A: Monogomous relationship
Test taking strategies:
1. Process of elimination:
2 correct answers, 2 incorrect answers
Q: For 1st/2nd/3rd/4th degree burns, nursing priority?
A: #1 INFECTION
#2 Dependent on the type of burn
1st & 2nd degree = PAIN
3rd & 4th degree = FLUID & ELECTROLYTE
NERVOUS SYSTEM
A. 3 DIVISIONS OF N/S
1. CNS
a. Brain
b. Spinal Cord H-shaped structure
2. Peripheral N/S (12 pairs of Cranial nerves)
I Olfactory
II Optic
III Occulomotor
IV Trochlear smallest CN
V Trigeminal largest CN
VI Abducen
VII Facial
VIII Acoustic
IX- Glossalpharyngeal
X Vagus longest CN
XI Spinal
XII Hypoglossal
3. Autonomic N/S
a. Symphatetic N/S
b. Parasymphatetic N/S
SYMPHATETIC (SNS)
FIGHT or Aggression Response
NOREPINEPHRINE @ Adrenal
Medulla
Adrenalins
VASOCONSTRICTOR
All bodily activities except
GIT - Constipation
ADRENERGIC or
Parasympatholytic response
When under STRESS,blood flows
to 3 important organs:
PARASYMPHATETIC (PNS)
FLIGHT or withdrawal response
ACETHYLCHOLINE
neurotransmitter
[ Acethylcholine = Bipolar
Disorder = Lithium
Acethylcholine = M.Gravies]
All bodily activities except
GIT - Diarrhea
CHOLINERGIC or Vagal or
Sympathetic response
#1 Brain - cerebration = to
think
#2 Heart propel blood to
systemic circulation
#3 Skeletal muscles
GIT = least important organ
blood flow
motility
CONSTIPATION
SYMPHATETIC (SNS)
Bodily
1. Eyes DILATES
Mydriasis aware of surroundings
2. Mouth DRY
salivation
3. Heart - HR BP
4. Lungs
BRONCHODILATION
- O2 because under stress
- RR
5. GIT CONSTIPATION
6. Urinary system
- URINARY RETENTION
PARASYMPHATETIC (PNS)
effects
- CONSTRICTS
Meiosis
- MOIST
salivation
- HR BP
- BRONCHOCONSTRICTION
- O2
- RR
- DIARRHEA
- URINARY FREQUENCY
III. Anti-hypertension
1. Beta-blockers LOL
2. ACE Inhibitors PRIL ending ex: CaptoPRIL EnalaPRIL
3. Ca antagonist ex: Nifedipine
IV. Mestinon (Prostigmine)
nice to know:
COPD
1. Bronchitis
2. Asthma
3. Bronchiectasis
4. Emphysema
- Blue bloaters,
- Allergens, Hereditary
- Pink puffer, barrel chest
capable of regeneration
with limited survival time
period
once destroyed, can not
regenerate
Location
GUT, GIT, epidermal,
respiratory cells
Kidney, Liver, Pancreas,
Salivary gland-parotid
gland
Osteocytes, retina cells,
neurons, cardiac cells
nice to know:
For shallow wound, scar suggest to give Vitamin C precursor
collagen, aid in wound healing
For stab wound apply direct pressure to stabbed area using clean
cloth -> use CTT
For artificial eyes -> dry N/R: use eye drops q30mins
paralysis
L/R paralysis
4 limbs paralysis
1 limb paralysis
low extremities, with urinary & bowel
incontinence -> relaxed bladder ->atony
bladder -> urine retention N/R: assist in
catheterization
There is no upper extremities paralysis
B. Neuroglia = acts as support and protection of neurons
majority of brain tumors arises from Neuroglia
1. Types:
a. ASTROCYTES outer surface, 90% astrocytoma -> brain
tumor
o maintains the integrity of the blood brain barrier
o semi-permeable membrane
o selective toxic substances can enter:
1) Ammonia = cerebral toxin, 1st toxic substance in the
brain
Ammonia
2. Confusion
3. Fetor hepaticus
4. LOC leads to hepatic coma
weight loss
fat catabolism
headache
Cholesterol
Ketones
Liver
converts ammonia
Urea
Urine
2) Bilirubin 2nd toxic substance yellow pigment irritant
to neurons
Bilirubin
Jaundice=icteric sclerae
Hyperbilirubenemia/Kernicterus
1.
2.
3.
4.
5.
MACROPHAGES
Microglia
Monocytes largest WBC
Kupffer macrophages
Alveolar macrophages
Histocytes
defense of CNS
Bacteria
Disease:
Hepatic Encephalopathy
Parkinsons Disease
Multiple Sclerosis
PTB
Pneumonia
Emphysema
Asthma
Diphtheria
Measles
Malaria
Dengue
Typhoid fever
Cholera
Appendicitis
Pancreatitis
OB Ectopic pregnancy
Meningitis
Hypocalcemia
Tetany, tetanus
Hyperthyroidism
Hepatitis
Liver cirrhosis
Leprosy
Bulimia nervosa
Addisons disease
Cushing syndrome
Pernicious anemia
Kawasaki syndrome
Down syndrome
Patent ductus arteriosis
Tetralogy of Fallot
Tet spells
Angina pectoris
Retinal detachment
Glaucoma
Cataract
SUBARACHNOID
I.
CEREBRUM largest
a) 2 parts: Right and Left Cerebral hemisphere; CORPUS
COLLOSUM=bridge between two hemisphere
b) 3 functions: Sensory, Motor, Integrative
c) 6 LOBES:
1. FRONTAL lobe > motor activity, personality development,
controls higher cortical thinking of brain, Broccas area =
motor/speech center
2. TEMPORAL lobe > hearing, short term memory loss =
Anterograde, Wernickes area = Receptive
3. PARIETAL lobe > appreciation/discrimination of sensory
impulses: pain, touch, pressure, hot, cold -> check if with
numbness
4. OCCIPITAL lobe > vision, check if with blindness
5. INSULA or ISLET of REIM > above frontal lobe, controls visceral
function/activities of internal organs
6. LIMBIC SYSTEM > controls smell
RHINENCEPHALON ANOSMIA = absence of smell, sexual
e. Basal Ganglia > areas of Grey matter, located deep within each
cerebral hemisphere, produces dopamine = controls gross
voluntary movement
NEUROTRANSMITTER:
1. AcH
2. Dopamine
M.Gravies, Ptosis
Parkinson
Bipolar Disorder
Schizophrenia
II. DIENCEPHALON
a) HYPOTHALAMUS
> thermoregulator center
> controls BP
> controls fluids & electrolytes
> controls thirst
> controls appetite & satiety
> controls sleep & wakefulness
> controls emotional response
> controls some PITUITARY FUNCTION, ex. Adrenergic = Testoterone &
Progesterone
MENOPAUSE = 40 Female; ANDEPAUSE = Male
PONS
Pneumotaxic center
Depth of respiration
Cerebrospinal Fluid
1. Normal Amount = 120-250ml/day
Head injury/trauma
Brain compression
Brain herniation
ICP
24-48H projectile vomiting; irregular RR/HR for monitoring
2. Site of CSF production: CHOROID PLEXUS
3. Composition = Clear, glucose, colorless, protein, WBC, no
RBC
4. CSF function = shock absorber, cushions
HYDROCEPHALUS = CSF = ICP
If postetriorly = theres early closure of posterior fontanelle
Blood
Stroke = partial/total brains blood supply
Circle of Willis = smallest part of artery
Collateral Circulation 24-48H Internal carotid and Middle Cererbral
Artery
blood circulation
If with seizure = DO NOT restrain, may lead to fracture
CUSHINGs reflex = vital signs different that of ICP
b. Headache, papilledema, projectile vomiting
c. Abnormal posturing
d. Unilateral dilation of pupil UNCAL HERNIATION
e. Possible seizure
3)
4)
5)
6)
7)
Tachycardia
Bradycardia
Extreme restlessness
Dyspnea
Cyanosis
LATE
Sends impulses
Lungs
Hyperventilation to remove
CO2
tissue perfusion
LATE sign of HYPOXIA: RAT-BED-C
1) Restlessness
2) Agitation
EARLY
MS 01-21-2006
Guillain Barre Syndrome (GBS) disorder of the CNS, characterized by
symmetrical, bi lateral olineuritis, leading to ascending paralysis
Polyneuritis>Inflammation of peripheral nerves
A.
Predisposing Factors
Idiopathic
Autoimmune
Antecedent viral infxn
Immunizations (best method URTI Annual flu vaccine) too
costly, not lifetime, yearly, USA 2 doses per year for freely given.
Pneumonia (rusty sputum) vaccine every 5 yrs - esp. 65 yrs old.
Pyloric stenosis olive shaped mass.
B.
C. Diagnostic Procedures
CSF Analysis : elevated CHON and IgG, (+) Lermic sign (post
lumbar tap increased/ forced fluids) CSF opening pressure 50160mmHg. ICP =0-15mmHg
D.
1.
a.
b.
Nursing Mgmt
Maintain patent airway and ventilation
assist in mechanical ventilation
assess pulmonary function test spirometer vital lung capacity
Incentive spirometry
c. Maintain side rails due to paralysis
d. Prevent complications of immobility every 2 hours, elderly 1 hour
e. Institute NGT feeding
f. Administer medications as ordered
Anticholinergics- (Autoimmune) Give
A. Predisposing factors
Head injury secondary to birth trauma
CO poisoning antidote: Hyperbaric oxygenation to remove
carbon dioxide and monoxide poisoning decrease Oxygen
carrying capacity of hemoglobin. (Lead poisoning Calcium
Edta)
Genetics
10
11
1. Deep Sternal
Pressure/ Stimulation
2. Orbital pressure
3. Pressure on Great
toes
LIGHT
close fist form a
knuckle, press the
sternum 3 strokes
with response
Tip of Thumbs press
orbital bones above
and below eyes, 3x,
with response
Press great toes 3x
with response
DEEP
without response
after 3 strokes
without response
after 3 storkes
without response
4. Corneal/ Blinking
Pass the cotton tip on Drop saline soln
Reflex Conscious
the eyes when
in the eyes it will
wisp of cotton hibla
looking straight to
blink even closed
dulo
the nurse, it will blink light coma,
Unconscious do not
if no response use cotton use one
deep
drop of saline solution
*PRECORDIAL TAP NEVER USED IN THE HOSPITAL causes:
fracture ribs, collapse lungs
*do not do CORNEAL PRESSURE may lead to corneal pressure,
cornea punit may lead to blindness
3 DEEP COMA
B. Comprehensive Neurological Exam
1. Survey of Mental Status and Speech
>> LOC
>> Test of memory
2. Levels of Orientation
3. Cranial Nerve Assessment
12 Vagus longest
Trigeminal largest
Trochlear - smalles
4. Motor Assessment
Movement of larger muscle
0 no movement plegia
1 smaller muscle
2
34
55. Sensory Assessment
6. Cerebellar Test Romberg Test Finger to nose Test (+)
Dymetria
7. DTRs
8. Autonomics
Test of memory
Short term memory what did you take this morning for breakfast
Anterograde TEMPORAL lobe affected
12
CN II - OPTIC NERVE
>> Sensory Vision
>> Tests:
Test of Visual Acuity/Central or Distance Vision. Materials used:
Snellens Chart 1) Snellens Alphabet Chart used for literate client
who can read 2) Snellens E chart used for illiterate who can
not read 3) Snellens Animal Chart used for pediatric clients,
children have shorter attention span
1.
Findings: 20/20
2.
Numerator FIXED CONSTANT indicates distance of
the person to the snellens chart 20 feet or 6-7
meters
3.
Denominator indicates the distance by which the
person can normally see the letters in the chart
4.
OD oculodexter ; right OS oculosinister left OU both
eyes, small letters od once a day
5.
ABNORMAL FINDING: 20/200 indicates blindness can
not read the letter E
6.
NORMAL FINDINGS: 20/20 - can read at least 2 letters
above the shaded red lines
7.
If the clients can still read below the shaded red lines
perfect vision
Visual Fields/Peripheral vision
Where is the examiner when testing the peripheral vision of the
client?
1.
Superiorly sa forehead
2.
Bitemporally near ears
3.
Nasally - nose
4.
Inferiorly sa baba
Instruct client to stare at the nurses forehead, occlude right eye
instruct Roxanne to count the numbers of fingers wingling, tapat fingers
on areas above.
DAMAGE in peripheral vision Nystagmus
4 COMMON DISORDERS:
1. Glaucoma increased intraocular pressure Normal=12-21mmHg
causes:
1. 40 yrs old
2. Hypertension
3. Obesity
13
4. Trauma
s/sx:
14
Surgical procedure:
1. Scleral Buckling
2. Cryosurgery cold application
3. Diathermy heat application
4. MACULAR DEGENERATION
> macula lutea yellowish spot at the center of the retina
- middle layer
Fovea centralis - site of perfect vision
Optic Disk covering of retina
Pathnognomonic signs:
Black spots
n
o
s
e
Left eye
SO
SR
MR LR
IR
IO
15
Meiners
disease
sensory
hearing loss
otitis media
Conductive
hearing loss
impacted
cerumen
Conductive
hearing loss
CN XI SPINAL/ACCESSORY
CONTROLS two muscles of
Sternocleidomastoid (neck)
Trapezius (Shoulder)
Ask client to shrug, and apply pressure, if he can not hold the pressure
paresis, or paralysis
CN XII - HYPOGLOSSAL
controls the movement of the tongue
ask client to say AHH, to protrude the tongue, should be
straight, if it deviates to left and right, theres damage to
cerebral hemisphere. Ask the client to push tongue against
his/her check he/she might have short frenum/frenulum
linguae located at the back of the tongue litid tongue-tied
bulol
TSE: spontaneous answer, dont humm, dont be nervous, use
nouns, adjectives, connecting words
16
ENDOCRINE SYSTEM
Pituitary gland main organ, (hypophysis cerebri) located at the
sella turcica at the base of the brain
master clock, master gland of the body because it secretes
hormones that controls or regulates all the metabolic fxn of the
body
thyroid
adrenal
gonads
Syndrome of
inappropriate ADH
HYPERSECRETION OF
ADH
2. Predisposing
Factors:
a. Head injury
b. Bronchogenic
cancer.(1.Lung cancer
initial: nonproductive
cough
2. Liver cancer 3.
Prostate cancer -40 4.
Testicular cancer 30,
BPH - 50)
C. Hyperplasia of
3. S/Sx:
Alcohol inhibits the
release of ADH A.
polyuria excessive
urination
B. Dehydration
- Thirst
- Agitation
-Poor skin turgor
-Dry mucous
membrane
C. weakness and
fatigue
D. Hypotension
E. Weight loss
if left untreated
F. hypovolemic shock
INITIAL: COOL
MOIST SKIN,
RESTLESSNESS LATE
SIGN: ANURIA
4. Diagnostic
procedures 1.010 to
1.030
a. Urine specific
gravity LOW
b. Serum Na 135145meq/L HIGH
5. Nursing Mgmt:
a. Forced fluids
b. Administer isotonic
soln as ordered
c. monitor VS and IO
d. Administer
medications as
ordered: Vassopressin
Pituitary gland
increased size of the
organ due to increased
number of cell
3. S/Sx:
a. Fluid retention
- Hypertension
- Weight gain
- edema
b. Water intoxication
may lead to cerebral
edema, lead to
increased ICP (N=015mmHg), may lead to
seizure activity
4. Diagnostic
Procedures:
a. Urine specific gravity
HIGH
b. Serum Na LOW
5. Nursing Mgmt.
a. Restrict fluid
b. Administer
medications as ordered
Diuretics both osmoticcerebral edema/loopedema GIVEN at AM,
10-15mins, max 6
17
IM
Petrissin
e. Prevent
complications:
Hypovolemic shock
18
ASA SE: Thrombis, dyspepsia, heart burn CI: Dengue, ulcer antiplatelet
Phenylbutazone
Cobalt
Endemic Goiter caused by goiter belt area
Sporadic Goiter caused by 2 goitrogenic food and drugs
enlarged thyroid gland
mild dysphagia
mild restlessness
Diagnostic procedures
a. Serum T3 and T4 may reveal normal and below normal
b. Thyroid scan - Enlarge thyroid gland
c. Serum TSH is INCREASED confirms presence of goiter
6. Nursing Management:
1. Administer meds as ordered
a. Iodine solution
6.
Lugols solution saturated solution of Potassium
Iodide- purple or violet administer with straw to
prevent staining of the teeth. (Drugs given with
straw: Lugols soln, Iron Tetracycline,
Nitrofurantoin (Macrodantin) urinary antiseptic
drug of choice of pyelonephritis )
2. Thyroid agents of hormones
19
i. Levothryroxine (Synthroid)
ii. Liothyronine (Cytomel)
iii. Thyroid extracts
Nsg Mgmt:
1. best taken in AM to prevent INSOMNIA
2. Monitor heart rate, most SE: Tachycardia,
palpitation hypertension, heat intolerance (due to
metabolism) SE: HYPERTHYROIDISM
3. Encourage increased intake of foods rich in iodine.
a. seaweeds
b. seafoods oyster #1, clams, crab, lobster, mababa iodine content =
SHRIMP
c. Iodized salt too salty best taken at raw, because heat destroys it.
Too much iodized salt may lead to hyperthyroidism
4. Surgical procedure: partial thyroidectomy
MS 01/22/2006
Hypothyroidism
1. Def: hypo secretion of decreased to T3 and T4
7.
Myxedema adult
8.
Cretinism children, the only endocrine disorder can
lead to mental retardation
2. Predisposing Factors:
a. Iatrogenic cause disease caused by medical intervention
surgery
(Hospital acquired infection health related infection)
b. Atrophy of the Thyroid gland due to:
I rradiation
T umor
T rauma
I nflammation
c. Iodine deficiency
d. Autoimmune Hashimotos disease
Diagnostic Procedures:
Serum T3 and T4 are normal or
Radioactive Iodine Uptake
Serum cholesterol due to weight gain
Nursing Mgmt:
Monitor VS and IO strictly
9.
Myxedema coma severe form of hypothyroidism,
characterized by:
severe hypotension
bradycardia
bradypnea
hypoventilation
hypoglycemia
hyponatremia *that may lead to progressive stupor and coma
COMA #
1. nsg management: - Assist in mechanical ventilation
2. Administer thyroid hormones
3. Forced fluids
b. Administer med as ordered
i. Levothryroxine (Synthroid)
ii. Liothyronine (Cytomel)
20
HYPERTHYROIDISM
- hyper secretion of T3 & T4
GRAVES DISEASE with Exopthalmus
- Thyrotoxicosis
Predisposing Factors:
a. Autoimmune - release of long-acting thyroid stimulator LATS
autoimmune antibodies responsible of occurrence of exopthalmus
b. Increased iodine intake
c. Hyperplasia (increase in the number of cells) of thyroid gland
Signs/Sympotms:
a. Hyperphagia increase in appetite
b. (+) weight loss T3 & T4 increase, metabolism increase
c. Moist skin
d. Diarrhea
e. Heat intolerance
f. VS -Hypertension, tachycardia, tachypnea, hyperthermia
21
a.
Acute tetany
Tingling sensation
Paresthesia
Dysphagia Anorexia
Irritability
(+) laryngospasm bronchospasm prepare trach set
(+) Trousseus sing
(+) Chevosteks sign
Complications: Arrhythmia
And Seizures
b. CHRONIC TETANY
S/Sx:
Cataract and photophobia
Loss of tooth enamel
Anorexia and general body malaise
Irritability and memory impairment
4. Diagnostic Procedures
a. Serum Ca (N=8.5-11mg/100ml)
b. Serum phosphate (N=2.5-4.5mg/100ml)
c. X-ray of long bones will show bone density
d. CT scan reveals degeneration of Basal Ganglia
5. Nursing Management:
a. Administer med as ordered
1.
Ca Gluconate IV slowly- for acute
2.
Oral calcium supplement for chronic ex. Calcium
lactate, Calcium carbonate, Calcium Gluconate
(facilitate by vitamin)
3.
Vit D sources: (Cholecalciferol) drug, diet (Calcidiol)
, sunlight (Calcitriol) (ex. Eat Cheese 5am, 7am-9am
sunlight, direct to bones)
4.
Phosphate binders - If phosphate is ex. Aluminum
hydroxide gel (Ampho-gel) antacid SE: Constipationbinds phosphate in the intestines promoting its
excretion in the urine.
b. Avoid precipitating stimulus such as bright and glaring
lights, due to photophobia result to seizure
22
c.
d.
e.
f.
g.
h.
i.
Diagnostic Procedure
Serum Ca
Serum Phosphate
Bone x-ray reveals bone demineralization
5. Nursing Management:
a. Forced fluids 2-3L due to kidney stones
b. Strain all the urine with gauze pad can filter the kidney stones
or precipitate for the laboratory for stone analysis: calcium,
uric acid
c. Provide warm sitz bath to promote comfort
d. Provide acid-ash diet cranberry, plums, grape juice, prunes,
Phils: orage-pineapple-ponkan-Vit C- acidify urine to prevent
bacterial multiplication
e. Administer med as ordered:
Narcotic analgesic respiratory depression
1.
Morphine Sulfate [antidote= Narcan, (Naloxol SE:
Tremors)]
2.
Demerol
f. Maintain side rails
g. Supervise/ Assist in ambulation
h. Diet: lean meat Phosphate Calcium
i. Assist in surgical procedure = Parathyroidectomy
j. Hormonal replacement for lifetime
k. Follow up care
l. Prevent complications: kidney stones ischemia death of
kidneys may lead to RENAL FAILURE
ADRENAL GLAND located on top of the kidney
Cortex outer part
Medulla inner part
Adrenal Medulla secretes catecholamines adrenalins
a. Epinephrine
b. Norepinephrine
Vasoconstriction SNS All bodily activities, except GI
23
c. Hyponatremia
> hypotension no water absorption
low salt
> Signs of dehydration
> Weight loss no water
d. Hyperkalemia
> Irritability and agitation
> Diarrhea
> Arrhythmias peak T wave
e. Decreased libido
f. Loss of pubic and axillary hair
g. PS: Bronze-like skin pigmentation
c. Hypernatremia
> hypertension
> edema
> weight gain
> moonface appearance,
buffalo humps, obese trunk,
pendulous abdomen, thin
extremities
d. Hypokalemia
> Weakness and fatigue
> Constipation
> U wave on ECG tracing
e. Hirsutism
f. Acne and striae, easy
bruising
g. Increased masculinity in
females
4. Diagnostic Procedure
a. FBS low N=18-120mg/dl
B. Serum NA low
c. Serum K high
d. Plasma cortisol low
5. Nursing Mgmt:
a. Monitor strictly VS, IO and
Addisonian crisis characterized by:
> hyponatremia
> hypovolemia
> dehydration
> weight loss which may lead to
progressive stupor and coma
N/R in Addisonian crisis:
1. Assist in mechanical ventilation
2. Administer steroids
3. Forced fluids
b. Administer meds as ordered
> Corticosteroids ONE
- Hydrocortisone, Dexamethasone,
Prednisone
N/R:
4. Diagnostic Procedure
a. FBS high
b. Serum high
c. Serum K low
d. Plasma cortisol high
5. Nursing Mgmt:
a. Monitor IO and VS
b. Restrict Na and fluids
c. weight patient daily and
assess for edema
d. Measure abdominal girth
daily and notify physician
e. Diet low in carbohydrate,
high in K, high in protein
f. Administer meds as ordered:
Provide diuretics:
DO NOT GIVE LOOP
DIURETICS LASIX : HypoK,
HyperGlycemia
give only
K-sparing diuretics
Spironolactone (Aldactone)
24
2.
3.
a.
b.
c.
d.
4.
a.
b.
c.
d.
e.
f.
5.
a.
b.
Def:
Juvenile Onset/ Non-obese
Incidence Rate
Only 10% of general population
Predisposing Factors
Hereditary total destruction of pancreatic cells
Viruses
Toxicties (carbon tetrachloride CCl4)
Drugs, steroids, and loop diuretics (Lasix, and steroids)
Signs/Sx: PPP-G
Polyuria, polydipsia, polyphagia
Glucosuria
Weight loss, anorexia, nausea and vomiting
Blurring of vision
Increased susceptibility to infection
Poor/delayed wound healing
Treatment:
Insulin therapy
Exercise
25
c. Diet
6. Most feared complications: DKA give Na Bicarbonate
DM II (NIDDM)
1. Def:
Adult Onset/Obese (40 yrs old and above)
2. Incidence Rate
90% of the general population, started to increase in early 80s
3. Predisposing Factors:
a. Obesity Q:Why obese persons develop DM? A: Obese
individuals lack insulin receptor binding sites
4. Signs and Symptoms:
a. Usual asymptomatic
5. TREATMENT
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise
6. HyperOsmolarNonKitetotic Coma (HONK)
BASIC PATHOGENESIS
Main food stuff
Anabolism building up
Carbohydrates
(CHO)
Protein (CHON)
Fats
Glucose
Amino acids
Fatty Acids
Catabolism breaking
down
Glycogen
Nitrogen
Free fatty acids
cholesterol and ketones
Blood circulation contains nutrients CHO[ ->increase glucose in blood > stimulate pancreas to secrete insulin -> insulin transport glucose
inside the cell, but it needs a receptor] blood removed glucose hypoglycemia, CHON, Fats
Cell -> will undergo chemical reaction converts glucose to ATP= main
fuel of body
Some glucose are stored = glycogen, reserved glucose for future use in
skeletal muscle and liver
Gluconeogenesis
Liver -> release protein -> converted to glucose -> no insulin -> osmotic
diuresis
Increased CHON catabolism -> (-) nitrogen balance -> tissue
wasting/cachexia (client not taking insulin)
Increased fat catabolism -> free fatty acids by product -> release
cholesterol -> atherosclerosis -> HPN -> MI and Stroke -> Death
Free fatty acids -> Ketones -> DKA -> Acetone breath odor and
Kussmauls respiration -> Diabetic Coma -> Death
Q: What is the part of the brain controls thirst and hunger?
A: HYPOTHALAMUS
Liver largest gland
Pancreas produces insulin
DKA DIABETIC KETOACIDOSIS acute complication of Type I DM,
characterized by severe CNS depression due to hyperglycemia
1.
a.
Precipitating Factors:
Hyperglycemia
26
b.
c.
Stress - #1
Infection
Sodium bicarbonate
Antimicrobial
5. Complication: HONK
HO> increased osmolality -> severe dehydration
27
Complications:
Allergic reactions
Lipodystrophy
Somogyi Phenomenon> hyperglycemia followed by periods of
hypoglycemia
Nice to
know:
Horse anti tetanus
Goats brain anti rabies
Chicken anti-measles (most
expensive)
ORAL HYPOGLYCEMICS
for Type II
Mechanism of action: Stimulates the pancreas to secrete insulin
1. Classification of OHA ending NASE
First generation sulfonylureas ex. Chlorpropamide (Diabenase)
1.
Tolbutamide (Orinase)
2.
Tolazamide (Tolinase)
Second generation sulfonylureas
1.
Glipzide (glucotrol)
2.
Diabeta (Micronase)
3.
Nursing Mgmt in giving OHA:
1. Instruct the client to take it with meals, to lessen GIT irritation
and to prevent hypoglycemia
2. Instruct the client to avoid alcohol- because added OHA can
result to severe hypoglycemic reactions
Diagnostic Procedures for DM:
a. FBS if it is increased 3 consecutive times plus 3 Ps and 1 G, it
confir
Nice to know:
ms
Most accessible and most safe: ABDOMEN
prese
Q: What needle gauge? A: G25-26 small bore needle
nce of
DM,
Use Insulin syringe or tuberculin syringe
use
(1cc/ml=100units -0.5ml=50units -0.1ml=10units)
gluco
meter
1ml of tuberculin syringe = 100 units of insulin
, prick
index
*too much insulin -> leads to hypoglycemia -> insulin
finger
coma -> death
sides
only lesser nerve endings wipe it with saline solution-if no saline
soln use dry cotton, dont use alcohol (fermented sugar = ethyl it
can alter the result)
b. Random blood sugar RBS it is elevated
c. Oral Glucose Tolerance Test (OGTT) it is elevated, most sensitive
test
d. Alpha Glycosylated Hemoglobin
Nursing Management for DM:
1. Monitor for signs and symptoms of hypoglycemia (TIRED)-cold
and clammy to touch -> offer hard candies or 1 glass of orange
juice => needs simple sugar for easier digestion and easier
glucose formation (coke and chocolate =>complex sugar) and
hyperglycemia (PPP) warm and dry to touch -> administer
insulin
28
Q: A client has history of DM, one morning her body was found in
the floor, unconscious
A: The brain can tolerate an increase/excessive amount of glucose,
but the brain can never tolerate deficiency of glucose->offer simple
sugar
2. Monitor strictly VS, Blood sugar, and I/O
3. Diabetic diet CHO 50%, CHON 30%, Fats 20% or offer alternate
food products/beverages: glass of orange juice
4. Exercise after meals - to promote increase utilization of glucose
5. Monitor for complications:
atherosclerosis -> HPN -> MI or CVA (Stroke) Neuropathy
Microangiopathies: affects the small capilliaries and arteries of
the eyes: premature cataract -> retinopathy -> blindness
and
kidneys -> recurrent pyelonephritis (inflammation of the
renal pelvis) -> Nephropathy or Renal Failure
gangrene formation
Shock
Peripheral neuropathy -> diarrhea -> constipation ->
sterility/impotence
6. Institute foot care management
a. Instruct the client not to walk barefooted
b. Encourage client to apply lanolin lotion to prevent skin
breakdown
c. Instruct the client to cut toenails straight
7. Instruct the client to avoid wearing constrictive garments
8. Encourage annual eye and kidney exam prevent retinopathy
and nephropathy
9. Monitor for signs of DKA or HONK
10. Assist in surgical wound debridement
11. Assist in surgical procedure:
a. BKA - Right below the Knee Amputation Procedure
b. AKA above knee amputation
29
01/28/2006
Hematology
Hematologic System
Consists of 3 structures:
1. Blood forming organs: > produces blood cells
a. Liver largest gland right hypochondriac region
b. Thymus located near the sternum, removed Thymus
Myasthemia Gravies autoimmune antibodies
c. Spleen kills the RBC once it reaches 80-120 days old,
proximal to the liver, when hepatomegally occurs, there
will be spleenamegally
d. Bone marrow- red bone marrow epiphysis RBC WBC
platelets, yellow bone marrow long bones humerus,
femur, fats cells most feared complications of fracture
of femur: fat embolism dyspnea & chest pain,
hemorrhage, compartment syndrome
e. Lymph nodes
f. Lymphoid organ - Salmonella Typhi Payers patches
rose spots in the abdomen defense mechanism
between small and large intestines for Thypoid fever
g. Veins LARGEST: superior & inferior vena cava, jugular
veins - towards heart unoxygenated blood dark red superficial
h. Arteries LARGEST: aorta & carotid artery away the
heart, scarlet red oxygenated blood deep
i. Capilliaries NOTE: Alternate expansion and recoil of artery = PULSE
Varicosities venous ulcer elevate legs
Thrombophelbitis deep vein thrombosis- Homan sign - venous
Aneurysm Abnormal dilation of an artery lead to subarchnoid
hemorrhage - arterial
Reynauds disease arterial Female 40 yrs old and above hands or
digits bluish, have intermittent claudication pain upon walking or
excertion, gangrene formation - smoking
Buergers disease Thromboanginitis Obliterans arterial smoking,
Male 40 yrs old and above feet bluish, have intermittent claudication
pain upon walking or excertion, gangrene formation,
III. Blood
Serum
Plasma Proteins
a. Albumin
most abundant in plasma protein maintains osmotic pressure
thereby preventing EDEMA
b. Globulin
1.
Alpha transports hormones, steroids, and bilirubin
2.
Beta transports iron and copper
3.
Gamma transports antibodies, immunoglobulins 5:
G-chronic, maternal circulation A-sweat, tears M-acute
E-allergic
c. Prothrombin clotting factors lead to bleeding and
hemorrhage when lack of clotting factors
d. Fibrinogen clotting factors lack of c & d Disseminated
Intravascular Coagulation
Cellular components:
RBC
Normal value=erythrocytes 4-6M cubic mm
biconcave disks
NOTE: theres hemolytic anemia in which the RBC assumes an Sshape structure SICKLE CELL anemia immature RBC easily
destroyed by spleen hemolysis- low rbc, low oxygen.
Priority Nsg Mgmt:
1. Airway = avoid deoxygenating activities
Q: Sickle cell anemia patient what exercises to indulge:
a. Mountain climbing - x
b. Hiking - x
c. Bowling -
d. Ice Skiing x
Anti-sickling agent Hgb-S via IM can use before flying
2. Force fluids
3. Pain (Comfort) if too much vaso occlusion blood flow
decreased > ischemia -> hypoxia o2 low in tissue-> anerobic
metabolism -> lactic acid -> irritating to tissue, stimulates
mediators, release of prostaglandin->stimulate nociceptor->pain
sensation; Give: Mefenamic acid inhibits prostaglandin
30
Hgb
F = 12-14gm %, lower blood volume due to women have monthly
menstruation
M = 14-16gm %, blood volume is higher
Child = higher blood volume compared to adults
C. HEMATOCRIT RBC percentage, 3x hemogblobin
Hct
F = 36-42%
M = 42-48%
Q: A client suffered a 3rd degree burns (Priority: Fluids & electrolytes),
the nurse will notice after 24-48 hours that the hct:
Pred factor: 3rd deg burn -> hypovolemia->ischemia->Hypoxia->major
stimulus for erythropoiesis-> stimulate kidneys->to secrete
erythropoietin -produced @ MACULA DENSA -> stimulate one marrow >increased RBC -> increased Hct
A: Elevated compensation
B: Decreased
C: The same
D: No change at all
Q: a pregnant woman on 1st trimester needs a larger amount of FOLIC
ACID to prevent neural tube defect SPINA BIFIDA/Myelo?-prone
position
3rd trimester needs IRON
WBC Basophil, Neutrophil, Eosinophil with granules granulocytes
In clients with DKA, Acute renal failure, 3rd degree burns Hct is
ALWAYS ELEVATED due to compensation
D. Substances needed for maturation of RBC
1.
folic acid
2.
iron
3.
vit B12 (Cyanocobalamin)
4.
vit C (Ascorbic Acid)
5.
vit B6 (Pyridoxine)
6.
intrinsic factor
E. Normal lifespan 80-120 days
F. Spleen graveyard of RBC at red pulp
WBC phagocytosis (Leukocytes)
Normal value = 5-10,000
Decreased WBC = Leukopnea increase susceptibility to infxn
Increased WBC = Leukocytosis (+) to infection
A. Granulocytes: (too check how long your infection, use the
differential count)
1. Polymorphonuclear Neutrophils > the most abundant of all
WBC, constitute 60-70% of WBC > involved in short term
phagocytosis-> acute inflammation because lifespan is only
good for 3-4Hrs (replaced by MOnocytes)
2. Polymorphonuclear Eosinophils > allergic rxn
3. Polymorphonuclear Basophils > involved in parasitic infxn >
involved in the release in chemical mediators for inflammation
(Prostaglandin, Histamine, Serotonin, Bradykinins) >
*RESPONSIBLE for dissolving or ingesting fat particles after
ingestion of high fat meal (presence of cholesterol if too much
fats and minimal basophils)
B. Monocytes the largest WBC (Macrophage) > fxn opposite of
neutrophils > long term > chronic inflammation > life span 8-12
months > non-granulocytes
C. Lymphocytes > non-granulocytes
B cells (arises from bone marrow)
T cells (arises from Thymus) > target site of HIV (incubation
period: 6mos to 5 yrs, window period: 6months-subjected to
ELISA-inaccurate-enzyme link immunosorbent assay,
confirmatory test = Western Blot) > non-granulocytes
NK (Natural killer cells) > have both anti-tumor, and anti-viral
property
III. Platelets (Thrombocytes)
Normal Values =
Promotes hemostatis prevention of blood loss
Immature/baby platelets Megakaryoctes, target site of virus =
Dengue Virus(Aedis Aegypti) increased capilliary fragility
Petechiae internal bleeding
31
Suicide
Poisoning-Aspirin
SIDS, suffocation
32
f.
33
Parietal cells/Oxyntic/Argentaffin
Secretes
Secretes
Intrinsic factor
hydrochloric acid
Fxn: promote
Reabsorption of
Aids in digestion VS Indigestion
Vitamin B12
Dyspepsia
promotes of maturation
of RBC
calories CHON
1. Predisposing Factors:
a. Subtotal gastrectomy
- Billroth I duodenostomy
- Billroth II Jejunostomy
b. Related to hereditary factors
c. Inflammatory disorders of the ileum
d. Autoimmune
e. Strictly vegetarian diet
2. S/SX:
12. headache
13. dizziness
14. dyspnea
15. palpitation
16. cold sensitivity
17. pallor
18. generalized body malaise
GIT changes:
19. mouth sores
20. red beefy tongue
21. Dyspepsia
22. Weight loss
23. Immature RBC jaundice
Neurologic changes:
24. Tingling sensation
25. Paresthesia
26. Ataxia
27. Psychosis
34
4.
a.
b.
c.
d.
e.
f.
g.
h.
Nursing Management:
Removal of underlying cause
BT as ordered
Enforce complete BR
Administer O2 inhalation
Institute reverse isolation
Monitor for signs of infection: fever cough
Avoid IM, SQ or any venipuncture sites provide heparin lock
Administer medications as ordered:
37. Immunosuppressants: Anti-lymphocyte Globulin
given 6days to 3 weeks via central venous catheter to
achieve the maximum effect of the drug
b.
c.
d.
e.
f.
g.
h.
Massive trauma
Massive Burns
Neoplasia -New growth of tissue or tumor
Anaphylaxis
Hemolytic Reactions
Pregnancy
Septicemia
2.
a.
b.
c.
d.
e.
f.
3. Diagnostic Procedure:
38. CBC reveals thrombocytopenia
39. Stool for occult blood (+)
40. Ophtalmoscopic exam
41. ABG analysis metabolic acidosis
Metabolic
acidosis
Chronic
Diarrhea
DM
Ileustomy
Metabolic
Alkalosis
Projective
Vomiting
Pyloric stenosis
Cushing
Respiratory
Acidosis
Emphysema
Respiratory
Alkalosis
Hyperventilation
Bronchitis
ROME respiratory
Before ABG, patient should be (+) Allens test: determines collateral
circulation, press radial & ulnar artery
ABG Normal Values
1.35-1.45
35-35
22-26
Polycytemia late sign- pruritus
35
Nursing Management
Monitor for signs of bleeding of all hema tests
Administer IV fluid replacement as ordered isotonic
Administer oxygen inhalation as ordered
42. Vitamin K (Aquamephyton)
43. Heparin short acting
44. Vasopressin, Pitrissin to prevent urination,
conserving water
d. Provide heplock, avoid IM SQ or any venipuctured sites
e. Institute NGT decompression gastric lavage
45. iced saline solution
46. cold saline solution
f. Prevent complications: Hypovolemic SHOCK, late sign = anuria
NOTES:
NGT tube kink closed for feeding gavage
NGT tube open drain sa bed side bottles lavage remove gastric
contents decompression
Give ice or cold water saline solution instill 1 litter, then decompress
BLOOD TRANSFUSIONS
1. FOUR objectives:
1.) To replace circulating blood volume
2.) To increase the oxygen carrying capacity of the blood
3.) To combat infection if decreased WBCs
4.) Prevent bleeding if decreased PLT
2. Nursing Management:
47. proper refrigeration
48. proper blood typing and cross-matching
O - universal donor
AB universal recipient
85% of general population is Rh (+)
49. Aseptically assemble all materials needed for BT:
Filter set (BT set)
PNSS isotonic to prevent hemolysis
Needle gauge 18-19 large bore needle
50. Instruct another RN to re-check the following
Name of patient
BT and crossmatching
Expiration date
Serial number
51. check blood unit for presence of bubbles, cloudiness,
sediments and dark color signs of contamination DO NOT DISPOSE, RETURN TO THE BLOOD BANK, for
re-exam
52. NEVER WARM BLOOD PRODUCT, it may destroy vital
components in the blood, wait for 30 minutes, let room
temperature warm the blood product, NEVER WRAP IT
53. WARMING of blood, used only through warming
DEVICE, emergency-RAPID BLOOD TRANSFUSION
54. Transfusion should be completed in 4 hours, blood that
is exposed more than 2 hours causes blood
deterioration, can result to bacterial contamination
55. Avoid mixing or administering drug at BT line may
cause to hemolysis
56. Regulate at KVO (Macro- 10-12gtts/min) at 100cc/hr
to prevent circulatory overload
57. Monitor VS BEFORE, DURING & AFTER transfusion,
especially every 15 minutes (majority of transfusion
rxn occurs in this period) for the first hour.
3. Signs of BT reaction - HAPCATCH
Hemolytic Reaction
Signs/sx:
58. dizziness
59. headache
60. dyspnea
61. hypotension
62. flush skin
63. lumbar, flank, sternal pain
64. red colored urine (portwine urine)
Nsg. Mgmt:
1. Stop the blood transfusion
2. Notify the physician
3. Flush it with PNSS, to prevent hemolysis
4. Administer isotonic fluid solution as ordered to counteract shock &
prevent acute tubular necrosis (leads to renal failure)
5. Return the blood unit to the blood bank for re-examination
6. Obtain urine & blood samples to laboratory for re-examination
7. Monitor vital signs
36
Allergic Reaction:
s/sx:
65. fever, chills
66. dyspnea
67. laryngospasm
68. bronchial wheezing
69. urticaria, pruritus
Nursing Mgmt:
1. to 3 same
4. Administer anti-histamines as ordered Diphenhydramide Hcl
(Benadryl) drowsiness, avoid driving and operating machineries
5. If (+) hypotension due to anaphylactic reaction
6. Return blood to blood bank (same)
Pyrogenic Reaction
s/sx:
-fever and chills
- headache
- dyspnea
- tachycardia and palpitations
- diaphoresis
Nursing Mgmt:
1. to 3 same
4. Administer anti-pyretics & antibiotics as ordered
5 to 7th same
8. Provide TSB
Circulatory Overload
S/Sx:
70. dyspnea
71. rales/crackles
72. orthopnea
Nsg Mgmt:
1 to 2 same
3. Administer loop diuretics as ordered: Lasix 10-15mins 6 H, given AM
Air embolism
Thrombocytopenia
Benign (Tumor)
well differentiated
with capsule
(-)
Good
Surgery-most chosen
treatment
Malignant (Cancer)
poorly differentiated
without capsule
(+)
Poor
Chemotherapy
Radiation many side
effects
Surgery
Bone marrow
Transplantation
Normal growth of cell: by straight line, with structure, pantay
Cancer cells: They pile each other, forming mass
37
Neutropenia
Thrombocytopenia
3. Warning danger signal signs: CAUTION
82. Change in bowel or bladder movements
83. A sore that doesnt heal
84. Unusual bleeding or discharges
85. Thickening of a lump in breast or elsewhere
86. Indigestion or dysphagia
87. Obvious change in a wart or mole
88. Nagging cough or hoarness
89. Unexplained anemia
90. Sudden weight loss
91. Anemia
92. Loss of weight
NOTE: 3 to 4 (+) signs, consult a doctor
4. Therapeutic Modalities
1. Chemo-utilization of various chemotherapeutic
agents that kills the cancer cells, and also kills
normal rapidly producing cells-GIT, hair follicles,
bone marrow.
Antimetabolites
Alkylating agents
Plant alkaloids
Hormones and steroids
Antineoplastic antibiotics
5. Side effect and nursing Management
a. Hair follicles alopecia
93. Encourage use wigs turban/bandana
94. Inform client that hair loss is temporary, hair will grow
back in 4-6months after chemotheraphy
b. GIT - Nausea and vomiting:
95. NPO before procedure
96. Administer anti-emetics (Metoclopramide) Plasil 4-6
hours before chemotheraphy
97. Bland diet post-chemo
98. Diarrhea :Administer anti-diarrhea agents 4-6hrs
before chemotherapy
99. Stomatitis: provide oral care, offer popsicles
100. Dysgeusia (altered taste sensitivity):
38
b. Methods of delivery
111. External utilizes electromagnetic waves
112. Internal involves injection or implantation /
transplantation or injection radioisotopes proximal to
the cancer site
113. Sealed implant radioisotope within a container and
does not contaminate body fluids ex. Phosphorus 32
114. Unsealed implant radioisotope without a container
and contaminates body fluids
c. Factors affecting Exposure
115. Half life time required for half of the radioisotope to
decay
116. Time shorter time lesser exposure
39
01/29/06
CARDIOVASCULAR SYSTEM
Heart muscular pumping organ of the body
A. the only organ located in the midastinum Left
B. it resembles like a closed fist
C. Weighs 300-400 grams
D. This is covered by a continuous sheet serous membrane
pericardium
3.
Parietal outside
4.
Visceral middle
Pericardial fluid approx 10-20cc in the middle
of parietal & visceral, to prevent pericardial
friction
E. Layers
Epicardium
Mayocardium
Endocardium
III. Chambers
a. Atria collecting or receiving chamber
b. Ventricles pumping or the contracting medium, left ventricleHIGHEST PRESSURE: 180-250mmHg needs pressure to force the
blood going to the aorta, going to the systemic circulation
TO PREVENT backflow,
IV.
a.
b.
1.
2.
Valves
atrioventricular valves
Tricuspid
Mitral
closure of the AV valves gives rise to: 1st heartsound S1 LAB
Semilunar valves
Pulmonic
Aortic
closure of the semilunar valves gives rise to: 2nd heart sound S2
DAB
Extra heart sound
1.
S3 ventricular gallop CHF LEFT
2.
S4 atrial gallop MI HPN
IV Coronary Arteries both supply the myocardium with blood
a. Arises from the base of the aorta
b. Right main coronary artery RMCA
c. Left MCA
If one of the coronary arteries is blocked, myocardial ischemia -> angina
pectoris -> if prolonged myocardial necrosis -> MI (heart attack)
V. Cardiac conduction sytem
a. SA node pacemaker, (Keith Flock node)
located at the junction of superior vena cava and right atrium
3.fxn: primary pacemaker of the heart, it is the one that initiates an
electrical impulse of 60-100bpm
4.if heart rate is below 60 brady, above 100 tachycardia -> arrythmias
b. AV node (Tawara node)
- located at the inter-atrial septum
- theres a delay of electrical impulse NORMAL= 0.08 milliseconds to
allow ventricular filling
- secondary pacemaker, can initiate electrical impulse only for about 4060bpm
c. Bundle of His
- R and L main bundle branch
- located in the interventricular septum
d. Purkinje fibers
- located at the walls of the ventricles
- leading to ventricular contractions (1 heartbeat)
Q: complete heart block = L R bundle of HIS are damaged
N/R: needs an artificial pacemaker made of metal, every 5 years has
to be changed
Q: sign of malfunction pacemaker= HICCUPS
Coronary Artery Disease Ischemic Heart Disease
Stages:
1. Myocardial injury Artherosclerosis = presence of lipid deposits
2. Myocardial Ischemia Angina Pectoris =lead to decreased blood
flow
3. Myocardial Necrosis Myocardial infarction, unpredictable disease
Atherosclerosis
narrowing of artery
lipid and fat deposits
Tunica intima
Arteriosclerosis
hardening of an artery
CHON protein and Ca deposits
Tunica media
40
deflate balloon, put KY, pasok sa femoral artery, inject dye (pre-op:
check for allergies-seafoods-shellfish dyes are iodine base), to clearly
visualize where to place the catheter, x-ray is used,if near atheroma,
syringe 10 cc insert air to inflate balloon to compress the atheroma
PTCA done to single occluded vessel
(post-op: force fluids, flush the dye, dyes are nephrotoxic agents it can
destroy the kidneys and dyes are osmotic diuretics-> leads to severe
DHN)
41
Nitroglycerin (NTG)
1.
Small doses dilates lower extremities, venous pulling
-> venous stasis -> leg retained can not return to
heart -> heart lesser pumping
2.
Large doses vaso dilator dilates all
Nursing Mgmt: (NTG)
1st dose of NTG = 3-5 mins
2nd dose of NTG = 3-5 mins
3rd & last dose of NTG = 3-5 mins
STOP giving the dose, notify the physician
Given only 3x at 3-5 mins interval, if not relieved by NTG = it is MI
1. Place the drug in a dry - AVOID heat & moisture as it may
inactivate the drug
2. Monitor side effects low BP -> Orthastatic hypotension,
transient headache, and dizziness
3. Instruct patient to rise slowly from sitting position
4. If giving transdermal patch, avoid placing near hairy areas as it
may decrease drug absorption, if hairy-shave it when giving
NGT, if auscultating put water (+) hairy chest water is good
conductor for sound waves
5. Avoid rotating transdermal patches decrease drug absorption,
avoid placing near microwave ovens during defibrillation-may
lead to burns-it contains aluminum foil in the package
6. Beta-blockers propanolol
7. ACE inhibitors captopril
8. Ca channel blockers nifedipine
9. Administer O2 inhalation low in flow 2-3LPM
42
43
02/04/06
PSYCHIATRIC NSG:
Thoughts -> Feelings
I am not prepared -> nervous -> restless
This is not right! -> angry -> frown
At last, after 48 years -> excited -> open eyes
Im on a diet -> hungry
I lack sleep -> sleepy -> closed eyes, open mouth, drooling
Somebody kissed me -> loved -> happy
No txt, no luv -> unloved -> sad
I am the queen of the world -> self-esteem -> flamboyant heavy make
up
Life is empty -> sad -> withdrawn suicide
The FBI is out to get me! -> sad scared -> withdrawn violent
I am fat. Fat is beautiful -> self-esteem
I am fat, Fat is ugly -> self-esteem -> diet, diet, diet
Belief determines your feelings
Feelings determines your behavior
Grandma slouching, sad, low self-esteem, withdrawn -> talk to her
NOTE: 1. Whatever you see, what you say
You seemed sad/happy today. -> the person seemed interest, the
person thinks he/she is important
NOTE: 2. Restating:
You are so sad today?
You dont want to eat?
*Listening to the client, whatever client she/he says is important
NOTE: 3. Recognition
You have done something right. You have combed hair, arranged the
bed.
NOTE: 4. Present reality
You are a monster. -> Good morning, mam. Im not a monster, I am
wilen. I will be your nurse for today.
Why are they dysfunctional? Why they are not normal? Why are they
different from us?
44
TT-> Bad mother ->> Dirty, disorganized, disobedient ANTISOCIAL = Weak Superego and ID = Anal Expulsive
Dr. Karen Horney disagrees with Dr. S.Freuds concept of Penis Envy
SUPPRESSION = conscious forgetting of an anxiety provoking
concept
Conscious = theres a level of awareness
Preconscious= tip of the tongue
Unconscious = unconscious forgetting of an anxiety provoking
concept/idea = REPRESSION= ex. birth traumatic experience =is to
be forgotten, not worth recalling, stored place
PHARMA MOMENTS:
ANTI-ANXIETY
V alium
L ibrium Liberty
A- tivan Ate guy
S erax Sira ulo
T ranxene LR -Transit
M iltown meal town down town
E quanil aqua/tubig
V istaril larVabista
A tarax Ang dami rocks
I nderal hINDE RALph
B uspar Bus pa taRa na
Ex. Childhood Kurt Cobain 27 years old, when he was 4-8 years old
Thanksgiving he performed, bullied, nobody wants to keep me=
became a successful Nirvana vocalist but killed himself, feeling of
emptiness
Erik Erikson theres more to life than just sex,
hence, the psychosocial theory of development
Stage
+
Factor
0-18
TRUST
MISTRUST
Feeding
months
18mos -3
AUTONOMY
SHAME/
Toilet training
y/o
- stand on his
DOUBT
own
3 6 y/o
INITIATIVE
GUILT
Independence
- imitates
-anger turned
parents
inwards
- initial steps
6-12 y/o
INDUSTRY
INFERIORITY INDUStry
- many steps
in da skul - SCHOOL
12-20 y/o
IDENTITY
ROLE
PEERS
The garden of
CONFUSION
Belief#1 Education is
life:
valuable
Belief #2 Success can
Who am I?
be achieved by
perseverance
Belief#3 I have the
capability to effect
changes in the society
45
20-25 y/o
25-45 y/o
45 &
above
INTIMACY
GENERATIVITY
grab
opportunity,
learning
EGO
INTEGRITY
- aging
- examine life,
replay events
- embrace all
experiences
because it
contributed to
their
development
ISOLATION
STAGNATION
LOVE
PARENTING
DESPAIR
REFLECTION
Occipital Lobe
Vision - eyes
Temporal Lobe
Hear
Smell
Parietal Lobe
Touch
Taste
CN
Olfactory
Optic
Oculomotor
ACTION
smell of food
open eyes - sight
move up light brighten up eyes constrict,
movement of pupil
Trochlear
look down food thrown at the floor
Trigeminal
pray 3, chewing
Abducens
look at the sides
Facial
taste, facial expression
Vestibulocochlear balance, hear
Glossopharyngeal throat, swallow
Vagal/vagus
bagal-parasympathetic
Accessory
move shoulders-happy
Hypoglossal
movement of tongue-Belat
How do you interact with your environment? SIM
SENSORY
Eyes
Nose
Ears
Tongue
INTEGRATION
MOTOR->> Voluntary = Voluntary Nervous System = SOMATIC
NERVOUS SYSTEM begins from the brain ->Spinal Cord -> Motor
Nerve [Synapse-neurotransmitter: ACETYLCHOLINE = chemical
responsible for movement ON]->Muscle Fiber
->>Involuntary = AUTOMATIC AUTONOMIC NERVOUS SYSTEM
46
ANS
----------------------------------------------
Sympathetic-Anticholinergic
Parasympathetic-Cholinergic
heart rate
heart rate
RR
RR
GI Constipation,Dry Mouth
Diarrhea, Moist Mouth
GU Retention
Urinary frequency
Dilate pupils DILAT-ALERT
Constrict
Mydriasis
Miotic
Vaso constrictor
Vaso dilation
BP
BP
Neurotransmitter:
Epinephrine
Norepinephrine
Acetycholine
Q: The following are anticholinergic side effects of antidepressants
exept:
a. urinary retention
b. Dry mouth
c. Constipation
Q: The following are anticholinergic side effects of antipsychotic agents
except
a. Tachyardia
b. Urinary retention
c. Diarrhea correct
MONOAMINE OXIDASE INHIBITORS - PANAMA
M
PLAN
N AR DIL
P
NATE
Therapeutic Communication Techniques:
If a person is withdrawn, will you ignore the person?
Offer self: I will be here with you. I will sit with you. I will go with you.
Lets so there. Lets sit down.
Silence: You want the client to think of any topic, and let the client to
talk and talk
Making Observations: You seem sad. You have made your bed
today.
Active Listening:
What if you want a person to continue speaking?
- nodding
- eye contact
- lean forward
Broad opening:
How are you today?
How are things going today?
How are you?
Tell us about yourself?
Who are you?
How do you make it verbal?
General Leads: Go on, Im listening. And then. What else?
Exploring: Who, What, When
Restating: Im sad. Youre sad?
Im happy. youre happy?
Refocusing: Dave, Im not asking what you do, who you are?
Deltner/Videbeek/Shives Psychiatric Nursing
Reflect VS Restate
Youre hungry? VS You want cheeseburger?
Non-Therapeutic :
False reassurance: Everythings going to be fine
Changing topic/subject
Ignore the client
Value based judgement: Avoid using ADJECTIVE
Nice weather were having today
You have the most wonderful bed in the ward
Why? = putting the client in defensive position
Flattery
You should do this now = Advising = Commanding
47
In my opinion
Arguing = No, you are wrong
Mind visualize things to happen
Fantasy > mental
Reality
You have to know where to go
You must know what you really want to have in life
STRESS use DEFENSE MECHANISM:
1. Displacement transfer of feelings to a lesser threatening objects,
than the one who provoked it.
2. Denial failure to acknowledge an unacceptable trait or situation
3. Dissociation - Pschological Flight From Self = amnesia - Raped
traumatic experience = Sino ka? Sino ako? = wants to forget
4. Regression return to an earlier developmental stage fetal position
5. Repression unconscious forgetting of an anxiety provoking concept
6. Rationalization illogical reasoning for a socially unacceptable trait.
Ex. I drink because I socialize and I socialize everyday
7. Reaction Formation done the opposite of your intention. Ex. Gusto
mo sakalin pero niyakap mo. Plastik, Tupperware, Orocan, Kyowa
8. Undoing do the opposite of what you have done/action. Ex. You
shown your true feelings, frown then other smile. Felt guilty, next
time you smiled
9. Identification assume trait for personal, social, occupational role.
Ex. I want to be like my father = Personal goal. I want to be the
president = Social role. Occupational role I want to be an
architect.
10. Projection attribute to others ones unacceptable trait. PASA LOAD
ex. My friends are alcoholic. Not me, but them.
11. Introjection assume another persons trait as your own, not just,
me too! Ako din.
12. Suppression conscious forgetting of an anxiety provoking concept.
13. Sublimation destructive energies/ sexual energies/ hostile energies
put towards more productive endeavors:music, poetry, writing lyrics,
dance, art, handicraft.
14. Conversion
15. Compensation overachievement in one area to cover a defective
part
Anger is repressed
Conversion
Nervous system
-----------------------------
Sensory
Motor
Numbness
Paralysis
16. Substitution replace difficult goals with more accessible one
SNS
Anxiety
SNS E/NE axn: bring the GABA - Anti-Anxiety Agents
Anticholinergic
Constipation
within 1 week
Urinary ret
Seizures
Rebound Phenomenon
Abrupt
Withdrawal
---------------------Anti-anxiety------------------------------------- Dependence
drowsy
Dev.Orthostatic Hypotension
Tapered dose
Relaxed
Anxiety - RR
48
pH 7.35-45
CO2 35-45
HCO3 22-26
Metabolic
acidosis
pH
CO2
HCO3
Respiratory
acidosis
pH
CO2
HCO3
Respiratory
Alkalosis
pH
CO2
HCO3
Metabolic
Alkalosis
pH
CO2
HCO3
Principles:
1.
2.
3.
4.
CO2 is opposite pH =
HCO3 is same Ph
Compensation: same direction for CO2 HCO3
CO2 HCO3 pH Normal = Fully, Abnormal = Partially
Interpretation:
1. ph acidosis alkalosis
2. CO2 opposite: RESPIRATORY
3. HCO3 same direction with the Ph: METABOLIC
PANIC
MILD
MODERATE
+1
Widened perceptual
field
Restless
Enhanced learning
capacity
+2
Pacing
Prn Meds
Valium
Librium
NR:
1. Sit
2. Dangle
3. Stand gradually
Anticholinergic SE in taking Antianxiety:
1. Constipation
2. Urinary retention
3. dry mouth
4. blurred
02/05/06
Fear something that protects us
Trade off/Price of gift of fear anxiety
Anxiety vague sense of impending doom
Doom - Parasympathetic SNS
Assess Level of Anxiety
Subjective Data:
I just dread being alone at night. I dont know why, but I do
SEVERE
+4
Suicide
+3
Safety
Dont know
Dont touch
what to do/
the client!
say
Respiratory
Directive:
Alkalosis
Lets go to the Breathe into
room.
bag!
Enter the room Sympathetic
Stop. Come
.here.
Anxiety
SNS
RR
CO2
pH
Respiratory Alkalosis
49
Planning/Implementation:
1. Decreased Level of Anxiety
2. Decreased Environmental Stimuli
3. Relaxation Technique
Manipulating the environment
Evaluation:Effective Individual Coping
6 months excessive worrying
Generalized Anxiety Disorder:GAD
Restless
Concentration difficulty
Sleep problems
Palpitations
Edge of the seat
Easy fatigability
if your worrying affects or interferes with ADLs
may lead to harm to self & others escape panic
attack
Panic attack may happen anytime
SNS activation but goes down, difficult to manage
15 to 30 minutes escalation of SNS
Agoraphobia fear of open spaces, they can not go outside
1. can still communicate with other people
Social Phobia fear of public/ other people
Victims - trauma, disaster, accident, rape, earthquake
new people
Flashbacks- haunted by the past
Assignments
Homeworks
No assignment
No homework
You think,
Teacher may get
angry!
Anxiety
Psychosomatic
I am sick
Malingering
Somatoform
pretending to be
sick-conscious
Absent
Escape
from
teacher
Primary Anxiety
Gain
Somatoform
no pretension
unconscious
no organic basis
Nervous system
Conversion disorder
La belle indifference
No reaction to the
s/sx happening
Mama
care
Attention Secondary
Gain
-result of malingering
where attention increases
Illusion of structural defect
Body Dysmorphic disorder
Minor discomfort
Interpreted as major illness
Hypochondriasis
50
Mind Psychophysiologic/Psychosomatic
Real pains/illness/ Real Symptoms
Body
SNS
PNS
Vasoconstriction
Bronchoconstriction
Cerebral
Left
Asthma
Artery
Gastric
Spasm
Artery
Migraine
O2
Mucosal lining
Stress Ulcer
* no causative agent
Duodenal ulcer Etiologic Agent: H-pylori
Thought-> Feelings->
Open
Anxiety
Burglar
Obsession-> Anxiety->
Behavior
-action
- return house
Compulsion->Anxiety
*gloves
*substitute
*schedule
*gradual withdrawal
Obsessive-Compulsive Disorder
fear of dirt or contamination
concern with order, symmetry, and exactness
51
Psychotherapy:
1. Free Association - Free to talk any ideas
2. Catharsis allowed to express feelings
3. Transference client to therapist ex. Client thinks of
the healthcare personnel as his father
4. Countertransference therapist to client
ALCOHOL
1ST Generation with history of alcoholism
1. can be passed on from generations
2. genetic make up
3. environmental
Intergenerational transmission
Alcohol
Blackout
Risk for injury
awake but Memory gap
unaware
Confabulation
Inventing stories to increase self esteem
Denial
Dependence -> Tolerance substance to maintain desired
euphoria
Anticholinergics-ABC
Artane
Akineton
Bendaryl
Cogentin
Dopaminergics-PLEASE
Parlodel
Larodopa
Symmetrel
Eldeprl
THERAPY:
Avoid alcohol therapy
Never Drink Alcohol
Aversion Therapy
12-hour interval
Alcoholics Anonymous
or else, nausea, vomiting and
Antabuse-Disulfiram
hypotension
B1 vitamin deficiency
Korsakoffs psychosis-memory
Delirium Tremens nurse I dont know my name?
-like anxiety/panic attack
-illusion, hallucination
The client must not take Antabuse if the client has just taken
alcohol, because there might be effects.
12 HOURS interval needed before giving antabuse
4-6 hours will experience withdrawal symptoms
24-72 hours will experience delirium tremens
Echolalia - repeats whatever people say, talk to them slowly,
they live in their own world = Autism
Autistic Savant gifted child, can concentrate
Nobody Nowhere Somebody, Somewhere by Donna Williams
Assess: ABC
Appearance Flat Affect no eye/poor eye contact
Consistent movement
no emotion, clean OCD
Behavior Repetitive
Ritualistic
keep on rocking relaxes them, love bicycles
Communication Echolalia
Incomprehensible
Nx Dx:
ANTI-PSYCHOTIC AGENTS
S telazin Stella Sin
P rolixin
S erentil serena til midnight
T horazine tora
T rilafon - tri band phone
C lozaril close na reel
M ellaril milya milya reel
H aldol hahaha
ADHD Attention Deficit Hyperactivity Disorder
If eight or more of the following statements accurately
describe your child or yourself as a child, particularly before
age 7 (ONSET), there may be reason to suspect ADHD. A
definitive diagnosis requires further examination.
1. often fidgets or squirms in seat.
2. has difficulty remaining seated
3. is easily distracted
4. has difficulty awaiting turn in groups
5. often blurts out answers to questions
6. has difficulty following instructions
7. has difficulty sustaining attention to tasks
8. Often shifts from one uncompleted activity to another
9. has difficulty playing quietly
10. often talks excessively
11. often interrupts or intrudes on others
12. often does not seem to listen
13. often loses things necessary for tasks
14. often engages in physically dangerous activities
without considering consequences.
can not control impulses ID is the dominant part,
always impulsive
7 yrs old and below
53
ADHD
Onset: 7 yrs old and below
Duration: 6 months and above
Settings: 2
Assess: ABC
Appearance:
Dirty
Behavior:
Clumsy, Hyperactive, Impatient
Communication:
Talkative, blurts out in class
Nx Dx: Risk for Injury High
Impaired Social Interaction
ID impulsive - Will not follow the mother, teacher, principal,
society-> Antisocial disorder: anger may build up = future
criminals
Planning/Implementation:
S tructure
S chedule time for everything
S et limits providing ample time, extent of what u can do
S afety
Evaluation:
Minimize Risk for injury
Improved social Interaction
Safety
Model Student
Toilet training
Social life inactive
Bulimia
Eat, eat, vomit
Normal weight
Irregular
Feel guilty when
Eating - PINGE
HCl dental carries,
Metabolic alkalosis hand
biting - wounds
Laxative Diarrhea
HCO3 same ph
Metabolic Acidosis
glucose
Ritalin after breakfast
54
FVD
BP
CO
O2
Heart
Brain
Arrhythmias
Excited
Relaxed
Self Actualization
Caregiver role
Self Esteem
strain
Safety
Impaired Social Interaction
Safety
NR:
eating
sleep
Hyperactive
Sex
Anxiety
55
Inappropriate
Appropriate
Flat
Blunt
SYMPTOMS
NEGATIVE
Hypoactive
Withdrawn
Apathy
POSITVE
Hyperactive
Sociable
Flight of ideas
Talkative
Assess:
Content of thought
Nx Dx:
Disturbed Thought Process
Planning/Implementation: Present Reality
Provide Safety
Evaluation: Improved Thought Process
Assess:
Nx Dx:
P/I:
E:
violence
Assess:
Nx Dx:
P/I:
Evaluation:
Suspicious
Risk for other directed violence
Present Reality, Provide Safety
Eliminate/minimize risk for other directed
Assess:
Nx. Dx:
Planning/I:
Evaluation:
violence
Suicidal
Risk for self-directed violence
Present Reality, Provide safety
Eliminate/minimize risk for self-directed
Hallucinations/Illusions
Disturbed Sensory Perception
Present reality, Provide safety
Improved Sensory perception
Looseness of Association =
two words with association,
with common words
Illusions
Present
Stimulus
Visual
Auditory
Tactile
Hallucinations
Acknowledgment:I know the voices are real to you.
Reality: But I dont hear them
Diversion: Lets go to the garden.
But what if nothing in the preceding interventions are seen?
Is it appropriate to assess what the voices are saying?
Command hallucinations assess what the voices are saying
to know if the client will commit suicide, or harm others
Delusion persecutory
The FBI is out to get me.
Delusion religious
I am Jesus Christ, the savior
Delusion grandeur
I am the Queen of world
Delusion Ideas of reference
57
02/11/06
Antipsychotic
D High Dopamine = Schizophrenia
TYPES
DISORGANIZED
-sad but smiles
Inappropriate affect
-no reaction
Flat affect
CATATONIC
Ambivalence
PARANOID
No
-flight of ideas
Disorganized speech
Negativism
-giggling
Hebephrenic
Positive/Negative S/S
RESIDUAL
No more positive
Just withdrawn
UNclassified
UNdifferentiated
Mixed classification
Cant be classified
AcH
Suspicious
Waxy Flexibility
Violent
Keep
Door
Open
Near
the
door
Dont
Touch
Eye
Contact
1 arm
away
Call
Reinforcement
AcH
D
AKATHISIA- Restless, Inability to sit
AKINESIA Muscle Rigidity
DYSTONIA
Torticollis- wryneck
Oculogyric Crisis fixed stare
Opisthotonos Arched back
MISTRUST->SCARED->WITHDRAWN
TRUST 1 TO 1
SHORT INTERACTION
FREQUENT
FOODS IN SEALED CONTAINER
MEDS WRAPPED
Tardive Dyskinesia
Lips Smacking
Tongue Protruding
Cheeks puffing
Irreversible
Neuroleptic Malignant Syndrome fever
ON = glucose = ATP used = heat
Other Side Effects:
1. photosensitivity:
a. use sunscreen
b. wear shades
c. wide brimmed hat
2. Agranulocytosis: Lymphocytes, Monocytes
neutrophils , Eosinophils, Basophils -> sore throat
58
ANTIDEPRESSANT:
A sendin to go up
N orpramin knorr para mainit
T ofranil lagyan ng tofu
S inequan sine Kuan
A nafranil Ana franing
A ventil aven til midnight
V ivactil- bye back til next week
E lavil e lab mo ba ako?
P rozac - pero zaka na tayo magpakasal
P axil isa kang taksil
Z oloft -mag SOLO ka
Task - esteem of the manic patient
Personality Disorders
1. SCHIZOID I avoid people. Theres no enjoyment
no reaction/flat affect, mechanical, they like computer hacking, cross
stitching, they avoid sex, do not engage in play, school activities, dont
have best friends-maybe have pets, no plan of marrying, not dated at all,
dont want people loving other people, people who can live by
themselves
2. AVOIDANT - I avoid people. Im afraid of criticisms longs for
people around them, to care for them
3. ANTI-SOCIAL used to steal, liars, violating the rules, engage in
bank robbery, drug trafficking, easily irritated, drug abuser,
dangerous sex, break the law, anti-social, good speakers, serial
killers
4. BORDERLINE my life is an empty glass (+) Fill Friends, usually
feel discontented, likes SPLITTING friends, SPLIT affect happy vs
sad LABILE affect (-) will commit suicide
5. DEPENDENT I cant live if living is without you.
Antidepressants
Safest
Selective
Side effects low
Serotonin
Reuptake
I to 4 weeks
Inhibitor
SSRI
serotonin
Two-four weeks
Two neurotransmitters
Tri
Cyclic
Antidepressant
Mono
Higher Incidence of
side effects
Inhibitors
TCA
serotonin
norepinephrine
Amine
Oxidase
Avoid tyramine-rich
foods, or else therell
be Hypertensive Crisis
2-6 weeks
Avocado
Fermented
Aged cheese foods
Beer
Pickles
Chocolate
Preserved
Soy sauce
food
59
Antianxiety
GABA
Anticholinergic
SEIZURE
Rebound
Abrupt
S/E
Constipation
Retention
Dry Mouth
Blurred Vision
WITHDRAWAL
D
E
P
E
N
D
E
N
C
E
Drowsy
Do not Drink Alcohol
Do not drink Coffee
Do not drive Equipment
Develop O.H.
GRADUAL
Antipsychotic
Anticholinergic
D
60
DOWNERS
ABON Much to take IN
A lcohol
Morph
B arbituates Code INE
O piates
Hero
N arcotic
M arijuana - ambivalent
ASSESS: S/S: Overdose
bradycardia
bradypnea
moist mouth
pupils constrict
constipation
retention
hypotension
coma, lethargy
asleep
weight gain
UPPERS
CHA CHA
C ocaine
H allucinogens
A mphetamines - shabu
S/S: Overdose
Tachycardia
tachypnea
dry mouth
pupils dilate
hypertension
seizures
alertness
awake
weight loss
RR
LOC COMA
BP
Self-Actualization
SEIZURE
SELF ESTEEM
T-A-S-K
WITHDRAWN
STAY
SLEEP
HYPOACTIVE
SEX
61
62
03/04/06
Fundamentals of Nursing
Nursing Process > the nursing process provides the framework
in which nurses their knowledge and skills to express human
caring and to help clients meet their health needs
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Characteristics of the nursing process
1. It is cyclic and dynamic rather than static
2. It is client-centered nurse organizes plan of care
according to client problems rather than nursing goals.
3. It is interpersonal and collaborative depends on open and
meaningful communication between client and the nurse.
4. It is universally applicable can be used with clients of any
age at any point of wellness-illness continuum; useful in a
variety of settings.
5. It is an adaptation of problem-solving techniques and
systems theory-based on the scientific method
6. It can be viewed as parallel to but separate from the
medical process = focuses on resolving the disease of the
patient; Health/nursing problems human response to
the existing to the health condition disease or
wellness state
The nursing process diagram in each phase (see handout)
Quality assurance = safety in caring out nursing intervention =
standards of nursing care
Q: volunteer, nursing graduate, what type of nursing care:
A: interventions should live up to the standards of nursing
profession, even if you are just a volunteer.
Evidence based nursing = Research findings
Rectal temperature taking = 3-5mins
Oral temperature taking = 2-3mins
NGT = testing if the end of tubing submerge in a basin of waterbubbles lungs; distention in stomach = gas; should always be
updated
Data gathering: 2 sources of data:
Primary
Secondary
client himself/herself
significant others
chart
doctors
members of the health team
other related literature
Methods used in data gathering:
Observation using senses
Interviewing nursing history, therapeutic communication skills
Examining physical examination
Nursing history:
using subjective data
Data base is more often based on
Gordons Typology of 11 Functional Patterns
Health-perception-health management pattern
2. Describes clients perceived pattern of health and wellbeing and how health is managed
Nutritional-metabolic pattern describes pattern of
food and fluid consumption relative to metabolic need
and pattern indicators of local nutrient supply
Elimination pattern describes patterns of excretory
function (bowel, bladder, and skin)
Activity-exercise pattern describes pattern of
exercise, activity, leisure and recreation
ADLs healthy lifestyle household chores
Regular -> 3x/week -> 5-10mins warm up; 20-30mins cardiophase; 5-10mins cool down
Cognitive-perceptual pattern describes sensoryperceptual and cognitive pattern
Sleep-rest pattern describes pattern of sleep, rest and
relaxation
63
palpation on
painful site =
(+)
tenderness
elevated
Self care
deficit
Anxiety
complicated
Pco3 on
ABG
behavior
Vomiting
Impaired
parenting
Temperature
38.5 pyrexic,
febrile, fever
Decreased
cardiac
output
diaphoresis
Hemoptysis
Phase II NURSING DIAGNOSIS
clinical judgment about individual, family or community
responses to actual and potential health problems/life
processes; provides a basis for the selection of nursing
interventions to achieve outcomes for the which the nurse
is accountable.
This means that:
1. Professional nurses are responsible for making nursing
diagnosis
2. Nursing diagnosis describe a continuum of health states
Actual
Health
Problems
Potential
Health
Problems
Nursing Diagnosis
Focus on identifying human
responses to health and illness
Describe problems treated by
nurses within the scope of
independent nursing practice
Changes from day to day as
client responses change
Healthy
Responses
Medical Diagnosis
Identifies disease
Describe problems for which
the physician directs the
primary treatment
Remains the same for as long
as the disease is present
64
Effective breastfeeding
Anticipatory grieving
PC+:+complication+related to + etiology
Ex. Potential complication: pneumothorax related to fracture ribs
65
Spouse abuse
related to
husbands
immaturity and
violent temper
Impaired skin
integrity related
to clients lying
on back all
night
Identifying as a
problem a
client respond
that is not
necessarily
unhealthy
Mild anxiety
related to
impending
surgery
Identifying as a
problem signs
and symptoms
of illness
Cough related
to long history
of smoking
Identifying as a
Alterations in
Write
diagnosis in
legally
advisable
terms:
statements
that may be
interpreted
as libel OR
that imply
nursing
negligence
are legally
hazardous
to all nurses
caring for
the patient
Include in
the problem
statement
of the
nursing
diagnosis
only client
responses
that are
unhealthy
or that the
client wants
to change
Avoid
including
signs and
symptoms
of illness
Express the
relationship)
High risk for
violence:
spouse abuse
related to
husbands
reported
inability to
control
behavior.
Impaired skin
integrity related
to immobility
No need for
nursing
diagnosis; mild
anxiety before
surgery is a
healthy
response that
motivates preoperative self
care behavior
Ineffective
airway
clearance
related to 20
year history of
smoking
Self care
client problem
or etiology
what cannot be
changed
Bowel
Elimination:
Permanent
colostomy
related to
cancer of the
bowel
Grieving
related to
death of
spouse
>grieving is a
normal
response to
death
> if
dysfunctional
grieving 1
year can not
accept death
Problem +
Etiology
Suggest
suggest that
objective/Goals intervention;
eliminate
etiology will
eventually
eliminate
problem
Identifying
environmental
factors rather
than client
factors as a
problem
Reversing
client
statement
and
etiologic
factors in
terms that
can be
changed;
otherwise,
nursing
energies
are being
directed to
a hopeless
task
Cluttered home
related to
inability to
discard
anything
Knowledge
Avoid
deficit: care of
colostomy,
related to
severe anxiety
about cancer
and feelings of
powerlessness
> do not put the
medical
diagnosis as
the etiologic
statement but
put the human
responses only
Inability to
accept the
death of the
spouse.
provide
psychological
support/
emotional
support to
client
High risk for
injury related to
cluttered home
(inability to
discard
anything)
Altered
66
clauses
Having both
clauses say
the same thing
Including value
judgments in
the nursing
diagnosis
Including the
medical
diagnosis in
the diagnostic
statement
deficit related
to alteration in
parenting
Alteration in
comfort related
to pain (pain is
the comfort
alteration
what is
contributing to
the pain?)
> describe,
location, type
of pain
Poor home
maintenance
management
related to
laziness
Impaired home
maintenance
management
related to
arthritis
reversing
the problem
statement
and
etiologic
statement
Be sure that
the two
parts of the
diagnosis
do not
mean the
same thing
Write the
diagnosis
without
value
judgments;
avoid words
such as
poor,
inadequate,
abnormal
unhealthy
as much as
possible
parenting
related to
knowledge
deficit: OR
LACK OF
INFORMATION
ABOUT child
growth and
developmental
discipline
Unrelieved
incisional pain
related to fear
of addiction
Impaired home
maintenance
management
related to low
value ascribed
to home safety
and cleanliness
Impaired home
maintenance
management
related to
mobility,
endurance and
comfort
alterations
RIGHT
Alteration in oral mucous
membranes related to the
effects of chemotherapy
stomatitis Oral care
Increase fluid
Risk for injury related to
disorientation and impaired
judgment
> can intervene
Self-feeding deficit (Level III)
related to joint pain/swelling
Impaired physical mobility :
level III related to general
muscle weakness and spasm
in the legs
Ineffective airway clearance
related to accumulation of
tenacious secretions in the
airway
Hyperthermia
Infection
Non compliance with renal diet
related to the clients
perception of its therapeutic
ineffectiveness
WRONG
Risk for injury related to
frequent falls
67
Ineffective management of
therapeutic regimen: families
related to economic difficulties
> may intervene because you
can refer
FIRST
Ineffective airway
clearance related to
accumulation of
viscous secretions
MEDIUM
Anxiety related to
difficulty in
breathing
> because you can
resolve it if the 1st
priority
LOW
Sleep pattern
disturbance
Self care deficit
Altered family
processes
NOT SMART
After 2 weeks, the nurse will
assist the client to ambulate in
the hall 3x a day.
68
Vital signs
wound care
Massage
assisting to
ambulate
perineal care
position client in
bed
administration of
medication
IV therapy
NGT feeding
Passive ROM
crutch walking
DEPENDENT
COLLOBORATIVE
69
X
Negligence
Malpractice
The X stitch
An OB Gyn is too tired after having 10 CS operation for the past
10 hours. It is a practice of said physician to delegate the suturing
of the last layer of the patients abdominal cavity to her OR nurse.
Nurse Kristeta being young and aggressive accepted the task
and does it well.
Normal spontaneous delivery with specific training on suturing of
perineal cavity episiorrhapy ALLOWED
Allowed to do the IE during normal spontaneous delivery, prior to
complete delivery: in the absence of maternal fetal
aberration/abnormalities: abrupt placenta placenta previa
abortion, H-mole and absence of full delivery = DOCTOR
Crime Affecting Nurses:
1. Manner of Commission
3. DOLO > crimes committed with deceit (sinadya mo ang
crime), real criminal intention
4. CULPA > unintentional, product of negligence (hindi mo
sinadya)
2. Stages of Execution
5. CONSUMMATED > when the crime was totally,
absolutely commited or perfected
6. FRUSTRATED > when the offender performs everything
to consummate the crime but it did not happen
7. ATTEMPTED > no crime done, overt acts = merely
showing the intention to commit the crime
Degree of Participation
1. Principal very, very important, indispensable, primary
author of the crime
2. Accomplice dispensable, before & during
3. Accessory after the crime has been committed
benefiting itself from the product of the crime
Q: Referral by a nurse to an abortionist, the nurse is considered
to accomplice to an Abortionist, before the committing the act
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Intervention:
SAFETY physical, emotional
REPORT 48h at barangay - accessibility
REFERRAL DWSD
Abortion expulsion/termination of the product of conception
before the age of viability 12-24 weeks or 3-6months AOG
Infanticide crime if you killed a person/infant less than 3 days
or 72 hours of life
Parricide killing another person, whom you have a relationship
Homicide killed another person without any relationship, no
intention to kill, product of negligence ex. Somera case, wrong
drug administration
Murder with an intention to kill another person
Simulation of Birth committed by any person who shall
substitute 1 child to another child or alter his identities for the
purpose of losing his civil status. (e.g. failure to report the birth of
the baby PD 651 Birth Registration Act = requires all person
who shall assist in giving birth, OB, midwife, hilot, nurse, to
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SM BANT
Supervisor/Manager/Head
Nurse per ward, per shift,
per department
B BSN RN
A Accredited Organization
N Nine units MAN
T Two years general staff
nursing experience
C/D Chief/Director the
whole hospital
RN+MAN+
5 years Supervisory
Experience
(except: N.B. IF primary
hospital = 50 Bed capacity)
COMMUNITY
MILITARY
HOSPITAL
ADD ONLY
MASTERS IN
PHN OR CHN
5 years
supervisory in
the Community
MAN + General
Staffing Course
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73
pour flush
No Transport
automatic flush or
pour flush
No Water
pail system
(bucket latrine),
arinola
- flying saucer
(ballot system)
1. pit privy (not
water sealed
maamoy
- Antipolo
- bored hole
- Ventilated
Improved Pit (VIP)
- Reed odorless
Earth Closet
- twin pit/ compose
2. Over hung
Latrine
POLITICAL SOCIALIZATION
POLITICAL COMMUNICATION
INTEREST AGGREGATION
INTEREST ARTICULATION
SILENCE AND PASSIVITY
POLITICAL COMMUNICATION
Facilitate PEOPLES ORGANIZATION, to have a venue
for political consensus, in UNITY, theres STRENGTH
POLITICAL SOCIALIZATION
mobilization through activities to serve the people for
responsible action
Radical
Ultra
Leftist
Agaw Lalaki-AL
Liberal
Rightist
Single but
Satisfied-SISA
Conservative
Centralist
Neutral
Opportunists
Waitress: naghihintay/nanabik
Rich
Extravagant
Oppressors
Poor
Deprived
Bias
Oppressed
- no access to social
services, more problem,
more vulnerable
Inter-sectoral Linkages
Agricultural
Social welfare
Education
Population control
Public works
Private sector
Community Participation
active and full participation of the people in decisionmaking process:
- Assessment
- Planning
- Implementation
- Monitoring and evaluation
Levels of Participation:
Genuine Participation
- Delegated power 0:100
people/citizen control/people
empowerment starts 40:60
- Partnership shared leadership
minimum level of participation
50:50, shared majority
Token Participation
- Placation palliative
- Consultation problem identification,
democratic process
- Information decision has been made
Non-participation
- Therapy
- Manipulation
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Herbal medicines:
1. Mayana pigsa, lavender, pink, red, yellow, orange
2. Chichirika white, violet flowers alkaloid vincristine
oncovin = gamut sa cancer 1 vial injection
3. Oregano cough & colds, boiled, adobo
4. Akapulko anti-fungal, scabies
5. Sambong cough & colds, renal stones, stomach ache
6. Malunggay - scabies
7. Tanglad for fever, cough & colds
8. Mangga cough & colds, high fever
Aromatic Medicinal plants:
Volatile oils used for fever, cough & colds, itchiness, gas
pain
1. Sampalok 2 saklot ng leaves boil
2. Luya boil, decoction , 1 glass for am, noon,
night add half glass sugar, dissolve to thin the
consistency syrup can last 3-5 days = SLK
3. Kalamansi use 7 pcs to add flavor to SLK.
Infants, lowers fever, boil leaves of kalamansi
4. Sambong cough & colds
5. Oregano cough & colds
6. Yerba-buena cough & colds, itchiness,
arthritis, tooth ache with swollen gums.
7. Alagaw
8. Tanglad
9. Mangga
10. Damong Marya
11. Bawang- high blood, with antiseptic properties
12. Sibuyas
Tincture-external use 1:5 alcohol maputi, aceuate reddish
Tubal Ligation
Vasectomy ejaculate 25-40x to check sterility after
procedure
and eyeballs
- dry lips, child is
irritable but
conscious
- (-) skin fold test
blood pressure
- (+) skin fold test
Intravenous Fluid
Available
YES NO
yes
no -> NGT
ors
yes
no
REFER
via NGT
REFER
REFER IVF
>1 YR
3%
Moderate
10%
6%
Severe
15%
9%
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