Q: How to prevent STD?

DEEPENING OF VOICE late to develop in men

A: Monogomous relationship
Puberty start at age=9 for both
Test taking strategies:
1. Process of elimination: Q: Most appropriate food for a toddler (active, playful)
2 correct answers, 2 incorrect answers A: Spaghetti

Q: For 1st/2nd/3rd/4th degree burns, nursing priority? X-hotdog, X-grapes = both have skin can cause CHOKING
A: #1 INFECTION X-milk = #1 cause of Iron deficiency
#2 Dependent on the type of burn
1st & 2nd degree = PAIN
3rd & 4th degree = FLUID & ELECTROLYTE

*Best/Most Important/Priority = IMMEDIATELY RELIEVE S/Sx

Airway
Breathing
Circulation
Safety

First/Initial Nursing Action:

Assess
Obtain base line data
Check

Q: Normal physical finding of thyroid gland (anterior of the neck,

only 1 gland with 2 lobes)
A: Nodular Consistency

X-palpable upon swallowing = if client has GOITER, and the only part
that can be palpated on the neck is the Thyroid cartilage (Adams apple)
= Men & women have Adams apple but men are more prominent
because of MORE FAT PADS, women has more fat pads on the BREAST
& HIPS

X-Tenderness, X-Marked asymmetry

THELARCHE breast enlargement 1st to develop in women

MENARCHE late to develop in women
ADRENARCHE pubic, auxillary hair development
TESTICULAR, PENILE ENLARGEMENT 1st to develop in men

1

NERVOUS SYSTEM
A. 3 DIVISIONS OF N/S
1. CNS
a. Brain
b. Spinal Cord H-shaped structure
2. Peripheral N/S (12 pairs of Cranial nerves)
I Olfactory
II Optic
III Occulomotor
IV Trochlear smallest CN
V Trigeminal largest CN
VI Abducen
VII Facial
VIII Acoustic
IX- Glossalpharyngeal
X Vagus longest CN
XI Spinal
XII Hypoglossal
3. Autonomic N/S
a. Symphatetic N/S
b. Parasymphatetic N/S
SYMPHATETIC (SNS)
FIGHT or Aggression Response FLIGHT or withdrawal response
NOREPINEPHRINE @ Adrenal
Medulla
Adrenalins
VASOCONSTRICTOR
All bodily activities except
GIT - Constipation
ADRENERGIC or
Parasympatholytic response
When under STRESS,blood flows
to 3 important organs:
PARASYMPHATETIC (PNS)
ACETHYLCHOLINE
neurotransmitter
[ Acethylcholine = Bipolar
Disorder = Lithium
Acethylcholine = M.Gravies]
All bodily activities except
GIT - Diarrhea
CHOLINERGIC or Vagal or
Sympathetic response
#1 Brain - cerebration = to
think
#2 Heart propel blood to
systemic circulation
#3 Skeletal muscles
GIT = least important organ
blood flow
motility
CONSTIPATION
SYMPHATETIC (SNS) PARASYMPHATETIC (PNS)
Bodily effects
1. Eyes DILATES - CONSTRICTS
Mydriasis aware of surroundings Meiosis
2. Mouth DRY - MOIST
salivation salivation
3. Heart - HR BP - HR BP
4. Lungs
BRONCHODILATION - BRONCHOCONSTRICTION
- O2 because under stress - O2
- RR - RR
5. GIT CONSTIPATION - DIARRHEA
6. Urinary system
- URINARY RETENTION - URINARY FREQUENCY
Correlation to clinical nursing practice:
SYMPHATETIC (SNS) PARASYMPHATETIC (PNS)
I. Adrenergic Agents I. Cholinergic or Sympatholytic
a. Epinephrine, Adrenalins Agents
SE: SNS All except GI a. Beta-adrenergic blocking agents
or beta-blockers LOL
- can not prevent
- expectant effect of drug PropranoLOL
- you can lessen/minimize AtenoLOL
MetropoLOL
II. Antipsychotic Agents
a. Haloperidol
b. Anti-depressants/Tricylic Effects:
Mono Amine Oxidase Inhibitors > Bronchoconstiction/spasm
> 2-4 weeks effects > Ellicits myocardial contraction
ex. PARnate > Treats hypertension
MARplan > AV conductor slows down anti-
NARdil arrythmic, mild arrhythmic
2
c. Anti-anxiety Valium DiazepamIndications: Angina pectoris/MI Parotid gland = located below and in front of ear
to BP HR Medulla Oblongata = respiratory center
SYMPHATETIC (SNS) Frontal lobe = motor/speech head
III. Anti-hypertension Sceaman creases on foot normal
1. Beta-blockers LOL Artificial eyes = dry = use eye drops q 30 mins
2. ACE Inhibitors PRIL ending ex: CaptoPRIL EnalaPRIL when bladder constricts = individual urinates
3. Ca antagonist ex: Nifedipine
IV. Mestinon (Prostigmine) plegia paralysis
hemiplegia L/R paralysis
nice to know: quadriplegia/tetraplegia 4 limbs paralysis
COPD monoplegia 1 limb paralysis
1. Bronchitis - Blue bloaters, paraplegia low extremities, with urinary & bowel
2. Asthma - Allergens, Hereditary incontinence -> relaxed bladder ->atony
3. Bronchiectasis bladder -> urine retention N/R: assist in
4. Emphysema - Pink puffer, barrel chest catheterization
There is no upper extremities paralysis
CENTRAL NERVOUS SYSTEM
A. Cells = Neurons = nerve impulse/conduction B. Neuroglia = acts as support and protection of neurons
Excitability affected to the external changes in the majority of brain tumors arises from Neuroglia
environment
Conductivity transmits away of excitation to one cell to another 1. Types:
Permanent cells once destroyed, not capable of regeneration a. ASTROCYTES outer surface, 90% astrocytoma -> brain
tumor
o maintains the integrity of the blood brain barrier
Types of Cells: o semi-permeable membrane
According to regenerative cells: Location o selective toxic substances can enter:
1. LABILE capable of regenerate GUT, GIT, epidermal, 1) Ammonia = cerebral toxin, 1st toxic substance in the
respiratory cells brain
2. STABLE capable of regeneration Kidney, Liver, Pancreas, Ammonia
with limited survival time Salivary gland-parotid
period gland hepatic encephalopathy (end stage)

3. PERMANENT once destroyed, can not Osteocytes, retina cells,
liver cirrhosis (necrosis of the liver)
regenerate neurons, cardiac cells
Primary cause: Malnutrition-Vit B1 Thiamine def.
nice to know:
Major cause: Alcoholism
For shallow wound, scar suggest to give Vitamin C precursor
collagen, aid in wound healing Early sign of Hepatic encephalopathy:
For stab wound apply direct pressure to stabbed area using clean 1. Asterixis flapping hand tremors
cloth -> use CTT Late signs:
For artificial eyes -> dry N/R: use eye drops q30mins 1. Headache

3
 2. Confusion 4) Lead poisoning 4th toxic substance, Parkinsons
3. Fetor hepaticus disease; Seizure activity. ANTIDOTE : Calcium EDTA
4. LOC leads to hepatic coma
5) Ketone CNS depressant = by product of fat catabolism

Diabetic Ketoacidosis [DKA] DM I-IDDM early sign:

Liver weight loss
fat catabolism headache
converts ammonia
free fatty acid
Urea
Cholesterol Ketones
Urine
Atherosclerosis DKA -> Diabetic coma -> Death
2) Bilirubin 2nd toxic substance yellow pigment irritant HPN
to neurons Late sign: fruity Kaussmauls respiration deep
Bilirubin Acetone rapid, shallow, breathing pattern
Breath odor
Jaundice=icteric sclerae
b. MICROGLIA = stationary cells Phagocytosis cell eating;
Hyperbilirubenemia/Kernicterus engulfing of bacteria or cellular debris

Irreversible Brain Damage nice to know:
ORGAN MACROPHAGES
nice to know: BRAIN 1. Microglia
Biliverdin green pigment BLOOD 2. Monocytes largest WBC
Hemoglobin red pigment KIDNEYS 3. Kupffer macrophages
Hemosiderin golden brown pigment LUNGS 4. Alveolar macrophages
Sclerae white normal SKIN subcutaneous tissues 5. Histocytes
Jaundice if yellow skin, discololoration & icteric sclerae
CAROTENEMIA = tumor in the pituitary gland if yellow skin but c. EPYNDEMAL CELLS secretes a glue-like substance that
NORMAL eyes concentrates bacteria = chemoattractants
HEPATITIS B = from serum most dangerous, may lead to liver cancer,
liver cirrhosis, AIDS Meninges
HEPA I = from infectious hepa Microglia (2)
HEPA A = from fecal-oral route .
Epyndemal cells defense of CNS
3) Carbon monoxide 3rd toxic substance, detaches hgb (1)
from the oxygen; face = pinkish in color; Parkinsons
disease Bacteria

4
 d. OLIGONDENDROCYTES produces myelin sheath covers Bronze like skin pigementation Addisons disease
neurons/fibers; acts as insulator facilitates nerve Buffalo humps, moon faced Cushing syndrome
impulses/conduction Red beefy tongue Pernicious anemia
Strawberry tongue Kawasaki syndrome
Pathognomonic Signs: Disease: Protrusion of tongue; Sceaman creases on Down syndrome
Asterixis flapping hand tremors Hepatic Encephalopathy palm
Pill rolling tremors Parkinsons Disease Machine-like murmur, acyanotic Patent ductus arteriosis
Intentional tremor Multiple Sclerosis Cyanotic, clubbing of fingrs Tetralogy of Fallot
Low grade fever afternoon PTB Hypoxemia with cyanosis Tet spells
Rusty sputum > needs penicillin Pneumonia (+) Levines sign = Hand clutching of chest Angina pectoris
Barrel chest Emphysema emote
Wheezing on expiration Asthma day light vision Retinal detachment
Pseudo membrane Diphtheria Glaucoma
Koplick spots Measles hazy vision Cataract
Chills with step-ladder fever 38-39-40-41oC Malaria
Petechiae Dengue DEMYELINATING DISORDERS: Palliative for s/sx, can not cure
Rose spots on abdomen Typhoid fever
Rice-watery stool, diarrhea = BRAToast Cholera 1. ALZHEIMERS DISEASE = atrophy (shrinkage of an organ) of
Rebound tenderness (+), flex right leg, Appendicitis brain tissue
palpate R iliac inguinal then remove mnesia partial/total loss of memory
immediately gnosia failure to familiarize
(+) Cullens sign bluish discoloration Pancreatitis praxia failure to do the purpose of the object ex.comb-
umbilicus and (+) Gray-turner ecchymosis used to brush teeth
of flank area phasia expressive &/or receptive
(+) Cullens sign and (+) Homans sign feet OB Ectopic pregnancy RICEPT OR COGNEX given best @ bedtime
dorsiflex with pain
(+) Kernigs - leg pain, and (+) Brudzenski Meningitis nice to know:
sign neck pain ANTEROGRADE short memory loss
(+) chevosteks sign face spastic; (+) Hypocalcemia RETROGRADE long term memory loss
Trouseus sign carpopedal spasm EXPRESSIVE APHASIA Broccas inability to speak;
Lock -jaw, sardonic smile, Tetany, tetanus FRONTAL = motor speech center
Exopthalmus Hyperthyroidism RECEPTIVE APHASIA Wernickes inability to understand;
Butterfly rashes TEMPORAL = general
Jaundice Hepatitis interpretative area
Spider angiomas Liver cirrhosis
Lions face Leprosy 2. MULTIPLE SCLEROSIS = chronic intermittent disorder of the
Chipmunk face, over eating, pinge & purge; Bulimia nervosa CNS, characterized by: WHITE PATCHES of demyelinization in
acid of stomach goes to mouth teeth the brain and spinal cord; remission & exacerbation
cavities A. Incidence Rate: women 13-25 y.o.
B. Predisposing Factors:

5
 1. Idopathic unknown cause SUBARACHNOID L3-L4 or L4-L5, no more spinal cord
2. Viruses
3. Autoimmune self-killing immunity ex. 2. Magnetic Resonance Imaging extent & site of
Glomerulonephritis, Systemic Lupus Erythematous = demyelinization with white patches = no nerve impulses; no
connective tissue destruction; Pernicious Anemia myelin sheath
nice to know: WBC = LYMPHOCYTES & ANTIBODY E. Nursing management Palliative
IgG > pass thru placental barrier = Passive (temporary, preventive 1. Administer medication, for acute exacerbation ACTH
action, short acting) ex. IgG to fetus 2. Provide relaxation techniques = deep breathing
> copies the genetic coding 3. Maintain side rails
IgA > present in bodily secretion: saliva; tears; sweat; colostrums 4. Prevent complications of immobility: Adult Q2, Elderly Q1
IgM > largest antibody; acute inflammation 5. Provide catheterization due to urinary incontinence/retention
IgE > allergic reaction 6. Encourage increase Oral fluid Intake, Forced: 2-3L/day (for
IgD > chronic inflammation constipation) and acid ash in the diet ->acidify urine

C. S/SX of Multiple Sclerosis: prune, grape, cranberry CGFNS
1. BLARING of vision visual disturbances orange, pineapple, vitamin C local board
2. IMPAIRED SENSATION to touch, pain, pressure, heat & cold, *avoid bacteria multiplication
7. Avoid heat application
tingling sensation, numbness
3. MOOD SWINGS euphoria elated sense of well being
nice to know: URINARY TRACT INFECTION
4. IMPAIRED MOTOR ACTIVITY
a) Weakness UTI female prone than male (20cm/8inches)
b) Spascity Risk factors:
c) Paralysis 1. Urethra 3-5cm or 1-1.5 inches
5. IMPAIRED CEREBELLAR FUNCTION 2. Poor perineal care/hygiene = back to front, dirtiest to cleanest
CHARCOTS TRIAD: INA 3. Vagina environment = moist, good source of bacterial growth
Intentional Tremors 4. Sexual intercourse without urination after act, leads to urinary
Nystagmus abnormal rotation of eyes to head movement retention
Ataxia unsteady gait
6. Urinary retention/incontinence COMPOSITION OF BRAIN:
7. Constipation 1. Brain mass = 80%
8. Decreased in sexual capacity 2. Blood = 10%
3. Cerebro Spinal Fluid = 10%
D. Diagnostic Procedures:
1. CSF Analysis = reveals IgG and Protein thru Lumbar
Tap/Spinal tap @ L3-L4 subarachnoid space because PARTS OF THE BRAIN:
spinal cord ends @ L1, L2. Aspirate CSF for microscopic I. CEREBRUM
exam II. DIENCEPHALON
nice to know: III. MIDBRAIN or MESENCEPHALON
DURA Subdural IV. BRAIN STEM
ARACHNOID Subarachnoid V. CEREBELLUM

6
I. CEREBRUM largest > FEAR = known cause, ANXIETY = unknown cause, impending doom ,
a) 2 parts: Right and Left Cerebral hemisphere; CORPUS excitement; PHOBIA = extreme fear - desensitization
COLLOSUM=bridge between two hemisphere b) THALAMUS
b) 3 functions: Sensory, Motor, Integrative > relay station for sensation
c) 6 LOBES:
1. FRONTAL lobe > motor activity, personality development, III. MIDBRAIN or MESENCEPHALON
controls higher cortical thinking of brain, Broccas area = relay station for sight and hearing
motor/speech center size of pupil Normal = 2-3mm
2. TEMPORAL lobe > hearing, short term memory loss = hearing acuity
Anterograde, Wernickes area = Receptive
3. PARIETAL lobe > appreciation/discrimination of sensory ISOCORIA = equal size pupil
impulses: pain, touch, pressure, hot, cold -> check if with ANISOCORIA = unequal size pupil
numbness (+) PERRLA = Normal = pupil equally round reactive to light and
4. OCCIPITAL lobe > vision, check if with blindness accommodation; constricts
5. INSULA or ISLET of REIM > above frontal lobe, controls visceral HEARING ACUITY = 30-40 decibels
function/activities of internal organs
6. LIMBIC SYSTEM > controls smell IV. BRAIN STEM
MEDULLA OBLONGATA PONS
RHINENCEPHALON ANOSMIA = absence of smell, sexual Function:
respiration Pneumotaxic center
e. Basal Ganglia > areas of Grey matter, located deep within each heart rate Depth of respiration
cerebral hemisphere, produces dopamine = controls gross vomiting
voluntary movement hiccup = SINGULTUS
swallowing
NEUROTRANSMITTER: vasomotor center
1. AcH M.Gravies, Ptosis Bipolar Disorder spinal deccussation
2. Dopamine Parkinson Schizophrenia *most dangerous if affected

II. DIENCEPHALON V. CEREBELLUM = smallest part of the brain

a) HYPOTHALAMUS balance equilibrium
> thermoregulator center posture, gait coordination
> controls BP
> controls fluids & electrolytes a) Cerebellar Test or Rombergs Test = stand 5 to 10 minutes to:
> controls thirst Assume anatomical posture VS Assume normal anatomical posture
> controls appetite & satiety
> controls sleep & wakefulness
> controls emotional response
> controls some PITUITARY FUNCTION, ex. Adrenergic = Testoterone &
Progesterone
MENOPAUSE = 40 Female; ANDEPAUSE = Male (+) Rombergs Test = ATAXIA: 2 nurses should support in both sides

7
 b) Finger to Nose Test (FTNT)
Individual - faster
(+) FTNT = DYMETRIA = inability
to stop a movement @ a
desired point
Doctor and patient:
Cerebrospinal Fluid
1. Normal Amount = 120-250ml/day
Head injury/trauma
Brain compression
Brain herniation
ICP

24-48H projectile vomiting; irregular RR/HR for monitoring

2. Site of CSF production: CHOROID PLEXUS
3. Composition = Clear, glucose, colorless, protein, WBC, no
RBC
Alternate Supination Pronation 4. CSF function = shock absorber, cushions
Normal: HYDROCEPHALUS = CSF = ICP
If postetriorly = theres early closure of posterior fontanelle

Blood
Stroke = partial/total brains blood supply
Circle of Willis = smallest part of artery
Collateral Circulation 24-48H Internal carotid and Middle Cererbral
Artery
ABNORMAL (+) Alternate Supination Pronation ICP = intracranial bulk brought about in 1 or the 3 major intracranial
*if hands do a Kung Fu style components
Monroe Kellie Hypothesis: A. Predisposing Factors:
Skull is a close container 1. Brain trauma/injury
ICP = 0-15mmHg
2. Brain tumor
C1 = Atlas cervical enlargement, can palpate 3. Localized abscess
C2 = Axis, with Foramen Magnum = hole, above Medulla Oblongata, 4. Hydrocephalous
below C1 5. Meningitis
6. Cerebral edema
B. S/Sx:
1. Early Signs ICP:
a. Agitation
b. Change or LOC
c. Confusion -> restlessness -> agitation -> irritation
d. Disorientation -> Lethargy -> stupor -> coma

8
LOC: wakefulness = AWAKE Level Of Orientation: 3) Tachycardia
1. Conscious 1. Aware 4) Bradycardia
2. Lethargy 2. Coherent 5) Extreme restlessness LATE
3. Stupor 3. Alert 6) Dyspnea
4. Coma 7) Cyanosis
Late signs ICP:
Hypoxia -> Cerebral Edema -> ICP
a. Changes in the vital signs:
> BP SBP, diastolic same
Powerful respiratory stimulant = CO2
> Cheyne Stokes respiration = normal then with episodes of apnea
> HR
b. Assist in mechanical ventilation
> Temperature, Temperature directly proportional BP
CO2
Example:
Patient has 120/80 Pulse pressure = 40mmHg Negative Feedback @ Medulla Oblongata
If ICP, BP 140/80, pulse pressure = 60mmHg -> widening of the pulse
pressure Sends impulses
Brain shock + Cardiac disorder = narrowing of pulse pressure
tissue perfusion Lungs

blood circulation Hyperventilation to remove
If with seizure = DO NOT restrain, may lead to fracture
CO2
CUSHINGs reflex = vital signs different that of ICP
Oxygen = maintain homeostasis
b. Headache, papilledema, projectile vomiting
c. Abnormal posturing
d. Unilateral dilation of pupil UNCAL HERNIATION
e. Possible seizure

C. Nursing Management ICP:

1. Maintain patent airway and adequate ventilation

a. Prevention of hypoxia and hypercabia

tissue oxygenation CO2 level

tissue perfusion

LATE sign of HYPOXIA: RAT-BED-C

1) Restlessness
2) Agitation EARLY

9
MS 01-21-2006
Guillain Barre Syndrome (GBS) disorder of the CNS, characterized by
symmetrical, bi lateral olineuritis, leading to ascending paralysis
Polyneuritis>Inflammation of peripheral nerves
A. Predisposing Factors
Idiopathic
Autoimmune
Antecedent viral infxn
Immunizations (best method URTI Annual flu vaccine) too
costly, not lifetime, yearly, USA 2 doses per year for freely given.
Pneumonia (rusty sputum) vaccine every 5 yrs - esp. 65 yrs old.
Pyloric stenosis olive shaped mass.
B. Signs and Symptoms
Initial sign CLUMSINESS
Dysphagia can lead to aspiration shld be NGT feeding
Ascending muscle paralysis
Decreased Deep Tendon Reflex paralysis (patellar/plantar)
Alternate hypotension/hypertension irregular heart rate
complications- arrythmia
Autonomic changes increased sweating increased lacrimation
/ salivation constipation give anticholinergic agents (Atropine
Sulfate)
C. Diagnostic Procedures
CSF Analysis : elevated CHON and IgG, (+) Lermic sign (post
lumbar tap increased/ forced fluids) CSF opening pressure 50-
160mmHg. ICP =0-15mmHg
D. Nursing Mgmt
1. Maintain patent airway and ventilation
a. assist in mechanical ventilation
b. assess pulmonary function test spirometer vital lung capacity
Incentive spirometry
c. Maintain side rails due to paralysis
d. Prevent complications of immobility every 2 hours, elderly 1 hour
e. Institute NGT feeding
f. Administer medications as ordered
Anticholinergics- (Autoimmune) Give
1. Corticosteroids to suppress immune response BEST
GIVEN IN AM 2/3 dose, and PM 1/3
2. Anti-arrhythmic agents
>> Lidocaine (Xylocaine) SE confusion
>> Bretyllim SE Blocks the release of norepinephrine -
vasodilation hypotension
>> Quinidines - anti-arrhythmic and malaria (king of
tropical diseases - QUEENS) agents Anophelus mosquito
female with antenna lay in the morning (female needs
blood for reproduction) NIGHT BITING [DAY BITING
Dengue Aedis Aegypti- 4 oclock habit-wash in the stagnant
water, lay in the afternoon or night, Complication:
hemorrhage, hypovolemic shocks INITIAL SIGN: COOL
MOIST SKIN RESTLESSNESS, LATE SIGN: ANURIA].
g. Assist in plasmapherresis removing autoimmune and returned
back to the client, other disease who undergoes the same: MG
h. Prevent complications. MOST FEARED: Anemia, respiratory
arrest prepare Trach set at bed side. CTT clamp- to prevent
air leakage prevent pneumothorax & air embolism and extra
bottle and petroleum gauze accidental removal of chest tube
to cover it. Liver cirrhosis complication esophageal varices -
veins of esophagus dilate - bleeding balde balde dugo-
prepare at bedside: Sengstaken Blakemore Tube to decompress
vein prevent bleeding may complain of difficulty of
breathing, prepare with scissor to cut the tube and deflate the
balloon. Hemodialysis Bulldog Clip to prevent embolism.
CONVULSIVE DISORDERS disorder of the CNS characterized by
paroxysmal seizures, with or without loss of consciousness, abnormal
motor activity, alteration in sensation and perception, and changes in
behavior. Is Seizure (1st convulsive attack) and Epilepsy (2nd
convulsive attack). Febrile seizure - <5 yrs old normal, >5 yrs old
epilepsy
A. Predisposing factors
Head injury secondary to birth trauma
CO poisoning antidote: Hyperbaric oxygenation to remove
carbon dioxide and monoxide poisoning decrease Oxygen
carrying capacity of hemoglobin. (Lead poisoning Calcium
Edta)
Genetics
10
 Brain tumor (Astrocytoma) Paranoid, Im Angry Are you angry?, Tactile hallucination
Nutritional and metabolic deficiencies Substance abuse)
Sudden withdrawal of anti-convulsive agent NUMBER 1 CAUSE
of status epilepticus drug of choice diazepam, valium, >> Status Epilepticus - continuous uninterrupted seizure
glucose continuous seizure increased firing in the brain activity, can lead to coma, drug of choice diazepam,
high metabolism glucose depletion may cause loss of oxygen valium, glucose
may lead to coma. Oxygen without 5 -10 mins irreversible brain
damage C. Diagnositc Procedures
1. CT Scan reveals brain lesion
B. Types of seizures 2. EEG - reveals hyperactivity of brain waves.
Generalized
a. Grand Mal (tonic clonic) D. Nursing Mgmt:
>> with or without AURA highly subjective - with blank 1. Maintain patent airway and promote safety before seizure activity.
stare, flashes, hear voices, smell something, ants crawling in a. Clear the site of sharps, blunt objects
the entire body initial size warning size pending seizure b. Loosen clothing of the patient
AURA. Initial sign of AURA (epigastric pain accompanied by c. Avoid use of restraints can lead to fracture
visual, auditory, olfactory and tactile sensory experience) d. Maintain side rails
>> Epileptic cry feeling of FALL, Loss of consciousness for e. Turn clients head to side to prevent aspiration
3-5mins. f. Place tongue guard on the clients mouth, prevent biting of
>> Tonic clonic contractions. Tonic- direct symmetrical the tongue, dont force anything during seizure, during
extensions of extremities - naninigas, clonic contractions emergency can use of spoon, clean piece of towel
>> post-ictal sleep un responsive sleep 2. Avoid precipitating stimulus
b. Petitmal seizure (Absence Seizure) common pediatric bright/glaring lights
clients characterized by: s/sx: noise
>> blank stare 3. drafts
>> decreased blinking of the eyes 2. Administer medication as ordered:
>> twitching of the mouth a. Phenytoin (Dilantin) toxic level 20 normal 10-19
>> loss of consciousness for 5-10 seconds prevent alcoholism may lead to severe PNS
b. Diazepam (Valium)
c. Partial Seizures c. Carbamazepine (Tegretol) > Treat trigeminal neuralgia
>> Jacksonian seizure (focal seizures) s/sx: jerky movement d. Phenobarbital (Luminal)
of index finger and tongue that spreads to the shoulder and 3. Institute seizure and safety precautions post seizure activity by:
to the other side of the body with jacksonian march a. administer O2 inhalation
>> Psychomotor sezure ( focal- motor seizures) s/sx: b. provide suction apparatus
-Automatism -stereotype repetitive and non purposive 4. Monitor and document the following:
behavior. 4. Onset and duration
- Clouding of consciousness - the client is not in contact with 5. Type of seizure
his environment or reality 6. Duration of post-ictal sleep, the loner post-ictal sleep
- Mild hallucinating sensory experience (3 types: Visual- danger to lead to status epilepticus
severe alcoholism - Korsakoffs Psychosis, Auditory-Schizo- 5. Assist in surgical procedure, cortical resection cortical (pial)
incision for frontal lobectomy

11
 4. Corneal/ Blinking Pass the cotton tip on Drop saline soln
Q: a one year old client is suffering from grandmal seizure. What is Reflex Conscious the eyes when in the eyes it will
the nursing priority? ABC-Safety/ Suffering wisp of cotton hibla looking straight to blink even closed
A. Place mouthpiece complete set of teeth at 2 -3 yrs old - dulo the nurse, it will blink light coma,
INCORRECT Unconscious do not if no response -
B. Administer O2 inhalation use cotton use one deep
C. Give pillows CORRECT prevent banging of the head drop of saline solution
D. Provide suction apparatus *PRECORDIAL TAP NEVER USED IN THE HOSPITAL causes:
fracture ribs, collapse lungs
Parkinson Stereotaxic thalamotomy *do not do CORNEAL PRESSURE may lead to corneal pressure,
cornea punit may lead to blindness
Huntingtons Chorea (pedia) & Parkinsons disease = decrease
dopamine 3 DEEP COMA
B. Comprehensive Neurological Exam
NEUROLOGICAL ASSESSMENT
A. Glasgow Coma 1. Survey of Mental Status and Speech
Scale: Components: >> LOC
1. Motor Response 6 >> Test of memory
2. Verbal Response 5 2. Levels of Orientation
3. Eye Opening 4 3. Cranial Nerve Assessment
Findings 15 12 Vagus longest
15-14 = Conscious/ Conscious - AWAKE Trigeminal largest
13-12 = Lethargy/Letahargic Drowsy, sleepy, obtunded Trochlear - smalles
11-9 = Stupor/ Stuporous client is only awaken by vigorous 4. Motor Assessment
stimulation, client is (+) generalized body weakness, and decreased Movement of larger muscle
bodily reflexes 0 no movement plegia
7 Coma/ Comatose LIGHT COMA (+) all forms to painful 1 smaller muscle
stimulation DEEP COMA (-) to all forms of painful stimulation 2
3-
LIGHT DEEP 4
1. Deep Sternal close fist form a without response 5-
Pressure/ Stimulation knuckle, press the after 3 strokes 5. Sensory Assessment
sternum 3 strokes 6. Cerebellar Test Romberg Test Finger to nose Test (+)
with response Dymetria
2. Orbital pressure Tip of Thumbs press without response 7. DTRs
orbital bones above after 3 storkes 8. Autonomics
and below eyes, 3x,
with response Test of memory
3. Pressure on Great Press great toes 3x without response Short term memory what did you take this morning for breakfast
toes with response Anterograde TEMPORAL lobe affected

12
Long term memory when is your birthday? validate in the clients CN II - OPTIC NERVE
data sheet >> Sensory Vision
Retrograde Diencephalon or Limbic system damage >> Tests:
Test of Visual Acuity/Central or Distance Vision. Materials used:
Levels of Orientation Snellens Chart 1) Snellens Alphabet Chart used for literate client
Time Ask for the period of date Umaga or Hapon or Gabi? who can read 2) Snellens E chart used for illiterate who can
Person Sino po ako? not read 3) Snellens Animal Chart used for pediatric clients,
Place Where po okay? children have shorter attention span
1. Findings: 20/20
Cranial Nerves Assessment 2. Numerator FIXED CONSTANT indicates distance of
I Olfactory - S the person to the snellens chart 20 feet or 6-7
II- Optic -S meters
III- Oculomotor -M 3. Denominator indicates the distance by which the
IV Trochlear - M person can normally see the letters in the chart
V Trigeminal - SM 4. OD oculodexter ; right OS oculosinister left OU both
VI Abducen - M eyes, small letters od once a day
VII Facial - SM 5. ABNORMAL FINDING: 20/200 indicates blindness can
VIII Acoustic S not read the letter E
IX Glossopharyngeal -SM 6. NORMAL FINDINGS: 20/20 - can read at least 2 letters
X- Vagus- SM above the shaded red lines
XI Accessory -M 7. If the clients can still read below the shaded red lines
XII- Hypoglossal -M perfect vision

NOTE: Some says marry money but my brother says bad business Visual Fields/Peripheral vision
marry money Where is the examiner when testing the peripheral vision of the
client?
CN I Olfactory nerve 1. Superiorly sa forehead
Sensory smell 2. Bitemporally near ears
Materials used DO NOT USE ALCOHOL AMMONIA PERFUME 3. Nasally - nose
irritating to nasal mucosa highly diffusible easily to evaporate 4. Inferiorly sa baba
USE COFFEE granules, VINEGAR, CIGARETTE TAR, BAR SOAP. Instruct client to stare at the nurses forehead, occlude right eye
Procedure: CLOSE HIS EYES, TEST EACH NOSTRIL, BY instruct Roxanne to count the numbers of fingers wingling, tapat fingers
OCCULDING 1, ask what odor -symmetrical body to check on areas above.
abnormalities DAMAGE in peripheral vision Nystagmus
>> Hyposmia decrease sensitivity to smell (matagal vinegar
lumayo soy sauce) 4 COMMON DISORDERS:
>> Dysosmia - distorted sense of smell 1. Glaucoma increased intraocular pressure Normal=12-21mmHg
>> Anosmia absence of smell might indicate: causes:
1. HEAD INJURY 1. 40 yrs old
2. INFLAMMATION sinus SINUSITIS 2. Hypertension
3. Obesity

13
4. Trauma
s/sx: 3. Cataract has decreased perception to colors.
1. LOSS of peripheral vision tunnel vision
2. Halos rainbow around lights 4.
3. Steamy cornea cloudy
4. Ocular Pain eye pain Diagnostic: opthalmoscopic examination
5. Headache
6. Nausea and Vomiting drug of choice:
*Can lead to blindness a. MYDRIATICS
ex. Mydriacyl, ATSO4 -dilates the pupil
Diagnostic Procedures: b. Cyclopegics
1. Tonometry ex. Cyclogyl paralyzes the ciliary muscle
2. Gonioscopy
3. Perimetry Surgical procedure:
E xtra
Drug of choice: C apsular
1. MIOTICS constricts the pupil C atarat
Ex. Pilocarpine Sodium, Carbachol L ens
2. Epinephrine eyedrops decrease aquaeous humor E extraction
3. Carbonic anhydrase inhibitor : Acetazolamide-Diamox promote > partial removal
drainage
4. Timoptics Timolol Maleate Intra Capsular Cataract Lens Extraction
Total Removal
1. Trabeculectomy
2. Peripheral Iridectomy Complication of lens extraction: RETINAL DETACHMENT
BOTH-drainage of aquaeous humor
3. RETINAL DETACHMENT
*It is preventable, but not curable, treatment is LIFETIME means of separation of epithelial cells of the retina
CAUSE:
2. Cataract opacity of the lens Degenerative/Senile Cataract 1. FOLLOWING LENS EXTRACTION
causes: 2. Myopia near sightedness Biconcave lens used as treatment
1. 65 yrs old and above Emmetropia- normal eye
2. Congenital Hyperopia far sightedness Biconvex lens used as treatment
3. DM Astigmatism - Distorted vision Cylindrical lens used as treatment
4. Prolong exposure to violent rays Presbyopia- old sight loss of - bi-focal lens used as treatment

s/sx: Pathognomonic signs:

1. Loss of central vision blaring or hazy vision s/sx:
Lens- should be transparent, getting old turns to opaque 1. Curtain-veil like vision
2. Floaters due to leakage of red blood cells
2. Milky white appearance at the center of the pupil.

14
Surgical procedure: Sensory controls sensation of face and teeth (pain diffused),
1. Scleral Buckling mucous membrane and corneal reflex
2. Cryosurgery cold application Motor mastication or chewing
3. Diathermy heat application Damage to CN V Trigeminal Neuralgia difficulty in chewing
and swallowing

4. MACULAR DEGENERATION Q: A client is suffering Trigeminal Neuralgia, the nurse should

> macula lutea yellowish spot at the center of the retina administer food products?
- middle layer A. hot milk-X, wafer-ok, butter-ok
Fovea centralis - site of perfect vision B. bread-ok, cereals-ok & cold drink-X
Optic Disk covering of retina C. potato-OK, toast, gelatin-OK
Pathnognomonic signs: D. gelatin-OK, salad-OK, potato-OK
Black spots
SALAD VS TOAST which is easy to chew
CN III OCULOMOTOR 4 EOM
CONTROLS THE RAISING OF THE UPPER LID *AVOID EXTREME TEMPERATURES
ISOCORIA = Equal
PERRLA = PUPIL CONSTRICTS Gelatin is CLEAR LIQUID DIET
CONTROLS THE SIZE OF THE PUPIL 2-3mm Porridge is SOFT DIET
CN IV TROCHLEAR SO
CN VI ABDUCENS Lateral Rectus CN VII FACIAL NERVE
innervates movement of extrinsic ocular motor EOM= 6 Sensory it controls taste anterior 2/3 of tongue. Cotton
applicator, pinch of sugar say ah place the sugar on the tip
Right eye n Left eye of the clients tongue, dont allow to taste it- TIP OF THE
SR SO o SO SR TONGUE SHOULD BE SWEET
LR MR s MR - LR Motor controls facial expression, instruct the client to smile to
IO IR e IR IO frown or raise his eyebrows

Follow the direction of my pen according to 6 cardinal gaze Bells palsy facial nerve paralysis temporary 4 to 6 months
PER EYE
4- rectus Q: What is the most evident clinical sign of facial symmetry?
2 - oblique A. Lips remove due to cleft lip
3 cranial nerves B. Cheeks
CN V Trigeminal C. Nasocranial bone remove due to cleft lip
Ophthalmic branch D. Nasolabial folds smiling N= face pantay right and left
Maxillary branch (+) Bells palsy = tabingi- no nasolabial folds
Mandibular branch
Sensory Motor CN VIII Acoustic/Vestibulocochlear Nerve
Largest CN inner ear
for balance Kinesthesia position sense movement and
orientation of the body in space.

15
 Cochlear hearing, organ of corti= TRUE SENSE ORGAN OF likod ng tonge to initiate gag-reflex, vagal stimulation eyes
HEARING constricts, moist mouth, decrease RR, BP, diarrhea -
Inner Middle Outer HYPOTENSION
cochlear Hummer Anvil pinna Damage in cerebral hemisphere
vestibule Stirups - external
Malleus I-? CN XI SPINAL/ACCESSORY
Stapes CONTROLS two muscles of
Eustachean Sternocleidomastoid (neck)
tube Trapezius (Shoulder)
Ask client to shrug, and apply pressure, if he can not hold the pressure
Meiners otitis media impacted paresis, or paralysis
disease cerumen
sensory Conductive Conductive CN XII - HYPOGLOSSAL
hearing loss hearing loss hearing loss controls the movement of the tongue
ask client to say AHH, to protrude the tongue, should be
Q: laws of physics:a client suffered from MSW multiple stab wound, straight, if it deviates to left and right, theres damage to
upon assessment, the client has difficulty of breathing, chest pain. cerebral hemisphere. Ask the client to push tongue against
Movement of air in and out of the lungs is carried by what principles: law his/her check he/she might have short frenum/frenulum
of PARTIAL pressure of gases. Atmospheric pressure(+) OUTSIDE, lungs linguae located at the back of the tongue litid tongue-tied
= (-) atmospheric pressure NORMAL; (+) atmospheric pressure (higher bulol
to lower) - DIFFUSION
A. Boyles TSE: spontaneous answer, dont humm, dont be nervous, use
B. Archimedes nouns, adjectives, connecting words
C. Daltons - CORRECT
D. Inertia
Q pregnant women on her 1st tri of pregnancy, visited a pre natal clinic
for check up, UTZ reveals fetus is suspended
LAW OF buoyancy Archimedes

Q: A client suffered from vertigo dizziness due to fasting for 5 days.

INERTIA
Law of motion

CN IX - GLOSSOPHARYNGEAL
controls taste, posterior 1/3 of tongue

CN X VAGUS
Gag reflex
Tested both, say client to say ah, check the position of uvula,
should be at the center or midline, put the tongue depressor sa

16
 ENDOCRINE SYSTEM Pituitary gland
increased size of the
Pituitary gland main organ, (hypophysis cerebri) located at the organ due to increased
sella turcica at the base of the brain number of cell
master clock, master gland of the body because it secretes 3. S/Sx: 3. S/Sx:
hormones that controls or regulates all the metabolic fxn of the Alcohol inhibits the a. Fluid retention
body release of ADH A. - Hypertension
thyroid polyuria excessive - Weight gain
adrenal urination - edema
gonads B. Dehydration
- Thirst b. Water intoxication
2 DIVISIONS OF pituitary gland - Agitation may lead to cerebral
1. Anterior pituitary (Adenohypophysis) -Poor skin turgor edema, lead to
2. Posterior pituitary (neurohypophysis) -Dry mucous increased ICP (N=0-
hormones: membrane 15mmHg), may lead to
1) Oxytocin promotes uterine contraction, thereby preventing C. weakness and seizure activity
bleeding or hemorrhage when is the best time to give: after fatigue
placental delivery to prevent uterine atony that may lead to bleeding D. Hypotension
and hemorrhage initiates milk let down reflex by the help of E. Weight loss
prolactin if left untreated
2) Antidiuretic Hormone ADH ADH replacement F. hypovolemic shock
>> Pitressin (vasopressin) prevents urination, conserving water INITIAL: COOL
MOIST SKIN,
Diabetes Insipidus Syndrome of RESTLESSNESS LATE
inappropriate ADH SIGN: ANURIA
1. Definition: HYPERSECRETION OF 4. Diagnostic 4. Diagnostic
HYPOSECRETION of ADH procedures 1.010 to Procedures:
ADH 1.030 a. Urine specific gravity
2. Predisposing 2. Predisposing a. Urine specific HIGH
Factors: Factors: gravity LOW b. Serum Na LOW
a. Pituitary surgery a. Head injury b. Serum Na 135-
b. Inflammation b. Bronchogenic 145meq/L HIGH
c. Trauma cancer.(1.Lung cancer 5. Nursing Mgmt: 5. Nursing Mgmt.
d. Tumor initial: nonproductive a. Forced fluids a. Restrict fluid
cough b. Administer isotonic b. Administer
2. Liver cancer 3. soln as ordered medications as ordered
Prostate cancer -40 4. c. monitor VS and IO Diuretics both osmotic-
Testicular cancer 30, d. Administer cerebral edema/loop-
BPH - 50) medications as edema GIVEN at AM,
C. Hyperplasia of ordered: Vassopressin 10-15mins, max 6

17
IM hours effect, SD, fast
Petrissin drip, c. 1st monitor VS Addison hyposecretion and Cushing diseases hypersecretion
e. Prevent BP, then I& O
complications: d. weight patient daily 3. PROLACTIN/Lactogenic Hormone initiates milk let down reflex
Hypovolemic shock and assess for edema development or enlargement of breast
e. meticulous skin care
4. MELANOCYTE STIMULATING Hormone (MSH) fxn: for skin
ANTERIOR PITUIATARY GLAND pigmentation sufficient amount of melanin brown skin can
1. Growth hormones/ somatotrophic hormones tolerate the heat of the sun
> promotes elongation of your long bones - Albinism - Hyposecretion of MSH, complications: blindness and
skin cancer
- DWARFISM - Vitiligo - Hypersecretion of MSH Dalmatian spots seen in chest
- GIGANTISM
- ACROMEGALY box/ squared face 5. LEUTENIZING HORMONE produces progesterone

distal ends epiphysis covered by epiphysial plate, shaft diaphysis 6. FOLLICLE STIMULATING HORMONE (FSH) secretes estrogen
periosteum, center cavity medullary cavity covered by
endosteum PINEAL GLAND secretes MELATONIN
inhibits leutenizing hormone secretion
long bones contain bone marrow RED epyphysies RBC, WBC, and controls circadian rhythm body clock
platelets AND YELLOW medullary cavity - produces fat cells
THYROID GLAND palpable only adams apple, if palpable you have
Q: if theres a fracture- (loss or break of continuity) of femur, the goiter
nurse would expect feared, complications: fat embolism nodular consistency = NORMAL
pulmonary embolism headache dizziness cerebral embolism; 1 thyroid gland continuous, left and right at the back
second hemorrhage, and compartment syndrome parathyroid, above-larynx
compression of the arteries and nerves assess neuro vascular located anterior to the neck
status 3 hormones secreted
a. T3 triiodothyronine
Puberty as early as 9 as late as 21 yrs old b. T4 tetraiodothyronine or thyroxine
c. Thyrocalcitonin
@ age 21 epiphyseal plates closes 1. inhibits the action parathormone promotes calcium
resorption breaking down
What to ask for person with Acromegally: 2. T3 and T4 metabolic or calorigenic hormone
Q: what is the sizes of your recent shoes? Brain increase thinking
V/S high
Drug of choice for Acromegally:
Ocreotide [Sandostatin] Hypothyroidism ALL ARE DECREASED except weight and menstruation
a. Loss of appetite but theres weight gain
2. ACTH Adenocorticotrophic Hormone promotes maturation and b. Menorrhagia excessive menstruation HIGH estrogen
development of adrenal cortex promotes lipolysis- breakdown of lipids, dislodge to fats, can be

18
 deposited to arteries, artherosclerosis, hypertension MI, stroke, ex. Cabbage, radish, singkamas turnips, all nuts, strawberries, sweet
Increase serum cholesterol potato, broccoli planted in mountainous area soil erosion, iodine is
washed away
Memory impairment
Forgetfulness c. Goitrogenic drugs
Constipation - Anti-thyroid agent (PTU) Prophyllthiuracil given to hyperthyroidism
Lethargy
Hypotension Surgery:
Hypothermic Graves disease = removal thyroidectomy subtotal
Low metabolism, no perspiration, skin dry, cold intolerance Total thyroidectomy only to Thyroid Cancer

Hyperthyroidism ALL ARE INCREASED except weight and menstruation - Lithium toxic 2 N=.6-1.2, forced fluid, increase Na, to prevent
a. Hyperphagia increased appetite, weight loss- high metabolim , dehydration
increased perspiration, heat intolerance
b. Amenorrhea absence of menstruation 3. ASA SE: Thrombis, dyspepsia, heart burn CI: Dengue, ulcer -
antiplatelet
CNS hyperactivity 4. Phenylbutazone
Irritability 5. Cobalt
Tremors
hallucination 1. Endemic Goiter caused by goiter belt area
diarrhea 2. Sporadic Goiter caused by 2 goitrogenic food and drugs
S/sx:
CRITICAL 16 section 3800 final coaching 3200, 340pax UE and ALIW, a. enlarged thyroid gland
Araneta PRC- St. Thomas Square Banco De Oro 2nd flr register b. mild dysphagia
c. mild restlessness
THYROID DISRODERS:
Diagnostic procedures
GOITER enlargement of the thyroid gland due to iodine deficiency a. Serum T3 and T4 may reveal normal and below normal
b. Thyroid scan - Enlarge thyroid gland
2. Predisposing Factors: c. Serum TSH is INCREASED confirms presence of goiter

a. Goiter belt area 6. Nursing Management:

- places far from the sea walang seafoods no iodine 1. Administer meds as ordered
- mountainous regions- cordilleria and Baguio City increase of a. Iodine solution
goitrogenic foods 6. Lugols solution saturated solution of Potassium
Iodide- purple or violet administer with straw to
b. Goitrogenic foods contains pro-goitrin, anti-thyroid agent that has no prevent staining of the teeth. (Drugs given with
iodine straw: Lugols soln, Iron Tetracycline,
- metabolism low Nitrofurantoin (Macrodantin) urinary antiseptic
drug of choice of pyelonephritis )
2. Thyroid agents of hormones

19
 i. Levothryroxine (Synthroid) 3. S/Sx: low metabolism hoarseness of voice, anorexia, MI
ii. Liothyronine (Cytomel)
iii. Thyroid extracts Early signs:
Nsg Mgmt: a. Weakness and fatigue
1. best taken in AM to prevent INSOMNIA b. loss of appetite but weight gain
2. Monitor heart rate, most SE: Tachycardia, c. Dry skin
palpitation hypertension, heat intolerance (due to d. Cold intolerance
metabolism) SE: HYPERTHYROIDISM e. Constipation
3. Encourage increased intake of foods rich in iodine.
a. seaweeds Late signs:
b. seafoods oyster #1, clams, crab, lobster, mababa iodine content = a. Brittleness of hair and nails
SHRIMP b. Non-pitting edema due to accumulation of mucopolysacchrides
c. Iodized salt too salty best taken at raw, because heat destroys it. in the subcutaneous tissue, hence to adult its Myxedema
Too much iodized salt may lead to hyperthyroidism c. Hoarseness of voice
d. Libido
4. Surgical procedure: partial thyroidectomy e. VS Hypotension, Bradycardia, Bradypnea,
f. CNS Changes lethargy, memory impairment, psychosis
MS 01/22/2006 g. Menorrhagia estrogen

Hypothyroidism 4. Diagnostic Procedures:

1. Def: hypo secretion of decreased to T3 and T4 a. Serum T3 and T4 are normal or
7. Myxedema adult b. Radioactive Iodine Uptake
8. Cretinism children, the only endocrine disorder can c. Serum cholesterol due to weight gain
lead to mental retardation 5. Nursing Mgmt:
a. Monitor VS and IO strictly
9. Myxedema coma severe form of hypothyroidism,
2. Predisposing Factors: characterized by:
a. Iatrogenic cause disease caused by medical intervention severe hypotension
surgery bradycardia
bradypnea
(Hospital acquired infection health related infection) hypoventilation
hypoglycemia
b. Atrophy of the Thyroid gland due to: hyponatremia *that may lead to progressive stupor and coma
I rradiation COMA #
T umor 1. nsg management: - Assist in mechanical ventilation
T rauma 2. Administer thyroid hormones
I nflammation 3. Forced fluids

c. Iodine deficiency b. Administer med as ordered

d. Autoimmune Hashimotos disease i. Levothryroxine (Synthroid)
ii. Liothyronine (Cytomel)

20
 iii. Thyroid extracts g. CNS changes irritability, agitation, tremors, restlessness,
Nsg Mgmt: insomnia, hallucinations
1. best taken in AM to prevent INSOMNIA h. Goiter
2. Monitor heart rate, most SE: Tachycardia, i. Exophtalmos protrusion of the eye
palpitation hypertension, heat intolerance (due to j. Amenorrhea
metabolism) SE: HYPERTHYROIDISM
c. Provide dietary intake low in calories due to weight gain Diagnostic Procedure
d. Institute meticulous skin care due to dry skin a. T3 & T4
e. Provide comfortable and warm environment - due to cold intolerance b. RAIU
f. Forced fluids c. Thyroid scan size of thyroid gland = goiter
g. Provide health teaching and discharge planning d. TSH High confirms goiter
> Avoidance of precipitating factors leading to myxedema coma Nice to know: Enophtalmos- severe dehydration late sign among
- Stress children, depression in the eye
- Infection
- Cold environment (do not put in air condition room) Nursing mgmt:
- Anesthetics, sedatives, and narcotics (lead to respiratory depression) a. Monitor VS and IO strictly complication of Thyroid
storm
Prevent complications: hypertension, MI, CHF, CVA, myxedema b. Administer med as ordered anti-thyroid agents
coma, hypovolemic shock Prophethiuracil (PTU)
Hormonal replacement therapy for lifetime Methimazole (Tapozole)
Importance of follow up
Q: What is the most common SE of anti-thyroidism
HYPERTHYROIDISM A: SE: Agranulocytosis increase WBC
- hyper secretion of T3 & T4 Agrunolocytes: Monocytes and Lymphocytes = theres infection
GRAVES DISEASE with Exopthalmus Fever, chills = CBC, sore throat throat swab/culture
- Thyrotoxicosis
c. Increased caloric diet to correct the weight loss
Predisposing Factors: d. Institute meticulous skin care due to moist skin
a. Autoimmune - release of long-acting thyroid stimulator LATS e. Provide comfortable and cool environment
autoimmune antibodies responsible of occurrence of exopthalmus f. Maintain side rails
b. Increased iodine intake g. Provide bilateral eye patch to prevent dryness of the eye
c. Hyperplasia (increase in the number of cells) of thyroid gland due to exophtalmos
h. Assist in surgical procedure subtotal thyroidectomy
Signs/Sympotms: Pre-op Nsg Mgmt: 1. Administer Lugols solution (SSKI) to
a. Hyperphagia increase in appetite decrease vascularity of the thyroid gland to prevent bleeding
b. (+) weight loss T3 & T4 increase, metabolism increase and hemorrhage
c. Moist skin Post-Op Nsg Mgmt:
d. Diarrhea 1. Watch out for signs of Thyroid storm TRIAD:
e. Heat intolerance Hyperthermia, Tachycardia, Agitation
f. VS -Hypertension, tachycardia, tachypnea, hyperthermia
Nsg mgmt if theres thyroid storm:

21
 1. Give medications: a. antipyretics, b. beta blockers a. Acute tetany
propanolol = SE: PNS Tingling sensation
2. WOF: inadvertent or accidental removal of Paresthesia
parathyroid gland can lead to hypocalcemia or Dysphagia Anorexia
tetany = trousseuas sign, chevosteks sign = Irritability
administer calcium gluconate IV slowly to prevent (+) laryngospasm bronchospasm prepare trach set
cardiac arrest, antidote: magnesium sulfate = (+) Trousseus sing
toxicity BP low Urine output low RR low Patellar (+) Chevosteks sign
reflex absent paralysis Complications: Arrhythmia
2. WOF accidental laryngeal nerve damage instruct the client And Seizures
to talk and speak after post op laryngeal nerve cut notify the
physician b. CHRONIC TETANY
3. WOF signs of bleeding post subtotal thyroidectomy =
feeling of fullness at the incisional site Nurse should check S/Sx:
soiled dressing at the back or nape area Notify the Cataract and photophobia
physician Loss of tooth enamel
4. WOF signs of laryngeal spasm difficulty of breathing or Anorexia and general body malaise
shortness of breath prepare at bedside trach set Irritability and memory impairment
5. Hormonal replacement therpy
6. Follow up care 4. Diagnostic Procedures
a. Serum Ca (N=8.5-11mg/100ml)
Tonsillectomy general anesthesia keeps swallowing may have b. Serum phosphate (N=2.5-4.5mg/100ml)
bleeding offer ice chips, no straw may add tension to suture line, or c. X-ray of long bones will show bone density
provide ice collar d. CT scan reveals degeneration of Basal Ganglia

PARATHYROID GLAND pair of small nodules located behind the 5. Nursing Management:
thyroid gland a. Administer med as ordered
1. Secretes parathormone promotes calcium reabsorption 1. Ca Gluconate IV slowly- for acute
antagonize Thyrocalcitonin calcium reabsorbtion 2. Oral calcium supplement for chronic ex. Calcium
CALCIUM lactate, Calcium carbonate, Calcium Gluconate
(facilitate by vitamin)
HYPOPARATHYROIDISM 3. Vit D sources: (Cholecalciferol) drug, diet (Calcidiol)
1. Definition: PARATHORMONE - calcium phosphate , sunlight (Calcitriol) (ex. Eat Cheese 5am, 7am-9am
hypocalcemia hyperphosphatemia sunlight, direct to bones)
Complications: tetany 4. Phosphate binders - If phosphate is ex. Aluminum
2. Predisposing Factors hydroxide gel (Ampho-gel) antacid SE: Constipation-
a. Following subtotal throidectomy binds phosphate in the intestines promoting its
b. Atrophy of parathyroid excretion in the urine.
Inflammation b. Avoid precipitating stimulus such as bright and glaring
Tumor lights, due to photophobia result to seizure
3. Signs/ SX

22
 c. Provide dietary intake Ca Phosphate diet of d. Anorexia and general body malaise
osteoperosis #1 SALMON, #2 Turnips, #3 Anchovies e. Irritability and memory impairment
d. Institute seizure and safety precaustions
e. Prepare trache set at bedside - for possible laryngeal 4. Diagnostic Procedure
spasm a. Serum Ca
f. Encourage the client to breath using paper bag. b. Serum Phosphate
Promotes mild respiratory acidosis, that can increased c. Bone x-ray reveals bone demineralization
ionized calcium levels
g. Prevent complications: Arrhythmias and Seizures 5. Nursing Management:
h. Hormonal replacement a. Forced fluids 2-3L due to kidney stones
i. Follow up care b. Strain all the urine with gauze pad can filter the kidney stones
or precipitate for the laboratory for stone analysis: calcium,
Nice to know: Antacids 2 TYPES uric acid
A-A-C : Aluminum containing Antacids SE: Constipation c. Provide warm sitz bath to promote comfort
M-A-D : Magnesium containing Antacids (Milk of Magnesia) SE: d. Provide acid-ash diet cranberry, plums, grape juice, prunes,
Diarrhea Phils: orage-pineapple-ponkan-Vit C- acidify urine to prevent
bacterial multiplication
Q: What is the most effective antacid with a fewer side effects: A: e. Administer med as ordered:
MAALOX Narcotic analgesic respiratory depression
1. Morphine Sulfate [antidote= Narcan, (Naloxol SE:
HYPERPARATHYROIDISM Tremors)]
1. Definition: 2. Demerol
Hypersecretion of parathormone - Calcium Phosphate f. Maintain side rails
g. Supervise/ Assist in ambulation
Hypercalcemia Ca in the blood h. Diet: lean meat Phosphate Calcium
> lead to bone demineralization lead to bone fracture i. Assist in surgical procedure = Parathyroidectomy
>-lead to kidney stones j. Hormonal replacement for lifetime
Calcium = 99%-bones, 1% blood k. Follow up care
l. Prevent complications: kidney stones ischemia death of
2. Predisposing factors kidneys may lead to RENAL FAILURE
a. hyperplasia of parathyroid glands
b. over compensation of parathyroid gland d/t Vitamin D ADRENAL GLAND located on top of the kidney
deficiency Cortex outer part
5. Ricketts children Medulla inner part
6. Osteomalacia adult
3. S/sx: Adrenal Medulla secretes catecholamines adrenalins
a. Bone pain especially at the back and bone fracture a. Epinephrine
b. Kidney stones b. Norepinephrine
renal colic pain
cool moist skin if with hypovolemic shock Vasoconstriction SNS All bodily activities, except GI
c. Ulceration

23
Pheochromocytoma catecholamine producing tumor -> c. Hyponatremia c. Hypernatremia
- > Increased norepinephrine -> HPN (resistant to non-pharmacological > hypotension no water absorption > hypertension
agents) -> Hypertensive crisis -> Stroke low salt > edema
> Signs of dehydration > weight gain
- disease of adrenal medulla > Weight loss no water > moonface appearance,
d. Hyperkalemia buffalo humps, obese trunk,
Drug of choice: Beta blockers > Irritability and agitation pendulous abdomen, thin
> Diarrhea extremities
Adrenal Cortex outermost > Arrhythmias peak T wave d. Hypokalemia
- consist of 3 zones or layers: e. Decreased libido > Weakness and fatigue
1. Zona Fasciculata SUGAR -> secretes GLUCOCORTICOIDS hormone ex. f. Loss of pubic and axillary hair > Constipation
Cortisol (steroid) fxn: it promotes glucose metabolism g. PS: Bronze-like skin pigmentation > U wave on ECG tracing
2. Zona reticularis SEX -> secretes ANDROGENIC hormones ex. F- e. Hirsutism
Estrogen (FSH), Progesterone (LH); M-Testosteron fxn: promotes f. Acne and striae, easy
secondary sexual characteristics bruising
3. Zona glomerulosa SALT -> secretes Mineralocorticoids ex. Aldosterone g. Increased masculinity in
-> promotes Na and water reabsorption, while promoting excretion of K females
( Na H2O K)
Addison HYPO - SSS Cushing HYPER SSS 4. Diagnostic Procedure 4. Diagnostic Procedure
1. Def: hyposecretion of adrenocortical 1. Def: hypersecretion of a. FBS low N=18-120mg/dl a. FBS high
hormones leading to: adrenocortical hormones B. Serum NA low b. Serum high
- metabolic disturbances SUGAR c. Serum K high c. Serum K low
- fluid & electrolyte imbalances SALT d. Plasma cortisol low d. Plasma cortisol high
- Deficiency of neuromuscular function 5. Nursing Mgmt: 5. Nursing Mgmt:
SUGAR & SEX a. Monitor strictly VS, IO and a. Monitor IO and VS
2. Predisposing Factors: 2. Predisposing Factors: Addisonian crisis characterized by: b. Restrict Na and fluids
a. Atrophy of the Adrenal gland a. Hyperplasia of Adrenal gland > hyponatremia c. weight patient daily and
b. Fungal infections b. Tubular infection with TB > hypovolemia assess for edema
Q: WHAT do you call the > dehydration d. Measure abdominal girth
spread of tuberculi bacilli to > weight loss which may lead to daily and notify physician
adjacent organ? A:MILLIARY progressive stupor and coma e. Diet low in carbohydrate,
TUBERCULOSIS N/R in Addisonian crisis: high in K, high in protein
3. S/Sx: 3. S/Sx: 1. Assist in mechanical ventilation f. Administer meds as ordered:
a. Hypoglycemia (TIRED) a. Hyperglycemia (PPP) 2. Administer steroids Provide diuretics:
> Tremors > Polyuria 3. Forced fluids DO NOT GIVE LOOP
> Irritability > Polydipsia b. Administer meds as ordered DIURETICS LASIX : HypoK,
> Extreme fatigue > Polyphagia > Corticosteroids ONE HyperGlycemia
> Diaphoresis & depression Complications: DM - Hydrocortisone, Dexamethasone, give only
b. Decreased tolerance to stress -> b. Increased susceptibility to Prednisone K-sparing diuretics
may lead to Addisonian crisis infection N/R: Spironolactone (Aldactone)

24
1. Best taken 2/3 dose in AM, 1/3 dose promotes Na excretion, while Islets of Langerhans (endocrine gland) ductless
in PM, to mimic normal diurnal rhythm. conserving K. alpha cells ->secretes glucagons -> hyperglycemia
Cortisol immune response/ strong g. Prevent complications: DM beta cells -> secretes insulin -> hypoglycemia
immune system in AM. h. Assist in surgical procedure- delta cells -> somatostatin -> antagonizes production of GH
2. Taper the dose instructs the client bilateral adrenalectomy
to withdraw gradually from the drug. If i. Hormonal replacement Disorders of the Pancreas
withhold immediately from drug j. Importance of follow up care 1. CANCER or TUMOR of Pancreas
3. Monitor SE: a. Moon-faced 2. Diabetes Mellitus
appearance, buffalo humps, HPN, 3. Pancreatitis autodigestion self digestion, self-eating - #1
edema, hirusitism = increase cause = alcoholism, #2 obesity
susceptible to infection = CUSHING
syndrome NICE TO KNOW:
> Mineralocoricoids lipase and amylase toxic substance in the body
- Fluorocortisone right pain gallstone
c. Forced fluids due to hyponatremia left pain - pancreatitis
d. maintain patent IV line GROIN pain inflammation of testicles (with fever), hernia, stones in
e. Diet in calories, protein the ureters-immobility, limited intake of fluid, concentrated of urine
Carbohydrates, Na but K Pain in right iliac region appendicitis
ex. Ham Na; French fries saturated Pain in gallbladder UTI
fat
f. Meticulous skin care DM I (IDDM)
g. Provide health teaching and
discharge planning 1. Def:
> Avoidance of precipitating factors Juvenile Onset/ Non-obese
leading to Addisonian crisis 2. Incidence Rate
- Stress Only 10% of general population
- Infection 3. Predisposing Factors
- Sudden withdrawal to steroids a. Hereditary total destruction of pancreatic cells
> Prevent complications: Addisonian b. Viruses
crisis > dehydration > hypovolemic c. Toxicties (carbon tetrachloride CCl4)
crisis d. Drugs, steroids, and loop diuretics (Lasix, and steroids)
> Hormonal replacement 4. Signs/Sx: PPP-G
> Importance of follow up care a. Polyuria, polydipsia, polyphagia
b. Glucosuria
c. Weight loss, anorexia, nausea and vomiting
PANCREAS located behind the stomach endocrine/exocrine gland d. Blurring of vision
Mixed gland: e. Increased susceptibility to infection
Acinar Cells (exocrine gland) with ducts f. Poor/delayed wound healing
secretes pancreatic juices goes through the pancreatic duct to 5. Treatment:
the stomach a. Insulin therapy
aids in digestion b. Exercise

25
 c. Diet If glucose is low -> cell sends impulses to hypothalamus -> stimulate
6. Most feared complications: DKA give Na Bicarbonate liver to undergo:
a. Glycogenesis = synthesis of glycogen
DM II (NIDDM) b. Glycogenolysis = breakdown of glycogen
1. Def: -> converts to glucose and undergo the normal function
Adult Onset/Obese (40 yrs old and above) c. Gluconeogenesis = formation of glucose from non-carbohydrate
2. Incidence Rate sources: Proteins and Fats
90% of the general population, started to increase in early 80s
3. Predisposing Factors: DM: I no insulin
a. Obesity Q:Why obese persons develop DM? A: Obese II low insulin
individuals lack insulin receptor binding sites Increased glucose -> remains in the circulation hyperglycemia
4. Signs and Symptoms: (because of no or low insulin) -> theres an increased Osmotic diuresis -
a. Usual asymptomatic > polyuria -> cellular dehydration -> stimulate the thirst center
5. TREATMENT (hypothalamus) Polydipsia
1. Oral Hypoglycemic Agents (OHA)
2. Diet Osmotic diuresis -> Glycosuria -> cellular starvation -> stimulate
3. Exercise appetite center, sense of hunger Polyphagia
6. HyperOsmolarNonKitetotic Coma (HONK)
Cellular starvation -> weight loss

BASIC PATHOGENESIS Gluconeogenesis

Main food stuff Anabolism building up Catabolism breaking Liver -> release protein -> converted to glucose -> no insulin -> osmotic
down diuresis
Carbohydrates Glucose Glycogen Increased CHON catabolism -> (-) nitrogen balance -> tissue
(CHO) wasting/cachexia (client not taking insulin)
Protein (CHON) Amino acids Nitrogen
Fats Fatty Acids Free fatty acids Increased fat catabolism -> free fatty acids by product -> release
cholesterol and ketones cholesterol -> atherosclerosis -> HPN -> MI and Stroke -> Death

Blood circulation contains nutrients CHO[ ->increase glucose in blood - Free fatty acids -> Ketones -> DKA -> Acetone breath odor and
> stimulate pancreas to secrete insulin -> insulin transport glucose Kussmauls respiration -> Diabetic Coma -> Death
inside the cell, but it needs a receptor] blood removed glucose - Q: What is the part of the brain controls thirst and hunger?
hypoglycemia, CHON, Fats A: HYPOTHALAMUS
Liver largest gland
Cell -> will undergo chemical reaction converts glucose to ATP= main Pancreas produces insulin
fuel of body
DKA DIABETIC KETOACIDOSIS acute complication of Type I DM,
Some glucose are stored = glycogen, reserved glucose for future use in characterized by severe CNS depression due to hyperglycemia
skeletal muscle and liver
1. Precipitating Factors:
a. Hyperglycemia

26
b. Stress - #1 NK -> absence of lypolysis -> no ketosis
c. Infection Coma s/sx: Headache, Confusion, Seizure, Decreased LOC

2. Signs and Symptoms: Treatment of HONK: the same DKA except NaBicarbonate
a. Polyuria, Polydipsia, Polyphagia
b. Glycosuria INSULIN THERAPY
c. Weight loss *early sign 1. Sources
d. N/Vomiting Animal pork and beef, rarely given because it can cause severe
e. Weakness and fatigue * early sign allergic reaction
LATE SIGN: Human Humulin it has less antigenecity property it can
a. acetone breath, fruity odor cause less allergic reaction
b. Kussmauls rapid shallow breathing pattern
c. Decreased level of consciousness -> COMA 2. Types of Insulin
Rapid (Short Acting Insulin)
3. Diagnostic Procedures the only clear insulin, peak: 2-4 hours
a. FBS N=80-20 mg/dl Intermediate AI
b. BUN N=10-20mg/dl due to severe dehydration, the body is - NPH (Non-Protamine Hagedorn)
compensating - cloudy, peak: 8-16 hours
c. Creatinine N=.8-1 > Long AI
d. Hematocrit red cell percentage in whole blood - Ultra lente
always 3x hemoglobin F=12-14gms% women menstruate - cloudy, peak 16-24 hours
M=14-16gms%
Hct F=36-42% *DO NOT MEMORIZE THE ONSET AND DURATION, only PEAK
M=42%-48% average = 42% HOURS = check for hypoglycemic reaction
ex. 5am = 250 mg/dl, give 6 units of Regular A-I due at peak: 7-
4. Nursing Mgmt: 9am = check for TIRED
a. #1 Airway Assist in mechanical ventilation
b. #2 Administer 0.9 NaCl, PNSS, isotonic, followed by 0.45 NaCl CBG N = 80-120mg/dl
hypotonic.
c. Monitor VS, IO and neuro check 3. Nursing Mgmt:
d. Administer meds. As ordered a. Administer insulin at room temperature to prevent
Insulin lipodystrophy (atrophy and hypertrophy of SQ)
b. Insulin only refrigerated once opened
Q: What is the type of insulin given to DKA c. Avoid shaking insulin, roll between palms only
A: Rapid acting insulin Regular - the d. Accuracy of administration is important
e. No need to aspirate after insulin injection
Sodium bicarbonate f. Administer insulin injection @ 45 (thin individual)-90 (fat
Antimicrobial individual) degree depending of the amount of tissue
deposit
5. Complication: HONK g. Gently rotate insulin sites prevent lipodystrophy
HO> increased osmolality -> severe dehydration

27
 h. Universal rule: when mixing 2 types of insulin aspirate 1. Glipzide (glucotrol)
the clear before the cloudy to prevent the 2. Diabeta (Micronase)
contaminating the clear insulin and to promote accurate 3.
calibration Nursing Mgmt in giving OHA:
1. Instruct the client to take it with meals, to lessen GIT irritation
4. Complications: and to prevent hypoglycemia
- Allergic reactions 2. Instruct the client to avoid alcohol- because added OHA can
- Lipodystrophy result to severe hypoglycemic reactions
- Somogyi Phenomenon> hyperglycemia followed by periods of
hypoglycemia Diagnostic Procedures for DM:
a. FBS if it is increased 3 consecutive times plus 3 Ps and 1 G, it
Nice to know: confir
Most accessible and most safe: ABDOMEN ms
Q: What needle gauge? A: G25-26 small bore needle prese
nce of
Use Insulin syringe or tuberculin syringe DM,
(1cc/ml=100units -0.5ml=50units -0.1ml=10units) use
gluco
1ml of tuberculin syringe = 100 units of insulin meter
, prick
*too much insulin -> leads to hypoglycemia -> insulin index
coma -> death finger

sides
only lesser nerve endings wipe it with saline solution-if no saline
Nice to know: soln use dry cotton, dont use alcohol (fermented sugar = ethyl it
Horse anti tetanus can alter the result)
Goats brain anti rabies b. Random blood sugar RBS it is elevated
Chicken anti-measles (most c. Oral Glucose Tolerance Test (OGTT) it is elevated, most sensitive
expensive) test
d. Alpha Glycosylated Hemoglobin

Nursing Management for DM:

ORAL HYPOGLYCEMICS 1. Monitor for signs and symptoms of hypoglycemia (TIRED)-cold
for Type II and clammy to touch -> offer hard candies or 1 glass of orange
Mechanism of action: Stimulates the pancreas to secrete insulin juice => needs simple sugar for easier digestion and easier
1. Classification of OHA ending NASE glucose formation (coke and chocolate =>complex sugar) and
First generation sulfonylureas ex. Chlorpropamide (Diabenase) hyperglycemia (PPP) warm and dry to touch -> administer
1. Tolbutamide (Orinase) insulin
2. Tolazamide (Tolinase)
Second generation sulfonylureas

28
Q: A client has history of DM, one morning her body was found in
the floor, unconscious
A: The brain can tolerate an increase/excessive amount of glucose,
but the brain can never tolerate deficiency of glucose->offer simple
sugar

2. Monitor strictly VS, Blood sugar, and I/O

3. Diabetic diet CHO 50%, CHON 30%, Fats 20% or offer alternate
food products/beverages: glass of orange juice
4. Exercise after meals - to promote increase utilization of glucose
5. Monitor for complications:
atherosclerosis -> HPN -> MI or CVA (Stroke) Neuropathy
Microangiopathies: affects the small capilliaries and arteries of
the eyes: premature cataract -> retinopathy -> blindness
and
kidneys -> recurrent pyelonephritis (inflammation of the
renal pelvis) -> Nephropathy or Renal Failure
gangrene formation
Shock
Peripheral neuropathy -> diarrhea -> constipation ->
sterility/impotence
6. Institute foot care management
a. Instruct the client not to walk barefooted
b. Encourage client to apply lanolin lotion to prevent skin
breakdown
c. Instruct the client to cut toenails straight
7. Instruct the client to avoid wearing constrictive garments
8. Encourage annual eye and kidney exam prevent retinopathy
and nephropathy
9. Monitor for signs of DKA or HONK
10. Assist in surgical wound debridement
11. Assist in surgical procedure:
a. BKA - Right below the Knee Amputation Procedure
b. AKA above knee amputation

29
01/28/2006
Hematology
Hematologic System
Consists of 3 structures:
1. Blood forming organs: > produces blood cells
a. Liver largest gland right hypochondriac region
b. Thymus located near the sternum, removed Thymus
Myasthemia Gravies autoimmune antibodies
c. Spleen kills the RBC once it reaches 80-120 days old,
proximal to the liver, when hepatomegally occurs, there
will be spleenamegally
d. Bone marrow- red bone marrow epiphysis RBC WBC
platelets, yellow bone marrow long bones humerus,
femur, fats cells most feared complications of fracture
of femur: fat embolism dyspnea & chest pain,
hemorrhage, compartment syndrome
e. Lymph nodes
f. Lymphoid organ - Salmonella Typhi Payers patches
rose spots in the abdomen defense mechanism
between small and large intestines for Thypoid fever
g. Veins LARGEST: superior & inferior vena cava, jugular
veins - towards heart unoxygenated blood dark red -
superficial
h. Arteries LARGEST: aorta & carotid artery away the
heart, scarlet red oxygenated blood deep
i. Capilliaries -
NOTE: Alternate expansion and recoil of artery = PULSE
Varicosities venous ulcer elevate legs
Thrombophelbitis deep vein thrombosis- Homan sign - venous
Aneurysm Abnormal dilation of an artery lead to subarchnoid
hemorrhage - arterial
Reynauds disease arterial Female 40 yrs old and above hands or
digits bluish, have intermittent claudication pain upon walking or
excertion, gangrene formation - smoking
Buergers disease Thromboanginitis Obliterans arterial smoking,
Male 40 yrs old and above feet bluish, have intermittent claudication
pain upon walking or excertion, gangrene formation,
III. Blood
a. 55% Plasma color yellow pigment bilirubin
NOTE: red cell pigment hemoglobin, green biliverdin, golden brown
pigment hemostindirin
Serum
Plasma Proteins
a. Albumin
most abundant in plasma protein maintains osmotic pressure
thereby preventing EDEMA
b. Globulin
1. Alpha transports hormones, steroids, and bilirubin
2. Beta transports iron and copper
3. Gamma transports antibodies, immunoglobulins 5:
G-chronic, maternal circulation A-sweat, tears M-acute
E-allergic
c. Prothrombin clotting factors lead to bleeding and
hemorrhage when lack of clotting factors
d. Fibrinogen clotting factors lack of c & d Disseminated
Intravascular Coagulation
Cellular components:
RBC
Normal value=erythrocytes 4-6M cubic mm
biconcave disks
NOTE: theres hemolytic anemia in which the RBC assumes an S-
shape structure SICKLE CELL anemia immature RBC easily
destroyed by spleen hemolysis- low rbc, low oxygen.
Priority Nsg Mgmt:
1. Airway = avoid deoxygenating activities
Q: Sickle cell anemia patient what exercises to indulge:
a. Mountain climbing - x
b. Hiking - x
c. Bowling -
d. Ice Skiing x
Anti-sickling agent Hgb-S via IM can use before flying
2. Force fluids
3. Pain (Comfort) if too much vaso occlusion blood flow
decreased > ischemia -> hypoxia o2 low in tissue-> anerobic
metabolism -> lactic acid -> irritating to tissue, stimulates
mediators, release of prostaglandin->stimulate nociceptor->pain
sensation; Give: Mefenamic acid inhibits prostaglandin

30
 decreased in RBC Anemia early sign: Weakness low hgb 5. vit B6 (Pyridoxine)
low oxygen complete bed rest 6. intrinsic factor
increased in RBC Polycythemia early sign: Headache; late E. Normal lifespan 80-120 days
sign: Pruritus/ Urticaria due to abnormal anti-histamine, can lead F. Spleen graveyard of RBC at red pulp
to Thrombosis, HPN, CVA, Stroke TIA early sign: headache
A. RBC is anucleated WBC phagocytosis (Leukocytes)
B. Molecules of Hgb (carries oxygen) Normal value = 5-10,000
Hgb Decreased WBC = Leukopnea increase susceptibility to infxn
F = 12-14gm %, lower blood volume due to women have monthly Increased WBC = Leukocytosis (+) to infection
menstruation A. Granulocytes: (too check how long your infection, use the
M = 14-16gm %, blood volume is higher differential count)
Child = higher blood volume compared to adults 1. Polymorphonuclear Neutrophils > the most abundant of all
C. HEMATOCRIT RBC percentage, 3x hemogblobin WBC, constitute 60-70% of WBC > involved in short term
Hct phagocytosis-> acute inflammation because lifespan is only
F = 36-42% good for 3-4Hrs (replaced by MOnocytes)
M = 42-48% 2. Polymorphonuclear Eosinophils > allergic rxn
Q: A client suffered a 3rd degree burns (Priority: Fluids & electrolytes), 3. Polymorphonuclear Basophils > involved in parasitic infxn >
the nurse will notice after 24-48 hours that the hct: involved in the release in chemical mediators for inflammation
Pred factor: 3rd deg burn -> hypovolemia->ischemia->Hypoxia->major (Prostaglandin, Histamine, Serotonin, Bradykinins) >
stimulus for erythropoiesis-> stimulate kidneys->to secrete *RESPONSIBLE for dissolving or ingesting fat particles after
erythropoietin -produced @ MACULA DENSA -> stimulate one marrow - ingestion of high fat meal (presence of cholesterol if too much
>increased RBC -> increased Hct fats and minimal basophils)
A: Elevated compensation B. Monocytes the largest WBC (Macrophage) > fxn opposite of
B: Decreased neutrophils > long term > chronic inflammation > life span 8-12
C: The same months > non-granulocytes
D: No change at all C. Lymphocytes > non-granulocytes
B cells (arises from bone marrow)
Q: a pregnant woman on 1st trimester needs a larger amount of FOLIC T cells (arises from Thymus) > target site of HIV (incubation
ACID to prevent neural tube defect SPINA BIFIDA/Myelo?-prone period: 6mos to 5 yrs, window period: 6months-subjected to
position ELISA-inaccurate-enzyme link immunosorbent assay,
3rd trimester needs IRON confirmatory test = Western Blot) > non-granulocytes
NK (Natural killer cells) > have both anti-tumor, and anti-viral
WBC Basophil, Neutrophil, Eosinophil with granules granulocytes property

In clients with DKA, Acute renal failure, 3rd degree burns Hct is III. Platelets (Thrombocytes)
ALWAYS ELEVATED due to compensation Normal Values =
D. Substances needed for maturation of RBC Promotes hemostatis prevention of blood loss
1. folic acid Immature/baby platelets Megakaryoctes, target site of virus =
2. iron Dengue Virus(Aedis Aegypti) increased capilliary fragility
3. vit B12 (Cyanocobalamin) Petechiae internal bleeding
4. vit C (Ascorbic Acid)

31
Signs of Platelet dysfunction: low platelet b. Common tropical areas: Philippines
1. Petechiae
2. Ecchymoses (purpura-many ecchymoses) 2. Causes:
3. Oozing of blood from venipunctured sites c. inadequate absorption of iron due to:
Disorder: DIC (provide heplock because it is contraindicated to injection) - Chronic diarrhea
Hemophilia-pedia = both risk for HEMORRHAGE (Hypovolemic shock) - r/t increased cereal intake with decreased animal CHON ingestion
- malabsorption syndrome
MOST DANGEROUS: Plasmodium Falciparium may lead to irreversible
brain damage, hemorrhage->hypovolemic shock (late sign: anuria) d. Inproper cooking of foods

NOTES: HIV complications: Signs/Sx:

4. Kaposis Sarcoma - skin a. Usually asymptomatic
5. Pneumocystic carini pneumonia b. Headache
6. Drug of choice: AZT(Zidovudine or Retrovir) c. Dizziness
d. Palpitations - low o2, compensation increase pumping of blood
Platelets Normal lifespan: 9-12 days e. Cold sensitivity
f. Generalized body malaise
7. Monocytes, Lymphocytes without granules non g. Pallor
granulocytes h. Brittleness of hair
Platelet namuo blood clot i. Spoon shaped nails Koilonychia
Note: j. Atrophic glossitis inflammation of the tongue, Stomatitis
mouth sore, dysphagia = collectively known as PLUMMER
What is the nsg dx decreased albumin & osmotic pressure? Impaired VINSONS SYNDROME
SKIN INTEGRITY k. Pica, abnormal appetite, craving for non-edible foods -> cerebral
PLASMA protein produce by liver hypoxia->psychosis-> neuronal impairment-> body will find an
immediate alternate source of nutrients (oxygen & glucose)

IRON DEFICIENCY ANEMIA NOTES: Nails 180 degrees normal, form a diamond shape, thumb to
thumb
1. Incidence rate:
a. Common on developed countries: USA 4. Diagnostic Procedure: ALL LOW
#1 due to DIET Increase cereal intake milk products less iron 1. RBC
#2 Trauma, due to accident -> blood loss -> anemia 2. Hgb
3. Hct
nice to know: 4. Reticulocytes
Teenagers Suicide 5. Iron
Children Poisoning-Aspirin 6. Ferritin
Infant SIDS, suffocation
RBC (80-120days) -> Spleen -> hgb disintegrate into ->>heme & ->>
b. Common tropical areas: Philippines blood sucking parasites globin ->back to spleen, while heme ->> ferrous & -> bilirubin & -
>biliverdin , ->>ferretin -> back to spleen

32
c. Women 15-35 yrs old-reproductive age f. Instruct with Vitamin C, orange juice to facilitate
absorption.
d. Common among the poor nutrition deficiency g. Monitor, and inform client of SE: all GIT
1. Anorexia
Chronic blood loss due to: 2. Nausea and vomiting
heavy trauma 3. Abdominal pain
menstruation 4. Diarrhea/constipation
GIT bleeding 5. Melena
hematemesis = vomiting of blood h. If the client can not tolerate iron preparation, theres poor
melena = passage of black tarry stool indicates upper GI compliance to iron preparation administer parenteral iron
bleeding stomach, small intestines preparations Iron Dextran IM or IV, Sorbitex IM
hematochezia = fresh blood in stool indicates lower GI Nsg Mgmt:
bleeding large intestines 1. Administer z-track method to prevent discoloration,
hemoptysis = coughing of blood discomfort, leakage to tissue
2. Avoid massaging the injection site, instead encourage
Bilirubin-> GIT (N flora) ->>Urine (urobilin), ->>stool (stercobilin) client to ambulate
If without bilirubin: urine tea colored, stool clay colored 3. Monitor and inform client of SE
6. pain at injection site
Alicia Dionisio member Psychiatric nursing 200 items 7. localized abscess
8. Lymphadenopathy
Q: What is the most possible cause of death of count Dracula? 9. Fever and chills
A. Eczema skin wounds 10. Pruirtus and urticaria
B. Halitosis bad breath 11. Hypotension, if (+) Anaphylactic Shock = Epinephrine
C. SLE butter fly rash SE: SNS, all increase except GIT
D. Porphyria increasing porphyrin (encircles ferritin) rings in the blood
severe photophobia, and psychotic behavior To use straw:
Tetracycline
5. Nursing Management: Lugos
a. Monitor for signs of bleeding of all hematest including Iron
urine, stool and GIT Nitrofurantoin macrolantin
b. Enforce CBR, so as not to overtire the client
c. Encourage increased iron diet: Chinese: white : genetic, diet=tea
Iron - #1 California Raisins, egg yolk, organ: liver, meat,
legumes, green leafy vegetables, sweet potato PERNICIOUS ANEMIA megaloblastic anemia, characterized by
d. Avoid tannates-major substance mixed in coffee & tea- macrocytic anemia due to deficiency of intrinsic factor leading to
gives color brown (impairs iron absorption) in tea hypochlorhydric (decreased to HCl acid secretion)
e. Administer medications as ordered: oral iron - most dangerous anemia because of neurological disturbances
preparations: ferrous sulfate, Fe gluconate, Fe fumarate
300mg/OD- take it with meals, to lessen GIT irritation, Pathogenesis:
when diluting to liquid iron preparation: administer with Stomach
straw to prevent staining in the teeth

33
 Parietal cells/Oxyntic/Argentaffin
Secretes
Intrinsic factor
Fxn: promote
Reabsorption of
Vitamin B12
promotes of maturation
of RBC
1. Predisposing Factors:
a. Subtotal gastrectomy
- Billroth I duodenostomy
- Billroth II Jejunostomy
b. Related to hereditary factors
c. Inflammatory disorders of the ileum
d. Autoimmune
e. Strictly vegetarian diet
Vit B12 maintains myelin sheath, without it may lead to
neurologic impairment
Secretes
hydrochloric acid 3. Diagnostic Procedures
28. Schillings Test reveals inadequate absorption of Vit
Aids in digestion VS Indigestion B12
a. Injection of nonradioactive vit b12 given at IM Gluteus
Dyspepsia maximus, or radioactive b12 ingested, Urine samples are
collected (water soluble vitamins, easily to excrete
calories CHON through urine)- High vit B12
4. Nursing Management
a. Enforce complete bed rest
b. Administer Vit B12 injections at monthly intervals for
lifetime as ordered, should not be given orally- client
may develop resistance, NOT DAILY, major SE: NONE
c. Increase caloric intake, CHON, CHO, Fe, and Vit C
d. Encourage client to use soft bristled toothbrush and
avoid irritating mouthwashes due to mouth sore, red
beefy tongue
e. Avoid heat application- can lead to burns

2. S/SX: Q: What are the sites of Vit B12 injections?

12. headache A: Ventrogluteal and dorsogluteal
13. dizziness
14. dyspnea APLASTIC ANEMIA
15. palpitation It is a stem cell disorder characterized by bone marrow depression ->
16. cold sensitivity leading to Pancytopenia (All blood cells are decreased ->> decreased
17. pallor RBC (Anemia) s:weakness, ->>decreased WBC (Leukopenia)s:increased
18. generalized body malaise susceptibility to infection, ->> decreased platelets (thrombocytopenia)
GIT changes: 1. Predisposing factors
19. mouth sores a. Chemicals
20. red beefy tongue 29. Benzene and its derivatives
21. Dyspepsia b. Irradiation
22. Weight loss c. Immunologic injury
23. Immature RBC jaundice d. Drugs
Neurologic changes: 30. Broad spectrum antibiotics
24. Tingling sensation Chloramphenicol
25. Paresthesia Sulfonamides (Bactrin) co-trimoxazole (UTI)
26. Ataxia 31. Chemotherapeutic Agents
27. Psychosis Nitrogen Mustard (anti-metabolite)
Vincristine (Plant Alkaloids)

34
 Methotrexate (Alkylating agent) b. Massive trauma
2. Signs/Sx: c. Massive Burns
a. Anemia Headache d. Neoplasia -New growth of tissue or tumor
b. Dizziness e. Anaphylaxis
c. Dyspnea f. Hemolytic Reactions
d. Palpitations g. Pregnancy
e. Pallor h. Septicemia
f. Cold sensitivity
g. Generalized body malaise 2. Signs and symptoms:
h. Leukopenia increased susceptibility a. Petechiae whole body
i. Thrombocytopenia PEO b. Ecchymoses whole body
32. Petechiae c. Oozing of blood
33. Ecchymoses d. Hemoptysis scarlet red
34. Oozing blood e. Hemorrhage
3. Diagnostics f. Oliguria (late sign)
35. CBC reveals Pancytopenia
36. Bone marrow biopsy or aspiration reveals fatty 3. Diagnostic Procedure:
streaks in the bone marrow 38. CBC reveals thrombocytopenia
Q: Site of bone marrow aspiration 39. Stool for occult blood (+)
A: posterior iliac crest 40. Ophtalmoscopic exam
41. ABG analysis metabolic acidosis
4. Nursing Management:
a. Removal of underlying cause Metabolic Metabolic Respiratory Respiratory
b. BT as ordered acidosis Alkalosis Acidosis Alkalosis
c. Enforce complete BR Chronic Projective Emphysema Hyperventilation
d. Administer O2 inhalation Diarrhea Vomiting
e. Institute reverse isolation DM Pyloric stenosis Bronchitis
f. Monitor for signs of infection: fever cough Ileustomy Cushing
g. Avoid IM, SQ or any venipuncture sites provide heparin lock
h. Administer medications as ordered: ROME respiratory
37. Immunosuppressants: Anti-lymphocyte Globulin Before ABG, patient should be (+) Allens test: determines collateral
given 6days to 3 weeks via central venous catheter to circulation, press radial & ulnar artery
achieve the maximum effect of the drug ABG Normal Values
1.35-1.45
DISSEMINATED INTRAVASCULAR COAGULATION an acute hemorrhagic 35-35
syndrome, characterized by wide spread & spontaneous bleeding & 22-26
thrombosis due to deficiency of prothrombin & fibrinogen -platelet
disorder
Polycytemia late sign- pruritus
1. Predisposing Factors
a. Rapid BT

35
Acidic hematemesis coffee ground, with HCl
4. Nursing Management
a. Monitor for signs of bleeding of all hema tests
b. Administer IV fluid replacement as ordered isotonic
c. Administer oxygen inhalation as ordered
42. Vitamin K (Aquamephyton)
43. Heparin short acting
44. Vasopressin, Pitrissin to prevent urination,
conserving water
d. Provide heplock, avoid IM SQ or any venipuctured sites
e. Institute NGT decompression gastric lavage
45. iced saline solution
46. cold saline solution
f. Prevent complications: Hypovolemic SHOCK, late sign = anuria
NOTES:
NGT tube kink closed for feeding gavage
NGT tube open drain sa bed side bottles lavage remove gastric
contents decompression
Give ice or cold water saline solution instill 1 litter, then decompress
BLOOD TRANSFUSIONS
1. FOUR objectives:
1.) To replace circulating blood volume
2.) To increase the oxygen carrying capacity of the blood
3.) To combat infection if decreased WBCs
4.) Prevent bleeding if decreased PLT
2. Nursing Management:
47. proper refrigeration
48. proper blood typing and cross-matching
O - universal donor
AB universal recipient
85% of general population is Rh (+)
49. Aseptically assemble all materials needed for BT:
Filter set (BT set)
PNSS isotonic to prevent hemolysis
Needle gauge 18-19 large bore needle
50. Instruct another RN to re-check the following
Name of patient
BT and crossmatching
Expiration date
Serial number
51. check blood unit for presence of bubbles, cloudiness,
sediments and dark color signs of contamination -
DO NOT DISPOSE, RETURN TO THE BLOOD BANK, for
re-exam
52. NEVER WARM BLOOD PRODUCT, it may destroy vital
components in the blood, wait for 30 minutes, let room
temperature warm the blood product, NEVER WRAP IT
53. WARMING of blood, used only through warming
DEVICE, emergency-RAPID BLOOD TRANSFUSION
54. Transfusion should be completed in 4 hours, blood that
is exposed more than 2 hours causes blood
deterioration, can result to bacterial contamination
55. Avoid mixing or administering drug at BT line may
cause to hemolysis
56. Regulate at KVO (Macro- 10-12gtts/min) at 100cc/hr
to prevent circulatory overload
57. Monitor VS BEFORE, DURING & AFTER transfusion,
especially every 15 minutes (majority of transfusion
rxn occurs in this period) for the first hour.
3. Signs of BT reaction - HAPCATCH
Hemolytic Reaction
Signs/sx:
58. dizziness
59. headache
60. dyspnea
61. hypotension
62. flush skin
63. lumbar, flank, sternal pain
64. red colored urine (portwine urine)
Nsg. Mgmt:
1. Stop the blood transfusion
2. Notify the physician
3. Flush it with PNSS, to prevent hemolysis
4. Administer isotonic fluid solution as ordered to counteract shock &
prevent acute tubular necrosis (leads to renal failure)
5. Return the blood unit to the blood bank for re-examination
6. Obtain urine & blood samples to laboratory for re-examination
7. Monitor vital signs
36
 Citrate intoxication hypocalcemia, tetany, trousseous sign
Allergic Reaction: Hyperkalemia indicates that blood is already expired lead to
s/sx: arrythmia
65. fever, chills
66. dyspnea Q: You have 4 patients, who will the nurse help in emergency case?
67. laryngospasm A: Hemolytic reactions
68. bronchial wheezing B: Allergic
69. urticaria, pruritus C: Pyrogenic
Nursing Mgmt: D: Circulatory
1. to 3 same Next is Anaphylactic reaction
4. Administer anti-histamines as ordered Diphenhydramide Hcl
(Benadryl) drowsiness, avoid driving and operating machineries
5. If (+) hypotension due to anaphylactic reaction Verbal order during emergency only, let another doctor to sign it for
6. Return blood to blood bank (same) the other doctors order

Pyrogenic Reaction Administer KCl 11.5 meq/L- (should be given 3.5-5.5meq/L) to be given
s/sx: via IV bolus now (may lead to cardiac arrest, should be given IV drip)
-fever and chills
- headache Hypotonic solution: what happened to the cell? SWELL
- dyspnea Hypertonic solution: SHRINK
- tachycardia and palpitations Insulin G25-26
- diaphoresis
RBC 1 unit/pack = 3-6 days refrigeration = 250cc
Nursing Mgmt: Platelet bag expiration = 3-5 days refrigeration = 110cc
1. to 3 same Whole blood with plasma= 2-3 months = 500cc
4. Administer anti-pyretics & antibiotics as ordered
5 to 7th same Oncology Nursing
8. Provide TSB Differences Benign (Tumor) Malignant (Cancer)
Differentiation well differentiated poorly differentiated
Encapsulation with capsule without capsule
Circulatory Overload Metastasis (-) (+)
S/Sx: Prognosis Good Poor
70. dyspnea Tx modality Surgery-most chosen Chemotherapy
71. rales/crackles treatment Radiation many side
72. orthopnea effects
Nsg Mgmt: Surgery
1 to 2 same Bone marrow
3. Administer loop diuretics as ordered: Lasix 10-15mins 6 H, given AM Transplantation
Normal growth of cell: by straight line, with structure, pantay
Air embolism Cancer cells: They pile each other, forming mass
Thrombocytopenia

37
 Neutropenia
Oldest type of cancer BREAST CANCER Thrombocytopenia
3. Warning danger signal signs: CAUTION
1. Predisposing Factors (Carcinogenesis) 82. Change in bowel or bladder movements
GIVE 83. A sore that doesnt heal
73. Genetic history (smoking, drinking, staying late at 84. Unusual bleeding or discharges
night=immunocompromised) with oncogenes 85. Thickening of a lump in breast or elsewhere
74. Immunologic factors: 86. Indigestion or dysphagia
75. Viral factors: Epstein barr virus infectious 87. Obvious change in a wart or mole
mononucleuosis KISSING DISEASE (dysphagia, 88. Nagging cough or hoarness
retinopathy, fever & chills, sore throat, spleenic 89. Unexplained anemia
rupture->immediate death); Human papelloma Virus 90. Sudden weight loss
wart-pre-carcinogenic (same as moles) (if it spreads, 91. Anemia
tender, 92. Loss of weight
76. Environmental factors NOTE: 3 to 4 (+) signs, consult a doctor
Physical factors
Radiation 4. Therapeutic Modalities
UV rays 1. Chemo-utilization of various chemotherapeutic
Nuclear explosion agents that kills the cancer cells, and also kills
Chronic irritation normal rapidly producing cells-GIT, hair follicles,
Direct trauma: cervical cancer bone marrow.
(multiple sexual partners or birth) Antimetabolites
Chemical factors Alkylating agents
Urethrane/hydrocarbons Plant alkaloids
Food additives (nitrates/nitrites) tocino Hormones and steroids
tapa-salitre Antineoplastic antibiotics
Drugs (stilbestrol, diethylstilbestrol, 5. Side effect and nursing Management
DES) a. Hair follicles alopecia
Smoking 93. Encourage use wigs turban/bandana
Hormones 94. Inform client that hair loss is temporary, hair will grow
back in 4-6months after chemotheraphy
2. Classification (based on tissue type) b. GIT - Nausea and vomiting:
77. Carcinoma -epithelial tissue and surface of the granular 95. NPO before procedure
tissue 96. Administer anti-emetics (Metoclopramide) Plasil 4-6
78. Sarcoma connective tissue hours before chemotheraphy
79. Multiple Myeloma arises from bone marrow & plasma 97. Bland diet post-chemo
cells, hypocalcemia, early sign: back pain especially in 98. Diarrhea :Administer anti-diarrhea agents 4-6hrs
AM before chemotherapy
80. Lymphoma arises from lymph glands 99. Stomatitis: provide oral care, offer popsicles
81. Leukemia arises from blood cells, CODE: ANT 100. Dysgeusia (altered taste sensitivity):
Anemia

38
 c. Bone Marrow Depression Anemia: 117. Distance the farther the distance, the lesser the
101. CBR exposure
102. Provide O2 inhalation 118. Shielding alpha and beta rays can be blocked by
103. Leukopenia: reverse isolation rubber gloves; gamma rays can be blocked by thick
104. Thrombocytopenia: encourage client to use electric lead and concrete
razor when shaving d. Major SE and nursing management:
d. Reproductive organs 119. Skin erythema/redness and sloughing of tissues
105. Sterility: encourage client to sperm banking before the Assist in bathing
start of chemotherapy Force fluids, to flush the radioisotopes, flush water
106. Genetic counseling (-) talcum powder, lotion may lead to skin irritation &
e. Renal System breakdown, use olive oil (NCLEX) or cornstarch (local exam)
107. Lead to increasd serum uric acid 1. GIT N/V, diarrhea, stomatitis
- Allopurinol 2. Bone marrow anemia, leucopenia, thrombocytopenia
- Colchicine Same intervention
f. Neurologic Disturbance
- Peripheral neuropathy NOTE:
- Paralytic ileus> absence of peristalsis, the only chemotherapeutic Atrophy of taste buds (decreased taste sensitivity) 40 yrs old
agent: Vincristin -plant alkaloid Phils: 95% Filipino males who have cancer are aged
European: dominant gene
II. Radiation therapy- utilization of electro-magnetic waves that kills the
cancer cells and inhibit their growth and also kills the normal rapid Q: what should be avoided post chemo?
producing cells A. custard
a. Types of energy emitted B. milk
108. Alpha does not penetrate skin tissues C. Pork (beef)
109. Beta internal radiation; more penetrating D. Banana
110. Gamma rays external radiation; penetrates deeper
underlying tissues (ex. cobalt)

b. Methods of delivery
111. External utilizes electromagnetic waves
112. Internal involves injection or implantation /
transplantation or injection radioisotopes proximal to
the cancer site
113. Sealed implant radioisotope within a container and
does not contaminate body fluids ex. Phosphorus 32
114. Unsealed implant radioisotope without a container
and contaminates body fluids
c. Factors affecting Exposure
115. Half life time required for half of the radioisotope to
decay
116. Time shorter time lesser exposure

39
 01/29/06 c. Left MCA
CARDIOVASCULAR SYSTEM If one of the coronary arteries is blocked, myocardial ischemia -> angina
Heart muscular pumping organ of the body pectoris -> if prolonged myocardial necrosis -> MI (heart attack)
A. the only organ located in the midastinum Left
B. it resembles like a closed fist V. Cardiac conduction sytem
C. Weighs 300-400 grams a. SA node pacemaker, (Keith Flock node)
D. This is covered by a continuous sheet serous membrane located at the junction of superior vena cava and right atrium
pericardium 3.fxn: primary pacemaker of the heart, it is the one that initiates an
3. Parietal outside electrical impulse of 60-100bpm
4. Visceral middle 4.if heart rate is below 60 brady, above 100 tachycardia -> arrythmias
Pericardial fluid approx 10-20cc in the middle b. AV node (Tawara node)
of parietal & visceral, to prevent pericardial - located at the inter-atrial septum
friction - theres a delay of electrical impulse NORMAL= 0.08 milliseconds to
E. Layers allow ventricular filling
Epicardium - secondary pacemaker, can initiate electrical impulse only for about 40-
Mayocardium 60bpm
Endocardium c. Bundle of His
III. Chambers - R and L main bundle branch
a. Atria collecting or receiving chamber - located in the interventricular septum
b. Ventricles pumping or the contracting medium, left ventricle- d. Purkinje fibers
HIGHEST PRESSURE: 180-250mmHg needs pressure to force the - located at the walls of the ventricles
blood going to the aorta, going to the systemic circulation - leading to ventricular contractions (1 heartbeat)
TO PREVENT backflow,
Q: complete heart block = L R bundle of HIS are damaged
IV.
Valves N/R: needs an artificial pacemaker made of metal, every 5 years has
a.atrioventricular valves to be changed
- Tricuspid Q: sign of malfunction pacemaker= HICCUPS
- Mitral
closure of the AV valves gives rise to: 1st heartsound S1 LAB Coronary Artery Disease Ischemic Heart Disease
b.Semilunar valves Stages:
1.Pulmonic 1. Myocardial injury Artherosclerosis = presence of lipid deposits
2.Aortic 2. Myocardial Ischemia Angina Pectoris =lead to decreased blood
closure of the semilunar valves gives rise to: 2nd heart sound S2 flow
DAB 3. Myocardial Necrosis Myocardial infarction, unpredictable disease
Extra heart sound
1. S3 ventricular gallop CHF LEFT Atherosclerosis Arteriosclerosis
2. S4 atrial gallop MI HPN narrowing of artery hardening of an artery
lipid and fat deposits CHON protein and Ca deposits
IV Coronary Arteries both supply the myocardium with blood Tunica intima Tunica media
a. Arises from the base of the aorta
b. Right main coronary artery RMCA

40
Layers of the artery : If 2 or more blood vessel or artery are occluded -> perform Coronary
Tunica adventitia/externa- external Arterial Bypass and Graft Surgery (CABG)
Tunica media middle
Tunica intima - innermost 1ST GRAFT give doctor 2-3 hours, get artery in the femur, placed in ice
or cold solution, open heart, xyphoid process to umbilicus, open ribs, put
Coronary Artery Disease Ischemic Heart Disease valve, coronary artery cut, harvested femoral connected through
1. Predisposing Factors cauterized
5. Sex: male CABG respiratory complications coughing
6. Race: Black 4. Same diagnostic/nursing management with Angina pectoris
7. Smoking nicotine vasoconstrictor
8. Hyperlipidemia genetic ANGINA PECTORIS
9. Obesity - >20% 1. Definition: a clinical syndrome characterized by paroxysmal chest
pain resulting from temporary myocardial ischemia, relieved by rest
Overweight >10% or by taking nitroglycerine
2. Predisposing Factors: same as atherosclerosis
10. prolonged use of oral contraceptives 3. Precipitating Factors: 4E
11. Sedentary lifestyle Excessive strenuous physical exertion
12. Diet high in saturated fats WHOLE MILK Extreme emotional response
13. DM Exposure to cold environment
14. Hypothyroidism Excessive intake of foods rich in saturated fats
2. S/sx: 4. Signs/Symptoms:
Chest pain > Initial sign: Levins sign hand clutching of the chest
Tachycardia > Chest pain sharp, stabbing, excruciating, crushing substernal pain
Palpitations > Usually radiates from back, shoulder, arms, axilla and jaw muscles
Diaphoresis > Usually relieved by rest or by taking NTG
3. Treatment > Dyspnea
- Percutaneous Transluminal Coronary Angioplasty (PTCA) > Tachycardia
Objectives: > Palpitations
> Revascularized myocardium > Diaphoresis
> prevent angina 5. Diagnostic Procedure
> increase survival rate ECG -reveals ST segment depression

deflate balloon, put KY, pasok sa femoral artery, inject dye (pre-op: ST elevation MI
check for allergies-seafoods-shellfish dyes are iodine base), to clearly
visualize where to place the catheter, x-ray is used,if near atheroma, Stress test trendmill abnormal
syringe 10 cc insert air to inflate balloon to compress the atheroma Serum uric acid and cholesterol HIGH
PTCA done to single occluded vessel 6. Nursing Management
(post-op: force fluids, flush the dye, dyes are nephrotoxic agents it can Nsg goal: decrease myocardial demand or workload REST the
destroy the kidneys and dyes are osmotic diuretics-> leads to severe heart
DHN) a. Enforce CBR
b. Administer medications as ordered

41
 Nitroglycerin (NTG) MYOCARDIAL INFARCTION (MI) HEART ATTACK
1. Small doses dilates lower extremities, venous pulling 1. Definition: terminal stage of CAD characterized by permanent
-> venous stasis -> leg retained can not return to malocculusion leading to necrosis and scarring
heart -> heart lesser pumping 2. Types: (depending on location)
2. Large doses vaso dilator dilates all 3. Transmural the most dangerous of all types of MI,
Nursing Mgmt: (NTG) characterized by occlusion (blocked) of both R and L coronary
1st dose of NTG = 3-5 mins arteries
2nd dose of NTG = 3-5 mins 4. Subendocardial occlusion either the L or R coronary artery
3rd & last dose of NTG = 3-5 mins 3. Critical period
STOP giving the dose, notify the physician 6-8 hours after MI, majority of arrhythmia occurs during this
Given only 3x at 3-5 mins interval, if not relieved by NTG = it is MI period, most common or #1 cause of death PVC premature
1. Place the drug in a dry - AVOID heat & moisture as it may ventricular contraction, if PVCs and conscious assist in the
inactivate the drug defibrillation but positive to PVC and unconscious assist in
2. Monitor side effects low BP -> Orthastatic hypotension, cardioversion
transient headache, and dizziness Ventricular tachycardia -2nd most common cause of death,
3. Instruct patient to rise slowly from sitting position ventricles are pumping ?180bpm -> lead to arrest N/R:
4. If giving transdermal patch, avoid placing near hairy areas as it Administer Lidocaine, Xylocaine SE: Confusion
may decrease drug absorption, if hairy-shave it when giving Ventricular Fibrillation NR: Administer epinephrine, assist in
NGT, if auscultating put water (+) hairy chest water is good defibrillation, perform advance cardiac life support or CPR
conductor for sound waves 4. Predisposing Factors: same as atherosclerosis
5. Avoid rotating transdermal patches decrease drug absorption, 5. Signs and symptoms:
avoid placing near microwave ovens during defibrillation-may Chest pain excruciating, visceral pain, substernal, rarely
lead to burns-it contains aluminum foil in the package precordial
6. Beta-blockers propanolol Radiates from back, shoulder, arms, axilla, jaws and abdominal
7. ACE inhibitors captopril muscles indigestion bloated may signify myocardial
8. Ca channel blockers nifedipine infarction, dont do valsalva maneuver - may have abdominal
9. Administer O2 inhalation low in flow 2-3LPM ischemia
Not relieved by NTG
4-5lpm WILL LEAD TO RESPIRATORY ARREST dyspnea
10. Place client on semi-fowlers position (lung expansion) hyperthermia high metabolism
11. Monitor strictly VS, IO and ECG tracing initial rise in BP
12. Diet- low in saturated fats, low in sodium, low in caffeine, avoid cool, moist, ashen skin
gas forming foods (prevent valsalva maneuver) mild apprehension, restlessness
13. Provide health teaching and discharge planning concerning: occasional findings:
- Avoidance of precipitating factors: 4Es 1. split S1 and S2
- Prevent complications: MI 2. pericardial friction rub
- Take medications before activity/exercise 3. rales/crackles
Instruct client to take medication before indulging in physical 4. S4- atrial gallop
exertion- to achieve maximum therapeutic effect of the drug S3 CHF Left side
- Importance of follow up care 6. Diagnostics
Cardiac Enzymes

42
 1. CPK MB Creatinine Phosphokinase Serum Increased > Tissue Plasminogen activating factor SE: chest pain
12-24H most important monitor for bleeding time
2. LDH lactic Acid Dehydrogenase Increased
3. SGPT (ALT) serum glutamic pyruvate transaminase g. administer medications as ordered
can be found in liver 9. anticoagulants
4. SGOT (AST) Serum oxaloacetic pyruvate transaminase heparin
- can be found in liver coumadin
5. Troponin Test Increased (+) MI, result released 10. antiplatelets PASA aspirin due to anti-thrombotic
within 1-2hours only CI: Dengue, ulcer, un known cause of headache
6. ECG reveals ST segment elevation and widening of h. encourage patient to take 20-30 cc/week of whiskey or brandy
QRS complexes indicative of arrhythmia to induce vasodilation red wine- prevent clot of fat
If theres a pathologic Q wave (depressed) i. assist in surgical procedure CABG
indicates infarction j. PROVIDE HEALTH teaching and d/c planning
Peak T waves 11. avoidance of precipitating factors
7. Serum uric acid increased 12. prevent complications
8. CBC increased WBC arrythmias
7. Nursing Management: cardiogenic shock late sign MI: OLIGURIA
Goal: decrease myocardial workload L CHF
a. Administer medications as ordere: Thrombophlebitis hOmans sign
>First give Morphine sulfate induces vasodilation respiratory DRESSLERS SYNDROME or post MI syndrome
depression antidote- narcan naloxon and relieve anxiety the client is non-resistant to pharmacological
>Administer O2 inhalation, low flow at 2-3 LPM agents
>enforce CBR without BP (not universal abbreviation) use bedside Administer 15-400T units of
commode streptokinase as ordered
b. instruct client to avoid activities of valsalva maneuver 13. regular adherence to medications
c. place client on semi-fowlers position 14. resumption of ADLs especially sexual activity (4-6
d. Diet provide general liquid to soft diet avoid saturated fats, sodium, weeks post-cardiac rehabilitation CABG) and instruct
caffeine, and gas forming foods patient to have sex as appetizer rather than a dessert -
e. monitor VS, IO, ECG strictly ST elevation QRS widening > have sex before meals, not after meals
f. administer medications as ordered: assume non-weight bearing position
- Vasodilators for high BP missionary normal, 69, 88
- NTG
- ISDN Isorsorbide dinitrate - Isordil via SL CPK MM for brain
- Anti arrhythmic agents lidocaine Q: What is the initial question- angina pectoris?
- beta blockers A: What did you do prior to having the chest pain?
- ACE inhibitors Q: What is the second question to ask?
g. Administer medications as ordered A: is the chest pain radiates? problem is cardiac in nature
- Thrombolytic/Fibrinolytic agents (should be administerd within 12 hours If it does not radiate respiratory in origin Pneumonia,
post MI) Emphysema, PTB, Pleural effusion
> Streptokinase SE: allergic rxn NTG is given sublingually prick it gel
> Urokinase Universal RULE: when given small doses renal dilator

43
02/04/06 we are the result of whatever happened to us when we were
kids
PSYCHIATRIC NSG: Structure of Personality
ID EGO SUPEREGO
Thoughts -> Feelings Impulsive Delays gratification
I am not prepared -> nervous -> restless I want to impronto Should not
This is not right! -> angry -> frown Pain avoidance Executive decision Small voice of God
At last, after 48 years -> excited -> open eyes Pleasure Principle Reality Principle Conscience
Im on a diet -> hungry MAN Schizophrenia OA
I lack sleep -> sleepy -> closed eyes, open mouth, drooling Manic Impaired reality Obsessive Compulsive
Somebody kissed me -> loved -> happy Anti-social perception- ego Anorexia Nervosa
No txt, no luv -> unloved -> sad Narcissistic disintegration
I am the queen of the world -> self-esteem -> flamboyant heavy make
up The Factory = Earth & Factory worker Mother
Life is empty -> sad -> withdrawn suicide Libido sexual energy responsible for survival
The FBI is out to get me! -> sad scared -> withdrawn violent It began when we were born
I am fat. Fat is beautiful -> self-esteem
I am fat, Fat is ugly -> self-esteem -> diet, diet, diet 0-18 months survival
want to eat, sleep, urinate, defecate
Belief determines your feelings ID developed CRY-> mother gives breast nipple SUCK ->
Feelings determines your behavior MOUTH = ORAL STAGE
When the child cries ->>Feed the infant -> important -> happy
Grandma slouching, sad, low self-esteem, withdrawn -> talk to her -> successful
NOTE: 1. Whatever you see, what you say When the child cries ->>If ignore the infant -> not important ->
You seemed sad/happy today. -> the person seemed interest, the NARCISSISTIC = to meet their needs for the entire lifetime
person thinks he/she is important FIXATION= when a person is stuck in a certain developmental
NOTE: 2. Restating: stage
You are so sad today? Mouth smoking, eat, talk, bite, suck, drink, gossip, lick, kiss,
You dont want to eat? chew REGRESSION return to an earlier developmental stage
*Listening to the client, whatever client she/he says is important EGO 6 MONTHS
NOTE: 3. Recognition
You have done something right. You have combed hair, arranged the 18months 3 years old ANAL STAGE
bed. You should NOT
NOTE: 4. Present reality Toilet Training
You are a monster. -> Good morning, mam. Im not a monster, I am SUPEREGO is developed
wilen. I will be your nurse for today. Ambivalence = Pulled to 2 forces to stay or not to stay
TT ->>Good mother -> Successful SuperEgo
Why are they dysfunctional? Why they are not normal? Why are they TT->> Bad mother ->> Clean, organized, obedient, OBSESSIVE-
different from us? COMPULSIVE = Strong Superego = Anal Retentive

Sigmund Freud father of psychoanalysis

44
 TT-> Bad mother ->> Dirty, disorganized, disobedient ANTI- ANTI-ANXIETY
SOCIAL = Weak Superego and ID = Anal Expulsive V alium
L ibrium Liberty
Q: But whos anal retentive and anal expulsive? A- tivan Ate guy
A: Anal expulsive Anti-Social S erax Sira ulo
A: Anal retentive Obsessive Compulsive T ranxene LR -Transit
M iltown meal town down town
3-6 years old E quanil aqua/tubig
PHALLIC STAGE V istaril larVabista
Preschooler A tarax Ang dami rocks
Penis I nderal hINDE RALph
Vagina B uspar Bus pa taRa na
Parents Ex. Childhood Kurt Cobain 27 years old, when he was 4-8 years old
Will have a relationship with the opposite sex parent Thanksgiving he performed, bullied, nobody wants to keep me=
Oedipus Complex - Boy loves mommy, IDENTIFICATION = became a successful Nirvana vocalist but killed himself, feeling of
imitates daddy, afraid of removing his testis Fear of Castration emptiness
Electra Complex - Girl loves daddy, IDENTIFICATION = imitates
mommy, Penis envy thinking of somebody cut off your penis, Erik Erikson theres more to life than just sex,
wants to have it hence, the psychosocial theory of development
Stage + - Factor
Dr. Karen Horney disagrees with Dr. S.Freuds concept of Penis Envy 0-18 TRUST MISTRUST Feeding
SUPPRESSION = conscious forgetting of an anxiety provoking months
concept 18mos -3 AUTONOMY SHAME/ Toilet training
Conscious = theres a level of awareness y/o - stand on his DOUBT
Preconscious= tip of the tongue own
Unconscious = unconscious forgetting of an anxiety provoking 3 6 y/o INITIATIVE GUILT Independence
concept/idea = REPRESSION= ex. birth traumatic experience =is to - imitates -anger turned
be forgotten, not worth recalling, stored place parents inwards
- initial steps
6-12 years old 6-12 y/o INDUSTRY INFERIORITY INDUStry
School LATENCY dormant, submissive, TULOG - many steps in da skul - SCHOOL
School phobia = Separation anxiety 12-20 y/o IDENTITY ROLE PEERS
Reading, WRiting, ARithmetic The garden of CONFUSION Belief#1 Education is
SUBLIMATION = Placing sexual energies toward more life: valuable
productive endeavors Belief #2 Success can
12 ABOVE = GENITAL STAGE Gising Who am I? be achieved by
most important, responsible of sexual intercourse, continuation perseverance
of human species Belief#3 I have the
capability to effect
PHARMA MOMENTS: changes in the society

45
20-25 y/o INTIMACY ISOLATION LOVE
25-45 y/o GENERATIVITY STAGNATION PARENTING BF Skinner Operant Conditioning
grab behavior can be repeated
opportunity, positive reinforcement = reward = result to repetition of
learning behavior
45 & EGO DESPAIR REFLECTION negative reinforcement = punishment = behavior is
above INTEGRITY stopped/extinct
- aging
- examine life, Frontal Lobe Occipital Lobe Temporal Lobe Parietal Lobe
replay events Language Vision - eyes Hear Touch
- embrace all Learning Smell Taste
experiences Personality
because it Judgment
contributed to
their CN ACTION
development Olfactory smell of food
Optic open eyes - sight
Oculomotor move up light brighten up eyes constrict,
Abraham Maslows Hierarchy of Needs movement of pupil
Self- Trochlear look down food thrown at the floor
Actualization Trigeminal pray 3, chewing
Self-Esteem Abducens look at the sides
Love & Belongingness Facial taste, facial expression
Safety and Security Vestibulocochlear balance, hear
Basic Needs: air, food, shelter, clothing, sex Glossopharyngeal throat, swallow
Vagal/vagus bagal-parasympathetic
Psychiatric Nursing goals: Accessory move shoulders-happy
1. Love & belongingness Hypoglossal movement of tongue-Belat
2. Self Esteem How do you interact with your environment? SIM
3. Self Actualization SENSORY
As a nurse, the role is to: Eyes
Acknowledge whatever the client has done Nose
- to improve the clients condition until the client reaches self- Ears
actualization Tongue
INTEGRATION
Behavioral Models: MOTOR->> Voluntary = Voluntary Nervous System = SOMATIC
Ivan Pavlovs Classical Conditioning NERVOUS SYSTEM begins from the brain ->Spinal Cord -> Motor
all behavior is learned Nerve [Synapse-neurotransmitter: ACETYLCHOLINE = chemical
1939, laboratory experiment, food = stimulus, has been shown responsible for movement ON]->Muscle Fiber
to a dog, dog salivates, he used a bell, followed by the food ->>Involuntary = AUTOMATIC AUTONOMIC NERVOUS SYSTEM

46
 ANS Making Observations: You seem sad. You have made your bed
---------------------------------------------- today.
Sympathetic-Anticholinergic Parasympathetic-Cholinergic
Active Listening:
heart rate heart rate What if you want a person to continue speaking?
RR RR - nodding
GI Constipation,Dry Mouth Diarrhea, Moist Mouth - eye contact
GU Retention Urinary frequency - lean forward
Dilate pupils DILAT-ALERT Constrict
Mydriasis Miotic Broad opening:
Vaso constrictor Vaso dilation
How are you today?
BP BP
How are things going today?
Neurotransmitter:
How are you?
Epinephrine
Norepinephrine Acetycholine Tell us about yourself?
Who are you?
Q: The following are anticholinergic side effects of antidepressants
exept: How do you make it verbal?
a. urinary retention
b. Dry mouth General Leads: Go on, Im listening. And then. What else?
c. Constipation
Exploring: Who, What, When
Q: The following are anticholinergic side effects of antipsychotic agents
except Restating: Im sad. Youre sad?
a. Tachyardia Im happy. youre happy?
b. Urinary retention
c. Diarrhea correct Refocusing: Dave, Im not asking what you do, who you are?

MONOAMINE OXIDASE INHIBITORS - PANAMA Deltner/Videbeek/Shives Psychiatric Nursing

Reflect VS Restate
M PLAN Youre hungry? VS You want cheeseburger?
N AR DIL
P NATE Non-Therapeutic :
False reassurance: Everythings going to be fine
Therapeutic Communication Techniques: Changing topic/subject
If a person is withdrawn, will you ignore the person? Ignore the client
Offer self: I will be here with you. I will sit with you. I will go with you. Value based judgement: Avoid using ADJECTIVE
Lets so there. Lets sit down. Nice weather were having today
You have the most wonderful bed in the ward
Silence: You want the client to think of any topic, and let the client to Why? = putting the client in defensive position
talk and talk Flattery
You should do this now = Advising = Commanding

47
 In my opinion No, I did not feel angry
Arguing = No, you are wrong
Anger is repressed
Mind visualize things to happen
Fantasy > mental Conversion
Reality
You have to know where to go Converted to physical symptoms
You must know what you really want to have in life
Nervous system
-----------------------------
STRESS use DEFENSE MECHANISM:
Sensory Motor
1. Displacement transfer of feelings to a lesser threatening objects,
Numbness Paralysis
than the one who provoked it.
2. Denial failure to acknowledge an unacceptable trait or situation
16. Substitution replace difficult goals with more accessible one
3. Dissociation - Pschological Flight From Self = amnesia - Raped
traumatic experience = Sino ka? Sino ako? = wants to forget
SNS
4. Regression return to an earlier developmental stage fetal position
Stop GABA Gamma Amino Butyric Acid
5. Repression unconscious forgetting of an anxiety provoking concept
slow down
6. Rationalization illogical reasoning for a socially unacceptable trait.
go Epinephrine/Norepinephrine
Ex. I drink because I socialize and I socialize everyday
7. Reaction Formation done the opposite of your intention. Ex. Gusto
Anxiety
mo sakalin pero niyakap mo. Plastik, Tupperware, Orocan, Kyowa SNS E/NE axn: bring the GABA - Anti-Anxiety Agents
8. Undoing do the opposite of what you have done/action. Ex. You
shown your true feelings, frown then other smile. Felt guilty, next Anticholinergic
time you smiled Constipation within 1 week
9. Identification assume trait for personal, social, occupational role. Urinary ret Seizures
Ex. I want to be like my father = Personal goal. I want to be the Rebound Phenomenon
president = Social role. Occupational role I want to be an Abrupt
architect.
10. Projection attribute to others ones unacceptable trait. PASA LOAD
ex. My friends are alcoholic. Not me, but them. Withdrawal
11. Introjection assume another persons trait as your own, not just, ---------------------Anti-anxiety------------------------------------- Dependence
me too! Ako din. drowsy
12. Suppression conscious forgetting of an anxiety provoking concept. can not drink alcohol
13. Sublimation destructive energies/ sexual energies/ hostile energies can not drink coffee Gradual
put towards more productive endeavors:music, poetry, writing lyrics, Dev.Orthostatic Hypotension Tapered dose
dance, art, handicraft. Relaxed
14. Conversion
15. Compensation overachievement in one area to cover a defective
part Anxiety - RR

48
 Metabolic Respiratory Respiratory Metabolic My thoughts wont shut off. Theyre constantly running, making
acidosis acidosis Alkalosis Alkalosis me worry
pH 7.35-45 pH pH pH pH If a loved one is ten minutes late, the person with generalized
CO2 35-45 CO2 CO2 CO2 CO2 anxiety fears the very worst
HCO3 22-26 HCO3 HCO3 HCO3 HCO3

Principles:
1. CO2 is opposite pH =
2. HCO3 is same Ph
3. Compensation: same direction for CO2 HCO3
PANIC
4. CO2 HCO3 pH Normal = Fully, Abnormal = Partially
MILD MODERATE SEVERE +4
Interpretation: Suicide
+3 Safety
1. ph acidosis alkalosis +1 +2
Dont know Dont touch
2. CO2 opposite: RESPIRATORY Widened perceptual Pacing
field Prn Meds what to do/ the client!
3. HCO3 same direction with the Ph: METABOLIC Restless Valium say Respiratory
Enhanced learning Librium Directive: Alkalosis
capacity Lets go to the Breathe into
room. bag!
NR: Enter the room Sympathetic
1. Sit Stop. Come
.here.
2. Dangle Simple words are enough Anxiety
3. Stand gradually You seem restless
SNS

Anticholinergic SE in taking Antianxiety: RR
1. Constipation
2. Urinary retention CO2

3. dry mouth pH
4. blurred
Respiratory Alkalosis

02/05/06 Nx Dx: Ineffective Individual Coping

Fear something that protects us Subjective: Hey, I can not handle things anymore.
Trade off/Price of gift of fear anxiety
Anxiety vague sense of impending doom Nx Dx: Powerlessness
Doom - Parasympathetic SNS Subjective: I have lost control over my life

Assess Level of Anxiety Nx. Dx: Impaired Skin Integrity

Subjective Data: Objective: keeps of cleaning hands
I just dread being alone at night. I dont know why, but I do

49
 Planning/Implementation: Post Traumatic Stress Disorder - PTSD
1. Decreased Level of Anxiety
2. Decreased Environmental Stimuli 6 yrs old Anxiety
3. Relaxation Technique Psychosomatic
Manipulating the environment Assignments I am sick
Homeworks
Evaluation:Effective Individual Coping Malingering Somatoform
6 months excessive worrying No assignment pretending to be
Generalized Anxiety Disorder:GAD No homework sick-conscious
Restless
Concentration difficulty You think, Absent
Sleep problems Teacher may get
Palpitations angry! Escape Mama
Edge of the seat from care
Easy fatigability teacher
if your worrying affects or interferes with ADLs Attention Secondary
may lead to harm to self & others escape panic Primary Anxiety Gain
attack Gain -result of malingering
where attention increases
Panic attack may happen anytime
SNS activation but goes down, difficult to manage Somatoform
15 to 30 minutes escalation of SNS no pretension Illusion of structural defect
unconscious Body Dysmorphic disorder
Agoraphobia fear of open spaces, they can not go outside no organic basis
1. can still communicate with other people
Social Phobia fear of public/ other people Nervous system Minor discomfort
Conversion disorder Interpreted as major illness
Victims - trauma, disaster, accident, rape, earthquake La belle indifference Hypochondriasis
No reaction to the
Survivor victims who were able to cope and emerged as s/sx happening
new people
Flashbacks- haunted by the past Favorite pastime: Symptom: Doctor Hopping
Nursing Focus: focus on clients feelings
Nightmares disorder happens > 1 month

50
 Mind Psychophysiologic/Psychosomatic constantly thinking about certain sounds, images,
Real pains/illness/ Real Symptoms words, or numbers
Body fear of harming a family member or friend
fear of thinking evil or sinful
SNS PNS
COMPULSIONS
Vasoconstriction Bronchoconstriction excessive hand washing
repeatedly checking that doors are locked and
Cerebral Left Asthma appliances are turned off
Artery Gastric arranging items in a precise order
Spasm Artery repeatedly counting to the same number
touching certain objects a precise number of times
Migraine O2
High Obsession High Compulsion
Mucosal lining
PHOBIA
Stress Ulcer irrational fear
* no causative agent immediate nursing intervention: REMOVAL of the
object
Duodenal ulcer Etiologic Agent: H-pylori stimulus -> anxiety
root of the clients phobia is the stimulus
Thought-> Feelings-> Behavior Aiming for behavioral change: SYSTEMATIC
Open Anxiety -action DESENSITIZATION = gradual EXPOSURE to the
- return house feared object. Ex: fear of snake- show black & white
Burglar picture, then colored picture, then show dead snake,
Obsession-> Anxiety-> Compulsion->Anxiety let client touch, then show alive snake, let the client
touch it. Brain/Mind is conditioned, theres a change
P/I: THOUGHT STOPPING RELAXATION *gloves of perception, a new response.
*explore feelings TECHNIQUES *substitute
*schedule
*gradual withdrawal Etiology of Phobia:
1. Knowledge
Obsessive-Compulsive Disorder
2. Experience
fear of dirt or contamination
concern with order, symmetry, and exactness

51
Psychotherapy: A need for detoxification:
1. Free Association - Free to talk any ideas Detoxification withdrawal with MD supervision
2. Catharsis allowed to express feelings Withdrawal - Stop taking a drug
3. Transference client to therapist ex. Client thinks of 1. Alcohol
the healthcare personnel as his father 2. Mouthwash
4. Countertransference therapist to client 3. Elixir alcohol based

ANTI-PARKINSON AGENTS - CAPABLES 1st subdivision of Anti-parkinson CAPABLES:

C ongentin Cogie Domingo B enadryl
A rtane arte L arodopa laro dapa Anticholinergics-ABC Dopaminergics-PLEASE
P arlodel ayos sa parlor E ldeprl elderly Artane Parlodel
A kineton akin eto S ymmetrel palit SIM Akineton Larodopa
Bendaryl Symmetrel
ALCOHOL Cogentin Eldeprl
1ST Generation with history of alcoholism
1. can be passed on from generations THERAPY:
2. genetic make up Avoid alcohol therapy Never Drink Alcohol
3. environmental Aversion Therapy 12-hour interval
Intergenerational transmission Alcoholics Anonymous or else, nausea, vomiting and
Antabuse-Disulfiram hypotension
Alcohol
B1 vitamin deficiency
Blackout Risk for injury Wernickes encephalopathy Vah-
awake but Memory gap Complications: motor
unaware Korsakoffs psychosis-memory
Delirium Tremens nurse I dont know my name?
Confabulation -like anxiety/panic attack
Inventing stories to increase self esteem -illusion, hallucination

Denial Formication bugs crawling under the skin
Dependence -> Tolerance substance to maintain desired Family therapy
euphoria
Ask the client:
Enabling Significant other tolerates abuser When was your last dose of alcohol?

52
The client must not take Antabuse if the client has just taken ANTI-PSYCHOTIC AGENTS
alcohol, because there might be effects. S telazin Stella Sin P rolixin
12 HOURS interval needed before giving antabuse S erentil serena til midnight
4-6 hours will experience withdrawal symptoms T horazine tora
24-72 hours will experience delirium tremens T rilafon - tri band phone
C lozaril close na reel
Echolalia - repeats whatever people say, talk to them slowly, M ellaril milya milya reel
they live in their own world = Autism H aldol hahaha
Autistic Savant gifted child, can concentrate ADHD Attention Deficit Hyperactivity Disorder
Nobody Nowhere Somebody, Somewhere by Donna Williams If eight or more of the following statements accurately
describe your child or yourself as a child, particularly before
Assess: ABC age 7 (ONSET), there may be reason to suspect ADHD. A
Appearance Flat Affect no eye/poor eye contact definitive diagnosis requires further examination.
Consistent movement 1. often fidgets or squirms in seat.
no emotion, clean OCD 2. has difficulty remaining seated
Behavior Repetitive 3. is easily distracted
Ritualistic 4. has difficulty awaiting turn in groups
keep on rocking relaxes them, love bicycles 5. often blurts out answers to questions
Communication Echolalia 6. has difficulty following instructions
Incomprehensible 7. has difficulty sustaining attention to tasks
8. Often shifts from one uncompleted activity to another
Nx Dx: Impaired Verbal Communication 9. has difficulty playing quietly
Impaired Social Interaction 10. often talks excessively
Self mutilation hurt oneself internal factors 11. often interrupts or intrudes on others
Risk for injury external factors 12. often does not seem to listen
Planning/Implementation: 13. often loses things necessary for tasks
Maslows Hierarchy of Needs: Language-important 14. often engages in physically dangerous activities
1. Use Expressive Therapy art, music, song, poetry without considering consequences.
2. Provide constant environment can not control impulses ID is the dominant part,
Evaluation: always impulsive
Enhanced communication 7 yrs old and below
Improved Social Interaction
Safety

53
 18 months 3 yrs 6yrs old -> Class Valedictorian
ADHD Model Student
Onset: 7 yrs old and below Toilet training Social life inactive
Duration: 6 months and above
Settings: 2 Clean obedient organized One night, a dream
Assess: ABC
Appearance: Dirty
Behavior: Clumsy, Hyperactive, Impatient Eating Disorders
Communication: Talkative, blurts out in class
Nx Dx: Risk for Injury High Anorexia Bulimia
Impaired Social Interaction Diet, diet, diet Eat, eat, vomit
ID impulsive - Will not follow the mother, teacher, principal, <85% of expected weight Normal weight
society-> Antisocial disorder: anger may build up = future Amenorrhea 3 months Irregular
criminals Sad
Planning/Implementation: Feel guilty when
S tructure Both are manipulative Eating - PINGE
S chedule time for everything If they want to go to the HCl dental carries,
S et limits providing ample time, extent of what u can do Bathroom, accompany them Metabolic alkalosis hand
S afety biting - wounds
Laxative Diarrhea
Evaluation: HCO3 same ph
Minimize Risk for injury Metabolic Acidosis
Improved social Interaction
Safety

CAT Scan --------------- glucose

Frontal

glucose Ritalin after breakfast
-give after meals: prevent loss of appetite
Judgement - stimulant
- be given 6 hours before bedtime
ADHD

54
 BIPOLAR DISORDER 1 MANIA
FVD Profile: Female, 20 yrs old & above, stress, obese

BP Excited

CO Relaxed

O2 Self Actualization
Caregiver role
Heart Brain Self Esteem strain
Safety
Arrhythmias Impaired Social Interaction Safety

NR: Risk for injury/other-directed violence

1. Restore fluid and electrolyte balance
2. Collaborate regarding menu contract eating sleep Hyperactive Sex
3. Target weight gain
4. After meals, stay for 30 mins-1 hour Finger food Private room Anxiety

MANIA high neurotransmitter NE Sexual urge promiscuous = confront behavior = aware but
Lithium vs Norepinephrine not in control you should not do it here
Check for kidney Renal Function Test
L evel 0.6-1.2 mEq/L Wait for 2-4 weeks of Lithium Therapy to end
I ncrease urination polyuria Patient teaching: #1 Drug compliance
T remors, fine hand
H ydration 3L/day to be hydrated #1 defense mechanism by manic patient: COMPENSATION
I ncrease flamboyant
U u diarrhea queen of the world, heavy make up, loud voice,
M outh, dry overachievement in one area to cover a defective part

1st 3 signs of Lithium toxicity: Nausea, vomiting, diarrhea self-esteem -> inc compensation -> up interferes ADLs
Na+ needed harm of others

55
up self esteem -> dec compensation -> down interferes
ADLs harm of others SYMPTOMS

How do you increase the self esteem of client? NEGATIVE POSITVE

T-A-S-K Hypoactive Hyperactive
No basketball, volleyball Withdrawn Sociable
No pingpong no to competition Apathy Flight of ideas
Yes - Gross motor skills: sweeps the floor, wiping the dining Talkative
table, watering the plant, Escorted walk outdoors Assess: Content of thought
= SUBLIMATION = put energies toward more productive Nx Dx: Disturbed Thought Process
endeavors & DISPLACEMENT punching bag Planning/Implementation: Present Reality
No - Cross stitch Fine motor skills Provide Safety
Evaluation: Improved Thought Process
SCHIZOPHRENIA
ego disintegration Assess: Suspicious
impaired reality perception Nx Dx: Risk for other directed violence
twin if one suffer, theres a possibility that other P/I: Present Reality, Provide Safety
genetic vulnerability E: Eliminate/minimize risk for other directed
stress diathesis model -> stress factor violence
Biological theory : Dopamine level, exact cause is Assess: Hallucinations/Illusions
unknown Nx Dx: Disturbed Sensory Perception
PROCESS: P/I: Present reality, Provide safety
Assess: Affect external patient feeling inside & emotion Evaluation: Improved Sensory perception
Mood internal subjective
Assess: Suicidal
Affect: Nx. Dx: Risk for self-directed violence
1. Inappropriate Planning/I: Present Reality, Provide safety
2. Appropriate Evaluation: Eliminate/minimize risk for self-directed
3. Flat violence
4. Blunt

Ambivalence caught to 2 choices

Autism trap in one world
Associative Looseness

56
 The nurses are talking about me
I am going to the mall. The I am going to the mall. People are looking at me
mall is big. Big is the tree. Where is the light? Go here,
Tree is tall. mineral water. Hurray! Concrete Association pilosopo
saan ka pupunta? Eh di sa pupuntahan.
Looseness of Association = Flight of ideas = no common Give a proverb & have it explained
two words with association, words
with common words Thought blocking interruption in the thought/ stream of
thought
Magical Thinking = I can turn you into a frog.
Hallucinations Illusions
Ambivalence = 2 opposing thoughts Stimulus Absent Present
Visual X
Echolalia = repeat what you say Auditory X
Tactile X
Echopraxia = repeat what you do Hallucinations
Acknowledgment:I know the voices are real to you.
Word salad = Just words, no rhyme life, like, lice Reality: But I dont hear them
Diversion: Lets go to the garden.
Clang Association= Clang Poet with rhyme life, wife, knife But what if nothing in the preceding interventions are seen?
Is it appropriate to assess what the voices are saying?
Neologisms = Plungplang, priskip, sertugil = Command hallucinations assess what the voices are saying
CLARIFICATION= What do you mean by thisplungplang? to know if the client will commit suicide, or harm others

Delusion persecutory
The FBI is out to get me.

Delusion religious
I am Jesus Christ, the savior

Delusion grandeur
I am the Queen of world

Delusion Ideas of reference

57
02/11/06 Antipsychotic
TYPES D High Dopamine = Schizophrenia

D
DISORGANIZED CATATONIC PARANOID
-sad but smiles AcH
Inappropriate affect Ambivalence Suspicious Violent
Keep
-no reaction Waxy Flexibility Door
Flat affect Open ON= Extrapyramidal Effects
No Near
-flight of ideas the AcH
Disorganized speech Negativism door D
Dont
-giggling Touch AKATHISIA- Restless, Inability to sit
Eye AKINESIA Muscle Rigidity
Hebephrenic Contact DYSTONIA
1 arm Torticollis- wryneck
Positive/Negative S/S away Oculogyric Crisis fixed stare
Call Opisthotonos Arched back
Reinforcement

RESIDUAL MISTRUST->SCARED->WITHDRAWN
No more positive
Just withdrawn TRUST 1 TO 1
SHORT INTERACTION Tardive Dyskinesia
FREQUENT Lips Smacking
FOODS IN SEALED CONTAINER Tongue Protruding
MEDS WRAPPED Cheeks puffing
UNclassified Irreversible
UNdifferentiated Neuroleptic Malignant Syndrome fever
Mixed classification ON = glucose = ATP used = heat
Cant be classified
Other Side Effects:
1. photosensitivity:
AcH- Acetycholine ON switch of muscle a. use sunscreen
D- Dopamine OFF switch of muscle b. wear shades
c. wide brimmed hat
ParkinsON disease Dopamine goes , Acetycholine 2. Agranulocytosis: Lymphocytes, Monocytes
neutrophils , Eosinophils, Basophils -> sore throat

58
Anticholinergic - minimize side effects of extrapyramidal effects -> Ach 6. HISTRIONIC - wants to be center of attention, manipulative, excited,
Dopaminergic both are used to keep balance, used as partners-> D dramatic wants to be seen by everyone
7. NARCISSISTIC I love myself, wants to be center of attention,
Anti-psychotic -> EPSE Given to restore balance blessed and cursed only wants the best for him
Anti-parkinson -> EPSE 8. OBSESSIVE COMPULSIVE I am so organized consistency
9. PARANOID I am suspicious leads to domestic violence
Antianxiety - > GABA drowsy
Sensory Frontal lobe chemical manipulated in the film
ANTIDEPRESSANT: Integration
Motor
A sendin to go up
N orpramin knorr para mainit
T ofranil lagyan ng tofu Serotonin Serotonin -> SAD
S inequan sine Kuan
A nafranil Ana franing Antidepressants
A ventil aven til midnight
V ivactil- bye back til next week Safest Two-four weeks Mono
Selective Two neurotransmitters
E lavil e lab mo ba ako?
Side effects low Tri Amine
P rozac - pero zaka na tayo magpakasal Serotonin Cyclic
P axil isa kang taksil Reuptake Antidepressant Oxidase
Z oloft -mag SOLO ka I to 4 weeks
Inhibitor Higher Incidence of Inhibitors
Task - esteem of the manic patient side effects
Personality Disorders SSRI TCA Avoid tyramine-rich
1. SCHIZOID I avoid people. Theres no enjoyment serotonin serotonin foods, or else therell
no reaction/flat affect, mechanical, they like computer hacking, cross
norepinephrine be Hypertensive Crisis
stitching, they avoid sex, do not engage in play, school activities, dont
have best friends-maybe have pets, no plan of marrying, not dated at all, 2-6 weeks
dont want people loving other people, people who can live by Avocado Fermented
themselves Aged cheese foods
2. AVOIDANT - I avoid people. Im afraid of criticisms longs for Beer Pickles
people around them, to care for them Chocolate Preserved
3. ANTI-SOCIAL used to steal, liars, violating the rules, engage in Soy sauce food
bank robbery, drug trafficking, easily irritated, drug abuser,
dangerous sex, break the law, anti-social, good speakers, serial MonoAmine Oxidase KILLS Serotonin
killers MAO -> Serotonin -> SAD
4. BORDERLINE my life is an empty glass (+) Fill Friends, usually
feel discontented, likes SPLITTING friends, SPLIT affect happy vs
sad LABILE affect (-) will commit suicide
5. DEPENDENT I cant live if living is without you.

59
How do you bring MonoAmine Oxidase DOWN?
MonoAmine Oxidase INHIBITORS or MAOIS
MAO -> Serotonin ->
Anti-depressants Side effects: Male Erectile Dysfunction - IMPOTENT

VLASTMEVAIB
Anxiety Anticholinergic SEIZURE
Rebound
E/NE S/E Abrupt
Constipation
Retention D
Dry Mouth E
Blurred Vision P
Antianxiety WITHDRAWAL E
N Antipsychotic
D Anticholinergic
Drowsy E D
Do not Drink Alcohol N
Do not drink Coffee C
Do not drive Equipment E
GABA Develop O.H.
GRADUAL

60
 DOWNERS UPPERS Cocaine withdrawal Crash Syndrome from elation to
ABON Much to take IN CHA CHA euphoria, then goes down when withdrawing - may commit
A lcohol Morph C ocaine suicide
B arbituates Code INE H allucinogens
O piates Hero A mphetamines - shabu Black crisis
N arcotic Blue return to original stage
M arijuana - ambivalent White pure optimist, gotten through troubles in life
ASSESS: S/S: Overdose S/S: Overdose Gold ambitious
bradycardia Tachycardia Black suffering depression
bradypnea tachypnea
moist mouth dry mouth DEPRESSION
1. ASSESS
pupils constrict pupils dilate
Are there things that got LOST?
constipation hypertension
STAGE OF GRIEF PROCESS
retention seizures
DENIAL No, this cant be! 1ST
hypotension
ANGER Why me? Why this? Why now? Why God?
coma, lethargy alertness BARGAINING if something happens, then Ill give
asleep awake something back
weight gain weight loss DEPRESSION Im down 2 weeks or more s/s = Major
Clinical Depression
Psychological well being of a client - EUPHORIA ACCEPTANCE Client acts according to situation
MELATONIN - HYPERSOMNIA responsible for sleep,
NARCAN (Naloxone HCl) Narcotics Antagonist drug of secreted by pineal gland
choice narcotics overdose When aged pineal gland calcified - INSOMNIA
Alcohol Overdose Withdrawal opposite of intoxication Self-Actualization
HR
RR SELF ESTEEM T-A-S-K
LOC COMA SEIZURE
BP WITHDRAWN STAY
Note: Overdose/Intoxication inversely proportional withdrawal
RISK FOR SELF-DIRECTED VIOLENCE
METHADONE - drug of choice narcotics detoxification
Detoxification is withdrawal with MD Supervision EAT SLEEP HYPOACTIVE SEX

SENSITIVITY TO CLIENTS NEEDS

61
SUICIDE -> VERBAL I wont be a problem anymore
This is my last day on earth
Ill soon be gone.

NON VERBAL
Give away valuables
Sudden change in mood be suspicious

When the client is suicidal, what will the nurse do?

4. helpless, hopeless
the nurse must
D irect discuss, Do you plan to commit suicide?
I rregular Interval unpredictable when checking client
E ndorsement Period Early A.M.

SAFETY - Avoid giving knife, no jigsaw, give simple task.

62
03/04/06 NGT = testing if the end of tubing submerge in a basin of water-
Fundamentals of Nursing bubbles lungs; distention in stomach = gas; should always be
Nursing Process > the nursing process provides the framework updated
in which nurses their knowledge and skills to express human
caring and to help clients meet their health needs Data gathering: 2 sources of data:
1. Assessment Primary Secondary
2. Diagnosis client himself/herself significant others
3. Planning chart
4. Implementation doctors
5. Evaluation members of the health team
other related literature
Characteristics of the nursing process
1. It is cyclic and dynamic rather than static Methods used in data gathering:
2. It is client-centered nurse organizes plan of care Observation using senses
according to client problems rather than nursing goals. Interviewing nursing history, therapeutic communication skills
3. It is interpersonal and collaborative depends on open and Examining physical examination
meaningful communication between client and the nurse.
4. It is universally applicable can be used with clients of any Nursing history:
age at any point of wellness-illness continuum; useful in a using subjective data
variety of settings. Data base is more often based on
5. It is an adaptation of problem-solving techniques and Gordons Typology of 11 Functional Patterns
systems theory-based on the scientific method Health-perception-health management pattern
6. It can be viewed as parallel to but separate from the 2. Describes clients perceived pattern of health and well-
medical process = focuses on resolving the disease of the being and how health is managed
patient; Health/nursing problems human response to Nutritional-metabolic pattern describes pattern of
the existing to the health condition disease or food and fluid consumption relative to metabolic need
wellness state and pattern indicators of local nutrient supply
Elimination pattern describes patterns of excretory
The nursing process diagram in each phase (see handout) function (bowel, bladder, and skin)
Quality assurance = safety in caring out nursing intervention = Activity-exercise pattern describes pattern of
standards of nursing care exercise, activity, leisure and recreation
ADLs healthy lifestyle household chores
Q: volunteer, nursing graduate, what type of nursing care: Regular -> 3x/week -> 5-10mins warm up; 20-30mins cardio-
A: interventions should live up to the standards of nursing phase; 5-10mins cool down
profession, even if you are just a volunteer. Cognitive-perceptual pattern describes sensory-
perceptual and cognitive pattern
Evidence based nursing = Research findings Sleep-rest pattern describes pattern of sleep, rest and
Rectal temperature taking = 3-5mins relaxation
Oral temperature taking = 2-3mins

63
 Self-perception-self-concept pattern psychosocial Pco3 on behavior
interventions; describes self-concept pattern and ABG
perceptions of self (e.g. body comfort, body image, feeling Impaired
state) Vomiting parenting
Role-relationship pattern describes pattern of role
engagements and relationships Temperature Decreased
Sexuality reproductive pattern describes clients patterns 38.5 pyrexic, cardiac
of satisfaction and dissatisfaction with sexuality; describes febrile, fever output
reproductive patterns
Coping stress tolerance pattern describes general diaphoresis
coping pattern and effectiveness of the pattern in terms of
stress tolerance Hemoptysis
Value belief pattern describes patterns of values beliefs,
including spiritual; or goals that guide choices or Phase II NURSING DIAGNOSIS
decisions. clinical judgment about individual, family or community
Sign Sx Treatment Medcl Dx Nsg Dx responses to actual and potential health problems/life
Restlessness Thirst Passive Hyper- Risk for processes; provides a basis for the selection of nursing
ROM tension latex interventions to achieve outcomes for the which the nurse
Hematuria Pain exercise allergy is accountable.
violent 3x/day Acute This means that:
behavior Reported prevent myocardial Non- 1. Professional nurses are responsible for making nursing
weight atrophy, infarction comp- diagnosis
Pain rating loss of contractures liance 2. Nursing diagnosis describe a continuum of health states
scale 20 promote Hyper-
0-no pain pounds circulation thyroidism Impaired
1-2 mild in 3 mos mobility Actual Potential Healthy
3-4 moderate Shampoo at Depression Health Health Responses
5-6 severe Nausea bedtime Impaired Problems Problems
7-8 very Schizo- tissue
severe Cholecystec- phrenia perfusion
9-10 worst tomy ABG Nursing Diagnosis Medical Diagnosis
possible pain Oxygen Focus on identifying human Identifies disease
responses to health and illness
palpation on Self care Describe problems treated by Describe problems for which
painful site = deficit nurses within the scope of the physician directs the
(+) independent nursing practice primary treatment
tenderness Anxiety Changes from day to day as Remains the same for as long
compli- client responses change as the disease is present
elevated cated

64
Types of Nursing Diagnosis Effective breastfeeding
1. Actual Diagnosis judgment about a clients response to Anticipatory grieving
a health problem at the time of assessment and is
signified by the presence of associated signs and 5. Syndrome Diagnosis comprises of a cluster of problems
symptoms
Formats: Format: one part statement
1 part statement problem format Ex.
2 part (problem related to etiology) Rape trauma syndrome
3 part (PES format) Problem related to etiology as manifested Post trauma response
by s/sx Defensive coping

2. Risk Nursing Diagnosis a clinical judgment that a client
is more vulnerable to develop the problem than others in
the same situation
Format: 2 part statement diagnostic label R/T risk factors
Ex. 1: Risk for disuse syndrome R/T immobility
Ex. 2: High risk for infection R/T compromised immune system
ALFAROs RULE FOR A COLLABORATIVE PROBLEM
To write a diagnostic statement for a collaborative problem, focus
on POTENTIAL COMPLICATIONS (PC) of the problem
PC+:+complication+related to + etiology
Ex. Potential complication: pneumothorax related to fracture ribs

3. Possible Nursing Diagnosis evidence about a certain Common Errors in Writing Nursing Diagnoses and
health problem is unclear or the causative factors are Recommendations
unknown; needs collection of more data either to support Error Example Correction Example
or refute it; not a real type of nursing diagnosis Writing the Needs Write the Self care
diagnosis in assistance with diagnosis in deficit: bathing
Format 2 part statement terms of needs bathing related terms of related to
Ex: possible social isolation R/T unknown etiology and not to bed rest response immobility
response rather than
4. Wellness Diagnosis is a clinical judgement about an need
individual, family or community in transition from a specific Making legally Noncompliance Use related Non
level of wellness to a higher level of wellness inadvisable due to hostility to rather compliance
Format: NANDA has specified that wellness diagnosis should be statements toward nursing than due to related to
developed as a one-part statement with: Potential + desired staff (the words or caused hostility toward
higher level of wellness; readiness for (+) desired higher level of due to imply a by to link nursing staff
wellness (LeFevre, 2004) direct cause the etiology (denotes a
Ex. and effect to the relation
Potential for enhanced parenting relationship) problem between the
Health seeking behaviors statement problem and
Family coping etiology but not
Potential for growth necessarily a
Enhanced Parenting causal

65
 relationship) client problem Bowel client deficit: care of
Spouse abuse Write High risk for or etiology Elimination: statement colostomy,
related to diagnosis in violence: what cannot be Permanent and related to
husbands legally spouse abuse changed colostomy etiologic severe anxiety
immaturity and advisable related to related to factors in about cancer
violent temper terms: husbands cancer of the terms that and feelings of
statements reported bowel can be powerlessness
that may be inability to changed;
interpreted control Grieving otherwise, > do not put the
as libel OR behavior. related to nursing medical
Impaired skin that imply Impaired skin death of energies diagnosis as
integrity related nursing integrity related spouse are being the etiologic
to clients lying negligence to immobility directed to statement but
on back all are legally >grieving is a a hopeless put the human
night hazardous normal task responses only
to all nurses response to
caring for death
the patient > if
Identifying as a Mild anxiety Include in No need for dysfunctional
problem a related to the problem nursing grieving 1
client respond impending statement diagnosis; mild year can not
that is not surgery of the anxiety before accept death
necessarily nursing surgery is a Problem + Etiology Inability to
unhealthy > more alert, diagnosis healthy Suggest suggest that accept the
normal, only client response that objective/Goals intervention; death of the
motivate to responses motivates pre- eliminate spouse.
understand that are operative self etiology will provide
unhealthy care behavior eventually psychological
or that the eliminate support/
client wants problem emotional
to change support to
Identifying as a Cough related Avoid Ineffective client
problem signs to long history including airway Identifying Cluttered home High risk for
and symptoms of smoking signs and clearance environmental related to injury related to
of illness symptoms related to 20 factors rather inability to cluttered home
of illness year history of than client discard (inability to
smoking factors as a anything discard
Identifying as a Alterations in Express the Self care problem anything)
Reversing Knowledge Avoid Altered

66
clauses deficit related reversing parenting endurance and
to alteration in the problem related to comfort
parenting statement knowledge alterations
and deficit: OR
etiologic LACK OF RIGHT WRONG
statement INFORMATION Alteration in oral mucous Risk for injury related to
ABOUT child membranes related to the frequent falls
growth and effects of chemotherapy
developmental stomatitis Oral care
discipline Increase fluid
Having both Alteration in Be sure that Unrelieved Risk for injury related to Dysfunctional grieving related
clauses say comfort related the two incisional pain disorientation and impaired to death of spouse
the same thing to pain (pain is parts of the related to fear judgment
the comfort diagnosis of addiction > can intervene
alteration do not Self-feeding deficit (Level III) Self-feeding deficit (Level III)
what is mean the related to joint pain/swelling related to arthritis
contributing to same thing Impaired physical mobility : Patient difficult to get along with
the pain?) level III related to general related to his frustrations at
> describe, muscle weakness and spasm being in the hospital.
location, type in the legs
of pain Ineffective airway clearance Alteration in bowel elimination:
Including value Poor home Write the Impaired home related to accumulation of stool incontinence related to
judgments in maintenance diagnosis maintenance tenacious secretions in the involuntary passage of stool
the nursing management without management airway
diagnosis related to value related to low Hyperthermia Elevation in temperature
laziness judgments; value ascribed Infection caused by infection
avoid words to home safety Non compliance with renal diet Alteration in level of
such as and cleanliness related to the clients consciousness due to grandmal
poor, perception of its therapeutic seizures
inadequate, ineffectiveness
abnormal self-care deficit: bathing related
unhealthy to inability to bathe self
as much as Nausea and vomiting related to
possible cancer of the pancreas
Including the Impaired home Impaired home Poor hygiene related to
medical maintenance maintenance laziness
diagnosis in management management Alteration in comfort related to
the diagnostic related to related to chest pain
statement arthritis mobility,

67
Alteration in nutritional intake: Nausea and vomiting related to FIRST MEDIUM LOW
less than body requirements alteration in nutritional intake Ineffective airway Anxiety related to Sleep pattern
related to as manifested by clearance related to difficulty in disturbance
nausea and vomiting accumulation of breathing Self care deficit
Impaired skin integrity Loss of skin integrity related to viscous secretions > because you can Altered family
prolonged bed rest and resolve it if the 1st processes
infrequent position changes priority
Ineffective management of Anger related to knowledge of Fluid volume deficit:
therapeutic regimen: families the diagnosis of cancer intake insufficient to
related to economic difficulties replace fluid loss
> may intervene because you related to
can refer diaphoresis
Impaired memory related to
observed experiences of
forgetting
Goal versus Objective versus Expected Outcome:
Airway, Breathing, Circulation first priority Goals are broad statements about the effects of nursing
intervention
Three helpful guides suggested by Atkinson and Murray (1990) Ex. The clients nutritional status will improve
for prioritizing client problems are:
Objectives are more specific statements about the effects of the
Maslows hierarchy of Human Needs: nursing intervention
Physiologic needs safety needs love and belonging needs Ex. The client will gain weight after two weeks.
self actualization needs. Criteria/Characteristics of objectives:
SMART- specific, measurable->observable, attainable,
Prioritizing nursing Diangnoses: realistic, time-bound
Client centered
Priority setting process of establishing a preferential order for Statement of a single human response-> human condition
nursing strategies or behavior -> performance of a procedure taught
FIRST PRIORITY is any threat to the vital functions of
breathing, heartbeat, and blood pressure Expected Outcomes are the more specific, measurable criteria,
MEDIUM PRIORITY health threatening problems that used to evaluate whether the goal has been met.
may result in delayed development or cause destructive Ex. The client will have a weight gain of 5 lbs by October 28
physical or emotional changes
LOW PRIORITY problems that arise from normal SMART NOT SMART
developmental needs or those that require minimal After 2 weeks, the client will be After 2 weeks, the nurse will
nursing support able to ambulate in the hall assist the client to ambulate in
3x/day. the hall 3x a day.

68
After nursing intervention, the After nursing intervention, the Vital signs administration of NGT feeding
clients lungs will be clear to clients lungs will be clear to medication
auscultation. auscultation and the RR will be wound care IV therapy Passive ROM
normal. Massage crutch walking
After nursing intervention the assisting to
clients RR will be normal by > should be of single human ambulate
afternoon of March 4, 2006 response perineal care
position client in
After 30 minutes of health After nursing intervention, the bed
teaching, the significant others significant others will know how
will explain, verbalizes, discuss, to prevent bedsores in the Writing the Evaluation statement
enumerate, identify the ways client actions are not the same
on how to prevent bedsores in as knowing, you will not know Conclusion + Supporting Data
the client. unless the client speaks or Conclusion:
answer the exam Goal Met
if psychomotor = demonstrate, knowing is not Goal Partially Met
perform, show measurable Goal Not met
will know how is
cognitive ask ND: Ineffective airway clearance related to viscous secretions
questions and shallow chest expansion
Expected Outcome: Demonstrates adequate air exchange as
Types of nursing Interventions: evidenced by:
1. Independent interventions those activities that nurses 1. absence of pallor and
are licensed to initiate on the basis of their knowledge and 2. absence of cyanosis (skin and mucous
skills membranes)
Ex. Physical care, ongoing assessment, health teachings,
emotional support, and comfort Evaluation:

2. Dependent Interventions activities carried out under the

physicians orders or supervision or according to
specified routines;
Ex. Medication, diagnostic tests, diet, treatment,
activity
3. Collaborative interventions actions nurse carries out in
collaboration with other health team members such as
physical therapists, social workers, dieticians and
physicians

INDEPENDENT DEPENDENT COLLOBORATIVE

69
March 11, 2006
LEGAL DOCTRINES IN NURSING
Professional Negligence
Definition: failure to do something which are reasonable and
prudent nurse should have done something under a particular
situation. (e.g. failure to raise side rails when the patient is
unconscious)
3 Elements:
1. duty
2. failure to do said duty
3. injury, harm, death important in negligence, not
in malpractice
Ms. Ara Mae Quinto, an OR nurse in a government hospital has
prior knowledge regarding some defective OR table. It is unsafe
to use for heavy patients. Due to some reason she still allows
patients to undergo surgery using said defective OR TABLE. One
day, a 40 year old obese female patient, will undergo
appendectomy, fell and suffered fracture.
The case of Humpee Dumpee
-drug rehabilitation clinic, he was having withdrawal syndrome,
p[sychiatrist provide a safe and calm environment for Humpee. In
a room with an open window. One night, while Gloria was about
to give medication, Humpee thought that Gloria was a dragon.
The patient jumped the window and died. Will the nurse be liable
for negligence?
X 1. Principal very, very important, indispensable, primary
Negligence Malpractice
Ex. Prescribing nurse has already memorized all the contents of
her drug handbook. She has a prescription pad bearing her
name, hospital that she is employed, license number and contact
number. She gives it for free for all her indigent patients.
The X stitch
An OB Gyn is too tired after having 10 CS operation for the past
10 hours. It is a practice of said physician to delegate the suturing
of the last layer of the patients abdominal cavity to her OR nurse.
Nurse Kristeta being young and aggressive accepted the task
and does it well.
Normal spontaneous delivery with specific training on suturing of
perineal cavity episiorrhapy ALLOWED
Allowed to do the IE during normal spontaneous delivery, prior to
complete delivery: in the absence of maternal fetal
aberration/abnormalities: abrupt placenta placenta previa
abortion, H-mole and absence of full delivery = DOCTOR
Crime Affecting Nurses:
1. Manner of Commission
3. DOLO > crimes committed with deceit (sinadya mo ang
crime), real criminal intention
4. CULPA > unintentional, product of negligence (hindi mo
sinadya)
2. Stages of Execution
5. CONSUMMATED > when the crime was totally,
absolutely commited or perfected
6. FRUSTRATED > when the offender performs everything
to consummate the crime but it did not happen
7. ATTEMPTED > no crime done, overt acts = merely
showing the intention to commit the crime
Degree of Participation
author of the crime
2. Accomplice dispensable, before & during
3. Accessory after the crime has been committed
benefiting itself from the product of the crime
Q: Referral by a nurse to an abortionist, the nurse is considered
to accomplice to an Abortionist, before the committing the act
70
RA 7877 Anti-Sexual Harassment Act mandatory report within 30 days before the Local Civil Registrars
Conditions: Office with penalty if beyond 30 days)
1. Any person who exercises authority ex. Doctor-nurse;
Head nurse-nurse, Teacher-student Pink baby girl Blue baby boy
2. Who is asking for sexual favors, in exchange for another
favor LAWS AFFECTING NURSES

Rape crisis situation 1) ACT 2808 (1919) 1ST TRUE NURSING LAW
1. Ordinary Rape a forcible penetration of an organ for under doctor
copulation to another organ for copulation, Victim is removed from the jurisdiction of the doctor and formed
women only Board of Nursing
2. Sexual Assault anything forcible penetration to any body Board of Nursing appointed 3 man team
orifice with sexual malice ex. Victims can be male or a) 1 chairman
female b) 2 members
c) ALL nurses
Intervention:
SAFETY physical, emotional 1920 - 1st nursing licensure examination
REPORT 48h at barangay - accessibility
REFERRAL DWSD TRAIDS
Iloilo mission hospital (1906) -1st nursing school
Abortion expulsion/termination of the product of conception PGH School of Nursing (1907)
before the age of viability 12-24 weeks or 3-6months AOG St. Lukes School of Nursing (1907)
Mary Johnston School of Nursing (1907)
Infanticide crime if you killed a person/infant less than 3 days St. Paul-Iloilo (1907)
or 72 hours of life San Juan De Dios (1907)
University of the Philippines - 1st college in the Philippines, 4 yrs
Parricide killing another person, whom you have a relationship Bucaullereate degree - Dean Julieta Sotejo

Homicide killed another person without any relationship, no 2) RA 7164 (1991)

intention to kill, product of negligence ex. Somera case, wrong BON = MAFSON PTC
drug administration M Man
A Accredited Nursing Organization
Murder with an intention to kill another person F Five Man Team = 1 chairman, 4 members, all NURSES
S Sixty Five y.o.
Simulation of Birth committed by any person who shall O One year Interim period
substitute 1 child to another child or alter his identities for the N not convicted of any crime
purpose of losing his civil status. (e.g. failure to report the birth of P Pecuniary Interest (Absence) monetary consideration
the baby PD 651 Birth Registration Act = requires all person T Ten Years nursing practice
who shall assist in giving birth, OB, midwife, hilot, nurse, to C Citizen of R.P.

71
 SM BANT COMMUNITY MILITARY
Supervisor/Manager/Head HOSPITAL
3) RA 9173 (OCT 21, 2002) Nurse per ward, per shift,
Board of Nursing MASIN PTC per department
M MAN B BSN RN
A Accredited Nursing Organization A Accredited Organization
S Seven man team N Nine units MAN
I Immediately resigned upon appointment T Two years general staff
N Not convicted of any crime nursing experience
P Pecuniary Interest (Absence) C/D Chief/Director the ADD ONLY MAN + General
T Ten years Nursing Practice but the last five years must be whole hospital MASTERS IN Staffing Course
in the Philippines RN+MAN+ PHN OR CHN
C Citizen and resident of the Philippines 5 years Supervisory 5 years
POWERS AND FUNCTIONS OF BON Experience supervisory in
L icensure Exam- formulates examination, not the PRC (except: N.B. IF primary the Community
I ssue Certificate Of Registration = it is a privilege, not a hospital = 50 Bed capacity)
right, PRC issues of nurse license = it is a privilege = with
all the qualification and not disqualification Nurse Licensure Examinees
M onitor standards of Nursing Practice- BON only have the Optional and Mandatory
power to inspect or recommend, only the CHED is authorized 1. Certificate of Good Moral Character (optional)
to open or close the school 30% passing rate consistent for 5 2. Proofs of Valid Holder of Filipino Citizenship given Birth
consecutive years Certificate (Mandatory)
E ducation 3. Proofs of Valid Holder of A BSN degree only from Schools
C ode of Ethics (2003) whose curriculum is approved by the CHED
H ear and decides cases of negligence/malpractice a. TOR with scanned photo
A ccredits different Organizations, training center b. RLE, MAN, licensure number, Chief Nurse, PNA number,
G uides Nursing Practice in the Philippines ex. ICU 1:1, notarized at the back of completion form; only 2
Ward 1:8 operations are allowed to have the same procedure, filing
Dean of PRC deadline May 22
1. RN
2. MAN Other Related Laws:
3. 5 years of nursing experience 1. PD 223 PRC Act
2. RA 1080 Civil Service Act, if you pass Civil Service,
CI - AMOR PRC, Magna Cum Laude, Summa Cum Laude, Cum
A ccredited member organization Laude = civil service eligible
M ay have MAN or any Other Allied Health courses 3. RA 6425 Dangerous Drugs Act 2 types of chemical
O ne year experience substances:
R-N
Nursing Administrator

72
 a) Prohibited absolutely, totally, can not be consumed by - Registration and Oath
cannabis, shabu, hallucinogen, cocaine, LSD, opium Q: What are the grounds for a nurse not to be registered?
can not use it even if theres physician order D dishonorable conduct
b) Regulated can use the drug, prescription, with U unsound mind
appropriate license from BFAD and Dangerous Drugs M moral turpitude
Board ex. Antipsychotic drugs I indecent, immoral conduct
4. RA 7600 - Baby Friendly Hospital, early bonding
between mother and child Sen. Flavier
a) Rooming in
b) Breastfeeding Galing Sa Ina Sustansya

Q: how can you promote bonding father and newborn?

A: cuddling, and embracing

5. E.O. Milk Code avoid manufactured or formulated

milk, use breast milk

HOW TO BE AN RN UNDER RA 9173?

1. Have all qualifications
2. Take the Exam June 11
3. Acquire the Required Ratings
In order to pass the exam, an examinee must obtain a general
average of at least seventy five percent with a rating of not below
sixty percent in any subject. An examinee who obtains an
average rating of seventy-five percent or higher but gets a rating
below sixty percent in any subject must take the examination
again but only in the subject or subjects where he/she is rated
below sixty percent exam, an examinee must obtain a rating of at
least seventy-five percent in the subject or subjects repeated.
- absolutely, totally, unconditionally pass = 60, 100, 100,
100, 100 because General Ave 75 higher, with no <60
- conditionally passed = 59, 100, 100, 100, 100 General
ave = 75 higher, with <60, repeat exam = 60, failed it
should be 75, may retake exam 2x in a year

6. RA 8391 - PRC modernization act at least 5000

examinees, after 5 days the result will be released or
check www.prc.gov.ph prc rating florante, Jude Thaddeus
C

73
 COMMUNITY HEALTH NURSING pour flush arinola
03-17-2006 - flying saucer
(ballot system)
PRIMARY LEVEL DISEASE PREVENTION No Transport Cistern flush with 1. pit privy (not
Through environmental control automatic flush or septic tank, best water sealed
I. Safe Water = tasteless, odorless, colorless, slightly basic ph pour flush method, aneorobic maamoy
- hard and soft water- rain water, can easily have bubbles type - Antipolo
but hard to rinse Japan: Vault Type - bored hole
- biological: e-coli present in feces excreted carthage sipsip - Ventilated
a.) HH: Boiling 5 minutes high fire then low fire Improved Pit (VIP)
b.) Filtration solid carbon blocks - Reed odorless
c.) Sedimentation let water stand for 1 hour Earth Closet
COMMUNITY - twin pit/ compose
1. Chlorination/Iodination 2. Over hung
2. Macrofiltration Latrine
3. Microfiltration
Aeration N/R: Respect of culture and way of life of people. DOH
Flocculation pure water tanks = high concentration of Sanitation Program example in Samar, mid 70s Halahala
chlorine Rizal socialization process = pag gabi all community
II. Food Hygiene
members have the same time to do bowel elimination in the
Safety:
1. Sources of raw food check food for pesticides
rice field - participatory
(biocides), soak with water with vinegar 1:1 portion, to
neutralize chemicals; check for slaughter houses double Best method squatting Credes = for bowel elimination
dead issue, 1st to absorb bacteria are clams, oysters,
mussel all shellfish, then squids = deep sea fish blue Negros: Hacindero versus Sacada workers, Europe =
marlin, salmon = no bulges and dents on canned Loo, or water closet
goods = source of lead poisoning grayish color
Chinese IV. Proper Refuse Management:
2. Food handlers - carrier of typhoid 40s female food Refuse = solid, and semi-solid wastes excluding
handler human excreta
3. Environmental sanitation
Garbage = biodegradable and Rubbish = recycling
Goal: preventing food intoxication ingestion of poison =
sudden effects, food infection ingestion of pathogens scrap iron, carton, paper, plastic, broken glasses, tin
cans
III. Safe excreta disposal Method of Refuse Mgmt except: X A. open burning
Water No Water Clean Air Act X B. Open Dumping = best reservoir
Transport Cistern flush, with pail system for infection, fire, causes floods, methane gas in
automatic flush or sewerage system (bucket latrine),

74
 smokey mountain = spontaneous smoke C. Burial D.
Composting
V. Safe Home Environment
Proper ventilation, adequate space, adequate lighting
VI. Safe Workplace
Health education very essential appreciate to prevent
diseases, and to manipulate their environment
Secondary Level Disease Prevention = Asymptomatic,
subclinical test
Mass screening = the more people we screen, the
better, simple & inexpensive and not complicated =
ex. Bantay presyon = hypertensive and high risk;
Operasyon Timbang FNPI International Standard
Case-finding positive diseases in the leading
causes of morbidity ex. TB TOP 10, Ideal Standard =
culture and sensitivity, Sputum Smear microscopy=
for community screening; tuberculin test children;
chest x-ray can be under or over read
Contact-tracing through the case, we can trace
other contact/s, ex. Leprosy = respiratory infection
droplet ex. Nasal discharge
Multi-phasic screening
Surveillance tantamount to research, RA7573 to
report cases ex. Scabies, sore eyes
HIV ANTIBODY TESTING
RNA count USA, RNA virus no capacity to replicate,
too expensive
Philippines setting:
Cell mediated
Humoral Response both produces antibodies
used as evidence if the client who has HIV infection,
Check presence of HIV antibody
Pre-test Counseling
a. Risk Appraisal try to approximate of the individuals
risk, extent of exposure of an individual or the
presence of risk behavior or risk situation=SEX
which can contribute to the development of the
disease, consider individuals uniqueness
Risk factors may act synergistically, potentiate action
HIV+ source, medium with adequate infectious load (32
liters of saliva), mode of transmission HIV to enter hosts
body, test after 6months of sexual intercourse= window
period time for the body to produce HIV antibodies, 10-
12 yrs incubation period
b. ELISA 1 results can be (-), and (+)/indiscriminate =
assume the worst than better
c. If negative, Post-Test Counseling Behavior change
d. If (+) ELISA 1, do ELISA 2 results can be (-) and
(+)/indiscriminate. If (-) go to C
e. If (+) ELISA 2, do Western Blot results can be (-)
go to C
f. If positive in Western Blot HIV/Aids registry, then
go to C
* Theres difference between exposed and infected.
Not all exposed are infected, but all infected are
exposed.
Intention: identify (+) cases provide prompt treatment,
prevent spread, shorten the disease process, and
enable client to perform the usual roles and functions as
soon as possible.
Serum (blood) once only
75
Health Education can also be given in the secondary
level, people will learn what are notifiable diseases. POLITICAL SOCIALIZATION
POLITICAL COMMUNICATION
INTEREST AGGREGATION
Tertiary Level Disease Prevention symptomatic or INTEREST ARTICULATION
clinical, client knows he is sick, seeks services of health SILENCE AND PASSIVITY
provider
Diagnosis assess, to have a correct diagnosis
Treatment POLITICAL COMMUNICATION
Management Facilitate PEOPLES ORGANIZATION, to have a venue
Rehabilitation upon approach of the client rehab for political consensus, in UNITY, theres STRENGTH
starts
POLITICAL SOCIALIZATION
Health education can be applied, much easier, theres a mobilization through activities to serve the people for
captive audience, will cooperate in the management., to responsible action
prevent occurrence of the diseases again.
Radical Ultra
Community participation to self reliance Leftist Rightist
Agaw Lalaki-AL Single but
COMMUNITY ORGANIZING ensuring peoples Satisfied-SISA
participation in health stayed in 6 months, and created Liberal Centralist Conservative
an organization, but the students functions were to Neutral
support other sector, or facilitate community Opportunists
a continuous and sustained process of: Waitress: naghihintay/nanabik
COPAR Awareness-raising conscientization,
Paolo Fraile in order people to learn increase the Basic Concepts and principles in Community Organizing:
level of awareness. Education is liberating from Based on concrete analysis of actual situation
oppression and ignorance scientific method
Organizing Basic trust on the people
Mobilizing of responsible action By, for, of, with and among the people
Any one is capable of change
Levels of Awareness Self willed changes over imposed changes
How the community members relate to existing problems
in the community? Fear-tactic will not learn

Context of Community Organizing:

1. Current Situation:

76
Rich Poor
Extravagant Deprived Bias Inter-sectoral Linkages
Oppressors Oppressed - Agricultural
- no access to social - Social welfare
services, more problem, - Education
more vulnerable - Population control
- Public works
Goal of Community Organizing: Community Development - Private sector
COMMUNITY DEVELOPMENT
A commitment towards the creation of a society that Community Participation
provides each and every individual member the equal active and full participation of the people in decision-
access to all benefits and opportunities the society can offer making process:
- Assessment
CO in H: - Planning
1. Health Sector Organizing - Implementation
2. Establishing Community based health - Monitoring and evaluation
programs
2 types: Levels of Participation:
1. Organized (Peoples Organization)
> Support Program done by nurses Genuine Participation
2. Unorganized (Virgin) entry point for organizing - Delegated power 0:100
Approach: people/citizen control/people
empowerment starts 40:60
Primary Health Care: essential care based on scientifically - Partnership shared leadership
sound and socially- acceptable methods and technology minimum level of participation
made universally available to individuals, families and 50:50, shared majority
communities at a cost that they can afford at any given
stage of their development through their full participation Token Participation
towards self-reliance and self-determination - Placation palliative
-1978 Alma Alta - Consultation problem identification,
Multi-sectoral Approach democratic process
Intra-sectoral Linkages - Information decision has been made
- Tertiary Non-participation
- Secondary - Therapy
- Primary - Manipulation

77
Nurses: Social apathy apolitical, apathetic
Community Organizing in Health
Social Investigation
- Preliminary before entry, baseline info
* 2ndary data sourcesUtilize findings of their studies and
data
- Deepening SI upon entry continuous, assessment
of community situation.
Entry
- best method for entry : LOW-KEY/ LOW PROFILE,
so as not to expect too much.
- Start:
1. DSI
2. Social Preparation
3. Community Integration
Social Preparation tempering the grounds for
setting up the health program/health situation, target:
community leaders courtesy calls meetings, 1st
establish rapport, establish trust, clarify expectation,
objectives
Community Integration - Imbibing community life,
house to house, places & events, production process
- Do spot mapping distribution of household, Cluster
8-15 HH, management of unit
Small group formation, election of community
health workers ano ang mga katangain kailangan
community health leader? 1st set of elected officers
(at least 5), not appointed
- decision making
- delivery of care
Election of Community Health Workers
Launching, community mass, induction, formally
launch table of organization
* Starts at entry, end at the launching of the organization
Community Diagnosis get the priority health
problem of the different units (small group)
Training and Services at least a year, not
continuous, staggered during weekends
Core-group formation extra special training,
program management, leadership skills, teaching
learning skills, advance accounting skills, these
leaders are committed, reliable, and dedicated
Phase Out for people to exercise self-reliance
3 to 6 months from Community to Phase out organized
community
3 years Entry to Phase out Virgin community
Appropriate Technology
Available
Acceptable
Affordable
Simple
Safe
Feasible doable
Acupuncture acus = needle to prick, in order to diagnose,
and treat
Acupressure acus = needle, Finger-pressure
Qi chi or te chi
Meridians - system that is hiwalay sa circulation &
lymphatic system 40
Yin-Yang 2 opposing forces, theres should be a balance,
if theres imbalance disease formation develops
Tsun natural boundaries of the body through body
measurement body itch
Ahshi points tender points indicating vital organs being
supplied by the meridian
2-3 cycles/second (1-5 minutes/point)
78
premature contraction can be used in abortion Elixir internal use 1:10 alcohol ginger chopped 1
tbsp:10 tbsp gin stay for 1 week = elixir, tbsp
Moxibustion Heat content is medicinal plant dahong dry cough related to TB.
Maria, for dysmenorrhea, cough & colds
BREAK (low battery)
Herbal medicines:
1. Mayana pigsa, lavender, pink, red, yellow, orange Goal of Family Planning Program
2. Chichirika white, violet flowers alkaloid vincristine Maternal and child health through:
oncovin = gamut sa cancer 1 vial injection Proper timing of pregnancy
3. Oregano cough & colds, boiled, adobo - Ideal age: 20-30 Ideal space: 3yrs No.3
4. Akapulko anti-fungal, scabies - below 20 to 18 with risk q 2 years 4
5. Sambong cough & colds, renal stones, stomach ache - below 30 to 35
6. Malunggay - scabies - below 18 high risk q year >4
7. Tanglad for fever, cough & colds - above 35
8. Mangga cough & colds, high fever Major Program Policies
- Improvement of family welfare with main focus on
Aromatic Medicinal plants: womens health, safe motherhood, and child survival
Volatile oils used for fever, cough & colds, itchiness, gas - Freedom of choice = informed choice
pain - Promotion of family solidarity and responsible
1. Sampalok 2 saklot ng leaves boil parenthood
2. Luya boil, decoction , 1 glass for am, noon,
night add half glass sugar, dissolve to thin the FAMILY PLANNING METHODS
consistency syrup can last 3-5 days = SLK 1. Spacing Methods
3. Kalamansi use 7 pcs to add flavor to SLK. - Hormones (pills, injectibles) with systemic effects
Infants, lowers fever, boil leaves of kalamansi - Barrier methods: Intrauterine Device (Arabs), 70s
4. Sambong cough & colds plastic, polyutherane looks like bituka ng manok
5. Oregano cough & colds - Condoms (male, female)- contraindicated to use oil-
6. Yerba-buena cough & colds, itchiness, based ex. baby oil to prevent tearing of condom,
arthritis, tooth ache with swollen gums. cervical cap(Leahs shield); diaphragm; sponge;
7. Alagaw spermicides = toxic shock syndrome TSS
8. Tanglad - Scientific, Natural (Cervical Mucus, Basal Body
9. Mangga Temp., Sympto-Thermal, Lactational Amenorrhea
10. Damong Marya Method-exclusive 6 months breastfeeding)-High
11. Bawang- high blood, with antiseptic properties literacy/education, Standard days Method, white
12. Sibuyas bead = fertile; brown bead = non-fertile
Tincture-external use 1:5 alcohol maputi, aceuate reddish 2. Permanent Methods
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 - Tubal Ligation Kochs Phenomenon normal inflammation of the site after 2-4
- Vasectomy ejaculate 25-40x to check sterility after days.
procedure NR: warm compression
Deep Abscess at site not normal.
Expanded Program on Immunization NR:incision and drainage; powdered INH, do use alcohol it will kill
the vaccine.
Goal EPI: morbidity and mortality reduction of immunizable Indolent Ulceration ulcer after 12 weeks
disease (p.14) NR: incision and drainage; INH powder
Glandular Enlargement not normal, treat as abscess
Types and Schedule of Vaccines
At birth Side effects: DPT
BCG anti-TB 0.05ml ID (infant) 0.1ml ID (school entrant) Fever for a day usually
Prevent leprosy Soreness at site within 3-4 days normal, warm compress
Abscess after a week or more incision and drainage,
1 month use local antiseptic: Betadine solution, or alcohol
DPT1 05ml IM Convulsions do not give next dose and refer for next
HEP B1 check up
TT Side Effects: Measles
OPV1 trivalent 3 class poliomyelitis virus 1,2,3 Fever after 5-7 days usually 1-3 days
Mild rashes
2 mos.
DPT2 Cold Chain
OPV2 Vaccines destroyed by heat
HEP2 Viral: BCG, DPT, OPV, TT, MEASLES, HEP B viral
Most sensitive to heat: OPV, measles
3 mo Destroyed by freezing: DPT, TT, HEP B
DPT3
OPV3 Control of Diarrheal Diseases:
HEP3 Control of dehydration,
Q: what is the reason to deaths due to diarrhea?
9-12mo A: Dehydration
Measles 0.5ml SQ
Classification of Dehydration VS Diarrhea
Side effects: BCG MILD MODERATE SEVERE
2-3 weeks abscess will ulcerate then heals leaving a scar 5-10 bouts of 10-15 bouts/day >15 bouts/day
(approx 12 weeks from vaccination) watery stool/day
- sunken fontanels -lethargic, normal - comatose,

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and eyeballs blood pressure almost (-) urine
- dry lips, child is - (+) skin fold test output
irritable but - dry tear ducts
conscious - (++) skin fold test
- (-) skin fold test

> Give ORS for 4- Intravenous Fluid

6 hours treatment
Less than 2 years Available
glass
ORS/bout or YES NO
- cup rice
water/bout Assess if child can drink
If 2 yrs & above
- 1 glass ORS or yes no -> NGT
- 1 cup of rice
water ors yes no
- Reassess after
4-6 hours REFER via NGT REFER
REFER IVF

Supplementary? Give to ensure proper nutrition to avoid

malnutrition

Weight loss
Mild <1 yr >1 YR
5% of total BW 3%

Moderate 10% 6%

Severe 15% 9%

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