MNEMONICS

HYPERNATREMIA
FRIED SALT
F - Fever (low), flushed skin
R - Restless (irritable)
I - Increased fluid retention & increased BP
E - Edema (peripheral and pitting)
D - Decreased urinary output, dry mouth

SALT
S - Skin flushed
A - Agitation
L - Low-grade fever
T - Thirst

HYPERKALEMIA - Signs & Symptoms
MURDER

M - Muscle weakness
U - Urine, oliguria, anuria
R - Respiratory distress
D - Decreased cardiac contractility
E - ECG changes
R - Reflexes, hyperreflexia, or areflexia (flaccid)

HYPERKALEMIA - Causes
MACHINE
M - Medications - ACE inhibitors, NSAIDS
A - Acidosis - Metabolic and respiratory
C - Cellular destruction - Burns, traumatic injury
H - Hypoaldosteronism/ hemolysis
I - Intake - Excessive
N - Nephrons, renal failure
E - Excretion - Impaired

HYPOCALCEMIA
CATS
C - Convulsions
A - Arrhythmias
T - Tetany
S - Spasms and stridor

BLEEDING - S/Sx
BEEP
B - Bleeding gums
E - Ecchymoses (bruises)
E - Epistaxis (nosebleed)
P - Petechiae (tiny purplish spots)

RESPIRATORY DEPRESSION - inducing drugs
STOP breathing
S - Sedatives and hypnotics
T - Trimethoprim
O - Opiates
P - Polymyxins

PNEUMOTHORAX - S/Sx
P-THORAX
P - Pleuretic pain
T - Trachea deviation
H - Hyperresonance
O - Onset sudden
R - Reduced breath sounds (& dypsnea)
A - Absent fremitus
X - X-ray shows collapse

PNEUMONIA - risk factors
INSPIRATION
I - Immunosuppression
N - Neoplasia
S - Secretion retention
P - Pulmonary oedema
I - Impaired alveolar macrophages
R - RTI (prior)
A - Antibiotics & cytotoxics
T - Tracheal instrumentation
I - IV dug abuse
O - Other (general debility, immobility)
N - Neurologic impairment of cough reflex, (eg NMJ disorders)

CROUP - S/Sx
SSS
S - Stridor
S - Subglottic swelling
S - Seal-bark cough

SHORTNESS OF BREATH - Causes
AAAA PPPP
A - Airway obstruction
A - Angina
A - Anxiety
A - Asthma
P - Pneumonia
P - Pneumothorax
P - Pulmonary Edema
P - Pulmonary Embolus




CARDIAC VALVES
"TRI before you BI":
Tricuspid valve is located in left heart and Bicuspid valve is located in right heart. Blood flows through the tricuspid before bicuspid.

FEMORAL HERNIA
FEMoral hernias are more common in FEMales.
"TRY PULLING MY AORTA":
Tricuspid
Pulmonary
Mitral
Aorta

PLACENTA-CROSSING SUBSTANCES
"Want My Hot Dog":
Wastes
Antibodies
Nutrients
Teratogens
Microorganisms
Hormones/ HIV
Drugs

EMERGENCY MEDICINE
ACTIVATED CHARCOAL: CONTRAINDICATIONSCHEMICAL CamP:
Cyanide
Hydrocarbons
Ethanol
Metals
Iron
Caustics
Airway unprotected
Lithium
CAMphor
Potassium

IPECAC: CONTRAINDICATIONS
4 C's:
Comatose
Convulsing
Corrosive
hydroCarbon

ATRIAL FIBRILLATION: CAUSES OF NEW ONSET
THE ATRIAL FIBS:
Thyroid
Hypothermia
Embolism (P.E.)
Alcohol
Trauma (cardiac contusion)
Recent surgery (post CABG)
Ischemia
Atrial enlargement
Lone or idiopathic
Fever, anemia, high-output states
Infarct
Bad valves (mitral stenosis)
Stimulants (cocaine, theo, amphet, caffeine)

ENDOTRACHEAL TUBE DELIVERABLE DRUGS
O NAVEL:
Oxygen
Naloxone
Atropine
Ventolin (albuterol)
Epinephrine
Lidocaine

MALARIA: COMPLICATIONS OF FALCIPARUM MALARIA
CHAPLIN:
Cerebral malaria/ Coma
Hypoglycemia
Anaemia
Pulmonary edema
Lactic acidosis
Infections
Necrois of renal tubules (ATN)

MI: IMMEDIATE TREATMENT
DOGASH:
Diamorphine
Oxygen
GTN spray
Asprin 300mg
Streptokinase
Heparin

PAIN HISTORY CHECKLIST
OLDER SAAB:
Onset
Location
Description (what does it feel like)
Exacerbating factors
Radiation
Severity
Associated symptoms
Alleviating factors
Before (ever experience this before)

SHOCK: SIGNS AND SYMPTOMS
TV SPARC CUBE:
Thirst
Vomiting
Sweating
Pulse weak
Anxious
Respirations shallow/rapid
Cool
Cyanotic
Unconscious
BP low
Eyes blank

SUBARACHNOID HEMORRHAGE (SAH) CAUSES
BATS:
Berry aneurysm
Arteriovenous malformation/ Adult polycystic kidney disease
Trauma (eg being struck with baseball bat)
Stroke

VENTRICULAR FIBRILLATION: TREATMENT
"Shock, Shock, Shock, Everybody Shock, Little Shock, Big Shock, Momma Shock, Poppa Shock":
Shock= Defibrillate
Everybody= Epinephine
Little= Lidocaine
Big= Bretylium
Momma= MgSO4
Poppa= Pocainamide

VFIB/VTACH DRUGS USED ACCORDING TO ACLS
"Every Little Boy Must Pray":
Epinephrine
Lidocaine
Bretylium
Magsulfate
Procainamide

DIABETIC KETOACIDOSIS MANAGEMENT
KING UFC:
K+ (potassium)
Insulin (5u/hour. Note: sliding scale no longer recommended in the UK)
Nasogastic tube (if patient comatose)
Glucose (once serum levels drop to 12)
Urea (check it)
Fluids (crytalloids)
Creatinine (check it)/ Catheterize

NEUROLOGICAL FOCAL DEFICITS
10 S's:
Sugar (hypo, hyper)
Stroke
Seizure (Todd's paralysis)
Subdural hematoma
Subarachnoid hemorrhage
Space occupying lesion (tumor, avm, aneurysm, abscess)
Spinal cord syndromes
Somatoform (conversion reaction)
Sclerosis (MS)
Some migraines

COMA: CONDITIONS TO EXCLUDE AS CAUSE
MIDAS:
Meningitis
Intoxication
Diabetes
Air (respiratory failure)
Subdural/ Subarachnoid hemorrhage

MALIGNANT HYPERTHERMIA TREATMENT
"Some Hot Dude Better Give Iced Fluids Fast!" (Hot dude = hypothermia):
Stop triggering agents
Hyperventilate/ Hundred percent oxygen
Dantrolene (2.5mg/kg)
Bicarbonate
Glucose and insulin
IV Fluids and cooling blanket
Fluid output monitoring/ Furosemide/ Fast heart [tachycardia]

RESUSCITATION: BASIC STEPS
ABCDE:
Airway
Breathing
Circulation
Drugs
Environment

RLQ PAIN: DIFFERENTIAL
APPENDICITIS:
Appendicitis/ Abscess
PID/ Period
Pancreatitis
Ectopic/ Endometriosis
Neoplasia
Diverticulitis
Intussusception
Crohns Disease/ Cyst (ovarian)

IBD
Torsion (ovary)
Irritable Bowel Syndrome
Stones

GASTRO INTESTINAL ISSUES OF OLDER ADULTS

GIT – Comprised of those organs necessary for digestion absorption and storage of vital nutrients and vitamins.

I. GIT System changes in the older adult
1.) Mouth dryness caused by decreased salivation.
2.) Retraction of Gingiva
3.) Shrinkage and fibrosis of root pulp
4.) Loss of bone density in alveolar bridge
5.) Loss of papillae on tongue, atrophied tasted buds
6.) Decreased esophageal motility, relaxed lower sphincter
7.) Weak gag reflex
8.) Reduced stomach emptying and motility
9.) Decreased secretion of hydrochloric acid
10.) Poor absorption of vitamins and minerals
11.) Atrophy of small and large intestines
12.) Reduction of peristaltic activity

A.) Gastritis and Ulcers
1. Def.: inflammatory change and erosion in the stomach’s mucus membrane.
2. Etiology : drug-induced ulcers resulting from increased acidity common in older adults (iron, aspirin, no steroids, anti-inflammatory medications), psychological stress, alcohol, disease processes
3. Incidence: both gastric and duodenal ulcers occur in the older adult, but gastric ulcers are more common, men are more prone to peptic ulcer disease.
4. Typical Clinical Presentation – epigastric pain, malaise, anorexia, emesis, wt. Loss, melena, anemia
5. Diagnostic Tests – stools for occult blood, GI series and endoscopy.

6. Nursing Management
a.) Assessment: vital signs, stool for occult blood, pain location, stress level, alcohol intake
b.) Nursing Diagnosis:
1.) Pain related to ulceration of stomach mucosa
2.) Knowledge Deficit related to self-care

c.) Interventions
1). Medical
a). Medications as ordered
b.) Relief of symptoms (antispasmodics)
c.) Dietary modifications (fiber rich, bland diet)
d.) Antacids to reduce acidity
e.) Stress reductions

3.) Nursing
a.) Report abnormal findings promptly, especially BP decrease, and pulse increase; blood in vomitus or stool
b.) Observe stool for occult blood, epigastric pain, monitor medications
c.) Reassurance
d.) Adequate rest
e.) Observation for constipation/diarrhea
f.) Diet, medication monitoring
g.) Stress reduction/ lifestyle modification

Evaluation
1.) Client will be free of pain
2.) No GI bleed will occur
3.) Ulcerations will diminish in size

B. Constipation – decrease in the frequency from the usual bowel elimination pattern or the onset of difficulty in defecating.
I. Etiology in the older adult
1. decreased physical activity and mobility leading to slower transit time
2. Decreased abdominal musculature
3. Chronic illness – prolonged bed rest
4. Prescription and non-prescription drugs I.e. anticholinergics, NSAIDS, iron preparation, analgesics, antidepressants, antacids w/ aluminum or calcium, diuretics
5. Poor toileting habits by ignoring urge or not allowing adequate time or privacy
6. Dietary factors – inadequate fluid intake; lack of interest in eating
7. Inappropriate or prolonged use of laxatives and enemas
8. Pathological conditions
a.) Diverticuloses
b.) Tumors
c.) Hemorrhoids
d.) Depression
e.) Dehydration

II. Clinical Presentation
1. Change in defecating pattern
2. Anorexia
3. Straining to defecate
4. Complaints of abdominal or rectal fullness
5. Abdominal distention with dullness to percussion
6. Fecal impaction

III. Management
a.) Assessment – refer to clinical presentation for objective cues, address history of causes
b.) Nursing diagnosis
a.) Abdominal pain
b.) Altered, patterns of bowel elimination
c.) Interventions
1.) Routine toileting schedule, encourage to sit 15-30 minutes, avoid straining
2.) Respond to urge to defecate
3.) Daily physical exercise, passive and active range of motion in the bed ridden
4.) Minimum daily fluid intake of 1500-2000 cc
5.) Discourage routine use of laxatives, enemas and suppositories
6.) Respond appropriately to client’s definition of constipation, explaining normal colonic physiology and emphasizing that daily defecation is not essential and less than daily defecations are normal for older adults.
7.) Address to environmental needs to promote mobility and functions.
8.) Appropriate and short term use pf pharmaceutical agents in the lowest effective dose. Bulk forming agents, laxatives, stool softness, stimulants and enemas.




Changes in Urinary Elimination
1.) The excretory function of the kidney diminishes with age.
2.) With age, the number of functioning nephrons decreases to some degree, thus impairing the kidney’s filtering abilities.
3.) The muscle tone of the bladder decreases with aging. This decrease the amount of urine it can hold. Complaints of urinary urgency and urinary frequency are common.
4.) In men, these changes are often due to an enlarge prostate gland and in women to weakened muscles supporting the bladder or weakness of the urethral sphincter.
5.) Retention of residual urine predisposes the elderly adult to bladder infections.
6.) Incontinence is a common problem for many older people. Bladder incontinence means the inability to control urination. Bowel incontinence means the inability to control bowel movements

Incontinence is not a “normal” consequence of aging
Women over the age of 60 have 2x the incidence as men
Without proper assessment, incontinence often leads to premature institutionalization
Social isolation and depression can accompany the embarrassment of incontinence.

II. Assessment
a) Identify contributing factors presence of acute and chronic illness, tumors, brain and spinal cord injuries; pharmaceuticals
b.) Environmental assessment
c.) Physical examination
d.) Laboratory work-ups

III. Interventions for urinary incontinence
A.) Behavioral techniques
1.) Bladder training for urges & stress incontinence.
2.) Habit training or timed voiding for urge incontinence.
3.) Kegel exercises (pelvic floor)
4.) Maintain fluid intake at 1500 cc or more before evening hours; limit caffeine products to breakfast and lunch hours.
5.) Modify environment for functional incontinence including adequate lighting, toilet w/in easy reach, portable commode if necessary, alteration of clothing with wide openings in slacks and easy closure.

B.) Pharmaceutical agents i.e. Anticholinergics, alpha-adrenergic agonists.
C.) Surgical intervention – should not be overlooked.
D.) Others

1.) Intermittent self-catheterization is appropriate measure to manage acute and chronic urinary retention.
2.) Indwelling catheter limited to 2-4 weeks.
3.) Absorbent pads and garments offer thorough evaluation.

SENSORIMOTOR STIMULATION

I. Age-Related Changes
- Occur slowly, bringing with them a decrease inactivity and function. Most older adults can continue to adopt and function in their usual environment.

1. Vision
1. Presbyopia – “farsightedness” – loss of range of accommodation for new vision
a.) Onset: often the age of 40 years
b.) Cause: loss of flexibility of the lens
c.) Corrective lenses assist individual to maintain visual function

2. Cataracts
a.) Clouding of the opacity of the lens of the eye
b.) Almost all of the individuals over the age of 65 will have some type of cataract formations
c.) Major causes of legal blindness
d.) Diabetes Mellitus and hypoparathyroidism increase risk of cataracts

3. Decreased Lacrimations
a.) “Dry eye”
b.) Interventions: Artificial lubrication; eliminate secondary infections caused by rubbing eyes

4. Senile Muscular Degeneration (SMD)
a.) Loss of central vision
b.) Individuals needs reassurance and assistance to learn to use peripheral vision
c.) No definitive, effective treatment
5. Glaucoma
a.) Often asymptomatic
b.) Occurs more frequently in African-Americans
c.) All individuals over age 40 years should have routine eye examinations that test for glaucoma (tonometry).
d.) Primary chronic open-angle glaucoma takes time to develop and individuals may not be aware of any vision changes, associated with diabetes.
e.) Primary acute-closed angle glaucoma is acute in nature; characterized by painful episodes and marked decrease in vision.

A. Auditory: because hearing loss is gradual and progressive, many learn to compensate by lip-reading and positioning themselves advantageously, often individuals limit conversation to assist with “guessing” which can lead in turn to isolation.
1. Presbycusis
a.) Inability to hear high-frequency sounds
b.) Inability to understand the spoken word
2. Cerumen
a.) Secreted in smaller amounts as one ages, but with more keratin, making it more difficult to remove.
b.) If not removed, can cause difficulty with hearing.

B. Smell
2.) Changes can be caused by disease, smoking and environment

C. Taste
1.) Changes include periodontal disease, gingivitis, tooth loss, decreased saliva secretions. Atrophic changes of the tongue can lead to decreased ability to taste.
2.) Sweet taste remains consistent, while salt taste diminishes with aging.

D. Touch
1.) Influenced by physical, as well as psychological and socio cultural issues.
2.) Decreased reaction time.



II. Sensory Stimulations – An important aspect of nursing care, it can be used to maintain as individual’s orientation.
A.) Sight
1.) Provide adequate lighting
2.) Offer large print books, playing cards.
3.) Face the client when speaking with him or her
4.) Do not cover mouth, smoke, or chew gum when speaking
5.) Allow TV or Radio
6.) Make sure eyeglasses, contact lenses are clean and worn
7.) Color-code doors
8.) Place telephone within reach
9.) Announce presence when entering the room
10.) In a new setting, tell client where the furniture is located and allow client to become oriented while you are present.
11.) Do not change client’s schedule without telling him or her.
12.) Explain to the client how his or her meal tray is arranged so he or she can feed himself or herself.
13.) Select clothes with large pockets so client can keep personal items there without losing them.

B.) Hearing
1.) Clean out ear wax
2.) If client has a hearing aid, make sure it is used.
3.) Explain extraneous noises.
4.) Speak at a moderate rate of speed.
5.) Make sure client can see your mouth.
6.) Inform client if topic of conversation changes.
7.) Always speak into client’s “good ear”.
8.) Keep pad and pencil near.

C.) Smell
1.) Encourage client to smell food
2.) After bathing, apply lotions and cologne.
3.) Encourage client to keep clean.
4.) Provide opportunities to use pleasant odors.
5.) Install smoke detectors.

D.) Taste
1.) Give consideration to special diets.
2.) Give client a choice of foods.
3.) Arrange food on a tray so it appears attractive
4.) Check food to be sure it is served at the correct temperature.
5.) Encourage oral hygiene before and after meals.

E.) Touch
1.) Offer back rubs with lotions
2.) Touch hands or arms when speaking to the client.
3.) Allow client to touch.

F.) Speech
1.) Utilize YES & NO signals, such as nodding or shaking head.
2.) Have picture word-cards available.
3.) Be alert to facial expressions, pointing, touching.
4.) Have pen and paper available for writing.

Neurological and Alzheimer ’s disease
The nervous system in the adult is composed of
1.) CNS
a.) Brain – Cognition, memory, behavior
b.) Spinal Cord – Communication with the brain, coordinates-reflexes and sensory activity.
2.) Peripheral Nervous System

Normal Physiologic changes in the elderly
A.) 1.) Small decrease in brain wt. And volume (7-8%)
2.) Loss of large neurons in selective cortical and sub cortical structures.
3.) Neurochemical changes includes decreased activity of catecholamine synthesis, enzymes
4.) Dec. amts. Of neurotransmitter.

B.) Age-Associated Memory Changes
1.) Forget specific details and names of people, but will remember these later
2.) General awareness of memory impairment.
3.) Able to learn new material but may have difficulty with information retrieval.
4.) Memory impairment does not impair daily functioning.

C.) No clinically significant changes in behavior or personality.
Some diseases affecting the CNS in the elderly include:
a.) Cerebral vascular accident (CVA)/Stroke – is a disease of circulatory system which affects brain function.
It is caused by a blood clot or bleeding in the brain which destroys brain tissue.
A stroke often affects the part of the brain controlling movements may cause paralysis on one side – Hemiplegia
Strokes can also affect speech centers and the client may have aphasia.

b.) Parkinson’s Disease
Cause the resident to have tremors or shaking; stiff, rigid muscles; a shuffling gait; and gen. Weakness.
Medication often helps ease some of these problems.

c.) Alzheimer’s – Type Dementia
1. Dementia – a set of symptoms which reflect a progressive deterioration in intellect and/or behavior, causing impairment in an individual’s ability to function in everyday life. There are over 70 progressive , irreversible disorders that cause dementia.
2. Alzheimer ’s disease (AD) – A progressive neurological disease that affects one’s ability to think, remember reason, judge, concentrate and perform day-to-day activities. It also affects one’s personality, language and behavior; approximately 66% of all dementias are Alzheimer ’s disease.

Management:
a.) Medical – Tacrine Hydrochloride is the only drug approved by the FDA for the treatment of AD.
b.) Nursing – Main goal is to help the client feel safe, comfortable, in control pleased, satisfied and able to experience the highest possible physical, emotional, intellectual and social functioning for as long as possible.

Psychosocial Development – A number of theories explain psychosocial aging.
1.) Disengagement Theory – Aging involves mutual withdrawal (disengagement) between the older person and others in the elderly person’s environment.
2.) Activity theory – The best way to age is to stay active physically and mentally
3.) Continuity Theory - People maintain their values, habits and behavior in old age.

Peck proposes the developmental tasks of the older adult as follows:
1.) Adjusting to decreasing physical strength and health.
2.) Adjusting to retirement and reduced income.
3.) Adjusting to the death of one’s spouse.
4.) Establishing an explicit affiliation with one’s age group.
5.) Meeting social and civic obligations.
6.) Establishing satisfactory living arrangements.
7.) Establishing satisfactory relationships with adult children.
8.) Finding meaning in life.



Gerontology – is the process including biologic, psychologic, and sociologic factors.

Geriatrics – is the term for the medical specialty that addresses the diagnosis and treatment of the physical problems of the elderly person.

Nursing practice that focuses on the care of the elderly requires basic nursing knowledge of skills combined with specialized knowledge of the diverse need of the aging population.

Category
Age 60-74 = the young old
Age 75-84 = the middle old
Age 85- older = the old old

Scientist have postulated theories of why people age. Biologic theories of aging are either extrinsic or intrinsic
Extrinsic theory – encompasses factors in the environment i.e. wear and tear theory
Intrinsic theory – address factors within the body e.g. free radical theory,
Genetic theory, immune theory.

Physical Changes of Aging
Integumentary System
Decreased vascularity of the dermis – skin becomes paler, loses its elasticity, slower wound healing.
ß melanin production – pallor; makes skin prone to skin cancer
ß Sebaceous and sweet glands function – causes dryness of the skin Þ itching; tolerance to extreme cold and warm climate.
ß collagen and SC fat - ß elasticity
ß thickness of the epidermis
Thinning of hair – due to ß vascularity of the tissue layer that produces hair follicle, loss of hair color is due to a decrease in the # of functioning melanocytes.
Decrease rate of the hair growth
Thickening of connective tissue – causes finger nails and toe nails to become thickened and brittle.

Body temp. - body temp. is lower in the elderly adult because of a decrease in the metabolic rate. It’s not uncommon for an elderly adult to have a 350C (950F) in the early morning as N base line.

Intolerance to cold Þ due to ß (diminished)
Shivering reflex and low metabolic rate.

Intolerance to heat Þ sluggish sweating and circulatory mechanism.

Basic Nursing Care

Protect your client from exposure to sun and elements; wind, cold, or rain.
-Use sun block or sunscreen at all times.
Reduce pressure on body parts at all times changing the position of your client frequently, as often as every 2 hours. (Use of special pads i.e. egg crate cushion)
Keep the client’s body as clean and dry as possible esp. if the client is incontinent. Use a disposable bed protector to make cleaning easier.
Keep linens wrinkle free, smooth and dry at all times. Do not let the client lie on catheters or any type of tubing.
Be alert to the effects that medication have on the skin.
Encourage good eating habits and the adequate intake of fluids.

waht to do before taking the exam

1. Exercise! 30 minutes of brisk walking 3x a week will do. Exercise promotes circulation at the same time gives you energy to study for long periods of time. You will be surprise on how much energy you will have if you do regular exercise.

2. In your review session, I see people copying everything in the black board and does not anymore pay attention to the lecturer, try to listen more to what the lecturer has to say and just copy key points, remember you already took this up at school, the lecturer are only trying to refresh your mind. You will get lots of tips from your lecturer if you listen attentively that you could not find in textbooks.

3. When you get home, try to review what you have written down at review class.

4. Try to go over past board exam questions. Ex. Try to finish 300 questions weekly. It will improve your comprehension at the same time familiarize yourself on how they struture their questions.

5. Have a study partner and take turn to discuss specific areas to be reviewed (cardiovascular system, respiratory sytem, endo etc). As the saying goes "Two heads are better than one". If you can't concentrate at home because of distractions, try the coffee station, library or even go to the beach to study.

6. Make your mnemonics. Post it all around you- in the bathroom, bedside table, in your bag , in the car etc.

7. Focus more on Psychiatric, Maternal Nursing, Community Nursing and Research. Drugs are rarely asked in the Nursing Board Exam. Try to also go over some Nclex questions regarding prioritization. Remember, questions in the exam are to test your competence if you are qualified for an ENTRY LEVEL NURSE only.

8. Try to avoid fatty foods. Drink Vitamin B complex, it helps in blood circulation and better memory.

9. Recommended books are Carl Balita textbooks, Community Health Nursing, passed board exam questionnaires.

10. Think Positive! Love and pamper yourself because it will reep all benefits in the end.

11. It helps if you can group together and ask each other questions. It speeds up learning.

12. Decide on a study habit. Ex. 1 hour daily before you sleep.

13. If you are wondering, "What if i made a mistake shading the wrong box, should i go ahead and erase it and shade the correct one?" What i did was, if I know the correct answer and that I shaded the wrong box, i went off and corrected my answer. BUT, you have to make sure to shade the back portion also so that it will not create dent.

14. Pray! It can it really do wonders...

pathophysiology: cholelithiasis

Cholelithiasis is the presence of stones in the gallbladder. Cholecystitis is acute or chronic inflammation of the gallbladder. Choledocholithiasis is the presence of stones in the common bile duct.

Most gallstones result from supersaturation of cholesterol in the bile, which acts as an irritant, producing inflammation in the gallbladder, and which precipitates out of bile, causing stones. Risk factors include gender (women four times as like to develop cholesterol stones as men), age (older than age 40), multiple parity, obesity, use of estrogen and cholesterol-lowering drugs, bile acid malabsorption with GI disease, genetic predisposition, rapid weight loss. Pigment stones occur when free bilirubin combines with calcium. These stones occur primarily in patients with cirrhosis, hemolysis, and biliary infections.

Acute cholecystitis is caused primarily by gallstone obstruction of the cystic duct with edema, inflammation, and bacterial invasion. It may also occur in the absence of stones, as a result of major surgical procedures, severe trauma, or burns.

Chronic cholecystitis results from repeated attacks of cholecystitis, presence of stones, or chronic irritation. The gallbladder becomes thickened, rigid, fibrotic, and functions poorly.
Complications of gallbladder disease include cholangitis; necrosis, empyema, and perforation of gallbladder; biliary fistula through duodenum; gallstone ileus; and adenocarcinoma of the gallbladder.

pathophysiology: CVA

Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than 24 hours. Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood vessel by cerebral thrombosis or embolism or hemorrhage (leakage of blood from a vessel causes compression of brain tissue and spasm of adjacent vessels). Hemorrhage may occur outside the dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance itself (intracerebral).

Risk factors for stroke include transient ischemic attacks (TIAs) – warning sign of impending stroke – hypertension, arteriosclerosis, heart disease, elevated cholesterol, diabetes mellitus, obesity, carotid stenosis, polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarette smoking. Complications of stroke include aspiration pneumonia, dysphagia, constractures, deep vein thrombosis, pulmonary embolism, depression and brain stem herniation.

pathophysiology: leukemia

Leukemia is malignant neoplasms of the cells derived from either the myeloid or lymphoid line of the hematopoietic stem cells in the bone marrow. Proliferating abnormal and immature cells (blast) spill out into the blood and infiltrate the spleen, lymph nodes, and other tissue. Acute leukemias are characterized by rapid progression of symptoms. High numbers (greater than 50,000/mm3) of circulating blast weaken blood vessel walls, with high risk for rupture and bleeding, including intracranial hemorrhage.

Lymphocytic leukemias involve immature lymphocytes and their progenitors. They arise in the bone marrows but infiltrate the spleen, lymph nodes, central nervous system (CNS), and other tissues. Myelogenous leukemias involve the pluripotent myeloid stem cells and, thus, interfere with the maturation of granulocytes, erythrocytes, and thrombocytes. Acute myelogenous leukemias (AML) and acute lymphatic leukemia (ALL) have similar presentations and courses. Approximately half of new leukemias are acute. Approximately 85 % of acute leukemias in adults are AML, and incidence of AML increases with age. ALL is the most common cancer in children, with peak incidence between ages 2 and 9.

Although the cause of leukemias is unknown, predisposing factors include genetic susceptibility, exposure to ionizing radiation or certain chemicals and toxins, some genetic disorder (Down syndromes, Fanconi’s anemia), and human T-cell leukemia-lymphoma virus. Complications include infection, leukostasis leading to hemorrhage, renal failure, tumor lysis syndrome, and disseminating intravascular coagulation.

pathophysiology: Hypertension (HPN)

Hypertension (high blood pressure) is a disease of vascular regulation resulting from malfunction of arterial pressure control mechanisms (central nervous system, rennin-angiotensinaldosterone system, extracellular fluid volume.) the cause is unknown, and there is no cure. The basic explanation is that blood pressure is elevated when there is increased cardiac output plus increased peripheral vascular resistance.

The two major types of hypertension are primary (essential) hypertension, in which diastrolic pressure is 90 mm Hg or higher and systolic pressure is 140 mm Hg or higher in absence of other causes of hypertension (approximately 95 % of patients); and Secondary hypertension, which results primarily from renal disease, endocrine disorders, and coarctation of the aorta. Either of these conditions may give rise to accelerated hypertension – a medical emergency – in which blood pressure elevates very rapidly to threaten one or more of the target organs: the brain, kidney, or the heart.

Hypertension is one of the most prevalent chronic diseases for which treatment is available; however, most patients with hypertension are unaware, untreated, or inadequately treated. Risk factors for hypertension are age between 30 and 70; black; overweight; sleep apnea; family history; cigarette smoking; sedentary lifestyle; and diabetes mellitus. Because hypertension presents no over symptoms, it is termed the “silent killer.” The untreated disease may progress to retinopathy, renal failure, coronary artery disease, heart failure, and stroke.

Hypertension in children is defined as the average systolic or diastolic blood pressure greater than or equal to the 95th percentile for age and sex with measurement on at lease three occasions. The incidence of hypertension in children is low, but it is increasingly being recognized in adolescents; and it may occur in neonates, infants, and young children with secondary causes.

pathophysiology: Apendicitis

Appendicitis is inflammation of the vermiform appendix caused by an obstruction attributable to infection, structure, fecal mass, foreign body, or tumor. Appendicitis can affect either gender at any age, but is most common in males 10 to 30. Appendicitis is the most common disease requiring surgery. If left untreated, appendicitis may progress to abscess, perforation, subsequent peritonitis, and death.

pathophysiology: liver Cirrhosis

Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissues. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Complications include hyponatremia, water retention, bleeding esophageal varices, coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.

Cirrhosis is known in three major forms. In Laennec’s (alcohol-induced) cirrhosis, fibrosis occurs mainly around central veins and portal areas. This is the most common form of cirrhosis and results from chronic alcoholism and malnutrition. Postnecrotic (micronodular) cirrhosis consist of broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis. Biliary cirrhosis consists of scarring of bile ducts and lobes of the liver and results from chronic biliary obstruction and infection (cholangitis), and is much rarer than the preceding forms.

pathophysiology: CHF

Heart Failure, also known as Congestive Heart Failure, is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricle’s ability to pump enough oxygenated blood to meet the body’s metabolic requirements.

Compensatory mechanisms of increased heart rate,

vasoconstriction,

hypertrophy eventually fail,

leading to the characteristic syndrome of heart failure:

Elevated ventricular or atrial pressures,

sodium and water retention,

decreased cardiac output, and

circulatory and pulmonary congestion.

Systolic dysfunction occurs when the left ventricle is unable to relax and fill sufficiently to accommodate enough oxygenated blood returning from the pulmonary circuit. Systolic dysfunction leads to increased vascular resistance and increased afterload. Diastolic dysfunction leads to pulmonary vascular congestion.

pathophysiology: chronic Bronchitis

• Chronic Obstructive Pulmonary Disease (COPD) is a disease characterized by airflow limitation that is not fully reversible. Airflow limitation is usually progressive and associated with an inflammatory response in the lungs stimulated by irritants. COPD includes chronic bronchitis and pulmonary emphysema. Although sometimes included in COPD, asthma is a reversible disorder and is therefore considered elsewhere.


• 
  Chronic bronchitis is chronic inflammation of the lower airways characterized by excessive secretion of mucus, hypertrophy of mucous glands, and recurring infection, progressing to narrowing and obstruction of airflow. Emphysema is the enlargement of the air spaces distal to the terminal bronchioles, with breakdown of alveolar walls and loss of elastic recoil of the lungs. The two conditions may overlap, resulting in subsequent derangement of airways dynamics (e.g., obstruction to airflow). In pulmonary emphysema, lung function progressively deteriorates for many years before the illness becomes apparent.


• 
  The most common cause of COPD is cigarette smoking. Air pollution, occupational exposures, allergens, and infections may also act as irritants. Alpha1-antitrypsin deficient is an infrequent cause. Complications include respiratory failure, pneumonia or other overwhelming respiratory infection, right heart failure (cor pulmonale), arrhythmias, and depression.
  
  

pathophysiology: HYDROCEPHALUS

The primary site of CSF formation is believed to be the choroid plexusus of the lateral ventricles.

• CSF flows from the lateral ventricles through the foramen of Monro to the third ventricle, then through the aqueduct of Sylvius into the fourth ventricle through the foramen of Luschka and the midline foramen of Magendie into the cisterna magna. From there it flows to the cerebral and cerebellar subarachnoid spaces where ti is absorbed.



• 
  Causes of Hydrocephalus are varied but result in either impaired absorption of CSF within the arachnoid space (formerly referred to as communicating hydrocephalus) or obstruction to the flow of CSF through the ventricular system (formerly referred as noncommunicating hydrocephalus.



• 
  Most cases of obstruction are the result of developmental malformations; other causes include neoplasms, infection and trauma. Obstruction to the normal flow can occur at any point in the CSF pathway, which produces increased pressure and dilation of the pathways proximal to the site of obstruction.



• 
  Impaired absorption can result form meningitis, prenatal maternal infections, meningeal malignancy (secondary to leukemia or lymphoma), an arachnoid cyst, and tuberculosis.

POST MORTEM CARE

Assessment:
1. Check vital functions and pronounce patient dead if permitted to do so, notify physician and record time of death and time pronounced dead.
2. Notify the following:
A. Attending Physician
B. Nursing Supervisor
C. Admitting or Census Department
D. Appropriate Agency for Organ Procedures
E. Medical Examiner
F. Designated Mortician

Planning:
1. Plan for any special religious/cultural practices desired by family.
2. Offer to transfer any other patients in room to another location temporarily.
3. Wash hands.
4. Gather equipments.

Implementation:
1. Place “No visitor - Check at Nurses’ Station” sign to door.
2. Place body in supine position with bed flat.
3. Place pillow under head.
4. Close patient’s eyes.
5. Remove watch, jewelry and all possessions, give it to the nearest relative.
6. Put on clean gloves.
7. Place small towel under chin.
8. Remove IV and other tubes unless autopsy is to take place.
9. Remove soiled dressings, ostomy bags and replace them.
10. Wash soiled areas of body.
11. Place ABD’s (disposable pads) to the perineal area to absorb any stool or urine released as the sphincter muscle relaxes.
12. Remove and discard gloves.
13. Put a clean gown on the patient.
14. Leave the wrist identifications band in place
15. Attach a second identification tag to the ankle or great toe.
16. If the body is to be viewed, replace top linens and tidy the unit.
17. Care for dentures and eye glasses, after viewing leave dentures in patients mount or place them in a denture container. Dentures and eyeglasses are sent to the morticians with the body.
18. Gather personal effects and give to the family or provide for safekeeping.
19. Wrap body and attach identification tag on outside, if facility policy indicates.
20. Transport body to facility morgue or wait for the arrival of the mortician.
21. Put away or dispose equipment and supplies used.
22. Wash your hands.
Evaluation:
1. Evaluate using the following criteria:
A. Body cared for and transported appropriately.
B. All necessary notifications carried out.
C. Family able to carry out rituals, viewing, and spend time with patient as desired. Possessions were carefully handled.

Documentation:
1. Document Post Mortem activities including:
A. Time of cessation of Vital Signs.
B. Persons notified and time of notification.
C. List and documentation of valuable and personal effects.
D. Time body removed from unit, destination and by whom removed.
E. Other information required by faculty.

COLOSTOMY CARE

Reasons for Performing a Colostomy
When feces cannot progress naturally from the colon to the anus
When it is more desirable or manageable to divert the feces, as for paraplegics
In any condition where the rectum or anus is nonfunctional because of disease, a birth defect or a traumatic condition.
It is performed to divert the fecal flow away from an area of inflammation or around an operative area

General Procedure for Changing an Ostomy Pouch

Assessment
Identify the type of ostomy the patient has and its location (Bowel Urinary Diversion)
Assess the skin integrity around the stoma and as general appearance
Note the amount and character of any fecal material or urine in the pouch
Determine whether the patient is being taught self-care at the moment

Planning
Wash your hands
Gather the equipment needed in changing a pouch or dressing
Cleansing supplies including tissues, warm water, mild soap, wash cloth and a towel
Clean pouch of the type currently being used
Seal or use tape to prevent leakage
Clean belt
Dressing materials
Receptacle for the soiled pouch or dressing (bedpan, paper bag/newspaper for wrapping)
Protective spray
Clean gloves
Determine whether the patient is to participate actively
Choose the appropriate location in performing the procedure (bathroom/ bedside)

Implementation
Identify the patient
Explain the procedure to the patient
Put on clean gloves for infection
Assist the patient to the bathroom or provide privacy
Remove the soiled dressing
Using warm water and a mild soap, cleanse the skin around the stoma thoroughly. Inspect the skin for redness or irritation.
Cover the stoma with a tissue to prevent feces or urine from contacting. Change tissues as necessary during the procedure
Dry the skin around the stoma carefully, patting gently
Apply a skin protective spray if needed
Allow the skin to dry thoroughly so the pouch will adhere firmly (a hair dryer on a low setting at least 18 inches from the skin may be used)
Remove the tissue from the stoma and apply the clean pouch or dressing
Remove gloves and wash hands

Evaluation
Evaluate using the following criteria
Pouch or dressing secure
Area clean
Odor free
Patient comfortable
If the patient is being taught the procedure, add the following criteria:
Patient is able to change pouch using correct technique
Patient verbalizes understanding of key points in care

Documentation
Record the following information:
The amount, color, and consistency of the fecal material or urine in the pouch
The application of the clean pouch and dressing change
The knowledge and ability of the patient t participate in the procedure or ability to change independently.

Nightingale Pledge

The Florence Nightingale Pledge

I solemnly pledge myself before God and presence of this assembly;To pass my life in purity and to practice my profession faithfully.I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug.I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling.With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.

Cystic Fibrosis

Is an autosomal recessive disorder affecting the exocrine glands, in which their secretions become abnormally viscous and liable to obstruct glandular ducts.

It primarily affects pulmonary and GI function.

The average life expectancy for the cystic fibrosis patient is currently age 30 to 40. Death may occur because of respiratory infection and failure.

Other complications include esophageal varices, diabetes, chronic sinusitis, pancreatitis, rectal polyps, intussusceptions, growth retardation, and infertility.

Assessment:

Usually present before age 6 months but severity varies and may present later.

Meconium ileus is found in neonate.

Usually present with respiratory symptoms, chronic cough, and wheezing.

Parents may report salty taste when skin is kissed.

Recurrent pulmonary infections.

Failure to gain weight or grow in the presence of a good appetite.

Frequent, bulky, and foul smelling stools (steatorrhea), excessive flatus, pancreatitis and obstructive jaundice may occur.

Protuberant abdomen, pot belly, wasted buttocks.

Bleeding disorders.

Clubbing of fingers in older child.

Increased anteroposterior chest diameter (barrel chest).

Decreased exertional endurance.

Hyperglycemia, glucosuria with polyuria, and weight loss.

Sterility in males.

Diagnostic Evaluation:

Sweat chloride test measures sodium and chloride level in sweat.
Chloride level of more than 60 mEq/L is virtually diagnostic.
Chloride level of 40 to 60 mEq/L is borderline and should be repeated.

Duodenal secretions: low trypsin concentration is virtually diagnostic.

Stool analysis:
Reduced trypsin and chymotrypsin levels-used for initial screening for cystic fibrosis.
Increased stool fat concentration.
BMC ( Boehringer-Mannheim Corp.) meconium strip test for stool includes lactose and protein content; used for screening.
Chest X-ray may be normal initially; later shows increased areas of infection, overinflation, bronchial thickening and plugging, atelectasis, and fibrosis.
Pulmonary function studies (after age 4) show decreased vital capacity and flow rates and increased residual volume or increased total lung capacity.
Diagnosis is made when a positive sweat test is seen in conjunction with one or more of the following:
Positive family history of cystic fibrosis.
Typical chronic obstructive lung disease.
Documented exocrine pancreatic insufficiency.
Genetic screening may be done for affected families.

Pharmacologic Interventions:

Antimicrobial therapy as indicated for pulmonary infection.
Oral or I.V. antibiotics as required.
Inhaled antibiotics, such as gentamicin or tobramycin, may be used for severe lung disease or colonization of organisms.
Bronchodilators to increase airway size and assist in mucus clearance.
Pulmozyme recombinant human DNase (an enzyme) administered via nebulization to decrease viscosity of secretions.
Pancreatic enzyme supplements with each feeding.
Favored preparation is pancrelipase.
Occasionally, antacid is helpful to improve tolerance of enzymes.
Favorable response to enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite, and lack of abdominal pain.
Gene therapy, in which recombinant DNA containing a corrected gene sequence is introduced into the diseased lung tissue by nebulization, is in clinical trials.

Nursing Interventions:

Monitor weight at least weekly to assess effectiveness of nutritional interventions.
Monitor respiratory status and sputum production, to evaluate response to respiratory care measures.
To promote airway clearance, employ intermittent aerosol therapy three to four times per day when the child is symptomatic.
Perform chest physical therapy three to four times per day after aerosol therapy.
Help the child to relax to cough more easily after postural drainage.
Suction the infant or young child when necessary, if not able to cough.
Teach the child breathing exercises using pursed lips to increase duration of exhalation.
Provide good skin care and position changes to prevent skin breakdown in malnourished child.
Provide frequent mouth care to reduce chances of infection because mucus is present.
Restrict contact with people with respiratory infection.
Encourage diet composed of foods high in calories and protein and moderate to high in fat because absorption of food is incomplete.
Administer fat-soluble vitamins, as prescribed, to counteract malabsorption.
Increase salt intake during hot weather, fever, or excessive exercise to prevent sodium depletion and cardiovascular compromise.
To prevent vomiting, allow ample time for feeding because of irritability if not feeling well and coughing.
Encourage regular exercise and activity to foster sense of accomplishments and independence and improve pulmonary function.
Provide opportunities for parents to learn all aspects of care for the child.
Teach the parents about dietary regimen and special need for calories, fat, and vitamins.
Discuss need for salt replacement, especially on hot summer days or when fever, vomiting, and diarrhea occur.

Hodgkin's disease

Is a malignant lymphoma of the reticuloendothelial system that results in an accumulation of dysfunctional, immature lymphoid-derived cells.

The disease generally spreads by lymphatic channels, involving lymph nodes, spleen, and ultimately (through the bloodstream) to extra lymphatic sites, such as gastrointestinal tract, bone marrow, skin, upper air passages, and other organs.

It is most common in patient ages 20 to 40 and in those older than age 60.
It’s cause is unknown.

Assessment:
Fatigue,
fever,
chills,
night sweats,
painless swelling of lymph nodes (generally unilateral),
pruritus,
weight loss.

Wide variety of symptoms may occur if there is pulmonary involvement, superior vena cava obstruction, hepatic or bone involvement, and involvement of other structures.

Diagnostic Evaluation:

Lymph node biopsy detects characteristic Reed-sternberg giant cell, helping to confirm diagnosis.

Complete blood count and bone marrow aspiration and biopsy determine whether there is bone marrow involvement.

X-rays,
CT scan,
MRI detect deep nodal involvement.

Lymphangiogram
detects size and location of deep nodes involved, including abdominal nodes, which may not be readily seen by CT scan.

Liver function test and liver biopsy determine hepatic involvement.

Gallium-67 detects areas of active disease; determines aggressiveness of disease.
Surgical staging (laparotomy with splenectomy, liver biopsy, multiple lymph node biopsies) may be done in selected patients.

Pharmacologic Interventions:

Chemotherapy may be used in combination with radiation.
Initial treatment often begins with a specific four-drug regimen known as MOPP (Mustargen, Oncovin, procarbazine, and prednisone).
Three or four drugs may be given in intermittent or cyclical courses, with periods of treatment to allow recovery from toxicities.

Surgical Interventions:
Autologous or allogeneic bone marrows or stem cell transplantation.

Nursing Interventions:
To protect the skin receiving radiation, avoid rubbing, powders, deodorants, lotions, or ointments (unless prescribed) or application of heat or cold.
Encourage patient to keep clean and dry, and to bathe the area affected by radiation gently with tepid water and mild soap.
Encourage wearing loose-fitting clothes and to protect skin from exposure to sun, chlorine, and temperature extremes.
To protect oral and gastro-intestinal tract mucous membranes, encourage frequent, small meals, using bland and soft diet at mild temperatures.
Teach the patients to avoid irritants such as alcohol, tobacco, spices, and extremely hot or cold foods.
Administer or teach self-administration of pain medication or antiemetic before eating or drinking, if needed.
Encourage mouth care at least twice per day and after meals using a soft toothbrush or toothete and mild mouth rinse.
Assess for ulcers, plaques, or discharge that may be indicative of superimposed infection.
For diarrhea, switch to low-residue diet and administer anti-diarrheals as ordered.
Teach patient about risk of infection. Advice patient to monitor temperature and report any fever or other sign of infection promptly.
Explain to patient that radiation therapy may cause sterility.