Nursing Care - Roxana Bucur

IN BED POSITIONS
I. In Dorsal Recumbent Position:

1. Arrange the pillows in the order to support the weight of the shoulders and head.
2. Relieve strain on the muscles of the back by supporting it, fill in the hollows with small pillows, small
pads, or a hot water bottle partially filled with warm water.
3. Relieve strain on the abdominal muscles and on tendons under the knees. Support with the knee
rest provided on the Gatch bed or with a pillow.
II. Turning to One Side:

A. To turn the patient toward you:
1. Move the patient to the side of the bed away from you by putting your forearms under the body then
sliding first the head and shoulders, next the hips then legs across the bed.
2. Place one of your arms across the patients back reaching from the far side to the side nearer you
and the other arm across his hips on the same way.
3. Lift and turn him gently toward you to the middle of the bed.
4. See that the head, shoulders and hips are properly adjusted, that the neck and shoulders are not
cramped and the arms are not pinned under the body.
5. Flex the knees with the upper leg flexed a little more than the lower leg.
6. Support the legs by placing a pad or small pillow between them.
7. Support the whole length of the back with pillows so that the patient can relax comfortably.
8. A small pillow placed against the abdomen gives relief and comfort especially when the patient is
suffering from gas pains.
B. To turn patient away from you:

1. From the side nearest you, slip one arm under the patients shoulder reaching the far shoulder and
place the other around the hips in the same way.
2. Lift and draw his far side slightly toward you so that he is gradually turned away from you.
Drug Study
Generic Name: Nifedipine
Brand Name: Adalat, Adalat CC, Nifedical XL, Procardia, Procardia XL
Classification: Antianginal, Antihypertensive, Calcium Channel Blocker
Indications:
1. Hypertension
2. Angina pectoris
3. Vasospastic angina
4. Raynauds phenomenon
Mechanism of Action
The action of Nifedipine is based on the fact that this medication works by slowing the movement of calcium
in the muscle cells that are found in the blood vessel wall. This drug blocks the calcium chennels in these
muscle cells. As a result, the muscle cells relax because the calcium is needed by the muscle cells to
contract. Thus depriving the muscle cells with calcium would end in muscular relaxation. Nifedipine
specifically acts on the muscle cells of the arterial walls, relaxing the arteries. The relaxation effect allows the
arteries in the body to widen. This is a double effect of this drug.
When the small arteries of the body is relaxed and widened the resistance that the heart pushes to pump the
blood around the body also decreases. This in return lowers the pressure within the blood vessels. Thus,
Nifedipine is used in decreased an elevated blood pressure.
Aside from lowering the blood pressure, the widening effect on the small arteries and arteries of the heart
also improves blood circulation and therefore increases the oxygen supply to the heart. This unique feature
of Nifedipine makes it ideal in the management of episodes of angina. Because chest pain in angina is
caused by the insufficient blood supply in the heart. Thus, as this drug improves oxygen supply and reduces
the effort of the heart to make the blood pump, it can be used for preventing angina attacks.
A circulatory disorder called a Raynauds phenomenon can also be managed by Nifedipine. With Raynauds
phenomenon, the blood vessels in the hands go into spasm and contarct excessively when the hands are
cold. As a result, the hands go white, numb and painful. With the administration of Nifedipine, the peripheral
arteries in the hands are relaxed that would cause them to widen and improve blood circulation in the
fingers.
Contraindications
1. Hypersensivity
2. Sick sinus syndrome
3. 2nd- or 3rd- degree AV block (unless an artificial pacemaker is in place)
4. Blood pressure <90 mmHg
5. Coadministration with grapefruit juice
Use Cautiously in patients with:

1. Severe hepatic impairment
2. History of porphyria
3. Geriatric patients
4. Severe renal impairment
5. History of serious ventricular arrhythmias or CHF
6. Pregnancy
7. Lactation
8. Children
Side Effects
1. Headache
2. Anxiety
3. Confusion
4. Dizziness
5. Drowsiness
6. Jitteriness
7. Nervousness
8. Weakness
9. Blurred vision
10. Tinnitus
11. Cough
12. Peripheral edema
13. Bradycardia
14. Chest pain
15. Hypotension
16. Palpitations
17. Syncope
18. Constipation
19. Diarrhea
20. Dry mouth
21. Nausea and vomiting
22. Photosensitivity
23. Muscle cramps.
Nursing Responsibilities
1. Monitor BP and pulse before therapy, during dose titration and periodically during the therapy.
2. ECG should be monitored during prolonged therapy.
3. Monitor intake and output rations and daily weight.
4. Assess for signs of CHF such as peripheral edema, rales/crackles, dyspnea, weight gain and
jugular vein distention.
5. For patients with angina, assess the location, duration, intensity and precipitating factors of patients
angina pain.
6. Instruct patient on technique for monitoring pulse. If heart rate is below 50 beats per minute, the
physician should be notified.
7. PO (per os) medications may be administered without regard to meals. If in case GI
(gastrointestinal) irritation becomes a problem, it can be administered with meals.
8. Adalat should never be administered with grapefruit juice. As it can increase the level of the
medicine in the blood and thus increase its effect on the blood pressure. This could make the patient feel
dizzy. If the patient has been regularly drinking grapefruit juice, this effect can last for at least three days after
his or her last drink.
9. Sublingual use is not recommended due to serious adverse drug reactions.
10. Instruct the patient to avoid concurrent use of alcohol or OTC (over-the-counter without
prescription) medications and natural or herbal products especially cold preparations, without consulting the
doctor.
11. Advise patient to take medication exactly as directed. Missed doses should be taken as soon as
remembered unless almost time for next dose.
12. Instruct the patient not to double doses.
13. Drug should be discontinued gradually.
14. Caution patient to change positions slowly to minimize orthostatic hypotension.
15. Advise patient to avoid driving or other activities requiring alertness until response to the medication
is known.
16. Caution patient to wear protective clothing and use sunscreen to prevent photosensitivity reactions.
17. Instruct patient on importance of maintaining good dental hygiene and seeing dentists frequently for
teeth cleaning to prevent tenderness, bleeding and gingival hyperplasia (gum bleeding).
18. Instruct the patient to contact the physician immediately if the following are experienced or
observed:
Irregular heartbeat
Dyspnea
Swelling of hands and feet
Pronounced dizziness
Nausea
Constipation
Hypotension
Severe or persistent headache
Generic Name: Hydralazine

Brand Name: Apresoline
Classification: Antihypertensive, Vasodilator
Indications:
Moderate to severe hypertension (with a diuretic). Lowering high blood pressure helps prevent
strokes, heart attacks, and kidney problems.
CHF (congestive heart failure) unresponsive to conventional therapy with Digoxin and diuretics
Mechanism of Action
Hydralazine is a vasodilator that works by relaxing the muscles in the blood vessels to help them dilate
(widen). This lowers blood pressure and allows blood to flow more easily through the veins and arteries.
Contraindications
1. Hypersensitivity
2. Severe tachycardia
3. Dissecting aortic aneurysm
4. Heart failure with high cardiac output
5. Cor pulmonale
6. Myocardial insufficiency due to mechanical obstruction
7. Coronary artery diseas
8. Idiopathic SLE (systemic lupus erytematosus)
9. Patients with recent MI
Use cautiously in:

1. Cardiovascular or Cerebrovascular disorders: Ischemic heart disease, rheumatic heart disease
affecting the mitral valve
2. Severe renal and hepatic disease
3. Pregnancy
4. Lactation
5. Children
Adverse Reactions and Side Effects:

1. Dizziness
2. Drowsiness (half-asleep, sleepy state)
3. Headache
4. Tachycardia
5. Angina
6. Arrhythmias
7. Edema
8. Orthostatic hypotension
9. Diarrhea
10. Nausea and vomiting
11. Rashes
12. Sodium retention
13. Arthralgias
14. Arthritis
15. Peripheral neuropathy
16. Drug induced lupus syndrome
Nursing Responsibilities
1. Monitor the clients blood pressure and pulse frequently during initial dosage adjustment and
periodically throughout therapy. Report significant changes to the physician.
2. Monitor frequency of prescription refills to determine adherence.
3. Prior to and periodically during prolonged therapy the following lab values should be monitored:
CBC (complete blood count), electrolytes, LE (lupus erytematosus) Cell Prep and ANA (antinuclear antibody)
titer. (Common Labs Tests)
4. The nurse must be aware that Hydralazine may cause a positive direct Coombs test result. (The
Coombs test looks for antibodies that may stick to your red blood cells and cause red blood cells to die too
early).
5. IM or IV route should be used only when the drug cannot be given orally.
6. Hydralazine may be administered concurrently with diuretics or beta blockers to permit lower doses
and minimize side effects.
7. Instruct the patient not to let anyone else take his or her medication.
8. Inform the patient to take hydralazine with meals or a snack.
9. Instruct the patient to take this medication exactly as prescribed by the doctor. He or she should not
take it in larger amounts or for longer than recommended. Directions on the prescription label should be
followed.
10. It is important to remind the patient to keep using Hydralazine as directed, even if he or she feels
well. High blood blood pressure often has no symptoms, so you may not know when your blood pressure is
high.
11. STORAGE: Store hydralazine at room temperature away from moisture and heat.
12. In cases where the patient missed a dose he or she should take the missed dose as soon as he or
she remembers. If it is almost time for the next dose, wait until then to take the medicine and skip the missed
dose. Do not take extra medicine to make up the missed dose.
13. Instruct the patient to call the physician immediately if he or she experiences the following
symptoms:
Fainting
Joint or muscle pain
Unexplained fever
Rapid heartbeat
Chest pain
Swollen ankles or feet
Numbing or tingling in hands or feet
HEMATOCRIT (HCT)
Normal Adult Female Range: 37 47%
Optimal Adult Female Reading: 42%
Normal Adult Male Range 40 54%
Optimal Adult Male Reading: 47
Normal Newborn Range: 50 62%
Optimal Newborn Reading: 56
HEMOGLOBIN (HGB)
Normal Adult Female Range: 12 16 g/dl
Optimal Adult Female Reading: 14 g/dl
Normal Adult Male Range: 14 18 g/dl
Optimal Adult Male Reading: 16 g/dl
Normal Newborn Range: 14 20 g/dl
Optimal Newborn Reading: 17 g/dl
MCH (Mean Corpuscular Hemoglobin)

Normal Adult Range: 27 33 pg
Optimal Adult Reading: 30
MCV (Mean Corpuscular Volume)

Normal Adult Range: 80 100 fl
Higher ranges are found in newborns and infants
MCHC (Mean Corpuscular Hemoglobin Concentration)

Normal Adult Range: 32 36 %
Higher ranges are found in newborns and infants
R.B.C. (Red Blood Cell Count)

Normal Adult Female Range: 3.9 5.2 mill/mcl
Optimal Adult Female Reading: 4.55
Normal Adult Male Range: 4.2 5.6 mill/mcl
Optimal Adult Male Reading: 4.9
Lower ranges are found in Children, newborns and infants
W.B.C. (White Blood Cell Count)

Normal Adult Range: 3.8 10.8 thous/mcl
Optimal Adult Reading: 7.3
Higher ranges are found in children, newborns and infants.
PLATELET COUNT
Normal Adult Range: 130 400 thous/mcl
Higher ranges are found in children, newborns and infants
NEUTROPHILS and NEUTROPHIL COUNT this is the main defender of the body against
infection and antigens. High levels may indicate an active infection.
Normal Childrens Range: 30 60 %
Optimal Childrens Reading: 45
LYMPHOCYTES and LYMPHOCYTE COUNT Elevated levels may indicate an active viral
infections such as measles, rubella, chickenpox, or infectious mononucleosis.
Normal Childrens Range: 25 50 %
Optimal Childrens Reading: 37.5
MONOCYTES and MONOCYTE COUNT Elevated levels are seen in tissue breakdown or
chronic infections, carcinomas, leukemia (monocytic) or lymphomas.
EOSINOPHILS and EOSINOPHIL COUNT Elevated levels may indicate an allergic
reactions or parasites.
BASOPHILS and BASOPHIL COUNT Basophilic activity is not fully understood but it is
known to carry histamine, heparin and serotonin. High levels are found in allergic
reactions.
Electrolyte Values
SODIUM - Sodium is the most abundant cation in the blood and its chief base. It functions
in the body to maintain osmotic pressure, acid-base balance and to transmit
nerve impulses. Very Low value: seizure and Neurologic Sx.
Normal Adult Range: 135-146 mEq/L
POTASSIUM Potassium is the major intracellular cation. Very low value: Cardiac
arythemia.
Normal Range: 3.5 5.5 mEq/L
CHLORIDE Elevated levels are related to acidosis as well as too much water crossing the
cell membrane. Decreased levels with decreased serum albumin may indicate
water deficiency crossing the cell membrane (edema).
CO2 (Carbon Dioxide) The CO2 level is related to the respiratory exchange of carbon
dioxide in the lungs and is part of the bodies buffering system. Generally when
used with the other electrolytes, it is a good indicator of acidosis and alkalinity.
Normal Childrens Range 20 28 mEq/L
CALCIUM involved in bone metabolism, protein absorption, fat transfer muscular

contraction, transmission of nerve impulses, blood clotting and cardiac function.
Regulated by parathyroid.
Normal Adult Range: 8.5-10.3 mEq/dl
PHOSPHORUS Generally inverse with Calcium.

Normal Adult Range: 2.5 4.5 mEq/dl
Normal Childrens Range: 3 6 mEq/dl
Optimal Childrens Range: 4.5
ANION GAP (Sodium + Potassium CO2 + Chloride) An increased measurement is

associated with metabolic acidosis due to the overproduction of acids (a state of
alkalinity is in effect). Decreased levels may indicate metabolic alkalosis due to
the overproduction of alkaloids (a state of acidosis is in effect).
Normal Adult Range: 4 14 (calculated)
CALCIUM/PHOSPHORUS Ratio
Normal Adult Range: 2.3 3.3 (calculated)
Normal Childrens range: 1.3 3.3 (calculated)
Optimal Childrens Reading: 2.3
SODIUM/POTASSIUM
Normal Adult Range: 26 38 (calculated)
Hepatic Enzymes
AST (Serum Glutamic-Oxalocetic Transaminase SGOT ) found primarily in the liver,

heart, kidney, pancreas, and muscles. Seen in tissue damage, especially heart
and live
Normal Adult Range: 0 42 U/L
ALT (Serum Glutamic-Pyruvic Transaminase SGPT) Decreased SGPT in combination

with increased cholesterol levels is seen in cases of a congested liver. We also
see increased levels in mononucleosis, alcoholism, liver damage, kidney
infection, chemical pollutants or myocardial infarction
ALKALINE PHOSPHATASE Used extensively as a tumor marker it is also present in bone

injury, pregnancy, or skeletal growth (elevated readings. Low levels are
sometimes found in hypoadrenia, protein deficiency, malnutrition and a number
of vitamin deficiencies
Normal Childrens Range: 40 400 U/L
GGT (Gamma-Glutamyl Transpeptidase) Elevated levels may be found in liver disease,

alcoholism, bile-duct obstruction, cholangitis, drug abuse, and in some cases
excessive magnesium ingestion. Decreased levels can be found in
hypothyroidism, hypothalamic malfunction and low levels of magnesium.
Normal Adult Female Range: 0 45 U/L
Optimal Female Reading: 22.5
Normal Adult Male Range: 0 65 U/L
Optimal Male Reading: 32.5
LDH (Lactic Acid Dehydrogenase) Increases are usually found in cellular death and/or
leakage from the cell or in some cases it can be useful in confirming myocardial
or pulmonary infarction (only in relation to other tests). Decreased levels of the
enzyme may be seen in cases of malnutrition, hypoglycemia, adrenal exhaustion
or low tissue or organ activity.
BILIRUBIN, TOTAL Elevated in liver disease, mononucleosis, hemolytic anemia, low
levels of exposure to the sun, and toxic effects to some drugs, decreased levels
are seen in people with an inefficient liver, excessive fat digestion, and possibly a
diet low in nitrogen bearing foods
Normal Adult Range 0 1.3 mg/dl
Optimal Adult Reading: .65
Renal Related
B.U.N. (Blood Urea Nitrogen) Increases can be caused by excessive protein intake,
kidney damage, certain drugs, low fluid intake, intestinal bleeding, exercise or
heart failure. Decreased levels may be due to a poor diet, malabsorption, liver
damage or low nitrogen intake.
Normal Adult Range: 7 25 mg/dl
CREATININE Low levels are sometimes seen in kidney damage, protein starvation, liver
disease or pregnancy. Elevated levels are sometimes seen in kidney disease due
to the kidneys job of excreting creatinine, muscle degeneration, and some drugs
involved in impairment of kidney function.
Normal Adult Range: .7 1.4 mg/dl
URIC ACID High levels are noted in gout, infections, kidney disease, alcoholism, high
protein diets, and with toxemia in pregnancy. Low levels may be indicative of
kidney disease, malabsorption, poor diet, liver damage or an overly acid kidney.
Normal Adult Female Range: 2.5 7.5 mg/dl
Optimal Adult Female Reading: 5.0
Normal Adult Male Range: 3.5 7.5 mg/dl
Optimal Adult Male Reading:5.5
BUN/CREATININE This calculation is a good measurement of kidney and liver function.

Normal Adult Range: 6 -25 (calculated)
Protein
PROTEIN, TOTAL Decreased levels may be due to poor nutrition, liver disease,
malabsorption, diarrhea, or severe burns. Increased levels are seen in lupus, liver
disease, chronic infections, alcoholism, leukemia, tuberculosis amongst many
others.
Normal Adult Range: 6.0 -8.5 g/dl
ALBUMIN major constituent of serum protein (usually over 50%). High levels are seen in
liver disease(rarely) , shock, dehydration, or multiple myeloma. Lower levels are
seen in poor diets, diarrhea, fever, infection, liver disease, inadequate iron intake,
third-degree burns and edemas or hypocalcemia
Normal Adult Range: 3.2 5.0 g/dl
GLOBULIN Globulins have many diverse functions such as, the carrier of some
hormones, lipids, metals, and antibodies(IgA, IgG, IgM, and IgE). Elevated levels
are seen with chronic infections, liver disease, rheumatoid arthritis, myelomas,
and lupus are present, . Lower levels in immune compromised patients, poor
dietary habits, malabsorption and liver or kidney disease.
Normal Adult Range: 2.2 4.2 g/dl (calculated)
A/G RATIO (Albumin/Globulin Ratio)

Normal Adult Range: 0.8 2.0 (calculated)
Lipids
CHOLESTEROL High density lipoproteins (HDL) is desired as opposed to the low density
lipoproteins (LDL), two types of cholesterol. Elevated cholesterol has been seen
in artherosclerosis, diabetes, hypothyroidism and pregnancy. Low levels are seen
in depression, malnutrition, liver insufficiency, malignancies, anemia and
infection.
LDL (Low Density Lipoprotein) studies correlate the association between high levels of
LDL and arterial artherosclerosis
Optimal Adult Reading: 81 mg/dl
HDL (High Density Lipoprotein) A high level of HDL is an indication of a healthy

metabolic system if there is no sign of liver disease or intoxication.
Optimal Adult Reading: +85 mg/dl
TRIGLYCERIDES Increased levels may be present in artherosclerosis, hypothyroidism,

liver disease, pancreatitis, myocardial infarction, metabolic disorders, toxemia,
and nephrotic syndrome. Decreased levels may be present in chronic obstructive
pulmonary disease, brain infarction, hyperthyroidism, malnutrition, and
malabsorption.
CHOLESTEROL/LDL RATIO
Normal Adult Range: 1 6
Thyroid
THYROXINE (T4) Increased levels are found in hyperthyroidism, acute thyroiditis, and
hepatitis. Low levels can be found in Cretinism, hypothyroidism, cirrhosis,
malnutrition, and chronic thyroiditis.
Normal Adult Range: 4 12 ug/dl
Optimal Adult Reading: 8 ug/dl
T3-UPTAKE Increased levels are found in hyperthyroidism, severe liver disease,

metastatic malignancy, and pulmonary insufficiency. Decreased levels are found
in hypothyroidism, normal pregnancy, and hyperestrogenis status.
Normal Adult Range: 27 47%
Optimal Adult Reading: 37 %
FREE T4 INDEX (T7)
Normal Adult Range: 4 12
THYROID-STIMULATING HORMONE (TSH) produced by the anterior pituitary gland,

causes the release and distribution of stored thyroid hormones. When T4 and T3
are too high, TSH secretion decreases, when T4 and T3 are low, TSH secretion
increases.
Normal Adult Range: .5 6 miliIU/L
Cardiac
Creatine phosphokinase (CK) Levels rise 4 to 8 hours after an acute MI, peaking at 16 to
30 hours and returning to baseline within 4 days
25-200 U/L
32-150 U/L
CK-MB CK isoenzyme It begins to increase 6 to 10 hours after an acute MI, peaks in 24

hours, and remains elevated for up to 72 hours.
< 12 IU/L if total CK is <400 IU/L
<3.5% of total CK if total CK is >400 IU/L
(LDH) Lactate dehydrogenase Total LDH will begin to rise 2 to 5 days after an MI; the
elevation can last 10 days.
140-280 U/L
LDH-1 and LDH-2 LDH isoenzymes Compare LDH 1 and LDH 2 levels. Normally, the
LDH-1 value will be less than the LDH-2. In the acute MI, however, the LDH 2
remains constant, while LDH 1 rises. When the LDH 1 is higher than LDH 2, the
LDH is said to be flipped, which is highly suggestive of an MI. A flipped pattern
appears 12-24 hours post MI and persists for 48 hours.
LDH-1 18%-33%
LDH-2 28%-40%
SGOT will begin to rise in 8-12 hours and peak in 18-30 hours
10-42 U/L
Myoglobin - early and sensitive diagnosis of myocardial infarction in the emergency

department This small heme protein becomes abnormal within 1 to 2 hours of
necrosis, peaks in 4-8 hours, and drops to normal in about 12 hours.
Troponin Complex Peaks in 10-24 hours, begins to fall off after 1-2 weeks.
Table of Cardiac markers
Serum Markers of Myocardial
Injury
Detected Peak Falls
Myoglobin 1-3 1-8 12-18
CK/CK-MB 3-8 12-16 24-48
MB Isoforms 1-6 4-8 12-48
cTnI: 5-9 days cTnT: 7-14
Troponin Complex 3-6 10-24
days
Typical Marker Values during AMI
General Nursing Responsibilities
1. Administering Drugs
2. Assessing drug effects
3. Intervening to make the drug regimen more tolerable
4. Providing patient teaching about drugs regimen
Principles of Medication Administration
1. Legal and ethical consideration (Nursing Act)
2. Types of medication order
a. Stat
b. Standing order
c. Renewal order
d. PRN order
e. Verbal order
f. Electronic transmission of patient order
3. Nursing responsibilities in administering drugs
a. Verification
b. Transcription
4. The six rights of administration
a. Right drug
b. Right time
c. Right dose
d. Right patient
e. Right route
f. Right documentation
Routes of Drug Administration
I. Enteral
a. Oral
Most convenient route
Access to systemic circulation
b. Sublingual
Small amount of drugs are required blood
Prompt relief (angina pectoris)
Venous drainage from the mouth Sup. Vena Cava
Drug is protected from rapid first pass metabolism by the liver and GIT
Achieves immediate absorption into the systemic circulation
c. Rectal anal portal rectum lower intestine
Useful in vomiting & unconscious patient

50% absorbed from the rectum will bypass he liver
Its absorption often irregular & incomplete
Many drugs causes irritation.
II. Parenteral
a. IV preferred for emergency immediate response

Irritation solutions given in the manner because the blood vessels walls (incentive) &
drug injected slowly diluted by the blood.
Liabilities:
Unfavorable reactions
High drug concentration attained rapidly
No retreat
Repeated administration dependent upon the patient vein
Drugs in an oily vehicle should not be given in hemodialysis
Must be perform slowly with constant monitoring
b. (IM) Intramuscular
Absorption relatively fast
Used when immediate effect is not required
Prompt effect is desirable
Absorption by diffusion
Rate of absorption following aqueous preparation into deltoid or Vastus lateral is
faster than gluteus maximums
Rate is lower for females in gluteus maximus (attributed to the different
distribution of subcutaneous fat, since fat relatively poorly perfused)
c. Subcutaneous (SC)
Injected into the alveolar connective tissue just below the skin
Absorption slower than IM
May be faster than by oral route
Used for non-irritating drugs
Rate of absorption constant & slow show sustained effect
Rate of absorption of a supplement of insoluble insulin is slow
(Compared to soluble preparation)
d. Intradermal
Below the dermis
e. Intrathecal / Intraventricular
Because of blood-brain barrier show entrance to CNS
Injected into spinal subarachnoid space.
f. Intra-arterial
To localized its effect in a particular tissue/organ
Diagnostic agents
Reserved for experts
g. Intraperitoneal
Offers large absorbing surface
Common lab procedure
Seldom employed clinically
Caution: Dangers of infection and adhesions
III. Inhalation
Gaseous or volatile subs systemic circulation
Absorbed through pulmonary epithelium and mucous membrane of the tract
Access to circulation is rapid because of large surface area
Advantages:
Instant absorption into the blood
Local application at the desired site
Disadvantages:
Poor ability to regulate the dose
Causes irritation of the pulmonary epithelium
IV. Topical / percutaneous

Immediately beneath the point of application
a. Mucous membrane of conjunctiva, nasopharynx, oropharynx, Vagina, urethra, etc. for local
effects
b. Skin
Systemic absorption abraided, burned or denuded skin
Inflammation enhance absorption
Oily vehicle + rubbing (inunction) enhance absorption
c. Eye
Local effect
Systemic absorption through nasolacrimal canal.
Placing the Patient in Different Positions for

Examination
I. Horizontal Recumbent
1. Place patient flat on back with legs extended or slightly flexed.
2. Place bath blanket over patient lengthwise. Fan bedding to foot of bed
Purpose:
1. General examination.
2. Abdominal surgery.
3. Surgery on head and extremities.
II. Dorsal Recumbent
1. Place patient flat on back with one pillow under head; have knees flexed and separated and feet flat
on bed.
2. Fold blanket in half lengthwise. Lay center of blanket over abdomen and ends over each foot. Fan
leading to foot on bed. Arrange blanket to cover extremities and expose perineum.
Purpose:
1. Rectal, vaginal and pelvic examinations and treatments.
2. Deliveries.
III. Sims or Left Lateral

1. Place patient on left side somewhat obliquely across the bed with buttocks to edge of mattress.
Incline the body forward, draw the left arm back under patient and place the right arm free in front. The
thighs should be flexed upon the bodythe right more than the left.
2. Place lengthwise bath blanket over patient, fanfold topsheet to foot of bed. Fold blanket back
exposing the area to be examined.
IV. Knee-Chest or Genu-Pectoral

1. Place patient in the prone position, then assist her to kneel so that her weight rests on her chest
and knees. Turn head to one side and flex her arms at the elbows extending, then to the bed in front of her.
Be sure the thighs are perpendicular to the level of the head. Watch pulse and general condition of the
patient.
Purpose:
1. To obtain better exposure of the vagina, cervix, and rectum.
2. To examine the bladder.
3. To help correct retroversion of the uterus.
4. To administer caudal and sacral anesthesia.
5. Vaginal and rectal examinations.
6. Operative procedures on the vagina, rectum and perineum. Operative deliveries
V. Dorsal Lithotomy or Dorso-sacral:

In bed:
1. Place the patient on her back across bed with the buttocks slightly beyond the edge of the mattress,
then flex knees over the abdomen and separate the knees. Support the knees by means of long sheet folded
diagonally and passed under the knees and around the neck.
2. Draw up gown over abdomen. Drape as for dorsal recumbent.
Purpose:
1. Vaginal and rectal examination.
2. Operative procedures on the vagina, rectum and perineum.
3. Deliveries and operative deliveries
On Examining Tables: Place patient on dorsal position with the knees flexed and feet in still-ups. Buttocks
are brought down to edge of examining table.
VI. Standing or Erect
When used for vaginal examination:
1. Have the patient standing with the knees separated about ten inches with one foot on a low stool.
Instruct her to place one hand on the buck of the chair for support and the other hand on her hip.
2. Either remove skirts or fold about waist. Wrap a folded sheet about the lower part of the body
stimulating skirt, with the sides overlapping in front. Pin it to hold in place.
When use for examination of spine and backs:

1. Remove patients slippers and have patient stand on towel.
2. Loosen gown, place bath blanket around shoulders with opening at the back. Pin at nape.
Purpose:
1. Vaginal examination for determining the degree of prolapse of the uterus.
2. Examination of hernia
VII. Prone
1. Let patient lie on his abdomen. Turn hand to one side. Allow pillow under the head and another
under the lower chest.
2. Draping same as in dorsal.
Purpose:
1. For treatment on the back.
2. To facilities drainage from wound.
3. To secure drainage of pus to front of abdomen.
4. To keep pus away from the spine.
VIII. Jack knife or Kroaske or Bozeman

1. Place patient on a prone position with the hips directly over the band of the examining table. Tip the
table with the head lower than the hips. Lower the foot part of the table so that the patients feet are below
the level of his head. Place pillow under the pelvis and abdomen to relieve the strain.
2. Drainage
Purpose: Operation on the rectum and coccyx

IX. Walchers Position
1. Place patient flat on her back with the sacrum resting on the edge of the table. Lower the legs
slowly toward the floor. Elevate the buttocks slightly if the table permits.
2. Draping is similar to that of the lithotomy position.
Purpose:
1. To increase the diagonal conjugate of the pelvis in high forcep delivery and in breach presentation.
2. Relax the perineum
X. Fowlers and Semi-Fowlers Position

Method I: Elevate head part of the bed by means of head elevator 8-24 inches high. Elevate knee to about 6
in.
Method II: Place patient in semi-sitting position by backrest. Flex knees and support with pillows.
Purpose:
1. To obtain good drainage in the pelvis.
2. To localize infection in the pelvis and prevent its spread to the peritoneum.
3. To prevent strain of abdominal muscles.
4. To facilitate breathing in patients with cardiac or respiratory embarrassment fur post-operative nasal
cases and/or thyroidectomy cases.
XI. Trendelenburg Position

1. Place patient in the horizontal recumbent position. Well-padded shoulder braces and knees and
arms restraints are adjusted. If on the operating table. Adjust the table so that the patients head is low the
body on an inclined phone and the knees flexed over the adjustable lower section of the table, which is
lowered.
2. If no bed, rise the foot part of the bed by means of bed elevator blocks also known as shock blocks.
Purpose:
1. Gynecological surgery and suprapubic prostatectomy cases.
2. To prevent shocks.
3. To prevent or relieve post-partum hemorrhage.
Role the Nurse in Physical Examination

1. Nurse plays an important role in the program of prevention of disease not only by encouraging the
individual to have such as examination but also by her tact and a kill in assisting in such a way as to
minimize embarrassment to the patient.
2. Explanation as to what is to be done and why usually facilitate the procedure both for the doctor and
the patient and will make the patient more relaxed and more cooperative.
3. Nurse can render invaluable assistance in expanding the examiners work and in conserving the
patients strength. Most thorough examination is lengthy and tiring.
4. When patient is a woman, the presence of nurse prevents embarrassment to the patient and it
protects the physician from any court action in case patient complains.
5. Nurse is held responsible in having all equipment and articles ready for the examination, preparing
the patient accordingly, anticipating the physicians needs and taking care of the used articles after the
examination.
Nursing Interventions for Pain
1. Asses pain every 2 hours using a 1-10 scale, pain scales provide a measure of pain which is consistent.
2. Observe for nonverbal signs of pain, are like: facial expression, posture, restlessness, crying / grimacing,
withdrawal, diaphoresis, changes in heart rate / breathing, blood pressure.
3. Teach patient adverse complication of uncontrolled pain, it is important the patient understand why pain is
treated so they will report discomfort.
4. Suggest to rest in a quiet room. Instruct patient to report pain immediately if the pain arises.
5. Teach patient deep breathing and visulization, these methods can reduce pain preception and return to
the patient a feeling of control.
6.Teach patient that addiction to pain meds is not formed when medication is needed due to acute pain.
7. Massage the head / neck / arm if the patient can tolerate the touch.
8. Use the techniques of therapeutic touch, visualization, biofeedback, hypnosis itself, and stress reduction
and relaxation techniques to another.
9.Instruct the patient to use a positive statement I am cured, Im relaxing, I love this life. Instruct the patient
to be aware of the external-internal dialogue and say stop or delay if it comes up negative thoughts.
10.Provide patient with distractions of choice such as TV, music or reading. Distraction can help to relieve
pain.
Interstitial cystitis, often mistaken for bladder pain syndrome or urinary tract infection, needs interventions
that start with comprehensive patient teaching about the continuous nature of the condition as well as
accurate assessments of the condition, prognoses, and likely reactions to the interventions. Continuous
reassurance along with emotional and physical support is vital as the diagnostic assessment goes on and
therapies are being done. Rarely will patients who have interstitial cystitis achieve complete, instant, and
long-lasting reaction to any specific intervention. They should be guided wholly about the non-existence of
universally efficient interventions. Most of the time, referral to the Interstitial Cystitis Association, especially if
to a nearby chapter, could be very helpful in giving a continuing system of support for the person.
Preferably, in clinical practice, interstitial cystitis treatment ought to begin with the most conservative, least
costly, and most reversible intervention. Typically, this includes dietary as well as fluid management, stress
and time controlling, and behavioural adjustment. Then, interventions are provided in a progressive manner,
each time getting more invasive until there is symptomatic relief achieved. Initial treatment level could also
be affected by clinical opinion, considering the seriousness of the symptoms presented and factors that are
specific to the patient.
Behavioural Therapy
After every intervention, the patient is assessed for reaction. Sad to say, interventions, most of the time, are
given in a random fashion, mixing a lot of different treatments before really assessing the reaction of the
patient to each. This kind of approach is, at times, propelled by unrealistic demands of the patient and
expectations about the success of the interventions. It should be emphasized that patients should receive
broad guidance about the nature as well as the prognosis of their condition and the probable reactions to
therapy. This is very important, and the counselling ought to be started before actually going on the invasive
interventions which have not revealed any benefit that could be achieved. Treatments like biofeedback,
pelvic floor rehabilitation, as well as bladder training programs, among other behavioural measures are great
starting interventions and actually have been used by some who have seen some successful outcomes.
Dietary measures have also been tried. Some foods are found to aggravate symptoms like alcohol, coffee,
vinegar, tomatoes, chocolate, spicy foods, and particular vegetables and fruits. Patients are advised to avoid
such food. Patients write down on a dietary journal what they usually have and these are modified in order to
prevent exacerbations. About 3-6 months length of behavioural therapy is necessary before moving in to
more invasive or costly interventions.
Oral Medication
Oral medications ought to be regarded only after the above conservative interventions have not been
successful. The duration for each medication is variable. The following drugs are often prescribed:
Oral pentosan polysulfate sodium
Hydroxyzine
Amitriptyline
Anticholinergics (oxybutynin, tolterodine)
Cyclosporine A
Elmiron
Oral therapy should be used with as much precaution since there are some side effects that could be
unpleasant to the patient or could exacerbate the condition.
Stable angina as a sign can be very helpful in evaluating patients who have the tendency to have a
heart attack. Chest pain as complained by patients must also be screened out in order to point out on what it
is the true state. Some chest pain is due to a pulmonary infection, embolism that blocks a lung artery or
narrowing of arteries. Psychological factors may also start chest pain as presenting sign panic attacks.
A successful evaluation whether a patient has suffered a stable angina is a good step in helping the patient
to function on a moderate level of activity. He or she can function properly without reaching the maximum
activity level thereby preventing future episodes of angina and eventually heart problems.
Characteristics of a stable angina:
1. Onset is predictable
2. The pain can be relieved with rest
3. Glyceryl trinitrate is sometimes used in order to relieve chest pain
4. The pain can be described to be reaching up to the jaw, shoulders and chest
Diagnostic Methods:
1. The patient must undergo electrocardiography in order to trace the electrical impulse of the heart.
2. Evaluation of the pain elicit so that it will be the determining factor of the severity of thecoronary
heart disease.
Nursing Management:
1. Assist the patient to explore his feelings when the pain affects his daily functioning, mood as well as
his lifestyle.
2. Encourage the patient to take medications prescribed such as beta-blockers which is considered as
the drug of choice for the initial therapy. There is another part of treatment that involves aspirin. This must be
well observed as it entitles the patient to a long-term therapy.
3. Explore the feelings as well as knowledge of the patient about stable angina. Clear out some of the
misconceptions about this as early as possible.
4. Allow the folks of the patient to know about the information as well as set up a plan of action that
will save the life of the patient whenever stable angina attacks.
5. Assist the patient as well as the family when surgical intervention is needed. A surgical
revascularisation will be done in order to pave way normal blood circulation to the heart. Secure the consent
as well as the full acceptance of the operation before the patient is sedated.
6. Assist as well as refer community services that would help the patient adjust after the surgery.
Assessment and Diagnosis

Venous disorders warrant careful assessment and history taking. High risk patients are those who
have undergone a major surgery; those who have history of cardiovascular disease, hypercoagulation,
varicose veins, neoplastic disease; or amongst the elderly, pregnant women who takes contraceptive pills
and obese individuals.
Assessment of signs and symptoms would require the following key points:
o Limb pain
o Ankle engorgement
o Edema
o Functional impairment
o Differences in leg circumference bilaterally from thigh to ankle
o Increase in surface temperature of the leg
o A feeling of heaviness
o Homans sign
Prevention
To prevent deep venous thrombosis and its possible complications, the following should be observed:
Patients should wear elastic compression stockings.
Patients should observe special body positioning and perform indicated exercise.
Patients should use intermittent pneumatic compression.
In surgical patients, subcutaneous unfractioned or low molecular weight heparin is administered.
Management
Medical Management
Anti coagulation Therapy
Anti coagulation therapy is indicated for patients with thrombophlebitis or DVT, recurrent embolus
formation and leg edema (from heart failure) in order to prevent and reduce blood clotting. This therapy is
also indicated for the elderly population with hip fractures (requires prolonged immobilization).
Unfractioned Heparin administered subcutaneously to prevent foomation of DVT or by IV. Given

adjuct with oral anti coagulant like warfarin. While under this treatment course, International Normalized
Ratio or INR, partial thromboplastin time and platelet count is continuously monitored.
Thrombolytic Therapy if heparins prevent DVT formation, thrombolytics on the other hand
dissolves clots and thrombus. It has a lesser damage on the venous valves and reduced incidence of
chronic venous insufficiency. However, use of thrombolytics could make the patient prone to bleeding, and
so, if bleeding becomes uncontrolled, the therapy is immediately stopped.
Surgical management there are cases where anti cougulant and thrombolytic therapy are
contraindicated so the goal of treatment will be surgery.
Thrombectomy removal of the thrombosis
Placement of a thrombi filter after the thrombectomy to sift emboli and thrombus.
Nursing Management
Assessing and monitoring anti coagulant therapy
o To prevent overdose of heparin, nurses should be able to calculate the dosage of the
medications and administer them accurately. Laboratories should be monitored and referred if within outside
the normal limits.
o Monitoring and managing potential complications
Bleeding bleeding is the prime complication of patients undergoing anti- coagulant therapy. Nurses should
be keen to monitor and detect signs of bleeding like bruises and nose bleeds. If bleeding occurs, fresh
frozen plasma transfusion is initiated and Vitamin K is administered as ordered.
Drug interactions
Thrombocytopenia taking in heparin for five days or more could cause
decrease in platelet count. Regular and close monitoring is recommended.
Provide rest and comfort
Bed rest
Analgesics
Warm compress to affected area
Elastic compression stockings (evenly distributes pressure over the
entire calf areas)
Elevation of affected extremity
Nursing Interventions: Nephrotic Syndrome

1. Administer medications, such as diuretics, antibiotics, and corticosteroids as ordered.
2. Ask dietitian to plan a low-sodium diet with moderate amounts of protein.
3. Provide meticulous skin care to combat the edema that usually occurs with nephrotic syndrome.
4. Encourage activity and exercise and provide antiembolism stockings as ordered.
5. Frequently check the patients urine for protein, indicated by frothy appearance.
6. Monitor and document the location and charater of edema.
7. Measure blood pressure while the patient is in s supine position and standing.
8. Monitor intake and output hourly.
9. Assess the patients response to prescribed medications.
10. Stress the importance of adhering to the special diet.
Nursing Interventions: Peptic Ulcers

1. Support the patient emotionally and offer reassurance.
2. Administer prescribed medications.
3. Provide six small meals a day or small hourly meals as ordered.
4. Schedule care so that the patient gets plenty of rest.
5. Monitor the effectiveness of administered medications, and also watch for adverse reactions.
6. Assess the patients nutritional status and the effectiveness of measures used to maintain it. Weigh
him regularly.
7. Teach the patient about peptic ulcer disease, and help him to recognize its signs and symptoms.
8. Review the proper use of prescribed medications, dicussing the desired actions and possible
adverse effect of each drug.
9. Instruct the patient to take antacids 1 hour after meals.
10. Warn the patient to avoid aspirin containing drugs because they irritate gastric mucosa.
11. Encourage the patient to make appropriate lifestyle changes.
Nursing Interventions: Pericarditis

1. Stress the importance of bed rest,
2. Assist the patient with bathing if necessary.
3. Provide a bedside commode because this method puts less stress on the heart rather than using a
bed pan.
4. Place the patient in upright position to relieve dyspnea and chest pain.
5. Provide analgesics to relieve pain and oxygen to prevent tissue hypoxia.
6. Assess the patients cardiovascular status frequently, watching for signs of cardiac tamponade.
7. Monitor the patients pain level and the effectiveness of analgesics.
8. Explain all tests and treatments to the patient.
9. Before giving antibiotics, obtain a patient history for allergy.
10. Tell the patient to resume his daily activities slowly and to schedule rest periods into his daily
routine for a while.
Nursing Interventions: Pneumonia

1. Maintain a patent airway and adequate oxygenation.
2. Obtain sputum specimens as needed.
3. Use suction if the patient cant produce a specimen.
4. Provide a high calorie, high protein diet of soft foods.
5. To prevent aspiration during nasogastric tube feedings, check the position of tube, and administer
feedings slowly.
6. To control the spread of infection, dispose secretions properly.
7. Provide a quiet, calm environment, with frequent rest periods.
8. Monitor the patients ABG levels, especially if hes hypoxic.
9. Assess the patients respiratory status. Auscultate breath sounds at least every 4 hours.
10. Monitor fluid and intake output.
11. Evaluate the effectiveness of administered medications.
12. Explain all procedures to the patient and family.
Nursing Interventions: Pulmonary Edema

1. Help the patient relax to promote oxygenation.
2. Place the patient in high Fowlers position to enhance lung expansion.
3. Administer oxygen as ordered.
4. Carefully record the time morphine is given and the amount administered.
5. Assess the patients condition frequently.
6. Watch for complications of treatment such as electrolyte depletion.
7. Monitor vital signs every 15 to 30 minutes or more often as indicated.
8. Urge the patient to comply with the prescribed medication regimen to avoid future episodes of
pulmonary edema.
9. Explain all procedure to the patient and his family.
10. Emphasize reporting early signs of fluid overload.
11. Review all prescribed medications with the patient.
12. Discuss ways to observe physical energy.
Nursing Interventions: Pseudomonas Infection
1. For respiratory infection, maintain a patent airway by suctioning secretions whenever necessary
and provide adequate oxygen.
2. Administer ordered analgesics as needed.
3. Protect immunocompromised patients from exposure to infection.
4. Use strict sterile technique when changing dressings that involve infected wounds.
5. Observe and record the character of wound exudates and sputum.
6. Ask the patient about a history of allergies, especially penicillin.
7. Monitor the patients hearing and renal function during treatment with aminoglycosides.
8. Reinforce the importance of completing the course of antibiotic therapy as prescribed.
9. Tell the patient to avoid drinking water when traveling to endemic areas.
10. Avoid using humidifiers in the patients room.
Nursing Interventions : Pressure Ulcers

1. Reposition the patient at least every 2 hours around the clock.
2. Perform passive range-of motion exercises.
3. Use pressure relief aids on the patients bed.
4. Give patient meticulous skin care.
5. Offer the patient bedpan or commode frequently.
6. Clean open lesions with normal saline solutions.
7. Encourage adequate food and fluid intake to maintain body weight and promote healing.
8. Encourage the patient to eat frequent, small meals that include protein and calorie-rich supplements.
9. Monitor the patient for infection at the ulcer site.
10. Teach the patient and his family position-changing techniques and active and passive ROM exercises.
11. Teach the patient to avoid skin-damaging agents such as harsh soaps, alcohol based products and
benzoin.
Interventions: Pneumothorax
1. Listen to the patients fear and concerns.
2. Keep the patient as comfortable as possible.
3. Administer analgesics as necessary.
4. Assess the patients respiratory status.
5. Monitor ABG levels regularly as ordered.
6. Watched for complications signaled by pallor, grasping respirations, and sudden chest pain.
7. Encourage the patient to perform deep breathing exercises every hour when awake.
8. Carefully monitor vital signs at least every hour for indications of shock.
9. Listen for breath sounds over both lungs.
10. Prepare the patient for thoracotomy as indicated.
Nursing Interventions: Parkinsons Disease

1. Administer medications promptky on schedule to maintain continuous therapy drug levels.
2. Encourage independence. Provide assistive devices as appropriate.
3. Provide rest periods between activities.
4. Provide frequent warm baths and massage to help relax muscles and relieve muscle cramps.
5. Protect the patient from injury.
6. Have the patient sit in an upright position when eating.
7. Provide the patient with semi-solid diet, which is easier to swallow than a diet consisting of solid
and liquids.
8. Monitor drug treatment and report any adverse reactions.
9. Monitor for complications caused by involuntary movements, such as aspiration or injury from falls.
10. Evaluate the patients nutritional intake, and weigh him regularly.
Pancreatitis
1. Maintain the nasogastric tube for drainage or suctioning.
2. Restrict the patient to bed rest, and provide a quiet and restful environment.
3. Place the patient in comfortable position that allows maximal chest expansion.
4. Keep water and other beverages at bed side, and encourage the patient to drink plenty of fluids.
5. Provide I.V. fluids and parenteral nutrition as ordered.
6. Assess the patients level of pain.
7. Assess pulmonary status at least every 4 hours to detect early signs of respiratory complications.
8. Monitor fluid and electrolyte balance, and report any abnormalities.
9. Emphasize the importance of avoiding factors that precipitate acute pancreatitis especially alcohol.
10. Stress the need for a diet high in carbohydrates and low in protein and fats.
11. Caution the patient to avoid caffeinated beverages and irritating foods.
Osteoporosis
1. Focus on careful positioning, ambulation, and prescribed exercises.
2. Administer analgesics and heat to relieve pain as ordered.
3. Include the patient and his family in all phases of care.
4. Encourage the patient to perform as much self-care as her immobility and pain allow.
5. Provide the patient activities that involve mild exercise.
6. Check the patients skin daily for redness, warmth, and new painsites.
7. Monitor the patients pain level, and assess her response to analgesics, heat therapy, and
diversional activities.
8. Explain all treatments, tests, and procedure to the patient.
9. Make sure the patient and her family clearly understand the prescribed drug regiman.
10. Tell the patient to report any new pain sites immediately, especially after trauma.
11. Provide emotional support and reassurance to help the patient cope with limited mobility.
Osteoarthritis
1. Administer anti-inflammatory medication and other drugs as ordered.]
2. Provide emotional support and reassurance to help the patient cope with limited mobility.
3. Encourage the patient to perform as much self-care as his immobility and pain allow.
4. To help promote sleep, adjust pain medications to allow for maximum rest.
5. Help the patient identify techniques and activities that promote rest and relaxation.
6. For joints in hand, provide hot soaks and paraffin dips to relieve pain as ordered.
7. Check crutches, cane, braces, or walker for proper fit.
8. Assess the patients pain patterns.
9. Watch for skin irritation caused by prolonged use of assistive devices.
10. Instruct the patient to plan for adequate rest during the day.
11. Instruct the patient to take medications exactly as prescribed
Osteomyelitis
1. Focus care on controlling infection, protecting the bone from injury, and providing support.
2. Encourage the patient to verbalize his concerns about his disorder.
3. Encourage the patient to perform as much self-care as his conditions allows.
4. Help the patient identify care techniques and activities that promote rest and relaxation and
encourage him to perform them.
5. Use strict aseptic technique when changing dressings and irrigating wounds.
6. Provide a well-balanced diet to promote healing.
7. Support the affected limb with firm pillows.
8. Provide thorough skin care.
9. Provide complete cast care.
10. Administer prescribed analgesics for pain.
11. Assess vital signs, observe wound appearance, and note any mew pain which may indicate
secondary infection.
12. Watch for signs of pressure ulcer formation.
13. Look for sudden malpositioning of the affected limb, which may indicate fracture.
14. Explain all the test and treatment procedures.
Myocardial Infarction
1. Administer analgesics as ordered.
2. Organize patient care and activities to allow periods of uninterrupted rest.
3. Provide a clear liquid diet until nausea subsides.
4. Provide stool softener to prevent straining during defecation.
5. Assist with range of motion exercises.
6. Provide emotional support, and help reduce stress and anxiety.
7. Assess and record the patients severity, location, type, and duration of pain.
8. Check his blood pressure after giving nitroglycerin, especially during first dose.
9. Thoroughly explain the medication and treatment regimen.
10. Review dietary restriction with the patient.
11. Advise the patient about appropriate responses to new or recurrent symptoms.
12. Stress the need to stop smoking.
Myasthenia Gravis
1. Listen to the patients concerns and answer the questions honestly.
2. Administer medications on time and at evenly spaced intervals, as ordered, to prevent relapses.
3. Plan exercise, meals, patient care, and activities to make the most of energy peaks.
4. When swallowing is difficult, give semi-solid foods instead of liquids to lessen the risk of choking.
5. After severe exacerbations, try to increase social activity as soon as possible.
6. Establish accurate neurologic and respiratory baseline.
7. Stay alert for signs of impending myesthenic crisis such as increased muscle weakness and
difficulty talking or chewing.
8. Help the patient plan daily activities to coincide with energy peaks.
9. Stress the need for frequent rest periods.
10. If surgery is scheduled, provide perioperative teaching.
Liver Cancer
1. Give analgesics as ordered and encourage the patient to identify care measures that promote
comfort.
2. Provide patient with a special diet that restricts sodium, fluids, and protein and that prohibits
alcohol.
3. To increase venous return and prevent edema, elevate the patients legs whenever possible.
4. Keep the patients fever down.
5. Provide meticulous skin care.
6. Turn the patient frequently and keep his skin clean to prevent pressure ulcers.
7. Prepare the patient for surgery, if indicated.
8. Provide comprehensive care and emotional assistance.
9. Monitor the patient for fluid retention and ascites.
10. Monitor respiratory function.
11. Explain the treatments to the patient and his family, including adverse reactions the patient may
experience.
Interventions: Kidney Cancer

1. Administer prescribed analgesics as needed by the patient.
2. Prepare for nephrectomy as indicated.
3. Provide symptomatic treatment for adverse effects of chemotherapeutic drugs.
4. Watch the patient for signs and symptoms of pulmonary, neurologic, and liver dysfunction.
5. Monitor laboratory test results for anemia, polycythemia, and abnormal blood chemistry.
6. Watch for adverse effects of radiation or chemotherapy.
7. Monitor the patients degree of pain and assess the effectiveness of analgesics.
8. Tell the patient what to expect from surgery and other treatments.
9. Explain the possible effects of radiation and drug therapy.
10. Stress the importance of compliance with any prescribed outpatient treatment.
11. Encourage the patient to express his anxieties and fears and remain with him during periods of
severe stress and anxiety.
Multiple Sclerosis
1. Provide emotional and psychological support for the patient and family.
2. Increase patient comfort with massages and relaxing baths.
3. Administer medications as needed.
4. Promote emotional stability. Help the patient establish a daily routine to maintain optimal
functioning.
5. Keep bedpan or urinal readily accessible because the need to void is immediate.
6. Encourage adequate fluid intake and regular urination.
7. Watch for adverse reactions to administered medications.
8. Monitor bowel and bladder function during hospitalization.
9. Assess patients neurologic status for deficits.
10. Educate the patient nad her family about this chronic disease.
11. Emphasize the importance of exercise.
12. Teach the patient about bowel and bladder training if
Mitral Stenosis
1. Before giving penicillin, ask the patient if shes ever had a hypersensitivity reaction to the drug.
2. Assist the patient with bathing as necessary.
3. Allow the patient to express his concerns over being unable to meet her responsibilities because of
activity restrictions.
4. Place the patient in an upright position to relieve dyspnea, if needed.
5. Prepare the patient for valve replacement or percutaneous balloon valvuloplasty, as indicated.
6. Keep the patient on a low-sodium diet.
7. Watch closely for signs of pulmonary dysfunction caused by pulmonary hypertension, tissue
ischemia caused by emboli, and adverse reactions to drug therapy.
8. Explain all tests and treatments to the patient.
9. Advise the patient to plan for periodic rest in her daily routine to prevent undue fatigue.
10. Teach the patient about diet restrictions.
Mastitis
1. Give analgesics as indicated.
2. Provide comfort measures such as a warm soaks.
3. Use meticulous hand-washing technique and provide good skin care.
4. Regularly measure the patients temperature and assess the effectiveness of antipyretic agents.
5. Inspect the patients breast daily for signs of impaired skin integrity, such as cracks and fissures.
6. Advise the patient to take antibiotics as ordered.
7. Stress the need to take the entire prescribed amount even if symptoms improve in the meantime.
8. Reassure the patient that breast-feeding during mastitis wont harm her infant because the infant is
the source of the infection.
9. If only one breast is affected, instruct the patient to offer the infant his breast first to promote
complete emptying and prevent clogged ducts.
10. Suggest applying a warm, wet towel to the affected breast or taking a warm shower to relax and
improve her ability to breast-fed
Malignant Lymphomas
1. Administer pain medications as ordered.
2. Provide rest periods if the patient tires easily.
3. Offer the patient such fluids as orange juice or ginger ale to counteract nausea.
4. Provide the patient with plenty of fluids to help flush out the cells that are destroyed during
treatment.
5. Provide a well balanced, high calorie, high protein diet.
6. If the patient cant tolerate oral feeding, administer I.V. fluids.
7. Listen to the patients fears and concerns.
8. Involve the patient and his family in his care whenever possible.
9. Monitor the effectiveness of administered analgesics and other medications.
10. Monitor the patients CBC, uric acid level, and serum calcium level for abnormalities.
11. Make sure the patient receives thorough explanations about all treatment.
Lyme Disease
1. Plan care to provide adequate rest.
2. Ask patient about possible drug allergies before administering antibiotics.
3. Administer ananlgesics and antipyretics as ordered.
4. If the patient has arthritis, help him with range of motion and strengthening exercises but avoid
overexerting him.
5. Protect the patient from sensory over load and reorient him if needed.
6. Monitor the patients vital signs, especially his temperature.
7. Watch for signs and symptoms of complications, such as cardiovascular or neurologic dysfunction
and arthritis.
8. Monitor the effectiveness of administered medication.
9. Instruct the patient to take antibiotic medications as prescribed.
10. Urge the patient to return for follow up check up care and to report recurrent or new symptoms to
the physician.
11. Inform the patient and his family about ways to prevent lyme disease.
Intussusception
1. Administer I.V. fluids as ordered. If the patient is in shock, give blood or plasma as ordered.
2. A nasogastric tube is inserted to decompress the bowel.
3. Replace volume lost as ordered.
4. Prepare the patient for hydrostatic reduction and answer question to allay fears.
5. Monitor vital signs frequently.
6. Check intake and output and watch for signs of dehydration and bleeding.
7. Monitor amount and type of drainage from the nasogastric tube.
8. Explain what happens in intussuseption to the patient and his family.
9. If surgery is required, provide preoperative teaching.
10. To minimize the stress of hospitalization, encourage patient to participate in their childs care as
much as possible.
Instestinal Onstruction
1. Allow the patient nothing by mouth, as ordered.
2. Insert a nasogastric tube to decompress the bowel as ordered.
3. Begin and maintain I.V. therapy as ordered.
4. Administer analgesics, broad spectrum antibiotics, and other medication, as ordered.
5. Keep the patient in semi-Fowlers or Fowlers position as much as possible to promote pulmonary
ventilation.
6. Look for signs of dehydration.
7. Monitor nasogastric tube drainage for color, consistency, and amount.
8. Monitor intake and output.
9. Monitor vital signs frequently.
10. When administering medication, monitor the patient for the desired effects and for adverse
reactions.
11. Continually assess the patients pain.
12. Monitor urine output carefully to assess renal function, circulating blood volume, and possible urine
retention due to bladder compression by the distended intestine.
13. Teach the patient about his disorder, focusing on his type of intestinal obstruction, its cause, and
signs and symptoms.
14. Emphasize the importance of following a structured bowel regimen, particularly if the patient had a
mechanical obstruction from fecal impaction.
Influenza
1. Administer analgesics, antipyretics, and decongestants, as ordered.
2. Follow droplet and standard precautions.
3. Provide cool, humidified air but change the water daily to prevent pseudomonas superinfection.
4. Encourage the patient to rest in bed and drink plenty of fluids.
5. Administer I.V. fluids as ordered.
6. Administer oxygen therapy if warranted.
7. Regularly monitor the patients vital signs, including his temperature.
8. Monitor the patients fluid intake and output for signs of dehydration.
9. Watch for signs and symptoms of developing pneumonia.
10. Advise the patient to use mouthwash or warm saline gargles to ease sore throat.
11. Teach the patient the importance of increasing fluid intake to prevent dehydration.
12. Suggest a warm bath or heating pad to relieve myalgia.
13. Review prevention of future influenza episodes with patient and the community.
Hypovolemic Shock
1. Check for patent airway and adequate circulation.
2. Begin an I.V. infusion with normal saline solution or lactated Ringers solution delivered through a
large bore.
3. Help insert a central venous line and pulmonary artery catheter for hemodynamic monitoring.
4. Insert an indwelling urinary catheter.
5. Draw an arterial blood sample to measure ABG levels.
6. Obtain and record the patients blood pressure, pulse and respiratory rates, and peripheral pulse
rates.
7. Monitor the patients CVP, right arterial pressure, pulmonary artery pressure, and cardiac output
atleast hourly as ordered.
8. Measure the patients urine output hourly.
9. Monitor the patients ABG and electrolyte levels frequently as ordered.
10. Watch for signs of impending coagulopathy such as petechiae, bruising, bleeding or oozing from
guns or venipuncture site.
11. Explain all procedures and their purposes to ease the patients anxiety.
12. Discuss the risk associated with blood transfusions to the patient and his family.
Hyperthyroidism
1. Administer prescribed antithyroid medications, as ordered.
2. If iodine is part of the treatment, mix it with milk, juice, or water to prevent gastrointestinal distress,
and give it through a straw to prevent tooth discoloration.
3. Give antidiarrheal preparations as ordered.
4. Consult a dietician to ensure a nutritious diet with adequate calories and fluids.
5. Avoid excessive palpation of the thyroid, this can precipitate thyroid storm.
6. Minimize physical and emotional distress.
7. Monitor and record patients vital signs, weight, fluid intake, and urine output.
8. Measure neck circumference daily to check for progression of thyroid enlargement.
9. Evaluate serum electrolyte levels, and check for hyperglycemia and glycosuria.
10. Assess the patient for signs of heart failure.
11. Stress the importance of regular medical follow up after discharge because hypothyroidism may
develop 2 to 4 weeks.
12. Reassure the patient and his family that mood swings and nervousness will probably subside with
treatment.
Hodgkins Disease
1. Provide a well balanced, high calorie, high protein diet.
2. Offer the patient grapefruit juice, orange juice, ginger ale to alleviate nausea and vomiting.
3. Perform comfort measures that promote relaxation.
4. Assess the patient for nutritional deficiencies and malnutrition.
5. Explain all the procedures and treaments associated with the plan of care.
6. If the patient is a woman of childbearing age, advise her to delay her pregnancy until long-term
remission occurs.
7. Stress the importance of maintaining good nutrition by eating small frequent meals and drinking
plenty of fluids.
8. Instruct the patient to pace his activities to counteract therapy induced fatigue.
9. Stress the importance of good oral hygiene to prevent stomatitis.
10. Advise the patient to avoid crowds and any person with a known infection.
11. Make sure that the patient understands the possible adverse effects of his treatments.
12. Advise the patient to seek follow-up care after he has completed the initial treatment.
Histoplasmosis
1. Provide oxygen therapy if needed. Plan rest periods.
2. Obtain chest X-ray results to determine if the patient has pulmonary or pleural effusion.
3. Assess the patient respiratory status every shift. Note diminished breath sounds or pleural friction
rub, and evaluate for effusion.
4. Check the patients cardiovascular status every shift.
5. Monitor the patients neurologic status every shift and report any changes in level of consciousness
or nuchal rigidity.
6. Observe for signs and symptoms of hypoglycemia and hyperglycemia, which indicate adrenal
dysfunction.
7. Test all stools for blood and report its presence.
8. Teach the patient about drug therapy, including adverse effects.
9. Inform the patient about the need for follow-up care on a regular basis for atleast a year.
10. Tell the patient to report to the doctor cardiac and pulmonary signs that could indicate effusions.
Hiatal Hernia
1. Prepare the patient for diagnostic tests, as needed.
2. Administer prescribed antacids and other medications
3. To reduce intra-abdominal pressure and prevent aspiration, have the patient sleep in a reverse
Trendelenburg position with the head of the bed elevated.
4. Assess the patients response to treatment.
5. Observe for complications, especially significant bleeding, pulmonary aspiration, or incarceration or
streangulation of the herniated stomach portion.
6. After endoscopy, watch for signs of perforation such as falling blood pressure, rapid pulse, shock,
and sudden pain caused by endoscope.
7. To enhance compliance, teach the patient about the disorder. Explain significant symptoms,
diagnostic tests, and prescribed treatments.
8. Review prescribed medications, explaining their desired actions and possible adverse effects.
9. Teach the patient dietary changes to reduce reflux.
10. Encourage the patient to delay lying down for 2 hours after eating.
Herniated Disk
1. With the patient and doctor, plan a pain control regimen.
2. Encourage the patient to express his concerns about the disorder.
3. Urge the patient to perform as much self-care as his immobility and pain allow.
4. Help the patient identify and perform care and activities that promote rest and relaxation.
5. Use antiembolism stockings, as prescribed, and encourage the patient to move his legs, as
allowed.
6. Assess the patients pain status and his response to the pain-control regimen.
7. Perform neurovascular checks of the patients legs such as color, motion, temperature, and
sensation.
8. Monitor vital signs, and check for bowel sounds and abdominal distention.
9. Teach the patient about treatments, which include bed rest and pelvic traction.
10. Urge the patient to maintain an ideal body weight to prevent lordosis caused by obesity.
11. Discuss all prescribed medications with the patient.
12. If surgery is required, explain all preoperative and postoperative procedures and treatments to the
patient and his family.
Hepatitis
1. Observe standard precautions to prevent disease transmission.
2. Provide rest periods throughout the day.
3. Schedule treatments and tests so the patient can rest between activities.
4. To help the patient maintain an adequate diet, avoid overloading his tray.
5. Administer supplemental vitamins and commercial feedings, as ordered.
6. Provide adequate fluid intake atleast 4 liters of liquid daily.
7. Observe the patient for desired and adverse effects of medication.
8. Record the patients weight daily, and keep accurate intake and output records.
9. Watch for signs of complications, such as changes in level of consciousness, ascites, edema,
dehydration, respiratory problems, myalgia, and arthalgia.
10. Teach the patient about the diseases, its signs and symptoms, and recommended treatments.
11. Explain all the necessary diagnostic tests.
12. Stress the importance of continued medical care.
Hepatic Encephalopathy
1. Promote rest, comfort, and a quiet atmosphere. Instruct the patient to avoid stressful exercise.
2. Administer medications, as ordered.
3. Ask the dietary department to provide specified low-protein diet, with carbohydrates supplying most
of the calories.
4. Provide good mouth care, as ordered.
5. Use appropriate safety measures to protect the patient fro injury.
6. Frequently assess and record the patients level of consciousness.
7. Monitor the patients intake, output, and fluid and electrolyte balance.
8. Watch for and immediately report laboratory indicators of clinical signs of anemia.
9. Assess the patient for the desired effects of medication and watch for adverse reactions.
10. Teach the patient and his family about the disease and treatment.
Hemorrhoids
1. Administer local anesthetic as prescribed.
2. As needed, provide warm sitz baths or cold compresses to reduce local pain, swelling, and
information.
3. Provide the patient with high fiber diet and encourage adequate fluid intake and exercise to prevent
constipation.
4. Monitor the patients pain level and the effectiveness of the prescribed medications.
5. Check for signs and symptoms of anal infection, such as increases pain and foul smelling anal
drainage.
6. Teach the patient about hemorrhoidal development, predisposing factors, and tests.
7. Encourage the patient to eat high fiber diet to promote regular bowel movement.
8. Emphasize the need for good anal hygiene. Caution against vigorous wiping with washcloths and
using harsh soaps.
9. Encourage the use of medicated astringent pads and toilet paper without dyes or perfumes.
Prepare the patient for surgery if necessary

Hemophilia
1. Provide emotional support, and listen to the patients fears and concerns.
2. If the patient has surface cuts or epistaxis, apply pressure.
3. Give the deficient clotting factor or plasma, as ordered.
4. Apply cold compress or ice bags and raise the injured part.
5. To prevent recurrence of bleeding, restrict activity for 48 hours after bleeding is under control.
6. Control pain with an analgesics, as ordered.
7. If the patient cant tolerate activities because of blood loss, provide rest periods between acivities.
8. To restore joint mobility, if ordered, begin range of motion exercises at least 48 hours after the
bleeding is controlled.
9. Watch for signs and symptoms of decreased tissue perfusion such as restlessness, anxiety,
confusion, pallor, cool and clammy skin, chest pain, decreased urine output.
10. Tell the patient to avoid heavy lifting and using power tools because they risk of injury that can
result in serious bleeding problem.
11. Advise the patient to notify the doctor immediately after even a minor injury
12. Teach the patient the importance of protecting his veins for lifelong therapy.
Heart Failure
1. Place the patient inn Fowlers position and give supplemental oxygen, as ordered.
2. Organize all activities to provide maximum rest periods.
3. To prevent deep vein thrombosis due to vascular congestion, assist the patient with range-of-motion
exercises.
4. Weigh the patient daily to help detect fluid retention and observe for peripheral edema.
5. Assess the patients vital signs for increased respiratory and heart rates and for narrowing pulse
pressure and mental status.
6. Frequently monitor blood urea nitrogen and serum creatinine, potassium, sodium, chloride, and
magnesium levels.
7. Watch for calf pain and tenderness.
8. Advise the patient to avoid foods high in sodium content.
9. Stress the need for regular medical check up and periodic blood tests to monitor drug levels.
10. Stress the importance of taking medications exactly as prescribed.
11. Tell the patient to notify the doctor if his pulse rate is usually irregular or less than 60 beats/min.
Fibromyalgia Syndrome
1. Monitor the patients sensory disturbances and level of pain.
2. Monitor for any adverse reactions to the medication given.
3. Exercise can be helpful in maintaining muscle conditioning, improving energy, and possibly,
improving sleep quality.
4. Teach the patient how to do stretches safely and effectively and encourage her to perform them
regularly.
5. The deconditioned fibromyalgia syndrome patient may experience increases muscle pain with the
initiation of a new exercise program.
6. Encourage the patient not to stop exercising altogether because even a limited amount of exercise
each day may be beneficial.
7. A bedtime dose of tricyclic antidepressant can cause morning drowsiness in some patients.
Sometimes taking the dose 1 to 2 hours before bedtime can improve sleep benefits while reducing this
morning after effect.
8. A daily stretching program can help preserve range of motion in the neck, shoulders, and hips.
9. Administer medications as ordered and monitor for effects.
10. Provide emotional support to the patient and family.
Esophageal Diverticula
1. If the patient regurgitates food and mucus, protect the patient from aspiration by positioning him
with his head elevated or turned to one side.
2. If the patient has dysphagia, record well tolerated foods and note circumstances that ease
swallowing.
3. Administer ordered antacids nad provide antireflux care.
4. Regularly assess the patients nutritional status.
5. Monitor the patients degree of discomfort and the effectiveness of treatment.
6. Monitor respiratory signs and symptoms that suggest aspiration.
7. Teach the patient about his disorder.
8. Explain necessary diagnostic tests and treatments.
9. Emphasize the need to chew food thoroughly to prevent food particles from becoming trapped in
the diverticulum.
10. Teach the patient how to perform massage or postural drainage to prevent aspiration.
11. Support the patient emotionally, especially if hes upset and concerned about his symptoms.
Escherichia Coli
1. Replace fluids and electrolytes as needed.
2. Use proper hand-washing technique.
3. Clean the perianal area and lubricate after each episode of diarrhea.
4. give nothing by mouth, administer antibiotics as ordered, and maintain body warmth.
5. Keep accurate intake and output records.
6. Measure stool volume and note the presence of blood and pus.
7. Monitor for decreases serum sodium and chloride levels and signs of gram-negative septic shock.
8. Watch for signs of dehydration.
9. Monitor vital signs to detect early indications of circulatory prolapse.
10. Explain proper hand-washing technique to patient and family.
Epilepsy
1. Administer anticonvulsant therapy as prescribed.
2. Protect the patient from injury during seizures.
3. Monitor the patient continuously during seizures.
4. If the patient is taking antiseizure medications, constantly monitor for toxic signs and symptoms
such as slurred speech, ataxia, lethary, and dizziness.
5. Monitor the patients compliance with anticonvulsant drug therapy.
6. Teach the patient to take exact dose of medication at the times prescribed.
7. Encourage the patient to eat balanced, regular meals.
8. Advise the patient to be alert for odors that may trigger an attack.
9. Limit or avoid alcohol intake.
10. Encourage to have enough sleep to prevent attacks
11. Avoid restraining the patient during a seizure.
12. Loosen any tight clothing, and place something flat and soft, such as pillow, jacket, or hand, under
his head.
13. Avoid any forcing anything into the patients mouth if his teeth is clenched.
14. Avoid using tongue blade or spoon during attacks which could lacerate the mouth and lips of
displace teeth, precipitating respiratory distress.
15. Protect the patients tongue, if his mouth is open, by placing a soft object between his teeth.
16. Turn the patients head to the side to provide an open airway.
17. Reassure patient after the seizure subsides by telling him that hes all right, orienting him to time
and place, and informing that hes had a seizure.
Endocarditis
1. Watch for signs and symptoms of embolization such as hematuria, pleuritic chest pain, left upper
quadrant pain, and paresis.
2. Monitor the patients renal status including blood urea nitrogen levels, creatinine clearance levels
and urine output.
3. Assess cardiovascular status frequently and watch for signs of left ventricular failure such as
dyspnea, hypotension, tachycardia, tachypnea, crackles, neck vein distention, edema, and weight gain.
4. Check for changes in cardiac rhythm or conduction.
5. Evaluate arterial blood gas values as needed to ensure adequate oxygenation.
6. Observe for signs of infiltration or inflammation at the venipuncture site.
7. Stress the importance of taking the medication and restricting activities for as long as the doctor
orders.
8. Tell patient to watch closely for fever, anorexia, and other signs of relapse for about 2 weeks after
treatment stops.
9. Teach the patient how to recognize symptoms of endocarditis, and tell him to notify the doctor
immediately if such symptoms occur.
10. Stress the importance of dental hygiene to prevent caries and possible recurrent endocarditis.
Encephalitis
1. Maintain adequate fluid intake to prevent dehydration, but avoid fluid overload, which may increase
cerebral edema.
2. Maintain adequate nutrition. Give small, frequent meals, or supplement meals with nasogastric tube
or parenteral feedings.
3. To prevent constipation and minimize the risk of increased ICP resulting from straining at stool,
provide a mild laxative or stool softener.
4. Carefully positioned the patient to prevent joint stiffness and neck pain, and turn the patient often.
5. Provide thorough mouth care.
6. Maintain a quiet environment. Darkening the room may decrease headache.
7. if the patient has seizures, take precautions to protect him from injury.
8. Measure and record intake and output.
9. If the patient becomes delirious or confused, try to reorient him often.
10. Teach the patient and his family about the disease and its effects.
Emphysema
1. If ordered, perform chest physiotherapy, including postural drainage and chest persussion and
vibration several times daily.
2. Schedule respiratory treatments at least 1 hour before and after meals.
3. Provide high calorie-protein rich diet to promote health and healing.
4. Make sure the patient receives adequate fluids at least 3 liters per day to loosen secretions.
5. Encourage daily activity and provide diversionary activities as appropriate.
6. Administer medications as ordered and record the patients response.
7. Monitor the patients respiratory function regularly.
8. Monitor the patients RBC count for increases (warning signs of increasing lung and vascular
congestion).
9. Watch for complications, such as respiratory tract infections, cor pulmonale, spontaneous
pneumothorax, respiratory failure, and peptic ulcer disease.
10. Include the patient and his family in care-related decision.
11. Provide supportive care, and help the patient adjust to lifestyle changes imposed by a chronic
illness.
Diverticular Disease
1. Administer antibiotics, stool softeners, and antispasmodics, as ordered. For severe pain, administer
analgesics as ordered.
2. Maintain bed rest for patient with acute diverticulitis.
3. Maintain liquid diet during the acute attack.
4. If diverticular bleeding occurs, the patient may require angiography and catheter placement for
vasopressin infusion.
5. When administering medications, monitor the patient for desired effects and possible adverse
reaction.
6. Inspect all stools carefully for color and consistency. Note frequency of bowel movements.
7. Monitor the patient for signs and symptoms of complications. Watch for temperature elevation,
increasing abdominal pain, blood in stools, and leukocytosis.
8. If the patient has had angiography for catheter placement and vasopressin infusion for diverticular
bleeding, inspect the insertion site frequently for bleeding.
9. Instruct the patient to notify the doctor if he has a temperature above 38.3 C.
10. Teach the patient about necessary diagnostic tests and prescribed treatments.
11. If a colostomy is constructed during surgery, teach the patient how to care for it.
12. If the patient expresses anxiety, provide psychological support
Head Injuries
1. Maintain a patent airway. Assist with endotracheal intubation or tracheotomy as necessary.

2. Administer medications as ordered.
3. Protect the patient for further injury by using side rails.
4. Assist the unsteady patient with walking.
5. Insert an indwelling urinary catheter if ordered.
6. If the patient is unconscious, insert a nasogastric tube to prevent aspiration.
7. Monitor the patients intake and output as needed to help maintain a normovolemic state.
8. Monitor vital signs continuously and check for additional injuries.
9. Observe the patient for headache, dizziness, irritability, and anxiety.
10. Monitor fluid and electrolyte levels and replace them as necessary.
11. Carefully observe the patient for CSF leakage.
12. Tell the patient to return to the hospital immediately if he experiences a persistent worsening
headache, forceful or constant vomiting, blurred vision, any change in personality, abnormal eye
movements, and twitching.
Gout
1. Give pain medication as needed especially during acute attacks.
2. Apply cold packs to inflamed joints to ease discomfort and reduce swelling.
3. Administer anti-inflammatory medication and other drugs, as ordered.
4. To promote sleep, administer pain medication at times that allow maximum rest.
5. Encourage bed rest, but use a bed cradle to keep bed linens off sensitive, in inflamed joints.
6. Encourage the patient to perform techniques that promote rest and relaxation.
7. Provide nutritious diet. Avoid purine rich foods.
8. Before and after surgery, administer colchicines to help prevent gout attacks as ordered.
9. Urge the patient to perform as much self-care as his immobility and pain allow.
10. Urge the patient to drink plenty if fluids 2 liters per day to prevent renal calculi.
11. Discuss the principles of gradual weight reduction with an obese patient.
12. Urge the patient to control hypertension, especially if he has tophaceous renal deposits.
13. Provide emotional support during diagnostic test and procedures.
Goodpastures Syndrome
1. Elevate the head of the bed and administer humidified oxygen to promote adequate oxygenation.
2. Encourage the patient to observe his energy.
3. Assist with plasmapheresis as ordered.
4. Administer blood transfusions to treat severe iron deficiency anemia, and administer
corticosteroids, as ordered.
5. Prepare the patient for dialysis or kidney transplantation to manage renal failure.
6. Assess the respiratory rate and breath sounds regularly.
7. Monitor the patients vital signs, arterial blood gas levels, hematocrit, and coagulation studies.
8. Monitor the patients daily intake and output, daily weight, creatinine clearance and BUN.
9. Watch closely for signs of a transfusion reaction or an adverse reaction to the corticosteroids.
10. Stress the importance of conserving energy, especially if the patient develops iron deficiency
anemia.
11. Teach the patient to follow low protein diet.
12. If the patient has a sore, dry mouth, advise him to suck on sugarless hard candy.
13. Teach the patient and his family the signs of respiratory or genitourinary bleeding.
Glomerulonephritis
1. Provide best rest during the acute phase.

2. Perform passive range of motion exercises for the patient on bed rest.
3. Allow the patient to resume normal activities gradually as symptoms subside.
4. Consult the dietician about a diet high in calories and low in protein, sodium, potassium, and fluids.
5. Protect the debilitated patient against secondary infection by providing good nutrition and hygienic
technique and preventing contact with infected people.
6. Check the patients vital signs and electrolyte values.
7. Monitor intake and output and daily weight.
8. Report peripheral edema or the formation of ascites.
9. Explain to the patient taking diuretics that he may experience orthostatic hypotension and dizziness
when he changes positions quickly.
10. Provide emotional support for the patient and his family.
11. If the patient is scheduled for dialysis, explain the procedure fully.
Glaucoma
1. Remember to administer cycloplegic eyedrops in the affected eye only. In the affected eye, these
drops may precipitate an attack of angle-closure glaucoma and threaten the patients residual vision.
2. After trabeculectomy, give medications as ordered to dilate pupila.
3. Apply topical corticostroids as ordered to rest the pupil.
4. After surgery, protect the affected eye by applying an eye patch and eye shield.
5. Position the patient on his back or unaffected side, and following general safety measures.
6. Administer pain medications as ordered.
7. Encourage ambulation immediately after surgery.
8. Encourage the patient to express his concerns related to having a chronic condition.
9. Monitor the patients ability to see clearly. Question the patient regularly about the occurrence of
visual changes.
10. Monitor the patients intra-occular pressures.
11. Stress the importance of meticulous compliance with prescribed drug therapy.
12. Instruct the patients family how to modify the patients environment for safety.
13. Teach the patient the signs and symptoms that require immediate medical attention, such as
sudden vision change or eye pain.
Gastroesophageal Reflux
1. In consultation with dietician, develop a diet for the patient that takes his food preferences into
account while helping to minimize reflux symptoms.
2. To reduce intra-abdominal pressure, have the patient sleep in reverse Trendelenburgs position with
the head of the bed elevated 6 to 12.
3. Encourage the patent to avoid lying down immediately after meals and late-night snacks.
4. Monitor the patients response to therapy and compliance with treatment.
5. If surgery was performed, monitor his intake and output and vital signs.
6. Monitor for complication of the disease and of surgery, if appropriate.
7. Teach the patient about the causes of gastroesophageal reflux, and review his antireflux regimen
for medication, diet, and positional therapy.
8. Discuss the recommended dietary changes.
9. Instruct the patient to avoid situations or activities that increase intra-abdominal pressure.
10. Encourage the patient compliance with his drug regimen.
Gastroenteritis
1. Plan care to allow uninterrupted rest periods for the patient.

2. If the patient is nauseated, advise him to avoid quick movements, which can increase the severity
of nausea.
3. If the patient can tolerate oral fluids, replace lost fluids and electrolytes with broth, ginger, ale, and
lemonade, as tolerated.
4. If dehydration occurs, administer oral and I.V. fluids as ordered.
5. To ease anal irritation caused by diarrhea, clean the area carefully and apply repellent cream, such
as petroleum jelly.
6. Wash hand thoroughly after giving care to avoid spreading of infection, and use standard
precaution whenever handling vomitus or stools.
7. Monitor the patients fluids status carefully.
8. Assess vital signs at least every 4 hours, weigh him daily, and record intake and output.
9. Teach the patient about gastroenteritis, describing its symptoms and varied causes.
10. Teach the patient the proper preventive measures.
Gastritis
1. If the patient is vomiting, give antiemetics.

2. Administer I.V. fluids as ordered to maintain fluid and electrolyte imbalance.
3. When the patient can tolerate oral feedings, provide a bland diet that takes into account his food
preference. Restart feedings slowly.
4. Offer smaller, more frequent servings to reduce the amount of irritating gastric secretions.
5. Help patient identify specific foods that cause gastric upset and eliminate them from his diet.
6. Administer antacids and other prescribed medications as ordered.
7. If pain or nausea interferes with the patients appetite, administer pain medications or antiemetics
about 1 hour before meals.
8. Monitor the patients fluid intake and output and electrolyte levels.
9. Assess the patient for presence of bowel sounds.
10. Monitor the patients response to antacids and other prescribed medications.
11. Monitor the patients compliance to treatment and elimination of risk factors in his lifestyle.
12. Teach the patient about the disorder.
13. Urge the patient to seek immediate attention for recurring signs and symptoms, such as
hematemesis, nausea, or vomiting.
Crohns Disease
1. Provide emotional support to the patient and his family.

2. Schedule patient care to include rest periods throughout the day.
3. If the patient is receiving parenteral nutrition, provide meticulous site care.
4. Give iron supplements and blood transfusion as ordered.
5. Administer medications as ordered.
6. Provide good patient hygiene and meticulous oral care if the patient is restricted to nothing by
mouth.
7. Record fluid intake and output, weigh the patient daily.
8. If the patient is receiving TPN, monitor his condition closely.
9. Evaluate the effectiveness of medication administration.
10. Emphasize the importance of adequate rest.
11. Give the patient a list of foods to avoid, including lactose-containing milk products, spicy or fried
high-residue foods.
12. Teach the patient about the prescribed medications, their desires effects and possible adverse
reactions.
Colorectal Cancer
1. Prepare the patient for surgery, as indicated.
2. Provide comfort measures and reassurance for patients undergoing radiation therapy.
3. Prepare the patient for the adverse effects of chemotherapy and take steps to minimize this effects.
4. Use strict aseptic technique when caring for I.V. catheters.
5. Have the patient wash his hands before and after meals and after going to the bathroom.
6. Listen to the patients fears and concerns, stay with him during periods of severe stress and
anxiety.
7. Encourage the patient to identify actions and care measures that will promote his comfort and
relaxation.
8. Monitor the patients bowel patterns.
9. Monitors the patients diet modification, and assess the adequacy of his nutrition intake.
10. Direct the patient to follow a high fiber diet.
11. Caution him to take laxatives or an antidiarrheal medications only as prescribed by the doctor.
12. Inform the patient about screening and early detection.
Cor Pulmonale
1. Listen to the patients fears and concerns about his illness.

2. Plan a nutritious diet carefully with the patient and the staff dietitian.
3. Prevent fluid retention by limiting the patients fluid intake to 1,000 to 2,000 ml daily and providing a
low sodium diet.
4. Reposition the bed ridden patient often to prevent atelectasis.
5. Provide meticulous respiratory care, including oxygen therapy and for COPD patients.
6. Pace patient care activities to avoid patient fatigue.
7. Monitor serum potassium levels closely if the patient takes a diuretic.
8. Be alert for complaints that signal digoxin toxicity, such as anorexia, nausea, vomiting, and seeing a
yellow halo around an object.
9. Measure ABG levels and watch for signs of respiratory failure as change in pulse rate, deep labored
respirations; and increased fatigue produced by exertion.
10. Instruct the patient to schedule frequent rest periods and to perform his breathing exercises
regularly.
Coronary Artery Disease
1. Keep nitroglycerin available for immediate use.

2. During anginal episodes, monitor blood pressure and heart rate.
3. Record duration of pain, amount of medication required to relieve ir, and accompanying symptoms.
4. Ask the patient to grade the sverity of his pain on a scale 1 to 10.
5. Monitor the patient for chest pain, hypotension, coronary artery spasm, and bleeding from the
catheter site.
6. Explain the cardiac catheterization to the patient.
7. If the patient is scheduled for surgery, explain the procedure and events.
8. Help the patient more effectively cope with stress and identify activities that precipitate pain.
9. Stress the need to follow the prescribed drug regimen.
10. Encourage the patient to maintain the prescribed diet.
11. Encourage regular, moderate exercise.
Cirrhosis
1. Position bed for maximal respiratory efficiency.

2. Provide oxygen as ordered.
3. Initiate efforts to prevent respiratory, circulatory, and vascular disturbances.
4. Encourage patient to increase activity gradually and plan rest with activity and mild exercise.
5. Provide a nutritious, high-protein diet supplemented by B-complex vitamins and others, including A,
C, and K and folic acid if there is no indication of impending coma.
6. Provide small, frequent meals, consider patient preferences, and encourage patient to eat; provide
protein supplements, if indicated.
7. Change the position frequently.
8. Avoid using irritating soap and adhesive tape.
9. Use padded side rails if patient becomes agitated or restless.
10. Orient to time, place, and procedures to minimize agitation.
11. Instruct patient to ask for assistance to get out of bed.
12. Provide safety measures to prevent injury or cuts.
13. Apply pressure to venipuncture sites to minimize bleeding.
Chlamdial Infections
1. Use standard precautions when examining the patient, giving patient care, and handling
contaminated material.
2. Double-bag all soiled dressings and contaminated instruments.
3. Examine and test the patients sexual contacts for Chlamydial infection.
4. Check the newborn infant of an infected mother for signs of infection.
5. Monitor the patient for complications.
6. Monitor the patients compliance with treatment, and evaluate the effectiveness of treatment.
7. Teach the patient the dosage requirements of his prescribed medication.
8. Teach the patient to follow proper hygiene measures.
9. To prevent eye contamination, tell the patient to avoid touching any discharge and to wash his
hands before touching his eyes.
10. To prevent re-infection during treatment, recommend that the patient either abstain from intercourse
or use condom.
11. Urge the patient to inform sexual partners of his infection so that they can seek treatment.
12. Tell the patient to return for follow-up testing.
Diabetes Mellitus
1. Administer insulin or an oral antidiabetic drug as prescribed.
2. Have the patient participate in a supervised exercise program.
3. Treat hypoglycemic reactions promptly by giving carbohydrates in the form of fruit juice, hard candy,
honey or I.V. dextrose.
4. Provide meticulous skin care, especially to the feet and legs.
5. Assist the patient to develop coping strategies.
6. Keep accurate records of vital signs, weight, fluid intake, urine output, and caloric intake.
7. Monitor diabetic effects on the cardiovascular, peripheral vascular, and nervous systems.
8. Observe for signs of urinary tract and vaginal infections, and monitor the patients urine for protein,
an early sign of nephropathy.
9. Recommend regular ophthalmologic examinations.
10. Teach the patient how to care for his feet.
11. Teach the patient and the family how to monitor the patients
Diabetes Insipidus
1. Institute safety precautions if the patient complains of dizziness or weakness.

2. Make sure the patient has easy access to the bathroom or bed pan, and answer his calls signals
promptly.
3. Give vasopressin cautiously to a patient with coronary artery disease because the drug may cause
vasoconstriction.
4. Provide meticulous skin and mouth care. Use soft toothbrush and mild mouth wash to avoid trauma
to the oral mucosa.
5. Keep accurate records of hourly fluid intake and urine output, vital signs, and daily weight.
6. Monitor urine specific gravity and serum electrolyte and blood urea nitrogen levels.
7. During dehydration testing, watch for signs of hypovolemic shock.
8. Check laboratory values for hyponatremia and hyupoglycemia.
9. Encourage the patient to maintain adequate fluid intake during the day to prevent severe
dehydration and to limit fluid in the evening.
10. Tell the patient to record his weigh daily.
11. Inform the patient and his family about long-term hormone replacement therapy.
Cholelithiasis
1. Place the patient in low Fowlers position.
2. Provide intravenous fluids and nasogastric suction.
3. Provide water and other fluids and soft diet, after bowel sounds return.
4. Instruct the patient to use a pillow to splint incision.
5. Administer analgesic agents as ordered.
6. Remind patient to expand lungs fully to prevent atelectasis.
7. Promote early ambulation.
8. Monitor elderly and obese patients most closely for respiratory problems,
9. Place drainage bag in patients pocket when ambulating.
10. Observe for indications of infection, leakage of bile, or obstruction of bile drainage.
11. Observe for jaundice.
12. Note and report right upper quadrant pain, nausea, and vomiting.
13. Change dressing frequently, using ointment to protect skin from irritation.
Cervical Cancer
1. Listen to the patients fears and concerns, and offer reassurance when appropriate.
2. Encourage the patient to use relaxation techniques to promote comfort during the
diagnostic procedures.
3. Monitor the patients response to therapy through frequent Pap tests and cone biopsies
as ordered.
4. Watch for complications related to therapy by listening to and observing the patient.
5. Monitor laboratory studies and obtain frequent vital signs.
6. Understand the treatment regimen and verbalize the need for adequate fluid and
nutritional intake to promote tissue healing.
7. Explain any surgical or therapeutic procedure to the patient, including what to expect both
before and after the procedure.
8. Review the possible complications of the type therapy ordered.
9. Remind the patient to watch for and report uncomfortable adverse reactions.
10.Reassure the patient that this disease and its treatment shouldnt radically alter her
lifestyle or prohibit sexual intimacy.
11. Explain the importance of complying with follow up visits to the gynecologist and
oncologist.
Cerebral Aneurysm
1. Establish and maintain a patent airway as needed.
2. Administer supplemental oxygen as ordered.
3. Position the patient to promote pulmonary drainage and prevent upper airway obstruction.
4. Avoid placing the patient in the prone position as well as hyperextending his neck.
5. Suction secretions from the airway as necessary to prevent hypoxia and vasodilation from
carbon dioxide accumulation.
6. Monitor pulse oximetry levels and arterial blood gas level as ordered. Use these levels as
a guide to determine appropriate needs for supplemental oxygen.
7. Prepare the patient for emergency craniotomy, if indicated.
8. If surgery cant be performed immediately, institute aneurysm precautions to minimize the
risk of rebleeding and to avoid increasing the patients intracranial pressure.
9. Administer hydralazine or another antihypertensive agent as ordered.
10.Turn the patient often. Encourage deep breathing and leg movement.
11. Apply elastic stockings or compression boots to the patients legs to reduce the risk of
deep vein thrombosis.
12.Give fluids as ordered and monitor I.V. infusions to avoid overhydration, which may
increase ICP.
13.If the patient has facial weakness, assist him during meals; assess his gag reflex and
place the food in the unaffected side of his mouth.
14.Implement a bowel elimination program based on previous habits.
15.Raise the beds side rails to protect the patient from injury.
16.Provide emotional support to the patient and his family.
Tunnel Syndrome
1. Administer mild analgesics as needed.
2. Encourage the patient to express her concerns.
3. Have her perform as much self-care, as her immobility and pain allow.
4. Provide her adequate time to perform these activities at her own pace.
5. Monitor the effectiveness of analgesics and other forms of therapy used to relieve the
patients discomfort.
6. Regularly assess the patients degree of physical mobility.
7. Teach the patient how to apply splint. Advise her not to make it too tight.
8. Show her how to remove splint to perform gentle range-of-motion exercises.
9. Advise the patient to occasionally exercise her hands in warm water.
10.If the patient is using a sling, tell her to move it several times a day to exercise her elbow
and shoulder.
11. Review prescribed medication regimen. Emphasize that drug therapy may require 2 to 4
weeks before maximum effect is achieved.
Cardiogenic Shock
1. Administer oxygen by face mask or artificial airway to ensure adequate oxygenation of
tissues.
2. Adjust the oxygen flow rate to higher or lower level, as blood gas measurements indicate.
3. Administer an osmotic diuretic, such as mannitol, if ordered to increase renal blood flow
and urine output.
4. Never flex the patients ballooned leg at the hip because this may displace or fracture
catheter.
5. To ease emotional stress, allow frequent rest periods as possible.
6. Allow family members to visit and comfort the patient as much as possible.
7. Monitor and record blood pressure, pulse, respiratory rate, and peripheral pulse every 1
to 5 minutes until the patient stabilizes.
8. Record hemodynamic pressure readings every 15 minutes.
9. Monitor ABG values, complete blood count, and electrolyte levels.
10.During therapy assess skin color and temperature and note any changes. Cold and
clammy skin may be a sign of continuing peripheral vascular constriction, indicating progressive
shock.

Nursing Care - Roxana Bucur

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Nursing Care - Roxana Bucur

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IN BED POSITIONS

I. In Dorsal Recumbent Position:

II. Turning to One Side:

B. To turn patient away from you:

Use Cautiously in patients with:

Generic Name: Hydralazine

Use cautiously in:

Adverse Reactions and Side Effects:

MCH (Mean Corpuscular Hemoglobin)

MCV (Mean Corpuscular Volume)

MCHC (Mean Corpuscular Hemoglobin Concentration)

R.B.C. (Red Blood Cell Count)

W.B.C. (White Blood Cell Count)

CALCIUM involved in bone metabolism, protein absorption, fat transfer muscular

PHOSPHORUS Generally inverse with Calcium.

ANION GAP (Sodium + Potassium CO2 + Chloride) An increased measurement is

AST (Serum Glutamic-Oxalocetic Transaminase SGOT ) found primarily in the liver,

ALT (Serum Glutamic-Pyruvic Transaminase SGPT) Decreased SGPT in combination

ALKALINE PHOSPHATASE Used extensively as a tumor marker it is also present in bone

GGT (Gamma-Glutamyl Transpeptidase) Elevated levels may be found in liver disease,

BUN/CREATININE This calculation is a good measurement of kidney and liver function.

A/G RATIO (Albumin/Globulin Ratio)

HDL (High Density Lipoprotein) A high level of HDL is an indication of a healthy

TRIGLYCERIDES Increased levels may be present in artherosclerosis, hypothyroidism,

T3-UPTAKE Increased levels are found in hyperthyroidism, severe liver disease,

THYROID-STIMULATING HORMONE (TSH) produced by the anterior pituitary gland,

CK-MB CK isoenzyme It begins to increase 6 to 10 hours after an acute MI, peaks in 24

Myoglobin - early and sensitive diagnosis of myocardial infarction in the emergency

General Nursing Responsibilities

c. Rectal anal portal rectum lower intestine

Useful in vomiting & unconscious patient

a. IV preferred for emergency immediate response

IV. Topical / percutaneous

Placing the Patient in Different Positions for

III. Sims or Left Lateral

IV. Knee-Chest or Genu-Pectoral

V. Dorsal Lithotomy or Dorso-sacral:

When use for examination of spine and backs:

VIII. Jack knife or Kroaske or Bozeman

Purpose: Operation on the rectum and coccyx

X. Fowlers and Semi-Fowlers Position

XI. Trendelenburg Position

Role the Nurse in Physical Examination

Nursing Interventions for Pain

Assessment and Diagnosis

Unfractioned Heparin administered subcutaneously to prevent foomation of DVT or by IV. Given

Assessing and monitoring anti coagulant therapy

Nursing Interventions: Nephrotic Syndrome

Nursing Interventions: Peptic Ulcers

Nursing Interventions: Pericarditis

Nursing Interventions: Pneumonia

Nursing Interventions: Pulmonary Edema

Nursing Interventions : Pressure Ulcers

Nursing Interventions: Parkinsons Disease

Interventions: Kidney Cancer

Prepare the patient for surgery if necessary

1. Maintain a patent airway. Assist with endotracheal intubation or tracheotomy as necessary.

1. Provide best rest during the acute phase.

1. Plan care to allow uninterrupted rest periods for the patient.

1. If the patient is vomiting, give antiemetics.

1. Provide emotional support to the patient and his family.

1. Listen to the patients fears and concerns about his illness.

Coronary Artery Disease

1. Keep nitroglycerin available for immediate use.