36190527-Gapuz-Notes-Day-1-7

NCLEX REVIEW – GAPUZ REVIEW CENTER

NCLEX REVIEW – GAPUZ REVIEW CENTER

(31 JANUARY – 17 FEBRUARY 2005, PICC, City of Manila)

DAY 1 (31 JANUARY 05)

STEPS IN PASSING

 Have a Right Attitude

 THINK POSITIVELY … have a Fresh Start  KNOW what YOU WANT and HOW TO GET IT  OVERVIEW OF ESSENTIAL CONCEPT

 TRY OUT

 Focus assessment

 7 habits of SUCCESSFUL EXAMINEE

MOSBY – growth and development

LIPPINCOTT – care of the Elderly and Communicable Disease

DIGOXIN – monitor the creatinine… “ the TV DOESN’T look good to me” (DIGOXIN TOXICITY – nausea/vomiting, abdl cramps)

Olive = butter

CK – normalize 1 – 3 days after MI LDH - 10 – 14 days

ATRIAL FLUTTER – SAW TOOTH

PROCESS OF ELIMINATION

 consider MASLOW’s H of NEEDS

 consider the COMPLICATION whether ACUTE – ALWAYS prioritize CHRONIC

 ABCs

 SAFETY FIRST  NSG PROCESS

MMR VACCINE – only vaccine for HIV pt.

Pt on HEPARIN – APTT (N 30-40sec), therefore if INCREASE – bleeding POISON - nursing action in order :

#1 CALL poison control center

# 2 MINIMIZE EXPOSURE of pt to poison – pull him/her away from the poison

# 3 IDENTIFY the poison

GENTAMYCIN – s/e tinnitus, vertigo, ototoxicity, oliguria

LITHIUM CARBONATE – for ELDERLY : N level NOT more than 1.0meq/L

ADULT : N .5 – 1.2 meq/L

DOWN SYNDROME – large tongue – feeding problem – poor sucking (infants) SAFETY PRINCIPLE

1. when can a child USE ADULT SEAT BELT?

- if the infant is 40 lbs and 40 inches in height

seat belt location in car: BACK CENTER SEAT

2. TODDLER – falls

3. SUPRATENTORIAL craniotomy – semi fowler’s position

INFRATENTORIAL – flat in bed 4. SCATTER RUGS – osteoporosis pts. 5. TRIAGE ; burns, open fx – “SHOCK”

Things NOT TO BE DELEGATED by RN:

Assessment, Teachings, Evaluation

Pt 50y/o and - mammogram – once a year.

Pt with PKU – LOW PHENYLALAMINE DIET (NOT phenyl FREE). – therefore LOW CHON

Pt with Rocky Mountain Fever – exposure to dog ticks Lyme’s Dses – deer ticks

PSYCHE PATIENTS

1. remember to stick to unit rules/policy – be consistent to pt. 2. encourage verbalization – “tel me how…..”

3. sound knowledge of cultural diversity - seek help of interpreter

4. acknowledge pt feelings – “it seems….”

“this must be difficult…..” 5. emphatize with your patients’s feelings

“ I understand how you feel…..”

CATARACT – CAUSES – aging and trauma

MRSA (methicillin resistant staphyliccocus aureus) - USE GLOVES AND GOWN WHEN W/ PT

T U B E S

1. GROSHONG CATHETER - 2 lumen

HICKMAN - 3 lumen

BROVIAC - 1 lumen

ALL requires Central Venous Access

- sites: cephalic, brachial, basilica and superior vena cava

PURPOSE: For TPN

Administration of Chemo Agents, Blood Products, Antibiotics

COMPLICATION:Thrombosis and Bleeding 2. CHEST TUBES – Water Sealed Drainage

Types: Anterior – w/c drains AIR Posterior - w/c drains FLUIDS

Water Sealed Drainage : 1 bottle, 2 bottle and Three bottle system

1 BOTTLE : 3 – 5cm of only (length of tube to be emerge)

2 BOTTLE : First bottle – drainage bottle (no tube emerge), 2nd _{bottle - long rod 3-5cm}

3 bottle : FREQUENTLY USED

1st _{bottle – drainage} 2nd _{bottle – water sealed}

3rd _{bottle – suction bottle control}

COMPLICATIONS: bubbling, breakage, blockage

Nsg ALERT:

 NORMAL : BUBBLING is N in the 3rd bottle – it indicates that suction is ADEQUATE

(if no bubbling STOPS in the 3rd _{bottle, meaning – inadequate suction)}

 ABNORMAL : if bubbling occurs at the 2nd bottle – indicates LEAKAGE – action, check sealed at air tight container and the pt and bottle connection. In case there BREAKAGE, have extra bottle and emerge tube ASAP to prevent entry of air and or may use forcep to clamp tube temporarily.

If pt. ambulates, keep bottle LOWER than the patient.

ABSENCE of OSCILLATION at the 2nd _{Bottle – indicates blockage}

TOWARDS THE BOTTLE - When MILKING the tubings.

EMERGENCY EQUIPMETS AT BEDSIDE: xtra bottle,clamp, gauze

3. TRACHEOSTOMY TUBE

- to maintain patent airway for pt w/ neurological problems and musculoskeletal disorders.

nursing care:

1. Suctioning – 10-15seconds

- if (+) bradycardia, STOP

- if accidentally dislodge, insert obturator to keep it open 2. AVOID: water sports – swimming

3. In changing ties – insert new one first BEFORE REMOVING old tie.

4. Ribbon or ties @ side of the neck only to avoid pressure.

5. Before and After suctioning – hyperoxygenate the patient.

4. PTCA – enlarge the passageway for bloodflow. problem: spasms that lead to arrhythmia

C-STENT (cardiac-stent) – alternative to PTCA

Maintains patency of bld vessels Problem: dislodge

IABP (Intra Aortic Balloon Pump) - for Cardiogenic Shock

problem: thrombus formation, infection and arrhythmia

5. PENROSE DRAIN

- wound drainage system

- doctors the one who removes this. - remove gradually

6. NASO GASTRIC TUBE – stomach and intestine (duodenum)

Types:

 Levine Tube – for stomach

- 1 lumen, for lavage (cleaning) and gavage (feeding)

 Salem Sump – for stomach

- 2 lumen (I for suctioning, I for lavage/gavage)

- if pt (infant) is having enteric coated meds, request for

change in form of meds

 Miller Abbot – for intestinal (w/ mercury b4 injection) - 2 lumen (insert then inject the mercury)

 Cantor – for intestinal - 1 lumen

Nursing Care for NGT:

1. tip of nose to earlobe to xyphoid process (for stomach)

2. tip of nose to earlobe to XP + 7-10 inches for intestinal NGT

3. accurate means to verify correct placement: ALWAYS consider Two checking criteria: ASPIRATION and Gurgling Sounds

Report the following:

If (-) or decrease drainage, (+) nausea and vomiting (+) abdml rigidity

Characteristic of Gastric Residual: more than 50 mo and coffee ground. Before feeding check for placement.

7. GASTROSTOMY TUBE (GT) PEG

• both for NUTRITIONAL PURPOSES GT – incision (abdomen to stomach)

- for pt (+) lesion at esophagus

- nsg care : report s/s of infection, abdl cramps, n/v - provide adequate skin care

PEG – incision at skin - long term therapy

8. T TUBE

- to drain excess bile until hearing occurs - place drainage bag at the level of t-tube

(obstruction of t-tube – there will be excess drainage) 500 ml – N drainage in 24hrs, if report ASAP.

9. HEMOVAC

JACKSON-PRATTS (JP)

 BOTH used as close wound drainage suction system  BOTH system function on the system of (-) pressure. JP – compress the container before attaching to the drainage.

WHEN TO EMPTY: when its usually 1/3 to ½ full then RECORD the amount.

10. THREE-WAY FOLEY

absence of clot – effective

Characteristic of drainage – 2-3 days after surgery (bloody to pinkish) – NO NEED TO REPORT THIS

11. SUPRAPUBIC CATHETER – for genito urinary problem

- inserted directly at the bladder wall - check if properly anchored

12. URETHRAL CATHETER

– to drain urine.

- never clamp because it can only hold 4-8 ml of urine. - keep open to drain urine from kidney pelvis.

SENGSTAKEN BLAKEMORE TUBE

- 3 lumen ( for esophageal balloon, gastric balloon, for meds) - for pt w/ esophageal varices

- balloon tamponade

- 48 hrs – keep balloon inflated for 10 minutes to decrease bleeding

LINTON TUBE – 3 lumen MINESOTTA TUBE – 4 lumen

 SCISSORS – important EQUIPMENT AT BEDSIDE FOR ALL TUBES.

 HEMOSTAT – important instrument that shld be @ bedside for water sealed drainage.

 Persistent bubbling at water drainage bottle – for bottle #2 – check if tubing is properly sealed.

 NGT IS REMOVED – if patient exhibits return of bowel sounds.  BULB SYRINGE – use to clean the nares of pt with NGT (child)

 To facilitate removal of air at lungs – purpose of water sealed chamber in 3 way bottle system.

THERAPEUTIC DIET

GENERAL CONSIDERATION

 Know the DIAGNOSIS of the patient

 Identify & incorporate the pt. dietary preferences  Instruct pt on what to avoid

 For pregnant pt, note dietary changes:

a. addtl calories (300 cal/day) average of 2400 - 2700 b. addtl of 10gms/day for CHON

c. IRON : 15-30mg/day

d. CALCIUM : RDA is 1000 then +200mg/day (broccoli,tuna,cheese) e. Galactogogues – increase production of milk

 PEDIATRIC pt

– by 4-6 mos – START iron supplement due to iron depletion and (-) extrusion reflex.

- cereals, fruits, vegetables,meat and table foods - egg yolk (6mos), egg white (1yr)

TRANSCULTURAL CONSIDERATION

 CHINESE – like cold desserts after surgery for optimum health

 JEWS – “kosher diet” (no meat and diary products at the same time)  EUROPEANS – main meal is served at mid day followed by espresso  MUSLIM – “halal diet” – no pork

 SDA – strictly vegs diet (vit B6 and B12 deficiency)

 MORMONS

– words of wisdom (no caffeine, alcohol and once a month fasting) – the amount due for food is donated to the church

KEY POINTS FOR NURSES

Sodium (Na) – source down the soil

Potassium (K) - source up the tree

Low Na Diet : AVOID processed foods, milk products and salty foods KNOW the serving: CHO - 6-11 servings

CHON - 2-3 FRUITS & Vegs - 3-4 FATS - sparingly

MOST COMMON DIET

 CLEAR LIQUID DIET (light can pass thru it, meaning TRANSPARENT)

- given to pt to relieve thirst, correct fld & electrolyte imbalance - given also to pt post-op

ex: apple juice, gelatin (strawberry), popsicle, candy

 RENAL DIET

- for kidney disorder (renal failure, AGN, Nephrotic syndrome) - to maintain fld & e imbalance

LOW CHON – avoid poultry products

LOW Na - avoid processed foods, milk products, & salty foods Low K - avoid fruits (anything you see in a tree)

- for liver disorder, cardiovascular and renal dses ALLOWED: lean meat, fruits, vegs and fish

AVOID : Sea foods, fried foods, preserved foods (cheese cake andcustard)

 HIGH FIBER DIET

- to prevent constipation, hemorrhoids & diverticulitis - vegs, fruits and grain products

 SOFT DIET

- for inflammatory conditions: esophagitis, peptic ulcer gastritis - pureed foods/ blenderized foods

- soup

 PURINE RESTRICTED DIET

- for gouty arthritis - increase fluid intake

- AVOID: preserved foods, sea foods, alcohol, organ meat (liver, gizzard)

 NA RESTRICTED DIET

- for cardiovascular dses, renal, fld & e imbalance - ALLOWED: fresh vegs

- AVOID : processed foods, milk products and salty foods

 BLAND DIET

- for peptic ulcer, inflammatory GI conditions

- AVOID: chemically and mechanically irritating foods such as fried foods, fresh and raw fruits & vegs (EXCEPT: avocado, banana & pinya) and spicy foods with preservatives

 HIGH PROTEIN, HIGH CARBO DIET - for burns (about 5000 cal/day)

- grain products and poultry – to aid the healing tissues

 ACID ASH DIET

- to decrease the ph of the urine

- indicated for pt w/ alkaline stone ex struvite - ex. 3 C’S – cranberry, cheese, & corn

 ALKALINE ASH DIET

- to increase ph of the urine

- indicated for acid stone ( uric acid stone, cystine stone) - ex. Milk

 GLUTEN-FREE DIET - for celiac dses

- ALLOWED : rice, corn, cereals, soy beans - AVOID (LIFETIME): barley, rye, oats, wheat

 PHENYLALANINE DIET

- for PKU, until age 10 and adolescence only

- AVOID : CHON rich foods (meat products – luncheon meat)

 FULL LIQUID DIET

- opaque

- transitional diet from liquid

- ex : cream soup, ice cream, milk, leche flan, pumpkin cake

“ABGs”

ATERIAL BLOOD GASES

Ph – 7.35 – 7.45 PCO2 - 35 – 35

HCO3 - 22 – 26 meq/L

Ph Compensatory Mechanism

Uncompensated abnormal no change

Partially compensated abnormal increase or decrease Fully Compensated normal increase or decrease

Diarrhea – metabolic acidosis Vomiting – metabolic alkalosis

PRIORITIZING of case: Med.-Surg – “abc” Psyche - safety first Fire - race

Triage - pt evaluation system (prioritizing)

0 1 2

Appearance pallor acrocyanosis all pink

Pulse (-) <100 >100

Grimace (-) grimace vigorous

Activity flaccid some flexion flexion & extension

Respiratory (-) irregular lusty cry

T.R.I.A.G.E -prioritizing LEVEL 1 “emergency”

 severe shock, cardiac arrest, cervical spine injury, airway compromise, altered level of consciousness, multiple system trauma, eclampsia

LEVEL 2 “urgent (stable)”

 can be delegated (fever, minor burns, lacerations, dizziness) LEVEL 3

 chronic/ minor illness (can be delegated) – dental problems, routine medications and chronic low back pain

TIPS ON PRIORITIZING

1. PT @ ER – sleeping pills overdose; 2. pt bp 80/30 & mother died of CVA

1st _{priority : assess pt for addtl risk factor;}

3. pt ask what procedure: Rn Action : notify the doctor

4. MI attack – 1st _{action : report ASAP (esp. presence of vent. Fibrillation)}

5. pt on NGT – check patency of tube

DELEGATION

- do not delegate Assessment, Teaching and Evaluation

- do not delegate meds preparation, administration, documentation

CONCEPT OF DELEGATION

 5 R’s in delegating (RIGHT task, person, circumstances, direction/communication supervision)  RN may delegate – feeding client, routine vital sign (pt w/ no complications)

MI ATTACK – enzymes to increase IN ORDER - #1 myoglobin #2 troponin #3 CK #4 LDH

RISK FOR INJURY – meniere’s dses

INEFFECTIVE BREATHING PATTERN – myasthenia gravis ALTERED TISSUE PERFUSION – pt w/ complete heart block

INEFFECTIVE AIRWAY CLEARANCE – pt w/ kussmaul’s breathing

D

DAY 3 ( 02 February 05)

POSITIONING FOR SPECIFIC SURGICAL CONDITION

- know the purpose of the position a. to prevent or promote soothing; b. what to prevent or promote; c. know your anatomy & physiology

(during the procedure – L side lying).

Hiatal Hernia – upright to prevent reflux.

 AMPUTATION

complication: hemorrhage (keep tourniquet @ bedside)

1st _{24hr – goal: to decrease edema – elevate the stump at foot part w/}

the use of pillow

AFTER 24hr – goal : to prevent contracture deformity (keep leg extended)

 APPENDICITIS

Unruptured : any position of comfort

Ruptured : semi to high fowler’s position to prevent the upward spread of infection

complication: peritonitis

Ruptured appendicitis indication: pain decreases or go away. (pt say, “I want to go home pain is gone”)

 BURNS

Position is FLAT or Modified Trendelenburg – to prevent shock. SHOCK occurs w/in 24-48hrs (immediate post burn phase).

Complication: infection

 CAST, EXTREMITY

Elevate the Extremity – to prevent edema (use rubber pillow) Nsg care:

a. capillary refill – N 1-3 seconds only (complication: altered circulation) b. note for s/s of infection (when there is musty odor inside the cast) c. pruritus (inject air using bulb syringe)

d. blood stained – mark and note (if increasing in diameter - report ASAP) e. tingling sensation – indicate nerve damage

 CRANIOTOMY

Types:

a. Supratentorial C – semi fowler’s orlow fowler’s position – to prevent accumulation of fluid at surgical site;

b. Infratentorial C - flat or supine. Purpose: same

 FLAIL CHEST

(+) Traumatic Injury – paradoxical chest movement – areas of chest GOES IN inspiration and OUT on Expiration

position: towards the affected side to stabilize the chest.

 GASTRIC RESECTION

- to prevent dumping syndrome – usually for 10 mos only NOT LIFETIME disorder (post gastrectomy)

- position : LIE FLAT for 1-2hrs post meal

 HIATAL HERNIA

- there is damage to esophageal mucosa

- what to prevent: gastric reflux therefore FEEP PT IN UPRIGHT POSITION.

 HIP PROSTHESIS

Position: to prevent subloxation (KEEP LEG ABDUCTED) with the use of wedge pillow or triangular pillow from perinium to the knees.

dumping syndrome : “flat”

 LAMINECTOMY

- “log-roll the patient” (3 nurses) – KEEP SPINE IN STRAIGHT ALIGNMENT

- AVOID: hyperflexion, hyperextension and prone – it causes hyperextension of the spine.

 LIVER BIOPSY

- before LB : supine or L side lying to expose the part - during LB : - do-

- after LB : R side lying w/ small pillow under the coastal margin to prevent bleeding.

 LOBECTOMY

- removal of Lobe (N R lobe – 3, L lobe – 2)

- position : semi fowler’s position – to promote lung expansion

 MASTECTOMY

- removal of breast

- elevate or extend affected arm to prevent lymp edema (or elevate higher that the level of the heart.

AVOID: venipuncture, specimen taking, blood pressure – ON THE AFFECTED ARM coz there is no more lymph node w/c predispose pt to bleeding.

Post mastectomy Exercises: squeezing exercises, finger wall climbing,

extension (folding of clothing, washing face, vacuuming the house)

Due to removal of axillary lymph node, avoid also gardening and hand sewing

 PNEUMONECTOMY

- either L or R lung. Position pt on the AFFECTED SIDE to promote lung expansion.

 RADIUM IMPLANT OF THE CERVIX

- keep pt on complete bed rest to prevent dislodge. - AVOIDE SEX (may burn penis bec of the implant inside)

 RESPIRATORY DISTRESS

Adult : Orthopneic position – over bed table then lean forward

Pedia : TRIPOD – lean forward and stick out tongue to maximize the Airflow

- to prevent further detachment, place pt on the AFFECTED SIDE. Ex. If operation is on the R outer of the R eye, place pt on the R position. If operation is on the L inner of the R eye, position pt on the L side

AVOID: sudden head movement.

 VEIN STRIPPING

- keep extremities extended then elevate the legs at level of the heart to promote venous return

T I P S

 liver biopsy is done on a pt. – during 1st _{24hrs after the procedure, turn the pt}

on his abdomen w/ pillow under the subcoastal area;

 when draining the L lower lobe of the lung – the pt shld be positioned on his R side w/ hip higher or slightly higher than the head;

 after tonsillectomy – position: prone

 a pt is about to go on thoracenthesis - how shld the nurse position the pt? – sitting w/ a arms resting on the overbed table;

 to maintain the integrity of pt w/ hip prosthesis – abduction splints  immediately after supratentorial craniotomy- fowler’s position

 best position for pt in shock – supine w/ lower extremities elevated

THERAPEUTIC COMMUNICATION

1. DON’T ASK WHY – this put pt on the defensive 2. AVOID PASSING BACK – “I will refer you to….”

3. DON’T GIVE FAKE REASSURANCE – “everything will be alright….” “you’re in the hands of the best” 4. AVOID NURSE CENTERED RESPONSE – “I felt same too…”

“I had the same feeling….”

In GROUP DISCUSSION – nurse is just a facilitator – let the group decide, he/she channel are concern back to the group.

THERAPEUTIC PHRASES

– it seems… you seem…. - open ended question

- close ended – for manic pt and pt in crisis - direct question- for suicidal pt

ISOLATION PRECAUTION

Purpose : to isolate infection transmission

TYPE PRIVATE ROOM HAND WASHING GOWN GLOVE MASK

STRICT

(airborne dses, direct contact-Diptheria)

RESPIRATORY OPTIONAL OPTIONAL

(AIRBORNE: BEYOND 3FT DROPLET : W/IN 3FT)

TB OPTIONAL OPTIONAL

(negative airflow room)

CONTACT (direct contact – NOT AIRBORNE DSES)

eX SCABIES

ENTERIC X OPTIONAL OPTIONAL

(fecal contamination)

DISCHARGE X OPTIONAL OPTIONAL

(drainage: pus ex burn pt)

UNIVERSAL X

(AIDS, HEPA b – TRANSMITTED BY BLD AND DODY FLUIDS)

TIPS:

 When implementing universal precaution, w/c nsg action require intervention: recapping the needle – this might prick your hand;

 When discarding the contents of the bed pan use by a pt under enteric precaution – GLOVE IS NECESSARY;

 A nurse is giving health teaching to the parents of child with scabies: family member must be treated;

 Preventing pediculosis in school age children: avoiding contact w/ hair articles of infected children like clips, head bands, hats – no sharing

 Patient with full blown AIDS is placed on isolation precaution – pt ask nurse why his visitors is wearing mask – response: it will help in the prevention of

 Essential when a pt w/ meningitis is kept in isolation: isolation precaution remains until 24hrs after initiating antibiotic therapy

DIAGNOSTIC PROCEDURES

side notes:

pt for IVP : assess for allergy (cleansing enema b4 the procedure) pt for KUB : no dye (don’t assess for allergy)

schilling test : 24hr urine specimen USG : no consent required

GENERAL CONSIDERATION

• EXPLAIN the procedure to the pt (initial nsg action) - if not ready inform the doctor;

- pt has the right to refuse procedure; - doctor the one who asked for consent

• Check pt for CONSENT – if INVASIVE – WITH CONSENT

NON INVASIVE – NO CONSENT needed

• CONTRAST MEDIUM – check for allergy

• For procedure requiring anesthesia – KEEP PT NPO B4 PROCEDURE When local anesthesia used – NPO, 1- 2HRS AFTER

General anesthesia – keep NPO at least 8hrd after (check gag reflex before meals)

• PEDIATRIC PATIENT – use flash cards, games and play to encourage participation

TRANSCULTURAL CONSIDERATION

HISPANIC PATIENT – women prefer same gender health care provider

Obtain help of interpreter when explaining procedures – (except or don’t ask family members)

For muslim patient - they prefer same sex health care provider however, if procedures require life threatening – they prefer to have male doctor.

- they only want good news information of their condition

DELEGATION and DOCUMENTATION

Delegation – assessment, monitoring and evaluation of treatment

(cannot be delegated) BUT standard and changing procedures can be delegated ex. – 24hr urine specimen and urine catheter

collection.

Documentation – type of treatment and any untoward reactions.

KEYPOINTS FOR NURSES

 Prepare the patient;

 Monitor for adverse reaction;  Report complication to the doctor

FRAMEWORK – includes the Purpose, Special Consideration and Interpretation

DIAGNOSTIC TESTS

)

 DAILY FETAL MOVEMENT

Purpose : to determine fetal activity by counting fetal movements – usually perform by pt himself

N Fetal Movement 10-12 for 12 hr period (average: 1 movement/hr with

average 3fm/hr)

 NON STRESS TEST (NST) – correlates fetal heart rate w/ fetal movement - monitor the baseline FHR then induce fetal movements by (HOW) :

a. ring a bell b. feed the patient

then check FHR, NST is (+) if FHR increase at least 15 beats/min than the baseline. (ex. 140 FHB baseline, then after challenge it increase to 155)

POSITIVE result means, BABY is REACTIVE (good condition) and no need for contraction stress test/oxytocin challenge test – coz baby is OK and doing well.

 CONTRACTION STRESS TEST (oxytocin challenge test) - correlates FHR with uterine contractions

- pt on NPO

- get baseline FHR then induce uterine contraction HOW:

Thru breast stimulation – it triggers the release of oxytocin from pituitary gland… If (-) patient is given Oxytocin – onset is 20-30 minutes. Then check FHR and note the presence of

DECELERATION (slowing of FHR) types of deceleration

a. early deceleration – indicates head compression (MIRROR IMAGE)

b. late deceleration – indicates placental insufficiency (REVERSE MIRROR IMAGE)

mgt: L Lateral Recumbent Position, Administer O2, Treat Hypotenson

c. variable deceleration – due to cord (image: U or W shape) and slowing of FHR can occur

If (+) CST, meaning there is deceleration, baby is NOT OK coz there is decrease FHR and during labor he/she may stand the labor process.

 BIOPHYSICAL PROFILE

– to determine fetal well being w/ the use of 5 CRITERIA

fetal breathing 2 points

movement 2 points

heart tone 2 points

reaction to NST 2 points

amniotic fld volume 2 points 10 points

score below 6, indicates fetal jeopardy

 ULTRASOUND

- provide data on placenta (age and location) gender of baby

structural abnormalities position of baby

- for pregnant: site is lower abdominal USG types:

a. Upper USG – NPO b. Lower USG - NPO

- preparation: increase fluid intake (oral) NO consent needed

If pt ask if it is painful: NO PAIN; Pt shld have full bladder

CHORIONIC VILLI SAMPLING – CVS AMNIOCENTESIS – AMNIO

PERCUTANEOUS UMBILICAL CORD BLOOD SAMPLING – PUBS

CVS AMNIO PUBS

Purpose: to detect chromosomal Purpose : same w/ CVS Purpose: to check chromosomal Aberration aberrations, & presence of RH

(eg. Down syndrome, Trisomy 21) Incompatibility

Done in 1st _{trimester can be done on the 2}nd _{wk (14-16 wk) Extract blood at umbilical cord}

(can be done as early as 5th _{wk but - but not recommended bec. of danger then it is tested if it really comes}

can be done on 8-10th _{wk) abortion (assess pt age of gestation) from the umbilical cord (can be}

done on either 2nd _{or 3}rd _tri.

or can be done on the 3rd _{wk (34-36 wk)}

purpose: to detect fetal maturity (FLM) Get sample at chorion (by 10-12wks – thru monitoring of L/S Ratio N 2:1 The placenta matures, get some sample) (if mother is (+) DM LS ratio is 3:1)

This procedure also check level of alpha-feto Protein – if INCREASE – spina befida; If DECRTEASE – down syndrome

(+) Consent – invasive (+) Consent (+) Consent

Bladder : Empty consider the Pt Age of Gestation (if age of gestation :

is higher than 20wks and above : empty bladder, if AOG is 20wks and below : full bladder

COMPLICATIONS of CVS, AMNIO & PUBS: a. infection

b. bleeding c. abortion d. fetal death

T I P S

• EARLY DECELERATION – expected in the fetal monitor when there is fetal head compression;

• AMNIOCENTESIS – was done @ 35 wks gestation – purpose: to determine fetal

lung maturity;

• A mother asked the nurse what will amniocentesis provide during pregnancy: it will show as whether the baby lungs are developed enough for the baby to be born;

• a nurse is preparing pt for lower abdl usg – w/c of the following done by the pt needs further teaching – pt voids b4 the procedure;

• after amniocentesis w/c of the following manifestation if observed by the nurse on the patient that needs to be reported : bleeding;

• pt ask the nurse – what deceleration means – it refers to slowing of baby’s heart rate;

• before Amniocentesis, what to check – USG DEVICE

DIAGNOSTIC TESTS

– use to diagnose apnea of infancy

– assess HR, RR, nasal airflow and O2 saturation – N 95-98% below 85 – report ASAP

GLUTEN CHALLENGE

- detect presence of Celiac Disease (CD) - intolerance to gluten; - pt is given gluten rich food for 3-4 months the observe s/s of CD s/s of CD: abdl cramps, steatorrhea, abdl rigidity, abdl distention

ORTOLANI’S TEST (OT) BARLOW’S MANUEVER (BM)

purpose: test developmental dysplacia of the hip or purpose : same

congenital hip dislocation

(+) if w/ click sound (lateral) (+) barlow’s click – press downward and w/ click sound

POLYSOMNOGRAPHY or “sleep test”

- EEG is connected to pt when he sleeps

- Check the brain waves, check for apnea of infancy - preparation : No Special prep,

HOLD CAFFEINE FOOD – 2days b4 test

SCOLIOMETER

- measure the degree or angle of scoliosis - check for: (+) scoliosis if uneven hemline

uneven waist

more prominent iliac rest and scapula on one side presence of rib hump

test for pre-teen : “bend over test” – bend and touch the toe;

(+) scoliosis – if presence of rib hump, therefore x-ray then scoliometer.

SICKLEDEX TEST HGB ELECTROPOISIS

Purpose: test for sickle cell anemia Purpose: test for sickle cell anemia

Specimen : Blood : (blood + solution, if (+) TURBID Specimen : Blood : bld + electropoiesis, if sickling of RBC

Therefore TRAIT CARRIER (S or C shape RBC), therefore + for SC Dses Test for TRAIT Test for Disease

GUTHRIE CAPILLARY BLOOD TEST (GCBT) - to detect PKU

(in PKU there is absence of PHENYLALAMINE HYDROXYLASE- PH)

Phenylalamine hydroxylase – is an enzyme that converts PH to Tyroxine – the one that gives color to hair, eyes and skin.

If absent PH, no one will convert PH to Tyroxine, therefore it will accumulates to brain and can cause mental retardation.

PH came from CHON rich food. At birth, it is usually negative, so give CHON food first for 3wks then retest.

Before test, give chon rich food for 1-4 days before test. (adult) N PH level - >2mg/dl

SWEAT CHLORIDE TEST

- to detect Cystic Fibrosis (in CF, the skin becomes impermeable to Na. meaning cannot reabsorb Na and it accumulates outside of the skin); - Mother complain that her baby taste salty;

- PILOCARPINE – used in the test to induce sweating; Types:

a. sweat chloride test – N 10-35 meq/L (above 40 meq/L– (+) b. serum chloride test – N 90-110 meq/L (above 140 meq/L – (+)

TIPS

 pt w/ PKU would more likely to have (+) result in gluten capillary bld test if there is – adequate CHON in the diet;

 mother complains that her baby taste salty – which test is to be performed : sweat chloride test;

 9 yo pt has (+) result for sweat test – this indicates possible dx of Cystic Fibrosis;  pilocarpine – drug used for pt undergoing seat chloride test;

 hgb electropoisis – test for sickle cell dses

DAY 4 (3 Feb 2005)

DIAGNOSTIC PROCEDURES

I.

CARDIOVASCULAR

A. ELECTROCARDIOGRAPHY – records the electrical activity of the HEART P wave – atrial depolarization

QRS complex – ventricular depolarization ST - repolarization

Rhythm – appearance of wave and distance

Rate - N 60-100 bpm – check on # of QRS then divide it by 300 (k) ABNORMALITIES

a. atrial fibrillation – p waves “halos magkadikit. (no discernable p waves) b. atrial flutter – “saw tooth” flutter waves c. ventricular – check on QRS (N - .8-.12)

ANGINA – st segment elevation, t wave inversion

MI - st segment elevation or depression, t wave inversion

B. CARDIAC CATHETERIZATION

- it determine the structural abnormalities in the heart - either L or R sided catheterization

- site: antecubital, femoral, brachial

common complications: embolism, bleeding, arrythimia “EBA” nsg mgt :

 monitor distal pulses (if brachial site: check @ radial

if femoral site : check @ dorsalis pedis)  if weak or no pulse – REPORT

 if (+) bleeding – report (“sandbag 10-20 lbs” – shld be at bedside)

C. STRESS TEST

- determines the ability of the heart to withstand stress - equipment : threadmill & ECG

- nsg alert : check pulse and BP

keep NPO an hr b4 the test NO Jewelries

D. CORONARY ARTERIOGRAPHY

- visualization of the bld vessels w/ contrast medium - nsg alert: (+)consent

check allergy to contrast medium

increase oral fluid intake after to excrete dye

epinephrine shld be ready for any untoward reaction

E. SWAN-GANZ CATHETERIZATION

- 4 lumen for the ff CVP, Pulmonary Capillary Wedge Pressure (PCWP), Pulmonary Artery Pressure,

Bld products, Balloon CVP – measure R side pressure of the heart

PCWP – L side of the heart

for SVC – 5-12

Nsg Alert : check pulse and s/s of bleeding

F. BLOOD CHEMISTRIES

 SODIUM (135 – 145 meq/L)

Addison’s Dses: hyponatremia (dec Na), hyperkalemia (inc K) – “FLD IMBALANCE”

Cushing Syndrome: hypernatremia, hypokalemia – “FLD VOL. EXCESS”

 POTASSIUM (3.5 – 5 meq/L)

Hyperkalemia : Addison’s dses Hypokalemia : Cushing Syndrome Inc or dec in K PT RISK of INJURY

Pt w/ digitalis & diuretics – monitor for arrhythmia

 CALCIUM (4.5 – 5 meq/L or 9-10mg/dl)

Hyperthyroidism – inc CA

Renal Calculi Formation – inc CA @ bld

 GLUCOSE (80-120)

- Higher than 140 – hyperglycemia (acidosis – may lead to ineffective breathing pattern and airway is the main problem)

- below 50 – hypoglycemia (pt prone to injury & altered thought process)

 Creatinine (.5-1.5)

- most sensitive index of kidney funx

(increase BUN but N creatinine – do not report to AP) - increase creatinine – kidney failure or renal disorder

 BUN (10-20 mg/dl)

- inc. if (+) kidney disorder

 LDH (40 – 90 u/L)

LDH1 – 27-37% (for heart – check for MI) LDH2 – 17-27% (for heart – check for MI) LDH3 – 8-15% (for respiratory system) LDH4 – 3-8% (for liver & kidney) LDH5 – 0-5% (for liver & kidney)

 CPK or CK

Male – 12-70 u/L Female - 10-55 u/L

Increase CPK 3-6hrs post MI then it normalize 3-4 dyas

 AST (SGOT) SGPT (ALT)

- N 8-20 u/L N 8-20 u/L

- for liver (inc. for liver dses) more on HEART (inc for cardiac dses)

G. HEMATOLOGIC STUDIES RBC (4.5 – 5.5 million)

- inc RBC – polycythemia – risk for injury – complication CVA - dec RBC – anemia – activity intolerance

WBC (5-10 thousand)

- to detect presence of infection, bld disorders like leukemia - dec WBC – pt prone to infection

- inc WBC – hyperleukocytosis – (+) to pt w/ leukemia – risk for infxn

PLATELET (150,000-450,000)

- spontaneous bleeding occurs when platelet dec (pt also prone to injury)

PT PTT APTT

(11-12 sec) (60-70 sec) (30-40 sec)

coumadin – check pt heparin – PTT

monitor pt 4 bleeding monitor pt 4 bleeding

HGB – male : 14-18 mg/dl Female : 12-16 mg/dl

Dec hgb – anemia (nsg dx: activity intolerance)

HCT - 35-45%

- determine the adequacy of hydration and the ration of plasma to the cellular component blood

inc hct : hemoconcentration (nsg dx: fld deficit – dehydrated pt) dec hct : hemodilution fld excess

DOPPLER USG

- to detect the patency of bld vessels – arteries & veins esp of lower extremities;

PULSE OXIMETRY

- determines the O2 saturation at blood

- N 95-98 – attach to finger or earlobe (do not expose e light)

II.

RESPIRATORY

 BRONCHOSCOPY

– visualization of b. tree or airway passages; – to gather specimen for biopsy;

– NPO b4 & after

– Gag reflex return after 1-2hrs;

– Pt may expect a sore feeling (PINK STINGED SPUTUM) – Report (+) stridor

 CHEST X-RAY

- to determine abnormalities of lungs and thoracic cavity; - no preparation;

- ABSOLUTE CONTRAINDICATED TO PREGNANCY - Check pt for radiation indicator

- Determine effectiveness of tx and whether pt is active or non-active

 SPUTUM STUDIES

- to determine the gross characteristic of the sputum (refers to the amount, color, abnormal particles, consistency and characteristic)

TYPE OF SPUTUM PNEUMONIA - Viral – thin & watery

Bacteria - rusty

TB - blood streaked BRONCHITIS - gelatinous

CHF/ PULMONARY EDEMA - pink stinged

Sputum specimen – sterile container  THORACENTESIS

- aspiration of fld at thoracic cavity (for diagnostic & therapeutic purpose)

position: DURING – sitting

AFTER - affected or unaffected side

Nsg alert:

NO COUGHING & DEEP BREATHING – during the procedure – coz this may cause puncture of the lungs;

Assess for breath sounds after;

Complication: bleeding and pneumothorax

 PULMONARY FUNCTION TEST

- thru the use of incentive spirometer

& out of lung after maximum inspiration.

PROCEDURE: EXHALE then INSERT mouth piece, BREATH iN, HOLD then EXHALE

 LUNG SCAN

- to identify the presence of blockage in the pulmonary bld vessels;

- with contrast medium; - (+) consent;

- assess for rxn to allergy

 MANTOUX TEST

- test for POSSIBLE TB EXPOSURE; - using PPD (purified chon derivatives)

- angle 10-15, BEVEL UP then read 48-72hrs after

5mm in duration – (+) for HIV, multiple sex, previously (+) pt; 10mm - (+) for immigrants, children below 3yo and for pt w/ medical condition – DM & Alcoholism 15mm - (+) for general population

 LUNG BIOPSY

- aspiration of tissues at lungs for dx of tumors, malignancy - assess for bleeding, breath sounds & report for s/s of dyspnea

III. NERVOUS

 EEG

- shampoo hair B4 (to remove chemicals)

and AFTER to remove electrode gel (shampoo or acetone) - measures electrical activity of the brain (gray matter)

- non invasive, (-) consent

- detect the ff: brain tumors, space occupying lessions alcohol brain waves and seizures nursing alert:

 dietary modification: WITHOLD CAFFEINE – coffee and tea;

 WITHOLD 48hrs b4 the procedure : tranquilizers, sedatives, anti-convulsant, alcohol

CT SCAN MRI PET

Use radiation to determine use electromagnetic field use gamma rays or positron electron tissue density to detect abnormality of tissue density to detect abnormality of tissue density; (detect cancer and tumor) also to detect O2 saturation @ tissue;

physiology of psychosis; and to evaluate tx like CA Tx give more detailed impression

(ex. Measurement of blocked artery)

NSG ALERT:

(w/ or w/out dye)

CONTRAINDICATION CONTRAINDICATION

(same w/ ct scan BUT w/ addtl)

a. pregnancy;

b. obese pt (more than 300 lbs); NO METAL OBJECTS

c. claustrophobia (give anti-anxiety b4) - jewelries, insulin pump,

d. pt w/ unstable v/s (arrhythmic & HPN); pacemaker, hip replacement e. pt w/ allergy to dye

“clicking sound” will be heard & lie still during the procedure lie still

lie still during the procedure and “thumping sound” will be heard

 CEREBRAL ANGIOGRAM

- involves visualization of bld vessels @ vein w/ the use of contrast medium.

CONTRAINDICATED IN:

pt w/ allergy; pregnant pt.; bleeding

Nursing Alert:

a. keep pt NPO; b. assess pt for allergy; c. monitor for signs of bldg; d. inc oral fld intake to excrete dye;

e. keep epinephrine and or benadryl at bedside for emergency

 LUMBAR PUNCTURE

- aspiration of CSF for assessment to check for infection or hemorrhage

position:

DURING : fetal or C-position

AFTER : FLAT to prevent spinal headache

Needle is inserted between L3 and L4 or L4 and L5

Increase fluid intake after.

 CSF ANALYSIS

- Assess for the characteristic of CSF.

- N amount: 100-200 ml

If REDDISH – hemorrhage If Yellowish – infection

Ear licking w/ fluid – test if (+) glucose bec. CSF has glucose.

 MYELOGRAM

- test for presence of slip disc or herniated nucleus porposus (HNP).

ALERT:

Know the type of dye use:

a. water based – called AMIPAQUE b. oil base – called PANTOPAQUE

 type of dye will determine the position of pt AFTER the procedure.  If water based, the HEAD OF BED ELEVATED;

 If oil based, FLAT after

Rationale for both oil and water based dye is TO PREVENT the upward dispersal of dye w/c can cause electrical meningitis (s/s includes: (+) seizure, headache)

IV. EENT

• TONOMETRY

- to measure IOP (N 12-21)

- painless but w/ local anesthesia

ACUTE GLUACOMA : 50 yo and above CHRONIC GALUCOMA : 25 yo

• CALORIC STIMULATION TEST

- test the presence of Minierre’s Dses (inner ear)

- involves introduction of warm and cold water then NOTE FOR NYSTAGMUS – jerky lateral movement of the eye.

SEVERE NYSTAGMUS – NORMAL MODERATE NYS - Minierre’s Dses NO NYSTAGMUS - Acoustic Neuroma

• GONIOSCOPY

- non-invasive, painless

WEBER TEST RINNE’S TEST

To determine lateralization of sound; To determine air and bone conduction If pt hears vibration better in GOOD EAR, Place tuning fork 2inches from the ear Problem would be SENSORINEURAL LOSS; place at mastoid bone or in teeth then….

if pt hear better in POOR EAR, - refers to if AIR CONDUCTION is LONGER, therefore CONDUCTIVE HEARING LOSS SENSORINEURAL HEARING LOSS;

If BONE CONDUCTION IS LONGER, therefore

CONDUCTIVE HEARING LOSS

V.

GASTRO INTESTINAL TRACT

 UPPER GI SERIES (Barium Swallow)

- xray visualization with contrast medium - Contrast Medium:

a. Gastrografin – water soluble, use straw

b. Barium - swallow – milk shake like (use feeding bottle of pt) - then pt is ask to assume different positions to

distribute dye @ esophagus

purpose: to detect disorders of esophagus feces : “chalky-white”

after: instruct pt to take laxative to excrete dye

 BARIUM ENEMA (for Lower GIT)

- involve rectal installation of barium;

- there is balloon catheter inserted @ anus then barium is instilled and pt is asked to roll-over at different position then xray is taken to detect:

hemorrhoids, diverculosis, polyps and lesions;

- after, give laxative to excrete dye (bec dye is constipating) instruct also patient to inc oral fld intake

 GUAIAC TEST

- to detect the presence of bleeding and inflammatory bowel condition like CANCER;

specimen : stool (this can be refrigerated awaiting laboratory)

AVOID the following 3 days B4 the test – bec it can yield to FALSE (+)

RESULT : Red Meat, Fish and Horse Radish

- visualization of biliary tree (includes, hepatic duct & common bile duct) – same with CHOLECYSTOGRAPY – but medium given orally;

- with contrast medium w/s is given thru IV

- ALERT: assess for allergy (epinephrine/benadryl)

- Post procedure: inc. oral fld intake – to facilitate excretion of dye

 GASTRIC ANALYSIS

- analysis of gastric secretion like HYDROCHLORIC ACID - Lower Level N : 2-5 meq/hr

- Upper Limit N: 10-20 meq/hr

UPPER LIMIT YPES

a. WITHOUT TUBE (tubeless gastric analysis)

- using DIAGNEX BLUE (specimen: urine);

if urine colors turns BLUE, therefore (+) HCL Acid; if urine (-) blue color, therefore (-) HCL Acid

- if (-) HCL Acid at stomach (achlorhydia), therefore Gastric CA;

- if Increase HCL Acid – therefore ZOLLINGER-ELLISON SYNDROME – (+) Gastric Tumor b. WITH TUBE – with the use of NGT then aspirate

 ULTRASONOGRAPHY

- upper abdl USG to detect abnormalities in the upper abdl area w/ includes biliary tree and Upper GI;

- painless;

- gel at abdomen and pt is NPO

 LIVER BIOPSY

- aspiration of sample tissue from the liver to detect: Hepatic CA and Cirrhosis; - ALERT: Check for Bleeding Time (N – 1-9 mins) and

Clotting Time (N – 10-12 mins) – because liver is highly vascular organ

- WHEN NEDDLE IS INSERTED tell pt to:

Inhale then Exhale then Hold Breath – to stabilize liver position - Position after : R side-lying position

- Things to report: s/s of SHOCK – inc PR, dec BP Check v/s

 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

- to visualize common bile duct and pancreatic duct; - invasive – (+) consent;

- NPO – tube insertion;

- Tell pt that tere will be feeling of soreness a wk after the procedure

 COLONOSCOPY

- visualization of colon to detect: inflammatory bowel condition Chron’s Dses Diverticulitis Hemmorhoids Tumor Polyps - (+) Consent - NPO b4

- clear liquid diet – 2days b4 the procedure

position: Lateral or side lying position or L Lateral Sims

VI. ENDOCRINE

 GLUCOSE TOLERANCE TEST

- to provide measure of bld sugar level at blood; - Inform pt to have high CHO diet 2 days b4 the test; - Instruct NPO a day b4 the test (npo post midnoc); - Inc sugar level, therefore Diabetes

 ACTH STIMULATION TEST

- to detect presence of Addison’s Dses - specimen: blood

- pt is given dose of ACTH (not nore than 40ug/dl)

- if still dec despite ACTH administration, therefore Adrenal Insufficiency – Addison’s Dses

 DEXAMETHASONE SUPRESSION TEST

- to detect endogenous depression – depression resulting thru endocrine disorder

- pt is given dexa then 24hr urine specimen is collected;

- a dose of dexa will suppress the release of adrenal hormones;

- if despite dexa administration still increase adrenal hormones, therefore pt is suffering depression

 17 KETOSTEROID & 170 HCS

Addison’s – dec secretion of ketones Cushing’s – ince secretion of ketones Specimen: 24 hr urine

 VANILLYLMANDELIC ACID TEST – VMA Test - bi-product of CATHECHOLAMINE Metabolism

epinephrine norepinephrine

inc if there is TUMOR (pheocromocytoma) of Adrenal Medulla

N 2-7 mg/dl / 24hrs – if inc, therefore tumor

AVOID: vanilla containing food 3 days b4 test – ice cream, coffee, chocolates

 R A I U

- pt is given iodine 131 then after 24hr followed by a thyroid scan - inc indicates hyperthyroidism, dec hypothyroidism

- AVOID: iodine rich-food (sea foods, sea shells, sea weeds) 7-10 days b4 and to include

other diagnostic procedures that uses contrast medium (“NO” - angiogram test). – bec it may yield to false (-) result.

 SULKOWITCH’S TEST

- detect amount of calcium excreted at urine;

- if to test for hypercalcemia and hyperthyroidism - gather specimen b4 meals; - to test for hypocalcemia and hypothyroidism – gather after meals

VII. R E NA L

 URINALYSIS

- examine the gross characteristic of the urine urine amount : 30-60ml/hr

color : clear, amber s. gravity : 1.010 – 1.025

abnormality: lower than 1.005 – diabetic insipidus higher than 1.030 – diabetic mellitus (+) glucose – infection, DM

(+) CHON - PIH, kidney dses. Urine maybe refrigerated if waiting to be examined.

 CULTURE & SENSITIVITY

- to detect infection

 K U B IVP

- xray of the kidneys, ureter and bladder - xray of the kidneys, ureter and bladder - NO SPECIAL PREPARATION NEEDED - uses contrast medium/ dye

- assess for allergy, then inc. oral fld intake after - benadryl or epinephrine at bedside for allergic rxn - NPO POST MIDNOC, cleansing enema in AM

 CYSTOSCOPY

- visualization of urinary bladder - after : monitor I & O;

- note for s/s of bleeding

 RENAL BIOPSY

- aspiration of tissues at kidney for biopsy to detect: a. malignancy/ Ca

b. malignant HPN c. kidney disorder - note for s/s of bleeding

 CYSTOURETROGRAM

- to check the patency of the ureter and bladder; - monitor I & O

 CYSTOMETROGRAM

- to evaluate the sensory and motor funx of bladder;

- to check if bladder respond to distention after installation of flds; - monitor I & O

VIII. MUSCULO-SKELETAL

 ELECTROMYOGRAPHY

- to detect electrical activity of the muscle; - (+) consent;

- to alternately contract and release the muscle as needle is inserted - HOLD muscle relaxant b4 the test

 ARTHROCENTESIS

- aspiration of fluids at synovial space to detect abnormalities; - check for order of analgesic;

 ARTHROSCOPY

- visualization of joints

- KEEP TORNIQUET, ICE PACK and ANALGESIC at bedside

 BONE SCAN

- detect rate of bone destruction or bone resorption for pt w/ osteoporosis; - lie still during the procedure;

- PAINLESS AND NON INVASIVE

IX. MISCELLANEOUS

 BONE MARROW BIOPSY

- to check abnormalities at the b. marrow (eg. Leukemia) - site : ILEAC REST

- (+) consent

- assess for bleeding

- sand bag at bedside (post procedure) – for emergency use

 SCHILLING’S TEST

- specimen: 24hr urine

- test for VIT B12 deficiency; - for pt w/ PERNICIOUS ANEMEIA;

- pt is given oral VIT B12 then urine is collected, then NOTE for RATE of EXCRETION of VIT B12 (N – less than 40%);

eg. If 100mg Vit b was taken – 60mg shld retain at stomach and 40mg will be excreted.

 URINE UROBILINOGEN

 to detect HEMOLYTIC DSES

 WITHOLD ALL MEDS – 24hrs b4 the test

 BENCE-JONES PROTEIN

 detect presence of MULTIPLE MYELOMA (malignancy of plasma cells);

 RELEASED by destroyed or damage bones

 ROMBERG’S TEST

 check FUNX of CEREBELLUM;

 stand erect, close eyes, and observe for inability to maintain posture (if pt is Swaying, therefore TUMOR at cerebellum)

 ERYTHROCYTE FRAGILITY TEST

solution (RBC Lifespan: 120 days)

if lifespan of RBC >120 days, therefore HEMOLYTIC ANEMIA (EX. SICKLE CELL)

 HETEROPHIL ANTIBODY TEST

- detect presence of IgM w/c is related to Epstein Virus infection

Epstein Virus Infection – causative agent of infectious mononucleousis (“kissing dses”)

mgt: AVOID SHARING of utensils and glass

 LYMES DSES SEROLOGY

- detect presence of BORRELIA BURGDORFERI – causative agent of lyme’s dses.

Treatment: tetracycline

TIPS FOR DIAGNOSTIC PROCEDURE

 2 moths old infant suspected of brocholitis is treated with oxygen therapy. Which result indicates that tx was effective : 02 SATURATION OF 98%.

 Pt is scheduled for liver biopsy. What shld the nurse instruct pt to do during needle insertion? -

hold breath during the procedure upon insertion of the needle.

 Staff nurse is observing a nurse caring for pt w/ cvp. W/c action of the nurse require intervention? –

touching the edge of the soiled dressing using clean gloves.

 Pt undergoing ERCP – important prep for nurse to make would be: keep pt NPO b4 the

procedure.

 Pt w/ coronary angiogram, the catheter was inserted at the L femoral artery. w/c intervention is appropriate after the procedure: palpate the popliteal and pedal pulses.

 In explaining to the pt about cystoscopy the nurse shld say : the bladder lining will be visualize.

 A mantoux test is (+) – if the nurse assesses w/c of the following: in duration.

 w/c of the ff will yield an accurate reading of CVP: when the zero level of the manometer is at

the level of R atrium.

 w/c responses made by the pt indicates that he understands the procedure to be done in a CT scan:

“a dye will be injected to me”.

 A pt is to have an upper GI series – which statement shows that he understood the instruction given : “I will drink the dye”.

 After liver biopsy, a potential complication: bleeding.

 MRI is the primary diagnostic tool for multiple scelosis bec it promotes visualization of plaques

DAY 5 (8 Feb 2005)

PHARMACOLOGY

I. GENERAL CONSIDERATIONS

• ONLY RN’s are allowed to administer (to include central line) LPN’s – peripheral IV Line route;

• ELDERLY PT – provide with memory aid

• PEDIATRIC PT – do not mix w/ milk (dosage depends on wt, age and size)

• For SIDE EFFECTS – GI symptoms (mostly)

• For AD. EFFECTS – always consider bone marrow (“leukocytopenia – all PENIA”)

• 3 COMMON DRUGS – with patients over 65 y/o

a. LITHIUM – if above 65 yo, dose shld not more than 1.0mEq

b. HALDOL – if above 65 yo, dose shld not more than 6mg/day

c. MEPERIDINE – if above 65 yo, shld not 50 mg

II. TRANSCULTURAL

ASIANS – are stoicism attitude (they refuse meds if for the 1st _time)

MIDDLE EASTERNERS - they expect meds during first contact w/ hx care provider

JEWISH – no meds restrictions

JEHOVAH’S WITNESS – do -

- treatment for diarrhea; - may cause lead toxicity

 ECHINECEA

- use to boost the immune system; - for pt. with cancer

 ST JOHN’S WORT

- anti-depressant (it funx like MAO inhibitor); - do not give to pt taking MAO

 VALERIAN

- sedative (used also as anti-anxiety agent) - adverse effects – GI Irritation

 GINGCO BILOBA

- blood thinner;

- use to enhance bld circulation; - for pt w/ alzeimers

- CONTRAINDICATED to pt with bleeding disorders COMMON CONTRAINDICATIONS for HERBAL MEDS:

 NO HERBAL MEDS for pregnant client;

 NO HERBAL to lactating pt;

 NO HERBAL for those with severe kidney and liver disorder

IV. THE CHECK PRINCIPLE C – lassification (FOR WHAT?)

H - ow will you know that he meds if effective (evaluation) E - xactly what time are you going to give it

C - lient teaching tips K - eys to giving it safely

 Lactulose – given to pt with hepatic enceph to dec ammonia absorption - s/e : diarrhea

 ANTABUSE (dizulfiram) – most appropriate time to take meds : after 12hrs of alcohol free.

 COGENTIN – to prevent pseudoparkinsonism (by decreasing muscle rigidity)

 TETRACYCLINE - can cause staining of teeth,

Photosensitivity (use sunscreen when outdoors)

 LITHIUM – shld have inc. fluid in the diet

III. DELEGATION AND DOCUMENTATION

Document all medical admin record: time, route, dosage and untoward reaction;

PSYCHOTROPIC

I. ANTIPSYCHOTIC

- major tranquilizer;

- for SCHIZOPHRENIA (pt has EXCESS DOPAMINE);

- plays as treatment to the symptoms NOT CURE to schizo – meaning it modify the symptoms (target symptom: to decrease dopamine)

ex. Haldol Chlorpromazine Clozapine (chlozaril) Olanzapine (zyprexa) Risperdon

BETS TO GIVE: after meals

DOPAMINE – neurotransmitter (facilitate the transmission of neurons) In SCHIZO there in INCREASE NEUROTANSMITTER.

Signs & Symptoms:

a. DELUSION – “FALSE BELIEF” b. HALUCINATION - hearing sounds

c. LOOSENES OF ASSOCIATION – shifting of topic

CLIENT TEACHINGS:

 Report ADVERSE EFFECTS of ANTI-PSYCHOTICS – which indicates agranulocytosis

a. fever

b. body malaise c. sore throat d. chills

 hyperpyrexia and muscle rigidity

- this indicates NEUROLEPTIC MALIGNANT SYNDROME (NMS)

drug of choice: Parlodel, Dantrium

 Assess SIGNS and SYMPTOMS of PSEUDOPARKINSONISM

a. mask-like face or expressionless face b. pill-rolling tremors

c. cogwheel’s rigidity or lead pipe rigidity

AKATHESIA – “restless leg syndrome” (I feel as if I have ants in my pants)

DYSTONIA

Avoid direct sunlight – because meds photosensitivity Instruct pt to rise slowly – to avoid orthostatic hypotension

Check: CBC, BP, AST/ALT

To prevent pseudoparkinsonism, administer ANTIPARKINSONIAN agents

IA. DOPAMINERGICS - ANTIPARKINSONIAN

in schizo there is increase dopamine, therefore give antipsychotic to dec dopamine then dec dopamine causes pseudoparkinsonism. Therefore give dopaminergic.

ex. L-Dopa Levodopa

Levodopa-Carbidopa

 Effective if decrease in tremors and rigidity within 2-3 days;  When to give: AFTER MEALS;

 Health Teachings :

a. dietary modification: AVOID CHON and Vit B6 - bec it decreases drug absorption

b. check for ORTHOSTATIC HYPOTENSION and PALPITATION; c. check BP and PR

IB. ANTICHOLINERGIC

- decrease ACETYLCHOLINE ex. Benadry

Cogentin

 effective: if decrease tremors and rigidity;  when to give: AFTER MEALS;

 Health Teachings:

a. side effects: blurred vision (no driving); b. dry mouth – suck on ice chips or hard candy; c. palpitations – check PR;

d. constipation – inc. roughage at diet; e. urinary retention NOT urinary frequency f. decrease BP – rise slowly

g. check BP, PR, ECG

II. ANTI-ANXIETY

- minor tranquilizer

- decrease Reticular Activity System – center of wakefulness

ex. Valium, diazepam, Librium, Tranxene

 Effective: Decrease Anxiety,

Decrease Muscle Spasm (to pt w/ traction) Promote Sleep

 B4 MEALS – because food delays absorption

a. report ADVERSE EFFECT:

PARADOXICAL REACTION – opposite of side effects

b. Danger of Dependency

c. AVOID:

Caffeine, Alcohol – it increase the depressant effect of the drug

d. check RR – it causes respiratory depression

e. administer VALIUM separately – because it is incompatible with any drug – use different syringe.

III. ANTI-DEPRESSANT/MANIC

a. TRICYCLICS b. MAO

c. STIMULANTS d. SSRI

PATIENT with DEPRESSION

– there is DECREASE norepinephrine and serotonin

A.

TRICYCLICS

–

Effective: If adequate sleep (8hrs only)

Increase appetite

Best given: AFTER MEALS

Hx Teachings:

 The INITIAL EFFECT 2-3 wks after FULL THERAPEUTIC EFFCET 3-4 wks

ONSET EFFECT in a WK

 AVOID : juice – because an acidic medium decrease absorption of drugs

 REPORT PALPITATION and TACHYCARDIA and ARRYTHMIAS – adverse effects of TRICYCLICS

 CHECK BP and ECG

B.

MAO INHIBITOR

(MonoAmine Oxidase)

- prevents the destruction of NEUROTRANSMITTERs ex. Parnate, Nardil and Marplan

Effective : if INCREASE SLEEP and APPETITE –

Give AFTER MEALS

Hx Teachings:

 AVOID – TYRAMINE CONTAINING FOOD

(1 day before FIRST DOSE and 14 days AFTER LAST DOSE)

Avocado, banana,

cheese (cheddar, aged and swiss) ALLOWED: cheese – cottage and cream, FRESH MEAT, VEGETABLES

COLA, CHICKEN LIVER SOY SAUCE

RED WINE PICKLES

 Check BP – the drug can cause HYPERTENSIVE CRISIS – occipital headache – “my nape is aching”

 2 WKS INTERVAL – when shifting ANTI DEPRESSANT

– to avoid HYPERTENSIVE CRISIS

ex . after MAO – 2 wks rest then can give ST JOHN’S WORT

C.

STIMULANTS

(Ritalin, Dexedrine and Cylert)

- directly stimulates the CNS.

Effective: Increase Appetite and Adequate sleep

Best to Give: AFTER MEALS

- if b4 meals, it suppresses the appetite;

- give NOT BEYOND 2pm bec. it causes INSOMNIA – 6 Hrs b4 bedtime; - shld be given in the morning – to avoid INSOMNIA

COMPLICATIONS: growth suppression

Hx Teachings:

 provide intervals or intermittently to avoid growth suppression;  check BP and PR

D.

SSRI

Adverse effects: DECREASE LIBIDO and Impotence

s/e: GI

III.1 ANTIMANIC

 Lithium (lithane, lithobid, escalith)  Tegretol

A. LITHIUM

- it alters level of neurotransmitters effective if DECREASE HYPERACTIVITY give AFTER MEALS

Hx Teachings:

 diet:

High Na (6-10 gms) and High Fluid (3-4L)

N Na – 3 gms, N fluid intake 3L Basically, Lithium is a salt

 Report the ff s/s (NAVDA) - Nausea - Anorexia - Vomiting - Diarrhea - Abdl Cramps Report also:

FINE HAND TREMORS progressing to COARSE HAND TREMORS,

THIRST and ATAXIC - sign of LITHIUM TOXICITY – Dug of choice: MANNITOL

DIAMOX

Hx Teachings:

• Avoid activity that increase perspiration – Na & H2o;

• Avoid caffeine;

• Monitor lithium level

(specimen: blood drawn in the morning b4 breakfast or at least 12 hrs after the last dose)

• Frequency of Lithium monitoring: ONCE A MONTH;

NORMAL LITHIUM LEVEL:

ACUTE DOSE MAINTENANCE DOSE

Below 65 yo .5 – 1.5 mEq/L .5 – 1.2 mEq/L Above 65 yo .6 – 1.0 mEq/L .4 - .8 mEq/L

Lithium is effective with 10 – 14 DAYS before it will reach its therapeutic level. CONTRAINDICATION OF LITHIUM:

• Pregnancy;

• Lactating;

• Kidney disorder

- if above s/s are (+) to patient, instead of lithium use TEGRETOL, DOPAKINE/ DEPAKOTE

tegretol – a/e : alopecia

dopakine/ depakote - gingivitis

ANTICONVULSANT

- for seizures, wherein there is abnormal discharge of impulse in the brain - action : IT INHIBITS the seizure focus and discharge

effective: if (-) seizure

given BEST AFTER MEALS (except for sedatives- like valium)

– MOST DRUGS THAT AFFECT CNS ARE BEST GIVEN AFTER MEALS TOO.

NSG ALERT:

• Report GINGIVITIS;

• Report S/S of Bone Marrow Depression – pancytopenia (dec RBC & WBC);

• Instruct pt to use SOFT BRISTTLED TOOTHBRUSH;

• Instruct pt to MASSAGE GUMS and frequent oral hygiene Check : CBC – due to pancytopenia

RBC, WBC and Platelet label

CHOLINESTERASE INHIBITORS

For MYASTHENIA GRAVIS : Prostigmin (long acting) and Tensillon (short acting)

For ALZEIMER’s DSES : Cognex (tacrine) and Aricept

Myasthenia Gravis – there is decrease or absence of Acethylcholine (ACTH)

ACTH is a neurotransmitter the delivers the order ex. Brain to muscle to contract/move.

Therefore, the drug is given to inhibit cholinesterase in destroying ACTH

(so, if dec cholinesterace and inc. ACTH, good muscle contraction)

PROSTIGMIN – long acting – for treatment

TENSILLON – short acting – only for 5 mins. – it increase muscle strength in 30 seconds (therefore, if muscle weakness disappear within 30 seconds – it is MYASTHENIA GRAVIS)

Drug Action:

• Increase muscle strength (ex. Increase chewing ability or able to chew food forcefully)

• GIVE B4 MEALS or any activity;

• Meds is FOR LIFE;

• Report s/s of HEPATOXICITY – RUQ pain of abdomen and JAUNDICE Antidote: ATSO4 – it reverses the effect of anticholinesterase

• Check for LIVER FUNX TEST;

• Keep at bedside: endotracheal tube – for resp. problem

ANTICOAGULANT

HEPARIN COUMADIN LOVENOX

For ACUTE CASES of Manic Case FOR MAINTENANCE or Chronic CASE Heparin Derivatives

Antidote: PROTAMINE SO4 Antidote: VIT K Antidote same w/ Heparin

Onset: 2-5 days (maintenance case)

Check PT (N 11-13 sec and INR 24 sec)

Effective if (-) clot Give same time of day

Report s/s of bleeding : Hemoptysis Hematemesis

HEPARIN: AVOID – green leafy vegetables – bec it is rich in Vit K and will counteract the effect of anti coagulant. Therefore, diet of patient – no appropriate.

NSG ALERT: monitor PTT (N 60-70 SEC, TIL INR of 175), if more than INR - HOLD “INR” – refers to the upper limit of meds from N value to the maximum dose

COAGULATION PROCESS:

thromboplastin

Vitamin K dependent clotting factors PRO THROMBIN THROMBIN

COUMADIN FIBRINOGEN HEPARIN

FIBRIN (CLOT)

COUMADIN – act as vit k dependent clotting factors

HEPARIN – converts PROTHROMBIN to THROMBIN and FIBRINOGEN to FIBRIN

- RAPID ACTING :onset : 24 – 48 hrs

Coumadin and Heparin

– NOT to dissolve clot

(only as THROMBOLYTIC – meaning it prevents ENLARGEMENT and FORMATION of CLOTS)

- can be given together

ANTIARRYTHIMICS

Side notes:

Characteristics of HEART MUSCLE:

a. CONDUCTIVITY – ability to propagate impulses;

b. AUTOMATICITY - ability of heart to initiate contraction;

c. REFRACTORINESS – ability of t heart to respond to stimulus while in the state of contraction; d. EXCITTABILITY - ability of the heart to be stimulated

Inotropic effect - force of contraction or strength of myocardial contraction;

Chromotropic Effect – conduction of impulses;

CHRONOTROPIC Effect - rate of contraction

ANTIARRYTHMIC (quinidex, pronestyl)