Acute laryngotracheobronchitis

LTB (Croup)

 Slow Onset
 Commonly Occurs Before Age 5
 U.R.I.’s Frequently Precede LTB
 Restlessness
 Barking Cough
 “Crowing Sounds”
 Supra-sternal Retractions
 Inspiratory Stridor
 Occurs at Night in Fall and Winter
 May Progress to Hypoxic State
 May Have Slight Temperature (<102")
 ↑ Respiratory Rate

TURP
(Transurethral Resection of the Prostate)

 Continuous or Intermittent Bladder Irrigation (C.B.I.)

(Usually DC’d after 24 hours, if No Clots)

 Close observation of drainage system-

(↑ Bladder Distention causes Fain & Bleeding).
 Maintain Catheter Patency
 Bladder Spasms
 Pain Control: Analgesics & ↓ Activity first 24 hours.
 Avoid straining with BMs. ↑Fiber diet & Laxatives.
Complications:

 Hemorrhage - Bleeding should gradually ↓to light pink in 24 hrs.

 Urinary Incontinence - Kegel Exercises
 Infections ↑ Fluids
 Prevent Deep Vein Thrombosis
 Sequential compression stockings
 Discourage sitting for prolonged periods
 POST MASTECTOMY NURSING CARE

 Elevate affected side with distal joint higher than proximal joint.
 No BP, injections or venipunctures on affected side.
 Watch for S & S of edema on affected arm. (edema may occur post op or years
later)
 Lymphedema can occur any time after axillary node dissection.
 Flexion and extension exercise of the hand in recovery.
 Abduction and external rotation arm exercises after wound has healed.
 Assess dressing for drainage.
 Assess wound drain for amount and color.
 Provide privacy when patient looks at incision.
 Chemotherapy, Radiation therapy.
 Monitor for Complications — hemorrhage, hematoma, lymphedema, infection,
postmastectomy pain syndrome.
Psychological concerns:

 Altered body image

 Altered sexuality
 Fear of disease outcome

SUICIDE PRECAUTIONS
SECURE ROOM:

 Windows Locked
 Breakproof Glass & Mirrors
 Plastic Flatware
NO:

 Cords - Phone
 Extension
 Equipment
 Curtains
 Belts/Shoelaces/Drawstring Pants
 Matches or Cigarettes
 Sharps/ Razors
PATIENT CARE:

 Frequent Observation... Preferably 1to1

  Staff Communication — Constant Risk Assessment/Documentation
 Develop Therapeutic Relationship
 Written Behavior Contract with Pt.
 Restraints as Necessary
 Medications
 Monitor and Restrict Visitors

SCHIZOPHRENIA

 Illogical thinking & impaired judgement

 Loss of ego boundaries
 Inability to trust
 Bizarre behavior
 Indifferent aloof
 Love/hate feelings
 Feelings of:
 Rejection
 Lack of self-respect
 Loneliness
 Hopelessness
 Speech incoherent & rambling
 Disorganized thinking
 Auditory hallucinations
 Delusions
 Hypersensitivity to sound, sight & smell
 Difficulty relating to others
 Negativism
 Religiosity
 Lack of social awareness
 Behavior- disorganized, motor agitation, catatonic
 Retreat to fantasy world
 Autism
MENTAL RETARDATION
9Rs

 Routine
 Repetition
 Reinforcement
 Routine
  Repetition
 Reinforcement
 Routine
 Repetition
 Reinforcement

HALLUCINATIONS VS ILLUSION VS DELUSIONS

Hallucinations

 Sensory impressions without external stimuli

Illusions

 Real stimuli, misinterpreted

Delusions

 False fixed belief

EATING DISORDERS
ANOREXIA NERVOSA

 Views self as fat — regardless of weight

 Intense fear of becoming fat
 Anxious about losing control
 Weight is ↓ 85% of normal
 Feels powerless
 Associated with obsessive compulsive disorder
BULIMIA

 Recurrent binge eating followed by self-induced vomiting, misuse of laxatives and

enemas
 Depressed mood following binge eating
 ↑ Anxiety and compulsivity
PICA

 Persistent eating of non-nutritive food and non-food substances

 Food — cornstarch, baking powder, coffee grounds
 Non-food — clay, soils, laundry starch paint chips
  More common in children, pregnant women, individuals with autism or cognitive
impairment, patients in chronic renal failure.
 Influenced by cultural background.
 Associated with iron and zinc deficiency.

BIPOLAR DISORDER
MANIC

 Onset between 18-30 yrs old

 Mood:
 Elevated
 Expansive
 Irritable
 Speech:
 Loud-Rapid
 Punning
 Poor Judgment
 Clanging
 Vulgar
 ? Wt. loss
 Grandiose delusions
 Distracted
 Hyperactive
 ↓ Need for sleep
 Inappropriate Dress
 Flight of ideas
DEPRESSIVE

 Previous manic episodes

 Feelings of
 Worthlessness
  Guilt
 Hopelessness
 ↑Anger & Irritability
 ↓ Interest in pleasure
 Negative views
 Fatigue & ↓ Energy
 ↓ Appetite
 Constipation
 Insomnia
 ↓ Libido
 Suicidal preoccupation
 May be agitated or have movement retardation

BASIC COMPONENTS OF A PSYCH ASSESSMENT

GENERAL HISTORY OF PATIENT

 Ethnicity
 Marital Status
 Living Arrangements
 Occupation
 Education
 Cultural Implications
 Religious & Spiritual
 Beliefs/ Affiliations
PRESENTING PROBLEM

 Why is Patient Seeking help?

 Recent Difficulties
 Relevant Family History
 ↑ Feelings of
 Depression
 Anxiety
 Hopelessness
 Confusion
 Suspiciousness
 Being Overwhelmed
 Somatic Changes
 RELEVANT PERSONAL HISTORY

 Previous Illness and Hospitalizations

 Growth and Development Patterns
 Social Patterns - Family & Friends
 Sexual Preference/Practice
 Interest
 Substance Use & Abuse
 Coping Abilities
RELEVANT FAMILY HISTORY

 Childhood
 Adolescence
 Drug Use
 Physical, Emotional or Sexual Abuse
 Family Physical or Psychosocial Problems

ASSESS CHANGES IN SENILE DEMENTIA

 Judgment
 Affect
 Memory
 Cognition
 Orientation
ALTERATIONS OF BODY IMAGE
Impact/ Shock/ Denial

 Despair
 Discouragement
 Withdrawal
Depression

 Insomnia
 Refusal to participate in self-care
 Sadness
Grief

 Normal reaction to loss

  Regression can and does occur
 Provide safe environment for expression of feelings
 Common in patients who have experienced mastectomy, amputations, burns, cancer,
disfiguring surgery, or spinal cord injury
Anger

 Refusal to discuss change of loss

 Low self esteem
 Hostile/ irritable
Adjustment

 Acceptance and adaptation

 Active participant in therapy/care
 Planning for future
 High self esteem

ALCOHOL WITHDRAWAL DELIRIUM

“Delirium Tremens (DTs)”

 DT’s 30-120 hours after last drink

 Peaks at 24-48 hours
 Shaking
 Vomiting
 ↑ pulse rate
 ↑ BP
 ↑ temperature
 Sweating
Caution

 Undiagnosed alcoholic may begin DTs after hospitalization, surgery or procedure

EAR DROPS ADMINISTRATION

 AD(UP)LT
 Pull ear back and up for older children and adults
  CHIL(DOWN)
 Pull ear down and back for infants and children below 3 years old
STROKE
(Brain Attack, CVA)

 Headache
 Mental Changes
 Confusion
 Disorientation
 Memory Impairment
 Aphasia (CVA Left Hemisphere)
 Resp Problems (↓ Neuromuscular Control)
 ↓ Cough / Swallow Reflex
 Agnosia (↓ sensory interpretation)
 Incontinence
 Seizures
 Hemiparesis or Hemiplegia
 Emotional Lability
 Visual Changes (Homonymous Hemianopsia)
 Diplopia, Ptosis, and Loss of Corneal Reflex
 Vomiting
 Spatial-Perceptual Defects (CVA Right Hemisphere)
 Hypertension
 Apraxia (↓ Learned movements)
Transient Ischemic Attack (TIA):

 Confusion
 Vertigo
 Dysarthria
 Transient hemiparesis
 Temporary vision changes
 Typically lasts less than 1 hour
Focal Neurological S & S:

 Paralysis
 Sensory Loss
 Language Disorder
 Reflex Changes
RISK FACTORS
Modifiable factors

 Hypertension
 Smoking
 Heart disease
 High cholesterol
 Excessive alcohol use
 Oral birth control with hx of high BP
 Obesity
 Sleep apnea
 DM
 Poor diet
 Drug use- cocaine
 Lack of physical exercise
Non-modifiable factors

 Age
 Gender
 Ethnicity/race
 Family history
 Heredity
Diagnostics

 Neuro exam, CT Scan, MRI

 Angiography
 Intra-arterial digital subtraction angiography (DSA)
 Transcranial doppler (TCD) ultrasonography
 LP
 LICOX monitoring
Nursing goals

 Airway-oxygenation
 Decrease ICP
 Nutrition
 Preserve function
 Rehabilitation
 Safety
 Education
Pupillary abnormalities
  Typically larger on the side opposite the lesion
 Conjugate deviation (looks toward lesion)
 Homonymous hemianopsia
Causes

 Atherosclerosis
 Thrombosis
 Embolism
 Cerebral hemorrhage (tissue damage/trauma)

PARKINSON’S DISEASE

 Onset usually gradual, after 50 (slowly progressive)

 Mask-like, blank expression
 Stooped posture
 Pill rolling tremors
 Possible mental deterioration
 Depression
 Shuffling, propulsive gait
 Has familial incidence; more common in men
Tremor

 Commonly in hands and arm

 Pill rolling motion with the fingers
 Occurs most often at rest
 May involve diaphragm, tongue, lips and jaw
 Increases with stress

Bradykinesia

 Loss of normal arm swing while walking

 ↓ blinking of the eyelids
 Loss of ability to swallow
 Blank expression
 Difficulty initiating movement
Muscle rigidity

 ↑ resistance to passive movement

 Cog wheel, jerky slow movement
INCREASED INTRACRANIAL PRESSURE

 Changes in LOC
 Flattening of affect
 ↑ orientation & attention
 Coma
 Eyes
 Papilledema
 Pupillary changes
 Impaired eye movement
 Posturing
 Decerebrate
 Decorticate
 Flaccid
 Decreased motor function
 Change in motor ability
 Posturing
 Headache
 Seizures
 Impaired sensory & motor function
 Changes in VS: Cushing’s Triad
 ↑ systolic BP (widening pulse pressure)
 ↓ pulse
 Irregular resp pattern
 Vomiting
 Not preceded by nausea
 May be projectile
 Changes in speech
 IN INFANTS:
 Bulging fontanels
 Cranial suture separation
 ↑ head circumference
 High pitched cry
INCREASED INTRACRANIAL PRESSURE (IICP)- CUSHING’S TRIAD
IICP (hyper, brady, brady)

 ↑ systolic BP
 ↓ pulse
 ↓ respirations
Shock (hypo, tachy, tachy)

 ↓ BP
 ↑ pulse
 ↑ respirations
Causes

 ↑ intracranial blood volume

 ↑ CSF
 Cerebral edema
 Cerebral hemorrhage
 Cellular toxins
 Ischemic cells
 Dilated cerebral arteries
 ↑ PCO2
 Acidotic state
risk factors/ etiology

 Secondary to initial damage

 Brain tumor
 Closed head injury
 Ruptured blood vessels
 Embolism
 Thrombosis & ischemia
 Hydrocephalus
Diagnostic

 CT Scan, MRI
 PET, EEG, Angiography
 LICOX brain tissue oxygenation catheter
 Transcranial doppler studies
 Evoked potential studies
Treatment

 ICP monitoring (ventriculostomy)

 Cerebral oxygenation monitoring (LICOX)
 Hypertonic saline IVs
 Medicate
 Osmotic diuretics
 Corticosteroids
  Antiseizure drugs
Complications

 Herniation
 Inadequate cerebral perfusion
 SIADH
 Diabetes insipidus
Nursing interventions
ID & ↓ ICP

 Neuro ✓’s
 Semi-fowlers
 Change position slowly
 Maintain hydration
 I&O
 NO coughing, sneezing, or Valsalva maneuver
 Maintain nutritional needs (enteral or parenteral feedings)
 GCS
 ↑ size → infant’s head
Resp function

 Airway patency
 PCO2 ok?
 Minimum suctioning
 Ventilator?
Protect from injury

 Seizure precaution
 CSF from ears/nose?
 Prevent aspiration
 Quiet environment
 Prevent eye damage
 Light sedative for agitation
Psychological equilibrium

 Explain neuro ✓’s

 Encourage for fear verbalization
 Maintain reality orientation
 Talk to unconscious clients
  Work thru feelings
Immobility

 ROM
 Pressure ulcer prevention
 Avoid extreme hip flexion
 Assess motor responses & movement
Elimination

 Insert urinary catheter

 Avoid straining during BM

FAST RECOGNITION OF A STROKE

 FACE – are both sides equal? Is the smile equal?

 ARMS – can the client raise both arms equally?
 SPEECH – is speech slurred? Can the client make a sentence?
 TIME – get help now!
BELL’S PALSY

 Forehead not wrinkled

 Eyeball rolls up
 Eyelid does not close
 Flat nasolabial fold
 Paralysis of lower face
Etiology

 Possible reactivation of herpes vesicles in and around the ear will proceed facial
paralysis
Treatment

 Corticosteroids
 Antivirals
 Full recovery by most patients in 6 months, especially if treatment is started
immediately
ABNORMAL POSTURING

 flexor posturing (Decorticate = to the cord)

 Arms are like C
 Problems with cervical spinal tract or cerebral hemisphere

 extensor posturing (Decerebrate)

 Arms are like E

 Problems within midbrain or pons

 flaccid

NURSING CARE FOR SPRINS & STRAINS

(RICE)

 Rest
 Ice
 Compression
 Elevation
HIP FRACTURES
Post op care

 Prevent adduction & external rotation of affected leg

 Assess extremity for: (to prevent neurovascular impairment)
 Color
 Temperature
 Capillary refill
 Distal pulses
 Edema
 Sensation
 Motor function
 Pain, muscle spams
Treatment

 Buck’s traction to relieve spasms up to 24-48 hours

 Surgery (depending on the client’s condition, type of fracture)
 Internal fixation pins – screws – plates, prosthetics
Nursing care

 Check doctor’s order

 Maintain abduction change
 Position q 2 – avoid affected side
 Use abduction pillow between legs
 Out of bed 1st post-op day
 Cough & deep breath
 Monitor I&O
 Exercise when ok
 Client teaching, self-care promotion
 Avoid extreme hip flexion
 Prevent external rotation
Signs & Symptoms

 Pain, muscle spasms

 Unable to bear weight
 Affected leg shortened
 Adduction of affected leg
 External rotation
 Deformity along lateral side of the hip fracture is displaced
 Ecchymosis
Risk factors

 ↑ age
 ↑ female
 ↑ history of osteoporosis
 Presence of chronic condition
Complications of hip fractures

 Circulatory compromise
 Immobility complications
 Delayed union – non union
 Fat embolism
 Nerve & vascular injury
 Infection
 Emboli
 Avascular necrosis
Special considerations for elderly patient
  ↓ tolerance to meds → prevent oversedation
 ↓ IV rate → avoid CHF
 ↑ risk of
 CHF
 Resp depression → pneumonia
 Immobility - complications contractures
 Disorientation
 Skin breakdown
 Circ problems → thrombophlebitis
 Safety → side rails and prevent falls
 Poor nutrition → constipation – fluid & electrolyte imbalance, poor healing

CARE OF PATIENT IN TRACTION

 Temperature (extremity, infection)

 Ropes hang freely
 Alignment
 Circulation check (6P’s)
 Type & location of fracture
 Increase fluid intake
 Overhead trapeze
 No weights on bed or floor

CARE OF PATIENTS WITH AMPUTATION

Residual limb wounds care:

 Elevate residual limb the first 24 hours

 Prevent contracture of the joint above amputation
 Discuss phantom limb pain
 Analgesics
 Evaluate healing
 Compression dressing to prevent edema
 Discourage semi-fowler’s position in patient with AKA to prevent contractures of
the hip
 Observe for bleeding
Residual limb care after wound has healed

 Assess for skin breakdown

  Wash, rinse & dry residual limb daily
 Do not apply anything to residual limb
 Alcohol = dries
 Lotion = skin too soft
 Encourage patient to wear prosthesis when he gets up & all day to prevent residual
limb swelling
 Teach patient that leather and metal parts of prosthesis should not get wet
Nursing care goals

 Promote good circulation in extremity

 Promote comfort
 Promote optimum level of mobility

TRACHEAL-ESOPHAGEAL FISTULA (3C’s)

 Choking
 Coughing
 Cyanosis

STAGES OF LABOR
First stage

 Stage of cervical dilation

 Begins with onset of regular contractions and ends with complete dilation
 Latent (0-3 cm) → Active (4-7 cm) → Transitional (8-10 cm)
Second stage

 Stage of expulsion
 Begins with complete cervical dilation and ends with delivery of fetus
Third stage

 Placental stage
 Begins immediately after fetus is born and ends when the placenta is delivered
Fourth stage
  Maternal homeostatic stabilization stage
 Begins after the delivery of the placenta and continues for 1-4 hours after delivery

PRENATAL CARE
Signs and symptoms

 Presumptive
 NO periods
 N&V
 Fatigue
 Increased urination
 Breast changes
 Probable
 + pregnancy test
 Enlarged abdomen
 Hegar’s Sign (softening of uterus)
 Chadwick’ Sign (bluish vagina)
 Goodell’s sign (softening of cervical lip)
 Ballottement – fetus rebounds
 Braxton-Hicks contractions
 Positive
 FHR
 Fetal movement (visible, felt by examiner)
 Fetal sonography

Pelvic exam

 PAP smear
 Bimanual exam
Lab tests

 RH + or –
 Rubella → if negative titer (<1:8) given immunization within 6 weeks after delivery
 VDRL/RPR
 CBC
 UA
 Hep B screen
 TB skin test
  HIV screen
 Glucose screening
Pregnancy tests

 + 7-10 days after conception

 Radioimmunoassay (RIA)
 Radioreceptor assay (RRA)
 Enzyme linked immunosorbent assay (ELISA)
EDB

 Naegel’s Rule
 LMP: -3 months, + 7 days, +1 yr
Assessment

 Initial visit
 History & physical
 Obstetric history
 Para = # of live births
 Gravida = # of pregnancies
 Schedule prenatal visits
 Vitals
 UA
 Weight
 Height of fundus
 FHR

POSTPARTUM ASSESSMENT
(BUBBLE)

 Breasts
 Uterus
 Bowels
 Bladder
 Lochia
 Episiotomy/ laceration/ C-section incision

PHYSIOLOGIC CHANGES IN PREGNANCY

Respiratory
  ↑ tidal volume
 ↑ O2 consumption
 Elevated diaphragm
 Nasal stiffness
 Epistaxis
Breasts

 ↑ breast size
 Heaviness, tingling
 Darkening of nipple
 Colostrum
Gastrointestinal

 Pregnancy gingivitis
 ↑ saliva – ptyalism
 ↓ gastric acidity
 N&V, heartburn
 ↓ tone & motility of smooth muscles
 Hemorrhage & constipation
 ↓ emptying of the gallbladder
Vagina

 Estrogen influence
 Smooth muscle hypertrophy
 Hyperplasia of lining
 ↑ thick white secretions – leukorrhea
 Chadwick’s sign

Integumentary

 ↑ skin pigmentation
 Facial mask – chloasma
 Acne vulgaris
 Dermatitis
 Vascular spider nevi
 Abdomen – stretch marks – striae gravidarum – linea nigra
Endocrine

 Placenta
  Produces hCG, hPL or hCS
 Thyroid
 ↑ size & activity
 ↑ basal metabolic rate
 ↑ parathyroid activity
 Pituitary
 Produces FSH, LH, thyrotropin adrenotropin & prolactin
Uterus

 ↑ size
 ↑ weight
 Lightening
 Braxton hicks
 Cervical softening – Goodell’s sign
 Mucus plug
Urinary

 Frequency
 ↓ bladder tone
 ↓ renal threshold for sugar
 ↑ glomerular filtration
Cardiovascular

 ↑ blood volume – 40-50%

 ↑ HR – 10-15 bpm
 ↑ cardiac palpitations
 Slight heart enlargement
 Murmurs
 Pseudoanemia

Musculoskeletal

 ↑ lumbar curve
 Altered center of gravity
 Duck waddling gait
Nutrition

 Normal weight gain – 25-35 lbs for single fetus & woman with normal BMI
  Balanced diet
 ↑ folic acid & iron
 ↑ caloric intake by 340-452 kcal/day for 2nd and 3rd trimesters
 ↑ need for H2O

NON-STRESS TEST (3N’s)

 Non-reactive
 Non-stress is
 Not good

NEWBORN ASSESSMENT
APGAR Score

 HR
 Resp effort
 Muscle tone
 Reflex irritability
 Color
Circulatory system: Blood flow from umbilical vessels & placenta stops at birth

 Closure of:
 Ductus arteriosus
 Foramen ovale
 Ductus venosus
 ↑ pulmonary circulation
 Transitory murmurs
 Hands & feet acrocyanosis
 HR 120-160 bpm
 ↓ temp → heat loss due to:
 Evaporation – moisture from skin & lungs
 Convection – body heart to cool air flow
 Conduction – body heat to blankets, etc.
 Radiation – heat loss to cool temps.
IN BOX:
Chilling =

 ↑ O2 consumption
  ↑ utilization of glucose (hypoglycemia <45mg %) & brown fat
 ↑ need for calories
 ↑ risk metabolic acidosis
 ↓ surfactant production
Sleeps: (in box)

 16-20 hours a day in the first 2 weeks

General characteristics

 Average length = 48 cm to 53 cm (19 in to 21 in)

 Weight
 3,400 grams (average) or 7 lbs. 8 oz.
 Usually 5-10% wight loss 1st few days
 Regained within 10-14 days
 Head
 Molding → elongated
 Caput succedaneum → edema
 Measurement → 33-35 cm (13-14 in.)
 Head = 2-3 cm > chest circ.
 Fontanels → bulging or sunken?
In box: extremes in size may indicate microcephaly, hydrocephaly or IICP

 Umbilical cord: AVA (2 arteries, 1 vein)

Respiratory system

 Resp effort: within 1st minute of birth

 Loud & lusty cry
 No dyspnea
 No retractions
 Resp rate 30-60 cpm
 Diaphragmatic & abdominal muscles used
 Nose breathers
 Lung maturation
 Lung function after 26th week gestation
 Surfactant OK at 35th week gestation

HIGH RISK NEWBORN NRUSING INTERVENTIONS

Temperature
  Minimize cold stress
 Maintain skin temp
 Continuously monitor temp
 Prevent rapid warming or cooling
 Use a cap to prevent heat loss from head
Foods & fluids

 Monitor for hypoglycemia

 Assess tolerance of oral or tube feedings
 Monitor hydration closely
 Assess for gastric residual, bowel sounds, change in stool pattern, abdominal girth
 Monitor weight gain or loss
Resp function

 Position ↑ O2 – semiprone/side lying

 Maintain resp tract patency
 Stimulate – remind to breathe
 Monitor O2 therapy
 Assess resp effort
 Grunting
 Nasal flaring
 Cyanosis
 Apnea

HELLP Syndrome
(Preeclampsia with liver involvement)

 Hemolysis
 Elevated Liver function tests
 Low Platelet count

EVALUATION OF EPISIOTOMY HEALING (REEDA)

 Redness
 Edema
 Ecchymosis
 Discharge, drainage
 Approximation
DEVELOPMENTAL DYSPLASIA OF THE HIP

 Malformation of the hip due to imperfect development of the femoral head,

acetabulum, or both
 Ortolani’s Sign
 When infant is supine and knees are flexed and hips are abducted, a click is
heard or felt

COMPLICATIONS WITH PREGNANCY

Hemorrhagic disorders

 Placenta previa (PAINLESS bright red bleeding during 2nd & 3rd trimester)
 Ectopic pregnancy (medical treatment= Methotrexate/ surgical treatment)
 Abortion
 Threatened
 Inevitable
 Incomplete
 Complete
 Missed
 Recurrent
 Abruptio placenta
 Vaginal bleeding or concealed hemorrhage
 Mild to severe abdominal pain
Incompetent cervix

 Purse string procedure = CERVICAL CERCLAGE

Hydramnios

 Amniotic fluid index (AFI) >24-25 cm

 Develops 3rd trimester in diabetics
 Complications – abruptio placenta, post partal hemorrhage
Hypertensive disorder

 Proteinuria
 ↑ BP
Hydatidiform mole (Molar pregnancy)

 Increased risk of cancer and hyperthyroidism

 Enlarged uterus
  Vaginal bleeding
 Passage of vesicles

CLEFT LIP- POST OP CARE

 Choking
 Lie on back
 Evaluate airway
 Feed slowly
 Teaching
 Larger nipple opening
 Incidence ↑ males
 Prevent crust formation, prevent aspiration

ASSESSMENT TESTS FOR FETAL WELL-BEING

Biophysical tests

 Daily fetal movement count (DFMC)

 Ultrasonography
 Biophysical profile (BPP)
 MRI
Biochemical tests

 Amniocentesis
 Chorionic villus sampling
 Percutaneous umbilical blood sampling
 Maternal serum alpha-fetoprotein
 Indirect coombs test
Biophysical profile

 Fetal breathing movements

 1 ep. Of 300 sec. in 30 min.
 Fetal tone
 At least 1 ep. Of extremity extension & flexion
 Body movement
 3 eps. Over 30 min.
 Amniotic fluid volume
 At least 1 pocket measure 2 cm in 2 perpendicular planes
  Non-stress test – reactive
 FHR ↑ with activity
Each has a possible score of 2. Max score = 10

HEPATIC ENCEPHALOPATHY (Hepatic Coma)

↑ blood ammonia

 Changes in LOC
 Progressive confusion
 Stuporous
 Impaired thinking & judgment
 Neuromuscular disturbances
 Asterixis “liver flap”
 Hyperreflexia
 Fetor hepaticus
 Treatment
 Administer vancomycin & lactulose
 Administer cathartics & enemas
 Promote diet ↑ carbohydrates & adequate fluids
 Problem increased by:
 Constipation
 Infection
 Hypovolemia
 Hypokalemia
 GI bleeding
 Opioid meds

CIRRHOSIS: LATER CLINICAL MANIFESTATIONS

 Jaundice
 Esophageal varices
 Ascites
 Hepatomegaly
 Splenomegaly
 Hemorrhoids
 Edema
  Peripheral neuropathy
 Changes in mental responsiveness & memory
 Spider angiomas (face-neck-shoulders)
 Anemia, leukopenia, thrombocytopenia, coagulation disorders
 Superficial veins visible on abdominal wall (caput medusae)
 Palmar erythema
 Sexual characteristics changes: gynecomastia & hirsutism

CHOLECYSTITIS

 Fever & leukocytosis

 Jaundice
 N&V
 Anorexia
 Abdominal distention
 Feeling of fullness
 Fat intolerance
 Pain
 RU quad or right shoulder
 May radiate to back
 Increases with deep breath
IMMUZATION SCHEDULE
0-2 months

 Hepatitis B (Hep B, 1st birth, 2nd 1-2 months)

2 months

 DTaP
 Hib
 IPV (inactivated polio vaccine)
 PCV (pneumococcal), RV (rotavirus)
4 months

 2nd doses of:

 DTaP
 Hib
 IPV
  PCV, RV
6 months

 3rd doses of:

 DTaP
 IPV
 PCV
 HepB # 3 at 6-18 months
12-18 months

 DTaP (4th dose)

 Hib
 PCV
 Influenza (yearly)
 MMR, 2 doses 4 weeks apart
 Varicella
 Hep A, 2 doses 6 months apart
4-6 years

 DTaP
 Varicella (2nd dose)
 Influenza (yearly)
 IPV (final)
11-12 years

 TDaP
 Influenza (yearly)
 HPV- Females x3 doses
 Meningococcal (MCV4)
14 years-adult

 Influenza (yearly)
 TDaP booster them Tetanus, Diphtheria (Td every 10 years)
 Zoster >60 years
 Pneumococcal >60 years

HIV INFECTION
Transmission
  Unprotected sexual intercourse
 Contact with blood or blood products
 Perinatal – during pregnancy, delivery or breastfeeding
Screening

 Enzyme immunoassay at 3 weeks, 6 weeks, 3 months after exposure

 Rapid HIV antibody testing – tests for antigens not antibodies, if +, need follow-up
with EIA and/or antibody/antigen test
Seroconversion

 Development of HIV specific antibodies

 Window period – may be 2 months between infection and detection of
antibodies (HIV +)

AIDS

 Presence of at least 1 or more:

 CD4 T cell count ↓ 200 cells/uL (compromised immune system)
 Opportunistic infections
 Fungal – candidiasis, Pneumocystis jiroveci pneumonia (PCP)
 Viral – cytomegalovirus
 Bacterial – Mycobacterium tuberculosis, pneumonia
 Protozoal – toxoplasmosis of brain, intestine
 Cancer
 Invasive cervical
 Kaposi’s sarcoma
 Lymphoma
 Wasting syndrome
 AIDS dementia complex
Treatment

 Antiretroviral therapy (ART) begins with confirmation of HIV

Goals

 Decrease viral load

 Maintain or ↑ CD4 T-cell count
 Delay onset of HIV related symptoms
 Prevent or delay opportunistic infections
Early chronic infection

 HIV infection to development of AIDs – average 11 yrs.

 Symptoms – fatigue, headache, lymphadenopathy, low grade fever
 Normal CD4 T-cell count
 ↑infections
Intermediate chronic infection

 CD4 T-cell count ↓ 200-500 cells/uL

 Increased viral load
 Increased infections, earlier symptoms more severe
Late chronic infection

 Diagnosis of AIDS

BLOOD TRANSFUSION
Febrile reaction

 Chills
 Fever
 Headache
 Flushing
 Tachycardia
 ↑ anxiety
Allergic reaction
Mild:

 Pruritus
 Hives
 Facial flushing
Severe:

 Shortness of breath
 Bronchospasm
 Anxiety
Hemolytic transfusion reaction

 ↑ anxiety
 Low back pain
 Hypotension
 Tachycardia
 Fever & chills
 Chest pain
 Tachypnea
 Hemoglobinuria
 May have immediate onset
(box) Nursing implications:

 Stop transfusion and notify physician

 Change IV tubing at hub and begin NS
 Treat symptoms if present → O2 fluids, epinephrine
 Check VS q 15
 Recheck crossmatch record with unit & send blood bag/tubing to the lab
 Obtain blood sample
 Obtain urine sample for hemoglobinuria
 Monitor fluid/electrolyte balance
 Evaluation serum calcium levels
BLOOD ADMINISTRATION

 Determine patient’s:
 Allergies
 Previous transfusion reactions
 Administer within 30 MINUTES of receiving from blood bank
 Never add any meds to blood products
 Check crossmatch record with 2 NURSES:
 ABO-group
 RH type
 Patient’s name
 ID Blood band
 Hospital no.
 Expiration date
 Do not warm UNLESS RISK OF:
 Hypothermic response
 THEN ONLY by specific blood warming equipment
 Infuse each unit over 2-4 hours BUT NO LOONGER than 4 hours
Notes:

 Verify patient’s ID
 Check doctor’s order
 Check labels on blood bag & blood bank transfusion record
 Baseline vitals
 #18G or #20G gauge needle
 Normal saline IV solution
 Blood administration set with filter
 Severe reactions most likely first 15 mins & first 50mL
 Blood tubing should be changed AFTER 4 HOURS

ANEMIAS

 ↓ B12
 Pernicious anemia lack of intrinsic factor
 Erythroblastosis Fetalis
 Destruction by antibodies
 Secondary bleeding, leukemia, cancer or CKD
 ↑ RBC destruction
 Sickle cell, enzyme deficiency
 Aplastic
 Malfunctioning bone marrow
 Hypochromic
 Iron or vitamin deficiency
PERITONITIS
Clinical manifestations

 Pain over area

 Presence of a cause
 Abdominal guarding
 Abdomen distention & rigidity “board-like” abdomen
 Fever (>100 F)
 Anorexia
 N&V
 ↑pulse & ↑BP
 ↓ bowel sounds
 Dehydration
 Shock
Risk factors

 Perforation
 Trauma
 Ulcer
 Appendix
 Diverticulum
 Abdomen surgery
 Ectopic pregnancy
Diagnostics

 X-ray
 CBC
 Peritoneal aspiration
 Peritoneoscopy
 Ultrasound
 CT scan
Treatment

 Identify cause
 Antibiotics & antiemetics
 IV fluids
 ↓ abdomen distention
 Surgery to close perforation
Nursing care

 Decrease pain
 Position with knees flexed
 Analgesics
 Quiet environment
 Prevent complications of immobility
 Maintain fluid & electrolyte (balance and ↓GI distention
 NG suction
 IVs (NS, LR)
 Electrolyte replacement
 Peristalsis → bowel sounds?
 I&O
 S&S dehydration – hypovolemia
PEPTIC ULCER DISEASE (PUD)
Common risk factors

 Stress
 H. pylori
 Alcohol
 Smoking
 Gastritis
Duodenal ulcers

 Most common
 Well nourished
 Pain 2-3 hrs. after meals
 Food may lower pain
Gastric ulcers

 Weight loss
 Acid – normal or hyposecretion
 Pain ½ - 1 hr after meals
 Vomiting
 Eating may increase pain
Stress ulcers

 Physiological stress
 Shock
 Cushing’ Ulcer-Brain injury
 Curling’s ulcer
 Extensive burns

CROHN’S DISEASE

 Occurs teens to mid-30s

 Second peak after age 60
 Autoimmune factors
 N&V
 Abdominal pain & distention
 Tenderness in RLQ
 Severe diarrhea
 Low grade fever
  Infrequent rectal bleeding
 Weight loss
 Sever malabsorption
Later signs & symptoms

 Dehydration
 Electrolyte imbalance
 Anemia
Complications

 Perineal abscesses
 Intestinal fistulas
 Peritonitis

INFLAMMATION (HIPER)

 Heat
 Induration
 Pain
 Edema
 Redness

TRIANGLE OF DIABETES MANAGEMENT

Exercis
e
Glucos Monitorin
e g
ME
D
Medicatio Diet
n
METABOLIC SYNDROME – SYNDROME X
AHHL- Angels Have Healthy Lifestyle
Avoid these factors, leads to: Diabetes, Stroke, & Heart Disease
Abdominal obesity

 Waist is ↑ 40” in men & ↑ 35” in women

 BMI> 25 kg/m2
Hyperglycemia

 Fasting BS ≥ 110 mg/dl or on diabetic meds

 IBW ↑ 20%
Hypertension

 Taking med for ↑ BP

↑Lipids

 Taking lipid medication

 Triglycerides > 150 mg/dl
 HDL < 40 mg/dl ♂
 HDL < 35 mg/dl ♀

CUSHING’S SYNDROME
(corticosteroid excess)

 Personality changes
 Moon face
 ↑ susceptibility to infection
 Male: gynecomastia
 Fat deposits on face & back of shoulders
 Osteoporosis
 Bruises & petechiae
 Purple striae
 Thin skin
 Female: amenorrhea, hirsutism
 GI distress - ↑ acid
 Thin extremities
 Na+ & fluid retention (edema)
 CNS irritability
 Hyperglycemia
BLOOD SUGAR MNEMONIC

 Hot & dry = sugar high

  Cold & clammy = need some candy

ADRENAL GLAND HORMONES (3S)

 Sugar (glucocorticoids)
 Salt (mineralocorticoids
 Sex (androgens)

ADDISON’S DISEASE
Adrenocortical Insufficiency

 Bronze pigmentation of skin

 Tachycardia
 GI disturbances
 Weakness, fatigue
 Depression
 Hypoglycemia
 Postural hypotension
 Weight loss, anorexia
Adrenal crisis:

 Profound fatigue
 Dehydration
 Vascular collapse (↓BP)
 ↓ serum Na+
 ↑ serum K+

POST OP NURSING CARE

Fluid & electrolytes

 IV fluid & rate

 Adequate hydration
 Electrolytes
 GI drainage
 Renal function
 Lab values
Comfort

 Analgesics
 Antiemetics
 Hygiene
 Position
 Rest
Respiratory function

 Adequate hydration
 Incentive spirometry
 Turn – cough – deep breathe – O2
Nutrition & elimination

 Bowel sounds
 Check NPO status
 NG tube?
 Encourage fluids
 Assess fluid tolerance
 Progressive diet
 Monitor for flatus or BM
 Assess output
Maintain cardiovascular function

 VS q 4
 Skin color
 Hematocrit
 Activity tolerance
 Early ambulation

POST OP COMPLICATIONS
Circulatory

 Pulmonary embolism
 Chest pain
 Dyspnea
 ↑ resp rate
 Tachycardia
 ↑ anxiety
  Diaphoresis
 ↓ orientation
 ↓ BP
 Blood gas changes
 Hypovolemic shock
 ↓ urine
 ↓ BP
 Weak pulse
 Cool clammy
 Restless
 ↑ bleeding
 ↑ thirst
Infection

 Redness
 Purulent drainage
 Fever
 Tachycardia
 Leukocytosis
Dehiscence

 Separation of incision
Evisceration

 Evidence of bowel through incision

 ↑ pain
Gastric dilation

 N&V
 Abdomen distention
Paralytic ileus

 ↓ bowel sounds
 No stool or flatus
 Nausea
 Vomiting
 Abdomen distention
 Abdomen tenderness
Respiratory
  Atelectasis
 Dyspnea
 ↓ O2 sats & ↓ PaO2
 ↓ breath sounds
 Asymmetrical chest movement
 Tachycardia
 ↑ restlessness
 Pneumonia
 Rapid shallow respirations
 Fever
 Wet breath sounds
 Asymmetrical chest movement
 Productive cough
 Hypoxia
 Tachycardia
 Leukocytosis
Urinary

 Urinary retention
 Should void within 6-8 hrs. post op
 Palpable bladder
 Frequent, small amount voiding
 Pain suprapubic area

DEHISCENE VS EVISCERATION

 Dehiscence
 Separation or splitting open of layers of a surgical wound
 Evisceration
 Extrusion of viscera or intestine through a surgical wound

CHARTING BODY FLUIDS (“COACH”)

 Color
 Odor
 Amount
 Consistency
 How the patient is tolerating it
RIGHT SIDED HEART FAILURE
Cor Pulmonale

 Fatigue
 ↑ peripheral venous pressure
 Ascites
 Enlarged liver & spleen
 Ma be secondary to COPD
 Distended jugular veins
 Anorexia & complaints of GI distress
 Weight gain
 Dependent edema

LEFT SIDED HEART FAILURE

 Paroxysmal nocturnal dyspnea

 Elevated pulmonary capillary wedge pressure
 Pulmonary congestion
 Cough
 Crackles
 Wheezes
 Blood-tinged sputum
 Tachypnea
 Restlessness
 Confusion
 Orthopnea
 Tachycardia
 Exertional dyspnea
 Fatigue
 Cyanosis

PRELOAD & AFTERLOAD

Preload

 Pressure from volume of blood in ventricles at end of diastole

 Increased in:
 Hypervolemia
 Regurgitation of cardiac valves
 Heart failure
Afterload

 Resistance left ventricle must overcome to circulate blood

 Increased in:
 Hypertension
 Vasoconstriction
In box ↑afterload = ↑ cardiac workload

MEDICAL ASEPSIS VS SURGICAL ASEPSIS

Medical asepsis

 Hand hygiene is NUMBER 1

 Reduces # of pathogens
 Referred to as “clean technique”
 Used in administration of:
 Medications
 Enemas
 Tube feedings
 Daily hygiene
Surgical asepsis

 Eliminates all pathogens

 Referred to as “sterile technique”
 Used in:
 Dressing changes
 Catheterizations
 Surgical procedures

MYOCARDIAL INFARCTION (MI)

Coronary occlusion/ heart attack

 Pain:
 Sudden onset
 Substernal
 Crushing
 Tightness
 Severe
 Unrelieved by nitro
  May radiate to:
 Back
 Neck
 Jaw/tooth
 Shoulder
 Arm
 Dyspnea
 Syncope (↓ BP)
 N&V
 Extreme weakness
 Diaphoresis
 Denial is common
 ↑ pulse
 Changes in ST segment
Treatment:

 O2 – IV – meds
 Monitor
 Dietary restrictions
 ↓ Na+, ↓ cholesterol, ↓ caffeine
 PCI? Surgery? Pacemaker?

CYANOTIC DEFECTS MNEMONIC (4-T’s)

 ↓ Pulmonary blood flow

 Tetralogy of Fallot
 Tricuspid Atresia
 Mixed blood flow
 Transposition of great arteries
 Truncus arteriosus

CONGENITAL HEART DEFECTS

 ↓ Pulmonary blood flow

 “I am doing the CYANOTIC SQUAT”
 Tetralogy of Fallot
 Tricuspid atresia
 Squatting
 Cyanosis
  Clubbing syncope
 ↑ Pulmonary blood flow
 “I am NOT BLUE, just TIRED all the time”
 Patent ductus arteriosus
 Atrial septal defect
 Ventricular septal defect
 ↑ fatigue
 Heart murmur
 ↑ risk endocarditis
 CHF
 Growth retardation

CONGENITAL HEART DEFECT SYMPTOMS

 ↑ pulse
 ↑ respirations
 Retarded growth
 Dyspnea, orthopnea
 Fatigue
 URI

CARDIAC ELECTROPHYSIOLOGY

 P-Wave
 Produced as impulse from SA node and causes atrial contraction
 QRS complex
 Conduction of impulse through the bundle of HIS to Purkinje fibers causing
contraction of ventricles
 S-T segment
 The heart’s resting period
 T-Wave
 Ventricular repolarization
 P-R interval
 Time between atrial depolarization and the start of ventricular conduction
(Depolarization)

ATROPINE OVERDOSE
  Decreased sweating = ↑ temp
 Confusion, delirium
 Flushed face
 Decreased secretions, thirsty

COMPARTMENT SYNDROME (6Ps)

 Pain
 Poikilothermia
 Pallor
 Paresthesia
 Pulselessness
 Paralysis

6Ps OF DYSPNEA

 Pulmonary bronchial constriction

 Possible foreign body
 Pulmonary embolus
 Pneumonia
 Pneumothorax
 Pump failure

BLOOD PRESSURE

 BP = Cardiac Output x Systemic Vascular Resistance (SVR)

CARDIAC OUTPUT

 CO = Heart Rate x Stroke Volume

HEART RATE CALCULATION

 Count the number of “R” waves in 6 seconds

 Formula
 300/ # of large blocks = 1 minute rate
  E.g. (3.2 large blocks) 300/3.2 = 93.75 or 94 bpm
 OR 1500/ # of small blocks = 1 minute rate
 E.g. (16 small blocks) 1500/16 = 93.75 or 94 bpm

CANES & WALKERS

Canes (COAL)

 Cane
 Opposite
 Affected
 Leg
Walker (WWAL)

 Walker
 With
 Affected
 Leg

CARDIOVERSION

 Elective procedure
 Client awake
 Synchronized with QRS
 Sedation
 50-200 joules
 Consent form
 ECG monitor
DEFIBRILLATION

 Emergency
 V-Fib/ V-Tach
 No cardiac output
 Begin with 200 joules up to 360 joules
 Client unconscious
 ECG monitor
HEART MURMURS

 Causes (SPAMS)
 Stenosis of a valve
 Partial obstruction
 Aneurysms
 Mitral regurgitation
 Septal defect
 Types
 Systolic
 Crescendo
 Decrescendo
 Diastolic
 Indicates pathologic disease
PARALYSIS

 Quadriplegia = 4
 Paraplegia = 2
 Hemiplegia = ½
ACE INHIBITORS

 Action - ↓ peripheral vascular resistance without:

 No ↑ cardiac output
 No ↑ cardiac rate
 No ↑ cardiac contractility
 Side effects
 Dizziness
 Orthostatic hypotension
 GI distress
 Cough
 Headache
ANTICANCER DRUGS ADVERSE REACTION/PRECAUTIONS

 Bone marrow suppression

 N&V
 Anorexia
 GI disturbances
 Alopecia
 Avoid pregnancy
BETABLOCKERD
  Action – blocker beta receptor in heart causing
 ↓ HR
 ↓ force of contraction
 ↓ rate of A-V conduction
 Side effects:
 Bradycardia
 Lethargy
 GI Disturbance
 CHF
 ↓ BP
 Depression
CALCIUM ANTAGONISTS

 Verapamil
 Nifedipine
 Diltiazem

 Action – blocks calcium access to cells causing

 ↓ contractility
 ↓ conductivity of the heart
 Side effects:
 ↓ BP
 Bradycardia
 May precipitate A-V block
 Headache
 Abdominal discomfort (constipation, nausea)
 Peripheral edema

CHOLINERGIC CRISIS (SULD)

 Salivation
 Lacrimation
 Urination
 Defecation

GUIDE TO MANAGEMENT OF A DRUG OVERDOSE

 Initial assessment
 Asymptomatic VS symptomatic?
  LOC
 Adequate resp and cardiac function
 Reflexes
 Pupillary
 Corneal
 Gag
 Deep tendon
 Gastric lavage
 Activated charcoal & specific antidotes
 Toxicologic analysis
 Respiratory support
 Assess cardia function
 Possible urinary catheterization
HEPARIN & COUMADIN LAB TESTS

 Coumadin: Prothrombin Time

 Heparin: Partial Thromboplastin Time + Activated Partial Thromboplastin Time

LIDOCAIN TOXICITY (SAMS)

 Slurred or difficult speech

 Paresthesia
 Numbness of lips/tongue
 Altered central nervous system
 Drowsiness
 Dizziness
 Arrhythmias
 Restlessness
 Confusion
 Muscle twitching
 Tremors
 Seizures
 Convulsions
 Respiratory depression
 Respiratory & cardiac arrest
MIXING INSULIN:

 Draw up the clear (fast acting) before the cloudy (long acting)
 To prevent contaminating a short-acting insulin with long-acting
SALICYLATE POISONING

 ↑ temp
 Hyperventilation
 Tinnitus
 N&V
 Lethargy/ excitability
Severe toxicity

 Metabolic acidosis
 Seizures
Toxic level for a 30 lb.

 Child = 12 adult aspirin or 48 baby aspirin

SASH TECHNIQUE
(to prevent mixing of IV solutions)

 Saline
 Antibiotic
 Saline
 Heparin
SERIOUS COMPLICATIONS OF ORAL BIRTH CONTROL PILLS (ACHES)

 Abdominal pain
 Chest pain – SOB
 Headaches (sudden/ persistent)
 Eye problems
 Severe leg pain

SIDE EFFECTS OF ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS)

Sample drugs

 Doxazosin (Cardura)
 Prazosin (Minipress)
 Methyldopa (Aldomet)
 Orthostatic hypotension
 Tachycardia
  Vertigo
 Sexual dysfunction

SIDE EFFECTS OF ADRENIRGIC ANTAGONISTS (BETA BLOKERS)

Samples drugs

 Propranolol (Inderal)
 Tenormin (Atenolol)
 Lopressor (Metoprolol)
 Hypotension
 Bradycardia (AV Block)
 Symptoms of CHF
 Drowsiness, depression

THESE DRUGS CAN INTERACT (TDCI)

 Theophylline
 Dilantin
 Coumadin
 Ilosone (Erythromycin)

TOXIC LEVELS

 2.0 mEq/L – lithium

 2.0 nq/mL – digoxin
 20 mcg/mL – theophylline

5As TO ALZHEIMER DIAGNOSIS

 Anomia
 Inability to remember names of things
 Apraxia
 Misuse of objects
 Agnosia
 Inability to recognize familiar objects, tastes, sounds, and other sensation
 Amnesia
 Memory loss
  Aphasia
 Inability to express oneself through speech

POST KIDNEY TRANSPLANT REJECTION SIGNS

 Acute
 1 weeks to 2 years post op
 Oliguria, anuria
 ↑ temp
 ↑ BP
 Flank tenderness
 Lethargy
 ↓ specific gravity
 Fluid retention
 Chronic
 Gradual over months to years
 Gradual ↑ in BUN and creatinine
 Imbalances in electrolytes
 Fatigue

ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)

Signs & symptoms

 Tachypnea
 Dyspnea
 Retractions
 Hypoxia
 Tachycardia
 Crackles
ABGs

 ↓ PO2 ↑ dyspnea
Causes

 Massive trauma
 Severe respiratory disorder
 Prolonged mechanical ventilation
 Hemorrhagic shock
  Fat emboli
 Septic condition

CYSTIC FIBROSIS
Symptoms

 Fatigue
 Chronic cough
 Recurrent URIs
 Thick, sticky mucus
 ↓ absorption of vitamins & enzymes
 Abdominal distention
 ↓ digestive enzymes
 Rectal prolapse
 Fatty, stinky stools

EPIGLOTTITIS (AIR RAID)

 Airway closed
 Increased pulse
 Restlessness
 Retractions
 Anxiety increased
 Inspiratory stridor
 Drooling

PNEUMOTHORAX

 Dyspnea
 Anxiety
 Tachycardia
 Pleural pain
 Asymmetrical chest wall expansion
 ↓ breath sounds
Causes

 Ruptured bleb (COPD)

 Thoracentesis
  Trauma
 Secondary infection
Diagnosed by:

 Chest x-ray
 ABGs
Treatment

 Chest tube

PNEUMONIA

 Obstruction of bronchioles
 ↓ gas exchange
 ↑ exudate
Symptoms

 Cough
 Fever
 Chills
 Tachycardia
 Tachypnea
 Dyspnea
 Pleural pain
 Malaise
 Respiratory distress
 ↓ breath sounds
Productive cough:

 Greenish – yellow
 Streptococcal infection
 Yellow or blood streaked
 Staphylococcal infection
SYMPTOMS OF HYPOXIA
Early (RAT)

 Restlessness
 Anxiety
 Tachycardia/ tachypnea
Late (BED)

 Bradycardia
 Extreme restlessness
 Dyspnea
In pediatrics (FINES)

 Feeding difficulty
 Inspiratory stridor
 Nares flare
 Expiratory grunting
 Sternal retractions

HINTS TO MALIGNANT MELANOMA (ABCD)

 Asymmetry
 Border irregularity
 Color variegation
 Diameter (greater than 6 mm)

KAWASAKI SYNDROME
(acute systemic vasculitis- usually children ↓ 5 y/o)

 Fever > 102.2 F

 Strawberry tongue
 Red lips
 Pallor of proximal fingernails & toenails
 Superficial skin layers, desquamate easily
 Red soles & palms
 Conjunctival redness
 Lethargy
 Irritability
 Cardiac complications in 5-20%
 Rash over trunk & perineal area
 Occasional intermittent colicky abdominal pain
 May last 2 to 12+ weeks

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