A COMPLETE GUIDE FOR

NURSING MEDSURG CLASS

Medical Surgical
Nursing Bundle
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NURSINGSTORERN
Nervous System Disorders ………………………………………………….. 1
Respiratory System Disorders ……………………………………………. 17
Cardiovascular System Disorders ……………………………………….. 30
EKG Interpretation …………………………………………………………….. 42
Gastrointestinal System Disorders ……………………………………. 52
Hepatic System Disorders …………………………………………………… 60
Renal-Urinary Disorders ……………………………………………………….. 63
Endocrine System Disorders …………………………………………………. 70
Integumentary System Disorders …………………………………….. 82
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Hematologic Disorders ………………………………………………………….. 89
Musculoskeletal System Disorders ……………………………………… 93
Reproductive System Disorders ………………………………………….. 99
Immune System …………………………………………………………………… 101

Cancer ……………………………………………………………………………………… 104

Shocks ……………………………………………………………………………………… 110
Bed Positions ………………………………………………………………………….. 111
Acid-Base Balance …………………………………………………………………. 114

Lab Values ……………………………………………………………………………… 118

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 Frontal Lobe Injured Brain Area Nursing Intervention
Parietal Lobe
Frontal Lobe Give simple instructions,
re-orientate as needed
Temporal Lobe Speak clearly due to
impaired hearing
Occipital Occipital Lobe Assist with ADL due to
Lobe visual disturbances.
Cerebellum Assist with walking

Brain Stem Monitor Vital Signs

Temporal Lobe
Cerebellum Parietal Lobe Provide simple, one-step
instructions

- Cerebrum
Consists in the Right and Left hemisphere. Each one receives sensory info from the opposite side of
the body.
- Cerebral Cortex
Outer grey matter NursingStoreRN
Frontal Lobe: Contains the motor cortex and Broca’s area (speech function)
Parietal Lobe: Contains the sensory cortex.
Occipital Lobe: Contains the visual cortex.
Temporal Lobe: Contains the auditory cortex and Wernicke’s area (comprehension of verbal/written
language).
- Basal Ganglia
Cell bodies in white matter that help cerebral cortex produce voluntary movements.
- Diencephalon
Thalamus: relays sensory impulses to the cortex. Provide a Pain gate. Part of Reticular activating
system.
Hypothalamus: Regulates responses of Sympathetic/Parasympathetic Nervous System. Regulates
Stress response, sleep, appetite, body temperature, fluid balance, and emotions. Responsible for
production of Hormones secreted by the Pituitary Gland and hypothalamus.
- Brainstem
Midbrain: Motor coordination. Visual reflex and auditory relay centers.
Pons: Respiratory center and regulates breathing.
Medulla Oblongata: Contains Afferent and efferent tracts, and cardiac, respiratory, vomiting, and
vasomotor center. Controls Heart Rate, respiration, blood vessel diameter, sneezing, swallowing,
vomiting and coughing.
- Cerebellum
Coordinates muscle movement, posture, equilibrium, and muscle tone.

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- Sympathetic (Adrenergic)
Fight or Flight. Originates at T1-L2 in the spinal cord.
Effects: Increase cardiac output, vasoconstriction (Increase BP), bronchodilation, pupil dilation,
Decrease secretions and peristalsis. Increase perspiration.
- Parasympathetic (Cholinergic)
Rest and Digest. Originates at S2-S4 in the spinal cord.
Effects: Decrease cardiac output, Vasodilation (Decrease BP), Bronchoconstriction, pupil constriction,
Increases Secretions and Peristalsis. Increase salivation, bladder contraction.

Computed Tomography (CT)

A brain scan that may or may not require injection of dye. Used to detect intracranial bleed, cerebral
edema, infarctions, hydrocephalus, cerebral atrophy, shifts of brain structures.
Pre-procedure: Assess for allergies to Iodine, contrast dyes, shellfish if using dye. Withhold metformin if
iodinated contrast dye used, risk of metformin-induced lactic acidosis.
Post-procedure: Fluids replacement, monitor for allergies to dye. Assess injection site for bleeding.

Magnetic Resonance Imaging (MRI)

Noninvasive procedure that identifies tissues, tumors, and vascular abnormalities. Provides more
detailed pictures than a CT.
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Pre-procedure: Remove all metal objects from the client. Make sure patient doesn’t have metal
implants, pace-maker, implanted defibrillator, hip prosthesis, vascular clip. Also contraindicated in
pregnant women (Increases temperature of Amniotic fluid). Assess for claustrophobia.
Post-procedure: Patient resumes normal activities.

Cerebral Angiography
Injection of contrast usually through the femoral artery into the carotid artery to visualize cerebral
arteries, and assess for lesions.
Pre-procedure: Assess for allergies to Iodine and shellfish. Assess Renal Function. Withhold
anticoagulation meds. NPO 4-6 hours before procedure. Assess and mark distal pulses (to easily
recheck them post-op).
Post-procedure: Monitor for swelling of the neck and difficulty swallowing. Bed rest for 12hrs. Check
insertion site for bleeding. Keep extremity straight and check for blood flow distal to the puncture site
(pulses, capillary refill, temp, color). Increase fluid intake.

Electroencephalography (EEG)
Used to identify seizures, sleep disorders, and other conditions. Electrodes place on scalp to record
electrical activity in the brain.
Pre-procedure: Wash the patient’s hair. Withhold coffee, tea, caffeine beverages, antidepressants,
tranquilizers, and seizure meds 24-48hrs before test. No NPO needed, can have breakfast.
During-procedure: Hyperventilation or strobe lights may be used to increase seizure activity.
Post-procedure: Wash patient’s hair. Safety precautions if patient was sedated.

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Lumbar Puncture
Sample of Cerebral Spinal Fluid (CSF) obtained from insertion of spinal needle (L3-L4). Used to
diagnosed meningitis, subarachnoid hemorrhage, neurological disorders.
Contraindicated in patients with Increased Intracranial Pressure (ICP).
Pre-procedure: Have the patient empty bladder. Position patient on their side in fetal position, lateral
recumbent position, or stretched over a table while sitting (so the back is arched).
Post-procedure: Lay flat for several hours. Increase fluids. Monitor for CSF leak, which can cause
headaches (epidural blood patch may be necessary).

Respirations
Cheyne-Stokes: Rhythmic, with periods of apnea. Can indicate metabolic disfunction or dysfunction in the
cerebral hemisphere or basal ganglia.
Neurogenic Hyperventilation: Regular rapid and deep sustained respirations. Indicates a dysfunction in
the low midbrain and middle pons.
Apneustic: Irregular, with pauses at the end of inspiration and expiration. Indicates a dysfunction in
the middle or caudal pons.
Ataxic: Totally Irregular. Indicates a dysfunction in the medulla.
Cluster: Cluster of breaths with irregular spaced pauses. Disfunction of Medulla and Pons.

Posture NursingStoreRN Decerebrate

Decerebrate (Extensor): brainstem lesion.
Decorticate (flexor): cortex problem. Cerebral dysfunction.
Flaccid: No motor response in any extremity. Decorticate

Meningeal Irritation
Irritability, nuchal rigidity, severe headaches, tachycardia, nausea and vomit, photophobia, nystagmus,
abnormal pupil reaction and eye movement.
- Kernig’s Sign: Loss of the ability of a supine patient to
straighten the leg completely when it is fully flexed at the knee and hip.
- Brudzinski’s Sign: Involuntary flexion of the hip and knee
when the neck is flexed.
Motor Response: Hemiparesis, hemiplegia, and decreased muscle tone.
Memory Changes: Short attention span, personality and behavior changes.

Reflexes
Deep Tendon Reflexes (DTRs): Biceps, triceps, brachioradial, quadriceps
Superficial Reflex: Plantar, abdominal, Babinski
Reflex Activity:
Absent, no response = 0
Weaker than normal = 1+
Normal = 2+
Stronger/more brisk = 3+
Hyperactive = 4+
3
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Deep Coma: 3
Comatose: ≤8
Normal: 15

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 A rise in pressure within the skull that can result from a brain injury or cause it.
Factors:
- Head injury with subdural or epidural hematoma. Normal ICP = 10-15 mmHg
- Cerebrovascular accident or cerebral edema. Elevated ICP: >20 mmHg, sustained
- Brain tumor, Hydrocephalus, Meningitis, encephalitis
- Ruptured aneurysm and subarachnoid hemorrhage
Manifestation
- Early Sing: Changes in LOC (Irritability, restlessness, confusion, Cushing’s Triad
drowsiness, lethargic). Headache, pupil abnormalities, Nausea and Systolic B/p
Vomit (projectile) abnormal breathing (Cheyne-Stokes, Biot’s),
abnormal posturing (decorticate or decerebrate). Pulse
- Cushing’s Triad Respirations
Nursing Interventions
Monitor VS and neurologic function. Keep head elevated 30-45 degree. Keep head in neutral position to
enhance drainage. Avoid Trendelenburg’s position. Avoid coughing, sneezing, straining, and suctioning.
Maintain maximum respiratory exchange (Hypercapnia causes vasodilation, thus increasing ICP).
Administer oxygen. Monitor I&O, may restrict fluid. Use hypothermia do decrease ICP. Intensive care
is required when monitoring ICP (ventriculostomy).
ICP Monitoring: Device inserted into the cranial cavity in the OR to measure pressure. Huge risk of
infection. Indications: Patient in coma (Glasgow Coma Scale <8).
Medications:
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- Osmotic Diuretics (MANNITOL (Osmitrol)) and steroids (Dexamethasone).
- Avoid opiates and sedatives unless ventilated (will restrict neurologic assessment).
- Acetaminophen for fever.
- Barbiturates to place patient into therapeutic coma with ventilator and cardiac monitoring.

Neurovascular disorder causing unilateral throbbing head pain that persists for 4-72 hours.
P: Poorly understood. Possibly caused by activation of CN V and cerebral arterial vasodilation.
RF: Women, family history
Triggers: Bright/flashing lights, stress, anxiety, menstrual cycles, sleep deprivation, foods (MSG,
tyramine, nitrites).
S/S: Unilateral throbbing pain, N&V, photophobia, phonophobia, aura.
Tx: NSAIDs (mild migraine), antiemetics, caffeine, sumatriptan or ergotamine (severe migraine).
Prophylactic med (antihypertensives, anticonvulsants)
Nurse: Promote Dark/quiet environment.

Severe, sudden head pain that last 30min-2hrs. Happens daily at the same time for months.
S/S: Severe unilateral, non-throbbing headache (around orbital region), facial sweating, nasal congestion
droopy eyelid, excess tearing, agitation and pacing.
Tx: O2 Therapy, sumatriptan, ergotamine, verapamil, corticosteroids.

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Open: Closed:
- Scalp lacerations - Concussions
- Fractures in the skull - Contusions
- Interruption of the dura mater - Fractures

Causes of Skull Fractures:

- Motor Vehicle Collision
- Falls
- Fire arms related injuries
- Assaults
- Sport related Injuries
- Recreational Accidents
- War related injuries
Death Can Occur at 3 points in time after injury:
1- Immediately After
2- Within 2 hours after
3- Three Weeks after injury
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Scalp Lacerations: Highly Vascular/High Risk of Blood Loss
Linear
Types of Skull Fractures
Simple (linear) fracture: is a break in the continuity of the bone.
Comminuted
Comminuted skull fracture: a splintered or multiple fracture line.
Depressed skull fractures: occur when the bones of the skull are
forcefully displaced downward. Depressed

Basal skull fracture: A fracture of the base of the skull. Basal

It allows CSF to leak from the nose and ears.
Signs of Basilar Skull:
A) Raccoon Eyes: Periorbital edema and ecchymosis.
B) Battle’s Sign: Postauricular ecchymosis noted on mastoid bone.
A
B
Testing for CSF (Cerebrospinal Fluid)
Dextrostix or Test-Tape Strips
Used to detect glucose found in CSF, however it is inaccurate if blood is in the sample as there is
glucose in the blood
Halo’s Sign
Allow drainage to leak onto a white gauze pad. Within a few
minutes, blood should gather in the center and CSF will create
a yellow ring around the blood

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Partial or Complete disruption of nerve tracts and neurons, resulting in paralysis, sensory
loss, altered activity, and autonomic nervous system dysfunction.

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Manifestations by the Level of Injury

Cervical: Partial or Complete quadriplegia/tetraplegia
- Respiratory dysfunction (patient may be ventilator dependent) C4↑ Loss of system
function.
- Partial or complete paralysis of all four extremities.
- Loss of bladder and bowel control, alteration in sexual dysfunction.
Thoracic Injury: Partial or Complete Paraplegia
- Loss of bladder and bowel control, alteration in sexual function.
- Partial or Complete paralysis of lower extremities and major control of body trunk
- Potential complication of autonomic dysreflexia – Injury above T6
- Respiratory Complications.
Lumbar
- Partial or Complete paralysis of lower extremities
- Loss of bladder and bowel control, alterations in sexual function.

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Paraplegia (Injury below T1): Paralysis or paresis (weakness) of lower extremities.
Quadriplegia (Injuries in the cervical region): Paralysis or paresis of all 4 extremities
Hypertonia (Injury to upper motor neurons, above L1/L2): Spastic muscle tone, spastic neurologic
bladder.
Hypotonia (Injury to lower motor neurons, below L1/L2): Flaccid muscle tone, flaccid neurogenic bladder.

Interventions:
- Stabilize spine, maintain patent airways, monitor VS, prevent pressure injuries.
- Monitor for spinal shock (loss of sensation, flaccid paralysis, and reflexes below the level of injury).
- Monitor for neurogenic shock (Decreased BP, HR, and cardiac output)
- Monitor for Autonomic Dysreflexia (life-threatening syndrome with sudden, severe hypertension
triggered by noxious stimuli below cord damage. Caused by impaction, bladder distention, pressure points
or ulcers, or pain.

Autonomic Dysreflexia: Severe Hypertension with bradycardia. Headache, flushing. Piloerection (goose
bumps), sweating. Nasal Congestion.
Nurse: High-Fowler’s position to help decrease BP, loosen constrictive clothing. Determine causative
stimuli. Teach patient bowel and bladder management. Administer meds. Therapeutic Measures
(Surgical management). Referral (Occupational and physical therapy).

Immobilization NursingStoreRN
- Spinal Board
- Halo Traction
- Gardner-Wells traction or Crutchfield tongs
- Cervical Collar

Halo Traction: Move patient as a unit, do not apply pressure to rods.

Mare sure wrench/screwdriver are attached to the vest to release
patient from device in the event of an emergency.

Skeletal Traction: Used to realign or reduce injury when skin

traction is not possible Ropes pulls and weights are used.
Traction needs to be maintained at all times. Weights must
hang freely and the knots in the rope are tied securely.

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Generalized Seizures
- Tonic-Clonic [Grand Mal]
Tonic-Clonic seizures may begin with an aura. The tonic phase
involves the stiffening or rigidity of the muscles of the arms
and legs and usually lasts 10 to 20 seconds, followed by loss of
consciousness. The Clonic phase consists of jerking of the
extremities and hyperventilation, and usually lasts about
30 sec. Full recovery from the seizure may take several hours.
- Absence [Petit Mal]
A brief seizure that lasts seconds, and the individual mayor may not lose consciousness. No loss or
change in muscle tone occurs. Seizures may occur several times during a day. The victim appears to be
daydreaming. This type of seizure is more common in children. Resembles “day dream”.
- Myoclonic
Myoclonic seizures present as a brief generalized jerking or stiffening of extremities. The victim may
fall from the seizure.
- Atonic or Akinetic [Drop Attacks]
An atonic seizure is a sudden momentary loss of muscle tone. The patient may fall.

Partial Seizures
- Simple Partial (Usually without alteration of consciousness)
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The simple partial seizure produces sensory symptoms accompanied by motor symptoms that are
localized or confined to a specific area. The client remains conscious and may report an aura.
- Complex Partial (Usually with impairment of consciousness)
The complex partial seizure is a psychomotor seizure. The area of the brain most usually involved is
the temporal lobe. The seizure is characterized by periods of altered behavior of
which the client is not aware. The client loses consciousness for a few seconds.

Phases of Seizure
- Prodromal: Symptoms preceding seizure: nervousness, lightheaded…
- Aural: Sensory Warning
- Ictal: Actual seizure
- Postictal: Altered state of consciousness - Can last 5-30 min after seizure.

Nurse: Maintain patent airways (position Side-Lying). Don’t put anything in patient’s mouth. Don’t
restrain. Note onset/duration.
Medication: Phenytoin, Carbamazepine, Valproic Acid, Phenobarbital, Levetiracetam, Topiramate.

Status Epilepticus: Life-threatening condition where there is a prolonged seizure (>5min) or fails to
regain consciousness in between seizures.
RF: CNS Infection, head trauma, drug withdrawal/toxicity.
Tx: Lorazepam (medication of choice), Diazepam, Fosphenytoin.
Phenytoin (IV slowly, no more than 50mg/min). Don’t mix with glucose. Administer in Normal Saline
(0.9%). Monitor for bradycardia and heart block.

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 –
Sudden temporary episode of neurological dysfunction lasting usually < 1hr secondary to decreased blood
flow to the brain. Warning Sign of a Stroke.
RF: Advanced age, male, genetics. Hypertension, Hyperlipidemia, Diabetes Mellitus, Smoking, Atrial
Fibrillation.
S/S: Sudden change in visual function. Sudden loss of sensory or motor functions.
Dx: Carotid Ultrasound, CT scan and/or MRI, Arteriography, 12-lead ECG.
Tx: Angioplasty. Carotid endarterectomy (removal of plaque from one or both carotid arteries).
Meds: Antiplatelet (Clopidogrel, Dipyridamole + Aspirin, Ticlopidine). Anticoagulants (Warfarin). Lipid-
lowering agents.
Nurse: DASH diet (high fruits and vegetables, moderate in low-fat dairy products, low animal protein).
Maintain body weight with regular exercise. Stop smoking.

CVA = STROKE = Brain Attack.

Sudden loss of brain function resulting from a disruption of blood supply to the brain.

Brain uses 20% of body’s total oxygen, it has no oxygen reserve.

Anoxia: >2-4 min - Cell Damage / 10 mins – Irreversible Damage
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Glucose is the main source of energy

Ischemic Strokes (80% of all Strokes)

Inadequate blood flow due to occlusion of an artery.

Embolic:
Clot can be made up of: Blood, fat, bacteria or air.
Caused when embolus lodges/occludes cerebral arteries. Sudden onset

Thrombotic:
Occurs in large arteries. Occurs from injury to a blood vessel wall, formation of a
blood clot. Gradual Onset. Typically occurs at night. Commonly precedes by TIA.

Hemorrhagic Strokes
Sudden onset of symptoms. Progression over minutes to hours because of
ongoing bleeding
- Most commonly caused by Hypertension
- Typically occurs during activity
Symptoms: Severe, sudden headache. N/V, Nuchal rigidity, Rapid deterioration of
function, HTN

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 –

Paralysis, weakness on RIGHT side Paralysis, weakness on LEFT side

Right visual field deficit Left visual field deficit
Aphasia Spatial-Perceptual deficit
- Expressive
Increased Distractibility
- Receptive
- Global Impulsive behavior/poor judgment
Altered intellectual ability Lack of awareness of deficits
Slow, cautious behavior Abilities overestimated
Increased level of frustration
Depression

Aphasia
- Expressive: Damage occurs in Broca’s area of the frontal brain. Patient understands what is said but
is unable to communicate verbally.
- Receptive: Injury involves Wernicke’s area in the temporoparietal area. Patient is unable to
understand the spoken and often the written word.
- Global or mixed: Language dysfunction occurs in expression and reception.
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Diagnostic Test
NON-contrast CT/MRI – to determine Ischemic or Hemorrhagic.
Lumbar Puncture, Cerebral Angiography or Angioplasty, Digital Subtraction, Angiography, Transcranial
Doppler Ultrasound.
PT/INR, PTT

Treatment
Ischemic Hemorrhagic
Thrombolytic Therapy Management of HTN
(Tissue Plasminogen Activator) Surgery (based on cause)
- MUST be given within 3.5 - 4 hrs of onset - Evaluate hematoma
- MUST rule out hemorrhage via CT - Clip aneurism
- Criteria: - Resection
- BP<185/110 - PT <15; INR < 1.7 Prevent ICP
- Not on coumadin - >18 years old Seizure prophylaxis if needed

Nurse:
- Assess swallowing and gag reflex before allowing patient to eat. Thicken liquids, teach patient to
tuck chin to chest when swallowing.
- Teach patient to use scanning technique (turn head from direction of unaffected side to affected
side) for homonymous hemianopsia.

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Chronic Progressive Autoimmune disorder, causes destruction of myelin, nerve fibers, and neurons in the
brain and spinal cord. Characterized by periods of relapsing and remitting.
RF: Women, 20-40yrs
S/S: Vision problems (diplopia/nystagmus), muscle spasticity and weakness, balance problems, bladder -
bowel dysfunction, cognitive changes, fatigue, emotional changes, pain.
Labs: MRI, Lumbar puncture (Increased protein in CSF).
Tx: Immunosuppressants, anti-inflammatories, muscle relaxants.
Nurse: Avoid triggers (temp extremes, stress, fatigue, illness).

Autoimmune disorder that causes severe muscle weakness. Characterized by periods of exacerbation
and remission.
P: Antibodies block/destroy ACh receptors at the Neuromuscular Junction.
S/S: Muscle weakness (worse with activity, improves with rest), diplopia, dysphagia, SOB, thymus
hyperplasia, drooping eyelids.
Dx:
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1- Edrophonium (Tensilon) test: Immediate improvement of symptoms that last 5 min (Positive).
Atropine (antidote) should be available in case of adverse effects (bradycardia, sweating, cramping).
2- Electromyography (EMG)
3- Repetitive Nerve stimulation
Tx:
- Medications: Anticholinesterase (Pyridostigmine) Antidote is Atropine.
Immunosuppressants (Prednisone), Immunoglobulins.
- Procedures: Plasmapheresis, Thymectomy.
Nurse: Maintain patent airways. Assist with ambulation. Encourage periods of rest. Provide small,
frequent, high caloric meals. Monitor for choking or aspiration. Administer eye drops, tape eyes shut at
night (to prevent corneal drying/damage).

Acute Autoimmune attack affecting the peripheral nervous system that causes a sudden onset of
weakness and paralysis.
P: GBS usually follows a respiratory or GI viral infection, leading to autoimmune destruction of the
myelin sheath and axons in motor and sensory nerves.
S/S: Symmetric Weakness, hyporeflexia, paresthesia and pain. Recovery takes several months – 2 years
Symptoms begin at lower extremities and ascend bilaterally.
Labs/Dx: Lumbar Puncture (Increase protein in CSF). Abnormal nerve conduction velocity test.
Tx: IV Immunoglobulin (IVIG), Plasmapheresis. May need mechanical ventilation.
Nurse: Maintain patent airways. Monitor for aspiration pneumonia, respiratory failure

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Neurodegenerative disease that attacks nerve cells (neurons) that control voluntary muscles (Lou
Gehrig’s disease). Cognitive function is not impacted.
RF: white, >40 yo, family history.
S/S: Muscle weakness, cramping, fasciculations. Respiratory paralysis (within 3-5 years). dysphagia,
dysarthria.
Dx: Clinical symptoms, rule out other neurologic diseases.
Tx: No cure. Riluzole slows deterioration of motor neurons.
Baclofen/Dantrolene/Diazepam (to manage spasticity).
Nurse: Maintain patent airways. Monitor for pneumonia,
respiratory failure. Coordinate with palliative team.

Progressive brain disorder that causes uncontrolled movements, emotional problems, and dementia.
P: Genetic (autosomal dominant) disorder that results in degeneration of GABA neurons (Inhibitory
neurotransmitters) and Increase Dopamine in the cerebral cortex and basal ganglia.
S/S: Chorea (abnormal/excessive involuntary movements), bradykinesia, dysphagia, cognitive issues
(dementia, memory loss, poor impulse control), psychiatric issues (depression, mania, personality
changes).
Dx: Genetic testing, family Hx.
Tx: No Cure. Symptoms management
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psychotropic agents, tetrabenazine.

Progressive neurodegenerative disease causing muscle rigidity, akinesia, and involuntary tremor.
P: Caused by loss of pigmented cells of substantia nigra and depletion of dopamine.
S/S: Muscle rigidity, tremor, slow/shuffling gait, postural instability, akinesia/bradykinesia, mask-like
expression, drooling, dysphagia.
Dx: Clinical Symptoms, rule out other neurologic diseases.
Tx:
Meds: Levodopa/Carbidopa, Benztropine.
Dopamine Agonist (Bromocriptine)
Procedures: Deep brain stimulation
Nurse: Monitor swallowing and food intake. Thicken food.
Sit patient upright to eat. Have suction equipment
available at the bedside. Encourage ROM and exercise.
Asist with ADLs, falls precautions.

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Gradual Irreversible dementia caused by nerve cell deterioration.
P: Beta-Amyloid deposits and neurofibrillary tangles develop in the brain. Neuron death leads to
atrophy of the affected areas.
RF: Older age, family Hx, Cardiovascular disease.

Agnosia: Failure to recognize or identify familiar objects despite intact sensory function.
Amnesia: Loss of memory caused by brain degeneration.
Aphasia: Language disturbance in understanding and expressing spoken words.
Apraxia: Inability to perform motor activities, despite intact motor function.

Stage I (Mild): Memory lapses. Losing/Misplacing items, poor concentration, short-term memory loss.
Stage II (Moderate): Forgetting events of one’s own history. Confusion, disorientation, agitation,
assistance with ADLs, incontinence.
Stage III (Severe): Bedridden, verbal/motor skills lost, dysphagia.

Tx: No Cure. Donepezil, Galantamine, Anxiolytics, antidepressants, antipsychotics.

Nurse: Maintain structured environment. Provide short directions, repetition,
frequent reorientation. Avoid overstimulation. Use a single-day calendar.
Maintain routine toileting schedule.
Home Safety: Remove scatter rugs. Install door locks (out of sight
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and patient reach), good lighting (especially over stairs). Mark step
edges with colored tape. Remove clutter.

Inflammation of the meninges (membranes around the brain and spinal cord).
P: Infectious organism enter the CNS through the bloodstream or gain access directly (trauma). Viral
meningitis typically resolves without treatment. Bacterial meningitis is contagious and potentially
fatal.
RF: Crowded conditions, immunosuppression, travel exposure.
Prevention: Hib Vaccine (given to infants). meningococcal vaccine (given to students living in dorms),
pneumococcal vaccine.
S/S: Nuchal rigidity, Headaches, Fever, Photophobia, Tachycardia, Nystagmus, altered mental status,
Positive Brudzinski’s & Kernig’s Signs, Seizures.
Labs/Dx: CSF analysis
-Bacterial: CSF is Cloudy with Decreased glucose, increased pressure, increased WBC, elevated protein.
-Viral: CSF is Clear, usually normal, Negative gram stain, slightly high protein and WBCs.
Tx: Antibiotics (Bacterial), anticonvulsants, analgesics
Precautions: Droplet Precautions for suspected/confirmed bacterial meningitis during the first 24 hrs
of antibiotic therapy.
Nurse: Seizure precautions. Monitor neurologic status. Provide quite room, dim light. Minimize increased
ICP (maintain HOB 30 degree, head midline, minimize suctioning).

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Inner ear disorder that affects balance and hearing.
P: Overproduction or decreased absorption of endolymphatic fluid leads to endolymph buildup in the inner
ear, which distorts the entire inner-canal system.
S/S: Tinnitus, unilateral sensorineural hearing loss, vertigo, balance issues, vomiting.
Dx: Hearing Test, Electrocochleography, CT/MRI to rule out tumor.
Tx: No Cure.
Meds: Antihistamine (Meclizine), Diazepam (for acute vertigo), antiemetics, diuretics.
Procedures: Labyrinthectomy, endolymphatic decompression.
Nurse: Avoid caffeine and alcohol. Low-Sodium Diet. Avoid aspirin and Monosodium Glutamate.

Slow progressive clouding of the lens.

P: Proteins in the lens deteriorate and clump together, causing the lens to thicken/harden. This
obstructs the passage of light through the lens to the retina.
RF: Aging, heredity, systemic disease (Diabetes), trauma
S/S: Gradual/painless loss of vision, blurred and double vision, white/grey pupil, absent Red Reflex.
Dx: Physical examination, Visual Acuity Test
Tx: Surgical removal of cataract.
Pre-Op: Dilate the eye. Administer Mydriatics, Antibiotics, Corticosteroids.
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Post-Op: Keep the operative eye close. HOB 30-450.
Patient Teaching: Importance of wearing sunglasses. Avoid Increase IOP
(Don’t bend at waist. Avoid sneezing, coughing, blowing nose, lifting >10lbs,
tight collars, straining with bowel movements). Best vision occurs 4-6 weeks after surgery.

Eye disorder that results in Increased IOP

Acute (Close-Angle) Ocular Emergency: Results in Sudden Increased of IOP from an obstruction to the
outflow of aqueous humor, or overproduction.
S/S: Severe Pain, rapidly progressive visual impairment, blurred vision, N&V,

Open Angle (Most Common): Insidious onset with slowly decreasing visual acuity. Gradual Increase of
IOP.
S/S: Usually bilateral, but one eye may be more affected. Halos around lights. Loss of peripheral Vision.

Dx: Tonometry to measure IOP (Normal Range: 10-20 mmHg)

Tx:
- Systemic: Mannitol (for close Angle).
- Local (eye drops): Timolol, Acetazolamide, Pilocarpine, Travoprost, Brimonidine.
- Surgery: Trabeculoplasty, Trabeculectomy.

NursingStoreRN 15
Deterioration of the macula, resulting in Central Loss of Vision.

Dry: Macula gets thinner with age and tiny clumps of protein (drusen) grow. More Common, slower
onset.
Wet: Abnormal blood vessels grow under the retina and leak blood/fluid, causing scarring of the macula.
Less Common, faster onset.

S/S: Loss of Central Vision, blurred vision.

Dx: Ophthalmoscopic examination.
Tx: No Cure. Dietary supplements,
photodynamic therapy.
Nurse: Teach quit smoking, wear sunglasses,
follow up care, home modifications to ensure safety.

Separation of the Retina from the Epithelium.

NursingStoreRN
P: Vitreous humor builds up behind the retina, which pushes the retina away from the back of the eye
and causes it to detach.
RF: Aging, injury, ocular tumor.
S/S: Curtain or shadow over visual field across one eye. Sudden visual disturbances, floaters, flashing
lights. Painless.
Dx: Ophthalmic Examination.
Tx: Emergency surgery to repair the detached retina.

NursingStoreRN 16
- Tracheal Sound: Harsh, hollow
- Bronchial Sound: High pitched, loud, hollow
- Bronchovesicular: Low Pitched, hollow,
Anterior and Posterior
- Vesicular: Low pitched, blowing
Anterior and Posterior

Name Location Cause Sound

Sudden reinflation of alveoli or fluid in Crinkle of crackle
Crackles R+L lung bases small airways Fine and short
Coarse of Medium
Can be cleared with cough
Trachea Fluid or Secretions in large airways Loud and low pitched
Ronchi Bronchi NursingStoreRN Heard on expiration
Fluid through a straw
Can be heard over all Narrowed or obstructed Bronchi High pitched
Wheezing lung fields. Usually heard Prolonged
louder posteriorly Heard on expiration
Pleural Rub Inflamed Pleura Rubbing or grating sound
Lateral Lung Fields heard on inspiration
Disrupted air flow of larynx or Trachea High pitched, wheezing
Stridor Upper lungs Croup, foreign body in airways, infection Mostly heard on inspiration

NursingStoreRN
✓ Tabaco Use or Smoking
✓ Persistent cough or sputum
production
✓ Chest Pain
✓ Environmental Exposures
✓ Chronic hoarseness
✓ Uncharacteristic Shortness of
Breath
✓ Family history of TB

NursingStoreRN 17
Bronchoscopy: Insertion of a tube in the airways to allow for visualization and collection
of specimens.
Pre-Procedure: NPO for 4-8 hours, prepare patient for sedation.
Post-Procedure: Ensure patient gag reflex has returned before allowing patient to
eat/drink. Sore/dry throat and blood-tinged sputum is expected. Monitor for
pneumothorax, which can occur within 24 hours after procedure.

Thoracentesis: Insertion of a needle in the posterior chest to aspirate fluid (<1L) or air
from pleural space.
Pre-Procedure: Patient sits Upright, with arms supported on pillows or overhead table
(tripod position). Educate patient to not move, talk, or cough during procedure.
Post-Procedure: Monitor patient for mediastinal shift, pneumothorax, bleeding,
hypotension. Chest X-ray performed if complications are suspected. Encourage deep
breaths to expand lungs.

NursingStoreRN
Pneumothorax: Air in the pleural space.
Hemothorax: Blood in the pleural space.
Tension Pneumothorax: Air in pleural space that doesn’t escape. Increased air in the pleural
space shifts organs and increases intrathoracic pressure. Tracheal deviation towards
unaffected side, absent breath sounds on affected side.
Flail Chest: Fracture of two or more adjacent ribs in two or more places with loss of chest wall
stability.
Cardiac Tamponade: Blood rapidly collects in pericardial sac, compresses Myocardium because
pericardium doesn’t stretch, and prevents ventricles from filling.

NURSE - Chest Drainage:

- Never elevate the system to the level of the patient’s chest (fluid drain back into the
lungs).
- If tube disconnect, place distal end of the tube in sterile water container at 2cm level.
- Milking or stripping chest tubes is NO recommended.
- Observe for Air fluctuation (tidaling) and bubbling in water seal chamber.
- If tidaling is NOT observed, the drainage system is blocked, the lungs are re-expanded or the
system is attached to suction.
- If bubbling increases, there may be an air leak (briefly clamp the chest tube, if the leak
stops, the air is coming from the patient.
- Report drainage >100 mL/hr to health care provider.

NursingStoreRN 18
Device Name O2 Rate Advantage Disadvantage
Lightweight Easily dislodged,
1-6 L/min Inexpensive skin breakdown
Nasal Cannula FiO2 Pt. can talk Mucosal drying
24-44% and eat

Simple to use, Poor fitting,

6-10 L/min inexpensive. must remove to
Simple FiO2 Can have eat
Face Mask 40-60% humidification

6-12 L/min Warm, poorly

Partial- FiO2 Moderate O2 fitting, remove
NursingStoreRN
Rebreathing 50-75% Concentration to eat

10-15 L/min
Non- FiO2 HIGH FLOW Poorly fitting,
Rebreathing 80-95 O2 remove to eat
Concentration

MOST
4-10 L/min PRECISE Remove to eat
Venturi FiO2 &
24-60% ACCURATE

NursingStoreRN 19
Breathing disruption in sleep that lasts >10sec and occurs >5 times per hour.
Patho:
Obstructive: Upper airways become blocked by overly relaxed airways muscles, or by
tongue/soft palate.
Central: The brain doesn’t send signals to the muscles that control breathing.
Rel Factors: Obesity, large tonsils, neuromuscular or endocrine disorders.
S/S: Persistent daytime sleepiness, irritability.
Dx: Polysomnography, overnight sleep study.
Tx: CPAP (Continuous Positive Airway Pressure), or BiPAP (Bi-Level Positive Airway
Pressure), adenoidectomy, tonsillectomy.

Genetic Disorder that severely impairs lung function and causes dysfunction in other
organs/tissues that make mucus or sweat.
Patho: Autosomal recessive disorder causes obstruction of NaCl transport within cell
membranes, producing secretions with low water content. This results in abnormally
NursingStoreRN
thick, sticky mucus that plugs organ ducts (pancreas, lungs, liver, small intestine,
reproductive organs), and leads to organ failure.
S/S: Respiratory: Wheezing, coughing, dyspnea, mucus plugs, cyanosis, barrel chest,
clubbing, chronic respiratory infections.
GI: Steatorrhea (fatty, malodorous stools), delayed growth, fat-soluble Vit deficiency
(A,D,E,K).
Skin: High NaCl content in sweat, saliva, and tears.
Labs/Dx: Sweat chloride test, DNA testing, PFTs, stool analysis.
Tx: Medications: Bronchodilators, anticholinergics, Dornase Alfa, antibiotics (for
pulmonary infection), pancreatic enzymes (take with meals and snacks), mucolytics.
Procedures: Chest physiotherapy (uses percussion, vibration, postural drainage, and
breathing exercises to loosen respiratory secretions). Schedule treatment before meals
or 1-2 hours after meals to avoid vomiting. Use bronchodilators 30min-1hr before
treatment.
Nurse: Administer O2. Encourage High Fluids, High Protein/Calorie diet. Supplements
(Vit A,D,E,K).

NursingStoreRN 20
A group of restrictive lung disorders that causes stiff and noncompliant lungs.
Patho: Chronic Inflammation of the lungs causes replacement of healthy lung tissue
with fibrotic scar tissue.
Rel Factors: Environmental inhalants, immune disorders, sarcoidosis.
S/S: Cough, dyspnea, chest discomfort, fatigue, clubbing.
Dx: X-ray, lung biopsy, PFTs.
Tx: Oxygen Therapy.
Medication: Anti-inflammatories (corticosteroids).
Procedures: Lung transplant

High Blood Pressure in the lungs.

Patho: High Vascular resistance and narrowing of the arteries in the lungs causes high
pressure in the right ventricle, leading to right ventricular enlargement/failure (Cor
Pulmonale).
Rel Factors: Cardiac defects/disease, pulmonary emboli, lung disease.
S/S: Dyspnea, pallor, fatigue,NursingStoreRN
chest pain on exertion, weakness, edema r/t right-side
heart failure.
Labs/Dx: Echocardiogram, Cardiac Cath, High PAP and PAWP.
Tx: Diuretics, Digoxin, Vasodilators
Nurse: O2 Therapy, fluid restriction, I&O, Daily weight, Encourage frequent rest
periods.

Rhinitis, Sinusitis, Pharyngitis, Laryngitis, Tonsillitis

Patho: Viral Infection, Bacterial Infection, or allergies causes release of histamine. This
results in local vasodilation, edema.
S/S: Rhinorrhea, Sore Throat, Headache, facial pain, fever, hoarseness, difficulty
swallowing.
Labs/Dx: Throat culture to rule out group A beta-hemolytic streptococcal infection
(strep throat), influenza, and Covid-19.
Tx: Nasal saline irritation, steam inhalation.
Medication: Expectorants, decongestants, analgesics, antibiotics for bacterial infection.

NursingStoreRN 21
Highly contagious acute viral respiratory infection.
Patho: Influenza A, B, or C virus is spread primarily through droplets from person to
person. The virus attaches to epithelial cells in the respiratory tract and replicates.
Prevention: Hand washing, annual vaccination, avoid close contact with infected pts.
S/S: Fever/chills, malaise, muscle aches, headache, rhinorrhea, cough, sore throat.
Labs/Dx: Rapid Influenza diagnostic test.
Tx: Saline gargles, rest, High fluid intake.
Medication: Antiviral agents (take within 48 hours after onset of symptoms),
analgesics, antitussives.

Infection in the Lungs caused by Mycobacterium tuberculosis.

Patho: Organism is transmitted via aerosolization and attaches to the alveoli. This
triggers an immune response, ingestion of the bacilli by macrophages, and formation of
granulomas (lesions).
NursingStoreRN
S/S: Cough lasting >3 weeks, purulent and/or bloody sputum, night sweats, weight loss,
lethargy.
Labs/Dx:
- QuantiFERON Gold blood test.
- Mantoux Skin Test: Intradermal injection, read in 48-72 hrs. Induration 10mm=
Positive Result (5mm for immunocompromised patients). Past BCG vaccination may
produce a false-positive result.
- Acid-fast bacilli culture: Use 3 early morning sputum samples.
- Chest X-ray: Shows active lesions in lungs.
Tx: Combination Drug Therapy, up to 4 antibiotics for 6-12 months of treatment
(Rifampin, Isoniazid, Pyrazinamide, Ethambutol).
Nurse: Place patient in Negative Airflow Room. Wear mask N95 in the room. Patient
should wear surgical mask when leaving the room. Screen family member for TB. Teach
patient that sputum samples will be needed every couple week. Patients are considered
not infectious after 3 Negative sputum cultures.

NursingStoreRN 22
Life-threatening blockage in the pulmonary vasculature.
Patho: Embolus (DVT) becomes lodged in pulmonary circulation. Pulmonary vascular
occlusion leads to impaired gas exchange and circulation.
Rel Factors: Immobility, smoking, combined oral contraceptives, obesity, surgery, AFIB,
long bone fractures (fat emboli), pregnancy.
S/S: Shortness of Breath, anxiety, chest pain wit inspiration, tachycardia, tachypnea,
hypotension, petechiae, diaphoresis.
Labs: High D-dimer (indicates presence of clot).
Dx: CT scan
Tx: Medication: Anticoagulants (heparin, warfarin), thrombolytics.
Surgery: Thrombectomy (removal of clot), vena cava filter (prevents new emboli from
entering the lungs).
Nurse: Sit patient Upright, administer O2.
Warfarin Therapy: Frequent blood draws needed to monitor PT/INR levels. Maintain
consistent intake of Vit K. Prevent bleeding (no aspirin, prevent falls, use an electric
shaver and soft toothbrush, avoid blowing nose forcefully).
Prevent DVTs: Stop smoking, Increase mobility, Wear compression stocks.
NursingStoreRN

Respiratory failure with non-cardiac associated pulmonary edema.

Patho: Systemic inflammatory response leads to alveolar permeability, inflammation, and
collapse.
Rel Factors: Sepsis, Shock, trauma, pneumonia, pancreatitis, inhalation of chemicals or
water (with near-drowning).
S/S: Dyspnea, rapid/shallow breathing, tachycardia, substernal retractions,
cyanosis/pallor, crackles.
Labs/Dx: ABGs, Chest X-ray (showing bilateral infiltrates).
Tx: Correct underlying cause, oxygen, mechanical ventilation.
Nurse: Maintain patient airways, monitor cardiac status (HR, BP), provide mechanical
ventilation care.

NursingStoreRN 23
Patho: Chronic lung disease that causes narrowing and inflammation of bronchi and
bronchioles. Intermittent and Reversible.
Asthma Attack:
1- Sooth muscle constricts = Chest Tightness dyspnea
2- Mucosa lining + goblet cells = more inflamed + excessive mucus production
goblet cells: collect bacteria to prevent going in the airways

S/S:
Early S/S Active S/S: VERY BAD!
1- Shortness of breath 1- Chest Tight 1- Rescue inhaler
2- Easy fatigue 2- Wheezing doesn’t work
3- Cough at night, trouble sleeping 3- Cough 2- Can’t speak
4- Sneezing, tired, scratchy throat 4- Dyspnea 3- Chest retractions
5- Wheezing 5- ↑HR 4- Cyanosis lips/Skin
6- ↓Peak flow best 6- Tachycardia 5- Sweaty
7- O2Sat <90%

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Triggers: Smoke, pollen, pollution, perfume, dander, dust, pest, mold, cool and dry air,
GERD, respiratory infection, exercise, hormonal shift, beta blockers/NSAIDS, Aspirin,
sulfites

Interventions: V/S, Keep Patient calm. High Fowlers. Oxygen / Bronchodilators.

Assess: lungs, cyanosis, ease of speak

Bronchodilators:
1- ALBUTEROL – Short Acting, fast relieve
-NOT for daily Tx-
2- SALMETEROL – Long Acting
-NOT for acute attack-
3- IPRATROPIUM – Short acting

Anti-Inflammatories:
1- CORTICOSTEROIDS – “-sone” “solone”
-NOT for acute attack-
2- MONTELUKAST – Oral – Relaxes smooth muscle,
↓mucus. for CONTROL and MAINTENANCE
-NOT for acute attack-

NursingStoreRN 24
Patho:
- COPD is characterized by airflow obstruction that is caused by chronic bronchitis or emphysema
- The obstruction is caused by inflammation which changes the structural function of the lung that
makes it harder to expire CO2
- The air becomes trapped causing the chest to hyper expand and become barrel shaped. This
prevents more air from being expired.
- Because of decreased expiration the pt. will become hypercapnic (↑CO2) and hypoxic (↓O2)
- The excess pressure can damage alveoli further causing a snowball effect of decreased function.
Complications:
Pulmonary Insufficiency - Impaired gas exchange r/t backflow from the Pulmonary Artery to Right
ventricle
Acute Exacerbation - Worsening or Symptoms. Tx: Assess ABGs, maintain fowler's position, suction
airway if necessary
Pulmonary hypertension - Excess Pressure in Lungs. Tx: Diuretics, vasodilators, anticoagulants +
Calcium Channel Blockers
Cor Pulmonale - Right Ventricle Hypertrophy. Tx: Treated with diuretics + management of underlying
cause
Risk Factors:
- Smoking - The major risk factor for developing COPD - hyperplasia, ↑mucus, ↓cilia
- NursingStoreRN
Occupational - Chemicals + Dusts (Dusts, vapors, irritants, fumes can increase the risk of COPD)
- Air pollution - Urban air pollution coal + biomass fuels used for heating
- Infection - Recurring infection in childhood are linked to reduced function
- Genetics or AAT Deficiency - Linked to poor lung function.
- Aging - Loss of recoil, stiffening of chest wall + impaired gas exchange
- Asthma - Can be secondary to COPD or contribute to progression of it
S/S:
Early Stages Late Stages Diagnosis:
- Symptoms develop slowly - Dyspnea at rest - History and physical Exam
- Chronic intermittent cough - Relies on accessory muscles - Spirometry - required
- Dyspnea that increase in severity to breathe - Chest X-Ray
- Inability to take a deep breath - Wheezing, chest tightness - A1 - antitrypsin levels (AAT)
- Prolonged expiration and ↓lung sounds - Fatigue, weight loss, - Blood gasses - in severe stage
anorexia - 6 min walk test

Classification Severity FEV1

↓FEV1 = ↑Obstruction
Stage 1 Mild >80%
FEV1 / FVC < 70% = COPD Stage 2 Moderate 50-80%
FEV1 = Forced Expiratory Vol/1Sec Stage 3 Severe 30-50%
Stage 4 Very Severe <30%

NursingStoreRN
Classification Severity FEV1 25
Stage 1 Mild >80%
Treatment:
Minimally invasive Pharmacology Surgical Pulmonary rehab
- Smoking cessation - Bronchodilators - Lung volume - Exercise training (ambulation
- Airway clearance techniques (↓Dyspnea, ↑FEV1) reduction + upper limb exercises)
- Hydration (if indicated) - Anticholinergics - Bullectomy - Smoking cessation
- Long - term O2 (if indicated) (↓Exacerbations) - Lung transplant - Nutrition counseling
- Exercise Plan (walking + upper body) - Corticosteroids - Education (Importance of
sleep and good nutrition)

Assessment Planning Diagnosis

Subjective Data Goals - Ineffective breathing
- Hx of exposure to - Prevent disease progression pattern
pollutants/irritants? - Maintain ability to care for self - Impaired gas exchange
- Hx of recent infection or hospital - Relieve symptoms – avoid - Ineffective airway clearance
stay? complications
- Do they use O2 therapy?
- Medications they're on? Implementation
1) bronchodilators Interventions
- Counsel smoking cessation
NursingStoreRN
2) corticosteroids
3) Anticholinergics - Breathing retraining: Pursed-lip (PLB) To prolong expiration. Easier
4) OTC to learn + should be 1st choice in acute situation
- Smoker? Pack years/ quit date - Diaphragmatic breathing: use of abdomen instead of accessory
- Weight Loss or Anorexia? muscles to prevent Fatigue and slow Respiratory rate
- Exercise / Activity Level? - Airway clearance (ACTs): loosen mucus/secretions then cleared by
- Anxiety / Depression? Sleep Pattern? huff coughing
- Chest Physiotherapy (CPT): Percussion / vibration loosens mucus
Objective Data - Postural drainage: Repositioning to drain secretions from specific
General areas
-Restlessness, Fatigue, Sitting - Nutritional therapy: Increase Kcals and protein
upright
Integument Education
Cyanosis, poor turgor, clubbing, - Encourage Pt. to avoid or control exposure to pollutants
bruising, edema, thin skin - Caution Pt. to avoid others who are sick and practice good hand
Respiratory hygiene
- Rapid + shallow breathing, prolonged - Explain importance of reporting changes in conditions to HCP
exp., - Remind Pt. to follow O2 therapy as ordered to prevent oxygen
- ↓Breath sounds, accessory muscle toxicity
breathing - Suggest nutritional meals options
- ↓Diaphragm movement, resp.
Evaluation
acidosis
- Assess need to change flow rate
Cardiovascular
- Evaluate compliance to meds.
- Tachycardia, Jugular vein distention,
- Monitor for signs of complications
edema in feet, dysrhythmias
- Determine O2 therapy effectiveness

NursingStoreRN 26
Patho:
An infection of the lung parenchyma. Usually your epiglottis, cough reflex, mucous membranes and
bronchoconstriction can protect the lungs from becoming infected, but they can become overwhelmed
and allow bacteria and viruses to grow.

Disease Process Common Causes:

Early Symptoms - Abdominal/thoracic surgery
- Purulent sputum - IV drug use
- Diminished lung sounds - Air pollution
- Fatigue - Immunosuppressive disease/meds
- Cough - Age of 65+
- Sore throat - Intestinal/gastric feeding via NG tube
Late Symptoms - Altered consciousness
- Chest pain - Malnutrition
- Tachycardia - Bed rest/immobility
- Sepsis - Tracheal intubation
- Dyspnea - Smoking
- Activity intolerance - Chronic disease
- Hemoptysis - Upper respiratory infection

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- Respiratory distress - Exposure to farm animal
- Diabetes
- Lung cancer
- CKD
- Recent antibiotics

Assessment Prevention Interventions

Lung sounds, VS, SaO2 %, Health Hx, - Wash Hands - Teach good handwashing
Medications, Recent Surgeries, Frequently; - Change position frequently
Smoking, Mobility Level, Fatigue - Eat A Balanced Diet; - Promote expectoration
LABs ABGs, Sputum Culture, WBCs - Get Adequate Rest; - Limit visitors to prevent spread of
- Exercise Regularly infection
- Cough + Sneeze into - Encourage adequate rest
Nutritional Considerations Elbow; - Educate pt. to report chest pain,
- Fruits + Vegetables build Immune
- Stop Smoking; fever, changes in sputum or altered
System
- Avoid Others Who Are sensorium
- Protein Rich Foods help Repair
Tissue ill - Provide comfort for pain
- Drink Plenty of Water and fluid to - Administer antipyretics as ordered
Maintain Fluid - Electrolyte Balance - Continuously monitor pulse oximetry
- Avoid Throat Irritating Foods Like - Suction secretion as needed
Milk That Can Cause Excess - Encourage early
Secretions ambulation/mobilization to speed up
recovery

NursingStoreRN 27
Uses:
- Removing Air, Fluid or Blood
- Preventing drained air and fluid from returning to the
pleural space
- Restoring Negative Pressure with the pleural space to
re-expand the lung

Placement:
Mid-anterior axillary line at the 4th or 5th intercostal
space on affected side

Complications:
- Bleeding
- Infection
- Air leak / Crepitus
- Clogged tubing – DO NOT MILK / STRIP TUBING
NursingStoreRN
- Tube disconnects from drainage system – Place chest tube in sterile water until new
system is set up

Heimlich Valve
Heimlich Valve:
One-way used with a chest tube to prevent air
from entering the pleural space.

Assessments (q2h):
- Pulmonary Status
- Dressing Status
- Assess for crepitus
- Check tubing
- Keep CDU (Chest Drainage Unit) below patient’s Chest Level
- Monitor Water Levels
- Assess for bubbling in water chamber
- Assess Drainage

NursingStoreRN 28
Patho: Occurs when Rib Cage fractures creating a “free” segment.
Causes: Severe Blunt Trauma
Symptoms:
- Tachycardia
- Dyspnea/Tachypnea
- Hypotension
- Cyanosis
- Chest Pain
- Anxiety
- Paradoxical Breathing
- Diminished Breath Sounds
Treatment:
- Oxygenation
- Mechanical Ventilation Expiration Inspiration
- IV Hydration
- Possible Surgical Intervention

NursingStoreRN
Patho: Life-threatening condition that develops when air is trapped in the pleural
cavity under positive pressure, displacing mediastinal structures. The air that enters
the chest cavity with each inspiration is trapped
Symptoms: Open Pneumothorax
- Acute Respiratory Distress
- Hypoxia
- Cyanosis
- Agitation I E
- Distended Neck Veins N X
- Drop in BP S P
- Tracheal Deviation away from P I
the affected side I R
Treatment: R A
- Emergency Thoracotomy A T
- Chest Tube Insertion T I
Thoracotomy: Incision in the chest wall I O
at: 4th Intercostal mid-axillary space O N
2nd and 3rd space at mid-clavicular line N
Right-Side ONLY
Tension Pneumothorax

NursingStoreRN 29
Conducting System
1- Sinoatrial (SA) Node [Primary Pacemaker 60-100bpm]
2- Atrioventricular (AV) Node [40-60 bpm]
3- Bundle of His
4- Bundle Branches
5- Purkinje Fibers

Properties of Cardiac Cells

Automaticity: The ability to initiate an impulse
Excitability: The ability to be electrically stimulated
Conductivity: The ability to transmit and impulse along
a membrane
Contractility: The ability to respond mechanically to
an impulse

Cardiac Output = HR x Stroke Vol

CO = 4-8 L/min (normal)
Mean Arterial Pressure
MAP=(SBP+2DBP)/3 Depolarization: When the charges are reversed. Heart Muscle Contract.
Normal > 60mmHg Repolarization: When the cells return to their original State
NursingStoreRN
Heart Sounds
S1- AV Valves Close – Heard at Apex
- Beginning of Systole
S2- Semilunar Valves close – Heard at Base
- End of Systole, Beginning of Diastole
S3- Heart Failure and Regurgitation
S4- Resistance w/ ventricular filling
Abormal

S3- VENTRICULAR GALLOP (Lub-de-dub)

Rapid Rush of Blood from the Atrium to the Ventricle
as it starts relaxing.
-Low Pitch / -Early Diastole
-May be Normal in Athlete, Pregnancy, Children
-Normal Up To 30 yrs
-Causes: HF, MI, Cardiomyopathy, HT,
S4- ATRIAL GALLOP
Sudden slowing of blood flow by the ventricle as the
atrium contracts.
- Low Intensity sound
- May be a sign of Diastolic HF or Ischemia
- Heard at apex
Causes: HF, MI, Cardiomyopathy
30
NursingStoreRN
Cardiac Enzymes are released when the Heart suffers Ischemia.
Troponin is the Most Specific.

Patho: Narrowing or obstruction of a coronary artery

due to plague buildup/ atherosclerosis
Dx: ECG, Catheterization, blood lipids
N: Educate about ↓ Kcal/fat, ↑ fiber diet & exercise
C: ↓ Perfusion, HTN, angina, MI

NursingStoreRN
Patho: Stretching of the medial wall of an artery caused
by vessel weakness
S/S: Thoracic - neck, shoulder, ↓back pain, ↑HR, dyspnea
Abdominal - pulsating mass in abdomen, Abd/back pain
Ruptured - severe Abd/back pain, shock, ↓BP
Dx: Ultrasound, CT Scan, arteriography
N: Monitor Vitals, check peripheral pulses, assess for
abdominal tenderness, ask pt. if abdominal or back pain is
present.

NursingStoreRN

Patho: Reduced cardiac output and tissue perfusion.

Usually caused by a corona artery blockage
S/S: Hypotension, pallor, tachycardia, disorientation,
chest pain, cool, clammy skin
N: Administer O2, morphine sulfate as ordered.
Prep for intubation, Monitor blood gas levels

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Sinus Tachycardia: Regular cardiac rhythm, HR > 100 bpm.
Causes: Physical activity, anxiety, fever, pain, anemia, medications, compensation for low cardiac output
or BP.
Tx: Treat underlying cause.

Sinus Bradycardia: Regular cardiac rhythm, HR < 60 bpm.

Causes: Excess vagal stimulation, cardiovascular disease/infection, hypoxia, medications. Normal in
athletes.
Tx: Atropine, Pacemaker (for symptomatic bradycardia).

Sinus Arrhythmia: Normal variant from normal sinus rhythm where the heart rate increases slightly
with inspiration and decrease slightly with expiration.
Causes: Common in children and typically disappears with age.
Tx: Not necessary

Rel Factors: Heart disease, cardiac

surgery, Older Age, Diabetes.
NursingStoreRN
A-FIB: Atrial: 350-600 beats/min.
Rapid and disorganized depolarization
of the atria, causing the atria to quiver
or fibrillate instead of fully squeezing.
This causes blood to collect on the atria,
placing the patient at High risk for clots.
Tx: Cardioversion, antiarrhythmics,
anticoagulants.

Atrial Flutter: Abnormal electrical

circuit forms in the atria, causing the
atria to depolarize 250-350 times/min.
Tx: Cardioversion, Antiarrhythmics.

32
NursingStoreRN
Ventricular Fibrillation:
Patho: Ventricles depolarize in a completely
disorganized way
S/S: Cardiac output ceases no pulse, BP,
Respirations and Pt. is unconscious
Nurse: Activate Emergency response,
Administer CPR, defibrillate and administer
O2 as ordered.

Premature Ventricular Contraction

Patho: Ventricles contract prematurely due to impulse initiation by purkinje fibers instead of SA node.
Nurse: Assess O2 saturation. Monitor anticoagulant and electrolytes as ordered.
Bigeminy - PVC every other heartbeat
Trigeminy - PVC every 3rd heartbeat
Quadrigeminy - PVC every 4th heartbeat
NursingStoreRN
NursingStoreRN

Patho: Cardiac tissue no longer has Oxygen Supply which can

lead to necrosis. Blockage of 1 or more arteries of the heart.
S/S: Chest pain, SOB, nausea, low back pain, diaphoresis,
pallor, fear + anxiety
Dx: Troponin levels, CK, CK-MB, Myoglobin, ECG
Nurse: Administer O2, Establish IV access, Obtain 12-lead
EKG,
Administer thrombolytic therapy, assess pulses, Monitor for
Blood Pressure Changes
Morphine – Pain and relaxes the heart
Oxygen – ↑O2 in the heart
Nitroglycerin - vasodilates
Aspirin – blood thinner
Percutaneous Coronary Intervention (PCI)
Procedure to open Coronary Arteries. Performed within 2 hours of onset of MI symptoms. Catheter
with a balloon is threaded through a blood vessel (usually femoral artery) up to the blocked coronary
artery. Balloon is inflated to allow stent placement to restore blood flow.
Nurse (Post-Surgery): Monitor for bleeding at insertion site. Check perfusion to extremity (pulse,
temperature, color). Monitor for complications: Artery dissection and thrombosis (reocclusion of vessel).

NursingStoreRN 33
Device that provides electrical stimulation of the heart when the natural pacemaker in the Heart
doesn’t maintain proper rhythm.
Types of Pacing:
- Atrial Pacing: Used with SA node failure.
- Ventricular Pacing: Used with a complete AV Block
- AV Pacing: Used with SA node failure AND complete AV Block.
Pacemaker Modes:
- Asynchronous: Fires at a constant rate regardless of heart’s electrical activity.
- Synchronous: Fires only when the heart’s intrinsic rate falls below certain rate.
Post-Op Nursing Care:
- Provide sling and instruct patient to minimize shoulder movement.
- Assess for hiccups, which may indicate pacemaker is pacing the diaphragm.
Patient Teaching:
- Carry pacemaker ID, take pulse daily, avoid contact sports and heavy lifting for 2
months.
- Pacemaker will set off airport security detectors.
- MRIs are contraindicated.
- It’s safe to use garage door opener and microwave.
NursingStoreRN

Heart muscle doesn’t pump enough blood to meet the body’s needs.
Patho: Congenital Heart defect or disorder (ex: coronary heart disease, cardiomyopathy,
Hypertension, valvular disease) damages or overworks the heart, decrease cardiac output.
S/S:
Left-Side HF: Results in pulmonary congestion. Dyspnea, cracklets, fatigue, pink/frothy
sputum.
Right-Side HF: Results in systemic congestion. Peripheral edema, ascites, jugular vein
distention, hepatomegaly.
Labs: High hBNP >100 pg/mL
Dx: Echocardiogram (Low Ejection Fraction), hemodynamic monitoring (High CVP, PAWP, Low
CO).
Tx: Diuretics, Digoxin, Beta Blockers, ACE Inhibitors, Angiotensin II blockers, Calcium Channel
Blockers, Vasodilators, Anticoagulants.
Nurse: Monitor daily weight, I&O. Sit patient Upright (High-Fowlers). Administer O2,
restrict fluid and sodium intake as ordered. Monitor for complications, including pulmonary
edema.

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 Normal Mitral Valve Normal Aortic Valve

Mitral Stenosis Aortic Stenosis

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Caused by Can lead to Treatment
- Valvuloplasty
- Rheumatic disease LV Enlargement
- Commissurotomy
- Strep Infection Right Side Heart Failure
(Removal of Scar Tissue)
- Valve Replacement

Symptoms: Symptoms:
Dyspnea Fatigue
Fatigue Chest Pain
Palpitations Shortness of Breath
Hemoptysis Syncope
Diastolic Murmur

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Blood leaks backward from aorta unto Left Ventricle.
Leads to Left Ventricle enlargement due to volume overload
from inadequate / incomplete emptying during systole.
Symptoms:
- Varies depending on cause/severity
- Increased C0 (early compensation)
- Paradoxical Nocturnal Dyspnea
- Pulmonary Edema
- Right Side Heart Failure
- Shock – Acute A.R.
Causes
Congenital Heart Valve Disease
TREATMENT
Age-Related heart changes
- Balloon Valvuloplasty
Endocarditis - Annuloplasty
Rheumatic Fever - Commissurotomy
Trauma - Valve Replacement

Backward of Blood from theNursingStoreRN

Left Ventricle to Left
Atrium due to an incompetent valve.
Symptoms
- Weakness
- Fatigue
- Paradoxical Nocturnal Dyspnea
- Murmur
- A-Fib
Causes
- Mitral Valve Prolapse
- Rheumatic Fever
- Endocarditis
- Heart Attack
- Cardiomegaly
- Trauma
TREATMENT
- Medication to Increase CO
- Annuloplasty
- Valvuloplasty
- MV Repair / Replacement

NursingStoreRN 36
Angina / Chest Pain: A narrowing of the coronary artery that supply the heart with blood and oxygen.
It occurs in times of HIGH demand for Oxygen (Exercise or Emotional Stress). If it goes untreated,
ischemia or myocardial infarction can occur.

Risk Factors: Smoking, diabetes, High BP, High Cholesterol, sedentary lifestyle, obesity, family history,
MEN>45 | WOMEN >55

Dx: Coronary Angiography – CT scan with dye to see occlusion

EKG + Echocardiogram
LFT’s
Lipid Profile – Cholesterol
Stress test to the heart
Blood test to see risk for Myocardial Infarction

S/S: Chest Pain constricting that radiates, pressure to the jaws, arms, back. Depending on the
severity: Nausea, pallor, SOB, diaphoresis, upper GI discomfort

Treatment:
1- Immediate relief – Nitroglycerin (dilates heart arteries to ↑ blood flow)

NursingStoreRN
1. For stable angina 1. For Unstable Angina
2. 1 pill q5m (up to 3 doses) 2. Rotate daily
3. Call 911 if symptoms persist 5 min after 1 tablet
st
3. Clean, dry, shaved area
4. Heat + Light sensitive. keep it in dark bottle 4. Shower ok
5. Don’t take with Sidenafil. 5. Wear gloves
6. HA and flushing are normal

2- Surgical: PCI- Stent in Artery | CABG-reroute around artery

3- Beta Blockers; CCB; -statins, anticoagulants

1- Occurs with exertion or stress 1- Occurs with exertion, stress and REST
2- Short duration – less than 5 min 2- Longer duration - > 30min indicative of Heart
3- Sx of CP relieved by rest or Nitroglycerin attack
4- Predictable 3- Unrelieved by medication or rest
4- Unpredictable

* Angina VS MI: Chest Pain unrelieved by rest or Nitroglycerin, lasting >30min is indicative of MI

NursingStoreRN 37
Patho: Bacteria or fungi adhere to the heart and form vegetative growths on the heart
valve or endocardium. This leads to necrosis and possible embolization of the growth.
Rel Factors: Congenital Heart disease, Valvular Heart Disease, prosthetic valve, IV drug use.
S/S: Fever, flu-like symptoms, murmur, petechiae, splinter hemorrhages (red streaks under nail
beds).
Labs/Dx: Positive blood culture, echocardiogram.
Tx: Antibiotics, valve replacement/repair.

Infection of the Heart that develops after a respiratory infection with group A beta
hemolytic streptococci bacteria
Patho: Strep infection triggers an autoimmune response (rheumatic fever), which leads to the
development of inflammatory lesions (Aschoff bodies) in the heart. These lesions cause damage
to the myocardium, pericardium, and heart valves.
S/S: Tachycardia, Cardiomegaly, murmur, friction rub, chest pain.
Labs/Dx: Throat culture + for Streptococcal Infection, Positive ASO titer, echocardiogram
Tx: Antibiotics, valve replacement/repair.

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Patho: Inflammatory response is triggered by Infection, Autoimmune disorder, or Trauma.
S/S: Chest Pain (worse when supine, relieved by sitting up and leaning forward), friction rub,
fever, dysrhythmias, dyspnea.
Labs/Dx: High WBC, EKG showing ST ot T spiking, echocardiogram.
Tx: -Meds: NSAIDs, corticosteroids, antibiotics (bacterial pericarditis).
-Procedures: Pericardiectomy
Nurse: Monitor for complications (Cardiac Tamponade)

Compression of the Heart due to the accumulation of fluid in the pericardial sac.
Patho: MI, Infection, Inflammatory disease, Autoimmune disease, or neoplasm leads to a build
up of pericardial fluid, which compresses the Heart, restricts blood flow into the ventricles, and
reduces cardiac output.
S/S: Muffled Heart Sounds, Paradoxical Pulse,
Jugular Vein Distension, Hypotension, electrical
alternans, dyspnea, fatigue
Dx: Chest X-Ray, Echocardiogram
Tx: Pericardiocentesis (removal of fluid
from pericardial sac).

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Patho: Heart muscle becomes enlarged, thickened, and/or rigid, which can lead to HF, arrhythmias,
pulmonary edema.
Types:
- Dilated (most common): Ventricles enlarge and weaken (starting with the left ventricle), affecting
systolic function.
- Hypertrophic: Ventricles and septum enlarge and thicken, affecting diastolic function and obstructing
outflow.
- Restrictive: Ventricles become stiff/rigid, restricting filling during diastole.
Rel Factors: Genetics, Coronary Artery Disease, Aortic stenosis, Hypertension, Viral Infection,
alcohol/drug use.
S/S: Shortness of breath, fatigue, dizziness, edema, arrhythmias, murmurs.
Dx: Echocardiogram, Coronary angiogram, EKG
Tx: -Meds: Digoxin, diuretics, antidysrhythmic, antihypertensive - Surgery: Septal myectomy, septal
ablation, implanted devices (CRT, ICD, LVAD, pacemaker), heart transplant.

Patho: Blood vessel damage causes inflammation and formation of plaques. Plaque deposits can become
large enough to narrow the lumen, reducing blood flow. Plaque rupture can lead to formation of a
thrombus or embolus, causing a MI or Stroke.
Rel Factors: Aging, Immobility, smoking, family history, hypercholesterolemia, diabetes, obesity, stress.
S/S: Hypertension, bruits NursingStoreRN
Labs: High LDL and Triglycerides.
Dx: Echocardiogram, CT/MRI, stress test, angiography.
Tx: Cholesterol-lowering meds (Ex: statins)
Nurse: Teaching about Smoking cessation, weight loss, exercise, heart-healthy diet.

Surgery to restore blood flow to an extremity due to a Peripheral Arterial Disease.

Nurse: Closely monitor pedal pulses, capillary refill, skin color and temperature. Patient needs to keep leg
straight for 24 hours after surgery.
Complications:
- Graft Occlusion: S/S: pallor, low pedal pulses and temperature, pain)
- Compartment Syndrome: S/S: Numbness, pain with passive movement, edema, taut skin.

Surgery to bypass one or more coronary arteries due to blockage or persistent ischemia, using the
patients own blood vessels (ex: saphenous vein) or synthetic grafts.
Nurse (Post Surgery): Monitor BP. Hypertension can cause bleeding from grafts. Hypotension can cause
collapse of grafts. Monitor Temperature. Treat hypothermia with rewarming procedures. Monitor for
bleeding. Notify Dr for Chest Tube drainage >150ml/hr. Monitor LOC, fluids and electrolytes, cardiac
rhythm, pain, neurovascular status of donor site. Monitor for complications (cardiac tamponade).

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Inadequate Blood flow to the lower extremities.
Patho: Atherosclerosis causes partial or total arterial occlusion, depriving the lower extremities
of oxygen and nutrients.
Rel Factors: Hypertension, diabetes, smoking, obesity, hyperlipidemia.
S/S: Intermittent claudication (ischemic leg pain that increase with exertion, and decrease
with dangling), pallor with elevation, dependent rubor, low capillary refill and pedal pulses, lack
of hair on calves, cool/shiny skin, thick toenails, dry/necrotic eschar on toes, delayed wound
healing.
Dx: Ankle-brachial index (ABI), doppler ultrasound.
Tx: Meds: Antiplatelets, statins.
Surgery: Angioplasty, peripheral bypass graft.
Nurse Teaching: Walk until the point of pain, stop and rest, then walk a little more. Avoid
crossing legs and restrictive clothing. Maintain a warm environment, wear socks. Avoid cold,
stress, caffeine, nicotine (which causes vasoconstriction).

Inflammatory condition that impairs circulation to extremities.

Patho: Chemicals in tobacco cause vasculitis, scarring and occlusion of blood vessels in the
arms/legs. NursingStoreRN
Rel Factors: Smoking
S/S: Claudication, numbness/tingling, low pedal pulse and temp, cyanosis in extremities.
Dx: Arteriogram
Tx: Vasodilators (ex: nifedipine)
Nurse Teach: Stop smoking, avoid extreme cold.

Rare vascular disorder that causes vasospasms in the arterioles/arteries, low blood flow to
the extremities.
Patho: Raynaud’s Disease (primary Raynaud’s): Idiopathic.
Raynaud’s Phenomenon (secondary Raynaud’s): Connective tissue disorder (ex: lupus or
scleroderma) damage the arteries.
S/S: Upon exposure to cold or stress, fingers become cyanotic, cold, numb, and painful. After
spam, tissue becomes hyperemic.
Dx: Clinical S/S, ANA titer to ID underlying autoimmune disease.
Tx: Vasodilators (ex: nifedipine), sympathectomy for severe symptoms.
Nurse: Avoid cold, wear warm clothing, no caffeine, stress. Stop smoking

NursingStoreRN 40
Blood clot that starts in the vein. Two types: Deep Vein Thrombosis (DVT) & Pulmonary Embolism
(PE)
Patho: Thrombus (blood clot) forms in a deep vein (usually lower leg, thigh, pelvis) due to Virchow’s
triad (endothelial injury, impaired blood flow, hypercoagulability). Inflammation occurs around the
thrombus and it breaks loose (becoming an embolus). The embolus travels to the pulmonary artery,
causing a pulmonary embolism (PE).
Rel Factors: Hip/knee replacement, Heart Failure, Immobility, Pregnancy, combined oral contraceptives,
family history, African Americans.
S/S:
- DVT: Calf/thigh pain, edema, erythema
- PE: Shortness of breath, dyspnea, anxiety, chest pain with inspiration, tachycardia, tachypnea,
hypotension, petechiae.
Labs/Dx: Positive D-dimer, venous duplex ultrasound, CT.
Tx: Meds: Anticoagulants (heparin, warfarin), thrombin inhibitor (ex: argatroban), thrombolytics
(alteplase) .
Procedures: Thrombectomy (removal of clot), vena cava filter (prevents new emboli from entering the
lungs).
Nurse:
- DVT: Elevate extremity (no pillow or knee gatch under knee), warm/moist compresses, No massaging
limb, apply compression stocking, monitor for S/S of PE.
- PE: Sit patient upright (High-Fowler’s position), administer Oxygen
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Veins in the lower extremities do not transport blood back to the heart effectively.
Patho: Valves in the lower leg become damaged due to prolonged venous hypertension or previous blood
clot.
Rel Factors: Obesity, immobility, pregnancy, history of DVT.
S/S: Edema, aching pain in legs, venous stasis ulcers (heavily draining, around the ankles), brown
discoloration (stasis dermatitis).
Tx: Elevate legs to increase venous return, apply compression stocking, monitor for complications
(cellulitis).
Nurse: Avoid sitting/standing still for too long, change position often. Avoid crossing legs and
restrictive pants. Apply compression stocking before getting out of bed in the morning.

Superficial veins enlarged and twisted. Most common in lower extremities and esophagus.
Patho: Pooling of blood in the legs causes the veins to become enlarged/weakened, impairs valve
function, and allows blood to flow backwards.
Rel Factors: Female, prolonged standing, pregnancy, obesity, family hx.
S/S: Enlarged, tortuous veins in lower extremities, visible below skin, aching pain, edema, pruritus.
Tx: Compression stocking, elevation, sclerotherapy (chemical injection), vein stripping (surgery/removal),
laser treatment.

NursingStoreRN 41
 Cardiac Cells have a (-) charge when resting. When Depolarization occurs, Cell becomes
P-wave: Atrial Depolarization Positive (Na+ and Ca+ enter the cell), Heart Muscle Contract.
QRS Complex: Ventricular Depolarization When Repolarization occurs, Cell becomes (-) (K+ Channels open and K+ leave the cell)
Heart Muscle Relax, cells return to their original (resting) state.
T-wave: Ventricular Repolarization

Normal Sinus Rhythm: 60-100 bpm

Assessment
Sinus Bradycardia: <60 bpm
Sinus Tachycardia: >100
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Rate: Is it Normal? (60-100) Fast (>100) Slow (<60)
Supraventricular Tachycardia: >150 bpm Rhythm: Is it Regular? Irregular?
PR Interval (Atrial Depolarization time): 0.12 - 0.20sec P Waves: Are they present? Are they 1:1 with the QRS?
QRS Complex (Ventricular Depolarization time): 0.04 - 0.12sec PR Interval: Is it normal? Does it remain consistent?
U wave: electrolyte abnormal (Hypokalemia) QRS Complex: Is it Normal? Or is it wide? (>10)
Extra: Are there any extra or abnormal complexes?

42
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 Normal Sinus Rhythm Sinus Bradycardia

Sinus Tachycardia Paroxysmal Supraventricular

Tachycardia

Atrial Flutter 1st Degree AV Block

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2nd Degree AV Block – Type I 2nd Degree AV Block – Type II

3rd Degree AV Block Ventricular Tachycardia

Ventricular Fibrillation

43
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 NursingStoreRN
Arrhythmias Description Causes Treatment
- Irregular Atrial and -Normal variation of
Sinus Arrhythmia normal sinus rhythm in
Ventricular rhythms.
- Normal P wave athletes, children, and
Atropine if rate decreases
preceding each QRS the elderly.
below 40bpm.
complex. - Can be seen in digoxin
toxicity and inferior wall
Ml.
- Normal physiologic response to
fever, exercise, anxiety,
Sinus Tachycardia Regular Atrial and
dehydration, or pain. - Correction of underlying
Ventricular rhythms. - May accompany shock, left- cause.
- Rate> 100 bpm. sided heart failure, cardiac
- Beta-adrenergic blockers
- Normal P wave tamponade, hyperthyroidism,
and anemia. or calcium channel blockers
preceding each QRS
- Atropine, epinephrine, for symptomatic patients.
complex. quinidine, caffeine, nicotine, and
alcohol use.
- Normal in a well-
- Regular Atrial and conditioned heart (e.g., - Follow ACLS protocol for
Sinus Bradycardia Ventricular rhythms. athletes). administration of Atropine
- Rate < 60 bpm. - Increased intracranial for symptoms of low
- Normal P wave
pressure; increased vagal cardiac output, dizziness,
tone due to straining during weakness, altered LOC, or
NursingStoreRN
preceding each QRS defecation, vomiting,
complex. low blood pressure.
intubation, mechanical - Pacemaker
ventilation.
- Infection
Sinoatrial Block - Atrial and Ventricular - Coronary artery disease, - Treat symptoms with
rhythms are normal except for degenerative heart Atropine I.V.
missing complexes. disease, acute inferior wall - Temporary pacemaker or
- Normal P wave preceding each Ml.
QRS complex. permanent pacemaker if
- Vagal stimulation, considered for repeated
- Pause not equal to multiple of
Valsalva's maneuver,
the previous rhythm. episodes.
carotid sinus massage.

- Atrial and ventricular rhythms

vary slightly.
Wandering Atrial Pacemaker - Irregular PR interval. - Rheumatic carditis due to - No treatment if patient
- P waves irregular with changing inflammation involving the is asymptomatic
configurations indicating that they
aren't all from SA node or single SA node. - Treatment of underlying
atrial focus; may appear after the - Digoxin toxicity cause if patient is
QRS complex. - Sick sinus syndrome symptomatic.
- QRS complexes are uniform in
shape but irregular in rhythm.

Premature Atrial Contraction - Premature, abnormal-looking P - May prelude - Usually no treatment is

(PAC) waves that differ in configuration supraventricular
from normal P waves.
needed.
tachycardia.
- QRS complexes after P waves - Treatment of underlying
except in very early or blocked PACs.
- Stimulants,
hyperthyroidism, COPD, causes if the patient is
- P wave often buried in the
preceding T wave or identified in infection and other heart symptomatic.
the preceding T wave. diseases. - Carotid sinus massage.

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 NursingStoreRN
Arrhythmias Description Causes Treatment
- Regular Atrial/Ventricular rhythms.
- HR > 160 bpm; rarely exceeds 250. - Physical exertion, emotion, - Unstable Patient: prepare for immediate
Paroxysmal Supraventricular - P waves regular but aberrant; difficult stimulants, rheumatic heart cardioversion.
to differentiate from preceding T waves. diseases. - Stable Patient: vagal stimulation, or
Tachycardia - P wave preceding each QRS complex.
- Intrinsic abnormality of AV Valsalva's maneuver, carotid sinus massage.
- Sudden onset and termination of - Adenosine by rapid I.V. bolus injection to
arrhythmia conduction system. rapidly convert arrhythmia.
- When a normal P wave is present, it's - Digoxin toxicity. - If normal ejection fraction, consider calcium
called paroxysmal atrial tachycardia; - Use of caffeine, marijuana, or channel blockers, beta-adrenergic blocks or
when a normal P wave isn't present, it's amiodarone.
called paroxysmal junctional tachycardia. central nervous system - If ejection fraction <40%, consider
stimulants. amiodarone.

- Atrial rhythm regular, Rate:

- Unstable patient with ventricular
250 to 400 bpm.
Atrial Flutter - Ventricular rate variable,
- Heart failure, tricuspid or rate > 150 bpm, prepare for immediate
mitral valve disease, cardioversion.
depending on degree of AV block - If the patient is stable, drug therapy
pulmonary embolism, car
- Saw-tooth shape P wave may include calcium channel blockers,
configuration. pulmonale, inferior wall Ml, beta-adrenergic blocks, or
- QRS complexes are uniform in carditis. antiarrhythmics.
shape but often irregular in - Digoxin toxicity. - Anticoagulation therapy may be
necessary.
rate.

- If unstable with ventricular rate >

Heart failure, COPD,
- Atrial rhythm grossly irregular 150bpm, prepare for immediate
thyrotoxicosis, constrictive
Atrial Fibrillation Rate > 300 to 600 bpm. pericarditis, ischemic heart
cardioversion.
- If stable, drug therapy (calcium
- Ventricular rhythm grossly
disease, sepsis, pulmonary me channel blockers, beta-adrenergic
irregular, rate 160 to 180 bpm
bolus, rheumatic heart disease, blockers, digoxin, procainamide, quinidine,
- PR interval indiscernible.
hypertension, mitral stenosis, ibutilide, or amiodarone.)

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- No P waves, or P waves that - Anticoagulation therapy to prevent
appear as erratic, irregular base-
atrial irritation, complication of
coronary bypass or valve emboli.
line fibrillatory waves - Dual chamber atrial pacing,
replacement surgery
implantable atrial pacemaker, or surgical

- Regular Atrial/ventricular rhythms. - Inferior wall Ml, or

Junctional Rhythm - Atrial rate 40 to 60 bpm.
- Ventricular rate is usually 40 to 60 - P
ischemia, hypoxia, vagal
- Correction of underlying cause.
- Atropine for symptomatic slow
waves preceding, hidden within (absent), stimulation, sick sinus rate
or after QRS complex; usually inverted if syndrome. - Pacemaker insertion if patient
visible.
- PR interval (when present) < 0.12 - Acute rheumatic fever. is refractory to drugs
second - Valve surgery - Discontinuation of digoxin if
- QRS complex configuration and duration appropriate.
normal, except in aberrant conduction. - Digoxin toxicity

Premature Junctional - Irregular Atrial and

ventricular rhythms. - Correction of underlying
Conjunctions - P waves inverted; may
- Ml or ischemia
cause.
- Digoxin toxicity and
precede be hidden within, or
excessive caffeine or - Discontinuation of digoxin
follow QRS complex.
- QRS complex configuration amphetamine use. if appropriate.
and duration normal.

- Myocardial ischemia or infarction,

Asystole aortic valve disease, heart failure,
- No Atrial or Ventricular
hypoxemia, hypokalemia, severe
rate or rhythm. acidosis, electric shock, ventricular
- No discernible P waves, arrhythmias, AV block, pulmonary Start CPR
embolism, heart rupture, cardiac
QRS complexes, or T tamponade, hyperkalemia,
waves electromechanical dissociation.
- Cocaine overdose.

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 NursingStoreRN
Arrhythmias Description Causes Treatment
- Correction of the underlying
First-Degree AV Block - Regular Atrial and - Inferior wall Ml or ischemia, cause.
ventricular rhythms. or infarction, hypothyroidism, - Possibly Atropine if PR interval
- PR interval > 0.20 second. hypokalemia, hyperkalemia. exceeds 0.26 second or
- P wave preceding each - Digoxin toxicity. symptomatic bradycardia develops.
- Use of quinidine, procainamide, - Cautious use of: digoxin, calcium
QRS complex.
beta-adrenergic blocks, calcium channel blockers, and
- QRS complex normal.
beta-adrenergic blockers.

- Regular Atrial rhythm

- Atropine, epinephrine, and
Second-Degree AV Block - Irregular Ventricular rhythm
dopamine for symptomatic
Mobitz I (Wenckebach) - Atrial rate > ventricular rate. - Severe coronary artery bradycardia.
- PR interval progressively, but
only slightly, longer with each
disease, anterior wall Ml, - Temporary or permanent
cycle until QRS complex acute myocarditis. pacemaker for symptomatic
disappears. - Digoxin toxicity bradycardia.
- PR interval shorter after - Discontinuation of digoxin if
dropped beat. appropriate.

- Regular Atrial rhythm.

Third-Degree AV Block - Ventricular rhythm regular and - Atropine, epinephrine, and
Complete Heart Block rate slower than atrial rate. dopamine for symptomatic
- No relation between P waves and - Inferior or anterior wall
bradycardia.
QRS complexes. Ml, congenital abnormality,
- No constant PR interval. - Temporary or permanent
rheumatic fever.
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- QRS interval normal (nodal pacemaker for symptomatic
pacemaker) or wide and bizarre bradycardia.
(ventricular pacemaker).

- Regular Atrial rhythm. - Heart failure; old or acute myocardial

Premature Ventricular - Irregular Ventricular rhythm. ischemia, infarction, or contusion. - If warranted, procainamide,
- QRS complex premature, usually - Myocardial irritation by ventricular lidocaine, or amiodarone I.V.
Contraction (PVC) followed by a complete compensatory catheters such as a pacemaker. - Treatment of underlying cause.
pause. - Hypercapnia, hypokalemia, - Discontinuation of drug causing
- QRS complexes are wide and distorted, hypocalcemia. toxicity.
usually >0.14 second. - Drug toxicity by cardiac glycosides,
- Premature QRS complexes occurring - Potassium chloride IV if PVC induced
aminophylline, tricyclic antidepressants,
singly, in pairs, or in threes; alternating beta-adrenergic.
by hypokalemia.
with normal beats; focus from one or - Caffeine, tobacco, or alcohol use. - Magnesium sulfate IV if PVC
more sites. - Psychological stress, anxiety, pain induced by hypomagnesaemia.
- Ominous when clustered, multifocal,

- Myocardial ischemia, infarction, or

aneurysm
Ventricular Tachycardia - Called "V-tach" - Coronary artery disease
- If pulseless: initiate CPR; follow
ACLS protocol for defibrillation.
- Ventricular rate 140 to 220 - Rheumatic heart disease
- Mitral valve prolapse, heart - If pulse: If hemodynamically
bpm, regular or irregular. stable, follow ACLS protocol for
failure, cardiomyopathy
- QRS complexes wide, bizarre, - Ventricular catheters. administration of amiodarone; if
and independent of P waves - Hypokalemia, Hypercalcemia. ineffective initiate synchronized
- P waves no discernible - Pulmonary embolism.
cardioversion.
- May start and stop suddenly - Digoxin, procainamide, epinephrine,
quinidine toxicity, anxiety.

- If pulseless: start CPR,

- Called "V-fib" - Myocardial ischemia or infarction,
follow ACLS protocol for
Ventricular Fibrillation - Electrical chaos in ventricles. R-on-T phenomenon, untreated
defibrillation, ET intubation,
No Cardiac Output or Pulse. ventricular tachycardia,
FATAL if more 3-5 min. - Hypokalemia, hyperkalemia, and administration of
Hypomagnesemia, alkalosis, epinephrine or vasopressin,
- Ventricular rhythm and rate
electric shock, hypothermia.
are rapid and chaotic. - Digoxin, epinephrine, or quinidine
lidocaine, or amiodarone;
- QRS complexes wide and toxicity. ineffective consider
irregular, no visible P waves magnesium sulfate.

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 Practice

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 Mouth – Amylase breaks down starch
Esophagus - Peristalsis brings foods to Stomach
Stomach - HCL breaks up food + activates enzymes. Pepsin converts proteins
Small Intestine - Duodenum contains bile, pancreatic ducts
Large Intestine - H2O absorption + waste elimination. Vit K synthesis
Pancreas - Maltase – Maltose > monosaccharides
Lactase – Lactose > galactose/glucose
Gallbladder – Stores, Concentrates Bile
Liver - Kupffer cells remove bacteria in the portal venous blood

P: Backflow of gastric and duodenal contents up into the esophagus caused by a dysfunctional lower sphincter
S/Sx: Frequent heartburn and epigastric pain, nausea, dyspepsia, dysphagia, regurgitation
N: Teach pt. to avoid irritants like peppermint, chocolate, coffee, fatty foods, alcohol, smoking. Avoid eating 2
hrs before bedtime. Avoid anticholinergics, NSAIDs. Keep HOB elevated after eating

P: An ulceration that erodes the lining of the stomach or S.I. Caused by irritation, H. pylori, NSAIDs
S/Sx: Sharp pain in left/mid epigastric area after meals 30-60 mins=gastric 90-180mins= duodenal
Rx: Proton pump inhibitors + H2 blockers
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Tx: Surgical: resection, vagotomy. Total gastrectomy, pyloroplasty

P: Inflammation of the gallbladder can be caused by slow bile emptying, contracted gallbladder or bacterial invasion
S/Sx: Murphy's sign > can't take deep breath when fingers are placed on the hepatic margin due to pain
Belching, flatulence, RUQ pain
N: Maintain NPO status during exacerbations. Educate pt. to eat small low-fat meals.

P: Inflammatory diseases of the bowel

S/Sx: Diarrhea, abdominal cramps for > 6 weeks
N: Educate about a low FODMAP diet, help decrease triggers and stress, avoid use of NSAIDS to ↓ GI bleeding

P: Acute inflammation of the appendix + surrounding tissue

S/Sx: Sharp, constant, abdominal pain that moves to the RLQ (McBurney’s point)
N: Administer pain meds, prep for imaging or surgery. If sudden relief of pain, indicate rupture of appendix.

P: Acute inflammation of pancreas

S/Sx: Nausea, vomiting, diarrhea, diffuse abdominal pain and cramping. Cullen’s Sign & Turner’s Sign.
Labs: ↑ Amylase, lipase, WBCs, bilirubin, glucose. ↓ Calcium, magnesium, platelets.
N: Pain control, nausea medication administration, limit oral intake. Pancreatic enzymes (w/ meals)
NursingStoreRN 52
Protrusion of the stomach through the diaphragm into
the chest cavity.
P: Weakening of the diaphragm allows the fundus of the
stomach to protrude through the esophageal hiatus
(opening in the diaphragm where the esophagus passes
from the thorax to the abdomen). High risk of
strangulation.
S/Sx: Heartburn, dysphagia, chest pain after meals.
Dx: Barium swallow study, EGD
Tx: GERD medications, fundoplication surgery.
Nurse: Teach pt. to avoid irritants like peppermint, chocolate, coffee, fatty foods, alcohol, smoking.
chocolate, coffee,
Elevate head fatty
of bed. foods,
Avoid alcohol,and
coughing smoking. Elevate
straining (use stool softeners).
head of bed. Avoid coughing and straining (use stool
softeners).

Section of intestine protrudes through a weakness in the abdominal muscle wall (inguinal or umbilical
hernia)

NursingStoreRN
P: Muscle weakness and/or increased intra-abdominal pressure allows for herniation. Risk of strangulation,
obstruction, and bowel necrosis.
R/F: Obesity, pregnancy, lifting of heavy objects.
S/S: Lump or protrusion at affected site. Severe pain and Decreased bowel sound with strangulation or
obstruction.
Tx: Truss (belt), surgical repair of hernia, bowel resection for bowel necrosis.
Nurse (post-op): Avoid coughing, if possible, splint when coughing/sneezing, avoid heavy lifting and
straining.

Complete or partial blockage of the intestines, Potentially life-threatening condition.

P: -Mechanical: Bowel is physically blocked.
R/F: Adhesion from surgery, tumor, hernia, fecal impaction.
-Non-Mechanical (paralytic ileus): Neuromuscular disorder causes decreased/absent peristalsis.
R/F: Abdominal surgery, electrolyte imbalances, inflammation/infection, intestinal ischemia.
S/S: Abdominal distention and pain, constipation, n/v, absent bowel sounds distal to obstruction.
Small bowel: Profuse vomiting (bilious or feculent), severe fluid and electrolyte imbalances, metabolic
alkalosis.
Large bowel: Minimal/no vomiting, no major imbalances.
Dx: Abdominal CT with contrast.
Tx: NPO, NG tube, IV fluids and electrolytes. Surgical: Colon resection, colostomy, lysis of adhesions.
Nurse: Strict I&O, monitor electrolytes and acid/base balance.

NursingStoreRN 53
A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosa of the stomach,
in the duodenum or in the esophagus.

Everything that reduces the protective mucosa layer:

1- H. Pylori – Bacteria that attacks the mucosa
2- NSAIDs – Inhibit prostaglandins - ↓Bicarbonate, = ↓Defense - ↑Acid
3- Smoking, ETOH, Genetics, STRESS
When damaged: histamine release - parietal cells stimulated to release more HCL acid

-Food makes it worst. Pain occurs IMMEDIATELY after eating.

-Pyrosis vomiting, constipation or diarrhea, and bleeding.
-If bleeding ulcer, hematemesis or melena (black, tarry stools)

-Food makes it better. Pain occurs 2-3 hours after meals.

- Pt. awake with pain during the night.
NursingStoreRN
- Stool- Dark, Tarry

Medication:
- PPI – Proton Pump Inhibitors (-prazole)
- Antibiotics – If confirmed H. Pylori
- Bismuth (Pepto-Bismol)
- H2 Blockers (-tidine)
- Antacids (Mag. Hydroxide, Calcium Carbonate, Sucralfate, Carafate)

NursingStoreRN 54
Backflow of gastric or duodenal contents into the esophagus, due to a weak/damaged lower
esophageal sphincter (LES)

Endoscopy – Will assess narrowing or ulcers formed

pH Monitoring – Measures the amount of acid in the esophagus

Most Common – Pyrosis (heartburn)

- Epigastric Pain
- Regurgitation
- Dry cough worse at night/ hoarseness
- Nausea
- Difficulty swallowing
- symptoms may mimic those of a heart attack
[Brunner & Suddarth’s Med Surg 14e page 1283]

NursingStoreRN
Lifestyle changes: Small meals
- last meal 30min before bedtime
- Sit up 1hr after meals
- Weight loss, smoking cessation
Avoid: fatty, ETOH, coffee, peppermint, acid foods (citrus, tomatoes)
Medication
- Antacids – Interferes with many drugs. Give alone, wait 1-2 hrs before taking another
meds
- Histamine Receptors Blockers – lowers Histamine – Lowers Inflammation
- PPIs – Protect lining of the stomach
- Bethanechol – Protect lining of stomach
Fundoplication Surgery – Reinforces the LES by wrapping a portion of the stomach around
the esophagus

NursingStoreRN 55
Inflammation or ulceration (or both) of the bowel.
Characterized by periods of remission and exacerbation.
May affect anywhere in the GI. Most common in ileum and the ascending colon.
Scattered patches – Not continuous with cobblestone appearance

1- Right Lower abdominal pain

- Mouth or GI ulcers
- Diarrhea (sometimes with blood, pus, mucus)
- Loss of appetite / weight
- Fissures with anal bleeding
- Abdominal bloating

NursingStoreRN
1- Abscesses: Form in the intestinal wall
2- Fistula: Worsening of abscess may lead to a hollow hole
3-Malnourishment: If affecting the Small Intestine
4- Fissures: If affecting anal area – loss of integrity
5- Strictures: Narrowing, Intestinal Blockage

1- Diet Education – AVOID high fiver, nuts vegies, fruits, dairy, spicy, high fat, gas causing food
Encourage- LOW fiber, HIGH protein, HIGH fluids
2- Medication
1st Line- Mild case: sulfasalazine.
Steroids: ↓Inflammation, NOT long term, ↑ Infection risk
2nd line- Immunosuppressors: ↑risk of infection, cancer, ↓Inflammation
3- Teach Ostomy care if surgery occurs
4- Smoking Cessation
5- In severe cases, TPN for malnourishment – Monitor weight
6- Monitor bowel movement, frequency and characteristics/ Bowel sounds
NursingStoreRN 56
Chronic ulcerative and inflammatory disease in the INNERMOST lining of the Colon and
Rectum ONLY. (There is NO abscesses, fistulas or fissures -usually)
“Continuous - Not Scattered”

- Cells of intestinal lining die from ulcers that pus and bleed.
- Intestine can’t absorb water as usual – Watery diarrhea that Includes Pus and Blood
- Urge to defecate frequently
- Periods of remission and exacerbation. Ulcer sites heal, but lining stays damaged, may form
polyps

- Lead-pipe Sign – large intestine starts to

lose its form. Will appear smooth (no Haustra)
- Repeated Ulceration – Rupture of bowels –
peritonitis
NursingStoreRN
- Toxic Megacolon – Large intestine dilates due
to inflammation – Unable to function properly

1- Surgery – Proctocolectomy ileoanal anastomosis

2- Diet Education – AVOID high fiver, nuts vegies,
fruits, dairy, spicy, high fat, gas causing food
Encourage- LOW fiber, HIGH protein, HIGH fluids
3- Medication:
1st Line- Mild case: sulfasalazine.
Steroids: ↓Inflammation, NOT long term, ↑ Infection risk
2nd line- Immunosuppressors: ↑risk of infection, cancer,
↓Inflammation
Also, Abx during flares up Antidiarrheals

NursingStoreRN 57
Surgical procedure that reroutes part of the intestine through the abdominal wall, forming a stoma.
Types of Ostomies:
Ileostomy: Created from the ileum (small
intestine). Bowel movements are loose/watery.
Colostomy: Created from the large intestine.
Bowel movements vary in consistency.
- Ascending colostomy: liquid
- Transverse colostomy: semi-solid
- Descending/Sigmoid colostomy: formed.
Nurse: Assess stoma regularly, should be pink/moist. Pale or blue stoma indicates ischemia. Empty bag
when it is 1/3 – ½ full. Change immediately for leaking. Cut opening in skin barrier <1/8” bigger than
measured stoma size to prevent skin damage from contact with ostomy output. Chew food thoroughly.
Consume low-fiber diet for first 6-8 weeks. Avoid
foods that cause gas/odor.

*A loop, or double-barrel stoma, is usually temporary.

Stool will be expelled from the proximal stoma only.

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P: Peritoneal cavity becomes contaminated by bacteria, resulting in inflammation.

RF: Infection, trauma, perforation r/t appendicitis, diverticulitis, peptic ulcer disease.
S/S: Rigid, board-like abdomen, abdominal pain, n/v, rebound tenderness, fever, tachycardia.
Dx: Abdominal X-ray, CT, ultrasound.
Tx: NPO, NG tube, IV fluids, antibiotics, analgesics. Surgery: Repair/removal of perforated organ, intra-
abdominal lavage.
Nurse: Monitor patient closely for sepsis.

P: High intraluminal pressure causes diverticula to form in weak spots in the GI wall. Undigested food and
bacteria accumulate in the diverticula, leading to inflammation.
RF: Low-fiber diet, genetics, obesity, smoking, alcohol, NSAIDs, corticosteroids.
S/S: LLQ abdominal pain (descending, sigmoid colon), bloating, fever, n/v.
Labs: High WBCs, ESR, Decrease Hgb/Hct with bleeding.
Dx: Barium Enema, Colonoscopy, CT, lower GI series.
Tx: Antibiotics, analgesics.
Nurse: Monitor for signs of complications (perforation, peritonitis, bleeding, fistula). NPO or clear liquid
diet during exacerbations, then progress to a low-fiber diet. Ongoing, eat a high-fiber diet.

NursingStoreRN 58
Swollen/fragile blood vessels in the esophagus that can hemorrhage (life-threatening)
P: Blood flows is impaired into the liver (due to cirrhosis, hepatitis), which leads to increased pressure in
the portal vein (portal hypertension). This causes blood to be pushed into the surrounding blood vessels,
including those in esophagus.
R/F: Portal Hypertension, portal vein obstruction.
S/S: Increased AST, ALT. With bleeding: hypotension, tachycardia, Decreased Hct/Hgb.
Tx: Blood transfusion.
- Meds: Vasoconstrictors, non-selective beta blockers.
- Procedures: Endoscopic sclerotherapy or band ligation, balloon tamponade, esophageal stent, transjugular
shunt.

Inflammation of the liver due to a virus or hepatotoxic drug/chemicals.

Types of Viral Hepatitis:
- Hep A: Acute Infection, fecal/oral transmission (ex: contaminated food/water). Self-resolving. Prevention
with HepA Vaccine.
- Hep B: Acute/chronic infection, blood/body fluids transmission. Prevention with HepB vaccine.
- Hep C: Acute/chronic infection. Blood/body fluids transmission.
NursingStoreRN
- Hep D: Acute/chronic infection. Blood/body fluids transmission. Only occurs with HepB infection.
- Hep E: Acute infection. Fecal/oral transmission (contaminated water) or undercooked meat.
S/S: Fever, lethargic, n/v, jaundice, dark-colored urine, clay-colored stools, arthralgia, abdominal pain.
Labs/Dx: Increased ALT, AST, and bilirubin. Serological assays.
Tx: Antiviral medications, supportive treatment.
Nurse: Encourage Hep A&B Vaccines, safe sex practices.

Reduction of gastric capacity or absorption in morbidly obese patients.

Post-op: Monitor for dumping syndrome (S/S: abdominal cramping, tachycardia, nausea, diarrhea,
diaphoresis).
Nurse: Chew food slowly and completely. Eat 6 small meals a day. Do NOT consume liquids with meals. Do
recline after meals to slow gastric emptying (with dumping syndrome). Avoid foods high in sugar, fat,
carbohydrates. Avoid foods high in sugar, fat, carbs. Take vitamin/minerals supplements as directed.

NursingStoreRN 59
- Largest gland of the body
- Located in the RUQ of abdomen
- Stores glucose (as glycogen)
- Converts ammonia to urea for excretion by the kidneys
- Synthesizes blood proteins, clotting factors
- Stores vit. A, D, K, Iron, copper
- Makes bile which aids in digestion by emulsifying fats
- Metabolizes drugs + binds them to be excreted in urine

- Glycogenesis: Glucose into glycogen

- Glycogenolysis: Breakdown of glycogen to glucose
NursingStoreRN
- Gluconeogenesis: Glycerol, amino acids or lactate into glucose
- Ketogenesis: Fatty acids or protein breakdown
- Ammonia conversion: Ammonia into urea
When there is not enough glucose, Fatty acids are converted into ketones

- Bile aids in digestion by forming bile salts which help emulsify fats.
- Bilirubin is a byproduct of hemoglobin breakdown.
- Metabolism of drugs by the liver are slowed in older adults which can increase their effects.
- Bile is made up of water, electrolytes, lecithin, fatty acids, cholesterol, bilirubin, bile salts.

NursingStoreRN 60
- Radioisotope Liver Scan: Uneven uptake of isotopes - ALP -Increased
- Abdominal ultrasound: Shows ascites - ALT + AST -Increased
- Laparoscopy: Can visualize tissue directly - LDH -Increased
- PT / INR -Prolonged
- ERCP: Shows biliary structures
- Electrolytes: ↓k+, ↓Na+
- CT Scan: Shows dense fatty areas - Bilirubin: Increased levels
- MRI: Shows neoplasms, cysts, obstructions - Protein: ↓Albumin/globulin
- Liver Biopsy: Large needle inserted into liver. - Ammonia: Increased levels
pt. has risk for hemorrhage - BUN: ↓Decreased

Pathophysiology
- Usually a gradual decline in function as liver tissue is slowly destroyed.
- hepatocyte + liver lobule destruction causes decreased metabolic function
NursingStoreRN
- Fibrous connective tissue forms which disrupts the flow of blood and bile, causing portal
hypertension
Manifestations
- Jaundice: r/t increased bilirubin levels
- Portal HTN: r/t Narrowed Vessels
- Ascites: r/t portal HTN
- Esophageal varices: r/t portal HTN

Portosystemic Encephalopathy Hemorrhage

r/t Accumulation of Neurotoxins r/t ↓ clotting factors
S/Sx: Asterixis, alteration in mental status, Sleep S/Sx: Tachycardia, hypotension
I. Normal LOC + Some lethargy Tx: Transfusion, fluid
II. Lethargy, disoriented, agitation replacement emergency surgery
III. Stupor, difficulty waking, incoherent
IV. Comatose, no response to stimuli
Tx: Small frequent meals, ↑ protein intake

NursingStoreRN 61
Etiology Treatment
- Malnutrition r/t alcoholism Slow progression of disease
- Infection -Stop drinking
- Diabetes - Eat healthier diet
- Nutritional deficiency Liver transplant
- Hypersensitivity - C/I w/ alcoholism or malignancy
Minimize bleeding
Manifestations - Monitor coagulation
- Jaundice - Institute bleeding precautions
- Portal hypertension Paracentesis (Aspiration of peritoneal cavity
- Ascites fluid)
- Varices - Helps relieve respiratory distress
- Hepatic Encephalopathy - 500 - 1000ml removed daily
- Albumin given during large vol.
Early
- Enlarged liver
- Weight loss Nursing Interventions for paracentesis
- Weakness NursingStoreRN
- Ensure informed consent obtained
- Anorexia - Instruct client to void to prevent
puncturing bladder
Later - Assess weight, Abd Girth + vital signs
- Portal HTN
- Place client in high fowler's/ upright
- Jaundice

Rx
Nursing Interventions
- Iron + folic acid - Treat anemia
- Encourage pt. to avoid alcohol
- Maintain fluid balance, I/O, Weight, - Diuretics - Reduce fluid retention
Assess urine - Lactulose - ↓Nitrogen + Ammonia
- Assess LOC, mental status - B blockers - Prevent varices bleeds
- Minimize bleeding, Bleeding precautions,
PT/INR
- Promote nutrition + protein

NursingStoreRN 62
- Creatinine: 0.6 – 1.2 mg/dL [Best Indicator Renal Disease]
- BUN: 12 – 20 mg/dL [Elevated doesn’t always means Real Disease]
- Urine pH: 4.0 – 8.0
- Specific Gravity: 1.003 – 1.030 [Ability of Kidneys to concentrate Urine]
• Increased: More Concentrated Urine. Low fluid intake, decreased renal perfusion,
Increased ADH
• Decreased: Less Concentrated Urine. High fluid intake, Diabetes Insipidus, Kidneys
Disease or inability to concentrate urine.
- Osmolality: 300-1300 mOsm/kg (mmol/kg)
- Creatinine Clearance Test [Provides the best estimate of Glomerular Filtration Rate
(GFR)] “Saunders”
- GFR: 125 mL/min in adults [GFR decreases with Age. By 65yo, GFR is 65 mL/min]

- Maintain body fluid, regulate electrolytes and acid-balance.

- Eliminate waste products (uric acid, urea, ammonia, creatinine)
- Regulate BP through the NursingStoreRN
release of Renin (When BP or fluid concentration is low in the
Distal Convoluted Tubule (DCT)
- Secrete Erythropoietin to stimulate RBC production in the bone marrow.
- Synthetize Vit D for Calcium absorption
- Total Bladder Capacity is 1L.

Functional units of the Kidney. Consists of glomerulus

(surrounded by the Bowman’s Capsule) and tubules.
Functions:
- Filtration: Blood enters the glomerulus from the
afferent arteriole and is filtered at a rate of
125mL/min (Glomerular filtration rate). Non-
filterable components exit via the efferent arteriole.
- Reabsorption & Secretion: Glomerular filtrate
moves through the proximal convoluted tubule, loop
of Henle, distal convoluted tubule, and collecting
tubule, where water, electrolytes, and other
substances are either reabsorbed into circulation, or
excreted into the urine, through the Renal Pelvis,
Ureters, Bladder, and Urethra.
63
NursingStoreRN
- Renin (an enzyme) is released from the Nephron when BP or fluid concentration is
LOW.
- Renin converts Angiotensinogen (from the liver) to Angiotensin I.
- Angiotensin-Converting Enzyme (ACE, from the Lungs) converts Angiotensin I to
Angiotensin II.
- Angiotensin II (potent vasoconstrictor) stimulates the secretion of Aldosterone.
- Aldosterone stimulate the Distal Convoluted Tubules to reabsorb Sodium and Secrete
Potassium. That extra Sodium increases water reabsorption and Increases Blood
Volume and BP, returning BP to normal.

Responsible for the reabsorption of Water by the Kidneys.

- ADH is produced in the Hypothalamus and secreted by the Posterior Lobe of the
Pituitary Gland.
- It is secreted when Dehydration, High Sodium Intake, or LOW Blood Volume.
- Makes the Distal Convoluted Tubules and Collecting Duct reabsorb water.
- Lack of ADH → Diabetes Insipidus (DI). Patients with DI produce large amount of
dilute urine. NursingStoreRN

- Atrial & Brain Natriuretic Hormones (AND & ANP) are secreted from cardiac muscle in
response to atrial stretch (High BP). ANP & BNP stimulates diuresis, which decreases
Volume and BP.
NursingStoreRN

→ Intravenous Urography: X-Ray with

radiopaque dye. Use to visualize
abnormalities in Renal System.
• Assess patient for Allergies to Iodine,
seafood, radiopaque dyes. Contraindicated
Pregnant Women, caution if Asthma,
Cardiac Disease, and Renal Insufficiency.
• S/E: Possible Throat Irritation, Flushing
of face, Warmth, or Salty or Metallic
Taste during Test.

NursingStoreRN 64
Patho: Bacteria in the urinary tract, contaminate the periurethral area, the colonize
the urethra, and migrate to the bladder. Most common causative: E. coli.
Risk F: Female (urethra is close to the rectum, also women have shorter urethra),
uncircumcised males, menopause, foley catheters, frequent sexual intercourse.
S/S: Burning urinating, frequency and urgency, dysuria, cloudy urine, foul-smelling urine,
confusion (elderly).
Lab: Urinalysis – Positive for Bacteria, WBC > 11,000 mm3, hematuria, leukocyte
esterase, nitrites.
Nurse: Increase Fluids 3000 mL/day. Discourage caffeine, tea, and cola. Avoid Alcohol.
Use Antibiotics.
Prevention: Female- wipe front to back, wear cotton underwear, avoid bubble baths,
tight clothing. Urinate before and after intercourse. Uncircumcised males, clean under
foreskin. Cranberry juice decreases risk of UTI.

- Stress Incontinence: Small urine loss when sneezing, coughing, laughing (abdominal
pressure). Caused by weakened pelvic floor.
NursingStoreRN
Risk F: Menopause, obesity, constipation, pelvic surgery.
Nurse: Kegel exercise, weight reduction, estrogen, vaginal cone therapy.
- Urge Incontinence: Inability to reach the bathroom in time due to overactive detrusor
muscle. Unknown cause.
Risk F: Neurologic disorders (stroke), bladder irritation.
Nurse: Anticholinergics (oxybutynin), bladder training, toilet schedule, avoid caffeine and
alcohol.

Patho: Inflammation of the renal pelvis caused by bacterial infection. Chronic

pyelonephritis occurs due to chronic urinary flow obstruction with reflux. Acute
Pyelonephritis occurs as a new infection or previous.
S/S: Costovertebral tenderness, Flank pain on affected side, fever, dysuria, tachycardia
and tachypnea, hypertension, nausea and vomit.
Tx: Antibiotics, opioids analgesics. Pyelolithotomy (Removal of a large stone from kidney).
Nephrectomy (Removal of the Kidney). Ureteroplasty (Repair or revise the ureter)
Nurse: Monitor vitals, electrolytes, specific gravity, and dehydration. Increase Fluids
3000 mL/day. Warm bath for pain. Provide warm, moist compresses to flank area to
relieve pain.

NursingStoreRN 65
Patho: Kidney disorders characterized by Inflammation injury un the glomerulus, most of
which are caused by an immunological reaction.
Causes: Often following a streptococcal Infection. Immunological disease. Autoimmune
disease. History of pharyngitis or tonsillitis 2-3 weeks before symptoms.
S/S: Dysuria, Oliguria, Anorexia, brown-colored urine (hematuria), Proteinuria,
Hypervolemia (cause Hypertension, dyspnea, crackles, periorbital and facial edema),
weight gain.
Labs: Urinalysis- hematuria, proteinuria. GFR decreased. Increased BUN, creatinine,
WBC. Positive Antistreptolysin O titers.
Tx: Antibiotics for infection, antihypertensives. Dialysis or plasmapheresis if necessary.
Nurse: Monitor I&O, daily weight. Decrease Fluids, Sodium, Protein.

Patho: Slow enlargement of the prostate gland

that can compress the urethra.
S/S: Hematuria, Nocturia, Decrease in urine force,
UTIs.
NursingStoreRN
Dx: Digital Rectal Exam, Cystoscopy, Prostate-
specific antigen (PSA)
Tx: Antibiotics, Alpha blockers to promote urinary
flow (Terazosin, Tamsulosin, Alfuzosin, Doxazosin).
Enzyme inhibitor to decrease size of prostate gland
(Dutasteride, Finasteride).
Transurethral Resection of Prostate (TURP): Enlarged portion of prostate is removed through
endoscopic instrument.
Pre-Op: Insert Urinary catheter. Antibiotics
Post-Op: Monitor for Shock and Hemorrhage. Avoid heavy lifting, prolonged sitting, constipation,
straining. Monitor for continuous bladder irrigation. Fluid 3L/day.
Assess for TURP syndrome (Hyponatremia, confusion, bradycardia, hypo/hypertension, nausea, vomiting,
visual changes). Keep catheter taped tightly to the client’s leg. Teach Kegel exercises.

Patho: Cyst formation and hypertrophy of the kidneys causing scar tissue, infection,
nephron damage. PKD is hereditary. Most common in Caucasian patients.
S/S: Flank or lumbar pain that worsens with activity + improves upon lying down,
Hematuria, proteinuria, recurrent UTI, Hypertension, Hyponatremia.
Nurse: Control BP, manage HT with medication. Monitor for hematuria which could
indicate a rupture. Increase sodium + water intake. Educate about possible need for
surgical interventions

NursingStoreRN 66
Patho: Stones that form in the urinary tract. Most
of the stones are composed of calcium phosphate or
calcium oxalate, but can contain other substances
(uric acid, struvite, cystine). A diet high in Calcium is
not believed to increase the risk of stones, unless
there is a metabolic disorder.
S/S: Severe intermittent pain, nausea, vomiting, low-
grade fewer, hematuria. Decreased urine flow with
particles (calcium).
Stone locations:
Nephrolithiasis: Stones formation in the Kidneys. Pain in the Costovertebral region.
Ureterolithiasis: Stones formation in the Ureter. Excruciating Pain described as wave-
like.
Nurse: Monitor temperature, encourage increased fluids, apply heat to flank area, diet
modification, increase ambulation.
Procedures: Extracorporeal Shock Wave Lithotripsy (ESWL) uses sound, laser, or shock-
NursingStoreRN
wave energies to break calculi into fragments. Nonsurgical Chemolysis uses chemical
agents to dissolve calculi. Surgical Intervention: Stenting, Retrograde Ureteroscopy,
Percutaneous Ureterolithotomy/Nephrolithotomy, Open surgery.
Complications: Scar tissue formation, infection and obstruction.

NursingStoreRN 67
Patho: Sudden loss of kidney ability to regulate volume, remove waste products, release
hormones or maintain body’s acid-base balance. Occurs abruptly and can be reversible.
Causes:
- Prolonged Renal Ischemia
- Nephrotoxic Injury leading to tubular necrosis

Caused by a reduced blood

flow to the kidneys.
Causes: Injury occurring from
- Vasoconstriction disease within the kidneys
- Hypotension Causes:
- Hypovolemia - Acute Tubular Nephritis
- Decreased cardiac output - Nephritis
- Nephrotoxic Injury
- Acute Glomerular
Nephritis
NursingStoreRN - Thrombolytic Disorders
Occurs when there is an - Malignant Hypotension
obstruction of urinary flow - SLE
causing intraluminal pressure - Infection
Causes:
- BPH
- Bladder Cancer
- Calculi
- Prostate Cancer
- Trauma

Initiation Phase: Onset of Injury / Onset of symptoms

Oliguria Phase: Decrease urine output to 400ml/day, usually 1-7 days after injury
Diuretic Phase: Increase urine output to 1-3L/day, caused by inability to concentrate
Risk of: hyponatremia, hypokalemia, dehydration
Recovery Phase: Increase in filtration rate, BUN/Creatinine

Nurse: Monitor V/S (HT, Tachycardia, Tachypnea, Irregular HR). Urine and I&O hourly.
Daily weight. Changes in BUN, Creatinine. Monitor for acidosis. LOC. WBC for infection.
Prepare for dialysis if prescribed.
NursingStoreRN 68
Patho: Slow progressive loss of kidney function resulting in uremia and hypervolemia -
the inability to conserve sodium and water. Decrease of Kidney Function >3 months
S/S: Polyuria, decreased skin turgor, edema, diluted urine, proteinuria
Nurse: low protein, potassium, phosphorus diet. Educate about fluid restriction and
possible dialysis treatment
Causes: Diabetes, Hypertension, AKI, Recurrent Infections, Renal Occlusions

Stages
Stage 1: GFR ≥90 mL/min
Stage 2: GFR = 60–89 mL/min
Stage 3: GFR = 30–59 mL/min
Stage 4: GFR = 15–29 mL/min
Stage 5: GFR <15 mL/min
GFR: Glomerular Filtration Rate
NursingStoreRN

Hemodialysis Peritoneal
The Process of filtering the blood Continuous Abdominal
through a dialyzer (Artificial Kidney) Peritoneal Dialysis (CAPD)
Frequency: 3 times a Week / 5-6 Uses Peritoneal Cavity as
hrs/day “Artificial Kidney”
Complications: Air Embolism,
Uses dextrose as osmotic
Hypotension, Muscle Cramps, Blood
Loss, Hepatitis, Sepsis, Disequilibrium agent
Syndrome Complications: Peritonitis
Nocturnal Hemodialysis: It’s done 5-6
days/week – 2-3 hrs/day.
If Air Embolism: Stop Hemodialysis, Turn
patient on left-side, head down
(Trendelenburg). Admin Oxygen

Withhold Antihypertensive Medication until after hemodialysis treatment. Also, water-

soluble Vit, antibiotics and digoxin (could be removed by dialysis).
NursingStoreRN
69
 Endocrine Glands:
Hypothalamus:
CRH – Corticotropin Releasing Hormone
GnRH – Gonadotropin Releasing Hormone
GHIH – Growth Hormone Inhibiting Hormone
GHRH – Growth Hormone Releasing Hormone
MIH – Melanocyte Inhibiting Hormone
PIH – Prolactin Inhibiting Hormone
TRH – Thyrotropin Releasing Hormone

Pituitary Gland
Adenohypophysis - Anterior Lobe
ACTH – Adrenocorticotropic Hormone
FSH – Follicle Stimulating Hormone
GH – Growth Hormone
LH – Luteinizing Hormone
MSH – Melanocyte Stimulating Hormone
PRL – Prolactin
TSH – Thyroid Stimulating Hormone

NursingStoreRN
Somatotropic Growth Stimulating Hormone
Neurohypophysis - Posterior Lobe
ADH – Antidiuretic Hormone/Vasopressin
Oxytocin

Thyroid Gland
T3 – Triiodothyronine
T4 – Thyroxine
Thyrocalcitonin (Calcitonin)

Parathyroid Glands
PTH – Parathyroid Hormone

Adrenal Glands
Adrenal Cortex (Outer shell of the Adrenal Gland)
Glucocorticoids: Cortisol (hydrocortisone), Cortisone,
Corticosterone
x Mineralocorticoids: Aldosterone
Adrenal Medulla (Inner part of the Adrenal Gland)
Epinephrine and Norepinephrine

Pancreas Ovaries Testes

Insulin Estrogen Testosterone
Glucagon Progesterone

70
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Growth Hormone (GH): “Somatotropin”. Controls growth and metabolism in the body (including protein
synthesis).
Pathway: GHRH (Hypothalamus) –> GH (Ant Pit)
Prolactin: Promotes lactation (primarily). Levels are controlled by levels of dopamine, estrogen, and
other hormones in the body.
ADH (Antidiuretic Hormone): Controls BP and Blood Volume by regulating reabsorption/excretion of
water in the kidneys. Higher levels cause reabsorption of water, lower levels cause excretion of water.
ADH is secreted from the posterior pituitary gland when body senses: low blood volume, low BP, and/or
hypernatremia.
Oxytocin: Females: causes Contraction of Uterus; promotes lactation. Males: Controls production of
testosterone and sperm release.
- Controlled through a positive feedback mechanism.
- In women, it’s released in response to uterine contractions and breastfeeding.

Thyroid Hormones (T3/T4): Regulates metabolism, growth and development, heart function, brain
function, muscle function, digestion, bone maintenance. T3 is the active form of T4.
Pathway: TRH(Hypothalamus) –> TSH (Ant Pit) –> T3/T4 (Thyroid Gland)
Calcitonin: Decreases Calcium levels. Opposite of PTH. It decreases activity of osteoclasts in bones, and
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Increases excretion of calcium in the kidneys.
Increased Blood calcium stimulate thyroid gland –> release calcitonin.

Parathyroid Hormone (PTH): Increases Calcium. It pulls calcium out of the bones and into the
bloodstream, causes the kidneys to reabsorb more calcium and release Vit D (which allows for
absorption of calcium), and Increase absorption of calcium in the intestines.
Decreased Calcium levels stimulates parathyroid gland –> release PTH

Cortisol (Glucocorticoid): Stress hormone. Regulates metabolism, Suppress Immune Response/Immune

System. Raises blood glucose. Plays a bigger role in chronic (vs acute) stress.
Pathway: CRH(Hypothalamus) –> ACTH (Ant Pit) –> Cortisol (Adrenal Cortex).
Aldosterone (mineralocorticoid): Increases BP/Blood Volume by promoting renal reabsorption of sodium
and water and excretion of potassium (in the distal portion of renal tubules). Controlled by the Renin
Angiotensin Aldosterone System (RAAS).
Renin Angiotensin Aldosterone System (RAAS): With low renal blood flow (Indicating low BP), kidneys
secrete Renin – which converts Angiotensinogen (from liver) to Angiotensin I.
Angiotensin-Converting Enzyme (ACE) (from the lungs) converts Angiotensin I to Angiotensin II.
Angiotensin II increases BP by:
- Vasoconstriction of the afferent arterioles in the nephrons, which Increases Sodium and Water
reabsorption.
- Release of aldosterone from the adrenal cortex, which causes the kidneys to Increase reabsorption of
Sodium and Water.
- Vasoconstriction of peripheral blood vessels.

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Epinephrine (adrenaline) and Norepinephrine: Catecholamines released in response to acute stress.
They prepare the body for the “fight or flight” response, causing Vasoconstriction, Increase HR and
BP, Bronchodilation, pupil dilation, Increase blood flow to the muscles, and Increase Blood Glucose.
Epinephrine has a stronger effect on the Heart. Norepinephrine has a stronger effect on the blood
vessels.
Acute stress causes activation of the Sympathetic Nervous System (SNS), which activates nerves
connected to the adrenal medulla, causing secretion of Epi/Norepi.

Insulin: Decrease Blood Glucose levels. Insulin allows glucose to leave the bloodstream and enter the
cells, where it can be used for energy.
Rise in blood glucose causes Pancreas’ Beta Cells (the Islets of Langerhans) –> release Insulin.
Glucagon: Increases Blood Glucose levels. Glucagon stimulates glycogenolysis (conversion of glycogen in
the liver into glucose, which is released into the bloodstream), gluconeogenesis (increased production of
glucose), and causes adipose tissue to break down fat for energy.
Low Blood Glucose causes Pancreas’ Alpha Cells –> release glucagon.

Estrogen: Stimulates development of female sex organs. Regulates menstrual cycle.

Pathway: GnRH (Hypothalamus) –> LH & FSH (Ant Pit) –> Estrogen (Ovaries)
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Progesterone: Regulates Menstrual cycle and plays a key role in the maintenance of pregnancy.
Pathway: GnRH (Hypothalamus) –> LH (Ant Pit) –> Progesterone (Ovaries)
Testosterone (Androgen): Stimulates development of male sex organs and sperm production.
Pathway: GnRH (Hypothalamus) – FSH & LH (Ant Pit) – Sperm and Testosterone Production (testes)

Negative Feedback Mechanism:

This mechanism regulates most endocrine hormones to achieve homeostasis, similar to a thermostat.
Thermostat: Your heater is on, and your thermostat is set at 75 degrees. The heater runs until
temperature gets above 75, and then it turns off. When the temp drops below 75 again, the heater
turns back on.
Body: If an endocrine gland senses that there is not enough of a hormone circulating in the body,
changes are initiated to increase production of that hormone. If the endocrine gland senses there is
too much of a hormone, changes are initiated to decrease production of that hormone.
Thyroid Negative Feedback Loop:
Hypothalamus releases TRH – Anterior pituitary gland release TSH – Thyroid gland release T3/T4.
If the Hypothalamus senses that T3/T4 levels are high, it decreases its production of TRH (which
causes a decrease in TSH, which causes a decrease in T3/T4).
If the Ant Pit Gland senses that T3/T4 levels are High, it decreases its production of TSH (which
causes a decrease in T3/T4).
Positive Feedback Mechanism:
Regulates some Endocrine hormones. Release of a hormone initiates actions that lead to additional
release of that hormone. (Ex: Release of oxytocin results in uterine contractions, which causes additional
oxytocin to be released. Release of oxytocin stops after childbirth.)

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Acromegaly: Hypersecretion of Growth Hormone (GH) that occurs after puberty.
S/S: Enlargement of skeletal extremities. Organ enlargement. Decalcification of the skeleton. Endocrine
disturbances similar to hyperthyroidism. Muscle weakness, headache, visual problems, and blindness.
Enlarged hands/feet, protruding jaw, kyphosis, arthritis, enlarged larynx (deep/hollow voice).
Dx: Elevated GH levels. CT and MRI of pituitary may show tumor. X-ray show abnormal bone growth.
Tx: Medication: Octreotide (synthetic GH analogue). Bromocriptine mesylate or pergolide-dopamine
agonist.
- Surgical removal of pituitary gland (transsphenoidal hypophysectomy).
- Replacement therapy following surgery. Corticosteroids, thyroid hormones.
- Radiation therapy.
Halo Sign
Transsphenoidal Hypophysectomy
Nurse: Monitor for S/S of Cerebrospinal Fluid (CSF): “Halo Sign” in drainage
(Clear in center, yellow edges), sweet-tasting drainage, presence of glucose
in nasal drainage, headache.
Teaching: Avoid activities that increase ICP: coughing, sneezing, blowing nose,
bending at waist, straining during bowel movements (increase fiber intake).
Decrease sense of smell expected for 1 month. Do not brush teeth for 2 weeks, OK to floss and rinse
mouth. Lifelong hormone replacement therapy required.
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Gigantism: Hypersecretion of GH that occurs in childhood prior to
closure of the growth plates.
S/S: Proportional overgrowth in all body tissue.
Dx: Same as Acromegaly

Dwarfism: Hyposecretion of GH during fetal development or

childhood that results in limited growth congenital or result from
damage to the pituitary gland.
S/S: Head and extremities are disproportionate to torso (Face may
appear younger than peers). Short stature, slow or flat growth
rate. Progressive bowed legs and lordosis. Delayed adolescence or
puberty.
Dx: MRI to assess pituitary gland. Serum GH level. Comparison of
heigh/weight to growth charts.
Tx: Meds: Human GH injections (Somatropin) via SC. Treatment
typically stopped when X-Ray shows epiphyseal closure.
Nurse: Teach how to administer supplemental GH, the earliest the
therapy is initiated, the better. GH therapy doesn’t work in all
children.
Somatropin:
Children: 0.16-0.24 mg/kg/wk divided in 6-7 daily doses
Adult: 0.04 mg/kg/wk initially divided in 6-7 daily doses.

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 Diabetes Insipidus (DI):
A deficiency of ADH (Antidiuretic Hormone-
Vasopressin) that results in kidneys being
unable to concentrate urine.
Neurogenic: Lack of Vasopressin production
or Secretion (Hypothalamus or Pituitary
tumor/Injury)
Nephrogenic: Renal resistance to Vasopressin
r/t Kidney infections or nephrotoxic drugs.
S/S: Polydipsia, Large amount of diluted urine,
dehydration, hypotension, anorexia.
Labs:
Urine: Low Specific gravity (<1.005), Low Osmolality (<200 mOsm/L)
Blood: High Serum Osmolality (>300 mOsm/L), Hypernatremia
Dx: Water deprivation Test, Vasopressin Test.
Tx: Vasopressin (Lifetime), Desmopressin
Nurse: Monitor I&O, Urine Specific Gravity, daily weight.

SIADH – Syndrome ofNursingStoreRN

Inappropriate Secretion of Antidiuretic Hormone
Excessive release of ADH from the Posterior Pit Gland, causing fluid retention and dilutional
Hyponatremia
Patho: Neoplastic tumor, head injury, meningitis, respiratory disorders, medication (vincristine,
phenothiazines, tricyclic antidepressants, thiazide diuretics)
S/S: Urine Concentrated (in small amounts), fluid vol excess (tachycardia, hypertension, crackles, JVD,
weight gain), headache, weakness, muscle cramping, confusion.
Labs:
Urine: High Specific Gravity (>1.030), High Osmolality and Sodium
Blood: Low Serum Osmolality (<270 mOsm/L) and Hyponatremia (dilutional hyponatremia).
Dx: Radioimmunoassay of ADH
Tx: Loop Diuretics, Vasopressin antagonists, hypertonic saline (3% NaCl), Demeclocycline
Nurse: Restrict fluid to 500-1000 mL/day. Monitor I&O, daily weight. Monitor mental status
frequently, initiate seizure precautions. Monitor fluid vol overload, pulmonary edema.

DIABETES INSIPIDUS SIADH

Too Much Diluted Urine Small amount of Urine
Anorexia, Dehydration, Polydipsia Weight gain, Fluid Vol Excess,
Urine: Weakness, Confusion.
Low Specific gravity, Low Urine:
Osmolality High Specific Gravity, High Osmolality
Blood: Blood:
High Serum Osmolality & Low Serum Osmolality &
Hypernatremia Hyponatremia

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 Addison’s Disease (Adrenal Insufficiency)
Hyposecretion of Adrenal Cortex Hormones cause by:
Primary: Autoimmune disorders, or adrenal gland injury/infection.
Secondary: Abrupt cessation of steroids medications.
S/S: Weakness, Fatigue, N&V, weight loss, Hyperpigmentation (bronzed skin),
hypotension, dehydration, hypoglycemia.
Labs:
LOW Cortisol/Sodium/Glucose
HIGH Potassium/Calcium/BUN
Dx: ACTH stimulation test (differentiates primary and secondary insufficiency),
Electrolytes panels
Tx: Hydrocortisone, Prednisone, Cortisone. Medication for Hyperkalemia: Sodium
polystyrene sulfonate, Insulin (with glucose), calcium (cardiac protection), sodium
bicarbonate.
Nurse: Assess HR and BP. Monitor Fluid and Electrolytes. Monitor and treat
Hypoglycemia. Monitor for Addisonian Crisis

Addisonian Crisis (Adrenal Crisis)

Sign of Shock (Severe Hypotension, Tachycardia, Tachypnea, Pallor), Severe Headache,
Weakness
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Trigger: Infection, stress, trauma, abrupt discontinuation of corticosteroids.
Tx: IV Glucocorticoids, IV fluids with dextrose, Identify/Treat underlying cause.
Nurse: Monitor BP, Neurological Status, V/S, I&O, weight. Provide Bed Rest and quiet environment

Cushing’s Disease & Cushing’s Syndrome (Adrenal Hypersecretion)

Cushing’s Syndrome is caused by exogenous use of steroid medications.
Patho: Hypersecretion of Glucocorticoids caused by hyperplasia of the adrenal cortex or
pituitary gland tumor.
S/S: Upper body obesity and thin extremities (moon face, buffalo hump, neck fat). Skin
fragility, purple striae. Osteoporosis. Hirsutism (Excessive hair growth on unexpected
areas), Hypertension, sexual disfunction, Immunosuppression, Peptic ulcer disease,
Backache, bone pain, tenderness.
Labs:
LOW Potassium/Calcium
HIGH Cortisol/Glucose/Sodium
Dx: Dexamethasone suppression test. CT, MRI, ultrasound to
identify pituitary or adrenal gland tumor
Tx:
Surgery: Tumor excision, hypophysectomy, adrenalectomy.
Meds: Ketoconazole, Metyrapone, Mitotane (Inhibits cortisol synthesis).
Nurse: Restrict fluid and Sodium. Increase intake Potassium, Calcium and Protein. Monitor
for fluid vol overload, pulmonary edema. Prevent injury from skin breakdown, bone
fractures, GI bleeding. Prevent Infection.

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Hypersecretion of Aldosterone from the Adrenal Cortex, usually due to a tumor. Manifestations similar
to Cushing’s Syndrome
S/S: Hypertension, Weakness, fatigue, headache, tetany, polyuria and polydipsia.
Labs/Dx: Abdominal CT, MRI. Hypokalemia, Hypernatremia, Increased Aldosterone, Decreased Renin.
Tx: Adrenalectomy. Meds: Spironolactone, Eplerenone (blocks action of aldosterone).
Nurse: Monitor Potassium, BP, I&O, and Cardiac activity. Low-Sodium, High-Potassium diet

Hypersecretion of Epinephrine and Norepinephrine usually because of a tumor in Adrenal Medulla.

S/S: Hypertension, Headache, Hyperhidrosis (excessive sweating), Hypermetabolism, Hyperglycemia,
Tachycardia, SOB.
Labs/Dx: 24hr urine test, CT, MRI, PET scan. Adrenal biopsy. Clonidine suppression test.
Tx: Tumor excision, adrenalectomy.
Meds: Calcium Channel Blockers (Nifedipine). Phentolamine and Propranolol prior to surgery.
Nurse: Do not palpate the abdomen, and avoid abdominal pressure, can cause hypertensive crisis. Don’t
assess for Costovertebral Angel tenderness, can rupture the tumor.

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Hyposecretion of Thyroid Hormones (T3/T4) by the Thyroid Gland, causing
decreased metabolism.
Primary: Injured Thyroid Gland, decreased T3/T4 production. Hashimoto’s
Disease (most common cause, autoimmune issue) causes antibodies to attack and
destroy thyroid cells.
Secondary: Thyroid is not being stimulated by the pituitary to produce hormones
(No TSH)
Tertiary: Problems with the Hypothalamus (No TRH; which stimulates TSH –>
T3/T4).
S/S: Lethargy and fatigue, Hypotension, Bradycardia, Cold Intolerance, weight gain, constipation,
Myxedema, thin hair, brittle fingernails, loss of memory.
Labs/Dx: Low T3/T4 , High TSH (in Primary hypothyroidism), Low TSH (in Secondary and Tertiary),
anemia.
Tx: Levothyroxine (lifelong medication therapy).
Nurse: Give medication in the Morning, with empty stomach. Encourage low-calorie, low-cholesterol, low-
fat diet. Daily weight. Encourage frequent rest periods.
Monitor for Med Overdose (Palpitations, tachycardia, restlessness, tremors, chest pain, insomnia).

Myxedema: Severe, life-threatening hypothyroidism

Causes: Untreated Hypothyroidism, Infection, Illness, abrupt stop Levothyroxine.
S/s: Hypotension, Bradycardia, Hypothermia, Hyponatremia, Hypoglycemia, Generalized Edema, Coma
Nurse: Maintain patent airways. Administer fluids, Levothyroxine Sodium IV, and Glucose IV.
Corticosteroids. Monitor Temp hourly. Monitor LOC.

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Hypersecretion of Thyroid Hormones (T 3/T4) by the Thyroid Gland, causing Exophthalmos
Increased metabolism.
Primary: Grave’s Disease (most common cause, autoimmune issue) or thyroid
nodule – hypersecretion.
Secondary: Anterior Pituitary Gland Tumor (Increased TSH secretion)
Tertiary: Hypothalamus dysfunction (Increased TRH – stimulates TSH –
Increase T3/T4 production
S/S: Tachycardia, Hypertension, Heat intolerance, Exophthalmos
(bulging eyes), weight loss, insomnia, diarrhea, warm/sweaty skin.
Labs/Dx: Increased T3/T4 (primary hyperthyroidism), High TSH (secondary and tertiary Hyperthyroidism).
Tx: Thyroidectomy.
Meds: Antithyroid Medication (Methimazole or Propylthiouracil), Iodine solutions, Propranolol for Tachycardia.
Nurse: Provide High-calorie and high protein intake. Monitor I&O, weight daily, vital signs.
For Exophthalmos: Elevate HOB, low-salt diet, tape eyelids closed for sleep, give ophthalmic medicine, eye
lubricant.

Post-op Thyroidectomy:
Semi-Fowlers position. Assess for signs of hemorrhage. Assess dressing. Assess for hoarseness. Assess for signs
of tetany (Chvostek’s and Trousseau’s Sign), which may indicate damage to parathyroid gland during surgery
(hypocalcemia). Gradually increase Range of Motion to the neck.

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Thyroid Storm: Life-threatening condition when uncontrollable hyperthyroidism.
Causes: Severe infection, stress, DKA, thyroidectomy.
S/S: Fever, Tachycardia, Systolic Hypertension, N&V, irritability, delirium, tremors.
Tx:
Meds: Anti-thyroid medication, Beta blockers, antipyretics
Surgery: Thyroidectomy
Nurse: Maintain patent airways, monitor for dysrhythmias

Hyposecretion of PTH, resulting in Hypocalcemia and Hyperphosphatemia. Caused by damage

to the Parathyroid Gland during Thyroidectomy, or radical neck dissection.
S/S: Hypocalcemia –>Paresthesia, muscle cramps, tetany, positive Chvostek’s and
Trousseau’s Sign. Numbness and tingling, seizure, dysrhythmias.
Tx: Calcium gluconate, calcium/vit D supplements, phosphate binders.
Nurse: Monitor ECG. High Calcium, Low Phosphorus diet. Give phosphate binders with meals.

Hypersecretion of PTH, resulting in Hypercalcemia and Hypophosphatemia (loss of calcium from the bones into
the serum). Caused by tumor, renal disease or Vit D deficiency.
S/S: Kidney stones, osteoporosis, Hypercalcemia & Hypophosphatemia. Hypertension, Cardiac Dysrhythmias.
Polyuria/Polydipsia. Constipation. N/V. Fatigue
Tx: Meds: Furosemide, phosphates, calcitonin.
Removal of adenoma, parathyroidectomy.
Nurse: Safety precaution prevention of fractures. Low Calcium, High Phosphorus diet. Increase fluids.

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Pancreas has Exocrine (secretion of the pancreatic enzymes amylase, trypsin, and lipase, which aid with
digestion) and Endocrine (secretion of insulin, glucagon, and somatostatin) functions.
Insulin lowers blood glucose by getting glucose into the cell.
Somatostatin lowers blood glucose levels.
Glucagon raises blood glucose by converting glycogen to glycose in the liver.

Diabetes Mellitus: Group or metabolic disorders characterized by

Hyperglycemia caused by altered Insulin production, action, or both.

Diagnosed in Children and Young adult. Insulin-Dependent

1- Immune System attacks beta cells responsible for Insulin production.
2- NO Insulin in the bloodstream – Increase glucose
3- Fats are metabolized for energy, results in Ketoacidosis

1- Progressive Insulin resistance and Decreased Insulin production.

2- Related to Obesity, Inactivity and heredity.
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3- Usually occurs over 35y/o. 80%-90% patients are obese

Develops during pregnancy. Detected at 24-28 weeks of gestation

Usually, glucose levels normalize at 6 weeks post-partum.
RISKs
Increased risk for C-Section, Perinatal death and neonatal complications.
Increased Risk for developing type 2 DM in 5-10 years

Also known as Syndrome X. Insulin resistance leads to increased Insulin production to

maintain glucose at a normal level. Characterized by: Hypertension,
Hypercholesterolemia, and abdominal obesity.
If Beta cells can’t produce enough Insulin to meet demands, Diabetes II develops.

Two or more, on different days: Insulin, Oral Hypoglycemic agents (type 2 only).
- Casual Blood Glucose >200 mg/dL Goal with therapy: HgbA1C <7%
- Fasting Blood Glucose >126 mg/dL
- Glucose >200mg/dL with OGTT
- HgbA1C >6.5%

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3 Ps (Polydipsia, Polyphagia, Polyuria), warm/dry skin, dehydration (weak pulse, decreased skin turgor),
fruity breath odor / Kussmaul respirations (Increased rate and depth of respirations), N&V,
weakness, lethargy, weight loss

Mild: Hunger, Nervousness, Palpitations, diaphoresis, tachycardia, tremors, pallor

Moderate: Confusion, Double vision, drowsiness, emotional changes, headache, poor concentration,
numbness of the lips, slurred speech.
Severe: Difficulty arousing, disoriented, loss of consciousness, seizures.

Nurse:
- Provide 15g of simple carbohydrate for conscious patients. Wait 15 min and recheck glucose. Give 15g
more if glucose still <70 mg/dL. Give 7g of protein when glucose is normal.
- For patients with Severe Hypoglycemia (semi/unconscious) do NOT administer oral food or fluids (risk
of aspiration). Treat with SC or IM glucagon 25-50 mL of 50% dextrose in water

Simple Carbs:
6-10 Life Savers or hard candy. 4 tsp of sugar. 4 sugar cubes. 1 Tbsp of honey or syrup. ½ cup of juice
or regular soft drink. 8oz of low-fat milk. 6 saltine crackers. 3 graham crackers.
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Both Are Hyperglycemic Conditions in The Morning, But with Different Mechanisms
Dawn Phenomenon: Characterized by Hyperglycemia when waking up because of excessive early morning
release of GH and Cortisol.
Tx: Increase Insulin dose or change time of administration

Somogyi Phenomenon: Hyperglycemia when waking up as a response to Hypoglycemia at 2am-3am.

Patient may complain of early morning headache, night sweats, or nightmares cause by early morning
Hypoglycemia.
Tx: Decrease Insulin dose or give bedtime snack.

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Life-threatening condition. Associated with Type 1. Related to Infection, Stress, missed Insulin dose.

Signs/Symptoms
- Rapid Onset (4-10 hours) - Dehydration, Abdominal Pain, Nausea, fatigue
- Blood Glucose >250 mg/dL and weight loss, Weakness
- pH < 7.35 (Acidosis) - 3 Ps - Polyuria, Polydipsia, Polyphagia.
- Kussmaul Respirations (rapid, deep breathing) - Ketones in Urine, Fruity breath
- Hyperkalemia (because of acidosis).
Treatment:
1- Treat Dehydration - 0.9% Normal Saline Insulin administration:
2- Lower Blood Sugar - Use short duration only.
>250: IV Regular Insulin only - IV bolus Regular (5-10 units) before
-Add K+ during IV Insulin (levels decrease with treatment) continuous infusion is begun.
<200 or if Ketones resolve - Iv Insulin for continuous infusion prepared in
SC Insulin + IV D5W 0.9%-0.45% NS. Always place Insulin infusion
3- Hourly Glucose Checks + Heart Monitor (K+) on an IV Infusion controller.

Nurse: Monitor patient for Increased ICP. If blood glucose falls too far or too fast, water is pulled
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from blood into the cerebrospinal fluid and the brain, causing cerebral edema and Increased ICP

Extreme Hyperglycemia without Ketosis or Acidosis. Associated with Type 2. Related to inadequate
fluid intake, Decreased Kidney function, Infection, stress, unmanaged Diabetes.

Signs/Symptoms
- Gradual Onset - Potassium Normal or low.
- Blood Glucose > 600 mg/dL (Severe 600-2400mg/dL) - pH > 7.40
- 3 Ps - Polyuria, Polydipsia, Polyphagia. - Dehydration
- NO Ketones. NO Metabolic Acidosis.

Treatment:
1- Treat Dehydration – 0.9% NS
2- Lower Blood Sugar
IV Regular Insulin, then titrate with SC Insulin + IV D5W
3- Hourly Glucose Checks
4- Assess Rehydration: Stable BP, Pink skin, warm temp, Urine Output >30mL/hr.

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- Diabetic Retinopathy: Chronic impairment of the retinal circulation that causes hemorrhage. Permanent vision
change/loss can occur.
S/S: Blurred Vision from Macular edema. Sudden loss of vision from retinal detachment. Cataracts.
Tx: Early prevention (control HT/glucose levels. Photocoagulation to remove hemorrhagic tissue. Cataract
removal.
- Diabetic Nephropathy: Progressive decrease in Kidney function.
S/S: Microalbuminuria, Thirst, Weight loss, Anemia, Fatigue, UTIs.
Tx: Early prevention (control HT/glucose levels). Monitor BUN/Creatinine/urine Albumin. Restrict
Protein/Sodium/Potassium. Dialysis. Kidney transplant.
- Diabetic Neuropathy: Deterioration of the Nervous System.
S/S: Neuropathic pain, Nerve damage, Nonhealing ulcers of the feet, gastric paresis, erectile dysfunction.
Tx: Early prevention. Foot care.
Foot Care
- Inspect feet daily using a mirror. Check shoes for objects.
- Wash feet with warm water and dry thoroughly.
- Avoid treating corns, blisters, or ingrown toenails.
- Apply moisturizer to feet, but NOT between toes.
- Wear loose, cotton socks and shoes (don’t go barefoot or wear open-toe shoes).
- Cut toenails straight across.
Illness Care
- Monitor Blood Glucose more frequently when Sick. Do not skip insulin when Sick. Test urine for Ketones. Prevent

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dehydration. Drink 3L of water/day.

1- Inject air into the NPH (cloudy) FIRST (without touching the insulin)
NPH must be rolled between palms first (Never Shake the vial)
2- Inject remaining air into the Regular Insulin (clear), then withdraw the regular dose.
3- Withdraw the NPH dosage
- Long-Acting Insulin (Glargine, Detemir) CAN NOT be mix with any type of Insulin.
- Use a 45–90-degree angle

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Injury to the skin and underlying tissue due to prolonged pressure. Typically, over bony prominences.
Tissue compression impairs blood flow, which leads to inadequate perfusion and oxygenation. This leads
to cell death. Stage 1 Stage 2

- Stage 1: Non-Blanchable but intact/unbroken skin

- Stage 2: partial-thickness injury, extends up to
epidermis or dermis.
- Stage 3: full thickness injury extends past dermis
FAT visible.
- Stage 4: full thickness injury extends past
Stage 3 Stage 4
subcutaneous/ BONE visible.
- Unstageable: unable to see thickness layers due to
excess exudate.
- Wound healing is promoted by a diet that is rich in
protein and vitamin C.

Tx: Debridement (Surgical, chemical, mechanical) of necrotic tissue. Negative pressure wound therapy
(wound vac), Hyperbaric Oxygen Therapy (HBOT), skin grafts/flaps.
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Nurse: Turn patient every 2 hrs. Keep HOB <30 degrees to more evenly distribute pressure. Do not
massage bony prominences. Ensure adequate nutrition, especially Protein.

- Serous Exudate: Clean wound. Watery in consistency & contains very little cellular matter. Consist of
serum (straw colored fluid that separates out of blood when clot is formed)
- Sanguineous: Deep wounds or wounds highly vascular areas. Bloody drainage. Damage to blood
capillaries. Fresh bleeding produces bright red drainage, whereas older, dried blood is darker, red blown
color
- Serosanguineous Drainage: New wounds. Combination of bloody & serous drainage
- Purulent drainage: Thick, often malodorous, drainage that is seen in infected wounds. Containing pus,
a protein-rich fluid filled w/WBCS, bacteria, & cellular debris.
- Purosanguineous: A mix drainage of pus and blood (newly infected wound).

Serous Sanguineous Serosang. Purulent

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Phases
- Inflammatory Phase: From day of injury to 3-5 days. Phagocytosis of bacteria. Local Edema, pain,
redness, and warmth. Vasoconstriction, platelet aggregation, clot formation.
- Proliferative Phase: Epithelialization (resurfacing with new skin cells. 2-3 days for incisional wounds).
Granulation (Wound fills with scar tissue [collagen produced by fibroblasts]. 2-3 weeks for incisional
wounds). Contraction (Reduction in wound size [open wounds only]).
- Maturation: May last 1 year. Scar tissue becomes thinner and is firm and inelastic on palpation.

Healing By Intention
- Primary Intention (1st): Wound closed surgically, wound edges are approximated (sutures).
- Secondary Intention (2nd): Wound left open to heal through process of granulation contraction, and
epithelialization.
- Tertiary Intention (3rd): Wound left open for Irrigation or Removal of debris and exudates. Once free
of debris and inflammation, wound is closed by Primary Intention.

RF for Delay Healing: Age (old), decreased Immune System, impaired nutrition (low protein), decreased
prefusion, smoking, diabetes.

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Folliculitis: Inflammation of a hair follicle. Small
erythematous pustule. It usually resolves by itself.
Topical Antibiotics can be used.

Furuncle (boil): Bacterial Infection of multiple hair follicles

and the adjacent tissue. Large erythematous, pus-filled
nodule. Solved by Warm compress, incision and drainage.

Cellulitis: Infection of deeper connective tissue. S/S:

Erythema, warmth, pain, edema, fever malaise. Treated
with Systemic Antibiotics

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 Oral - Thrush
Candidiasis
P: Imbalance in local flora allows for overgrowth of C.
Albicans, which results in a mucocutaneous infection.
RF: Immunosuppression, Antibiotics, Pregnancy,
Diabetes.
S/S: Red, irritated skin with itching and burning, white
patches in the mouth (thrush), “cottage cheese”
discharge (vaginal).
Dx: HOH test, clinical examination
Tx: Topical Antifungals.
Nurse: Keep skin clean and dry. Wear cotton underwear Yeast Infection
and avoid tight clothing to prevent vaginal candidiasis. (a type of fungus)
Only take Antibiotics if Necessary (Antibiotics kills
beneficial vaginal bacteria)

Dermatophytosis

P: Direct contact with infected NursingStoreRN

person/animal or item causes:
ringworm, tinea pedis (athlete’s
foot), tinea cruris ((jock itch), tinea
capitis (head), or tinea corporis
(body).

RF: Lockers room, infected pets,

warm/moist skin.

S/S: Itchy skin, ring-shaped rash,

red/scaly/cracked skin, hair loss
(tinea capitis).

Dx: KOH test, clinical examination.

Tx: Topical Antifungals, selenium

sulfide shampoo for tinea capitis.

Nurse: Keep skin clean and dry, don’t

share personal items, wash hands
after playing with pets.

NursingStoreRN 84
HSV-1: Spread through contact with contaminated saliva.
HSV-2: Spread by sexual contact.
P: After infection with the Herpes virus, it remains dormant in the nerve ganglia and becomes
reactivated during times of stress. Burning, pain and tingling may precede vesicles.
S/S: Painful vesicular or ulcerative lesions on the mouth/lips for HSV-1 and on the genitals for HSV-2.
Fever, malaise
Labs: Clinical presentation, Type-specific HSV serologic test.
Tx: No Cure. Antiviral Medication (topical/systemic), analgesics, topical anesthetic agents.
Nurse: Condom use. Abstain from sex when active viral shedding (visible lesions).

Herpes Zoster (Shingles)

P: After a previous varicella infection, the herpes zoster virus remains dormant in the nerve ganglia
until it becomes reactivated. Triggers include immunosuppression, infection, stress, fatigue.
S/S: Pre-Eruptive Phase: Abnormal skin sensations (burning), malaise, low-grade fiver 48 hrs before
lesions appear.
Eruptive Phase: Painful, unilateral vesicular rash that runs along a dermatome, low grade fiver,
paresthesia.
Labs/Dx: Clinical presentation, PCR test of vesicle.
Tx: Antiviral medication, analgesics.
Nurse: Isolate patient (airborne/contact precautions) until lesions have crusted. Avoid patient contact
NursingStoreRN
with people who haven’t had chickenpox and are not vaccinated. Monitor for postherpetic neuralgia
(pain that last more than 1 month after onset).
Prevention with Zostavax vaccine for adults >60 yo.

Autoimmune disorder results in overproduction of keratin in the epidermis. Characterized by periods of

exacerbations and remissions. Causes erythematous plaques with silver scales. Non-Contagious.
S/S: Scaly patches, pitting/crumbling nails.
Labs/Dx: Clinical presentation, skin biopsy, increased uric acid.
Tx:
Meds: Topical steroids, immunosuppressants, coal tar.
Procedures: UV light therapy. Provide eye protection to patient. Psoralen may be taken beforehand to
enhance the effects of UV light therapy.

P: Damage to tissue/vessels as a result of prolonged exposure to cold

S/Sx: White plaque around redness, blisters, bluish skin and numbness of extremities
Tx: Re-warm slowly with moist heat + monitor CMS and for signs of compartment syndrome

NursingStoreRN 85
NursingStoreRN

NursingStoreRN 86
Thermal: liquid, steam, fire
Chemical: powder, gas (inhalation injury)
Electric: usually have an entry or exit wound. Injuries may be internal
Cold: Frostbite
Radiation: Dun, Radiation
Friction: Road rash

Superficial - 1st Degree Burn

- Only affect Top Layer (Epidermis)
- No Blister or Scars
- Pink or Red
- May be Tender or Painful
- Some pain, minor Edema, and Erythema

Partial Thickness - 2st Degree Burn

NursingStoreRN
- Epidermis and Dermis
- Raw, mottled, red appearance
- Skin is moist; May blister or need grafting
- Painful, blanching
- Shiny, Scars left behind; 2-6 weeks healing time

Full Thickness – 3rd Degree Burn

- Through all dermal layers; SQ tissue, muscle, bone, and/or
organs involved.
- Nerves burnt away, so, little to no pain.
- May need grafting
- Eschar must be removed

- Ensure patient Tetanus shot if >5-10 years

- Watch for temperature loss = shivering
- Pain control – IV rout (best)
- Wound Care – Premedicate debridement – remove necrotic tissue
- No pillows for the ear or neck. Use rolled towel under shoulder
- Watch for Webbing

NursingStoreRN 87
 Head and Neck
9%

Upper Limbs
9% Each

Trunks 36%
18% Front
18% Back

Genitalia
NursingStoreRN1%

Lower Limbs
18% Each

Once stablished the total body surface area% burned, we use the Parkland Burn Formula,
for 2nd and 3rd Degree Burn

4mL x TBSA % x Weight (Kg)

1st HALF of the Solution, over the 1st 8 Hours
2nd HALF of the Solution, over the next 16 Hours (½ in 8hrs, then ½ last 8hrs)
*TBSA% - Total Body Surface Area Burned

NursingStoreRN 88
E: Inadequate diet, malabsorption, blood loss, hemolysis - microcytic & hypochromic
L: ↓Hgb, ↓Hct, ↓MVC, ↓MCH ↓MCHC retic. Serum iron, TIBC
S/Sx: Pallor, glossitis, Cheilitis, black stool
T: Replace iron, transfusion, diet teaching, emphasize compliance
R: Pregnancy, premenopausal women, blood loss, older adults, low socioeconomic backgrounds

E: Impaired DNA synthesis, GI surgery, ETOH, Smoking, *Gastric bypass, PPI use.
L: ↓B12, macrocytic RBCs, MCV >100
S/Sx: Neurological - tingling, paresthesia, beefy tongue, weakness
T: B12 injection or intranasally 1/week

E: Genetically - Autosomal Recessive

L: Sickled RBC
S/Sx: Occlusions, necrosis, ↓perfusion, pain on exertion
NursingStoreRN
T: Avoid ↑Altitude + ↑Temp, bone marrow transplant, O2 therapy

E: Celiac, Crohn's, alcoholism, hemodialysis, malabsorption

L: Macrocytic (MCV > 100) ↓folate
S/Sx: Weakness, fatigue, bruising, No neuro symptoms, weight loss
T: Replacement (green leafy veg) 1 mg/day tablet

E: Infection or Autoimmune
L: ↓RBC ↓WBC ↓Platelets
S/Sx: Respiratory Fatigue, Weakness
T: Transfusion, ↑WBC, Bone Marrow Transplant

L: ↓Platelets ↑INR + ↑PT/PTT

S/Sx: Prolonged bleeding time.
T: Platelet Transfusion, Bone Marrow Transplant or Corticosteroid Treatment.
N: Avoid lacerations - use electric razors, monitor Hgb, Hct and bleeding times.

NursingStoreRN 89
Antigens on the blood Identifies the cell

Antibodies protect the cell from certain antigens

A antigen Donates to: A, AB

[B antibodies] Receives from: A, O

B antigen Donates to: AB, B

[A antibodies] Receives from: B, O

AB antigen Donates ONLY to: AB

[NO antibodies] NursingStoreRN
Receives from:

NO antigen Donates:
[AB antibodies] Receives ONLY from: O

Contains: Uses
RBC To Increase Oxygen Carrying capacity.
Whole WBC Restoration of Blood Volume
Blood
Platelets
Plasma

NursingStoreRN 90
 Contains: Uses
Fresh Frozen Bleeding, r/t coag. factor deficiencies,
Plasma DIC, Hemorrhage, Vit K Deficiency,
1 Unit=250mL Liver disease, Anticoagulated patients.

Packed RBC Increase RBC mass

Packed 1 Unit=250mL Symptomatic Anemia
RBC Replaces 500mL Loss
Will ↑ HgB 1%,
HcT 3%

Platelets To Prevent / Control Bleeding

Plate-
1 Unit=50mL
lets Rapid Infusion
↑ Platelets by 10,000/
Units
NursingStoreRN

Cryoprecipitate Significant hypofibrinogenemia.

Cryopre 6 pooled units prepared Hemophilia.
cipitate
from Plasma, contains Excessive anticoagulation
clotting factors DIC
von Willebrand's

Adverse Effects
Albumin Hypovolemia - Pulmonary Edema
Moves water – Shock
intravascular space - CHF Precipitation
Burns - HTN
Infuse Slowly
5% Isotonic
Peritonitis - Anaphylaxis
25% Hypertonic Pancreatitis - Hypervolemia
Post-Op Albumin Loss - Tachycardia

Washed RBC Given when there is an anticipated risk of

Washed Rinsed w/ 1-3L of NS Reaction
RBC

NursingStoreRN 91
Overview
Used to replace blood volume, preserve oxygen-carrying capability, or increase coagulation
capabilities; autologous blood transfusions: donating your own blood before anticipated surgery;
religious considerations.

Initiating a Blood Transfusion

Type and cross-matching; informed consent; infuse each unit of blood within 2 to 4 hours; begin
with normal saline with Y administration set to prime tubing; do not infuse any solution containing
dextrose (causes blood to lyse or be destroyed); inspect for leakage, unusual appearance (bubbles or
purplish color indicate contamination); roller clamp; remain with patient for first 15 to 20 minutes;
after transfusion, flush tubing with normal saline; if giving more than one unit, use fresh tubing.

Blood Transfusion Reactions

- “Not feeling right,” sense of impending doom, chills, fever, low back pain, pruritus (itching),
hypotension, nausea and vomiting, decreased urine output, back pain, chest pain, wheezing, dyspnea
(BRONCO CONSTRICTION) ; stop infusion immediately; infuse normal saline solution with new
tubing then call provider; keep remaining blood product and send it back to pharmacy, lab, or blood
bank for analysis; document all findings; reactions generally happen within first 15 minutes but
NursingStoreRN
some reactions occur 60 to 90 minutes or days to weeks later; asses for circulatory overload.
- LOW BACK PAIN DUE TO KIDNEY PAIN/ENLARGEMENT. (SYSTEM WIDE
INFLAMMATION) LOW BACK PAIN = BAD
- FEVER IS A SIGN OF INFLAMMATION & INFECTION

Nursing Process
Data Collection / Patient Problems
- Assess risk for fluid, electrolyte, and acid-base imbalances and presence of alterations; monitor
vital signs, height, weight, neurological function, intake and output, laboratory studies, past and
present medical history, medication history.
- The RN will choose the patient problem such as “compromised blood flow to tissue,” “inadequate
fluid volume,” etc. The LPN must act accordingly.

Expected Outcomes and Planning / Goal / Outcomes

- Prioritize fluid, electrolyte, and acid-base balance.
- Baseline normal vital signs, normal skin turgor, moist mucous membranes, baseline weight, no
edema, clear breath sounds; normal urine electrolytes ABG’s, intake and output.

Implementation / Evaluation / Goal / Evaluative Measures

- Prevention of fluid, electrolyte, and acid-base imbalances.
- Obtain daily weight, vital signs, intake and output; auscultate lung sounds, check oral mucous
membranes, check tissue turgor, monitor serum electrolyte levels.

NursingStoreRN 92
P: An autoimmune response that causes deformities
S/Sx: Fatigue, anorexia, stiffness, weight loss
Event may trigger: Childbirth, Infection, Stress
Permanent deformity, Symmetrical
Dx: Rheumatoid factor- Blood Test + - >60 u/mL
↑ Erythrocyte sedimentation rate (ESR) -non specific
CRP, ANA
Radiology showing joint space deterioration
C: Nodular myositis, contractures Sjogren's syndrome, cataracts
Tx: Surgery to restore function

P: Bone demineralization caused by loss of calcium and phosphorus. Bone resorption occurs
faster than bone formation
S/Sx: Loss of bone density andNursingStoreRN
easily fractured bones
N: Encourage a well - balanced diet high in protein, calcium, iron, vit D + C

P: On inflammatory degeneration, gradual loss of articular cartilage. Asymmetrical

R: trauma, aging, obesity, smoking, ↓estrogen, genetic changes
S/Sx: Exacerbated by temperature + climate changes. Joint space narrowing. One leg
shorter than other. Pain is increased after rest
T: Regular exercise -> preventative. Avoid prolonged standing, kneeling and squatting.
Apply cold for inflammation / Heat for stiffness

P: A vertebral disk slips out of place which can

cause pain due to compression of spinal nerve
R: Numbness and tingling in back and extremities.
Severe pain.
Tx: Surgery to realign vertebra, physical therapy
and adjustment by a chiropractor can alleviate
pain but doesn’t fix the herniation

NursingStoreRN 93
 P: Uric acid crystals build up in joints and body tissues. Can
result from poor metabolism of purine
S/Sx: Swelling + inflammation of joints, low grade fever, malaise,
itchiness + pain at joints
N: Low purine diet, increase fluid intake.
Ed: Instruct client to avoid alcohol and excessive use of the joint

1- Transverse: A break that is perpendicular to the long axis

2- Comminuted: The bone fragments into pieces
3- Open / Compound: Part of the bone is through skin
4- Greenstick: The bone is splintered on one side

N: Elevate for 24-48 hours to promote venous drainage. Allow plasters casts to dry for 24-72 Hours
Ed: Instruct client to report skin irritation and hot spot
NursingStoreRN
N: Ensure weights are freely hanging + off the floor. Assess skin integrity frequently with skin traction

Fat Embolism: Altered mental status, impaired respiratory function, decreased perfusion distal
to embolus site.
Compartment Syndrome: Pressure is an extremity that can't escape, i.e., under a cast.
Numbness + tingling, pain that increase with elevation, Pallor, pain W/ Movement

Sprains: The ligament connecting two bones becomes torn or stretched

s rains: The muscle or endon attached to a bone becomes injured or over stretched

Ensure residual limb sock is worn at all times, position is

prone position as prescribed. Educate patient about
cleaning prosthesis socket daily.
Above Knee: Prevent internal and
external rotation of the hip
Below Knee: Discourage long period of
sitting to reduce Flexion.
Don't allow limb to dangle
94
NursingStoreRN
 Active range of motion: Can move joint without assistance
Passive range of motion: Can only move w/ assistance
Goniometer: Measures range of motion of a joint

Muscle Strength Scale

O = No muscle contraction
1 = A barely detectable contraction
2 = Active muscle contraction without gravity
3 = Active muscle contraction against gravity
4 = Active muscle contraction against some resistance
5 = Active movement against full resistance

NursingStoreRN
Diagnostics
X – Ray: Remove any radiopaque obj.
Abnormalities CT scan: Verify no shellfish allergy if
Atrophy: Decrease Size / Strength of a muscle contrast dye is used
Ankylosis: Stiffness at a joint Bone Scan: Ensure bladder is empty
Kyphosis: Thoracic curvature of spine
Myalgia: General Muscle Pain / Tenderness
ASSESS
Scoliosis: Asymmetrical elevation of shoulders
- Joints + muscles for crepitation or
Paresthesia: Pins + Needles
tenderness
Lordosis: Excessive inward curve of spine
- Muscle strength
(pregnancy)
- Range of motion

Fall Prevention
- Eliminate scatter rugs
- Use supportive shoes that have good
grip
- Use a walker or cone for support

95
NursingStoreRN
Impingement Syndrome
Soft tissue/nerves trapped under coracoacromial arch
Give: NSAIDS, Rest, ROM + Strengthening

Rotator Cuff Tear

Rest, NSAIDS + Strengthening + Surgery if Severe

Shin Sprints
Periostitis in calf -> ice, stretching + supportive shoes

Tendonitis
Inflammation of a tendon -> Rest, Ice, NSAIDS, brace, gradual return

Meniscus Injury
Injury to fibrocartilage discs in knee -> R.I.C.E and arthroscopic surgery PRN
NursingStoreRN

Dislocation: Complete displacement or separation of the articular surfaces of a joint

Subluxation: Partial or incomplete dislocation
Nursing Care
Dislocation is an orthopedic emergency r/t the risk of vascular injury. Assist with
realignment and pain management. Physical therapy and Rom exercise are imperative to
achieve full recovery

NursingStoreRN 96
Colles' Fracture: Fracture of the distal radius
TX: Closed reduction
Long Bone Fracture
TX: Immobilization, traction, int./ext. fixation
Hip Fraction
TX: Hip compression screw, partial replacement or total replacement
N: encourage early ambulation, assess color, temperature, cap refill, pulses, edema,
sensation motor function + pain, do not position on the affected side. Do not allow > 90°
knee flexion
Ed: Teach pt. to avoid crossing legs, internally rotate hip or sit in the low chairs
Stable Vertebral Fracture
TX: Immobilize spine, evaluate existence of cord damage, pain meds, kyphoplasty

NursingStoreRN

Infection: A serious complication

Tx: Antibiotics + surgical debridement
Compartment Syndrome
Swelling causes increased pressure that can compromise
nerves and blood vessels.
S/Sx: pain, pressure, paresthesia pallor, paralysis,
pulselessness. Cool skin at extremities
Tx: Do not elevate or apply cold.
Fat Embolism
Fat globules from the fracture travel to the lungs, blood
vessels or other organs
S/Sx: tachypnea, cyanosis, dyspnea, and low O2 sat.
Tx: Fluid resuscitation, blood transfusion, intubation
N: encourage cough + deep breathe, provide O2 therapy

NursingStoreRN 97
Pulling force to an affected extremity Skin Traction Skeletal Traction
- Reduces muscle spasm - short term (48-72 hours) - Long term (>72 hours)
- Immobilizes - reduce muscle spasms - alignment of bone
- Reduces a fracture - applied directly to the skin - pins or wires are surgically
- Can treat pathologic joint conditions - 5-10 pounds inserted into the bone
- 5-45 pounds

1. Ensuring traction weights never touch the floor Possible Complications

2. Keep patient in the correct body alignment to enhance traction Atrophy: teach isotonic
muscle strengthening
3. Assess for S/Sx of Compartment Syndrome
Muscle Spasms: heat
4. If pulleys are being used, make sure knots have enough slack
application reduces
5. Check skin integrity around pins or skin traction site frequently spasms

NursingStoreRN
6. Apply ice to prevent swelling Contracture: reposition
7. Suggest the use of a hairdryer on cool to help relieve itching frequency + provide ROM
8. Teach pt. importance of keeping proximal joints mobile Pain: determine / treat
underlying cause
9. Ensure pt. never inserts any objects inside the cast

A device used for long term immobilization / Allows freedom to perform most ADLS
Hip spica cast: used for femur fx in children
Body jacket brace: used for stable spiral spinal injury

- Never cover a plaster cast until it's dry because the heat will build up and cause a burn
- Handle with an open palm to avoid denting
- Ensure edges of cast are smooth to avoid skin irritation or breakdown
- Check color, temperature, cap. refill and pulses
- monitor for S/Sx of compartment syndrome
- S cast on a lower extremity should be elevated for the first 24hrs after application
- When a sling is used, ensure the axillary area is well padded.

NursingStoreRN 98
Non-cancerous changes in the breast that includes fibrotic connective tissue and cysts.
P: Hormone imbalance (High estrogen and Low Progesterone) results in hyperproliferation of fibrotic
connective tissue.
R/F: Estrogen and anti-estrogen treatment, 35-50 y/o female.
S/S: Breast pain. Movable, tender, rubber-like cysts (commonly occur bilaterally in the upper-outer
quadrants of the breasts).
Dx: Breast ultrasound, mammogram, biopsy.
Tx: Supportive measures (analgesics, supportive bra, ice/heat). Symptoms resolve after menopause
(decrease estrogen).

P: Abnormalities with the metabolism of androgens and estrogen

S/Sx: Hirsutism, Infertility, Diabetes, Sleep Apnea, Obesity and menstrual dysfunction
Tx: Diet, Exercise, Weight loss, Oral contraceptives, anti-androgens, hypoglycemic agents

P: The endometrium lining the uterus growth in places it should not which can cause cramping or infertility
S/Sx: Intense pelvic pain. Painful intercourse, diagnosis is confirmed by laparoscopy
Tx: Monitor for S/Sx of anemia during menses, educate about the importance of annual exams, help patient
NursingStoreRN
relieve painful cramp with ordered meds and heat compress

P: Infection of the reportative system usually caused by STDs

S/Sx: Pelvic pain, fever, discharge, cramping, painful menses
Tx: Antibiotics, education about using protection

Menorrhagia: Prolonged or excessive menstrual bleeding. Can result in anemia

Dysmenorrhea: Painful menstruation.
Amenorrhea: Absence of menses. Causes include pregnancy, tumors, endocrine lesions, weight loss, Cushing’s
syndrome.
PMS: Varying symptoms (irritability, depression, breast tenderness, bloating, headache) that occur prior
to menstruation.

Uterine Prolapse: Pelvic floor muscles and ligaments weaken, causing the uterus to protrude into vagina.
Cystocele: Protrusion of the bladder through the anterior vaginal wall, can cause UTI, stress incontinence.
Rectocele: Protrusion of the rectum through the posterior vaginal wall, which can cause constipation and
hemorrhoids.
R/F: Pregnancy/childbirth, obesity, chronic constipation, decreased estrogen.
Tx: Kegel exercises, vaginal pessaries, intravaginal estrogen, surgical repair.

99
NursingStoreRN
P: An enlargement of the veins in the scrotum caused by blood pooling in veins
S/Sx: A Dull, recurring pain in the scrotum, visibly large and twisted veins, a lump or swelling
N: Encourage pt to wear supportive underwear or jock strap.

P: Inability to reproduce as a result of various causes including low sperm count, chromosomal abnormalities
or inadequate hormones
Tx: Hormone replacement, fertility drugs, surgery, artificial insemination, Psychosocial counselling to help pt.
develop coping methods

P: Inability to keep an erection long enough for sexual intercourse

Tx: Vasodilator or hormone therapy, Smoking Cessation. PDE-5 inhibitors (sildenafil)

P: Uncontrolled, prolonged painful erection without sexual desire.

Complications: Circulation impairment and inability to void.
Tx: Urinary catherization, cavernous aspiration, vasoconstrictors, surgical intervention.

NursingStoreRN
P: Decreased androgenic hormones with aging causes enlargement of the prostate. This impairs urine
outflow from the bladder, resulting in urinary retention, high risk of infection and reflux into the kidneys.
S/S: Urinary frequency, incontinence, urgency, hesitancy, retention. Post-void dribbling, reduced urinary
stream force. Hematuria, nocturia. Frequent urinary tract infections.
Labs/Dx: DRE, High PSA (>4ng/mL), High WBCs w/ UTI, High creatinine and BUN w/ kidney involvement.
Tx: Meds: Finasteride, tamsulosin, tadalafil. Surgery: Transurethral resection of the prostate (TURP)

Hydrocele: Fluid collection that forms around the testis, causing painless swelling in the testicle. Common in
newborns or r/t scrotal injury, inflammation.
Spermatocele: Sperm-containing cyst on the epididymis, usually asymptomatic.
Testicular Torsion: Twisting of the spermatic cord, inhibiting blood flow of the testicle and causing severe
pain and swelling. Immediate surgical repair required.

Continuous Bladder Irrigation with 3-way catheter. The goal is to keep irrigation outflow light pink.
Increase CBI rate of outflow is bright red or contains clots.
For catheter obstruction (S/S: bladder spasms, low outflow), turn off CBI and irrigate using large piston
syringe. Expected: Patient will feel a continuous need to urinate.
Meds: Analgesics, antispasmodics, antibiotics (prophylactic), stool softeners (to prevent straining).
Nurse: Drink >2L of water per day. Avoid caffeine of alcohol. If urine is bloody, stop activity, rest, fluids.
100
NursingStoreRN
 Immune System
Immunity
Active Natural Immunity: Body produces antibodies in response to exposure to a live pathogen.
Active Artificial Immunity: Body produces antibodies in response to a vaccine.
Passive Natural Immunity: Mom passes antibodies to her baby through the breast milk or the
placenta.
Passive Artificial Immunity: Immunoglobulins are administered to an individual (not produced by the
body, therefore no memory cells for antigen).

Immune System malfunction

Hypersensitivity: Exaggerated or inappropriate response upon exposure to an antigen (allergen),
resulting in inflammation and destruction of healthy tissue.
Autoimmune Reactions: Body’s normal defenses recognize self-antigens as foreign and target them.
Caused by genetic, hormonal, and environmental factors.
Immunodeficiency: Absent or depressed immune response, due to viral infections, medications, or genetic
disorders. Places the patient at higher risk for infection.

Systemic Lupus erythematosus (SLE)

Chronic, Progressive, systemic Inflammation disorder that can cause major organs and systems to fail.
There is No cure for the disease. Discoid Lupus Erythematosus (DLE) affects only the skin.
NursingStoreRN
P: Autoimmune disorder results in production of Antinuclear Antibodies (ANA), leading to inflammation
and damage to most major body systems (skin, lungs, kidneys, heart, etc.). Characterized by periods of
exacerbations and remissions.
R/F: Females, ages 20-40, race (African American, Asian, Native Americans).
S/S: Butterfly rash on face, Fatigue, joint pain, fever, Raynaud’s phenomenon, anemia, pericarditis,
lymphadenopathy.
Labs/Dx: Positive ANA titer, decreased serum complement (C3, C4).
Low RBC, WBC, platelets. High BUN and Creatinine with kidney involvement.
Tx: NSAIDs, Immunosuppressants (prednisone, methotrexate),
Hydroxychloroquine, topical steroid creams for rash.
Nurse: Monitor Blood Urea Nitrogen and Creatinine frequently for signs of
Renal Failure. Avoid UV/Sun exposure and sick people. Rest frequently

polyarteritis nodosa
Collagen disease. Form of systemic vasculitis that causes inflammation of the arteries in visceral
organs, brain, and skin. Affects middle age MEN.
S/S: Weakness, abdominal pain, bloody diarrhea, weight loss, Elevated ESR
Tx: Similar to SLE

Pemphigus
Rare autoimmune disease. Treatment aimed to suppress the immune response and blister formation
S/S: Partial-thickness lesions bleed, weep and form crusts. Weakness, pain, dysphagia, Nikolsky’s Sign
(separation of the epidermis by rubbing the skin), foul smelling discharge from skin. Leukocytosis.
Tx: Corticosteroids, cytotoxic agents, antibiotics, soothing baths.

NursingStoreRN 101
 Immune System
Scleroderma (Systemic Sclerosis)
Chronic inflammation Connective Tissue Disease. Similar to SLE.
P: Autoimmune disorder results in damage and occlusion of blood vessels, and overproduction of collagen,
which causes tissue inflammation, fibrosis, and sclerosis (hard).
-Limited: Skin thickening limited to distal extremities and face
-Diffuse: Skin thickening over most of the body and organ involvement.
R. Factors: Female (30-50 yo)
S/S: Pain, Arthralgia (joint pain), Raynaud’s phenomenon, pitting edema in hands with taut/shiny skin,
GI disfunction (reflux, dysphagia), arrhythmias and dyspnea (cardiac and pulmonary fibrosis),
malignant hypertension (renal involvement).
Labs/Dx: Positive ANA tites, High ESR
Tx: No cure. Immunosuppressants, ACE Inhibitors
Nurse: Skin moisturization, frequent rest periods. Avoid stress, cold hands/feet (Raynaud’s)

Human Immunodeficiency Virus

P: Retrovirus that causes Low Immunity and High Susceptibility to Infections. Virus targets CD4+
lymphocytes (helper T-cells), causing immunodeficiency, autoimmunity, and neurologic dysfunction.
R. Factors: Unprotected sex, multiple sexual partners, perinatal exposure, IV drug use, health care
workers.
S/S: Flu-like symptoms, lymphadenopathy, thrush, weakness, night sweats, fever, weight loss, rash.
NursingStoreRN
Labs: Low WBC, CD4+ count <500 cells/mm3
Dx: Positive ELISA test, confirmed with Western Blood Test.
AIDS criteria: CD4+ <200 cells/mm3
S/S: Kaposi’s Sarcoma, TB, Pneumonia, wasting syndrome, candidiasis on the airways, and + infections.
Tx: Antiretroviral Therapy
Nurse: Practice safe sex. Encourage PrEP (pre-exposure prophylaxis) for uninfected partners. Monitor
CD4+ counts. Prevent Infections (hand hygiene, bath with antimicrobial soap, avoid raw food, etc).

Gout
Gout or Gout Arthritis is the most common inflammatory arthritis. Systemic disease caused by
disruption in purine metabolism, and uric acid crystal are deposited in joints and body tissues.
Primary Gout (most common): Uric acid production > excretion of it by the kidneys.
Secondary Gout: Excessive Uric Acid in the blood caused by another disease (Chronic Kidney Failure,
Carcinomas, excessive diuretic use).
R. Factors: Obesity, Heredity, Cardiovascular Disease, Alcoholism, Diuretic use, Chemo, CKF
S/S: Severe Joint Pain, redness, swelling, and warmth of affected joint.
Labs: BUN and Creatinine Elevated, Urinary Uric Acid elevated.
Dx: Aspiration of synovial fluid for analysis or uric acid crystals in affected joints.
Tx:
-Acute Gout: Antigout Agents (Colchicine), NSAIDs, Corticosteroids (Prednisone).
-Chronic Gout: Allopurinol or Febuxostat. Uricosuric (Probenecid), Enzymes (Pegloticase).
Nurse: Low Purine Diet (no organ meats or shellfish). Avoid alcohol, starvation diets, aspirin, and
diuretics. Increase fluid intake.

NursingStoreRN 102
 Immune System
Fibromyalgia
Chronic Pain syndrome that manifests as Pain, Stiffness, and tenderness at trigger points in the body.
R. Factors: Female (30-50 yo), Hx of Rheumatologic conditions, Lyme disease, trauma, influenza
S/S: Chest Pain, dysrhythmias, dyspnea, fatigue, numbness/tingling of extremities, headaches, jaw pain,
depression, abdominal pain, heartburn.
Tx: SNRIs and Anticonvulsants. Duloxetine (SNRI) and Pregabalin (anticonvulsant). NSAIDs, Tricyclic
Antidepressants.
Nurse: Limit caffeine, alcohol. exercise regularly, complementary therapies.

Rheumatoid Arthritis (RA)

RA is a Chronic-Progressive-Inflammatory
Disease that affects Tissues and Organs, but
principally attacks the Joints, producing
inflammatory synovitis. RA typically affects
upper joints first.
P: Autoimmune disease where WBCs attack
synovial tissue, causing it to become inflamed
and thickened. Inflammation can extend to
cartilage, bone, tendons, and ligaments,
resulting in Joint deformity andNursingStoreRN
bone erosion.
RA has periods of Exacerbation and Remission.

R. Factors: Female, Age 30-60 yo, Epstein-Barr virus, Environmental factors, stress and
smoking. Genetic link HLA-DR4
S/S: Morning Stiffness, Pain, Pleuritic pain, Xerostomia, Anorexia, fatigue, Paresthesia,
Subcutaneous nodules, fever, Lymph node enlargement.
- Joint Swelling and Deformity (these are late manifestations of RA). Joint swelling, warmth,
and erythema are common. Finger, hands, wrists, knees, and foot joints are most affected.
Finger joints affected are the proximal interphalangeal and metacarpophalangeal joints. Ulnar
deviation, swan neck, and boutonniere deformities in fingers.
Labs: Anti-CCP antibodies Positive. Rheumatoid factor antibody (1:40-1:60). High ESR (ESR is
associated with inflammation or infection). C-reactive protein (inflammation if elevated).
Antinuclear Antibody (ANA) titer. High WBCs.
Dx: Arthrocentesis (synovial fluid aspiration by needle). X-ray
Tx: NSAIDs, COX-2 enzyme blockers, Corticosteroids (Prednisone). Disease Modifying anti-
rheumatic drugs (DMARDs). Hydroxychloroquine, Sulfasalazine, Methotrexate, Etanercept,
Infliximab.
Procedures: Plasmapheresis, Total Joint arthroplasty, Synovectomy
Nurse: Morning Stiffness (hot shower), Pain in hands (heated paraffin), Edema (cold therapy).

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P: Any cancer originating in the epithelium
S/Sx: A growing lump with a crusty surface, slow growing flat patch of redness
R: Overexposure to sun, repetitive irritation, genetic predisposition, lighter skin, older than
60 years

P: Cancer originating in the connective tissues

S/Sx: Visible lump or mass in the soft tissue
R: Lymphedema. Von Willebrand disease. Genetic predisposition

P: A cancer originating in melanocytes which are located in the basal layer of epithelium
S/Sx: New marks on skin, mole that changes shape or size, new pigments of the skin

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P: Cancer of blood-forming cells. Either acute or chronic
S/Sx: Prevent infection by avoiding invasive procedures such as catheterizations and
injections. Prevent excessive bleeding due to possible low platelet count

- Treat nausea, educate about carbohydrate ↓ for prevention (Antiemetic 30min prior to chemo)
- Maintain meticulous infection control for yourself, the patient and visitors. (Neutropenic precautions)
- Provide non pharmacological and pharm pain control

Surgery: Tumor is removed or destroyed - Change in bowel/bladder

Radiation: Localized destruction of cancer - Any sore that doesn't heal
cells. Can cause local irritation + fatigue - Unusual bleeding/discharge
Chemotherapy: Kills + stops the reproduction - Thickening or lumps
of neoplastic cells. - Indigestion
-Skin, hair, nail, GI cells also impacted - Obvious skin changes
- Nagging cough/hoarseness

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 - Usually begin in the bronchi
- Spread more quickly than NSCLC
- Early metastasis to Lymph
- Poorest Prognosis
- Survival Rate of 12-18 months
- Staging not useful due to
aggressive nature

Adenocarcinoma Squamous Cell Large Cell

- Associated with scarring - Slow growing - Associated with Tobacco abuse
(chronic fibrosis) - Resectable - Highly metastatic
- Resection attemptable - Often causes Bronchial - High reoccurrence
- Most common in non-smoker Obstructions - Surgery not attempted

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Occult-stage:
Cancer cells are found in sputum, but no tumor can be found in the lung by imaging tests or bronchoscopy,
or the tumor is too small to be checked.

Stage 0
Cancer at this stage is also known as carcinoma in situ. The cancer is tiny in size and has not spread into
deeper lung tissues or outside the lungs.

Stage I
Cancer may be present in the underlying lung tissues, but the lymph nodes remain unaffected.

Stage II
The cancer may have spread to nearby lymph nodes or into the chest wall.

Stage III
The cancer is continuing to spread from the lungs to the lymph nodes or to nearby structures and organs,
such as the heart, trachea and esophagus.

Stage IV
The most advanced form of the disease. In stage IV, the cancer has metastasized, or spread, beyond
the lungs into other areas of the body.

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 Wedge Resection Segmentectomy - Segmental Resection
Removal of “wedge” of lung A portion of the lung is removed.
tissue Larger than a wedge, while leaving a
portion of the lobe.

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Lobectomy Pneumonectomy
Removal of a Single Lobe Removal of the entire lung.
Post Op Consideration – Place pt. on operative
side to facilitate expansion of remaining lung.

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Types of Skin Cancer:
- Basal Cell Carcinoma: Waxy nodule with pearly borders. Originates in the basal layers of
the epidermis. Most common type of skin cancer.
- Squamous Cell Carcinoma: Oozing, crusting lesion. Originates in the upper layer of the
epidermis.
- Melanoma: Irregular lesion, various color hues. Originates in the melanocytes (melanin-
producing epidermis cells), highly metastatic. Most deadly form of skin cancer.

Ways to Prevent:
- Avoid midday sun, wear sunscreen and protective clothing, perform regular skin checks.

Treatment:
Excision, cryosurgery,
topical chemotherapy
(5-fluorouracil cream),
NursingStoreRN Mohs surgery.

Lymphoma: Solid tumor in the lymphoid tissue (lymph nodes and spleen), causing
overgrowth of lymphocytes.
- Hodgkin’s: Reed-Sternberg cells, local/regional
- Non-Hodgkin’s: No Reed-Sternberg cells, disseminated spread.
Multiple Myeloma: Cancer that causes overgrowth of plasma cells in the bone marrow,
resulting in excess of secretion of antibodies and cytokines. This prevents growth of RBCs,
platelets, and WBCs.
Treatment: Chemotherapy, radiation, targeted therapy, stem cell transplantation.
Nurse: There is a HIGH risk of anemia, thrombocytopenia, and neutropenia.

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Screening: Annual mammogram starting at age 40, monthly BSE.
RF: Genetics, early menarche, late menopause, long-term use of contraceptives, smoking
S/S: Firm, non-tender, immobile breast lump. Dimpling or peau d’ orange appearance. Nipple
discharge, ulceration, or retraction.
Tx: Hormone therapy (tamoxifen), chemo, radiation
surgery (lumpectomy, mastectomy).
Mastectomy Care:
- Don’t administer injections, obtain blood, or take
Blood Pressure in affected arm(s).
- Wear sling when ambulating, wear loose clothing,
perform arm/hand exercises to prevent edema.

Endometrial Cancer: Cancer in the inner uterine lining, often due to prolonged exposure to
estrogen without progesterone. Key symptom is postmenopausal bleeding.
Cervical Cancer: Cancer in the cervix, usually caused by the human papillomavirus (HPV).
Key symptom is painless vaginal bleeding.
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- Prevention: HPV vaccine (3 injections over 6 months)
- Screening: Pap smears (every 1-3 years, started 3 years after sexual intercourse or by
age 21).
Ovarian Cancer: Epithelial tumor that grows on the surface of the ovaries and spreads
rapidly. Symptoms are vague (GI disturbances), resulting in low survival rates due to late
detection.
Tx: Chemo, internal/external radiation, ablation therapy, surgery (hysterectomy,
salpingectomy, oophorectomy).

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Screening: FOBT (Fecal occult blood test) annually, colonoscopy every 10 years (or
sigmoidoscopy every 5 years) starting at 50.
RF: Older age, high-fat diet (especially red meat), genetics, smoking, obesity, alcohol,
physical inactivity.
S/S: Rectal bleeding, change in bowel color, shape, consistency.
Labs/Dx: Colonoscopy with biopsy (definitive), positive FOBT, CT/MRI
Tx: Chemo, radiation, surgery (colon resection or colectomy with colostomy/ileostomy)

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Screening: Annual PSA test and digital rectal exam (DRE) starting at 50 (earlier if higher
risk). Take PSA before DRE.
RF: Older age, high-fat, race (African American), genetics
S/S: Urinary retention, hesitancy, frequency. Frequent bladder infections, hematuria,
nocturia.
Labs/Dx: Elevated PSA (>4ng/mL), transrectal
ultrasound, biopsy.
Tx: Hormone therapy (leuprolide), chemo, radiation,
prostatectomy, orchiectomy.

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 NursingStoreRN
Anaphylactic Shock - Allergic Reaction
Immediate Type 1 - Anaphylaxis (Swelling, low BP, dilated Blood Vessels)
Delayed Type 2
EpiPen Yellow (adult-0.30mg) EpiPen Green (child-0.15mg) More than that - CARDIAC
ARREST
Hypovolemic Shock (Pt lost 20% or 1/5 of body blood or fluid) Low Preload
When: Hemorrhage, Severe Dehydration, Diaphoresis, Diabetes Insipidus (No ADH, so
excessive urine and thirst - Desmopressin), Vomiting, Diarrhea, Peritonitis, Pancreatitis-
Demerol (Cullen's Sign) (Gray-Turners: black on the sides), Severe Burns
Tx: Vasoconstrictors- Improve MAP, by Increasing peripheral resistance, ↑venous return ↑
Myocardial contractility [i.e., Dopamine, NorEpi, Phenylephrine]
Neurogenic Shock (Hypotension - Bradycardia)
When: High Injury Spinal Cord, Spinal anesthesia, Disrupted Blood Circulation, Poikilothermic
(Cold Body), WARM Extremities
Tx: IV Fluids, Norepinephrine
C7 Up- Quadriplegia/Tetraplegia C7 Down-Paraplegia(legs)
Spinal Shock (Vasogenic Shock) - Autonomic Dysreflexia (Spinal Cord Injury T6 or Higher)

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NursingStoreRN

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Fowlers: 45- 60 degrees; good for procedures (ex: suctioning, NG tube), provides better ventilation.
Semi-fowlers: 15-45 degrees (usually 30 degrees); prevents aspiration and helps with ventilation.
High fowlers: 60-90 degrees; good for severe dyspnea and during meals (to prevent aspiration).
Lateral / Side-Lying: Patient lies on their side with most of the weight on dependent hip and shoulder
and the arms flexed in front of the body. Pillow under head and neck, upper arm, and legs and thighs.
Good for prevention of pressure ulcers.
Lithotomy: Patient lying flat on its back with legs elevated to hip level or above. Good for
gynecological procedures and childbirth.
Supine: patient is flat on back with head and shoulder elevated by a pillow.
Prone: patient is on stomach; helps to prevent hip flexion contractures after lower extremity
amputation.
Trendelenburg: Whole bed is tilted with HOB lower than foot of bed; promotes venous return.
Reverse Trendelenburg: Whole bed is tilted with foot of bed lower than HOB; promotes gastric
emptying (prevents reflux).
Modified Trendelenburg: Patient lies flat with legs elevated above his/her heart; good for
hypovolemia.
Sims: Patient lies on their left side, with their left hip and lower extremity straight, and right hip
and knee bent; used for enemas and rectal examinations.
Orthopneic: patient sits on side of bed with arms on overbed table; good for COPD (Promotes lung
expansion)
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Mastectomy
Position: Arm elevated on pillow. Turn only to unaffected side and back
Why? Promotes lymphatic fluid drainage from accumulating (decreases lymph edema).
Head Injury / Surgery
Position: Semi-Fowler’s (HOB usually about 30-45 degrees); Head midline, no head flexion. Do not
position client on side where there is a removed bone flap
Why? Reduces ICP by allowing venous drainage from head. Head flexion will increase ICP. Lying on side
where there is a bone flap will increase ICP.
Immediate Post-Op /Post Procedure (in clients who aren’t yet alert)
Position: Side-lying
Why? Allows secretions to drain from mouth and prevents aspiration.
COPD / Respiratory Distress
Position: High Fowler’s / Elevate HOB 90 degrees / Tripod or orthopneic position
Why? Increases maximum lung expansion, allowing for more ventilation and oxygenation.
Enema Administration
Position: Left-lateral or Sim’s position
Why? Allows solutions to flow by gravity into the natural direction of the colon.

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Leg Amputation
Position: Elevate affected limb on pillow x 24 hours only Prone as tolerated, 20-30 mins at a time, at least
twice daily
Why? Reduces edema post-op, however, after 24 hours, DO NOT elevate stump because it can lead to
contractures. Prone position will stretch out hip and leg muscles to prevent hip flexion contraction.
Thyroidectomy
Position: Head midline / Semi-Fowler’s to Fowler’s (30 to 45 degrees) / Support neck while turning/moving
Why? Reduces swelling and edema in the neck area.
Shock
Position: Modified Trendelenburg
Why? This will aid in perfusion of upper body and head without causing pulmonary edema.
Thoracentesis
Position: Seated upright at side of bed, with an overbed table in front of client.
Why? This will exposure required area for procedure.
Liver biopsy
Position: During: On the client’s left side to exposure liver area (which is on the right).
After: On the client’s right side.
Why? Left side during the procedure will expose the area for biopsy site.
Right side after procedure will use gravity to help stop bleeding
Paracentesis
Position: Seated upright in chair or semi-Fowler’s in bed.
Why? To exposure area for puncture site, as this will assist in insertion of needle.
Nasogastric or Gastrostomy Tubes NursingStoreRN
Position: High Fowler’s for NG insertion.
HOB at least 30 degrees (semi-Fowler’s) for NG/GT feeding, irrigation.
Why? For insertion: It will aid in insertion by closing off the trachea and opening the esophagus.
For NG/GT feed and irrigation: To prevent aspiration of gastric contents.
Laminectomy
Position: Keep client straight. Logroll the client
Why? To avoid twisting of the spine, as this may cause complications.
CVA (Ischemic / Hemorrhagic)
Position: Ischemic – Usually flat
Hemorrhagic – HOB 30 degrees
Why? Ischemia – Head flat to perfuse blood to head.
Hemorrhagic – HOB 30 degrees to avoid ICP.
S/P Cardiac catherization
Position: Bedrest x 6 hours. Affected extremity straight. HOB no more than 30 degrees
Why? This position avoids pressure on the puncture site. Client can turn from side to side, but must avoid
pressure on insertion site.
Maternal Patient with Dizziness
Position: Left lateral
Why? As the uterus enlarges, pressure on the inferior vena cava increases. This pressure compromises venous
return and causes blood pressure to drop, which may lead to syncope and accompanying symptoms when the
client is supine.
Turning the client on her left side relieves pressure on the vena cava, restoring normal venous return and blood
pressure.

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 –

1- Look at the pH (7.35 - 7.45)

- If the pH is HIGH, this is ALKALOSIS
- If the pH is LOW, this is ACIDOSIS
2- Look at the PaC02 (35 - 45) - PaC02 – Respiratory
- If PaC02 is HIGH, this is ACIDOSIS
- If PaC02 is LOW, this is ALKALOSIS
3- Look at the HC03 (22 - 26) - HCO3 – Metabolic
- If HC03 is HIGH, this is ALKALOSIS
- If HC03 is LOW, this is ACIDOSIS

Interpret
Step 1: Analyze the pH. It will tell you ACIDOSIS or ALKALOSIS
Step 2: Analyze the PaC02 and the HC03
- Is PaC02 below 35? It is Alkalotic. Above 45 it is Acidic
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- Is HC03 below 22? It is Acidic. Above 26 it is Alkalotic
Step 3: Match the PaC02 or the HC03 with the pH
For example, if the pH is acidotic, and the PaC02, then the Acid-Base disturbance is being
caused by the respiratory
system. Therefore, we call it Respiratory Acidosis
Step 4: Does the PaC02 or the HC03 go the opposite direction of the pH?
If so, there is compensation by the systems. For example, if the pH is acidotic, and the PaC02
is acidotic, and the HC03 is
alkalotic.
If they don’t go the opposite direction, It is UNCOMPENSATED
Step 5: Is the pH in normal range? Fully Compensated / Partially Compensated /
Uncompensated
If there is Compensation, and the pH is in normal range (7.35-7.45), then it is Fully
Compensated
If there is Compensation, and the pH is out of range, then it is Partially Compensated
Step 6: Are the pO2 and the O2 saturation normal?
If they are below normal, there is evidence of Hypoxemia

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 –
1- Practice Question
A 72 yr. old with pneumonia.
pH - 7.31 (Acidic)
PaC02 – 60 (Acidic)
HC03 - 34 (Alkalotic)
pO2 – 50 (LOW)

#1 – pH is below 35, so It is Acidosis

#2 – Who is doing the same as the pH (Acidic)? PaC02
It is Respiratory
#3 – Does the HCO3 go in opposite direction as the pH? YES – Alkalotic
So, there is Compensation
#4 – Is the pH in normal range? NO
So, it is Partially Compensated

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#5 – Is the pO2 in normal range? NO
The patient has Hypoxemia
The full Diagnosis is:
Partially Compensated Respiratory Acidosis with Hypoxemia

2- Practice Question
A 20 years old, acute renal failure
pH - 7.18 (Acidic)
PaC02 – 44 (Normal) #1 – pH is below 35, so It is Acidosis
HC03 - 16 (Acidotic) #2 – Who is doing the same as the pH (Acidic)? HC03
pO2 – 92 (Normal)
It is Metabolic
#3 – Does the PaC02 go in opposite direction as the pH? NO
So, there is NO Compensation
#4 – Is the pH in normal range? NO
So, it is Uncompensated
#5 – Is the pO2 in normal range? YES
The patient doesn’t have Hypoxemia
The full Diagnosis is:
Uncompensated Metabolic Acidosis.
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 –

1. pH: 7.11 CO2: 51 HCO3: 27

2. pH: 7.39 CO2: 54 HCO3: 38

3. pH: 7.14 CO2: 51 HCO3: 28

4. pH: 7.39 CO2: 53 HCO3: 27

5. pH: 7.45 CO2: 40 HCO3: 22

6. pH: 7.50 CO2: 44 HCO3: 31

7. pH: 7.35 CO2: 20 HCO3: 17

8. pH: 7.12 CO2: 44 HCO3: 14

9. pH: 7.28 CO2: 54 HCO3: 26

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10. pH: 7.30 CO2: 35 HCO3: 17

11. pH: 7.19, CO2: 39, HCO3: 18

12. pH: 7.7, CO2: 52, HCO3: 35

13. pH: 7.42, CO2: 54, HCO3: 28

14. pH: 7.84, CO2: 49, HCO3: 30

15. pH: 7.75, CO2: 43, HCO3: 37

16. pH: 7.87, CO2: 26, HCO3: 24

17. pH: 7.37, CO2: 20, HCO3: 15

18. pH: 7.14, CO2: 31, HCO3: 20

19. pH: 7.58, CO2: 50, HCO3: 36

20. pH: 7.43, CO2: 32, HCO3: 12

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 –

1. pH: 7.11, CO2: 51, HCO3: 27 - Partially Compensated Respiratory Acidosis

2. pH: 7.39, CO2: 54, HCO3: 38 - Fully Compensated Respiratory Acidosis

3. pH: 7.14, CO2: 51, HCO3: 28 - Partially Compensated Respiratory Acidosis

4. pH: 7.39, CO2: 53, HCO3: 27 - Fully Compensated Respiratory Acidosis

5. pH: 7.45, CO2: 40, HCO3: 22 - Normal

6. pH: 7.5, CO2: 44, HCO3: 31 - Uncompensated Metabolic Alkalosis

7. pH: 7.35, CO2: 20, HCO3: 17 - Fully Compensated Metabolic Acidosis

8. pH: 7.12, CO2: 44, HCO3: 14 - Uncompensated Metabolic Acidosis

9. pH: 7.28, CO2: 54, HCO3: 26 - Uncompensated Respiratory Acidosis

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10. pH: 7.3, CO2: 35, HCO3: 17 - Uncompensated Metabolic Acidosis

11. pH: 7.19, CO2: 39, HCO3: 18 - Uncompensated Metabolic Acidosis

12. pH: 7.7, CO2: 52, HCO3: 35 - Partially Compensated Metabolic Alkalosis

13. pH: 7.42, CO2: 54, HCO3: 28 - Fully Compensated Metabolic Alkalosis

14. pH: 7.84, CO2: 49, HCO3: 30 - Partially Compensated Metabolic Alkalosis

15. pH: 7.75, CO2: 43, HCO3: 37 - Uncompensated Metabolic Alkalosis

16. pH: 7.87, CO2: 26, HCO3: 24 - Uncompensated Respiratory Alkalosis

17. pH: 7.37, CO2: 20, HCO3: 15 - Fully Compensated Metabolic Acidosis

18. pH: 7.14, CO2: 31, HCO3: 20 - Partially Compensated Metabolic Acidosis

19. pH: 7.58, CO2: 50, HCO3: 36 - Partially Compensated Metabolic Alkalosis

20. pH: 7.43, CO2: 32, HCO3: 12 - Fully Compensated Respiratory Alkalosis

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Electrolytes: Arterial Blood Gases (ABGs)
Sodium (Na+): 135-145 mEq/L pH: 7.35-7.45
Chloride (Cl-): 98-106 mEq/L PaCO2: 35-45 mmHg
Calcium (Ca2+): 9-10.5 mg/dL PaO2: 80-100 mmHg
Potassium (K+): 3.5-5.0 mEq/L HCO3: 22-26 mEq/L
Phosphate (PO4): 3-4.5 mg/dL SaO2: 95-100%; <95% Indicates Hypoxemia
Magnesium (Mg2+): 1.5-2.5 mEq/L

CBC WBC Differential Count:

RBC: males 4.7-6.1 million/uL; females 4.2-5.4 million/uL Neutrophils: 55-70%
Hgb: males 14-18 g/dL; females 12-16 g/dL Lymphocytes (T & B Cells): 20-40%
Hct: males 42-52%; females 37-47% (hct 36-54 NCLEX) Monocytes: 2-8%
WBC: 5,000-10,000 mm3 Eosinophils: 1-4%
Erythrocyte sedimentation rate (ESR): <20 mm/hour Basophils: 0.5-1.5%
Serum lactate (lactic acid): 0.5-1.0 mmol/L
Platelet: 150,000 – 400,000 mm3

Blood Lipid Levels

Total serum cholesterol: desirable <200 mg/dL
LDL (low-density lipids): desirable <130 mg/dL; Bad Cholesterol
HDL (high-density lipids): males >45 mg/dL; females >55 mg/dL; Good Cholesterol
Triglycerides: desirable <150 mg/dL; males 40-160; females 35-135; over 65 years: 55-220 mg/dL

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Anticoagulant Therapy Coagulation Times Liver Function Tests
Therapeutic INR: 2-3 sec (Normal Range: 0.8-1.1) Albumin: 3.5-5.0 g/dL
PT: 11-12.5 sec Ammonia: 10-80 mg/dL
Platelets: 150,000 - 400,000 mm3 Total bilirubin: 0.3-1.0 mg/dL
Indirect/unconjugated bilirubin: 0.2-0.8
Liver Enzymes Urinalysis mg/dL
ALT: 4-36 u/L Specific gravity: 1.005-1.030 Total protein: 6-8 g/dL;
AST: 0-35 u/L Protein: 0-0.8 mg/dL Prealbumin: 19-38 mg/dL
ALP: 30-120 u/L Glucose: 50-300 mg/day
pH: 4.6-8
I&O
Blood Glucose Fluid intake: 2,000-3,000 mL/day
Renal Function
Levels Daily urine output: 1,200-1,500 mL/day
Creatinine: 0.6 - 1.2 mg/dL
Glucose (fasting): BUN: 10-20 mg/dL Hourly urine output: ≥30 mL/hour; <30 mL
70-110 mg/dL for >2 consecutive hours = CONCERN!!
Glycosylated Pancreas Polyuria (consistently high urine volume):
hemoglobin Amylase: 30-120 units/L >2,000-2,500 mL/day
(HbA1c): 4-6% Lipase: 0-160 units/L

BMI Ranges
Underweight: <18.5 Healthy: 18.5-24.9 Overweight: 25-29.9 Obese: ≥30

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