart rate and blood pressure, urine output, and
body weight. Monitor for signs of resolving heart failure
Digoxin
Increased force of myocardial contraction, and decreased Heart Rate
Avoid hypokalemea (nausea/vomiting, general weakness) - Risk for Dig Toxicity
Therapeutic serum levels : 0.5 to 2.0 ng/mL. Toxic – HAD DNV (Halo, Anorexia,
Diarrhea, Dizzness, N/V)
Don’t miss dose –don’t take double if missed. Check apical pulse, hold if < 60
Nitroglycerin
Nitroglycerin (NTG) dilates veins and decreases venous return (preload), which
decreases cardiac oxygen demand.
Headache – give tylenol, may reduce dose of NTG.
Orthostatic hypotension – safety. Reflex tachycardia – may need beta blocker
Nitro S/L : Prophylactic. Place under the tongue and allow it to dissolve. Store in
original bottles, and in a cool, dark place.
One tab * 3 times, 5 mts apart. If pain not relieved by first tablet, call 911, then
take a second tablet.
 167
AppleRN Classes

Nitro patch: To ensure appropriate dose, patches should not be cut.

Place the patch on a hairless area of skin (chest, back, or abdomen) and rotate
sites to prevent skin irritation.
Remove old patch, wash skin with soap and water, and dry thoroughly before
applying new patch. Remove the patch at night to reduce the risk of developing
tolerance to nitroglycerin.
Be medication-free between 10 and 12 hr/day. Ointment: Avoid touching
ointment with the hands. Do not crush or chew oral nitro tablets.
Ranolazine (Ranexa): Anti anginal (reduces cardiac oxygen demand)
S/E : QT prolongation: Get ECG baseline. Contraindicated in clients -liver
dysfunction
Monitor the client's vital signs and electrocardiogram (ECG) frequently.
Sodium channel blockers : Stabilize cardiac membranes, Procainamide, Quinidine
S/E Systemic lupus syndrome (fever, painful and swollen joints, butterfly-shaped
rash on face).
Potassium channel blockers: Prolong cardiac cycle : Amiodarone, sotalol
Amiodarone - Pulmonary toxicity. Obtain baseline chest x-ray and pulmonary
function tests. Visual issues, photophobia. Avoid grapefruit juice (toxicity)
Adverse effects may continue for an extended period of time after the medication
is discontinued.
Statins
Antilipemic agents (lower cholesterol), Hepatotoxic, Renal toxic
Baseline liver and kidney function tests should be obtained and monitored
periodically throughout the course of therapy.
Myopathy can occur – Monitor CK levels
Rhabdomyolysis.: Advise clients to report muscle aches, pain, and tenderness
Evening dosing is best because most cholesterol is synthesized during the night.
 168
AppleRN Classes

GI system
Anatomy and Physiology
Functions of gastrointestinal (GI) system: Process food substances; absorb
products of digestion into blood; excrete unabsorbed materials; provide
environment for microorganisms to synthesize nutrients, such as vitamin K
Assessment: Abdominal assessment
Inspect abdominal skin for color, abnormalities, contour, tautness, abdominal
distention
Auscultate for bowel sounds, Percuss for air or solids
Palpate for tenderness or masses – Referred pain

Bowel sounds
Auscultate prior to percussion and palpation
Normal bowel sounds occur 5 to 30 times/min: Auscultate in all four quadrants
Listen at least 5 minutes in each quadrant before assuming sounds are absent
Bowel sounds are normally intermittent (every 5-15 seconds)
Borborygmi sounds: Borborygmi sounds are loud, gurgling sounds
 169
AppleRN Classes

Usually normal - suggesting increased peristalsis.

Can also be abnormal – Gastroenteritis and the early phases of mechanical
obstruction.
GERD
Backflow of gastric and duodenal contents into esophagus
Caused by incompetent lower esophageal (cardiac) sphincter, pyloric stenosis,
motility disorder
The primary treatment of GERD is diet and lifestyle changes, advancing to
medication use (antacids, H2-receptor antagonists, proton pump inhibitors) and
surgery (Fundoplication).
Untreated GERD: inflammation, adenocarcinoma of the esophagus.
Fundoplication: The fundus of the stomach is wrapped around and behind the
esophagus through a laparoscope to create a physical barrier
Risk Factors (GERD)
Obesity, Older age (delayed gastric emptying and weakened LES tone)
Sleep apnea, Nasogastric tube, Excessive ingestion of foods that relax the LES
fatty and fried foods, chocolate, caffeinated beverages (coffee), peppermint, spicy
foods, tomatoes, citrus fruits, and alcohol
Physical Assessment Findings: Tooth erosion, Hoarseness
Contributing factors
Abdominal distention (from overeating or delayed emptying)
Increased abdominal pressure from obesity, pregnancy, bending at the waist,
ascites, or tight clothing at the waist
Medications that relax the LES (theophylline, nitrates, calcium channel blockers,
anticholinergics, and diazepam
Increased gastric acid caused by medications (NSAIDs) or stress (environmental)
Debilitation resulting in weakened LES tone
 170
AppleRN Classes

Hiatal hernia (LES displacement into the thorax with delayed esophageal
clearance), Lying flat
Subjective Data (GERD): Dyspepsia (indigestion )
Pain is “wavelike” and may radiate (neck, jaw, or back) , worsens with position
(bending, straining, laying down). Relieved by antacids
Pain occurs after eating and may last 20 min to 2 hr.
Throat irritation (chronic cough, laryngitis), hypersalivation, bitter taste in mouth
(caused by regurgitation). Chronic GERD can lead to dysphagia.
Atypical chest pain (from esophageal spasm). Increased flatus and eructation
(burping).
Interventions GERD: Avoid triggers
Follow low-fat, high-fiber diet; avoid caffeine, tobacco, carbonated beverages
Avoid eating and drinking 2 hours before bedtime
Meds : antacids, histamine H2 inhibitors, gastric acid pump inhibitors
Complications: Aspiration of gastric secretion
Reflux of gastric fluids into the esophagus can be aspirated into the trachea.
Risks associated with aspiration include: Asthma exacerbations from inhaled
aerosolized acid.
Frequent upper respiratory, sinus, or ear infections.
Aspiration pneumonia.
Barrett’s epithelium (premalignant) and esophageal adenocarcinoma.
Cause – Reflux of gastric fluids leads to esophagitis. In chronic esophagitis, the
body continuously heals inflamed tissue, eventually replacing normal esophageal
epithelium with premalignant tissue (Barrett’s epithelium) or malignant
adenocarcinoma.
Nursing Actions – Determine the cause of GERD with the client and review
lifestyle changes that can decrease gastric reflux.
 171
AppleRN Classes

Esophageal Varices
Dilated, tortuous veins in submucosa of esophagus caused by portal hypertension
Assessment
Hematemesis; melena; tarry stools; ascites; jaundice; hepatosplenomegaly;
dilated abdominal veins
Physical Assessment Findings (Bleeding Esophageal Varices)
Hypotension and Tachycardia
The client may experience no manifestations until the varices begin to bleed.
Activities that precipitate bleeding are the Valsalva maneuver, lifting heavy
objects, coughing, sneezing, and alcohol consumption.
Risk Factors
Portal hypertension (elevated blood pressure in veins that carry blood from the
intestines to the liver) is caused by impaired circulation of blood through the liver.
Collateral circulation subsequently develops, creating varices in the upper
stomach and esophagus. Varices are fragile and can bleed easily.
Portal hypertension is the primary risk factor for the development of esophageal
varices
Alcoholic cirrhosis, Viral hepatitis.
Older adult clients frequently have depressed immune function, decreased liver
function, and cardiac disorders that make them especially vulnerable to bleeding.
Nursing Care If bleeding is suspected
Establish IV access with a large bore needle. Monitor vital signs and hematocrit
type and crossmatch for possible blood transfusions. Monitor for overt and occult
bleeding.
Medications
Nonselective beta-blockers (propranolol [Inderal]) are prescribed to decrease
heart rate and consequently reduce hepatic venous pressure.
 172
AppleRN Classes

Used prophylactically (not for emergency hemorrhage).

Vasoconstrictors : IV synthetic vasopressin and natural somatostatin have been
proven most effective to increase portal inflow.
Nursing Considerations – Vasopressin cannot be given to clients who have
coronary artery disease due to resultant coronary constriction.
Potent vasoconstriction may also cause problems with peripheral and cerebral
circulation.
Procedures
Endoscopic injection sclerotherapy or variceal band ligation
Ligating bands can be placed, and/or injection sclerotherapy can be performed
during an endoscopic procedure. Used only for active bleeding and not
prophylactically.
Nursing Actions: Administer preprocedure sedation. After the procedure, monitor
vital signs and take measures to prevent aspiration.
Sclerotherapy carries a greater risk of postoperative hemorrhage.
Antacids and/or H2 receptor blockers are administered postoperatively.
Esophagogastric balloon tamponade
An esophagogastric tube with esophageal and gastric balloons is used to
compress blood vessels in the esophagus and stomach.
Nursing Actions: Check balloons for leaks prior to insertion.
Monitor placement of the tube and observe for possible obstruction of airway.
Monitor for aspiration into the lungs and secretions or blood from the esophagus
Provide oral suction as needed.
Maintain balloon pressure at prescribed pressure for prescribed time to decrease
risk of esophageal or gastric necrosis from ischemia.
Irrigate the tube as prescribed and document color of return (clear vs. bloody).
 173
AppleRN Classes

Monitor the client who has decreased mentation or confusion and who may pull
on the tube.
Complication: Hypovolemic Shock – due to hemorrhage from varices.
Observe for manifestations of hemorrhage and shock (tachycardia, hypotension).
Monitor vital signs, Hgb, Hct, and coagulation studies.
Replace losses and support therapeutic procedures to stop and control bleeding.
Cirrhosis
Cirrhosis is extensive scarring of the liver. Normal liver tissue is replaced with
fibrotic tissue that lacks function.
Affect the liver’s ability to handle the flow of bile. Jaundice is often the result.
Health Promotion and Disease Prevention
The three types of cirrhosis
Postnecrotic: caused by viral hepatitis or certain medications or toxins.
Laennec’s: caused by chronic alcoholism.
Biliary: caused by chronic biliary obstruction or autoimmune disease.
Stay current on immunizations. Encourage the client to avoid drinking alcohol.
Alcohol recovery program.
Risk Factors
Alcohol abuse, Hepatitis – Autoimmune/ Hep B,C,D/Biliary
Steatohepatitis (fatty liver disease causing chronic inflammation)
Damage to the liver caused by drugs, toxins, and other infections
Cardiac cirrhosis : severe right heart failure inducing necrosis and fibrosis due to
lack of blood flow
Subjective Data and assessment findings
Fatigue, Weight loss, abdominal pain, distention
 174
AppleRN Classes

Pruritus (severe itching of skin)

Confusion or difficulty thinking – hepatic encephalopathy
Personality and mentation changes :emotional lability, euphoria, sometimes
depression
Altered sleep/wake pattern. Gastrointestinal bleeding– Varices
Other bleeding signs : Petechiae, ecchymoses, nose bleed
Physical Assessment Findings
Dependent peripheral edema of extremities and sacrum
Asterixis (liver flapping tremor) – coarse tremor characterized by rapid,
nonrhythmic extension and flexion of the wrists and fingers
It is assessed by having the client extend the arms and dorsiflex the wrists
Correlates with progression into hepatic encephalopathy
Fetor hepaticus (liver breath) – fruity or musty odor
Nursing Care
Respiratory status – Monitor oxygen saturation levels and distress.
Position : sit in a chair or elevate the head of the bed to 30° with feet elevated.
Skin integrity – Monitor for skin breakdown. Prevent pressure ulcers.
Pruritus: Wash with cold water, apply lotion
Fluid balance – Monitor for signs of fluid volume excess. Keep strict intake and
output, obtain daily weights, and assess ascites and peripheral edema. Restrict
fluids and sodium if prescribed.
Vital signs – Monitor vital signs and pain level .
Neurological status : Hepatic encephalopathy : Lactulose
Nutritional status – give diet education
High-carbohydrate, low-protein, moderate-fat, and low-sodium diet with vitamin
supplements such as thiamine, folate, and multivitamins.
 175
AppleRN Classes

Gastrointestinal status
Ascites: measure abdominal girth daily over the largest part of the abdomen.
Mark the location of tape for consistency. Observe the client for potential
bleeding complications.
Medications
Avoid opioids, sedatives, and barbiturates. Give Diuretics: Decrease excessive
fluid in the body. Give Beta-blocking agent: to prevent bleeding varices
Lactulose : Used to promote excretion of ammonia from the body through the
stool. Nonabsorbable antibiotic: Rifaximin : Can be used in place of lactulose.
Surgery – Liver transplant Procedure – Paracentesis
Complication – Encephalopathy, Varices
Client Education : Diet
■■ Encourage the client abstain from alcohol and engage in alcohol recovery
program.
Helps prevent further scarring and fibrosis of liver.
Allows healing and regeneration of liver tissue.
Prevents irritation of the stomach and esophagus lining.
Helps decrease the risk of bleeding.
Helps to prevent other life-threatening complications.
■■ Consult with provider prior to taking any over-the-counter medications or
herbal supplements.
Vitamin B12 Deficiency (Pernicious Anemia)
Results from inadequate intake of vitamin B12 or lack of absorption of ingested
vitamin from intestinal tract
Assessment : Smooth, beefy red tongue, Paresthesias of hands and feet
Disturbance in gait and balance
 176
AppleRN Classes

Interventions
Administer vitamin B12 injections as prescribed for life
Hiatal Hernia : Portion of stomach herniates through diaphragm and into thorax
Heartburn; regurgitation or vomiting; dysphagia; feeling of fullness
Interventions
Provide small frequent meals. Limit amount of liquid taken with meals
Advise client not to recline for 1 hour after feeding
Appendicitis
Assessment: Abdominal pain most intense at McBurney’s point
Client in side-lying position, with abdominal guarding
Constipation or diarrhea, Peritonitis
Increased fever; chills; pallor; progressive abdominal distention; abdominal pain;
restlessness; right guarding of abdomen; tachycardia; tachypnea
Surgery - Appendectomy
Signs in Appendicitis
Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal irritation
Obturator sign (RLQ pain with internal and external rotation of the flexed right
hip): Suggests the inflamed appendix is located deep in the right hemipelvis
Psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip
against resistance): Suggests that an inflamed appendix is located along the
course of the right psoas muscle
Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough): Suggests
localized peritonitis
Preoperative interventions
Monitor for signs of ruptured appendix, peritonitis
Position client in right side-lying or low to semi-Fowler’s position
 177
AppleRN Classes

Avoid application of heat to abdomen, Avoid laxatives, enemas

Postoperative interventions, Maintain NPO status until bowel function returns
With rupture, expect Penrose drain to be in place or incision left open
Drainage from Penrose may be profuse
Position client in right side-lying or low to semi-Fowler’s position, legs flexed to
facilitate drainage
Ruptured Appendix
Peritonitis : acute inflammation of peritoneum- the endothelial lining of the
abdominal cavity.
Clinical manifestations : distended abdomen; a rigid, boardlike abdomen;
diminished bowel sounds; inability to pass flatus
abdominal pain (localized, poorly localized, or referred to the shoulder or thorax);
anorexia, nausea, and vomiting; rebound tenderness in the abdomen;
high fever; tachycardia; dehydration from the high fever; decreased urinary
output; Hiccups, possible compromise in respiratory status.
LACTOSE INTOLERANCE
Due to not enough lactase from small intestine
Lactase : the enzyme that digests the milk sugar lactose.
S/S : Pain, abdominal cramps, bloating, and diarrhea.
Test to diagnose : Hydrogen breath test
More hydrogen is produced due to fermentation of lactose in colon (which is not
absorbed in small intestine)
Treatment – lactose-free dairy products , supplements
Peptic Ulcer Disease
It is an erosion of the mucosal lining of the stomach or duodenum.
There are gastric ulcers and duodenal ulcers
 178
AppleRN Classes

Pain : Gastric Ulcer : 30 to 60 min after a meal. Rarely occurs at night

Pain exacerbated by ingestion of food
Pain : Duodenal Ulcer : 1.5 to 3 hr after a meal. Often occurs at night.
Pain may be relieved by ingestion of food or antacid.
Assessment findings:
Epigastric pain upon palpation.
Pain that radiates to the back may indicate perforation is imminent.
Sudden, severe abdominal pain is a sign of perforation.
May be left upper epigastrium (gastric) or right epigastrium (duodenal).
Bloody emesis (hematemesis) or stools (melena). Weight loss.
Risk Factors: Causes of peptic ulcers:
Helicobacter pylori (H. pylori) infection
Nonsteroidal anti-inflammatory drug (NSAID) and corticosteroid use
Severe stress, Excess alcohol ingestion, Chronic pulmonary or kidney disease
Zollinger-Ellison syndrome (combination of peptic ulcers, hypersecretion of
gastric acid, and gastrin secreting tumors)
Diagnostic Procedures
Esophagogastroduodenoscopy (EGD) : Provide definitive diagnosis
Gastric samples are obtained to test for H. pylori.
Medications (bismuth, misoprostol, sucralfate, histamine2 antagonists) can
interfere with testing for H. pylori (false negatives). Therefore, a complete
medication history should be reviewed prior to testing.
Nursing Care
Instruct client to avoid foods that cause distress.
Monitor for orthostatic changes in vital signs and tachycardia as these findings are
suggestive of gastrointestinal bleeding.
 179
AppleRN Classes

Administer medication as prescribed. Decrease environmental stress.

Encourage rest periods. Encourage smoking cessation and avoiding alcohol
consumption.
Medications: Antibiotics: Eliminate H. pylori infection
Histamine2-receptor antagonists: ranitidine hydrochloride (Zantac), famotidine
(Pepcid)
Suppress the secretion of gastric acid by selectively blocking H2 receptors in
parietal cells lining the stomach.
Nursing Considerations
Ranitidine and famotidine can be administered IV in acute situations.
Ranitidine can be taken with or without food.
Treatment of peptic ulcer disease is usually started as an oral dose twice a day
until the ulcer is healed, followed by a maintenance dose usually taken once a day
at bedtime.
Proton pump inhibitors: pantoprazole (Protonix), esomeprazole (Nexium)
Reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces
gastric acid.
Reduce basal and stimulated acid production.
Client Education
Instruct the client not to crush, chew, or break sustained-release capsules.
Instruct the client to take med once a day prior to eating in the morning.
Encourage the client to avoid alcohol and irritating medications (NSAIDs).
Mucosal protectant: sucralfate (Carafate)
Give 1 hr before meals and at bedtime.
Monitor for adverse effect of constipation.
Antacids: aluminum carbonate, magnesium hydroxide (Milk of Magnesia)
 180
AppleRN Classes

Antacids are given 1 to 3 hr after meals to neutralize gastric acid, which occurs
with food ingestion and at bedtime.
Nursing Considerations – Give 1 hr apart from other medications to avoid
reducing the absorption of other medications.
Client Education
Encourage compliance by reinforcing the intended effect of the antacid (relief of
pain, healing of ulcer).
Teach clients to take all medications at least 1 hr before or after taking an antacid.
Gastric surgeries
Gastrectomy – All or part of the stomach is removed with laparoscopic or open
approach.
Antrectomy – The antrum portion of the stomach is removed.
Gastroduodenal reconstrduction
Gastrojejunostomy (Billroth II procedure) – The lower portion of the stomach is
excised, the remaining stomach is anastomosed to the jejunum, and the
remaining duodenum is surgically closed.
Vagotomy – A highly selective vagotomy severs only the nerve fibers that disrupt
acid production.
Pyloroplasty – The opening between the stomach and small intestine is enlarged
to increase the rate of gastric emptying.
Nursing Actions (surgery) : Monitor incision for evidence of infection.
Position : semi-Fowler’s position to facilitate lung expansion.
NG tube : Scant blood may be seen in first 12 to 24 hr.
Notify the provider before repositioning or irrigating the nasogastric tube
(disruption of sutures). Monitor bowel sounds. Advance diet as tolerated.
Administer medication as prescribed (analgesics, stool softeners).
 181
AppleRN Classes

vitamin and mineral supplements: vitamin B12, vitamin D, calcium, iron, and
folate. Consume small, frequent meals while avoiding large quantities of
carbohydrates as directed – No concentrated sweets
Complications : Perforation/Hemorrhage : it is an emergency situation. severe
epigastric pain spreading across the abdomen.
The abdomen is rigid, board-like, hyperactive to diminished bowel sounds, and
there is rebound tenderness.
shock (hypotension, tachycardia, dizziness, confusion), and decreased
hemoglobin.
Nursing Actions: Perform frequent assessments . Report findings. Prepare the
client for endoscopic or surgical intervention.
Replace fluid and blood losses to maintain blood pressure. Insert nasogastric
tube, and provide saline lavages.
Pernicious anemia occurs due to a deficiency of the intrinsic factor normally
secreted by the gastric mucosa.
Manifestations include pallor, glossitis, fatigue, and paresthesias.
Client Education – Monthly lifelong vitamin B12 injections will be necessary.
Dumping syndrome
After gastric surgery- occur following eating, Rapid gastric emptying
Assist/instruct the client to lie down when vasomotor manifestations occur
 182
AppleRN Classes

Client Education
Lying down after a meal slows the movement of food within the intestines.
Limit the amount of fluid ingested at one time.
Eliminate liquids with meals, for 1 hr prior to, and following a meal.
Consume a high-protein, high-fat, ? low-fiber (insoluble) , and low- to moderate-
carbohydrate diet.
Avoid milk, sweets, or sugars (fruit juice, sweetened fruit, milk shakes, honey,
syrup, jelly).
Consume small, frequent meals rather than large meals.
Hemorrhoids
Hemorrhoids are distended or edematous intestinal veins resulting from
increased intra-abdominal pressure (straining, obesity).
Pregnancy increases the risk of hemorrhoids.
Assessment : Bright red bleeding with defecation
Surgery – hemorrhoidectomy. Pain is a priority as patient will dread having BM
Postoperative interventions following hemorrhoidectomy
Manage Pain, Assist client to prone or side-lying position
Maintain ice packs over dressing as prescribed, Monitor for urinary retention
Instruct client to limit sitting to short periods. Instruct client to use sitz baths 3 to
4 times a day
Bariatric Surgery
Size of stomach reduced using various procedures
Obese clients at increased postoperative risk for pulmonary, thromboembolic
complications, death
Postoperative interventions: Client teaching points about diet
Instruct client to eat small frequent meals, low in calories
 183
AppleRN Classes

Instruct client to eat, drink fluids at separate times during meal

Instruct client to take chewable or liquid multivitamin daily as prescribed
Gastritis
Gastritis is an inflammation in the lining of the stomach.
Acute gastritis - sudden onset - gastric bleeding if severe.
Chronic gastritis - slow onset -pernicious anemia.
Erosive gastritis: Black, tarry stools; coffee-ground emesis
Acute abdominal pain: Medications and surgery – same as PUD
NPO, except ice chips, until symptoms of acute gastritis subside, then advance
diet as prescribed
Monitor for signs of hemorrhage such as hematemesis, tachycardia, hypotension;
report immediately
Instruct client to avoid irritating foods, such as spicy foods, highly seasoned foods,
caffeine, alcohol, nicotine
Irritable Bowel Syndrome
IBS causes changes in bowel function (chronic diarrhea, constipation, or
abdominal pain). IBS is difficult to diagnose with specific tests
Client education: Avoid foods that contain dairy, eggs, and wheat products.
Avoid alcoholic and caffeinated beverages and other fluids containing fructose
and sorbitol.
Drink 2 to 3 L of fluid per day from food and fluid sources.
Increase the amount of daily fiber intake (approximately 30 to 40 g/day).
Cholecystitis
Inflammation of the gallbladder that may occur as an acute or chronic process
Assessment: Epigastric pain radiating to scapula 2 to 4 hours after eating fatty
foods
 184
AppleRN Classes

Feeling of abdominal fullness, dyspepsia, Pain localized in right upper quadrant

Guarding, rigidity, rebound tenderness, Mass palpated in right upper quadrant
Murphy’s sign : Cessation of breathing while palpating liver
Biliary obstruction: Jaundice; dark orange and foamy urine; steatorrhea; clay-
colored stools; pruritus
Pruritis Management
Apply cool wet cloths to skin . Apply lotion – calamine, lanolin
Use gloves (cotton), Long sleeved shirt, No hot shower, Cut nails short, Mild soap
Interventions
NPO during nausea or vomiting episodes
Administer analgesics as prescribed (morphine sulfate or codeine sulfate
generally avoided because they cause spasm of sphincter of Oddi, increase pain
Instruct client to eat small, low-fat meals, avoiding gas-forming foods
Surgical interventions: Cholecystectomy, Choledochotomy
Postoperative interventions
Monitor for respiratory complications – sims position to expel co2 gas used in lap
surgery , Encourage coughing, deep-breathing
Maintain NPO status, NG tube suction as prescribed
Advance diet from clear liquids to solids as prescribed
Instruct client about splinting abdomen to prevent discomfort during coughing
Intestinal Obstruction
Bowel sounds are hyperactive above the obstruction and hypoactive below.
Mechanical (90%) or nonmechanical (10%) causes.
Mechanical obstruction : Adhesions, tumors, fibrosis, Hernia, Fecal impactions
Volvulus (twisting) or intussusception (telescoping) of bowel segments
 185
AppleRN Classes

Nonmechanical obstructions (paralytic ileus) result from decreased peristalsis

secondary to:
Neurogenic disorders (manipulation of the bowel during major surgery and spinal
fracture)
Vascular disorders (vascular insufficiency and mesenteric emboli)
Electrolyte imbalances (hypokalemia). Inflammatory responses (peritonitis or
sepsis)
Intussusceptions in Children
The classic clinical triad is
1. intermittent, severe, crampy abdominal pain;
2. A palpable “sausage-shaped” mass on the right side of the abdomen;
3. “currant jelly” stools: mixture of blood and mucus
Other manifestations include
inconsolable crying, drawing the knees up to the chest during episodes of pain,
and vomiting.
The child may appear normal and comfortable between episodes.
A contrast enema is used for diagnostic purposes and often reduces the
intussusceptions. An air enema is considered safer than a barium enema.
Small bowel obstruction : Rapid onset of Nausea, vomiting, intermittent
abdominal pain, abdominal distention.
Delay in treatment can lead to vascular compromise, bowel ischemia, perforation
Large bowel obstruction : Gradual onset of symptoms, cramping pain, abdominal
distention, absolute constipation, lack of flatus
Pediatrics- inconsolable cry and drawing up of legs towards abdomen – suspect
intestinal obstruction
Nursing Care
Nonmechanical cause of obstruction. Nothing by mouth with bowel rest.
 186
AppleRN Classes

Assess bowel sounds. Provide oral hygiene.

Administer IV fluid and electrolyte replacement (particularly potassium).
Pain management, as prescribed (once diagnosis identified).
Encourage ambulation. Mechanical obstruction usually requires surgery –
Exploratory laparotomy
Monitor for hemodynamic instability. Administer IV fluid replacement and
maintenance as prescribed.
Monitor bowel sounds. Maintain NG tube patency and measure output.
Clamp NG tube as prescribed to assess the client’s tolerance prior to removal.
Advance diet as tolerated when prescribed, beginning with clear liquids – clamp
tube after eating for 1 to 2 hr.
Instruct client to report intolerance of intake following NG tube removal (nausea,
vomiting, increasing distention).
Complications: Dehydration (potential hypotension), Electrolyte Imbalance
Metabolic Alkalosis (vomiting)
Perforation - Peritonitis. This condition can be fatal if it is not treated quickly.
Ulcerative Colitis
Ulcerative and inflammatory disease of bowel (large intestine)
Results in poor absorption of nutrients
Assessment: Severe diarrhea; may contain blood, mucus
Dehydration, electrolyte imbalances, anemia from blood loss.
Nonsurgical interventions
Administer intravenous (IV) fluids, total parenteral nutrition as prescribed
Restrict activity level as prescribed . Monitor bowel function, abdominal
distention . Low-residue diet as prescribed . Administer bulk-forming agents as
prescribed
 187
AppleRN Classes

Postoperative colostomy
Monitor for color changes in stoma (pink to bright red, shiny is normal)
Expect liquid stool in immediate postoperative period, depending on area of
colostomy
Instruct client to avoid foods that cause excess gas formation, odor (broccoli,
Brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, and peas, should
be avoided)
Foods that help eliminate odor with a colostomy include yogurt, buttermilk,
cranberry juice, and parsley.
Postoperative ileostomy
Normal stool is liquid. Monitor for dehydration, electrolyte imbalances
No suppositories administered through ileostomy
Peristomal skin care
Cleansing peristomal skin with mild soap and water
Ensuring that the ostomy appliance fits well so that skin is protected from liquid
stool drainage
Trimming the appliance opening to 1/8 inch (0.32 cm) larger than the stoma so
that it "hugs" the stoma without touching stoma tissue
Ileostomy Diet
Diet- immediate post op period – low fiber – to prevent obstruction of the narrow
lumen of small intestine and stoma.
Low fiber – white rice, refined grains, pasta, Most canned or well-cooked
vegetables and fruits without skins or seeds
After ileostomy heals, introduce fibrous foods one at a time.
Patient should chew thoroughly. Use cooked vegetables
 188
AppleRN Classes

Avoid – high fiber – popcorn, coconut, brown rice, multigrain bread, Dried fruits
and prune juice, Raw fruit, Raw or undercooked vegetables, including corn, Dried
beans, peas and lentils
Avoid Stringy vegetables – celery, broccoli, asparagus
Avoid Seeds/pits – strawberry, raspberry, olives
Crohn’s Disease
Inflammatory disease; can occur anywhere in GI tract, but most often affects
terminal ileum
Cramp-like, colicky pain after meals, Diarrhea (semisolid); may contain mucus, pus
Dehydration, electrolyte imbalances
Interventions: Similar to ulcerative colitis
Colostomy irrigation
Daily irrigation help to gain more control over passage of stool.
Donot use an enema set. Use cone tipped applicator
Fill chamber with 500-1000 ml lukewarm water, flush tubing, reclamp, hang the
container in IV pole
Client sit on toilet, place irrigation sleeve over stoma. Place irrigation container
18-24 inch above stoma
Lubricate cone tipped irrigator and insert gently into stoma, hold in place
Slowly open clamp, clamp if cramping occurs
Diverticulosis and Diverticulitis
Outpouching or herniation of intestinal mucosa
Diverticulosis becomes diverticulitis with inflammation of one or more
diverticula; results when diverticulum perforates
Assessment: Left lower quadrant abdominal pain, increasing with coughing,
straining, lifting
 189
AppleRN Classes

Palpable, tender rectal mass, Melena

Interventions: Provide bed rest during acute phase. Maintain NPO status, clear
fluids during acute phase
Monitor for perforation, hemorrhage, fistulas, abscess formation
Instruct client to avoid gas-forming foods, foods containing indigestible roughage,
seeds, nuts, high-fiber foods (when inflammation occurs)
A low-residue diet, which avoids all high-fiber foods, may be used in treating
acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is
resumed to prevent future episodes.
Surgical interventions: Colon resection with primary anastomosis
Temporary or permanent colostomy may be required
Pancreatitis
Acute or chronic inflammation of pancreas with associated escape of pancreatic
enzymes
Pancreatitis is an autodigestion of the pancreas by pancreatic digestive enzymes
The islets of Langerhans in the pancreas secrete insulin and glucagon.
The pancreatic tissues secrete digestive enzymes that break down carbohydrates,
proteins, and fats.
Acute attack signs : Severe, constant, knifelike pain (left upper quadrant, mid-
epigastric, and/or radiating to the back) that is unrelieved by nausea and
vomiting.
Inflammation can vary from mild edema to severe necrosis
Pancreatic abscess: Report immediately any signs of sudden fever. (leads to
peritonitis). The abscess must be treated promptly to prevent sepsis.
Assess for sudden abdominal pain, midepigastric region, radiating to back, pain
aggravated by fatty meal or alcohol
Assess for Cullen’s sign, Turner’s sign (Seepage of blood-stained exudates into
tissue as a result of pancreatic enzyme actions)
 190
AppleRN Classes

Assess for absent or decreased bowel sounds, Assess for lab tests
Tetany (low calcium), Trousseau’s sign (hand spasm when blood pressure cuff is
inflated), Chvostek’s sign (facial twitching when facial nerve is tapped)
Administer meperidine hydrochloride (Demerol) as prescribed
Maintain NPO status; hydrate with IV fluids. Instruct client to comply with follow-
up visits
Notify physician if client develop acute abdominal pain and fever (pancreatic
abscess) or Dark-colored stools, or urine – biliary obstruction
Chronic pancreatitis
Assess for abdominal pain, tenderness, left upper quadrant mass
Assess for steatorrhea, Assess for signs and symptoms of diabetes mellitus
Instruct client in prescribed dietary measures
Administer pancreatic enzymes as prescribed; fat, protein intake may be limited
Have bland diet. Administer insulin or oral hypoglycemics as prescribed
Instruct client to notify physician if increased steatorrhea, abdominal distention,
cramping or fever occur

Hepatitis
Inflammation of liver caused by virus, bacteria, exposure to medications or
hepatotoxins
Types of viral hepatitis : Hepatitis A, B, C, D, E
Stages of viral hepatitis: Preicteric stage: Flu-like symptoms; precedes jaundice
Icteric stage: Appearance of jaundice; elevated bilirubin levels; dark or tea-
colored urine; clay-colored stools
Posticteric stage: Jaundice decreases; color of stool, urine returns to normal
 191
AppleRN Classes

Laboratory assessment: Elevated levels of alanine aminotransferase, aspartate

aminotransferase, alkaline phosphatase, bilirubin
Health Promotion and Disease Prevention
Encourage hepatitis prevention activities: Aseptic technique for the preparation
and administration of parenteral medications.
Sterile, single-use, disposable needle and syringe for each injection.
Use single-dose vials as often as possible. Use needleless systems or safety caps.
Use personal protective equipment, such as gown, gloves, and goggles,
appropriate to the type of exposure.
Proper hand hygiene (before preparing and eating food, after using the toilet or
changing a diaper).
When traveling to underdeveloped countries, drink purified water, and avoid
sharing eating utensils and bed linens.
Diet
It is important to explain to the client with hepatitis that the majority of calories
should be eaten in the morning hours because nausea most often occurs in the
afternoon and evening.
Clients should select a diet high in calories because energy is required for healing.
Changes in bilirubin interfere with fat absorption so low-fat diets are better
tolerated.
Client and Family Home Care: Strict and frequent hand washing. Do not share
bathrooms unless client strictly adheres to personal hygiene measures
Use of individual towels, eating utensils, toothbrushes, razors, Client should not
be food preparer for family
Client should avoid over-the-counter medications, alcohol, Client should increase
activity gradually
Client should consume small, frequent high-carbohydrate, low-fat foods
Client should not donate blood. Discourage close personal contact, such as kissing
 192
AppleRN Classes

Client should keep follow-up appointments

Pediatric GI
Esophageal Atresia and Tracheoesophageal Fistula
Esophagus terminates before it reaches the stomach and/or fistula present that
forms unnatural connection with trachea
Assessment : Three Cs: Coughing, choking, cyanosis
Preoperative interventions : NPO , IV fluids as prescribed
Suction mouth, pharynx PRN , Maintain upright position at all times
Maintain esophageal catheter to low suction as prescribed
Maintain gastrostomy tube as prescribed
Administer antibiotics as prescribed
Postoperative interventions
Monitor respiratory status, I&O, daily weights, surgical site, pain, signs of
dehydration
Maintain IV fluids, total parenteral nutrition, antibiotics as prescribed
Maintain gastrostomy tube as prescribed. Suction PRN
 193
AppleRN Classes

Begin oral feedings with sterile water as prescribed

Hypertrophic Pyloric Stenosis
Narrowing of pyloric canal between stomach and duodenum
Assessment: Visible peristaltic waves from left to right across epigastrium during
and immediately following feeding
Olive-shaped mass in epigastrium, just right of umbilicus. Projectile Vomiting
Interventions
Monitor vital signs, I&O, signs of dehydration, signs of electrolyte imbalances
Pyloromyotomy: Incision through muscle fibers of pylorus
Postoperatively, feed infant slowly, burp frequently, handle minimally following
feeding
Celiac Disease
Intolerance to gluten, protein component of, barley, rye, oats, wheat. BROW
Assessment: Acute or insidious diarrhea; anorexia; abdominal pain, distention;
muscle wasting, especially in buttocks and extremities; vomiting; anemia
Celiac crisis: Precipitated by fever, infection, gluten ingestion
Electrolyte imbalances; rapid dehydration; severe acidosis; profuse watery
diarrhea; vomiting
Interventions: Maintain gluten-free diet, substituting corn, rice, millet as grain
sources.
Instruct in lifelong elimination of gluten sources: Beer, pasta, crackers, cereals,
and many more substances contain gluten.
Abdominal Wall Defects
Omphalocele
Herniation of abdominal contents through umbilical ring
Immediately after birth, sac covered with sterile gauze soaked in normal saline
 194
AppleRN Classes

Preoperatively, maintain NPO status, administer IV fluids, monitor for signs of

infection, handle infant carefully
Gastroschisis
Herniation of intestine, lateral to umbilical ring
Exposed bowel covered loosely in saline-soaked pads, with abdomen wrapped in
plastic drape
Preoperatively, care similar to that of omphalocele, with surgery performed
within several hours after birth.
Postoperatively: Perform measures to control pain, infection, fluid and
electrolyte imbalances; provide nutrition as prescribed
Hirschsprung’s Disease
Congenital anomaly; aganglionic megacolon
presents with fever, gastrointestinal bleeding, explosive, watery diarrhea
Assessment: Newborn: Delayed passage or absence of meconium stool
Children: Ribbon-like, foul-smelling stools
Interventions: Medical management
Dietary management; administer stool softeners as prescribed; perform daily
rectal irrigations with normal saline as prescribed
Preoperative interventions: Assess bowel function, I&O, abdominal girth, weight;
administer antibiotics as prescribed; no rectal temperatures
Postoperative interventions: Monitor vital signs, with no rectal temperatures,
Measure abdominal girth
Assess surgical site and stoma. Maintain NPO until bowel sounds return .
Maintain NG tube suction as prescribed . Monitor for fluid, electrolyte imbalances
Antacids
Should be taken on regular schedule; some as prescribed
To be taken 1 to 3 hours after each meal or at bedtime
 195
AppleRN Classes

Tablets should be chewed thoroughly, followed with glass of water or milk

Allow 1 hour between antacid administration, administration of other
medications
Aluminum hydroxide preparations
Contain significant amounts of sodium; use with caution in clients with
hypertension, heart failure
Constipation most common side effect
Can reduce effects of tetracyclines, warfarin sodium (Coumadin), digoxin
(Lanoxin); reduce phosphate absorption; can cause hypophosphatemia
Calcium carbonate: Calcium carbonate preparations rapid acting.
Can cause constipation.
Magnesium hydroxide preparations
Also saline laxative; most common side effect diarrhea
Contraindicated in clients with intestinal obstruction, appendicitis, undiagnosed
abdominal pain. In clients with renal impairment, magnesium can accumulate,
leading to toxicity
Sodium bicarbonate
Can cause systemic alkalosis in clients with renal impairment
Use with caution in clients with hypertension, heart failure
Pepto-Bismol - bismuth subsalicylate
Not for children : Reye's syndrome : brain and liver damage. The first symptom of
Reye’s is usually vomiting. Other signs : Irritability, aggressiveness, confusion,
lethargy. They may have seizures or coma
Gastrointestinal medications
Antiemetics:
Prochlorperazine, Metoclopramide (Reglan)
Extrapyramidal symptoms (Restlessness, anxiety, spasms of face and neck)
 196
AppleRN Classes

• Protruding and twisting of the tongue, Lip smacking

• Puffing of cheeks, Chewing movements
• Frowning or blinking of eyes, Twisting fingers
• Twisted or rotated neck (torticollis)
Stop medication
Administer an anticholinergic medication, such as diphenhydramine (Benanadryl)
or benztropine (Cogentin), to treat symptoms.
Antiemetics: Prochlorperazine, Metoclopramide (Reglan)
Administer an anticholinergic medication, such as diphenhydramine (Benanadryl)
or benztropine (Cogentin), to treat symptoms.
Anticholinergic effects (dry mouth, urinary retention, constipation)
Instruct clients to increase fluid intake.
Instruct clients to increase physical activity by engaging in regular exercise.
Tell clients to suck on hard candy or chew gum to help relieve dry mouth.
Advise clients to void every 4 hr. Monitor I&O and palpate the lower abdomen
area every 4 to 6 hr to assess the bladder.
Ondansetron (Zofran) : Headache, diarrhea, dizziness
Scopolamine : sedation, anticholinergic effect
Laxatives : Psyllium (Metamucil) : Bulk-forming, act like dietary fiber, Take with
full glass of water. Full effect may take upto 2-3 days
Docusate sodium (Colace) : Stool softner (allow more water in stool)
Bisacodyl (Dulcolax) : Stimulate intestinal peristalsis
Milk and antacids can destroy enteric coating of bisacodyl. (take 1 hr apart)
Take on empty stomach for maximum effectiveness.
Administer at bedtime for morning effect. (PO will take 6-12 hrs )
 197
AppleRN Classes

Magnesium hydroxide (Milk of Magnesia) : Increase mass of stool and increase

peristalsis, Can lead to accumulation of toxic levels of magnesium, may cause
dehydration
Other Medications: senna (Senokot), lactulose (Cephulac)
Lactulose aids in the clearance of ammonia via the gastrointestinal tract.
Reduces ammonia levels : Hepatic encephalopathy
Administered orally or rectally, Cause Diarrhea
Laxatives are contraindicated in clients who have fecal impaction, bowel
obstruction, and acute surgical abdomen to prevent perforation.
Antidiarrheals
Diphenoxylate plus atropine (Lomotil)
Administer initial dose of diphenoxylate, 4 mg. Follow each loose stool with
additional dose of 2 mg, but do not exceed 16 mg/day.
loperamide (Imodium)
Patient to drink small amounts of clear liquids or a commercial oral electrolyte
solution to maintain electrolyte balance for the first 24 hr
Advise clients to avoid caffeine. Caffeine exacerbates diarrhea by increasing GI
motility.
Follow BRAT diet : Banana, Rice, Applesause, Tea/Toast – to reduce diarrhea
Gastric Protectants
Misoprostol (Cytotec): Administer with meals. Causes diarrhea, abdominal pain
Sucralfate (Carafate) : Administered orally on empty stomach, May cause
constipation
May impede absorption of warfarin sodium, phenytoin (Dilantin), theophylline,
digoxin, some antibiotics
Administer 2 hours apart from these medications
Histamine 2 Receptor Antagonists
 198
AppleRN Classes

Suppress secretion of gastric acid

Should be used with caution in clients with impaired renal or hepatic failure
Cimetidine (Tagamet); Food reduces rate of absorption
Administer 1 hour apart from antacids
Passes blood-brain barrier; central nervous system side effects may occur
Reduced dosage in clients with renal impairment necessary
IV administration can lead to hypotension, dysrhythmias.
If administered IV, need to be diluted and infused over 15 to 20 minutes
Ranitidine (Zantac) : Side effects uncommon
Does not penetrate blood-brain barrier
For IV administration, dilute and administer slowly
Famotidine (Pepcid), nizatidine (Axid)
Do not need to be administered with food
Proton Pump Inhibitors
Example: Omeprazole, Pantoprazole, Lansoprazole (Prevacid)
Suppress gastric acid secretion
Used to treat active ulcer disease, erosive esophagitis, pathological
hypersecretory conditions
Contraindicated in hypersensitivity
Common side effects include headache, diarrhea, abdominal pain, nausea
PPIs impair intestinal calcium absorption and therefore are associated with
decreased bone density, which increases the possibility of fractures of the spine,
hip, and wrist.
PPIs cause acid suppression that otherwise would have prevented pathogens
from more easily colonizing the upper gastrointestinal tract. This leads to
increased risk of pneumonias.
 199
AppleRN Classes

PPI use may also increase the risk for clostridium difficile-associated diarrhea
(CDAD); currently the cause is unclear
Helicobacter pylori Infections
Antibacterial agent alone not effective in eradicating bacterium
Dual, triple, quadruple therapy with variety of combinations used
Combinations include antibacterial agents, proton pump inhibitors, histamine 2
receptor antagonists, antacids
Common treatment protocol is triple therapy with two antibacterial agents, one
proton pump inhibitor
If triple therapy fails, quadruple therapy recommended, with two antibiotics, one
proton pump inhibitor, one bismuth or histamine 2 receptor antagonist
Gastrointestinal (GI) Stimulants
Stimulate motility of upper GI tract, increase rate of gastric emptying
Used to treat gastroesophageal reflux, paralytic ileus
May cause restlessness, drowsiness, extrapyramidal reactions, insomnia,
headache
Usually administered 30 minutes before meals or at bedtime
Contraindicated in clients with sensitivity, mechanical obstruction, perforation, GI
hemorrhage
Can precipitate hypertensive crisis in clients with pheochromocytoma
Metoclopramide (Reglan) can cause parkinsonian symptoms
Anticholinergics, opioid analgesics antagonize effects of metoclopramide
Alcohol, sedatives, cyclosporine (Sandimmune), tranquilizers produce additive
effect
Bile Acid Sequestrants
Act by absorbing, combining with intestinal bile salts, which are then secreted in
feces, preventing intestinal reabsorption
 200
AppleRN Classes

Used to treat hypercholesterolemia, biliary obstruction, pruritus associated with

biliary disease
Taste, palatability causes for noncompliance
Should be used cautiously in clients with bowel obstruction, severe constipation
Side effects include nausea, bloating, constipation
Stool softeners, other sources of fiber can be used to relieve side effects
Pancreatic Enzyme Replacements
Used to supplement, replace pancreatic enzymes
Should be taken with meals or snack
High-fiber diet may increase efficacy of medication
Side effects include abdominal cramps, pain, nausea, diarrhea
Products that contain calcium carbonate or magnesium hydroxide interfere with
action of enzyme replacement

Neurology
Central Nervous System: Brain and Spinal cord
Brain - Normal contents are 80% brain tissue, 10% blood, 10% CSF
Covered and protected by three layers of tissue called meninges. Dura mater,
Arachnoid mater, and Pia mater.
The dura mater is a strong, thick membrane that closely lines the inside of the
skull
The arachnoid mater is a thin, web-like membrane that covers the entire brain.
The arachnoid is made of elastic tissue.
The space between the dura and arachnoid membranes is called the subdural
space.
The pia mater hugs the surface of the brain and has many blood vessels that
reach deep into the brain.
 201
AppleRN Classes

The space between the arachnoid and pia is called the subarachnoid space. It is
here where the cerebrospinal fluid bathes and cushions the brain.

Cerebral circulation
Receives 15% to 20% of cardiac output (750 ml per min)
Carotid arteries (anterior circulation) Vertebral arteries (posterior circulation)
Cerebral veins empty into venous sinuses- jugular veins
The sole source of cellular energy for the brain is glucose. As the brain is unable to
store glucose, it requires a constant supply.
Cerebral glucose < 70 mg/dL = confusion
Cerebral glucose < 20 mg/dL = damage
Blood Brain Barrier : Helps to maintain a stable environment at brain
OK to pass : water, oxygen, CO2, glucose, Vitamins, minerals
Not OK : Waste : urea, creatinine, toxins, most drugs
Antidepressants, anti-anxiety medications, alcohol and cocaine might also pass.
Infection, radiation, hypertension, trauma can alter BBB
 202
AppleRN Classes

Risk factors, Cranial nerves, Level of alertness, Level of consciousness

Vital signs, Pupils - Normal pupils are 3-5 mm in diameter - PERRLA
Motor function, Posturing, Reflexes, Sensory function, Glasgow Coma Scale
DTR - A) Biceps, B) Brachioradial, C) Triceps, D) Patellar, E) Achilles
 203
AppleRN Classes
 204
AppleRN Classes

Meningitis
Infectious process of CNS caused by bacteria and viruses;
May be acquired as primary disease or as result of complications of neurosurgery,
trauma, infection of sinuses or ears, systemic infections, Viral illnesses such as the
mumps, measles, herpes
Vaccine : Haemophilus influenzae type b (Hib) vaccine – Infants
Pneumococcal polysaccharide vaccine (PPSV) – Vaccinate adults who are
immunocompromised, have a chronic disease, smokers, live in long-term care
facility. Give one dose to adults older than 65 years of age who have not
previously been vaccinated nor have history of disease.
Meningococcal vaccine – For adolescents living in a residential setting in college,
military persons against Neisseria meningitidis
There is no vaccine against viral meningitis.
Diagnostic Procedures
Cerebrospinal fluid (CSF) analysis: Most definitive diagnostic procedure.
Appearance of CSF – cloudy (bacterial) or clear (viral)
Elevated WBC, Elevated protein, Decreased glucose (bacterial), Elevated CSF
pressure
 205
AppleRN Classes

Glass test : Meningitis rash doesn’t fade when you apply pressure to the skin.

Babinski reflex: Babinski reflex can be present up to age 1-2 years and is a
normal, expected finding

Infants/toddler additional signs : - Poor feeding; high-pitched cry; bulging anterior

fontanel, sunsetting eyes
 206
AppleRN Classes

opisthotonus posture (Hyperextended neck and head – relieve some discomfort

from meningeal irritation)
Nursing Care: Isolate the client as soon as meningitis is suspected
Droplet isolation for bacterial meningitis
for first 24 hrs of antibiotics and when oral and nasal secretions are no longer
infectious.
Standard precautions are implemented for all clients who have meningitis.
Report meningococcal infections to the public health department.
Decrease environmental stimuli. Implement fever-reduction measures, such as a
cooling blanket, if necessary
Minimize exposure to bright light (natural and electric).
Maintain bed rest with the HOB elevated to 30°.
Monitor the client for increased intracranial pressure (ICP). Avoid coughing and
sneezing, which increase ICP.
Maintain client safety, such as seizure precautions. Replace fluid and electrolytes
Older adult clients are at an increased risk for secondary complications, such as
pneumonia.
Prophylactic antibiotics given to individuals in close contact with the client.
Complications: Increased ICP (possibly to the point of brain herniation)
Meningitis can cause ICP to increase.
Nursing Actions: Monitor for signs of increasing ICP (LOC changes, pupillary
changes, impaired extraocular movements).
Provide interventions to reduce ICP (positioning and avoidance of coughing and
straining). Mannitol can be administered via IV.
Septic emboli (leading to disseminated intravascular coagulation or cardiovascular
accident).
 207
AppleRN Classes

Septic emboli can form during meningitis and travel to other parts of the body,
particularly the handsand feet.
Complications of Meningitis
Syndrome of inappropriate antidiuretic hormone (SIADH)
SIADH can be a complication of meningitis by abnormal stimulation to the
hypothalamic area of the brain, causing excess secretion of antidiuretic hormone
(vasopressin).
Nursing Actions: Monitor for signs and symptoms (dilute blood, concentrated
urine).
Provide interventions, such as the administration of demeclocycline (diuretic type
property)and restriction of fluid.
Increased Intracranial Pressure (ICP)
Rise in pressure in cranial vault caused by trauma, hemorrhage, tumors, edema,
or inflammation.
ICP Normal level is upto 15 mm Hg (5-15)
ICP may be increased by:
Hypercarbia, which leads to cerebral vasodilation and edema, Endotracheal or
oral tracheal suctioning, Coughing, Blowing the nose forcefully
Extreme neck or hip flexion/extension, Maintaining the head of the bed at an
angle less than 30°, Increasing intra-abdominal pressure (restrictive clothing,
Valsalva maneuver).
Early signs include restlessness and change in level of consciousness
Late signs include increasing systolic blood pressure with widened pulse pressure,
slowed heart rate, irregular respirations (cushing’s triad)
A change in body temperature may also occur because increased ICP affects the
hypothalamus.
Cheyne-Stokes respirations, Occular signs can happen.
Assess neurological status Q 1 to 2 hrs
 208
AppleRN Classes

Assess bowel (constipation) and bladder (distention) to avoid valsalva maneuver

Ocular Signs
Compression of cranial nerve (CN) III, the oculomotor nerve, results in
Dilation of the pupil on the same side (ipsilateral) as the mass/ lesion
Sluggish or no response to light. Inability to move the eye upward
Ptosis of the eyelid.
These signs can be the result of a shifting of the brain from the midline,
compressing the trunk of CN III and paralyzing the muscles controlling pupillary
size and shape.
A fixed, unilateral, dilated pupil is considered a neurologic emergency that
indicates herniation of the brain.
Other cranial nerves may also be affected leading to blurred vision, diplopia, and
changes in extraocular eye movements.
Elevate head 30° to reduce ICP and to promote venous drainage.
Avoid extreme flexion, extension, or rotation of the head, and maintain the body
in a midline neutral position.
Maintain a patent airway. Provide mechanical ventilation as indicated.
Hyperventilate clients on mechanical ventilation to keep the PaCO2 between 35
to 38 mm Hg. This reduces cerebral blood flow.
Administer oxygen as indicated to maintain an oxygen saturation level of greater
than 92%. Maintain cervical spine stability until cleared by an x-ray.
Provide a calm, restful environment (limit visitors, minimize noise).
Plan activities to avoid stress- not too long . Monitor fluid and electrolyte values
Maintain safety and seizure precautions
Meds: Diuretics (manitol and lasix)
Draw water from edematous tissues into vascular system. (look for fluid overload
if too much manitol)
 209
AppleRN Classes

Might also disturb glucose and electrolyte levels. Patient need strict I/O (insert
foley)
Corticosteroids :- Reduce inflammation
Teaching
Avoid coughing , blowing nose, straining, pushing against bed/side rails
Maintain neutral head and neck alignment
Family to maintain quiet environment
Head Injury
Types
1. open/ penetrating trauma (skull integrity compromised)
2. closed/ blunt trauma (skull integrity maintained)
Fractures
Linear – most common – possible hematoma but dura intact. Minimal risk
Comminuted and Depressed – overlying skin and dura can be damaged.
High risk for brain damage and infection. Need surgery within 24 hrs
Basilar – involve base of skull – CSF leakage - prevent meningitis
Closed head injury
Evaluate the patient for Concussion : neurologic changes after a blow to the head
- GCS
Contusion : bruise on the brain
Skull fracture , Epidural or subdural bleeding.

Basilar Skull Fracture Signs

Battle’s Sign : Ecchymosis over mastoid process
Hemotympanum – Blood visible behind tympanic membrane
 210
AppleRN Classes

Raccoon eyes – Bilateral peri orbital echymosis

Rhinorrhea – CSF leakage through nose
Otorrhea - CSF leakage through ear
CSF – test reveal glucose. Mucus – no glucose. Halo sign
1 hr “golden window” for treatment of head injuries- emergency treatment
provided during this time frame decreases the morbidity and mortality
Coup-contrecoup head injury
1. Brain injury under the area of impact (coup),
2. Rebound injury to the opposite side (contrecoup).
Occipital lobe damage is common – visual problems.
Common in motor vehicle accidents and shaken baby syndrome.
Head injuries may be associated with hemorrhage
Epidural Hematoma: Between dura and skull
Usually from a tear in meningeal artery, Rapid deterioration in neurological status
Subdural Hematoma: Usually involve veins (might involve small arteries)
Intra cerebral: Bleeding into brain tissue . Most common – frontal or temporal
lobes
Monitor for severe headache, rapid decline in level of consciousness, worsening
neurological function and herniation, and changes in ICP.
Surgery needed to remove subdural & epidural hematoma. Intracranial
hemorrhage is treated with osmotic diuretics.

Nursing Care
Assess/monitor the client at regularly scheduled intervals:
Respiratory status – Brain function declines after 3 min of oxygen deprivation.
 211
AppleRN Classes

Changes in LOC (GCS), Cranial nerve function. Findings of infection (nuchal rigidity
occurs with meningitis)
Bilateral sensory and motor responses
Intracranial pressure (ICP): Teach patient to report any changes, avoid taking
alcohol or any sedative med, don’t drive soon
Craniotomy
A craniotomy is the removal of nonviable brain tissue that allows for expansion
and/or removal of epidural or subdural hematomas.
It involves drilling a burr hole or creating a bone flap to permit access to the
affected area.
This is a life-saving procedure, and is associated with many potential
complications, such as:
Severe neurological impairment, infection, persistent seizures, neurological
deficiencies, and/or death.
Nursing Actions
Postoperative treatment will depend upon the neurological status of the client
after surgery.
For supratentorial surgery, maintain HOB at least 30° with body positioning to
prevent increased ICP.
For infratentorial craniotomy, keep client flat and on either side for 24 to 48 hr to
prevent pressure on neck incision site.
Hyperventilate the mechanically ventilated client for 24 to 48 hr as prescribed to
maintain PaCO2 around 35 mm Hg.
Monitor wound dressing and mark drainage every 1 to 2 hr. Monitor and
maintain wound drain, documenting output every 8 hr
 212
AppleRN Classes

Seizures
Abnormal, sudden, excessive discharge of electrical activity within the brain.
A generalized seizure is also called a tonic-clonic seizure (grand mal seizure).
It may begin with an aura (alteration in vision, smell, hearing, or emotional
feeling).
A generalized seizure begins for only a few seconds with a tonic episode
(stiffening of muscles) and loss of consciousness.
A 1- to 2-min clonic episode (rhythmic jerking of the extremities) follows the tonic
episode.
Incontinence can also accompany a seizure.
During the postictal phase, a period of confusion and sleepiness follows the
seizure.
 213
AppleRN Classes

Complex partial seizure

Complex partial seizures have associated automatisms (behaviors that the client is
unaware of, such as lip smacking or picking at clothes).
The seizure can cause a loss of consciousness for several minutes.
Amnesia may occur immediately prior to and after the seizure.
Simple partial seizures
Consciousness is maintained throughout simple partial seizures.
Seizure activity may consist of unusual sensations, a sense of deja vu, autonomic
abnormalities, such as changes in heart rate and abnormal flushing, unilateral
abnormal extremity movements, pain or offensive smell.
Nursing Care
During a seizure:
Protect the client’s privacy and the client from injury (move furniture away, hold
head in lap if on the floor).
Position client to provide a patent airway. Be prepared to suction oral secretions.
Turn the client to the side to decrease the risk of aspiration.
Loosen restrictive clothing. Do not attempt to restrain the client.
Do not attempt to open jaw or insert airway during seizure activity (may damage
teeth, lips, and tongue). Do not use padded tongue blades.
Document onset and duration of seizure and client findings/observations prior to,
during, and following the seizure (level of consciousness, apnea, cyanosis, motor
activity, incontinence).
Post seizure: The postictal phase of the seizure episode.
Maintain the client in a side-lying position to prevent aspiration and to facilitate
drainage of oral secretions.
Check vital signs. Assess for injuries.
Perform neurological checks. Allow the client to rest if necessary.
 214
AppleRN Classes

Reorient and calm the client (may be agitated or confused).

Institute seizure precautions including placing the bed in the lowest position and
padding the side rails to prevent future injury.
Determine if client experienced an aura, which can possibly indicate the origin of
seizure in the brain.
Try to determine possible trigger (fatigue).
Status Epilepticus
Prolonged seizure activity occurring over a 30-min time frame.
Complications due to decreased oxygen levels, inability of the brain to return to
normal functioning, and continued assault on neuronal tissue.
The usual causes are withdrawal from drugs or alcohol, sudden withdrawal from
antiepileptic medication, head injury, cerebral edema, infection, and fever.
Nursing Actions
Maintain an airway, provide oxygen, establish IV access, perform ECG monitoring,
and monitor pulse oximetry and ABG results.
Give medications. Phenytoin
S/E : gingival hyperplasia : need good oral hygiene
Folic acid deficiency- need supplementation
Therapeutic range 10-20 mcg/mL. Need regular blood test
Early signs of toxicity : nystagmus and unsteady gait
Late signs : lethargy, confusion, coma.
Arteriovenous malformation (AVM)
Weak and dilated connections in Artery and Vein in Brain
AVM can cause neurologic deficits. Treatment - blood pressure control
AVMs - high risk for intracranial bleed - report any neurologic changes
immediately . Sudden severe headache, nausea, and vomiting
 215
AppleRN Classes

Stroke
Sudden, focal neurological deficit
Risk factors : Cerebral aneurysm, AVM , DM, HTN, Obesity, Atherosclerosis,
Hyperlipidemia, Hypercoagulability, Atrial fibrillation, Use of oral contraceptives,
Smoking, Cocaine use
Assessment: Depends on area of brain affected, Airway patency is priority

Left Sided Stroke

The left cerebral hemisphere is responsible for language, mathematics skills, and
analytic thinking.
Symptoms consistent with a left-hemispheric stroke include the following:
Expressive and receptive aphasia (inability to speak and understand language
respectively)
Agnosia (unable to recognize familiar objects)
 216
AppleRN Classes

Alexia (reading difficulty)

Agraphia (writing difficulty)
Right extremity hemiplegia (paralysis) or hemiparesis (weakness)
Slow, cautious behavior
Depression, anger, and quick to become frustrated
Visual changes, such as hemianopsia (loss of visual field in one or both eyes-right)
Dysphasia - impaired ability to communicate – speech problem
Apraxia - loss of the ability to perform a learned movement (eg, whistling,
clapping, dressing) due to neurological impairment.
Right Sided Stroke
The right cerebral hemisphere is responsible for visual and spatial awareness and
proprioception.
Altered perception of deficits (overestimation of abilities)
One-sided neglect syndrome (ignore left side of the body – cannot see, feel, or
move affected side, so client unaware of its existence). Can occur with left-
hemispheric strokes, but is more common with right-hemispheric strokes.
Loss of depth perception, Poor impulse control and judgment
Left hemiplegia or hemiparesis, Visual changes, such as hemianopsia (left)
Nursing Care: Monitor the client’s vital signs every l to 2 hr.
HTN - Notify the provider immediately (crisis 180/110)
Monitor temperature. Fever – ICP increase
Provide oxygen (Spo2 >92%). cardiac assessment, Tele monitor (arrhythmias)
ICP? – LOC changed, position HOB 30, seizure precaution.
Communication
Assist with safe feeding. Assess swallowing and gag reflexes before feeding.
Consult Speech therapy. Use thickener to avoid aspiration.
 217
AppleRN Classes

Position upright : swallow with the head and neck flexed slightly forward.
Place food in the back of the mouth on the unaffected side.
Have suction on standby. Maintain a distraction-free environment during meals.
Prevent complications of immobility.
Passive ROM every 2 hr to the affected extremities and active ROM every 2 hr to
the unaffected extremities
Elevate, SCD, TED hose, PT. Maintain skin integrity. Reposition the client
frequently and use padding. Monitor bony prominences, paying particular
attention to the affected extremities.
Unilateral neglect
Unilateral neglect is the loss of awareness of the side affected by the stroke.
(forgets that it exists)
Observe for injury . Apply an arm sling
Ensure the foot rest is on the wheelchair and ankle brace is on the affected foot.
Instruct the client to dress the affected side first.
Teach the client how to care for the affected side : pull the affected extremity to
midline to avoid injury
Teach the client to look over the affected side periodically.
Maintain a safe environment to reduce the risk of falls.
Use assistive devices : transfer belts and sliding boards.
Impaired balance : Leaning towards affected side while sitting – provide support.
Shoulder subluxation - painful dislocation of the shoulder from its socket due to
weight of unused arm. Use arm sling or pillows.
Client with homonomous hemianopsia (loss of the same visual field in both eyes)
instruct to use a scanning technique (turning head from the direction of the
unaffected side to the affected side) when eating and ambulating.
 218
AppleRN Classes

Provide assistance with ADLs as needed.

Medications: Anticoagulants (heparin sodium, enoxaparin [Lovenox], warfarin
Use of anticoagulants is controversial and not recommended due to the high risk
of intracerebral bleeding.
Antiplatelets (aspirin)
Low-dose aspirin is given within 24 to 48 hr following a stroke to prevent further
clot formation.
Thrombolytic medications reteplase recombinant (rtPA [Retavase])
Give within 4.5 hours of the initial symptoms.
Antiepileptic medications (phenytoin [Dilantin], gabapentin [Neurontin])
These medications are given if client develops seizures.
Gabapentin can be given for paresthetic pain in an affected extremity.
Multiple Sclerosis
Neurological disease resulting in impaired and worsening function of voluntary
muscles.
Autoimmune disorder characterized by development of plaque in CNS , it
damages the myelin sheath.
Relapses and remission occur many times. Finally leading to quadriplegia.
Triggers : Viruses, infectious, cold climate, injury, stress , Pregnancy, Fatigue, Hot
shower/bath
Signs of MS
Fatigue – especially of the lower extremities
Pain or paresthesia , Spasticity (rigid muscle) Visual changes , diplopia, nystagmus
Uhthoff’s sign (temporary worsening of vision & neurological functions)
Dysphagia, Dysarthria (slurred and nasal speech) . Bowel, bladder and sexual
dysfunction
 219
AppleRN Classes

Cognitive changes (memory loss, impaired judgment)

Meds: Azathioprine (Imuran) and cyclosporine (Sandimmune)
Immunosuppressive agents are used to reduce the frequency of relapses.
Monitor for long-term effects. Be alert for manifestations of infection.
Assess for hypertension. Assess for kidney dysfunction.
Prednisone: To reduce inflammation in acute exacerbations.
Monitor for increased risk of infection, hypervolemia, hypernatremia,
hypokalemia, hyperglycemia. Taper dose.
Antispasmodics are used to treat muscle spasticity
Intrathecal baclofen (a CNS depressant used as a skeletal muscle relaxant) can be
used for severe cases of MS . Avoid stopping baclofen abruptly
Nursing care
Assessment . Avoid triggers
Apply alternating eye patches to treat diplopia (double vision). Teach scanning
techniques.
Fluids-to prevent urinary tract infection.
Bladder and Bowel training (might need catheterzation)
Promote energy conservation by grouping cares and planning rest periods.
Safety precautions
Myasthenia gravis (MG)
It is a progressive autoimmune disease that produces severe muscular weakness.
It is characterized by periods of exacerbation and remission.
Muscle weakness improves with rest and worsens with increased activity.
Muscles are stronger in the morning and become weaker with the day's activity as
the supply of available acetylcholine is depleted.
 220
AppleRN Classes

It is caused by antibodies that interfere with the transmission of acetylcholine at

the neuromuscular junction.
Therapeutic procedure: Plasmapheresis removes circulating antibodies from the
plasma. This is usually done several times over a period of days and may continue
on a regular basis for some clients.
Factors that trigger exacerbations: Infection, Stress, emotional upset, and fatigue
Pregnancy, Increases in body temperature (fever, sunbathing, hot tubs).
Diagnostic Procedures : Tensilon testing
Baseline assessment of the cranial muscle strength is done.
Edrophonium (Tensilon) is administered.
Medication inhibits the breakdown of acetylcholine, making it available for use at
the neuromuscular junction.
A positive test results in marked improvement in muscle strength that lasts
approximately 5 min.
Have atropine available, which is the antidote for edrophonium (bradycardia,
sweating, and abdominal cramps, V fib)
Subjective Data
Progressive muscle weakness, Diplopia, Difficulty chewing and swallowing (bulbar
sign), Respiratory dysfunction, Bowel and bladder dysfunction, Poor posture,
Fatigue after exertion
Assessment
Impaired respiratory status (difficulty managing secretions, decreased respiratory
effort. Decreased swallowing ability.
Decreased muscle strength, especially of the face, eyes, and proximal portion of
major muscle groups.
Incontinence. Drooping eyelids – unilateral or bilateral
Assess and intervene as needed to maintain a patent airway (muscle weakness of
diaphragm, respiratory, and intercostal muscles).
 221
AppleRN Classes

Use energy conservation measures. Allow for periods of rest.

Assess swallowing to prevent aspiration.
oxygen, endotracheal intubation, suctioning equipment, and a bag valve mask
available at the client’s bedside.
Provide small, frequent, high-calorie meals and schedule at times when
medication is peaking.
Have the client sit upright when eating, and use thickener in liquids as necessary.
Soft food is better.
Apply a lubricating eye drop during the day and ointment at night if the client is
unable to completely close his eyes.
The client may also need to patch or tape his eyes shut at night to prevent
damage to the cornea.
Patient to wear a medical id band
Medications : Anticholinesterase agents are the first line in therapy.
Ensure that the medication is given at the specified time, usually four times a day.
If periods of weakness are observed, discuss change in administration times with
the provider.
Use cautiously in clients who have a history of asthma or cardiac dysrhythmias.
Client Education
Take with food to address gastrointestinal side effects.
Eat within 45 min of taking the medication to strengthen chewing and reduce the
risk for aspiration.
Stress the importance of maintaining therapeutic levels and taking the medication
at the same time each day.
Pyridostigmine and neostigmine (Prostigmin)
Used to increase muscle strength in the symptomatic treatment of MG. It inhibits
the breakdown of acetylcholine and prolongs its effects.
 222
AppleRN Classes

Nursing Considerations
Assess the client for a history of seizures.
Use cautiously in clients who have a history of asthma and cardiovascular disease.
Complications
Myasthenic crisis occurs when the client is experiencing a stressor that causes an
exacerbation of MG (infection, under medication)
Cholinergic crisis occurs when the client has taken too much cholinesterase
inhibitor (over medication)
The manifestations of both can be very similar (muscle weakness, respiratory
failure).
An edrophonium test may be performed to determine the crisis
Worsening of the symptoms after the test dose of medication is administered
indicates a cholinergic crisis.
Myasthenic crisis
Myasthenic crisis Clinical manifestations:
increased diaphoresis, bowel and bladder incontinence, absent cough and
swallow reflex, sudden marked rise in blood pressure because of hypoxia,
increased heart rate, severe respiratory distress and cyanosis, increased
secretions, increased lacrimation, restlessness, and dysarthria.
Trigeminal Neuralgia
Sensory disorder of trigeminal cranial nerve
Severe pain on lips, gums, nose, or across cheeks. Pain is severe, intense, burning,
or electric shock-like
Interventions
Avoiding hot or cold fluids or foods, Chew food on unaffected side
Administer medications- The drug of choice is carbamazepine – (risk of infection)
 223
AppleRN Classes

Triggers can include washing the face, chewing food, brushing teeth, yawning, or
talking.
Bell’s Palsy (Facial Paralysis)
Lower motor lesion of facial nerve that results in paralysis on one side of face -
Inflammation of the facial nerve (cranial nerve VII)
Assessment: Unilateral facial paralysis
Inability to raise eyebrows, frown, smile, close eyelids, or puff out cheeks on the
affected side
Interventions
Protect eye from dryness –patch eye. Prevent client injury, Supportive care
Vision, balance, consciousness, and extremity motor function are not impaired
with Bell's palsy.
Guillain-Barré Syndrome
Acute, infectious neuronitis of cranial and peripheral nerves
Assessment
Motor weakness and flaccid paralysis , that starts from lower extremities
Gradual progressive weakness of upper extremities, facial muscles, and possible
progression to respiratory failure
“Ground to brain”
Interventions: Prepare to initiate respiratory support, Provide supportive care
Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease)
ALS is a disease of the upper and lower motor neurons that results in
deterioration and death of the motor neurons.
This results in progressive paralysis and muscle wasting that eventually causes
respiratory paralysis and death
ALS does not involve sensory alterations or cognitive changes.
 224
AppleRN Classes

Assessment: Fatigue, Twitching and cramping of muscles

Objective Data: Muscle weakness – usually begins in one part of the body, Muscle
atrophy, Dysphagia, Dysarthria, Hyperreflexia of deep tendon reflexes
Interventions ALS
Care is directed toward treatment of symptoms.
Maintain a patent airway, and suction and/or intubate as needed. Monitor ABGs,
and administer oxygen
Keep the head of the bed at 45°; turn, cough, and deep breathe every 2 hr; and
conduct incentive spirometry/chest physiotherapy.
Assess swallow reflex and ensure safety with oral intake. Thicken fluids as
needed.
Meet nutritional needs for calories, fiber, and fluids. When no longer able to
swallow, provide enteral nutrition as prescribed.
Facilitate effective communication. Use energy conservation measures.
Spinal cord injuries
Spinal cord injuries (SCIs) involve the loss of motor function, sensory function,
reflexes, and control of elimination.
Injuries in the cervical region result in quadriplegia (tetraplegia) –
paralysis/paresis of all four extremities and trunk.
Injuries below T1 result in paraplegia – paralysis/paresis of the lower extremities.
The level of cord involved dictates the consequences of spinal cord injury
Nursing Care : Respiratory status : First priority.
oxygen and suction : intubation and mechanical ventilation if necessary.
Assist the client to cough by applying abdominal pressure when attempting to
cough.
Teach client about use of incentive spirometer, coughing and deep breathing
Intake and output, Fluids and nutritional support - may be NPO for days.
 225
AppleRN Classes

Neurological status , Muscle strength and tone

Treatment : Patient may be placed in traction (Halo)
Tissue perfusion : Neurogenic shock occurs after a SCI
Hypotension, dependent edema, and loss of temperature regulation.
When in an upright position, clients who are in neurogenic shock will experience
postural hypotension. Transferring the client to a wheelchair should occur in
stages.
Monitor the client for signs of thrombophlebitis (anticoagulants)
Bladder Issues
Clients with upper motor neuron injury (above L1 & L2)
spastic muscle tone after neurogenic shock - spastic bladder – fills with urine-
reflex trigger automatic emptying- always leak.
With lower motor neuron injuries (below L1 and L2)
a flaccid type of paralysis- a flaccid bladder – slow/absent reflex – patient wont
feel fullness – urine back up (reflux)- damage kidney
Bladder management : intermittent catheterization
Crede’s method (downward pressure placed on the bladder to manually express
the urine).
Gastrointestinal function –Ileus- Monitor for bowel sounds.
Skin Integrity – Changing the client’s position every 2 hr is critical (every 1 hr
when in a wheelchair).
Encourage active range-of-motion (ROM) exercises
Pressure-relief devices in both the bed and the wheelchair must be consistently
used.
Complications: Orthostatic hypotension
Change the client’s positioning slowly and place the client in a wheelchair that
reclines.
 226
AppleRN Classes

Use thigh-high elastic hose or elastic wraps to increase venous return.

Elastic wraps may need to extend all the way up the client’s legs and include the
client’s abdomen.
Neurogenic shock/spinal shock
Neurogenic shock is a common
Check Reflex - Areflexia characterizes spinal shock;
Other Symptoms : bradycardia, hypotension, paralysis and paralytic ileus
Monitor vital signs for hypotension and bradycardia.
Treat symptoms with appropriate medications (vasopressors or atropine).
Normal saline 0.9% - an isotonic solution
Autonomic dysreflexia
Imbalanced reflex discharge, leading to potentially life-threatening hypertension.
Symptoms : Sudden severe headache, pallor below the level of the spinal cord’s
lesion, blurred vision, diaphoresis, restlessness, nausea, and piloerection (goose
bumps)
It is considered a medical emergency and must be recognized immediately.
Triggers: bladder distention, bowel distention, visceral distention, or stimulation
of pain on skin.
autonomic dysreflexia can cause seizures, retinal hemorrhage, pulmonary edema,
renal insufficiency, myocardial infarction, cerebral hemorrhage, and death.
Clients who have lesions below T6 do not experience dysreflexia: because the
parasympathetic nervous system is able to neutralize the sympathetic response.

Neuro Pediatric considerations

Hydrocephalus
 227
AppleRN Classes

Results in head enlargement (prior to fontanels closing), increased ICP

Types: Communicating: Result of impaired absorption within subarachnoid space
Noncommunicating: Obstruction of cerebrospinal fluid (CSF) flow within
ventricular system
Assessment
Infant: Increased head circumference; widening sutures; bulging fontanel; dilated
scalp veins; frontal bossing; sunsetting eyes
If the head circumference is greater than or equal to 4 cm larger than the chest
circumference, this can be an indication of hydrocephalus
Child: Irritability; lethargy; headache on awakening; nausea and vomiting; ataxia;
nystagmus
Surgical interventions
Goal of treatment to prevent further CSF accumulation by bypassing blockage,
draining fluid from ventricles to location where it may be reabsorbed
Preoperative interventions
NPO status, Reposition head frequently to prevent pressure sores
Prepare the child and family for surgery
Postoperative interventions
Position on nonoperative side to prevent pressure on shunt valve
Keep flat as prescribed
Observe for increased ICP; if present, elevate head of bed 15 to 30 degrees
Cerebral Palsy
Disorder characterized by impaired movement and posture; results from
abnormality in extrapyramidal or pyramidal motor system
Assessment
Abnormal posturing, such as opisthotonos (exaggerated arching of back)
 228
AppleRN Classes

Stiff and rigid arms and legs, Feeding difficulties , Delayed gross motor activity
Alterations of muscle tone , Persistence of primitive infantile reflexes
Interventions
Assess developmental level , Encourage early intervention programs
Prepare for use of mobilizing devices , Provide safe environment
Provide safe, developmentally appropriate toys , Position upright after meals
Administer muscle relaxants as prescribed
Spina Bifida
Central nervous system (CNS) defect occurs as result of neural tube failure to
close during embryonic development
Types: Spina Bifida Occulta .
Spina Bifida Cystica - Meningocele , Myelomeningocele
Assessment : Depends on spinal cord involvement; visible spinal defect; flaccid
paralysis of legs; altered bladder, bowel function; hip, joint deformities

Protect sac by covering with sterile, moist, nonadherent dressing as prescribed;

change every 2 to 4 hours as prescribed
Prone position. Aseptic technique

Protect the membrane with a sterile

covering and plastic to prevent
drying.
 229
AppleRN Classes

Observe for leakage of the cerebrospinal fluid.

Handle the newborn gently by positioning him prone or to the side to prevent
trauma.
Prevent infection by keeping the area free from contamination by urine and feces.
Measure the circumference of the newborn’s head to identify hydrocephalus.
Assess the newborn for increased intracranial pressure.

Reyes Syndrome
Acute encephalopathy that follows viral illness. cerebral edema, fatty changes in
liver
Administration of aspirin not recommended for children with varicella or
influenza
Acetaminophen (Tylenol) considered medication of choice for pediatric clients
Goal of treatment is maintenance of effective cerebral perfusion, control of
increasing ICP
Assessment
 230
AppleRN Classes

History of systemic viral illness 4 to 7 days preceding onset of symptoms; malaise;

nausea and vomiting; progressive neurological deterioration
Interventions
Frequent monitoring of neurological status. Monitor intake and output
Provide rest. Decrease environmental stimuli
Monitor for signs of bleeding, impaired coagulation. Monitor liver function
studies
Parkinson’s disease (PD)
It is a progressively debilitating disease that grossly affects motor function.
It is characterized by four primary symptoms: tremor, muscle rigidity,
bradykinesia (slow movement), and postural instability.
These symptoms occur due to overstimulation of the basal ganglia by
acetylcholine (and depletion of dopamine)
Clients with PD have an imbalance between dopamine and acetylcholine in which
dopamine is not produced in high enough quantities to inhibit acetylcholine.
Monitor swallowing and maintain adequate nutrition.
Maintain client mobility for as long as possible. Monitor client’s mental and
cognitive status. Observe for signs of depression and dementia.
Provide a safe environment (no throw rugs, encourage the use of an electric
razor).
Promote client communication. Teach the client facial muscle strengthening
exercises. Encourage the client to speak slowly and to pause frequently. Use
alternate forms of communication as appropriate.
Refer client to a speech-language pathologist
Medication
May take several weeks of use before improvement of symptoms is seen.
 231
AppleRN Classes

levodopa (Dopar): converted to dopamine in the brain. Give with food to

minimize GI side effects
may be combined with carbidopa (Sinemet) to decrease peripheral metabolism of
levodopa
Anticholinergics : help control tremors and rigidity
Monitor for anticholinergic effects (dry mouth, constipation, urinary retention,
acute confusion, acute glucoma).
Alzheimer’s disease
Nonreversible type of dementia
Characterized by memory loss, problems with judgment, and changes in
personality leading to severe physical decline
Sundowning: increased confusion experienced by an individual with dementia at
night, when lighting is inadequate, or when the client is excessively fatigued – use
simple commands
Meds- Aricept – Prevent breakdown of Ach result in increased nerve impulses at
the nerve sites.
Antipsychotics, anxiolytics, antidepresents
Ginkgo biloba – herbal- memory improvement
Alzheimer disease and eating
It is common for clients to forget that they have eaten recently.
The best approach is for caregivers to give clients something to eat when they say
they are hungry.
Smaller meals throughout the day, along with low-calorie snacks, are effective
strategies for clients who forget that they have eaten.
Home Safety
Remove scatter rugs, lock cleaning supplies, Install door locks and place alarms on
doors. Keeping a lock on the water heater and thermostat
 232
AppleRN Classes

Provide good lighting, especially on stairs. Place mattress on the floor.

Install handrails on stairs, mark step edges with colored tape.
Remove clutter and clearing hallways for walking. Secure electrical cords to
baseboards.
Install handrails in the bathroom, at bedside, and in the tub; placing a shower
chair in the tub.
Having the client wear a medical identification bracelet
Monitoring for improvement in memory and the client’s quality of life.
Immunology
Sjögren's syndrome
Chronic autoimmune disorder
Moisture-producing exocrine glands of the body are attacked by white blood cells
The most commonly affected glands are the salivary and lacrimal glands, leading
to dry eyes (xerophthalmia) and dry mouth (xerostomia).
Dryness in these areas can lead to corneal ulcerations, dental caries, and oral
thrush.
Skin - dry skin and rashes
Throat and bronchi - chronic dry cough
Supportive care : Alleviate symptoms
Over-the-counter or prescribed drops are used to relieve itching, burning,
dryness, and gritty sensation in the eyes.
Wear goggles
Dry mouth : sugarless gum and candy or artificial saliva.
Lukewarm water and mild soap when showering can prevent dry skin.
Use humidifier, avoid decongestents
Systemic lupus erythematosus
 233
AppleRN Classes

Chronic multisystem inflammatory autoimmune disease

No cure – treatment is supportive. More common in women
Remissions and relapses (Flares). Anti Nuclear Antibody and ESR will be elevated
Most commonly affects skin, muscles, lining of lungs, heart, nervous tissue, and
kidneys
Arthritis occurs in more than 90% of patients with SLE : Painful/swollen joints,
morning stiffness
Lupus nephritis : serious complication of SLE : Look for abnormal KFT
Multisystem Involvement of SLE
Health Promotion and SLE. Infection is a major cause of death for patients with
SLE, Pneumonia being the most common infection.
Vaccination is essential, avoid contact with sick people. Follow a healthy lifestyle
(eg, 7-8 hours of sleep, no smoking).
Balanced exercise with alternating periods of rest (no extreme fatigue)
Rash : Sunlight – Avoid exposure between 10 AM-4 PM, Apply sunscreen. Wash
with mild soap and water (no harsh soap)
Treatment : Corticosteroids – immunosuppression
Antimalarial drugs (hydroxychloroquine and chloroquine ) and antileprosy drugs
(dapsone) might also be used to treat fatigue and moderate skin and joint
problems.
 234
AppleRN Classes

Antimalarial drug will take long time to be effective (issue of noncompliance)

Retinal toxicity and visual disturbances can occur with hydroxychloroquine – need
regular ophthalmic check ups
Supportive treatment
The SLE increased risk for : spontaneous abortion, stillbirth, and intrauterine
growth retardation.
Infertility can result , Renal involvement. Women with serious SLE should be
counseled against pregnancy. Exacerbation is common during the postpartum
period
Fibromyalgia
Fibromyalgia (FM) results from abnormal central nervous system pain
transmission and processing.
 235
AppleRN Classes

Signs : Chronic musculoskeletal pain, Multiple tender points, Fatigue,

Sleep/cognitive disturbances.
Treatment : Duloxetine (Cymbalta) and amitriptyline (Antidepressant) :Help with
neuropathic pain-relief, sleep issues and fatigue
Tender Points in Fibromyalgia
Anaphylactic shock
Acute onset, and manifestations usually develop quickly (20-30 minutes).
Common Causes: Drugs (eg, antibiotics), Foods (eg, shellfish, peanuts)
Diagnostic agents (eg, contrast), Biologic agents (eg, blood, vaccines)
Poison - venom (eg, bees, snakes)
Signs: Cardiovascular : Vasodilation → hypotension and tissue edema, Tachycardia
Respiratory: Upper airway edema → stridor & hoarseness, Bronchospasm →
wheezing
Cutaneous: Urticarial rash, pruritus, flushing
Gastrointestinal: Nausea, vomiting, abdominal pain
Management of anaphylactic shock . Airway and Oxygen . Remove insect stinger if
present
IM epinephrine : Repeat every 5 to 15mts if needed
Place in recumbent position and elevate legs, maintain BP with IV fluids and meds
Bronchodilator (albuterol) , Antihistamine (diphenhydramine)
Corticosteroids (methylprednisolone)
Anticipate tracheostomy with severe laryngeal edema
EpiPen
The EpiPen is designed to be administered through clothing . Do not waste the
precious time to save the client.
Use a swing and firm push against the mid-outer thigh until the injector clicks.
 236
AppleRN Classes

Hold the position for 10 seconds to allow the entire contents to be injected
The site should be massaged for an additional 10 seconds.
Important Notes on Vaccination
Assess for allergies to vaccine components (eg, neomycin, gelatin, yeast, eggs)
Screen for an allergy to latex (eg, lips swelling from contact with bananas, kiwis,
or latex balloons).
Severely immunocompromised children (eg, corticosteroid therapy,
chemotherapy, AIDS) generally should not receive live vaccines

Live vaccines are : varicella-zoster vaccine, measles-mumps-rubella, rotavirus, flu

vaccine (nasal) and yellow fever
OK to give even if allergic to Penicillin
Mild illness (with or without an elevated temperature) is not a contraindication
Mild site reactions (eg, swelling, erythema, soreness) are expected
Current course of antibiotics does not prevent illness from all. Hence child should
still take vaccination.
 237
AppleRN Classes

Renal System
Renal System Overview : Urine Formation
Hemodialysis: Hemodialysis shunts the client’s blood from the body through a
dialyzer and back into circulation.
Vascular access is needed for hemodialysis
Central line
AV fistula (requires several weeks to months to mature before it can be used)
AV Graft (can be used 2-4 weeks after placement)
Maturing of the fistula is aided by having the client perform hand exercises, such
as squeezing a rubber ball, that increase blood flow through the vein.
Nursing Considerations - Dialysis
Obtain Consent, Medications- might be on hold
Assess Vitals and Lab works, Obtain daily weight
Assess patency of AV fistula/ graft, Presence of bruit, palpable thrill, distal pulses
Restrictions on the extremity with AVF/G. Avoid taking blood pressure
Do not administer injections through AVF/G
Do not perform veni punctures or insert IV lines
Nursing Considerations - Dialysis
Assess for the following:
Complications (hypotension, clotting of vascular access, headache, muscle
cramps, bleeding)
Indications of bleeding, and/or infection at the access site
Signs of disequilibrium syndrome (due to too rapid decrease in BUN and fluids –
can result in cerebral edema and ICP- Signs include N/V, headache, fatigue,
confusion, convulsion, coma )
Signs of Hypovolemia (hypotension, dizziness, tachycardia)
 238
AppleRN Classes

Peritoneal Dialysis
Instill dialysate solution into peritoneal cavity and drain. The peritoneum serves
as the filtration membrane.
The client may feel fullness when the dialysate is dwelling.
Continuous ambulatory peritoneal dialysis (CAPD) is usually done 7 days a week
for 4 to 8 hr. Clients may continue normal activities during CAPD.
Continuous-cycle peritoneal dialysis (CCPD)- The exchange occurs at night while
the client is sleeping.
Access site care : strict sterile technique
Monitor weight, serum electrolytes, creatinine, BUN, and blood glucose (might
need insulin).
Warm the dialysate prior to instilling. Avoid the use of microwaves, which cause
uneven heating.
Monitor the color (clear, light yellow is expected) and amount (expected to equal
or exceed amount of dialysate inflow) of outflow.
Cloudy - infection
Reposition the client if inflow or outflow is inadequate.
Movement of the client will help disseminate the fluid throughout the abdomen
Monitor for signs of infection (fever; bloody, cloudy, or frothy dialysate return;
drainage at access site) and for complications (peritonitis, respiratory distress,
abdominal pain, insufficient outflow, discolored outflow).
Renal disorders
Acute Kidney Injury (renal failure)
Sudden cessation of renal function - when blood flow to the kidneys is
significantly compromised.
AKI is comprised of four phases:
 239
AppleRN Classes

Onset – Begins with the onset of the event, ends when oliguria develops, and lasts
for hours to days.
Oliguria – Begins with the kidney insult, urine output is 100 to 400 mL/24 hr with
or without diuretics, and lasts for 1 to 3 weeks.
Diuresis – Begins when the kidneys start to recover, diuresis of a large amount of
fluid occurs, and can last for 2 to 6 weeks.
Recovery – Continues until kidney function is fully restored and can take up to 12
months.
Acute Renal Injury Causes

Nursing Considerations
Monitor urine, input and output, urine color, characteristics
Monitor daily weight, Monitor for signs of infection
Monitor lungs for wheezes, rhonchi, edema, Administer prescribed diet
Restrict dietary intake of potassium, phosphate, and magnesium during oliguric
phase.
 240
AppleRN Classes

Potassium and sodium is regulated according to the stage of kidney injury.

High-protein diet to replace the high rate of protein breakdown due to stress
from the illness. Possible total parenteral nutrition (TPN).
Chronic Renal Failure
A slow, progressive, irreversible loss in kidney function
Primary causes : May follow acute renal failure, Diabetes mellitus and other
metabolic disorders, Hypertension, Chronic urinary obstruction
Assessment – entire body functions
Decreased sodium and calcium; increased potassium, phosphorus, and
magnesium.
Decreased hemoglobin and hematocrit from anemia secondary to the loss of
erythropoietin
CRF – Body Systems
Neurologic – lethargy, decreased attention span, slurred speech, tremors,
seizures, coma
Cardiovascular – fluid overload , hypertension, dysrhythmias, heart failure,
orthostatic hypotension
Respiratory – uremic halitosis (NHC03- by product in saliva –urea) with deep
sighing, yawning, shortness of breath, tachypnea, hyperpnea, Kussmaul
respirations, crackles, pleural friction rub, frothy pink sputum
Hematologic – anemia (pallor, weakness, dizziness), ecchymoses, petechiae,
melena
Gastrointestinal – ulcers in mouth and throat, foul breath, blood in stools, nausea,
vomiting
Musculoskeletal – thin fragile bones
Renal – urine contains protein, blood, particles; change in the amount, color,
concentration
 241
AppleRN Classes

Skin – decreased skin turgor, yellow cast to skin, dry, pruritus, urea crystal on skin
(uremic frost)
Special considerations
For anemia, administer epoetin alfa (Epogen, Procrit), darbepoetin alfa (Aranesp)
Administer blood transfusions if prescribed for anemia.
Instruct the client to avoid antacids containing magnesium.
Avoid administration of acetylsalicylic acid (aspirin) or NSAIDS to prevent
gastrointestinal bleeding.
Avoid administering antimicrobial medications (e.g., aminoglycosides and
amphotericin B), angiotensin-converting enzyme inhibitors and angiotensin-
receptor blockers, and IV contrast dye, which are nephrotoxic.
Nursing Considerations:
Monitor for signs of hypervolemia, hypovolemia, dehydration, signs of congestive
heart failure, pulmonary edema, signs of infection, peripheral neuropathy
Monitor for hyperkalemia - cardiac monitoring (dysrhythmias). Provide low-
potassium diet if prescribed for hyperkalemia. Avoid potassium-sparing diuretics
Sodium polystyrene (Kayexalate) to eliminate serum potassium
Diet : Restrict the client’s dietary sodium, potassium, phosphorous, and
magnesium.
Provide the client a diet that is high in carbohydrates and moderate in fat.
Low-protein diet helps prevent kidney disease progression. But if the client is
already on dialysis, liberal protein intake is recommended to prevent
malnutrition.
Protect clients eyes from ocular irritation
Provide end-of-life care for client with end-stage renal disease
Avoid diuretics for end stage if possible. It increases destruction of the remaining
nephrons in the kidney.
 242
AppleRN Classes

Glomerulonephritis
Inflammation of the glomerular capillaries.
Risk Factors
group A beta-hemolytic streptococcal infection of pharynx or skin
History of pharyngitis or tonsillitis 2 to 3 weeks before symptoms
HTN, DM, Excessively High protein and high sodium diet
Types : Acute - usually has fever. Chronic (cause not known) – Usually has
pruritis
Labs : Antistreptolysin-O (ASO) titer (positive indicating the presence of strep
antibodies),
Eleavted RFT, Urinanalysis (proteinuria, hematuria, casts, sp.gravity increases
Renal symptoms
Decreased urine output, Smoky or coffee-colored urine (hematuria), Proteinuria
Fluid volume excess symptoms (edema, SOB, weight, crackles, HTN) - severe
hypertension must be identified early.
LOC changes, Older adult clients may report vague symptoms (nausea, fatigue,
joint aches) which may mask glomerular disease.
Nursing Care
Daily weight , Intake and output., urinary pattern change
Labs - serum electrolytes, BUN, and creatinine., skin - pruritus.
Bed rest to decrease metabolic demands.
Maintain prescribed dietary restrictions. Fluid restriction (24 hr output + 500 to
600 mL)
Sodium restriction (1 to 3 g/day) begins when fluid retention occurs
Protein restriction (if azotemia is present = increased BUN)
Other Complications
 243
AppleRN Classes

Uremia : Monitor the client for muscle cramps, fatigue, pruritus, anorexia, and a
metallic taste in mouth. Maintain skin integrity. Encourage mouth rinses,
chewing gum, or hard candy.
Pulmonary edema, congestive heart failure, pericarditis. Anemia
Therapeutic Procedures - Plasmapheresis (filters antibodies out of circulating
blood volume by removing the plasma)
Weigh the client before and after the procedure . Monitor for hypovolemia
Administer replacement fluids - albumin
Monitor for signs of tetany if too much calcium is removed.
Renal Calculi
Urolithiasis is the presence of calculi (stones) in the urinary tract.
The majority of stones (75%) are composed of calcium phosphate or calcium
oxalate, but they may contain other substances (uric acid, struvite, cystine).
Most clients can expel stones without invasive procedures.
Renal Stone : Severe pain (renal colic)
Pain intensifies as the stone moves through the ureter.
Flank pain suggests stones are located in the kidney or ureter.
Flank pain that radiates to the abdomen, scrotum, testes, or vulva is suggestive of
stones in the ureter or bladder.
Urinary frequency or dysuria (stones in the bladder)
Nausea, vomiting, Diaphoresis, Pallor, Fever
Oliguria/anuria (occurs with stones that obstruct urinary flow); urinary tract
obstruction is a medical emergency and needs to be treated to preserve kidney
function.
Strain all urine to check for passage of the stone and save the stone for laboratory
analysis.
Encourage increased oral intake to 3 L/day unless contraindicated.
 244
AppleRN Classes

Administer IV fluids as prescribed. Encourage ambulation to promote passage of

the stone.
Surgical Interventions
ureteroscopy (dilate ureter using scope for passage of stone
Ureterolithotomy - insertion of an ultrasonic or laser lithotripter into the ureter or
kidney to grasp and extract the stone.
Open Surgery (large stone)
Therapeutic Procedures
Extracorporeal shock wave lithotripsy (ESWL)
Uses sound, laser, or shock-wave energies to break stones into fragments.
Requires moderate (conscious) sedation and ECG monitoring during the
procedure.
Nursing Actions
Educate the client regarding ESWL.
Assess for gross hematuria and strain urine following the procedure.
Administer analgesics as prescribed.
Client Education
Inform the client that bruising is normal at the site where waves are applied.
Explain to the client that there will be hematuria postprocedure.
Uric acid stone : Decrease intake of purine sources (organ meats, poultry, fish,
gravies, red wine, sardines).
Calcium Stone : Limit intake of food high in animal protein (reduction of protein
intake decreases calcium precipitation).
Avoid oxalate sources: Spinach, black tea, rhubarb, cocoa, beets, pecans, peanuts,
okra, chocolate, wheat germ, lime peel, and Swiss chard.
 245
AppleRN Classes

Ileal conduit
Surgery – Use a piece of the client's ileum to create an outlet (No bladder)
The client's ureters are connected to the ileal conduit ------ to abdominal stoma ---
bag ---to pass urine.
A healthy stoma should be pink to brick-red and moist, indicating vascularity and
viability.
Dusky or any shade of blue : Impaired perfusion. Contact the HCP immediately. -
medical emergency
UTI
An upper UTI : pyelonephritis.
Pyelonephritis is an infection and inflammation of the kidney pelvis, calyces, and
medulla.
The infection usually begins in the lower urinary tract with organisms ascending
into the kidney pelvis.
Administer antipyretic, such as acetaminophen (Tylenol), as needed for fever and
opioid analgesics for pain associated with pyelonephritis
UA: Bacteria, sediment, white blood cells (WBC), and red blood cells (RBC).
Positive leukocyte esterase and nitrates (68% to 88% positive results indicates
UTI)
Nursing Considerations
Fluid intake : up to 3 L daily, Antibiotics, Frequent voiding : urinate every 3 to 4
hrs, Warm sitz bath : comfort. Body hygiene : Wipe from front to back after
urination. Avoid urinary catheters if possible. Hand washing
Kidney Transplant
Risk : immunosuppression, organ rejection
Immunosuppressants (steroids, Cyclosporine). Early signs of organ rejection :
fever, hypertension, pain
 246
AppleRN Classes

Post procedure : Signs of infection???

Other complications: cardiovascular disease; recurrence; Steroid side effects,
malignancies.
Diet recommendations: Low fat, high fiber, increased protein
Steroid diet – Low CHO, Low Na
Magnesium supplements (cyclosporine can reduce magnesium levels)
Avoid grapefruit (interfere absorption).
Activity : Avoid contact sports
Nephrotic Syndrome
Kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema
No specific treatment. Might develop into ESRD
Can be genetic (child lives < 2 yrs.)
Assessment: Weight gain, Periorbital and facial edema, Dependent edema,
Oliguria, Dark and frothy urine, Abdominal swelling may occur.
Blood pressure normal or slightly decreased, or hypertensive later
Intervention: Monitor vital signs, intake and output, edema, daily weight
Watch for ICP increase, Monitor urine for protein, specific gravity
High protein, high calorie and restricted sodium diet
Administer corticosteroids, immunosuppressants and/or diuretics as prescribed
Monitor for signs of infection, need to avoid contact with others who may be
infectious
Wilms tumor (nephroblastoma)
Kidney tumor that usually occurs in children age <5.
Usual sign: unusual contour/bulging/swelling in one side of child's abdomen.
Once the diagnosis is suspected or confirmed, the abdomen should not be
palpated, as this can disrupt the encapsulated tumor.
 247
AppleRN Classes

post the sign "DO NOT PALPATE ABDOMEN" at the bedside

Handle the child carefully during bathing.
A nephrectomy, is usually performed within 24 to 48 hours of diagnosis as it’s a
highly invasive tumor.
Reproductive System Disorder
Benign Prostatic Hyperplasia (BPH)
BPH can significantly impair the outflow of urine from the bladder, making a client
susceptible to infection and retention.
Excessive amounts of urine retained can cause reflux of urine into the kidney,
dilating the ureter and causing kidney infections.
Symptoms:
urinary frequency, urgency, incomplete emptying of the bladder, urinary
hesitancy, urinary incontinence, dribbling post-voiding,
nocturia, diminished force of urinary stream, straining with urination, and
painless hematuria
Teaching : Avoid drinking large amounts of fluids at one time
Urinate when the urge is initially felt.
Avoid bladder stimulants, such as alcohol and caffeine.
Avoid medications that cause decreased bladder tone, such as anticholinergics,
decongestants, and antihistamines.
Transurethral resection of the prostate (TURP)
CBI: continuous bladder irrigation: indwelling three-way catheter.
The rate of the CBI is adjusted to keep the irrigation return pink or lighter.
If the catheter becomes obstructed (bladder spasms, reduced irrigation outflow),
turn off the CBI and irrigate with 50 mL of irrigation solution using a large piston
syringe. Contact the surgeon if unable to dislodge the clot.
 248
AppleRN Classes

Record the amount of irrigating solution instilled (generally very large volumes)
and the amount of return. The difference equals urine output.
Avoid kinks in the tubing.
Hysterectomy
A hysterectomy is the removal of the uterus.
A bilateral salpingo oophrectomy is the removal of the ovaries and fallopian
tubes.
There are three methods of performing a hysterectomy
Abdominal approach, also known as a total abdominal hysterectomy
Vaginal approach (TVA)
Laparoscopy-assisted vaginal hysterectomy (LAVH)
Pre-procedure Nursing Actions
Ensure that clients who have been taking anitcoagulant medications, aspirin,
nonsterodial anti‑inflammatory drugs (NSAIDs), or vitamin E have discontinued
their use.
Rule out pregnancy. Administer preoperative antibiotics.
Place antiembolism stockings. Complete psychological assessment.
Maintain NPO status. Ensure that informed consent has been obtained.
Client Education: Teach the client how to turn, cough, and deep breathe, and the
importance of early ambulation.
Instruct the client how to use an incentive spirometer.
Teach the client about preoperative and postoperative medications.
Post op Care: Monitor bleeding, vital signs, breath sounds, bowel sounds, urine
output
Provide IV fluid and electrolyte replacement
Incision: infection, integrity, risk of dehiscence.
 249
AppleRN Classes

Complication : DVT? Monitor the client’s blood loss (Hgb and Hct).
Discharge Teaching: Well-balanced diet : high in protein , iron, vitamin C
Oophorectomy - Hormone Replacement Therapy
Activity restriction for 6 weeks: (heavy lifting, strenuous activity, driving, stairs,
sexual activity)
Notify s/s infection : fever, drainage, UTI
Menstrual Disorders
Dysfunctional uterine bleeding (DUB) : due to a hormonal imbalance and may
include menorrhagia and metrorrhagia.
Menorrhagia is excessive bleeding (in amount and duration), possibly with clots
and for longer than 7 days.
Metrorrhagia is bleeding between menstrual periods more frequently than every
21 days.
Treatment : Dilatation and curettage: Endometrial ablation
Used to remove endometrial tissue in the uterus.
The tissue may be removed by laser, heat, electricity, or cryotherapy.
Hysterectomy if other treatments are unsuccessful
Premenstrual syndrome (PMS)
Caused by an imbalance between estrogen and progesterone.
Symptoms can vary among women and can vary for an individual woman from
one cycle to the next.
Common symptoms include irritability, impaired memory, depression, poor
concentration, mood swings, binge eating, breast tenderness, bloating, weight
gain, headache, and back pain.
Endometriosis
Overgrowth of endometrial tissue : into the fallopian tubes, onto the ovaries, and
into the pelvis.
 250
AppleRN Classes

Common cause of infertility - Blockage of the fallopian tubes by endometrial

tissue
CA-125 : may be elevated – also high in ovarian cancer.
NSAIDs – ibuprofen (Motrin) May be given for endometriosis to inhibit production
of prostaglandins
Laparoscopic removal of ectopic tissue and adhesions can be done.
Renal and GU Medications
Diuretics : Discussed with CV system
Finasteride (Proscar)
For BPH : It decrease the production of testosterone in the prostate gland, reduce
the size. Reinforce that it may take 6 months to 1 year before effects of the
medication are evident.
Inform the client that impotence and a decrease in libido are possible side effects.
Report breast enlargement to the provider.
Finasteride is teratogenic to a male fetus. The medication can be absorbed
through the skin. Pregnant women should not be in contact with tablets that are
crushed or broken.
Tamsulosin (Flomax): Relaxation of the bladder outlet and prostate gland.
postural hypotension may occur, and that changes in position must be made
slowly. Warn the client that concurrent use with cimetidine (Tagamet) can
potentiate the hypotensive effect.
Hormone Therapy : To suppress hot flashes associated with menopause, to
prevent atrophy of vaginal tissue, and to reduce the risk of fractures due to
osteoporosis.
Short term treatment – less than 5 yrs.
At risk for a number of adverse conditions, including coronary heart disease,
myocardial infarction, deep-vein thrombosis, stroke, and breast cancer.
 251
AppleRN Classes

Teach the client how to prevent and assess the development of venous
thrombosis. Avoid wearing knee-high stockings and clothing or socks that are
restrictive. Note and report symptoms of unilateral leg pain, edema, warmth, and
redness.
Avoid sitting for long periods of time. Take short walks throughout the day to
promote circulation
Oral contraceptive
Usually taken for 21 consecutive days, stopped for 7 days; cycle then repeated.
One pill daily at the same time every day. The client must be instructed to use a
second birth control method during the first pill cycle of contraceptives.
If miss one pill, take as soon as the client remembers and continue the daily dose.
If miss two pills, take them both, as soon as possible, and take two pills the next
day also.
Additionally, the client must be instructed that, if she misses three pills, she will
need to discontinue pill use for that cycle and use another birth control method.
Instruct client to report signs of thromboembolic complications
Advise client to use alternative form of birth control when taking antibiotics
Instruct client to perform breast self-examination (BSE) monthly. Oral
contraceptives may increase growth of a pre-existing breast cancer. Do not give
to women who have breast cancer.
If client decides to discontinue contraceptive to become pregnant, recommend
alternative form of birth control for 2-month period. If using patch and it remains
off for less than 24 hours, reapply. If using patch and it is off longer than 24 hours,
new 4-week cycle must be started immediately
 252
AppleRN Classes

Endocrine

How does hormones work on cell? Two kinds of Travel

• 1. Lipid soluble : Made from cholesterol. Ex: corticosteroids, sex hormones,
thyroid hormones. Need plasma proteins to travel
• 2. Water Soluble - circulate freely in the blood. Ex: insulin, growth
hormone, and prolactin
Hypothalamus : Control centre : SAT : Sleep, Appetite,Temperature
 253
AppleRN Classes

Disorders of Pituitary Gland

Hypopituitarism
• Hyposecretion of one or more pituitary hormones; caused by
tumors, trauma, encephalitis, autoimmunity, stroke
• May need hormone replacement
Hyperpituitarism : Hypersecretion of one or more pituitary hormones
One form is acromegaly, hypersecretion of growth hormone of anterior pituitary
gland; caused by tumor of pituitary gland - Hypertension, heart failure (s3 and s4)
May need radiation therapy, hypophysectomy
Acromegaly
overproduction of growth hormone (GH).
overgrowth of soft tissues of the face, hands, feet, and organs.
 254
AppleRN Classes

Hypophysectomy
Monitor and correct electrolytes, especially sodium, potassium, and chloride.
Monitor and adjust serum glucose levels.
Monitor ECG. Protect the client from developing an infection.
Use caution to prevent a fracture
Monitor for bleeding. The client may have nasal packing postoperatively and need
to breathe through his mouth.
Monitor nasal drainage for CSF leak (halo sign, glucose +)
Numbness at the surgical site and a diminished sense of smell may be
experienced for 3 to 4 months after surgery
Assess neurologic condition every hour for the first 24 hr and then every 4 hr.
Administer glucocorticoids to prevent an abrupt drop in cortisol level.
Avoid increased ICP. (stool softeners, no bending over waist, cough, blowing,
sneezing)
Avoid tooth brushing for 10 days – might disrupt suture
Deficiency of ADH causes diabetes insipidus (DI).
DI is characterized by the excretion of a large quantity of diluted urine, excessive
thirst, and excessive fluid intake.
Types of diabetes insipidus
 255
AppleRN Classes

Neurogenic (also known as central or primary) – Caused by damage to the

hypothalamus or pituitary gland from trauma, irradiation, or cranial surgery.
Nephrogenic – Inherited; renal tubules do not react to ADH.
Drug-induced – Lithium carbonate (Lithobid) or demeclocycline (Declomycin) may
alter the way the kidneys respond to ADH.
Diabetes Insipidus -Signs and Symptoms
Polyuria (abrupt onset of excessive urination, urinary output of 4 to 20 L/day of
dilute urine)
Polydipsia (excessive thirst, consumption of 2 to 20 L/day)
Nocturia, Fatigue: Dehydration, as evidenced by extreme thirst, weight loss,
muscle weakness, headache, constipation, and dizziness
Sunken eyes, Tachycardia, Hypotension
Loss or absence of skin turgor, Dry mucous membranes
Water deprivation test
This is an easy and reliable diagnostic test. Dehydration is induced by withholding
fluids. Urine output is measured and tested hourly.
Nursing Care
Monitor vital signs, urinary output, central venous pressure, I&O, specific gravity,
and laboratory studies (low urine specific gravity, high serum osmolarity).
Weigh daily.
Promote the prescribed diet (regular diet with restriction of foods that exert a
diuretic effect, such as caffeine).
IV therapy – Hydration (intake and output must be matched to prevent
dehydration), and electrolyte replacement.
Promote safety – Keep bedside rails up while client is in bed, and provide
assistance with ambulation due to dizziness or muscle weakness. Ensure easy
access to a bathroom or bedpan.
 256
AppleRN Classes

Add bulk foods and fruit juices to the diet if constipation develops. A laxative may
be needed. Assess skin turgor and mucous membranes.
Provide skin and mouth care, and apply a lubricant to cracked or sore lips.
Use a soft toothbrush and mild mouthwash to avoid trauma to the oral mucosa.
Use alcohol-free skin care products, and apply emollient lotion after baths.
Encourage the client to drink fluids in response to thirst.
Administer medications as prescribed – ADH replacements, synthetic vasopressin
(desmopressin)
Carbamazepine (anticonvulsant which stimulate release of ADH).
Syndrome of inappropriate antidiuretic hormone (SIADH).
Excessive secretion of ADH
In SIADH, the kidneys retain water and urine output decreases.
Early manifestations of SIADH: headache, weakness, anorexia, muscle cramps,
weight gain.
Increased water re-absorption and intravascular volume, which results
in dilutional hyponatremia and a high urine sodium level
Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum
sodium drops below 120 mEq/L (120 mmol/L)
As the serum sodium level decreases, the client experiences personality changes,
hostility, sluggish deep tendon reflexes, nausea, vomiting, diarrhea, and
oliguria.
Malignant lung tumors are a common cause of syndrome of inappropriate
antidiuretic hormone secretion (SIADH).
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Physical Assessment Findings
Confusion, lethargy, and Cheyne-Stokes respirations.
 257
AppleRN Classes

When the serum sodium level drops further, seizures, coma, and death may
occur.
Manifestations of fluid volume excess include tachycardia, possible hypertension,
crackles in lungs, distended neck veins, and taut skin.
Intake is greater than output.
Too much ADH causes increased total body water, resulting in a low serum
osmolality and low serum sodium. As ADH is secreted and water is retained,
urine output is decreased and concentrated, resulting in a high urine specific
gravity.
Nursing Care - SIADH
Restrict oral fluids to 500 to 1,000 mL/day to prevent further hemodilution (first
priority).
During fluid restriction, provide comfort measures for thirst, including mouth
care, ice chips, lozenges, and staggered water intake.
Flush all enteral and gastric tubes with 0.9% sodium chloride, instead of water, to
prevent further hemodilution.
Monitor I&O. Report decreased urine output. Monitor vital signs for increased
blood pressure, tachycardia, and hypothermia.
Monitor for urine and blood work. Weigh daily.
Report altered mental status (headache, confusion, lethargy, seizures, coma).
Reduce environmental stimuli and position the client as needed.
Provide a safe environment for clients who have altered levels of consciousness.
Maintain seizure precautions.
Monitor the client for indications of heart failure, which can occur from fluid
overload. Use of a loop diuretic may be indicated.
Meds- Demeclocycline, Lithium, Lasix
Thyroid and parathyroid
 258
AppleRN Classes

Thyroxin (T3, T4) Increase metabolism

Calcitonin Lower serum calcium

Thyroid : Palpate thyroid gland

Assessment of Endocrine System: Diagnostic Studies of Thyroid
1. Ultrasonography : ? fluid filled nodule or solid tumor ?
2. Thyroid scan : For nodules. Radioactive isotopes are given orally or
IV.
Benign nodules appear as warm spots because they take up radionuclide.
Malignant tumors appear as cold spots because they tend not to take up
radionuclide.
3. Radioactive iodine uptake (RAIU)
1. Direct measure of thyroid activity.
2. Radioactive iodine given either orally or IV.
3. The uptake by the thyroid gland is measured in intervals such
as 2 to 4 hours and at 24 hours.
4. Instruct patient to drink increased amount of fluids for 24 to 48
hours unless this is contraindicated. Radionuclide will be
eliminated in 6 to 24 hours.
 259
AppleRN Classes

Myxedema : Life threatening Crisis : Edema throughout body, severe metabolic

disorders (hypoglycemia) , CV collapse, Coma
Major : Airway patency, ECG, Vital signs and ABG
? Hypoxia , ?Hypothermia
Med : Levothyroxine IV bolus, corticosteroids
Nursing : I/O, daily weight, vital signs
Any trigger? (no meds? Infection?)
Levothyroxine : Adjust dose – blood test
High levels of TSH – start/increase Levothyroxin. Dose - Once daily – an empty
stomach
Usually - lifelong therapy. Can take up to 8 weeks to see the full effect
Exophthalmos
Increased orbital tissue expansion - can be irreversible.
 260
AppleRN Classes

Cornea : risk for dryness, injury, and infection.

Maintain the head of the bed in a raised position - fluid drainage
Use artificial tears - prevent corneal drying
Tape the client’s eyelids shut during sleep if they do not close on their own
Teach : Regular ophthalmologist visit
Need Anti-thyroid drugs : Ex: propylthiouracil, methimazole
Smoking cessation - smoking increases exophthalmos.
Restrict salt intake to decrease periorbital edema.
Use dark glasses - decrease glare, prevent external irritants and infection.
Perform intraocular muscle exercises (turning the eyes using complete range of
motion) to maintain flexibility
Thyroid Storm/ Crisis
From a sudden surge of large amounts of thyroid hormones into the blood
Greater increase in body metabolism - medical emergency
Precipitating factors - infection, trauma, emotional stress, diabetic ketoacidosis,
and digitalis toxicity.
It also can occur following a surgical procedure or a thyroidectomy as a result of
manipulation of the gland during surgery.
Findings are hyperthermia, hypertension, hyperglycemia, dysrhythmias, chest
pain, palpitations delirium, vomiting, abdominal pain and dyspnea
Thyroid Storm – Nursing Care
Maintain a patent airway. Start oxygen, continuous cardiac monitoring
Hyperthermia management- Medicine, cool sponge, cooling blamket
Administer Meds: anti-thyroid drugs- thionamides
 261
AppleRN Classes

propranolol to block sympathetic nervous system effects (tachycardia,

palpitations). Glucocorticoids to treat shock. IV fluids to provide adequate
hydration, Insulin
Thyroidectomy
Airway swelling is a life-threatening complication of thyroid surgery.
Signs of respiratory distress such as stridor and dyspnea require rapid
intervention. Have tracheostomy set, oxygen, suctioning at bedside at all times
Position client in semi-Fowler’s position, Assess neck dressing for bleeding
Monitor for hypocalcemic crisis, Assess for signs of potential tetany
Monitor for laryngeal nerve damage
Diet with Hyperthyroidism
Hyperthyroidism leads to a high metabolic rate:
Diet high in calories (high in protein, carbohydrates, vitamins, and minerals) to
satisfy hunger and prevent weight loss and tissue wasting.
Avoidance of high-fiber foods due to the constant hyperstimulation of the
gastrointestinal (GI) tract. However, high-fiber diets are recommended if the
client with hyperthyroidism has constipation.
Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft
drinks). Avoidance of spicy foods as these can also increase GI stimulation.
Disorders of Parathyroid Gland
Hyperparathyroidism: Hypersecretion of parathyroid hormones leads to increased
Ca re-absorption and increased phosphate excretion.
Assess for hypercalcemia – Bones, Stones, Groans, Moans
Psychic Moans (fatigue, depression, weakness)
Elevated levels in PTH will accelerate osteoporosis as calcium is released from
storage.
Calcium has a diuretic effect, producing symptoms of polyuria and polydipsia.
 262
AppleRN Classes

High calcium levels can cause constipation (Abdominal groans)

Assess for Hypophosphatemia (Muscle dysfunction and weakness, mental status
changes)
Parathyroidectomy – care as thyroidectomy
Hypoparathyroidsm
Hyposecretion of parathyroid hormones
Assess for hypocalcemia – CATS (Convulsion, Arrythmia, Tetany, Spasm/Stridor)
positive Trousseau’s sign, positive Chvostek’s sign.
Have tracheostomy set, oxygen, suctioning at bedside at all times
Prepare to administer calcium gluconate as prescribed for hypocalcemia
Initiate seizure precautions. Client should have high-calcium, low-phosphorus diet

Cushing’s disease and Cushing’s syndrome

Over secretion of ACTH by pitutaty or the hormones by adrenal cortex or by long-
term use of glucocorticoids to treat other conditions, such as asthma or RA
Clinical Manifestations : Moon Face, Buffalo hump, Weakness, fatigue, sleep
disturbances, weight gain
 263
AppleRN Classes

Back and joint pain, thin fragile bone , Frequent infections, poor wound healing
Altered emotional state (may include irritability or depression)
Lab test – Cortisol (salivary cortisol also elevated)
K and Calcium – low. Na and Glucose - High
Nursing Care- Cushing’s disease
Diet: Decreased sodium intake and increased intake of potassium, protein, and
calcium.
Monitor I/O, and daily weight.
Assess hypervolemia (edema, distended neck veins, shortness of breath, presence
of adventitious breath sounds, hypertension, tachycardia).
Low calcium : Fractures
Prevent Infection and skin trauma.
Medications – suppress /inhibit adrenal cortex (Mitotane, Ketoconazole,
aldectone)
Surgery - Surgical removal of the pituitary gland (Hypophysectomy) or
Adrenalectomy
Adrenalectomy
Provide glucocorticoid and hormone replacement as needed.
Monitor for adrenal crisis due to an abrupt drop in cortisol level. Findings may
include hypotension, tachycardia, tachypnea, nausea, and headache.
Monitor vital signs and hemodynamic levels frequently initially (every 15 min).
Monitor fluids and electrolytes. Monitor the incision site for bleeding.
Monitor bowel sounds. Slowly introduce foods.
Provide pain medication as needed. Administer stool softeners as needed.
Assess the abdomen for distention and tenderness.
Monitor the incision site for redness, discharge, and swelling.
 264
AppleRN Classes

Adrenal Crisis
Sudden drop in corticosteroids due to sudden withdrawal of medication or tumor
removal. Medical Emergency – Life threatening.
Precipitating Factors : Sepsis, Trauma, Stress (myocardial infarction, surgery,
anesthesia, hypothermia, volume loss, hypoglycemia), Adrenal hemorrhage and
Steroid withdrawal.
Indications include hypotension, tachycardia , hypoglycemia, hyperkalemia,
hyponatremia, confusion, abdominal pain, weakness, and weight loss.
Administration of glucocorticoids treats acute adrenal insufficiency.
Instruct the client to gradually taper steroid medications.
Additional glucocorticoids may be needed to prevent adrenal crisis.
long-term corticosteroid replacement
Do not discontinue glucocorticoid therapy abruptly (addisonian crisis, a life-
threatening complication)
Report any signs and symptoms of infection to the HCP immediately.
Stay attuned to signs and symptoms of stress and increase dose of
corticosteroid during times of stress.
A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels,
triggering addisonian crisis
A side effect of corticosteroid therapy is hyperglycemia. (caution in DM)
long-term corticosteroid replacement
Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle
weakness).
A diet high in calcium (at least 1500 mg/day) and protein (1.5 g/kg/day) but low in
fat and simple carbohydrates is recommended.
Cataracts are a side effect of corticosteroids, particularly glucocorticoid . Need
yearly eye exam.
 265
AppleRN Classes

Corticosteroid medications can cause gastric irritation and should not be taken on
an empty stomach.
Recognize signs and symptoms of Cushing syndrome and report to the PHCP.
Addison’s disease
Adrenocortical insufficiency
Decreased production of mineralocorticoids and glucocorticoids : resulting in
decreased aldosterone and cortisol.
Lab tests - K+, calcium, BUN and creatinine – increased
Na, Glucose and cortisol decreased.
Bronze color skin – Likely due to ACTH interference with MSH
Hyperpigmentation
Nursing Care – Addison’s disease
Monitor fluid deficits and electrolyte imbalances. IV fluids.
Observe for dehydration. Obtain orthostatic vital signs.
Administer hydrocortisone IV bolus and a continuous infusion or intermittent IV
bolus.
Monitor for and treat hyperkalemia: Obtain a serum potassium and ECG. Give
Kayexalate and other meds
Monitor for and treat hypoglycemia. Maintain a safe environment:
Provide assistance ambulating, Raise side rails.
Prevent falls by keeping floors clear.
Meds- Steroids: In a client taking corticosteroids Report signs and symptoms of
infection, even a low-grade fever.
This is because the anti-inflammatory properties of these drugs can mask
infection that can spread quickly.
 266
AppleRN Classes

Situations necessitating corticosteroid adjustment are fever, influenza, extraction

of teeth, and rigorous physical activity, such as playing tennis on a hot day or
running a marathon
Tachycardia, moon face, and weight gain are also side effects of long-term
corticosteroid therapy.
Pheocromocytoma (Adrenal medulla tumor)
Catacholamines increase (adrenalin, noradrenaline) resulting in
paroxysmal hypertensive crisis.
6 P : Pounding Pain (Headache), Perspiration, Pallor, Panic, Palpitation, Pressure
Meds: nitroprusside or another vasodilator : Hypertension is difficult to treat and
is often resistant to multiple drugs.
The client should avoid activities that can precipitate a hypertensive crisis (eg,
bending, lifting, Valsalva maneuver).
Abdominal palpation should be avoided as manipulation of the adrenal gland
and release of catecholamines can precipitate a hypertensive crisis.
Pheocromocytoma – Care Points
Hypertension is difficult to treat and is often resistant to multiple drugs.
Avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting,
Valsalva maneuver).
Avoid Abdominal palpation : Manipulation of the adrenal gland and release of
catecholamines can precipitate a hypertensive crisis.
Med – Nitroprusside - vasodilator given via infusion and can be titrated to keep
the BP with in range
 267
AppleRN Classes

Pancreas

Laboratory Tests : Diagnostic criteria for diabetes include two findings (on
separate days) of one of the following:
1. Manifestations of diabetes plus casual blood glucose concentration greater
than 200 mg/dL (without regard to time since last meal)
2. Fasting blood glucose greater than 126 mg/dL
3. Two-hr glucose greater than 200 mg/dL with an oral glucose tolerance test
Glycosylated hemoglobin (HbA1c) - average blood glucose level for the past 120
days. Normal - 4% to 6%. For good control DM - less than 7%.
Laboratory Tests
Fasting blood glucose (FBG/FBS)
Nursing Actions – Avoid antidiabetic medication until after the level is drawn.
Instruct the client to fast (no food or drink other than water) for the 8 hr prior to
the blood test.
Oral glucose tolerance test (OGT)
A fasting blood glucose level is drawn at the start of the test.
The client is then instructed to consume a specified amount of glucose. Blood
glucose levels are obtained every 30 min for 2 hr. (Watch for hypoglycemia)
Instruct the client to consume a balanced diet for 3 days prior to the test.
 268
AppleRN Classes

Then instruct the client to fast for 10 to 12 hr prior to the test.

Compare DM1 and DM II

Insulin- Other names

Lispro-=Aspart= Glulisine = Humalog = Novolog (Rapid acting)
Humalin R= NovolinR = Regular Insulin = Short Acting
Lantus = Levemir = Detemir= Glargine = Long Acting
It is important for the nurse to ensure that the client eats within 15 minutes of
administration of rapid acting insulin to prevent an insulin-related hypoglycemic
reaction
NPH is an intermediate-acting insulin and typically prescribed twice a day
 269
AppleRN Classes

Storing insulin:
Avoid extreme temperatures . Do not freeze or keep in direct sunlight
Insulin injection sites: Main areas include abdomen, arms (posterior surface),
thighs (anterior surface), hips
Administering insulin
Before use, swirl vial gently or rotate between palms, but avoid vigorous shaking
Administer mixed dose within 5 to 15 minutes of preparation
Regular insulin is only type of insulin that can be administered IV
Complications of insulin therapy
Local reactions include redness, edema, tenderness, induration at site of injection
Lipodystrophy (loss of subcutaneous fat) and Lipohypertrophy (development of
fibrous fatty masses at injection site)
Rotate injection sites for prevention; instruct client not to inject into altered sites
Insulin resistance occurs when client develops immune antibodies that bind with
insulin, making it unavailable to body for use
Administer purer insulin preparation as prescribed for prevention
Dawn phenomenon
The dawn phenomenon is a normal rise in blood sugar as a person's body
prepares to wake up.
Develops between 5 and 8 AM (hyperglycemia) (DM patients don’t have insulin in
their body to counteract this normal rise)
Treatment: Administer evening dose of intermediate-acting insulin at 10 PM.
Somogyi phenomenon : hypoglycemia occurs between 2 and 3 AM, causing
increase in production of counter regulatory hormones (growth hormone,
cortisol, and catecholamines – raises blood glucose)
Blood glucose level rebounds to hyperglycemic range.
 270
AppleRN Classes

Increase evening dose of intermediate-acting insulin

Take a bedtime snack
If the blood sugar level is normal or high at 2 a.m. to 3 a.m., it's likely the dawn
phenomenon. If the blood sugar level is low at 2 a.m. to 3 a.m., suspect the
Somogyi effect.
Hypoglycemia Signs: mild shakiness, mental confusion, sweating, palpitations,
Tremors
Complications of Diabetes -Hypoglycemia
Check blood glucose level (Hypo- glucose of 70 mg/dL or less)
take 15 to 20 g of a readily absorbable carbohydrate (4 to 6 oz of fruit juice or
regular soft drink, 3 to 4 glucose tablets, 8 to 10 hard candies, or 1 tbsp of honey)
and recheck blood glucose in 15 min.
Repeat the administration of carbohydrates if not within normal limits, and
recheck blood glucose in 15 min.
If the client is unconscious or unable to swallow, administer glucagon
subcutaneous or IM (repeat in 10 min if still unconscious) and notify the provider.
Administer 50% dextrose if IV access is available.
Foot Care
Inspect feet daily. Wash feet daily with mild soap and warm water.
Test water temperature with hands before washing feet.
Pat feet dry gently, especially between the toes, and avoid lotions between toes
to decrease excess moisture and prevent infection.
Use mild foot powder (powder with cornstarch) on sweaty feet.
Do not use commercial remedies for the removal of calluses or corns, which may
increase the risk for tissue injury and infection.
The best time to perform nail care is after a bath/shower, when toenails are soft
and easier to trim.
 271
AppleRN Classes

Separate overlapping toes with cotton or lamb’s wool.

Avoid open-toe, open-heel shoes. Leather shoes are preferred to plastic. Wear
shoes that fit correctly. Wear slippers with soles. Do not go barefoot.
Wear clean, absorbent socks or stockings of cotton
No hot water bottles or heating pads to warm feet. Wear socks for warmth.
Avoid prolonged sitting, standing, and crossing of legs.
Nail Care- trim toenails straight across with clippers and filing edges.
Teach the client to cleanse cuts with warm water and mild soap, gently dry, and
apply a dry dressing.
Instruct the clients to monitor healing and to seek intervention promptly.
Diabetic ketoacidosis
Lack of sufficient insulin - type 1 diabetes mellitus
Reduced or missed dose of insulin (insufficient dosing of insulin or error in
dosage)
Any condition that increases carbohydrate metabolism, such as physical or
emotional stress, illness, infection (No. 1 cause of DKA), surgery, or trauma that
requires an increased need for insulin
Kussmaul Respiration
Complication - Diabetic ketoacidosis
Treat dehydration initially with IV normal saline
Prior to starting an insulin drip, the client should be rehydrated to lower the
blood glucose.
Administer regular insulin IV
Flush insulin solution through infusion set, discarding first 50 to 100 mL of
solution before connecting and administering to client
Always use IV infusion controller
 272
AppleRN Classes

Complication - Diabetic ketoacidosis

Cerebral edema and increased intracranial pressure may occur if glucose level
falls too fast
Potassium level will fall rapidly within first hour of treatment.
Insulin shifts the potassium back into the intracellular space.
As a result, serum potassium levels will then begin to decrease once insulin is
started
Insulin Drip – Tips to remember
Prior to starting an insulin drip, the client should be rehydrated to lower the
blood glucose
D5W is added to the IV fluid when blood glucose is <250 mg/dL (13.9 mmol/L) to
prevent a hypoglycemic reaction with regular (short-acting) IV insulin
The insulin infusion is titrated down as blood glucose is lowered
It is discontinued when the client is switched to subcutaneous injections. Usually
with blood glucose <200 mg/dL and there is no evidence of metabolic acidosis

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Clients are able to produce enough insulin to prevent diabetic ketoacidosis but
not enough to prevent extreme hyperglycemia
Profound hyperglycemia (greater than 600 mg/dL)
Because some insulin is produced, blood glucose rises slowly and symptoms may
not be recognized until hyperglycemia is extreme,
No Ketones
The onset generally occurs gradually over several days
More neurological symptoms. HHNS Happens with Type 2
Client Teaching : Encourage all clients to wear a medical alert bracelet.
 273
AppleRN Classes

Take measures to decrease the risk of dehydration. Drink at least 3 L of water/day

unless contraindicated by other health problems.
Monitor glucose every 4 hr when ill and continue to take insulin.
Consume liquids with carbohydrates and electrolytes (sports drinks) when unable
to eat solid food.
Client Teaching
Notify the provider if: Illness lasts more than 1 day, Blood glucose is greater than
240 mg/dL., Client is unable to tolerate food or fluids, Ketones are found in urine
for more than 24 hr, Temperature for 24 hr of 38.6° C (101.5° F).
Chronic Complications of Diabetes Mellitus
Diabetic retinopathy : Chronic, progressive impairment of retinal circulation that
can eventually cause hemorrhage
Assessment: Change in vision. Early prevention via control of hypertension, blood
glucose levels
Diabetic nephropathy: Progressive decrease in kidney function
Assessment: Microalbuminuria; thirst; anemia; fatigue
Early prevention via control of hypertension, blood glucose levels
Diabetic neuropathy : General deterioration of nervous system throughout body
Paresthesias, decreased sensation, poor peripheral pulses, postural hypotension
Early prevention via control of hypertension, blood glucose levels
Care of Diabetic Client Undergoing Surgery
Preoperative care : Check with physician about withholding oral hypoglycemic
medications or insulin
Monitor serum glucose level, Administer IV fluids as prescribed
Intraoperative care: Monitor serum glucose level, vital signs, Maintain sterile
technique
Postoperative care: Monitor blood glucose levels frequently
 274
AppleRN Classes

When tolerating food, ensure that client receives adequate amount of

carbohydrates to prevent hypoglycemia, ketosis
Might need more insulin - stress
A note on Parents with DM child
Initial teaching of the parents of a child with newly diagnosed type 1 diabetes
should focus on basic safety and survival skills
These include proper insulin administration and adequate monitoring of blood
sugars.
Information should be introduced slowly and should be repeated often
Teaching given based on the child's developmental age
Coping with a new diagnosis might take time
Oral Antidiabetics
Sulfonylureas : Help with Insulin release from the pancreas
chlorpropamide (Diabinese), glipizide, tolzamide, glyburide, glimepiride (Amaryl)
gastrointestinal symptoms, hypoglycemia, photosensitivity
Chlorpropamide (Diabinese) can cause disulfiram (Antabuse)-type reaction when
alcohol ingested
Sitagliptin (Januvia) : Help hormones to promote release of insulin and decrease
secretion of glucagon.
Lowers fasting and postprandial blood glucose levels
Metformin :Reduces the production of glucose within the liver, increases use of
glucose by muscle
GI distress, Lactic acidosis (hyperventilation, myalgia, sluggishness)
Nursing Care: Obtain medication history
Instruct client not to ingest alcohol with sulfonylureas
Inform client that insulin may be needed during stress, surgery, infection
 275
AppleRN Classes

Teach client about signs and symptoms of hypoglycemia and hyperglycemia

Pituitary Medications
Administered to replace deficient amounts of hormones secreted by the anterior
and posterior pituitary gland
The anterior pituitary gland secretes growth hormone (GH), thyroid-stimulating
hormone (TSH), adrenocorticotropic hormone (ACTH), prolactin, melanocyte-
stimulating hormone (MSH), and gonadotropins (follicle-stimulating hormone
[FSH] and luteinizing hormone [LH])
The posterior pituitary gland secretes antidiuretic hormones (vasopressin) and
oxytocin
Growth hormones and related medications
Assess child’s physical growth; compare with standards
Monitor blood glucose levels, thyroid function tests
Teach client, family signs of hyperglycemia, importance of follow-up blood tests
Antidiuretic Hormones
Description : desmopressin
Enhance reabsorption of water in kidneys, promoting antidiuretic effect,
regulating fluid balance
Side effects Include flushing, headache, water intoxication, hypertension
Interventions
Monitor strict intake and output; urine osmolality
Monitor daily weights, vital signs, Monitor electrolyte serum levels
Restrict fluid intake as prescribed
Monitor for signs of water intoxication (hyponaatremia), including drowsiness,
listlessness, headache
Instruct client how to use intranasal spray medication
 276
AppleRN Classes

Instruct client to report any signs of water intoxication, dyspnea, shortness of

breath, headache to primary health care provider
Thyroid Hormones
Control metabolic rate of tissues; accelerate heat production, oxygen
consumption
Should be given at least 4 hours apart from multivitamins, aluminum hydroxide,
magnesium hydroxide, simethicone, calcium carbonate, bile acid sequestrants,
iron, sucralfate (Carafate)
Side effects : Include weight loss, nervousness, insomnia, diaphoresis,
tachycardia, hypertension, chest palpitations, chest pain
Interventions : Instruct client to take medication at same time each day,
preferably in morning, without food
Advise client to report symptoms of hyperthyroidism (tachycardia, chest pain,
palpitations, diaphoresis)
Antithyroid Medications : Inhibit synthesis of thyroid hormone
Side effects : Include agranulocytosis with leukopenia, thrombocytopenia,
hypothyroidism (toxic response), iodism
Interventions: Instruct client how to take pulse
Advise client to contact physician if fever, sore throat develops
Instruct client regarding importance of medication compliance
Advise client to consult physician before eating iodized salt, foods containing
iodine
Instruct client to avoid acetylsalicylic acid (aspirin), medications containing iodine
Monitor for signs of thyroid storm (fever, flushed skin, confusion, behavioral
changes, tachycardia, dysrhythmias, signs of heart failure)
Parathyroid Medications : Regulate serum calcium levels
Hyperparathyroidism results in high serum calcium levels, bone demineralization
 277
AppleRN Classes

Hypoparathyroidism results in low serum calcium levels, neuromuscular

excitability
Interventions : Assess for symptoms of tetany in client with hypocalcemia
Instruct client to maintain intake of vitamin D if receiving oral calcium
supplements
Instruct client receiving calcium regulators to: Swallow tablet whole with water at
least 30 minutes before breakfast
Not to lie down for at least 30 minutes
Instruct client using antihypercalcemic agents to avoid foods rich in calcium,
including green leafy vegetables
Instruct client not to take other medications within 1 hour of taking calcium salts
Corticosteroids (Mineralocorticoids)
Used for replacement therapy in primary or secondary adrenal insufficiency in
Addison’s disease
Side effects : Include sodium and water retention, hypokalemia, hypertension,
weight gain
Interventions : Instruct client not to stop medication abruptly, Instruct client to
take medication with food or milk
Instruct client to consume diet high in potassium as prescribed
Instruct client to notify physician if signs of infection, muscle aches, sudden
weight gain, headache occur
Instruct client not to take aspirin products without consulting physician
Corticosteroids (Glucocorticoids)
• Alter the normal immune response, suppress inflammation
• Promote sodium and water retention, potassium excretion
• Produce anti-inflammatory, antiallergic, antistress effects
• May be used as replacement for adrenocortical insufficiency
 278
AppleRN Classes

– Side effects
• Include hyperglycemia, sodium and fluid retention, weight
gain, mood swings, moon face and buffalo hump, increased
susceptibility to infection, hirsutism
– Contraindications and cautions
• Should be used with caution in clients with DM
• Use with extreme caution in clients with infections
– Interventions
• Instruct client to take medication with food
• Instruct client to avoid individuals with infections
• Instruct client to eat diet high in potassium as prescribed
• Instruct client to report signs of Cushing’s syndrome
Estrogens and Progestins
Preparations may be used to stimulate endogenous hormones to restore
hormonal balance; treat hormone-sensitive tumors; for contraception
Contraindications and cautions
Estrogens : Contraindicated in clients with breast cancer, endometrial
hyperplasia, endometrial cancer, history of thromboembolism, known or
suspected pregnancy or lactation
Barbiturates, phenytoin (Dilantin), rifampin (Rifadin) decrease effectiveness
Progestins : Contraindicated in clients with thromboembolic disorders; should be
avoided in clients with breast tumors, hepatic disease
Side effects: Hypertension, stroke, myocardial infarction, thromboembolism
Interventions: Instruct client not to smoke
Instruct client to undergo routine breast and pelvic examinations
Contraceptives
 279
AppleRN Classes

Usually taken for 21 consecutive days, stopped for 7 days; cycle then repeated
Risk factors include smoking, obesity, hypertension
Contraindicated in women with hypertension, thromboembolic disease,
cerebrovascular or coronary artery disease, cancer, pregnancy
Should be avoided with use of hepatotoxic medications
Side effects: Breakthrough bleeding; excessive cervical mucus formation; breast
tenderness; hypertension; nausea and vomiting
Interventions : Instruct client to report signs of thromboembolic complications
Advise client to use alternative form of birth control when taking antibiotics
Instruct client to perform breast self-examination (BSE) monthly
If client decides to discontinue contraceptive to become pregnant, recommend
alternative form of birth control for 2-month period
If using patch and it remains off for less than 24 hours, reapply
If using patch and it is off longer than 24 hours, new 4-week cycle must be started
immediately
 280
AppleRN Classes

Infectious Disease
Chickenpox (Varicella): Caused by varicella zoster virus
Transmission: direct contact, droplet spread, contaminated objects
Assessment : Macular rash that begins on scalp and trunk, moves to extremities;
lesions become pustules, vesicles, then crusts
Interventions: In hospital setting, strict isolation (contact, droplet precautions)
Supportive care at home
Prevent scratching of lesions, Administer oatmeal or Aveeno baths for pruritus
Administer antihistamines as prescribed
Isolate child until all lesions are crusted
Herpes Zoster (Shingles)
Herpes zoster is a viral infection. It initially produces chickenpox, after which the
virus lies dormant.
It is then reactivated as shingles later in life.
Shingles is usually preceded by a prodromal period of several days, during which
pain, itching, tingling, or burning may occur along the involved dermatome.
A dermatome is an area of skin that is mainly supplied by a single spinal nerve
Shingles can be very painful and debilitating.
Risk Factors: Concurrent illness, Stress, Compromise to the immune system
Fatigue, Poor nutritional status
Laboratory Tests
Cultures provide a definitive diagnosis (but the virus grows so slowly that cultures
are often of minimal diagnostic use).
Occasionally, an immuno fluorescence assay can be done.
Subjective Data: Paresthesia, Pain that is unilateral and extends horizontally along
a dermatome
 281
AppleRN Classes

Objective Data: Vesicular, unilateral rash (the rash and lesions occur on the skin
area innervated by the infected nerve)
Changes in or loss of vision if the eye is affected
Rash that is erythematous, vesicular, pustular, or crusting (depending on the
stage)
Rash that usually lasts several weeks, Low-grade fever
Nursing Care
Assess/Monitor : Pain, Condition of lesions, Presence of fever, Neurologic
complications, Indications of infection
Use an air mattress or bed cradle for pain prevention/control of affected areas.
Maintain strict wound care precautions
CDC guidelines : Generally : Isolate the client until the vesicles have crusted over.
Localized herpes zoster : standard precautions + cover lesions
Disseminated herpes zoster: standard precautions + airborne + contact
precautions - until lesions are dry and crusted.
Nursing Care : The virus can be transmitted through direct contact, causing
chickenpox.
Avoid exposing the client to infants, pregnant women who have not had
chickenpox, and clients who are immunocompromised.
Moisten dressings with cool tap water or 5% aluminum acetate (Burow’s solution)
and apply to the affected skin for 30 to 60 min, four to six times per day as
prescribed.
Use lotions, such as calamine lotion, or recommend oatmeal baths to help relieve
itching and discomfort.
Administer medications as prescribed.
Medications : Analgesics (NSAIDs, narcotics) enhance client comfort.
 282
AppleRN Classes

If started soon after the rash appears, antiviral agents, such as acyclovir (Zovirax),
can decrease the severity of the infection and shorten the clinical course.
Recommend zoster vaccine live (Zostavax) for clients 50 and over to prevent
shingles.
This vaccine does not treat active shingles infections.
Complications
Postherpetic neuralgia
Characterized by pain that persists for longer than 1 month following resolution
of the vesicular rash.
Tricyclic antidepressants may be prescribed.
Postherpetic neuralgia is common in adults older than 60 years of age.
Rubeola (Measles): Paramyxovirus virus
Transmission: Airborne, direct contact with infectious droplets, transplacental
Assessment: Coryza (common cold), cough, conjunctivitis; Koplik’s spots in buccal
mucosa
Child is contagious from 4 days before rash appears to 5 days after rash appears.
Interventions: Airborne droplet precautions if child hospitalized
– Quiet activities and bed rest
– Tepid bath and antipyretics
– Cool mist vaporizer as prescribed
Supplementation with vitamin A decreases morbidity and mortality in measles.
Roseola
• Human herpesvirus type 6
Children under 3 years of age are typically more prone to develop this infection.
• The peak age for development is 6 to 15 months.
• The incubation period is 5 to 15 days.
 283
AppleRN Classes

Assessment: The child displays a high fever for 3 to 4 days, but appears well.
Rash with presence of rose-colored macules that blanche (develop after fever)
– Interventions: Supportive home care
Rubella (German Measles) : Rubella virus
Transmission: Airborne or direct contact with infectious droplets; transplacental;
indirectly via articles freshly contaminated with nasopharyngeal secretions or
urine
Assessment: Pink-red macular rash; begins on face, spreads to entire body in 1 to
3 days; petechial spots on soft palate
Interventions: Isolate infected child from pregnant women, Supportive home
care
All women of childbearing age should have rubella titer drawn to determine if
they have adequate antibodies
Rubella screen
A positive maternal titer indicates that a significant antibody titer has developed
in response to a prior exposure to the Rubivirus.
All children of pregnant women should receive their immunizations according to
schedule.
Rubella vaccine is not given during pregnancy because the live attenuated virus
may cross the placenta and present a risk to the developing fetus.
The female client who received a rubella vaccine need to use a contraception
method for at least 2 to 3 months afterward.
The rubella virus is teratogenic and may affect the fetus during the first trimester
of pregnancy.
Women should receive a rubella vaccination before the pregnancy.

Variola virus (Smallpox)

 284
AppleRN Classes

In 1980, the World Health Assembly declared smallpox eradicated.

But it can be used as an agent of bioterrorism.
Signs : A rash starts as small red spots on the tongue and in the mouth.
Smallpox patients became contagious once the first sores appeared in their
mouth and throat
Rash start on the face and spread to the arms and legs, and then to the hands and
feet. Usually, it spreads to all parts of the body within 24 hours.
Fever is common. Rash will become pustules – then crust and become scab
Once all scabs have fallen off, the person is no longer contagious.
Nursing Care : Isolate, Supportive treatment
Antiviral drugs : Vaccination : Currently, the smallpox vaccine is not available to
the general public because smallpox has been eradicated.
However, there is enough smallpox vaccine to vaccinate every person in the
United States if a smallpox outbreak were to occur.
Mumps
Paramyxovirus : Direct contact or droplet spread from infected person
Assessment : Parotid gland swelling , Jaw and ear pain with chewing. Orchitis may
occur
Interventions: Droplet precautions, Bed rest till parotid gland swelling subsides
Heat and/or cold therapy to neck as prescribed. Avoid foods that require intense
chewing (pain)
The most common complication of mumps is aseptic meningitis. (virus present in
the cerebrospinal fluid). Common signs include nuchal rigidity, lethargy, and
vomiting.
Points to remember
Contraindications of the measles, mumps, and rubella (MMR) vaccine include:-
 285
AppleRN Classes

severe allergic reaction to a previous dose or vaccine component (gelatin,

neomycin, eggs), Pregnancy, known immunodeficiency.
The nurse should take a thorough history of the allergy to a previous MMR and
report this to the physician.
If it is the first MMR, the physician should be aware of the egg sensitivity before
administering the vaccine
Pertussis (Whooping Cough)
Caused by Bordetella pertussis
Transmission: Direct contact, droplet spread, contamination from freshly
contaminated objects
Assessment: Respiratory infection with whooping cough, low grade fever
Interventions: Isolate child during catarrhal stage; if hospitalized, use droplet
precautions
Administer antimicrobial therapy as prescribed. Reduce environmental factors
that could elicit coughing episodes. Provide suctioning, humidification, oxygen as
prescribed
Diphtheria
Caused by Corynebacterium diphtheriae
Transmission: Direct contact with infected persons, carrier, or contaminated
articles
Assessment: Dense, pseudomembrane of throat; lymphadenitis; purulent nasal
drainage
Interventions : Ensure strict isolation, if hospitalized, Administer diphtheria
antitoxin and antimicrobial therapy as prescribed
Provide suctioning, humidification, oxygen as prescribed
Scarlet Fever
Caused by group A beta-hemolytic streptococci
 286
AppleRN Classes

Transmission: Direct contact with infected person, droplet spread, indirectly by

contaminated articles, ingestion of contaminated milk, foods
Assessment: Abrupt high fever; enlarged lymph nodes in neck; sandpaper-like
rash on body, except face, blanches with pressure (Schultz-Charlton sign) except
in areas of deep creases and joints (Pastia’s sign); white strawberry tongue;
enlarged tonsils
Interventions
Institute respiratory precautions until 24 hours after initiation of therapy
Encourage fluid intake, Supportive therapy
Erythema Infectiosum (Fifth Disease)
Human parvovirus B19
Transmission unknown; possibly respiratory secretions or blood- the
communicability period is before the rash appears or symptoms begin.
Assessment: Rash develops as erythema of face; maculopapular red spots
symmetrically distributed on extremities.
Intense fiery red edematous rash on the cheeks, which gives an appearance that
the child has been slapped.
Interventions: Child not usually hospitalized. Pregnant women should avoid
infected person
Supportive care, including administration of antipyretics, anti-inflammatories,
analgesics as prescribed
Infectious Mononucleosis
Epstein-Barr virus, Transmission: Direct intimate contact
Assessment : Fever; flu-like symptoms; lymphadenopathy; hepatosplenomegaly;
discrete macular rash may appear over trunk
Interventions : Bed rest, supportive care, Administer analgesics as prescribed
• Monitor closely for splenic rupture
 287
AppleRN Classes

Rocky Mountain Spotted Fever

Caused by Rickettsia rickettsia. Transmission: Bite of infected tick
Assessment : Fever; anorexia; malaise; maculopapular or petechial rash, primarily
on extremities
Intervention: Teach child, parents protective measures against tick bites
Administer antibiotics as prescribed (doxycycline or chloramphenicol.
Teach family preventive measures such as wearing long sleeves and pants in tick-
prone areas
 288
AppleRN Classes

Eyes
Anatomy and Physiology of eye
To measure visual acuity: Children –10 ft Adults – 20 ft
If child has glasses, keep it. Both eyes open – cover one eye at a time
Test each eye separately – the ‘bad’ eye first
Correctly say 4 of 6 letters in each line before moving to the next.
Higher referral : cannot identify 4 correct letters on 20/30 vision with either eye.
Ophthalmoscopy
An ophthalmoscope is used to examine the back part of the eyeball (fundus),
including the retina, optic disc, macula, and blood vessels.
Disorders of the Eye
Risk factors related to eye disorders. Aging process, Congenital, Hereditary
Medications – dry eyes : Diuretics, Antihistamines, Antidepressants, Cholesterol-
lowering drugs, Beta-blockers.
Trauma, Diabetes mellitus, HTN Diet – Vit A deficiency, low carotene
Legally blind : In United States, this refers to a medically diagnosed central visual
acuity of 20/200 or less in the better eye with the best possible correction
Provide safe environment, Orient client to environment, Promote independence
as much as possible
Vitamin A Foods
Eye Must Feel Very Lively
Eggs, Milk (cheese, butter), Fruits /Fish , Sweet potato, tropical fruits
Vegetable, Carrots, Kale, Spinach, Broccoli. Liver (beef).
Vitamin A is a fat soluble vitamin, and therefore, needs to be consumed with fat
in order to have optimal absorption.
 289
AppleRN Classes

Macular degeneration
Central loss of vision that affects the macula of the eye.
The macula is a small area in the retina that is responsible for central vision,
allowing to see fine details clearly.
Gradual blockage in retinal capillary arteries, which results in the macula
becoming ischemic and necrotic due to the lack of retinal cells.
There is no cure for macular degeneration. No. 1 cause of vision loss in people
over the age of 60.
Risk Factors: Smokers, Hypertension, Female, Family history, Diet lacking
carotene and vitamin A
Client Education
Encourage clients to consume foods high in antioxidants: Vit A, vitamin E, and
B12. Retinol- Vitamin A from animal sources. Beta carotene – Vitamin A from
plant sources
Monthly eye exams are essential in managing this disease.
As loss of vision progresses, clients will be challenged with the ability to eat, drive,
write, and read, as well as other activities of daily living.
Refer clients to community organizations that can assist with transportation,
reading devices, and large-print books.
High Antioxidant Foods : Berries, Dark chocolate, Pecans, Artichoke:,
Elderberries, Kidney beans, Cranberries
Cataracts
A cataract is an opacity in the lens of an eye that impairs vision.
Encourage annual eye examinations and good eye health, especially in adults over
the age of 40.
Cataract S/S : Decreased visual acuity (prescription changes, reduced night vision),
Blurred vision, Diplopia – double vision, Glare and light sensitivity – photo
sensitivity
 290
AppleRN Classes

Halo around lights, Progressive and painless loss of vision, Absent red reflex
Glaucoma
Glaucoma is a disturbance of optic nerve, mostly due to Increased intraocular
pressure (IOP)
Increased IOP Causes atrophic changes of the optic nerve and visual defects.
IOP increase due to Decreased fluid drainage or increased fluid secretion
Two kinds : Open angle and Closed angle: Angle - between the iris and sclera
Loss of peripheral vision
Diabetes is a risk factor for the development of glaucoma.
There is a familial tendency and a significantly higher incidence in African
Americans ( screen after 40 yrs)
Open-angle glaucoma
Most common form of glaucoma.
The aqueous humor outflow is decreased due to blockages in the eye’s drainage
system causing a rise in IOP.
S/S: Headache, Mild eye pain, Loss of peripheral vision, Decreased
accommodation, Elevated IOP (greater than 21 mm Hg)
Angle-closure glaucoma
Less common form of glaucoma. IOP rises suddenly. Rapid onset of elevated IOP
Decreased or blurred vision, Seeing halos around lights
Pupils are nonreactive to light, Severe pain and nausea, Photophobia
Glaucoma Treatment : Surgery
Medication: Client teaching should include the following:
Prescribed eye medication is beneficial if used every 12 hr. Instill one drop in each
eye twice daily.
 291
AppleRN Classes

Wait 10 to 15 min in between eye drops if more than one is prescribed by the
provider.
Avoid touching the tip of the application bottle to the eye. Always wash hands
before and after use.
Once eye drop is instilled, apply pressure (placing pressure on the inner corner of
the eye).
The older client is instructed to lie down on a bed or sofa to instill the eye drops
(balance issues, tremors)
Cataract and Glaucoma
Teach clients to wear sunglasses while outside and wear protective eyewear
Magnifying lens and large print books/newspapers
Postoperative interventions: Elevate head of bed 30 to 45 degrees
Turn client to back or non operative side
Report severe pain or nausea (increased IOP - hemorrhage).
Avoid activities that increase IOP : Bending over at the waist, Sneezing and
Coughing, Straining, Head hyperflexion, Restrictive clothing, Avoid tilting the head
back to wash hair.
Limit cooking and housekeeping. Avoid rapid, jerky movements, such as
vacuuming and sports
Best vision is not expected until 4 to 6 weeks following the surgery.
Glucoma - Instruct client on need for lifelong medication use
Conjunctivitis
“Pinkeye,” indicating inflammation of conjunctiva
Usually caused by allergy, infection, trauma
Bacterial or viral—extremely contagious
Assessment : Itching, burning, scratchy eyelids; redness; edema; discharge
 292
AppleRN Classes

Interventions
Instruct parents regarding infection control measures, such as good hand
washing, no sharing of towels, washcloths
Administer antibiotic or antiviral eye drops, ointment as prescribed
Instruct parents, child in proper administration of eye medication
Cool compresses to eye(s) as prescribed
Instruct child to avoid rubbing eyes, wear contact lenses, wear dark glasses if in
sun
Retinal detachment (medical emergency)
Sensations of flashes of light, floaters or curtain being drawn over eye
Immediate interventions : Provide bed rest, Cover both eyes with patches.
Postoperative interventions: Maintain eye patches
Position – area of detachment should be down (inferior/dependent) to maintain
pressure of the repaired retinal area and improve contact with choroid
Avoid activities which increase IOP
Notify physician if sudden, sharp eye pain occurs
Disorders of the Eye
Hyphema (Bleeding in to eye) : Encourage rest in semi-Fowlers position, bedrest,
eye patches
Contusion : Place ice on eye immediately
Foreign bodies : If dust or dirt, remove carefully with a cotton applicator
Penetrating objects : Do not remove
Client should be seen by physician immediately
Chemical burns : Flush eyes at site of injury with water for at least 15 to 20
minutes
Refractive errors
 293
AppleRN Classes

Myopia : nearsightedness- OK to see near

Hyperopia : farsightedness- OK to see far
Presbyopia : loss of near vision with age due to decreased elasticity of the lense
Astigmatism : an imperfection in the curvature of cornea
Strabismus
Misalignment of eyes - lack of eye muscle cordination
– Normal in young infant, but not after 4 months of age
Assessment : Loss of binocular vision; impairment of depth perception; frequent
headaches; squinting or tilting of head to see
Interventions : Corrective lenses may be indicated
– Patching “good” eye to strengthen weak eye. (good eye
patched 1-2 hrs daily)
– Eye drops to good eye to induce blurred vision
Retinoblastoma
Retinal tumor : Common in children under age 2 and is usually first recognized
when parents report a white "glow" of the pupil
Light reflecting off the tumor will cause the pupil to appear white instead of
displaying the usual red reflex
Can be hereditary
Eye Irrigation
For accidental eye exposure to body fluids (eg, blood, urine) or chemicals
Immediately flush the affected eye with water or saline for at least 10 minutes to
reduce exposure to potentially infected material and prevent/reduce injury (eg,
burn).
 294
AppleRN Classes

Ear
Functions: Hearing and maintenance of balance (vestibular)
External ear (pinna), Middle ear, Inner ear
Otoscope : Properly sized speculum
Ear pinna - pull up and back for adults, and down and back for children
Tympanic Membrane (ear drum) should be a pearly gray color and intact.
Inner ear problems are characterized by tinnitus (continuous ringing in ear),
vertigo (whirling sensation), and dizziness.
Auditory assessment – Whisper test
Tuning fork tests – Rinne Test, weber test

Romberg - balance
Black cerumen may indicate the presence of blood and is an unexpected finding
during an otoscopic examination.
Warm sterile solution irrigation is used to remove cerumen.
 295
AppleRN Classes

Presbycusis occurs as part of the aging process;

It is a progressive sensorineural hearing loss.
Clients show adequate adaptation by obtaining and regularly using a hearing aid.
Swimmers ear – otitis externa
Otitis Media
Infection of the middle ear secondary to blocked eustachian tube
Common in children(Infants eustachian tubes -ineffective drainage and protection
from respiratory secretions)
Child at Risk – secondary smoking (resp.inflamation)
Assessment : Fever, Irritability, Anorexia, Rolling of head from side to side, Pulling
or rubbing on ear
Earache or pain, Signs of hearing loss , Purulent ear drainage
Red, opaque, bulging, or retracting tympanic membrane
Interventions : Teach parents to feed infants in upright position; prevents reflux ,
avoid excessive pacifier use.
Immunization should be current
Instruct parents about procedure for administering ear medications
Myringotomy- Surgery of tympanic membrane to allow drainage
Insertion of tympanostomy tubes into middle ear to equalize pressure and keep
ear aerated
Untreated OM – Mastoiditis
Adults OM- Apply local heat 3 times per day for 20 mts. Antibiotics - Amoxicillin
Tympanostomy tubes
After the insertion of tubes into the tympanic membrane, it is important to avoid
getting water in the ears.
 296
AppleRN Classes

A shower cap or earplug may be used when showering, if allowed by the health
care provider.
Swimming, showering without a shower cap or ear plugs, and washing the hair
are avoided after surgery until the time frame designated for each is identified by
the surgeon
Myringotomy care
A myringotomy is the surgical opening of the eardrum to drain middle ear fluids.
After ear surgery - for 3 weeks :- Avoid bending over
rapid movements of the head or bouncing, straining when having a bowel
movement; drinking through a straw, air travel, excessive coughing
Stay away from individuals with colds
Blow the nose gently, one side at a time, with the mouth open
Avoid wetting the head and showering for 1 week
Keep the ear dry for 6 weeks by placing a ball of cotton coated with petroleum
jelly in the ear (this should be changed daily);
Report excessive drainage to the health care provider immediately.
Meniere’s Disease
Inner ear – fluid accumulation
Severe vertigo, tinnitus, nausea, headache. unilateral hearing impairment might
be present
Trigger – salt intake, allergy, stress
Meds- diuretics, Meclizine (Antivert)
Patient education : Low salt diet, avoid sugar and stimulants (alcohol, coffee,
nicotine)
Avoid sudden movements, position changes, Safety
Management of Vertigo: Clutter-free home
 297
AppleRN Classes

Remove throw rugs - because the effort of trying to regain balance after slipping
could trigger the onset of vertigo.
Change position slowly . Turn the entire body, not just the head, when spoken to.
Avoid driving and using public transportation. The sudden movements could
precipitate an attack.
If vertigo does occur, the client should immediately sit down or lie down (rather
than walking to the bedroom) or grasp the nearest piece of furniture.
Ear Drops (Adults)
To administer ear drops, the client is placed on the side with the affected ear
upward.
The solution is warmed to room temp before use.
The nurse pulls the pinna backward and upward and instills the medication by
holding the dropper about 1 cm above the ear canal.
The dropper is not allowed to touch any object or any part of the client's skin.
Epistaxis (Nosebleeds)
Nose bleeding secondary to direct trauma, presence of foreign body, nose picking,
underlying disease
Interventions: Have client sit up, lean forward
Apply continuous pressure to nose with thumb and forefinger for at least 10
minutes
Insert cotton into each nostril; if still bleeding, apply cold compress to bridge of
nose
Packing or cauterization may be prescribed for uncontrollable bleeding
Use humudified air
After nose bleed- (for 3-4 days) : Client should not bend forward
Avoid hot liquids, hot shower, Avoid excessive exercise
 298
AppleRN Classes

Pediatric consideration
Routine hearing test
Toddlers with hearing deficits may appear shy, timid, or withdrawn, often
avoiding social interaction.
They may seem extremely inattentive when given directions and appear
"dreamy."
Speech is usually monotone, difficult to understand, and loud.
Increased use of gestures and facial expressions is also common.
Ototoxic Medications
Multiple antibiotics – gentamicin, amikacin, or metronidazole (Flagyl)
Diuretics – furosemide (Lasix)
NSAIDs – ibuprofen (Advil)
Aspirin - Antiplatelet
Chemotherapeutic agents – cisplatin
 299
AppleRN Classes

Hematology
Bone Marrow Aspiration/Biopsy
To diagnose causes of blood disorders, such as anemia or thrombocytopenia, or
to rule-out diseases, such as leukemia and other cancers, and infection.
Usual sites – Post. Sup. Iliac spine, Iliac Crust: Consent, Hold anticoagulants
Transfusion Types
Homologous transfusions – Blood from donors is used.
Autologous transfusions – The client’s blood is collected in anticipation of future
transfusions (elective surgery); this blood is designated for and can be used only
by the client.
Clients may donate blood 5 weeks in advance up to 72 hr prior to surgery.
Intraoperative blood salvage – blood loss during certain surgeries can be recycled
through a cell‑saver machine and transfused intraoperatively or postoperatively
(orthopedic surgeries, CABG).
Rh system
• The Rh system is based on a third antigen, D, which is also on the RBC
membrane.
• Rh-positive people have the D antigen, whereas Rh-negative people do not.
• A Coombs test is used to evaluate the person’s Rh status.

•
 300
AppleRN Classes

Precautions and Nursing Responsibilities

Need doctor’s order. Need Consent – Telephone consent (2 RN)
Type and Cross match. Initiate large-bore IV access
Obtain blood products from the blood bank. Inspect the blood for discoloration,
excessive bubbles, or cloudiness.
Only two RNs may check blood bag against client’s blood identification band.
Measure vital signs, lung sounds before and after 15 minutes of transfusion, then
every hour until completed.
Remain with the client for the first 15 to 30 min of the infusion
Blood must be administered as soon as possible after being received from blood
bank, within 20 to 30 minutes
Check blood bag for date of expiration; inspect bag for leaks, abnormal color,
clots, bubbles.
Blood administration sets should be changed every 4 to 6 hours or according to
agency policy
Blood should not be infused rapidly unless platelets, which may be infused
rapidly, with caution
No medications should be added to blood bag or piggybacked into blood
transfusion
Only normal saline should be infused or added to blood components.
Transfusion Reaction Interventions. Stop the transfusion.
Keeping vein open with 0.9% normal saline.
Notify physician and blood bank
Monitor client closely, prepare to administer emergency medications (e.g.,
antihistamines, vasopressors, corticosteroids),
Send urine specimen to laboratory. Return all blood tubing and bags to blood
bank. Document.
 301
AppleRN Classes

Complications :
Disease Transmission – HIV, Hep C, Hep B, malaria
Hyperkalemia
The older the blood, the greater the risk for hyperkalemia, because hemolysis
causes potassium release
Monitor for muscle weakness, paresthesias, abdominal cramps, diarrhea,
dysrhythmias
Septicemia : Rapid onset of chills and high fever, vomiting, diarrhea, hypotension,
shock. obtain blood cultures and cultures from blood bag
Administer oxygen, IV fluids, antibiotics, vasopressors, and corticosteroids as
prescribed

Circulatory overload
 302
AppleRN Classes

Monitor for signs; cough, dyspnea, chest pain, wheezing, hypertension,

tachycardia
Interventions : slow rate of infusion. Place client upright with feet in dependent
position. Notify physician
Administer oxygen, diuretics, and morphine sulfate as prescribed
Monitor for dysrhythmias
Anemia
Anemias are due to: Blood loss
Inadequate RBC production (renal failure, bone marrow depression, malignancy,
radiation)
Increased RBC destruction (hemolytic, sickle cell, autoimmune disorder)
Deficiency of necessary components such as folic acid, iron, erythropoietin,
and/or vitamin B12 (pernicious anemia after gastric surgery)
Iron-deficiency anemia: due to inadequate intake, due to blood loss (such as from
a gastrointestinal ulcer)
Bone-marrow aspiration/biopsy is used to diagnose aplastic anemia (failure of
bone marrow to produce RBCs as well as platelets and WBCs).
 303
AppleRN Classes

Sickle Cell Anemia

Autosomal recessive blood disorder -abnormal sickled hemoglobin present-
sRBC- 20 days life span
Precipitating sickling conditions: fever, emotional and physical stress, conditions
that increase the need for oxygen, weather
Assessment of crisis
Pain in abdomen, long bones; painful and swollen joints; possibly dyspnea, chest
pain
Spleenomegaly – priority- shock.
Interventions: Hydration, oxygen, analgesics as prescribed
Prevent sickling - no dehydration, high altitude, infection (get flu and pneumonia
vaccine), stress, extreme weather
Avoid meperidine (Demerol); may cause seizures
 304
AppleRN Classes

Iron Deficiency Anemia

Normally Iron formed in intestine – converted to ferritin and stored in liver,
spleen, bone marrow.
Duodenum – most iron absorption happens here
In this anemia, Iron stores are depleted
Assessment: Pallor; weakness; fatigue; Irritability, SOB, dizziness,
Brittle spoon like nails, Cheilosis (cracks in corner of mouth)
Interventions : Oral iron supplements- Give with orange juice/vit c
Antacids interfere with absorption.
Liquid iron preparations stain teeth; should be given through a straw. Rinse
mouth thoroughly
Instruct the client to take iron supplements empty stomach (or between meals).
Food delays absoption
Stool – greenish tarry color . Constipation common (fluids and fiber)
Parenteral iron supplements (iron dextran) are only given for severe anemia (Z
track method)
Aplastic Anemia
Deficiency of circulating erythrocytes due to suppression of bone marrow cells
(congenital/radiation/toxins/viral and bacterial infection)
Assessment
• Pancytopenia; petechiae; purpura; pallor, weakness, fatigue,
tachycardia, bleeding from gums, nose
Interventions
• Prepare for bone marrow transplantation, if planned
• Reverse isolation, limit visitors, bleeding precautions
• Frequent rest periods, hand washing
 305
AppleRN Classes

• Administer immunosuppressive medications, Blood

• Educate about wearing Medic-Alert bracelet
Polycythemia vera
Chronic disorder of the bone marrow : too many red blood cells, white cells, and
platelets are produced.
Risk of developing blood clots due to increased blood volume and viscosity
Nursing Care
Elevate the legs and feet when sitting, Wear support stockings,
Report signs of thrombosis (eg, swelling and tenderness in the legs).
Adequate fluid intake during exercise and hot weather - to reduce fluid loss and
decrease viscosity
periodic phlebotomy to remove excess blood(the removal of 300 to 500 milliliters
of blood through venipuncture= may require phlebotomy every other day until
the goal hematocrit is reached.
Coagulation Disorders
Idiopathic thrombocytopenic purpura (ITP)
An autoimmune disorder : The life span of platelets is decreased by anti platelet
antibodies although platelet production is normal.
In ITP, platelets are coated with antibodies- when they reach the spleen, the
antibody-coated platelets are recognized as foreign and are destroyed by
macrophages.
This can result in severe hemorrhage following a cesarean birth or lacerations.
Disseminated intravascular coagulation (DIC)
A life-threatening coagulopathy in which clotting and anti clotting mechanisms
occur at the same time.
 306
AppleRN Classes

The client who has DIC is at risk for both internal and external bleeding, as well as
damage to organs resulting from ischemia caused by micro clots – need
anticoagulants
Clinical Manifestation : Unusual spontaneous bleeding from the client’s gums and
nose (epistaxis)
Oozing, trickling, or flow of blood from incisions or lacerations, Petechiae and
ecchymoses
Excessive bleeding from venipuncture, injection sites, or slight traumas
Tachycardia, hypotension, and diaphoresis. Organ failure secondary to micro
emboli
Medications
ITP – Corticosteroids and immunosuppressants
DIC – Anticoagulants (heparin)
Nursing Considerations
Regularly take vital signs, and assess hemodynamic status.
Monitor for signs of organ failure or intracranial bleed (oliguria, decreased level of
consciousness).
Monitor laboratory values for clotting factors.
Administer fluid volume replacement.
Transfuse blood, platelets, and other clotting products.
Avoid use of NSAIDs.
Administer supplemental oxygen.
Provide protection from injury.
Instruct client to avoid Valsalva maneuver (could cause cerebral hemorrhage).
Implement bleeding precautions (avoid use of needles).
Bleeding Precaution: Monitor : signs of bleeding. Gentle Handling, no heat
 307
AppleRN Classes

Avoiding injections and IV. Use smallest gauge needle

5 to 10 mts pressure to needle stick site
No rectal temperatures, enemas, and suppositories
Use electric razor (not straight)
Use soft-bristled toothbrush and avoid flossing or chewing on hard food
Avoid nose blowing; hard sneezing, contact sports.
Hemophilia
Bleeding disorder; results from deficiency of specific coagulation proteins
Transmitted as X-linked recessive genetic disorder
Assessment: Abnormal bleeding in response to trauma, surgery; epistaxis
Ecchymoses, Purpura
Pain, swelling, tenderness in joints
Normal platelet count, but abnormal coagulation factor results
Interventions (Hemophilia) : Bleeding precautions , Protect from trauma
Administer replacement factors as prescribed. Immobilize affected joints, if
applicable
Assess neurological status for changes secondary to bleeding . Monitor for
hematuria
Educate child, parents in signs of internal bleeding and how to control bleeding, if
occurs
Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes
should be used.
Von Willebrand disease (VWD) is a genetic disorder caused by missing or
defective von Willebrand factor (VWF), a clotting protein.
Beta thalassemia is a blood disorder that reduces the production of hemoglobin.
 308
AppleRN Classes

Hematology Medications
Anticoagulants : Prevent clotting
Ex: Heparin, Enoxaparin (Lovenox)
Nursing Interventions: Monitor vital signs.
Advise clients to observe for bleeding (Hypotension, tachycardia, bruising,
petechiae, hematomas, black tarry stools).
use an electric razor for shaving and brush with a soft toothbrush.
Use gloves when working in garden
Heparin
Use an infusion pump for continuous IV administration.
Monitor rate of infusion every 30 to 60 min.
Monitor activated partial thromboplastin time (aPTT).
Keep value at 1.5 to 2 times the baseline. Therapeutic level is 60 to 80 seconds.
Apply gentle pressure for 1 to 2 min after the injection.
Rotate and record injection sites.
In the case of overdose, stop heparin, administer protamine, and avoid aspirin.
Do not rub the site for 1 to 2 min after the injection
Enoxaparin (Lovenox)
Mild pain, bruising, irritation, or redness of the skin at the injection site is
common.
Do NOT rub the site with the hand.
Using an ice cube on the injection site can provide relief
Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal
supplements (Ginkgo biloba, vitamin E) - increase the risk of bleeding
Monitor CBC for thrombocytopenia
 309
AppleRN Classes

warfarin (Coumadin)
Monitor levels of PT and international normalized ratio (INR) periodically.
Therapeutic range of INR = 2-3
INR of 3 to 3.5 (?4) for mechanical heart valve or recurrent systemic embolism.
Overdose? – Give Vit. K
Hepatotoxic - Monitor liver enzymes. Assess for jaundice
Minimize Vit K food : dark green leafy vegetables (lettuce, cooked spinach),
cabbage, broccoli, Brussels sprouts, mayonnaise, canola, and soybean oil
Full therapeutic effect is not achieved for 3 to 5 days.
Antiplatelets
Inhibit platelet aggregation Ex: Aspirin, clopidogrel
Meds may be discontinued week before surgery.
Aspirin : GI effects (nausea, vomiting, dyspepsia), Tinnitus, hearing loss.
Use cautiously - peptic ulcer disease and severe renal and/or hepatic disorders.
Do not give to children or adolescents with fever or recent chickenpox (Reye’s
syndrome – swelling of liver and brain)
Reye's syndrome (Aspirin)
Reye's syndrome most often affects children and teenagers recovering from a
viral infection, most commonly the flu or chickenpox.
Signs and symptoms such as confusion, seizures and loss of consciousness require
emergency treatment.
Early diagnosis and treatment of Reye's syndrome can save a child's life.
Aspirin has been linked with Reye's syndrome, so use caution when giving aspirin
to children or teenagers
Thrombolytic Medications
Alteplase (tPA) – Give within 3 hrs (stroke pts)
 310
AppleRN Classes

Serious risk of bleeding from different sites – internal bleeding (GI or GU tracts
and cerebral bleeding), as well as superficial bleeding (wounds, IV catheter sites).
Obtain baseline platelet counts, hemoglobin (Hgb), hematocrit (Hct), aPTT, PT,
INR, and fibrinogen levels, and monitor periodically.
Limit venipunctures and injections. Apply pressure dressings to recent wounds.
Monitor for changes in vital signs, alterations in level of consciousness, weakness,
and indications of intracranial bleeding.
Notify the provider if symptoms occur. Monitor aPTT and PT, Hgb, and Hct.
Rivaroxaban (Xarelto)
Provides anticoagulation selectively and directly by inhibiting factor Xa.
Prevents DVT and pulmonary embolism in clients who are undergoing total hip or
knee arthroplasty surgery.
S/E : Hepatotoxic, bleeding (GI/GU/Retinal/Cranial)
Teach client to report bleeding, bruising, headache, eye pain.
Monitor hemoglobin and hematocrit.
Wait at least 18 hr following last dose to remove an epidural catheter, and wait 6
hr after removal before starting rivaroxaban again.
No antidote is available for severe bleeding; not removed by dialysis.
Dabigatran (Pradaxa)
Works by directly inhibiting thrombin
S/E ; Bleeding, GI discomfort, Hypotension and headache
Take dabigatran with food.
Client may need a proton pump inhibitor, such as omeprazole (Prilosec) or an H2
receptor antagonist, such as ranitidine (Zantac) for GI manifestations.
Erythropoietic Growth Factors: Act on the bone marrow to increase production
of red blood cells.
 311
AppleRN Classes

Renal failure, chemo, HIV patients

EX: Epoetin alfa (Epogen, Procrit), Aranesp
S/E : Hypertension, Headache.
Not to be used if Hb> 11 (risk for thrombus)
Neupogen
Stimulate the bone marrow to increase production of neutrophils.
S/E : Bone pain, Splenomegaly and risk of splenic rupture with long‑term use
Monitor CBC two times per week.
 312
AppleRN Classes

Oncology
Factors that influence cancer development
Environmental, dietary, genetic predisposition, age, immune function
Exposure to certain viruses and bacteria
Liver Epstein-Barr virus has been linked to an increased risk of lymphocancer can
develop after many years of infection with hepatitis B or hepatitis C.
Infection with Epstein-Barr virus has been linked to an increased risk of
lymphoma.
Human papillomavirus (HPV) infection is the main cause of cervical cancer.
HIV increases the risk of lymphoma and Kaposi’s sarcoma.
Helicobacter pylori may increase the risk of stomach cancer and lymphoma of the
stomach lining.
A diet high in fat and red meat, and low in fiber
Sun, ultraviolet light, or radiation exposure Prevention
Avoidance of known or potential carcinogens; avoidance or modification of
factors associated with development of cancers
Early detection
Mammography; Papanicolaou’s test;
Stools for occult blood;
sigmoidoscopy; colonoscopy;
breast self-examination (BSE); testicular self-examination (TSE); skin inspection
 313
AppleRN Classes

• Cervical Cancer Screen

– Age 21 to 29: Every 3 years with cytology (Pap testing)
– Age 30 to 65: Every 5 years with HPV co-test (Pap + HPV
test) OR every 3 years with cytology.
• Mammogram – Yearly starting at age 50
Colorectal cancer risk factors
• Personal or family (first-degree relative) history of colorectal cancer/polyps
• Personal history of inflammatory bowel disease, Crohn's disease, or
ulcerative colitis
• Presence of autosomal dominant gene- Lynch syndrome – causes various
cancer.
• Lifestyle factors such as obesity, a diet high in red meat, cigarette smoking,
and alcohol consumption
Cancer Screening
C – Change in bowel or bladder
A – a sore that does not heal
U – Unusual bleeding or discharge
 314
AppleRN Classes

T – Thickening or lump
I – Indigestion or difficulty swallowing
O – obvious change in a wart or mole
N – nagging cough or hoarseness
Diagnostic Tests
Performance depends on suspected primary or metastatic sites of cancer
Biopsy, Endoscopy
Radiology – X ray, CT, MRI etc
Blood tests – CBC, Electrolytes, LFT, RFT
Tumor marker assays – detect the presence of normal body proteins at higher
than expected levels
(carcinoembryonic antigen [CEA], prostate-specific antigen [PSA], alpha
fetoprotein [AFP]).
Samples of urine, stool, tissue, blood, or other body fluids are tested for an excess
of specific proteins or DNA patterns.
Used to detect cancer, measure the severity of cancer, or monitor for a positive
response to the cancer treatment.
Surgery
Used to diagnose, stage, treat cancer
Prophylactic surgery : Performed in clients with existing premalignant condition or
known family history that strongly predisposes person to cancer development
Curative surgery: All gross and microscopic tumor removed, destroyed
Control surgery: Removal of part of tumor; decreases number of cancer cells,
increases chances of success of other therapies
Palliative surgery: Performed to improve quality of life during survival time
 315
AppleRN Classes

Reconstructive or rehabilitative surgery: Performed to improve quality of life by

restoring maximal function and appearance, such as breast reconstruction
Side effects of surgery
Loss or loss of function of specific body part
Reduced function as result of organ loss
Scarring or disfigurement
Grieving about altered body image, change in lifestyle
Chemotherapy
Kills or inhibits reproduction of neoplastic cells, but also attacks and kills normal
cells. Effects are systemic.
Normal cells profoundly affected include those of skin, hair, lining of
gastrointestinal (GI) tract, spermatocytes, hematopoietic cells
Usually several medications used in combination to increase therapeutic response
May be combined with other therapies, such as radiation or surgery
Side effects include alopecia, nausea and vomiting, mucositis, immuno-
suppression, anemia, thrombocytopenia
Neutropenic precautions.
Have the client remain in his room unless he needs to leave for a diagnostic
procedure or therapy. In this case, place a mask on him during transport.
Protect the client from possible sources of infection (plants, change water in
equipment daily).
Have client, staff, and visitors perform frequent hand hygiene. Restrict visitors
who are ill.
Avoid invasive procedures that could cause a break in tissue unless necessary
(rectal temperatures, injections).
Keep dedicated equipment in the client’s room (blood pressure machine,
thermometer, stethoscope).
 316
AppleRN Classes

Administer medicine Filgrastim (Neupogen, Neulasta) as prescribed to stimulate

WBC production
Complication
Immuno-suppression due to bone marrow suppression by chemo medications is
the most significant adverse effect of chemotherapy.
Nursing Actions: Monitor temperature and white blood cell (WBC) count.
A fever greater than 37.8° C (100° F) should be reported to the provider
immediately.
Monitor skin and mucous membranes for infection (breakdown, fissures,
abscess).
Cultures should be obtained prior to initiating antimicrobial therapy.
Neutropenic precautions (WBC drops below 1,000/uL)
Mucositis (stomatitis)
inflammation of tissues in the mouth, such as the gums, tongue, roof and floor of
the mouth, and inside the lips and cheeks.
Nursing care (Mucositis)
Examine the client’s mouth several times a day, and inquire about the presence of
oral lesions.
Document the location and size of lesions that are present. Lesions should be
cultured and reported to the provider.
Palifermin – is a good choice
Avoid using glycerin-based mouthwashes or mouth swabs. Nonalcoholic,
anesthetic mouthwashes are recommended.
Administer a topical anesthetic prior to meals. Viscous lidocaine HCl (Xylocaine)
Discourage consumption of salty, acidic, or spicy foods.
Nursing care (Mucositis) : Offer oral hygiene before and after each meal.
Use lubricating or moisturizing agents to counteract dry mouth.
 317
AppleRN Classes

Encourage the client to eat soft, bland foods and supplements that are high in
calories (mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream,
frozen yogurt, bananas, and breakfast mixes).
Health Education (on chemo)
Encourage the client to avoid crowds while undergoing chemotherapy.
Take temperature daily. Report elevated temperature to the provider.
Avoid food sources that could contain bacteria (fresh fruits and vegetables;
undercooked meat, fish, and eggs; pepper and paprika).
Avoid yard work, gardening, or changing a pet’s litter box. Avoid fluids that have
been sitting at room temperature for longer than 1 hr.
Wash all dishes in hot, soapy water or dishwasher. Always wash glasses and cups
after one use.
Wash toothbrush daily in dishwasher or rinse in bleach solution. Do not share
toiletry or personal hygiene items with others.
Report fever greater than 37.8° C (100° F) or other manifestations of bacterial or
viral infections immediately to the provider.
Radiation Therapy
Destroys cancer cells with minimal exposure of normal cells to damaging effects
of radiation
External beam radiation : Actual radiation external to client. Client does not emit
radiation, does not pose a hazard to anyone
Brachytherapy: Can be administered internally with an implant(s)
The client’s body fluids are contaminated with radiation and should be disposed
of appropriately
External Radiation Therapy
Delivered over the course of several weeks and aimed at the body from an
external source.
 318
AppleRN Classes

Provide a well-balanced diet that does not contain red meat. Radiation can make
foods such as red meat unpalatable.
Help the client manage fatigue by scheduling activities with rest periods in
between and using energy-saving measures (sitting during showers and ADLs).
Monitor for radiation injury to skin and mucous membranes and implement a skin
care regimen.
Skin – blanching, erythema, desquamation, sloughing, hemorrhage
Mouth – mucositis, xerostomia (dry mouth)
Neck – difficulty swallowing
Abdomen – gastroenteritis
Monitor CBC (possible decreased platelets and WBCs).
External Radiation Therapy- Skin care
The client’s skin over the targeted area is marked with “tattoos” that guide the
positioning of the external radiation source.
Gently wash the skin over the irradiated area with mild soap and water. Dry the
area thoroughly using patting motions.
Do not remove or wash off radiation “tattoos” (markings) that are used to guide
therapy.
Do not apply powders, ointments, lotions, deodorants, or perfumes to the
irradiated skin.
Wear soft clothing and avoid tight or constricting clothes. Do not expose the
irradiated skin to sun or a heat source
Brachytherapy: Nursing Care
Place the client in a private room away from other clients when possible.
Place appropriate sign on the door warning of the radiation source.
Limit visitors to 30-min visits, and have visitors maintain a distance of 6 ft from
the source.
 319
AppleRN Classes

Visitors and health care personnel who are pregnant or under the age of 16
should not come into contact with the client or radiation source.
Dosimeter film badge and lead apron for staff.
Instruct the client to remain on bedrest to prevent dislodgement of the implant
(cervical/endometrial)
Keep a lead container in the client’s room if the delivery method could allow
spontaneous loss of radioactive material. Tongs are available for placing
radioactive material into this container.
Precautions listed above should be carried out at home if the client is discharged
during therapy.
General Cancer Complications
Malnutrition: Clients at increased risk for weight loss and anorexia.
The presence of carcinoma in the body increases the amount of energy required
for metabolic function.
Cancer can impair the body’s ability to ingest, digest, and absorb nutrients.
Management
Administer anti emetics and antacids as prescribed.
Administer megestrol (Megace) to increase the appetite if prescribed
Monitor relevant laboratory data (albumin, ferritin, transferrin).
Encourage frequent oral hygiene. Incorporate client preferences into meal
planning
Perform calorie counts to determine intake. Provide liquid nutritional
supplements as needed. Add protein powders to food or tube feedings
Administer antiemetics and schedule them prior to meals.
Encourage the client to eat several small meals a day if better tolerated.
Low-fat and dry foods (crackers, toast) and avoiding drinking liquids during meals
can prevent nausea.
 320
AppleRN Classes

Suggest that the client select foods that are served cold and do not require
cooking, which can emit odors that stimulate nausea.
Encourage consumption of high-protein, high-calorie, nutrient-dense foods and
avoidance of low- or empty-calorie foods. Use meal supplements as needed.
Encourage the use of plastic eating utensils, sucking on hard candy, and avoiding
red meats to prevent or reduce the sensation of metallic taste.
Teach the client to create a food diary to identify items that can trigger nausea.
General Cancer Complications and Nursing care
Paraneoplastic syndromes : T cells in the body attack normal cells rather than
cancerous ones, resulting in changes in neurological function (movement,
sensation, mental function).
Management : Recognize manifestations of paraneoplastic syndrome.
Administer medications (steroids, immune suppressants) as prescribed.
Provide a safe environment until client returns to baseline mental status.
Use aids for vision or hearing deficits, as indicated.
Cancer disorders
Skin Cancer
Sunlight exposure is the leading cause of skin cancer. (Refer Table below)
Melanoma
ABCDEs of suspicious lesions
A – Asymmetry: One side does not match the other
B – Borders: Ragged, notched, irregular, or blurred edges
C – Color: Lack of uniformity in pigmentation (shades of tan, brown, or black)
D – Diameter: Width greater than 6 mm, about the size of a pencil eraser or a pea
E – Evolving: Or change in appearance (shape, size, color, height, texture) or
condition (bleeding, itching)
 321
AppleRN Classes

Leukemia
Leukemias are cancers of white blood cells or of cells that develop into white
blood cells. These white blood cells are not functional and destroy bone marrow.
Overgrowth of leukemic cells prevents growth of other blood components
(platelets, erythrocytes, mature leukocytes).
Infection : Major cause of death in immunosuppressed client
Leukemias
Acute lymphocytic leukemia (ALL)
Acute myelogenous leukemia (AML)
Chronic lymphocytic leukemia (CLL)
Chronic myelogenous leukemia (CML)
 322
AppleRN Classes

Nursing Care : Monitor for evidence of infection.

Assess for other physiological indicators of infection (lung crackles, cough, urinary
frequency or urgency, oliguria, lesions of skin or mucous membrane).
Prevent infection. (Implement neutropenic precautions.)
Frequent, thorough hand hygiene is a priority intervention.
 323
AppleRN Classes

Place the client in a private room. Allow only well visitors; when unavoidable,
visitors who are ill must wear a mask. Screen visitors carefully.
Restrict foods that may be contaminated with bacteria (no fresh or raw fruits,
vegetables). Monitor WBC.
Prevent transmission of bacteria and viruses (no live plants, flowers)
Eliminate standing water (humidifiers, denture cups, vases) to prevent bacteria
breeding.
Encourage good personal hygiene. Avoid crowds. Prevent injury.
Monitor platelets. Assess frequently for obvious and occult bleeding.
Protect the client from trauma (avoid injections and venipunctures, apply firm
pressure, increase vitamin K intake).
Teach the client how to avoid trauma (use electric shaver, soft bristled
toothbrush, avoid contact sports).
Lymphomas
Malignancy of lymph nodes; originates in single lymph node or single chain of
nodes.
There are two types of lymphoma.
■■ Hodgkin’s lymphoma (HL): Most cases involve young adults.
Possible causes include viral infections and exposure to chemical agents.
■■ Non-Hodgkin’s lymphoma (NHL)
More common in clients older than 50.
Possible causes include gene damage, viral infections, autoimmune disease, and
exposure to radiation or toxic chemicals.
Lymphomas can metastasize to almost any organ.
Radiation and chemotherapy are the treatment of choice
 324
AppleRN Classes

Multiple Myeloma
• Malignant proliferation of plasma cells, tumors within bone
Assessment: Bone, skeletal pain, especially in ribs, spine, pelvis, Osteoporosis
Recurrent infections; fatigue; anemia; thrombocytopenia; granulocytopenia;
elevated uric acid and calcium serum levels
Interventions: Monitor for signs of bleeding, infection, skeletal fractures, renal
failure.
Encourage fluids, at least 2 L/day, Encourage ambulation
Provide skeletal support during movement
Gastric Cancer
Malignant growth in stomach
Assessment
Fatigue; anorexia; indigestion; epigastric discomfort; sensation of pressure in
stomach; dysphagia; ascites; anemia; palpable mass
Interventions: Monitor vital signs , Monitor weight, Monitor hemoglobin,
hematocrit levels
Administer analgesics as prescribed , Administer pre-, post chemotherapy, and/or
radiation care as prescribed
Prepare client for surgery as prescribed
Postoperative interventions
Place in Fowler’s position. Do not irrigate or remove nasogastric tube
Monitor fluid, electrolyte balance. Administer IV fluids and electrolytes as
prescribed
Monitor for signs of dumping syndrome, diarrhea, hypoglycemia, vitamin B12
deficiency
 325
AppleRN Classes

Pancreatic Cancer
Most common neoplasm of pancreas; more common in blacks than whites, in
smokers, in men
Assessment- S/S
Nausea, vomiting; unexplained weight loss; clay-colored stools; dark urine,
glucose intolerance;
Pain - abdominal pain, Pain that radiates to the back and is unrelieved by change
in position, and is more severe at night.
Jaundice (late finding). Ascites, Pruritus (buildup of bile salt)
Early satiety or anorexia
Nursing Care
Administer pre-, postchemotherapy as prescribed.
Palliative care – nutrition –Jejunostomy/TPN
Monitor blood glucose and give insulin.
Partial pancreatectomy – small tumors
Prepare client for Whipple’s procedure (pancreaticoduodenectomy)
Removal of the "head" (wide part) of the pancrea along with duodenum, a
portion of the common bile duct, gallbladder, and sometimes part of the
stomach.
Thyroid Cancer
Monitor airway patency in client who has a tumor affecting or compressing the
trachea.
Assess swallowing in client who has a tumor affecting or compressing the
esophagus.
Clients who are treated for thyroid cancer are hypothyroid.
Monitor vital signs for impaired oxygenation, hypotension, or bradycardia.
 326
AppleRN Classes

Use ECG monitoring to detect dysrhythmias.

Assess mental status and provide a safe environment.
Thyroidectomy care
Support neck with pillows or sandbags.
Maintain a humidifier to promote airway clearance.
During surgery, the parathyroid glands or laryngeal nerve may be damaged.
Monitor for hemorrhage (incision site, hypotension, tachycardia, increased
swallowing or throat “tickling”).
Monitor for respiratory distress (caused by tetany, swelling, or laryngeal nerve
damage).
Monitor for parathyroid injury (decreased PTH, hypocalcemia, tetany).
Radioactive iodine (RAI) therapy
The client ingests RAI in liquid or tablet form, which is absorbed by thyroid cells
which are then destroyed.
Teach the client about radioactive precautions to reduce risk of radiation
exposure.
Instruct the client to chew gum or hard candy to relieve dry mouth or reduced
salivation. Alteration in taste is expected.
RAI Precautions
Avoid close proximity to pregnant women or children. Do not breastfeed as RAI
may be excreted through breast milk and could harm the infant
Do not share utensils with others or use bare hands to handle food that is to be
served to others
Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it
separately. Use a separate toilet from the rest of the family and flush 2-3 times
after each use
Wash hands frequently and thoroughly, especially after restroom use
 327
AppleRN Classes

Drink plenty of fluids

Sleep in a separate bed from others and do not sit near others in an enclosed area
for a prolonged period of time (eg, train or flight travel)
Lung Cancer
One of the leading causes of cancer-related deaths.
Risk Factors : Cigarette smoking (both firsthand and secondhand smoke)
Radiation exposure, Chronic exposure to inhaled environmental irritants (air
pollution, asbestos, other talc dusts)
Older adult clients, clients with structural abnormality
Determine the pack-year history (number of packs of cigarettes smoked per day
times the number of years smoked).
Monitor for a cough that changes in pattern, hoarseness
Types of Lung cancer

Ca Lung Management
Chemotherapy is the primary choice of treatment for lung cancers. It is often used
in combination with radiation and/or surgery.
 328
AppleRN Classes

Surgery involves removal of a lung (pneumonectomy), lobe (lobectomy) or

segment (segmentectomy)
Monitor vital signs, oxygenation (SaO2, ABG values), and for evidence of
hemorrhage.
Manage the chest tube and drainage system.
Administer oxygen and manage the ventilator if appropriate.
Educate – avoid crowds, report to doc any complications and increase in pain
Use upright position, Teach pursed lip breathing
Bronchodilators and corticosteroids can be given to help decrease inflammation
and to dry secretions.
Oropharyngeal Cancer
Mouth lesions that do not heal within 2 weeks may be cancerous.
Protecting the airway and providing adequate nutrition are priority interventions
in managing oropharyngeal cancer.
Monitor for adequate clearance of secretions (have the client turn, cough, deep
breathe; suctionas needed).
Auscultate for adventitious lung sounds: wheezes (due to aspiration) or stridor
(due to obstruction).
Position the client in semi- or high-Fowler’s position to promote chest expansion.
Provide frequent Oral care. Assess for difficulty swallowing
Treatment Options
Radiation (external, implanted, or both) is commonly used prior to surgery to
reduce tumor size.
External radiation is used cautiously to minimize radiation dose to the brain and
spinal cord.
Implanted radiation is used to cure early lesion on the floor of the mouth or
anterior tongue.
 329
AppleRN Classes

Hospitalization is typically required until radiation dosing is complete.

Surgery-Tumor excision is used to remove lesions (might include neck dissection,
glossectomy, mandibular resection)
May include placement of a tracheostomy or wound drain
Nursing Care
Provide clear liquid diet for 24 hr (clients having small lesions removed locally).
Maintain NPO status until intraoral suture lines heal (clients who have large
tumors).
Provide routine tracheostomy care and suctioning. Consult a speech therapist.
Provide comfort to clients who have permanent loss of voice or disfigurement.
Teach clients to avoid mouthwashes containing alcohol or lemon-glycerin swabs
(acidic) to prevent pain and worsening of condition.
Encourage the client to rinse mouth frequently with warm sodium bicarbonate or
0.9% sodium chloride solution.
Laryngeal Cancer
Malignant tumor of larynx
Signs and Symptoms
Persistent hoarseness, sore throat, painless neck mass, hemoptysis, feeling of
lump in throat, dysphagia, change in voice quality, halitosis
Treatment
Surgery : partial or complete laryngectomy with tracheostomy
Chemotherapy and radiation
Testicular Cancer
Early detection: Routine testicular self-examination (TSE)
Assessment: Painless testicular swelling
“Dragging” or “pulling” sensation in scrotum
 330
AppleRN Classes

Presence of lumps or masses in testicle

Treatment – Surgery (Orchiectomy), chemo, Radiation
Avoid heavy lifting and strenuous activity for 3 weeks
Instruct the client to wear a scrotal support for several days.
Prevent irritation of scrotum by wearing a dry dressing and loose clothing.
Emphasize the importance of notifying the health care provider if chills, fever,
drainage, redness, or discharge occurs
Instruct the client to continue TSE and promptly report unexpected findings.
Prostate Cancer
Prostate cancer is a slow-growing cancer
Risk : High fat diet, smoking, STD, older -50 yrs
Assessment
Prostate-specific antigen (PSA) level elevated
Hard, pea-size nodule, irregularities palpated on rectal examination (PSA to be
done before DRE)
Diagnosis made through biopsy
Treatment – Hormonal therapy, Chemo, radiation,
Surgery : Transurethral resection of prostate, Suprapubic prostatectomy
Retropubic prostatectomy, Perineal prostatectomy
Postoperative interventions
Monitor for bleeding, Increase fluids to 2400 to 3000 mL/day
Expect red to light pink urine for 24 hours, turning amber in 72 hours
Instruct client to avoid attempts to void around catheter
Postoperative interventions: Suprapubic prostatectomy
 331
AppleRN Classes

Clamp suprapubic catheter after Foley removed, instructing client to void; then
assess residual
When consistently voiding, with residual less than 75 mL, remove suprapubic
catheter as prescribed
Monitor suprapubic incision dressing
Postoperative interventions: Retropubic prostatectomy
No bladder entry leads to no urinary drainage on abdominal dressing
If urinary or purulent drainage noted on dressing, notify surgeon
Postoperative interventions: Perineal prostatectomy
Avoid rectal thermometers, rectal tubes, enemas
Cervical cancer
Two tests are used for cervical cancer screening, the Pap test and the test for
HPV.
The Pap test : to identify precancerous and cancerous cells of the cervix.
The HPV test is used to identify HPV infections that can lead to cervical cancer.
Age 21 to 29: Every 3 years with cytology (Pap testing)
Age 30 to 65: Every 5 years with HPV co-test (Pap + HPV test) OR every 3 years
with cytology.
Assessment:
Painless vaginal bleeding , foul-smelling vaginal discharge;
pelvic, lower back, leg or groin pain; anorexia; dysuria; hematuria
Treatment options: Chemotherapy, RT, Surgery
Post op precautions : Assist with coughing, deep-breathing exercises
Apply antiembolism stockings as prescribed, Monitor bowel sounds
Avoid stair climbing for 1 month, avoid sitting for long
Avoid strenuous activity or lifting more than 20 lb
 332
AppleRN Classes

Ovarian Cancer
• Cancer of ovaries; grows rapidly, spreads quickly
• Often bilateral
• Metastasis occurs by direct spread to organs in pelvis or through lymphatic
drainage (distal spread)
Assessment
• Abdominal discomfort; abdominal swelling; early satiety, gastrointestinal
disturbances; dysfunctional vaginal bleeding; abdominal mass
Interventions
• Administer pre-, postradiation and/or chemotherapy care as prescribed
• Prepare client for total hysterectomy if prescribed
Endometrial Cancer
Slow-growing tumor; associated with menopausal years
Risk factors
History of uterine polyps; nulliparity; polycystic ovary disease; estrogen
stimulation; late menopause; family history
Assessment
Postmenopausal bleeding; water, sero-sanguineous discharge; low back, pelvic,
abdominal pain; enlarged uterus in advanced stages
Nonsurgical interventions
Administer pre-, postchemotherapy, and/or radiation therapy care as prescribed
Administer medroxyprogesterone (Depo-Provera) as prescribed for estrogen-
dependent tumors

Breast Cancer
 333
AppleRN Classes

Invasive when it penetrates tissue surrounding mammary duct, grows in irregular

pattern
Second most common malignancy and death in women
Types : Lobular (milk glands) or ductal (milk passages), pagets, inflammatory
(peau d’organge)
Risk factors
Family history; early menarche and late menopause; previous cancer of breast,
uterus, or ovaries; nulliparity; obesity; high doses of radiation exposure to chest
Assessment
Mass felt during BSE. Early detection: BSE monthly, Yearly mammography starting
at age 40 CDC update : age 50
Mass usually in upper outer quadrant, beneath nipple or axilla
Histology : 3 receptors : estrogen, progesterone, HER2 (human epidermal growth
factor receptor )
Paget’s Disease
Rare malignancy of breast (areola and nipple)
Persistent lesion of the nipple and areola with or without palpable mass
Different from Paget’s disease of the bone (abnormal bone growth and deformity)
Itching, burning, bloody nipple discharge
Treatment – mastectomy
Nonsurgical interventions : Hormonal manipulation
– Tamoxifen (Nolvadex) for estrogen-dependent tumors
Surgical interventions: Lumpectomy; modified radical mastectomy; radical
mastectomy
Postoperative interventions: Place client in semi-Fowler’s position, turning from
back to nonoperative side, with affected arm elevated above level of heart.
 334
AppleRN Classes

Assess axillary region along with surgical wound.

If drain, maintain suction; note drainage characteristics
Sign above bed, “No IVs, No Injections, No BP in Affected Arm”
• Prophylactic oophorectomy and mastectomy in women with BRCA1 or
BRCA2 mutations
Lymphedema management
Massage to mobilize fluid
Compression sleeves or intermittent pneumatic compression sleeve
Clothing should be less constrictive at the proximal arm and over the chest.
Elevation of arm above the heart , Arm exercises
Injury prevention to affected arm
Tamoxifen
It has differential action in different tissues (mixed agonist/antagonist).
In the breast, they block estrogen (antagonist) and are therefore helpful in
inhibiting the growth of estrogen-receptive breast cancer cells.
In uterus – it is estrogen-stimulating (agonist)- resulting in excessive endometrial
proliferation (endometrial hyperplasia) – can lead to endometrial cencer.
Risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein
thrombosis).
Breast Cancer Home Care
Avoid overuse of affected arm for first few months, Keep affected arm elevated
Provide incision care with lanolin as prescribed. Instruct client about BSE
Protect affected arm and hand at all times from trauma, cuts, bruises – use
gloves, use lanolin cream for skin
Avoid wearing constrictive clothing on affected side. Call physician if signs of
inflammation occur
 335
AppleRN Classes

Prevent infection – use mosquito repellant. Wear Medic-Alert bracelet stating

lymphedema arm. Donot cut the cuticles on the nails
Intestinal Tumors
Malignant lesions; develop in cells lining bowel wall or as polyps in colon or
rectum
Risk factors for colorectal cancer: Age older than 50 years; history of ulcerative
colitis or Crohn’s disease; family history of intestinal cancer
Assessment: Blood in stools; anorexia; weight loss; vomiting; malaise; anemia;
diarrhea or constipation; abdominal distention; abdominal mass (late sign)
Non-surgical interventions
Monitor for complications : bowel perforation, abscess or fistula formation,
hemorrhage, complete intestinal obstruction
Administer pre-, postradiation, chemotherapy care as prescribed
Surgical interventions : Colostomy, ileostomy
Administer intestinal antiseptics, antibiotics as prescribed preoperatively
Bladder Cancer
Papillomatous growth in bladder urothelium; undergoes malignant changes, may
infiltrate bladder wall
Assessment: Gross, painless hematuria; frequency; urgency; dysuria; bladder
biopsy confirms diagnosis
Radiation : Usually need high doses. Surgery
Chemotherapy: Treat urine as biohazard
For 6 hours following intravesical chemotherapy, disinfect toilet with bleach
after each voiding

Oncological Emergencies
Sepsis, disseminated intravascular coagulation (DIC)
 336
AppleRN Classes

Maintain strict aseptic technique;

administer antibiotics, anticoagulants, clotting factors as prescribed
Syndrome of inappropriate antidiuretic hormone (SIADH)
Tumors can produce, secrete, stimulate brain to synthesize ADH
Initiate fluid restriction, increased sodium intake as prescribed; administer
demeclocycline (Declomycin) as prescribed
Spinal cord compression
• Occurs when tumor directly enters spinal cord
Assess for back pain, neurological deficits; prepare client for radiation,
chemotherapy as prescribed
Hypercalcemia
Late manifestation of extensive malignancy, often in clients with bone cancer
Monitor serum calcium level; give fluids, administer medications to lower calcium
levels as prescribed
Superior vena cava syndrome
Occurs when vein compressed, obstructed by tumor growth
Neurological symptoms
Prepare client for radiation therapy as prescribed
Tumor lysis syndrome
Occurs when large numbers of tumor cells destroyed rapidly, indicating cancer
treatment is effective
hyperuricemia, hyperkalemia,hyperphosphatemia, hypocalcemia, and acute renal
failure.
Encourage oral hydration; administer diuretics as prescribed
Oncology Pharmacology
Chemo precautions
 337
AppleRN Classes

Extravasations: the leakage of medication into surrounding skin and

subcutaneous tissue.
Stop the infusion, Leave the needle in place
Attempt to aspirate any residual medication from the site (the needle would be
removed after treatment of the event)
Administer an antidote if available
Direct pressure is not applied to the site because it could further injure tissues
exposed to the chemotherapeutic agent. Assess the site for complications.
Chemo Home Care
The client may excrete the chemotherapeutic agent for 48 hours or more after
administration.
Blood, emesis, and excreta may be considered contaminated during this time.
Client should not share a bathroom with children or pregnant women during this
time.
Any contaminated linens or clothing should be washed separately and then
washed a second time, if necessary.
All contaminated disposable items should be sealed in plastic bags and disposed
of as hazardous waste.
Bone marrow suppression: One of the common side effect. low WBC count or
neutropenia, bleeding caused by thrombocytopenia or low platelet count, Anemia
or low RBCs
Hormonal agents are effective against tumors that are supported or suppressed
by hormones.
 338
AppleRN Classes
 339
AppleRN Classes
 340
AppleRN Classes
 341
AppleRN Classes
 342
AppleRN Classes
 343
AppleRN Classes

Musculoskeletal System
Lab studies related to MS
ANA – Anti nuclear antibodies- to detect autoimmune disorders (RA, Scleroderma,
SLE)
Ca++ and Ph – high: cancer, fracture, immobilization
Low : osteomalacia / Rickets
(softening of the bones, typically through a deficiency of vitamin D or calcium /
ph.)
ESR – normal <20 mm/hr – High: RA, osteomyelitis
RA – Rheumatoid factor – antibodies
Uric Acid – High : Gout
Fracture : Open (compound) vs Closed (simple)
Complete (break completely through bone) Vs Incomplete (bone still in one
piece)
Initial care of extremity fracture
Immobilize, Cover an open wound, Assess neurovascular status
Cast/Traction/Surgery
Proper fit of the sling
Elbow is flexed at 90 degrees , shoulder support, prevent swelling
Hand is held slightly above the level of the elbow , prevent venous pooling
Bottom of the sling ends in the middle of the palm with the fingers visible
for assessment
Sling supports the wrist joint with the thumb facing upward or inward toward the
body : to maintain proper alignment
Cast : Prior to casting, the area is cleaned and dried.
 344
AppleRN Classes

Tubular cotton web roll is placed over the affected area to maintain skin integrity.
The casting material is then applied.
Cast Care
Monitor neurovascular status and assess pain.
Apply ice for 24 to 48 hr.
Handle a plaster cast with the palms, not fingertips, until the cast is dry to
prevent denting the cast.
Avoid setting the cast on hard surfaces or sharp edges. Use gloves to touch the
cast until it is completely dry.
Elevate the cast above the level of the heart during the first 24 to 48 hr to prevent
edema of the affected extremity.
Monitor for drainage : Special consideration - Older adult clients (fragile skin)
Do not place any foreign objects under the cast.
Itching? - blow cool air from a hair dryer under the cast.
Plastic coverings to avoid soiling from urine or feces.
Report “hot spot” : painful/ drainage/warm/ foul odor areas under the cast -
infection.
Instruct the client to report immobility and complications such as shortness of
breath, skin breakdown, and constipation.
Traction
Skin (tape, boots, splints) – short term
to decrease muscle spasms and immobilize the extremity
Temporary until surgery: Example - Buck's traction
Skeletal – directly to bone (pins and screws) -It is used when a greater force needs
to be applied
 345
AppleRN Classes

Balanced Slings or splints to support the fractured extremity while pulling with
ropes and weights.
The client’s body can be moved without altering the traction.
Halo Traction
Clients who have cervical fractures may be placed in a halo fixation device or
cervical tongs to provide traction and/or immobilize the spinal column.
Nursing Actions: Maintain body alignment and ensure cervical tong weights hang
freely.
Monitor skin integrity by providing pin care and assessing the skin under the halo
fixation vest as appropriate.
Do not use the halo device to turn or move a client.
Client Education: If the client goes home with a halo fixation device on, provide
instruction on pin and vest care.
Teach the client signs of infection and skin breakdown.
Scanning technique, Fall Precautions
Use of a walker and rubber-soled shoes to prevent falls and injury.
Scan the environment :
because the client's peripheral vision is limited (neck movement). Avoid bending
at the waist
Halo vest is heavy, and the client's trunk is limited in flexibility.
The nurse instructs the client and family that the metal frame on the device is
never used to move or lift the client because this will disrupt the attachment to
the client's skull, which is stabilizing the fracture.
Assess neurovascular status of the affected body part every hour for 24 hr and
every 4 hr after that.
Maintain body alignment. Avoid lifting or removing weights.
Ensure that weights hang freely and are not resting on the floor.
 346
AppleRN Classes

If the weights are accidentally displaced, replace the weights. If the problem is not
corrected, notify the provider.
Ensure that pulley ropes are free of knots, fraying, loosening, and improper
positioning at least every 8 to 12 hr.
Monitor skin integrity and document
Pin care: Monitor for signs of infection including: Drainage and redness (color,
amount, odor). Loosening of pins. Tenting of skin at pin site (skin rising up pin).
One cotton-tip swab is designated for each pin to avoid cross-contamination.
Pin care is provided usually once a shift, 1 to 2 times a day, or per facility protocol.
Crusting at the pin site should not be removed as this provides a natural barrier to
bacteria.
Traction – Complication
Compartment syndrome: Pressure from a swollen muscle compress nerves and
blood flow- severe pain – ischemia
Pressure can also be from tight cast or a constrictive bulky dressing.
Volkmann contracture (wrist contracture, inability to extend the fingers) occurs
as a result of ischemia from compartment syndrome after a distal humerus
fracture
Acute Compartment syndrome (ACS) is assessed by using the five P’s (pain,
paralysis, paresthesia, pallor, and pulselessness).
Surgery - fasciotomy
Open Reduction and Internal Fixation (ORIF)
Visualization of a fracture through an incision in the skin, and internal fixation
with plates, screws, pins, rods, and prosthetics as needed.
After the bone heals, the hardware may be removed, depending on the location
and type of hardware.
• Care : Skin integrity, prevent complications
 347
AppleRN Classes

Complications
Skin breakdown – position, mobility, skin care, nutrition
DVT and PE – Prevention : Anticoagulants, Early Ambulation
Fat embolism – minimize movement
When a long bone is fractured, pressure within the bone marrow leads to release
of fat globules into the bloodstream.
Cutaneous petechiae –on the neck, chest, upper arms, and abdomen (from the
blockage of the capillaries by the fat globules).
Only in fat emmbolism. This is a discriminating finding from pulmonary embolism
and is a late sign.
Osteomyelitis
Terms for abnormal spinal curvatures
Scoliosis – Exaggerated lateral (side)curvature
Kyphosis – Exaggerated curvature of the thoracic spine (common among older
adults)
Lordosis – Exaggerated curvature of the lumbar spine (common during the
toddler years and pregnancy)
Braces
Types : The Boston brace, Wilmington brace
Thoracolumbosacral orthosis (TLSO) brace, Milwaukee brace
Braces do not cure - but prevent further worsening
Worn around the trunk of the body under the client’s outer clothing.
Wear cotton t-shirt under the brace to decrease skin irritation and absorb sweat.
Compliance/psychological support for children
The Milwaukee brace should be worn about 23 hours a day. Child can be out of
the brace for about an hour when showering or exercising.
 348
AppleRN Classes

Spinal immobilization
Indications for Spinal immobilization
Abnormal neurological findings (Paresthesia)
Significant mechanism of injury (fall/accident)
Tenderness/ Painful over the spine.
Pain : patient may not report pain if :-
Change in LOC
Intoxication (impaired decision making/lack of awareness)
Distracting injury (another big injury somewhere- and focus is on that one)
Crutches
Crutches: Support body weight on the hands and arms, not the axillae to avoid
localized damage to the radial nerve at the axilla.
Measuring for Crutches
Crutch walking
Four point gait
WB on both legs, Slow gait, maximal support
Move each foot and crutch forward separately
Right crutch-left foot- left crutch-right foot
Two point gait
Partial WB on each foot – opposite leg and opposite crutch moved together
Move Lt crutch and Rt foot forward together; move Rt crutch and Lt foot forward
together
Three point gait
Two crutches and unaffected leg bear weight alternatively
Weaker leg and both crutches move together followed by stronger leg
 349
AppleRN Classes

Crutch Walking Stairs

Going Up Stairs
Weight on crutches and move good leg into step
Transfer weight to good (unaffected) leg and move crutches and bad (affected)
leg together
Going Down Stairs
Transfer weight to good (unaffected) leg
move crutches and bad (affected) leg together to first downward step
Transfer weight on crutches and move good leg into step
Cane
Cane length should equal the distance from the greater trochanter to the floor.
Maintain two points of support on the ground at all times.
Keep the cane on the stronger side (unaffected) of the body.
Support body weight on both legs, move the cane forward 6 to 10 inches (lateral
to fifth toe) while advancing the weaker leg.
Move the stronger leg after.
Cane / Quad Cane
Hip Fracture
S/S : external rotation, shortened extremity, pain, muscle spasm
Maintain leg and hip in proper alignment and prevent internal or external rotation
Turn client to unaffected side and only to affected side as prescribed by physician
Avoid weight bearing on affected leg . Use walker to avoid WB
Avoid hip flexion greater than 90 degrees and avoid low chairs when out of bed.
Neurovascular assessment of affected extremity: check color, pulses, capillary
refill, movement and sensation
 350
AppleRN Classes

Instruct client to avoid crossing legs and activities that require bending over
Abduction Pillow
Some terms
Ankylosis – Stiffness and fixation of a joint
Ankylosing spondylitis : Inflammatory rheumatic disorder of spine – stiff spine–
bamboo spine- do stretching and breathing exercise daily
Ataxia – Staggering, uncoordinated gait
Tennis elbow – Lateral epicondylitis : Dull ache along outer aspect of elbow,
worsens with twisting and grasping movements.
Subluxation- partial dislocation of joint
Total Knee Replacement
Implantation of a device to substitute for the knee joint
Postoperative interventions : Monitor for infection
Continuous passive motion (CPM) as prescribed : CPM provides passive range of
motion from full extension to the prescribed amount of flexion
Avoid weight-bearing as prescribed and instruct in crutch-walking
Amputation of a Lower Extremity
Below-knee amputation (BKA) or above-knee amputation (AKA)
Keep tourniquet at bedside
Elevate foot of bed to control edema, Evaluate phantom limb sensation, pain
Rehabilitation: Instruct in crutch-walking
Instruct in exercises to maintain range of motion and upper body strengthening
Residual Limb care
Prepare residual limb for prosthesis
The patient lies in the prone position several times daily to prevent flexion
contractures of the hip.
 351
AppleRN Classes

Do not use lotion on the stump.

The residual limb should not be elevated because this would encourage flexion
contracture
Osteoporosis
Demineralization of bone leading to fragile bone and subsequent fractures.
Inadequate intake of calcium and vitamin D.
Assessment : Reduced height (postmenopausal) Acute back pain after lifting or
bending (worse with activity, relieved by rest). Pelvic or hip pain, Problems with
balance. Kyphosis of dorsal spine, Pathological fractures
Interventions : Assess risk for and prevent injury. Institute measures to prevent
injury

Colles' fracture and Smith

Fracture : Common with osteoporosis (when falling)
Take a calcium supplement with vitamin D, especially if lactose intolerant
Limit the amount of coffee and carbonated beverages, which may cause calcium
loss.
Expose areas of skin to sun 5 to 30 min at least twice a week : Vit D
Engage in weight-bearing exercises (e.g. walking, lifting weights).
Avoid smoking and high alcohol intake as it causes decreased bone formation
(osteoblasts) and increased bone absorption (osteoclasts).
 352
AppleRN Classes

Avoid immobility : Bones need the stress of weight-bearing activity for bone
rebuilding and maintenance
Fall Precautions
Old age : bone remodeling –reduction in height is expected.
Calcium Rich Food
Secondary osteoporosis : results from medical conditions including:
Hyperparathyroidism.
Long-term corticosteroid use (asthma, systemic lupus erythematosus).
Long-term anticonvulsant medication use (phenytoin [Dilantin] and phenobarbital
affect the absorption and metabolism of calcium).
Long-term lack of weight-bearing (spinal cord injury).
Osteomyelitis :
Infection of the bone, bone marrow and surrounding soft tissue.
Most – Staphylococcus aureus.
Bone pain that is constant, pulsating, localized, and worse with movement.
Erythema and edema at the site of the infection
Osteomyelitis is caused by bacteria and frequently is found after an internal
infection, such as an ear infection.
Bone scan – radioisotop (gallium) given 24 -72 hrs before scan. Laxative may be
given. Flush toilet three times after use
Treatment: Chronic : Long course (3 months) of IV and oral antibiotic therapy
Hyperbaric oxygen treatments : If fails, amputation
Rheumatoid Arthritis (RA)
Chronic systemic inflammatory disease that leads to destruction of connective
tissue and synovial membrane within joints
Assessment : Inflammation, tenderness, and stiffness of joints
 353
AppleRN Classes

Moderate to severe pain with morning stiffness lasting longer than 30 minutes
Rheumatoid factor : A blood test used to diagnose rheumatoid arthritis
– Pain – more with morning stiffness
– Physical mobility, Finger/hand deformity (Swan neck and
boutonnière )
RA intervention
A balanced diet and weight control are important
Range of motion exercises are more effective after a warm bath or
shower as stiffness is decreased, thereby improving flexibility.
Nonsteroidal anti-inflammatory drugs - take with food

–
Teaching in RA
Maintain joint in neutral position to minimize deformity.
Use strongest joint available for any task
Distribute weight over many joints rather than few – don’t lift , slide
Change positions frequently, Avoid repetitious movements
Modify chores to avoid stress on joints – sit instead of standing when cooking/
talking
Juvenile Idiopathic Arthritis (JIA)
 354
AppleRN Classes

A chronic autoimmune inflammatory disease affecting joints and other tissues.

Physical Assessment Findings : Joint swelling, stiffness : worse in the morning or
after naps, Fever, Rash, Enlarged lymph nodes, Delayed growth
Uveitis: eye inflammation and swelling that can destroy eye tissues :
Need regular eye exams
Interventions
Pain management – relaxation techniques, non pharmacological therapy,
analgesics
Exercise : PT, Encourage activity as tolerated.
Apply heat or warm moist packs to the child’s affected joints prior to exercise.
Teach parents to apply splints for nighttime sleep. Splints should be applied to
knees, wrists, and hands to decrease pain and prevent flexion deformities.
Encourage proper positioning with sleep, Provide firm mattress and discourage
use of pillows under knees.
Use no pillow or/ flat pillow for head
Encourage the use of electric blankets or sleeping bags for extra warmth.
Osteoarthritis (Degenerative Joint Disease)
A progressive degeneration of joints as a result of wear and tear that causes
formation of bony buildup and loss of articular cartilage in joints
Assessment : Joint pain that diminishes after rest, intensifies after activity.
Crepitus, Physical mobility issues,
– Heberden’s and Bouchard’s nodes
– Not much systemic involvement like RA.
 355
AppleRN Classes

Septic arthritis (infectious arthritis)

Acute joint inflammation due to an infection.
Severe, pulsating pain, usually with sudden onset and exacerbated by movement
Pathogens may enter the joint from the bloodstream, direct penetration (eg,
intraarticular injection), or infected adjacent tissue (eg, osteomyelitis).
Septic arthritis can lead to irreversible joint damage
GOUT (Podagra)
Systemic disease in which urate crystals deposit in the joints or other body tissues
Assessment : Swelling and inflammation of joints leading to pain – uric acid
crystals deposits, Tophi, Low-grade fever, Pruritis, Renal calculi
Risk Factors :Obesity, Excessive Alcohol intake, Impaired kidney function, HTN
Chemo, Use of TB meds, Diuretics, Aspirin
 356
AppleRN Classes

Interventions : Gout
Prevent bed linen from touching the extremity due to tenderness.
Increase fluid intake, Low purine diet as prescribed
Bed rest during acute attack, Protection of affected joint.
Analgesics, anti-inflammatory, Allopurinol
Avoid precipitating factors- dehydration, fever, trauma, alcohol
High-purine foods: Purines are found in high-protein foods and alcoholic drinks.
Limit or avoid foods high in purine.
Seafood, Wild game meats, like goose and duck
Organ meats, such as brains, heart, kidney, liver, and sweetbreads
Gravies and sauces made with meat
Yeast extracts taken in the form of a supplement
Vegetables such as lentils, asparagus, and spinach
Carpel Tunnel Syndrome
Pain, numbness, and tingling in the hand and arm due to median nerve
compression
Tinel's sign
Phalen’s sign
The most commonly used conservative treatment is wrist splinting, particularly
at nighttime. Splinting of the wrist prevents excessive flexion or extension,
which could narrow the carpal tunnel.
Sprains and Strains
Sprain – A stretch and/or tear of a ligament
Ligaments – connects bone to bone
Tendons- attach muscle to bone
 357
AppleRN Classes

Strain – A twist, pull and/or tear that may involve both muscles and tendons
Nursing care: Assess – neurovascular
RICE approach to recovery
Rest, Ice, Compression elastic bandage, Elevate
Ligaments and tendon has relatively poor blood supply – take more time to heal.
Musculoskeletal Congenital Disorders
Clubfoot : A complex deformity of the ankle and foot. Series of castings starting
shortly after birth
ROM exercise, Assess neurovascular status. Perform cast care- keep dry, assess,
elevate foot. Monitor growth and development
Legg-Calve-Perthes Disease
Aseptic necrosis of the femoral head (lack of blood supply)
Can be unilateral or bilateral.
S/S : Intermittent painless limp, Hip stiffness, Limited ROM, Thigh pain
Shortening of the affected leg, Muscle wasting
Maintain rest and non weightbearing
Developmental dysplasia of the hip
A variety of disorders resulting in abnormal development of the hip structures
that can affect infants or children.
Infant: Asymmetry of gluteal and thigh folds, Limited hip abduction
Shortening of the femur
Positive Ortolani test (hip is reduced by abduction)
Positive Barlow test (hip is dislocated by adduction)
Child: One leg shorter than the other, Walking on toes on one foot
Walk with a limp
 358
AppleRN Classes

Pavlic Harness
It keep infant’s hips slightly flexed and abducted .
Skin Assessment : 2-3 times daily
Lightly massage skin under the straps every day to promote circulation
Dress : Shirt and knee socks under the harness to protect the skin
Apply diapers underneath the straps to keep the harness clean and dry. No
lotions.
Leave the harness on at all times, unless said by the HCP
Pavlik harnesses are typically worn for 3-5 months or until the hip joint is stable.
Straps assessed and adjusted only by health care provider every 1-2 weeks.
Musculoskeletal Medications
Muscle Relaxants
Act directly on neuromuscular junction or indirectly on CNS
Centrally acting muscle relaxants: diazepam (Valium), Baclofen (Lioresal),
Cyclobenzaprine (Flexeril), Tizanidine (Zanaflex)
Peripherally acting muscle relaxants: dantrolene (Dantrium)
Contraindicated in clients with severe liver, renal, heart disease
Side effects : Drowsiness, Dizziness, Muscle weakness, Hypotension
Interventions
Assess involved joints, muscles for pain, mobility
Monitor liver and renal function test results, Instruct client to take with food
Nursing considerations

Dantrolene (Dantrium) : Liver damage most serious adverse effect

Instruct client to notify physician if rash, bloody, tarry stool, jaundice develops
 359
AppleRN Classes

Cyclobenzaprine (Flexeril) : Contraindicated in clients receiving MAO inhibitors

within 14 days of initiation of cyclobenzaprine therapy
Methocarbamol (Robaxin) : Parenteral form can cause hypotension, bradycardia,
anaphylaxis, seizures
May turn urine brown, black, or green
Inform client to notify physician if blurred vision, nasal congestion, urticaria, rash
develops
Nursing consideration
Tizanidine (Zanaflex) – Hepatotoxic – Obtain LFT
Baclofen (Lioresal): S/E – constipation, N/V, Urinary retention
Can be administered by physician via intrathecal infusion
increase intake of high-fiber foods. Monitor I/O
All muscle relaxants and antispasmodics: CNS depression (sleepiness,
lightheadedness, fatigue)
Advise clients to avoid hazardous activities, such as driving and concurrent use of
other CNS depressants, including alcohol.
Antigout Medications
Allopurinol (Zyloprim) : can increase effects of warfarin &oral hypoglycemic
agents
Side effects : Blood dyscrasias, Uric acid kidney stones, Hypersensitivity reaction,
fever, and rash, eye pain
Nursing Consideration : Maintain fluid intake of at least 2000 to 3000 mL/day
Do not take large doses of vitamin C concurrently- interaction
Avoid foods high in purine (red meat, scallops, cream sauces). Instruct client to
take with food – GI distress
Have yearly eye exam. Minimize exposure to sunlight.
 360
AppleRN Classes

Do not take aspirin concurrently- interaction. Use acetaminophen (Tylenol)

instead of aspirin
Antiarthritic Medications
Inflammation control is key to preserving joint function
Nonsteroidal anti-inflammatory medications (NSAIDs) : Ibuprofen (Motrin, Advil) ,
Diclofenac (Voltaren), Indomethacin (Indocin), Meloxicam (Mobic) , Naproxen
(Naprosyn), Celecoxib (Celebrex)
Disease-modifying antirheumatic drugs (DMARDs) : They slow joint degeneration
and progression of rheumatoid arthritis.
full therapeutic effect will take several months.
Etanercept (Enbrel), Infliximab (Remicade), Adalimumab (Humira), Rituximab
Hydroxychloroquine sulfate (Plaquenil) (antimalarial drug)
S/E – Retinal damage – Eye exam. Report blurred vision
Methotrexate : S/E : Hepatotoxic, Bone marrow suppression, GI issues
Prevent infection, Baseline CBC, LFT
Inspect mouth, gums, and throat daily for ulcerations, bleeding, or color changes.
Report Anorexia, abdominal fullness
Take the medication with food or a full glass of water
Gold salts
Monitor client for 30 minutes after injection for anaphylaxis, allergic reaction
Teach client about signs and symptoms of gold toxicity. If toxicity develops,
dimercaprol (BAL in Oil) may be prescribed
Calcium
Calcium citrate, Calcium carbonate (Tums, Rolaids), Calcium acetate (PhosLo)
For IV : Calcium chloride, Calcium gluconate
Monitor serum calcium levels to maintain between 9.0 to 10.5 mg/dL.
 361
AppleRN Classes

Spinach, rhubarb, bran, and whole grains may decrease calcium absorption.
Raloxifene (Evista) : Work like estrogen. Decreases bone reabsorption
Prevent and treat postmenopausal osteoporosis and prevent spinal fractures in
female clients
S/E : Hot flashes, Increases risk for PE and DVT
Clients should undergo a bone density scan every 12 to 18 months
Monitor liver function tests. Raloxifene levels may be increased in clients with
hepatic impairment.
Encourage clients to perform weight-bearing exercises daily, such as walking 30 to
40 min each day.
Alendronate (Fosamax) : Decrease the number and action of osteoclasts and
inhibits bone resorption.
Other Medications :Ibandronate (Boniva), Risedronate (Actonel), zoledronic
(Reclast, Zometa)
S/E : Esophagitis, GI disturbances, Visual disturbances,
Instruct client to sit upright or ambulate for 30 min after taking this medication
orally.
Take the medication first thing in the morning after getting out of bed.
Take with lots of water, but no food or calcium tablets together
 362
AppleRN Classes

Integumentary System
Skin: Largest sensory organ of body
Function : First line of defense against infections
3 Layers:
Epidermis- Outer -waterproof barrier
Dermis –Hair follicles, and sweat glands.
Hypodermis -fat and connective tissue
Epidermal appendages: Nails, hair, glands
Normal bacterial flora
Skin Diagnostic Studies
Wood’s light examination
Ultraviolet light is used to produce specific colors to reveal a skin infection.
Examination is performed in a dark room to evaluate pigment changes in a light-
skinned client.
Skin culture and sensitivity
Culture refers to isolation of the pathogen on culture media. Sensitivity refers to
the effect that antimicrobial agents have on the micro-organism. A culture and
sensitivity can be done on a sample of purulent drainage from a skin lesion.
Cultures should be done prior to initiating antimicrobial therapy. Results of a
culture and sensitivity test usually are available preliminarily within 24 to 48 hr,
and final results in 72 hr.
Indications
Skin lesions, which may be infectious, may appear raised, reddened, edematous,
and/or warm. There may be purulent drainage and/or fever.
 363
AppleRN Classes

Skin cancer : ABCDE (Melanoma). Assess for changes in color, size, shape of
preexisting lesions, pruritus, local soreness. Educate client about preventive
measures
Contact dermatitis : Elevate extremity to reduce edema, Apply cool, wet dressings
as prescribed
Poison ivy & poison : Cleanse skin of plant oils immediately
PSORIASIS
Skin disorder that is characterized by scaly, dermal patches (silvery) and is caused
by an overproduction of keratin.
An autoimmune disorder and has periods of exacerbations and remissions.
Can also affect the joints, causing arthritis-type changes and pain.
Treatments :- Meds- antihistamines, antibiotic, steroids, chemo meds,
phototherapy
Skin Care : Instruct client not to scratch affected areas, keep skin lubricated to
minimize itching. Pat dry (no rubbing).
Apply emolient lotions immediately after bath. Use antibacterial soaps for
handwashing
Avoid wool or constrictive clothing (itching, trap sweats)
Eczema (Atopic dermatitis)
Inflammatory skin disorder, unknown cause
Main s/s: pruritus, erythema, and dry skin.
Triggers – stress, humidity, allergens, irritants (soap, detergent, wool)
Red raised lesions start from cheek, spread to forehead, arm and legs.
Identify and control triggers, keep skin dry and lubricated. – Tepid bath, Pat dry,
apply emolient
Infants- keep finger nails clean and short, place cotton gloves or socks to prevent
scratching.
 364
AppleRN Classes

Impetigo
Highly contagious bacterial infection of skin
Caused by beta-hemolytic streptococci, staphylococci, or both
Assessment : Honey crust Lesions; pruritus; burning; secondary lymph node
involvement
Interventions : Contact isolation, Teach to prevent spread of infection
Inform of need to use separate towels, linens, dishes
All linens, clothes of infected client need to be washed with detergent and hot
water, separately from others in family
Administer topical and oral antibiotics as prescribed-Scabs or crusts must be
carefully removed for the antibiotic ointment to be effective.
Apply warm compresses to lesions 2 or 3 times/day as prescribed
Herpes zoster (shingles)
Reactivation of varicella-zoster virus
A viral culture of the lesion provides the definitive diagnosis – Contact
precautions.
CDC guidelines
– Generally : Isolate the client until the vesicles have crusted over.
– Localized herpes zoster : standard precautions + cover lesions
– Disseminated herpes zoster: standard precautions + airborne +
contact precautions - until lesions are dry and crusted.
The classic presentation is grouped vesicles on an erythematous base along a
dermatome. Because they follow nerve pathways, the lesions do not cross the
body's midline.
Assist in application of acetic acid compresses, cool wet compresses. Tepid baths
as prescribed. Administer analgesics.
Pediculosis Capitis (Lice)
 365
AppleRN Classes

• Infestation of hair and scalp with lice

Assessment: Intense pruritus; small gray specks in hair; visible nits, firmly
attached to hair shaft near scalp
Interventions: Instruct parents how to administer permethrin (Nix) rinse to hair
Instruct parents that bedding, clothing used by child should be changed daily,
laundered in hot water with detergent, dried in hot dryer for 20 minutes
Instruct parents to seal toys that cannot be washed or dried in plastic bag for 2
weeks
Teach child not to share clothing, headwear, brushes, combs
Scabies
Parasitic skin disorder caused by infestation of Sarcoptes scabiei (itch mite)
Assessment: Intense pruritus, especially at night; burrows (straight or wavy lines)
beneath skin
Interventions : Lindane: should not be used in children younger than 2 years
Household members, contacts of infected child need to be treated at same time.
Instruct parents that all clothing, bedding used by child need to be changed daily,
washed in hot water and detergent, dried in hot dryer, ironed before reuse for 1
week
Instruct parents that non-washable toys, other items should be sealed in plastic
bags for 4 days
Toxic Epidermal Necrolysis
Acute skin disorder, most commonly associated with a medication reaction
Widespread erythema, blistering, epidermal shedding, keratoconjunctivitis,
and skin erosion (ie, denuded skin) ---- lead to sepsis
Management: Wound care: Sterile, moist dressings to open skin area
Eye care: Sterile, cool compresses to relieve discomfort. Lubricants may relieve
dryness and prevent corneal abrasion
 366
AppleRN Classes

Reverse isolation : Fluids and nutrition, Prevent hypothermia (warm room)

Paronychia
Infection of tissue around nail plate. Assist client with warm soaks as prescribed
Folliculitis : Deep bacterial inflammation of hair follicles caused by Staphylococcus
Give Antibiotics
Boils- Folliculitis with pus. Apply warm compresses as prescribed until drainage
occurs
Acne vulgaris
Administer topical or oral antibiotics as prescribed
Administer Isotretinoin (Accutane) or other medications as prescribed
● Made with Vit A. (do not take extra vitamin A)
● vitamin A toxicity (increased ICP, GI upset, liver damage, and changes in
skin and nails)
● Blood donation is prohibited up to a month after treatment ends.
● Teratogenic – birth defects – No pregnancy
● 2 forms of contraception to prevent pregnancy.
Frostbite
Numbness and paresthesia; may progress to necrosis, gangrene
Re warm affected tissue rapidly, continuously with warm water (immerse for
about 30 mts) or use warm washcloths. Avoid débriding blisters
Pressure ulcer
Prevention of skin breakdown major role of nurse
Risk factors include malnutrition, incontinence, immobility, decreased sensory
perception
Institute measures to prevent pressure ulcers
Stage 1: Ulcer is reddened area; returns to normal color after 15 to 20 minutes of
pressure relief
 367
AppleRN Classes

Stage 2: Ulcer is area with top layer of skin missing; shallow with pink-red base;
white-yellow eschar may be present
Stage 3: Deep ulcer; extends into dermis, subcutaneous tissue; white-gray-yellow
eschar usually present at bottom of ulcer; purulent drainage common
Stage 4: Deep ulcer; extends into muscle, bone; foul-smelling; brown or black
eschar present; purulent drainage common
Pressure Ulcer
Nursing Interventions to prevent pressure ulcer
◯◯ Keep skin clean, dry, and intact. Provide a firm, wrinkle-free foundation with
wrinkle-free linens.
◯◯ Use pressure-reducing surfaces and devices.
◯◯ Inspect the client’s skin frequently and document the client’s risk using a
tool such as the Braden scale.
◯◯ Clean the skin with a mild cleansing agent and pat it dry immediately
following urine or stool incontinence.
◯◯ Bathe with tepid water (not hot) and minimal scrubbing.
◯◯ Apply dimethicone-based moisture barrier creams or alcohol-free barrier
films to the skin of clients who are incontinent.
◯◯ Do not use powder or cornstarch to prevent friction or repel moisture due to
their abrasive grit and aspiration potential.
◯◯ Reposition the client in bed at least every 2 hr and every 1 hr in a chair.
Document position changes.
◯◯ Keep the head of the bed at or below a 30° angle (or flat), unless
contraindicated, to relieve pressure on the sacrum, buttocks, and heels.
◯◯ Use pressure-reducing devices (overlays; replacement mattresses; specialty
beds; kinetic therapy; foam, gel, or air cushions).
◯◯ Keep clients from sliding down in bed, as this increases shearing forces that
pull tissue layers apart and cause damage.
◯◯ Lift, rather than pull, clients up in bed or in a chair, because pulling creates
friction that can damage the outer layer of skin (epidermis).
 368
AppleRN Classes

◯◯ Raise heels off of the bed to prevent pressure.

◯◯ Ambulate clients as soon as possible and as often as possible.
◯Instruct clients who are mobile to shift their weight every 15 min when sitting.
◯◯ Implement active and passive exercises for clients who are immobile.
◯◯ Do not massage bony prominences.
◯Provide adequate hydration (2,000 to 3,000 mL/day) and meet protein and
calorie needs.
◯◯ Note if serum albumin levels are low (below 3.5 g/dL), because a lack of
protein puts the client at greater risk for skin breakdown, slowed healing, and
infection.
◯◯ Provide nutritional support as indicated, such as vitamin and mineral
supplements (especially A, C, zinc, copper), nutritional supplements, and enteral
and parenteral nutrition.
The primary focus : optimal nutrition and hydration.
Assess all clients regularly : Braden scale. Keep skin clean, dry, and intact.
Bathe with tepid water (not hot) and minimal scrubbing. Reposition, Ambulate
Raise heels off of the bed
Lift patient, don’t pull or push (reduce friction)
 369
AppleRN Classes

• Very High Risk: Total Score 9 or less

• High Risk: Total Score 10-12
• Moderate Risk: Total Score 13-14
• Mild Risk: Total Score 15-18
• No Risk: Total Score 19-23
Assess all clients regularly : Braden scale. Keep skin clean, dry, and intact.
Bathe with tepid water (not hot) and minimal scrubbing. Reposition, Ambulate
Raise heels off of the bed. Lift patient, don’t pull or push (reduce friction)
Hoyerlift: Use pressure-reducing surfaces and devices.
Provide a firm, wrinkle-free foundation with wrinkle-free linens.
Lab test – albumin, vitamins, nutrients
Scleroderma
overproduction of collagen that causes tightening and hardening of the skin and
connective tissue.
 370
AppleRN Classes

This is a progressive disease without a cure.

Heartburn and dysphagia are common symptoms
Complications: Raynaud phenomenon (vasospasm), Pulmonary fibrosis
Renal crisis (life-threatening) : Malignant hypertension due to narrowing of the
vessels that provide blood to the kidneys.

Burns
Thermal burns: exposure to flames, steam, or hot liquids.
Chemical burns: occur when there is exposure to a caustic agent. (drain cleaner,
bleach) and agents used in the industrial setting (caustic soda, sulfuric acid)
Electrical burns: loss of organ function, tissue destruction with subsequent need
for amputation of a limb, and cardiac and/or respiratory arrest.
Radiation burns: most frequently occur as a result of therapeutic treatment for
cancer or from sunburn.
Burn Process
Metabolism increases to maintain body heat as a result of burn injury and tissue
damage.
The severity of the burn is based on:
Percentage of total body surface area (TBSA) – Standardized charts for age groups
are used to identify the extent of the injury.
Depth of the burn – Burns are classified according to the layers of skin and tissue
involved.
Body location of the burn – In areas where the skin is thinner, there is more
damage to underlying tissue (any part of the face, hand, perineum, feet).
Burn Assessments
Rule of Nines – Quick method to approximate the extent of burn by dividing the
body into multiples of nine. The total of the sum is equal to the total body surface
area (TBSA). This determines the measurement and the extent of the burn.
 371
AppleRN Classes

Lund and Browder Method – A more exact method estimating the extent of burn
by the percentage of surface area of anatomic parts. Dividing body into smaller
parts and providing a TBSA for each body part, an estimate of TBSA can be
determined.
Palmer Method – Quick method to approximate scattered burns using the palm of
the client’s hand. The palm of the client’s hand (excluding the fingers) is equal to
0.5% TBSA. This method can be used for all age groups.
Rule of Nine
 372
AppleRN Classes
 373
AppleRN Classes

Management of Burn
Extensive burns result in generalized edema, decreased circulating intravascular
blood volume, leading to hypotension.
Fluid replacement is important during the first 24 hr. (LR)
Hypovolemia and shock may result when injury to at least 20% to 30% TBSA
occurs.
Decrease in organ perfusion secondary to fluid losses – oliguria
urine output is the greatest indicator of adequate fluid resuscitation.
Laboratory Tests – Due to fluid shift,
First 24 hrs : - H&H and K High, Na-Low
48 to 72 hr after injury- H&H, K and Na-Low, Glucose-high
Fluid formula

Minor Burns
Stop the burning process.
Remove clothing or jewelry that might conduct heat (If not stuck to skin)
In a chemical burn injury, the burning process continues as long as the chemical is
in contact with the skin.
 374
AppleRN Classes

All clothing, including gloves and shoes, is immediately removed and water lavage
is instituted before and during the transport to the emergency department.
Apply cool water soaks or run cool water over injury; do not use ice. Flush
chemical burns with large volume of water. Cover the burn with clean cloth to
prevent contamination and hypothermia.
Provide warmth. No butter, ointment, lotion. Provide analgesics. Cleanse with
mild soap and tepid water (avoid excess friction). Use antimicrobial ointment - if
prescribed by a health care provider.
Apply dressing (nonadherent, hydrocolloid) if the burn area is irritated by
clothing. Educate the family to avoid using greasy lotions or butter on burn.
Educate family to monitor for evidence of infection. Check immunization status
for tetanus and determine need for immunization
Moderate and Major Burns
Maintain airway and ventilation. A nasogastric tube may be indicated for clients
at risk for aspiration.
Assist client to cough and deep breathe every hour. Suction every hour or as
needed.
Keep head of bed elevated at all times. Provide humidified supplemental oxygen
as prescribed.
Monitor vital signs. Pain management. Avoid IM or subcutaneous injections
Maintain cardiac output – IV fluids, Blood products, Albumin.
Monitor for manifestations of shock : Alterations in sensorium (confusion),
Increased capillary refill time, Urine output less than 30 mL/hr, Rapid elevations
of temperature, Decreased bowel sounds
Psychological Support of Client and Family. Prevent Infection
Nutrition – High Calorie, High Protein, TPN
 375
AppleRN Classes

Restoration of Mobility
Maintain correct body alignment, splint extremities, and facilitate position
changes to
Prevent contractures. Maintain active and passive range of motion.
Assist with ambulation as soon as the client is stable.
Apply pressure dressings to prevent contractures and scarring.
Monitor areas at high risk for pressure sores (heels, sacrum, back of head).
Wound Care
Hyperbaric Oxygen - By helping the body fight infection, hyperbaric oxygen can
improve healing, lessen damage from infection, and thereby decrease the chance
of death associated with severe burns
Biologic skin coverings: promote healing of large burns, reduce pain by covering
nerve endings, help in retaining water and protiens.
Hydrotherapy – Place the client in a warm tub of water or use warm running
water, as if to shower, to cleanse the wound.
Use mild soap or detergent to gently wash burns and then rinse with room-
temperature water.
Whirlpool: for the removal of necrotic cellular debris
Wound Graft
Autografting: Permanent wound coverage created from client’s own unburned
skin
Care of graft site: Elevate, immobilize site; keep free from pressure; monitor for
signs of infection; protect site from direct sunlight
Care of donor site: Moist gauze dressing as prescribed; keep site clean, dry; keep
free from pressure; educate client not to scratch site; apply lubricating lotions to
healed site as prescribed
 376
AppleRN Classes

Rehabilitation phase
Begins after the client's wounds have fully healed and lasts about 12 months
Counseling or other psychosocial support
Gentle massage with water-based lotion to alleviate itching and minimize scarring
Planning for reconstructive surgery
Pressure garments to prevent hypertrophic scars and promote circulation
Range-of-motion exercises to prevent contractures
Sunscreen and protective clothing to prevent sunburns and hyper pigmentation
Pediatric considerations
Very young child with severe burn- higher mortality
Increased risk for fluid and heat loss, dehydration, metabolic acidosis versus adult
Burns involving more than 10% of total body surface area require some form of
fluid resuscitation
Parameters such as vital signs, urine output, adequacy of capillary filling,
sensorium status determine adequacy of fluid resuscitation
Scarring more severe in children
Extent of burn injury: Modified rule of nines may be used for pediatric population
Pain management: Administer pain medications, including opioid analgesics prior
to any procedure or activity involving high risk for pain
 377
AppleRN Classes

Mental Health
Each encounter with a client involves an ongoing assessment.
Psychosocial History: Perception of own health, beliefs about illness and wellness
Activity/leisure activities, how the client passes time
Use of substances/substance use disorder
Stress level and coping abilities – usual coping strategies, support systems
Cultural beliefs and practices, Spiritual beliefs
Mental Status Examination and Assessment
Physical appearance :personal hygiene, grooming, and clothing choice
Behavior : voluntary and involuntary body movements, and eye contact.
Assess the client’s orientation to time, person, and place.
Abstract thinking (higher thought process) and Judgment
Assess the client’s memory, both recent and remote.
Immediate – Ask the client to repeat a series of numbers or a list of objects.
Recent – Ask the client to recall recent events, such as visitors from the current
day, or the purpose of the current mental health appointment or admission.
Remote – Ask the client to state a fact from his past that is verifiable, such as his
birth date or his mother’s maiden name
Mental Status Examination
Level of consciousness
Alert – The client is responsive and able to fully respond by opening her eyes and
attending to a normal tone of voice and speech. She answers questions
spontaneously and appropriately.
Lethargy – The client is able to open her eyes and respond but is drowsy and falls
asleep readily.
 378
AppleRN Classes

Stupor – The client requires vigorous or painful stimuli (pinching a tendon or

rubbing the sternum) to elicit a brief response. She may not be able to respond
verbally.
Coma - NO response can be achieved from repeated painful stimuli.
Glasgow Coma Scale
Safety, No access to sharp or otherwise harmful objects, Restriction of client
access to restricted or locked areas, Monitoring of visitors
Restriction of alcohol and illegal substance access or use
Rapid de-escalation of disruptive and potentially violent behaviors through
planned interventions by trained staff
Seclusion rooms and restraints should be set up for safety and used only after all
less restrictive measures have been exhausted. When used, facility policies and
procedures must be followed.
Plan for safe access to recreational areas, occupational therapy, and meeting
rooms.
Therapeutic Nurse-Client Relationship
Consistently focus on the client’s ideas, experiences, and feelings.
Identify and explore the client’s needs and problems.
Discuss problem-solving alternatives with the client.
Help to develop the client’s strengths and new coping skills.
Encourage positive behavior change in the client.
Assist the client to develop a sense of autonomy and self-reliance.
Portray genuineness, empathy, and a positive regard toward the client.
The nurse practices empathy by remaining nonjudgmental and attempting to
understand the client’s actions and feelings.
This differs from sympathy, in which the nurse allows herself to feel the way the
client does and is non therapeutic.
 379
AppleRN Classes

Client centered – not social or reciprocal (taking advantage)

Purposeful, planned, and goal-directed, Attending behaviors, caring, active
listening, Nonjudgmental attitude, trust, honesty, empathy
Therapeutic Communication: Children
Use simple, straightforward language.
Be aware of own nonverbal messages, as children are sensitive to nonverbal
communication.
Enhance communication by being at the child’s eye level.
Incorporate play in interactions
Older Adult Clients
Recognize that the client may require amplification.
Minimize distractions, and face the client when speaking.
Allow plenty of time for the client to respond.
When impaired communication is assessed, ask for input from caregivers or
family to determine the extent of the deficits and how best to communicate.
Effective Skills and Techniques
Silence : Allows time for meaningful reflection.
Active listening: The nurse is able to hear, observe, and understand what the
client communicates and to provide feedback.
Open-ended questions : This technique facilitates spontaneous responses and
interactive discussion
Showing acceptance and recognition
Focusing : helps client to concentrate on what is important
Asking questions
Summarizing : emphasizes important points and reviews what has been
discussed.
 380
AppleRN Classes

Clarifying techniques:
This technique is used to determine if the message received was accurate:
Restating – uses the client’s exact words.
Reflecting – directs the focus back to the client in order for the client to examine
his feelings.
Paraphrasing – restates the client’s feelings and thoughts for the client to confirm
what has been communicated.
Exploring – allows the nurse to gather more information regarding important
topics mentioned by the client.
Barriers to Effective Communication
Asking irrelevant personal questions -Why didn’t you marry yet?
Offering personal opinions -If it was me, I would have opted for DNR
Giving advice, Giving false reassurance
Minimizing feelings – “ You should not be this depressed over it”
Changing the topic, Asking “why” questions
Offering value judgments : You form an opinion about it based on your principles
and beliefs and not on facts which can be checked or proved.
“You should not accept blood transfusion. Its not right”
Excessive questioning
Responding approvingly or disapprovingly – “Abortion is women’s right”
 381
AppleRN Classes

CBT :5 components: Education about the client's specific disorder

Self-observation and Monitoring - the client learns how to monitor anxiety,
identify triggers, and assess the severity.
Physical control strategies – Deep breathing and muscle relaxation exercises.
Cognitive restructuring – learning new ways to reframe thinking patterns,
challenging negative thoughts
Behavioral strategies – focusing on situations that cause anxiety and practicing
new coping behaviors, desensitization to anxiety-provoking situations or events.
 382
AppleRN Classes

Stress, Coping and Defense Mechanisms

Stress causes anxiety.
Coping : term that describes how an individual deals with problems and issues.
(Adaptive –good), Maladaptive (not good)
Nurses role – Identify coping strategies, promote healthy ones.
Defense Mechanism: Strategies that assist client to protect own ego and reduce
anxiety. Dysfunctional behavior may occur when a defense mechanism is used as
a response to anxiety.
Altruism and sublimation are defense mechanisms that are always healthy.
Immature – projection, displacement, splitting, denial.
Terms to know
Transference : Transference occurs when the client views a member of the health
care team as having characteristics of another person who has been significant to
the client’s personal life.
Counter transference : Counter transference occurs when a health care team
member displaces characteristics of people in her past onto a client.
 383
AppleRN Classes

Mental Health Disorders

Anxiety
Mild anxiety occurs in the normal experience of everyday living.
It increases one’s ability to perceive reality. There is an identifiable cause of the
anxiety.
 384
AppleRN Classes

Other characteristics include a vague feeling of mild discomfort, restlessness,

irritability, impatience, and apprehension.
The client may exhibit behaviors such as finger- or foot-tapping, fidgeting, or
lip‑chewing as mild tension-relieving behaviors.
Moderate anxiety
Moderate anxiety occurs when mild anxiety escalates.
Slightly reduced perception and processing of information occurs, and selective
inattention may occur.
Ability to think clearly is hampered, but learning and problem solving may still
occur.
Other characteristics include concentration difficulties, tiredness, pacing, change
in voice pitch, voice tremors, shakiness, and increased heart rate and respiratory
rate.
The client may report somatic complaints including headaches, backache, urinary
urgency and frequency, and insomnia.
The client with this type of anxiety usually benefits from the direction of others.
Clients with anxiety disorders are advised to limit their intake of caffeine,
chocolate, and alcohol because these products have the potential to increase
anxiety
 385
AppleRN Classes

Severe Anxiety
Perceptual field is greatly reduced with distorted perceptions.
›› Learning and problem-solving do not occur.
›› Functioning is ineffective.
››Other characteristics include confusion, feelings of impending doom,
hyperventilation, tachycardia, withdrawal, loud and rapid speech, and aimless
activity.
›› The client with severe anxiety usually is not able to take direction from others.
Panic-level anxiety
Panic-level anxiety is characterized by markedly disturbed behavior.
›› The client is not able to process what is occurring in the environment and may
lose touch with reality.
›› The client experiences extreme fright and horror.
›› The client experiences severe hyperactivity or flight.
›› Immobility can occur.
 386
AppleRN Classes

››Other characteristics may include dysfunction in speech, dilated pupils, severe

shakiness, severe withdrawal, inability to sleep, delusions, and hallucinations.
Nursing care in Panic Anxiety
Safe environment : Quiet, safe. Minimize stimulation
Stay with the patient. Meds and restraints- If no other way
Encourage walking and other activity which will channel the energy
Set Limits – Use firm, short and simple statements. Help to focus on reality

Medication for Anxiety

Sedative Hypnotic Anxiolytic – Benzodiazepine
alprazolam (Xanax), Diazepam (Valium), Lorazepam (Ativan), Oxazepam
Chlordiazepoxide (Librium), Clorazepate , Clonazepam (Klonopin)
Relief from anxiety occurs rapidly following administration
Diazepam is contraindicated in clients who have sleep apnea, respiratory
depression and/or glaucoma.
Benzodiazepines are generally used short term –dependence
 387
AppleRN Classes

Avoid abrupt discontinuation – Taper the dose. Give with food to reduce GI
discomfort
Benzodiazepine toxicity – Assessment, IV, Gastric Llevage, Administering
flumazenil (to reverse the effect)

Nonbarbiturate Anxiolytic - Buspirone (BuSpar)

Dependency is much less likely. No sedation
S/E : Dizziness, nausea, headache, lightheadedness, agitation
Might take upto 3 to 6 weeks for the full benefit
Buspirone is not recommended for women who are breastfeeding
Buspirone is contraindicated for concurrent use with MAOI antidepressants or for
14 days after MAOIs are discontinued. Hypertensive crisis may result.
Selective Serotonin Reuptake Inhibitors (SSRI Antidepressants)
Sertraline , Citalopram, Escitalopram, Fluoxetine, Paroxetine and Fluvoxamine
May take up to 4 weeks for therapeutic effect. Medications may be taken with
food. Avoid alcohol.
 388
AppleRN Classes

Sleep disturbances are minimized by taking medication in the morning.

Early adverse effects (first few days/weeks):
nausea, diaphoresis, tremor, fatigue, drowsiness : Instruct clients to take the
medication as prescribed, Advise clients that these effects should soon subside.
SSRI - Other Side Effects
Later adverse effects (after 5 to 6 weeks of therapy): sexual dysfunction, weight
gain
GI bleeding, Hyponatremia
Bruxism: grinding and clenching of teeth, usually during sleep
Paroxetine is contraindicated in clients taking some antidepressants like MAOIs or
a TCA.
Withdrawal syndrome : Taper the dose. Nausea, sensory disturbances, anxiety,
tremor, malaise, unease:
Serotonin syndrome : HATRED FACT
Hallucinations, Agitation, Tremors, Reflex - hyper, Easily distracted (difficulty
concentrating), Diaphoresis, Fever, Anxiety, Confusion (disorientation),
Tachycardia
Usually begins 2 to 72 hr after initiation of treatment
Resolves when the medication is discontinued
Watch for and advise clients to report any of these manifestations, which could
indicate a lethal problem.
SSRI side effects (major)
S – Sleep problems,
S – Sexual Dysfunction
S - Stomach upset
S – Serotonin Syndrome
 389
AppleRN Classes

S – Scale (weight gain – long term)

Generalized Anxiety Disorder
Unrealistic anxiety about everyday worries that persists over time and is not
associated with a mental health or medical disorder
Assessment: Restlessness, Chronic muscular tension, Inability to concentrate,
Chronic fatigue and sleep problems
Interventions: Address physical discomforts
Assist client to identify thoughts that aroused anxiety (stressors/triggers)
Assist client to change unrealistic thoughts to more realistic ones
Recognize that some level of anxiety is normal in daily life.
Obsessive-Compulsive Disorder (OCD)
Obsessions: Preoccupation with persistent intrusive thoughts and ideas
Compulsions: Performance of rituals or repetitive behaviors designed to prevent
some event, divert unacceptable thoughts, and decrease anxiety. If the ritual is
interrupted, the client will experience increased anxiety.
Interventions: Ensure basic needs are met
Identify situations that precipitate the compulsive behavior
Encourage client to express feelings
Do not interrupt the compulsive behavior; set limits and protect client from harm
Establish written contract that will assist client to decrease frequency of behaviors
Post-Traumatic Stress Disorder
After experiencing a psychologically traumatic event, the individual re-
experiences the event and has recurrent and intense dreams and flashbacks
• Stressors : Natural disaster, Terrorist attack, Combat experience
• Accidents, Victims of rape, crime, or violence
Assessment: Sleep disturbances and nightmares , Flashbacks of event
 390
AppleRN Classes

Poor concentration and avoidance of activities that trigger recollection of event

Emotional numbness, detachment, depression
Interventions: Assist client to recognize association of feelings and trauma
experience
Assist client to express feelings and develop adaptive coping mechanisms
Hypnotherapy or systematic desensitization may be recommended
Support groups
• Mysophobia : fear of contamination and germs
• Nyctophobia : fear of the night or of darkness
• Pyrophobia : fear of fire
• Social phobia
• Xenophobia: fear towards foreigners
• Zoophobia : animal phobia
• Interventions
• Remain with client when activity level is high
• Allow client to verbalize feelings
• Accept the client but do not support the phobia
• Teach relaxation techniques
• Desensitization may be recommended
Delusions and Hallucinations
Delusion: Alterations in thought which are false fixed beliefs that cannot be
corrected by reasoning.
Hallucinations : Alterations in perception
Hallucinations are sensory perceptions that do not have any apparent external
stimulus.
 391
AppleRN Classes

Examples include the following:

Auditory – hearing voices or sounds.
Command – the voice instructs the client to perform an action, such as to hurt self
or others.
Visual – seeing persons or things.
Olfactory – smelling odors.
Gustatory – experiencing tastes.
Tactile – feeling bodily sensations.

Communication – Delusion and Hallucination

Ask the client directly about hallucinations. The nurse should not argue or agree
with the client’s view of the situation, but may offer a comment, such as, “I don’t
hear anything, but you seem to be feeling frightened.”
Do not argue with a client’s delusions, but focus on the client’s feelings and
possibly offer reasonable explanations, such as, “I can’t imagine that the
president of the United States would have a reason to kill a citizen, but it must be
frightening for you to believe that.”
 392
AppleRN Classes

Assess the client for paranoid delusions, which can increase the risk for violence
against others.
Provide for safety if the client is experiencing command hallucinations due to the
increased risk for harm to self or others.
Attempt to focus conversations on reality-based subjects.
Identify symptom triggers, such as loud noises (may trigger auditory
hallucinations in certain clients) and situations that seem to trigger conversations
about the client’s delusions.
Be genuine and empathetic in all dealings with the client.
Symptom management techniques include such strategies as using music to
distract from “voices,” attending activities, walking, talking to a trusted person
when hallucinations are most bothersome, and interacting with an auditory or
visual hallucination by telling it to stop or go away.
Depression
Psychotic features – the presence of auditory hallucinations (for example, voices
telling the client she is sinful) or the presence of delusions (for example, client
thinking that she has a fatal disease)
Postpartum onset – a depressive episode that begins within 4 weeks of childbirth
(known as postpartum depression) and may include delusions, which may put the
newborn infant at high risk of being harmed by the mother
Seasonal characteristics – seasonal affective disorder (SAD), which occurs during
winter and may be treated with light therapy. May be associated with melatonin
levels
Major Depression (WONT WISH LIFE)
Loss of interest in life and a depressed mood
Diminished interest in pleasure, Weight loss /gain, Insomnia
Psychomotor agitation or retardation everyday
Fatigue or loss of energy everyday
 393
AppleRN Classes

Cant think, concentrate or take decisions (No concentration)

Social Withdrawal,Suicidal ideation, thought of death
Hopelessness, Major Depression (WONT WISH LIFE)
Withdrawal , Overwhelming Mood (agitation/retardation)
No concentration or Thinking, Weight change (loss /gain), Insomnia
Suicidal ideation, Hopelessness, Loss of interest in life
Interest Deficit (Diminished interest in pleasure), Fatigue or loss of energy
everyday , Energy loss
Treatment
Cognitive-behavioral therapy (CBT) : assists the client to identify and change
negative behavior and thought patterns.
Electroconvulsive therapy (ECT)
ECT is effective for clients who have bipolar disorder and suicidal ideation.
Temporary memory loss is possible
Nursing care – same for surgery patient with sedation.
Protect airway, Monitor vital signs, safety . ECT
Nursing care - Depression
Assist with activities of daily living and attend to physiological needs (e.g.,
nutrition, rest)
Avoid presenting complex decision-making situations to client
Provide structured environment and activities in which client can achieve success
Safety of Nurse : Remove objects or barriers to prevent injury
Decrease environmental stimuli
Antidepressants
Do not discontinue medication suddenly.
 394
AppleRN Classes

Therapeutic effects are not immediate, and it may take several weeks or more to
reach full therapeutic benefits.
Avoid hazardous activities, such as driving or operating heavy
equipment/machinery, due to the potential adverse effect of sedation.
Notify the provider of any thoughts of suicide.
Avoid alcohol while taking an antidepressant.
St. John’s wort : used as herbal medicine to treat depression
A plant product (Hypericum perforatum), not regulated by the U.S. FDA: To
relieve manifestations of mild depression.
Adverse effects include photosensitivity, skin rash, rapid heart rate,
gastrointestinal distress, and abdominal pain.
St. John’s wort can increase or reduce levels of some medications if taken
concurrently. Potentially fatal serotonin syndrome with SSRI.
Foods containing tyramine should be avoided : Aged cheese, smoked meats, red
wines, and pickled meats, Avocado, Meat Extracts
Suicidal ideation
Interventions for depression
Assess for suicidal ideation and provide safety
Danger more prominent when client begins to regain strength and hope,
especially beginning of antidepressant meds
Assess frequently – ask questions about any plans for suicide, Sign “No self-harm”
contract.
Assess carefully for verbal and nonverbal clues. It is essential to ask the client if he
is thinking of suicide. This will not give the client the idea to commit suicide.
Overt sign – sudden happiness, giving away possessions, inability to see future of
self, refuse meds or therapy, making comments.
SAD PERSONS (risk for suicide)
 395
AppleRN Classes

S: Sex (men kill themselves more often than women; women make more
attempts)
A: Age (teenagers/young adults, age >45)
D: Depression (and hopelessness)
P: Prior history of suicide attempt
E: Ethanol and/or drug abuse
R: Rational thinking loss (hearing voices to harm self)
S: Support system loss (living alone)
O: Organized plan; having a method in mind (with lethality and availability)
N: No significant other
S: Sickness (terminal illness)
Suicide precautions
Initiate one-on-one constant supervision around the clock, always having the
client in sight and close.
Document the client’s location, mood, quoted statements, and behavior every 15
min or per facility protocol.
Remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal
nail files, matches, razors, perfume, shampoo, and plastic bags from the client’s
room and vicinity.
Allow the client to use only plastic eating utensils. Check the environment for
possible hazards (such as windows that open)
Do not assign to a private room if possible and keep door open at all times.
Ensure that the client swallows all medications. Restrict the visitors from bringing
possibly harmful items to the client.
Bipolar disorders (Manic Depressive Disorder)
Periods of normal functioning alternate with periods of illness,
 396
AppleRN Classes

Some clients are not able to maintain full occupational and social functioning.
Also called Manic- Depressive disorder
A client in a true manic state usually will not stop moving, and does not eat, drink,
or sleep. This can become a medical emergency.

Acute Manic Episode care

Provide a safe environment during the acute phase.
Assess the client regularly for suicidal thoughts, intentions, and escalating
behavior. Decrease stimulation without isolating the client if possible.
 397
AppleRN Classes

Be aware of noise, music, television, and other clients, all of which may lead to an
escalation of the client’s behavior.
In certain cases, seclusion may be the only way to safely decrease stimulation for
the client. Provide high-calorie finger foods, fluids
Provide outlets for physical activity. Implement frequent rest periods.
Do not involve the client in activities that last a long time or that require a high
level of concentration and/or detailed instructions.
Avoid competitive games. Supervise self-administration of medication
Protect client from poor judgment and impulsive behavior, such as giving money
away and sexual comments and triggers.
Communications- Use a calm, matter-of-fact, specific approach.
Do not react personally to the client’s comments
Medications and treatment
Mood stabilizers : Lithium carbonate (Lithobid)
Anticonvulsants that act as mood stabilizers, including valproic acid (Depakote),
clonazepam
Benzodiazepines, such as lorazepam (Ativan), used on a short-term basis for a
client experiencing sleep impairment related to mania
Antidepressants, such as the SSRI fluoxetine (Prozac), used to manage a major
depressive episode
Therapeutic Procedures – ECT (not helpful in prevention of bipolar, not used for
initial therapy- medications are used as initial therapy)
Lithium Therapeutic drug level – 1.5
Mild side effects : Drowsiness, weight gain, dry mouth, GI upset
Take with food. Maintain adequate fluids and salt
 398
AppleRN Classes

Lithium toxicity : with dehydration, hyponatremia, decreased renal function, and

drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide
diuretics).
Educate and monitor for above conditions to avoid lithium toxicity
Autism Spectrum disorder (ASD)
Genetic component : Common in siblings
Children exhibit sensory processing problems:
Hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells
A calming environment with minimal stimulation: Nursing Action:-
Use a quiet or monotone voice when speaking to the child
Use eye contact and gestures carefully,Move slowly
Limit visual clutter, Maintain minimal lighting
Provide the child with a single object to focus on
Private rooms away from busy areas are the best room assignment.

Schizophrenia
Characterized by psychotic features (hallucinations and delusions), disordered
thought processes, and disrupted interpersonal relationships
 399
AppleRN Classes

Assessment
Neglecting physical needs. Inappropriate or bizarre motor activity
May view the world as threatening or unsafe. Compulsive rituals
Inappropriate affect. Impaired thought processes
Hallucinations, delusions, language and communication disturbances
Types of schizophrenia
Paranoid : Others are out to harm him, auditory hallucinations
Disorganized: Disorganized speech, behavior, flat affect
Catatonic : Stupor (unconsciousness), inappropriate posture, echolalia
Undifferentiated: Delusions and hallucinations present
Residual : No prominent symptom, social withdrawal present.
Medications - Antipsychotics
Antipsychotics- to treat positive and negative symptoms
Positive symptoms – The manifestation of things that are not normally present.
These are the most easily identified symptoms
Example- Delusions and Hallucinations
Negative symptoms – The absence of things that are normally present. These
symptoms are more difficult to treat successfully than positive symptoms.
Example : Affect –flat (facial expression never changes)
Personality Disorders
Maladaptive behavior patterns or traits that impair functioning and relationships
(Antisocial, paranoid, OCD, Dependant)
Self-assessment is vital for nurses.
General interventions for clients with personality disorder. Maintain safety
against self-destructive behaviors
 400
AppleRN Classes

A firm, yet supportive approach and consistent care. Offer the client realistic
choices to enhance the client’s sense of control.
Encourage client to discuss feelings rather than act on them. Discuss expectations
and consequences that follow certain behaviors
Assist client to deal directly with mood changes (e.g., anger)
Set and maintain limits to decrease manipulative behavior. Provide praise for
positive behaviors
Clients who have schizoid personality disorders tend to isolate themselves, and
the nurse should respect this need.
Substance Abuse
Alcohol, sedatives (pain meds), stimulants (cocaine)
The nurse must self-assess his own feelings first.
Safety is the primary focus of nursing care during acute intoxication or
withdrawal. Prevent falls; implement seizure precautions
Orient the client to time, place, and person. Maintain adequate nutrition and fluid
balance.
Create a low-stimulation environment. Administer medications
Teaching – client and family
Opioid withdrawal
Signs: Generalized myalgias, abdominal cramps, diarrhea, piloerection (goose
bumps), Tachycardia, insomnia, anxiety and pupillary dilation
Other common features include nausea, vomiting, frequent yawning,
restlessness, rhinorrhea, and increased lacrimation.
Alcohol - Resources and self-help groups
Alcoholics Anonymous (AA) – provides help and support to individuals who want
to stop drinking. AA uses a 12-step approach that provides guidelines on
attaining and maintaining sobriety.
 401
AppleRN Classes

Adult Children of Alcoholics (ACOA) – provides assistance to adults who grew up

in homes that were dysfunctional due to alcoholism.
Al-Anon – provides help for spouses, significant others, family, and friends of
alcoholics to share their personal experiences and coping strategies.
Alateen – part of Al-Anon; provides support to adolescent children of alcoholics
National Association for Children of Alcoholics (NACOA) – raises public awareness
of alcoholism and its effects through leadership in public policy, advocacy for
prevention services, and online resources.
How to help family when there is a critical incident
Acknowledge the severity of the event. Its overwhelming for family.
Assis the family in identifying their feelings.
Shock, denial, anger, helplessness, numbness, disbelief, and confusion are
common.
Give the family an opportunity to ventilate : This reduces immediate emotional
stress. Reduce the immediate emotional impact of disruptive crisis on family.
Provide psychological support. Check for physical symptoms and offer supportive
care. Hyperventilation, abdominal pain, and dizziness are common
Somatoform Disorders
Characterized by persistent worry or complaints regarding physical illness
without supporting physical findings
Interventions: Discourage verbalization about physical symptoms
Allow specific time period to discuss physical complaints
Convey understanding that physical symptoms are real to client
Encourage diversional activities
Eating Disorder
Anorexia nervosa : Clients are preoccupied with food and the rituals of eating,
along with a voluntary refusal to eat.
 402
AppleRN Classes

Clients exhibit a morbid fear of obesity and a refusal to maintain a minimally

normal body weight (body weight is less than 85% of expected normal weight for
the individual) in the absence of a physical cause.
Most often in females from adolescence to young adulthood.
Two types:
Restricting type – The individual drastically restricts food intake and does not
binge or purge.
Binge-eating/purging type – The individual engages in binge eating or purging
behaviors.
Bulimia nervosa
Clients recurrently eat large quantities of food over a short period of time (binge
eating), which may be followed by inappropriate compensatory behaviors, such as
self-induced vomiting (purging), to rid the body of the excess calories.
Most clients maintain a weight within a normal range or slightly higher.
The average age of onset in females is 15 to 18 years of age.
■■ Two types:
Purging type, in which the client uses self-induced vomiting, laxatives, diuretics,
and/or enemas to lose or maintain weight
Non-purging type, in which the client may also compensate for binge eating
through other means, such as excessive exercise and the misuse of laxatives,
diuretics, and/or enemas
Nursing Care
Perform self-assessment regarding possible feelings of frustration regarding client
eating behaviors, the belief that the disorder is self-imposed, or the need to
nurture rather than care for the client.
Provide a highly structured milieu (the safe place) in an acute care unit for the
client requiring intensive therapy.
 403
AppleRN Classes

Develop and maintain a trusting nurse/client relationship through consistency and

therapeutic communication.
Use a positive approach and support to promote client self-esteem and positive
self-image.
Encourage client decision making and participation in the plan of care to allow for
a sense of control.
Establish realistic goals for weight loss or gain. Promote cognitive-behavioral
therapies:
■■ Relaxation techniques, Journal writing, Desensitization exercises
Monitor the client’s vital signs, intake and output, and weight.
Use behavioral contracts to modify client behaviors.
Reward the client for positive behaviors, such as completing meals or consuming
a set number of calories.
Closely monitor the client during and after meals to prevent purging, which may
necessitate accompanying the client to the bathroom.
Teach and encourage self-care activities, exercise
Work with a dietitian : correcting misinformation regarding food, meal planning,
and food selection. Consider the client’s preferences.
high in fiber (constipation), low sodium (fluid retention)
Supplements (vitamins, Minerals)
A structured and inflexible eating schedule
Provide small, frequent meals, which are better tolerated. No stimulants (caffein)
Treatment : Meds- SSRI
Teamwork and Collaboration (nutritionist, nurse, physician)
Care After Discharge : Assist the client to develop and implement a maintenance
plan related to weight management.
◯◯ Encourage follow-up treatment in an outpatient setting.
 404
AppleRN Classes

◯◯ Encourage client participation in a support group.

◯◯ Continue individual and family therapy as indicated.
Complications - Refeeding syndrome
■■ Refeeding syndrome is the potentially fatal complication that can occur when
fluids, electrolytes, and carbohydrates are introduced to a severely malnourished
client.
■■ Nursing actions: Care for the client in a hospital setting.
Consult with the provider and dietitian to develop a controlled rate of nutritional
support during initial treatment.
Monitor serum electrolytes, and administer fluid replacement as prescribed.
Cardiac dysrhythmias, severe bradycardia, and hypotension
■■ Nursing actions:
Place the client on continuous cardiac monitoring.
Monitor the client’s vital signs frequently. Report changes in the client’s status to
the provider.

End of life care

End-of-life care attempts to meet the client’s physical, spiritual, emotional, and
psychosocial needs.
End-of-life issues
decision-making in a highly stressful time during which the nurse must consider
the desires of the client and the family.
Decisions are shared with other health care personnel for a smooth transition
during this time of stress, grief, and bereavement.
Palliative Care
The nurse serves as an advocate for the client’s sense of dignity and self-esteem
by providing palliative care at the end of life.
 405
AppleRN Classes

It improves the quality of life of clients and their families facing end-of-life issues.
Primarily used for dying patients and family members who are grieving.
Palliative care interventions focus on the relief of physical manifestations such as
pain as well as addressing spiritual, emotional, and psychosocial aspects of the
client’s life.
Palliative care may be provided by an inter professional team
Physicians, nurses, social workers, physical therapists, massage therapists,
occupational therapists, music/art therapists, touch/energy therapists, and
chaplains.
Hospice care
A comprehensive care delivery system implemented when a client is not expected
to live longer than 6 months.
Further medical care aimed toward a cure is stopped, and the focus becomes
enhancing quality of life and supporting the client toward a peaceful and dignified
death.
Promote continuity of care and communication by limiting assigned staff changes.
Assist the client and family to set priorities for end-of-life care.
Physical Care
Give priority to controlling clinical findings.
Administer medications that manage pain, air hunger, and anxiety.
Perform ongoing assessment to determine the effectiveness of treatment and the
need for modifications of the treatment plan, such as lower or higher doses of
medications.
Manage adverse effects of medications. Reposition the client to maintain airway
patency and comfort.
Maintain the integrity of skin and mucous membranes.
Signs of nearing death
 406
AppleRN Classes

Coolness and paleness or mottling of the extremities

A slack, relaxed jaw and open mouth from loss of facial muscle tone
Difficulty in maintaining body posture or positions
Eyelids half-open
Cheyne-Stokes or uneven respirations with periods of apnea
Urine output usually decreases and darkens (concentrated) from dehydration as
the client nears death.
Nursing Responsibility
Therapeutic communication. Respect culture and religion
Provide an environment that promotes dignity and self-esteem.
Use of relaxation techniques- breathing, music
Promote decision-making in food selection, activities, and health care to give the
client as much control as possible.
Allow patient to control own ADL as much as possible
Support family in grieving process.
Cognitive Disorder
Cognitive disorders are a group of conditions characterized by the disruption of
thinking, memory, processing, and problem solving.
Two types: Delirium and Neurocognitive Disorder (includes Alzheimer’s disease)
Cause Delirium: secondary to another medical condition, such as infection,
substance use
Cognitive deficits are not related to another mental health disorder.
But can be related to Alzheimer’s disease, Traumatic brain injury, Parkinson’s
disease and Other disorders affecting the neurological system
Defense Mechanisms Used in Cognitive Disorders
 407
AppleRN Classes

Denial : Both the client and family members may refuse to believe that changes,
such as loss of memory, are taking place, even when those changes are obvious to
others.
Confabulation : The client may make up stories when questioned about events or
activities that she does not remember. This may seem like lying, but it is actually
an unconscious attempt to save self-esteem and prevent admitting that she does
not remember the occasion.
Perseveration : The client avoids answering questions by repeating phrases or
behavior. This is another unconscious attempt to maintain self-esteem when
memory has failed.
Nursing Care
Assign the client to a room close to the nurse’s station for close observation.
Provide a room with a low level of visual and auditory stimuli.
Provide for a well-lit environment, minimizing contrasts and shadows.
Have the client sit in a room with windows to help with time orientation.
Have the client wear an identification bracelet; use monitors and bed alarm
devices as needed.
Use restraints only as an intervention of last resort.
Monitor client’s level of comfort and assess for non-verbal indications of
discomfort.
Use caution when administering medications PRN for agitation or anxiety.
Assess client’s risk for injury and ensure safety in the physical environment, such
as a lowered bed and removal of scatter rugs to prevent falls.
Provide compensatory memory aids, such as clocks, calendars, photographs,
memorabilia,
seasonal decorations, and familiar objects. Reorient as necessary.
Provide eyeglasses and assistive hearing devices as needed.
Keep a consistent daily routine. Maintain consistent caregivers.
 408
AppleRN Classes

Ensure adequate food and fluid intake. Allow for safe pacing and wandering.
Cover or remove mirrors to decrease fear and agitation.
Communication
Communicate in a calm, reassuring tone.
Speak in positive rather than negatively worded phrases. Do not argue or
question hallucinations or delusions.
Reinforce reality. Reinforce orientation to time, place, and person.
Introduce self to client with each new contact.
Establish eye contact and use short, simple sentences when speaking to the client.
Focus on one item of information at a time.
Encourage reminiscence about happy times; talk about familiar things.
Break instructions and activities into short timeframes.
Limit the number of choices when dressing or eating.
Minimize the need for decision making and abstract thinking to avoid frustration.
Avoid confrontation. Encourage family visitation as appropriate.
Medications
donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne)
Avoid NSAIDs with these meds (GI Bleed)
Nausea and diarrhea, which occur in approximately 10% of clients
Monitor for gastrointestinal adverse effects and for fluid volume deficits.
Promote adequate fluid intake.
Bradycardia : Teach the family to monitor pulse rate for the client who lives at
home
Screen for underlying heart disease
memantine (Namenda) : the only medication approved for moderate to severe
stages of Alzheimer’s disease.
 409
AppleRN Classes

S/E : dizziness, headache, confusion, and constipation.

Home safety measures - same as Alzheimer’s disease
Clients experience loss in many aspects of their lives:
Actual and Perceived loss
Grief is the inner emotional response to loss and is exhibited in as many ways as
there are individuals.

Theories of Grief
Denial – The client has difficulty believing a terminal diagnosis or loss.
Anger – The client lashes out at other people or things.
Bargaining – The client negotiates for more time or a cure.
Depression – The client is overwhelmingly saddened over the inability to change
the situation.
Acceptance – The client acknowledges what is happening and plans for the future.
Stages may not be experienced in order, and the length of each stage varies from
person to person.
Nursing Interventions : Facilitate Mourning
Grant time for the grieving process.
Identify expected grieving behaviors, such as crying, somatic manifestations, and
anxiety.
Use therapeutic communication.
Name the emotion the client is feeling. For example, the nurse can say, “You
sound as though you are angry. Anger is a normal feeling for someone who has
lost a loved one. Tell me about how you are feeling.”
Communication Tips
Avoid communication that inhibits the open expression of feelings:
Avoid offering false reassurance, Do not give advice
 410
AppleRN Classes

Do not change the subject. Avoid taking the focus away from the grieving
individual.
Nursing Intervention
Assist the grieving individual to accept the reality of the loss and take forwards
steps.
Provide continuing support; encourage the support of family and friends.
Assess for evidence of ineffective coping, such as refusing to leave the home
months after the client’s spouse died.
Resources: Share information, support groups, Spiritual Advisor
Victim Abuse and Nursing Care
Age-Specific Assessments
Infants
Shaken baby syndrome – Shaking may cause intracranial hemorrhage.
Assess for respiratory distress, bulging fontanelles, and an increase in head
circumference.
Retinal hemorrhage may be present.
Any bruising on an infant before age 6 months is suspicious.
Preschoolers to adolescents
Assess for unusual bruising, such as on abdomen, back, or buttocks.
Bruising is common on arms and legs in these age groups.
Assess the mechanism of injury, which may not be congruent with the physical
appearance of the injury.
Numerous bruises at different stages of healing may indicate ongoing beatings.
Be suspicious of bruises or welts that resemble the shape of a belt buckle or other
object.
 411
AppleRN Classes

Assess for burns. Burns covering “glove” or “stocking” areas of the hands or feet
may indicate forced immersion into boiling water.
Small, round burns may be from lit cigarettes.
Assess for fractures with unusual features, such as forearm spiral fractures, which
could be a result of twisting the extremity forcefully.
The presence of multiple fractures is suspicious.
Assess for human bite marks.
Assess for head injuries – level of consciousness, equal and reactive pupils, and
nausea or vomiting
Older and other vulnerable adults
Assess for any bruises, lacerations, abrasions, or fractures in which the physical
appearance does not match the history or mechanism of injury.
Patient-Centered Care
Priority must be placed on ascertaining whether the person is in any immediate
danger.
Mandatory reporting of suspected or actual cases of child or vulnerable adult
abuse.
Complete and accurate documentation of subjective and objective data obtained
during assessment.
Self Check by Nurses:
The nurse must work through personal fears and prejudices in order to be an
advocate and to effectively identify and interact therapeutically with victims of
physical violence.
Nursing Care_Abused clients
Conduct a nursing history.
Provide privacy when conducting interviews about family abuse.
Be direct, honest, and professional.
 412
AppleRN Classes

Use language the client understands.

Be understanding and attentive.
Use therapeutic techniques that demonstrate understanding.
Use open-ended questions to elicit descriptive responses.
Inform the client if a referral must be made to child or adult protective services.
And, be sure to explain the process.

Anxiety Meds -
Sedative Hypnotic
Anxiolytic :
Benzodiazepine
Name Action Side Effect Nursing Role
alprazolam (Xanax), Anti anxiety CNS depression, Advise clients to
Diazepam (Valium), (sedation,lightheadedness observe for CNS
Lorazepam (Ativan), , ataxia, decreased depression. Instruct
Chlordiazepoxide cognitive function) the client to notify
(Librium), Clorazepate the provider if effects
(Tranxene), Oxazepam occur. ›› Advise
(Serax), Clonazepam clients to avoid
(Klonopin) hazardous activities
(driving,operating
heavy
equipment/machiner
y).
Anterograde amnesia Advise clients to
(difficulty recalling events observe for
that occur after dosing) manifestations.
Instruct clients to
notify the provider if
effects occur.
 413
AppleRN Classes

Diazepam is Acute toxicity, Oral For oral toxicity,

contraindicated in toxicity (drowsiness, gastric lavage can be
clients who have lethargy, confusion),IV used,followed by the
sleep apnea, toxicity (may lead to administration of
respiratory respiratory depression, activated charcoal or
depression and/or severe hypotension, or saline. For IV toxicity,
glaucoma cardiac/respiratory arrest) administer flumazenil
(Romazicon) to
counteract sedation
and reverse adverse
effects.Monitor the
client’s vital signs,
maintain patent
airway, and provide
fluids to maintain
blood pressure. Have
resuscitation
equipment available.
Use diazepam Manifestations of Advise clients that
cautiously in clients withdrawal include withdrawal effects
who have liver anxiety, insomnia, are not common with
disease diaphoresis, tremors,ight- short-term use.Advise
headedness. clients who have
been taking diazepam
regularly and in high
doses to taper the
dose over several
weeks
Nonbarbiturate
Anxiolytic
buspirone (BuSpar) Dependency is less Dizziness, nausea, Buspirone is
likely headache,lightheadednes contraindicated for
s, agitation concurrent use with
MAOI antidepressants
or for 14 days after
MAOIs are
discontinued.
Hypertensive crisis
may result.
Advise the client to take Take the medication
with food to decrease with meals to prevent
nausea, Instruct client gastric irritation. It
that most adverse effects may take a week to
are self-limiting. notice the first
therapeutic effects
and 3 to 6 weeks for
the full benefit.
Medication should be
 414
AppleRN Classes

taken on a regular
basis and not PRN.

Selective Serotonin
Reuptake Inhibitors
(SSRI Antidepressant
s)
Paroxetine (Paxil), Paroxetine is Early adverse effects (first Instruct clients to
Sertraline (Zoloft), contraindicated in few days/weeks):nausea, report adverse effects
Escitalopram (Lexapro), clients taking MAOIs diaphoresis, tremor, to the provider.
Fluoxetine (Prozac), or a TCA fatigue, drowsiness Instruct clients to
Fluvoxamine (Luvox) take the medication
as prescribed. Advise
clients that these
effects should soon
subside.
Use paroxetine Serotonin syndrome. Watch for and advise
cautiously in clients Agitation, confusion, clients to report any
who have liver and disorientation, difficulty of these
renal dysfunction, concentrating, anxiety, manifestations, which
seizure disorders, or hallucinations,hyperreflex could indicate a lethal
a history of GI ia, incoordination, problem. Usually
bleeding. tremors, fever, begins 2 to 72 hr after
diaphoresis initiation of
treatment. Resolves
when the medication
is discontinued
Later adverse effects Bruxism: grinding and Use a mouth guard
(after 5 to 6 weeks of clenching of teeth (sleep). during sleep.Switch
therapy): sexual Withdrawal syndrome the client to another
dysfunction, Weight class of medication.
gain, GI bleeding, Sleep disturbances
Hyponatremia are minimized by
taking med in
morning. Do not
discontinue use
abruptly
Atypical
Antidepressants
 415
AppleRN Classes

bupropion HCL treat Depression, Aid Headache, dry mouth, GI Advise clients to
(Wellbutrin) to quit smoking distress, constipation, observe for effects
increased heart rate, and to notify the dr.,
nausea, restlessness, and Treat headache with
insomnia,Seizures mild analgesic,sip on
fluids to treat dry
mouth,increase
dietary fiber to
prevent
constipation.Monitor
clients for seizures,
and treat accordingly
Other Atypical
Antidepressants
Venlafaxine (Effexor), headache, nausea, Monitor sodium level,
duloxetine (Cymbalta) agitation, anxiety,sleep Monitor for increase
disturbances, in diastolic pressure.
hyponatremia
Mirtazapine (Remeron) sleepiness, weight gain,
high cholesterol

Reboxetine (Edronax) dry mouth, decreased Donot use with MAOI.

blood pressure,
constipation, sexual
dysfunction, and urinary
hesitancy or retention,
Sedation
Tricyclic
Antidepressants
(TCAs)
Amitriptyline (Elavil), Use cautiously in Orthostatic hypotension, Instruct clients about
Imipramine (Tofranil) clients who have Sedation the effects of postural
Doxepin (Sinequan) coronary artery hypotension,
Nortriptyline (Aventyl) disease; diabetes, (lightheadedness,
Amoxapine (Asendin) liver, kidney, and dizziness). If these
Trimipramine respiratory disorders; occur, advise the
(Surmontil) urinary retention and client to sit or lie
obstruction; angle- down. Orthostatic
closure glaucoma; hypotension is
benign prostatic minimized by
hyperplasia; and changing positions
hyperthyroidism. slowly. Monitor blood
pressure and heart
rate for clients in the
hospital for
orthostatic changes
before administration
 416
AppleRN Classes

and 1 hr after. If a
significant decrease in
blood pressure
and/or increase in
heart rate is noted,
do not administer the
medication, and
notify the provider

contraindicated in Anticholinergic effects, Instruct clients on

clients who have »»Dry mouth ways to minimize
seizure disorders. »»Blurred vision anticholinergic
»»Photophobia effects. Chewing
»»Urinary hesitancy or sugarless gum
retention »»Sipping on water
»»Constipation »»Wearing sunglasses
»»Tachycardia when outdoors
»»Eating foods high in
fiber
»»Participating in
regular exercise
»»Increasing fluid
intake to at least 2 to
3 L a day from
beverages and food
sources
»»Voiding just before
taking medication
›› Advise the client to
notify the provider if
effects persist.
Monoamine Oxidase These medications Toxicity (restlessness, Obtain clients’
Inhibitors (MAOIs) block MAO in the anxiety, insomnia, baseline ECG.Monitor
brain, thereby Dizziness, hypertension, vital signs frequently.
increasing the dysrhythmias, ››Monitor clients for
amount of mental confusion, and signs of toxicity.
norepinephrine, agitation, followed by ›› Notify the provider
dopamine, and seizures, if signs of toxicity
serotonin available coma, and possible death) occur.
for transmission of
impulses. An
increased amount of
these
neurotransmitters at
 417
AppleRN Classes

nerve endings
intensifies responses
and relieves
depression.

phenelzine (Nardil), These medications CNS stimulation (anxiety, Advise clients to

Isocarboxazid are contraindicated agitation, mania, or observe for effects
(Marplan), in clients taking SSRIs hypomania), Orthostatic and notify the
Tranylcypromine and in those who hypotension provider if they occur.
(Parnate), Selegiline have
(Emsam) – transdermal pheochromocytoma,
MAOI heart failure,
cardiovascular and
cerebral vascular
disease, and severe
renal insufficiency
Assist with Hypertensive crisis Administer
medication regimen resulting from intake of phentolamine
adherence by dietary tyramine›› Severe (Regitine) IV, arapid-
informing clients that hypertension occurs as a acting alpha-
it can take 1 to 3 result of intensive adrenergic blocker
weeks to vasoconstriction and ornifedipine
beginexperiencing stimulation of the heart.›› (Procardia) SL.››
therapeutic effects. Clients will most likely Provide continuous
Full therapeutic experience headache, cardiac monitoring
effects may take 2 to nausea, and increased andrespiratory
3 months. heart rate and blood support as indicated.
pressure.
Local rash may occur with Choose a clean, dry
transdermal preparation. area for each
application.
›› Apply a topical
glucocorticoid on the
affected area.
Mood Stabilizer
lithium carbonate Can be used in Gastrointestinal (GI) Advise clients that
Bipolar, Alcohol use distress effects are usually
disorder, Bulimia (nausea, diarrhea, transient.
nervosa, Psychotic abdominal pain) ›› Administer
disorders medication with
meals or milk.
 418
AppleRN Classes

Monitor plasma lithium Lithium toxicity:Early Fine hand tremors that ›› Administer beta-
levels while undergoing indications: Less can adrenergic blocking
treatment. than interfere with purposeful agents such as
1.5 mEq/L : Diarrhea, motor propranolol
nausea, vomiting, skills and can be (Inderal).
thirst, polyuria, exacerbated by ›› Adjust to lowest
muscle factors such as stress and possible dosage, give
weakness, fine hand caffeine in divided doses, or
tremor, use
slurred speech long-acting
formulations.
›› Advise clients to
report an increase in
tremors.
Advanced Polyuria, mild thirst Use a potassium-
indications: 1.5 to sparing diuretic, such
2.0 mEq/L, Ongoing as spironolactone
gastrointestinal (Aldactone).
distress, including ›› Instruct clients to
nausea, maintain adequate
vomiting, and fluid intake by
diarrhea; mental consuming at least
confusion; poor 2,000 to 3,000 mL of
coordination; fluid from beverages
coarse tremors: - and food sources.
Advise clients to
withhold medication
and notify
the provider
Severe toxicity : 2.0 Renal toxicity Monitor the client’s
to 2.5 mEq/L. I&O.
Extreme polyuria of ›› Adjust dosage, and
dilute urine, tinnitus, keep dose low.
blurred vision, ataxia, ›› Assess baseline
seizures, severe kidney function, and
hypotension leading monitor kidney
to coma and possibly function periodically.
death from
respiratory
complications.
Gastric lavage or
administer urea,
mannitol, or
aminophylline to
increase the rate of
excretion.
 419
AppleRN Classes

Greater than Goiter and Monitor thyroid

2.5 mEq/L, Rapid hypothyroidism with function
progression of long-term treatment
symptoms leading to
coma
and death, Need
Hemodialysis
Mood-Stabilizing
Antiepileptic Drugs
(AEDs)
Carbamazepine Advise clients to nystagmus, double vision, Administer low doses
(Tegretol, Equetro) avoid use in vertigo, staggering gait, initially, then
pregnancy. headache gradually increase
Carbamazepine is dosage.
contraindicated in ›› Advise clients that
clients who have CNS effects should
bone marrow subside within a
suppression or few weeks.
bleeding disorders. ›› Administer dose at
bedtime.
Monitor serum Blood dyscrasias Obtain the client’s
sodium. (leukopenia, anemia, baseline CBC and
››Monitor the client thrombocytopenia) platelets, and
for edema, decrease perform
in urine output, ongoing monitoring.
and hypertension. ››Observe the client
for indications of
bruising and bleeding
of gums.
››Monitor the client
for sore throat,
fatigue, or other
indications
of infection.
Grapefruit juice Skin disorders (dermatitis, Treat mild reactions
inhibits metabolism, rash, with anti-
thus Stevens-Johnson inflammatory or
increasing syndrome) antihistamine
carbamazepine medications.
levels. ›› Advise clients to
wear sunscreen.
›› Instruct clients to
notify the provider if
Stevens-Johnson
syndrome rash occurs
and to withhold
medication.
 420
AppleRN Classes

Lamotrigine (Lamictal) double or blurred vision, Caution clients about

dizziness, headache, performing activities
nausea, and requiring
vomiting.Serious skin concentration.Instruc
rashes including Stevens- t client to withhold
Johnson syndrome medication and notify
provider if
rash occurs.
Valproic acid Valproic acid is GI effects (nausea, ›› Advise clients that
(Depakote), contraindicated in vomiting, indigestion) manifestations are
clients who have usually self-limiting.
liver disorders. ›› Advise clients to
take medication with
food or switch to
enteric-coated pills.
Advise the client to Hepatotoxicity as ›› Assess baseline
avoid use in evidenced by anorexia, liver function, and
pregnancy. nausea, vomiting, fatigue monitor liver function
abdominal pain, jaundice regularly.
›› Advise clients to
observe for
indications and to
notify the provider if
they occur.
›› Avoid using in
children younger than
2 years old.
›› Administer lowest
effective dose.
Pancreatitis as ›› Advise clients to
evidencedby nausea, observe for
vomiting, andabdominal indications and to
pain notify the
providerimmediately
if they
occur.››Monitor
amylase levels.››
Discontinue
medication if
pancreatitis develops.
Thrombocytopenia ›› Advise clients to
observe for
manifestations, such
as bruising, and to
notify
the provider if these
occur.
 421
AppleRN Classes

››Monitor the client’s

platelet counts.

Antipsychotics
chlorpromazine, Treatment of acute Extrapyramidal side Continuos
Haloperidol (Haldol), and chronic effects (EPSs): - Acute monitoring,
Fluphenazine, psychotic disorders, dystonia (severe spasms Administer the lowest
Perphenazine,Thiothixe Schizophrenia of tongue, neck, face, or dosage possible, treat
ne spectrum disorders, back), Parkinsonism, each condition in EPS
Bipolar disorders Akathisia (continuosly with respective meds.
(primarily the manic pacing and agitated), Administer
phase), Tourette’s Tardive dyskinesia anticholinergics, beta-
disorder (involuntary movements) blockers, and
benzodiazepines to
control early EPS.
Advise clients that
some therapeutic
effects may be
noticeable within a
few days, but
significant
improvement may
take 2 to 4 weeks,
and possibly several
months for full
effects.
gynecomastia, Neuroleptic malignant Stop antipsychotic
Seizures, skin effets syndrome (high-grade medication, Monitor
(photosensitivity), fever, vital signs.
Sexual dysfunction, blood pressure ›› Apply cooling
Agranulocytosis, fluctuations, blankets.Administer
dysrhythmias dysrhythmias, muscle antipyretics (aspirin,
rigidity, and LOC changes) acetaminophen).
Increase fluid intake.
›› Administer
diazepam (Valium) to
control anxiety.
Wait 2 weeks before
resuming therapy.
 422
AppleRN Classes

Anticholinergic effects »Chewing sugarless

(Dry mouth gum, Sipping water
›› Blurred vision »»Avoid hazardous
›› Photophobia activities
›› Urinary »»Wearing sunglasses
hesitancy/retention when outdoors
›› Constipation »»Eat foods high in
›› Tachycardia) fiber, Participating in
regular exercise
»»Maintaining fluid
intake of 2 to 3 L of
water each day from
food and beverage
sources
»»Voiding just before
taking medication
risperidone (Risperdal), New onset of diabetes Obtain baseline
Olanzapine (Zyprexa) mellitus or fasting blood glucose
◯◯ Quetiapine loss of glucose control in and monitor
(Seroquel) clients who have diabetes, throughout
◯◯ Aripiprazole Weight gain, treatment.
(Abilify) Hypercholesterolemia, ›› Instruct client to
◯◯ Ziprasidone Orthostatic hypotension, report indications
(Geodon) Anticholinergic effects (increased thirst,
◯◯ Clozapine such as urinary urination, and
(Clozaril) hesitancy or retention, appetite. Monitor
◯◯ Asenapine dry mouth, Mild EPS, such cholesterol,
(Saphris) as tremor, Agitation, triglycerides.
◯◯ Lurasidone dizziness, sedation, and
(Latuda) sleep disruption
◯◯ Paliperidone
(Invega)
◯◯ Iloperidone
(Fanapt)
 423
AppleRN Classes

CONCEPT: Nutrition and Diet

High-fiber diet Protein-restricted diet

Healthy diet – variety of nutrients
Consists of fruits and vegetables
Used to treat renal and liver disease
Minimize salt, sugar and saturated and whole-grain products
fat The less protein allowed in the diet,
Increase fiber gradually, provide the more important that protein in
BMI and weight management adequate fluids the diet be of high biological value
Overall indicator of nutritional Cardiac diet (all essential amino acids)
level – Albumin
Restrict saturated fat, trans-fat, Potassium-modified diet
Special concern – pregnancy, cholesterol, sodium Foods low in potassium include
adolescent, elderly
Fat-restricted diet applesauce, green beans, cabbage,
Clear-liquid diet lettuce, grapes, blueberries,
Restrict amount of total fat, summer squash
Intended for short-term use or as including saturated, trans-,
transition diet polyunsaturated, Foods high in potassium include
monounsaturated fats avocado, bananas, carrots, fish,
Consists of clear fluids or foods oranges, potatoes, raisins, spinach,
that are relatively transparent to High-calorie, high-protein diet strawberries, tomatoes
light, liquid at body temperature
Foods include whole milk and High-calcium diet
Foods include water, fat-free milk products, peanut butter,
broth, bouillon, clear carbonated nuts, seeds, beef, chicken, fish, Lactose-intolerant clients should
beverages, gelatin, hard candy, pork, eggs, sugar, cream, incorporate nondairy sources of
lemonade, frozen fruit bars, mayonnaise, milkshakes, calcium in their diet regularly
diluted juices, regular or nutritional supplements
decaffeinated coffee or tea
Low-purine diet
Carbohydrate-consistent diet Restrict such foods as anchovies,
Mechanically altered diet
Used in management of diabetes herring, mackerel, sardines,
Foods to be avoided include nuts, mellitus, hypoglycemia, lactose glandular meats, gravies, meat
dried fruits, raw fruits and intolerance, galactosemia, extracts, goose
vegetables, fried foods, chocolate dumping syndrome, obesity
products, smoked or salted meats,
High-iron diet
foods with coarse textures Sodium-restricted diet Foods include organ meats, egg
Used to treat hypertension, yolks, whole-wheat products, green
Soft diet :Avoid foods that contain
congestive heart failure, cardiac leafy vegetables, dried fruits
seeds or nuts
and liver disease Enteral Nutrition
Low-residue, low-fiber diet
Encourage intake of fresh rather Monitor weight, labs (metabolic
Foods include white bread, than processed foods issues), Check tube placement,
refined cooked cereals, cooked check residual
potatoes without skins, white rice, Avoid canned, boxed,
refined pasta microwaved foods Intake and output, Flush tube with
water before an after (prevent
Avoid raw fruits, vegetables, nuts, Renal diet
dehydration)
seeds, plant fiber, whole grains Used to treat acute renal failure,
chronic renal failure HOB 30 degree
 424
AppleRN Classes

CONCEPT: TPN

Pre TPN Consideration Presence of oily appearance

Parenteral Nutrition
or a layer of fat on top of
Supplies all necessary Review the client’s medical the solution – DONOT USE
nutrients via veins record. TPN also includes
administration of lipids (egg The bag and tubing should
Indications allergy) be changed every 24 hr.
New tubing is used with
Severe dysfunctional or Document patient’s weight (daily), every bag.
nonfunctional BMI, nutritional status, diagnosis,
gastrointestinal (GI) tract, or and current laboratory data. Discontinuation should be
unable to process nutrients done gradually. Use D10W
Blood test :- serum chemistry if there is discontinuation.
Limited oral intake profile, PT/aPTT, iron, total iron-
AIDS, cancer, burn injuries,
binding capacity, lipid profile, liver Complications
function tests, electrolyte panel,
malnutrition, or receiving Air embolism,
BUN, prealbumin and albumin
chemotherapy Hypervolumea
level, creatinine, blood glucose,
Components and platelet count. Hyperglycemia
Carbohydrates : Mainly in the Use IV pump and special filter for
Monitor blood glucose
form of glucose; ranges from administering TPN solution.
levels every 4 to 6 hours
5% glucose solution for
No additives to solution
peripheral parenteral Administer regular insulin
nutrition to 50% to 70% Ongoing Care as prescribed
glucose solution for TPN
I&O, daily weights, vital signs Infection
Amino acids, Vitamins,
Minerals and trace elements, Lab values (e.g., serum Pneumothorax – catheter
Water electrolytes, blood glucose) correct place
Electrolytes: sodium, ongoing evaluation of the client’s
potassium, magnesium, underlying condition. This data is
calcium used to determine the client’s
response to therapy.
Insulin, Heparin : May be
added to reduce buildup of Monitor serum and urine glucose
fibrinous clot at catheter tip – insulin sliding scale

Fat emulsion (lipids) : Most

fat emulsions prepared from
soybean or safflower oil, with
egg yolk for emulsification
 425
AppleRN Classes

Test Taking Strategies

Don’t overthink
Focus only on what the question is asking.
Look for the strategic words
Use the process of elimination
Positive Vs Negative (good or bad)
Expected abnormal Vs Unexpected abnormal
Acute Vs Chronic
Actual vs Potential
• Prioritize using the ABCDs —airway, breathing, and circulation, Disability
• A severe circulation problem -priority over a minor breathing problem.
• Systemic issues Vs Local issues (Hypotension is priority than leg pain)
• Prioritize using Maslow’s Hierarchy of Needs theory. (learn the order- see
the picture)
• Prioritize using the steps of the nursing process. (Assessment always comes
first in nursing process)
• Steps of physical examination – Inspection, Palpation, Percussion,
Auscultation
 426
AppleRN Classes

• Hands are always washed first!

• Treatments/procedures are always explained before implementation!
• You will check for an informed consent before any invasive procedure!
• Documenting a client’s condition and treatment response is done after care
and implementation of treatments!
 427
AppleRN Classes

Medication Calculation
Standard conversion factors
1 mg = 1,000 mcg
1 g = 1,000 mg
1 kg = 1,000 g
1 oz = 30 mL
1 L = 1,000 mL
1 tsp = 5 mL
1 tbsp = 15 mL
1 tbsp = 3 tsp
1 kg = 2.2 lb (pounds)
1 gr = 60 mg
1 million = 1,000,000 (10 lacs)
General Rounding Guidelines
Rounding up: If the number to the right is equal to or greater than 5, round up by
adding 1 to the number on the left.
Example : 5.6 = 6
Rounding down: If the number to the right is less than 5, round down by dropping
the number, leaving the number to the left as is.
Example : 5.4 = 5
For dosages less than 1.0, round to the nearest hundredth.
For example (rounding up): 0.746 mL = 0.75 mL.
(rounding down):- 0.743 mL = 0.74 mL
For dosages greater than 1.0, round to the nearest tenth.
1.38 = 1.4
 428
AppleRN Classes

1.34 mL = 1.3 mL.

Med Calc
What is the dose needed?
Dose needed = Desired
What is the dose available?
Dose available = Have.
What is the quantity of the dose available?
Quantity
Do conversions if needed(gm/mg/cap/lb/kg)
Use Equation.

IV Flow rate Calculations

Using an IV pump.

Formula

Look for need of conversion (mt to hr, hr to day)

Drop factor (Manual) : the number of drops that fall into the drip chamber over
the period of 1 min.
IV flow rates
 429
AppleRN Classes

Pharmacology
Have a complete order.
Check allergies (including Latex, food, contrast media)
Assessment first- implementation later
Notify Physician and clarify if there is a questionable order
6 R’s – calculate dose accurately
Right Patient, Dose, Medicine, Time, Route, Documentation
Do not use unlabeled medicine
Discard any partially used single dose containers. Label the multi dose vials with
date, time, initial and expiration date.
Patient education!!!
 430
AppleRN Classes

Tips

› Dialysis – Hold blood pressure meds

› Pediatric liquid medications are often dispensed with a measuring device

designed to administer the exact dose prescribed (Avoid using spoons)

› Therapeutic level is expected range- might be more than normal (warfarin

– INR) – beware of herbal meds

› Check apical pulse before giving digoxin. Hold for bradycardia

› Peak and Trough (Vancomycin: therapeutic range =10-20 mg/L)

› Hyperkalemia- Might get IV insulin. (Without the insulin, the potassium

cannot enter the cells and more of the potassium is allowed to float around
in the blood)
 431
AppleRN Classes

Patient-controlled analgesia (PCA)

PCA delivers a set amount of IV analgesic each time the client presses the
administration button.
With many PCA pumps, a continuous IV solution (eg, normal saline) is required
to keep the vein open and flush the PCA medication through the line so that the
boluses reach the client.
Two nurses need to witness when initiating PCA, changing Medication/ syringe,
and when discontinuing PCA.
Herbal Meds

› Garlic, ginkgo biloba, and vitamin E may interfere with platelet aggregation
and increase the risk for bleeding in clients who are taking warfarin, which
is an anticoagulant medication.

› St John's wort – use for depression and insomnia- Risk for Hypertensive
crisis

› Licorice –to treat Stomach ulcers – Risk for Hypertension, Hypokalemia

› Echinacea-Treatment & prevention of cold & flu- Risk for Anaphylaxis

(more likely in asthmatics)
Points to remember _ central venous catheters

› Patency maintained by flushing with diluted heparin solution or normal

saline, depending on type of catheter and agency policy.

› Upper body central lines are preferred- less chance of contamination

(urine, stool)

› Sterile technique – dressing change, removal

Discontinuing a central venous catheter
Instruct the client to lie in a supine position.
This will increase the central venous pressure and decrease the possibility of air
getting into the vessel.
 432
AppleRN Classes

Instruct the client to bear down or exhale.

The client should never inhale during removal of the line; inhalation will suck
more air into the blood vessel via negative suction pressure.
Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help
prevent a delayed air embolism. If possible, the nurse should attempt to cover
the site with the occlusive dressing while pulling out the line.
Pull the line cautiously and never pull harder if there is resistance.
Doing so could cause the catheter to break or become dislodged in the client's
vessel
Z track Injection

› Using the non-dominant hand to move and to hold the skin and
subcutaneous tissue.

› Dart the syringe rapidly into the displaced skin at a 90 degree angle.

› Aspirate on the syringe to be sure that a blood vessel has not been
penetrated. Inject the medication slowly into the muscle.

› Continue holding the displaced skin and tissue until after the needle is
removed.

› Upon withdrawal of the syringe, immediately release the skin and

subcutaneous tissue.

› Do not massage the site. Do not let patient wear any tight fitting cloths at
the injection site.
 433
AppleRN Classes

CBC ABG ELECTROLYTE

Platelet 150,000 to PH 7.35 -7.45 SODIUM 135- 145
400,000 mm3
Hb Female 12 to 16 HCO3 22- 28 POTASSIUM 3.5-5.0
g/dL; male 14 to
18 g/dL.
Hct female 37 to 47%; PCO2 35-45 CALCIUM 8.6- 10.2
male 42 to 52%.
RBC Female 4.2 to PO2 80-100 MAGNESIUM 1.3 -2.1
5.4 million/uL; mmHg
male 4.7 to
6.1 million/uL
WBC 4,000 to SAO2 > 95% IRON Females: 60 to 160
mcg/dL
11,000/mm3. Males: 80 to 180
mcg/dL
Platelet 150,000- CHLORIDE 98 - 106
400,000 u/l
PT 11 THYROID PHOSPHORUS 3 -4.5
to 12.5 sec
PTT 1.5 to 2 times TSH 0.4- 4.2 mU/L GLUCOSE FBS 70-110
normal range
of 30 to 40 seconds
(desired
range for
anticoagulation)
INR INR 0.7 to 1.8.- T3 0.6 – 3.14 Hba1c Less than 6.5
normal.
2 to 3 on warfarin nmol/L (Glycosylated Hb)
(Coumadin)
therapy
FIBRINOGEN 200 to 400 mg/dL T4 4.6- 11 POST PRANDIAL Less than 140
mcg/dl
CLOTTING TIME 4-10 mts LIVER FUNCTION LIPIDS
BLEEDING TIME 2-7 mts TOTAL BILIRUBIN 0.2 – 1.2 HDL >50 mg/dl
mg/dl
ESR Less than 30 DIRECT BILI 0.1 – 0.3 LDL 100 or less
mg/dl
RENAL INDIRECT BILI 0.1- 1 mg/dl TOTAL <200 mg/dl
CHOLESTEROL
URIC ACID F: 2.3 – 6.6 Alk. Phosphatase 38-126 U/L TRIGLYCERIDE <150 mg/dl
M: 4.4 – 7.6
BUN 6-20 AST 10-30 U/L D Dimer 0.43 to 2.33 mcg/mL
0 to 250 ng/mL
CREATININE 0.6 to 1.3 mg/dl ALT 10-40 U/L BNP 100 or less
AMONIA GGT 0-30 U/L CK 20 -200 U/L
URINE SPECIFIC 1.003 – 1.030 Ammonia 11 to 32 μmol/L

GRAVITY
GFR 90-130 PANCREAS
URINE PH 4-8 AMYLASE 30-122 U/L
URINE OSMOLARITY 300-1300 LIPASE 31- 186 U/L
 434
AppleRN Classes

Good Luck with your Exam!

For further studies and courses please visit www.AppleRN.com or contact any of
our associates at
+1 832-692-1560
+91 953-930-5316
+91 940-019-2615
+91 884-815-0685
+91 730-680-7662
(WhatsApp available on all numbers)

Other resources
https://www.youtube.com/learnnursinginternational
https://www.facebook.com/AppleRNClasses