CHEAT CODES: WALKTHROUGH TO ACE THE NLE 08/06/2024

CHEAT CODE VI- MEDICAL- SURGICAL NURSING

Leukemia

• This refers to malignant disease of the bone marrow. It is the most common malignancy in
children and young adults. This can either be acute or chronic; myelogenous (non-lymphocytic) or
lymphoblastic.

Types
A. Acute Leukemia is caused by a block of differentiation of cells in the hematopoietic cell line that results
in a massive accumulation of immature, non-functional cells or blasts in the bone marrow and other
blood-forming organs (liver, spleen, lymph nodes) and other sites throughout the body.

▪ AcuteMyelogenousLeukemia: common in adults (median age:65years old).

▪ Acute Lymphoblastic Leukemia: common in children (median age: 10 years old).

B. Chronic Leukemia is caused by an unregulated proliferation of hematopoietic cells or disordered

apoptosis.

1. Chronic Myelogenous Leukemia: originates in the pluripotent stem cell. Initially, the bone
marrow is hypercellular with most cells normal.
2. Chronic Lymphoblastic Leukemia is characterized by the proliferation of early B lymphocytes
and increased numbers of mature and slightly immature lymphocytes.

Clinical Manifestations are associated with the development of pancytopenia:

1. Anemia
2. Decreased White Blood Cells
3. Thrombocytopenia
4. Other signs and symptoms include splenomegaly, hepatomegaly and lymphadenopathy

Diagnostic Tests

1. Complete Blood Count, Peripheral Blood Smear

2. Bone Marrow Aspiration Biopsy
3. MRI, CT Scan, X-ray

Management
1. Chemotherapy (chlorambucil, cyclophosphamide, and Fludarabine: nucleoside analog)

2. Radiation Therapy
3. Targeted Therapy

▪ Gemtuzumab ozogamicin (Mylotarg)

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▪ Imatinib Mesylate(Gleevec)
▪ Dasatinib (Sprycel)
▪ Nilotinib (Tasigna)
▪ Alemtuzumab(Campath)
▪ Rituximab (Rituxan)

4. Apheresis: to reduce the number of white blood cells

5. Serial Blood Transfusions
6. Antibiotic Therapy
7. Bone Marrow Transplantation (BMT). This acts as the last resort in diseases affecting the function of
the bone marrow. This is usually followed by high-doses of chemotherapy and radiation therapy.

Pancreatic Cancer

• cancer that forms within pancreatic tissues

Clinical Manifestations:

Non-specific:

• Anorexia, nausea, weight loss

• Flatulence, dull epigastric pain

Location-Based:

● Pancreatic head: jaundice, clay-colored stools, dark urine, pruritus

● Body of the pancreas: pain that increases when the person eats or lies supine
● Tail of the pancreas: usually asymptomatic unless with metastasis

Late

• Palpable abdominal mass

• Ascites

Diagnostics:

• UTZ / CT Scan (with contrast media)

Percutaneous fine-needle aspiration cytology of the pancreas

Management:

1. Surgery: Whipple’s Procedure (Pancreatoduodenectomy)

Post-operative considerations:
o Semi-Fowler’s position
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o Maintain GI suction (usually with the use of Salem tube)

o Monitor and manage pain
o Assist with turning, coughing and deep breathing exercises every 1-2 hours
o Watch out for signs of hemorrhage / hypovolemic shock

2. Radiation Therapy

3. Chemotherapy

4. Nursing Interventions Include:

o Weigh daily
o Administer intravenous fluid / total parental nutrition (TPN)
• When oral feeding is resumed,
• High carbohydrate, low protein, low fat
• Avoid alcohol, coffee, spicy foods, gas-producing foods

Parkinson’s Disease

• Degeneration and destruction of nerve cells of the basal ganglia throughout the brain

• loss of dopamine

Signs and symptoms:

• cogwheel rigidity
• pill rolling or resting tremor
• masklike appearance of face
• slow monotonous speech
• Shuffling propulsive gait
• Flat affect
• Stooped posture
• Moist oily skin
• Soft monotonous voice
• Shaky small handwriting

Collaborative management:

• Thick liquid diet

• Increase fluid intake and fiber
• Aspiration precaution

Nursing management:

• Levo-dopa to increase dopamine

• Carbidopa-Levodopa
• Sinemet to prevent breakdown of dopamine
• Anticholinergics to reduce rigidity and tremors (Akineton)
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• Avoid pyridoxine – blocks the effect of levodopa

• Avoid MAOI – hypertensive crisis

Multiple Sclerosis (MS)

• demyelination of the nerve fibers of the brain and spinal cord

• DESCENDING PARALYSIS

Signs and Symptoms

• Visual disturbances – DIPLOPIA

• Charcot’s Neurologic Triad (SIN)
o Scanning speech
o Intentional tremors
o Nystagmus
• partial or total loss of vision
• Weakness/numbness of the extremities
• Fatigue
• Increased susceptibility to URTI
• Dysphagia
• Ataxic gait
• MS plaques in MRI

Diagnostics

• Lumbar Puncture
• total CSF protein is normal
• IgG is elevated
o IgG reflects hyperactivity of the immune system due to chronic demyelinaton
• EEG-abnormalities in brain waves

Management:

• Provide regular activity, rest, and relaxation.

• Assist with muscle stretching, relaxation and coordination exercise, walking exercise.
• Encourage well balanced, high fiber diet.
• Force fluids to prevent constipation.
• Avoid hot baths
• Eye patch
• Speech therapy – to manage dysarthria
• plasmapheresis

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Pharmacotherapy:

• Glucocorticoids (Prednisone, Dexamethasone, Corticotropin)- to reduce edema of the myelin

sheet; speeds recovery from attack
• Amantadine, Ritalin, or antidepressants –to manage fatigue
• Low-dose TCAs- to manage sensory symptoms such as pains, numbness, burning, and tingling
sensations
• Muscle relaxants

Myasthenia Gravis
• Decreased - acetylcholine receptor sites
• increased – cholinesterase

Signs and Symptoms:

• PTOSIS
• “snarl smile” – slow smiling
• Muscular weakness
• Fatigue
• Weight loss
• Muscle atrophy

Diagnostic assessment:

• Tensilon test
• injection of Tensilon (Endrophonium Cl) then muscle weakness disappears but comes
back when medication wears off

Nursing Management:

• Anticholinesterase – prostigmin; mestinon to be taken at specified time; before meals

• Myasthenic crisis – due to undermedication
▪ management – anticholinesterase
• Cholinergic crisis – due to overmedication
▪ management – atropine sulfate
• Brittle crisis – receptors at neuromuscular junction becomes insensitive to anticholinesterase

Management:

• Assess gag reflex before feeding

• Administer medications 20-30 min before meals
• Adequate ventilation
• Avoid muscle relaxants, barbiturates, morphine, tranquilizers and neomycin
• Avoid stress, colds and infection
• Never rush, provide rest periods
• Avoid unnecessary muscle activity

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Amyotropic Lateral Sclerosis (ALS)

• Lou Gehrig’s Disease

• PROBLEM: excess glutamate

Clinical Manifestations:
• Dysphagia
• Unilateral disability of arm and leg
• Respiratory difficulty
• Muscle weakness

Management:
• Gastrostomy feeding
• Avoid aspiration
• Assist with ADLs

Guillain Barre Syndrome (GBS)

• Neuronitis of cranial and peripheral nerves

• MAIN PROBLEM: DOB

Clinical manifestation:
• Ascending paralysis

Management:
• Symptomatic
• Supportive
• READY TRACHEOSTOMY

Alzheimer’s Disease (AD)

• Degenerative disorder of cerebral cortex resulting to microscopic plaques

• Impaired intellectual function and progressive loss of function

4 A’s
• Amnesia
• Agnosia
• Aphasia
• Apraxia

STAGES:

• Stage 1: EARLY CONFUSION

o Difficulty recalling names

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• Stage 2: MODERATE
o Unable to perform complex task (e.g. planning a dinner party)

• Stage 3: EARLY DEMENTIA

o Needs assistance for survival
o Reminders to bath and other daily function

• Stage 4: SEVERE DEMENTIA

o Forgets spouse and family
o Unaware of surroundings
o Disruption of 3 spheres
o Paranoia, delusions, agitations

• Stage 5: VERY SEVERE DEMENTIA

o Limited to 5 words or less
o Person may scream or make other sounds
o Unable to hold head erect

COLLABORATIVE MANAGEMENT:
• Close supervision
• Close and secure doors
• Use of ID bracelet
• Remove toxic substances
• Orient client
• Walk with escort
• Allow client to wander in a safe place
• Prevent shadows in the room
• Avoid agitation and violence (scolding, arguing, reasoning)
• Avoid stressful environment
• Call the client by name
• One question at a time
• Place a calendar and clock in a visible place
• Provide structured activities, simple environment and allow the client to reminisce
• Prevent SUNDOWN SYNDROME
• AVOID: Change of routine and excessive demands

MEDICATIONS:
• C - Cognex
• A - Aricept
• R - Reminyl
• E – Exelon

Trigeminal Neuralgia

• Neurologic disorder affecting the 5th cranial nerve.

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• Possible fifth cranial nerve root compression

• Manifested by excruciating, recurrent paroxysms of sharp, stabbing facial pain
MANAGEMENT:
• Narcotic analgesics; anticonvulsants
• Tegretol
• Dilantin
• Chew food on the unaffected side
• Alcohol injection of the nerve
• Avoid extremes of heat and cold

Surgical Management
• Surgical division of the trigeminal nerve (neurectomy)

Bell’s Palsy
• Disease of the cranial nerve VII
• complete recovery in 18 weeks
• If recovery is partial, contractures may develop on the paralyzed side of the face.

Management:
• Unilateral facial weakness
• Drooping mouth & drooling saliva
• Loss of taste
• Smooth forehead appearance
• Impaired ability to close the eye on the weak side
• Bell’s phenomenon-Upward rolling of the eyes when attempting to close them
• Excessive tearing
• Ringing in the ear
• Protect eyes from dryness
• Frequent oral care
• Analgesics- to relieve pain
• Steroids- to reduce facial nerve edema & improve edema & improve nerve conduction & blood
flow
• Possible electrotherapy
• Surgery for persistent paralysis

Stroke/ Cerebrovascular Accident (CVA)

Disruption of the Blood

o sudden loss of neurologic function

Note:
o Middle Cerebral Artery is commonly affected

Classification:
o ischemic (a thrombus or embolus blocks circulation

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o hemorrhagic (a blood vessel ruptures)

Signs and Symptoms

• Hemiplegia – weakness/paralysis of half the body
• Cognitive impairment- BROCA’s or WERNICKE’s or GLOBAL
• Apraxia – can move but cannot do the purpose; inability to perform complex movements
• Visual changes – homonymous hemianopsia
• Dysarthria- difficulty in speech articulation due to lack of muscle control
• Kinesthesia – loss of sensation (of bodily movement)
• Incontinence –inability to control urination or defecation
• Fluid imbalances
• Cerebral edema
• Aspiration
• Altered LOC

Management:
• Approach on the unaffected side
• Place the items on the unaffected side
• Prevent aspiration
• Feed slowly
• Prevent unilateral neglect by letting the patient tap the affected side
• Encourage independence

Autonomic Dysreflexia

• Above T6 damage
• Hyperstimulation of the sympathetic nervous system

PROBLEM:
• BLADDER DISTENTION
• FECAL IMPACTION
• HYPERTENSION

MANAGEMENT:
• Sitting position
• Catheterization
• Manual extraction
• Mannitol

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Coronary Artery Diseases

Angina Pectoris Myocardial Infarction

MAIN PROBLEM O2 demand > O2 supply Occlusion

ABRUPT cessation of blood and O2

PRECIPITATING • EXERTION • embolus and thrombus

FACTORS • EMOTIONS • hemorrhage, shock
• HEAVY MEALS • Hypercholesterolemia
• ENVIRONMENT • Smoking
• Obesity, Sedentary lifestyle
• Stress

PAIN Relieved by REST and NTG Not relieved by REST and NTG

QUALITY Aching, stabbing Excruciating

RADIATION Unilateral (chest, left arm, Bilateral (chest, both arms, both
left shoulders) shoulders, scapula, jaw)

SEVERITY Mild to moderate Severe

TIME Less than 30 mins More than 30 mins

ECG PATTERN Pathologic Q wave

Angina Pectoris Myocardial Infarction

Nursing • Assess pain • Increase fiber, dec Na, fat Cholesterol

Intervention • NTG in the diet
• Give 02 at 3Lpm • NTG
• Fowler’s

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• Instruct to stop activity and • Administer MONA

rest if pain occurs • Record BP after admin of meds
• Notify physician if pain • Cardiac monitoring
persists • Thrombolytic therapy
• Aspirin • I-monitor ECG changes
• O2 at 2-4 Lpm
• Note for signs of bleeding if receiving
thrombolytic therapy

Cardiomyopathies

DILATED HYPERTROPHIC RESTRICTIVE

CHARACTERISTICS Enlarged heart Hypertrophic ventricles Restricted

contraction

CAUSES • Idiopathic • Idiopathic Infections in the lungs

• Alcohol • Hyperparathyroidism
• cocaine • HPN

S/SX • Weakness and • Sudden death - • Weakness

fatigue initial • Exertional
• Activity dyspnea
intolerance
• dysrhythmias

MGT heart transplant • do not give diuretics, • Diuretics

dopamine, digitalis • Vasodilators
• Ethanol injection – • digitalis
DOC

Heart Failure

RSHF (Right Sided Heart Failure) LSHF (Left Sided Heart Failure)

• Peripheral dependent, pitting edema • Dyspnea on exertion

• Weight gain • Orthopnea

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• Distended neck vein • crackles/rales

• hepatomegaly • Cough

• Ascites • Tachycardia

• Body weakness

• Anorexia, nausea

Diagnostics:

• CXR: CARDIOMEGALY
• 2D Echo: HYPOKINETIC HEART
• Pulse Oximetry: DEC O2 SATURATION
• PCWP (Pulmonary Capillary Wedge Pressure): LSHF
• CVP (Central Venous Pressure): RSHF

Management:
• Fowlers
• Administer high O2 (venturi)
• Inotropic drugs (Dopamine)
• Lanoxin/Digoxin
• and intake monitoring
• Record daily weight
• Administer diuretics and digoxin

Cardiac Tamponade

• Cardiac emergency
• Rapid accumulation of fluid in the pericardial sac

Becks Triad

• Jugular vein distention

• Muffled heart sounds
• Hypotension

Management:

• Fowler’s
• Pericardiocentesis

Defibrillation

• Asynchronous delivery of shock

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o First shock -200 J

o Second -300-360 J
o Third -360 J

PADDLE:

• First (“sternum”) paddle

• Second (“apex”) paddle

Management: NO OXYGEN, NO TOUCH

Cardioversion

• Synchronous delivery of shock

• Shock during the QRS complex
• Smaller amount – 50 J

Pre- procedure
• Consent
• Serum K
• Digitalis (therapeutic level)
• Premedicate of antidysrhythmic drugs to ensure maintenance after cardioversion

Post- procedure
• Check for normal sinus rhythm
• Check pulse
• Maintain airway patency

Aneurysm

• Dilation involving an artery formed at a weak point in the vessel wall

TYPES:

a. Saccular – sac formation

b. Fusiform – both sides

c. Dissecting – layer affectation

**Ruptured aneurysm – 50% survival

• If >5cm – with manifestations

• If <5cm – asymptomatic

Manifestations:

• Asymptomatic

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• Pulsatile sensation on the abdomen

• Auscultated bruit
• Palpable thrill

Medical Management:

• Anti-hypertensives

Abdominal Aortic Aneurysm (AAA)

• Administer medications
• Emphasize the need to avoid increased abdominal pressure
• No deep abdominal palpation
• Remind patient the need for serial ultrasound to detect diameter changes

Peripheral Occlusive Diseases

Arterial Venous

PAIN • Intermittent claudication • Homan’s pain

• Aggravated by walking and • Improved by exercise and
elevation of legs elevation

HAIR Thin, shiny skin, Loss of hair Brown pigments around ankles

TOES Thick toe nails Normal toenails

SKIN • Pale skin on elevation • Redness on dependency

• Skin is cool to touch • Warm to touch
(thrombophlebitis)

FEELING • Decreased sensation Itching

• Numbness, Paresthesia, Itching

PULSE Pulse is diminished or absent Pulse is present

EDEMA Edema is absent Edema is present, worst at the end of

the day, improved with elevation

ULCERS Ulcers on toes Ulcers in ankles

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COMPLICATIONS Gangrene may develop Gangrene does no develop

REYNAUD’S BUERGER’S

Another name n/a Thromboangitis obliterans

Mechanism Vasospasm Inflammation leading to clot then

occlusion
Constriction

Gender Females (Reyna) Males

Etiology Unknown Unknown

Cold, stress, caffeine nicotine Smoking!!!

Manifestations • Tingling sensation • Intermittent claudication

• CYANOSIS due to deoxygenated • Paresthesia
blood • Cyanosis of the legs
• RUBOR d/t reflow of blood

Management • Avoid cold temp • Avoid SMOKING

• Avoid nicotine • Amputation
• Avoid sharps • nifedipine
• nifedipine

COPD (Chronic Obstructive Pulmonary Disease)/CAL (Chronic Airflow Limitation)

Etiologies:
• Chronic cigarette smoking
• Aging process
• Male > female
• Chronic respiratory infections
• Environmental pollutants
• EMPHYSEMA
• CHRONIC BRONCHITIS

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CHRONIC BRONCHITIS
CRITERIA:
• Persistent productive cough
• Duration: 3 months in 2 consecutive years

Manifestations:
• “blue bloaters”
• Productive cough
• Wheezing
• SOB
• Prolonged expiration + blowing
• Clubbing
• Cyanosis
• Hypercapnia and hypoxia

EMPHYSEMA
• Loss of elastic recoil > overdistended alveoli
• Air trapping > resp acidosis

Manifestations:
• “pink puffers”
• Pursed lip breathing
• DOB on exertion
• Speaks in short phrases
• Use of accessory muscles for breathing
• Barrel chest – widened AP
• clubbing

Management:
• Orthopneic position
• Increase OFI
• Diet – increase CHON, Vit. C
• O2 inhalation – 1-2 Lpm

COPD/CAL COLLABORATIVE MANAGEMENT:

• Rest
• Increase OFI
• Diet – increase CHON, calorie, decrease CHO
• O2 therapy – 1 -3 Lpm (average 2 Lpm)
• CPT
• Steam inhalation
• Expectorants
• Antitussive – given at night
• Bronchodilators

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• Antimicrobials

Pneumothorax and Pleural Effusion

Pleural Effusion
• Hydrothorax
• Hemothorax
• Pyothorax – empyema

Causes:
• Infection
• CA
• trauma
• Thoracentesis
• Surgery
• Emphysema

Manifestations:
• SOB
• Decreased or absent BS
• Sudden sharp chest pain
• Restlessness
• Tachycardia
• Tachypnea
• Chest asymmetry
• Tracheal deviation
• Pneumothorax – hyperresonance
• Hemothorax - dull

Management:
• Stay calm
• High fowler’s
• O2 – 10-15 Lpm
• CTT
• WOF S/Sx of shock
• Tension pneumothorax – needle thoracentesis
• Open pneumothorax – cover with sterile. Non-porous dressing
• *** how? Tape 3 sides, 1 side left open to vent pressure
• Hemothorax – BT

Acute Respiratory Distress Syndrome (ARDS)

• aka Hyperpermeable pulmonary edema
• alveolar capillary membrane becomes more permeable to fluids
• Hypoxia that exists even when O2 is administered at 100%

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Causes:
• Shock
• Aspiration
• O2 toxicity
• DIC
• Near-drowning
• Trauma
• Infection
• Fat emboli
• Narcotic abuse

Findings
• restlessness, anxiety
• dyspnea
• tachycardia
• Central cyanosis
• Retractions
• Fine crackles
• ABG – decreased pa O2, increased pa CO2

Diagnostics
• hypoxemia on ABG despite increasing inspired oxygen level
• chest radiograph shows diffuse infiltrates

Management:
• Symptomatic and supportive therapy

Pulmonary Embolism
• thrombi – most of which originated in the deep calf, femoral, popliteal or lilac veins
• major operations
• tumors, air, fat, bone marrow, amniotic fluid

MANIFESTATTIONS:
• Cardinal initial sign – RESTLESSNESS
• Stabbing chest pain
• Virchow’s triad
• Pink frothy sputum
• DOB
• Cyanosis
• Apprehension, Tachycardia
• Diaphoresis
• Dysrhythmias
• hypotension

MANAGEMENT:
• O2 stat

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• Do not massage
• Relieve pain
• HOB
• Heparin 2 weeks then coumadin 3-6 mos
• Slow infusion of DOBUTAMINE
• Slow dose of morphine

Pneumonia
• Definition - acute infection of lung parenchyma - specifically in alveolar sacs

Manifestations:
• Rusty sputum
• Fever and chills
• Rales
• Pleuritic chest pain – MGT > splint rib cage
• Dyspnea
• Cough
• Dimished breath sound
• Increased tactile fremitus
• leukocytosis

Management:
• Bed rest
• Increase OFI
• O2 + semi-fowler
• Postural drainage
• Chest splinting
• Antibiotics - ANST

HISTOPLASMOSIS
• Systemic fungal disease
• CA – Histoplasma capsulatum
• Fungus present in
- Chicken dropping
- Pigeon droppings
- Bird droppings
- Soil
- Mushroom cellars
- Bat caves

Manifestations:
• Asymptomatic
• Fever

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• Cough
• Malaise
• Joint pain
• diagnostics:
• CXR
• Histoplasmin skin test – result same as PPD

Management:
• Amphotericin-B and Polymyxin-B
• Wet down manure to prevent airborne spread

Sarcoidosis
• aka Boeck’s disease
• Cause – unknown
• Chronic disease characterized by formation of nodules that resemble like tubercles
• Location – lymph nodes, liver, spleen, CNS, skin, eyes, fingers and parotid glands
Diagnostic – CXR every 6 months
Treatment - corticosteroids

Pneumoconiosis
• aka “miner’s disease” or “dust disease”
• Prolonged inhalation of high concentrations of:
o Asbestos - asbestosis
o Silicon - silicosis
o hay dust – Bagossis
o Coal worker’s pneumoconiosis – Black lung
• Leads to pulmonary fibrosis
• s/sx – cough, dyspnea on exertion, chest pain

Management
• avoidance of exposure

Flail Chest
• d/t rib fracture (2 or more adjacent ribs)
• PARADOXICAL RESPIRATION
o Inhalation – depressed chest
o Exhalation – elevated chest

Management
• Semi-fowler’s
• Support affected side
• O2 therapy
• Splint area to stabilize
• Muscle relaxants, pain relievers

Carbon Monoxide Poisoning

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• Carboxyhemoglobin

Manifestations:
• headache. Faintness, vertigo, cherry pink color, paralysis, loss of consciousness
• CO level > 50% - - - >coma and death

Management:
• Remove patient from the immediate are of poisoning
• Initiate CPR
• O2
• VS
• Mech Vent 100% - until carboxyhemoglobin is dec to 5% + normal RR
Gastroesophageal Reflux Disease and Hiatal Hernia

GERD HIATAL HERNIA

Main problem Incompetent LES Portion of stomach protruded in the

diaphragm

Manifestations • Forceful vomiting • Asymptomatic

• Heartburn • Heartburn
• Bitter taste in mouth • Regurgitation
• Dysphagia • Nocturnal dyspnea
• Odynophagia
• Hoarseness

Diagnostics Barium Swallow Endoscopy

Nursing • Low fat, high fiber • SFF

management • SFF • Avoid increase abdominal pressure
• AVOID: spicy foods, tobacco, • Upright position
caffeine, alcohol • Herniorrhapy
• H2 blockes, antacids, PPI
• HOB 6-8 in during sleeping

Peptic Ulcer Disease

Causes:
• Bacteria
• excessive HCl secretion
• decreased mucosal barrier
• Curling’s ulcer

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GASTRIC DUODENAL

Main problem Weak gastric mucosa Increased HCl

Aka “poor man’s” or “laborer’s “executive ulcer”

ulcer”

Incidence 20% 80%

Malnutrition Well-nourished

Age 50 y/o and above 25 – 50 y/o

Precipitating Food Gastric emptying

factor

Relieving factor Vomiting Food

Quality Dull, aching, gnawing Dull, aching, gnawing

Region/Radiation Radiates to L Radiates to R

Time Pain 30 min to 2 hrs 3 to 4 hours

Complications Hematemesis Melena

Perforation Perforation

Nursing High CHO diet High fat diet

management Avoid stimulants Avoid stimulants
Antacids Stress reduction
Bland diet – attacks Bland diet - attacks
Surgical Pyloroplasty
management Antrectomies
- Billroth I
- Billroth II

Dumping Syndrome

• s/sx: (5-30 min after eating)

Nursing managements:

• Diet – SFF high protein, high fat, low CHO

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• Dry food is a must

• Direct to a lying down after meals > left side lying
• Don’t take large fluids with meals

Appendicitis

Considerations

• P – soas’s sign
• R – ovsing’s sign
• O– bturator sign
• B – lumberg’s sign
• L – axative, heat, enema
• E – pigastric pain
• M – cBurney’s point
• S – ide lying position > fetal

Nursing Management:

• NPO
• AVOID: HELP (Heat, Enema, Laxative, Palpations)

Peritonitis

Manifestations:

• Fluid shifting – 300 – 500 ml/hr

• Rigid board-like abdomen
• Abdominal pain, guarding
• Distention
• Hypoactive bowel sound
• Shallow breathing
• Fever
• WBC 20,000
• Paralytic ileus
• Signs of shock

Nursing management:

• Fluid balance monitoring

• NGT insertion
• Semi-Fowlers
• DBE
• Drainage tubes – Penrose drain
• Colloid replacement

Inflammatory Bowel Diseases

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CROHN’S DISEASE ULCERATIVE COLITIS

aka Regional enteritis Rectum and descending colon

Ileum and ascending

Level of involvement transmural Mucosa to submucosa

Characteristics • Cobblestone • Continuous

• Segmental • “crypt abscess”
• “skip lesions” • Exudative

Incidence 20-40, both gender 15-40, female

Diarrhea 5-6 soft stools (pus and mucus) 20-30 bloody stools (pus, mucus,
blood)

Complications Fistula, abscess, growth retard, Colon CA

peritonitis, PERFORATION
Peritonitis

Diagnostic Barium swallow – “string sign” Barium enema – “lesions”

NI • Low fiber • Low fiber

• TPN • TPN
• Steroids • Steroids
• Ileostomy • Ileostomy
• Colectomy • Proctocolectomy

Ostomy

Types Color Consistency Bag Nursing Dx Nursing Intervention

Ileostomy Transparent Liquid Y Impaired Spinach

skin integrity
Parsley

Yogurt

Broccoli

Ascending Transparent Semi liquid Y

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Transverse Light yellow Mushy Y

Descending Golden Formed N Disturbed

brown body image

Sigmoidostomy Golden formed N

brown

Liver Cirrhosis

Manifestations:

• Anorexia – initial
• Fever
• Skin:
• Urine:
• Pruritus
• Dec Vit. ADEK
• Infection
• Portal Hypertension

End Stage Hepatic Encephalopathy

Manifestations:

• Asterixis
• confusion/disorientation
• delirium/hallucination
• fetor hepaticus
• hepatic coma

Management:

LIVER CIRRHOSIS HEPATIC ENCEPHALOPATHY

DIET High calorie Low protein

Moderate protein

WOF bleeding Changes in LOC

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Nursing Daily weight Prepare for Sengstaken- Blakemore tube insertion

responsibilities
Prepare for paracentesis

Pruritus – warm bath

Medications Vit K as ordered Neomycin

Lactulose

Outcome Dec manifestations of Vit. Improvement in handwriting

ADEK deficiency

Pancreatitis

• Autodigestion of the pancreas

• Cause: alcohol, biliary obstruction
• Acute and Chronic
• Amylase, lipase, trypsin (most damaging)

Manifestations:

• Pain
• Nausea and vomiting
• Anorexia
• Abdominal tenderness
• Steatorrhea
• Hyperglycemia
• Increased serum amylase
• Hemorrhage
o Grey-Turner’s sign- discoloration in the flank area
o Cullen’s sign- discoloration in the periumbilical area

Management:
• DOC: Meperidine
• NPO
• NGT – remove gastrin and secretin
• Pancreatic enzymes – given with meals
• ADEK
• H2 blockers, antacids, anticholinergics
• Avoid alcohol

Anti- Diuretic Hormone Disorders

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SIADH (Syndrome of Inappropriate D.I. (Diabetes Insipidus)

Anti-Diuretic Hormone)

Main problem Excessive ADH Deficiency in ADH

Manifestation • Confusion (cerebral • Polyuria

edema) • Polydipsia
• Lethargy • Dehydration
• Irritability

Diagnostics • D.Hyponatremia • Decreased urine specific gravity

• Increased urine specific gravity after fluid deprivation test (4-18hrs)
• Diluted blood • Increased serum sodium
• HPN • Concentrated blood

WOF Fluid overload Fluid volume deficit

Management • Fluid restriction (<500ml/day) • Inc OFI

• Diuretics/(Demeclocycline) • I and O monitoring
• Desmopressin acetate (intranasal)

Thyroid Gland Disorders

HYPERTHYROIDISM HYPOTHYRODISM

Main problem Increase T3 and T4 Decrease T3 and T4

AKA Thyrotoxicosis/Grave’s disease

Manifestation • Heat intolerance Cold intolerance

• Diaphoresis
Dry skin
• Amenorrhea
• Tachycardia Menorrhagia/Amenorrhea
• Hypertension
• Diarrhea Bradycardia
• Body wasting Hypotension
• Fine hand tremors
• Goiter Constipation

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• HYPERCALCEMIA Obesity

Diagnostics Inc T3 and T4 Dec T3 and T4

Management Cool environment Warm environment

High calorie diet Low calorie diet

Calm, dec stimuli

Medications PTU (Prophylthiouracil) (AVOID DOC – Levothyroxine Na (effect after 2-3

ASA) and Lugol’s solution (STRAW wks)
and JUICE)

• S/E – agranulocytosis,
thrombocytopenia

Complications Exopthalmos Cretinism – at birth

Thyroid storm Myxedema coma – severe

• Emergency • With hypoventilation

• Hypertension • Hypothermia
• Hyperthermia • Hypercalcemia
• Bradycardia
• hypotension

Surgery Thyroidectomy

Cushing’s Disease and Addison’s Disease

Cushing’s Disease Addison’s Disease

Main problem Hypersecretion of SSS Adrenal hyposecretion of SSS

Manifestation Due to SUGAR: Bronze skin

• Trunkal obesity Aldosterone: hyponatremia, hyperkalemia,

• Buffalo hump dehydration, Hypotension
• Poor wound healing

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• Due to SALT:
• Moon face
• Due to Sex:
• Hirsutism

Diagnostics • Inc cortisol level • Dec cortisol level

• hyperNa • hypoNa
• hypoK • hyperK
• hypertension • hypotension
• Hyperglycemia • Hypoglycemia

WOF Fluid overload Fluid deficit

CONN’s SYNDROME ADDISONIAN CRISIS (Admin Glucocorticoid)

(Hyperaldosteronism)

• HPN
• Hypokalemia

Management • Low Na, High K diet • High Na, low K diet

• Glucocorticoid • Glucocorticoid lifetime admin
antagonist (Mitotane)
lifetime admin
• Adrenalectomy (WOF)

Diabetes Mellitus

TYPE 1 TYPE 2

AKA IDDM NIDDM

Main problem - destruction of beta cells of the - disturbance in insulin reception in the cells
pancreas  little or no insulin
-  number of insulin receptors
production

Age Less than 20 Over 40

Manifestations • Polyuria, Polydipsia, Polyphagia

 blood sugar / glucose level
• weight loss
• Weakness

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• glycosuria
• nausea /vomiting
• changes in LOC (severe hyperglycemia), (sleepiness,
drowsiness → coma)
• prolonged wound healing
• genital pruritus

Insulin Therapy

• REFRIGERATE
• GIVEN at ROOM TEMP
• GENTLY ROTATED, NOT SHAKEN
• ROUTE: SQ
• SITE OF INJECTION: ½ inch apart
o ABDOMEN
o ANTERIOR THIGH
o ARM
o UPPER BACK
o BUTTOCKS
• SYRINGE: 1/2 INCH; Gauge 27-29

Renal Failure

• A metabolic and elimination derangement in which the kidneys fail to remove and regulate
fluids, electrolytes, and pH balance.

Acute Renal Failure

• Ischemic changes in nephrons

• Renal changes as a result of toxic substances or mechanical trauma

• PRERENAL CAUSES

o “no necrosis”

o Hemorrhage, shock, dehydration, hypovolemia, hypotension

• INTRARENAL/INTRINSIC

o Parenchymal damage to the glomeruli and tubules

• POST RENAL CAUSES

o 10% of cases

o Obstruction into normal urine flow

Courses/Phases of ARF

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1. Initiation
2. Oliguric/non-oliguric (1-3 weeks)
3. Diuretic (1week)
4. Recovery phases (1 year)- AVOID NEPHROTOXIC DRUGS

Clinical Manifestations:

• Oliguria or diuresis
• Fluid overload/deficit
• Edema
• Hypertension
• Metabolic acidosis
• s/sx or uremia
• Uremic encephalophathy
• Electrolyte imbalances
• GI distress
• Anemia
• Platelet dysfunction

MEDICAL MANAGEMENT:

RESTORATION AND MAINTAINANCE OF F & E

I. Careful fluid replacement

• Total output of previous day + 400 ml

• Daily weight loss of 0.2 – 0.5 kg

II. Diuretic therapy

• Furosemide and mannitol

• Fluid restriction
• Low dose dopamine

III. Correction of electrolyte imbalance and acidosis

• Sodium polystyrene sulfonate (Kayexalate) with sorbitol

• Insulin and glucose
• Sodium bicarbonate
• Aluminum hydroxide
• Calcium carbonate
• dialysis

Chronic Renal Failure

STAGES:

1. Stage of diminished renal reserve (40- 50 remaining function)

2. Renal insufficiency (20- 40 remaining function)
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3. Renal failure (10-20 remaining function)

4. End Stage Renal Disease (UREMIA)

OTHER S/SX

A. Fluid retention

• Cardiovascular symptoms: edema, hyperlipidemia, hypertension

• Respiratory complications

B. Electrolyte imbalance

- ↑ Na, K, PO4

C. Retention of metabolic wastes

• Changes in micturition
• Acidosis
• Uremia, azotemia
• Dermatologic symptoms
• Neurologic changes

D. Loss of non-excretory renal function

• reproductive
• Hematologic
• Immunologic

MEDICAL MANAGEMENT:

A. Preservation of renal function and delay of dialysis

B. Alleviate extrarenal manifestations

• Control of pruritus
• Neurologic changes
• Cardiovascular changes

C. Absence of toxicity of medications that are inadequately excrete

D. Restoration of homeostasis > delay of death

Hemodialysis

NURSING REPONSIBILITIES

• Proper client education

• Continuous monitoring during procedure – LOC, VS
• Weight client before and after procedure
• Assessment and care of access sites to prevent clotting and infection
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• Assess bruit and thrill

• Withhold antihypertensives and sedatives
• Provide adequate nutrition
• Observe for psychologic problems: depression, changes in body image, anxiety, suicidal
behaviors, denial

Dialysis can improve the following:

• Edema
• Elevated BUN and creatinine
• Elevated electrolytes
• Elevated blood pressure

Peritoneal Dialysis

Nursing Interventions

1. Have client void before the procedure

2. Weight client
3. VS and acquire baseline electrolytes
4. Maintain asepsis
5. Keep accurate record of fluid balance
6. Procedure:
7. Warm dialysate 1-2 L of 1.5%, 2.5%, or 4.25% glucose solution
8. Allow to flow in by gravity
• 10 mins inflow time
• 20 mins of equilibration (dwell time)
• 30 mins of drainage (clear yellow)

9. Continued to 24-48 exchanges

10. Monitor for complications:
• peritonitis, bleeding, respiratory difficulty, abdominal pain, bladder perforation

Glomerulonephritis

Clinical manifestations:

• Gross hematuria
• Urine is “smokey cola-colored”
• Azotemia
• Proteinuria
• Generalized edema
• Diminished visual acuity
• Hypertension
• Flank pain

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• ELDERLY: circulatory overload, DOB, distended neck veins, pulmonary edema,

cardiomegaly
• COMPLICATIONS: Hypertensive encephalopathy, optic neuropathy, ESRD

Management:

• Angiotensin converting enzyme inhibitors

• Penicillin

Nephrotic Syndrome

Clinical manifestations:

• Proteinuria - > 3.5g/day

• Hypoalbuminemia and edema
• Anemia

Management:

• Intravenous cyclophosphamide

Nephritic Syndrome

• “hematuria” + 1 (oliguria, HPN, ↑BUN, ↓GFR)

Medical Management:

• Maintain F & E balance

• Reduce inflammation
• Prevent thrombosis
• Dialysis – in uremia
• Residual strep infection – penicillin
• Plasma volume expanders – albumin, dextran, plasma
• Administer glucose as ordered

Arthritis

Criteria Rheumatoid Arthritis Osteoarthritis Gouty Arthritis

Pain Morning stiffness At the end of the day During movement

Manifestations CRITERIA: • Heberden’s • Extreme

(Distal) sensitivity
• Morning stiffness
• Bouchard’s • Big toe
• Polyarthritis
(Proximal) • Swelling and
• symmetrical
• Crepitus warmth
• Fever

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• Rheumatoid • Enlarged • Tophi

nodules joints • Renal – HPN,
• (+) RF • spasms calculi, oliguria
• Radiographic
changes - Hand
deformities

Ulnar drift

Boutonnière

Swan neck

Diagnostics • ESR X-ray studies • ESR

• C-reactive protein • Uric acid
• Rheumatoid Factor (RF) • Synovial fluid
+ Antinuclear antibodies sample -
(ANA) confirmatory
• Synovial fluid sample

Nursing Increase iron • Alternate heat • Inc. OFI – 2-3 L

and cold • Purine
Management • Daily ROM
• Low impact restriction
• Warm bath before aerobics
activity
• 1-2 scheduled rest per
day

Medications • NSAIDs • NSAID • Allopurinol – 1

• Corticosteroids • Glucosamine week
• Aspirin • Colchicine
• DMARD’s (Disease- • Probenicid
Modifying Anti
OTHERS:
Rheumatic Drugs)
• -Methotrexate Indomethacin –
• Gold compounds alternative for
(Chrysotherapy) Colchicine

• NaHCO3

Traction

• T – trapeze – used during exercise

• R – requires FREE hanging weights
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• A - analgesics
• C – circulation check
• T – temp monitoring
• I – immobility prevention
• O & I monitoring
• N - utrition
• S – skin inspection

Visual Disorders

GLAUCOMA RETINAL CATARACT

DETACHMENT

MAIN PROBLEM Increase IOP 2 layers of the retina Clouding of the lens
detached

RISK FACTORS • Injury • Myopic • Senile

• Infection degeneration • Traumatic
• genetics • Trauma • Congenital
• Secondary

MANIFESTATIONS Vision loss - irreversible V – isual curtains Blurring or opacity of

vision
V – isual floaters

V – isual flashes

Diagnostics Tonometry Ophthalmoscopy Snellen’s Test

NURSING - HOB 30 degrees mydriatics • AVOID: bending

MANAGEMENT and lifting
• DIET: high fiber
• DRESSING
REMOVAL: 7-10
days

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MEDICATIONS/ • Miotics Scleral Buckling • Cryoextraction

• Azetazolamide • Phacoemulsification
SURGERY • Pre-op – supine
(Diamox)
• Post-op – prone ***sudden eye pain
• Glycerol
• Patch means - hemorrhage
• Sedentary
activities – resume
after 3 wks
• Occupational
activities – resume
after 6 wks

Auditory Disorders

MENIERE’S DSE OTOSCLEROSIS CHOLESTEATOMA

PROBLEM Increase endolymph Bony overgrowth in the Cyst/tumor lined with

stapes epithelial cells

LOCATION Inner ear Middle ear Middle ear

MANIFESTATIONS “I feel like the room is Tinnitus Conductive hearing loss

revolving”
Conductive hearing loss Scanty discharge
TRIAD

Vertigo, tinnitus,
hearing loss

Nursing safety Stapedectomy Radical mastoidectomy

Interventions
Low Na Post-op- DO NOT: NO shower, driving for 1
weeks
Dark room Blow nose, diving,
smoking, flying

Stages of Anesthesia

Stage 1 (Induction/ Stage of Analgesia)

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o Starts from induction period until patient loses consciousness

o Patient may appear drowsy or dizzy

o Safety – bed rails and body straps

o Keep the room quiet

Stage 2 (Excitement/ Delirium)

o Lasts from the time the patient loses consciousness until he loses certain reflexes such as
swallowing, gag and eyelid

o May appear excited, may breathe irregularly

o Sensitive to external stimuli

o Maintain silence

Stage 3 (Surgical Anesthesia)

o from the period the patient lost certain reflexes and respiratory paralysis occurs

o Patient with regular respiration, constricted pupils, jaws relax and auditory sensation is lost

o Assist the team!

Stage 4 (Stage of Danger)

o Reached when too much anesthesia has been given and the patient has not been

observed carefully

o Death may result from respiratory and or cardiac arrest unless resuscitated properly

o Patient is not breathing with little to no heart beat

o Medullary paralysis – cardiopulmonary arrest

o Too much anesthesia

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